Targeted Immunomodulator Agents
eculizumab (Soliris®) | ||
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PA Criteria:
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Erythropoietin Stimulating Agents |
romiplostim (Nplate®) | ||
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PA Criteria:
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Tier 1 |
Tier 2 |
Tier 3 |
DMARDs appropriate to disease state:
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*Drug product applies to all formulations unless otherwise specified.
methotrexate injection (Rasuvo®/Otrexup™) | ||
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PA Criteria:
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mercaptopurine oral solution (Purixan®) |
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PA Criteria:
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PA Criteria:
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natalizumab (Tysabri®) | ||
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PA Criteria:
Prior Authorization Forms |
rilonacept (Arcalyst®) |
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PA Criteria:
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Respiratory Agents | ||
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omalizumab (Xolair®) | ||
palivizumab (Synagis®) |
denosumab (Xgeva®) *Medical billing only |
teriparatide (Forteo®) |
botulinum toxins injections (Botox® Myobloc® Dysport® Xeomin®)*Medical billing only | ||
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Botulinum injections require a Prior Authorization for all diagnoses. Covered diagnoses for all products
Botox® only criteria (effective April 24, 2013) Consideration for approval requires the following critria for Botox for Prevention of Migraine Headaches (other botulinum toxins will not be approved for this use):
Consideration for approval requires the following criteria for Botox® for Non-Neurogenic Overactive Bladder (other botulinum toxins will not be approved for this use):
Consideration for approval requires the following criteria for Botox for Neurogenic Overactive Bladder (other botulinum toxins will not be approved for this use):
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