The following drugs require utilization review.
|
PROCEDURE |
DESCRIPTION |
STEP THERAPY |
|---|---|---|
|
J0585 |
INJECTION, ONABOTULINUMOTXINA, 1 UNIT |
|
|
J0587 |
INJECTION, RIMABOTULINUMTOXINB, 100 UNITS |
STEP THERAPY |
|
J0588 |
INJECTION, INCOBOTULINUMTOXIN A, 1 UNIT |
STEP THERAPY |
|
J1437 |
INJECTION, FERRIC DERISOMALTOSE, 10 MG |
STEP THERAPY |
|
J1439 |
INJECTION, FERRIC CARBOXYMALTOSE, 1 MG |
STEP THERAPY |
|
J1443 |
INJECTION, FERRIC PYROPHOSPHATE CITRATE SOLUTION (TRIFERIC), 0.1 MG OF IRON |
STEP THERAPY |
|
J1444 |
INJECTION, FERRIC PYROPHOSPHATE CITRATE POWDER, 0.1 MG OF IRON |
STEP THERAPY |
|
J1445 |
INJECTION, FERRIC PYROPHOSPHATE CITRATE SOLUTION (TRIFERIC AVNU), 0.1 MG OF IRON |
STEP THERAPY |
|
J1449 |
INJECTION, EFLAPEGRASTIM-XNST (ROLVEDON), 0.1 MG |
STEP THERAPY |
|
J1460 |
INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 1 CC |
STEP THERAPY |
|
J1560 |
INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, OVER 10 CC |
STEP THERAPY |
|
Q0138 |
INJECTION, FERUMOXYTOL, FOR TREATMENT OF IRON DEFICIENCY ANEMIA, 1MG (NON-ESRD USE) |
STEP THERAPY |
|
Q0139 |
INJECTION, FERUMOXYTOL, FOR TREATMENT OF IRON DEFICIENCY ANEMIA, 1MG (FOR ESRD ON DIALYSIS) |
STEP THERAPY |
|
Q5126 |
INJECTION, BEVACIZUMAB-MALY, BIOSIMILAR, (ALYMSYS), 10 MG |
STEP THERAPY |
|
Q5127 |
INJECTION, PEGFILGRASTIM-FPGK (STIMUFEND), BIOSIMILAR, 0.5 MG |
STEP THERAPY |
|
Q5128 |
INJECTION, RANIBIZUMAB-EQRN (CIMERLI), BIOSIMIAR, 0.1 MG |
STEP THERAPY |
|
Q5129 |
INJECTION, BEVACIZUMAB-ADCD (VEGZELMA), BIOSIMILAR, 10 MG |
STEP THERAPY |
|
Q5130 |
INJECTION, PEGFILGRASTIM-PBBK (FYLNETRA), BIOSIMILAR, 0.5 MG |
STEP THERAPY |
