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

Bortezomib

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

Polivy (polatuzumab vedotin-piiq)

Supprelin LA (histrelin)

Trelstar Depot
(triptorelin)

Vantas
(histrelin acetate)

Velcade 
(bortezomib)

Xeomin
(Incobotulinum toxin A)

Zaltrap 
(ziv-aflibercept)

Zarxio
(filgrastim-sndz)

Zoladex
(goserelin acetate)

 

 

 

View Security Health Plan Clinical Guidelines policies.