2016 Prior Authorization Criteria - Login · 2016 Prior Authorization Criteria Last ... ottenere...

2016 Prior Authorization Criteria

Last Updated: 10/25/16

HPMS Approved Formulary File Submission 00016419

Version Number 32

If you or someone you’re helping has questions about Florida Health Care Plans, you have the right to get help

and information in your language at no cost. To talk to an interpreter, call 1-877-615-4022. (TTY: TRS Relay 711)

Si usted o alguien a quien ayuda tienen preguntas sobre Florida Health Care Plans, tienen derecho a obtener

ayuda e información en su idioma de manera gratuita. Para hablar con un intérprete, llame al 1-877-615-4022.

(TTY: TRS Relay 711)

Si ou menm, oswa yon moun w ap ede, gen kesyon sou Florida Health Care Plans ,ou gen dwa pou jwenn

enfòmasyon nan lang ou gratis. Pou ale ak yon entèprèt, rele 1-877-615-4022. (TTY: TRS Relay 711)

Nêu quy vi, hoăc ngươi nao đo ma quy vi đang giup đơ, co cac thăc măc vê Florida Health Care Plans, quy vi co

quyên đươc nhân trơ giup va thông tin băng ngôn ngư cua quy vi miên phi. Đê trao đôi vơi phiên dich, hay goi

theo sô 1-877-615-4022. (TTY: TRS Relay 711)

Se você, ou alguém que estiver a ajudar, tiver dúvidas sobre Florida Health Care Plans, tem o direito de obter

ajuda e informações na sua língua, sem nenhumas custas. Para falar com um intérprete, ligue para 1-877-615-

4022. (TTY: TRS Relay 711)

如果您或您正協助的某人對Florida Health Care Plans

有疑問，您有權免費以您的語言取得本協助及資訊。如欲與口譯員交談，請致電1-877-615-4022. (TTY: TRS

Relay 711)

Si vous ou une personne que vous aidez avez des questions au sujet de Florida Health Care Plans, vous avez le

droit d'obtenir gratuitement de l'aide et des informations dans votre langue. Pour parler à un interprète,

veuillez appeler le 1-877-615-4022. (TTY: TRS Relay 711)

Kung ikaw, o ang isang taong tinutulungan mo, ay may mga tanong tungkol sa Florida Health Care Plans,

mayroon kang karapatang humingi ng tulong at impormasyon sa iyong wika nang walang bayad. Upang

makipag-usap sa isang interpreter, tumawag sa 1-877-615-4022. (TTY: TRS Relay 711)

Если у Вас или у кого-то, кому Вы помогаете, есть вопросы о программе Florida Health Care Plans, Вы

имеет право бесплатно получить ответы в переводе на Ваш язык. Для того чтобы воспользоваться

помощью устного переводчика, позвоните по телефону 1-877-615-4022. (TTY: TRS Relay 711)

,يحق لك تلقي المساعدة والمعلومات بلغتك مجانا. تحدث إلى Florida Health Care Plansحول ]ذا كان لديك أو الشخص الذي تساعده استفسارات

.(TTY: TRS Relay 711) .4022-615-877-1مترجم فوري، اتصل على الرقم ]

se voi, o una persona che state aiutando, avete domande relative al Florida Health Care Plans, avete diritto a

ottenere assistenza e informazioni gratuitamente nella vostra lingua. Per parlare con un interprete, chiamare il

numero 1-877-615-4022. (TTY: TRS Relay 711)

Falls Sie oder jemand, dem Sie helfen, irgendwelche Fragen über Florida Health Care Plans haben, so haben Sie

Anspruch auf kostenlose Unterstützung und Informationen in Ihrer eigenen Sprache. Bitte rufen Sie uns unter

der Nummer 1-877-615-4022. (TTY: TRS Relay 711) an, um mit einem Dolmetscher/einer Dolmetscherin zu

sprechen.

귀하 또는 귀하가 도와드리고 있는 분이Florida Health Care Plans에 관한 질문이 있을 경우, 귀하에게는

무료로 본인이 구사하는 언어로 도움과 정보를 받을 권리가 있습니다. 통역으로 전화 연결되려면1-877-615-

4022. (TTY: TRS Relay 711) 번으로 전화해 주십시오.

Jeśli Ty lub ktoś, komu pomagasz macie pytania dotyczące Florida Health Care Plans, macie prawo uzyskać

pomoc i informacje w swoim języku, bez żadnych kosztow. Porozmawiaj z tłumaczem, zadzwoń pod numer 1-

877-615-4022. (TTY: TRS Relay 711)

જો તમન અથવા તમ જન મદદ કરી રહાા છો તમન Florida Health Care Plans વવશ કોઈ પરશનો હોય, તો તમન તમારી ભાષામાા કોઇ પણ ખરચ વવના મદદ અન માહહતી મળવવાનો હક છ. દભાવષયા સાથ વાત કરવા માટ 1-877-615-4022. (TTY: TRS Relay

711)

પર ફોન કરો.

หากคณ หรอคนทคณก าลงชวยเหลออยมค าถามเกยวกบ Florida Health Care Plans

คณจะไดรบการชวยเหลอและไดรบขอมลในภาษาของคณโดยทไมมคาใชจายใดๆ หากตองการพดคยกบลามแปลภาษา โทร.

1-877-615-4022. (TTY: TRS Relay 711)

Discrimination is Against the Law

Florida Health Care Plans complies with applicable Federal civil rights laws and does not discriminate on the

basis of race, color, national origin, age, disability, or sex. Florida Health Care Plans does not exclude people

or treat them differently because of race, color, national origin, age, disability, or sex.

Florida Health Care Plans:

• Provides free aids and services to people with disabilities to communicate effectively with us, such as:

o Qualified sign language interpreters o Written information in other formats (large print, audio, accessible electronic formats, other

formats) • Provides free language services to people whose primary language is not English, such as:

o Qualified Interpreters o Information written in other languages

If you need these services, contact Daria Siciliano, RN-BC, CCM.

If you believe that Florida Health Care Plans has failed to provide these services or discriminated in another

way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with:

Daria Siciliano, RN-BC, CCM,

Manager of Member Services,

1340 Ridgewood Avenue

Holly Hill, FL 32117.

Phone: 1-844-219-6137,

TTY: TRS Relay 711,

Fax: 386-676-7149,

Email: [email protected].

You can file grievance in person or by mail, fax, or email. If you need help filing a grievance, Daria Siciliano,

RN-BC, CCM Manager of Member Services is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for

Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at

https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services

200 Independence Avenue, SW

Room 509F, HHH Building

Washington, D.C. 20201

1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

H1035_A5228 CMS Accepted (08/11/2016)

ABILIFY

DrugsARIPiprazole ORAL TABLET, ARIPiprazole ORAL TABLET DISPERSIBLE, Aristada

Covered UsesAll medically accepted indications not otherwise excluded from part D

Exclusion CriteriaFDA labeled contraindications

Required Medical InformationDiagnosis

Age RestrictionAges approved in FDA labeling/compendia

Prescriber RestrictionPsychiatry/ Neurology

Coverage Duration12 months

Other Criteria

5

ACTIMMUNE

DrugsActimmune



Required Medical InformationDiagnosis, Bone biopsy if osteopetrosis, Antibiotic failure if chronic granulomatous disease


Prescriber RestrictionInfectious Disease/Hematology/Orthopedist


Other CriteriaSulfamethoxazole/Trimethoprim and/or itraconazole failure for infections secondary to chronic granulomatous disease. Osteopetrosis must be severe malignant

6

Adempas

DrugsAdempas

Covered UsesAll FDA approved indications not otherwise excluded from Part D

Exclusion Criteria

Required Medical Information

Age Restriction

Prescriber Restrictionpulmonologist/cardiologist


Other CriteriaFor PAH must have tried and failed bosentan and sildenafil, CTPH does not require failure of bosentan

7

Alecensa

DrugsAlecensa


Exclusion Criteria


Age Restriction

Prescriber RestrictionHematology/Oncology


Other CriteriaApproved for ALK+ Non Small Cell Lung Cancer after progression on crizotinib

8

AMITIZA

DrugsAmitiza

Covered UsesAll FDA-approved indications not otherwise excluded from Part D

Exclusion CriteriaFDA labeled contraindication

Required Medical InformationPrevious Treatment History

Age RestrictionAges in FDA label

Prescriber RestrictionGastroenterology


Other CriteriaFailure of Lactulose and polyethylele glycol 3350 (Miralax)

9

Anti-thymocyte globulin

DrugsAtgam

Covered UsesAll FDA approved indications not otherwise excluded by part D

Exclusion Criteria


Age Restriction

Prescriber Restriction

Coverage Duration1 month

Other CriteriaCoverage Criteria Based on current Medicare Part B LCD/NCD

10

APOKYN

DrugsApokyn



Required Medical InformationMedical notes, previous treatment history


Prescriber RestrictionNeurologist


Other CriteriaPatient must have poorly controlled off time episodes and failed dopamine agonist and COMT inhibitor

11

Aptiom

DrugsAptiom

Covered UsesAll FDA approved indications not otherwise excluded by Part D

Exclusion Criteria


Age Restriction

Prescriber RestrictionNeurology


Other CriteriaFailure of carbamazepine and Oxcarbazepine

12

ARANESP

DrugsAranesp (Albumin Free) INJECTION 100 MCG/0.5ML, 300 MCG/0.6ML, 40 MCG/0.4ML, 60 MCG/0.3ML, Aranesp (Albumin Free) INJECTION SOLUTION 10 MCG/0.4ML, 100 MCG/ML, 200 MCG/ML, 25 MCG/ML, 40 MCG/ML, 60 MCG/ML



Required Medical InformationMedical notes and Scr and HGB and T-sat and Ferritin

Age RestrictionAges approved in FDA labeling



Other CriteriaFailure of Procrit. Hemoglobin required to be within FDA approved ranges for initiation and maintenance. Patient must have adequate iron stores to initiate and continue treatment. ESRD would be covered under part B benefit

13

ARCALYST

DrugsArcalyst



Required Medical InformationCoverage will be based on a Diagnosis of CAPS, failure of 1 other treatment used for this condition such as cancakinumab, nsaids

Age Restriction

Prescriber RestrictionImmunologist


Other Criteria

14

AVASTIN

DrugsAvastin

Covered UsesAll medically accepted indications not otherwise excluded from part D OR Metastatic carcinoma of the colon or rectum when used in combination with intravenous 5-Fluorouracil based chemotherapy for first-line or second-line treatment OR Metastatic human epidermal growth factor receptor 2 (HER2)-negative breast cancer when used in combination with paclitaxel for the treatment of patients who have not received chemotherapy for metastatic HER2-negative breast cancer OR Nonsquamous non-small cell lung cancer in combination with carboplatin and paclitaxel for the first-line treatment of patients with unresectable or locally advanced or recurrent or metastatic non-squamous cell disease OR Central nervous system (CNS) cancers OR Renal cell carcinoma (RCC) OR Ovarian cancer OR Cervical cancer OR wet AMD OR diabetic macular edema OR macular retinal edema


Required Medical InformationMedical notes and previous treatment history and associated studies


Prescriber RestrictionOncologist, ophthalmologist

Coverage Duration12 months or until disease progression

Other Criteria

15

Azilect

DrugsAzilect


Exclusion Criteria


Age Restriction



Other CriteriaFailure of Selegiline and Levodopa/Carbidopa

16

BANZEL

DrugsBanzel




Age Restrictionages 4 and up



Other Criteria

17

BOSULIF

DrugsBosulif


Exclusion Criteria


Age Restriction



Other CriteriaRequires failure of another Tyrosine Kinase inhibitor for CML

18

BOTOX

DrugsBotox INJECTION SOLUTION RECONSTITUTED 100 UNIT


Exclusion CriteriaFDA labeled contraindications OR cosmetic conditions

Required Medical InformationDiagnosis, supporting notes




Other Criteria

19

Briviact

DrugsBriviact

Covered UsesAll FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria


Age Restriction



Other CriteriaFailure of Levetiracetam

20

BUDESONIDE EC

DrugsBudesonide ORAL





Prescriber RestrictionGastroenterologist


Other CriteriaCovered for Short term use in mild to moderate Crohn's up to 3 months as approved in FDA Label

21

BUPRENORPHINE

DrugsBuprenorphine HCl SUBLINGUAL, Buprenorphine HCl-Naloxone HCl





Prescriber RestrictionPhysician licensed to use the medication for addiction


Other CriteriaNot covered for pain management

22

BYDUREON

DrugsBydureon SUBCUTANEOUS* 2 MG


Exclusion Criteria


Age Restriction



Other CriteriaPatient must be on maximal tolerated doses of sulfonylurea and Metformin unless contraindicated. Not covered for combination use outside of FDA label.

23

BYETTA

DrugsByetta 10 MCG Pen SUBCUTANEOUS*, Byetta 5 MCG Pen SUBCUTANEOUS*



Required Medical InformationMedical notes, previous treatment history, HA1c BG


Prescriber Restrictionnone


Other CriteriaPatient must be on maximal tolerated doses of sulfonylurea and Metformin, unless contraindicated

24

Cabometyx

DrugsCabometyx


Exclusion Criteria


Age Restriction



Other CriteriaCovered until disease progression.

25

CARBAGLU

DrugsCarbaglu

Covered UsesAll FDA approved indications not otherwise excluded from part D

Exclusion Criteria


Age Restriction



Other Criteria

26

CEREZYME

DrugsCerezyme INTRAVENOUS* SOLUTION RECONSTITUTED 400 UNIT

Covered UsesAll FDA-approved indications not otherwise excluded from Part D. Approved for treatment of type 1 Gauchers with a history of Thrombocytopenia OR splenomegaly OR bone disease OR hepatomegaly

Exclusion Criteria

Required Medical InformationMedical notes


Prescriber RestrictionMedical Geneticist


Other Criteria

27

Cinryze

DrugsCinryze

Covered UsesAll Medically acceptable indications not otherwise excluded by part D

Exclusion Criteria


Age Restriction



Other CriteriaPatient must have two or more angioedema attacks per month and has failed danazol

28

CLOTRIMAZOLE TROCHE

DrugsClotrimazole MOUTH/THROAT TROCHE



Required Medical InformationPrevious treatment history

Age RestrictionNone


Coverage Duration14 days

Other CriteriaFailure of Nystatin and Fluconazole unless contraindicated

29

Cometriq

DrugsCometriq (100 mg Daily Dose), Cometriq (140 mg Daily Dose), Cometriq (60 mg Daily Dose)


Exclusion Criteriacombination use with other tyrosine Kinase inhibitors.


Age Restriction

Prescriber Restrictiononcology/hematology


Other CriteriaCovered for Metastatic Thyroid Medullary Cancer

30

Cotellic

DrugsCotellic


Exclusion Criteria


Age Restriction



Other CriteriaCovered for BRAF+ metastatic melanoma for combination use in with Zelboraf

31

DALIRESP

DrugsDaliresp

Covered UsesAll medically acceptable indications not otherwise excluded by Part D

Exclusion Criteria


Age Restriction



Other CriteriaFailure or intolerance of combination inhaled corticosteroid/Long Acting Beta Agonist and long acting muscarinic antagonist.

32

Diclofenac 1% topical(Voltaren gel)

DrugsVoltaren TRANSDERMAL

Covered UsesAll medically acceptable indications not otherwise excluded by part D

Exclusion Criteria


Age Restriction


Coverage Duration12month

Other CriteriaFailure or contraindication to oral NSAID and one other analgesic in past six months

33

DRONABINOL

DrugsDronabinol





Prescriber RestrictionInfectious disease/oncologist/gastroenterologist

Coverage Durationup to 12 months

Other CriteriaFor HIV/Cancer related cachexia patient must fail megestrol, For Chemotherapy induced nausea, patient must fail Emend and Ondansetron.

34

ELAPRASE

DrugsElaprase



Required Medical InformationPrevious Treatment History, medical notes supporting diagnosis


Prescriber RestrictionMedical Geneticist, Endocrinologist


Other Criteria

35

ELITEK

DrugsElitek INTRAVENOUS* SOLUTION RECONSTITUTED 1.5 MG





Prescriber Restrictiononcologist


Other CriteriaPatient must fail xanthine oxidase inhibitor

36

ELMIRON

DrugsElmiron


Exclusion Criteria


Age Restriction

Prescriber RestrictionRestricted to Urology


Other Criteria

37

EMEND

DrugsEmend ORAL CAPSULE 40 MG, 80 & 125 MG, 80 MG





Prescriber RestrictionHematologist/oncologist/Surgeon


Other CriteriaPatient must fail treatment with ondansetron (PA not applicable for PONV)

38

EMSAM

DrugsEmsam TRANSDERMAL PATCH 24 HR 6 MG/24HR, 9 MG/24HR



Required Medical InformationMedical notes, prior medication failures




Other CriteriaPatient must fail 6 week trial with two formulary anti-depressants

39

ENBREL

DrugsEnbrel SUBCUTANEOUS* 50 MG/ML, Enbrel SUBCUTANEOUS* SOLUTION RECONSTITUTED, Enbrel SureClick SUBCUTANEOUS*


Exclusion CriteriaFDA labeled contraindications combination with other biologic



Prescriber RestrictionRheumatology/Dermatology or Specialist trained in management of prescribed condition


Other CriteriaFor RA Patient must fail adequate trial of MTX in combination with a DMARD If MTX contraindicated, must try combination of 2-nonbiologic DMARDS. For Ankylosing Spondylitis PT must fail 2 NSAIDS within past 6 months. For Plaque Psoriasis patient must fail MTX or Soriatane and Topical Therapy(ie. high potency steroids Vit D analogs). for Psoriatic Arthritis Patient must fail adequate trial of MTX or LEF in past 6 months.

40

Esbriet

DrugsEsbriet


Exclusion Criteria


Age Restriction



Other CriteriaConfirmed Diagnosis of idiopathic pulmonary fibrosis (IPF) through exclusion of other fibrosing conditions/causes and definitive High resolution CT IPF pattern or Biopsy proven IPF. FVC of at least 50% of predicted value DLCO of at least 30%

41

EXJADE

DrugsExjade



Required Medical InformationMedical notes, previous treatment history, iron indices


Prescriber RestrictionHematologist/oncologist


Other CriteriaPatient must fail or have contraindication to deferoximine

42

FABRAZYME

DrugsFabrazyme INTRAVENOUS* SOLUTION RECONSTITUTED 35 MG





Prescriber RestrictionMedical Geneticist


Other CriteriaPatient must have a diagnosis of Fabry's disease with significant cardiac or renal manifestations.

43

FANAPT

DrugsFanapt







Other Criteria

44

Farydak

DrugsFarydak

Covered UsesAll FDA-approved indications not otherwise excluded from part D

Exclusion Criteria


Age Restriction


Coverage Duration12months

Other Criteria

45

FENTANYL LOZENGE

DrugsFentaNYL Citrate BUCCAL





Prescriber RestrictionPain management physician/oncologist


Other CriteriaCovered for breakthrough pain in patients receiving long acting opioid treatment and are opioid tolerant. Patient must fail two immediate release C-II opioid such as hydromorphone, morphine, oxycodone.

46

FENTANYL PATCH

DrugsFentaNYL TRANSDERMAL PATCH 72 HR 100 MCG/HR, 12 MCG/HR, 25 MCG/HR, 50 MCG/HR, 75 MCG/HR





Prescriber RestrictionPain management physician/oncologist


Other Criteria

47

Ferriprox

DrugsFerriprox ORAL TABLET


Exclusion Criteria


Age Restriction

Prescriber Restrictiononcologist/hematologist


Other CriteriaFailure of Exjade and Desferal

48

Fetzima

DrugsFetzima


Exclusion Criteria


Age Restriction



Other CriteriaMust fail two generically available anti-depressants in past12 months

49

FIRAZYR

DrugsFirazyr

Covered UsesAll FDA approved indications not otherwise excluded by part D.

Exclusion Criteria


Age Restriction



Other Criteria

50

FONDAPARINUX

DrugsFondaparinux Sodium







Other CriteriaCoverage will be based on allergy to Lovenox or other condition where Lovenox use is not appropriate

51

FORTEO

DrugsForteo SUBCUTANEOUS* SOLUTION 600 MCG/2.4ML


Exclusion CriteriaFDA labeled contraindications/ cumulative tx more than 24month

Required Medical InformationMedical notes, previous treatment history, BMD, PTH, VITD

Age RestrictionLate adolescents and Adults only



Other CriteriaPatient must fail or have contraindication to bisphosphonates, Vitamin D (25,OH), PTH must be WNL

52

FOSRENOL

DrugsFosrenol ORAL PACKET, Fosrenol ORAL TABLET CHEWABLE 1000 MG, 500 MG, 750 MG



Required Medical InformationPrevious treatment history, CA, PO4, IPTH


Prescriber RestrictionNephrologist


Other CriteriaPatient must fail or not be a candidate for calcium based phosphate binders based on KDOQI guidelines for use

53

fycompa

DrugsFycompa


Exclusion Criteria


Age Restriction



Other CriteriaCovered for use as an adjunctive agent for partial onset seizures

54

GAMMAGARD

DrugsGammagard INJECTION SOLUTION 2.5 GM/25ML


Exclusion Criteria

Required Medical InformationMedical notes, immunoglobulin studies




Other Criteria

55

Gattex

DrugsGattex


Exclusion Criteria


Age Restriction

Prescriber RestrictionGastroenterologist

Coverage Duration6 months initially

Other CriteriaDiagnosis of Short Bowel Syndrome Dependent on Parenteral Support Baseline Records of parenteral hydration After 6 month trial of Gattex, patient must demonstrate 20% reduction in weekly parenteral fluid volume for continuation.

56

GEODON

DrugsGeodon INTRAMUSCULAR*







Other Criteria

57

Gilenya

DrugsGilenya

Covered UsesAll Medically Acceptable indications not otherwise covered by Part D

Exclusion Criteria


Age Restriction



Other CriteriaTrial of one other formulary medication which can be used for MS Copaxone, Interferons, leflunamide

58

Gilotrif

DrugsGilotrif

Covered UsesAll medically accepted indications not otherwise excluded from Part D

Exclusion Criteria

Required Medical InformationMedical Notes, Labs to support the Genetic tumor markers Exon 19 deletion, Exon 21 (L858R) substitution

Age Restriction

Prescriber RestrictionOncology/Hematology


Other CriteriaOff label use must be supported by NCCN criteria with evidence rating of 2a or 1

59

GUANFACINE ER

DrugsGuanFACINE HCl ER


Exclusion Criteria


Age Restriction



Other CriteriaFailure of Guanfacine IR

60

HEPSERA

DrugsAdefovir Dipivoxil



Required Medical InformationMedical notes, previous treatment history, associated studies




Other Criteria

61

Hetlioz

DrugsHetlioz


Exclusion Criteria


Age Restriction



Other CriteriaConfirmed Diagnosis of non-24 hour sleep-Wake disorder Sleep study to rule out Sleep/apnea or other contributory sleep disorders Patient must be totally Blind

62

High Risk Medications in the Elderly

DrugsAmitriptyline HCl ORAL, Butalbital-APAP-Caffeine ORAL CAPSULE 50-300-40 MG, Butalbital-Aspirin-Caffeine ORAL CAPSULE, Clorazepate Dipotassium, Cyclobenzaprine HCl ORAL TABLET 10 MG, Diazepam ORAL SOLUTION 1 MG/ML, Diazepam ORAL TABLET, Dicyclomine HCl ORAL, Digoxin ORAL TABLET 250 MCG, Doxepin HCl ORAL, Estradiol ORAL, Estradiol TRANSDERMAL PATCH WEEKLY, Estropipate ORAL, Flurazepam HCl, GlyBURIDE Micronized ORAL TABLET 3 MG, GlyBURIDE ORAL, HydrOXYzine HCl ORAL SYRUP, HydrOXYzine HCl ORAL TABLET, HydrOXYzine Pamoate ORAL, Imipramine HCl ORAL, MedroxyPROGESTERone Acetate INTRAMUSCULAR*, MedroxyPROGESTERone Acetate ORAL, Methocarbamol ORAL, Nitrofurantoin Macrocrystal ORAL CAPSULE 100 MG, 50 MG, Nitrofurantoin ORAL CAPSULE, PHENobarbital ORAL ELIXIR, PHENobarbital ORAL TABLET 16.2 MG, 32.4 MG, 64.8 MG, 97.2 MG, Promethazine HCl ORAL TABLET 25 MG, Zaleplon, Zolpidem Tartrate ORAL

Covered UsesAll FDA-approved indications not otherwise excluded from part D

Exclusion CriteriaFDA Labeled contraindications


Age RestrictionNo authorization needed for patients less than 65 years old



Other CriteriaFor patients 65 years of age or older, the provider must submit: 1) Supporting statement that the benefit outweighs the risk for this patient. 2) Plan for routine monitoring for adverse effects related to the medication. 3) Documentation that patient or caretaker has been informed of risks and side effects related to the use of this medication on older adults. For Nitrofurantoin, Zolpidem, Zaleplon no authorization is needed if patients will use less than 90 days of medication in a year.

63

HUMIRA

DrugsHumira Pediatric Crohns Start SUBCUTANEOUS* 40 MG/0.8ML, Humira Pen SUBCUTANEOUS*, Humira SUBCUTANEOUS*





Prescriber RestrictionDermatologist/rheumatologist/ Gastroenterologist


Other CriteriaFor RA Patient must fail adequate trial of MTX in combination with a DMARD If MTX contraindicated, must try combination of 2-nonbiologic DMARDS. For Ankylosing Spondylitis PT must fail 2 NSAIDS within past 6 months. For Plaque Psoriasis patient must fail MTX or Soriatane and Topical Therapy(ie. high potency steroids Vit D analogs). for Psoriatic Arthritis Patient must fail adequate trial of MTX or LEF in past 6 months. For Inflammatory Bowel disease patient must fail recent 3 month trial of immunosupressive and anti-inflammatory in past 6 months

64

Ibrance

DrugsIbrance


Exclusion Criteria


Age Restriction



Other Criteria

65

Iclusig

DrugsIclusig


Exclusion Criteria


Age Restriction



Other CriteriaFailure of imitanib or other first line CML tyrosine Kinase Inhibitor

66

Ilaris

DrugsIlaris

Covered UsesAll FDA approved indications not otherwise excluded by partD

Exclusion Criteria


Age Restriction



Other CriteriaFor JRA patient must fail Enbrel and Humira

67

Imbruvica

DrugsImbruvica

Covered UsesAll medically accepted indications not otherwise excluded from Part D

Exclusion Criteria


Age Restriction



Other CriteriaOff Label and combination use must be supported by NCCN guidelines with evidence rating of 2a or 1

68

INCRELEX

DrugsIncrelex





Prescriber RestrictionEndocrinologist


Other Criteria

69

IRESSA

DrugsIressa


Exclusion CriteriaIressa is contraindicated in patients with severe hypersensitivity to gefitinib or other components.


Age RestrictionPatient must be at least 18 years old or older.



Other CriteriaApproved for Non Small Cell Lung Cancer with Egfr exon 19 deletion or Exon 21 substitution.

70

isotretinoin

DrugsClaravis ORAL CAPSULE 30 MG, Myorisan ORAL CAPSULE 10 MG, Zenatane ORAL CAPSULE 20 MG, 40 MG

Covered UsesAll medically acceptable indications not otherwise excluded by part D

Exclusion Criteria


Age Restriction



Other CriteriaFor cystic, nodular or scarring acne, must be refractory to oral antibiotics and topical retinoids. Trial of combination oral teracycline and topical retinoid most have been tried in most recent 6 months.

71

ITRACONAZOLE

DrugsItraconazole ORAL, Sporanox ORAL SOLUTION



Required Medical InformationMedical notes, previous treatment history, fungal culture and sensitivity



Coverage Durationminimum of 12 week up to 12 months

Other CriteriaFailure of terbinafine for onychomycosis

72

IVIG

DrugsGamunex-C INJECTION SOLUTION 1 GM/10ML


Exclusion Criteria

Required Medical InformationDiagnosis, immunoglobulin studies

Age Restriction



Other CriteriaFor ITP Must fail corticosteroids and Anti-D immunoglobulin (if indicated).

73

JAKAFI

DrugsJakafi


Exclusion CriteriaFDA labeled contraindications, Low risk Disease



Prescriber RestrictionHematology-oncology


Other CriteriaContinuation will be based on reduction in spleen size from baseline or symptomatic improvement. Not covered when used in combination with antiproliferative drugs (i.e lenalidomide), or other JAK or Tyrosine Kinase inhibitors.

74

JANUVIA

DrugsJanuvia


Exclusion CriteriaFDA labeled contraindications, Non FDA approved combinations





Other CriteriaPatient must be on maximal tolerated doses of sulfonylurea and Metformin unless contraindicated

75

Juxtapid

DrugsJuxtapid


Exclusion Criteria


Age Restriction


Coverage Duration3 months initially, 12 months for continuation

Other CriteriaGenetic confirmation that patient is HoFH and failure of Statin and PCSK-9 therapy. Continuation of Juxtapid after 3 month trial based on LDL reduction of at least 25% while on therapy.

76

kalydeco

DrugsKalydeco ORAL TABLET


Exclusion Criteria


Age Restriction



Other CriteriaGenotyping supportive of mutation status in the FDA label

77

KINERET

DrugsKineret SUBCUTANEOUS*





Prescriber RestrictionRheumatology


Other CriteriaFor RA/JRA failure of Enbrel and Humira

78

Korlym

DrugsKorlym


Exclusion Criteria


Age Restriction

Prescriber Restrictionendocrinologist


Other CriteriaDiagnosis of Cushings syndrome , Type 2 diabetes mellitus , Failed surgery OR not a candidate for surgery , Failure of ketoconazole

79

KUVAN

DrugsKuvan ORAL PACKET 500 MG, Kuvan ORAL TABLET SOLUBLE





Prescriber RestrictionMedical Geneticist, neurologist, hepatologist


Other CriteriaCoverage will be based on medical history/status, response to previous treatments, and the consideration of other therapeutic options

80

Kynamro

DrugsKynamro SUBCUTANEOUS*


Exclusion Criteria


Age Restriction


Coverage Duration3 months initially, 12 months after response

Other CriteriaGenetic confirmation that patient is HoFH and failure of Statin, Ezetimibe, and PCSK-9 therapy. Continuation of Kynamro after 3 month trial based on LDL reduction of at least 25% while on therapy.

81

LATUDA

DrugsLatuda







Other Criteria

82

Lenvima

DrugsLenvima 10 MG Daily Dose, Lenvima 14 MG Daily Dose, Lenvima 18 MG Daily Dose, Lenvima 20 MG Daily Dose, Lenvima 24 MG Daily Dose, Lenvima 8 MG Daily Dose, Lenvima 8mg Daily Dose


Exclusion Criteria


Age Restriction

Prescriber RestrictionHematology Oncology


Other Criteria

83

LIDODERM

DrugsLidocaine EXTERNAL PATCH 5 %







Other CriteriaCovered for PHN, patient must fail gabapentin

84

linzess

DrugsLinzess


Exclusion Criteria


Age Restriction

Prescriber RestrictionGastroenterology



85

Lonsurf

DrugsLonsurf


Exclusion Criteria


Age Restriction



Other CriteriaDiagnosis of Metastatic colorectal cancer, failure of 2 standard lines of chemotherapy

86

LOTRONEX

DrugsAlosetron HCl





Prescriber RestrictionPhysician enrolled in Lotronex program


Other CriteriaApproved initially for 3 months continuation up to 12 months if patient has improvement in symptoms.

87

Lynparza

DrugsLynparza


Exclusion Criteria


Age Restriction



Other Criteria

88

Mekinist

DrugsMekinist


Exclusion Criteria


Age Restriction



Other CriteriaMutation analysis showing BRAF V600E or V600K positive, not covered for combination use with other anti-neoplastics unless FDA indication or NCCN recommended with a class 2A or greater evidence rating.

89

Menest

DrugsMenest

Covered UsesAll FDA-labeled indications not otherwise excluded from Part D

Exclusion CriteriaFDA contraindications


Age Restriction

Prescriber RestrictionOncologist


Other CriteriaCovered for palliative treatment of breast cancer. Coverage for Hormone replacement therapy would required failure of formulary estrogens which do not have utilization management (ie. premarin, estradiol, estropipate)

90

MODAFINIL

DrugsModafinil



Required Medical InformationMedical notes, Sleep study or MSLT when appropriate


Prescriber RestrictionNone


Other Criteria

91

Movantik

DrugsMovantik


Exclusion Criteria


Age Restriction




92

multaq

DrugsMultaq


Exclusion Criteria


Age Restriction



Other CriteriaFailure of sotalol and amiodarone

93

Myrbetriq

DrugsMyrbetriq


Exclusion Criteria


Age Restriction



Other CriteriaFailure of Toviaz and Oxybutynin

94

NAGLAZYME

DrugsNaglazyme





Prescriber Restrictionmedical geneticist, endocrinologist


Other CriteriaMust demonstrate improvement in 3 minute stair climb or 12 minute walk distance for continuation at 24 weeks

95

Natpara

DrugsNatpara

Covered UsesAll FDA approved uses not otherwise excluded from part D

Exclusion Criteria


Age Restriction



Other CriteriaUncontrolled hypocalcemia on adequate doses of calcium and vitamin D.

96

Neupro

DrugsNeupro


Exclusion Criteria


Age Restriction



Other CriteriaFailure of Ropinirole and Pramipexole

97

NICOTROL INHALER

DrugsNicotrol






Coverage Duration24 weeks

Other CriteriaPatient must have failed bupropion and be actively enrolled in smoking cessation program, plan sponsors Quit Smart

98

Ninlaro

DrugsNinlaro


Exclusion Criteria


Age Restriction



Other CriteriaFailure of Velcade and Revlimid required for coverage

99

Northera

DrugsNorthera


Exclusion Criteria


Age Restriction



Other CriteriaDocumented orthostatic hypotension resulting in falls and dizziness, failure of midodrine or Fludrocortisone. No perquisite drugs required for Dopamine-Beta-Hydroxylase deficiency

100

Noxafil

DrugsNoxafil ORAL


Exclusion Criteria


Age Restriction



Other CriteriaFailure, resistance or contraindication to itraconazole, fluconazole, voriconazole

101

Nuedexta

DrugsNuedexta


Exclusion Criteria


Age Restriction

Prescriber Restrictionneurology


Other Criteria

102

NULOJIX

DrugsNulojix


Exclusion CriteriaSeronegative for Epstein Barr-Virus exposure, Liver Transplantation

Required Medical InformationDiagnosis, previous treatment history, EBV titers


Prescriber RestrictionTransplant/nephrology


Other CriteriaDocumentation of failure or intolerance to calcineurin inhibitor

103

Nuplazid

DrugsNuplazid


Exclusion Criteria


Age Restriction

Prescriber RestrictionNeurology/psychiatry


Other Criteria

104

ODOMZO

DrugsOdomzo


Exclusion Criteria


Age Restriction


Coverage Duration3 - 12 months

Other CriteriaApproval will initially be for three months, if patient has a response to therapy will be renewed for 12 months

105

Ofev

DrugsOfev


Exclusion Criteria


Age Restriction

Prescriber Restrictionpulmonologist


Other CriteriaConfirmed Diagnosis of idiopathic pulmonary fibrosis (IPF) through exclusion of other fibrosing conditions/causes and definitive High resolution CT IPF pattern or Biopsy proven IPF. FVC of at least 50% of predicted value DLCO of at least 30%

106

OMNITROPE

DrugsOmnitrope



Required Medical InformationMedical notes, studies establishing diagnosis of indication.




Other Criteria

107

ONFI

DrugsOnfi ORAL SUSPENSION, Onfi ORAL TABLET 10 MG, 20 MG




Age RestrictionFDA approved Ages

Prescriber RestrictionRestricted to Neurology

Coverage Duration12 Months

Other Criteria

108

ONGLYZA

DrugsOnglyza ORAL TABLET 2.5 MG, 5 MG


Exclusion CriteriaFDA labeled contraindications, Non FDA approved combinations





Other CriteriaPatient must be on maximal tolerated doses of sulfonylurea and Metformin unless contraindicated

109

Opsumit

DrugsOpsumit

Covered UsesAll FDA approved uses not otherwise excluded from Part D

Exclusion Criteria


Age Restriction

Prescriber Restrictionpulmonologist/cardiologist


Other CriteriaFailure of sildenafil and Bosentan

110

ORENCIA

DrugsOrencia INTRAVENOUS*


Exclusion CriteriaFDA labeled contraindications, combination therapy with other biologics



Prescriber RestrictionRheumatologist


Other CriteriaPatient must fail enbrel, humira, and xeljanz

111

OXANDROLONE

DrugsOxandrolone ORAL TABLET 2.5 MG


Exclusion Criteria


Age Restriction

Prescriber RestrictionOncology Hematology


Other Criteria

112

Oxybutynin ER

DrugsOxybutynin Chloride ER

Covered UsesAll FDA approved indications not excluded by Part D

Exclusion Criteria


Age Restriction



Other CriteriaFailure or intolerance toviaz for all indications other than detrussor overactivity secondary to a neurologic condition.

113

PEGASYS

DrugsPegasys SUBCUTANEOUS* SOLUTION 180 MCG/0.5ML


Exclusion CriteriaFDA labeled contraindications, HCV Retreatment for Peg INF+RBV Non-responders

Required Medical InformationMedical notes, Viral Load


Prescriber RestrictionGastroenterologist/ Infectious Disease


Other CriteriaFor HCV patient must have allergy of contraindication to Peg-Intron. For HBV Patient must be Pegasys naive, with chronic HBV infection with chronically elevated transaminases.

114

POMALYST

DrugsPomalyst

Covered UsesAll FDA approved indications not otherwise excluded by PartD

Exclusion CriteriaFDA contraindications


Age Restriction



Other CriteriaApprove for patients with multiple myeloma who have received at least two prior therapies including lenalidomide and bortezomib and have demonstrated disease progression on or within 60 days of completion of the last therapy

115

PROCRIT

DrugsProcrit



Required Medical InformationMedical notes, Scr, HGB, T-sat, Ferritin




Other CriteriaHemoglobin must be within FDA approved ranges for initiation and maintenance. Patient must have adequate iron stores to initiate and continue treatment. ESRD will be covered under Medicare Part B

116

prolia

DrugsProlia


Exclusion Criteria


Age Restriction



Other CriteriaIntolerance or contraindication to injectable bisphosphonate required for coverage of prolia

117

PROMACTA

DrugsPromacta ORAL TABLET 12.5 MG, 25 MG, 50 MG



Required Medical InformationMedical Notes, CBC ,Platelet count less than 50,000


Prescriber RestrictionHematologist/oncologist, Hepatologist, Infectious Disease


Other CriteriaChronic ITP Refractory to IVIG, corticosteroids or splenectomy as per FDA approval studies not applicable to HCV related thrombocytopenia

118

PULMOZYME

DrugsPulmozyme



Required Medical InformationMedical notes, Spirometry


Prescriber RestrictionPulmonologist


Other CriteriaFor Patients with Cystic Fibrosis with an FVC greater or equal to 40% of predicted value, who have had recurrent pulmonary infections

119

Quinine

DrugsQuiNINE Sulfate ORAL


Exclusion Criteria


Age Restriction



Other CriteriaNotes supporting diagnosis of malaria

120

RANEXA

DrugsRanexa



Required Medical InformationRecent Cardiology notes, previous treatment history for angina


Prescriber RestrictionCardiologist


Other CriteriaPt must fail one agent in two of the three following medication classes used for angina- Long acting nitrates including isosorbide dinitrate or isosorbide mononitrate, CCB including amlodipine and nifedapine and a Beta blocker metoprolol, atenolol, carvedilol, propranolol, labetalol.

121

Ravicti

DrugsRavicti


Exclusion Criteria


Age Restriction

Prescriber Restrictionhepatologist or metabolic specialist such as a endocrinologist or geneticist


Other CriteriaClinical Failure of Buphenyl and dietary management.

122

RELISTOR

DrugsRelistor SUBCUTANEOUS* SOLUTION 12 MG/0.6ML





Prescriber RestrictionPain management physician, gastroenterologist, oncologist


Other CriteriaCovered for patients with advanced illness receiving palliative opioid treatment who fail Lactulose and metoclopramide at therapeutic doses.

123

REMICADE

DrugsRemicade


Exclusion CriteriaFDA labeled contraindications, combination therapy with other biologics



Prescriber RestrictionRheumatology/Dermatology or Specialist trained in management of prescribed condition


Other CriteriaFor RA, Plaque Psoriasis, or Psoriatic Arthritis patient must fail Humira. For Inflammatory Bowel Disease must have moderate to severe disease refractory to conventional therapies or steroid dependency despite use of adequate doses of immunosuppressive agents. Conventional therapies includes adequate doses of anti-inflammatories and immunosuppressive agents supported by current peer reviewed guidelines (American Gastroenterology Association).

124

REMODULIN

DrugsRemodulin


Exclusion CriteriaFDA labeled contraindications, combination therapy with other PAH medications

Required Medical InformationMedical notes, previous treatment history, 6 min walk, diffusion studies,Rt Heart Cath


Prescriber RestrictionPulmonologist/Cardiologist


Other CriteriaPulmonary hypertension must be diagnosed by heart catheterization ,Evaluation, EKG, diffusion studies, catheterization results and an objective test of exercise ability (6 minute walk) must be submitted with referral, Patient must fail Tracleer.

125

REVATIO

DrugsSildenafil Citrate ORAL



Required Medical InformationMedical notes, previous treatment history, 6 min walk, diffusion studies,Rt Heart Cath


Prescriber RestrictionPulmonologist/Cardiologist


Other CriteriaPulmonary hypertension must be diagnosed by heart catheterization ,Evaluation, EKG, diffusion studies, catheterization results and an objective test of exercise ability (6 minute walk) must be submitted with referral ,Coverage will be based on medical history/status, vasoreactivity tests, response to previous treatments, and the consideration of other therapeutic options including Revatio

126

REVLIMID

DrugsRevlimid



Required Medical InformationMedical notes, CBC, Bone Marrow Biopsy, Karyotype




Other CriteriaPatient must fail Thalidomide for Multiple Myeloma.

127

Rexulti

DrugsRexulti


Exclusion Criteria


Age Restriction

Prescriber RestrictionNeurology/Psychiatry


Other CriteriaFailure of aripiprazole and risperidone for schizophrenia or failure of combination SSRI and aripiprazole for major depressive disorder.

128

RILUTEK

DrugsRiluzole







Other CriteriaDiagnosis is definite or probable ALS by Neurology, symptoms present for less than 5 years, Vital Capacity is 60% or more of predicted, patient does not have a tracheotomy

129

RITUXAN

DrugsRituxan INTRAVENOUS* SOLUTION 500 MG/50ML



Required Medical InformationMedical notes, immunohistopathy


Prescriber RestrictionHematologist/oncologist, rheumatologist


Other CriteriaFor Rheumatoid Arthritis coverage patient must fail 2 TNF antagonists. Patient must also be on methotrexate unless contraindicated or intolerant.

130

Rozerem

DrugsRozerem


Exclusion Criteria


Age Restriction



Other Criteriafailure of Zolpidem and one other medication used for insomnia, such as temazepam, zaleplon, doxepin, trazodone.

131

SABRIL

DrugsSabril







Other CriteriaPatient must fail treat with adjunctive treatment combination (applies to Refractory Partial Complex only)

132

SAPHRIS

DrugsSaphris







Other Criteria

133

SENSIPAR

DrugsSensipar





Prescriber RestrictionNephrologist/endocrinologist/oncologist


Other CriteriaFor secondary hyperparathyroidism related to CKD, patient must fail active vit-D therapy/phosphate binders, iPTH must be greater than 300 in ESRD

134

Signifor

DrugsSignifor, Signifor LAR

Covered UsesAll FDA approved uses not excluded form part D

Exclusion Criteria


Age Restriction



Other CriteriaFor Cushings Disease Failed or poor surgical candidate for pituitary resection For Acromegaly Failed or poor surgical candidate for pituitary resection Failure of octreotide

135

SOLARAZE

DrugsDiclofenac Sodium TRANSDERMAL GEL 3 %





Prescriber RestrictionDermatologist, oncologist


Other Criteria

136

Somatuline

DrugsSomatuline Depot


Exclusion Criteria


Age Restriction



Other CriteriaNeed clinical notes and labs supporting diagnosis of Acromegaly GH, IGF-1

137

SOMAVERT

DrugsSomavert SUBCUTANEOUS* SOLUTION RECONSTITUTED 10 MG







Other Criteria

138

Soriatane

DrugsAcitretin


Exclusion Criteria


Age Restriction

Prescriber RestrictionDermatologist


Other CriteriaMust have severe psoriasis and failed one other systemic therapy and one topical therapy.

139

SOVALDI

DrugsSovaldi

Covered UsesAll FDA approved indications not otherwise excluded by Part D.

Exclusion Criteria

Required Medical InformationGenotype, Previous treatment history, Viral load, information supporting diagnosis of HCC or cirrhosis.

Age Restriction

Prescriber RestrictionInfectious Disease, Gastroenterology, Hepatology

Coverage Duration12 to 48 weeks as described below

Other CriteriaCoverage of Sovaldi will be limited to 48 weeks in patients with HCC awaiting liver transplant Coverage of Sovaldi for Genotype 2 will be limited to 12 to 24 weeks in combination with Ribavirin in accordance with current AASLD guidelines Coverage of Sovaldi for Genotype 3 will be limited to 24 weeks in combination with Ribavirin Coverage of Sofosbuvir based regimens for GT-1 Will be approved only if patient has a contraindication to Viekira Pak, or ribavirin if required as part of the V-PAK regimen. Sofosbuvir based regimens would require a formulary exception for either Simeprevir, Daclastasvir, or Ledipasvir/Sofosbuvir. The treament of HCV is rapidly evolving, as ASLD Guidelines are updated and new HCV antiviral treatments are approved by the FDA, this criteria may be amended such that the most cost-effective AASLD guideline supported Treatment or FDA approved Treatment regimen may be required, unless a contraindication exists that should preclude use of a more cost effective regimen.

140

SUBOXONE

DrugsSuboxone SUBLINGUAL FILM


Exclusion CriteriaFDA labeled contraindications, prescriber not licensed to treat addiction, use for pain management



Prescriber RestrictionPhysician licensed to use the medication for addiction


Other Criteria

141

SYLATRON

DrugsSylatron SUBCUTANEOUS* KIT 200 MCG, 300 MCG, 600 MCG



Required Medical InformationFDA labeled contraindications


Prescriber Restrictiononcology


Other CriteriaMust be used as adjuvant treatment within 84 days of surgical resection in patients with metastatic melanoma with nodal involvement

142

Sylvant

DrugsSylvant INTRAVENOUS* SOLUTION RECONSTITUTED 100 MG


Exclusion Criteria


Age Restriction

Prescriber RestrictionHematology Oncology


Other Criteria

143

SYMLIN

DrugsSymlinPen 120 SUBCUTANEOUS*, SymlinPen 60 SUBCUTANEOUS*





Prescriber RestrictionEndocrinologist, Internist


Other CriteriaPatient BG must be non-controlled on optimal doses of insulin

144

SYNAREL

DrugsSynarel



Required Medical InformationDiagnosis, Notes, Previous treatment history

Age RestrictionAges approved in FDA Label



Other CriteriaCovered after patient fails treatment with Lupron for endometriosis or precocious puberty

145

Tafinlar

DrugsTafinlar


Exclusion Criteria


Age Restriction



Other CriteriaMutation analysis showing BRAF V600E or V600K positive, not covered for combination use with other anti-neoplastics unless FDA indication or NCCN recommended with a class 2A or greater evidence rating.

146

Tagrisso

DrugsTagrisso


Exclusion Criteria


Age Restriction



Other CriteriaCoverage requires Diagnosis of Non Small Cell Lung cancer, progression on an EGRF TKI inhibitor, and confirmation of T790M mutation

147

TASIGNA

DrugsTasigna







Other CriteriaCovered for failure or relapse of CML when previously treated with imatinib. Covered for newly diagnosed CML patients who are Philadelphia chromosome +. Will also be covered for intolerance or adverse reaction to imatinib. Combination therapy with other tyrosine kinase inhibitors or MTOR inhibitors for CML is not supported.

148

TAZORAC

DrugsTazorac EXTERNAL CREAM, Tazorac EXTERNAL GEL 0.1 %





Prescriber Restrictiondermatologist


Other CriteriaFor Psoriasis patient must have failed medium to high potency topical corticosteroid, For acne patient must have failed Tretinoin and oral antibiotic

149

TECHNIVIE

DrugsTechnivie


Exclusion Criteria


Age Restriction



Other CriteriaDocumentation of Chronic HVC with Genotype 4

150

THALOMID

DrugsThalomid





Prescriber RestrictionHematologist/oncologist/infectious disease


Other Criteria

151

TRACLEER

DrugsTracleer



Required Medical InformationMedical notes, Right heart Catheterization, 6 Minute Walk time


Prescriber RestrictionPulmonologist or cardiologist


Other CriteriaPulmonary hypertension must be diagnosed by heart catheterization ,Evaluation, EKG, diffusion studies, catheterization results and an objective test of exercise ability (6 minute walk) must be submitted with referral ,Coverage will be based on medical history/status, vasoreactivity tests, response to previous treatments, and the consideration of other therapeutic options including Revatio

152

Transderm-Scop

DrugsTransderm-Scop (1.5 MG)


Exclusion Criteria


Age Restriction



Other CriteriaFailure of two oral anti-emetics

153

TRETINOIN CAPSULE

DrugsTretinoin ORAL







Other Criteria

154

TRETINOIN TOPICAL

DrugsTretinoin EXTERNAL CREAM, Tretinoin EXTERNAL GEL 0.01 %, 0.025 %


Exclusion CriteriaFDA labeled contraindications, treatment of photoaging, wrinkles





Other Criteria

155

Trintellix

DrugsTrintellix


Exclusion Criteria


Age Restriction



Other CriteriaFailure of two generically available anti-depressants within past 6 months

156

TYKERB

DrugsTykerb





Prescriber RestrictionOncologist/hematologist


Other CriteriaPatient is using in combination with capecitabine for HER/NEU + Metastatic breast CA, having failed an anthracycline, Herceptin and a taxane, or Patient must be using in combination with an aromatase inhibitor and have HER/NEU+ HR+ metastatic breast CA

157

Tysabri

DrugsTysabri


Exclusion Criteria


Age Restriction

Prescriber Restrictionneurologist/Gastroenterologist


Other CriteriaRequires failure of first line Multiple Sclerosis agent or Tumor Necrosis Factor inhibitor for Crohn's Disease, and a negative JC antibody test.

158

TYZEKA

DrugsTyzeka




Age Restriction



Other Criteria

159

Vancomycin Capsules

DrugsVancomycin HCl ORAL


Exclusion Criteria

Required Medical InformationDiagnostic confirmation of clostridium difficile diarrhea

Age Restriction

Prescriber RestrictionGastroenterology, infectious disease, oncology

Coverage Duration10 days

Other CriteriaFailure or contraindication to oral metronidazole

160

Venclexta

DrugsVenclexta, Venclexta Starting Pack


Exclusion Criteria

Required Medical InformationNotes supporting Diagnosis and documentation of 17p deletion

Age Restriction



Other Criteria

161

Viekira Pak

DrugsViekira Pak, Viekira XR


Exclusion Criteria


Age Restriction

Prescriber RestrictionHepatology, Infectious Disease, Gastroenterologist

Coverage Duration12-24 weeks

Other CriteriaDiagnosis of HCV Genotype 1, Viekira is the preferred Agent over sofosbuvir based regimens for this genotype.

162

VIMPAT

DrugsVimpat ORAL




Age Restriction17 and older



Other Criteria

163

VOLTAREN GEL

DrugsDiclofenac Sodium TRANSDERMAL GEL 1 %


Exclusion Criteria


Age Restriction


Coverage DurationPA will be approved through the remainder of contract year

Other CriteriaDocumentation of the trial and failure or contraindication/intolerance to a meloxicam-containing product and one additional oral non-steroidal anti-inflammatory drug (NSAID).

164

Voriconazole

DrugsVoriconazole ORAL SUSPENSION RECONSTITUTED, Voriconazole ORAL TABLET 200 MG


Exclusion Criteria


Age Restriction



Other CriteriaCovered when two of the following medications have been tried, unless resistance or contraindication precludes use, Itraconazole, fluconazole, ketoconazole. Exclusions to prerequisite medications are Invasive pulmonary aspergillosis, Scedosporium apiospermum, Fusarium

165

Vraylar

DrugsVraylar ORAL CAPSULE


Exclusion Criteria


Age Restriction

Prescriber RestrictionPsychiatry or Neurology


Other CriteriaRequires failure of aripiprazole and risperidone.

166

Welchol

DrugsWelchol ORAL TABLET


Exclusion Criteria


Age Restriction



Other CriteriaFor diabetes must fail Metformin and DPP-IV inhibitor, For Hyperlipidemia must fail cholestyramine

167

XALKORI

DrugsXalkori

Covered UsesAll FDA approved indications not otherwise excluded from part D, locally advanced or metastatic ALK+ NSCLC

Exclusion CriteriaFDA labeled contraindications, NCLC which is Anaplastic Lymphoma Kinase negative, combination therapy with other tyrosine kinase inhibitors or EGRf inhibitors.

Required Medical InformationDiagnosis, documentation support ALK+ NSLC




Other CriteriaContinuation will be based on lack of disease progression

168

XELJANZ

DrugsXeljanz, Xeljanz XR


Exclusion Criteria


Age Restriction

Prescriber RestrictionRheumatology


Other Criteria3 month trial of Combination DMARD therapy in past 6 months.

169

XENAZINE

DrugsXenazine ORAL TABLET 25 MG







Other CriteriaPatient must have moderate to severe chorea.

170

XGEVA

DrugsXgeva

Covered UsesAll Medically Acceptable indications not otherwise excluded by PART D

Exclusion Criteria


Age Restriction

Prescriber Restrictiononcology/endocrinology


Other CriteriaFailure or contraindication to bisphosphonate for osteolytic cancer indications other than giant cell tumor of the bone.

171

XOLAIR

DrugsXolair



Required Medical InformationMedical Notes, Previous treatment history, RAST and aeroallergens results, Ige values


Prescriber RestrictionPulmonologist/allergist


Other CriteriaPatient Must Fail Combination LABA/ICS and LTA4 receptor antagonist

172

XTANDI

DrugsXtandi


Exclusion Criteria


Age Restriction



Other CriteriaFailure of docetaxel and Abiraterone

173

XYREM

DrugsXyrem


Exclusion Criteria


Age Restriction

Prescriber RestrictionPhysician Board certified in Sleep Medicine or neurologist


Other CriteriaFailure of Modafanil and amphetamine/dextroamphetamine or failure of fluoxetine for narcolepsy with cataplexy

174

YERVOY

DrugsYervoy INTRAVENOUS* SOLUTION 50 MG/10ML



Required Medical InformationDiagnosis, medical notes




Other CriteriaApproval will be for up to 4 doses at 3mg/kg. Not covered for combination therapy with BRAF inhibitors, MEK inhibitors, Adjuvant agents (Interferon), Interleukins subject to FDA approval changes or Listings within Medicare Approved compendia. Not covered for patients who previously experienced a severe immune mediated reaction related to ipilimumab.

175

Zaltrap

DrugsZaltrap INTRAVENOUS* SOLUTION 100 MG/4ML

Covered UsesAll FDA Approved indications not otherwise excluded by Part D

Exclusion Criteria


Age Restriction

Prescriber RestrictionHematology/oncology


Other CriteriaFailure Allergy or contraindication to Avastin.

176

ZAVESCA

DrugsZavesca





Prescriber RestrictionOncologist, Neurologist, Medical Geneticist


Other CriteriaCoverage will be based on medical history/status, response to previous treatments, and the consideration of other therapeutic options

177

ZELBORAF

DrugsZelboraf

Covered UsesAll medically accepted indications not otherwise excluded from part D, Metastatic Melanoma Stage IIIC unresectable or Stage IV

Exclusion CriteriaAbsence of Braf V600E mutation, Combination therapy with other antineoplastic agents

Required Medical InformationDiagnosis, verification of a positive Braf V600e Mutation


Prescriber RestrictionOncology


Other CriteriaAuthorization for continuation past 90 days will be based on absence of disease progression.

178

ZEMPLAR

DrugsParicalcitol ORAL



Required Medical InformationMedical notes, previous treatment history, CA PO4, iPTH


Prescriber RestrictionNephrologist/endocrinologist


Other CriteriaPatient must fail or have contraindication to Calcitriol or phosphate binder if appropriate

179

ZOLINZA

DrugsZolinza



Required Medical InformationMedical Notes


Prescriber RestrictionOncologist/hematologist/dermatologist


Other CriteriaFailed minimum of two systemic treatments, one of which must be Targretin, unless contraindicated

180

Zydelig

DrugsZydelig


Exclusion Criteria


Age Restriction



Other Criteria

181

ZYKADIA

DrugsZykadia


Exclusion Criteria


Age Restriction



Other CriteriaRestricted to use in ALK+ Non Small Cell Lung Cancer in patients who have failed crizotinib.

182

ZYPREXA IM INJ

DrugsOLANZapine INTRAMUSCULAR*







Other Criteria

183

ZYTIGA

DrugsZytiga





Prescriber RestrictionOncology/urology


Other CriteriaPatient Must have castrate resistant metastatic prostate cancer and have failed docetaxel

184

ZYVOX

DrugsLinezolid INTRAVENOUS* SOLUTION 600 MG/300ML, Zyvox ORAL



Required Medical InformationDiagnosis, culture and sensitivity

Age RestrictionAges supported by medical literature


Coverage Duration10 to 28 days

Other CriteriaCoverage will be based on medical history/status, response to previous treatments, and the consideration of other therapeutic options, Culture and sensitivity must be submitted

185

Index

Index

Acitretin ...................................................................... 139Actimmune ..................................................................... 6Adefovir Dipivoxil ......................................... 61Adempas ............................................................................ 7Alecensa ............................................................................. 8Alosetron HCl ....................................................... 87Amitiza ................................................................................. 9Amitriptyline HCl ORAL .................... 63Apokyn ............................................................................. 11Aptiom .............................................................................. 12Aranesp (Albumin Free) INJECTION 100 MCG/0.5ML, 300 MCG/0.6ML, 40 MCG/0.4ML, 60 MCG/0.3ML ... 13Aranesp (Albumin Free) INJECTION SOLUTION 10 MCG/0.4ML, 100 MCG/ML, 200 MCG/ML, 25 MCG/ML, 40 MCG/ML, 60 MCG/ML ....................... 13Arcalyst ........................................................................... 14ARIPiprazole ORAL TABLET ...... 5ARIPiprazole ORAL TABLET DISPERSIBLE ........................................................ 5Aristada ............................................................................... 5Atgam ................................................................................. 10Avastin ............................................................................. 15Azilect ............................................................................... 16Banzel ................................................................................ 17Bosulif ............................................................................... 18Botox INJECTION SOLUTION RECONSTITUTED 100 UNIT....................................................................................................... 19Briviact ............................................................................. 20Budesonide ORAL ......................................... 21Buprenorphine HCl SUBLINGUAL ................................................... 22Buprenorphine HCl-Naloxone HCl....................................................................................................... 22Butalbital-APAP-Caffeine ORAL CAPSULE 50-300-40 MG ................. 63Butalbital-Aspirin-Caffeine ORAL CAPSULE ................................................................... 63Bydureon SUBCUTANEOUS* 2 MG ......................................................................................... 23Byetta 10 MCG Pen SUBCUTANEOUS* .................................. 24Byetta 5 MCG Pen SUBCUTANEOUS* .................................. 24Cabometyx ................................................................. 25Carbaglu ......................................................................... 26Cerezyme INTRAVENOUS* SOLUTION RECONSTITUTED 400 UNIT ..................................................................... 27Cinryze ............................................................................. 28

Index

Claravis ORAL CAPSULE 30 MG....................................................................................................... 71Clorazepate Dipotassium ...................... 63Clotrimazole MOUTH/THROAT TROCHE ...................................................................... 29Cometriq (100 mg Daily Dose)....................................................................................................... 30Cometriq (140 mg Daily Dose)....................................................................................................... 30Cometriq (60 mg Daily Dose) ...... 30Cotellic ............................................................................. 31Cyclobenzaprine HCl ORAL TABLET 10 MG ............................................... 63Daliresp ........................................................................... 32Diazepam ORAL SOLUTION 1 MG/ML ........................................................................... 63Diazepam ORAL TABLET ............. 63Diclofenac Sodium TRANSDERMAL GEL 1 % ...... 164Diclofenac Sodium TRANSDERMAL GEL 3 % ...... 136Dicyclomine HCl ORAL ...................... 63Digoxin ORAL TABLET 250 MCG .................................................................................... 63Doxepin HCl ORAL .................................... 63Dronabinol .................................................................. 34Elaprase ........................................................................... 35Elitek INTRAVENOUS* SOLUTION RECONSTITUTED 1.5 MG ............................................................................. 36Elmiron ............................................................................ 37Emend ORAL CAPSULE 40 MG, 80 & 125 MG, 80 MG .............................. 38Emsam TRANSDERMAL PATCH 24 HR 6 MG/24HR, 9 MG/24HR .................................................................... 39Enbrel SUBCUTANEOUS* 50 MG/ML ........................................................................... 40Enbrel SUBCUTANEOUS* SOLUTION RECONSTITUTED....................................................................................................... 40Enbrel SureClick SUBCUTANEOUS* .................................. 40Esbriet ................................................................................ 41Estradiol ORAL .................................................. 63Estradiol TRANSDERMAL PATCH WEEKLY ........................................ 63Estropipate ORAL .......................................... 63Exjade ................................................................................ 42Fabrazyme INTRAVENOUS* SOLUTION RECONSTITUTED 35 MG ............................................................................... 43Fanapt ................................................................................. 44Farydak ............................................................................ 45

Index

FentaNYL Citrate BUCCAL .......... 46FentaNYL TRANSDERMAL PATCH 72 HR 100 MCG/HR, 12 MCG/HR, 25 MCG/HR, 50 MCG/HR, 75 MCG/HR ......................... 47Ferriprox ORAL TABLET ................ 48Fetzima ............................................................................. 49Firazyr ............................................................................... 50Flurazepam HCl ................................................. 63Fondaparinux Sodium ............................... 51Forteo SUBCUTANEOUS* SOLUTION 600 MCG/2.4ML .... 52Fosrenol ORAL PACKET ................. 53Fosrenol ORAL TABLET CHEWABLE 1000 MG, 500 MG, 750 MG ........................................................................... 53Fycompa ......................................................................... 54Gammagard INJECTION SOLUTION 2.5 GM/25ML ............. 55Gamunex-C INJECTION SOLUTION 1 GM/10ML ................... 73Gattex ................................................................................. 56Geodon INTRAMUSCULAR*....................................................................................................... 57Gilenya ............................................................................. 58Gilotrif .............................................................................. 59GlyBURIDE Micronized ORAL TABLET 3 MG ................................................... 63GlyBURIDE ORAL ..................................... 63GuanFACINE HCl ER ............................. 60Hetlioz ............................................................................... 62Humira Pediatric Crohns Start SUBCUTANEOUS* 40 MG/0.8ML ................................................................. 64Humira Pen SUBCUTANEOUS*....................................................................................................... 64Humira SUBCUTANEOUS* ........ 64HydrOXYzine HCl ORAL SYRUP ............................................................................ 63HydrOXYzine HCl ORAL TABLET ........................................................................ 63HydrOXYzine Pamoate ORAL....................................................................................................... 63Ibrance .............................................................................. 65Iclusig ................................................................................. 66Ilaris ...................................................................................... 67Imbruvica ..................................................................... 68Imipramine HCl ORAL .......................... 63Increlex ............................................................................ 69Iressa .................................................................................... 70Itraconazole ORAL ....................................... 72Jakafi ................................................................................... 74Januvia .............................................................................. 75Juxtapid ........................................................................... 76

187

Index

Kalydeco ORAL TABLET ............... 77Kineret SUBCUTANEOUS* ........ 78Korlym ............................................................................. 79Kuvan ORAL PACKET 500 MG....................................................................................................... 80Kuvan ORAL TABLET SOLUBLE .................................................................. 80Kynamro SUBCUTANEOUS*....................................................................................................... 81Latuda ................................................................................ 82Lenvima 10 MG Daily Dose ........... 83Lenvima 14 MG Daily Dose ........... 83Lenvima 18 MG Daily Dose ........... 83Lenvima 20 MG Daily Dose ........... 83Lenvima 24 MG Daily Dose ........... 83Lenvima 8 MG Daily Dose ............... 83Lenvima 8mg Daily Dose ................... 83Lidocaine EXTERNAL PATCH 5 % ................................................................................................ 84Linezolid INTRAVENOUS* SOLUTION 600 MG/300ML ... 185Linzess .............................................................................. 85Lonsurf ............................................................................. 86Lynparza ........................................................................ 88MedroxyPROGESTERone Acetate INTRAMUSCULAR* ............................. 63MedroxyPROGESTERone Acetate ORAL ................................................................................. 63Mekinist .......................................................................... 89Menest ............................................................................... 90Methocarbamol ORAL ............................ 63Modafinil ...................................................................... 91Movantik ....................................................................... 92Multaq ............................................................................... 93Myorisan ORAL CAPSULE 10 MG ......................................................................................... 71Myrbetriq ...................................................................... 94Naglazyme .................................................................. 95Natpara ............................................................................. 96Neupro .............................................................................. 97Nicotrol ............................................................................ 98Ninlaro .............................................................................. 99Nitrofurantoin Macrocrystal ORAL CAPSULE 100 MG, 50 MG ......................................................................................... 63Nitrofurantoin ORAL CAPSULE....................................................................................................... 63Northera ...................................................................... 100Noxafil ORAL .................................................. 101Nuedexta .................................................................... 102Nulojix .......................................................................... 103Nuplazid ..................................................................... 104Odomzo ....................................................................... 105Ofev .................................................................................. 106

Index

OLANZapine INTRAMUSCULAR* ......................... 183Omnitrope ................................................................ 107Onfi ORAL SUSPENSION ......... 108Onfi ORAL TABLET 10 MG, 20 MG ..................................................................................... 108Onglyza ORAL TABLET 2.5 MG, 5 MG ............................................................................... 109Opsumit ....................................................................... 110Orencia INTRAVENOUS* .......... 111Oxandrolone ORAL TABLET 2.5 MG ..................................................................................... 112Oxybutynin Chloride ER .................. 113Paricalcitol ORAL ...................................... 179Pegasys SUBCUTANEOUS* SOLUTION 180 MCG/0.5ML................................................................................................... 114PHENobarbital ORAL ELIXIR....................................................................................................... 63PHENobarbital ORAL TABLET 16.2 MG, 32.4 MG, 64.8 MG, 97.2 MG ......................................................................................... 63Pomalyst .................................................................... 115Procrit ............................................................................. 116Prolia ............................................................................... 117Promacta ORAL TABLET 12.5 MG, 25 MG, 50 MG ................................ 118Promethazine HCl ORAL TABLET 25 MG ............................................... 63Pulmozyme ............................................................ 119QuiNINE Sulfate ORAL ................... 120Ranexa .......................................................................... 121Ravicti ........................................................................... 122Relistor SUBCUTANEOUS* SOLUTION 12 MG/0.6ML ......... 123Remicade .................................................................. 124Remodulin ............................................................... 125Revlimid .................................................................... 127Rexulti ........................................................................... 128Riluzole ....................................................................... 129Rituxan INTRAVENOUS* SOLUTION 500 MG/50ML ....... 130Rozerem ..................................................................... 131Sabril ............................................................................... 132Saphris .......................................................................... 133Sensipar ....................................................................... 134Signifor ........................................................................ 135Signifor LAR ...................................................... 135Sildenafil Citrate ORAL .................... 126Somatuline Depot ........................................ 137Somavert SUBCUTANEOUS* SOLUTION RECONSTITUTED 10 MG ........................................................................... 138Sovaldi .......................................................................... 140Sporanox ORAL SOLUTION ...... 72

Index

Suboxone SUBLINGUAL FILM................................................................................................... 141Sylatron SUBCUTANEOUS* KIT 200 MCG, 300 MCG, 600 MCG................................................................................................... 142Sylvant INTRAVENOUS* SOLUTION RECONSTITUTED 100 MG ....................................................................... 143SymlinPen 120 SUBCUTANEOUS* .............................. 144SymlinPen 60 SUBCUTANEOUS* .............................. 144Synarel .......................................................................... 145Tafinlar ......................................................................... 146Tagrisso ....................................................................... 147Tasigna ......................................................................... 148Tazorac EXTERNAL CREAM................................................................................................... 149Tazorac EXTERNAL GEL 0.1 %................................................................................................... 149Technivie .................................................................. 150Thalomid ................................................................... 151Tracleer ........................................................................ 152Transderm-Scop (1.5 MG) ............. 153Tretinoin EXTERNAL CREAM................................................................................................... 155Tretinoin EXTERNAL GEL 0.01 %, 0.025 % ............................................................. 155Tretinoin ORAL ............................................. 154Trintellix .................................................................... 156Tykerb ........................................................................... 157Tysabri .......................................................................... 158Tyzeka ........................................................................... 159Vancomycin HCl ORAL .................. 160Venclexta .................................................................. 161Venclexta Starting Pack ..................... 161Viekira Pak ............................................................ 162Viekira XR ............................................................. 162Vimpat ORAL ................................................... 163Voltaren TRANSDERMAL ............ 33Voriconazole ORAL SUSPENSION RECONSTITUTED ................................. 165Voriconazole ORAL TABLET 200 MG ..................................................................................... 165Vraylar ORAL CAPSULE ............. 166Welchol ORAL TABLET ............... 167Xalkori .......................................................................... 168Xeljanz ......................................................................... 169Xeljanz XR ............................................................ 169Xenazine ORAL TABLET 25 MG................................................................................................... 170Xgeva ............................................................................. 171Xolair .............................................................................. 172Xtandi ............................................................................. 173

188

Index

Xyrem ............................................................................ 174Yervoy INTRAVENOUS* SOLUTION 50 MG/10ML ........... 175Zaleplon .......................................................................... 63Zaltrap INTRAVENOUS* SOLUTION 100 MG/4ML ........... 176Zavesca ........................................................................ 177Zelboraf ....................................................................... 178Zenatane ORAL CAPSULE 20 MG, 40 MG ............................................................... 71Zolinza .......................................................................... 180Zolpidem Tartrate ORAL .................... 63Zydelig ......................................................................... 181Zykadia ........................................................................ 182Zytiga ............................................................................. 184Zyvox ORAL ...................................................... 185

189

Part D vs Part B only

Product

Abilify Maintena SUSPENSION RECONSTITUTED 300 MG INTRAMUSCULAR*

Abilify Maintena SUSPENSION RECONSTITUTED 300 MG INTRAMUSCULAR* (1.5ML SYRINGE)

Abilify Maintena SUSPENSION RECONSTITUTED 300 MG INTRAMUSCULAR* (1.5ML SYRINGE)



Abraxane SUSPENSION RECONSTITUTED 100 MG INTRAVENOUS*

Acetylcysteine SOLUTION 10 % INHALATION

Adagen SOLUTION 250 UNIT/ML INTRAMUSCULAR*

A-Hydrocort SOLUTION RECONSTITUTED 100 MG INJECTION



Albuterol Sulfate NEBULIZATION SOLUTION (2.5 MG/3ML) 0.083% INHALATION

Aldurazyme SOLUTION 2.9 MG/5ML INTRAVENOUS*

Alimta SOLUTION RECONSTITUTED 500 MG INTRAVENOUS*

Aloxi SOLUTION 0.25 MG/5ML INTRAVENOUS*

AmBisome SUSPENSION RECONSTITUTED 50 MG INTRAVENOUS*

Amifostine SOLUTION RECONSTITUTED 500 MG INTRAVENOUS*

Amikacin Sulfate SOLUTION 500 MG/2ML INJECTION

Amphotericin B SOLUTION RECONSTITUTED 50 MG INJECTION

Ampicillin Sodium SOLUTION RECONSTITUTED 1 GM INJECTION

Ampicillin-Sulbactam Sodium SOLUTION RECONSTITUTED 3 (2-1) GM INJECTION

Atropine Sulfate SOLUTION 0.1 MG/ML INJECTION

AzaCITIDine SUSPENSION RECONSTITUTED 100 MG INJECTION

AzaTHIOprine TABLET 50 MG ORAL

Aztreonam SOLUTION RECONSTITUTED 1 GM INJECTION

BCG Vaccine INJECTABLE INJECTION

Beleodaq SOLUTION RECONSTITUTED 500 MG INTRAVENOUS*

Benlysta SOLUTION RECONSTITUTED 120 MG INTRAVENOUS*

Benlysta SOLUTION RECONSTITUTED 400 MG INTRAVENOUS*

Bleomycin Sulfate SOLUTION RECONSTITUTED 30 UNIT INJECTION

Botox SOLUTION RECONSTITUTED 200 UNIT INJECTION

Botox SOLUTION RECONSTITUTED 200 UNIT INJECTION

Bumetanide SOLUTION 0.25 MG/ML INJECTION

Buprenorphine HCl SOLUTION 0.3 MG/ML INJECTION


Butorphanol Tartrate SOLUTION 1 MG/ML INJECTION

Capastat Sulfate SOLUTION RECONSTITUTED 1 GM INJECTION

CeFAZolin Sodium SOLUTION RECONSTITUTED 1 GM INJECTION

Cefepime HCl SOLUTION RECONSTITUTED 1 GM INJECTION

CefOXitin Sodium SOLUTION RECONSTITUTED 10 GM INJECTION

CefTRIAXone Sodium SOLUTION RECONSTITUTED 250 MG INJECTION

CefTRIAXone Sodium SOLUTION RECONSTITUTED 500 MG INJECTION

Cefuroxime Sodium SOLUTION RECONSTITUTED 1.5 GM INJECTION

Cerebyx SOLUTION 500 MG PE/10ML INJECTION

ChlorproMAZINE HCl SOLUTION 50 MG/2ML INJECTION

Cleocin Phosphate SOLUTION 900 MG/6ML INJECTION

Colistimethate Sodium SOLUTION RECONSTITUTED 150 MG INJECTION

Cromolyn Sodium NEBULIZATION SOLUTION 20 MG/2ML INHALATION

Cubicin SOLUTION RECONSTITUTED 500 MG INTRAVENOUS*

Cyclophosphamide CAPSULE 25 MG ORAL

Cyclophosphamide CAPSULE 50 MG ORAL

CycloSPORINE CAPSULE 100 MG ORAL

CycloSPORINE CAPSULE 25 MG ORAL

CycloSPORINE Modified CAPSULE 100 MG ORAL



CycloSPORINE Modified SOLUTION 100 MG/ML ORAL

Cyramza SOLUTION 100 MG/10ML INTRAVENOUS*

Cyramza SOLUTION 500 MG/50ML INTRAVENOUS*

Darzalex SOLUTION 100 MG/5ML INTRAVENOUS*

DAUNOrubicin HCl INJECTABLE 5 MG/ML INTRAVENOUS*

Decitabine SOLUTION RECONSTITUTED 50 MG INTRAVENOUS*

Desmopressin Acetate SOLUTION 4 MCG/ML INJECTION

Dexamethasone Sodium Phosphate SOLUTION 120 MG/30ML INJECTION

Dexamethasone Sodium Phosphate SOLUTION 120 MG/30ML INJECTION

Digoxin SOLUTION 0.25 MG/ML INJECTION

DiphenhydrAMINE HCl SOLUTION 50 MG/ML INJECTION



Doxycycline Hyclate SOLUTION RECONSTITUTED 100 MG INTRAVENOUS*


Duramorph SOLUTION 0.5 MG/ML INJECTION

Duramorph SOLUTION 1 MG/ML INJECTION

Empliciti SOLUTION RECONSTITUTED 300 MG INTRAVENOUS*

Empliciti SOLUTION RECONSTITUTED 400 MG INTRAVENOUS*

Engerix-B SUSPENSION 10 MCG/0.5ML INJECTION

Engerix-B SUSPENSION 10 MCG/0.5ML INJECTION (0.5ML SYRINGE)

Engerix-B SUSPENSION 20 MCG/ML INJECTION

Eraxis SOLUTION RECONSTITUTED 50 MG INTRAVENOUS*

Erwinaze SOLUTION RECONSTITUTED 10000 UNIT INJECTION

FluPHENAZine Decanoate SOLUTION 25 MG/ML INJECTION

FluPHENAZine HCl SOLUTION 2.5 MG/ML INJECTION

Fomepizole SOLUTION 1 GM/ML INTRAVENOUS*

Furosemide SOLUTION 10 MG/ML INJECTION

Gentamicin Sulfate SOLUTION 40 MG/ML INJECTION

Glycopyrrolate SOLUTION 4 MG/20ML INJECTION

Haloperidol Lactate SOLUTION 5 MG/ML INJECTION

Heparin Sodium (Porcine) SOLUTION 1000 UNIT/ML INJECTION



Herceptin SOLUTION RECONSTITUTED 440 MG INTRAVENOUS*

HydrALAZINE HCl SOLUTION 20 MG/ML INJECTION

Intralipid EMULSION 30 % INTRAVENOUS*

INVanz SOLUTION RECONSTITUTED 1 GM INJECTION

Invega Sustenna SUSPENSION 117 MG/0.75ML INTRAMUSCULAR*

Invega Sustenna SUSPENSION 156 MG/ML INTRAMUSCULAR*




Kadcyla SOLUTION RECONSTITUTED 100 MG INTRAVENOUS*

Keytruda SOLUTION 100 MG/4ML INTRAVENOUS*

Keytruda SOLUTION RECONSTITUTED 50 MG INTRAVENOUS*

Keytruda SOLUTION RECONSTITUTED 50 MG INTRAVENOUS*

Leucovorin Calcium SOLUTION RECONSTITUTED 100 MG INJECTION

Leukine SOLUTION RECONSTITUTED 250 MCG INTRAVENOUS*

Leuprolide Acetate KIT 1 MG/0.2ML INJECTION


Lidocaine HCl (PF) SOLUTION 0.5 % INJECTION

Lupron Depot KIT 11.25 MG INTRAMUSCULAR*



Lupron Depot-Ped KIT 11.25 MG INTRAMUSCULAR*

Lupron Depot-Ped KIT 15 MG INTRAMUSCULAR*

Magnesium Sulfate SOLUTION 50 % INJECTION (10ML SYRINGE)

Meperidine HCl SOLUTION 50 MG/ML INJECTION

Methadone HCl SOLUTION 10 MG/ML INJECTION

MethylPREDNISolone Acetate SUSPENSION 40 MG/ML INJECTION






MethylPREDNISolone Sodium Succ SOLUTION RECONSTITUTED 125 MG INJECTION

MethylPREDNISolone Sodium Succ SOLUTION RECONSTITUTED 125 MG INJECTION

Metoclopramide HCl SOLUTION 5 MG/ML INJECTION

Metoclopramide HCl SOLUTION 5 MG/ML INJECTION

Mozobil SOLUTION 24 MG/1.2ML SUBCUTANEOUS*

Mycophenolate Mofetil CAPSULE 250 MG ORAL

Mycophenolate Mofetil SUSPENSION RECONSTITUTED 200 MG/ML ORAL

Mycophenolate Mofetil TABLET 500 MG ORAL

Mycophenolate Sodium TABLET DELAYED RELEASE 180 MG ORAL

Mycophenolate Sodium TABLET DELAYED RELEASE 360 MG ORAL

Naloxone HCl SOLUTION 1 MG/ML INJECTION

Nebupent SOLUTION RECONSTITUTED 300 MG INHALATION

Oncaspar SOLUTION 750 UNIT/ML INJECTION

Ondansetron HCl SOLUTION 4 MG/2ML INJECTION

Ondansetron HCl SOLUTION 4 MG/2ML INJECTION (2ML SYRINGE)

Ondansetron HCl SOLUTION 4 MG/5ML ORAL

Ondansetron HCl TABLET 4 MG ORAL

Ondansetron HCl TABLET 8 MG ORAL

Ondansetron TABLET DISPERSIBLE 4 MG ORAL

Ondansetron TABLET DISPERSIBLE 8 MG ORAL


Opdivo SOLUTION 40 MG/4ML INTRAVENOUS*

Oxacillin Sodium SOLUTION RECONSTITUTED 2 GM INJECTION

Pamidronate Disodium SOLUTION 6 MG/ML INTRAVENOUS*

Paricalcitol SOLUTION 2 MCG/ML INTRAVENOUS*

Penicillin G Potassium SOLUTION RECONSTITUTED 5000000 UNIT INJECTION

Pentam SOLUTION RECONSTITUTED 300 MG INJECTION

Perjeta SOLUTION 420 MG/14ML INTRAVENOUS*

Phenytoin Sodium SOLUTION 50 MG/ML INJECTION

Procainamide HCl SOLUTION 500 MG/ML INJECTION

Prochlorperazine Edisylate SOLUTION 5 MG/ML INJECTION

Prochlorperazine Edisylate SOLUTION 5 MG/ML INJECTION

Prolastin-C SOLUTION RECONSTITUTED 1 MG INTRAVENOUS

Prolastin-C SOLUTION RECONSTITUTED 1000 MG INTRAVENOUS*

Promethazine HCl SOLUTION 25 MG/ML INJECTION




Protonix SOLUTION RECONSTITUTED 40 MG INTRAVENOUS*

Rapamune SOLUTION 1 MG/ML ORAL

Recombivax HB SUSPENSION 10 MCG/ML INJECTION

Recombivax HB SUSPENSION 10 MCG/ML INJECTION (1ML SYRINGE)

Recombivax HB SUSPENSION 40 MCG/ML INJECTION

Recombivax HB SUSPENSION 5 MCG/0.5ML INJECTION

RisperDAL Consta SUSPENSION RECONSTITUTED 25 MG INTRAMUSCULAR*




Sirolimus TABLET 0.5 MG ORAL

Sirolimus TABLET 1 MG ORAL

Sirolimus TABLET 2 MG ORAL

Solu-CORTEF SOLUTION RECONSTITUTED 250 MG INJECTION



Synagis SOLUTION 50 MG/0.5ML INTRAMUSCULAR*

Synagis SOLUTION 50 MG/0.5ML INTRAMUSCULAR*


Synercid SOLUTION RECONSTITUTED 150-350 MG INTRAVENOUS*

Tacrolimus CAPSULE 0.5 MG ORAL

Tacrolimus CAPSULE 1 MG ORAL

Tacrolimus CAPSULE 5 MG ORAL

Tazicef SOLUTION RECONSTITUTED 1 GM INJECTION

Tazicef SOLUTION RECONSTITUTED 2 GM INJECTION

Tecentriq SOLUTION 1200 MG/20ML INTRAVENOUS*

Tenivac INJECTABLE 5-2 LFU INTRAMUSCULAR*

Tobramycin NEBULIZATION SOLUTION 300 MG/5ML INHALATION

Tobramycin Sulfate SOLUTION 80 MG/2ML INJECTION

Travasol SOLUTION 10 % INTRAVENOUS*

Treanda SOLUTION RECONSTITUTED 100 MG INTRAVENOUS*

Trisenox SOLUTION 10 MG/10ML INTRAVENOUS*

Tygacil SOLUTION RECONSTITUTED 50 MG INTRAVENOUS*

Velcade SOLUTION RECONSTITUTED 3.5 MG INJECTION

Virazole SOLUTION RECONSTITUTED 6 GM INHALATION

Virazole SOLUTION RECONSTITUTED 6 GM INHALATION

Voriconazole SOLUTION RECONSTITUTED 200 MG INTRAVENOUS*

Vpriv SOLUTION RECONSTITUTED 400 UNIT INTRAVENOUS*

Yondelis SOLUTION RECONSTITUTED 1 MG INTRAVENOUS*

Zoledronic Acid CONCENTRATE 4 MG/5ML INTRAVENOUS*

Zoledronic Acid SOLUTION 5 MG/100ML INTRAVENOUS*

Zortress TABLET 0.25 MG ORAL



ZyPREXA Relprevv SUSPENSION RECONSTITUTED 210 MG INTRAMUSCULAR*

ZyPREXA Relprevv SUSPENSION RECONSTITUTED 210 MG INTRAMUSCULAR*

2016 Prior Authorization Criteria - Login · 2016 Prior Authorization Criteria Last ... ottenere...

Documents

Transcript of 2016 Prior Authorization Criteria - Login · 2016 Prior Authorization Criteria Last ... ottenere...