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)