COVERED USES All medically accepted indications not otherwise excluded from Part D
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1 BOSULIF BOSULIF Signed statement of diagnosis from the physician, hepatic panel and CBC, trial and failure ofofimiatinib or dasatinibi and documentation of a 90 day response 12/31/15 PAGE 1 LAST UPDATED 03/2015
2 CIALIS - CIALIS TAB 2.5 MG - CIALIS TAB 5 MG Supporting statement of diagnosis from the physician and prior trial and failure of at least one alpha blocker and one alpha reductase inhibitor 12/31/15 PAGE 2 LAST UPDATED 03/2015
3 ERWINAZE ERWINAZE Supporting statement of diagnosis from the physician 12/31/15 PAGE 3 LAST UPDATED 03/2015
4 ESBRIET ESBRIET. Appropriate diagnosis (idopathic pulmonary fibrosis [IPF]), monitoring (hepatiac function/lfts) pulmonologist. 12/31/2015. PAGE 4 LAST UPDATED 03/2015
5 ESRD THERAPY - PROCRIT SOLUTION UNIT/ML - PROCRIT SOLUTION UNIT/ML - PROCRIT SOLUTION 2000 UNIT/ML - PROCRIT SOLUTION 3000 UNIT/ML - PROCRIT SOLUTION 4000 UNIT/ML - PROCRIT SOLUTION UNIT/ML Hemogloblin less than 10 g/dl for patients receiving Cancer Chemotherapy and Hemoglobin less than 12 and Hematacrit less than 33 for other approved FDA indications in addition to supporting statement of diagnosis from physician 3 months PAGE 5 LAST UPDATED 03/2015
6 FENTANYL - FENTORA TAB 200 MCG - FENTORA TAB 400 MCG - FENTORA TAB 600 MCG - FENTORA TAB 800 MCG Supporting statement of diagnosis from the physician 12/31/15 PAGE 6 LAST UPDATED 03/2015
7 FULYZAQ FULYZAQ All FDA approved indications not otherwise excluded from Part D. Dx of non-infectious diarrhea and HIV, member must be on antiretroviral therapy. 12/31/15 PAGE 7 LAST UPDATED 03/2015
8 GILOTRIF GILOTRIF Supporting statement of diagnosis from the physician in patients with EGFR exon 19 deletions or exon 21 (L858R) substitution as detected by an FDA-approved test. 12/31/15 PAGE 8 LAST UPDATED 03/2015
9 GROWTH HORMONE - HUMATROPE RECON SOLN 12 MG - - NUTROPIN AQ NUSPIN 20 - HUMATROPE RECON SOLN 24 MG NUTROPIN AQ NUSPIN 5 - NUTROPIN AQ PEN SOLUTION 20 MG/2ML - SAIZEN CLICK.EASY Supporting statement of diagnosis from the physician 12/31/15 PAGE 9 LAST UPDATED 03/2015
10 HARVONI HARVONI Must submit documentation of chronic hepatitis C genotype (confirmed by HCV RNA level within the last 6 months) and subtype. Must submit laboratory results within 6 weeks of initiating therapy including: 1) CBC w Platelets, 2) AST/ALT, 3)Total Bilirubin, 4)Serum Albumin, 5)PT/INR, 6)Serum Creatinine, and 7)GFR. Must also submit documentation that the member does not have decompensated liver disease (i.e. Child-Pugh Score greater than 6. If patient is cirrhotic must submit documentation of severity (i.e. Metavir score, Ishak score, FibroSure, Fibroscan, Batts- Ludwig, APRI, or Radiologic imaging consistent with cirrhosis or physical findings/clinical evidence consistent with cirrhosis as attested by the prescribing physician). Patient must be age 18 or over Prescriber must be a gastroenterologist, hepatologist, or infectious disease specialist 24 weeks: treatment-experienced with cirrhosis, 12 weeks: All others PAGE 10 LAST UPDATED 03/2015
11 HRM - AMITRIPTYLINE HCL TAB 10 MG - - AMITRIPTYLINE HCL TAB 150 MG - - AMITRIPTYLINE HCL TAB 50 MG - - ASCOMP-CODEINE - - BENZTROPINE MESYLATE TAB 1 MG - - BUTALBITAL-APAP-CAFF-COD CAP MG - CHLORDIAZEPOXIDE-AMITRIPTYLINE TAB MG - CHLORPROPAMIDE - - CLOMIPRAMINE HCL CAP 50 MG - - CYCLOBENZAPRINE HCL TAB 10 MG - - CYPROHEPTADINE HCL 4 MG - - DIGITEK - - DIGOXIN TAB 125 MCG - - DIPYRIDAMOLE 25 MG - - DIPYRIDAMOLE TAB 25 MG - - DIPYRIDAMOLE TAB 75 MG - - DISOPYRAMIDE PHOSPHATE CAP 150 MG - - DOXEPIN HCL CAP 100 MG - - DOXEPIN HCL CAP 25 MG - - DOXEPIN HCL CAP 75 MG - - DUO-VIL ESTRADIOL TAB 0.5 MG - - ESTRADIOL TAB 2 MG - - GLYBURIDE 2.5 MG - - GLYBURIDE MICRONIZED TAB 1.5 MG - AMITRIPTYLINE HCL TAB 100 MG AMITRIPTYLINE HCL TAB 25 MG AMITRIPTYLINE HCL TAB 75 MG BENZTROPINE MESYLATE TAB 0.5 MG BENZTROPINE MESYLATE TAB 2 MG BUTISOL SODIUM CHLORDIAZEPOXIDE-AMITRIPTYLINE TAB MG CLOMIPRAMINE HCL CAP 25 MG CLOMIPRAMINE HCL CAP 75 MG CYCLOBENZAPRINE HCL TAB 5 MG CYPROHEPTADINE HCL TAB 4 MG DIGOX DIGOXIN TAB 250 MCG DIPYRIDAMOLE 75 MG DIPYRIDAMOLE TAB 50 MG DISOPYRAMIDE PHOSPHATE CAP 100 MG DOXEPIN HCL CAP 10 MG DOXEPIN HCL CAP 150 MG DOXEPIN HCL CAP 50 MG DOXEPIN HCL CONC 10 MG/ML DUO-VIL 2-25 ESTRADIOL TAB 1 MG GLYBURIDE 1.25 MG GLYBURIDE 5 MG GLYBURIDE MICRONIZED TAB 3 MG PAGE 11 LAST UPDATED 03/2015
12 - GLYBURIDE MICRONIZED TAB 6 MG - - GLYBURIDE TAB 2.5 MG - - GLYBURIDE-METFORMIN - - HYDROXYZINE HCL 10 MG - - HYDROXYZINE HCL 50 MG - - HYDROXYZINE HCL SOLUTION 25 MG/ML - - HYDROXYZINE HCL SYRUP 10 MG/5ML - - HYDROXYZINE HCL TAB 25 MG - - HYDROXYZINE PAMOATE CAP 100 MG - - HYDROXYZINE PAMOATE CAP 50 MG - - IMIPRAMINE HCL TAB 25 MG - - IMIPRAMINE PAMOATE - - INDOMETHACIN CAP 50 MG - - INTUNIV - - KETOROLAC TROMETHAMINE 30 MG/ML - - KETOROLAC TROMETHAMINE SOLUTION - 15 MG/ML - KETOROLAC TROMETHAMINE SOLUTION - 60 MG/2ML - MEGACE ES - - MEGESTROL ACETATE SUSPENSION MG/10ML - MEGESTROL ACETATE TAB 20 MG - - MENEST - - METHOCARBAMOL TAB 500 MG - - METHYLDOPA TAB 250 MG - - METHYLDOPA-HYDROCHLOROTHIAZIDE - - METHYLPHENIDATE HCL ER TAB ER 27 - MG GLYBURIDE TAB 1.25 MG GLYBURIDE TAB 5 MG GUANFACINE HCL ER HYDROXYZINE HCL 25 MG HYDROXYZINE HCL SOLUTION 10 MG/5ML HYDROXYZINE HCL SOLUTION 50 MG/ML HYDROXYZINE HCL TAB 10 MG HYDROXYZINE HCL TAB 50 MG HYDROXYZINE PAMOATE CAP 25 MG IMIPRAMINE HCL TAB 10 MG IMIPRAMINE HCL TAB 50 MG INDOMETHACIN CAP 25 MG INDOMETHACIN ER CAP ER 75 MG KETOROLAC TROMETHAMINE 15 MG/ML KETOROLAC TROMETHAMINE 60 MG/2ML KETOROLAC TROMETHAMINE SOLUTION 30 MG/ML KETOROLAC TROMETHAMINE TAB 10 MG MEGESTROL ACETATE SUSPENSION 40 MG/ML MEGESTROL ACETATE SUSPENSION 800 MG/20ML MEGESTROL ACETATE TAB 40 MG MEPROBAMATE METHOCARBAMOL TAB 750 MG METHYLDOPA TAB 500 MG METHYLDOPATE HCL NIFEDIPINE CAP 10 MG PAGE 12 LAST UPDATED 03/2015
13 - NIFEDIPINE CAP 20 MG - - NITROFURANTOIN MACROCRYSTAL CAP - 50 MG - ORPHENADRINE CITRATE ER TAB ER 12H MG - PALGIC SOLUTION 4 MG/5ML - - PERPHENAZINE-AMITRIPTYLINE - - PREMARIN 0.9 MG - - PREMARIN TAB 0.3 MG - - PREMARIN TAB MG - - PREMARIN TAB 1.25 MG - - PREMPRO TAB MG - - PREMPRO TAB MG - - SECONAL - - THIORIDAZINE HCL TAB 100 MG - - THIORIDAZINE HCL TAB 50 MG - - TRIHEXYPHENIDYL HCL ELIXIR 0.4 MG/ML - - TRIHEXYPHENIDYL HCL TAB 5 MG - NITROFURANTOIN MACROCRYSTAL CAP 100 MG NITROFURANTOIN MONOHYD MACRO ORPHENADRINE CITRATE SOLUTION 30 MG/ML PENTAZOCINE-NALOXONE HCL PREMARIN MG PREMARIN 1.25 MG PREMARIN TAB 0.45 MG PREMARIN TAB 0.9 MG PREMPHASE PREMPRO TAB MG RESERPINE TAB 0.1 MG THIORIDAZINE HCL TAB 10 MG THIORIDAZINE HCL TAB 25 MG TICLOPIDINE HCL TRIHEXYPHENIDYL HCL TAB 2 MG ZALEPLON 10 MG - ZALEPLON CAP 10 MG - ZOLPIDEM TARTRATE High risk medication. Automatically approved for beneficiaries less than or equal to 64 years. Attestation to the medical necessity for using this high risk medication, AND Monitoring plan for adverse side effects, AND Anticipated treatment course/duration, AND If formulary alternatives considered safe and effective in the elderly are available, then the member had an inadequate response, intolerable side effect, or contraindication to the alternative(s). PAGE 13 LAST UPDATED 03/2015
14 Less than or equal to 64 years old, claim for target drug automatically pays. Greater than or equal to 65 years old, prior authorization exception request is required indicating medically accepted indication not otherwise excluded from Part D. 12/31/15 PAGE 14 LAST UPDATED 03/2015
15 ICLUSIG ICLUSIG TAB 15 MG Must have documented trial and failure of another tyrosine kinase inhibitor Plan Year PAGE 15 LAST UPDATED 03/2015
16 IMBRUVICA IMBRUVICA Supporting statement of diagnosis from the physician 12/31/15 PAGE 16 LAST UPDATED 03/2015
17 INCIVEK INCIVEK Supporting statement of diagnosis from the physician that includes diagnosis, viral load, genotype, and labs indicating status of liver function as compensated liver disease 12 weeks PAGE 17 LAST UPDATED 03/2015
18 KALYDECO KALYDECO Supporting statement of diagnosis from the physician 12/31/15 PAGE 18 LAST UPDATED 03/2015
19 KEYTRUDA KEYTRUDA Must have documented trial and failure or contraindication to Yervoy. If patient is BRAF V600 mutation positive, must also try a BRAF inhibitor prior to approval of Keytruda Plan Year PAGE 19 LAST UPDATED 03/2015
20 KORLYM KORLYM Pregnancy Supporting statement of diagnosis and relevant medical information from physician 12/31/15 PAGE 20 LAST UPDATED 03/2015
21 LIDODERM LIDODERM PATCH 5 % Supporting statement of diagnosis from the physician 12/31/15 PAGE 21 LAST UPDATED 03/2015
22 LYNPARZA LYNPARZA. Appropriate diagnosis and testing for BRCA mutation (deleterious or suspected deleterious germline BRCA mutated (as detected by an FDA approved test) advanced ovarian cancer that has been treated with 3 or more prior lines of chemotherapy). 12/31/2015. PAGE 22 LAST UPDATED 03/2015
23 NORTHERA NORTHERA Prior authorization will be approved for the following indication(s): orthostatic dizziness, lightheadedness, or "the feeling that you are about to black out" in adults with neurogenic orthostatic hypotension (NOH) caused by primary autonomic failure (i.e., Parkinson disease, multiple system atrophy, pure autonomic failure), dopamine beta-hydroxylase deficiency, and non-diabetic autonomic neuropathy) Plan Year PAGE 23 LAST UPDATED 03/2015
24 OLYSIO OLYSIO Must have chronic hepatitis C genotype 1 infection. Must not have Q80K polymorphism resistance (confirmed by Genosure NS3/4 resistance testing). Patient must be age 18 or over. Prescriber must be a gastroenterologist, hepatologist, or infectious disease specialist 12 weeks PAGE 24 LAST UPDATED 03/2015
25 OPDIVO OPDIVO. Appropriate diagnosis (unresectable or metastatic melanoma and disease progression following ipilimumab [Yervoy]) and testing for BRAF V600 mutation. 12/31/2015 PAGE 25 LAST UPDATED 03/2015
26 PART D VS PART B - ABRAXANE - - ACYCLOVIR SODIUM SOLUTION 50 MG/ML - - ALBUTEROL SULFATE NEBU SOLN (5 - MG/ML) 0.5% - ALBUTEROL SULFATE NEBU SOLN MG/3ML - AMIFOSTINE - - AMINOSYN II SOLUTION 7 % - - AMINOSYN II/ELECTROLYTES - - AMINOSYN-HBC - - AMINOSYN-RF - - ARCALYST - - ARZERRA - - ATGAM - - AZASAN - - BICNU - - BUSULFEX - - CARBOPLATIN SOLUTION 150 MG/15ML - - CARBOPLATIN SOLUTION 50 MG/5ML - - CISPLATIN SOLUTION 100 MG/100ML - - CISPLATIN SOLUTION 50 MG/50ML - - CARIMUNE NF - - CELLCEPT RECON SUSP 200 MG/ML - - CHLORPROMAZINE HCL SOLUTION 25 - MG/ML - CLADRIBINE - ACYCLOVIR SODIUM RECON SOLN 500 MG ALBUTEROL SULFATE NEBU SOLN (2.5 MG/3ML) 0.083% ALBUTEROL SULFATE NEBU SOLN 0.63 MG/3ML ALDURAZYME AMINOSYN II SOLUTION 10 % AMINOSYN II SOLUTION 8.5 % AMINOSYN M AMINOSYN-PF AMINOSYN/ELECTROLYTES ARRANON ASTAGRAF XL AZATHIOPRINE TAB 50 MG BENLYSTA BIVIGAM CARBOPLATIN RECON SOLN 150 MG CARBOPLATIN SOLUTION 450 MG/45ML CARBOPLATIN SOLUTION 600 MG/60ML CISPLATIN SOLUTION 200 MG/200ML CALCITONIN (SALMON) CELLCEPT INTRAVENOUS CEREZYME CHLORPROMAZINE HCL TAB 10 MG CLINIMIX E/DEXTROSE (2.75/10) PAGE 26 LAST UPDATED 03/2015
27 - CLINIMIX E/DEXTROSE (2.75/5) - - CLINIMIX E/DEXTROSE (4.25/25) - - CLINIMIX E/DEXTROSE (5/15) - - CLINIMIX E/DEXTROSE (5/25) - - CLINIMIX/DEXTROSE (4.25/10) - - CLINIMIX/DEXTROSE (4.25/25) - - CLINIMIX/DEXTROSE (5/15) - - CLINIMIX/DEXTROSE (5/25) - - COSMEGEN - - CYCLOSPORINE 100 MG - - CYCLOSPORINE CAP 25 MG - - CYCLOSPORINE SOLUTION 50 MG/ML - - CYCLOPHOSPHAMIDE CAP 50 MG - - CYCLOPHOSPHAMIDE TAB 50 MG - - CYTARABINE RECON SOLN 1 GM - - CYTARABINE SOLUTION 20 MG/ML - - DOXORUBICIN HCL - - DEPO-PROVERA SUSPENSION 400 MG/ML - - DEXTROSE 10 % - - DEXTROSE SOLUTION 10 % - - DOCEFREZ - - DRONABINOL - - ELIGARD - - ELLENCE - - EMEND CAP 40 MG - - EMEND CAP 80 MG - - ENGERIX-B SUSPENSION 10 MCG/0.5ML - - EPIRUBICIN HCL SOLUTION 200 MG/100ML - - ERBITUX - CLINIMIX E/DEXTROSE (4.25/10) CLINIMIX E/DEXTROSE (4.25/5) CLINIMIX E/DEXTROSE (5/20) CLINIMIX/DEXTROSE (2.75/5) CLINIMIX/DEXTROSE (4.25/20) CLINIMIX/DEXTROSE (4.25/5) CLINIMIX/DEXTROSE (5/20) CLOLAR CROMOLYN SODIUM NEBU SOLN 20 MG/2ML CYCLOSPORINE CAP 100 MG CYCLOSPORINE MODIFIED CYCLOPHOSPHAMIDE CAP 25 MG CYCLOPHOSPHAMIDE TAB 25 MG CYTARABINE (PF) CYTARABINE RECON SOLN 2 GM DAUNORUBICIN HCL DACARBAZINE RECON SOLN 200 MG DEXRAZOXANE DEXTROSE 5 % DEXTROSE SOLUTION 5 % DOXIL ELAPRASE ELITEK EMEND CAP 125 MG EMEND CAP 80 & 125 MG ENGERIX-B INJECTABLE 20 MCG/ML ENGERIX-B SUSPENSION 20 MCG/ML EPIRUBICIN HCL SOLUTION 50 MG/25ML ETOPOPHOS PAGE 27 LAST UPDATED 03/2015
28 - ETOPOSIDE SOLUTION 1 GM/50ML - - ETOPOSIDE SOLUTION 500 MG/25ML - - FASLODEX - - FLUOROURACIL SOLUTION 1 GM/20ML - - FLUOROURACIL SOLUTION 5 GM/100ML - - FOLOTYN - - FUSILEV - - GAMMAGARD S/D - - GAMMAPLEX - - GENGRAF - - HEPATAMINE - - IDARUBICIN HCL - - IFEX RECON SOLN 1 GM - - IFOSFAMIDE SOLUTION 1 GM/20ML - - IMOVAX RABIES - - IPRATROPIUM BROMIDE SOLUTION 0.02 % - - IRINOTECAN HCL - - JEVTANA - - LEUCOVORIN CALCIUM RECON SOLN MG - LEUCOVORIN CALCIUM RECON SOLN MG - MELPHALAN HCL - - METHOTREXATE 2.5 MG - - METHOTREXATE SODIUM (PF) - - METRONIDAZOLE IN NACL - - MITOMYCIN 20 MG - - MITOMYCIN RECON SOLN 40 MG - - MUSTARGEN - - MYCOPHENOLIC ACID - ETOPOSIDE SOLUTION 100 MG/5ML FABRAZYME FIRMAGON FLUOROURACIL SOLUTION 2.5 GM/50ML FLUOROURACIL SOLUTION 500 MG/10ML FREAMINE HBC GAMMAGARD GAMMAGARD S/D LESS IGA GANCICLOVIR SODIUM GRANISETRON HCL HERCEPTIN IDAMYCIN PFS IFOSFAMIDE RECON SOLN 1 GM IFOSFAMIDE SOLUTION 3 GM/60ML INTRALIPID EMULSION 20 % IPRATROPIUM-ALBUTEROL IXEMPRA KIT KEPIVANCE LEUCOVORIN CALCIUM RECON SOLN 200 MG LEUCOVORIN CALCIUM RECON SOLN 50 MG MESNA METHOTREXATE SODIUM METHOTREXATE TAB 2.5 MG MIRCERA MITOMYCIN RECON SOLN 20 MG MITOMYCIN RECON SOLN 5 MG MYCOPHENOLATE MOFETIL NAGLAZYME PAGE 28 LAST UPDATED 03/2015
29 - NEBUPENT - - NULOJIX - - ONDANSETRON - - ONDANSETRON HCL 4 MG/2ML - - ONDANSETRON HCL 8 MG - - ONDANSETRON HCL SOLUTION 4 MG/5ML - - ONDANSETRON HCL TAB 24 MG - - ONDANSETRON HCL TAB 8 MG - - PACLITAXEL CONC 100 MG/16.7ML - - PACLITAXEL CONC 300 MG/50ML - - PREMASOL SOLUTION 6 % - - PROGRAF SOLUTION 5 MG/ML - - PROLEUKIN - - PULMOZYME - - RAPAMUNE SOLUTION 1 MG/ML - - RAPAMUNE TAB 2 MG - - RECOMBIVAX HB - - RHEUMATREX - - SANDIMMUNE CAP 25 MG - - SIROLIMUS TAB 0.5 MG - - SIROLIMUS TAB 2 MG - - TACROLIMUS CAP 1 MG - - TAXOTERE CONC 20 MG/ML - - TETANUS-DIPHTHERIA TOXOIDS TD - - TOBRAMYCIN NEBU SOLN 300 MG/5ML - - TOPOTECAN HCL RECON SOLN 4 MG - - TRAVASOL - - TREANDA RECON SOLN 25 MG - - TRELSTAR DEPOT MIXJECT - NEPHRAMINE ONCASPAR ONDANSETRON HCL 4 MG ONDANSETRON HCL 40 MG/20ML ONDANSETRON HCL SOLUTION 4 MG/2ML ONDANSETRON HCL SOLUTION 40 MG/20ML ONDANSETRON HCL TAB 4 MG OXALIPLATIN PACLITAXEL CONC 30 MG/5ML PARICALCITOL SOLUTION 5 MCG/ML PROCALAMINE PROLASTIN-C PROSOL RABAVERT RAPAMUNE TAB 1 MG RECLAST REMICADE SANDIMMUNE CAP 100 MG SANDIMMUNE SOLUTION 100 MG/ML SIROLIMUS TAB 1 MG TACROLIMUS CAP 0.5 MG TACROLIMUS CAP 5 MG TAXOTERE CONC 80 MG/4ML THYMOGLOBULIN TOPOSAR TORISEL TREANDA RECON SOLN 100 MG TRELSTAR TRELSTAR LA MIXJECT PAGE 29 LAST UPDATED 03/2015
30 - TRELSTAR MIXJECT - TRISENOX - UVADEX - VENTAVIS - VINBLASTINE SULFATE SOLUTION 1 MG/ML - VINCASAR PFS - ZEMPLAR - TREXALL - TYSABRI - VECTIBIX - VINBLASTINE SULFATE RECON SOLN 10 MG - VINCRISTINE SULFATE SOLUTION 1 MG/ML - VINORELBINE TARTRATE - ZINECARD RECON SOLN 250 MG - ZINECARD RECON SOLN 500 MG DETAILS - ZOLEDRONIC ACID CONC 4 MG/5ML This drug may be covered under Medicare Part B or D depending on the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination. PAGE 30 LAST UPDATED 03/2015
31 PROTECTED CLASS - ANDROID - - CARAC - - EQUETRO - - GAMASTAN S/D - - GAMUNEX-C - - LAMICTAL ODT TAB DISP 200 MG - - LAMICTAL ODT TAB DISP 50 MG - - LAMICTAL STARTER KIT 25 (42)-100 (7) MG - - LAMICTAL XR KIT 25 & 50 & 100 MG - - LAMICTAL XR KIT 50 & 100 & 200 MG - - PRIVIGEN - APLENZIN TAB ER 24H 522 MG DILANTIN CAP 30 MG FLUOROURACIL CREAM 0.5 % GAMUNEX LAMICTAL ODT TAB DISP 100 MG LAMICTAL ODT TAB DISP 25 MG LAMICTAL STARTER KIT 25 (35) MG LAMICTAL STARTER KIT 25 (84)-100(14) MG LAMICTAL XR KIT 25 (21)-50 (7) MG NIPENT SIMULECT - TESTRED - ZANOSAR Diagnosis Plan Year PAGE 31 LAST UPDATED 03/2015
32 AgeWei11-Tier- Formulary ID: Version 8 PAGE 32 LAST UPDATED 03/2015
33 PROVIGIL - MODAFINIL TAB 100 MG - MODAFINIL TAB 200 MG Supporting statement of diagnosis from the physician 12/31/15 PAGE 33 LAST UPDATED 03/2015
34 REGRANEX REGRANEX Diabetic Neuropathic Ulcers: Diabetic patient with ulcer wound. Treatment will be given in combination with ulcer wound care (eg, debridement, infection control, and/or pressure relief). Diabetic Neuropathic Ulcers: Maximum 5 months. PAGE 34 LAST UPDATED 03/2015
35 REVATIO - REVATIO SOLUTION 10 MG/12.5ML - SILDENAFIL CITRATE TAB 20 MG Supporting statement of diagnosis from the physician 12/31/15 PAGE 35 LAST UPDATED 03/2015
36 SAMSCA SAMSCA Supporting statement of diagnosis from the physician 12/31/15 PAGE 36 LAST UPDATED 03/2015
37 SOVALDI SOVALDI Must have genotype 1,2,3,4,5, or 6 Patient must be age 18 or over. Prescriber must be a gastroenterologist, hepatologist, or infectious disease specialist 12 weeks:genotype 1,2,or4_24 wks:genotype 3 OR no interferon_48 wks:liver cancer awaiting transplant PAGE 37 LAST UPDATED 03/2015
38 STIVARGA STIVARGA Supporting statement of diagnosis from the physician 12/31/15 PAGE 38 LAST UPDATED 03/2015
39 VICTRELIS VICTRELIS Supporting statement of diagnosis from the physician that includes diagnosis, viral load, genotype, and labs indicating status of liver function as compensated liver disease 44 weeks PAGE 39 LAST UPDATED 03/2015
40 XALKORI XALKORI Supporting statement of diagnosis from the physician that establishes the cancer as anaplastic lymphoma kinase (ALK)-positive must be prescribed by an oncologist 12/31/15 PAGE 40 LAST UPDATED 03/2015
41 XTANDI XTANDI Supporting statement of diagnosis from the physician and prior trial and failure of docetaxel 12/31/15 PAGE 41 LAST UPDATED 03/2015
42 ZOHYDRO - ZOHYDRO ER CAP ER 12H 10 MG - ZOHYDRO ER CAP ER 12H 20 MG - ZOHYDRO ER CAP ER 12H 15 MG - ZOHYDRO ER CAP ER 12H 30 MG - ZOHYDRO ER CAP ER 12H 40 MG - ZOHYDRO ER CAP ER 12H 50 MG All FDA approved indications not otherwise excluded from Part D. Must have severe pain requiring around the clock long term opioid, AND all of these: 1- ONE of the following formulary opioid options, hydrocodone IR, oxycodone IR, morphine IR, hydromorphone IR, methadone, OR oxymorphone IR are ineffective,not tolerated or inadequate for controlling pain AND fentanyl patches are ineffective, not tolerated, or inadequate for controlling pain 2-Must discontinue all other around-the-clock opioids when initiated 3-Care plan/agreement for opioid therapy has been established 4-Pt advised of risks and provides informed consent for chronic opioid therapy 5-Pt assessed for all these (i)pain severity (ii)suitability of non-opioids (iii)physical & emotional functional status (iv)risk of or current aberrant drug behavior 5-Prescriber will monitor for signs of misuse, abuse and addiction during therapy AND ONE of these: A-Opioid naive/non-tolerant must start at 10mg twice day for 7 days before titrating up OR B-Opioid tolerant, receiving one of these doses per day for at least 1 week: 60mg oral morphine, 25mcg transdermal fentanyl/hr, 30mg oral oxycodone, 8mg oral hydromorphone, 25mg oral oxymorphone Patient must be age 18 or over. Prescriber is knowledgeable in the use of potent opioids for the management of chronic pain PAGE 42 LAST UPDATED 03/2015
43 AgeWei11-Tier- Formulary ID: Version 8 90 days PAGE 43 LAST UPDATED 03/2015
44 AgeWei11-Tier- Formulary ID: Version 8 PAGE 44 LAST UPDATED 03/2015
BELEODAQ. Prior Authorization Criteria Memorial Hermann Advantage HMO & PPO Formulary ID: Version 10 Effective Date: 6/1/2015
Memorial Hermann Advantage HMO & PPO Formulary ID: 15190 Version 10 BELEODAQ BELEODAQ All FDA approved indications not otherwise excluded from Part D. Plan Year Y0110_PriorAuthCriteria4 IA 04/09/2015 PAGE
BELEODAQ. Prior Authorization Criteria Memorial Hermann HMO Formulary ID: Version 19 Effective Date: 10/27/2015. PRODUCT(s) AFFECTED BELEODAQ
BELEODAQ BELEODAQ All FDA approved indications not otherwise excluded from Part D. Plan Year PAGE 1 BEXAROTENE BEXAROTENE All Medically Accepted Indications not otherwise excluded from Part D Patient must
AgeWell 5 Tier 2016 Prior Authorization Criteria
ADCIRCA - ADCIRCA TAB 20MG. Patient requires nitrate therapy on a regular or intermittent basis Statement of diagnosis from the physician Effective 05/01/2016 1 BOSULIF - BOSULIF TAB 100MG BOSULIF TAB
Drug Name Tier Drug Name Tier
Drug Name Tier Drug Name Tier ABELCET 100 MG/20 ML VIAL 4 ACETYLCYSTEINE 10% VIAL 2 ACETYLCYSTEINE 20% VIAL 2 ACYCLOVIR 1,000 MG/20 ML VIAL 2 ACYCLOVIR 500 MG/10 ML VIAL 2 ADRUCIL 500 MG/10 ML VIAL 2 ALBUTEROL
Agewell 1 Tier 2016 Prior Authorization Criteria
ADCIRCA - ADCIRCA TAB 20MG. Patient requires nitrate therapy on a regular or intermittent basis Statement of diagnosis from the physician Effective 07/01/2016 1 BOSULIF - BOSULIF TAB 100MG BOSULIF TAB
Agewell 5 Tier 2016 Prior Authorization Criteria
ADCIRCA - ADCIRCA TAB 20MG. Patient requires nitrate therapy on a regular or intermittent basis Statement of diagnosis from the physician 12/31/2016 Effective 11/01/2016 1 BOSULIF - BOSULIF TAB 100MG BOSULIF
ANDROID. Products Affected ANDROID. Prior Authorization Criteria HEALTH CHOICE EXCHANGE Effective Date: 12/01/2016
Prior Authorization HEALTH CHOICE EXCHANGE Effective Date: 12/01/2016 ANDROID ANDROID Supporting statement of diagnosis from the physician. Other 1 BLINCYTO BLINCYTO Known hypersensitivity to blinatumomab
ADCIRCA. Products Affected ADCIRCA. Covered Uses All medically accepted indications not otherwise excluded from Part D.
ADCIRCA ADCIRCA. Other Patient requires nitrate therapy on a regular or intermittent basis Statement of diagnosis from the physician 12/31/2017 1 ALUNBRIG ALUNBRIG Other Diagnosis of metastatic, ALK positive
ADCIRCA. Tribute 2017 Formulary 2017 Prior Authorization Criteria. Products Affected. Adcirca
ADCIRCA Adcirca All FDA approved indications not otherwise excluded from Part D. Concomitant administration of riociguat with a specific PDE5 inhibitor (eg, sildenafil, tadalafil, vardenafil) Treatment
ADCIRCA. Products Affected ADCIRCA. Covered Uses All medically accepted indications not otherwise excluded from Part D.
ADCIRCA ADCIRCA Other Concurrent use of organic nitrate or guanylate cyclase stimulators (includes intermittent use) Pulmonary arterial hypertension (PAH) (Initial): Diagnosis of PAH. PAH is symptomatic.
2014 AlohaCare Advantage (HMO) and AlohaCare Advantage Plus Formulary (HMO SNP) Drugs with Prior Authorization Requirements
2014 AlohaCare Advantage (HMO) and AlohaCare Advantage Plus Formulary (HMO SNP) with Prior Authorization Requirements You may need prior authorization for certain drugs that are on the formulary or drugs
J1556 INJECTION, IMMUNE GLOBULIN (BIVIGAM) 500 MG $ J1559 INJECTION, IMMUNE GLOBULIN (HIZENTRA) 100 MG $14.364
G0333 INITIAL 30-DAY SUPPLY AS A BENEFICIARY $57.000 J0133 INJECTION, ACYCLOVIR 5 MG $0.470 J0285 INJECTION, AMPHOTERICIN B 50 MG $10.280 J0287 INJECTION, AMPHOTERICIN B LIPID COMPLEX 10 MG $21.850 J0288
DME MAC Jurisdiction C Drug Fees, Pharmacy Dispensing Fees and Pharmacy Supply Fees Effective 01/01/2018 through 03/31/2018
G0333 PHARMACY DISPENSING FEE FOR INHALATION DRUG(S); INITIAL 30-DAY SUPPLY AS A BENEFICIARY $57.000 J0133 INJECTION, ACYCLOVIR 5 MG $0.068 J0285 INJECTION, AMPHOTERICIN B 50 MG $32.987 J0287 INJECTION,
DME MAC Jurisdiction B Drug Fees, Pharmacy Dispensing Fees and Pharmacy Supply Fees Effective 01/01/2019 through 03/31/2019
G0333 PHARMACY DISPENSING FEE FOR INHALATION DRUG(S); INITIAL 30-DAY SUPPLY AS A BENEFICIARY $57.000 J0133 INJECTION, ACYCLOVIR 5 MG $0.048 J0285 INJECTION, AMPHOTERICIN B 50 MG $31.668 J0287 INJECTION,
ADCIRCA. Products Affected ADCIRCA. Covered Uses All medically accepted indications not otherwise excluded from Part D.
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