Prior Authorization Program Information and Authorization Forms
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Lists numerous drug products with routing (CoverMyMeds vs Availity) and preferred-agent notes (biosimilars, insulin products that do not require PA).
No material clinical or coverage changes noted; this section is an administrative listing of drugs with routing and preference notes.
Policy fragment summary
This administrative fragment lists numerous drugs and maps each to the electronic prior-authorization submission platform to be used (primarily CoverMyMeds or Availity), and highlights preferred biosimilars and insulin products that do not require prior authorization. It conveys examples of preferred substitutions (e.g., Procrit/Retacrit preferred over Aranesp/Epogen; Nivestym/Zarxio preferred over Neupogen/Granix; Norditropin, Genotropin, Omnitrope preferred within growth-hormone class), and names insulin agents that are preferred and do not require prior authorization (examples include Fiasp, Humalog, Humalog Mix, Humulin 70/30, Humulin N, Humulin R, Lyumjev, Novolin 70/30, Novolin N, Novolin R, Novolog, Novolog 70/30). The operational purpose is administrative routing (directing providers which portal to use for PA requests) and to provide formulary preferred-agent guidance. Current policy status is CURRENT and providers are instructed to use the designated channel per drug (CoverMyMeds or Availity) per the listing.
Drug lists, preferred agents, and portal routing
| KALYDECO | |
| KANJINTI | |
| KEVZARA | |
| KEYTRUDA QLEX | |
| KHAPZORY | |
| KHINDIVI | |
| KINERET | |
| KISQALI | |
| KLISYRI | |
| KOATE |
What providers must do
Use specified submission channel
Submit prior authorization requests via the channel indicated for each drug (CoverMyMeds or Availity) or follow routing notes such as 'For Non-Fertility related diagnoses - SEND to Availity'.
- Follow per-drug portal indicated (CoverMyMeds or Availity)
Send prior authorization via Availity for non-fertility diagnoses
For many listed drugs (notably non-fertility related diagnoses and several named products) the instruction is to send prior authorization requests to Availity; providers should route PA accordingly.
- Examples: MENOPUR (For Non-Fertility related diagnoses - SEND to Availity), PREGNYL W/DILUENT BENZYL ALCOHOL/NACL (For Non-Fertility related diagnoses - SEND to Availity), NOURIANZ (For Non-Fertility related diagnoses - SEND to Availity)
Use CoverMyMeds when indicated
Many drugs reference CoverMyMeds as the platform for prior authorization submissions; providers should use CoverMyMeds where specified.
- Many listed drugs reference CoverMyMeds for ePA
- Examples: GAVRETO, GAZYVA, GEFITINIB (from code_groups[2]); OMNITROPE, HYRNUO (from code_groups[5])
Follow preferred-agent guidance where indicated
When entries indicate preferred alternatives (e.g., Procrit/Retacrit preferred over Aranesp/Epogen; Nivestym/Zarxio preferred over Neupogen/Granix; Norditropin/Genotropin/Omnitrope preferred in class), providers should consider preferred agents per formulary guidance.
- Procrit and Retacrit preferred over Aranesp and Epogen (example notes present)
- Nivestym and Zarxio preferred over Neupogen and Granix (noted repeatedly)
- Norditropin, Genotropin and Omnitrope preferred in the growth-hormone class
Use designated portals for PA submissions
Submit prior authorization requests via the indicated portal per drug (CoverMyMeds or Availity) as listed; some products have explicit preferred alternatives noted.
- Submission must follow the portal listed for each drug (CoverMyMeds or Availity)
- Some entries specify starter packs or special kits (e.g., PALFORZIA starter kits, PLEGRIDY starter pack, HEPZATO Kit)
Follow preference guidance where indicated
When preference notes are present (e.g., Humira Abbvie NDCs beginning with 00074, Hadlima; Nivestym and Zarxio preferred over Neupogen and Granix; Procrit and Retacrit preferred over Aranesp and Epogen; Norditropin/Genotropin/Omnitrope preferred for ZOMACTON class), document chosen product rationale.
- Document rationale when selecting a non-preferred product
- Example: Humira (Abbvie NDCs beginning with 00074) and Hadlima are noted as preferred in multiple entries
Definitions
This fragment is strictly an administrative routing and reference list that indicates the submission channel for prior authorization requests and notes preferred agents; it does not provide clinical coverage criteria or decision trees. There are no criteria_trees included in this segment; clinical necessity and coverage determinations are handled by the program’s medical-necessity criteria referenced elsewhere.
Document changes
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