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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.

  1. Bevacizumab-awwb, Mvasi (Q5107) and Bevacizumab-bvzr, Zirabev (Q5118) will be the preferred bevacizumab agent.
  2. 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).
  3. Trastuzumab-dkst, Ogivri (Q5114) and trastuzumab-qyyp, Trazimera (Q5116) will be the preferred trastuzumab agents.
  4. Step therapy will require try and failure of Epoetin Alfa-epbx, Retacrit (Q5106) before using Darbepoetin, Aranesp (J0881).
  5. Step therapy will require try and failure of Epoetin Alfa-epbx, Retacrit (Q5106) before using Methoxy polyethylene glycol-epoetin beta, Mircera (J0888).
  6. 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.