ACAMPROSATE (CAMPRAL)
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1 ACAMPROSATE (CAMPRAL) ACAMPROSATE CALCIUM Creatinine clearance less than 30 PAGE 1 LAST UPDATED 06/2016
2 ADALIMUMAB (HUMIRA) HUMIRA, HUMIRA PEDIATRIC CROHN'S, HUMIRA PEN, HUMIRA PEN CROHN'S-UC-HS, HUMIRA PEN PSORIASIS must have inadequate response to at least one disease-modifying anti-rheumatic drug None PAGE 2 LAST UPDATED 06/2016
3 AMBRISENTAN (LETAIRIS) LETAIRIS Pregnancy enrollment in LEAP Program PAGE 3 LAST UPDATED 06/2016
4 APIXABAN (ELIQUIS) ELIQUIS PAGE 4 LAST UPDATED 06/2016
5 APOMORPHINE (APOKYN) APOKYN PAGE 5 LAST UPDATED 06/2016
6 APREMILAST (OTEZLA) OTEZLA PAGE 6 LAST UPDATED 06/2016
7 APREPITANT (EMEND) EMEND 125 MG CAPSULE, EMEND 40 MG CAPSULE, EMEND 80 MG CAPSULE, EMEND TRIPACK 3 months None PAGE 7 LAST UPDATED 06/2016
8 CINACALCET (SENSIPAR) SENSIPAR PAGE 8 LAST UPDATED 06/2016
9 CLOPIDOGREL (PLAVIX) CLOPIDOGREL 75 MG TABLET PAGE 9 LAST UPDATED 06/2016
10 DABIGATRAN (PRADAXA) PRADAXA. Beneficiary has tried and failed warfarin therapy PAGE 10 LAST UPDATED 06/2016
11 DALFAMPRIDINE (AMPYRA) AMPYRA PAGE 11 LAST UPDATED 06/2016
12 DAPTOMYCIN (CUBICIN) CUBICIN 2 weeks PAGE 12 LAST UPDATED 06/2016
13 DENOSUMAB (PROLIA) PROLIA PAGE 13 LAST UPDATED 06/2016
14 DESVENLAFAXINE SUCCINATE (PRISTIQ) DESVENLAFAXINE ER PAGE 14 LAST UPDATED 06/2016
15 DEXTROMETHORPHAN/QUINIDINE (NUEDEXTA) NUEDEXTA Amyotrophic Lateral Sclerosis and Multiple Sclerosis PAGE 15 LAST UPDATED 06/2016
16 DICLOFENAC (SOLARAZE) DICLOFENAC SODIUM 3% GEL PAGE 16 LAST UPDATED 06/2016
17 DICLOFENAC EPOLAMINE (FLECTOR) FLECTOR 2 weeks PAGE 17 LAST UPDATED 06/2016
18 DIMETHYL FUMARATE (TECFIDERA) TECFIDERA PAGE 18 LAST UPDATED 06/2016
19 DORNASE ALFA (PULMOZYME) PULMOZYME PAGE 19 LAST UPDATED 06/2016
20 DROXIDOPA (NORTHERA) NORTHERA PAGE 20 LAST UPDATED 06/2016
21 DULAGLUTIDE (TRULICITY) TRULICITY PAGE 21 LAST UPDATED 06/2016
22 ELTROMBOPAG (PROMACTA) PROMACTA PAGE 22 LAST UPDATED 06/2016
23 EMPAGLIFLOZIN (JARDIANCE) JARDIANCE Currently on other anti-diabetic agents. PAGE 23 LAST UPDATED 06/2016
24 ENOXAPARIN (LOVENOX) ENOXAPARIN SODIUM reduce frequency with creatinine clearance less than 30 Minimum of 5 days of therapy and may extend up to 35 days unless prescribed for a shorter duration None PAGE 24 LAST UPDATED 06/2016
25 EPOETIN (EPOGEN) 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 to be continued only if hemoglobin is 12 or less 6 months PAGE 25 LAST UPDATED 06/2016
26 EPOETIN (PROCRIT) PROCRIT bleeding, autoimmune hemolytic anemia, inufficient vitamin stores, uncontrolled HTN, cancer patients with radiation alone to be continued only if hemoglobin is 12 or less 6 months PAGE 26 LAST UPDATED 06/2016
27 EVEROLIMUS (ZORTRESS) ZORTRESS PAGE 27 LAST UPDATED 06/2016
28 FENTANYL LOZENGE 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 Opiod tolerant PAGE 28 LAST UPDATED 06/2016
29 FENTANYL TRANSDERMAL PATCH FENTANYL 100 MCG/HR PATCH, FENTANYL 12 MCG/HR PATCH, FENTANYL 25 MCG/HR PATCH, FENTANYL 50 MCG/HR PATCH, FENTANYL 75 MCG/HR PATCH Refractory or intolerant to oral pain management PAGE 29 LAST UPDATED 06/2016
30 FIDAXOMICIN (DIFICID) DIFICID 10 days PAGE 30 LAST UPDATED 06/2016
31 FILGRASTIM (NEUPOGEN) NEUPOGEN, ZARXIO not for afebrile neutropenia 6 months None PAGE 31 LAST UPDATED 06/2016
32 GOLIMUMAB (SIMPONI) SIMPONI, SIMPONI ARIA PAGE 32 LAST UPDATED 06/2016
33 IMIQUIMOD (ALDARA) IMIQUIMOD 5% CREAM PACKET 4 months PAGE 33 LAST UPDATED 06/2016
34 INFLIXIMAB (REMICADE) REMICADE None PAGE 34 LAST UPDATED 06/2016
35 INTERFERON BETA 1A (REBIF, AVONEX) AVONEX, AVONEX ADMINISTRATION PACK, AVONEX PEN, REBIF, REBIF REBIDOSE Neurologist 3 months PAGE 35 LAST UPDATED 06/2016
36 IVACAFTOR (KALYDECO) KALYDECO PAGE 36 LAST UPDATED 06/2016
37 LEDIPASVIR/SOFOSBUVIR (HARVONI) HARVONI 12 weeks in patients without cirrhosis, 24 weeks in patients with cirrhosis PAGE 37 LAST UPDATED 06/2016
38 LENALIDOMIDE (REVLIMID) REVLIMID 3 months PAGE 38 LAST UPDATED 06/2016
39 LEVOMILNACIPRAN (FETZIMA) FETZIMA PAGE 39 LAST UPDATED 06/2016
40 LINEZOLID (ZYVOX) LINEZOLID, LINEZOLID-0.9% NACL low tyramine diet 28 days PAGE 40 LAST UPDATED 06/2016
41 LOMITAPIDE MESYLATE (JUXTAPID) JUXTAPID PAGE 41 LAST UPDATED 06/2016
42 LUBIPROSTONE (AMITIZA) AMITIZA PAGE 42 LAST UPDATED 06/2016
43 MACITENTAN (OPSUMIT) OPSUMIT PAGE 43 LAST UPDATED 06/2016
44 MEGESTROL MEGESTROL ACET 40 MG/ML SUSP, MEGESTROL ACET 400 MG/10 ML Assess for weight gain after initial coverage duration 6 months PAGE 44 LAST UPDATED 06/2016
45 METHYLNALTREXONE (RELISTOR) RELISTOR PAGE 45 LAST UPDATED 06/2016
46 MIPOMERSEN SODIUM (KYNAMRO) KYNAMRO PAGE 46 LAST UPDATED 06/2016
47 MODAFANIL (PROVIGIL) MODAFINIL None PAGE 47 LAST UPDATED 06/2016
48 NINTEDANIB ESYLATE (OFEV) OFEV PAGE 48 LAST UPDATED 06/2016
49 PARATHYROID HORMONE (NATPARA) NATPARA PAGE 49 LAST UPDATED 06/2016
50 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, AMINOSYN II, AMINOSYN II WITH ELECTROLYTES, AMINOSYN M, AMINOSYN WITH ELECTROLYTES, AMINOSYN-HBC, AMINOSYN-PF, AMINOSYN-RF, AZATHIOPRINE 50 MG TABLET, AZATHIOPRINE SODIUM, BUDESONIDE 0.25 MG/2 ML SUSP, BUDESONIDE 0.5 MG/2 ML SUSP, BUDESONIDE 1 MG/2 ML INH SUSP, CARIMUNE NF NANOFILTERED, CELLCEPT 500 MG VIAL, CLINIMIX, CLINIMIX E 4.25%-10% SOLUTION, CLINISOL, 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, ELIGARD, ENGERIX-B ADULT, ENGERIX-B PEDIATRIC-ADOLESCENT, ETOPOSIDE 1,000 MG/50 ML VIAL, ETOPOSIDE 100 MG/5 ML VIAL, ETOPOSIDE 500 MG/25 ML VIAL, GAMMAGARD LIQUID, GAMMAGARD S-D, GAMMAPLEX, GAMUNEX, GAMUNEX-C, GENGRAF, HEPARIN 10,000 UNIT/10 ML VIAL, HEPARIN 30,000 UNIT/30 ML VIAL, HEPARIN 40,000 UNITS/4 ML VIAL, HEPARIN 50,000 UNITS/5 ML VIAL, HEPARIN SOD 1,000 UNIT/ML VIAL, HEPARIN SOD 10,000 UNIT/ML VL, HEPATAMINE, INTRALIPID, IPRATROPIUM BR 0.02% SOLN, IPRATROPIUM- ALBUTEROL, LEVALBUTEROL CONCENTRATE, LEVALBUTEROL 0.31 MG/3 ML SOL, LEVALBUTEROL 0.63 MG/3 ML SOL, LEVALBUTEROL 1.25 MG/3 ML SOL, LUPRON DEPOT, LUPRON DEPOT-PED, METHOTREXATE 1 GM VIAL, METHOTREXATE 100 MG/4 ML VIAL, METHOTREXATE 2.5 MG TABLET, METHOTREXATE SODIUM, MYCOPHENOLATE MOFETIL, NEBUPENT, NULOJIX, NUTRILIPID, ONDANSETRON 4 MG/5 ML SOLUTION, ONDANSETRON HCL 24 MG TABLET, ONDANSETRON HCL 4 MG TABLET, ONDANSETRON HCL 8 MG TABLET, ONDANSETRON ODT, PREMASOL, PRIVIGEN, PROCALAMINE, PROGRAF 5 MG/ML AMPULE, PROLEUKIN, PROSOL, RECOMBIVAX HB 10 MCG/ML VIAL, RECOMBIVAX HB 40 MCG/ML VIAL, RECOMBIVAX HB 5 MCG/0.5 ML VL, SULFAMETHOXAZOLE-TMP INJ VIAL, TOBRAMYCIN 300 MG/5 ML AMPULE, TRAVASOL, TROPHAMINE, VANCOMYCIN 1 GM ADD-VAN VIAL, VANCOMYCIN 1 GM VIAL, VANCOMYCIN 500 MG A-V VIAL, VANCOMYCIN 500 MG VIAL, VANCOMYCIN HCL 10 GM VIAL, VANCOMYCIN HCL 5 GM VIAL, VANCOMYCIN HCL 750 MG 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 50 LAST UPDATED 06/2016
51 PLERIXAFOR (MOZOBIL) MOZOBIL 4 days PAGE 51 LAST UPDATED 06/2016
52 POMALIDOMIDE (POMALYST) POMALYST 3 months PAGE 52 LAST UPDATED 06/2016
53 PREGABALIN (LYRICA) LYRICA PAGE 53 LAST UPDATED 06/2016
54 QUININE SULFATE QUININE SULFATE 324 MG CAPSULE 1 week PAGE 54 LAST UPDATED 06/2016
55 RIBAVIRIN ORAL REBETOL 40 MG/ML SOLUTION, RIBAVIRIN 3 months PAGE 55 LAST UPDATED 06/2016
56 RIFAXIMIN (XIFAXAN) XIFAXAN 200 MG TABLET 3 days PAGE 56 LAST UPDATED 06/2016
57 RIOCIGUAT (ADEMPAS) ADEMPAS PAGE 57 LAST UPDATED 06/2016
58 ROFLUMILAST (DALIRESP) DALIRESP PAGE 58 LAST UPDATED 06/2016
59 ROTIGOTINE (NEUPRO) NEUPRO PAGE 59 LAST UPDATED 06/2016
60 SARGRAMOSTIM (LEUKINE) LEUKINE 250 MCG VIAL 2 months PAGE 60 LAST UPDATED 06/2016
61 SELEGILENE TRANSDERMAL EMSAM PAGE 61 LAST UPDATED 06/2016
62 SILDENAFIL CITRATE (REVATIO) SILDENAFIL PAGE 62 LAST UPDATED 06/2016
63 SIMEPREVIR (OLYSIO) OLYSIO 12 or 24 weeks Duration depends on past medical history, cirrhosis history, and genotype PAGE 63 LAST UPDATED 06/2016
64 SIROLIMUS (RAPAMUNE) RAPAMUNE 1 MG/ML ORAL SOLN, SIROLIMUS 0.5 MG TABLET, SIROLIMUS 1 MG TABLET, SIROLIMUS 2 MG TABLET PAGE 64 LAST UPDATED 06/2016
65 SOFOSBUVIR (SOLVALDI) SOVALDI 12, 16, 24 or 48 weeks Consider genotype, cirrhosis status, previous failure of PEG-IFN/RBV/protease inhibitors/sofosbuvir, HCV in an allograft, decompensated cirrhosis, if awaiting transplant and concurrent treatment PAGE 65 LAST UPDATED 06/2016
66 SOMATROPIN GENOTROPIN, HUMATROPE, NORDITROPIN FLEXPRO, NORDITROPIN NORDIFLEX, NUTROPIN AQ, NUTROPIN AQ NUSPIN, OMNITROPE, SAIZEN, SEROSTIM, ZORBTIVE PAGE 66 LAST UPDATED 06/2016
67 TACROLIMUS (PROGRAF) ASTAGRAF XL, ENVARSUS XR, TACROLIMUS 0.5 MG CAPSULE, TACROLIMUS 1 MG CAPSULE, TACROLIMUS 5 MG CAPSULE PAGE 67 LAST UPDATED 06/2016
68 TADALAFIL (ADCIRCA) ADCIRCA PAGE 68 LAST UPDATED 06/2016
69 TASIMELTEON (HETLIOZ) HETLIOZ PAGE 69 LAST UPDATED 06/2016
70 TEDIZOLID PHOSPHATE (SIVEXTRO) SIVEXTRO 6 days PAGE 70 LAST UPDATED 06/2016
71 TERIFLUNOMIDE (AUBAGIO) AUBAGIO 1 year PAGE 71 LAST UPDATED 06/2016
72 TERIPARATIDE (FORTEO) FORTEO 2 years None PAGE 72 LAST UPDATED 06/2016
73 TETRAHYDROCANNABINOL DRONABINOL PAGE 73 LAST UPDATED 06/2016
74 TICAGRELOR (BRILINTA) BRILINTA PAGE 74 LAST UPDATED 06/2016
75 TIGECYCLINE (TYGACIL) TYGACIL 14 days PAGE 75 LAST UPDATED 06/2016
76 TOFACITINIB CITRATE (XELJANZ) XELJANZ, XELJANZ XR PAGE 76 LAST UPDATED 06/2016
77 TREPROSTINIL (REMODULIN) REMODULIN PAGE 77 LAST UPDATED 06/2016
78 VANCOMYCIN ORAL SOLUTION VANCOMYCIN HCL 125 MG CAPSULE, VANCOMYCIN HCL 250 MG CAPSULE 2 weeks None PAGE 78 LAST UPDATED 06/2016
79 VARENICLINE (CHANTIX) CHANTIX 0.5 MG TABLET, CHANTIX 1 MG CONT MONTH BOX, CHANTIX 1 MG TABLET, CHANTIX STARTING MONTH BOX 12 weeks None PAGE 79 LAST UPDATED 06/2016
80 VILAZODONE (VIIBRYD) VIIBRYD 10 MG TABLET, VIIBRYD MG STARTER PACK, VIIBRYD 20 MG TABLET, VIIBRYD 40 MG TABLET PAGE 80 LAST UPDATED 06/2016
81 VORTIOXETINE (BRINTELLIX) BRINTELLIX PAGE 81 LAST UPDATED 06/2016
82 PAGE 82 LAST UPDATED 06/2016
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
2010 Drugs Requiring Prior Authorization
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RAHF PFM ALPHANINE SD COAGULATION FACTOR IX J7193 COAGULATION FACTOR IX (RFIXFC)
INFECTIOUS DISEASE ACTIMMUNE INTERFERON GAMMA 1B J9216 ADVATE RAHF PFM ONCOLOGY ORAL AFINITOR EVEROLIMUS J7527 INFECTIOUS DISEASE ALFERON N INTERFERON ALFA N3 J9215 ALPHANATE VWF J7186 ALPHANINE SD J7193
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J1556 INJECTION, IMMUNE GLOBULIN (BIVIGAM) 500 MG $ J1559 INJECTION, IMMUNE GLOBULIN (HIZENTRA) 100 MG $14.364
G0333 INITIAL 30-DAY SUPPLY AS A BENEFICIARY $57.000 J0133 INJECTION, ACYCLOVIR 5 MG $0.470 J0285 INJECTION, AMPHOTERICIN B 50 MG $10.280 J0287 INJECTION, AMPHOTERICIN B LIPID COMPLEX 10 MG $21.850 J0288
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G0333 PHARMACY DISPENSING FEE FOR INHALATION DRUG(S); INITIAL 30-DAY SUPPLY AS A BENEFICIARY $57.000 J0133 INJECTION, ACYCLOVIR 5 MG $0.068 J0285 INJECTION, AMPHOTERICIN B 50 MG $32.987 J0287 INJECTION,
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G0333 PHARMACY DISPENSING FEE FOR INHALATION DRUG(S); INITIAL 30-DAY SUPPLY AS A BENEFICIARY $57.000 J0133 INJECTION, ACYCLOVIR 5 MG $0.048 J0285 INJECTION, AMPHOTERICIN B 50 MG $31.668 J0287 INJECTION,
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Abstral fentanyl citrate oral tablet Controlled Dangerous substance Actemra tocilizumab Monoclonal antibody Acthar corticotropin Hormone Actimmune interferon gamma 1b Interferon Actiq fentanyl citrate
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ADCIRCA ADCIRCA Coverage will be provided if the member has filled a prescription for sildenafil (at least a 30 day supply within the past 365 ) ELIDEL 76-F ELIDEL Coverage will be provided if the member
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MEDICATION(S) ORENCIA 125 MG/ML SYRINGE, ORENCIA 50 MG/0.4 ML SYRINGE, ORENCIA 87.5 MG/0.7 ML SYRINGE, ORENCIA CLICKJECT
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PRESCRIPTION DRUGS REQUIRING PRIOR AUTHORIZATION
Abstral fentanyl citrate oral tablet Controlled Dangerous substance Actemra tocilizumab Monoclonal antibody Acthar corticotropin Hormone Actimmune interferon gamma 1b Interferon Actiq fentanyl citrate
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BOSULIF BOSULIF Signed statement of diagnosis from the physician, hepatic panel and CBC, trial and failure ofofimiatinib or dasatinibi and documentation of a 90 day response 12/31/15 PAGE 1 LAST UPDATED
ARANESP ALBUMIN FREE ARANESP ALBUMIN FREE SURE ARICEPT ARICEPT ODT EXELON
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