2018 Prior Authorizations (List of Prior Authorizations)

Transcription

1 Prior Authorization Last Updated: April 24, 2018 Effective Date: May 1, Prior Authorizations (List of Prior Authorizations) PLEASE READ CAREFULLY: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE PRIOR AUTHORIZATIONS ON DRUGS THAT WE COVER IN THIS PLAN. Note to existing members: Beneficiaries must use network pharmacies to access their prescription drug benefit. Benefits, List of Covered Drugs, pharmacy and provider networks and copayments may change from time to time throughout the year and on January 1 of each year. IEHP DualChoice Cal MediConnect Plan (Medicare-Medicaid Plan) is a Health Plan that contracts with both Medicare and Medi-Cal to provide benefits of both programs to enrollees. You can get this information for free in other languages. Call IEHP (4347), 8am 8pm (PST) 7 days a week, including holidays.tty/tdd users should call The call is free. Usted puede obtener esta información gratis en otros idiomas. Llame al IEHP (4347), 8am 8pm (Hora del Pacífico), los 7 días de la semana, incluidos días festivos. Los usuarios de TTY/TDD deben llamar al La llamada es gratuita. H5355_CMC_18_888463

2 ABELCET ABELCET PA Details Age Other Failure or clinically significant adverse effects to the formulary alternative: conventional Amphotericin B. 1

3 ABILIFY DISCMELT aripiprazole oral tablet, disintegrating PA Details Age Other Bipolar and Schizophrenia: Failure or clinically significant adverse effects to two of the formulary alternatives: olanzapine, risperidone, quetiapine, or ziprasidone. Depression: Failure or clinically significant adverse effects to two of the formulary alternatives: citalopram, escitalopram, fluoxetine, mirtazapine, paroxetine, sertraline, or venlafaxine. 2

4 ABILIFY MAINTENA ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION, EXTENDED REL RECON 300 MG ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION, EXTENDED REL SYRING PA Details Age Other Until the end of calendar year The member has a documented history of receiving oral aripiprazole without any clinically significant side effects. Additionally, the member has a documented trial and failure or medical reason (e. g. intolerance, hypersensitivity or contraindication) for not utilizing these therapies to manage their medical condition: Invega Sustenna, Invega Trinza or Risperdal Consta. 3

5 ABRAXANE ABRAXANE PA Details Age Other Hematologist, Oncologist Until the end of calendar year Failure or clinically significant adverse effects to one of the formulary alternatives: conventional paclitaxel or docetaxol or to the standard hypersensitivity premedications. 4

6 ACITRETIN acitretin PA Details Age Other Dermatologist Failure or clinically significant adverse effects to two of the formulary alternatives: calcipotriene, clobetasol, cyclosporine, fluocinonide, methotrexate, or Tazorac. 5

7 ACTEMRA ACTEMRA INTRAVENOUS PA Details Age Other Rheumatologist Subject to Part B vs Part D determination. Rheumatoid Arthritis: Failure or clinically significant adverse effects to all the formulary alternatives: Enbrel and Humira. 6

8 ACTIMMUNE ACTIMMUNE PA Details Age Other Hematologist, Infectious disease specialist, Oncologist, Orthopedist, Rheumatologist 7

9 ADAGEN ADAGEN PA Details Age Other Diagnosis of Adenosine Deaminase Deficiency must be confirmed by blood or genetic testing. Subject to Part B vs Part D determination 8

10 ADCIRCA ADCIRCA PA Details Age Other Concurrent use of nitrates and PDE5 inhibitors. Cardiologist, Pulmonologist Failure or clinically significant adverse effects to the formulary alternative: sildenafil. 9

11 ADEFOVIR adefovir PA Details Age Other Gastroenterologist, Hepatologist, Infectious disease specialist 10

12 ADEMPAS ADEMPAS PA Details Age Other Concomitant use of phosphodiesterase (PDE) inhibitors or nitrates Cardiologist, Pulmonologist Until the end of calendar year For Pulmonary Arterial Hypertension only: Failure or clinically significant adverse effects to the formulary alternative: sildenafil. Other indication(s) do not require failure or clinically significant adverse effects to sildenafil. 11

13 ADHD dexmethylphenidate oral tablet dextroamphetamine oral tablet dextroamphetamine-amphetamine oral tablet methylphenidate hcl oral capsule, er biphasic methylphenidate hcl oral capsule, er biphasic mg, 30 mg, 40 mg methylphenidate hcl oral solution methylphenidate hcl oral tablet methylphenidate hcl oral tablet extended release PA Details Age Other 12

14 ADRIAMYCIN adriamycin intravenous solution 20 mg/10 ml PA Details Age Other Hematologist, Oncologist Subject to Part B vs Part D determination. 13

15 AFINITOR AFINITOR AFINITOR DISPERZ PA Details Age Other Oncologist Advanced renal cell carcinoma: Failure or clinically significant adverse effects to one of the formulary alternatives: Nexavar or Sutent. Advanced hormone receptor-positive, HER2 negative breast cancer in postmenopausal women: Use in combination with exemestane and failure or clinically significant adverse effects to one of the formulary alternatives: anastrozole or letrozole. 14

16 ALDURAZYME ALDURAZYME PA Details Age Other Mucopolysaccharidosis, Type I (Hurler and Hurler-Scheie forms) and Scheie form: diagnosis confirmed by measurement of alpha-l-iduronidase activity (enzymatic assay) or DNA testing. Subject to Part B vs Part D determination 15

17 ALECENSA ALECENSA PA Details Age Other Documentation of anaplastic lymphoma kinase (ALK) positive Oncologist Until the end of calendar year Failure or clinically significant adverse effects to the formulary alternative: Xalkori 16

18 ALIMTA ALIMTA INTRAVENOUS RECON SOLN 500 MG PA Details Age Other Documentation that ANC greater than 1500cells/m3, platelets greater than 100,000cells/m3, and CrCL greater than 45mL/min Oncologist Subject to Part B vs Part D determination. 17

19 ALIQOPA ALIQOPA PA Details Age Other Documentation of at least 2 prior systemic therapies Hematologist, Oncologist Subject to Part B vs Part D determination. 18

20 ALLI ALLI 60 MG CAPSULE STARTER PACK PA Covered Uses Age Other Details Obesity management including weight loss and weight maintenance when used in conjunction with a reduced-calorie diet. BMI greater than or equal to 27 kg/m2 with one or more comorbidity (e. g. coronary heart disease, dyslipidemia, hypertension, type 2 diabetes mellitus, sleep apnea), OR BMI greater than or equal to 30 kg/m2. Reauthorization: Documented weight loss of 5% during the first 6 month period and lack of side effects. Therapy beyond the first year can be authorized every 6 months with documentation of weight maintenance and lack of side effects. 6 months. 19

21 ALUNBRIG ALUNBRIG PA Details Age Other Documentation of ALK positive. Oncologist 20

22 AMBISOME AMBISOME PA Details Age Other Subject to Part B vs Part D determination. Failure or clinically significant adverse effects to the formulary alternative: conventional Amphotericin B. 21

23 AMITRIPTYLINE amitriptyline PA Details Age Other Approve if less than 65 years of age. If aged 65 years and older, prior authorization criteria will apply. Depression: Failure or clinically significant adverse effects to two of the formulary alternatives: citalopram, escitalopram, fluoxetine, mirtazapine, paroxetine, sertraline, or venlafaxine. 22

24 AMOXAPINE amoxapine PA Details Age Other Approve if less than 65 years of age. If aged 65 years and older, prior authorization criteria will apply. Failure or clinically significant adverse effects to two of the formulary alternatives: citalopram, escitalopram, fluoxetine, mirtazapine, nortriptyline, sertraline, or venlafaxine. 23

25 AMPHOTERICIN B amphotericin b PA Details Age Other Subject to Part B vs Part D determination 24

26 AMPYRA AMPYRA PA Details Age Other Concurrently on a disease-modifying agent for multiple sclerosis. Documentation of difficulty walking (such as timed 25-foot walk test: Patient must be able to walk 25 feet within 8-45 sec). Neurologist Until the end of calendar year 25

27 ANDROGEL PUMP ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP MG/1. 25 GRAM (1. 62 %) PA Details Age Other Documented pretreatment serum testosterone levels less than the laboratory's lower reference limit within the recent 3 months Failure or clinically significant adverse effects to two of the formulary alternatives: Androderm, testosterone cypionate, testosterone enanthate or testosterone transdermal gel. 26

28 ANDROGENS ANDRODERM testosterone transdermal gel in metered-dose pump testosterone transdermal solution in metered pump w/app PA Details Age Other Documented pretreatment serum testosterone levels less than the laboratory's lower reference limit within the recent 3 months Failure or clinically significant adverse effects to one of the formulary alternatives: testosterone cypionate or testosterone enanthate. 27

29 APOKYN APOKYN PA Details Age Other Failure or clinically significant adverse effects to two of the formulary alternatives: antiparkinson drugs such as amantadine, bromocriptine, carbidopa/levodopa, entacapone, pramipexole, ropinirole, or selegiline. 28

30 APTIOM APTIOM ORAL TABLET 200 MG, 400 MG, 600 MG, 800 MG PA Details Age Other Neurologist Failure or clinically significant adverse effects to one of the formulary alternatives: carbamazepine, clonazepam, divalproex, ethosuximide, felbamate, gabapentin, lamotrigine, levetiracetam, lorazepam, oxcarbazepine, phenytoin, tiagabine, topiramate, or zonisamide. 29

31 ARCALYST ARCALYST PA Details Age Other Concurrently taking any tumor necrosis factor (TNF)-blocking agents such as Enbrel, Humira, or Remicade. Approve if 12 years old or older. 30

32 ARIPIPRAZOLE aripiprazole oral tablet PA Details Age Other Bipolar and Schizophrenia: Failure or clinically significant adverse effects to two of the formulary alternatives: olanzapine, risperidone, quetiapine, or ziprasidone. Depression: Failure or clinically significant adverse effects to two of the formulary alternatives: citalopram, escitalopram, fluoxetine, mirtazapine, paroxetine, sertraline, or venlafaxine. 31

33 ARIPIPRAZOLE SOLUTION aripiprazole oral solution PA Details Age Other Documentation of difficulty of swallowing Until the end of calendar year Bipolar and Schizophrenia: Failure or clinically significant adverse effects to one of the formulary alternatives: olanzapine, risperidone, quetiapine, or ziprasidone. Depression: Failure or clinically significant adverse effects to one of the formulary alternatives: bupropion, citalopram, desvenlafaxine, duloxetine, escitalopram, fluoxetine, mirtazapine, paroxetine, sertraline, or venlafaxine. 32

34 ARRANON ARRANON PA Details Age Other Hematologist, Oncologist Failure or clinically significant adverse effects to two prior systemic therapies. 33

35 ATGAM ATGAM PA Details Age Other Subject to Part B vs Part D determination. 34

36 ATOVAQUONE atovaquone PA Details Age Other Pneumocystic pneumonia: Failure or clinically significant adverse effects to the formulary alternative: trimethoprim/sulfamethoxazole. 35

37 AUBAGIO AUBAGIO PA Details Age Other Neurologist 36

38 AUSTEDO AUSTEDO ORAL TABLET 12 MG, 6 MG, 9 MG PA Details Age Other Concurrent use with an MAOI. Neurologist 37

39 AVASTIN AVASTIN PA Details Age Other Metastatic colorectal cancer: used in combination with intravenous 5- fluorouracil-based chemotherapy. Metastatic colorectal cancer in members who have progressed on a first-line Avastin-containing regimen: used in combination with fluoropyrimidine/irinotecan- or fluoropyrimidine/oxaliplatin-based chemotherapy. Nonsquamous nonsmall cell lung cancer that is recurrent or metastatic, unresectable, locally advanced: used in combination with paclitaxel and carboplatin. Metastatic renal cell carcinoma: used in combination with interferon alfa. Oncologist Subject to Part B vs Part D determination. 38

40 AVONEX AVONEX (WITH ALBUMIN) AVONEX INTRAMUSCULAR PEN INJECTOR KIT AVONEX INTRAMUSCULAR SYRINGE KIT PA Details Age Other Neurologist 39

41 AZACITIDINE azacitidine PA Details Age Other Documentation of CBC, liver chemistries, and serum creatine within the past month. Hematologist, Oncologist Subject to Part B vs Part D determination. 40

42 BARACLUDE BARACLUDE ORAL SOLUTION entecavir PA Details Age Other Gastroenterologist, Infectious diseases specialist 41

43 BAVENCIO BAVENCIO PA Details Age Other Dermatologist, Oncologist Subject to Part B vs Part D determination. 42

44 BELEODAQ BELEODAQ PA Details Age Other Hematologist, Oncologist Subject to Part B vs Part D determination 43

45 BENLYSTA BENLYSTA INTRAVENOUS PA Details Age Other Rheumatologist Failure or clinically significant adverse effects to two of the formulary alternatives: betamethasone, dexamethasone, hydrocortisone, hydroxychloroquine, methylprednisonlone, prednisolone, prednisone, or triamcinolone. 44

46 BENZTROPINE benztropine oral PA Details Age Other Approve if less than 65 years of age. If aged 65 years and older, prior authorization criteria will apply. Parkinsonism: Failure or clinically significant adverse effects to two of the formulary alternatives: amantadine, bromocriptine, carbidopa/levodopa, entacapone, pramipexole, ropinirole, or selegiline. Medication-induced movement disorder - extrapyramidal disease: Failure or clinically significant adverse effects to the formulary alternative: amantadine. 45

47 BETASERON BETASERON SUBCUTANEOUS KIT PA Details Age Other Neurologist 46

48 BICNU BICNU PA Details Age Other Hematologist, Oncologist Subject to Part B vs Part D determination. 47

49 BLEOMYCIN SULFATE bleomycin injection recon soln 30 unit PA Details Age Other Hematologist, Oncologist Subject to Part B vs Part D determination 48

50 BORTEZOMIB bortezomib PA Details Age Other Hematologist, Oncologist Subject to Part B vs Part D determination. 49

51 BOSULIF BOSULIF PA Details Age Other Hematologist, Oncologist Failure or clinically significant adverse effects to one of the formulary alternatives: Gleevec, Sprycel or Tasigna. 50

52 BOSULIF 400MG BOSULIF PA Details Age Other Hematologist, Oncologist 51

53 BRIVIACT BRIVIACT INTRAVENOUS BRIVIACT ORAL SOLUTION BRIVIACT ORAL TABLET 10 MG, 100 MG, 25 MG, 50 MG, 75 MG PA Details Age Other Neurologist Failure or clinically significant adverse effects to one of the formulary alternatives: carbamazepine, clonazepam, divalproex, ethosuximide, felbamate, gabapentin, lamotrigine, levetiracetam, lorazepam, oxcarbazepine, phenytoin, tiagabine, topiramate, or zonisamide. 52

54 BUSULFAN busulfan PA Details Age Other Hematologist, Oncologist, Transplant specialist Subject to Part B vs Part D determination. 53

55 CABOMETYX CABOMETYX PA Details Age Other Documentation of prior anti-angiogenic therapy Oncologist Until the end of calendar year 54

56 CALQUENCE CALQUENCE PA Details Age Other Documentation of at least one prior therapy. Hematologist, Oncologist 55

57 CAPASTAT CAPASTAT PA Details Age Other Subject to Part B vs Part D determination 56

58 CAPRELSA CAPRELSA PA Details Age Other Congenital long QT syndrome. Endocrinologist, Oncologist 57

59 CARBAGLU CARBAGLU PA Details Age Other N-acetylglutamate synthase deficiency must be confirmed by FDA approved testing Until the end of calendar year 58

60 CARBINOXAMINE carbinoxamine maleate oral liquid carbinoxamine maleate oral tablet 4 mg PA Details Age Other Approve if less than 65 years of age. If aged 65 years and older, prior authorization criteria will apply. Allergic rhinitis: Failure or clinically significant adverse effects to two of the formulary alternatives: azelastine, cetirizine, flunisolide or levocetirizine. All other FDA-approved indications: Documentation explaining specific benefit established with the medication, and how that benefit outweighs the potential risk. 59

61 CARIMUNE NANOFILTERED carimune nf nanofiltered intravenous recon soln 6 gram PA Details Age Other 3 months. Approve under Part B for these types of Primary Humoral Immunodeficiency: Congenital agammaglobulinemia, Common variable immunodeficiency, Wiskott-Aldrich syndrome, X-linked agammaglobulinemia, Severe combined immunodeficiency. Subject to Part B vs Part D determination. 60

62 CARISOPRODOL carisoprodol oral tablet 350 mg PA Details Age Other Approve if less than 65 years of age. If aged 65 years and older, prior authorization criteria will apply. Documentation explaining specific benefit established with the medication, and how that benefit outweighs the potential risk 61

63 CASPOFUNGIN caspofungin PA Details Age Other Subject to Part B vs Part D determination 62

64 CAYSTON CAYSTON PA Details Age Other Infectious disease specialist, Pulmonologist 4 weeks Subject to Part B vs Part D determination 63

65 CERDELGA CERDELGA PA Details Age Other Documentation of CYP2D6 metabolism as an extensive metabolizer (EM), intermediate metabolizer (IM) or poor metabolizer (PM) determined by a FDA-cleared test. 64

66 CEREZYME CEREZYME INTRAVENOUS RECON SOLN 400 UNIT PA Details Age Other Diagnosis of Gaucher disease, type 1, must be confirmed by blood or genetic testing. Subject to Part B vs Part D determination 65

67 CHOLBAM CHOLBAM PA Details Age Other 66

68 CIDOFOVIR cidofovir PA Details Age Other Subject to Part B vs Part D determination 67

69 CINRYZE CINRYZE PA Details Age Other Diagnosis of hereditary angioedema (HAE), must be confirmed by blood testing. Allergist, immunologist, hematologist Failure or clinically significant adverse effects to the formulary alternative: danazol. 68

70 CLADRIBINE cladribine PA Details Age Other Hematologist, Oncologist Subject to Part B vs Part D determination. 69

71 CLEMASTINE clemastine oral tablet mg PA Details Age Other Approve if less than 65 years of age. If aged 65 years and older, prior authorization criteria will apply. Allergic rhinitis: Failure or clinically significant adverse effects to two of the formulary alternatives: azelastine, cetirizine, cromolyn, flunisolide, or levocetirizine. Cutaneous hypersensitivity, urticaria, or angioedema: Failure or clinically significant adverse effects to all of the formulary alternatives: cetirizine and levocetirizine. 70

72 CLOFARABINE clofarabine PA Details Age Other Hematologist, Oncologist Subject to Part B vs Part D determination. 71

73 CLOMIPRAMINE clomipramine PA Details Age Other Approve if less than 65 years of age. If aged 65 years and older, prior authorization criteria will apply. Failure or clinically significant adverse effects to two of the formulary alternatives: fluoxetine, fluvoxamine, paroxetine, or sertraline. 72

74 CLONIDINE ER clonidine hcl oral tablet extended release 12 hr PA Details Age Other Failure or clinically significant adverse effects to the formulary alternative: guanfacine ER. 73

75 CLOZAPINE ODT clozapine oral tablet, disintegrating 100 mg, mg, 150 mg, 200 mg, 25 mg PA Details Age Other Psychiatrist Failure or clinically significant adverse effects to the formulary alternative: clozapine tablet. 74

76 COMETRIQ COMETRIQ PA Details Age Other Recent history of hemorrhage or hemoptysis. Oncologist 75

77 CORLANOR CORLANOR PA Details Age Other Documented New York Association (NYHA) class II to IV heart failure with an ejection fraction of less than or equal to 35% and sinus rhythm with a resting heart rate greater than or equal to 70 beats per minute. Documentation that patient is on maximally tolerated dose of beta blocker or has a history of a documented intolerance, contraindication or a hypersensitivity to beta blocker. Documented concurrent use with an ACE inhibitor or ARB, unless both are not tolerated or contraindicated. Cardiologist 76

78 COTELLIC COTELLIC PA Details Age Other Documentation of BRAF V600E or V600K mutation Dermatologist, Oncologist Until the end of calendar year 77

79 CUBICIN daptomycin PA Details Age Other Infectious disease specialist Subject to Part B vs Part D determination 78

80 CYCLOBENZAPRINE cyclobenzaprine oral tablet 10 mg, 5 mg PA Details Age Other Approve if less than 65 years of age. If aged 65 years and older, prior authorization criteria will apply. Documentation explaining specific benefit established with the medication, and how that benefit outweighs the potential risk 79

81 CYCLOSET CYCLOSET PA Details Age Other Failure or clinically significant adverse effects to two of the formulary alternatives: glipizide, glimepiride, metformin, or pioglitazone. 80

82 CYPROHEPTADINE cyproheptadine PA Details Age Other Approve if less than 65 years of age. If aged 65 years and older, prior authorization criteria will apply. Allergic rhinitis: Failure or clinically significant adverse effects to two of the formulary alternatives: azelastine, cetirizine, cromolyn, flunisolide, or levocetirizine. Pruritus or urticaria: Failure or clinically significant adverse effects to all of the formulary alternatives: cetirizine and levocetirizine. 81

83 CYRAMZA CYRAMZA PA Details Age Other Documentation of hemorrhage and gastrointestinal hemorrhage, or documentation of gastrointestinal perforation. Oncologist Subject to Part B vs Part D determination. 82

84 CYSTAGON CYSTAGON PA Details Age Other 83

85 CYSTARAN CYSTARAN PA Details Age Other Until the end of calendar year 84

86 CYTARABINE cytarabine cytarabine (pf) injection solution 2 gram/20 ml (100 mg/ml) PA Details Age Other Hematologist, Neurologist, Oncologist Subject to Part B vs Part D determination. 85

87 DACTINOMYCIN dactinomycin PA Details Age Other Hematologist, Oncologist Subject to Part B vs Part D determination. 86

88 DALIRESP DALIRESP ORAL TABLET 500 MCG PA Details Age Other Failure or clinically significant adverse effects to two of the formulary alternatives: Advair Diskus, Anoro Ellipta, Serevent, Spiriva or Tudorza. 87

89 DARAPRIM DARAPRIM PA Details Age Other Hematologist, HIV specialist, Infectious Disease specialist, Oncologist, Transplant specialist Primary prophylaxis of toxoplasmic encephalitis: Failure or clinically significant adverse effects to the formulary alternative: trimethoprimsulfamethoxazole. 88

90 DARZALEX DARZALEX PA Details Age Other Hematologist, Oncologist Until the end of calendar year Subject to Part B vs Part D determination 89

91 DECITABINE decitabine PA Details Age Other Hematologist, Oncologist Subject to Part B vs Part D determination. 90

92 DEMSER DEMSER PA Details Age Other Essential hypertension. 91

93 DESIPRAMINE desipramine PA Details Age Other Failure or clinically significant adverse effects to two of the formulary alternatives: citalopram, escitalopram, fluoxetine, mirtazapine, paroxetine, sertraline or venlafaxine. 92

94 DIASTAT DIASTAT DIASTAT ACUDIAL PA Details Age Other 93

95 DIAZEPAM SOLUTION diazepam intensol diazepam oral solution 5 mg/5 ml (1 mg/ml) PA Details Age Other 94

96 DIGOXIN digitek digox digoxin injection solution digoxin oral solution 50 mcg/ml digoxin oral tablet LANOXIN ORAL TABLET 125 MCG, 250 MCG PA Details Age Other Approve if less than 65 years of age. If aged 65 years and older, prior authorization criteria will apply. Average daily doses greater than mg require a clinical justification. Approve for average daily doses of mg or less. 95

97 DISOPYRAMIDE disopyramide phosphate oral capsule PA Details Age Other Approve if less than 65 years of age. If aged 65 years and older, prior authorization criteria will apply. Failure or clinically significant adverse effects to two of the formulary alternatives: acebutolol, amiodarone, flecainide, mexiletine, procainamide, propafenone, quinidine, or sotalol. 96

98 DOCETAXEL docetaxel intravenous solution 160 mg/16 ml (10 mg/ml), 80 mg/4 ml (20 mg/ml) PA Details Age Other Hematologist, Oncologist Subject to Part B vs Part D determination 97

99 DOXEPIN doxepin oral PA Details Age Other Approve if less than 65 years of age. If aged 65 years and older, prior authorization criteria will apply. For the average daily dose of doxepin that is greater than 6 mg: Anxiety: Failure or clinically significant adverse effects to two of the formulary alternatives: buspirone, escitalopram, paroxetine, or venlafaxine. Depression: Failure or clinically significant adverse effects to two of the formulary alternatives: citalopram, escitalopram, fluoxetine, mirtazapine, paroxetine, sertraline, or venlafaxine. 98

100 DRONABINOL dronabinol PA Details Age Other Chemotherapy-induced nausea and vomiting: Failure or clinically significant adverse effects to two of the formulary alternatives: chlorpromazine, granisetron, metoclopramide, ondansetron, or prochlorperazine. 99

101 ELAPRASE ELAPRASE PA Details Age Other Diagnosis of Mucopolysaccharidosis, Type II (Hunter syndrome) must be confirmed by a blood, urine, or tissue test. Subject to Part B vs Part D determination 100

102 ELIDEL ELIDEL PA Details Age Other Failure or clinically significant adverse effects to one of the topical formulary alternatives: clobetasol, betamethasone, fluocinolone or fluocinonide and failure or clinically significant adverse effects to the formulary alternative: tacrolimus ointment. 101

103 ELIGARD ELIGARD ELIGARD (3 MONTH) ELIGARD (4 MONTH) ELIGARD (6 MONTH) PA Details Age Other Oncologist, Urologist Subject to Part B vs Part D determination 102

104 EMCYT EMCYT PA Details Age Other Oncologist 103

105 EMEND aprepitant PA Details Age Other 6 months. Subject to Part B vs Part D determination. Failure or clinically significant adverse effects to one of the formulary 5-HT3 antagonist alternatives: ondansetron or granisetron except when the member is on any chemotherapy. 104

106 EMFLAZA EMFLAZA PA Details Age Other Neurologist Failure or clinically significant adverse effects to the formulary alternative: prednisone 105

107 EMPLICITI EMPLICITI PA Details Age Other Hematologist, Oncologist Until the end of calendar year Subject to Part B vs Part D determination 106

108 EMSAM EMSAM PA Details Age Other Failure or clinically significant adverse effects to all of the formulary alternatives: phenelzine and tranylcypromine. 107

109 ENBREL ENBREL ENBREL SURECLICK PA Details Age Other Plaque psoriasis: documentation of psoriasis of greater than 5% BSA or affecting crucial body areas such as hands, feet, face or genitals Dermatologist, Rheumatologist Rheumatoid Arthritis: Failure or clinically significant adverse effects to two of the formulary alternatives: azathioprine, cyclosporine, hydroxychloroquine, leflunomide, methotrexate, or sulfasalazine. Psoriatic arthritis: Failure or clinically significant adverse effects to the formulary alternative: methotrexate. Ankylosing spondylitis: Failure or clinically significant adverse effects to two of the formulary alternatives: celecoxib, diclofenac, indomethacin, naproxen, or sulindac. Plaque psoriasis: Failure or clinically significant adverse effects to two of the following: acitretin, cyclosporine, methotrexate or phototherapy 108

110 ENDARI ENDARI PA Details Age Other Documented concurrent use with hydroxyurea. Documentation of two or more painful sickle cell crises within the past 12 months. Hematologist 109

111 ENGERIX-B ENGERIX-B (PF) INTRAMUSCULAR SYRINGE ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE PA Details Age Other 6 months. Subject to Part B vs Part D determination. 110

112 ENTRESTO ENTRESTO PA Details Age Other Left ventricular ejection fraction less than 40%. Cardiologist 111

113 EPCLUSA EPCLUSA PA Details Age Other Documentation of chronic hepatitis C infection confirmed by a detectable serum hepatitis C virus RNA through quantitative assay. Documentation of genotype. Documentation of the absence or presence of cirrhosis and if compensated or decompensated. Documentation of any previous treatment. Documentation of liver transplant status. Treatment length is determined by FDA labeling or AASLD recommendation Gastroenterologist, Hepatologist, Infectious disease specialist 12 weeks. Treatment regimen will be approved based on genotype and previous treatment experience as defined by current AASLD guidelines. For genotype 1 and 4 only: failure or clinically significant adverse effects to the formulary alternative: Zepatier. 112

114 EPIRUBICIN HCL epirubicin intravenous solution 200 mg/100 ml PA Details Age Other Hematologist, Oncologist Subject to Part B vs Part D determination 113

115 EPOGEN EPOGEN INJECTION SOLUTION 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML PA Details Covered Uses All medically accepted indications not otherwise excluded from Part D. Age Other Uncontrolled hypertension For anemia due to chronic kidney disease: Hemoglobin (Hgb) is less than 10g/dL and documentation of transferrin saturation greater than or equal to 20% and ferritin greater than or equal to 100ng/mL. For anemia due to chemotherapy: Hemoglobin (Hgb) is less than 10g/dL. For surgical FDA indications: Hemoglobin (Hgb) is 10g/dL-13g/dL and patient is not a candidate for autologous blood donation and significant blood loss is anticipated from elective, non cardiac, or nonvascular surgery. Zidovudine induced: Hemoglobin (Hgb) is less than 11g/dL. Myelodyspastic syndrome: Hemoglobin (Hgb) is less than 11g/dL and erythropoietin is less than or equal to 500 mu/ml. Subject to Part B vs Part D determination. 114

116 ERBITUX ERBITUX INTRAVENOUS SOLUTION 100 MG/50 ML PA Details Age Other Hematologist, Oncologist Subject to Part B vs Part D determination 115

117 ERGOLOID ergoloid PA Details Age Other Members with acute and chronic psychosis Approve if less than 65 years of age. If aged 65 years and older, prior authorization criteria will apply. Failure or clinically significant adverse effects to two of the formulary alternatives: donepezil, galantamine, or rivastigmine. 116

118 ERIVEDGE ERIVEDGE PA Details Age Other Oncologist 117

119 ERLEADA ERLEADA PA Details Age Other Oncologist, Urologist 118

120 ERWINAZE ERWINAZE PA Details Age Other Hematologist, Oncologist Subject to Part B vs Part D determination 119

121 ESBRIET ESBRIET ORAL CAPSULE ESBRIET ORAL TABLET 267 MG, 801 MG PA Details Age Other Pulmonologist 120

122 ESTROGENS estradiol oral estradiol transdermal patch weekly estropipate jinteli PA Details Age Other Approve if less than 65 years of age. If aged 65 years and older, prior authorization criteria will apply. Postmenopausal osteoporosis prophylaxis: Failure or clinically significant adverse effects to two of the formulary alternatives: alendronic acid, ibandronic acid, or risedronate. Vulvar and vaginal atrophy: Failure or clinically significant adverse effects to one of the formulary alternatives: Estrace cream or Premarin Cream. 121

123 EXJADE EXJADE PA Details Age Other Hematologist 122

124 EXONDYS EXONDYS 51 PA Details Age Other Documentation of confirmed mutation of the Duchenne muscular dystrophy gene amenable to exon 51 skipping 123

125 FABRAZYME FABRAZYME INTRAVENOUS RECON SOLN 35 MG PA Details Age Other Subject to Part B vs Part D determination 124

126 FANAPT FANAPT ORAL TABLET FANAPT ORAL TABLETS, DOSE PACK PA Details Age Other Failure or clinically significant adverse effects to two of the formulary alternatives: olanzapine, quetiapine, risperidone or ziprasidone. 125

127 FARYDAK FARYDAK PA Details Age Other Oncologist Until the end of calendar year Failure or clinically significant adverse effects to two prior regimens which include the formulary alternative: Velcade and an immunomodulatory agent. 126

128 FASLODEX FASLODEX PA Details Age Other Hematologist, Oncologist Subject to Part B vs Part D determination 127

129 FENTANYL LOZENGE fentanyl citrate PA Details Age Other Acute, intermittent, or postoperative pain. Documentation of opioid tolerance taking around-the-clock opioid therapy consisting of at least 60mg of oral morphine daily, at least 25mg transdermal fentanyl/hour, at least 30 mg of oral oxycodone daily, at least 8mg oral hydromorphone daily, at least 25mg oral oxymorphone daily or an equianalgesic dose of another opioid daily for a week or longer for breakthrough pain of cancer. Patients must remain on around-the clock opioids when taking transmucosal immediate release fentanyl. Pain Specialist, Oncologist 128

130 FERRIPROX FERRIPROX PA Details Age Other Hematologist Until the end of calendar year Failure or clinically significant adverse effects to the formulary alternative: Exjade. 129

131 FETZIMA FETZIMA ORAL CAPSULE, EXT REL 24HR DOSE PACK FETZIMA ORAL CAPSULE, EXTENDED RELEASE 24 HR PA Details Age Other Failure or clinically significant adverse effects to two of the formulary alternatives: citalopram, escitalopram, fluoxetine, mirtazapine, paroxetine, sertraline, or venlafaxine. 130

132 FIRAZYR FIRAZYR PA Details Age Other Diagnosis of hereditary angioedema (HAE), must be confirmed by blood testing. Allergist, Immunologist, Hematologist Failure or clinically significant adverse effects to the formulary alternative: danazol. 131

133 FIRMAGON FIRMAGON KIT W DILUENT SYRINGE PA Details Age Other Oncologist, Urologist Subject to Part B vs Part D determination. 132

134 FOLOTYN FOLOTYN INTRAVENOUS SOLUTION 40 MG/2 ML (20 MG/ML) PA Details Age Other Documentation that ANC greater than 1000/mcL and platelet greater than 100,000/mcL for initiation of therapy Hematologist, oncologist Until the end of calendar year Subject to Part B vs Part D determination 133

135 FORTEO FORTEO PA Details Age Other Bone mineral density (BMD) T score of or less based on BMD measurements from lumbar spine (at least two vertebral bodies), hip (femoral neck, total hip), or radius (one-third radius site) OR BMD T- score between and (BMD T-score greater than and less than or equal to -2. 5) based on BMD measurements from lumbar spine (at least two vertebral bodies), hip (femoral neck, total hip), or radius (one-third radius site) and a history of fractures. Failure or clinically significant adverse effects to one of the formulary alternatives: alendronic acid, ibandronic acid, or risedronate. justification required for treatment duration beyond 24 months. 134

136 FRAGMIN FRAGMIN SUBCUTANEOUS SYRINGE 10,000 ANTI-XA UNIT/ML, 12,500 ANTI- XA UNIT/0. 5 ML, 15,000 ANTI-XA UNIT/0. 6 ML, 18,000 ANTI-XA UNIT/0. 72 ML, 2,500 ANTI-XA UNIT/0. 2 ML, 5,000 ANTI- XA UNIT/0. 2 ML PA Details Age Other Failure or clinically significant adverse effects to one of the formulary alternatives: enoxaparin, fondaparinux, or warfarin. 135

137 FYCOMPA FYCOMPA ORAL SUSPENSION FYCOMPA ORAL TABLET PA Details Age Other Neurologist Failure or clinically significant adverse effects to one of the formulary alternatives: carbamazepine, clonazepam, divalproex, ethosuximide, felbamate, gabapentin, lamotrigine, levetiracetam, lorazepam, oxcarbazepine, phenytoin, tiagabine, topiramate, or zonisamide. 136

138 GAMMAGARD LIQUID gammagard liquid PA Details Age Other 3 months. Approve under Part B for these types of Primary Humoral Immunodeficiency: Congenital agammaglobulinemia, Common variable immunodeficiency, Wiskott-Aldrich syndrome, X-linked agammaglobulinemia, Severe combined immunodeficiency. Subject to Part B vs Part D determination. 137

139 GAMMAPLEX GAMMAPLEX PA Details Age Other 3 months. Approve under Part B for these types of Primary Humoral Immunodeficiency: Congenital agammaglobulinemia, Common variable immunodeficiency, Wiskott-Aldrich syndrome, X-linked agammaglobulinemia, Severe combined immunodeficiency. Subject to Part B vs Part D determination. 138

140 GARDASIL 9 GARDASIL 9 (PF) PA Details Age Other Approve if 9 to 26 years of age. 6 months. Subject to Part B vs Part D determination 139

141 GATTEX GATTEX 30-VIAL PA Details Age Other Documented dependence on parenteral nutrition support for at least 12 months Gastroenterologist Until the end of calendar year 140

142 GEMCITABINE gemcitabine intravenous recon soln 1 gram PA Details Age Other Oncologist Subject to Part B vs Part D determination. 141

143 GENOTROPIN GENOTROPIN GENOTROPIN MINIQUICK PA Details Age Other AGHD(initial): diagnosis confirmed as a result of past diagnosis of childhood-onset GHD, or adult-onset GHD with documentation of hormone deficiency due to hypothalamic-pituitary disease from organic or known causes (eg: damage from surgery, cranial irradiation, head trauma, subarachnoid hemorrhage) and documentation of one growth-hormone stimulant test (eg: insulin tolerance test, arginine/ghrh,glucagon,arginine) to confirm adult GHD w/corresponding peak GH values ([ITT at or below 5mcg/L],[GHRH+ARG at or below 11mcg/L if BMI less than 25kg/m2, at or below 8mcg/L if BMI at or above 25 and below 30kg/m2, or at or below 4mcg/L if BMI at or above 30kg/m2],[glucagon at or below 3mcg/L],[Arg at or below 0. 4mcg/L]) or documentated deficiency of 3 anterior pituitary hormones (prolactin, ACTH, TSH, FSH/LH) and IFG- 1/somatomedinC below age and gender adjusted normal range as provided by physicians lab. AGHD(reauthorization): Documentation of positive experience by the patient. Endocrinologist 142

144 GEODON SOLUTION GEODON INTRAMUSCULAR PA Details Age Other Subject to Part B vs Part D determination. 143

145 GILENYA GILENYA PA Details Age Other Class III or IV heart failure, decompensated heart failure requiring hospitalization, myocardial infarction, stroke, transient ischemic attack or unstable angina within the last 6 months. Concomitant use of Class Ia or Class III anti-arrhythmic drugs. Mobitz type II second-degree or thirddegree atrioventricular block, or sick-sinus syndrome unless the patient has a functional pacemaker. QT interval at baseline 500 ms or greater. Neurologist 144

146 GILOTRIF GILOTRIF PA Details Age Other Oncologist 145

147 GLATIRAMER glatiramer PA Details Age Other Neurologist 146

148 GLATOPA glatopa subcutaneous syringe 20 mg/ml PA Details Age Other Neurologist 147

149 GLEEVEC imatinib oral tablet 100 mg, 400 mg PA Details Age Other Oncologist 148

150 GLYBURIDE glyburide micronized glyburide oral tablet mg, 2. 5 mg, 5 mg glyburide-metformin oral tablet mg, mg, mg PA Details Age Other Approve if less than 65 years of age. If aged 65 years and older, prior authorization criteria will apply. Failure or clinically significant adverse effects to all of the formulary alternatives: glipizide and glimepiride. 149

151 GOCOVRI GOCOVRI ORAL CAPSULE, EXTENDED RELEASE 24HR 137 MG, MG PA Details Age Other Documentation of concurrent levodopa therapy. Neurologist 150

152 GUANFACINE guanfacine oral tablet guanfacine oral tablet extended release 24 hr PA Details Age Other Approve if less than 65 years of age. If aged 65 years and older, prior authorization criteria will apply. Hypertension: Failure or clinically significant adverse effects to two of the formulary alternatives: benazepril, fosinopril, hydrochlorothiazide, irbesartan, lisinopril, losartan, losartan/hydrochlorothiazide, lisinopril/hydrochlorothiazide, quinapril/hydrochlorothiazide, quinapril, ramipril, or valsartan/hydrochlorothiazide. ADHD: Failure or clinically significant adverse effects to two of the formulary alternatives: amphetamine/dextroamphetamine, dexmethylphenidate, dextroamphetamine, or methylphenidate. 151

153 HALAVEN HALAVEN PA Details Age Other Oncologist Subject to Part B vs Part D determination. 152

154 HARVONI HARVONI PA Details Age Other Documentation of chronic hepatitis C infection confirmed by a detectable serum hepatitis C virus RNA through quantitative assay. Documentation of genotype. Documentation of the absence or presence of cirrhosis and if compensated or decompensated. Documentation of any previous treatment. Documentation of liver transplant status. Treatment length is determined by FDA labeling or AASLD recommendation Gastroenterologist, Hepatologist, Infectious disease specialist 12 to 24 weeks dependent on cirrhosis, liver transplant status, or previous treatment. 153

155 HERCEPTIN HERCEPTIN PA Details Age Other Documentation of HER2 overexpression Oncologist Subject to Part B vs Part D determination. 154

156 HETLIOZ HETLIOZ PA Details Age Other Neurologist, Sleep specialist Until the end of calendar year 155

157 HEXALEN HEXALEN PA Details Age Other Oncologist 156

158 HUMIRA HUMIRA HUMIRA PEN HUMIRA PEN CROHN'S-UC-HS START PA Details Age Other Plaque psoriasis: documentation of psoriasis of greater than 5% BSA or affecting crucial body areas such as hands, feet, face or genitals Dermatologist, Gastroenterologist, Ophthalmologist, Rheumatologist Rheumatoid Arthritis: Failure or clinically significant adverse effects to two of the formulary alternatives: azathioprine, cyclosporine, hydroxychloroquine, leflunomide, methotrexate, or sulfasalazine. Psoriatic arthritis: Failure or clinically significant adverse effects to the formulary alternative: methotrexate. Ankylosing spondylitis: Failure or clinically significant adverse effects to two of the formulary alternatives: celecoxib, diclofenac, indomethacin, naproxen, or sulindac. Plaque psoriasis: Failure or clinically significant adverse effects to two of the formulary alternatives: acitretin, cyclosporine, methotrexate or phototherapy. Crohn's disease and Ulcerative colitis: Failure or clinically significant adverse effects to two of the formulary alternatives: budesonide, mesalamine or sulfasalazine. 157

159 HUMIRA PEDIATRIC CROHNS HUMIRA PEDIATRIC CROHN'S START PA Details Age Other Greater or equal to 6 years of age Gastroenterologist, Pediatrician Until the end of calendar year 158

160 HUMIRA PSORIASIS HUMIRA PEN PSORIASIS-UVEITIS PA Details Age Other Plaque psoriasis: documentation of psoriasis of greater than 5% BSA or affecting crucial body areas such as hands, feet, face or genitals Dermatologist, Rheumatologist, Ophthalmologist, Gastroenterologist Plaque psoriasis: Failure or clinically significant adverse effects to two of the following: acitretin, cyclosporine, methotrexate or phototherapy. 159

161 HYDROXYZINE hydroxyzine hcl intramuscular hydroxyzine hcl oral solution 10 mg/5 ml hydroxyzine pamoate PA Details Age Other Approve if less than 65 years of age. If aged 65 years and older, prior authorization criteria will apply. Urticaria: Failure or clinically significant adverse effects to all of the formulary alternatives: cetirizine and levocetirizine. Nausea and vomiting: Failure or clinically significant adverse effects to two of the formulary alternatives: chlorpromazine, granisetron, ondansetron, or prochlorperazine. Anxiety: Failure or clinically significant adverse effects to two of the formulary alternatives: buspirone, escitalopram, paroxetine, or venlafaxine. Pruritus: Failure or clinically significant adverse effects to one of the formulary topical alternatives: betamethasone or triamcinolone. 160

162 IBANDRONIC ACID ibandronate intravenous solution PA Details Age Other Failure or clinically significant adverse effects to one of the formulary alternatives: alendronic acid, ibandronic acid oral tablet, or risedronate. 161

163 IBRANCE IBRANCE PA Details Age Other Oncologist Until the end of calendar year 162

164 ICLUSIG ICLUSIG ORAL TABLET 15 MG, 45 MG PA Details Age Other Hematologist, Oncologist Failure or clinically significant adverse effects to one of formulary alternatives: Bosulif, Gleevec, Sprycel or Tasigna except when the member has a diagnosis of Chronic Myeloid Leukemia T315l-positive or Ph+ALL T315-positive. 163

165 IDARUBICIN idarubicin PA Details Age Other Oncologist Subject to Part B vs Part D determination. 164

166 IDHIFA IDHIFA PA Details Age Other Documentation of isocitrate dehydrogenase-2 (IDH2) mutation as detected by a FDA approved test Hematologist, Oncologist 165

167 ILARIS ILARIS (PF) SUBCUTANEOUS RECON SOLN PA Details Age Other Concurrent treatment with one of the following: Tumor necrosis factor inhibitors (eg: etanercept, adalimumab, infliximab) or Interleukin-1 inhibitioes (eg: rilonacept, anakinra) Allergist, Immunologist, Rheumatologist 166

168 IMBRUVICA IMBRUVICA ORAL CAPSULE 140 MG PA Details Age Other Hematologist, Oncologist Failure or clinically significant adverse effects to one prior systemic therapy except when the member has a diagnosis of Chronic Lymphocytic Leukemia with 17p deletion. 167

169 IMFINZI IMFINZI PA Details Age Other Oncologist Subject to Part B vs Part D determination. 168

170 IMIPRAMINE imipramine hcl imipramine pamoate PA Details Age Other Approve if less than 65 years of age. If aged 65 years and older, prior authorization criteria will apply. For Depression Only: Failure or clinically significant adverse effects to two of the formulary alternatives: citalopram, escitalopram, fluoxetine, mirtazapine, paroxetine, sertraline, or venlafaxine. 169

171 INCRELEX INCRELEX PA Details Age Other Endocrinologist 170

172 INDOMETHACIN indomethacin oral capsule PA Details Age Other Approve if less than 65 years of age. If aged 65 years and older, prior authorization criteria will apply. Failure or clinically significant adverse effects to two of the formulary alternatives: celecoxib, diclofenac, flurbiprofen, ibuprofen, meloxicam, nabumetone, naproxen, or sulindac. 171

173 INFLECTRA INFLECTRA PA Details Age Other Plaque psoriasis: documentation of psoriasis of greater than 5% BSA or affecting crucial body areas such as hands, feet, face or genitals Dermatologist, Gastroenterologist, Rheumatologist Subject to Part B vs Part D determination. Rheumatoid Arthritis: Failure or clinically significant adverse effects to all of the formulary alternatives: Enbrel and Humira. Crohn's Disease and Ulcerative Colitis: Failure or clinically significant adverse effects to the formulary alternative: Humira. Plaque Psoriasis: Failure or clinically significant adverse effects to all of the formulary alternatives: Enbrel and Humira. Ankylosing spondylitis: Failure or clinically significant adverse effects to all of the formulary alternatives: Enbrel and Humira. Psoriatic arthritis: Failure or clinically significant adverse effects to all of the formulary alternatives: Enbrel and Humira. 172

174 INLYTA INLYTA PA Details Age Other Oncologist Failure or clinically significant adverse effects to one of the formulary alternatives: Afinitor, Avastin, Nexavar, Sutent or Torisel. 173

175 INTRALIPID INTRALIPID INTRAVENOUS EMULSION 30 % PA Details Age Other 3 months. Subject to Part B vs Part D determination. 174

176 INVANZ INVANZ INJECTION PA Details Age Other Infectious disease specialist Subject to Part B vs Part D determination 175

177 INVEGA SUSTENNA INVEGA SUSTENNA PA Details Age Other Failure or clinically significant adverse effects to one of the formulary alternatives: oral Invega or oral risperidone. 176

178 INVEGA TRINZA INVEGA TRINZA PA Details Age Other Failure or clinically significant adverse effects to one of the formulary alternatives: oral paliperidone or oral risperidone and failure or clinically significant adverse effects to the formulary alternative: Invega Sustenna. 177

179 IRESSA IRESSA PA Details Age Other Documentation of EGFR exon 19 deletion or exon 21 (L858R) substitution mutation detected by a FDA approved genetic test Oncologist Until the end of calendar year 178

180 ISOTRETINOIN claravis isotretinoin PA Details Age Other Until the end of calendar year 179

181 ISTODAX ISTODAX PA Details Age Other Hematologist, Oncologist Subject to Part B vs Part D determination 180

182 JAKAFI JAKAFI PA Details Age Other Hematologist, Oncologist Failure or clinically significant adverse effects to t the formulary alternative: hydroxyurea 181

183 JEVTANA JEVTANA PA Details Age Other Documentation of concurrent use of prednisone Oncologist, Urologist Subject to Part B vs Part D determination. 182

184 JUXTAPID JUXTAPID ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG, 5 MG, 60 MG PA Details Age Other Hepatic impairment, moderate or severe (Child-Pugh category B or C) Concurrent use with other lipid-lowering treatments Until the end of calendar year Failure or clinically significant adverse effects to two of the formulary alternatives: atorvastatin, lovastatin, pravastatin, simvastatin, Vytorin, or Zetia. 183

185 KADCYLA KADCYLA PA Details Age Other Documentation of Left Ventricular Ejection Fraction (LVEF) Oncologist Subject to Part B vs Part D determination 184

186 KALYDECO KALYDECO PA Details Age Other Diagnosis of Cystic Fibrosis mutation must be confirmed by DNA testing Until the end of calendar year 185

187 KANUMA KANUMA PA Details Age Other Until the end of calendar year Subject to Part B vs Part D determination 186

188 KEVEYIS KEVEYIS PA Details Age Other Until the end of calendar year Subject to Part B vs Part D determination 187

189 KEYTRUDA KEYTRUDA PA Details Age Other Oncologist Subject to Part B vs Part D determination 188

190 KINERET KINERET PA Details Age Other Pediatrician, Rheumatologist Rheumatoid Arthritis: Failure or clinically significant adverse effects to all of the formulary alternatives: Enbrel and Humira. 189

191 KISQALI KISQALI ORAL TABLET 200 MG/DAY (200 MG X 1), 400 MG/DAY (200 MG X 2), 600 MG/DAY (200 MG X 3) PA Details Age Other Oncologist 190

192 KISQALI FEMARA KISQALI FEMARA CO-PACK PA Details Age Other Documentation of HER2 negative. Documentation of hormone receptor positive. Oncologist 191

193 KORLYM KORLYM PA Details Age Other Concomitant use of simvastatin, lovastatin and CYP3A substrates with narrow therapeutic ranges (e. g. cyclosporine, fentanyl, sirolimus, etc.). History of unexplained vaginal bleeding or endometrial hyperplasia with atypia or endometrial carcinoma. Until the end of calendar year 192

194 KUVAN KUVAN PA Details Age Other 193

195 KYNAMRO KYNAMRO PA Details Age Other Moderate or severe hepatic impairment (Child-Pugh B or C) or active liver disease. Concurrent use with other lipid-lowering treatments Until the end of calendar year Failure or clinically significant adverse effects to two of the formulary alternatives: atorvastatin, lovastatin, pravastatin, simvastatin, Vytorin, or Zetia. 194

196 KYPROLIS KYPROLIS PA Details Age Other Hematologist, Oncologist Subject to Part B vs Part D determination. 195

197 LARTRUVO LARTRUVO PA Details Age Other Oncologist Subject to Part B vs Part D determination. 196

198 LATUDA LATUDA PA Details Age Other Failure or clinically significant adverse effects to two of the formulary alternatives: olanzapine, quetiapine, risperidone or ziprasidone. 197

199 LAZANDA LAZANDA PA Details Age Other Acute or postoperative pain, including headache/migraine or dental pain. Documentation of opioid tolerance taking around-the-clock opioid therapy consisting of at least 60mg of oral morphine daily, at least 25mg transdermal fentanyl/hour, at least 30 mg of oral oxycodone daily, at least 8mg oral hydromorphone daily, at least 25mg oral oxymorphone daily or an equianalgesic dose of another opioid daily for a week or longer for breakthrough pain of cancer. Oncologist, Pain specialist 198

200 LENVIMA LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG X 1/DAY), 14 MG/DAY(10 MG X 1-4 MG X 1), 20 MG/DAY (10 MG X 2), 24 MG/DAY(10 MG X 2-4 MG X 1) PA Details Age Other Oncologist Until the end of calendar year 199