Excluded Drug Criteria. Coverage Duration. Age Restrictions. Prescriber Restrictions. Prior Authorization Type Description.

Transcription

1 2015 Cigna-HealthSpring - H Cigna-HealthSpring Preferred (HMO), Cigna-HealthSpring Achieve Plus (HMO SNP), Cigna- HealthSpring Preferred Plus (HMO) (Updated December 2015) Name Other ABELCET ABRAXANE ACETYLCYSTEINE ACTEMRA ACTEMRA Documentation of diagnosis and past medication history. Treatment of rheumatoid arthritis (RA) when ANY of the following criteria are met: 1) history of positive clinical response to tocilizumab therapy OR 2) inadequate response, intolerance, or contraindication to at least one disease-modifying anti-rheumatic drug (DMARD) (i.e., Methotrexate (MTX) Azathioprine, gold, Hydroxychloroquine, Penicillamine, Sulfasalazine). For RA new starts that meet the above criteria, the patient must also have failure, contraindication or intolerance to Enbrel or Humira before authorization of Actemra. BvsD Determinaton ACTHAR HP ACTHAR HP All FDA-approved excluded from part D. For the treatment of multiple sclerosis the patient must have failure, contraindication or intolerance to intravenous corticosteroid therapy and currently maintained on one of the following formulary drugs Avonex, Copaxone, Extavia or Rebif before Acthar HP is authorized. ACYCLOVIR SODIUM ADCIRCA ADCIRCA All FDA-approved excluded from part D. Medical documentation of pulmonary arterial hypertension. ALBUTEROL SULFATE ALIMTA ALORA HRM - Estrogens Safer alternatives to the estrogen high risk medications depend on the indication. For Hot Flashes, safer alternatives are: Estradiol Valerate, Depo-Estradiol, SSRIs, venlafaxine, gabapentin, and Femring. For Vaginal Symptoms, safer alternatives are: Premarin Cream, Estring, Femring, and Estradiol Valerate. For Bone Density, safer alternatives are: alendronate, risedronate, Evista, and Prolia. ALOSETRON LOTRONEX Lotronex (alosetron) will not be approved for use in men, as safety and efficacy in men has not been established. must be enrolled in the prescribing program for alosetron.

2 Name Other ALOXI AMBISOME AMIFOSTINE AMINOSYN AMINOSYN 7%/ELECTROLYTES AMINOSYN 8.5%/ELECTROLYTES AMINOSYN II AMINOSYN II 8.5%/ELECTROLYTES AMINOSYN M AMINOSYN-HBC AMINOSYN-PF AMINOSYN-PF 5.2 % AMINOSYN-PF 7% AMITRIPTYLINE HCL to New Starts HRM - Tricyclic Antidepressants Safer alternatives depend on indication. For Depression, safer alternatives are: Nortriptyline, Protriptyline, Desipramine, Amoxapine, Citalopram, Venlafaxine, Fluoxetine, Paroxetine, Sertraline, Duloxetine, and Bupropion. For headache prophylaxis, safer alternatives are: Propranolol, Topiramate, and Divalproex sodium. For headache treatment, safer alternatives are: Sumatriptan, Naratriptan, and Dihydroergotamine. For Pain/Neuropathy, safer alternatives are: Duloxetine, Lyrica, and Gabapentin. AMPHOTERICIN B

3 Name Other AMPYRA AMPYRA Documentation of diagnosis. Ampyra is considered medically necessary for patients with multiple sclerosis with medical documentation of impaired walking ability. ANGELIQ HRM - Estrogens Safer alternatives to the estrogen high risk medications depend on the indication. For Hot Flashes, safer alternatives are: Estradiol Valerate, Depo-Estradiol, SSRIs, venlafaxine, gabapentin, and Femring. For Vaginal Symptoms, safer alternatives are: Premarin Cream, Estring, Femring, and Estradiol Valerate. For Bone Density, safer alternatives are: alendronate, risedronate, Evista, and Prolia. ANZEMET ANZEMET INJ ARALAST NP Alpha-1 Proteinase Inhibitor Therapy All FDA-approved excluded from part D. Intravenous alpha1-proteinase inhibitor (human) is authorized for the treatment of congenital alpha1-proteinase inhibitor deficiency-associated lung disease when all of the following criteria are met: 1) alpha1-antitrypsin (AAT) concentration less than 80mg/dl or less than 11 micromolar and 2) obstructive lung disease as defined by a forced expiratory volume in one second (FEV1) of 30 to 65% of predicted or a rapid decline in lung function defined as a change in FEV1 of greater than 120ml per year. BvsD Determination. ARANESP ALBUMIN FREE ARCALYST HEMATOPOIETICS ARCALYST For the indication of anemia, documentation of Hemoglobin less than 11, Hematocrit, transferrin saturation greater than 20%, and ferritin levels greater than 100 obtained over the last 3 months. Documentation of diagnosis of Cryopyrin-Associated Periodic Syndromes (CAPS), including Familial Cold Autoinflammatory Syndrome (FCAS) and Muckle-Wells Syndrome (MWS). 12 years of age and older 6 months BvD Determination. Patients must also have failure, contraindication or intolerance to Procrit or Aranesp before Epogen will be authorized. BvsD Determination ARRANON ARZERRA ASCOMP/CODEINE HRM - Butalbital Combinations Safer alternatives are: naproxen sodium and ibuprofen. ASTAGRAF XL AUBAGIO AUBAGIO Aubagio will be used as monotherapy for the treatment of multiple sclerosis. Patient must also have failure, contraindication or intolerance to one of the following formulary alternatives Avonex, Copaxone, Extavia or Rebif before Aubagio will be authorized. AVASTIN

4 Name AVONEX IMMUNOMODULATO RS Other AZACITIDINE AZATHIOPRINE BENLYSTA BENLYSTA The patient must have a positive autoantibody test (i.e., antinuclear antibody [ANA] greater than or equal to 1:80 and/or anti-double-stranded DNA [anti-dsdna] greater than or equal to 30 IU/ml) AND active disease state as documented by a SELENA-SLEDAI score of 6 or greater on the current treatment regimen. The patient must be receiving one standard therapy for SLE with any of the following: corticosteroids, hydroxychloroquine, immunosuppressives (cyclophosphamide, azathioprine, mycophenolate, methotrexate, cyclosporine) or nonsteroidal anti-inflammatory drugs AND there must be an absence of severe active lupus nephritis or severe active central nervous system lupus before Benlysta is authorized. BvsD Determination BENZTROPINE MESYLATE HRM - Benztropine If only one (1) safer formulary alternative is available, then only that particular medication would need to be documented as tried and failed or clinical rationale provided as to why that one safer formulary alternative is not Safer alternatives depend on indication. For Parkinsonism, safer alternatives are: Carbidopa/Levodopa, Pramipexole, Ropinirole, Bromocriptine, Amantadine, and Selegiline. For extrapyramidal symptoms, a safer alternative is: Amantadine. BERINERT BERINERT Berinert is authorized for the treatment of acute angioedema attacks with hereditary angioedema (HAE) when BOTH of the following criteria are met: 1) confirmed diagnosis of (HAE) as evidenced by a C4 level below the lower limit of normal as defined by the laboratory performing the test AND EITHER a) C1 inhibitor (C1INH) antigenic level below the lower limit 10 years and older of normal as defined by the laboratory performing the test or b) C1INH functional level below the lower limit of normal as defined by the laboratory performing the test AND 2) history of a moderate or severe attack (e.g., airway swelling, severe abdominal pain, facial swelling, nausea and vomiting, painful facial distortion). BETHKIS BICNU BIVIGAM BLEOMYCIN SULFATE BONIVA

5 Name BOTOX BOTOX Exclude when used for cosmetic purposes. Documentation of diagnosis 3 months Other BROVANA BUDESONIDE BUSULFEX BUTAL/ASA/CAFF HRM - Butalbital Combinations Safer alternatives are: naproxen sodium and ibuprofen. BUTALBITAL/ACETA MINOPHEN HRM - Butalbital Combinations Safer alternatives are: naproxen sodium and ibuprofen. BUTALBITAL/ACETA MINOPHEN/CAFFEINE HRM - Butalbital Combinations Safer alternatives are: naproxen sodium and ibuprofen. BUTALBITAL/ACETA MINOPHEN/CAFFEINE /CODEINE HRM - Butalbital Combinations Safer alternatives are: naproxen sodium and ibuprofen.

6 Name Other BUTALBITAL/APAP/C AFFEINE HRM - Butalbital Combinations Safer alternatives are: naproxen sodium and ibuprofen. CALCITRIOL CARBOPLATIN CARIMUNE NANOFILTERED CARISOPRODOL HRM - Skeletal Muscle Relaxants documented the ongoing monitoring plan for the agent. age.prior Auth CARISOPRODOL/ASPI RIN HRM - Skeletal Muscle Relaxants documented the ongoing monitoring plan for the agent. age.prior Auth CARISOPRODOL/ASPI RIN/CODEINE HRM - Skeletal Muscle Relaxants documented the ongoing monitoring plan for the agent. age.prior Auth CELLCEPT CELLCEPT INTRAVENOUS CEREZYME

7 Name Other CESAMET CHLORDIAZEPOXIDE/ AMITRIPTYLINE to New Starts HRM - Tricyclic Antidepressants Safer alternatives depend on indication. For Depression, safer alternatives are: Nortriptyline, Protriptyline, Desipramine, Amoxapine, Citalopram, Venlafaxine, Fluoxetine, Paroxetine, Sertraline, Duloxetine, and Bupropion. For headache prophylaxis, safer alternatives are: Propranolol, Topiramate, and Divalproex sodium. For headache treatment, safer alternatives are: Sumatriptan, Naratriptan, and Dihydroergotamine. For Pain/Neuropathy, safer alternatives are: Duloxetine, Lyrica, and Gabapentin. CHLORZOXAZONE to New Starts HRM - Skeletal Muscle Relaxants documented the ongoing monitoring plan for the agent. CIALIS CIALIS All FDA-approved excluded from part D. Cialis 2.5mg and 5mg are only covered for the treatment of benign prostatic hyperplasia (BPH). CINRYZE CINRYZE Patient must have a confirmed diagnosis of HAE as evidenced by a C4 level below the lower limit of normal as defined by the laboratory performing the test AND EITHER of the following: 1) C1 inhibitor (C1INH) antigenic level below the lower limit of normal as defined by the laboratory performing the test 2) C1INH functional level below the lower limit of normal as defined by the laboratory performing the test or 3) known HAE-causing C1INH mutation. The patient must have a history of more than one severe event per month and have failure, contraindication or intolerance to one conventional therapy for HAE prophylaxis such as aminocaproic acid, danazol or tranexamic acid. CISPLATIN CLADRIBINE CLIMARA PRO HRM - Estrogens Safer alternatives to the estrogen high risk medications depend on the indication. For Hot Flashes, safer alternatives are: Estradiol Valerate, Depo-Estradiol, SSRIs, venlafaxine, gabapentin, and Femring. For Vaginal Symptoms, safer alternatives are: Premarin Cream, Estring, Femring, and Estradiol Valerate. For Bone Density, safer alternatives are: alendronate, risedronate, Evista, and Prolia. CLINIMIX 2.75%/DEXTROSE 5% CLINIMIX 4.25%/DEXTROSE 10%

8 Name Other 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 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% CLOLAR CLOMIPRAMINE HCL to New Starts HRM - Tricyclic Antidepressants Safer alternatives depend on indication. For Depression, safer alternatives are: Nortriptyline, Protriptyline, Desipramine, Amoxapine, Citalopram, Venlafaxine, Fluoxetine, Paroxetine, Sertraline, Duloxetine, and Bupropion. For headache prophylaxis, safer alternatives are: Propranolol, Topiramate, and Divalproex sodium. For headache treatment, safer alternatives are: Sumatriptan, Naratriptan, and Dihydroergotamine. For Pain/Neuropathy, safer alternatives are: Duloxetine, Lyrica, and Gabapentin.

9 Name Other COMBIPATCH HRM - Estrogens Safer alternatives to the estrogen high risk medications depend on the indication. For Hot Flashes, safer alternatives are: Estradiol Valerate, Depo-Estradiol, SSRIs, venlafaxine, gabapentin, and Femring. For Vaginal Symptoms, safer alternatives are: Premarin Cream, Estring, Femring, and Estradiol Valerate. For Bone Density, safer alternatives are: alendronate, risedronate, Evista, and Prolia. COSMEGEN CROMOLYN SODIUM CYCLOBENZAPRINE HCL HRM - Skeletal Muscle Relaxants documented the ongoing monitoring plan for the agent. CYCLOPHOSPHAMIDE CYCLOSPORINE CYCLOSPORINE MODIFIED CYPROHEPTADINE HCL HRM - Cyproheptadine failed one (1) safer formulary alternative if available or provided clinical rationale why the safer formulary alternative is not age.prior Auth For perennial and seasonal allergic rhinitis, safer alternatives are: Levocetirizine, Desloratadine. For any other indications, trial of formulary alternatives are not required. CYTARABINE CYTARABINE AQUEOUS DACARBAZINE DACTINOMYCIN

10 Name Other DAUNORUBICIN HCL DAUNOXOME DECITABINE DEXRAZOXANE DEXTROSE 10%/NACL 0.45% DEXTROSE 5% /ELECTROLYTE #48 VIAFLEX DEXTROSE 10% FLEX CONTAINER DEXTROSE 10%/NACL 0.2% DEXTROSE 2.5%/SODIUM CHLORIDE 0.45% DEXTROSE 5% DEXTROSE 20% DEXTROSE 25% DEXTROSE 30% DEXTROSE 30% PARTIAL FILL DEXTROSE 40% DEXTROSE 50% DEXTROSE 70% DEXTROSE 5%/NACL 0.2%

11 Name Other DEXTROSE 5%/NACL 0.225% DEXTROSE 5%/NACL 0.3% DEXTROSE 5%/NACL 0.33% DEXTROSE 5%/NACL 0.45% DEXTROSE 5%/NACL 0.9% DEXTROSE 5%/POTASSIUM CHLORIDE 0.15% DIFICID DIFICID 18 years of age and older. 10 days DIGOX HRM - Digoxin the physician has documented that the patient has tried digoxin 0.125mg daily or provided clinical rationale as to why the lower dose is not DIGOXIN HRM - Digoxin the physician has documented that the patient has tried digoxin 0.125mg daily or provided clinical rationale as to why the lower dose is not DIPYRIDAMOLE HRM - Platelet Modifying nts Safer alternatives are: Clopidogrel, Warfarin, Jantoven, and Aggrenox. DOCEFREZ DOCETAXEL

12 Name Other DOXEPIN HCL to New Starts HRM - Tricyclic Antidepressants Safer alternatives depend on indication. For Depression, safer alternatives are: Nortriptyline, Protriptyline, Desipramine, Amoxapine, Citalopram, Venlafaxine, Fluoxetine, Paroxetine, Sertraline, Duloxetine, and Bupropion. For headache prophylaxis, safer alternatives are: Propranolol, Topiramate, and Divalproex sodium. For headache treatment, safer alternatives are: Sumatriptan, Naratriptan, and Dihydroergotamine. For Pain/Neuropathy, safer alternatives are: Duloxetine, Lyrica, and Gabapentin. DOXERCALCIFEROL DOXORUBICIN HCL DOXORUBICIN HCL LIPOSOME DRONABINOL DYSPORT DYSPORT Exclude when used for cosmetic purposes. 3 months EGRIFTA EGRIFTA All FDA-approved excluded from part D. Males must have a waist circumference of at least 95cm (37.5in) and a waist-to-hip ratio of at least Females must have a waist circumference of at least 94cm (37in) and a waist-to-hip ratio of at least Patients must have a baseline CT documenting increased visceral adipose tissue (VAT). Reauthorization is contingent upon ONE of the following: 1) decrease in VAT measured by CT scan or 2) reduction of waist circumference and waist-to-hip ratio from baseline measurement. Patient must be on a stable antiretroviral regimen for at least 8 weeks. ELIGARD to New Starts ELIGARD Patient must have failure, contraindication or intolerance to Trelstar before Eligard is authorized. BvsD Determination ELITEK ELLENCE ELOXATIN EMEND

13 Name Other Use of Humira, Enbrel, or Remicade is considered medically necessary for the treatment of: 1. Rheumatoid Arthritis in patients that have tried and failed methotrexate OR at least 2 alternative disease modifying antirheumatic drugs (DMARDs). 2. Juvenile Rheumatoid Arthritis in patients that have tried and failed at least 2 DMARDs. 3. Ankylosing Spondylitis in patients that have tried and failed at least 1 non-steroidal antiinflammatory drug (NSAID), corticosteroid, OR sulfasalazine. 4. Plaque Psoriasis in patients that have: a) moderate to severe chronic disease, b) minimum body surface area (BSA) ENBREL IMMUNE SUPPRESSANTS Documentation of diagnosis and past medication history. involvement of greater than or equal to 5% OR involvement of the palms, soles, head, neck or genitalia, c) tried and failed at least 1 topical agent (topical steroid, calcipotriene, or tazarotene), AND d) tried and failed at least 1 systemic therapy (cyclosporine, methotrexate, or acitretin) OR phototherapy. 5. Psoriatic Arthritis in patients with active disease. In addition, use of Humira or Remicade is considered medically necessary for the treatment of: 1. Moderate to severe Crohn s Disease in patients that have tried and failed at least 2 of the following: immunomodulators, corticosteroids, or aminosalicylates. 2. Treatment of moderately to severely active ulcerative colitis in patients who have had inadequate response to at least 2 of the following: corticosteroids, sulfasalazine, mesalamine, azathioprine, 6-mercaptopurine. Use of Remicade will also be considered medically necessary for the treatment of fistulizing Crohn's disease. B vs D determination required for Remicade. Use of Humira, Enbrel, or Remicade is considered medically necessary for the treatment of: 1. Rheumatoid Arthritis in patients that have tried and failed methotrexate OR at least 2 alternative disease modifying antirheumatic drugs (DMARDs). 2. Juvenile Rheumatoid Arthritis in patients that have tried and failed at least 2 DMARDs. 3. Ankylosing Spondylitis in patients that have tried and failed at least 1 non-steroidal antiinflammatory drug (NSAID), corticosteroid, OR sulfasalazine. 4. Plaque Psoriasis in patients that have: a) moderate to severe chronic disease, b) minimum body surface area (BSA) ENBREL SURECLICK IMMUNE SUPPRESSANTS Documentation of diagnosis and past medication history. involvement of greater than or equal to 5% OR involvement of the palms, soles, head, neck or genitalia, c) tried and failed at least 1 topical agent (topical steroid, calcipotriene, or tazarotene), AND d) tried and failed at least 1 systemic therapy (cyclosporine, methotrexate, or acitretin) OR phototherapy. 5. Psoriatic Arthritis in patients with active disease. In addition, use of Humira or Remicade is considered medically necessary for the treatment of: 1. Moderate to severe Crohn s Disease in patients that have tried and failed at least 2 of the following: immunomodulators, corticosteroids, or aminosalicylates. 2. Treatment of moderately to severely active ulcerative colitis in patients who have had inadequate response to at least 2 of the following: corticosteroids, sulfasalazine, mesalamine, azathioprine, 6-mercaptopurine. Use of Remicade will also be considered medically necessary for the treatment of fistulizing Crohn's disease. B vs D determination required for Remicade. ENGERIX-B EPIRUBICIN HCL EPOGEN HEMATOPOIETICS For the indication of anemia, documentation of Hemoglobin less than 11, Hematocrit, transferrin saturation greater than 20%, and ferritin levels greater than 100 obtained over the last 3 months. 6 months BvD Determination. Patients must also have failure, contraindication or intolerance to Procrit or Aranesp before Epogen will be authorized. ERBITUX

14 Name Other ERGOLOID MESYLATES HRM - Antidementia nts Safer alternatives are: donepezil, galantamine and rivastigmine. ERWINAZE ESTRADIOL HRM - Estrogens Safer alternatives to the estrogen high risk medications depend on the indication. For Hot Flashes, safer alternatives are: Estradiol Valerate, Depo-Estradiol, SSRIs, venlafaxine, gabapentin, and Femring. For Vaginal Symptoms, safer alternatives are: Premarin Cream, Estring, Femring, and Estradiol Valerate. For Bone Density, safer alternatives are: alendronate, risedronate, Evista, and Prolia. ESTRADIOL/NORETHI NDRONE ACETATE HRM - Estrogens Safer alternatives to the estrogen high risk medications depend on the indication. For Hot Flashes, safer alternatives are: Estradiol Valerate, Depo-Estradiol, SSRIs, venlafaxine, gabapentin, and Femring. For Vaginal Symptoms, safer alternatives are: Premarin Cream, Estring, Femring, and Estradiol Valerate. For Bone Density, safer alternatives are: alendronate, risedronate, Evista, and Prolia. ESTROPIPATE HRM - Estrogens Safer alternatives to the estrogen high risk medications depend on the indication. For Hot Flashes, safer alternatives are: Estradiol Valerate, Depo-Estradiol, SSRIs, venlafaxine, gabapentin, and Femring. For Vaginal Symptoms, safer alternatives are: Premarin Cream, Estring, Femring, and Estradiol Valerate. For Bone Density, safer alternatives are: alendronate, risedronate, Evista, and Prolia. ETOPOPHOS ETOPOSIDE EXTAVIA IMMUNOMODULATO RS FABRAZYME FASLODEX

15 Name Other FEMHRT LOW DOSE HRM - Estrogens Safer alternatives to the estrogen high risk medications depend on the indication. For Hot Flashes, safer alternatives are: Estradiol Valerate, Depo-Estradiol, SSRIs, venlafaxine, gabapentin, and Femring. For Vaginal Symptoms, safer alternatives are: Premarin Cream, Estring, Femring, and Estradiol Valerate. For Bone Density, safer alternatives are: alendronate, risedronate, Evista, and Prolia. FENTANYL CITRATE FENTANYL CITRATE ORAL TRANSMUCOSAL TRANSMUCOSAL FENTANYL CITRATE All FDA-approved Documentation from the medical record of diagnosis. 16 years of age and older for fentanyl citrate (lozenge/troche). 18 years of age and older for Enrollment in the Transmucosal Immediate- Release Fentanyl (TIRF) REMS Access program. Transmucosal fentanyl products will only be covered with documentation of breakthrough cancer pain. The patient must be currently receiving and be tolerant to opioid therapy for persistent cancer pain.the patient must be enrolled in the TIRF REMS Access program. FIRAZYR FIRAZYR Patient must have a confirmed diagnosis of HAE as evidenced by a C4 level below the lower limit of normal as defined by the laboratory performing the test AND EITHER of the following: 1) C1 inhibitor (C1INH) antigenic level below the lower limit of normal as defined by the laboratory performing the test 2) C1INH functional level below the lower limit of normal as defined by the laboratory performing the test. Authorized for patients 18 years of age and older. The patient must have a history of a moderate or severe attack (e.g., airway swelling, severe abdominal pain, facial swelling, nausea and vomiting, painful facial distortion). FIRMAGON FLEBOGAMMA FLUDARABINE PHOSPHATE FLUOROURACIL FOLOTYN FOSCARNET SODIUM FREAMINE HBC 6.9% FREAMINE III GAMASTAN S/D GAMMAGARD LIQUID GAMMAGARD S/D

16 Name Other GAMMAGARD S/D IGA LESS THAN 1MCG/ML GAMMAKED GAMMAPLEX GAMUNEX-C GANCICLOVIR GATTEX GATTEX As long as the patient requires TPN, 3 months up to. GAZYVA GEMCITABINE GEMCITABINE HCL GENGRAF GENOTROPIN GENOTROPIN For GHD in children or adults, Turner Syndrome, SGA, SHOX gene deletion or growth delay in children with chronic kidney disease, the patient must have failure, contraindication or intolerance to Humatrope or Saizen before coverage of Genotropin. GENOTROPIN MINIQUICK GENOTROPIN For GHD in children or adults, Turner Syndrome, SGA, SHOX gene deletion or growth delay in children with chronic kidney disease, the patient must have failure, contraindication or intolerance to Humatrope or Saizen before coverage of Genotropin. GILENYA GILENYA Gilenya will be used as monotherapy for the treatment of multiple sclerosis. Patients must also have failure, contraindication or intolerance to one of the following formulary alternatives Avonex, Copaxone, Extavia or Rebif before Gilenya will be authorized. GLASSIA Alpha-1 Proteinase Inhibitor Therapy All FDA-approved excluded from part D. Intravenous alpha1-proteinase inhibitor (human) is authorized for the treatment of congenital alpha1-proteinase inhibitor deficiency-associated lung disease when all of the following criteria are met: 1) alpha1-antitrypsin (AAT) concentration less than 80mg/dl or less than 11 micromolar and 2) obstructive lung disease as defined by a forced expiratory volume in one second (FEV1) of 30 to 65% of predicted or a rapid decline in lung function defined as a change in FEV1 of greater than 120ml per year. BvsD Determination.

17 Name Other GLYBURIDE HRM - Glyburide failed glipizide or provided clinical rationale as to why that safer formulary alternative is not GLYBURIDE MICRONIZED HRM - Glyburide failed glipizide or provided clinical rationale as to why that safer formulary alternative is not GRANISETRON HCL GRANISOL HARVONI Prior authorization applies HARVONI Previous failure of Harvoni Genotype, HCV RNA viral levels prior to treatment, documentation of presence/absence of cirrhosis Hepatologist, gastroenterologist, infectious disease specialist or managed by a liver transplant center 12 to 24 weeks based on indication and established treatment guidelines HECORIA HEPATAMINE HEPATASOL HERCEPTIN HIZENTRA HUMATROPE HUMATROPE COMBO PACK HUMATROPE HUMATROPE

18 Name Other Use of Humira, Enbrel, or Remicade is considered medically necessary for the treatment of: 1. Rheumatoid Arthritis in patients that have tried and failed methotrexate OR at least 2 alternative disease modifying antirheumatic drugs (DMARDs). 2. Juvenile Rheumatoid Arthritis in patients that have tried and failed at least 2 DMARDs. 3. Ankylosing Spondylitis in patients that have tried and failed at least 1 non-steroidal antiinflammatory drug (NSAID), corticosteroid, OR sulfasalazine. 4. Plaque Psoriasis in patients that have: a) moderate to severe chronic disease, b) minimum body surface area (BSA) HUMIRA IMMUNE SUPPRESSANTS Documentation of diagnosis and past medication history. involvement of greater than or equal to 5% OR involvement of the palms, soles, head, neck or genitalia, c) tried and failed at least 1 topical agent (topical steroid, calcipotriene, or tazarotene), AND d) tried and failed at least 1 systemic therapy (cyclosporine, methotrexate, or acitretin) OR phototherapy. 5. Psoriatic Arthritis in patients with active disease. In addition, use of Humira or Remicade is considered medically necessary for the treatment of: 1. Moderate to severe Crohn s Disease in patients that have tried and failed at least 2 of the following: immunomodulators, corticosteroids, or aminosalicylates. 2. Treatment of moderately to severely active ulcerative colitis in patients who have had inadequate response to at least 2 of the following: corticosteroids, sulfasalazine, mesalamine, azathioprine, 6-mercaptopurine. Use of Remicade will also be considered medically necessary for the treatment of fistulizing Crohn's disease. B vs D determination required for Remicade. Use of Humira, Enbrel, or Remicade is considered medically necessary for the treatment of: 1. Rheumatoid Arthritis in patients that have tried and failed methotrexate OR at least 2 alternative disease modifying antirheumatic drugs (DMARDs). 2. Juvenile Rheumatoid Arthritis in patients that have tried and failed at least 2 DMARDs. 3. Ankylosing Spondylitis in patients that have tried and failed at least 1 non-steroidal antiinflammatory drug (NSAID), corticosteroid, OR sulfasalazine. 4. Plaque Psoriasis in patients that have: a) moderate to severe chronic disease, b) minimum body surface area (BSA) HUMIRA PEN-CROHNS DISEASESTARTER IMMUNE SUPPRESSANTS Documentation of diagnosis and past medication history. involvement of greater than or equal to 5% OR involvement of the palms, soles, head, neck or genitalia, c) tried and failed at least 1 topical agent (topical steroid, calcipotriene, or tazarotene), AND d) tried and failed at least 1 systemic therapy (cyclosporine, methotrexate, or acitretin) OR phototherapy. 5. Psoriatic Arthritis in patients with active disease. In addition, use of Humira or Remicade is considered medically necessary for the treatment of: 1. Moderate to severe Crohn s Disease in patients that have tried and failed at least 2 of the following: immunomodulators, corticosteroids, or aminosalicylates. 2. Treatment of moderately to severely active ulcerative colitis in patients who have had inadequate response to at least 2 of the following: corticosteroids, sulfasalazine, mesalamine, azathioprine, 6-mercaptopurine. Use of Remicade will also be considered medically necessary for the treatment of fistulizing Crohn's disease. B vs D determination required for Remicade. Use of Humira, Enbrel, or Remicade is considered medically necessary for the treatment of: 1. Rheumatoid Arthritis in patients that have tried and failed methotrexate OR at least 2 alternative disease modifying antirheumatic drugs (DMARDs). 2. Juvenile Rheumatoid Arthritis in patients that have tried and failed at least 2 DMARDs. 3. Ankylosing Spondylitis in patients that have tried and failed at least 1 non-steroidal antiinflammatory drug (NSAID), corticosteroid, OR sulfasalazine. 4. Plaque Psoriasis in patients that have: a) moderate to severe chronic disease, b) minimum body surface area (BSA) HUMIRA PEN- PEDIATRIC CROHNS DISEASESTARTER IMMUNE SUPPRESSANTS Documentation of diagnosis and past medication history. involvement of greater than or equal to 5% OR involvement of the palms, soles, head, neck or genitalia, c) tried and failed at least 1 topical agent (topical steroid, calcipotriene, or tazarotene), AND d) tried and failed at least 1 systemic therapy (cyclosporine, methotrexate, or acitretin) OR phototherapy. 5. Psoriatic Arthritis in patients with active disease. In addition, use of Humira or Remicade is considered medically necessary for the treatment of: 1. Moderate to severe Crohn s Disease in patients that have tried and failed at least 2 of the following: immunomodulators, corticosteroids, or aminosalicylates. 2. Treatment of moderately to severely active ulcerative colitis in patients who have had inadequate response to at least 2 of the following: corticosteroids, sulfasalazine, mesalamine, azathioprine, 6-mercaptopurine. Use of Remicade will also be considered medically necessary for the treatment of fistulizing Crohn's disease. B vs D determination required for Remicade.

19 Name Other Use of Humira, Enbrel, or Remicade is considered medically necessary for the treatment of: 1. Rheumatoid Arthritis in patients that have tried and failed methotrexate OR at least 2 alternative disease modifying antirheumatic drugs (DMARDs). 2. Juvenile Rheumatoid Arthritis in patients that have tried and failed at least 2 DMARDs. 3. Ankylosing Spondylitis in patients that have tried and failed at least 1 non-steroidal antiinflammatory drug (NSAID), corticosteroid, OR sulfasalazine. 4. Plaque Psoriasis in patients that have: a) moderate to severe chronic disease, b) minimum body surface area (BSA) involvement of greater than or equal to 5% OR involvement of the palms, soles, head, neck or genitalia, c) tried and failed at least 1 topical agent (topical steroid, calcipotriene, or tazarotene), AND d) tried and failed at least 1 systemic therapy (cyclosporine, methotrexate, or acitretin) OR phototherapy. 5. Psoriatic Arthritis in patients with active disease. In addition, use of Humira or Remicade is considered medically necessary for the treatment of: 1. Moderate to severe Crohn s Disease in patients that have tried and failed at least 2 of the following: immunomodulators, corticosteroids, or aminosalicylates. 2. Treatment of moderately to severely active ulcerative colitis in patients who have had inadequate response to at least 2 of the following: corticosteroids, sulfasalazine, mesalamine, azathioprine, 6-mercaptopurine. Use of Remicade will also be considered medically necessary for the treatment of fistulizing Crohn's disease. B vs D determination required for Remicade. HUMIRA PEN- PSORIASIS STARTER IMMUNE SUPPRESSANTS Documentation of diagnosis and past medication history. HYCAMTIN HYDROXYZINE HCL HRM - Hydroxyzine Oral For pruritus, safer alternatives are: Levocetirizine, Desloratadine. For anxiety, safer alternatives are: Buspirone, Fluoxetine, Paroxetine, Citalopram, and Venlafaxine. HYDROXYZINE HCL SOLUTION HRM - Hydroxyzine IM For anxiety, safer alternatives are: Buspirone, Fluoxetine, Paroxetine, Citalopram, and Venlafaxine. For nausea and vomiting, the safer alternative is ondansetron. HYDROXYZINE PAMOATE HRM - Hydroxyzine Oral For pruritus, safer alternatives are: Levocetirizine, Desloratadine. For anxiety, safer alternatives are: Buspirone, Fluoxetine, Paroxetine, Citalopram, and Venlafaxine. HYPERLYTE-CR IDAMYCIN PFS

20 Name Other IDARUBICIN HCL IFOSFAMIDE IFOSFAMIDE/MESNA ILARIS ILARIS BvsD Determination IMIPRAMINE HCL to New Starts HRM - Tricyclic Antidepressants Safer alternatives depend on indication. For Depression, safer alternatives are: Nortriptyline, Protriptyline, Desipramine, Amoxapine, Citalopram, Venlafaxine, Fluoxetine, Paroxetine, Sertraline, Duloxetine, and Bupropion. For headache prophylaxis, safer alternatives are: Propranolol, Topiramate, and Divalproex sodium. For headache treatment, safer alternatives are: Sumatriptan, Naratriptan, and Dihydroergotamine. For Pain/Neuropathy, safer alternatives are: Duloxetine, Lyrica, and Gabapentin. IMIPRAMINE PAMOATE to New Starts HRM - Tricyclic Antidepressants Safer alternatives depend on indication. For Depression, safer alternatives are: Nortriptyline, Protriptyline, Desipramine, Amoxapine, Citalopram, Venlafaxine, Fluoxetine, Paroxetine, Sertraline, Duloxetine, and Bupropion. For headache prophylaxis, safer alternatives are: Propranolol, Topiramate, and Divalproex sodium. For headache treatment, safer alternatives are: Sumatriptan, Naratriptan, and Dihydroergotamine. For Pain/Neuropathy, safer alternatives are: Duloxetine, Lyrica, and Gabapentin. INCIVEK INCRELEX INCIVEK INCRELEX Documentation from the medical record of diagnosis including genotype, current medication regimen, and HCV-RNA levels. Documentation of diagnosis. Documentation of lab data reflecting height standard deviation score, basal IGF-1 score, and growth hormone level. Prescribing physician must be an endocrinologist. 12 weeks Concurrent therapy with peginterferon alfa and ribavirin is required for Incivek. Height standard deviation score must be less than or equal to -3.0 AND the basal IGF-1 score must be below the lower limits of normal for the reporting lab AND the patient must have a normal or elevated growth hormone level (excluding patients with growth hormone gene deletion) AND epiphyses must be confirmed as open in patients greater than or equal to 10 years of age. INDOMETHACIN HRM - Indomethacin Safer alternatives are: Diclofenac, Diflunisal, Etodolac, Fenoprofen, Flurbiprofen, Ibuprofen, Ketoprofen, Nabumetone, Naproxen, Piroxicam, and Meloxicam.

21 Name Other INDOMETHACIN ER HRM - Indomethacin Safer alternatives are: Diclofenac, Diflunisal, Etodolac, Fenoprofen, Flurbiprofen, Ibuprofen, Ketoprofen, Nabumetone, Naproxen, Piroxicam, and Meloxicam. INFERGEN INFERGEN Documentation of genotype to determine length of therapy. 6 months INTRALIPID INVEGA TRINZA to New Starts INVEGA TRINZA excluded from Part D Documentation of diagnosis and past medication history Use of Invega Sustenna for a minimum of 4 months is required prior to use of Invega Trinza. IONOSOL- B/DEXTROSE 5% IONOSOL- MB/DEXTROSE 5% IPRATROPIUM BROMIDE IPRATROPIUM BROMIDE/ALBUTERO L SULFATE IRINOTECAN ISOLYTE-P/DEXTROSE 5% ISOLYTE-S ISTODAX IXEMPRA KIT JEVTANA KABIVEN KADCYLA

22 Name Other KALBITOR KALBITOR Kalbitor is authorized for the treatment of acute angioedema attacks with hereditary angioedema (HAE) when BOTH of the following criteria are met: 1) confirmed diagnosis of (HAE) as evidenced by a C4 level below the lower limit of normal as defined by the laboratory performing the test AND EITHER a) C1 inhibitor (C1INH) antigenic level below the lower limit of normal as defined by the laboratory performing the test or b) C1INH functional level below the lower limit of normal as defined by the laboratory performing the test AND 2) history of a moderate or severe attack (e.g., airway swelling, severe abdominal pain, facial swelling, nausea and vomiting, painful facial distortion). 16 years old and older KALYDECO KCL 0.075%/D5W/NACL 0.45% KALYDECO Patients with cystic fibrosis (CF) who are homozygous for the F508del mutation in the CFTR gene. CF mutation test documenting a G551D, G1244E, G1349D, G178R, G551S, S1251N, S1255P, S549N, or S549R mutation in the CFTR gene. 6 years of age and older KCL 0.15%/D5W/LR KCL 0.15%/D5W/NACL 0.2% KCL 0.15%/D5W/NACL 0.225% KCL 0.15%/D5W/ NACL 0.3% KCL 0.15%/D5W/NACL 0.9% KCL 0.3%/D5W/NACL 0.45% KCL 0.3%/D5W/NACL 0.9% KCL 0.3%/D5W/LR IV LAC RING KEYTRUDA KORLYM LACTATED RINGERS DEXTROSE 5% VIAFLEX KORLYM

23 Name Other LANOXIN HRM - Digoxin the physician has documented that the patient has tried digoxin 0.125mg daily or provided clinical rationale as to why the lower dose is not LANOXIN PEDIATRIC HRM - Digoxin the physician has documented that the patient has tried digoxin 0.125mg daily or provided clinical rationale as to why the lower dose is not LAZANDA TRANSMUCOSAL FENTANYL CITRATE All FDA-approved Documentation from the medical record of diagnosis. 17 years of age and older for fentanyl citrate (lozenge/troche). 18 years of age and older for Lazanda. Enrollment in the Transmucosal Immediate- Release Fentanyl (TIRF) REMS Access program. Transmucosal fentanyl products will only be covered with documentation of breakthrough cancer pain. The patient must be currently receiving and be tolerant to opioid therapy for persistent cancer pain.the patient must be enrolled in the TIRF REMS Access program. LEUPROLIDE ACETATE to New Starts LEUPROLIDE ACETATE INJ For the treatment of prostate cancer, the patient must have failure, contraindication or intolerance to Trelstar before Lupron is authorized. BvsD Determination LEVALBUTEROL LEVALBUTEROL HCL LIDOCAINE LIDOCAINE PATCH For the FDA-labeled indication of postherpetic neuralgia, no additional criteria are required to be met. For OTHER types of offlabeled neuropathic pain: the patient must have previous use and inadequate response or intolerance to any ONE neuropathic pain medication, including (but not limited to) duloxetine and Lyrica that are labeled for neuropathic pain. LIPODOX LIPODOX 50 LIPOSYN II LIPOSYN III

24 Name Other LOPREEZA HRM - Estrogens Safer alternatives to the estrogen high risk medications depend on the indication. For Hot Flashes, safer alternatives are: Estradiol Valerate, Depo-Estradiol, SSRIs, venlafaxine, gabapentin, and Femring. For Vaginal Symptoms, safer alternatives are: Premarin Cream, Estring, Femring, and Estradiol Valerate. For Bone Density, safer alternatives are: alendronate, risedronate, Evista, and Prolia. LOTRONEX LUPRON DEPOT LUPRON DEPOT-PED LOTRONEX LEUPROLIDE ACETATE INJ LEUPROLIDE ACETATE INJ Lotronex (alosetron) will not be approved for use in men, as safety and efficacy in men has not been established. must be enrolled in the prescribing program for alosetron. For the treatment of prostate cancer, the patient must have failure, contraindication or intolerance to Trelstar before Lupron is authorized. BvsD Determination For the treatment of prostate cancer, the patient must have failure, contraindication or intolerance to Trelstar before Lupron is authorized. BvsD Determination MAGNESIUM SULFATE MAKENA MAKENA Makena is authorized to reduce the risk of preterm birth when ALL of the following are met: 1) current singleton pregnancy AND 2) previous singleton spontaneous preterm birth (preterm birth defined as birth from the period of viability through week 36, 6 days gestation) AND 3) treatment will be initiated between week 16, 0 days and week 20, 6 days of gestation and not continue beyond week 36, 6 days of gestation or time of delivery (whichever occurs first). up to 21 weeks BvsD Determination MARTEN-TAB HRM - Butalbital Combinations Safer alternatives are: naproxen sodium and ibuprofen. MEGACE ES HRM - Megestrol Suspension failed dronabinol or provided clinical rationale as to why that safer formulary alternative is not

25 Name Other MEGESTROL ACETATE SUSPENSION to New Starts HRM - Megestrol Suspension failed dronabinol or provided clinical rationale as to why that safer formulary alternative is not MEGESTROL ACETATE TABS to New Starts HRM - Megestrol Tabs documented the ongoing monitoring plan for the agent. age.prior Auth MELPHALAN HYDROCHLORIDE MENEST HRM - Menest failed one (1) safer formulary alternative or provided clinical rationale why the safer formulary alternative is not appropriate for the patient. For palliative therapy of metastatic breast cancer, no trial of a formulary alternative is required. age.prior Auth For vasomotor symptoms of menopause, safer alternatives are: SSRIs, venlafaxine, gabapentin, and Femring. For vaginal symptoms of menopause, safer alternatives are: Premarin Cream, Estring, and Femring. For all other indications, no formulary alternative is required. MENOSTAR HRM - Estrogens Safer alternatives to the estrogen high risk medications depend on the indication. For Hot Flashes, safer alternatives are: Estradiol Valerate, Depo-Estradiol, SSRIs, venlafaxine, gabapentin, and Femring. For Vaginal Symptoms, safer alternatives are: Premarin Cream, Estring, Femring, and Estradiol Valerate. For Bone Density, safer alternatives are: alendronate, risedronate, Evista, and Prolia. MESNA METHAMPHETAMINE HCL METHAMPHETAMINE HCL Patient must have failure, contraindication or intolerance to one formulary alternative such as dextroamphetamine, amphetamine/dextroamphetamine, methylphenidate or dexmethylphenidate before methamphetamine hcl is authorized.

26 Name Other MIMVEY HRM - Estrogens Safer alternatives to the estrogen high risk medications depend on the indication. For Hot Flashes, safer alternatives are: Estradiol Valerate, Depo-Estradiol, SSRIs, venlafaxine, gabapentin, and Femring. For Vaginal Symptoms, safer alternatives are: Premarin Cream, Estring, Femring, and Estradiol Valerate. For Bone Density, safer alternatives are: alendronate, risedronate, Evista, and Prolia. MITOMYCIN MITOXANTRONE HCL MODAFINIL MODAFINIL Documentation of diagnosis and sleep study for the diagnosis of sleep apnea or narcolepsy. For the treatment of narcolepsy, the patient must have failure, contraindication, or intolerance to methylphenidate or dextroamphetamine sulfate before modafinil is authorized. MUSTARGEN MYCOPHENOLATE MOFETIL MYCOPHENOLIC ACID DR MYFORTIC NAVELBINE NEBUPENT NEORAL NEPHRAMINE NEUMEGA NEUMEGA Documentation of diagnosis and lab data reflecting platelet count. Certified Hematologist and/or Oncologist up to 6 months Neumega is considered medically necessary for patients that have experienced severe thrombocytopenia (platelet count less than or equal to 20,000 mcg/l) from previous chemotherapy OR patients cosidered to be at high risk for the development of severe thrombocytopenia. BvsD Determination. NIPENT

27 Name Other NORDITROPIN FLEXPRO NORDITROPIN For GHD in children or adults, Turner Syndrome, SGA, SHOX gene deletion or growth delay in children with chronic kidney disease, the patient must have failure, contraindication or intolerance to Humatrope or Saizen before coverage of Norditropin. NORDITROPIN NORDIFLEX PEN NORDITROPIN For GHD in children or adults, Turner Syndrome, SGA, SHOX gene deletion or growth delay in children with chronic kidney disease, the patient must have failure, contraindication or intolerance to Humatrope or Saizen before coverage of Norditropin. NORETHINDRONE ACETATE/ETHINYL ESTRADIOL 2.5MCG; 0.5MG HRM - Estrogens Safer alternatives to the estrogen high risk medications depend on the indication. For Hot Flashes, safer alternatives are: Estradiol Valerate, Depo-Estradiol, SSRIs, venlafaxine, gabapentin, and Femring. For Vaginal Symptoms, safer alternatives are: Premarin Cream, Estring, Femring, and Estradiol Valerate. For Bone Density, safer alternatives are: alendronate, risedronate, Evista, and Prolia. NORMOSOL-M IN D5W NORMOSOL-R NORMOSOL-R IN D5W NULOJIX NUTRILIPID 20% IV FAT EMULSION NUTROPIN NUTROPIN For GHD in children or adults, Turner Syndrome, SGA or SHOX gene deletion, the patient must have failure, contraindication or intolerance to Humatrope or Saizen before coverage of Nutropin. NUTROPIN AQ NUSPIN 5 NUTROPIN For GHD in children or adults, Turner Syndrome, SGA or SHOX gene deletion, the patient must have failure, contraindication or intolerance to Humatrope or Saizen before coverage of Nutropin. NUTROPIN AQ PEN NUTROPIN For GHD in children or adults, Turner Syndrome, SGA or SHOX gene deletion, the patient must have failure, contraindication or intolerance to Humatrope or Saizen before coverage of Nutropin. NUVIGIL NUVIGIL Documentation of diagnosis and sleep study for the diagnosis of sleep apnea or narcolepsy. For the treatment of narcolepsy, the patient must have failure, contraindication, or intolerance to methylphenidate or dextroamphetamine sulfate before Nuvigil is authorized.

28 Name Other OCTAGAM OLYSIO OLYSIO Previous failure to respond to treatment with other HCV directacting protease inhibitors or Documentation from the medical record of diagnosis including repeated courses of simeprevir genotype, current medication regimen, and HCV-RNA levels. will result in exclusion of coverage for Olysio. 12 to 24 weeks based on indication and established treatment guidelines Concurrent therapy with peginterferon alfa and ribavirin is required for Olysio (unless Olysio is being used in combination with sofosbuvir). OMNITROPE OMNITROPE For GHD in children or adults, Turner Syndrome, SGA, SHOX gene deletion or growth delay in children with chronic kidney disease, the patient must have failure, contraindication or intolerance to Humatrope or Saizen before coverage of Omnitrope. ONCASPAR ONDANSETRON HCL ONDANSETRON ODT OPDIVO ORENCIA ORENCIA IV 6 years old and older Treatment of rheumatoid arthritis (RA) and when ANY of the following criteria are met: 1) history of positive clinical response to abatacept therapy OR 2) inadequate response, intolerance, or contraindication to at least one disease-modifying anti-rheumatic drug (DMARD) (i.e., Methotrexate (MTX) Azathioprine, gold, Hydroxychloroquine, Penicillamine, Sulfasalazine) AND when the following condition is met: the patient has had failure, contraindication, or intolerance to Enbrel or Humira. ORPHENADRINE CITRATE HRM - Skeletal Muscle Relaxants documented the ongoing monitoring plan for the agent. age.prior Auth ORPHENADRINE CITRATE ER HRM - Skeletal Muscle Relaxants documented the ongoing monitoring plan for the agent. age.prior Auth

29 Name Other OXALIPLATIN PACLITAXEL PAMIDRONATE DISODIUM PARICALCITOL PEG-INTRON PEG-INTRON REDIPEN PEG-INTRON PEG-INTRON Documentation of genotype to determine length of therapy. Documentation of genotype to determine length of therapy. 6 months 6 months PERFOROMIST PERIKABIVEN PERJETA PERPHENAZINE/AMIT RIPTYLINE to New Starts HRM - Perphenazine/Amitriptyli ne Safer alternatives are: Nortriptyline, Protriptyline, Desipramine, Amoxapine, Citalopram, Venlafaxine, Fluoxetine, Paroxetine, Sertraline, Duloxetine, and Bupropion. PHENADOZ HRM - Promethazine failed one (1) safer formulary alternative if available or provided clinical rationale why the safer formulary alternative is not age.prior Auth For nausea and vomiting, the safer alternative is ondansetron (QL = 90/30). For perennial and seasonal allergic rhinitis, safer alternatives are: levocetirizine and desloratadine. For any other indications, trial of a formulary alternative is not required. PHYSIOLYTE PHYSIOSOL IRRIGATION PLASMA-LYTE A PLASMA-LYTE-148

30 Name Other PLASMA-LYTE-56/D5W POTASSIUM CHLORIDE POTASSIUM CHLORIDE 0.15% /NACL 0.45% VIAFLEX POTASSIUM CHLORIDE 0.15% D5W/NACL 0.33% POTASSIUM CHLORIDE 0.15% D5W/NACL 0.45% POTASSIUM CHLORIDE 0.15%/NACL 0.9% POTASSIUM CHLORIDE 0.22% D5W/NACL 0.45% POTASSIUM CHLORIDE 0.3%/ NACL 0.9% POTASSIUM CHLORIDE 0.3%/D5W PREFEST HRM - Estrogens Safer alternatives to the estrogen high risk medications depend on the indication. For Hot Flashes, safer alternatives are: Estradiol Valerate, Depo-Estradiol, SSRIs, venlafaxine, gabapentin, and Femring. For Vaginal Symptoms, safer alternatives are: Premarin Cream, Estring, Femring, and Estradiol Valerate. For Bone Density, safer alternatives are: alendronate, risedronate, Evista, and Prolia. PREMARIN HRM - Estrogens Safer alternatives to the estrogen high risk medications depend on the indication. For Hot Flashes, safer alternatives are: Estradiol Valerate, Depo-Estradiol, SSRIs, venlafaxine, gabapentin, and Femring. For Vaginal Symptoms, safer alternatives are: Premarin Cream, Estring, Femring, and Estradiol Valerate. For Bone Density, safer alternatives are: alendronate, risedronate, Evista, and Prolia. PREMASOL

31 Name Other PREMPHASE HRM - Estrogens Safer alternatives to the estrogen high risk medications depend on the indication. For Hot Flashes, safer alternatives are: Estradiol Valerate, Depo-Estradiol, SSRIs, venlafaxine, gabapentin, and Femring. For Vaginal Symptoms, safer alternatives are: Premarin Cream, Estring, Femring, and Estradiol Valerate. For Bone Density, safer alternatives are: alendronate, risedronate, Evista, and Prolia. PREMPRO HRM - Estrogens Safer alternatives to the estrogen high risk medications depend on the indication. For Hot Flashes, safer alternatives are: Estradiol Valerate, Depo-Estradiol, SSRIs, venlafaxine, gabapentin, and Femring. For Vaginal Symptoms, safer alternatives are: Premarin Cream, Estring, Femring, and Estradiol Valerate. For Bone Density, safer alternatives are: alendronate, risedronate, Evista, and Prolia. PRIALT PRIVIGEN PROCALAMINE PROCRIT HEMATOPOIETICS For the indication of anemia, documentation of Hemoglobin less than 11, Hematocrit, transferrin saturation greater than 20%, and ferritin levels greater than 100 obtained over the last 3 months. 6 months BvD Determination. Patients must also have failure, contraindication or intolerance to Procrit or Aranesp before Epogen will be authorized. PROGRAF PROLASTIN-C Alpha-1 Proteinase Inhibitor Therapy All FDA-approved excluded from part D. Intravenous alpha1-proteinase inhibitor (human) is authorized for the treatment of congenital alpha1-proteinase inhibitor deficiency-associated lung disease when all of the following criteria are met: 1) alpha1-antitrypsin (AAT) concentration less than 80mg/dl or less than 11 micromolar and 2) obstructive lung disease as defined by a forced expiratory volume in one second (FEV1) of 30 to 65% of predicted or a rapid decline in lung function defined as a change in FEV1 of greater than 120ml per year. BvsD Determination. PROLEUKIN PROMETHAZINE HCL HRM - Promethazine failed one (1) safer formulary alternative if available or provided clinical rationale why the safer formulary alternative is not age.prior Auth For nausea and vomiting, the safer alternative is ondansetron (QL = 90/30). For perennial and seasonal allergic rhinitis, safer alternatives are: levocetirizine and desloratadine. For any other indications, trial of a formulary alternative is not required.