2019 Prior Authorization And Specialty Rx Management-PDF Free Download

2019 Prior Authorization and Specialty RX Management
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Codeine Migranal Nasal Spray 1 x8ml Troxyca ER, Conzip Monurol 1 Vantrella. Diflucan 150mg 2 Morphabond Viagra 25 50 100 mg 6, Dolophine Morphine Xtampza ER. Edex 6 Muse 6 Zohydro, Edluar 30 Nucynta Zohydro ER. Embeda OxyContin Zomig Nasal Spray 12 ea, Emverm 12 tabs per 365 days Oxycodone Zomig Zomig ZMT 2 5mg 5mg. Exalgo Oxymorphone, Frova 2 5 mg Tab 18 Pentazocine naloxone.
Hydromorphone Relenza cap 40 1 fill of either, Releza or Tamiflu every 90 days. Hysingla ER Relpaz 20mg 40 mg Tab 12, Imitrex 25mg 50mg 100mg Rozerem 30. Plans implementing morphine milligram equivalent MME based quantity limits on opioids are providing. coverage for an initial amount of 90 MME or less per day. This program requires a post limit review to provide coverage for additional quantities of the prescribed. opioids of 200 MME or less per day, Neither initial quantities nor post limit quantities will be set up for patients with cancer a terminal condition. or pain being managed through hospice or palliative care. Nippon Life Insurance Company of America 2 NC2021 29 rev 01 19. Dos e Opt i m i z a t i o n, A cost savings program that identifies medications where a different dosage or quantity would be more efficient The. pharmacy works with the physician to recommend such options Dose optimization Quantity Limit 30 tablets. Drug Dose mg Drug Dose mg, Abilify 5 10 15 Lozol 1 25.
Actos 15 Luvox 25 50, Altoprev 20 Micardis HCT 40 12 5. Amaryl 1 Mobic 7 5, Amturnide 150 5 12 5 Movantik 12 5. Aplenzin 174 Namenda XR 7 14, Arava 10 Nesina 6 25 12 5. Aricept 5 Niaspan 500, Aricept ODT 5 Nifedical XL 30. Avapro 75 150 Norvasc 2 5 5, Azilect 0 5 Oleptro 150.
Azor 5 20 Onglyza 2 5, Benicar HCT 20 12 5 Oseni 12 5 15. Brintellix 5 10 Paxil 10 20, Bystolic 2 5 5 10 Paxil CR 12 5. Caduet 2 5 10 2 5 Pexeva 10 20, Cardura 1 2 4 Plendil 2 5 5. Cardura XL 4 Pravachol 10 20 40, Cartrol 2 5 Prinivil 5 10 20. Celexa 10 20 Pristiq 50, Coreg CR 10 20 40 Procardia XL 30.
Corgard 20 40 Prozac 10, Crestor 5 10 20 Razadyne ER 8. Depakote ER 250 Remeron Remeron Rapid 7 5 15, Detrol LA 2 Requip XL 2 4 6. Dexilant 30 Reyataz 150, Diflucan 100 Rifadin 150, Diovan HCT 80 12 5 Seroquel XR 50 150 200. Ditropan XL 5 Silenor 3, Edarbi 40 Sular 8 5 17 20. Effexor XR 37 5 75 Symbyax 3 25 6 25, Enablex 7 5 Tekturna 150.
Exforge 5 160 Tekturna HCT 150 12 5, Nippon Life Insurance Company of America 3 NC2021 29 rev 01 19. Exforge HCT 5 160 12 5 Toprol XL 25 50 100, Farxiga 5 Toviaz 4. Fetzima 20 40 Tribenzor 20 5 12 5, Fosamax 5 Trintellix 5 10. Inderal LA 60 80 Twynsta 40 5, Ingrezza 40 venlafaxine HCI ER 37 5 75. Intuniv 1 2 Verelan PM 100, Invega 1 5 3 Vesicare 5.
Invokana 100 Viibryd 10 20, Januvia 25 50 Xadago 50. Kerlone 10 Xarelto 10, Khedezla ER 50 Xigduo XR 5 500. Latuda 20 40 60 Zaroxlyn 2 5 5, Levaquin 250 Zestoretic 10 12 5. Lexapro 5 10 Zestril 5 10 20, Linzess 145 Zocor 5 10 20. Lipitor 10 20 40 Zoloft 25 50, Livalo 1 2 Zyprexa Zydis 5.
Lotrel 2 5 10 5, Nippon Life Insurance Company of America 4 NC2021 29 rev 01 19. Pri o r Aut h o r i z a t i o n Dru g s, Your physician will have to provide additional information to indicate medical necessity to CVS Caremark for the following. drugs to be filled, Acne Agents Topical tretinoins Atralin Avita Retin A Retin A Micro Tretin X Tretinoin and Differin for ages 35 and older and all. ages for Fabior and Tazorac, Anabolic Steroids Anadrol 50 Oxandrin. Antifungals ciclopirox topical solutions Jublia Kerydin Lamisil terabinafine Onmel itraconazole Penlac ciclopirox. Sporanox itraconazole, Anti viral Sitavig, Compounds All Compounds.
Dental products Arestin, Dermatological Santyl Solaraze Trianex Dermatological Medical Products. Diabetes Generic Glumetza Generic Fortament, Eczema Eucrisa. Infant Formulas New Jersey Only, Erectile Dysfunction Caverject Cialis Edex Muse Stayxn Viagra through age 49. GI Motility Lotronex, Narcolepsy Provigil Xyrem, Narcotic Analgesics Actiq Fentora Onsolis Subsys. Pain Management Duexis Vimovo, Medical Products Saliva substitutes.
Testosterones Enanthate injection Cypionate injection topical gel topical cream topical ointment topical. solution transdermal patch nasal gel mucoadhesive buccal system propionate implant pellets powder crystals. for compounding Androderm Axiron Fortesta Striant Testosterone Ointment Testosterone Cream. Methyltestosterone Oral Fluoxymesterone Testopel, Topical Analgesics Pain Patches. Ulcer Generic Zegerid, A compound medication is one that is made by combining mixing or altering ingredients in response to a prescription to. create a customized medication that is not otherwise commercially available. Pri o r A uthor i z a t i o n Pro c ess, For the medications above that indicate a prior authorization is required please follow the process below. 1 Bring your prescription to a pharmacist, 2 If drugs require prior authorization the pharmacist will receive a message stating that the physician must call. CVS Caremark at 800 294 5979, 3 Your pharmacist should advise you as well as your physician of the Prior Authorization process and number to call.
4 This means that your physician will have to call the number or FAX a letter of medical necessity to CVS Caremark. Physician prior authorization number is 800 294 5979 Physician prior authorization FAX number is 888 836 0730. 5 CVS Caremark will evaluate the information received based on internally developed clinical criteria The decision. will be an approval denial or review for more information. App r ova l, After a claim is approved an override is applied so that the claim will process electronically at the pharmacy and a. letter will be sent to you and your physician indicating the approval and the time period of the approval. If the medication is denied then a letter is sent to both you and your physician The denial letter will outline. directions on how to appeal the decision, Mis s i n g I n f o r m a t i o n. If more information is required the physician s office will be contacted Once the physician s office provides. CVS Caremark with the required information then a review will be completed within 24 48 hours. Additional drugs may be added to the Prior Authorization or Quantity Limit list throughout the year Your specific benefit. Nippon Life Insurance Company of America 5 NC2021 29 rev 01 19. design may not cover certain drugs even though they appear on this list This document is a summary reference and may. not necessarily reflect all coverage and exclusions of the plan benefit system. Nippon Life Insurance Company of America 6 NC2021 29 rev 01 19. Prior Authorization Process on Formulary Drugs and S upplies. with Clinically Effective Alternatives, The following drugs and supplies are included. Supply Name Supply Usage Available Alternatives, All insulin needles that are not BD brand Diabetes Supplies Needles BD Ultrafine Needles. needles Examples include but are not, limited to Owen Mumford Needles Ultimed.
All insulin syringes that are not BD brand Diabetes Supplies Syringes BD Insulin Syringes. syringes Examples include but are not, limited to Allison Medical Insulin Syringes. Techlite Insulin Syringes Trividia Insulin, Syringes Ultimed Insulin Syringes. Vanishpoint Insulin Syringes, All strips and kits that are not Accu Chek Diabetes Supplies Strips and Kits Accu Chek Strips and Kits. brand strips and kits Examples include, but are not limited to Ascensia Breeze 2. Contour Contour Next Freestyle One, Touch Precision Xtra Sure Test Truetest.
Drug Name Medication Usage Available Alternatives, Abilify Depression aripiprazole clozapine. olanzapine quetiapine, quetiapine ext rel risperidone. ziprasidone Latuda Vraylar, Acanya Topical Derm Acne adapalene benzoyl peroxide. clindamycin solution, clindamycin benzoyl peroxide. erythromycin solution, erythromycin benzoyl, peroxide tretinoin Atralin.
Differin Epiduo Retin A Micro, Acticlate Anti Infective doxycycline hyclate. Actemra Rheumatoid Arthritis Enbrel Humira Kevzara. Xelijanz Xelijanz XR, Actos Diabetes pioglitazone, Adderall XR Attention deficit hyperactivity amphetamine dextroamphetamine. mixed salts ext rel, methylphenidate ext rel Mydayis. Aerospan Asthma Asmanex Flovent Pulmicort, Flexhaler Qvar Qvar. Alcortin A Dermatology desonide hydrocortisone, Alevicyn Gel Alevicyn Kit Alevicyn SG Dermatology desonide hydrocortisone.
Alevicyn solution, Alprolix Hemophilia IX Consult doctor. Aloquin Dermatology desonide hydrocortisone, Altoprev Cardiovascular antilipemics atorvastatin ezetimibe simvastatin. fluvastatin lovastatin pravastatin, rosuvastatin simvastatin. Nippon Life Insurance Company of America 7 NC2021 29 rev 01 19. Alvesco Asthma Arnuity Ellipta Asmanex, Flovent Pulmicort Flexhaler. Qvar Qvar Redihaler, Amrix Musculoskeletal agents cyclobenzaprine.
Androgel 1 Testosterone Relacement testosterone gel 2 testosterone solution. Androderm Androgel 1 62, Apexicon E Dermatology desoximetasone fluocinonide. Apidra Diabetes Fiasp Novolog, Arthrotec Anti inflammatory celecoxib diclofenac sodium. meloxicam or naproxen WITH, esomeprazole lansoprazole. omeprazole pantoprazole or Dexilant, Asacol HD Inflammatory bowel disease balsalazide sulfasalazine. sulfasalazine del rel Apriso Lialda, Atacand High blood pressure candesartan eprosartan irbesartan.
losartan olmesartan telmisartan, Atacand HCT High blood pressure candesartan hydrochlorothiazide. irbesartan hydrochlorothiazide, losartan hydrochlorothiazide. olmesartan hydrochlorothiazide, telmisartan hydrochlorothiazide. valsartan hydrochlorothiazide, Avenova Ophthalmic Consult doctor. Beconase AQ Allergies flunisolide spray fluticasone spray. mometasone spray, triamcinolone spray Dymista, Benicar Benicar HCT High Blood Pressure candesartan candesartan.
hydrochlorothiazide eprosartan, irbesartan irbesartan. hydrochlorothiazide losartan, losartan hydrochlorothiazide. olmesartan olmesartan, hydrochlorothiazide telmisartan. telmisartan hydrochlorothiazide, valsartan valsartan. hydrochlorothiazide, Bensal HP Dermatology Misc Skin Conditions desonide hydrocortisone.
Benzaclin Topical Derm Acne adapalene benzoyl peroxide. clindamycin solution clindamycin, benzoyl peroxide erythromycin. solution erythromycin benzoyl, peroxide tretinoin Atralin Differin. Epiduo Retin A Micro Tazorac, Betapace Tab and Betapace AF Tab Ventricula Arrhythmias sotalol. butalbital acetaminophen caffeine capsule Pain diclofenac sodium naproxen. Bydureon Diabetes Ozempic Trulicity Victoza, Byetta Diabetes injectable Ozempic Trulicity Victoza. Cafergot Migraines eletriptan ergotamine caffeine naratriptan. rizatriptan sumatriptan zolmitriptan Onzetra, Xsail Zembrace Symtouch Zomig Nasal.
Cambia Migraine NSAID diclofenac sodium meloxicam naproxen. Nippon Life Insurance Company of America 8 NC2021 29 rev 01 19. Carac Dermatology fluorouracil cream 5 fluorouracil soln. imiquimod Picato Tolac Zyclara, Cardizem High Blood Pressure diltiazem ext rel except generic of Cardizem. Cardizem CD High Blood Pressure diltiazem ext rel except generic of Cardizem. Cardizem LA and its generics High Blood Pressure diltiazem ext rel except generic of Cardizem. Carnitor Carnitine Deficiency Agents levocarnitine. Carnitor SF Carnitine Deficiency Agents levocarnitine. Cimzia Crohn s Disease Cosentyx Enbrel Humira Kevzara Otezla. Stelara Subcutaneous Plaque Psoriasis and, Psoriatic Arthritis only Xelijanz Xelijanz XR. clobetasol spray Dermatology clobetasol foam, Clobex Spray Dermatology clobetasol foam. Colazal Gastrointestinal Inflammatory Bowel Disease balsalazide. Contrave Anti Obesity Oral Belviq BelviqXR Saxenda. Crestor Cardiovascular Antilipemics atorvastatin ezetimibe simvastatin. fluvastatin lovastatin pravastatin, rosuvastatin simvastatin. Cymbalta Depression desvenlafaxine ext rel duloxetine. venlafaxine venlafaxine ext rel, Daklinza Anti infectives antivirals Epclusa Harvoni.
Delzicol Inflammatory bowel disease balsalazide sulfasalazine. sulfasalazine del rel Apriso Lialda, Detrol LA Overactive bladder darifenacin ext rel oxybutynin ext rel. tolterodine tolterodine ext rel trospium, trospium ext rel Myrbetriq Toviaz. Dexpak Pain and Inflammation dexamethasone methylprednisolone. prednisone solution prednisone, Diovan High Blood Pressure candesartan eprosartan irbesartan. losartan olmesartan telmisartan valsartan, Diovan HCT High blood pressure candesartan hydrochlorothiazide irbesartan. hydrochlorothiazide losartan, hydrochlorothiazide olmesartan.
hydrochlorothiazide telmisartan, hydrochlorothiazide valsartan. hydrochlorothiazide, Doryx Doryx MPC Dermatology doxycycline hyclate. Dulera Asthma Advair Breo Ellipta Symbicort, Dutoprol High Blood Pressure metoprolol succinate ext rel with. hydrochlorothiazide, Dyrenium Cap Edema amiloride, Edarbi High blood pressure candesartan eprosartan irbesartan. losartan olmesartan telmisartan, Edarbyclor High blood pressure candesartan hydrochlorothiazide.
irbesartan hydrochlorothiazide, losartan hydrochlorothiazide. olmesartan hydrochlorothiazide, telmisartan hydrochlorothiazide. valsartan hydrochlorothiazide, E E S Granules Infections erythromycins. Nippon Life Insurance Company of America 9 NC2021 29 rev 01 19. CVS Caremark at 800 294 5979 3 Your pharmacist should advise you as well as your physician of the Prior Authorization process and number to call 4 This means that your physician will have to call the number or FAX a letter of medical necessity to CVS Caremark Physician prior authorization number is 800 294 5979 Physician prior

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