4T Basic 2012 PA Criteria Medicare Part Band DPrior Approvals Spanish
MedicarePartBandPartDPriorApprovalsSpanish_old050912 MedicarePartBandPartDPriorApprovalsSpanish_old050912
MedicarePartBandPartDPriorApprovals_Old_04062012 MedicarePartBandPartDPriorApprovals_Old_04062012
User Manual: MedicarePartBandPartDPriorApprovalsSpanish
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GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP 2012 Prior Authorization Criteria ACTEMRA .................................................................................................................................................... 20 ACTEMRA® .............................................................................................................................................. 20 ACTIMMUNE ............................................................................................................................................... 21 ACTIMMUNE® ......................................................................................................................................... 21 ADAGEN ...................................................................................................................................................... 22 ADAGEN® ................................................................................................................................................ 22 ADCIRCA ...................................................................................................................................................... 23 ADCIRCA® ................................................................................................................................................ 23 AFINITOR ..................................................................................................................................................... 24 AFINITOR® ............................................................................................................................................... 24 ALDURAZYME .............................................................................................................................................. 25 ALDURAZYME® ........................................................................................................................................ 25 ALPHA1-PROTEINASE INHIBITOR ................................................................................................................ 26 ARALAST NP® .......................................................................................................................................... 26 AMPHETAMINES ......................................................................................................................................... 27 AMPHETAMINE SALT COMBO ................................................................................................................ 27 DEXTROAMPHETAMINE SULFATE ........................................................................................................... 27 AMPYRA ...................................................................................................................................................... 28 AMPYRA® ................................................................................................................................................ 28 ANABOLIC STEROIDS ................................................................................................................................... 29 ANADROL-50® ......................................................................................................................................... 29 OXANDROLONE ....................................................................................................................................... 29 H6864_MMG12_02 File & Use 09212011 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP ANAGRELIDE................................................................................................................................................ 30 ANAGRELIDE HCL .................................................................................................................................... 30 ARCALYST .................................................................................................................................................... 31 ARCALYST® .............................................................................................................................................. 31 ATYPICAL ODT ............................................................................................................................................. 32 FAZACLO®................................................................................................................................................ 32 AVONEX....................................................................................................................................................... 33 AVONEX ADMINISTRATION PACK® ......................................................................................................... 33 AVONEX®................................................................................................................................................. 33 B vs D - Part B versus Part D Coverage PA .................................................................................................. 34 ACETYLCYSTEINE ..................................................................................................................................... 34 ADRIAMYCIN ........................................................................................................................................... 34 ALBUTEROL SULFATE .............................................................................................................................. 34 ALIMTA® .................................................................................................................................................. 34 AMIFOSTINE ............................................................................................................................................ 34 AMINOSYN II 3.5% M-DEXTROSE 5%® .................................................................................................... 34 AMINOSYN II 3.5%-DEXTROSE 25%® ...................................................................................................... 34 AMINOSYN II 3.5%-DEXTROSE 5%® ........................................................................................................ 34 AMINOSYN II 4.25%-DEXTROSE 25%® .................................................................................................... 34 AMINOSYN II 5% IN 25% DEXTROSE® ..................................................................................................... 34 AMINOSYN II IN DEXTROSE® ................................................................................................................... 34 AMINOSYN II WITH LYTES-CA-DW® ........................................................................................................ 34 Page 2 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP AMINOSYN II® ......................................................................................................................................... 34 AMINOSYN M® ........................................................................................................................................ 34 AMINOSYN® ............................................................................................................................................ 34 AMINOSYN-HBC® .................................................................................................................................... 34 AMINOSYN-HF®....................................................................................................................................... 34 AMINOSYN-PF® ....................................................................................................................................... 34 AMIODARONE HCL .................................................................................................................................. 34 AMPHOTERICIN B .................................................................................................................................... 34 ASTRAMORPH-PF® .................................................................................................................................. 34 AVASTIN® ................................................................................................................................................ 34 AZASAN® ................................................................................................................................................. 34 AZATHIOPRINE ........................................................................................................................................ 34 AZATHIOPRINE SODIUM ......................................................................................................................... 34 BICNU® .................................................................................................................................................... 34 BLEOMYCIN SULFATE .............................................................................................................................. 34 BUDESONIDE ........................................................................................................................................... 34 BUSULFEX® .............................................................................................................................................. 34 CALCITRIOL .............................................................................................................................................. 34 CAMPATH® .............................................................................................................................................. 34 CARBOPLATIN ......................................................................................................................................... 34 CELLCEPT® ............................................................................................................................................... 35 CISPLATIN ................................................................................................................................................ 35 Page 3 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP CLADRIBINE ............................................................................................................................................. 35 CLINIMIX E® ............................................................................................................................................. 35 CLINIMIX®................................................................................................................................................ 35 CLINISOL® ................................................................................................................................................ 35 COLISTIMETHATE SODIUM ..................................................................................................................... 35 COSMEGEN® ........................................................................................................................................... 35 CROMOLYN SODIUM .............................................................................................................................. 35 CUBICIN® ................................................................................................................................................. 35 CYCLOPHOSPHAMIDE ............................................................................................................................. 35 CYCLOSPORINE ........................................................................................................................................ 35 CYCLOSPORINE MODIFIED ...................................................................................................................... 35 CYTARABINE ............................................................................................................................................ 35 DACARBAZINE ......................................................................................................................................... 35 DAUNORUBICIN HCL ............................................................................................................................... 35 DEPO-PROVERA®..................................................................................................................................... 35 DEXRAZOXANE ........................................................................................................................................ 35 DIPHTHERIA-TETANUS TOXOID®............................................................................................................. 35 DOXIL®..................................................................................................................................................... 35 DOXORUBICIN HCL .................................................................................................................................. 35 DURAMORPH® ........................................................................................................................................ 35 ELITEK® .................................................................................................................................................... 35 ELSPAR® .................................................................................................................................................. 35 Page 4 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP EMEND® .................................................................................................................................................. 35 ENGERIX-B® ............................................................................................................................................. 35 EPIRUBICIN HCL....................................................................................................................................... 35 ETOPOSIDE .............................................................................................................................................. 35 FASLODEX®.............................................................................................................................................. 35 FENTANYL CITRATE ................................................................................................................................. 35 FLUDARABINE PHOSPHATE® ................................................................................................................... 35 FLUOROURACIL ....................................................................................................................................... 35 FREAMINE III WITH ELECTROLYTES® ....................................................................................................... 35 FREAMINE III® ......................................................................................................................................... 35 GAMASTAN S-D® ..................................................................................................................................... 36 GANCICLOVIR SODIUM ........................................................................................................................... 36 GEMZAR® ................................................................................................................................................ 36 GENGRAF................................................................................................................................................. 36 GRANISETRON HCL.................................................................................................................................. 36 HEPARIN SODIUM ................................................................................................................................... 36 HEPARIN SODIUM IN 0.45% NACL .......................................................................................................... 36 HEPARIN SODIUM IN 0.9% NACL ............................................................................................................ 36 HEPARIN SODIUM IN 5% DEXTROSE ....................................................................................................... 36 HEPATAMINE® ........................................................................................................................................ 36 HEPATASOL® ........................................................................................................................................... 36 HERCEPTIN® ............................................................................................................................................ 36 Page 5 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP HYDROMORPHONE HCL.......................................................................................................................... 36 IDARUBICIN HCL ...................................................................................................................................... 36 IFEX®........................................................................................................................................................ 36 IFOSFAMIDE ............................................................................................................................................ 36 IFOSFAMIDE-MESNA ............................................................................................................................... 36 INTRALIPID® ............................................................................................................................................ 36 INTRON A® .............................................................................................................................................. 36 IPRATROPIUM BROMIDE ........................................................................................................................ 36 IPRATROPIUM-ALBUTEROL ..................................................................................................................... 36 IRINOTECAN HCL ..................................................................................................................................... 36 ISTODAX® ................................................................................................................................................ 36 LEUCOVORIN CALCIUM ........................................................................................................................... 36 LEVALBUTEROL CONCENTRATE .............................................................................................................. 36 LEVOCARNITINE ...................................................................................................................................... 36 LIPOSYN II® .............................................................................................................................................. 36 LIPOSYN III ............................................................................................................................................... 36 MELPHALAN HCL ..................................................................................................................................... 36 MESNA .................................................................................................................................................... 36 METHOTREXATE ...................................................................................................................................... 36 MIACALCIN® ............................................................................................................................................ 36 MITOMYCIN ............................................................................................................................................ 36 MITOXANTRONE HCL .............................................................................................................................. 36 Page 6 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP MORPHINE SULFATE ............................................................................................................................... 37 MUSTARGEN® ......................................................................................................................................... 37 MYCOPHENOLATE MOFETIL ................................................................................................................... 37 MYFORTIC® ............................................................................................................................................. 37 NEORAL® ................................................................................................................................................. 37 NEPHRAMINE® ........................................................................................................................................ 37 NEUMEGA® ............................................................................................................................................. 37 ONDANSETRON HCL................................................................................................................................ 37 ONDANSETRON ODT ............................................................................................................................... 37 ONTAK® ................................................................................................................................................... 37 OXALIPLATIN ........................................................................................................................................... 37 PACLITAXEL ............................................................................................................................................. 37 PENTOSTATIN.......................................................................................................................................... 37 PERFOROMIST® ....................................................................................................................................... 37 PHOTOFRIN® ........................................................................................................................................... 37 PREMASOL® ............................................................................................................................................ 37 PROCALAMINE® ...................................................................................................................................... 37 PROGRAF® ............................................................................................................................................... 37 PROLEUKIN® ............................................................................................................................................ 37 PROSOL® ................................................................................................................................................. 37 PULMOZYME® ......................................................................................................................................... 37 RAPAMUNE® ........................................................................................................................................... 37 Page 7 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP RECOMBIVAX HB® ................................................................................................................................... 37 REMODULIN® .......................................................................................................................................... 37 SANDIMMUNE® ...................................................................................................................................... 37 TACROLIMUS ........................................................................................................................................... 37 TAXOTERE® ............................................................................................................................................. 37 TETANUS DIPHTHERIA TOXOIDS® ........................................................................................................... 37 TETANUS TOXOID ADSORBED ................................................................................................................. 37 TETANUS-DIPHTERIA-DECAVAC® ............................................................................................................ 37 TOBI®....................................................................................................................................................... 37 TOPOSAR ................................................................................................................................................. 37 TOPOTECAN HCL ..................................................................................................................................... 37 TPN ELECTROLYTES® ............................................................................................................................... 37 TRAVASOL® ............................................................................................................................................. 38 TREANDA® ............................................................................................................................................... 38 TRELSTAR® .............................................................................................................................................. 38 TRISENOX® .............................................................................................................................................. 38 TROPHAMINE® ........................................................................................................................................ 38 VANCOMYCIN HCL .................................................................................................................................. 38 VELCADE® ................................................................................................................................................ 38 VIDAZA® .................................................................................................................................................. 38 VINBLASTINE SULFATE ............................................................................................................................ 38 VINCRISTINE SULFATE ............................................................................................................................. 38 Page 8 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP VINORELBINE TARTRATE ......................................................................................................................... 38 ZEMPLAR® ............................................................................................................................................... 38 ZOMETA® ................................................................................................................................................ 38 ZORTRESS® .............................................................................................................................................. 38 BANZEL ........................................................................................................................................................ 39 BANZEL® .................................................................................................................................................. 39 BUPRENORPHINE ........................................................................................................................................ 40 BUPRENORPHINE HCL ............................................................................................................................. 40 SUBOXONE® ............................................................................................................................................ 40 BYETTA ........................................................................................................................................................ 41 BYETTA® .................................................................................................................................................. 41 CAMPRAL .................................................................................................................................................... 42 CAMPRAL® .............................................................................................................................................. 42 CAYSTON ..................................................................................................................................................... 43 CAYSTON® ............................................................................................................................................... 43 CEREZYME ................................................................................................................................................... 44 CEREZYME® ............................................................................................................................................. 44 CHANTIX ...................................................................................................................................................... 45 CHANTIX® ................................................................................................................................................ 45 CIMZIA ......................................................................................................................................................... 46 CIMZIA® ................................................................................................................................................... 46 COPAXONE .................................................................................................................................................. 47 Page 9 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP COPAXONE® ............................................................................................................................................ 47 DRONABINOL .............................................................................................................................................. 48 DRONABINOL .......................................................................................................................................... 48 ELAPRASE .................................................................................................................................................... 50 ELAPRASE® .............................................................................................................................................. 50 EMSAM........................................................................................................................................................ 51 EMSAM®.................................................................................................................................................. 51 EPLERENONE ............................................................................................................................................... 52 EPLERENONE ........................................................................................................................................... 52 EPO .............................................................................................................................................................. 53 PROCRIT® ................................................................................................................................................ 53 EXJADE ........................................................................................................................................................ 54 EXJADE® .................................................................................................................................................. 54 EXTAVIA....................................................................................................................................................... 55 EXTAVIA®................................................................................................................................................. 55 FABRAZYME ................................................................................................................................................ 56 FABRAZYME® .......................................................................................................................................... 56 FENTANYL PATCH ........................................................................................................................................ 57 FENTANYL................................................................................................................................................ 57 GILENYA ...................................................................................................................................................... 58 GILENYA® ................................................................................................................................................ 58 GLEEVEC ...................................................................................................................................................... 59 Page 10 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP GLEEVEC® ................................................................................................................................................ 59 GONADOTROPIN ......................................................................................................................................... 60 CHORIONIC GONADOTROPIN ................................................................................................................. 60 NOVAREL ................................................................................................................................................. 60 PREGNYL®................................................................................................................................................ 60 GROWTH HORMONE .................................................................................................................................. 61 NORDITROPIN FLEXPRO® ........................................................................................................................ 61 NORDITROPIN NORDIFLEX® .................................................................................................................... 61 HEPSERA...................................................................................................................................................... 63 HEPSERA® ................................................................................................................................................ 63 HRM EDITS .................................................................................................................................................. 65 CARISOPRODOL ....................................................................................................................................... 65 CHLORZOXAZONE ................................................................................................................................... 65 CYCLOBENZAPRINE HCL .......................................................................................................................... 65 CYPROHEPTADINE HCL............................................................................................................................ 65 DICYCLOMINE HCL .................................................................................................................................. 65 DIPHENOXYLATE-ATROPINE.................................................................................................................... 65 DIPYRIDAMOLE ....................................................................................................................................... 65 ESTROPIPATE........................................................................................................................................... 65 HYDROXYZINE HCL .................................................................................................................................. 65 HYDROXYZINE PAMOATE ........................................................................................................................ 65 METAXALONE.......................................................................................................................................... 65 Page 11 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP METHOCARBAMOL ................................................................................................................................. 65 ORPHENADRINE CITRATE ........................................................................................................................ 65 ORPHENADRINE COMPOUND ................................................................................................................. 65 ORPHENADRINE COMPOUND FORTE ..................................................................................................... 65 ORTHO-EST®............................................................................................................................................ 65 PHENADOZ .............................................................................................................................................. 65 PROMETHAZINE HCL ............................................................................................................................... 65 PROMETHAZINE VC ................................................................................................................................. 65 PROMETHEGAN ...................................................................................................................................... 65 TRANSDERM-SCOP® ................................................................................................................................ 65 TRIMETHOBENZAMIDE HCL .................................................................................................................... 65 HUMIRA....................................................................................................................................................... 67 HUMIRA® ................................................................................................................................................ 67 INCRELEX ..................................................................................................................................................... 69 INCRELEX® ............................................................................................................................................... 69 INFERGEN .................................................................................................................................................... 70 INFERGEN® .............................................................................................................................................. 70 INVEGA SUSTENNA ..................................................................................................................................... 71 INVEGA SUSTENNA® ............................................................................................................................... 71 ITRACONAZOLE ........................................................................................................................................... 72 ITRACONAZOLE ....................................................................................................................................... 72 IVIG .............................................................................................................................................................. 74 Page 12 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP GAMMAGARD LIQUID® ........................................................................................................................... 74 GAMUNEX® ............................................................................................................................................. 74 KUVAN......................................................................................................................................................... 76 KUVAN®................................................................................................................................................... 76 LETAIRIS....................................................................................................................................................... 77 LETAIRIS®................................................................................................................................................. 77 LEUKINE....................................................................................................................................................... 78 LEUKINE®................................................................................................................................................. 78 LIDODERM ................................................................................................................................................... 80 LIDODERM®............................................................................................................................................. 80 LUPRON ....................................................................................................................................................... 81 LEUPROLIDE ACETATE ............................................................................................................................. 81 LUPRON DEPOT® ..................................................................................................................................... 81 LUPRON DEPOT-PED® ............................................................................................................................. 81 METHYLPHENIDATES .................................................................................................................................. 83 METADATE ER ......................................................................................................................................... 83 METHYLIN ............................................................................................................................................... 83 METHYLPHENIDATE HCL ......................................................................................................................... 83 METHYLPHENIDATE SR ........................................................................................................................... 83 MOZOBIL ..................................................................................................................................................... 84 MOZOBIL® ............................................................................................................................................... 84 MYOZYME ................................................................................................................................................... 85 Page 13 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP MYOZYME® ............................................................................................................................................. 85 NAGLAZYME ................................................................................................................................................ 86 NAGLAZYME® .......................................................................................................................................... 86 NEUPOGEN.................................................................................................................................................. 87 NEUPOGEN®............................................................................................................................................ 87 NEXAVAR ..................................................................................................................................................... 89 NEXAVAR® ............................................................................................................................................... 89 NICOTINE..................................................................................................................................................... 90 NICOTROL NS® ........................................................................................................................................ 90 NICOTROL®.............................................................................................................................................. 90 NUEDEXTA................................................................................................................................................... 91 NUEDEXTA®............................................................................................................................................. 91 NUVIGIL ....................................................................................................................................................... 92 NUVIGIL® ................................................................................................................................................. 92 OCTREOTIDE................................................................................................................................................ 93 OCTREOTIDE ACETATE ............................................................................................................................ 93 ORAL FENTANYL .......................................................................................................................................... 94 FENTANYL CITRATE ................................................................................................................................. 94 ORAL TESTOSTERONES................................................................................................................................ 95 ANDROXY® .............................................................................................................................................. 95 ORFADIN ..................................................................................................................................................... 96 ORFADIN® ............................................................................................................................................... 96 Page 14 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP OSTEOPOROSIS ........................................................................................................................................... 97 FORTEO® ................................................................................................................................................. 97 OXSORALEN................................................................................................................................................. 98 OXSORALEN-ULTRA® ............................................................................................................................... 98 PEGASYS ...................................................................................................................................................... 99 PEGASYS® ................................................................................................................................................ 99 PEGINTRON ............................................................................................................................................... 101 PEGINTRON REDIPEN® .......................................................................................................................... 101 PEGINTRON® ......................................................................................................................................... 101 PROMACTA ............................................................................................................................................... 102 PROMACTA® ......................................................................................................................................... 102 RANEXA ..................................................................................................................................................... 104 RANEXA® ............................................................................................................................................... 104 REBIF ......................................................................................................................................................... 105 REBIF® ................................................................................................................................................... 105 RELISTOR ................................................................................................................................................... 106 RELISTOR® ............................................................................................................................................. 106 REMICADE ................................................................................................................................................. 107 REMICADE® ........................................................................................................................................... 107 REVATIO .................................................................................................................................................... 109 REVATIO® .............................................................................................................................................. 109 REVLIMID................................................................................................................................................... 110 Page 15 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP REVLIMID® ............................................................................................................................................ 110 RIBAVIRIN .................................................................................................................................................. 112 REBETOL® .............................................................................................................................................. 112 RIBAPAK ................................................................................................................................................ 112 RIBASPHERE .......................................................................................................................................... 112 RIBAVIRIN .............................................................................................................................................. 112 RISPERDAL CONSTA................................................................................................................................... 114 RISPERDAL CONSTA® ............................................................................................................................ 114 RITUXAN .................................................................................................................................................... 115 RITUXAN® .............................................................................................................................................. 115 SABRIL ....................................................................................................................................................... 116 SABRIL® ................................................................................................................................................. 116 SANCUSO................................................................................................................................................... 117 SANCUSO®............................................................................................................................................. 117 SANDOSTATIN LAR .................................................................................................................................... 118 SANDOSTATIN LAR® .............................................................................................................................. 118 SOMATULINE DEPOT................................................................................................................................. 119 SOMATULINE DEPOT®........................................................................................................................... 119 SOMAVERT ................................................................................................................................................ 120 SOMAVERT® .......................................................................................................................................... 120 SPRYCEL ..................................................................................................................................................... 121 SPRYCEL®............................................................................................................................................... 121 Page 16 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP STRATTERA ................................................................................................................................................ 122 STRATTERA® .......................................................................................................................................... 122 SUTENT...................................................................................................................................................... 123 SUTENT®................................................................................................................................................ 123 SYMLIN ...................................................................................................................................................... 124 SYMLIN® ................................................................................................................................................ 124 SYMLINPEN 120® .................................................................................................................................. 124 SYMLINPEN 60® .................................................................................................................................... 124 TARCEVA ................................................................................................................................................... 125 TARCEVA® ............................................................................................................................................. 125 TARGRETIN ................................................................................................................................................ 126 TARGRETIN® .......................................................................................................................................... 126 TASIGNA .................................................................................................................................................... 127 TASIGNA® .............................................................................................................................................. 127 TAZORAC ................................................................................................................................................... 128 TAZORAC® ............................................................................................................................................. 128 TESTOSTERONES ....................................................................................................................................... 129 ANDRODERM® ...................................................................................................................................... 129 TESTIM® ................................................................................................................................................ 129 THALOMID................................................................................................................................................. 130 THALOMID®........................................................................................................................................... 130 THIORIDAZINE ........................................................................................................................................... 131 Page 17 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP THIORIDAZINE HCL ................................................................................................................................ 131 TOPICAL IMMUNOSUPPRESSANT ............................................................................................................. 132 ELIDEL® .................................................................................................................................................. 132 PROTOPIC® ............................................................................................................................................ 132 TOPICAL-ULCERS ....................................................................................................................................... 133 REGRANEX® ........................................................................................................................................... 133 TRACLEER .................................................................................................................................................. 134 TRACLEER® ............................................................................................................................................ 134 TYKERB ...................................................................................................................................................... 135 TYKERB® ................................................................................................................................................ 135 TYZEKA ...................................................................................................................................................... 136 TYZEKA® ................................................................................................................................................ 136 VIMPAT ..................................................................................................................................................... 138 VIMPAT® ............................................................................................................................................... 138 VOTRIENT .................................................................................................................................................. 139 VOTRIENT® ............................................................................................................................................ 139 VPRIV ......................................................................................................................................................... 140 VPRIV®................................................................................................................................................... 140 XENAZINE .................................................................................................................................................. 141 XENAZINE® ............................................................................................................................................ 141 XIFAXAN .................................................................................................................................................... 142 XIFAXAN® .............................................................................................................................................. 142 Page 18 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP XOLAIR....................................................................................................................................................... 143 XOLAIR®................................................................................................................................................. 143 XYREM ....................................................................................................................................................... 144 XYREM® ................................................................................................................................................. 144 ZAVESCA .................................................................................................................................................... 145 ZAVESCA® .............................................................................................................................................. 145 Index.......................................................................................................................................................... 146 Page 19 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP ACTEMRA Affected 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. Must have an inadequate response or intolerance/contraindication to one TNF [Tumor necrosis factor] antagonist therapy. Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration Plan Year. Other Criteria For renewals, patient must have responded to Actemra therapy (e. g. , condition improved or stabilized). Page 20 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP ACTIMMUNE Affected Drugs ACTIMMUNE® Covered Uses All FDA approved indications not otherwise excluded from Part D. Exclusion Criteria N/A Required Medical Information N/A Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration Plan Year. Other Criteria N/A Page 21 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP ADAGEN Affected 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 N/A Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration Plan Year. Other Criteria Use for direct replacement for deficient enzyme (no benefit achieved in patients with immunodeficiency due to other causes). Page 22 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP ADCIRCA Affected Drugs ADCIRCA® Covered Uses All FDA approved indications not otherwise excluded from Part D. Exclusion Criteria Nitrate therapy. Required Medical Information PAH [Pulmonary Arterial Hypertension] been confirmed by right heart catheterization. Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration Plan Year. Other Criteria N/A Page 23 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP AFINITOR Affected Drugs AFINITOR® Covered Uses All FDA approved indications not otherwise excluded from Part D. Exclusion Criteria N/A Required Medical Information N/A Age Restrictions N/A Prescriber Restrictions Oncologist. Coverage Duration Plan Year. Other Criteria N/A Page 24 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP ALDURAZYME Affected Drugs ALDURAZYME® Covered Uses All FDA approved indications not otherwise excluded from Part D. Exclusion Criteria N/A 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 N/A Prescriber Restrictions N/A Coverage Duration Plan Year. Other Criteria N/A Page 25 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP ALPHA1-PROTEINASE INHIBITOR Affected 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 N/A Coverage Duration Plan Year. Other Criteria N/A Page 26 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP AMPHETAMINES Affected Drugs AMPHETAMINE SALT COMBO 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 N/A Coverage Duration Plan Year. Other Criteria Consider benefits of use versus the potential risks of serious cardiovascular events. Page 27 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP AMPYRA Affected 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 N/A Prescriber Restrictions N/A 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. Page 28 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP ANABOLIC STEROIDS Affected Drugs ANADROL-50® OXANDROLONE Covered Uses All FDA approved indications not otherwise excluded from Part D. 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 N/A Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration 6 months. Other Criteria N/A Page 29 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP ANAGRELIDE Affected Drugs ANAGRELIDE HCL Covered Uses All FDA approved indications not otherwise excluded from Part D. Exclusion Criteria Severe hepatic impairment. Required Medical Information N/A Age Restrictions N/A Prescriber Restrictions Oncologist or hematologist. Coverage Duration 6 months. Other Criteria N/A Page 30 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP ARCALYST Affected 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 N/A Age Restrictions 12 years of age and older. Prescriber Restrictions N/A Coverage Duration Plan Year. Other Criteria For renewal, patient's condition must have improved or stabilized. Page 31 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP ATYPICAL ODT Affected 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 N/A Prescriber Restrictions N/A Coverage Duration Plan Year. Other Criteria N/A Page 32 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP AVONEX Affected Drugs AVONEX ADMINISTRATION PACK® AVONEX® Covered Uses All FDA approved indications not otherwise excluded from Part D. Exclusion Criteria N/A Required Medical Information N/A Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration Plan Year. Other Criteria N/A Page 33 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP B VS D - PART B VERSUS PART D COVERAGE PA Affected Drugs ACETYLCYSTEINE ADRIAMYCIN ALBUTEROL SULFATE ALIMTA® AMIFOSTINE AMINOSYN II 3.5% M-DEXTROSE 5%® AMINOSYN II 3.5%-DEXTROSE 25%® AMINOSYN II 3.5%-DEXTROSE 5%® AMINOSYN II 4.25%-DEXTROSE 25%® AMINOSYN II 5% IN 25% DEXTROSE® AMINOSYN II IN DEXTROSE® AMINOSYN II WITH LYTES-CA-DW® AMINOSYN II® AMINOSYN M® AMINOSYN® AMINOSYN-HBC® AMINOSYN-HF® AMINOSYN-PF® AMIODARONE HCL AMPHOTERICIN B ASTRAMORPH-PF® AVASTIN® AZASAN® AZATHIOPRINE AZATHIOPRINE SODIUM BICNU® BLEOMYCIN SULFATE BUDESONIDE BUSULFEX® CALCITRIOL CAMPATH® CARBOPLATIN Page 34 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP CELLCEPT® CISPLATIN CLADRIBINE CLINIMIX E® CLINIMIX® CLINISOL® COLISTIMETHATE SODIUM COSMEGEN® CROMOLYN SODIUM CUBICIN® CYCLOPHOSPHAMIDE CYCLOSPORINE CYCLOSPORINE MODIFIED CYTARABINE DACARBAZINE DAUNORUBICIN HCL DEPO-PROVERA® DEXRAZOXANE DIPHTHERIA-TETANUS TOXOID® DOXIL® DOXORUBICIN HCL DURAMORPH® ELITEK® ELSPAR® EMEND® ENGERIX-B® EPIRUBICIN HCL ETOPOSIDE FASLODEX® FENTANYL CITRATE FLUDARABINE PHOSPHATE® FLUOROURACIL FREAMINE III WITH ELECTROLYTES® FREAMINE III® Page 35 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP GAMASTAN S-D® GANCICLOVIR SODIUM GEMZAR® GENGRAF GRANISETRON HCL HEPARIN SODIUM HEPARIN SODIUM IN 0.45% NACL HEPARIN SODIUM IN 0.9% NACL HEPARIN SODIUM IN 5% DEXTROSE HEPATAMINE® HEPATASOL® HERCEPTIN® HYDROMORPHONE HCL IDARUBICIN HCL IFEX® IFOSFAMIDE IFOSFAMIDE-MESNA INTRALIPID® INTRON A® IPRATROPIUM BROMIDE IPRATROPIUM-ALBUTEROL IRINOTECAN HCL ISTODAX® LEUCOVORIN CALCIUM LEVALBUTEROL CONCENTRATE LEVOCARNITINE LIPOSYN II® LIPOSYN III MELPHALAN HCL MESNA METHOTREXATE MIACALCIN® MITOMYCIN MITOXANTRONE HCL Page 36 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP MORPHINE SULFATE MUSTARGEN® MYCOPHENOLATE MOFETIL MYFORTIC® NEORAL® NEPHRAMINE® NEUMEGA® ONDANSETRON HCL ONDANSETRON ODT ONTAK® OXALIPLATIN PACLITAXEL PENTOSTATIN PERFOROMIST® PHOTOFRIN® PREMASOL® PROCALAMINE® PROGRAF® PROLEUKIN® PROSOL® PULMOZYME® RAPAMUNE® RECOMBIVAX HB® REMODULIN® SANDIMMUNE® TACROLIMUS TAXOTERE® TETANUS DIPHTHERIA TOXOIDS® TETANUS TOXOID ADSORBED TETANUS-DIPHTERIA-DECAVAC® TOBI® TOPOSAR TOPOTECAN HCL TPN ELECTROLYTES® Page 37 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP TRAVASOL® TREANDA® TRELSTAR® TRISENOX® TROPHAMINE® VANCOMYCIN HCL VELCADE® VIDAZA® VINBLASTINE SULFATE VINCRISTINE SULFATE VINORELBINE TARTRATE 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. Page 38 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP BANZEL Affected 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 N/A Prescriber Restrictions Neurologist or affiliated with neurology practice. Coverage Duration Plan Year. Other Criteria N/A Page 39 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP BUPRENORPHINE Affected 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. Page 40 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP BYETTA Affected 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, the patient demonstrated a reduction in HbA1c since initiating Byetta therapy. Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration Plan Year. Other Criteria N/A Page 41 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP CAMPRAL Affected 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 N/A Prescriber Restrictions N/A Coverage Duration 6 months. Other Criteria N/A Page 42 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP CAYSTON Affected Drugs CAYSTON® Covered Uses All FDA approved indications not otherwise excluded from Part D. Exclusion Criteria N/A 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 N/A Prescriber Restrictions N/A Coverage Duration Plan Year. Other Criteria N/A Page 43 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP CEREZYME Affected 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 bglucocerebrosidase 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 reauthorization. Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration Plan Year. Other Criteria N/A Page 44 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP CHANTIX Affected Drugs CHANTIX® 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 N/A Prescriber Restrictions N/A Coverage Duration 12 weeks initial, 12 weeks additional upon renewal. Other Criteria Member is participating in a smoking cessation program. Page 45 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP CIMZIA Affected Drugs CIMZIA® Covered Uses All FDA approved indications not otherwise excluded from Part D. Exclusion Criteria Active infection (including TB). Concurrent therapy 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 (RA) - Must have an inadequate response to either Enbrel or Humira and one of following: 1) inadequate response to methotrexate, 2) inadequate response to another nonbiologic DMARD [Disease-modifying antirheumatic drug] (e. g. , leflunomide, hydroxychloroquine, sulfasalazine) if contraindicated or intolerant to MTX [methotrexate] or, 3) intolerance or contraindication to at least 2 nonbiologic DMARDs [Diseasemodifying antirheumatic drugs]. Crohn's Disease - Must have an inadequate response or contraindication/intolerance to at least one oral corticosteroid and Humira. Age Restrictions 18 years of age and older. Prescriber Restrictions N/A Coverage Duration Initial: Plan Year for RA [Rheumatoid Arthritis], 3 months for Crohn's disease. Renewal: Plan Year. Other Criteria For re-authorization, patient's condition must have improved or stabilized. Page 46 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP COPAXONE Affected 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 N/A Age Restrictions N/A Prescriber Restrictions N/A 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. Page 47 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP DRONABINOL Affected Drugs DRONABINOL Covered Uses All FDA approved indications not otherwise excluded from Part D. Exclusion Criteria N/A 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 has failed to respond to a 30-day drug regimen of megestrol (Megace) c. 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 has had a full trial and failure through at least one cycle of chemotherapy with IV 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 N/A Prescriber Restrictions N/A Page 48 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP Coverage Duration 6 months. Other Criteria B vs D coverage determination per CMS guidelines. Page 49 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP ELAPRASE Affected Drugs ELAPRASE® Covered Uses All FDA approved indications not otherwise excluded from Part D. Exclusion Criteria N/A Required Medical Information Diagnosis confirmed by DNA testing or enzymatic analysis (deficiency of iduronate 2-sulfatase enzyme activity). Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration Plan Year. Other Criteria N/A Page 50 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP EMSAM Affected 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 N/A Prescriber Restrictions Psychiatrist or affiliated with a psychiatry practice. Coverage Duration Plan Year. Other Criteria N/A Page 51 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP EPLERENONE Affected Drugs EPLERENONE Covered Uses All FDA approved indications not otherwise excluded from Part D. Exclusion Criteria N/A Required Medical Information A. Diagnosis of hypertension or post-myocardial infarction with LVEF less than or equal to 40% and clinical evidence of CHF [Congestive Heart Failure] 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 [Congestive Heart Failure] 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 AND the patient had an inadequate treatment response to maximum tolerated doses of a 60-day trial or had unacceptable toxicity to spironolactone therapy. Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration Plan Year. Other Criteria N/A Page 52 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP EPO Affected Drugs PROCRIT® Covered Uses All FDA approved indications not otherwise excluded from Part D. 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 N/A Prescriber Restrictions N/A Coverage Duration 12 weeks. Other Criteria N/A Page 53 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP EXJADE Affected 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 ironcontaining products. Required Medical Information The patient must meet all of the following criteria: 1) Diagnosis of transfusiondependent 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 N/A Page 54 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP EXTAVIA Affected 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 N/A Age Restrictions N/A Prescriber Restrictions N/A 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. Page 55 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP FABRAZYME Affected Drugs FABRAZYME® Covered Uses All FDA approved indications not otherwise excluded from Part D. Exclusion Criteria N/A Required Medical Information Diagnosis confirmed with an enzyme assay measuring a deficiency of alphagalactosidase enzyme activity or DNA testing. Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration Plan Year. Other Criteria N/A Page 56 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP FENTANYL PATCH Affected 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 N/A Coverage Duration 6 months. Other Criteria N/A Page 57 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP GILENYA Affected Drugs GILENYA® Covered Uses All FDA approved uses not otherwise excluded from Part D. Exclusion Criteria N/A 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 N/A Prescriber Restrictions N/A Coverage Duration Plan Year. Other Criteria N/A Page 58 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP GLEEVEC Affected Drugs GLEEVEC® Covered Uses All FDA approved indications not otherwise excluded from Part D. Exclusion Criteria N/A 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 [Chronic Myeloid Leukemia], 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 N/A Prescriber Restrictions N/A Coverage Duration Plan Year. Other Criteria N/A Page 59 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP GONADOTROPIN Affected Drugs CHORIONIC GONADOTROPIN NOVAREL PREGNYL® 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 N/A Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration Plan Year. Other Criteria N/A Page 60 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP GROWTH HORMONE Affected Drugs NORDITROPIN FLEXPRO® NORDITROPIN NORDIFLEX® 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 [growth hormone] 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 IGF1/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 [Short child born small for gestational age]: 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. Page 61 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP Age Restrictions For Turner syndrome and SGA [Short child born small for gestational age], 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 N/A Page 62 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP HEPSERA Affected 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-nave 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 (+ or -) serological marker 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 HBeAgnegative 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 Intron A. F. AND documented evidence of diagnosis, serological markers or liver biopsy, viral load and liver aminotransferases. G. 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 and 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. Page 63 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP Coverage Duration Plan Year. Other Criteria N/A Page 64 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP HRM EDITS Affected Drugs CARISOPRODOL CHLORZOXAZONE CYCLOBENZAPRINE HCL CYPROHEPTADINE HCL DICYCLOMINE HCL DIPHENOXYLATE-ATROPINE DIPYRIDAMOLE ESTROPIPATE HYDROXYZINE HCL HYDROXYZINE PAMOATE METAXALONE METHOCARBAMOL ORPHENADRINE CITRATE ORPHENADRINE COMPOUND ORPHENADRINE COMPOUND FORTE ORTHO-EST® PHENADOZ PROMETHAZINE HCL PROMETHAZINE VC PROMETHEGAN TRANSDERM-SCOP® TRIMETHOBENZAMIDE HCL 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 N/A Page 65 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration Plan Year. Other Criteria N/A Page 66 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP HUMIRA Affected Drugs HUMIRA® 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 [Disease-modifying antirheumatic drug] (e. g. , leflunomide, hydroxychloroquine, sulfasalazine) if contraindicated or intolerant to MTX [methotrexate], 3) intolerance or contraindication to at least 2 nonbiologic DMARDs [Disease-modifying antirheumatic drugs] or, 4) use Humira as first-line therapy with MTX [methotrexate] for severely active RA [Rheumatoid Arthritis]. Polyarticular JIA [Juvenile Idiopathic Arthritis] - Must have an inadequate response to at least one nonbiologic DMARD [Disease-modifying antirheumatic drug] or intolerance/contraindication to at least 2 nonbiologic DMARDs [Disease-modifying antirheumatic drugs]. 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 [Disease-modifying antirheumatic drug] 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 [Body surface area] 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 [methotrexate], acitretin) unless contraindicated or intolerant to such therapies. Crohn's disease - Must have an inadequate response to at Page 67 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP least a 60-day trial of 2 conventional therapies (e. g. , sulfasalazine, mesalamine, azathioprine, corticosteroids) unless contraindicated or intolerant to such therapies OR an inadequate response or intolerance to either Remicade or Cimzia. Age Restrictions For psoriasis, patient must be 18 years of age and older. Prescriber Restrictions N/A 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. Page 68 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP INCRELEX Affected Drugs INCRELEX® Covered Uses All FDA approved indications not otherwise excluded from Part D. Exclusion Criteria Epiphyseal closure, IV administration of Increlex, active malignancy, use in neonates, concurrent use with GH [growth hormone] therapy, patient has secondary causes of IGF-1 deficiency. Required Medical Information Prior to starting therapy, a height greater than 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 [growth hormone] level. For continuation of therapy, patient grew more than 2. 5 cm/year. Age Restrictions Between 2 and 20 years of age. Prescriber Restrictions Endocrinologist. Coverage Duration Plan Year. Other Criteria N/A Page 69 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP INFERGEN Affected 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 nave, patient must have tried and had intolerance to pegylated interferon based treatment regimen. Allow Infergen monotherapy for treatment nave 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 N/A 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. Page 70 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP INVEGA SUSTENNA Affected Drugs INVEGA SUSTENNA® Covered Uses All FDA approved indications not otherwise excluded from Part D. Exclusion Criteria Treatment of patients with dementia-related psychosis, patients with occurrence of torsade de pointes, prior use of risperidone demonstrated a hypersensitivity reaction. Required Medical Information A. Diagnosis is an FDA-approved indication: acute and maintenance treatment of schizophrenia in adults. B. AND the diagnosis is NOT documented as dementia-related psychosis. C. AND Invega Sustenna therapy will not be used if prior use of risperidone demonstrated a hypersensitivity reaction D. AND the patient has a history of noncompliance and/or refuses to utilize oral medication E. AND the patient has received at least ONE of the following: a. three test doses of risperidone b. three test doses of oral Invega c. previous use of Invega Sustenna. F. If the patient in increasing the dose of Invega Sustenna, the patient must have a history of two prior injections. Age Restrictions N/A Prescriber Restrictions Psychiatrist or receiving input from a psychiatry practice. Coverage Duration Plan Year. Other Criteria N/A Page 71 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP ITRACONAZOLE Affected 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 [Congestive Heart Failure]) do not use for onychomycosis. B. If the patient is taking/receiving any of the following: concomitant use with drugs metabolized by CYP3A4 (e. g. , 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 N/A Prescriber Restrictions N/A Coverage Duration 12 weeks. Page 72 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP Other Criteria N/A Page 73 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP IVIG Affected Drugs GAMMAGARD LIQUID® GAMUNEX® Covered Uses All FDA approved indications not otherwise excluded from Part D. 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 Serum trough and IgG levels below 600, platlet counts, CD4 counts and lymphocyte counts. Chart notes of past illness and for multiple myeloma, any infections in the past year. Evidence of positive GMI antibodies Age Restrictions N/A Prescriber Restrictions CIDP diagnosis by a neurologist. Coverage Duration Plan Year. Page 74 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP Other Criteria Gamunex/Gamunex-C: if administered SC outside of a controlled healthcare setting, appropriate treatment (eg, anaphylaxis kit) should be available for managing an acute hypersensitivity reaction. Page 75 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP KUVAN Affected Drugs KUVAN® Covered Uses All FDA approved indications not otherwise excluded from Part D. Exclusion Criteria N/A 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 N/A Prescriber Restrictions N/A 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. Page 76 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP LETAIRIS Affected 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 [Pulmonary Arterial Hypertension] been confirmed by right heart catheterization. Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration Plan Year. Other Criteria UD or two appropriate contraceptive methods will be used for women of childbearing potential. Page 77 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP LEUKINE Affected Drugs LEUKINE® Covered Uses All FDA approved indications not otherwise excluded from Part D. 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 [Acute Myeloid Lymphoma] 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 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 N/A Page 78 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP Prescriber Restrictions N/A Coverage Duration 6 months. Other Criteria N/A Page 79 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP LIDODERM Affected Drugs LIDODERM® Covered Uses All FDA approved indications not otherwise excluded from Part D. Exclusion Criteria Patient has a sensitivity to local anesthetics of the amide type (e. g. , procaine, tetracaine, benzocaine. Dose in excess of 3 patches per day. Required Medical Information A. The diagnosis is documented as post-herpetic neuralgia B. The skin where the patch is to be applied is intact (not broken or inflamed). C. The patient has completed a documented one month trial and failure of the following two medications: gabapentin OR Lyrica D. OR the patient has a contraindication or demonstrated an adverse event to the prerequisite drugs. Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration 3 months. Other Criteria N/A Page 80 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP LUPRON Affected Drugs LEUPROLIDE ACETATE LUPRON DEPOT® LUPRON DEPOT-PED® Covered Uses All FDA approved indications not otherwise excluded from Part D. 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 N/A Page 81 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP Coverage Duration Prostate CA: 1 year but 6 months for short term use, Fibroids: 3 months, Endometriosis: 6 months, CPP: 1 year. Other Criteria N/A Page 82 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP METHYLPHENIDATES Affected Drugs METADATE ER METHYLIN METHYLPHENIDATE HCL METHYLPHENIDATE SR 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 N/A Coverage Duration Plan Year. Other Criteria Consider benefits of use versus the potential risks of serious cardiovascular events. Page 83 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP MOZOBIL Affected Drugs MOZOBIL® Covered Uses All FDA approved indications not otherwise excluded from Part D. Exclusion Criteria N/A Required Medical Information N/A Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration 6 months. Other Criteria Mozobil is given in combination with granulocyte-colony stimulating factor. Page 84 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP MYOZYME Affected Drugs MYOZYME® Covered Uses All FDA approved indications not otherwise excluded from Part D. Exclusion Criteria N/A Required Medical Information Diagnosis confirmed by DNA testing or an enzymatic assay showing a deficiency in acid alpha glucosidase. Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration Plan Year. Other Criteria N/A Page 85 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP NAGLAZYME Affected Drugs NAGLAZYME® Covered Uses All FDA approved indications not otherwise excluded from Part D. Exclusion Criteria N/A 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 N/A Prescriber Restrictions N/A Coverage Duration Plan Year. Other Criteria N/A Page 86 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP NEUPOGEN Affected Drugs NEUPOGEN® Covered Uses All FDA approved indications not otherwise excluded from Part D. 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 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 N/A Prescriber Restrictions N/A Page 87 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP Coverage Duration 6 months. Other Criteria N/A Page 88 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP NEXAVAR Affected Drugs NEXAVAR® Covered Uses All FDA approved indications not otherwise excluded from Part D. Exclusion Criteria Combination with carboplatin and paclitaxel in patients with squamous cell lung cancer. Required Medical Information N/A Age Restrictions N/A Prescriber Restrictions Oncologist. Coverage Duration Plan Year. Other Criteria N/A Page 89 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP NICOTINE Affected Drugs NICOTROL NS® NICOTROL® Covered Uses All FDA approved indications not otherwise excluded from Part D. Exclusion Criteria N/A Required Medical Information Documentation that the patient is enrolled in a smoking cessation program. Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration 6 months. Other Criteria N/A Page 90 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP NUEDEXTA Affected 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 N/A Prescriber Restrictions N/A Coverage Duration Plan Year. Other Criteria N/A Page 91 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP NUVIGIL Affected Drugs NUVIGIL® Covered Uses All FDA approved indications not otherwise excluded from Part D. Exclusion Criteria N/A Required Medical Information If diagnosis is narcolepsy require Sleep Lab Evaluation, if diagnosis of OSAHS [Obstructive sleep apnea/hypoapnea syndrome] require polysomnography and whether the patient is using CPAP [Continuous positive airway pressure] or CPAP [Continuous positive airway pressure] 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 N/A Prescriber Restrictions N/A Coverage Duration Plan Year. Other Criteria N/A Page 92 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP OCTREOTIDE Affected Drugs OCTREOTIDE ACETATE Covered Uses All FDA approved indications not otherwise excluded from Part D. Exclusion Criteria N/A Required Medical Information N/A Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration Plan Year. Other Criteria N/A Page 93 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP ORAL FENTANYL Affected Drugs FENTANYL CITRATE 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 N/A Age Restrictions 16 years of age and older (Actiq), 18 years of age and older all others. Prescriber Restrictions N/A Coverage Duration 6 months. Other Criteria N/A Page 94 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP ORAL TESTOSTERONES Affected 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 N/A Prescriber Restrictions N/A Coverage Duration Plan Year. Other Criteria Patients who have tried and failed or unable to tolerate non-oral forms of testosterone supplementation. Page 95 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP ORFADIN Affected Drugs ORFADIN® Covered Uses All FDA approved indications not otherwise excluded from Part D. Exclusion Criteria N/A 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 N/A Prescriber Restrictions N/A Coverage Duration Plan Year. Other Criteria Protein-restricted diet that is low in phenylalanine and tyrosine. Page 96 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP OSTEOPOROSIS Affected 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 N/A Prescriber Restrictions N/A Coverage Duration Plan Year. Other Criteria N/A Page 97 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP OXSORALEN Affected Drugs OXSORALEN-ULTRA® Covered Uses All FDA approved indications not otherwise excluded from Part D. Exclusion Criteria N/A 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 N/A Prescriber Restrictions Dermatologist or Oncologist or affiliated with a dermatologist/oncologist practice. Coverage Duration Plan Year. Other Criteria N/A Page 98 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP PEGASYS Affected Drugs PEGASYS® Covered Uses All FDA approved indications not otherwise excluded from Part D. Exclusion Criteria Decompensated liver disease. Autoimmune hepatitis. Concomitant administration of didanosine with ribavirin in patients coinfected with HIV. Required Medical Information HCV: Prior to initiating therapy, detectable levels of HCV RNA in the serum. For HCV treatment nave, allow Pegasys monotherapy if patient has a contraindication or intolerance to ribavirin. For HCV retreatment, must use in combination with ribavirin and must have nonresponse or relapse with prior HCV therapy. Allow only one time for retreatment with pegylated interferon and ribavirin. 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. HBV: 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 HBVDNA greater than 100, 000 copies/mL or greater than 20, 000 IU/mL. For HBeAg negative, must have serum HBV-DNA greater than 10, 000 copies/mL or greater than 2, 000 IU/mL. Age Restrictions N/A Prescriber Restrictions ID specialist, Gastroenterologist, Oncologist. Page 99 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP Coverage Duration HCV:12 weeks to 72 weeks total depending on genotype and initial vs. renewal therapy. HBV:48 weeks. Other Criteria Monitor for evidence of depression. Page 100 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP PEGINTRON Affected Drugs PEGINTRON REDIPEN® PEGINTRON® Covered Uses All FDA approved indications not otherwise excluded from Part D. Exclusion Criteria Decompensated liver disease. Autoimmune hepatitis. Concomitant administration of didanosine with ribavirin in patients coinfected with HIV. Required Medical Information HCV: Prior to initiating therapy, detectable levels of HCV RNA in the serum. For HCV treatment nave, allow PegIntron monotherapy if patient has a contraindication or intolerance to ribavirin. For retreatment, must use in combination with ribavirin and must have nonresponse or relapse with prior HCV therapy. Allow only one time for retreatment with pegylated interferon and ribavirin. 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 N/A Prescriber Restrictions ID specialist, Gastroenterologist, Oncologist. Coverage Duration 12 weeks to a total 72 weeks depending on genotype and initial vs. renewal therapy. Other Criteria Monitor for evidence of depression. Page 101 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP PROMACTA Affected Drugs PROMACTA® Covered Uses All FDA approved indications not otherwise excluded from Part D. Exclusion Criteria N/A Required Medical Information For new starts, at the time of diagnosis of ITP [Immune thrombocytopenic purpura] 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 N/A Prescriber Restrictions N/A Page 102 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP Coverage Duration 6 month initial, 12 month renewal if adequate platelet response, 3 month w/o platelet response. Other Criteria N/A Page 103 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP RANEXA Affected 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 with symptoms limiting daily activities. B. AND the patient is NOT receiving a medication 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 N/A Prescriber Restrictions Cardiologist or affiliated with a cardiology practice. Coverage Duration 3 months initial, 12 months renewal. Other Criteria N/A Page 104 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP REBIF Affected Drugs REBIF® Covered Uses All FDA approved indications not otherwise excluded from Part D. Exclusion Criteria N/A Required Medical Information N/A Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration Plan Year. Other Criteria N/A Page 105 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP RELISTOR Affected 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 must have previous trial/failure of polyethylene glycol. Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration 4 Months. Other Criteria N/A Page 106 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP REMICADE Affected 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 An inadequate response or intolerance to Enbrel or Humira and one of the following: 1) inadequate response to methotrexate (MTX), 2) inadequate response to another nonbiologic DMARD [Disease-modifying antirheumatic drug] (e. g. , leflunomide, hydroxychloroquine, sulfasalazine) if contraindicated or intolerant to MTX [methotrexate], 3) intolerance or contraindication to at least 2 nonbiologic DMARDs [Disease-modifying antirheumatic drugs]. Psoriatic arthritis with predominantly peripheral symptoms - Must meet both of the following: 1) have an inadequate response or intolerance to either Enbrel or Humira, and 2) have an inadequate response to at least an 8-week maximum tolerated dose trial of at least 1 nonbiologic DMARD [Disease-modifying antirheumatic drug] 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 nonsteroidal anti-inflammatory drugs (NSAIDs). For plaque psoriasis - More than 10% BSA [Body surface area] 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 [methotrexate], acitretin) unless contraindicated or intolerant to such therapies. Crohn's disease - Must meet both of the following: 1) have an inadequate response to at least a 60-day trial of 1 conventional therapy (e. g. , corticosteroids, sulfasalazine, azathioprine, mesalamine) unless Page 107 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP contraindicated or intolerant to such therapy, and 2) have an inadequate response or intolerance to either Humira or Cimzia. 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 N/A Coverage Duration Initial: 3 months for Crohn's disease and UC [Ulcerative colitis], plan year for all others. Renewal: plan year. Other Criteria For continuation of therapy, patient's condition must have improved or stabilized. Page 108 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP REVATIO Affected 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 [Pulmonary Arterial Hypertension] been confirmed by right heart catheterization. If patient is an infant, PAH [Pulmonary Arterial Hypertension] diagnosed by Doppler echocardiogram. The patient has had an inadequate response or intolerance to Adcirca. Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration Plan Year. Other Criteria N/A Page 109 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP REVLIMID Affected Drugs REVLIMID® Covered Uses All FDA approved indications not otherwise excluded from Part D. 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 [Myelodysplastic syndrome] 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 N/A Prescriber Restrictions N/A Coverage Duration Plan Year. Page 110 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP 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. Page 111 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP RIBAVIRIN Affected 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 Prior to initiating therapy, detectable levels of HCV RNA in the serum. Must use in combination with interferon. For retreatment: patient must have nonresponse or relapse with prior HCV therapy. Allow only one time retreatment with pegylated interferon and ribavirin OR Infergen and ribavirin. 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 N/A Prescriber Restrictions ID specialist, gastroenterologist, or oncologist. Coverage Duration 12 weeks to a total 72 weeks depending on genotype and initial vs. renewal therapy. Page 112 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP Other Criteria Patient has been instructed to practice effective contraception during therapy and for six months after stopping ribavirin therapy. Page 113 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP RISPERDAL CONSTA Affected Drugs RISPERDAL CONSTA® Covered Uses All FDA approved indications not otherwise excluded from Part D. Exclusion Criteria Dementia-related psychosis. Required Medical Information A. The patient has a history of non-compliance or refuses to utilize oral medications. B. The patient must have history of 3 test doses of oral risperidone. C. If the patient is increasing the dose of Risperdal Consta they must have a history of two prior injections. Age Restrictions N/A Prescriber Restrictions Psychiatrist or receiving input from psychiatry practice. Coverage Duration Plan Year. Other Criteria N/A Page 114 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP RITUXAN Affected Drugs RITUXAN® Covered Uses All FDA approved indications not otherwise excluded from Part D. Exclusion Criteria History of severe skin or infusion reaction with Rituxan that cannot be appropriately managed, use in combination with another biologic agent. Required Medical Information Chart notes showing pharmacological treatments and the severity of rheumatoid arthritis must be moderate to severe. Evidence of Methotrexate treatment and inadequate response to 1 or more TNF antagonist Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration Plan Year. Other Criteria Monitored for pulmonary toxicity. Page 115 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP SABRIL Affected 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). For continuation of therapy, patient's vision will be assessed by an ophthalmologist every 3 months (except for patients who have blindness). 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 N/A 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. Page 116 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP SANCUSO Affected Drugs SANCUSO® Covered Uses All FDA approved indications not otherwise excluded from Part D. Exclusion Criteria N/A Required Medical Information Documentation showing that the patient has had a previous trial/failure to any oral therapy. Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration Plan Year. Other Criteria N/A Page 117 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP SANDOSTATIN LAR Affected Drugs SANDOSTATIN LAR® Covered Uses All FDA approved indications not otherwise excluded from Part D. Exclusion Criteria N/A 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 N/A Prescriber Restrictions N/A Coverage Duration Plan Year. Other Criteria N/A Page 118 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP SOMATULINE DEPOT Affected Drugs SOMATULINE DEPOT® Covered Uses All FDA approved indications not otherwise excluded from Part D. Exclusion Criteria N/A Required Medical Information N/A Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration Plan Year. Other Criteria N/A Page 119 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP SOMAVERT Affected Drugs SOMAVERT® Covered Uses All FDA approved indications not otherwise excluded from Part D. Exclusion Criteria IV administration of Somavert, concomitant use of Sandostatin or Somatuline. Required Medical Information Diagnosis of acromegaly was confirmed by an elevated IGF-1 level or elevated GH [growth hormone] level with a glucose tolerance test. Patient has tried and failed at least a 3 month trial of Sandostatin or Somatuline. For renewal, reduction in IGF-1 level from baseline. Age Restrictions N/A Prescriber Restrictions Endocrinologist. Coverage Duration Plan Year. Other Criteria N/A Page 120 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP SPRYCEL Affected Drugs SPRYCEL® Covered Uses All FDA approved indications not otherwise excluded from Part D. Exclusion Criteria N/A 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 [Chronic Myeloid Leukemia], patient meets one of the following: 1) newly diagnosed in chronic phase, 2) resistance or intolerance to imatinib, 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 N/A Coverage Duration Plan Year. Other Criteria N/A Page 121 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP STRATTERA Affected 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 N/A Age Restrictions 6 years of age and older. Prescriber Restrictions N/A Coverage Duration Plan Year. Other Criteria Monitor for suicidality, clinical worsening, changes in behavior, blood pressure changes, heart rate changes, liver injury. Page 122 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP SUTENT Affected Drugs SUTENT® Covered Uses All FDA approved indications not otherwise excluded from Part D. Exclusion Criteria Clinical manifestations of congestive heart failure. Required Medical Information For gastrointestinal stromal tumor (GIST), disease progression while on an at least 30-day regimen of Gleevec or intolerance to Gleevec is required. LFT monitoring at initiation of therapy and throughout treatment. Age Restrictions N/A Prescriber Restrictions Oncologist. 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. Page 123 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP SYMLIN Affected 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 N/A Age Restrictions N/A Prescriber Restrictions N/A 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. Page 124 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP TARCEVA Affected Drugs TARCEVA® Covered Uses All FDA approved indications not otherwise excluded from Part D. Exclusion Criteria N/A 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 N/A Prescriber Restrictions N/A Coverage Duration Plan Year. Other Criteria N/A Page 125 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP TARGRETIN Affected 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 N/A Prescriber Restrictions N/A Coverage Duration Plan Year. Other Criteria Patient has been instructed on the importance of and proper utilization of contraception. Page 126 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP TASIGNA Affected Drugs TASIGNA® Covered Uses All FDA approved indications not otherwise excluded from Part D. 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 [Chronic Myeloid Leukemia], patient meets one of the following: 1) newly diagnosed in chronic phase, 2) resistance to imatinib, 3) intolerance/toxicity to imatinib or dasatinib, or 4) relapse after stem cell transplant. Age Restrictions 18 years of age and older. Prescriber Restrictions N/A 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. Page 127 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP TAZORAC Affected Drugs TAZORAC® Covered Uses All FDA approved indications not otherwise excluded from Part D. Exclusion Criteria N/A 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 N/A Prescriber Restrictions N/A 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. Page 128 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP TESTOSTERONES Affected Drugs ANDRODERM® TESTIM® Covered Uses All FDA approved indications not otherwise excluded from Part D. Exclusion Criteria Female, prostate cancer, breast 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 N/A Prescriber Restrictions N/A Coverage Duration Plan Year. Other Criteria N/A Page 129 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP THALOMID Affected Drugs THALOMID® Covered Uses All FDA approved indications not otherwise excluded from Part D. 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 N/A Prescriber Restrictions N/A 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. Page 130 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP THIORIDAZINE Affected Drugs THIORIDAZINE HCL 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 N/A Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration Plan Year. Other Criteria N/A Page 131 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP TOPICAL IMMUNOSUPPRESSANT Affected Drugs ELIDEL® PROTOPIC® Covered Uses All FDA approved indications not otherwise excluded from Part D. Exclusion Criteria N/A 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 two 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 N/A Coverage Duration Plan Year. Other Criteria N/A Page 132 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP TOPICAL-ULCERS Affected 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 relief E. AND the ulcer must be less than 10 cm2 in size. Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration 10 weeks. Other Criteria N/A Page 133 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP TRACLEER Affected 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 [Pulmonary Arterial Hypertension] confirmed by right heart catheterization. NYHA Class II-IV symptoms. Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration Plan Year. Other Criteria Female patients of childbearing potential must use more than one method of contraception concurrently. Page 134 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP TYKERB Affected Drugs TYKERB® Covered Uses All FDA approved indications not otherwise excluded from Part D. Exclusion Criteria N/A 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 N/A Prescriber Restrictions N/A Coverage Duration Plan Year. Other Criteria N/A Page 135 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP TYZEKA Affected 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-nave 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 (+ or -) serological marker 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 HBeAgnegative 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 has been tested for HIV and is negative. F. AND 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 aminotransferases. G. AND the patient is not receiving duplicate therapy that includes Baraclude, Epivir and/or Intron A. H. 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 and 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. Page 136 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP Coverage Duration Plan Year. Other Criteria N/A Page 137 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP VIMPAT Affected Drugs VIMPAT® Covered Uses All FDA approved indications not otherwise excluded from Part D. Exclusion Criteria N/A Required Medical Information A. The patient will receive Vimpat as an adjunctive anticonvulsant for the treatment of partial onset seizures. B. The patient had a previous or present trial/failure/contraindication to two or more of the following: carbamazepine, divalproex, ethosuximide, ethotoin, gabapentin, lamotrigine, levetiracetam, methsuximide, oxcarbazepine, phenytoin, phenobarbital, pregabalin, rufinamide, tiagabine, topiramate, valproic acid or zonisamide. Age Restrictions 17 years of age and older. Prescriber Restrictions N/A Coverage Duration Plan Year. Other Criteria N/A Page 138 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP VOTRIENT Affected Drugs VOTRIENT® Covered Uses All FDA approved indications not otherwise excluded from Part D. Exclusion Criteria Alanine transaminase (ALT) greater than 3 times the upper limit of normal (ULN) and bilirubin greater than 2 times the ULN. Required Medical Information N/A Age Restrictions N/A Prescriber Restrictions Oncologist. Coverage Duration Plan Year. Other Criteria N/A Page 139 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP VPRIV Affected 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 N/A Prescriber Restrictions N/A Coverage Duration Plan Year. Other Criteria N/A Page 140 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP XENAZINE Affected 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 N/A Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration Plan Year. Other Criteria N/A Page 141 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP XIFAXAN Affected Drugs XIFAXAN® Covered Uses All FDA approved indications not otherwise excluded from Part D. Exclusion Criteria Hypersensitivity reaction to rifamycin antimicrobial agents. For hepatic encephalopathy, Xifaxan exceeding the recommended dose of two 550mg tablets daily. Required Medical Information N/A Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration Hepatic encephalopathy-6 months. Other Criteria N/A Page 142 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP XOLAIR Affected Drugs XOLAIR® Covered Uses All FDA approved indications not otherwise excluded from Part D. Exclusion Criteria N/A Required Medical Information N/A 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. Page 143 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP XYREM Affected 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 N/A Prescriber Restrictions N/A Coverage Duration 3 months. Other Criteria N/A Page 144 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP ZAVESCA Affected 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 bglucocerebrosidase 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 N/A Coverage Duration Plan Year. Other Criteria N/A Page 145 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP INDEX ACETYLCYSTEINE, 34 ACTEMRA®, 20 ACTIMMUNE®, 21 ADAGEN®, 22 ADCIRCA®, 23 ADRIAMYCIN, 34 AFINITOR®, 24 ALBUTEROL SULFATE, 34 ALDURAZYME®, 25 ALIMTA®, 34 AMIFOSTINE, 34 AMINOSYN II 3.5% M-DEXTROSE 5%®, 34 AMINOSYN II 3.5%-DEXTROSE 25%®, 34 AMINOSYN II 3.5%-DEXTROSE 5%®, 34 AMINOSYN II 4.25%-DEXTROSE 25%®, 34 AMINOSYN II 5% IN 25% DEXTROSE®, 34 AMINOSYN II IN DEXTROSE®, 34 AMINOSYN II WITH LYTES-CA-DW®, 34 AMINOSYN II®, 34 AMINOSYN M®, 34 AMINOSYN®, 34 AMINOSYN-HBC®, 34 AMINOSYN-HF®, 34 AMINOSYN-PF®, 34 AMIODARONE HCL, 34 AMPHETAMINE SALT COMBO, 27 AMPHOTERICIN B, 34 AMPYRA®, 28 ANADROL-50®, 29 ANAGRELIDE HCL, 30 ANDRODERM®, 128 ANDROXY®, 94 ARALAST NP®, 26 ARCALYST®, 31 ASTRAMORPH-PF®, 34 AVASTIN®, 34 AVONEX ADMINISTRATION PACK®, 33 AVONEX®, 33 AZASAN®, 34 AZATHIOPRINE, 34 AZATHIOPRINE SODIUM, 34 BANZEL®, 39 BICNU®, 34 BLEOMYCIN SULFATE, 34 BUDESONIDE, 34 BUPRENORPHINE HCL, 40 BUSULFEX®, 34 BYETTA®, 41 CALCITRIOL, 34 CAMPATH®, 34 CAMPRAL®, 42 CARBOPLATIN, 34 CARISOPRODOL, 65 CAYSTON®, 43 CELLCEPT®, 35 CEREZYME®, 44 CHANTIX®, 45 CHLORZOXAZONE, 65 CHORIONIC GONADOTROPIN, 60 Page 146 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP CIMZIA®, 46 CISPLATIN, 35 CLADRIBINE, 35 CLINIMIX E®, 35 CLINIMIX®, 35 CLINISOL®, 35 COLISTIMETHATE SODIUM, 35 COPAXONE®, 47 COSMEGEN®, 35 CROMOLYN SODIUM, 35 CUBICIN®, 35 CYCLOBENZAPRINE HCL, 65 CYCLOPHOSPHAMIDE, 35 CYCLOSPORINE, 35 CYCLOSPORINE MODIFIED, 35 CYPROHEPTADINE HCL, 65 CYTARABINE, 35 DACARBAZINE, 35 DAUNORUBICIN HCL, 35 DEPO-PROVERA®, 35 DEXRAZOXANE, 35 DEXTROAMPHETAMINE SULFATE, 27 DICYCLOMINE HCL, 65 DIPHENOXYLATE-ATROPINE, 65 DIPHTHERIA-TETANUS TOXOID®, 35 DIPYRIDAMOLE, 65 DOXIL®, 35 DOXORUBICIN HCL, 35 DRONABINOL, 48 DURAMORPH®, 35 ELAPRASE®, 50 ELIDEL®, 131 ELITEK®, 35 ELSPAR®, 35 EMEND®, 35 EMSAM®, 51 ENGERIX-B®, 35 EPIRUBICIN HCL, 35 EPLERENONE, 52 ESTROPIPATE, 65 ETOPOSIDE, 35 EXJADE®, 54 EXTAVIA®, 55 FABRAZYME®, 56 FASLODEX®, 35 FAZACLO®, 32 FENTANYL, 57 FENTANYL CITRATE, 35, 93 FLUDARABINE PHOSPHATE®, 35 FLUOROURACIL, 35 FORTEO®, 96 FREAMINE III WITH ELECTROLYTES®, 35 FREAMINE III®, 35 GAMASTAN S-D®, 35 GAMMAGARD LIQUID®, 74 GAMUNEX®, 74 GANCICLOVIR SODIUM, 36 GEMZAR®, 36 GENGRAF, 36 GILENYA®, 58 GLEEVEC®, 59 GRANISETRON HCL, 36 HEPARIN SODIUM, 36 HEPARIN SODIUM IN 0.45% NACL, 36 HEPARIN SODIUM IN 0.9% NACL, 36 HEPARIN SODIUM IN 5% DEXTROSE, 36 Page 147 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP HEPATAMINE®, 36 HEPATASOL®, 36 HEPSERA®, 63 HERCEPTIN®, 36 HUMIRA®, 67 HYDROMORPHONE HCL, 36 HYDROXYZINE HCL, 65 HYDROXYZINE PAMOATE, 65 IDARUBICIN HCL, 36 IFEX®, 36 IFOSFAMIDE, 36 IFOSFAMIDE-MESNA, 36 INCRELEX®, 69 INFERGEN®, 70 INTRALIPID®, 36 INTRON A®, 36 INVEGA SUSTENNA®, 71 IPRATROPIUM BROMIDE, 36 IPRATROPIUM-ALBUTEROL, 36 IRINOTECAN HCL, 36 ISTODAX®, 36 ITRACONAZOLE, 72 KUVAN®, 75 LETAIRIS®, 76 LEUCOVORIN CALCIUM, 36 LEUKINE®, 77 LEUPROLIDE ACETATE, 80 LEVALBUTEROL CONCENTRATE, 36 LEVOCARNITINE, 36 LIDODERM®, 79 LIPOSYN II®, 36 LIPOSYN III, 36 LUPRON DEPOT®, 80 LUPRON DEPOT-PED®, 80 MELPHALAN HCL, 36 MESNA, 36 METADATE ER, 82 METAXALONE, 65 METHOCARBAMOL, 65 METHOTREXATE, 36 METHYLIN, 82 METHYLPHENIDATE HCL, 82 METHYLPHENIDATE SR, 82 MIACALCIN®, 36 MITOMYCIN, 36 MITOXANTRONE HCL, 36 MORPHINE SULFATE, 36 MOZOBIL®, 83 MUSTARGEN®, 36 MYCOPHENOLATE MOFETIL, 37 MYFORTIC®, 37 MYOZYME®, 84 NAGLAZYME®, 85 NEORAL®, 37 NEPHRAMINE®, 37 NEUMEGA®, 37 NEUPOGEN®, 86 NEXAVAR®, 88 NICOTROL NS®, 89 NICOTROL®, 89 NORDITROPIN FLEXPRO®, 61 NORDITROPIN NORDIFLEX®, 61 NOVAREL, 60 NUEDEXTA®, 90 NUVIGIL®, 91 OCTREOTIDE ACETATE, 92 ONDANSETRON HCL, 37 ONDANSETRON ODT, 37 Page 148 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP ONTAK®, 37 ORFADIN®, 95 ORPHENADRINE CITRATE, 65 ORPHENADRINE COMPOUND, 65 ORPHENADRINE COMPOUND FORTE, 65 ORTHO-EST®, 65 OXALIPLATIN, 37 OXANDROLONE, 29 OXSORALEN-ULTRA®, 97 PACLITAXEL, 37 PEGASYS®, 98 PEGINTRON REDIPEN®, 100 PEGINTRON®, 100 PENTOSTATIN, 37 PERFOROMIST®, 37 PHENADOZ, 65 PHOTOFRIN®, 37 PREGNYL®, 60 PREMASOL®, 37 PROCALAMINE®, 37 PROCRIT®, 53 PROGRAF®, 37 PROLEUKIN®, 37 PROMACTA®, 101 PROMETHAZINE HCL, 65 PROMETHAZINE VC, 65 PROMETHEGAN, 65 PROSOL®, 37 PROTOPIC®, 131 PULMOZYME®, 37 RANEXA®, 103 RAPAMUNE®, 37 REBETOL®, 111 REBIF®, 104 RECOMBIVAX HB®, 37 REGRANEX®, 132 RELISTOR®, 105 REMICADE®, 106 REMODULIN®, 37 REVATIO®, 108 REVLIMID®, 109 RIBAPAK, 111 RIBASPHERE, 111 RIBAVIRIN, 111 RISPERDAL CONSTA®, 113 RITUXAN®, 114 SABRIL®, 115 SANCUSO®, 116 SANDIMMUNE®, 37 SANDOSTATIN LAR®, 117 SOMATULINE DEPOT®, 118 SOMAVERT®, 119 SPRYCEL®, 120 STRATTERA®, 121 SUBOXONE®, 40 SUTENT®, 122 SYMLIN®, 123 SYMLINPEN 120®, 123 SYMLINPEN 60®, 123 TACROLIMUS, 37 TARCEVA®, 124 TARGRETIN®, 125 TASIGNA®, 126 TAXOTERE®, 37 TAZORAC®, 127 TESTIM®, 128 Page 149 of 150 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP TETANUS DIPHTHERIA TOXOIDS®, 37 TETANUS TOXOID ADSORBED, 37 TETANUS-DIPHTERIA-DECAVAC®, 37 THALOMID®, 129 THIORIDAZINE HCL, 130 TOBI®, 37 TOPOSAR, 37 TOPOTECAN HCL, 37 TPN ELECTROLYTES®, 37 TRACLEER®, 133 TRANSDERM-SCOP®, 65 TRAVASOL®, 37 TREANDA®, 37 TRELSTAR®, 37 TRIMETHOBENZAMIDE HCL, 65 TRISENOX®, 38 TROPHAMINE®, 38 TYKERB®, 134 TYZEKA®, 135 VANCOMYCIN HCL, 38 VELCADE®, 38 VIDAZA®, 38 VIMPAT®, 137 VINBLASTINE SULFATE, 38 VINCRISTINE SULFATE, 38 VINORELBINE TARTRATE, 38 VOTRIENT®, 138 VPRIV®, 139 XENAZINE®, 140 XIFAXAN®, 141 XOLAIR®, 142 XYREM®, 143 ZAVESCA®, 144 ZEMPLAR®, 38 ZOMETA®, 38 ZORTRESS®, 38 GuildNet Gold HMO-POS SNP and GuildNet Health Advantage HMO-POS SNP are Coordinated Care plans with a Medicare Advantage contract and a contract with the New York Medicaid program. Updated 09/2011 Page 150 of 150
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