ACAMPROSATE (CAMPRAL) ACAMPROSATE CALCIUM Creatinine clearance less than 30 PAGE 1 LAST UPDATED 06/2016
ADALIMUMAB (HUMIRA) HUMIRA, HUMIRA PEDIATRIC CROHN'S, HUMIRA PEN, HUMIRA PEN CROHN'S-UC-HS, HUMIRA PEN PSORIASIS must have inadequate response to at least one disease-modifying anti-rheumatic drug None PAGE 2 LAST UPDATED 06/2016
AMBRISENTAN (LETAIRIS) LETAIRIS Pregnancy enrollment in LEAP Program PAGE 3 LAST UPDATED 06/2016
APIXABAN (ELIQUIS) ELIQUIS PAGE 4 LAST UPDATED 06/2016
APOMORPHINE (APOKYN) APOKYN PAGE 5 LAST UPDATED 06/2016
APREMILAST (OTEZLA) OTEZLA PAGE 6 LAST UPDATED 06/2016
APREPITANT (EMEND) EMEND 125 MG CAPSULE, EMEND 40 MG CAPSULE, EMEND 80 MG CAPSULE, EMEND TRIPACK 3 months None PAGE 7 LAST UPDATED 06/2016
CINACALCET (SENSIPAR) SENSIPAR PAGE 8 LAST UPDATED 06/2016
CLOPIDOGREL (PLAVIX) CLOPIDOGREL 75 MG TABLET PAGE 9 LAST UPDATED 06/2016
DABIGATRAN (PRADAXA) PRADAXA. Beneficiary has tried and failed warfarin therapy PAGE 10 LAST UPDATED 06/2016
DALFAMPRIDINE (AMPYRA) AMPYRA PAGE 11 LAST UPDATED 06/2016
DAPTOMYCIN (CUBICIN) CUBICIN 2 weeks PAGE 12 LAST UPDATED 06/2016
DENOSUMAB (PROLIA) PROLIA PAGE 13 LAST UPDATED 06/2016
DESVENLAFAXINE SUCCINATE (PRISTIQ) DESVENLAFAXINE ER PAGE 14 LAST UPDATED 06/2016
DEXTROMETHORPHAN/QUINIDINE (NUEDEXTA) NUEDEXTA Amyotrophic Lateral Sclerosis and Multiple Sclerosis PAGE 15 LAST UPDATED 06/2016
DICLOFENAC (SOLARAZE) DICLOFENAC SODIUM 3% GEL PAGE 16 LAST UPDATED 06/2016
DICLOFENAC EPOLAMINE (FLECTOR) FLECTOR 2 weeks PAGE 17 LAST UPDATED 06/2016
DIMETHYL FUMARATE (TECFIDERA) TECFIDERA PAGE 18 LAST UPDATED 06/2016
DORNASE ALFA (PULMOZYME) PULMOZYME PAGE 19 LAST UPDATED 06/2016
DROXIDOPA (NORTHERA) NORTHERA PAGE 20 LAST UPDATED 06/2016
DULAGLUTIDE (TRULICITY) TRULICITY PAGE 21 LAST UPDATED 06/2016
ELTROMBOPAG (PROMACTA) PROMACTA PAGE 22 LAST UPDATED 06/2016
EMPAGLIFLOZIN (JARDIANCE) JARDIANCE Currently on other anti-diabetic agents. PAGE 23 LAST UPDATED 06/2016
ENOXAPARIN (LOVENOX) ENOXAPARIN SODIUM reduce frequency with creatinine clearance less than 30 Minimum of 5 days of therapy and may extend up to 35 days unless prescribed for a shorter duration None PAGE 24 LAST UPDATED 06/2016
EPOETIN (EPOGEN) EPOGEN 10,000 UNITS/ML VIAL, EPOGEN 2,000 UNITS/ML VIAL, EPOGEN 20,000 UNITS/2 ML VIAL, EPOGEN 20,000 UNITS/ML VIAL, EPOGEN 3,000 UNITS/ML VIAL, EPOGEN 4,000 UNITS/ML VIAL to be continued only if hemoglobin is 12 or less 6 months PAGE 25 LAST UPDATED 06/2016
EPOETIN (PROCRIT) PROCRIT bleeding, autoimmune hemolytic anemia, inufficient vitamin stores, uncontrolled HTN, cancer patients with radiation alone to be continued only if hemoglobin is 12 or less 6 months PAGE 26 LAST UPDATED 06/2016
EVEROLIMUS (ZORTRESS) ZORTRESS PAGE 27 LAST UPDATED 06/2016
FENTANYL LOZENGE FENTANYL CIT OTFC 1,200 MCG, FENTANYL CIT OTFC 1,600 MCG, FENTANYL CITRATE OTFC 200 MCG, FENTANYL CITRATE OTFC 400 MCG, FENTANYL CITRATE OTFC 600 MCG, FENTANYL CITRATE OTFC 800 MCG Opiod tolerant PAGE 28 LAST UPDATED 06/2016
FENTANYL TRANSDERMAL PATCH FENTANYL 100 MCG/HR PATCH, FENTANYL 12 MCG/HR PATCH, FENTANYL 25 MCG/HR PATCH, FENTANYL 50 MCG/HR PATCH, FENTANYL 75 MCG/HR PATCH Refractory or intolerant to oral pain management PAGE 29 LAST UPDATED 06/2016
FIDAXOMICIN (DIFICID) DIFICID 10 days PAGE 30 LAST UPDATED 06/2016
FILGRASTIM (NEUPOGEN) NEUPOGEN, ZARXIO not for afebrile neutropenia 6 months None PAGE 31 LAST UPDATED 06/2016
GOLIMUMAB (SIMPONI) SIMPONI, SIMPONI ARIA PAGE 32 LAST UPDATED 06/2016
IMIQUIMOD (ALDARA) IMIQUIMOD 5% CREAM PACKET 4 months PAGE 33 LAST UPDATED 06/2016
INFLIXIMAB (REMICADE) REMICADE None PAGE 34 LAST UPDATED 06/2016
INTERFERON BETA 1A (REBIF, AVONEX) AVONEX, AVONEX ADMINISTRATION PACK, AVONEX PEN, REBIF, REBIF REBIDOSE Neurologist 3 months PAGE 35 LAST UPDATED 06/2016
IVACAFTOR (KALYDECO) KALYDECO PAGE 36 LAST UPDATED 06/2016
LEDIPASVIR/SOFOSBUVIR (HARVONI) HARVONI 12 weeks in patients without cirrhosis, 24 weeks in patients with cirrhosis PAGE 37 LAST UPDATED 06/2016
LENALIDOMIDE (REVLIMID) REVLIMID 3 months PAGE 38 LAST UPDATED 06/2016
LEVOMILNACIPRAN (FETZIMA) FETZIMA PAGE 39 LAST UPDATED 06/2016
LINEZOLID (ZYVOX) LINEZOLID, LINEZOLID-0.9% NACL low tyramine diet 28 days PAGE 40 LAST UPDATED 06/2016
LOMITAPIDE MESYLATE (JUXTAPID) JUXTAPID PAGE 41 LAST UPDATED 06/2016
LUBIPROSTONE (AMITIZA) AMITIZA PAGE 42 LAST UPDATED 06/2016
MACITENTAN (OPSUMIT) OPSUMIT PAGE 43 LAST UPDATED 06/2016
MEGESTROL MEGESTROL ACET 40 MG/ML SUSP, MEGESTROL ACET 400 MG/10 ML Assess for weight gain after initial coverage duration 6 months PAGE 44 LAST UPDATED 06/2016
METHYLNALTREXONE (RELISTOR) RELISTOR PAGE 45 LAST UPDATED 06/2016
MIPOMERSEN SODIUM (KYNAMRO) KYNAMRO PAGE 46 LAST UPDATED 06/2016
MODAFANIL (PROVIGIL) MODAFINIL None PAGE 47 LAST UPDATED 06/2016
NINTEDANIB ESYLATE (OFEV) OFEV PAGE 48 LAST UPDATED 06/2016
PARATHYROID HORMONE (NATPARA) NATPARA PAGE 49 LAST UPDATED 06/2016
PART D VS PART B ACETYLCYSTEINE 10% VIAL, ACETYLCYSTEINE 20% VIAL, ALBUTEROL 2.5 MG/0.5 ML SOL, ALBUTEROL 5 MG/ML SOLUTION, ALBUTEROL SUL 0.63 MG/3 ML SOL, ALBUTEROL SUL 1.25 MG/3 ML SOL, ALBUTEROL SUL 2.5 MG/3 ML SOLN, AMINOSYN II, AMINOSYN II WITH ELECTROLYTES, AMINOSYN M, AMINOSYN WITH ELECTROLYTES, AMINOSYN-HBC, AMINOSYN-PF, AMINOSYN-RF, AZATHIOPRINE 50 MG TABLET, AZATHIOPRINE SODIUM, BUDESONIDE 0.25 MG/2 ML SUSP, BUDESONIDE 0.5 MG/2 ML SUSP, BUDESONIDE 1 MG/2 ML INH SUSP, CARIMUNE NF NANOFILTERED, CELLCEPT 500 MG VIAL, CLINIMIX, CLINIMIX E 4.25%-10% SOLUTION, CLINISOL, CROMOLYN 20 MG/2 ML NEB SOLN, CYCLOPHOSPHAMIDE 25 MG CAPSULE, CYCLOPHOSPHAMIDE 50 MG CAPSULE, CYCLOSPORINE 100 MG CAPSULE, CYCLOSPORINE 100 MG/ML SOLN, CYCLOSPORINE 25 MG CAPSULE, CYCLOSPORINE 50 MG/ML AMPUL, CYCLOSPORINE 50 MG/ML VIAL, CYCLOSPORINE MODIFIED, ELIGARD, ENGERIX-B ADULT, ENGERIX-B PEDIATRIC-ADOLESCENT, ETOPOSIDE 1,000 MG/50 ML VIAL, ETOPOSIDE 100 MG/5 ML VIAL, ETOPOSIDE 500 MG/25 ML VIAL, GAMMAGARD LIQUID, GAMMAGARD S-D, GAMMAPLEX, GAMUNEX, GAMUNEX-C, GENGRAF, HEPARIN 10,000 UNIT/10 ML VIAL, HEPARIN 30,000 UNIT/30 ML VIAL, HEPARIN 40,000 UNITS/4 ML VIAL, HEPARIN 50,000 UNITS/5 ML VIAL, HEPARIN SOD 1,000 UNIT/ML VIAL, HEPARIN SOD 10,000 UNIT/ML VL, HEPATAMINE, INTRALIPID, IPRATROPIUM BR 0.02% SOLN, IPRATROPIUM- ALBUTEROL, LEVALBUTEROL CONCENTRATE, LEVALBUTEROL 0.31 MG/3 ML SOL, LEVALBUTEROL 0.63 MG/3 ML SOL, LEVALBUTEROL 1.25 MG/3 ML SOL, LUPRON DEPOT, LUPRON DEPOT-PED, METHOTREXATE 1 GM VIAL, METHOTREXATE 100 MG/4 ML VIAL, METHOTREXATE 2.5 MG TABLET, METHOTREXATE SODIUM, MYCOPHENOLATE MOFETIL, NEBUPENT, NULOJIX, NUTRILIPID, ONDANSETRON 4 MG/5 ML SOLUTION, ONDANSETRON HCL 24 MG TABLET, ONDANSETRON HCL 4 MG TABLET, ONDANSETRON HCL 8 MG TABLET, ONDANSETRON ODT, PREMASOL, PRIVIGEN, PROCALAMINE, PROGRAF 5 MG/ML AMPULE, PROLEUKIN, PROSOL, RECOMBIVAX HB 10 MCG/ML VIAL, RECOMBIVAX HB 40 MCG/ML VIAL, RECOMBIVAX HB 5 MCG/0.5 ML VL, SULFAMETHOXAZOLE-TMP INJ VIAL, TOBRAMYCIN 300 MG/5 ML AMPULE, TRAVASOL, TROPHAMINE, VANCOMYCIN 1 GM ADD-VAN VIAL, VANCOMYCIN 1 GM VIAL, VANCOMYCIN 500 MG A-V VIAL, VANCOMYCIN 500 MG VIAL, VANCOMYCIN HCL 10 GM VIAL, VANCOMYCIN HCL 5 GM VIAL, VANCOMYCIN HCL 750 MG VIAL DETAILS This drug may be covered under Medicare Part B or D depending on the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination. PAGE 50 LAST UPDATED 06/2016
PLERIXAFOR (MOZOBIL) MOZOBIL 4 days PAGE 51 LAST UPDATED 06/2016
POMALIDOMIDE (POMALYST) POMALYST 3 months PAGE 52 LAST UPDATED 06/2016
PREGABALIN (LYRICA) LYRICA PAGE 53 LAST UPDATED 06/2016
QUININE SULFATE QUININE SULFATE 324 MG CAPSULE 1 week PAGE 54 LAST UPDATED 06/2016
RIBAVIRIN ORAL REBETOL 40 MG/ML SOLUTION, RIBAVIRIN 3 months PAGE 55 LAST UPDATED 06/2016
RIFAXIMIN (XIFAXAN) XIFAXAN 200 MG TABLET 3 days PAGE 56 LAST UPDATED 06/2016
RIOCIGUAT (ADEMPAS) ADEMPAS PAGE 57 LAST UPDATED 06/2016
ROFLUMILAST (DALIRESP) DALIRESP PAGE 58 LAST UPDATED 06/2016
ROTIGOTINE (NEUPRO) NEUPRO PAGE 59 LAST UPDATED 06/2016
SARGRAMOSTIM (LEUKINE) LEUKINE 250 MCG VIAL 2 months PAGE 60 LAST UPDATED 06/2016
SELEGILENE TRANSDERMAL EMSAM PAGE 61 LAST UPDATED 06/2016
SILDENAFIL CITRATE (REVATIO) SILDENAFIL PAGE 62 LAST UPDATED 06/2016
SIMEPREVIR (OLYSIO) OLYSIO 12 or 24 weeks Duration depends on past medical history, cirrhosis history, and genotype PAGE 63 LAST UPDATED 06/2016
SIROLIMUS (RAPAMUNE) RAPAMUNE 1 MG/ML ORAL SOLN, SIROLIMUS 0.5 MG TABLET, SIROLIMUS 1 MG TABLET, SIROLIMUS 2 MG TABLET PAGE 64 LAST UPDATED 06/2016
SOFOSBUVIR (SOLVALDI) SOVALDI 12, 16, 24 or 48 weeks Consider genotype, cirrhosis status, previous failure of PEG-IFN/RBV/protease inhibitors/sofosbuvir, HCV in an allograft, decompensated cirrhosis, if awaiting transplant and concurrent treatment PAGE 65 LAST UPDATED 06/2016
SOMATROPIN GENOTROPIN, HUMATROPE, NORDITROPIN FLEXPRO, NORDITROPIN NORDIFLEX, NUTROPIN AQ, NUTROPIN AQ NUSPIN, OMNITROPE, SAIZEN, SEROSTIM, ZORBTIVE PAGE 66 LAST UPDATED 06/2016
TACROLIMUS (PROGRAF) ASTAGRAF XL, ENVARSUS XR, TACROLIMUS 0.5 MG CAPSULE, TACROLIMUS 1 MG CAPSULE, TACROLIMUS 5 MG CAPSULE PAGE 67 LAST UPDATED 06/2016
TADALAFIL (ADCIRCA) ADCIRCA PAGE 68 LAST UPDATED 06/2016
TASIMELTEON (HETLIOZ) HETLIOZ PAGE 69 LAST UPDATED 06/2016
TEDIZOLID PHOSPHATE (SIVEXTRO) SIVEXTRO 6 days PAGE 70 LAST UPDATED 06/2016
TERIFLUNOMIDE (AUBAGIO) AUBAGIO 1 year PAGE 71 LAST UPDATED 06/2016
TERIPARATIDE (FORTEO) FORTEO 2 years None PAGE 72 LAST UPDATED 06/2016
TETRAHYDROCANNABINOL DRONABINOL PAGE 73 LAST UPDATED 06/2016
TICAGRELOR (BRILINTA) BRILINTA PAGE 74 LAST UPDATED 06/2016
TIGECYCLINE (TYGACIL) TYGACIL 14 days PAGE 75 LAST UPDATED 06/2016
TOFACITINIB CITRATE (XELJANZ) XELJANZ, XELJANZ XR PAGE 76 LAST UPDATED 06/2016
TREPROSTINIL (REMODULIN) REMODULIN PAGE 77 LAST UPDATED 06/2016
VANCOMYCIN ORAL SOLUTION VANCOMYCIN HCL 125 MG CAPSULE, VANCOMYCIN HCL 250 MG CAPSULE 2 weeks None PAGE 78 LAST UPDATED 06/2016
VARENICLINE (CHANTIX) CHANTIX 0.5 MG TABLET, CHANTIX 1 MG CONT MONTH BOX, CHANTIX 1 MG TABLET, CHANTIX STARTING MONTH BOX 12 weeks None PAGE 79 LAST UPDATED 06/2016
VILAZODONE (VIIBRYD) VIIBRYD 10 MG TABLET, VIIBRYD 10-20 MG STARTER PACK, VIIBRYD 20 MG TABLET, VIIBRYD 40 MG TABLET PAGE 80 LAST UPDATED 06/2016
VORTIOXETINE (BRINTELLIX) BRINTELLIX PAGE 81 LAST UPDATED 06/2016
PAGE 82 LAST UPDATED 06/2016