Effective: 12/01/2016 H2986_PD_049 Updated 11/2016
ALPHA 1-PROTEINASE INHIBITOR GLASSIA PRIOR CLAIM FOR ARALAST NP OR ZEMAIRA WITHIN THE PAST 120 DAYS.
ANALGESICS, NARCOTICS KADIAN MORPHINE SULFATE ER PRIOR CLAIM FOR MORPHINE SULFATE SUSTAINED ACTION TABLET (MS CONTIN) WITHIN THE PAST 120 DAYS.
ANTI-INFLAMMATORY AGENTS - GI DIPENTUM GIAZO LIALDA PENTASA PRIOR CLAIM FOR ANY 1 OF THE FOLLOWING: DELZICOL, ASACOL, MESALAMINE 800MG DR TAB, BALSALAZIDE OR APRISO WITHIN THE PAST 120 DAYS
ANTIBACTERIALS (EENT) BESIVANCE PRIOR CLAIM FOR CIPROFLOXACIN OPHTHALMIC DROPS, CIPROFLOXACIN OPHTHALMIC OINTMENT, OR OFLOXACIN OPHTHALMIC DROPS WITHIN THE LAST 120 DAYS.
ANTIDIABETIC AGENTS - INSULINS LEVEMIR LEVEMIR FLEXTOUCH PRIOR CLAIM FOR INSULIN GLARGINE (LANTUS OR LANTUS SOLOSTAR OR TOUJEO) WITHIN THE PAST 120 DAYS.
ANTIDIABETIC AGENTS - MISCELLANEOUS GLYXAMBI INVOKAMET INVOKANA JARDIANCE SYNJARDY PRIOR CLAIM FOR METFORMIN, METFORMIN ER, A SULFONYLUREA AGENT (GLYBURIDE, GLIPIZIDE, GLIMEPIRIDE, TOLAZAMIDE, TOLBUTAMIDE), COMBINATION OF A SULFONYLUREA-METFORMIN, PIOGLITAZONE, OR A COMBINATION PIOGLITAZONE-METFORMIN OR PIOGLITAZONE- GLIMEPIRIDE WITHIN THE PAST 120 DAYS.
ANTIDIABETIC AGENTS - SGLT-2 FARXIGA XIGDUO XR PRIOR CLAIM FOR INVOKANA OR INVOKAMET OR JARDIANCE OR SYNJARDY AND METFORMIN, METFORMIN ER, A SULFONYLUREA AGENT (GLYBURIDE, GLIPIZIDE, GLIMEPIRIDE), COMBINATION OF A SULFONYLUREA-METFORMIN, PIOGLITAZONE, OR A COMBINATION PIOGLITAZONE-METFORMIN OR PIOGLITAZONE- GLIMEPIRIDE WITHIN THE PAST 365 DAYS.
ANTIPSYCHOTIC AGENTS CLOZAPINE ODT FANAPT FAZACLO SAPHRIS VERSACLOZ PRIOR CLAIM FOR FORMULARY VERSIONS OF ANTIPSYCHOTICS RISPERIDONE TABLET, RISPERIDONE DISINTEGRATING TABLET, CLOZAPINE TABLET, OLANZAPINE TABLET, OLANZAPINE ORAL DISINTEGRATING TABLET, IMMEDIATE RELEASE QUETIAPINE FUMARATE, OR ZIPRASIDONE, AND ABILIFY OR ARIPIPRAZOLE WITHIN THE PAST 365 DAYS.
ANTIULCER AGENTS DEXILANT ESOMEPRAZOLE MAGNESIUM ESOMEPRAZOLE STRONTIUM NEXIUM PREVACID PRIOR CLAIM FOR GENERIC FEDERAL LEGEND OMEPRAZOLE, PANTOPRAZOLE, OR LANSOPRAZOLE WITHIN THE PAST 120 DAYS.
B VERSUS D ADMINISTRATIVE STEP CYCLOPHOSPHAMIDE METHOTREXATE RHEUMATREX TREXALL IN ORDER TO ASSIST IN A PART B VS. D PAYMENT DETERMINATION, A PRIOR CLAIM SEEN FOR A RHEUMATOID ARTHRITIS, PSORIASIS OR ACTIVE POLYARTICULAR JUVENILE IDIOPATHIC ARTHRITIS DRUG WITHIN THE PAST 120 DAYS WILL QUALIFY FOR PART D PAYMENT. ALL OTHER INDICATIONS WILL HAVE A PART B VS. D PAYMENT DETERMINATION MADE THROUGH THE FORMULARY EXCEPTION PROCESS PRIOR TO THE APPROVAL OF THE DRUG.
BELBUCA BELBUCA PRIOR CLAIM FOR BUTRANS PATCH WITHIN THE PAST 120 DAYS.
BUDESONIDE - UCERIS UCERIS PRIOR CLAIM FOR BALSALAZIDE WITHIN THE PAST 120 DAYS.
BUDESONIDE-FORMOTEROL FUMARATE SYMBICORT PRIOR CLAIM FOR ADVAIR OR DULERA WITHIN THE PAST 120 DAYS.
COPD II INCRUSE ELLIPTA SEEBRI NEOHALER PRIOR CLAIM FOR SPIRIVA WITHIN THE PAST 120 DAYS.
COPD III UTIBRON NEOHALER PRIOR CLAIM FOR STIOLTO WITHIN THE PAST 120 DAYS.
ELUXADOLINE VIBERZI PRIOR CLAIM FOR DICYCLOMINE AND XIFAXAN 550MG WITHIN THE PAST 120 DAYS.
FACTOR XA INHIBITORS PRADAXA PRIOR CLAIM FOR ELIQUIS AND XARELTO IN THE PAST 365 DAYS.
GAPABENTIN SR GRALISE PRIOR CLAIM FOR GABAPENTIN IMMEDIATE RELEASE WITHIN THE PAST 120 DAYS.
GLP-1 ANALOGS II BYDUREON BYDUREON PEN BYETTA TANZEUM PRIOR CLAIM FOR VICTOZA OR TRULICITY AND EITHER METFORMIN, METFORMIN ER, A SULFONYLUREA AGENT (GLYBURIDE, GLIPIZIDE, GLIMEPIRIDE), COMBINATION OF A SULFONYLUREA- METFORMIN, PIOGLITAZONE, OR A COMBINATION PIOGLITAZONE-METFORMIN OR PIOGLITAZONE-GLIMEPIRIDE WITHIN THE PAST 365 DAYS.
IVABRADINE CORLANOR PRIOR CLAIM FOR METOPROLOL SUCCINATE, BISOPROLOL OR CARVEDILOL WITHIN THE PAST 120 DAYS.
MULTIPLE SCLEROSIS AGENTS AVONEX AVONEX PEN BETASERON EXTAVIA PLEGRIDY PLEGRIDY PEN PRIOR CLAIM FOR REBIF (INTERFERON BETA-1A) OR FORMULARY GLATIRAMER ACETATE WITHIN THE PAST 120 DAYS.
MULTIPLE SCLEROSIS AGENTS II ZINBRYTA PRIOR CLAIM FOR TWO FORMULARY MULTIPLE SCLEROSIS AGENTS: AUBAGIO, AVONEX, BETASERON, EXTAVIA, FORMULARY GLATIRAMER ACETATE, GILENYA, MITOXANTRONE, PLEGRIDY, REBIF, TECFIDERA AND TYSABRI.
OPHTHALMIC ANTIHISTAMINES ALREX BEPREVE ELESTAT EMADINE LASTACAFT PATADAY PATANOL PAZEO PRIOR CLAIM FOR LEVOCETIRIZINE OR CROMOLYN SODIUM EYE DROPS, EPINASTINE, OLOPATADINE 0.1% EYE DROPS WITHIN THE PAST 120 DAYS.
ORAL INHALED CORTICOSTEROID II AEROSPAN PRIOR CLAIM FOR QVAR AND FLOVENT WITHIN THE PAST 365 DAYS.
ORAL INHALED CORTICOSTEROIDS ALVESCO ARNUITY ELLIPTA ASMANEX PULMICORT FLEXHALER PRIOR CLAIM FOR QVAR WITHIN THE PAST 120 DAYS.
QUETIAPINE FUMARATE EXTENDED RELEASE SEROQUEL XR PRIOR CLAIM FOR FORMULARY VERSIONS OF ATYPICAL ANTIPSYCHOTICS: RISPERIDONE TABLET, RISPERIDONE DISINTEGRATING TABLET, CLOZAPINE TABLET, OLANZAPINE TABLET, OLANZAPINE ORAL DISINTEGRATING TABLET, IMMEDIATE RELEASE QUETIAPINE FUMARATE, ZIPRASIDONE,CITALOPRAM, FLUOXETINE, PAROXETINE, SERTRALINE, DULOXETINE, VENLAFAXINE, AND ARIPIPRAZOLE WITHIN THE PAST 365 DAYS.
RENIN ANGIOTENSION SYSTEM INHIBITORS ATACAND ATACAND HCT AVALIDE AVAPRO DIOVAN DIOVAN HCT EDARBI EDARBYCLOR EXFORGE EXFORGE HCT MICARDIS MICARDIS HCT TEKTURNA TEKTURNA HCT TWYNSTA PRIOR CLAIM FOR AN ANGIOTENSIN CONVERTING ENZYME INHIBITOR (ACE INHIBITOR), OR ACE INHIBITOR COMBINATION OR A GENERIC ANGIOTENSIN RECEPTOR BLOCKER (ARB), OR GENERIC ARB COMBINATION WITHIN THE PAST 120 DAYS.
SPRITAM SPRITAM PRIOR CLAIM FOR LEVETIRACETAM SOLUTION IN THE PAST 120 DAYS
VIVLODEX VIVLODEX PRIOR CLAIM FOR GENERIC MELOXICAM 7.5MG OR 15MG TABLETS WITHIN THE PAST 120 DAYS.