Drug List Limitations, Exclusions and Preauthorization Criteria

Save this PDF as:
 WORD  PNG  TXT  JPG

Size: px
Start display at page:

Download "Drug List Limitations, Exclusions and Preauthorization Criteria"

Transcription

1 Blue Cross and Blue Shield of New Mexico (BCBSNM) provides coverage of many drugs for our members. Effective communication about specific drug limitations is important for consistent benefit administration and customer satisfaction. The following information includes the drug exclusions and preauthorization criteria for the Blue Cross Community Centennial prescription drug plan. We do our best to update this document on a regular basis, but not all drugs that require preauthorization may be listed. Because indications and dosing recommendations are subject to change, please consult the product package insert for the most current prescribing information. Coverage for any drug may require review to assess proper utilization, quality, therapy, medical appropriateness, and costs per NMAC regulations. Reasons for coverage denials may include, but are not limited to, over-utilization, under-utilization, therapeutic duplication, drug-to-disease and drug-to-drug interactions, incorrect drug dosage or duration of treatment, and clinical abuse or misuse. Last revised December 2015 Table of Contents Select a category below to access information. Medication Therapy Index: Alphabetic list of brand-name drugs and their generic equivalents Drug Limitations: Specialty Pharmacy Program and Step Therapy Drug Exclusions: Medications for Weight Loss, Erectile Dysfunction, Infertility, Hair Loss, Cosmetic, Investigational Drugs, Drugs for International Travel, Compounded Medications Drug Preauthorization: Medications primarily acquired at retail pharmacies that require preauthorization 12/15 Page 1 of 41 rx_pa_criteria_medicaid_nm.doc

2 Medication Therapy Index All Listed Medications Require Clinical Review Search Tip: For fast look up, use Control F to find drugs within this document. Brand Name ABILIFY MAINTENA ABSTRAL ACTIQ ADCIRCA AFINITOR AMITIZA AMPYRA ANDRODERM, ANDROGEL, AXIRON ATRALIN AUBAGIO AVITA AVONEX BETASERON BYETTA Buprenorphine-Opioid Combinations Generic Name aripiprazole fentanyl citrate fentanyl citrate tadalafil everolimus lubiprostone dalfampridine testosterone tretinoin teriflunomide tretinoin interferon Beta-1a interferon Beta-1b exenatide CAYSTON aztreonam CIMZIA certolizumab pegol COPAXONE glatiramer COPEGUS ribavirin DAKLINZA daclatasvir Doxycycline and Minocycline BRANDED products (ADOXA, ALODOX, AVIDOXY, DORYX, MONODOX, ORACEA, ORAXYL, PERIOSTAT, VIBRAMYCIN, VIBRA-TABS, CLEERAVUE-M, DYNACIN, MINOCIN, MINOCIN PAC, SOLODYN) ENBREL etanercept Enteral Feeding products Enteral feeding products may be covered if prior authorization criteria is met and are limited to a 30-day supply during any 30-day period. A copay will apply IF the member has a copay. (SCHIP, WDI). EXALGO hydromorphone extended release EXJADE EXTAVIA FENTORA FORTEO FORTESTA GENOTROPIN degerasirox interferon beta-1b fentanyl citrate teriparatide testosterone somatropin 12/15 Page 2 of 41 rx_pa_criteria_medicaid_nm.doc

3 Brand Name GILENYA GLEEVEC Growth Hormones: ACCRETROPIN, GENOTROPIN, HUMATROPE, NORDITROPIN, NUTROPIN (AQ), NUTROPIN, OMNITROPE, SAIZEN, SEROSTIM, TEV-TROPIN, ZORBTIVE HARVONI HEPATITIS C Therapies, Provider Checklist HUMATROPE HUMIRA Injectable Hypercholesterolemia Drugs (PCSK Inhibitors): PRALUENT, REPATHA Injectable Long-Acting Antipsychotics: ABILIFY MAINTENA, INVEGA SUSTENNA, INVEGA TRINZA, RISPERDAL CONSTA, ZYPREXA RELPREVV INTRON-A INVEGA SUSTENNA INVEGA TRINZA KINERET KUVAN LAMISIL LAZANDA LETAIRIS LINZESS LOTRONEX MORPHINE EQUIVALENT DOSE NEXAVAR NORDITROPIN NUTROPIN, NUTROPIN (AQ) OLYSIO OMNITROPE ONSOLIS Oral Disease Modifying Multiple Sclerosis Therapies: GILENYA, AUBAGIO, TECFIDERA PEGASYS Generic Name fingolimod imatinib mesylate somatropin ledipasvir + sofosbuvir somatropin adalimumab alirocumab, evolocumab aripiprazole, paliperidone palmitate, risperidone, olanzapine interferon alfa 2b paliperidone palmitate paliperidone palmitate anakinra sapropterin dihydrochloride terbinafine fentanyl nasal spray ambrisentan linaclotide alosetron hcl various opioids sorafenib somatropin somatropin simeprevir somatropin fentanyl buccal soluble film fingolimod, teriflunomide, dimethyl fumarate peginterferon alfa-2a and alfa 2b 12/15 Page 3 of 41 rx_pa_criteria_medicaid_nm.doc

4 Brand Name PEG-INTRON PLEGRIDY PRADAXA PRALUENT PROMACTA PULMOZYME REBETOL REBIF REPATHA RETIN-A REVATIO REVLIMID RIBASPHERE RIBATAB RISPERDAL CONSTA SAIZEN SANDOSTATIN SEROSTIM SIMPONI SOVALDI SPRYCEL STRATTERA STRIANT SUTENT TARCEVA TASIGNA TAZORAC TECFIDERA TECHNIVIE TEMODAR TESTIM Testosterone: ANDRODERM, ANDROGEL, AXIRON, FORTESTA, STRIANT, TESTIM TEV-TROPIN THALOMID Generic Name peginterferon alfa-2a and alfa 2b peginterferon beta-1a dabigatran alirocumab eltrombopag dornase alfa ribavirin interferon beta 1a evolocumab tretinoin sildenafil citrate lenalidomide ribavirin ribavirin risperidone somatropin octreotide somatropin golimumab sofosbuvir dasatinib atomoxetine testosterone sunitinib erlotinib nilotinib tazarotene topical gel dimethyl fumarate ombitasvir/paritaprevir/ritonavir temozolomide testosterone testosterone somatropin thalidomide 12/15 Page 4 of 41 rx_pa_criteria_medicaid_nm.doc

5 Brand Name TRACLEER TRETIN-X TYKERB TYVASO VENTAVIS VFEND VIEKIRA PAK VIVITROL XELODA XENAZINE XIFAXAN XYREM ZORBTIVE ZORTRESS ZYPREXA RELPREVV ZYVOX Generic Name bosentan tretinoin lapatinib treprostinil iloprost voriconazole ombitasvir, paritaprevir, ritonavir, dasabuvir naltrexone capecitabine tetrabenazine rifaximin sodium oxybate somatropin everolimus olanzapine linezolid 12/15 Page 5 of 41 rx_pa_criteria_medicaid_nm.doc

6 Drug List Limitations The following limitations apply to the prescription benefit: Specialty Pharmacy Program Specialty medications are used to treat serious or chronic conditions such as cancer, multiple sclerosis, pulmonary hypertension, hepatitis, and rheumatoid arthritis. Specialty medications are available in both injectable and oral forms; these are intended to be administered by a patient or family member. Specialty medications are dispensed by a specialty pharmacy provider and limited to a 30-day supply. All Specialty Pharmacy drugs require preauthorization. Please check the Drug List. Step Therapy Requires the use of a generic drug within the same drug class be tried and failed before a branded product may be used. Examples of Step Therapies include: 4 The use of generic cholesterol lowering drugs (simvastatin, lovastatin, pravastatin, atorvastatin) before the branded drug product (CRESTOR) 4 The use of generic omeprazole, pantoprazole, lansoprazole, rabeprazole for gastroesophageal reflux disease (GERD) before the branded drug products NEXIUM, DEXILANT) 4 The use of a preferred blood glucose test strip (ACCU-CHEK, CONTOUR, OR BREEZE) before other brands of test strips For a complete list of Step Therapy medications, see the Drug List. Quantity Limits Specific drug quantity limits are identified in the preface of the Drug List. Requests for larger quantities are to be referred to the Blue Cross Community Centennial Pharmacy Department for review and must be supported by clinical documentation. Generics First Blue Cross Community Centennial is a generics first program. When possible, members must use at least two generic products available on the preferred drug list before a brand-name product will be covered. In some cases, members may be required to use all generic therapeutic alternatives before a brand-name product will be covered. 12/15 Page 6 of 41 rx_pa_criteria_medicaid_nm.doc

7 Drug List Exclusions Certain classes of medications are excluded from the prescription drug benefit and, therefore, are not covered. Examples of common exclusions are drugs for: Drug Class Representative Drugs in Class Benefit Coverage Drugs used for weight loss: Drugs used to treat erectile dysfunction: Drugs to treat infertility: Phentermine, IONAMIN, ADIPEX-P, or PRO- FAST (SA, HS, SR) Benzphetamine, DIDREX Phendimetrazine, BONTRIL (PDM, SR), MELFIAT-105, PRELU-2 Diethylpropion XENICAL, ALLI (OTC) (orlistat) VIAGRA Alprostadil, MUSE, EDEX, CAVERJECT LEVITRA CIALIS STAXYN STENDRA Ganirelix FACTRL (gonadorelin) Chorionic Gonadotropin, PROFASI, CHORON 10, GONIC, NAVAREL, PREGNYL FOLLISTIM AQ (follitropin beta) GONAL-F (follitropin alfa) BRAVELLE (urofollitropin) MENOPUR, REPRONEX (menotropins) Clomiphene, CLOMID, SEROPHENE, MILOPHENE Excluded Excluded Excluded Drugs to treat hair loss: Drugs considered cosmetic: PROPECIA (Finasteride) ROGAINE (monoxadil) Tretinoin, RENOVA, RETIN-A, ALTINAC VANIQA (eflornithine) Hydroquinone (various) EGRIFTA (tesamorelin) Excluded Excluded 12/15 Page 7 of 41 rx_pa_criteria_medicaid_nm.doc

8 Drug Class Representative Drugs in Class Benefit Coverage Drugs for international travel: Non-formulary drugs: Compounded medications: Drugs considered experimental and investigational: Drugs Excluded by Federal Regulation Commerciallyavailable Food Alternatives LARIAM/mefloquine MALARONE (no generic) VIVOTIF BERNA (no generic) Various Various Various Drugs not approved as effective by the FDA (i.e., DESI drugs) Various Excluded Preauthorization required BCBSNM covers prescriptions written for traditional compounded drugs (medications with at least one ingredient that is a prescription drug) for Medicaid members. BCBSNM does NOT cover compounds that contain drugs or combinations of drugs that have not been approved by the FDA. Bulk powders used in compounding are not FDA approved and are not covered. Excluded Excluded Excluded Coverage does not include low- or sodium-free foods, lowor fat-free foods, low- or sugarfree foods, low- or high-calorie foods for weight loss or weight gain, or alternative foods due to food allergies or intolerance. 12/15 Page 8 of 41 rx_pa_criteria_medicaid_nm.doc

9 Drug Preauthorization Requests for drug preauthorization are to be directed to the Blue Cross Community Centennial Pharmacy Department. Changes to the list are published in the Blue Review provider newsletter and on the BCBSNM website ( Current BCBSNM Medical Policy regarding off-label use of FDA approved drugs as prescribed by a physician to treat chronic, disabling, or life-threatening illnesses may be considered medically necessary when supported by robust clinical research that appears in peer-reviewed literature and is recognized by standard reference compendia specific for the indication in question. New medications often will not have criteria developed. Available literature is frequently limited; therefore, coverage will be restricted to approved FDA indications only. All requests for offlabel use must be forwarded to the Blue Cross Community Centennial Pharmacy Department for review. BCBSNM allows for certain off-label uses of drugs when the off-label use has reputable medical literature supporting its safe and effective use. Use the following criteria in evaluating use of medication off label : Drug must have been approved by the FDA for at least one indication Must be prescribed by a participating licensed health care provider within his/her scope of practice Drugs in clinical phase I or II trials are considered investigational/experimental and, therefore, not a covered benefit Note: Not all medications requiring preauthorization may appear on the list. Please Note: For all medications on the preauthorization list: Hypersensitivity to any of the medications is a contraindication for use. Inclusion in the list by itself does not imply that the drug will be approved. Uses other than those defined in the criteria must meet the BCBSNM criteria for approval of new technologies and off-label use. Authorization duration may be different than stated in the criteria if warranted by individual circumstances in the reviewer's professional judgment. New members may be eligible for a 30-day transition fill for medications requiring preauthorization Satisfaction of stated criteria does not guarantee approval as other program requirements or individual circumstances may, in the exercise of the reviewer's professional judgment, warrant the application and evaluation of additional criteria. 12/15 Page 9 of 41 rx_pa_criteria_medicaid_nm.doc

10 Medications Requiring Preauthorization Primarily Acquired at Retail Pharmacies ACTIQ transmucosal (fentanyl citrate), FENTORA buccal tablet (fentanyl citrate), ONSOLIS (fentanyl buccal soluble film), ABSTRAL sublingual tablet (fentanyl citrate), or LAZANDA (fentanyl nasal spray) Treatment of: Breakthrough pain control for oncology patients ONLY Tolerant of opioid therapy Prescribed by either oncologist or pain management specialist Maximum Daily Dose: 4 doses per day Duration: 6 months (quantity limited to 120 units per month) Abuse potential, fatal overdose due to respiratory depression, fatal pediatric poisoning ADCIRCA (tadalafil) Documented Pulmonary Arterial Hypertension (PAH) Concurrent therapy limited to any two agents at a time (LETAIRIS, FLOLAN, REVATIO/VIAGRA/ADCIRCA, TRACLEER, VENTAVIS) Usual Dose: 40mg (two 20mg tablets) once daily. Dividing the dose over the course of the day is NOT recommended. 12/15 Page 10 of 41 rx_pa_criteria_medicaid_nm.doc

11 AFINITOR (everolimus) Advanced, hormone receptor positive, HER-2 negative breast cancer in postmenopausal women: In combination with exemestane after failure of treatment with letrozole or anastrozole PNET (Progressive neuroendocrine tumors of pancreatic origin): For unresectable, locally advanced, or metastatic tumors Advanced renal cell carcinoma: For the treatment of patients with advanced renal cell carcinoma after failure of treatment with sunitinib (SUTENT) or sorafenib (NEXAVAR) Renal angiomyolipoma and tuberous sclerosis complex: For patients not requiring immediate surgery Subependymal giant cell astrocytoma (SEGA) in pediatric and adult patients with tuberous sclerosis complex: For patients that require therapeutic intervention, but cannot be curatively resected Usual dose: 10mg once daily (for advanced PNET, advanced-hormone-receptor positive breast cancer, advanced renal cell carcinoma, and renal angiomyolipoma with tuberous sclerosis complex); initial dosing for SEGA is based upon body surface area (4.5mg/m 2) and subsequent dosage adjustments are based upon therapeutic drug monitoring. Note: For advanced SEGA only (AFINITOR): 3 months initial, then evaluate changes in SEGA volume. May be approved for 6 months thereafter. AMITIZA (lubiprostone) Chronic Idiopathic Constipation (CIC) Opioid-induced Constipation in Adults with chronic non-cancer pain (OIC) Treatment of Irritable Bowel Syndrome with constipation in women 18 years of age an older (IBS-C) AND Provider has supplied documentation that at least 2 OTC laxatives AND lactulose have been tried for 3 months without relief Usual Dose: CIC and OIC: 24 mcg twice daily IBS-C: 8 mcg twice daily Duration: 3 months initial, then evaluate response 12/15 Page 11 of 41 rx_pa_criteria_medicaid_nm.doc

12 AMPYRA (dalfampridine) Multiple Sclerosis with documentation that patient is ambulatory AND œ Prescriber is a neurologist or has consulted a neurologist AND œ Patient is 18 years of age or older AND œ The patient is receiving concurrent therapy with a disease modifying product, if indicated AND œ There is documentation of significant limitations to activities of daily living related to slow ambulation AND œ Baseline walking speed must be provided (using the 25-foot walk test, with a timed speed between 8 and 45 seconds). Re-authorizations (after at least 2 months of therapy) will require documentation that walking speed (using the 25-foot walk test) has improved at least 20% from baseline. œ Contraindicated in patients with a history of seizure or moderate-severe renal impairment (CrCl less than 50mL/min) Usual Dose: 10mg twice daily. No additional benefit was demonstrated at doses greater than 10mg twice daily and adverse reactions and discontinuations because of adverse events were more frequent at higher doses. Duration: Initial request: 3 months; Renewal: 12 months only with documented 20% improvement in walking speed AVONEX (interferon beta-1a), BETASERON (interferon beta-1b),copaxone (glatiramer), EXTAVIA (interferon beta-1b), PLEGRIDY (peginterferon beta-1a), REBIF (interferon beta-1a) Relapsing, Remitting Multiple Sclerosis (RRMS only) Usual Dose: AVONEX: 30mcg IM once weekly (pkg of 4 pre-filled syringes) BETASERON: 0.25mg SQ every other day; titrated from mg QOD to 0.25mg QOD over a 6-week period COPAXONE: 20mg SQ once daily (pkg of 30 pre-filled syringes) EXTAVIA: 0.25mg SQ every other day; titrated from mg QOD to 0.25mg QOD over a 6-week period (pkg of 15 blister units, each containing a single use lyophilized powder vial, pre-filled diluent syringe, alcohol prep pads, vial adapter with needle) PLEGRIDY: 64mcg SQ on day 1, 94 mcg SQ on day 15, maintenance of 125 mcg SQ every 14 days beginning on day 29. REBIF: 22mcg or 44mcg SQ 3 times weekly (pkg of 12 pre-filled syringes) 12/15 Page 12 of 41 rx_pa_criteria_medicaid_nm.doc

13 Buprenorphine-Opioid Combinations Acute Pain, such as that related to surgery œ Ideally, buprenorphine should be discontinued 1-2 days prior to surgery œ Authorization for a short-acting opioid will be limited to a quantity sufficient to cover the acute pain episode (7-10 days of therapy) Usual Dose: Varies Duration: One-time fill Note: Alternatively, patients who are receiving buprenorphine for opioid replacement therapy AND who experience acute pain episodes can be treated with an increased dose of buprenorphine for a short period of time (7-10 days of therapy). BYETTA (exenatide) Note: VICTOZA is the preferred product in this class (requires step therapy through an oral antidiabetic agent) Type 2 Diabetes AND œ Monotherapy or adjunct therapy with a thiazolidinedione (TZD), metformin, sulfonylureas, and/or Lantus/Levemir but have not achieved adequate glycemic control (A1C>7) œ Metformin is recommended as first-line therapy Usual Dose: Initiate at 5mcg twice daily; increase to 10mcg twice daily after 1 month based on response Note: Exenatide is not a substitute for insulin. Exenatide should not be used in patients with Type 1 Diabetes or for the treatment of diabetic ketoacidosis, as it would not be effective in these settings. The concurrent use of exenatide with short-acting (prandial) insulin has not been studied and cannot be recommended. 12/15 Page 13 of 41 rx_pa_criteria_medicaid_nm.doc

14 CAYSTON (aztreonam) Cystic Fibrosis in patients with documented evidence of colonization with Pseudomonas Aeruginosa AND œ Indicated for use in patients 7 years of age and older with FEV-1 of 25% to 75% predicted œ Must be administered ONLY with the Altera Nebulizer System œ Treatment must be preceded by use of an inhaled beta-agonist œ NOT for use in combination with TOBI; If alternating with TOBI, send to apharmacist for review Usual Dose: One inhaled dose (1 single-use vial and 1 ampule of diluent) 3 times daily for 28 days (followed by 28 days off Cayston therapy) Duration: 6 months CIMZIA (certolizumab pegol) Note: HUMIRA is the preferred product in this class. Crohn s Disease AND prior failure/intolerance/contraindication to conventional therapy (oral aminosalicylates, topical mesalamine, oral corticosteroids, or immunomodulators, such as azathioprine or cyclosporine) Usual Dose for Crohn s Disease: 400mg (two 200mg SQ doses) at weeks 0, 2, 4, followed by 400mg every 4 weeks Rheumatoid or Psoriatic Arthritis AND prior failure/intolerance/contraindication with at least 1 DMARD (such as methotrexate) Usual Dose for Rheumatoid and Psoriatic Arthritis: 400mg (two 200mg SQ doses) at weeks 0, 2, 4, followed by 200mg every other week (400mg every 4 weeks can be considered for maintenance dosing) Ankylosing Spondylitis AND prior treatment with at least 2 NSAIDS after 3 months use of each Usual Dose for Ankylosing Spondylitis: 400mg (two 200mg SQ doses) at weeks 0, 2, 4, followed by 200mg every other week (400mg every 4 weeks can be considered for maintenance dosing) Note: Initial dose may be billed through the Medical benefit, but subsequent doses should be routed through the Pharmacy benefit Risk of serious infection, risk of malignancies in children and adolescents 12/15 Page 14 of 41 rx_pa_criteria_medicaid_nm.doc

15 Doxycycline and Minocycline BRANDED products (ADOXA, ALODOX, AVIDOXY, DORYX, MONODOX, ORACEA, ORAXYL, PERIOSTAT, VIBRAMYCIN, VIBRA-TABS, CLEERAVUE-M, DYNACIN, MINOCIN, MINOCIN PAC, SOLODYN) Moderate to severe Acne Vulgaris, Acne Rosacea (for ORACEA), adjunctive therapy to scaling and root planning in adults with periodontitis (for PERIOSTAT) AND Therapeutic failure of oral generic formulary alternatives (regular-release minocycline, tetracycline, doxycycline, demeclocycline) Usual Dose: Varies by product Duration: 3 months ONLY (except for ORACEA, which can be approved for up to 4 months AND PERIOSTAT, which can be approved for up to 9 months) ENBREL (etanercept) Note: HUMIRA is the preferred product in this class. Moderate to severe Rheumatoid Arthritis (RA), Polyarticular Juvenile Idiopathic Arthritis in patients 2 years of age and older, Psoriatic Arthritis Ankylosing Spondylitis: trial/failure of 2 NSAIDs after 3 months use of each Moderate to severe chronic Plaque Psoriasis by rheumatologist and history of topical steroids and methotrexate, cyclosporine, oral retinoids, OR UVB/PUVA and affected BSA>10% AND therapeutic failure of adequate trial of at least one of the following: PLAQUENIL (hydroxychloroquine) SOLGANAL or RIDAURA (gold) Methotrexate IMURAN (azathioprine) CUPRIMINE (penicillimine) AZULFIDINE(sulfasalazine) ARAVA (leflunomide) Usual Dose: Rheumatoid and Psoriatic Arthritis: 50mg once weekly (with or without methotrexate) Polyarticular Juvenile Idiopathic Arthritis: 0.8mg/kg weekly to a maximum of 50mg per week Psoriasis: 50mg twice weekly for 3 months, then 50mg once weekly Ankylosing Spondylitis: 50mg once weekly Risk of serious infections; risk of malignancies in children and adolescents 12/15 Page 15 of 41 rx_pa_criteria_medicaid_nm.doc

16 Enteral Feeding Products (Nutritional Supplements) Nonprescription enteral nutritional products and special medical foods only when: Delivered by a medically necessary enteral access tube that has been surgically placed (e.g., gastrostomy, jejunostomy) OR Meeting the definition of special medical foods used to treat and to compensate for the metabolic abnormality of persons with genetic inborn errors of metabolism in order to maintain their adequate nutritional status OR When medically necessary to correct or ameliorate physical illnesses or conditions in an eligible member under the age of 21 Supply considerations: Benefits are limited to a 30-day supply during any 30-day period Duration: 12 months EXALGO (hydromorphone extended release) Diagnosis of : Moderate to severe pain in opioid-tolerant patients requiring continuous analgesia for an extended period of time AND Have failed or are intolerant of previous preferred long-acting narcotic analgesics (such as morphine sulfate ER, methadone, or fentanyl patch) Usual Dose: 8 64mg once daily Abuse Potential, life-threatening respiratory depression, accidental exposure 12/15 Page 16 of 41 rx_pa_criteria_medicaid_nm.doc

17 EXJADE (deferasirox) Chronic iron overload due to blood transfusions in patients 2 years of age and older Chronic iron overload due to non-transfusion-dependent thalassemia (NTDT) in patients 10 years of age and older and with a liver iron concentration of at least 5 mg Fe per gram of dry weight and a serum ferritin of greater than 300 mcg/l Usual Dose blood transfusion patients: Weight-based; 20 mg/kg once daily. Dose may be increased to 30 mg/kg when administered with potent UGT inducers (rifampicin, phenytoin, phenobarbital, or ritonavir) or with cholestyramine. Maximum recommended dose is 40mg/kg for this indication. Usual Dose NTDT patients: Weight-based, 10mg/kg once daily. May titrate up to 20mg/kg daily max dose. Hepatic or renal failure; gastrointestinal hemorrhage FORTEO (teriparatide) Osteoporosis in postmenopausal women who are at high risk for fracture (defined as a T-score of -2.5 or lower). This includes women with a history of osteoporotic fracture, or who have multiple risk factors for fracture. Primary or Hypogonadal Osteoporosis in men who are at high risk for fracture; treatment to increase bone mass. This includes men with a history of osteoporotic fracture, or who have multiple risk factors for fracture. Glucocorticoid-induced Osteoporosis in men and women at high risk for fracture AND Have failed or are intolerant of previous osteoporosis therapy (FOSAMAX, ACTONEL, BONIVA, SKELID, EVISTA, MIACALCIN) Usual Dose: 20mcg SQ once daily Duration: 12 months; maximum therapy of 24 months Potential risk of osteosarcoma 12/15 Page 17 of 41 rx_pa_criteria_medicaid_nm.doc

18 GLEEVEC (imatinib mesylate) Philadelphia Chromosome positive Chronic Myeloid Leukemia (CML) Philadelphia Chromosome positive Acute Lymphoblastic Leukemia (ALL) in adult and pediatric patients Myelodysplastic/Myeloproliferative Disease associated with PDGFR (platelet-derived growth factor receptor) gene re-arrangementskit-positive unresectable and/or metastatic malignant gastrointestinal stromal tumors (GIST); adjuvant treatment of adult patients following resection of KIT-positive GIST Adult Aggressive Systemic Mastocytosis (ASM) without the D816V C-KIT mutation or with C-KIT mutational status unknown Dermatofibrosarcoma Protuberans (DFSP) Hypereosinophilic Syndrome (HES) and/or Chronic Eosinophilic Leukemia (CEL) Myelodysplastic/Myeloproliferative diseases Usual Dose: Varies according to diagnosis, but generally mg daily Growth Hormones HUMATROPE, GENOTROPIN, NORDITROPIN, NUTROPIN (AQ), NUTROPIN, OMNITROPE, SAIZEN, SEROSTIM, TEV-TROPIN, ZORBTIVE Note: OMNITROPE is the preferred product in this class In Children Panhypopituitarism Turner s Syndrome Prader-Willi Syndrome Growth failure associated with Noonan Syndrome Children with Chronic Renal Insufficiency Short Stature Homeobox (SHOX) containing gene deficiency; for the treatment of short stature or growth failure in children with SHOX deficiency whose epiphyses are not closed Growth hormone deficiency in children: œ Fail two provocative growth hormone stimulation tests (L-dopa, clonidine, glucagon, propranolol, arginine, or insulin Peak<10ng/ml) (24-hour monitoring of IGF or IGFBP are considered experimental) OR œ Documentation of growth hormone deficiency resulting from a destructive lesion of the pituitary, a medical treatment (such as ablative pituitary radiation or surgery) or trauma AND œ Height at least 2 standard deviations below the mean over one year or more OR more than 1.5 standard deviations sustained over two years œ Growth velocity of <5.0cm/yr AND œ Bone age (determined by standard x-ray techniques) of 2 standard deviations below chronological age Continued on page 19 12/15 Page 18 of 41 rx_pa_criteria_medicaid_nm.doc

19 Growth Hormones, Continued In Adults Growth hormone deficiency in adults: œ Have no contraindications to therapy; active malignancy, benign intracranial hypertension, proliferative or pre-proliferative diabetic retinopathy AND œ Fail 2 provocative growth hormone stimulation tests (insulin is the preferred test in most adults), each with a peak value < 5ng/ml OR œ Documentation of growth hormone deficiency resulting from a destructive lesion of the pituitary, a medical treatment (such as ablative pituitary radiation or surgery) or trauma OR œ Growth hormone deficiency during childhood with growth hormone deficiency syndrome confirmed as an adult before replacement therapy with somatropin is started. Panhypopituitarism AIDS wasting or Cachexia Full-thickness skin loss associated with third degree burn NOS Short Bowel Syndrome Usual Dose: Weight-based, according to diagnosis Duration: 6 months Growth hormone approved through Specialty Pharmacy Program providers only. For continuation of therapy every six months: Must be compliant with therapy For children with growth hormone deficiency: Usually discontinued when growth velocity is less that 2cm/yr, when epiphyseal fusion occurs, or when height reaches 5th percentile of expected adult height. 12/15 Page 19 of 41 rx_pa_criteria_medicaid_nm.doc

20 HEPATITIS C Therapies DAKLINZA (daclatasvir), HARVONI (ledipasvir + sofosbuvir), OLYSIO (simeprevir), SOVALDI (sofosbuvir), TECHNIVIE (ombitasvir/paritaprevir/ritonavir), VIEKIRA PAK (ombitasvir, paritaprevir, and ritonavir tablets; dasabuvir tablets) Note: HARVONI is the preferred product in this class Chronic Hepatitis C and genotype indicated for requested therapy in accordance with current AASLD/IDSA Guidelines(laboratory confirmation required) AND all of the following: œ Patient is at least 17 years of age œ An appropriate treatment regimen and duration of therapy is requested as per current Guidelines œ A pre-treatment HCV-RNA lab is provided œ The patient does not have any contraindications or drug interactions as listed on the package insert for the requested therapy or therapies. AND one of the following: APRI 0.7 FIB Liver biopsy confirming METAVIR score of F2 Fibroscan Score 7.1 kpa Fibrosure Score of 0.49 Diagnosis of Cirrhosis obtained though imaging studies (MRI, CT, Ultrasound or other) Extra-hepatic manifestation of HCV to include leukocytoplastic vasculitis, type 2 or 3 essential mixed cryoglobulinemia with end-organ manifestations or kidney disease (proteinuria, nephrotic syndrome or mebranoproliferative glomerulonephritis) Decompensated Cirrhosis (ascites, variceal hemorrhage, encephalopathy, jaundice) with life expectancy of at least 12 months HIV- co-infection Hepatocellular Carcinoma (HCC) with life expectancy of at least 12 months Pre- or Post-liver transplant or other solid organ transplant Type 2 Diabetes Mellitus (insulin resistant) Debilitating fatigue impacting quality of life (e.g., secondary to extra-hepatic manifestations and/or liver disease) as documented in chart notes over prior 6 months Porphyria cutanea tarda Usual Dose/Duration: In accordance with current AASLD/IDSA Guidelines NOTE: Treatment with Harvoni for 8 weeks can be considered for treatment naïve patients without cirrhosis IF the pretreatment HCV-RNA is < 6 million IU/ml. Treatment experienced patients are those who have failed treatment with either peginterferon alfa + ribavirin OR HCV Protease Inhibitor + peginterferon alfa + ribavirin. Non-adherence to therapy will result in the preauthorization being discontinued. No additional treatments will be approved. Non-adherence is defined as failure to obtain refills in a timely manner, leading to an interruption in therapy. Upon receipt of request, BCBSNM will refer all patients to care coordination for disease management. Resistance-associated variants (RAVs) testing may be required based on AASLD guidance. Request will be denied if the patient s life expectancy is less than 12 months 12/15 Page 20 of 41 rx_pa_criteria_medicaid_nm.doc

21 HEPATITIS C Therapies, Continued Uniform New Mexico HCV Checklist for Centennial Care 1. DIAGNOSIS: Chronic Hepatitis C Infection a. Genotype Subtype (if applicable) (attach results) b. HCV RNA Level within the past 3 months: Level: Date: / / (attach results) c. Yes No Does the patient have HIV-1 coinfection or one of the following extra-hepatic manifestation of HCV Infection (if yes, circle and include documentation): Lymphoma, Vasculitis, or Renal Disease, insulin resistant DM, debilitating fatigue (documented in chart notes x 6 months), porphyria cutanea tarda. 2. ADDITIONAL REQUIRED LABS (within 3 months of request- please attach results) AST, ALT, Bilirubin, Albumin, INR, Platelet count, ANC, Hemoglobin, Creatinine 3. Yes No Patient has had or is patient being considered for LIVER TRANSPLANT? If yes, do not complete the rest of this form; just fax this form and relevant labs/records to member s Health Plan. 4. LIVER ASSESSMENT a. Yes No Does the patient have (circle all that apply) APRI >= 0.7 (F2), OR Fib-4 >= 1.45, OR METAVIR Score >= F2, OR Transient Elastography Score >= 7.1 kp (F2), OR FibroSure >= 0.49 (F2), OR radiographic imaging or physical examination findings consistent with cirrhosis (attach relevant results and notes) 5. Yes No Is patient TREATMENT EXPERIENCED? (If Yes, answer a, b & c. If No, go to 6) a. List regimen(s) patient has received in past including year and duration of therapy: b. Yes No Unknown Did patient complete treatment regimen(s)? If not, reason for discontinuation: c. What was patient s response to therapy? Unknown Relapse (post treatment SVR, then elevated HCV RNA level some time later). Non-response (HCV RNA remained detectable after complete treatment course) 6. REQUESTED MEDICATION(S) Drug: Dose: Duration: weeks Drug: Dose: Duration: weeks Drug: Dose: Duration: weeks I am agreeable to approval and use of alternative and equivalent formulary drug(s) with equal or greater SVR; please substitute and notify me. I am agreeable to approval and use of alternative drug(s), dose(s) and/or duration(s) based on current AASLD/IDSA guidance. Comments: Important Additional Recommendations: 1. If patient has alcohol or illicit drug abuse history, please refer patient to addiction specialist for counseling and treatment 2. HIV and Hepatitis A and B screening including HAV Ab, HBsAg, anti-hbs, anti-hbc, should be performed 3. Hepatitis A and Hepatitis B vaccination series should be initiated if not already completed (and patient non-immune) 4. If patient has decompensated liver disease (Child-Pugh B or C) it is recommended that treatment be co-managed with a gastroenterologist, infectious disease specialist or hepatologist, and that referral for transplant be strongly considered 5. Patients being considered for retreatment after failure of initial treatment with all-oral therapy should be considered for presentation to Project ECHO (attach notes) 12/15 Page 21 of 41 rx_pa_criteria_medicaid_nm.doc

22 HUMIRA (adalimumab) Note: HUMIRA is the preferred product in this class. Diagnosis by rheumatologist of moderate to severe: Rheumatoid Arthritis Juvenile Idiopathic Arthritis Psoriatic Arthritis AND therapeutic failure of adequate trial of at least one of the following: PLAQUENIL (hydroxychloroquine) SOLGANAL or RIDAURA (gold) Methotrexate IMURAN (azathioprine) CUPRIMINE (penicillimine) AZULFIDINE (sulfasalazine) ARAVA (leflunomide) Moderate to severe chronic Plaque Psoriasis (affected BSA > 10%), confirmed by a rheumatologist, and history of use of topical steroids AND methotrexate, cyclosporine, oral retinoids, or UVB/PUVA OR Moderate to severe Crohn s Disease or Ulcerative Colitis (confirmed by a gastroenterologist) and prior failure/intolerance/contraindication to conventional therapy (oral aminosalicylates, topical mesalamine, oral corticosteroids, or immunomodulators, such as azathioprine or cyclosporine) OR Ankylosing Spondylitis and trial/failure of 2 NSAIDS after 3 months use of each Hydradenitis Supurativa evaluated by a specialist Usual Dose: Varies according to diagnosis, but limited to 2 doses per month (every other week). Requests for weekly dosing should be referred to a pharmacist for review. Serious infections (e.g., Tuberculosis, invasive fungal infections, other opportunistic infections), Malignancy in children and adolescents 12/15 Page 22 of 41 rx_pa_criteria_medicaid_nm.doc

23 INJECTABLE LONG-ACTING ANTIPSYCHOTICS: ABILIFY MAINTENA (aripiprazole), INVEGA SUSTENNA, and INVEGA TRINZA (paliperidone palmitate), RISPERDAL CONSTA (risperidone), ZYPREXA RELPREVV (olanzapine) Schizophrenia Bipolar I Disorder (for Risperdal ONLY for use alone or in combination with lithium or valproate for maintenance therapy) AND Previous trial of oral therapy to ensure tolerance AND Documented non-compliance with oral therapy for at least 3 months or hospitalization due to noncompliance Usual Dose: ABILIFY: 400mg IM monthly, some patients may do well on lower doses INVEGA SUSTENNA: Initial doses of 254mg IM, then 156mg 2 weeks later. Recommended maintenance is 117mg monthly, but can range anywhere from 39mg-254mg INVEGA TRINZA: ONLY after successful treatment with SUSTENNA for a minimum of 4 months. INVEGA TRINZA is given once every 3 months Last Dose of SUSTENNA INITIAL DOSE OF TRINZA 78 mg 273 mg 117 mg 410 mg 156 mg 546 mg 234 mg 819 mg RISPERDAL: 25mg 50mg IM every 2 weeks ZYPREXA: 150mg 300mg IM every 2 weeks or 300mg 405mg every 4 weeks œ Zyprexa Relprevv is only available through a restricted distribution program called Zyprexa Reprevv Patient Care Program. Administration requires prescriber, health care facility, patient, and pharmacy enrollment and a minimum 3-hour patient observation period after each injection. Duration: 9 Months initial, then 12 months after assessment of compliance and lack of psych-related hospitalizations Increased mortality in elderly patients with dementia-related psychosis 12/15 Page 23 of 41 rx_pa_criteria_medicaid_nm.doc

24 INJECTABLE HYPERCHOLESTEROLEMIA DRUGS (PCSK9 Inhibitors): PRALUENT(alirocumab), REPATHA (evolocumab) Heterozygous Familial Hypercholesterolemia, Homozygous Familial Hypercholesterolemia, or Atherosclerotic Cardiovascular Disease AND Patient is on a high-intensity statin, with at least a 6-month history of adherence OR Has documented history of intolerance to at least 2 different statins or documented contraindication to use of statins AND Patient is also taking ezetimibe, with at least a 6-month history of adherence Usual Dose: PRALUENT: 75mg administered subcutaneously once every 2 weeks; may be increased to a maximum of 150mg every 2 weeks REPATHA: 140mg administered subcutaneously once every weeks OR 420 mg every once monthly Duration: 6 months, unless there is a change in dosing INTRON-A (interferon alfa 2b) Hairy Cell Leukemia AIDS-related Kaposi s Sarcoma Chronic Hepatitis B, serum HBe Ag positive (1 year of age or older for this diagnosis only) Condylomata Acuminata involving external surfaces of the genital or perianal area Non-Hodgkin s Lymphoma (clinically aggressive follicular NHL) Malignant Melanoma Note: Must be 18 years of age and older. Usual Dose: Varies according to diagnosis ; maximum therapy 2 years for Hepatitis C Fatal or life-threatening neuropsychiatric, autoimmune, ischemic, and infectious disorders 12/15 Page 24 of 41 rx_pa_criteria_medicaid_nm.doc

25 KINERET (anakinra) Moderate to severe Rheumatoid Arthritis (RA), confirmed by a rheumatologist AND the following: Not currently on ENBREL or REMICADE AND Therapeutic failure of adequate trial of at least one of the following: œ PLAGUENIL (hydroxychloroquine) œ SOLGANAL or RIDAURA (gold) œ Methotrexate œ IMURAN (azathioprine) œ CUPRIMINE (penicillimine) œ AZULFIDINE (sulfasalazine) œ ARAVA (leflunomide Note: Cryopyrin-Associated Periodic Syndromes (CAPS) Refer all requests to a pharmacist for review Usual Dose: 100mg/day SQ Duration: 6 months initial treatment, for a quantity of thirty 100mg injections per month; 12 months thereafter KUVAN (sapropterin dihydrochloride) Note: Refer all requests for KUVAN to a pharmacist for review LAMISIL (terbinafine) Fingernail Onychomycosis Duration: 6-week course of therapy; one course per lifetime as documented by BCBSNM Toenail Onychomycosis Duration: 12-week course of therapy; one course per lifetime as documented by BCBSNM Tinea Capitis (only oral granules indicated for this diagnosis) Duration: 6-week course of therapy for the treatment of Tinea Capitis in patients 4 years of age and older Usual Dose: 250mg once daily (tablets); dosage for Lamisil granules is weight-based Note: For treatment of onychomycosis, LAMISIL will not be approved if there is documentation of prior use of either itraconazole or fluconazole. 12/15 Page 25 of 41 rx_pa_criteria_medicaid_nm.doc

26 LETAIRIS (ambrisentan) Pulmonary Arterial Hypertension AND Concurrent therapy limited to any two agents at a time (LETAIRIS, FLOLAN, REVATIO/VIAGRA/ADCIRCA, TRACLEER, TYVASO, VENTAVIS), recommended in combination with ADCIRCA (tadalafil) 20mg once daily Usual Dose: Initiate at 5mg once daily; may be increased to 10mg once daily if tolerated. Doses higher than 10mg once daily have not been studied in patients with Pulmonary Arterial Hypertension. Serious risk of birth defects contraindicated in pregnancy LINZESS (linaclotide) Irritable Bowel Syndrome with Constipation (IBS-C) Chronic Idiopathic Constipation (CIC) AND Provider has supplied documentation that at least 2 OTC laxatives AND lactulose have been tried for 3 months without relief Usual Dose: IBS-c: 290 mcg once daily CIC: 145 mcg once daily Duration: 3 months initial, then evaluate response Pediatric Risk-Safety and efficacy not established in pediatric patient under the age of 18 12/15 Page 26 of 41 rx_pa_criteria_medicaid_nm.doc

27 LOTRONEX (alosetron hcl) Severe diarrhea-predominant Irritable Bowel Syndrome (IBS) ONLY IN WOMEN who have chronic IBS symptoms (generally lasting 6 months or longer) and who have not responded adequately to conventional therapy Usual Dose: Initiate at 0.5mg twice daily; may be increased to 1mg twice daily after 4 weeks if tolerated Note: Discontinue Lotronex in patients who have not had adequate control of IBS symptoms after 4 weeks of treatment with 1mg twice daily. Gastrointestinal, serious complications of constipation and ischemic colitis MORPHINE EQUIVALENT DOSE ( MED various opioids) Usual Dose: Morphine equivalent dose is, generally, limited to 240mg morphine equivalents per day. Doses greater than 240 mg MED will be approved when the following criteria are met: The patient has a diagnosis of cancer, is enrolled in hospice, or meets hospice criteria for life expectancy less than 6 months OR The patient is undergoing treatment of chronic (non-cancer) pain and ALL of the following are met œ Prescriber provides documentation of formal evaluation of the primary pain state, including diagnosis and a complete medical history that details prior pharmacologic and nonpharmacologic interventions œ The prescriber has a narcotic contract with the patient, and the patient has complied with the rules of the contract œ The New Mexico Prescription Monitoring Program ( PMP ) report for the patient is appropriate and indicates that the member is using only one provider for their controlled substance medications within the past 90 days œ The prescriber has confirmed that there is no suspicion of abuse/diversion and/or urine drug screens have been appropriate for the past 90 days, showing the presence of all prescribed substances as tested œ The prescriber has submitted clinically-sound documentation/rationale to support a higher dose œ The patient is being managed by a pain management specialist and/or in consultation with a pain management specialist œ The patient is being routinely monitored for changes in severity of pain, ability to function, and adverse effects Duration: At the discretion of the approving clinician 12/15 Page 27 of 41 rx_pa_criteria_medicaid_nm.doc

28 NEXAVAR (sorafenib) Advanced Renal Cell Carcinoma Unresectable Hepatocellular Carcinoma Locally recurrent or metastatic, progressive, differentiated thyroid carcinoma refractory to radioactive iodine treatment Usual Dose: 400mg (2 tablets) twice daily Oral Disease Modifying Multiple Sclerosis Therapies: GILENYA (fingolimod), AUBAGIO (teriflunomide), TECFIDERA (dimethyl fumarate) Relapsing Multiple Sclerosis and prior use of a biological product (AVONEX, REBIF, BETASERON, or EXTAVIA) or COPAXONE Usual Dose: GILENYA: 0.5mg orally once daily AUBAGIO: 7 or 14mg by mouth once daily TECFIDERA: 120mg by mouth twice daily initially, titrated to 240mg twice daily maintenance dose Duration: 6 months initial; then 12 months thereafter if no change in dosing AUBAGIO: Hepatotoxicity and teratogenicity 12/15 Page 28 of 41 rx_pa_criteria_medicaid_nm.doc

29 PEGASYS (peginterferon alfa-2a) and PEGINTRON (peginterferon alfa-2b) Preferred Product: PEGASYS Chronic Hepatitis C Diagnosis by gastroenterologist of Chronic Hepatitis C in patients who meet the following criteria: œ Must be used in accordance with current AASLD/IDSA guidelines Usual Dose: Pegasys: 180mcg once weekly PegIntron: 1.5mcg/kg/week (Adult); 60mcg/m 2 /week (Pediatric); 1 mcg/kg/week for monotherapy (Adult only) Duration: Will vary dependent upon individual diagnosis and treatment combination being used. Fatal or life-threatening neuropsychiatric, autoimmune, ischemic, and infectious disorders; pregnancy warning with combination ribavirin use PRADAXA (dabigatran) Note: XARELTO is the preferred product in this class (where clinically appropriate) Reduction of risk of Stroke and Systemic Embolism in patients with Non-Valvular Atrial Fibrillation (a-fib) Treatment of Deep Venous Thrombosis (DVT) and Pulmonary Embolism (PE) Reduction in risk of recurrence of DVT and PE Prophylaxis of DVT and PE following hip replacement surgery Usual Dose: between once or twice daily depending on diagnosis Duration: 6 months initial, then 12 months thereafter is no change in dosing Note: Refer requests for off-label indications to a pharmacist for review Discontinuing Pradaxa without adequate continuous anticoagulation increases risk of stroke 12/15 Page 29 of 41 rx_pa_criteria_medicaid_nm.doc

30 PROMACTA (eltrombopag) Chronic Immune (Idiopathic) Thrombocytopenic Purpura (ITP) œ Patients who have had an insufficient response to corticosteroids, immunoglobulins, or splenectomy œ Should not be used in an attempt to normalize platelet counts (maintain count above 50,000) Maximum Daily Dose: 75mg Risk of hepatotoxicity requires lab monitoring of liver function tests prior to and during therapy PULMOZYME, rhdnase (dornase alfa) Cystic Fibrosis œ Five years of age or older AND œ Baseline forced vital capacity (FVC) > 40% of predicted Usual Dose: 2.5mg once daily dosing (some patients may benefit from twice daily dosing) Duration: 12 months REBETOL, RIBASPHERE, RIBATAB, COPEGUS (ribavirin) Chronic Hepatitis C in patients with compensated liver disease and meets the following criteria: œ Must be used in accordance with current AASLD/IDSA guidelines Usual Dose: Weight-based Duration: Will vary dependent upon individual diagnosis and treatment combination being used. Note: Diagnosis must be confirmed by gastroenterologist. Will not be approved in patients with decompensated cirrhosis. Refer to BCBSNM medical director for use during pregnancy. Ribavirin monotherapy not effective for treatment of chronic Hepatitis C, Hemolytic Anemia and worsening cardiac disease, significant teratogenic and/or embryocidal effects 12/15 Page 30 of 41 rx_pa_criteria_medicaid_nm.doc

31 RETIN-A, AVITA, ATRALIN, TRETIN-X (tretinoin) (RENOVA is not a covered benefit) Acne Vulgaris in patients age > 40 years Actinic Keratosis in patients age > 40 years Usual Dose: Apply once daily at bedtime Duration: 12 months Please Note: RENOVA is not a covered benefit since it is only indicated for cosmetic purposes. REVATIO (sildenafil citrate) Pulmonary Arterial Hypertension (PAH) in adults Note: Concurrent therapy limited to any two agents at a time (LETAIRIS, FLOLAN, REVATIO/VIAGRA/ADCIRCA, TRACLEER, TYVASO, or VENTAVIS) Usual and Maximum Daily Dose: 20mg TID Note: NOT recommended for use in pediatric patients (increased mortality with increasing doses) Adding sildenafil to bosentan therapy does not result in any beneficial effect on exercise capacity REVLIMID (lenalidomide) MDS Myelodysplastic Syndrome Multiple Myeloma (combination with dexamethasone, after at least one prior therapy thalidomide) Mantle Cell Lymphoma (MCL) that has relapsed or progressed after prior treatment with bortezomib (VELCADE) and one other prior therapy. Usual Dose MDS: 10mg once daily Usual Dose Multiple Myeloma and MCL: 25mg once daily on days 1-21 of repeated 28-day cycles Note: Not recommended for the treatment of patients with CLL Duration: 6 months, acquired through FDA approved restricted distribution program REVASSIST Teratogenic effects, hematologic toxicity (neutropenia and thrombocytopenia), DVT&PE 12/15 Page 31 of 41 rx_pa_criteria_medicaid_nm.doc

32 SANDOSTATIN (octreotide)/sandostatin LAR Acromegaly Metastatic Carcinoid Tumor with severe diarrhea/flushing episodes Vasoactive Intestinal Peptide Tumors (VIPomas) with profuse watery diarrhea Usual Dose: Varies according to diagnosis Duration: 3 months initial, then 6 months thereafter Note: Sandostatin LAR will only be approved in those patients have previously received Sandostatin and have responded to and tolerated treatment. Note: Refer requests for off-label indications to a pharmacist for review SIMPONI (golimumab) Note: HUMIRA is the preferred product in this class. Ankylosing Spondylitis (AS) Psoriatic Arthritis (PsA) alone or in combination with methotrexate Ulcerative Colitis (UC) - moderate to severe with inadequate response or intolerance to prior treatment or requiring continuous steroid therapy Rheumatoid Arthritis (RA) moderate to severe in combination with methotrexate with therapeutic failure or adequate trial of at least one of the following: œ PLAQUENIL (hydroxychloroquine) œ SOLGANAL or RIDAURA (gold) œ Methotrexate œ IMURAN (azathioprine) œ CUPRIMINE (penicillimine) œ AZULFIDINE (sulfasalazine) œ ARAVA (leflunomide) Usual Dose: AS, PsA and RA: 50mg subcutaneously once monthly, UC: 200mg initial, 100mg at week 2, then 100mg every 4 weeks Note: SIMPONI is intended for use under the guidance and supervision of a health care provider. After proper training, a patient may self-inject if a health care provider determines that it is appropriate. Serious infections (e.g., Tuberculosis, invasive fungal infections, and other opportunistic infections); malignancy in children and adolescents 12/15 Page 32 of 41 rx_pa_criteria_medicaid_nm.doc

33 SPRYCEL (dasatinib) Chronic Myeloid Leukemia (CML) Acute Lymphoblastic Leukemia (ALL) Usual Dose Chronic phase: 100mg once daily Usual Dose Accelerated phase or myeloid/lymphoid blast phase: 140mg once daily Usual Dose Acute Lymphoblastic Leukemia: 140mg once daily Duration: 6 months STRATTERA (atomoxetine) Attention Deficit Hyperactivity Disorder AND at least one of the following: Trial and failure of at least 2 formulary therapeutic alternatives for ADHD Any medical history of cardiovascular disease Any history of drug abuse or addiction to stimulants Usual Dose: 40mg daily, target dose of 80mg daily, MAX 100mg daily Duration: 3 months initial, 12 months continuation if no change in dosing SUTENT (sunitinib) GI Stromal Tumor (GIST) Advanced Renal Cell Carcinoma (RCC) Progressive, well-differentiated Pancreatic Neuroendocrine Tumors (PNET) in patients with unresectable locally advanced or metastatic disease Usual Dose GIST/RCC: 50mg once daily (4 weeks of treatment followed by 2 weeks off) Usual Dose PNET: 37.5mg once daily continuously (without a schedule off-treatment period) Hepatotoxicity 12/15 Page 33 of 41 rx_pa_criteria_medicaid_nm.doc

PRIOR AUTHORIZATION PROTOCOL FOR HEPATITIS C TREATMENT

PRIOR AUTHORIZATION PROTOCOL FOR HEPATITIS C TREATMENT PRIOR AUTHORIZATION PROTOCOL FOR HEPATITIS C TREATMENT HARVONI (90mg ledipasvir/400mg sofosbuvir): tablet (PREFERRED AGENT) SOVALDI (sofosbuvir ): 400mg tablets (PREFERRED AGENT ) OLYSIO (simeprivir) PEG-INTRON

More information

Sovaldi (sofosbuvir) Prior Authorization Criteria

Sovaldi (sofosbuvir) Prior Authorization Criteria INITIAL REVIEW CRITERIA Sovaldi (sofosbuvir) Prior Authorization Criteria 1. Adult patient age 18 years old; AND 2. Prescribed by a hepatologist, gastroenterologist, infectious disease specialist, transplant

More information

HEPATITIS C THERAPY PRIOR AUTHORIZATION FORM: Page 1 of 3 Patient Information. Diagnosis Acute Hep C Chronic Hep C Hepatocellular Carcinoma

HEPATITIS C THERAPY PRIOR AUTHORIZATION FORM: Page 1 of 3 Patient Information. Diagnosis Acute Hep C Chronic Hep C Hepatocellular Carcinoma HEPATITIS C THERAPY PRIOR AUTHORIZATION FORM: Page 1 of 3 Patient Information Recipient: MA#: Date of Birth: Phone #: Body Weight: Treatment Plan Sovaldi (sofosbuvir) 400mg: Take once daily for weeks Olysio

More information

Request for Prior Authorization HEPATITIS C TREATMENTS

Request for Prior Authorization HEPATITIS C TREATMENTS IA Medicaid Member ID # Patient name DOB FAX Completed Form To 1 (800) 574-2515 Provider Help Desk 1 (877) 776-1567 Patient address Patient phone Provider NPI Prescriber name Phone Prescriber address Fax

More information

Clinical Criteria for Hepatitis C (HCV) Therapy

Clinical Criteria for Hepatitis C (HCV) Therapy Diagnosis Clinical Criteria for Hepatitis C (HCV) Therapy Must have chronic hepatitis C (HCV infection > 6 months), genotype and sub-genotype specified to determine the length of therapy; Liver biopsy

More information

Hepatitis C Treatment Criteria Commercial & Minnesota Health Care Programs

Hepatitis C Treatment Criteria Commercial & Minnesota Health Care Programs Last update: February 23, 2015 Hepatitis C Treatment Criteria Commercial & Minnesota Health Care Programs Please see healthpartners.com for Medicare coverage criteria. Table of Contents 1. Harvoni 2. Sovaldi

More information

PHARMACY PRIOR AUTHORIZATION

PHARMACY PRIOR AUTHORIZATION PHARMACY PRIOR AUTHORIZATION Hepatitis C Clinical Guideline Harvoni (sofosbuvir/ledipasvir), Sovaldi (sofosbuvir), Viekira PAK (ombitsavir, paritapravir/ritonavir, dasubavir), and Olysio (simeprevir) Authorization

More information

Clinical Criteria for Hepatitis C (HCV) Therapy

Clinical Criteria for Hepatitis C (HCV) Therapy Diagnosis Clinical Criteria for Hepatitis C (HCV) Therapy Must have chronic hepatitis C, genotype and sub-genotype specified to determine the length of therapy; Liver biopsy or other accepted test demonstrating

More information

Immune Modulating Drugs Prior Authorization Request Form

Immune Modulating Drugs Prior Authorization Request Form Patient: HPHC member ID #: Requesting provider: Phone: Servicing provider: Diagnosis: Contact for questions (name and phone #): Projected start and end date for requested Requesting provider NPI: Fax:

More information

Prior Authorization Conditions for Approval of Hepatitis C Agents

Prior Authorization Conditions for Approval of Hepatitis C Agents Prior Authorization Conditions for Approval of Hepatitis C Agents All requests for Hepatitis C Agents require a prior authorization and will be screened for medical necessity and appropriateness using

More information

July 2015 Preferred Drug List Review and Other Pharmacy Policy Changes

July 2015 Preferred Drug List Review and Other Pharmacy Policy Changes Update June 2015 No. 2015-27 Affected Programs: BadgerCare Plus, Medicaid, SeniorCare To: Blood Banks, Dentists, Federally Qualified Health Centers, Hospital Providers, Nurse Practitioners, Nursing Homes,

More information

Hepatitis C Second Generation Antivirals (Harvoni, Technivie TM, Viekira Pak ) Prior Authorization - Through Preferred Agent(s) Program Summary

Hepatitis C Second Generation Antivirals (Harvoni, Technivie TM, Viekira Pak ) Prior Authorization - Through Preferred Agent(s) Program Summary Hepatitis C Second Generation Antivirals (Harvoni, Technivie TM, Viekira Pak ) Prior Authorization - Through Preferred Agent(s) Program Summary This program applies to Health Insurance Marketplace, FlexRx

More information

MEDICAL ASSISTANCE HANDBOOK PRIOR AUTHORIZATION OF PHARMACEUTICAL SERVICES. I. Requirements for Prior Authorization of Hepatitis C Agents

MEDICAL ASSISTANCE HANDBOOK PRIOR AUTHORIZATION OF PHARMACEUTICAL SERVICES. I. Requirements for Prior Authorization of Hepatitis C Agents MEDICAL ASSISTANCE HBOOK I. Requirements for Prior Authorization of Hepatitis C Agents A. Prescriptions That Require Prior Authorization Prescriptions for Hepatitis C Agents that meet any of the following

More information

Medical Policy An independent licensee of the Blue Cross Blue Shield Association

Medical Policy An independent licensee of the Blue Cross Blue Shield Association Hepatitis C Second Generation Antivirals (2015) Page 1 of 14 Medical Policy An independent licensee of the Blue Cross Blue Shield Association Title: See also: Hepatitis C Second Generation Antivirals Through

More information

Original Policy Date

Original Policy Date MP 5.01.20 Tysabri (natalizumab) Medical Policy Section Prescription Drug Issue 12:2013 Original Policy Date 12:2013 Last Review Status/Date Local Policy/12:2013 Return to Medical Policy Index Disclaimer

More information

Medicare Part D Plans Deliver Significant Savings on Innovative, Breakthrough Medicines

Medicare Part D Plans Deliver Significant Savings on Innovative, Breakthrough Medicines Medicare Part D Plans Deliver Significant Savings on Innovative, Breakthrough Medicines Survey Finds Private Sector Negotiations Provide Both Savings and Choice, Making Government Interference Unnecessary

More information

Medical Policy An independent licensee of the Blue Cross Blue Shield Association

Medical Policy An independent licensee of the Blue Cross Blue Shield Association Hepatitis C Second Generation Antivirals Page 1 of 22 Medical Policy An independent licensee of the Blue Cross Blue Shield Association Title: Hepatitis C Second Generation Antivirals Through Preferred

More information

Co-pay assistance organizations offering assistance

Co-pay assistance organizations offering assistance Acromegaly Acute Exacerbations of Multiple Sclerosis Acute Porphyrias Advanced Idiopathic Parkinson' s Disease Age-Related Macular Degeneration www.theassistancefund.org Alcohol Dependence Alpha-1 Antitrypsin

More information

Indication: Indication: Protaxos is indicated in adults.

Indication: Indication: Protaxos is indicated in adults. Maklumat tambahan indikasi untuk upload pada laman web Year 2013 Products Approved For Additional Indication (DCA 262 28 Mac 2013) NO PRODUCT (ACTIVE INGREDIENT) 1. 1.1 EVISTA TABLET 60MG [ Raloxifene

More information

New IDSA/AASLD Guidelines for Hepatitis C

New IDSA/AASLD Guidelines for Hepatitis C NORTHWEST AIDS EDUCATION AND TRAINING CENTER New IDSA/AASLD Guidelines for Hepatitis C John Scott, MD, MSc Associate Professor, UW SoM Asst Director, Liver Clinic, Harborview Medical Center Presentation

More information

The TIRF REMS Access program is a Food and Drug Administration (FDA) required risk management program

The TIRF REMS Access program is a Food and Drug Administration (FDA) required risk management program Subject: Important Drug Warning Announcement of a single shared REMS (Risk Evaluation and Mitigation Strategy) program for all Transmucosal Immediate Release Fentanyl (TIRF) products due to the potential

More information

MEDICAL POLICY STATEMENT

MEDICAL POLICY STATEMENT MEDICAL POLICY STATEMENT Original Effective Date Next Annual Review Date Last Review / Revision Date 5/21/2014 3/24/2016 3/24/2015 Policy Name Policy Number Hepatitis C Oral SRx-0003 Medical Policy Statements

More information

Education Program for Prescribers and Pharmacists

Education Program for Prescribers and Pharmacists Transmucosal Immediate Release Fentanyl (TIRF) Products Risk Evaluation and Mitigation Strategy (REMS) Education Program for Prescribers and Pharmacists Products Covered Under This Program Abstral (fentanyl)

More information

Prior Authorization Form

Prior Authorization Form Prior Authorization Form Growth Hormone This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign and date. Fax signed forms to CVS/Caremark at

More information

Committee Approval Date: December 12, 2014 Next Review Date: December 2015

Committee Approval Date: December 12, 2014 Next Review Date: December 2015 Medication Policy Manual Policy No: dru299 Topic: Tecfidera, dimethyl fumarate Date of Origin: May 16, 2013 Committee Approval Date: December 12, 2014 Next Review Date: December 2015 Effective Date: January

More information

FDA Approved Indications

FDA Approved Indications Preferred Agents: Humatrope (somatropin) Nutropin (somatropin) Medication Nutropin AQ (somatropin) Nutropin AQ NuSpin (somatropin) Non-Preferred Agents: Genotropin (somatropin) Omnitrope (somatropin) Norditropin

More information

MEDICAL ASSISTANCE BULLETIN

MEDICAL ASSISTANCE BULLETIN ISSUE DATE May 11, 2015 SUBJECT EFFECTIVE DATE May 18, 2015 MEDICAL ASSISTANCE BULLETIN NUMBER *See below BY Prior Authorization of Multiple Sclerosis Agents Pharmacy Service Leesa M. Allen, Deputy Secretary

More information

SASKATCHEWAN FORMULARY BULLETIN Update to the 62nd Edition of the Saskatchewan Formulary

SASKATCHEWAN FORMULARY BULLETIN Update to the 62nd Edition of the Saskatchewan Formulary November 1, 2014 Bulletin #150 ISSN 1923-0761 SASKATCHEWAN FORMULARY BULLETIN Update to the 62nd Edition of the Saskatchewan Formulary New Exception Drug Status (EDS) Listings Effective November 1, 2014

More information

Review: How to work up your patient with Hepatitis C

Review: How to work up your patient with Hepatitis C Review: How to work up your patient with Hepatitis C You screened your patient, and now the HCV antibody test is positive. What do you do next? The antibody test only means they have been exposed to HCV.

More information

MEDICAL ASSISTANCE HANDBOOK PRIOR AUTHORIZATION OF PHARMACEUTICAL SERVICES. I. Requirements for Prior Authorization of Hepatitis C Agents

MEDICAL ASSISTANCE HANDBOOK PRIOR AUTHORIZATION OF PHARMACEUTICAL SERVICES. I. Requirements for Prior Authorization of Hepatitis C Agents MEDICAL ASSISTANCE HBOOK PRI AUTHIZATION OF PHARMACEUTICAL SERVICES I. Requirements for Prior Authorization of Hepatitis C Agents A. Prescriptions That Require Prior Authorization Prescriptions for Interferon,

More information

GROWTH HORMONE THERAPY

GROWTH HORMONE THERAPY GROWTH HORMONE THERAPY Line(s) of Business: HMO; PPO; QUEST Integration Original Effective Date: 05/21/1999 Current Effective Date: 10/01/2015 POLICY A. INDICATIONS The indications below including FDA-approved

More information

Drug Formulary Update, July 2013

Drug Formulary Update, July 2013 Drug Formulary Update, July 2013 Updates to the HealthPartners Drug Formularies are listed below. Updates for the Commercial Drug Formularies and the Minnesota Health Care Programs (Medicaid and Minnesota

More information

Chronic Hepatitis C Virus (Chronic HCV)

Chronic Hepatitis C Virus (Chronic HCV) Chronic Hepatitis C Virus (Chronic HCV) Amie Baumgartner PA-C Fall 2015 Purpose of Lecture! Educate Gastroenterology nurses about Hepatitis C and its treatment in order to improve their knowledge and confidence

More information

5.07.09. Aubagio. Aubagio (teriflunomide) Description

5.07.09. Aubagio. Aubagio (teriflunomide) Description Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.07.09 Subject: Aubagio Page: 1 of 6 Last Review Date: December 5, 2014 Aubagio Description Aubagio (teriflunomide)

More information

Medication Policy Manual. Topic: Aubagio, teriflunomide Date of Origin: November 9, 2012

Medication Policy Manual. Topic: Aubagio, teriflunomide Date of Origin: November 9, 2012 Medication Policy Manual Policy No: dru283 Topic: Aubagio, teriflunomide Date of Origin: November 9, 2012 Committee Approval Date: December 12, 2014 Next Review Date: December 2015 Effective Date: January

More information

Ledipasvir/Sofosbuvir (Harvoni) for Treatment of Hepatitis C

Ledipasvir/Sofosbuvir (Harvoni) for Treatment of Hepatitis C Ledipasvir/Sofosbuvir (Harvoni) for Treatment of Hepatitis C Policy Number: Original Effective Date: MM.04.034 12/1/2014 Line(s) of Business: Current Effective Date: HMO; PPO; QUEST Integration 12/1/2014

More information

SECTION 3. Criteria for Special Authorization of Select Drug Products. Section 3 Criteria for Special Authorization of Select Drug Products

SECTION 3. Criteria for Special Authorization of Select Drug Products. Section 3 Criteria for Special Authorization of Select Drug Products SECTION 3 Criteria for Special Authorization of Select Drug Products Section 3 Criteria for Special Authorization of Select Drug Products CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS The

More information

North Carolina Rheumatology Association Position Statements

North Carolina Rheumatology Association Position Statements North Carolina Rheumatology Association Position Statements I. Biologic Agents A. Appropriate delivery, handling, storage and administration of biologic agents B. Indications for biologic agents II. III.

More information

Hepatitis C Virus Direct-Acting Antivirals Prior Authorization Request Form

Hepatitis C Virus Direct-Acting Antivirals Prior Authorization Request Form Hepatitis C Virus Direct-Acting Antivirals Prior Authorization Request Form For assistance, please call 1-855-552-6028 or fax completed form to 570-271-5610. Medical documentation may be requested. This

More information

Rheumatoid Arthritis

Rheumatoid Arthritis Rheumatoid Arthritis While rheumatoid arthritis (RA) has long been feared as one of the most disabling types of arthritis, the outlook has dramatically improved for many newly diagnosed patients. Certainly

More information

Biologic Treatments for Rheumatoid Arthritis

Biologic Treatments for Rheumatoid Arthritis Biologic Treatments Rheumatoid Arthritis (also known as cytokine inhibitors, TNF inhibitors, IL 1 inhibitor, or Biologic Response Modifiers) Description Biologics are new class of drugs that have been

More information

Applicable Coding: GCN: Solvaldi - 35708; Harvoni 037179; Viekira Pak 037614; Daklinza 037073, 037074; Technivie - 037844

Applicable Coding: GCN: Solvaldi - 35708; Harvoni 037179; Viekira Pak 037614; Daklinza 037073, 037074; Technivie - 037844 Policy Subject: Policy Number: Classification: Hepatitis C Agents (new) SHS PBD38 Anti-virals: Hepatitis C Policy Type: Medical Pharmacy Department: Pharmacy Product (check all that apply): Group HMO/POS

More information

BCBSNM Drug List Limitations, Exclusions, and Preauthorization Criteria

BCBSNM Drug List Limitations, Exclusions, and Preauthorization Criteria The Blue Cross and Blue Shield of New Mexico (BCBSNM) Pharmacy Benefit provides coverage of most drugs for our members. Effective communication about specific drug limitations is important for consistent

More information

Update on Hepatitis C. Sally Williams MD

Update on Hepatitis C. Sally Williams MD Update on Hepatitis C Sally Williams MD Hep C is Everywhere! Hepatitis C Magnitude of the Infection Probably 8 to 10 million people in the U.S. are infected with Hep C 30,000 new cases are diagnosed annually;

More information

INITIATING ORAL AUBAGIO (teriflunomide) THERAPY

INITIATING ORAL AUBAGIO (teriflunomide) THERAPY FOR YOUR PATIENTS WITH RELAPSING FORMS OF MS INITIATING ORAL AUBAGIO (teriflunomide) THERAPY WARNING: HEPATOTOXICITY AND RISK OF TERATOGENICITY Severe liver injury including fatal liver failure has been

More information

Medical School for Actuaries. June 12, 2013. Baltimore, Maryland

Medical School for Actuaries. June 12, 2013. Baltimore, Maryland Medical School for Actuaries June 12, 2013 Baltimore, Maryland Developments in the Treatment of Conditions Treated with Specialty Mediations (Cancer, MS, RA, Hemophilia) Mark S. Matusik, PharmD Developments

More information

Newer Anticoagulants and Newer Diabetic Drug Classes. Nicole N. Nguyen, PharmD Senior Clinical Pharmacist Health Care Services August 21, 2013

Newer Anticoagulants and Newer Diabetic Drug Classes. Nicole N. Nguyen, PharmD Senior Clinical Pharmacist Health Care Services August 21, 2013 Newer Anticoagulants and Newer Diabetic Drug Classes Nicole N. Nguyen, PharmD Senior Clinical Pharmacist Health Care Services August 21, 2013 Apixaban Newer Anticoagulants Dabigatran etexilate Rivaroxaban

More information

Hepatitis C Treatment Expansion Initiative Multi-Site Conference Call. March 16, 2011

Hepatitis C Treatment Expansion Initiative Multi-Site Conference Call. March 16, 2011 Hepatitis C Treatment Expansion Initiative Multi-Site Conference Call March 16, 2011 Case Presentations Kansas City Free Health Clinic Carilion Clinic Didactic Session Challenges in Determining HCV Treatment

More information

Outpatient Prescription Drug Benefit

Outpatient Prescription Drug Benefit Outpatient Prescription Drug Benefit GENERAL INFORMATION This supplemental Evidence of Coverage and Disclosure Form is provided in addition to your Member Handbook and Health Plan Benefits and Coverage

More information

Remicade (infliximab)

Remicade (infliximab) Criteria for approval Commercial Only Remicade (infliximab) Background: Tumor Necrosis Factor (TNF) alpha is one of two proinflammatory cytokines that appear to play a dominant role in the inflammatory

More information

Prior Authorization Policy

Prior Authorization Policy Prior Authorization Policy http://www.paramounthealthcare.com/providers Ribavirin Rebetol (ribavirin capsule or oral solution) Copegus (ribavirin tablet), Moderiba (ribavirin tablet), Ribasphere (ribavirin

More information

Rheumatoid Arthritis. Outline. Treatment Goal 4/10/2013. Clinical evaluation New treatment options Future research Discussion

Rheumatoid Arthritis. Outline. Treatment Goal 4/10/2013. Clinical evaluation New treatment options Future research Discussion Rheumatoid Arthritis Robert L. Talbert, Pharm.D., FCCP, BCPS University of Texas at Austin College of Pharmacy University of Texas Health Science Center at San Antonio Outline Clinical evaluation New treatment

More information

HEPATITIS C TREATMENT GUIDELINES

HEPATITIS C TREATMENT GUIDELINES HEPATITIS C TREATMENT GUIDELINES Updated May 21, 2014 INSTRUCTIONS: 1. Review the posted Hepatitis C Treatment Guidelines document to validate that your patient meets the criteria for treatment. 2. Complete

More information

Medication Policy Manual. Topic: Aubagio, teriflunomide Date of Origin: November 9, 2012

Medication Policy Manual. Topic: Aubagio, teriflunomide Date of Origin: November 9, 2012 Medication Policy Manual Policy No: dru283 Topic: Aubagio, teriflunomide Date of Origin: November 9, 2012 Committee Approval Date: December 11, 2015 Next Review Date: December 2016 Effective Date: January

More information

Transmission of HCV in the United States (CDC estimate)

Transmission of HCV in the United States (CDC estimate) Transmission of HCV in the United States (CDC estimate) Past and Future US Incidence and Prevalence of HCV Infection Decline among IDUs Overall incidence Overall prevalence Infected 20+ years Armstrong

More information

Specialty Pharmacy: Understanding the Market and Solution. Your Goals. Presented by Chris Brown November 2009

Specialty Pharmacy: Understanding the Market and Solution. Your Goals. Presented by Chris Brown November 2009 Specialty Pharmacy: Understanding the Market and Solution Presented by Chris Brown November 2009 Your Goals What What is a Specialty is a specialty Medication? medication? Specialty drugs are injectable,

More information

MEDICAL ASSISTANCE HANDBOOK PRIOR AUTHORIZATION OF PHARMACEUTICAL SERVICES. A. Prescriptions That Require Prior Authorization

MEDICAL ASSISTANCE HANDBOOK PRIOR AUTHORIZATION OF PHARMACEUTICAL SERVICES. A. Prescriptions That Require Prior Authorization MEDICAL ASSISTANCE HBOOK I. Requirements for Prior Authorization of Anticoagulants A. Prescriptions That Require Prior Authorization Prescriptions for Anticoagulants which meet any of the following conditions

More information

PRIOR AUTHORIZATION POLICY

PRIOR AUTHORIZATION POLICY PRIOR AUTHORIZATION POLICY Harvoni (sofosbuvir/ledipasvir tablets Gilead) To initiate a Coverage Review, Call 1-800-417-1764 OVERVIEW Harvoni is a fixed-dose combination of ledipasvir, a hepatitis C virus

More information

www.oxfordhealth.com

www.oxfordhealth.com www.oxfordhealth.com Oxford s HMO products are underwritten by Oxford Health Plans (NY), Inc., Oxford Health Plans (NJ), Inc., and Oxford Health Plans (CT), Inc., and insurance products are underwritten

More information

MEDICATION GUIDE. ACTEMRA (AC-TEM-RA) (tocilizumab) Solution for Intravenous Infusion

MEDICATION GUIDE. ACTEMRA (AC-TEM-RA) (tocilizumab) Solution for Intravenous Infusion MEDICATION GUIDE ACTEMRA (AC-TEM-RA) (tocilizumab) Solution for Intravenous Infusion ACTEMRA (AC-TEM-RA) (tocilizumab) Injection, Solution for Subcutaneous Administration Read this Medication Guide before

More information

SPECIAL AUTHORIZATION GUIDELINES

SPECIAL AUTHORIZATION GUIDELINES 91B ALBERTA DRUG BENEFIT LIST SPECIAL AUTHORIZATION GUIDELINES 37BSpecial Authorization Policy 90BDrug Products Eligible for Consideration by Special Authorization Drug Products may be considered for coverage

More information

MEDICAL ASSISTANCE HANDBOOK PRIOR AUTHORIZATION OF PHARMACEUTICAL SERVICES `I. Requirements for Prior Authorization of Cytokine and CAM Antagonists

MEDICAL ASSISTANCE HANDBOOK PRIOR AUTHORIZATION OF PHARMACEUTICAL SERVICES `I. Requirements for Prior Authorization of Cytokine and CAM Antagonists MEDICAL ASSISTANCE HBOOK `I. Requirements for Prior Authorization of Cytokine and CAM Antagonists A. Prescriptions That Require Prior Authorization All prescriptions for Cytokine and CAM Antagonists must

More information

The following should be current within the past 6 months:

The following should be current within the past 6 months: EVALUATION Baseline Labs Obtain at time or prior to initial evaluation CBC with diff PT/INR CMP HCV Genotype (obtained PRIOR TO consult visit) HCV RNA (obtained PRIOR TO consult visit) Hep A IgG Hep BsAg,

More information

Inpatient Anticoagulation Safety. To provide safe and effective anticoagulation therapy through a collaborative approach.

Inpatient Anticoagulation Safety. To provide safe and effective anticoagulation therapy through a collaborative approach. Inpatient Anticoagulation Safety Purpose: Policy: To provide safe and effective anticoagulation therapy through a collaborative approach. Upon the written order of a physician, Heparin, Low Molecular Weight

More information

Prescriber Guide. 20mg. 15mg. Simply Protecting More Patients. Simply Protecting More Patients

Prescriber Guide. 20mg. 15mg. Simply Protecting More Patients. Simply Protecting More Patients Prescriber Guide 20mg Simply Protecting More Patients 15mg Simply Protecting More Patients 1 Dear Doctor, This prescriber guide was produced by Bayer Israel in cooperation with the Ministry of Health as

More information

ORAL MEDICATIONS FOR MS! Gilenya and Aubagio

ORAL MEDICATIONS FOR MS! Gilenya and Aubagio ORAL MEDICATIONS FOR MS! Gilenya and Aubagio Champions against MS 4/20/13 Alexandra Goodyear, MD Stanford University Oral Medications Since 2010, 3 new oral medications for MS: Gilenya 2010 Aubagio 2012

More information

PARTNERSHIP HEALTHPLAN OF CALIFORNIA

PARTNERSHIP HEALTHPLAN OF CALIFORNIA Authorization for the Treatment of Hepatitis C 4665 Business Center Drive Fairfield, California 94534 July 1, 2016 Re: Authorization for the use of Sovaldi/Harvoni/Viekira Pak/Daklinza/Technivie/Zepatier/Epclusa

More information

Progress in MS: Current and Emerging Therapies

Progress in MS: Current and Emerging Therapies Progress in MS: Current and Emerging Therapies Presented by: Dr. Kathryn Giles, MD MSc FRCPC The MS Society gratefully acknowledges the grant received from Biogen Idec Canada, which makes possible the

More information

Medicines for Rheumatoid. Arthritis. A Review of the Research for Adults

Medicines for Rheumatoid. Arthritis. A Review of the Research for Adults Medicines for Rheumatoid Arthritis A Review of the Research for Adults Is This Information Right for Me? Yes, this summary is for you if: Your doctor* has told you that you have rheumatoid (pronounced

More information

Relapsing-remitting multiple sclerosis Ambulatory with or without aid

Relapsing-remitting multiple sclerosis Ambulatory with or without aid AVONEX/BETASERON/COPAXONE/EXTAVIA/GILENYA/REBIF/TYSABRI Applicant must be covered on an Alberta Government sponsored drug program. Page 1 of 5 PATIENT INFMATION Surname First Name Middle Initial Sex Date

More information

PRESCRIPTION DRUG PLAN

PRESCRIPTION DRUG PLAN PRESCRIPTION DRUG PLAN The Plan Administrator will pay a portion of the cost of covered prescriptions. Maximum benefits are paid when prescriptions are filled through the CVS Caremark network pharmacies.

More information

Growth Hormone Deficiency

Growth Hormone Deficiency Growth Hormone Deficiency What is growth hormone deficiency? 1,2 Growth hormone deficiency is when your body doesn t make enough growth hormone. Growth hormone is one of many hormones made by the pituitary

More information

PREPARED BY THE CENTER FOR HEALTH LAW AND POLICY INNOVATION OF HARVARD LAW SCHOOL

PREPARED BY THE CENTER FOR HEALTH LAW AND POLICY INNOVATION OF HARVARD LAW SCHOOL Pennsylvania PREPARED BY THE CENTER FOR HEALTH LAW AND POLICY INNOVATION OF HARVARD LAW SCHOOL Pennsylvania Hepatitis C Virus (HCV) in Pennsylvania Prevalence + + Although state-wide data were unavailable,

More information

MEDICAL ASSISTANCE HANDBOOK PRIOR AUTHORIZATION OF PHARMACEUTICAL SERVICES. A. Prescriptions That Require Prior Authorization

MEDICAL ASSISTANCE HANDBOOK PRIOR AUTHORIZATION OF PHARMACEUTICAL SERVICES. A. Prescriptions That Require Prior Authorization MEDICAL ASSISTANCE HBOOK PRI AUTHIZATION OF PHARMACEUTICAL SERVICES I. Requirements for Prior Authorization of Anticoagulants A. Prescriptions That Require Prior Authorization Prescriptions for Anticoagulants

More information

Updates to the Alberta Human Services Drug Benefit Supplement

Updates to the Alberta Human Services Drug Benefit Supplement Updates to the Alberta Human Services Drug Benefit Supplement Effective December 1, 2014 Inquiries should be directed to: Pharmacy Services Alberta Blue Cross 10009 108 Street NW Edmonton AB T5J 3C5 Telephone

More information

Coventry Health Care of Georgia, Inc. Coventry Health and Life Insurance Company

Coventry Health Care of Georgia, Inc. Coventry Health and Life Insurance Company Coventry Health Care of Georgia, Inc. Coventry Health and Life Insurance Company PRESCRIPTION DRUG RIDER This Prescription Drug Rider is an attachment to the Coventry Health Care of Georgia, Inc. ( Health

More information

NEW DRUGS FOR THE TREATMENT OF HEPATITIS C. Marcella Honkonen, PharmD, BCPS AzPA Annual Convention. Sunday, June 29 th, 2014 (1:15-2:15)

NEW DRUGS FOR THE TREATMENT OF HEPATITIS C. Marcella Honkonen, PharmD, BCPS AzPA Annual Convention. Sunday, June 29 th, 2014 (1:15-2:15) NEW DRUGS FOR THE TREATMENT OF HEPATITIS C Marcella Honkonen, PharmD, BCPS AzPA Annual Convention. Sunday, June 29 th, 2014 (1:15-2:15) Objectives Determine initial treatment options for patients with

More information

MOH Policy for dispensing NEOPLASTIC DISEASES DRUGS

MOH Policy for dispensing NEOPLASTIC DISEASES DRUGS MOH Policy for dispensing NEOPLASTIC DISEASES DRUGS All prescriptions for antineoplastic drugs must be accompanied by the MOH special form. All the attachments mentioned on this form shall be submitted

More information

New York State Auto Dealers Association Group Insurance Trust (GIT) Prescription Drug Coverage Summary

New York State Auto Dealers Association Group Insurance Trust (GIT) Prescription Drug Coverage Summary New York State Auto Dealers Association Group Insurance Trust (GIT) Prescription Drug Coverage Summary Effective January 1, 2014, all pharmacy coverage will be administered by Express Scripts and its affiliates.

More information

NB Drug Plans Formulary Update

NB Drug Plans Formulary Update Bulletin #902 March 6, 2015 NB Drug Plans Formulary Update This update to the New Brunswick Drug Plans Formulary is effective March 6, 2015. Included in this bulletin: Regular Benefit Additions Special

More information

Growth Hormone Therapy

Growth Hormone Therapy Growth Hormone Therapy Policy Number: Original Effective Date: MM.04.011 05/21/1999 Line(s) of Business: Current Effective Date: HMO; PPO; QUEST 10/28/2011 Section: Prescription Drugs Place(s) of Service:

More information

HCV/HIVCo-infection A case study by. Dominic Côté, Nurse Clinician B.Sc Chronic Viral Illness Services McGill University Health Centre

HCV/HIVCo-infection A case study by. Dominic Côté, Nurse Clinician B.Sc Chronic Viral Illness Services McGill University Health Centre HCV/HIVCo-infection A case study by Dominic Côté, Nurse Clinician B.Sc Chronic Viral Illness Services McGill University Health Centre Objectives By sharing a case study of a patient co-infected with HIV/HCV

More information

Prior Authorization Guideline

Prior Authorization Guideline Prior Authorization Guideline Guideline: PDP IBT Inj - Vivitrol Therapeutic Class: Central Nervous System Agents Therapeutic Sub-Class: Opiate Antagonist Client: 2007 PDP IBT Inj Approval Date: 2/20/2007

More information

HERTFORDSHIRE MEDICINES MANAGEMENT COMMITTEE (HMMC) RIVAROXABAN RECOMMENDED see specific recommendations for licensed indications below

HERTFORDSHIRE MEDICINES MANAGEMENT COMMITTEE (HMMC) RIVAROXABAN RECOMMENDED see specific recommendations for licensed indications below Name: generic (trade) Rivaroxaban (Xarelto ) HERTFORDSHIRE MEDICINES MANAGEMENT COMMITTEE (HMMC) RIVAROXABAN RECOMMENDED see specific recommendations for licensed indications below What it is Indications

More information

Current Rheumatoid Arthritis Treatment Options: Update for Managed Care and Specialty Pharmacists

Current Rheumatoid Arthritis Treatment Options: Update for Managed Care and Specialty Pharmacists Current Rheumatoid Arthritis Treatment Options: Update for Managed Care and Specialty Pharmacists 1. Which of the following matches of biologic targets that contribute to rheumatoid arthritis (RA) and

More information

Medicines for Psoriatic Arthritis. A Review of the Research for Adults

Medicines for Psoriatic Arthritis. A Review of the Research for Adults Medicines for Psoriatic Arthritis A Review of the Research for Adults Is This Information Right for Me? Yes, this information is right for you if: Your doctor* has told you that you have psoriatic (pronounced

More information

Pharmaceutical Risk Sharing Agreements C. Bernie Good MD MPH Department of Veterans Affairs June 2014

Pharmaceutical Risk Sharing Agreements C. Bernie Good MD MPH Department of Veterans Affairs June 2014 Pharmaceutical Risk Sharing Agreements C. Bernie Good MD MPH Department of Veterans Affairs June 2014 Objectives Describe concept of Risk-Share Agreements Describe types of agreements Identify specific

More information

Liver Disease & Hepatitis Program Providers: Brian McMahon, MD, Steve Livingston, MD, Lisa Townshend, ANP. Primary Care Provider:

Liver Disease & Hepatitis Program Providers: Brian McMahon, MD, Steve Livingston, MD, Lisa Townshend, ANP. Primary Care Provider: Liver Disease & Hepatitis Program Providers: Brian McMahon, MD, Steve Livingston, MD, Lisa Townshend, ANP Primary Care Provider: If you are considering hepatitis C treatment, please read this treatment

More information

Prescription Drug Rider

Prescription Drug Rider Prescription Drug Rider This Rider is part of the Evidence of Coverage and is effective on the date Your group is effective or renews its coverage with Southern Health Services, Inc. Benefits are available

More information

September 2014. Strategy or Medications Added or Modified Remove belladonna alkaloidsphenobarbital. Therapeutic Class/Drug Name.

September 2014. Strategy or Medications Added or Modified Remove belladonna alkaloidsphenobarbital. Therapeutic Class/Drug Name. The following changes to the Neighborhood formulary were recently approved by the Pharmacy and s (P&T) Committee. These changes are effective immediately unless otherwise indicated. Belladonna alkaloidsphenobarbital

More information

SOUTH TAMPA MULTIPLE SCLEROSIS CENTER PATIENT/ CARE GIVER QUESTIONNAIRE

SOUTH TAMPA MULTIPLE SCLEROSIS CENTER PATIENT/ CARE GIVER QUESTIONNAIRE SOUTH TAMPA MULTIPLE SCLEROSIS CENTER PATIENT/ CARE GIVER QUESTIONNAIRE DEMOGRAPHIC INFORMATION Patient Name: Date: Address: City: State: Zip Code Best Phone Number: Marital Status Phone (H): (W) (Cell):

More information

An Approach to the Diagnosis and Treatment of Hepatitis C Virus Infection in 2015. Matthew McMahon, MD

An Approach to the Diagnosis and Treatment of Hepatitis C Virus Infection in 2015. Matthew McMahon, MD An Approach to the Diagnosis and Treatment of Hepatitis C Virus Infection in 2015 Matthew McMahon, MD In the United States, 2.2-3.2 million people are infected with the hepatitis C virus (HCV) Half unaware

More information

SECTION 2. Section 2 Multiple Sclerosis (MS) Drug Coverage

SECTION 2. Section 2 Multiple Sclerosis (MS) Drug Coverage SECTION 2 Multiple Sclerosis (MS) Drug Coverage Section 2 Multiple Sclerosis (MS) Drug Coverage ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST Selected Drug Products used in the treatment of patients with

More information

National MS Society Information Sourcebook www.nationalmssociety.org/sourcebook

National MS Society Information Sourcebook www.nationalmssociety.org/sourcebook National MS Society Information Sourcebook www.nationalmssociety.org/sourcebook Chemotherapy The literal meaning of the term chemotherapy is to treat with a chemical agent, but the term generally refers

More information

PULMONARY ARTERIAL HYPERTENSION AGENTS

PULMONARY ARTERIAL HYPERTENSION AGENTS Approvable Criteria: PULMONARY ARTERIAL HYPERTENSION AGENTS Brand Name Generic Name Length of Authorization Revatio Sildenafil citrate Calendar Year Adcirca Tadalafil Calendar Year Letairis Ambrisentan

More information

Recruitment Start date: April 2010 End date: Recruitment will continue until enrolment is fully completed

Recruitment Start date: April 2010 End date: Recruitment will continue until enrolment is fully completed Apitope study The study drug (ATX-MS-1467) is a new investigational drug being tested as a potential treatment for relapsing forms of multiple sclerosis (RMS). The term investigational drug means it has

More information

Cytokine and CAM Antagonists

Cytokine and CAM Antagonists Texas Prior Authorization Program Clinical Edit Criteria Drug/Drug Class Clinical Edit Information Included in this Document Actemra (Tocilizumab) Drugs requiring prior authorization: the list of drugs

More information

BCCA Protocol Summary for Therapy of Multiple Myeloma Using Lenalidomide with Dexamethasone

BCCA Protocol Summary for Therapy of Multiple Myeloma Using Lenalidomide with Dexamethasone BCCA Protocol Summary for Therapy of Multiple Myeloma Using Lenalidomide with Dexamethasone Protocol Code Tumour Group Contact Physician Contact Pharmacist UMYLENDEX Lymphoma, Leukemia/BMT Dr. Kevin Song

More information

Prescription Drug Plan

Prescription Drug Plan Prescription Drug Plan The prescription drug plan helps you pay for prescribed medications using either a retail pharmacy or the mail order program. For More Information Administrative details and procedures

More information