Commercial Payer Information

Commercial Payer Information

Payers create their own policies with regard to product coverage. Since information varies by payer, it is important to contact the payer directly or consult its Web site to obtain product-specific coverage.

Select a state to learn more about reimbursement in that state.

Third-party reimbursement is affected by many factors. The content provided is for informational purposes only and is not intended to provide reimbursement or legal advice and does not promise or guarantee coverage, levels of reimbursement, payment, or charge. Similarly, all CPT®* and HCPCS codes are supplied for informational purposes only and represent no promise or guarantee that these codes will be appropriate or that reimbursement will be made. It is not intended to increase or maximize reimbursement by any payer. Laws, regulations, and policies concerning reimbursement are complex and are updated frequently. While we have made an effort to be current as of the issue date of this document, the information may not be as current or comprehensive when you view it. We strongly recommend that you consult with your payer organization(s) for local or actual coverage and reimbursement policies and with your internal reimbursement specialist for any reimbursement or billing questions.

*CPT® copyright 2016 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association.

Janssen CarePath does not endorse and is not responsible for the content on any of the Web sites listed below, or the services provided by these organizations. Clicking on any of the links below will take you to a Web site to which our Privacy Policy does not apply. We encourage you to read the Privacy Policy of every Web site you visit.

Commercial and Medicare Part D payers each have their own forms and requirements for requesting prior authorization of a prescription drug. In the Commercial table below are links to payer Web sites where you may obtain more information on the approval process, policies and direct links to drug prior authorization forms. For Medicare Part D, click on the link for Contact Janssen CarePath Support. It is important to contact the payer directly or consult its Web site to obtain product-specific information.

Uniform Prescription Drug Prior Authorization Request Form & Notification Requirements for Health Plans

Some health plans in select states must use their state's Uniform Prior Authorization request form. Please contact Janssen CarePath at 877-CarePath (877-227-3728) for assistance in obtaining prior authorization forms.

Click here to see if your state is included:

Uniform Prior Authorization Information for Select States

Payer Prior Authorization Information
Aetna Pharmacy Clinical Policy Bulletins and Prior Authorization
Health Care Professional (Pharmacy) Forms
Arkansas Blue Cross and Blue Shield Prior Authorization Request Form
Provider Forms
Blue Cross of Idaho Provider Prior Authorization Requirements: Pharmacy Requests
Blue Cross and Blue Shield of Alabama Specialty Pharmacy Form
Prescription Drug Guides
Blue Cross Blue Shield of Arizona Prior Authorization Guidelines (Standard Pharmacy Plans)
Prior Authorization Guidelines (Employer Sponsored Plans)
Blue Cross and Blue Shield of Florida/Florida Blue Medication Guides
Quantity Limit Request Form
Specialty Pharmacy Request Form
Blue Cross and Blue Shield of Illinois Prior Authorization and Step Therapy Programs
Blue Cross and Blue Shield of Kansas Prescription Drugs
Precertification / Pre-authorization
Blue Cross and Blue Shield of Minnesota Prescription Drugs
Minnesota Uniform Form for PA Requests and Formulary Exceptions
Blue Cross and Blue Shield of Montana Provider Forms and Documents
Prior Authorization and Step Therapy Programs
Blue Cross and Blue Shield of Nebraska Policies & Forms: Pre-Authorization Forms
Blue Cross and Blue Shield of New Mexico Prior Authorization and Step Therapy Programs
Blue Cross and Blue Shield of North Carolina Prior Review and Limitations
Blue Cross and Blue Shield of Oklahoma Prior Authorization and Step Therapy Programs
BlueCross BlueShield of South Carolina Drug Management and Prior Authorization
BlueCross BlueShield of Texas Prior Authorization and Step Therapy Programs
Blue Cross Blue Shield of Wyoming Pharmacy Guide & Forms
CareFirst BlueCross BlueShield Prior Authorization/Step Therapy
Pharmacy Forms
Cigna Pharmacy Resources and Forms
CVS Caremark Prior Authorization Information
Electronic Prior Authorization
Electronic Prior Authorization FAQs
Clinical Prior Authorization Criteria Request Form
Geisinger Health/Geisinger Health Plan Prior Authorization Form
Gundersen Health Plan Pharmacy Forms for Healthcare Providers: Prior Authorization
Highmark (formerly Blue Cross of Northeastern Pennsylvania) Provider Rx Prior Authorization Form
Drug Utilization Management Criteria
Humana Pharmacy Prior Authorizations
Independence Blue Cross Prior Authorization: Pharmacy Benefit
Midwest Health Plan, Inc. Pharmacy Approval Criteria
Pharmacy Documents
Medical Mutual of Ohio Provider Home
Prior Approval List
Prior Approval Form
Neighborhood Health Plan Standardized Prior Authorization Request Form
Regence BlueCross BlueShield Prior Authorization Form
Wellmark Blue Cross and Blue Shield Provider Drug Information
Provider Prior Authorization

R2

Medicare Part D

Contact Janssen CarePath

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Commercial Payer: State-Specific Information

Alabama Commercial Payer Information

Commercial
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes 2, 4 Yes For more information
Cigna Yes 3   For more information
Humana Yes 3, 4, Specialty Yes For more information
UnitedHealthcare Yes 2 Yes For more information
Medicare Part D
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes Plan dependent Yes For more information
Cigna Yes 5 Yes For more information
UnitedHealthcare Yes 5 Yes For more information

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Alaska Commercial Payer Information

Commercial
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes 2, 4 Yes For more information
Cigna Yes 3   For more information
Humana Yes 3, 4, Specialty Yes For more information
UnitedHealthcare Yes 2 Yes For more information
Medicare Part D
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes Plan dependent Yes For more information
Cigna Yes 5 Yes For more information
UnitedHealthcare Yes 5 Yes For more information

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Arizona Commercial Payer Information

Commercial
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes 2, 4 Yes For more information
Cigna Yes 3   For more information
Humana Yes 3, 4, Specialty Yes For more information
UnitedHealthcare Yes 2 Yes For more information
Medicare Part D
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes Plan dependent Yes For more information
Cigna Yes 5 Yes For more information
UnitedHealthcare Yes 5 Yes For more information

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Arkansas Commercial Payer Information

Commercial
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes 2, 4 Yes For more information
Cigna Yes 3   For more information
Humana Yes 3, 4, Specialty Yes For more information
UnitedHealthcare Yes 2 Yes For more information
Medicare Part D
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes Plan dependent Yes For more information
Cigna Yes 5 Yes For more information
UnitedHealthcare Yes 5 Yes For more information

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California Commercial Payer Information

California requires that certain health plans must use the uniform Prior Authorization (PA) Request Form. In addition, there are new rules in California regarding the PA process. The rules are effective October 1, 2014 or January 1, 2015, depending on the type of health plan. Click on the PDF below for more information.

Uniform Prescription Drug Prior Authorization Request Form & Notification Requirements for Health Plans in California

Commercial
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes 2, 4 Yes For more information
Anthem Blue Cross of California Yes 2, Specialty Yes For more information
Blue Shield of California Yes 4, Specialty Yes  
Cigna Yes 3   For more information
Health Net Yes 2   For more information
Humana Yes 3, 4, Specialty Yes For more information
UnitedHealthcare Yes 2 Yes For more information
Medicare Part D
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes Plan dependent Yes For more information
Anthem Blue Cross of California Yes 5 Yes For more information
Blue Shield of California Yes 6 Yes  
Cigna Yes 5 Yes For more information
Health Net   5   For more information
UnitedHealthcare Yes 5 Yes For more information

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Colorado Commercial Payer Information

Colorado requires that certain health plans must use the uniform Prior Authorization (PA) Request Form. In addition, there are new rules in Colorado regarding the PA process. The rules are effective January 1, 2015. Click on the PDF below for more information.

Uniform Prescription Drug Prior Authorization Request Form & Notification Requirements for Health Plans in Colorado

Commercial
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes 2, 4 Yes For more information
Cigna Yes 3   For more information
Humana Yes 3, 4, Specialty Yes For more information
UnitedHealthcare Yes 2 Yes For more information
Medicare Part D
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes Plan dependent Yes For more information
Cigna Yes 5 Yes For more information
UnitedHealthcare Yes 5 Yes For more information

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Connecticut Commercial Payer Information

Commercial
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes 2, 4 Yes For more information
Cigna Yes 3   For more information
Humana Yes 3, 4, Specialty Yes For more information
UnitedHealthcare Yes 2 Yes For more information
Medicare Part D
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes Plan dependent Yes For more information
Cigna Yes 5 Yes For more information
UnitedHealthcare Yes 5 Yes For more information

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Delaware Commercial Payer Information

Commercial
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes 2, 4 Yes For more information
Cigna Yes 3   For more information
Humana Yes 3, 4, Specialty Yes For more information
UnitedHealthcare Yes 2 Yes For more information
Medicare Part D
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes Plan dependent Yes For more information
Cigna Yes 5 Yes For more information
UnitedHealthcare Yes 5 Yes For more information

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District of Columbia DC Commercial Payer Information

Commercial
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes 2, 4 Yes For more information
Cigna Yes 3   For more information
Humana Yes 3, 4, Specialty Yes For more information
UnitedHealthcare Yes 2 Yes For more information
Medicare Part D
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes Plan dependent Yes For more information
Cigna Yes 5 Yes For more information
UnitedHealthcare Yes 5 Yes For more information

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Florida Commercial Payer Information

Commercial
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes 2, 4 Yes For more information
Blue Cross and Blue Shield of Florida, Inc./Florida Blue Yes 2, 4 Yes For more information
Cigna Yes 3   For more information
Humana Yes 3, 4, Specialty Yes For more information
SantaFe HealthCare, Inc./AvMed Health Plans Yes 4 Yes For more information
UnitedHealthcare Yes 2 Yes For more information
Medicare Part D
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes Plan dependent Yes For more information
Blue Cross and Blue Shield of Florida (Florida Blue) Yes 5 Yes For more information
Cigna Yes 5 Yes For more information
Humana Yes 5 Yes For more information
SantaFe HealthCare, Inc./AvMed Health Plans Yes 5 Yes For more information
UnitedHealthcare Yes 5 Yes For more information

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Georgia Commercial Payer Information

Commercial
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes 2, 4 Yes For more information
Cigna Yes 3   For more information
Humana Yes 3, 4, Specialty Yes For more information
UnitedHealthcare Yes 2 Yes For more information
Medicare Part D
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes Plan dependent Yes For more information
Cigna Yes 5 Yes For more information
UnitedHealthcare Yes 5 Yes For more information

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Hawaii Commercial Payer Information

Commercial
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes 2, 4 Yes For more information
Cigna Yes 3   For more information
Humana Yes 3, 4, Specialty Yes For more information
UnitedHealthcare Yes 2 Yes For more information
Medicare Part D
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes Plan dependent Yes For more information
Cigna Yes 5 Yes For more information
UnitedHealthcare Yes 5 Yes For more information

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Idaho Commercial Payer Information

Commercial
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes 2, 4 Yes For more information
Cigna Yes 3   For more information
Humana Yes 3, 4, Specialty Yes For more information
UnitedHealthcare Yes 2 Yes For more information
Medicare Part D
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes Plan dependent Yes For more information
Cigna Yes 5 Yes For more information
UnitedHealthcare Yes 5 Yes For more information

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Illinois Commercial Payer Information

Commercial
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes 2, 4 Yes For more information
Blue Cross and Blue Shield of Illinois Yes Specialty Yes For more information
Cigna Yes 3   For more information
Health Alliance Medical Plans of Illinois Yes Specialty    
Humana Yes 3, 4, Specialty Yes For more information
UnitedHealthcare Yes 2 Yes For more information
Medicare Part D
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes Plan dependent Yes For more information
Blue Cross and Blue Shield of Illinois Yes 5 Yes For more information
Cigna Yes 5 Yes For more information
Health Alliance Medical Plans of Illinois Yes 5    
UnitedHealthcare Yes 5 Yes For more information

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Indiana Commercial Payer Information

Commercial
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes 2, 4 Yes For more information
Cigna Yes 3   For more information
Humana Yes 3, 4, Specialty Yes For more information
UnitedHealthcare Yes 2 Yes For more information
Medicare Part D
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes Plan dependent Yes For more information
Cigna Yes 5 Yes For more information
UnitedHealthcare Yes 5 Yes For more information

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Iowa Commercial Payer Information

Commercial
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes 2, 4 Yes For more information
Cigna Yes 3   For more information
Humana Yes 3, 4, Specialty Yes For more information
UnitedHealthcare Yes 2 Yes For more information
Medicare Part D
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes Plan dependent Yes For more information
Cigna Yes 5 Yes For more information
UnitedHealthcare Yes 5 Yes For more information

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Kansas Commercial Payer Information

Commercial
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes 2, 4 Yes For more information
Cigna Yes 3   For more information
Humana Yes 3, 4, Specialty Yes For more information
UnitedHealthcare Yes 2 Yes For more information
Medicare Part D
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes Plan dependent Yes For more information
Cigna Yes 5 Yes For more information
UnitedHealthcare Yes 5 Yes For more information

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Kentucky Commercial Payer Information

Commercial
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes 2, 4 Yes For more information
Cigna Yes 3   For more information
Humana Yes 3, 4, Specialty Yes For more information
UnitedHealthcare Yes 2 Yes For more information
Medicare Part D
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes Plan dependent Yes For more information
Cigna Yes 5 Yes For more information
UnitedHealthcare Yes 5 Yes For more information

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Louisiana Commercial Payer Information

Commercial
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes 2, 4 Yes For more information
Cigna Yes 3   For more information
Humana Yes 3, 4, Specialty Yes For more information
UnitedHealthcare Yes 2 Yes For more information
Medicare Part D
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes Plan dependent Yes For more information
Cigna Yes 5 Yes For more information
UnitedHealthcare Yes 5 Yes For more information

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Maine Commercial Payer Information

Commercial
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes 2, 4 Yes For more information
Cigna Yes 3   For more information
Humana Yes 3, 4, Specialty Yes For more information
UnitedHealthcare Yes 2 Yes For more information
Medicare Part D
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes Plan dependent Yes For more information
Cigna Yes 5 Yes For more information
UnitedHealthcare Yes 5 Yes For more information

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Maryland Commercial Payer Information

Commercial
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes 2, 4 Yes For more information
Cigna Yes 3   For more information
Humana Yes 3, 4, Specialty Yes For more information
UnitedHealthcare Yes 2 Yes For more information
Medicare Part D
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes Plan dependent Yes For more information
Cigna Yes 5 Yes For more information
UnitedHealthcare Yes 5 Yes For more information

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Massachusetts Commercial Payer Information

Commercial
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes 2, 4 Yes For more information
Cigna Yes 3   For more information
Humana Yes 3, 4, Specialty Yes For more information
UnitedHealthcare Yes 2 Yes For more information
Medicare Part D
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes Plan dependent Yes For more information
Cigna Yes 5 Yes For more information
UnitedHealthcare Yes 5 Yes For more information

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Michigan Commercial Payer Information

Commercial
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes 2, 4 Yes For more information
Cigna Yes 3   For more information
Humana Yes 3, 4, Specialty Yes For more information
UnitedHealthcare Yes 2 Yes For more information
Medicare Part D
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes Plan dependent Yes For more information
Cigna Yes 5 Yes For more information
UnitedHealthcare Yes 5 Yes For more information

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Minnesota Commercial Payer Information

Commercial
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes 2, 4 Yes For more information
Cigna Yes 3   For more information
Humana Yes 3, 4, Specialty Yes For more information
UnitedHealthcare Yes 2 Yes For more information
Medicare Part D
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes Plan dependent Yes For more information
Cigna Yes 5 Yes For more information
UnitedHealthcare Yes 5 Yes For more information

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Mississippi Commercial Payer Information

Commercial
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes 2, 4 Yes For more information
Cigna Yes 3   For more information
Humana Yes 3, 4, Specialty Yes For more information
UnitedHealthcare Yes 2 Yes For more information
Medicare Part D
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes Plan dependent Yes For more information
Cigna Yes 5 Yes For more information
UnitedHealthcare Yes 5 Yes For more information

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Missouri Commercial Payer Information

Commercial
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes 2, 4 Yes For more information
Cigna Yes 3   For more information
Humana Yes 3, 4, Specialty Yes For more information
UnitedHealthcare Yes 2 Yes For more information
Medicare Part D
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes Plan dependent Yes For more information
Cigna Yes 5 Yes For more information
UnitedHealthcare Yes 5 Yes For more information

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Montana Commercial Payer Information

Commercial
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes 2, 4 Yes For more information
Cigna Yes 3   For more information
Humana Yes 3, 4, Specialty Yes For more information
UnitedHealthcare Yes 2 Yes For more information
Medicare Part D
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes Plan dependent Yes For more information
Cigna Yes 5 Yes For more information
UnitedHealthcare Yes 5 Yes For more information

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Nebraska Commercial Payer Information

Commercial
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes 2, 4 Yes For more information
Cigna Yes 3   For more information
Humana Yes 3, 4, Specialty Yes For more information
UnitedHealthcare Yes 2 Yes For more information
Medicare Part D
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes Plan dependent Yes For more information
Cigna Yes 5 Yes For more information
UnitedHealthcare Yes 5 Yes For more information

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Nevada Commercial Payer Information

Commercial
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes 2, 4 Yes For more information
Cigna Yes 3   For more information
Humana Yes 3, 4, Specialty Yes For more information
UnitedHealthcare Yes 2 Yes For more information
Medicare Part D
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes Plan dependent Yes For more information
Cigna Yes 5 Yes For more information
UnitedHealthcare Yes 5 Yes For more information

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New Hampshire Commercial Payer Information

Commercial
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes 2, 4 Yes For more information
Cigna Yes 3   For more information
Humana Yes 3, 4, Specialty Yes For more information
UnitedHealthcare Yes 2 Yes For more information
Medicare Part D
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes Plan dependent Yes For more information
Cigna Yes 5 Yes For more information
UnitedHealthcare Yes 5 Yes For more information

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New Jersey Commercial Payer Information

Commercial
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes 2, 4 Yes For more information
Cigna Yes 3   For more information
Humana Yes 3, 4, Specialty Yes For more information
UnitedHealthcare Yes 2 Yes For more information
Medicare Part D
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes Plan dependent Yes For more information
Cigna Yes 5 Yes For more information
UnitedHealthcare Yes 5 Yes For more information

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New Mexico Commercial Payer Information

Commercial
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes 2, 4 Yes For more information
Cigna Yes 3   For more information
Humana Yes 3, 4, Specialty Yes For more information
UnitedHealthcare Yes 2 Yes For more information
Medicare Part D
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes Plan dependent Yes For more information
Cigna Yes 5 Yes For more information
UnitedHealthcare Yes 5 Yes For more information

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New York Commercial Payer Information

Commercial
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes 2, 4 Yes For more information
Cigna Yes 3   For more information
Empire BlueCross BlueShield Yes 2 Yes For more information
Excellus BlueCross BlueShield Yes 2 Yes For more information
Humana Yes 3, 4, Specialty Yes For more information
UnitedHealthcare Yes 2 Yes For more information
Medicare Part D
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes Plan dependent Yes For more information
Cigna Yes 5 Yes For more information
EmblemHealth   5   For more information
Empire BlueCross BlueShield Yes 5 Yes For more information
Excellus BlueCross BlueShield Yes 3, 5 Yes For more information
UnitedHealthcare Yes 5 Yes For more information

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North Carolina Commercial Payer Information

Commercial
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes 2, 4 Yes For more information
Cigna Yes 3   For more information
Humana Yes 3, 4, Specialty Yes For more information
UnitedHealthcare Yes 2 Yes For more information
Medicare Part D
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes Plan dependent Yes For more information
Cigna Yes 5 Yes For more information
UnitedHealthcare Yes 5 Yes For more information

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North Dakota Commercial Payer Information

Commercial
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes 2, 4 Yes For more information
Cigna Yes 3   For more information
Humana Yes 3, 4, Specialty Yes For more information
UnitedHealthcare Yes 2 Yes For more information
Medicare Part D
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes Plan dependent Yes For more information
Cigna Yes 5 Yes For more information
UnitedHealthcare Yes 5 Yes For more information

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Ohio Commercial Payer Information

Commercial
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes 2, 4 Yes For more information
Cigna Yes 3   For more information
Humana Yes 3, 4, Specialty Yes For more information
UnitedHealthcare Yes 2 Yes For more information
Medicare Part D
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes Plan dependent Yes For more information
Cigna Yes 5 Yes For more information
UnitedHealthcare Yes 5 Yes For more information

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Oklahoma Commercial Payer Information

Commercial
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes 2, 4 Yes For more information
Cigna Yes 3   For more information
Humana Yes 3, 4, Specialty Yes For more information
UnitedHealthcare Yes 2 Yes For more information
Medicare Part D
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes Plan dependent Yes For more information
Cigna Yes 5 Yes For more information
UnitedHealthcare Yes 5 Yes For more information

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Oregon Commercial Payer Information

Oregon requires that certain health plans must use the uniform Prior Authorization (PA) Request Form. In addition, there are new rules in Oregon regarding the PA process. The rules are effective July 1, 2015. Click on the PDF below for more information.

Uniform Prescription Drug Prior Authorization Request Form & Notification Requirements for Health Plans in Oregon

Commercial
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes 2, 4 Yes For more information
Cigna Yes 3   For more information
Humana Yes 3, 4, Specialty Yes For more information
UnitedHealthcare Yes 2 Yes For more information
Medicare Part D
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes Plan dependent Yes For more information
Cigna Yes 5 Yes For more information
UnitedHealthcare Yes 5 Yes For more information

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Pennsylvania Commercial Payer Information

Commercial
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes 2, 4 Yes For more information
Cigna Yes 3   For more information
Humana Yes 3, 4, Specialty Yes For more information
UnitedHealthcare Yes 2 Yes For more information
Medicare Part D
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes Plan dependent Yes For more information
Cigna Yes 5 Yes For more information
UnitedHealthcare Yes 5 Yes For more information

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Rhode Island Commercial Payer Information

Commercial
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes 2, 4 Yes For more information
Cigna Yes 3   For more information
Humana Yes 3, 4, Specialty Yes For more information
UnitedHealthcare Yes 2 Yes For more information
Medicare Part D
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes Plan dependent Yes For more information
Cigna Yes 5 Yes For more information
UnitedHealthcare Yes 5 Yes For more information

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South Carolina Commercial Payer Information

Commercial
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes 2, 4 Yes For more information
Cigna Yes 3   For more information
Humana Yes 3, 4, Specialty Yes For more information
UnitedHealthcare Yes 2 Yes For more information
Medicare Part D
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes Plan dependent Yes For more information
Cigna Yes 5 Yes For more information
UnitedHealthcare Yes 5 Yes For more information

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South Dakota Commercial Payer Information

Commercial
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes 2, 4 Yes For more information
Cigna Yes 3   For more information
Humana Yes 3, 4, Specialty Yes For more information
UnitedHealthcare Yes 2 Yes For more information
Medicare Part D
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes Plan dependent Yes For more information
Cigna Yes 5 Yes For more information
UnitedHealthcare Yes 5 Yes For more information

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Tennessee Commercial Payer Information

Commercial
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes 2, 4 Yes For more information
Cigna Yes 3   For more information
Humana Yes 3, 4, Specialty Yes For more information
UnitedHealthcare Yes 2 Yes For more information
Medicare Part D
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes Plan dependent Yes For more information
Cigna Yes 5 Yes For more information
UnitedHealthcare Yes 5 Yes For more information

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Texas Commercial Payer Information

Commercial
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes 2, 4 Yes For more information
BlueCross BlueShield of Texas Yes Specialty Yes For more information
Cigna Yes 3   For more information
Humana Yes 3, 4, Specialty Yes For more information
Scott & White Health Plan Yes 2, Specialty    
UnitedHealthcare Yes 2 Yes For more information
Medicare Part D
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes Plan dependent Yes For more information
BlueCross BlueShield of Texas Yes 5 Yes For more information
Cigna Yes 5 Yes For more information
Scott & White Health Plan   5    
UnitedHealthcare Yes 5 Yes For more information

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Utah Commercial Payer Information

Commercial
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes 2, 4 Yes For more information
Cigna Yes 3   For more information
Humana Yes 3, 4, Specialty Yes For more information
UnitedHealthcare Yes 2 Yes For more information
Medicare Part D
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes Plan dependent Yes For more information
Cigna Yes 5 Yes For more information
UnitedHealthcare Yes 5 Yes For more information

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Vermont Commercial Payer Information

Commercial
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes 2, 4 Yes For more information
Cigna Yes 3   For more information
Humana Yes 3, 4, Specialty Yes For more information
UnitedHealthcare Yes 2 Yes For more information
Medicare Part D
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes Plan dependent Yes For more information
Cigna Yes 5 Yes For more information
UnitedHealthcare Yes 5 Yes For more information

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Virginia Commercial Payer Information

Commercial
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes 2, 4 Yes For more information
Cigna Yes 3   For more information
Humana Yes 3, 4, Specialty Yes For more information
UnitedHealthcare Yes 2 Yes For more information
Medicare Part D
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes Plan dependent Yes For more information
Cigna Yes 5 Yes For more information
UnitedHealthcare Yes 5 Yes For more information

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Washington Commercial Payer Information

Commercial
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes 2, 4 Yes For more information
Cigna Yes 3   For more information
Humana Yes 3, 4, Specialty Yes For more information
UnitedHealthcare Yes 2 Yes For more information
Medicare Part D
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes Plan dependent Yes For more information
Cigna Yes 5 Yes For more information
UnitedHealthcare Yes 5 Yes For more information

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West Virginia Commercial Payer Information

Commercial
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes 2, 4 Yes For more information
Cigna Yes 3   For more information
Humana Yes 3, 4, Specialty Yes For more information
UnitedHealthcare Yes 2 Yes For more information
Medicare Part D
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes Plan dependent Yes For more information
Cigna Yes 5 Yes For more information
UnitedHealthcare Yes 5 Yes For more information

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Wisconsin Commercial Payer Information

Commercial
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes 2, 4 Yes For more information
Cigna Yes 3   For more information
Humana Yes 3, 4, Specialty Yes For more information
UnitedHealthcare Yes 2 Yes For more information
Medicare Part D
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes Plan dependent Yes For more information
Cigna Yes 5 Yes For more information
UnitedHealthcare Yes 5 Yes For more information

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Wyoming Commercial Payer Information

Commercial
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes 2, 4 Yes For more information
Cigna Yes 3   For more information
Humana Yes 3, 4, Specialty Yes For more information
UnitedHealthcare Yes 2 Yes For more information
Medicare Part D
Payer Prior
Authorization
Tier Quantity
Limits
Exception & Appeals
Aetna Yes Plan dependent Yes For more information
Cigna Yes 5 Yes For more information
UnitedHealthcare Yes 5 Yes For more information

R9

Indication

ZYTIGA® (abiraterone acetate) in combination with prednisone is indicated for the treatment of patients with metastatic castration-resistant prostate cancer (mCRPC).

Important Safety Information For ZYTIGA®

Contraindications - ZYTIGA® (abiraterone acetate) is not indicated for use in women. ZYTIGA® can cause fetal harm (Pregnancy Category X) when administered to a pregnant woman and is contraindicated in women who are or may become pregnant.

Hypertension, Hypokalemia and Fluid Retention Due to Mineralocorticoid Excess - Use with caution in patients with a history of cardiovascular disease or with medical conditions that might be compromised by increases in blood pressure, hypokalemia, or fluid retention. ZYTIGA® may cause hypertension, hypokalemia, and fluid retention as a consequence of increased mineralocorticoid levels resulting from CYP17 inhibition. Safety has not been established in patients with LVEF <50% or New York Heart Association (NYHA) Class III or IV heart failure (in Study 1) or NYHA Class II to IV heart failure (in Study 2) because these patients were excluded from these randomized clinical trials. Control hypertension and correct hypokalemia before and during treatment. Monitor blood pressure, serum potassium, and symptoms of fluid retention at least monthly.

Adrenocortical Insufficiency (AI) - AI was reported in patients receiving ZYTIGA® in combination with prednisone, after an interruption of daily steroids and/or with concurrent infection or stress. Use caution and monitor for symptoms and signs of AI if prednisone is stopped or withdrawn, if prednisone dose is reduced, or if the patient experiences unusual stress. Symptoms and signs of AI may be masked by adverse reactions associated with mineralocorticoid excess seen in patients treated with ZYTIGA®. Perform appropriate tests, if indicated, to confirm AI. Increased dosages of corticosteroids may be used before, during, and after stressful situations.

Hepatotoxicity - In postmarketing experience, there have been ZYTIGA®-associated severe hepatic toxicities, including fulminant hepatitis, acute liver failure and deaths. Monitor liver function and modify, withhold, or discontinue ZYTIGA® dosing as recommended (see Prescribing Information for more information). Measure serum transaminases [alanine aminotransferase (ALT) and aspartate aminotransferase (AST)] and bilirubin levels prior to starting treatment with ZYTIGA®, every two weeks for the first three months of treatment, and monthly thereafter. Promptly measure serum total bilirubin, AST, and ALT if clinical symptoms or signs suggestive of hepatotoxicity develop. Elevations of AST, ALT, or bilirubin from the patient's baseline should prompt more frequent monitoring. If at any time AST or ALT rise above five times the upper limit of normal (ULN) or the bilirubin rises above three times the ULN, interrupt ZYTIGA® treatment and closely monitor liver function. Re-treatment with ZYTIGA® at a reduced dose level may take place only after return of liver function tests to the patient’s baseline or to AST and ALT less than or equal to 2.5X ULN and total bilirubin less than or equal to 1.5X ULN.

Permanently discontinue ZYTIGA® for patients who develop a concurrent elevation of ALT greater than 3X ULN and total bilirubin greater than 2X ULN in the absence of biliary obstruction or other causes responsible for the concurrent elevation.

Adverse Reactions - The most common adverse reactions (≥10%) are fatigue, joint swelling or discomfort, edema, hot flush, diarrhea, vomiting, cough, hypertension, dyspnea, urinary tract infection and contusion.

The most common laboratory abnormalities (>20%) are anemia, elevated alkaline phosphatase, hypertriglyceridemia, lymphopenia, hypercholesterolemia, hyperglycemia, elevated AST, hypophosphatemia, elevated ALT and hypokalemia.

Drug Interactions - Based on in vitro data, ZYTIGA® is a substrate of CYP3A4. In a drug interaction trial, co-administration of rifampin, a strong CYP3A4 inducer, decreased exposure of abiraterone by 55%. Avoid concomitant strong CYP3A4 inducers during ZYTIGA® treatment. If a strong CYP3A4 inducer must be co-administered, increase the ZYTIGA® dosing frequency only during the co-administration period [see Dosage and Administration (2.3)]. In a dedicated drug interaction trial, co-administration of ketoconazole, a strong inhibitor of CYP3A4, had no clinically meaningful effect on the pharmacokinetics of abiraterone.

ZYTIGA® is an inhibitor of the hepatic drug-metabolizing enzymes CYP2D6 and CYP2C8. Avoid co-administration with CYP2D6 substrates with a narrow therapeutic index. If alternative treatments cannot be used, exercise caution and consider a dose reduction of the CYP2D6 substrate drug. In a CYP2C8 drug interaction trial in healthy subjects, the AUC of pioglitazone, a CYP2C8 substrate, was increased by 46% when administered with a single dose of ZYTIGA®. Patients should be monitored closely for signs of toxicity related to a CYP2C8 substrate with a narrow therapeutic index if used concomitantly with ZYTIGA®.

Use in Specific Populations - Do not use ZYTIGA® in patients with baseline severe hepatic impairment (Child-Pugh Class C).

051320-160413