Notice of Changes to Prior Authorization Requests

OhioHealth has a partnership with Archimedes, a healthcare solutions company, to ensure that those using the OhioHealthy Preferred Network (OhioHealth associates and their dependents) are receiving quality specialty care. As part of this endeavor, Archimedes and OhioHealth perform periodic reviews of the formulary.

Certain specialty medications and biosimilar agents require a prior authorization. Access the medical drug authorization forms to complete a request.

The following changes to the formulary will go into effect September 1, 2021.

Medications that will now require a prior authorization:

Drug Name Drug Code
Onivyde (irinotecan liposome) J9205
Poteligeo (mogamulizumab-kpkc) J9204
Evenity (romosozumab-aqqg) J3111
Onpattro (patisiran) J0222
Ultomiris (ravulizumab-cwvz) J1303
Mometasone sinus sinuva J7402
Blenrep (belantamab mafodont blmf) J9037
Infugem (gemcitabine) J9198
Monjuvi (tafasitamab-cxix) J9349
Nyvepria (pegfilgrastim) Q5122
Simponi (golimumab) J1602

Medications that are no longer covered under the medical benefit:

Drug Name Drug Code
Makena (hydroxyprogesterone caproate) J1729
Makena (HYDROXYprogesterone) J1725
Makena (HYDROXYprogesterone) J1726
Makena (HYDROXYprogesterone) J1729
Makena (HYDROXYprogesterone) Q9885
Makena (HYDROXYprogesterone) Q9986
Supprelin LA (histrelin acetate) J9226
Enhertu (fam-trastuzumab deruxtecan-nxki) J9358
Xembify (immune globulin) J1558
Libtayo (cemiplimab-rwlc) J9119
Sarclisa (isatuximab-irfc) J9227
Asceniv (immune globulin) J1554
Cutaquig (immune globulin) J3590
Padcev (enfortumab vedotin-ejfv) J9177
Beovu (brolucizumab-dbll) J0179
Stelara (ustekinumab) SUBQ J3357

OhioHealth appreciates your partnership in helping maintain an affordable and sustainable benefit for its employees.

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