GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP Prior Authorization (PA) Criteria

Transcription

1 GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP 2014 Prior Authorization (PA) Certain drugs require prior authorization from GuildNet Gold and GuildNet Health Advantage Medicare Plans. This means that your doctor must contact us to get approval before prescribing the drug to you. If your doctor does not get prior approval, the drug may not be covered. This list also includes drugs that may be covered under Medicare Part B or Part D depending on how the drugs are used or administered. If your drug is on this list, your doctor should call us and to provide information describing the use and administration of the drug so we can advise on whether the drug will be covered. To see if your drug is on the list, refer to the index located at the end of this document for the medication you are looking for. Updated: 07/2014 H6864_MGM14_33 PA Web Posting_Approved

2 ACTEMRA Products Affected Actemra INJ 200MG/10ML PA Age Other Details Active infection (including TB). Concurrent therapy with other biologic agent(s). Screening for latent tuberculosis is required. If results are positive, patient must have completed treatment or must currently be receiving treatment for latent tuberculosis. Evaluate for HBV risk and initiate treatment if appropriate. Must have an inadequate response or intolerance/contraindication to one TNF antagonist therapy. For renewals, patient must have responded to Actemra therapy (e.g., condition improved or stabilized). 1

3 ACTHAR Products Affected Acthar Hp PA Details All FDA-approved indications not otherwise excluded from Part D. Age Other Use in patients with multiple sclerosis (MS) as pulse therapy on a monthly basis. MS exacerbation, history of corticosteroid use. Infantile spasms, prescribed by or in consultation with a neurologist or an epileptologist. MS exacerbation, prescribed by or in consultation with a neurologist or physician that specializes in the treatment of MS. Infantile spasms, 12 months. MS exacerbation, approve 1 month. For MS exacerbation, approve if the patient cannot use high-dose IV corticosteroids because IV access is not possible or if the patient has tried high-dose corticosteroids administered IV for an acute MS exacerbation and has experienced a severe or limiting adverse effect. 2

4 ACTIMMUNE Products Affected Actimmune PA Age Other Details 3

5 ADCIRCA Products Affected Adcirca PA Age Other Details Nitrate therapy PAH been confirmed by right heart catheterization. 4

6 AFINITOR Products Affected Afinitor Afinitor Disperz PA Age Other Details Oncologist 5

7 AVONEX Products Affected Avonex PA Age Other Details 6

8 CIALIS Products Affected Cialis ORAL TABS 2.5MG, 5MG PA Details All FDA-approved indications not otherwise excluded from Part D. Age Other Indication for which tadalafil is being prescribed. Authorization will be for 12 mos. Benign prostatic hyperplasia (BPH), after confirmation that tadalafil is being prescribed to treat the signs and symptoms of BPH and not for the treatment of erectile dysfunction (ED) and after a trial of an alpha-1 blocker (eg, doxazosin [Cardura XL], terazosin, tamsulosin [Flomax], alfuzosin extended-release [UroXatral]) or 5 alpha reductase inhibitor (eg, finasteride, dutasteride [Avodart]). 7

9 CIMZIA Products Affected Cimzia INJ 200MG/ML PA Age Other Details Active infection (including TB). Concurrent therapy with other biologics. Screening for latent TB infection and assessment for Hep B risk. For positive latent TB, patient must have completed treatment or is currently receiving treatment for LTBI. HBV infection ruled out or treatment initiated for positive infection. Rheumatoid arthritis (RA) - Must have an inadequate response to either Enbrel or Humira and one of following: 1) inadequate response to methotrexate, 2) inadequate response to another nonbiologic DMARD (e.g., leflunomide, hydroxychloroquine, sulfasalazine) if contraindicated or intolerant to MTX or, 3) intolerance or contraindication to at least 2 nonbiologic DMARDs. Crohn's Disease - Must have an inadequate response or contraindication/intolerance to at least one oral corticosteroid and Humira. 18 years of age and older Initial: for RA, 3 months for Crohn's disease. Renewal: Plan Year For re-authorization, patient's condition must have improved or stabilized. 8

10 COPAXONE Products Affected Copaxone PA Age Other Details Concurrent use of any of the following medications: Interferon-beta therapy (Avonex, Betaseron, Extavia, or Rebif), or mitoxantrone. Patients with previous use (12 or more months) of Copaxone must demonstrate one of the following clinical responses: decrease in the frequency of relapses, slowing of disease progression, diminished MRI lesions, OR patient is stable on therapy. 9

11 ERWINAZE Products Affected Erwinaze PA Age Other Details All FDA-approved indications not otherwise excluded from Part D Documentation of hypersensitivity to Escherichia coli derived asparaginase as a component of a multi-agent chemotherapeutic regimen. 10

12 EXTAVIA Products Affected Extavia PA Age Other Details Concurrent use of any of the following medications: Interferon-beta therapy (Avonex, Betaseron, or Rebif), glatiramer acetate, or mitoxantrone. Patients with previous use (12 or more months) of Extavia must demonstrate one of the following clinical responses: decrease in the frequency of relapses, slowing of disease progression, MRI lesions have diminished with therapy, OR patient is stable on therapy. 11

13 GILOTRIF Products Affected Gilotrif PA Age Other Details All FDA-approved indications not otherwise excluded from Part D Documentation of metastatic non-small cell lung cancer (NSCLC) whose tumors have epidermal growth factor receptor (EGFR) exon 19 deletions or exon 21 (L858R) substitution mutations as detected by an FDAapproved test 12

14 GLEEVEC Products Affected Gleevec PA Age Other Details Chronic myeloid leukemia (CML) and acute lymphoblastic leukemia (ALL) must be positive for the Philadelphia chromosome or BCR-ABL gene. For CML, patient meets one of the following: 1) newly diagnosed, 2) resistance or intolerance to prior therapy, or 3) recurrence after stem cell transplant. For ALL, patient meets one of the following: 1) newly diagnosed and Gleevec is used in combination with chemotherapy, or 2) ALL is relapsed or refractory. For GIST, patient meets one of the following: 1) unresectable, recurrent, or metastatic disease, or 2) use of Gleevec for adjuvant therapy following resection, or 3) use of Gleevec for pre-operative therapy and patient is at risk for significant surgical morbidity. 13

15 GROWTH HORMONE Products Affected Norditropin Flexpro Norditropin Nordiflex Pen INJ 30MG/3ML PA Age Other Details For pediatric GHD in neonate with hypoglycemia: patient has a randomly assessed GH level less than 20 ng/ml, other causes of hypoglycemia have been ruled out, and other treatments have been ineffective. For all pediatric patients: patients have short stature or slow growth velocity and have been evaluated for other causes of growth failure. For pediatric GHD, patient has delayed bone age. For pediatric GHD without pituitary disease, patient failed 2 stimulation tests. For pediatric GHD with a pituitary or CNS disorder, patient has clinical evidence of GHD and low IGF-1/IGFBP3. For TS and SHOX patients: diagnosis confirmed by genetic testing. For CRI patients: metabolic, endocrine and nutritional abnormalities have been treated or stabilized and patient has not had a kidney transplant. For SGA: patient has a low birth weight or length for gestational age. For ISS: pediatric GHD has been ruled out with one stimulation test. For adult GHD, patient was assessed for other causes of GHD-like symptoms. For adult GHD without pituitary disease, patient failed 2 stimulation tests. For adult GHD with at least 3 pituitary hormone deficiencies (PHD) or panhypopituitarism: have a low IGF-1. For adult GHD with less than 3 PHD, low IGF-1 and failed one stimulation test. For renewal for pediatric patients, growing more than 2 cm per year and for PWS only: improved body composition. For renewal for adult patients: patient has seen clinical improvement and IGF-1 will be monitored. For Turner syndrome and SGA, 2 years of age and older. For Noonan syndrome and SHOX, 3 years of age and older. Endocrinologist, Pediatric Nephrologist, Gastroenterologist, Nutritional Support Specialist, Infectious Disease Specialist 14

16 HRM Products Affected Alprazolam ORAL TABS Alprazolam Er TB24 0.5MG Alprazolam Odt Alprazolam Xr ORAL TB24 1MG, 2MG, 3MG Benztropine Mesylate ORAL TABS Butalbital/acetaminophen/caffeine/co deine CAPS 325MG; 50MG; 40MG; 30MG Clemastine Fumarate TABS 2.68MG Cyproheptadine Hcl SYRP Cyproheptadine Hcl TABS Eszopiclone Intuniv Lanoxin ORAL TABS Lorazepam ORAL TABS Lorazepam Intensol Lunesta Meprobamate Metaxalone Methyldopa/hydrochlorothiazide Oxazepam Reserpine ORAL TABS Temazepam PA Age Other Details Patients aged less than 65 years, approve. Patients aged 65 years and older, other criteria apply. Approve when the provider has assessed the risk versus benefit in using this High Risk Medication (HRM) in the patient and has confirmed that they would still like to initiate or continue therapy 15

17 HRM BENZOS Products Affected Clonazepam ORAL TABS Clonazepam Odt Diazepam ORAL TABS Diazepam RECTAL GEL Diazepam SOLN Diazepam Intensol PA Age Other Details Patients aged less than 65 years, approve. Patients aged 65 years and older, other criteria apply. Approve when the provider has assessed the risk versus benefit in using this High Risk Medication (HRM) in the patient and has confirmed that they would still like to initiate or continue therapy 16

18 IMBRUVICA Products Affected Imbruvica PA Age Other Details All FDA-approved indications not otherwise excluded from Part D History of prior treatment with RCHOP therapy 17

19 INFERGEN Products Affected Infergen INJ 15MCG/0.5ML PA Age Other Details Decompensated liver disease. Autoimmune hepatitis. Prior to initiating therapy, detectable levels of HCV RNA in the serum. For treatment nave, patient must have tried and had intolerance to pegylated interferon based treatment regimen. Allow Infergen monotherapy for treatment nave if patient has a contraindication or intolerance to ribavirin. For retreatment, must use in combination with ribavirin and must have tried and failed to respond to pegylated interferon and ribavirin. Allow only one time for retreatment. For Genotype 1 and 4: undetectable HCV RNA after 12 weeks of treatment OR at least 2 log decrease in HCV RNA after 12 weeks of therapy and undetectable HCV RNA after 24 weeks of treatment. ID specialist, gastroenterologist, or oncologist 12 weeks to a total of 72 weeks depending on genotype and initial vs. renewal therapy Monitored for evidence of depression. 18

20 KUVAN Products Affected Kuvan TBSO PA Age Other Details Blood phenylalanine (Phe) levels. Pretreatment blood phenylalanine (Phe) levels greater than 10mg/dL if the patient is older than 12 years of age or greater than 6mg/dL if less than or equal to 12 years of age. Response to a therapeutic trial (greater than or equal to a 30% reduction in blood Phe levels) is required for long-term authorization. 1 month initial, plan year on renewal Blood Phe levels should be checked after 1 week of therapy and periodically up to one month during a therapeutic trial. 19

21 LETAIRIS Products Affected Letairis PA Age Other Details Pregnancy NYHA class II or III symptoms. PAH been confirmed by right heart catheterization. UD or two appropriate contraceptive methods will be used for women of childbearing potential. 20

22 LEUKINE Products Affected Leukine INJ 250MCG PA Age Other Details Administration within 24 hours preceding or following chemotherapy or radiotherapy, hypersensitivity to yeast-derived products. For prophylaxis of febrile neutropenia: use to increase the chemotherapy dose intensity or dose schedule above established regimens. For treatment of febrile neutropenia, when patient receives Neulasta during the current chemotherapy cycle. For AML only, excessive (greater than or equal to 10%) leukemic myeloid blasts in the bone marrow or peripheral blood. For patients with nonmyeloid malignancies receiving myelosuppressive chemotherapy: Leukine may be used for the prevention of chemotherapyinduced febrile neutropenia if the patient experienced febrile neutropenia with a prior chemotherapy cycle OR the patient is at high risk (greater than 20%) or intermediate risk (10-20%) for developing febrile neutropenia. Patients at low risk (less than 10%) for developing febrile neutropenia may also receive Leukine for prophylaxis if there is a significant risk for serious medical consequences due to febrile neutropenia and the intent of chemotherapy is to prolong survival or cure the disease. Leukine is allowable for the treatment of febrile neutropenia in patients who have received prophylaxis with Leukine (or Neupogen) OR in patients at risk for infection-related complications. All patients must receive baseline and regular monitoring of complete blood counts and platelet counts. 6 months 21

23 MEKINIST Products Affected Mekinist PA Age Other Details All FDA-approved indications not otherwise excluded from Part D Documentation of the detected BRAFV600E or BRAFV600K mutation 22

24 NEUPOGEN Products Affected Neupogen INJ 300MCG/0.5ML, 480MCG/0.8ML, 480MCG/1.6ML PA Age Other Details Administration within 24 hours preceding or following chemotherapy or radiotherapy, E coli hypersensitivity. For prophylaxis of febrile neutropenia: use to increase the chemotherapy dose intensity or dose schedule beyond established regimen. For treatment of febrile neutropenia, when patient receives Neulasta during the current chemotherapy cycle. For patients with nonmyeloid malignancies receiving myelosuppressive chemotherapy: Neupogen may be used for the prevention of chemotherapy-induced febrile neutropenia if the patient experienced febrile neutropenia with a prior chemotherapy cycle OR the patient is at high risk (greater than 20%) or intermediate risk (10-20%) for developing febrile neutropenia. Patients at low risk (less than 10%) for developing febrile neutropenia may receive Neupogen for prophylaxis if there is a significant risk for serious medical consequences due to febrile neutropenia and the intent of chemotherapy is to prolong survival or cure the disease. Neupogen is allowable for the treatment of febrile neutropenia in patients who have received prophylaxis with Neupogen (or Leukine) OR in patients at risk for infection-related complications. All patients must receive baseline and regular monitoring of complete blood counts and platelet counts. 6 months 23

25 NEXAVAR Products Affected Nexavar PA Age Other Details Combination with carboplatin and paclitaxel in patients with squamous cell lung cancer Oncologist 24

26 OCTREOTIDE Products Affected Octreotide Acetate PA Age Other Details 25

27 ONCASPAR Products Affected Oncaspar PA Age Other Details All FDA-approved indications not otherwise excluded from Part D 26

28 ONFI Products Affected Onfi PA Age Other Details The patient will receive Onfi for the treatment of seizures associated with Lennox-Gastaut syndrome. 2 years of age and older 27

29 PEGASYS Products Affected Pegasys Pegasys Proclick INJ 135MCG/0.5ML PA Age Other Details Decompensated liver disease. Autoimmune hepatitis. Concomitant administration of didanosine with ribavirin in patients coinfected with HIV. HCV: Prior to initiating therapy, detectable levels of HCV RNA in the serum. For HCV treatment nave, allow Pegasys monotherapy if patient has a contraindication or intolerance to ribavirin. For HCV retreatment, must use in combination with ribavirin and must have nonresponse or relapse with prior HCV therapy. Allow only one time for retreatment with pegylated interferon and ribavirin. For Genotype 1 and 4: undetectable HCV RNA after 12 weeks of treatment OR at least 2 log decrease in HCV RNA after 12 weeks of therapy and undetectable HCV RNA after 24 weeks of treatment. HBV: Must have been HBsAg positive for at least 6 months and have persistent or intermittently elevated ALT greater than 2x ULN or liver biopsy showing chronic hepatitis with moderate to severe necroinflammation. For HBeAg positive, must have serum HBV-DNA greater than 100,000 copies/ml or greater than 20,000 IU/mL. For HBeAg negative, must have serum HBV-DNA greater than 10,000 copies/ml or greater than 2,000 IU/mL. ID specialist, Gastroenterologist, Oncologist HCV:12 weeks to 72 weeks total depending on genotype and initial vs. renewal therapy. HBV:48 weeks. Monitor for evidence of depression. 28

30 PEGINTRON Products Affected Peg-intron Peg-intron Redipen PA Age Other Details Decompensated liver disease. Autoimmune hepatitis. Concomitant administration of didanosine with ribavirin in patients coinfected with HIV. HCV: Prior to initiating therapy, detectable levels of HCV RNA in the serum. For HCV treatment nave, allow PegIntron monotherapy if patient has a contraindication or intolerance to ribavirin. For retreatment, must use in combination with ribavirin and must have nonresponse or relapse with prior HCV therapy. Allow only one time for retreatment with pegylated interferon and ribavirin. For Genotype 1 and 4: undetectable HCV RNA after 12 weeks of treatment OR at least 2 log decrease in HCV RNA after 12 weeks of therapy and undetectable HCV RNA after 24 weeks of treatment. ID specialist, Gastroenterologist, Oncologist 12 weeks to a total 72 weeks depending on genotype and initial vs. renewal therapy. Monitor for evidence of depression. 29

31 POMALYST Products Affected Pomalyst PA Age Other Details Pregnancy For active myeloma, patient meets the following: 1) Pomalyst is used after at least two prior therapies or as salvage therapy. 2) Pomalyst may be used with dexamethasone. For female patients of childbearing potential, pregnancy is excluded by 2 negative serum or urine pregnancy tests. For all patients, complete blood counts are monitored for hematologic toxicity while receiving Pomalyst. Male and female patients of child-bearing potential should be instructed on the importance of proper utilization of appropriate contraceptive methods for Pomalyst use. Patients should be monitored for signs and symptoms of thromboembolism. 30

32 PROTEASE INHIBITORS/HEPATITIS Products Affected Incivek PA Age Other Details UP TO 12 WEEKS 31

33 REBIF Products Affected Rebif Rebif Titration Pack PA Age Other Details 32

34 REMICADE Products Affected Remicade PA Age Details Active infection (including TB), concurrent use with other biologics, unstable moderate to severe HF (NYHA Functional Class III/IV). Screening for latent TB infection and assessment for Hep B risk. For positive latent TB, patient must have completed treatment or is currently receiving treatment for LTBI. HBV infection ruled out or treatment initiated for positive infection. Rheumatoid arthritis - An inadequate response or intolerance to Enbrel or Humira and one of the following: 1) inadequate response to methotrexate (MTX), 2) inadequate response to another nonbiologic DMARD (e.g., leflunomide, hydroxychloroquine, sulfasalazine) if contraindicated or intolerant to MTX, 3) intolerance or contraindication to at least 2 nonbiologic DMARDs. Psoriatic arthritis with predominantly peripheral symptoms - Must meet both of the following: 1) have an inadequate response or intolerance to either Enbrel or Humira, and 2) have an inadequate response to at least an 8-week maximum tolerated dose trial of at least 1 nonbiologic DMARD unless contraindicated or intolerant to such therapy. Psoriatic arthritis with predominantly axial symptoms and ankylosing spondylitis - Must have an inadequate response or intolerance/contraindication to at least 2 nonsteroidal anti-inflammatory drugs (NSAIDs). For plaque psoriasis - More than 10% BSA affected or has crucial body areas (e.g., feet, hands, face) affected. An inadequate response to at least a 60-day trial of 2 conventional therapies (e.g., phototherapy, calcipotriene, MTX, acitretin) unless contraindicated or intolerant to such therapies. Crohn's disease - Must meet both of the following: 1) have an inadequate response to at least a 60-day trial of 1 conventional therapy (e.g., corticosteroids, sulfasalazine, azathioprine, mesalamine) unless contraindicated or intolerant to such therapy, and 2) have an inadequate response or intolerance to either Humira or Cimzia. Ulcerative colitis - An inadequate response to at least a 60-day trial of 2 conventional therapies (e.g., corticosteroids, mesalamine) unless contraindicated or intolerant to such therapies. For plaque psoriasis, patient must be 18 years of age and older. 33

35 Other Initial: 3 months for Crohn's disease and UC, plan year for all others. Renewal: plan year For continuation of therapy, patient's condition must have improved or stabilized. 34

36 REVATIO Products Affected Sildenafil Citrate TABS PA Age Other Details Nitrate therapy Diagnosis of pulmonary arterial hypertension (PAH), (WHO Group 1). PAH been confirmed by right heart catheterization. If patient is an infant, PAH diagnosed by Doppler echocardiogram. The patient has had an inadequate response or intolerance to Adcirca. 35

37 REVLIMID Products Affected Revlimid PA Age Other Details Pregnancy For active myeloma, patient meets one of the following: 1) Revlimid is used after at least one prior therapy or as salvage therapy. 2) Revlimid is used with dexamethasone as primary induction therapy or in combination with melphalan and prednisone in nontransplant candidates. 3) Revlimid is used as maintenance monotherapy following response to either stem cell transplant or primary induction therapy. For Low or Intermediate-1 Risk myelodysplastic syndrome (MDS): for those with 5q deletion, patients should have transfusion-dependent anemia or symptomatic anemia with clinically significant cytopenias. For those with non-5q deletion MDS and symptomatic anemia, patients should have failed to respond to epoetin alfa or darbepoetin or have a pretreatment serum erythropoietin levels greater than 500 mu/ml and a low probability of response to immunosuppressive therapy. For female patients of childbearing potential, pregnancy is excluded by 2 negative serum or urine pregnancy tests. For all patients, complete blood counts are monitored for hematologic toxicity while receiving Revlimid. Male and female patients of child-bearing potential should be instructed on the importance of proper utilization of appropriate contraceptive methods for Revlimid use. Patients should be monitored for signs and symptoms of thromboembolism. 36

38 RIBAVIRIN Products Affected Rebetol SOLN Ribasphere Ribasphere Ribapak Ribavirin CAPS Ribavirin TABS PA Age Other Details Hemoglobin less than 8.5 g/dl. Hemoglobinopathy. History of unstable heart disease. Creatinine clearance less than 50 ml/minute and unwilling to use modified dose of ribavirin. Pregnancy (self or partner).unwilling to use effective contraception. Coadministration with didanosine in HIV coinfected patients. Prior to initiating therapy, detectable levels of HCV RNA in the serum. Must use in combination with interferon. For retreatment: patient must have nonresponse or relapse with prior HCV therapy. Allow only one time retreatment with pegylated interferon and ribavirin OR Infergen and ribavirin. For Genotype 1 and 4: undetectable HCV RNA after 12 weeks of treatment OR at least 2 log decrease in HCV RNA after 12 weeks of therapy and undetectable HCV RNA after 24 weeks of treatment. ID specialist, gastroenterologist, or oncologist 12 weeks to a total 72 weeks depending on genotype and initial vs. renewal therapy. Patient has been instructed to practice effective contraception during therapy and for six months after stopping ribavirin therapy. 37

39 SABRIL Products Affected Sabril PA Age Other Details Patients with or at high risk of vision loss (except patients who have blindness). Patients using other medications associated with serious adverse ophthalmic effects such as retinopathy or glaucoma. Initial treatment infantile spasms, 1 month to 2 years. Initial treatment CPS, 16 years or older. Infantile spasms: initial 4 weeks, reauth 6 months. CPS: initial 3 months, reauth 12 months 38

40 SANDOSTATIN LAR Products Affected Sandostatin Lar Depot PA Age Other Details Patient received initial treatment with Sandostatin Injection (not the Depot form) for at least 2 weeks and treatment with Sandostatin Injection was effective and tolerable. 39

41 SPRYCEL Products Affected Sprycel PA Age Other Details Acute lymphoblastic leukemia (ALL) and newly diagnosed chronic myeloid leukemia (CML) must be positive for the Philadelphia chromosome or BCR-ABL gene. For CML, patient meets one of the following: 1) newly diagnosed in chronic phase, 2) resistance or intolerance to imatinib, or 3) relapse after stem cell transplant. For ALL, patient meets one of the following: 1) ALL is newly diagnosed and Sprycel is used in combination with chemotherapy, or 2) resistance or intolerance to prior therapy. 18 years of age and older 40

42 SUTENT Products Affected Sutent PA Age Other Details Clinical manifestations of congestive heart failure. For gastrointestinal stromal tumor (GIST), disease progression while on an at least 30-day regimen of Gleevec or intolerance to Gleevec is required. LFT monitoring at initiation of therapy and throughout treatment. Oncologist Therapy will be interrupted for serious hepatic adverse events and discontinued if serious hepatic adverse events do not resolve. 41

43 TAFINLAR Products Affected Tafinlar PA Age Other Details All FDA-approved indications not otherwise excluded from Part D Documentation of the detected BRAF V600E mutation 42

44 TARCEVA Products Affected Tarceva PA Age Other Details For 1st line therapy of locally advanced or metastatic NSCLC, patient should have a known active EGFR mutation or amplification of the EGFR gene. 43

45 TARGRETIN Products Affected Targretin CAPS PA Age Other Details Pregnancy For capsules, patient meets one of the following: 1) cutaneous T cell lymphoma (includes mycosis fungoides [MF] and Sezary syndrome [SS]) refractory to prior systemic therapy, 2) advanced-stage MF/Sezary syndrome, 3) early-stage MF refractory/progressive to skin-directed therapy, or 4) early-stage MF with blood involvement or folliculotropic/large cell transformation. Patient has been instructed on the importance of and proper utilization of contraception. 44

46 TASIGNA Products Affected Tasigna PA Age Other Details Long QT syndrome, uncorrected electrolyte disorders (hypokalemia, hypomagnesemia). ECG obtained at baseline, 7-10 days after initiation of therapy and periodically throughout therapy. Newly diagnosed chronic myeloid leukemia (CML) must be positive for the Philadelphia chromosome or BCR-ABL gene. For CML, patient meets one of the following: 1) newly diagnosed in chronic phase, 2) resistance to imatinib, 3) intolerance/toxicity to imatinib or dasatinib, or 4) relapse after stem cell transplant. 18 years of age and older Patient has been instructed to avoid eating food 2 hours before and 1 hour after taking Tasigna. Concomitant use of drugs known to prolong the QT interval and strong CYP3A4 inhibitors should be avoided. 45

47 THALOMID Products Affected Thalomid PA Age Other Details Pregnancy For active myeloma, patient meets one of the following: 1) Thalomid is used as salvage or palliative therapy. 2) Thalomid is used for newly diagnosed disease or as primary induction therapy in combination with dexamethasone or in combination with melphalan and prednisone in nontransplant candidates. 3) Thalomid is used as maintenance monotherapy following response to either stem cell transplant or primary induction therapy. For female patients of childbearing potential, pregnancy is excluded by a negative pregnancy test. Patients are monitored for signs and symptoms of thromboembolism. Male and female patients of child-bearing potential are instructed on the importance of proper utilization of appropriate contraceptive methods. 46

48 THIORIDAZINE Products Affected Thioridazine Hcl ORAL TABS PA Age Other Details 47

49 TRACLEER Products Affected Tracleer PA Age Other Details AST/ALT level greater than 3 times upper limit of normal (ULN). Pregnancy. Concomitant use of cyclosporine A or glyburide. PAH confirmed by right heart catheterization. NYHA Class II-IV symptoms. Female patients of childbearing potential must use more than one method of contraception concurrently. 48

50 TYKERB Products Affected Tykerb PA Age Other Details Liver function tests must be monitored at baseline and every four to six weeks during therapy and as clinically indicated. In patients with severe hepatic impairment, Tykerb is used at a reduced dose. 49

51 VIMPAT Products Affected Vimpat PA Age Other Details A. The patient will receive Vimpat as an adjunctive anticonvulsant for the treatment of partial onset seizures. B. The patient had a previous or present trial/failure/contraindication to two or more of the following: carbamazepine, divalproex, ethosuximide, ethotoin, gabapentin, lamotrigine, levetiracetam, methsuximide, oxcarbazepine, phenytoin, phenobarbital, pregabalin, rufinamide, tiagabine, topiramate, valproic acid or zonisamide. 17 years of age and older 50

52 VOTRIENT Products Affected Votrient PA Age Other Details Alanine transaminase (ALT) greater than 3 times the upper limit of normal (ULN) and bilirubin greater than 2 times the ULN. Oncologist 51

53 XALKORI Products Affected Xalkori PA Age Other Details All FDA-approved indications not otherwise excluded from Part D. Plus, patients with non-small cell lung cancer (NSCLC) already started on crizotinib. For the FDA-approved indication of NSCLC for patients new to therapy, ALK status required. Authorization will be for 12 mos. NSCLC, patient new to therapy must be ALK-positive for approval. 52

54 XOLAIR Products Affected Xolair PA Age Other Details 12 years of age and older Pulmonologist, allergist or immunologist To continue therapy, patients must demonstrate an improvement in asthma control with use of Xolair. 53

55 XTANDI Products Affected Xtandi PA Age Other Details. Plus patients already started on Xtandi for a Covered Use. Diagnosis for which Xtandi is being used. For metastatic castrationresistant prostate cancer, prior therapies tried. Authorization will be for 12 months. For prostate cancer, patient must have metastatic, castration-resistant prostate cancer for approval. For metastatic, castration-resistant prostate cancer, patient must have previously received therapy with docetaxel for approval. 54

56 ZELBORAF Products Affected Zelboraf PA Age Other Details All FDA-approved indications not otherwise excluded from Part D. Plus, patients with melanoma already started on vemurafenib. For the FDA-approved indication of melanoma, for patients new to therapy, BRAFV600E status required. Authorization will be for 12 mos. Melanoma, patient new to therapy must have BRAFV600E mutation for approval. 55

57 ZYVOX Products Affected Zyvox PA Age Other Details All FDA-approved indications not otherwise excluded from Part D Culture and sensitivity and CBC within normal limits Up to 28 days 56

58 PART B VERSUS PART D Products Affected Abilify INJ Abilify Maintena INJ 300MG Acetylcysteine INHALATION SOLN Acyclovir Sodium INJ 500MG Adagen A-hydrocort Albuterol Sulfate INHALATION NEBU Aldurazyme Alimta INJ 500MG Ambisome Amifostine Amikacin Sulfate INJ 1GM/4ML, 50MG/ML Aminophylline INJ Aminosyn 8.5%/electrolytes Aminosyn II Aminosyn II 8.5%/electrolytes Aminosyn M Aminosyn-hbc Aminosyn-pf Aminosyn-pf 7% Amiodarone Hcl INJ 50MG/ML Amphotericin B INJ Ampicillin Sodium INJ 10GM, 125MG, 1GM Ampicillin-sulbactam INJ 10GM; 5GM, 2GM; 1GM Aralast Np INJ 400MG Arcalyst Astagraf XL Avastin INJ 100MG/4ML Avelox INJ Azasan Azathioprine TABS Azithromycin INJ 500MG Baciim Bacitracin INJ Bactocill In Dextrose Bcg Vaccine Benlysta INJ 120MG Benztropine Mesylate INJ Bicillin C-r Bicillin L-a Bicnu Bleomycin Sulfate INJ 30UNIT Budesonide INHALATION SUSP 0.25MG/2ML, 0.5MG/2ML Buprenorphine Hcl INJ Busulfex Calcitriol INJ 1MCG/ML Calcitriol ORAL CAPS Calcitriol ORAL SOLN Cancidas Capastat Sulfate Carboplatin INJ 150MG/15ML Cefazolin Sodium INJ 10GM, 1GM, 1GM; 5%, 500MG Cefepime INJ 1GM, 2GM Cefotaxime Sodium INJ 10GM, 1GM, 2GM, 500MG Cefoxitin Sodium Ceftazidime INJ 1GM, 2GM Ceftriaxone Sodium INJ Cefuroxime Sodium INJ 1.5GM, 7.5GM, 750MG Cellcept Cellcept Intravenous Cerezyme INJ 200UNIT Chloramphenicol Sodium Succinate Chorionic Gonadotropin INJ Cidofovir Cimzia INJ 200MG Cinryze Ciprofloxacin INJ 400MG/40ML Cisplatin INJ 100MG/100ML Cladribine Clindamycin Phosphate Add-vantage Clinimix 2.75%/dextrose 5% Clinimix 4.25%/dextrose 10% Clinimix 4.25%/dextrose 20% 57

59 Clinimix 4.25%/dextrose 25% Clinimix 4.25%/dextrose 5% Clinimix 5%/dextrose 15% Clinimix 5%/dextrose 20% Clinimix 5%/dextrose 25% Clinimix E 2.75%/dextrose 10% Clinimix E 2.75%/dextrose 5% Clinimix E 4.25%/dextrose 25% Clinimix E 4.25%/dextrose 5% Clinimix E 5%/dextrose 15% Clinimix E 5%/dextrose 20% Clinimix E 5%/dextrose 25% Clinisol Sf 15% Colistimethate Sodium INJ Cosmegen Cromolyn Sodium NEBU Cubicin Cyclophosphamide ORAL TABS Cyclosporine INJ Cyclosporine ORAL CAPS Cyclosporine Modified Cytarabine INJ 500MG Cytarabine Aqueous INJ 20MG/ML Dacarbazine INJ 200MG Daunorubicin Hcl INJ 5MG/ML Decitabine Depo-provera Dexamethasone Sodium Phosphate INJ 10MG/ML, 120MG/30ML Dexrazoxane INJ 250MG Dextrose 10% Flex Container Dextrose 10%/nacl 0.2% Dextrose 2.5%/sodium Chloride 0.45% Dextrose 5% Dextrose 5%/lactated Ringers Dextrose 5%/nacl 0.2% Dextrose 5%/nacl 0.225% Dextrose 5%/nacl 0.33% Dextrose 5%/nacl 0.45% Dextrose 5%/nacl 0.9% Dextrose 5%/potassium Chloride 0.15% Diltiazem Hcl INJ 100MG, 50MG/10ML Doxil Doxorubicin Hcl INJ 2MG/ML Dronabinol Duramorph Elaprase Elelyso Elitek INJ 1.5MG Emend ORAL CAPS Engerix-b Epirubicin Hcl INJ 50MG/25ML Erythrocin Lactobionate INJ 500MG Esomeprazole Sodium Estradiol Valerate INJ 20MG/ML, 40MG/ML Etoposide INJ 500MG/25ML Fabrazyme INJ 35MG Famotidine INJ 20MG/2ML Famotidine Premixed Faslodex Fluconazole In Dextrose INJ 56MG/ML; 400MG/200ML Fludarabine Phosphate INJ 50MG Fluorouracil INJ 2.5GM/50ML Fluphenazine Decanoate INJ Fluphenazine Hcl INJ Fomepizole Fosphenytoin Sodium INJ 100MG PE/2ML Furosemide INJ Gammagard Liquid Gamunex-c INJ 1GM/10ML Ganciclovir INJ Gemcitabine Hcl INJ 1GM Gemzar INJ 1GM Gengraf Gentamicin Sulfate INJ Gentamicin Sulfate/0.9% Sodium Chloride INJ 1MG/ML; 0.9% Geodon INJ Granisetron Hcl INJ 0.1MG/ML, 1MG/ML Granisetron Hcl TABS 58

60 Granisol Haloperidol Decanoate INJ Haloperidol Lactate Havrix Heparin Sodium INJ 10000UNIT/ML, 1000UNIT/ML, 20000UNIT/ML, 5000UNIT/ML Heparin Sodium/d5w INJ 5%; 40UNIT/ML Heparin Sodium/nacl 0.45% Heparin Sodium/sodium Chloride 0.9% Premix Hepatamine Hepatasol Herceptin Hydralazine Hcl INJ Hydromorphone Hcl INJ 500MG/50ML Hydroxyzine Hcl INJ Idarubicin Hcl INJ 10MG/10ML Ifex INJ 3GM Ifosfamide INJ 1GM Imipenem/cilastatin Increlex Intralipid Intron-a INJ UNIT/ML Intron-a W/diluent INJ 10MU Invanz Invega Sustenna Ionosol-b/dextrose 5% Ionosol-mb/dextrose 5% Ipratropium Bromide INHALATION SOLN 0.02% Ipratropium Bromide/albuterol Sulfate Irinotecan INJ 100MG/5ML Isotonic Gentamicin INJ 0.8MG/ML; 0.9% Istodax Kadcyla INJ 100MG Kcl 0.075%/d5w/nacl 0.45% Kcl 0.15%/d5w/lr Kcl 0.15%/d5w/nacl 0.2% Kcl 0.15%/d5w/nacl 0.225% Kcl 0.15%/d5w/nacl 0.9% Kcl 0.3%/d5w/nacl 0.45% Kcl 0.3%/d5w/nacl 0.9% Labetalol Hcl INJ Leucovorin Calcium INJ 100MG, 350MG Levalbuterol NEBU Levetiracetam INJ 500MG/5ML Levocarnitine INJ Levocarnitine ORAL SOLN Levocarnitine TABS Levofloxacin INJ Levothyroxine Sodium INJ 100MCG Lidocaine Hcl INJ 0.5%, 1% Liposyn III INJ 2.5%; 10%, 2.5%; 20% Lupron Depot INJ 22.5MG, 3.75MG, 30MG, 45MG, 7.5MG Lupron Depot-ped INJ 11.25MG, 11.25MG, 15MG Magnesium Sulfate INJ 50% Melphalan Hydrochloride Meropenem INJ 500MG Mesna Methadone Hcl INJ Methotrexate TABS Methotrexate Sodium INJ 1GM, 50MG/2ML Methylprednisolone Acetate INJ Methylprednisolone Sodiumsuccinate INJ 125MG, 40MG Metoclopramide Hcl INJ Metoprolol Tartrate INJ Miacalcin INJ Mitomycin INJ 20MG Mitoxantrone Hcl Mozobil Mustargen Mycophenolate Mofetil Mycophenolic Acid Dr Myfortic Myozyme Nafcillin Sodium INJ 10GM, 1GM Naglazyme 59

61 Nalbuphine Hcl INJ Nallpen/dextrose INJ 0; 1GM/50ML Naloxone Hcl INJ 1MG/ML Nebupent Neoral Nephramine Neumega Nexium I.v. Nitroglycerin INJ Normosol-m In D5w Normosol-r Normosol-r In D5w Novarel Nulojix Ondansetron Hcl INJ 4MG/2ML Ondansetron Hcl ORAL SOLN Ondansetron Hcl ORAL TABS Ondansetron Odt Orencia INJ 250MG Oxacillin Sodium INJ 1GM Oxaliplatin INJ 100MG/20ML Paclitaxel INJ 300MG/50ML Pamidronate Disodium INJ 30MG/10ML, 6MG/ML, 90MG/10ML Paricalcitol Penicillin G Potassium INJ 5MU Penicillin G Procaine Penicillin G Sodium Pentam 300 Perforomist Perjeta Phenytoin Sodium INJ Piperacillin Sodium/tazobactam Sodium INJ 3GM; 0.375GM, 4GM; 0.5GM Plasma-lyte A Plasma-lyte-148 Plasma-lyte-56/d5w Potassium Chloride 0.15% D5w/nacl 0.33% Potassium Chloride 0.15% D5w/nacl 0.45% Viaflex Potassium Chloride 0.15% Nacl 0.9% Potassium Chloride 0.22% D5w/nacl 0.45% Potassium Chloride 0.3%/ Nacl 0.9% Potassium Chloride 0.3%/d5w Pregnyl W/diluent Benzyl Alcohol/nacl Premarin INJ Premasol Primaxin IV Procalamine Procrit Prograf ORAL CAPS Proleukin Prolia Propranolol Hcl INJ Prosol Pulmozyme Ranitidine Hcl INJ 150MG/6ML Rapamune Reclast Recombivax Hb INJ 10MCG/ML, 40MCG/ML Remodulin Rheumatrex Rifampin INJ Ringers Injection Risperdal Consta Rituxan Sancuso Sandimmune ORAL CAPS Sandimmune SOLN Simulect INJ 20MG Sirolimus TABS Solu-cortef INJ 250MG Somatuline Depot Somavert Streptomycin Sulfate INJ Sulfamethoxazole/trimethoprim INJ Synribo Tacrolimus ORAL CAPS Terbutaline Sulfate INJ Testosterone Cypionate INJ Testosterone Enanthate INJ Tetanus Toxoid Adsorbed 60

62 Tetanus/diphtheria Toxoids-adsorbed Adult Tobi Tobramycin Sulfate INJ 10MG/ML, 80MG/2ML Toposar INJ 1GM/50ML Topotecan Hcl INJ 4MG Tpn Electrolytes Tranexamic Acid INJ Travasol Treanda INJ 100MG Trelstar Depot Mixject Trelstar La Mixject Trelstar Mixject Trisenox Trophamine Twinrix Tysabri Valproate Sodium INJ Vancomycin Hcl INJ 1000MG, 10GM, 500MG Vaqta INJ 25UNIT/0.5ML Velcade Verapamil Hcl INJ Vfend IV Vinblastine Sulfate INJ 1MG/ML Vincasar Pfs Vincristine Sulfate INJ Vinorelbine Tartrate INJ 50MG/5ML Voriconazole INJ Vpriv Xgeva Zaltrap INJ 100MG/4ML Zemplar Zometa Zortress Details 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. 61

63 INDEX A Abilify Abilify Maintena Acetylcysteine Actemra... 1 Acthar... 2 Acthar Hp... 2 Actimmune... 3 Acyclovir Sodium Adagen Adcirca... 4 Afinitor... 5 Afinitor Disperz... 5 A-hydrocort Albuterol Sulfate Aldurazyme Alimta Alprazolam Alprazolam Er Alprazolam Odt Alprazolam Xr Ambisome Amifostine Amikacin Sulfate Aminophylline Aminosyn 8.5%/electrolytes Aminosyn II Aminosyn II 8.5%/electrolytes Aminosyn M Aminosyn-hbc Aminosyn-pf Aminosyn-pf 7% Amiodarone Hcl Amphotericin B Ampicillin Sodium Ampicillin-sulbactam Aralast Np Arcalyst Astagraf XL Avastin Avelox Avonex... 6 Azasan Azathioprine Azithromycin B Baciim Bacitracin Bactocill In Dextrose Bcg Vaccine Benlysta Benztropine Mesylate... 15, 57 Bicillin C-r Bicillin L-a Bicnu Bleomycin Sulfate Budesonide Buprenorphine Hcl Busulfex Butalbital/acetaminophen/caffeine/codeine C Calcitriol Cancidas Capastat Sulfate Carboplatin Cefazolin Sodium Cefepime Cefotaxime Sodium Cefoxitin Sodium Ceftazidime Ceftriaxone Sodium Cefuroxime Sodium Cellcept

64 Cellcept Intravenous Cerezyme Chloramphenicol Sodium Succinate Chorionic Gonadotropin Cialis... 7 Cidofovir Cimzia... 8, 57 Cinryze Ciprofloxacin Cisplatin Cladribine Clemastine Fumarate Clindamycin Phosphate Add-vantage Clinimix 2.75%/dextrose 5% Clinimix 4.25%/dextrose 10% Clinimix 4.25%/dextrose 20% Clinimix 4.25%/dextrose 25% Clinimix 4.25%/dextrose 5% Clinimix 5%/dextrose 15% Clinimix 5%/dextrose 20% Clinimix 5%/dextrose 25% Clinimix E 2.75%/dextrose 10% Clinimix E 2.75%/dextrose 5% Clinimix E 4.25%/dextrose 25% Clinimix E 4.25%/dextrose 5% Clinimix E 5%/dextrose 15% Clinimix E 5%/dextrose 20% Clinimix E 5%/dextrose 25% Clinisol Sf 15% Clonazepam Clonazepam Odt Colistimethate Sodium Copaxone... 9 Cosmegen Cromolyn Sodium Cubicin Cyclophosphamide Cyclosporine Cyclosporine Modified Cyproheptadine Hcl Cytarabine Cytarabine Aqueous D Dacarbazine Daunorubicin Hcl Decitabine Depo-provera Dexamethasone Sodium Phosphate Dexrazoxane Dextrose 10% Flex Container Dextrose 10%/nacl 0.2% Dextrose 2.5%/sodium Chloride 0.45% Dextrose 5% Dextrose 5%/lactated Ringers Dextrose 5%/nacl 0.2% Dextrose 5%/nacl 0.225% Dextrose 5%/nacl 0.33% Dextrose 5%/nacl 0.45% Dextrose 5%/nacl 0.9% Dextrose 5%/potassium Chloride 0.15% Diazepam Diazepam Intensol Diltiazem Hcl Doxil Doxorubicin Hcl Dronabinol Duramorph E Elaprase Elelyso Elitek Emend Engerix-b Epirubicin Hcl Erwinaze Erythrocin Lactobionate Esomeprazole Sodium Estradiol Valerate Eszopiclone Etoposide Extavia F Fabrazyme Famotidine Famotidine Premixed Faslodex Fluconazole In Dextrose

65 Fludarabine Phosphate Fluorouracil Fluphenazine Decanoate Fluphenazine Hcl Fomepizole Fosphenytoin Sodium Furosemide G Gammagard Liquid Gamunex-c Ganciclovir Gemcitabine Hcl Gemzar Gengraf Gentamicin Sulfate Gentamicin Sulfate/0.9% Sodium Chloride Geodon Gilotrif Gleevec Granisetron Hcl Granisol Growth Hormone H Haloperidol Decanoate Haloperidol Lactate Havrix Heparin Sodium Heparin Sodium/d5w Heparin Sodium/nacl 0.45% Heparin Sodium/sodium Chloride 0.9% Premix. 59 Hepatamine Hepatasol Herceptin Hrm Hrm Benzos Hydralazine Hcl Hydromorphone Hcl Hydroxyzine Hcl I Idarubicin Hcl Ifex Ifosfamide Imbruvica Imipenem/cilastatin Incivek Increlex Infergen Intralipid Intron-a Intron-a W/diluent Intuniv Invanz Invega Sustenna Ionosol-b/dextrose 5% Ionosol-mb/dextrose 5% Ipratropium Bromide Ipratropium Bromide/albuterol Sulfate Irinotecan Isotonic Gentamicin Istodax K Kadcyla Kcl 0.075%/d5w/nacl 0.45% Kcl 0.15%/d5w/lr Kcl 0.15%/d5w/nacl 0.2% Kcl 0.15%/d5w/nacl 0.225% Kcl 0.15%/d5w/nacl 0.9% Kcl 0.3%/d5w/nacl 0.45% Kcl 0.3%/d5w/nacl 0.9% Kuvan L Labetalol Hcl Lanoxin Letairis Leucovorin Calcium Leukine Levalbuterol Levetiracetam Levocarnitine Levofloxacin Levothyroxine Sodium Lidocaine Hcl Liposyn III Lorazepam Lorazepam Intensol

66 Lunesta Lupron Depot Lupron Depot-ped M Magnesium Sulfate Mekinist Melphalan Hydrochloride Meprobamate Meropenem Mesna Metaxalone Methadone Hcl Methotrexate Methotrexate Sodium Methyldopa/hydrochlorothiazide Methylprednisolone Acetate Methylprednisolone Sodiumsuccinate Metoclopramide Hcl Metoprolol Tartrate Miacalcin Mitomycin Mitoxantrone Hcl Mozobil Mustargen Mycophenolate Mofetil Mycophenolic Acid Dr Myfortic Myozyme N Nafcillin Sodium Naglazyme Nalbuphine Hcl Nallpen/dextrose Naloxone Hcl Nebupent Neoral Nephramine Neumega Neupogen Nexavar Nexium I.v Nitroglycerin Norditropin Flexpro Norditropin Nordiflex Pen Normosol-m In D5w Normosol-r Normosol-r In D5w Novarel Nulojix O Octreotide Octreotide Acetate Oncaspar Ondansetron Hcl Ondansetron Odt Onfi Orencia Oxacillin Sodium Oxaliplatin Oxazepam P Paclitaxel Pamidronate Disodium Paricalcitol Part B Versus Part D Pegasys Pegasys Proclick Pegintron Peg-intron Peg-intron Redipen Penicillin G Potassium Penicillin G Procaine Penicillin G Sodium Pentam Perforomist Perjeta Phenytoin Sodium Piperacillin Sodium/tazobactam Sodium Plasma-lyte A Plasma-lyte Plasma-lyte-56/d5w Pomalyst Potassium Chloride 0.15% D5w/nacl 0.33% Potassium Chloride 0.15% D5w/nacl 0.45% Viaflex Potassium Chloride 0.15% Nacl 0.9%

67 Potassium Chloride 0.22% D5w/nacl 0.45% Potassium Chloride 0.3%/ Nacl 0.9% Potassium Chloride 0.3%/d5w Pregnyl W/diluent Benzyl Alcohol/nacl Premarin Premasol Primaxin IV Procalamine Procrit Prograf Proleukin Prolia Propranolol Hcl Prosol Protease Inhibitors/hepatitis Pulmozyme R Ranitidine Hcl Rapamune Rebetol Rebif Rebif Titration Pack Reclast Recombivax Hb Remicade Remodulin Reserpine Revatio Revlimid Rheumatrex Ribasphere Ribasphere Ribapak Ribavirin Rifampin Ringers Injection Risperdal Consta Rituxan S Sabril Sancuso Sandimmune Sandostatin Lar Sandostatin Lar Depot Sildenafil Citrate Simulect Sirolimus Solu-cortef Somatuline Depot Somavert Sprycel Streptomycin Sulfate Sulfamethoxazole/trimethoprim Sutent Synribo T Tacrolimus Tafinlar Tarceva Targretin Tasigna Temazepam Terbutaline Sulfate Testosterone Cypionate Testosterone Enanthate Tetanus Toxoid Adsorbed Tetanus/diphtheria Toxoids-adsorbed Adult Thalomid Thioridazine Thioridazine Hcl Tobi Tobramycin Sulfate Toposar Topotecan Hcl Tpn Electrolytes Tracleer Tranexamic Acid Travasol Treanda Trelstar Depot Mixject Trelstar La Mixject Trelstar Mixject Trisenox Trophamine Twinrix Tykerb Tysabri

68 V Valproate Sodium Vancomycin Hcl Vaqta Velcade Verapamil Hcl Vfend IV Vimpat Vinblastine Sulfate Vincasar Pfs Vincristine Sulfate Vinorelbine Tartrate Voriconazole Votrient Vpriv X Xalkori Xgeva Xolair Xtandi Z Zaltrap Zelboraf Zemplar Zometa Zortress Zyvox