Change in Medication Prior Authorization Requirement
Date: 07/01/20
Effective August 1, 2020, Buckeye Health Plan (Buckeye) is making changes to services requiring prior authorization for Medicaid members.
Please note the following important changes:
- Bevacizumab, Avastin, J9035
- Bevacizumab-awwb, Mvasi, Q5107 (preferred)
- Bevacizumab-bvzr, Zirabev, Q5118 (preferred)
- Rituximab, Rituxan, J9312
- Rituximab-pvvr, Ruxience, Q5119 (preferred)
- Infliximab-dyyb, Inflectra, Q5103 (preferred)
- Infliximab-abad, Renflexis, Q5104 (preferred)
- Trastuzumab, Herceptin, J9355
- Trastuzumab-dkst, Ogivri, Q5114 (preferred)
- Trastuzumab-qyyp, Trazimera, Q5116 (preferred)
- Darbepoetin, Aranesp, J0881
- Epoetin Alfa-epbx, Retacrit Q5106 (preferred)
- Methoxy polyethylene glycol-epoetin beta, Micera, J0888
- Filgrastim, Neupogen, J1442
- Filgrastim-sndz, Zarxio, Q5101 (preferred)
On August 1, 2020, the following changes will take effect.
- Bevacizumab-awwb, Mvasi (Q5107) and Bevacizumab-bvzr, Zirabev (Q5118) will be the preferred bevacizumab agent.
- For all oncology or pemphigus vulgaris or pemphigus foliaceus diagnoses, the preferred rituximab agent is Rituximab-pvvr, Ruxience (Q5119). For Rheumatoid arthritis, step therapy will require try and failure of Methotrexate, one conventional DMARD, and then Infliximab before using rituximab. Infliximab requests must be for infliximab-dyyb, Inflectra (Q5103) or infliximab-abad, Renflexis (Q5104).
- Trastuzumab-dkst, Ogivri (Q5114) and trastuzumab-qyyp, Trazimera (Q5116) will be the preferred trastuzumab agents.
- Step therapy will require try and failure of Epoetin Alfa-epbx, Retacrit (Q5106) before using Darbepoetin, Aranesp (J0881).
- Step therapy will require try and failure of Epoetin Alfa-epbx, Retacrit (Q5106) before using Methoxy polyethylene glycol-epoetin beta, Mircera (J0888).
- Filgrastim-sndz, Zarxio (Q5101) will be the preferred agent for filgrastim and pegfilgrastim requests.
These changes affect the following site of care settings: provider-administered, outpatient hospital or ambulatory care center. To access the Prior Authorization forms, please visit Buckeye’s website at https://www.buckeyehealthplan.com/providers/pharmacy/prior-auth-specialty.html or contact Provider Services at 866-296-8731.