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Priority Partners Pharmacy & Formulary

Priority Partners wants our providers to: Prescribe Thoughtfully

2014 Drug Formulary Quick Reference Guide and Over-the-Counter Coverage
2014 Drug Formulary Booklet

Please note: The Maryland Department of Health and Mental Hygiene is responsible for formulary management of most drugs used for behavioral health purposes. Please refer to the Maryland Public Mental Health Formulary for a complete listing of covered drugs. This list may also be viewed at www.mdmahealthchoicerx.com.

For medications requiring  Prior-Authorizations
For medications with Managed Drug Limitations (MDL)

Please note that in the event the Priority Partners precertification unit is closed, or a pharmacist cannot contact the prescribing physician, the pharmacist may dispense up to a 96-hour supply of the requested medication to an eligible Priority Partners member.

A printed copy of Priority Partners' pharmaceutical management procedures is available to providers upon request. Please call (888) 819-1043, option 4 to request this information.

Pharmacy J Code

Codes J9035 (Avastin), J1745 (Remicade) and J9010 (Rituxan) will require pre-authorization effective 11/11/2013. The form to request pre-authorization is here.

To expedite treatment and claims processing for indications included in FDA labeling or national guidelines, select ICD-9 diagnoses will be exempt from the prior authorization requirement. These diagnoses are listed below.

 

CodeExempt Diagnoses
J9035 (Avastin)Antineoplastic Chemotherapy 153.xx MALIGNANT NEOPLASM OF COLON
154.1x MALIGNANT NEOPLASM OF RECTUM
154.8x MALIGNANT NEOPLASM OF OTHER SITES OF RECTUM RECTOSIGMOID JUNCTION AND ANUS
162.xx MALIGNANT NEOPLASM OF TRACHEA BRONCHUS AND LUNG
189.xx MALIGNANT NEOPLASM OF KIDNEY EXCEPT PELVIS
191.xx MALIGNANT NEOPLASM OF BRAIN
183.xx NEOPLASM OF OVARY
174.xx; 175.xx MALIGNANT NEOPLASM OF BREAST Opthalmic Therapy 362.5x EXUDATIVE SENILE MACULAR DEGENERATION, CYSTOID MASCULAR DEGENERATION
362.07x DIABETIC MACULAR EDEMA
362.2X RETINOPATHY OF PREMATURITY
362.83 RETINAL EDEMA
362.3X RETINAL VASCULAR OCCLUSION
J1745 (Remicade)555.xx REGIONAL ENTERITIS
556.xx ULCERATIVE ENTEROCOLITIS
569.xx OTHER DISORDERS OF INTESTINE
619.1x DIGESTIVE-GENITAL TRACT FISTULA FEMALE
696.0x PSORIATIC ARTHROPATHY
696.1x OTHER PSORIASIS AND SIMILAR DISORDERS
714.0x RHEUMATOID ARTHRITIS
714.1x FELTY'S SYNDROME
714.2x OTHER RHEUMATOID ARTHRITIS WITH VISCERAL OR SYSTEMIC INVOLVEMENT
720.0x ANKYLOSING SPONDYLITIS
J9310 (Rituxan)200.xx LYMPHOSARCOMA AND RETICULOSARCOMA AND OTHER SPECIFIED MALIGNANT TUMORS OF LYMPHATIC TISSUE
202.0x NODULAR LYMPHOMA
202.4x LEUKEMIC RETICULOENDOTHELIOSIS
202.8x OTHER MALIGNANT LYMPHOMAS
202.9x OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE
204.1x CHRONIC LYMPHOID LEUKEMIA
446.00 POLYARTERITIS NODOSA
446.4x WEGENER'S GRANULOMATOSIS
714.00 RHEUMATOID ARTHRITIS

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