Medical specialty drug policies

For all AllWays Health Partners lines of business, certain medical specialty drugs require prior authorization. Search below to find a specific drug.

Prior authorization and infusion drug information

Medical Specialty Drugs that require prior authorization through NovoLogix (NLX)
These medical specialty drugs require prior authorization through NovoLogix (NLX).
Prior authorization form — Medical Specialty Drugs (PDF)
Infusion Drugs reviewed for Home Infusion Therapy
For AllWays Health Partners members except My Care Family members, certain infusion therapy drugs must be administered in the home setting. View the list (PDF).

Requests for other sites of care will be approved only when it is medically necessary to be performed in a setting other than the home. Prior authorization is required through CVS Caremark^®.
How to submit prior authorizations

How to submit prior authorizations
Please use the MA Standardized Prior Authorization form to submit your request to NovoLogix via phone at 844-345-2803 or fax 844-851-0882.

Medical specialty drug policies

A-E
Actemra (effective 8/14/17)
Adagen (effective 1/1/18)
Aldurazyme (effective 1/1/18)
Alimta (effective 3/1/18)
Alpha₁-Proteinase Inhibitors (effective 1/1/18)
Aranesp (effective 1/1/18)
Arcalyst (effective 1/1/18)
Avastin (effective 10/1/17)

Bavencio (effective 3/1/18)
Benlysta (effective 10/1/17)
Berinert (effective 10/1/17)
Botox, Myobloc, Dysport and Xeomin

Cerezyme (effective 1/1/18)
Cinqair
Cinryze (effective 10/1/17)
Corifact (effective 10/1/17)
Cytogam (effective 8/14/17)

Docetaxel (effective 3/1/18)

Elaprase (effective 1/1/18)
Elelyso (effective 1/1/18)
Eligard (effective 1/1/18)
Entyvio
Epogen, Procrit (effective 10/1/17)
Epoprostenol, Flolan, Veletri (effective 1/1/18)
Erbitux (effective 3/1/18)
Exondys 51 (effective 1/1/18)
Eylea (effective 10/1/17)
F-M
Fabrazyme (effective 1/1/18)
Factor VIII (effective 10/1/17)
Factor IX (effective 10/1/17)
Factor_IX_Complex (effective 10/1/17)
Fasenra (effective 10/1/18)
Firazyr (effective 10/1/17)
Firmagon (effective 3/1/18)

Haegarda (effective 3/1/18)
Herceptin (effective 3/1/18)
Hizentra, HyQvia, Cuvitru (effective 8/1/17)
Hyaluronates (effective 10/1/17)

Ilaris (effective 8/1/17)
Imfinzi (effective 3/1/18)
IVIG (effective 8/1/17)

Kalbitor (effective 10/1/17)
Kanuma (effective 1/1/18)
Keytruda (effective 8/1/17)
Krystexxa (effective 8/1/17)

Lemtrada (effective 8/1/17)
Leukine (effective 1/1/18)
Leuprolide (effective 10/1/17)
Lucentis (effective 10/1/17)
Lumizyme (effective 1/1/18)
Lupaneta Pack (effective 3/1/18)
Lupron Depot (Endometriosis, Fibroids) (effective 10/1/17)
Lupron Depot-PED (effective 10/1/17)
Lupron Depot (Prostate Cancer) (effective 10/1/17)

Makena (effective 8/1/17)
Mircera (effective 1/1/18)
N-Z
Neulasta (effective 10/1/17)
Neupogen, Granix, Zarxio (effective 10/1/17)
Novoseven RT (effective 10/1/17)
Nplate (effective 10/1/17)
Nucala PA (effective 8/1/17)

Obizur (effective 10/1/17)
Ocrevus (effective 1/1/18)
Octreotide, Sandostatin, Sandostatin LAR (effective 10/1/17)
Opdivo
Orencia (effective 8/14/17)

Perjeta (effective 3/1/18)
Prolia (effective 8/14/17)

Reclast, zoledronic acid (effective 10/1/17)
Remicade, Inflectra, Renflexis (effective 8/14/17)
Remodulin (effective 1/1/18)
Rituxan (Oncology) (effective 10/1/17)
Rituxan (Rheumatoid Arthritis) (effective 10/1/17)
Ruconest (effective 10/1/17)

Signifor LAR (effective 10/1/17)
Simponi Aria (effective 8/14/17)
Soliris (effective 8/14/17)
Somatuline Depot (effective 10/1/17)
Somavert (effective 1/1/18)
Spinraza
Stelara (effective 8/14/17)
Supprelin LA (effective 10/1/17)

Tecentriq (effective 10/1/17)
Tretten (effective 10/1/17)
Tysabri (effective 3/1/18)

Velcade (effective 3/1/18)
Vimizim (effective 10/1/17)
VPRIV (effective 1/1/18)

Wilate (effective 10/1/17)

Xgeva (effective 8/1/17)
Xolair PA (effective 8/1/17)

Yervoy (effective 3/1/18)

Zoladex (effective 3/1/18)
Zometa, zoledronic acid (effective 10/1/17)

Questions about pharmacy guidelines?

Call provider services at 855-444-4647.

Medical specialty drug policies

Prior authorization and infusion drug information

Medical specialty drug policies

Questions about pharmacy guidelines?

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