prior authorization/notification list for inet and onet ... - Health Net
prior authorization/notification list for inet and onet ... - Health Net
prior authorization/notification list for inet and onet ... - Health Net
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PHARMACEUTICAL PRIOR AUTHORIZATION REQUIREMENTS<br />
Practitioners may Fax completed Prior Authorization Form to<br />
<strong>Health</strong> <strong>Net</strong> Pharmaceutical Services (HNPS) at (800) 977-8226<br />
The following medications/classes require Prior Authorization<br />
DRUGS THAT REQUIRE PRIOR AUTHORIZATION FOR PRESCRIPTION PLANS<br />
NOT APPLICABLE TO MEDICAID HEALTHY OPTIONS PLANS<br />
SEE SEPARATE HEALTHY OPTIONS PRIOR AUTHORIZATION LIST<br />
DRUG CLASS / GENERIC NAME<br />
BRAND NAME EXAMPLES<br />
Compounded Prescriptions<br />
N/A<br />
COX-2 Inhibitors: Celecoxib, Etoricoxib,<br />
ARCOXIA, BEXTRA, CELEBREX, DYNASTAT, PREXIGE,<br />
Lumiracoxib, Parecoxib, Tilmacoxib, Valdecoxib<br />
Drugs used <strong>for</strong> Sexual Dysfunction <strong>for</strong> members ALISTA, ALPROX-TD, CAVERJECT, CIALIS, EDEX, INTRINSA, LEVITRA, MUSE, VIAGRA<br />
under age 40: Alprostadil, Tadalafil, Testosterone,<br />
Vardenafil, Sildenafil<br />
Medication Exceptions due to Drug Utilization See: QUANTITY LIMIT / DRUG UTILIZATION REVIEW List<br />
Review (DUR)<br />
Non-Sedating Antihistamines<br />
ALLEGRA, ALLEGRA-D, CLARINEX, ZYRTEC, ZYRTEC-D<br />
Cetirizine, Desloratadine, Fexofenadine<br />
Nutritional Supplements<br />
MSUD, PHENYL-FREE, XP-ANALOG, XPHEN, NEOCATE<br />
Onychomycosis Agents<br />
LAMISIL, PENLAC, SPORANOX<br />
(Not covered <strong>for</strong> cosmetic treatment):<br />
Ciclopirox, Itraconazole, Terbinafine<br />
Proton Pump Inhibitors:<br />
NEXIUM, PREVACID, PRILOSEC, PROTONIX, ZEGERID<br />
Esomeprazole, Lansoprazole, Omeprazole,<br />
Pantoprazole, Rabeprazole<br />
Testosterone Preparations<br />
ANDRODERM, ANDROGEL, STRIANT, TESTODERM, TESTIM, TOSTRELLE<br />
Topical Retinoids <strong>for</strong> members age 36 or older: AVITA, DIFFERIN, RETIN-A<br />
(Not covered <strong>for</strong> cosmetic use)<br />
Adapalene, Tretinoin<br />
Fentanyl Lozenge<br />
ACTIQ<br />
Apomorphine<br />
APOKYN<br />
Amlodipine / Atorvastatin<br />
CADUET<br />
Ribavirin COPEGUS, REBETOL, RIBASPHERE<br />
Duloxetine<br />
CYMBALTA<br />
Acamprosate<br />
CAMPRAL<br />
Fentanyl Patch<br />
DURAGESIC<br />
Inhaled Insulin<br />
EXUBERA<br />
Teriparatide<br />
FORTEO<br />
Enfuvirtide<br />
FUZEON<br />
Imatinib<br />
GLEEVEC<br />
Adefovir<br />
HEPSERA<br />
Eplerenone<br />
INSPRA<br />
Gefitinib<br />
IRESSA<br />
Eszopiclone<br />
LUNESTA<br />
Meloxicam<br />
MOBIC<br />
Oxycodone SR 12 HR<br />
OXYCONTIN<br />
Modafinil<br />
PROVIGIL<br />
Cyclosporine Ophthalmic<br />
RESTASIS<br />
Cinacalcet<br />
SENSIPAR<br />
Montelukast<br />
SINGULAIR<br />
Tiotropium<br />
SPIRIVA<br />
Erlotinib<br />
TARCEVA<br />
Temazolomide<br />
TEMODAR<br />
Thalidomide<br />
THALOMID<br />
Bosentan<br />
TRACLEER<br />
Sodium Oxybate<br />
XYREM<br />
Miglustat<br />
ZAVESCA<br />
HEALTH NET RESERVES THE RIGHT TO REQUIRE PRIOR AUTHORIZATION FOR ORAL AND TOPICAL DRUGS EXCEPT WHERE MANDATED BY LAW.<br />
Revised 3/18/2005<br />
Rx Prior Authorization – Requirements<br />
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