P&T Committee Changes
August 10, 2023Drug Quantity Management Program
August 10, 2023BeneCard PBF’s clinical review program utilizes online claim adjudication edits to prevent claim payment until BeneCard PBF has assessed the patient’s drug history and/or current diagnosis through communication with the member’s physicians to ensure appropriate and safe utilization of the medication. Drugs requiring clinical review are associated with a diagnosis-based drug utilization protocol that is used to determine coverage. These protocols are based on clinical information, clinical trials, and industry standards, as well as pharmaceutical compendia such as Micromedex, Facts & Comparison, and AHFS proving for clinically appropriate and sound evidence-based medical standards. Rationale for requiring that a product undergo clinical review before adjudication relates to the following issues: safety, off-label use, product availability/rationing, and special request by the client. One or more of these characteristics could predispose a medication to clinical review status.
| GPI-12 | Drug Name | GPI Name | Therapeutic Category |
|---|---|---|---|
| PENDING | ABRILADA | Adalimumab-afzb | Anti-TNF-alpha - Monoclonal Antibodies |
| 665000700020 | ACTEMRA | Tocilizumab IV Inj | Interleukin-6 Receptor Inhibitors |
| 303000100040 | ACTHAR HP | Corticotropin Inj Gel | Corticotropin |
| 217000607020 | ACTIMMUNE | Interferon Gamma-1B Inj | Antineoplastics Miscellaneous |
| 651000251084 | ACTIQ | Fentanyl Citrate Lollipop | Opioid Agonists |
| 856010100021 | ACTIVASE | Alteplase for Inj | Thrombolytic Agents |
| 828070207020 | ADAKVEO | Crizanlizumab-tmca IV Soln | Blood Form, Coag, and Thromb Agent |
| 9027308045E5 | ADBRY | Tralokinumab-ldrm Subcutaneous Soln | Skin and Mucous Membrane Agents, Misc |
| 213532202021 | ADCETRIS | Brentuximab | Antineoplastic |
| 401430800003 | ADCIRCA | Tadalafil Tab | Pulmonary Hypertension - Phosphodiesterase Inhibitors |
| 621750300003 | ADDYI | Flibanserin | Mixed Serotonin Agonist/Antagonist |
| 401340500003 | ADEMPAS | Riociguat Tab | Pulmonary Hypertension - Soluble Guanylae Cyclase (sGC) Stimulator |
| 61200070100310 | ADIPEX-P (brand only) | Phentermine HCl Tab 37.5 MG | Anorexigenic Agents |
| 2717005600 | ADLYXIN | Lixisenatide Soln Pen-injector | Incretin Mimetics |
| PENDING | ADSTILADRIN | Nadofaragene firadenovec-vncg Susp | Gene Therapy |
| 620505101020 | ADUHELM | Aducanumab-avwa IV Soln | Central Nervous System Agents, Misc |
| 851000102521 | ADVATE | Antihemophilic Factor rAHF-PFM | Antihemophilics |
| 851000104021 | ADYNOVATE | Antihemophilic Factor Recomb Pegylated for Inj | Antihemophilics |
| 16000048200620 | AEMCOLO | Rifamycin Sodium Tab Delayed Release | Antibacterials, Miscellaneous |
| 215325300003 | AFINITOR | Everolimus Tab | Antineoplastic Enzyme Inhibitors |