Upload
trinhnhu
View
217
Download
4
Embed Size (px)
Citation preview
V14.0-02/27/2014 1
FIDELIS CARE NEW YORK – DEPARTMENT OF PHARMACY SERVICES J-Code Prior Authorizations & Required Clinical Information
Medicaid, Family Health Plus, Child Health Plus, NY State of Health
Brand Generic J-Code Covered Uses Required Medical Information and Criteria
Orencia Abatacept J0129 Rheumatoid arthritis Juvenile idiopathic arthritis for ages 6 and older
Failed TNF blockers +/- DMARDS Patient weight, CBC with differential, tuberculin skin test
results, immunization history
Depo-Provera Medroxyprogesterone J0150 Abnormal uterine bleeding Endometrial hyperplasia Endometriosis Secondary physiologic amenorrhea
Diagnostic measures to rule out malignancy
Fabrazyme Algalsidase beta J0180 Fabry Disease for ages 8 and older Enzyme assay showing deficiency of alpha-galactosidase activity or DNA testing
Patient's weight, IgG, IgE, serum creatinine, BUN Premedicate with antipyretics
Ceredase Alglucerase J0205 Gaucher Disease (type 1) for ages 2 and over
Patient's weight, CBC, platelets, acid phosphatase (AP), liver function tests, plasma glucocerebroside, IgG antibody
Amevive Alefacept J0215 Plaque psoriasis CD4+ T-lymphocyte, immunization history transaminase, body surface area affected, tuberculin skin test results
Previous trial of phototherapy Previous trial with adalimumab and etanercept
Myozyme Alglucosidase alfa J0220 Pompe Disease Patient weight, liver enzymes, IgG & IgE antibodies
Lumizyme Alglucosidase alfa J0221 Pompe Disease Patient weight, liver enzymes, IgG & IgE antibodies Enrolled in Lumizyme ACE program
Prolastin, Aralast (Multiple)
Alpha 1-proteinase inhibitor
J0256 Alpha 1-antitrypsin deficiency Patient weight, pulmonary function tests, non-smoker COPD diagnosis - emphysema, concomitant COPD
treatment, normal CRP levels Absence of IgA deficiency/ anti- IgA antibodies
Glassia Alpha 1-proteinase inhibitor
J0257 Alpha 1-antitrypsin deficiency Patient weight, pulmonary function tests, non-smoker COPD diagnosis - emphysema, concomitant COPD
treatment, CRP levels Absence of IgA deficiency/ anti- IgA antibodies
V14.0-02/27/2014 2
Brand Generic J-Code Covered Uses Required Medical Information and Criteria
Caverject Alprostadil J0270 Covered for diagnostic purposes Appropriate clinical documentation per indication
Lioresal Baclofen intrathecal J0476 Spasticity Spinal cord injury, multiple sclerosis, or other spinal disease Previous trial of baclofen oral therapy
Simulect Basiliximab J0480 Renal transplant rejection Concomitant use of cyclosporine and corticosteroid CBC, renal function
Benlysta Belimumab J0490 Systemic lupus erythematosus Patient weight, serum creatinine, immunization history No concurrent use of cyclophosphamide or biological
therapies Concomitant use of conventional lupus treatment
Botox Onabotulinum toxinA J0585 Blepharospasm ≥ 12 years of age Cervical dystonia ≥ 16 years of age Migraine prophylaxis Hyperhidrosis of axilla Incontinence – overactive bladder Strabismus ≥ 12 years of age Upper limb spasticity
Previous trial of 2 migraine prophylaxis agents , ≥15 headaches per month with ≥4 hours/day duration
Previous trial of a topical agent for hyperhidrosis of axilla dx, hyperhidrosis disease severity scale score
Previous trial with an anticholinergic medication for overactive bladder dx, detrusor overactivity related to a neurologic condition
Dysport Abobotulinum toxinA J0586 Cervical dystonia
Failed trial with muscle relaxant
Myobloc Rimabotulinum toxinB J0587 Cervical dystonia Failed trial with muscle relaxant
Xeomin Incobotulinum toxin A J0588 Blepharospasm Cervical dystonia Rhytide of glabellar skin
Previous trial with Botox
Buprenex Buprenorphine J0592 Moderate-to-severe pain Patient liver enzyme levels Previous trial of long acting opioids, adequate dose based
on conversion
Berinert C1-esterase inhibitor J0597 Hereditary angioedema Patient weight, history of attacks Previous medication trials and outcome ≥12 years of age
V14.0-02/27/2014 3
Brand Generic J-Code Covered Uses Required Medical Information and Criteria
Cinryze C1-esterase Inhibitor J0598 Hereditary angioedema, prophylaxis
Patient weight, history of attacks Previous medication trials and outcome ≥9 years of age
Ilaris Canakinumab J0638 Cryopyrin associated periodic syndrome Familial cold urticarial ≥ 4 years of age Muckle-Wells syndrome ≥ 4 years of age Systemic onset juvenile chronic arthritis ≥ 2 years of age
Patient weight, CRP and amyloid A levels, CBC with differential, immunization history, tuberculin skin test results
Failed TNF blockers +/- DMARDS for juvenile chronic arthritis dx
Cafcit Caffeine citrate J0706 Apnea of prematurity Patient weight, serum caffeine levels Previous outcome with theophylline if applicable
Novarel, Pregnyl (Multiple)
Chorionic gonadotropin J0725 Cryptorchidism Hypogonadotropic hypogonadism
Serum testosterone levels
Xiaflex Clostridium histolyticum
J0775 Dupuytren’s contracture Involvement of metacarpophalangeal or proximal interphalangeal joints
Positive table top test
Prolia, Xgeva
Denosumab J0897 Prolia: postmenopausal osteoporosis, osteoporosis in men, osteopenia in men receiving androgen deprivation therapy, osteopenia in women receiving aromatase inhibitor therapy Xgeva: prophylaxis of skeletal related events in patients with bone metastases, unresectable giant cell tumor of bone
Documented corresponding cancer and use of chemotherapy agent if applicable
Bone mineral density (T score), serum creatinine, calcium, vitamin D, phosphorus, and magnesium levels
Concurrent calcium and vitamin D intake Previous mediation trials
Kalbitor Ecallantide J1290 Hereditary angioedema ≥16 years of age Patient weight, history of attacks Previous medication trials and outcome
V14.0-02/27/2014 4
Brand Generic J-Code Covered Uses Required Medical Information and Criteria
Soliris Eculizumab J1300 Hemolytic uremic syndrome Paroxysmal nocturnal hemoglobinuria (PNH)
• Meningococcal vaccine at least 2 weeks prior to treatment • Immunization history, CBC with differential, lactic
dehydrogenase (LDH), AST, urinalysis, serum creatinine
Flolan Epoprostenol J1325 Pulmonary arterial hypertension Patient weight, blood pressure, heart rate, baseline 6 minute walking distance test
Failed therapy to oral CCB, conventional oral medications WHO Group 1, NYHA Class III or IV
Privigen, GamaStan, Gammaplex Carimune (Multiple brand names)
IV immune Globulin J1459 J1460 J1557 J1559 J1560 J1561 J1566 J1568 J1569 J1572 J1599
Bacterial infection prophylaxis Hepatitis A prophylaxis Idiopathic thrombocytopenic purpura Inflammatory demyelinating polyradiculoneuropathy Kawasaki disease Measles post exposure prophylaxis Motor neuropathy with multiple conduction block Rubella post-exposure prophylaxis Primary immune deficiency disorder Varicella *FDA approved indications vary based on brand name*
Patient weight, serum creatinine/BUN, hemoglobin, hematocrit, platelets, blood viscosity, anti-neutrophil antibodies, immunization history
Absence of risk factors for acute renal failure and IgA deficiency
Boniva Ibandronate J1740 Postmenopausal osteoporosis
Bone mineral density (T score), serum creatinine, calcium, vitamin D, phosphorus, and magnesium levels
Concurrent calcium and vitamin D intake Failed trial with oral bisphosphonates
V14.0-02/27/2014 5
Brand Generic J-Code Covered Uses Required Medical Information and Criteria
Corvert Ibutilide fumarate J1742 Atrial arrhythmia Patient weight, onset of arrhythmia Anticoagulation for atrial fibrillation with a ≥3 day duration
Elaprase Idursulfase J1743 Hunter syndrome (Mucopolysaccharidosis II)
Patient weight Enzyme assay demonstrating a deficiency of iduronate 2-
sulfatase enzyme activity or DNA testing
Remicade
Infliximab J1745 Ankylosing spondylitis Psoriatic arthritis Rheumatoid arthritis Plaque psoriasis Crohn’s disease Ulcerative colitis
Patient weight, tuberculin skin test results, hepatitis B screening
Failed trial with more cost-effective agents and conventional therapy depending on dx o Psoriatic arthritis, ankylosing spondylitis – failed trial
with a NSAID and DMARD o RA – failed trial with at least 2 nonbiologic DMARDS (one
of which is methotrexate) o Plaque psoriasis – failed trial of phototherapy and
conventional systemic therapy o Crohn’s disease– failed trial with at least 2 conventional
therapies o Ulcerative colitis – failed trial with at least 1
conventional therapy Concomitant use of methotrexate for dx of RA
Cerezyme Imiglucerase J1786 Type 1 Gaucher's Disease
Patient's weight, CBC, platelets, hemoglobin, hematocrit, liver function tests, IgG antibody, acid phosphatase, MRI/CT results of liver and spleen
β-glucocerebrosidase enzyme assay, DNA testing, or bone marrow histology confirming dx
Somatuline Lanreotide J1930 Acromegaly Serum GH, IGF-1, glucose levels, heat rate, gall bladder ultrasonography, TRH tests, CT results of pituitary
Previous history of surgery and/or radiotherapy
Aldurazyme Laronidase J1931 Hurler & Hurler-Scheie forms of mucopolysaccharidosis (Type 1)
Patient weight, baseline disease status Alpha-L iduronidase activity or DNA testing confirming dx
V14.0-02/27/2014 6
Brand Generic J-Code Covered Uses Required Medical Information and Criteria
Zyvox Linezolid J2020 Community acquired pneumonia Nosocomial pneumonia VRE faecium infection Skin/subcutaneous infection
Culture, antibiotic sensitivity results, CBC with differential
Tysabri Natalizumab J2323 Crohn’s disease Multiple sclerosis
MRI results/medical records confirming dx of relapsing forms of MS, enrolled in the TOUCH prescribing program
Failed trial with conventional therapy for MS dx Failed trial with conventional therapy and a TNF- α inhibitor
for Crohn’s dx
Xolair Omalizumab J2357 Allergic asthma IgE levels, positive allergy tests, pulmonary function tests, non-smoker
Moderate to severe persistent asthma as indicated by number of asthma exacerbations, ER visits, significant functional impairment
≥12 years of age Failed trial with high-dose ICS, LABA, and leukotriene
modifier
Zyprexa Relprevv Olanzapine J2358 Schizophrenia History of non-adherence with oral antipsychotics, history of violent behavior, failed trial with at least one typical and atypical antipsychotic
Previous history with oral olanzapine
Invega Sustenna Paliperidone J2426 Schizophrenia History of non-adherence with oral antipsychotics, history of violent behavior, failed trial with at least one typical and atypical antipsychotic
Previous history with oral paliperidone
Papacon Papaverine J2440 Angina Cerebrovascular disease Ischemic heart disease Peripheral vascular disease with vasospasm Smooth muscle spasm Thromboembolic disorder
Demonstrated trial with safer and more effective alternatives
Macugen Pegaptanib J2503 Neovascular age-related macular degeneration
Intraocular pressure, baseline visual acuity
V14.0-02/27/2014 7
Brand Generic J-Code Covered Uses Required Medical Information and Criteria
Krystexxa Pegloticase J2507 Gout Serum uric acid level, G6PD deficiency screening Number of gout attacks, gout tophus or gouty arthritis Failed trial with conventional therapy Prophylaxis with NSAID or colchicine one week before
administration
Mozobil Plerixafor J2562 Harvesting of peripheral blood stem cells in patients with non-Hodgkin's lymphoma and multiple myeloma
Patient’s weight, serum creatinine, CBC with differential, platelets
Administer after patient has received filgrastim 10mcg/kg daily for 4 days
Lucentis Ranibizumab J2778 Exudative age- related macular degeneration Diabetic macular edema Macular retinal edema – thrombosis of retinal vein
Intraocular pressure, baseline visual acuity ≥18 years of age
Arcalyst Rilonacept J2793 Cryopyrin-Associated Periodic Syndromes
Patient weight, lipid profile, CBC with differential, C-reactive protein, serum amyloid A, immunization history, tuberculin skin test results
≥12 years of age
Risperdal Consta Risperidone J2794 Schizophrenia Bipolar I disorder
History of non-adherence with oral antipsychotics, history of violent behavior
Failed trial with at least one typical and atypical antipsychotic
Previous history with oral risperidone
Nplate Romiplostim J2796 Idiopathic chronic immune thrombocytopenia purpura
Failed trial with corticosteroids, immune globulin, or splenectomy
Patients weight, CBC with differential and platelet count
Actemra Tocilizumab J3262 Rheumatoid arthritis Juvenile idiopathic arthritis Polyarticular juvenile rheumatoid arthritis
Failed TNF blockers +/- DMARDS Patient weight, CBC with differential, liver function tests,
lipid panel, tuberculin skin test results, immunization history, hepatitis B screening
Remodulin Treprostinil J3285 Pulmonary arterial hypertension Patient weight, blood pressure, heart rate, baseline 6 minute walking distance test
Failed therapy to oral CCB, conventional oral medications WHO Group 1, NYHA Class II- IV
V14.0-02/27/2014 8
Brand Generic J-Code Covered Uses Required Medical Information and Criteria
Bravelle Urofollitropin J3355 Polycystic ovary syndrome Concomitant use of human chorionic gonadotropin
Stelara Ustekinumab J3357 Plaque psoriasis Psoriatic arthritis
Patient weight, CBC with differential, tuberculin skin test results, immunization history, body surface area affected
Failed therapy with NSAIDS and DMADs for dx psoriatic arthritis
Failed therapy with conventional systemic therapy and phototherapy for dx plaque psoriasis
VPRIV Velaglucerase alfa J3385 Non-neuropathic Gaucher’s disease Patient's weight, CBC, platelets, hemoglobin, hematocrit, liver function tests, IgG antibody, acid phosphatase, MRI/CT results of liver and spleen
Visudyne Verteporfin J3396 Age related macular degeneration Histoplasmosis Myopia
CBC with differential, liver function tests, fluorescein angiography, baseline visual acuity
Unclassified drugs; Unclassified biologics
J3490 J3590
Appropriate clinical documentation per indication
Corifact Factor XIII, human J7180 Factor XIII deficiency Patient weight, hemoglobin, hematocrit Factor XIII levels
Wilate Humate P
Von Willebrand Factor Complex, human
J7183 J7187
Hemophilia A Von Willebrand disorder
Patient weight, hemoglobin, hematocrit, heart rate, blood pressure
vWF activity, Factor VIII levels
Xyntha Factor VIII, recombinant
J7185 Hemophilia A Patient weight, hemoglobin, hematocrit, heart rate, blood pressure
Factor VIII levels
Novoseven Factor VIIa, recombinant
J7189 Factor VII deficiency Hemophilia
Patient weight, prothrombin time, aPTT, factor VII levels Hematocrit, hemoglobin
Koate Factor VIII, human J7190 Hemophilia A Patient weight, hemoglobin, hematocrit, heart rate, blood pressure
Factor VIII levels
Helixate FS (Multiple)
Factor VIII, recombinant
J7192 Hemophilia A Factor VIII deficiency
Patient weight, hemoglobin, hematocrit, heart rate, blood pressure
Factor VIII levels
V14.0-02/27/2014 9
Brand Generic J-Code Covered Uses Required Medical Information and Criteria
Alphanine, Mononine
Factor IX, non-recombinant
J7193 Hemophilia B Patient weight, aPTT, blood pressure, heart rate Factor IX levels
Bebulin VH (Multiple)
Factor IX, complex J7194 Hemophilia B Patient weight, aPTT, blood pressure, heart rate Factor IX levels
Benefix Factor IX recombinant J7195 Hemophilia B Patient weight, aPTT, blood pressure, heart rate Factor IX levels
Feiba VH (Multiple)
Anti-inhibitor coagulant complex
J7198 Hemophilia Patient weight, fibrinogen, platelets, thrombin time Blood pressure, heart rate, hemoglobin, hematocrit
Hemophilia clot factor NOC
J7199 Appropriate clinical documentation per indication
Ozurdex Dexamethasone J7312 Macular edema due to BRVO or CRVO Noninfective uveitis
Intraocular pressure, baseline visual acuity Failed trial with corticosteroid ophthalmic drops
Synvisc (Multiple)
Hyaluronic acid J7321 J7323 J7324 J7325 J7326
Osteoarthritis of the knee Failed trial with either NSAIDS or intra-articular corticosteroid injections and physical therapy
Qutenza Capsaicin J7335 Postherpetic neuralgia Failed trial wit h at least 2 oral agents (i.e. TCA, gabapentin)
Thymoglobulin Antithymocyte globulin J7511 Renal transplant rejection Failed trial with standard oral immunosuppressive therapy Concomitant use of standard immunosuppressive therapy
Patient weight, CBC with differential, platelet count, renal function
Sandimmune Cyclosporine
J7516 Kidney, liver, and heart transplant rejection prophylaxis
Failed trial with standard oral immunosuppressive therapy Concomitant use of adrenal corticosteroids for kidney, liver,
and heart transplant Patient weight, CBC with differential, liver enzyme, serum
creatinine, and BUN levels
Prograf Tacrolimus J7525 Heart, kidney, liver, transplant rejection prophylaxis
Failed trial with standard oral immunosuppressive therapy Concomitant use of azathioprine or mycophenolate mofetil
and adrenal corticosteroids for heart and kidney transplant Concomitant use of adrenal corticosteroids for liver
transplant Patient weight, CBC with differential, calcium, magnesium,
potassium, liver enzyme, serum creatinine, and BUN levels
V14.0-02/27/2014 10
Brand Generic J-Code Covered Uses Required Medical Information and Criteria
Afinitor Everolimus J7527 Angiomyolipoma of kidney Breast cancer, hormone receptor positive, HER2 negative Liver transplant rejection prophylaxis Neuroendocrine tumor, pancreatic Renal cell carcinoma, Renal transplant rejection prophylaxis Subependymal giant cell astrocytoma
CBC with differential, liver function tests, serum creatinine, BUN, immunization history
Failed trial with tyrosine kinase inhibitor (i.e. sunitinib) for dx renal cell carcinoma
Immunosuppressive drug not otherwise classified
J7599 Appropriate clinical documentation per indication
Levalbuterol comp J7607 Asthma Documentation of clinical reason why final formulation was inappropriate for use
Albuterol comp J7609 J7610
Asthma Documentation of clinical reason why final formulation was inappropriate for use
Beclomethasone inhalation comp
J7622 Asthma
Documentation of clinical reason why final formulation was inappropriate for use
Betamethasone inhalation comp
J7624 Documentation of clinical reason why final formulation of an inhaled corticosteroid was not used
Bitolterol inhalation comp
J7629 Asthma Documentation of clinical reason why final formulation was inappropriate for use
Budesonide inhalation J7633 J7634
Asthma Compounded formulation: documentation of clinical reason why final formulation was inappropriate for use
Atropine inhalation comp
J7635 J7636
Documentation of clinical reason why final formulation of an inhaled anticholinergic was not used
V14.0-02/27/2014 11
Brand Generic J-Code Covered Uses Required Medical Information and Criteria
Dexamethasone inhalation comp
J7637 J7638
Documentation of clinical reason why final formulation of an inhaled corticosteroid was not used
Pulmozyme Dornase alfa J7639 Cystic fibrosis Pulmonary function tests (i.e. FEV1, FVC) Concomitant use of standard therapy for CF (i.e. antibiotics,
bronchodilators, ICS) ≥5 years of age
Flunisolide inhalation comp
J7641 Asthma Documentation of clinical reason why final formulation was inappropriate for use
Glycopyrrolate inhalation comp
J7642 J7643
Asthma Documentation of clinical reason why final formulation of an inhaled anticholinergic was not used
Terbutaline inhalation comp
J7680 J7681
Asthma Documentation of clinical reason why final formulation of a beta agonist was not used
Triamcinolone inhalation comp
J7683 J7684
Asthma Documentation of clinical reason why final formulation was inappropriate for use
Tobramycin comp J7685 Cystic fibrosis infection due to pseudomonas aeruginosa
Documentation of clinical reason why final formulation was inappropriate for use
Tyvaso Treprostinil inhalation J7686 Pulmonary arterial hypertension Patient weight, blood pressure, heart rate, baseline 6 minute walking distance test
Failed therapy to oral CCB, conventional oral medications WHO Group 1, NYHA Class III- IV
Myleran Busulfan J8510 Palliative treatment of chronic myelogenous leukemia Hemopoietic stem cell transplant conditioning
Patient weight, CBC with differential, platelet count, liver function tests
Temodar Temozolomide J8700 Anaplastic astrocytoma of brain, refractory Glioblastoma multiforme of brain, newly diagnosed
Patient weight, height, CBC with differential, platelet count, liver function tests
Trial with nitrosurea and procarbazine for dx anaplastic astrocytoma of brain
V14.0-02/27/2014 12
Brand Generic J-Code Covered Uses Required Medical Information and Criteria
Yervoy Ipilimumab J9228 Malignant melanoma, unresectable or metastatic
Patient weight, liver function tests, thyroid function tests
Arzerra Ofatumumab J9302 Chronic lymphoid leukemia, refractory
Patient weight, CBC with differential, platelet count Hepatitis B screening Trial with fludarabine and alemtuzumab
Rituxan Rituximab J9310 Oncologic use
Rheumatoid arthritis Wegener’s granulomatosis Microscopic polyarteritis nodosa
No prior authorization needed
Patient weight, height, CBC with differential, platelet count Hepatitis B screening Failed trial with TNF blockers + oral DMARD for dx
rheumatoid arthritis