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February 2015

UA Local 190 health and welfare plan added to Medical Drug Prior Authorization Program

Effective April 1, 2015, all groups enrolled in the UA Local 190 health and welfare plan will participate in the Medical Drug Prior Authorization Program.

Note: The prior authorization requirement does not apply to Medicare, Medicare Advantage or Federal Employee Program® members.

The list below reflects all the medications that are part of the Medical Drug Prior Authorization Program.

Actemra®

Flebogamma® DIF

Nplate®

Acthar® gel

Gammagard Liquid

Octagam®

Adagen®               

Gammagard® S/D

Orencia®

Aldurazyme®       

Gammaked®

Privigen®

Aralast NP

Gammaplex®

Prolastin®-C

Benlysta®

Gamunex®  

Prolia®

Berinert®

Glassia

Ruconest®

Bivigam™

Hizentra® 

Simponi® Aria™

Botox®

HyQvia

Soliris®

Carimune® NF

Ig, IV injection NOS

Stelara®

Cerezyme®           

Ilaris®

Synagis®

Cimzia®

Kalbitor®

Tysabri®             

Cinryze®

Krystexxa®

Vimizim™

Dysport®

Lemtrada™

Vpriv®                   

Elaprase®              

Lumizyme®           

Xeomin®

Elelyso™                 

Makena®

Xgeva®

Entyvio™

Myobloc®

Xiaflex®

Fabrazyme®          

Myozyme®           

Xolair®

Firazyr®

Naglazyme®         

Zemaira®

For more information about this change, contact your provider consultant.

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*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2014 American Medical Association. All rights reserved.
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