Prior Authorization FID VER.7 UPDATED 8/2015

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1 Prior Authorization FID VER.7 UPDATED 8/2015

2 Prior Authorization 2016 MAPD Leon 3 Tier Last Updated: 10/22/2015 ACTEMRA Products Affected Actemra INJ 162MG/0.9ML PA Details Other 1

3 ACTIMMUNE Products Affected Actimmune PA Covered Uses Other Details All medically accepted indications not otherwise excluded from Part D 12 Months 2

4 ADEMPAS Products Affected Adempas PA Details Other 3

5 AFINITOR Products Affected Afinitor Afinitor Disperz PA Details Other Documentation of diagnosis and past medication history Afinitor is considered medically necessary for the treatment of patients with advanced renal cell carcinoma after failure of treatment with Sutent (sunitinib) OR Nexavar (sorafenib). 4

6 ALCOHOL DEPENDENCE AGENTS Products Affected Acamprosate Calcium Dr PA Details Covered Uses All FDA approved indications not otherwise excluded from Part D. Other Documentation of alcohol dependence 5

7 ALDARA Products Affected Zyclara Zyclara Pump CREA 2.5% PA Covered Uses Other Details All medically accepted indications not otherwise excluded from Part D 12 Months 6

8 ANTIANGIOGENIC AGENTS Products Affected Votrient PA Details Other Documentation of diagnosis. Votrient is considered medically necessary for the treatment of patients with a diagnosis of 1.) advanced renal cell carcinoma or 2.)advanced soft tissue sarcoma who have received prior chemotherapy 7

9 ANTIBACTERIALS, OTHER Products Affected Linezolid TABS Zyvox SUSR PA Details Other Documentation from the medical record of diagnosis, site of infection, recent culture and sensitivity data, current or previous treatment for infection. 1 to 3 months Use of linezolid is considered medically necessary for use in infections resulting from VRE and MRSA. Zyvox is also considered medically accepted for other clinically appropriate infections when drug allergies prevent the use of clinically appropriate 1st-line agents in other infections. 8

10 ANTIEMETICS Products Affected Akynzeo Anzemet Emend ORAL CAPS Granisetron Hcl TABS Sancuso PA Details Other 9

11 ANTIFUNGALS, AZOLE Products Affected Voriconazole INJ Voriconazole ORAL TABS Voriconazole SUSR PA Details Other Documented fungal culture and or notes from medical record suggestive of a serious fungal infection 3 to 6 months, depending on indication 10

12 ARCALYST Products Affected Arcalyst PA Details Other Documentation of diagnosis of Cryopyrin-Associated Periodic Syndromes (CAPS), including Familial Cold Auto-inflammatory Syndrome (FCAS) and Muckle-Wells Syndrome (MWS) 12 years of age and older B vs D coverage determination 11

13 AUBAGIO Products Affected Aubagio PA Details Other 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, Extavia, glatiramer acetate or Rebif before Aubagio will be authorized. 12

14 BENLYSTA Products Affected Benlysta INJ 120MG PA Details Other The patient must have a positive autoantibody test (i.e., anti-nuclear 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. 13

15 BOTULINUM TOXIN Products Affected Botox Dysport INJ 300UNIT Xeomin INJ 50UNIT PA Details Other Exclude when used for cosmetic purposes. Documentation of diagnosis 3 months 14

16 COLONY STIMULATING FACTORS Products Affected Leukine INJ 250MCG Neulasta Neupogen PA Details Other Documentation of diagnosis and either CBC with differential or ANC. 6 months 15

17 ERIVEDGE Products Affected Erivedge PA Details Other 16

18 FORTEO Products Affected Forteo PA Details Other BMD T-Score, documentation reflecting high risk for a fracture, medication history regarding the prior use of bisphosphonates Patients with a BMD T-score indicating high risk despite therapy with a bisphosphonate for six months OR Patients with a history of osteoporotic fracture while receiving treatment with bisphosphonates OR Patients unable to tolerate oral bisphosphonates due to gastrointestinal comorbidities or is unable to adhere to dosing requirements (i.e., unable to remain upright for 30 minutes). For the diagnosis of postmenopausal osteoporosis patients unable to tolerate oral bisphosphonates must have tried and failed Prolia for a total duration of at least 6 months prior to the use of Forteo. 17

19 GRANIX Products Affected Granix PA Details Other 18

20 GROWTH HORMONE Products Affected Genotropin Genotropin Miniquick Humatrope INJ 12MG, 24MG, 6MG Humatrope Combo Pack Norditropin Flexpro INJ 10MG/1.5ML, 15MG/1.5ML, 5MG/1.5ML Norditropin Nordiflex Pen Nutropin Aq Nuspin 5 Nutropin Aq Pen Omnitrope Saizen Saizen Click.easy Serostim Zomacton Zorbtive PA Covered Uses Other Details All medically accepted indications not otherwise excluded from Part-D Growth hormone stimulation test required for adult-onset pituitary disease, hypothalamic disease, surgery, radiation therapy, trauma, childhood-onset GH deficiency 19

21 HARVONI Products Affected Harvoni PA Details Other Documentation from the medical record of diagnosis including genotype, HCV RNA viral levels prior to treatment, history of previous HCV therapies, and 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 20

22 HEMATOPOIETICS Products Affected Aranesp Albumin Free INJ 100MCG/0.5ML, 100MCG/ML, 10MCG/0.4ML, 150MCG/0.3ML, 200MCG/0.4ML, 200MCG/ML, 25MCG/0.42ML, 25MCG/ML, 300MCG/0.6ML, 300MCG/ML, 40MCG/0.4ML, 40MCG/ML, 500MCG/ML, 60MCG/0.3ML, 60MCG/ML Epogen Mircera Procrit PA Details Other For the indication of anemia, documentation of Hemoglobin less than 11, transferrin saturation greater than 20%, and ferritin levels greater than 100 obtained over the last 3 months 6 months BvD determination 21

23 HEPATITIS B AGENTS Products Affected Adefovir Dipivoxil PA Details Other 22

24 HETLIOZ Products Affected Hetlioz PA Details Other Documentation that patient is totally blind and lacks light perception 23

25 HORMONAL AGENTS, SOMATOSTATIN ANALOGS Products Affected Octreotide Acetate Sandostatin Lar Depot Signifor Lar Somatuline Depot PA Details Other Documentation of diagnosis 6 months 24

26 HRM - SKELETAL MUSCLE RELAXANTS Products Affected Carisoprodol TABS 350MG Carisoprodol/aspirin Carisoprodol/aspirin/codeine Cyclobenzaprine Hcl ORAL TABS Soma TABS 250MG PA Details Other The physician has documented the indication for the continued use of the HRM (high risk med) with an explanation of the specific benefit established with the medication and how that benefit outweighs the potential risk, AND the physician has documented the ongoing monitoring plan for the agent. Automatic approval if member is less than 65 years of age.prior Auth required for age 65 or older. Approval duration is through the end of the plan year. 25

27 IDIOPATHIC PULMONARY FIBROSIS Products Affected Esbriet Ofev PA Details Other 26

28 IMMUNE STIMULANTS, NON-VACCINE Products Affected Moderiba TABS Moderiba 1200 Dose Pack Moderiba 800 Dose Pack Pegasys Pegasys Proclick Pegintron INJ 120MCG/0.5ML, 150MCG/0.5ML, 80MCG/0.5ML Peg-intron INJ 50MCG/0.5ML Peg-intron Redipen Rebetol SOLN Ribasphere Ribasphere Ribapak Ribavirin CAPS Ribavirin TABS Virazole PA Details Other Documentation of genotype to determine length of therapy 12 to 48 weeks based on indication and established treatment guidelines. 27

29 IMMUNE SUPPRESSANTS Products Affected Cimzia Cosentyx Sensoready Pen Enbrel Enbrel Sureclick Humira Humira Pen-crohns Diseasestarter Orencia Remicade Simponi PA Covered Uses Details All medically accepted indications not otherwise excluded from Part D Documentation of diagnosis and past medication history 28

30 Other 1.)Use of Humira, Enbrel, Cimzia, Orencia, Simponi and Remicade is considered medically necessary for the treatment of Rheumatoid Arthritis in patients that have tried and failed methotrexate OR at least 2 alternative disease modifying antirheumatic drugs (DMARDs). 2.)Use of Humira, Enbrel, and Remicade is considered medically necessary for the treatment of Juvenile Rheumatoid Arthritis in patients that have tried and failed at least 2 DMARDs. 3.)Use of Humira, Enbrel, Cimzia, Simponi and Remicade is considered medically necessary for the treatment Ankylosing Spondylitis in patients that have tried and failed at least 1 non-steroidal anti-inflammatory drug (NSAID), corticosteroid, OR sulfasalazine. 4.)Use of Humira, Enbrel, Cimzia,Simponi and Remicade is considered medically necessary for the treatment of Psoriatic Arthritis in patients with active disease. 5.)Use of Humira, Remicade and Cimzia is considered medically necessary for the treatment of Moderate to severe Crohn s Disease in patients that have tried and failed at least 2 of the following: immunomodulators, corticosteroids, or aminosalicylates. 6.)Use of Humira, Simponi and Remicade is considered medically necessary for 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. 7.)Use of Humira, Enbrel, and Remicade is considered medically necessary for the treatment of 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 8.)Use of Remicade will be considered medically necessary for the treatment of fistulizing Crohn's disease. B vs D determination required for Remicade. 29

31 IMMUNE SUPPRESSANTS - TRANSPLANT RELATED Products Affected Astagraf XL Atgam Azasan Azathioprine TABS Cellcept Intravenous Cyclosporine INJ Cyclosporine ORAL CAPS Cyclosporine Modified Gengraf Mycophenolate Mofetil Mycophenolic Acid Dr Nulojix Prograf INJ Rapamune SOLN Sandimmune SOLN Sirolimus ORAL TABS Tacrolimus ORAL CAPS Zortress PA Details Other B vs D determination. 30

32 IMMUNOMODULATORS Products Affected Avonex Avonex Pen Betaseron Copaxone INJ 40MG/ML Extavia Glatopa Plegridy Plegridy Starter Pack Rebif Rebif Rebidose Rebif Rebidose Titration Pack Rebif Titration Pack PA Details Other 31

33 INTRON-A Products Affected Intron A INJ 18MU, 50MU, UNIT/ML Intron A W/diluent INJ 10MU PA Covered Uses Other Details All medically accepted indications not otherwise excluded from Part-D 6 months Hepatitis C: Patient has no documented failure or intolerance to pegylated interferons 32

34 KALYDECO Products Affected Kalydeco PA Details Other 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, R117H, S1251N, S1255P, S549N, or S549R mutation in the CFTR gene. 2 years of age and older for packets. 6 years of age and older for tablets 33

35 KINERET Products Affected Kineret PA Details Other Kineret combined with TNF blocking agents 34

36 KORLYM Products Affected Korlym PA Details Other 35

37 LIDOCAINE PATCH Products Affected Lidocaine PTCH PA Details Other For the FDA-labeled indication of post-herpetic neuralgia, no additional criteria are required to be met. For diabetic neuropathic pain: the patient must have previous use and inadequate response or intolerance to any ONE medication that is FDA-labeled for diabetic peripheral neuropathy, including (but not limited to) duloxetine and Lyrica. 36

38 LONG-ACTING OPIOID ANALGESICS Products Affected Zohydro Er ORAL C12A PA Details Covered Uses All FDA approved indications not otherwise excluded from Part D. Other 37

39 METABOLIC BONE DISEASE AGENTS Products Affected Ibandronate Sodium INJ PA Details Other Intolerance to oral bisphosphonates or is unable to tolerate oral bisphosphonates due to gastrointestinal conmorbidities or is unable to adhere to dosing requirements. 38

40 MOLECULAR TARGET INHIBITORS Products Affected Bosulif Caprelsa Cometriq Farydak Gilotrif Gleevec Ibrance Iclusig Imbruvica Inlyta Jakafi Lenvima 10mg Daily Dose Lenvima 14mg Daily Dose Lenvima 20mg Daily Dose Lenvima 24mg Daily Dose Lynparza Mekinist Nexavar Pomalyst Sprycel Stivarga Sutent Synribo Tafinlar Tarceva Tasigna Tykerb Xalkori Zydelig Zykadia PA Details Other 39

41 MONOCLONAL ANTIBODIES Products Affected Xolair PA Details Other Laboratory data reflecting IgE levels greater than 30 but less than 700 IU/mL, medical history documenting previous trial and response to inhaled corticosteroids and a leukotriene receptor antagonist. 40

42 MUCOLYTICS Products Affected Pulmozyme PA Covered Uses Other Details All medically accepted indications not otherwise excluded from Part D Patient has a known hypersensitivity to dornase-alfa or to chinese Hamster ovary cell products. 41

43 MYALEPT Products Affected Myalept PA Details Other 42

44 NATPARA Products Affected Natpara PA Details Other 43

45 NON AMPHETAMINE CENTRAL NERVOUS SYSTEM AGENTS Products Affected Modafinil Nuvigil PA Details Other Documentation of diagnosis and sleep study for the diagnosis of sleep apnea or narcolepsy 44

46 NORTHERA Products Affected Northera PA Details Other Documentation from the medical record of diagnosis and prior medication history 45

47 OLYSIO Products Affected Olysio PA Covered Uses Other Details All medically accepted indications not otherwise excluded from Part D Previous failure of Olysio, Incivek or Victrelis. Documentation from the medical record of diagnosis including genotype, current medication regimen, HCV-RNA levels, history of previous HCV therapies and presence/absence of cirrhosis. Hepatologist, gastroenterologist, infectious disease specialist or managed by a liver transplant center. 12 to 24 weeks based on indication and treatment guidelines. Olysio must be used with other concurrent therapy based on indication and established treatment guidelines. For genotype 1, clinical information must be provided confirming the patient is not a candidate for Harvoni before combination therapy with Olysio and Sovaldi will be authorized. 46

48 ORAL TRETINOINS Products Affected Absorica Amnesteem Claravis Myorisan ORAL CAPS 10MG, 20MG, 40MG Zenatane PA Details Other 6 months 47

49 OTREXUP Products Affected Otrexup INJ 10MG/0.4ML, 15MG/0.4ML, 20MG/0.4ML, 25MG/0.4ML PA Details Other 48

50 PROCYSBI Products Affected Procysbi PA Details Other The patient must have failure, contraindication or intolerance to Cystagon before Procysbi will be authorized. 49

51 RASUVO Products Affected Rasuvo PA Details Other 50

52 REGRANEX Products Affected Regranex PA Covered Uses Other Details All medically accepted indications not otherwise excluded from Part-D Ulcer staging documentation using WOCN or NPUAP classification system. 3 months 51

53 RETINOIDS TOPICAL Products Affected Adapalene CREA Adapalene EXTERNAL GEL Atralin Avita Differin LOTN Retin-a Micro Pump GEL 0.08% Tretinoin EXTERNAL CREA Tretinoin EXTERNAL GEL 0.01%, 0.025% Tretinoin Microsphere Veltin Ziana PA Covered Uses Other Details All medically accepted indications not otherwise excluded from Part-D Documentation of diagnosis 6 months 52

54 REVLIMID Products Affected Revlimid PA Details Other Documentation of diagnosis 53

55 RUCONEST Products Affected Ruconest PA Details Other 54

56 SIVEXTRO Products Affected Sivextro TABS PA Details Other Documentation from the medical record of diagnosis, site of infection, recent culture and sensitivity data, current or previous treatment for infection. 30 days Use of Sivextro is considered medically necessary for use in infections resulting from MRSA. Sivextro is also considered medically accepted for other clinically appropriate infections when drug allergies prevent the use of clinically appropriate 1st-line agents in other infections. 55

57 SMOKING CESSATION PRODUCTS Products Affected Chantix ORAL TABS 0.5MG, 1MG Chantix Continuing Month Pak Chantix Starting Month Pak PA Covered Uses Other Details All FDA-approved indications not otherwise excluded from Part-D The patient must be enrolled in a behavioral support/ modification program (e.g., community program, manufacturer sponsored program, counseling by the physician, internet, or telephone quitline). The patient must be 18 years of age or older 6 months Patient has tried and failed therapy with an adequate dose of bupropion for a minimum of 7 weeks. 56

58 SOVALDI Products Affected Sovaldi PA Details Other Documentation from the medical record of diagnosis including genotype, current medication regimen, HCV-RNA levels, history of previous HCV therapies and presence/absence of cirrhosis. Hepatologist, gastroenterologist, infectious disease specialist or managed by a liver transplant center. 12 to 48 weeks based on indication and established treatment guidelines. Must be used with other concurrent therapy based on indication and established treatment guidelines. For genotype 1, clinical information must be provided confirming the patient is not a candidate for Harvoni before combination therapy with Olysio and Sovaldi will be authorized. 57

59 SYLATRON Products Affected Sylatron PA Covered Uses Other Details All medically accepted indications not otherwise excluded from Part D Documentation of diagnosis Sylatron is considered medically necessary in patients with a diagnosis of malignant melanoma 58

60 THALIDOMIDE (THALOMID) Products Affected Thalomid PA Details Other 59

61 THROMBOPOIETIN RECEPTOR AGONIST Products Affected Promacta PA Details Other Documentation of diagnosis of: a) thrombocytopenia in patients with chronic hepatitis C, or b) chronic immune (idopathic) thrombocytopenic purpura (ITP) with documentation of previous therapy with corticosteroids OR intravenous immune globuline (IVIG) therapy over a period of at least 30 days OR insufficient response to a splenectomy. Use of Promacta for the treatment of thrombocytopenia is considered medically necessary in: a) patients with chronic hepatitis C, or b) patients with chronic immune (idopathic) thrombocytopenic purpura (ITP) that have failed corticosteroid OR intravenous immune globuline (IVIG) therapy OR have had an insufficient response to a splenectomy. 60

62 TOPICAL ANTI-INFLAMMATORIES Products Affected Diclofenac Sodium GEL Flector PA Details Other Diclofenac Gel only: Dermatologist Diclofenac Gel: 3 months and Flector Patch only: 6 months 61

63 TOPICAL IMMUNOMODULATORS Products Affected Elidel Tacrolimus EXTERNAL OINT PA Covered Uses Other Details All medically accepted indications not otherwise excluded from Part-D 2 months for tacrolimus ointment and 6 months for Elidel 62

64 TRANSMUCOSAL FENTANYL CITRATE Products Affected Abstral Fentanyl Citrate Oral Transmucosal Fentora Lazanda Subsys SUBLINGUAL LIQD 100MCG, 200MCG, 400MCG, 600MCG, 800MCG PA Details Covered Uses All FDA-approved indications not otherwise excluded from Part D. Other 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 Lazanda, Abstral and Fentora 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. 63

65 VALCHLOR GEL Products Affected Valchlor PA Details Other Documentation of diagnosis and past medical history. Valchlor Topical Gel is considered medically necessary for the treatment of patients with Stage 1A and 1B mycosis fungoides-type cutaneous T- cell lymphoma who have received prior skin-directed therapy. 64

66 VASODILATORS Products Affected Adcirca Opsumit Orenitram Sildenafil Tracleer PA Details Covered Uses All FDA-approved indications not otherwise excluded from Part D. Other Documentation of pulmonary arterial hypertension 65

67 XELJANZ Products Affected Xeljanz PA Details Other 66

68 XENAZINE Products Affected Xenazine PA Details Covered Uses All medically accepted indications not otherwise excluded from part D. Other Documentation of diagnosis of chorea associated with Huntington s Disease. CYP 2D6 genotype must be provided for doses greater than 50mg/day. 67

69 XTANDI Products Affected Xtandi PA Details Other Documentation from medical records of diagnosis. Xtandi is considered medically necessary in patients who have a diagnosis of metastatic castration-resistant prostate cancer. 68

70 ZELBORAF Products Affected Zelboraf PA Details Covered Uses All medically accepted indications not otherwise excluded from part D. Other Documentation of accepted genetic test results 69

71 ZYTIGA Products Affected Zytiga PA Details Other Documentation from medical record of diagnosis. Zytiga is approved for use in combination with prednisone. 70

72 PART B VERSUS PART D Products Affected Acetylcysteine INHALATION SOLN Actemra INJ 200MG/10ML Acyclovir Sodium INJ 50MG/ML Adagen Albuterol Sulfate INHALATION NEBU Aldurazyme Aminophylline Amiodarone Hcl INJ 50MG/ML Apokyn Aralast Np INJ 400MG Argatroban INJ 125MG/125ML; 0.9%, 250MG/2.5ML Arzerra INJ 100MG/5ML Atropine Sulfate INJ 0.05MG/ML, 0.1MG/ML Bcg Vaccine Berinert Bethkis Bivigam INJ 10GM/100ML Brovana Budesonide INHALATION SUSP 0.25MG/2ML, 0.5MG/2ML Buprenorphine Hcl INJ Capastat Sulfate Cardene IV INJ 20MG/200ML; 0.86%, 40MG/200ML; 0.83% Carimune Nanofiltered INJ 6GM Cerezyme INJ 400UNIT Cidofovir Cinryze Cosmegen Cromolyn Sodium NEBU Cyclophosphamide ORAL CAPS Daunoxome Depo-provera Diltiazem Hcl INJ 100MG, 50MG/10ML Docefrez INJ 20MG Docetaxel INJ 80MG/4ML, 80MG/8ML Doxercalciferol INJ Elelyso Eligard Engerix-b Erwinaze Fabrazyme INJ 35MG Faslodex Firmagon Flebogamma Dif INJ 10% Folotyn INJ 40MG/2ML Fomepizole Foscarnet Sodium Fusilev Gablofen INJ 10000MCG/20ML, 40000MCG/20ML, 50MCG/ML Gamastan S/d Gammagard Liquid INJ 2.5GM/25ML Gammaked INJ 1GM/10ML Gammaplex INJ 10GM/200ML Gamunex-c INJ 1GM/10ML Ganciclovir INJ Granisetron Hcl INJ 0.1MG/ML H.p. Acthar Halaven Hydralazine Hcl INJ Hydromorphone Hcl INJ 500MG/50ML Ilaris Imovax Rabies (h.d.c.v.) Invega Sustenna Ipratropium Bromide INHALATION SOLN 0.02% Ipratropium Bromide/albuterol Sulfate Jevtana Kadcyla INJ 100MG Kepivance Ketorolac Tromethamine INJ 15MG/ML, 30MG/ML 71

73 Labetalol Hcl INJ Leuprolide Acetate INJ Levalbuterol NEBU Levalbuterol Hcl INHALATION NEBU 0.31MG/3ML, 0.63MG/3ML Levetiracetam INJ Levoleucovorin Calcium Lidocaine Hcl INJ 0.5%, 2% Lioresal Intrathecal INJ 0.05MG/ML, 10MG/20ML, 10MG/5ML Lumizyme Lupaneta Pack Lupron Depot Lupron Depot-ped INJ 11.25MG, 15MG Magnesium Sulfate INJ 50%, 50% Meperidine Hcl INJ 100MG/ML, 25MG/ML, 50MG/ML Methadone Hcl INJ Methyldopate Hcl Metoprolol Tartrate INJ Mozobil Myozyme Naglazyme Nalbuphine Hcl INJ Nebupent Neumega Nicardipine Hcl INJ Nitroglycerin INJ Octagam INJ 25GM/500ML, 2GM/20ML Oncaspar Ondansetron Hcl INJ 4MG/2ML, 4MG/2ML Ondansetron Hcl ORAL SOLN Ondansetron Hcl ORAL TABS Ondansetron Odt Opdivo INJ 40MG/4ML Orphenadrine Citrate INJ Pamidronate Disodium INJ 30MG/10ML, 6MG/ML, 90MG/10ML Paricalcitol INJ Penicillin G Procaine Pentam 300 Perforomist Perjeta Privigen INJ 20GM/200ML Procainamide Hcl INJ Prolastin-c Prolia Propranolol Hcl INJ Pulmicort SUSP 1MG/2ML Rabavert Recombivax Hb Remodulin Rheumatrex Rifampin INJ Simponi Aria Simulect INJ 20MG Somavert Stelara Synagis INJ 50MG/0.5ML Terbutaline Sulfate INJ Thymoglobulin Tobramycin NEBU Trelstar Mixject Trexall Trisenox Tysabri Tyvaso Uvadex Ventavis Verapamil Hcl INJ Vivitrol Vpriv Xgeva Yervoy INJ 50MG/10ML Zaltrap INJ 100MG/4ML Zanosar Zemaira Zemplar INJ Zoledronic Acid INJ 4MG/5ML, 5MG/100ML Zuplenz 72

74 Details This drug may be covered under Medicare Part B or D depending upon the circumstances. may need to be submitted describing the use and setting of the drug to make the determination. 73

75 INDEX T To create the index select this text and press the function key, F

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