Affinity Health Plan – Department Of Pharmacy (Medicaid, Child Health Plus, Family Health Plus) **Medications Requiring Authorization under Medical Benefit** Click Here For Medication Authorization Request Form (please fax request to 718.536.3329) (Last Revised 9/16/14

Items Enteral formula

Covered Benefit for Medicaid/CHP/FHP 1000-2000 calories/day

Preferred Vendor Trinity

Contact Information Phone: 718-961-1634 Fax: 718-762- 8741

Tubing, bags, pumps, syringes Insulin pump/supplies,

Medicaid ONLY Medicaid/CHP/FHP

Better Living Now

Phone 1-800-854-5729 Fax: 800-654-7515 Email: [email protected]

Medicaid ONLY

Integra

Phone 718-369-0012

Medicaid/CHP/FHP

Oncomed

Phone: 877-662-6633

Continuous Glucose Monitoring Diapers, Ostomy supplies, etc. Chemotherapy, parenteral

Review the quantities in the “Fee Schedule” Excel document for a list of Medicaid covered supplies/DME with quantity limits at https://www.emedny.org/ProviderManuals/DME/index.aspx https://www.emedny.org/ProviderManuals/Pharmacy/PDFS/Pharmacy_Procedure_Codes.pdf

It is the policy of Affinity Health Plan to require prior authorization for medical claims for the following drugs when administered in an office or clinic setting: In addition, all drugs requested by nonparticipating providers shall require prior authorization i.e. Specialty Pharmacies. All drugs that are self-administered are covered as part of the Pharmacy Benefit. Prior authorization will be required in order to be covered as a Medical Benefit. Any drug that does not have the indication supported by FDA or Compendia requires authorization. Acceptable Compendia are Micromedex DrugDex and NCCN (National Comprehensive Cancer Network).

HCPCS Code

1 Billable Unit

Brand

Generic

Solesta

Dextranomer/ hyaluronic acid

L8605

1 ml

External ambulatory infusion pump, insulin Disposable insulin delivery system

E0784

1 unit

A9274

Sensor Transmitter Receiver Monitor

A9276 A9277 A9278

Onabotulinumtoxin A

J0585

Insulin Pump & Supplies

Continuous Glucose Monitoring Systems

Botox

Covered Uses

Required Medical Information and Criteria

Exclusion Criteria

• Evidence of treatment failure • C-peptide • Evidence of member motivation & pump training • Glucose monitoring log • Insulin frequency

Urinary incontinence

1 unit

Adults with Type I DM without • Glucose monitoring adequate control despite log frequent self-monitoring of • Insulin frequency blood glucose levels

1 unit

• Primary axillary hyperhidrosis • Neurologic workup in adults • Trial of at least 3 classes of migraine • Blepharospasm (>12 years old) prophylaxis • Strabismus (>12 years old) • Hyperhidrosis • Cervical Dystonia (>16 years disease severity scale (HDSS) score old) • Hemifacial Spasm • Upper extremity spasticity • Overactive bladder • Neurogenic bladder • Chronic migraine prophylaxis • Spasticity related to Cerebral

• Type II DM • Children/Adolescents with Type I DM • Pregnancy/Gestational DM • Cosmetics uses • Lower limb spasticity • Diabetic neuropathic pain

Adults with Fecal incontinence • Type 1 or Type 2 diabetes AND the patient has completed a comprehensive diabetes education program and has been on multiple injections of insulin with frequent self-adjustments for at least 6 months OR • Gestational diabetes AND has the patient completed a comprehensive diabetes education program.

Myobloc

Rimabotulinumtoxin B

J0587

100units

Dysport

Abobotulinumtoxin A

J0586

5 units

Xeomin

Incobotulinumtoxin A

J0588

1 unit

J0598

Cinryze C1 esterase inhibitor (human)

• Blepharospasm • Cervical Dystonia • Hereditary angioedema (HAE) (>12 years old) prophylaxis

J0597

Berinert Firazyr

10 units

Palsy • Achalasia • Cervical Dystonia

Icatibant

• Acute attacks of HAE

J1744

1 mg Kalbitor

Ecallantide

Caverject

Alprostadil

J0270

1.25 mcg

Aplrostadil urethral

J0275

125 mcg

Pavacot

Papaverine

J2440

60 mg

Oraverse

Phentolamine

J2760

5 mg

Muse

J1290

•

Diagnosis of Erectile Dysfunction (ED)

• Neurologic workup with previous methods tried

• Previous medication trials • Confirmed diagnosis of HAE by laboratory testing • Laboratory confirmation of HAE • Administered by appropriate health care specialist

• Emergency CABG

•

• •

Complete physical examination.

•

Treatment of ED Registered Sex Offender Male infertility

• J1950

Lupron Depot

3.75 mg • •

Leuprolide

Central Precocious Puberty (CPP) Endometriosis Uterine leiomyomata with anemia

• • • •

J9217

7.5 mg

• • •

Prostate Cancer (PC) Breast Cancer (BC) Ovarian Cancer

J9225

50 mg

•

Prostate Cancer (PC)

Lupron

Vantas

Histrelin Implant

• • •

Supprelin LA

Histrelin Implant

J9226

50 mg

•

Central Precocious Puberty

• •

Makena

Hydroxyprogesterone Caproate

J1725

1 mg

•

Reduce the risk of preterm • birth in women, with a singleton pregnancy, who has a history of singleton • spontaneous preterm birth. •

•

Delayed puberty for short stature

Laboratory confirmation GnRH test, bone age assessment, imaging of the brain, age.

• •

Age < 2 Delayed puberty

Previous history of singleton pregnancy Previous history of spontaneous preterm birth. Compounded hydroxyprogester one preferred (No Authorization required)

• •

Short cervix Current or planned cerclage

Laboratory confirmation PC: PSA, Gleason score. BC: hormone receptor (+), CPP: GnRH test, bone age assessment, imaging of the brain, age. Laboratory confirmation PSA, Gleason Score. Disease staging

Xolair

Synagis (Seasonal usage November-March)

Omalizumab

Palivizumab

J2357

90378

5 mg

50 mg

Cytogam

J0850

50 ml

Bivigam

J1556

500mg

Privigen

J1459

500 mg

J1460

1 ml

•

Provider can contact Alere directly at 800999-0225 or fax 516-240-1577 Age > 12 y/o IgE level Body Weight Documented medication history

• •

Moderate to severe persistent asthma & (+) skin test reactive to perennial aroallergen & Inadequately controlled by corticosteroids. • Moderate to severe urticarial unresponsive to 6 months of antihistamines, corticosteroids or leukotriene. Prevention of lower respiratory tract disease in infants at high risk for RSV • Chronic Lung Disease • Premature Infant • Congenital Abnormality of airway/Neuromuscular Condition • Hemodynamically unstable chronic heart disease

• • • •

Gestational age Weight Risk factors

• • •

Hypersensitivity Age > 12 months Healthy infants born > 29 wks/0 days gestation

Primary Immune Deficiency:  Congenital Agammaglobulinemia  Hypogammaglobulinemia

 IgG Subclass levels – levels should be while patient is free from infection  Serum antibody titers to pneumococcus, tetanus, and/or diphtheria  Details of recurrent

• • • •

Fibromyalgia Lyme Disease Pediatric Epilepsy Neuropathy

• • •

• •

Allergy to peanuts Allergic rhinitis prophylaxis Latex Allergy Dosing outside manufacturer’s recommendations according to body weight and IgE levels

infections  Re-Authorizations – trough IgG levels; documenting patient response to Ig.

Immune Globulin

J1557

Gammaplex

500 mg

Hizentra

J1559

100 mg

Gammaked

J1561

500 mg

Transplant:  Bone Marrow Transplant

Bone Marrow Transplant – Date of transplant, detailed patient history

Kawasaki

Immune Globulin Gamunex

J1561

500 mg

Vivaglobin

J1562

100 mg

Gammagard liquid

J1566

500 mg

Octagam

J1568

500 mg

Hyperrho S/D

J2788

Carimune Flebogamma

J1566 J1572

50mcg/ 250 IU 500mg 500mg

 CBC  Serum ESR  Serum C-reactive protein  Serum LFTs

Secondary Immunodeficiency:  Chronic Lymphocytic Leukemia with Hypogammaglobulinemi a (CLL)  B cell CLL

 Total IgG levels

Hematology:  Idiopathic Thrombocytopenia Purpura (ITP)  Prophylaxis of rubella during pregnancy  Prophylaxis of hepatitis A  Post-exposure prophylaxis varicella

Neurological Conditions:  Chronic Inflammatory Demyelinating Polyneuropathy (CIPD)  Inflammatory Myopathies (Polymyositis, Dermatomyositis)  Guillain-Barre Syndrome  Myasthenia Gravis exacerbation  Multifocal Motor Neuropathy  Relapsing/Remitting Multiple Sclerosis

Euflexxa

J7323

Gel-One

J7326

Hyalgan

J7321

Orthovisc

Hyaluronate Sodium

J7321

Supartz Synvisc

J7324

Hylan GF 20

J7325

Per dose (20mg/2ml) Per dose (30mg/3ml) Per dose (20mg/2ml) Per dose (30mg/2ml) Per dose (25mg/2.5 ml) 1mg

Treatment of pain in Osteoarthritis (OA) of the knee is no longer considered a covered benefit

 Laboratory values used to confirm diagnosis

Testing used to confirm diagnosis (examples: EMG, Nerve Conduction Study (NCS), muscle biopsy, MRI, CSF protein, Anti-Mag antibodies, Anti-GD1a, Anti-GD1b)  Documentation of standard treatment tried/failed/contraindicat e Multifocal Motor Neuropathy – Anti-GM 1 antibody results

non-FDA approved indication

Miscellaneous Codes

Unclassified Meds

J3490 J3590

•

Requires review with clinical documentation