Prior Authorization Requirements. Effective: 01/01/2016

Transcription

1 Effective: 01/01/2016 Updated 09/2015

2 ABILIFY MAINTENA ABILIFY MAINTENA DIAGNOSIS OF SCHIZOPHRENIA MUST BE 18 YEARS OF AGE OR OLDER 12 MONTHS DOCUMENTED HISTORY OF POOR ADHERENCE TO ORAL MEDICATIONS AND DOCUMENTATION THAT PATIENT EDUCATION TO IMPROVE ADHERENCE HAS BEEN ATTEMPTED. FAILURE ON, INTOLERANCE TO, OR CONTRAINDICATION TO TWO FORMULARY ALTERNATIVES (RISPERDAL CONSTA, ZYPREXA RELPREVV, INVEGA SUSTENNA), ONE OF WHICH MUST BE RISPERDAL CONSTA.

3 ABRAXANE ABRAXANE ALL MEDICALLY ACCEPTED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D DIAGNOSIS OF BREAST CANCER OR DIAGNOSIS OF LOCALLY ADVANCED OR METASTATIC NON-SMALL CELL LUNG CANCER (NSCLC) OR DIAGNOSIS OF METASTATIC ADENOCARCINOMA OF THE PANCREAS. HEMATOLOGIST OR ONCOLOGIST FOR BREAST CANCER - DOCUMENTATION OF FAILURE OF COMBINATION CHEMOTHERAPY FOR METASTATIC DISEASE OR RELAPSE WITHIN 6 MONTHS OF ADJUVANT CHEMOTHERAPY AND DOCUMENTATION OF FAILURE ON, INTOLERANCE TO, OR CONTRAINDICATION TO ANTHRACYCLINE AND DOCUMENTATION OF FAILURE ON, INTOLERANCE TO, OR CONTRAINDICATION TO STANDARD PACLITAXEL THERAPY. FOR NSCLC - DOCUMENTATION OF ABRAXANE USED AS FIRST-LINE TREATMENT IN COMBINATION WITH CARBOPLATIN WHO ARE NOT CANDIDATES FOR CURATIVE SURGERY OR RADIATION THERAPY. FOR ADENOCARCINOMA OF PANCREAS - DOCUMENTATION OF USE IN COMBINATION WITH GEMCITABINE.

4 ACTEMRA ACTEMRA DX OF RHEUMATOID ARTHRITIS MADE IN ACCORADANCE WITH THE AMERICAN COLLEGE OF RHEUMATOLOGY CRITERIA FOR THE CLASSIFICATION AND DIAGNOSIS OF RHEUMATOID ARTHRITIS AND DOCUMENATION OF THE NUMBER OF SWOLLEN OR TENDER JOINTS PRIOR TO INITIATING THERAPY WITH A MINIMUM DOCUMENTED JOINT COUNT OF FOUR OR MORE SWOLLEN OR TENDER JOINTS BASED ON A 28 JOINT COUNT OR SIX OR MORE SWOLLEN OR TENDER JOINTS BASED ON A JOINT COUNT. DX OF ACTIVE SYSTEMIC JUVENILE IDIOPATHIC ARTHRITIS (JIA) AND PRESCRIPTION WRITTEN FOR IV FORMULATION. DX OF ACTIVE POLYARTICULAR JUVENILE IDIOPATHIC ARTHRITIS WITH AT LEAST 5 SWOLLEN OR TENDER JOINTS AND PRESCRIPTION WRITTEN FOR IV FORMULATION. FOR JIA OR POLYARTICULAR JUVENILE IDIOPATHIC ARTHRITIS- MUST BE 2 YEARS OF AGE OR OLDER. FOR RA- MUST BE 18 YEARS OF AGE OR OLDER. RHEUMATOLOGIST 6 MONTHS INITIAL AND 1 YEAR CONTINUATION

5 Geisinger Health Plan FOR RA: FAILURE ON, INTOLERANCE TO, OR CONTRAINDICATION TO A MINIMUM 3 MONTH TRIAL OF HUMIRA AND ENBREL. FOR POLYARTICULAR JUVENILE IDIOPATHIC ARTHRITIS: FAILURE ON, INTOLERANCE TO, OR CONTRAINDICATION TO A MINIMUM 4 MONTH TRIAL OF HUMIRA AND ENBREL. FOR CONTINUED THERAPY. MEDICAL RECORD DOCUMENTATION SHOWING MAINTENANCE OR IMPROVEMENT OF CONDITION.

6 ACTIQ FENTANYL CITRATE DOCUMENTATION OF USE TO MANAGE BREAKTHROUGH CANCER PAIN IN PATIENTS WITH CANCER CONCOMITANT MORPHINE 60 MG/DAY OR MORE, TRANSDERMAL FENTANYL 25 MCG/H, OXYCODONE 30 MG/DAY, ORAL HYDROMORPHONE 8 MG/DAY, OR AN EQUIANALGESIC DOSE OF ANOTHER OPIOID FOR 1 WEEK OR LONGER.

7 ADCIRCA ADCIRCA DOCUMENTATION OF A DIAGNOSIS OF FUNCTIONAL CLASS 2,3, OR 4 PULMONARY ARTERIAL HYPERTENSION PULMONOLOGIST OR CARDIOLOGIST FAILURE ON, INTOLERANCE TO, OR CONTRAINDICATION TO SILDENAFIL AND LETAIRIS

8 ADEMPAS ADEMPAS WHO FUNCTIONAL CLASS II, III, OR IV SYMPTOMS AND EITHER DOCUMENTATION OF WHO GROUP 1 PULMONARY ARTERIAL HYPERTENSION OR CHRONIC THROMBOEMBOLIC PULMONARY HYPERTENSION (CTEPH) (WHO GROUP 4) WHICH IS INOPERABLE OR PREVIOUSLY TREATED SURGICALLY. CARDIOLOGIST OR PULMONOLOGIST 6 MONTHS CHRONIC-THROMBOEMBOLIC PULMONARY HYPERTENSION: DOCUMENTATION OF A BASELINE 6-MINUTE WALKING DISTANCE. 6 MONTH REAUTHORIZATION WILL REQUIRE DOCUMENTATION OF AN IMPROVEMENT IN 6-MINUTE WALKING DISTANCE FROM BASELINE OR IMPROVED OR STABLE DIAGNOSIS OF WHO FUNCTIONAL CLASS. PULMONARY ARTERIAL HYPERTENSION: DOCUMENTATION OF A BASELINE 6-MINUTE WALKING DISTANCE. FAILURE ON, INTOLERANCE TO, OR CONTRAINDICATION TO SILDENAFIL AND TRACLEER. 6 MONTH REAUTHORIZATION WILL REQUIRE DOCUMENTATION OF AN IMPROVEMENT IN 6- MINUTE WALKING DISTANCE FROM BASELINE OR IMPROVED OR STABLE DIAGNOSIS OF WHO FUNCTIONAL CLASS.

9 AFINITOR AFINITOR AFINITOR DISPERZ ALL MEDICALLY ACCEPTED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D DX OF RENAL CELL CARCINOMA. DX OF HORMONE-RECEPTOR POSITIVE, HER-2 NEGATIVE ADVANCED BREAST CANCER. DX OF PROGRESSIVE NEUROENDOCRINE TUMORS OF PANCREATIC ORIGIN (PNET) THAT IS UNRESCTABLE, LOCALLY ADVANCED OR METASTATIC. DX OF SUBEPENDYMAL GIANT CELL ASTROCYTOMA (SEGA) ASSOCIATED WITH TUBEROUS SCLEROSIS (TS) WHO REQUIRE THERAPEUTIC INTERVENTION BUT ARE NOT CANDIDATES FOR CURATIVE SURGICAL RESECTION. DX OF RENAL ANGIOMYOLIPOMA AND TUBUEROUS SCLEROSIS COMPLEX/SPORADIC LYMPHANGIOLEIOMYMATOSIS NOT REQUIRING IMMEDIATE SURGERY. ONCOLOGIST OR NEPHROLOGIST OR UROLOGIST 3 MONTHS FOR RENAL CELL CARCINOMA: THERAPEUTIC FAILURE ON, INTOLERANCE TO, OR CONTRAINDICATION TO SUTENT OR NEXAVAR. FOR BREAST CANCER: FAILURE ON, INTOLERANCE TO, OR CONTRAINDICATION TO PREVIOUS ENDOCRINE THERAPY TREATMENT AND AFINITOR MUST BE USED IN COMBINATION WITH AN

10 AROMATASE INHIBITOR. FOR RENAL ANGIOMYOLIPOMA AND TUBUEROUS SCLEROSIS COMPLEX/SPORADIC LYMPHANGIOLEIOMYMATOSIS: AT LEAST ONE ANGIOMYOLIPOMA OF GREATER THAN OR EQUAL TO 3CM IN LONGEST DIAMETER ON CT/MRI BASED ON LOCAL RADIOLOGY ASSESSMENT.

11 AKYNZEO AKYNZEO DOCUMENTATION OF USE FOR THE PREVENTION OF CHEMOTHERAPY-INDUCED NAUSEA AND VOMITING IN PATIENTS WHO ARE RECEIVING MODERATELY TO HIGHLY EMETOGENIC CHEMOTHERAPY, INCLUDING, BUT ARE NOT LIMITED TO REGIMENS CONTAINING BENDAMUSTINE, CARBOPLATIN, CISPLATIN, CYCLOPHOSPHAMIDE, DACARBAZINE, DOXORUBICIN, IFOSFAMIDE, IRINOTECAN, OXALIPLATIN, AND TEMOZOLOMIDE MUST BE 18 YEARS OF AGE OR OLDER

12 ALDURAZYME ALDURAZYME DX OF HURLER FORM OF MPS I OR HURLER-SCHEIE FORM OF MPS I OR SCHEIE FORM OF MPS WITH MODERATE TO SEVERE SYMPTOMS METABOLIC SPECIALIST WITH EXPERIENCE TREATING MUCOPOLYSACCHARIDOSIS

13 ALINIA ALINIA DOCUMENTATION OF DIARRHEA CAUSED BY GIARDIA LAMBLIA OR CRYPTOSPORIDIUM PARVUM

14 AMPYRA AMPYRA DIAGNOSIS OF REMITTING-REPLASING MS WITH DIFFICULTY AMBULATING WITH 25 FT TIMED GAIT TEST NEUROLOGIST 3 MONTHS CONCOMITANT THERAPY ON BETASERON, COPAXONE, OR AVONEX. REAUTHORIZATION WILL REQUIRE DOCUMENTATION OF AT LEAST A 10% IMPROVEMENT IN TIMED 25 FT GAIT TEST AS COMPARED TO BASE LINE.

15 ANTIPARKINSON AGENT HRM BENZTROPINE MESYLATE TRIHEXYPHENIDYL HCL DX OF EXTRAPYRAMIDAL SIDE EFFECTS (EPS) OR PARKINSON'S DISEASE ONLY APPLIES TO MEMBERS 65 YEARS OF AGE AND OLDER PRIOR AUTHORIZATION APPLIES ONLY TO MEMBERS 65 YEARS OF AGE AND OLDER WHO WILL BE EVALUATED FOR APPROPRIATE USE OF HIGH RISK MEDICATION. DIAGNOSIS OF EPS WILL REQUIRE FAILURE ON, INTOLERANCE TO, OR CONTRAINDICATION TO AMANTADINE. DIAGNOSIS OF PARKINSON'S WILL REQUIRE FAILURE ON, INTOLERANCE TO, OR CONTRAINDICATION TO TWO OF THE FOLLOWING: CARBIDOPA/LEVODOPA, PRAMIPEXOLE, ROPINIROLE.

16 APTIOM APTIOM DIAGNOSIS OF PARTIAL ONSET SEIZURES MUST BE 18 YEARS OF AGE OR OLDER NEUROLOGIST DOCUMENTATION OF FAILURE ON, INTOLERANCE TO, OR CONTRAINDICATION TO TWO FORMULARY ALTERNATIVES ONE OF WHICH MUST BE OXCARBAZEPINE. DOCUMENTATION OF CONCOMITANT USE WITH AT LEAST ONE OTHER FORMULARY ANTI-EPILEPTIC DRUG

17 ARALAST ARALAST NP PROLASTIN C DX OF PANACINAR EMPHYSEMA 12 MONTHS DOCUMENTATION OF A DECLINE IN FORCED EXPIRATORY VOLUME IN 1 SECOND (FEV1) DESPITE OPTIMAL MEDICAL THERAPY (BRONCHODILATORS, CORTICOSTEROIDS, OXYGEN IF INDICATED) AND DOCUMENTATION OF PHENOTYPE ASSOCIATED WITH CAUSING SERUM ALPHA 1-ANTITRYPSIN OF LESS THAN 80 MG/DL AND DOCUMENTATION OF AN ALPHA 1-ANTITRYPSIN SERUM LEVEL BELOW THE VALUE OF 35% OF NORMAL (LESS THAN 80 MG/DL).

18 ARRANON ARRANON ALL MEDICALLY ACCEPTED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D DIAGNOSIS OF T-CELL ACUTE LYMPHOBLASTIC LEUKEMIA OR T-CELL LYMPHOBLASTIC LYMPHOMA HEMATOLOGIST OR ONCOLOGIST 12 MONTHS DOCUMENTATION OF FAILURE TO RESPOND TO, OR RELAPSE FOLLOWING TREATMENT WITH A MINIMUM OF 2 CHEMOTHERAPY REGIMENS.

19 ARZERRA ARZERRA ALL MEDICALLY ACCEPTED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D DX OF CHRONIC LYMPHOCYTIC LEUKEMIA (CLL) HEMATOLOGIST OR ONCOLOGIST FAILURE ON, INTOLERANCE TO, OR CONTRAINDICATION TO CAMPATH AND FLUDARABINE OR RITUXAN, OR IN COMBINATION WITH CHLORAMBUCIL IN PREVIOUSLY UNTREATED PATIENTS WHEN FLUDARABINE BASED THERAPY IS INAPPROPRIATE.

20 ASPARAGINASE ERWINAZE ALL MEDICALLY ACCEPTED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D DOCUMENTATION OF TREATMENT OF PATIENT WITH ACUTE LYMPHOBLASTIC LEUKEMIA (ALL) WHO HAS DEVELOPED A HYPERSENITIVITY TO E.COLI DERIVED ASPARAGINASE (PEGASPARGASE) HEMATOLOGIST OR ONCOLOGIST 12 MONTHS

21 AUBAGIO AUBAGIO DIAGNOSIS OF RELAPSING FORM OF MULTIPLE SCLEROSIS NEUROLOGIST FAILURE ON, INTOLERANCE TO, OR CONTRAINDICATION TO BETASERON AND COPAXONE

22 AVASTIN AVASTIN ALL MEDICALLY ACCEPTED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D DX OF METASTATIC RENAL CELL CARCINOMA WHEN USED IN COMBINATION WITH INTERFERON ALFA. DX OF GLIOBLASTOMA AS A SINGLE AGENT WHERE CANCER HAS PROGRESSED AFTER PRIOR TREATMENT. DX OF METASTATIC COLORECTAL CANCER WHEN GIVEN WITH 5-FU BASED CHEMOTHERAPY FOR FIRST OR SECOND LINE TREATMENT. DX OF METASTATIC COLORECTAL CANCER WITH FLUOROPYRIMIDINE-IRINOTECAN OR FLUOROPYRIMIDINE-OXALIPLATIN BASED CHEMOTHERAPY FOR SECOND LINE TREATMENT IN PATIENTS WHO HAVE PROGRESSED ON A FIRST LINE AVASTIN CONTAINING REGIMEN. DX OF ADVANCED NON-SQUAMOUS NON-SMALL CELL LUNG CANCER WHEN GIVEN IN COMBINATION WITH CARBOPLATIN AND PACLITAXEL AS FIRST LINE THERAPY IN UNRESECTABLE, LOCALLY ADVANCED, RECURRENT OR METASTATIC DISEASE. DIAGNOSIS OF CERVICAL CANCER WHEN GIVEN IN COMBINATION WITH PACLITAXEL AND CISPLATIN OR PACLITAXEL AND TOPOTECAN FOR PERSISTENT, RECURRENT, OR METASTATIC DISEASE. DIAGNOSIS OF EPITHELIAL OVARIAN, FALLOPIAN TUBE OR PRIMARY PERITONEAL CANCER WHEN GIVEN IN COMBINATION WITH PACLITAXEL, PEGYLATED LIPOSOMAL DOXORUBICIN OR TOPOTECAN IN PLATINUM RESISTANT, RECURRENT DISEASE. HEMATOLOGIST OR ONCOLOGIST

23 12 MONTHS SUBSEQUENT APPROVAL AFTER 12 MONTHS WILL REQUIRE DOCUMENTATION OF CONTINUED DISEASE IMPROVEMENT OR LACK OF DISEASE PROGRESSION.

24 BANZEL BANZEL DX OF LENNOX-GASTAUT SYNDROME OR FOR USE IN INTRACTABLE EPILEPSY AS DEFINED AS FAILURE ON TWO FORMULARY SEIZURE MEDICATIONS MUST BE 1 YEAR OF AGE OR OLDER NEUROLOGIST

25 BELEODAQ BELEODAQ ALL MEDICALLY ACCEPTED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D DIAGNOSIS OF RELAPSED OR REFRACTORY PERIPHERAL T-CELL LYMPHOMA MUST BE 18 YEARS OF AGE OR OLDER ONCOLOGIST OR HEMATOLOGIST 12 MONTHS

26 BENLYSTA BENLYSTA DOCUMENTATION OF ACTIVE SYSTEMIC LUPUS ERYTHEMATOSUS AND DOCUMENTATION OF A POSITIVE ANA/ANTI-DSDNA ANTIBODY AND DOCUMENTATION OF BEING ON A STABLE TREATMENT REGIMEN WITH PREDNISONE, NSAID, ANTI-MALARIAL OR IMMUNOSUPPRESSANT AND NO DOCUMENTATION OF SEVERE NEPHRITIS OR CNS INVOLVEMENT RHEUMATOLOGIST 6 MONTHS REAUTHORIZATION WILL REQUIRE DOCUMENTATION SHOWING CLINICAL BENEIFT OF ONE OF THE FOLLOWING: IMPROVEMENT IN FUNCTIONAL IMPAIRMENT, DECREASE IN THE NUMBER OF EXACERBATIONS SINCE STARTING THERAPY, OR DECREASE IN THE DAILY REQUIRED DOSE OF ORAL CORTICOSTEROIDS

27 BETHKIS BETHKIS DX OF CYSTIC FIBROSIS PULMONOLOGIST OR INFECTIOUS DISEASE SPECIALIST FAILURE ON, INTOLERANCE TO, OR CONTRAINDICATION TO GENERIC TOBRAMYCIN INHALATION SOLUTION

28 BONIVA IV IBANDRONATE SODIUM DX OF OSTEOPOROSIS IN POSTMENOPAUSAL WOMEN INTOLERANCE TO ORAL BIPHOSPHONATES OR INABILITY TO REMAIN IN AN UPRIGHT POSITION FOR A MINIMUM OF MINUTES AFTER INGESTION OR DISRUPTION OF THE ALIMENTARY TRACT DUE TO ANY OF THE FOLLOWING REASONS WHICH PRECLUDES THE USE OF ORAL BISPHOSPHONATES: OBSTRUCTING STRICTURE OR NEOPLASM OF THE ESOPHAGUS, STOMACH OR INTESTINE OR SHORT BOWEL SYNDROME SECONDARY TO EXTENSIVE SMALL BOWEL RESECTION OR MOTILITY DISORDER OR MALABSORPTION SECONDARY TO ENTEROVESICAL, ENTEROCUTANEOUS OR ENTEROCOLIC FISTULAS OR PROLONGED PARALYTIC ILEUS FOLLOWING SURGERY OR INJURY AND FAILURE ON, INTOLERANCE TO, OR CONTRAINDICATION TO RECLAST. THIS DRUG MAY BE EITHER BUNDLED WITH AND COVERED UNDER END STAGE RENAL DISEASE DIALYSIS RELATED SERVICES OR COVERED UNDER MEDICARE D DEPENDING UPON THE CIRCUMSTANCES. INFORMATION MAY NEED TO BE SUBMITTED DESCRIBING THE USE AND SETTING OF THE DRUG TO MAKE THE DETERMINATION.

29 BOSULIF BOSULIF ALL MEDICALLY ACCEPTED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D DOCUMENTATION OF CHRONIC, ACCELERATED, OR BLAST PHASE PH POSITIVE CHRONIC MYELOGENOUS LEUKEMIA (CML) HEMATOLOGIST OR ONCOLOGIST 3 MONTHS FAILURE ON, INTOLERANCE TO, OR CONTRAINDICATION TO ONE OF THE FOLLOWING PRIOR THERAPIES GLEEVEC, SPRYCEL, OR TASIGNA

30 BRINTELLIX BRINTELLIX DIAGNOSIS OF MAJOR DEPRESSIVE DISORDER MUST BE AT LEAST 18 YEARS OF AGE DOCUMENTATION OF FAILURE ON, INTOLERANCE TO, OR CONTRAINDICATION TO AT LEAST TWO ANTIDEPRESSANT CLASSES.

31 BROVANA BROVANA DX OF COPD MUST BE 18 YEARS OF AGE OR OLDER FAILURE ON, INTOLERANCE TO, OR CONTRAINDICATION TO FORADIL AND SEREVENT OR DOCUMENTATION OF INABILITY TO USE AN INHALER.

32 BUTRANS BUTRANS DX OF MODERATE TO SEVERE CHRONIC PAIN REQUIRING A CONTINUOUS, AROUND-THE-CLOCK OPIOID ANALGESIC FOR AN EXTENDED PERIOD OF TIME. FAILURE ON, INTOLERANCE TO, OR CONTRAINDICATION TO TWO FORMULARY OPIOIDS, ONE OF WHICH MUST BE MORPHINE SULFATE ER.

33 BVD ONLY ABELCET ACETYLCYSTEINE ACYCLOVIR SODIUM ADRUCIL ALBUTEROL SULFATE AMBISOME AMINOSYN II AMINOSYN II WITH ELECTROLYTES AMINOSYN M AMINOSYN WITH ELECTROLYTES AMINOSYN-HBC AMINOSYN-PF AMINOSYN-RF AMPHOTERICIN B ANZEMET ASTAGRAF XL AZASAN AZATHIOPRINE BCG (TICE STRAIN) BLEOMYCIN SULFATE BUDESONIDE CELLCEPT CLADRIBINE CLINISOL CROMOLYN SODIUM CYCLOPHOSPHAMIDE CYCLOSPORINE CYCLOSPORINE MODIFIED CYTARABINE DEXTROSE IN WATER DOXORUBICIN HCL ENGERIX-B ADULT ENGERIX-B PEDIATRIC-ADOLESCENT FLUOROURACIL FOSCARNET SODIUM GANCICLOVIR SODIUM GENGRAF GRANISETRON HCL HERCEPTIN IFOSFAMIDE IMOVAX RABIES VACCINE INTRALIPID IPRATROPIUM BROMIDE IPRATROPIUM-ALBUTEROL KEPIVANCE METHOTREXATE MITOMYCIN MYCOPHENOLATE MOFETIL MYCOPHENOLIC ACID NEBUPENT NUTRILIPID ONDANSETRON HCL ONDANSETRON ODT PREMASOL PROGRAF PROSOL PULMICORT RABAVERT RAPAMUNE RECOMBIVAX HB SIMULECT SIROLIMUS TACROLIMUS TRAVASOL TROPHAMINE VINBLASTINE SULFATE VINCASAR PFS VINCRISTINE SULFATE 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.

34 CARBAGLU CARBAGLU DOCUMENTATION OF A DIAGNOSIS OF HYPERAMMONEMIA DUE TO THE DEFICIENCY OF THE HEPATIC ENZYME N-ACETYLGLUTAMATE SYNTHASE (NAGS) METABOLIC DISORDER SPECIALIST 6 MONTHS

35 CEREZYME CEREZYME DOCUMENTATION OF A DIAGNOSIS OF TYPE 1 GAUCHER DISEASE ALONG WITH AT LEAST ONE OF THE FOLLOWING CONDITIONS: ANEMIA, THROMBOCYTOPENIA, BONE DISEASE, HEPATOMEGALY OR SPLENOMEGALY METABOLIC SPECIALIST WITH EXPERIENCE TREATING GAUCHER DISEASE FAILURE ON, INTOLERANCE TO, OR CONTRAINDICATION TO ELELYSO FOR THOSE 4 YEARS OF AGE AND OLDER

36 CIALIS CIALIS DOCUMENTATION OF A DIAGNOSIS OF BENIGN PROSTATIC HYPERPLASIA (BPH) FAILURE ON, INTOLERANCE TO, OR CONRAINDICATION TO ONE FORMULARY 5- ALPHA REDUCTASE INHIBITOR (FINASTERIDE OR DUTASTERIDE) AND ONE FORMULARY ALPHA-1 ADRENERIGIC BLOCKER (ALFUZOSIN, TAMSULOSIN, DOXAZOSIN, TERAZOSIN)

37 CLOLAR CLOLAR ALL MEDICALLY ACCEPTED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D DX OF RELAPSED OR REFRACTORY ACUTE LYMPHOBLASTIC LEUKEMIA 1 TO 21 YEARS OF AGE HEMATOLOGIST OR ONCOLOGIST FAILURE ON, INTOLERANCE TO, OR CONTRAINDICATION TO TWO PRIOR TREATMENT REGIMENS

38 CLOMIPRAMINE HRM CLOMIPRAMINE HCL ONLY APPLIES TO MEMBERS 65 YEARS OF AGE AND OLDER PRIOR AUTHORIZATION APPLIES ONLY TO MEMBERS 65 YEARS OF AGE AND OLDER WHO WILL BE EVALUATED FOR APPROPRIATE USE OF HIGH RISK MEDICATION AND WILL FAILURE ON, INTOLERANCE TO, OR CONTRAINDICATION TO TWO OF THE FOLLOWING: FLUOXETINE, FLUVOXAMINE, SERTRALINE, PAROXETINE

39 COMETRIQ COMETRIQ ALL MEDICALLY ACCEPTED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D DIAGNOSIS OF PROGRESSIVE METASTATIC MEDULLARY THYROID CANCER ONCOLOGIST

40 CORLANOR CORLANOR DOCUMENTATION OF STABLE, SYMPTOMATIC HEART FAILURE WITH A LEFT VENTRICULAR EJECTION FRACTION LESS THAN OR EQUAL TO 35% AND DOCUMENTATION OF BEING IN SINUS RHYTHM WITH RESTING HEART RATE GREATER THAN OR EQUAL TO 70 BEATS PER MINUTE AND DOCUMENTATION OF HOSPITALIZATION FOR WORSENING HEART FAILURE WITHIN THE PREVIOUS 12 MONTHS CARDIOLOGIST FAILURE ON, INTOLERANCE TO, OR CONTRAINDICATION TO THE MAXIMUM TOLERATED DOSES OF TWO FORMULARY BETA-BLOCKERS ONE OF WHICH MUST BE CARVEDILOL

41 CORTICOSTEROID B VERSUS D DETERMINATION A-HYDROCORT CORTISONE ACETATE DEXAMETHASONE DEXAMETHASONE SODIUM PHOSPHATE HYDROCORTISONE METHYLPREDNISOLONE METHYLPREDNISOLONE ACETATE METHYLPREDNISOLONE SOD SUCC PREDNISOLONE SODIUM PHOSPHATE PREDNISONE SOLU-MEDROL VERIPRED 20 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.

42 CRIZOTINIB XALKORI ALL MEDICALLY ACCEPTED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D DIAGNOSIS OF LOCALLY ADVANCED OR METASTATIC NON-SMALL CELL LUNG CANCER (NSCLC) THAT IS ANAPLASTIC LYMPHOMA KINASE (ALK) POSITIVE AS DETECTED BY AN FDA APPROVED TEST ONCOLOGIST 6 MONTHS THE FDA APPROVED TEST TO MAKE ALK POSITIVE DETERMINATION IS THE VYSIS ALK BREAK-APART FISH PROBE KIT

43 DACOGEN DECITABINE ALL MEDICALLY ACCEPTED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D DOCUMENTATION OF MYELODYSPLASTIC SYNDROME (MDS) INCLUDING PREVIOUSLY TREATED AND UNTREATED, DE NOVO AND SECONDARY MDS OF ALL FRENCH-AMERICAN-BRITISH SUBTYPES (REFRACTORY ANEMIA, REFRACTORY ANEMIA WITH RINGED SIDEROBLASTS, REFRACTORY ANEMIA WITH EXCESS BLASTS, REFRACTORY ANEMIA WITH EXCESS BLASTS IN TRANSFORMATION, AND CHRONIC MYELOMONOCYTIC LEUKEMIA) AND INTERMEDIATE-1, INTERMEDIATE- 2, AND HIGH RISK INTERNATIONAL PROGNOSTIC SCORING SYSTEM GROUPS HEMATOLOGIST OR ONCOLOGIST 12 MONTHS FAILURE ON, INTOLERANCE TO, OR CONTRAINDICATION TO VIDAZA

44 DALIRESP DALIRESP DIAGNOSIS OF COPD ASSOCIATED WITH CHRONIC BRONCHITIS CONCOMITANT USE OF, FAILURE ON, INTOLERANCE TO, OR CONTRAINDICATION TO SPIRIVA AND ONE LONG ACTING BETA AGONISTS.

45 DEMSER DEMSER TREATMENT OF PHEOCHROMOCYTOMA PREOPERATIVELY. TREATMENT OF PHEOCHROMOCYTOMA IN MANAGEMENT OF PATIENTS WHEN SURGERY IS CONTRAINDICATED. CHRONIC TREATMENT OF MALIGNANT PHEOCHROMOCYTOMA.

46 DUAVEE DUAVEE DOCUMENTATION OF AN INTACT UTERUS. DOCUMENTATION OF USE FOR ABNORMAL VASOMOTOR FUNCTION OR PREVENTION OF POSTMENOPAUSAL OSTEOPOROSIS AGE LESS THAN 75 YEARS FOR ABNORMAL VASOMOTOR FUNCTION: FAILURE ON, INTOLERANCE TO, OR CONTRAINDICATION TO FEMRING. FOR PREVENTION OF POSTMENOPAUSAL OSTEOPOROSIS: FAILURE ON, INTOLERANCE TO, OR CONTRAINDICATION TO TWO OF THE FOLLOWING: ALENDRONATE, IBANDRONATE, RALOXIFENE, RISEDRONATE.

47 ELAPRASE ELAPRASE DX OF HUNTER'S SYNDROME (MPS II) METABOLIC SPECIALIST WITH EXPERIENCE TREATING MPS II

48 ELELYSO ELELYSO DIAGNOSIS OF TYPE 1 GAUCHER DISEASE WITH AT LEAST ONE OF THE FOLLOWING - ANEMIA, THROMBOCYTOPENIA, BONE DISEASE, HEPATOMEGALY OR SPLENOMEGALY METABOLIC SPECIALIST WITH EXPERIENCE TREATING GAUCHER DISEASE

49 ELIDEL ELIDEL DX OF ATOPIC DERMATITIS DERMATOLOGIST OR ALLERGIST FAILURE ON, INTOLERANCE TO OR CONTRAINDICATION TO AT LEAST 2 FORMULARY TOPICAL CORTICOSTEROIDS UNLESS INADVISABLE DUE TO RISKS (SUCH AS USE ON SENSITIVE SKIN AREAS (FACE, AXILLAE, GROIN))

50 ELITEK ELITEK DX OF HYPERURICEMIA IN PATIENTS WITH LEUKEMIA, LYMPHOMA, AND SOLID TUMOR MALIGNANCIES HEMATOLOGIST OR ONCOLOGIST 1 COURSE OF THERAPY (5 DAYS) DOCUMENTATION OF A HIGH RISK OF TUMOR LYSIS SYNDROME CHARACTERIZED BY ELEVATED SERUM CREATININE OR LEUKEMIAS WITH VERY HIGH WHITE BLOOD CELL COUNTS OF GREATER THAN OR EQUAL TO 25,000 / MM(3) OR BURKETTE'S LYMPHOMA OR T-CELL NON-HODGKIN'S LYMPHOMA OR SERUM URIC ACID LEVEL GREATER THAN OR EQUAL TO 8 MG/DL AND FAILURE ON, INTOLERANCE TO, OR CONTRAINDICATION TO ORAL OR INJECTABLE ALLOPURINOL

51 EMEND EMEND CHEMOTHERAPY REGIMEN WITH MODERATE TO HIGH EMETOGENIC POTENTIAL OR INDICATION OF POSTOPERATIVE NAUSEA/VOMITING. HEMATOLOGIST, ONCOLOGIST, SURGEON 12 MONTHS MUST BE USED IN COMBINATION WITH OTHER ORAL ANTIEMETIC AGENTS WHEN USED FOR THE PREVENTION OF CHEMOTHERAPY INDUCED NAUSEA

52 EPOGEN EPOGEN ALL MEDICALLY ACCEPTED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D FOR NON-SURGICAL INDICATIONS: HEMOGLOBIN MUST BE LESS THAN 11GM/DL FOR NEW STARTS OR LESS THAN 12GM/DL FOR CONTINUATION OF THERAPY. DOCUMENTATION OF ADEQUATE IRON STORES W/ SERUM FERRITIN GREATER THAN 100 NG/ML OR TRANSFERRIN LEVEL SATURATION GREATER THAN 20%. TX OF SYMPTOMATIC ANEMIA OF CHRONIC RENAL INSUFFICIENCY, CHRONIC RENAL FAILURE, INCLUDING ESRD. TX OF SYMPTOMATIC ANEMIA IN AZT TREATED HIV INFECTED INDIVIDUALS - MUST HAVE ENDOGENOUS ERYTHROPOIETIN LEVELS OF 500MU/ML OR LESS AND AZT DOSES OF 4200MG/WEEK OR LESS. TX OF ANEMIA IN NON-HEMATOLOGIC MALIGNANCY - MUST BE ON ANEMIA CAUSING CHEMO OR RECEIVED ANEMIA INDUCING CHEMO IN LAST 3 MONTHS. TX OF SYMPTOMATIC ANEMIA SECONDARY TO MDS - BASELINE ENDOGENOUS ERYTHROPOEITIN LEVEL OF 500MU/ML OR LESS. TX OF SYMPTOMATIC ANEMIA OF CHRONIC DISEASE - SEVERE COMORBIDITY AND IMPAIRMENTS TO ADL, EXERCISE INTOLERANCE, TACHYCARDIA AND SOB WITH MINIMAL ACTIVITY. TX OF ANEMIA IN MULTIPLE MYELOMA - DOCUMENTATION OF CHEMO OR TRANSFUSION DEPENDENCE OR RENAL INSUFFICIENCY. 6 MONTHS

53 Geisinger Health Plan FOR SURGICAL INDICATIONS: HEMOGLOBIN MUST BE GREATER THAN 10GM/DL BUT LESS THAN 13GM/DL. FOR ALLOGENEIC BLOOD TRANSFUSION IN ANEMIC INDIVIDUALS UNDERGOING SURGERY IN ELECTIVE NON CARDIAC, NON-VASCULAR SURGERY WHERE ANTICIPATED BLOOD LOSS IS GREATER THAN 2 UNITS AND NEED FOR TRANSFUSION IS ANTICIPATED. TREATMENT OF ANEMIC PATIENTS WHO ARE AT HIGH RISK FOR PERI-OPERATIVE BLOOD LOSS FROM ELECTIVE, NON-CARDIAC, OR NON-VASCULAR SURGERY TO REDUCE THE NEED FOR ALLOGENIC BLOOD TRANSFUSIONS.THIS DRUG MAY BE EITHER BUNDLED WITH AND COVERED UNDER END STAGE RENAL DISEASE DIALYSIS RELATED SERVICES OR COVERED UNDER MEDICARE D DEPENDING UPON THE CIRCUMSTANCES. INFORMATION MAY NEED TO BE SUBMITTED DESCRIBING THE USE AND SETTING OF THE DRUG TO MAKE THE DETERMINATION.

54 ERAXIS ERAXIS (WATER DILUENT) NON-NEUTROPENIC PATIENT WITH DX OF CANDIDEMIA OR OTHER CANDIDA INFECTION (OTHER THAN ENDOCARDITIS, OSTEOMYELITIS OR MENINGITIS). 17 YEARS OF AGE OR OLDER INFECTIOUS DISEASE SPECIALIST 8 WEEKS (TWO COURSES OF THERAPY) FOR A DIAGNOSIS OF ESOPHAGEAL CANDIDIASIS - FAILURE ON, INTOLERANCE TO, OR CONTRAINDICATION TO FLUCONAZOLE THERARPY

55 ERBITUX ERBITUX ALL MEDICALLY ACCEPTED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D DX OF COLORECTAL CANCER WITH DOCUMENTATION OF KRAS MUTATION NEGATIVE (WILD-TYPE), EGFR EXPRESSING, METASTATIC COLORECTAL CANCER AS DETERMINED BY FDA APPROVED TESTS AND DOCUMENTATION OF ONE OF THE FOLLOWING: USED IN COMBO WITH FOLFIRI FOR FIRST LINE TREATMENT OR MONOTHERAPY FOR EGFR-EXPRESSING METASTATIC COLORECTAL CANCER AFTER FAILURE OF BOTH IRINOTECAN AND OXALIPLATIN BASED REGIMENS OR AS AN ADJUNT IN COMBO WITH IRINOTECAN IN IRINOTECAN REFRACTORY EGFR- EXPRESSING METASTATIC COLORECTAL CANCER. DX OF HEAD AND NECK CANCER AND DOCUMENTATION OF ONE OF THE FOLLOWING: IN COMBO WITH RADIATION THERAPY FOR FIRST LINE TREATMENT OF LOCALLY OR REGINALLY ADVANCED SQUAMOUS CELL CARCINOMA OF THE HEAD AND NECK (SCCHN) OR IN COMBO WITH PLATINUM-BASED THERAPY WITH 5-FU FOR THE TREATMENT OF PATIENTS WITH RECURRENT LOCOREGIONAL DISEASE OR METASTATIC SQUAMOUS CELL CARCINOMA OF THE HEAD AND NECK OR AS A SINGLE AGENT IN RECURRENT OR METASTATIC SCCHN WHERE PRIOR PLATINUM-BASED CHEMO HAS FAILED. HEMATOLOGIST OR ONCOLOGIST 12 MONTHS

56 FOR COLON CANCER: NO DOCUMENTATION OF PRIOR TREATMENT WITH PANITUMUMAB OR CETUXIMAB OR NO DOCUMENTATION OF KRAS MUTATIONS IN CODON 12 OR 13. SUBSEQUENT APPROVAL AFTER 12 MONTHS WILL REQUIRE DOCUMENTATION OF CONTINUED DISEASE IMPROVEMENT OR LACK OF DISEASE PROGRESSION.

57 ESBRIET ESBRIET DOCUMENTATION OF IDIOPATHIC PULMONARY FIBROSIS (IPF) CONFIRMED BY EITHER A USUAL INTERSTITIAL PNEUMONIA PATTERN ON HIGH RESOLUTION CT SCAN OR BOTH HRCT AND SURGICAL LUNG BIOPSY PATTERN SUGGESTIVE OF IPF OR PROBABLE IPF MADE BY AN INTERDISCIPLINARY TEAM INCLUDING, BUT NOT LIMITED TO SPECIALISTS FROM PULMONARY MEDICINE, RADIOLOGY, THORACIC SURGERY, PATHOLOGY OR RHEUMATOLOGY AND DOCUMENTATION THAT THERE ARE NO OTHER KNOWN CAUSES OF INTERSTITIAL LUNG DISEASE SUCH AS DOMESTIC AND OCCUPATIONAL ENVIRONMENTAL EXPOSURES, CONNECTIVE TISSUE DISEASE OR DRUG TOXICITY AND DOCUMENTATION THAT THE PATIENT WAS TAUGHT PULMONARY REHABILITATION TECHNIQUES AND DOCUMENTATION THAT MEDICATION IS NOT BEING USED IN COMBINATION WITH NINTEDANIB MUST BE 18 YEARS OF AGE OR OLDER PULMONOLOGIST

58 ESRD B VERSUS D DETERMINATION CALCITRIOL DOXERCALCIFEROL HECTOROL HEPARIN SODIUM LEVOCARNITINE LIDOCAINE LIDOCAINE HCL LIDOCAINE-PRILOCAINE MIACALCIN PAMIDRONATE DISODIUM PARICALCITOL ZEMPLAR 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.

59 ESTROGENS HRM (ORAL AND TOPICAL PATCH PRODUCTS ONLY) ESTRADIOL ESTRADIOL-NORETHINDRONE ACETAT ESTROPIPATE JINTELI LOPREEZA MENEST MIMVEY MIMVEY LO NORETHINDRON-ETHINYL ESTRADIOL PREMARIN PREMPHASE PREMPRO ONLY APPLIES TO MEMBERS 65 YEARS OF AGE AND OLDER PRIOR AUTHORIZATION APPLIES ONLY TO MEMBERS 65 YEARS OF AGE AND OLDER WHO WILL BE EVALUATED FOR APPROPRIATE USE OF HIGH RISK MEDICATION. DX OF ABNORMAL VASOMOTOR FUNCTION WILL REQUIRE FAILURE ON, INTOLERANCE TO, OR CONTRAINDICATION TO FEMRING. DX OF VAGINAL/VULVAR ATROPHY WILL REQUIRE FAILURE ON, INTOLERANCE TO, OR CONTRAINDICATION TO ONE OF THE FOLLOWING: ESTRACE VAGINAL CREAM, PREMARIN VAGINAL CREAM, ESTRING, VAGIFEM. DX OF POSTMENOPAUSAL OSTEOPOROSIS WILL REQUIRE FAILURE ON, INTOLERANCE TO, OR CONTRAINDICATION TO TWO OF THE FOLLOWING: ALENDRONATE, IBANDRONATE, RALOXIFENE. ESTROGENS FOR USE IN CANCER, PALLIATIVE CARE, OR HYPOESTROGENISM DUE TO HYPOGONADISM, CASTRATION OR PRIMARY OVARIAN FAILURE WILL BE APPROVED.

60 EXJADE EXJADE DIAGNOSIS OF CHRONIC IRON OVERLOAD CAUSED BY TRANSFUSION DEPENDENT THALASSEMIA OR CHRONIC IRON OVERLOAD CAUSED BY NON-TRANSFUSION DEPENDENT THALASSEMIA FOR TRANSFUSION DEPENDENT THALASSEMIA: MUST BO TWO YEARS OF AGE OR OLDER. FOR NON-TRANSFUSION DEPENDENT THALASSEMIA: MUST BY 10 YEARS OF AGE OR OLDER 3 MONTHS FOR TRANSFUSION DEPENDENT THALASSEMIA: DOCUMENTATION OF A SERUM FERRITIN LEVEL GREATER THAN 1000 MCG/L. CONTINUATION OF COVERAGE REQUIRES DOCUMENTATION OF A DECREASED SERUM FERRITIN FROM BASELINE. FOR NON-TRANSFUSION DEPENDENT THALASSEMIA: DOCUMENTATION OF LIC (LIVER IRON CONCENTRATION) OF GREATER THAN 5 MILLIGRAMS OF IRON PER GRAM OF DRY LIVER TISSUE WEIGHT (FE/G DW) AND SERRUM FERRITIN GREATER THAN 300 MCG/L. CONTINUATION OF COVERAGE REQUIRES DOCUMENTATION OF A DECREASED LIC FROM BASELINE AND A SERRUM FERRITIN LEVEL LESS THAN 300 MCG/L.

61 FABIOR FABIOR DX OF ACNE, ACNE VULGARIS, OR ADULT ONSET ACNE FAILURE ON, INTOLERANCE TO, OR CONTRAINDICATION TO TWO FORMULARY MEDICATIONS FOR THE TREATMENT OF ACNE

62 FABRAZYME FABRAZYME DX OF FABRY DISEASE METABOLIC SPECIALIST WITH EXPERIENCE TREATING FABRY DISEASE

63 FARYDAK FARYDAK ALL MEDICALLY ACCEPTED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D DIAGNOSIS OF MULTIPLE MYELOMA AND DOCUMENTATION OF BEING USED IN COMBINATION WITH VELCADE AND DEXAMETHASONE HEMATOLOGIST OR ONCOLOGIST 6 MONTHS INITIAL AND CONTINUATION. MAXIMUM OF 12 MONTHS FAILURE ON, INTOLERANCE TO, OR CONTRAINDICATION TO BORTEZOMIB AND AN IMMUNOMODULATORY AGENT (INCLUDING, BUT NOT LIMITED TO POMALYST, REVLIMID, THALOMID)

64 FERRIPROX FERRIPROX DX OF TRANSFUSIONAL IRON OVERLOAD DUE TO THALASSEMIA SYNDROME HEMATOLOGIST THERAPEUTIC FAILURE ON, INTOLERANCE TO, OR CONTRAINDICATION TO EXJADE. DOCUMENTATION OF ANC GREATER THAN 1.5 X (10 TO THE 9TH POWER) / L

65 FETZIMA FETZIMA DIAGNOSIS OF MAJOR DEPRESSIVE DISORDER MUST BE 18 YEARS OF AGE OR OLDER FAILURE ON, INTOLERANCE TO, OR CONTRAINDICATION TO AT LEAST TWO ANTIDEPRESSANT CLASSES.

66 FIRAZYR FIRAZYR DIAGNOSIS OF HEREDITARY ANGIOEDEMA SUPPORTED BY PHYSICIAN DOCUMENTATION OF RECURRENT, SELF-LIMITING NON-INFLAMMATORY SUBCUTANEOUS ANGIOEDEMA WITHOUT URTICARIA LASTING MORE THAN 12 HRS OR LARYNGEAL EDEMA OR RECURRENT, SELF-REMITTING ABDOMINAL PAIN LASTING MORE THAN 6 HRS WITHOUT CLEAR ORGANIC ETIOLOGY AND THE PRESENCE OF SPECIFIC ABNORMALITIES IN COMPLEMENT PROTEINS IN THE SETTING OF A SUGGESTIVE CLINICAL HISTORY OF EPISODIC ANGIOEDEMA WITHOUT URTICARIA SUPPORTED BY DOCUMENTATION OF TWO OR MORE SETS OF COMPLEMENT STUDIES, SEPARATED BY ONE MONTH OR MORE SHOWING LOW C4 LEVELS AND LESS THAN 50 PERCENT OF THE LOWER LIMIT OF NORMAL C1 INH ANTIGENIC PROTEIN LEVELS OR FUNCTION LEVELS. MUST BE AT LEAST 18 YEARS OF AGE ALLERGIST, IMMUNOLOGIST, HEMATOLOGIST, OR DERMATOLOGIST 6 MONTHS DOCUMENTATION THAT FIRAZYR IS BEING USED FOR TREATMENT OF ACUTE HEREDITARY ANGIOEDEMA ATTACK. DOCUMENTATION OF CONCURRENT USE OR

67 FAILURE ON, INTOLERANCE TO, OR CONTRAINDICATION TO PROPHYLACTIC THERAPY WITH DANAZOL. DOCUMENTATION THAT FIRAZYR IS NOT BEING USED IN COMBINATION WITH OTHER APPROVED TREATMENTS FOR ACUTE HAE ATTACKS.

68 FLECTOR FLECTOR DIAGNOSIS OF USE FOR THE TREATMENT OF ACUTE PAIN DUE TO MINOR STRAINS, SPRAINS, CONTUSIONS. 12 WEEKS FAILURE ON, INTOLERANCE TO, OR CONTRAINDICATION TO TWO ORAL FORMULARY NSAIDS

69 FORTEO FORTEO PREVIOUS FRACTURE OR T SCORE (-1.5 FOR WOMEN, LESS THAN -2 FOR MEN) OR BELOW ENDOCRINOLOGIST OR RHEUMATOLOGIST 24 MONTHS ATTEMPT OF THERAPY WITH OR CONTRAINDICATION TO BISPHOSPHONATE

70 GATTEX GATTEX DIAGNOSIS OF SHORT BOWEL SYNDROME MUST BE AT LEAST 18 YEARS OF AGE GASTROENTEROLOGIST 6 MONTHS INITIAL AND 1 YEAR CONTINUATION DOCUMENTATION THAT THE MEMBER HAS BEEN DEPENDENT ON PARENTERAL NUTRITION/INTRAVENOUS SUPPORT FOR A MINIMUM OF 12 CONSECUTIVE MONTHS CONTINUOUSLY AND THAT THE MEMBER REQUIRES PARENTERAL NUTRITION AT LEAST 3 TIMES PER WEEK.

71 GILOTRIF GILOTRIF ALL MEDICALLY ACCEPTED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D DOCUMENTATION OF FIRST OR SECOND LINE TREATMENT FOR METASTATIC NON- SMALL CELL LUNG CANCER (NSCLC) WITH EGFR EXON 19 DELETIONS OR EXON 21 (L858R) SUBSTITUTION MUTATIONS AS DETECTED BY AN FDA APPROVED TEST ONCOLOGIST OR HEMATOLOGIST

72 GRANIX GRANIX PREVENTION OF FEBRILE NEUTROPENIA WHEN RISK DUE TO MYELOSUPPRESIVE CHEMO REGIMEN IS 20% OR GREATER. TO PREVENT FEBRILE NEUTROPENIA WHEN THE RISK OF DEVELOPING FEBRILE NEUTROPENIA IS LESS THAN 20% WITH THE FOLLOWING RISK FACTORS: 65 YRS OR OLDER, POOR PERFORMANCE STATUS, PREVIOUS HISTORY OF FEBRILE NEUTROPENIA, EXTENSIVE PRIOR RADIATION OF CHEMO TREATMENT, POOR NUTRITIONAL STATUS, OPEN WOUNDS OR ACTIVE INFECTION, ADVANCED CANCER. 6 MONTHS

73 GROWTH HORMONE GENOTROPIN NORDITROPIN FLEXPRO NORDITROPIN NORDIFLEX NUTROPIN AQ NUSPIN OMNITROPE GROWTH HORMONE STIMULATION TESTS, IGF-I LEVELS, GROWTH VELOCITY CURVES ENDOCRINOLOGIST OR NEPHROLOGIST

74 HALAVEN HALAVEN ALL MEDICALLY ACCEPTED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D DX OF METASTATIC BREAST CANCER HEMATOLOGIST OR ONCOLOGIST 12 MONTHS FAILURE ON, INTOLERANCE TO, OR CONTRAINDICATION TO AT LEAST 2 PRIOR CHEMOTHERAPEUTIC REGIMENS. PRIOR THERAPY SHOULD HAVE INCLUDED AN ANTHRACYCLINE AND A TAXANE IN THE ADJUVANT OR METASTATIC SETTING

75 HETLIOZ HETLIOZ DOCUMENTATION OF A DIAGNOSIS OF NON-24-HOUR SLEEP-WAKE DISORDER (FREE-RUNNING DISORDER) AND DOCUMENTATION THAT THE MEMBER IS TOTALLY BLIND WITH NO PERCEPTION OF LIGHT MUST BE 18 YEARS OF AGE OR OLDER 6 MONTHS

76 IBRANCE IBRANCE ALL MEDICALLY ACCEPTED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D DIAGNOSIS OF HORMONE RECEPTOR POSITIVE, HER2 NEGATIVE METASTATIC BREAST CANCER MUST BE 18 YEARS OF AGE OR OLDER ONCOLOGIST 3 MONTHS DOCUMENTATION THAT IBRANCE WILL BE PRESCRIBED IN COMBINATION WITH LETROZOLE

77 ICLUSIG ICLUSIG ALL MEDICALLY ACCEPTED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D DX OF CHRONIC PHASE, ACCELERATED PHASE, OR BLAST PHASE CHRONIC MYELOID LEUKEMIA (CML) OR PHILADELPHIA CHROMOSOME POSITIVE ACUTE LYMPHOBLASTIC LEUKEMIA (PH+ALL) HEMATOLOGIST OR ONCOLOGIST 3 MONTHS DOCUMENTATION OF RESISTANCE OR INTOLERANCE TO ONE PRIOR TYROSINE KINASE INHIBITOR THERAPY OR DOCUMENTATION OF CML CELL MUTATION T3151

78 IMBRUVICA IMBRUVICA ALL MEDICALLY ACCEPTED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D DIAGNOSIS OF MANTLE CELL LYMPHOMA (MCL) WHO HAVE RECEIVED AT LEAST ONE PRIOR THERAPY. DIAGNOSIS OF CHRONIC LYMPHOCYTIC LEUKEMIA (CLL) WHO HAVE RECEIVED AT LEAST ONE PRIOR THERAPY. DIAGNOSIS OF CHRONIC LYMHOCYTIC LEUKEMIA (CLL) WITH 17P CHROMOSOME DELETION. DIAGNOSIS OF WALDENSTROM MACROGLOBULINEMIA. HEMATOLOGIST OR ONCOLOGIST 6 MONTHS FOR CLL FAILURE ON, INTOLERANCE TO, OR CONTRAINDICATION TO ONE PRIOR THERAPY INCLUDING BUT NOT LIMITED TO HYPERCVAD, NORDIC REGIMEN, CALGB REGIMEN, RCHOP/RICE, RCHOP/RDHAP, BENDAMUSTINE PLUS RITUXIMAB, CHOP PLUS RITUXIMAB, CLADRIBINE PLUS RITUXIMAB, CVP PLUS RITUXIMAB, EPOCH PLUS RITUXIMAB.

79 INLYTA INLYTA ALL MEDICALLY ACCEPTED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D DX OF ADVANCED RENAL CELL CARCINOMA ONCOLOGIST 6 MONTHS FAILURE ON ONE PRIOR SYSTEMIC THERAPY

80 INTUNIV GUANFACINE HCL ER DX OF ATTENTION DEFICIT HYPERACTIVITY DISORDER (ADHD) MUST BE BETWEEN 6 TO 17 YEARS OF AGE. FAILURE ON, INTOLERANCE TO, OR CONTRAINDICATION TO TWO FORMULARY STIMULANTS

81 INVEGA SUSTENNA INVEGA SUSTENNA DIAGNOSIS OF SCHIZOPHRENIA MUST BE 18 YEARS OF AGE OR OLDER 12 MONTHS DOCUMENTED HISTORY OF POOR ADHERENCE TO ORAL MEDICATIONS AND DOCUMENTATION THAT PATIENT EDUCATION TO IMPROVE ADHERENCE HAS BEEN ATTEMPTED. FAILURE ON, INTOLERANCE TO, OR CONTRAINDICATION TO RISPERDAL CONSTA AND ZYPREXA RELPREVV.

82 INVOKAMET INVOKAMET DIAGNOSIS OF TYPE II DIABETES MELLITUS MUST BE 18 YEARS OF AGE OR OLDER DOCUMENATION OF ESTIMATED GLOMERULAR FILTRATION RATE (EGFR) GREATER THAN OR EQUAL TO 45 ML/MIN. FAILURE ON, INTOLERANCE TO, OR CONTRAINDICATION TO JARDIANCE AND METFORMIN USED IN COMBINATION.

83 INVOKANA INVOKANA DIAGNOSIS OF TYPE II DIABETES MELLITUS MUST BE AT LEAST 18 YEARS OF AGE DOCUMENATION OF ESTIMATED GLOMERULAR FILTRATION RATE (EGFR) GREATER THAN OR EQUAL TO 45 ML/MIN FOR THE 100 MG TABLET, OR AN ESTIMATED GLOMERULAR FILTRATION RATE (EGFR) GREATER THAN OR EQUAL TO 60 ML/MIN FOR THE 300 MG TABLET.. FAILURE ON, INTOLERANCE TO, OR CONTRAINDICATION TO JARDIANCE

84 ISTODAX ISTODAX ALL MEDICALLY ACCEPTED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D DX OF CUTANEOUS OR PERIPHERAL T-CELL LYMPHOMA HEMATOLOGIST OR ONCOLOGIST 6 MONTHS DOCUMENTATION OF DISEASE PROGRESSION WHILE ON AT LEAST ONE PRIOR SYSTEMIC THERAPY INCLUDING BUT NOT LIMITED TO CHOP REGIMENS, CHOEP, ICE, IVE, EPOCH, HYPERCVAD.

85 ITRACONAZOLE ITRACONAZOLE POSITIVE CULTURE SUBSTANTIATING DIAGNOSIS FOR ONYCHOMYCOSIS: FAILURE ON, CONTRAINDICATION TO, OR INTOLERANCE TO TERBINAFINE

86 IXEMPRA IXEMPRA ALL MEDICALLY ACCEPTED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D DX OF METASTATIC OR LOCALLY ADVANCED BREAST CANCER HEMATOLOGIST OR ONCOLOGIST 12 MONTHS DOCUMENTATION OF USE IN COMBO WITH CAPECITABINE FOR THE TREATMENT OF METASTATIC OR LOCALLY ADVANCED BREAST CANCER WITH RESISTANCE TO AN ANTHRACYCLINE AND A TAXANE OR CANCER THAT IS TAXANE RESISTANT AND FURTHER ANTHRACYCLINE THERAPY IS CONTRAINDICATED OR DOCUMENTATION OF USE AS A MONOTHERAPY WITH TUMORS RESISTANT OR REFRACTORY TO ANTHRACYCLINES, TAXANES AND CAPECITABINE.

87 JEVTANA JEVTANA ALL MEDICALLY ACCEPTED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D DX OF HORMONE-REFRACTORY METASTATIC PROSTATE CANCER HEMATOLOGIST OR ONCOLOGIST DOCUMENTATION OF TUMOR WIHTOUT NEUROENDOCRINE FEATURES AND DOCUMENTATION OF NEUTROPHIL COUNT GREATER THAN 1500 CELLS/MM(3) AND FAILURE ON, INTOLERANCE TO, OR CONTRAINDICATION TO A DOCETAXEL-BASED REGIMEN.

88 JUXTAPID JUXTAPID DIAGNOSIS OF HOMOZYGOUS FAMILIAL HYPERCHOLESTEROLEMIA THAT IS CAUSED BY MUTATIONS OF THE LDL RECEPTOR GENE AND DOCUMENTATION OF FAILURE TO ADEQUATELY CONTROL LDL LEVELS WITH COMBINATION OF MAXIMUM TOLERATED STATIN DOSE AND LDL APHERESIS TREATMENTS DEFINED AS GREATER THAN OR EQUAL TO 200 MG/DL IN PATIENTS WITHOUT CVD OR GREATER THAN OR EQUAL TO 160 MG/DL IN PATIENTS WITH ESTABLISHED CVD AND DOCUMENTATION OF MEDICATION BEING USED IN ADJUNCT WITH MAXIMUM TOLERATED STATIN DOSE AND LDL APHERESIS MUST BE 18 YEARS OF AGE OR OLDER HEPATOLOGIST, LIDIPOLOGIST OR CARDIOLOGIST REGISTERED WITH THE JUXTAPID REMS PROGRAM 6 MONTHS FAILURE ON, INTOLERANCE TO, OR CONTRAINDICATION TO KYNAMRO

89 KADCYLA KADCYLA ALL MEDICALLY ACCEPTED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D DIAGNOSIS OF HER2-POSITIVE, METASTATIC BREAST CANCER HEMATOLOGIST OR ONCOLOGIST 12 MONTHS DOCUMENTATION OF PREVIOUS TREATMENT WITH TRASTUZUMAB (HERCEPTIN) AND A TAXANE (PACLITAXEL OR DOCETAXEL), SEPARATELY OR IN COMBINATION. MUST HAVE EITHER RECEIVED PRIOR THERAPY FOR METASTATIC DISEASE OR DEVELOPED DISEASE RECURRENCE DURING OR WITHIN SIX MONTHS OF COMPLETING ADJUVANT.

90 KETEK KETEK DX OF COMMUNITY ACQUIRED PNEUMONIA FAILURE ON, CONTRAINDICATION TO, OR INTOLERANCE TO AZITHROMYCIN, CLARITHROMYCIN OR ERYTHROMYCIN

91 KEYTRUDA KEYTRUDA ALL MEDICALLY ACCEPTED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D DIAGNOSIS OF UNRESECTABLE OR METASTATIC MELANOMA MUST BE 18 YEARS OF AGE OR OLDER ONCOLOGIST OR HEMATOLOGIST 6 MONTHS DOCUMENTATION THAT KEYTRUDA IS NOT BEING USED IN COMBINATION WITH ANY OTHER AGENTS FOR THE TREATMENT OF UNRESCTABLE OR METASTATIC MELANOMA. SUBSEQUENT APPROVAL AFTER 6 MONTHS WILL REQUIRE DOCUMENTATION OF CONTINUED DISEASE IMPROVEMENT OR LACK OF DISEASE PROGRESSION.

92 KORLYM KORLYM PREGNANCY DX OF ENDOGENOUS CUSHING'S SYNDROME AND DOCUMENTATION OF FAILED SURGICAL TREATMENT FOR CUSHING'S SYNDROME OR THAT PATIENT IS NOT A CANDIDATE FOR SURGERY. DOCUMENTATION OF A NEGATIVE PREGNANCY TEST WITHIN 14 DAYS OF INITIATING THERAPY IN WOMEN OF REPRODUCTIVE POTENTIAL ENDOCRINOLOGIST THERAPEUTIC FAILURE ON, CONTRAINDICATION TO, OR INTOLERANCE TO AT LEAST TWO FORMULARY ANTI-DIABETIC ALTERNATIVES

93 KUVAN KUVAN BASELINE BLOOD PHE LEVEL LESS THAN 450 UMOL/L. BASELINE BLOOD PHE LEVELS. FOR CONTINUATION OF THERAPY, MUST PROVIDE THE FOLLOWING BLOOD PHE LEVELS, BASELINE, 1 WEEK, 4 WEEKS AND 8 WEEKS. METABOLIC SPECIALIST INITIALLY 2 MONTHS THEN INDEFINITE IF PATIENT IS A RESPONDER COMPLIANT WITH A PHE RESTRICTED DIET, 30% OR GREATER REDUCTION IN PHE AT WK 8 FOR INDEFINITE AUTH

94 KYNAMRO KYNAMRO DIAGNOSIS OF HOMOZYGOUS FAMILIAL HYPERCHOLESTEROLEMIA THAT IS CAUSED BY MUTATIONS OF THE LDL RECEPTOR GENE MUST BE AT LEAST 18 YEARS OF AGE HEPATOLOGIST, LIDIPOLOGIST OR CARDIOLOGIST REGISTERED WITH THE KYNAMRO REMS PROGRAM 6 MONTHS INITIAL AND 1 YEAR CONTINUATION DOCUMENTATION OF FAILURE TO ADEQUATELY CONTROL LDL LEVELS WITH A COMBINATION OF MAXIMUM TOLERATED STATIN DOSE AND LDL APHERESIS TREATMENTS DEFINED AS GREATER THAN OR EQUAL TO 200MG/DL IN PATIENTS WITHOUT CARDIOVASCULAR DISEASE OR GREATER THAN OR EQUAL TO 160MG/DL IN PATIENTS WITH ESTABLISHED CARDIOVASCULAR DISEASE AND DOCUMENTATION THAT KYNAMRO WILL BE USED IN ADJUNCT WITH MAXIMUM TOLERATED STATIN DOSE AND DOCUMENTATION THAT KYNAMRO WILL NOT BE USED IN CONJUNCTION WITH LDL APHERESIS.

95 LATUDA LATUDA ALL MEDICALLY ACCEPTED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D DX OF SCHIZOPHRENIA OR DX OF DEPRESSIVE EPISODES ASSOCIATED WITH BIPOLAR 1 DISORDER (BIPOLAR DEPRESSION) FOR SCHIZOPHRENIA: FAILURE ON, INTOLERANCE TO, OR CONTRAINDICATION TO TWO FORMULARY ATYPICAL ANTIPSYCHOTICS (OLANZAPINE, RISPERIDONE, QUETIAPINE, ZIPRASIDONE, ABILIFY) OR FAILURE ON, INTOLERANCE TO, OR CONTRAINDICATION TO ZIPRASIDONE AND ABILIFY FOR MEMBERS WITH METABOLIC SYNDROME. FOR BIPOLAR DEPRESSION: FAILURE ON, INTOLERANCE TO, OR CONTRAINDICATION TO QUETIAPINE.

96 LAZANDA LAZANDA DIAGNOSIS OF CANCER AND OF USE TO MANAGE BREAKTHROUGH CANCER PAIN MEDICAL RECORD DOCUMENTATION OF CONCOMITANT MORPHINE 60 MG/DAY OR MORE, TRANSDERMAL FENTANYL 25 MCG/H, OXYCODONE 30 MG/DAY, ORAL HYDROMORPHONE 8 MG/DAY, OR AN EQUIANALGESIC DOSE OF ANOTHER OPIOID FOR 1 WEEK OR LONGER AND FAILURE ON, INTOLERANCE TO, OR CONTRAINDICATION TO GENERIC FENTANYL LOZENGES.

97 LENVIMA LENVIMA ALL MEDICALLY ACCEPTED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D DIAGNOSIS OF LOCALLY RECURRENT OR METASTATIC, PROGRESSIVE, RADIOACTIVE IODINE-REFRACTORY DIFFERENTIATED THYROID CANCER HEMATOLOGIST OR ONCOLOGIST 6 MONTHS SUBSEQUENT APPROVAL AFTER 6 MONTHS WILL REQUIRE DOCUMENTATION OF CONTINUED DISEASE IMPROVEMENT OR LACK OF DISEASE PROGRESSION.

98 LETAIRIS LETAIRIS DIAGNOSIS OF FUNCTIONAL CLASS 2 OR 3 PULMONARY ARTERIAL HYPERTENSION PULMONOLOGIST OR CARDIOLOGIST FAILURE ON, INTOLERANCE TO, OR CONTRAINDICATION TO REVATIO AND TRACLEER

99 LEUKINE LEUKINE PROPHYLAXIS DURING CHEMO REGIMENS WITH A FEBRILE NEUTROPENIA RISK LESS THAN 20% AND NO HIGH RISK FOR COMPLICATIONS, THOSE WHO ARE NEUTROPENIC BUT AFEBRILE, TO ALLOW AN INCREASE IN THE DOSE-INTENSITY OF CYTOTOXIC CHEMO BEYOND ESTABLISHED DOSE RANGES, NO RESPONSE SEEN WITHIN 45 DAYS OF TREATMENT PREVENTION OF FEBRILE NEUTROPENIA WHEN RISK DUE TO MYELOSUPPRESIVE CHEMO REGIMEN IS 20% OR GREATER. TO PREVENT FEBRILE NEUTROPENIA WHEN THE RISK OF DEVELOPING FEBRILE NEUTROPENIA IS LESS THAN 20% WITH THE FOLLOWING RISK FACTORS: 65 YRS OR OLDER, POOR PERFORMANCE STATUS, PREVIOUS HISTORY OF FEBRILE NEUTROPENIA, EXTENSIVE PRIOR RADIATION OR CHEMOTHERAPY TREATMENT, POOR NUTRITIONAL STATUS, OPEN WOUNDS OR ACTIVE INFECTION, ADVANCED CANCER. PREVENTION OF FEBRILE NEUTROPENIA WHEN A PREVIOUS CYCLE RESULTED IN A NEUTROPENIC COMPLICATION AND DOSE REDUCTION WILL COMPROMISE DISEASE FREE OR OVERALL SURVIVAL OR TREATMENT OUTCOME, AS AN ADJUNCT TO ANTIBIOTICS FOR TREATMENT OF FEBRILE NEUTROPENIA WITH HIGH RISK FOR INFECTION RELATED COMPLICATIONS. FOR USE IN DOSE DENSE THERAPY, TO MOBILIZE PERIPHERAL BLOOD PROGENITOR CELL ADMINISTRATION AFTER AUTOLOGOUS PBPC TRANSPLANT, LYMPHOMA TREATED WITH CURATIVE THERAPY, LEUKEMIA OR MYELODYSPLASTIC SYNDROMES, NON-MYELOID MALIGNANCY, RADIATION THERAPY.

100 6 MONTHS

101 LEVALBUTEROL NEB LEVALBUTEROL HCL FAILURE ON, INTOLERANCE TO, OR CONTRAINDICATION TO ALBUTEROL SOLUTION FOR INHALATION.

102 LIDODERM LIDOCAINE DX OF POST-HERPETIC NEURALGIA FAILURE ON, CONTRAINDICTION TO, OR INTOLERANCE TO GABAPENTIN

103 LINZESS LINZESS DX OF IRRITABLE BOWEL SYNDROME WITH CONSTIPATION OR CHRONIC IDIOPATHIC CONSTIPATION MUST BE 6 YEARS OF AGE OR OLDER DOCUMENTATION OF FAILURE ON, INTOLERANCE TO, OR CONTRAINDICATION TO TWO FORMULARY CATHARTICS AND LAXATIVES

104 MACROLIDES AZITHROMYCIN CLARITHROMYCIN CLARITHROMYCIN ER E.E.S. 400 ERY-TAB ERYTHROCIN STEARATE ERYTHROMYCIN ERYTHROMYCIN ETHYLSUCCINATE PCE PRIOR AUTHORIZATION APPLIES ONLY IF THERE IS CONCURRENT USE OF DIGOXIN AND ONE OF THE FOLLOWING MACROLIDE ANTIBIOTICS - CLARITHROMYCIN, ERYTHROMYCIN, OR AZITHROMYCIN. IF THE MEMBER IS NOT CONCURRENTLY RECEIVING DIOGXIN, PRIOR AUTHORIZATION WILL NOT BE REQUIRED. 1 MONTH FAILURE ON, INTOLERANCE TO, OR CONTRAINDICATION TO TWO FORMULARY ANTIBIOTIC CLASS ALTERNATIVES WHICH INCLUDE 2ND OR 3RD GENERATION CEPHALSPORINS (SUCH AS CEFACLOR OR CEFPODOXIME), PENICILLINS (SUCH AS AMOXICILLIN OR AMOXICILLIN/CLAVULANATE), OR QUINOLONES (SUCH AS CIPROFLOXACIN OR LEVOFLOXACIN) IF CONCURRENT USE OF DIGOXIN

105 MEKINIST MEKINIST ALL MEDICALLY ACCEPTED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D DIAGNOSIS OF UNRESECTABLE OR METASTATIC MELANOMA WITH OR WITHOUT CONCURRENT USE OF TAFINLAR (DABRAFENIB). DOCUMENTATION OF BRAF V600E OR V600K MUTATION AS DETECTED BY AN FDA APPROVED TEST ONCOLOGIST OR HEMATOLOGIST OR DERMATOLOGIST 6 MONTHS NO PRIOR THERAPEUTIC FAILURE WITH A BRAF INHIBITOR THERAPY (ZELBORAF (VEMURAFENIB) OR TAFINLAR (DABRAFENIB)) OR MEK INHIBITOR THERAPY SUCH AS MEKINIST.

106 MEPROBAMATE HRM MEPROBAMATE DIAGNOSIS OF ANXIETY ONLY APPLIES TO MEMBERS 65 YEARS OF AGE AND OLDER PRIOR AUTHORIZATION APPLIES ONLY TO MEMBERS 65 YEARS OF AGE AND OLDER WHO WILL BE EVALUATED FOR APPROPRIATE USE OF HIGH RISK MEDICATION AND WILL REQUIRE FAILURE ON, INTOLERANCE TO, OR CONTRAINDICATION TO TWO OF THE FOLLOWING: BUSPIRONE, PAROXETINE, ESCITALOPRAM, OR VENLAFAXINE XR.

107 MYOZYME MYOZYME DX OF INFANTILE ONSET POMPE DISEASE (IOPD) METABOLIC SPECIALIST

108 NAGLAZYME NAGLAZYME DX OF MUCOPOLYSACCHARIDOSIS VI (MAROTEAUX-LAMY DISEASE) METABOLIC SPECIALIST

109 NATPARA NATPARA DOCUMENTATIONS OF A DIAGNOSIS OF HYPOCALCEMIA SECONDARY TO HYPOPARATHYROIDISM AND DOCUMENTATION OF NO INCREASED BASELINE RISK FOR OSTEOSARCOMA AND DOCUMENTATION THAT PREVIOUS TREATMENT WITH CALCIUM SUPPLEMENTS AND ACTIVE FORMS OF VITAMIN D WERE NOT SUCCESSFUL IN TREATING HYPOCALCEMIA AND DOCUEMENTATION THAT MEDICATION IS GOING TO BE USED CONCURRENTLY WITH A CALCIUM SUPPLEMENT ENDOCRINOLOGIST 6 MONTHS REAUTHORIZATION WILL REQUIRE DOCUMENTATION SUPPORTING THE CONTINUED USE OF THE LOWEST DOSE THAT ACHIEVES A TOTAL SERUM CALCIUM (ALBUMIN CORRECTED) WITHIN THE LOWER HALF OF THE NORMAL TOTAL SERUM CALCIUM RANGE

110 NEULASTA NEULASTA PROPHYLAXIS DURING CHEMO REGIMENS WITH A FEBRILE NEUTROPENIA RISK LESS THAN 20% AND NO HIGH RISK FOR COMPLICATIONS, THOSE WHO ARE NEUTROPENIC BUT AFEBRILE, TO ALLOW AN INCREASE IN THE DOSE-INTENSITY OF CYTOTOXIC CHEMO BEYOND ESTABLISHED DOSE RANGES, NO RESPONSE SEEN WITHIN 45 DAYS OF TREATMENT PREVENTION OF FEBRILE NEUTROPENIA WHEN RISK DUE TO MYELOSUPPRESIVE CHEMO REGIMEN IS 20% OR GREATER. TO PREVENT FEBRILE NEUTROPENIA WHEN THE RISK OF DEVELOPING FEBRILE NEUTROPENIA IS LESS THAN 20% WITH THE FOLLOWING RISK FACTORS: 65 YRS OR OLDER, POOR PERFORMANCE STATUS, PREVIOUS HISTORY OF FEBRILE NEUTROPENIA, EXTENSIVE PRIOR RADIATION OF CHEMO TREATMENT, POOR NUTRITIONAL STATUS, OPEN WOUNDS OR ACTIVE INFECTION, ADVANCED CANCER. 6 MONTHS

111 NEUPRO NEUPRO FAILURE ON, INTOLERANCE TO, OR CONTRAINDICATION TO PRAMIPEXOLE AND ROPINIROLE

112 NEXAVAR NEXAVAR ONCOLOGIST

113 NEXIUM IV ESOMEPRAZOLE SODIUM DOCUMENTATION OF FAILURE ON, INTOLERANCE TO, OR CONTRAINDICATION TO PANTOPRAZOLE IV.

114 NITROFURANTOIN NITROFURANTOIN NITROFURANTOIN MONO-MACRO ONLY APPLIES TO MEMBERS 65 YEARS OF AGE AND OLDER PRIOR AUTHORIZATION AND QUANTITY LIMIT APPLIES ONLY TO MEMBERS 65 YEARS OF AGE AND OLDER WHO WILL BE EVALUATED FOR APPROPRIATE USE OF HIGH RISK MEDICATION. WILL APPROVE FOR UP TO 90 DAYS SUPPLY WITHIN A 12 MONTH PERIOD. CONTINUED USE OVER A 90 DAYS SUPPLY FOR DX OF UTI WILL REQUIRE CREATININE CLEARANCE GREATER THAN OR EQUAL TO 60 ML/MIN AND POSITIVE CULTURE REPORT SHOWING THAT THE BACTERIA IS ONLY SENSITIVE TO NITROFURANTOIN OR ONLY SENSITIVE TO NITROFURANTOIN AND OTHER MEDICATIONS THAT THE MEMBER IS ALLERGIC TO OR FAILURE ON, INTOLERANCE TO, OR CONTRAINDICATION TO TWO OF THE FOLLOWING FORMULARY ALTERNATIVES: AMOXICILLIN/CLAVULANIC ACID, CEFUROXIME, CEFADROXIL, CEPHALEXIN, CIPROFLOXACIN, SULFAMETHOXAZOLE/TRIMETHOPRIM, OR TRIMETHOPRIM. CONTINUED PROPHYLACTIC USE OVER A 90 DAYS SUPPLY WILL REQUIRE CREATININE CLEARANCE GREATER THAN OR EQUAL TO 60 ML/MIN AND FAILURE ON,

115 INTOLERANCE TO, OR CONTRAINDICATION TO TWO OF THE FOLLOWING FORMULARY ALTERNATIVES: CEPHALEXIN, CIPROFLOXACIN, SULFAMETHOXAZOLE/TRIMETHOPRIM, OR TRIMETHOPRIM.

116 NOXAFIL NOXAFIL DOCUMENTATION OF USE FOR PROPHYLAXIS OF INVASIVE ASPERGILLUS AND CANDIDA INFECTIONS IN SEVERELY IMMUNOCOMPROMISED PATIENTS (HEMATOPOIETIC STEM CELL TRANSPLANT (HSCT) RECIPIENTS WITH GRAFT- VERSUS-HOST-DISEASE (GVHD) OR THOSE WITH HEMATOLOGIC MALIGNANCIES WITH PROLONGED NEUTROPENIA FROM CHEMOTHERAPY) OR DIAGNOSIS OF OROPHARYNGEAL CANDIDIASIS. FOR OROPHARYNGEAL CANDIDIASIS: FAILURE ON, INTOLERANCE TO, OR CONTRAINDICATION TO ITRACONAZOLE ORAL SOLUTION AND FLUCONAZOLE.

117 NUEDEXTA NUEDEXTA DIAGNOSIS OF PSEUDOBULBAR AFFECT IN PATIENTS WITH AMYOTROPHIC LATERAL SCLEROSIS (ALS) OR MULTIPLE SCLEROSIS (MS).

118 NULOJIX NULOJIX DOCUMENTATION OF RENAL TRANSPLANT DOCUMENTATION OF EPSTEIN-BARR VIRUS (EBV) SEROPOSITIVITY

119 NUVIGIL NUVIGIL DX OF OBSTRUCTIVE SLEEP APNEA/HYPOPNEA SYNDROME, NARCOLEPSY OR SHIFT-WORK FOR OBSTRUCTIVE SLEEP APNEA, DOCUMENTATION OF CPAP HISTORY OR STATUS. FAILURE ON, INTOLERANCE TO, OR CONTRAINDICATION TO MODAFINIL.

120 OFEV OFEV DOCUMENTATION OF IDIOPATHIC PULMONARY FIBROSIS (IPF) CONFIRMED BY EITHER A USUAL INTERSTITIAL PNEUMONIA PATTERN ON HIGH RESOLUTION CT SCAN OR BOTH HRCT AND SURGICAL LUNG BIOPSY PATTERN SUGGESTIVE OF IPF OR PROBABLE IPF MADE BY AN INTERDISCIPLINARY TEAM INCLUDING, BUT NOT LIMITED TO SPECIALISTS FROM PULMONARY MEDICINE, RADIOLOGY, THORACIC SURGERY, PATHOLOGY OR RHEUMATOLOGY AND DOCUMENTATION THAT THERE ARE NO OTHER KNOWN CAUSES OF INTERSTITIAL LUNG DISEASE SUCH AS DOMESTIC AND OCCUPATIONAL ENVIRONMENTAL EXPOSURES, CONNECTIVE TISSUE DISEASE OR DRUG TOXICITY AND DOCUMENTATION THAT THE PATIENT WAS TAUGHT PULMONARY REHABILITATION TECHNIQUES AND DOCUMENTATION THAT MEDICATION IS NOT BEING USED IN COMBINATION WITH PIRFENIDONE MUST BE 18 YEARS OF AGE OR OLDER PULMONOLOGIST

121 ONFI ONFI ALL MEDICALLY ACCEPTED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D DX OF LENNOX-GASTAUT SYNDROME OR FOR USE IN INTRACTABLE EPILEPSY AS DEFINED AS FAILURE ON TWO FORMULARY SEIZURE MEDICATIONS NEUROLOGIST

122 OPSUMIT OPSUMIT DX OF WHO FUNCTIONAL CLASS II, III, OR IV PULMONARY ARTERIAL HYPERTENSION AND NEGATIVE PREGNANCY TEST IN FEMALES OF CHILDBEARING POTENTIAL CARDIOLOGIST OR PULMONOLOGIST DOCUMENTATION THAT OPSUMIT WILL BE USED IN COMBINATION WITH OR THERAPEUTIC FAILURE ON, INTOLERANCE TO, OR CONTRAINDICATION TO SILDENAFIL AND THERAPEUTIC FAILURE ON, INTOLERANCE TO, OR CONTRAINDICATION TO TRACLEER

123 ORENITRAM ORENITRAM ER DOCUMENTATION OF WHO GROUP 1 PULMONARY ARTERIAL HYPERTENSION WITH WHO FUNCTIONAL CLASS II OR III SYMPTOMS CARDIOLOGIST OR PULMONOLOGIST 6 MONTHS DOCUMENTATION OF A BASELINE 6-MINUTE WALKING DISTANCE. DOCUMENTATION THAT ORENITRAM IS NOT BEING USED IN COMBINATION WITH ENDOTHELIN RECEPTOR ANTAGONISTS (LETAIRIS, TRACLEER, OPSUMIT) OR PDE5 INHIBITORS (REVATIO OR ADCIRCA). REAUTHORIZATION WILL REQUIRE DOCUMENTATION OF AN IMPROVEMENT IN 6-MINUTE WALKING DISTANCE FROM BASELINE OR IMPROVED OR STABLE DIAGNOSIS OF WHO FUNCTIONAL CLASS AND DOCUMENTATION THAT ORENITRAM IS NOT BEING USED IN COMBINATION WITH ENDOTHELIN RECEPTOR ANTAGONISTS (LETAIRIS, TRACLEER, OPSUMIT) OR PDE5 INHIBITORS (REVATIO OR ADCIRCA).

124 OTEZLA OTEZLA DOCUMENTATION OF ACTIVE PSORIATIC ARTHRITIS WHICH MUST INCLUDE THE FOLLOWING: DOCUMENTATION OF AT LEAST THREE SWOLLEN JOINTS AND AT LEAST THREE TENDER OR PAINFUL JOINTS AND DOCUMENTATION OF EITHER ACTIVE PSORIATIC LESIONS OR A DOCUMENTED HISTORY OF PSORIASIS. DOCUMENTATION OF MODERATE TO SEVERE PLAQUE PSORIASIS CHARACTERIZED BY 5% OR GREATER INVOLVMENT OF BOADY SURFACE AREA OR DISEASE INVOVLING CRUCIAL BODY AREAS SUCH AS THE HANDS, FEET, FACE, OR GENITALS. MUST BE 18 YEARS OF AGE OR OLDER RHEUMATOLOGIST OR DERMATOLOGIST 6 MONTHS INITIAL AND 1 YEAR CONTINUATION DOCUMENTATION OF FAILURE ON, INTOLERANCE TO, OR CONTRAINDICATION TO AT LEAST 3 MONTH TRIAL OF THERAPY WITH HUMIRA AND ENBREL. FOR CONTINUED THERAPY, MEDICAL RECORD DOCUMENTATION OF CLINICAL OR SUSTAINED IMPROVEMENT OF SIGNS AND SYMPTOMS OF PSORIATIC ARTHRITIS OR PLAQUE PSORIASIS.