Prior Authorization Criteria
Stivarga
Covered Uses
Exclusion Criteria
Required Medical
Information
Age Restrictions
Coverage Duration
Other Criteria
All medically accepted indications not otherwise excluded from Part D
Not applicable
Supporting statement of diagnosis from the physician
None
Once approved, the override will be covered through 12/31/2015
None
Xalkori
Covered Uses
Exclusion Criteria
Required Medical
Information
Prescriber
Age Restrictions
Coverage Duration
Other Criteria
All medically accepted indications not otherwise excluded from Part D
Not applicable
Supporting statement of diagnosis from the physician that establishes the
cancer as anaplastic lymphoma kinase (ALK)-positive
Must be prescribed by an oncologist
None
Once approved, the override will be covered through 12/31/2015
None
Lidoderm
Covered Uses
Exclusion Criteria
Required Medical
Information
Age Restrictions
Coverage Duration
Other Criteria
All medically accepted indications not otherwise excluded from Part D
Not applicable
Supporting statement of diagnosis from the physician
None
Once approved, the override will be covered through 12/31/2015
None
Growth Hormone
Covered Uses
Exclusion Criteria
Required Medical
Information
Age Restrictions
Coverage Duration
Other Criteria
All medically accepted indications not otherwise excluded from Part D
Not applicable
Supporting statement of diagnosis from the physician
None
Once approved, the override will be covered through 12/31/2015
None
HRM
Covered Uses
Exclusion Criteria
Required Medical
Information
All medically accepted indications not otherwise excluded from Part D
Not applicable
High risk medication. Automatically approved for beneficiaries less than
or equal to 64 years. Attestation to the medical necessity for using this
high risk medication, AND Monitoring plan for adverse side effects, AND
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H2758_PACriteria_15185_2015 CMS Approved 10/20/2014
Anticipated treatment course/duration, AND If formulary alternatives
considered safe and effective in the elderly are available, then the member
had an inadequate response, intolerable side effect, or contraindication to
the alternative(s).
Age Restrictions Less than or equal to 64 years old, claim for target drug automatically
pays. Greater than or equal to 65 years old, prior authorization exception
request is required indicating medically accepted indication not otherwise
excluded from Part D.
Coverage Duration Once approved, the override will be covered through 12/31/2015
Other Criteria None
Incivek
Covered Uses
Exclusion Criteria
Required Medical
Information
Age Restrictions
Coverage Duration
Other Criteria
All medically accepted indications not otherwise excluded from Part D
None
Supporting statement of diagnosis from the physician
None
12 Weeks
None
Victrelis
Covered Uses
Exclusion Criteria
Required Medical
Information
Age Restrictions
Coverage Duration
Other Criteria
All medically accepted indications not otherwise excluded from Part D
None
Supporting statement of diagnosis from the physician
None
44 Weeks
None
Provigil
Covered Uses
Exclusion Criteria
Required Medical
Information
Age Restrictions
Coverage Duration
Other Criteria
All medically accepted indications not otherwise excluded from Part D
None
Supporting statement of diagnosis from the physician
None
Once approved, the override will be covered through 12/31/2015
None
Revatio
Covered Uses
Exclusion Criteria
Required Medical
Information
Age Restrictions
Coverage Duration
Other Criteria
All medically accepted indications not otherwise excluded from Part D
None
Supporting statement of diagnosis from the physician
None
Once approved, the override will be covered through 12/31/2015
None
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H2758_PACriteria_15185_2015 CMS Approved 10/20/2014
Samsca
Covered Uses
Exclusion Criteria
Required Medical
Information
Age Restrictions
Coverage Duration
Other Criteria
All medically accepted indications not otherwise excluded from Part D
None
Supporting statement of diagnosis from the physician
None
Once approved, the override will be covered through 12/31/2015
None
Cialis
Covered Uses
Exclusion Criteria
Required Medical
Information
Age Restrictions
Coverage Duration
Other Criteria
All medically accepted indications not otherwise excluded from Part D
None
Supporting statement of diagnosis from the physician and prior trial and
failure of at least one alpha blocker and one alpha reductase inhibitor
None
Once approved, the override will be covered through 12/31/2015
None
Xtandi
Covered Uses
Exclusion Criteria
Required Medical
Information
Age Restrictions
Coverage Duration
Other Criteria
All medically accepted indications not otherwise excluded from Part D
None
Supporting statement of diagnosis from the physician and prior trial and
failure of docetaxel
None
Once approved, the override will be covered through 12/31/2015
None
Bosulif
All medically accepted indications not otherwise excluded from Part D
None
Signed statement of diagnosis from the physician, hepatic panel and CBC,
trial and failure ofofimiatinib or dasatinibi and documentation of a 90 day
response
Age Restrictions None
Coverage Duration Once approved, the override will be covered through 12/31/2015
Other Criteria None
Covered Uses
Exclusion Criteria
Required Medical
Information
ESRD Therapy
All medically accepted indications not otherwise excluded from Part D
None
Hemogloblin less than 10 g/dl for patients receiving Cancer
Chemotherapy and Hemoglobin less than 12 and Hematacrit less than 33
for other approved FDA indications in addition to supporting statement of
diagnosis from physician
Age Restrictions None
Coverage Duration 3 months
Covered Uses
Exclusion Criteria
Required Medical
Information
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H2758_PACriteria_15185_2015 CMS Approved 10/20/2014
Other Criteria None
Fentanyl
Covered Uses
Exclusion Criteria
Required Medical
Information
Age Restrictions
Coverage Duration
Other Criteria
All medically accepted indications not otherwise excluded from Part D
None
Supporting statement of diagnosis from the physician
None
Once approved, the override will be covered through 12/31/2015
None
Erwinaze
Covered Uses
Exclusion Criteria
Required Medical
Information
Age Restrictions
Coverage Duration
Other Criteria
All medically accepted indications not otherwise excluded from Part D
None
Supporting statement of diagnosis from the physician
None
Once approved, the override will be covered through 12/31/2015
None
Fulyzaq
Covered Uses
Exclusion Criteria
Required Medical
Information
Age Restrictions
Coverage Duration
Other Criteria
All FDA approved indications not otherwise excluded from Part D
None
Dx of non-infectious diarrhea and HIV, member must be on antiretroviral
therapy.
None
Once approved, the override will be covered through 12/31/2015
None
Gilotrif
All medically accepted indications not otherwise excluded from Part D
None
Supporting statement of diagnosis from the physician in patients with
EGFR exon 19 deletions or exon 21 (L858R) substitution as detected by
an FDA-approved test.
Age Restrictions None
Coverage Duration Once approved, the override will be covered through 12/31/2015
Other Criteria None
Covered Uses
Exclusion Criteria
Required Medical
Information
Imbruvica
Covered Uses
Exclusion Criteria
Required Medical
Information
Age Restrictions
Coverage Duration
Other Criteria
All medically accepted indications not otherwise excluded from Part D
None
Supporting statement of diagnosis from the physician
None
Once approved, the override will be covered through 12/31/2015
None
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H2758_PACriteria_15185_2015 CMS Approved 10/20/2014
Olysio
Covered Uses
Exclusion Criteria
Required Medical
Information
Age Restrictions
Prescriber
Coverage Duration
Other Criteria
All medically accepted indications not otherwise excluded from Part D
None
Must have chronic hepatitis C genotype 1 infection. Must not have Q80K
polymorphism resistance (confirmed by Genosure NS3/4 resistance
testing).
Patient must be age 18 or over
Prescriber must be a gastroenterologist, hepatologist, or infectious disease
specialist
12 weeks
Must not be taking Olysio as monotherapy. Must have not taken a HCV
protease inhibitor such as Victrelis or Incivek in the past.
Regranex
All medically accepted indications not otherwise excluded from Part D
None
Diabetic Neuropathic Ulcers: Diabetic patient with ulcer wound.
Treatment will be given in combination with ulcer wound care (eg,
debridement, infection control, and/or pressure relief).
Age Restrictions None
Coverage Duration Diabetic Neuropathic Ulcers: Maximum 5 months.
Other Criteria None
Covered Uses
Exclusion Criteria
Required Medical
Information
Sovaldi
Covered Uses
Exclusion Criteria
Required Medical
Information
Prescriber
All medically accepted indications not otherwise excluded from Part D
None
Must have genotype 1,2,3,4,5, or 6
Prescriber must be a gastroenterologist, hepatologist, or infectious disease
specialist
Age Restrictions Patient must be age 18 or over.
Coverage Duration 12 weeks:genotype 1,2,or4_24 wks:genotype 3 OR no interferon_48
wks:liver cancer awaiting transplant
Other Criteria For genotypes 2,3, and 4, patient must be taking ribavirin with Sovaldi.
Zohydro
Covered Uses
Exclusion Criteria
Required Medical
Information
All FDA approved indications not otherwise excluded from Part D.
None
Must have severe pain requiring around the clock long term opioid, AND
all of these: 1- ONE of the following formulary opioid options,
hydrocodone IR, oxycodone IR, morphine IR, hydromorphone IR,
methadone, OR oxymorphone IR are ineffective,not tolerated or
inadequate for controlling pain AND fentanyl patches are ineffective, not
tolerated, or inadequate for controlling pain 2-Must discontinue all other
around-the-clock opioids when initiated 3-Care plan/agreement for opioid
therapy has been established 4-Pt advised of risks and provides informed
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H2758_PACriteria_15185_2015 CMS Approved 10/20/2014
Age Restrictions
Prescriber
Coverage Duration
Other Criteria
consent for chronic opioid therapy 5-Pt assessed for all these (i)pain
severity (ii)suitability of non-opioids (iii)physical & emotional functional
status (iv)risk of or current aberrant drug behavior 5-Prescriber will
monitor for signs of misuse, abuse and addiction during therapy AND
ONE of these: A-Opioid naive/non-tolerant must start at 10mg twice day
for 7 days before titrating up OR B-Opioid tolerant, receiving one of these
doses per day for at least 1 week: 60mg oral morphine, 25mcg
transdermal fentanyl/hr, 30mg oral oxycodone, 8mg oral hydromorphone,
25mg oral oxymorphone
Patient must be age 18 or over.
Prescriber is knowledgeable in the use of potent opioids for the
management of chronic pain
90 days`
None
Korlym
Covered Uses
Exclusion Criteria
Required Medical
Information
Age Restrictions
Coverage Duration
Other Criteria
All medically accepted indications not otherwise excluded from Part D
Pregnancy
Supporting statement of diagnosis and relevant medical information from
physician
None
Once approved, the override will be covered through 12/31/2015
None
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H2758_PACriteria_15185_2015 CMS Approved 10/20/2014