No prior authorization required for:

• Emergency room
• Inpatient
• 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.

Code(s): J3590, C9490

Benefit: Medical

Notes: Reduce recurrence of C- Diff infection 

Criteria for coverage:

• See PA form for criteria for Medicare (Part D)

• Refer to CMS local coverage determination criteria for Part B when available.

• Not covered for Commercial and Medicaid