BELEODAQ. Prior Authorization Criteria Memorial Hermann Advantage HMO & PPO Formulary ID: Version 10 Effective Date: 6/1/2015
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1 Memorial Hermann Advantage HMO & PPO Formulary ID: Version 10 BELEODAQ BELEODAQ All FDA approved indications not otherwise excluded from Part D. Plan Year Y0110_PriorAuthCriteria4 IA 04/09/2015 PAGE 1 LAST UPDATED 05/27/2015
2 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 2 LAST UPDATED 05/27/2015
3 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 3 LAST UPDATED 05/27/2015
4 DELESTROGEN DELESTROGEN OIL 10 MG/ML All FDA approved indications not otherwise excluded from Part D diagnosis of menopause and must have documented trial/failure, contraindication or intolerance to formulary generic estrogen oral product 12/31/2015 PAGE 4 LAST UPDATED 05/27/2015
5 ERWINAZE ERWINAZE Supporting statement of diagnosis from the physician 12/31/15 PAGE 5 LAST UPDATED 05/27/2015
6 ESBRIET ESBRIET Appropriate diagnosis (idopathic pulmonary fibrosis [IPF]) and monitoring (hepatiac function/lfts) Prescriber must be a pulmonologist 12/31/2015 PAGE 6 LAST UPDATED 05/27/2015
7 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 7 LAST UPDATED 05/27/2015
8 FARYDAK FARYDAK Statement of diagnosis from physician 12/31/2015 PAGE 8 LAST UPDATED 05/27/2015
9 FENTANYL - FENTORA TAB 200 MCG - FENTORA TAB 600 MCG - FENTORA TAB 400 MCG - FENTORA TAB 800 MCG - LAZANDA Supporting statement of diagnosis from the physician 12/31/15 PAGE 9 LAST UPDATED 05/27/2015
10 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 10 LAST UPDATED 05/27/2015
11 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 11 LAST UPDATED 05/27/2015
12 GROWTH HORMONE - HUMATROPE RECON SOLN 12 MG - - NUTROPIN AQ NUSPIN NUTROPIN AQ PEN SOLUTION 20 MG/2ML - HUMATROPE RECON SOLN 24 MG NUTROPIN AQ NUSPIN 5 SAIZEN - SAIZEN CLICK.EASY Supporting statement of diagnosis from the physician 12/31/15 PAGE 12 LAST UPDATED 05/27/2015
13 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 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 Must not have the following: decompensated liver disease, co-infection with hepatitis B or HIV-1, hepatocellular carcinoma, or post-liver transplant. Must not be taking P-gp inducers such as rifampin or St. John's wort. Does not have ESRD and has a GFR greater than PAGE 13 LAST UPDATED 05/27/2015
14 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 - - DIGOX TAB 250 MCG - - DIGOXIN SOLUTION 0.05 MG/ML - - 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 ESTRADIOL TAB 1 MG - - GLYBURIDE 1.25 MG - - GLYBURIDE 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 TAB 30 MG CHLORDIAZEPOXIDE-AMITRIPTYLINE TAB MG CLOMIPRAMINE HCL CAP 25 MG CLOMIPRAMINE HCL CAP 75 MG CYCLOBENZAPRINE HCL TAB 5 MG CYPROHEPTADINE HCL TAB 4 MG DIGOXIN 0.05 MG/ML DIGOXIN SOLUTION 0.25 MG/ML 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 2-10 ESTRADIOL TAB 0.5 MG ESTRADIOL TAB 2 MG GLYBURIDE 2.5 MG GLYBURIDE MICRONIZED TAB 1.5 MG PAGE 14 LAST UPDATED 05/27/2015
15 - GLYBURIDE MICRONIZED TAB 3 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 30 MG/ML - - KETOROLAC TROMETHAMINE SOLUTION - 15 MG/ML - KETOROLAC TROMETHAMINE SOLUTION - 60 MG/2ML - MACRODANTIN CAP 50 MG - - MEGESTROL ACETATE SUSPENSION 40 - MG/ML - MEGESTROL ACETATE SUSPENSION MG/20ML - MEGESTROL ACETATE TAB 40 MG - - MEPROBAMATE - - METHOCARBAMOL TAB 750 MG - - METHYLDOPA TAB 500 MG - - METHYLDOPATE HCL - 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 KETOROLAC TROMETHAMINE 15 MG/ML KETOROLAC TROMETHAMINE 60 MG/2ML KETOROLAC TROMETHAMINE SOLUTION 30 MG/ML KETOROLAC TROMETHAMINE TAB 10 MG MEGACE ES MEGESTROL ACETATE SUSPENSION 400 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 - NIFEDIPINE CAP 10 MG - NIFEDIPINE CAP 20 MG PAGE 15 LAST UPDATED 05/27/2015
16 - NITROFURANTOIN MACROCRYSTAL CAP MG - NITROFURANTOIN MONOHYD MACRO - - ORPHENADRINE CITRATE SOLUTION 30 - MG/ML - PERPHENAZINE-AMITRIPTYLINE - - PREMARIN 0.9 MG - - PREMARIN TAB 0.3 MG - - PREMARIN TAB MG - - PREMARIN TAB 1.25 MG - - PREMPRO - - SECONAL - - THIORIDAZINE HCL TAB 10 MG - - THIORIDAZINE HCL TAB 25 MG - - TICLOPIDINE HCL - - TRIHEXYPHENIDYL HCL TAB 2 MG - - ZALEPLON 10 MG - NITROFURANTOIN MACROCRYSTAL CAP 50 MG ORPHENADRINE CITRATE ER TAB ER 12H 100 MG PENTAZOCINE-NALOXONE HCL PREMARIN MG PREMARIN 1.25 MG PREMARIN TAB 0.45 MG PREMARIN TAB 0.9 MG PREMPHASE RESERPINE TAB 0.1 MG SURMONTIL THIORIDAZINE HCL TAB 100 MG THIORIDAZINE HCL TAB 50 MG TRIHEXYPHENIDYL HCL ELIXIR 0.4 MG/ML TRIHEXYPHENIDYL HCL TAB 5 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 16 LAST UPDATED 05/27/2015
17 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 17 LAST UPDATED 05/27/2015
18 IBRANCE IBRANCE All FDA approved indications not otherwise excluded from part D Appropriate diagnosis (used in combination with letrozole for the treatment of postmenopausal women with estrogen receptor (ER)-positive, human epidermal growth factor receptor 2 (HER2)- negative advanced breast cancer) 12/31/2015 PAGE 18 LAST UPDATED 05/27/2015
19 ICLUSIG ICLUSIG Must have documented trial and failure of another tyrosine kinase inhibitor Plan Year PAGE 19 LAST UPDATED 05/27/2015
20 IMBRUVICA IMBRUVICA Supporting statement of diagnosis from the physician 12/31/15 PAGE 20 LAST UPDATED 05/27/2015
21 KALYDECO KALYDECO TAB 150 MG Supporting statement of diagnosis from the physician 12/31/15 PAGE 21 LAST UPDATED 05/27/2015
22 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 22 LAST UPDATED 05/27/2015
23 KORLYM KORLYM Pregnancy Supporting statement of diagnosis and relevant medical information from physician 12/31/15 PAGE 23 LAST UPDATED 05/27/2015
24 LIDODERM LIDODERM PATCH 5 % 12/31/15 PAGE 24 LAST UPDATED 05/27/2015
25 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) none none 12/31/2015 none PAGE 25 LAST UPDATED 05/27/2015
26 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 26 LAST UPDATED 05/27/2015
27 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 27 LAST UPDATED 05/27/2015
28 OPDIVO OPDIVO Appropriate diagnosis (unresectable or metastatic melanoma and disease progression following ipilimumab [Yervoy]) and testing for BRAF V600 mutation. none none 12/31/2015 none PAGE 28 LAST UPDATED 05/27/2015
29 ORENITRAM ORENITRAM All FDA approved indications not otherwise excluded from Part D. Supporting statement of diagnosis from the physician 12/31/15 PAGE 29 LAST UPDATED 05/27/2015
30 PART D VS PART B - ABRAXANE - ALBUTEROL SULFATE NEBU SOLN (2.5 MG/3ML) 0.083% - ALBUTEROL SULFATE NEBU SOLN 0.63 MG/3ML - AMBISOME - AMINOSYN II SOLUTION 7 % - AMINOSYN II/ELECTROLYTES - AMINOSYN-HBC - AMINOSYN-RF - AMITRIPTYLINE HCL TAB 25 MG - ARZERRA - ATGAM - AZASAN - 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 - CHLORPROMAZINE HCL TAB 10 MG - CLINIMIX E/DEXTROSE (2.75/10) - CLINIMIX E/DEXTROSE (4.25/10) - CLINIMIX E/DEXTROSE (4.25/5) - CLINIMIX E/DEXTROSE (5/20) - ADRUCIL - ALBUTEROL SULFATE NEBU SOLN (5 MG/ML) 0.5% - ALBUTEROL SULFATE NEBU SOLN 1.25 MG/3ML - AMINOSYN II SOLUTION 10 % - AMINOSYN II SOLUTION 8.5 % - AMINOSYN M - AMINOSYN-PF - AMINOSYN/ELECTROLYTES - ARRANON - ASTAGRAF XL - AZATHIOPRINE TAB 50 MG - BICNU - BUSULFEX - CARBOPLATIN SOLUTION 150 MG/15ML - CARBOPLATIN SOLUTION 50 MG/5ML - CISPLATIN SOLUTION 100 MG/100ML - CISPLATIN SOLUTION 50 MG/50ML - CARIMUNE NF - CHLORPROMAZINE HCL SOLUTION 25 MG/ML - CLADRIBINE - CLINIMIX E/DEXTROSE (2.75/5) - CLINIMIX E/DEXTROSE (4.25/25) - CLINIMIX E/DEXTROSE (5/15) - CLINIMIX E/DEXTROSE (5/25) PAGE 30 LAST UPDATED 05/27/2015
31 - 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 - - CYTARABINE (PF) - - CYTARABINE RECON SOLN 2 GM - - DAUNORUBICIN HCL - - DACARBAZINE RECON SOLN 200 MG - - DEPO-PROVERA SUSPENSION 400 MG/ML - - DEXAMETHASONE SODIUM PHOSPHATE - SOLUTION 10 MG/ML - DOXIL - - ELLENCE - - EMEND CAP 40 MG - - EMEND CAP 80 MG - - ENGERIX-B SUSPENSION 10 MCG/0.5ML - - EPIRUBICIN HCL SOLUTION 200 MG/100ML - - ERBITUX - - ETOPOSIDE SOLUTION 1 GM/50ML - - ETOPOSIDE SOLUTION 500 MG/25ML - - FLEBOGAMMA DIF SOLUTION 20 - GM/200ML - FLUOROURACIL SOLUTION 1 GM/20ML - 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 CYTARABINE RECON SOLN 1 GM CYTARABINE SOLUTION 20 MG/ML DOXORUBICIN HCL DAUNOXOME DEXAMETHASONE SOD PHOSPHATE PF DOCEFREZ RECON SOLN 20 MG ELIGARD 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 ETOPOSIDE SOLUTION 100 MG/5ML FLEBOGAMMA DIF SOLUTION 10 GM/100ML FLEBOGAMMA DIF SOLUTION 5 GM/50ML FLUOROURACIL SOLUTION 2.5 GM/50ML - FLUOROURACIL SOLUTION 5 GM/100ML - FLUOROURACIL SOLUTION 500 MG/10ML PAGE 31 LAST UPDATED 05/27/2015
32 - FOLOTYN - - GAMMAGARD - - GAMMAGARD S/D LESS IGA - - GAMMAPLEX - - GENGRAF - - HEPATAMINE - - IDARUBICIN HCL - - IFEX - - INTRALIPID EMULSION 20 % - - IPRATROPIUM-ALBUTEROL - - IXEMPRA KIT - - KEPIVANCE - - MESNA - - METHOTREXATE SODIUM - - METHOTREXATE TAB 2.5 MG - - MIRCERA SOLUTION 100 MCG/0.3ML - - MIRCERA SOLUTION 75 MCG/0.3ML - - MITOMYCIN RECON SOLN 20 MG - - MITOMYCIN RECON SOLN 5 MG - - MYCOPHENOLATE MOFETIL CAP 250 MG - - MYCOPHENOLIC ACID - - 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 - FREAMINE HBC GAMMAGARD S/D GAMMAKED GANCICLOVIR SODIUM GRANISETRON HCL HERCEPTIN IDAMYCIN PFS IFOSFAMIDE IPRATROPIUM BROMIDE SOLUTION 0.02 % IRINOTECAN HCL JEVTANA MELPHALAN HCL METHOTREXATE 2.5 MG METHOTREXATE SODIUM (PF) METRONIDAZOLE IN NACL MIRCERA SOLUTION 50 MCG/0.3ML MITOMYCIN 20 MG MITOMYCIN RECON SOLN 40 MG MUSTARGEN MYCOPHENOLATE MOFETIL TAB 500 MG 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 PAGE 32 LAST UPDATED 05/27/2015
33 - PACLITAXEL CONC 30 MG/5ML - PARICALCITOL SOLUTION 2 MCG/ML - PROCALAMINE - PROSOL - RABAVERT - RECOMBIVAX HB - 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 - TREXALL - VECTIBIX - VINBLASTINE SULFATE RECON SOLN 10 MG - VINCRISTINE SULFATE SOLUTION 1 MG/ML - VINORELBINE TARTRATE - ZEMPLAR CAP 1 MCG - ZEMPLAR SOLUTION 2 MCG/ML - PACLITAXEL CONC 300 MG/50ML - PREMASOL SOLUTION 6 % - PROGRAF SOLUTION 5 MG/ML - PULMOZYME - RAPAMUNE SOLUTION 1 MG/ML - 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 - UVADEX - VENTAVIS - VINBLASTINE SULFATE SOLUTION 1 MG/ML - VINCASAR PFS - VORICONAZOLE RECON SOLN 200 MG - ZEMPLAR CAP 2 MCG - ZINECARD RECON SOLN 250 MG - ZINECARD RECON SOLN 500 MG DETAILS - ZORTRESS 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 33 LAST UPDATED 05/27/2015
34 PROVIGIL - MODAFINIL TAB 100 MG - MODAFINIL TAB 200 MG Supporting statement of diagnosis from the physician 12/31/15 PAGE 34 LAST UPDATED 05/27/2015
35 QUININE QUININE SULFATE CAP 324 MG All FDA approved indications not otherwise excluded from Part D. Supporting statement of diagnosis and relevant medical information from physician 12/31/15 PAGE 35 LAST UPDATED 05/27/2015
36 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 36 LAST UPDATED 05/27/2015
37 RELISTOR RELISTOR. 12/31/2015 PAGE 37 LAST UPDATED 05/27/2015
38 REVATIO - REVATIO SOLUTION 10 MG/12.5ML - SILDENAFIL CITRATE TAB 20 MG Supporting statement of diagnosis from the physician 12/31/15 PAGE 38 LAST UPDATED 05/27/2015
39 SAMSCA SAMSCA Supporting statement of diagnosis from the physician 12/31/15 PAGE 39 LAST UPDATED 05/27/2015
40 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 40 LAST UPDATED 05/27/2015
41 STIVARGA STIVARGA Supporting statement of diagnosis from the physician 12/31/15 PAGE 41 LAST UPDATED 05/27/2015
42 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 42 LAST UPDATED 05/27/2015
43 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 43 LAST UPDATED 05/27/2015
44 XTANDI XTANDI Supporting statement of diagnosis from the physician and prior trial and failure of docetaxel 12/31/15 PAGE 44 LAST UPDATED 05/27/2015
45 ZOHYDRO ZOHYDRO ER 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 Adults: 18 years and older. Prescriber is knowledgeable in the use of potent opioids for the management of chronic pain 90 days PAGE 45 LAST UPDATED 05/27/2015
46 PAGE 46 LAST UPDATED 05/27/2015
47 PAGE 47 LAST UPDATED 05/27/2015
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
COVERED USES All medically accepted indications not otherwise excluded from Part D
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
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
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
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.
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.
ADCIRCA ADCIRCA Age Concurrent use of organic nitrate or guanylate cyclase stimulators (includes intermittent use) Pulmonary arterial hypertension (PAH) (Initial): Diagnosis of PAH. PAH is symptomatic.
LIST OF DRUGS THAT MAY BE COVERED UNDER YOUR MEDICAL BENEFIT
LIST OF DRUGS THAT MAY BE COVERED UNDER YOUR MEDICAL BENEFIT The following medications may be covered under your medical benefit if they are provided to you in your doctor s office or outpatient infusion
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.
Measure #238 (NQF 0022): Use of High-Risk Medications in the Elderly National Quality Strategy Domain: Patient Safety
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