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Vyndaqel® (tafamidis meglumine) Vyndamax® (tafamidis)

WEBLimitations. Approvals will be authorized for 12 months. The following quantity limits apply: Vyndaqel 80mg 120 capsules per 30 days. Mass General Brigham Health Plan includes …

Actived: 8 days ago

URL: https://resources.massgeneralbrighamhealthplan.org/pharmacy/PharmacyPolicies/Commercial/Vyndamax,%20Vyndaqel%20PA_ComExch_Rx.pdf

Program Type Specialty Medications

WEBMass General Brigham Health Plan 2 . Daytrana, QuilliChew ER, and Quillivant XR . 1. The member has a diagnosis of ADD/ADHD or Narcolepsy . AND. 2. The member has tried …

Category:  Health Go Health

Pregabalin_PA_MH_Rx.docx

WEBPregabalin is a GABA analog which binds to alpha-2-delta subunit of voltage-gated calcium channels within the CNS and modulates calcium influx at the nerve terminals, thereby …

Category:  Health Go Health

Program Type Specialty Medications

WEBOverview. Elzonris® (tagraxofusp-erzs) is a CD123-directed cytotoxin indicated for the treatment of blastic plasmacytoid dendritic cell neoplasm (BPDCN) in adults and in …

Category:  Health Go Health

Program Type Specialty Medications

WEBMass General Brigham Health Plan 2 . Limitations . 1. Initial approvals and reauthorizations will be granted for 12 months. References . 1. Somavert [package insert].

Category:  Health Go Health

Program Type Specialty Medications

WEBMass General Brigham Health Plan 2 References 1. Litfulo [package insert]. New York, NY: Pfizer Inc.; June 2023. 2. King B, Zhang X, Harcha WG, et al. Efficacy and safety of …

Category:  Health Go Health

Program Type Specialty Medications

WEBMass General Brigham Health Plan 2 . Note: Medication regimens being used in accordance with National Comprehensive Cancer Network (NCCN) guidelines with at …

Category:  Cancer Go Health

Program Type Specialty Medications

WEBMass General Brigham Health Plan includes Mass General Brigham Health Plan, Inc. and Mass General Brigham Health Insurance Company. Xifaxan 550mg (rifamycin)

Category:  Health Go Health

Program Type Medical and Specialty Medications

WEB2 Reauthorizations requires physician attestation of continuation of therapy and who achieve or maintain a positive clinical response as evidenced by low disease activity …

Category:  Health Go Health

Program Type Medical and Specialty Medications Non …

WEBMass General Brigham Health Plan includes Mass General Brigham Health Plan, Inc. and Mass General Brigham Health Insurance Company. Ocaliva (obeticholic acid)

Category:  Health Go Health

Program Type Specialty Medications

WEBMass General Brigham Health Plan 2 2. Prescriber is an oncologist 3. Appropriate dosing (weight required)Metastatic Gastric or GEJ Adenocarcinoma . ALL. …

Category:  Health Go Health

Zyvox (linezolid) tablets Linezolid oral suspension

WEB1. Zyvox (linezolid) [prescribing information]. New York, NY: Pharmacia & Upjohn Co; July 2018. 2. Stevens DL, Bisno AL, Chambers HF, Everett ED, Dellinger P

Category:  Health Go Health

Xifaxan 550mg (rifamycin) Effective 07/01/2019

WEBThe following quantity limits apply: Hepatic Encephalopathy 550mg twice a day; 60 tablets per 30 days. 399 Revolution Drive, Suite 810, Somerville, MA 02145 | …

Category:  Health Go Health

Glaucoma Step Therapy Effective 02/01/2024

WEBMass General Brigham Health Plan 2 1. Xalatan (latanoprost) [prescribing information]. New York, NY: Pfizer; April 2017 2. Lumigan (bimatoprost) [prescribing information].

Category:  Health Go Health

Cerezyme (imiglucerase) Elelyso (taliglucerase alfa) VPRIV

WEBMass General Brigham Health Plan 2 • Thrombocytopenia 4. For Cerezyme: The member is at least 2 years of age 5. For Elelyso and VPRIV: The member is at least 4 years of age

Category:  Health Go Health

Schedule of Benefits

WEBFor more information about your benefits, log into Member.MassGeneralBrighamHealthPlan.org to see your plan documents and get …

Category:  Health Go Health

TESTOPEL® (testosterone pellets)

WEBThe member has a diagnosis of gender dysphoria/incongruence or gender identity disorder or is status-post gender reassignment surgery. The medication is being prescribed by or …

Category:  Health Go Health

Avastin (bevacizumab) Mvasi (bevacizumab-awwb) Zirabev …

WEBColorectal cancer (CRC) The member has a diagnosis of colorectal cancer, including small bowel adenocarcinoma, appendiceal carcinoma, and anal adenocarcinoma. For Avastin …

Category:  Cancer Go Health

Program Type Medical and Specialty Medications Non …

WEBAll Plans Phone: 877-519-1908 Fax: 855-540-3693

Category:  Health Go Health

Acromegaly, Carcinoid, Cushing Syndrome Agents Mycapssa …

WEB399 Revolution Drive, Suite 810, Somerville, MA 02145 | allwayshealthpartners.org AllWays Health Partners includes AllWays Health Partners, Inc. and AllWays H ealth Partners …

Category:  Health Go Health

Over Active Bladder Long-Acting Anticholinergics

WEB1. Detrol LA (tolterodine) [prescribing information]. New York, NY: Pfizer; July 2018 2. Enablex (darifenacin) [prescribing information]. Irvine, CA: Allergan USA Inc

Category:  Health Go Health

Avsola® (infliximab -axxq) Inflectra ® (infliximab-dyyb) …

WEBRequests for Inflectra or Renflexis that document stability can be approved without documentation of failed trials with the preferred infliximab agents for ankylosing …

Category:  Health Go Health

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