Prior Authorization Criteria

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Prior Authorization Criteria

Adalimumab

Based on the review of medical literature Adalimumab Injection is considered appropriate treatment for those members who meet the following criteria:

A. A documented diagnosis of moderate to severe active rheumatoid arthritis.

OR

B. A documented diagnosis of moderate to severe active polyarticular-course juvenile rheumatoid arthritis

AND

C. A documented diagnosis of moderate to severe chronic plaque psoriasis.

AND

D. Failure of a trial of methotrexate, unless contraindicated;

OR

E. Patients intolerant of or have contraindication to methotrexate or have failed therapy with other DMARDs (cyclophosphamide, cyclosporine, corticosteroids, D-pencillamine, gold,

hydroxychloroquine, sulfasalazine AND

F. Must be self administered or administered by a family member.

OR

G. Documented diagnosis of Chrohn’s Disease.

Artemether-Lumefantrine

Based on the review of medical literature Artemether-Lumefantrine is considered appropriate or the

treatment of acute, uncomplicated malaria infections due to Plasmodium falciparum in patients weighing 5 kg or more.

AND

Administered in 6 doses (3 days) of 4 tablets Atovaquone-Proguanil HCL

Based on the review of medical literature Atovaquone-Proguanil HCL is considered appropriate as prophylaxis of Plasmodium falciparum malaria, including in areas where chloroquine resistance has been reported.

AND

Administered as 1 tablet daily starting 1 or 2 days before entering the affected area continued during the stay and for 7 days after return.

OR

As treatment of acute, uncomplicated P. falciparummalaria AND

Administered as 4 tablets daily for 3 consecutive days.

Azathioprine

Based on the review of medical literature Azathioprine is considered appropriate when used for one of the following:

A. As adjunct therapy for the prevention of rejection in patient receiving renal (kidney) homotransplantations.

OR

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B. For the treatment of active rheumatoid arthritis

Becaplermin

Based on the review of medical literature Becaplermin is considered appropriate treatment for those members who meet the following criteria:

A. Approved for diabetic patient with lower extremity ulcer that has adequate perfusion and extends into subcutaneous tissue.

AND

A. Limit approval to 6 months, then re-evaluate progress Calcipotriene

Based on the review of medical literature Calcipotriene cream, ointment and solution are considered appropriate treatment for those members who meet the following criteria:

A. A diagnosis of plaque psoriasis or moderately severe psoriasis of the scalp AND

B. Patient is at least eighteen (18) years old AND

C. Failure of an adequate trial of topical corticosteroid preperations Calcipotriene-Betamethasone

Based on the review of medical literature Calcipotriene-Betamethasone ointment is considered appropriate treatment for the treatment of psoriasis vulgaris in adults (age 18 and over) ONLY, and is limited to 4 weeks of treatment.

Carbidopa

Based on the review of medical literature Carbidopa is considered appropriate treatment for those members who meet the following criteria

A. A diagnosis of Parkinson’s Disease AND

B. Is being used in conjunction with Levodopa Carisoprodol 250

Based on the review of medical literature Carisoprodol 250 is considered appropriate treatment only after the physician has been made aware there is a cheaper alternative (Carisoprodol 350) on the market and has indicated necessity for the 250 mg.

Chloroquine Phosphate

Based on the review of medical literature Chloroquine Phosphate is considered appropriate for prophylaxis for those members who are traveling to areas known to have the following types of parasites at the dose of :

A. Plasmodium vivax OR

B. Plasmodium malariae OR

C. Plasmodium ovale AND

D. Administered in doses of 500 mg starting 2 weeks prior to exposure and extending for 8 weeks after leaving the area.

OR

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For treatment of malaria caused by one of the following parasites:

A. Plasmodium vivax OR

B. Plasmodium malariae OR

C. Plasmodium ovale OR

D. Susceptible strains of Plasmodium falciparum AND

E. Administered as 1 gram daily for 2 days then 500 mg daily for 2-3 weeks.

(Cyclosporine Modified)

Sandimmune^® (Cyclosporine Modified)

Based on the review of medical literature Sandimmune is considered appropriate for the treatment of:

A. Prophylaxis of rejection in patient receiving one of the following types of transplants:

a. Renal (Kidney) b. Cardiac (Heart) c. Hepatic (Liver)

Neoral^®/Gengraf^® (Cyclosporine Modified)

Based on the review of medical literature Neoral and Gengraf is considered appropriate for the treatment of:

a. Renal (Kidney) b. Cardiac (Heart) c. Hepatic (Liver) OR

B. For the treatment of recalcitrant plaque psoriasis in nonimmunocompromised adult patients for whom other systemic therapies are contraindicated or not tolerated

OR

C. For the treatment of severe, active rheumatoid arthritis in patients that are not adequately responding to methotrexate.

Desmopressin

Based on the review of medical literature Desmopressin is considered appropriate treatment for those members who meet the following criteria:

A. For patients at least 6 years old:

AND

B. A documented diagnosis of nocturnal enuresis (NE) AND

C. Child must have failed or be undergoing at least one other treatment including drug (imipramine, etc.) or behavioral therapy or wet alarms.

OR

D. Diagnosis of DI or temporary polydipsia.

OR

E. Also used to treat temporary polyuria and polydipsia following head trauma or surgery in the pituitary region.

NOTE: Ineffective for the treatment of nephrogenic diabetes insipidus.

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Dolasetron

Based on the review of medical literature Dolasetron is considered appropriate treatment for those members who meet the following criteria:

A. According to the manufacturer, Dolasetron is given, in a dose up to 100 mg, once per day, on the day of surgery or the day(s) chemotherapy is given.

AND

B. Anzemet 50 mg, 100mg tablets – up to 8 tablets per copay.

Darbepoetin

Based on the review of medical literature Darbepoetin Injection is considered appropriate treatment for those members who meet the following criteria:

A. A documented diagnosis of anemia associated with chronic renal failure (CRF) and for the treatment of anemia in patients with nonmyeloid malignancies where anemia is caused by coadministered chemotherapy.

AND

B. Must be self administered or administered by a family member.

Dornase alfa

Based on the review of medical literature Dornase alfa is considered appropriate treatment for symptomatic management of cystic fibrosis in patients older than five (5) years old.

Epoetin alfa

Epogen^® (epoetin alfa)

Based on the review of medical literature Epogen Injections is considered appropriate treatment for those members who meet the following criteria:

A. For the treatment of anemia associated with chronic renal failure (CRF).

OR

B. For the treatment of anemia associated with end stage renal failure (ESRF).

OR

C. For the treatment of anemia related to zidovudine therapy in HIV-infected patients.

OR

D. For the treatment of non-myeloid cancer with chemotherapy where anemia is an expected effect and where chemotherapy has been administered for at least two (2) months.

AND

E. Hgb < 12 g/dl AND

F. Baseline ferritin of 100-500 ng/ml Procrit^® (epoetin alfa)

Based on the review of medical literature Procrit is considered appropriate treatment for those members who meet the following criteria:

A. For the treatment of anemia associated with chronic renal failure (CRF).

OR

B. For the treatment of anemia related to zidovudine therapy in HIV-infected patients.

OR

C. For the treatment of non-myeloid cancer with chemotherapy where anemia is an expected effect and where chemotherapy has been administered for at least two (2) months.

AND

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D. Hgb < 12 g/dl AND

E. Baseline ferritin of 100-500 ng/ml Etanercept

Based on the review of medical literature Etanercept Injection is considered appropriate treatment for those members who meet the following criteria:

OR

AND

C. Failure of a trial of methotrexate, unless contraindicated;

OR

D. Patients intolerant of or have contraindication to methotrexate should fail therapy with other DMARDs (cyclophosphamide, cyclosporine, corticosteroids, D-pencillamine, gold,

E. Must be self administered or administered by a family member.

Exemestane

Based on the review of medical literature Exemestane is considered appropriate treatment for those members who meet the following criteria:

A. A documented diagnosis of breast cancer.

AND

B. Patient is postmenopausal.

AND

C. Failure of an adequate clinical trial of Tamoxifen

Exenatide

PBM Plus will authorize coverage of Exenatide for those members with a documented diagnosis of diabetes.

Filgrastim

Based on the review of medical literature Filgrastim Injection is considered appropriate treatment for those members who meet the following criteria:

A. Treatment for patients with low counts of white blood cells due to bone marrow transplants, AIDS patients with CMV retinitis being treated with Cytovene (ganciclovir) and other discharge

medications.

AND

Finasteride

Based on the review of medical literature Finasteride is considered appropriate treatment for those members who meet the following criteria:

I. Member is male –

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A. A documented diagnosis of benign prostatic hyperplasia (BPH) OR

B. Documented:

• Contraindication to one (1) formulary alternative indicated for the member’s condition OR,

• Intolerance to one (1) formulary alternative indicated for the member’s condition OR,

• Failure of an adequate trial of one (1) month of one (1) formulary alternative indicated for the member’s condition

OR

C. Documentation of a prostate volume > 40 cm3 II. Member is female –

A. Member is NOT pregnant (As indicated by the physician OR claims history shows current use of oral contraceptives)

AND

B. Documented diagnosis of hirsutism secondary to ovarian or adrenal dysfunction (for example, polycystic ovary syndrome, adrenal or ovarian tumor.)

OR

C. Member’s physician provides documentation (controlled clinical trial) from the peer-reviewed medical literature for medical use in females.

Granisetron Transdermal System

Will be approved is used for the treatment of nausea and vomiting in patients receiving moderately and/or highly emetogenic chemotherapy.

Halofantrine HCL

Based on the review of medical literature Halofantrine HCL is considered appropriate for the treatment of malaria caused by susceptible strains of P. falciparum and P. vivax at the dose of 500 mg every 6 hours for 3 doses then repeated 1 week later.

Histrelin

Supprelin^®(histrelin)

Based on the review of medical literature Supprelin is considered appropriate treatment for those members who meet the following criteria:

A. For the treatment of endometriosis as an alternative to danazol treatment.

OR

B. For treatment of central precocious puberty.

OR

C. For the treatment of uterine leiomyomata and prostatic hyperplasia Vantas^®(histrelin)

Documented diagnosis of advanced prostate cancer.

Imatinib mesylate

Based on the review of medical literature Imatinib mesylate is considered appropriate treatment for those members who meet the following criteria:

A documented:

A. Diagnosis of chronic myeloid leukemia (CML) AND the member is:

• In the chronic phase of CML OR,

• In the accelerated phase of CML OR,

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• In blast crisis OR,

• Philadelphia chromosome positive OR

Diagnosis of gastrointestinal stromal tumor (GIST) Infliximab

Based on the review of medical literature Infliximab Injection is considered appropriate treatment for those members who meet the following criteria:

OR

AND

C. Failure of a trial of methotrexate, unless contraindicated;

OR

D. Patients intolerant of or have contraindication to methotrexate should fail therapy with other DMARDs (cyclophosphamide, cyclosporine, corticosteroids, D-pencillamine, gold,

E. Must be self administered or administered by a family member.

Interferon alfa-2b

Based on the review of medical literature Interferon alfa-2bis considered appropriate treatment for those members who meet the following criteria:

A. For the treatment of hairy cell leukemia.

OR

B. For the treatment of AIDS related Kaposi’s sarcoma OR

C. For the treatment of chronic hepatitis C OR

D. For the treatment of external genital and perianal warts OR

E. For the treatment of hepatitis B OR

F. For the treatment of follicular lymphoma OR

G. As adjuvant treatment to surgery for melanoma AND

H. Must be self administered or by family member Interferon alfa-n3

Based on the review of medical literature Interferon alfa-n3 Injection is considered appropriate treatment for those members who meet the following criteria:

A. A documented diagnosis of recurring external condylomata acuminata (venereal/genital warts).

AND

Interferon beta-1a

Based on the review of medical literature Interferon beta-1a is considered appropriate treatment for those members who meet the following criteria:

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A. A diagnosis of relapsing-remitting or exacerbating-remitting multiple sclerosis (MS) by a neurologist.

AND

B. Patients should have active MS (at least 2 acute exacerbations within previous 2 years).

AND

C. Must be self administered or by family member OR

D. Early interferon therapy may be warranted in patients who have had one demyelinating event and have brain lesions on MRI indicating a high risk of clinically definite MS.

Interferon beta-1b

Based on the review of medical literature Interferon beta-1b is considered appropriate treatment for those members who meet the following criteria:

A. A diagnosis of relapsing-remitting or exacerbating-remitting multiple sclerosis (MS) by a neurologist.

AND

B. Patients should have active MS (at least 2 acute exacerbations within previous 2 years).

AND

C. Must be self administered or by family member OR

D. Early interferon therapy may be warranted in patients who have had one demyelinating event and have brain lesions on MRI indicating a high risk of clinically definite MS.

Interferon gamma 1-b

Based on the review of medical literature Interferon gamma 1-b is considered appropriate treatment for those members who meet the following criteria:

A. A documented diagnosis of chronic granulomatous disease.

OR

B. A documented diagnosis of osteoporosis congenital.

AND

C. Must be self administered or administered by a family member.

Ivermectin

Based on the review of medical literature Ivermectin is considered appropriate treatment for those members who meet the following criteria:

A. A documented diagnosis of intestinal strongyloidiasis OR

B. A diagnosis of onchocerciasis AND

C. Maximum quantity:

3 mg = 5 tablets 6 mg = 3 tablets Linezolid

PBM Plus will authorize coverage of Linezolid for those members who meet the following criteria:

A documented:

A. Diagnosis of vancomycin-resistant Enterococcus faecium infection OR

B. Diagnosis of methicillin-resistant Staphylococcus aureus infection OR

C. Diagnosis of penicillin-resistant Sterptococcus pneumoniae infection

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OR

D. Diagnosis of nonsocomial pneumonia, community-acquired pneumonia, or skin or skin structure infections caused by susceptible organisms (Staphylococcus aureus, Streptococcus pneumoniae, Streptococcus pyogenes, or Streptococcus agalactiae)

AND

• Contraindication to two (2) formulary alternatives indicated for the member’s condition OR,

• Intolerance to two (2) formulary alternatives indicated for the member’s condition OR,

• Allergy to two (2) formulary alternatives indicated for the member’s condition OR,

• Documented lack of bacterial sensitivity to two (2) formulary alternatives indicated for the member’s condition OR,

• Failure of an adequate trial of three (3) days each of two (2) formulary alternatives indicated for the member’s condition OR,

Mecasermin Inj

Based on the review of medical literature Mecasermin Inj is considered appropriate as treatment for growth failure in children with severe primary insulin-like growth factor-1 (IGF-1) deficiency (primary IGFD) or with growth hormone gene deletion who have developed neutralizing antibodies to growth hormone. Severe IGFD is defined by:

A. Height standard deviation score ≤ -3 AND

B. Basal IGF-1 standard deviation score ≤ -3 AND

C. Normal or elevated growth hormone

NOTE: This product is not intended for use in patient with secondary forms of IGF-1 deficiency i.e. GH deficiency, malnutrition or hypothyroidism

Mefloquine

Based on the review of medical literature Mefloquine is considered appropriate for for those members who are traveling to areas known to have the following types of parasites:

A. Plasmodium falciparum (including chloroquine resistant strains) OR

B. Plasmodium vivax AND

C. Administered at doses of 250 mg once weekly beginning 1 week prior to arrival in the affected area and continued for 4 weeks after leaving

OR

For the treatment of mild-to-moderate acute malaria caused by Mefloquine susceptible strains of one of the following parasites:

D. Plasmodium vivax OR

E. Susceptible strains of Plasmodium falciparum AND

F. Given as a single 1,250 mg dose Methylnaltraxone bromide

Based on the review of medical literature Methylnaltraxone bromideis considered appropriate treatment for members using large amounts of opioid medication. Upon receipt of a call from the pharmacy or member regarding a PA rejection for this medication, the patient profile will need to be

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reviewed. If no opioids exist on the patient profile the PA is rejected; if opioid use is present all opioids being used and the duration will need to be recorded and presented to a pharmacist to review.

Approval/ denial is based solely on this criteria – it is not necessary to send a PA form to the physician.

Modafinil

Based on the review of medical literature Modafinil is considered appropriate treatment for those members who meet the following criteria:

B. A documented diagnosis of narcolepsy or idiopathic hypersomnia AND

One of the following:

• Contraindication to two (2) formulary alternatives indicated for the member’s condition OR

• Intolerance to two (2) formulary alternatives indicated for the member’s condition OR

• Allergy to two (2) formulary alternatives indicated for the member’s condition OR

• Failure of an adequate clinical trial of two (2) weeks each of two (2) formulary alternatives indicated for the member’s condition

OR

C. A documented diagnosis of fatigue associated with multiple sclerosis AND

One of the following:

• Contraindication to one (1) formulary alternative indicated for the member’s condition OR

• Intolerance to one (1) formulary alternative indicated for the member’s condition OR

• Allergy to one (1) formulary alternative indicated for the member’s condition OR

• Failure of an adequate clinical trial of two (2) weeks of one (1) formulary alternative indicated for the member’s condition

Note: If patient is under the age of 18 an additional call will need to be made to the physician making them aware this medication has not been approved by the FDA for use in children. Additionally, if diagnosis indicated is ADHD the prior authorization should be denied as this medication is not approved for this use.

Mycophenolate Mofetil

Based on the review of medical literature Mycophenolate Mofetil is considered appropriate for prophylaxis of organ rejection in patients receiving the following types of transplants as the doses indicated:

A. Renal (Kidney) transplant administered as 1 gram (1,000 mg) twice daily OR

B. Cardiac (Heart) transplant administered as 1.5 grams (1,500 mg) twice daily OR

C. Hepatic (Liver) transplant administered as 1.5 grams (1,500 mg) twice daily Nadolone

PBM Plus will authorize coverage of Nadolone for those members who meet the following criteria:

A. For prevention of nausea and vomiting associated with initial and repeat courses of cancer chemotherapy

AND

B. Failure to respond adequately to conventional antiemetic treatments including Zofran, Zofran ODT and Kytril

AND

C. Quantity limit based on 3 capsules per day of therapy plus 2 days.

Nafarelin acetate

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Nafarelin acetate will be approved if be used:

A. In adults – documented diagnosis of endometriosis OR

B. In children – Documented diagnosis of precocious puberty

Nimodipine

Documented diagnosis of subarachnoid hemorrhage.

Onabotulinumtoxina

PBM Plus will authorize coverage of Onabotulinumtoxina for those members who meet the following criteria:

A. Being used for the treatment of migraines AND

B. Not written by a dermatologist Oprelevkin

Based on the review of medical literature Oprelevkin is considered appropriate treatment for patients on chemotherapy to stimulate blood platelet production.

Pegfilrastim

Based on the review of medical literature Pegfilrastim Injection is considered appropriate treatment for those members who meet the following criteria:

A. To decrease the incidence of infection, as manifested by febrile neutropenia, in patients with nonmyeloid malignancies receiving myelosuppressive anticancer drugs associated with a clinically significant incidence of febrile neutropenia.

AND

Peginterferon alfa-2b

Is approved for the treatment of malignant melanoma stages 2b-4.

Pimecrolimus

Based on the review of medical literature Pimecrolimus is considered appropriate treatment for those members who meet the following criteria:

A. Patients at least two (2) years old AND

B. A diagnosis of mild to moderate atopic dermatitis.

AND

C. Failure of an adequate trial of topical corticosteroid preperations.

Primaquine Phosphate

Based on the review of medical literature Primaquine Phosphate is considered appropriate as:

A. a radical cure for Vivax Malaria OR

B. When used as a prevention of relapse of vivax malaria OR

C. Following the termination of chloroquine phosphate suppressive therapy in an area where vivax malaria is an epidemic.

AND

D. Administered as 1 tablet daily for 14 days

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Pyrimethamine

Based on the review of medical literature Pyrimethamine is considered appropriate as chemoprophylaxis of malaria only in Daraprim susceptible strains.

OR

In conjunction with a sulfonamide (eg, sulfadoxine) to initiate transmission control and suppression of acute malaria for susceptible strains of plasmodia.

AND

Administered at 1 tablet weekly for the prevention of malaria

Quinine Sulfate

Based on the review of medical literature Quinine Sulfate is considered appropriate only for the treatment malaria, all other uses will not be approved.

Ribavirin

Copegus®/Rebetrol^® (ribavirin)

Based on the review of medical literature Copegus or Rebetrol is considered appropriate treatment for patients diagnosed with hepatitis C.

Rebetol^® (ribavirin)

Based on the review of medical literature Rebetol is considered appropriate treatment for hepatitis C.

Ribapak^®(Ribavirin)

PBM Plus will authorize coverage of Ribapak for those members with a documented diagnosis of chronic Hepatitis C infection.

Virazole^®(ribavirin)

Based on the review of medical literature Virazole is considered appropriate treatment for hepatitis C in children under the age of 6 in a hospital setting. Plan sponsor approval of cost will be additionally necessary.

Riluzole

Based on the review of medical literature Riluzole is considered appropriate treatment for amyotrophic lateral sclerosis (ALS).

Rosiglitazone maleate/ metformin

Based on new criteria received from the manufacturer Rosiglitazone maleate/ metformin is considered appropriate treatment under the following conditions:

A. Continuation of Therapy OR

A. Patient is unable to achieve adequate glycemic control on other diabetes medications AND

B. Patient has been advised of the risks and benefits of this medication including increase risk of MI AND

C. Patient has decided, in consultation with their healthcare provider, not to take Pioglitazone Rosiglitazone maleate/ glimepiride

Based on new criteria received from the manufacturer Rosiglitazone maleate/ glimepiride is considered appropriate treatment under the following conditions:

A. Patient is unable to achieve adequate glycemic control on other diabetes medications

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AND

C. Patient has decided, in consultation with their healthcare provider, not to take Pioglitazone Rosiglitazone maleate

Based on new criteria received from the manufacturer Rosiglitazone maleate is considered appropriate treatment under the following conditions:

A. Patient is unable to achieve adequate glycemic control on other diabetes medications AND

C. Patient has decided, in consultation with their healthcare provider, not to take Pioglitazone Sargramostim

Based on the review of medical literature Sargramostim Injection is considered appropriate treatment for those members who meet the following criteria:

1. Treatment for patients with low counts of white blood cells associated with bone marrow transplants, graft failure or promotion of early engraftment.

AND

2. Must be self administered or administered by a family member.

Sildenafil

Documented diagnosis of pulmonary arterial hypertension; not approved for erectile dysfunction

Sirolimus

Based on the review of medical literature Sirolimusis considered appropriate as prophylaxis of organ rejection in patient 13 years or older receiving renal (kidney) transplants.

Tacrolimus

Based on the review of medical literature Tacrolimus is considered appropriate as:

a. Renal (Kidney) b. Cardiac (Heart) c. Hepatic (Liver)

NOTE: It is recommended this product be used along with adrenal corticosteroids.

Temozolomide

Based on the review of medical literature Temozolomide is considered appropriate treatment for those members diagnosed with brain cancer.

- Quantity Limits:

5 mg = 15 tablets/copay 10 mg = 20 tablets/copay 100 mg = 20 tablets/copay 250 mg = 10 tablets/copay

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Teriflunomide

Teriflunomidewill be approved for all members with a documented diagnosis of relapsing forms of Multiple Sclerosis^.

Note:because of the cost of this medication it will likely reject for claim $ amount exceeded as well as PA required. Please be sure to get ALL appropriate approvals prior to communicating this product has been approved.

Teriparatide

Based on the review of medical literature Teriparatide is considered appropriate treatment for those members who meet the following criteria:

I. Member is female:

A. For the treatment of postmenopausal women with osteoporosis who are at high risk for fracture.

OR

B. Patient has failed or is intolerant to previous osteoporosis therapy, based upon physician assessment.

AND

C. Must be self administered or administered by a family member.

II. Member is male:

A. To increase bone mass in men with primary or hypogonadal osteoporosis who are at high risk for fracture.

OR

B. Patient has failed or is intolerant to previous osteoporosis therapy, based upon physician assessment.

AND

D. Must be self administered or administered by a family member.

NOTE: The safety and efficacy of teriparatide has not been evaluated beyond 2 years of treatment.

Consequently, use of the drug for more than 2 years is not recommended.

Testosterone Implant

Based on the review of medical literature Testosterone Implant is considered appropriate treatment for those members with an established diagnosis of :

A. Primary hypogonadism (congenital or acquired) OR

B. Hypogonadotropic hypogonadism (congenital or acquired) OR

C. Delayed puberty Tinzaparin

Based on the review of medical literature Tinzaparin Injection is considered appropriate for the treatment of acute symptomatic deep vein thrombosis (DVT).

Tofacitinib Citrate

Based on the review of medical literature tofacitinib citrate is considered appropriate as treatment for patients with moderate to severe rheumatoid arthritis.

Tolcapone

Based on the review of medical literature Tolcapone is considered appropriate treatment for those members who meet the following criteria:

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A. A diagnosis of Parkinson’s disease.

AND

B. Patient must also be on levodopa/carbidopa AND

C. Must be prescribed by a neurologist.

AND

D. Only approve for one (1) month. May approve indefinitely if after 1 month liver function is normal and patient improved.

Trientine hydrochloride

Documented diagnosis of Wilson Disease.

Somatropin

(Criteria for All Brands unless listed below with different criteria)

Based on the review of medical literature Growth Hormones are considered appropriate treatment for those members who meet the following criteria:

A. Prescription is written by a Pediatric Endocrinologist AND

B. There is a documented growth deficiency per AMA guidelines.

Serostim^® (somatropin)

Based on the review of medical literature Serostim ^® is considered appropriate only for the treatment wasting syndrome secondary to HIV/ AIDS.

Smoking Cessation Products As outlined by plan sponsor

Combination Injectable Contraception

No products are currently available criteria will be re-evaluated when one comes on the market.