Prior Authorization Medications Requiring Review Criteria for Use

Transcription

1 Prior Authorization Medications Requiring Review Criteria for Use The Medicare Part D formulary does not allow prior authorization or criteria restrictions on medications; this document applies to the Brand Name and/or Generic Name J-Code Medicare Status Therapeutic Class Aubagio Teriflunomide Medicare Part D Acthar Corticotropin gel J0800 Medicare Part D Ampyra Dalfampridine Medicare Part D Arcalyst Rilonacept powder for solution J3490 Medicare Part D Berinert Human C1 Inhibitor Medicare Part D Botulinum Toxin: Botox (P) Dysport (N) Myobloc (N) Xeomin (N) Botulinum Toxins Type A Injections Botulinum Toxins Type B Injections J0585 (type A) J0587 (type B) Medicare Part D Cinryze Human C1 Inhibitor Medicare Part B or D Dipeptidyl peptidase 4 (DPP- Medicare Part D IV) inhibitors: Januvia (P) Janumet (N) Jentadueto (N) Junvisync (N) Nesina (N) Onglyza (N) Tradjenta (N) Kazano (N) Kombiglyze XR (N) Oseni (N) Sitagliptin Sitagliptin and metformin Linagliptin and metformin Sitagliptin and simvastatin Alogliptin Saxagliptin Linagliptin Alogliptin and metformin Saxagliptin and metformin ER Alogliptin and pioglitazone Firazyr (N) Icatibant Medicare Part D Gattex (N) Teduglutide Medicare Part D Gilenya (N) Fingolimod Medicare Part D GLP-1 Receptor Agonists: Bydureon (P) Byetta (P) Victoza (N) Growth Hormones: Omnitrope (P) Genotropin (N) Humatrope (N) Norditropin (N) Nutropin AQ (N) Saizen (N) Serostim (N) Zorbtive (N) Hyaluronic Acid Derivatives (viscosupplements): Exenatide Extended-Release Exenatide SQ solution Liraglutide injection Medicare Part D Somatropin (Growth hormone) injectable J2940-J2941 Medicare Part D Hyaluronic Acid Injections J7321-J7322 Medicare Part B Page 1 of 39

2 Brand Name and/or Therapeutic Class Supartz (P) Synvisc (2) Euflexxa (N) Hyalgan (N) Orthovisc (N) Synvisc-One (N) Generic Name J-Code Medicare Status Ilaris Canakinumab Medicare Part D Invokana Canagliflozin Medicare Part D Juxtapid Lomitapide Medicare Part D Kalbitor Ecallantide Medicare Part D Kalydeco Ivacaftor Medicare Part D Kuvan Sapropterin tablets J3490 Medicare Part D Kynamro Mipomersen sodium Medicare Part D Mozobil Plerixafor injection Medicare Part D Provenge Sipuleucel-T Q2043 Medicare Part B Sabril Vigabatrin Medicare Part D Soliris Eculizumab J1300 Medicare Part B Supprelin LA Histrelin implant J9226 Medicare Part D Symlin Pramlintide SQ solution J3490 Medicare Part D Tecfidera Dimethyl fumarate Medicare Part D Tysabri Natalizumab IV solution J2323 Medicare Part B Xgeva Denosumab Medicare Part B Xiaflex Collagenase clostridium histolyticum injection J0775 Medicare Part B Xolair Omalizumab injectable J2357 Medicare Part D P- Preferred 2-2 nd line (if preferred failed) NP- Non-preferred Page 2 of 39

3 Aubagio (Teriflunomide) Medications Requiring Review Criteria for Use Candidates for treatment with Aubagio should meet ALL the following criteria: 1. Documented diagnosis of relapsing multiple sclerosis (MS) 2. Prescribed by a Neurologist 3. Documented inadequate response to ONE interferon therapy (ie. Avonex, Extavia or Rebif )* 4. Documented inadequate response or unable to tolerate to Copaxone * 5. Documented disease progression on current MS therapy i. Patients who are stable and well-controlled (not having disease progressing symptoms) on other MS therapies should not be changed to Aubagio 6. Females of child bearing age (12-50 years of age) should have a baseline negative pregnancy test (within 1 month) AND they must be on at least one form of effective contraception 7. Negative PPD (tuberculin) test 8. Used as monotherapy for treatment of relapsing MS *NOTE: Injection fatigue or fear of needles is not a reason for intolerance or inadequate response. Due to the possibility of increased risk of infections: Teriflunomide should be used as monotherapy and not in combination with Avonex (interferon beta-1a), other beta-interferons (Betaseron or Rebif ), or glatiramer acetate (Copaxone ). Teriflunomide should usually not be used in patients who are receiving chronic immunosuppressant therapy, who are receiving other immunomodulatory drugs, or are significantly immunocompromised for any reason. Initial approval period: 6 months Continued approval for treatment with Aubagio should meet ALL the following criteria: 1. Review of compliance to Aubagio 2. Documented beneficial effect from therapy 3. Documented ALT measured monthly for first six (6) months of therapy 4. Document serum transaminase, bilirubin, and CBC measured within (6) months of therapy Continued approval: 1 year Dosage and Administration The recommended dose of Aubagio is 7 mg or 14 mg daily. Monitoring All patients should have the following laboratory values completed within 6 months prior to and post initiation of therapy: complete blood count (CBC), liver transaminase, and serum bilirubin. All patients should be monitored for signs and symptoms of infection All patients should have a baseline and periodic monitoring of blood pressure Renal function and potassium levels should be monitored in patients with symptoms of renal failure or elevated potassium levels All patients should be screened for latent tuberculosis infection with a tuberculin skin test Page 3 of 39

4 before starting drug For women of childbearing potential, patient agrees to use a form or contraception to prevent pregnancy during teriflunomide treatment and for two months after discontinuation of teriflunomide Ordering information: Aubagio is available through the KP Specialty Pharmacy. Prescribers must complete the KP-SP Aubagio Order Form and fax it to KP-Specialty Pharmacy ( ). Acthar (Corticotropin (gel)) Candidates for treatment with Acthar should meet the following pertinent criteria: Acthar gel will not be covered in patients with any of the following diagnoses: Congestive heart failure Uncontrolled Hypertension Osteoporosis History of or presence of Peptic Ulcer Primary adrenocortical insufficiency or adrenocortical hyperactivity Scleroderma Hypersensitivity to porcine protein Pancreatitis Thromboembolic disorder Ocular herpes simplex Systemic fungal infections Criteria for use for diagnosis of infantile spasms: 1. Diagnosis of infantile spasms 2. Less than 2 years of age 3. Prescribed by pediatric neurologist or neurologist Criteria for use for Nephritic Syndrome: 1. A diagnosis of idiopathic nephritic syndrome 2. Prescriber must be a nephrologist 3. Patient failed to achieve a sustained partial or complete remission of nephritic syndrome after 6 months of therapy with first line therapy (i.e., corticosteroids) AND after 6 months of therapy with second line therapies with demonstrated efficacy (i.e., cyclosporine, tacrolimus, rituximab, and mycophenolate mofetil). Patient is expected to continue therapy for at least 3 months and is able to afford the cost of therapy in order to prevent abrupt discontinuation of therapy. Criteria for use for FDA-approved corticosteroid responsive conditions: 1. A documented diagnosis of any of the following conditions: a. Rheumatic Disorder (psoriatic arthritis, rheumatoid arthritis, ankylosis spondylitis) b. Collagen Diseases (SLE, polymyositis) c. Treatment of serum sickness d. Treatment of systematic sarcoidosis e. Ophthalmic-disease (keratitis, iritis, optic neuritis, anterior segment inflammation) f. Dermatological diseases (severe erythema multiforme or Stevens Johnson syndrome) 2. Patient experienced a limited or unsatisfactory response or experienced intolerance to IV or high dose oral steroids Page 4 of 39

5 Criteria for use for acute exacerbation of MS: 1. Documented diagnosis of acute exacerbations of multiple sclerosis 2. Prescribed by a neurologist 3. Patient experienced a limited or unsatisfactory response or experienced intolerance to IV or high dose oral steroids 4. Patient is currently on an immunomodulator agent for the treatment of multiple sclerosis 5. Patient demonstrates severe exacerbation symptoms? (i.e severe weakness, severe loss of vision, severe coordination problems, or severe walking impairment) Approval period: 6 months for nephritic syndrome and 3 months all other indications Ampyra (Dalfampridine) Monitoring: Laboratory monitoring for BMP, blood pressure, pulse, A1C, weight, and TSH, cholesterol (i.e., TC, LDL, HDL and triglycerides) should be completed at baseline and every 3 months for the duration of treatment with Acthar gel Ampyra extended release tablets should be reserved for treatment intended to improve walking capacity in ambulatory patients with multiple sclerosis (MS). Ampyra is symptomatic treatment only and is not disease-modifying. Candidates for treatment with Ampyra should meet the following criteria: 1. Must be prescribed by a neurologist 2. Patient has a confirmed diagnosis of MS. 3. Patient is ambulatory with a baseline 25 foot walk between 8 to 45 seconds a. Documentation of baseline timed 25 foot walk must be submitted by the prescribing physician. 4. Should be used for improvement of speed of ambulation. 5. Physical therapy should be considered and appropriately used before exposing patients to Ampyra 6. Patient must have normal renal function (CrCl > 50 ml/min). 7. Patient does not have a history of seizures Reasons for non-coverage Ampyra should NOT be used in patients with any of the following: 1. History of seizures 2. Moderate or severe renal impairment o Moderate renal impairment is defined as creatinine clearance (CrCl) of 30 to 50 ml/min; severe impairment is defined as CrCl of less than 30 ml/min. 3. Non-Ambulatory patients o Ampyra clinical trials included only ambulatory patients. Therefore, efficacy and safety have not been tested in non-ambulatory patients. 4. Patients taking any other form of fampridine, such as compounded fampridine (4- aminopyridine or 4-AP) products. Initial approval period: 2 months Patient should be evaluated for response days after starting the medication Patient should be instructed that continuation on the drug depends upon being evaluated for response. Patients should be advised that the reason for this evaluation is to avoid any unnecessary exposure to the drug and its possible risk. Continued approval: If a response is obtained during the first 2 months that the patient is on the medication, medical records documenting this response, including the walking time for the 25 foot Page 5 of 39

6 walking test after taking Ampyra along with a new prior authorization request should be submitted prior to continued approval being granted. Continued approval period is 12 months. Response Assessment: A response should become evident within two weeks. Patients should be given a trial of Ampyra lasting from 30 to 60 days and then evaluated for response to determine whether to continue the drug. One objective indicator should be used, along with any subjective indicators, to assess response. a. A useful objective assessment is the Timed 25-Foot Walk (T25FW) test. This was the test used in clinical trials qualifying Ampyra for approval. i. A baseline should be established at one or more visit after any possible physical therapy and before initiation of Ampyra. ii. Response to Ampyra can then be evaluated with repeat T25FW tests (or equivalent) after 30 to 60 days of drug. b. A subjective assessment should include meaningful improvements in functional parameters or activities of daily living. c. Response to Ampyra should be evident within two months. i. Continuation of Ampyra in patients who do not have a significant response a majority of patients in clinical trials may expose these patients to the risk of seizures without sufficient benefit to justify the risk. ii. Modest improvements in walking speed or function must be considered against the risk of seizures. Dosing: The maximum dose of Ampyra is one 10 mg tablet twice daily, approximately 12 hours apart. Patients should NOT take more than 10 mg every 12 hours. o Patient education must include emphasis on spacing doses approximately 12 hours apart. Irregular dosing intervals will result in uneven blood levels since the drug itself has a relatively short half-life. Uneven drug levels could raise the risk for seizures. o Patients must be cautioned not to double-up if they miss a dose and not to take a possible extra dose if they have forgotten whether they took a dose. o Patients must be advised to always swallow tablets whole and to never split, crush, chew, or otherwise disrupt the extended-release formulation, since this could lead to uneven blood levels. Notes: Ampyra results were modest in published studies. o Only about 30% of clinical trial patients had an improvement in average walking speed of 20% or more (while about 10% of placebo-treated patients had the same level of improvement). To put this in perspective, an average 20% improvement in a timed walk over a 25-foot distance means on average the patient walked 25 feet 8 seconds if baseline was 10 seconds, or in 10 seconds if baseline was 12.5 seconds. o In clinical trials, a response was defined as having an improvement in walking speed in more than half of the timed 25-foot walk tests. In two trials, 35% and 43% of patients met this standard for improvement (versus 8% and 9% of placebo-treated patients. In the minority of patients who achieved this response criterion, the improvements amounted to just under 2 seconds improvement over 25 feet, versus a 0.5 second improvement with placebo. These average improvements should be weighed against the risks of treatment primarily the risk for seizures. Ordering information: Ampyra is available through the KP Specialty Pharmacy. Prescribers must complete the KP Specialty Page 6 of 39

7 Arcalyst (Rilonacept) Pharmacy Ampyra Order Form at CMS/California/Information/ViewMedSafetyDNMgmtCA.aspx?I32Object=1084&nodeValue=113 and fax it to KP-SP ( ). Candidates for treatment with Arcalyst should meet ALL the following criteria: 1. Diagnosis of cryopyrin-associated periodic syndromes (CAPS) 2. Patient has documented laboratory evidence of a genetic mutation in the Cold-Induced Autoinflammatory Syndrome 1 (CIAS1- sometimes referred to as the NLRP3). 3. There is clinical documentation that the patient is experiencing classic symptoms of CAPS in either criteria below: a. Familial Cold Auto-Inflammatory Syndrome (FCAS) - recurrent episodes of rash, fever/chills, and joint pain following exposure to mild cold environment (e.g. cool breeze, air conditioning). Symptoms generally last for up to 24 hours. b. Muckle-Wells Syndrome (MWS) - chronic fever and rash sometimes exacerbated by generalized cold exposure. Episodes can last up to 2-3 days. 4. There is clinical documentation of significant functional impairment leading to limitations of activities of daily living (ADLs). 5. Failed, intolerant, or allergic to at least one of the following: a. Anakinra (Kineret ) injection b. Canakinumab (Ilaris ) injection Reasons for non-coverage: Concurrent use of live vaccines or tumor necrosis factor Chronic or active infections Untreated latent tuberculosis 11 years or younger Initial approval period: 1 month Continued approval: 12 months based on physician documentation of disease stability and improvement. Caution: Increased risk of malignancies may occur Monitoring: Improvement in signs and symptoms of cryopyrin-associated periodic syndromes (ie, fever, urticaria-like rash, arthralgia, myalgia, fatigue, and conjunctivitis) Lipid profiles; 2 to 3 months after initiation of therapy and periodically Dosing: Adult dose: The recommended loading dose is 320 milligrams (mg) subcutaneously (SubQ) as 2 doses of 160 mg at 2 different sites. Followed by 160 mg SubQ once-weekly. Do not administer more than once weekly. Pediatric dose: The recommended loading dose is 4.4 milligrams/kilogram (mg/kg) Page 7 of 39

8 Berinert (Human C1 Inhibitor) subcutaneously (SubQ) (up to a maximum dose of 320 mg) as 1 or 2 injections with a maximum volume of 2 ml. If administered as 2 injections, then administer at 2 different sites. Followed by 2.2 mg/kg (up to a maximum dose of 160 mg) SubQ once weekly. Do not administer more than once weekly Candidates for treatment with Berinert should meet ALL the following criteria: 1. A diagnosis of Type I or Type II hereditary angioedema. 2. Prescriber must be an allergist. 3. Treatment of acute facial or abdominal facial attacks of HAE in adult or adolescent patients 4. Contraindications or inability to tolerate 17α-alkylated androgens (ex. danazol, oxandrolone and stanozolol) (especially in females of child-bearing age, years of age), including hirsutism, menstrual irregularities, hepatic dysfunction, undiagnosed vaginal bleeding, porphyria, cardiac or renal disease, depression, muscle cramps and thrombosis. Patients with significant lipid abnormalities might also be considered. 5. Lack of response to currently available therapies such as 17α-alkylated androgens as evidenced by lack of symptom control. Reasons for non-coverage: Routine prophylaxis against angioedema attacks in adolescent and adult patients with HAE Treatment for laryngeal attacks 12 years of age or younger Initial Approval: 3 months Subsequent approval will be based on clinical documentation of functional improvement, a decrease in frequency of HAE attack, and an improvement in severity and duration of attacks. Monitoring: Symptomatic improvement Symptoms of hypersensitivity reaction during or after infusion Signs of thrombosis Consider long-term prophylaxis for patients with HAE who experience one severe event per month or who are disabled more than five days per month OR if the patient has a history of previous airway compromise. Options include: 1. 17α-alkylated androgens (danazol, stanozolol if available, and oxandrolone): Generally treatment of choice for long-term preventative treatment. Contraindications include pregnancy, breastfeeding, significantly impaired renal/ hepatic function, etc (refer to package insert for complete list). See Milan or Budapest Protocols for dosing recommendations. Use in children should be undertaken only with great caution. 2. Antifibrinolytics (epsilon aminocaproic acid [Amicar]): Less effective than androgens. Often reserved for patients who do not tolerate or in whom anabolic androgens are contraindicated. 3. Human C1 inhibitor (Cinryze ) replacement: May be necessary in patients in whom androgens are not effective (frequent angioedema attacks), not tolerated or contraindicated. o Human C1 inhibitor prophylaxis is the safest prophylactic agent to use during Page 8 of 39

9 Botulinum Toxins: pregnancy. Candidates for treatment with Botulinum products should meet ALL the following pertinent criteria: Preferred: Botox Type A Injections Botulinum products are not interchangeable; potency differences may exist between the products. Use of Botulinum Toxin for Chronic Migraine Headaches* Non-preferred: Dysport Type A Injection Myobloc Type B Injections Xeomin Type A Injection Patients must meet ALL of the criteria for coverage: 1. Must be prescribed by a neurologist trained to inject botulinum toxin 2. Chronic migraine headaches for > 6 months 3. Unsuccessful treatment with at least 3 classes of prophylactic medications with each agent at the appropriate dose for 4-6 weeks. Examples of prophylactic medications include: a. Beta Blockers i. Propranolol 20 mg to 240 mg by mouth daily in divided doses ii. Atenolol 25 mg to 100 mg by mouth daily iii. Timolol (NF) 20 mg to 20 mg by mouth daily in divided doses b. Antidepressants (TCA), SSRI, or SNRI) i. Nortriptyline 10 mg to 100 mg by mouth daily ii. Amitriptyline 10 mg to 100 mg by mouth daily iii. Venlafaxine 37.5 mg by mouth daily, titrate up to 150 mg daily c. Calcium Channel Blockers i. Verapamil SR 180 mg to 480 mg by mouth daily d. Anticonvulsants i. Divalproex DR: 500 to 1000 mg PO daily ii. Topiramate 100 to 200 mg PO daily in divided doses 4. Assessment and treatment of psychosomatic factors (e.g stress, depression, and anxiety) 5. Complete Neurological Evaluation 6. No contraindications (e.g. infection in target muscle, neuromuscular disorder, or sensitivity to Botox A) 7. Women of childbearing potential (12-50 years of age) must use adequate contraception Use of Botulinum Toxin for Hyperhidrosis* Patient must meet ALL criteria for coverage: 1. Receive recommendation from Dermatology after failed medical treatment with Drysol and Robinul. 2. Medical complications from hyperhidrosis including skin maceration or dermatitis. 3. No history of neuromuscular disease. 4. No recent infection or malignancy in affected area. 5. No history of hyperthyroidism. 6. Women of childbearing potential (12-50 years of age) must use adequate contraception Use of Botulinum Toxin for Blepharospasm** Patient must meet ALL criteria for coverage Page 9 of 39

10 1. Diagnosis of bilateral blepharospasm 2. Jankovic Rating Scale (JRS) severity subscore > 2 3. No neuroleptic-induce blepharospasm 4. No known hypersensitivity to botulinum toxins, human serum albumin, or sucrose 5. No treatment with botulinum toxins for any other indications within the past 16 weeks 6. Women of childbearing potential (12-50 years of age) must use adequate contraception Use of Botulinum Toxin for Cervical Dystonia Patient must meet ALL criteria for coverage 1. Diagnosis of primary cervical dystonia (CD) 2. Toronto Western Spasmodic Torticollis Rating Score (TWSTRS) > No history of neuromuscular disease 4. No clinically significant dystonias 5. No known hypersensitivity to botulinum toxins, serum albumin, or sucrose 6. No treatment with botulinum toxins for any other indications within the past 16 weeks 7. Women of childbearing potential (12-50 years of age) must use adequate contraception Use of Botulinum Toxin for Overactive Bladder 1. Diagnosis of overactive bladder 2. Symptoms of urge urinary incontinence, urgency, and frequency 3. Documented inadequate response to or are intolerant to at least 2 of the following: a. Oxybutynin b. Trospium c. Oxytrol d. Tolterodine 4. Women of childbearing potential (12-50 years of age) must use adequate contraception Use of Botulinum Toxin for Upper Limb Spasticity* Patient must meet ALL criteria for coverage: 1. Complete neurological evaluation 2. Failure to improve with standard therapy which includes dopaminergic medications (Sinemet, Artane ), muscle relaxants (Lioresal ), and benodiazepines (Valium ). 3. Spasticity in biceps, wrist, or fingers 4. No weakness, atrophy, or infection in the target muscle 5. No hypersensitivity to botulinum toxin or other component of the product 6. No evidence of pre-existing cardiovascular disease or dysphagia 7. Women of childbearing potential (12-50 years of age) must use adequate contraception. Initial approval : 6 months Continued Approval: Up to 4 treatments per 12 months if there is documented evidence of response to therapy NOTE: The FDA has received reports of systemic adverse reactions including respiratory compromise and Page 10 of 39

11 death following the use of Botulinum toxins types A (Botox, Botox Cosmetic) and B (Myobloc ) for both FDA-approved and unapproved uses. The reactions reported are suggestive of botulism, which occurs when Botulinum toxin spreads in the body beyond the site where it was injected. The most serious cases had outcomes that included hospitalization and death, and occurred mostly in children treated for cerebral palsy-associated limb spasticity. Consider these adverse events when reviewing requests. * Consider Botulinum Toxin A (Botox ) before Botulinum Toxin B (Myobloc ) and Botulinum Toxin A (Dysport ). ** Xeomin is FDA approved for the treatment of blepharospasm in patients previously treated with Botox and cervical dystonia and should only be covered for FDA-approved indications. Cinryze (Human C1 Inhibitor solution) The Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS) is the most commonly used. It consists of three subscales: severity (range 0-35), disability (range 0-23), and pain (range 0-20), which together add up to the TWSTRS Total score of 0-87 Candidates for treatment with Cinryze should meet ALL the following criteria: 1. A diagnosis of Type I or Type II hereditary angioedema. 2. Prescriber must be an allergist. 3. Contraindications or inability to tolerate 17α-alkylated androgens (ex.danazol, oxandrolone and stanozolol) (especially in females of child-bearing age), including hirsutism, menstrual irregularities, hepatic dysfunction, undiagnosed vaginal bleeding, porphyria, cardiac or renal disease, depression, muscle cramps and thrombosis. Patients with significant lipid abnormalities might also be considered. 4. Lack of response to currently available therapies such as 17α-alkylated androgens as evidenced by lack of symptom control. 5. Special circumstances may include use in pregnant females with hereditary angioedema (HAE). [Note: Studies in pregnant women have not been conducted and the effects on the fetus or on reproductive capacity are not definitively known. At this time, Cinryze should be given to a pregnant woman only if clearly needed.] Reasons for non-coverage: Treatment of angioedema acute attacks in adult and adolescent patients with HAE Under 9 years of age Initial Approval: 3 months Subsequent approval will be based on clinical documentation of functional improvement, a decrease in frequency of HAE attack, and an improvement in severity and duration of attacks. Monitoring: Reduction in number, severity, and duration of swelling attacks Symptoms of hypersensitivity during or after infusion Signs of thrombosis Page 11 of 39

12 Short-term Prophylaxis: 1. Minor Procedures: Use of human C1 inhibitor is not required before minor manipulations if human C1 inhibitor is immediately available. As an alternative, danazol can be used in appropriate patients (starting at least 7days before the procedure). 2. Major Procedures or Intubation: Consider the use of human C1 inhibitor for short-term prophylaxis to prevent attacks of angioedema when a patient with HAE has a planned exposure to a situation likely to trigger an attack, such as substantial dental work, invasive medical procedures, and surgical procedures. a. Doses of 500-1,500 units intravenously given one hour before the provoking event have been studied. b. Two doses of human C1 inhibitor should be available. c. Although there is limited data in the United States regarding the use of human C1 inhibitor in pregnancy, a set of international consensus guidelines state that human C1 inhibitor is the safest prophylactic agent to use during pregnancy. DPP-IV inhibitors: Preferred: Januvia (Sitagliptin) Non-Preferred: Onglyza (Saxagliptin) Long-term Prophylaxis: For patients with HAE who experience one severe event per month or who are disabled more than five days per month OR if the patient has a history of previous airway compromise, consider long-term prophylaxis. Options include: 1. 17α-alkylated androgens (danazol, stanozolol if available, and oxandrolone): Generally treatment of choice for long-term preventative treatment. Contraindications include pregnancy, breastfeeding, significantly impaired renal/ hepatic function, etc (refer to package insert for complete list). See Milan or Budapest Protocols for dosing recommendations. Use in children should be undertaken only with great caution. 2. Antifibrinolytics (epsilon aminocaproic acid [Amicar ]): Less effective than androgens. Often reserved for patients who do not tolerate or in whom anabolic androgens are contraindicated. 3. Human C1 inhibitor replacement: May be necessary in patients in whom androgens are not effective (frequent angioedema attacks), not tolerated or contraindicated. o Human C1 inhibitor prophylaxis is the safest prophylactic agent to use during pregnancy. Candidates for treatment with DPP-IV inhibitors should meet ALL the following criteria: ***NOTE: Non-preferred DPP-IV inhibitors are only to be used when the preferred DPP-IV inhibitor (Januvia) has failed*** **For combination products, patients must meet criteria for DPP-IV inhibitors below. Separate prescriptions are required for metformin and the DPP-IV inhibitor in place of the combination product (Kazano, Jentadueto, Kombiglyze, and Janumet XR); simvastatin and Januvia in place of Juvisync ; and pioglitazone and Nesina in place of Oseni ** DDP-IV inhibitors will be covered for current KP new start members who meet ALL of the following criteria: Tradjenta (Linagliptin) Nesina (Alogliptin) 1. A diagnosis of type 2 diabetes mellitus 2. Must be prescribed by an Endocrinologist 3. HgbA1c level 7% 9% 4. Failed to obtain adequate glycemic control on combination therapy with: a. Maximum tolerated doses of metformin monotherapy (unless patient is not a candidate for metformin therapy) and Page 12 of 39

13 Non-Covered combination products (separate prescriptions required for ingredients in combination products): Kazano (Alogliptin and metformin) Oseni (Alogliptin and pioglitazone) Jentadueto (Linagliptin and metformin) Kombiglyze XR (Saxagliptin and metformin extended-release) Janumet (Sitagliptin and metformin) Juvisync (Sitagliptin and simvastatin) b. Maximum tolerated doses of a sulfonylurea (unless the patient is not a candidate for sulfonylurea therapy) and c. Maximum tolerated titration of insulin OR meets EITHER of the following criteria: i. The DPP-IV inhibitor may be initiated prior to insulin trial, in either of the following two conditions: 1. Endocrinologist indicates hypoglycemia is uniquely undesirable, so unable to use insulin (e.g., in patients who have hazardous jobs) OR 2. Endocrinologist indicates promotion of weight loss is a major consideration and this patients HgbA1c is close to target (<8.0%) **As outlined above, DPP-IV inhibitors are not substitutes for insulin in patients whose diabetes control may benefit from insulin therapy. Reasons for non-coverage: Type 1 diabetes mellitus Treatment of diabetic ketoacidosis Concurrent use with insulin Pediatric patients (<18 years old) Prior history of a serious allergic reaction to DPP-IV inhibitors (i.e., anaphylaxis, angioedema, Stevens-Johnson syndrome, etc.) Severe hepatic insufficiency (Child-Pugh score >9) Initial approval period: 6 months Continued approval: 1 year, based on review of compliance to therapy and documented improved glycemic control as evidenced by HgbA1c lowering from pretreatment level to HgbA1c goal <8% The preferred DPP-IV inhibitor, Januvia, will be covered for new members to KP already taking Januvia who meet the following criteria: 1. A diagnosis of type 2 diabetes mellitus and 2. HgbA1c level <8% Non-preferred DPP-IV inhibitor will be covered for new members to KP already taking a non-preferred DPP-IV inhibitor who meet the following criteria: 1. A diagnosis of type 2 diabetes mellitus and 2. HgbA1c level <8% and 3. Unable to tolerate or inadequate response to Januvia. ***Note: New members to KP currently taking a DPP-IV inhibitor upon enrollment whose diabetes is not controlled with a DPP-IV inhibitor (i.e., HgbA1c> 8%) will need to meet the general criteria for KP new start members. Use caution in the following patients: ESRD requiring hemodialysis or peritoneal dialysis Pregnant/nursing women Concomitant use with a sulfonylurea due to increased risk of hypoglycemia History of pancreatitis Monitoring: Renal function prior to initiation of the DPP-IV inhibitor and periodically afterwards HgbA 1c level Page 13 of 39

14 Serum glucose level Development of pancreatitis after initiation or dose increases Firazyr (Icatibant) Candidates for treatment with Firazyr should meet ALL the following criteria: 1. A diagnosis of Type I or Type II hereditary angioedema. 2. Prescriber must be an allergist. 3. Treatment of acute facial or abdominal facial attacks of HAE in adult or adolescent patients 4. Contraindications or inability to tolerate 17α-alkylated androgens (especially in females of childbearing age), including hirsutism, menstrual irregularities, hepatic dysfunction, undiagnosed vaginal bleeding, porphyria, cardiac or renal disease, depression, muscle cramps and thrombosis. Patients with significant lipid abnormalities might also be considered. 5. Lack of response to currently available therapies such as 17α-alkylated androgens as evidenced by lack of symptom control. Reasons for non-coverage: Routine prophylaxis against angioedema attacks in adolescent and adult patients with HAE 18 years of age or younger Initial Approval: 3 months Subsequent approval will be based on clinical documentation of functional improvement, a decrease in frequency of HAE attack, and an improvement in severity and duration of attacks. Monitoring: Symptomatic improvement Patients with laryngeal attacks should seek medical attention to assure that airway obstruction in resolved. Gattex Consider long-term prophylaxis for patients with HAE who experience one severe event per month or who are disabled more than five days per month OR if the patient has a history of previous airway compromise. Options include: 1. 17α-alkylated androgens (danazol, stanozolol if available, and oxandrolone): Generally treatment of choice for long-term preventative treatment. Contraindications include pregnancy, breastfeeding, significantly impaired renal/ hepatic function, etc (refer to package insert for complete list). See Milan or Budapest Protocols for dosing recommendations. Use in children should be undertaken only with great caution. 2. Antifibrinolytics (epsilon aminocaproic acid [Amicar ]): Less effective than androgens. Often reserved for patients who do not tolerate or in whom anabolic androgens are contraindicated. 3. Human C1 inhibitor (Cinryze ) replacement: May be necessary in patients in whom androgens are not effective (frequent angioedema attacks), not tolerated or contraindicated. o Human C1 inhibitor prophylaxis is the safest prophylactic agent to use during pregnancy. Candidates for treatment with Gattex should meet ALL the following criteria: Page 14 of 39

15 (Teduglutide) 1. Diagnosis of short bowel syndrome (SBS) 2. Dependent on parenteral nutrition (PN) and/or intravenous (IV) fluids continuously for at least 12 months 3. Prescribed by a gastroenterologist who is a certified REMS provider *NOTE: For more information and to enroll, please go to the following site: years or age or older 5. Colonoscopy performed within the last 6 months 6. Serum bilirubin, alkaline phosphatase, lipase and amylase levels drawn within the last 6 months Initial approval period: 1 year Continued approval: 1 year, based on review of compliance to therapy and documented beneficial effect from therapy. Patient must also have documented colonoscopy 1 year after therapy with Gattex. Dosing and Administration: SubQ: 0.05 mg/kg once daily Monitoring: Serum bilirubin, alkaline phosphatase, lipase and amylase (baseline [within 6 months prior to initiation] and every 6 months thereafter) Colonoscopy of entire colon and removal of polyps (baseline [within 6 months prior to initiation], 1 year, and 5 years thereafter) Monitor fluid status in patients with cardiovascular disease; signs/symptoms of intestinal obstruction; signs/symptoms suggestive of gall bladder disease or pancreatitis Gilneya (Fingolimod) Ordering information Gattex is only available from certified pharmacies that are enrolled in the Gattex REMS program. At this time, Gattex is not available through our KP pharmacies or the KP Specialty Pharmacy. Prescriber s should review the education materials which are part of the REMS and complete post-training knowledge assessment questions at Candidates for treatment with Gilneya should meet ALL the following criteria: 1. Diagnosis of Multiple Sclerosis 2. Fingolimod (Gilenya ) should be reserved for treatment of relapsing forms of multiple sclerosis (MS). 3. Documented inadequate response to ONE interferon therapy (ie. Avonex, Extavia or Rebif )* 4. Documented inadequate response to Copaxone * 5. Patient is having disease progressing symptoms on another MS therapy i. Patients who are stable and well-controlled (not having disease progressing symptoms) on other MS therapies should not be changed to fingolimod 6. Inadequate response to or unable to tolerate Aubagio Due to the possibility of increased risk of infections: o Fingolimod should be used as monotherapy and not in combination with Avonex Page 15 of 39

16 o (interferon beta-1a), other beta-interferons (Betaseron or Rebif ), or glatiramer acetate (Copaxone ). Fingolimod should usually not be used in patients who are receiving chronic immunosuppressant therapy, who are receiving other immunomodulatory drugs, or are significantly immunocompromised for any reason. *NOTE: Injection fatigue or fear of needles are not reasons for intolerance or inadequate response. Initial approval period: 6 months Continued approval: 1 year, based on review of compliance to therapy and documented beneficial effect from therapy with decrease in number of or no relapses and documentation of recent ophthalmologic examination (within 3-4 months) Dosage and Administration Fingolimod is dosed at 0.5 mg orally once daily, with or without food. Doses higher than 0.5 mg daily are associated with minimal benefit and a higher risk of adverse events. All patients should be observed for six hours after the first dose is given, monitoring for signs and symptoms of bradycardia. GLP-1 Receptor Agonists Preferred: Monitoring All patients should be observed for six hours after the first dose is given, monitoring for signs and symptoms of bradycardia. o Patients at increased risk for bradycardia or bradyarrhythmia should have a baseline electrocardiogram (ECG) performed if an ECG has not been done in the previous 6 months. o Risk for development of bradycardia or heart block is considered to be increased in patient concurrently treated with beta blockers, calcium channel blockers, or antiarrhythmics (Class Ia or Class III) or in patients with a low heart rate, history of syncope, sick sinus syndrome, 2nd degree or higher conduction block, ischemic heart disease, or congestive heart failure according to Gilenya prescribing information. (Note: Class Ia antiarrhythmics include quinidine, procainamide, and disopyramide. Class III antiarrhythmics include amiodarone and sotalol.) All Patients should have the following laboratory values completed within 6 months prior to initiating therapy: complete blood count (CBC), liver transaminase, and serum bilirubin o Patients should be monitored for any new signs or symptoms which might suggest PML. At the first such sign or symptom of PML, fingolimod treatment should be withheld immediately and diagnostic measures should be undertaken. All Patients should have documented immunity to varicella zoster virus (chicken pox). All patients should have a baseline ophthalmologic exam prior to initiation of fingolimod and at 3-4 months after treatment initiation. For women of childbearing potential, patient agrees to use a form or contraception to prevent pregnancy during fingolimod treatment and for two months after discontinuation of fingolimod GLP-1 receptor agonists will be covered for current KP new start members who meet the following criteria: 1. A diagnosis of type 2 diabetes mellitus and Page 16 of 39

17 Bydureon (Exenatide Extended-Release) Byetta (Exenatide) Non-Preferred: Victoza (Liraglutide) **NOTE**: Non-preferred GLP-1 receptor agonists are only to be used when a preferred GLP-1 receptor agonist (Bydureon or Byetta ) has failed 2. Must be prescribed by endocrinologist and 3. HgbA1c level 7% 9% and 4. Failed to obtain adequate glycemic control on combination therapy with: a. Maximum tolerated doses of metformin (unless patient is not a candidate for metformin therapy) and b. Maximum tolerated doses of a sulfonylurea (unless the patient is not a candidate for a sulfonylurea therapy) and c. Maximum tolerated titration of insulin. i. GLP-1 receptor agonists may be initiated prior to insulin trial, in either of the following two conditions: 1. Endocrinologist indicates hypoglycemia is uniquely undesirable, so unable to use insulin (e.g., in patients who have hazardous jobs) OR 2. Endocrinologist indicates promotion of weight loss is a major consideration and this patients A1C is close to target (<8.0%) **As outlined above, GLP-1 receptor agonists are not substitutes for insulin in patients whose diabetes may benefit from insulin treatment** Reasons for non-coverage: Type 1 diabetes mellitus Treatment of diabetic ketoacidosis Concurrent use with meglitinides (i.e., repaglinide, nateglinide), or alpha-glucosidase inhibitors (i.e., acarbose, miglitol) Pediatric patients (<18 years old) ESRD or severe renal impairment (CrCl <30 ml/min) Patients with severe gastrointestinal disease (including gastroparesis) Diagnosis of pancreatitis, including hemorrhagic and necrotizing, prior to or after initiation of GLP-1 receptor agonists (postmarketing cases, including fatalities, have been reported, therapy should be discontinued immediately). Prior history of a serious allergic reaction to a GLP-1 receptor agonist (i.e., anaphylaxis, angioedema, Stevens-Johnson syndrome, etc.) Personal or family history of medullary thyroid cancer (MTC) or in patients with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2) Initial approval period: 6 months Continued approval: 1 year, based on review of compliance to therapy and documented improved glycemic control as evidenced by A1c lowering from pretreatment level to A1c goal <8% Preferred GLP-1 receptor agonists will be covered for new members to KP already taking a preferred GLP-1 receptor who meet the following criteria: 1. A diagnosis of type 2 diabetes mellitus and 2. HgbA1c level <8% Non-Preferred GLP-1 receptor agonists will be covered for new members to KP already taking a nonpreferred GLP-1 receptor who meet the following criteria: 1. A diagnosis of type 2 diabetes mellitus and 2. HgbA1c level <8% and 3. Unable to tolerate or inadequate response to a preferred GLP-1 receptor agonists Page 17 of 39

18 ***Note: New members to KP currently taking a preferred or non-preferred GLP-1 receptor agonist upon enrollment whose diabetes is not controlled (i.e., A1c> 8%) will need to meet the general criteria for KP new start members. Use caution in the following patients: Pregnant/nursing women (Pregnancy Category C) Concomitant use with pharmacologic agents known to affect renal function/hydration status/ and or patients experiencing nausea/vomiting/diarrhea with or without dehydration (i.e., aceinhibitors, NSAIDS, diuretics) Concomitant use with a sulfonylurea (hypoglycemia) Concomitant use with warfarin (increased INR, sometimes with bleeding) Concomitant use with oral medications that require rapid gastric gastrointestinal absorption (GLP-1 receptor agonists slow gastric emptying) Concomitant use with oral medications dependent on threshold concentrations for efficacy (i.e., contraceptives, antibiotics) Patients should take drugs 1 hour prior to GLP-1 receptor agonist injection Monitoring: Renal function prior to initiation of a GLP-1 receptor agonist and periodically afterwards HgbA1c level Fasting and postprandial glucose Signs/symptoms of acute pancreatitis including unexplained, persistent, severe abdominal pain with or without vomiting Growth hormones: Preferred: Omnitrope cartridges for use in pen Non-preferred: Gentropin Humatrope Norditropin Nutropin AQ Saizen Serostim Zorbtive **NOTE**: Non-preferred growth hormone is **NOTE**: Non-preferred GLP-1 receptor agonists are only to be used when a preferred GLP-1 agonist (Bydureon or Byetta ) has failed Candidates for treatment with Growth hormones should meet ALL the following criteria: ** Note: For all first time approvals, Omnitrope is the first-line agent when growth hormone is indicated for growth hormone deficiency. Omnitrope should be tried before approval is granted for other growth hormone agents. Criteria for use of growth hormones in children (<18 years of age): 1. A diagnosis of Turner s Syndrome that is confirmed by abnormal karyotype in female children greater than five years of age with appropriate timing and use of hormone replacement therapy; OR 2. Patients who have a diagnosis of classical growth hormone deficiency and who meet all the criteria below: a. Height is consistently two standards deviation below mean for like age, pubertal maturation and gender over at least one year of serial measurements; and b. Growth velocity that is less than the tenth percentile of normal for like age, pubertal maturation and gender over at least one year of serial measurements; and c. Two provocative tests for growth hormones secretion with neither having a Peak > 10 ng/ ml; OR **Bone age determination within six months of the request, reflecting more than two standards deviations below that for like age and gender; with (c.) AND either (a.) or (b.), OR 3. Children with Prader-Willi Syndrome confirmed by appropriate genetic testing WITHOUT therapeutic contraindications: severe obesity or respiratory impairment; OR 4. Pre-pubertal children with chronic renal insufficiency, before renal transplant, providing: nutritional status optimized; metabolic abnormalities optimized; and steroid therapy Page 18 of 39

19 only to be used when preferred (Omnitrope ) growth hormone has failed minimized; OR 5. Patients who are small for gestational age and meet all the criteria below: a. Patient is 2 years of age or older b. Child was born small for gestational age, defined as birth weight and/or length at least two standard deviations below the mean for gestational age. c. Child fails to manifest catch-up growth by two years of age, defined as height at least two standard deviations below the mean for age and sex. **Note: Bone age reflects the potential for the response to GH. Height standard deviation score for chronologic age increase throughout all treatment years, but for bone age (BA) did not change significantly. Human GH treatment cannot make up a deficit in height prognosis already present at diagnosis, but prevents further loss of stature, which is why early diagnosis is important so that GH therapy can be instituted before significant height for BA deficit has occurred. (J Pediatr 1988;112:875-9). Discontinuation of treatment: Treatment with growth hormone will be discontinued if one or more of the following occurs: 1. Height velocity is not at or above the tenth percentile for like age, pubertal maturation and gender after one year of treatment (i.e. the treatment is not effective in achieving a significant increase in stature after one year of treatment). a. Height velocity must be obtained by at least two measurements over a one-year period on stable HGH dosage; 2. Bone age is greater than or equal to 14 years of age for females and 16 years of age for males; OR 3. The patient achieves a height that is within the 3rd percentile for normal adult height for the same sex Criteria for use of growth hormones in adults (>18 years of age): Initial Evaluation 1. The patient has one of the following: a. The patient has growth hormone deficiency syndrome, either alone or with multiple hormone deficiencies, as a result of pituitary disease, hypothalamic disease, surgery, radiation or trauma OR b. Patients who were growth hormone-deficient during childhood who have growth hormone deficiency syndrome confirmed as an adult before replacement therapy is started AND 2. The patient has failed at least one growth hormone (GH) stimulation test as an adult a. Failure of GH stimulation test is defined as: i. A peak GH value of <5 mcg/l after stimulation when measure by RIA (polyclonal antibody) OR ii. A peak GH value of <2.5 mg/l after stimulation when measured by IRMA (monoclonal antibody) Reasons for Non-Coverage: Growth hormone should not be administered or covered in patients with any of the following: o Acute critical illness (e.g., with complications after cardiac or abdominal surgery, with multiple accidental trauma, or with acute respiratory failure) o Evidence of active malignancy [One possible approach would be to consider growth hormone therapy if the patient has been free of active malignancy for one year after Page 19 of 39

20 therapy for pituitary tumor or five years after other malignancies.] o Proliferative retinopathy o Uncontrolled hypertension o Benign intracranial hypertension o Pregnancy (relative contraindication due to lack of study evidence and the fact that placental GH is secreted in the second and third trimester.) Growth hormones will not be covered when being used for any of the following: o Performance enhancement in athletes o Treatment of obesity o Prevention or delay of the aging process o Treatment of partial growth hormone deficiency Initial Approval Period: 12 months Continued Evaluation 1. The patient has been approved for GH previously through QRM AND 2. The patient is being monitored for adverse effects of GH AND 3. The patient s IGF-1 level has been evaluated to confirm the appropriateness of the current dose AND 4. The patient has had benefits from GH therapy in any of the following response parameters; body composition, hip-to-waist ratio, cardiovascular health, bone mineral density, serum cholesterol, physical strength, or quality of life. Hyaluronic Acid Injection: Preferred: Supartz (P) Non-preferred: Synvisc (2 nd Line) Euflexxa (N) Hyalgan (N) Synvisc-One (N) **Note**: Supartz is the preferred medication. Synvisc may be approved if Supartz is deemed ineffective or the patient has intolerance to Continued Approval Period: 12 months Candidates for treatment with Hyaluronic Acid Injection should meet ALL the following criteria: 1. Patient has clinically documented osteoarthritis of the knees (American College of Rheumatology criteria) confirmed by history, exam, x-ray, and synovial fluid analysis, and requested for use in knee 2. Failed or intolerant to nonpharmacological therapies (physical therapy, ice, weight loss, etc.) 3. Documented inadequate control of pain or intolerance to an adequate trial (at least 3 months) of ONE of the following: acetaminophen (4 grams/day), NSAIDs, intraarticular corticosteroid injections, and other non-narcotic or narcotic analgesics 4. Efficacy of intra-articular corticosteroid injection lasting less than 6-8 weeks Initial Approval: 1 to 5 weeks depending on the product Criteria for Continuation of Therapy: There are no data on repeated courses of therapy for Euflexxa and Supartz ; there is no evidence of inc reased adverse drug events in repeated courses of therapy for Hyalgan, Synvisc, and Orthovisc when separated by at least six months. **Note: Supartz is the preferred medication. Synvisc may be approved if Supartz is deemed ineffective or the patient has intolerance to Supartz. Page 20 of 39