Product Group Covered Uses Exclusion Criteria Required Medical Information Age Restrictions

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1 2016 Cigna-HealthSpring Criteria - H Cigna-HealthSpring Preferred (HMO), Cigna-HealthSpring Achieve Plus (HMO SNP), Cigna-HealthSpring Preferred Plus (HMO) (Updated November 2016) Drug Name Type Description Product Group Covered Uses Exclusion Criteria Required Medical Information Age Restrictions Prescriber Restrictions Coverage Duration Other Criteria Excluded Drug Criteria ABELCET ABRAXANE ACETYLCYSTEINE ACYCLOVIR SODIUM ADCIRCA ADCIRCA All FDA-approved indications not otherwise excluded from part D. Medical documentation of pulmonary arterial hypertension. ADRUCIL ALBUTEROL SULFATE ALIMTA ALORA ALOSETRON HYDROCHLORIDE LOTRONEX Alosetron will not be approved for use in men, as safety and efficacy in men has not been established. ALOXI AMBISOME AMIFOSTINE AMINOSYN AMINOSYN 7%/ELECTROLYTES AMINOSYN 8.5%/ELECTROLYTES AMINOSYN II AMINOSYN II 8.5%/ELECTROLYTES AMINOSYN M AMINOSYN-HBC AMINOSYN-PF AMINOSYN-PF 7% AMINOSYN-RF AMITRIPTYLINE HCL to New Starts Only HRM - Tricyclic Antidepressants Safer alternatives depend on indication. For Depression, safer alternatives are: Nortriptyline, Protriptyline, Desipramine, Amoxapine, Citalopram, Venlafaxine, Fluoxetine, Paroxetine, Sertraline, Duloxetine, and Bupropion. For headache prophylaxis, safer alternatives are: Propranolol, Topiramate, and Divalproex sodium. For headache treatment, safer alternatives are: Sumatriptan, Naratriptan, and Dihydroergotamine. For Pain/Neuropathy, safer alternatives are: Duloxetine, Lyrica, and Gabapentin.

2 AMPHOTERICIN B AMPYRA AMPYRA Documentation of diagnosis. Ampyra is considered medically necessary for patients with multiple sclerosis with medical documentation of impaired walking ability. ANADROL-50 ANABOLIC STEROIDS, ANDROGENS Documentation of diagnosis. ANGELIQ ANZEMET ANZEMET INJ ARALAST NP ANZEMET INJ ARANESP ALBUMIN FREE HEMATOPOIETICS For the indication of anemia, documentation of Hemoglobin less than 11, transferrin saturation greater than 20%, and ferritin levels greater than 100 obtained over the last 3 months. 6 months BvD Determination. Patients must also have failure, contraindication or intolerance to Procrit or Aranesp before Epogen will be authorized. ARCALYST ARCALYST Documentation of diagnosis of Cryopyrin-Associated Periodic Syndromes (CAPS), including Familial Cold Auto-inflammatory Syndrome (FCAS) and Muckle-Wells Syndrome (MWS). 12 years of age and older BvsD Determination ARMODAFINIL NUVIGIL Documentation of diagnosis and sleep study for the diagnosis of sleep apnea or narcolepsy. For the treatment of narcolepsy, the patient must have failure, contraindication, or intolerance to methylphenidate or dextroamphetamine sulfate before armodafinil or Nuvigil is authorized. ARRANON ARZERRA ASCOMP/CODEINE HRM - Butalbital Combinations Safer alternatives are: naproxen sodium and ibuprofen. ASTAGRAF XL ATGAM to New Starts Only to New Starts Only B vs D determination. B vs D determination. AUBAGIO AUBAGIO Aubagio will be used as monotherapy for the treatment of multiple sclerosis. Patient must also have failure, contraindication or intolerance to one of the following formulary alternatives Avonex, Extavia, glatiramer acetate or Rebif before Aubagio will be authorized. AVASTIN AZACITIDINE

3 AZATHIOPRINE BELEODAQ BENDEKA to New Starts Only B vs D determination. BENLYSTA BENLYSTA The patient must have a positive autoantibody test (i.e., antinuclear antibody [ANA] greater than or equal to 1:80 and/or antidouble-stranded DNA [anti-dsdna] greater than or equal to 30 IU/ml) AND active disease state as documented by a SELENA- SLEDAI score of 6 or greater on the current treatment regimen. The patient must be receiving one standard therapy for SLE with any of the following: corticosteroids, hydroxychloroquine, immunosuppressives (cyclophosphamide, azathioprine, mycophenolate, methotrexate, cyclosporine) or nonsteroidal antiinflammatory drugs AND there must be an absence of severe active lupus nephritis or severe active central nervous system lupus before Benlysta is authorized. BvsD Determination. BENZTROPINE MESYLATE HRM - Benztropine formulary alternatives if two are available or provided clinical rationale why two safer formulary alternatives are not appropriate for the patient. If only one (1) safer formulary alternative is available, then only that particular medication would need to be documented as tried and failed or clinical rationale provided as to why that one safer formulary alternative is not appropriate for the patient. Safer alternatives depend on indication. For Parkinsonism, safer alternatives are: Carbidopa/Levodopa, Pramipexole, Ropinirole, Bromocriptine, Amantadine, and Selegiline. For extrapyramidal symptoms, a safer alternative is: Amantadine. BERINERT BERINERT Berinert is authorized for the treatment of acute angioedema attacks with hereditary angioedema (HAE) when BOTH of the following criteria are met: 1) confirmed diagnosis of (HAE) as evidenced by a C4 level below the lower limit of normal as defined by the laboratory performing the test AND EITHER a) C1 inhibitor (C1INH) antigenic level below the lower limit of normal as defined by the laboratory performing the test or b) C1INH functional level below the lower limit of normal as defined by the laboratory performing the test AND 2) history of a moderate or severe attack (e.g., airway swelling, severe abdominal pain, facial swelling, nausea and vomiting, painful facial distortion). BETHKIS BICNU BIVIGAM BLEOMYCIN SULFATE BOTOX BROVANA BUDESONIDE BUSULFEX BOTOX Exclude when used for cosmetic purposes. Documentation of diagnosis 3 months BUTALBITAL/ACETAMI NOPHEN HRM - Butalbital Combinations Safer alternatives are: naproxen sodium and ibuprofen.

4 BUTALBITAL/ACETAMI NOPHEN/CAFFEINE HRM - Butalbital Combinations Safer alternatives are: naproxen sodium and ibuprofen. BUTALBITAL/APAP/CAF FEINE HRM - Butalbital Combinations Safer alternatives are: naproxen sodium and ibuprofen. BUTALBITAL/ASPIRIN/C AFFEINE HRM - Butalbital Combinations Safer alternatives are: naproxen sodium and ibuprofen. BUTALBITAL/ASPIRIN/C AFFEINE/CODEINE HRM - Butalbital Combinations Safer alternatives are: naproxen sodium and ibuprofen. CABOMETYX to New Starts Only CABOMETYX CARBOPLATIN CARIMUNE NANOFILTERED CELLCEPT CELLCEPT INTRAVENOUS CEREZYME CESAMET to New Starts Only to New Starts Only B vs D determination. B vs D determination. CIALIS CIALIS All FDA-approved indications not otherwise excluded from part D. Cialis 2.5mg and 5mg are only covered for the treatment of benign prostatic hyperplasia (BPH). CINRYZE CINRYZE Patient must have a confirmed diagnosis of HAE. The patient must have a history of more than one severe event per month and have failure, contraindication or intolerance to one conventional therapy for HAE prophylaxis such as aminocaproic acid, danazol or tranexamic acid. B vs D Determination.

5 CISPLATIN CLADRIBINE CLIMARA PRO CLINIMIX 2.75%/DEXTROSE 5% CLINIMIX 4.25%/DEXTROSE 10% CLINIMIX 4.25%/DEXTROSE 20% CLINIMIX 4.25%/DEXTROSE 25% CLINIMIX 4.25%/DEXTROSE 5% CLINIMIX 5%/DEXTROSE 15% CLINIMIX 5%/DEXTROSE 20% CLINIMIX 5%/DEXTROSE 25% CLINIMIX E 2.75%/DEXTROSE 10% CLINIMIX E 2.75%/DEXTROSE 5% CLINIMIX E 4.25%/DEXTROSE 10% CLINIMIX E 4.25%/DEXTROSE 25% CLINIMIX E 4.25%/DEXTROSE 5% CLINIMIX E 5%/DEXTROSE 15% CLINIMIX E 5%/DEXTROSE 20% CLINIMIX E 5%/DEXTROSE 25% CLINISOL SF 15% CLOLAR CLOMIPRAMINE HCL to New Starts Only HRM - Tricyclic Antidepressants Safer alternatives depend on indication. For Depression, safer alternatives are: Nortriptyline, Protriptyline, Desipramine, Amoxapine, Citalopram, Venlafaxine, Fluoxetine, Paroxetine, Sertraline, Duloxetine, and Bupropion. For headache prophylaxis, safer alternatives are: Propranolol, Topiramate, and Divalproex sodium. For headache treatment, safer alternatives are: Sumatriptan, Naratriptan, and Dihydroergotamine. For Pain/Neuropathy, safer alternatives are: Duloxetine, Lyrica, and Gabapentin. COMBIPATCH COSMEGEN CROMOLYN SODIUM

6 CYCLOBENZAPRINE HCL HRM - Skeletal Muscle Relaxants the ongoing monitoring plan for the agent. CYCLOPHOSPHAMIDE CYCLOSPORINE CYCLOSPORINE MODIFIED CYRAMZA CYTARABINE CYTARABINE AQUEOUS DACARBAZINE DARZALEX DAUNORUBICIN HCL DECITABINE DEXRAZOXANE DEXTROSE 10%/NACL 0.45% DEXTROSE 5% /ELECTROLYTE #48 VIAFLEX DEXTROSE 10% FLEX CONTAINER DEXTROSE 10%/NACL 0.2% DEXTROSE 2.5%/SODIUM CHLORIDE 0.45% DEXTROSE 20% DEXTROSE 25% DEXTROSE 30% DEXTROSE 30% PARTIAL FILL DEXTROSE 40% DEXTROSE 5% to New Starts Only to New Starts Only B vs D determination. B vs D determination. DEXTROSE 5%/LACTATED RINGERS DEXTROSE 5%/NACL 0.2% DEXTROSE 5%/NACL 0.225% DEXTROSE 5%/NACL 0.3% DEXTROSE 5%/NACL 0.33% DEXTROSE 5%/NACL 0.45% DEXTROSE 5%/NACL 0.9% DEXTROSE 5%/POTASSIUM CHLORIDE 0.15% DEXTROSE 50% DEXTROSE 70%

7 DIFICID DIFICID 18 years of age and older. 10 days DIGITEK HRM - Digoxin documented that the patient has tried and failed digoxin 0.125mg daily or provided clinical rationale as to why the lower dose is not appropriate for the patient. DIGOX HRM - Digoxin documented that the patient has tried and failed digoxin 0.125mg daily or provided clinical rationale as to why the lower dose is not appropriate for the patient. DIGOXIN HRM - Digoxin documented that the patient has tried and failed digoxin 0.125mg daily or provided clinical rationale as to why the lower dose is not appropriate for the patient. DOCEFREZ DOCETAXEL DOXEPIN HCL to New Starts Only HRM - Tricyclic Antidepressants Safer alternatives depend on indication. For Depression, safer alternatives are: Nortriptyline, Protriptyline, Desipramine, Amoxapine, Citalopram, Venlafaxine, Fluoxetine, Paroxetine, Sertraline, Duloxetine, and Bupropion. For headache prophylaxis, safer alternatives are: Propranolol, Topiramate, and Divalproex sodium. For headache treatment, safer alternatives are: Sumatriptan, Naratriptan, and Dihydroergotamine. For Pain/Neuropathy, safer alternatives are: Duloxetine, Lyrica, and Gabapentin. DOXORUBICIN HCL DRONABINOL DYSPORT DYSPORT Exclude when used for cosmetic purposes. 3 months EGRIFTA EGRIFTA All FDA-approved indications not otherwise excluded from part D. Males must have a waist circumference of at least 95cm (37.5in) and a waist-to-hip ratio of at least Females must have a waist circumference of at least 94cm (37in) and a waist-to-hip ratio of at least Patients must have a baseline CT documenting increased visceral adipose tissue (VAT). Reauthorization is contingent upon ONE of the following: 1) decrease in VAT measured by CT scan or 2) reduction of waist circumference and waist-to-hip ratio from baseline measurement. Patient must be on a stable antiretroviral regimen for at least 8 weeks. ELIGARD ELITEK EMEND to New Starts Only ELIGARD BvsD Determination

8 EMPLICITI Use of Humira, Enbrel, or Remicade is considered medically necessary for the treatment of: 1. Rheumatoid Arthritis in patients that have tried and failed methotrexate OR at least 2 alternative disease modifying antirheumatic drugs (DMARDs). 2. Juvenile Rheumatoid Arthritis in patients that have tried and failed at least 2 DMARDs. 3. Ankylosing Spondylitis in patients that have tried and failed at least 1 non-steroidal anti-inflammatory drug (NSAID), corticosteroid, OR sulfasalazine. 4. Plaque Psoriasis in patients that have: a) moderate to severe chronic disease, b) minimum body surface area (BSA) involvement of greater than or equal to 5% OR involvement of the palms, soles, head, neck or ENBREL SUPPRESSANTS Documentation of diagnosis and past medication history. genitalia, c) tried and failed at least 1 topical agent (topical steroid, calcipotriene, or tazarotene), AND d) tried and failed at least 1 systemic therapy (cyclosporine, methotrexate, or acitretin) OR phototherapy. 5. Psoriatic Arthritis in patients with active disease. In addition, use of Humira or Remicade is considered medically necessary for the treatment of: 1. Moderate to severe Crohn s Disease in patients that have tried and failed at least 2 of the following: immunomodulators, corticosteroids, or aminosalicylates. 2. Treatment of moderately to severely active ulcerative colitis in patients who have had inadequate response to at least 2 of the following: corticosteroids, sulfasalazine, mesalamine, azathioprine, 6-mercaptopurine. Use of Humira will also be considered medically necessary for the treatment of hidradenitis suppurativa and uveitis. Use of Remicade will also be considered medically necessary for the treatment of fistulizing Crohn's disease. B vs D determination required for Remicade. Use of Humira, Enbrel, or Remicade is considered medically necessary for the treatment of: 1. Rheumatoid Arthritis in patients that have tried and failed methotrexate OR at least 2 alternative disease modifying antirheumatic drugs (DMARDs). 2. Juvenile Rheumatoid Arthritis in patients that have tried and failed at least 2 DMARDs. 3. Ankylosing Spondylitis in patients that have tried and failed at least 1 non-steroidal anti-inflammatory drug (NSAID), corticosteroid, OR sulfasalazine. 4. Plaque Psoriasis in patients that have: a) moderate to severe chronic disease, b) minimum body surface area (BSA) involvement of greater than or equal to 5% OR involvement of the palms, soles, head, neck or ENBREL SURECLICK SUPPRESSANTS Documentation of diagnosis and past medication history. genitalia, c) tried and failed at least 1 topical agent (topical steroid, calcipotriene, or tazarotene), AND d) tried and failed at least 1 systemic therapy (cyclosporine, methotrexate, or acitretin) OR phototherapy. 5. Psoriatic Arthritis in patients with active disease. In addition, use of Humira or Remicade is considered medically necessary for the treatment of: 1. Moderate to severe Crohn s Disease in patients that have tried and failed at least 2 of the following: immunomodulators, corticosteroids, or aminosalicylates. 2. Treatment of moderately to severely active ulcerative colitis in patients who have had inadequate response to at least 2 of the following: corticosteroids, sulfasalazine, mesalamine, azathioprine, 6-mercaptopurine. Use of Humira will also be considered medically necessary for the treatment of hidradenitis suppurativa and uveitis. Use of Remicade will also be considered medically necessary for the treatment of fistulizing Crohn's disease. B vs D determination required for Remicade. ENGERIX-B ENTRESTO ENTRESTO Documentation of diagnosis The patient must have a diagnosis of chronic Heart Failure, NYHA Class II IV, have left ventricular ejection fraction less than or equal to 40%), and have no concomitant therapy with an ACE inhibitor, ARB, or direct renin inhibitor when starting on Entresto ENVARSUS XR EPIRUBICIN HCL to New Starts Only B vs D determination. EPOGEN HEMATOPOIETICS For the indication of anemia, documentation of Hemoglobin less than 11, transferrin saturation greater than 20%, and ferritin levels greater than 100 obtained over the last 3 months. 6 months BvD Determination. Patients must also have failure, contraindication or intolerance to Procrit or Aranesp before Epogen will be authorized. ERBITUX ERGOLOID MESYLATES HRM - Antidementia Agents Safer alternatives are: donepezil, galantamine and rivastigmine.

9 ERWINAZE ESBRIET ESBRIET All FDA-approved indications not otherwise excluded from part D. Other known causes of interstitial lung disease e.g., domestic and occupational environmental exposures, connective tissue disease, and drug toxicity. Diagnosis confirmed by 1) in patients without surgical lung biopsy: Usual interstitial pneumonia (UIP) pattern on high resolution computed tomography (HRCT) is indicative of IPF. or 2) in patients with surgical lung biopsy: The combination of HRCT and biopsy pattern is indicative of IPF. Documented forced vital capacity (% FVC) greater than or equal to 50% performed within the last 6 months. Prescribed by pulmonologist. Esbriet will be used as monotherapy. ESGIC HRM - Butalbital Combinations Safer alternatives are: naproxen sodium and ibuprofen. ESTRADIOL ESTRADIOL/NORETHIND RONE ACETATE ESTROPIPATE ETOPOPHOS ETOPOSIDE EXTAVIA FABRAZYME FASLODEX FENTANYL CITRATE IMMUNOMODULATOR S FENTANYL CITRATE ORAL TRANSMUCOSAL TRANSMUCOSAL FENTANYL CITRATE All FDA-approved indications not otherwise excluded from Part D. Documentation from the medical record of diagnosis. 16 years of age and Enrollment in the older for fentanyl Transmucosal citrate Immediate-Release (lozenge/troche). 18 Fentanyl (TIRF) years of age and REMS Access older for Lazanda. program. Transmucosal fentanyl products will only be covered with documentation of breakthrough cancer pain. The patient must be currently receiving and be tolerant to opioid therapy for persistent cancer pain.the patient must be enrolled in the TIRF REMS Access program.

10 FIRAZYR FIRAZYR Patient must have a confirmed diagnosis of HAE. Authorized for patients 18 years of age and older. The patient must have a history of a moderate or severe attack (e.g., airway swelling, severe abdominal pain, facial swelling, nausea and vomiting, painful facial distortion). FIRMAGON FLEBOGAMMA DIF FLUDARABINE PHOSPHATE FLUOROURACIL FOLOTYN FOSCARNET SODIUM FREAMINE HBC 6.9% FYAVOLV FREAMINE III GAMASTAN S/D GAMMAGARD LIQUID GAMMAGARD S/D GAMMAGARD S/D IGA LESS THAN 1MCG/ML GAMMAKED GAMMAPLEX GAMUNEX-C GANCICLOVIR GATTEX GAZYVA GEMCITABINE GEMCITABINE HCL GENGRAF to New Starts Only GATTEX As long as the patient requires parenteral nutrition and/or IV fluids, 3 months up to 12 months. B vs D determination. GILENYA GILENYA Gilenya will be used as monotherapy for the treatment of multiple sclerosis. Patients must also have failure, contraindication or intolerance to one of the following formulary alternatives Avonex, Extavia, glatiramer acetate or Rebif before Gilenya will be authorized. GLASSIA GRANISETRON HCL

11 H.P. ACTHAR ACTHAR HP All FDA-approved indications not otherwise excluded from part D. For the treatment of multiple sclerosis the patient must have failure, contraindication or intolerance to intravenous corticosteroid therapy and currently maintained on one of the following formulary drugs Avonex, Extavia, glatiramer acetate or Rebif before Acthar HP is authorized. HARVONI HARVONI Documentation from the medical record of diagnosis including genotype, HCV RNA viral levels prior to treatment, history of previous HCV therapies, and presence/absence of cirrhosis. Hepatologist, gastroenterologist, 12 to 24 weeks infectious disease based on indication specialist or and established managed by a liver treatment guidelines transplant center HECORIA HEPATAMINE HERCEPTIN to New Starts Only B vs D determination. HETLIOZ HETLIOZ Documentation that patient is totally blind and lacks light perception HIZENTRA HUMIRA SUPPRESSANTS Documentation of diagnosis and past medication history. Use of Humira, Enbrel, or Remicade is considered medically necessary for the treatment of: 1. Rheumatoid Arthritis in patients that have tried and failed methotrexate OR at least 2 alternative disease modifying antirheumatic drugs (DMARDs). 2. Juvenile Rheumatoid Arthritis in patients that have tried and failed at least 2 DMARDs. 3. Ankylosing Spondylitis in patients that have tried and failed at least 1 non-steroidal anti-inflammatory drug (NSAID), corticosteroid, OR sulfasalazine. 4. Plaque Psoriasis in patients that have: a) moderate to severe chronic disease, b) minimum body surface area (BSA) involvement of greater than or equal to 5% OR involvement of the palms, soles, head, neck or genitalia, c) tried and failed at least 1 topical agent (topical steroid, calcipotriene, or tazarotene), AND d) tried and failed at least 1 systemic therapy (cyclosporine, methotrexate, or acitretin) OR phototherapy. 5. Psoriatic Arthritis in patients with active disease. In addition, use of Humira or Remicade is considered medically necessary for the treatment of: 1. Moderate to severe Crohn s Disease in patients that have tried and failed at least 2 of the following: immunomodulators, corticosteroids, or aminosalicylates. 2. Treatment of moderately to severely active ulcerative colitis in patients who have had inadequate response to at least 2 of the following: corticosteroids, sulfasalazine, mesalamine, azathioprine, 6-mercaptopurine. Use of Humira will also be considered medically necessary for the treatment of hidradenitis suppurativa and uveitis. Use of Remicade will also be considered medically necessary for the treatment of fistulizing Crohn's disease. B vs D determination required for Remicade. HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK SUPPRESSANTS Documentation of diagnosis and past medication history. Use of Humira, Enbrel, or Remicade is considered medically necessary for the treatment of: 1. Rheumatoid Arthritis in patients that have tried and failed methotrexate OR at least 2 alternative disease modifying antirheumatic drugs (DMARDs). 2. Juvenile Rheumatoid Arthritis in patients that have tried and failed at least 2 DMARDs. 3. Ankylosing Spondylitis in patients that have tried and failed at least 1 non-steroidal anti-inflammatory drug (NSAID), corticosteroid, OR sulfasalazine. 4. Plaque Psoriasis in patients that have: a) moderate to severe chronic disease, b) minimum body surface area (BSA) involvement of greater than or equal to 5% OR involvement of the palms, soles, head, neck or genitalia, c) tried and failed at least 1 topical agent (topical steroid, calcipotriene, or tazarotene), AND d) tried and failed at least 1 systemic therapy (cyclosporine, methotrexate, or acitretin) OR phototherapy. 5. Psoriatic Arthritis in patients with active disease. In addition, use of Humira or Remicade is considered medically necessary for the treatment of: 1. Moderate to severe Crohn s Disease in patients that have tried and failed at least 2 of the following: immunomodulators, corticosteroids, or aminosalicylates. 2. Treatment of moderately to severely active ulcerative colitis in patients who have had inadequate response to at least 2 of the following: corticosteroids, sulfasalazine, mesalamine, azathioprine, 6-mercaptopurine. Use of Humira will also be considered medically necessary for the treatment of hidradenitis suppurativa and uveitis. Use of Remicade will also be considered medically necessary for the treatment of fistulizing Crohn's disease. B vs D determination required for Remicade.

12 HUMIRA PEN SUPPRESSANTS Documentation of diagnosis and past medication history. Use of Humira, Enbrel, or Remicade is considered medically necessary for the treatment of: 1. Rheumatoid Arthritis in patients that have tried and failed methotrexate OR at least 2 alternative disease modifying antirheumatic drugs (DMARDs). 2. Juvenile Rheumatoid Arthritis in patients that have tried and failed at least 2 DMARDs. 3. Ankylosing Spondylitis in patients that have tried and failed at least 1 non-steroidal anti-inflammatory drug (NSAID), corticosteroid, OR sulfasalazine. 4. Plaque Psoriasis in patients that have: a) moderate to severe chronic disease, b) minimum body surface area (BSA) involvement of greater than or equal to 5% OR involvement of the palms, soles, head, neck or genitalia, c) tried and failed at least 1 topical agent (topical steroid, calcipotriene, or tazarotene), AND d) tried and failed at least 1 systemic therapy (cyclosporine, methotrexate, or acitretin) OR phototherapy. 5. Psoriatic Arthritis in patients with active disease. In addition, use of Humira or Remicade is considered medically necessary for the treatment of: 1. Moderate to severe Crohn s Disease in patients that have tried and failed at least 2 of the following: immunomodulators, corticosteroids, or aminosalicylates. 2. Treatment of moderately to severely active ulcerative colitis in patients who have had inadequate response to at least 2 of the following: corticosteroids, sulfasalazine, mesalamine, azathioprine, 6-mercaptopurine. Use of Humira will also be considered medically necessary for the treatment of hidradenitis suppurativa and uveitis. Use of Remicade will also be considered medically necessary for the treatment of fistulizing Crohn's disease. B vs D determination required for Remicade. HUMIRA PEN-CROHNS DISEASESTARTER SUPPRESSANTS Documentation of diagnosis and past medication history. Use of Humira, Enbrel, or Remicade is considered medically necessary for the treatment of: 1. Rheumatoid Arthritis in patients that have tried and failed methotrexate OR at least 2 alternative disease modifying antirheumatic drugs (DMARDs). 2. Juvenile Rheumatoid Arthritis in patients that have tried and failed at least 2 DMARDs. 3. Ankylosing Spondylitis in patients that have tried and failed at least 1 non-steroidal anti-inflammatory drug (NSAID), corticosteroid, OR sulfasalazine. 4. Plaque Psoriasis in patients that have: a) moderate to severe chronic disease, b) minimum body surface area (BSA) involvement of greater than or equal to 5% OR involvement of the palms, soles, head, neck or genitalia, c) tried and failed at least 1 topical agent (topical steroid, calcipotriene, or tazarotene), AND d) tried and failed at least 1 systemic therapy (cyclosporine, methotrexate, or acitretin) OR phototherapy. 5. Psoriatic Arthritis in patients with active disease. In addition, use of Humira or Remicade is considered medically necessary for the treatment of: 1. Moderate to severe Crohn s Disease in patients that have tried and failed at least 2 of the following: immunomodulators, corticosteroids, or aminosalicylates. 2. Treatment of moderately to severely active ulcerative colitis in patients who have had inadequate response to at least 2 of the following: corticosteroids, sulfasalazine, mesalamine, azathioprine, 6-mercaptopurine. Use of Humira will also be considered medically necessary for the treatment of hidradenitis suppurativa and uveitis. Use of Remicade will also be considered medically necessary for the treatment of fistulizing Crohn's disease. B vs D determination required for Remicade. HUMIRA PEN-PSORIASIS STARTER SUPPRESSANTS Documentation of diagnosis and past medication history. Use of Humira, Enbrel, or Remicade is considered medically necessary for the treatment of: 1. Rheumatoid Arthritis in patients that have tried and failed methotrexate OR at least 2 alternative disease modifying antirheumatic drugs (DMARDs). 2. Juvenile Rheumatoid Arthritis in patients that have tried and failed at least 2 DMARDs. 3. Ankylosing Spondylitis in patients that have tried and failed at least 1 non-steroidal anti-inflammatory drug (NSAID), corticosteroid, OR sulfasalazine. 4. Plaque Psoriasis in patients that have: a) moderate to severe chronic disease, b) minimum body surface area (BSA) involvement of greater than or equal to 5% OR involvement of the palms, soles, head, neck or genitalia, c) tried and failed at least 1 topical agent (topical steroid, calcipotriene, or tazarotene), AND d) tried and failed at least 1 systemic therapy (cyclosporine, methotrexate, or acitretin) OR phototherapy. 5. Psoriatic Arthritis in patients with active disease. In addition, use of Humira or Remicade is considered medically necessary for the treatment of: 1. Moderate to severe Crohn s Disease in patients that have tried and failed at least 2 of the following: immunomodulators, corticosteroids, or aminosalicylates. 2. Treatment of moderately to severely active ulcerative colitis in patients who have had inadequate response to at least 2 of the following: corticosteroids, sulfasalazine, mesalamine, azathioprine, 6-mercaptopurine. Use of Humira will also be considered medically necessary for the treatment of hidradenitis suppurativa and uveitis. Use of Remicade will also be considered medically necessary for the treatment of fistulizing Crohn's disease. B vs D determination required for Remicade. HYDROXYPROGESTERO NE CAPROATE MAKENA Makena is authorized to reduce the risk of preterm birth when ALL of the following are met: 1) current singleton pregnancy AND 2) previous singleton spontaneous preterm birth (preterm birth defined as birth from the period of viability through week 36, 6 days gestation) AND 3) treatment will be initiated between week 16, 0 days and week 20, 6 days of gestation and not continue beyond week 36, 6 days of gestation or time of delivery (whichever occurs first). 21 weeks BvsD Determination HYPERLYTE-CR IDARUBICIN HCL

13 IFOSFAMIDE IFOSFAMIDE/MESNA ILARIS ILARIS BvsD Determination IMIPRAMINE HCL to New Starts Only HRM - Tricyclic Antidepressants Safer alternatives depend on indication. For Depression, safer alternatives are: Nortriptyline, Protriptyline, Desipramine, Amoxapine, Citalopram, Venlafaxine, Fluoxetine, Paroxetine, Sertraline, Duloxetine, and Bupropion. For headache prophylaxis, safer alternatives are: Propranolol, Topiramate, and Divalproex sodium. For headache treatment, safer alternatives are: Sumatriptan, Naratriptan, and Dihydroergotamine. For Pain/Neuropathy, safer alternatives are: Duloxetine, Lyrica, and Gabapentin. IMIPRAMINE PAMOATE to New Starts Only HRM - Tricyclic Antidepressants Safer alternatives depend on indication. For Depression, safer alternatives are: Nortriptyline, Protriptyline, Desipramine, Amoxapine, Citalopram, Venlafaxine, Fluoxetine, Paroxetine, Sertraline, Duloxetine, and Bupropion. For headache prophylaxis, safer alternatives are: Propranolol, Topiramate, and Divalproex sodium. For headache treatment, safer alternatives are: Sumatriptan, Naratriptan, and Dihydroergotamine. For Pain/Neuropathy, safer alternatives are: Duloxetine, Lyrica, and Gabapentin. INTRALIPID IONOSOL-B/DEXTROSE 5% IONOSOL- MB/DEXTROSE 5% IPRATROPIUM BROMIDE IPRATROPIUM BROMIDE/ALBUTEROL SULFATE IRINOTECAN ISOLYTE-P/DEXTROSE 5% ISOLYTE-S ISOLYTE-S PH 7.4 ISTODAX IXEMPRA KIT JEVTANA JINTELI KABIVEN KADCYLA

14 KALBITOR KALBITOR Kalbitor is authorized for the treatment of acute angioedema attacks with hereditary angioedema (HAE) when BOTH of the following criteria are met: 1) confirmed diagnosis of (HAE) as evidenced by a C4 level below the lower limit of normal as defined by the laboratory performing the test AND EITHER a) C1 inhibitor (C1INH) antigenic level below the lower limit of normal as defined by the laboratory performing the test or b) C1INH functional level below the lower limit of normal as defined by the laboratory performing the test AND 2) history of a moderate or severe attack (e.g., airway swelling, severe abdominal pain, facial swelling, nausea and vomiting, painful facial distortion). 16 years old and older BvsD Determination KALYDECO KALYDECO Patients with cystic fibrosis (CF) who are homozygous for the F508del mutation in the CFTR gene. CF mutation test documenting a G551D, G1244E, G1349D, G178R, G551S, R117H, S1251N, S1255P, S549N, or S549R mutation in the CFTR gene. 2 years of age and older for packets. 6 years of age and older for tablets. KCL 0.075%/D5W/NACL 0.45% KCL 0.15%/D5W/ NACL 0.3% KCL 0.15%/D5W/LR KCL 0.15%/D5W/NACL 0.2% KCL 0.15%/D5W/NACL 0.225% KCL 0.15%/D5W/NACL 0.45% KCL 0.15%/D5W/NACL 0.9% KCL 0.3%/D5W/LR IV LAC RING KCL 0.3%/D5W/NACL 0.45% KCL 0.3%/D5W/NACL 0.9% KETOROLAC TROMETHAMINE KEYTRUDA KETOROLAC TROMETHAMINE 1 month KINERET KINERET For RA: 18 years and older Treatment of rheumatoid arthritis (RA) in adults and when the following criteria are met: inadequate response, intolerance, or contraindication to at least one disease-modifying anti-rheumatic drug (DMARD) (i.e., Methotrexate (MTX) Azathioprine, gold, Hydroxychloroquine, Penicillamine, Sulfasalazine) AND the patient has had failure, contraindication, or intolerance to Enbrel or Humira. KORLYM KORLYM LACTATED RINGERS DEXTROSE 5% VIAFLEX LANOXIN HRM - Digoxin documented that the patient has tried and failed digoxin 0.125mg daily or provided clinical rationale as to why the lower dose is not appropriate for the patient.

15 LANOXIN PEDIATRIC HRM - Digoxin documented that the patient has tried and failed digoxin 0.125mg daily or provided clinical rationale as to why the lower dose is not appropriate for the patient. LAZANDA TRANSMUCOSAL FENTANYL CITRATE All FDA-approved indications not otherwise excluded from Part D. Documentation from the medical record of diagnosis. 16 years of age and Enrollment in the older for fentanyl Transmucosal citrate Immediate-Release (lozenge/troche). 18 Fentanyl (TIRF) years of age and REMS Access older for Lazanda. program. Transmucosal fentanyl products will only be covered with documentation of breakthrough cancer pain. The patient must be currently receiving and be tolerant to opioid therapy for persistent cancer pain.the patient must be enrolled in the TIRF REMS Access program. LEUPROLIDE ACETATE LEVALBUTEROL LEVALBUTEROL HCL LEUPROLIDE ACETATE to New Starts Only INJ BvsD Determination LIDOCAINE LIDOCAINE PATCH For the FDA-labeled indication of post-herpetic neuralgia, no additional criteria are required to be met. For diabetic neuropathic pain: the patient must have previous use and inadequate response or intolerance to any ONE medication that is FDAlabeled for diabetic peripheral neuropathy, including (but not limited to) duloxetine and Lyrica. LIPOSYN II LIPOSYN III LOPREEZA LUPRON DEPOT LUPRON DEPOT-PED MAGNESIUM SULFATE LEUPROLIDE ACETATE to New Starts Only INJ LEUPROLIDE ACETATE INJ BvsD Determination BvsD Determination MAKENA MAKENA Makena is authorized to reduce the risk of preterm birth when ALL of the following are met: 1) current singleton pregnancy AND 2) previous singleton spontaneous preterm birth (preterm birth defined as birth from the period of viability through week 36, 6 days gestation) AND 3) treatment will be initiated between week 16, 0 days and week 20, 6 days of gestation and not continue beyond week 36, 6 days of gestation or time of delivery (whichever occurs first). 21 weeks BvsD Determination MARGESIC HRM - Butalbital Combinations Safer alternatives are: naproxen sodium and ibuprofen.

16 MARQIBO MARTEN-TAB HRM - Butalbital Combinations Safer alternatives are: naproxen sodium and ibuprofen. MEGACE ES HRM - Megestrol Suspension documented that the patient has tried and failed dronabinol or provided clinical rationale as to why that safer formulary alternative is not appropriate for the patient. MEGESTROL ACETATE SUSP to New Starts Only HRM - Megestrol Suspension documented that the patient has tried and failed dronabinol or provided clinical rationale as to why that safer formulary alternative is not appropriate for the patient. MEGESTROL ACETATE SUSP (GENERIC TO MEGACE ES) HRM - Megestrol Suspension documented that the patient has tried and failed dronabinol or provided clinical rationale as to why that safer formulary alternative is not appropriate for the patient. MEGESTROL ACETATE TABS to New Starts Only HRM - Megestrol Tabs the ongoing monitoring plan for the agent. MELPHALAN HYDROCHLORIDE MENEST HRM - Menest documented that the patient has tried and failed one (1) safer formulary alternative or provided clinical rationale why two safer formulary alternative is not appropriate for the patient. For palliative therapy of metastatic breast cancer, no trial of a formulary alternative is required. For vasomotor symptoms of menopause, safer alternatives are: SSRIs, venlafaxine, gabapentin, and Femring. For vaginal symptoms of Estring, and Femring. For all other indications, no formulary alternative is required.

17 MENOSTAR MESNA METHAMPHETAMINE HCL METHAMPHETAMINE HCL Patient must have failure, contraindication or intolerance to one formulary alternative such as dextroamphetamine, amphetamine/dextroamphetamine, methylphenidate or dexmethylphenidate before methamphetamine hcl is authorized. MIMVEY MIMVEY LO MITOMYCIN MITOXANTRONE HCL MODAFINIL MODAFINIL Documentation of diagnosis and sleep study for the diagnosis of sleep apnea or narcolepsy. For the treatment of narcolepsy, the patient must have failure, contraindication, or intolerance to methylphenidate or dextroamphetamine sulfate before modafinil is authorized. MUSTARGEN MYCOPHENOLATE MOFETIL MYCOPHENOLIC ACID DR MYFORTIC NATPARA NEBUPENT NEORAL NEPHRAMINE to New Starts Only to New Starts Only to New Starts Only to New Starts Only Natpara B vs D determination. B vs D determination. B vs D determination. B vs D determination.

18 NEUMEGA NEUMEGA Documentation of diagnosis and lab data reflecting platelet count. Certified Hematologist and/or Oncologist 6 months Neumega is considered medically necessary for patients that have experienced severe thrombocytopenia (platelet count less than or equal to 20,000 mcg/l) from previous chemotherapy OR patients cosidered to be at high risk for the development of severe thrombocytopenia. BvsD Determination. NIPENT NORETHINDRONE ACETATE/ETHINYL ESTRADIOL NORMOSOL-M IN D5W NORMOSOL-R NORMOSOL-R IN D5W NORTHERA NORTHERA Documentation from the medical record of diagnosis and prior medication history NULOJIX to New Starts Only B vs D determination. NUPLAZID to New Starts Only NUPLAZID NUTRILIPID NUTRILYTE NUTRILYTE II NUVIGIL NUVIGIL Documentation of diagnosis and sleep study for the diagnosis of sleep apnea or narcolepsy. For the treatment of narcolepsy, the patient must have failure, contraindication, or intolerance to methylphenidate or dextroamphetamine sulfate before armodafinil or Nuvigil is authorized. OCTAGAM OLYSIO OLYSIO Previous failure of Olysio, Incivek or Victrelis. Documentation from the medical record of diagnosis including genotype, current medication regimen, HCV-RNA levels, history of previous HCV therapies and presence/absence of cirrhosis. Hepatologist, gastroenterologist, infectious disease specialist or managed by a liver transplant center. 12 to 24 weeks based on indication and treatment guidelines. Olysio must be used with other concurrent therapy based on indication and established treatment guidelines. For genotype 1, clinical information must be provided confirming the patient is not a candidate for Harvoni before combination therapy with Olysio and Sovaldi will be authorized. ONCASPAR ONDANSETRON HCL ONDANSETRON ODT OPDIVO OPSUMIT OPSUMIT All FDA-approved indications not otherwise excluded from Part D. Documentation of pulmonary arterial hypertension

19 ORENCIA ORENCIA IV 6 years old and older Treatment of rheumatoid arthritis (RA) and when ANY of the following criteria are met: 1) history of positive clinical response to abatacept therapy OR 2) inadequate response, intolerance, or contraindication to at least one disease-modifying anti-rheumatic drug (DMARD) (i.e., Methotrexate (MTX) Azathioprine, gold, Hydroxychloroquine, Penicillamine, Sulfasalazine) AND when the following condition is met: the patient has had failure, contraindication, or intolerance to Enbrel or Humira. ORPHENADRINE CITRATE ER HRM - Skeletal Muscle Relaxants the ongoing monitoring plan for the agent. OXALIPLATIN OXANDROLONE PACLITAXEL PAMIDRONATE DISODIUM PARICALCITOL INJ ANABOLIC STEROIDS, ANDROGENS Documentation of diagnosis. PEGINTRON PEG-INTRON Documentation of genotype to determine length of therapy. 24 to 48 weeks based on indication and established treatment guidelines PEG-INTRON PEG-INTRON Documentation of genotype to determine length of therapy. 24 to 48 weeks based on indication and established treatment guidelines PEG-INTRON REDIPEN PEG-INTRON Documentation of genotype to determine length of therapy. 24 to 48 weeks based on indication and established treatment guidelines PEG-INTRON REDIPEN PAK 4 PEG-INTRON Documentation of genotype to determine length of therapy. 24 to 48 weeks based on indication and established treatment guidelines PERFOROMIST PERIKABIVEN PERJETA PERPHENAZINE/AMITRI PTYLINE HRM - to New Starts Only Perphenazine/Amitriptyline Safer alternatives are: Nortriptyline, Protriptyline, Desipramine, Amoxapine, Citalopram, Venlafaxine, Fluoxetine, Paroxetine, Sertraline, Duloxetine, and Bupropion.

20 PHENADOZ HRM - Promethazine documented that the patient has tried and failed one (1) safer formulary alternative if available or provided clinical rationale why the safer formulary alternative is not appropriate for the patient. For nausea and vomiting, the safer alternative is ondansetron (QL = 90/30). For perennial and seasonal allergic rhinitis, safer alternatives are: levocetirizine and desloratadine. For any other indications, trial of a formulary alternative is not required. PHENERGAN HRM - Promethazine documented that the patient has tried and failed one (1) safer formulary alternative if available or provided clinical rationale why the safer formulary alternative is not appropriate for the patient. For nausea and vomiting, the safer alternative is ondansetron (QL = 90/30). For perennial and seasonal allergic rhinitis, safer alternatives are: levocetirizine and desloratadine. For any other indications, trial of a formulary alternative is not required. PHYSIOLYTE PHYSIOSOL IRRIGATION PLASMA-LYTE A PLASMA-LYTE-148 PLASMA-LYTE-56/D5W PLENAMINE PORTRAZZA POTASSIUM CHLORIDE POTASSIUM CHLORIDE 0.15% /NACL 0.45% VIAFLEX POTASSIUM CHLORIDE 0.15% D5W/NACL 0.33% POTASSIUM CHLORIDE 0.15% D5W/NACL 0.45% POTASSIUM CHLORIDE 0.15% D5W/NACL 0.45% VIAFLEX POTASSIUM CHLORIDE 0.15% NACL 0.9% POTASSIUM CHLORIDE 0.15% W/NACL 0.9% VIAFLEX POTASSIUM CHLORIDE 0.15%/NACL 0.9% POTASSIUM CHLORIDE 0.22% D5W/NACL 0.45% POTASSIUM CHLORIDE 0.3%/ NACL 0.9% POTASSIUM CHLORIDE 0.3%/D5W PREFEST

21 PREMARIN PREMASOL PREMPHASE PREMPRO PRIALT PRIVIGEN PROCALAMINE PROCRIT HEMATOPOIETICS For the indication of anemia, documentation of Hemoglobin less than 11, transferrin saturation greater than 20%, and ferritin levels greater than 100 obtained over the last 3 months. 6 months BvD Determination. Patients must also have failure, contraindication or intolerance to Procrit or Aranesp before Epogen will be authorized. PROGRAF PROLASTIN-C PROLEUKIN to New Starts Only B vs D determination. PROMETHAZINE HCL HRM - Promethazine documented that the patient has tried and failed one (1) safer formulary alternative if available or provided clinical rationale why the safer formulary alternative is not appropriate for the patient. For nausea and vomiting, the safer alternative is ondansetron (QL = 90/30). For perennial and seasonal allergic rhinitis, safer alternatives are: levocetirizine and desloratadine. For any other indications, trial of a formulary alternative is not required. PROMETHAZINE HCL PLAIN HRM - Promethazine documented that the patient has tried and failed one (1) safer formulary alternative if available or provided clinical rationale why the safer formulary alternative is not appropriate for the patient. For nausea and vomiting, the safer alternative is ondansetron (QL = 90/30). For perennial and seasonal allergic rhinitis, safer alternatives are: levocetirizine and desloratadine. For any other indications, trial of a formulary alternative is not required.

22 PROMETHAZINE VC PLAIN HRM - Promethazine documented that the patient has tried and failed one (1) safer formulary alternative if available or provided clinical rationale why the safer formulary alternative is not appropriate for the patient. For nausea and vomiting, the safer alternative is ondansetron (QL = 90/30). For perennial and seasonal allergic rhinitis, safer alternatives are: levocetirizine and desloratadine. For any other indications, trial of a formulary alternative is not required. PROMETHEGAN HRM - Promethazine documented that the patient has tried and failed one (1) safer formulary alternative if available or provided clinical rationale why the safer formulary alternative is not appropriate for the patient. For nausea and vomiting, the safer alternative is ondansetron (QL = 90/30). For perennial and seasonal allergic rhinitis, safer alternatives are: levocetirizine and desloratadine. For any other indications, trial of a formulary alternative is not required. PROSOL PULMICORT PULMOZYME QUININE SULFATE RAPAMUNE RECOMBIVAX HB to New Starts Only QUININE SULFATE All FDA-approved indications not otherwise excluded from part D and babesiosis. For malaria the authorization is for 7 days. For babesiosis the authorization is 10 days. B vs D determination. REGRANEX REGRANEX Documentation of wound type and wound care therapy provided. Regranex must be used as adjunctive therapy to clinically appropriate ulcer wound care including debridement, infection control, and/or pressure relief. REMICADE SUPPRESSANTS Documentation of diagnosis and past medication history. Use of Humira, Enbrel, or Remicade is considered medically necessary for the treatment of: 1. Rheumatoid Arthritis in patients that have tried and failed methotrexate OR at least 2 alternative disease modifying antirheumatic drugs (DMARDs). 2. Juvenile Rheumatoid Arthritis in patients that have tried and failed at least 2 DMARDs. 3. Ankylosing Spondylitis in patients that have tried and failed at least 1 non-steroidal anti-inflammatory drug (NSAID), corticosteroid, OR sulfasalazine. 4. Plaque Psoriasis in patients that have: a) moderate to severe chronic disease, b) minimum body surface area (BSA) involvement of greater than or equal to 5% OR involvement of the palms, soles, head, neck or genitalia, c) tried and failed at least 1 topical agent (topical steroid, calcipotriene, or tazarotene), AND d) tried and failed at least 1 systemic therapy (cyclosporine, methotrexate, or acitretin) OR phototherapy. 5. Psoriatic Arthritis in patients with active disease. In addition, use of Humira or Remicade is considered medically necessary for the treatment of: 1. Moderate to severe Crohn s Disease in patients that have tried and failed at least 2 of the following: immunomodulators, corticosteroids, or aminosalicylates. 2. Treatment of moderately to severely active ulcerative colitis in patients who have had inadequate response to at least 2 of the following: corticosteroids, sulfasalazine, mesalamine, azathioprine, 6-mercaptopurine. Use of Humira will also be considered medically necessary for the treatment of hidradenitis suppurativa and uveitis. Use of Remicade will also be considered medically necessary for the treatment of fistulizing Crohn's disease. B vs D determination required for Remicade. REMODULIN

23 REPATHA REPATHA Diagnosis of one of the following: Clinical atherosclerotic cardiovascular disease OR Heterozygous familial hypercholesterolemia (HeFH) (confirmed by genetic testing or WHO/Dutch Lipid Group criteria or Simon-Broome criteria) OR Homozygous Familial Hypercholesterolemia (HoFH) (confirmed by either: Genetic testing or History of untreated low-density lipoprotein cholesterol (LDL-C) greater than 500mg/dl or treated LDL greater than 300mg/dl with either: presence of xanthomas before the age of 10 years or evidence of heterozygous familial hypercholesterolemia in both parents) Prescriber must be cardiologist, endocrinologist, or lipid specialist Initial:6 mo. Reauthorization for 12 mo requires documented evidence of clinical beneficial response For atherosclerotic cardiovascular disease (ASCVD) or heterozygous familial hypercholesterolemia (HeFH): Patient is on highintensity statin therapy or maximally tolerated statin therapy, is not at LDL-C level goal, and will be continued on high intensity or maximally tolerated statin therapy while on Repatha. (For patients intolerant to statins, no concurrent statin use required.) For Homozygous Familial Hypercholesterolemia (HoFH): Patient is on highintensity or maximally tolerated lipid-lowering therapy (such as statins and/or Zetia), and is not at LDL-C level goal, and will be continued on high intensity or maximally tolerated lipid-lowering therapy while on Repatha. (For patients intolerant to statins, no concurrent statin use required.) REPATHA PUSHTRONEX REPATHA Diagnosis of one of the following: Clinical atherosclerotic cardiovascular disease OR Heterozygous familial hypercholesterolemia (HeFH) (confirmed by genetic testing or WHO/Dutch Lipid Group criteria or Simon-Broome criteria) OR Homozygous Familial Hypercholesterolemia (HoFH) (confirmed by either: Genetic testing or History of untreated low-density lipoprotein cholesterol (LDL-C) greater than 500mg/dl or treated LDL greater than 300mg/dl with either: presence of xanthomas before the age of 10 years or evidence of heterozygous familial hypercholesterolemia in both parents) Prescriber must be cardiologist, endocrinologist, or lipid specialist Initial:6 mo. Reauthorization for 12 mo requires documented evidence of clinical beneficial response For atherosclerotic cardiovascular disease (ASCVD) or heterozygous familial hypercholesterolemia (HeFH): Patient is on highintensity statin therapy or maximally tolerated statin therapy, is not at LDL-C level goal, and will be continued on high intensity or maximally tolerated statin therapy while on Repatha. (For patients intolerant to statins, no concurrent statin use required.) For Homozygous Familial Hypercholesterolemia (HoFH): Patient is on highintensity or maximally tolerated lipid-lowering therapy (such as statins and/or Zetia), and is not at LDL-C level goal, and will be continued on high intensity or maximally tolerated lipid-lowering therapy while on Repatha. (For patients intolerant to statins, no concurrent statin use required.) REPATHA SURECLICK REPATHA Diagnosis of one of the following: Clinical atherosclerotic cardiovascular disease OR Heterozygous familial hypercholesterolemia (HeFH) (confirmed by genetic testing or WHO/Dutch Lipid Group criteria or Simon-Broome criteria) OR Homozygous Familial Hypercholesterolemia (HoFH) (confirmed by either: Genetic testing or History of untreated low-density lipoprotein cholesterol (LDL-C) greater than 500mg/dl or treated LDL greater than 300mg/dl with either: presence of xanthomas before the age of 10 years or evidence of heterozygous familial hypercholesterolemia in both parents) Prescriber must be cardiologist, endocrinologist, or lipid specialist Initial:6 mo. Reauthorization for 12 mo requires documented evidence of clinical beneficial response For atherosclerotic cardiovascular disease (ASCVD) or heterozygous familial hypercholesterolemia (HeFH): Patient is on highintensity statin therapy or maximally tolerated statin therapy, is not at LDL-C level goal, and will be continued on high intensity or maximally tolerated statin therapy while on Repatha. (For patients intolerant to statins, no concurrent statin use required.) For Homozygous Familial Hypercholesterolemia (HoFH): Patient is on highintensity or maximally tolerated lipid-lowering therapy (such as statins and/or Zetia), and is not at LDL-C level goal, and will be continued on high intensity or maximally tolerated lipid-lowering therapy while on Repatha. (For patients intolerant to statins, no concurrent statin use required.) RITUXAN to New Starts Only RITUXAN Treatment of rheumatoid arthritis (RA) in combination with methotrexate and when EITHER of the following criteria are met: 1) history of positive clinical response to rituximab therapy OR 2) inadequate response, intolerance, or contraindication to at least one disease-modifying anti-rheumatic drug (DMARD) (i.e., Methotrexate (MTX) Azathioprine, gold, Hydroxychloroquine, Penicillamine, Sulfasalazine) AND failure, contraindication, or intolerance to Enbrel or Humira. BvsD Determination. SAIZEN SAIZEN CLICK.EASY SAIZEN SAIZEN SANCUSO SANCUSO Patient must have failure, contraindication or intolerance to one formulary alternative granisetron hcl or ondansetron before authorization of Sancuso.