RIVERSPRING STAR ISNP PRIOR AUTHORIZATION
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- Marion Summers
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1 ACROMEGALY RIVERSPRING STAR ISNP PRIOR AUTHORIZATION SIGNIFOR, SIGNIFOR LAR, SOMATULINE DEPOT, SOMAVERT 10 MG VIAL, SOMAVERT 15 MG VIAL, SOMAVERT 20 MG VIAL Must provide clinical documentation of Acromegaly diagnosis PAGE 1 LAST UPDATED 04/2016
2 AGE CARISOPRODOL 350 MG TABLET, CONCERTA, CYCLOBENZAPRINE 10 MG TABLET, CYCLOBENZAPRINE 5 MG TABLET, CYCLOBENZAPRINE 7.5 MG TABLET, DAYTRANA 15 MG/9 HR PATCH, DEXMETHYLPHENIDATE HCL, DEXMETHYLPHENIDATE ER 15 MG CP, DEXMETHYLPHENIDATE ER 30 MG CP, DEXMETHYLPHENIDATE ER 40 MG CP, DEXRAZOXANE, DEXTROAMPHETAMINE 10 MG TAB, DEXTROAMPHETAMINE 5 MG TAB, DEXTROAMPHETAMINE SULFATE ER, DICYCLOMINE 10 MG CAPSULE, DICYCLOMINE 10 MG/5 ML SOLN, DICYCLOMINE 20 MG TABLET, FOCALIN XR, HYDROXYZINE 10 MG/5 ML SOLN, HYDROXYZINE 10 MG/5 ML SYRUP, HYDROXYZINE 50 MG/25 ML SYRUP, HYDROXYZINE HCL 10 MG TABLET, HYDROXYZINE HCL 25 MG TABLET, HYDROXYZINE HCL 50 MG TABLET, HYDROXYZINE PAM 100 MG CAP, HYDROXYZINE PAM 25 MG CAP, HYDROXYZINE PAM 50 MG CAP, METADATE CD 30 MG CAPSULE, METADATE CD 40 MG CAPSULE, METHOCARBAMOL 500 MG TABLET, METHOCARBAMOL 750 MG TABLET, METHYLIN 10 MG CHEWABLE TABLET, METHYLIN 2.5 MG CHEWABLE TAB, METHYLIN 5 MG CHEWABLE TABLET, METHYLPHENIDATE ER, METHYLPHENIDATE 10 MG TABLET, METHYLPHENIDATE 10 MG/5 ML SOL, METHYLPHENIDATE 20 MG TABLET, METHYLPHENIDATE 5 MG TABLET, METHYLPHENIDATE 5 MG/5 ML SOLN, METHYLPHENIDATE HCL CD, METHYLPHENIDATE LA, METHYLPHENIDATE SR, ORPHENADRINE ER 100 MG TABLET, PROMETHAZINE 12.5 MG SUPPOS, PROMETHAZINE 12.5 MG TABLET, PROMETHAZINE 25 MG SUPPOSITORY, PROMETHAZINE 25 MG TABLET, PROMETHAZINE 50 MG TABLET, PROMETHAZINE 6.25 MG/5 ML SYRP, RITALIN LA 20 MG CAPSULE, RITALIN LA 30 MG CAPSULE, RITALIN LA 40 MG CAPSULE, THIORIDAZINE HCL, TRIMETHOBENZAMIDE 300 MG CAP, VYVANSE 20 MG CAPSULE, VYVANSE 30 MG CAPSULE, VYVANSE 40 MG CAPSULE, VYVANSE 50 MG CAPSULE, VYVANSE 60 MG CAPSULE, VYVANSE 70 MG CAPSULE, ZINECARD PAGE 2 LAST UPDATED 04/2016
3 Must be under the age of 65 unless there is documented proof that the benefit outweighs the risk. PAGE 3 LAST UPDATED 04/2016
4 ANTINEOPLASTICS ABRAXANE, AFINITOR, AFINITOR DISPERZ, ALIMTA, ANDROID, ARRANON, ARZERRA, AVASTIN, AZACITIDINE, BICNU, BLEOMYCIN SULFATE, BOSULIF, BUSULFEX, CAPRELSA, CARBOPLATIN, CISPLATIN, CLADRIBINE, CLOLAR, COMETRIQ, COSMEGEN, CYCLOPHOSPHAMIDE 25 MG CAPSULE, CYCLOPHOSPHAMIDE 50 MG CAPSULE, CYTARABINE 2 G/20 ML VIAL, CYTARABINE 20 MG/ML VIAL, DACARBAZINE, DAUNORUBICIN HCL, DECITABINE, DOCEFREZ 20 MG VIAL, DOCETAXEL 140 MG/7 ML VIAL, DOCETAXEL 160 MG/16 ML VIAL, DOCETAXEL 20 MG/2 ML VIAL, DOCETAXEL 20 MG/ML VIAL, DOCETAXEL 200 MG/20 ML VIAL, DOCETAXEL 80 MG/4 ML VIAL, DOCETAXEL 80 MG/8 ML VIAL, DOXIL, DOXORUBICIN HCL, ELIGARD, EMCYT, EPIRUBICIN HCL, ERIVEDGE, ERWINAZE, FARESTON, FASLODEX, FIRMAGON, FLUDARABINE PHOSPHATE, FOLOTYN, GEMCITABINE HCL, GILOTRIF, GLEEVEC, HALAVEN, HEXALEN, ICLUSIG 45 MG TABLET, IDARUBICIN HCL, IFOSFAMIDE, IMATINIB MESYLATE, IMBRUVICA, INLYTA, INTRON A 10 MILLION UNIT/ML, INTRON A 10 MILLION UNITS VIAL, INTRON A 18 MILLION UNITS VIAL, INTRON A 50 MILLION UNITS VIAL, INTRON A 6 MILLION UNIT/ML VL, IRINOTECAN HCL, ISTODAX, IXEMPRA, JAKAFI, JEVTANA, KADCYLA, LUPRON DEPOT, LUPRON DEPOT-PED MG 3MO, LUPRON DEPOT-PED 15 MG KIT, LUPRON DEPOT- PED 30 MG 3MO KIT, LUPRON DEPOT-PED 7.5 MG KIT, MATULANE, MEKINIST, MELPHALAN HCL, MITOMYCIN 20 MG VIAL, MITOMYCIN 40 MG VIAL, MITOMYCIN 5 MG VIAL, MITOXANTRONE HCL, MUSTARGEN, NEXAVAR, ONCASPAR, OXALIPLATIN, PACLITAXEL, PANRETIN, POMALYST, PROLEUKIN, REVLIMID, RITUXAN, SOLTAMOX, SPRYCEL, STIVARGA, SUTENT, SYNRIBO, TABLOID, TAFINLAR, TARCEVA, TARGRETIN 75 MG CAPSULE, TARGRETIN 75 MG SOFTGEL, TASIGNA, TESTRED, TOPOTECAN HCL, TORISEL, TREANDA, TRELSTAR, TRELSTAR DEPOT, TRELSTAR LA, TRISENOX, TYKERB, VELCADE, VINBLASTINE SULFATE, VINCASAR PFS, VINCRISTINE SULFATE, VINORELBINE TARTRATE, VOTRIENT, XALKORI, XTANDI, YERVOY, ZALTRAP, ZANOSAR, ZELBORAF, ZOLINZA, ZORTRESS PAGE 4 LAST UPDATED 04/2016
5 PAGE 5 LAST UPDATED 04/2016
6 ARANESP ARANESP 100 MCG/0.5 ML SYRINGE, ARANESP 100 MCG/ML VIAL, ARANESP 150 MCG/0.3 ML SYRINGE, ARANESP 150 MCG/0.75 ML VIAL, ARANESP 200 MCG/0.4 ML SYRINGE, ARANESP 200 MCG/ML VIAL, ARANESP 25 MCG/0.42 ML SYRING, ARANESP 25 MCG/ML VIAL, ARANESP 300 MCG/0.6 ML SYRINGE, ARANESP 300 MCG/ML VIAL, ARANESP 40 MCG/0.4 ML SYRINGE, ARANESP 40 MCG/ML VIAL, ARANESP 500 MCG/1 ML SYRINGE, ARANESP 60 MCG/0.3 ML SYRINGE, ARANESP 60 MCG/ML VIAL Must provide current labwork (Hemoglobin, transferrin saturation, and ferritin) Must be prescribed by hematology/oncology or nephrology PAGE 6 LAST UPDATED 04/2016
7 ASTHMA THERAPY XOLAIR Must have documented diagnosis of asthma and must provide all pulmonary function tests from within the previous 3 months. Must provide clinical documentation of proper diagnosis Must be prescribed by a pulmonologist or an immunologist. PAGE 7 LAST UPDATED 04/2016
8 BONE MARROW TRANSPLANT MOZOBIL Must provide clinical documentation of proper diagnosis. PAGE 8 LAST UPDATED 04/2016
9 BOTOX BOTOX 100 UNITS VIAL Must provide clinical documentation of proper diagnosis. PAGE 9 LAST UPDATED 04/2016
10 CARDIOVASCULAR THERAPY AGENTS PULMONARY ARTERIAL HYPERTENSIVE AGENTS ADCIRCA, ADEMPAS, CIALIS 2.5 MG TABLET, CIALIS 5 MG TABLET, LETAIRIS, OPSUMIT, REMODULIN, SILDENAFIL, TRACLEER Must have documentation of Pulmonary Arterial Hypertension Group 1 or Benign Prostatic Hypertrophy. Must be prescribed by a Cardiologist or Pulmonologist. PAGE 10 LAST UPDATED 04/2016
11 CARIMUNE CARIMUNE NF NANOFILTERED Must provide current progress notes. PAGE 11 LAST UPDATED 04/2016
12 CELLCEPT CELLCEPT Must provide clinical documentation of proper diagnosis. Must be prescribed by a cardiac or hepatic transplant specialist, or other physician experienced in immunosuppresive therapy and management of kidney transplant patients. PAGE 12 LAST UPDATED 04/2016
13 CINRYZE CINRYZE 1. Patient is diagnosed with idiopathic angioedema or drug induced angioedema. Must provide clinical documentation detailing diagnosis, treatment history and disease history. Verify medication is being used for prophylaxis of HAE attacks Must be prescribed by or in consultation with an allergist, immunologist or hematologist. PAGE 13 LAST UPDATED 04/2016
14 CMV CIDOFOVIR 375 MG/5 ML VIAL, GANCICLOVIR SODIUM Documentation of CMV Diagnosis. PAGE 14 LAST UPDATED 04/2016
15 COPD THERAPY DALIRESP Must have documented diagnosis of COPD. Must have be prescribed by a pulmonologist. PAGE 15 LAST UPDATED 04/2016
16 DESMOPRESSIN DESMOPRESSIN 40 MCG/10 ML VIAL, DESMOPRESSIN AC 4 MCG/ML AMPUL, DESMOPRESSIN AC 4 MCG/ML VIAL Diagnosis of Hemophilia A with Factor VIII coagulant level greater than 5% or Von Willebrands Disease Type 1 PAGE 16 LAST UPDATED 04/2016
17 DIASTAT DIAZEPAM 10 MG RECTAL GEL SYST, DIAZEPAM 2.5 MG RECTAL GEL SYS, DIAZEPAM 20 MG RECTAL GEL SYST, DIAZEPAM 5 MG/ML ORAL CONC Must provide clinical documentation detailing the diagnosis and treatment history. Must be prescribed by a neurologist, psychiatrist, or addiction medicine specialist. PAGE 17 LAST UPDATED 04/2016
18 EXJADE EXJADE, FERRIPROX 500 MG TABLET Documentation of trial and failure of Desferal. Must be prescribed by Hematologist. PAGE 18 LAST UPDATED 04/2016
19 FDA CARBAGLU, CYSTAGON, CYTOVENE, ESBRIET, FARYDAK, GATTEX, HETLIOZ, JUXTAPID 10 MG CAPSULE, JUXTAPID 20 MG CAPSULE, JUXTAPID 5 MG CAPSULE, KORLYM, KYNAMRO, LENVIMA, NORTHERA, OFEV, RAVICTI, SIRTURO, TARGRETIN 1% GEL, VPRIV PAGE 19 LAST UPDATED 04/2016
20 FENTANYL FENTANYL CIT OTFC 1,200 MCG, FENTANYL CIT OTFC 1,600 MCG, FENTANYL CITRATE OTFC 200 MCG, FENTANYL CITRATE OTFC 400 MCG, FENTANYL CITRATE OTFC 600 MCG, FENTANYL CITRATE OTFC 800 MCG Must provide clinical documentation detailing diagnosis of Cancer and trial/failure of Fentanyl patches. PAGE 20 LAST UPDATED 04/2016
21 FIRAZYR FIRAZYR 1. Medication is being used for prophylaxis of HAE attacks. 2. Patient is diagnosed with idiopathic angioedema or drug induced angioedema. Must provide clinical documentation detailing diagnosis, treatment history and disease history. Must be prescribed by or in consultation with an allergist, immunologist or hematologist. PAGE 21 LAST UPDATED 04/2016
22 FLECTOR FLECTOR Must provide clinical documentation that 2 or more oral NSAIDs are not effective and/or the inability to take oral medications. PAGE 22 LAST UPDATED 04/2016
23 FORTEO FORTEO Cannot be used for longer then 2 years Must provide clinical documentation detailing the diagnosis and treatment history, documented trial and failure or intolerance to oral biphosphonates and injectable biphosphonates (including date range of therapy), BMD results confirming T-score of -2.5 or less,evidence of supplemental treatment with Calcium and Vitamin D. PAGE 23 LAST UPDATED 04/2016
24 GAMMAGARD BIVIGAM, GAMMAGARD LIQUID, GAMMAGARD S-D, PRIVIGEN Must provide current progress notes. PAGE 24 LAST UPDATED 04/2016
25 GROWTH DEFICIENCY GENOTROPIN, INCRELEX, OMNITROPE Must provide clinical documentation of Primary Growth Deficiency diagnosis PAGE 25 LAST UPDATED 04/2016
26 HARVONI HARVONI Request is for repeat course of treatment with Harvoni with an identical treatment regimen following failure of a full course of treatment 2. Autoimmune hepatitis 3. Request is for greater than 24 weeks of therapy Documented diagnosis of Genotype 1a, 1b, 4, 5, or 6 infection, lab report documenting viral load, detailed medical history of previous treatment. Must be prescribed by a gastroenterology, hepatology, or infectious disease PAGE 26 LAST UPDATED 04/2016
27 HEPATITIS B TYZEKA Lab tests indicating diagnosis of Hepatitis B. Active Hepatitis B. Active Inflammation (serum transaminases). Applies to sylatron and tyzeka. PAGE 27 LAST UPDATED 04/2016
28 HEPATITIS C PEGASYS, PEGINTRON 50 MCG KIT, PEGINTRON REDIPEN, REBETOL 40 MG/ML SOLUTION, RIBASPHERE 400 MG TABLET, RIBASPHERE 600 MG TABLET, RIBAVIRIN Documentation of Hepatitis C. Documentation of appropriate genotype. Member must be greater than 18 years old. Member must have a negative pregnancy test and use 2 forms of contraception during and for 6 months post therapy. PAGE 28 LAST UPDATED 04/2016
29 INTUNIV INTUNIV ER 3 MG TABLET, INTUNIV ER 4 MG TABLET Must provide clinical documentation of ADHD 17 and under PAGE 29 LAST UPDATED 04/2016
30 INVEGA INVEGA SUSTENNA 1. Member is not receiving concomitant treatment with Carbamazepine. 2. Members over 65 with dementia and psychosis. Must provide clinical documentation detailing diagnosis and treatment history, documented trial and failure of Risperdal and Zyprexa or Geodon. Must be 12 years or older. PAGE 30 LAST UPDATED 04/2016
31 IV ANTIBIOTICS CUBICIN, DORIBAX 500 MG VIAL, IMIPENEM-CILASTATIN SODIUM, PIPERACIL-TAZOBACT 2.25 GM VL, PIPERACIL-TAZOBACT GM VL, PIPERACIL-TAZOBACT 4.5 GM VIAL, PIPERACIL-TAZOBACT 40.5 GRAM, ZOSYN 2.25 GM/50 ML GALAXY BAG, ZOSYN GM/50 ML GALAXY, ZOSYN 4.5 GM/100 ML GALAXY BAG, ZYVOX 200 MG/100 ML IV SOLN, ZYVOX 600 MG/300 ML IV SOLN Current Culture and Sensitivity to support the use of the requested antibiotic and excludes use of non restricted antibiotics. Documentation of failure or rationale documenting why non-restricted antibiotics cannot be used. Must add current progress notes. Must be prescribed by an Infectious Disease Specialist. PAGE 31 LAST UPDATED 04/2016
32 IV ANTIFUNGAL ABELCET, AMBISOME, CANCIDAS, FLUCONAZOLE IN DEXTROSE, VORICONAZOLE 200 MG VIAL Current Culture and Sensitivity to support the use of the antifungal medication. Documentation of failure or rationale documenting why non-restricted antifungals cannot be used. Must add current progress notes. Must be prescribed by an Infectious Disease Specialist. PAGE 32 LAST UPDATED 04/2016
33 KALYDECO KALYDECO 150 MG TABLET Must provide clinical documentation detailing the diagnosis and treatment history, Genetic testing. Must be 6 years or older. PAGE 33 LAST UPDATED 04/2016
34 KINERET KINERET Diagnosis of Rheumatoid Arthritis. Failed intolerance to Methotrexate and Humira. PAGE 34 LAST UPDATED 04/2016
35 KUVAN KUVAN 100 MG TABLET Must have documentation of PKU PAGE 35 LAST UPDATED 04/2016
36 LEUKINE LEUKINE 250 MCG VIAL PAGE 36 LAST UPDATED 04/2016
37 LEUPROLIDE LEUPROLIDE 2WK 1 MG/0.2 ML KIT Must provide current progress notes. PAGE 37 LAST UPDATED 04/2016
38 LIDODERM LIDOCAINE 5% PATCH, LIDODERM Must provide clinical documentation of diagnosis of postherpetic neuralgia. PAGE 38 LAST UPDATED 04/2016
39 LOVENOX ENOXAPARIN 100 MG/ML SYRINGE, ENOXAPARIN 120 MG/0.8 ML SYR, ENOXAPARIN 150 MG/ML SYRINGE, ENOXAPARIN 30 MG/0.3 ML SYR, ENOXAPARIN 40 MG/0.4 ML SYR, ENOXAPARIN 60 MG/0.6 ML SYR, ENOXAPARIN 80 MG/0.8 ML SYR Documentation of intolerance or contraindication to Warfarin and Heparin -or- documentation of need for bridge to Coumadin -or- documentation of knee or hip arthroplasty. PAGE 39 LAST UPDATED 04/2016
40 LUMIZYME LUMIZYME, MYOZYME Confirmed diagnosis of Pompe's disease. PAGE 40 LAST UPDATED 04/2016
41 LUNG ENZYME THERAPY PROLASTIN C, ZEMAIRA Clinically documented alpha-1 antitrypsin deficiency. Clinical evidence of emphysema. PiZZ, PiZ() or Pi(,) phenotype (homozygous) alpha 1-antitrypsin deficiency or other phenotypes associated with serum alpha 1-antitrypsin concentrations less than 80 mg/dl. Serum alpha 1-antitrypsin (ATT) greater than 80mg/dl (35% of normal). Progressive panacinar emphysema with documented rate of decline in FEV1. Must be prescribed by a pulmonologist. PAGE 41 LAST UPDATED 04/2016
42 LUPUS BENLYSTA Documentation of diagnosis. Must be prescribed by a rheumatologist. PAGE 42 LAST UPDATED 04/2016
43 MULTAQ MULTAQ Patients with NYHA Class IV heart failure or NYHA Class II - III heart failure with a recent decompensation requiring hospitalization or referral to a specialized heart failure clinic. Second- or third- degree atrioventicular (AV) block or sick sinus synd Must provide clinical documentation of proper diagnosis. PAGE 43 LAST UPDATED 04/2016
44 MULTIPLE SCLEROSIS AMPYRA, AVONEX, AVONEX ADMINISTRATION PACK, AVONEX PEN, BETASERON, EXTAVIA, GILENYA, REBIF 22 MCG/0.5 ML SYRINGE, REBIF 44 MCG/0.5 ML SYRINGE, TYSABRI Must have documentation of multiple sclerosis diagnosis. Must be prescribed by neurologist. PAGE 44 LAST UPDATED 04/2016
45 NARCOLEPSY MODAFINIL, NUVIGIL All medically accepted indications not otherwise excluded from Part D Must provide clinical documentation detailing the diagnosis of Narcolepsy, Shift Work Sleep Disorder, or obstructive sleep apnea. If for Narcolepsy, must show trial and failure to at least one formulary/preferred agent, such as Methylphenidate or dextroamphetamine, or rationale as to why these agents cannot be used. If for obstructive sleep apnea, must show documentation of CPAP history and status. Must be 16 years or older. Must be prescribed by a Neurologist or Pulmonary specialist. PAGE 45 LAST UPDATED 04/2016
46 NEUMEGA NEUMEGA Must have received chemotherapy PAGE 46 LAST UPDATED 04/2016
47 NEUTROPENIC NEULASTA, NEUPOGEN Labs must be submitted that support the diagnosis of neutropenia. PAGE 47 LAST UPDATED 04/2016
48 NUEDEXTA NUEDEXTA Documented diagnosis of pseudobulbar affect (PBA) secondary to amyotrophic lateral sclerosis (ALS), multiple sclerosis (MS), or Bilateral Stroke. PAGE 48 LAST UPDATED 04/2016
49 NULOJIX NULOJIX Must provide clinical documentation of a new kidney transplant, patient must be Epstein-Barr virus seropositive Must be prescribed by a physician experienced in immunosuppresive therapy and management of kidney transplant patients PAGE 49 LAST UPDATED 04/2016
50 OCTREOTIDE OCTREOTIDE 1,000 MCG/5 ML VIAL, OCTREOTIDE 1,000 MCG/ML VIAL, OCTREOTIDE 5,000 MCG/5 ML VIAL, OCTREOTIDE ACET 0.05 MG/ML VL, OCTREOTIDE ACET 100 MCG/ML AMP, OCTREOTIDE ACET 100 MCG/ML VL, OCTREOTIDE ACET 200 MCG/ML VL, OCTREOTIDE ACET 50 MCG/ML AMP, OCTREOTIDE ACET 50 MCG/ML VIAL, OCTREOTIDE ACET 500 MCG/ML AMP, OCTREOTIDE ACET 500 MCG/ML VL Must provide current progress notes. PAGE 50 LAST UPDATED 04/2016
51 OLYSIO OLYSIO 1. Request is for repeat course of treatment with Olysio following failure of a full course of treatment with a regimen including Olysio 2. Autoimmune hepatitis. When used in combination with peginterferon alfa/ribavirin 4. Request is for greater than 24 weeks of therapy Documented diagnosis of Genotype 1 infection, lab report documenting viral load, detailed medical history of previous treatment. Must be prescribed by a gastroenterologist, Infectious Disease specialist or Hepatologist. PAGE 51 LAST UPDATED 04/2016
52 ORAL ANTIBIOTICS DIFICID, KETEK, XIFAXAN, ZYVOX 100 MG/5 ML SUSPENSION, ZYVOX 600 MG TABLET Current Culture and Sensitivity to support the use of the requested antibiotic and excludes use of non restricted antibiotics. Documentation of failure or rationale documenting why non-restricted oral antibiotics cannot be used. Must add current progress notes Must be prescribed by an Infectious Disease Specialist. PAGE 52 LAST UPDATED 04/2016
53 OSTEOPOROSIS PROLIA, RECLAST, XGEVA, ZOLEDRONIC ACID 5 MG/100 ML Must have labs and bone density scan submitted to establish proper diagnosis. PAGE 53 LAST UPDATED 04/2016
54 PART D VS PART B ACETYLCYSTEINE 10% VIAL, ACETYLCYSTEINE 20% VIAL, ALBUTEROL 2.5 MG/0.5 ML SOL, ALBUTEROL 5 MG/ML SOLUTION, ALBUTEROL SUL 0.63 MG/3 ML SOL, ALBUTEROL SUL 1.25 MG/3 ML SOL, ALBUTEROL SUL 2.5 MG/3 ML SOLN, ALOXI, AMIKACIN SULF 1 GRAM/4 ML VIAL, AMIKACIN SULF 500 MG/2 ML VIAL, AMINOSYN II 10% IV SOLUTION, AMINOSYN II 15% IV SOLUTION, AMINOSYN II 7% IV SOLUTION, AMINOSYN II WITH ELECTROLYTES, AMINOSYN M, AMINOSYN-HBC, AMINOSYN-PF, ANZEMET, ASTAGRAF XL, AZASAN, AZATHIOPRINE 50 MG TABLET, BUDESONIDE 0.25 MG/2 ML SUSP, BUDESONIDE 0.5 MG/2 ML SUSP, CALCITRIOL 1 MCG/ML SOLUTION, CALCIUM FOLINATE 10 MG/ML VIAL, CELLCEPT 200 MG/ML ORAL SUSP, CEREZYME, CESAMET, CLINIMIX, CLINIMIX E 2.75%-10% SOLUTION, CLINIMIX E 2.75%-5% SOLUTION, CLINIMIX E 4.25%-25% SOLUTION, CLINIMIX E 4.25%-5% SOLUTION, CLINIMIX E 5%-15% SOLUTION, CLINIMIX E 5%-20% SOLUTION, CLINIMIX E 5%-25% SOLUTION, CROMOLYN 20 MG/2 ML NEB SOLN, CYCLOPHOSPHAMIDE 25 MG CAPSULE, CYCLOPHOSPHAMIDE 50 MG CAPSULE, CYCLOSPORINE 100 MG CAPSULE, CYCLOSPORINE 100 MG/ML SOLN, CYCLOSPORINE 25 MG CAPSULE, CYCLOSPORINE 50 MG/ML AMPUL, CYCLOSPORINE 50 MG/ML VIAL, CYCLOSPORINE MODIFIED, DRONABINOL, ELITEK, EMEND 125 MG CAPSULE, EMEND 40 MG CAPSULE, EMEND 80 MG CAPSULE, ENGERIX-B ADULT, ENGERIX-B PEDIATRIC- ADOLESCENT, EPOGEN 10,000 UNITS/ML VIAL, EPOGEN 2,000 UNITS/ML VIAL, EPOGEN 20,000 UNITS/2 ML VIAL, EPOGEN 20,000 UNITS/ML VIAL, EPOGEN 3,000 UNITS/ML VIAL, EPOGEN 4,000 UNITS/ML VIAL, ERBITUX, FLUOROURACIL 1,000 MG/20 ML VL, FLUOROURACIL 2,500 MG/50 ML VL, FLUOROURACIL 2.5 GM/50 ML VIAL, FLUOROURACIL 5 GM/100 ML VIAL, FLUOROURACIL 5,000 MG/100 ML, FLUOROURACIL 500 MG/10 ML VIAL, GAMMAPLEX, GAMUNEX, GAMUNEX-C, GENGRAF, GRANISETRON HCL, HEPATAMINE, HERCEPTIN, IMURAN, INTRALIPID, IPRATROPIUM BR 0.02% SOLN, IPRATROPIUM- ALBUTEROL, LEUCOVORIN CAL 500 MG/50 ML VL, LEUCOVORIN CALCIUM 100 MG VIAL, LEUCOVORIN CALCIUM 200 MG VIAL, LEUCOVORIN CALCIUM 350 MG VIAL, LEUCOVORIN CALCIUM 50 MG VIAL, LEUCOVORIN CALCIUM 500 MG VL, LEVOCARNITINE 100 MG/ML SOLN, LEVOCARNITINE 330 MG TABLET, LEVOLEUCOVORIN CALCIUM, LUPRON DEPOT- PED MG KIT, METHOTREXATE 1 GM VIAL, METHOTREXATE 100 MG/4 ML VIAL, METHOTREXATE 2.5 MG TABLET, METHOTREXATE SODIUM, METOCLOPRAMIDE 10 MG/2 ML VIAL, MYCOPHENOLATE MOFETIL, MYCOPHENOLIC ACID, MYFORTIC, NALBUPHINE 10 PAGE 54 LAST UPDATED 04/2016
55 MG/ML AMPUL, NALBUPHINE 100 MG/10 ML VIAL, NALBUPHINE 20 MG/ML AMPUL, NALBUPHINE 200 MG/10 ML VIAL, NEBUPENT, NEORAL, NORMAL SALINE FLUSH SYRINGE, NUTRILIPID, ONDANSETRON 4 MG/2 ML AMPULE, ONDANSETRON 4 MG/5 ML SOLUTION, ONDANSETRON HCL 24 MG TABLET, ONDANSETRON HCL 4 MG TABLET, ONDANSETRON HCL 4 MG/2 ML VIAL, ONDANSETRON HCL 8 MG TABLET, ONDANSETRON ODT, OTREXUP 10 MG/0.4 ML AUTO-INJ, OTREXUP 15 MG/0.4 ML AUTO-INJ, OTREXUP 20 MG/0.4 ML AUTO-INJ, OTREXUP 25 MG/0.4 ML AUTO-INJ, PERJETA, PREMASOL, PRIVIGEN, PROCALAMINE, PROCRIT, PROGRAF, PROSOL, PULMOZYME, RAPAMUNE, RECOMBIVAX HB 10 MCG/ML VIAL, RECOMBIVAX HB 40 MCG/ML VIAL, RECOMBIVAX HB 5 MCG/0.5 ML VL, SANDIMMUNE, SANDOSTATIN LAR, SANDOSTATIN LAR DEPOT, SIROLIMUS 0.5 MG TABLET, SIROLIMUS 1 MG TABLET, SIROLIMUS 2 MG TABLET, SALINE 0.45% SOLN-EXCEL CON, SALINE 0.9% SOLN-EXCEL CONT, SODIUM CHLORIDE 0.45% SOLN, SODIUM CHLORIDE 0.45% SOLUTION, SODIUM CHLORIDE 0.9% 100 ML, SODIUM CHLORIDE 0.9% 250 ML, SODIUM CHLORIDE 0.9% 50 ML, SODIUM CHLORIDE 0.9% 500 ML, SODIUM CHLORIDE 0.9% IRRIG., SODIUM CHLORIDE 0.9% SOLN, SODIUM CHLORIDE 0.9% SOLUTION, SODIUM CHLORIDE 0.9% VIAL, SODIUM CHLORIDE 3% IV SOLN, SODIUM CHLORIDE 5% IV SOLN, SODIUM CL 2.5 MEQ/ML VIAL, TACROLIMUS 0.5 MG CAPSULE, TACROLIMUS 1 MG CAPSULE, TACROLIMUS 5 MG CAPSULE, TRAVASOL, TREXALL, TROPHAMINE, VECTIBIX, VIRAZOLE, ZOLEDRONIC ACID 4 MG VIAL, ZOLEDRONIC ACID 4 MG/5 ML VIAL, ZOMETA 4 MG/5 ML VIAL DETAILS This drug may be covered under Medicare Part B or D depending on the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination. PAGE 55 LAST UPDATED 04/2016
56 PHOTOCHEMOTHERAPY METHOXSALEN 10 MG CAPSULE, OXSORALEN-ULTRA Must be undergoing photochemotherapy PAGE 56 LAST UPDATED 04/2016
57 PICATO PICATO Must provide clinical documentation detailing the diagnosis and treatment history, documented trial and failure of Fluorouracil or Imiquimod. PAGE 57 LAST UPDATED 04/2016
58 PROMACTA PROMACTA 25 MG TABLET, PROMACTA 50 MG TABLET, PROMACTA 75 MG TABLET Must provide current progress notes. PAGE 58 LAST UPDATED 04/2016
59 RANEXA RANEXA Diagnosis of angina with documentation of failure of nitrocglycerin. PAGE 59 LAST UPDATED 04/2016
60 RISPERDAL RISPERDAL, RISPERDAL CONSTA, RISPERDAL M-TAB Must provide clinical documentation detailing the diagnosis and treatment history, documented trial and failure or inability to use oral antipsychotic agents. PAGE 60 LAST UPDATED 04/2016
61 SABRIL SABRIL Must provide clinical documentation of refractory complex partial seizures or infantile spasms, documented trial and failure of 2 other anticonvulsant agents, baseline eye exam. Must be prescribed by a specialist in the neurology field of study and be registered with SHARE program. PAGE 61 LAST UPDATED 04/2016
62 SIMULECT SIMULECT Must provide clinical documentation detailing the diagnosis and treatment history. Must be prescribed by a physician experienced in immunosuppresive therapy and management of kidney transplant patients PAGE 62 LAST UPDATED 04/2016
63 SOVALDI SOVALDI 1. Request is for repeat course of treatment 2. Autoimmune hepatitis. 3. When used in combination with peginterferon alfa/ribavirin 4. Request is for greater than 24 weeks of therapy Documented diagnosis of Genotype 1a, 1b, 2, 3, 4, 5, or 6 infection,lab report documenting viral load, detailed medical history of previous treatment. Must be prescribed by a gastroenterologist, Infectious Disease specialist or Hepatologist. PAGE 63 LAST UPDATED 04/2016
64 SYMLIN SYMLINPEN 120, SYMLINPEN 60 Diagnosis of Type II diabeteshba1c greater than 7.5%Failed to reach HbA1c goal with maximum dose of metformin (1,500mg/day) or TZD (pioglitazone at 45mg/day, rosiglitazone at 8mg/day), for at least 90 days over the past 120 days or Diagnosis of Type I diabetes who have failed to achieve desired glucose control despite optimal insulin therapy. PAGE 64 LAST UPDATED 04/2016
65 SYNAGIS SYNAGIS 1. Patient has hemodynamically insignificant heart disease (eg. Secundum atrialseptal defect, small ventricular septal defect, pullmonic stenosis, uncomplicatedaortic stenosis, mild coarctation of the aorta, and patent ductus arteriosus). Must provide clinical documentation of proper diagnosis. PAGE 65 LAST UPDATED 04/2016
66 THALOMID THALOMID Must provide clinical documentation of proper diagnosis. PAGE 66 LAST UPDATED 04/2016
67 TNF ACTEMRA 200 MG/10 ML VIAL, ACTEMRA 400 MG/20 ML VIAL, ACTEMRA 80 MG/4 ML VIAL, ENBREL, HUMIRA 20 MG/0.4 ML SYRINGE, HUMIRA 40 MG/0.8 ML SYRINGE, HUMIRA PEN, HUMIRA PEN CROHN'S-UC-HS, HUMIRA PEN PSORIASIS, ORENCIA 125 MG/ML SYRINGE, REMICADE, SIMPONI 50 MG/0.5 ML SYRINGE Must provide clinical documentation of proper diagnosis. Must be prescribed by a dermatologist, gastroenterologist or rheumatologist. PAGE 67 LAST UPDATED 04/2016
68 TOBI TOBI, TOBRAMYCIN 300 MG/5 ML AMPULE Must provide clinical documentation of Cystic Fibrosis diagnosis PAGE 68 LAST UPDATED 04/2016
69 VIEKIRA VIEKIRA PAK Request is for repeat course of treatment with Viekira with an identical treatment regimen following failure of a full course of treatment 2. Autoimmune hepatitis 3. Request is for greater than 24 weeks of therapy Documented diagnosis of Genotype 1 infection, lab report documenting viral load, detailed medical history of previous treatment. Must be prescribed by a gastroenterologist, hepatology, or infectious diease PAGE 69 LAST UPDATED 04/2016
70 XENAZINE XENAZINE Must provide clinical documentation of Huntingtons Disease diagnosis PAGE 70 LAST UPDATED 04/2016
71 ZYTIGA ZYTIGA Must provide clinical documentation of proper diagnosis. PAGE 71 LAST UPDATED 04/2016
72 PAGE 72 LAST UPDATED 04/2016
Drug Name Tier Drug Name Tier
Drug Name Tier Drug Name Tier ABELCET 100 MG/20 ML VIAL 4 ACETYLCYSTEINE 10% VIAL 2 ACETYLCYSTEINE 20% VIAL 2 ACYCLOVIR 1,000 MG/20 ML VIAL 2 ACYCLOVIR 500 MG/10 ML VIAL 2 ADRUCIL 500 MG/10 ML VIAL 2 ALBUTEROL
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acromegaly SIGNIFOR, SOMATULINE DEPOT SUBCUTANEOUS SYRINGE 120 MG/0.5 ML, 60 MG/0.2 ML, 90 MG/0.3 ML, SOMAVERT SUBCUTANEOUS RECON SOLN 15 MG, 20 MG, 25 MG, 30 MG All medically accepted indications not
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