Security Health Plan Post Service Claims Edit Policies
PLEASE NOTE: For the following policies, SHP applies pre-payment, post-service claim edits using diagnosis and maximum unit criteria. Prior authorization criteria do not apply for these policies.
Alpha-1-Proteinase Inhibitors:
Aralast NP
Glassia,
Prolastin-C
Zemaira
Dacogen
(decitabine)
Emend
(fosaprepitant)
Faslodex
(fulvestrant)
Granix
(tbo-filgrastim)
Hyaluronic Acid: (Osteoarthritis)
Gel-One
Hylagan
Leukine
(sargramostim)
Lupron Depot/Lupron Depot-Ped/Eligard/Fensolvi/Camcevi
(leuprolide Suspension)
PAH IV: (Pulmonary Arterial Hypertension ,Intravenous/Subcutaneous)
Flolan/Veletri (epoprestenol)
Remodulin (teprostinil)
Revatio (sildenafil)
PAH OA: (Pulmonary Arterial Hypertension)
(Oral/Inhalation),
Adcirca (tadalafil),
Adempas (riociguat),
Letairis (ambrisentan),
Opsumit (macitentan),
Orenitram (treprostinil),
Revatio (sildenafil),
Tracleer (bosentan),
Tyvaso/Tyvaso DPI (treprostinil),
Uptravi (selexipag),
Ventavis (iloprost)
Polivy (polatuzumab vedotin-piiq)
Retacrit
(Epoetin alfa)
Supprelin LA (histrelin)
Trelstar Depot
(triptorelin)
Vantas
(histrelin acetate)
Velcade
(bortezomib)
Xeomin
(Incobotulinum toxin A)
Zarxio
(filgrastim-sndz)
Zoladex
(goserelin acetate)