Emblem MAPD 2016 Part D Prior Authorization Criteria 5
User Manual: Part-D-Prior-Authorization-Criteria-5
Open the PDF directly: View PDF 
.
Page Count: 160
| Download | |
| Open PDF In Browser | View PDF |
2016 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: 09/2016 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: 09/2016 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 3 ADEMPAS Adempas 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 PAH and CTEPH- must be precribed by or in consultation with a cardiologist or a pulmonologist. Coverage Duration Plan Year Other Criteria For PAH - must have PAH (WHO Group 1) and had a right heart catheterization to confirm the diagnosis of PAH (WHO Group 1). Right heart cathererization is not required in pts who are currently receiving Adempas or another agent indicated for WHO group 1. Updated: 09/2016 H0811_GN134_Web Prior Auth_Approved 4 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 5 ALECENSA Alecensa Products Affected PA Criteria Criteria Details Covered Uses All FDA-approved indications not otherwise excluded from Part D. Patients already started on Alecensa for a covered use Exclusion Criteria Xalkori (Crizotinib) treatment naive patients Required Medical Information Confirmed ALK-positive NSCLC as detected by an FDA-approved test and prior therapies tried Age Restrictions 18 years and older Prescriber Restrictions Prescribed by, or in consultation with, an Oncologist Coverage Duration Plan Year Other Criteria Anaplastic lymphoma kinase (ALK)-positive, metastatic non-small cell lung cancer (NSCLC): The patient has metastatic ALK-positive NSCLC as detected by an FDA-approved test AND The patient has progressed on or are intolerant to Xalkori (crizotinib) Updated: 09/2016 H0811_GN134_Web Prior Auth_Approved 6 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 7 ANTICONVULSANTS topiramate oral tablet zonisamide Products Affected topiramate oral capsule, sprinkle topiramate oral capsule,sprinkle,ER 24hr 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 8 APOKYN APOKYN 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 9 APTIOM Aptiom 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 10 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 Plan Year Other Criteria CAPS renewal - approve if they have had a response and are continuing therapy to maintain response/remission. Updated: 09/2016 H0811_GN134_Web Prior Auth_Approved 11 AVONEX Avonex intramuscular pen injector kit 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 12 BANZEL Banzel oral tablet 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 13 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 14 BRIVIACT Briviact 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 15 CABOMETYX Cabometyx Products Affected PA Criteria Criteria Details Covered Uses All medically accepted indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information Diagnosis, medication history, histology, RET gene rearrangement status Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration Plan Year Other Criteria Advance Renal Cell Carcinoma-Patients must meet both 1 AND 2-1. Patient has RCC with predominant clear-cell histology 2. Patient has tried one tyrosine kinase inhibitor therapy (e.g., Sutent [sunitinib malate capsules], Votrient [pazopanib tablets], Inlyta [axitinib tablets], Nexavar [sorafenib tosylate tablets]). Updated: 09/2016 H0811_GN134_Web Prior Auth_Approved 16 CARBAGLU Carbaglu 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 17 CHOLBAM Cholbam 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 baseline liver function tests Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration Initial approval for 3 months, continuation approval for plan year Other Criteria For continuation of therapy to be approved patient must meet 2 of the 3 following lab criteria or meet 1 of the 3 follow lab criteria and have body weight increased by 10% or stable at greater than the 50th percentile. Lab criteria: (1) patient alanine aminotransferase (ALT) or aspartate aminotransferase (AST) less than 50 U/L or the baseline levels reduced by 80%, (2) patient total bilirubin level must be reduced to less than or equal to 1 mg/dL, (3) patient must not have evidence of cholestasis on liver biopsy. Updated: 09/2016 H0811_GN134_Web Prior Auth_Approved 18 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 19 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 20 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 21 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 22 COPAXONE Copaxone subcutaneous syringe 20 mg/mL, 40 mg/mL Glatopa 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), mitoxantrone, fingolimod, teriflunomide, or dimethyl fumarate. 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 23 COTELLIC Cotellic 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 Previous therapies tried, presence of BRAF V600E or V600K mutation confirmed by an FDA approved test Age Restrictions 18 years and older Prescriber Restrictions Prescribed by, or in consultation with, an Oncologist Coverage Duration Plan Year Other Criteria Melanoma - being prescribed in combination with vemurafenib Updated: 09/2016 H0811_GN134_Web Prior Auth_Approved 24 CYRAMZA Cyramza 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 Previous therapies tried Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration Plan Year Other Criteria For gastric cancer or malignant neoplasm of cardio-esophageal junction of stomach, prior therapy with fluoropyrimidine- or platinum-containing therapy. For metastatic colorectal cancer, in combination with 5fluorouracil, leucovorin, irinotecan (FOLFIRI) and prior therapy with Avastin (bevacizumab), oxaliplatin, and a fluoropyrimidine. For metastatic NSCLC, in combination with docetaxel and prior therapy with platinum-based chemotherapy. Part B versus D determination per CMS guidance. Updated: 09/2016 H0811_GN134_Web Prior Auth_Approved 25 DARZALEX Darzalex Products Affected PA Criteria Criteria Details Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria Treatment-naive patients Required Medical Information History of previous treatments Age Restrictions N/A Prescriber Restrictions Prescribed by, or in consultation with, an Oncologist Coverage Duration Plan Year Other Criteria For the treatment of Multiple myeloma treatment patients must have received at least three prior lines of therapy including a proteasome inhibitor (PI) and an immunomodulatory agent or are double-refractory to a PI and an immunomodulatory agent. Updated: 09/2016 H0811_GN134_Web Prior Auth_Approved 26 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 27 DICLOFENAC GEL diclofenac sodium topical gel 3 % 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 28 EGRIFTA Egrifta subcutaneous recon soln 1 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 29 EMPLICITI Empliciti Products Affected PA Criteria Criteria Details Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria Treatment-naive patients Required Medical Information History of previous treatments Age Restrictions N/A Prescriber Restrictions Prescribed by, or in consultation with, an Oncologist Coverage Duration Plan Year Other Criteria For the treatment of multiple myeloma, patient must have received atleast one prior therapy. Part B versus Part D determination will be made at time of prior authorization review per CMS guidance. Updated: 09/2016 H0811_GN134_Web Prior Auth_Approved 30 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 patients BCC has recurred following surgery or the patient is not a candidate for surgery or radiation therapy. Updated: 09/2016 H0811_GN134_Web Prior Auth_Approved 31 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 32 ESBRIET Esbriet Products Affected PA Criteria Criteria Details Covered Uses All FDA-approved indications not otherwise excluded from Part D. Exclusion Criteria Combination use with Nintedanib Required Medical Information N/A Age Restrictions 18 years of age and older Prescriber Restrictions Prescribed by or in combination with a pulmonologist Coverage Duration Plan Year Other Criteria IPF baseline - must have FVC greater than or equal to 50 percent of the predicted value AND IPF must be diagnosed with either findings on highresolution computed tomography (HRCT) indicating usual interstitial pneumonia (UIP) or surgical lung biopsy demonstrating UIP. Updated: 09/2016 H0811_GN134_Web Prior Auth_Approved 33 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, Extavia, or Rebif), mitoxantrone, fingolimod, teriflunomide, or dimethyl fumarate. 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 34 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 35 FERRIPROX Ferriprox oral tablet 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 36 FIRAZYR Firazyr 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 Prescribed by, or in consultation with, an allergist/immunologist or a physican that specializes in the treatment of HAE or related disorders. Coverage Duration Plan Year Other Criteria N/A Updated: 09/2016 H0811_GN134_Web Prior Auth_Approved 37 FYCOMPA Fycompa oral tablet Products Affected Fycompa 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 N/A Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration Plan Year Other Criteria N/A Updated: 09/2016 H0811_GN134_Web Prior Auth_Approved 38 GATTEX Gattex One-Vial 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 39 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 40 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 41 GROWTH HORMONE Norditropin FlexPro Products Affected PA Criteria Criteria Details Covered Uses All medically accepted 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 2.5 cm per year and for PWS only: improved body composition. For renewal for adult patients: patient has seen clinical improvement. Age Restrictions For Turner syndrome and SGA, 2 years of age and older. For Noonan syndrome and SHOX, 3 years of age and older. Prescriber Restrictions Endocrinologist, Pediatric Nephrologist, Gastroenterologist, Nutritional Support Specialist, Infectious Disease Specialist Coverage Duration Plan Year Other Criteria N/A Updated: 09/2016 H0811_GN134_Web Prior Auth_Approved 42 HARVONI Harvoni 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 Viekira Required Medical Information Prior to initiating therapy, detectable levels of HCV RNA in the serum. Genotype 1, 4, 5, 6. Cirrhosis documented by FibroScan, liver biopsy, or radiological imaging Age Restrictions 18 years or older Prescriber Restrictions Prescribed by or in consultation w/ GI, hepatologist, ID, or a liver transplant MD Coverage Duration 24WK: Gen 1-exp w cirr, Gen1/4 trans. 12WK: Gen 1-nv, exp w/o cirr, Gen 4/5/ 6, Gen 1/4 trans +RBV Other Criteria N/A Updated: 09/2016 H0811_GN134_Web Prior Auth_Approved 43 HETLIOZ Hetlioz 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 the indication of Non-24-Hour Sleep-Wake Disorder (Non-24), approval will only be granted for patients who are totally blind. Updated: 09/2016 H0811_GN134_Web Prior Auth_Approved 44 HRM Products Affected benztropine oral butalbital-acetaminop-caf-cod clemastine oral tablet 2.68 mg cyclobenzaprine oral tablet cyproheptadine dicyclomine oral capsule dicyclomine oral solution dicyclomine oral tablet Digitek digoxin injection solution digoxin oral solution 50 mcg/mL digoxin oral tablet ergoloid Lanoxin oral meprobamate metaxalone methyldopa-hydrochlorothiazide promethazine oral tablet reserpine trihexyphenidyl 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 45 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 if the patient has tried one other agent for this condition (eg, ropinirole, pramipexole, carbidopa-levodopa [immediate-release or extendedrelease]). 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 46 HRM BENZODIAZEPINES/ANTICONVULSANTS Products Affected clonazepam clorazepate dipotassium Diastat Diazepam Intensol diazepam oral solution 5 mg/5 mL (1 mg/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: 09/2016 H0811_GN134_Web Prior Auth_Approved 47 HRM PD Products Affected amitriptyline clomipramine doxepin oral estradiol oral imipramine HCl imipramine pamoate megestrol oral tablet perphenazine-amitriptyline phenobarbital Surmontil trimipramine 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 48 HYDROXYPROGESTERONE hydroxyprogesterone caproate 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 49 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 50 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 51 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 Plan Year 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 52 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 For patients with mantle cell lymphoma (MCL)-history of prior treatment. For patients with chronic lymphoid leukemia (CLL)-one prior treatment or 17p chromosome deletion Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration Plan Year Other Criteria N/A Updated: 09/2016 H0811_GN134_Web Prior Auth_Approved 53 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 54 IRESSA Iressa 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 Prescribed by, or in consultation with, an Oncologist Coverage Duration Plan Year Other Criteria Metastatic NSCLC - The patient has epidermal growth factor receptor (EGFR) exon 19 deletions OR has exon 21 (L858R) substitution mutations as detected by an FDA-approved test. Updated: 09/2016 H0811_GN134_Web Prior Auth_Approved 55 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 pts home. Updated: 09/2016 H0811_GN134_Web Prior Auth_Approved 56 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 57 JUXTAPID Juxtapid 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 58 KALYDECO Kalydeco 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 59 KEVEYIS Keveyis Products Affected PA Criteria Criteria Details Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria Patient with history of hypersensitivity to diclorphenamide or other sulfonamides, Patient on high dose aspirin, Patient with severe pulmonary disease, Patient with hepatic insufficiency Required Medical Information N/A Age Restrictions N/A Prescriber Restrictions Prescribed by or in consultation with a neurologist or a physician who specializes in the care of patients with primary periodic paralysis (e.g., muscle disease specialist, physiatrist). Coverage Duration Initial therapy - 2 months, Continuing therapy - plan year Updated: 09/2016 H0811_GN134_Web Prior Auth_Approved 60 PA Criteria Criteria Details Other Criteria Hyperkalemic Periodic Paralysis (HyperPP) and Related Variants: Patient has a confirmed diagnosis of primary hyperkalemic periodic paralysis by meeting at least ONE of the following criteria: Patient has had an increase from baseline in serum potassium concentration of greater than or equal to 1.5 mEq/L during a paralytic attack OR Patient has had a serum potassium concentration during a paralytic attack of greater than 5.0 mEq/L OR Patient has a family history of the condition OR Patient has a genetically confirmed skeletal muscle sodium channel mutation AND The prescribing physician has excluded other reasons for acquired hyperkalemia (e.g., drug abuse, renal and adrenal dysfunction) For Continuation of treatment a patient has decrease in the frequency or severity of paralytic attacks with treatment as determined by the prescribing physician. For Hypokalemic Periodic Paralysis (HypoPP) and Related Variants for Initiation of treatment: Patient has a confirmed diagnosis of primary hypokalemic periodic paralysis by meeting at least ONE of the following: Patient has had a serum potassium concentration of less than 3.5 mEq/L during a paralytic attack OR Patient has a family history of the condition OR Patient has a genetically confirmed skeletal muscle calcium or sodium channel mutation AND Patient has had improvements in paralysis attack symptoms with potassium intake. For Continuation of treatment: Patient has decrease in the frequency or severity of paralytic attacks with treatment as determined by the prescribing physician Updated: 09/2016 H0811_GN134_Web Prior Auth_Approved 61 KORLYM Korlym 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 62 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 63 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 64 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 65 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 risk of developing febrile neutropenia. 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. Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration 6 months Other Criteria N/A Updated: 09/2016 H0811_GN134_Web Prior Auth_Approved 66 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 67 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 68 LONSURF Lonsurf Products Affected PA Criteria Criteria Details Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria Treatment-naive patients Required Medical Information N/A Age Restrictions N/A Prescriber Restrictions Prescribed by, or in consultation with, an Oncologist Coverage Duration Plan year Other Criteria For Metastatic colorectal cancer, patient must have previously been treated with a fluoropyrimidine (e.g., capecitabine, 5-FU) AND oxaliplatin AND irinotecan AND an anti-VEGF therapy And if RAS wild type, ananti-EGFR therapy. Updated: 09/2016 H0811_GN134_Web Prior Auth_Approved 69 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 70 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 71 NAMENDA Namenda Titration Pak Namenda XR Products Affected memantine 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 72 NATPARA Natpara Products Affected PA Criteria Criteria Details Covered Uses All FDA approved indications not otherwise excluded from Part D Exclusion Criteria Hypoparathyroidism caused by calcium-sensing receptor mutations. Patients with acute post-surgical hypoparathyroidism. Required Medical Information Serum calcium level Age Restrictions 18 years of age and older Prescriber Restrictions N/A Coverage Duration Plan year Other Criteria For diagnosis of hypocalcemia in patients with hypoparathyroidism, documentation required to show hypocalcemia is not corrected by calcium supplements and active forms of vitamin D alone. Updated: 09/2016 H0811_GN134_Web Prior Auth_Approved 73 NEUPOGEN Neupogen 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, 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 risk of developing febrile neutropenia. 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. Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration 6 months Other Criteria N/A Updated: 09/2016 H0811_GN134_Web Prior Auth_Approved 74 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 75 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 76 NINLARO Ninlaro 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 Previous therapies tried and failed, baseline CBC Age Restrictions 18 years and older Prescriber Restrictions Prescribed by, or in consultation with, an Oncologist Coverage Duration Plan Year Other Criteria For multiple myeloma, patient has received at least one prior therapy AND will be used in combination with lenalidomide and dexamethasone. Updated: 09/2016 H0811_GN134_Web Prior Auth_Approved 77 NORTHERA Northera 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 Initial 4 weeks, renewal 6 months Other Criteria N/A Updated: 09/2016 H0811_GN134_Web Prior Auth_Approved 78 NUPLAZID Nuplazid 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 79 NUVIGIL/PROVIGIL modafinil 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 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 80 OCTREOTIDE octreotide acetate injection solution 100 mcg/mL, 200 mcg/mL, 50 mcg/mL Products Affected octreotide acetate injection solution 1,000 mcg/mL, 500 mcg/mL 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 81 ODOMZO Odomzo 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 Prescribed by, or in consultation with, an Oncologist Coverage Duration Plan year Other Criteria For locally advanced basal cell carcinoma (BCC) has recurred following surgery or radiation therapy or if the patient is not a candidate for surgery and the patient is not a candidate for radiation therapy, according to the prescribing physician. Updated: 09/2016 H0811_GN134_Web Prior Auth_Approved 82 OFEV Ofev Products Affected PA Criteria Criteria Details Covered Uses All FDA-approved indications not otherwise excluded from Part D. Exclusion Criteria Combination use with pirfenidone Required Medical Information N/A Age Restrictions 18 years of age and older Prescriber Restrictions Prescribed by or in combination with a pulmonologist Coverage Duration Plan Year Other Criteria IPF baseline - must have FVC greater than or equal to 50 percent of the predicted value AND IPF must be diagnosed with either findings on highresolution computed tomography (HRCT) indicating usual interstitial pneumonia (UIP) or surgical lung biopsy demonstrating UIP. Updated: 09/2016 H0811_GN134_Web Prior Auth_Approved 83 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 84 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 85 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 86 OPSUMIT Opsumit 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 PAH WHO group, right heart catherization Age Restrictions N/A Prescriber Restrictions PAH - must be prescribed by or in consultation with a cardiologist or a pulmonologist. Coverage Duration Plan Year Other Criteria Pulmonary arterial hypertension (PAH) WHO Group 1 patients not currently on Opsumit or another agent indicated for WHO Group 1 PAH are required to have had a right-heart catheterization to confirm the diagnosis of PAH to ensure appropriate medical assessment. PAH WHO Group 1 patients currently on Opsumit or another agent indicated for WHO Group 1 PAH may continue therapy without confirmation of a right-heart catheterization. For patients not currently on Opsumit with confirmed diagnosis of PAH, approval will be given after a trial of Letairis, unless contraindicated. Updated: 09/2016 H0811_GN134_Web Prior Auth_Approved 87 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. Age Restrictions N/A Prescriber Restrictions ID specialist, Gastroenterologist, Oncologist Coverage Duration Plan Year Other Criteria Monitor for evidence of depression. Updated: 09/2016 H0811_GN134_Web Prior Auth_Approved 88 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 89 PHENOXYBENZAMINE phenoxybenzamine 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 90 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 91 POTIGA Potiga 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 92 PRALUENT Products Affected Praluent Pen subcutaneous pen injector 150 mg/mL, 75 mg/mL Praluent Syringe subcutaneous syringe 150 mg/mL, 75 mg/mL PA Criteria Criteria Details Covered Uses All FDA-approved indications not otherwise excluded from Part D. Exclusion Criteria Concurrent use of Praluent with Repatha, Juxtapid or Kynamro. Required Medical Information Current LDL-C (within the past 30 days), prior therapies tried, medication adverse event history Age Restrictions 18 years of age and older. Prescriber Restrictions Prescribed by, or in consultation with, a cardiologist, endocrinologist, or a physician who focuses in the treatment of CV risk management and/or lipid disorders Coverage Duration Initial Prior Authorization: 6 months,Continuation of Therapy: Plan Year Updated: 09/2016 H0811_GN134_Web Prior Auth_Approved 93 PA Criteria Criteria Details Other Criteria Hyperlipidemia in pts w/ (ASCVD) apprv if the pt has a curr LDL-C lvl of grtr or eq to 70 mg/dL w/in the past 30 ds (after tx with antihyperlipidemic agnts but prior to PCSK9 inh tx such as Praluent or Repatha) AND the pt has had one of the following conds or dxs: prev MI,OR has a hx of an acute coronary syndrome, OR The pt has a dx of angina (stable or unstable) ,OR The pt has a past hx of stroke or TIA, OR The pt has PAD, The pt has undergone a coronary or other arterial revascularization procedure AND The pt has tried 1 high-intensity statin tx (i.e., atorvastatin 80 mg daily or Crestor 40 mg daily) for equal or more than 12 cont wks AND the LDL-C lvl remains equal or more than70 mg/dL unless pt experienced statin-related rhabdomyolysis, OR the pt experienced skeletal-related muscle symptoms while receiving separate trials of atorvastatin and Crestor and during both trials the skeletal-related symptoms resolved during d/c. AND If pt able to tolerate statins cont to rec. the max tolerated dose of a statin while rec. Praluent tx. Heterozygous Familial Hypercholesterolemia apprve if the pt has a curnt LDL-C lvl eq or more than 100 mg/dL w/in the past 30 days, AND the pts dx of HeFH is def by WHO/Dutch Lipid grp criteria OR Simon-Broome Criteria OR genetic testing, AND The pt has tried 1 high-intensity statin txs (i.e., atorvastatin 80 mg daily or Crestor 40 mg daily) for equal or more than 12 cont wks, AND the LDL-C lvl remains eq or more than 100 mg/dL, unless pt experienced statin-related rhabdomyolysis, OR the pt experienced skeletal-related muscle symptoms while receiving separate trials of atorvastatin and Crestor and during both trials the skeletal-related symptoms resolved during d/c. AND If pt able to tolerate statins cont to rec. the max tolerated dose of a statin while rec. Praluent tx. Updated: 09/2016 H0811_GN134_Web Prior Auth_Approved 94 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 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. 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 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 Updated: 09/2016 H0811_GN134_Web Prior Auth_Approved 95 PA Criteria Criteria Details 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 96 PROMACTA Promacta oral tablet 12.5 mg, 25 mg, 50 mg 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 N/A 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 97 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 98 RAVICTI Ravicti 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 99 REBIF Rebif Rebidose subcutaneous pen injector 22 mcg/0.5 mL, 44 mcg/0.5 mL, 8.8mcg/0.2mL-22 mcg/0.5mL (6) 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 100 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 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. 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 Coverage Duration Initial: 3 months for Crohn's disease and UC, plan year for all others. Renewal: plan year Updated: 09/2016 H0811_GN134_Web Prior Auth_Approved 101 PA Criteria Criteria Details Other Criteria For continuation of therapy, patient's condition must have improved or stabilized. Updated: 09/2016 H0811_GN134_Web Prior Auth_Approved 102 REPATHA Repatha Syringe Products Affected Repatha SureClick PA Criteria Criteria Details Covered Uses All FDA-approved indications not otherwise excluded from Part D. Exclusion Criteria Concurrent use of Repatha with Praluent, Juxtapid or Kynamro Required Medical Information Current LDL-C (within the past 30 days), prior therapies tried, medication adverse event history Age Restrictions ASCVD/HeFH - 18 yo and older, HoFH 13 yo and older. Prescriber Restrictions Prescribed by, or in consultation with, a cardiologist, endocrinologist, or a physician who focuses in the treatment of CV risk management and/or lipid disorders Coverage Duration Initial Prior Authorization: 6 months,Continuation of Therapy: Plan Year Updated: 09/2016 H0811_GN134_Web Prior Auth_Approved 103 PA Criteria Criteria Details Other Criteria Hyperlipidemia in pts w/ (ASCVD) apprv if the pt has a curr LDL-C lvl of grtr or eq to 70 mg/dL w/in the past 30 ds (after tx with antihyperlipidemic agnts but prior to PCSK9 inh tx such as Praluent or Repatha) AND the pt has had one of the following conds or dxs: prev MI,OR has a hx of an acute coronary syndrome, OR The pt has a dx of angina (stable or unstable) ,OR The pt has a past hx of stroke or TIA, OR The pt has PAD, The pt has undergone a coronary or other arterial revascularization procedure AND The pt has tried 1 high-intensity statin tx (i.e., atorvastatin 80 mg daily or Crestor 40 mg daily) for equal or more than 12 cont wks AND the LDL-C lvl remains equal or more than70 mg/dL unless pt experienced statin-related rhabdomyolysis, OR the pt experienced skeletal-related muscle symptoms while receiving separate trials of atorvastatin and Crestor and during both trials the skeletal-related symptoms resolved during d/c. AND If pt able to tolerate statins cont to rec. the max tolerated dose of a statin while rec. Repatha tx. Heterozygous Familial Hypercholesterolemia apprve if the pt has a curnt LDL-C lvl eq or more than 100 mg/dL w/in the past 30 days, AND the pts dx of HeFH is def by WHO/Dutch Lipid grp criteria OR Simon-Broome Criteria OR genetic testing, AND The pt has tried 1 high-intensity statin txs (i.e., atorvastatin 80 mg daily or Crestor 40 mg daily) for equal or more than 12 cont wks, AND the LDL-C lvl remains eq or more than 100 mg/dL, unless pt experienced statin-related rhabdomyolysis, OR the pt experienced skeletal-related muscle symptoms while receiving separate trials of atorvastatin and Crestor and during both trials the skeletal-related symptoms resolved during d/c. AND If pt able to tolerate statins cont to rec. the max tolerated dose of a statin while rec. Repatha tx. HoFH approve if meets all of the following has one of the following genetic confirmation of two mutant alleles at the LDLR, APOB, PCSK9, or LDLRAP1 gene locus AND LDL-C lvl grtr or eq to 100 mg/dL within the past 30 ds AND tried 1 high-intensity statin therapystatin tx (i.e., atorvastatin 80 mg daily or Crestor 40 mg daily) for equal or more than 12 cont wks AND the LDL-C lvl remains equal or more than 100 mg/dL unless pt experienced statin-related rhabdomyolysis, OR the pt experienced skeletal-related muscle symptoms while receiving separate trials of atorvastatin and Crestor and during both trials the skeletal-related symptoms resolved during d/c. AND If pt able to tolerate statins cont to rec. the max tolerated dose of a statin while rec. Repatha tx. Updated: 09/2016 H0811_GN134_Web Prior Auth_Approved 104 REVATIO sildenafil oral 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 105 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 in combination with dexamethasone. 2) Revlimid is used as maintenance monotherapy following response to either stem cell transplant or primary induction therapy. For mantle cell lymphoma (MCL): Revlimid is used after 2 prior therapies, 1 of which is bortezomib. 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 106 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 10 g/dL. Hemoglobinopathy. History of preexisting 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 Harvoni, interferon, Viekira, or Sovaldi. Cirrhosis documented by FibroScan, liver biopsy, or radiological imaging Age Restrictions N/A Prescriber Restrictions ID specialist, gastroenterologist, or oncologist Coverage Duration 12 wks, 24 wks, or 48 wks as specified in Other Criteria. Other Criteria Adults: 12wk: geno 1a+no cirr-w/Viekira, geno 2-w/Sovaldi, geno 3, 4, 5, 6-w/PEG/Sovaldi, Gen 1/4 post-transplant +Harvoni. 16wk: geno 2 w/cirr + Sovaldi. 24wk: geno 1a+cirr-w/Viekira, geno 3, 4-w/Sovaldi. Children: 48 wk all genotypes Updated: 09/2016 H0811_GN134_Web Prior Auth_Approved 107 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 108 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 N/A 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 109 SAMSCA Samsca oral tablet 15 mg, 30 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 N/A Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration Up to 30 days Other Criteria N/A Updated: 09/2016 H0811_GN134_Web Prior Auth_Approved 110 SANDOSTATIN LAR Sandostatin LAR Depot intramuscular suspension,extended rel recon 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 111 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 112 SOVALDI Sovaldi 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 Prior to initiating therapy, detectable levels of HCV RNA in the serum. Must be used in combination with interferon+ribavirin, ribavirin, or Olysio. Cirrhosis documented by FibroScan, liver biopsy, or radiological imaging Age Restrictions 18 years or older Prescriber Restrictions Prescribed by or in consultation w/ GI, hepatologist, ID, or a liver transplant MD Coverage Duration 12 wks, 24 wks, or 48 wks as specified in Other Criteria. Other Criteria Geno 1-Patient must have tried Viekira or Harvoni. Geno 2,3,4,5,6 prescribed in combo with RBV. Coverage duration: 12wk: geno 1+no cirr, geno 2 naive-w/RBV, geno 2 prior tx fail w/PEG/RBV or SOV/RBV-w/PEG/RBV, geno 3 naive-w/PEG/RBV, geno 3 prior tx fail w/PEG/RBV or SOV/RBV-w/PEG/RBV, geno 4 naïve w/PEG/RBV, geno 4 prior tx fail w/ PEG/RBV -w/PEG/RB , geno 5/6 naïve/exp w/PEG/RBV. 16wk: geno 2 naive+cirr w/RBV. 24wk: geno 1+cirr, geno 2 prior tx fail w/PEG/RBV (16 weeks if requested by prescriber)-w/RBV, post-liver transplant +cirr w/RBV, geno 3 naive-w/RBV, post-liver transplant + cirr w/RBV, geno 4 naïve w/ RBV, geno 4 prior tx fail w/ PEG/RBV -w/RBV. 48wk: Others Updated: 09/2016 H0811_GN134_Web Prior Auth_Approved 113 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, 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 114 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 115 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 116 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 117 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 118 PA Criteria Criteria Details 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 119 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 or V600K mutations Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration Plan Year Other Criteria N/A Updated: 09/2016 H0811_GN134_Web Prior Auth_Approved 120 TAGRISSO Tagrisso Products Affected PA Criteria Criteria Details Covered Uses All FDA-approved indications not otherwise excluded from Part D. Plus patients already started on Tagrisso for a covered use. Exclusion Criteria EGFR tyrosine kinase inhibitor treatment naive patients Required Medical Information Confirmed T790M mutation-positive NSCLC as detected by an FDA approved test and Prior therapies tried Age Restrictions 18 years or older Prescriber Restrictions Prescribed by, or in consultation with, an Oncologist Coverage Duration Plan Year Other Criteria The patient has metastatic epidermal growth factor receptor (EGFR) T790M mutation-positive NSCLC as detected by an FDA approved test AND The patient has progressed on or after one of Tarceva (erlotinib tablets), Iressa (gefitinib tablets), or Gilotrif (afatinib tablets) therapy. Updated: 09/2016 H0811_GN134_Web Prior Auth_Approved 121 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 exon 19 deletions or exon 21 substitution mutation or amplification of the EGFR gene. Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration Plan Year Other Criteria N/A Updated: 09/2016 H0811_GN134_Web Prior Auth_Approved 122 TARGRETIN Targretin oral Products Affected bexarotene PA Criteria Criteria Details Covered Uses All medically accepted 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 123 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 124 TECENTRIQ Tecentriq 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 125 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 126 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 127 THIOTEPA thiotepa 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 128 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 Plan Year 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 129 TRETINOIN tretinoin microspheres topical gel with pump tretinoin topical Products Affected adapalene topical cream adapalene topical gel 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 130 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 131 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 132 PA Criteria Criteria Details 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 133 VENCLEXTA Venclexta Starting Pack Products Affected Venclexta PA Criteria Criteria Details Covered Uses All FDA approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information Diagnosis, prior therapy, 17p deletion status Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration Plan Year Other Criteria CLL - approve if the patient has 17p deletion and has tried one prior therapy. Updated: 09/2016 H0811_GN134_Web Prior Auth_Approved 134 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 24 wks G1a w cirrh and prior null response to HVC therapy, Rec HCV Post-Liver Trans, 12 wks others Other Criteria Geno 1a w/ or w/o cirrhosis-prescribed in combination with RBV. Liver transplant recipients with normal hepatic function and metavir score less than 2-prescribed in combination with RBV. Updated: 09/2016 H0811_GN134_Web Prior Auth_Approved 135 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 136 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 137 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 138 XENAZINE Xenazine Products Affected tetrabenazine 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 or tetrabenazine must be prescribed by or after consultation with a neurologist. For TD, Xenazine or tetrabenazine must be prescribed by or after consultation with a neurologist or psychiatrist. Coverage Duration Plan Year Other Criteria N/A Updated: 09/2016 H0811_GN134_Web Prior Auth_Approved 139 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 For IgE-mediated allergic asthma: pre-treatment serum IgE and patient's weight 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 140 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. Updated: 09/2016 H0811_GN134_Web Prior Auth_Approved 141 YERVOY Yervoy intravenous solution 50 mg/10 mL (5 mg/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: 09/2016 H0811_GN134_Web Prior Auth_Approved 142 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 143 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 144 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 145 ZYVOX Products Affected linezolid intravenous linezolid oral suspension for reconstitution linezolid oral tablet Zyvox intravenous parenteral solution 600 mg/300 mL Zyvox oral PA Criteria Criteria Details Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information Culture and sensitivity and CBC within normal limits Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration 28 days Other Criteria N/A Updated: 09/2016 H0811_GN134_Web Prior Auth_Approved 146 PART B VERSUS PART D Products Affected Abelcet Abilify Maintena intramuscular suspension,extended rel recon 300 mg Abilify Maintena intramuscular suspension,extended rel syring Abraxane acetylcysteine Actemra intravenous 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 amino acids 15 % 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 Aralast NP intravenous recon soln 500 mg Astagraf XL Updated: 09/2016 H0811_GN134_Web Prior Auth_Approved 147 Avastin Avelox in NaCl (iso-osmotic) Azasan azathioprine azathioprine sodium azithromycin intravenous BACiiM bacitracin intramuscular BCG vaccine, live (PF) Beleodaq Benlysta benztropine injection Bicillin C-R BiCNU bleomycin injection recon soln 30 unit budesonide inhalation suspension for nebulization 0.25 mg/2 mL, 0.5 mg/2 mL, 1 mg/2 mL 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 cefuroxime sodium injection recon soln 1.5 gram, 750 mg cefuroxime sodium intravenous CellCept Intravenous CellCept oral suspension for reconstitution 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 colistin (colistimethate Na) 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 dacarbazine intravenous recon soln 200 mg daunorubicin intravenous solution decitabine Delestrogen intramuscular oil 10 mg/mL Updated: 09/2016 H0811_GN134_Web Prior Auth_Approved 148 Depo-Provera intramuscular solution dexamethasone sodium phosphate injection solution dexrazoxane HCl intravenous recon soln 250 mg dextrose 10 % and 0.2 % NaCl dextrose 10 % in water (D10W) 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 doxorubicin intravenous solution 50 mg/25 mL doxorubicin, peg-liposomal Doxy-100 doxycycline hyclate intravenous dronabinol oral capsule 10 mg dronabinol oral capsule 2.5 mg, 5 mg Duramorph (PF) injection solution 0.5 mg/mL, 1 mg/mL Elaprase Elelyso Elitek Emend oral capsule Emend oral capsule,dose pack Engerix-B (PF) intramuscular syringe Engerix-B Pediatric (PF) Envarsus XR epirubicin intravenous solution 50 mg/25 mL Erythrocin intravenous recon soln 500 mg esomeprazole sodium estradiol valerate intramuscular oil 20 mg/mL, 40 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 fluconazole in NaCl (iso-osm) intravenous piggyback 200 mg/100 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 Gengraf oral capsule 100 mg, 25 mg Gengraf oral solution 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 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 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 idarubicin ifosfamide intravenous recon soln 1 gram imipenem-cilastatin Increlex Intralipid intravenous emulsion 20 %, 30 % Intron A injection recon soln Updated: 09/2016 H0811_GN134_Web Prior Auth_Approved 149 Intron A injection solution 6 million unit/mL Invanz injection Invega Sustenna Invega Trinza 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 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 lidocaine (PF) injection solution 5 mg/mL (0.5 %) lidocaine HCl injection solution 20 mg/mL (2 %) 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 Miacalcin injection mitomycin intravenous recon soln 20 mg mitoxantrone morphine intravenous syringe 10 mg/mL, 8 mg/mL Mozobil Mustargen mycophenolate mofetil mycophenolate sodium 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 % 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 Orencia (with maltose) oxacillin in dextrose(iso-osm) intravenous piggyback 1 gram/50 mL oxacillin in dextrose(iso-osm) intravenous piggyback 2 gram/50 mL 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 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 Updated: 09/2016 H0811_GN134_Web Prior Auth_Approved 150 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 capsule 0.5 mg, 1 mg tacrolimus oral capsule 5 mg Teflaro terbutaline subcutaneous testosterone cypionate testosterone enanthate tetanus-diphtheria toxoids-Td tobramycin in 0.225 % NaCl tobramycin sulfate injection solution Toposar topotecan intravenous recon soln tranexamic acid intravenous Travasol 10 % Treanda intravenous recon soln 100 mg Trelstar intramuscular suspension for reconstitution Trelstar intramuscular syringe 11.25 mg/2 mL, 3.75 mg/2 mL Trisenox TrophAmine 10 % Trophamine 6% Twinrix (PF) intramuscular suspension valproate sodium vancomycin intravenous recon soln 1,000 mg, 10 gram, 500 mg 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: 09/2016 H0811_GN134_Web Prior Auth_Approved 151 Index APOKYN .................................................... 9 Aptiom ...................................................... 10 Aralast NP ............................................... 147 Arcalyst ..................................................... 11 Astagraf XL ............................................ 147 Avastin .................................................... 147 Avelox in NaCl (iso-osmotic) ................. 147 Avonex (with albumin) ............................. 12 Avonex intramuscular pen injector kit ...... 12 Avonex intramuscular syringe kit ............. 12 Azasan ..................................................... 147 azathioprine ............................................. 147 azathioprine sodium ................................ 147 azithromycin ........................................... 147 B BACiiM................................................... 147 bacitracin ................................................. 147 Banzel oral tablet ...................................... 13 BCG vaccine, live (PF) ........................... 147 Beleodaq ................................................. 147 Benlysta................................................... 147 benztropine.............................................. 147 benztropine oral ........................................ 45 bexarotene ............................................... 123 Bicillin C-R ............................................. 147 BiCNU .................................................... 147 bleomycin ................................................ 147 Bosulif ....................................................... 14 Briviact ...................................................... 15 budesonide .............................................. 147 buprenorphine HCl.................................. 147 Busulfex .................................................. 147 butalbital-acetaminop-caf-cod .................. 45 C Cabometyx ................................................ 16 calcitriol .................................................. 147 Cancidas .................................................. 147 Capastat ................................................... 147 Carbaglu .................................................... 17 carboplatin............................................... 147 cefazolin .................................................. 147 cefazolin in dextrose (iso-os) .................. 147 cefepime .................................................. 147 cefotaxime ............................................... 147 A Abelcet .................................................... 147 Abilify Maintena ..................................... 147 Abraxane ................................................. 147 acetylcysteine .......................................... 147 Actemra ................................................... 147 Acthar H.P................................................... 1 Actimmune.................................................. 2 acyclovir sodium ..................................... 147 Adagen .................................................... 147 adapalene topical cream .......................... 130 adapalene topical gel ............................... 130 Adcirca ........................................................ 3 Adempas ..................................................... 4 Adrucil .................................................... 147 Afinitor........................................................ 5 Afinitor Disperz .......................................... 5 A-Hydrocort ............................................ 147 albuterol sulfate ....................................... 147 Aldurazyme ............................................. 147 Alecensa ...................................................... 6 Alimta ..................................................... 147 alprazolam ................................................. 46 AmBisome .............................................. 147 amifostine crystalline .............................. 147 amikacin .................................................. 147 amino acids 15 % .................................... 147 Aminosyn 8.5 %-electrolytes .................. 147 Aminosyn II 10 % ................................... 147 Aminosyn II 15 % ................................... 147 Aminosyn II 7 % ..................................... 147 Aminosyn II 8.5 % .................................. 147 Aminosyn II 8.5 %-electrolytes .............. 147 Aminosyn M 3.5 % ................................. 147 Aminosyn-HBC 7% ................................ 147 Aminosyn-PF 10 % ................................. 147 Aminosyn-PF 7 % (sulfite-free).............. 147 Aminosyn-RF 5.2 % ............................... 147 amiodarone .............................................. 147 amitriptyline .............................................. 48 amphotericin B ........................................ 147 ampicillin sodium.................................... 147 ampicillin-sulbactam ............................... 147 Ampyra ....................................................... 7 Updated: 09/2016 H0811_GN134_Web Prior Auth_Approved 152 cefoxitin .................................................. 147 cefoxitin in dextrose, iso-osm ................. 147 ceftazidime .............................................. 147 ceftriaxone............................................... 147 cefuroxime sodium.................................. 147 CellCept .................................................. 148 CellCept Intravenous .............................. 147 Cerezyme ................................................ 148 chloramphenicol sod succinate ............... 148 Cholbam .................................................... 18 chorionic gonadotropin, human ................ 19 Cialis oral tablet 2.5 mg, 5 mg .................. 20 cidofovir .................................................. 148 Cimzia Powder for Reconst .................... 148 Cinryze ...................................................... 21 ciprofloxacin lactate ................................ 148 cisplatin ................................................... 148 cladribine................................................. 148 clemastine oral tablet 2.68 mg .................. 45 clindamycin phosphate............................ 148 Clinimix 5%/D15W Sulfite Free ........... 148 Clinimix 5%/D25W sulfite-free ............. 148 Clinimix 2.75%/D5W Sulfit Free ........... 148 Clinimix 4.25%/D10W Sulf Free ........... 148 Clinimix 4.25%/D5W Sulfit Free ........... 148 Clinimix 4.25%-D20W sulf-free ............ 148 Clinimix 4.25%-D25W sulf-free ............ 148 Clinimix 5%-D20W(sulfite-free) ............ 148 Clinimix E 2.75%/D10W Sul Free ......... 148 Clinimix E 2.75%/D5W Sulf Free .......... 148 Clinimix E 4.25%/D10W Sul Free ......... 148 Clinimix E 4.25%/D25W Sul Free ......... 148 Clinimix E 4.25%/D5W Sulf Free .......... 148 Clinimix E 5%/D15W Sulfit Free ........... 148 Clinimix E 5%/D20W Sulfit Free ........... 148 Clinimix E 5%/D25W Sulfit Free ........... 148 clomipramine ............................................ 48 clonazepam ............................................... 47 clorazepate dipotassium ............................ 47 colistin (colistimethate Na) ..................... 148 Cometriq ................................................... 22 Copaxone subcutaneous syringe 20 mg/mL, 40 mg/mL .............................................. 23 Cotellic ...................................................... 24 cromolyn ................................................. 148 Cubicin .................................................... 148 cyclobenzaprine oral tablet ....................... 45 cyclophosphamide................................... 148 cyclosporine ............................................ 148 cyclosporine modified ............................. 148 cyproheptadine .......................................... 45 Cyramza .................................................... 25 cytarabine ................................................ 148 D D2.5 %-0.45 % sodium chloride ............. 148 D5 % and 0.9 % sodium chloride ........... 148 D5 %-0.45 % sodium chloride ................ 148 dacarbazine ............................................. 148 Darzalex .................................................... 26 daunorubicin ........................................... 148 decitabine ................................................ 148 Delestrogen ............................................. 148 Demser ...................................................... 27 Depen Titratabs ......................................... 89 Depo-Provera .......................................... 148 dexamethasone sodium phosphate .......... 148 dexrazoxane HCl ..................................... 148 dextrose 10 % and 0.2 % NaCl ............... 148 dextrose 10 % in water (D10W) ............. 148 dextrose 5 % in water (D5W) ................. 148 dextrose 5 %-lactated ringers .................. 148 dextrose 5%-0.2 % sod chloride ............. 148 dextrose 5%-0.3 % sod.chloride ............. 148 Dextrose With Sodium Chloride ............. 148 Dextrose-KCl-NaCl ................................ 148 Diastat ....................................................... 47 Diazepam Intensol .................................... 47 diazepam oral solution 5 mg/5 mL (1 mg/mL) ................................................. 47 diazepam oral tablet .................................. 47 diazepam rectal ......................................... 47 diclofenac sodium topical gel 3 % ............ 28 dicyclomine oral capsule........................... 45 dicyclomine oral solution .......................... 45 dicyclomine oral tablet .............................. 45 Digitek....................................................... 45 digoxin injection solution ......................... 45 digoxin oral solution 50 mcg/mL .............. 45 digoxin oral tablet ..................................... 45 diltiazem HCl .......................................... 148 diphenhydramine HCl ............................. 148 doxepin oral .............................................. 48 Updated: 09/2016 H0811_GN134_Web Prior Auth_Approved 153 doxorubicin ............................................. 148 doxorubicin, peg-liposomal .................... 148 Doxy-100 ................................................ 148 doxycycline hyclate ................................ 148 dronabinol ............................................... 148 Duramorph (PF) ...................................... 148 E Egrifta subcutaneous recon soln 1 mg ...... 29 Elaprase ................................................... 148 Elelyso..................................................... 148 Eligard ....................................................... 67 Elitek ....................................................... 148 Emend ..................................................... 148 Empliciti.................................................... 30 Engerix-B (PF) ........................................ 148 Engerix-B Pediatric (PF)......................... 148 Envarsus XR ........................................... 148 epirubicin ................................................ 148 ergoloid ..................................................... 45 Erivedge .................................................... 31 Erwinaze ................................................... 32 Erythrocin ............................................... 148 Esbriet ....................................................... 33 esomeprazole sodium .............................. 148 estradiol oral.............................................. 48 estradiol valerate ..................................... 148 etoposide ................................................. 148 Extavia subcutaneous kit........................... 34 F Fabrazyme ............................................... 148 famotidine (PF) ....................................... 148 famotidine (PF)-NaCl (iso-os) ............... 148 Farydak ..................................................... 35 Faslodex .................................................. 148 fentanyl citrate buccal lozenge on a handle 1,200 mcg, 1,600 mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg ...................... 129 Ferriprox oral tablet .................................. 36 Firazyr ....................................................... 37 fluconazole in dextrose(iso-o)................. 148 fluconazole in NaCl (iso-osm) ................ 149 fludarabine .............................................. 149 fluorouracil .............................................. 149 fluphenazine decanoate ........................... 149 fluphenazine HCl .................................... 149 fomepizole............................................... 149 fosphenytoin ............................................ 149 furosemide............................................... 149 Fycompa oral suspension .......................... 38 Fycompa oral tablet................................... 38 G Gammagard Liquid ................................... 56 Gamunex-C injection solution 1 gram/10 mL (10 %) ............................................. 56 ganciclovir sodium .................................. 149 Gattex One-Vial ........................................ 39 gemcitabine ............................................. 149 Gengraf ................................................... 149 gentamicin ............................................... 149 gentamicin in NaCl (iso-osm) ................. 149 Geodon .................................................... 149 Gilotrif....................................................... 40 Glatopa ...................................................... 23 Gleevec oral tablet 100 mg, 400 mg ......... 41 granisetron (PF) ...................................... 149 granisetron HCl ....................................... 149 H haloperidol decanoate ............................. 149 haloperidol lactate ................................... 149 Harvoni ..................................................... 43 heparin (porcine) ..................................... 149 heparin (porcine) in 5 % dex ................... 149 Hepatamine 8% ....................................... 149 Herceptin ................................................. 149 Hetlioz ....................................................... 44 hydralazine .............................................. 149 hydromorphone (PF) ............................... 149 hydroxyprogesterone caproate .................. 49 hydroxyzine HCl ..................................... 149 I Ibrance....................................................... 50 Iclusig ........................................................ 51 idarubicin ................................................ 149 ifosfamide ............................................... 149 Ilaris (PF) .................................................. 52 Imbruvica .................................................. 53 imipenem-cilastatin ................................. 149 imipramine HCl ........................................ 48 imipramine pamoate.................................. 48 Increlex ................................................... 149 Inlyta ......................................................... 54 Intralipid .................................................. 149 Updated: 09/2016 H0811_GN134_Web Prior Auth_Approved 154 Intron A ................................................... 149 Invanz ...................................................... 149 Invega Sustenna ...................................... 149 Invega Trinza .......................................... 149 Ionosol-B in D5W ................................... 149 Ionosol-MB in D5W ............................... 149 ipratropium bromide ............................... 149 ipratropium-albuterol .............................. 149 Iressa ......................................................... 55 irinotecan................................................. 149 Istodax ..................................................... 149 J Jakafi oral tablet 10 mg, 15 mg, 20 mg, 25 mg, 5 mg ............................................... 57 Juxtapid ..................................................... 58 K Kadcyla ................................................... 149 Kalydeco ................................................... 59 Keveyis ..................................................... 60 Keytruda .................................................. 149 Korlym ...................................................... 62 Kuvan oral tablet,soluble .......................... 63 L labetalol ................................................... 149 Lanoxin oral .............................................. 45 Lenvima .................................................... 64 Letairis ...................................................... 65 leucovorin calcium .................................. 149 Leukine injection recon soln ..................... 66 levalbuterol HCl ...................................... 149 levetiracetam ........................................... 149 levetiracetam in NaCl (iso-os) ................ 149 levocarnitine ............................................ 149 levocarnitine (with sugar) ....................... 149 levofloxacin............................................. 149 levoleucovorin calcium ........................... 149 lidocaine (PF) .......................................... 149 lidocaine HCl .......................................... 149 lidocaine topical adhesive patch,medicated ............................................................... 68 linezolid intravenous ............................... 146 linezolid oral suspension for reconstitution ............................................................. 146 linezolid oral tablet ................................. 146 Lonsurf ...................................................... 69 Lorazepam Intensol ................................... 46 lorazepam oral tablet ................................. 46 Lupron Depot ............................................ 67 Lupron Depot (3 Month) ........................... 67 Lupron Depot (4 Month) ........................... 67 Lupron Depot (6 Month) ........................... 67 Lupron Depot-Ped intramuscular kit 11.25 mg, 15 mg ............................................. 67 Lynparza ................................................... 70 M magnesium sulfate .................................. 149 megestrol oral tablet .................................. 48 Mekinist .................................................... 71 melphalan HCl ........................................ 149 memantine ................................................. 72 meprobamate ............................................. 45 meropenem .............................................. 149 mesna ...................................................... 149 metaxalone ................................................ 45 methadone ............................................... 149 methotrexate sodium ............................... 149 methotrexate sodium (PF) ....................... 149 methyldopa-hydrochlorothiazide .............. 45 methylprednisolone acetate ..................... 149 methylprednisolone sodium succ ............ 149 metoclopramide HCl ............................... 149 metoprolol tartrate ................................... 149 Miacalcin................................................. 149 mitomycin ............................................... 149 mitoxantrone ........................................... 149 modafinil ................................................... 80 morphine ................................................. 150 Mozobil ................................................... 150 Mustargen ............................................... 150 mycophenolate mofetil............................ 150 mycophenolate sodium ........................... 150 N nafcillin ................................................... 150 nafcillin in dextrose iso-osm ................... 150 Naglazyme .............................................. 150 nalbuphine ............................................... 150 Namenda ................................................... 72 Namenda Titration Pak ............................. 72 Namenda XR ............................................. 72 Natpara ...................................................... 73 Nebupent ................................................. 150 Neoral ...................................................... 150 Updated: 09/2016 H0811_GN134_Web Prior Auth_Approved 155 Nephramine 5.4 % .................................. 150 Neupogen .................................................. 74 Neupro....................................................... 75 Nexavar ..................................................... 76 Ninlaro ...................................................... 77 nitroglycerin ............................................ 150 Norditropin FlexPro .................................. 42 Normosol-M in 5 % dextrose.................. 150 Normosol-R in 5 % dextrose................... 150 Normosol-R pH 7.4................................. 150 Northera .................................................... 78 Novarel ...................................................... 19 Nulojix .................................................... 150 Nuplazid .................................................... 79 O octreotide acetate injection solution 1,000 mcg/mL, 500 mcg/mL .......................... 81 octreotide acetate injection solution 100 mcg/mL, 200 mcg/mL, 50 mcg/mL ...... 81 Odomzo ..................................................... 82 Ofev........................................................... 83 Oncaspar ................................................... 84 ondansetron ............................................. 150 ondansetron HCl ..................................... 150 ondansetron HCl (PF) ............................. 150 Onfi oral suspension ................................. 85 Onfi oral tablet 10 mg, 20 mg ................... 85 Opdivo intravenous solution 40 mg/4 mL 86 Opsumit ..................................................... 87 Orencia (with maltose) ............................ 150 oxacillin................................................... 150 oxacillin in dextrose(iso-osm)................. 150 oxaliplatin ............................................... 150 oxazepam .................................................. 46 P paclitaxel ................................................. 150 pamidronate............................................. 150 paricalcitol............................................... 150 PegIntron ................................................... 88 PegIntron Redipen .................................... 88 penicillin G potassium ............................ 150 penicillin G procaine ............................... 150 penicillin G sodium ................................. 150 Pentam..................................................... 150 Perforomist .............................................. 150 Perjeta ..................................................... 150 perphenazine-amitriptyline ....................... 48 phenobarbital............................................. 48 phenoxybenzamine ................................... 90 phenytoin sodium .................................... 150 piperacillin-tazobactam ........................... 150 Plasma-Lyte 148 ..................................... 150 Plasma-Lyte A ........................................ 150 Plasma-Lyte-56 in 5 % dextrose ............. 150 Pomalyst .................................................... 91 potassium chlorid-D5-0.45%NaCl .......... 150 potassium chloride in 0.9%NaCl ............ 150 potassium chloride in 5 % dex ................ 150 potassium chloride in LR-D5 .................. 150 potassium chloride-D5-0.2%NaCl .......... 150 potassium chloride-D5-0.3%NaCl .......... 150 potassium chloride-D5-0.9%NaCl .......... 150 Potiga ........................................................ 92 Praluent Pen subcutaneous pen injector 150 mg/mL, 75 mg/mL ................................ 93 Praluent Syringe subcutaneous syringe 150 mg/mL, 75 mg/mL ................................ 93 Pregnyl ...................................................... 19 Premarin .................................................. 150 Premasol 10 % ........................................ 150 Premasol 6 % .......................................... 150 Procalamine 3% ...................................... 150 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 ............................................................... 95 Proleukin ................................................. 150 Prolia ....................................................... 150 Promacta oral tablet 12.5 mg, 25 mg, 50 mg ............................................................... 97 promethazine oral tablet ............................ 45 propranolol .............................................. 150 Prosol 20 % ............................................. 150 Pulmozyme ............................................. 150 Q quinine sulfate ........................................... 98 R ranitidine HCl.......................................... 150 Rapamune ............................................... 150 Ravicti ....................................................... 99 Rebif (with albumin) ............................... 100 Updated: 09/2016 H0811_GN134_Web Prior Auth_Approved 156 Rebif Rebidose subcutaneous pen injector 22 mcg/0.5 mL, 44 mcg/0.5 mL, 8.8mcg/0.2mL-22 mcg/0.5mL (6) ...... 100 Rebif Titration Pack ................................ 100 Recombivax HB (PF) .............................. 150 Remicade................................................. 101 Remodulin ............................................... 150 Repatha SureClick .................................. 103 Repatha Syringe ...................................... 103 reserpine .................................................... 45 Revlimid.................................................. 106 Rheumatrex ............................................. 150 ribavirin oral capsule............................... 107 ribavirin oral tablet 200 mg..................... 107 rifampin ................................................... 150 ringers ..................................................... 150 Risperdal Consta ..................................... 150 Rituxan .................................................... 108 S Sabril ....................................................... 109 Samsca oral tablet 15 mg, 30 mg ............ 110 Sancuso ................................................... 150 Sandimmune ........................................... 150 Sandostatin LAR Depot intramuscular suspension,extended rel recon ............ 111 Signifor ................................................... 112 sildenafil oral .......................................... 105 Simulect .................................................. 150 sirolimus.................................................. 150 Solu-Cortef (PF)...................................... 150 Somatuline Depot.................................... 150 Somavert ................................................. 150 Sovaldi .................................................... 113 Sprycel oral tablet 100 mg, 140 mg, 20 mg, 50 mg, 70 mg, 80 mg .......................... 114 Stivarga ................................................... 115 streptomycin ............................................ 151 sulfamethoxazole-trimethoprim .............. 151 Surmontil................................................... 48 Sutent ...................................................... 116 Sylatron ................................................... 117 Synagis intramuscular solution 50 mg/0.5 mL ....................................................... 118 Synercid .................................................. 151 Synribo .................................................... 151 T tacrolimus ................................................ 151 Tafinlar .................................................... 120 Tagrisso ................................................... 121 Tarceva oral tablet 100 mg, 150 mg, 25 mg ............................................................. 122 Targretin oral .......................................... 123 Tasigna .................................................... 124 Tecentriq ................................................. 125 Teflaro ..................................................... 151 temazepam ................................................ 46 terbutaline ............................................... 151 testosterone cypionate ............................. 151 testosterone enanthate ............................. 151 tetanus-diphtheria toxoids-Td ................. 151 tetrabenazine ........................................... 139 Thalomid ................................................. 126 thioridazine ............................................. 127 thiotepa.................................................... 128 tobramycin in 0.225 % NaCl .................. 151 tobramycin sulfate ................................... 151 topiramate oral capsule, sprinkle ................ 8 topiramate oral capsule,sprinkle,ER 24hr ... 8 topiramate oral tablet .................................. 8 Toposar ................................................... 151 topotecan ................................................. 151 tranexamic acid ....................................... 151 Travasol 10 % ......................................... 151 Treanda ................................................... 151 Trelstar .................................................... 151 tretinoin microspheres topical gel with pump ............................................................. 130 tretinoin topical ....................................... 130 trihexyphenidyl ......................................... 45 trimipramine.............................................. 48 Trisenox .................................................. 151 TrophAmine 10 %................................... 151 Trophamine 6% ....................................... 151 Twinrix (PF)............................................ 151 Tykerb ..................................................... 131 Tysabri .................................................... 132 V valproate sodium ..................................... 151 vancomycin ............................................. 151 Velcade ................................................... 151 Venclexta ................................................ 134 Updated: 09/2016 H0811_GN134_Web Prior Auth_Approved 157 Venclexta Starting Pack .......................... 134 verapamil................................................. 151 Viekira Pak.............................................. 135 Vimpat intravenous ................................. 136 Vimpat oral solution ............................... 136 Vimpat oral tablet ................................... 136 vinblastine ............................................... 151 Vincasar PFS ........................................... 151 vincristine................................................ 151 vinorelbine .............................................. 151 Virazole ................................................... 151 voriconazole ............................................ 151 Votrient ................................................... 137 VPRIV..................................................... 151 X Xalkori .................................................... 138 Xenazine ................................................. 139 Xgeva ...................................................... 151 Xolair ...................................................... 140 Xtandi ...................................................... 141 Y Yervoy intravenous solution 50 mg/10 mL (5 mg/mL) ........................................... 142 Z Zaltrap ..................................................... 151 Zelboraf ................................................... 143 Zemplar ................................................... 151 zoledronic acid ........................................ 151 zoledronic acid-mannitol-water .............. 151 Zometa .................................................... 151 zonisamide .................................................. 8 Zortress ................................................... 151 Zydelig .................................................... 144 Zykadia ................................................... 145 Zyprexa Relprevv.................................... 151 Zyvox intravenous parenteral solution 600 mg/300 mL .......................................... 146 Zyvox oral ............................................... 146 Updated: 09/2016 H0811_GN134_Web Prior Auth_Approved 158 GuildNet Gold Plus FIDA Plan is a managed care plan that contracts with both Medicare and New York State Department of Health (Medicaid) to provide benefits of both programs to Participants through the Fully Integrated Duals Advantage (FIDA) Demonstration. Beneficiaries must use network pharmacies to access their premium and/or copayment/coinsurance may change on January 1, 2017. This document includes GuildNet Gold Plus FIDA Plan’s partial formulary as of September 1, 2016 For a complete, updated formulary, please visit our website at www.guildnetny.org or call 1-800-815-0000 (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) 1-800-662-1220，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. 16143 v14 Updated: 09/2016 H0811_GN134_Web Prior Auth_Approved 159
Source Exif Data:
File Type : PDF File Type Extension : pdf MIME Type : application/pdf PDF Version : 1.5 Linearized : No Page Count : 160 Language : en-US Tagged PDF : Yes Title : Emblem MAPD 2016 Author : ESI Medicare Custom Subject : Prior Authorization Keywords : Prior, Authorization Creator : Microsoft® Word 2010 Create Date : 2016:08:30 09:54:46-04:00 Modify Date : 2016:08:30 09:54:46-04:00 Producer : Microsoft® Word 2010EXIF Metadata provided by EXIF.tools