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Here you will find pharmacy-related information including the Medicare formulary as well as links to request or appeal drug coverage.

AcariaHealth Specialty Pharmacy
Available at no additional cost to patients undergoing treatment for long-term, life-threatening or rare conditions.

CVS Caremark Mail Service Pharmacy 
Tell your patients about this convenient way to have maintenance medications delivered to their doorstep.

Coverage Determination 
Request coverage or exception for a prescription drug.

Medication Appeals 
Appeal a coverage determination decision.

Formulary
Use the Find My Plan tool to find the most up-to-date complete formulary.


약국

Drug Prior Authorization Requests Supplied by the Physician/Facility

This policy provides a list of drugs that require step therapy. Step therapy is when we require the trial of a preferred therapeutic alternative prior to coverage of a non-preferred drug for a specific indication.

Fill out and submit this form to request prior authorization (PA) for your Medicare prescriptions.

Fill out and submit this form to request an appeal for Medicare medications.

Pharmacy Clinical Policies

Hydroxyprogesterone caproate (Makena®/compound) is a progestin.

Eculizumab (Soliris®) is a complement inhibitor.

Mogamulizumab-kpkc (Poteligeo®) is a CC chemokine receptor type 4 (CCR4)-directed monoclonal antibody.

The following are factor VIII products requiring prior authorization: human – Hemofil M®, Koate-DVI®; recombinant – Advate®, Adynovate®, Afstyla®, Eloctate®, Esperoct®, Helixate FS®, Jivi®, Kogenate FS®, Kogenate FS with Vial Adapter®, Kogenate FS with Bio-Set®, Kovaltry®, NovoEight®, Nuwiq®, Obizur®, Recombinate®, ReFacto®, Xyntha®, and Xyntha® Solofuse™.

Factor VIIa, recombinant (NovoSeven® RT) and coagulation factor VIIa (recombinant)-jncw (SevenFact®) are coagulation factors.

AbobotulinumtoxinA (Dysport®) is an acetylcholine release inhibitor and a neuromuscular blocking agent.

IncobotulinumtoxinA (Xeomin®) is an acetylcholine release inhibitor and a neuromuscular blocking agent.

OnabotulinumtoxinA (Botox®) is an acetylcholine release inhibitor and a neuromuscular blocking agent.

RimabotulinumtoxinB (Myobloc®) is an acetylcholine release inhibitor and a neuromuscular blocking agent.

Eteplirsen (Exondys 51™) is an antisense oligonucleotide.

Ocrelizumab (Ocrevus™) is a CD20-directed cytolytic antibody.

Cerliponase alfa (Brineura®) is a hydrolytic lysosomal N-terminal tripeptidyl peptidase.

Edaravone (Radicava™) is a member of the substituted 2-pyrazolin-5-one class that acts as a free-radical scavenger of peroxyl radicals and peroxynitrite.

Testosterone pellet (Testopel®) is an implantable androgen. Testosterone undecanoate (Jatenzo®) is an oral androgen.

Tisagenlecleucel (Kymriah™) is a CD19-directed, genetically modified, autologous T-cell immunotherapy.

Axicabtagene ciloleucel (Yescarta™) is a CD19-directed, genetically modified, autologous T-cell immunotherapy.

Voretigene neparvovec-rzyl (Luxturna™) is an adeno-associated virus vector-based gene therapy.

Ibalizumab-uiyk (Trogarzo™) is a CD4-directed post-attachment human immunodeficiency virus type 1 (HIV-1) inhibitor.

Patisiran (Onpattro™) is a double-stranded small interfering ribonucleic acid, formulated as a lipid complex for delivery to hepatocytes.

Ravulizuamb-cwvz (Ultomiris®) is a complement inhibitor.

Caplacizumab-yhdp (Cablivi®) is a von Willebrand factor (vWF)-directed antibody fragment.

Elapegademase-lvlr (Revcovi®) is a recombinant adenosine deaminase.

Onasemnogene abeparvovec (Zolgensma®) is an adeno-associated virus (AAV) vector-based gene therapy.

Trientine (Syprine®) is a chelating agent.

Crizanlizumab-tmca (Adakveo®) is a selectin blocker.

Golodirsen (Vyondys 53TM) is an antisense oligonucleotide.

Inebilizumab-cdon (Uplizna ™ ) is an anti-CD19 monoclonal antibody.

Belantamab mafodotin (Blenrep®/™ ) is an anti-B-cell maturation antigen (BCMA) monoclonal antibody and microtubule inhibitor conjugate.

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Last Updated On: 5/7/2021
Medicare 가입자: Medicare 사기로부터 자신을 보호하고 도난을 식별하십시오! 미국 보건복지부(Department of Health and Human Services) 감사관실(Office of Inspector General)은 유전자 검사와 관련된 사기 수법에 대해 대중에게 경고하고 있습니다. 자신을 보호하는 방법을 알아보십시오.
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