Part DClinical Prior Approval Drug List
User Manual: PartDClinicalPriorApprovalDrugList
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GuildNet Gold HMO-POS SNP 2015 Prior Authorization (PA) Criteria Certain drugs require prior authorization from GuildNet Gold Medicare Plan. This means that your doctor must contact us to get approval before prescribing the drug to you. If your doctor does not get prior approval, the drug may not be covered. This list also includes drugs that may be covered under Medicare Part B or Part D depending on how the drugs are used or administered. If your drug is on this list, your doctor should call us and to provide information describing the use and administration of the drug so we can advise on whether the drug will be covered. To see if your drug is on the list, refer to the index located at the end of this document for the medication you are looking for. ACTHAR Products Affected Acthar H.P. PA Criteria Criteria Details Covered Uses All FDA-approved indications not otherwise excluded from Part D. Exclusion Criteria Use in patients with multiple sclerosis (MS) as pulse therapy on a monthly basis. Required Medical Information MS exacerbation, history of corticosteroid use. Age Restrictions N/A Prescriber Restrictions Infantile spasms, prescribed by or in consultation with a neurologist or an epileptologist. MS exacerbation, prescribed by or in consultation with a neurologist or physician that specializes in the treatment of MS. Coverage Duration Infantile spasms, Plan Year. MS exacerbation, approve 1 month. Other Criteria For MS exacerbation, approve if the patient cannot use high-dose IV corticosteroids because IV access is not possible or if the patient has tried high-dose corticosteroids administered IV for an acute MS exacerbation and has experienced a severe or limiting adverse effect. Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 1 ACTIMMUNE Products Affected Actimmune PA Criteria Criteria Details 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 Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 2 ADCIRCA Products Affected Adcirca PA Criteria Criteria Details Covered Uses All FDA approved indications not otherwise excluded from Part D Exclusion Criteria Nitrate therapy Required Medical Information PAH been confirmed by right heart catheterization. Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration Plan Year Other Criteria N/A Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 3 AFINITOR Products Affected Afinitor Disperz Afinitor PA Criteria Criteria Details 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 Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 4 AMPYRA Products Affected Ampyra PA Criteria Criteria Details Covered Uses All FDA-approved indications not otherwise excluded from Part D. Plus patient already started on dalfampridine extended-release for Multiple Sclerosis (MS). Exclusion Criteria N/A Required Medical Information N/A Age Restrictions N/A Prescriber Restrictions MS. If prescribed by, or in consultation with, a neurologist or MS specialist. Coverage Duration Plan Year Other Criteria N/A Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 5 ANTICONVULSANTS Products Affected Qudexy XR topiramate oral capsule, sprinkle topiramate oral tablet zonisamide PA Criteria Criteria Details 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 Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 6 ARCALYST Products Affected Arcalyst PA Criteria Criteria Details Covered Uses All FDA-approved indications not otherwise excluded from Part D. Plus patient already started on rilonacept for Muckle Wells Syndrome (MWS) or Familial Cold Autoinflammatory Syndrome (FCAS). Exclusion Criteria Rilonacept should not be given in combination with biologic therapy (e.g. tumor necrosis factor (TNF) blocking agents (eg, adalimumab, certolizumab pegol, etanercept, golimumab, infliximab), anakinra, or canakinumab). Required Medical Information N/A Age Restrictions Initial tx CAPS-Greater than or equal to 12 years of age. Prescriber Restrictions Initial tx CAPS-prescribed by, or in consultation with, a rheumatologist, geneticist, or dermatologist. Coverage Duration Initial approval of MWS/FCAS, 2 mos. Subsequent auth for Plan Year if pt had a response. Other Criteria CAPS renewal - approve if they have had a response and are continuing therapy to maintain response/remission. Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 7 AVONEX Products Affected Avonex intramuscular syringe kit Avonex intramuscular kit PA Criteria Criteria Details 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 Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 8 BOSULIF Products Affected Bosulif PA Criteria Criteria Details Covered Uses All FDA approved indications not otherwise excluded from Part D. Plus patients already started on Bosulif for a Covered Use. Exclusion Criteria N/A Required Medical Information Diagnosis for which Bosulif is being used. For chronic myelogenous leukemia (CML), the Philadelphia chromosome (Ph) status of the leukemia must be reported. For CML, prior therapies tried must be reported to confirm resistance or intolerance. Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration Plan Year Other Criteria For CML, patient must have Ph-positive CML and must have resistance or intolerance to prior therapy for approval. Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 9 CHORIONIC GONADOTROPINS (HCG) Products Affected chorionic gonadotropin, human Novarel Pregnyl PA Criteria Criteria Details Covered Uses All medically accepted 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 Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 10 CIALIS Products Affected Cialis oral tablet 2.5 mg, 5 mg PA Criteria Criteria Details Covered Uses All FDA-approved indications not otherwise excluded from Part D. Exclusion Criteria N/A Required Medical Information Indication for which tadalafil is being prescribed. Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration Plan Year Other Criteria Benign prostatic hyperplasia (BPH), after confirmation that tadalafil is being prescribed to treat the signs and symptoms of BPH and not for the treatment of erectile dysfunction (ED) and after a trial of an alpha-1 blocker (eg, doxazosin [Cardura XL], terazosin, tamsulosin [Flomax], alfuzosin extended-release [UroXatral]) or 5 alpha reductase inhibitor (eg, finasteride, dutasteride [Avodart]). Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 11 CINRYZE Products Affected Cinryze PA Criteria Criteria Details Covered Uses All FDA-approved indications not otherwise excluded from Part D. Plus for the acute treatment of Hereditary Angioedema (HAE). Exclusion Criteria N/A Required Medical Information N/A Age Restrictions N/A Prescriber Restrictions Must be prescribed by, or in consultation with, an allergist/immunologist or a physician that specializes in the treatment of HAE or related disorders. Coverage Duration Plan Year Other Criteria N/A Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 12 COMETRIQ Products Affected Cometriq PA Criteria Criteria Details Covered Uses All FDA approved indications not otherwise excluded from Part D. Plus patients already started on Cometriq for a Covered Use. Exclusion Criteria N/A Required Medical Information Diagnosis of progressive, metastatic medullary thyroid cancer. Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration Plan Year Other Criteria N/A Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 13 COPAXONE Products Affected Copaxone subcutaneous syringe kit Copaxone subcutaneous syringe 40 mg/mL PA Criteria Criteria Details 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. Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 14 DEMSER Products Affected Demser PA Criteria Criteria Details 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 Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 15 DICLOFENAC GEL Products Affected diclofenac sodium topical gel PA Criteria Criteria Details 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 Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 16 EGRIFTA Products Affected Egrifta subcutaneous recon soln 2 mg PA Criteria Criteria Details Covered Uses All FDA approved indications not otherwise excluded from Part D. Exclusion Criteria N/A Required Medical Information Diagnosis. Age Restrictions Adults Prescriber Restrictions Prescribed by or in consultation with an endocrinologist or a physician specializing in the treament of HIV (eg, infectious disease, oncology). Coverage Duration Plan Year Other Criteria HIV-infected adult patients (18 years of age or older) with lipodystrophy AND Egrifta is being used to reduce excessive abdominal fat Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 17 ERIVEDGE Products Affected Erivedge PA Criteria Criteria Details Covered Uses All FDA-approved indications not otherwise excluded from Part D. Plus, patient already started on Erivedge for a covered use. Exclusion Criteria N/A Required Medical Information N/A Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration Plan Year Other Criteria Locally advanced basal cell carcinoma (LABCC), approve if the patient's BCC has recurred following surgery or the patient is not a candidate for surgery or radiation therapy. Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 18 ERWINAZE Products Affected Erwinaze PA Criteria Criteria Details Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information Documentation of hypersensitivity to Escherichia coli-derived asparaginase as a component of a multi-agent chemotherapeutic regimen. Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration Plan Year Other Criteria N/A Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 19 EXTAVIA Products Affected Extavia subcutaneous kit PA Criteria Criteria Details 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. Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 20 GILOTRIF Products Affected Gilotrif PA Criteria Criteria Details Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information Documentation of metastatic non-small cell lung cancer (NSCLC) whose tumors have epidermal growth factor receptor (EGFR) exon 19 deletions or exon 21 (L858R) substitution mutations as detected by an FDAapproved test Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration Plan Year Other Criteria N/A Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 21 GLEEVEC Products Affected Gleevec oral tablet 100 mg, 400 mg PA Criteria Criteria Details 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, 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 Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 22 GROWTH HORMONE Products Affected Norditropin Nordiflex Norditropin FlexPro PA Criteria Criteria Details Covered Uses All FDA approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information For pediatric GHD in neonate with hypoglycemia: patient has a randomly assessed GH level less than 20 ng/mL, other causes of hypoglycemia have been ruled out, and other treatments have been ineffective. For all pediatric patients: patients have short stature or slow growth velocity and have been evaluated for other causes of growth failure. For pediatric GHD, patient has delayed bone age. For pediatric GHD without pituitary disease, patient failed 2 stimulation tests. For pediatric GHD with a pituitary or CNS disorder, patient has clinical evidence of GHD and low IGF-1/IGFBP3. For TS and SHOX patients: diagnosis confirmed by genetic testing. For CRI patients: metabolic, endocrine and nutritional abnormalities have been treated or stabilized and patient has not had a kidney transplant. For SGA: patient has a low birth weight or length for gestational age. For ISS: pediatric GHD has been ruled out with one stimulation test. For adult GHD, patient was assessed for other causes of GHD-like symptoms. For adult GHD without pituitary disease, patient failed 2 stimulation tests. For adult GHD with at least 3 pituitary hormone deficiencies (PHD) or panhypopituitarism: have a low IGF-1. For adult GHD with less than 3 PHD, low IGF-1 and failed one stimulation test. For renewal for pediatric patients, growing more than 2 cm per year and for PWS only: improved body composition. For renewal for adult patients: patient has seen clinical improvement and IGF-1 will be monitored. Age Restrictions For Turner syndrome and SGA, 2 years of age and older. For Noonan syndrome and SHOX, 3 years of age and older. Prescriber Restrictions Endocrinologist, Pediatric Nephrologist, Gastroenterologist, Nutritional Support Specialist, Infectious Disease Specialist Coverage Duration Plan Year Other Criteria N/A Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 23 HRM Products Affected benztropine oral butalbital-acetaminop-caf-cod oral capsule 50325-40-30 mg clemastine oral syrup clemastine oral tablet 2.68 mg cyclobenzaprine oral tablet cyproheptadine eszopiclone Lanoxin oral meprobamate metaxalone methyldopa-hydrochlorothiazide nitrofurantoin macrocrystal oral capsule 50 mg nitrofurantoin monohyd/m-cryst reserpine PA Criteria Criteria Details Covered Uses All FDA approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information N/A Age Restrictions Patients aged less than 65 years, approve. Patients aged 65 years and older, other criteria apply. Prescriber Restrictions N/A Coverage Duration Plan Year Other Criteria Approve when the provider has assessed the risk versus benefit in using this High Risk Medication (HRM) in the patient and has confirmed that they would still like to initiate or continue therapy Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 24 HRM - BENZODIAZEPINES Products Affected alprazolam Lorazepam Intensol lorazepam oral tablet oxazepam temazepam PA Criteria Criteria Details Covered Uses All medically accepted indications not otherwise excluded from Part D. Exclusion Criteria N/A Required Medical Information N/A Age Restrictions Patients aged less than 65 years, approve. Patients aged 65 years and older, other criteria apply. Prescriber Restrictions N/A Coverage Duration Procedure-related sedation = 1mo. All other conditions = Plan Year. Other Criteria All medically accepted indications other than Restless Leg Syndrome and insomnia, authorize use. Restless Leg Syndrome, approve clonazepam or temazepam if the patient has tried one other agent for this condition (eg, ropinirole, pramipexole, carbidopa-levodopa [immediate-release or extended-release]). Insomnia, approve lorazepam, oxazepam, or temazepam if the patient has had a trial with two of the following: ramelteon, trazodone, doxepin 3mg or 6 mg, eszopiclone, zolpidem, or zaleplon. Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 25 HRM BENZODIAZEPINES/ANTICONVULSANTS Products Affected clonazepam clorazepate dipotassium Diazepam Intensol diazepam oral solution 5 mg/5 mL diazepam oral tablet diazepam rectal PA Criteria Criteria Details Covered Uses All FDA approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information N/A Age Restrictions Patients aged less than 65 years, approve. Patients aged 65 years and older, other criteria apply. Prescriber Restrictions N/A Coverage Duration Plan Year Other Criteria Approve when the provider has assessed the risk versus benefit in using this High Risk Medication (HRM) in the patient and has confirmed that they would still like to initiate or continue therapy Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 26 HRM PD Products Affected Surmontil estradiol oral PA Criteria Criteria Details Covered Uses All FDA-approved indications not otherwise excluded from Part D. Exclusion Criteria N/A Required Medical Information N/A Age Restrictions Patients aged less than 65 years, approve. Patients aged 65 years and older, other criteria apply. Prescriber Restrictions N/A Coverage Duration Plan Year Other Criteria Approve when the provider has assessed the risk versus benefit in using this High Risk Medication (HRM) in the patient and has confirmed that they would still like to initiate or continue therapy Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 27 ILARIS Products Affected Ilaris (PF) PA Criteria Criteria Details Covered Uses All FDA-approved indications not otherwise excluded from Part D. Exclusion Criteria When used in combination with concurrent biologic therapy (e.g.TNF antagonists, etanercept, adalimumab, certolizumab pegol, golimumab, infliximab), anakinra, or rilonacept. Required Medical Information N/A Age Restrictions CAPS-4 years of age and older. SJIA-2 years of age and older. Prescriber Restrictions CAPS/MWS/FCAS initial- Prescribed by or in consultation with a rheumatologist, geneticist, or dermatologist. SJIA initial- prescribed by or in consultation with a rheumatologist Coverage Duration CAPS/MWS/FCAS-Initial 2 mos, renewal 12 mos. SJIA initial-2 mos, renewal 12 mos Other Criteria For renewal of CAPS/MWS/FCAS - after pt had been started on Ilaris, approve if the pt had a response to therapy as determined by prescribing physician and the pt is continuing therapy to maintain a response/remission. For treatment of SJIA, initial therapy approve if the pt meets one of the following 1. has tried at least 2 other biologics for SJIA (tocilizumab, abatacet, TNF antagonists (e.g. etanercept, adalimumab, infliximab) OR 2. pt has features of poor prognosis (e.g. arthritis of the hip, radiographic damage, 6-month duration of significant active systemic diease, defined by fever, elevated inflammatory markers, or requirement for treatment with systemic glucocorticoids AND tried Actemra or Kineret. SJIA renewal approve if it patient was already started on Ilaris and the pt had a response (e.g. resolution of fever, improvement in limitions of motion, less joint pain or tenderness, decreased duration of morning stiffness or fatigue, improved function or ADLs, reduced dosage of CS) and the pt is continuing therapy to maintain response/remission. Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 28 IMBRUVICA Products Affected Imbruvica PA Criteria Criteria Details Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information History of prior treatment with RCHOP therapy Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration Plan Year Other Criteria N/A Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 29 INLYTA Products Affected Inlyta PA Criteria Criteria Details Covered Uses All FDA-approved indications not otherwise excluded from Part D. Plus, patients already started on Inlyta for a Covered Use. Exclusion Criteria N/A Required Medical Information N/A Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration Plan Year Other Criteria Advanced renal cell carcinoma, approve the patient has failed at least one prior systemic therapy (eg, Torisel, Avastin, Sutent, IFN-alpha, IL-2, Votrient, Nexavar). Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 30 IVIG Products Affected Gammagard Liquid Gamunex-C injection solution 1 gram/10 mL (10 %) PA Criteria Criteria Details Covered Uses All medically accepted 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 Authorization will be for Plan Year. Other Criteria Part B versus D determination per CMS guidance to establish if drug used for PID in pt's home. Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 31 JAKAFI Products Affected Jakafi oral tablet 10 mg, 15 mg, 20 mg, 25 mg, 5 mg PA Criteria Criteria Details Covered Uses All FDA-approved indications not otherwise excluded from Part D. Plus, patients already started on Jakafi for a Covered Use. 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 Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 32 KUVAN Products Affected Kuvan oral tablet,soluble PA Criteria Criteria Details 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. Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 33 LETAIRIS Products Affected Letairis PA Criteria Criteria Details 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 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. Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 34 LEUKINE Products Affected Leukine injection recon soln PA Criteria Criteria Details 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 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 chemotherapyinduced 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 Prescriber Restrictions N/A Coverage Duration 6 months Other Criteria N/A Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 35 LEUPROLIDE Products Affected Eligard Lupron Depot Lupron Depot (3 Month) Lupron Depot (4 Month) Lupron Depot (6 Month) Lupron Depot-Ped intramuscular kit 11.25 mg, 15 mg PA Criteria Criteria Details Covered Uses All FDA-approved indications not otherwise excluded from Part D but specific to the following drugs as follows: Prostate cancer (Lupron Depot [7.5 mg-1mo, 22.5 mg-3-mo, 30 mg-4-mo, 45 mg-6-mo] OR Eligard [7.5 mg-1-mo, 22.5mg-3-mo, 30 mg-4-mo, 45 mg-6-mo]), Endometriosis (Lupron Depot [3.75 mg-1-mo, 11.25 mg-3-mo]), Uterine leiomyomata (Lupron Depot [3.75 mg-1-mo, 11.25 mg-3-mo]), Treatment of central precocious puberty (Lupron Depot Ped [11.25 mg-1-mo, 15 mg-1-mo]). Ovarian cancer (Lupron Depot [7.5 mg-1-mo]). Breast cancer (Lupron Depot [3.75 mg-1-mo, 11.25 mg-3-mo]). Prophylaxis or treatment of uterine bleeding in premenopausal women with hematologic malignancy or prior to bone marrow/stem cell transplantation (BMT/SCT) (Lupron Depot [3.75 mg-1-mo, 7.5 mg-1-mo]). Exclusion Criteria N/A Required Medical Information N/A Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration For abnrml uterine bleeding, uterine leiomyomata,endometriosis-6 mo.All other=Plan Year Other Criteria N/A Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 36 LIDOCAINE PATCH Products Affected lidocaine topical adhesive patch,medicated PA Criteria Criteria Details Covered Uses All FDA-approved indications not otherwise excluded from Part D. Plus diabetic neuropathic pain. 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 Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 37 MEKINIST Products Affected Mekinist PA Criteria Criteria Details Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information Documentation of the detected BRAFV600E or BRAFV600K mutation Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration Plan Year Other Criteria N/A Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 38 NAMENDA Products Affected Namenda XR Namenda oral solution PA Criteria Criteria Details 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 Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 39 NEUPOGEN Products Affected Neupogen injection syringe Neupogen injection solution 480 mcg/1.6 mL PA Criteria Criteria Details 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 Coverage Duration 6 months Other Criteria N/A Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 40 NEUPRO Products Affected Neupro PA Criteria Criteria Details 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 Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 41 NEXAVAR Products Affected Nexavar PA Criteria Criteria Details 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 Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 42 NUVIGIL/PROVIGIL Products Affected Nuvigil oral tablet 150 mg, 250 mg, 50 mg modafinil PA Criteria Criteria Details Covered Uses All FDA-approved indications not otherwise excluded from Part D. Exclusion Criteria N/A Required Medical Information N/A Age Restrictions Patients must be greater than or equal to 17 years of age. Prescriber Restrictions N/A Coverage Duration Plan year Other Criteria Excessive sleepiness due to SWSD if the patient is working at least 5 overnight shifts per month. Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 43 OCTREOTIDE Products Affected octreotide acetate injection solution octreotide acetate injection solution PA Criteria Criteria Details 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 Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 44 OLYSIO Products Affected Olysio PA Criteria Criteria Details Covered Uses All FDA approved indications not otherwise excluded from Part D. Exclusion Criteria N/A Required Medical Information N/A Age Restrictions 18 years or older Prescriber Restrictions Prescribed by or in consultation with a GI, hepatologist, ID, or a liver transplant MD Coverage Duration 12 weeks Other Criteria Genotype 1 - prescribed in combination with PegINF and RBV or in combination with Sovaldi. Has not failed therapy with Olysio or another NS3/4A Protease Inhibitor for HCV (i.e., Incivek or Victrelis). Pts with genotype 1a must NOT have the Q80K polymorphism (unknown Q80K status is not covered). Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 45 ONCASPAR Products Affected Oncaspar PA Criteria Criteria Details 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 Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 46 ONFI Products Affected Onfi oral tablet 10 mg, 20 mg Onfi oral suspension PA Criteria Criteria Details Covered Uses All FDA approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information The patient will receive Onfi for the treatment of seizures associated with Lennox-Gastaut syndrome. Age Restrictions 2 years of age and older Prescriber Restrictions N/A Coverage Duration Plan Year Other Criteria N/A Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 47 PEGINTRON Products Affected PegIntron Redipen PegIntron PA Criteria Criteria Details 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. Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 48 PENICILLAMINE Products Affected Depen Titratabs PA Criteria Criteria Details 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 Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 49 POMALYST Products Affected Pomalyst PA Criteria Criteria Details Covered Uses All FDA approved indications not otherwise excluded from Part D Exclusion Criteria Pregnancy Required Medical Information For active myeloma, patient meets the following: 1) Pomalyst is used after at least two prior therapies or as salvage therapy. 2) Pomalyst may be used with dexamethasone. 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 Pomalyst. Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration Plan Year Other Criteria Male and female patients of child-bearing potential should be instructed on the importance of proper utilization of appropriate contraceptive methods for Pomalyst use. Patients should be monitored for signs and symptoms of thromboembolism. Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 50 PROCRIT Products Affected Procrit injection solution 10,000 unit/mL, 2,000 unit/mL, 20,000 unit/mL, 3,000 unit/mL, 4,000 unit/mL, 40,000 unit/mL PA Criteria Criteria Details Covered Uses All FDA-approved indications not otherwise excluded from Part D worded as anemia associated with chronic renal failure (CRF), including patients on dialysis and not on dialysis, and worded as anemia secondary to myelosuppressive anticancer chemotherapy in solid tumors, multiple myeloma, lymphoma, and lymphocytic leukemia, . Plus anemia in patients with HIV who are receiving zidovudine. Anemic patients (Hb of 13.0 g/dL or less) at high risk for perioperative transfusions (secondary to significant, anticipated blood loss and are scheduled to undergo elective, noncardiac, nonvascular surgery to reduce the need for allogeneic blood transfusions). Additional off-label coverage is provided for Anemia due to myelodysplastic syndrome (MDS), Anemia associated with use of ribavirin therapy for hepatitis C (in combination with interferon or pegylated interferon alfa 2a/2b products with or without the direct-acting antiviral agents Victrelis or Incivek), and Anemia in HIV-infected patients. Exclusion Criteria N/A Required Medical Information Confirmation of adequate iron stores (eg, prescribing information recommends supplemental iron therapy when serum ferritin is less than 100 mcg/L or when serum transferrin saturation is less than 20%).CRF anemia in patients on and not on dialysis.Hemoglobin (Hb) of less than 10.0 g/dL for adults or less than or equal to 11 g/dL for children to start.Hb less than or equal to 11.5 g/dL for adults or 12 g/dL or less for children. Anemia w/myelosuppressive chemotx.pt must be currently receiving myelosuppressive chemo and Hb 10.0 g/dL or less to start.Hb less than or equal to 12.0 g/dL .MDS, approve if Hb is 10 g/dL or less or serum erythropoietin level is 500 mU/mL or less to start. Surgical pts to reduce RBC transfusions - pt is unwilling or unable to donate autologous blood prior to surgery Age Restrictions MDS anemia/HepC anemia = 18 years of age and older Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 51 Prescriber Restrictions MDS anemia, prescribed by or in consultation with, a hematologist or oncologist. Hep C anemia, prescribed by or in consultation with hepatologist, gastroenterologist or infectious disease physician who specializes in the management of hepatitis C. Coverage Duration Anemia w/myelosuppress = 4 mos.Transfus=1 mo.Other= 6mo. HIV + zidovudine = 4 mo Other Criteria Part B versus Part D determination will be made at time of prior authorization review per CMS guidance to establish if the drug prescribed is to be used for an end-stage renal disease (ESRD)-related condition. Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 52 PROMACTA Products Affected Promacta PA Criteria Criteria Details Covered Uses All FDA-approved indications not otherwise excluded from Part D. Thrombocytopenia due to hepatitis C virus (HCV)-related cirrhosis. Exclusion Criteria Use in the management of thrombocytopenia in myelodysplastic syndrome (MDS). Use in combination with Nplate for treatment of thrombocytopenia in patients with chronic immune (idiopathic) thrombocytopenia purpura. Required Medical Information Cause of thrombocytopenia. Thrombocytopenia due to HCV-related cirrhosis, platelet counts. Age Restrictions Adults Prescriber Restrictions Treatment of thrombocytopenia due to chronic immune (idiopathic) thrombocytopenic purpura (ITP), approve if prescribed by, or after consultation with, a hematologist. Treatment of thrombocytopenia due to HCV-related cirrhosis, approve if prescribed by, or after consultation with, either a gastroenterologist, a hepatologist, or a physician who specializes in infectious disease. Coverage Duration Plan Year Other Criteria Thrombocytopenia in patients with chronic immune (idiopathic) thrombocytopenia purpura, approve if the patient has tried corticosteroids or IVIG or has undergone a splenectomy. Treatment of thrombocytopenia due to HCV-related cirrhosis, approve to allow for initiation of antiviral therapy if the patient has low platelet counts (eg, less than 75,000 mm3) and the patient has chronic HCV infection and is a candidate for hepatitis C therapy . Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 53 QUININE Products Affected quinine sulfate PA Criteria Criteria Details 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 Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 54 REBIF Products Affected Rebif Titration Pack Rebif (with albumin) PA Criteria Criteria Details 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 Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 55 REMICADE Products Affected Remicade PA Criteria Criteria Details 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 (e.g., leflunomide, hydroxychloroquine, sulfasalazine) if contraindicated or intolerant to MTX, 3) intolerance or contraindication to at least 2 nonbiologic DMARDs. Psoriatic arthritis with predominantly peripheral symptoms - Must 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 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 affected or has crucial body areas (e.g., feet, hands, face) affected. An inadequate response to at least a 60-day trial of 2 conventional therapies (e.g., phototherapy, calcipotriene, MTX, acitretin) unless contraindicated or intolerant to such therapies. Crohn's disease Must 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 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 Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 56 Coverage Duration Initial: 3 months for Crohn's disease and UC, plan year for all others. Renewal: plan year Other Criteria For continuation of therapy, patient's condition must have improved or stabilized. Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 57 REVATIO Products Affected sildenafil PA Criteria Criteria Details Covered Uses All FDA approved indications not otherwise excluded from Part D Exclusion Criteria Nitrate therapy Required Medical Information Diagnosis of pulmonary arterial hypertension (PAH), (WHO Group 1). PAH been confirmed by right heart catheterization. If patient is an infant, PAH diagnosed by Doppler echocardiogram. Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration Plan Year Other Criteria N/A Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 58 REVLIMID Products Affected Revlimid PA Criteria Criteria Details 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 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 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. Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 59 RIBAVIRIN Products Affected ribavirin oral tablet 200 mg ribavirin oral capsule PA Criteria Criteria Details 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 the end of the plan year depending on genotype and initial vs. renewal therapy. Other Criteria Patient has been instructed to practice effective contraception during therapy and for six months after stopping ribavirin therapy. Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 60 RITUXAN Products Affected Rituxan PA Criteria Criteria Details Covered Uses All medically-accepted indications not otherwise excluded from Part D. Patients already started on Rituxan for a Covered Use. Exclusion Criteria Concurrent use with a biologic agent (TNF alpha antagonists (eg, adalimumab, certolizumab pegol, etanercept, golimumab, infliximab), or anakinra, abatacept, tocilizumab or tofacitinib. Required Medical Information N/A Age Restrictions RA, adults. Prescriber Restrictions Adult with RA (initial course). Prescribed by a rheumatologist or in consultation with a rheumatologist. Coverage Duration RA,1mo. Othr= Plan Year. Other Criteria Adult with RA (initial course), approve if Rituxan is prescribed in combination with methotrexate or another traditional DMARD (eg, leflunomide or sulfasalazine) unless the patient has been shown to be intolerant or has a contraindication to one or more traditional DMARDs AND the patient has tried one of certolizumab pegol, etanercept, adalimumab, infliximab, golimumab (ie, a TNF antagonist) OR if the patient has not yet tried a TNF antagonist, the patient must have a trial with etanercept or adalimumab. Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 61 SABRIL Products Affected Sabril PA Criteria Criteria Details 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 N/A 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 wks, reauth 6 mths. CPS: initial 3 mths, reauth to plan year Other Criteria N/A Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 62 SANDOSTATIN LAR Products Affected Sandostatin LAR Depot PA Criteria Criteria Details 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 Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 63 SIGNIFOR Products Affected Signifor PA Criteria Criteria Details Covered Uses All FDA approved indications not otherwise excluded from Part D. Exclusion Criteria N/A Required Medical Information Diagnosis for which Signifor is being used. Age Restrictions Cushing's, 18 years of age and older. Prescriber Restrictions Initial course, prescribed by or in consultation with an endocrinologist. Coverage Duration Initial therapy, approve for 3 months. Continuation therapy, approve for the plan year. Other Criteria Cushing's disease, approve if according to the prescribing physician the patient is not a candidate for surgery or surgery has not been curative. Patients who have already been started on Signifor for Cushing's disease will be approved if the patient has had a response, as determined by the prescribing physician and the patient is continuing therapy to maintain response. Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 64 SOVALDI Products Affected Sovaldi PA Criteria Criteria Details Covered Uses All FDA-approved indications not otherwise excluded from Part D. Exclusion Criteria prior treatment with Sovaldi Required Medical Information Will not be used in combination use with NS3/4A Protease Inhibitor (i.e., telaprevir, boceprevir) Age Restrictions 18 years or older Prescriber Restrictions Prescribed by or in consultation w/ GI, hepatologist, ID, or a liver transplant MD Coverage Duration 12wk-geno1 triple tx,other.24 wk-geno1 dual tx,geno3/4 rbv only.48 wk geno1,2,3,4 liver trans Other Criteria Geno 1 - prescribed in combination with PegINF and RBV (PR), unless pt can't take INF based on a documented comorbid medical condition (e.g., autoimmune disorder, significant psychiatric disease, seizure disorder) then must be used in combo with RBV OR in combination with Olysio. Geno 2/3 - prescribed in combo with RBV. Geno 4 - prescribed in combo with PegINF/RBV. Geno 1, 2, 3, or 4 awaiting liver transplant has HCC and prescribed in combination with RBV. Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 65 SPRYCEL Products Affected Sprycel oral tablet 100 mg, 140 mg, 20 mg, 50 mg, 70 mg, 80 mg PA Criteria Criteria Details 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, 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 Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 66 STIVARGA Products Affected Stivarga PA Criteria Criteria Details Covered Uses All FDA approved indications not otherwise excluded from Part D. Plus patients already started on Stivarga for a Covered Use. Exclusion Criteria N/A Required Medical Information Diagnosis for which Stivarga is being used. For metastatic colorectal cancer (CRC)and gastrointestinal stromal tumors (GIST), prior therapies tried. For metastatic CRC, KRAS mutation status. Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration Plan Year Other Criteria For metastatic CRC with KRAS mutation, patient must have previously been treated with each of the following for approval: a fluoropyrimidine (eg, Xeloda, 5-FU), oxaliplatin, irinotecan, anti-VEGF therapy (eg, Avastin, Zaltrap). For metastatic CRC with no detected KRAS mutations (ie, KRAS wild-type), patient must have previously been treated with each of the following for approval: a fluoropyrimidine (eg, Xeloda, 5FU), oxaliplatin, irinotecan, anti-VEGF therapy (eg, Avastin, Zaltrap), anti-EGFR therapy (eg, Eribitux, Vectibix). For GIST, patient must have previously been treated with imatinib (Gleevec) and sunitinib (Sutent). Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 67 SUTENT Products Affected Sutent oral capsule 12.5 mg, 25 mg, 50 mg PA Criteria Criteria Details 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. Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 68 SYLATRON Products Affected Sylatron PA Criteria Criteria Details 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 Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 69 SYNAGIS Products Affected Synagis intramuscular solution 50 mg/0.5 mL PA Criteria Criteria Details Covered Uses All FDA-approved indications not otherwise excluded from Part D. Exclusion Criteria N/A Required Medical Information Prophylaxis of Respiratory Syncytial Virus (RSV): One of the following: (criteria 1) all of the following: Infant is less than 24 months of age, infant has chronic lung disease (CLD), infant required medical therapy (supplemental oxygen, bronchodilator, diuretic or corticosteroid therapy) within 6 months prior to the start of RSV season, (criteria 2) all of the following: infant was born at 28 weeks of gestation or earlier, infant does not have chronic lung disease (CLD), and infant was less than 12 months of age at the start of RSV season, (criteria 3) all of the following: infant was born at 29 to 32 weeks of gestation (ie, 31 weeks, 6 days or less), infant does not have chronic lung disease (CLD), and infant was less than 6 months of age at the start of RSV season. (criteria 4): infant was born at 32 to less than 35 weeks of gestation (ie, between 32 weeks, 0 days through 34 weeks, 6 days), infant does not have CLD, infant was less than 3 months of age at the start of the RSV season, and infant has one of the following risk factors: (1) Child care attendance defined as a home or facility in which care is provided for any number of infants or toddlers OR (2) Infant has a sibling younger than 5 years of age, (criteria 5) both of the following: Infants and children 24 months of age and younger, or Infant or child has one of the following: (1) Congenital abnormalities of the airways, or (2) Neuromuscular condition that compromises handling of respiratory secretions, (criteria 6) both of the following: Infants and children 24 months of age or younger, or infant or child has hemodynamically significant cyanotic or acyanotic congenital heart disease (CHD) (eg, receiving medication to control congestive heart failure, moderate to severe pulmonary hypertension), (criteria 7) both of the following: Infants and children 24 months of age and younger, infant or child has severe immunodeficiency (eg, severe combined immunodeficiency or advanced AIDS) (off label). Age Restrictions N/A Prescriber Restrictions N/A Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 70 Coverage Duration 5 months Other Criteria Synagis will not be approved for the following conditions unless one of the required criteria is met: 1) Infants and children with hemodynamically insignificant heart disease (eg, secundum atrial septal defect, small ventricular septal defect, pulmonic stenosis, uncomplicated aortic stenosis, mild coarctation of the aorta, and patent ductus arteriosus), 2) Infants with lesions adequately corrected by surgery, unless they continue to require medication for congestive heart failure, 3) Infants with mild cardiomyopathy who are not receiving medical therapy for the condition. Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 71 TAFINLAR Products Affected Tafinlar PA Criteria Criteria Details Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information Documentation of the detected BRAF V600E mutation Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration Plan Year Other Criteria N/A Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 72 TARCEVA Products Affected Tarceva oral tablet 100 mg, 150 mg, 25 mg PA Criteria Criteria Details 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 Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 73 TARGRETIN Products Affected Targretin oral PA Criteria Criteria Details 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. Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 74 TASIGNA Products Affected Tasigna PA Criteria Criteria Details 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, 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. Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 75 THALOMID Products Affected Thalomid PA Criteria Criteria Details 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. Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 76 THIORIDAZINE Products Affected thioridazine PA Criteria Criteria Details 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 Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 77 TIRF MEDICATIONS Products Affected fentanyl citrate buccal lozenge on a handle 1,200 mcg, 1,600 mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg PA Criteria Criteria Details 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 Authorization will be for the plan year, unless otherwise specified. Other Criteria For breakthrough pain in patients with cancer if patient is unable to swallow, has dysphagia, esophagitis, mucositis, or uncontrollable nausea/vomiting OR patient is unable to take 2 other short-acting narcotics (eg, oxycodone, morphine sulfate, hydromorphone, etc) secondary to allergy or severe adverse events AND patient is on or will be on a long-acting narcotic (eg, Duragesic), or the patient is on intravenous, subcutaneous, or spinal (intrathecal, epidural) narcotics (eg, morphine sulfate, hydromorphone, fentanyl citrate). Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 78 TRACLEER Products Affected Tracleer PA Criteria Criteria Details Covered Uses All FDA approved indications not otherwise excluded from Part D Exclusion Criteria AST/ALT level greater than 3 times upper limit of normal (ULN). Pregnancy. Concomitant use of cyclosporine A or glyburide. Required Medical Information PAH confirmed by right heart catheterization. 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. Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 79 TRETINOIN Products Affected adapalene topical cream adapalene topical gel 0.1 % tretinoin topical PA Criteria Criteria Details Covered Uses All medically accepted indications not otherwise excluded from Part D. Exclusion Criteria Coverage is not provided for cosmetic use. Required Medical Information N/A Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration Plan Year Other Criteria N/A Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 80 TYKERB Products Affected Tykerb PA Criteria Criteria Details 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 Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 81 TYSABRI Products Affected Tysabri PA Criteria Criteria Details Covered Uses All FDA approved indications not otherwise excluded from Part D. Plus patients already started on Tysabri for a Covered Use. Exclusion Criteria Concurrent use of another immunomodulator (eg, Rebif, Betaseron, Extavia, Copaxone or Avonex or Aubagio), Tecfidera, or fingolimod (Gilenya) or an immunosuppressant such as mitoxantrone, cyclophosphamide, rituximab (Rituxan), alemtuzumab (Campath), azathioprine, MTX, or mycophenolate mofetilin in multiple sclerosis (MS) patients. Concurrent use with immunosuppressants (eg, 6mercaptopurine, azathioprine, cyclosporine, methotrexate) or tumor necrosis factor (TNF) alfa inhibitors (eg, infliximab, adalimumab, certolizumab pegol) in Crohn's disease (CD) patients. Per warning and precautions, coverage is not provided for immune compromised patients with MS or CD. Required Medical Information Adults with MS. Patient has a relapsing form of MS (relapsing forms of MS are relapsing remitting [RRMS], secondary progressive [SPMS] with relapses, and progressive relapsing [PRMS]). Adults with CD. Patient has moderately to severely active CD with evidence of inflammation (eg, elevated C-reactive protein). Age Restrictions Adults Prescriber Restrictions MS. Prescribed by, or in consultation with , a neurologist or physician who specializes in the treatment of MS.CD. Prescribed by or in consultation with a gastroenterologist. Coverage Duration Plan Year Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 82 Other Criteria Adults with a relapsing form of MS. Patient has had an inadequate response to, or is unable to tolerate, therapy with at least one of the following MS medications: interferon beta-1a (Avonex, Rebif), interferon beta-1b (Betaseron, Extavia), glatiramer acetate (Copaxone), fingolimod (Gilenya), Tecfidera, or Aubagio OR the patient has highly active or aggressive disease according to the prescribing physician. Adults with CD. Patient has moderately to severely active CD with evidence of inflammation (eg, elevated C-reactive protein) and patient has tried two TNF antagonists for CD for at least 2 months each, adalimumab, certolizumab pegol, or infliximab, and had an inadequate response or was intolerant to the TNF antagonists. Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 83 VIMPAT Products Affected Vimpat intravenous Vimpat oral solution Vimpat oral tablet PA Criteria Criteria Details 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 Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 84 VOTRIENT Products Affected Votrient PA Criteria Criteria Details 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 Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 85 XALKORI Products Affected Xalkori PA Criteria Criteria Details Covered Uses All FDA-approved indications not otherwise excluded from Part D. Plus, patients with non-small cell lung cancer (NSCLC) already started on crizotinib. Exclusion Criteria N/A Required Medical Information For the FDA-approved indication of NSCLC for patients new to therapy, ALK status required. Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration Plan Year Other Criteria NSCLC, patient new to therapy must be ALK-positive for approval. Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 86 XENAZINE Products Affected Xenazine PA Criteria Criteria Details Covered Uses All FDA-approved indications not otherwise excluded from Part D. Tardive dyskinesia (TD). Tourette syndrome and related tic disorders. Hyperkinetic dystonia. Hemiballism. Exclusion Criteria N/A Required Medical Information N/A Age Restrictions N/A Prescriber Restrictions For treatment of chorea associated with Huntington's disease, Tourette syndrome or related tic disorders, hyperkinetic dystonia, or hemiballism, Xenazine must be prescribed by or after consultation with a neurologist. For TD, Xenazine must be prescribed by or after consultation with a neurologist or psychiatrist. Coverage Duration Plan Year Other Criteria N/A Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 87 XOLAIR Products Affected Xolair PA Criteria Criteria Details 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. Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 88 XTANDI Products Affected Xtandi PA Criteria Criteria Details Covered Uses All FDA approved indications not otherwise excluded from Part D. Plus patients already started on Xtandi for a Covered Use. Exclusion Criteria N/A Required Medical Information Diagnosis for which Xtandi is being used. For metastatic castrationresistant prostate cancer, prior therapies tried. Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration Plan Year Other Criteria For prostate cancer, patient must have metastatic, castration-resistant prostate cancer for approval. For metastatic, castration-resistant prostate cancer, patient must have previously received therapy with docetaxel for approval. Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 89 ZELBORAF Products Affected Zelboraf PA Criteria Criteria Details Covered Uses All FDA-approved indications not otherwise excluded from Part D. Plus, patients with melanoma already started on vemurafenib. Exclusion Criteria N/A Required Medical Information For the FDA-approved indication of melanoma, for patients new to therapy, BRAFV600E status required. Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration Plan Year Other Criteria Melanoma, patient new to therapy must have BRAFV600E mutation for approval. Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 90 ZYKADIA Products Affected Zykadia PA Criteria Criteria Details 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 For metastatic non-small cell lung cancer that is anaplastic lymphoma kinase positive, patient must have progressed or be intolerant to crizotinib for approval. Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 91 ZYVOX Products Affected Zyvox intravenous parenteral solution 600 mg/300 mL Zyvox oral PA Criteria Criteria Details Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information Culture and sensitivity and CBC within normal limits Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration Up to 28 days Other Criteria N/A Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 92 PART B VERSUS PART D Products Affected A-Hydrocort Abelcet Abilify intramuscular Abilify Maintena intramuscular suspension,extended rel recon 300 mg acetylcysteine solution Actemra intravenous solution 200 mg/10 mL (20 mg/mL) acyclovir sodium intravenous solution Adagen albuterol sulfate inhalation solution for nebulization 0.63 mg/3 mL, 1.25 mg/3 mL, 2.5 mg /3 mL (0.083 %), 5 mg/mL Aldurazyme Alimta intravenous recon soln 500 mg AmBisome amifostine crystalline amikacin injection solution 500 mg/2 mL aminophylline intravenous solution 250 mg/10 mL Aminosyn 8.5 %-electrolytes Aminosyn II 10 % Aminosyn II 15 % Aminosyn II 7 % Aminosyn II 8.5 % Aminosyn II 8.5 %-electrolytes Aminosyn M 3.5 % Aminosyn-HBC 7% Aminosyn-PF 10 % Aminosyn-PF 7 % (sulfite-free) amiodarone intravenous solution amphotericin B ampicillin sodium injection recon soln 1 gram, 10 gram, 125 mg ampicillin-sulbactam injection recon soln 15 gram, 3 gram Aralast NP intravenous recon soln 500 mg Astagraf XL Avastin Avelox in NaCl (iso-osmotic) Azasan azathioprine azithromycin intravenous BACiiM bacitracin intramuscular BCG vaccine, live (PF) Benlysta intravenous recon soln 120 mg benztropine injection Bicillin C-R BiCNU bleomycin injection recon soln 30 unit budesonide inhalation buprenorphine HCl injection syringe Busulfex calcitriol intravenous solution 1 mcg/mL calcitriol oral Cancidas Capastat carboplatin intravenous solution cefazolin injection recon soln 1 gram, 10 gram, 500 mg cefazolin in dextrose (iso-os) intravenous piggyback 1 gram/50 mL cefepime cefotaxime cefoxitin cefoxitin in dextrose, iso-osm ceftazidime injection recon soln 1 gram, 2 gram ceftriaxone injection recon soln 10 gram, 250 mg, 500 mg ceftriaxone intravenous recon soln cefuroxime sodium injection recon soln 1.5 gram, 750 mg cefuroxime sodium intravenous CellCept oral suspension for reconstitution CellCept Intravenous Cerezyme intravenous recon soln 400 unit chloramphenicol sod succinate cidofovir Cimzia Powder for Reconst Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 93 ciprofloxacin intravenous solution 400 mg/40 dextrose 5 % in water (D5W) intravenous mL parenteral solution cisplatin dextrose 5 %-lactated ringers cladribine dextrose 5%-0.2 % sod chloride clindamycin phosphate intravenous solution 600 dextrose 5%-0.3 % sod.chloride mg/4 mL diltiazem HCl intravenous Clinimix 5%/D15W Sulfite Free diphenhydramine HCl injection solution 50 mg/mL Clinimix 5%/D25W sulfite-free Clinimix 2.75%/D5W Sulfit Free Doxil Clinimix 4.25%-D20W sulf-free doxorubicin intravenous solution 50 mg/25 mL Clinimix 4.25%-D25W sulf-free doxycycline hyclate intravenous Clinimix 4.25%/D10W Sulf Free dronabinol Clinimix 4.25%/D5W Sulfit Free Duramorph (PF) injection solution 0.5 mg/mL, 1 mg/mL Clinimix 5%-D20W(sulfite-free) Elaprase Clinimix E 2.75%/D10W Sul Free Elelyso Clinimix E 2.75%/D5W Sulf Free Elitek intravenous recon soln 1.5 mg Clinimix E 4.25%/D25W Sul Free Emend oral capsule 125 mg, 40 mg, 80 mg Clinimix E 4.25%/D5W Sulf Free Emend oral capsule,dose pack Clinimix E 5%/D15W Sulfit Free Engerix-B (PF) intramuscular syringe Clinimix E 5%/D20W Sulfit Free Engerix-B Pediatric (PF) Clinimix E 5%/D25W Sulfit Free epirubicin intravenous solution 50 mg/25 mL Clinisol SF 15 % Erythrocin intravenous recon soln 500 mg colistin (colistimethate Na) esomeprazole sodium Cosmegen estradiol valerate intramuscular oil 20 mg/mL cromolyn inhalation etoposide intravenous Cubicin Fabrazyme intravenous recon soln 35 mg cyclophosphamide oral famotidine (PF) cyclophosphamide oral famotidine (PF)-NaCl (iso-os) cyclosporine intravenous Faslodex cyclosporine oral capsule fluconazole in dextrose(iso-o) intravenous cyclosporine modified piggyback 400 mg/200 mL cytarabine fludarabine intravenous recon soln D2.5 %-0.45 % sodium chloride fluorouracil intravenous solution 2.5 gram/50 D5 % and 0.9 % sodium chloride mL D5 %-0.45 % sodium chloride fluphenazine decanoate dacarbazine intravenous recon soln 200 mg fluphenazine HCl injection daunorubicin intravenous solution fomepizole decitabine fosphenytoin injection solution 100 mg PE/2 mL Depo-Provera intramuscular solution furosemide injection solution dexamethasone sodium phosphate injection ganciclovir sodium dexrazoxane intravenous recon soln 250 mg gemcitabine intravenous recon soln 1 gram dextrose 10 % and 0.2 % NaCl Gemzar intravenous recon soln 1 gram dextrose 10 % in water (D10W) intravenous Gengraf parenteral solution Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 94 gentamicin injection solution 40 mg/mL gentamicin in NaCl (iso-osm) intravenous piggyback 100 mg/100 mL gentamicin in NaCl (iso-osm) intravenous piggyback 80 mg/100 mL gentamicin sulfate (PF) intravenous solution 80 mg/8 mL Geodon intramuscular granisetron intravenous solution 1 mg/mL (1 mL) granisetron oral granisetron (PF) intravenous solution 100 mcg/mL Granisol haloperidol decanoate haloperidol lactate injection Havrix (PF) intramuscular suspension 1,440 Elisa unit/mL Havrix (PF) intramuscular syringe 720 Elisa unit/0.5 mL heparin (porcine) injection solution heparin (porcine) in 5 % dex intravenous parenteral solution 20,000 unit/500 mL (40 unit/mL), 25,000 unit/250 mL(100 unit/mL), 25,000 unit/500 mL (50 unit/mL) heparin (porcine) in NaCl (PF) intravenous parenteral solution 1,000 unit/500 mL Hepatamine 8% Hepatasol 8 % Herceptin hydralazine injection hydromorphone (PF) injection solution 10 mg/mL hydroxyzine HCl intramuscular idarubicin Ifex intravenous recon soln 1 gram ifosfamide intravenous recon soln 1 gram imipenem-cilastatin Increlex Intralipid intravenous emulsion 20 %, 30 % Intron A injection recon soln 10 million unit (1 mL) Intron A injection solution 6 million unit/mL Invanz injection Invega Sustenna Ionosol-B in D5W Ionosol-MB in D5W ipratropium bromide inhalation ipratropium-albuterol irinotecan intravenous solution 100 mg/5 mL Istodax Kadcyla intravenous recon soln 100 mg labetalol intravenous solution leucovorin calcium injection recon soln 100 mg, 350 mg levalbuterol HCl inhalation solution for nebulization 0.31 mg/3 mL, 0.63 mg/3 mL, 1.25 mg/0.5 mL levetiracetam intravenous levocarnitine intravenous levocarnitine oral tablet levocarnitine (with sugar) levofloxacin intravenous levothyroxine intravenous recon soln 100 mcg lidocaine (PF) injection solution 10 mg/mL (1 %), 5 mg/mL (0.5 %) Liposyn III intravenous emulsion 10 %, 20 % magnesium sulfate injection syringe melphalan meropenem intravenous recon soln 500 mg mesna methadone injection methotrexate sodium oral methotrexate sodium (PF) methylprednisolone acetate methylprednisolone sodium succ injection recon soln 125 mg, 40 mg metoclopramide HCl injection solution metoprolol tartrate intravenous solution Miacalcin injection mitomycin intravenous recon soln 20 mg mitoxantrone Mozobil Mustargen mycophenolate mofetil mycophenolate sodium Myozyme nafcillin injection recon soln 1 gram Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 95 nafcillin injection recon soln 10 gram nafcillin in dextrose iso-osm intravenous piggyback 1 gram/50 mL Naglazyme nalbuphine injection solution 10 mg/mL, 20 mg/mL Nebupent Neoral Nephramine 5.4 % Neumega Nexium IV nitroglycerin intravenous Normosol-M in 5 % dextrose Normosol-R in 5 % dextrose Normosol-R pH 7.4 Nulojix ondansetron ondansetron HCl oral solution ondansetron HCl oral tablet 24 mg, 4 mg, 8 mg ondansetron HCl (PF) injection solution Orencia (with maltose) oxacillin injection recon soln 10 gram oxacillin intravenous recon soln 2 gram oxacillin in dextrose(iso-osm) oxaliplatin intravenous solution 100 mg/20 mL paclitaxel pamidronate intravenous solution paricalcitol penicillin G potassium injection recon soln 5 million unit penicillin G procaine intramuscular syringe 1.2 million unit/2 mL penicillin G sodium Pentam Perforomist Perjeta phenytoin sodium intravenous solution piperacillin-tazobactam intravenous recon soln 3.375 gram, 4.5 gram Plasma-Lyte 148 Plasma-Lyte A Plasma-Lyte-56 in 5 % dextrose potassium chlorid-D5-0.45%NaCl potassium chloride in 0.9%NaCl intravenous parenteral solution 20 mEq/L, 40 mEq/L potassium chloride in 5 % dex intravenous parenteral solution 20 mEq/L, 40 mEq/L potassium chloride in LR-D5 intravenous parenteral solution 20 mEq/L potassium chloride-D5-0.2%NaCl intravenous parenteral solution 20 mEq/L potassium chloride-D5-0.3%NaCl intravenous parenteral solution 20 mEq/L potassium chloride-D5-0.9%NaCl Premarin injection Premasol 10 % Premasol 6 % Procalamine 3% Proleukin Prolia propranolol intravenous Prosol 20 % Pulmozyme ranitidine HCl injection solution 25 mg/mL Rapamune Recombivax HB (PF) intramuscular suspension 10 mcg/mL, 40 mcg/mL Remodulin Rheumatrex rifampin intravenous ringers intravenous Risperdal Consta Sancuso Sandimmune oral Simulect intravenous recon soln 20 mg sirolimus Solu-Cortef (PF) injection recon soln 100 mg/2 mL, 250 mg/2 mL Somatuline Depot Somavert subcutaneous recon soln 10 mg, 15 mg, 20 mg streptomycin intramuscular sulfamethoxazole-trimethoprim intravenous Synercid Synribo tacrolimus Teflaro Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 96 terbutaline subcutaneous testosterone cypionate testosterone enanthate tetanus toxoid,adsorbed (PF) tetanus-diphtheria toxoids-Td tobramycin in 0.225 % NaCl tobramycin sulfate injection solution Toposar topotecan intravenous recon soln TPN Electrolytes tranexamic acid intravenous Travasol 10 % Treanda intravenous recon soln 100 mg Trelstar intramuscular suspension for reconstitution Trelstar intramuscular syringe 11.25 mg/2 mL, 3.75 mg/2 mL Trisenox TrophAmine 10 % Trophamine 6% Twinrix (PF) intramuscular suspension valproate sodium vancomycin intravenous recon soln 1,000 mg, 10 gram, 500 mg Vaqta (PF) intramuscular suspension 25 unit/0.5 mL Velcade verapamil intravenous solution vinblastine intravenous solution vincristine intravenous solution 1 mg/mL vinorelbine intravenous solution 50 mg/5 mL Virazole voriconazole intravenous VPRIV Xgeva Zaltrap intravenous solution 100 mg/4 mL (25 mg/mL) Zemplar intravenous zoledronic acid intravenous solution zoledronic acid-mannitol-water intravenous solution Zometa intravenous solution 4 mg/100 mL Zortress Details 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. Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 97 Index A Abelcet ...................................................... 93 Abilify ....................................................... 93 Abilify Maintena ....................................... 93 acetylcysteine ............................................ 93 Actemra ..................................................... 93 Acthar H.P................................................... 1 Actimmune.................................................. 2 acyclovir sodium ....................................... 93 Adagen ...................................................... 93 adapalene topical cream ............................ 80 adapalene topical gel 0.1 % ...................... 80 Adcirca ........................................................ 3 Afinitor........................................................ 4 Afinitor Disperz .......................................... 4 A-Hydrocort .............................................. 93 albuterol sulfate ......................................... 93 Aldurazyme ............................................... 93 Alimta ....................................................... 93 alprazolam ................................................. 25 AmBisome ................................................ 93 amifostine crystalline ................................ 93 amikacin .................................................... 93 aminophylline ........................................... 93 Aminosyn 8.5 %-electrolytes .................... 93 Aminosyn II 10 % ..................................... 93 Aminosyn II 15 % ..................................... 93 Aminosyn II 7 % ....................................... 93 Aminosyn II 8.5 % .................................... 93 Aminosyn II 8.5 %-electrolytes ................ 93 Aminosyn M 3.5 % ................................... 93 Aminosyn-HBC 7% .................................. 93 Aminosyn-PF 10 % ................................... 93 Aminosyn-PF 7 % (sulfite-free)................ 93 amiodarone ................................................ 93 amphotericin B .......................................... 93 ampicillin sodium...................................... 93 ampicillin-sulbactam ................................. 93 Ampyra ....................................................... 5 Aralast NP ................................................. 93 Arcalyst ....................................................... 7 Astagraf XL .............................................. 93 Avastin ...................................................... 93 Avelox in NaCl (iso-osmotic) ................... 93 Avonex intramuscular kit ............................ 8 Avonex intramuscular syringe kit ............... 8 Azasan ....................................................... 93 azathioprine ............................................... 93 azithromycin ............................................. 93 B BACiiM..................................................... 93 bacitracin ................................................... 93 BCG vaccine, live (PF) ............................. 93 Benlysta..................................................... 93 benztropine................................................ 93 benztropine oral ........................................ 24 Bicillin C-R ............................................... 93 BiCNU ...................................................... 93 bleomycin .................................................. 93 Bosulif ......................................................... 9 budesonide ................................................ 93 buprenorphine HCl.................................... 93 Busulfex .................................................... 93 butalbital-acetaminop-caf-cod oral capsule 50-325-40-30 mg .................................. 24 C calcitriol .................................................... 93 Cancidas .................................................... 93 Capastat ..................................................... 93 carboplatin................................................. 93 cefazolin .................................................... 93 cefazolin in dextrose (iso-os) .................... 93 cefepime .................................................... 93 cefotaxime ................................................. 93 cefoxitin .................................................... 93 cefoxitin in dextrose, iso-osm ................... 93 ceftazidime ................................................ 93 ceftriaxone................................................. 93 cefuroxime sodium.................................... 93 CellCept .................................................... 93 CellCept Intravenous ................................ 93 Cerezyme .................................................. 93 chloramphenicol sod succinate ................. 93 chorionic gonadotropin, human ................ 10 Cialis oral tablet 2.5 mg, 5 mg .................. 11 cidofovir .................................................... 93 Cimzia Powder for Reconst ...................... 93 Cinryze ...................................................... 12 Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 98 ciprofloxacin ............................................. 94 cisplatin ..................................................... 94 cladribine................................................... 94 clemastine oral syrup ................................ 24 clemastine oral tablet 2.68 mg .................. 24 clindamycin phosphate.............................. 94 Clinimix 5%/D15W Sulfite Free ............. 94 Clinimix 5%/D25W sulfite-free ............... 94 Clinimix 2.75%/D5W Sulfit Free ............. 94 Clinimix 4.25%/D10W Sulf Free ............. 94 Clinimix 4.25%/D5W Sulfit Free ............. 94 Clinimix 4.25%-D20W sulf-free .............. 94 Clinimix 4.25%-D25W sulf-free .............. 94 Clinimix 5%-D20W(sulfite-free) .............. 94 Clinimix E 2.75%/D10W Sul Free ........... 94 Clinimix E 2.75%/D5W Sulf Free ............ 94 Clinimix E 4.25%/D25W Sul Free ........... 94 Clinimix E 4.25%/D5W Sulf Free ............ 94 Clinimix E 5%/D15W Sulfit Free ............. 94 Clinimix E 5%/D20W Sulfit Free ............. 94 Clinimix E 5%/D25W Sulfit Free ............. 94 Clinisol SF 15 % ....................................... 94 clonazepam ............................................... 26 clorazepate dipotassium ............................ 26 colistin (colistimethate Na) ....................... 94 Cometriq ................................................... 13 Copaxone subcutaneous syringe 40 mg/mL ............................................................... 14 Copaxone subcutaneous syringe kit .......... 14 Cosmegen .................................................. 94 cromolyn ................................................... 94 Cubicin ...................................................... 94 cyclobenzaprine oral tablet ....................... 24 cyclophosphamide..................................... 94 cyclosporine .............................................. 94 cyclosporine modified ............................... 94 cyproheptadine .......................................... 24 cytarabine .................................................. 94 D D2.5 %-0.45 % sodium chloride ............... 94 D5 % and 0.9 % sodium chloride ............. 94 D5 %-0.45 % sodium chloride .................. 94 dacarbazine ............................................... 94 daunorubicin ............................................. 94 decitabine .................................................. 94 Demser ...................................................... 15 Depen Titratabs ......................................... 49 Depo-Provera ............................................ 94 dexamethasone sodium phosphate ............ 94 dexrazoxane .............................................. 94 dextrose 10 % and 0.2 % NaCl ................. 94 dextrose 10 % in water (D10W) ............... 94 dextrose 5 % in water (D5W) ................... 94 dextrose 5 %-lactated ringers .................... 94 dextrose 5%-0.2 % sod chloride ............... 94 dextrose 5%-0.3 % sod.chloride ............... 94 Diazepam Intensol .................................... 26 diazepam oral solution 5 mg/5 mL ........... 26 diazepam oral tablet .................................. 26 diazepam rectal ......................................... 26 diclofenac sodium topical gel ................... 16 diltiazem HCl ............................................ 94 diphenhydramine HCl ............................... 94 Doxil ......................................................... 94 doxorubicin ............................................... 94 doxycycline hyclate .................................. 94 dronabinol ................................................. 94 Duramorph (PF) ........................................ 94 E Egrifta subcutaneous recon soln 2 mg ...... 17 Elaprase ..................................................... 94 Elelyso....................................................... 94 Eligard ....................................................... 36 Elitek ......................................................... 94 Emend ....................................................... 94 Engerix-B (PF) .......................................... 94 Engerix-B Pediatric (PF)........................... 94 epirubicin .................................................. 94 Erivedge .................................................... 18 Erwinaze ................................................... 19 Erythrocin ................................................. 94 esomeprazole sodium ................................ 94 estradiol oral.............................................. 27 estradiol valerate ....................................... 94 eszopiclone................................................ 24 etoposide ................................................... 94 Extavia subcutaneous kit........................... 20 F Fabrazyme ................................................. 94 famotidine (PF) ......................................... 94 famotidine (PF)-NaCl (iso-os) ................. 94 Faslodex .................................................... 94 Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 99 fentanyl citrate buccal lozenge on a handle 1,200 mcg, 1,600 mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg ........................ 78 fluconazole in dextrose(iso-o)................... 94 fludarabine ................................................ 94 fluorouracil ................................................ 94 fluphenazine decanoate ............................. 94 fluphenazine HCl ...................................... 94 fomepizole................................................. 94 fosphenytoin .............................................. 94 furosemide................................................. 94 G Gammagard Liquid ................................... 31 Gamunex-C injection solution 1 gram/10 mL (10 %) ............................................. 31 ganciclovir sodium .................................... 94 gemcitabine ............................................... 94 Gemzar ...................................................... 94 Gengraf ..................................................... 94 gentamicin ................................................. 95 gentamicin in NaCl (iso-osm) ................... 95 gentamicin sulfate (PF) ............................. 95 Geodon ...................................................... 95 Gilotrif....................................................... 21 Gleevec oral tablet 100 mg, 400 mg ......... 22 granisetron................................................. 95 granisetron (PF) ........................................ 95 Granisol ..................................................... 95 H haloperidol decanoate ............................... 95 haloperidol lactate ..................................... 95 Havrix (PF) ............................................... 95 heparin (porcine) ....................................... 95 heparin (porcine) in 5 % dex ..................... 95 heparin (porcine) in NaCl (PF) ................. 95 Hepatamine 8% ......................................... 95 Hepatasol 8 % ........................................... 95 Herceptin ................................................... 95 hydralazine ................................................ 95 hydromorphone (PF) ................................. 95 hydroxyzine HCl ....................................... 95 I idarubicin .................................................. 95 Ifex ............................................................ 95 ifosfamide ................................................. 95 Ilaris (PF) .................................................. 28 Imbruvica .................................................. 29 imipenem-cilastatin ................................... 95 Increlex ..................................................... 95 Inlyta ......................................................... 30 Intralipid .................................................... 95 Intron A ..................................................... 95 Invanz ........................................................ 95 Invega Sustenna ........................................ 95 Ionosol-B in D5W ..................................... 95 Ionosol-MB in D5W ................................. 95 ipratropium bromide ................................. 95 ipratropium-albuterol ................................ 95 irinotecan................................................... 95 Istodax ....................................................... 95 J Jakafi oral tablet 10 mg, 15 mg, 20 mg, 25 mg, 5 mg ............................................... 32 K Kadcyla ..................................................... 95 Kuvan oral tablet,soluble .......................... 33 L labetalol ..................................................... 95 Lanoxin oral .............................................. 24 Letairis ...................................................... 34 leucovorin calcium .................................... 95 Leukine injection recon soln ..................... 35 levalbuterol HCl ........................................ 95 levetiracetam ............................................. 95 levocarnitine .............................................. 95 levocarnitine (with sugar) ......................... 95 levofloxacin............................................... 95 levothyroxine ............................................ 95 lidocaine (PF) ............................................ 95 lidocaine topical adhesive patch,medicated ............................................................... 37 Liposyn III ................................................ 95 Lorazepam Intensol ................................... 25 lorazepam oral tablet ................................. 25 Lupron Depot ............................................ 36 Lupron Depot (3 Month) ........................... 36 Lupron Depot (4 Month) ........................... 36 Lupron Depot (6 Month) ........................... 36 Lupron Depot-Ped intramuscular kit 11.25 mg, 15 mg ............................................. 36 M magnesium sulfate .................................... 95 Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 100 Mekinist .................................................... 38 melphalan .................................................. 95 meprobamate ............................................. 24 meropenem ................................................ 95 mesna ........................................................ 95 metaxalone ................................................ 24 methadone ................................................. 95 methotrexate sodium ................................. 95 methotrexate sodium (PF) ......................... 95 methyldopa-hydrochlorothiazide .............. 24 methylprednisolone acetate ....................... 95 methylprednisolone sodium succ .............. 95 metoclopramide HCl ................................. 95 metoprolol tartrate ..................................... 95 Miacalcin................................................... 95 mitomycin ................................................. 95 mitoxantrone ............................................. 95 modafinil ................................................... 43 Mozobil ..................................................... 95 Mustargen ................................................. 95 mycophenolate mofetil.............................. 95 mycophenolate sodium ............................. 95 Myozyme .................................................. 95 N nafcillin ............................................... 95, 96 nafcillin in dextrose iso-osm ..................... 96 Naglazyme ................................................ 96 nalbuphine ................................................. 96 Namenda oral solution .............................. 39 Namenda XR ............................................. 39 Nebupent ................................................... 96 Neoral ........................................................ 96 Nephramine 5.4 % .................................... 96 Neumega ................................................... 96 Neupogen injection solution 480 mcg/1.6 mL ......................................................... 40 Neupogen injection syringe ...................... 40 Neupro....................................................... 41 Nexavar ..................................................... 42 Nexium IV ................................................ 96 nitrofurantoin macrocrystal oral capsule 50 mg ......................................................... 24 nitrofurantoin monohyd/m-cryst ............... 24 nitroglycerin .............................................. 96 Norditropin FlexPro .................................. 23 Norditropin Nordiflex ............................... 23 Normosol-M in 5 % dextrose.................... 96 Normosol-R in 5 % dextrose..................... 96 Normosol-R pH 7.4................................... 96 Novarel ...................................................... 10 Nulojix ...................................................... 96 Nuvigil oral tablet 150 mg, 250 mg, 50 mg ............................................................... 43 O octreotide acetate injection solution.......... 44 Olysio ........................................................ 45 Oncaspar ................................................... 46 ondansetron ............................................... 96 ondansetron HCl ....................................... 96 ondansetron HCl (PF) ............................... 96 Onfi oral suspension ................................. 47 Onfi oral tablet 10 mg, 20 mg ................... 47 Orencia (with maltose) .............................. 96 oxacillin..................................................... 96 oxacillin in dextrose(iso-osm)................... 96 oxaliplatin ................................................. 96 oxazepam .................................................. 25 P paclitaxel ................................................... 96 pamidronate............................................... 96 paricalcitol................................................. 96 PegIntron ................................................... 48 PegIntron Redipen .................................... 48 penicillin G potassium .............................. 96 penicillin G procaine ................................. 96 penicillin G sodium ................................... 96 Pentam....................................................... 96 Perforomist ................................................ 96 Perjeta ....................................................... 96 phenytoin sodium ...................................... 96 piperacillin-tazobactam ............................. 96 Plasma-Lyte 148 ....................................... 96 Plasma-Lyte A .......................................... 96 Plasma-Lyte-56 in 5 % dextrose ............... 96 Pomalyst .................................................... 50 potassium chlorid-D5-0.45%NaCl ............ 96 potassium chloride in 0.9%NaCl .............. 96 potassium chloride in 5 % dex .................. 96 potassium chloride in LR-D5 .................... 96 potassium chloride-D5-0.2%NaCl ............ 96 potassium chloride-D5-0.3%NaCl ............ 96 potassium chloride-D5-0.9%NaCl ............ 96 Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 101 Pregnyl ...................................................... 10 Premarin .................................................... 96 Premasol 10 % .......................................... 96 Premasol 6 % ............................................ 96 Procalamine 3% ........................................ 96 Procrit injection solution 10,000 unit/mL, 2,000 unit/mL, 20,000 unit/mL, 3,000 unit/mL, 4,000 unit/mL, 40,000 unit/mL ............................................................... 51 Proleukin ................................................... 96 Prolia ......................................................... 96 Promacta ................................................... 53 propranolol ................................................ 96 Prosol 20 % ............................................... 96 Pulmozyme ............................................... 96 Q Qudexy XR ................................................. 6 quinine sulfate ........................................... 54 R ranitidine HCl............................................ 96 Rapamune ................................................. 96 Rebif (with albumin) ................................. 55 Rebif Titration Pack .................................. 55 Recombivax HB (PF) ................................ 96 Remicade................................................... 56 Remodulin ................................................. 96 reserpine .................................................... 24 Revlimid.................................................... 59 Rheumatrex ............................................... 96 ribavirin oral capsule................................. 60 ribavirin oral tablet 200 mg....................... 60 rifampin ..................................................... 96 ringers ....................................................... 96 Risperdal Consta ....................................... 96 Rituxan ...................................................... 61 S Sabril ......................................................... 62 Sancuso ..................................................... 96 Sandimmune ............................................. 96 Sandostatin LAR Depot ............................ 63 Signifor ..................................................... 64 sildenafil .................................................... 58 Simulect .................................................... 96 sirolimus.................................................... 96 Solu-Cortef (PF)........................................ 96 Somatuline Depot...................................... 96 Somavert ................................................... 96 Sovaldi ...................................................... 65 Sprycel oral tablet 100 mg, 140 mg, 20 mg, 50 mg, 70 mg, 80 mg ............................ 66 Stivarga ..................................................... 67 streptomycin .............................................. 96 sulfamethoxazole-trimethoprim ................ 96 Surmontil................................................... 27 Sutent oral capsule 12.5 mg, 25 mg, 50 mg ............................................................... 68 Sylatron ..................................................... 69 Synagis intramuscular solution 50 mg/0.5 mL ......................................................... 70 Synercid .................................................... 96 Synribo ...................................................... 96 T tacrolimus .................................................. 96 Tafinlar ...................................................... 72 Tarceva oral tablet 100 mg, 150 mg, 25 mg ............................................................... 73 Targretin oral ............................................ 74 Tasigna ...................................................... 75 Teflaro ....................................................... 96 temazepam ................................................ 25 terbutaline ................................................. 97 testosterone cypionate ............................... 97 testosterone enanthate ............................... 97 tetanus toxoid,adsorbed (PF) .................... 97 tetanus-diphtheria toxoids-Td ................... 97 Thalomid ................................................... 76 thioridazine ............................................... 77 tobramycin in 0.225 % NaCl .................... 97 tobramycin sulfate ..................................... 97 topiramate oral capsule, sprinkle ................ 6 topiramate oral tablet .................................. 6 Toposar ..................................................... 97 topotecan ................................................... 97 TPN Electrolytes ....................................... 97 Tracleer ..................................................... 79 tranexamic acid ......................................... 97 Travasol 10 % ........................................... 97 Treanda ..................................................... 97 Trelstar ...................................................... 97 tretinoin topical ......................................... 80 Trisenox .................................................... 97 TrophAmine 10 %..................................... 97 Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 102 Trophamine 6% ......................................... 97 Twinrix (PF).............................................. 97 Tykerb ....................................................... 81 Tysabri ...................................................... 82 V valproate sodium ....................................... 97 vancomycin ............................................... 97 Vaqta (PF) ................................................. 97 Velcade ..................................................... 97 verapamil................................................... 97 Vimpat intravenous ................................... 84 Vimpat oral solution ................................. 84 Vimpat oral tablet ..................................... 84 vinblastine ................................................. 97 vincristine.................................................. 97 vinorelbine ................................................ 97 Virazole ..................................................... 97 voriconazole .............................................. 97 Votrient ..................................................... 85 VPRIV....................................................... 97 X Xalkori ...................................................... 86 Xenazine ................................................... 87 Xgeva ........................................................ 97 Xolair ........................................................ 88 Xtandi ........................................................ 89 Z Zaltrap ....................................................... 97 Zelboraf ..................................................... 90 Zemplar ..................................................... 97 zoledronic acid .......................................... 97 zoledronic acid-mannitol-water ................ 97 Zometa ...................................................... 97 zonisamide .................................................. 6 Zortress ..................................................... 97 Zykadia ..................................................... 91 Zyvox intravenous parenteral solution 600 mg/300 mL ............................................ 92 Zyvox oral ................................................. 92 Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 103 Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. Beneficiaries must use network pharmacies to access their prescription drug benefit. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change on January 1, 2016. This document includes GuildNet Gold and GuildNet Health Advantage partial formulary as of October 1, 2014. For a complete, updated formulary, please visit our Web site at www.guildnetny.org or call the Member Services number below. This information is available for free in other languages. Please contact Member Services at 1-800-8150000 for additional information. (TTY users should call 1-800-662-1220). Hours are Monday through Friday, 8 am to 8 pm. Member Services has free language interpreter services available for non-English speakers. Esta información esta disponible en otros idiomas a gratis. Por favor llame a Servicios a los Clientes, al 1800-815-0000 por información adicional. (Los usuarios de TTY deben llamar al 1-800-662-122). Se atiende de lunes a viernes, de 8 a. m. a 8 p. m. Servicios a los Clientes tienen los servicios gratuitos de intérprete de idioma disponibles para altavoces de no-inglés. GuildNet Gold and GuildNet Health Advantage are HMO-POS SNP plans with Medicare and New York State contracts. Enrollment in GuildNet Gold and GuildNet Health Advantage depends on contract renewal. Updated 10/2014 H6864_MGM14_33 PA Criteria Web Posting_Approved 104
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