REQUEST FOR PRIOR AUTHORIZATION FAX (559) 224-2405 or …

Abraxane Enbrel Kineret Remodulin Actemra Entyvio Krystexxa Rituxan Acthar Epogen Kyprolis (Blue Shield) Rocephin – for Lyme Disease Only Actimmune Erbitux Lanreotide Roferon-A

  Remodulin

Clinical Site of Care Drug List - aimproviders.com

q5103 inflammatory conditions inflectra intravenous 90283 immune serums ivig generic intravenous j7195 factor ixinity intravenous j1290

RBC Review list

RBC Prescription Drug Plan - Drug Review List Date: January 2019 Name

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AmeriHealth New Jersey services that require precertification

AmeriHealth New Jersey services that require precertification Inpatient services: • Acute rehabilitation admissions • Elective surgical and nonsurgical inpatient admissions

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2017 Service Benefit Plan Specialty Drug List - Caremark

1 Prior Approval Required *covered only under pharmacy benefit Products distributed by CVS Caremark Specialty Pharmacy, as well as products covered by a plan member’s prescription benefit plan, may change from time to time. in addition, a plan

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Oregon and Washington Authorization Requirements

Health Net Health Plan of Oregon, Inc. EPO, POS, PPO, CommunityCare Effective January 1, 2019 Page 3 of 7 OUTPATIENT PROCEDURES, SERVICES OR EQUIPMENT

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