2018 BCN Advantage Prior Authorization Criteria Last updated: November, 2017
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1 Abstral Actemra Adcirca Adempas Afinitor Afinitor- Disperz Alecensa Alunbrig Amitiza Amitriptyline Ampyra Anadrol-50 Androgel Androderm Aralast NP Aranesp Arcalyst Armodafinil Aubagio Avonex Bavencio Beleodaq Berinert Betaseron Bexarotene Bosulif Briviact Bydureon Byetta Cabometyx Cayston Cholbam Chorionic Gonadotropin Cimzia Cinryze Clomipramine Cometriq Copaxone Cotellic Crinone Cyramza Daliresp Darzalex Doxepin Duopa Dysport Empliciti Epclusa Epogen Erivedge Esbriet Estradiol Extavia Farydak Fentanyl Oral Fentora Firazyr Forteo Gattex Genotropin Gilenya Gilotrif Glassia Harvoni Hetlioz Humatrope Ibrance Iclusig Ilaris Imbruvica Imfinzi Imipramine Increlex Inflectra Inlyta Jakafi Juxtapid Kalydeco Kanuma Kineret Kisqali Kisqali Femara Korlym Kuvan Kynamro Kyprolis Lartruvo Lazanda Lenvima Letairis Lidocaine Transdermal Linzess Lonsurf Lynparza Mekinist Menest Modafinil Movantik Mozobil Myalept Natpara Nexavar Ninlaro Norditropin Novarel Nuplazid Nutropin Nutropin Aq Odomzo Ofev Omnitrope Opsumit Orencia, Orencia Clickject Orenitram Orkambi Otezla Oxandrolone Oxymetholone Pegasys Plegridy Pomalyst Praluent Procrit Procysbi Prolastin C Prolia Promacta Ravicti Rebif Relistor Remicade Remodulin Repatha Revatio Revlimid Rubraca Rydapt Saizen Samsca Serostim Sildenafil Simponi Sirturo Somavert Sovaldi Sprycel Stelara Strensiq Subsys Sutent Sylatron Sylvant SymlinPen Tabloid Tafinlar Tagrisso Tarceva Targretin Tasigna Tecentriq Tecfidera Testim Testostero ne Tetrabenazine Thalomid Thioridazine Topiramate Tracleer Treanda Trimipramine Tysabri Uptravi Vecamyl Vectibix Venclexta Victoza Votrient Xalkori Xeljanz Xgeva Xolair Xtandi Xyrem Yondelis Yervoy Zaleplon Zelboraf Zemaira Zejula Zolinza Zonisamide Zorbtive Zurampic Zydelig Zykadia Zytiga 1 of 84 H5883_Ph_18Nov17PAlist_NM
2 Actemra Exclusion criteria Required med info Prescriber restrictions Prescribing physician is a rheumatologist Coverage duration One Year Requires trial of etanercept (Enbrel) and adalimumab (Humira) when these medications are FDA labeled for the Part D coverable medically accepted indication. Adempas Exclusion criteria Required med info Prescriber restrictions 2 of 84
3 Afinitor Exclusion criteria Required med info Prescriber restrictions Prescriber is an oncologist Coverage is not provided when Affinitor is used in combination with Nexavar or Sutent Alecensa Exclusion criteria Required med info Prescriber restrictions Coverage duration Lifetime 3 of 84
4 Alunbrig Exclusion criteria Required med info Prescriber restrictions Amitzia Exclusion criteria Required med info Diagnosis: 1. Chronic idiopathic constipation (CIC) in adults or 2. Opioid-induced constipation in adults with chronic, non-cancer pain or 3. Irritable bowel syndrome (IBS) with constipation in women 18 years of age and older Prescriber restrictions Documentation of trial/failure within the last 12 months of: 1. A fiber laxative and 2. One of the following: a stimulant laxative or an osmotic laxative 4 of 84
5 Ampyra Exclusion criteria Patients with a history of seizure or moderate to severe renal impairment defined by a crcl of 50ml/min or less Required med info Initial requests require documentation of a 25 foot timed walk test. Renewal requests require documentation of improvement in walking distance of a 25 foot timed walk test compared to pretreatment. Prescriber restrictions Prescriber is a neurologist Coverage duration INITIAL = Three Months RENEWAL = One Year Initial coverage is provided to improve walking distance in patients with a diagnosis of multiple sclerosis who have the ability to walk a timed 25 foot walk test. renewal criteria: documentation that the member has shown an improvement in walking distance of a 25 foot timed walk test compared to pretreatment. 5 of 84
6 Transdermal Androgens Androgel, Androderm, Testim, Testipel, Testosterone Exclusion criteria Required med info Documentation of androgen deficiency syndrome confirmed by two morning testosterone levels less than 300 ng/dl and at least 2 clinical signs or symptoms specific to androgen deficiency Prescriber restrictions ALPHA-1-PROTEINASE INHIBITOR (Aralast NP, Glassia, Prolastin C, Zemaira) Exclusion criteria Required med info Prescriber restrictions 6 of 84
7 Arcalyst Exclusion criteria Required med info 12 years of age and older Prescriber restrictions Aubagio Exclusion criteria Required med info Prescriber restrictions 7 of 84
8 Avonex Exclusion criteria Required med info Prescriber restrictions Coverage duration Lifetime Bavencio Exclusion criteria Required med info Prescriber restrictions Coverage duration Lifetime 8 of 84
9 Beleodaq Exclusion criteria Required med info Prescriber restrictions Berinert Exclusion criteria Required med info Prescriber restrictions Prescribing physician is an immunologist or hematologist 9 of 84
10 Betaseron Exclusion criteria Required med info Prescriber restrictions Coverage duration Lifetime Bosulif Exclusion criteria Required med info Prescriber restrictions 10 of 84
11 Briviact Exclusion criteria Required med info Prescriber restrictions Cabometyx Exclusion criteria Required med info Prescriber restrictions 11 of 84
12 Cayston Exclusion criteria Required med info Prescriber restrictions Cayston is subject to Part B versus Part D coverage review Cholbam Exclusion criteria Required med info Prescriber restrictions 12 of 84
13 Chorionic Gonadotropin Exclusion criteria Required med info Prescriber restrictions 13 of 84
14 Cimzia Exclusion criteria Required med info Requires documentation of diagnosis and medication history or intolerance(s) Prescriber restrictions Crohn's Disease: Prescribed or recommended by a gastroenterologist RA: Prescribed or recommended by a rheumatologist. Rheumatoid arthritis, ankylosing spondylitis and psoriatic arthritis requires the member has tried and failed Humira and Enbrel, except if not tolerated due to documented clinical side effects. Crohn's disease, requires: 1) treatment with an adequate course of systemic corticosteroids (e.g., 40 mg to 60 mg prednisone per day for 7 to 14 days) has been ineffective or is contraindicated or 2) the patient has been unable to taper off an adequate course of systemic corticosteroids without experiencing worsening of disease or 3) the patient is experiencing breakthrough disease (e.g., active disease flares) while stabilzed for at least 2 months on an immunomodulatory medication (such as azathioprine, mercaptopurine, cyclosporine, or methotrexate) and 4) adalimumab (Humira) is not effective after at least an initial 3-dose induction period, except if not tolerated due to documented clincial side effects. 14 of 84
15 Cinryze Exclusion criteria Required med info Prescriber restrictions Prescribed by an immunologist, allergist, or rheumatologist Cometriq Exclusion criteria Required med info Prescriber restrictions 15 of 84
16 Copaxone Exclusion criteria Required med info Prescriber restrictions Coverage duration Lifetime Cotellic Exclusion criteria Required med info Prescriber restrictions Coverage duration Lifetime 16 of 84
17 Crinone Exclusion criteria Required med info Prescriber restrictions Cyramza Exclusion criteria Required med info Prescriber restrictions Coverage duration Lifetime 17 of 84
18 Daliresp Exclusion criteria Required med info Diagnosis and patient medication history Prescriber restrictions Coverage is provided for the treatment of severe chronic obstructive pulmonary disease (COPD) associated with chronic bronchitis in patients with a history of exacerbations and patient is receiving: 1. inhaled long-acting beta-2 agonist [for example, Formoterol, Salmeterol] AND 2. inhaled long-acting anticholinergic agent [for example, Tiotropium] AND 3. inhaled corticosteroid [for example, Fluticasone] OR 4. Patient experienced intolerance or has contraindications to use of these medications Darzalex Exclusion criteria Required med info Prescriber restrictions Coverage duration Lifetime 18 of 84
19 Duopa Exclusion criteria Required med info Prescriber restrictions Subject to Part B versus D coverage review. Duopa may be covered under Medicare Part B if the patient is receiving enteral suspension administered as a continuous infusion using a portable infusion pump. It may be covered under Medicare Part D if the patient is receiving enteral suspension short-term via a naso-jejunal tube 19 of 84
20 Dysport Exclusion criteria Will not be covered for cosmetic purposes Required med info Prescriber restrictions Empliciti Exclusion criteria Required med info Prescriber restrictions Coverage duration Lifetime 20 of 84
21 Epclusa Exclusion criteria Required med info CRITERIA WILL BE APPLIED CONSISTENT WITH CURRENT AASLD/IDSA GUIDANCE Prescriber restrictions Coverage duration CRITERIA WILL BE APPLIED CONSISTENT WITH CURRENT AASLD/IDSA GUIDANCE CRITERIA WILL BE APPLIED CONSISTENT WITH CURRENT AASLD/IDSA GUIDANCE Erythropoesis Stimulating Agents: Aranesp, Epogen, Procrit Exclusion criteria Required med info Prescriber restrictions Coverage duration 3 months Erythropoesis stimulating agents are subject to Part B vs Part D review. 21 of 84
22 Erivedge Exclusion criteria Required med info Prescriber restrictions Prescribed by or in consultation with a dermatologist or oncologist Esbriet Exclusion criteria Required med info Prescriber restrictions 22 of 84
23 Estrogens (Estradiol, Menest) Exclusion criteria Required med info Authorization is required for members 65 years of age and older Prescriber restrictions Oral Estrogen (Menest) will be approved when used as part of a cancer treatment regimen. For all other uses, Menest will be approved if two of the following safer alternatives as been tried and failed or are not appropriate or contraindicated. Safer alternatives include: e.g., SSRIs, venlafaxine ER, Premarin vaginal cream, Estrace vaginal creams, Estring or Femring Vaginal Rings, Vagifem vaginal tablets 23 of 84
24 Extavia Exclusion criteria Required med info Prescriber restrictions Coverage duration Lifetime Farydak Exclusion criteria Required med info Prescriber restrictions 24 of 84
25 Firazyr Covered uses Exclusion criteria Required med info Prescriber restrictions Coverage duration For acute attacks of hereditary angioedema (HAE). All FDA approved indications not otherwise excluded from Part D. 18 years of age or older Prescribing physician is an immunologist or hematologist One Year Forteo Exclusion criteria Coverage is not provided for hypocalcemia Required med info Prescriber restrictions Coverage duration One year with maximum two years of therapy Requires patient has tried and failed at least one bisphosphonate except when: 1. Contraindication to an oral and intravenous bisphosphonate (such as a stricture or aclasia, inability to stand or sit upright for at least 30 minutes and increased risk of aspiration) 2. Documented intolerance to a bisphosphonate 25 of 84
26 Gattex Exclusion criteria Required med info Prescriber restrictions Coverage duration Lifetime Gilenya Exclusion criteria Required med info Prescriber restrictions 26 of 84
27 Giltorif Exclusion criteria Required med info Prescriber restrictions Harvoni Exclusion criteria Required med info Prescriber restrictions Coverage duration Criteria will be applied consistent with current AASLD/IDSA guidance Criteria will be applied consistent with current AASLD/IDSA guidance 27 of 84
28 Growth Hormone: Genotropin, Humatrope, Increlex, Norditropin, Nutropin, Nutropin AQ, Omnitrope, Saizen, Serostim, Somavert, Zorbtive Exclusion criteria Required med info Covered for the replacement of endogenous growth hormone in adults with growth hormone deficiency of childhood onset or adult onset. Covered if initial diagnosis based on two growth hormone stimulation tests and that the patient does not have edema, arthralgias, or carpal tunnel syndrome. Serostim is covered for aids wasting cachexia. Norditropin is covered for Noonan syndrome, Turner syndrome, and adult growth hormone deficiency. Nutropin is covered for Turner syndrome, and adult growth hormone deficiency. Omnitrope and Saizen are covered for adult growth hormone deficiency. Zorbtive is covered for the treatment of short-bowel syndrome in patients receiving specialized nutritional support. Somavert is covered for acromegaly. Prescriber restrictions 28 of 84
29 Hetlioz Exclusion criteria Required med info Documentation of patient visual capabilities Prescriber restrictions Coverage duration Lifetime Hepatitis Treatments: Pegasys, Pegasys proclick Exclusion criteria Required med info Documentation of concomitant Ribavarin use (or contraindications) is required when requesting initial use for Hepatitis C. Documentation of viral genotype is required for Hepatitis C. Documentation of response to therapy is required for requests for continuation of therapy for Hepatitis C Prescriber restrictions Coverage duration Initiation of Therapy: 12 weeks Continuation Therapy: 24 to 48 weeks 29 of 84
30 High Risk in the Elderly Medications: High Risk in the Elderly Drugs: Tricyclic Antidepressants: Amitriptyline, Clomipramine, Doxepin, Imipramine, Trimipramine Exclusion criteria Required med info Authorization is required for formulary high risk medications for members 65 years of age and older Prescriber restrictions High Risk Tricyclic Antidepressants are approved if patient has a history of use. For patients initiating therapy, the high risk tricyclic antidepressant is approved if at least one of the suggested alternatives (nortriptyline, desipramine, citalopram, escitalopram, mirtazapine, sertraline, venlafaxine) with less sedation and fewer anticholinergic effects have been tried and failed or is not appropriate or contraindicated for the intended use. 30 of 84
31 High Risk in the Elderly Medications: Zaleplon Exclusion criteria Required med info Authorization is required for formulary high risk medications for members 65 years of age and older Prescriber restrictions Lunesta (Zaleplon) is approved if at least one of the suggested alternatives, (low dose Trazodone (25-50mg) or Rozerem), has been tried and failed or is not appropriate or contraindicated for the intended use. High Risk in the Elderly Medications: Thioridiazine Exclusion criteria Required med info Prior authorization is required for formulary high risk medications for members 65 years of age and older Prescriber restrictions Thioridizine is covered for patients who have a history of use. For patients initiating therapy, thioridizine is covered if patient has a failure of or intolerance to at least one other safer alternative antipsychotic such as aripiprazole or quetiapine. 31 of 84
32 Ibrance Exclusion criteria Required med info Prescriber restrictions Iclusig Exclusion criteria Required med info Prescriber restrictions 32 of 84
33 Ilaris Exclusion criteria Required med info Requires documentation of diagnosis. Prescriber restrictions Imbruvica Exclusion criteria Required med info Prescriber restrictions 33 of 84
34 Imfinzi Exclusion criteria Required med info Prescriber restrictions Inflectra Exclusion criteria Required med info Prescriber restrictions 34 of 84
35 Injectable Diabetic Medications: Byetta, Bydureon, Victoza, SymlinPen Exclusion criteria Not covered for non Type 2 diabetes diagnosis. Not covered for weight loss in patients with or without diabetes. Required med info Prescriber restrictions Coverage duration Lifetime Byetta, Bydureon, Victoza: Approved as adjunctive therapy to improve glycemic control in patients who have a diagnosis of Type II Diabetes Mellitus and are currently taking or have tried and failed at least One of the following: Metformin, a Sulfonylurea, or a Thiazolidinedione, or One of the following: a combination of metformin and a sulfonylurea or a combination of Metformin and a Thiazolidinedione. SymlinPen is covered for patients that have failed intensive treatment with insulin monotherapy and for concurrent use with an insulin product 35 of 84
36 Inlyta Exclusion criteria Coverage is not provided for combination use with other tyrosine kinase inhibitors such as Sorafenib, Sunitinib Required med info Coverage for the treatment of renal cell carcinoma is provided after failure with one prior systemic therapy Prescriber restrictions Jakafi Exclusion criteria Required med info Prescriber restrictions Prescribed by a hematologist / oncologist 36 of 84
37 Juxtapid Exclusion criteria Required med info Requires documentation of diagnosis of homozygous familial hypercholesterolemia. Prescriber restrictions Coverage duration Lifetime Requires trial and failure of Kynamro Kalydeco Exclusion criteria Required med info Prescriber restrictions Coverage duration Lifetime 37 of 84
38 Kanuma Exclusion criteria Required med info Prescriber restrictions Kineret Exclusion criteria Required med info Prescriber restrictions Rheumatoid arthritis requires a treatment failure or contraindication to Enbrel or Humira. 38 of 84
39 Kisqali, Kisqali Femara Exclusion criteria Required med info Prescriber restrictions Korlym Exclusion criteria Required med info Prescriber restrictions 39 of 84
40 Kynamro Exclusion criteria Required med info Prescriber restrictions Coverage duration Lifetime Kyprolis Exclusion criteria Required med info Prescriber restrictions Coverage duration Lifetime 40 of 84
41 Lartruvo Effective Date: March 1, 2018 Exclusion criteria Required med info Prescriber restrictions Coverage duration Lifetime Lenvima Exclusion criteria Required med info Prescriber restrictions 41 of 84
42 Lidocaine Transdermal Patch Exclusion criteria Required med info Prescriber restrictions Linzess Exclusion criteria Required med info Prescriber restrictions Chronic idiopathic constipation (CIC) requires documentation of failure within the last 12 months of use of a fiber laxative and one of the following: a stimulant laxative or an osmotic laxative. Drug-induced constipation must be ruled out. 42 of 84
43 Lonsurf Exclusion criteria Required med info Prescriber restrictions Coverage duration Lifetime Lynparza Exclusion criteria Required med info Prescriber restrictions 43 of 84
44 Mekinist Exclusion criteria Required med info Confirmation of the presence of BRAF V600E or V600K mutation in tumor specimen Prescriber restrictions Modafinil, Armodafinil Exclusion criteria Required med info Prescriber restrictions 44 of 84
45 Movantik Exclusion criteria Required med info Prescriber restrictions Mozobil Exclusion criteria Required med info Prescriber restrictions Coverage duration Duration requested up to one month 45 of 84
46 Myalept Exclusion criteria Coverage is not provided for the following: general obesity, HIV-related lipodystrophy, partial lipodystrophy, metabolic disease (without concurrent generalized lipodystrophy) or liver disease. Required med info Diagnosis of congenital or acquired generalized lipodystrophy Prescriber restrictions Prescribing physician is an endocrinologist Coverage duration Initial = 3 months Renewal = 1 year Narcotic Analgesics: Abstral, Fentanyl Citrate Oral Transmucosal, Fentora, Lazanda, Onsolis, Subsys Exclusion criteria Required med info Requires documentation of diagnosis and medication history Prescriber restrictions Covered for cancer or cancer related diagnosis in patients already receiving long acting opioids 46 of 84
47 Natpara Exclusion criteria Required med info Prescriber restrictions Nexavar Exclusion criteria Required med info Prescriber restrictions Hepato-cellular carcinoma: Prescribed by an oncologist, hepatologist, or gastroenterologist All other indications: Prescribed by an oncologist Ninlaro 47 of 84
48 Exclusion criteria Required med info Prescriber restrictions Coverage duration Lifetime Nuplazid Exclusion criteria Required med info Prescriber restrictions Odomzo 48 of 84
49 Exclusion criteria Required med info Prescriber restrictions Coverage duration Lifetime Ofev Exclusion criteria Required med info Prescriber restrictions Coverage duration One year 49 of 84
50 Orencia, Orencia Clickject Exclusion criteria Required med info Prescriber restrictions Coverage is provided when there has been a trial and failure or contraindication to Enbrel or Humira Orenitram Exclusion criteria Required med info Prescriber restrictions Coverage duration Lifetime Orkambi 50 of 84
51 Exclusion criteria Required med info Prescriber restrictions Coverage duration Lifetime Otezla Exclusion criteria Required med info Prescriber restrictions Coverage is provided for moderate to severe plaque psoriasis or psoriatic arthritis when there has been a trial and failure or contraindication to Enbrel or Humira Oxandrolone 51 of 84
52 Covered uses Exclusion criteria Required med info Prescriber restrictions Coverage duration All medically accepted indications not otherwise excluded from Part D One Year Oxymetholone, Anadrol-50 Exclusion criteria Coverage will not be provided if anabolic steroids are used to enhance athletic performance or for anti-aging purposes Required med info Oxymetholone: Documentation that use is 1) for therapy to offset protein catabolism associated with prolonged use of corticosteroids. 2) for bone pain associated with osteoporosis. 3) as prophylactic therapy in patients with hereditary angioedema. anadrol-50 requires documentation of:1) HIV associated wasting.2) prophylactic therapy for hereditary angioedema.3) clinically diagnosed anemia. Prescriber restrictions 52 of 84
53 Plegridy Exclusion criteria Required med info Prescriber restrictions Pomalyst Exclusion criteria Required med info Diagnosis of multiple myeloma Prescriber restrictions Coverage is provided if: 1) Patient has received at least two prior therapies including Lenalidomide and Bortezomib and 2) Demonstrated disease progression on or within 60 days of completion of the last therapy. 53 of 84
54 Praluent Exclusion criteria Required med info Prescriber restrictions Procysbi Exclusion criteria Required med info Prescriber restrictions Coverage duration Lifetime 54 of 84
55 Prolia Exclusion criteria Coverage is not provided for hypocalcemia Required med info Prescriber restrictions Prolia is subject to Part B versus Part D review Requirements: Patient has tried and failed at least one bisphosphonate except when: 1. Contraindication to a bisphosphonate (oral and intravenous) such as a stricture or aclasia, inability to stand or sit upright for at least 30 minutes and increased risk of aspiration 2. Documented intolerance to a bisphosphonate 55 of 84
56 Promacta Exclusion criteria Required med info Requires documentation of diagnosis, medication history or intolerance(s), platlet counts. Prescriber restrictions Prescribed or recommended by a hematologist, hepatologist or gastroenterologist. Coverage duration Initiation of therapy 12 week approval Continuation therapy - 12 month approval Pulmonary Agents: Adcirca, Letairis, Opsumit, Revatio oral suspension, Sildenafil Citrate 20mg, Remodulin, Tracleer Exclusion criteria Required med info Prescriber restrictions Coverage for Revatio and Adcirca is not provided in situations where patients are receiving nitrate therapy. 56 of 84
57 Ravicti Exclusion criteria Required med info Prescriber restrictions 57 of 84
58 Rebif Exclusion criteria Required med info Prescriber restrictions Coverage duration Lifetime Relistor Exclusion criteria Required med info Prescriber restrictions Coverage duration Three Months Requires adequate treatment consisting of 5 days duration of treatment of agents for constipation, including at least any two of the following: Bulk laxatives, saline laxatives or osmotic laxatives. Coverage may not be provided if there are contraindications to Methylnaltrexone therapy. 58 of 84
59 Remicade Exclusion criteria Required med info Verification that the patient has been evaluated for TB and treated accordingly Prescriber restrictions Remodulin Exclusion criteria Required med info Prescriber restrictions 59 of 84
60 Repatha Exclusion criteria Required med info Prescriber restrictions Revlimid Exclusion criteria Required med info Prescriber restrictions Prescribed by or in consultation with an oncologist or hematologist 60 of 84
61 Rubraca Exclusion criteria Required med info Prescriber restrictions Rydapt Exclusion criteria Required med info Prescriber restrictions 61 of 84
62 Samsca Exclusion criteria Required med info Documentation that patient does not have underlying liver disease Prescriber restrictions Coverage duration One Month Kuvan (Sapropterin hydrochloride) Exclusion criteria Required med info Prescriber restrictions Coverage duration Initial - 2 months auth will be extended for 1 year if documented response after initial therapy Renewal criteria: after initial therapy of 2 months. a 30% or greater reduction in phenylalanine from baseline 62 of 84
63 Simponi Exclusion criteria Required med info Requires verification that the patient has been evaluated for TB and treated accordingly Prescriber restrictions For ulcerative colitis, coverage is provided when the member has tried and failed Humira unless contraindicated or not tolerated due to documented clinical side effects. All other indications for use require the member has tried and failed Humira and Enbrel, except if contraindicated or not tolerated due to documented clinical side effects. Sirturo Exclusion criteria Required med info Diagnosis Prescriber restrictions Must be used in combination with at least 3 other agents 63 of 84
64 Sovaldi Exclusion criteria Required med info Prescriber restrictions Coverage duration Criteria will be applied consistent with current AASLD/IDSA guidance Criteria will be applied consistent with current AASLD/IDSA guidance Sprycel Exclusion criteria Required med info Prescriber restrictions Prescribed by oncologist 64 of 84
65 Stelara Exclusion criteria Crohn's disease Required med info Requires verification that the patient has been evaluated for TB and has been treated accordingly. Prescriber restrictions For Crohn's, coverage is provided when the member has tried and failed Humira unless contraindicated or not tolerated due to documented clinical side effects. All other indications for use require the member has tried and failed Humira and Enbrel, except if contraindicated or not tolerated due to documented clinical side effects. Strensiq Exclusion criteria Required med info Prescriber restrictions 65 of 84
66 Sutent Exclusion criteria Required med info Prescriber restrictions Prescribed by oncologist Sylatron Exclusion criteria Required med info Prescriber restrictions Prescribed by oncologist 66 of 84
67 Sylvant Exclusion criteria Required med info Prescriber restrictions Tabloid Exclusion criteria Required med info Prescriber restrictions Prescribed by oncologist or hematologist 67 of 84
68 Tafinlar Exclusion criteria Required med info Confirmation of the presence of BRAF V600E or BRAF V600K mutation in tumor specimen as detected by an FDA-approved test Prescriber restrictions Tagrisso Exclusion criteria Required med info Prescriber restrictions Coverage duration Lifetime 68 of 84
69 Tarceva Exclusion criteria Required med info Prescriber restrictions Prescribed by oncologist Targretin/Bexarotene Exclusion criteria Required med info Prescriber restrictions Prescribed by oncologist or dermatologist 69 of 84
70 Tasigna Exclusion criteria Required med info Prescriber restrictions Ticfidera Exclusion criteria Required med info Prescriber restrictions Coverage duration Lifetime 70 of 84
71 Tecentriq Exclusion criteria Required med info Prescriber restrictions Tetrabenazine Exclusion criteria Coverage for Xenazine or Tetrabenazine will not be provided for patients who have hepatic function impairment, patients who are actively suicidal or who have untreated or inadequately treated depression, or patients taking monoamine oxidase inhibitors or reserpine. Required med info Prescriber restrictions Coverage duration Lifetime 71 of 84
72 Thalomid Exclusion criteria Required med info Prescriber restrictions Topiramate Exclusion criteria Required med info Prescriber restrictions 72 of 84
73 Treanda Exclusion criteria Required med info Prescriber restrictions Tysabri Exclusion criteria Required med info Prescriber restrictions Coverage is provided for relapsing-remitting form of multiple sclerosis when there is documentation of a trial of Copaxone and at least one other interferon beta product unless contraindicated. For Crohns disease coverage is provided with documentation of a trial and failure of Humira and either Cimzia or Stelara 73 of 84
74 Uptravi Exclusion criteria Required med info Prescriber restrictions Vecamyl Exclusion criteria Required med info Prescriber restrictions 74 of 84
75 Vectibex Exclusion criteria Required med info Prescriber restrictions Prescribed by an oncologist Venclexta Exclusion criteria Required med info Prescriber restrictions 75 of 84
76 Votrient Exclusion criteria Required med info Documentation of advanced renal cell carcinoma Prescriber restrictions Prescribed by an oncologist Xalkori Exclusion criteria Required med info Diagnosis of locally advanced or metastatic non-small cell lung cancer (NSCLC) that is anaplastic lymphoma kinase (alk)-positive as detected by a FDA-approved test. Prescriber restrictions 76 of 84
77 Xeljanz Exclusion criteria Required med info Requires documentation of diagnosis and medication history or intolerance(s). Prescriber restrictions Prescribed or recommended by a rheumatologist Requires a treatment failure or contraindication to Enbrel and Humira. Xgeva Exclusion criteria Required med info Prescriber restrictions 77 of 84
78 Xolair Exclusion criteria Required med info Prescriber restrictions Xtandi Exclusion criteria Required med info Coverage is provided for the treatment of metastatic castration-resistant prostate cancer where the patient has had prior treatment with docetaxel. Prescriber restrictions Prescribed or recommended by an oncologist or urologist 78 of 84
79 Xyrem Exclusion criteria Required med info Prescriber restrictions Yervoy Exclusion criteria Required med info Prescriber restrictions Prescribed by an oncologist 79 of 84
80 Yondelis Exclusion criteria Required med info Prescriber restrictions Coverage duration Lifetime Zejula Exclusion criteria Required med info Prescriber restrictions Coverage duration Lifetime 80 of 84
81 Zelboraf Exclusion criteria Will not be covered in combination with Yervoy Required med info Prescriber restrictions Prescribed by an oncologist Zolinza Exclusion criteria Required med info Prescriber restrictions 81 of 84
82 Zonisamide Exclusion criteria Required med info Prescriber restrictions Zurampic Exclusion criteria Required med info Prescriber restrictions 82 of 84
83 Zydelig Exclusion criteria Required med info Prescriber restrictions Zykadia Exclusion criteria Required med info Prescriber restrictions Coverage duration Lifetime 83 of 84
84 Zytiga Exclusion criteria Required med info Prescriber restrictions 84 of 84
2018 BCN Advantage Prior Authorization Criteria Last updated: April, 2018
Abstral Actemra Adcirca Adempas Aliqopa Afinitor Afinitor- Disperz Alecensa Alunbrig Amitiza Amitriptyline Ampyra Anadrol-50 Androgel Androderm Aralast NP Aranesp Arcalyst Armodafinil Aubagio Avonex Bavencio
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ANTIDEPRESSANTS EMSAM PATCH 24 HOUR 12 MG/24HR TRANSDERMAL EMSAM PATCH 24 HOUR 6 MG/24HR TRANSDERMAL EMSAM PATCH 24 HOUR 9 MG/24HR TRANSDERMAL FETZIMA CAPSULE EXTENDED RELEASE 24 HOUR 120 MG FETZIMA CAPSULE
Diagnosis of severe congenital A1-PI deficiency who have clinically evident emphysema, weight, A1-PI phenotype, A1-PI baseline level
AAT DEFICIENCY Aralast NP intravenous recon soln 1,000 mg Glassia Prolastin-C intravenous recon soln Zemaira Other Diagnosis of severe congenital A1-PI deficiency who have clinically evident emphysema,
Covered Uses All medically accepted indications not otherwise excluded from Part D.
AAT DEFICIENCY Aralast NP intravenous recon soln 1,000 mg Glassia Prolastin-C intravenous recon soln Zemaira PA Details Age Other Diagnosis of severe congenital A1-PI deficiency who have clinically evident
LIMITED DISTRIBUTION MEDICATIONS
ACTEMRA IV (USSC can dispense 162 mg PFS) ACTHAR HP ACTIMMUNE ADAGEN ADCETRIS CVS Specialty 1-800-237-2767 1-800-237-2767 ADEMPAS ADVATE ALDURAZYME ALECENSA ALIQOPA ALUNBRIG AMPYRA APOKYN ARALAST NP ARCALYST
Diagnosis of severe congenital A1-PI deficiency who have clinically evident emphysema, weight, A1-PI phenotype, A1-PI baseline level
AAT DEFICIENCY Aralast NP intravenous recon soln 1,000 Prolastin-C intravenous recon soln mg Zemaira Glassia Other Diagnosis of severe congenital A1-PI deficiency who have clinically evident emphysema,
ACNE AGENTS_NVT Chinese Community Health Plan Senior Select Program (HMO SNP)
ACNE AGENTS_NVT adapalene 0.3% gel pump adapalene topical cream adapalene topical gel avita tretinoin tretinoin microspheres topical gel Age Other 1 ADAGEN_NVT ADAGEN Age Other 2 ADCIRCA_NVT 2017 ADCIRCA
ANTIDEPRESSANTS. Details. Step Therapy 2018 Last Updated: 8/21/2018
ANTIDEPRESSANTS EMSAM PATCH 24 HOUR 12 MG/24HR TRANSDERMAL EMSAM PATCH 24 HOUR 6 MG/24HR TRANSDERMAL EMSAM PATCH 24 HOUR 9 MG/24HR TRANSDERMAL FETZIMA CAPSULE EXTENDED RELEASE 24 HOUR 120 MG ORAL FETZIMA
ACTHAR HP GEL PA MEDICATION(S) H.P. ACTHAR. COVERED USES All FDA-approved indications not otherwise excluded from Part D. EXCLUSION CRITERIA N/A
ACTHAR HP GEL PA H.P. ACTHAR Criteria for approval are ALL of the following: 1. ONE of: A. Diagnosis of infantile spasm OR B. Diagnosis of multiple sclerosis AND i. Patient is experiencing an acute exacerbation
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ACITRETIN. Products Affected
ACITRETIN acitretin Other For prophylaxis of skin cancer in patients with previously treated skin cancers who have undergone an organ transplantation the request will be approved. For psoriasis: the patient
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ARISTADA Aristada Prefilled Syringe 1064 MG/3.9ML Intramuscular Aristada Prefilled Syringe 441 MG/1.6ML Intramuscular Aristada Prefilled Syringe 662 MG/2.4ML Intramuscular Aristada Prefilled Syringe 882
Somavert ALL FDA-APPROVED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D.
ACROMEGALY THERAPY Somatuline Depot subcutaneous syringe 120 mg/0.5 ml, 60 mg/0.2 ml, 90 mg/0.3 ml Somavert Age Other ALL FDA-APPROVED INDICATIONS NOT OTHERWISE PATIENT PROGRESS NOTES, DOCUMENTATION OF
2015 PRIOR AUTHORIZATION CRITERIA TABLE OF CONTENTS ACTHAR HP GEL... 8 ADCIRCA... 9 AFINITOR AFINITOR DISPERZ AMITIZA...
2015 PRIOR AUTHORIZATION CRITERIA TABLE OF CONTENTS ACTHAR HP GEL... 8 ADCIRCA... 9 AFINITOR... 77 AFINITOR DISPERZ... 77 AMITIZA... 10 amitriptyline... 48 AMPYRA... 11 ANADROL-50... 14 RODERM... 17 ROGEL...
AAT DEFICIENCY. Products Affected Aralast Np INJ 1000MG, 500MG Glassia Prolastin-c INJ 1000MG Zemaira
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PRESCRIPTION DRUGS REQUIRING PRIOR AUTHORIZATION
Abstral fentanyl citrate oral tablet Controlled Dangerous substance Actemra tocilizumab Monoclonal antibody Acthar corticotropin Hormone Actimmune interferon gamma 1b Interferon Actiq fentanyl citrate
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DIFICID. Products Affected Step 2: DIFICID TABLET 200 MG ORAL. Details
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ACITRETIN. Products Affected
ACITRETIN acitretin Other For prophylaxis of skin cancer in patients with previously treated skin cancers who have undergone an organ transplantation the request will be approved. For psoriasis: the patient
1 P a g e. Systemic Juvenile Idiopathic Arthritis (SJIA) (1.3) Patients 2 years of age and older with active systemic juvenile idiopathic arthritis.
LENGTH OF AUTHORIZATION: Initial: 3 months for Crohn s or Ulcerative Colitis; 1 year for all other indications. Renewal: 1 year dependent upon medical records supporting response to therapy and review
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Cimzia. Cimzia (certolizumab pegol) Description
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Medicare Plus Blue PPO Essential, Vitality, Signature and Assure Plus Comprehensive Formulary Prior Authorization / Step Therapy Program 2017 Plan Year (Updated ) BCBSM Medicare Plus Blue PPO Essential,
Simponi / Simponi ARIA (golimumab)
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.70.51 Subject: Simponi / Simponi ARIA Page: 1 of 6 Last Review Date: September 15, 2016 Simponi / Simponi
Cimzia. Cimzia (certolizumab pegol) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 Subject: Cimzia Page: 1 of 5 Last Review Date: March 17, 2017 Cimzia Description Cimzia (certolizumab pegol)
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3. Has the patient shown improvement in signs and symptoms of the disease? Y N
Pharmacy Prior Authorization MERC CARE (MEDICAID) Renflexis (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign and date. Fax
ARISTADA. Products Affected Step 2: ARISTADA PREFILLED SYRINGE 1064 MG/3.9ML INTRAMUSCULAR ARISTADA PREFILLED SYRINGE 441 MG/1.
ARISTADA ARISTADA PREFILLED SYRINGE 1064 MG/3.9ML INTRAMUSCULAR ARISTADA PREFILLED SYRINGE 441 MG/1.6ML INTRAMUSCULAR ARISTADA PREFILLED SYRINGE 662 MG/2.4ML INTRAMUSCULAR ARISTADA PREFILLED SYRINGE 882
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2018 PRIOR AUTHORIZATION CRITERIA TABLE OF CONTENTS
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All medically accepted Prior authorization applies to new starts only excluded from Part D. 12 months
2018 Cigna-HealthSpring Prior Authorization Criteria Drug Name Excluded Prior Authorization Product Age Prescriber Coverage Covered Uses Exclusion Criteria Required Medical Information Other Criteria Drug
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Medicare Plus Blue Group PPO Essential, Vitality, Signature and Assure, Medicare Plus Group PPO, and Prescription Blue Group PDP Plus Comprehensive Formulary Prior Authorization / Step Therapy Program
PRESCRIPTION DRUGS REQUIRING PRIOR AUTHORIZATION
Abstral fentanyl citrate oral tablet Controlled Dangerous substance Actemra tocilizumab Monoclonal antibody Acthar corticotropin Hormone Actimmune interferon gamma 1b Interferon Actiq fentanyl citrate
Pulmonary Hypertension Weight Loss Skin Conditions. Skin Conditions Multiple Sclerosis Endocrine Disorder. Endocrine Disorder.
Prior Authorization PricewaterhouseCoopers The following medications may require prior authorization prior to dispensing at a participating retail pharmacy or through the Express Scripts Pharmacy home
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CIMZIA (certolizumab pegol)
Pre - PA Allowance None Prior-Approval Requirements Age Diagnoses 18 years of age or older Patient must have ONE of the following: 1. Moderate to severe Crohn s Disease (CD) a. Inadequate response, intolerance
Regulatory Status FDA- approved indication: Simponi and Simponi ARIA are tumor necrosis factor (TNF) blockers indicated for the treatment of: (2-3)
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.70.51 Subject: Simponi / Simponi ARIA Page: 1 of 9 Last Review Date: March 16, 2018 Simponi / Simponi
2. Does the patient have a diagnosis of ulcerative colitis or Crohn s? Y N
Pharmacy Prior Authorization AETA BETTER HEALTH LOUISIAA (MEDICAID) Remicade (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign
Regulatory Status FDA- approved indication: Simponi and Simponi ARIA are tumor necrosis factor (TNF) blockers indicated for the treatment of:
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.70.51 Subject: Simponi / Simponi ARIA Page: 1 of 8 Last Review Date: March 17, 2017 Simponi / Simponi
RAHF PFM ALPHANINE SD COAGULATION FACTOR IX J7193 COAGULATION FACTOR IX (RFIXFC)
INFECTIOUS DISEASE ACTIMMUNE INTERFERON GAMMA 1B J9216 ADVATE RAHF PFM ONCOLOGY ORAL AFINITOR EVEROLIMUS J7527 INFECTIOUS DISEASE ALFERON N INTERFERON ALFA N3 J9215 ALPHANATE VWF J7186 ALPHANINE SD J7193
2. Is the patient responding to Remicade therapy? Y N
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Regulatory Status FDA-approved indication: Orencia is a selective T cell costimulation modulator indicated for: (1)
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after reconstitution No Yes Refrigerate; do Not freeze. Discard unused portions; do Not save for further Immune Deficiencies & Related
Store at room temp. Protect from bright light. Freezing or refrigerating do not adversely affect the stability of intact vials. Different standards apply Abraxane Oncology- Injectable IV No No Yes after
First Name. Specialty: Fax. First Name DOB: Duration:
Prescriber Information Last ame: First ame DEA/PI: Specialty: Phone - - Fax - - Member Information Last ame: First ame Member ID umber DOB: - - Medication Information: Drug ame and Strength: Diagnosis:
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