Prior Authorization Program Information - Prime Therapeutics
Prior Authorization Program Information - Prime Therapeutics
Prior Authorization Program Information - Prime Therapeutics
Create successful ePaper yourself
Turn your PDF publications into a flip-book with our unique Google optimized e-Paper software.
<strong>Prior</strong> <strong>Authorization</strong><br />
<strong>Program</strong> <strong>Information</strong><br />
<strong>Prior</strong> <strong>Authorization</strong><br />
Certain drugs require prior authorization to help promote safe, quality and affordable pharmacy<br />
care. Your doctor will need to submit a prior authorization request to <strong>Prime</strong> <strong>Therapeutics</strong>, which<br />
must be approved before you can continue to receive coverage for these drugs.<br />
The <strong>Prior</strong> <strong>Authorization</strong> form that your physician will need to complete to request an approval<br />
can be found on the My<strong>Prime</strong>Tools website (located on the same page where this form is found).<br />
<strong>Prior</strong> <strong>Authorization</strong> Drugs included in program<br />
program name<br />
ANDROGENS / ANABOLIC STEROIDS<br />
Androgens / Anabolic<br />
Steroids<br />
Androderm, AndroGel, Axiron, Bio-T-Gel, Fortesta, Striant, Testim, First-<br />
Testosterone, First-Testosterone MC , Delatestryl, Depo-Testosterone,<br />
Testopel, Android, Androxy, Methitest, Testred, Anadrol-50, danazol,<br />
Oxandrin<br />
ASTHMA<br />
Xolair<br />
Xolair<br />
ATTENTION DEFICIT-HYPERACTIVITY DISORDER (ADHD)<br />
ADHD<br />
(with quantity limits)<br />
<strong>Prior</strong> <strong>Authorization</strong> applies to Brand products only:<br />
Adderall, Adderall XR, Concerta, Daytrana, Dexedrine, Desoxyn,<br />
Dextroamphetamine, Focalin, Focalin XR, Intuniv, Kapvay, Metadate<br />
CD, Metadate ER, Methylin, Procentra, Quillivant XR, Ritalin, Ritalin LA,<br />
Ritalin SR, Strattera, Vyvanse<br />
BLOOD MODIFYING DRUGS<br />
Aranesp, Epogen, Procrit<br />
Erythropoietins<br />
Preferred Product: Aranesp, Procrit<br />
CANCER / ONCOLOGY<br />
Afinitor, Bosulif, Caprelsa, Cometriq, Erivedge, Gleevec, Hexalen,<br />
Hycamtin, Iclusig, Inlyta, Jakafi, Lysodren, Matulane, Nexavar, Oforta,<br />
Self Administered Oncology Pomalyst, Revlimid, Sprycel, Stivarga, Sutent, Sylatron, Tarceva,<br />
Targretin, Tasigna, Temodar, Thalomid, Tretinoin (oral), Tykerb,<br />
Votrient, Xalkori, Xeloda, Xtandi, Zelboraf, Zolinza, Zytiga<br />
Yervoy<br />
Yervoy<br />
DERMATOLOGY<br />
<strong>Prior</strong> <strong>Authorization</strong> applies to only Brand products and generics as listed<br />
below:<br />
Doxycycline Products: Adoxa, Alodox, Avidoxy DK, Doryx, Doryx<br />
Doxycycline/Minocycline generic equivalent, Doxycycline, Monodox, Morgidox Kit, Nutridox Kit,<br />
Ocudox Kit, Oracea, Oraxyl, Vibramycin<br />
Minocycline Products: Dynacin, Minocin, Minocin Kit, Solodyn, Solodyn<br />
generic equivalent<br />
Retinoids (Topical)<br />
Atralin, Avita, Differin, Epiduo, Fabior, Retin-A, Retin-A Micro, Tazorac,<br />
Applies to ages 40 and over Tretin-X, Veltin, Ziana<br />
ENDOCRINOLOGY<br />
H.P. Acthar Gel<br />
H.P. Acthar Gel<br />
GROWTH HORMONE<br />
Genotropin, Humatrope, Norditropin Flexpro, Norditropin NordiFlex,<br />
Nutropin, Nutropin AQ, Nutropin AQ Nuspin, Omnitrope, Saizen, Saizen<br />
Growth Hormone<br />
Click.Easy, Serostim, Tev-Tropin, Zorbtive<br />
Preferred Product: Norditropin, Nutropin<br />
HEPATITIS B & HEPATITIS C<br />
Hepatitis B / Hepatitis C<br />
Incivek, Pegasys, Pegasys Proclick, PegIntron, Victrelis<br />
Agents<br />
HUNTINGTON’S CHOREA<br />
Xenazine<br />
Xenazine<br />
<strong>Prime</strong> <strong>Therapeutics</strong> LLC (<strong>Prime</strong>), the independent pharmacy benefit management company selected by your employer, is dedicated to<br />
providing innovative, clinically based, cost-effective pharmacy solutions.<br />
5484-A Page 1 of 2
<strong>Prior</strong> <strong>Authorization</strong> Drugs included in program<br />
program name<br />
HYPERTENSION (HIGH BLOOD PRESSURE)<br />
Letairis and Tracleer<br />
Letairis, Tracleer<br />
METABOLIC DISORDERS<br />
Kuvan<br />
Kuvan<br />
MULTIPLE SCLEROSIS<br />
Ampyra<br />
Ampyra<br />
PAIN MANAGEMENT<br />
Fentanyl Oral / Nasal<br />
Abstral, Actiq, Fentora, Lazanda, Onsolis, Subsys<br />
RESPIRATORY<br />
Synagis<br />
Synagis<br />
SLEEP DISORDERS<br />
Nuvigil Provigil<br />
Nuvigil, Provigil<br />
THYROID / PARATHYROID<br />
Sensipar<br />
Sensipar<br />
MISCELLANEOUS<br />
Bivigam, Carimune, Flebogamma, Flebogamma 5%, 10% DIF,<br />
GamaSTAN S/D, Gammagard S/D, Gammagard S/D (IgA less than 1<br />
Immune Globulins<br />
mcg/mL), Gammagard Liquid, Gammaked Liquid, Gammaplex Liquid,<br />
Gamunex, Gamunex-C, Hizentra, Octagam, Privigen<br />
Immune Thrombocytopenic<br />
Nplate, Promacta<br />
Purpura (ITP)<br />
Brand names are the property of their respective owners.<br />
ER: extended-release<br />
SR: sustained-release<br />
Unless otherwise noted, <strong>Prior</strong> <strong>Authorization</strong> <strong>Program</strong>s will apply to both brand drugs and their generic<br />
equivalents.<br />
This program is subject to change without notice.<br />
<strong>Prime</strong> <strong>Therapeutics</strong> LLC (<strong>Prime</strong>), the independent pharmacy benefit management company selected by your employer, is dedicated to<br />
providing innovative, clinically based, cost-effective pharmacy solutions.<br />
5484-A Page 2 of 2
Change language