Part D Prior Authorization Criteria4
User Manual: Part-D-Prior-Authorization-Criteria4
Open the PDF directly: View PDF 
.
Page Count: 114
| Download | |
| Open PDF In Browser | View PDF |
2015 Prior Authorization (PA) Criteria Certain drugs require prior authorization from GuildNet Gold Plus FIDA Plan Medicare Plans. 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 Acthar H.P. Products Affected 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 1 ACTIMMUNE Actimmune Products Affected 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 2 ADCIRCA Adcirca Products Affected 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 3 AFINITOR Afinitor Disperz Products Affected 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 4 AMPYRA Ampyra Products Affected 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 5 ANTICONVULSANTS topiramate oral tablet zonisamide Products Affected Qudexy XR topiramate oral capsule, sprinkle 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 6 ARCALYST Arcalyst Products Affected 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 7 AVONEX Avonex intramuscular syringe kit Products Affected Avonex (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: 07/2015 H0811_GN134_Web Prior Auth_Approved 8 BOSULIF Bosulif Products Affected 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 9 CHORIONIC GONADOTROPINS (HCG) Novarel Pregnyl Products Affected chorionic gonadotropin, human 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 10 CIALIS Cialis oral tablet 2.5 mg, 5 mg Products Affected 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 11 CINRYZE Cinryze Products Affected 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 12 COMETRIQ Cometriq Products Affected 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 13 COPAXONE Copaxone subcutaneous syringe 20 mg/mL, 40 mg/mL Products Affected 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 14 DEMSER Demser Products Affected 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 15 DICLOFENAC GEL diclofenac sodium topical gel Products Affected 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 16 EGRIFTA Egrifta subcutaneous recon soln 2 mg Products Affected 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 17 ERIVEDGE Erivedge Products Affected 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 18 ERWINAZE Erwinaze Products Affected 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 19 EXTAVIA Extavia subcutaneous kit Products Affected 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 20 FARYDAK Farydak Products Affected 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 21 GILOTRIF Gilotrif Products Affected 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 22 GLEEVEC Gleevec oral tablet 100 mg, 400 mg Products Affected 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 23 GROWTH HORMONE Norditropin Nordiflex Products Affected Norditropin FlexPro subcutaneous pen injector 10 mg/1.5 mL (6.7 mg/mL), 15 mg/1.5 mL (10 mg/mL), 5 mg/1.5 mL (3.3 mg/mL) 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 Updated: 07/2015 H0811_GN134_Web Prior Auth_Approved 24 Other Criteria N/A Updated: 07/2015 H0811_GN134_Web Prior Auth_Approved 25 HRM Products Affected benztropine oral butalbital-acetaminop-caf-cod 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 26 HRM - BENZODIAZEPINES lorazepam oral tablet oxazepam temazepam Products Affected alprazolam Lorazepam Intensol 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 27 HRM BENZODIAZEPINES/ANTICONVULSANTS Products Affected clonazepam clorazepate dipotassium Diastat Diastat AcuDial 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 28 HRM PD Surmontil Products Affected 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 29 IBRANCE Ibrance Products Affected 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 30 ICLUSIG Iclusig Products Affected 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 31 ILARIS Ilaris (PF) Products Affected 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 32 IMBRUVICA Imbruvica Products Affected 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 33 INLYTA Inlyta Products Affected 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 34 IVIG Gamunex-C injection solution 1 gram/10 mL (10 %) Products Affected Gammagard Liquid 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 35 JAKAFI Jakafi oral tablet 10 mg, 15 mg, 20 mg, 25 mg, 5 mg Products Affected 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 36 KUVAN Kuvan oral tablet,soluble Products Affected 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 37 LENVIMA Lenvima Products Affected 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 38 LETAIRIS Letairis Products Affected 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 39 LEUKINE Leukine injection recon soln Products Affected 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 40 LEUPROLIDE Lupron Depot (4 Month) Lupron Depot (6 Month) Lupron Depot-Ped intramuscular kit 11.25 mg, 15 mg Products Affected Eligard Lupron Depot Lupron Depot (3 Month) 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 41 LIDOCAINE PATCH lidocaine topical adhesive patch,medicated Products Affected 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 42 LYNPARZA Lynparza Products Affected 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 43 MEKINIST Mekinist Products Affected 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 44 NAMENDA Namenda Titration Pak Namenda XR Products Affected Namenda 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 45 NEUPOGEN Neupogen injection syringe Products Affected 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 46 NEUPRO Neupro Products Affected 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 47 NEXAVAR Nexavar Products Affected 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 48 NUVIGIL/PROVIGIL Nuvigil Products Affected 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 49 OCTREOTIDE octreotide acetate injection solution Products Affected 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 50 OLYSIO Olysio Products Affected 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 51 ONCASPAR Oncaspar Products Affected 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 52 ONFI Onfi oral tablet 10 mg, 20 mg Products Affected 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 53 OPDIVO Opdivo intravenous solution 40 mg/4 mL Products Affected 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 54 PEGINTRON PegIntron Redipen Products Affected 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 55 PENICILLAMINE Depen Titratabs Products Affected 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 56 POMALYST Pomalyst Products Affected 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 57 PROCRIT 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 Products Affected 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 58 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 59 PROMACTA Promacta Products Affected 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 60 QUININE quinine sulfate Products Affected 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 61 REBIF Rebif Titration Pack Products Affected 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 62 REMICADE Remicade Products Affected 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 63 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 64 REVATIO sildenafil Products Affected 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 65 REVLIMID Revlimid Products Affected 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 66 RIBAVIRIN ribavirin oral tablet 200 mg Products Affected 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 67 RITUXAN Rituxan Products Affected 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 68 SABRIL Sabril Products Affected 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 69 SANDOSTATIN LAR Sandostatin LAR Depot intramuscular kit Products Affected 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 70 SIGNIFOR Signifor Products Affected 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 71 SOVALDI Sovaldi Products Affected 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 72 SPRYCEL Sprycel oral tablet 100 mg, 140 mg, 20 mg, 50 mg, 70 mg, 80 mg Products Affected 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 73 STIVARGA Stivarga Products Affected 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 74 SUTENT Sutent Products Affected 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 75 SYLATRON Sylatron Products Affected 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 76 SYNAGIS Synagis intramuscular solution 50 mg/0.5 mL Products Affected 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 77 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 78 TAFINLAR Tafinlar Products Affected 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 79 TARCEVA Tarceva oral tablet 100 mg, 150 mg, 25 mg Products Affected 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 80 TARGRETIN Targretin oral Products Affected 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 81 TASIGNA Tasigna Products Affected 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 82 THALOMID Thalomid Products Affected 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 83 THIORIDAZINE thioridazine Products Affected 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 84 TIRF MEDICATIONS fentanyl citrate buccal lozenge on a handle 1,200 mcg, 1,600 mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg Products Affected 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 85 TRACLEER Tracleer Products Affected 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 86 TRETINOIN tretinoin microspheres topical gel with pump tretinoin topical Products Affected adapalene topical cream adapalene topical gel 0.1 % 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 87 TYKERB Tykerb Products Affected 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 88 TYSABRI Tysabri Products Affected 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 89 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 90 VIEKIRA Viekira Pak Products Affected PA Criteria Criteria Details Covered Uses All FDA-approved indications not otherwise excluded from Part D. Exclusion Criteria Concurrent treatment with interferon, Sovaldi, Olysio, or Harvoni Required Medical Information Genotype and subtype 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: Gen-1a-no cirr+rbv, Gen-1b-no cirr, Gen-1b/cirr+rbv. 24WK: Gen-1a/cirr+rb, Liver tran+rbv. Other Criteria Geno 1a w/ or w/o cirrhosis-prescribed in combination with RBV. Geno 1b w/ cirrhosis-prescribed in combination with RBV.Liver transplant recipients with normal hepatic function and metavir score less than 2prescribed in combination with RBV. Updated: 07/2015 H0811_GN134_Web Prior Auth_Approved 91 VIMPAT Vimpat oral solution Vimpat oral tablet Products Affected Vimpat intravenous 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 92 VOTRIENT Votrient Products Affected 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 93 XALKORI Xalkori Products Affected 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 94 XENAZINE Xenazine Products Affected 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 95 XOLAIR Xolair Products Affected 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 96 XTANDI Xtandi Products Affected 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 97 ZELBORAF Zelboraf Products Affected 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 98 ZYDELIG Zydelig Products Affected 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 AST/ALT less than 20 x ULN and Bilirubin less than 10 x ULN. Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration Plan Year Other Criteria N/A Updated: 07/2015 H0811_GN134_Web Prior Auth_Approved 99 ZYKADIA Zykadia Products Affected 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 100 ZYVOX Zyvox intravenous parenteral solution 600 mg/300 mL Zyvox oral Products Affected linezolid 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 101 PART B VERSUS PART D Products Affected Abelcet Abilify intramuscular Abilify Maintena intramuscular suspension,extended rel recon 300 mg Abilify Maintena intramuscular suspension,extended rel syring acetylcysteine solution Actemra intravenous solution 200 mg/10 mL (20 mg/mL) acyclovir sodium intravenous solution Adagen Adrucil intravenous solution 500 mg/10 mL A-Hydrocort 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) Aminosyn-RF 5.2 % 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 Updated: 07/2015 H0811_GN134_Web Prior Auth_Approved 102 ampicillin-sulbactam intravenous recon soln 1.5 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) Beleodaq 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 in dextrose (iso-os) intravenous piggyback 1 gram/50 mL cefazolin injection recon soln 1 gram, 10 gram, 500 mg cefepime cefotaxime injection recon soln 1 gram, 2 gram, 500 mg 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 Intravenous CellCept oral suspension for reconstitution Cerebyx injection solution 500 mg PE/10 mL Cerezyme intravenous recon soln 400 unit chloramphenicol sod succinate cidofovir Cimzia Powder for Reconst ciprofloxacin lactate intravenous solution 400 mg/40 mL cisplatin cladribine clindamycin phosphate intravenous solution 600 mg/4 mL Clinimix 5%/D15W Sulfite Free Clinimix 5%/D25W sulfite-free Clinimix 2.75%/D5W Sulfit Free Clinimix 4.25%/D10W Sulf Free Clinimix 4.25%/D5W Sulfit Free Clinimix 4.25%-D20W sulf-free Clinimix 4.25%-D25W sulf-free Clinimix 5%-D20W(sulfite-free) Clinimix E 2.75%/D10W Sul Free Clinimix E 2.75%/D5W Sulf Free Clinimix E 4.25%/D10W Sul Free Clinimix E 4.25%/D25W Sul Free Clinimix E 4.25%/D5W Sulf Free Clinimix E 5%/D15W Sulfit Free Clinimix E 5%/D20W Sulfit Free Clinimix E 5%/D25W Sulfit Free Clinisol SF 15 % colistin (colistimethate Na) Cosmegen cromolyn inhalation Cubicin cyclophosphamide oral capsule cyclosporine intravenous cyclosporine modified cyclosporine oral capsule cytarabine D2.5 %-0.45 % sodium chloride D5 % and 0.9 % sodium chloride D5 %-0.45 % sodium chloride Updated: 07/2015 H0811_GN134_Web Prior Auth_Approved 103 dacarbazine intravenous recon soln 200 mg daunorubicin intravenous solution decitabine Delestrogen Depo-Provera intramuscular solution dexamethasone sodium phosphate injection dexrazoxane HCl intravenous recon soln 250 mg dextrose 10 % and 0.2 % NaCl dextrose 10 % in water (D10W) intravenous parenteral solution dextrose 5 % in water (D5W) intravenous parenteral solution dextrose 5 %-lactated ringers dextrose 5%-0.2 % sod chloride dextrose 5%-0.3 % sod.chloride Dextrose With Sodium Chloride Dextrose-KCl-NaCl diltiazem HCl intravenous diphenhydramine HCl injection solution 50 mg/mL Doxil doxorubicin intravenous solution 50 mg/25 mL Doxy-100 doxycycline hyclate intravenous dronabinol Duramorph (PF) injection solution 0.5 mg/mL, 1 mg/mL Elaprase Elelyso Elitek intravenous recon soln 1.5 mg Emend oral capsule 125 mg, 40 mg, 80 mg Emend oral capsule,dose pack Engerix-B (PF) intramuscular syringe Engerix-B Pediatric (PF) epirubicin intravenous solution 50 mg/25 mL Erythrocin intravenous recon soln 500 mg esomeprazole sodium estradiol valerate intramuscular oil 20 mg/mL etoposide intravenous Fabrazyme intravenous recon soln 35 mg famotidine (PF) famotidine (PF)-NaCl (iso-os) Faslodex fluconazole in dextrose(iso-o) intravenous piggyback 400 mg/200 mL fludarabine intravenous recon soln fluorouracil intravenous solution 2.5 gram/50 mL fluphenazine decanoate fluphenazine HCl injection fomepizole fosphenytoin injection solution 100 mg PE/2 mL furosemide injection ganciclovir sodium gemcitabine intravenous recon soln 1 gram Gemzar intravenous recon soln 1 gram Gengraf gentamicin in NaCl (iso-osm) intravenous piggyback 100 mg/100 mL gentamicin in NaCl (iso-osm) intravenous piggyback 80 mg/100 mL gentamicin injection solution 40 mg/mL gentamicin sulfate (PF) intravenous solution 80 mg/8 mL Geodon intramuscular granisetron (PF) intravenous solution 100 mcg/mL granisetron HCl intravenous solution 1 mg/mL (1 mL) granisetron HCl oral 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) 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) injection solution Hepatamine 8% Herceptin hydralazine injection hydromorphone (PF) injection solution 10 mg/mL hydroxyzine HCl intramuscular Updated: 07/2015 H0811_GN134_Web Prior Auth_Approved 104 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 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 Keytruda intravenous recon soln 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 in NaCl (iso-os) levetiracetam intravenous levocarnitine (with sugar) levocarnitine intravenous levocarnitine oral tablet levofloxacin intravenous levoleucovorin calcium levothyroxine intravenous recon soln 100 mcg lidocaine (PF) injection solution 5 mg/mL (0.5 %) lidocaine HCl injection solution 20 mg/mL (2 %) Liposyn III intravenous emulsion 10 %, 20 % magnesium sulfate injection melphalan HCl meropenem intravenous recon soln 500 mg mesna methadone injection methotrexate sodium (PF) methotrexate sodium oral 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 morphine intravenous syringe 10 mg/mL, 8 mg/mL Mozobil Mustargen mycophenolate mofetil mycophenolate sodium Myozyme nafcillin in dextrose iso-osm intravenous piggyback 1 gram/50 mL nafcillin injection recon soln 1 gram nafcillin injection recon soln 10 gram 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 (PF) ondansetron HCl oral solution ondansetron HCl oral tablet 24 mg, 4 mg, 8 mg oxacillin in dextrose(iso-osm) oxacillin injection recon soln 10 gram oxacillin intravenous recon soln 2 gram oxaliplatin intravenous solution 100 mg/20 mL paclitaxel pamidronate intravenous solution paricalcitol oral Updated: 07/2015 H0811_GN134_Web Prior Auth_Approved 105 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 Recombivax HB (PF) intramuscular syringe 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 streptomycin intramuscular sulfamethoxazole-trimethoprim intravenous Synercid Synribo tacrolimus oral tacrolimus oral Teflaro terbutaline subcutaneous testosterone cypionate intramuscular oil 200 mg/mL 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 Treanda intravenous solution 45 mg/0.5 mL 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 Vincasar PFS intravenous solution 1 mg/mL 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 Zyprexa Relprevv intramuscular suspension for reconstitution 210 mg 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: 07/2015 H0811_GN134_Web Prior Auth_Approved 106 Index Avastin .................................................... 102 Avelox in NaCl (iso-osmotic) ................. 102 Avonex (with albumin) ............................... 8 Avonex intramuscular syringe kit ............... 8 Azasan ..................................................... 102 azathioprine ............................................. 102 azithromycin ........................................... 102 B BACiiM................................................... 102 bacitracin ................................................. 102 BCG vaccine, live (PF) ........................... 102 Beleodaq ................................................. 102 Benlysta................................................... 102 benztropine.............................................. 102 benztropine oral ........................................ 26 Bicillin C-R ............................................. 102 BiCNU .................................................... 102 bleomycin ................................................ 102 Bosulif ......................................................... 9 budesonide .............................................. 102 buprenorphine HCl.................................. 102 Busulfex .................................................. 102 butalbital-acetaminop-caf-cod .................. 26 C calcitriol .................................................. 102 Cancidas .................................................. 102 Capastat ................................................... 102 carboplatin............................................... 102 cefazolin .................................................. 102 cefazolin in dextrose (iso-os) .................. 102 cefepime .................................................. 102 cefotaxime ............................................... 102 cefoxitin .................................................. 102 cefoxitin in dextrose, iso-osm ................. 102 ceftazidime .............................................. 102 ceftriaxone............................................... 102 cefuroxime sodium.................................. 102 CellCept .................................................. 103 CellCept Intravenous .............................. 103 Cerebyx ................................................... 103 Cerezyme ................................................ 103 chloramphenicol sod succinate ............... 103 chorionic gonadotropin, human ................ 10 Cialis oral tablet 2.5 mg, 5 mg .................. 11 A Abelcet .................................................... 102 Abilify ..................................................... 102 Abilify Maintena ..................................... 102 acetylcysteine .......................................... 102 Actemra ................................................... 102 Acthar H.P................................................... 1 Actimmune.................................................. 2 acyclovir sodium ..................................... 102 Adagen .................................................... 102 adapalene topical cream ............................ 87 adapalene topical gel 0.1 % ...................... 87 Adcirca ........................................................ 3 Adrucil .................................................... 102 Afinitor........................................................ 4 Afinitor Disperz .......................................... 4 A-Hydrocort ............................................ 102 albuterol sulfate ....................................... 102 Aldurazyme ............................................. 102 Alimta ..................................................... 102 alprazolam ................................................. 27 AmBisome .............................................. 102 amifostine crystalline .............................. 102 amikacin .................................................. 102 aminophylline ......................................... 102 Aminosyn 8.5 %-electrolytes .................. 102 Aminosyn II 10 % ................................... 102 Aminosyn II 15 % ................................... 102 Aminosyn II 7 % ..................................... 102 Aminosyn II 8.5 % .................................. 102 Aminosyn II 8.5 %-electrolytes .............. 102 Aminosyn M 3.5 % ................................. 102 Aminosyn-HBC 7% ................................ 102 Aminosyn-PF 10 % ................................. 102 Aminosyn-PF 7 % (sulfite-free).............. 102 Aminosyn-RF 5.2 % ............................... 102 amiodarone .............................................. 102 amphotericin B ........................................ 102 ampicillin sodium.................................... 102 ampicillin-sulbactam ............................... 102 Ampyra ....................................................... 5 Aralast NP ............................................... 102 Arcalyst ....................................................... 7 Astagraf XL ............................................ 102 Updated: 07/2015 H0811_GN134_Web Prior Auth_Approved 107 cidofovir .................................................. 103 Cimzia Powder for Reconst .................... 103 Cinryze ...................................................... 12 ciprofloxacin lactate ................................ 103 cisplatin ................................................... 103 cladribine................................................. 103 clemastine oral syrup ................................ 26 clemastine oral tablet 2.68 mg .................. 26 clindamycin phosphate............................ 103 Clinimix 5%/D15W Sulfite Free ........... 103 Clinimix 5%/D25W sulfite-free ............. 103 Clinimix 2.75%/D5W Sulfit Free ........... 103 Clinimix 4.25%/D10W Sulf Free ........... 103 Clinimix 4.25%/D5W Sulfit Free ........... 103 Clinimix 4.25%-D20W sulf-free ............ 103 Clinimix 4.25%-D25W sulf-free ............ 103 Clinimix 5%-D20W(sulfite-free) ............ 103 Clinimix E 2.75%/D10W Sul Free ......... 103 Clinimix E 2.75%/D5W Sulf Free .......... 103 Clinimix E 4.25%/D10W Sul Free ......... 103 Clinimix E 4.25%/D25W Sul Free ......... 103 Clinimix E 4.25%/D5W Sulf Free .......... 103 Clinimix E 5%/D15W Sulfit Free ........... 103 Clinimix E 5%/D20W Sulfit Free ........... 103 Clinimix E 5%/D25W Sulfit Free ........... 103 Clinisol SF 15 % ..................................... 103 clonazepam ............................................... 28 clorazepate dipotassium ............................ 28 colistin (colistimethate Na) ..................... 103 Cometriq ................................................... 13 Copaxone subcutaneous syringe 20 mg/mL, 40 mg/mL .............................................. 14 Cosmegen ................................................ 103 cromolyn ................................................. 103 Cubicin .................................................... 103 cyclobenzaprine oral tablet ....................... 26 cyclophosphamide................................... 103 cyclosporine ............................................ 103 cyclosporine modified ............................. 103 cyproheptadine .......................................... 26 cytarabine ................................................ 103 D D2.5 %-0.45 % sodium chloride ............. 103 D5 % and 0.9 % sodium chloride ........... 103 D5 %-0.45 % sodium chloride ................ 103 dacarbazine ............................................. 103 daunorubicin ........................................... 103 decitabine ................................................ 103 Delestrogen ............................................. 103 Demser ...................................................... 15 Depen Titratabs ......................................... 56 Depo-Provera .......................................... 103 dexamethasone sodium phosphate .......... 103 dexrazoxane HCl ..................................... 103 dextrose 10 % and 0.2 % NaCl ............... 103 dextrose 10 % in water (D10W) ............. 103 dextrose 5 % in water (D5W) ................. 103 dextrose 5 %-lactated ringers .................. 103 dextrose 5%-0.2 % sod chloride ............. 103 dextrose 5%-0.3 % sod.chloride ............. 103 Dextrose With Sodium Chloride ............. 103 Dextrose-KCl-NaCl ................................ 103 Diastat ....................................................... 28 Diastat AcuDial ......................................... 28 Diazepam Intensol .................................... 28 diazepam oral solution 5 mg/5 mL ........... 28 diazepam oral tablet .................................. 28 diazepam rectal ......................................... 28 diclofenac sodium topical gel ................... 16 diltiazem HCl .......................................... 103 diphenhydramine HCl ............................. 103 Doxil ....................................................... 103 doxorubicin ............................................. 103 Doxy-100 ................................................ 103 doxycycline hyclate ................................ 103 dronabinol ............................................... 103 Duramorph (PF) ...................................... 103 E Egrifta subcutaneous recon soln 2 mg ...... 17 Elaprase ................................................... 103 Elelyso..................................................... 103 Eligard ....................................................... 41 Elitek ....................................................... 103 Emend ..................................................... 103 Engerix-B (PF) ........................................ 103 Engerix-B Pediatric (PF)......................... 103 epirubicin ................................................ 103 Erivedge .................................................... 18 Erwinaze ................................................... 19 Erythrocin ............................................... 103 esomeprazole sodium .............................. 103 estradiol oral.............................................. 29 Updated: 07/2015 H0811_GN134_Web Prior Auth_Approved 108 estradiol valerate ..................................... 103 eszopiclone................................................ 26 etoposide ................................................. 103 Extavia subcutaneous kit........................... 20 F Fabrazyme ............................................... 103 famotidine (PF) ....................................... 103 famotidine (PF)-NaCl (iso-os) ............... 103 Farydak ..................................................... 21 Faslodex .................................................. 103 fentanyl citrate buccal lozenge on a handle 1,200 mcg, 1,600 mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg ........................ 85 fluconazole in dextrose(iso-o)................. 103 fludarabine .............................................. 103 fluorouracil .............................................. 104 fluphenazine decanoate ........................... 104 fluphenazine HCl .................................... 104 fomepizole............................................... 104 fosphenytoin ............................................ 104 furosemide............................................... 104 G Gammagard Liquid ................................... 35 Gamunex-C injection solution 1 gram/10 mL (10 %) ............................................. 35 ganciclovir sodium .................................. 104 gemcitabine ............................................. 104 Gemzar .................................................... 104 Gengraf ................................................... 104 gentamicin ............................................... 104 gentamicin in NaCl (iso-osm) ................. 104 gentamicin sulfate (PF) ........................... 104 Geodon .................................................... 104 Gilotrif....................................................... 22 Gleevec oral tablet 100 mg, 400 mg ......... 23 granisetron (PF) ...................................... 104 granisetron HCl ....................................... 104 H haloperidol decanoate ............................. 104 haloperidol lactate ................................... 104 Havrix (PF) ............................................. 104 heparin (porcine) ..................................... 104 heparin (porcine) in 5 % dex ................... 104 Hepatamine 8% ....................................... 104 Herceptin ................................................. 104 hydralazine .............................................. 104 hydromorphone (PF) ............................... 104 hydroxyzine HCl ..................................... 104 I Ibrance....................................................... 30 Iclusig ........................................................ 31 idarubicin ................................................ 104 Ifex .......................................................... 104 ifosfamide ............................................... 104 Ilaris (PF) .................................................. 32 Imbruvica .................................................. 33 imipenem-cilastatin ................................. 104 Increlex ................................................... 104 Inlyta ......................................................... 34 Intralipid .................................................. 104 Intron A ................................................... 104 Invanz ...................................................... 104 Invega Sustenna ...................................... 104 Ionosol-B in D5W ................................... 104 Ionosol-MB in D5W ............................... 104 ipratropium bromide ............................... 104 ipratropium-albuterol .............................. 104 irinotecan................................................. 104 Istodax ..................................................... 104 J Jakafi oral tablet 10 mg, 15 mg, 20 mg, 25 mg, 5 mg ............................................... 36 K Kadcyla ................................................... 104 Keytruda .................................................. 104 Kuvan oral tablet,soluble .......................... 37 L labetalol ................................................... 104 Lanoxin oral .............................................. 26 Lenvima .................................................... 38 Letairis ...................................................... 39 leucovorin calcium .................................. 104 Leukine injection recon soln ..................... 40 levalbuterol HCl ...................................... 104 levetiracetam ........................................... 104 levetiracetam in NaCl (iso-os) ................ 104 levocarnitine ............................................ 104 levocarnitine (with sugar) ....................... 104 levofloxacin............................................. 104 levoleucovorin calcium ........................... 104 levothyroxine .......................................... 104 lidocaine (PF) .......................................... 104 Updated: 07/2015 H0811_GN134_Web Prior Auth_Approved 109 lidocaine HCl .......................................... 104 lidocaine topical adhesive patch,medicated ............................................................... 42 linezolid................................................... 101 Liposyn III .............................................. 104 Lorazepam Intensol ................................... 27 lorazepam oral tablet ................................. 27 Lupron Depot ............................................ 41 Lupron Depot (3 Month) ........................... 41 Lupron Depot (4 Month) ........................... 41 Lupron Depot (6 Month) ........................... 41 Lupron Depot-Ped intramuscular kit 11.25 mg, 15 mg ............................................. 41 Lynparza ................................................... 43 M magnesium sulfate .................................. 104 Mekinist .................................................... 44 melphalan HCl ........................................ 104 meprobamate ............................................. 26 meropenem .............................................. 104 mesna ...................................................... 104 metaxalone ................................................ 26 methadone ............................................... 104 methotrexate sodium ............................... 104 methotrexate sodium (PF) ....................... 104 methyldopa-hydrochlorothiazide .............. 26 methylprednisolone acetate ..................... 104 methylprednisolone sodium succ ............ 104 metoclopramide HCl ............................... 105 metoprolol tartrate ................................... 105 Miacalcin................................................. 105 mitomycin ............................................... 105 mitoxantrone ........................................... 105 modafinil ................................................... 49 morphine ................................................. 105 Mozobil ................................................... 105 Mustargen ............................................... 105 mycophenolate mofetil............................ 105 mycophenolate sodium ........................... 105 Myozyme ................................................ 105 N nafcillin ................................................... 105 nafcillin in dextrose iso-osm ................... 105 Naglazyme .............................................. 105 nalbuphine ............................................... 105 Namenda ................................................... 45 Namenda Titration Pak ............................. 45 Namenda XR ............................................. 45 Nebupent ................................................. 105 Neoral ...................................................... 105 Nephramine 5.4 % .................................. 105 Neumega ................................................. 105 Neupogen injection solution 480 mcg/1.6 mL ......................................................... 46 Neupogen injection syringe ...................... 46 Neupro....................................................... 47 Nexavar ..................................................... 48 Nexium IV .............................................. 105 nitrofurantoin macrocrystal oral capsule 50 mg ......................................................... 26 nitrofurantoin monohyd/m-cryst ............... 26 nitroglycerin ............................................ 105 Norditropin FlexPro subcutaneous pen injector 10 mg/1.5 mL (6.7 mg/mL), 15 mg/1.5 mL (10 mg/mL), 5 mg/1.5 mL (3.3 mg/mL) .......................................... 24 Norditropin Nordiflex ............................... 24 Normosol-M in 5 % dextrose.................. 105 Normosol-R in 5 % dextrose................... 105 Normosol-R pH 7.4................................. 105 Novarel ...................................................... 10 Nulojix .................................................... 105 Nuvigil ...................................................... 49 O octreotide acetate injection solution.......... 50 Olysio ........................................................ 51 Oncaspar ................................................... 52 ondansetron ............................................. 105 ondansetron HCl ..................................... 105 ondansetron HCl (PF) ............................. 105 Onfi oral suspension ................................. 53 Onfi oral tablet 10 mg, 20 mg ................... 53 Opdivo intravenous solution 40 mg/4 mL 54 oxacillin................................................... 105 oxacillin in dextrose(iso-osm)................. 105 oxaliplatin ............................................... 105 oxazepam .................................................. 27 P paclitaxel ................................................. 105 pamidronate............................................. 105 paricalcitol............................................... 105 PegIntron ................................................... 55 Updated: 07/2015 H0811_GN134_Web Prior Auth_Approved 110 PegIntron Redipen .................................... 55 penicillin G potassium ............................ 105 penicillin G procaine ............................... 105 penicillin G sodium ................................. 105 Pentam..................................................... 105 Perforomist .............................................. 105 Perjeta ..................................................... 105 phenytoin sodium .................................... 105 piperacillin-tazobactam ........................... 105 Plasma-Lyte 148 ..................................... 105 Plasma-Lyte A ........................................ 105 Plasma-Lyte-56 in 5 % dextrose ............. 105 Pomalyst .................................................... 57 potassium chlorid-D5-0.45%NaCl .......... 105 potassium chloride in 0.9%NaCl ............ 105 potassium chloride in 5 % dex ................ 105 potassium chloride in LR-D5 .................. 105 potassium chloride-D5-0.2%NaCl .......... 105 potassium chloride-D5-0.3%NaCl .......... 105 potassium chloride-D5-0.9%NaCl .......... 105 Pregnyl ...................................................... 10 Premarin .................................................. 105 Premasol 10 % ........................................ 105 Premasol 6 % .......................................... 105 Procalamine 3% ...................................... 105 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 ............................................................... 58 Proleukin ................................................. 105 Prolia ....................................................... 105 Promacta ................................................... 60 propranolol .............................................. 105 Prosol 20 % ............................................. 105 Pulmozyme ............................................. 105 Q Qudexy XR ................................................. 6 quinine sulfate ........................................... 61 R ranitidine HCl.......................................... 105 Rapamune ............................................... 105 Rebif (with albumin) ................................. 62 Rebif Titration Pack .................................. 62 Recombivax HB (PF) .............................. 105 Remicade................................................... 63 Remodulin ............................................... 105 reserpine .................................................... 26 Revlimid.................................................... 66 Rheumatrex ............................................. 105 ribavirin oral capsule................................. 67 ribavirin oral tablet 200 mg....................... 67 rifampin ................................................... 105 ringers ..................................................... 105 Risperdal Consta ..................................... 105 Rituxan ...................................................... 68 S Sabril ......................................................... 69 Sancuso ................................................... 105 Sandimmune ........................................... 105 Sandostatin LAR Depot intramuscular kit 70 Signifor ..................................................... 71 sildenafil .................................................... 65 Simulect .................................................. 105 sirolimus.................................................. 106 Solu-Cortef (PF)...................................... 106 Somatuline Depot.................................... 106 Somavert ................................................. 106 Sovaldi ...................................................... 72 Sprycel oral tablet 100 mg, 140 mg, 20 mg, 50 mg, 70 mg, 80 mg ............................ 73 Stivarga ..................................................... 74 streptomycin ............................................ 106 sulfamethoxazole-trimethoprim .............. 106 Surmontil................................................... 29 Sutent ........................................................ 75 Sylatron ..................................................... 76 Synagis intramuscular solution 50 mg/0.5 mL ......................................................... 77 Synercid .................................................. 106 Synribo .................................................... 106 T tacrolimus ................................................ 106 Tafinlar ...................................................... 79 Tarceva oral tablet 100 mg, 150 mg, 25 mg ............................................................... 80 Targretin oral ............................................ 81 Tasigna ...................................................... 82 Teflaro ..................................................... 106 temazepam ................................................ 27 terbutaline ............................................... 106 testosterone cypionate ............................. 106 testosterone enanthate ............................. 106 Updated: 07/2015 H0811_GN134_Web Prior Auth_Approved 111 tetanus toxoid,adsorbed (PF) .................. 106 tetanus-diphtheria toxoids-Td ................. 106 Thalomid ................................................... 83 thioridazine ............................................... 84 tobramycin in 0.225 % NaCl .................. 106 tobramycin sulfate ................................... 106 topiramate oral capsule, sprinkle ................ 6 topiramate oral tablet .................................. 6 Toposar ................................................... 106 topotecan ................................................. 106 TPN Electrolytes ..................................... 106 Tracleer ..................................................... 86 tranexamic acid ....................................... 106 Travasol 10 % ......................................... 106 Treanda ................................................... 106 Trelstar .................................................... 106 tretinoin microspheres topical gel with pump ............................................................... 87 tretinoin topical ......................................... 87 Trisenox .................................................. 106 TrophAmine 10 %................................... 106 Trophamine 6% ....................................... 106 Twinrix (PF)............................................ 106 Tykerb ....................................................... 88 Tysabri ...................................................... 89 V valproate sodium ..................................... 106 vancomycin ............................................. 106 Vaqta (PF) ............................................... 106 Velcade ................................................... 106 verapamil................................................. 106 Viekira Pak................................................ 91 Vimpat intravenous ................................... 92 Vimpat oral solution ................................. 92 Vimpat oral tablet ..................................... 92 vinblastine ............................................... 106 Vincasar PFS ........................................... 106 vincristine ................................................ 106 vinorelbine .............................................. 106 Virazole ................................................... 106 voriconazole ............................................ 106 Votrient ..................................................... 93 VPRIV..................................................... 106 X Xalkori ...................................................... 94 Xenazine ................................................... 95 Xgeva ...................................................... 106 Xolair ........................................................ 96 Xtandi ........................................................ 97 Z Zaltrap ..................................................... 106 Zelboraf ..................................................... 98 Zemplar ................................................... 106 zoledronic acid ........................................ 106 zoledronic acid-mannitol-water .............. 106 Zometa .................................................... 106 zonisamide .................................................. 6 Zortress ................................................... 106 Zydelig ...................................................... 99 Zykadia ................................................... 100 Zyprexa Relprevv.................................... 106 Zyvox intravenous parenteral solution 600 mg/300 mL .......................................... 101 Zyvox oral ............................................... 101 Updated: 07/2015 H0811_GN134_Web Prior Auth_Approved 112 GuildNet Gold Plus FIDA Plan is an MMP-POS plan with a Medicare and New York State Medicaid contract. Enrollment in GuildNet Gold Plus FIDA Plan depends on contract renewal. Beneficiaries must use network pharmacies to access their premium and/or copayment/coinsurance may change on January 1, 2016. This document includes GuildNet Gold Plus FIDA Plan’s partial formulary as of July 1, 2015. For a complete, updated formulary, please visit our website at www.guildnetny.org or call 1-800815-0000 (TTY 1-800-662-1220). For alternative formats or language, please call Participant Services toll free at: 1-800-815-0000, Monday through Sunday from 8am to 8pm. TTY/TDD users should call 1-800-662-1220. You can get this information for free in other languages. Call 1-800-815-0000 and TTY/TDD 1800-662-1220 during 8am to 8pm. The call is free. Usted puede obtener esta información en otros idiomas gratis. Llame al 1-800-815-0000 o TTY/TDD al 1-800-662-1220, de lunes a domingo de 8am a 8pm. La llamada es gratis. Queste informazioni sono disponibili gratuitamente in altre lingue. Chiamare il numero verde 1800-815-0000 o 1-800-662-1220 mediante un telefono testuale per non udenti (TTY/TDD), da lunedì a domenica, dalle 8 alle 20. La chiamata è gratuita. 您可以免費獲得本信息的其他語言版本。請撥打 1-800-815-0000 或聽障／語障人士專線(TTY/TDD) 1800-662-1220，星期一至星期日上午8 時至晚上8 時。撥打該電話免費。 Ou kapab jwenn enfòmasyon sa yo gratis nan lòt lang. Rele nimewo 1-800-815-0000 oswa TTY/TDD 1-800-662-1220, lendi jiska dimanch, depi 8am jiska 8pm. Koutfil la gratis. 다른 언어로 작성된 이 정보를 무료로 얻으실 수 있습니다. 월요일 - 일요일 오전 8시부터 오후 8시 사이에 1-800-815-0000번이나 TTY/TDD 1-800-662-1220번으로 전화주세요. 통화는 무료입니다. Вы можете бесплатно получить эту информацию на других языках. Позвоните по телефону 1-800-815-0000 и TTY/TDD 1-800-662-1220. Служба работает с понедельника по воскресенье с 08:00 до 20:00 ч. Звонок бесплатный. The State of New York has created a participant ombudsman program called the Independent Consumer Advocacy Network (ICAN) to provide Participants free, confidential assistance on any services offered by GuildNet Gold Plus FIDA Plan. ICAN may be reached toll-free at 1-844614-8800 or online at icannys.org. 15387 v10 Updated: 07/2015 H0811_GN134_Web Prior Auth_Approved 113
Source Exif Data:
File Type : PDF File Type Extension : pdf MIME Type : application/pdf PDF Version : 1.5 Linearized : No Page Count : 114 Language : en-US Tagged PDF : Yes Author : Torhan, Iryna Creator : Microsoft® Word 2010 Create Date : 2015:06:30 11:48:12-04:00 Modify Date : 2015:06:30 11:48:12-04:00 Producer : Microsoft® Word 2010EXIF Metadata provided by EXIF.tools