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.

Botox J0585
(onabotulinum toxin A)

Dacogen J0894
(decitabine)

Dysport J0586
(abobotulinum toxin A)

Emend J1453
(fosaprepitant)

Faslodex J9395
(fulvestrant)

Granix J1447
(tbo-filgrastim)

Hyaluronic Acid: (Osteoarthritis)
(Gel-One J7326,
Hylagan J7321)

Leukine J2820
(sargramostim)

Lupron Depot/Eligard J1950, J9217
(leuprolide acetate (for depot suspension))

Myobloc J0587
(rimabotulinum toxin B)

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 (treprostinil),
Uptravi (selexipag),
Ventavis (iloprost)

Retacrit Q5106
(Anemia)

Trelstar Depot J3315
(triptorelin)

Vantas J9225
(histrelin acetate)

Velcade J9041
(bortezomib)

Xeomin J0588
(Incobotulinum toxin A)

Zarxio Q5101
(filgrastim-sndz)

Zoladex J9202
(goserelin acetate)

 

 

 

View Security Health Plan Clinical Guidelines policies.