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 
(onabotulinum toxin A)

Dacogen
(decitabine)

Dysport 
(abobotulinum toxin A)

Emend 
(fosaprepitant)

Faslodex 
(fulvestrant)

Granix 
(tbo-filgrastim)

Hyaluronic Acid: (Osteoarthritis)
Gel-One
Hylagan

Leukine
(sargramostim)

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

Myobloc
(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
(Anemia)

Trelstar Depot
(triptorelin)

Vantas
(histrelin acetate)

Velcade 
(bortezomib)

Xeomin
(Incobotulinum toxin A)

Zarxio
(filgrastim-sndz)

Zoladex
(goserelin acetate)

 

 

 

View Security Health Plan Clinical Guidelines policies.