Provider Alerts

Effective February 20, 2023, the Pharmacy and Therapeutics Committee has approved the following changes to the medical benefit.

1. Code J1745 – INJECTION, INFLIXIMAB, EXCLUDES BIOSIMILAR (REMICADE), 10 MG
   1. 1. For PSORIASIS and PSORIATIC ARTHRITIS:
         1. PA required. Reserved for treatment failure to 12 weeks of dose-optimized, oral DMARD therapy (Methotrexate 15-25mg/week, Cyclosporine, and Acitretin). If patient is unable to tolerate one oral DMARD, a second oral DMARD must be tried.
         2. Must be prescribed by a dermatologist
      2. For ANKYLOSING SPONDYLITIS:
         1. PA required. Reserved for documented symptomatic AS despite treatment with NSAIDs (unless NSAID-intolerant). An adequate trial is defined as at least 2 different NSAIDs tried over 1 month or 2 different NSAIDs over 2 months.
         2. Must be initiated by a rheumatologist.
      3. For RHEUMATOID ARTHRITIS:
         1. PA required. Reserved for treatment failure to 12 weeks of dose-optimized, oral DMARD therapy (Methotrexate 15-25mg/week, Leflunomide, Hydroxychloroquine, Sulfasalazine, Azathioprine). If patient is unable to tolerate one oral DMARD, a second oral DMARD must be tried.
         2. Must be initiated by a rheumatologist.
      4. For CROHN’S DISEASE or ULCERATIVE COLITIS:
         1. PA required. Reserved for treatment failure to adequate trial of oral immunosuppressive agents (Azathioprine, Mercaptopurine, Mesalamine, and Sulfasalazine) OR intolerance to corticosteroids.
         2. Must be prescribed by a gastroenterologist.
2. Code J0717 – INJECTION, CERTOLIZUMAB PEGOL (CIMZIA), 1 MG
   1. 1. For ANKYLOSING SPONDYLITIS:
         1. PA required. Reserved for treatment failure to Adalimumab, Etanercept, or Infliximab OR
            women that are currently pregnant or breastfeeding.
         2. Must be initiated by a rheumatologist.
      2. For CROHN’S DISEASE:
         1. PA required.
         2. Must meet one of the following:
            • Reserved for treatment failure to adequate trial of oral immunosuppressive agents (Azathioprine, Mercaptopurine, Mesalamine, and Sulfasalazine) OR intolerance to corticosteroids.
            • Women that are currently pregnant or breastfeeding.
         3. Must be prescribed by a gastroenterologist.
3. Code J1602 – INJECTION, GOLIMUMAB (SIMPONI), 1 MG for ULCERATIVE COLITIS:
   1. PA required. Reserved for treatment failure to adequate trial of oral immunosuppressive agents (Azathioprine, Mercaptopurine, Mesalamine, and Sulfasalazine) OR intolerance to corticosteroids.
   2. Must be prescribed by a gastroenterologist.
4. Code J0585 – INJECTION, ONABOTULINUMTOXINA (BOTOX), 1 UNIT
   1. PA required.
   2. For patients ages 18 years or older.
   3. Must be prescribed by a Neurologist.
   4. ALL of the following criteria must be met:
      1. ≥ 15 or more days per month for ≥ 3 month
      2. ≥ 4 hours a day or longer duration, as indicated by 5 or more attacks with ALL of the following:
         1. Headache symptoms, as indicated by 2 or more of the following: *Aggravation by or causing avoidance of routine physical activity, or *Moderate or severe pain intensity, or *Pulsating quality, or *Unilateral location
         2. Migraine-associated symptoms, as indicated by 1 or more of the following: *Nausea or vomiting, or *Photophobia and phonophobia
         3. Other potential causes of headaches have been excluded
      3. Use 2 (two) different preventive medications at therapeutic dose (eg, betablocker, Calcium channel blocker, tricyclic antidepressant, anticonvulsant) unless therapy has been ineffective or not tolerated for trial of at least 8 (eight) weeks each.
      4. No neuromuscular disease (eg, myasthenia gravis).
5. Code J3030 – INJECTION, SUMATRIPTAN SUCCINATE, 6 MG
   1. No restrictions.
6. Code J3032 – INJECTION, EPTINEZUMAB-JJMR (VYEPTI), 1 MG
   1. PA required. Reserved for patients who have failed 6 months of therapy with Botox and are 18 years of age or older.
   2. Must be prescribed by a Neurologist.
7. Code J0630 – INJECTION, CALCITONIN SALMON (MIACALCIN), UP TO 400 UNITS
   1. Limited to hypercalcemia use only (when billed via the medical benefit).
   2. For osteoporosis or Paget’s Disease, Calcitonin must be billed via the pharmacy benefit.

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