Network Health Insurance Corporation 2013 P A Criteria

Transcription

1 Network Health Insurance Corporation 2013 P A Criteria ACTEMRA ACTEMRA ACTHAR H.P. ACTHAR AMPYRA AMPYRA ANDROGEL ANDRODERM ANDROGEL AXIRON FORTESTA STRIANT TESTIM ARANESP PROCRIT EPOGEN ARANESP EPOGEN PROCRIT ARCALYST ARCALYST B vs D - Part B versus Part D Coverage PA ANZEMET ATGAM AZASAN Updated: 08/2013 1

2 AZATHIOPRINE AZATHIOPRINE SODIUM BONIVA CALCIJEX CALCITRIOL CARIMUNE NF NANOFILTERED CARNITOR CELLCEPT CESAMET CUBICIN CYCLOPHOSPHAMIDE CYCLOSPORINE CYCLOSPORINE MODIFIED DRONABINOL EMEND GAMMAGARD LIQUID GAMMAPLEX GAMUNEX-C GENGRAF GRANISETRON HCL GRANISOL HECTOROL HEPARIN SODIUM HEPARIN SODIUM IN 0.45% NACL HEPARIN SODIUM IN 0.9% NACL Updated: 08/2013 2

3 HEPARIN SODIUM-D5W IMURAN LEVOCARNITINE MARINOL METHOTREXATE MIACALCIN MITOXANTRONE HCL MYCOPHENOLATE MOFETIL MYFORTIC NEORAL NULOJIX ONDANSETRON HCL ONDANSETRON ODT PAMIDRONATE DISODIUM PRIVIGEN PROGRAF RAPAMUNE RHEUMATREX ROCALTROL SANDIMMUNE SIMULECT TACROLIMUS THYMOGLOBULIN TREXALL VANCOMYCIN HCL Updated: 08/2013 3

4 ZEMPLAR ZOFRAN ODT ZOFRAN ZORTRESS CIALIS CIALIS CIMZIA CIMZIA CINRYZE CINRYZE DIFICID DIFICID EGRIFTA EGRIFTA ENBREL ENBREL GROWTH HORMONE GENOTROPIN HUMATROPE NORDITROPIN FLEXPRO NORDITROPIN NORDIFLEX NUTROPIN AQ NUSPIN NUTROPIN AQ NUTROPIN OMNITROPE Updated: 08/2013 4

5 SAIZEN SEROSTIM TEV-TROPIN ZORBTIVE HEMATOPOIETIC GROWTH FACTOR PROMACTA HIGH RISK FIRST GENERATION ANTIHISTAMINES CYPROHEPTADINE HCL DIPHENHYDRAMINE HCL HYDROXYZINE HCL HYDROXYZINE PAMOATE PROMETHAZINE HCL PROMETHAZINE VC VISTARIL HIGH RISK MEDICATION - BARBITURATES BUTISOL SODIUM HIGH RISK MEDICATION - BENZODIAZEPINES ALPRAZOLAM ALPRAZOLAM ER ALPRAZOLAM INTENSOL ALPRAZOLAM ODT ATIVAN CHLORDIAZEPOXIDE HCL CLONAZEPAM CLORAZEPATE DIPOTASSIUM Updated: 08/2013 5

6 DIAZEPAM ESTAZOLAM FLURAZEPAM HCL HALCION KLONOPIN LORAZEPAM LORAZEPAM INTENSOL NIRAVAM ONFI OXAZEPAM RESTORIL TEMAZEPAM TRANXENE T-TAB TRIAZOLAM VALIUM XANAX XR XANAX HIGH RISK SKELETAL MUSCLE RELAXANTS AMRIX CARISOPRODOL CARISOPRODOL COMPOUND CARISOPRODOL COMPOUND-CODEINE CHLORZOXAZONE CYCLOBENZAPRINE HCL FEXMID Updated: 08/2013 6

7 LORZONE METHOCARBAMOL ORPHENADRINE CITRATE ORPHENADRINE COMPOUND ORPHENADRINE COMPOUND FORTE PARAFON FORTE DSC SKELAXIN SOMA HUMIRA HUMIRA ILARIS ILARIS INCIVEK INCIVEK KALYDECO KALYDECO KINERET KINERET KORLYM KORLYM KUVAN KUVAN ORENCIA ORENCIA PANRETIN Updated: 08/2013 7

8 PANRETIN PEDICULOSIS CAPITIS SKLICE PROLEUKIN PROLEUKIN REVATIO ADCIRCA REVATIO SILDENAFIL RILUTEK RILUTEK SAMSCA SAMSCA SIMPONI SIMPONI SPORANOX ITRACONAZOLE ONMEL SPORANOX STELARA STELARA TAZORAC TAZORAC TOPICAL RETINOID PRODUCTS ATRALIN Updated: 08/2013 8

9 AVITA AVITA RETIN-A MICRO RETIN-A TRETINOIN TRETIN-X VELTIN ZIANA VICTRELIS VICTRELIS XALKORI XALKORI XENAZINE XENAZINE XOLAIR XOLAIR XOPENEX XOPENEX HFA ZELBORAF ZELBORAF Index Updated: 08/2013 9

10 ACTEMRA ACTEMRA All FDA-approved indications not otherwise excluded from Part D. The diagnosis is moderate to severe rheumatoid arthritis and the disease must be active. Rheumatologist. Indefinite. Must have failed and had an inadequate response to a 2 month trial of one other TNF antagonist therapy. Updated: 08/

11 ACTHAR H.P. ACTHAR All FDA-approved indications not otherwise excluded from Part D. Use in patients with multiple sclerosis (MS) as pulse therapy on a monthly basis. MS exacerbation, history of corticosteroid use. 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. Infantile spasms, 12 months. MS exacerbation, approve 1 month. 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: 08/

12 AMPYRA AMPYRA All FDA-approved indications not otherwise excluded from Part D. Neurologist. Indefinite. Updated: 08/

13 ANDROGEL ANDRODERM ANDROGEL AXIRON FORTESTA STRIANT TESTIM All FDA-approved indications not otherwise excluded from Part D. Erectile dysfunction. Decreased Libido. Patient must be symptomatic with a total testosterone level of less than 300ng/dl. Aged 18 years or older. Indefinite. Gender must be male. Updated: 08/

14 ARANESP PROCRIT EPOGEN ARANESP EPOGEN PROCRIT All FDA-approved indications not otherwise excluded from Part D. All agents will also be covered for anemia related to Multiple Myeloma, Refractory Anemia related to Myelodysplastic Syndrome. Procrit and Epogen only will be covered for anemia related to chronic disease. Refractory anemia related to Myelodysplastic Syndrome must be an EPO insufficiency that cannot be assigned to a specific vitamin or mineral deficiency. Uncontrolled hypertension. Anemic patients willing to donate autologous blood. Anemia due to factors other than diagnoses noted (iron or folate deficiency, hemolysis, GI bleeding). Patients receiving hormonal agents, therapeutic biological products, or radiotherapy UNLESS also receiving concomitant myelosuppressive chemotherapy. For immediate anemia correction or as a substitute for emergency transfusion. Prophylactic use to prevent chemotherapy included anemia. Chronic renal failure patients not on dialysis must have symptomatic anemia with a HGB of 10g/dl or less. HIV-infected Zidovudine use requires a Zidovudine dose of 4200mg/week or less and an endogenous serum EPO level less than or equal to 500mUnits/ml. Non myeloid malignancy chemotherapy induced anemia must have HCT of 30% or less or HBC of 10g/dl or less in past 30 days. Multiple myeloma anemia must have HCT of 30% or less or HGB of 10g/dl or less in past 30 days. For Myelodysplastic Syndrome refractory anemia diagnosis must include excess blasts, or excess blasts in transformation to leukemia when, for medical reasons, the patient is not a candidate for active treatment of active leukemia. For Myelodysplastic Syndrome the patient must have a HCT of 30% or less or HGB of 10g/dl or less, and endogenous EPO serum level less than 500mu/ml. Anemia of chronic disease must have pretreatment HCT of 30% or less and pretreatment EPO level of 100mu/ml or less. Anemia patients scheduled to undergo elective surgery require hemoglobin greater than 10 but 13 or less. Updated: 08/

15 Indefinite. For all agents, For anemia related to chemotherapy must have received chemotherapy in past 8 weeks and will be receiving chemo for a minimum of 2 months. For Procrit and Epogen only, For anemia of chronic disease if the member has been transfusion dependent for at least 2 months. For Procrit and Epogen only, In anemic patients scheduled to undergo surgery, the surgery must be elective, noncardiac and nonvascular, or in patients at high risk for perioperative transfusion with significant anticipated blood loss who are receiving anticoagulant prophylaxis. 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: 08/

16 ARCALYST ARCALYST All FDA-approved indications not otherwise excluded from Part D. 12 years or greater. Indefinite. Must be up to date and have received all recommended vaccines, or must receive all recommended vaccinations prior to initiation of therapy. Updated: 08/

17 B VS D - PART B VERSUS PART D COVERAGE PA ANZEMET ATGAM AZASAN AZATHIOPRINE AZATHIOPRINE SODIUM BONIVA CALCIJEX CALCITRIOL CARIMUNE NF NANOFILTERED CARNITOR CELLCEPT CESAMET CUBICIN CYCLOPHOSPHAMIDE CYCLOSPORINE CYCLOSPORINE MODIFIED DRONABINOL EMEND GAMMAGARD LIQUID GAMMAPLEX GAMUNEX-C GENGRAF GRANISETRON HCL GRANISOL HECTOROL HEPARIN SODIUM HEPARIN SODIUM IN 0.45% NACL HEPARIN SODIUM IN 0.9% NACL HEPARIN SODIUM-D5W IMURAN LEVOCARNITINE MARINOL METHOTREXATE MIACALCIN MITOXANTRONE HCL MYCOPHENOLATE MOFETIL MYFORTIC Updated: 08/

18 NEORAL NULOJIX ONDANSETRON HCL ONDANSETRON ODT PAMIDRONATE DISODIUM PRIVIGEN PROGRAF RAPAMUNE RHEUMATREX ROCALTROL SANDIMMUNE SIMULECT TACROLIMUS THYMOGLOBULIN TREXALL VANCOMYCIN HCL ZEMPLAR ZOFRAN ODT ZOFRAN ZORTRESS 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: 08/

19 CIALIS CIALIS All FDA-approved indications not otherwise excluded from Part D. Erectile Dysfunction. Concomitant use of nitrates. The member must have a diagnosis of benign prostatic hyperplasia. Initial duration 3 months. If BPH symptoms improve (AUA-SI score decrease), approve for 1 year. The member must have symptoms of at least moderate severity that are bothersome, as defined by the American Urological Association Symptom Index (AUA- SI) greater than or equal to 8. Must have tried and failed or be intolerant of or contraindicated to two other drugs, one each from any two of the following different therapeutic classes: alpha-1 adrenergic blockers (terazosin, doxazosin, tamsulosin, alfuzosin, silodosin), 5-alpha reductase inhibitors (finasteride, dutasteride), combination alpha-1 adrenergic blocker/5-alpha reductase inhibitors (dutasteride/tamsulosin). Updated: 08/

20 CIMZIA CIMZIA All FDA-approved indications not otherwise excluded from Part D. Concomitant use of other Interleukin-1 antagonist or TNF agent. For Rheumatoid Arthritis, the member must have a confirmed diagnosis of moderate to severe Rheumatoid Arthritis and the disease must be active. For Crohn's Disease, the member must have a confirmed diagnosis of moderate to severe Crohn's Disease. Rheumatologist, Gastroenterologist. Indefinite. For Rheumatoid Arthritis, must first try and fail or have an inadequate response to a 2-month trial of methotrexate, OR if the member has a contraindication to methotrexate, then must fail at least one other DMARD for at least 2 months or have a contraindication to the use of one alternative DMARD. For Crohn's Disease, must first try and fail or have an inadequate response to either Corticosteroids AND one of Azathioprine or Mercaptopurine, OR Remicade or Humira. Must be up to date and received all recommended vaccines, or must receive all recommended vaccines prior to initiation of therapy. Updated: 08/

21 CINRYZE CINRYZE All FDA-approved indications not otherwise excluded from Part D. Acute attacks of hereditary angioedema. Confirmation of diagnosis of hereditary angioedema based on laboratory verification of C1 inhibitor deficiency. Long term prophylaxis 1 yr. Short term prophylaxis or treatment of acute attack 1 time dose. Long term prophylaxis requires that the member must have previously tried and failed or be intolerant of or contraindicated to one of the following: danazol, oxandrolone, Amicar (aminocaproic acid), or Cyklokapron (tranexamic acid) AND either of the following: The member has 2 or more episodes of angioedema per month OR the member's attack location occurs in body sites associated with a high risk of mortality (e.g. laryngeal). Short term prophylaxis requires one of the following instances occur: prior to minor manipulations (i.e. mild dental procedures) or prior to intubation or major procedures. Acute attacks require that airway involvement is suspected. Updated: 08/

22 DIFICID DIFICID All FDA-approved indications not otherwise excluded from Part D. Ten days. Must first try and fail or have recurrence of disease after two courses of either metronidazole or vancomycin in the past 90 days, with at least one course of treatment being vancomycin. If members are allergic to both vancomycin and metronidazole, Dificid will be approved. If members are continuing therapy started during a hospitalization, Dificid will be approved. Updated: 08/

23 EGRIFTA EGRIFTA All FDA-approved indications not otherwise excluded from Part D. Diagnosis is HIV-associated lipodystrophy. Egrifta is prescribed for the reduction of excess abdominal fat. Patient is HIV-infected. Adults. Prescribed by or in consultation with an endocrinologist or a physician specializing in the treatment of HIV (eg, infectious disease, oncology). Authorization will be for 12 months. Updated: 08/

24 ENBREL ENBREL All FDA-approved indications not otherwise excluded from Part D. For Rheumatoid Arthritis the member must have a confirmed diagnosis of moderate to severe Rheumatoid Arthritis and the disease must be active. For Juvenile Idiopathic Arthritis, the member must have a confirmed diagnosis of moderate to severe Juvenile Idiopathic Arthritis and the disease must be active. For Anklyosing Spondylitis, the member must have a confirmed diagnosis of Ankylosing Spondylitis as defined by presence of active disease for at least 4 weeks defined by any disease specific functional scoring tool (i.e. a BASDAI Index of at least 4, Health Assessment Questionnaire (HAQ), Modified Health Assessment Questionnaire (MHAQ), etc...) and an expert opinion based on clinical features, acute phase reactants and imaging modalities. For Psoriasis with Arthropathy, the member must have a confirmed diagnosis of Psoriasis with Arthropathy. For Plaque Psoriasis, the member must have a confirmed diagnosis of chronic and moderate to severe Plaque Psoriasis, and defined as a minimum body surface area involvement of greater than or equal to 5%. Rheumatologist, Dermatologist. Indefinite. For Ankylosing Spondylitis, 12wk trial initially, with positive response then ok x 1yr. For Rheumatoid Arthritis, must first try and fail or have an inadequate response to a 2-month trial of methotrexate, OR if the member has a contraindication to methotrexate, then must fail at least one other DMARD for at least 2 months or have a contraindication Updated: 08/

25 to the use of one alternative DMARD. For Juvenile Idiopathic Arthritis and non axial forms of Psoriasis with Arthropathy, must first try and fail methotrexate for at least two months, OR if the member has an absolute contraindication to methotrexate, then Enbrel will be approved. For axial forms of Psoriasis with Arthropathy, must first try and fail methotrexate or NSAIDS for at least two months, or if the member has an absolute contraindication to methotrexate and NSAIDs, then Enbrel will be approved. For non axial forms of Ankylosing Spondylitis, the member must first try and fail any two of the following conventional therapies over a three month period: NSAIDs, intraarticular steroids, methotrexate, DMARDs (failure is defined as improvement of less than 50% or 2 units, on a 0-10 scale, of the BASDAI scale, or less than 50% on other scoring tools). For Plaque Psoriasis, the member must first try and fail over a three month period, both one topical therapy AND one of the following: Methotrexate, Oral retinoids, cyclosporine, phototherapy. Updated: 08/

26 GROWTH HORMONE GENOTROPIN HUMATROPE NORDITROPIN FLEXPRO NORDITROPIN NORDIFLEX NUTROPIN AQ NUSPIN NUTROPIN AQ NUTROPIN OMNITROPE SAIZEN SEROSTIM TEV-TROPIN ZORBTIVE All FDA-approved indications not otherwise excluded from Part D. Growth hormone (GH) deficiency (DF) (except Serostim and Zorbtive). Non-GH deficient short stature (idiopathic short stature, ISS) (except Serostim and Zorbtiv). Turner's syndrome (TS) (except Serostim and Zorbtive). SHOX (short stature homeobox-containing gene) deficiency (except Serostim and Zorbtive). Chronic renal insufficiency (CRI) (except Serostim and Zorbtive). Prader-Willi syndrome (PW) (except Serostim and Zorbtive). Noonan syndrome (NS) (except Serostim and Zorbtive). Short bowel syndrome (SBS) (except Serostim). Human Immunodeficiency Virus (HIV) infection with wasting or cachexia (Serostim only). HIV-associated failure to thrive (Serostim only). Use in the management of acute critical illness due to complications of surgery, trauma, or with acute respiratory failure, as antiaging therapy, to improve functional status in elderly, somatopause, enhancement of athletic ability, bone marrow transplant (BMT) without total body irradiation, bony dysplasias, burn injury, cardiac transplantation, central precocius puberty, chronic fatigue syndrome, congenital adrenal hyperplasia, constitutional delay of growth and puberty, corticosteroid-induced short stature including a variety of chronic glucocorticoid-dependent conditions, such as asthma, juvenile rheumatoid arthritis, after renal, heart, liver, or BMT, Crohn's disease, cystic fibrosis, dilated cardiomyopathy/heart failure, end-stage renal disease in adults undergoing hemodialysis, Down's syndrome, familial dysautonomia, fibromyalgia, HIVinfected patients with alterations in body fat distribution, infertility, kidney transplant patients (children) with a functional renal allograft, liver transplantation, multiple system Updated: 08/

27 atrophy, myelomeningocele, obesity, osteogenesis imperfecta, osteoporosis (postmenopausal, idiopathic in men, glucocorticoid-induced), thalassemia, and X-linked hypophosphatemic rickets (familial hypophosphatemia, hypophosphatemic rickets). Child/adolesc GH DF initial tx, eval by pediatric endocrinologist (PE), documented GH stim test (levodopa, insulin-induced hypoglycemia, arginine, clonidine, glucagon) w/gh response less than 10 ng/ml AND baseline height (Ht) less than the 3rd percentile (pct) for gender/age AND pretx Ht growth rate (GR) child less than 3 yrs of less than 7 cm/yr and child greater than or equal to 3 yrs of less than 4 cm/yr OR child any age GR less than the 10th pct for age/gender based on min 6 mos of data.child w/brain radiation does not have to meet baseline Ht crit.congenital hypopituitarism does not have to meet Ht or GR crit.child w/hypophysectomy, approve.child/adolesc GH DF cont tx, GR increased by 2.5 cm/yr or more in most recent yr (MRY) per MD AND epiphyses open (older than 12 yrs), both crit exclude adolesc w/hypopituitarism.review GR annually (not applied to hypopituitarism).adoles/yng adult w/completed linear growth (GR less than 2 cm/yr), review for adult GH DF.Greater than 18 yrs, auth not allowed if midparental ht attained.iss child w/open epiphyses,6 mo trial if baseline Ht less than 3rd pct (greater than 2 SD below mean for gender/age) AND pretx GR child less than 3 yrs of less than 7 cm/yr and child greater than or equal to 3 yrs of less than 4 cm/yr OR child any age GR less than the 10th pct for age/gender based on min 6 mos of data AND PE certifies child's basic activities of daily living limited by SS and has condition which GH is/may be effective AND PE certifies via bone-age x-ray, predicted adult Ht less than 3rd pct.auth after initial tx (auth for 12 mos) based on adequate clinical response (annualized GR doubles).cont tx (after 12 to 18 mos), GR increased by 2.5 cm/yr or more in MRY per MD AND epiphyses open (older than 12 yrs).greater than 18 yrs, auth not allowed if midparental ht attained.adult GH DF or PW/trans adoles, eval by or in consultation w/endocrinologist (start and annually).ns/show/child PW, eval by PE.CRI, eval by PE or nephrologist. TS, children. SHOX/CRI/NS, children/adolescents. HIV failure to thrive, less than 17 yrs. SBS/HIV cachexia/wasting, adults. For adults, the endocrinologist must certify that the somatropin is not being prescribed for anti-aging therapy or to enhance athletic ability. Updated: 08/

28 GH DF 12 mos.sbs 4 wks/yr.non-gh DF ISS 6 mos.hiv wast/cach 24 wks.hiv failure to thrive 12 wks. Adult GH DF (start), document diagnosis of GH DF due to adult-onset (GH alone or multiple hormone deficiencies/hypopituitarism from pituitary dz, hypothalamic dz, surgery, cranial radiation tx, tumor txment, traumatic brain injury, or subarachnoid hemorrhage) or due to childhood-onset (GH not rec in adults who had GH tx as child for uses not due to GH DF) AND negative response to 1 GH stim test (insulin tolerance [peak less than 5 mcg/l], or glucagon [peak less than 3 mcg/l]) [GHRH plus arginine may be used if available] (exclude stim test for childhood-onset due to mutations, lesions, congenital defects), transition adoles off somatropin 1 mo before retesting, OR 3 or more pituitary hormone deficiencies (TSH, ACTH, LH/FSH, or AVP) AND serum IGF-1 84 microg/l or less using the Esoterix ECB RIA or age/gender adjusted serum IGF-1 SDS below the 2.5 percentile.ts start, female and has short stature (SS).SHOX start, open epiphyses.cri w/growth failure (GF), start, approve.child PW w/gf or adult PW, approve.ns start, baseline ht less than 3rd percentile.ts/shox/cri/child PW/NS, cont tx, GR increased by 2.5 cm/yr or more in most recent yr (MRY) AND epiphyses open.hiv w/wasting or cachexia, HIV-positive AND have 1 of the following, documented unintentional wt loss of greater than or equal to 10% from baseline OR wt less than 90% of the lower limit of ideal body wt OR BMI less than or equal to 20 kg/m2 AND able to consume or be fed via parenteral or enteral feedings 75% or more of maintenance energy requirements based on current body weight AND on antiretroviral tx greater than or equal to 30 days prior to beginning GH tx and will continue antiretroviral tx throughout GH txment. Repeat 12 or 24-wk courses of GH may be authorized after initial 12 or 24- wk GH course for HIV infection w/wasting or cachexia provided that they are off GH for at least 1 mo and meet all of previous HIV criteria.hiv-assoc failure to thrive.able to consume or be fed via parenteral or enteral feedings 75% or more of maintenance energy requirements based on current body wt AND on antiretroviral tx for greater than or equal to 30 days prior to beginning GH tx and will continue antiretroviral tx.sbs, receiving specialized nutritional support.sbs pts eval on case-by-case basis for more than one 4-wk course per yr. Updated: 08/

29 HEMATOPOIETIC GROWTH FACTOR PROMACTA All FDA-approved indications not otherwise excluded from Part D. Promacta only will be allowed for coverage of Hepatitis C related thrombocytopenia. Chronic ITP is defined as greater than 6 months. Baseline platelet count must be less than 30,000/mm3, OR baseline platelet count must be 30,000-50,000/mm3 AND in the presence of a clinically significant previous bleeding episode OR at high risk of experiencing a clinically significant bleeding episode (for example, upcoming surgery, if the member is at high risk of falls, etc...). For continuation of therapy, a clinically positive response is either a platelet count with a positive increase to greater than 50,000/mm3 OR a clinically significant improvement in bleeding status if platelet count remains less than 50,000/mm3. If the platelet count does not increase after 4 weeks at maximum dose, then therapy will not be reauthorized. For Hepatitis C related thrombocytopenia, must be prescribed by or in consultation with a gastroenterologist or infectious disease physician. ITP 90 day initial trial, then 1 yr w/positive clinical response. Hep C thrombocytopenia 12 months. For chronic ITP must try and have insufficient response to or be intolerant to both of the following: Corticosteroids AND one of either splenectomy, IVIG, or anti-d immunoglobulins. For Hepatitis C related thrombocytopenia, if currently on interferon based therapy, the member must have attempted and failed to improve platelet levels through interferon dose reduction. Updated: 08/

30 HIGH RISK FIRST GENERATION ANTIHISTAMINES CYPROHEPTADINE HCL DIPHENHYDRAMINE HCL HYDROXYZINE HCL HYDROXYZINE PAMOATE PROMETHAZINE HCL PROMETHAZINE VC VISTARIL All FDA-approved indications not otherwise excluded from Part D. Patients aged less than 65 years, approve. Patients aged 65 years and older, other criteria apply. Authorization will be for 12 months, unless otherwise specified. Approve promethazine hydrochloride tablets or syrup if the patient has tried a prescription oral anti-emetic agent (ondansetron, granisetron, dolasetron, palonosetron, aprepitant) for the current condition. Approve diphenhydramine (capsules or elixir) if the patient has tried at least two other FDA-approved products for the management of insomnia. Approve hydroxyzine hydrochloride (tablets and syrup) or hydroxyzine pamoate (capsules) for the treatment of pruritic conditions other than urticaria, and for the management of anxiety if the patient has tried at least two other FDA-approved products. Updated: 08/

31 HIGH RISK MEDICATION - BARBITURATES BUTISOL SODIUM All medically accepted indications not otherwise excluded from Part D. Plus, patients currently taking the barbiturate being requested for a Covered Use. Authorization will be for 12 months. Updated: 08/

32 HIGH RISK MEDICATION - BENZODIAZEPINES ALPRAZOLAM ALPRAZOLAM ER ALPRAZOLAM INTENSOL ALPRAZOLAM ODT ATIVAN CHLORDIAZEPOXIDE HCL CLONAZEPAM CLORAZEPATE DIPOTASSIUM DIAZEPAM ESTAZOLAM FLURAZEPAM HCL HALCION KLONOPIN LORAZEPAM LORAZEPAM INTENSOL NIRAVAM ONFI OXAZEPAM RESTORIL TEMAZEPAM TRANXENE T-TAB TRIAZOLAM VALIUM XANAX XR XANAX All medically accepted indications not otherwise excluded from Part D. Plus, patients currently taking the benzodiazepine being requested for a Covered Use. Updated: 08/

33 Patients aged less than 65 years, approve. Patients aged 65 years and older, other criteria apply. Procedure-related sedation = 1mo. All other conditions = 12 months. Restless Leg Syndrome, approve clonazepam or temazepam if the patient has tried one other agent for this condition (eg, ropinirole, pramipexole, carbidopa-levodopa [immediate-release or extended-release]). Insomnia, approve estazolam, flurazepam, lorazepam, oxazepam, temazepam or triazolam if the patient has had a trial with one of the following - ramelteon, eszopiclone, zolpidem, or zaleplon. Updated: 08/

34 HIGH RISK SKELETAL MUSCLE RELAXANTS AMRIX CARISOPRODOL CARISOPRODOL COMPOUND CARISOPRODOL COMPOUND-CODEINE CHLORZOXAZONE CYCLOBENZAPRINE HCL FEXMID LORZONE METHOCARBAMOL ORPHENADRINE CITRATE ORPHENADRINE COMPOUND ORPHENADRINE COMPOUND FORTE PARAFON FORTE DSC SKELAXIN SOMA All FDA-approved indications not otherwise excluded from Part D. Patients aged less than 65 years, approve. Patients aged 65 years and older, other criteria apply. Authorization will be for 1 month. Updated: 08/

35 Musculoskeletal conditions/disorders, approve if the patient has tried two other therapies for the current condition. Updated: 08/

36 HUMIRA HUMIRA All FDA-approved indications not otherwise excluded from Part D. For Rheumatoid Arthritis the member must have a confirmed diagnosis of moderate to severe Rheumatoid Arthritis and the disease must be active. For Juvenile Idiopathic Arthritis, the member must have a confirmed diagnosis of Juvenile Idiopathic Arthritis and the disease must be active. For Anklyosing Spondylitis, the member must have a confirmed diagnosis of Ankylosing Spondylitis as defined by presence of active disease for at least 4 weeks defined by any disease specific functional scoring tool (i.e. a BASDAI Index of at least 4, Health Assessment Questionnaire (HAQ), Modified Health Assessment Questionnaire (MHAQ), etc...) and an expert opinion based on clinical features, acute phase reactants and imaging modalities. For Psoriasis with Arthropathy, the member must have a confirmed diagnosis of Psoriasis with Arthropathy. For Plaque Psoriasis, the member must have a confirmed diagnosis of chronic and moderate to severe Plaque Psoriasis, and defined as a minimum body surface area involvement of greater than or equal to 5%. For Crohn's Disease, the member must have a confirmed diagnosis of moderate to severe Crohn's Disease. For Ulcerative Colitis, the member must have a confirmed diagnosis of moderate to severe ulcerative colitis. Rheumatologist, Dermatologist, Gastroenterologist. Indefinite. AS 12wk initial, w/pos resp x 1 yr. UC 8wk initial, w/remission evidence x indefinite. Updated: 08/

37 For Rheumatoid Arthritis, must first try and fail or have an inadequate response to a 2-month trial of methotrexate, OR if the member has a contraindication to methotrexate, then must fail at least one other DMARD for at least 2 months or have a contraindication to the use of one alternative DMARD. For Juvenile Idiopathic Arthritis and non axial forms of Psoriasis with Arthropathy, must first try and fail methotrexate for at least two months, OR if the member has an absolute contraindication to methotrexate, then Humira will be approved. For axial forms of Psoriasis with Arthropathy, must first try and fail methotrexate or NSAIDS for at least two months, or if the member has an absolute contraindication to methotrexate and NSAIDs, then Humira will be approved. For non axial forms of Ankylosing Spondylitis, the member must first try and fail any two of the following conventional therapies over a three month period: NSAIDs, intraarticular steroids, methotrexate, DMARDs (failure is defined as improvement of less than 50% or 2 units, on a 0-10 scale, of the BASDAI scale, or less than 50% on other scoring tools). For Plaque Psoriasis, the member must first try and fail over a three month period, both topical therapy AND one of the following: Methotrexate, Oral retinoids, cyclosporine, phototherapy. For Crohn's Disease, must first try and fail or have an inadequate response to either Corticosteroids AND one of Azathioprine or Mercaptopurine, OR Remicade or Cimzia. For Ulcerative Colitis, must first try and fail or have an inadequate response to either Corticosteroids AND one of Azathioprine or Mercaptopurine, OR Remicade. Updated: 08/

38 ILARIS ILARIS All FDA-approved indications not otherwise excluded from Part D. 4 years or greater. Indefinite. Must be up to date and have received all recommended vaccines, or must receive all recommended vaccinations prior to initiation of therapy. Updated: 08/

39 INCIVEK INCIVEK All FDA-approved indications not otherwise excluded from Part D. Use in Hepatitis C genotypes 2-6. Hepatitis C genotype 1. HCV RNA level at 4 weeks. Prescriber is either a gastroenterologist or an infectious disease specialist. Initial approval for 6 weeks. With positive response, approve additional 6 weeks. Positive response is defined as improved titer level after initial 4 weeks of treatment, which is an HCV RNA level/viral load less than 1000IU/ml. Updated: 08/

40 KALYDECO KALYDECO All FDA-approved indications not otherwise excluded from Part D. Patients who are homozygous for the F508del mutation. For patients new to therapy, G551D mutation in the CFTR gene status required. Members already started on therapy prior to joining health plan with unconfirmed mutation status must confirm G551D mutation status to continue. G551D mutation cnfrmed, indefinite. If cont use from prior to joining plan and mutation unknwn, 1mo. Patients new to therapy must have G551D mutation. Patients continuing therapy from prior to joining health plan already started on therapy must confirm G551D mutation to continue treatment. Updated: 08/

41 KINERET KINERET All FDA-approved indications not otherwise excluded from Part D. The member must have a confirmed diagnosis of Rheumatoid Arthritis and the disease must be active. Rheumatologist. Indefinite. For Rheumatoid Arthritis, must first try and fail or have an inadequate response to a 2-month trial of methotrexate, OR if the member has a contraindication to methotrexate, then must fail at least one other DMARD for at least 2 months or have a contraindication to the use of one alternative DMARD. Updated: 08/

42 KORLYM KORLYM All FDA-approved indications not otherwise excluded from Part D. Pregnancy. The member must have a confirmed diagnosis of endogenous Cushing s syndrome, requiring control of hyperglycemia secondary to hypercortisolism, with Type 2 Diabetes Mellitus or glucose intolerance. Female members must not be pregnant, as evidenced by a documented negative pregnancy test prior to the initiation of treatment. For continuation of therapy, the member must achieve 25% or greater improvement in glucose tolerance, as measured by a standard two-hour glucose tolerance test after 12 weeks of treatment, OR must achieve improved glycemic control as evidenced by the member's HbA1C value. Aged 18 years or older. Endocrinologist or specialist in treating Cushing's syndrome. Initial authorization 3 months. If improvement met, then indefinite. The member must have failed surgery, or is not a candidate for surgery. Updated: 08/

43 KUVAN KUVAN All FDA-approved indications not otherwise excluded from Part D. Initial 2 months, if positive response, then indefinite. In pregnancy, through term. Patient must continue to receive a specialized phenylalanine restricted diet in conjunction with Kuvan. For continuation of therapy, a positive response is defined as showing a 30% or greater reduction in blood phenylalanine level after initial 2 months of therapy. Updated: 08/

44 ORENCIA ORENCIA All FDA-approved indications not otherwise excluded from Part D. The member must have a confirmed diagnosis of Rheumatoid Arthritis or polyarticular Juvenile idiopathic arthritis and the disease must be active. Rheumatologist. Indefinite. For Rheumatoid Arthritis, must first try and fail or have an inadequate response to a 2-month trial of methotrexate, OR if the member has a contraindication to methotrexate, then must fail at least one other DMARD for at least 2 months or have a contraindication to the use of one alternative DMARD. For Juvenile Idiopathic Arthritis, must first try and fail methotrexate for at least two months, OR if the member has an absolute contraindication to methotrexate, then Orencia will be approved. Updated: 08/

45 PANRETIN PANRETIN All FDA-approved indications not otherwise excluded from Part D. Indefinite. Updated: 08/

46 PEDICULOSIS CAPITIS SKLICE All FDA-approved indications not otherwise excluded from Part D. 6 months or greater. 14 days. Must have tried and failed any two or more of the following other treatments: permethrin 1% (Nix), pyrethrins with piperonyl butoxide (Rid, or others), Malathion (Ovide), benzyl alcohol 5% lotion (Ulesfia), lindane (Kwell), crotamiton 10% lotion (Eurax). Note, two treatments is considered any of the following: any one listed product filled on two separate dates, any one listed product filled once but with a sufficient quantity for 2 treatments, or any two listed products tried individually. Updated: 08/

47 PROLEUKIN PROLEUKIN All FDA-approved indications not otherwise excluded from Part D. Kaposi's Sarcoma, Colorectal Cancer. 18 years or greater. Indefinite. Updated: 08/

48 REVATIO ADCIRCA REVATIO SILDENAFIL All FDA-approved indications not otherwise excluded from Part D. Erectile dysfunction. Benign Prostatic hyperplasia. Indefinite. Updated: 08/

49 RILUTEK RILUTEK All FDA-approved indications not otherwise excluded from Part D. Neurologist. Indefinite. Requires documentation of exclusion of other diagnoses by neurologist. Updated: 08/

50 SAMSCA SAMSCA All FDA-approved indications not otherwise excluded from Part D. Patients requiring urgent intervention to raise serum sodium acutely. Patients unable to sense or appropriately respond to thirst. Patients with hypovolemic hyponatremia. Concomitant use of strong CYP 3A inhibitors. Patients who are anuric. The diagnosis must be clinically significant hyponatreima, hypervolemic or euvolemic, defined as serum sodium less than 125meq/l or less, and the patient must be symptomatic (symptoms may include nausea/vomiting, headache, confusion, lethargy, fatigue, loss of appetite, restlessness and irritability, muscle weakness, spasm, cramps, seizures, decreased consciousness, or coma), including patients with heart failure, cirrhosis, and SIADH. 4 days initially, if positive response then 6 months. Therapy must be initiated or re-initiated in a hospital setting. The patient must have failed or resisted correction with both fluid restriction and one other means of treatment, such as loop diuretics, hypertonic saline, or salt tablets. The patient has been discontinued from any other possible cases of drug-induced hyponatremia or SIADH (such as carbamazepine, oxcarbazepine, chlorpropamide, fluoxetine, sertraline, vincristine, vinblastine, cisplatin, cyclophosphamide, thiothixene, thioridazine, haloperidol, amitriptyline, MAO inhibitors, methotrexate, NSAIDs, interferon alpha and gamma, amiodarone, ciprofloxacin, and opiates). Updated: 08/

51 SIMPONI SIMPONI All FDA-approved indications not otherwise excluded from Part D. For Rheumatoid Arthritis, the member must have a confirmed diagnosis of moderate to severe Rheumatoid Arthritis as made by a rheumatologist and the disease must be active. For Anklyosing Spondylitis, the member must have a confirmed diagnosis of Ankylosing Spondylitis as made by a rheumatologist as defined by presence of active disease for at least 4 weeks defined by a BASDAI Index of at least 4 and an expert opinion based on clinical features, acute phase reactants and imaging modalities. For Psoriasis with Arthropathy, the member must have a confirmed diagnosis of Psoriasis with Arthropathy as made by a rheumatologist or dermatologist. Rheumatologist, Dermatologist. Indefinite. In Ankylosing Spondylitis, 12wk trial initially, if positive response then indefinite. For Rheumatoid Arthritis, must first try and fail or have an inadequate response to a 2-month trial of methotrexate, OR if the member has an intolerance/contraindication to methotrexate, then must fail at least one other DMARD for at least 2 months or have a contraindication to the use of one alternative DMARD. For non axial forms of Ankylosing Spondylitis, the member must first try and fail any two of the following conventional therapies over a three month period: NSAIDs, intraarticular steroids, methotrexate, DMARDs (failure is defined as improvement of less than 50% or 2 units, on a 0-10 scale, of the BASDAI scale). For Psoriasis with Arthropathy, must first try and fail Updated: 08/

52 methotrexate for at least two months, OR if the member has an absolute contraindication to methotrexate, then Simponi will be approved. Updated: 08/

53 SPORANOX ITRACONAZOLE ONMEL SPORANOX All FDA-approved indications not otherwise excluded from Part D. Onchomycosis. Other Tinea type infections including Versicolor, Capitis, Barbae, Crurus, Faciei, Manuum, Imbricata, Pedis (non moccasin or non chronic type), Corporis. Plantar type or Moccasin type dry chronic Tinea Pedis. Vaginal Candidiases. Prevention of recurrent vulvovaginal or vaginal candidiasis. Pityriasis versicolor. Other superficial and systemic mycosis. Oral and esophageal candidiasis. Vaginal candidiasis hypersensitivity syndrome. Onychomycosis must be due to dermatophytes, and treatment must not be solely for cosmetic purposes as cosmetic use is excluded under Medicare Part D. Twelve weeks. Tinea or Pityrisis Versicolor requires one trial and failure of ketoconazole or a topical antifungal agent first. Tinea Capitis and Barbae require failure of one trial of griseofulvin or ketoconazole first. Tinea Cruris, Faciei, Manuum, Imbricata and Pedis (non moccasin or chronic type) require failure of one topical antifungal agent. Tinea Corporis requires failure of one topical antifungal agent first, except when condition is considered extensive. Vaginal Candidiases requires failure of both one topical antifungal regimen and one trial of oral fluconazole (patients of age less than 16 years are excluded from a trial of a topical vaginal antifungal preparation). For oral and esophageal candidiasis, Updated: 08/

54 must try and fail ketoconazole or fluconazole first. For febrile neutropenia, must be intolerant of or refractory to amphotericin B therapy. For Aspergillosis, must be intolerant of or refractory to Amphotericin B. Itraconazole may be covered for other systemic infection if used for continuation of itraconazole therapy that has already been started and stabilized. Updated: 08/

55 STELARA STELARA All FDA-approved indications not otherwise excluded from Part D. Diagnosis of moderate to severe plaque psoriasis must be made by a dermatologist and is defined as a minimum body surface area (BSA) involvement of greater than or equal to 5 percent. Dermatologist, Rheumatologist. Indefinite. Patient must have tried and failed over a three month period a trial of both topical therapy AND one of the following: methotrexate, oral retinoids, cyclosporine, or phototherapy. Updated: 08/

56 TAZORAC TAZORAC All FDA-approved indications not otherwise excluded from Part D. Pregnancy. Fine wrinkle disorder/fine wrinkles on face. Indefinite. Diagnosis of acne vulgaris requires failure on at least two other formulary anti-acne preparations. Updated: 08/

57 TOPICAL RETINOID PRODUCTS ATRALIN AVITA AVITA RETIN-A MICRO RETIN-A TRETINOIN TRETIN-X VELTIN ZIANA All FDA-approved indications not otherwise excluded from Part D. For topical tretinoin products (examples include Atralin, Avita, Retin-A, Retin-A Micro, Tretin-X, and generic topical tretinoin), additional covered uses include: Ichthyosis, Keloids, Lichen planus, Oral leukoplakia, Confluent and reticulated papillomatosis. Authorization will be for 12 months, unless otherwise noted. Updated: 08/

58 VICTRELIS VICTRELIS All FDA-approved indications not otherwise excluded from Part D. Use in Hepatitis C genotypes 2-6. Hepatitis C genotype 1. HCV RNA Level at treatment weeks 8, 12, and 24. Prescriber is either a gastroenterologist or an infectious disease specialist. Initial approval for 12 weeks. May be extended to treatment week 44. If no response at treatment week 12 defined as HCV RNA greater than = 100 IU/ml, then discontinue. If confirmed detectable HCV-RNA at treatment week 24, then discontinue. Otherwise, continue therapy for up to 44 weeks. Updated: 08/

59 XALKORI XALKORI All FDA-approved indications not otherwise excluded from Part D. Plus, patients with non-small cell lung cancer (NSCLC) already started on crizotinib prior to joining health plan in the absence of confirmed ALK status. Patients with anaplastic lymphoma kinase (ALK)-negative NSCLC. Patients with NSCLC initiating therapy whose ALK status is unknown. For patients new to therapy, ALK status required. Members already started on therapy prior to joining health plan with unconfirmed ALK status must confirm ALK positive status to continue. ALK positive confrmd, indefinite. If continuing use from prior to joining plan and ALK unknown, 1mo. Patients new to therapy must have ALK positive NSCLC. Patients continuing therapy from prior to joining health plan already started on therapy must confirm ALK positive status to continue treatment. Updated: 08/

60 XENAZINE XENAZINE All FDA-approved indications not otherwise excluded from Part D. Impaired hepatic function, Concomitant use of MAOIs or Reserpine, Non- Huntington's related chorea. Diagnosis must be chorea associated with Huntington's Disease. Indefinite. Updated: 08/

61 XOLAIR XOLAIR All FDA-approved indications not otherwise excluded from Part D. Diagnosis must be moderate to severe persistent asthma. Must have a positive skin test or in vitro testing (blood test for allergen-specific IgE antibiotics such as RAST) for one or more perennial aeroallergens or for one or more seasonal aeroallergens. 12 years or greater. Indefinite. Requires trial and failure to control symptoms by inhaled moderate to high dose corticosteroids after at least 2 months of therapy. Failure is demonstrated by hospitalization for asthma, requirement for systemic (oral or parenteral) corticosteroids to control exacerbations of asthma, increasing need (usually greater than once per day) for short-acting inhaled beta2 agonist for symptom control (excluding preventive use of exercise induced asthma). Updated: 08/

62 XOPENEX XOPENEX HFA All FDA-approved indications not otherwise excluded from Part D. Indefinite. Must have tried and failed, or be intolerant to albuterol secondary to clinically significant adverse cardiovascular effects, such as increased pulse rate, increased blood pressure, and/or other sympathetic nervous system symptoms. Updated: 08/

63 ZELBORAF ZELBORAF All FDA-approved indications not otherwise excluded from Part D. Plus, patients with melanoma already started on vemurafenib prior to joining health plan in the absence of confirmed BRAF V600E mutation status. Patients with melanoma with wild-type BRAF (i.e., no detected BRAFV600E mutation). Patients with melanoma initiating therapy with vemurafenib whose BRAFV600E status is unknown. For patients new to therapy, BRAFV600E status required. Members already started on therapy prior to joining health plan with unconfirmed BRAF status must confirm BRAFV600E status to continue. BRAFV600E confirmed, indefinite. If continuing use from prior to joining plan and BRAF unknown, 1mo. Patients new to therapy must have BRAFV600E mutation. Patients continuing therapy from prior to joining health plan already started on therapy must confirm BRAFV600E to continue treatment. Updated: 08/

64 Index ACTEMRA, 10 ADCIRCA, 48 ALPRAZOLAM, 32 ALPRAZOLAM ER, 32 ALPRAZOLAM INTENSOL, 32 ALPRAZOLAM ODT, 32 AMPYRA, 12 AMRIX, 34 ANDRODERM, 13 ANDROGEL, 13 ANZEMET, 17 ARANESP, 14 ARCALYST, 16 ATGAM, 17 ATIVAN, 32 ATRALIN, 57 AVITA, 57 AVITA, 57 AXIRON, 13 AZASAN, 17 AZATHIOPRINE, 17 AZATHIOPRINE SODIUM, 17 BONIVA, 17 BUTISOL SODIUM, 31 CALCIJEX, 17 CALCITRIOL, 17 CARIMUNE NF NANOFILTERED, 17 CARISOPRODOL, 34 CARISOPRODOL COMPOUND, 34 CARISOPRODOL COMPOUND- CODEINE, 34 CARNITOR, 17 CELLCEPT, 17 CESAMET, 17 CHLORDIAZEPOXIDE HCL, 32 CHLORZOXAZONE, 34 CIALIS, 19 CIMZIA, 20 CINRYZE, 21 CLONAZEPAM, 32 CLORAZEPATE DIPOTASSIUM, 32 CUBICIN, 17 CYCLOBENZAPRINE HCL, 34 CYCLOPHOSPHAMIDE, 17 CYCLOSPORINE, 17 CYCLOSPORINE MODIFIED, 17 CYPROHEPTADINE HCL, 30 DIAZEPAM, 32 DIFICID, 22 DIPHENHYDRAMINE HCL, 30 DRONABINOL, 17 EGRIFTA, 23 EMEND, 17 ENBREL, 24 EPOGEN, 14 ESTAZOLAM, 32 FEXMID, 34 FLURAZEPAM HCL, 32 FORTESTA, 13 GAMMAGARD LIQUID, 17 GAMMAPLEX, 17 GAMUNEX-C, 17 GENGRAF, 17 GENOTROPIN, 26 GRANISETRON HCL, 17 GRANISOL, 17 H.P. ACTHAR, 11 HALCION, 32 HECTOROL, 17 HEPARIN SODIUM, 17 HEPARIN SODIUM IN 0.45% NACL, 17 HEPARIN SODIUM IN 0.9% NACL, 17 HEPARIN SODIUM-D5W, 17 HUMATROPE, 26 HUMIRA, 36 HYDROXYZINE HCL, 30 Updated: 08/

65 HYDROXYZINE PAMOATE, 30 ILARIS, 38 IMURAN, 17 INCIVEK, 39 ITRACONAZOLE, 53 KALYDECO, 40 KINERET, 41 KLONOPIN, 32 KORLYM, 42 KUVAN, 43 LEVOCARNITINE, 17 LORAZEPAM, 32 LORAZEPAM INTENSOL, 32 LORZONE, 34 MARINOL, 17 METHOCARBAMOL, 34 METHOTREXATE, 17 MIACALCIN, 17 MITOXANTRONE HCL, 17 MYCOPHENOLATE MOFETIL, 17 MYFORTIC, 17 NEORAL, 18 NIRAVAM, 32 NORDITROPIN FLEXPRO, 26 NORDITROPIN NORDIFLEX, 26 NULOJIX, 18 NUTROPIN AQ NUSPIN, 26 NUTROPIN AQ, 26 NUTROPIN, 26 OMNITROPE, 26 ONDANSETRON HCL, 18 ONDANSETRON ODT, 18 ONFI, 32 ONMEL, 53 ORENCIA, 44 ORPHENADRINE CITRATE, 34 ORPHENADRINE COMPOUND, 34 ORPHENADRINE COMPOUND FORTE, 34 OXAZEPAM, 32 PAMIDRONATE DISODIUM, 18 PANRETIN, 45 PARAFON FORTE DSC, 34 PRIVIGEN, 18 PROCRIT, 14 PROGRAF, 18 PROLEUKIN, 47 PROMACTA, 29 PROMETHAZINE HCL, 30 PROMETHAZINE VC, 30 RAPAMUNE, 18 RESTORIL, 32 RETIN-A MICRO, 57 RETIN-A, 57 REVATIO, 48 RHEUMATREX, 18 RILUTEK, 49 ROCALTROL, 18 SAIZEN, 26 SAMSCA, 50 SANDIMMUNE, 18 SEROSTIM, 26 SILDENAFIL, 48 SIMPONI, 51 SIMULECT, 18 SKELAXIN, 34 SKLICE, 46 SOMA, 34 SPORANOX, 53 STELARA, 55 STRIANT, 13 TACROLIMUS, 18 TAZORAC, 56 TEMAZEPAM, 32 TESTIM, 13 TEV-TROPIN, 26 THYMOGLOBULIN, 18 TRANXENE T-TAB, 32 TRETINOIN, 57 TRETIN-X, 57 Updated: 08/

66 TREXALL, 18 TRIAZOLAM, 32 VALIUM, 32 VANCOMYCIN HCL, 18 VELTIN, 57 VICTRELIS, 58 VISTARIL, 30 XALKORI, 59 XANAX XR, 32 XANAX, 32 XENAZINE, 60 XOLAIR, 61 XOPENEX HFA, 62 ZELBORAF, 63 ZEMPLAR, 18 ZIANA, 57 ZOFRAN ODT, 18 ZOFRAN, 18 ZORBTIVE, 26 ZORTRESS, 18 Updated: 08/