Pharmacy Services Clinical Criteria - Avastin, Herceptin, and Xolair
8/7/2020
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Posted by Provider Relations
Fidelis Care may authorize requests for Avastin, Herceptin, and Xolair when appropriate criteria are met for the Child Health Plus (CHP), Medicaid Managed Care, HealthierLife (HARP), Health Exchange, and Essential Plan lines of business. This clinical criteria addresses the use of the following drugs on the medical benefit: Xolair (J2357), Avastin (J9035), and Herceptin (J9355), which are available with prior authorization required, and Perjeta (9306) without prior authorization.