Advantra (HMO), Advantra (PPO), Advantra Advantage · PDF fileCoventry Advantra Silver (HMO),...

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Advantra (HMO), Advantra (PPO), Advantra Advantage (HMO), Advantra Cares (HMO SNP), Advantra Choice (HMO), Advantra Freedom (PPO), Advantra Freedom Plus (PPO), Advantra Gold (PPO), Advantra Option 1 (HMO-POS), Advantra Option 2 (HMO), Advantra Platinum (HMO), Advantra Preferred (PPO), Advantra Silver (HMO), Advantra Silver (PPO), Advantra Silver Plus (HMO), Advantra Silver Plus (PPO), Advantra Total Care (HMO), Advantra Value (PPO), AdvantraOne (PPO), Altius Advantra (HMO), Altius Advantra Select (HMO), Coventry Advantage (HMO), Coventry Advantage Plus (HMO-POS), Coventry Advantra Platinum (PPO), Coventry Advantra Silver (HMO), Coventry Medicare Advantage (PPO), Coventry Medicare Advantage Total Care (HMO), Coventry Total Care (HMO), Coventry Total Care (HMO-POS), Coventry Total Care (PPO), Gold Advantage (HMO) Last Updated: 12/01/2017 ACTEMRA SC Products Affected Actemra INJ 162MG/0.9ML PA Criteria Criteria Details Covered Uses All FDA-approved indications not otherwise excluded from Part D. Exclusion Criteria N/A Re quire d Medical Information N/A Age Restrictions N/A Prescriber Restrictions Rheumatologist Coverage Duration Through end of plan contract year. Other Criteria For moderately to severely active rheumatoid arthritis in adult patients: Patient has a documented trial and failure or contraindication to Enbrel (etanercept) AND Humira (adalimumab). NR_0009_3741 09/2014 Formulary ID: 17025: version 19 1

Transcript of Advantra (HMO), Advantra (PPO), Advantra Advantage · PDF fileCoventry Advantra Silver (HMO),...

Page 1: Advantra (HMO), Advantra (PPO), Advantra Advantage  · PDF fileCoventry Advantra Silver (HMO), Coventry Medicare Advantage (PPO), Coventry Medicare

Advantra (HMO), Advantra (PPO), Advantra Advantage (HMO), Advantra Cares (HMO SNP), Advantra Choice (HMO), Advantra Freedom (PPO), Advantra Freedom Plus (PPO), Advantra Gold (PPO), Advantra Option 1 (HMO-POS), Advantra Option 2 (HMO), Advantra Platinum (HMO), Advantra Preferred (PPO), Advantra Silver (HMO), Advantra Silver (PPO), Advantra Silver Plus (HMO), Advantra Silver Plus (PPO), Advantra Total Care (HMO), Advantra Value (PPO), AdvantraOne (PPO), Altius Advantra (HMO), Altius Advantra Select (HMO), Coventry Advantage (HMO), Coventry Advantage Plus (HMO-POS), Coventry Advantra Platinum (PPO), Coventry Advantra Silver (HMO), Coventry Medicare Advantage (PPO), Coventry Medicare Advantage Total Care (HMO), Coventry Total Care (HMO), Coventry Total Care (HMO-POS), Coventry Total Care (PPO), Gold Advantage (HMO) Last Updated: 12/01/2017

ACTEMRA SC

Products Affected • Actemra INJ 162MG/0.9ML

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

Rheumatologist

Coverage Duration

Through end of plan contract year.

Other Criteria For moderately to severely active rheumatoid arthritis in adult patients: Patient has a documented trial and failure or contraindication to Enbrel (etanercept) AND Humira (adalimumab).

NR_0009_3741 09/2014 Formulary ID: 17025: version 19

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ACTIMMUNE Products Affected • Actimmune

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

N/A

Coverage Duration

Through end of plan contract year.

Other Criteria N/A

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ADAGEN Products Affected • Adagen

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

Contraindicated in bone marrow transplantation and in patients with severe thrombocytopenia due to increased risk of bleeding.

Required Medical Information

Adenosine deaminase deficiency in patients with severe combined immunodeficiency disease who are not suitable candidates for or who have failed bone marrow transplantation.

Age Restrictions N/A

Prescriber Restrictions

N/A

Coverage Duration

6 months

Other Criteria N/A

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ADEMPAS Products Affected • Adempas

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

Concurrent use with organic nitrates (i.e. isosorbide mononitrate, isosorbide dinitrate, nitroglycerin) or PDE inhibitors (i.e. sildenafil, Adcirca, dipyridamole, theophylline). Pregnancy.

Required Medical Information

For Persistent/recurrent Chronic Thromboembolic Pulmonary Hypertension (CTEPH) (WHO Group 4) after surgical treatment or inoperable CTEPH AND patient has a mean pulmonary artery pressure greater than 25 mm Hg at rest or greater than 30 mm Hg with exertion, documented by right-heart catheterization or echocardiography AND Patient has a documented thromboembolic occlusion of the pulmonary vasculature. For Pulmonary Arterial Hypertension (PAH) (WHO Group 1) and WHO functional class II to IV symptoms AND patient has mean pulmonary artery pressure greater than 25 mm Hg at rest or greater than 30 mm Hg with exertion, documented by right-heart catheterization or echocardiography.

Age Restrictions N/A

Prescriber Restrictions

Pulmonologist or cardiologist

Coverage Duration

Through end of plan contract year.

Other Criteria N/A

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AFINITOR Products Affected • Afinitor

• Afinitor Disperz

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

Oncologist

Coverage Duration

Through end of plan contract year.

Other Criteria For advanced renal cell carcinoma, prior therapy with Sutent (sunitinib) and Inlyta (axitinib). For postmenopausal women with advanced hormone receptor-positive, HER2-negative breast cancer (advanced HR+ BC), Afinitor is being used in combination with exemestane after failure of treatment with letrozole or anastrozole. There are no additional requirements for advanced neuroendocrine tumors of the pancreatic origin, renal angiomyolipoma with tuberous sclerosis complex and subependymal giant cell astrocytoma with tuberculous sclerosis complex. Applies to new starts only.

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ALDURAZYME Products Affected

• Aldurazyme

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

Mucopolysaccharidosis, Type I (Hurler and Hurler-Scheie forms) and Scheie form with moderate to severe symptoms.

Age Restrictions N/A

Prescriber Restrictions

N/A

Coverage Duration

Through end of plan contract year.

Other Criteria Not covered for mildly affected patients with the Scheie form.

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ALECENSA Products Affected • Alecensa

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

For anaplastic lymphoma kinase (ALK)-positive, metastatic non-small cell lung cancer (NSCLC): progressed on or intolerance to crizotinib (Xalkori).

Age Restrictions N/A

Prescriber Restrictions

Oncologist

Coverage Duration

Through end of plan contract year.

Other Criteria Applies to new starts only.

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ALIMTA Products Affected • Alimta

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

Oncologist

Coverage Duration

Through end of plan contract year.

Other Criteria Requests for new starts are covered with malignant mesothelioma of pleura in combination with cisplatin in patients who are not candidates for surgical resection. Requests for new starts are covered with locally advanced or metastatic non-small cell lung cancer after prior chemotherapy as a single agent OR as initial therapy in combination with cisplatin OR as maintenance therapy for patients whose disease has not progressed after four cycles of platinum-based first-line chemotherapy. Applies to new starts only.

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ALIQOPA

Products Affected • Aliqopa

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

Oncologist or Hematologist

Coverage Duration

Through end of plan contract year

Other Criteria Applies to new starts only.

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ALPHA1-PROTEINASE INHIBITORS Products Affected • Prolastin-c

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

Not covered for patients with the PiMZ or PiMS phenotypes of alpha 1 -antitrypsin deficiency as they appear to be at small risk for panacinar emphysema.

Required Medical Information

Diagnosis of panacinar emphysema AND documentation of a decline in forced expiratory volume in 1 second (fev1) despite optimal medical therapy (bronchodilators, corticosteroids, oxygen if indicated) AND documentation of phenotype (pi*zz, pi*znull or pi*nullnull) associated with causing serum alpha 1-antitrypsin of less than 80 mg/dl AND documentation of an alpha 1-antitrypsin serum level below the value of 35% of normal (less than 80 mg/dl).

Age Restrictions N/A

Prescriber Restrictions

N/A

Coverage Duration

Through end of plan contract year.

Other Criteria Prolastin-C is preferred formulary agent. For other Alpha 1 proteinase inhibitors on formulary: patient must have a documented trial and failure or contraindication to Prolastin-C.

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ALUNBRIG Products Affected • Alunbrig

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

Hematologist or Oncologist

Coverage Duration

Through end of plan contract year.

Other Criteria Applies to new starts only.

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AMPYRA Products Affected • Ampyra

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

Patients with history of seizures. Creatinine Clearance (CrCl) less than 50mL/min.

Required Medical Information

Documented diagnosis of multiple sclerosis (MS). Patient has sustained walking impairment. Patient is able to walk 25 feet with or without assistance.

Age Restrictions N/A

Prescriber Restrictions

Neurologist

Coverage Duration

Initial approval: 6 months. Renewal: Through end of plan contract year.

Other Criteria For renewals: Patient has continued therapeutic response to Ampyra.

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ANALGESICS-AGE EDIT Products Affected • Ketorolac Tromethamine TABS

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

Prescriber must acknowledge that medication benefits outweigh potential risks in patients 65 years of age or older.

Age Restrictions This prior authorization only applies to members 65 years of age or older to ensure safe use of a potentially high risk medication in the elderly population. Members under 65 years of age are not subject to the prior authorization requirements.

Prescriber Restrictions

N/A

Coverage Duration

Through end of plan contract year.

Other Criteria For moderate to severe pain: Patient has a trial or failure or a documented contraindication to one non-HRM alternative drug, such as ibuprofen, tramadol, oxycodone/APAP, hydrocodone/APAP, morphine sulfate). For gout: The patient had an inadequate treatment response OR intolerance to allopurinol or febuxostat (Uloric).

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ANDROGEL

Products Affected • Androgel • Androgel Pump

• Testosterone GEL 25MG/2.5GM,50MG/5GM

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

Testosterone levels within normal range (range for the lab doing the testing). Female patients. Men with carcinoma of the breast or suspected carcinoma of the prostate. Use for muscle building purposes.

Required Medical Information

For members initiating testosterone replacement therapy: Testosterone levels (total or free). Require either ONE low total testosterone level OR ONE low free testosterone level. (normal ranges as provided by office or clinic performing labs). Note: Members that are already stabilized on therapy will not be required to provide labs and can be approved as continuation.

Age Restrictions N/A

Prescriber Restrictions

N/A

Coverage Duration

Through end of plan contract year.

Other Criteria N/A

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ANTIDEPRESSANTS-AGE EDIT Products Affected • Amitriptyline Hcl TABS• Clomipramine Hcl CAPS• Doxepin Hcl CAPS

• Doxepin Hcl CONC• Imipramine Hcl TABS• Trimipramine Maleate CAPS

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

Prescriber must acknowledge that medication benefits outweigh potential risks in patients 65 years of age or older.

Age Restrictions This prior authorization only applies to members 65 years of age or older to ensure safe use of a potentially high risk medication in the elderly population. Members under 65 years of age are not subject to the prior authorization requirements.

Prescriber Restrictions

N/A

Coverage Duration

Through end of plan contract year.

Other Criteria N/A

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ANTIHISTAMINES-AGE EDIT Products Affected • Clemastine Fumarate SYRP• Clemastine Fumarate TABS 2.68MG• Cyproheptadine Hcl TABS• Diphenhydramine Hcl INJ 50MG/ML• Phenadoz

• Phenergan SUPP• Promethazine Hcl SUPP• Promethazine Hcl SYRP• Promethazine Hcl TABS• Promethegan

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

Prescriber must acknowledge that medication benefits outweigh potential risks in patients 65 years of age or older.

Age Restrictions This prior authorization only applies to members 65 years of age or older to ensure safe use of a potentially high risk medication in the elderly population. Members under 65 years of age are not subject to the prior authorization requirements.

Prescriber Restrictions

N/A

Coverage Duration

Through end of plan contract year.

Other Criteria N/A

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ANTIPARKINSON AGENTS-AGE EDIT

Products Affected • Benztropine Mesylate INJ

• Benztropine Mesylate TABS• Trihexyphenidyl Hcl

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

Prescriber must acknowledge that medication benefits outweigh potential risks in patients 65 years of age or older.

Age Restrictions This prior authorization only applies to members 65 years of age or older to ensure safe use of a potentially high risk medication in the elderly population. Members under 65 years of age are not subject to the prior authorization requirements.

Prescriber Restrictions

N/A

Coverage Duration

Through end of plan contract year.

Other Criteria Patient has a documented trial and failure or contraindication to one of the following: amantadine, pramipexole, or ropinirole.

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ANTISPASMOTICS-AGE EDIT Products Affected • Dicyclomine Hcl CAPS

• Dicyclomine Hcl SOLN • Dicyclomine Hcl TABS

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

Prescriber must acknowledge that medication benefits outweigh potential risks in patients 65 years of age or older.

Age Restrictions This prior authorization only applies to members 65 years of age or older to ensure safe use of a potentially high risk medication in the elderly population. Members under 65 years of age are not subject to the prior authorization requirements.

Prescriber Restrictions

N/A

Coverage Duration

Through end of plan contract year.

Other Criteria N/A

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APOKYN Products Affected • Apokyn INJ 30MG/3ML

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

Off label use for erectile dysfunction as treatment for ED are CMS exclusions. Contraindicated when used concomitantly with 5HT3 receptor antagonists such as ondansetron or granisetron.

Required Medical Information

For Parkinson's disease: medical history that documents patient experiences motor fluctuations despite an optimized oral drug regimen which includes levodopa.

Age Restrictions N/A

Prescriber Restrictions

N/A

Coverage Duration

Through end of plan contract year.

Other Criteria Requests for Parkinson's disease are covered following an appropriate trial of a levodopa-containing regimen.

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APTIOM Products Affected • Aptiom

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

N/A

Coverage Duration

Through end of plan contract year.

Other Criteria Requests for adjunct therapy for partial-onset seizure disorder are covered with documentation that the patient is currently on an anticonvulsant (including lamotrigine, phenytoin, divalproex, levetiracetam, gabapentin, carbamazepine, topiramate, zonisamide). Applies to new starts only.

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ARANESP Products Affected • Aranesp Albumin Free

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

Uncontrolled hypertension

Required Medical Information

For initiation of therapy: adequate iron stores have been demonstrated by means of bone marrow iron or serum ferritin levels or serum iron saturation studies within the prior 12 months (Note: for persons with iron deficiency, erythropoietin analog therapy may be initiated simultaneous with iron replacement), and the following criteria is met: hemoglobin (Hgb) is approaching or has fallen below 10 g/dl (CKD not on dialysis-adult, cancer), 11 g/dL (CKD on dialysis), 12 g/dL (pediatric CKD) or hematocrit of 30% OR patient will be starting myelosuppressive therapy and will have an anticipated hemoglobin drop associated with their therapy. For continuation of therapy: documentation of the below: for persons with anemia due to myelosuppressive anticancer chemotherapy: Hgb target of 12 g/dl For persons with chronic renal failure and end-stage renal disease (ESRD): Hgb target 10-11 g/dl. Continued use of the therapy is not covered if the hemoglobin rises less than 1 g/dl (hematocrit rise less than 3%) compared to pretreatment baseline by 12 weeks of treatment and whose hemoglobin level remains less than 10 g/dL (or the hematocrit is less than 30%).

Age Restrictions N/A

Prescriber Restrictions

N/A

Coverage Duration

12 weeks

Other Criteria Excluded from patients with Hgb at or above 10 g/dL (CKD not on dialysis-adult, cancer), 11 g/dL (CKD on dialysis), 12 g/dL (pediatric CKD).

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ARCALYST Products Affected • Arcalyst

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions 12 years of age or older.

Prescriber Restrictions

N/A

Coverage Duration

Through end of plan contract year.

Other Criteria N/A

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ARZERRA Products Affected • Arzerra

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

Oncologist

Coverage Duration

Through end of plan contract year.

Other Criteria Applies to new starts only.

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AVASTIN Products Affected • Avastin

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

Oncologist

Coverage Duration

Through end of plan contract year.

Other Criteria Applies to new starts only.

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BANZEL Products Affected • Banzel

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

Banzel is not covered for members with the diagnosis of Familial Short QT syndrome.

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

N/A

Coverage Duration

Through end of plan contract year.

Other Criteria Patient has a documented trial and failure or contraindication to lamotrigine. For Lennox-Gastaut Syndrome: Only approved as adjunctive therapy. Applies to new starts only.

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BAVENCIO Products Affected • Bavencio

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

Oncologist or dermatologist

Coverage Duration

Through end of plan contract year

Other Criteria Applies to new starts only.

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BELEODAQ Products Affected • Beleodaq

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

Oncologist

Coverage Duration

Through end of plan contract year.

Other Criteria For patients with a diagnosis of peripheral T-cell lymphoma (PTCL), patient has relapsed or is refractory to prior therapies. Applies to new starts only.

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BENLYSTA

Products Affected • Benlysta

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

N/A

Coverage Duration

Through end of plan contract year.

Other Criteria A documented diagnosis of systemic lupus erythematosus (SLE) and an active, autoantibody-positive test who are receiving standard therapy comprising any of the following (alone or in combination): anti-malarials, corticosteroids, immunosuppressives (excluding intravenous cyclophosphamide), and non-steroidal anti-inflammatory drugs.

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BESPONSA

Products Affected • Besponsa

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

Oncologist or Hematologist

Coverage Duration

Through end of plan contract year

Other Criteria Applies to new starts only.

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BLINCYTO Products Affected • Blincyto

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

Oncologist

Coverage Duration

Through end of plan contract year.

Other Criteria Applies to new starts only. Drug is also subject to a Part B versus Part D coverage determination.

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BOSULIF Products Affected • Bosulif

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

Oncologist or Hematologist

Coverage Duration

Through end of plan contract year.

Other Criteria For diagnosis of chronic or accelerated Philadelphia chromosome positive (Ph+) chronic myelogenous leukemia (CML): documentation of resistance or intolerance to prior therapy with nilotinib (Tasigna) or dasatinib (Sprycel). For diagnosis of blast phase Philadelphia chromosome positive (Ph+) chronic myelogenous leukemia (CML): documentation of resistance or intolerance to prior therapy with imatinib (Gleevec),dasatinib (Sprycel), or nilotinib (Tasigna). Applies to new starts only.

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BOTOX

Products Affected • Botox

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

Cosmetic Use

Required Medical Information

For the treatment of cervical dystonia to decrease the severity of abnormal head position and neck pain. For the treatment of severe primary axillary hyperhidrosis. For the treatment of strabismus and blepharospasm associated with dystonia, including benign essential blepharospasm or VII nerve disorders. Cerebral Palsy and Spastic hemiplegia. For the treatment of upper or lower limb spasticity. For prophylaxis of headaches in patients with chronic migraine (less than or equal to 15 days per month with headache lasting 4 hours a day or longer) following adequate trial and failure or contraindication to two preventative/prophylactic oral agents. For treatment of incontinence due to detrusor instability, associated with a neurologic condition such as spinal cord injury or MS that had an inadequate response or are intolerant to oxybutynin and tropsium. For the treatment of overactive bladder (OAB) with symptoms of urge urinary incontinence, urgency, and frequency that had an inadequate response or are intolerant to oxybutynin and tropsium.

Age Restrictions N/A

Prescriber Restrictions

N/A

Coverage Duration

12 weeks

Other Criteria N/A

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BRIVIACT Products Affected • Briviact

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

N/A

Coverage Duration

Through end of plan contract year

Other Criteria Applies to new starts only. Requests for adjunct therapy for partial-onset seizure disorder are covered with documentation that the patient is currently on an anticonvulsant such as: lamotrigine, phenytoin, divalproex, levetiracetam, gabapentin, carbamazepine, topiramate, zonisamide.

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BUPHENYL Products Affected • Buphenyl TABS

• Sodium Phenylbutyrate POWD3GM/TSP

• Sodium Phenylbutyrate TABS

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

Contraindicated for acute hyperammonemia emergency management.

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

N/A

Coverage Duration

Through end of plan contract year.

Other Criteria Cycle disorders: As adjunctive therapy in the chronic management of patients with urea cycle disorders involving deficiencies of carbamoyl phosphate synthetase (CPS), ornithine transcarbamoylase (OTC) or argininosuccinic acid synthetase (AAS). In all patients with neonatal-onset deficiency (complete enzymatic deficiency, presenting within the first 28 days of life). In patients with late-onset disease (partial enzymatic deficiency, presenting after the first month of life) who have a history of hyperammonemic encephalopathy.

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BUTALBITAL-AGE EDIT

Products Affected • Ascomp/codeine • Butalbital Compound/codeine CAPS

325MG; 50MG; 40MG; 30MG • Butalbital/acetaminophen/caffeine

CAPS • Butalbital/acetaminophen/caffeine

TABS 325MG; 50MG; 40MG • Butalbital/acetaminophen/caffeine/co

deine

• Butalbital/aspirin/caffeine • Butalbital/aspirin/caffeine/codeine • Capacet • Esgic CAPS • Margesic • Phrenilin Forte CAPS 300MG;

50MG; 40MG • Zebutal CAPS 325MG; 50MG;

40MG

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

Prescriber must acknowledge that medication benefits outweigh potential risks in patients 65 years of age or older.

Age Restrictions This prior authorization only applies to members 65 years of age or older to ensure safe use of a potentially high risk medication in the elderly population. Members under 65 years of age are not subject to the prior authorization requirements.

Prescriber Restrictions

N/A

Coverage Duration

Through end of plan contract year.

Other Criteria N/A

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CABOMETYX Products Affected • Cabometyx

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

Oncologist

Coverage Duration

Through end of plan contract year

Other Criteria Applies to new starts only. For advanced renal cell carcinoma, prior therapy with Sutent (sunitinib) and Inlyta (axitinib).

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CAMPATH Products Affected • Campath INJ 30MG/ML

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

Oncologist or Hematologist

Coverage Duration

Through end of plan contract year

Other Criteria Applies to new starts only.

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CAPRELSA

Products Affected • Caprelsa

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

Do not use in patients with congenital long QT syndrome.

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

Oncologist or Endocrinologist

Coverage Duration

Through end of plan contract year.

Other Criteria Applies to new Starts Only.

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CARDIOVASCULAR-AGE EDIT Products Affected• Disopyramide Phosphate CAPS

• Ticlopidine Hcl

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

Prescriber must acknowledge that medication benefits outweigh potential risks in patients 65 years of age or older.

Age Restrictions This prior authorization only applies to members 65 years of age or older to ensure safe use of a potentially high risk medication in the elderly population. Members under 65 years of age are not subject to the prior authorization requirements.

Prescriber Restrictions

N/A

Coverage Duration

Through end of plan contract year.

Other Criteria N/A

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CEREZYME Products Affected • Cerezyme

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

N/A

Coverage Duration

Through end of plan contract year.

Other Criteria N/A

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CINRYZE Products Affected • Cinryze

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

Member has a history of at least 2 HAE attacks per month AND Diagnosis of HAE is documented based on evidence of a normal C1 level and a low C4 level (C4 less than 14 mg/dL normal range 14 to 40 mg/dL), or C4 below the lower limit of normal as defined by the laboratory performing the test) plus: A low C1 inhibitor (C1INH) antigenic level (C1INH less than 19 mg/dL normal range 19 to 37 mg/dL, or C1INH antigenic level below the lower limit of normal as defined by the laboratory performing the test) OR A normal C1INH antigenic level (C1INH greater than or equal to 19 mg/dL) and a low C1INH functional level (functional C1INH less than 50% or C1INH functional level below the lower limit of normal as defined by the laboratory performing the test) OR A known HAE-causing C1INH mutation. Medications known to cause angioedema (i.e. ACE-Inhibitors, estrogens, angiotensin II receptor blockers) have been evaluated and discontinued when appropriate. Member has tried and failed or is intolerant to or has a contraindication to danazol.

Age Restrictions N/A

Prescriber Restrictions

Immunologist or Rheumatologist

Coverage Duration

Initial approval: 6 months. Extended approval: Through end of plan contract year.

Other Criteria N/A

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COLY-MYCIN Products Affected

• Colistimethate Sodium INJ

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

Administration via nebulizer

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

Infectious disease

Coverage Duration

3 months

Other Criteria Allow intravenous (IV) or intramuscularly (IM) use only. CMS endorsed compendia do not support inhalation/nebulization of colistimethate.

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COMETRIQ Products Affected • Cometriq

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

Oncologist

Coverage Duration

Through end of plan contract year.

Other Criteria Applies to new Starts Only.

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COPAXONE Products Affected • Copaxone INJ 20MG/ML, 40MG/ML

• Glatopa

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

Documentation that other therapies used for treating multiple sclerosis will be discontinued ( Note: This does NOT require having to discontinue Ampyra).The member has a diagnosis of a relapsing form of multiple sclerosis OR has experienced a first clinical episode and has MRI features consistent with multiple sclerosis.

Age Restrictions N/A

Prescriber Restrictions

Neurologist

Coverage Duration

Through end of plan contract year.

Other Criteria N/A

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CORLANOR Products Affected • Corlanor

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

Acute decompensated heart failure. Blood pressure less than 90/50 mmHg. Sick sinus syndrome, sinoatrial block, or 3rd degree AV block, unless a functioning demand pacemaker is present. Resting heart rate less than 60 bpm prior to treatment. Severe hepatic impairment. Pacemaker dependence (heart rate maintained exclusively by the pacemaker). Concomitant use of strong cytochrome P450 3A4 (CYP3A4) inhibitors (Examples: azole antifungals (e.g., itraconazole), macrolide antibiotics (e.g., clarithromycin, telithromycin), HIV protease inhibitors (e.g., nelfinavir), and nefazodone).

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

N/A

Coverage Duration

Through end of plan contract year.

Other Criteria Failure of 1 month of ACE Inhibitor or ACE Inhibitor/HCTZ combination or Angiotensin-Receptor Blocker or Angiotensin-Receptor Blocker/HCTZ combination AND one of the following beta blockers: bisoprolol/bisoprolol-HCTZ, carvedilol, carvedilol CR, metoprolol succinate/metoprolol succinate-HCTZ, nevibolol.

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COTELLIC Products Affected • Cotellic

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

For unresectable or metastatic melanoma: confirmation of BRAF V600E or V600K mutation.

Age Restrictions N/A

Prescriber Restrictions

Oncologist

Coverage Duration

Through end of plan contract year.

Other Criteria For unresectable or metastatic melanoma with a BRAF V600E or V600K mutation: Must be used with vemurafenib (Zelboraf). Applies to new Starts Only.

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CYCLOSPORINE Products Affected • Cyclosporine CAPS• Cyclosporine INJ

• Cyclosporine Modified • Gengraf • Sandimmune SOLN

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

N/A

Coverage Duration

Through end of plan contract year.

Other Criteria Drug is also subject to a Part B versus Part D coverage determination.

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CYRAMZA Products Affected

• Cyramza

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

Oncologist

Coverage Duration

Through end of plan contract year.

Other Criteria For patients with advanced or metastatic, gastric or gastro-esophageal junction adenocarcinoma: Patient has had disease progression on or after prior fluoropyrimidine- or platinum-containing chemotherapy. For Non-Small Cell Lung cancer: Used in combination with docetaxel. For colorectal cancer: Used in combination with FOLFIRI (irinotecan, folinic acid, and 5-fluorouracil), and patient has had disease progression on or after prior therapy with bevacizumab, oxaliplatin, and a fluoropyrimidine. Applies to new Starts Only.

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CYSTAGON Products Affected • Cystagon

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

N/A

Coverage Duration

Through end of plan contract year.

Other Criteria N/A

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DARZALEX Products Affected • Darzalex

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

Documentation of previous treatment history.

Age Restrictions N/A

Prescriber Restrictions

Oncologist or Hematologist

Coverage Duration

Through end of plan contract year.

Other Criteria Applies to new Starts Only

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DEFERASIROX Products Affected • Exjade

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

Deferasirox is indicated for the treatment of chronic iron overload due to blood transfusions (transfusional hemosiderosis) when the patient is receiving transfusions and has a serum ferritin consistently above 1000 mcg/L. Deferasirox is also covered when used for the indication of the treatment of chronic iron overload with non-transfusion-dependent thalassemia syndromes who have liver iron concentrations of at least 5 mg Fe/g dry weight and serum ferritin levels greater than 300 mcg/L. Coverage for this diagnosis is approved based upon laboratory values and when verified as not being used in combination with other iron chelators since safety has not been established.

Age Restrictions N/A

Prescriber Restrictions

N/A

Coverage Duration

Through end of plan contract year.

Other Criteria N/A

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DIABETES-AGE EDIT Products Affected • Glyburide TABS

• Glyburide Micronized • Glyburide/metformin Hcl

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

Prescriber must acknowledge that medication benefits outweigh potential risks in patients 65 years of age or older.

Age Restrictions This prior authorization only applies to members 65 years of age or older to ensure safe use of a potentially high risk medication in the elderly population. Members under 65 years of age are not subject to the prior authorization requirements.

Prescriber Restrictions

N/A

Coverage Duration

Through end of plan contract year.

Other Criteria Patient has a documented trial and failure or a contraindication to glipizide and glimepiride.

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DRONABINOL Products Affected • Dronabinol

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

N/A

Coverage Duration

CINV:6 months, PONV:1 month, Other medically accepted indications: through end of plan contract year

Other Criteria For the diagnosis of nausea and vomiting associated with cancer chemotherapy, the following must be met: 1. The patient is receiving cancer chemotherapy AND 2. The patient has failed one 5HT-3 receptor antagonist such as ondansetron or granisitron. There are no additional requirements for anorexia associated with weight loss in patients with AIDS. Drug is also subject to a Part B versus Part D coverage determination.

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EGRIFTA Products Affected • Egrifta

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

Egrifta is not covered for weight loss management, patients with active malignancy or patients who are pregnant, and in patients with disruption of the hypothalamic-pituitary axis due to hypophysectomy, hypopituitarism, pituitary tumor/surgery, head irradiation or head trauma.

Required Medical Information

For HIV-infected patients with lipodystrophy, documentation of active antiretroviral therapy.

Age Restrictions N/A

Prescriber Restrictions

N/A

Coverage Duration

Through end of plan contract year.

Other Criteria N/A

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ELITEK Products Affected • Elitek

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

Glucose-6-phosphate dehydrogenase (G6PD) deficiency.

Required Medical Information

For the treatment of uric acid levels in patient with diagnosis of leukemia, lymphoma or solid tumor malignancies AND are receiving chemotherapy that is expected to cause tumor lysis.

Age Restrictions N/A

Prescriber Restrictions

N/A

Coverage Duration

5 days

Other Criteria N/A

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EMPLICITI Products Affected • Empliciti

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

Documentation of previous treatment history.

Age Restrictions N/A

Prescriber Restrictions

Oncologist or Hematologist

Coverage Duration

Through end of plan contract year.

Other Criteria For multiple myeloma: must be used in combination with lenalidomide and dexamethasone. Applies to new Starts Only.

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ENBREL Products Affected • Enbrel

• Enbrel Sureclick

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

For the treatment of adult patients with moderate to severe chronic plaque psoriasis: PASI score of 10 or more and body surface area (BSA) involvement equal to or greater than 5% OR affecting crucial body areas such as the hands, feet, face, or genitals. For continuation of therapy: patient has shown improvement and dose requested does not exceed the FDA maximum dose.

Age Restrictions N/A

Prescriber Restrictions

Rheumatologist or Dermatologist

Coverage Duration

Plaque psoriasis: 12 weeks, Other: Initial, 6 months. Then through end of plan contract year

Other Criteria For the treatment of adult patients with moderate to severe chronic plaque psoriasis: Documentation of a trial of at least one non-biologic therapy, such as phototherapy, MTX, acitretin or cyclosporine.

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ENTRESTO Products Affected • Entresto

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

History of angioedema related to previous ACE inhibitor or ARB therapy. Concomitant use of ACE inhibitors. Concomitant use of aliskiren (Tekturna) in patients with diabetes.

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

N/A

Coverage Duration

Through end of plan contract year.

Other Criteria N/A

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EPCLUSA Products Affected • Epclusa

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

Confirmation of hepatitis C genotype. Previous hepatitis C treatment history (if any). Other medications that will be used with current AASLD/IDSA protocol (if any). Presence or absence of cirrhosis.

Age Restrictions N/A

Prescriber Restrictions

Infectious disease, gastroenterologist, hepatologist

Coverage Duration

Duration will be applied consistent with current AASLD/IDSA guidance.

Other Criteria (A) For Genotypes 1 and 4, patient must have documented failure/contraindication/intolerance to Harvoni (ledipasvir and sofosbuvir) OR Zepatier (elbasvir and grazoprevir), if appropriate based on current AASLD/IDSA guidance. For Genotype 5 and 6, patient must have documented failure/contraindication/intolerance to Harvoni (ledipasvir and sofosbuvir), if appropriate based on current AASLD/IDSA guidance, AND (B) Criteria will be applied consistent with current AASLD/IDSA guidance.

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ERAXIS Products Affected • Eraxis

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

N/A

Coverage Duration

6 weeks

Other Criteria The patient will need to have tried and failed fluconazole and oral voriconazole.

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ERBITUX Products Affected • Erbitux

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

A documented diagnosis of colorectal cancer AND both of the below-documented evidence of positive EGFR expression from primary tumor or metastatic tumor site AND documented K-ras (KRAS) mutation analysis to predict non-response. There are no additional requirements for squamous cell carcinoma of the head and neck.

Age Restrictions N/A

Prescriber Restrictions

Oncologist

Coverage Duration

Through end of plan contract year.

Other Criteria Applies to new Starts Only.

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ERGOLOID-AGE EDIT Products Affected • Ergoloid Mesylates TABS

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

Prescriber must acknowledge that medication benefits outweigh potential risks in patients 65 years of age or older.

Age Restrictions This prior authorization only applies to members 65 years of age or older to ensure safe use of a potentially high risk medication in the elderly population. Members under 65 years of age are not subject to the prior authorization requirements.

Prescriber Restrictions

N/A

Coverage Duration

Through end of plan contract year.

Other Criteria For treatment of Alzeihmer’s/Dementia: Patient has a documented trial and failure or a contraindication to one of the following: galantamine, rivastigmine, or donepezil.

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ERIVEDGE Products Affected

• Erivedge

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

For diagnosis of locally advanced basal cell carcinoma that has recurred following surgery or patient is not candidate for surgery or radiation. For Metastatic basal cell carcinoma, no additional information required.

Age Restrictions N/A

Prescriber Restrictions

Oncologist

Coverage Duration

Through end of plan contract year.

Other Criteria Applies to new Starts Only

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ERWINAZE Products Affected • Erwinaze

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

Oncologist or Hematologist

Coverage Duration

Through end of plan contract year.

Other Criteria Patient has developed hypersensitivity to E. coli-derived asparaginase. Applies to new Starts Only.

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ESBRIET Products Affected • Esbriet

PA Criteria Criteria Details

Covered Uses All FDA approved indications not otherwise excluded from Part D

Exclusion Criteria

N/A

Required Medical Information

Confirmation of diagnosis of IPF.

Age Restrictions N/A

Prescriber Restrictions

Pulmonologist

Coverage Duration

Through end of plan contract year.

Other Criteria Patient has a documented trial and failure or contraindication to Ofev (nintedanib) or clinical rationale as to why patient cannot used preferred agent Ofev (nintedanib).

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ESTROGEN-AGE EDIT

Products Affected • Amabelz• Estradiol ORAL TABS 0.5MG,

1MG, 2MG• Estradiol PTTW• Estradiol PTWK• Estradiol/norethindrone Acetate• Fyavolv• Jevantique Lo

• Jinteli • Lopreeza• Menest• Mimvey • Mimvey Lo• Norethindrone Acetate/ethinyl

Estradiol TABS 2.5MCG; 0.5MG,5MCG; 1MG

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

Prescriber must acknowledge that medication benefits outweigh potential risks in patients 65 years of age or older.

Age Restrictions This prior authorization only applies to members 65 years of age or older to ensure safe use of a potentially high risk medication in the elderly population. Members under 65 years of age are not subject to the prior authorization requirements.

Prescriber Restrictions

N/A

Coverage Duration

Through end of plan contract year.

Other Criteria N/A

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EVOMELA Products Affected • Evomela

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

Oncologist or Hematologist

Coverage Duration

Through end of plan contract year.

Other Criteria Applies to new starts only.

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FABRAZYME Products Affected • Fabrazyme

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

N/A

Coverage Duration

Through end of plan contract year.

Other Criteria N/A

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FARYDAK Products Affected • Farydak

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

Oncologist or Hematologist

Coverage Duration

Through end of plan contract year.

Other Criteria For multiple myeloma: Must be used with bortezomib and dexamethasone. Applies to new Starts Only.

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FASLODEX Products Affected • Faslodex INJ 250MG/5ML

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

Oncologist

Coverage Duration

Through end of plan contract year.

Other Criteria Applies to new Starts Only.

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FENTANYL ORAL Products Affected • Fentanyl Citrate Oral Transmucosal

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

The drug is not indicated in the management of acute or post-operative pain. This medication must not be used in opioid non-tolerant patients. The patient must not have any of the following contraindications: Not covered for patients with pain not associated with cancer.

Required Medical Information

For the management of breakthrough cancer pain in patients with malignancies already receiving and tolerant to opioid therapy for their underlying cancer pain.

Age Restrictions N/A

Prescriber Restrictions

Oncologists and pain specialists who are experienced in the use of Schedule II opioids to treat cancer pain.

Coverage Duration

Through end of plan contract year.

Other Criteria Diagnosis of breakthrough cancer pain in opioid-tolerant patients AND concomitant use of long acting opioid therapy, such as ONE of these- controlled-release morphine or extended-release morphine or controlled-release oxycodone or extended-release oxymorphone or fentanyl transdermal or methadone.

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FERRIPROX Products Affected • Ferriprox

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

N/A

Coverage Duration

Through end of plan contract year.

Other Criteria N/A

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FIRAZYR Products Affected • Firazyr

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

Member must have a diagnosis of HAE and where diagnosis is documented by documented based on evidence of a normal C1 level and a low C4 level (C4 less than 14 mg/dL normal range 14 to 40 mg/dL, or C4 below the lower limit of normal as defined by the laboratory performing the test) plus: a) A low C1 inhibitor (C1INH) antigenic level (C1INH less than 19mg/dL normal range 19 to 37 mg/dL or C1INH antigenic level below the lower limit of normal as defined by the laboratory performing the test) OR b) A normal C1INH antigenic level (C1INH greater than or equal to 19 mg/dL) and a low C1INH functional level (functional C1INH less than 50%, or below the lower limit of normal as defined by the laboratory performing the test) and Member must be experiencing at least one symptom of the moderate or severe attack (e.g., airway swelling, severe abdominal pain, facial swelling, nausea and vomiting, painful facial distortion) and Medications known to cause angioedema (i.e. ACE-Inhibitors, estrogens, angiotensin II receptor blockers) have been evaluated and discontinued when appropriate.

Age Restrictions N/A

Prescriber Restrictions

Immunologist or Rheumatologist

Coverage Duration

Through end of plan contract year.

Other Criteria N/A

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FIRMAGON Products Affected • Firmagon

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

Not covered for pregnant women or women of child-bearing age.

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

Oncologist

Coverage Duration

Through end of plan contract year.

Other Criteria Applies to new starts only.

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FORTEO Products Affected • Forteo INJ 600MCG/2.4ML

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

Diagnosis of underlying hypercalcemic disorder such as hypercalcemia, hyperparathyroidism or hypoparathyroidism, or high risk for osteosarcoma (Pagets disease, prior radiation therapy, bone metastases, open epiphyses, etc.). Treatment duration greater than 24 months.

Required Medical Information

Fracture history. Documentation of high risk for fracture for postmenopausal women, high risk defined with the presence of two of the following: low BMD scores (T-score less than or equal to -2.5 at the spine or hip or both), advanced age, or positive family history for osteoporosis in a 1st degree relative (parent, sibling, or offspring), Start date of therapy.

Age Restrictions N/A

Prescriber Restrictions

N/A

Coverage Duration

2 years from initiation of therapy

Other Criteria For postmenopausal women with osteoporosis at high risk for fracture and men with primary or hypogonadal osteoporosis, require documentation of trial and failure on at least one first-line therapy (alendronate, Evista or ibandronate) or documentation of intolerance to at least two first-line therapies. For patients with glucocorticoid induced osteoporosis, require documentation of trial and failure to alendronate or documented intolerance to alendronate.

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FYCOMPA Products Affected • Fycompa

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

N/A

Coverage Duration

Through end of plan contract year.

Other Criteria Applies to new starts only.

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GATTEX Products Affected • Gattex

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

Documentation of the following: Patient has had a colonoscopy (or alternate imaging) of the entire colon with no evidence of neoplastic disease including polyps (or if polyps, they were removed within 6 months prior to starting treatment with Gattex) AND patient has had an initial laboratory assessment (bilirubin, alkaline phosphatase, lipase and amylase) within 6 months prior to starting treatment with Gattex to identify abnormal test levels.

Age Restrictions N/A

Prescriber Restrictions

N/A

Coverage Duration

Through end of plan contract year.

Other Criteria Patient has been dependent on parenteral nutrition/intravenous support for at least 12 months AND requires parenteral nutrition at least three times per week.

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GAZYVA Products Affected • Gazyva

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

HBsAGg and anti-HBc. If positive, a physician with expertise in managing hepatitis B has been consulted regarding monitoring and consideration for HBV antiviral therapy.

Age Restrictions N/A

Prescriber Restrictions

Oncologist

Coverage Duration

Through end of plan contract year.

Other Criteria For chronic lymphocytic leukemia (CLL): CLL is previously untreated and will be used in combination with chlorambucil. Applies to new Starts Only.

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GILENYA Products Affected • Gilenya

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

Patients who in the last 6 months experienced myocardial infarction, unstable angina, stroke, TIA, decompensated heart failure requiring hospitalization or Class III/IV heart failure. History or presence of Mobitz Type II second-degree or third-degree atrioventricular (AV) block or sick sinus syndrome, unless patient has a functioning pacemaker. Baseline QTc interval greater than or equal to 500 ms. Treatment with Class Ia or Class III anti-arrhythmic drugs.

Required Medical Information

Documentation that other therapies used for treating multiple sclerosis will be discontinued ( Note: This does NOT require having to discontinue Ampyra).The member has a diagnosis of a relapsing form of multiple sclerosis OR has experienced a first clinical episode and has MRI features consistent with multiple sclerosis.

Age Restrictions N/A

Prescriber Restrictions

Neurologist

Coverage Duration

Through end of plan contract year.

Other Criteria N/A

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GILOTRIF Products Affected • Gilotrif

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

Oncologist

Coverage Duration

Through end of plan contract year.

Other Criteria Applies to new Starts Only.

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GLEEVEC Products Affected • Imatinib Mesylate

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

Oncologist or Hematologist

Coverage Duration

Through end of plan contract year.

Other Criteria Applies to new starts only

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HALAVEN

Products Affected • Halaven

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

Oncologist

Coverage Duration

Through end of plan contract year.

Other Criteria A documented diagnosis of metastatic breast cancer AND documented prior therapy with both an anthracycline (i.e. daunorubicin, bleomycin), and a taxane (i.e. paclitaxel, docetaxel). Applies to new Starts Only.

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HARVONI Products Affected • Harvoni

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

Confirmation of hepatitis C genotype. Previous hepatitis C treatment history (if any). Other medications that will be used with current AASLD/IDSA protocol (if any). Presence or absence of cirrhosis.

Age Restrictions N/A

Prescriber Restrictions

Infectious disease, gastroenterologist, hepatologist

Coverage Duration

Duration will be applied consistent with current AASLD/IDSA guidance.

Other Criteria Criteria will be applied consistent with current AASLD/IDSA guidance.

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HERCEPTIN Products Affected • Herceptin

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

HER2-protein expression test (require positive or equivocal HER2 over-expression). As part of a regimen for the adjuvant treatment of HER2-overexpressing, breast cancer. As first-line therapy for metastatic HER2 positive breast cancer in combination with paclitaxel. As a single agent, for the adjuvant treatment of HER2-overexpressing node-negative (ER/PR negative or with one high-risk feature) or node positive breast cancer, following multi-modality anthracycline based therapy. As a single agent for the treatment of HER2-overexpressing breast cancer in patients who have received one or more chemotherapy regimens for metastatic disease. As a single agent for the treatment of HER2-overexpressing breast cancer in patients who have received one or more chemotherapy regimens for metastatic disease. As part of a regimen for HER2-positive esophageal or gastric cancer. As first line treatment for HER2 overexpressing metastatic gastric or gastroesophageal junction adenocarcinoma in combination with cisplatin and either capecitabine (Xeloda) or 5-FU.

Age Restrictions N/A

Prescriber Restrictions

Oncologist

Coverage Duration

Through end of plan contract year.

Other Criteria Applies to new Starts Only.

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HETLIOZ Products Affected • Hetlioz

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

For non-24- hour sleep-wake disorder (“non-24”): Member is documented to be totally blind and has no light perception AND other sleep disorders have been ruled out or treated appropriately (i.e. sleep apnea).

Age Restrictions N/A

Prescriber Restrictions

N/A

Coverage Duration

Through end of plan contract year.

Other Criteria N/A

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HUMIRA Products Affected • Humira • Humira Pediatric Crohns Disease

Starter Pack

• Humira Pen• Humira Pen-crohns Diseasestarter• Humira Pen-psoriasis Starter

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

For the treatment of adult patients with moderate to severe chronic plaque psoriasis: PASI score of 10 or more. For continuation of therapy: patient has shown improvement and dose requested does not exceed the FDA maximum dose.

Age Restrictions N/A

Prescriber Restrictions

Gastroenterologist, Ophthalmologist, Rheumatologist or Dermatologist

Coverage Duration

Initial for PsO and UC: 12 weeks. Other: 6 months. Continuation: Through end of plan contract year

Other Criteria For the treatment of adult patients with moderate to severe chronic plaque psoriasis: Documentation of a trial of at least one non-biologic therapy, such as phototherapy, MTX, acitretin or cyclosporine.

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HYDROXYPROGESTERONE CAPROATE Products Affected • Hydroxyprogesterone Caproate INJ

1.25GM/5ML

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

Contraindications per FDA labeling.

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

N/A

Coverage Duration

Through end of plan contract year.

Other Criteria Applies to new starts only.

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HYDROXYZINE-AGE EDIT Products Affected

• Hydroxyzine Hcl INJ

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

Prescriber must acknowledge that medication benefits outweigh potential risks in patients 65 years of age or older.

Age Restrictions This prior authorization only applies to members 65 years of age or older to ensure safe use of a potentially high risk medication in the elderly population. Members under 65 years of age are not subject to the prior authorization requirements.

Prescriber Restrictions

N/A

Coverage Duration

Through end of plan contract year.

Other Criteria For alcohol withdrawal syndrome: Patient has a documented trial and failure or a contraindication to clorazepate or diazepam. For N/V: Patient has a documented trial and failure or a contraindication to ondansetron. For anxiety: Patient has a documented trial and failure or a contraindication to one of the following: duloxetine, citalopram, or venlafaxine ER. For Allergic Rhinitis: Patient has a documented trial and failure or a contraindication to one of the following: levocetirizine, desloratadine, azelastine (nasal), or fluticasone (nasal). For pruritus: Patient has a documented trial and failure or a contraindication to one of the following: levocetirizine, desloratadine, or topical steroids.

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IBRANCE Products Affected • Ibrance

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

Oncologist

Coverage Duration

Through end of plan contract year.

Other Criteria Applies to new Starts Only.

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ICLUSIG Products Affected • Iclusig

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

Oncologist or Hematologist

Coverage Duration

Through end of plan contract year.

Other Criteria A documented diagnosis of one of the following: 1. Chronic phase, accelerated phase, or blast phase chronic myeloid leukemia (CML) AND Documented confirmation of the presence of the T315i mutation OR No other tyrosine kinase inhibitor (TKI) therapy is indicated (i.e., imatinib (Gleevec), dasatinib (Sprycel), or nilotinib (Tasigna)). 2. Philadelphia chromosome positive acute lymphoblastic leukemia (Ph+ALL) AND Documented confirmation of the presence of the T315i mutation OR No other tyrosine kinase inhibitor (TKI) therapy is indicated (i.e., imatinib (Gleevec). Applies to new Starts Only.

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IDHIFA Products Affected • Idhifa

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

Oncologist or Hematologist

Coverage Duration

Through end of plan contract year

Other Criteria Applies to new starts only.

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ILARIS Products Affected • Ilaris

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

N/A

Coverage Duration

Through end of plan contract year.

Other Criteria N/A

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IMBRUVICA Products Affected • Imbruvica

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

Oncologist

Coverage Duration

Through end of plan contract year.

Other Criteria Applies to new start only.

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94

IMFINZI Products Affected • Imfinzi

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

Hematologist or Oncologist

Coverage Duration

Through end of plan contract year.

Other Criteria Applies to new starts only.

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IMMUNE GLOBULIN Products Affected • Gamastan S/d

• Gammaplex • Gamunex-c

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

For dermatomyositis and polymyositis: standard 1st line treatments (corticosteroids or immunosuppressants) have been tried but were unsuccessful or not tolerated OR patient is unable to receive standard therapy because of a contraindication or other clinical reason. For GBS: physical mobility must be severely affected such that the patient requires an aid to walk AND IVIG therapy must be initiated within 2 weeks of symptom onset. For RRMS: a documented failure/contraindication/intolerance to two of the following: interferon beta-1a (Rebif), fingolimod hydrochloride (Gilenya), glatiramer (Copaxone). For CLL: serum IgG less than 600 mg/dL OR a history of recurrent bacterial infections. For BMT/HSCT: serum IgG less than 400 mg/dL. For pediatric HIV infection: serum IgG less than 400 mg/dL OR a history of recurrent bacterial infections. PRCA is secondary to parvovirus B19 infection. For all indications: patients with any of the following risk factors for renal dysfunction must receive the minimum dose or concentration available of IVIG and the minimum infusion rate practicable: pre-existing renal insufficiency, diabetes mellitus, age over 65 years, volume depletion, sepsis, paraproteinemia, or receiving concomitant nephrotoxic drugs. For all indications: patients with any of the following risk factors for thrombosis must receive the minimum dose or concentration available of IVIG and the minimum infusion rate practicable: age 45 years or older, prolonged immobilization, hypercoagulable conditions, history of venous or arterial thrombosis, use of estrogens, indwelling central vascular catheters, hyperviscosity, or cardiovascular risk factors.

Age Restrictions N/A

Prescriber Restrictions

N/A

Coverage Duration

Through end of plan contract year.

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Other Criteria Patient has a documented trial and failure or contraindication to Gammaplex and Gamunex-c. Drug is also subject to a Part B versus Part D coverage determination.

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INCRELEX Products Affected • Increlex

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

Increlex is contraindicated for growth promotion in patients with closed epiphyses, for IV administration, in patients with active or suspected neoplasia. Increlex should be discontinued if neoplasia develops while on therapy.

Required Medical Information

Child has one of the following conditions: Severe primary IGF-1 deficiency OR Growth hormone gene deletion with developed neutralizing antibodies to growth hormone OR Genetic mutation of GH receptor (i.e. Laron Syndrome) AND Child has severe growth retardation with height standard deviation score (SDS) more than 3 SDS below the mean for chronological age and sex AND Child with IGF-1 level greater than or equal to 3 standard deviations below normal based on lab reference range for age and sex AND Child with normal or elevated growth hormone (GH) levels based on at least one growth hormone stimulation test AND Evidence of open epiphyses.

Age Restrictions N/A

Prescriber Restrictions

Pediatrician or Endocrinologist

Coverage Duration

Through end of plan contract year.

Other Criteria N/A

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INLYTA Products Affected

• Inlyta

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

Oncologist

Coverage Duration

Through end of plan contract year.

Other Criteria For renal cell carcinoma: Requests for new starts are covered following a trial and failure of Sutent. Applies to new starts only.

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INSOMNIA AGENTS-AGE EDIT

Products Affected • Eszopiclone

• Zaleplon • Zolpidem Tartrate TABS

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

Prescriber must acknowledge that medication benefits outweigh potential risks in patients 65 years of age or older.

Age Restrictions This prior authorization only applies to members 65 years of age or older to ensure safe use of a potentially high risk medication in the elderly population. Members under 65 years of age are not subject to the prior authorization requirements.

Prescriber Restrictions

N/A

Coverage Duration

Through end of plan contract year.

Other Criteria N/A

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INTRON-A Products Affected • Intron A

• Intron A W/diluent INJ 10MU

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

Autoimmune hepatitis. Decompensated liver disease

Required Medical Information

For malignant melanoma: Adjuvant to surgical treatment with malignant melanoma who are free of disease but are at high risk for systemic recurrence within 56 days of surgery. For the initial treatment of clinically aggressive follicular non-Hodgkin lymphoma, used in conjunction with anthracycline-containing combination chemotherapy. Chronic hepatitis C: In patients with compensated liver disease who have a history of blood or blood product exposure and/or patients who are hepatitis C virus (HCV)-antibody-positive. Chronic hepatitis B: In patients with compensated liver disease and patients must be serum HBsAg-positive for at least 6 months and have HBV replication (serum HBeAg-positive) with elevated serum ALT.

Age Restrictions N/A

Prescriber Restrictions

N/A

Coverage Duration

Through end of plan contract year.

Other Criteria Applies to new Starts Only.

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IRESSA Products Affected • Iressa

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

For metastatic non-small cell lung cancer (NSCLC): patient’s tumors have epidermal growth factor receptor (EGFR) exon 19 deletions or exon 21 (L858R) substitution mutations as detected by an FDA-approved test.

Age Restrictions N/A

Prescriber Restrictions

Oncologist

Coverage Duration

Through end of plan contract year.

Other Criteria Applies to new Starts Only.

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102

ISTODAX Products Affected • Istodax

• Istodax (overfill)

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

Oncologist

Coverage Duration

Through end of plan contract year.

Other Criteria Diagnosis of Cutaneous T-cell Lymphoma OR Peripheral T-cell Lymphoma AND prior use of one systemic therapy such as one of the following, a retinoid (ex. Bexarotene (Targretin), all-trans retinoic acid (Vesanoid), acitretin (Soriatane). Diagnosis of Peripheral T-cell Lymphoma and prior use of one therapy such as one of the following: Beleodaq (belinostat) or Folotyn (pralatrexate). Applies to new Starts Only.

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ITRACONAZOLE Products Affected • Itraconazole CAPS

• Sporanox SOLN

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

Diagnosis of onychomycosis requires a positive laboratory test such as (potassium hydroxide-KOH preparation, fungal culture, or nail biopsy) to confirm the diagnosis.

Age Restrictions N/A

Prescriber Restrictions

N/A

Coverage Duration

Onychomycosis: Fingernail- 6 weeks, Toenail-12 weeks. Other indications: 3 months

Other Criteria For the diagnosis of oropharyngeal or esophageal candidiasis, the solution will be used. For oropharyngeal or esophageal candidiasis, patient has failed fluconazole. For treatment of aspergillosis, blastomycosis, febrile neutropenia, empiric therapy of febrile neutropenic (ETFN) patients with suspected fungal infections, histoplasmosis (treatment of histoplasmosis, including chronic cavitary pulmonary disease and disseminated, nonmeningeal histoplasmosis in non-immunocompromised or immunocompromised patients), and onychomycosis of the fingernails or toenails the oral capsule will be used. For aspergillosis, patient has failed or is intolerant or refractory to amphotericin B.

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IXEMPRA Products Affected • Ixempra Kit

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

Oncologist

Coverage Duration

Through end of plan contract year.

Other Criteria For the treatment of metastatic or locally advanced breast cancer in patients that have not responded to an anthracycline and taxane chemotherapy agent: Used in combination with capecitabine. If used as monotherapy in patients with metastatic or locally advanced breast cancer, patient must have tumor that is resistant or refractory to anthracyclines, taxanes and capecitabine. Applies to new Starts Only.

104

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JAKAFI Products Affected • Jakafi

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

For myelofibrosis, any one of the following: either primary myelofibrosis, or post-polycythemia vera myelofibrosis or post-essential thrombocythemia myelofibrosis.

Age Restrictions N/A

Prescriber Restrictions

Oncologist or Hematologist

Coverage Duration

Through end of plan contract year.

Other Criteria For polycythemia vera: patient has a documented trial and failure or contraindication to hydroxyurea. Applies to new starts only.

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JEVTANA Products Affected • Jevtana

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

Oncologist

Coverage Duration

Through end of plan contract year.

Other Criteria A documented diagnosis of hormone-refractory metastatic prostate cancer AND documented failure of a docetaxel-based chemotherapy AND used in combination with prednisone. Applies to new starts only.

106

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KADCYLA Products Affected • Kadcyla

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

HER2-protein expression test (require positive or equivocal HER2 over-expression test). Documentation of past therapies and outcomes. Patients must have received prior therapy for metastatic disease OR developed disease recurrence during or within six months of completing adjuvant therapy. Confirm treatment is for patients with HER2-positive, metastatic breast cancer who previously received trastuzumab (Herceptin) and a taxane, either separately or in combination.

Age Restrictions N/A

Prescriber Restrictions

Oncologist

Coverage Duration

Through end of plan contract year.

Other Criteria Applies to new starts only.

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108

KALYDECO Products Affected • Kalydeco

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

Kalydeco is not effective in patients with CF who are homozygous for the F508del mutation in the CFTR gene.

Required Medical Information

Treatment of cystic fibrosis (CF) in patients who have a mutation in the CFTR gene.

Age Restrictions N/A

Prescriber Restrictions

N/A

Coverage Duration

Through end of plan contract year.

Other Criteria N/A

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109

KEYTRUDA Products Affected • Keytruda

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

Oncologist

Coverage Duration

Through end of plan contract year.

Other Criteria Applies to new starts only.

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KISQALI Products Affected • Kisqali • Kisqali Femara 200 Dose

• Kisqali Femara 400 Dose • Kisqali Femara 600 Dose

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

Oncologist or Hematologist

Coverage Duration

Through end of plan contract year

Other Criteria Applies to new starts only.

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KORLYM Products Affected • Korlym

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

Pregnancy. Patients taking simvastatin, lovastatin, and CYP3A substrates with narrow therapeutic ranges, such as cyclosporine, dihydroergotamine, ergotamine, fentanyl, pimozide, quinidine, sirolimus, and tacrolimus. Concomitant treatment with systemic corticosteroids for serious medical conditions or illnesses. Women with a history of unexplained vaginal bleeding. Women with endometrial hyperplasia with atypia or endometrial carcinoma.

Required Medical Information

For hyperglycemia secondary to hypercortisolism in adult patients with endogenous Cushing's syndrome who have type 2 diabetes mellitus or glucose intolerance: patient had an inadequate or partial response to surgery or there is a clinical reason for why the patient is not a candidate for surgery.

Age Restrictions N/A

Prescriber Restrictions

Endocrinologist

Coverage Duration

Through end of plan contract year.

Other Criteria N/A

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KUVAN Products Affected • Kuvan

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

For diagnosis of hyperphenylalaninemia (HPA) due to tetrahydrobiopterin- (BH4-) responsive Phenylketonuria (PKU): dosing is within the range of 5 to 20 mg/kg/day. Extended Approval: Documented maintenance response of greater than or equal to 30% reduction in baseline Phe level AND patient continues to be under the appropriate care and re-evaluations of a specialist knowledgeable in the management of PKU.

Age Restrictions N/A

Prescriber Restrictions

Endocrinologist, Geneticist or Metabolic Specialist

Coverage Duration

Initial approval: 2 months. Extended approval: 6 month intervals

Other Criteria N/A

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KYNAMRO Products Affected • Kynamro

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

Documentation of moderate or severe hepatic impairment or active liver disease including unexplained persistent abnormal liver function tests.

Required Medical Information

Documentation that Kynamro will not be used as adjunct to LDL apheresis.

Age Restrictions N/A

Prescriber Restrictions

N/A

Coverage Duration

Through end of plan contract year.

Other Criteria Documentation that Kynamro will be used in combination with at least one other lipid-lowering therapy to decrease blood lipids to reach treatment targets.

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KYPROLIS Products Affected • Kyprolis

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

Oncologist or hematologist

Coverage Duration

Through end of plan contract year.

Other Criteria Applies to new starts only.

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LARTRUVO Products Affected • Lartruvo

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

Oncologist or hematologist

Coverage Duration

Through end of plan contract year.

Other Criteria Applies to new starts only.

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LENVIMA Products Affected • Lenvima 10 Mg Daily Dose• Lenvima 14 Mg Daily Dose• Lenvima 18 Mg Daily Dose

• Lenvima 20 Mg Daily Dose • Lenvima 24 Mg Daily Dose• Lenvima 8 Mg Daily Dose

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

Oncologist

Coverage Duration

Through end of plan contract year.

Other Criteria Applies to new starts only.

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LETAIRIS Products Affected • Letairis

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

Not covered for patients who are pregnant. Not covered for patients with idiopathic pulmonary fibrosis.

Required Medical Information

For Pulmonary Arterial Hypertension (PAH) (WHO Group 1) and WHO functional class II to IV symptoms AND patient has mean pulmonary artery pressure greater than or equal to 25 mm Hg at rest or greater than 30 mm Hg with exertion, documented by right-heart catheterization or echocardiography.

Age Restrictions N/A

Prescriber Restrictions

Pulmonologist or cardiologist

Coverage Duration

Through end of plan contract year.

Other Criteria N/A

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LEUKINE Products Affected • Leukine INJ 250MCG

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D or Febrile neutropenia.

Exclusion Criteria

N/A

Required Medical Information

Primary prophylaxis in conjunction with chemotherapy: in previously untreated adult and pediatric members with non-myeloid malignancies receiving established myelosuppressive chemotherapy that is expected to result in a greater than 20% i ncidence of febrile neutropenia OR members receiving chemotherapy who are at increased risk for chemotherapy-induced infectious complications because of bone marrow compromise or comorbidity. Febrile neutropenia: Adjunctive use with antibiotics in high-risk, febrile, neutropenic members who have one or more prognostic factors that are predictive of clinical deterioration: Documented neutropenia with absolute neutrophil count (ANC) under 1000/m, or uncontrolled primary disease, or Pneumonia, or Hypotension, or Multi-organ dysfunction (sepsis syndrome): or Invasive fungal infection. Dose-intensive chemotherapy: Use in settings where clinical research demonstrates that dose-intensive therapy produces improvement in disease control, when these therapies are expected to produce significant rates of febrile neutropenia. This include: Dose dense treatment given at every 2 weeks for early-stage breast cancer, or CHOP regimen for non-Hodgkin’s lymphoma. Acute myeloid leukemia: For administration shortly after the completion of induction or consolidation AML therapy, to achieve decreases in the duration of neutropenia. Acute lymphoblastic leukemia (ALL): For administration after completion of the first few days of chemotherapy of the initial induction or first post-remission course. Myelodysplastic Syndromes: Intermittent use only in member with myelodysplastic syndromes who has less than 15% bl asts in their bone marrow, AND has severe neutropenia (ANC less then 500/mL) and recurrent infections.

Age Restrictions N/A

Prescriber Restrictions

N/A

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Coverage Duration

Initial approval: 3 months. Extended approval: Through end of plan contract year.

Othe r Criteria N/A

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LEUPROLIDE Products Affected • Leuprolide Acetate INJ• Lupron Depot (1-month)• Lupron Depot (3-month)

• Lupron Depot (4-month) • Lupron Depot (6-month)• Lupron Depot-ped (1-month)• Lupron Depot-ped (3-month)

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

Contraindicated in pregnancy

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

N/A

Coverage Duration

Through end of plan contract year.

Other Criteria N/A

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LIDODERM Products Affected • Lidocaine PTCH

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

N/A

Coverage Duration

Through end of plan contract year.

Other Criteria Patient has a documented trial and failure of one month of generic gabapentin.

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LONSURF Products Affected • Lonsurf

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

For diagnosis of metastatic colorectal cancer, patient has been previously treated with fluoropyrimidine-, oxaliplatin- and irinotecan-based chemotherapy, an anti-VEGF biological therapy and for patients with RAS wild-type, patient has been previously treated with an anti-EGFR therapy.

Age Restrictions N/A

Prescriber Restrictions

Oncologist

Coverage Duration

Through end of plan contract year.

Other Criteria Applies to new starts only.

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LYNPARZA Products Affected • Lynparza

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

Oncologist

Coverage Duration

Through end of plan contract year.

Other Criteria Applies to new starts only.

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LYRICA Products Affected • Lyrica

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

N/A

Coverage Duration

Through end of plan contract year.

Other Criteria For neuropathic pain associated with diabetic peripheral neuropathy: a documented trial, failure, or contraindication of duloxetine (Cymbalta). For postherpetic neuralgia: a documented trial, failure, or contraindication of gabapentin. For partial seizures: a documented trial, failure, or contraindication of gabapentin. For fibromyalgia: a documented trial, failure, or contraindication of duloxetine (Cymbalta). For neuropathic pain associated with spinal cord injury, no prerequisite therapy is required.

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MARQIBO Products Affected • Marqibo

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

Patients with demyelinating conditions including Charcot-Marie-Tooth syndrome.

Required Medical Information

For Ph- ALL: patients in second or greater relapse or whose disease progressed following two or more anti-leukemia therapies.

Age Restrictions N/A

Prescriber Restrictions

Oncologist or Hematologist

Coverage Duration

Through end of plan contract year.

Other Criteria Applies to new starts only.

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MEGESTROL-AGE EDIT Products Affected • Megestrol Acetate SUSP 40MG/ML

• Megestrol Acetate TABS

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

Prescriber must acknowledge that medication benefits outweigh potential risks in patients 65 years of age or older.

Age Restrictions This prior authorization only applies to members 65 years of age or older to ensure safe use of a potentially high risk medication in the elderly population. Members under 65 years of age are not subject to the prior authorization requirements.

Prescriber Restrictions

N/A

Coverage Duration

Through end of plan contract year.

Other Criteria N/A

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MEKINIST Products Affected • Mekinist

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

A documented BRAF V600E or V600K mutations as detected by an FDA-approved test

Age Restrictions N/A

Prescriber Restrictions

Oncologist or dermatologist

Coverage Duration

Through end of plan contract year.

Other Criteria Can be used in combination with Tafinlar. However, if Mekinist is being used as a single agent, it is not indicated for use in patients who have received prior BRAF inhibitor therapy (i.e. Zelboraf, Tafinlar). Applies to new starts only.

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MEPRON Products Affected • Atovaquone SUSP

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

N/A

Coverage Duration

Through end of plan contract year.

Other Criteria Requests for patients with Pneumocystis pneumonia will be covered following a trial and failure of co-trimoxazole (SMZ/TMP). Request for prevention of Pneumocystis jiroveci pneumonia will be covered following a trial and failure of co-trimoxazole (SMZ/TMP).

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MODAFINIL Products Affected • Modafinil

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

Require diagnosis for excessive daytime sleepiness associated with narcolepsy. For treatment of excessive daytime sleepiness associated with obstructive sleep apnea (OSA) when the patient meets the following criteria: (1) A Standard Diagnostic Nocturnal Polysomnography (NPSG) has confirmed the diagnosis of OSA and meets ICSD or DSM diagnostic criteria AND (2) that the daytime fatigue is significantly impacting, impairing, or compromising the patient's ability to function normally AND (3) the prescribing physician has established a patient care plan to treat the cause of OSA in conjunction with treating the daily fatigue. For shift work sleep disorder (SWSD): Require confirmed diagnosis and the patient must have a job that requires them to frequently rotate shifts or work at night, and be unable to adjust to their schedule.

Age Restrictions N/A

Prescriber Restrictions

Board certified as a sleep specialist, ear, nose and throat, neurologist or pulmonologist or has obtained a consult from a board certified sleep specialist.

Coverage Duration

Through end of plan contract year.

Other Criteria N/A

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MOZOBIL Products Affected • Mozobil

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

N/A

Coverage Duration

Through end of plan contract year.

Other Criteria Diagnosis of non-Hodgkin’s lymphoma (NHL) and multiple myeloma (MM) requiring autologous transplantation of stem cells AND being used in combination with one granulocyte-colony stimulating factor (G-CSF) such as sargramostim (Leukine) or filgrastim (Neupogen).

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MUSCLE RELAXANTS-AGE EDIT Products Affected • Chlorzoxazone TABS 500MG

• Cyclobenzaprine Hcl TABS

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

Prescriber must acknowledge that medication benefits outweigh potential risks in patients 65 years of age or older.

Age Restrictions This prior authorization only applies to members 65 years of age or older to ensure safe use of a potentially high risk medication in the elderly population. Members under 65 years of age are not subject to the prior authorization requirements.

Prescriber Restrictions

N/A

Coverage Duration

Through end of plan contract year.

Other Criteria N/A

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MYLOTARG

Products Affected • Mylotarg

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

Oncologist or Hematologist

Coverage Duration

Through end of plan contract year

Other Criteria Applies to new starts only.

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NAGLAZYME Products Affected • Naglazyme

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

The intravenous administration of Naglazyme is indicated for patients with Maroteaux-Lamy syndrome (Mucopolysaccharidosis VI). For renewal, patient has shown improvement in walking and stair climbing capacity.

Age Restrictions N/A

Prescriber Restrictions

N/A

Coverage Duration

Initial approval: 6 months. Renewal: Through end of plan contract year.

Other Criteria N/A

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NAMENDA

Products Affected • Memantine Hcl • Memantine Hcl Titration Pak • Memantine Hydrochloride SOLN

• Namenda SOLN • Namenda Xr• Namenda Xr Titration Pack • Namzaric

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions This prior authorization only applies to members under 45.

Prescriber Restrictions

N/A

Coverage Duration

Through end of plan contract year.

Other Criteria N/A

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NATPARA Products Affected • Natpara

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

N/A

Coverage Duration

Through end of plan contract year.

Other Criteria For diagnosis of hypoparathyroidism patient must be using in combination with calcium and vitamin D supplements AND had a trial and failure of calcitriol.

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NERLYNX Products Affected • Nerlynx

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

Oncologist or Hematologist

Coverage Duration

Through end of plan contract year

Other Criteria Applies to new starts only.

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NEUMEGA Products Affected • Neumega

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

Documentation that the medication is being used following myelosuppressive chemotherapy in adult patients with non-myeloid malignancies who are at high risk for severe thrombocytopenia.

Age Restrictions N/A

Prescriber Restrictions

Oncologist or Hematologist

Coverage Duration

Through end of plan contract year.

Other Criteria N/A

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NEUPOGEN Products Affected • Neupogen

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

Confirm use is associated with one of the following: 1. Non-myeloid malignancies receiving a myelosuppressive chemotherapy regimen associated with a significant risk of severe neutropenia with fever 2. Induction or consolidation treatment for Acute myeloid leukemia (AML) 3. Bone marrow transplantation 4. Peripheral Blood Progenitor Cell(PBPC) Collection 5. Severe Chronic Neutropenia (SCN) with ANC less than 500/ml 6. Advanced HIV with ANC under 1000/ml to allow scheduled dosing of myelosuppressive anti-retroviral medications (e.g. zidovudine and ganciclovir).

Age Restrictions N/A

Prescriber Restrictions

N/A

Coverage Duration

Through end of plan contract year.

Other Criteria N/A

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NEXAVAR Products Affected • Nexavar

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

Approved for hepatocellular carcinoma (HCC) when it is unresectable. Approved for renal cell carcinoma that is advanced. Approved for locally recurrent or metastatic progressive differentiated thyroid carcinoma (DTC) that is refractory to iodine treatment.

Age Restrictions N/A

Prescriber Restrictions

Oncologist

Coverage Duration

Through end of plan contract year.

Other Criteria Applies to new starts only.

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NINLARO Products Affected • Ninlaro

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

Documentation of previous treatment history.

Age Restrictions N/A

Prescriber Restrictions

Oncologist or Hematologist

Coverage Duration

Through end of plan contract year.

Other Criteria For multiple myeloma: must be used in combination with lenalidomide and dexamethasone. Applies to new starts only.

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NORDITROPIN Products Affected • Norditropin Flexpro

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

Growth Hormone Deficiency in Children and Adolescents: Patient has failed to respond to at least 2 standard GH stimulation tests. One abnormal GH test is sufficient for children with brain tumors and irradiation with documented multiple pituitary hormone deficiency (MPHD) AND Appropriate imaging (MRI or CT) of the brain to exclude tumor on hypothalamic-pituitary region One of the following criteria are met: Child has severe growth retardation with height standard deviation score (SDS) more than 3 SDS below the mean for chronological age and sex OR Child has moderate growth retardation with height SDS –2 and –3 SDS below the mean chronological age and sex and decreased growth rate (growth velocity measured over one year below 25th percentile for age and sex) OR Child exhibits severe deceleration in growth rate (growth velocity measured over 1 year –2 SDS below the mean for age and sex) OR Child has decreasing growth rate combined with a predisposing condition like previous cranial irradiation or tumor OR Child exhibits evidence of other pituitary hormone deficiencies or signs of congenital GHD (hypoglycemia, microphallus). GH Deficiency in Adults: Covered for adult GH deficiency who meet ALL the following criteria: Adult onset: Patients who have GH deficiency either alone or with multiple hormone deficiencies (hypopituitarism), as a result of EITHER disease of the pituitary or hypothalamus OR injury to either the pituitary or hypothalmus from surgery, radiation therapy, or trauma OR Childhood onset: Patients who were GH deficient during childhood who have GH deficiency confirmed as adult before therapy is started. AND Biochemical diagnosis of GH deficiency, by means of a negative response to two standard GH stim tests (maximum peak less then 5 ng/ml when measured by RIA or less then 2.5 ng/ml when measured by IRMA) AND Patients already receiving supplementation of other hormones as required AND Objective measurement of clinical features of GH deficiency.

Age Restrictions N/A

Prescriber Restrictions

Endocrinologist

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Coverage Duration

Through end of plan contract year.

Othe r Criteria N/A

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NORTHERA Products Affected • Northera

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

N/A

Coverage Duration

3 months initially, then through end of plan contract year if still effective

Other Criteria N/A

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NOXAFIL Products Affected • Noxafil

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

N/A

Coverage Duration

6 months

Other Criteria For treatment of oropharyngeal candidiasis: Noxafil oral suspension is drug being requested and patient’s oropharyngeal candidiasis is refractory to itraconazole or fluconazole. Refractoriness is defined as progression of infection or failure to improve after a minimum of 7 days or prior therapeutic doses of effective antifungal therapy. For prophylaxis of invasive Aspergillus and Candida infections: patient is at high risk of developing these infections due to being severely immunocompromised, such as hematopoietic stem cell transplant (HSCT) recipients with graft-versus-host disease (GVHD) or those with hematologic malignancies with prolonged neutropenia from chemotherapy.

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NULOJIX Products Affected • Nulojix

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

Not covered in patients who are EBV seronegative or with unknown EBV serostatus.

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

N/A

Coverage Duration

Through end of plan contract year.

Other Criteria Documented diagnosis of of prophylaxis of organ rejection in kidney transplant in combination with basiliximab (Simulect) during induction therapy and used concurrently with mycophenolate mofetil and corticosteroids. Drug is also subject to a Part B versus Part D coverage determination.

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NUPLAZID Products Affected • Nuplazid

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

For Parkinson's disease psychosis: Prescribed by or after consultation with a neurologist or psychiatrist.

Coverage Duration

Through end of plan contract year

Other Criteria Applies to new starts only.

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NUVIGIL Products Affected • Armodafinil

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

Require diagnosis for excessive daytime sleepiness associated with narcolepsy. For treatment of excessive daytime sleepiness associated with obstructive sleep apnea (OSA) when the patient meets the following criteria: (1) A Standard Diagnostic Nocturnal Polysomnography (NPSG) has confirmed the diagnosis of OSA and meets ICSD or DSM diagnostic criteria. (2) that the daytime fatigue is significantly impacting, impairing, or compromising the patient's ability to function normally (3) the prescribing physician has established a patient care plan to treat the cause of OSA in conjunction with treating the daily fatigue. For shift work sleep disorder (SWSD): Require confirmed diagnosis and the patient must have a job that requires them to frequently rotate shifts or work at night, and be unable to adjust to their schedule.

Age Restrictions N/A

Prescriber Restrictions

Board certified as a sleep specialist, ear, nose and throat, neurologist or pulmonologist or has obtained a consult from a board certified sleep specialist.

Coverage Duration

Through end of plan contract year.

Other Criteria N/A

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NYMALIZE

Products Affected • Nymalize

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

N/A

Coverage Duration

21 days

Other Criteria Diagnosis of subarachnoid hemorrhage and trial and failure of nimodipine capsules.

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OCTREOTIDE Products Affected • Octreotide Acetate

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

N/A

Coverage Duration

Through end of plan contract year.

Other Criteria N/A

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ODOMZO Products Affected • Odomzo

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

For diagnosis of locally advanced basal cell carcinoma that has recurred following surgery or patient is not candidate for surgery or radiation.

Age Restrictions N/A

Prescriber Restrictions

Oncologist

Coverage Duration

Through end of plan contract year.

Other Criteria Applies to new starts only.

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OFEV Products Affected • Ofev

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

Confirmation of diagnosis of IPF.

Age Restrictions N/A

Prescriber Restrictions

Pulmonologist

Coverage Duration

Through end of plan contract year.

Other Criteria N/A

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ONIVYDE Products Affected • Onivyde

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

Oncologist

Coverage Duration

Through end of plan contract year.

Other Criteria For metastatic adenocarcinoma of the pancreas: Must be used in combination with fluorouracil and leucovorin.

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OPDIVO Products Affected • Opdivo

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

For unresectable or metastatic melanoma: Used as a single agent for BRAF V600 wild-type OR Used as a single agent for BRAF V600 mutation positive OR Used in combination with ipilimumab (Yervoy). For Metastatic non-small cell lung cancer (NSCLC): patient has had progression on or after platinum based chemotherapy (for example cisplatin or carboplatin). For advanced renal cell carcinoma (RCC): patient has a documented trial and failure or contraindication to Sutent (sunitinib) and Inlyta (axitinib).

Age Restrictions N/A

Prescriber Restrictions

Oncologist

Coverage Duration

Through end of plan contract year.

Other Criteria Applies to new starts only.

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OPSUMIT Products Affected • Opsumit

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

Pregnancy

Required Medical Information

The patient is WHO Group I and patient has WHO functional class II to IV symptoms. Patient has mean pulmonary artery pressure greater than or equal to 25 mm Hg at rest or greater than 30 mm Hg with exertion, documented by right-heart catheterization or echocardiography.

Age Restrictions N/A

Prescriber Restrictions

Pulmonologist or cardiologist

Coverage Duration

Through end of plan contract year.

Other Criteria N/A

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ORFADIN Products Affected • Orfadin

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

N/A

Coverage Duration

Through end of plan contract year.

Other Criteria N/A

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ORKAMBI Products Affected • Orkambi

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

Documentation that the patient is homozygous for the F508del mutation in the CFTR gene.

Age Restrictions N/A

Prescriber Restrictions

N/A

Coverage Duration

Through end of plan contract year.

Other Criteria N/A

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OXANDROLONE Products Affected • Oxandrolone TABS

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

The indication of weight gain. Known or suspected carcinoma of the prostate or the male breast. Carcinoma of the breast in females with hypercalcemia. Pregnancy. Nephrosis. Hypercalcemia.

Required Medical Information

Documentation to support diagnosis for use as follows: Bone pain: For the relief of the bone pain frequently accompanying osteoporosis. Protein catabolism: To offset the protein catabolism associated with prolonged administration of corticosteroids.

Age Restrictions N/A

Prescriber Restrictions

N/A

Coverage Duration

1 month, renewals for return of symptoms

Other Criteria N/A

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PEG-INTRON Products Affected • Pegintron

• Peg-intron Redipen

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

Autoimmune hepatitis. Hepatic decompensation (Child-Pugh score greater than 6 [class B and C]) in cirrhotic patients before treatment.

Required Medical Information

Confirmation of genotype. Previous hepatitis C treatment history and response. Other medications that will be used with Peg-Intron. For continuation of therapy: HCV RNA levels have declined greater than 2 log10 IU/ml at 12 weeks of therapy.

Age Restrictions N/A

Prescriber Restrictions

N/A

Coverage Duration

HCV: Initial 12 weeks, total duration 12 to 48 weeks based on genotype & drug regimen.

Other Criteria Criteria will be applied consistent with current AASLD-IDSA guidance

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PERJETA Products Affected • Perjeta

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

A documented diagnosis of HER2-positive metastatic breast cancer for patients who have not received prior anti-HER2 therapy or chemotherapy AND taken in combination with trastuzumab and docetaxel. Patient has not received prior anti-HER2 therapy or chemotherapy for metastatic disease. OR Used in combination with trastuzumab and docetaxel as neoadjuvant treatment of patients with HER2-positive, locally advanced, inflammatory, or early stage breast cancer (either greater than 2 cm in diameter or node positive) as part of a complete treatment regimen for early breast cancer.

Age Restrictions N/A

Prescriber Restrictions

Oncologist

Coverage Duration

Through end of plan contract year.

Other Criteria Applies to new starts only.

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PHENOBARBITAL-AGE EDIT Products Affected• Phenobarbital ELIX 20MG/5ML• Phenobarbital TABS 100MG, 15MG,

16.2MG, 30MG, 32.4MG, 60MG,64.8MG, 97.2MG

• Phenobarbital Sodium INJ130MG/ML, 65MG/ML

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

Prescriber must acknowledge that medication benefits outweigh potential risks in patients 65 years of age or older.

Age Restrictions This prior authorization only applies to members 65 years of age or older to ensure safe use of a potentially high risk medication in the elderly population. Members under 65 years of age are not subject to the prior authorization requirements.

Prescriber Restrictions

N/A

Coverage Duration

Through end of plan contract year.

Other Criteria Patient has a trial and failure or a documented contraindication to one non-HRM alternative formulary drug (such as carbamazepine, lamotrigine, or topiramate).

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POMALYST

Products Affected • Pomalyst

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

Pregnant patients.

Required Medical Information

For the treatment of patients with multiple myeloma who have received prior therapy with Revlimid (lenalidomide) and Velcade (bortezomib) and whose disease has progressed on or within 60 days of completion of the last therapy.

Age Restrictions N/A

Prescriber Restrictions

Oncologist or Hematologist

Coverage Duration

Through end of plan contract year.

Other Criteria Applies to new starts only.

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PORTRAZZA Products Affected • Portrazza

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

For metastatic squamous NSCLC: Confirmation of combination use with gemcitabine and cisplatin.

Age Restrictions N/A

Prescriber Restrictions

Oncologist

Coverage Duration

Through end of plan contract year.

Other Criteria Applies to new starts only.

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PRALUENT Products Affected • Praluent

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

1. Heterozygous Familial Hypercholesterolemia (HeFH) as supported bythe presence of causal mutation of familial hypercholesterolemia by genetic testing, physical signs of FH (e.g. xanthomas, xanthelasma), clinical diagnosis based on WHO criteria/Dutch Lipid Clinical Network criteria with score greater than 8 points, or Simon Broome register diagnostic criteria AND LDL-C greater than or equal to 190 mg/dL prior to lipid lowering therapy (greater than or equal to 160 mg/dL if age less than 20) or LDL-C greater than or equal to 160 mg/dL after treatment with antihyperlipidemic agents but prior to Praluent (alirocumab) therapy AND Previous treatment with at least two trials of different high-intensity statins (e.g. atorvastatin, rosuvastatin, simvastatin) has been ineffective in achieving LDL-C goal AND Praluent (alirocumab) must be used concomitantly with a statin which is dosed at maximally tolerated dose OR documentation of statin intolerance is provided as defined by statin related rhabdomyolysis or skeletal-related muscle symptoms while receiving at least 2 separate trials of different high intensity statin which resolved upon discontinuation of statin. 2. Hypercholesterolemia ASCVD (e.g. acute coronary syndrome, history of myocardial infarction) AND Previous treatment with at least two trials of different high-intensity statins (e.g. atorvastatin, rosuvastatin, simvastatin) has been ineffective in achieving LDL-C goal (LDL-C is still greater than or equal to 100 mg/dL) AND Praluent (alirocumab) must be used concomitantly with a statin which is dosed at maximally tolerated dose OR documentation of statin intolerance is provided as defined by statin related rhabdomyolysis or skeletal-related muscle symptoms while receiving at least 2 separate trials of different high intensity statin which resolved upon discontinuation of statin.

Age Restrictions N/A

Prescriber Restrictions

Prescribed by or in consultation with a cardiologist, lipid specialist, or endocrinologist

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Coverage Duration

6 months initial authorization, 12 months reauthorization

Othe r Criteria For reauthorization, documentation showing an LDL-C reduction on Praluent (alirocumab) therapy from baseline must be provided.

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PROCRIT Products Affected

• Procrit

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

Uncontrolled hypertension. Pure red cell aplasia (PRCA) that begins after treatment with PROCRIT or other erythropoietin protein drugs.

Required Medical Information

For initiation of therapy: adequate iron stores have been demonstrated by means of bone marrow iron or serum ferritin levels or serum iron saturation studies within the prior 12 months (Note: for persons with iron deficiency, erythropoietin analog therapy may be initiated simultaneous with iron replacement), and the following criteria is met: hemoglobin (Hgb) is approaching or has fallen below 10 g/dl or hematocrit of 30% or less OR for patients who are undergoing elective, noncardiac, nonvascular surgery, perioperative hemoglobin is greater than 10 AND less than or equal to 13 g/dL OR patient will be starting myelosuppressive therapy and will have an anticipated hemoglobin drop associated with their therapy. For continuation of therapy: documentation of the following: for persons with anemia due to myelosuppressive anticancer chemotherapy - Hgb target of 12 g/dl For persons with chronic renal failure and end-stage renal disease (ESRD): Hgb target 10-11 g/dl For persons with other indications (eg ZVD HIV therapy): Hgb target of 12 g/dl For persons undergoing high risk surgery: Hgb target of 13 g/dl Continued use of the therapy is not covered if the hemoglobin rises less than 1 g/dl (hematocrit rise less than 3 %) compared to pretreatment baseline by 8 weeks of treatment and whose hemoglobin level remains less than 10 g/dL (or the hematocrit is less than 30%).

Age Restrictions N/A

Prescriber Restrictions

N/A

Coverage Duration

Surgery: 4 weeks, all other indications: 12 weeks

Other Criteria N/A

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PROMACTA Products Affected • Promacta

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

Platelet count. For chronic immune (idiopathic) thrombocytopenia (ITP): patient has a documented insufficient response to corticosteroids, immunoglobulins, or splenectomy. For aplastic anemia: patient has a documented insufficient response to immunosuppressive therapy. For the initiation and maintenance of interferon-based therapy in patients with chronic hepatitis C: patient’s degree of thrombocytopenia prevents the initiation of interferon-based therapy or limits the ability to maintain interferon-based therapy. Documentation of concomitant hepatitis C treatment regimen.

Age Restrictions N/A

Prescriber Restrictions

N/A

Coverage Duration

Through end of plan contract year.

Other Criteria For coverage of thrombocytopenia in chronic hepatitis C patients: approved if the platelet count is less than 50 billion cells/L AND the patient is not being treated with a direct acting antiviral. Promacta should be withheld when platelet counts exceed 400,000/mcL or if there’s no response within 4 weeks of treatment at the maximum dose. Not covered in the presence of clinical symptoms of liver injury or evidence of hepatic decompensation.

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PULMONARY HYPERTENSION-OTHER Products Affected • Epoprostenol Sodium

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

For Pulmonary arterial hypertension in WHO Group I and patient has NYHA functional class III or IV symptoms AND patient has mean pulmonary artery pressure greater than 25 mm Hg at rest or greater than 30 mm Hg with exertion, documented by right-heart catheterization or echocardiography.

Age Restrictions N/A

Prescriber Restrictions

Pulmonologist or cardiologist

Coverage Duration

Through end of plan contract year.

Other Criteria An acute vasoreactivity test is required for persons with primary pulmonary hypertension and other persons with Group 1 pulmonary hypertension. For persons with a positive acute vasoreactivity test result, documentation of a trial and failure of a calcium channel blocker (dihydropyridine or diltiazem) is required, unless contraindicated, such as in persons with right heart failure or hemodynamic instability. A trial of a calcium channel blocker is not required for persons with a negative acute vasoreactivity test result. A vasoreactivity test and a trial of a calcium channel blocker is not required for other pulmonary hypertension groups (i.e., persons with pulmonary hypertension secondary to sarcoidosis, congenital diaphragmatic hernia, or chronic thromboembolic pulmonary hypertension). Drug is also subject to a Part B versus Part D coverage determination.

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PURIXAN Products Affected • Purixan

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

Oncologist or Hematologist

Coverage Duration

Through end of plan contract year.

Other Criteria Purixan will be used as part of a combination regimen for the treatment of ALL. Patient is unable to use the tablet formulation, for example, patient is unable to swallow tablets, pediatric patient, or unable to get needed dose with tablet formulation. Applies to new starts only.

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QUININE SULFATE Products Affected • Quinine Sulfate CAPS 324MG

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

Treatment or prevention of leg cramps. Prevention of malaria or in patients with complicated P. falciparum. Prolonged QT interval. Glucose-6-phosphate dehydrogenase (G6PD) deficiency.

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

N/A

Coverage Duration

7 days

Other Criteria N/A

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RAVICTI Products Affected

• Ravicti

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

Urea cycle disorders due to N-acetylglutamatesynthetase deficiency.

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

N/A

Coverage Duration

Through end of plan contract year.

Other Criteria N/A

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REBIF Products Affected • Rebif • Rebif Rebidose

• Rebif Rebidose Titration Pack • Rebif Titration Pack

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

Documentation that other therapies used for treating multiple sclerosis will be discontinued ( Note: This does NOT require having to discontinue Ampyra).The member has a diagnosis of a relapsing form of multiple sclerosis OR has experienced a first clinical episode and has MRI features consistent with multiple sclerosis.

Age Restrictions N/A

Prescriber Restrictions

Neurologist

Coverage Duration

Through end of plan contract year.

Other Criteria N/A

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REGRANEX Products Affected • Regranex

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

Treatment of lower-extremity diabetic neuropathic ulcers that extend into the subcutaneous tissue or beyond and have an adequate blood supply. To be used as an adjunct to, and not a substitute for, good ulcer care practices including initial sharp debridement, pressure relief and infection control. Confirmed underlying diagnosis/status of diabetes either by history of current diabetic medical treatment or labs provided by the prescriber. Documentation of a wound care plan. Ulcer description of the following: located on the lower extremity, extends into the subcutaneous tissue or beyond, and has adequate blood supply. Reapproval requires patient to experience improvement by week 10 .

Age Restrictions N/A

Prescriber Restrictions

N/A

Coverage Duration

Initial approval: 10 weeks. Reapproval: 10 weeks with documentation of response.

Other Criteria N/A

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RELISTOR Products Affected • Relistor

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

Contraindicated in patients with known or suspected mechanical gastrointestinal obstruction.

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

N/A

Coverage Duration

4 months

Other Criteria Requests will be covered following a documented trial and failure or contraindication to lactulose AND polyethylene glycol.

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REMICADE Products Affected • Remicade

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

For the treatment of adult patients with moderate to severe chronic plaque psoriasis: PASI score of 10 or more and body surface area (BSA) involvement equal to or greater than 10% OR affecting crucial body areas such as the hands, feet, face, or genitals. For fistulizing Crohn's disease: Require diagnosis of fistulizing disease. For continuation of therapy: patient has shown improvement and dose requested does not exceed the FDA maximum dose.

Age Restrictions N/A

Prescriber Restrictions

Gastroenterologist, Rheumatologist or Dermatologist

Coverage Duration

Initial approval: 6 months. Extended approval: Through end of plan contract year.

Other Criteria Moderate to severe active Crohn's disease AND inadequate response to one corticosteroid (ex. prednisone, budesonide, methylprednisolone) OR severe chronic plaque psoriasis AND prior use of one of the following-cyclosporine or methotrexate or methoxsalen with UVA light (PUVA) OR active psoriatic arthritis AND prior use of one corticosteroid (ex. dexamethasone, methylprednisolone) OR moderate to severe rheumatoid arthritis AND concomitant treatment with methotrexate OR moderate to severe active ulcerative colitis AND inadequate response to one 5-aminosalicylic acid product (5-ASA ex. sulfasalazine, mesalamine, balsalazide) or one corticosteroid (ex. prednisone, methylprednisolone). For ankylosing spondylitis: Require documentation of inadequate response to maximum tolerated doses of at least (2) non-steroidal anti-inflammatory drugs (NSAIDs).

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REPATHA Products Affected • Repatha

• Repatha Pushtronex System • Repatha Sureclick

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

1.Homozygous Familial Hypercholesterolemia(HoFH) supported bygenetic confirmation of two mutant alleles at LDLR, APOB, OCSK9, or LDLRAP1 gene or untreated LDL-C greater than 500mg/dL (or treated LDL-C greater than 300mg/dL) with cutaneous or tendon xanthoma before age 10 yrs or heterozygous familial hypercholesterolemia(HeFH) in both parents AND will be used with a maximally tolerated statin unless all statins are contraindicated or not tolerated AND will not be used with lomitapide, mipomersen, or another PCSK9 inhibitor. 2.HeFH supported by presence of causal mutation of FH by genetic testing, physical signs of FH (e.g. xanthomas, xanthelasma), diagnosis based on WHO criteria/Dutch Lipid Clinical Network criteria with score greater than 8 points, or Simon Broome register criteria AND LDL-C greater than or equal to 190mg/dL prior to lipid lowering therapy (greater than or equal to 160mg/dL if age less than 20) or LDL-C greater than or equal to 160mg/dL after treatment with antihyperlipidemic agents but prior to therapy AND Prior therapy with at least 2 trials of different high-intensity statins (e.g. atorvastatin, rosuvastatin, simvastatin) has not achieved LDL-C goal AND must be used with maximally tolerated statin dose OR documentation of statin intolerance as defined by statin related rhabdomyolysis or skeletal muscle symptoms while receiving at least 2 separate trials of different high intensity statin which resolved upon discontinuation of statin. 3.Hypercholesterolemia ASCVD AND Prior therapy with at least 2 trials of different high-intensity statins (e.g. atorvastatin, rosuvastatin, simvastatin) has not achieved LDL-C goal (LDL-C is still greater than or equal to 100mg/dL) AND must be used with maximally tolerated statin dose OR documentation of statin intolerance as defined by statin related rhabdomyolysis or skeletal muscle symptoms while receiving at least 2 separate trials of different high intensity statin which resolved upon discontinuation of statin.

Age Restrictions N/A

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Prescribe r Restrictions

Prescribed by or in consultation with a cardiologist, lipid specialist, or endocrinologist

Coverage Duration

6 months initial authorization, 12 months reauthorization

Othe r Criteria For reauthorization, documentation showing an LDL-C reduction on Repatha (evolocumab) therapy from baseline must be provided.

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REVLIMID Products Affected • Revlimid

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

Not covered for patients who are pregnant.

Required Medical Information

Covered for patients with transfusion-dependent anemia in low- or intermediate-1 risk MDS with a 5 q (q31-33) cytogenetic abnormality, OR for members with no 5q deletion that have failed or have a contraindication to erythropoietin therapy. Transfusion dependence is defined as having greater than 2 units of red blood cells within 8 weeks of treatment. Low- or intermediate-1 risk MDS is defined as having an International Prognostic Scoring System (IPSS) Score for MDS of 0 to 1. For the diagnosis of multiple myeloma patient is taking in combination with dexamethasone. For the diagnosis of mantle cell lymphoma (MCL) documentation that disease has relapsed or progressed after two prior therapies, one of which included bortezomib (Velcade).

Age Restrictions N/A

Prescriber Restrictions

Oncologist or Hematologist

Coverage Duration

Through end of plan contract year.

Other Criteria Transfusion dependence is defined as having greater than 2 units of red blood cells within 8 weeks of treatment. Low- or intermediate-1 risk MDS is defined as having an International Prognostic Scoring System (IPSS) Score for MDS of 0 to 1. Applies to new starts only.

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RITUXAN Products Affected • Rituxan

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

N/A

Coverage Duration

Through end of plan contract year.

Other Criteria For the diagnosis of rheumatoid arthitis, Rituxan is being used in combination with methotrexate AND patient has had an inadequate response to Remicade. For diagnosis of previously untreated and previously treated CD20-positive Chronic Lymphocytic Leukemia (CLL) used in combination with fludarabine and cyclophosphamide (FC). For diagnosis of Granulomatosis with Polyangiitis (GPA) (Wegener's Granulomatosis) and Microscopic Polyangiitis (MPA) used in combination with glucocorticoids.

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RITUXAN HYCELA

Products Affected • Rituxan Hycela

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

Member has received as least one full dose of a rituximab product by intravenous infusion prior to the initiation of therapy.

Age Restrictions N/A

Prescriber Restrictions

N/A

Coverage Duration

Through end of plan contract year

Other Criteria Applies to new starts only.

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RUBRACA Products Affected • Rubraca

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

Oncologist or hematologist

Coverage Duration

Through end of plan contract year.

Other Criteria Applies to new starts only.

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181

RYDAPT Products Affected • Rydapt

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

Hematologist or Oncologist

Coverage Duration

Through end of plan contract year.

Other Criteria Applies to new starts only.

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SABRIL Products Affected • Vigabatrin• Sabril

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

For complex partial seizure disorder: Require documentation that the patient is currently stable on Sabril therapy OR that the patient is currently receiving another antiepileptic drug AND the patient has experienced treatment failure from two previous agents (antiepileptics include lamotrigine, phenytoin, divalproex, levetiracetam, gabapentin, carbamazepine, topiramate, zonisamide).

Age Restrictions N/A

Prescriber Restrictions

N/A

Coverage Duration

Through end of plan contract year.

Other Criteria N/A

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SAMSCA

Products Affected • Samsca

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

Documented concurrent use of strong CYP3A inhibitors (for example, ketoconazole, clarithromycin, itraconazole, ritonavir, indinavir, nelfinavir, saquinavir, nefazodone, telithromycin).

Required Medical Information

Treatment with Samsca is being initiated or re-initiated in a hospital where serum sodium can be monitored closely.

Age Restrictions N/A

Prescriber Restrictions

N/A

Coverage Duration

30 days

Other Criteria N/A

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SIGNIFOR Products Affected • Signifor

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

N/A

Coverage Duration

6 Months

Other Criteria Approvable in patients for whom pituitary surgery is not an option or has not been curative. For continuation of therapy, patient is responding to therapy.

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SILDENAFIL Products Affected • Sildenafil TABS

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

Concurrent use of organic nitrates (for example, isosorbide mononitrate, isosorbide dinitrate, nitroglycerin). Sildenafil is not covered for the diagnosis of ED/impotence.

Required Medical Information

For Pulmonary Arterial Hypertension (PAH) (WHO Group 1) and WHO functional class II to IV symptoms AND patient has mean pulmonary artery pressure greater than or equal to 25 mm Hg at rest or greater than 30 mm Hg with exertion, documented by right-heart catheterization or echocardiography.

Age Restrictions N/A

Prescriber Restrictions

Pulmonologist or cardiologist

Coverage Duration

Through end of plan contract year.

Other Criteria An acute vasoreactivity test is required for persons with primary pulmonary hypertension and other persons with Group 1 pulmonary hypertension. For persons with a positive acute vasoreactivity test result, documentation of a trial and failure of a calcium channel blocker (dihydropyridine or diltiazem) is required, unless contraindicated, such as in persons with right heart failure or hemodynamic instability. A trial of a calcium channel blocker is not required for persons with a negative acute vasoreactivity test result. A vasoreactivity test and a trial of a calcium channel blocker is not required for other pulmonary hypertension groups (i.e., persons with pulmonary hypertension secondary to sarcoidosis, congenital diaphragmatic hernia, or chronic thromboembolic pulmonary hypertension). Sildenafil citrate-PAH is only approved for 20 mg three times a day.

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SIRTURO Products Affected • Sirturo

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

Infectious disease

Coverage Duration

24 weeks

Other Criteria Patient has multidrug resistant TB and there is no other effective treatment regimen. Drug is being used in combination with at least 3 other drugs to which the patient's MDR-TB isolate has been shown to be susceptible in vitro. If in vitro testing results are unavailable, treatment may be initiated with SIRTURO in combination with at least 4 other drugs to which the patient's MDR-TB isolate is likely to be susceptible.

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SOLTAMOX Products Affected • Soltamox

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

Documentation of inability to swallow tablet formulation.

Age Restrictions N/A

Prescriber Restrictions

Oncologist

Coverage Duration

Through end of plan contract year.

Other Criteria Applies to new starts only.

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SOMATULINE Products Affected • Somatuline Depot

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

For acromegaly: documented inadequate response to surgery and/or radiotherapy, or for whom surgery and/or radiotherapy is not an option OR have failed an adequate trial of octreotide. For Gastroenteropancreatic Neuroendocrine Tumors (GEP-NETs): tumors are unresectable, well-differentiated or moderately differentiated and locally advanced or metastatic.

Age Restrictions N/A

Prescriber Restrictions

N/A

Coverage Duration

Through end of plan contract year.

Other Criteria For acromegaly continuation of therapy: the IGF-1 level decreased or normalized.

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SOMAVERT Products Affected • Somavert

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

Acromegaly: For the treatment of acromegaly in patients who have had an inadequate response to surgery and/or radiation therapy and/or other medical therapies, or for whom these therapies are not appropriate. Annual reauthororization is based upon patient's response to therapy as evidenced by normalization of IGF-I levels and liver function tests that are less than 5 times upper limit of normal, without signs/symptoms of hepatitis or other liver injury, or increase in serum TBIL.

Age Restrictions N/A

Prescriber Restrictions

N/A

Coverage Duration

Through end of plan contract year.

Other Criteria N/A

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SORIATANE Products Affected • Acitretin

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

Not covered in pregnant females.

Required Medical Information

Indicated for the treatment of severe psoriasis in adults as monotherapy or in combination with phototherapy.

Age Restrictions N/A

Prescriber Restrictions

Rheumatologist or Dermatologist

Coverage Duration

6 months

Other Criteria For the treatment of psoriasis, a trial of one of the following: methotexate, DMARD or cyclosporine.

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SOVALDI Products Affected • Sovaldi

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

Confirmation of hepatitis C genotype. Previous hepatitis C treatment history (if any). Other medications that will be used with current AASLD/IDSA protocol (if any). Presence or absence of cirrhosis.

Age Restrictions N/A

Prescriber Restrictions

Infectious disease, gastroenterologist, hepatologist

Coverage Duration

Duration will be applied consistent with current AASLD/IDSA guidance.

Other Criteria (A) Patient must have documented failure/contraindication/intolerance to Harvoni AND Zepatier if appropriate based on current AASLD/IDSA guidance AND (B) Criteria will be applied consistent with current AASLD/IDSA guidance.

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SPRITAM Products Affected

• Spritam

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

N/A

Coverage Duration

Through end of plan contract year.

Other Criteria Applies to new starts only. Patient has a documented trial and failure of generic levetiracetam tablets and generic levetiracetam oral solution OR patient has an inability to swallow tablets and solutions.

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SPRYCEL Products Affected • Sprycel

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

Oncologist or Hematologist

Coverage Duration

Through end of plan contract year.

Other Criteria Applies to new starts only.

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STIVARGA Products Affected • Stivarga

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

Oncologist

Coverage Duration

Through end of plan contract year.

Other Criteria Applies to new starts only.

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SUBOXONE Products Affected • Buprenorphine Hcl/naloxone Hcl

• Suboxone FILM

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

Diagnosis of pain.

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

N/A

Coverage Duration

Initial approval: 3 months. Maintenance: Through end of plan contract year.

Other Criteria N/A

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SUBUTEX Products Affected • Buprenorphine Hcl SUBL

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

Diagnosis of pain.

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

N/A

Coverage Duration

Induction: 3 months, Maintenance: through end of plan contract year, Pregnancy: 10 months

Other Criteria If buprenorphine is being prescribed for maintenance therapy for opioid dependence treatment, the patient must have a documented intolerance or contraindication to naloxone or the patient is pregnant.

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SUTENT Products Affected • Sutent

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

Oncologist

Coverage Duration

Through end of plan contract year.

Other Criteria Gastrointestinal stromal tumor AND after disease progression on or intolerance to imatinib. Applies to new starts only.

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SYLATRON Products Affected • Sylatron

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

Autoimmune hepatitis. Hepatic decompensation (Child-Pugh score greater than 6 [class B and C].

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

Oncologist

Coverage Duration

Through end of plan contract year.

Other Criteria For melanoma, Sylatron must be requested within 84 days (12 weeks) of the surgical resection. Applies to new starts only.

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SYLVANT Products Affected • Sylvant

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

For patients with multicentric Castleman’s disease (MCD), patient is HIV negative and human herpesvirus-8 (HHV-8) negative.

Age Restrictions N/A

Prescriber Restrictions

Oncologist or Hematologist

Coverage Duration

Through end of plan contract year.

Other Criteria Applies to new starts only.

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SYNAGIS Products Affected • Synagis INJ 100MG/ML,

50MG/0.5ML

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

N/A

Coverage Duration

Through end of plan contract year.

Other Criteria N/A

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SYNRIBO Products Affected • Synribo

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

Oncologist or Hematologist

Coverage Duration

Through end of plan contract year.

Other Criteria A documented diagnosis of chronic or accelerated phase chronic myeloid leukemia (CML) with resistance and/or intolerance to two tyrosine kinase inhibitors (TKIs) (imatinib (Gleevec), nilotinib (Tasigna), or dasatinib (Sprycel)). Applies to new starts only.

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TAFINLAR Products Affected • Tafinlar

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

A documented positive BRAF V600E or V600K mutation as detected by an FDA-approved test.

Age Restrictions N/A

Prescriber Restrictions

Oncologist or dermatologist

Coverage Duration

Through end of plan contract year.

Other Criteria Tafinlar should not be used in patients with wild-type BRAF melanoma due to the potential risk of tumor promotion in these patients. Applies to new starts only.

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TAGRISSO Products Affected • Tagrisso

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

Previous treatment with EGFR tyrosine kinase inhibitor (TKI) therapy such as: Tarceva, Iressa, or Gilotrif. Confirmation of T790M mutation prior to initiation of therapy.

Age Restrictions N/A

Prescriber Restrictions

Oncologist

Coverage Duration

Through end of plan contract year.

Other Criteria Applies to new starts only.

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204

TARCEVA Products Affected • Tarceva

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

Oncologist

Coverage Duration

Through end of plan contract year.

Other Criteria Applies to new starts only.

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205

TARGRETIN CAPS Products Affected • Bexarotene

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

This medication should not be administered to patients who are pregnant.

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

Oncologist

Coverage Duration

Through end of plan contract year.

Other Criteria Definite diagnosis of cutaneous T-cell lymphoma (CTCL) AND refractory to any prior systemic therapy (such as methotrexate). Applies to new starts only.

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206

TARGRETIN GEL Products Affected • Targretin GEL

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

This medication should not be administered to patients who are pregnant.

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

Oncologist

Coverage Duration

Through end of plan contract year.

Other Criteria Diagnosis of cutaneous lesions in patients with cutaneous T-cell lymphoma (CTCL) (Stage IA and IB) AND have refractory or persistent disease after one or more other therapies or who have not tolerated one or more other therapies. Other therapies may include: topical corticosteroids, methoxsalen, phototherapy, topical chemotherapy (mechlorethamine, carmustine). Applies to new starts only.

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207

TASIGNA Products Affected • Tasigna

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

Hypokalemia. Hypomagnesemia. Long QT syndrome.

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

Oncologist or Hematologist

Coverage Duration

Through end of plan contract year.

Other Criteria Applies to new starts only.

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208

TECENTRIQ Products Affected • Tecentriq

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

Oncologist

Coverage Duration

Through end of plan contract year

Other Criteria Applies to new starts only.

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TESTOSTERONE

Products Affected • Testim

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

Testosterone levels within normal range (range for the lab doing the testing). Female patients. Men with carcinoma of the breast or suspected carcinoma of the prostate. Use for muscle building purposes.

Required Medical Information

For members initiating testosterone replacement therapy: Testosterone levels (total or free). Require either ONE low total testosterone level OR ONE low free testosterone level. (normal ranges as provided by office or clinic performing labs). Note: Members that are already stabilized will not be required to provide labs and can be approved as continuation of therapy.

Age Restrictions N/A

Prescriber Restrictions

N/A

Coverage Duration

Through end of plan contract year.

Other Criteria Patient has a documented trial and failure or contraindication to Androgel.

209

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TESTOSTERONE INJ

Products Affected • Depo-testosterone INJ 100MG/ML, 200MG/ML

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

Testosterone levels within normal range (range for the lab doing the testing). Female patients. Men with carcinoma of the breast or suspected carcinoma of the prostate. Use for muscle building purposes.

Required Medical Information

For members initiating testosterone replacement therapy: Testosterone levels (total or free). Require either ONE low total testosterone level OR ONE low free testosterone level. (normal ranges as provided by office or clinic performing labs). Note: Members that are already stabilized will not be required to provide labs and can be approved as continuation of therapy.

Age Restrictions N/A

Prescriber Restrictions

N/A

Coverage Duration

Through end of plan contract year.

Other Criteria N/A

210

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211

THALOMID Products Affected • Thalomid

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

Not covered for patients who are pregnant.

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

Oncologist or Hematologist

Coverage Duration

Through end of plan contract year.

Other Criteria For multiple myeloma, covered for previously treated and untreated patients in combination with dexamethasone. Applies to new starts only.

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212

THIORIDAZINE-AGE EDIT Products Affected • Thioridazine Hcl TABS 100MG,

10MG, 25MG, 50MG

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

Prescriber must acknowledge that medication benefits outweigh potential risks in patients 65 years of age or older.

Age Restrictions This prior authorization only applies to members 65 years of age or older to ensure safe use of a potentially high risk medication in the elderly population. Members under 65 years of age are not subject to the prior authorization requirements.

Prescriber Restrictions

N/A

Coverage Duration

Through end of plan contract year.

Other Criteria Patient has a trial and failure or a documented contraindication to two non-HRM formulary alternative drugs (aripiprazole, olanzapine, paliperidone, quetiapine, risperidone, ziprasidone).

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TOPICAL TRETINOIN Products Affected • Avita • Tretinoin CREA

• Tretinoin GEL• Tretinoin Microsphere• Tretinoin Microsphere Pump

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

Cosmetic use

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

N/A

Coverage Duration

Through end of plan contract year.

Other Criteria N/A

213

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214

TRACLEER Products Affected • Tracleer

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

Not covered for the following: concomitant administration with cyclosporine or glyburide, AND pregnancy (monthly pregnancy tests should be obtained while on therapy).

Required Medical Information

For Pulmonary Arterial Hypertension (PAH) (WHO Group 1) and WHO functional class II to IV symptoms AND patient has mean pulmonary artery pressure greater than or equal to 25 mm Hg at rest or greater than 30 mm Hg with exertion, documented by right-heart catheterization or echocardiography.

Age Restrictions N/A

Prescriber Restrictions

Pulmonologist or cardiologist

Coverage Duration

Through end of plan contract year.

Other Criteria N/A

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TREATMENT OF ATTENTION DEFICIT DISORDER - AGE EDIT

Products Affected • Amphetamine/dextroamphetamine

TABS • Dexedrine TABS• Dexmethylphenidate Hcl• Dextroamphetamine Sulfate SOLN• Dextroa mphetamine Sulfate TABS• Metadate Er TBCR 20MG

• Methylphenidate Hcl TABS• Methylphenidate Hcl Er CP24• Methylphenidate Hcl Er TBCR

10MG, 20MG• Methylphenidate Hcl Er (la)• Methylphenidate Hcl Sr• Zenzedi TABS 10MG, 5MG

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

Prescriber must acknowledge that medication benefits outweigh potential risks in patients 65 years of age or older.

Age Restrictions This prior authorization only applies to members 65 years of age or older to ensure safe use of a potentially high risk medication in the elderly population. Members under 65 years of age are not subject to the prior authorization requirements.

Prescriber Restrictions

N/A

Coverage Duration

Through end of plan contract year.

Other Criteria N/A

215

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216

TRELSTAR Products Affected • Trelstar

• Trelstar Mixject

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

Pregnancy

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

N/A

Coverage Duration

Through end of plan contract year.

Other Criteria N/A

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217

TRISENOX Products Affected • Trisenox

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

Indicated for induction and consolidation of acute promyelocytic leukemia (APL) characterized by t(15,17) translocation or PML/RAR-alpha gene expression, in patients who are refractory to or have relapsed from retinoid and anthracycline chemotherapy.

Age Restrictions N/A

Prescriber Restrictions

Oncologist or Hematologist

Coverage Duration

Through end of plan contract year.

Other Criteria Applies to new starts only.

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218

TYKERB Products Affected • Tykerb

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

Oncologist

Coverage Duration

Through end of plan contract year.

Other Criteria Coverage is provided in combination with capecitabine, for the treatment of patients with advanced or metastatic breast cancer whose tumors overexpress HER2 and who have received prior therapy including an anthracycline, a taxane, and trastuzumab OR in combination with letrozole for the treatment of postmenopausal women with hormone receptor positive metastatic breast cancer that overexpresses the HER2 receptor for whom hormonal therapy is indicated. Applies to new starts only.

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219

TYSABRI Products Affected • Tysabri

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

Patients who have or have had progressive multifocal leukoencephalopathy (PML)

Required Medical Information

For multiple sclerosis: Documentation that other therapies used for treating multiple sclerosis will be discontinued (Note: This does NOT require having to discontinue Ampyra (dalfampridine)). The member has a diagnosis of a relapsing form of multiple sclerosis OR has experienced a first clinical episode and has MRI features consistent with multiple sclerosis. For Crohn's Disease: Evidence of inflammation (e.g., elevated C-reactive protein [CRP], elevated erythrocyte sedimentation rate, presence of fecal leukocytes).

Age Restrictions N/A

Prescriber Restrictions

Neurologist or gastroenterologist

Coverage Duration

Through end of plan contract year.

Other Criteria For multiple sclerosis: a documented failure/contraindication/intolerance to two of the following: interferon beta-1a (Rebif), fingolimod hydrochloride (Gilenya), glatiramer (Copaxone). Requests for new starts for Crohn's Disease will be covered following trial and failure of Humira (adalimumab). Not covered in combination with chronic immunosuppressant, immunomodulatory therapies, antineoplastics and or TNF-α inhibitors due to increased risk of PML.

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220

VALCHLOR Products Affected • Valchlor

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

Oncologist or Dermatologist

Coverage Duration

Through end of plan contract year.

Other Criteria Patient has a diagnosis of Stage IA OR IB mycosis fungoides-type cutaneous T-cell lymphoma AND Patient has received one or more skin directed therapies, such as topical corticosteroids, phototherapy, Targretin gel, or topical nitrogen mustard. Applies to new starts only.

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221

VECTIBIX Products Affected • Vectibix INJ 100MG/5ML,

400MG/20ML

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

A documented diagnosis of metastatic colorectal carcinoma (mCRC) AND evidence of positive EGFR expression from primary tumor or metastatic tumor site.

Age Restrictions N/A

Prescriber Restrictions

Oncologist

Coverage Duration

Through end of plan contract year.

Other Criteria For Metastatic Colorectal Cancer: As first-line therapy in combination with leucovorin, fluorouracil and oxaliplatin (FOLFOX) OR As monotherapy following disease progression after prior treatment with fluoropyrimidine-, oxaliplatin-, and irinotecan-containing chemotherapy. Applies to new starts only.

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222

VELCADE Products Affected • Velcade

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

Oncologist or Hematologist

Coverage Duration

Through end of plan contract year.

Other Criteria Applies to new starts only.

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223

VENCLEXTA Products Affected • Venclexta

• Venclexta Starting Pack

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

For CLL: patient has 17p deletion detected by an FDA approved test (e.g., Vysis CLL FISH Probe Kit) and has received at least one prior therapy.

Age Restrictions N/A

Prescriber Restrictions

Oncologist

Coverage Duration

Through end of plan contract year.

Other Criteria Applies to new starts only.

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VENTAVIS Products Affected • Ventavis

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

For Pulmonary Arterial Hypertension (PAH) (WHO Group 1) and WHO functional class II to IV symptoms AND patient has mean pulmonary artery pressure greater than or equal to 25 mm Hg at rest or greater than 30 mm Hg with exertion, documented by right-heart catheterization or echocardiography.

Age Restrictions N/A

Prescriber Restrictions

Pulmonologist or cardiologist

Coverage Duration

Through end of plan contract year.

Other Criteria An acute vasoreactivity test is required for persons with primary pulmonary hypertension and other persons with Group 1 pulmonary hypertension. For persons with a positive acute vasoreactivity test result, documentation of a trial and failure of a calcium channel blocker (dihydropyridine or diltiazem) is required, unless contraindicated, such as in persons with right heart failure or hemodynamic instability. A trial of a calcium channel blocker is not required for persons with a negative acute vasoreactivity test result. A vasoreactivity test and a trial of a calcium channel blocker is not required for other pulmonary hypertension groups (i.e., persons with pulmonary hypertension secondary to sarcoidosis, congenital diaphragmatic hernia, or chronic thromboembolic pulmonary hypertension). Drug is also subject to a Part B versus Part D coverage determination.

224

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VERZENIO

Products Affected • Verzenio

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

Breast cancer: Pre/perimenopausal women treated in combination with fulvestrant will also receive a gonadotropin-releasing hormone agonist.

Age Restrictions N/A

Prescriber Restrictions

Oncologist or Hematologist

Coverage Duration

Through end of plan contract year

Other Criteria Applies to new starts only.

225

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226

VIDAZA Products Affected • Azacitidine

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

Patients with advanced malignant hepatic tumors.

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

Oncologist or Hematologist

Coverage Duration

Through end of plan contract year.

Other Criteria Applies to new starts only.

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227

VOTRIENT Products Affected • Votrient

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

Oncologist

Coverage Duration

Through end of plan contract year.

Other Criteria Applies to new starts only.

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228

VPRIV Products Affected • Vpriv

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

N/A

Coverage Duration

Through end of plan contract year.

Other Criteria N/A

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VYXEOS

Products Affected • Vyxeos

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

Oncologist or Hematologist

Coverage Duration

Through end of plan contract year

Other Criteria Applies to new starts only.

229

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230

XALKORI Products Affected • Xalkori

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

Treatment of patients with locally advanced or metastatic non-small cell lung cancer (NSCLC) that is anaplastic lymphoma kinase (ALK)-positive or ROS1-positive as detected by an FDA-approved test.

Age Restrictions N/A

Prescriber Restrictions

Oncologist

Coverage Duration

Through end of plan contract year.

Other Criteria Applies to new starts only.

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231

XATMEP Products Affected • Xatmep

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

Pregnancy

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

N/A

Coverage Duration

Through end of plan contract year

Other Criteria Applies to new starts only. Member must have tried and failed, or has a contraindication or intolerance to formulary generic oral methotrexate tablets.

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XENAZINE Products Affected • Tetrabenazine

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

NOT covered for members with the following: Patients who are actively suicidal, or patients with untreated or inadequately treated depression. Patients with impaired hepatic function. Patients currently taking monoamine oxidase inhibitors.

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

Neurologist

Coverage Duration

Through end of plan contract year.

Other Criteria N/A

232

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233

XGEVA Products Affected • Xgeva

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

Uncorrected pre-existing hypocalcemia.

Required Medical Information

For diagnosis of solid tumors: patient has documented bone metastases. For giant cell tumor of bone: patient has unresectable disease or surgical resection is likely to result in severe morbidity. For hypercalcemia of malignancy: condition is defined as albumin-corrected serum calcium level of greater than 12.5 mg/dL, and is refractory to intravenous (IV) bisphosphonate therapy (e.g., zoledronic acid, pamidronate).

Age Restrictions N/A

Prescriber Restrictions

Oncologist

Coverage Duration

Through end of plan contract year.

Other Criteria Applies to new starts only.

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234

XIFAXAN Products Affected • Xifaxan

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

N/A

Coverage Duration

Through end of plan contract year.

Other Criteria Diagnosis of hepatic encephalopathy AND a trial of one month of one preferred alternative agent such as lactulose OR Diagnosis of traveler's diarrhea caused by noninvasive strains of Escherichia coli (non-bloody diarrhea without fever) and trial of 2 weeks of ciprofloxacin or azithromycin OR Diagnosis of irritable bowel syndrome with diarrhea (IBS-D) and had a documented one month trial, intolerance, or contraindication to Loperamide and dicyclomine.

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235

XOLAIR Products Affected • Xolair

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

Documentation of the following: Moderate to severe persistent asthma (NHLBI definition) meeting all the following criteria: Evidence of reversible disease (12% or greater improvement in FEV1 with at least a 200ml increase or 20% or greater improvement in PEF as a result of a short-acting bronchodilator challenge). Evidence of specific allergic sensitivity to a perennial aeroallergen (positive skin test or in vitro test). Failure of an adequate trial of standard therapy as defined by a trial of at least a 3 month course of high-dose inhaled corticosteroids and long-acting beta2-agonists unless contraindicated or not tolerated. Extended approval for 6 months if demonstrated benefit, meeting at least 2 of the following criteria: PEF improvement OR FEV1 improvement OR reduction in symptoms (wheezing, shortness of breath, cough, chest tightness) OR reduction in systemic corticosteroids and rescue drug use OR reduction of asthma-related hospitalizations and other medical contacts. OR Diagnosis of chronic idiopathic urticaria in patients who remain symptomatic despite trial of two oral antihistamines, extended approval for patients who are no longer symptomatic after 6 months of treatment.

Age Restrictions N/A

Prescriber Restrictions

Dermatologist, Allergist, immunologist, or pulmonologist

Coverage Duration

Initial approval: 6 month trial. Extended approval: 6 months if demonstrated benefit

Other Criteria N/A

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236

XTANDI Products Affected • Xtandi

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

Pregnancy

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

Oncologist or Urologist

Coverage Duration

Through end of plan contract year.

Other Criteria Requests for new starts are covered following unsatisfactory effects or contraindication to Zytiga (abiraterone). Applies to new starts only.

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237

XYREM Products Affected • Xyrem

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

Taking alcohol or sedative hypnotic agents while taking Xyrem.

Required Medical Information

Treatment of excessive daytime sleepiness associated with narcolepsy OR cataplexy associated with narcolepsy

Age Restrictions N/A

Prescriber Restrictions

N/A

Coverage Duration

Through end of plan contract year.

Other Criteria N/A

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238

YERVOY Products Affected • Yervoy

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

Oncologist

Coverage Duration

Through end of plan contract year.

Other Criteria Applies to new starts only.

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239

YONDELIS Products Affected • Yondelis

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

Oncologist

Coverage Duration

Through end of plan contract year.

Other Criteria Patient has received a prior anthracycline-containing regimen. Applies to new starts only.

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240

ZALTRAP Products Affected • Zaltrap

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

Oncologist

Coverage Duration

Through end of plan contract year.

Other Criteria A documented diagnosis of metastatic colorectal cancer AND documentation of the following: resistance to or progression of the disease following an oxaliplatin-containing regimen and will be used in combination with 5-fluorouracil, leucovorin, and irinotecan. Applies to new starts only.

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241

ZAVESCA Products Affected • Zavesca

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

Mild to moderate type 1 Gaucher disease for whom enzyme replacement therapy is not a therapeutic option due to allergy, hypersensitivity, or poor venous access.

Age Restrictions N/A

Prescriber Restrictions

N/A

Coverage Duration

Through end of plan contract year.

Other Criteria N/A

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242

ZEJULA Products Affected • Zejula

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

Oncologist

Coverage Duration

Through end of plan contract year

Other Criteria Applies to new starts only.

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243

ZELBORAF Products Affected • Zelboraf

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

Treatment of unresectable or metastatic malignant melanoma in patients with V600E mutation of the BRAF gene as detected by an FDA-approved test. Positive result confirming mutation using Cobas 4800 BRAF V600 Mutation Test or equivalent.

Age Restrictions N/A

Prescriber Restrictions

Oncologist

Coverage Duration

Through end of plan contract year.

Other Criteria Applies to new starts only.

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244

ZEPATIER Products Affected • Zepatier

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

Moderate or severe hepatic impairment (Child-Pugh B or C). Concomitant use with organic anion transporting polypeptides 1B1/3 (OATP1B1/3) inhibitors, strong inducers of cytochrome P450 3A (CYP3A), and efavirenz.

Required Medical Information

Confirmation of hepatitis C genotype. Previous hepatitis C treatment history (if any). Other medications that will be used with current AASLD/IDSA protocol (if any). Presence or absence of cirrhosis. If genotype 1a: testing for the presence of virus with NS5A resistance-associated polymorphisms will be performed.

Age Restrictions N/A

Prescriber Restrictions

Infectious disease, gastroenterologist, hepatologist

Coverage Duration

Duration will be applied consistent with current AASLD/IDSA guidance.

Other Criteria Criteria will be applied consistent with current AASLD/IDSA guidance.

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245

ZOLINZA Products Affected • Zolinza

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

N/A

Coverage Duration

Through end of plan contract year.

Other Criteria For Cutaneous T-cell lymphoma, patient has progressive, persistent or recurrent disease. Applies to new starts only.

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246

ZORTRESS Products Affected • Zortress

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

N/A

Coverage Duration

Through end of plan contract year.

Other Criteria For prophylaxis of organ rejection in kidney transplant in combination with basiliximab (Simulect) during induction therapy and used concurrently with reduced doses of cyclosporine and corticosteroids OR for prophylaxis of organ rejection in liver transplant in adults no earlier than 30 days post-transplant and used in combination with tacrolimus (reduced doses) and corticosteroids. Drug is also subject to a Part B versus Part D coverage determination.

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247

ZYDELIG Products Affected • Zydelig

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

Oncologist or Hematologist

Coverage Duration

Through end of plan contract year.

Other Criteria For Relapsed Chronic Lymphocytic Leukemia, Zydelig will be used in combination with rituximab (Rituxan). For Relapsed Follicular B-cell non-Hodgkin Lymphoma and Relapsed Small Lymphocytic Lymphoma, patient has received at least two prior systemic therapies such as Rituxan, Treanda, or other chemotherapy. Applies to new starts only.

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248

ZYKADIA Products Affected • Zykadia

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

N/A

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

Oncologist

Coverage Duration

Through end of plan contract year.

Other Criteria Applies to new starts only.

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249

ZYTIGA Products Affected • Zytiga

PA Criteria Criteria Details

Covered Uses All medically accepted indications not otherwise excluded from Part D.

Exclusion Criteria

Women who are or may become pregnant

Required Medical Information

Documentation that prednisone will be used in combination.

Age Restrictions N/A

Prescriber Restrictions

Oncologist or Urologist

Coverage Duration

Through end of plan contract year.

Other Criteria Applies to new starts only.

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250

ZYVOX Products Affected • Linezolid

PA Criteria Criteria Details

Covered Uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria

Not covered with concomitant use of MAOI therapy.

Required Medical Information

N/A

Age Restrictions N/A

Prescriber Restrictions

N/A

Coverage Duration

28 days

Other Criteria Confirmed diagnosis of Vancomycin-resistant Enterococcus faecium Infections OR a trial of three days each of two preferred antibiotics indicated for the members condition such as amoxicillin, moxifloxacin, azithromycin, cephalosporin, clindamycin or dicloxicillin OR Discharge from hospital or medical facility due to a documented diagnosis/covered use AND Documented initial treatment with vancomycin OR intravenous (IV) Zyvox (linezolid) while in the hospital/medical facility.

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PART B VERSUS PART D Products Affected• Abelcet • Acetylcysteine INHALATION SOLN • Acyclovir Sodium INJ 500MG,

50MG/ML • Adrucil INJ 2.5GM/50ML,

500MG/10ML, 5GM/100ML • Albuterol Sulfate NEBU • Alkeran TABS • Ambisome • Aminosyn INJ 148MEQ/L;

1280MG/100ML; 980MG/100ML; 1280MG/100ML; 300MG/100ML; 720MG/100ML; 940MG/100ML; 720MG/100ML; 400MG/100ML; 440MG/100ML; 5.4MEQ/L; 860MG/100ML; 420MG/100ML; 520MG/100ML; 160MG/100ML; 44MG/100ML; 800MG/100ML, 90MEQ/L; 1100MG/100ML; 850MG/100ML; 35MEQ/L; 1100MG/100ML; 260MG/100ML; 620MG/100ML; 810MG/100ML; 624MG/100ML; 340MG/100ML; 380MG/100ML; 5.4MEQ/L; 750MG/100ML; 370MG/100ML; 460MG/100ML; 150MG/100ML; 44MG/100ML; 680MG/100ML

• Aminosyn 7%/electrolytes • Aminosyn 8.5%/electrolytes

• Aminosyn II INJ 107.6MEQ/L; 1490MG/100ML; 1527MG/100ML; 1050MG/100ML; 1107MG/100ML; 750MG/100ML; 450MG/100ML; 990MG/100ML; 1500MG/100ML; 1575MG/100ML; 258MG/100ML; 447MG/100ML; 1083MG/100ML; 795MG/100ML; 50MEQ/L; 600MG/100ML; 300MG/100ML; 405MG/100ML; 750MG/100ML, 50.3MEQ/L; 695MG/100ML; 713MG/100ML; 490MG/100ML; 517MG/100ML; 350MG/100ML; 210MG/100ML; 462MG/100ML; 700MG/100ML; 735MG/100ML; 120MG/100ML; 209MG/100ML; 505MG/100ML; 371MG/100ML; 31.3MEQ/L; 280MG/100ML; 140MG/100ML; 189MG/100ML; 350MG/100ML, 61.1MEQ/L; 844MG/100ML; 865MG/100ML; 595MG/100ML; 627MG/100ML; 425MG/100ML; 255MG/100ML; 561MG/100ML; 850MG/100ML; 893MG/100ML; 146MG/100ML; 253MG/100ML; 614MG/100ML; 450MG/100ML; 33.3MEQ/L; 340MG/100ML; 170MG/100ML; 230MG/100ML; 425MG/100ML, 71.8MEQ/L; 993MG/100ML; 1018MG/100ML; 700MG/100ML; 738MG/100ML; 500MG/100ML; 300MG/100ML; 660MG/100ML; 1000MG/100ML; 1050MG/100ML; 172MG/100ML; 298MG/100ML; 722MG/100ML; 530MG/100ML; 45.3MEQ/L; 400MG/100ML; 200MG/100ML; 270MG/100ML; 500MG/100ML

• Aminosyn II 8.5%/electrolytes

251

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• Aminosyn M INJ 65MEQ/L; 448MG/100ML; 343MG/100ML; 40MEQ/L; 448MG/100ML; 105MG/100ML; 252MG/100ML; 329MG/100ML; 252MG/100ML; 3MEQ/L; 140MG/100ML; 154MG/100ML; 3.5MMOLE/L; 13MEQ/L; 300MG/100ML; 147MG/100ML; 40MEQ/L; 182MG/100ML; 56MG/100ML; 31MG/100ML; 280MG/100ML

• Aminosyn-hbc • Aminosyn-pf INJ 46MEQ/L;

698MG/100ML; 1227MG/100ML; 527MG/100ML; 820MG/100ML; 385MG/100ML; 312MG/100ML; 760MG/100ML; 1200MG/100ML; 677MG/100ML; 180MG/100ML; 427MG/100ML; 812MG/100ML; 495MG/100ML; 3.4MEQ/L; 70MG/100ML; 512MG/100ML; 180MG/100ML; 44MG/100ML; 673MG/100ML

• Aminosyn-pf 7% • Aminosyn-rf • Amphotericin B INJ • Aprepitant • Atgam • Azathioprine INJ • Azathioprine TABS • Bleo 15k • Bleomycin Sulfate INJ • Brovana • Budesonide SUSP • Cellcept Intravenous • Cladribine • Clinimix 2.75%/dextrose 5% • Clinimix 4.25%/dextrose 10% • Clinimix 4.25%/dextrose 20% • Clinimix 4.25%/dextrose 25% • Clinimix 4.25%/dextrose 5% • Clinimix 5%/dextrose 15% • Clinimix 5%/dextrose 20% • Clinimix 5%/dextrose 25% • Clinimix E 2.75%/dextrose 10%

• Clinimix E 2.75%/dextrose 5% • Clinimix E 4.25%/dextrose 10% • Clinimix E 4.25%/dextrose 25% • Clinimix E 4.25%/dextrose 5% • Clinimix E 5%/dextrose 15% • Clinimix E 5%/dextrose 20% • Clinimix E 5%/dextrose 25% • Clinisol Sf 15% • Cromolyn Sodium NEBU • Cyclophosphamide CAPS • Cytarabine Aqueous • Dextrose 20% • Dextrose 25% INJ 250MG/ML • Dextrose 30% • Dextrose 40% • Dextrose 50% • Dextrose 70% • Doxorubicin Hcl INJ 10MG,

2MG/ML, 50MG • Duramorph • Emend CAPS • Emend Tripack • Engerix-b • Envarsus Xr • Fluorouracil INJ 1GM/20ML,

2.5GM/50ML, 5GM/100ML • Ganciclovir INJ 500MG • Granisetron Hcl TABS • Hecoria • Hepatamine • Hydromorphone Hcl INJ 10MG/ML,

1MG/ML, 2MG/ML, 4MG/ML, 50MG/5ML

• Imovax Rabies (h.d.c.v.) • Intralipid INJ 20GM/100ML,

30GM/100ML • Ipratropium Bromide INHALATION

SOLN 0.02% • Ipratropium Bromide/albuterol

Sulfate • Kabiven • Levalbuterol NEBU • Levalbuterol Hcl NEBU

252

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• Liposyn III INJ 1.2GM/100ML; 2.5GM/100ML; 10GM/100ML, 1.2GM/100ML; 2.5GM/100ML; 20GM/100ML

• Melphalan • Morphine Sulfate INJ 0.5MG/ML,

10MG/ML, 150MG/30ML, 15MG/ML, 1MG/ML, 25MG/ML, 2MG/ML, 4MG/ML, 50MG/ML, 5MG/ML, 8MG/ML

• Mycophenolate Mofetil • Nebupent • Nephramine • Nutrilipid • Ondansetron Hcl ORAL SOLN • Ondansetron Hcl TABS • Ondansetron Odt • Perforomist

• Perikabiven • Plenamine • Premasol • Prograf INJ • Pulmozyme • Rabavert • Rapamune SOLN • Recombivax Hb • Simulect • Sirolimus TABS • Tacrolimus CAPS • Temodar INJ • Thymoglobulin • Tobramycin NEBU • Vinblastine Sulfate INJ 1MG/ML • Vincasar Pfs • Vincristine Sulfate INJ

Details

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.

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INDEX

A

Abelcet 251 Acetylcysteine 251 Acitretin 190 Actemra 1 Actemra Sc 1 Actimmune 2 Acyclovir Sodium 251 Adagen 3 Adempas 4 Adrucil 251 Afinitor 5 Afinitor Disperz 5 Albuterol Sulfate 251 Aldurazyme 6 Alecensa 7 Alimta 8 Aliqopa 9 Alkeran 251 Alpha1-proteinase Inhibitors 10 Alunbrig 11 Amabelz 66 Ambisome 251 Aminosyn 251 Aminosyn 7%/electrolytes 251 Aminosyn 8.5%/electrolytes 251 Aminosyn II 251 Aminosyn II 8.5%/electrolytes 251 Aminosyn M 252 Aminosyn-hbc 252 Aminosyn-pf 252 Aminosyn-pf 7% 252 Aminosyn-rf 252 Amitriptyline Hcl . 15 Amphetamine/dextroamphetamine 215 Amphotericin B 252 Ampyra 12

............................................................................................................

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Androgel .......................................................... .................................................

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........................................... .....................

...........................

14 Androgel Pump 14 Apokyn 19 Aprepitant 252 Aptiom 20 Aranesp 21 Aranesp Albumin Free 21 Arcalyst 22 Armodafinil 147 Arzerra 23 Ascomp/codeine 35 Atgam 252 Atovaquone 128 Avastin 24 Avita 213 Azacitidine 226 Azathioprine 252

B

Banzel 25 Bavencio 26 Beleodaq 27 Benlysta 28 Benztropine Mesylate 17 Besponsa 29 Bexarotene 205 Bleo 15k 252 Bleomycin Sulfate 252 Blincyto 30 Bosulif 31 Botox 32 Briviact 33 Brovana 252 Budesonide 252 Buphenyl 34 Buprenorphine Hcl 196 Buprenorphine Hcl/naloxone Hcl 195 Butalbital Compound/codeine 35

254

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Butalbital/acetaminophen/caffeine ..............................

.................................. .....................

........................................................ ...........................................................

............................................................. ............................................................

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35 Butalbital/acetaminophen/caffeine/codeine 35 Butalbital/aspirin/caffeine 35 Butalbital/aspirin/caffeine/codeine 35

C

Cabometyx 36 Campath 37 Capacet 35 Caprelsa 38 Cellcept Intravenous 252 Cerezyme 40 Chlorzoxazone 131 Cinryze 41 Cladribine 252 Clemastine Fumarate 16 Clinimix 2.75%/dextrose 5% 252 Clinimix 4.25%/dextrose 10% 252 Clinimix 4.25%/dextrose 20% 252 Clinimix 4.25%/dextrose 25% 252 Clinimix 4.25%/dextrose 5% 252 Clinimix 5%/dextrose 15% 252 Clinimix 5%/dextrose 20% 252 Clinimix 5%/dextrose 25% 252 Clinimix E 2.75%/dextrose 10% 252 Clinimix E 2.75%/dextrose 5% 252 Clinimix E 4.25%/dextrose 10% 252 Clinimix E 4.25%/dextrose 25% 252 Clinimix E 4.25%/dextrose 5% 252 Clinimix E 5%/dextrose 15% 252 Clinimix E 5%/dextrose 20% 252 Clinimix E 5%/dextrose 25% 252 Clinisol Sf 15% 252 Clomipramine Hcl 15 Colistimethate Sodium 42 Coly-mycin 42 Cometriq 43 Copaxone 44 Corlanor 45 Cotellic 46 Cromolyn Sodium 252 Cyclobenzaprine Hcl 131 Cyclophosphamide 252 Cyclosporine 47 Cyclosporine Modified 47

Cyproheptadine Hcl .......................................... ........................................................... ..........................................................

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16 Cyramza 48 Cystagon 49 Cytarabine Aqueous 252

D

Darzalex 50 Deferasirox 51 Depo-testosterone 210 Dexedrine 215 Dexmethylphenidate Hcl 215 Dextroamphetamine Sulfate 215 Dextrose 20% 252 Dextrose 25% 252 Dextrose 30% 252 Dextrose 40% 252 Dextrose 50% 252 Dextrose 70% 252 Dicyclomine Hcl 18 Diphenhydramine Hcl 16 Disopyramide Phosphate 39 Doxepin Hcl 15 Doxorubicin Hcl 252 Dronabinol 53 Duramorph 252

E

Egrifta 54 Elitek 55 Emend 252 Emend Tripack 252 Empliciti 56 Enbrel 57 Enbrel Sureclick 57 Engerix-b 252 Entresto 58 Envarsus Xr 252 Epclusa 59 Epoprostenol Sodium 167 Eraxis 60 Erbitux 61 Ergoloid Mesylates 62 Erivedge 63 Erwinaze 64 Esbriet 65

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Esgic................................................................. ...........................................................

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35 Estradiol 66 Estradiol/norethindrone Acetate 66 Eszopiclone 99 Evomela 67 Exjade 51

F

Fabrazyme 68 Farydak 69 Faslodex 70 Fentanyl Citrate Oral Transmucosal 71 Fentanyl Oral 71 Ferriprox 72 Firazyr 73 Firmagon 74 Fluorouracil 252 Forteo 75 Fyavolv 66 Fycompa 76

G

Gamastan S/d 95 Gammaplex 95 Gamunex-c 95 Ganciclovir 252 Gattex 77 Gazyva 78 Gengraf 47 Gilenya 79 Gilotrif 80 Glatopa 44 Gleevec 81 Glyburide 52 Glyburide Micronized 52 Glyburide/metformin Hcl 52 Granisetron Hcl 252

H

Halaven 82 Harvoni 83 Hecoria 252 Hepatamine 252 Herceptin 84 Hetlioz 85

Humira ............................................................. ...

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86 Humira Pediatric Crohns Disease Starter Pack 86 Humira Pen 86 Humira Pen-crohns Diseasestarter 86 Humira Pen-psoriasis Starter 86 Hydromorphone Hcl 252 Hydroxyprogesterone Caproate 87 Hydroxyzine Hcl 88

I

Ibrance 89 Iclusig 90 Idhifa 91 Ilaris 92 Imatinib Mesylate 81 Imbruvica 93 Imfinzi 94 Imipramine Hcl 15 Immune Globulin 95 Imovax Rabies (h.d.c.v.) 252 Increlex 97 Inlyta 98 Intralipid 252 Intron A 100 Intron A W/diluent 100 Intron-a 100 Ipratropium Bromide 252 Ipratropium Bromide/albuterol Sulfate 252 Iressa 101 Istodax 102 Istodax (overfill) 102 Itraconazole 103 Ixempra 104 Ixempra Kit 104

J

Jakafi 105 Jevantique Lo 66 Jevtana 106 Jinteli 66

K

Kabiven 252 Kadcyla 107 Kalydeco 108

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Ketorolac Tromethamine ................................... .........................................................

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13 Keytruda 109 Kisqali 110 Kisqali Femara 200 Dose 110 Kisqali Femara 400 Dose 110 Kisqali Femara 600 Dose 110 Korlym 111 Kuvan 112 Kynamro 113 Kyprolis 114

L

Lartruvo 115 Lenvima 116 Lenvima 10 Mg Daily Dose 116 Lenvima 14 Mg Daily Dose 116 Lenvima 18 Mg Daily Dose 116 Lenvima 20 Mg Daily Dose 116 Lenvima 24 Mg Daily Dose 116 Lenvima 8 Mg Daily Dose 116 Letairis 117 Leukine 118 Leuprolide 120 Leuprolide Acetate 120 Levalbuterol 252 Levalbuterol Hcl 252 Lidocaine 121 Lidoderm 121 Linezolid 250 Liposyn III 253 Lonsurf 122 Lopreeza 66 Lupron Depot (1-month) 120 Lupron Depot (3-month) 120 Lupron Depot (4-month) 120 Lupron Depot (6-month) 120 Lupron Depot-ped (1-month) 120 Lupron Depot-ped (3-month) 120 Lynparza 123 Lyrica 124

M

Margesic 35 Marqibo 125 Megestrol Acetate 126

Mekinist .......................................................... .......................................................

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127 Melphalan 253 Memantine Hcl 134 Memantine Hcl Titration Pak 134 Memantine Hydrochloride 134 Menest 66 Mepron 128 Metadate Er 215 Methylphenidate Hcl 215 Methylphenidate Hcl Er 215 Methylphenidate Hcl Er (la) 215 Methylphenidate Hcl Sr 215 Mimvey 66 Mimvey Lo 66 Modafinil 129 Morphine Sulfate 253 Mozobil 130 Mycophenolate Mofetil 253 Mylotarg 132

N

Naglazyme 133 Namenda 134 Namenda Xr 134 Namenda Xr Titration Pack 134 Namzaric 134 Natpara 135 Nebupent 253 Nephramine 253 Nerlynx 136 Neumega 137 Neupogen 138 Nexavar 139 Ninlaro 140 Norditropin 141 Norditropin Flexpro 141 Norethindrone Acetate/ethinyl Estradiol 66 Northera 143 Noxafil 144 Nulojix 145 Nuplazid 146 Nutrilipid 253 Nuvigil 147 Nymalize 148

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Octreotide ..................................................................................................

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149 Octreotide Acetate 149 Odomzo 150 Ofev 151 Ondansetron Hcl 253 Ondansetron Odt 253 Onivyde 152 Opdivo 153 Opsumit 154 Orfadin 155 Orkambi 156 Oxandrolone 157

P

Part B Versus Part D 251 Pegintron 158 Peg-intron 158 Peg-intron Redipen 158 Perforomist 253 Perikabiven 253 Perjeta 159 Phenadoz 16 Phenergan 16 Phenobarbital 160 Phenobarbital Sodium 160 Phrenilin Forte 35 Plenamine 253 Pomalyst 161 Portrazza 162 Praluent 163 Premasol 253 Procrit 165 Prograf 253 Prolastin-c 10 Promacta 166 Promethazine Hcl 16 Promethegan 16 Pulmonary Hypertension-other 167 Pulmozyme 253 Purixan 168

Q

Quinine Sulfate 169

R

Rabavert .......................................................... .......................................................

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253 Rapamune 253 Ravicti 170 Rebif 171 Rebif Rebidose 171 Rebif Rebidose Titration Pack 171 Rebif Titration Pack 171 Recombivax Hb 253 Regranex 172 Relistor 173 Remicade 174 Repatha 175 Repatha Pushtronex System 175 Repatha Sureclick 175 Revlimid 177 Rituxan 178 Rituxan Hycela 179 Rubraca 180 Rydapt 181

S

Sabril 182 Samsca 183 Sandimmune 47 Signifor 184 Sildenafil 185 Simulect 253 Sirolimus 253 Sirturo 186 Sodium Phenylbutyrate 34 Soltamox 187 Somatuline 188 Somatuline Depot 188 Somavert 189 Soriatane 190 Sovaldi 191 Sporanox 103 Spritam 192 Sprycel 193 Stivarga 194 Suboxone 195 Subutex 196 Sutent 197

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Sylatron ...........................................................................................................................................................................................................................................

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198 Sylvant 199 Synagis 200 Synribo 201

T

Tacrolimus 253 Tafinlar 202 Tagrisso 203 Tarceva 204 Targretin 206 Targretin Caps 205 Targretin Gel 206 Tasigna 207 Tecentriq 208 Temodar 253 Testim 209 Testosterone 14, 209 Testosterone Inj 210 Tetrabenazine 232 Thalomid 211 Thioridazine Hcl 212 Thymoglobulin 253 Ticlopidine Hcl 39 Tobramycin 253 Topical Tretinoin 213 Tracleer 214 Trelstar 216 Trelstar Mixject 216 Tretinoin 213 Tretinoin Microsphere 213 Tretinoin Microsphere Pump 213 Trihexyphenidyl Hcl 17 Trimipramine Maleate 15 Trisenox 217 Tykerb 218 Tysabri 219

V

Valchlor 220 Vectibix 221 Velcade 222 Venclexta 223

Venclexta Starting Pack ................................... ....................................................................................................................

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223 Ventavis 224 Verzenio 225 Vidaza 226 Vigabatrin 182 Vinblastine Sulfate. 253 Vincasar Pfs 253 Vincristine Sulfate 253 Votrient 227 Vpriv 228 Vyxeos 229

X

Xalkori 230 Xatmep 231 Xenazine 232 Xgeva 233 Xifaxan 234 Xolair 235 Xtandi 236 Xyrem 237

Y

Yervoy 238 Yondelis 239

Z

Zaleplon 99 Zaltrap 240 Zavesca 241 Zebutal 35 Zejula 242 Zelboraf 243 Zenzedi 215 Zepatier 244 Zolinza 245 Zolpidem Tartrate 99 Zortress 246 Zydelig. 247 Zykadia 248 Zytiga 249 Zyvox 250

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