Medica Medical Pharmacy Claims Edit Policies

For the following policies, Medica applies pre-payment claims edits using diagnosis and maximum unit criteria. Prior authorization criteria do not apply for these policies.

Medica Prime Solution® is the only Medicare exclusion from Prior Authorization and Post Service Claim Edits.

Acthar HP (corticotropin)

Alpha-1-Proteinase Inhibitors (Aralast NP, Glassia, Prolastin-C, Zemaira)

Arcalyst (Rilonacept)

Arzerra (ofatumumab)

Botox (onabotulinum toxin A)

Cinvanti (aprepitant)

Doxil/Lipodox (doxorubicin (liposomal))

Dysport (abobotulinum toxin A)

Eloxatin (oxaliplatin)

Emend (fosaprepitant)

Faslodex (fulvestrant)

Firmagon (degaralix)

Folotyn (pralatrexate)

Gemzar (gemcitabine)

HA Derivatives (Gel-One/Euflexxa)

Halaven (eribulin)

Hycamtin (topotecan)

Ilaris (canakinumab)

Kyprolis (carfilzomib)

Kytril (granisetron)

Leukine (sargramostim)

Lupron Depot/Eligard (leuprolide acetate (for depot suspension))

Mircera (epoetin beta)

Mozobil (plerixafor)

Myobloc (rimabotulinum toxin B)

Prolia/Xgeva (denosumab)

Qutenza (capsaicin 8%)

Sandostatin LAR (octreotide)

Synribo (omacetaxine)

Taxol (paclitaxel)

Taxotere (docetaxel)

Trelstar Depot (triptorelin)

Vantas (histrelin acetate)

Xeomin (Incobotulinum toxin A)

Zaltrap (ziv-aflibercept)

Zarxio (filgrastim-sndz)

Zofran (ondansetron)

Zoladex (goserelin acetate)

Zoledronic Acid (Zometa/Reclast) 

 

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