Prior Authorization (PA) for Physician-Administered Drugs

PROVIDER ALERT

Effective with dates of service on or after Nov. 1, 2016, the following physician-administered medications will require prior authorization (PA) to ensure that use is consistent with the medication’s indication(s) and appropriate clinical guidelines.

 

HCPCS Code                       Medication Name

J3262                                     Actemra

                J0800                                     Acthar HP

                J0717                                     Cimzia

                J3380                                     Entyvio

                J1602                                     Simponi Aria

                J1300                                     Soliris

                J3357                                     Stelara

                Q5101                                   Zarxio

 

Requests for PA should be submitted to Magellan Rx Management at http://ih.magellanrx.comor by calling 1 (800) 424-8219.

 

Please note: With this change, PA requests for botulinum toxins (J0585, J0586, J0587 and J0588) will be processed by Magellan Rx Management, rather than KEPRO.

 

Physician administered drugs provided during inpatient hospitalizations or emergency room visit are not subject to PA requirements. For additional information, please consult the appropriate Medicaid Provider Manual, available at scdhhs.gov.

 

This alert applies only to beneficiaries enrolled under Fee-for-Service (FFS) Medicaid.

 

Thank you for your continued support of the Medicaid program.

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