Prior Authorization Drugs

For certain prescription drugs, we have additional requirements for coverage or limits on our coverage. This ensures that our members use these drugs in a safe way. It also helps to control costs for everyone!

We require you to get prior authorization (prior approval) before certain drugs will be covered under the plan. This means that your doctor or health care provider will need to contact us before you fill your prescription.

Without the necessary information on the Prior Authorization Form, we may not cover the drug.

Step Therapy Drugs

In some cases, we require you to first try one drug to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may require your doctor to prescribe Drug A first. If Drug A does not work for you, then we will cover Drug B.

To see if one or more of the drugs you are taking requires prior authorization or step therapy, type the name of the drug in the Look-Up box below. If a drug you are taking requires prior authorization or step therapy from the Plan, please download and complete a Prior Authorization Form and ask your doctor or other prescriber to fax it to us at 1-855-633-7673.

If you would like a printable Prior Authorization Criteria or Step Therapy document, click:
Prior Authorization Plus Criteria
Prior Authorization Value Criteria
Step Therapy Plus Criteria
Step Therapy Value Criteria
If you need to download a free copy of Adobe Reader, please scroll to the bottom of the page.

To find out if the drug you take is subject to these additional requirements or limits, look in your printed formulary booklet, on our Web site (please choose the plan you are in), or Contact Us.

The information on this page is currently under review and may be updated. Please check back later for updates or Contact Us for information on your drugs.

Updated 11/01/2012

Prior Authorization Drugs

ACTEMRA

PA

Drugs: ACTEMRA
Covered Uses: All FDA approved indications not otherwise excluded from Part D
Exclusion Criteria: Active infection (including TB). Concurrent therapy with other biologic agent(s).
Required Medical Information: Screening for latent tuberculosis is required. If results are positive, patient must have completed treatment or must currently be receiving treatment for latent tuberculosis. Evaluate for HBV risk and initiate treatment if appropriate. For RA, must have an inadequate response or intolerance/contraindication to one TNF antagonist therapy. For sJIA, pediatric patients must have active systemic features (e.g., fever) AND inadequate response, contraindication or intolerance to corticosteroids.
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: Plan Year
Other Criteria: For renewals, patient must have responded to Actemra therapy (e.g., condition improved or stabilized).
ACTIMMUNE

PA

Drugs: ACTIMMUNE
Covered Uses: All FDA approved indications not otherwise excluded from Part D, Mycosis fungoides, Sezary syndrome
Exclusion Criteria:
Required Medical Information:
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: Plan Year
Other Criteria:
ADAGEN

PA

Drugs: ADAGEN
Covered Uses: All FDA approved indications not otherwise excluded from Part D
Exclusion Criteria: Severe thrombocytopenia. Use in preparation for or in support of bone marrow transplantation.
Required Medical Information:
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: Plan Year
Other Criteria: Use for direct replacement for deficient enzyme (no benefit achieved in patients with immunodeficiency due to other causes).
ADCIRCA

PA

Drugs: ADCIRCA
Covered Uses: All FDA approved indications not otherwise excluded from Part D
Exclusion Criteria: Nitrate therapy
Required Medical Information: PAH confirmed by right heart catheterization OR by Doppler echocardiogram in infants.
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: Plan Year
Other Criteria:
AFINITOR

PA

Drugs: AFINITOR
Covered Uses: All FDA approved indications not otherwise excluded from Part D. Monotherapy for progressive or relapsed Waldenstrom's macroglobulinemia/lymphoplasmacytic lymphoma. Unresectable or advanced (stage IIIB-IV) disease with low- or intermediate-grade (atypical or typical carcinoid) lung neuroendocrine tumors, breast cancer
Exclusion Criteria:
Required Medical Information: For renal angiomyolipoma associated with TSC: patient does not require immediate surgery. For breast cancer: 1) patient has hormone receptor-positive, HER2-negative metastatic breast cancer, 2) previously treated with letrozole or anastrozole, and 3) Afinitor will be used in combination with exemestane.
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: Plan Year
Other Criteria:
ALDURAZYME

PA

Drugs: ALDURAZYME
Covered Uses: All FDA approved indications not otherwise excluded from Part D
Exclusion Criteria:
Required Medical Information: Diagnosis confirmed by measurement of alpha-L-iduronidase activity (enzymatic assay) or DNA testing. For Scheie form of MPS I, must have at least 2 moderate to severe symptoms. Must demonstrate improvement in lung function in patients who have received at least 26 weeks of Aldurazyme on re-authorization.
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: Plan Year
Other Criteria:
ALPHA1-PROTEINASE INHIBITOR

PA

Drugs: ARALAST NP
Covered Uses: All FDA approved indications not otherwise excluded from Part D
Exclusion Criteria: Patient has IgA deficiency with antibodies against IgA.
Required Medical Information: Alpha1-proteinase inhibitor concentration is less than 11 micromoles per liter. The FEV1 level is between 35% and 60% predicted OR greater than 60% predicted. If the FEV1 is greater than 60% predicted, then the patient has experienced a rapid decline in lung function (ie, reduction of FEV1 more than 120 mL/year) that warrants treatment.
Age Restrictions: 18 years old and older
Prescriber Restrictions:
Coverage Duration: Plan Year
Other Criteria:
AMPHETAMINES

PA

Drugs: AMPHETAMINE/DEXTROAMPHETA, DEXTROAMPHETAMINE SULFATE
Covered Uses: All FDA approved indications not otherwise excluded from Part D
Exclusion Criteria: MAOI concurrent use or within the last 14 days except if prescriber is a psychiatrist with experience prescribing both MAOI and amphetamine/dextroamphetamine drugs.
Required Medical Information: Sleep studies for narcolepsy diagnosis
Age Restrictions: 3 years of age and older
Prescriber Restrictions:
Coverage Duration: Plan Year
Other Criteria: Consider benefits of use versus the potential risks of serious cardiovascular events
AMPYRA

PA

Drugs: AMPYRA
Covered Uses: All FDA approved indications not otherwise excluded from Part D
Exclusion Criteria: Moderate to severe renal impairment (CrCL less than or equal to 50 mL/min), history of seizures, Ampyra at doses exceeding 10 mg twice daily.
Required Medical Information: Patient must demonstrate sustained walking impairment, but with the ability to walk 25 feet (with or without assistance) prior to starting Ampyra.
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: 2 months, then plan year upon renewal
Other Criteria: To continue therapy, the patient must experience an improvement in walking speed or other objective measure of walking ability since starting Ampyra.
ANABOLIC STEROIDS

PA

Drugs: ANADROL-50, OXANDROLONE
Covered Uses: All FDA approved indications not otherwise excluded from Part D, HIV-wasting
Exclusion Criteria: Known or suspected carcinoma of the prostate or breast (in male patients), carcinoma of the breast in women with hypercalcemia, pregnancy, nephrosis (the nephrotic phase of nephritis), hypercalcemia.
Required Medical Information:
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: 6 months
Other Criteria:
ANAGRELIDE

PA

Drugs: ANAGRELIDE HYDROCHLORIDE
Covered Uses: All FDA approved indications not otherwise excluded from Part D
Exclusion Criteria: Severe hepatic impairment
Required Medical Information:
Age Restrictions:
Prescriber Restrictions: Oncologist or hematologist
Coverage Duration: 6 months
Other Criteria:
ARANESP

PA

Drugs: ARANESP ALBUMIN FREE
Covered Uses: All FDA approved indications not otherwise excluded from Part D. Non-del(5q) MDS with anemia and sEPO at or below 500 mU/mL.
Exclusion Criteria: Uncontrolled hypertension, hemoglobin greater than or equal to 13 g/dL
Required Medical Information: All patients must meet the following criteria: 1) The pretreatment hemoglobin level is less than 10 g/dL (or less than or equal to 11 g/dL with clinical symptoms of anemia). 2) Once on therapy for 12 weeks, the hemoglobin must increase at least 1 g/dL in response to Aranesp. 3) Once on therapy, the hemoglobin should be maintained to a level below 12 g/dL and if the level exceeds 12 g/dL, the prescriber must reduce the dose. Patients with chronic kidney disease or those treated with myelosuppressive chemotherapy must have adequate iron stores or be receiving concomitant iron supplementation.
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: 12 weeks
Other Criteria: Patient is instructed by the prescriber to report any signs or symptoms of adverse cardiovascular or thrombotic events.
ARCALYST

PA

Drugs: ARCALYST
Covered Uses: All FDA approved indications not otherwise excluded from Part D
Exclusion Criteria: Active or chronic infection. Concurrent therapy with other biologics.
Required Medical Information:
Age Restrictions: 12 years of age and older
Prescriber Restrictions:
Coverage Duration: Plan Year
Other Criteria: For renewal, patient's condition must have improved or stabilized.
ATYPICAL ODT

PA

Drugs: FAZACLO
Covered Uses: All FDA approved indications not otherwise excluded from Part D
Exclusion Criteria: For Fazaclo: a. if the patient has any of the following contraindications: agranulocytosis, bone marrow suppression, coma, ileus, leukopenia, myocarditis or neutropenia b. if the patient has CNS depression, dementia-related psychosis or uncontrolled epilepsy.
Required Medical Information: The patient must be unable/unwilling to take tablets or capsules or are high risk for non-compliance AND must not be receiving other tablets or capsules indicating that they can take non-dissolvable tablets.
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: Plan Year
Other Criteria:
AVONEX

PA

Drugs: AVONEX
Covered Uses: All FDA approved indications not otherwise excluded from Part D
Exclusion Criteria:
Required Medical Information:
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: Plan Year
Other Criteria:
B VS. D

PA

Drugs: ACETYLCYSTEINE, ADRIAMYCIN, ALBUTEROL SULFATE, ALIMTA, AMIFOSTINE, AMINOSYN, AMINOSYN 8.5%/ELECTROLYTE, AMINOSYN II, AMINOSYN II 3.5%/DEXTROSE, AMINOSYN II 3.5/DEXTROSE, AMINOSYN II 4.25/DEXTROSE, AMINOSYN II 5/DEXTROSE 25, AMINOSYN II 8.5%/ELECTROL, AMINOSYN II M 3.5%/DEXTRO, AMINOSYN M, AMINOSYN-HBC, AMINOSYN-HF, AMINOSYN-PF, AMINOSYN-PF 7%, AMIODARONE HCL, AMPHOTERICIN B, ASTRAMORPH, AVASTIN, AZASAN, AZATHIOPRINE, AZATHIOPRINE SODIUM, BICNU, BLEOMYCIN SULFATE, BONIVA, BUDESONIDE, BUSULFEX, CALCITRIOL, CAMPATH, CARBOPLATIN, CELLCEPT, CISPLATIN, CLADRIBINE, CLINIMIX 2.75%/DEXTROSE 5, CLINIMIX 4.25%/DEXTROSE 1, CLINIMIX 4.25%/DEXTROSE 2, CLINIMIX 4.25%/DEXTROSE 5, CLINIMIX 5%/DEXTROSE 15%, CLINIMIX 5%/DEXTROSE 20%, CLINIMIX 5%/DEXTROSE 25%, CLINIMIX E 2.75%/DEXTROSE, CLINIMIX E 4.25%/DEXTROSE, CLINIMIX E 5%/DEXTROSE 15, CLINIMIX E 5%/DEXTROSE 20, CLINIMIX E 5%/DEXTROSE 25, CLINISOL SF 15%, COLISTIMETHATE SODIUM, COSMEGEN, CROMOLYN SODIUM, CUBICIN, CYCLOPHOSPHAMIDE, CYCLOSPORINE, CYCLOSPORINE MODIFIED, CYTARABINE, CYTARABINE AQUEOUS, DACARBAZINE, DAUNORUBICIN HCL, DAUNOXOME, DECAVAC, DEPO-PROVERA, DEXRAZOXANE, DIPHTHERIA/TETANUS TOXOID, DOCETAXEL, DOXIL, DOXORUBICIN HCL, DURAMORPH, ELITEK, ELSPAR, EMEND, ENGERIX-B, EPIRUBICIN HCL, ETOPOSIDE, FASLODEX, FENTANYL CITRATE, FLUDARABINE PHOSPHATE, FLUOROURACIL, FREAMINE III, FREAMINE III 3%, GAMASTAN S/D, GANCICLOVIR, GEMCITABINE, GEMCITABINE HCL, GENGRAF, GRANISETRON HCL, HECTOROL (Plus Formulary Only), HEPARIN SODIUM, HEPARIN SODIUM/D5W, HEPARIN SODIUM/NACL 0.45%, HEPARIN SODIUM/SODIUM CHL, HEPATAMINE, HEPATASOL, HERCEPTIN, HYDROMORPHONE HCL, IBANDRONATE SODIUM, IDARUBICIN HCL, IFEX, IFOSFAMIDE, IFOSFAMIDE/MESNA, INTRALIPID, INTRON-A, INTRON-A W/DILUENT, IPRATROPIUM BROMIDE, IPRATROPIUM BROMIDE/ALBUT, IRINOTECAN, ISTODAX, LEUCOVORIN CALCIUM, LEVALBUTEROL, LEVOCARNITINE, LIDOCAINE/PRILOCAINE, LIPOSYN II, LIPOSYN III, MELPHALAN HYDROCHLORIDE, MESNA, METHOTREXATE SODIUM, MIACALCIN, MITOMYCIN, MITOXANTRONE HCL, MORPHINE SULFATE, MUSTARGEN, MYCOPHENOLATE MOFETIL, MYFORTIC, NEORAL, NEPHRAMINE, NULOJIX, ONDANSETRON HCL, ONDANSETRON ODT, ONTAK, OXALIPLATIN, PACLITAXEL, PENTOSTATIN, PERFOROMIST, PREMASOL, PROCALAMINE, PROGRAF, PROLEUKIN, PROSOL, PULMOZYME, RAPAMUNE, RECOMBIVAX HB, REMODULIN, SANDIMMUNE, TACROLIMUS, TAXOTERE, TETANUS TOXOID ADSORBED, TETANUS/DIPHTHERIA TOXOID, TOBI, TOPOSAR, TOPOTECAN HCL, TPN ELECTROLYTES, TRAVASOL, TREANDA, TRELSTAR DEPOT MIXJECT, TRELSTAR LA MIXJECT, TRELSTAR MIXJECT, TRISENOX, TROPHAMINE, VANCOMYCIN HCL, VELCADE, VIDAZA, VINBLASTINE SULFATE, VINCASAR PFS, VINCRISTINE SULFATE, VINORELBINE TARTRATE, XOPENEX (Plus Formulary Only), ZEMPLAR, ZOMETA, ZORTRESS
Covered Uses: This drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination.
Exclusion Criteria:
Required Medical Information:
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: NA
Other Criteria:
BANZEL

PA

Drugs: BANZEL
Covered Uses: All FDA approved indications not otherwise excluded from Part D
Exclusion Criteria: The patient is diagnosed with familial short QT Syndrome.
Required Medical Information: The patient must be diagnosed with seizures associated with Lennox-Gastaut Syndrome.
Age Restrictions:
Prescriber Restrictions: Neurologist or affiliated with neurology practice
Coverage Duration: Plan Year
Other Criteria:
BETASERON

PA

Drugs: BETASERON
Covered Uses: All FDA approved indications not otherwise excluded from Part D
Exclusion Criteria: Concurrent use of any of the following medications: Interferon-beta therapy (Avonex, Extavia, or Rebif), glatiramer acetate, or mitoxantrone
Required Medical Information: MRI has been performed and has features suggestive of MS (evidence of lesion)
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: Plan Year
Other Criteria: Patients with previous use (12 or more months) of Betaseron must demonstrate 1 of the following clinical responses: decrease in the frequency of relapses, slowing of disease progression, MRI lesions have diminished with therapy, OR patient is stable on therapy.
BRILINTA

PA

Drugs: BRILINTA
Covered Uses: All FDA approved indications not otherwise excluded from Part D
Exclusion Criteria: A. Active pathological bleeding such as peptic ulcer or intracranial hemorrhage. B. History of intracranial hemorrhage. C. Severe hepatic impairment. D. Maintenance dose of aspirin above 100 mg will be used.
Required Medical Information:
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: 12 months, OR 15 months for patient receiving a bare-metal stent (BMS) or drug-eluting stent (DES)
Other Criteria: A. If the patient has received 12 months or more of Brilinta (ticagrelor) therapy, patient is at continued risk for thrombosis or a vascular event and has a need for prolonged Brilinta (ticagrelor) therapy (e.g., DES placement, or lesion characteristics, bifurcation, small diameter vessel, etc.)
BUPRENORPHINE

PA

Drugs: BUPRENORPHINE HCL, SUBOXONE
Covered Uses: All FDA approved indications not otherwise excluded from Part D
Exclusion Criteria: Dose in excess of 4 units daily
Required Medical Information: Documentation that the member is not receiving other opioids
Age Restrictions: 16 years of age and older
Prescriber Restrictions: Prescribers must be certified through CSAT (The Center for Substance Abuse Treatment) of SAMHSA (Substance Abuse and Mental Health Services Administration) to prescribe Suboxone and Subutex
Coverage Duration: Buprenorphine - one month (12 months if pregnant). Buprenorphine-naloxone - 12 months.
Other Criteria: Buprenorphine and buprenorphine-naloxone should be part of an overall treatment program. The patient should be monitored periodically.
BYDUREON

PA PLUS FORMULARY ONLY

Drugs: BYDUREON
Covered Uses: All FDA-approved indications not otherwise excluded from Part D.
Exclusion Criteria: A. History of pancreatitis B. Personal or family history of medullary thyroid carcinoma (MTC) C. Multiple Endocrine Neoplasia syndrome type (MEN 2).
Required Medical Information: A. Diagnosis of type 2 diabetes mellitus, B. A creatinine clearance of greater than 30mL per minute or normal kidney function AND C. The patient is being switched from Byetta or Victoza therapy OR D. The patient has an HbA1c level greater than 7 percent AND E. The patient demonstrated an inadequate treatment response, contraindication or been intolerant to metformin OR a sulfonylurea OR a thiazolidinedione OR F. If the patient has been receiving Bydureon therapy for at least 3 months, the patient demonstrated an expected reduction in HbA1c since starting Bydureon therapy.
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: Plan Year
Other Criteria:
BYETTA

PA

Drugs: BYETTA
Covered Uses: All FDA approved indications not otherwise excluded from Part D
Exclusion Criteria: History of pancreatitis
Required Medical Information: A. The patient is diagnosed as having type-2 diabetes with an HbA1c level greater than 7. B. The patient has a creatinine clearance of greater than 30mL/minute or normal kidney function. C. The patient has had an inadequate treatment response, intolerance or contraindication to metformin or a sulfonylurea medication. D. If the patient has received previous Byetta therapy for at least 3 months, the patient demonstrated a reduction in HbA1c since initiating Byetta therapy.
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: Plan Year
Other Criteria:
CAMPRAL

PA

Drugs: CAMPRAL
Covered Uses: All FDA approved indications not otherwise excluded from Part D
Exclusion Criteria: Renal failure.
Required Medical Information: A. Clinical diagnosis for alcohol dependence. B. AND clinical evidence indicated that the patient will be abstinent at least 5 days prior to treatment initiation. C. AND a trial of naltrexone (oral/injectable) has been attempted, at clinically significant dosage and duration. Or therapy is documented to be clinically inappropriate (hepatic insufficiency, chronic pain medication use). D. AND medication administration should be part of a comprehensive psychosocial treatment program.
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: 6 months
Other Criteria:
CAYSTON

PA

Drugs: CAYSTON
Covered Uses: All FDA approved indications not otherwise excluded from Part D
Exclusion Criteria:
Required Medical Information: Diagnosis of cystic fibrosis is confirmed by appropriate diagnostic or genetic testing. Confirmation of P. aeruginosa in cultures of the airways. For continuation of therapy in patients younger than 6 years of age, a clinical reason to continue therapy, such as symptomatic improvement, is required. For continuation of therapy in patients older than 6 years of age, pulmonary function tests have not deteriorated more than 10% from baseline or there is a clinical reason to continue therapy, such as symptomatic improvement.
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: Plan Year
Other Criteria:
CELEBREX

PA

Drugs: CELEBREX
Covered Uses: All FDA approved indications not otherwise excluded from Part D
Exclusion Criteria: Post-operative pain following CABG surgery.
Required Medical Information:
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: 6 months for JRA, 12 months for dysmenorrhea, OA, RA, AS, 1 month for acute pain
Other Criteria:
CEREZYME

PA

Drugs: CEREZYME
Covered Uses: All FDA approved indications not otherwise excluded from Part D
Exclusion Criteria: Concurrent therapy with Zavesca.
Required Medical Information: Diagnosis confirmed by bone marrow histology, DNA testing, or b-glucocerebrosidase enzyme assay (enzyme activity less than 30 percent). Must have at least one of following conditions: anemia, thrombocytopenia, bone disease, hepatomegaly, or splenomegaly. Must demonstrate a decrease in liver and spleen volume and/or increase in platelet count and/or increase in Hgb concentration in patients who have received at least 24 months of Cerezyme therapy on re-authorization.
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: Plan Year
Other Criteria:
CHANTIX

PA

Drugs: CHANTIX, CHANTIX STARTING MONTH PA
Covered Uses: All FDA approved indications not otherwise excluded from Part D
Exclusion Criteria: Concurrent Zyban use
Required Medical Information: Evaluation for neuropsychiatric symptoms. If the patient is currently receiving Chantix, the patient's treatment, including the use of Chantix, has resulted in smoking cessation.
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: 12 weeks initial, 12 weeks additional upon renewal
Other Criteria:
COPAXONE

PA

Drugs: COPAXONE
Covered Uses: All FDA approved indications not otherwise excluded from Part D
Exclusion Criteria: Concurrent use of any of the following medications: Interferon-beta therapy (Avonex, Betaseron, Extavia, or Rebif), or mitoxantrone.
Required Medical Information:
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: Plan Year
Other Criteria: Patients with previous use (12 or more months) of Copaxone must demonstrate one of the following clinical responses: decrease in the frequency of relapses, slowing of disease progression, diminished MRI lesions, OR patient is stable on therapy.
DRONABINOL

PA

Drugs: DRONABINOL
Covered Uses: All FDA approved indications not otherwise excluded from Part D
Exclusion Criteria:
Required Medical Information: A. The diagnosis is documented as anorexia associated with weight loss in a patient with AIDS a. AND the patient has had an involuntary weight loss of greater than 10% of pre-illness baseline body weight or a body mass index (BMI) less than 20kg/m2 in the absence of a concurrent illness or medical condition other than HIV that may cause weight loss b. AND the patient demonstrated an inadequate treatment response to a 30-day drug regimen of megestrol acetate (Megace) c. OR patient has a contraindication to or been intolerant to megestrol acetate (Megace) d. AND if the patient has received previous dronabinol therapy, he/she must show a positive response to therapy by maintaining or increasing their initial weight and/or muscle mass before initiating dronabinol therapy. B. The diagnosis is documented as nausea and vomiting associated with cancer chemotherapy in a cancer patient a. AND the patient is receiving a chemotherapy or radiation regimen b. AND the patient, through at least one cycle of chemotherapy, experienced an inadequate treatment response to or intolerance to intravenous ondansetron and at least one of the following oral anti-emetic agents: metoclopramide, promethazine, prochlorperazine, meclizine, trimethobenzamide, oral 5-HT3 receptor antagonists e. AND if the patient has received previous dronabinol therapy, he/she must show a positive response by showing a reduced incidence of emesis and/or nausea.
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: 6 months
Other Criteria: B vs D coverage determination per CMS guidelines
ELAPRASE

PA

Drugs: ELAPRASE
Covered Uses: All FDA approved indications not otherwise excluded from Part D
Exclusion Criteria:
Required Medical Information: Diagnosis confirmed by DNA testing or enzymatic analysis (deficiency of iduronate 2-sulfatase enzyme activity).
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: Plan Year
Other Criteria:
EMSAM

PA

Drugs: EMSAM
Covered Uses: All FDA approved indications not otherwise excluded from Part D
Exclusion Criteria: Pheochromocytoma, concurrent use of the following medications: dextromethorphan, St. John's Wort.
Required Medical Information: A. Clinical diagnosis of major depressive disorder not responsive other antidepressants as demonstrated by at least 2 documented trials (clinically sufficient dose and duration of six weeks or longer) of the following: selective serotonin reuptake inhibitors (SSRI), serotonin/norepinephrine reuptake inhibitors (SNRI), bupropion, mirtazapine, or tricyclic/tetracyclic antidepressants B. OR clinical diagnosis of major depressive disorder for those patients who cannot take any oral preparations (including commercially available liquid antidepressants). C. For requests over 6 mg/24 hours, patient must agree to adhere to a tyramine restrictive diet.
Age Restrictions:
Prescriber Restrictions: Psychiatrist or affiliated with a psychiatry practice
Coverage Duration: Plan Year
Other Criteria:
ENBREL

PA

Drugs: ENBREL
Covered Uses: All FDA approved indications not otherwise excluded from Part D
Exclusion Criteria: Concomitant use with another biologic, active infection (including TB).
Required Medical Information: Screening for latent TB infection and assessment for Hep B risk. For positive latent TB, patient must have completed treatment or is currently receiving treatment for LTBI. HBV infection ruled out or treatment initiated for positive infection. Rheumatoid arthritis - Must have one of following: 1) inadequate response to methotrexate (MTX), 2) inadequate response to another nonbiologic DMARD (e.g., leflunomide, hydroxychloroquine, sulfasalazine) if contraindicated or intolerant to MTX, 3) intolerance or contraindication to at least 2 nonbiologic DMARDs or, 4) use Enbrel as first-line therapy with MTX for severely active RA. Polyarticular JIA - Must have an inadequate response to at least one nonbiologic DMARD or intolerance/contraindication to at least 2 nonbiologic DMARDs. Psoriatic arthritis with predominantly peripheral symptoms - Must have an inadequate response to at least an 8-week maximum tolerated dose trial of at least 1 nonbiologic DMARD unless contraindicated or intolerant to such therapy. Psoriatic arthritis with predominantly axial symptoms and ankylosing spondylitis Inadequate response or intolerance/contraindication to at least 2 NSAIDs. For plaque psoriasis - Must have more than 10% BSA affected or has crucial body areas (e.g., feet, hands, face) affected. Patient must have an inadequate response to at least a 60-day trial of 2 conventional therapies (e.g., phototherapy, calcipotriene, MTX, acitretin) unless contraindicated or intolerant to such therapies.
Age Restrictions: For psoriasis, patient must be 18 years of age or older
Prescriber Restrictions:
Coverage Duration: Plan Year
Other Criteria: For continuation of therapy, patient's condition must have improved or stabilized.
EPLERENONE

PA

Drugs: EPLERENONE
Covered Uses: All FDA approved indications not otherwise excluded from Part D
Exclusion Criteria:
Required Medical Information: A. Diagnosis of hypertension or post-myocardial infarction with LVEF less than or equal to 40% and clinical evidence of CHF after an acute MI. B. AND a serum potassium level less than 5.5 mEq/L. C. For diagnosis of post MI with LVEF less than or equal to 40% and clinical evidence of CHF after an acute MI, the patient must meet the following requirement: creatinine clearance greater than 30 mL/min. D. For the diagnosis of hypertension, the patient must meet the following requirements: the patient does not have type-2 diabetes with microalbuminuria AND the patient has a creatinine clearance greater than 50 mL/min.
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: Plan Year
Other Criteria:
EPO

PA

Drugs: PROCRIT
Covered Uses: All FDA approved indications not otherwise excluded from Part D. Non-del(5q) MDS with anemia and sEPO at or below 500 mU/mL.
Exclusion Criteria: Uncontrolled hypertension
Required Medical Information: For use in an anemic patient prior to surgery, the patient must also receive concomitant iron supplementation. For other indications, all of the following criteria are required: 1) The pretreatment Hgb is less than or equal to 10 g/dL for initial authorization. 2) The patient is receiving concomitant iron supplementation if iron stores are inadequate. 3) The Hgb is maintained at or below 12 g/dL once on therapy. 4) Once on therapy for 12 weeks, the hemoglobin must increase at least 1 g/dL in response to epoetin alfa.
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: 12 weeks
Other Criteria:
ERIVEDGE

PA

Drugs: ERIVEDGE
Covered Uses: All FDA-approved indications not otherwise excluded from Part D.
Exclusion Criteria:
Required Medical Information: Patient meets the following criteria: 1) Metastatic BCC, OR 2) Locally advanced BCC that has recurred following surgery or the patient is not a candidate for radiation or surgery.
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: Plan Year
Other Criteria: For female patients of childbearing potential, verify pregnancy status prior to initiation of therapy and be instructed on the importance and proper use of appropriate contraceptive methods. Male patients are instructed on the importance and proper use of appropriate contraceptive methods. Prior authorization applies to new starts only. Refills will be approved unless use is not coverable under Part D per Medicare drug coverage policies.
EXJADE

PA

Drugs: EXJADE
Covered Uses: All FDA approved indications not otherwise excluded from Part D
Exclusion Criteria: Creatinine clearance less than 40 mL/min or evidence of overt proteinuria, platelet count less than 50 x 10(9)/L, advanced malignancy, high-risk myelodysplastic syndrome (MDS) with poor performance status, or concurrent use of deferoxamine or iron-containing products.
Required Medical Information: The patient must meet all of the following criteria: 1) Diagnosis of transfusion-dependent anemia with chronic iron overload due to blood transfusions, 2) Pretreatment serum ferritin level within the last 60 days of at least 1,000 mcg/L, and 3) Patient will have baseline and monthly monitoring of serum ferritin, serum creatinine, creatinine clearance, serum transaminases, and bilirubin. For patients already receiving Exjade, the prescriber will consider temporary interruption of Exjade when serum ferritin is less than 500 mcg/L.
Age Restrictions: 2 years of age and older
Prescriber Restrictions: Hematologist
Coverage Duration: 3 months
Other Criteria:
EXTAVIA

PA

Drugs: EXTAVIA
Covered Uses: All FDA approved indications not otherwise excluded from Part D
Exclusion Criteria: Concurrent use of any of the following medications: Interferon-beta therapy (Avonex, Betaseron, or Rebif), glatiramer acetate, or mitoxantrone.
Required Medical Information:
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: Plan Year
Other Criteria: Patients with previous use (12 or more months) of Extavia must demonstrate one of the following clinical responses: decrease in the frequency of relapses, slowing of disease progression, MRI lesions have diminished with therapy, OR patient is stable on therapy.
FABRAZYME

PA

Drugs: FABRAZYME
Covered Uses: All FDA approved indications not otherwise excluded from Part D
Exclusion Criteria:
Required Medical Information: Diagnosis confirmed with an enzyme assay measuring a deficiency of alpha-galactosidase enzyme activity or DNA testing.
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: Plan Year
Other Criteria:
FENTANYL PATCH

PA

Drugs: FENTANYL
Covered Uses: All FDA approved indications not otherwise excluded from Part D
Exclusion Criteria: Patients who are not opioid tolerant, patients who do not require continuous opioid analgesia. Patients who are taking any CYP450 3A4 agents who are not being monitored.
Required Medical Information: Assessment for clinical risk of opioid/substance abuse/addiction through Screener and Opioid Assessment for Patients with Pain (SOAPP 1.0), Screener and Opioid Assessment for Patients with Pain, Revision (SOAPP-R), Opioid Risk Tool (ORT), Current Opioid Misuse Measure (COMM), The Diagnosis, Intractability, Risk, and Efficacy Score (DIRE) or other assessment tool.
Age Restrictions: 2 years of age and older
Prescriber Restrictions:
Coverage Duration: 6 months
Other Criteria:
GILENYA

PA

Drugs: GILENYA
Covered Uses: All FDA approved uses not otherwise excluded from Part D
Exclusion Criteria:
Required Medical Information: For new starts, patient had an inadequate response to a trial of a beta interferon agent or Copaxone unless contraindicated or not tolerated.
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: Plan Year
Other Criteria: NA
GLEEVEC

PA

Drugs: GLEEVEC
Covered Uses: All FDA approved indications not otherwise excluded from Part D. Desmoid tumors. Pigmented villonodular synovitis/tenosynovial giant cell tumor, as a single agent.
Exclusion Criteria:
Required Medical Information: Chronic myeloid leukemia (CML) and acute lymphoblastic leukemia (ALL) must be positive for the Philadelphia chromosome or BCR-ABL gene. For CML, patient meets one of the following: 1) newly diagnosed, 2) resistance or intolerance to prior therapy, or 3) recurrence after stem cell transplant. For ALL, patient meets one of the following: 1) newly diagnosed and Gleevec is used in combination with chemotherapy, or 2) ALL is relapsed or refractory. For GIST, patient meets one of the following: 1) unresectable, recurrent, or metastatic disease, or 2) use of Gleevec for adjuvant therapy following resection, or 3) use of Gleevec for pre-operative therapy and patient is at risk for significant surgical morbidity.
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: Plan Year
Other Criteria:
GONADOTROPIN

PA

Drugs: CHORIONIC GONADOTROPIN, NOVAREL, PREGNYL W/DILUENT BENZYL
Covered Uses: All FDA approved indications not otherwise excluded from Part D
Exclusion Criteria: Female. For prepubertal cryptorchidism, presence of anatomic obstruction or precocious puberty. For hypogonadotropic hypogonadism, presence of prostatic carcinoma or other androgen-dependent neoplasm.
Required Medical Information:
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: Plan Year
Other Criteria:
GROWTH HORMONE

PA

Drugs: NORDITROPIN FLEXPRO, NORDITROPIN NORDIFLEX PEN
Covered Uses: All FDA approved indications not otherwise excluded from Part D
Exclusion Criteria: Active malignancy or history of malignancy in past 12 months, active proliferative or severe non-proliferative diabetic retinopathy, acute critical illness, concurrent use with Increlex, and closed epiphyses for pediatric patients. For PWS only: upper airway obstruction and severe respiratory impairment.
Required Medical Information: For pediatric GHD in neonate with hypoglycemia: patient has a randomly assessed GH level less than 20 ng/mL, other causes of hypoglycemia have been ruled out, and other treatments have been ineffective. For all pediatric patients: patients have short stature or slow growth velocity and have been evaluated for other causes of growth failure. For pediatric GHD, patient has delayed bone age. For pediatric GHD without pituitary disease, patient failed 2 stimulation tests. For pediatric GHD with a pituitary or CNS disorder, patient has clinical evidence of GHD and low IGF-1/IGFBP3. For TS and SHOX patients: diagnosis confirmed by genetic testing. For CRI patients: metabolic, endocrine and nutritional abnormalities have been treated or stabilized and patient has not had a kidney transplant. For SGA: patient has a low birth weight or length for gestational age. For ISS: pediatric GHD has been ruled out with one stimulation test. For adult GHD, patient was assessed for other causes of GHD-like symptoms. For adult GHD without pituitary disease, patient failed 2 stimulation tests. For adult GHD with at least 3 pituitary hormone deficiencies (PHD) or panhypopituitarism: have a low IGF-1. For adult GHD with less than 3 PHD, low IGF-1 and failed one stimulation test. For renewal for pediatric patients, growing more than 2 cm per year and for PWS only: improved body composition. For renewal for adult patients: patient has seen clinical improvement and IGF-1 will be monitored.
Age Restrictions: For Turner syndrome and SGA, 2 years of age and older. For Noonan syndrome and SHOX, 3 years of age and older.
Prescriber Restrictions: Endocrinologist, Pediatric Nephrologist, Gastroenterologist, Nutritional Support Specialist, Infectious Disease Specialist
Coverage Duration: Plan Year
Other Criteria:
HEPSERA

PA

Drugs: HEPSERA
Covered Uses: All FDA approved indications not otherwise excluded from Part D, prophylaxis against HBV infection with liver transplantation.
Exclusion Criteria: Renal impairment without dosing adjustment, if the patient is taking/receiving tenofovir or PMPA. Use of Hepsera as a first-line therapy in treatment-naïve patients with HBV.
Required Medical Information: A. Hepsera is not being requested as a first-line therapy in treatment-naïve patients with HBV. B. AND the patient has been diagnosed with chronic hepatitis B. C. AND the patient has evidence of a positive HBsAg (HBeAg + or -) serological marker for greater than 6 months OR evidence by a liver biopsy showing chronic hepatitis. D. AND the patient has a documented Hepatitis B viral load greater than 20,000 IU/mL (100,000 copies per mL) except if for HBeAg-negative HBV, the viral load is greater than 2,000 IU per mL (10,000 copies per mL). E. AND the patient has elevations in liver aminotransferases (ALT or AST) that are two (2) times greater than normal OR normal liver aminotransferase (ALT or AST) levels with evidence of significant disease found on biopsy. F. AND documented evidence of diagnosis, serological markers or liver biopsy, viral load and liver aminotransferases. OR G. Hepsera is not being requested for first-line therapy in treatment-naïve patients with HBV and the patient has compensated cirrhosis with a documented Hepatitis B viral load greater than 2,000 IU per mL (10,000 copies per mL) and normal or minimally elevated liver aminotransferase (ALT or AST) levels OR a documented Hepatitis B viral load less than 2,000 IU per mL (10,000 copies per mL) and elevations in liver aminotransferases (ALT or AST) that are two (2) times greater than normal. H. If Hepsera has been requested as a first-line therapy in a treatment-naive patient, the patient has decompensated cirrhosis and detectable HBV DNA level. I. If the patient has received previous Hepsera treatment, there is documented clinical improvement shown by a drop in viral load or reduction in the patient's liver aminotransferases.
Age Restrictions: 12 years or older
Prescriber Restrictions: Gastroenterologist or infectious disease specialist or affiliated with an infectious disease or gastroenterology practice, or a primary care physician with experience in treating HBV.
Coverage Duration: Plan Year
Other Criteria:
HRM EDITS

PA

Drugs: CARISOPRODOL, CHLORZOXAZONE, CYCLOBENZAPRINE HCL, CYPROHEPTADINE HCL, DICYCLOMINE HCL, DIPHENOXYLATE/ATROPINE, DIPYRIDAMOLE, ESTROPIPATE, HYDROXYZINE HCL, HYDROXYZINE PAMOATE, METAXALONE, METHOCARBAMOL, ORPHENADRINE CITRATE ER, ORPHENADRINE COMPOUND DS, ORPHENADRINE/ASA/CAFFEINE, ORTHO-EST, PHENADOZ, PREMARIN, PREMPHASE, PREMPRO, PROMETHAZINE HCL, PROMETHAZINE VC, PROMETHEGAN, TRANSDERM-SCOP, TRIMETHOBENZAMIDE HCL
Covered Uses: All FDA approved indications not otherwise excluded from Part D
Exclusion Criteria:
Required Medical Information:
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: Plan Year
Other Criteria: Prescriber must acknowledge that medication benefits outweigh potential risks in patients 65 years of age or older.
HRM EDITS_2

PA

Drugs: MENEST
Covered Uses: All FDA approved indications not otherwise excluded from Part D
Exclusion Criteria: Not covered for those who are 65 years of age and older
Required Medical Information:
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: Plan Year
Other Criteria: Prescriber must acknowledge that medication benefits outweigh potential risks in patients 65 years of age or older.
HUMIRA

PA

Drugs: HUMIRA, HUMIRA PEN-CROHNS DISEASE
Covered Uses: All FDA approved indications not otherwise excluded from Part D
Exclusion Criteria: Active infection (including TB), concurrent use with other biologics.
Required Medical Information: Screening for latent TB infection and assessment for Hep B risk. For positive latent TB, patient must have completed treatment or is currently receiving treatment for LTBI. HBV infection ruled out or treatment initiated for positive infection. Rheumatoid arthritis - Must have one of following: 1) inadequate response to methotrexate (MTX), 2) inadequate response to another nonbiologic DMARD (e.g., leflunomide, hydroxychloroquine, sulfasalazine) if contraindicated or intolerant to MTX, 3) intolerance or contraindication to at least 2 nonbiologic DMARDs or, 4) use Humira as first-line therapy with MTX for severely active RA. Polyarticular JIA - Must have an inadequate response to at least one nonbiologic DMARD or intolerance/contraindication to at least 2 nonbiologic DMARDs. Psoriatic arthritis with predominantly peripheral symptoms - Must have an inadequate response to at least an 8-week maximum tolerated dose trial of at least 1 nonbiologic DMARD unless contraindicated or intolerant to such therapy. Psoriatic arthritis with predominantly axial symptoms and ankylosing spondylitis - Inadequate response or intolerance/contraindication to at least 2 non-steroidal anti-inflammatory drugs (NSAIDs). For plaque psoriasis - Must have more than 10% BSA affected or has crucial body areas (e.g., feet, hands, face) affected. Must have an inadequate response to at least a 60-day trial of 2 conventional therapies (e.g., phototherapy, calcipotriene, MTX, acitretin) unless contraindicated or intolerant to such therapies. Crohn's disease - Must have an inadequate response to at least a 60-day trial of 2 conventional therapies (e.g., sulfasalazine, mesalamine, azathioprine, corticosteroids) unless contraindicated or intolerant to such therapies.
Age Restrictions: For psoriasis, patient must be 18 years of age and older
Prescriber Restrictions:
Coverage Duration: Initial: 3 months for Crohn's disease and plan year for all other indications Renewal: Plan Year
Other Criteria: For re-authorization, patient's condition must have improved or stabilized.
INCIVEK

PA

Drugs: INCIVEK
Covered Uses: All FDA approved indications not otherwise excluded from Part D
Exclusion Criteria: Failed previous therapy with a treatment regimen that includes a protease inhibitor (e.g., Incivek, Victrelis). Concomitant administration with a drug that is highly dependent on CYP3A for clearance or strongly induce CYP3A.
Required Medical Information: Hepatitis C virus (HCV) infection confirmed by presence of viral load in serum. HCV Genotype 1. HCV-RNA less than or equal to 1,000 IU/mL at week 4 of treatment.
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: Initial: 6 weeks. Renewal: Up to 12 weeks.
Other Criteria: Must be given in combination with pegylated interferon (i.e., Pegasys or PegIntron) and ribavirin. Assess HCV RNA level at weeks 4, 12, and 24 of Incivek triple therapy.
INCRELEX

PA

Drugs: INCRELEX
Covered Uses: All FDA approved indications not otherwise excluded from Part D
Exclusion Criteria: Epiphyseal closure, active malignancy, concurrent use with GH therapy, patient has secondary causes of IGF-1 deficiency.
Required Medical Information: Prior to starting therapy, a height greater than or equal to 3 SD below the mean for chronological age and sex, and an IGF-1 level greater than or equal to 3 SD below the mean for chronological age and gender. One stimulation test showing patient has a normal or elevated GH level. For continuation of therapy, patient grew more than 2 cm/year.
Age Restrictions:
Prescriber Restrictions: Endocrinologist
Coverage Duration: Plan Year
Other Criteria:
INFERGEN

PA

Drugs: INFERGEN
Covered Uses: All FDA approved indications not otherwise excluded from Part D
Exclusion Criteria: Decompensated liver disease. Autoimmune hepatitis.
Required Medical Information: Prior to initiating therapy, detectable levels of HCV RNA in the serum. For treatment naïve, patient must have tried and had intolerance to pegylated interferon based treatment regimen. Allow Infergen monotherapy for treatment naïve if patient has a contraindication or intolerance to ribavirin. For retreatment, must use in combination with ribavirin and must have tried and failed to respond to pegylated interferon and ribavirin. Allow only one time for retreatment. For Genotype 1 and 4: undetectable HCV RNA after 12 weeks of treatment OR at least 2 log decrease in HCV RNA after 12 weeks of therapy and undetectable HCV RNA after 24 weeks of treatment.
Age Restrictions:
Prescriber Restrictions: ID specialist, gastroenterologist, or oncologist
Coverage Duration: 12 weeks to a total of 72 weeks depending on genotype and initial vs. renewal therapy
Other Criteria: Monitored for evidence of depression.
INLYTA

PA

Drugs: INLYTA
Covered Uses: All FDA-approved indications not otherwise excluded from Part D.
Exclusion Criteria:
Required Medical Information: Patient has a diagnosis of advanced renal cell carcinoma (RCC) that has progressed after at least 1 prior systemic therapy for RCC. Examples of prior systemic therapies for RCC include regimens containing bevacizumab, pazopanib, sorafenib, sunitinib, temsirolimus, and cytokines (interferon alpha or interleukin-2).
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: Plan Year
Other Criteria: Prior authorization applies to new starts only. Refills will be approved unless use is not coverable under Part D per Medicare drug coverage policies.
ITRACONAZOLE

PA

Drugs: ITRACONAZOLE
Covered Uses: All FDA approved indications not otherwise excluded from Part D
Exclusion Criteria: A. ventricular dysfunction (e.g., congestive heart failure (CHF) or history of CHF) do not use for onychomycosis. B. If the patient is taking/receiving any of the following: cisapride, dofetilide, pimozide, quinidine.
Required Medical Information: Patients with a diagnosis of blastomycosis, pulmonary or extrapulmonary OR patients with a diagnosis of histoplasmosis, including chronic cavitary pulmonary disease or disseminated, non-meningeal histoplasmosis OR patients with a diagnosis of aspergillosis, pulmonary or extrapulmonary OR patients with a diagnosis of onychomycosis of the toenail, with or without fingernail involvement, due to dermatophytes (tinea unguium) OR patients with a diagnosis of onychomycosis of the fingernail due to dermatophytes (tinea unguium). For onychomycosis, diagnosis has been confirmed with a fungal diagnostic test (e.g., KOH preparation, fungal culture, or nail biopsy).
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: 12 weeks
Other Criteria:
IVIG

PA

Drugs: CARIMUNE NANOFILTERED, GAMMAGARD LIQUID, GAMMAPLEX, GAMUNEX-C
Covered Uses: All FDA approved indications not otherwise excluded from Part D. CLL and Kawasaki syndrome. Pure red cell aplasia secondary to parvovirus B19 infection.
Exclusion Criteria: IgA deficiency with antibody formation and a history of hypersensitivity. History of anaphylaxis or severe systemic reaction to human immune globulin. Presence of risk factor(s) for acute renal failure, unless the patient will receive IGIV products at the minimum concentration available and at the minimum rate of infusion practicable OR Gamunex/Gamunex-C is administered SC for PID.
Required Medical Information: CIDP: presence of objective findings consistent with diagnosis. CLL: serum IgG level less than 500 mg/dL and recurrent bacterial infections. Kawasaki syndrome: use of IGIV in conjunction with high-dose aspirin.
Age Restrictions:
Prescriber Restrictions: CIDP diagnosis by a neurologist
Coverage Duration: Plan Year
Other Criteria:
JAKAFI

PA

Drugs: JAKAFI
Covered Uses: All FDA approved indications not otherwise excluded from Part D
Exclusion Criteria:
Required Medical Information: Have intermediate or high-risk myelofibrosis
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: Plan Year
Other Criteria: Prior authorization applies to new starts only. Refills will be approved unless use is not coverable under Part D per Medicare drug coverage policies.
KUVAN

PA

Drugs: KUVAN
Covered Uses: All FDA approved indications not otherwise excluded from Part D
Exclusion Criteria:
Required Medical Information: Blood phenylalanine (Phe) levels. Pretreatment blood phenylalanine (Phe) levels greater than 10mg/dL if the patient is older than 12 years of age or greater than 6mg/dL if less than or equal to 12 years of age. Response to a therapeutic trial (greater than or equal to a 30% reduction in blood Phe levels) is required for long-term authorization.
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: 1 month initial, plan year on renewal
Other Criteria: Blood Phe levels should be checked after 1 week of therapy and periodically up to one month during a therapeutic trial.
LETAIRIS

PA

Drugs: LETAIRIS
Covered Uses: All FDA approved indications not otherwise excluded from Part D
Exclusion Criteria: Pregnancy
Required Medical Information: NYHA class II or III symptoms. PAH confirmed by right heart catheterization OR by Doppler echocardiogram in infants.
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: Plan Year
Other Criteria: UD or two appropriate contraceptive methods will be used for women of childbearing potential.
LEUKINE

PA

Drugs: LEUKINE
Covered Uses: All FDA approved indications not otherwise excluded from Part D. Acute lymphocytic leukemia following induction or consolidation chemotherapy. MDS for recurrent or resistant infections in neutropenic patients.
Exclusion Criteria: Administration within 24 hours preceding or following chemotherapy or radiotherapy, hypersensitivity to yeast-derived products. For prophylaxis of febrile neutropenia: use to increase the chemotherapy dose intensity or dose schedule above established regimens. For treatment of febrile neutropenia, when patient receives Neulasta during the current chemotherapy cycle. For AML only, excessive (greater than or equal to 10%) leukemic myeloid blasts in the bone marrow or peripheral blood.
Required Medical Information: For patients with nonmyeloid malignancies receiving myelosuppressive chemotherapy: Leukine may be used for the prevention of chemotherapy-induced febrile neutropenia if the patient experienced febrile neutropenia or a dose-limiting neutropenic complication with a prior chemotherapy cycle OR the patient is at high risk (greater than 20%) or intermediate risk (10-20%) for developing febrile neutropenia. Patients at low risk (less than 10%) for developing febrile neutropenia may also receive Leukine for prophylaxis if there is a significant risk for serious medical consequences due to febrile neutropenia and the intent of chemotherapy is to prolong survival or cure the disease. Leukine is allowable for the treatment of febrile neutropenia in patients who have received prophylaxis with Leukine (or Neupogen) OR in patients at risk for infection-related complications. All patients must receive baseline and regular monitoring of complete blood counts and platelet counts.
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: 6 months
Other Criteria:
LUMIZYME

PA

Drugs: LUMIZYME
Covered Uses: All FDA approved indications not otherwise excluded from Part D
Exclusion Criteria:
Required Medical Information: Diagnosis of Pompe disease was confirmed by an enzyme assay demonstrating a deficiency of GAA enzyme activity OR by DNA testing that identifies mutations in the GAA gene. Patient has a late (non-infantile) onset Pompe disease with no evidence of cardiac hypertrophy.
Age Restrictions: 8 years of age and older
Prescriber Restrictions:
Coverage Duration: Plan Year
Other Criteria: Appropriate medical support is readily available when Lumizyme is administered in the event of anaphylaxis, severe allergic reaction, or acute cardiorespiratory failure.
LUPRON

PA

Drugs: LEUPROLIDE ACETATE, LUPRON DEPOT, LUPRON DEPOT-PED
Covered Uses: All FDA approved indications not otherwise excluded from Part D, ovarian cancer with following subtypes: 1) ovarian stromal tumor, must have relapsed stage II-IV granulosa cell tumors 2) Epithelial ovarian cancer/fallopian tube cancer/primary peritoneal cancer, disease must be stable, recurrent, or persistent with primary therapy and use Lupron (3.75 mg only) as a single agent, breast cancer (leuprolide acetate injection only) who is premenopausal and have hormone receptor positive disease. Use as an adjuvant therapy OR in combination with endocrine therapy if disease is recurrent or metastatic
Exclusion Criteria: Pregnancy and breast feeding in female patients of childbearing potential For prostate cancer, use as neoadjuvant androgen deprivation therapy (ADT) for radical prostatectomy For endometriosis and fibroids, undiagnosed abnormal vaginal bleeding
Required Medical Information: For prostate cancer: 1) allow therapy for locally advanced, recurrent or metastatic disease, 2) allow initial long-term neoadjuvant/concurrent/adjuvant ADT in combination with radiation therapy for clinically localized disease with high risk of recurrence, 3) allow initial short-term neoadjuvant/concurrent/adjuvant ADT in combination with radiation therapy for clinically localized disease with intermediate risk of recurrence or with brachytherapy for clinically localized disease with high risk of recurrence, or 4) allow neoadjuvant therapy in conjunction with brachytherapy in patients with a large prostate to shrink the prostate to an acceptable size for brachytherapy For endometriosis: patient must have completed a trial and failure of at least 2 of the following therapies: oral contraceptives, medroxyprogesterone, or danazol.
Age Restrictions: For CPP, patient must be less than 12 years old if female and less than 13 years old if male.
Prescriber Restrictions:
Coverage Duration: Prostate CA: 1 yr but 6 mos for short term use, Fibroids: 3 mos, Endometriosis: 6 mos, CPP: 1 yr
Other Criteria:
METHYLPHENIDATES

PA

Drugs: CONCERTA (Plus Formulary Only), METADATE CD (Plus Formulary Only), METHYLIN (Plus Formulary Only), METHYLPHENIDATE HCL, METHYLPHENIDATE HCL ER (Plus Formulary Only), METHYLPHENIDATE HYDROCHLO, RITALIN LA (Plus Formulary Only)
Covered Uses: All FDA approved indications not otherwise excluded from Part D
Exclusion Criteria: MAOI concurrent use or within the last 14 days
Required Medical Information: Sleep studies for narcolepsy diagnosis
Age Restrictions: 6 years of age and older
Prescriber Restrictions:
Coverage Duration: Plan Year
Other Criteria: Consider benefits of use versus the potential risks of serious cardiovascular events.
MOZOBIL

PA

Drugs: MOZOBIL
Covered Uses: All FDA approved indications not otherwise excluded from Part D
Exclusion Criteria:
Required Medical Information:
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: 6 months
Other Criteria: Mozobil is given in combination with granulocyte-colony stimulating factor
MYOZYME

PA

Drugs: MYOZYME
Covered Uses: All FDA approved indications not otherwise excluded from Part D
Exclusion Criteria:
Required Medical Information: Diagnosis confirmed by DNA testing or an enzymatic assay showing a deficiency in acid alpha glucosidase.
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: Plan Year
Other Criteria:
NAGLAZYME

PA

Drugs: NAGLAZYME
Covered Uses: All FDA approved indications not otherwise excluded from Part D
Exclusion Criteria:
Required Medical Information: Diagnosis confirmed by DNA testing or an enzymatic assay showing a deficiency in N-acetylgalactosamine activity. Patient must have at least one MPS VI symptom. For re-authorization of Naglazyme, patient must demonstrate improvement in walking and/or stair-climbing capacity.
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: Plan Year
Other Criteria:
NEUPOGEN

PA

Drugs: NEUPOGEN
Covered Uses: All FDA approved indications not otherwise excluded from Part D. Acute lymphocytic leukemia following induction or consolidation chemotherapy. Leukemic relapses, as an alternative or adjunct to donor leukocyte infusions following allogeneic stem cell transplantation. MDS for recurrent or resistant infections in neutropenic patients or used in combination with epoetin alfa or darbapoetin alfa for the treatment of symptomatic anemia.
Exclusion Criteria: Administration within 24 hours preceding or following chemotherapy or radiotherapy, E coli hypersensitivity. For prophylaxis of febrile neutropenia: use to increase the chemotherapy dose intensity or dose schedule beyond established regimen. For treatment of febrile neutropenia, when patient receives Neulasta during the current chemotherapy cycle.
Required Medical Information: For patients with nonmyeloid malignancies receiving myelosuppressive chemotherapy: Neupogen may be used for the prevention of chemotherapy-induced febrile neutropenia if the patient experienced febrile neutropenia or a dose-limiting neutropenic complication with a prior chemotherapy cycle OR the patient is at high risk (greater than 20%) or intermediate risk (10-20%) for developing febrile neutropenia. Patients at low risk (less than 10%) for developing febrile neutropenia may receive Neupogen for prophylaxis if there is a significant risk for serious medical consequences due to febrile neutropenia and the intent of chemotherapy is to prolong survival or cure the disease. Neupogen is allowable for the treatment of febrile neutropenia in patients who have received prophylaxis with Neupogen (or Leukine) OR in patients at risk for infection-related complications. All patients must receive baseline and regular monitoring of complete blood counts and platelet counts.
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: 6 months
Other Criteria:
NEXAVAR

PA

Drugs: NEXAVAR
Covered Uses: All FDA approved indications not otherwise excluded from Part D. Clinically progressive or symptomatic, nonradioiodine-responsive, non-CNS follicular, Hurthle cell, or papillary thyroid carcinoma. Disseminated symptomatic medullary thyroid carcinoma after progression on vandetanib or vandetanib is not appropriate. Progressive gastrointestinal stromal tumor (GIST) after inadequate response to imatinib or sunitinib. Monotherapy for angiosarcoma.
Exclusion Criteria: Combination with carboplatin and paclitaxel in patients with squamous cell lung cancer
Required Medical Information:
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: Plan Year
Other Criteria:
NICOTINE

PA

Drugs: NICOTROL INHALER, NICOTROL NS
Covered Uses: All FDA approved indications not otherwise excluded from Part D
Exclusion Criteria:
Required Medical Information: Documentation that the patient is enrolled in a smoking cessation program
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: 6 months
Other Criteria:
NUEDEXTA

PA

Drugs: NUEDEXTA
Covered Uses: All FDA approved indications not otherwise excluded from Part D
Exclusion Criteria: Concomitantly taking other drugs containing quinidine, quinine, mefloquine, monoamine oxidase inhibitors (MAOIs), or drugs that both prolong QT interval and are metabolized by CYP2D6 (e.g., thioridazine and pimozide), patient has a prolonged QT interval, congenital long QT syndrome or a history suggestive of torsades de pointes, or heart failure, patient has complete atrioventricular (AV) block without implanted pacemaker, or is at high risk of complete AV block. Dose in excess of 2 capsules per day.
Required Medical Information: Patient has amyotrophic lateral sclerosis (ALS) OR multiple sclerosis (MS)
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: Plan Year
Other Criteria:
NUVIGIL

PA

Drugs: NUVIGIL
Covered Uses: All FDA approved indications not otherwise excluded from Part D
Exclusion Criteria:
Required Medical Information: If diagnosis is narcolepsy require Sleep Lab Evaluation, if diagnosis of OSAHS require polysomnography and whether the patient is using CPAP or CPAP is contraindicated or ineffective. If diagnosis of Shift Work Sleep Disorder (work the night shift (at least 6 hours between the hours of 10pm and 8am permanently or work the night shift (at least 6 hours between the hours of 10pm and 8am) frequently (5 times or more per month) AND experience excessive sleepiness while working. If diagnosis of mild obstructive sleep apnea/hypopnea syndrome and whether patient is using and compliant with an oral appliance
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: Plan Year
Other Criteria:
OCTREOTIDE

PA

Drugs: OCTREOTIDE ACETATE
Covered Uses: All FDA approved indications not otherwise excluded from Part D
Exclusion Criteria:
Required Medical Information:
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: Plan Year
Other Criteria:
ORAL FENTANYL

PA

Drugs: FENTANYL CITRATE ORAL TRA
Covered Uses: All FDA approved indications not otherwise excluded from Part D
Exclusion Criteria: Patients taking strong or moderate cytochrome P450 3A4 inhibitor(s) (e.g., aprepitant, clarithromycin, diltiazem, erythromycin, fosamprenavir, fluconazole, itraconazole, ketoconazole, nefazodone, nelfinavir, ritonavir, verapamil) who will not be monitored or have dosing adjustments made if necessary.
Required Medical Information:
Age Restrictions: 16 years of age and older (Actiq), 18 years of age and older all others
Prescriber Restrictions:
Coverage Duration: 6 months
Other Criteria:
ORAL TESTOSTERONES

PA

Drugs: ANDROXY
Covered Uses: All FDA approved indications not otherwise excluded from Part D
Exclusion Criteria: Male patients who have confirmed or suspected carcinoma of the prostate or breast.
Required Medical Information: For female patients being treated for inoperable metastatic breast cancer who are 1 to 5 years postmenopausal (either naturally or surgically) and who have had an incomplete response to other therapies for metastatic breast cancer. For male patients being treated for primary or secondary hypogonadism, a confirmed low testosterone level (morning total testosterone less than 300 ng/dL, morning free or bioavailable testosterone less than 5 ng/dL) or absence of endogenous testosterone. For male patients being treated for delayed puberty, bone development must be checked at least every 6 months.
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: Plan Year
Other Criteria: Patients who have tried and failed or unable to tolerate non-oral forms of testosterone supplementation.
ORFADIN

PA

Drugs: ORFADIN
Covered Uses: All FDA approved indications not otherwise excluded from Part D
Exclusion Criteria:
Required Medical Information: Confirmation of diagnosis by either biochemical testing (e.g., detection of succinylacetone in urine) and appropriate clinical picture OR DNA testing (mutation analysis).
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: Plan Year
Other Criteria: Protein-restricted diet that is low in phenylalanine and tyrosine.
OSTEOPOROSIS

PA

Drugs: FORTEO
Covered Uses: All FDA approved indications not otherwise excluded from Part D
Exclusion Criteria: Paget's disease of bone, unexplained elevations in alkaline phosphatase, open epiphyses, prior radiation therapy involving the skeleton, history of a skeletal malignancy or bone metastases, pre-existing hypercalcemia, metabolic bone disease other than osteoporosis, concurrent bisphosphonate use, or cumulative use of Forteo for more than 24 months lifetime.
Required Medical Information: Patient meets one of the following criteria: 1) Patient has experienced a prior fragility fracture, or 2) Patient had an inadequate response to an adequate trial of a bisphosphonate (one year) or patient has a contraindication or intolerance to bisphosphonate trial, or 3) Patient has 2 of the following risk factors for fracture: advanced age, parental history of fracture, low body mass index, current smoker, chronic alcohol use, rheumatoid arthritis, chronic steroid use, or other secondary cause of osteoporosis.
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: Plan Year
Other Criteria:
OXSORALEN

PA

Drugs: OXSORALEN ULTRA
Covered Uses: All FDA approved indications not otherwise excluded from Part D, cutaneous T-cell lymphoma (CTCL), non-Hodgkin's lymphoma - mycosis fungoides/Sezary syndrome
Exclusion Criteria: Aphakia, melanoma, or invasive squamous cell carcinoma
Required Medical Information: The patient must be diagnosed with cutaneous T-cell lymphoma OR psoriasis AND if the diagnosis is psoriasis, the patient must have previous must have previous inadequate treatment response or intolerance or contraindication to at least one topical steroid.
Age Restrictions:
Prescriber Restrictions: Dermatologist or Oncologist or affiliated with a dermatologist/oncologist practice
Coverage Duration: Plan Year
Other Criteria:
PEGASYS

PA

Drugs: PEGASYS, PEGASYS PROCLICK
Covered Uses: All FDA-approved indications not otherwise excluded from Part D, chronic myelogenous leukemia who is unable to tolerate tyrosine kinase inhibitor(s) or post-transplant patient without remission or with relapse
Exclusion Criteria: Decompensated liver disease. Autoimmune hepatitis. Concomitant administration of didanosine with ribavirin in patients coinfected with HIV.
Required Medical Information: Hepatitis C: Detectable levels of HCV-RNA in the serum prior to initiating therapy. For HCV treatment naïve, allow Pegasys monotherapy if patient has a contraindication or intolerance to ribavirin. Dual therapy with ribavirin (Genotype 1 and 4) or monotherapy (regardless of genotypes): Undetectable HCV-RNA after 12 weeks of treatment OR at least 2 log decrease in HCV-RNA after 12 weeks of therapy and undetectable HCV-RNA after 24 weeks of treatment. Triple therapy with Pegasys, ribavirin and Victrelis: HCV Genotype 1. Receive 4 weeks of Pegasys and ribavirin prior to starting Victrelis. Assess HCV-RNA level at weeks 4, 8, 12, and 24 of treatment. HCV-RNA less than 100 IU/mL at week 12 of treatment. Undetectable HCV-RNA at week 24 of treatment. Triple therapy with Pegasys, ribavirin and Incivek: HCV Genotype 1. Assess HCV-RNA level at weeks 4, 12, and 24 of treatment. HCV-RNA less than or equal to 1,000 IU/mL at weeks 4 and 12 of treatment. Undetectable HCV-RNA at week 24 of treatment. Retreatment with dual therapy: Use in combination with ribavirin. Have nonresponse or relapse with prior HCV therapy. Allow only one time retreatment with PEG-IFN and ribavirin. Hepatitis B: Must have been HBsAg positive for at least 6 months and have persistent or intermittently elevated ALT greater than 2x ULN or liver biopsy showing chronic hepatitis with moderate to severe necroinflammation. For HBeAg positive, must have serum HBV-DNA greater than 100,000 copies/mL or greater than 20,000 IU/mL. For HBeAg negative and cirrhosis, must have serum HBV-DNA greater than or equal to 10,000 copies/mL or greater than or equal to 2,000 IU/mL.
Age Restrictions:
Prescriber Restrictions: ID specialist, Gastroenterologist, Oncologist
Coverage Duration: HCV:Based on genotype and response 12to72 wks for dual tx, 6to48 wks for triple tx. HBV,CML=48 wks
Other Criteria: Monitor for evidence of depression.
PEGINTRON

PA

Drugs: PEG-INTRON, PEG-INTRON REDIPEN
Covered Uses: All FDA-approved indications not otherwise excluded from Part D, chronic myelogenous leukemia who is unable to tolerate tyrosine kinase inhibitor(s) OR post-transplant patient without remission or with relapse
Exclusion Criteria: Decompensated liver disease. Autoimmune hepatitis. Concomitant administration of didanosine with ribavirin in patients coinfected with HIV.
Required Medical Information: Detectable levels of HCV-RNA in the serum prior to initiating therapy. Allow PegIntron monotherapy if patient has a contraindication or intolerance to ribavirin. Dual therapy with ribavirin (Genotype 1 and 4) or monotherapy: undetectable HCV-RNA after 12 weeks of treatment OR at least 2 log decrease in HCV-RNA after 12 weeks of therapy and undetectable HCV-RNA after 24 weeks of treatment. Triple therapy with PegIntron and ribavirin and Victrelis: HCV Genotype 1. Receive 4 weeks of PegIntron and ribavirin prior to starting Victrelis. Assess HCV-RNA level at weeks 4, 8, 12, and 24 of treatment. HCV-RNA less than 100 IU/mL at week 12 of treatment. Undetectable HCV-RNA at week 24 of treatment. Triple therapy with PegIntron and ribavirin and Incivek: HCV Genotype 1. Assess HCV-RNA level at weeks 4, 12, and 24 of treatment. HCV-RNA less than or equal to 1,000 IU/mL at weeks 4 and 12 of treatment. Undetectable HCV-RNA at week 24 of treatment. Retreatment with dual therapy: Must use in combination with ribavirin. Must have nonresponse or relapse with prior HCV therapy. Allow only one time retreatment with PEG-IFN and ribavirin.
Age Restrictions:
Prescriber Restrictions: ID specialist, Gastroenterologist, Oncologist
Coverage Duration: HCV=Based on genotype and response 12 to 72 wks for dual tx, 6 to 48 wks for triple tx. CML=48 wks
Other Criteria: Monitor for evidence of depression.
PRIVIGEN

PA

Drugs: PRIVIGEN
Covered Uses: All FDA approved indications not otherwise excluded from Part D, B-cell chronic lymphocytic leukemia (CLL), Kawasaki syndrome, chronic inflammatory demyelinating polyneuropathy (CIDP), pure red cell aplasia associated with parvovirus B19 infection.
Exclusion Criteria: IgA deficiency with antibodies to IgA and a history of hypersensitivity. History of anaphylaxis or severe systemic reaction to human immune globulin. Hyperprolinemia. Presence of risk factor(s) for acute renal failure (pre-existing renal insufficiency, diabetes, age greater than 65 years, volume depletion, sepsis, paraproteinemia, or receiving known nephrotoxic drugs), unless the patient will receive Privigen at the minimum concentration available and at the minimum rate of infusion practicable.
Required Medical Information: For Kawasaki syndrome: use of Privigen in conjunction with high-dose aspirin. For CLL: serum IgG level less than 500 mg/dL and recurrent bacterial infections. For CIDP: presence of objective findings consistent with diagnosis (for example, electromyography, elevated cerebrospinal fluid protein, or nerve biopsy).
Age Restrictions:
Prescriber Restrictions: CIDP diagnosis by a neurologist
Coverage Duration: Plan Year
Other Criteria:
PROMACTA

PA

Drugs: PROMACTA
Covered Uses: All FDA approved indications not otherwise excluded from Part D
Exclusion Criteria:
Required Medical Information: For new starts, at the time of diagnosis of ITP one of the following are required: 1) a pretreatment platelet count less than 30,000/microL or 2) a platelet count less than or equal to 50,000/microL with significant mucous membrane bleeding or risk factors for bleeding. Patients must be evaluated for other causes of thrombocytopenia and have had an insufficient response or intolerance to corticosteroids, or immunoglobulins, or splenectomy. For continuation of therapy, one of the following are required: 1) an increase in platelet count to greater than or equal to 50,000/microL or 2) an increase in platelet level that is sufficient to avoid clinically important bleeding after at least 4 weeks of Promacta at the maximum dose. For all patients receiving Promacta therapy, if platelets increase above 200,000/microL, therapy will be adjusted to maintain the minimal platelet count needed to reduce the risk for bleeding. Liver function must be assessed pretreatment and regularly throughout therapy. To continue Promacta therapy, alanine aminotransferase levels must not be greater than or equal to 3 times the upper limit of normal with any of the following characteristics: progressive, persistent, accompanied by increased bilirubin or symptoms of liver injury or evidence of hepatic decompensation.
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: 6 month initial, 12 month renewal if adequate platelet response, 3 month w/o platelet response
Other Criteria:
PROVIGIL

PA PLUS FORMULARY ONLY

Drugs: MODAFINIL, PROVIGIL
Covered Uses: All FDA approved indications not otherwise excluded from Part D
Exclusion Criteria:
Required Medical Information: If diagnosis is narcolepsy require Sleep Lab Evaluation, if diagnosis of OSAHS require polysomnography and whether the patient is using CPAP or CPAP is contraindicated or ineffective. If diagnosis of Shift Work Sleep Disorder (work the night shift (at least 6 hours between the hours of 10pm and 8am permanently or work the night shift (at least 6 hours between the hours of 10pm and 8am) frequently (5 times or more per month) AND experience excessive sleepiness while working. If diagnosis of mild obstructive sleep apnea/hypopnea syndrome and whether patient is using and compliant with an oral appliance
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: Plan Year
Other Criteria:
RANEXA

PA

Drugs: RANEXA
Covered Uses: All FDA approved indications not otherwise excluded from Part D
Exclusion Criteria: Patients with clinically significant hepatic impairment.
Required Medical Information: A. The diagnosis documented as chronic angina B. AND the patient is NOT receiving a strong CYP3A inhibitor that prolongs the QT interval.C. AND the patient has tried, failed and/or been intolerant (continues to have angina symptoms that limits daily activities) to a 30-day trial of the following: with a nitrate plus a beta blocker OR a calcium channel blocker. D. AND if the patient has received prior treatment with Ranexa, the patient must experience a decrease in angina frequency since initiating treatment.
Age Restrictions:
Prescriber Restrictions: Cardiologist or affiliated with a cardiology practice
Coverage Duration: 3 months initial, 12 months renewal
Other Criteria:
REBIF

PA

Drugs: REBIF, REBIF TITRATION PACK
Covered Uses: All FDA approved indications not otherwise excluded from Part D
Exclusion Criteria:
Required Medical Information:
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: Plan Year
Other Criteria:
RELISTOR

PA

Drugs: RELISTOR
Covered Uses: All FDA approved indications not otherwise excluded from Part D
Exclusion Criteria: Mechanical gastrointestinal obstruction, known or suspected.
Required Medical Information: A. Relistor is being prescribed for treatment of opioid-induced constipation in patients with advanced illness who are receiving palliative care. B. Patient demonstrated an inadequate treatment response or intolerance to a drug regimen of polyethylene glycol 3350 (PEG) OR C. patient has a documented contraindication to polyethylene glycol 3350 (PEG)
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: 4 Months
Other Criteria:
REMICADE

PA

Drugs: REMICADE
Covered Uses: All FDA approved indications not otherwise excluded from Part D
Exclusion Criteria: Active infection (including TB), concurrent use with other biologics, unstable moderate to severe HF (NYHA Functional Class III/IV).
Required Medical Information: Screening for latent TB infection and assessment for Hep B risk. For positive latent TB, patient must have completed treatment or is currently receiving treatment for LTBI. HBV infection ruled out or treatment initiated for positive infection. Rheumatoid arthritis - One of the following: 1) inadequate response to methotrexate (MTX), 2) inadequate response to another nonbiologic DMARD (e.g., leflunomide, hydroxychloroquine, sulfasalazine) if contraindicated or intolerant to MTX, 3) intolerance or contraindication to at least 2 nonbiologic DMARDs. Psoriatic arthritis with predominantly peripheral symptoms - Must have an inadequate response to at least an 8-week maximum tolerated dose trial of at least 1 nonbiologic DMARD unless contraindicated or intolerant to such therapy. Psoriatic arthritis with predominantly axial symptoms and ankylosing spondylitis - Must have an inadequate response or intolerance/contraindication to at least 2 non-steroidal anti-inflammatory drugs (NSAIDs). For plaque psoriasis - More than 10% BSA affected or has crucial body areas (e.g., feet, hands, face) affected. An inadequate response to at least a 60-day trial of 2 conventional therapies (e.g., phototherapy, calcipotriene, MTX, acitretin) unless contraindicated or intolerant to such therapies. Crohn's disease - Must have an inadequate response to at least a 60-day trial of 1 conventional therapy (e.g., corticosteroids, sulfasalazine, azathioprine, mesalamine) unless contraindicated or intolerant to such therapy. Ulcerative colitis - An inadequate response to at least a 60-day trial of 2 conventional therapies (e.g., corticosteroids, mesalamine) unless contraindicated or intolerant to such therapies.
Age Restrictions: For plaque psoriasis, patient must be 18 years of age and older.
Prescriber Restrictions:
Coverage Duration: Initial: 3 months for Crohn's disease and UC, plan year for all others. Renewal: plan year
Other Criteria: For continuation of therapy, patient's condition must have improved or stabilized.
REVATIO

PA

Drugs: REVATIO
Covered Uses: All FDA approved indications not otherwise excluded from Part D
Exclusion Criteria: Nitrate therapy
Required Medical Information: Diagnosis of pulmonary arterial hypertension (PAH), (WHO Group 1). PAH been confirmed by right heart catheterization. If patient is an infant, PAH diagnosed by Doppler echocardiogram. The patient has had an inadequate response or intolerance to Adcirca.
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: Plan Year
Other Criteria:
REVLIMID

PA

Drugs: REVLIMID
Covered Uses: All FDA approved indications not otherwise excluded from Part D. Primary treatment of systemic light chain amyloidosis (SLCA) with dexamethasone, CLL, and as a single agent or with rituximab for any of the following subtypes of relapsed, refractory or progressive NHL: cutaneous B-cell lymphoma, diffuse large B-cell lymphoma, follicular lymphoma, gastric MALT lymphoma, mantle cell lymphoma, nodal marginal zone lymphoma, nongastric MALT lymphoma, and splenic marginal zone lymphoma.
Exclusion Criteria: Pregnancy
Required Medical Information: For active myeloma, patient meets one of the following: 1) Revlimid is used after at least one prior therapy or as salvage therapy. 2) Revlimid is used with dexamethasone as primary induction therapy or in combination with melphalan and prednisone in nontransplant candidates. 3) Revlimid is used as maintenance monotherapy following response to either stem cell transplant or primary induction therapy. For Low or Intermediate-1 Risk myelodysplastic syndrome (MDS): for those with 5q deletion, patients should have transfusion-dependent anemia or symptomatic anemia with clinically significant cytopenias. For those with non-5q deletion MDS and symptomatic anemia, patients should have failed to respond to epoetin alfa or darbepoetin or have a pretreatment serum erythropoietin levels greater than 500 mU/mL and a low probability of response to immunosuppressive therapy. For female patients of childbearing potential, pregnancy is excluded by 2 negative serum or urine pregnancy tests. For all patients, complete blood counts are monitored for hematologic toxicity while receiving Revlimid.
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: Plan Year
Other Criteria: Male and female patients of child-bearing potential should be instructed on the importance of proper utilization of appropriate contraceptive methods for Revlimid use. Patients should be monitored for signs and symptoms of thromboembolism.
RIBAVIRIN

PA

Drugs: REBETOL, RIBAPAK, RIBASPHERE, RIBAVIRIN
Covered Uses: All FDA approved indications not otherwise excluded from Part D
Exclusion Criteria: Hemoglobin less than 8.5 g/dL. Hemoglobinopathy. History of unstable heart disease. Creatinine clearance less than 50 mL/minute and unwilling to use modified dose of ribavirin. Pregnancy (self or partner).Unwilling to use effective contraception. Coadministration with didanosine in HIV coinfected patients.
Required Medical Information: Detectable levels of HCV-RNA in the serum prior to initiating therapy. Dual therapy with alfa interferon (Genotype 1 and 4): Undetectable HCV-RNA after 12 weeks of treatment OR at least 2 log decrease in HCV-RNA after 12 weeks of therapy and undetectable HCV-RNA after 24 weeks of treatment. Triple therapy with PEG-IFN and Victrelis: HCV Genotype 1. Receive 4 weeks of PEG-IFN and ribavirin prior to starting Victrelis. Assess HCV-RNA level at weeks 4, 8, 12, and 24 of treatment. HCV-RNA less than 100 IU/mL at week 12 of treatment. Undetectable HCV-RNA at week 24 of treatment. Triple therapy with PEG-IFN and Incivek: HCV Genotype 1. Assess HCV-RNA level at weeks 4, 12, and 24 of treatment. HCV-RNA less than or equal to 1,000 IU/mL at weeks 4 and 12 of treatment. Undetectable HCV-RNA at week 24 of treatment. Retreatment with alfa interferon: Patient must have nonresponse or relapse with prior HCV therapy. Allow only one time retreatment with PEG-IFN and ribavirin OR Infergen and ribavirin
Age Restrictions:
Prescriber Restrictions: ID specialist, gastroenterologist, or oncologist
Coverage Duration: Based on genotype and response 12 to 72 weeks for dual therapy and 6 to 48 weeks for triple therapy
Other Criteria: Patient has been instructed to practice effective contraception during therapy and for six months after stopping ribavirin therapy.
RITUXAN

PA

Drugs: RITUXAN
Covered Uses: All FDA approved indications not otherwise excluded from Part D. CNS cancers with lesions, metastatic. Primary CNS lymphoma. Lymphocyte-predominant Hodgkin lymphoma, as primary treatment. Marginal zone lymphomas (nodal, splenic, MALT). Small lymphocytic lymphoma. Post-transplant lymphoproliferative disorder. Primary cutaneous B-cell lymphoma. Acute lymphoblastic leukemia, in combination with hyperCVAD chemotherapy. Hairy cell leukemia, relapsed or refractory. Multicentric Castleman's disease with HIV. Waldenstrom's macroglobulinemia/lymphoplasmacytic lymphoma.
Exclusion Criteria: History of severe skin or infusion reaction with Rituxan than cannot be appropriately managed, use in combination with another biologic agent
Required Medical Information: For rheumatoid arthritis (RA): an inadequate response to a TNF antagonist (unless contraindicated). For continuation of RA therapy, improvement in clinical symptoms is required from the last treatment course, which was at least 16 weeks earlier. Hematologic malignancies must be positive for CD20. Rituxan must be used in combination with chemotherapy for mantle cell lymphoma (or other agents), Burkitt lymphoma, and lymphoblastic lymphoma. AIDS-related B-cell lymphoma is also a covered use. Prior to initiating therapy, prescriber must have assessed the patient's risk for hepatitis B and, if appropriate, ruled out or initiated treatment for hepatitis B.
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: Plan Year
Other Criteria: Monitored for pulmonary toxicity
SABRIL

PA

Drugs: SABRIL
Covered Uses: All FDA approved indications not otherwise excluded from Part D
Exclusion Criteria: Patients with or at high risk of vision loss (except patients who have blindness). Patients using other medications associated with serious adverse ophthalmic effects such as retinopathy or glaucoma.
Required Medical Information: Vision is assessed at baseline or will be assessed by an ophthalmologist no longer than 4 weeks after starting Sabril (except patients who have blindness OR are formally exempted from vision testing in the SHARE program). For continuation of therapy, patient's vision will be assessed by an ophthalmologist every 3 months (except for patients who have blindness OR who are formally exempted from vision testing in the SHARE program). For complex partial seizures (CPS), the patient has failed an adequate regimen with either carbamazepine or phenytoin, unless there is a contraindication or intolerance.
Age Restrictions: Initial treatment infantile spasms, 1 month to 2 years. Initial treatment CPS, 16 years or older.
Prescriber Restrictions:
Coverage Duration: Infantile spasms: initial 4 weeks, reauth 6 months. CPS: initial 3 months, reauth 12 months
Other Criteria: For continuation of therapy, patient has shown substantial clinical benefit from Sabril therapy.
SANCUSO

PA

Drugs: SANCUSO
Covered Uses: All FDA approved indications not otherwise excluded from Part D
Exclusion Criteria:
Required Medical Information: Documentation showing that the patient has had a previous trial/failure to any oral therapy.
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: Plan Year
Other Criteria:
SANDOSTATIN LAR

PA

Drugs: SANDOSTATIN LAR DEPOT
Covered Uses: All FDA approved indications not otherwise excluded from Part D
Exclusion Criteria:
Required Medical Information: Patient received initial treatment with Sandostatin Injection (not the Depot form) for at least 2 weeks and treatment with Sandostatin Injection was effective and tolerable.
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: Plan Year
Other Criteria:
SOMATULINE DEPOT

PA

Drugs: SOMATULINE DEPOT
Covered Uses: All FDA approved indications not otherwise excluded from Part D
Exclusion Criteria:
Required Medical Information:
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: Plan Year
Other Criteria:
SOMAVERT

PA

Drugs: SOMAVERT
Covered Uses: All FDA approved indications not otherwise excluded from Part D
Exclusion Criteria:
Required Medical Information: Diagnosis of acromegaly was confirmed by an elevated IGF-1 level or elevated GH level with a glucose tolerance test. Patient has tried and failed a trial of Sandostatin or Somatuline. For renewal, reduction in IGF-1 level from baseline.
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: Plan Year
Other Criteria:
SORIATANE

PA PLUS FORMULARY ONLY

Drugs: SORIATANE
Covered Uses: All FDA approved indications not otherwise excluded from Part D, prevention of non-melanoma skin cancers in high risk individuals
Exclusion Criteria: Severely impaired liver function, severely impaired kidney function, chronic abnormally elevated blood lipid values, currently taking methotrexate or tetracycline.
Required Medical Information: 1. If the patient is female and able to bear children (e.g., no hysterectomy, not reached menopause, has achieved menses). AND 2. the patient is unresponsive to other therapies for this diagnosis OR the other therapies for the treatment of this diagnosis are contraindicated due to the clinical condition of the patient AND 3. pregnancy has been excluded as confirmed by 2 negative urine or serum pregnancy tests with a sensitivity of at least 25 mIU/mL. AND 4. the patient has chosen to use any of the following methods of contraception: one primary form (e.g., tubal ligation, partner's vasectomy, intrauterine devices, birth control pills, injectable/implantable/insertable/topical hormonal birth control products) plus one secondary form (e.g., diaphragms, latex condoms, cervical caps) used in combination with a spermicide OR absolute abstinence AND 5. the patient has agreed to use her chosen form of contraception for at least 1 month before initiation of Soriatane therapy, during Soriatane therapy, and for at least 3 years after discontinuation of therapy AND 6. the patient has been advised that ethanol must not be ingested by female patients during Soriatane treatment and for 2 months following therapy AND 7. the patient will have a negative pregnancy test on a monthly basis.
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: Plan Year
Other Criteria: Female patient or guardian signed a Patient Agreement/Informed Consent.
SPRYCEL

PA

Drugs: SPRYCEL
Covered Uses: All FDA approved indications not otherwise excluded from Part D. GIST in patients with disease progression on imatinib or sunitinib.
Exclusion Criteria:
Required Medical Information: Acute lymphoblastic leukemia (ALL) and newly diagnosed chronic myeloid leukemia (CML) must be positive for the Philadelphia chromosome or BCR-ABL gene. For CML, patient meets one of the following: 1) newly diagnosed in chronic phase, 2) resistance or intolerance/toxicity to imatinib or nilotinib, or 3) relapse after stem cell transplant. For ALL, patient meets one of the following: 1) ALL is newly diagnosed and Sprycel is used in combination with chemotherapy, or 2) resistance or intolerance to prior therapy.
Age Restrictions: 18 years of age and older
Prescriber Restrictions:
Coverage Duration: Plan Year
Other Criteria:
STRATTERA

PA

Drugs: STRATTERA
Covered Uses: All FDA approved indications not otherwise excluded from Part D
Exclusion Criteria: MAOI concurrent use or within the last 14 days
Required Medical Information:
Age Restrictions: 6 years of age and older
Prescriber Restrictions:
Coverage Duration: Plan Year
Other Criteria: Monitor for suicidality, clinical worsening, changes in behavior, blood pressure changes, heart rate changes, liver injury.
SUTENT

PA

Drugs: SUTENT
Covered Uses: All FDA approved indications not otherwise excluded from Part D. Clinically progressive or symptomatic, nonradioiodine-responsive, non-CNS follicular, Hurthle cell, or papillary thyroid carcinoma. Disseminated symptomatic medullary thyroid carcinoma after progression on vandetanib or vandetanib is not appropriate. Unresectable or advanced (stage IIIB-IV) disease with low- or intermediate-grade (atypical or typical carcinoid) lung neuroendocrine tumors. Monotherapy for solitary fibrous tumor, hemangiopericytoma, and angiosarcoma.
Exclusion Criteria: Clinical manifestations of congestive heart failure.
Required Medical Information: For gastrointestinal stromal tumor (GIST), disease progression while on Gleevec or intolerance to Gleevec is required. LFT monitoring at initiation of therapy and throughout treatment.
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: Plan Year
Other Criteria: Therapy will be interrupted for serious hepatic adverse events and discontinued if serious hepatic adverse events do not resolve.
SYLATRON

PA

Drugs: SYLATRON
Covered Uses: All FDA approved indications not otherwise excluded from Part D, chronic myelogenous leukemia.
Exclusion Criteria: Autoimmune hepatitis, decompensated hepatic disease, uncontrolled major depression or severe mental illness.
Required Medical Information: For melanoma, all of the following initial criteria are required: melanoma has microscopic or gross nodal involvement AND Sylatron is used following surgical resection of the tumor and complete lymphadenectomy AND Sylatron is being requested for use within 84 days (12 weeks) of the surgical resection. For CML, the patient meets one of the following criteria: patient is unable to tolerate a tyrosine kinase inhibitor (e.g., imatinib, dasatinib, or nilotinib) OR patient is post-transplant without remission or with relapse of CML.
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: Plan Year
Other Criteria: The patient is monitored and evaluated for signs and symptoms of depression and other psychiatric symptoms throughout treatment with Sylatron.
SYMLIN

PA

Drugs: SYMLIN, SYMLINPEN 120, SYMLINPEN 60
Covered Uses: All FDA approved indications not otherwise excluded from Part D
Exclusion Criteria: Severe hypoglycemia that required assistance during the past 6 months, gastroparesis, patient requires drug therapy to stimulate gastrointestinal motility, the presence of hypoglycemia unawareness (i.e., inability to detect and act upon the signs or symptoms of hypoglycemia).
Required Medical Information:
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: Plan Year
Other Criteria: The patient must have inadequate glycemic control (HbA1c greater than 7% but less than 9%) at initiation of therapy, patient currently receiving optimal mealtime insulin therapy. If taking Symlin in previous 6 months, patient demonstrated a reduction in HbA1c since initiating Symlin therapy
TARCEVA

PA

Drugs: TARCEVA
Covered Uses: All FDA approved indications not otherwise excluded from Part D
Exclusion Criteria:
Required Medical Information: For 1st line therapy of locally advanced or metastatic NSCLC, patient should have a known active EGFR mutation or amplification of the EGFR gene.
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: Plan Year
Other Criteria:
TARGRETIN

PA

Drugs: TARGRETIN
Covered Uses: All FDA approved indications not otherwise excluded from Part D
Exclusion Criteria: Pregnancy
Required Medical Information: For capsules, patient meets one of the following: 1) cutaneous T cell lymphoma (includes mycosis fungoides [MF] and Sezary syndrome [SS]) refractory to prior systemic therapy, 2) advanced-stage MF/Sezary syndrome, 3) early-stage MF refractory/progressive to skin-directed therapy, or 4) early-stage MF with blood involvement or folliculotropic/large cell transformation.
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: Plan Year
Other Criteria: Patient has been instructed on the importance of and proper utilization of contraception.
TASIGNA

PA

Drugs: TASIGNA
Covered Uses: All FDA approved indications not otherwise excluded from Part D. Acute lymphoblastic leukemia must be positive for the Ph chromosome or BCR-ABL gene and disease is relapsed/refractory. GIST in patients with disease progression on imatinib or sunitinib.
Exclusion Criteria: Long QT syndrome, uncorrected electrolyte disorders (hypokalemia, hypomagnesemia).
Required Medical Information: ECG obtained at baseline, 7-10 days after initiation of therapy and periodically throughout therapy. Newly diagnosed chronic myeloid leukemia (CML) must be positive for the Philadelphia chromosome or BCR-ABL gene. For CML, patient meets one of the following: 1) newly diagnosed in chronic phase, 2) resistance to imatinib or dasatinib, 3) intolerance/toxicity to imatinib or dasatinib, or 4) relapse after stem cell transplant.
Age Restrictions: 18 years of age and older
Prescriber Restrictions:
Coverage Duration: Plan Year
Other Criteria: Patient has been instructed to avoid eating food 2 hours before and 1 hour after taking Tasigna. Concomitant use of drugs known to prolong the QT interval and strong CYP3A4 inhibitors should be avoided.
TAZORAC

PA

Drugs: TAZORAC
Covered Uses: All FDA approved indications not otherwise excluded from Part D
Exclusion Criteria:
Required Medical Information: For patients being treated for plaque psoriasis Tazorac will be applied to less than 20 percent of the body surface area. For female patients who are able to bear children (no hysterectomy, not reached menopause, has achieved menses), a negative pregnancy test (sensitivity down to at least 50 mIU/mL for hCG) must be obtained within 2 weeks prior to Tazorac therapy, beginning during a normal menstrual cycle. Physician must discuss with the patient the potential risks of fetal harm and importance of birth control while using Tazorac.
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: Plan Year
Other Criteria: For patients being treated for plaque psoriasis a trial of at least two topical corticosteroids (clobetasol, fluocinonide, mometasone, triamcinolone) (patient may still be using a corticosteroid product in addition to Tazorac) or patient has a contraindication to topical corticosteroids.
TESTOSTERONES

PA

Drugs: ANDRODERM, ANDROGEL (Plus Formulary Only), ANDROGEL PUMP (Plus Formulary Only), TESTIM
Covered Uses: All FDA approved indications not otherwise excluded from Part D
Exclusion Criteria: Female, carcinoma of the breast or known or suspected prostate cancer.
Required Medical Information: Before the start of testosterone therapy patient has (or patient currently has) a confirmed low testosterone level (i.e. total testosterone less than 300 ng/dL, free or bioavailable, testosterone less than 5 ng/dL) or absence of endogenous testosterone.
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: Plan Year
Other Criteria:
THALOMID

PA

Drugs: THALOMID
Covered Uses: All FDA approved uses not otherwise excluded from Part D. Primary treatment of systemic light chain amyloidosis (SLCA) with dexamethasone, Waldenstrom macroglobulinemia as monotherapy or with rituximab, mantle cell lymphoma with rituximab for relapsed, refractory of progressive disease, and myelofibrosis with myeloid metaplasia.
Exclusion Criteria: Pregnancy
Required Medical Information: For active myeloma, patient meets one of the following: 1) Thalomid is used as salvage or palliative therapy. 2) Thalomid is used for newly diagnosed disease or as primary induction therapy in combination with dexamethasone or in combination with melphalan and prednisone in nontransplant candidates. 3) Thalomid is used as maintenance monotherapy following response to either stem cell transplant or primary induction therapy. For female patients of childbearing potential, pregnancy is excluded by a negative pregnancy test.
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: Plan Year
Other Criteria: Patients are monitored for signs and symptoms of thromboembolism. Male and female patients of child-bearing potential are instructed on the importance of proper utilization of appropriate contraceptive methods.
THIORIDAZINE

PA

Drugs: THIORIDAZINE HCL
Covered Uses: All FDA approved indications not otherwise excluded from Part D
Exclusion Criteria:
Required Medical Information:
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: Plan Year
Other Criteria: Prescriber must acknowledge that medication benefits outweigh potential risks in patients 65 years of age or older.
TOPICAL IMMUNOSUPPRESSANT

PA

Drugs: ELIDEL, PROTOPIC
Covered Uses: All FDA approved indications not otherwise excluded from Part D
Exclusion Criteria:
Required Medical Information: A. The diagnosis is documented as atopic dermatitis or eczema. B. AND patients must be at least 2 years of age C. AND patients who have completed a documented trial and failure of at least one medium or higher potency topical steroids or have documented intolerance or unresponsiveness to medium or higher potency topical steroids D. AND patients have been advised that Elidel and Protopic should only be used to treat the immediate problem and then should be stopped when the condition improves.
Age Restrictions: 2 years of age and older
Prescriber Restrictions:
Coverage Duration: Plan Year
Other Criteria:
TOPICAL-ULCERS

PA

Drugs: REGRANEX
Covered Uses: All FDA approved indications not otherwise excluded from Part D
Exclusion Criteria: Neoplasm(s) at site(s) of application
Required Medical Information: A. Must be used for treatment of lower-extremity diabetic ulcers B. AND the ulcer must extend into subcutaneous tissue or beyond C. AND the tissue must have an adequate blood supply D. AND the patient must have concurrent good ulcer treatment practices including ALL of the following: a. Debridement b. Pressure relief c. Infection control.
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: 20 weeks
Other Criteria:
TRACLEER

PA

Drugs: TRACLEER
Covered Uses: All FDA approved indications not otherwise excluded from Part D
Exclusion Criteria: AST/ALT level greater than 3 times upper limit of normal (ULN). Pregnancy. Concomitant use of cyclosporine A or glyburide.
Required Medical Information: PAH confirmed by right heart catheterization OR by Doppler echocardiogram in infants. NYHA class II-IV symptoms.
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: Plan Year
Other Criteria: Female patients of childbearing potential must use more than one method of contraception concurrently.
TYKERB

PA

Drugs: TYKERB
Covered Uses: All FDA approved indication not otherwise excluded from Part D, in combination with trastuzumab (without cytotoxic therapy) in patients who have received a prior therapy that includes trastuzumab containing regimen or another aromatase inhibitor (e.g., anastrozole, exemestane)
Exclusion Criteria:
Required Medical Information: Liver function tests must be monitored at baseline and every four to six weeks during therapy and as clinically indicated. In patients with severe hepatic impairment, Tykerb is used at a reduced dose.
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: Plan Year
Other Criteria:
TYZEKA

PA

Drugs: TYZEKA
Covered Uses: All FDA approved indications not otherwise excluded from Part D
Exclusion Criteria: Use of Tyzeka as a first-line therapy in treatment-naïve patients with HBV
Required Medical Information: A. The patient has been diagnosed with chronic hepatitis B. B. AND the patient has evidence of a positive HBsAg (HBeAg + or -) for greater than 6 months OR evidence by a liver biopsy showing chronic hepatitis. C. AND the patient has a Hepatitis B viral load greater than 20,000 IU/mL (100,000 copies per mL) except if for HBeAg-negative HBV, the viral load is greater than 2,000 IU per mL (10,000 copies per mL). D. AND the patient has elevations in liver aminotransferases (ALT or AST) that are two (2) times greater than normal OR normal liver aminotransferase (ALT or AST) levels with evidence of significant disease found on biopsy. E. AND the patient is not receiving duplicate therapy that includes Baraclude (entecavir), Epivir (lamivudine) and/or Intron A (interferon A-2b, recombinant). F. AND evidence of diagnosis, serological markers or liver biopsy, viral load, and liver aminotransferases is documented in patient's chart.
Age Restrictions: 16 years of age or older
Prescriber Restrictions: Infectious Disease specialist or Gastroenterologist or affiliated with an infectious disease or gastroenterology practice or a primary care physician with experience in treating HBV
Coverage Duration: Plan Year
Other Criteria: If the patient has received previous Tyzeka treatment, there is documented clinical improvement shown by a drop in viral load or reduction in the patient's liver aminotransferase levels.
VICTRELIS

PA

Drugs: VICTRELIS
Covered Uses: All FDA approved indications not otherwise excluded from Part D
Exclusion Criteria: Failed previous therapy with a treatment regimen that includes a protease inhibitor (e.g., Incivek, Victrelis). Concomitant administration with a drug that is highly dependent on CYP3A4/5 for clearance or potent CYP3A4/5 inducer.
Required Medical Information: Hepatitis C virus (HCV) infection confirmed by presence of viral load in serum. HCV Genotype 1. HCV-RNA less than 100 IU/mL at week 12 of treatment. Undetectable HCV-RNA at week 24 of treatment.
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: Initial: 10 weeks. Renewal: Up to 44 weeks.
Other Criteria: Must be given in combination with pegylated interferon (i.e., Pegasys or PegIntron) and ribavirin. Must receive 4 weeks of pegylated interferon and ribavirin prior to starting Victrelis.
VOTRIENT

PA

Drugs: VOTRIENT
Covered Uses: All FDA approved indications not otherwise excluded from Part D
Exclusion Criteria: Either of the following: 1) alanine transaminase (ALT) greater than 3 times the upper limit of normal (ULN) and bilirubin greater than 2 times the ULN, OR 2) bilirubin greater than 3 times the ULN.
Required Medical Information: For advanced soft tissue sarcoma (STS): 1) patient does not have adipocytic STS or gastrointestinal stromal tumor, and 2) patient has previously received chemotherapy.
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: Plan Year
Other Criteria:
VPRIV

PA

Drugs: VPRIV
Covered Uses: All FDA approved indications not otherwise excluded from Part D
Exclusion Criteria: Concomitant use of miglustat (Zavesca)
Required Medical Information: Diagnosis confirmed by bone marrow histology, DNA testing, or measurement of beta-glucocerebrosidase enzyme activity of less than 30 percent. Patient must have at least one of the following conditions as a result of Type 1 Gaucher disease: anemia, thrombocytopenia, bone disease, hepatomegaly, or splenomegaly. Patients who have previously received 24 months of VPRIV therapy must have one of the following responses to continue therapy: 1) A decrease in liver and spleen volume 2) An increase in platelet count, or 3) An increase in hemoglobin concentration.
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: Plan Year
Other Criteria:
XALKORI

PA

Drugs: XALKORI
Covered Uses: All FDA approved indications not otherwise excluded from Part D
Exclusion Criteria:
Required Medical Information: Patient has a diagnosis of locally advanced or metastatic non-small cell lung cancer that is ALK-positive as detected by an FDA-approved test.
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: Plan Year
Other Criteria: Prior authorization applies to new starts only. Refills will be approved unless use is not coverable under Part D per Medicare drug coverage policies.
XENAZINE

PA

Drugs: XENAZINE
Covered Uses: All FDA approved indications not otherwise excluded from Part D
Exclusion Criteria: Patients with untreated or inadequately treated depression or who are actively suicidal, history of hepatic disease, use in combination with MAO inhibitors or reserpine (or it has been less than 20 days since reserpine was discontinued).
Required Medical Information:
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: Plan Year
Other Criteria:
XIFAXAN

PA

Drugs: XIFAXAN
Covered Uses: All FDA approved indications not otherwise excluded from Part D
Exclusion Criteria: For hepatic encephalopathy, Xifaxan exceeding the recommended dose of two 550mg tablets daily.
Required Medical Information:
Age Restrictions: 18 years of age and older
Prescriber Restrictions:
Coverage Duration: Hepatic encephalopathy-6 months
Other Criteria:
XOLAIR

PA

Drugs: XOLAIR
Covered Uses: All FDA approved indications not otherwise excluded from Part D
Exclusion Criteria:
Required Medical Information: Patient must meet all of the following criteria for Xolair use: 1) Patient has evidence of reversible disease (demonstrates at least 20 percent improvement in PEF with a short-acting bronchodilator challenge). 2) Patient has experienced two or more asthma exacerbations per month within the last three months. 3) Patient had a positive skin test to at least one perennial aeroallergen. 4) Baseline IgE level at or above 30 IU/mL. 5) Patient's asthma is inadequately controlled despite adherent use of inhaled corticosteroids. 6) Patient had an inadequate response to a trial of a leukotriene modifier or long-acting beta2-agonist (unless patient demonstrates intolerance to the therapeutic trial).
Age Restrictions: 12 years of age and older
Prescriber Restrictions: Pulmonologist, allergist or immunologist
Coverage Duration: Plan Year
Other Criteria: To continue therapy, patients must demonstrate an improvement in asthma control with use of Xolair.
XYREM

PA

Drugs: XYREM
Covered Uses: All FDA approved indications not otherwise excluded from Part D
Exclusion Criteria: If the patient is taking/receiving any of the following: anxiolytics, sedatives, hypnotics, barbiturates, benzodiazepines or ethanol.
Required Medical Information: A. The diagnosis is documented as excessive daytime sleepiness with symptoms that limit their ability to perform normal daily activities. B. AND the diagnosis is documented as cataplexy (a condition characterized by weak or paralyzed muscles) in patients with narcolepsy. C. AND if the patient has received prior treatment with Xyrem, the patient must experience a decrease in daytime sleepiness and/or cataplexy in a narcoleptic patient.
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: 3 months
Other Criteria:
ZAVESCA

PA

Drugs: ZAVESCA
Covered Uses: All FDA approved indications not otherwise excluded from Part D
Exclusion Criteria: Severe renal impairment. Pregnancy.
Required Medical Information: Diagnosis confirmed by bone marrow histology, DNA testing, or b-glucocerebrosidase enzyme assay (enzyme activity less than 30 percent). Trial of enzyme replacement therapy (ERT) or ERT is not a therapeutic option (eg, allergy, poor venous access). Female patients of childbearing age will use an effective method of contraception. Female patients of childbearing age will be educated about the potential hazards associated with Zavesca use in pregnancy (ie, potential harm to fetus). Must demonstrate a decrease in liver and spleen volume and/or increase in platelet count and/or increase in Hgb concentration in patients who received at least 24 months of Zavesca therapy.
Age Restrictions: 18 years of age and older
Prescriber Restrictions:
Coverage Duration: Plan Year
Other Criteria:
ZELBORAF

PA

Drugs: ZELBORAF
Covered Uses: All FDA approved indications not otherwise excluded from Part D
Exclusion Criteria:
Required Medical Information: Patient has a diagnosis of unresectable or metastatic melanoma AND the tumor is positive for the BRAF V600E mutation as detected by an FDA-approved test.
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: Plan Year
Other Criteria: Prior authorization applies to new starts only. Refills will be approved unless use is not coverable under Part D per Medicare drug coverage policies.
ZYTIGA

PA

Drugs: ZYTIGA
Covered Uses: All FDA approved indications not otherwise excluded from Part D
Exclusion Criteria:
Required Medical Information:
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: Plan Year
Other Criteria: Used in combination with prednisone. Received prior chemotherapy containing docetaxel.

Step Therapy Drugs

AMITIZA

ST

Drug Names AMITIZA
Step Therapy Criteria
  1. The patient has had at least a 30 day trial of polyethylene glycol 3350 (PEG 3350) or lactulose.
ATYPICAL ANTIPSYCHOTICS

ST

Drug Names FANAPT, FANAPT TITRATION PACK, INVEGA
Step Therapy Criteria
  1. The patient is currently taking the prescribed medication with evidence of improvement OR
  2. The patient has tried and failed a 30 day trial of generic risperidone (any dosage form), Geodon, Seroquel, Seroquel XR or Zyprexa (olanzapine) OR
  3. The patient is intolerant to or had a confirmed adverse reaction with generic risperidone (any dosage form), Geodon, Seroquel, Seroquel XR or Zyprexa (olanzapine).
INTRANASAL STEROID

ST PLUS FORMULARY ONLY

Drug Names RHINOCORT AQUA
Step Therapy Criteria
  1. The member has filled a prescription for generic nasal steroid OR
  2. The member has a documented contraindication to or a potential drug interaction with a generic nasal steroid OR
  3. The member is intolerant to or had a confirmed adverse event with a generic nasal steroid OR
  4. The member has had an inadequate treatment response to a generic nasal steroid.
MIGRAINE

ST PLUS FORMULARY ONLY

Drug Names FROVA, RELPAX, ZOMIG, ZOMIG ZMT
Step Therapy Criteria
  1. The patient has a documented contraindication to or a potential drug interaction with a generic triptan (e.g., sumatriptan, naratriptan) OR
  2. The patient is intolerant to or had a confirmed adverse event with a generic triptan (e.g., sumatriptan, naratriptan) OR
  3. The patient has demonstrated an inadequate treatment response after at least a 30 day trial of a generic triptan (e.g., sumatriptan, naratriptan) OR
  4. The patient requires use of a specific dosage form (e.g., suspension, solution) that is not available as a generic triptan (e.g., sumatriptan, naratriptan)
ULORIC

ST

Drug Names ULORIC
Step Therapy Criteria
  1. The patient has demonstrated an inadequate treatment response to allopurinol after a trial of at least 30 days OR
  2. The patient has had an adverse event or had a documented contraindication to allopurinol that would prohibit a 30 day trial.
URINARY ANTISPASMOTICS

ST PLUS FORMULARY ONLY

Drug Names DETROL, OXYTROL, SANCTURA XR, TOVIAZ
Step Therapy Criteria
  1. The patient has a documented contraindication to or a potential drug interaction with a generic urinary antispasmodic (e.g., oxybutynin, oxybutynin extended release, trospium) OR
  2. The patient is intolerant to or had a confirmed adverse event with a generic urinary antispasmodic (e.g., oxybutynin, oxybutynin extended release, trospium) OR
  3. The patient has demonstrated an inadequate treatment response after at least a 30 day trial of a generic urinary antispasmodic (e.g., oxybutynin, oxybutynin extended release, trospium).