ACITRETIN acitretin Other For prophylaxis of skin cancer in patients with previously treated skin cancers who have undergone an organ transplantation the request will be approved. For psoriasis: the patient has documented adequate trials and/or has another documented medical reason for not using at least 2 of the treatment options listed: topical steroids, Tazorac (tazarotene), methotrexate, and cyclosporine. must be a dermatologist or an oncologist. 1
ACTEMRA ACTEMRA ACTPEN ACTEMRA SUBCUTANEOUS Other Documentation was submitted indicating that the member was evaluated for active or latent TB infection (i.e. tuberculin skin test). Specialist for submitted diagnosis. Trial and failure or medical reason for not using Humira (adalimumab) and Enbrel (etanercept) for appropriate indications. 2
ACTIMMUNE ACTIMMUNE Other 3
ADEMPAS ADEMPAS Other Concomitant use with PDE inhibitor or nitrate therapy Documentation of pulmonary arterial hypertension (PAH) WHO Group classification. For WHO Group I and IV, documentation of PAH Functional Class. Reviewer will verify available patient claim history to confirm patient is not using PDE inhibitors or nitrates. must be a pulmonologist or cardiologist 4
AFINITOR AFINITOR AFINITOR DISPERZ Other Documentation of members treatment history for relevant disease state. Provider attests that patient's complete blood count with differential, liver function, renal function, blood glucose and lipid profile will be monitored for the duration of therapy as indicated in compendia. Provider also attests that for patients who have subependymal giant cell astrocytoma (SEGA) or tuberous sclerosis complex (TSC)-associated partial seizure, whole blood trough concentration will be routinely monitored as indicated in compendia. must be an oncologist or neurologist. 5
ALECENSA ALECENSA Other Provider attests that patient's liver function tests, heart rate and blood pressure will be monitored for the duration of therapy as indicated in compendia. must be an oncologist. 6
ALPHA-1 PROTEINASE INHIBITORS ARALAST NP GLASSIA PROLASTIN-C ZEMAIRA Other Documentation of hereditary alpha1-antitrypsin deficiency as evident by pretreatment serum AAT levels below 11 micrometer/l and progressive FEV1 or FVC decline demonstrating symptomatic lung disease must be a pulmonologist. If the medication request is for an Alpha1-Proteinase Inhibitor (human) product other than Prolastin, the patient has a documented medical reason (such as trial, failure or contraindication) for not using Prolastin to treat their medical condition. 7
ALUNBRIG ALUNBRIG Other Provider attests that blood pressure, heart rate, serum glucose, creatine phosphokinase and lipase & amylase levels will be monitored for the duration of therapy as indicated in compendia. must be an oncologist 8
ANADROL ANADROL-50 Other 9
APOKYN APOKYN Other Apokyn (apomorphine hydrochloride) is contraindicated in concomitant use with serotonin 5-HT3 receptor antagonists. Reviewer will verify available patient claim history to confirm patient is not using 5-HT3 receptor antagonists. If diagnosis is Parkinsons, the patient has a documented trial and failure or intolerance to two formulary alternatives such as entacapone, tolcapone, rasagiline, selegiline, carbidopa/levodopa, bromocriptine, pramipexole or ropinirole. 10
ARCALYST ARCALYST Other 11
ARIPIPRAZOLE LONG ACTING ABILIFY MAINTENA ARISTADA INITIO ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 1,064 MG/3.9 ML, 441 MG/1.6 ML, 662 MG/2.4 ML, 882 MG/3.2 ML Other 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 one of these therapies to manage their medical condition: Invega Sustenna, Invega Trinza or Risperdal Consta. 12
BENLYSTA BENLYSTA SUBCUTANEOUS Other Documentation has been provided indicating the patient has had an adequate trial of two or more of the following agents: glucocorticoids, azathioprine, methotrexate, mycophenolate, or hydroxychloroquine. must be a rheumatologist. 13
BENZNIDAZOLE benznidazole Other Patients who have used disulfiram within two weeks of initiation of benznidazole Documentation of a consultation with an infectious disease specialist. Reviewer will verify available patient claim history to confirm that patient has not used disulfiram within two weeks prior to benznidazole initiation. If all conditions are met, the request will be authorized for 60 days of treatment. 14
BOSULIF BOSULIF Other Provider attests that complete blood count, liver function tests and renal function will be monitored for the duration of therapy as indicated in compendia must be an oncologist. 15
BOTOX BOTOX Other must be an optometrist or ophthalmologist. Patient must have a documented trial and failure or medical reason (intolerance, hypersensitivity or contraindication) for not utilizing intravitreal bevacizumab. 16
BRAFTOVI BRAFTOVI Other Confirmation of BRAF V600E or V600K mutation status with a FDA approved test. must be an oncologist. 17
C1 ESTERASE INHIBITOR CINRYZE HAEGARDA Other Documentation of either trial or a medical reason (e.g. intolerance or hypersensitivity) for not being able to use Danazol to manage their medical condition 18
CABOMETYX CABOMETYX Other Provider attests that urine protein levels and blood pressure will be monitored daily for the duration of therapy as indicated in compendia. must be an oncologist. If all conditions are met the request will be approved until the end of 19
CALQUENCE CALQUENCE Other Provider attests that complete blood cell count will be monitored prior to initiation and throughout duration of therapy as indicated in compendia must be a hematologist or an oncologist. 20
CANCIDAS caspofungin Other Documentation of a consultation with an infectious disease specialist. 21
CARBAGLU CARBAGLU Other 22
CERDELGA CERDELGA Other For Cerdelga requests, patients with undetermined CYP2D6 metabolizer status If request is for Cerdelga, patient's CYP2D6 metabolizer status, as determined by an FDA approved test. For reauthorization, patient must have continued benefit with the use of agent. 23
CGRP ANTAGONISTS AIMOVIG AUTOINJECTOR AIMOVIG AUTOINJECTOR (2 PACK) Other Provider attests that patient has at least 4 migraine days per month or one or more severe migraines lasting for greater than 12 hours despite use of abortive therapy (e.g. triptans or NSAIDs). must be a neurologist. Initial request will be authorized for 6 months. Reauthorization until end of benefit year. For patient newly initiated on CGRP antagonists: Patient must have documented trial and failure, intolerance or a medical reason for not being able to use two medications from the following classes (with each drug belonging to a different class): beta adrenergic blockers, anti-epileptics (topiramate, valproate or divalproex). For reauthorization, patient must have experienced reduction of at least 1 headache day per month within the last month of the initial authorization period. 24
CHOLBAM CHOLBAM Other must be a hepatologist or gastroenterologist. contract year 25
CIMZIA CIMZIA CIMZIA POWDER FOR RECONST CIMZIA STARTER KIT Other Documentation was submitted indicating that the member was evaluated for active or latent TB infection (i.e. tuberculin skin test). Specialist for submitted diagnosis. Trial and failure or medical reason for not using Humira (adalimumab) and Enbrel (etanercept) for appropriate indications. 26
COMETRIQ COMETRIQ Other Provider attests that blood pressure and urine protein will be monitored routinely for the duration of therapy as indicated in compendia must be an oncologist. 27
COPIKTRA COPIKTRA Other Provider attests that complete blood counts, blood chemistries and liver function tests will be completed for the duration of therapy as indicated in compendia. must be an oncologist or a hematologist. 28
CORLANOR CORLANOR Other Blood pressure less than 90/50 mmhg New starts for chronic heart failure must have all of the following: 1) chronic heart failure (NYHA II through IV), have LVEF of 35% or less 2) have sinus rhythm and have resting heart rate greater than or equal to 70 bpm 3) blood pressure greater than or equal to 90/50 mmhg and 4) Tried or is currently receiving beta blocker unless the patient has a contraindication to the use of beta blocker therapy. must be a cardiologist Continuation of therapy for chronic heart failure: decreased number of hospitalizations due to acute heart failure while using Corlanor. 29
COSENTYX COSENTYX COSENTYX (2 SYRINGES) COSENTYX PEN COSENTYX PEN (2 PENS) Other Documentation was submitted indicating that the member was evaluated for active or latent TB infection (i.e. tuberculin skin test). Specialist for submitted diagnosis Trial and failure or medical reason for not using Humira (adalimumab) and Enbrel (etanercept) for appropriate indications. 30
COTELLIC COTELLIC Other Provider attests that LVEF, SCr, CPK, LFTs have been assessed, and dermatologic and ophthalmologic evaluations have been performed prior to initiation of therapy, and will be routinely assessed throughout the duration of therapy as indicated in compendia. Additionally, for appropriate indications confirmation of BRAF V600K or V600E mutation status with an FDA approved test. must be an oncologist. 31
CUBICIN daptomycin Other Documentation of a consultation with an infectious disease specialist. 32
CYSTAGON CYSTAGON Other 33
DALFAMPIRIDINE ER dalfampridine Other History of seizure. If diagnosis is RRMS, documentation has been provided that member is ambulatory (able to walk at least 25 feet), has a documented walking impairment, and is currently being treated with a disease modifying agent (e.g. immunomodulator, interferon, etc) or has a medical reason why member is unable to use a disease modifying agent for their condition. For all other types of MS, only documentation that member is ambulatory with a documented walking impairment is required. must be a neurologist. For re-authorization, member must experience improvement in walking due to use of dalfampiridine ER. 34
DAURISMO DAURISMO Other Provider attests that ECG and blood chemistries including electrolytes will be completed prior to initiation of therapy as indicated in compendia. must be an oncologist or hematologist. 35
DEFERASIROX EXJADE JADENU JADENU SPRINKLE Other Patients with serum creatinine greater than 2 times the age-appropriate upper limit of normal or creatinine clearance less than 40ml/min, patients with platelet counts less than 50,000/mm3 For diagnosis of chronic iron overload due to transfusions: laboratory result within 30 days of request for serum ferritin concentration is greater than 1000 mcg/l, platelet count, SCr and CrCl. For diagnosis of chronic iron overload in nontransfusion-dependent thalassemia syndromes: laboratory results with 30 days of request for serum ferritin concentration is greater than 300mcg/L, platelet counts, SCr and CrCl. 36
DEMSER DEMSER Other Documentation of one of the following: 1)Concurrent use of alpha adrenergic blockers 2) medical reason for being unable to use an alpha adrenergic blocker OR 3)patient is not a candidate for surgical resection and requires long term treatment with Demser 37
DEPEN DEPEN TITRATABS Other Specialist for submitted diagnosis. Trial and failure or medical reason for not using Humira (adalimumab) and Enbrel (etanercept) for appropriate indications. 38
DEPO-PROVERA DEPO-PROVERA INTRAMUSCULAR SUSPENSION 400 MG/ML Other must be a gynecologist, family practice or an oncologist. 39
DIFICID DIFICID Other If all conditions are met, the request will be authorized for 10 days Documentation of prior use, or a medical reason for being unable to use oral vancomycin for current infection. 40
DOPTELET DOPTELET DOPTELET (10 TAB PACK) DOPTELET (15 TAB PACK) Other Provider attests that complete blood count with differential will be monitored throughout the duration of the therapy as indicated in compendia. If all conditions are met, the request will be authorized for 5 days. 41
DORIPENEM doripenem intravenous recon soln 500 mg Other If all conditions are met, the request will be authorized for 14 days of treatment. 42
DUPIXENT DUPIXENT Other must be a dermatologist, immunologist allergist, pulmonologist Documented trial and failure or medical reason (e.g. very large surface area affected by atopic dermatitis) for not using the following therapies: 1) topical tacrolimus or Elidel and 2) Eucrisa. For diagnosis of asthma: documentation that symptoms are not adequately controlled with highdose inhaled corticosteroid (ICS) plus long-acting beta2-agonist (LABA) for at least 3 months or medical reason has been provided indicating why a patient is not able to utilize a high-dose inhaled corticosteroid (ICS) plus long-acting beta2-agonist (LABA) to treat their medical condition. 43
EGRIFTA EGRIFTA Other Documentation of active antiretroviral therapy for at least 8 weeks. 44
ENBREL ENBREL ENBREL MINI ENBREL SURECLICK Other Documentation was submitted indicating that the member was evaluated for active or latent TB infection (i.e. tuberculin skin test). Specialist for submitted diagnosis. Trial and failure or medical reason for not using the following if applicable for submitted diagnosis: 1) For Rheumatoid Arthritis, Psoriatic Arthritis, or Juvenile Idiopathic Arthritis: one DMARD (e.g. methotrexate, sulfasalazine, generic leflunomide (Arava), etc.), 2) For Ankylosing Spondylitis: two nonsteroidal anti-inflammatory drugs (NSAIDS), 3) For Plaque Psoriasis one of the following: topical steroids, topical calcipotriene, Tazorac (tazorotene), Methotrexate, UVB phototherapy and/or PUVA therapy. 45
ENDARI ENDARI Other Documentation that patient has had two or more painful sickle cell crises within the past 12 months and that they have been taking hydroxyurea for the past three months or longer. must be a hematologist. 46
EPIDIOLEX EPIDIOLEX Other Provider attests that liver function tests and bilirubin levels will be completed for the duration of therapy as indicated in compendia. must be neurologist. 47
ERAXIS ERAXIS(WATER DILUENT) Other Documentation of a consultation with an infectious disease specialist. If all conditions are met, the request will be approved for up to 42 days of treatment per request. 48
ERIVEDGE ERIVEDGE Other must be an oncologist or dermatologist 49
ERLEADA ERLEADA Other For appropriate indication(s) patient must have history of bilateral orchiectomy or must be concurrently using Erleada with gonadotropinreleasing hormone (GnRH). must be an oncologist. 50
ERTAPENEM ertapenem Other 51
ERYTHROPOETIN STIMULATING AGENTS ARANESP (IN POLYSORBATE) EPOGEN INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML PROCRIT Other Laboratory results within 30 days of request: Hemoglobin If all conditions are met, the request will be authorized for 6 months. For initial therapy, the Hgb must be less than 10g/dL for all indications or within compendia range for treatment of the requested medical condition. If the request is for Aranesp, the provider submitted a documented medical reason (i.e. intolerance, contraindication, hypersensitvity) why they are unable to use Epogen or Procrit. For re-authorization, Hgb must not exceed 10g/dL(cancer), 12g/dL(zidovudine-treated HIV patients), 10 to 13g/dL(Elective, noncardiac, nonvascular surgery needing red blood cell allogeneic transfusion reduction). 52
ESBRIET ESBRIET Other must be an pulmonologist. 53
EUCRISA EUCRISA Other must be a dermatologist, immunologist or an allergist Documented trial and failure or medical reason (e.g. intolerance or hypersensitivity) for not using the following therapies: Topical tacrolimus or Elidel. 54
FARESTON FARESTON toremifene Other Provider attests that complete blood count, electrolytes levels (including magnesium, potassium and calcium), and liver function tests will be monitored for the duration of therapy as indicated in compendia. must be an oncologist. Patient must have documented trial and failure or intolerance to tamoxifen. 55
FARYDAK FARYDAK Other Documentation of prior treatment history for related indications. Provider attests that complete blood count with differential and platelets, serum electrolytes (including potassium, magnesium, and phosphate), liver function tests and ECG monitoring will be completed for the duration of therapy as indicated in compendia. must be an oncologist or a hematologist 56
FENTANYL CITRATE ORAL TRANSMUCOSAL fentanyl citrate Other If all conditions are met, the request will be authorized for 6 months. Patient is currently receiving long-acting opioid therapy. 57
FERRIPROX FERRIPROX ORAL TABLET Other For initial therapy, documentation of the patient's serum ferritin level above 2,500 mcg/l and absolute neutrophil count (ANC) greater than 1.5x10^9/L within 30 days of request. For continuation of therapy, approve if the patient is benefiting from therapy as confirmed by the prescribing provider. 58
FIRAZYR FIRAZYR Other 59
FIRDAPSE FIRDAPSE Other History of seizures. must be a neurologist. 60
FORTEO FORTEO Other Documentation showing patient falls into one of the following categories:postmenopausal woman who has a bone mineral density (BMD) value consistent with osteoporosis (i.e., T-scores equal to or less than -2.5) or postmenopausal woman who has had an osteoporotic fracture.postmenopausal woman who has T-scores from -1.5 to -2.5 and at least one of the following risk factors for fracture: thinness [low body mass index (less than 21 kg/m2)], history of fragility fracture since menopause, or history of hip fracture in a parent. Male greater than or equal to 65 years of age with T-score of -2.5 or less. Male less than 65 years of age with T-score of -2.5 or less and 2 or more risk factors for fractures or previous osteoporotic fracture. In addition, the following criteria is also applicable:the patient has a documented treatment failure or has a documented medical reason (intolerance, hypersensitivity, contraindication, etc) for not utilizing an oral bisphosphonate to manage their medical condition AND The therapy does not exceed the therapy maximum of 2 years. 61
GALAFOLD GALAFOLD Other 62
GATTEX GATTEX 30-VIAL GATTEX ONE-VIAL Other Documentation that patient is dependent on parenteral support Provider is a gastroenterologist 63
GILOTRIF GILOTRIF Other Provider attests that liver function monitoring will be completed for the duration of therapy as indicated in compendia. For appropriate indications, documentation of the FDA-approved test results confirming EGFR mutation status were submitted. must be an oncologist. 64
GLEOSTINE GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG Other Provider attests that complete blood count with differential, liver function tests, renal function tests and pulmonary function tests will be completed for the duration of therapy as indicated in compendia. must be an oncologist or hematologist. 65
GNRH AGONISTS ELIGARD ELIGARD (3 MONTH) ELIGARD (4 MONTH) ELIGARD (6 MONTH) FIRMAGON KIT W DILUENT SYRINGE FIRMAGON SUBCUTANEOUS RECON SOLN 120 MG LUPRON DEPOT LUPRON DEPOT (3 MONTH) LUPRON DEPOT (4 MONTH) LUPRON DEPOT (6 MONTH) LUPRON DEPOT-PED (3 MONTH) INTRAMUSCULAR SYRINGE KIT 11.25 MG LUPRON DEPOT-PED INTRAMUSCULAR KIT 7.5 MG (PED) TRELSTAR Other If the medication request is for the treatment of prostate cancer and if the request is for any other GnRH agonist other than Eligard, the patient must have a documented treatment failure after receiving an trial of Eligard and/or has another documented medical reason for not utilizing Eligard to treat their prostate cancer. 66
GOCOVRI GOCOVRI Other Initial request: documented trial and failure or medical reason for not using generic amantadine. must be a neurologist. Initial request will be authorized for 3 months. Reauthorization until end of Re-authorization: confirmation of improvement in levodopa-induced dyskinesia due to use of Gocovri 67
GROWTH HORMONES GENOTROPIN GENOTROPIN MINIQUICK HUMATROPE NORDITROPIN FLEXPRO NUTROPIN AQ NUSPIN OMNITROPE Other for new starts for growth hormone deficiency: Growth Hormone Stimulation Test results, Insulin Growth Factor 1 level, bone age testing, MRI of brain to rule out tumor, height, and weight. All other medically accepted uses can be approved. must be Endocrinologist Initial request will be authorized for 6 months. Reauthorization until end of for continuation of therapy for growth hormone deficiency: medical records showing positive response to treatment. 68
H. P. ACTHAR ACTHAR H.P. Covered Uses Other All medically-accepted indications not otherwise excluded from Part D For initial MS exacerbation, rheumatic disorders, collagen diseases, dermatologic diseases, serum sickness, ophthalmic disease and respiratory diseases, documentation was submitted indicating trials and/or a documented medical reason (e.g. intolerance, hypersensitivity or contraindication) for not utilizing high-dose parenteral corticosteroids to manage their medical condition. For Infantile spasms and MS exacerbation: neurologist. For Rheumatic Disorders and Collagen Diseases: rheumatologist. For Dermatologic: dermatologist. For Allergic state: allergist, immunologist. For Ophthalmic disease: optometrist, ophthalmologist. Respiratory diseases: pulmonologist. For Edematous state: nephrologist, rheumatologist. MS exacerbation: 1 month. Other conditions: initial for 3 months and reauth end of Reauthorization : 1) For continuation of therapy for MS exacerbation, documentation of symptom improvement and confirmation that member is currently maintained on multiple sclerosis drugs such as Copaxone, Avonex, or Aubagio. 2) For all other conditions, documented evidence of disease response to treatment as indicated by improvement in symptoms. 69
HEPSERA adefovir Other For the diagnosis of hepatitis B:Submitted current (within 30 days of request) laboratory values indicating evidence of active viral replication. Submitted current laboratory values indicating persistent elevations in ALT or AST or histologically active disease. Clinical evidence of Lamivudine-resistant hepatitis B virus or documented treatment failure with Lamivudine therapy. 70
HETLIOZ HETLIOZ Other Provider is a sleep specialist or neurologist. 71
HEXALEN HEXALEN Other Provider attests that complete blood count with differential and neurologic examination will be completed for the duration of therapy as indicated in compendia. must be an oncologist. 72
HIGH DOSE OPIOID fentanyl transdermal patch 72 hour 100 mcg/hr methadone oral tablet 10 mg morphine oral tablet extended release 100 mg, 200 mg oxycodone oral tablet,oral only,ext.rel.12 hr Covered Uses Other All medically-accepted indications not otherwise excluded from Part D NEW START: ONE of the following (A) pain associated with cancer or sickle cell disease OR (B) chronic non-cancer pain and member has ALL of the following: (1) documented trial and failure and/or intolerance to two non-opioid containing pain medications (ex. NSAIDs, antidepressants, etc.) (2)current regimen is the lowest possible effective dose of opioid therapy (3) member is not being treated for substance abuse (4) if member is on concurrent benzodiazepines and/or muscle relaxant therapy, the prescriber should provide attestation of an intent to monitor side effects AND provide documentation that patient counseling has and will continue to take place outlining the risks and potential side effects of concurrent use of benzodiazepines, opioids and/or muscle relaxants. CONTINUING THERAPY: ONE of the following: (A) pain associated with cancer or sickle cell disease OR (B) chronic non-cancer pain and ALL of the following: (1) member's pain has been assessed within the last 6 months (2) member is not being treated for substance abuse (3) if member is on concurrent benzodiazepines and/or muscle relaxant therapy, the prescriber provides attestation of an intent to monitor 73
side effects AND provide documentation that patient counseling has and will continue to take place outlining the risks and potential side effects of concurrent use. 74
HIGH RISK MEDICATION amitriptyline benztropine oral chlorzoxazone oral tablet 500 mg clemastine oral tablet 2.68 mg clomipramine COMFORT PAC-CYCLOBENZAPRINE CYCLOTENS REFILL CYCLOTENS STARTER cyproheptadine dexmethylphenidate dextroamphetamine oral capsule, extended release 10 mg, 15 mg, 5 mg dextroamphetamine oral tablet 10 mg, 5 mg dextroamphetamine-amphetamine oral capsule,extended release 24hr dextroamphetamine-amphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 30 mg, 5 mg, 7.5 mg dihydroergotamine injection dipyridamole oral disopyramide phosphate oral capsule doxepin oral ergoloid estropipate oral tablet 0.75 mg glyburide micronized oral tablet 1.5 mg, 3 mg, 6 mg glyburide oral tablet 1.25 mg, 2.5 mg, 5 mg glyburide-metformin oral tablet 1.25-250 mg, 2.5-500 mg, 5-500 mg guanfacine oral tablet hydroxyzine hcl oral solution 10 mg/5 ml hydroxyzine hcl oral tablet hydroxyzine pamoate imipramine hcl imipramine pamoate indomethacin oral ketorolac oral megestrol oral suspension 400 mg/10 ml (10 ml), 400 mg/10 ml (40 mg/ml), 625 mg/5 ml megestrol oral tablet MENEST ORAL TABLET 0.3 MG, 0.625 MG, 1.25 MG meperidine oral solution meperidine oral tablet methocarbamol oral methyldopa methyldopa-hydrochlorothiazide methylphenidate hcl oral capsule, er biphasic 30-70 methylphenidate hcl oral capsule,er biphasic 50-50 20 mg, 30 mg, 40 mg, 60 mg methylphenidate hcl oral solution methylphenidate hcl oral tablet methylphenidate hcl oral tablet extended release 10 mg, 20 mg methylphenidate hcl oral tablet extended release 24hr 18 mg, 27 mg, 36 mg, 54 mg methylphenidate hcl oral tablet,chewable nifedipine oral capsule NORPACE CR orphenadrine citrate oral pentazocine-naloxone perphenazine-amitriptyline promethazine oral promethazine rectal suppository 12.5 mg, 25 mg PROMETHAZINE VC promethazine-phenylephrine PROMETHEGAN RECTAL SUPPOSITORY 50 MG thioridazine trihexyphenidyl trimethobenzamide oral trimipramine 75
Other For patients 65 years old and older: The prescriber has documented the indication for the use of the high risk medication with an explanation of the specific benefit with the medication, and how that benefit outweighs the potential risk. The prescriber provides attestation of an intent to monitor side effects AND The prescriber must document that patient counseling has and will continue to take place outlining the risks and potential side effects of the medication. If the patient is 64 years old or younger, the request will be approved. If the patient is 65 years old or older, the patient will require prior authorization for the drug. 76
HIGH RISK MEDICATION, BUTALBITAL ASCOMP WITH CODEINE BUTALBITAL COMPOUND W/CODEINE butalbital-acetaminop-caf-cod oral capsule 50-325-40-30 mg butalbital-acetaminophen oral tablet 50-325 mg butalbital-acetaminophen-caff oral capsule 50-325-40 mg butalbital-acetaminophen-caff oral tablet 50-325-40 mg butalbital-aspirin-caffeine oral capsule codeine-butalbital-asa-caff Other For patients 65 years old and older: The prescriber has documented the indication for the use of the high risk medication with an explanation of the specific benefit with the medication, and how that benefit outweighs the potential risk. The prescriber provides attestation of an intent to monitor side effects AND The prescriber must document that patient counseling has and will continue to take place outlining the risks and potential side effects of the medication. Additionally, documentation was submitted of adequate trials and/or medical reason (e.g. intolerance or hypersensitivity) for not utilizing this therapy to manage their medical condition: one formulary oral NSAID If the patient is 64 years old or younger, the request will be approved. If the patient is 65 years old or older, the patient will require prior authorization for the drug. 77
HIGH RISK MEDICATION, DIGOXIN DIGITEK ORAL TABLET 250 MCG DIGOX ORAL TABLET 250 MCG digoxin oral solution 50 mcg/ml digoxin oral tablet 250 mcg Other For patients 65 years old and older: Patient must have documented trial and failure to doses up to 0.125mg per day OR the prescriber has documented the indication for the use of doses greater than 0.125mg per day. The prescriber provides attestation of an intent to monitor side effects AND The prescriber must document that patient counseling has and will continue to take place outlining the risks and potential side effects of the medication. If the patient is 64 years old or younger, the request will be approved. If the patient is 65 years old or older, the patient will require prior authorization for the drug. 78
HIGH RISK MEDICATION, SHORT TERM MUSCLE RELAXANT carisoprodol carisoprodol-asa-codeine carisoprodol-aspirin cyclobenzaprine oral tablet 10 mg, 5 mg Other For patients 65 years old and older: The prescriber has documented the indication for the use of the high risk medication with an explanation of the specific benefit with the medication, and how that benefit outweighs the potential risk. The prescriber provides attestation of an intent to monitor side effects AND The prescriber must document that patient counseling has and will continue to take place outlining the risks and potential side effects of the medication. If the patient is 64 years old or younger, the request will be approved. If the patient is 65 years old or older, the patient will require prior authorization for the drug. If all conditions are met, the request will be authorized for 30 days. 79
HUMIRA HUMIRA HUMIRA PEDIATRIC CROHNS START HUMIRA PEN HUMIRA PEN CROHNS-UC-HS START HUMIRA PEN PSOR-UVEITS-ADOL HS HUMIRA(CF) HUMIRA(CF) PEDI CROHNS STARTER HUMIRA(CF) PEN HUMIRA(CF) PEN CROHNS-UC-HS HUMIRA(CF) PEN PSOR-UV-ADOL HS Other Documentation was submitted indicating that the member was evaluated for active or latent TB infection (i.e. tuberculin skin test). Specialist for submitted diagnosis. For Hidradenitis suppurativa: confirmation of Hurley Stage II or III disease. Trial and failure or medical reason for not using the following if applicable for submitted diagnosis: 1) For Rheumatoid Arthritis, Psoriatic Arthritis, or Juvenile Idiopathic Arthritis: one DMARD (e.g. methotrexate, sulfasalazine, generic leflunomide (Arava), etc.), 2) For Ankylosing Spondylitis: two nonsteroidal anti-inflammatory drugs (NSAIDS), 3) For Plaque Psoriasis: one of the following: moderate to high potency topical steroids, topical calcipotriene, Tazorac (tazorotene), Methotrexate, UVB phototherapy and/or PUVA therapy. 4) For Crohns Disease and Ulcerative Colitis: one conventional oral therapy (e.g. azathioprine, sulfasalazine, prednisone, mesalamine products). 5) For Non-infectious Uveitis: one ophthalmic corticosteroid. 80
IBRANCE IBRANCE Other For diagnosis of breast cancer, documentation of specific type of cancer (e.g. HR-positive, HER2-negative). Provider attests that complete blood count with differential test will be completed for the duration of therapy as indicated in compendia. must be an oncologist. 81
ICLUSIG ICLUSIG Other Provider attests that complete blood count with differential, liver function tests, serum lipase, cardiac function and blood pressure will be monitored for the duration of therapy as indicated in compendia. must be an oncologist or hematologist. 82
IDHIFA IDHIFA Other Provider attests that complete blood count and serum potassium, phosphate, calcium and uric acid levels will be monitored throughout the duration of the therapy as indicated in compendia. For appropriate indications, confirmation of IDH2 mutation status prior to treatment initiation. must be an oncologist or hematologist. 83
IMATINIB imatinib Other Provider attests that complete blood count with differential and liver function tests will be completed for the duration of therapy as indicated in compendia. must be an oncologist or hematologist. 84
IMBRUVICA IMBRUVICA Other Provider attests that complete blood count with differential will be completed for the duration of therapy as indicated in compendia. must be an oncologist, hematologist or transplant specialist. 85
INCRELEX INCRELEX Other 86
INLYTA INLYTA Other Provider attests that liver function tests, thyroid function, blood pressure and urinalysis will be completed for the duration of therapy as indicated in compendia. must be an oncologist. 87
INTRAVITREAL INJECTIONS EYLEA LUCENTIS MACUGEN Other must be an optometrist or ophthalmologist. Patient must have a documented trial and failure or medical reason (intolerance, hypersensitivity or contraindication) for not utilizing intravitreal bevacizumab. 88
INTRON-A INTRON A INJECTION Other 89
IRESSA IRESSA Other Provider attests that liver function monitoring will be completed for the duration of therapy as indicated in compendia. For appropriate indications, documentation of the FDA-approved test results confirming mutation were submitted. must be an oncologist. 90
JAKAFI JAKAFI Other Provider attests that complete blood count and lipid profile monitoring will be completed for the duration of therapy as indicated in compendia. must be an oncologist or a hematologist 91
JUXTAPID JUXTAPID Other Patients with moderate or severe hepatic impairment (Child- Pugh B or C) or active liver disease. Documentation of treatment history, trial and failure after three months with Repatha AND THEN Kynamro (mipomersen), or has a documented medical reason (e.g. intolerance, hypersensitivity or contraindication) for not utilizing these therapies to manage their condition. In addition, a fasting lipid panel report with abnormal LDL cholesterol results (over 70mg/dL) and baseline LFTs and bilirubin, along with patient's Child Pugh Score are required within 90 days of request. must be a cardiologist, specialist in treatment of lipid disorders or endocrinologist. 92
JYNARQUE JYNARQUE Other Provider attests that transaminases and bilirubin will be monitored prior to initiation and throughout duration of therapy as indicated in compendia. must be a nephrologist. 93
KALYDECO KALYDECO Other Combination use with Orkambi Documentation of cystic fibrosis mutation. must be a pulmonologist 94
KEVEYIS KEVEYIS Other Initial request: 1) Provider attests that serum potassium and serum bicarbonate will be monitored for the duration of therapy as indicated in compendia 2) Documentation has been provided that the patient has tried and failed or has a documented medical reason for not utilizing acetazolamide. must be a geneticist, neurologist, or endocrinologist. Initial request will be authorize for 2 months. Reauthorization until end of Reauthorization requires documentation of clinical improvement with therapy. Provider attests that serum potassium and serum bicarbonate will be monitored for the duration of therapy as indicated in compendia 95
KINERET KINERET Other Specialist for submitted diagnosis. Trial and failure or medical reason for not using Humira (adalimumab) and Enbrel (etanercept) for appropriate indications. 96
KISQALI KISQALI KISQALI FEMARA CO-PACK Other Provider attests that complete blood count with differential, liver function test, serum electrolytes and ECG monitoring will be completed for the duration of therapy as indicated in compendia. must be an oncologist. 97
KORLYM KORLYM Other For all members patient must not be currently on simvastatin, lovastatin, cyclosporine, dihydroergotamine, ergotamine, fentanyl, pimozide, quididine, sirolimus, and tacrolimus. Reviewer will verify available claim history to confirm member is not taking simvastatin, lovastatin, cyclosporine, dihydroergotamine, ergotamine, fentanyl, pimozide, quididine, sirolimus or tacrolimus concurrently with Korylm. 98
KUVAN KUVAN Other For initial therapy, documentation of elevated baseline phenylalanine levels Initial request will be authorized for 3 months. Reauthorization until end of contract year Reauthorization criteria: prescriber has confirmed improvement in phenylalanine levels from baseline 99
KYNAMRO KYNAMRO Other Patients with moderate or severe hepatic impairment (Child- Pugh B or C) or active liver disease Documentation of treatment history, trial and failure after three months with Repatha or has a documented medical reason (e.g. intolerance, hypersensitivity or contraindication) for not utilizing Repatha to manage their condition. In addition, a fasting lipid panel report with abnormal LDL cholesterol results (over 70mg/dL) and baseline ALT/AST and bilirubin results, along with patient's Child Pugh Score are required within 90 days of request. must be a cardiologist or specialist in treatment of lipid disorders. 100
LAZANDA LAZANDA NASAL SPRAY,NON-AEROSOL 100 MCG/SPRAY, 300 MCG/SPRAY, 400 MCG/SPRAY Other This product must not be used in opioid intolerant patients and contraindicated in the management of acute or postoperative pain. The patient is currently receiving and tolerant to opioid therapy for chronic pain. Patient is unable to swallow, has dysphagia, esophagitis, mucositis, or uncontrolled nausea/vomiting. Patient must have documented trial and failure or intolerance to fentanyl citrate oral transmucosal. 101
LENVIMA LENVIMA Other Provider attests that liver function, renal function, thyroid function will be monitored for the duration of therapy as indicated in compendia. must be an oncologist. 102
LETAIRIS LETAIRIS Other Documentation of pulmonary arterial hypertension (PAH) WHO Group classification and PAH Functional Class. must be a pulmonologist or cardiologist 103
LIDOCAINE PATCH lidocaine topical adhesive patch,medicated Other 104
LONSURF LONSURF Other Provider attests that complete blood count including differential and absolute neutrophil count will be monitored for the duration of therapy as indicated in compendia. must be an oncologist. 105
LORBRENA LORBRENA Other Provider attests that ECG, serum cholesterol and triglycerides will be completed prior to initiation of therapy as indicated in compendia. must be an oncologist. 106
LUCEMYRA LUCEMYRA Other If all conditions are met, the request will be authorized for 14 days. Patient must have documented trial and failure or intolerance to clonidine. Reauthorization criteria: chart notes that show positive response to prior treatment. 107
LYNPARZA LYNPARZA Other Provider attests that CBC and renal function will be monitored for the duration of therapy as indicated in compendia. For appropriate indications, documentation FDA approved test confirming BRCA mutation. Documentation of patient's treatment history for related conditions. must be an oncologist. 108
MAVYRET MAVYRET Other Labs within 3 months of request: ALT/AST, detectable HCV RNA viral load. In addition, documentation of genotype, treatment history, and if cirrhotic, documentation of compensated or decompensated cirrhosis. must be a hepatologist, gastroenterologist, infectious disease specialist, nephrologist or transplant specialist. If all conditions are met, request will be authorized for 8-16 weeks as per AASLD-IDSA guidance. 109
MEKINIST MEKINIST Other Provider attests that CBC, liver function and LVEF will be monitored for the duration of therapy as indicated in compendia. For appropriate indications, documentation of FDA approved mutation testing was submitted confirming the presence of BRAF V600E or V600K mutations. must be an oncologist. 110
MEKTOVI MEKTOVI Other Provider attests that liver function test and LVEF will be completed for the duration of therapy as indicated in compendia. Additionally, confirmation of BRAF V600E or V600K mutation status with a FDA approved test. must be an oncologist. 111
METHYLTESTOSTERONE methyltestosterone oral capsule Other 112
MULTIPLE SCLEROSIS AGENTS AUBAGIO BETASERON SUBCUTANEOUS KIT BETASERON SUBCUTANEOUS RECON SOLN EXTAVIA SUBCUTANEOUS RECON SOLN GILENYA ORAL CAPSULE 0.5 MG glatiramer GLATOPA REBIF (WITH ALBUMIN) REBIF REBIDOSE REBIF TITRATION PACK TECFIDERA Other must be a neurologist. If the medication request is for glatiramer or Aubagio, the request will be approved. If the medication is not for glatiramer or Aubagio, will require documentation showing trial of two of the following agents: Aubagio and glatiramer OR the patient has another documented medical reason (intolerance, hypersensitivity, etc) for not taking any of these therapies to manage their medical condition. 113
MYCAMINE MYCAMINE Other If all conditions are met, the request will be approved for 12 weeks 114
NATPARA NATPARA Other Documentation of serum calcium greater than 7.5 mg/dl and vitamin D level (within 30 days of request). Provider is an endocrinologist. 115
NERLYNX NERLYNX Other attests that liver function tests will be assessed prior to initiation and throughout the duration of therapy as indicated in compendia. must be an oncologist. 116
NEXAVAR NEXAVAR Covered Uses Other All medically accepted indications not otherwise excluded from Part D Provider attests that liver function and blood pressure will be monitored for the duration of therapy as indicated in compendia. must be an oncologist. 117
NINLARO NINLARO Other Provider attests that liver function and platelet counts will be monitored for the duration of therapy as indicated in compendia. must be an oncologist or a hematologist 118
NITISINONE ORFADIN Other 119
NITYR NITYR Other 120
NOCTIVA NOCTIVA Other Provider attests that egfr and serum sodium will be monitored throughout the duration of the therapy, and that the patient does not have baseline hyponatremia or primary nocturnal enuresis. must be a urologist If all conditions are met, the request will be authorized for the contract year For patients newly starting on Noctiva: For respective indications, patient must have shown either a lack of benefit during trial of one of the following medications, or is experiencing nocturia unrelated to any of the following etiologies. Nocturia secondary to lower urinary tract symptoms or benign prostate enlargement: trial of alpha adrenergic antagonists (e.g. tamsulosin, alfuzosin). Nocturia secondary to benign prostate hyperplasia: trial of alpha adrenergic antagonist and 5-alpha reductase inhibitor (e.g. finasteride). Nocturia due to nocturnal polyuria: trial of bumetanide during daytime. Nocturia secondary to overactive bladder: trial of an antimuscarinic agent (e.g. oxybutynin). 121
NON-AMPHETAMINE CENTRAL NERVOUS SYSTEM AGENTS armodafinil modafinil Other 122
NOXAFIL NOXAFIL ORAL Other Documentation of a consultation with an infectious disease specialist. 28 days for oropharyngeal candidiasis, end of contract year for other indications For treatment of oropharyngeal candidiasis, there must be documentation of either at least a one week trial or a medical reason (e.g. intolerance, known resistance, hypersensitivity) for not being able to use one of the following agents: fluconazole or itraconazole 123
NUEDEXTA NUEDEXTA Other 124
NUPLAZID NUPLAZID ORAL CAPSULE NUPLAZID ORAL TABLET 10 MG, 17 MG Other 125
OCALIVA OCALIVA Other Members with complete biliary obstruction. Initial for primary biliary cholagnitis (PBC): 1) member has failed at least a 12 month trial of ursodiol, or a medical reason was submitted (e.g. intolerance, hypersensitivity) that the member is unable to tolerate ursodiol, 2) lab results for baseline ALT/AST, alkaline phosphatase (ALP), bilirubin, and lipid profile within 90 days of request. Reauthorization for primary biliary cholangitis (PBC): repeat ALT/AST, ALP, bilirubin and lipid profile within 30 days of request with improvement in at least ALP and/or bilirubin values. must be a gastroenterologist, hepatologist, or transplant specialist. Initial request will be authorized for 4 months. Reauthorization until end of 126
OCTREOTIDE ACETATE octreotide acetate injection solution SOMATULINE DEPOT SUBCUTANEOUS SYRINGE 120 MG/0.5 ML, 60 MG/0.2 ML, 90 MG/0.3 ML Other If criteria are met, a prior authorization for the generic octreotide will be approved. Otherwise, documentation showing an adverse event or inadequate response associated with use of the generic agent must be submitted for review. 127
ODOMZO ODOMZO Other Provider attests that serum creatine kinase levels and renal function will be monitored for the duration of therapy as indicated in compendia. must be an oncologist. 128
OFEV OFEV Other Documentation was provided including ALT/AST and bilirubin within 30 days of request. If diagnosis is idiopathic pulmonary fibrosis, member must have documented trial of Esbriet or provide medical justification (e.g. intolerance or hypersensitivity) for not utilizing Esbriet. must be a pulmonologist 129
ORAL ANTIPSYCHOTICS FANAPT ORAL TABLET FANAPT ORAL TABLETS,DOSE PACK LATUDA ORAL TABLET 120 MG, 20 MG, 40 MG, 60 MG, 80 MG VRAYLAR ORAL CAPSULE VRAYLAR ORAL CAPSULE,DOSE PACK Other For a diagnosis of schizophrenia and manic or mixed episodes associated with bipolar l disorder, the patient must have documented trial and failure or intolerance to two formulary generic antipsychotics (aripiprazole, risperidone, olanzapine, quetiapine, or ziprasidone) and Saphris. For major depressive disorder associated with bipolar l disorder, the patient must have documented trial and failure or intolerance to two formulary generic antipsychotics (aripiprazole, risperidone, olanzapine, quetiapine, or ziprasidone). 130
ORENCIA ORENCIA ORENCIA (WITH MALTOSE) ORENCIA CLICKJECT Other Documentation was submitted indicating that the member was evaluated for active or latent TB infection (i.e. tuberculin skin test). Specialist for submitted diagnosis. Trial and failure or medical reason for not using Humira (adalimumab) and Enbrel (etanercept) for appropriate indications. 131
ORKAMBI ORKAMBI ORAL GRANULES IN PACKET ORKAMBI ORAL TABLET Other Combination use with Kalydeco Documentation of cystic fibrosis mutation. must be an pulmonologist. 132
ORLISSA ORILISSA Other must be an OB/GYN. Patient must have documentation of trial and failure, intolerance, or contraindication of at least two of following classes used concurrently for the treatment of endometriosis: analgesic pain reliever (e.g. NSAIDs, COX-2 inhibitors) AND either combined estrogen-progestin oral contraceptive, progestin (e.g. medroxyprogesterone acetate, norethindrone), gonadotropin-releasing hormone (GnRH) agonists (e.g. Lupron Depot), OR danazol. For reauthorization, patient must have continued benefit with use of agent. 133
OTEZLA OTEZLA OTEZLA STARTER Other Trial and failure or medical reason for not using Humira (adalimumab) and Enbrel (etanercept) for appropriate indications. Specialist for submitted diagnosis. 134
OXERVATE OXERVATE Other must be an ophthalmologist. If all conditions are met, the request will be authorized for 8 weeks. 135
OXSORALEN ULTRA methoxsalen Other Patient must have documented trial and failure or intolerance to methotrexate. 136
OXYCODONE ER oxycodone oral tablet,oral only,ext.rel.12 hr Covered Uses All medically accepted indications not otherwise excluded from Part D Other NEW START: Patient must meet ALL of the following criteria: (1) patient has a documented trial and failure or intolerance to two formulary long-acting pain medications (2) member is not being treated for substance abuse (3) if member is on concurrent benzodiazepines and/or muscle relaxant therapy, the prescriber should provide attestation of an intent to monitor side effects AND provide documentation that patient counseling has and will continue to take place outlining the risks and potential side effects of concurrent use of benzodiazepines, opioids and/or muscle relaxants AND (4) member has documented history of receiving a non-opioid analgesic or immediate-release opioid. CONTINUING THERAPY: Documentation of ALL of the following : (1)member's pain has been assessed within the last 3 months (2) member has demonstrated improved functioning on current medication regimen (3) member is not being treated for substance abuse AND (4) if member is on concurrent benzodiazepines and/or muscle relaxant therapy, the prescriber should provide attestation of an intent to monitor side effects AND provide documentation that patient counseling has and will continue to take place outlining the risks and potential side effects of concurrent use of benzodiazepines, opioids and/or muscle relaxants. 137
PALIPERIDONE paliperidone oral tablet extended release 24hr 1.5 mg, 3 mg, 6 mg, 9 mg Other For the diagnosis of schizophrenia: the patient must have documented failure or intolerance to a formulary second generation atypical antipsychotic 138
PALIPERIDONE LONG ACTING INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 117 MG/0.75 ML, 156 MG/ML, 234 MG/1.5 ML, 39 MG/0.25 ML, 78 MG/0.5 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 273 MG/0.875 ML, 410 MG/1.315 ML, 546 MG/1.75 ML, 819 MG/2.625 ML Other The member has a documented history of receiving oral risperidone or oral paliperidone without any clinically significant side effects. For requests for Invega Trinza, the member has documented treatment with Invega Sustenna for at least 4 months. 139
PEGINTERFERON PEGASYS PEGASYS PROCLICK SUBCUTANEOUS PEN INJECTOR 180 MCG/0.5 ML Other For Hepatitis C: Labs within 3 months of request: ALT/AST, and detectable HCV RNA viral load. In addition, documentation of genotype, treatment history, and if cirrhotic, documentation of compensated or decompensated cirrhosis. For Hepatitis B: Labs within 3 months of request: ALT/AST. In addition, documentation of HBeAg status is required. must be a gastroenterologist, hepatologist, infectious disease doctor or transplant specialist. If all conditions are met request will be authorized for up to 48 weeks as defined by compendia 140
PENTAM 300 PENTAM Other 141
PERSERIS PERSERIS Other The member has a documented history of receiving oral risperidone 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. 142