Medicaid: This is considered a carve out drug. Please contact Medicaid fee for service for coverage.
Medicare: Not covered
No prior authorization required for:
- Emergency room
- Skilled nursing facility
Injectable auth/billing notes:
Medications billed with miscellaneous codes will be reviewed. Explanatory notes must accompany the claim.
Priority Health Medicare applies CMS local coverage determination criteria when available for Part B drugs.
Benefit: Pharmacy only
Notes: Up to 40 units, infantile spasms
Criteria for coverage: See PA forms