Abilify

ADD-ADHD

Alferon-N*

Amevive

Amphetamines

Androgel

Anticoagulants

Anti-emetics

Anti-Hemophilic Factor

Aranesp *

Arava *

Avita
PA required if patient over
40 years of age

Avonex, Rebif*

Betaseron *

Botox *

Byetta

Caverject/Edex/Muse *

Celebrex

Copaxone *

Copegus *

COX-II

Cytovene

Cytoxan

Dexedrine Spansule
PA required if patient over
18 years of age

DDAVP

Elidel
PA required if patient over
18 years of age

Emend

Enbrel *

Enbrel Medicaid

Engerix - B Recombivax

Flolan

Flonase

Flumist

Forteo *

Flu Therapies

Fluoride w/VITAMINS and
MINERALS
PA required if patient over
14 years of age

Growth Hormone

Hepsera*

Hepatitis B Vaccine

Humira*

Hyalgan*

Immunosuppressive Agents

Imitrex

Immune Globulin Intravenous*

Infergen*

Infertility Medications*

Influenza Vaccines

 

LeuLotronexprolide acetate*

Intron-A*

Kineret*

Lamisil

Lupron

Leukine*

Leuprolide acetate*

Lotronex

Marinol

Maxalt

Methotrxate

Neulasta*

Neumega

Neupogen*

Oral Contraceptives

PPIs

Pegasys*

Peg-Intron*

Penlac

Pnemovax

Prevnar

Procrit, Epogen *

Protopic
PA required if patient over
18 years of age

Provigil

Pulmozyme*

Raptiva*

Rebetron*

Remicade*

Remodulin

Restasis

Retin A - Retain A Micro
PA required if patient over
40 years of age

Revatio

Risperdal Consta

Smoking Cessation Products
(all dosage forms)

Roferon-A*

Serostim

Singulair

Sporanox

Stimate

Strattera

Supartz*

Synagis*

Synvisc*

Tobi*

Tracleer*

Tretinon

Vfend*

Xeloda

Xenical

Xolair*

Xyrem*

Zelnorm

Zofran (non-Medicare only)

Zyvox

*Specialty Pharmacy Medication

PRIOR AUTHORIZATION PROGRAM - Oral Contraceptives

Oral Contraceptives - ProCare Rx also administers a medically necessary
PA program for those Plans that do not cover contraceptives. For
contraceptives prior authorizations for a medical reason other than birth
control for these plans, the member or physician must fax an authorization
form to ProCare Rx for authorization.

PRIOR AUTHORIZATION (PA) REQUEST SUMMARY

To initiate a prior authorization request, the physicians must call
1-800-662-0586. Physician may also fax prior authorization requests
to 1-800-662-0590. If a physician requests a prior authorization by
phone, ProCare Rx will obtain the required information which includes,
but is not limited to:

Member name
Member Identification Number
Date of Birth
Prescribing physician name
Drug Requested
Diagnosis and Medical Justification

During the phone call, ProCare Rx will inform the physician if the request
meets the established criteria and/or if the request is approved. If approved,
ProCare Rx will immediately enter the prior authorization into our pharmacy
claims system and notify patient and pharmacy. Prior Authorization approvals
are generally valid for one year from the date of issuance. Since scientific
literature may change - prior authorization criteria are subject to change
without notice.

Upon request, ProCare Rx will fax a PA criteria form to the physician's office for completion and return to ProCare Rx via fax.

TURNAROUND TIME
For all PA requests is 24-48 hours from the time the completed PA requests
are received by ProCare Rx.

INCOMPLETE REQUESTS
If the criteria form is incomplete, ProCare Rx will contact physician (via phone
or fax) to obtain missing information. Requests will be denied if the completed
form is not returned within 48 hours. On mail prescriptions, the request will be
denied if the required information is not provided within 72 hours.

MEMBER AND PHARMACIST INQUIRIES
Members and pharmacists may call ProCare Rx Pharmacy Help Desk at
1-800-699-3542 to inquire about drugs that require prior authorization.
Members may also contact ProCare Rx at 1-800-662-0586 to determine the
status of prior authorization request submitted on their behalf by their physicians.

BOTTOM LINE

INCREASE in CARE and DECREASE in COST - Our prior authorization
program helps ensure medical necessity is confirmed before benefits are
provided for high cost medications.