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Zoledronic acid: Zometa®; Reclast®

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URL: https://specialtydrug.magellanprovider.com/media/121433/hne_mrxm_zoledronic_acid_07_20.pdf

Specialty Pharmacy Home Page

WebAt Magellan Rx Management, we believe physician business processes should be simple and efficient. Take advantage of our online resources to easily request or review …

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Health New England PA

WebZoladex (goserelin acetate). Zoledronic Acid Zometa Reclast Health New England Site-of-Service. View HNE Site of Service Policy. View Magellan/HNE Site of Service FAQ. …

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Palivizumab (Synagis®) Criteria for Respiratory Syncytial Virus …

WebPalivizumab (Synagis) is a respiratory syncytial virus (RSV) F protein inhibitor monoclonal antibody indicated for the prevention of serious lower respiratory tract disease caused by …

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Independent Health PA

WebIndependent Health Clinical Guidelines. Please Note: Criteria may differ by line of business. Review the appropriate policy for specific criteria or refer to the Part D or Part B Step …

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Nucala® (mepolizumab)

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Saphnelo® (anifrolumab-fnia) (Intravenous)

WebAppendix 1 – Covered Diagnosis Codes. ICD-10. ICD-10 Description. M32.10. Systemic lupus erythematosus organ or system involvement unspecified. M32.11. Endocarditis in …

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Pluvicto® (lutetium Lu 177 vipivotide tetraxetan)

WebThe recommended Pluvicto dosage is 7.4 GBq (200 mCi) intravenously every 6 weeks (up to 10 weeks for toxicities) for up to 6 doses, or until disease progression, or …

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Policies and Guidelines

WebPolicies and Guidelines. Please note that some of our health plan customers require login for their clinical policies to be displayed to their contracted providers.

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Hemgenix® (etranacogene dezaparvovec-drlb)

WebCalculate the dose as follows: − Hemgenix dose (in mL) = patient body weight (in kilogram) x 2. The multiplication factor 2 represents the per kilogram dose (2 × 1013 gc/kg) divided …

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Magellan Rx Specialty Provider Providers User Sign In

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Imfinzi (durvalumab)

WebPage 5 | Imfinzi® (durvalumab) Prior Auth Criteria Proprietary Information. Restricted Access – Do not disseminate or copy without approval.

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Independent Health PSCE

WebOncaspar. (pegaspargase) Rylaze. (asparaginase Erwinia chrysanthemi (recombinant)‐rywn) Xeomin. (incobotulinumtoxinA) Independent Health applies pre …

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Esketamine (Spravato®) Criteria

WebPage 2 | Spravato Suggested Utilization Management – September 2020 Proprietary Information. Restricted Access – Do not disseminate or copy without approval.

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SCIG (immune globulin SQ): Hizentra®, Gammagard Liquid®, …

WebTo calculate the initial weekly dose, divide the monthly IVIG dose in grams by the number of weeks between IGIV infusions and then multiply this value with a Dose …

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Hemgenix® (etranacogene dezaparvovec

WebCalculate the dose as follows: Hemgenix dose (in mL) = patient body weight (in kilogram) x 2. The multiplication factor 2 represents the per kilogram dose (2 × 1013 …

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