8-MOP. Products Affected

Transcription

1 2018 First Choice VIP Care Plus Document: 2018 Prior Authorization Formulary ID: Last Updated: 10/2018 Effective Date: MOP 8-MOP Age must be a dermatologist or an oncologist. 1

2 ABILIFY MAINTENA ABILIFY MAINTENA Age The member has a documented history of receiving oral aripiprazole without any clinically significant side effects. Additionally, the member has a documented trial and failure or medical reason (e.g. intolerance, hypersensitivity or contraindication) for not utilizing these therapies to manage their medical condition: Invega Sustenna, Invega Trinza or Risperdal Consta. 2

3 2018 First Choice VIP Care Plus Document: 2018 Prior Authorization Formulary ID: Last Updated: 10/2018 Effective Date: ABRAXANE ABRAXANE Age Provider must submit documentation that the patient has a baseline (with in 30 days of the request) neutrophil count of greater than or equal to 1500 cells/mm3. Provider must be an oncologist. 3

4 ACTEMRA ACTEMRA Age Documentation was submitted indicating that the member was evaluated for active or latent TB infection (i.e. tuberculin skin test). must be a rheumatologist. Documentation of trial and failure or medical reason (e.g. intolerance, hypersensitivity or contraindication) for not being able to use the following agents was submitted: Humira (adalimumab) and Enbrel (etanercept). For diagnosis of giant cell arteritis, the request will be approved. 4

5 2018 First Choice VIP Care Plus Document: 2018 Prior Authorization Formulary ID: Last Updated: 10/2018 Effective Date: ACTIMMUNE ACTIMMUNE Age 5

6 ADAGEN ADAGEN Age 6

7 2018 First Choice VIP Care Plus Document: 2018 Prior Authorization Formulary ID: Last Updated: 10/2018 Effective Date: ADEMPAS ADEMPAS Age Concomitant use with PDE inhibitor or nitrate therapy Documentation of pulmonary arterial hypertension (PAH) WHO Group classification. For WHO Group I, documentation of PAH Functional Class. Reviewer will verify patient claim history to confirm patient is not using PDE inhibitors or nitrates. must be a pulmonologist or cardiologist 7

8 AFINITOR AFINITOR AFINITOR DISPERZ Age Documentation of members treatment history for relevant disease state. Provider attests that patient's CBC with differential, liver function, renal function, blood glucose and lipid profile will be monitored for the duration of therapy as indicated in compendia must be an oncologist or neurologist. For the diagnosis of advanced renal cell carcinoma the patient must have a documented trial and failure, intolerability, or contraindication to Sutent or Nexavar. 8

9 2018 First Choice VIP Care Plus Document: 2018 Prior Authorization Formulary ID: Last Updated: 10/2018 Effective Date: ALDURAZYME ALDURAZYME Age 9

10 ALECENSA ALECENSA Age Provider attests that patient's liver function tests will be monitored for the duration of therapy as indicated in compendia. Member has documented ALK positive non-small cell lung cancer based on an FDA-approved test. must be an oncologist. 10

11 2018 First Choice VIP Care Plus Document: 2018 Prior Authorization Formulary ID: Last Updated: 10/2018 Effective Date: ALIMTA ALIMTA Age Provider attests that patient's CBC and renal function tests will be monitored throughout the course of therapy, prior to initiation of each cycle of Alimta. must be an oncologist. 11

12 ALIQOPA ALIQOPA Age Provider attests that complete blood cell count, blood pressure, and blood glucose will be monitored prior to initiation and throughout duration of therapy as indicated in compendia must be an oncologist or hematologist. 12

13 2018 First Choice VIP Care Plus Document: 2018 Prior Authorization Formulary ID: Last Updated: 10/2018 Effective Date: ALPHA-1 PROTEINASE INHIBITORS ARALAST NP GLASSIA PROLASTIN-C ZEMAIRA Age Documentation of hereditary alpha1-antitrypsin deficiency as evident by serum AAT levels consistently below 11 micrometer/l, and progressive FEV1 or FVC decline demonstrating symptomatic lung disease must be a pulmonologist. If the medication request is for an Alpha1-Proteinase Inhibitor (human) product other than Prolastin, the patient has a documented medical reason (such as trial, failure or contraindication) for not using Prolastin to treat their medical condition. 13

14 ALUNBRIG ALUNBRIG Age Provider attests that blood pressure, heart rate, serum glucose, creatine phosphokinase and lipase & amylase levels will be monitored for the duration of therapy as indicated in compendia. must be an oncologist 14

15 2018 First Choice VIP Care Plus Document: 2018 Prior Authorization Formulary ID: Last Updated: 10/2018 Effective Date: AMPYRA AMPYRA dalfampridine Age History of seizure. If diagnosis is RRMS, documentation has been provided that member is ambulatory (able to walk at least 25 feet), has a documented walking impairment, and is currently being treated with a disease modifying agent (e.g. immunomodulator, interferon, etc) or has a medical reason why member is unable to use a disease modifying agent for their condition. For all other types of MS, only documentation that member is ambulatory with a documented walking impairment is required. must be a neurologist. 15

16 ANADROL ANADROL-50 Age 16

17 2018 First Choice VIP Care Plus Document: 2018 Prior Authorization Formulary ID: Last Updated: 10/2018 Effective Date: APOKYN APOKYN Age Apokyn (apomorphine hydrochloride) is contraindicated in concomitant use with serotonin 5-HT3 receptor antagonists. Reviewer will verify patient claim history to confirm patient is not using 5-HT3 receptor antagonists. If diagnosis is Parkinsons, the patient has a documented trial and failure or intolerance to two formulary alternatives. 17

18 ARANESP ARANESP (IN POLYSORBATE) Age Laboratory results within 30 days of request: Hemoglobin, hematocrit, serum ferritin (normal level is greater than 100ng/ml), transferrin saturation (TSAT-normal level is greater than 20%), total iron binding capacity (TIBC) and serum iron. If all conditions are met, the request will be authorized for 3 months. Laboratory results for Hemoglobin is less than 10g/dl for initial requests, or hemoglobin is within compendia range for treatment for the requested medical use for any request, with dose reduction or interruption required if hemoglobin exceeds 10 g/dl (CKD not on dialysis-adult, cancer), 11 g/dl (CKD on dialysis), 12 g/dl (pediatric CKD). If being used to treat a condition caused by end-stage renal disease(esrd) and member is on dialysis, please bill to Medicare Part B. 18

19 2018 First Choice VIP Care Plus Document: 2018 Prior Authorization Formulary ID: Last Updated: 10/2018 Effective Date: ARCALYST ARCALYST Age 19

20 ARISTADA ARISTADA INITIO ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 1,064 MG/3.9 ML, 441 MG/1.6 ML, 662 MG/2.4 ML, 882 MG/3.2 ML Age The member has a documented history of receiving oral aripiprazole without any clinically significant side effects. Additionally, the member has a documented trial and failure or medical reason (e.g. intolerance, hypersensitivity or contraindication) for not utilizing these therapies to manage their medical condition: Invega Sustenna, Invega Trinza or Risperdal Consta. 20

21 2018 First Choice VIP Care Plus Document: 2018 Prior Authorization Formulary ID: Last Updated: 10/2018 Effective Date: ARRANON ARRANON Age Provider attests that patient's CBC will be monitored on a regularly throughout the duration of therapy. must be an oncologist. 21

22 AVASTIN AVASTIN Age Documentation was submitted includes the following that were obtained within 30 days of request: CBC with an ANC greater than 1000 cells/mm3, platelet count greater than 100 x103/mm3 and two different blood pressure readings indicating the member's blood pressure is less than 200/110 mmhg. must be an oncologist. 22

23 2018 First Choice VIP Care Plus Document: 2018 Prior Authorization Formulary ID: Last Updated: 10/2018 Effective Date: AZACITIDINE azacitidine Age Provider attests that patient's liver function tests, CBC and renal function will be assessed prior to each cycle throughout the duration of therapy must be an oncologist or a hematologist. 23

24 AZASAN AZASAN Age Patient must have documented trial and failure or intolerance to generic azathioprine. 24

25 2018 First Choice VIP Care Plus Document: 2018 Prior Authorization Formulary ID: Last Updated: 10/2018 Effective Date: BAVENCIO BAVENCIO Age Provider attests that patient's liver function tests, thyroid function test, renal function tests, CBC and serum blood glucose will be monitored prior to initiation and periodically throughout treatment with Bavencio must be an oncologist. 25

26 BELEODAQ BELEODAQ Age Provider attests that patient's CBC will be monitored at baseline and then weekly throughout the duration of therapy. LFT and SCr will be monitored before each treatment cycle. must be an oncologist. 26

27 2018 First Choice VIP Care Plus Document: 2018 Prior Authorization Formulary ID: Last Updated: 10/2018 Effective Date: BENLYSTA BENLYSTA Age Documentation has been provided indicating the patient has had an adequate trial of two or more of the following agents: glucocorticoids, azathioprine, methotrexate, mycophenolate, or hydroxychloroquine. is a rheumatologist. 27

28 BENLYSTA SUBCUTANEOUS BENLYSTA Age Documentation has been provided indicating the patient has had an adequate trial of two or more of the following agents: glucocorticoids, azathioprine, methotrexate, mycophenolate, or hydroxychloroquine. is a rheumatologist. 28

29 2018 First Choice VIP Care Plus Document: 2018 Prior Authorization Formulary ID: Last Updated: 10/2018 Effective Date: BENZNIDAZOLE benznidazole Age Patients who have used disulfiram within two weeks of initiation of benznidazole Documentation of a consultation with an infectious disease specialist. Reviewer will verify patient claim history to confirm that patient has not used disulfiram within two weeks prior to benznidazole initiation If all conditions are met, the request will be authorized for 60 days of treatment. 29

30 BESPONSA BESPONSA Age Provider attests that patient EKG and electrolytes will be monitored prior to treatment initiation, and liver function tests and complete blood count will be monitored throughout the duration of therapy as indicated in compendia. must be an oncologist. If all conditions are met, the request will be authorized for 6 months. 30

31 2018 First Choice VIP Care Plus Document: 2018 Prior Authorization Formulary ID: Last Updated: 10/2018 Effective Date: BICNU BICNU carmustine Age Provider attests that CBC with differential, liver function tests, renal function tests and pulmonary function tests will be completed for the duration of therapy as indicated in compendia. must be an oncologist. 31

32 BOSULIF BOSULIF Age Provider attests that CBC, liver function tests and renal function will be monitored for the duration of therapy as indicated in compendia must be an oncologist. 32

33 2018 First Choice VIP Care Plus Document: 2018 Prior Authorization Formulary ID: Last Updated: 10/2018 Effective Date: BRAFTOVI BRAFTOVI Age Confirmation of BRAF V600E or V600K mutation status with a FDA approved test. must be an oncologist. 33

34 BRIVIACT BRIVIACT Age Documented trial and failure or intolerance two formulary anticonvulsant agents. must be a neurologist. 34

35 2018 First Choice VIP Care Plus Document: 2018 Prior Authorization Formulary ID: Last Updated: 10/2018 Effective Date: BROVANA BROVANA Age Documentation of either trial or a medical reason (e.g. intolerance or hypersensitivity) for not being able to use a formulary long acting beta adrenergic agonist (LABA) 35

36 BUPHENYL sodium phenylbutyrate Age 36

37 2018 First Choice VIP Care Plus Document: 2018 Prior Authorization Formulary ID: Last Updated: 10/2018 Effective Date: BUSULFAN busulfan Age Provider attests that CBC and neutrophil counts will be monitored daily during administration of therapy must be an oncologist. 37

38 CABOMETYX CABOMETYX Age must be an oncologist. If all conditions are met the request will be approved until the end of 38

39 2018 First Choice VIP Care Plus Document: 2018 Prior Authorization Formulary ID: Last Updated: 10/2018 Effective Date: CALQUENCE CALQUENCE Age Provider attests that complete blood cell count will be monitored prior to initiation and throughout duration of therapy as indicated in compendia must be a hematologist or an oncologist. 39

40 CANCIDAS CANCIDAS caspofungin Age 40

41 2018 First Choice VIP Care Plus Document: 2018 Prior Authorization Formulary ID: Last Updated: 10/2018 Effective Date: CARBAGLU CARBAGLU Age 41

42 CGRP ANTAGONISTS AIMOVIG AUTOINJECTOR (2 PACK) Age Provider attests that patient has at least 4 migraine days per month or one or more severe migraines lasting for greater than 12 hours despite use of abortive therapy (e.g. triptans or NSAIDs). must be a neurologist. Initial request will be authorized for 6 months. Reauthorization until end of benefit year. For patient newly initiated on CGRP antagonists: Patient must have documented trial and failure, intolerance or a medical reason for not being able to use two medications from the following classes (with each drug belonging to a different class): beta adrenergic blockers, anti-epileptics (topiramate, valproate or divalproex). Patients with cluster headaches must try verapamil and one other agent from the list above. For reauthorization, patient must have experienced reduction of at least 1 headache day per month within the last month of the previous authorization period. Pending CMS Review. 42

43 2018 First Choice VIP Care Plus Document: 2018 Prior Authorization Formulary ID: Last Updated: 10/2018 Effective Date: CHOLBAM CHOLBAM Age Provider attests that liver function will be monitored for the duration of therapy as indicated in compendia. must be a hepatologist or pediatric gastroenterologist. contract year 43

44 CHORIONIC GONADOTROPIN chorionic gonadotropin, human Age 44

45 2018 First Choice VIP Care Plus Document: 2018 Prior Authorization Formulary ID: Last Updated: 10/2018 Effective Date: CIMZIA CIMZIA CIMZIA POWDER FOR RECONST CIMZIA STARTER KIT Age Documentation was submitted indicating that the member was evaluated for active or latent TB infection (i.e. tuberculin skin test). must be a rheumatologist, or gastroenterologist. Documentation of either trial or a medical reason (e.g. intolerance or hypersensitivity) for not being able to use the following agents was submitted: Humira (adalimumab) for Crohn's disease, and both Humira (adalimumab) and Enbrel (etanercept) for all other indications 45

46 CINRYZE CINRYZE Age 46

47 2018 First Choice VIP Care Plus Document: 2018 Prior Authorization Formulary ID: Last Updated: 10/2018 Effective Date: CLOFARABINE clofarabine Age Provider attests that CBC with differential, hepatic function, renal function, and cardiac function will be monitored for the duration of therapy as indicated in compendia. must be an oncologist 47

48 COMETRIQ COMETRIQ Age Provider attests that prior to initiation of therapy, blood pressure has been evaluated and will be monitored routinely, along with urine protein for the duration of therapy as indicated in compendia must be an oncologist. 48

49 2018 First Choice VIP Care Plus Document: 2018 Prior Authorization Formulary ID: Last Updated: 10/2018 Effective Date: CORLANOR CORLANOR Age For new starts only: patient must have chronic heart failure (NYHA II through IV), have LVEF of 35% or less, be in sinus rhythm and have resting heart rate greater than or equal to 70 bpm. Patient must be stabilized on the maximally tolerated dose of a beta blocker (unless if contraindicated). Patient also has history of hospitalization due to acute heart failure. must be a cardiologist Reauthorization criteria: lack of hospitalization due to acute heart failure while using Corlanor 49

50 COTELLIC COTELLIC Age Provider attests that LVEF, SCr, CPK, LFTs have been assessed, and dermatologic and ophthalmologic evaluations have been performed prior to initiation of therapy, and will be routinely assessed throughout the duration of therapy as indicated in compendia. Additionally, confirmation of BRAF V600K or V600E mutation status with an FDA approved test. must be an oncologist. 50

51 2018 First Choice VIP Care Plus Document: 2018 Prior Authorization Formulary ID: Last Updated: 10/2018 Effective Date: CUBICIN daptomycin intravenous recon soln 500 mg Age Documentation of a consultation with an infectious disease specialist. If being used to treat a condition caused by end-stage renal disease(esrd) and member is on dialysis, please bill to Medicare Part B. 51

52 CYRAMZA CYRAMZA Age Documentation of prior treatment history for related indications. Provider attests that liver function, proteinuria, thyroid function and blood pressure will be monitored for the duration of therapy as indicated in compendia. must be an oncologist. 52

53 2018 First Choice VIP Care Plus Document: 2018 Prior Authorization Formulary ID: Last Updated: 10/2018 Effective Date: CYSTAGON CYSTAGON Age 53

54 DACTINOMYCIN dactinomycin Age Provider attests that complete blood cell count, renal function, and liver function tests will be monitored prior to initiation and throughout duration of therapy as indicated in compendia must be an oncologist. 54

55 2018 First Choice VIP Care Plus Document: 2018 Prior Authorization Formulary ID: Last Updated: 10/2018 Effective Date: DARZALEX DARZALEX Age Documentation of prior treatment history for related indications. Provider attests that CBC monitoring will be completed for the duration of therapy as indicated in compendia. must be an oncologist. 55

56 DEFERASIROX EXJADE JADENU JADENU SPRINKLE Age Patients with serum creatinine greater than 2 times the age-appropriate upper limit of normal or creatinine clearance less than 40ml/min, patients with platelet counts less than 50,000/mm3 For diagnosis of Chronic iron overload due to transfusions: Laboratory Result within 30 days of request for Serum Ferritin concentration is (must remain greater than 1000 mcg/l), platelet counts, SCr and CrCl. For the diagnosis of chronic iron overload in nontransfusion-dependent thalassemia syndromes: Laboratory results with 30 days of result for serum ferritin levels (must remain greater than 300mcg/L), platelet counts, SCr and CrCl. 56

57 2018 First Choice VIP Care Plus Document: 2018 Prior Authorization Formulary ID: Last Updated: 10/2018 Effective Date: DEMSER DEMSER Age 57

58 DEPEN DEPEN TITRATABS Age For rheumatoid arthritis, documentation of either trial or a medical reason (e.g. intolerance, hypersensitivity or contraindication) for not being able to use the following agents was submitted: Humira (adalimumab) and Enbrel (etanercept). For Wilson's disease or cystinuria, the request will be approved 58

59 2018 First Choice VIP Care Plus Document: 2018 Prior Authorization Formulary ID: Last Updated: 10/2018 Effective Date: DEPO-PROVERA DEPO-PROVERA INTRAMUSCULAR SUSPENSION 400 MG/ML Age must be a gynecologist, family practice or an oncologist. 59

60 DIFICID DIFICID Age If all conditions are met, the request will be authorized for 10 days. Documentation of prior use, or a medical reason for being unable to use oral vancomycin for current infection. 60

61 2018 First Choice VIP Care Plus Document: 2018 Prior Authorization Formulary ID: Last Updated: 10/2018 Effective Date: DOPTELET DOPTELET Age Provider attests that complete blood count with differential will be monitored throughout the duration of the therapy as indicated in compendia. If all conditions are met, the request will be authorized for 5 days. 61

62 DORIBAX doripenem Age If all conditions are met, the request will be authorized for 14 days of treatment. 62

63 2018 First Choice VIP Care Plus Document: 2018 Prior Authorization Formulary ID: Last Updated: 10/2018 Effective Date: DORIPENEM doripenem Age If all conditions are met, the request will be authorized for 14 days of treatment. 63

64 DOXIL doxorubicin, peg-liposomal Age Provider attests that CBC with differential and cardiac function will be monitored for the duration of therapy as indicated in compendia. must be an oncologist. Documentation was submitted indicating trial and/or a documented medical reason (e.g. intolerance, hypersensitivity or contraindication) for not utilizing conventional doxorubicin to manage their medical condition 64

65 2018 First Choice VIP Care Plus Document: 2018 Prior Authorization Formulary ID: Last Updated: 10/2018 Effective Date: EGRIFTA EGRIFTA Age Documentation of active antiretroviral therapy for at least 8 weeks. 65

66 ELAPRASE ELAPRASE Age 66

67 2018 First Choice VIP Care Plus Document: 2018 Prior Authorization Formulary ID: Last Updated: 10/2018 Effective Date: ELITEK ELITEK Age must be an oncologist. If all conditions are met, the request will be approved for a 5 day duration. 67

68 EMCYT EMCYT Age Provider attests that serum calcium, liver function tests monitoring will be completed for the duration of therapy as indicated in compendia. must be an oncologist. 68

69 2018 First Choice VIP Care Plus Document: 2018 Prior Authorization Formulary ID: Last Updated: 10/2018 Effective Date: EMPLICITI EMPLICITI Age Documentation of prior treatment history for related indications. Provider attests that liver function test will be completed for the duration of therapy as indicated in compendia. must be an oncologist. 69

70 ENBREL ENBREL ENBREL MINI ENBREL SURECLICK Age Documentation was submitted indicating that the member was evaluated for active or latent TB infection (i.e. tuberculin skin test). must be a rheumatologist or dermatologist. Documentation was submitted indicating trials and/or a documented medical reason (e.g. intolerance, hypersensitivity or contraindication) for not utilizing these therapies to manage their medical condition: 1) For Rheumatoid Arthritis, Psoriatic Arthritis or Juvenile Idiopathic Arthritis: one DMARD (e.g. methotrexate, sulfasalazine, generic leflunomide (Arava), etc.). 2) For Ankylosing Spondylitis: two nonsteroidal antiinflammatory drugs (NSAIDS). 3) For Plaque Psoriasis: One of the following: moderate to high potency topical steroids, topical calcipotriene, Tazorac (tazorotene), methotrexate, UVB phototherapy and/or PUVA therapy. 70

71 2018 First Choice VIP Care Plus Document: 2018 Prior Authorization Formulary ID: Last Updated: 10/2018 Effective Date: ENDARI ENDARI Age Documentation that patient has had two or more painful sickle cell crises within the past 12 months and that they have been taking hydroxyurea for the past three months or longer. must be a hematologist. 71

72 EPCLUSA EPCLUSA Age Labs within 3 months of request: ALT/AST, and detectable HCV RNA viral load. In addition, documentation of genotype, treatment history, and if cirrhotic, documentation of compensated or decompensated cirrhosis. For appropriate genotypes, patient must have documented trial of Zepatier or Mavyret, or provide medical justification (e.g. intolerance or hypersensitivity) for not utilizing Zepatier or Mavyret to manage medical condition. must be a hepatologist, gastroenterologist, infectious disease specialist, or transplant specialist. If all conditions are met, request will be authorized for weeks based on AASLD-IDSA guidelines will be applied consistent with current AASLD-IDSA guidance. 72

73 2018 First Choice VIP Care Plus Document: 2018 Prior Authorization Formulary ID: Last Updated: 10/2018 Effective Date: EPOETIN ALFA EPOGEN INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML PROCRIT Age Laboratory results within 30 days of request: Hemoglobin, hematocrit, serum ferritin (normal level is greater than 100ng/ml), transferrin saturation (TSAT-normal level is greater than 20%), total iron binding capacity (TIBC) and serum iron. If all conditions are met, the request will be authorized for 3 months. For initial therapy, the Hgb must be less than 10g/dL for all indications. For re-authorization, Hgb must not exceed 10g/dL(cancer, CKD-not on dialysis), 11g/dL(CKD-on dialysis), 12g/dL(pediatric CKD, zidovudinetreated HIV patients), 10 to 13g/dL(Elective, noncardiac, nonvascular surgery needing red blood cell allogeneic transfusion reduction). 73

74 ERAXIS ERAXIS(WATER DILUENT) Age Documentation of a consultation with an infectious disease specialist. If all conditions are met, the request will be approved for up to 42 days of treatment per request. 74

75 2018 First Choice VIP Care Plus Document: 2018 Prior Authorization Formulary ID: Last Updated: 10/2018 Effective Date: ERBITUX ERBITUX INTRAVENOUS SOLUTION 100 MG/50 ML Age must be an oncologist. 75

76 ERIVEDGE ERIVEDGE Age must be an oncologist or dermatologist 76

77 2018 First Choice VIP Care Plus Document: 2018 Prior Authorization Formulary ID: Last Updated: 10/2018 Effective Date: ERLEADA ERLEADA Age For appropriate indication(s) patient must have history of bilateral orchiectomy or must be concurrently using Erleada with gonadotropinreleasing hormone (GnRH). must be an oncologist. 77

78 ERWINAZE ERWINAZE Age must be an oncologist. 78

79 2018 First Choice VIP Care Plus Document: 2018 Prior Authorization Formulary ID: Last Updated: 10/2018 Effective Date: ESBRIET ESBRIET Age Provider attests that liver function will be monitored for the duration of therapy as indicated in compendia. must be an pulmonologist. 79

80 ETOPOPHOS ETOPOPHOS Age Provider attests that CBC with differential will be monitored for the duration of therapy as indicated in compendia. must be an oncologist. 80

81 2018 First Choice VIP Care Plus Document: 2018 Prior Authorization Formulary ID: Last Updated: 10/2018 Effective Date: EXONDYS 51 EXONDYS 51 Age Documentation of baseline dystrophin level. Patient has ambulatory capacity and has been stable on corticosteroid therapy at least 6 months. Initial approval-6 months Reauth-end of the contract year Reauthorization criteria: prescriber has confirmed improvement in dystrophin levels from baseline 81

82 FABRAZYME FABRAZYME Age 82

83 2018 First Choice VIP Care Plus Document: 2018 Prior Authorization Formulary ID: Last Updated: 10/2018 Effective Date: FARESTON FARESTON Age Provider attests that CBC, electrolytes levels (including magnesium, potassium and calcium), and liver function tests will be monitored for the duration of therapy as indicated in compendia. must be an oncologist. Patient must have documented trial and failure or intolerance to tamoxifen. 83

84 FARYDAK FARYDAK Age Documentation of prior treatment history for related indications. Provider attests that CBC with differential and platelets, serum electrolytes (including potassium, magnesium, and phosphate), liver function tests and ECG monitoring will be completed for the duration of therapy as indicated in compendia. must be an oncologist. 84

85 2018 First Choice VIP Care Plus Document: 2018 Prior Authorization Formulary ID: Last Updated: 10/2018 Effective Date: FASLODEX FASLODEX Age Faslodex is contraindicated in pregnant women. If diagnosis is breast cancer, documentation of testing to confirm diagnosis. must be an oncologist. 85

86 FENTANYL CITRATE ORAL TRANSMUCOSAL fentanyl citrate Age The patient must be enrolled in the TIRF/REMS access program. must be an oncologist or pain specialist If all conditions are met, the request will be authorized for 6 months. Patient is currently receiving long-acting opioid therapy. 86

87 2018 First Choice VIP Care Plus Document: 2018 Prior Authorization Formulary ID: Last Updated: 10/2018 Effective Date: FERRIPROX FERRIPROX ORAL TABLET Age Documentation of the patient's serum ferritin level and absolute neutrophil count (ANC) greater than 1.5x10^9/L within 30 days of request. 87

88 FIRAZYR FIRAZYR Age 88

89 2018 First Choice VIP Care Plus Document: 2018 Prior Authorization Formulary ID: Last Updated: 10/2018 Effective Date: FLUDARABINE FLUDARABINE Age Provider attests that CBC with differential will be monitored for the duration of therapy as indicated in compendia. must be an oncologist. 89

90 FORTEO FORTEO Age Documentation showing patient falls into one of the following categories:postmenopausal woman who has a bone mineral density (BMD) value consistent with osteoporosis (i.e., T-scores equal to or less than -2.5) or postmenopausal woman who has had an osteoporotic fracture.postmenopausal woman who has T-scores from -1.5 to -2.5 and at least one of the following risk factors for fracture: thinness [low body mass index (less than 21 kg/m2)], history of fragility fracture since menopause, or history of hip fracture in a parent. Male greater than or equal to 65 years of age with T-score of -2.5 or less. Male less than 65 years of age with T-score of -2.5 or less and 2 or more risk factors for fractures or previous osteoporotic fracture. In addition, the following criteria is also applicable:the patient has a documented treatment failure or has a documented medical reason (intolerance, hypersensitivity, contraindication, etc) for not utilizing an oral bisphosphonate to manage their medical condition AND The therapy does not exceed the therapy maximum of 2 years. 90

91 2018 First Choice VIP Care Plus Document: 2018 Prior Authorization Formulary ID: Last Updated: 10/2018 Effective Date: GATTEX GATTEX 30-VIAL GATTEX ONE-VIAL Age Documentation that patient is dependent on parenteral support Provider is a gastroenterologist 91

92 GAUCHER DISEASE ENZYME REPLACEMENT THERAPY CEREZYME INTRAVENOUS RECON SOLN 400 UNIT ELELYSO VPRIV Age For Cerezyme requests: There is documentation that the patient has Gauchers disease severe enough to result in one of the following: moderate to severe anemia, thrombocytopenia with bleeding tendency, bone disease, and/or significant hepatomegaly or splenomegaly. For Cerezyme and Elelyso, there must be documentation of either trial or a medical reason (e.g. intolerance or hypersensitivity) for not being able to use VPRIV 92

93 2018 First Choice VIP Care Plus Document: 2018 Prior Authorization Formulary ID: Last Updated: 10/2018 Effective Date: GAUCHER DISEASE ORAL AGENTS CERDELGA miglustat ZAVESCA Age For Cerdelga requests, patients with undetermined CYP2D6 metabolizer status If request is for Cerdelga, patient's CYP2D6 metabolizer status, as determined by an FDA approved test. If request is for Zavesca or miglustat, documentation of medical reason why patient is unable to use VPRIV For reauthorization, patient must have continued benefit with the use of agent 93

94 GEODON INJECTION GEODON INTRAMUSCULAR Age 94

95 2018 First Choice VIP Care Plus Document: 2018 Prior Authorization Formulary ID: Last Updated: 10/2018 Effective Date: GILOTRIF GILOTRIF Age Provider attests that liver function monitoring will be completed for the duration of therapy as indicated in compendia. If diagnosis is non-small cell lung cancer, documentation of the FDA-approved test results confirming EGFR mutation status were submitted. must be an oncologist. 95

96 GLEEVEC imatinib Age Provider attests that CBC with differential and liver function tests will be completed for the duration of therapy as indicated in compendia. must be an oncologist. 96

97 2018 First Choice VIP Care Plus Document: 2018 Prior Authorization Formulary ID: Last Updated: 10/2018 Effective Date: GLEOSTINE GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG Age Provider attests that CBC with differential, liver function tests, renal function tests and pulmonary function tests will be completed for the duration of therapy as indicated in compendia. must be an oncologist. 97

98 GNRH AGONISTS ELIGARD ELIGARD (3 MONTH) ELIGARD (4 MONTH) ELIGARD (6 MONTH) FIRMAGON KIT W DILUENT SYRINGE FIRMAGON SUBCUTANEOUS RECON SOLN 120 MG LUPRON DEPOT LUPRON DEPOT (3 MONTH) LUPRON DEPOT (4 MONTH) LUPRON DEPOT (6 MONTH) LUPRON DEPOT-PED LUPRON DEPOT-PED (3 MONTH) TRELSTAR Age If the medication request is for the treatment of prostate cancer and if the request is for any other GnRH agonist other than Eligard, the patient must have a documented treatment failure after receiving an trial of Eligard and/or has another documented medical reason for not utilizing Eligard to treat their prostate cancer. 98

99 2018 First Choice VIP Care Plus Document: 2018 Prior Authorization Formulary ID: Last Updated: 10/2018 Effective Date: GOCOVRI GOCOVRI Age Patient must have a documented trial and intolerance to (or a medical reason for not being able to use) generic amantadine formulations. must be a neurologist. Initial request will be authorized for 3 months. Reauthorization until end of benefit year Re-authorization: confirmation of improvement in levodopa-induced dyskinesia due to use of Gocovri 99

100 GROWTH HORMONES GENOTROPIN GENOTROPIN MINIQUICK HUMATROPE NORDITROPIN FLEXPRO NUTROPIN AQ NUSPIN NUTROPIN AQ SUBCUTANEOUS CARTRIDGE 20 MG/2 ML (10 MG/ML) OMNITROPE Age Growth hormone deficiency-growth Hormone Stimulation Test results, Insulin Growth Factor 1 level, bone age testing, MRI of brain to rule out tumor, height, and weight. All other medically accepted uses can be approved. must be Endocrinologist Reauth criteria: For Growth hormone deficiency, require updated chart notes showing positive response to treatment 100

101 2018 First Choice VIP Care Plus Document: 2018 Prior Authorization Formulary ID: Last Updated: 10/2018 Effective Date: H. P. ACTHAR ACTHAR H.P. Covered Uses Age All medically-accepted indications not otherwise excluded from Part D For initial MS exacerbation, rheumatic disorders, collagen diseases, dermatologic diseases, serum sickness, ophthalmic disease and respiratory diseases, documentation was submitted indicating trials and/or a documented medical reason (e.g. intolerance, hypersensitivity or contraindication) for not utilizing high-dose parenteral corticosteroids to manage their medical condition. For Infantile spasms and MS exacerbation: neurologist. For Rheumatic Disorders and Collagen Diseases: rheumatologist. For Dermatologic: dermatologist. For Allergic state: allergist, immunologist. For Ophthalmic disease: optometrist, ophthalmologist. Respiratory diseases: pulmonologist. For Edematous state: nephrologist, rheumatologist. For MS exacerbation,1month. For other conditions, approve for 3months and reauth for coverage year. Reauthorization : 1) For continuation of therapy for MS exacerbation, documentation of symptom improvement and confirmation that member is currently maintained on multiple sclerosis drugs such as Copaxone, Avonex, or Aubagio. 2) For all other conditions, documented evidence of disease response to treatment as indicated by improvement in symptoms. 101

102 HAEGARDA HAEGARDA Age 102

103 2018 First Choice VIP Care Plus Document: 2018 Prior Authorization Formulary ID: Last Updated: 10/2018 Effective Date: HALAVEN HALAVEN Age Provider attests that patien's CBC will be monitored prior to each dose and that the patient will be screened for neuropathy throughout the course of therapy. must be an oncologist. 103

104 HEPSERA ADEFOVIR Age For the diagnosis of hepatitis B:Submitted current (within 30 days of request) laboratory values indicating evidence of active viral replication. Submitted current laboratory values indicating persistent elevations in ALT or AST or histologically active disease. Clinical evidence of Lamivudine-resistant hepatitis B virus or documented treatment failure with Lamivudine therapy. 104

105 2018 First Choice VIP Care Plus Document: 2018 Prior Authorization Formulary ID: Last Updated: 10/2018 Effective Date: HERCEPTIN HERCEPTIN Age Provider attests that left ventricular function will be monitored for the duration of therapy as indicated in compendia. For appropriate indication, detection of HER2 protein overexpression and HER2 gene amplification confirmed via FDA-approved tests by laboratories with demonstrated proficiency. must be an oncologist. 105

106 HETLIOZ HETLIOZ Age Diagnosis of non-24-hour sleep-wake disorder (non-24). Provider is a sleep specialist or neurologist. 106

107 2018 First Choice VIP Care Plus Document: 2018 Prior Authorization Formulary ID: Last Updated: 10/2018 Effective Date: HEXALEN HEXALEN Age Provider attests that CBC with differential testing will be completed for the duration of therapy as indicated in compendia. must be an oncologist. 107

108 HIGH DOSE OPIOID fentanyl transdermal patch 72 hour 100 mcg/hr methadone oral tablet 10 mg morphine oral tablet extended release 100 mg, 200 mg oxycodone oral tablet,oral only,ext.rel.12 hr Covered Uses Age All medically-accepted indications not otherwise excluded from Part D If all conditions are met, initial request: 6 months and continuing therapy: 12 months NEW TO HIGH DOSE OPIOID THERAPY (morphine equivalent dose 200 mg per day or greater): ONE of the following (A) pain associated with cancer or sickle cell disease OR (B) chronic non-cancer pain and member has a documented trial and failure and/or intolerance to ALL of the following: (1)two non-opioid containing pain medications (ex. NSAIDs, antidepressants, etc.) (2)current regimen is the lowest possible effective dose of opioid therapy (3) member is not being treated for substance abuse (4) if member is on concurrent benzodiazepines and/or muscle relaxant therapy, the prescriber should provide attestation of an intent to monitor side effects AND provide documentation that patient counseling has and will continue to take place outlining the risks and potential side effects of concurrent use of benzodiazepines, opioids and/or muscle relaxants. CONTINUING HIGH DOSE OPIOID THERAPY (morphine equivalent dose 200 mg per day or greater): ONE of the following: (A) pain associated with cancer or sickle cell disease OR (B) chronic non-cancer pain and ALL of the following: (1) member's pain has been assessed within the last 6 months (2) member is not being treated for substance abuse (3) if member is on concurrent benzodiazepines and/or muscle relaxant therapy, the prescriber provides attestation of an intent to monitor side effects AND provide documentation that patient counseling 108

109 2018 First Choice VIP Care Plus Document: 2018 Prior Authorization Formulary ID: Last Updated: 10/2018 Effective Date: has and will continue to take place outlining the risks and potential side effects of concurrent use. 109

110 HIGH RISK MEDICATION amitriptyline benztropine oral chlorzoxazone oral tablet 500 mg clemastine oral tablet 2.68 mg clomipramine COMFORT PAC-CYCLOBENZAPRINE cyclobenzaprine oral tablet 10 mg, 5 mg CYCLOTENS REFILL CYCLOTENS STARTER cyproheptadine dexmethylphenidate dextroamphetamine oral capsule, extended release 10 mg, 15 mg, 5 mg dextroamphetamine oral tablet 10 mg, 5 mg dextroamphetamine-amphetamine oral capsule,extended release 24hr dextroamphetamine-amphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 30 mg, 5 mg, 7.5 mg dihydroergotamine injection diphenhydramine hcl injection solution 50 mg/ml dipyridamole oral disopyramide phosphate oral capsule doxepin oral ergoloid estropipate glyburide micronized oral tablet 1.5 mg, 3 mg, 6 mg glyburide oral tablet 1.25 mg, 2.5 mg, 5 mg glyburide-metformin oral tablet mg, mg, mg guanfacine oral tablet hydroxyzine hcl oral solution 10 mg/5 ml hydroxyzine hcl oral tablet hydroxyzine pamoate imipramine hcl imipramine pamoate indomethacin oral ketorolac oral megestrol oral suspension 400 mg/10 ml (10 ml), 400 mg/10 ml (40 mg/ml), 625 mg/5 ml megestrol oral tablet MENEST meperidine oral solution meperidine oral tablet meprobamate methocarbamol oral methyldopa methyldopa-hydrochlorothiazide methyldopate methylphenidate hcl oral tablet methylphenidate hcl oral tablet extended release 20 mg methylphenidate hcl oral tablet extended release 24hr 18 mg, 27 mg, 36 mg, 54 mg nifedipine oral capsule NORPACE CR orphenadrine citrate oral pentazocine-naloxone perphenazine-amitriptyline phenadoz rectal suppository 12.5 mg promethazine oral promethazine rectal suppository 12.5 mg, 25 mg promethazine vc promethazine-phenylephrine promethegan rectal suppository 25 mg, 50 mg thioridazine trihexyphenidyl trimethobenzamide oral trimipramine 110

111 2018 First Choice VIP Care Plus Document: 2018 Prior Authorization Formulary ID: Last Updated: 10/2018 Effective Date: Age For patients 65 years old and older: The prescriber has documented the indication for the use of the high risk medication with an explanation of the specific benefit with the medication, and how that benefit outweighs the potential risk. The prescriber provides attestation of an intent to monitor side effects AND The prescriber must document that patient counseling has and will continue to take place outlining the risks and potential side effects of the medication. If the patient is 64 years old or younger, the request will be approved. If the patient is 65 years old or older, the patient will require prior authorization for the drug. 111

112 HIGH RISK MEDICATION, BUTALBITAL ascomp with codeine butalbital compound w/codeine butalbital-acetaminop-caf-cod oral capsule mg butalbital-acetaminophen oral tablet mg butalbital-acetaminophen-caff oral capsule mg butalbital-acetaminophen-caff oral tablet mg butalbital-aspirin-caffeine oral capsule codeine-butalbital-asa-caff Age For patients 65 years old and older: The prescriber has documented the indication for the use of the high risk medication with an explanation of the specific benefit with the medication, and how that benefit outweighs the potential risk. The prescriber provides attestation of an intent to monitor side effects AND The prescriber must document that patient counseling has and will continue to take place outlining the risks and potential side effects of the medication. Additionally, documentation was submitted of adequate trials and/or medical reason (e.g. intolerance or hypersensitivity) for not utilizing this therapy to manage their medical condition: one formulary oral NSAID If the patient is 64 years old or younger, the request will be approved. If the patient is 65 years old or older, the patient will require prior authorization for the drug. 112

113 2018 First Choice VIP Care Plus Document: 2018 Prior Authorization Formulary ID: Last Updated: 10/2018 Effective Date: HIGH RISK MEDICATION, CARISOPRODOL carisoprodol carisoprodol-asa-codeine carisoprodol-aspirin Age For patients 65 years old and older: The prescriber has documented the indication for the use of the high risk medication with an explanation of the specific benefit with the medication, and how that benefit outweighs the potential risk. The prescriber provides attestation of an intent to monitor side effects AND The prescriber must document that patient counseling has and will continue to take place outlining the risks and potential side effects of the medication. If the patient is 64 years old or younger, the request will be approved. If the patient is 65 years old or older, the patient will require prior authorization for the drug. If all conditions are met, the request will be authorized for 30 days. 113

114 HIGH RISK MEDICATION, DIGOXIN digitek oral tablet 250 mcg digox oral tablet 250 mcg digoxin oral solution 50 mcg/ml digoxin oral tablet 250 mcg Age For patients 65 years old and older: Patient must have documented trial and failure to doses up to 0.125mg per day OR the prescriber has documented the indication for the use of doses greater than 0.125mg per day. The prescriber provides attestation of an intent to monitor side effects AND The prescriber must document that patient counseling has and will continue to take place outlining the risks and potential side effects of the medication. If the patient is 64 years old or younger, the request will be approved. If the patient is 65 years old or older, the patient will require prior authorization for the drug. 114

115 2018 First Choice VIP Care Plus Document: 2018 Prior Authorization Formulary ID: Last Updated: 10/2018 Effective Date: HUMIRA HUMIRA HUMIRA PEDIATRIC CROHN'S START HUMIRA PEN HUMIRA PEN CROHN'S-UC-HS START HUMIRA PEN PSORIASIS-UVEITIS Age Documentation was submitted indicating that the member was evaluated for active or latent TB infection (i.e. tuberculin skin test). must be a rheumatologist, dermatologist, gastroenterologist or ophthalmologist For Hidradenitis suppurativa: confirmation of Hurley Stage II or III disease. Documentation was submitted indicating trials and/or a documented medical reason (e.g. intolerance, hypersensitivity or contraindication) for not utilizing these therapies to manage their medical condition: 1) For Rheumatoid Arthritis, Psoriatic Arthritis or Juvenile Idiopathic Arthritis: one DMARD (e.g. methotrexate, sulfasalazine, generic leflunomide (Arava), etc.). 2) For Ankylosing Spondylitis: two nonsteroidal anti-inflammatory drugs (NSAIDS). 3) For Plaque Psoriasis: One of the following: moderate to high potency topical steroids, topical calcipotriene, Tazorac (tazorotene), Methotrexate, UVB phototherapy and/or PUVA therapy. 4) For Crohns Disease and Ulcerative Colitis: one conventional oral therapy (e.g. azathioprine, sulfasalazine, prednisone, mesalamine products). 5) For Non-infectious Uveitis: one ophthalmic corticosteroid. 115

116 HYCAMTIN topotecan Age Provider attests that CBC with differential test will be completed for the duration of therapy as indicated in compendia. must be an oncologist 116

117 2018 First Choice VIP Care Plus Document: 2018 Prior Authorization Formulary ID: Last Updated: 10/2018 Effective Date: IBRANCE IBRANCE Age For diagnosis of breast cancer, documentation of specific type of cancer (e.g. HR-positive, HER2-negative). Provider attests that CBC with differential test will be completed for the duration of therapy as indicated in compendia. must be an oncologist. 117

118 ICLUSIG ICLUSIG Age Provider attests that CBC with differential, liver function tests, serum lipase, cardiac function and blood pressure will be monitored for the duration of therapy as indicated in compendia. must be an oncologist. 118

119 2018 First Choice VIP Care Plus Document: 2018 Prior Authorization Formulary ID: Last Updated: 10/2018 Effective Date: IDHIFA IDHIFA Age Provider attests that complete blood count and serum potassium, phosphate, calcium and uric acid levels will be monitored throughout the duration of the therapy as indicated in compendia. must be an oncologist or hematologist. 119

120 ILARIS ILARIS (PF) SUBCUTANEOUS RECON SOLN 180 MG/1.2 ML (150 MG/ML) ILARIS (PF) SUBCUTANEOUS SOLUTION Age 120

121 2018 First Choice VIP Care Plus Document: 2018 Prior Authorization Formulary ID: Last Updated: 10/2018 Effective Date: IMBRUVICA IMBRUVICA Age Provider attests that CBC with differential will be completed for the duration of therapy as indicated in compendia. must be an oncologist. 121

122 IMFINZI IMFINZI Age Provider attests that patient's liver function tests, thyroid function test, renal function tests, and serum blood glucose will be monitored prior to initiation and periodically throughout treatment with Imfinzi as indicated in compendia. must be an oncologist 122

123 2018 First Choice VIP Care Plus Document: 2018 Prior Authorization Formulary ID: Last Updated: 10/2018 Effective Date: IMMUNE SUPPRESSANT INJECTIONS mycophenolate mofetil hcl PROGRAF INTRAVENOUS Age A statement of medical necessity from the prescribing physician, including therapeutic trial of the oral equivalent to this product, and identification of adverse event or inadequate response associated with use of the oral agent. 123

124 INCRELEX INCRELEX Age 124

125 2018 First Choice VIP Care Plus Document: 2018 Prior Authorization Formulary ID: Last Updated: 10/2018 Effective Date: INGREZZA INGREZZA Age must be a neurologist or psychiatrist. For initial therapy: 6 months. Re-authorization: until end of benefit year Reauthorization: Confirmation of improvement in tardive dyskinesia symptoms due to use of Ingrezza 125

126 INLYTA INLYTA Age Provider attests that liver function tests, thyroid function and urinalysis will be completed for the duration of therapy as indicated in compendia. must be an oncologist. 126

127 2018 First Choice VIP Care Plus Document: 2018 Prior Authorization Formulary ID: Last Updated: 10/2018 Effective Date: INTRON-A INTRON A INJECTION Age 127

128 INVANZ ertapenem INVANZ Age 128

129 2018 First Choice VIP Care Plus Document: 2018 Prior Authorization Formulary ID: Last Updated: 10/2018 Effective Date: INVEGA paliperidone oral tablet extended release 24hr 1.5 mg, 3 mg, 6 mg, 9 mg Age For the diagnosis of schizophrenia: the patient must have documented failure or intolerance to a formulary second generation atypical antipsychotic 129

130 INVEGA SUSTENNA INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 117 MG/0.75 ML, 156 MG/ML, 234 MG/1.5 ML, 39 MG/0.25 ML, 78 MG/0.5 ML Age The member has a documented history of receiving oral risperidone or oral paliperidone without any clinically significant side effects. 130

131 2018 First Choice VIP Care Plus Document: 2018 Prior Authorization Formulary ID: Last Updated: 10/2018 Effective Date: INVEGA TRINZA INVEGA TRINZA INTRAMUSCULAR SYRINGE 273 MG/0.875 ML, 410 MG/1.315 ML, 546 MG/1.75 ML, 819 MG/2.625 ML Age The member has documented adequate treatment with Invega Sustenna for at least 4 months. 131

132 IRESSA IRESSA Age Provider attests that liver function monitoring will be completed for the duration of therapy as indicated in compendia. For metastatic non-small cell lung cancer (NSCLC), documentation of the FDA-approved test results confirming mutation were submitted. must be an oncologist. 132