Commonwealth of Massachusetts
Executive Office of Health and Human Services
Division of Medical Assistance
600 Washington Street
Boston, MA  02111

MassHealth
Nurse Practitioner Bulletin 5
July 1999

TO:      Nurse Practitioners Participating in MassHealth

FROM:      Mark E. Reynolds, Acting Commissioner

RE:      Prior Authorization for Enbrel, Herceptin, and Remicade

Background                     As an ongoing part of the management of the pharmacy program, three drugs—Enbrel, Herceptin, and Remicade—have been added to those that must be dispensed in a prescriber’s office.  These drugs also require prior authorization.

This bulletin also details the procedures for obtaining prior authorization for and dispensing any drug on the following list.

Injectable or                      The Division requires prior authorization for the prescription (or refill) of Infusable                           the following injectable or infusable drugs and devices, which must be Drugs and                         dispensed in a provider’s office.  Use Service Code X3333 to bill for all Devices                             drugs on this list.

Enbrel, Herceptin, and Remicade have been added to the list. Algucerase (Ceredease, Cerezyme)
Alpha-1 proteinase inhibitor (Prolastin) Dornase alpha inhalation solution (Pulmozyne) Enbrel
Erythropoietin (Epogen, Procrit) Filgrastim (Neupogen) Herceptin
Hyalgan
Immune globulins (Gamastan IM, Gamimune, Gammagard, Gammar IM, Iveegam, Ngammar IV, Polygam, Sandolglobulin, Venoglobulin I)
Recombinant human growth hormones [for example, somatrem
(Protopin), somatropin (Humatrope, Nutropin)] Remicade

MassHealth
Nurse Practitioner Bulletin 5
July 1999
Page 2

PA Requirements               Enbrel, Herceptin, and Remicade require prior authorization. The
for Enbrel,                         following are guidelines for the appropriate use of each of these drugs.
Herceptin, and
Remicade                          Enbrel

Enbrel is a new drug that has been approved for the treatment of active rheumatoid arthritis.  It may be used in combination with methotrexate.

·  Enbrel may be appropriate for patients who have failed or who have not responded to at least one course of therapy with disease- modifying antirheumatic drugs.

·  Enbrel should not be used in patients with mild disease or as first-line therapy.

Herceptin

Herceptin is a new drug that has been approved for the treatment of metastatic breast cancer.

· Herceptin should only be used for patients with metastatic breast cancer whose tumors overexpress HER2 protein.

Remicade

Remicade is a new drug that has been approved for the treatment of moderately to severely active Crohn’s disease.

· Remicade should only be used to reduce the signs and symptoms in patients who have had an inadequate response to conventional therapy.

· Remicade may also be used in patients with fistulizing Crohn’s disease to reduce the number of draining enterocutaneous fistulas.

Prior-Authorization            You must submit a completed Request for Prior Authorization form as Procedures                        described in Subchapter 5 of your provider manual.  The request must contain the servicing provider number of the individual practitioner who
will be performing the procedure.  Do not enter the group-practice provider number (the seven-digit number beginning with 97).

Note:  This instruction applies only when you are requesting prior authorization and does not change the way in which you enter provider numbers on the claim form.

MassHealth
Nurse Practitioner Bulletin 5
July 1999
Page 3

Prior-Authorization            Submit the request to the Division at the following address.
Procedures
(cont.)                                        Prior-Authorization Unit
Division of Medical Assistance
600 Washington Street
Boston, MA  02111
Fax:  (617) 210-5088

Claims for                         You must submit on a claim form no. 5 any claim for drugs and
Payment                            devices dispensed in your office.  Use Service Code X3333 to bill for these drugs.  The claim must contain the name, strength, and dosage of the drug or device.  A copy of the current invoice showing the actual acquisition cost must be attached to the claim form.  Claims will be denied if required information is missing.

Supplies of the                  To obtain supplies of the Request for Prior Authorization form, send or fax
PA Form                            a written request to the following address or fax number. Unisys
ATTN: Forms Distribution
P.O. Box 9101
Somerville, MA  02145
Fax:  (617) 576-4087

Questions                         If you have any questions about the information in this bulletin, please contact the Unisys Provider Services Department at (617) 628-4141 or 1-800-325-5231.