MDwise MANAGED MEDICAID PRIOR AUTHORIZATION GUIDELINES
MDwise MANAGED MEDICAIDPRIOR AUTHORIZATION GUIDELINESMDwise MANAGED MEDICAIDPRIOR AUTHORIZATION GUIDELINESHHW-HIPP0505(7/17)Revised: 06/13/2022Page 1
MDwise MANAGED MEDICAIDPRIOR AUTHORIZATION TIDEHICLGCN44231Exception/OtherGUIDELINES FOR USEThe guideline named ABALOPARATIDE (Tymlos) requires that the patient has a diagnosis ofpostmenopausal osteoporosis and has not received a total of 24 months or more of parathyroidhormone therapy with Tymlos or Forteo. In addition, one of the following criteria must be met: High risk for fractures defined as ONE of the following:o History of osteoporotic (e.g., fragility, low trauma) fracture(s)o 2 or more risk factors for fracture (e.g., history of multiple recent low trauma fractures, BMDT-score less than or equal to -2.5, corticosteroid use, or use of GnRH analogs such asnafarelin, etc.)o No prior treatment for osteoporosis AND FRAX score 20% for any major fracture OR 3%for hip fracture Unable to use oral therapy (e.g., upper gastrointestinal [GI] problems - unable to tolerate oralmedication, lower GI problems - unable to absorb oral medications, trouble remembering to takeoral medications or coordinating an oral bisphosphonate with other oral medications or their dailyroutine) The patient has an adequate trial of, intolerance to, or a contraindication to bisphosphonates (e.g.,Fosamax, Actonel, Boniva)RATIONALETo ensure safe and appropriate use of abaloparatide per approved indication and dosing and nationaltreatment guidelines.FDA APPROVED INDICATIONSIndicated for the treatment of postmenopausal women with osteoporosis at high risk for fracture definedas a history of osteoporotic fracture, multiple risk factors for fracture, or patients who have failed or areintolerant to other available osteoporosis therapy. In postmenopausal women with osteoporosis,Tymlos reduces the risk of vertebral fractures and nonvertebral fractures.DOSAGE AND ADMINISTRATIONThe recommended dosage of Tymlos is 80 mcg subcutaneously once daily. Cumulative use of Tymlosand parathyroid hormone analogs (e.g., teriparatide) for more than 2 years during a lifetime is notrecommended. Patients should receive supplemental calcium and vitamin D if dietary intake isinadequate.REFERENCES Tymlos [Prescribing Information]. Waltham, MA: Radius Health, Inc.; October 2018. Miller PD, Hattersley G, Riis BJ, et al. Effect of abaloparatide vs placebo on new vertebral fracturesin postmenopausal women with osteoporosis: a randomized clinical trial. JAMA. 2016;316:722-33. American Association of Clinical Endocrinologists and American College of Endocrinology(AACE/ACE) medical guidelines for clinical practice for the diagnosis and treatment ofpostmenopausal osteoporosis. Accessed online April 13, 2017.Created: 05/17Effective: 04/20/20HHW-HIPP0505(7/17)Revised: 06/13/2022Client Approval: 03/25/20P&T Approval: N/APage 2
MDwise MANAGED MEDICAIDPRIOR AUTHORIZATION GUIDELINESGenericABATACEPT/MALTOSEBrandORENCIA - IVABATACEPT - IVHICLGCN26306Exception/OtherNOTE: For requests for the SQ dosage form of Orencia, please see the ABATACEPT SQGuideline.GUIDELINES FOR USEINITIAL CRITERIA (NOTE: FOR RENEWAL CRITERIA SEE BELOW)Our guideline named ABATACEPT - IV (Orencia - IV) requires the following rule(s) be met forapproval:A. You have ONE of the following indications for treatment:1. Moderate to severe rheumatoid arthritis (RA: a type of joint condition)2. Moderate to severe Polyarticular juvenile idiopathic arthritis (PJIA: a type of joint condition)3. Psoriatic arthritis (PsA: a type of skin and joint condition)4. Prevention of acute graft-versus-host disease (aGVHD)B. If you have moderate to severe rheumatoid arthritis (RA), approval also requires:1. You are 18 years of age or older2. You have previously tried at least ONE of the following DMARDs (disease-modifyingantirheumatic drugs): methotrexate, leflunomide, hydroxychloroquine, or sulfasalazine3. You have previously tried ONE of the following: Enbrel or HumiraC. If you have moderate to severe polyarticular juvenile idiopathic arthritis (PJIA), approvalalso requires:1. You are 2 years of age or older2. You have previously tried at least ONE of the following DMARDs (disease-modifyingantirheumatic drugs): methotrexate, leflunomide, hydroxychloroquine, or sulfasalazine3. You have previously tried ONE of the following: Enbrel or HumiraD. If you have psoriatic arthritis (PsA), approval also requires:1. You are 18 years of age or older2. You have previously tried at least ONE of the following DMARDs (disease-modifyingantirheumatic drugs): methotrexate, leflunomide, hydroxychloroquine, or sulfasalazine3. You have previously tried TWO of the following: Cosentyx, Enbrel, or HumiraE. For the prevention of acute graft-versus-host disease (aGVHD), approval also requires:1. You are 2 years of age or older2. The requested medication will be used concurrently with a calcineurin inhibitor ANDmethotrexate3. You will be concurrently undergoing hematopoietic stem cell transplantation (HSCT) from amatched or 1 allele-mismatched unrelated-donorCONTINUED ON NEXT PAGEHHW-HIPP0505(7/17)Revised: 06/13/2022Page 3
MDwise MANAGED MEDICAIDPRIOR AUTHORIZATION GUIDELINESABATACEPT - IVGUIDELINES FOR USE (CONTINUED)NOTE: For the diagnosis of acute graft versus host disease (aGVHD), please refer to the Initial Criteriasection.RENEWAL CRITERIAThe guideline named ABATACEPT - IV (ORENCIA - IV) renewal requires a diagnosis of moderate tosevere rheumatoid arthritis, psoriatic arthritis, or moderate to severe juvenile idiopathic arthritis forrenewal. In addition, the following criteria must be met:Renewal for the diagnosis of moderate to severe rheumatoid arthritis, approval requires: Documentation (i.e., chart notes) that the patient has experienced or maintainedsymptomatic improvement while on therapyRenewal for the diagnosis of moderate to severe polyarticular juvenile idiopathicarthritis, approval requires: Documentation (i.e., chart notes) that the patient has experienced or maintainedsymptomatic improvement while on therapyRenewal for the diagnosis of psoriatic arthritis, approval requires: Documentation (i.e., chart notes) that the patient has experienced or maintainedsymptomatic improvement while on therapyCONTINUED ON NEXT PAGEHHW-HIPP0505(7/17)Revised: 06/13/2022Page 4
MDwise MANAGED MEDICAIDPRIOR AUTHORIZATION GUIDELINESABATACEPT - IVRATIONALEEnsure appropriate diagnostic, utilization and safety criteria are met for the management of requests forabatacept.FDA APPROVED INDICATIONSOrencia is a selective T cell costimulation modulator indicated for:Adult Rheumatoid Arthritis (RA)Moderately to severely active RA in adults. Orencia may be used as monotherapy or concomitantlywith DMARDs other than TNF antagonists.Polyarticular Juvenile Idiopathic Arthritis (PJIA)Moderately to severely active polyarticular juvenile idiopathic arthritis in patients 2 years of age andolder. Orencia may be used as monotherapy or concomitantly with methotrexate.Adult Psoriatic Arthritis (PsA)Orencia is indicated for the treatment of adult patients with active psoriatic arthritis (PsA).Prophylaxis for acute graft-versus-host disease (aGVHD)Orencia is indicated for the prophylaxis of acute graft versus host disease (aGVHD), in combinationwith a calcineurin inhibitor and methotrexate, in adults and pediatric patients 2 years of age and olderundergoing hematopoietic stem cell transplantation (HSCT) from a matched or 1 allele-mismatchedunrelated-donor.DOSINGAdult Rheumatoid Arthritis (RA) and Adult Psoriatic Arthritis (PsA)Dose according to body weight as specified in the table below. Following the initial administration,abatacept should be given at 2 and 4 weeks after the first infusion, then every 4 weeks thereafter.Dose of Orencia for intravenous administration for Adult RA and PsABODY WEIGHT OF PATIENTDOSENUMBER OF VIALS 60 kg500 mg260 to 100kg750 mg3 100 kg1,000 mg4CONTINUED ON NEXT PAGEHHW-HIPP0505(7/17)Revised: 06/13/2022Page 5
MDwise MANAGED MEDICAIDPRIOR AUTHORIZATION GUIDELINESABATACEPT - IVFDA APPROVED INDICATIONS (CONTINUED)DOSINGPolyarticular Juvenile Idiopathic Arthritis (PJIA)Dose according to body weight as specified in the table below. Following the initial administration,abatacept should be given at 2 and 4 weeks after the first infusion, then every 4 weeks thereafter.Dose of Orencia for intravenous administration for PJIABODY WEIGHT OF PATIENT 75 kg75 to 100kg 100 kgDOSE (ONCE WEEKLY)10mg/kg750 mg1,000 mgProphylaxis for acute graft-versus-host disease (aGVHD)For patients 6 years and older, administer Orencia 10 mg/kg (maximum dose of 1,000 mg) as anintravenous infusion over 60 minutes on the day before transplantation (Day 1), followed byadministration on Days 5, 14, and 28 after transplantation.For patients 2 to less than 6 years old, administer ORENCIA 15 mg/kg as an intravenous infusion over60 minutes on the day before transplantation (Day 1), followed by 12 mg/kg as an intravenous infusionover 60 minutes on Days 5, 14, and 28 after transplantation.REFERENCES Orencia [Prescribing Information]. Princeton, NJ: E.R. Squibb & Sons, L.L.C. February 2022. Beukelman T, Patkar NM, et al. 2011 American College of Rheumatology recommendations for thetreatment of juvenile idiopathic arthritis: Initiation and safety monitoring of therapeutic agents for thetreatment of arthritis and systemic features. Arthritis Care Res, 63: 465–482. doi:10.1002/acr.20460. Singh JA, Guyatt G, et al. 2018 American College of Rheumatology/National Psoriasis FoundationGuideline for the Treatment of Psoriatic Arthritis. Arthritis Care & Research. Vol. 71, No. 1, January2019, pp 2–29. DOI 10.1002/acr.2378. Singh JA, Saag KG, et al. 2015 American College of Rheumatology Guideline for the Treatment ofRheumatoid Arthritis. Arthritis Care & Research. 2016;68(1):1-25. DOI 10.1002/acr.22783. National Comprehensive Cancer Network (NCCN). Hematopoietic Cell Transplantation (HCT)(Version 5.2021). https://www.nccn.org/professionals/physician gls/pdf/hct.pdf Accessed February2, 2022.Created: 02/18Effective: 03/28/22HHW-HIPP0505(7/17)Revised: 06/13/2022Client Approval: 02/22/22P&T Approval: N/APage 6
MDwise MANAGED MEDICAIDPRIOR AUTHORIZATION GUIDELINESGenericABATACEPT - SQABATACEPT - SQBrandHICLORENCIA - SQ,ORENCIA E: For the IV dosage form of Orencia, please see the ABATACEPT IV Guideline.GUIDELINES FOR USEINITIAL CRITERIA (NOTE: FOR RENEWAL CRITERIA SEE BELOW)Our guideline named ABATACEPT SQ (Orencia SQ) requires the following rule(s) be met forapproval:A. You have ONE of the following diagnoses:1. Moderate to severe rheumatoid arthritis (RA: inflammation and stiffness in joints)2. Polyarticular juvenile idiopathic arthritis (PJIA: swelling and stiffness in many joints inchildren)3. Psoriatic arthritis (PsA: joint pain and swelling with red scaly skin patches)B. If you have moderate to severe rheumatoid arthritis (RA), approval also requires:1. You are 18 years of age or older2. You have previously tried at least ONE of the following DMARDs (disease-modifyingantirheumatic drugs): methotrexate, leflunomide, hydroxychloroquine, or sulfasalazine3. You have previously tried ONE of the following: Enbrel or HumiraC. If you have polyarticular juvenile idiopathic arthritis (PJIA), approval also requires:1. You are 2 years of age or older2. You have previously tried at least ONE of the following DMARDs (disease-modifyingantirheumatic drugs): methotrexate, leflunomide, hydroxychloroquine, or sulfasalazine3. You have previously tried ONE of the following: Enbrel or HumiraD. If you have psoriatic arthritis (PsA), our guideline also requires:1. You are 18 years of age or older2. You have previously tried at least ONE of the following DMARDs (disease-modifyingantirheumatic drugs): methotrexate, leflunomide, hydroxychloroquine, or sulfasalazine3. You have previously tried TWO of the following: Cosentyx, Enbrel, or HumiraRENEWAL CRITERIAOur guideline named ABATACEPT SQ (Orencia SQ) requires the following rule(s) be met for renewal:A. You have ONE of the following diagnoses:1. Moderate to severe rheumatoid arthritis (RA: inflammation and stiffness in joints)2. Moderate to severe polyarticular juvenile idiopathic arthritis (PJIA: swelling and stiffnessin joints in children)3. Psoriatic arthritis (PsA: joint pain and swelling with red scaly skin patches)B. You have experienced or maintained symptomatic improvement while on therapy.CONTINUED ON NEXT PAGEHHW-HIPP0505(7/17)Revised: 06/13/2022Page 7
MDwise MANAGED MEDICAIDPRIOR AUTHORIZATION GUIDELINESABATACEPT - SQRATIONALEEnsure appropriate diagnostic, utilization and safety criteria are met for the management of requests forabatacept.FDA APPROVED INDICATIONSOrencia is a selective T cell costimulation modulator indicated for:Adult Rheumatoid Arthritis (RA)Moderately to severely active RA in adults. Orencia may be used as monotherapy or concomitantlywith DMARDs other than TNF antagonists.Polyarticular Juvenile Idiopathic Arthritis (PJIA)Moderately to severely active polyarticular juvenile idiopathic arthritis in patients 2 years of age andolder. Orencia may be used as monotherapy or concomitantly with methotrexate. The safety andefficacy of Orencia ClickJect auto-injector for subcutaneous injection has not been studied in patientsunder 18 years of age.Adult Psoriatic Arthritis (PsA)Orencia is indicated for the treatment of adult patients with active psoriatic arthritis (PsA).Important Limitations of UseOrencia should not be given concomitantly with TNF antagonists. Orencia is not recommended for useconcomitantly with other biologic rheumatoid arthritis therapy such as anakinra.DOSINGAdult Rheumatoid Arthritis (RA)Orencia 125 mg in prefilled syringes or in Orencia ClickJect autoinjector should be administered bysubcutaneous injection once weekly and may be initiated with or without an intravenous loading dose.For patients initiating therapy with an intravenous loading dose, Orencia should be initiated with asingle intravenous infusion, followed by the first 125 mg subcutaneous injection administered within aday of the intravenous infusion.Adult Psoriatic Arthritis (PsA)Orencia SC 125 mg should be administered by subcutaneous injection once weekly without the needfor an intravenous loading dose.Polyarticular Juvenile Idiopathic Arthritis (PJIA)Orencia for subcutaneous injection should be initiated without an intravenous loading dose and beadministered utilizing the weight range-based dosing as specified in the Table below.Dose of Orencia for subcutaneous administration for PJIABODY WEIGHT OF PATIENT10 to less than 25 kg25 to less than 50 kg50 kg or moreDOSE (ONCE WEEKLY)50 mg87.5 mg125 mgCONTINUED ON NEXT PAGEHHW-HIPP0505(7/17)Revised: 06/13/2022Page 8
MDwise MANAGED MEDICAIDPRIOR AUTHORIZATION GUIDELINESABATACEPT - SQREFERENCES Orencia package insert. Princeton, NJ: Bristol-Myers Squibb Company; June 2020. Beukelman T, Patkar NM, et al. 2011 American College of Rheumatology recommendations for thetreatment of juvenile idiopathic arthritis: Initiation and safety monitoring of therapeutic agents for thetreatment of arthritis and systemic features. Arthritis Care Res, 63: 465–482. doi:10.1002/acr.20460. Singh JA, Guyatt G, et al. 2018 American College of Rheumatology/National Psoriasis FoundationGuideline for the Treatment of Psoriatic Arthritis. Arthritis Care & Research. Vol. 71, No. 1, January2019, pp 2–29DOI 10.1002/acr.2378. Singh JA, Saag KG, et al. 2015 American College of Rheumatology Guideline for the Treatment ofRheumatoid Arthritis. Arthritis Care & Research. 2016;68(1):1-25. DOI 10.1002/acr.22783.Created: 03/15Effective: 04/11/22HHW-HIPP0505(7/17)Revised: 06/13/2022Client Approval: 03/10/22P&T Approval: N/APage 9
MDwise MANAGED MEDICAIDPRIOR AUTHORIZATION IBHICLGCN44537Exception/OtherGUIDELINES FOR USEThe guideline named ABEMACICLIB (Verzenio) requires a diagnosis of advanced or metastatic breastcancer that is hormone receptor (HR ) positive and human epidermal growth factor 2 negative. Inaddition, ONE of the following criteria must be met: The medication will be used in combination with fulvestrant and ALL of the following criteriaare met:o The patient is femaleo The patient has had disease progression following endocrine therapyo The patient has NOT experienced disease progression following prior CDK inhibitor therapy The medication will be used as monotherapy and ALL of the following criteria are met:o The patient is 18 years of age or oldero The patient has had disease progression following endocrine therapy and prior chemotherapy inthe metastatic settingo The patient has NOT experienced disease progression following prior CDK inhibitor therapy The medication will be used in combination with an aromatase inhibitor and ALL of thefollowing criteria are met:o The patient is a female and postmenopausalo The requested medication will be used in combination with an aromatase inhibitor (e.g.,letrozole, anastrozole, or exemestane)o The patient has not received prior endocrine therapy for metastatic breast cancer (e.g.,letrozole, anastrozole, tamoxifen, fulvestrant, exemestane)o The patient has NOT experienced disease progression following prior CDK inhibitor therapyRATIONALEPromote appropriate utilization of ABEMACICLIB (Verzenio) based on FDA approved indication anddosing.FDA APPROVED INDICATIONSVERZENIO is a kinase inhibitor indicated: In combination with fulvestrant for the treatment of women with hormone receptor (HR)-positive,human epidermal growth factor receptor 2 (HER2)-negative advanced or metastatic breast cancerwith disease progression following endocrine therapy As monotherapy for the treatment of adult patients with HR positive, HER2-negative advanced ormetastatic breast cancer with disease progression following endocrine therapy and priorchemotherapy in the metastatic setting In combination with an aromatase inhibitor as initial endocrine-based therapy for the treatment ofpostmenopausal women with hormone receptor (HR)-positive, human epidermal growth factorreceptor 2 (HER2)-negative advanced or metastatic breast cancerCONTINUED ON NEXT PAGEHHW-HIPP0505(7/17)Revised: 06/13/2022Page 10
MDwise MANAGED MEDICAIDPRIOR AUTHORIZATION GUIDELINESABEMACICLIBDOSAGE AND ADMINISTRATIONWhen used in combination with fulvestrant or an aromatase inhibitor, the recommended dose ofVERZENIO is 150 mg taken orally twice daily. When given with VERZENIO, the recommended dose offulvestrant is 500 mg administered on Days 1, 15, and 29; and once monthly thereafter.Pre/perimenopausal women treated with the combination of VERZENIO plus fulvestrant should betreated with a gonadotropin-releasing hormone agonist according to current clinical practice standards.When used as monotherapy, the recommended dose of VERZENIO is 200 mg taken orally twice daily.When given with VERZENIO, refer to the Full Prescribing Information for the recommended dose of thearomatase inhibitor being used.Continue treatment until disease progression or unacceptable toxicity. VERZENIO may be taken withor without food. Instruct patients to take their doses of VERZENIO at approximately the same timesevery day. If the patient vomits after taking the dose, or misses a dose, no additional dose should betaken that day. The next prescribed dose should be taken at the usual time. VERZENIO tablets shouldbe swallowed whole (tablets should not be chewed, crushed or split prior to swallowing). No tabletshould be ingested if it is broken, cracked, or otherwise not intact.The recommended VERZENIO dose modifications for adverse reactions are provided in the tablebelow.*If further dose reduction below 50 mg twice daily is required, discontinue the treatment.VERZENIO Dose inVERZENIO Dose forDose LevelCombination with FulvestrantMonotherapyor an aromatase inhibitorRecommended starting dose150 mg twice daily200 mg twice dailyFirst dose reduction100 mg twice daily150 mg twice dailySecond dose reduction50 mg twice daily100 mg twice dailyThird dose reductionNot applicable50 mg twice daily*Avoid concomitant use of the strong CYP3A inhibitor ketoconazole.AVAILABLE STRENGTHSTablets: 50 mg, 100 mg, 150 mg, and 200 mgREFERENCES Verzenio [Prescribing Information]. Indianapolis, IN. Eli Lilly and Company; February 2018.Created: 10/17Effective: 04/15/19HHW-HIPP0505(7/17)Revised: 06/13/2022Client Approval: 03/29/18P&T Approval: N/APage 11
MDwise MANAGED MEDICAIDPRIOR AUTHORIZATION ATERONEHICLGCN37571Exception/OtherGUIDELINES FOR USEApproval requires a diagnosis of metastatic castration-resistant prostate cancer (CRPC) or metastatichigh-risk castration-sensitive prostate cancer (CSPC). In addition, the requested medication must beused in combination with prednisone.RATIONALETo ensure appropriate use of Zytiga consistent with FDA approved indication.FDA APPROVED INDICATIONSZytiga is indicated for use in combination with prednisone for the treatment of patients with metastaticcastration-resistant prostate cancer CRPC) and metastatic high-risk castration-sensitive prostatecancer (CSPC).DOSAGE AND ADMINISTRATIONMetastatic castration-resistant prostate cancer: The recommended dose of Zytiga is 1,000 mg (two500 mg tablets or four 250 mg tablets) administered orally once daily in combination with prednisone 5mg administered orally twice daily.Metastatic high-risk castration-sensitive prostate cancer: The recommended dose of Zytiga is1,000 mg (two 500 mg tablets or four 250 mg tablets) administered orally once daily in combination withprednisone 5 mg administered orally once daily.Patients receiving ZYTIGA should also receive a gonadotropin-releasing hormone (GnRH) analogconcurrently or should have had bilateral orchiectomy. ZYTIGA must be taken on an empty stomach,either one hour before or two hours after a meal [see Clinical Pharmacology (12.3)]. The tablets shouldbe swallowed whole with water. Do not crush or chew tab.If a strong CYP3A4 inducer must be co-administered, increase the Zytiga dosing frequency to twice aday only during the co-administration period (e.g., from 1,000 mg once daily to 1,000 mg twice a day).REFERENCES Zytiga package insert. Horsham, PA: Centocor Ortho Biotech Inc. February 2018.Created: 06/15Effective: 04/15/19HHW-HIPP0505(7/17)Revised: 06/13/2022Client Approval: 03/29/18P&T Approval: 11/13Page 12
MDwise MANAGED MEDICAIDPRIOR AUTHORIZATION AABIRATERONE SUBMICRONIZEDHICLGCN44946Exception/OtherROUTE ORALGUIDELINES FOR USEThe guideline named YONSA (abiraterone, submicronized) requires that the patient have a diagnosisof metastatic castration-resistant prostate cancer (CRPC). In addition, the requested medication mustbe used combination with methylprenisolone.RATIONALEPromote appropriate utilization of Yonsa based on FDA approved indication and dosing.DOSAGEThe recommended dose of Yonsa is 500 mg (four 125 mg tablets) administered orally once daily incombination with methylprednisolone 4 mg administered orally twice daily.Patients receiving Yonsa should also receive a gonadotropin-releasing hormone (GnRH) analogconcurrently or should have had bilateral orchiectomy.FDA APPROVED INDICATIONSYonsa is indicated for the treatment of patients with metastatic castration-resistant prostate cancer(CRPC).REFERENCES Yonsa [Prescribing Information]. Sun Pharma. Cranbury, NJ. May 2018.Created: 06/18Effective: 08/20/18HHW-HIPP0505(7/17)Revised: 06/13/2022Client Approval: 07/06/18P&T Approval: N/APage 13
MDwise MANAGED MEDICAIDPRIOR AUTHORIZATION BHICLGCN47767Exception/OtherGUIDELINES FOR USEINITIAL CRITERIA (NOTE: FOR RENEWAL CRITERIA SEE BELOW)Our guideline named ABROCITINIB (Cibinqo) requires the following rule(s) be met for approval:A. You have moderate to severe atopic dermatitis (a type of skin condition)B. You are 18 years of age or olderC. You had a trial of a high or super-high potency topical corticosteroid (such as triamcinoloneacetonide, fluocinonide, clobetasol propionate, halobetasol propionate) AND one nonsteroidal topical immunomodulating agent (such as Eucrisa, Opzelura, pimecrolimus,tacrolimus)D. You had a trial of or contraindication to Rinvoq (upadacitinib)RENEWAL CRITERIAOur guideline named ABROCITINIB (Cibinqo) requires the following rule(s) be met for renewal:A. You have moderate to severe atopic dermatitis (a type of skin condition)B. You have experienced or maintained improvement in at least TWO of the following:1. Intractable pruritus (a type of skin condition)2. Cracking and oozing/bleeding of affected skin3. Impaired activities of daily livingRATIONALEEnsure appropriate diagnostic, utilization and safety criteria are used for the management of requestsfor Cibinqo.INDICATIONSCibinqo is a janus kinase (JAK) inhibitor indicated for the treatment of adults with refractory, moderateto-severe atopic dermatitis whose disease is not adequately controlled with other systemic drugproducts, including biologics, or when use of those therapies is inadvisable.DOSINGThe recommended dosage of Cibinqo is 100 mg orally once daily. If an adequate response is notachieved with Cibinqo 100mg orally daily after 12 weeks, consider increasing dosage to 200 mg orallyonce daily. Discontinue therapy if inadequate response is seen after dosage increase to 200 mg oncedaily.REFERENCESCibinqo [Prescribing Information]. New York, NY: Pfizer Labs; January 2022.Created: 03/22Effective: 04/18/22HHW-HIPP0505(7/17)Revised: 06/13/2022Client Approval: 03/22/22P&T Approval: N/APage 14
MDwise MANAGED MEDICAIDPRIOR AUTHORIZATION RUTINIBHICLGCN44607Exception/OtherGUIDELINES FOR USEOur guideline named ACALABRUTINIB (Calquence) requires the following rules be met for approval:A. You have a diagnosis of mantle cell lymphoma (MCL: a type of cancer), chronic lymphocyticleukemia (CLL: cancer of the blood and bone marrow), or small lymphocytic lymphoma(SLL: cancer of the blood and bone marrow)B. You are 18 years of age or olderC. If you have mantle cell lymphoma (MCL), approval also requires:1. You have received at least one prior therapy for mantle cell lymphomaRATIONALETo promote appropriate utilization of Calquence based on FDA approved indication.FDA APPROVED INDICATIONSCalquence is a kinase inhibitor indicated for the treatment of adult patients with: Mantle cell lymphoma (MCL) who have received at least one prior therapy Chronic lymphocytic leukemia (CLL) or small lymphocytic lymphoma (SLL)DOSINGThe recommended dose of Calquence is 100 mg taken orally approximately every twelve hours untildisease progression or unacceptable toxicity.REFERENCES Calquence [Prescribing Information]. AstraZeneca Pharmaceuticals: Wilmington, DE; November2019.Created: 11/17Effective: 01/01/22HHW-HIPP0505(7/17)Revised: 06/13/2022Client Approval: 11/24/21P&T Approval: N/APage 15
MDwise MANAGED MEDICAIDPRIOR AUTHORIZATION CLGCN24800Exception/OtherGUIDELINES FOR USEINITIAL CRITERIA (NOTE: FOR RENEWAL CRITERIA SEE BELOW)Our guideline named ADALIMUMAB (Humira) requires the following rule(s) be met for approval:A. You have ONE of the following diagnoses:1. Moderate to severe rheumatoid arthritis (RA: inflammation and stiffness in joints)2. Psoriatic arthritis (PsA: joint pain and swelling with red scaly skin patches)3. Moderate to severe polyarticular juvenile idiopathic arthritis (PJIA: swelling and stiffness injoints in children)4. Ankylosing spondylitis (AS: inflammation and stiffness affecting spine and large joints)5. Moderate to severe plaque psoriasis (PsO: dry, itchy skin patches with scales)6. Moderate to severe Crohn's disease (CD: type of inflammatory disease that affects lining ofdigestive tract)7. Moderate to severe ulcerative colitis (UC: type of inflammatory disease that affects lining ofdigestive tract)8. Moderate to severe hidradenitis suppurativa (skin condition with lumps)9. Non-infectious intermediate posterior and panuveitis (serious inflammation of eye)B. If you have moderate to severe rheumatoid arthritis (RA), approval also requires:1. You have previously tried at least ONE of the following DMARDs (disease-modifyingantirheumatic drugs): methotrexate, leflunomide, hydroxychloroquine, or sulfasalazineC. If you have moderate to severe polyarticular juvenile idiopathic arthritis (PJIA), approvalalso requires:1. There is documentation of your current weight if you are less than or equal to 17 years ofageD. If you have moderate to severe plaque psoriasis (PsO), approval also requires:1. You have previously tried ONE of the following conventional therapies: PUVA(Phototherapy Ultraviolet Light A), UVB (Ultraviolet Light B), topical corticosteroids,calcipotriene, acitretin, methotrexate, or cyclosporineE. If you have moderate to severe Crohn's disease (CD), approval also requires:1. You have previously tried ONE or more of the following conventional agents, corticosteroids(e.g., budesonide, methylprednisolone), azathioprine, mercaptopurine, methotrexate, ormesalamineF. If you have moderate to severe hidradenitis suppurativa (HS), approval also requires:1. You have previously tried oral or topical antibiotic therapy2. You have previously tried oral or injectable corticosteroid therapyG. If you have non-infectious intermediate, posterior and panuveitis, approval also requires:1. You have previously tried at least ONE of the following: oral or injectable corticosteroidtherapy, methotrexate, mycophenolate, azathioprine, cyclosporine, tacrolimus, orcyclophosphamide2. There is documentation of your current weight if you are less than or equal to 17 years ofageCONTINUED ON NEXT PAGEHHW-HIPP0505(7/17)Revised: 06/13/2022Page 16
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treatment of arthritis and systemic features. Arthritis Care Res, 63: 465-482. doi: 10.1002/acr.20460. Singh JA, Guyatt G, et al. 2018 American College of Rheumatology/National Psoriasis Foundation Guideline for the Treatment of Psoriatic Arthritis. Arthritis Care & Research. Vol. 71, No. 1, January 2019, pp 2-29. DOI 10.1002/acr.2378.
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Managed Care 101 Medicaid, Managed Care, and Children More than 70% of Medicaid beneficiaries are enrolled in private managed care organizations (MCOs) Almost 9 of every 10 children enrolled in Medicaid and CHIP receive health care through a managed care arrangement 39 states rely on MCOs to cover all or some of their Medicaid
the MDwise website (For Providers/Forms/Prior Authorization). A provider who is not contracted with MDwise must always obtain a referral authorization to see the member (except emergency services). All HIP delivery syst
will go into a POWER Account. POWER Account stands for Personal Wellness Responsibility Account. You will have 1,100 in your POWER Account. You will get a MDwise card in the mail. Use this MDwise card whenever you go to the doctor, the pharmacy or anytime that you get health care services. Except for your preventive care,File Size: 1MBPage Count: 31
In 2001, CIMCO teamed up with IU Health Plan (IUHP) and organized its affiliated providers under a new name, MDwise. In August 2007, MDwise was selected to begin negotiations to serve as an insurance provider for the Healthy Indiana Plan (HIP). Under the HIP program, the State of Indiana contracts with statewide, risk-bearing entities toFile Size: 1MBPage Count: 127myMDwise Provider Portal · Forms · Claims · Contact Information ·
Who is MDwise? A local, not-for-profit company serving Hoosier Healthwise (HHW) and Healthy Indiana Plan (HIP) members Exclusively serving Indiana families since 1994 oOver 355,000 members o3,000 primary care providers NCQA Accredited Health Plan 95% of MDwise member
MDwise Formulary Introduction – Hoosier Healthwise (HHW) HHW members must use MDwise network pharmacies to access their prescription drug benefit. How do I use the formulary? There are two ways to find your drug within the formulary: Medical Condition Drugs in this formulary are grouped into categories depending on the type of medical
