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Pavilizumab PA Form 470-4110 24.68 KB |
Palivizumab (Synagis®) approval periods will begin November 1, 2018 and will be considered through March 31, 2019. A maximum of five doses will be allowed per member during this time period. No allowances will be made for a sixth dose. Requests may be submitted beginning October 15, 2018 for a therapy start date of November 1, 2018. |
2018/09/05 |
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Linezolid (Zyvox) PA Form 470-4275 31.85 KB |
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2018/08/20 |
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Biologicals for Plaque Psoriasis PA Form 470-4524 28.08 KB |
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2018/08/20 |
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Extended Release Formulation PA Form 470-4550 22.9 KB |
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2018/08/20 |
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Oral Constipation Agents PA Form 470-5174 33.68 KB |
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2018/08/20 |
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Chronic Pain Syndromes PA Form 470-4551 31.78 KB |
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2018/08/20 |
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CNS Stimulants and Atomoxetine PA Form 470-4116 71.06 KB |
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2018/08/20 |
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Janus Kinase Inhibitors PA Form 470-5175 29.27 KB |
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2018/08/20 |
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Apremilast (Otezla) PA Form 470-5293 61.86 KB |
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2018/08/20 |
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Hepatitis C Treatments PA Form 470-5270 169.03 KB |
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2018/08/20 |
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Anti-Fungal PA Form 470-4094 24.11 KB |
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2018/08/20 |
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Granulocyte Colony Stimulating Factor PA Form 470-4099 23.8 KB |
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2018/08/20 |
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Letermovir (Prevymis) PA Form 470-5548 235.31 KB |
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2018/08/20 |
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Methotrexate Injection PA Form 470-5294 28.92 KB |
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2018/08/20 |
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Biologicals for Arthritis PA Form 470-4522 30.01 KB |
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2018/08/20 |
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Tezacaftor/Ivacaftor (Symdeko) PA Form 470-5549 199.65 KB |
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2018/08/20 |
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Vesicular Monoamine Transporter (VMAT) 2 Inhibitors PA Form 470-5534 234.08 KB |
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2018/08/20 |
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High Dose Opioids PA Form 470-5531 57.41 KB |
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2018/05/24 |
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Insulin, Pre-Filled Pens PA Form 470-4111 27.3 KB |
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2018/04/23 |
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Buprenophine/Naloxone PA Form 470-5142 33.63 KB |
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2018/04/23 |
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Alpha 2 Agonist, Extended Release PA Form 470-5018 26.39 KB |
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2018/04/23 |
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Pulmonary Arterial Hypertension PA Form 470-4327 30.02 KB |
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2018/04/23 |
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Anti-Diabetic, Non-Insulin Agents PA Form 470-5259 26.52 KB |
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2018/04/23 |
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Serotonin 5-HT1-receptor Agonists PA Form 470-4113 25.3 KB |
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2018/04/23 |
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Topical Acne and Rosacea Products PA Form 470-5426 41.18 KB |
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2018/04/23 |
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Modified Formulations PA Form 470-4705 24.58 KB |
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2018/04/23 |
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Kalydeco (ivacaftor) PA Form 470-5117 30.28 KB |
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2018/02/23 |
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Valsartan/Sacubitril (Entresto) PA Form 470-5398 65.93 KB |
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2018/02/23 |
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Immunomodulators - Topical PA Form 470-5040 52.79 KB |
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2018/02/23 |
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Lidocaine Patch (Lidoderm) PA Form 470-4898 25.11 KB |
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2018/02/23 |
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Biologicals for Ankylosing Spondylitis PA Form 470-4521 29.65 KB |
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2018/02/23 |
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Biologicals for Inflammatory Bowel Disease PA Form 470-4523 29.32 KB |
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2018/02/23 |
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Age Edit Override- Codeine or Tramadol PA Form 470-5507 231.46 KB |
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2018/02/22 |
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Antidepressant PA Form 470-5098 26.88 KB |
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2017/11/20 |
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Testosterone Products PA Form 470-5188 35.12 KB |
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2017/11/20 |
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Dupilumab (Dupixent) PA Form 470-5497 238.07 KB |
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2017/11/20 |
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Eluxadoline (Viberzi) PA Form 470-5410 30.99 KB |
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2017/08/24 |
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Selected Brand Name Drug PA Form 470-5039 & 470-4119 43.17 KB |
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2017/08/24 |
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Deflazacort (Emflaza) PA Form 470-5489 25.98 KB |
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2017/08/23 |
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Crisaborole (Eucrisa) PA Form 470-5488 26.29 KB |
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2017/08/23 |
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GLP-1 Agonist/Basal Insulin Combinations PA Form 470-5490 24.77 KB |
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2017/08/23 |
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Sapropterin (Kuvan) PA Form 470-5493 64.98 KB |
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2017/08/23 |
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New to Market Drugs PA Form 470-5492 23.02 KB |
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2017/08/23 |
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Calcifediol (Rayaldee) PA Form 470-5487 24.57 KB |
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2017/08/23 |
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Lesinurad (Zurampic) PA Form 470-5491 68.3 KB |
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2017/08/23 |
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Eteplirsen (Exondys 51) PA Form 470-5476 236.33 KB |
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2017/04/25 |
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Antiemetic-5HT3 receptor Antogonists/Substance P Neurokinin Agents PA Form 470-4410 27.72 KB |
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2017/04/25 |
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Novel Oral Anticoagulants PA Form 470-5423 101.27 KB |
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2017/04/25 |
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Lumacaftor/Ivacaftor (Orkambi) PA Form 470-5366 182.06 KB |
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2017/04/25 |
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Fentanyl, Short Acting Products PA Form 470-4092 188.79 KB |
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2017/04/18 |
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Hepatitis C Post Treatment Information Sustained Virologic Response (SVR) Reporting PA Form 470-5463 237.5 KB |
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2017/02/24 |
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Narcan (Naloxone) Nasal Spray PA Form 470-5461 174.93 KB |
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2017/02/20 |
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Multiple Sclerosis Agents - Oral PA Form 470-5060 266.76 KB |
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2017/02/20 |
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Concurrent IM/PO Antipsychotic PA Form 470-4594 174.21 KB |
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2017/02/07 |
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Duplicate Therapy Edit Override PA Form 470-5460 174.36 KB |
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2017/02/07 |
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Short Acting Opioids PA Form 470-4899 243.69 KB |
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2016/11/21 |
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Lupron Depot - Adult PA Form 470-5435 248.74 KB |
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2016/11/21 |
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Lupron Depot - Pediatric PA Form 470-5434 244.15 KB |
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2016/11/21 |
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Deferasirox (Exjade) PA Form 470-5330 64.2 KB |
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2016/08/19 |
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Mepolizumab (Nucala) PA Form 470-5424 67.76 KB |
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2016/08/19 |
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Potassium Binders PA Form 470-5425 25.16 KB |
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2016/08/19 |
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Nicotine Replacement Therapy 470-4421 193.75 KB |
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2016/08/02 |
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Smoking Cessation Therapy - Oral PA Form 470-4517 248.28 KB |
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2016/08/02 |
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Biologicals for Hidradenitis Suppurativa PA Form 470-5408 179.68 KB |
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2016/06/22 |
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Ivabradine (Corlanor) PA Form 470-5409 238.47 KB |
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2016/06/22 |
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Rifaximin (Xifaxan) PA Form 470-5411 235.8 KB |
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2016/06/22 |
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Long-Acting Opioids PA form 470-4409 240.23 KB |
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2016/06/22 |
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Non-Parenteral Vasopressin Derivatives PA 470-4107 257.36 KB |
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2016/04/26 |
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Non-Steroidal Anti-Inflammatory Drugs PA Form 470-4109 196.36 KB |
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2016/04/26 |
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Sodium Oxybate (Xyrem) PA Form 470-5016 249.1 KB |
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2016/04/26 |
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PCSK9 Inhibitors PA Form 470-5399 294.12 KB |
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2016/04/25 |
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Cholic Acid (Cholbam) PA Form 470-5391 280.27 KB |
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2016/03/08 |
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Binge Eating Disorder Agents PA Form 470-5336 238.27 KB |
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2016/03/08 |
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Isotretinoin (Oral) PA Form 470-4101 31.76 KB |
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2015/11/24 |
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Select Oncology Agents PA Form 470-5367 182.43 KB |
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2015/11/23 |
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Topical Antifungals for Onychomycosis PA Form 470-5368 177.29 KB |
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2015/11/23 |
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Alpha1-Proteinase Inhibitor Enzymes PA Form 470-5365 237 KB |
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2015/11/23 |
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Idiopathic Pulmonary Fibrosis PA Form 470-5346 70.34 KB |
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2015/08/27 |
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Topical Corticosteroids PA Form 470-5347 22.21 KB |
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2015/08/27 |
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Dextromethorphan and Quinidine (Nuedexta™) PA Form 470-5084 30.17 KB |
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2015/06/04 |
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Sedative/Hypnotic-Non_benzodiazepine PA Form 470-4328 28.77 KB |
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2015/06/04 |
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Benzodiazepines PA Form 470-4117 32.44 KB |
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2015/04/21 |
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Oral Immunotherapy PA Form 470-5295 28.8 KB |
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2015/04/21 |
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Thrombopoietin Receptor Agonists PA Form 470-4850 73.62 KB |
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2015/04/21 |
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Vorapaxar (Zontivity) PA Form 470-5331 23.4 KB |
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2015/04/17 |
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Growth Hormone PA Form 470-4100 205.4 KB |
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2015/03/08 |
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Tasimelteon (Hetlioz) PA Form 470-5296 22.64 KB |
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2014/11/24 |
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Proton Pump Inhibitors PA Form 470-4112 27.56 KB |
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2014/04/23 |
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Antihistamines PA Form 470-4095 21.13 KB |
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2014/04/23 |
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Repository Corticotropin Injection PA Form 470-5172 19.2 KB |
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2013/08/26 |
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Erythropoesis Stimulating Agents PA Form 470-4098 72.46 KB |
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2013/03/18 |
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Korlym (mifepristone) PA Form 470-5141 19.78 KB |
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2013/01/16 |
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Ketorolac PA Form 470-4102 22.66 KB |
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2012/06/26 |
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Nebivolol (Bystolic) PA Form 470-5099 17.28 KB |
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2012/03/13 |
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Roflumilast (Daliresp™) PA Form 470-5085 56.57 KB |
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2011/12/28 |
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Muscle Relaxants PA Form 470-4105 19.17 KB |
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2011/09/12 |
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Fifteen Day Initial Prescription Supply Override PA Form 470-5038 14.22 KB |
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2011/07/11 |
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Vitamins Minerals and Multiple Vitamins PA Form 470-4115 13.95 KB |
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2011/06/16 |
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Non-Preferred Drug PA Form 470-4108 13.86 KB |
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2011/06/16 |
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Dalfampridine (Ampyra) PA Form 470-5015 17.63 KB |
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2011/02/11 |
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Quantity Limit Override Form 470-4556 96.04 KB |
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2010/10/06 |
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Amylino Mimetic PA Form 470-4406 33.02 KB |
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2009/12/09 |
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Febuxostat (Uloric) PA Form 470-4849 34.86 KB |
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2009/10/02 |
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Narcotic Agonist Antagonist Nasal Spray PA Form 470-4106 33.79 KB |
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2009/07/27 |
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Vusion Ointment PA form 470-4655 27.19 KB |
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2008/12/11 |
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Becaplermin (Regranex) PA Form 470-4276 47.11 KB |
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2008/09/05 |
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Miscellaneous PA Form 470-4104 29.29 KB |
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2007/12/26 |