Products Affected ACTEMRA SUBCUTANEOUS ACTEMRA INTRAVENOUS SOLUTION 400 MG/20 ML (20 MG/ML), 80 MG/4 ML (20 MG/ML)

Transcription

1 Current as of October 1, 2016 ACTEMRA ACTEMRA SUBCUTANEOUS ACTEMRA INTRAVENOUS SOLUTION 400 MG/20 ML (20 MG/ML), 80 MG/4 ML (20 MG/ML) PA Other Documentation of diagnosis, previous treatment with one or more disease-modifying anti-rheumatic drugs, and documented clinical failure with Humira (adalimumab) or Enbrel (etanercept). Rheumatologist Indefinite as long as member is eligible. Updated 09/28/2016

2 AMPYRA AMPYRA PA Moderate to severe renal impairment (CrCL less than or equal to 50ml/min), patient not able to walk 25 feet in 8-45 seconds. Documentation of diagnosis, lab results, and patient progress notes to include results of timed 25 foot walk Neurologist Initially for 3 months Continuation requests may be approved open ended based on response.. Other Continuation of treatment: A positive response is defined as a 20% improvement in walking speed or an improvement in functional impairment and activities of daily living. 2

3 ANTIBIOTIC linezolid SIVEXTRO ZYVOX INTRAVENOUS PARENTERAL SOLUTION 600 MG/300 ML ZYVOX ORAL PA Covered Uses All medically accepted indications not otherwise excluded from Part D. Other Documentation of diagnosis and previous treatments Infectious Disease Specialist Requested acute need 6 to 28 days, longer for refractory disease 3

4 ANTIFUNGALS CRESEMBA itraconazole JUBLIA KERYDIN LAMISIL ORAL TABLET SPORANOX SPORANOX PULSEPAK PA Covered Uses All medically accepted indications not otherwise excluded from Part D. Other For onychomycosis: documentation of failed oral terbinafine antifungal therapy, pertinent lab/microbiology test results such as positive KOH, PAS, biopsy with a positive methenamine silver stain or fungal culture positive for a typical skin/nail pathogen. Concomitant conditions as identified by any of the following: pain surrounding nail, soft tissue involvement, diabetes mellitus, peripheral vascular disease, immunosuppression, concurrent cancer chemotherapy, concurrent chronic oral corticosteroid use, history of solid organ transplant, HIV, or severe peripheral vascular disease. For a topical fungal infection other than onychomycosis: documentation of diagnosis and failed a 14-day trial of topical antifungal therapy or oral terbinafine where indicated. For systemic fungal infection: diagnosis of a systemic fungal infection including, but not limited to blastomycosis, histoplasmosis, or aspergillosis. Onychomycosis oral 12 wks topical 48 wks Other topical infection 60 ds Systemic infection up to 1 yr for retreatment of the onychomycosis shall not be granted unless a time period of 12 months or more has elapsed since the initial authorization. 4

5 ANTIVIRALS/ANTI HEPATITIS C AGENTS VIEKIRA PAK PA Other Documentation of hepatitis C virus diagnosis, genotype, cirrhosis status, and medical history. Previous treatment failure of Harvoni. Gastroenterologist, hepatologist, or infectious disease specialist 12 or 24 weeks based on genotype, cirrhosis status, medical history, and AASLD guidelines. 5

6 CIALIS CIALIS ORAL TABLET 2.5 MG, 5 MG PA Other Not covered for sexual dysfunction unrelated to BPH. information to support the diagnosis of benign prostatic hyperplasia (BPH). Indefinite as long as member is eligible. 6

7 CIMZIA CIMZIA CIMZIA POWDER FOR RECONST PA Other Documentation of diagnosis and previous treatments. Member must be greater than 18 years old Rheumatologist or Gastroenterologist Indefinite as long as member is eligible. will be provided for the listed approved indications when the following criteria are met. RHEUMATOID or PSORIATIC ARTHRITIS: 1) Confirmation of diagnosis and 2) Documented clinical failure, inadequate response or valid contraindication with one or more Disease Modifying Anti-rheumatic Drug (DMARDS) such as hydroxychloroquine, leflunomide, methotrexate or sulfasalazine and an inadequate response to Humira or Enbrel. CROHN'S DISEASE: 1) Confirmation of diagnosis and 2) Documentation of clinical failure, inadequate response or valid contraindication with one or more first line treatments such as corticosteroids, 6-mercaptopurine, azathioprine, methotrexate or sulfasalazine and an inadequate response to Humira. ANKYLOSING SPONDYLITIS: 1) Confirmation of diagnosis and 2) Documented clinical failure, inadequate response or valid contraindication for treatment with one or more non-steroidal antiinflammatory drug (NSAIDs/COX-2 inhibitor)and an inadequate response to Humira or Enbrel. 7

8 COLONY STIMULATING FACTORS GRANIX LEUKINE INJECTION RECON SOLN NEULASTA SUBCUTANEOUS SYRINGE NEUPOGEN ZARXIO PA Other Documentation and cause of diagnosis. BMT or PBPC mobilization-1mo. Myelodysplasia-AIDS-HIV neutropenia-4 mos. All other diagnosis 6 mos. 8

9 CYSTIC FIBROSIS AGENT KALYDECO ORKAMBI PA Other Documentation of diagnosis and confirmation of the mutation as detected by a FDA-cleared test. Initial approval for 3 months, continuation request may be approved for 1 year based on response. 9

10 DAKLINZA DAKLINZA PA Covered Uses Other All FDA-approved indications not otherwise excluded from Part D. All AASLD approved guidelines. Documentation of hepatitis C virus diagnosis, genotype and any previous treatment failures. Gastroenterologist, hepatologist or infectious disease specialist. 12 or 24 weeks based on genotype, cirrhosis status, medical history and AASLD guidelines. 10

11 DERMATOLOGICAL PRODUCTS (RETINOIDS AND ACNE MEDS) adapalene topical cream adapalene topical gel ATRALIN avita DIFFERIN TOPICAL CREAM DIFFERIN TOPICAL GEL DIFFERIN TOPICAL LOTION RETIN-A RETIN-A MICRO RETIN-A MICRO PUMP TOPICAL GEL WITH PUMP 0.08 % tretinoin microspheres topical gel with pump tretinoin topical cream tretinoin topical gel 0.01 %, % PA Other Confirmation of non-cosmetic indication. Indefinite as long as member is eligible. 11

12 DIFICID DIFICID PA Other Documentation of Clostridium Difficile Associated Diarrhea diagnosis AND medical records or pharmacy claims documenting previous drug treatments. Infectious Disease Specialist or Gastroenterologist. 10 days. Member must have a documented prior trial or contraindication with metronidazole and/or vancomycin. 12

13 ENBREL ENBREL ENBREL SURECLICK PA Other Documentation of diagnosis and documentation of previous treatments. Dermatologist or Rheumatologist depending on condition being treated. Indefinite as long as member is eligible. will be provided for the listed approved indications when the following criteria are met. RHEUMATOID, PSORIATIC or JUVENILE IDIOPATHIC ARTHRITIS: 1) Confirmation of diagnosis and 2) Documented clinical failure, inadequate response or valid contraindication with one or more Disease Modifying Anti-rheumatic Drugs (DMARDS) such as hydroxychloroquine, leflunomide, methotrexate or sulfasalazine. PLAQUE PSORIASIS: 1) Confirmation of diagnosis and 2) Documented clinical failure, inadequate response or valid contraindication with one or more topical therapies such as coal tar or topical corticosteroids and 3) Documented clinical failure, inadequate response or valid contraindication with at least one systemic therapy such as PUVA, methotrexate, soriatane or cyclosporine. ANKYLOSING SPONDYLITIS: 1) Confirmation of diagnosis and 2) Documented clinical failure, inadequate response or valid contraindication for treatment with one or more non-steroidal anti-inflammatory drug (NSAIDs/COX-2 inhibitor)or sulfasalazine. 13

14 EXJADE EXJADE FERRIPROX ORAL SOLUTION JADENU PA Other Documentation of a diagnosis of chronic iron overload due to blood transfusions (transfusional hemosideriosis)or non-transfusion dependent thalassemia (NTDT). Hematologist Indefinite as long as member is eligible. 14

15 FAMILIAL HYPERCHOLESTEROLEMIA JUXTAPID KYNAMRO PA Other Documentation of diagnosis, laboratory data and previous treatments. Initially for 6 months. Continuation requests may be approved for 6 months based on response. will be approved if the following criteria are met: 1)Prescribed by a physician who is enrolled in the REMS Program 2)Documentation confirming a clinical or laboratory diagnosis of homozygous familial hypercholesterolemia 3)Member has documented clinical failure, inadequate response, intolerance or contraindication with one or more hyperlipidemia agents. 15

16 FLECTOR FLECTOR PA Other Indefinite as long as member is eligible. 16

17 FORTEO FORTEO PA Covered Uses All medically accepted indications not otherwise excluded from Part D. Other Documentation of a diagnosis, pertinent bone density test results and previous treatments. Endocrinologist or Rheumatologist 2 years Teriparatide (Forteo) is approved when: 1. Prescribed by a metabolic bone specialist (a Rheumatologist or an Endocrinologist) for the treatment of osteoporosis (men with primary or hypogonadal osteoporosis or postmenopausal women with osteoporosis*) and, 2. The member has had an unsatisfactory response to compliant antiresorptive therapy (such as excessive fractures, upper GI intolerance or continued loss of bone mass), or 3. Member has unusually low bone mass (such as individuals with a T- score below -3.5) or, 4. Member has a contraindication to other pharmacological treatments of osteoporosis. Note: *Diagnosis is osteoporosis as defined by WHO as a bone mineral density less than or equal to 2.5 standard deviations below the mean for young, white adult women. May also be defined clinically regardless of BMD by history of osteoporotic fractures. An osteoporotic fracture is a low-velocity fracture (to the spine, pelvis, hip or radius) resulting from a fall at standing height or equivalent force.**if patient is unable to self-administer and drug is being given in the patient's home by a home health nurse possible Part B coverage should be evaluated. 17

18 GATTEX GATTEX ONE-VIAL PA Other Documentation of diagnosisand medical records. Gastroenterologist 1 year records are needed to confirm member dependence on total parental/iv nutrition. 18

19 GLP-1 RECEPTOR AGONISTS TANZEUM TRULICITY PA Covered Uses All medically accepted indications not otherwise excluded from Part D. Other Confirmation of a diabetes type 2 diagnosis, HgbA1C value and documentation (prescription claims records or medical records) supporting an adequate trial of metformin. Indefinite as long as member is eligible. Maybe approved if the following criteria are met: 1. Member has a diagnosis of diabetes mellitus type II AND 2. Member has an HgbA1C value greater than 7.0% despite an adequate trial of metformin at maximally tolerated doses OR documentation that the member has a contraindication or intolerance to metformin. (Maximum metformin daily dose varies by product (2000mg-2550mg/day).) 19

20 GROWTH HORMONE NORDITROPIN FLEXPRO NUTROPIN AQ NUSPIN NUTROPIN AQ SUBCUTANEOUS CARTRIDGE 10 MG/2 ML (5 MG/ML) PA Covered Uses All medically accepted indications not otherwise excluded from Part D. Documentation of diagnosis, patient progress notes including growth curves for children and pertinent lab/genetic testing results to confirm growth hormone deficiency (such as 2 provocative growth hormone stimulation tests or IGF-1 and other pituitary hormone values if stimulation tests are not done). Genetic testing as needed to verify diagnosis of Prader - Willi, Turner or Noonan syndromes. Endocrinologist for growth hormone deficiency indications Children:6 month intervals based on response Adults: 6 months initial then open ended if response. 20

21 PA Other 1. Member must be, a. is a child with a proven* GH deficiency or, b. is an adult with a proven* GH deficiency, or c. is a child with height less than 3rd percentile for chronological age with chronic renal insufficiency or, d. has Prader-Willi Syndrome confirmed by appropriate genetic testing or, e. is a child with short stature associated with Turners syndrome or, f. is a child with short stature associated with Noonan syndrome ) or, g. has AIDS-related wasting. *Proven GH deficiency (GHD) is defined as an abnormal response to TWO provocative stimulation tests, such as L-dopa, clonidine, glucagon, propranolol, arginine or insulin. (For children, abnormal response is defined as less than 10ng/ml and 5ng/ml or less for adults. Adults may alternatively demonstrate 3 other pituitary hormone deficiencies. GHD stimulation testing is not necessary for conditions c-g above, or for those members with a history of surgery or irradation in the region of the hypothalamus and pituitary. It is also not necessary for children who have evidence of additional pituitary hormone deficiencies, pituitary stalk agenosis, empty sella or supra-sellar mass lesion is documented with short stature. CRITERIA FOR CONTINUATION OF GROWTH HORMONE COVERAGE IN CHILDREN: 1. First year of therapy: height rate must be double the pre-treatment growth rate or the growth rate has increased by 3cm/yr or more. 2. Therapy past the first year: growth velocity remains above 2.5cm/yr 3. Radiologic evidence shows epiphysis has not yet closed (applies to children over age 10). 21

22 GROWTH HORMONE RELEASING FACTOR ANALOG EGRIFTA SUBCUTANEOUS RECON SOLN 1 MG PA Other Documentation of a diagnosis of excess abdominal fat secondary to HIV - associated lipedystrophy. Indefinite as long as member is eligible. 22

23 HEPATITIS C VIRUS (HCV) COMBINATION NS5A AND NS5B PROTEASE INHIBITOR EPCLUSA HARVONI PA Other Documentation of hepatitis C virus diagnosis, genotype documentation, and any previous treatment failures Gastroenterologist, hepatologist, or infectious disease specialist 12 or 24 weeks per diagnosis and AASLD guidelines. 8 week approval per prescriber request. 23

24 HIGH RISK MEDICATIONS - SKELETAL MUSCLE RELAXANTS AMRIX carisoprodol carisoprodol-asa-codeine carisoprodol-aspirin cyclobenzaprine oral tablet 10 mg, 5 mg SOMA PA Other Only applies to members 65 years of age or older. Authorization will be for 21 days. Prior authorization only applies to members 65 years of age and older who will be evaluated for appropriate use of high risk medication. Use will only be approved if prescribing provider has assessed risk versus benefit in using this medication in this member and has confirmed that he/she believes it is in member's best interest to initiate/continue therapy. 24

25 HUMIRA HUMIRA HUMIRA PEN HUMIRA PEN CROHN'S-UC-HS START HUMIRA PEN PSORIASIS-UVEITIS PA Other Documentation of diagnosis and documentation of previous therapies. Dermatologist, Rheumatologist or Gastroenterologist depending on the condition being treated. Indefinite as long as member is eligible. will be provided for the listed approved indications when the following criteria are met. RHEUMATOID, PSORIATIC or JUVENILE IDIOPATHIC ARTHRITIS: 1) Confirmation of diagnosis and 2) Documented clinical failure, inadequate response or valid contraindication with one or more Disease Modifying Anti-Rheumatic Drugs (DMARDS) such as hydroxychloroquine, leflunomide, methotrexate or sulfasalazine. PLAQUE PSORIASIS: 1) Confirmation of diagnosis and 2) Documented clinical failure, inadequate response or valid contraindication with one or more topical therapies or systemic therapies such as phototherapy or methetrexate. ANKYLOSING SPONDYLITIS: 1) Confirmation of diagnosis and 2) Documented clinical failure, inadequate response or valid contraindication for treatment with one or more non-steroidal anti-inflammatory drugs (NSAIDs,COX-2 inhibitor or sulfasalazine). CROHN'S DISEASE: 1) Confirmation of diagnosis and 2) Documentation of failure with one or more first line treatments such as corticosteroids, 6-mercaptopurine, azathioprine, methotrexate or sulfasalazine. ULCERATIVE COLITIS: 1) Confirmation of diagnosis and 2) Documnetation of failure with one or more first line treatments such as corticosteroids, 6-mercaptopurine or azathioprine. 25

26 INCRELEX INCRELEX PA Covered Uses All medically accepted indications not otherwise excluded from Part D. Other Closed epiphyses Documentation of diagnosis, patient progress notes including growth measurements/charts and pertinent lab test results including basal IGF-1 values or documentation supporting growth hormone (GH) gene deletion and development of neutralizing antibodies to GH. Endocrinologist 1 year for mecasermin may be approved when the following conditions are met: 1. The member is a child with a diagnosis of growth failure with severe primary IGFD or with growth hormone (GH) gene deletion who has developed neutralizing antibodies to GH and, 2. The members height standard deviation score less than or equal to -3.0 for age and sex and, 3. The members basal IGF-1 standard deviation score less than or equal to -3.0 and, 4. The member has normal or elevated growth hormone (GH)and confirmation that epiphyses open. 26

27 INTERFERONS INTRON A INJECTION RECON SOLN INTRON A INJECTION SOLUTION 6 MILLION UNIT/ML PEGASYS PEGASYS PROCLICK PEGINTRON PEGINTRON REDIPEN PA Other Documentation of viral genotype and abscense of ascites, hepatic encephalopathy, variceal bleeding, or other clinical signs of decompensation. For any other FDA approved indication (ex. hepatitis B or hairy cell leukemia) only documentation of diagnosis is required. HCV type 2,3-24 weeks. HCV type 1,4-48 weeks. Open ended for all other approved indications. 27

28 INTERLEUKIN RECEPTOR ANTAGONIST COSENTYX COSENTYX PEN TALTZ AUTOINJECTOR TALTZ SYRINGE PA Other Documentation of diagnosis, previous treatment with one or more topical or systemic treatments, and documented clinical failure with Humira (adalimumab) or Enbrel (etanercept). Rheumatologist or Dermatologist Indefinite as long as member is eligible. 28

29 KINERET KINERET PA Other Documentation of diagnosis and previous treatments Rheumatologist, Dermatologist, or Gastroentrologist depending on condition being treated. Indefinite as long as member is eligible. will be provided for the listed approved indications when the following criteria are met. RHEUMATOID ARTHRITIS: 1) Confirmation of diagnosis and 2) Documented clinical failure, inadequate response or valid contraindication with one or more Disease Modifying Anti-rheumatic Drug (DMARDS) such as hydroxychloroquine, leflunomide, methotrexate or sulfasalazine and an inadequate response to Humira or Enbrel. CRYOPYRIN-ASSOCIATED PERIODIC SYNDROME: 1) Confirmation of diagnosis. 29

30 LIDODERM lidocaine topical adhesive patch,medicated LIDODERM PA Other Documentation of diagnosis Indefinite as long as member is eligible. 30

31 MELATONIN RECEPTOR AGONIST HETLIOZ PA Other Documentation of diagnosis of Non-24-hour sleep-wake disorder without light perception, and any previous treatments. Sleep specialist or neurologist. Initial coverage for 3 months, continuation coverage is for 1 year Continuation requests are based on a greater than or equal to 45 minute increase in nighttime sleep and greater than or equal to 45 minute decrease in daytime sleep. 31

32 MULTIPLE SCLEROSIS AGENTS AUBAGIO BETASERON SUBCUTANEOUS KIT GILENYA PLEGRIDY REBIF (WITH ALBUMIN) REBIF REBIDOSE REBIF TITRATION PACK PA Other Documentation of diagnosis and previous treatments Neurologist Indefinite as long as member is eligible. Documentation of multiple sclerosis (MS) diagnosis and medical record or prescription drug claims history documenting prior drug treatments. will be provided if there is a documented clinical failure, inadequate response or valid contrindication to prior treatment with interferon beta-1a (Avonex),interferon beta-1b (Extavia), glatiramer acetate (Copaxone) OR dimethyl fumarate (Tecfidera). 32

33 NOXAFIL NOXAFIL ORAL PA Other Documentation of diagnosis and previous treatments. Excluded for members who are younger than 13 years old Infectious disease provider or hematologist/oncologist for 1 month for oropharyngeal candiasis or 6 months for all other indications. Members with diagnosis of oropharyngeal candidiasis that have tried and failed at least 2 weeks of therapy with, or is not a candidate for, fluconazole or itraconazole. Also, prophylactic use against Aspergillus and Candida infection in individuals that are immunosuppressed due to hematopoietic stem cell transplant secondary to graft-versus host disease or hematologic malignancy with prolonged neutropenia secondary to chemotherapy. 33

34 NUEDEXTA NUEDEXTA PA Covered Uses Other All FDA-approved indications not otherwise excluded from Part D. Documentation of diagnosis. Neurologist Indefinite as long as member is eligible. Documentation of diagnosis of pseudobulbar affect (PBA) related to amyotrophic lateral sclerosis (ALS) or multiple sclerosis (MS). 34

35 OLYSIO OLYSIO PA Other Failure of previous hepatitis C virus (HCV) protease inhibitor therapy. Documentation of Hepatitis C, genotype years of age or older. Gastroenterologist, hepatologist, or infectious disease specialist. 12 or 24 weeks based on genotype, cirrhosis status, medical history, and AASLD guidelines. 35

36 ORAL ANTINEOPLASTICS AFINITOR AFINITOR DISPERZ ALECENSA bexarotene BOSULIF ORAL TABLET 100 MG, 500 MG CABOMETYX CAPRELSA COMETRIQ COTELLIC CYRAMZA DARZALEX EMPLICITI ERIVEDGE FARYDAK GILOTRIF GLEEVEC GLEOSTINE IBRANCE ICLUSIG imatinib IMBRUVICA INLYTA IRESSA JAKAFI KEYTRUDA INTRAVENOUS SOLUTION LENVIMA LONSURF LYNPARZA MEKINIST NINLARO ODOMZO PERJETA POMALYST SPRYCEL STIVARGA SUTENT SYNRIBO TAFINLAR TAGRISSO TARCEVA TASIGNA TECENTRIQ thiotepa TYKERB VENCLEXTA VENCLEXTA STARTING PACK VOTRIENT XALKORI XTANDI ZELBORAF ZOLINZA ZYDELIG ZYKADIA ZYTIGA PA Covered Uses All medically accepted indications not otherwise excluded from Part D. Documentation of diagnosis. 36

37 PA Other Oncologist or hematologist Initial approval for 6 months then indefinitely based on positive clinical response and tolerance. The listed anti-cancer agents will be covered when being used for an FDA approved indication or when being used for an off-label indication that is supported by one of the approved compendia as specified by Medicare Part D guidelines. The currently recognized compendia are: 1)American Hospital Formualry Service Drug (AHFS DI), 2) United States Pharmacopeia - Drug (USP DI), 3) Thomson Micromedex DRUGDEX System, 4)National Comprehensive Cancer Network Drugs and Biological Compendium (NCCN)and 5) Elsevier Gold Standard's Clinical Pharmacology. 37

38 ORENCIA (SUBCUTANEOUS ABATACEPT) ORENCIA ORENCIA CLICKJECT PA Other NA Documentation of diagnosis and previous treatments NA Rheumatologist Indefinite as long as member is eligible. Documented clinical failure, inadequate response or valid contraindication with one or more Disease Modifying Anti-rheumatic Drugs (DMARDS) such as hydroxychloroquine, leflunomide, methotrexate or sulfasalazine and an inadequate response to Humira or Enbrel. will also be provided for individuals transitioning from Orencia intravenous therapy. 38

39 OTEZLA OTEZLA OTEZLA STARTER ORAL TABLETS,DOSE PACK 10 MG (4)-20 MG (4)-30 MG (47) PA Documentation of diagnosis and documentation of previous treatments. Member must be greater than 18 years old Dermatologist or Rheumatologist Indefinite as long as member is eligible. Other will be provided with: 1) Confirmation of diagnosis and 2) Documented clinical failure, inadequate response or valid contraindication with one or more Disease Modifying Anti-rheumatic Drugs (DMARDS) such as hydroxychloroquine, leflunomide, methotrexate or sulfasalazine and an inadequate response to Humira or Enbrel. 39

40 PCSK-9 INHIBITORS PRALUENT PEN PRALUENT SYRINGE REPATHA PUSHTRONEX REPATHA SURECLICK REPATHA SYRINGE PA Other record documentation of diagnosis. Evidence of maximally tolerated statin therapy. Indefinite as long as member is eligible. 40

41 PULMONARY ARTERIAL HYPERTENSION ADCIRCA ORENITRAM REVATIO ORAL sildenafil oral UPTRAVI ORAL TABLET 1,000 MCG, 1,200 MCG, 1,400 MCG, 1,600 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG UPTRAVI ORAL TABLETS,DOSE PACK PA Other Documentation of diagnosis. Indefinite as long as member is eligible. Documentation of diagnosis of pulmonary arterial hypertension. 41

42 PULMONARY FIBROSIS AGENTS ESBRIET OFEV PA Other Documentation of diagnosis. Prescribed by or in consultation with a Pulmonologist. Indefinite as long as member is eligible. Esbriet (pirfenidone) is not to be used in conjunction with Ofev (nintedanib). 42

43 QUALAQUIN QUALAQUIN quinine sulfate PA Covered Uses All medically accepted indications not otherwise excluded from Part D. Other is excluded for treatment of leg cramps. Documentation of diagnosis. 7 to 10 days. will be approved for diagnosis of uncomplicated Plasmodium falciparum malaria or babesiosis. 43

44 REGRANEX REGRANEX PA Covered Uses All medically accepted indications not otherwise excluded from Part D. Other Documentation of diagnosis, adequate blood supply to ulcer and persistence of good ulcer care. 3 month intervals Regranex (becaplermin) gel is covered when the following conditions are met: 1) Member has chronic lower extremity diabetic neuropathic ulcers extending into the subcutaneous tissue or beyond, and 2) Ulcer has adequate tissue blood supply (determined by a transcutaneous oxygen pressure of TcpO2 greater than 30mm Hg or verified with Doppler flow), and 3) Member or members provider has been practicing good ulcer care 8 weeks prior to initiation of treatment. Good ulcer care includes, but is not limited to the following: adequate blood supply has been determined as outlined above, serum albumin level greater than 2g/dL, initial sharp debridement and ongoing debridement if necessary, pressure relief, infection control and maintenance of a moist wound environment. 44

45 REVLIMID REVLIMID PA Other Documentation of diagnosis and previous treatments Oncologist or hematologist One year. Enrollee, practitioner and dispensing pharmacist are enrolled in and adhere to conditions of the Revassist program. 45

46 SIMPONI SIMPONI SIMPONI ARIA PA Other Documentation of diagnosis and previous treatments. Member must be greater than 18 years old Rheumatologist or gastroenterologist Indefinite as long as member is eligible. will be provided for the listed approved indications when the following criteria are met. RHEUMATOID or PSORIATIC ARTHRITIS: 1) Confirmation of diagnosis and 2) Documented clinical failure, inadequate response or valid contraindication with one or more Disease Modifying Anti-rheumatic Drug (DMARDS) such as hydroxychloroquine, leflunomide, methotrexate or sulfasalazine and an inadequate response to Humira or Enbrel. ANKYLOSING SPONDYLITIS: 1) Confirmation of diagnosis and 2) Documented clinical failure, inadequate response or valid contraindication for treatment with one or more non-steroidal anti-inflammatory drug (NSAIDs/COX-2 inhibitor) and an inadequate response to Humira or Enbrel. ULCERATIVE COLITIS: 1) Confirmation of diagnosis and 2) Documentation of corticosteroid dependence or inadequate response or failure to tolerate aminosalicylates, corticosteroids or 6-mercaptopurine and an inadequate response to Humira. 46

47 SOLARAZE diclofenac sodium topical gel 3 % SOLARAZE PA Other Documentation of diagnosis. Indefinite as long as member is eligible. 47

48 SOMATOSTATINS octreotide acetate injection solution SANDOSTATIN SANDOSTATIN LAR DEPOT INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON PA Other Documentation of diagnosis Endocrinologist for acromegaly use. One year 48

49 SOVALDI SOVALDI PA Other CrCl less than 30ml/min or ESRD requiring hemodialysis. Documentation of Hepatitis C, genotype test. 18 years of age or older. Gastroenterologist, hepatologist, or infectious disease specialist. 12, 16, 24, or 48 weeks based on genotype, cirrhosis status, medical history and AASLD guidelines. 49

50 STELARA STELARA SUBCUTANEOUS SYRINGE PA Other Documentation of diagnosis and previous treatments Member must be greater than 18 years old Dermatologist and Rheumatologist Indefinite as long as member is eligible. will be provided when the following criteria are met. Psoriatic arthritis: 1) Confirmation of diagnosis and 2) Documented clinical failure, inadequate response or valid contraindication with one or more Disease Modifying Anti-rheumatic Drug(s) (DMARDS) such as hydroxychloroquine, leflunomide, methotrexate, or sulfasalazine, and an inadequate response to Humira or Enbrel. 50

51 STIMULANTS (NON-AMPHETAMINE) armodafinil modafinil oral tablet 100 mg, 200 mg NUVIGIL PROVIGIL ORAL TABLET 100 MG, 200 MG PA Covered Uses All medically accepted indications not otherwise excluded from Part D. Other Confirmation of diagnosis, sleep study documentation, documentation of CPAP or BiPAP history, documentation of work schedule Indefinite for narcolepsy and obstructive sleep apnea. Shift work sleep disorder, one year. For initial coverage for shift work sleep disorder, the member must have letter from employer stating that the patient is working variable, alternating or 3rd shift. Continuation requests reviewed annually to review the member schedule. 51

52 TAZAROTENE PRODUCTS FABIOR TAZORAC PA Covered Uses All medically accepted indications not otherwise excluded from Part D. Other 1.) Diagnosis of plaque psoriasis OR 2.) Diagnosis of acne vulgaris. Indefinite as long as member is eligible. 52

53 TECHNIVIE TECHNIVIE PA Covered Uses Other All FDA-approved indications not otherwise excluded from Part D. All AASLD approved guidelines. Documentation of hepatitis C virus, genotype, cirrhosis, and any previous treatment failures. Gastroenterologist, hepatologist, or infectious disease specialist. 12 weeks Documented clinical failure, inadequate response, or valid contraindication to Harvoni where guidelines permit use. 53

54 TESTOSTERONE REPLACEMENT ANDRODERM TRANSDERMAL PATCH 24 HOUR 2 MG/24 HOUR, 4 MG/24 HR ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP MG/1.25 GRAM (1.62 %) ANDROGEL TRANSDERMAL GEL IN PACKET 1 % (25 MG/2.5GRAM), 1 % (50 MG/5 GRAM), 1.62 % (20.25 MG/1.25 GRAM), 1.62 % (40.5 MG/2.5 GRAM) DEPO-TESTOSTERONE INTRAMUSCULAR OIL 200 MG/ML TESTIM testosterone cypionate intramuscular oil 200 mg/ml testosterone enanthate TESTOSTERONE TRANSDERMAL GEL IN METERED-DOSE PUMP 1.25 GRAM/ ACTUATION (1 %) TESTOSTERONE TRANSDERMAL GEL IN PACKET PA Other Diagnosis of primary hypogonadism (congenital or acquired) or secondary (hypogonadotropic) hypogonadism (congenital or acquired) in males. Serum testosterone level. Indefinite as long as member is eligible. Hypogonadism (primary or secondary) in males, approve if hypogonadism has been confirmed by a low for age serum testosterone (total or free) level defined by the normal laboratory reference values. 54

55 THALOMID THALOMID PA Covered Uses All medically accepted indications not otherwise excluded from Part D. Other Documentation of diagnosis Oncologist, hematologist or dermatologist 1 year 55

56 TRANSMUCOSAL IMMEDIATE-RELEASE FENTANYL (TIRF) ABSTRAL ACTIQ FENTANYL CITRATE FENTORA BUCCAL TABLET, EFFERVESCENT 100 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG LAZANDA SUBSYS SUBLINGUAL SPRAY,NON- AEROSOL 100 MCG/SPRAY, 200 MCG/SPRAY, 400 MCG/SPRAY, 600 MCG/SPRAY, 800 MCG/SPRAY PA Other Documentation of diagnosis and previous treatments Indefinite as long as member is eligible. 56

57 VORICONAZOLE VFEND voriconazole oral PA Covered Uses All medically accepted indications not otherwise excluded from Part D. Other Documentation of diagnosis and other first-line medications tried (as appropriate) unless contraindicated. Initial coverage for 1 month for esophageal candidiasis and 6 months for any other indication. Vfend coverage will be approved if the following conditions are met: patient has a documented infection of invasive aspergillosis OR patient has a documented infection of Scedosporium apiospermum, Fusarium species OR.patient has documented esophageal candidiasis or candidemia AND patient has failed treatment with at least one other systemic antifungal agent OR.patient is at high risk of developing invasive Aspergillus or Candida due to being severely immunocompromised 57

58 XELJANZ XELJANZ XELJANZ XR PA Documentation of diagnosis and previous treatments. 18 years of age or older. Rheumatologist. Indefinite as long as member is eligible. Other will be provided when the following criteria are met: 1) Confirmation of diagnosis and 2) Documented clinical failure, inadequate response or valid contraindication to adalimumab (Humira) and etanercept (Enbrel). Not covered in combination with biologic DMARDS or with potent immunosuppressants such as azathioprine and cyclosporine. 58

59 XGEVA XGEVA PA Other Documentation of diagnosis. Oncologist 1 year 59

60 ZEPATIER ZEPATIER PA Covered Uses Other All FDA-approved indications not otherwise excluded from Part D. All AASLD approved guidelines. Documentation of hepatitis C virus diagnosis, genotype documentation, concomitant treatment, and any previous treatment failures. Gastroenterologist, hepatologist, or infectious disease specialist. 12 or 16 weeks per diagnosis and AASLD guidelines 60

61 PART B VERSUS PART D acetylcysteine solution AKYNZEO ORAL CAPSULE albuterol sulfate inhalation solution for nebulization 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg /3 ml (0.083 %), 5 mg/ml AMBISOME INTRAVENOUS SUSPENSION FOR RECONSTITUTION AMINOSYN 7 % WITH ELECTROLYTES INTRAVENOUS PARENTERAL SOLUTION aminosyn 8.5 %-electrolytes intravenous parenteral solution AMINOSYN II 10 % INTRAVENOUS PARENTERAL SOLUTION AMINOSYN II 15 % INTRAVENOUS PARENTERAL SOLUTION AMINOSYN II 7 % INTRAVENOUS PARENTERAL SOLUTION AMINOSYN II 8.5 % INTRAVENOUS PARENTERAL SOLUTION AMINOSYN II 8.5 %-ELECTROLYTES INTRAVENOUS PARENTERAL SOLUTION AMINOSYN M 3.5 % INTRAVENOUS PARENTERAL SOLUTION AMINOSYN-HBC 7% INTRAVENOUS PARENTERAL SOLUTION AMINOSYN-PF 10 % INTRAVENOUS PARENTERAL SOLUTION AMINOSYN-PF 7 % (SULFITE-FREE) INTRAVENOUS PARENTERAL SOLUTION AMINOSYN-RF 5.2 % INTRAVENOUS PARENTERAL SOLUTION amphotericin b injection recon soln ANZEMET ORAL TABLET ARANESP (IN POLYSORBATE) INJECTION SOLUTION 100 MCG/ML, 200 MCG/ML, 25 MCG/ML, 300 MCG/ML, 40 MCG/ML, 60 MCG/ML ARANESP (IN POLYSORBATE) INJECTION SYRINGE ASTAGRAF XL ORAL CAPSULE,EXTENDED RELEASE 24HR AZASAN ORAL TABLET azathioprine oral tablet BETHKIS INHALATION SOLUTION FOR NEBULIZATION BONIVA INTRAVENOUS SYRINGE BROVANA INHALATION SOLUTION FOR NEBULIZATION budesonide inhalation suspension for nebulization CARIMUNE NF NANOFILTERED INTRAVENOUS RECON SOLN 6 GRAM CELLCEPT ORAL CAPSULE CELLCEPT ORAL SUSPENSION FOR RECONSTITUTION CELLCEPT ORAL TABLET CLINIMIX 5%/D15W SULFITE FREE INTRAVENOUS PARENTERAL SOLUTION CLINIMIX 5%/D25W SULFITE-FREE INTRAVENOUS PARENTERAL SOLUTION CLINIMIX 2.75%/D5W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION CLINIMIX 4.25%/D10W SULF FREE INTRAVENOUS PARENTERAL SOLUTION CLINIMIX 4.25%/D5W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION CLINIMIX 4.25%-D20W SULF-FREE INTRAVENOUS PARENTERAL SOLUTION CLINIMIX 4.25%-D25W SULF-FREE INTRAVENOUS PARENTERAL SOLUTION CLINIMIX 5%-D20W(SULFITE-FREE) INTRAVENOUS PARENTERAL SOLUTION CLINIMIX E 2.75%/D10W SUL FREE INTRAVENOUS PARENTERAL SOLUTION CLINIMIX E 2.75%/D5W SULF FREE INTRAVENOUS PARENTERAL SOLUTION CLINIMIX E 4.25%/D10W SUL FREE INTRAVENOUS PARENTERAL SOLUTION CLINIMIX E 4.25%/D25W SUL FREE INTRAVENOUS PARENTERAL SOLUTION CLINIMIX E 4.25%/D5W SULF FREE INTRAVENOUS PARENTERAL SOLUTION 61

62 CLINIMIX E 5%/D15W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION CLINIMIX E 5%/D20W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION CLINIMIX E 5%/D25W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION cromolyn inhalation solution for nebulization CYCLOPHOSPHAMIDE ORAL CAPSULE cyclosporine modified oral capsule 100 mg, 25 mg CYCLOSPORINE MODIFIED ORAL CAPSULE 50 MG cyclosporine modified oral solution cyclosporine oral capsule dronabinol oral capsule EMEND ORAL CAPSULE EMEND ORAL CAPSULE,DOSE PACK EMEND ORAL SUSPENSION FOR RECONSTITUTION ENGERIX-B (PF) INTRAMUSCULAR SYRINGE ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SUSPENSION ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE ENVARSUS XR ORAL TABLET EXTENDED RELEASE 24 HR EPOGEN INJECTION SOLUTION 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML FREAMINE HBC 6.9 % INTRAVENOUS PARENTERAL SOLUTION GAMASTAN S/D INTRAMUSCULAR SOLUTION GAMMAGARD LIQUID INJECTION SOLUTION GAMMAPLEX INTRAVENOUS SOLUTION GAMUNEX-C INJECTION SOLUTION 1 GRAM/10 ML (10 %) gengraf oral capsule gengraf oral solution granisetron hcl oral tablet HEPATAMINE 8% INTRAVENOUS PARENTERAL SOLUTION ibandronate intravenous solution IMURAN ORAL TABLET INTRALIPID INTRAVENOUS EMULSION 20 %, 30 % ipratropium bromide inhalation solution ipratropium-albuterol inhalation solution for nebulization levalbuterol hcl inhalation solution for nebulization 0.31 mg/3 ml, 0.63 mg/3 ml, 1.25 mg/0.5 ml MARINOL ORAL CAPSULE MIRCERA INJECTION SYRINGE mycophenolate mofetil oral capsule mycophenolate mofetil oral suspension for reconstitution mycophenolate mofetil oral tablet mycophenolate sodium oral tablet,delayed release (dr/ec) MYFORTIC ORAL TABLET,DELAYED RELEASE (DR/EC) NEBUPENT INHALATION RECON SOLN NEORAL ORAL CAPSULE NEORAL ORAL SOLUTION NEPHRAMINE 5.4 % INTRAVENOUS PARENTERAL SOLUTION NULOJIX INTRAVENOUS RECON SOLN NUTRILIPID INTRAVENOUS EMULSION ondansetron hcl (pf) injection solution ondansetron hcl (pf) injection syringe ondansetron hcl oral solution ondansetron hcl oral tablet ondansetron oral tablet,disintegrating pamidronate intravenous solution PERFOROMIST INHALATION SOLUTION FOR NEBULIZATION PREMASOL 10 % INTRAVENOUS PARENTERAL SOLUTION PREMASOL 6 % INTRAVENOUS PARENTERAL SOLUTION PRIVIGEN INTRAVENOUS SOLUTION PROCRIT INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML, 40,000 UNIT/ML PROGRAF INTRAVENOUS SOLUTION PROGRAF ORAL CAPSULE 62

63 PROSOL 20 % INTRAVENOUS PARENTERAL SOLUTION PULMICORT INHALATION SUSPENSION FOR NEBULIZATION PULMOZYME INHALATION SOLUTION RAPAMUNE ORAL SOLUTION RAPAMUNE ORAL TABLET RECLAST INTRAVENOUS SOLUTION RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 10 MCG/ML, 40 MCG/ML RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE SANDIMMUNE INTRAVENOUS SOLUTION SANDIMMUNE ORAL CAPSULE SANDIMMUNE ORAL SOLUTION sirolimus oral tablet tacrolimus oral capsule TOBI INHALATION SOLUTION FOR NEBULIZATION tobramycin in % nacl inhalation solution for nebulization TRAVASOL 10 % INTRAVENOUS PARENTERAL SOLUTION Details TROPHAMINE 10 % INTRAVENOUS PARENTERAL SOLUTION TROPHAMINE 6% INTRAVENOUS PARENTERAL SOLUTION TYVASO INHALATION SOLUTION FOR NEBULIZATION vancomycin intravenous recon soln 1,000 mg, 10 gram, 500 mg VENTAVIS INHALATION SOLUTION FOR NEBULIZATION XOPENEX INHALATION SOLUTION FOR NEBULIZATION ZOFRAN (AS HYDROCHLORIDE) INTRAVENOUS SOLUTION ZOFRAN (AS HYDROCHLORIDE) ORAL SOLUTION ZOFRAN (AS HYDROCHLORIDE) ORAL TABLET ZOFRAN ODT ORAL TABLET,DISINTEGRATING zoledronic acid-mannitol-water intravenous solution ZORTRESS ORAL TABLET This drug may be covered under Medicare Part B or D depending upon the circumstances. may need to be submitted describing the use and setting of the drug to make the determination. 63

64 Index ABSTRAL acetylcysteine ACTEMRA INTRAVENOUS SOLUTION 400 MG/20 ML (20 MG/ML), 80 MG/4 ML (20 MG/ML)... 1 ACTEMRA SUBCUTANEOUS... 1 ACTIQ adapalene topical cream adapalene topical gel ADCIRCA AFINITOR AFINITOR DISPERZ AKYNZEO albuterol sulfate ALECENSA AMBISOME AMINOSYN 7 % WITH ELECTROLYTES aminosyn 8.5 %-electrolytes AMINOSYN II 10 % AMINOSYN II 15 % AMINOSYN II 7 % AMINOSYN II 8.5 % AMINOSYN II 8.5 %-ELECTROLYTES 61 AMINOSYN M 3.5 % AMINOSYN-HBC 7% AMINOSYN-PF 10 % AMINOSYN-PF 7 % (SULFITE-FREE). 61 AMINOSYN-RF 5.2 % amphotericin b AMPYRA... 2 AMRIX ANDRODERM TRANSDERMAL PATCH 24 HOUR 2 MG/24 HOUR, 4 MG/24 HR ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP MG/1.25 GRAM (1.62 %) ANDROGEL TRANSDERMAL GEL IN PACKET 1 % (25 MG/2.5GRAM), 1 % (50 MG/5 GRAM), 1.62 % (20.25 MG/1.25 GRAM), 1.62 % (40.5 MG/2.5 GRAM) ANZEMET ARANESP (IN POLYSORBATE) armodafinil ASTAGRAF XL ATRALIN AUBAGIO avita AZASAN azathioprine BETASERON SUBCUTANEOUS KIT.. 32 BETHKIS bexarotene BONIVA BOSULIF ORAL TABLET 100 MG, 500 MG BROVANA budesonide CABOMETYX CAPRELSA CARIMUNE NF NANOFILTERED carisoprodol carisoprodol-asa-codeine carisoprodol-aspirin CELLCEPT CIALIS ORAL TABLET 2.5 MG, 5 MG... 6 CIMZIA... 7 CIMZIA POWDER FOR RECONST... 7 CLINIMIX 5%/D15W SULFITE FREE. 61 CLINIMIX 5%/D25W SULFITE-FREE. 61 CLINIMIX 2.75%/D5W SULFIT FREE.. 61 CLINIMIX 4.25%/D10W SULF FREE CLINIMIX 4.25%/D5W SULFIT FREE.. 61 CLINIMIX 4.25%-D20W SULF-FREE CLINIMIX 4.25%-D25W SULF-FREE CLINIMIX 5%-D20W(SULFITE-FREE) 61 CLINIMIX E 2.75%/D10W SUL FREE.. 61 CLINIMIX E 2.75%/D5W SULF FREE.. 61 CLINIMIX E 4.25%/D10W SUL FREE.. 61 CLINIMIX E 4.25%/D25W SUL FREE.. 61 CLINIMIX E 4.25%/D5W SULF FREE.. 61 CLINIMIX E 5%/D15W SULFIT FREE. 62 CLINIMIX E 5%/D20W SULFIT FREE. 62 CLINIMIX E 5%/D25W SULFIT FREE. 62 COMETRIQ COSENTYX

65 COSENTYX PEN COTELLIC CRESEMBA... 4 cromolyn cyclobenzaprine oral tablet 10 mg, 5 mg.. 24 CYCLOPHOSPHAMIDE cyclosporine cyclosporine modified CYCLOSPORINE MODIFIED CYRAMZA DAKLINZA DARZALEX DEPO-TESTOSTERONE INTRAMUSCULAR OIL 200 MG/ML 54 diclofenac sodium topical gel 3 % DIFFERIN TOPICAL CREAM DIFFERIN TOPICAL GEL DIFFERIN TOPICAL LOTION DIFICID dronabinol EGRIFTA SUBCUTANEOUS RECON SOLN 1 MG EMEND EMPLICITI ENBREL ENBREL SURECLICK ENGERIX-B (PF) ENGERIX-B PEDIATRIC (PF) ENVARSUS XR EPCLUSA EPOGEN ERIVEDGE ESBRIET EXJADE FABIOR FARYDAK FENTANYL CITRATE FENTORA BUCCAL TABLET, EFFERVESCENT 100 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG FERRIPROX ORAL SOLUTION FLECTOR FORTEO FREAMINE HBC 6.9 % GAMASTAN S/D GAMMAGARD LIQUID GAMMAPLEX GAMUNEX-C GATTEX ONE-VIAL gengraf GILENYA GILOTRIF GLEEVEC GLEOSTINE granisetron hcl GRANIX... 8 HARVONI HEPATAMINE 8% HETLIOZ HUMIRA HUMIRA PEN HUMIRA PEN CROHN'S-UC-HS START HUMIRA PEN PSORIASIS-UVEITIS ibandronate IBRANCE ICLUSIG imatinib IMBRUVICA IMURAN INCRELEX INLYTA INTRALIPID INTRON A INJECTION RECON SOLN 27 INTRON A INJECTION SOLUTION 6 MILLION UNIT/ML ipratropium bromide ipratropium-albuterol IRESSA itraconazole... 4 JADENU JAKAFI JUBLIA... 4 JUXTAPID KALYDECO... 9 KERYDIN... 4 KEYTRUDA INTRAVENOUS SOLUTION KINERET KYNAMRO LAMISIL ORAL TABLET... 4 LAZANDA

66 LENVIMA LEUKINE INJECTION RECON SOLN... 8 levalbuterol hcl lidocaine topical adhesive patch,medicated LIDODERM linezolid... 3 LONSURF LYNPARZA MARINOL MEKINIST MIRCERA modafinil oral tablet 100 mg, 200 mg mycophenolate mofetil mycophenolate sodium MYFORTIC NEBUPENT NEORAL NEPHRAMINE 5.4 % NEULASTA SUBCUTANEOUS SYRINGE... 8 NEUPOGEN... 8 NINLARO NORDITROPIN FLEXPRO NOXAFIL ORAL NUEDEXTA NULOJIX NUTRILIPID NUTROPIN AQ NUSPIN NUTROPIN AQ SUBCUTANEOUS CARTRIDGE 10 MG/2 ML (5 MG/ML) NUVIGIL octreotide acetate injection solution ODOMZO OFEV OLYSIO ondansetron ondansetron hcl ondansetron hcl (pf) ORENCIA ORENCIA CLICKJECT ORENITRAM ORKAMBI... 9 OTEZLA OTEZLA STARTER ORAL TABLETS,DOSE PACK 10 MG (4)-20 MG (4)-30 MG (47) pamidronate PEGASYS PEGASYS PROCLICK PEGINTRON PEGINTRON REDIPEN PERFOROMIST PERJETA PLEGRIDY POMALYST PRALUENT PEN PRALUENT SYRINGE PREMASOL 10 % PREMASOL 6 % PRIVIGEN PROCRIT PROGRAF PROSOL 20 % PROVIGIL ORAL TABLET 100 MG, 200 MG PULMICORT PULMOZYME QUALAQUIN quinine sulfate RAPAMUNE REBIF (WITH ALBUMIN) REBIF REBIDOSE REBIF TITRATION PACK RECLAST RECOMBIVAX HB (PF) REGRANEX REPATHA PUSHTRONEX REPATHA SURECLICK REPATHA SYRINGE RETIN-A RETIN-A MICRO RETIN-A MICRO PUMP TOPICAL GEL WITH PUMP 0.08 % REVATIO ORAL REVLIMID SANDIMMUNE SANDOSTATIN SANDOSTATIN LAR DEPOT INTRAMUSCULAR 66

67 SUSPENSION,EXTENDED REL RECON sildenafil oral SIMPONI SIMPONI ARIA sirolimus SIVEXTRO... 3 SOLARAZE SOMA SOVALDI SPORANOX... 4 SPORANOX PULSEPAK... 4 SPRYCEL STELARA SUBCUTANEOUS SYRINGE STIVARGA SUBSYS SUBLINGUAL SPRAY,NON- AEROSOL 100 MCG/SPRAY, 200 MCG/SPRAY, 400 MCG/SPRAY, 600 MCG/SPRAY, 800 MCG/SPRAY SUTENT SYNRIBO tacrolimus TAFINLAR TAGRISSO TALTZ AUTOINJECTOR TALTZ SYRINGE TANZEUM TARCEVA TASIGNA TAZORAC TECENTRIQ TECHNIVIE TESTIM testosterone cypionate intramuscular oil 200 mg/ml testosterone enanthate TESTOSTERONE TRANSDERMAL GEL IN METERED-DOSE PUMP 1.25 GRAM/ ACTUATION (1 %) TESTOSTERONE TRANSDERMAL GEL IN PACKET THALOMID thiotepa TOBI tobramycin in % nacl TRAVASOL 10 % tretinoin microspheres topical gel with pump tretinoin topical cream tretinoin topical gel 0.01 %, % TROPHAMINE 10 % TROPHAMINE 6% TRULICITY TYKERB TYVASO UPTRAVI ORAL TABLET 1,000 MCG, 1,200 MCG, 1,400 MCG, 1,600 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG UPTRAVI ORAL TABLETS,DOSE PACK vancomycin VENCLEXTA VENCLEXTA STARTING PACK VENTAVIS VFEND VIEKIRA PAK... 5 voriconazole oral VOTRIENT XALKORI XELJANZ XELJANZ XR XGEVA XOPENEX XTANDI ZARXIO... 8 ZELBORAF ZEPATIER ZOFRAN (AS HYDROCHLORIDE) ZOFRAN ODT zoledronic acid-mannitol-water ZOLINZA ZORTRESS ZYDELIG ZYKADIA ZYTIGA ZYVOX INTRAVENOUS PARENTERAL SOLUTION 600 MG/300 ML... 3 ZYVOX ORAL