2018 Prior Authorization Requirements

Transcription

1 Kaiser Permanente Medicare Advantage HMO 2018 Prior Authorization Requirements PLEASE READ: Kaiser Permanente requires you to get prior authorization for certain drugs. This means that you will need to get approval from Kaiser Permanente before you fill your prescriptions. If you don t get approval, Kaiser Permanente may not cover the drug. The medications in this document have requirements that must be met for coverage to be considered. Beneficiaries must use network pharmacies to access their prescription drug benefit. Kaiser Permanente is an HMO plan with a Medicare contract. Enrollment in Kaiser Permanente depends on contract renewal. Formulary ID Version 13 Last updated: 10/2018

2 Prior Authorization KPWA_2018_6T Effective: 11/01/2018 ADCIRCA Products Affected Adcirca Tadalafil TABS 20MG PA Details Other 1

3 AIMOVIG Products Affected Aimovig PA Details Covered Uses All FDA approved indications not otherwise excluded from Part D. Other one year Covered for patients who have failure, contraindication, or intolerance to at least two preventative agents including topiramate and beta-blocker. If on onabotulinumtoxina, onabotulinumtoxina is discontinued and at least 8 weeks has passed since the last dose before beginning this therapy. 2

4 ALIROCUMAB Products Affected Praluent PA Details Other Must be prescribed by or in consultation with cardiology specialist or endocrinologist with lipid management expertise Covered for patients age 18 years or older with 1) clinical ASCVD (i.e., coronary heart disease, cerebrovascular disease, or peripheral artery disease) or, 2) heterozygous familial hypercholesterolemia based on genetic testing or a score of greater than 8 on World Health Organization Diagnostic and, 3) treatment with maximally tolerated highintensity statin therapy (atorvastatin 40 or 80 mg, rosuvastatin 20 mg or 40 mg) has been ineffective (unable to achieve and maintain low-density lipoprotein cholesterol (LDL-C) at or below goal of less than 100 mg/dl for heterozygous familial hypercholesterolemia or 70 mg/dl for clinical ASCVD) or contraindicated or not tolerated. Statin intolerance is defined as the inability to tolerate at least two statins, one at the lowest starting daily dose (e.g., rosuvastatin 5 mg, atorvastatin 10 mg, simvastatin 10 mg, lovastatin 20 mg, pravastatin 40 mg, fluvastatin 40 mg, and pitavastatin 2 mg) due to either objectionable symptoms or abnormal lab determinations, which are temporally related to statin treatment and reversible upon statin discontinuation, but reproducible by re-challenge with other potential causes being excluded. 3

5 ANAKINRA Products Affected Kineret PA Details Covered Uses All medically accepted indications not otherwise excluded from Part D. Other Covered for patients with rheumatoid arthritis who have failure, significant systemic intolerance, or contraindication to 1) adalimumab, etanercept, or infliximab, and 2) abatacept. Covered for active systemic juvenile idiopathic arthritis and neonatal onsent multisystem inflammatory disease (NOMID). 4

6 ARMODAFINIL Products Affected Armodafinil Nuvigil PA Details Covered Uses All medically accepted indications not otherwise excluded from Part D. Other 5

7 AURYXIA Products Affected Auryxia PA Details Other one year 6

8 AVONEX Products Affected Avonex Avonex Pen PA Details Other Covered for patients with a diagnosis of relapsing forms of multiple sclerosis who have failure, contraindication, or intolerance to two or more of the following: Rebif, Extavia, or Copaxone. 7

9 AZTREONAM INHALATION Products Affected Cayston PA Details Other 8

10 BETASERON Products Affected Betaseron PA Details Other Covered for patients who have failure, contraindication, or intolerance to Extavia and either Rebif or glatiramer. 9

11 BOTULINUM TOXIN Products Affected Botox Dysport Myobloc Xeomin PA Details Other 10

12 CARISOPRODOL Products Affected Carisoprodol TABS Carisoprodol/aspirin Carisoprodol/aspirin/codeine Soma PA Details Other 30 days 11

13 CERTOLIZUMAB Products Affected Cimzia PA Details Other Covered for patients with rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis who have failure, significant systemic intolerance, or contraindication to two of the following: adalimumab, etanercept, infliximab. Covered for patients with Crohn's disease who have failed infliximab and adalimumab. 12

14 CHORIONIC GONADOTROPIN Products Affected Chorionic Gonadotropin INJ Novarel Pregnyl W/diluent Benzyl Alcohol/nacl PA Details Covered Uses All FDA approved indications not otherwise excluded from Part D. Other 13

15 COPAXONE 20 MG Products Affected Copaxone INJ 20MG/ML PA Details Other Covered for patients with 1) diagnosis of relapsing-remitting or relapsing forms of secondary progressive multiple sclerosis based on McDonald criteria, and 2) with failure or intolerance to Glatopa. Minor injection site reactions alone are not considered medication failure or intolerance qualified for coverage. 14

16 COPAXONE 40 MG Products Affected Copaxone INJ 40MG/ML PA Details Other Covered for patients with 1) diagnosis of relapsing-remitting or relapsing forms of secondary progressive multiple sclerosis based on McDonald criteria, and 2) with failure or intolerance to glatiramer 20 mg/ml and one other disease modifying drug (e.g., interferon, fingolimod, teriflunomide, dimethyl fumarate). Minor injection site reactions alone are not considered medication failure or intolerance qualified for coverage. 15

17 CORTICOTROPIN Products Affected H.p. Acthar PA Details Other Contraindication to corticosteroids when used for the treatment of acute exacerbations of multiple sclerosis. 16

18 CYSTEAMINE DELAYED-RELEASE Products Affected Procysbi PA Details Other A trial of cysteamine bitartrate (Cystagon) 17

19 DACLATASVIR Products Affected Daklinza PA Details Covered Uses All medically accepted indications not otherwise excluded from Part D. Other Test for HBV infection by measuring HBsAG and anti-hbc within 6 months of treatment Must be prescribed by or in consultation with infectious disease specialist, gastroenterology specialist, or hepatologist Consistent with AASLD/IDSA guidance Covered for patients with chronic Hepatitis C who meet one of the following criteria 1) Genotype 1 patients who have intolerance or contraindication to Harvoni and Epclusa, or 2) Post-transplant genotype 1 or 4 patients who have intolerance or contraindication to Harvoni, or 3) Genotype 2 or 3 patients who have intolerance or contraindication to Epclusa, or 4) Post-transplant genotype 2 or 3 patients, or 5) Genotype 4 patients who have decompensated cirrhosis and have intolerance or contraindication to Harvoni and Epclusa 18

20 DALFAMPRIDINE Products Affected Ampyra Dalfampridine Er PA Details Other Not covered for patients with moderate to severe renal impairment (CrCL less than 50 ml/min or a history of seizures. Covered for patients with a diagnosis of multiple sclerosis, and if diagnosis is relapsing, remitting multiple sclerosis (RRMS), patient is receiving concomitant therapy with a disease modifying drug (e.g., interferon, glatiramer, fingolimod,teriflunomide, dimethyl fumarate) 19

21 DICLOFENAC TRANSDERMAL Products Affected Flector PA Details Covered Uses All medically accepted indications not otherwise excluded from Part D. Other 20

22 DROXIDOPA Products Affected Northera PA Details Other Covered for patients with symptomatic neurogenic orthostatic hypotension (NOH) caused by primary autonomic failure (e.g., Parkinson's disease, multiple system atrophy, pure autonomic failure), dopamine beta-hydroxylase deficiency, and non-diabetic autonomic neuropathy who have failure, contraindication, or intolerance to midodrine. NOH is defined by a sustained drop in SBP (less than or equal to 20 mmhg) or in DBP (less than or equal to 10 mmhg) upon standing for greater than or equal to 3 minutes. 21

23 EPCLUSA Products Affected Epclusa PA Details Covered Uses All medically accepted indications not otherwise excluded from Part D. Other Test for HBV infection by measuring HBsAG and anti-hbc within 6 months of treatment Must be prescribed by or in consultation with infectious disease specialist, gastroenterology specialist, or hepatologist. Consistent with AASLD/IDSA guidance 22

24 ESTROGENS Products Affected Activella Alora Amabelz Angeliq Climara Climara Pro Combipatch Depo-estradiol INJ 5MG/ML Divigel Duavee Elestrin Enjuvia TABS 0.3MG, 0.45MG, 0.625MG, 0.9MG Estrace TABS Estradiol ORAL TABS 0.5MG, 1MG, 2MG Estradiol PTTW Estradiol PTWK Estradiol/norethindrone Acetate Estropipate TABS Evamist Femhrt Low Dose Fyavolv Jevantique Lo Jinteli Lopreeza Menest Menostar Mimvey Mimvey Lo Minivelle Norethindrone Acetate/ethinyl Estradiol TABS 2.5MCG; 0.5MG, 5MCG; 1MG Prefest Premarin INJ Premarin TABS 0.3MG, 0.45MG, 0.625MG, 0.9MG, 1.25MG Premphase Prempro Vivelle-dot PA Covered Uses Details All medically accepted indications not otherwise excluded from Part D Applies to patients age 65 to 105 years. Prior authorization not required for patients age 0 to

25 Other Members will be evaluated for more than one fill within the current plan year. For vaginal/vulvar atrophy, patient must try and fail two of the following: Estrace vaginal cream, Premarin vaginal cream, Estring, Vagifem. For postmenopausal osteoporosis, patient must try and fail two of the following: alendronate, ibandronate, raloxifene. Covered for use in cancer, palliative care, or hypoestrogenism due to hypogonadism, castration or primary ovarian failure. 24

26 EVOLOCUMAB Products Affected Repatha Repatha Pushtronex System Repatha Sureclick PA Details Must be prescribed by or in consultation with cardiology specialist or endocrinologist with lipid management expertise 25

27 Other Homozygous familial hypercholesterolemia: covered for patients age 13 or older with 1) positive genetic testing or untreated low-density lipoprotein cholesterol (LDL-C) levels of greater than 300 mg/dl with documentation of cutaneous or tendon xanthomas before age 10 or evidence of heterozygous familial hypercholesterolemia in both parents and, 2) treatment with maximally tolerated high-intensity statin therapy (i.e., atorvastatin 40 or 80 mg, rosuvastatin 20 or 40 mg) has been ineffective (LDL-C greater than 100 mg/dl) or contraindicated or not tolerated. Statin intolerance is defined as the inability to tolerate at least two statins, one at the lowest starting daily dose (e.g., rosuvastatin 5 mg, atorvastatin 10 mg, simvastatin 10 mg, lovastatin 20 mg, pravastatin 40 mg, fluvastatin 40 mg, and pitavastatin 2 mg) due to either objectionable symptoms or abnormal lab determinations, which are temporally related to statin treatment and reversible upon statin discontinuation, but reproducible by re-challenge with other potential causes being excluded. Heterozygous familial hypercholesterolemia: covered for patients age 18 years of older with 1) positive genetic testing or a score of greater than 8 on World Health Organization Diagnostic and, 2) treatment with maximally tolerated high-intensity statin therapy has been ineffective (unable to achieve and maintain LDL-C below goal of less than 100 mg/dl) or contraindicated or not tolerated. Clinical ASCVD: covered for patients age 18 years or older with 1) clinical ASCVD (i.e., coronary heart disease, cerebrovascular disease, or peripheral artery disease) and, 2) treatment with maximally tolerated high-intensity statin therapy has been ineffective (unable to achieve and maintain LDL-C at or below goal of less than 70 mg/dl) or contraindicated or not tolerated. 26

28 FENTANYL TRANSMUCOSAL Products Affected Abstral Actiq Fentanyl Citrate Oral Transmucosal Fentora TABS 100MCG, 200MCG, 400MCG, 600MCG, 800MCG Lazanda Subsys LIQD 100MCG, 200MCG, 400MCG, 600MCG, 800MCG PA Details Other 27

29 GOLIMUMAB Products Affected Simponi Simponi Aria PA Details Other Covered for patients with rheumatoid arthritis who have failure, significant systemic intolerance, or contraindication to 1) adalimumab, etanercept, or infliximab, and 2) abatacept. Covered for patients with ulcerative colitis who have failed infliximab and adalimumab. 28

30 GUSELKUMAB Products Affected Tremfya PA Details Other Covered for the treatment of moderate to severe plaque psoriasis in patients who failed or have contraindication to one anti-tnf agent (i.e., etanercept, adalimumab, infliximab) and secukinumab. 29

31 HIGH-RISK NSAIDS Products Affected Indocin SUPP Indocin SUSP Indomethacin CAPS Indomethacin Er Ketorolac Tromethamine INJ 15MG/ML, 30MG/ML Ketorolac Tromethamine TABS Tivorbex PA Details Other Applies to patients age 65 to 105 years. Prior authorization not required for patients age 0 to 64. Members will be evaluated for more than one fill within the current plan year. Patients must try and fail naproxen and ibuprofen. 30

32 HYDROCODONE ER Products Affected Hysingla Er Zohydro Er C12A PA Details Other Trial and intolerance of morphine extended-release and oxycodone extended-release. 31

33 INTRAROSA Products Affected Intrarosa PA Details Other 32

34 IVACAFTOR Products Affected Kalydeco PA Details Other 33

35 IXEKIZUMAB Products Affected Taltz PA Details Other Covered for the treatment of moderate to severe plaque psoriasis in patients who failed or have contraindication to one anti-tnf agent (i.e., etanercept, adalimumab, infliximab) and secukinumab. 34

36 KEVEYIS Products Affected Keveyis PA Details Other 35

37 LEDIPASVIR-SOFOSBUVIR Products Affected Harvoni PA Details Covered Uses All medically accepted indications not otherwise excluded from Part D. Other Test for HBV infection by measuring HBsAG and anti-hbc within 6 months of treatment Must be prescribed by or in consultation with infectious disease specialist, gastroenterology specialist, or hepatologist Consistent with AASLD/IDSA guidance 36

38 LIDOCAINE TRANSDERMAL Products Affected Lidocaine PTCH Lidoderm Lidotrex GEL 2% Ztlido PA Covered Uses Other Details All medically accepted indications not otherwise excluded from Part D 37

39 LOMITAPIDE Products Affected Juxtapid PA Details Other Covered for patients with a diagnosis of homozygous familial hypercholesterolemia based on 1) positive genetic testing, or 2) untreated low-density lipoprotein cholesterol (LDL-C) levels of greater than 300 mg/dl with documentation of cutaneous or tendon xanthomas before age 10 or evidence of heterozygous familial hypercholesterolemia in both parents. 38

40 LUMACAFTOR/IVACAFTOR Products Affected Orkambi PA Details Other 39

41 MACITENTAN Products Affected Opsumit PA Details Other 40

42 MAVYRET Products Affected Mavyret PA Details Other Test for HBV infection by measuring HBsAG and anti-hbc within 6 months of treatment Must be prescribed by or in consultation with infectious disease specialist, gastroenterology specialist, or hepatologist Consistent with AASLD/IDSA guidance 41

43 MEPERIDINE Products Affected Demerol INJ Meperidine Hcl INJ 100MG/ML, 10MG/ML, 25MG/ML, 50MG/ML Meperidine Hcl ORAL SOLN PA Details Covered Uses All FDA approved indications not otherwise excluded from Part D. Other 42

44 METHAMPHETAMINE Products Affected Desoxyn Methamphetamine Hcl PA Details Covered Uses All FDA approved indications not otherwise excluded from Part D. Other 43

45 MIFEPRISTONE 300MG Products Affected Korlym PA Details Other Pregnancy 44

46 MIPOMERSEN Products Affected Kynamro PA Details Other Covered for patients with a diagnosis of homozygous familial hypercholesterolemia based on 1) positive genetic testing, or 2) untreated low-density lipoprotein cholesterol (LDL-C) levels of greater than 300 mg/dl with documentation of cutaneous or tendon xanthomas before age 10 or evidence of heterozygous familial hypercholesterolemia in both parents. 45

47 MODAFINIL Products Affected Modafinil Provigil PA Details Covered Uses All medically accepted indications not otherwise excluded from Part D. Other 46

48 NATALIZUMAB Products Affected Tysabri PA Details Other 47

49 NATPARA Products Affected Natpara PA Details Other 48

50 NINTEDANIB Products Affected Ofev PA Details Other Must be prescribed by or in consultation with a pulmonologist 49

51 NON BENZODIAZEPINE HYPNOTICS Products Affected Ambien Ambien Cr Edluar Eszopiclone Intermezzo Lunesta Sonata Zaleplon Zolpidem Tartrate Zolpidem Tartrate Er Zolpimist PA Details Other Applies to patients age 65 to 105 years. Prior authorization not required for patients age 0 to days except eszopiclone 4 months Members will be evaluated for more than one fill within the current plan year. For insomnia, patients must have trial, failure, or contraindication to trazodone and low dose doxepin (less than or equal to 6 mg/day). The prescriber must attest that they are aware that the medication is considered a high risk medication in the elderly and that the benefits outweigh the risk. 50

52 OSPHENA Products Affected Osphena PA Details Other 51

53 OTEZLA Products Affected Otezla PA Details Other Starter pack will be approved for new starts to reduce gastrointestinal side effects. 52

54 PALYNZIQ Products Affected Palynziq PA Covered Uses Other Details All FDA approved indications not otherwise excluded from Part D 53

55 PAROXETINE Products Affected Paroxetine Hcl Paroxetine Hcl Er Paxil Paxil Cr Pexeva PA Details Covered Uses All medically accepted indications not otherwise excluded from Part D. Other Applies to patients age 65 to 105 years. Prior authorization not required for patients age 0 to 64 years. Paroxetine is considered a high risk medication in the elderly. Patients must try and fail two other SSRIs (e.g., fluoxetine, escitalopram, or sertraline). The prescriber must attest that they are aware that the medication is considered a high risk medication in the elderly and that the benefits outweigh the risk. 54

56 PEGINTERFERON BETA-1A (PLEGRIDY) Products Affected Plegridy Plegridy Starter Pack PA Details Other Covered for patients who have failure, contraindication, or intolerance to two ore more of the following: Rebif, Extavia, or Copaxone. 55

57 PIRFENIDONE Products Affected Esbriet PA Details Other Must be prescribed by or in consultation with a pulmonologist 56

58 PROGESTERONE Products Affected Crinone PA Details Covered Uses All FDA approved indications not otherwise excluded from Part D. Other 57

59 RIOCIGUAT Products Affected Adempas PA Details Other 58

60 SARILUMAB Products Affected Kevzara PA Details Other Covered for patients with rheumatoid arthritis who have failure, significant systemic intolerance, or contraindication to 1) adalimumab, etanercept, or infliximab, and 2) abatacept. 59

61 SECUKINUMAB Products Affected Cosentyx Cosentyx Sensoready Pen PA Details Other Covered for the treatment of moderate to severe plaque psoriasis, ankylosing spondylitis, psoriatic arthritis in patients who failed or have contraindication to two or more of the following: adalimumab, etanercept, or infliximab. 60

62 SILDENAFIL Products Affected Revatio Sildenafil INJ Sildenafil TABS 20MG PA Details Other 61

63 SIMEPREVIR Products Affected Olysio PA Details Other Test for HBV infection by measuring HBsAG and anti-hbc within 6 months of treatment Must be prescribed by or in consultation with infectious disease specialist, gastroenterology specialist, or hepatologist Consistent with AASLD/IDSA guidance Covered for patients 1) with chronic Hepatitis C genotype 1 who have contraindication or intolerance to Harvoni, or 2) with chronic Hepatitis C genotype 4 who have contraindication or intolerance to Harvoni and Technivie. Not covered in patients who have failed previous treatment with either boceprevir or telaprevir. 62

64 SKELETAL MUSCLE RELAXANTS Products Affected Amrix Cyclobenzaprine Hcl TABS Fexmid Meprobamate Metaxall Metaxalone Methocarbamol INJ 1000MG/10ML Methocarbamol TABS Orphenadrine Citrate INJ Orphenadrine Citrate Er Robaxin INJ 1000MG/10ML Robaxin TABS Robaxin-750 Skelaxin TABS 800MG PA Details Other Applies to patients age 65 to 105 years. Prior authorization not required for patients age 0 to 64 years. 30 days except meprobamate 4 months Members will be evaluated for more than one fill within the current plan year. The prescriber must attest that they are aware that the medication is considered a high risk medication in the elderly and that the benefits outweigh the risk. 63

65 SODIUM OXYBATE Products Affected Xyrem PA Details Other Covered for patients 1) with narcolepsy with cataplexy or 2) with excessive daytime sleepiness in narcolepsy who have contraindication, intolerance or failure to a stimulant. 64

66 SOFOSBUVIR Products Affected Sovaldi PA Details Covered Uses All medically accepted indications not otherwise excluded from Part D. Other Test for HBV infection by measuring HBsAG and anti-hbc within 6 months of treatment Must be prescribed by or in consultation with infectious disease specialist, gastroenterology specialist, or hepatologist Consistent with AASLD/IDSA guidance Covered for patients 1) with chronic Hepatitis C genotype 2, 3, and 5, or 2) with chronic Hepatitis C genotype 1, 4, and 6 who have a contraindication or intolerance to Harvoni. Not covered if patient has CrCL less than 30 ml/min. 65

67 SOMATROPIN Products Affected Genotropin Genotropin Miniquick Humatrope INJ 12MG, 24MG, 6MG Humatrope Combo Pack Norditropin Flexpro Nutropin Aq Nuspin 10 Nutropin Aq Nuspin 20 Nutropin Aq Nuspin 5 Nutropin Aq Pen INJ 20MG/2ML Omnitrope Saizen Saizen Click.easy Saizenprep Reconstitutionkit Serostim INJ 4MG, 5MG, 6MG Zomacton Zorbtive PA Details Other 66

68 SYMDEKO Products Affected Symdeko PA Details Other 67

69 TADALAFIL Products Affected Cialis TABS 2.5MG, 5MG PA Details Other Covered for treatment of the signs and symptoms of benign prostatic hyperplasia at the FDA-approved dose for this indication (dose may not exceed 5 mg/day), provided that the patient has had failure, intolerance or contraindication to one alpha-1 adrenergic blocking agents (e.g., prazosin, doxazosin, terazosin, tamsulosin), and has had failure, intolerance or contraindication to one 5-alpha-reductase inhibitor (e.g., finasteride, dutasteride). 68

70 TASIMELTEON Products Affected Hetlioz PA Details Other 69

71 TECHNIVIE Products Affected Technivie PA Details Other Test for HBV infection by measuring HBsAG and anti-hbc within 6 months of treatment Must be prescribed by or in consultation with infectious disease specialist, gastroenterology specialist, or hepatologist Consistent with AASLD/IDSA guidance Covered for patients with chronic Hepatitis C genotype 4 who have contraindication or intolerance to Harvoni. 70

72 TEDUGLUTIDE Products Affected Gattex PA Details Other 71

73 TOBRAMYCIN INHALATION BRAND Products Affected Bethkis Kitabis Pak Tobi Tobi Podhaler PA Details Other Trial and failure of generic tobramycin inhalation solution 72

74 TOBRAMYCIN INHALATION GENERIC Products Affected Tobramycin NEBU PA Details Other 73

75 TOCILIZUMAB Products Affected Actemra PA Details Other Covered for patients with rheumatoid arthritis who have tried and failed two of the following agents (adalimumab, etanercept, infliximab, abatacept). Covered for patients with active systemic juvenile idiopathic arthritis or polyarticular juvenile idiopathic arthritis or giant cell arteritis. 74

76 TOFACITINIB Products Affected Xeljanz Xeljanz Xr PA Details Other Covered for patients with rheumatoid arthritis who have failure, significant systemic intolerance, or contraindication to 1) adalimumab, etanercept, or infliximab, and 2) abatacept. 75

77 TRICYCLIC ANTIDEPRESSANTS Products Affected Amitriptyline Hcl TABS Amoxapine Anafranil Clomipramine Hcl CAPS Desipramine Hcl TABS Elavil TABS 25MG Imipramine Hcl TABS 25MG, 50MG Imipramine Hydrochloride TABS 10MG Imipramine Pamoate Norpramin Nortriptyline Hcl CAPS Nortriptyline Hcl SOLN Pamelor CAPS Protriptyline Hcl Surmontil Tofranil TABS Trimipramine Maleate CAPS PA Details Covered Uses All medically accepted indications not otherwise excluded from Part D. Other Applies to patients 65 years of age and older. Prior authorization not required for patients age 0 to 64 years. Tricyclic antidepressants are considered high risk medications in the elderly. For depression: patients must have trial, failure, or contraindication to a SSRI (e.g., fluoxetine, escitalopram, or sertraline). For neuropathic pain or fibromyalgia: after failure of two preferred agents (e.g., gabapentin, duloxetine). For headache prophylaxis, patients must have trial, failure, or contraindication to two preferred agents (e.g., topiramate, divalproex delayed release, propranolol, metoprolol). 76

78 USTEKINUMAB Products Affected Stelara PA Details Other Covered for patients with plaque psoriasis, psoriatic arthritis or Crohn's disease who have tried and failed two anti-tnf agents (i.e., adalimumab, etanercept, infliximab). 77

79 VIEKIRA PAK Products Affected Viekira Pak Viekira Xr PA Details Covered Uses All medically accepted indications not otherwise excluded from Part D. Other Test for HBV infection by measuring HBsAG and anti-hbc within 6 months of treatment Must be prescribed by or in consultation with infectious disease specialist, gastroenterology specialist, or hepatologist Consistent with AASLD/IDSA guidance Covered for patients with chronic Hepatitis C 1) genotype 1a or 1b who have contraindication or intolerance to Harvoni and Epclusa, or 2) genotype 1 post-transplant who have contraindication or intolerance to Harvoni and daclatasvir in combination with sofosbuvir and ribavirin. 78

80 VOSEVI Products Affected Vosevi PA Details Other Test for HBV infection by measuring HBsAG and anti-hbc within 6 months of treatment Must be prescribed by or in consultation with infectious disease specialist, gastroenterology specialist, or hepatologist 12 weeks 79

81 ZEPATIER Products Affected Zepatier PA Details Covered Uses All medically accepted indications not otherwise excluded from Part D. Other Test for HBV infection by measuring HBsAG and anti-hbc within 6 months of treatment Must be prescribed by or in consultation with infectious disease specialist, gastroenterology specialist, or hepatologist Consistent with AASLD/IDSA guidance Covered for patients with chronic Hepatitis C 1) genotype 1 or 4 who have contraindication or intolerance to Harvoni or Epclusa, or 2) treatment-experienced genotype 3 with compensated cirrhosis who have contraindication or intolerance to Epclusa/ribavirin 80

82 PART B VERSUS PART D Products Affected Acetylcysteine INHALATION SOLN Akynzeo CAPS Albuterol Sulfate NEBU A-methapred INJ 40MG Aminosyn INJ 148MEQ/L; 1280MG/100ML; 980MG/100ML; 1280MG/100ML; 300MG/100ML; 720MG/100ML; 940MG/100ML; 720MG/100ML; 400MG/100ML; 440MG/100ML; 5.4MEQ/L; 860MG/100ML; 420MG/100ML; 520MG/100ML; 160MG/100ML; 44MG/100ML; 800MG/100ML, 90MEQ/L; 1100MG/100ML; 850MG/100ML; 35MEQ/L; 1100MG/100ML; 260MG/100ML; 620MG/100ML; 810MG/100ML; 624MG/100ML; 340MG/100ML; 380MG/100ML; 5.4MEQ/L; 750MG/100ML; 370MG/100ML; 460MG/100ML; 150MG/100ML; 44MG/100ML; 680MG/100ML Aminosyn II INJ 107.6MEQ/L; 1490MG/100ML; 1527MG/100ML; 1050MG/100ML; 1107MG/100ML; 750MG/100ML; 450MG/100ML; 990MG/100ML; 1500MG/100ML; 1575MG/100ML; 258MG/100ML; 447MG/100ML; 1083MG/100ML; 795MG/100ML; 50MEQ/L; 600MG/100ML; 300MG/100ML; 405MG/100ML; 750MG/100ML, 50.3MEQ/L; 695MG/100ML; 713MG/100ML; 490MG/100ML; 517MG/100ML; 350MG/100ML; 210MG/100ML; 462MG/100ML; 700MG/100ML; 735MG/100ML; 120MG/100ML; 209MG/100ML; 505MG/100ML; 371MG/100ML; 31.3MEQ/L; 280MG/100ML; 140MG/100ML; 189MG/100ML; 350MG/100ML, 61.1MEQ/L; 844MG/100ML; 865MG/100ML; 595MG/100ML; 627MG/100ML; 425MG/100ML; 255MG/100ML; 561MG/100ML; 850MG/100ML; 893MG/100ML; 146MG/100ML; 253MG/100ML; 614MG/100ML; 450MG/100ML; 33.3MEQ/L; 340MG/100ML; 170MG/100ML; 230MG/100ML; 425MG/100ML, 71.8MEQ/L; 993MG/100ML; 1018MG/100ML; 700MG/100ML; 738MG/100ML; 500MG/100ML; 300MG/100ML; 660MG/100ML; 1000MG/100ML; 1050MG/100ML; 172MG/100ML; 298MG/100ML; 722MG/100ML; 530MG/100ML; 38MEQ/L; 400MG/100ML; 200MG/100ML; 270MG/100ML; 500MG/100ML Aminosyn-hbc 81

83 Aminosyn-pf INJ 46MEQ/L; 698MG/100ML; 1227MG/100ML; 527MG/100ML; 820MG/100ML; 385MG/100ML; 312MG/100ML; 760MG/100ML; 1200MG/100ML; 677MG/100ML; 180MG/100ML; 427MG/100ML; 812MG/100ML; 495MG/100ML; 3.4MEQ/L; 70MG/100ML; 512MG/100ML; 180MG/100ML; 44MG/100ML; 673MG/100ML Aminosyn-pf 7% Aminosyn-rf Anzemet TABS Aprepitant Aranesp Albumin Free INJ 100MCG/0.5ML, 100MCG/ML, 10MCG/0.4ML, 150MCG/0.3ML, 200MCG/0.4ML, 200MCG/ML, 25MCG/0.42ML, 25MCG/ML, 300MCG/0.6ML, 300MCG/ML, 40MCG/0.4ML, 40MCG/ML, 500MCG/ML, 60MCG/0.3ML, 60MCG/ML Astagraf XL Azasan Azathioprine INJ Azathioprine TABS Betamethasone Sodium Phosphate/betamethasone Acetate Bivigam Brovana Budesonide SUSP Carimune Nanofiltered INJ 12GM, 6GM Celestone-soluspan Cellcept Cellcept Intravenous Cesamet Cladribine Clinisol Sf 15% Cortef TABS Cortisone Acetate TABS 25MG Cromolyn Sodium NEBU Cuvitru Cyclophosphamide CAPS Cyclosporine CAPS Cyclosporine INJ Cyclosporine Modified Deferoxamine Mesylate Depo-medrol Desferal INJ 500MG Dexamethasone ELIX Dexamethasone SOLN Dexamethasone TABS 0.5MG, 0.75MG, 1.5MG, 1MG, 2MG, 4MG, 6MG Dexamethasone 10-day Dose Pack Dexamethasone 6-day Dose Pack Dexamethasone Sodium Phosphate INJ 100MG/10ML, 10MG/ML, 120MG/30ML, 4MG/ML Dexpak 10 Day TBPK Dexpak 6 Day Dronabinol Emend CAPS Emend SUSR Emend Tripack Engerix-b Envarsus Xr Epogen INJ 10000UNIT/ML, 20000UNIT/ML, 2000UNIT/ML, 3000UNIT/ML, 4000UNIT/ML Flebogamma Dif Freamine Hbc 6.9% Freamine III INJ 89MEQ/L; 710MG/100ML; 950MG/100ML; 3MEQ/L; 24MG/100ML; 1400MG/100ML; 280MG/100ML; 690MG/100ML; 910MG/100ML; 730MG/100ML; 530MG/100ML; 560MG/100ML; 10MMOLE/L; 120MG/100ML; 1120MG/100ML; 590MG/100ML; 10MEQ/L; 400MG/100ML; 150MG/100ML; 660MG/100ML Gablofen 82

84 Gammaplex INJ 10GM/100ML; 0, 10GM/200ML, 20GM/200ML, 20GM/400ML, 5GM/100ML, 5GM/50ML Gengraf Granisetron Hcl TABS Hepatamine Heplisav-b Hizentra Hydrocortisone TABS Hypersal NEBU 7% Hyper-sal Imovax Rabies (h.d.c.v.) Imuran TABS Intralipid INJ 20GM/100ML, 30GM/100ML Ipratropium Bromide INHALATION SOLN 0.02% Ipratropium Bromide/albuterol Sulfate Levalbuterol NEBU Levalbuterol Hcl NEBU Lioresal Intrathecal INJ 0.05MG/ML, 2000MCG/ML, 40MG/20ML, 500MCG/ML Locort 11-day Locort 7-day Marinol Medrol TABS 16MG, 2MG, 32MG, 4MG, 8MG Medrol Dosepak Methylprednisolone TABS Methylprednisolone Acetate INJ 40MG/ML, 50MG/ML, 80MG/ML Methylprednisolone Dose Pack TBPK Methylprednisolone Sodiumsuccinate INJ 1000MG, 125MG, 40MG Millipred Millipred Dp Mycophenolate Mofetil Mycophenolic Acid Dr Myfortic Nebupent Nebusal NEBU 3% Neoral Nephramine Nulojix Nutrilipid Octagam INJ 10GM/100ML, 10GM/200ML, 1GM/20ML, 2.5GM/50ML, 20GM/200ML, 2GM/20ML, 5GM/100ML, 5GM/50ML Ondansetron Hcl ORAL SOLN Ondansetron Hcl TABS Ondansetron Odt Orapred Odt Pediapred SOLN Perforomist Plenamine Prednisolone SOLN Prednisolone Sodium Phosphate ORAL SOLN 10MG/5ML, 15MG/5ML, 20MG/5ML, 25MG/5ML, 5MG/5ML Prednisolone Sodium Phosphate Odt Premasol Privigen Procrit Prograf Prosol Pulmicort Pulmosal Pulmozyme Rabavert Rapamune Recombivax Hb Remodulin Retacrit Sandimmune CAPS 100MG, 25MG Sandimmune INJ Sandimmune SOLN Simulect Sirolimus TABS Sodium Chloride NEBU 0.9%, 10%, 3%, 7% Solu-cortef Solu-medrol INJ 1000MG, 125MG, 2GM, 40MG, 500MG Syndros Tacrolimus CAPS 83

85 Taperdex 12-day Taperdex 6-day Tigan CAPS 300MG Travasol INJ 52MEQ/L; 1760MG/100ML; 880MG/100ML; 34MEQ/L; 1760MG/100ML; 372MG/100ML; 406MG/100ML; 526MG/100ML; 492MG/100ML; 492MG/100ML; 526MG/100ML; 356MG/100ML; 356MG/100ML; 390MG/100ML; 34MG/100ML; 152MG/100ML Trimethobenzamide Hcl CAPS 300MG Trophamine Tyvaso Tyvaso Refill Tyvaso Starter Varubi Ventavis Veripred 20 Vincasar Pfs Vincristine Sulfate INJ Xopenex Xopenex Concentrate Zodex 12-day Zodex 6-day Zofran SOLN Zofran TABS 4MG, 8MG Zofran Odt Zonacort 11 Day Zonacort 7 Day Zortress Zuplenz Details This drug may be covered under Medicare Part B or D depending upon the circumstances. may need to be submitted describing the use and setting of the drug to make the determination. 84

86 INDEX A Abstral Acetylcysteine Actemra Actiq Activella Adcirca... 1 Adempas Aimovig... 2 Ajovy... 3 Akynzeo Albuterol Sulfate Alirocumab... 4 Alora Amabelz Ambien Ambien Cr A-methapred Aminosyn Aminosyn II Aminosyn-hbc Aminosyn-pf Aminosyn-pf 7% Aminosyn-rf Amitriptyline Hcl Amoxapine Ampyra Amrix Anafranil Anakinra... 5 Angeliq Anzemet Aprepitant Aranesp Albumin Free Armodafinil... 6 Astagraf XL Auryxia... 7 Avonex... 8 Avonex Pen... 8 Azasan Azathioprine Aztreonam Inhalation... 9 B Betamethasone Sodium Phosphate/betamethasone Acetate Betaseron Bethkis Bivigam Botox Botulinum Toxin Brovana Budesonide C Carimune Nanofiltered Carisoprodol Carisoprodol/aspirin Carisoprodol/aspirin/codeine Cayston... 9 Celestone-soluspan Cellcept Cellcept Intravenous Certolizumab Cesamet Chorionic Gonadotropin Cialis Cimzia Cladribine Climara Climara Pro Clinisol Sf 15% Clomipramine Hcl Combipatch Copaxone... 15, 16 85

87 Copaxone 20 Mg Copaxone 40 Mg Cortef Corticotropin Cortisone Acetate Cosentyx Cosentyx Sensoready Pen Crinone Cromolyn Sodium Cuvitru Cyclobenzaprine Hcl Cyclophosphamide Cyclosporine Cyclosporine Modified Cysteamine Delayed-release D Daclatasvir Daklinza Dalfampridine Dalfampridine Er Deferoxamine Mesylate Demerol Depo-estradiol Depo-medrol Desferal Desipramine Hcl Desoxyn Dexamethasone Dexamethasone 10-day Dose Pack Dexamethasone 6-day Dose Pack Dexamethasone Sodium Phosphate Dexpak 10 Day Dexpak 6 Day Diclofenac Transdermal Divigel Dronabinol Droxidopa Duavee Dysport E Edluar Elavil Elestrin Emend Emend Tripack Engerix-b Enjuvia Envarsus Xr Epclusa Epogen Esbriet Estrace Estradiol Estradiol/norethindrone Acetate Estrogens Estropipate Eszopiclone Eteplirsen Evamist Evolocumab Exondys F Femhrt Low Dose Fentanyl Citrate Oral Transmucosal Fentanyl Transmucosal Fentora Fexmid Flebogamma Dif Flector Freamine Hbc 6.9% Freamine III Fyavolv G Gablofen Gammaplex Gattex Gengraf Genotropin Genotropin Miniquick Golimumab Granisetron Hcl Guselkumab H H.p. Acthar Harvoni... 38

88 Hepatamine Heplisav-b Hetlioz High-risk Nsaids Hizentra Humatrope Humatrope Combo Pack Hydrocodone Er Hydrocortisone Hypersal Hyper-sal Hysingla Er I Imipramine Hcl Imipramine Hydrochloride Imipramine Pamoate Imovax Rabies (h.d.c.v.) Imuran Indocin Indomethacin Indomethacin Er Intermezzo Intralipid Intrarosa Ipratropium Bromide Ipratropium Bromide/albuterol Sulfate Ivacaftor Ixekizumab J Jevantique Lo Jinteli Juxtapid K Kalydeco Ketorolac Tromethamine Keveyis Kevzara Kineret... 5 Kitabis Pak Korlym Kynamro L Lazanda Ledipasvir-sofosbuvir Levalbuterol Levalbuterol Hcl Lidocaine Lidocaine Transdermal Lidoderm Lidotrex Lioresal Intrathecal Locort 11-day Locort 7-day Lomitapide Lopreeza Lumacaftor/ivacaftor Lunesta M Macitentan Marinol Mavyret Medrol Medrol Dosepak Menest Menostar Meperidine Meperidine Hcl Meprobamate Metaxall Metaxalone Methamphetamine Methamphetamine Hcl Methocarbamol Methylprednisolone Methylprednisolone Acetate Methylprednisolone Dose Pack Methylprednisolone Sodiumsuccinate Mifepristone 300mg Millipred Millipred Dp Mimvey Mimvey Lo Minivelle Mipomersen

89 Modafinil Mycophenolate Mofetil Mycophenolic Acid Dr Myfortic Myobloc N Natalizumab Natpara Nebupent Nebusal Neoral Nephramine Nintedanib Non Benzodiazepine Hypnotics Norditropin Flexpro Norethindrone Acetate/ethinyl Estradiol Norpramin Northera Nortriptyline Hcl Novarel Nulojix Nutrilipid Nutropin Aq Nuspin Nutropin Aq Nuspin Nutropin Aq Nuspin Nutropin Aq Pen Nuvigil... 6 O Octagam Ofev Olysio Omnitrope Ondansetron Hcl Ondansetron Odt Opsumit Orapred Odt Orkambi Orphenadrine Citrate Orphenadrine Citrate Er Osphena Otezla P Palynziq Pamelor Paroxetine Paroxetine Hcl Paroxetine Hcl Er Part B Versus Part D Paxil Paxil Cr Pediapred Peginterferon Beta-1a (plegridy) Perforomist Pexeva Pirfenidone Plegridy Plegridy Starter Pack Plenamine Praluent... 4 Prednisolone Prednisolone Sodium Phosphate Prednisolone Sodium Phosphate Odt Prefest Pregnyl W/diluent Benzyl Alcohol/nacl Premarin Premasol Premphase Prempro Privigen Procrit Procysbi Progesterone Prograf Prosol Protriptyline Hcl Provigil Pulmicort Pulmosal Pulmozyme R Rabavert Rapamune Recombivax Hb Remodulin

90 Repatha Repatha Pushtronex System Repatha Sureclick Retacrit Revatio Riociguat Robaxin Robaxin S Saizen Saizen Click.easy Saizenprep Reconstitutionkit Sandimmune Sarilumab Secukinumab Serostim Sildenafil Simeprevir Simponi Simponi Aria Simulect Sirolimus Skelaxin Skeletal Muscle Relaxants Sodium Chloride Sodium Oxybate Sofosbuvir Solu-cortef Solu-medrol Soma Somatropin Sonata Sovaldi Stelara Subsys Surmontil Symdeko Syndros T Tacrolimus Tadalafil... 1, 70 Taltz Taperdex 12-day Taperdex 6-day Tasimelteon Technivie Teduglutide Tigan Tivorbex Tobi Tobi Podhaler Tobramycin Tobramycin Inhalation Brand Tobramycin Inhalation Generic Tocilizumab Tofacitinib Tofranil Travasol Tremfya Tricyclic Antidepressants Trimethobenzamide Hcl Trimipramine Maleate Trophamine Tysabri Tyvaso Tyvaso Refill Tyvaso Starter U Ustekinumab V Varubi Ventavis Veripred Viekira Pak Viekira Xr Vincasar Pfs Vincristine Sulfate Vivelle-dot Vosevi X Xeljanz Xeljanz Xr Xeomin Xopenex Xopenex Concentrate... 86

91 Xyrem Z Zaleplon Zepatier Zodex 12-day Zodex 6-day Zofran Zofran Odt Zohydro Er Zolpidem Tartrate Zolpidem Tartrate Er Zolpimist Zomacton Zonacort 11 Day Zonacort 7 Day Zorbtive Zortress Ztlido Zuplenz