H2986_PD_048 Updated 11/2015
Prior Authorization Requirements
5HT3 ANTI-NAUSEA AGENT BVD DETERMINATION
DRUG NAME
ANZEMET | GRANISETRON HCL | ONDANSETRON HCL | ONDANSETRON ODT | ZOFRAN | ZOFRAN ODT | ZUPLENZ
COVERED USES
THIS DRUG MAY BE COVERED UNDER MEDICARE PART B OR D DEPENDING UPON THE CIRCUMSTANCES. INFORMATION MAY NEED TO BE SUBMITTED DESCRIBING THE USE AND SETTING OF THE DRUG TO MAKE THE DETERMINATION.
EXCLUSION CRITERIA
REQUIRED MEDICAL INFORMATION AGE RESTRICTIONS
PRESCRIBER RESTRICTIONS COVERAGE DURATION OTHER CRITERIA
ABATACEPT IV
DRUG NAME ORENCIA
COVERED USES
ALL FDA APPROVED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D. EXCLUSION CRITERIA
REQUIRED MEDICAL INFORMATION
RENEWAL: RHEUMATOID ARTHRITIS/JUVENILE IDIOPATHIC ARTHRITIS:
EXPERIENCED OR MAINTAINED 20% OR GREATER IMPROVEMENT IN TENDER AND SWOLLEN JOINT COUNT.
AGE RESTRICTIONS
PRESCRIBER RESTRICTIONS
PRESCRIBED BY OR IN CONSULTATION WITH: RHEUMATOID ARTHRITIS,
POLYARTICULAR JUVENILE IDIOPATHIC ARTHRITIS, ANKYLOSING SPONDYLITIS: RHEUMATOLOGIST. PSORIATIC ARTHRITIS: DERMATOLOGIST OR
RHEUMATOLOGIST. PSORIASIS: DERMATOLOGIST. CROHN S DISEASE/ULCERATIVE COLITIS: GASTROENTEROLOGIST. COVERAGE DURATION
INITIAL: 4 MONTHS RENEWAL: 12 MONTHS OTHER CRITERIA
INITIAL: RHEUMATOID ARTHRITIS (RA)/ JUVENILE IDIOPATHIC ARTHRITIS (JIA): PREVIOUS TRIAL WITH HUMIRA AND ONE DMARD (DISEASE-MODIFYING
ANTIRHEUMATIC DRUG) AGENT SUCH AS METHOTREXATE, LEFLUNOMIDE,
HYDROXYCHLOROQUINE, OR SULFASALAZINE. NOT APPROVED FOR PATIENTS ON CONCURRENT THERAPY WITH KINERET (ANAKINRA), OR A TNF (TUMOR NECROSIS FACTOR) INHIBITOR: HUMIRA, ENBREL, CIMZIA, REMICADE, SIMPONI, OR SIMPONI ARIA.
ABATACEPT SQ
DRUG NAME ORENCIA
COVERED USES
ALL FDA APPROVED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D. EXCLUSION CRITERIA
REQUIRED MEDICAL INFORMATION
RENEWAL: RHEUMATOID ARTHRITIS: EXPERIENCED OR MAINTAINED 20% OR GREATER IMPROVEMENT IN TENDER AND SWOLLEN JOINT COUNT. NOT
APPROVED FOR PATIENTS ON CONCURRENT THERAPY WITH KINERET
(ANAKINRA), OR A TNF (TUMOR NECROSIS FACTOR) INHIBITOR: HUMIRA, ENBREL, CIMZIA, REMICADE, SIMPONI, OR SIMPONI ARIA.
AGE RESTRICTIONS 18 YEARS OR OLDER.
PRESCRIBER RESTRICTIONS
PRESCRIBED BY OR IN CONSULTATION WITH: RHEUMATOLOGIST. COVERAGE DURATION
INITIAL: 4 MONTHS RENEWAL: 12 MONTHS OTHER CRITERIA
ABIRATERONE
DRUG NAME ZYTIGA
COVERED USES
ALL FDA APPROVED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D. EXCLUSION CRITERIA
REQUIRED MEDICAL INFORMATION AGE RESTRICTIONS
PRESCRIBER RESTRICTIONS COVERAGE DURATION 12 MONTHS
ADALIMUMAB
DRUG NAME
HUMIRA | HUMIRA CROHN'S COVERED USES
ALL FDA APPROVED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D. EXCLUSION CRITERIA
REQUIRED MEDICAL INFORMATION
INITIAL: POLYARTICULAR JUVENILE IDIOPATHIC ARTHRITIS: CURRENT WEIGHT. PLAQUE PSORIASIS: MODERATE TO SEVERE PLAQUE PSORIASIS INVOLVING
GREATER THAN OR EQUAL TO 5 PERCENT BODY SURFACE AREA OR PSORIATIC LESIONS AFFECT THE HANDS, FEET, OR GENITAL AREA. RENEWAL: RHEUMATOID ARTHRITIS/JUVENILE IDOPATHIC ARTHRITIS/PSORIATIC ARTHRITIS:
EXPERIENCED OR MAINTAINED 20 PERCENT IMPROVEMENT IN TENDER OR SWOLLEN JOINT COUNT WHILE ON THERAPY. ANKYLOSING SPONDYLITIS: EXPERIENCED OR MAINTAINED IMPROVEMENT OF AT LEAST 50 PERCENT OR 2 UNITS IN THE BATH ANKYLOSING SPONDYLITIS DISEASE ACTIVITY INDEX (BASDAI). PLAQUE PSORIASIS: ACHIEVED OR MAINTAINED CLEAR OR MINIMAL DISEASE OR A DECREASE IN PSORIASIS AREA AND SEVERITY INDEX (PASI) OF AT LEAST 50% OR MORE.
AGE RESTRICTIONS
PRESCRIBER RESTRICTIONS
PRESCRIBED BY OR IN CONSULTATION WITH: RHEUMATOID ARTHRITIS,
DMARD (DISEASE-MODIFYING ANTIRHEUMATIC DRUG) AGENT SUCH AS
METHOTREXATE, LEFLUNOMIDE, HYDROXYCHLOROQUINE, OR SULFASALAZINE. PLAQUE PSORIASIS (PSO): PREVIOUS TRIAL WITH ONE OF THE FOLLOWING
CONVENTIONAL THERAPIES SUCH AS PUVA (PHOTOTHERAPY ULTRAVIOLET LIGHT A), UVB (ULTRAVIOLET LIGHT B), TOPICAL CORTICOSTEROIDS,
CALCIPOTRIENE, ACITRETIN, METHOTREXATE, OR CYCLOSPORINE. CROHNS DISEASE (CD)/ULCERATIVE COLITIS (UC): PREVIOUS TRIAL WITH ONE OF THE FOLLOWING CONVENTIONAL AGENTS SUCH AS CORTICOSTEROIDS (I.E., BUDESONIDE, METHYLPREDNISOLONE), AZATHIOPRINE, MERCAPTOPURINE, METHOTREXATE, OR MESALAMINE). NOT APPROVED FOR PATIENT ON
CONCURRENT THERAPY WITH KINERET (ANAKINRA), ORENCIA (ABATACEPT), RITUXAN (RITUXIMAB), OR A TNF INHIBITOR (ENBREL, CIMZIA, REMICADE, SIMPONI, OR SIMPONI ARIA).
ADO-TRASTUZUMAB EMTANSINE
DRUG NAME KADCYLA COVERED USES
ALL FDA APPROVED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D. EXCLUSION CRITERIA
REQUIRED MEDICAL INFORMATION AGE RESTRICTIONS
PRESCRIBER RESTRICTIONS COVERAGE DURATION 12 MONTHS
AFATINIB DIMALEATE
DRUG NAME GILOTRIF COVERED USES
ALL FDA APPROVED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D. EXCLUSION CRITERIA
REQUIRED MEDICAL INFORMATION AGE RESTRICTIONS
PRESCRIBER RESTRICTIONS COVERAGE DURATION 12 MONTHS
ALLERGEN EXTRACT - SHORT RAGWEED POLLEN
DRUG NAME RAGWITEK COVERED USES
ALL FDA APPROVED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D. EXCLUSION CRITERIA
REQUIRED MEDICAL INFORMATION
POSITIVE SKIN PRICK TEST FOR SHORT RAGWEED POLLEN OR IN VITRO TESTING FOR POLLEN-SPECIFIC IGE ANTIBODIES FOR SHORT RAGWEED POLLEN.
AGE RESTRICTIONS 18 YEARS OR OLDER.
PRESCRIBER RESTRICTIONS
PRESCRIBED OR IN CONSULTATION WITH BY ALLERGIST OR IMMUNOLOGIST OR OTHER PHYSICIAN EXPERIENCED IN DIAGNOSIS AND TREATMENT OF ALLERGIC DISEASES.
COVERAGE DURATION 12 MONTHS
OTHER CRITERIA
DIAGNOSIS OF PERSISTENT AND MODERATE-TO-SEVERE SYMPTOMS OF ALLERGIC RHINITIS. PERSISTENT SYMPTOMS ARE DEFINED AS SYMPTOMS PRESENTING AT
ALLERGEN EXTRACT - TIMOTHY GRASS POLLEN
DRUG NAME GRASTEK
COVERED USES
ALL FDA APPROVED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D. EXCLUSION CRITERIA
REQUIRED MEDICAL INFORMATION
POSITIVE SKIN PRICK TEST FOR TIMOTHY GRASS POLLEN GRASS POLLEN OR POSITIVE TITRE TO SPECIFIC IGE ANTIBODIES FOR TIMOTHY GRASS OR CROSS-REACTIVE GRASS POLLENS.
AGE RESTRICTIONS
5 YEARS THROUGH 65 YEARS OF AGE PRESCRIBER RESTRICTIONS
PRESCRIBED OR RECOMMENDED BY AN ALLERGIST OR IMMUNOLOGIST. COVERAGE DURATION
12 MONTHS
OTHER CRITERIA
DIAGNOSIS OF PERSISTENT AND MODERATE-TO-SEVERE SYMPTOMS OF ALLERGIC RHINITIS. CURRENT CLAIM OR CURRENT PRESCRIPTION FOR AN
AUTO-INJECTABLE EPINEPHRINE WITHIN THE PAST 365 DAYS. BETWEEN AGES 5 TO 17: TRIAL OF AT LEAST ONE INTRANASAL CORTICOSTEROID (FLUNISOLIDE OR
TRIAMCINOLONE) OR ONE ANTIHISTAMINE (LEVOCETIRIZINE) WITHIN THE PAST 120 DAYS. ABOVE AGE 18 YEARS AND OLDER: TRIAL OF AT LEAST ONE INTRANASAL CORTICOSTEROID (FLUNISOLIDE OR TRIAMCINOLONE) AND ONE ANTIHISTAMINE (LEVOCETIRIZINE).
AMPHETAMINE SULFATE
DRUG NAME EVEKEO
COVERED USES
ALL FDA APPROVED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D. EXCLUSION CRITERIA
USE IN TREATMENT OF EXOGENOUS OBESITY. REQUIRED MEDICAL INFORMATION
AGE RESTRICTIONS
NARCOLEPSY: 6 YEARS OF AGE AND OLDER. ATTENTION DEFICIT DISORDER WITH HYPERACTIVITY: 3 YEARS OF AGE AND OLDER.
PRESCRIBER RESTRICTIONS COVERAGE DURATION 12 MONTHS
ANAKINRA
DRUG NAME KINERET
COVERED USES
ALL FDA APPROVED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D. EXCLUSION CRITERIA
REQUIRED MEDICAL INFORMATION
RENEWAL: RHEUMATOID ARTHRITIS: EXPERIENCED OR MAINTAINED 20% OR GREATER IMPROVEMENT IN TENDER AND SWOLLEN JOINT COUNT.
AGE RESTRICTIONS RA: 18 YEARS OR OLDER PRESCRIBER RESTRICTIONS
PRESCRIBED BY OR IN CONSULTATION WITH: RHEUMATOID ARTHRITIS: RHEUMATOLOGIST.
COVERAGE DURATION
INITIAL: RA : 4 MOS. NOMI OR CAPS: 12 MOS. RENEWAL: 12 MOS FOR ALL DIAGNOSES.
OTHER CRITERIA
INITIAL: RHEUMATOID ARTHRITIS (RA)): PREVIOUS TRIAL WITH HUMIRA FOLLOWED BY ONE OF THE FOLLOWING PREFERRED AGENTS: ORENCIA,
XELJANZ, OR CIMZIA.. NOT APPROVED FOR PATIENTS ON CONCURRENT THERAPY WITH A TNF (TUMOR NECROSIS FACTOR) INHIBITOR: HUMIRA, ENBREL, CIMZIA, REMICADE, SIMPONI, OR SIMPONI ARIA.
APREMILAST
DRUG NAME OTEZLA
COVERED USES
ALL FDA APPROVED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D. EXCLUSION CRITERIA
REQUIRED MEDICAL INFORMATION AGE RESTRICTIONS
18 YEARS OF AGE OR OLDER. PRESCRIBER RESTRICTIONS
PRESCRIBED BY OR IN CONSULTATION WITH: PSORIATIC ARTHRITIS: DERMATOLOGIST OR RHEUMATOLOGIST. PSORIASIS: DERMATOLOGIST. COVERAGE DURATION
INITIAL: PSORIARTIC ARTHRITIS 4 MONTHS. PSORIASIS: 5 MONTHS RENEWAL: 12 MONTHS.
OTHER CRITERIA
INITIAL: PSORIATRIC ARTHRITIS (PSA): PREVIOUS TRIAL WITH HUMIRA AND ONE DMARD (DISEASE-MODIFYING ANTIRHEUMATIC DRUG) AGENT SUCH AS
METHOTREXATE, LEFLUNOMIDE, HYDROXYCHLOROQUINE, OR SULFASALAZINE. PLAQUE PSORIASIS (PSO): PREVIOUS TRIAL WITH HUMIRA AND ONE OF THE
APREPITANT BVD DETERMINATION
DRUG NAME EMEND
COVERED USES
THIS DRUG MAY BE COVERED UNDER MEDICARE PART B OR D DEPENDING UPON THE CIRCUMSTANCES. INFORMATION MAY NEED TO BE SUBMITTED DESCRIBING THE USE AND SETTING OF THE DRUG TO MAKE THE DETERMINATION.
EXCLUSION CRITERIA
REQUIRED MEDICAL INFORMATION AGE RESTRICTIONS
PRESCRIBER RESTRICTIONS COVERAGE DURATION OTHER CRITERIA
ASPARAGINASE
DRUG NAME
ERWINAZE | ONCASPAR COVERED USES
ALL FDA APPROVED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D. EXCLUSION CRITERIA
REQUIRED MEDICAL INFORMATION AGE RESTRICTIONS
PRESCRIBER RESTRICTIONS COVERAGE DURATION 3 MONTHS
AXITINIB
DRUG NAME INLYTA
COVERED USES
ALL FDA APPROVED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D. EXCLUSION CRITERIA
REQUIRED MEDICAL INFORMATION AGE RESTRICTIONS
PRESCRIBER RESTRICTIONS COVERAGE DURATION 12 MONTHS
OTHER CRITERIA
TRIAL OF AT LEAST ONE SYSTEMIC THERAPY FOR THE TREATMENT OF RCC SUCH AS NEXAVAR (SORAFENIB), TORISEL (TEMSIROLIMUS), SUTENT (SUNITINIB),
VOTRIENT (PAZOPANIB), OR AVASTIN (BEVACIZUMAB) IN COMBINATION WITH INTERFERON.
BACILLUS OF CALMETTE AND GUERIN VACCINE BVD DETERMINATION
DRUG NAME
BCG (TICE STRAIN) COVERED USES
THIS DRUG MAY BE COVERED UNDER MEDICARE PART B OR D DEPENDING UPON THE CIRCUMSTANCES. INFORMATION MAY NEED TO BE SUBMITTED DESCRIBING THE USE AND SETTING OF THE DRUG TO MAKE THE DETERMINATION.
EXCLUSION CRITERIA
REQUIRED MEDICAL INFORMATION AGE RESTRICTIONS
PRESCRIBER RESTRICTIONS COVERAGE DURATION OTHER CRITERIA
BECAPLERMIN
DRUG NAME REGRANEX COVERED USES
ALL FDA APPROVED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D. EXCLUSION CRITERIA
NON-DIABETIC. KNOWN NEOPLASM AT APPLICATION SITE. PRESSURE OR VENOUS STASIS ULCERS. ULCER DOES NOT EXTEND THROUGH DERMIS.
REQUIRED MEDICAL INFORMATION AGE RESTRICTIONS
PRESCRIBER RESTRICTIONS
VASCULAR SURGEON, PODIATRIST, ENDOCRINOLOGIST OR PHYSICIAN PRACTICING IN A SPECIALTY WOUND CLINIC ONLY
COVERAGE DURATION 3 MONTHS
BEDAQUILINE FUMARATE
DRUG NAME SIRTURO
COVERED USES
ALL FDA APPROVED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D. EXCLUSION CRITERIA
REQUIRED MEDICAL INFORMATION AGE RESTRICTIONS
18 YEARS OF AGE AND OLDER. PRESCRIBER RESTRICTIONS COVERAGE DURATION 24 WEEKS
OTHER CRITERIA
SIRTURO USED IN COMBINATION WITH AT LEAST 3 OTHER ANTIBIOTICS FOR IN THE TREATMENT OF PULMONARY MULTI-DRUG RESISTANT TUBERCULOSIS.
BELIMUMAB
DRUG NAME BENLYSTA COVERED USES
ALL FDA APPROVED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D. EXCLUSION CRITERIA
REQUIRED MEDICAL INFORMATION AUTOANTIBODY POSITIVE LUPUS TEST. AGE RESTRICTIONS
PRESCRIBER RESTRICTIONS COVERAGE DURATION
INITIAL: 6 MONTHS. RENEWAL: 12 MONTHS OTHER CRITERIA
INITIAL: SELENA-SELDAI SCORE GREATER THAN OR EQUAL TO 6. RENEWAL: MAINTAIN AT LEAST A 4 POINT REDUCTION IN SELENA-SELDAI SCORE FROM
BASELINE. MEMBER IS CURRENTLY TAKING CORTICOSTEROIDS, ANTIMALARIALS, NSAIDS, OR IMMUNOSUPPRESSIVE AGENTS. NO APPROVAL FOR DIAGNOSIS OF SEVERE ACTIVE LUPUS NEPHRITIS OR SEVERE CENTRAL NERVOUS SYSTEM LUPUS OR CONCURRENT USE OF BIOLOGIC AGENTS, OR INTRAVENOUS
BELINOSTAT
DRUG NAME BELEODAQ COVERED USES
ALL FDA APPROVED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D. EXCLUSION CRITERIA
REQUIRED MEDICAL INFORMATION AGE RESTRICTIONS
PRESCRIBER RESTRICTIONS COVERAGE DURATION 12 MONTHS
BEVACIZUMAB
DRUG NAME AVASTIN
COVERED USES
ALL FDA APPROVED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D. EXCLUSION CRITERIA
REQUIRED MEDICAL INFORMATION AGE RESTRICTIONS
PRESCRIBER RESTRICTIONS COVERAGE DURATION 12 MONTHS
BEXAROTENE
DRUG NAME TARGRETIN COVERED USES
ALL FDA APPROVED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D. EXCLUSION CRITERIA
REQUIRED MEDICAL INFORMATION AGE RESTRICTIONS
PRESCRIBER RESTRICTIONS COVERAGE DURATION 12 MONTHS
BORTEZOMIB
DRUG NAME VELCADE
COVERED USES
ALL FDA APPROVED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D. EXCLUSION CRITERIA
REQUIRED MEDICAL INFORMATION AGE RESTRICTIONS
PRESCRIBER RESTRICTIONS COVERAGE DURATION 12 MONTHS
BOSUTINIB
DRUG NAME BOSULIF
COVERED USES
ALL FDA APPROVED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D. EXCLUSION CRITERIA
REQUIRED MEDICAL INFORMATION AGE RESTRICTIONS
PRESCRIBER RESTRICTIONS COVERAGE DURATION 12 MONTHS
OTHER CRITERIA
CML: BCR-ABL MUTATIONAL ANALYSIS CONFIRMING THAT BOTH T315I AND V299L MUTATIONS ARE NOT PRESENT.
BOTULINUM NEUROTOXIN
DRUG NAME
BOTOX | DYSPORT | XEOMIN COVERED USES
ALL FDA APPROVED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D. EXCLUSION CRITERIA
COSMETIC DIAGNOSIS: WRINKLES. REQUIRED MEDICAL INFORMATION AGE RESTRICTIONS
PRESCRIBER RESTRICTIONS COVERAGE DURATION 12 MONTHS
OTHER CRITERIA
MIGRAINE HEADACHE: TRIAL OF TWO OF THE FOLLOWING: BETA BLOCKERS, TRICYCLIC ANTIDEPRESSANTS, OR VALPROIC ACID. OVERACTIVE BLADDER: TRIAL OR CONTRAINDICATION TO THE USE OF ONE ANTICHOLENERGIC MEDICATION ORAL OXYBUTYNIN, ORAL OXYBUTYNIN ER, TOLTERODINE, TOLTERODINE ER, TOVIAZ, TROSPIUM, OR TROPSIUM ER.
C1 ESTERASE INHIBITOR
DRUG NAME
BERINERT | CINRYZE | RUCONEST COVERED USES
ALL FDA APPROVED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D. EXCLUSION CRITERIA
REQUIRED MEDICAL INFORMATION AGE RESTRICTIONS PRESCRIBER RESTRICTIONS HEMATOLOGIST, IMMUNOLOGIST COVERAGE DURATION 12 MONTHS OTHER CRITERIA
CABOZANTINIB
DRUG NAME COMETRIQ COVERED USES
ALL FDA APPROVED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D. EXCLUSION CRITERIA
REQUIRED MEDICAL INFORMATION AGE RESTRICTIONS
PRESCRIBER RESTRICTIONS COVERAGE DURATION 12 MONTHS
CANAKINUMAB
DRUG NAME ILARIS
COVERED USES
ALL FDA APPROVED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D. EXCLUSION CRITERIA
REQUIRED MEDICAL INFORMATION AGE RESTRICTIONS
CAPS: 4 YEARS AND OLDER. SJIA: 2 YEARS AND OLDER. PRESCRIBER RESTRICTIONS
PRESCRIBED OR SUPERVISED BY RHEUMATOLOGIST COVERAGE DURATION
12 MONTHS
CANNABINOIDS
DRUG NAME MARINOL
COVERED USES
ALL FDA APPROVED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D. EXCLUSION CRITERIA
REQUIRED MEDICAL INFORMATION AGE RESTRICTIONS
PRESCRIBER RESTRICTIONS COVERAGE DURATION 6 MONTHS
OTHER CRITERIA
B VS D COVERAGE CONSIDERATION. FOR PART D COVERAGE CONSIDERATION: TRIAL OF OR CONTRAINDICATION TO CONVENTIONAL ANTIEMETIC THERAPIES (ONDANSETRON, STEROIDS USED FOR EMESIS, EMEND).
CERITINIB
DRUG NAME ZYKADIA
COVERED USES
ALL FDA APPROVED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D. EXCLUSION CRITERIA
REQUIRED MEDICAL INFORMATION
POSITIVE FOR ANAPLASTIC LYMPHOMA KINASE (ALK) FUSION ONCOGENE. AGE RESTRICTIONS
PRESCRIBER RESTRICTIONS COVERAGE DURATION 12 MONTHS
CERTOLIZUMAB PEGOL
DRUG NAME CIMZIA
COVERED USES
ALL FDA APPROVED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D. EXCLUSION CRITERIA
REQUIRED MEDICAL INFORMATION
RENEWAL: RHEUMATOID ARTHRITIS/ACTIVE PSORIATIC ARTHRITIS:
EXPERIENCED OR MAINTAINED 20% OR GREATER IMPROVEMENT IN TENDER AND SWOLLEN JOINT COUNT. FOR ANKYLOSING SPONDYLITIS: EXPERIENCED OR
MAINTAINED IMPROVEMENT OF AT LEAST 50 PERCENT OR 2 UNITS IN THE BATH ANKYLOSING SPONDYLITIS DISEASE ACTIVITY INDEX (BASDAI).
AGE RESTRICTIONS
PRESCRIBER RESTRICTIONS
PRESCRIBED BY OR IN CONSULTATION WITH: RHEUMATOID ARTHRITIS/ ANKYLOSING SPONDYLITIS: RHEUMATOLOGIST. PSORIATIC ARTHRITIS: DERMATOLOGIST OR RHEUMATOLOGIST. CROHN S DISEASE:
GASTROENTEROLOGIST. COVERAGE DURATION
INITIAL: RA /PSA/AS: 4 MONTHS. CD: 12 MONTHS. RENEWAL: 12 MONTHS FOR ALL DIAGNOSES.
OTHER CRITERIA
INITIAL: RHEUMATOID ARTHRITIS (RA)//PSORIATRIC ARTHRITIS (PSA)/: TRIAL OF HUMIRA AND PREVIOUS TRIAL WITH ONE DMARD (DISEASE-MODIFYING
ANTIRHEUMATIC DRUG) AGENT SUCH AS METHOTREXATE, LEFLUNOMIDE,
HYDROXYCHLOROQUINE, OR SULFASALAZINE. ANKYLOSING SPONDYLITIS: TRIAL OF HUMIRA. CROHN S DISEASE (CD): PREVIOUS TRIAL WITH HUMIRA AND ONE OF
CIMZIA, REMICADE, SIMPONI, OR SIMPONI ARIA) OR ANY OTHER BIOLOGIC DMARDS (DISEASE-MODIFYING ANTIRHEUMATIC DRUG) AGENTS SUCH AS (ACTEMRA, KINERET, STELARA, COSENTYX, ENTYVIO, TYSABRI, ORENCIA, OR RITUXAN).
CETUXIMAB
DRUG NAME ERBITUX
COVERED USES
ALL FDA APPROVED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D. EXCLUSION CRITERIA
REQUIRED MEDICAL INFORMATION AGE RESTRICTIONS
PRESCRIBER RESTRICTIONS COVERAGE DURATION 12 MONTHS
CHENODIOL
DRUG NAME CHENODAL COVERED USES
ALL FDA APPROVED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D. EXCLUSION CRITERIA
RADIOLUCENT GALLSTONES: NO FAILED TREATMENT WITH URSODIOL REQUIRED MEDICAL INFORMATION
AGE RESTRICTIONS
PRESCRIBER RESTRICTIONS COVERAGE DURATION 12 MONTHS
CLOBAZAM
DRUG NAME ONFI
COVERED USES
ALL FDA APPROVED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D. EXCLUSION CRITERIA
REQUIRED MEDICAL INFORMATION AGE RESTRICTIONS
2 YEARS OF AGE OR OLDER PRESCRIBER RESTRICTIONS COVERAGE DURATION 12 MONTHS
OTHER CRITERIA
TRIAL OF LAMOTRIGINE OR TOPIRAMATE. REQUESTS FOR ORAL SUSPENSION APPROVABLE IF PATIENT IS UNABLE TO SWALLOW OR IS UNDER THE AGE OF 5 YEARS.
CORTICOSTEROID BVD DETERMINATION
DRUG NAME
A-HYDROCORT | CORTEF | CORTISONE ACETATE | DEPO-MEDROL |
DEXAMETHASONE | DEXAMETHASONE SODIUM PHOSPHATE | HYDROCORTISONE | KENALOG-10 | KENALOG-40 | MEDROL | METHYLPREDNISOLONE |
METHYLPREDNISOLONE ACETATE | METHYLPREDNISOLONE SOD SUCC | ORAPRED ODT | PREDNISOLONE SODIUM PHOSPHATE | PREDNISONE | PREDNISONE INTENSOL | RAYOS | SOLU-CORTEF | SOLU-MEDROL | VERIPRED 20
COVERED USES
THIS DRUG MAY BE COVERED UNDER MEDICARE PART B OR D DEPENDING UPON THE CIRCUMSTANCES. INFORMATION MAY NEED TO BE SUBMITTED DESCRIBING THE USE AND SETTING OF THE DRUG TO MAKE THE DETERMINATION.
EXCLUSION CRITERIA
REQUIRED MEDICAL INFORMATION AGE RESTRICTIONS
PRESCRIBER RESTRICTIONS COVERAGE DURATION OTHER CRITERIA
CORTICOTROPIN
DRUG NAME H.P. ACTHAR COVERED USES
ALL FDA APPROVED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D. EXCLUSION CRITERIA
REQUIRED MEDICAL INFORMATION AGE RESTRICTIONS
PRESCRIBER RESTRICTIONS COVERAGE DURATION
INFANTILE SPASMS: 28 DAYS. MULTIPLE SCLEROSIS: 21 DAYS. OTHER FDA APPROVED INDICATIONS: 12 MONTHS
OTHER CRITERIA
ALL FDA APPROVED INDICATIONS EXCEPT INFANTILE SPASMS REQUIRE A TRIAL OR CONTRAINDICATION TO IV CORTICOSTEROIDS. NOT APPROVED IN PATIENTS WITH ACUTE EXACERBATION OF MULTIPLE SCLEROSIS OR OTHER FDA APPROVED INDICATIONS IF IV ACCESS CAN BE OBTAINED. NOT APPROVED FOR DIAGNOSTIC PURPOSES.
CRIZOTINIB
DRUG NAME XALKORI
COVERED USES
ALL FDA APPROVED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D. EXCLUSION CRITERIA
REQUIRED MEDICAL INFORMATION
LOCALLY ADVANCED OR METASTATIC NON SMALL CELL LUNG CANCER IS ANAPLASTIC LYMPHOMA KINASE POSITIVE.
AGE RESTRICTIONS
PRESCRIBER RESTRICTIONS COVERAGE DURATION 12 MONTHS
CYCLOPHOSPHAMIDE BVD DETERMINATION
DRUG NAME
CYCLOPHOSPHAMIDE COVERED USES
THIS DRUG MAY BE COVERED UNDER MEDICARE PART B OR D DEPENDING UPON THE CIRCUMSTANCES. INFORMATION MAY NEED TO BE SUBMITTED DESCRIBING THE USE AND SETTING OF THE DRUG TO MAKE THE DETERMINATION.
EXCLUSION CRITERIA
REQUIRED MEDICAL INFORMATION AGE RESTRICTIONS
PRESCRIBER RESTRICTIONS COVERAGE DURATION OTHER CRITERIA
DABRAFENIB MESYLATE
DRUG NAME TAFINLAR COVERED USES
ALL FDA APPROVED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D. EXCLUSION CRITERIA
REQUIRED MEDICAL INFORMATION AGE RESTRICTIONS
PRESCRIBER RESTRICTIONS COVERAGE DURATION 12 MONTHS
DALFAMPRIDINE
DRUG NAME AMPYRA
COVERED USES
ALL FDA APPROVED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D. EXCLUSION CRITERIA
REQUIRED MEDICAL INFORMATION
WALKING DISABILITY SUCH AS MILD TO MODERATE BILATERAL LOWER
EXTREMITY WEAKNESS OR UNILATERAL WEAKNESS PLUS LOWER EXTREMITY OR TRUNCAL ATAXIA.
AGE RESTRICTIONS
PRESCRIBER RESTRICTIONS NEUROLOGIST
COVERAGE DURATION
INITIAL: 3 MONTHS. RENEWAL: 12 MONTHS OTHER CRITERIA
RENEWAL: PATIENT HAS EXPERIENCED OR MAINTAINED AT LEAST 15% IMPROVEMENT IN WALKING ABILITY.
DASATINIB
DRUG NAME SPRYCEL
COVERED USES
ALL FDA APPROVED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D. EXCLUSION CRITERIA
REQUIRED MEDICAL INFORMATION AGE RESTRICTIONS
PRESCRIBER RESTRICTIONS COVERAGE DURATION 12 MONTHS
OTHER CRITERIA
PREVIOUSLY TREATED CML REQUIRES MUTATIONAL ANALYSIS NEGATIVE FOR THE FOLLOWING MUTATIONS FOLLOWING BCR-ABL MUTATIONAL ANALYSIS - T315I, V299L, T315A, F317L/V/I/C.
DENOSUMAB-XGEVA
DRUG NAME XGEVA
COVERED USES
ALL FDA APPROVED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D. EXCLUSION CRITERIA
DIAGNOSIS OF MULTIPLE MYELOMA REQUIRED MEDICAL INFORMATION AGE RESTRICTIONS
PRESCRIBER RESTRICTIONS COVERAGE DURATION 12 MONTHS
DICLOFENAC EPOLAMINE
DRUG NAME FLECTOR
COVERED USES
ALL FDA APPROVED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D. EXCLUSION CRITERIA
REQUIRED MEDICAL INFORMATION AGE RESTRICTIONS
PRESCRIBER RESTRICTIONS COVERAGE DURATION 12 MONTHS
DIMETHYL FUMARATE
DRUG NAME TECFIDERA COVERED USES
ALL FDA APPROVED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D. EXCLUSION CRITERIA
REQUIRED MEDICAL INFORMATION AGE RESTRICTIONS
18 YEARS AND OLDER
PRESCRIBER RESTRICTIONS COVERAGE DURATION
120 MG: 1 MONTH. 120-240 MG: 1 MONTH. 240 MG: 12 MONTHS OTHER CRITERIA
DROXIDOPA
DRUG NAME NORTHERA COVERED USES
ALL FDA APPROVED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D. EXCLUSION CRITERIA
REQUIRED MEDICAL INFORMATION AGE RESTRICTIONS
PRESCRIBER RESTRICTIONS COVERAGE DURATION 3 MONTHS
ELIGLUSTAT TARTRATE
DRUG NAME CERDELGA COVERED USES
ALL FDA APPROVED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D. EXCLUSION CRITERIA
REQUIRED MEDICAL INFORMATION AGE RESTRICTIONS
PRESCRIBER RESTRICTIONS COVERAGE DURATION 12 MONTHS
ELTROMBOPAG
DRUG NAME PROMACTA COVERED USES
ALL FDA APPROVED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D. EXCLUSION CRITERIA
REQUIRED MEDICAL INFORMATION AGE RESTRICTIONS
PRESCRIBER RESTRICTIONS COVERAGE DURATION
INITIAL:1 MOS. RENEWAL: CLINICAL RESPONSE: 12 MOS. MAX DOSE FOR 4 WEEKS: 1 MOS. HEP C: 12 MOS.
OTHER CRITERIA
CHRONIC IMMUNE (IDIOPATHIC) THROMBOCYTOPENIA PURPURA (ITP): INITIAL: TRIAL OF OR CONTRAINDICATION TO CORTICOSTEROIDS, IMMUNOGLOBULINS, OR AN INSUFFICIENT RESPONSE TO SPLENECTOMY. ITP: RENEWAL: PATIENT HAS A CLINICAL RESPONSE AS DEFINED BY AN INCREASE IN PLATELET COUNT OF GREATER THAN OR EQUAL TO 50 X10^9/L (GREATER THAN OR EQUAL TO 50,0000 PER UL) AT THE MAX DOSE OF 75MG PER DAY FOR 4 WEEKS. HEPATITIS C:
ENDOTHELIN RECEPTOR ANTAGONISTS
DRUG NAME
LETAIRIS | OPSUMIT | TRACLEER COVERED USES
ALL FDA APPROVED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D. EXCLUSION CRITERIA
REQUIRED MEDICAL INFORMATION AGE RESTRICTIONS PRESCRIBER RESTRICTIONS CARDIOLOGIST OR PULMONOLOGIST. COVERAGE DURATION 12 MONTHS OTHER CRITERIA
ENZALUTAMIDE
DRUG NAME XTANDI
COVERED USES
ALL FDA APPROVED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D. EXCLUSION CRITERIA
REQUIRED MEDICAL INFORMATION AGE RESTRICTIONS
PRESCRIBER RESTRICTIONS COVERAGE DURATION 12 MONTHS
OTHER CRITERIA
TRIAL OF OR CONTRAINDICATION TO DOCETAXEL. TRIAL OF ZYTIGA
(ABIRATERONE ACETATE) IS ALSO REQUIRED IN PATIENTS WHO DO NOT HAVE A CONTRAINDICATION OR INTOLERANCE TO PREDNISONEDOCETAXEL
ERIBULIN
DRUG NAME HALAVEN COVERED USES
ALL FDA APPROVED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D. EXCLUSION CRITERIA
REQUIRED MEDICAL INFORMATION AGE RESTRICTIONS
PRESCRIBER RESTRICTIONS COVERAGE DURATION 12 MONTHS
ERLOTINIB
DRUG NAME TARCEVA COVERED USES
ALL FDA APPROVED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D. EXCLUSION CRITERIA
REQUIRED MEDICAL INFORMATION AGE RESTRICTIONS
PRESCRIBER RESTRICTIONS COVERAGE DURATION 12 MONTHS
ERYTHROPOIESIS STIMULATING AGENTS - ARANESP
DRUG NAME ARANESP
COVERED USES
ALL FDA APPROVED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D. EXCLUSION CRITERIA
REQUIRED MEDICAL INFORMATION
INITIAL: CHRONIC RENAL FAILURE (CRF) REQUIRES HEMOGLOBIN LEVEL LESS THAN 10G/DL, CANCER CHEMOTHERAPY REQUIRES HEMOGLOBIN LESS THAN 11 G/DL OR HEMOGLOBIN LEVEL HAS DECREASED AT LEAST 2G/DL BELOW BASELINE. RENEWAL: CHRONIC RENAL FAILURE REQUIRES HEMOGLOBIN LEVELS LESS
THAN 10 G/DL IF NOT ON DIALYSIS AND LESS THAN 11 G/DL IF ON DIALYSIS OR HEMOGLOBIN HAS REACHED 11 G/DL IF ON DIALYSIS AND DOSE
REDUCTION/INTERRUPTION IS REQUIRED TO REDUCE THE NEED FOR BLOOD TRANSFUSIONS OR HEMOGLOBIN HAS REACHED 10 G/DL IF NOT ON DIALYSIS AND DOSE REDUCTION/INTERRUPTION IS REQUIRED TO REDUCE THE NEED FOR BLOOD TRANSFUSIONS. ANEMIA DUE TO EFFECT OF CONCOMITANTLY ADMINISTERED CANCER CHEMOTHERAPY REQUIRES HEMOGLOBIN LEVELS BETWEEN 10 AND 12 G/DL.
AGE RESTRICTIONS
PRESCRIBER RESTRICTIONS COVERAGE DURATION
ANEMIA DUE TO MYELOSUPPRESSIVE CHEMO/CKD WITHOUT DIALYSIS: 12 MONTHS.
ERYTHROPOIESIS STIMULATING AGENTS - EPOETIN ALFA
DRUG NAME
EPOGEN | PROCRIT COVERED USES
ALL FDA APPROVED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D. ADDITIONAL OFF LABEL ANEMIA IN HEPATITIS C BEING TREATED IN
COMBINATION WITH RIBAVIRIN AND AN INERFERON ALFA OR PEGINTERFERON ALFA.
EXCLUSION CRITERIA
REQUIRED MEDICAL INFORMATION
INITIAL: CHRONIC RENAL FAILURE (CRF) AND ANEMIA RELATED TO ZIDOVUDINE THERAPY REQUIRES HEMOGLOBIN LEVEL LESS THAN 10G/DL, CANCER
CHEMOTHERAPY REQUIRES HEMOGLOBIN LESS THAN 11 G/DL OR HEMOGLOBIN LEVEL HAS DECREASED AT LEAST 2G/DL BELOW BASELINE, ANEMIA DUE TO CONCURRENT HEPATITIS C TREATMENT WITH RIBAVIRIN AND INTERFERON ALFA/PEGINTERFERON ALFA REQUIRES HEMOGLOBIN LESS THAN 10G/DL AND RIBAVIRIN DOSE REDUCTION (UNLESS CONTRAINDICATED), ELECTIVE
NONCARDIAC OR NONVASCULAR SURGERY REQUIRES HEMOGLOBLIN LESS THAN 13G/DL RENEWAL: CRF HEMOGLOBIN LEVELS LESS THAN 10 G/DL IF NOT ON
DIALYSIS AND LESS THAN 11 G/DL IF ON DIALYSIS OR HEMOGLOBIN HAS REACHED 11 G/DL IF ON DIALYSIS AND DOSE REDUCTION/INTERRUPTION IS REQUIRED TO REDUCE THE NEED FOR BLOOD TRANSFUSIONS OR HEMOGLOBIN HAS REACHED 10 G/DL IF NOT ON DIALYSIS AND DOSE REDUCTION/INTERRUPTION IS REQUIRED TO REDUCE THE NEED FOR BLOOD TRANSFUSIONS. ANEMIA DUE TO EFFECT OF CONCOMITANTLY ADMINISTERED CANCER CHEMOTHERAPY OR ANEMIA DUE TO CONCURRENT HEPATITIS C TREATMENT WIITH RIBAVIRIN AND INTERFERON ALFA/PEGINTERFERON ALFA OR ANEMIA DUE TO ZIDOVUDINE THERAPY REQUIRES HEMOGLOBIN LEVELS BETWEEN 10 AND 12 G/DL.
AGE RESTRICTIONS
OTHER CRITERIA
ALL INDICATIONS: TRIAL OF PROCRIT. PART D MEMBER RECEIVING DIALYSIS OR IDENTIFIED AS A PART D END STAGE RENAL DISEASE MEMBER: PAYS UNDER PART B.
ERYTHROPOIESIS STIMULATING AGENTS -MIRCERA
DRUG NAME MIRCERA
COVERED USES
ALL FDA APPROVED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D. EXCLUSION CRITERIA
REQUIRED MEDICAL INFORMATION
CHRONIC RENAL FAILURE: INITIAL: HEMOGLOBIN LEVELS LESS THAN 10 G/DL RENEWAL: HEMOGLOBIN LEVELS LESS THAN 10 G/DL IF NOT ON DIALYSIS AND LESS THAN 11 G/DL IF ON DIALYSIS OR HEMOGLOBIN HAS REACHED 11 G/DL IF ON DIALYSIS AND DOSE REDUCTION/INTERRUPTION IS REQUIRED TO REDUCE THE NEED FOR BLOOD TRANSFUSIONS OR HEMOGLOBIN HAS REACHED 10 G/DL IF NOT ON DIALYSIS AND DOSE REDUCTION/INTERRUPTION IS REQUIRED TO REDUCE THE NEED FOR BLOOD TRANSFUSIONS.
AGE RESTRICTIONS
PRESCRIBER RESTRICTIONS COVERAGE DURATION
ANEMIA DUE TO CKD WITH OR WITHOUT DIALYSIS: 12 MONTHS. OTHER CRITERIA
TRIAL OF PROCRIT. PART D MEMBER RECEIVING DIALYSIS OR IDENTIFIED AS A PART D END STAGE RENAL DISEASE MEMBER: PAYS UNDER PART B.
ESRD BVD DETERMINATION
DRUG NAME
BONIVA | CALCITRIOL | CARNITOR | CARNITOR SF | DOXERCALCIFEROL | EMLA | HECTOROL | HEPARIN SODIUM | IBANDRONATE SODIUM | LEVOCARNITINE | LIDOCAINE | LIDOCAINE HCL | LIDOCAINE-PRILOCAINE | MIACALCIN |
PAMIDRONATE DISODIUM | PARICALCITOL | ROCALTROL | ZEMPLAR | ZOMETA COVERED USES
THIS DRUG MAY BE COVERED UNDER MEDICARE PART B OR D DEPENDING UPON THE CIRCUMSTANCES. INFORMATION MAY NEED TO BE SUBMITTED DESCRIBING THE USE AND SETTING OF THE DRUG TO MAKE THE DETERMINATION.
EXCLUSION CRITERIA
REQUIRED MEDICAL INFORMATION AGE RESTRICTIONS
PRESCRIBER RESTRICTIONS COVERAGE DURATION OTHER CRITERIA
ETANERCEPT
DRUG NAME ENBREL
COVERED USES
ALL FDA APPROVED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D. EXCLUSION CRITERIA
PATIENT IS NOT CURRENTLY TAKING KINERET (ANAKINRA) OR ORENCIA (ABATACEPT).
REQUIRED MEDICAL INFORMATION
INITIAL: PLAQUE PSORIASIS: MODERATE TO SEVERE PLAQUE PSORIASIS
INVOLVING GREATER THAN OR EQUAL TO 5 PERCENT BODY SURFACE AREA OR PSORIATIC LESIONS AFFECT THE HANDS, FEET, OR GENITAL AREA. RENEWAL: RHEUMATOID ARTHRITIS/JUVENILE IDIOPATHIC ARTHRITIS/PSORIATIC
ARTHRITIS: EXPERIENCED OR MAINTAINED 20 PERCENT OR GREATER
IMPROVEMENT IN TENDER OR SWOLLEN JOINT COUNT WHILE ON THERAPY.
ANKYLOSING SPONDYLITIS: EXPERIENCED OR MAINTAINED IMPROVEMENT OF AT LEAST 50 PERCENT OR 2 UNITS IN THE BATH ANKYLOSING SPONDYLITIS DISEASE ACTIVITY INDEX (BASDAI). PLAQUE PSORIASIS: ACHIEVED OR MAINTAINED CLEAR OR MINIMAL DISEASE OR A DECREASE IN PSORIASIS AREA AND SEVERITY INDEX (PASI) OF AT LEAST 50% OR MORE.
AGE RESTRICTIONS
PRESCRIBER RESTRICTIONS
PRESCRIBED BY OR IN CONSULTATION WITH: RHEUMATOID ARTHRITIS,
POLYARTICULAR JUVENILE IDIOPATHIC ARTHRITIS, ANKYLOSING SPONDYLITIS: RHEUMATOLOGIST. PSORIATIC ARTHRITIS: DERMATOLOGIST OR
RHEUMATOLOGIST. PSORIASIS: DERMATOLOGIST. COVERAGE DURATION
INITIAL: RA /PJIA: 3 MONTHS. PSA/AS/PSO: 4 MONTHS. RENEWAL: 12 MONTHS FOR ALL DIAGNOSES.
POLYARTICULAR JUVENILE IDIOPATHIC ARTHRITIS (PJIA):PREVIOUS TRIAL OF HUMIRA AND ORENCIA. PSORIATRIC ARTHRITIS (PSA): PREVIOUS TRIAL WITH HUMIRA FOLLOWED BY ONE OF THE FOLLOWING PREFERRED AGENT: CIMZIA, OR OTEZLA. ANKYLOSING SPONDYLITIS: PREVIOUS TRIAL WITH HUMIRA AND
CIMZIA. PLAQUE PSORIASIS (PSO): PREVIOUS TRIAL WITH HUMIRA FOLLOWED BY ONE OF THE FOLLOWING PREFERRED AGENT: COSENTYX OR OTEZLA. NOT
APPROVED FOR PATIENTS ON CONCURRENT THERAPY WITH KINERET (ANAKINRA) OR ORENCIA (ABATACEPT).
EVEROLIMUS
DRUG NAME
AFINITOR | AFINITOR DISPERZ COVERED USES
ALL FDA APPROVED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D. EXCLUSION CRITERIA
REQUIRED MEDICAL INFORMATION AGE RESTRICTIONS
PRESCRIBER RESTRICTIONS COVERAGE DURATION 12 MONTHS
OTHER CRITERIA
ADVANCED RENAL CELL CARCINOMA (RCC): TRIAL OF OR CONTRAINDICATION TO SUTENT OR NEXAVAR.
FENTANYL NASAL SPRAY
DRUG NAME LAZANDA COVERED USES
ALL FDA APPROVED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D. EXCLUSION CRITERIA
REQUIRED MEDICAL INFORMATION AGE RESTRICTIONS
PRESCRIBER RESTRICTIONS COVERAGE DURATION 6 MONTHS
OTHER CRITERIA
CANCER: CURRENTLY ON A MAINTENANCE DOSE OF CONTROLLED-RELEASE OPIOID PAIN MEDICATION (SUCH AS MORPHINE SULFATE SR, OXYCODONE SR, OR FENTANYL). EITHER A TRIAL OR CONTRAINDICATION TO AT LEAST ONE (1)
IMMEDIATE-RELEASE ORAL OPIOID PAIN AGENT (SUCH AS MORPHINE SULFATE IR, OXYCODONE/ASPIRIN, OXYCODONE/ACETAMINOPHEN,
CODEINE/ACETAMINOPHEN, HYDROMORPHONE, OR MEPERIDINE) OR MEMBER HAS DIFFICULTY SWALLOWING TABLETS/CAPSULES AND TRIAL OR
FENTANYL SUBLINGUAL SPRAY
DRUG NAME SUBSYS
COVERED USES
ALL FDA APPROVED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D. EXCLUSION CRITERIA
REQUIRED MEDICAL INFORMATION AGE RESTRICTIONS
PRESCRIBER RESTRICTIONS COVERAGE DURATION 6 MONTHS
OTHER CRITERIA
CANCER: CURRENTLY ON A MAINTENANCE DOSE OF CONTROLLED-RELEASE OPIOID PAIN MEDICATION (SUCH AS MORPHINE SULFATE SR, OXYCODONE SR, OR FENTANYL). EITHER A TRIAL OR CONTRAINDICATION TO AT LEAST ONE (1)
IMMEDIATE-RELEASE ORAL OPIOID PAIN AGENT (SUCH AS MORPHINE SULFATE IR, OXYCODONE/ASPIRIN, OXYCODONE/ACETAMINOPHEN,
CODEINE/ACETAMINOPHEN, HYDROMORPHONE, OR MEPERIDINE) OR MEMBER HAS DIFFICULTY SWALLOWING TABLETS/CAPSULES AND TRIAL OR
FENTANYL TRANSDERMAL PATCH
DRUG NAME
DURAGESIC | FENTANYL COVERED USES
ALL FDA APPROVED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D. EXCLUSION CRITERIA
REQUIRED MEDICAL INFORMATION AGE RESTRICTIONS
PRESCRIBER RESTRICTIONS COVERAGE DURATION 12 MONTHS
OTHER CRITERIA
OPIOID TOLERANCE (DEFINED AS THOSE WHO ARE TAKING, FOR ONE WEEK OR LONGER, AT LEAST 60 MG ORAL MORPHINE PER DAY, 25 MCG TRANSDERMAL FENTANYL/HOUR, 30 MG ORAL OXYCODONE/DAY, 25 MG ORAL
OXYMORPHONE/DAY, 8 MG ORAL HYDROMORPHONE/DAY, OR AN EQUIANALGESIC DOSE OF ANOTHER OPIOID). EVERY 48 HOUR DOSING CONSIDERED FOR PATIENTS WHO FAIL EVERY 72 HOUR DOSING. NO APPROVAL WHEN PRESCRIBED FOR AS NEEDED DOSAGE FREQUENCY.
FENTANYL TRANSMUCOSAL AGENTS
DRUG NAME
ABSTRAL | ACTIQ | FENTORA COVERED USES
ALL FDA APPROVED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D. EXCLUSION CRITERIA
REQUIRED MEDICAL INFORMATION AGE RESTRICTIONS
PRESCRIBER RESTRICTIONS COVERAGE DURATION 6 MONTHS
OTHER CRITERIA
CANCER: CURRENTLY ON A MAINTENANCE DOSE OF CONTROLLED-RELEASE OPIOID PAIN MEDICATION (SUCH AS MORPHINE SULFATE SR, OXYCODONE SR, OR FENTANYL). EITHER A TRIAL OR CONTRAINDICATION TO AT LEAST ONE (1)
IMMEDIATE-RELEASE ORAL OPIOID PAIN AGENT (SUCH AS MORPHINE SULFATE IR, OXYCODONE/ASPIRIN, OXYCODONE/ACETAMINOPHEN,
CODEINE/ACETAMINOPHEN, HYDROMORPHONE, OR MEPERIDINE) OR MEMBER HAS DIFFICULTY SWALLOWING TABLETS/CAPSULES AND TRIAL OR
FENTANYL TRANSMUCOSAL AGENTS - FENTANYL CITRATE
DRUG NAME
FENTANYL CITRATE COVERED USES
ALL FDA APPROVED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D. EXCLUSION CRITERIA
REQUIRED MEDICAL INFORMATION AGE RESTRICTIONS
PRESCRIBER RESTRICTIONS COVERAGE DURATION 6 MONTHS
OTHER CRITERIA
CANCER: CURRENTLY ON A MAINTENANCE DOSE OF CONTROLLED-RELEASE OPIOID PAIN MEDICATION (SUCH AS MORPHINE SULFATE SR, OXYCODONE SR, OR FENTANYL). EITHER A TRIAL OR CONTRAINDICATION TO AT LEAST ONE (1)
IMMEDIATE-RELEASE ORAL OPIOID PAIN AGENT (SUCH AS MORPHINE SULFATE IR, OXYCODONE/ASPIRIN, OXYCODONE/ACETAMINOPHEN,
CODEINE/ACETAMINOPHEN, HYDROMORPHONE, OR MEPERIDINE) OR MEMBER HAS DIFFICULTY SWALLOWING TABLETS/CAPSULES.
FINGOLIMOD
DRUG NAME GILENYA
COVERED USES
ALL FDA APPROVED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D. EXCLUSION CRITERIA
RECENT (WITHIN THE PAST 6 MONTHS) OCCURRENCE OF MYOCARDIAL INFARCTION, UNSTABLE ANGINA, STROKE, TRANSIENT ISCHEMIC ATTACK,
DECOMPENSATED HEART FAILURE REQUIRING HOSPITALIZATION, OR CLASS III/IV HEART FAILURE. HISTORY OR PRESENCE OF MOBITZ TYPE II 2ND DEGREE OR 3RD DEGREE AV BLOCK OR SICK SINUS SYNDROME, UNLESS PATIENT HAS A
PACEMAKER. BASELINE QTC INTERVAL OF 500MS OR ABOVE. TREATMENT WTIH CLASS 1A (QUINIDINE, PROCAINAMIDE, OR DISOPYRAMIDE) OR CLASS III ANTI-ARRHYTHMIC DRUGS (AMIODARONE, DOFETILIDE, DRONEDARONE, IBUTILIDE, OR SOTALOL).
REQUIRED MEDICAL INFORMATION AGE RESTRICTIONS
PRESCRIBER RESTRICTIONS COVERAGE DURATION 12 MONTHS
OTHER CRITERIA
MEDICATION WILL NOT BE APPROVED FOR PATIENTS WITH ONE OF THE
FOLLOWING CONDITIONS: RECENT (WITHIN PAST 6 MONTHS) OCCURRENCE OF MYOCARDIAL INFARCTION, UNSTABLE ANGINA, STROKE, TRANSIENT ISCHEMIC ATTACK, DECOMPENSATED HEART FAILURE REQUIRING HOSPITALIZATION, OR CLASS III/IV HEART FAILURE. HISTORY OR PRESENCE OF MOBITZ TYPE II 2ND DEGREE OR 3RD DEGREE AV BLOCK OR SICK SINUS SYNDROME, UNLESS PATIENT
GLP-1 ANALOGS
DRUG NAME
BYDUREON | BYDUREON PEN | BYETTA | TANZEUM COVERED USES
ALL FDA APPROVED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D. EXCLUSION CRITERIA
REQUIRED MEDICAL INFORMATION AGE RESTRICTIONS
PRESCRIBER RESTRICTIONS COVERAGE DURATION 12 MONTHS
OTHER CRITERIA
TRIAL OF OR CONTRAINDICATION TO A FORMULARY GLP-1 AGONIST (VICTOZA, TRULICITY) AND ONE OF THE FOLLOWING: METFORMIN, METFORMIN ER, A
SULFONYLUREA, A METFORMIN-SULFONYLUREA COMBINATION, PIOGLITAZONE, A PIOGLITAZONE-METFORMIN COMBINATION OR A PIOGLITAZONE-GLIMEPIRIDE COMBINATION.
GLYCEROL PHENYLBUTYRATE
DRUG NAME RAVICTI
COVERED USES
ALL FDA APPROVED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D. EXCLUSION CRITERIA
REQUIRED MEDICAL INFORMATION AGE RESTRICTIONS
PRESCRIBER RESTRICTIONS COVERAGE DURATION 12 MONTHS
OTHER CRITERIA
GOLIMUMAB IV
DRUG NAME SIMPONI ARIA COVERED USES
ALL FDA APPROVED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D. EXCLUSION CRITERIA
REQUIRED MEDICAL INFORMATION
RHEUMATOID ARTHRITIS. RENEWAL: AT LEAST 20% IMPROVEMENT IN TENDER JOINT COUNT AND SWOLLEN JOINT COUNT.
AGE RESTRICTIONS
18 YEARS OF AGE AND OLDER PRESCRIBER RESTRICTIONS
PRESCRIBED BY OR IN CONSULTATION WITH: RHEUMATOLOGIST. COVERAGE DURATION
INITIAL: 4 MOS RENEWAL: 12 MOS OTHER CRITERIA
INITIAL: PREVIOUS TRIAL HUMIRA FOLLOWED BY ONE OF THE FOLLOWING PREFERRED AGENT: ORENCIA, XELJANZ, OR CIMZIA. NOT APPROVED FOR PATIENTS ON CONCURRENT THERAPY WITH ORENCIA OR KINERET.
GOLIMUMAB SQ
DRUG NAME SIMPONI
COVERED USES
ALL FDA APPROVED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D. EXCLUSION CRITERIA
REQUIRED MEDICAL INFORMATION
RENEWAL: ACTIVE RHEUMATOID ARTHRITIS/PSORIATIC ARTHRITIS: MAINTAINED OR EXPERIENCED GREATER THAN 20% IMPROVEMENT IN TENDER JOINT COUNT AND SWOLLEN JOINT COUNT. ANKYLOSING SPONDYLITIS: MAINTAINED OR
EXPERIENCED GREATER THAN 20% IMPROVEMENT IN ANKYLOSING SPONDYLITIS (ASAS20) CRITERIA.
AGE RESTRICTIONS 18 YEARS OR OLDER
PRESCRIBER RESTRICTIONS
PRESCRIBED BY OR IN CONSULTATION WITH: RHEUMATOID ARTHRITIS, ANKYLOSING SPONDYLITIS: RHEUMATOLOGIST. PSORIATIC ARTHRITIS: DERMATOLOGIST OR RHEUMATOLOGIST. ULCERATIVE COLITIS:
GASTROENTEROLOGIST. COVERAGE DURATION
INITIAL: RA /PSA/AS: 4 MONTHS. UC: 12 MONTHS RENEWAL: 12 MONTHS FOR ALL DIAGNOSES.
METHOTREXATE, OR MESALAMINE. NOT APPROVED FOR PATIENTS ON CONCURRENT THERAPY WITH ORENCIA OR KINERET.
HEPATITIS B VACCINE BVD DETERMINATION
DRUG NAME
ENGERIX-B ADULT | ENGERIX-B PEDIATRIC-ADOLESCENT | RECOMBIVAX HB COVERED USES
THIS DRUG MAY BE COVERED UNDER MEDICARE PART B OR D DEPENDING UPON THE CIRCUMSTANCES. INFORMATION MAY NEED TO BE SUBMITTED DESCRIBING THE USE AND SETTING OF THE DRUG TO MAKE THE DETERMINATION.
EXCLUSION CRITERIA
REQUIRED MEDICAL INFORMATION AGE RESTRICTIONS
PRESCRIBER RESTRICTIONS COVERAGE DURATION OTHER CRITERIA
HIGH RISK DRUGS IN THE ELDERLY - ANTI-INFECTIVE
DRUG NAME
FURADANTIN | MACROBID | MACRODANTIN | NITROFURANTOIN | NITROFURANTOIN MONO-MACRO
COVERED USES
ALL FDA APPROVED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D. EXCLUSION CRITERIA
REQUIRED MEDICAL INFORMATION AGE RESTRICTIONS
APPROPRIATE HIGH RISK MEDICATION USE: 65 YEARS OF AGE OR OLDER. PA NOT REQUIRED FOR AGE 0-64 YEARS.
PRESCRIBER RESTRICTIONS COVERAGE DURATION 12 MONTHS
OTHER CRITERIA
TRIAL OF (UNLESS CONTRAINDICATED) OF SULFAMETHOXAZOLE/TRIMETHOPRIM (TMP-SMX) OR TRIMETHOPRIM.
HIGH RISK DRUGS IN THE ELDERLY - ANTICHOLINERGICS - BENZTROPINE_TRIHEXYPHENIDYL
DRUG NAME
BENZTROPINE MESYLATE | COGENTIN | TRIHEXYPHENIDYL HCL COVERED USES
ALL FDA APPROVED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D. EXCLUSION CRITERIA
REQUIRED MEDICAL INFORMATION AGE RESTRICTIONS
APPROPRIATE HIGH RISK MEDICATION USE: 65 YEARS OF AGE OR OLDER. PA NOT REQUIRED FOR AGE 0-64 YEARS.
PRESCRIBER RESTRICTIONS COVERAGE DURATION 12 MONTHS
OTHER CRITERIA
PRESCRIBER ACKNOWLEDGEMENT/AWARENESS DRUG IS LABELED AS HIGH RISK MEDICATION IN THE ELDERLY FOR PATIENTS 65 YEARS AND OLDER.
HIGH RISK DRUGS IN THE ELDERLY - ANTICHOLINERGICS - DIPHENHYDRAMINE
DRUG NAME
DIPHENHYDRAMINE HCL COVERED USES
ALL FDA APPROVED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D. EXCLUSION CRITERIA
REQUIRED MEDICAL INFORMATION AGE RESTRICTIONS
APPROPRIATE HIGH RISK MEDICATION USE: 65 YEARS OF AGE OR OLDER. PA NOT REQUIRED FOR AGE 0-64 YEARS.
PRESCRIBER RESTRICTIONS COVERAGE DURATION 12 MONTHS
OTHER CRITERIA
PRURITUS/URTICARIA/SEASONAL/PERENNIAL ALLERGY: TRIAL OR
CONTRAINDICATION TO A NON-SEDATING ANTIHISTAMINE (LEVOCETIRIZINE). MOTION SICKNESS: TRIAL OR CONTRAINDICATION TO MECLIZINE. INSOMNIA: TRIAL OF SILENOR AND ROZERUM.
HIGH RISK DRUGS IN THE ELDERLY - ANTICHOLINERGICS - HYDROXYZINE
DRUG NAME
HYDROXYZINE HCL | HYDROXYZINE PAMOATE | VISTARIL COVERED USES
ALL FDA APPROVED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D. SEASONAL/PERENNIAL ALLERGIC RHINITIS.
EXCLUSION CRITERIA
REQUIRED MEDICAL INFORMATION AGE RESTRICTIONS
APPROPRIATE HIGH RISK MEDICATION USE: 65 YEARS OF AGE OR OLDER. PA NOT REQUIRED FOR AGE 0-64 YEARS.
PRESCRIBER RESTRICTIONS COVERAGE DURATION 12 MONTHS
OTHER CRITERIA
PRURITUS/URTICARIA/SEASONAL/PERENNIAL ALLERGY: TRIAL OR CONTRAINDICATION TO A NON-SEDATING ANTIHISTAMINE SUCH AS
LEVOCETIRIZINE. ANXIETY: TRIAL OR CONTRAINDICATION TO TWO (2) OF THE FOLLOWING - BUSPIRONE, PAROXETINE, DULOXETINE, OR VENLAFAXINE.
HIGH RISK DRUGS IN THE ELDERLY - ANTICHOLINERGICS - PROMETHAZINE
DRUG NAME
PHENADOZ | PHENERGAN | PROMETHAZINE HCL | PROMETHEGAN COVERED USES
ALL FDA APPROVED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D. EXCLUSION CRITERIA
REQUIRED MEDICAL INFORMATION AGE RESTRICTIONS
APPROPRIATE HIGH RISK MEDICATION USE: 65 YEARS OF AGE OR OLDER. PA NOT REQUIRED FOR AGE 0-64 YEARS.
PRESCRIBER RESTRICTIONS COVERAGE DURATION 12 MONTHS
OTHER CRITERIA
PRURITUS/URTICARIA/SEASONAL/PERENNIAL ALLERGY: TRIAL OR CONTRAINDICATION TO A NON-SEDATING ANTIHISTAMINE SUCH AS
LEVOCETIRIZINE. ANXIETY: TRIAL OR CONTRAINDICATION TO TWO (2) OF THE FOLLOWING - BUSPIRONE, PAROXETINE, DULOXETINE, OR VENLAFAXINE. MOTION SICKNESS: TRIAL OR CONTRAINDICATION TO MECLIZINE.
HIGH RISK DRUGS IN THE ELDERLY - BARBITURATE COMBINATIONS
DRUG NAME
ACETAMINOPHEN-BUTALBITAL | ASCOMP WITH CODEINE | BUTALB-ACETAMINOPH-CAFF-CODEIN | BUTALB-CAFF-ACETAMINOPH-CODEIN |
BUTALBITAL-ACETAMINOPHEN-CAFFE | BUTALBITAL-ASPIRIN-CAFFEINE | ESGIC | FIORICET WITH CODEINE | FIORINAL | FIORINAL WITH CODEINE #3
COVERED USES
ALL FDA APPROVED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D. EXCLUSION CRITERIA
REQUIRED MEDICAL INFORMATION AGE RESTRICTIONS
APPROPRIATE HIGH RISK MEDICATION USE: 65 YEARS OF AGE OR OLDER. PA NOT REQUIRED FOR AGE 0-64 YEARS.
PRESCRIBER RESTRICTIONS COVERAGE DURATION 6 MONTHS
OTHER CRITERIA
PRESCRIBER ACKNOWLEDGEMENT/AWARENESS DRUG IS LABELED AS HIGH RISK MEDICATION IN THE ELDERLY FOR PATIENTS 65 YEARS AND OLDER.
HIGH RISK DRUGS IN THE ELDERLY - BENZODIAZEPINE SEDIATIVE HYPNOTICS
DRUG NAME
ESTAZOLAM | FLURAZEPAM HCL | HALCION | RESTORIL | TEMAZEPAM | TRIAZOLAM
COVERED USES
ALL FDA APPROVED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D. EXCLUSION CRITERIA
REQUIRED MEDICAL INFORMATION AGE RESTRICTIONS
APPROPRIATE HIGH RISK MEDICATION USE: 65 YEARS OF AGE OR OLDER. PA NOT REQUIRED FOR AGE 0-64 YEARS.
PRESCRIBER RESTRICTIONS COVERAGE DURATION
INITIAL: TRIAL OF SILENOR AND ROZERUM: 12 MOS. PRESCRIBER ACKNOWLEGE HRM: 2 MOS. RENEW: 12 MOS
OTHER CRITERIA
INITIAL: TRIAL OF SILENOR AND ROZEREM QUALIFIES FOR 12 MONTH APPROVAL. PRESCRIBER ACKNOWLEDGEMENT/ AWARENESS DRUG IS LABELED AS HIGH RISK MEDICATION IN THE ELDERLY FOR PATIENTS 65 YEARS AND OLDER QUALIFIES FOR 2 MONTH APPROVAL RENEWAL: PRESCRIBER
ACKNOWLEDGEMENT/AWARENESS DRUG IS LABELED AS HIGH RISK MEDICATION IN THE ELDERLY FOR PATIENTS 65 YEARS AND OLDER OR TRIAL OF SILENOR AND ROZEREM.
HIGH RISK DRUGS IN THE ELDERLY - CARDIOVASCULAR
DRUG NAME
GUANFACINE HCL | METHYLDOPA | METHYLDOPA-HYDROCHLOROTHIAZIDE | NIFEDIPINE | PROCARDIA | TENEX
COVERED USES
ALL FDA APPROVED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D. EXCLUSION CRITERIA
REQUIRED MEDICAL INFORMATION AGE RESTRICTIONS
APPROPRIATE HIGH RISK MEDICATION USE: 65 YEARS OF AGE OR OLDER. PA NOT REQUIRED FOR AGE 0-64 YEARS.
PRESCRIBER RESTRICTIONS COVERAGE DURATION 12 MONTHS
OTHER CRITERIA
HYPERTENSION: TRIAL OR CONTRAINDICATION TO TWO (2) OF THE FOLLOWING - BENAZEPRIL, BENAZEPRIL/HYDROCHLOROTHIAZIDE, CAPTOPRIL,
CAPTOPRIL/HYDROCHLOROTHIAZIDE, ENALAPRIL, ENALAPRIL/HYDROCHLOROTHIAZIDE, FOSINOPRIL, FOSINOPRIL/HYDROCHLOROTHIAZIDE, LISINOPRIL,
BISOPROLOL/HYDROCHLOROTHIAZIDE, CARVEDILOL, METOPROLOL TARTRATE, NADOLOL, ACEBUTOLOL, BETAXOLOL, LABETAOL, METOPROLOL SUCCINATE, METOPROLOL/HYDROCHLOROTHIAZIDE, PINDOLOL, PROPANOLOL,
HIGH RISK DRUGS IN THE ELDERLY - CENTRAL NERVOUS SYSTEM - MEPROBAMATE
DRUG NAME MEPROBAMATE COVERED USES
ALL FDA APPROVED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D. EXCLUSION CRITERIA
REQUIRED MEDICAL INFORMATION AGE RESTRICTIONS
APPROPRIATE HIGH RISK MEDICATION USE: 65 YEARS OF AGE OR OLDER. PA NOT REQUIRED FOR AGE 0-64 YEARS.
PRESCRIBER RESTRICTIONS COVERAGE DURATION 12 MONTHS
OTHER CRITERIA
ANXIETY: PRESCRIBER ACKNOWLEDGEMENT/AWARENESS DRUG IS LABELED AS HIGH RISK MEDICATION IN THE ELDERLY FOR PATIENTS 65 YEARS AND OLDER.
HIGH RISK DRUGS IN THE ELDERLY - CENTRAL NERVOUS SYSTEM - THIORIDAZINE
DRUG NAME
THIORIDAZINE HCL COVERED USES
ALL FDA APPROVED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D. EXCLUSION CRITERIA
REQUIRED MEDICAL INFORMATION AGE RESTRICTIONS
PRESCRIBER RESTRICTIONS COVERAGE DURATION 12 MONTHS
OTHER CRITERIA
65 YEARS AND OLDER: SCHIZOPHRENIA - PRESCRIBER
ACKNOWLEDGEMENT/AWARENESS DRUG IS LABELED AS HIGH RISK MEDICATION IN THE ELDERLY FOR PATIENTS 65 YEARS AND OLDER. PRIOR AUTHORIZTAION APPLIES TO NEW START ONLY
HIGH RISK DRUGS IN THE ELDERLY - DIGOXIN
DRUG NAME
DIGITEK | DIGOX | DIGOXIN | LANOXIN COVERED USES
ALL FDA APPROVED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D. EXCLUSION CRITERIA
REQUIRED MEDICAL INFORMATION DIGOXIN LEVEL
AGE RESTRICTIONS
APPROPRIATE HIGH RISK MEDICATION USE: 65 YEARS OF AGE OR OLDER. PA NOT REQUIRED FOR AGE 0-64 YEARS.
PRESCRIBER RESTRICTIONS COVERAGE DURATION 12 MONTHS
OTHER CRITERIA
APPROVAL FOR MEMBERS STABLE ON DOSES GREATER THAN 125 MCG PER DAY WITH DOCUMENTED THERAPEUTIC DIGOXIN LEVEL TAKEN WITHIN THE PAST YEAR.
HIGH RISK DRUGS IN THE ELDERLY - ENDOCRINE - ESTROGEN
DRUG NAME
ACTIVELLA | ALORA | ANGELIQ | CLIMARA | CLIMARA PRO | COMBIPATCH | DIVIGEL | DUAVEE | ELESTRIN | ENJUVIA | ESTRACE | ESTRADIOL | ESTRADIOL-NORETHINDRONE ACETAT | ESTROPIPATE | EVAMIST | FEMHRT | JINTELI | LOPREEZA | MENEST | MENOSTAR | MIMVEY | MIMVEY LO | MINIVELLE | NORETHINDRON-ETHINYL ESTRADIOL | PREFEST | PREMARIN | PREMPHASE | PREMPRO | VIVELLE-DOT
COVERED USES
ALL FDA APPROVED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D. EXCLUSION CRITERIA
REQUIRED MEDICAL INFORMATION AGE RESTRICTIONS
APPROPRIATE HIGH RISK MEDICATION USE: 65 YEARS OF AGE OR OLDER. PA NOT REQUIRED FOR AGE 0-64 YEARS.
PRESCRIBER RESTRICTIONS COVERAGE DURATION 12 MONTHS
OTHER CRITERIA
VULVAR/VAGINAL ATROPHY: TRIAL OR CONTRAINDICATION TO TWO (2) OF THE FOLLOWING - ESTRACE VAGINAL CREAM, PREMARIN VAGINAL CREAM, OR VAGIFEM. OSTEOPOROSIS: TRIAL OR CONTRAINDICATION TO ONE OF THE FOLLOWING - ALENDRONATE, IBANDRONATE, OR RALOXIFENE. VASOMOTOR SYMPTOMS OF MENOPAUSE: PRESCRIBER ACKNOWLEDGEMENT/AWARENESS DRUG IS LABELED AS HIGH RISK MEDICATION IN THE ELDERLY FOR PATIENTS 65 YEARS AND OLDER. ALL OTHER FDA APPROVED INDICATIONS, SUCH AS
HIGH RISK DRUGS IN THE ELDERLY - ENDOCRINE - SULFONYLUREAS
DRUG NAME
CHLORPROPAMIDE | DIABETA | GLUCOVANCE | GLYBURIDE | GLYBURIDE MICRONIZED | GLYBURIDE-METFORMIN HCL | GLYNASE
COVERED USES
ALL FDA APPROVED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D. EXCLUSION CRITERIA
REQUIRED MEDICAL INFORMATION AGE RESTRICTIONS
APPROPRIATE HIGH RISK MEDICATION USE: 65 YEARS OF AGE OR OLDER. PA NOT REQUIRED FOR AGE 0-64 YEARS.
PRESCRIBER RESTRICTIONS COVERAGE DURATION
INITIAL: TRIAL OF ALTERNATIVES: 12 MOS. PRESCRIBER ACKNOWLEGEMENT OF HRM: 2 MOS. RENEWAL: 12 MOS
OTHER CRITERIA
INITIAL: TRIAL OF GLIIMEPIRIDE OR GLIPIZIDE QUALIFIED FOR 12 MONTH
APPROVAL. PRESCRIBER ACKNOWLEDGEMENT/ AWARENESS DRUG IS LABELED AS HIGH RISK MEDICATION IN THE ELDERLY FOR PATIENTS 65 YEARS AND OLDER QUALIFIES FOR 2 MONTH APPROVAL RENEWAL: PRESCRIBER
ACKNOWLEDGEMENT/AWARENESS DRUG IS LABELED AS HIGH RISK MEDICATION IN THE ELDERLY FOR PATIENTS 65 YEARS AND OLDER OR TRIAL OF GLIMEPIRIDIE OR GLIPIZIDE.
HIGH RISK DRUGS IN THE ELDERLY - INDOMETHACIN
DRUG NAME
INDOCIN | INDOMETHACIN COVERED USES
ALL FDA APPROVED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D. EXCLUSION CRITERIA
REQUIRED MEDICAL INFORMATION AGE RESTRICTIONS
APPROPRIATE HIGH RISK MEDICATION USE: 65 YEARS OF AGE OR OLDER. PA NOT REQUIRED FOR AGE 0-64 YEARS.
PRESCRIBER RESTRICTIONS COVERAGE DURATION 12 MONTHS
OTHER CRITERIA
TRIAL OF OR CONTRAINDICATION TO CELECOXIB OR A TOPICAL NON-STEROIDAL ANTI-INFLAMMATORY DRUG (NSAID) SUCH AS VOLTAREN GEL OR FLECTOR.
PRESCRIPTIONS WRITTEN BY A RHEUMATOLOGIST DO NOT REQUIRE TRIAL OF FORMULARY ALTERNATIVES.
HIGH RISK DRUGS IN THE ELDERLY - NON-BENZODIAZEPINE
DRUG NAME
AMBIEN | AMBIEN CR | EDLUAR | ESZOPICLONE | INTERMEZZO | LUNESTA | SONATA | ZALEPLON | ZOLPIDEM TARTRATE | ZOLPIDEM TARTRATE ER | ZOLPIMIST
COVERED USES
ALL FDA APPROVED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D. EXCLUSION CRITERIA
REQUIRED MEDICAL INFORMATION AGE RESTRICTIONS
APPROPRIATE HIGH RISK MEDICATION USE: 65 YEARS OF AGE OR OLDER. PA NOT REQUIRED FOR AGE 0-64 YEARS.
PRESCRIBER RESTRICTIONS COVERAGE DURATION
INITIAL: TRIAL OF SILENOR AND ROZERUM: 12 MOS. PRESCRIBER ACKNOWLEGE HRM: 2 MOS. RENEW: 12 MOS
OTHER CRITERIA
INITIAL: TRIAL OF SILENOR AND ROZEREM QUALIFIES FOR 12 MONTH APPROVAL. PRESCRIBER ACKNOWLEDGEMENT/ AWARENESS DRUG IS LABELED AS HIGH RISK MEDICATION IN THE ELDERLY FOR PATIENTS 65 YEARS AND OLDER QUALIFIES FOR 2 MONTH APPROVAL RENEWAL: PRESCRIBER
ACKNOWLEDGEMENT/AWARENESS DRUG IS LABELED AS HIGH RISK MEDICATION IN THE ELDERLY FOR PATIENTS 65 YEARS AND OLDER OR TRIAL OF SILENOR AND ROZEREM.
HIGH RISK DRUGS IN THE ELDERLY - SKELETAL MUSCLE RELAXANTS
DRUG NAME
AMRIX | CARISOPRODOL | CARISOPRODOL-ASPIRIN | CARISOPRODOL-ASPIRIN-CODEINE | CHLORZOXAZONE | CYCLOBENZAPRINE HCL | FEXMID | LORZONE | METAXALONE | METHOCARBAMOL | ORPHENADRINE CITRATE | PARAFON FORTE DSC | SKELAXIN | SOMA
COVERED USES
ALL FDA APPROVED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D. EXCLUSION CRITERIA
REQUIRED MEDICAL INFORMATION AGE RESTRICTIONS
APPROPRIATE HIGH RISK MEDICATION USE: 65 YEARS OF AGE OR OLDER. PA NOT REQUIRED FOR AGE 0-64 YEARS.
PRESCRIBER RESTRICTIONS COVERAGE DURATION 12 MONTHS
OTHER CRITERIA
PRESCRIBER ACKNOWLEDGEMENT/AWARENESS DRUG IS LABELED AS HIGH RISK MEDICATION IN THE ELDERLY FOR PATIENTS 65 YEARS AND OLDER.
HIGH RISK DRUGS IN THE ELDERLY - TCA
DRUG NAME
AMITRIPTYLINE HCL | ANAFRANIL | CHLORDIAZEPOXIDE-AMITRIPTYLINE |
CLOMIPRAMINE HCL | DOXEPIN HCL | IMIPRAMINE HCL | IMIPRAMINE PAMOATE | PERPHENAZINE-AMITRIPTYLINE | SURMONTIL | TOFRANIL | TOFRANIL-PM
COVERED USES
ALL FDA APPROVED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D. MIGRAINE HEADACHE AND POST-HERPETIC NEURALGIA.
EXCLUSION CRITERIA
REQUIRED MEDICAL INFORMATION AGE RESTRICTIONS
PRESCRIBER RESTRICTIONS COVERAGE DURATION 12 MONTHS
OTHER CRITERIA
APPLIES TO MEMBERS 65 YEARS AND OLDER FOR THE FOLLOWING: MIGRAINE PROPHYLAXIS: TRIAL OR CONTRAINDICATION TO TWO (2) OF THE FOLLOWING - PROPRANOLOL, TIMOLOL, TOPIRAMATE, VALPROIC ACID, OR DIVALPROEX. DEPRESSION: TRIAL OR CONTRAINDICATION TO TWO (2) OF THE FOLLOWING - PAROXETINE, SERTRALINE, VENLAFAXINE, DULOXETINE, CITALOPRAM,
ESCITALOPRAM, FLUOXETINE, OR TRAZODONE. POSTHERPERTIC NEURALGIA: TRIAL OR CONTRAINDICATION TO GABAPENTIN OR PREGABALIN. PRIOR
HYDROCODONE BITARTRATE EXTENDED RELEASE
DRUG NAME
HYSINGLA ER | ZOHYDRO ER COVERED USES
ALL FDA APPROVED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D. EXCLUSION CRITERIA
USE AS AN AS NEEDED PAIN ANALGESIC. REQUIRED MEDICAL INFORMATION AGE RESTRICTIONS
PRESCRIBER RESTRICTIONS COVERAGE DURATION 12 MONTHS
OTHER CRITERIA
MUST MEET DEFINED CRITERIA FOR OPIOID TOLERANCE (OPIOID TOLERANCE ARE THOSE RECEIVING, FOR ONE WEEK OR LONGER, AT LEAST 60 MG ORAL MORPHINE PER DAY, 25 MCG TRANSDERMAL FENTANYL PER HOUR, 30 MG ORAL OXYCODONE PER DAY, 8 MG ORAL HYDROMORPHONE PER DAY, 25 MG ORAL OXYMORPHONE PER DAY, OR AN EQUIANALGESIC DOSE OF ANOTHER OPIOID) IN ORDER TO START AT HIGHER DOSES THAN 10MG EVERY 12 HRS.
HYDROMORPHONE ER
DRUG NAME
EXALGO | HYDROMORPHONE ER COVERED USES
ALL FDA APPROVED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D. EXCLUSION CRITERIA
REQUIRED MEDICAL INFORMATION AGE RESTRICTIONS
PRESCRIBER RESTRICTIONS COVERAGE DURATION 12 MONTHS
OTHER CRITERIA
OPIOID TOLERANCE (DEFINED AS THOSE WHO ARE TAKING, FOR ONE WEEK OR LONGER, AT LEAST 60 MG ORAL MORPHINE PER DAY, 25 MCG TRANSDERMAL FENTANYL/HOUR, 30 MG ORAL OXYCODONE/DAY, 25 MG ORAL
OXYMORPHONE/DAY, 8 MG ORAL HYDROMORPHONE/DAY, OR AN EQUIANALGESIC DOSE OF ANOTHER OPIOID). REQUESTS FOR 32 MG STRENGTH REQUIRE PAIN
SPECIALIST RECOMMENDATION. NO APPROVAL WHEN PRESCRIBED FOR AS NEEDED DOSAGE FREQUENCY.
IBRUTINIB
DRUG NAME IMBRUVICA COVERED USES
ALL FDA APPROVED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D. EXCLUSION CRITERIA
REQUIRED MEDICAL INFORMATION AGE RESTRICTIONS
PRESCRIBER RESTRICTIONS COVERAGE DURATION 12 MONTHS
IDELALISIB
DRUG NAME ZYDELIG
COVERED USES
ALL FDA APPROVED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D. EXCLUSION CRITERIA
REQUIRED MEDICAL INFORMATION AGE RESTRICTIONS
PRESCRIBER RESTRICTIONS COVERAGE DURATION 12 MONTHS