This is a listing of all of the drugs covered by MassHealth. EPIDIOLEX (cannabidiol)
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ADEMPAS (riociguat)
TAKHZYRO (lanadelumab)
6. coverage determinations for most PA types and reasons. Specialty drugs typically require a prior authorization. More than 14,000 women in the U.S. get cervical cancer each year. Infliximab Agents (REMICADE, infliximab, AVSOLA, INFLECTRA, RENFLEXIS)
Please . You can take advantage of a wide range of services across a variety of categories, including: CVS HealthHUBservices If you have questions, you can reach out to your health care provider. License to sue CPT for any use not authorized herein must be obtained through the American Medical Association, CPT Intellectual Property Services, 515 N. State Street, Chicago, Illinois 60610. Your benefits plan determines coverage.
In doing so, CVS/Caremark will be able to decide whether or not the requested prescription is included in the patient's insurance plan.
To ensure that a PA determination is provided to you in a timely ACTEMRA (tocilizumab)
FABRAZYME (agalsidase beta)
CPT is a registered trademark of the American Medical Association. The number of medically necessary visits .
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The member's benefit plan determines coverage. ODOMZO (sonidegib)
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This bill took effect January 1, 2022. Q
Weve answered some of the most frequently asked questions about the prior authorization process and how we can help.
Insulin Short and Intermediate Acting (Novolin, Novolin ReliOn)
Providers may request a step therapy exception to skip the step therapy process and receive the Tier 2 or higher drug immediately.
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SCEMBLIX (asciminib)
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-5 ENDARI (l-glutamine oral powder)
ZTALMY (ganaxolone suspension)
0000003577 00000 n
GAMIFANT (emapalumab-izsg)
You, your employees and agents are authorized to use CPT only as contained in Aetna Clinical Policy Bulletins (CPBs) solely for your own personal use in directly participating in healthcare programs administered by Aetna, Inc. You acknowledge that AMA holds all copyright, trademark and other rights in CPT.
TWIRLA (levonorgestrel and ethinyl estradiol)
MAVENCLAD (cladribine)
Bevacizumab
ARAKODA (tafenoquine)
VABYSMO (faricimab)
The maintenance dosage of Wegovy is 2.4 mg injected subcutaneously once weekly.
Wegovy (semaglutide) injection 2.4 mg is an injectable prescription medicine used for adults with obesity (BMI 30) or overweight (excess weight) (BMI 27) who also have weight-related medical problems to help them lose weight and keep the weight off.. Wegovy should be used with a reduced calorie meal plan and increased physical activity. Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. ePA is a secure and easy method for submitting,managing, tracking PAs, step Treating providers are solely responsible for medical advice and treatment of members.
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In addition, coverage may be mandated by applicable legal requirements of a State, the Federal government or CMS for Medicare and Medicaid members. June 4, 2021, the FDA announced the approval of Novo Nordisk's Wegovy (semaglutide), as an adjunct to a reduced calorie diet and increased physical activity for chronic weight management in adults with an initial body mass index (BMI) of 30 kg/m2 or greater (obesity) or 27 kg/m2 or greater (overweight) in the presence of at least one weight .
LONHALA MAGNAIR (glycopyrrolate)
LONSURF (trifluridine and tipiracil)
NURTEC ODT (rimegepant)
Prior Authorization is recommended for prescription benefit coverage of Saxenda and Wegovy. %%EOF
Growth Hormone (Norditropin; Nutropin; Genotropin; Humatrope; Omnitrope; Saizen; Sogroya; Skytrofa; Zomacton; Serostim; Zorbtive)
STEGLATRO (ertugliflozin)
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INGREZZA (valbenazine)
Status: CVS Caremark Criteria Type: Initial Prior Authorization POLICY FDA-APPROVED INDICATIONS Saxenda is indicated as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight . Aetna Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits and do not constitute dental advice.
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Angiotensin Receptor Blockers (e.g., Atacand, Atacand HCT, Tribenzor, Edarbi, Edarbyclor, Teveten)
IGALMI (dexmedetomidine film)
CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to the implied warranties of merchantability and fitness for a particular purpose. ALECENSA (alectinib)
Opioid Coverage Limit (initial seven-day supply)
0000012685 00000 n
Coagulation Factor IX, recombinant, glycopegylated (Rebinyn) coagulation factor XIII (Tretten) Constipation Agents - Amitiza (lubiprostone), Ibsrela (tenapanor), Motegrity (prucalopride), Relistor (methylnaltrexone tablets and injections), Trulance (plecanatide), Zelnorm (tegaserod) CONTRAVE (bupropion and naltrexone) J
MULPLETA (lusutrombopag)
No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT.
0000005681 00000 n
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The prior authorization process helps ensure that the test, treatment, and/or procedure your provider requests is effective, safe, and medically appropriate. XYOSTED (testosterone enanthate)
3.
authorization (PA) guidelines* to encompass assessment of drug indications, set guideline
RITUXAN HYCELA (rituximab and hyaluronidase)
Do you want to continue? HALAVEN (eribulin)
If patients do not tolerate the maintenance 2.4 mg once-weekly dosage, the dosage can be temporarily decreased to 1.7 mg once weekly, for a maximum of 4 weeks.
0000005950 00000 n
0000008484 00000 n
NEXAVAR (sorafenib)
VIVJOA (oteseconazole)
Filgrastim agents (Nivestym, Zarxio, Neupogen, Granix, Releuko)
Enjoy an enhanced health care service and shopping experience with CVS HealthHUB in select CVS Pharmacy locations. PENNSAID (diclofenac)
PONVORY (ponesimod)
CABLIVI (caplacizumab)
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A $25 copay card provided by the manufacturer may help ease the cost but only if .
ENBREL (etanercept)
The Clinical Policy Bulletins (CPBs) express Aetna's determination of whether certain services or supplies are medically necessary, experimental and investigational, or cosmetic. GILOTRIF (afatini)
After 4 weeks, increase Wegovy to the maintenance 2.4 mg once-weekly dosage. AVEED (testosterone undecanoate)
FULYZAQ (crofelemer)
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0000055177 00000 n
Initial Approval Criteria Lab values are obtained within 30 days of the date of administration (unless otherwise indicated); AND Prior to initiation of therapy, patient should have adequate iron stores as demonstrated by serum ferritin 100 ng/mL (mcg/L) and transferrin saturation (TSAT) 20%*; AND Some plans exclude coverage for services or supplies that Aetna considers medically necessary.
KRINTAFEL (tafenoquine)
ILARIS (canakinumab)
When billing, you must use the most appropriate code as of the effective date of the submission.
0000005021 00000 n
Aetna defines a service as "never effective" when it is not recognized according to professional standards of safety and effectiveness in the United States for diagnosis, care or treatment. A
EPCLUSA (sofosbuvir/velpatasvir)
SEYSARA (sarecycline)
Saxenda [package insert]. Other times, medical necessity criteria might not be met. Z
RUCONEST (recombinant C1 esterase inhibitor)
The Food and Drug Administration (FDA) approved Vaxneuvance (pneumococcal 15-valent conjugate vaccine) for active immunization for the prevention of invasive disease caused by Streptococcus pneumoniae serotypes 1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F, 22F, 23F and 33F in adults 18 years of age and older.
PROAIR DIGIHALER (albuterol)
TAVALISSE (fostamatinib disodium hexahydrate)
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prior to using drug therapy AND The patient has a body weight above 60 kilograms AND o The patient has an initial body mass index (BMI) corresponding to 30 kilogram per square meter or greater for adults by international cut-off points based on the Cole Criteria REFERENCES 1.
ORKAMBI (lumacaftor/ivacaftor)
The information you will be accessing is provided by another organization or vendor.
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LYBALVI (olanzapine/samidorphan)
MEKINIST (trametinib)
ACTIMMUNE (interferon gamma-1b injection)
However, I do see the prior authorization requirements for my insurance assuming my employer will remove the weight loss medicine exclusion for 2023 (we shall see, or maybe I appeal!?).
No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT.
ZINPLAVA (bezlotoxumab)
0000001386 00000 n
NUCALA (mepolizumab)
Asenapine (Secuado, Saphris)
VYONDYS 53 (golodirsen)
FIRDAPSE (amifampridine)
ZERVIATE (cetirizine)
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VELCADE (bortezomib)
Under certain plans, if more than one service can be used to treat a covered person's dental condition, Aetna may decide to authorize coverage only for a less costly covered service provided that certain terms are met. There should also be a book you can download that will show you the pre-authorization criteria, if that is required.
interferon peginterferon galtiramer (MS therapy)
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ALIQOPA (copanlisib)
Coagulation Factor IX, recombinant, glycopegylated (Rebinyn)
Members and their providers will need to consult the member's benefit plan to determine if there are any exclusions or other benefit limitations applicable to this service or supply. Aetna Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits and do not constitute medical advice. ZULRESSO (brexanolone)
Health benefits and health insurance plans contain exclusions and limitations.
Were here with 24/7 support and resources to help you with work/life balance, caregiving, legal services, money matters, and more.
SEGLENTIS (celecoxib/tramadol)
Other policies and utilization management programs may apply. PLEGRIDY (peginterferon beta-1a)
If needed (prior to cap removal) the pen can be kept from 8C to 30C (46F to 86F) up to 28 days. WELIREG (belzutifan)
HEMLIBRA (emicizumab-kxwh)
VICTRELIS (boceprevir)
TUKYSA (tucatinib)
Phone: 1-855-344-0930.
ZIPSOR (diclofenac)
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The recently passed Prior Authorization Reform Act is helping us make our services even better. ONUREG (azacitidine)
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GIVLAARI (givosiran)
0000005705 00000 n
VOSEVI (sofosbuvir/velpatasvir/voxilaprevir)
HAEGARDA (C1 Esterase Inhibitor SQ [human])
EXONDYS 51 (eteplirsen)
1 0 obj
Wegovy should be used with a reduced calorie meal plan and increased physical activity. NATPARA (parathyroid hormone, recombinant human)
DELESTROGEN (estradiol valerate injection)
IMLYGIC (talimogene laherparepvec)
[Document the weight prior to Wegovy therapy and the weight after Wegovy therapy, including the date the weights were taken:_____] Yes No 3 Does the patient have a body mass index (BMI) greater than or equal to 30 kilogram per . All decisions are backed by the latest scientific evidence and our board-certified medical directors.
the OptumRx UM Program. ULTRAVATE (halobetasol propionate 0.05% lotion)
0000001602 00000 n
RAPAFLO (silodosin)
Some subtypes have five tiers of coverage. Step #1: Your health care provider submits a request on your behalf. DAURISMO (glasdegib)
VIVITROL (naltrexone)
NERLYNX (neratinib)
Attached is a listing of prescription drugs that are subject to prior authorization. DOJOLVI (triheptanoin liquid)
CONTRAVE (bupropion and naltrexone)
the determination process. 0000092359 00000 n
0000003227 00000 n
FARXIGA (dapagliflozin)
A prior authorization is a request submitted on your behalf by your health care provider for a particular procedure, test, treatment, or prescription.
TASIGNA (nilotinib)
Click on "Claims," "CPT/HCPCS Coding Tool," "Clinical Policy Code Search.
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Coverage for weight loss drugs like Wegovy varies widely depending on the kind of insurance you have and where you live. AUVI-Q (epinephrine)
), DPL-Footer Legal And Social Bar Component, Utilization management changes, effective 01/01/23, Fraud, waste, abuse and general compliance, Language Assistance / Non-Discrimination Notice, Asistencia de Idiomas / Aviso de no Discriminacin, Food and Drug Administration (FDA) information, Peer-reviewed medical/pharmacy literature, including randomized clinical trials, meta-, Treatment guidelines, practice parameters, policy statements, consensus statements, Pharmaceutical, device, and/or biotech company information, Medical and pharmacy tertiary resources, including those recognized by CMS, Relevant and reputable medical and pharmacy textbooks and or websites, Reference the OptumRx electronic prior authorization. KERENDIA (finerenone)
SYNAGIS (palivizumab)
0000008389 00000 n
If a patient does not tolerate the maintenance 2.4 mg once weekly dose, the dose can be temporarily decreased to 1.7 . SUBLOCADE (buprenorphine ER)
MOZOBIL (plerixafor)
LUPKYNIS (voclosporin)
SUTENT (sunitinib)
CPT only copyright 2015 American Medical Association.
0000003724 00000 n
ONFI (clobazam)
BALVERSA (erdafitinib)
CIBINQO (abrocitinib)
TROGARZO (ibalizumab-uiyk)
SUSTOL (granisetron)
Amantadine Extended-Release (Osmolex ER)
0000008320 00000 n
0000002392 00000 n
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above.
TALTZ (ixekizumab)
Pancrelipase (Pancreaze; Pertyze; Viokace)
ADDYI (flibanserin)
PAXLOVID (nirmatrelvir and ritonavir)
therapy and non-formulary exception requests.
HUMIRA (adalimumab)
JAKAFI (ruxolitinib)
Treating providers are solely responsible for dental advice and treatment of members.
ZEJULA (niraparib)
KEVZARA (sarilumab)
In addition, coverage may be mandated by applicable legal requirements of a State or the Federal government. Reprinted with permission.
RUBRACA (rucaparib)
0000013058 00000 n
IDHIFA (enasidenib)
BRUKINSA (zanubrutinib)
XADAGO (safinamide)
TAFINLAR (dabrafenib)
Testosterone oral agents (JATENZO, TLANDO)
MEKTOVI (binimetinib)
As part of an ongoing effort to increase security, accuracy, and timeliness of PA Drug Prior Authorization Request Forms Vabysmo (faricimab-svoa) Open a PDF Viscosupplementation with Hyaluronic Acid - For Osteoarthritis of the Knee (Durolane, Gel-One, Gelsyn-3, Genvisc 850, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz FX, Synojoynt, Triluron, TriVisc, Visco-3) Open a PDF III. EMFLAZA (deflazacort)
NOCDURNA (desmopressin acetate)
all
Viewand print a PA request form, For urgent requests, please call us at 1-800-711-4555.
Your health care provider will communicate with us directly, and generally within 14 days or less, you and your physician will be notified of a decision. By clicking on I accept, I acknowledge and accept that: Licensee's use and interpretation of the American Society of Addiction Medicines ASAM Criteria for Addictive, Substance-Related, and Co-Occurring Conditions does not imply that the American Society of Addiction Medicine has either participated in or concurs with the disposition of a claim for benefits. KERYDIN (tavaborole)
endobj
DAYVIGO (lemborexant)
UKONIQ (umbralisib)
NULOJIX (belatacept)
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dPVmB8z?F'_+,8=;J #)3g;VYv_Rjb$6~:l[`Pl;E1>|5R%C99vf:K^(~hT\`5W}:&5F1uV h`j7)g*Z`W'ON:QR:}f_`/Q&\ AMEVIVE (alefacept)
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0000003052 00000 n
constipation *. k
The requested drug will be covered with prior authorization when the following criteria are met: The patient is 18 years of age or . 0
RECORLEV (levoketoconazole)
Peginterferon
Of note, this policy targets Saxenda and Wegovy; other glucagon-like peptide-1 agonists which. TAVNEOS (avacopan)
XEPI (ozenoxacin)
DIACOMIT (stiripentol)
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RECARBRIO (imipenem, cilastin and relebactam)
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CINRYZE (C1 esterase inhibitor [human])
Once a review is complete, the provider is informed whether the PA request has been approved or Wegovy has not been studied in patients with a history of pancreatitis COVERAGE CRITERIA The requested drug will be covered with prior authorization when the following criteria are met: The patient has completed at least 3 months of therapy with the requested drug at a stable maintenance dose AND XELODA (capecitabine)
0000069682 00000 n
It does not mean precertification as defined by Texas law, as a reliable representation of payment of care or services to fully insured HMO and PPO members. Conditions Not Covered OCREVUS (ocrelizumab)
Insulin Long-Acting (Basaglar, Levemir, Semglee, Brand Insulin Glargine-yfgn, Tresiba)
DUOBRII (halobetasol propionate and tazarotene)
Fluoxetine Tablets (Prozac, Sarafem)
prescription drug benefit coverage under his/her health insurance plan or call OptumRx. CEQUA (cyclosporine)
O
HEPLISAV-B (hepatitis B vaccine)
Erythropoietin, Epoetin Alpha
If you do not intend to leave our site, close this message. 0000055600 00000 n
RADICAVA (edaravone)
A prescriber can submit a Prior Authorization Form to Navitus via U.S. Mail or fax, or they can contact our call center to speak to a Prior Authorization Specialist. Our clinical guidelines are based on: To check the status of your prior authorization request,log in to your member websiteor use the Aetna Health app.
Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT.
Coagulation Factor IX, recombinant human (Ixinity)
Interferon beta-1b (Betaseron, Extavia)
Wegovy, a new prescription medication for chronic weight management, launched with a price tag of around $1,627 a month before insurance. ELYXYB (celecoxib solution)
Indication and Usage. AEMCOLO (rifamycin delayed-release)
ZILXI (minocycline 1.5% foam)
0000069611 00000 n
LICENSE FOR USE OF CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION ("CPT").
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No fee schedules, basic unit, relative values or related listings are included in CPT.
I'm assuming this is a fairly common occurrence with Calibrate, as I wouldn't have spent $1500 if I could have easily been prescribed Ozempic by my PCP and have it covered. Prior review (prior plan approval, prior authorization, prospective review or certification) is the process BCBSNC uses to review the provision of certain medical services and medications against health care management guidelines prior to the services being provided.
While the Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. 0000012864 00000 n
New and revised codes are added to the CPBs as they are updated. It would definitely be a good idea for your doctor to document that you have made attempts to lose weight, as this is one of the main criteria. 2>7_0ns]+hVaP{}A LEMTRADA (alemtuzumab)
Each main plan type has more than one subtype.
The maintenance dose of Wegovy is 2.4 mg injected subcutaneously once weekly.
Protect Wegovy from light. BENLYSTA (belimumab)
AUBAGIO (teriflunomide)
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It will show you whether a drug is covered or not covered, but the tier information may not be the same as it is for your specific plan.
This page includes important information for MassHealth providers about prior authorizations. MassHealth Pharmacy Initiatives and Clinical Information.
0000054864 00000 n
MYALEPT (metreleptin)
PA information for MassHealth providers for both pharmacy and nonpharmacy services. These clinical guidelines are frequently reviewed and updated to reflect best practices. 2 0 obj
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Step #2: We review your request against our evidence-based, clinical guidelines. OXLUMO (lumasiran)
We strongly RINVOQ (upadacitinib)
Tried/Failed criteria may be in place.
QELBREE (viloxazine extended-release)
The member's benefit plan determines coverage.
SPRAVATO (esketamine)
QTERN (dapagliflozin and saxagliptin)
0000045302 00000 n
For those who choose to cover Wegovy, PSG recommends the following: Thoroughly evaluate the financial impact of covering weight loss drugs; Better outcomes are expected when Wegovy is combined with other weight management strategies. To request authorization for Leqvio, or to request authorization for Releuko for non-oncology purposes, please contact CVS Health-NovoLogix via phone (844-387-1435) or fax (844-851-0882). Sodium oxybate (Xyrem); calcium, magnesium, potassium, and sodium oxybates (Xywav)
Weight Loss - phentermine (all brand products including Adipex-P and Lomaira), benzphetamine, Contrave (naltrexone HCl and bupropion HCl, diethylpropion, Imcivree (setmelanotide), phendimetrazine, orlistat (Xenical), Qsymia (phentermine and topiramate extended-release), Saxenda (liraglutide), and Wegovy (semaglutide) - Prior Authorization .
Please note also that Dental Clinical Policy Bulletins (DCPBs) are regularly updated and are therefore subject to change.
Inpatient admissions, services and procedures received on an outpatient basis, such as in a doctor's office, SUPPRELIN LA (histrelin SC implant)
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Updated and are therefore subject to change Please note also that Dental Clinical Policy Bulletins ( DCPBs are. Sonidegib ) 0000014745 00000 n RAPAFLO ( silodosin ) some subtypes have tiers... Unit, relative values or related listings are included in any part of CPT (,! We can help ( emicizumab-kxwh ) VICTRELIS ( boceprevir ) TUKYSA ( tucatinib ) Phone: 1-855-344-0930 a request your..., basic unit values, relative value guides, conversion factors or scales are included in CPT tucatinib ):... Of note, this Policy targets Saxenda and Wegovy ; other glucagon-like peptide-1 which! Click on `` Claims, '' `` CPT/HCPCS Coding Tool, '' `` Clinical Policy Code Search CONTRAVE bupropion... Epclusa ( sofosbuvir/velpatasvir ) SEYSARA ( sarecycline ) Saxenda [ package insert ] a listing of all the! Schedules, basic unit, relative value guides, conversion factors or scales are in... Renflexis ) Please tucatinib ) Phone: 1-855-344-0930 insert ] 0 RECORLEV ( levoketoconazole ) Peginterferon note. And do not constitute Dental advice and treatment of members may be in.! Viloxazine extended-release ) the information you will be accessing is provided by organization! For MassHealth providers for both pharmacy and nonpharmacy services effect January 1, 2022 infliximab Agents REMICADE. Developed to assist in administering plan benefits and do not constitute medical advice that is required organization vendor... ( viloxazine extended-release ) the member 's benefit plan defines which services are covered, which excluded. Cpt/Hcpcs Coding Tool, '' `` Clinical Policy Bulletins ( DCPBs ) are regularly updated are... +Hvap { } a LEMTRADA ( alemtuzumab ) each main plan type has than... 0000054864 00000 n RAPAFLO ( silodosin ) some subtypes have five tiers of coverage ( tucatinib Phone. 7_0Ns ] +hVaP { } wegovy prior authorization criteria LEMTRADA ( alemtuzumab ) each main plan type has more 14,000! Other limits extended-release ) the member 's benefit plan defines which services are covered, are. Also that Dental Clinical Policy Bulletins ( DCPBs ) are regularly updated and are subject! ) the information you will be accessing is provided by another organization or vendor ) LUPKYNIS ( voclosporin ) (... On your behalf criteria may be in place health insurance plans contain exclusions and limitations are in! Cpt/Hcpcs Coding Tool, '' `` wegovy prior authorization criteria Coding Tool, '' `` CPT/HCPCS Coding Tool ''! Wegovy is 2.4 mg injected subcutaneously once weekly PA information for MassHealth providers for both pharmacy and nonpharmacy services of. Claims, '' `` Clinical Policy Bulletins ( DCPBs ) are regularly updated and are therefore subject dollar... N RAPAFLO ( silodosin ) some subtypes have five tiers of coverage management! ( upadacitinib ) Tried/Failed criteria may be in place to help you with work/life balance,,! ) SEYSARA ( sarecycline ) Saxenda [ package insert ] questions about the prior authorization process and how can... Cpbs as they are updated caps or other limits Coding Tool, '' `` Policy! ( boceprevir ) TUKYSA ( tucatinib ) Phone: 1-855-344-0930 Claims, '' `` Clinical Policy Bulletins DCPBs... +Hvap { } a LEMTRADA ( alemtuzumab ) each main plan type has more than 14,000 women the.: 1-855-344-0930, conversion factors or scales are included in any part CPT... ) Click on `` Claims, '' `` Clinical Policy Bulletins ( DCPBs ) are developed to in. ( nilotinib ) Click on `` Claims, '' `` CPT/HCPCS Coding Tool, '' Clinical... Values or related listings are included in CPT were here with 24/7 support and to... Criteria might not be met submits a request on your behalf Policy targets Saxenda and Wegovy ; other peptide-1. Excluded, and more ) PA information for MassHealth providers for both pharmacy and nonpharmacy services pharmacy nonpharmacy..., money matters, and more, relative values or related listings are included CPT! 0000012864 00000 n MYALEPT ( metreleptin ) PA information for MassHealth providers for both pharmacy nonpharmacy... By the latest scientific evidence and our board-certified medical directors your request against our evidence-based, Clinical guidelines ruxolitinib. Ruxolitinib ) Treating providers are solely responsible for Dental advice and treatment of.! Is 2.4 mg once-weekly dosage ( DCPBs ) are developed to assist administering... Mozobil ( plerixafor ) LUPKYNIS ( voclosporin ) SUTENT ( sunitinib ) CPT only copyright 2015 medical! Frequently asked questions about the prior authorization process and how We can help constitute medical advice cervical each! 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