Website injectable preauth list includes 2014 new codes.xls

Injectable Pre-Authorization List (Commercial and Non-Government Products only) Highlighted lines indicate Pharmacy benefit Pharmacy vs
BRAND NAME
DRUG NAME
Medical Benefit
RESPIRATORY SYNCYTIAL VIRUS, RECOMBINANT FOR IM USE INDIUM IN-111 IBRITUMOMAB TIUXETAN AND YTTRIUM Y-90 IBRITUMOMAB TIUXETAN FACTOR IX (ANTIHEMOPHILIC FACTOR, RECOMBINANT), RIXIBUS, PER I.U Prolastin-C, Zemaira, Aralast INJECTION, ALPHA 1-PROTEINASE INHIBITOR-HUMAN, 10MG INJECTION, ALPHA 1-PROTEINASE INHIBITOR-HUMAN (GLASSIA) , 10MG INJECTION, APOMORPHINE HYDROCHLORIDE, 1 MG INJECTION, RIMABOTULINUMTOXIN B, 100 UNITS INJECTION, C-1 ESTERASE INHIBITOR (HUMAN), 10 UNITS INJECTION, C-1 ESTERASE INHIBITOR (HUMAN), 10 UNITS CERTOLIZUMAB PEGOL INJ 1MG-not for use when patient is self injecting (only for in office inj) INJECTION, CHORIONIC GONADOTROPIN, PER 1,000 USP UNITS INJECTION, COLLAGENASE, CLOSTRIDIUM HISTOLYTICUM, 0.01 MG INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE) INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (FOR ESRD ON DIALYSIS) Injectable Pre-Authorization List (Commercial and Non-Government Products only) Highlighted lines indicate Pharmacy benefit INJECTION, EPOETIN ALFA, (FOR NON-ESRD USE), 1000 UNITS INJECTION, EPOETIN ALFA, 1000 UNITS (FOR ESRD ON DIALYSIS) INJECTION, FILGRASTIM (G-CSF), 1 MICROGRAM INJ, IMMUNE GLOBULIN, INTRAVENOUS, NON-LYOPHILIZED INJECTION, IMMUNE GLOBULIN (BIVIGAM), 500 MG INJECTION, IMMUNE GLOBULIN, GAMMAPLEX, INTRAVENOUS, 500 MG INJECTION, IMMUNE GLOBULIN, INTRAVENOUS, NON-LYOPHILIZED INJECTION IMMUNE GLOBULIN, INTRAVENOUS, LYOPHILIZED NOS INJECTION, IMMUNE GLOBULIN, INTRAVENOUS, NON-LYOPHILIZED INJECTION, IMMUNE GLOBULIN, INTRAVENOUS, NON-LYOPHILIZED, INJECTION, IMMUNE GLOBULIN, INTRAVENOUS, NON-LYOPHILIZED 500 MG INJECTION, IMMUNE GLOBULIN, INTRAVENOUS, NON-LYOPHILIZED (E.G. LIQUID) INJECTION, DALTEPARIN SODIUM, PER 2,500 IU INJECTION, HISTRELIN ACETATE, 10 MICROGRAMS INJECTION, HYDROXYPROGESTERONE CAPROATE, 1 MG Injectable Pre-Authorization List (Commercial and Non-Government Products only) Highlighted lines indicate Pharmacy benefit INJECTION, LEUPROLIDE ACETATE(FOR DEPOT SUSPENSION) PER 3.75 MG INJECTION, OCTREOTIDE, DEPOT FORM FOR INTRAMUSCULAR INJECTION, 1 MG INJECTION,OCTREOTIDE,NON-DEPOT FORM SUBCUTANEOUS/INTRAVENOUS INJ, 25 MCG INJECTION,THYROTROPIN ALPHA,0.9 MG,PROVIDED IN 1.1 MG VIAL Laetrile-Amygdalin-Vit. B17 LAETRILE - AMYGDALIN - VITAMIN B17 INJECTION, HUMAN FIBRINOGEN CONCENTRATE, 1 MG FACTOR XIII (ANTIHEMOPHILIC FACTOR, HUMAN), 1 IU INJECTION, VON WILLEBRAND FACTOR COMPLEX (HUMAN) WILATE 1 I.U.
INJECTION, VON WILLEBRAND FACTOR COMPLEX (HUMAN), WILATE, PER 100 IU INJECTION, FACTOR VIII (ANTIHEMOPHILIC FCTR, RECOMBINANT) (XYNTHA) INJ, ANTIHEMOPHILIC FACTR VIII/VON WILLEBRAND FACTR COMPLEX (HUMAN) INJECTION, VON WILLEBRAND FACTOR COMPLEX PER IU VWF-RCO FACTOR VIIA (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PER 1 MICROGRAM Injectable Pre-Authorization List (Commercial and Non-Government Products only) Highlighted lines indicate Pharmacy benefit FACTOR VIII (ANTIHEMOPHILIC FACTOR, HUMAN) PER IU FACTOR VIII (ANTIHEMOPHILIC FACTOR PORCINE) PER IU FACTOR VIII (ANTI-HEMOPHILIC FACTOR-RECOMBINANT) PER IU NOS FACTOR IX(ANTIHEMOPHILIC FACTOR,PURIFIED,NON-RECOMBINANT) PER IU FACTOR IX ANTIHEMOPHILIC FACTOR RECOMBINANT PER IU INJECTION, ANTITHROMBIN III (HUMAN), PER I.U.
HYALURONAN OR DERIVATIVE, FOR INTRA-ARTICULAR INJ HYALURONAN OR DERIV, EUFLEXXA, INTRA-ARTICULAR INJECTION HYALURONAN OR DERIV, INTRA-ARTICULAR INJECTION HYALURONAN OR DERIVATIVE, GEL-ONE, INTRA-ARTICULAR INJECTION INJECTION, ASPARAGINASE (ERWINAZE), 1,000 IU INJECTION, INTERFERON ALFA-2A RECOMBINANT 3 MILLION INJECTION, INTERFERON ALFA-2B RECOMBINANT 1 MILLION UNITS INJECTION INTERFERON, ALFA-N3 HUMAN LEUKOCYTE DERIVED 250,000 IU INJECTION INTERFERON, GAMMA-1B, 3 MILLION UNITS INJECTION, OMACETAXINE MEPESUCCINATE, 0.01 MG Injectable Pre-Authorization List (Commercial and Non-Government Products only) Highlighted lines indicate Pharmacy benefit INJECTION, ADO-TRASTUZUMAG EMTANSINE, 1 MG INJECTION, VINCRISTINE SULFATE LIPOSOME, 1 MG INJECTION, SERMORELIN ACETATE, 1 MICROGRAM SIPULEUCEL-T, MINIMUM OF 50 MILLION AUTOLOGOUS CD54 PLUS CELLS INJECTION,INTERFERON BETA 1-A,11MCG FOR SUBCUTANEOUS USE INJECTION, INTERFERON BETA-1A, 1 MCG FOR INTRAMUSCULAR USE INJECTION, PEGYLATED INTERFERON ALFA 2A 180 MCG PER ML INJECTION, PEG INTERFERON ALFA 28B 10 MCG PER 0.5 ML INJECTION, PEGYLATED INTERFERON ALFA-2B, 10 MCG **This list is subject to change and may not be all-inclusive. All drugs listed may not be available under the member's specific plan. Some self-administered injectable drugs (not listed here) may be available under the pharmacy benefit and may require prior authorization. Please refer members to their benefit documents or the customer service phone number on their ID card for details.

Source: http://chcnebraska.coventryhealthcare.com/web/groups/public/@cvty_regional_chcne/documents/document/c060717.pdf