Standard Specialty PA and QL List October 2013
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1 Anti-infectives Antiretrovirals, Hepatitis B Antiretrovirals, HIV Cardiology Antilipemic Pulmonary Arterial Hypertension Central Nervous System Depressant Neurotoxins Parkinson's Endocrinology & Metabolism Gonadotropins Growth Hormones and Related Therapy BARACLUDE (entecavir) HEPSERA (adefovir) TYZEKA (telbivudine ) FUZEON (enfuvirtide) SELZENTRY (maraviroc) 60 vials or 1 kit/30 days TRUVADA (emtricitabine/tenofovir) JUXTAPID (lomitapide) 20 mg JUXTAPID (lomitapide) 5 mg, 10 mg 3 tabs/day KYNAMRO (mipomersen) 4 syringes/28 days ADCIRCA (tadalafil) FLOLAN (epoprostenol) LETAIRIS (ambrisentan) REMODULIN (treprostinil) REVATIO (sildenafil) 3 tabs or vials/day TRACLEER (bosentan) TYVASO (treprostinil) 1 ampule/day VELETRI (epoprostenol) VENTAVIS (iloprost) 9 ampules/day XYREM (sodium oxybate) BOTOX (onabotulinumtoxina) 3 bottles (540 ml)/30 days DYSPORT (abobotulinumtoxina) MYOBLOC (rimabotulinumtoxinb) XEOMIN (incobotulinumtoxina) APOKYN (apomorphine) ELIGARD (leuprolide) 22.5 mg (3-month) ELIGARD (leuprolide) 30 mg (4-month) 1 injection/112 days ELIGARD (leuprolide) 45 mg (6-month) 1 injection/168 days ELIGARD (leuprolide) 7.5 mg (1-month) FIRMAGON (degarelix) 120 mg FIRMAGON (degarelix) 80 mg 2 vials/year 1 vial/28 days LUPRON (leuprolide) 1 mg/0.2 ml No QL for this strength LUPRON DEPOT (leuprolide) mg & 22.5 mg (3-month) LUPRON DEPOT (leuprolide) 3.75 mg & 7.5 mg (1-month) LUPRON DEPOT (leuprolide) 30 mg (4-month) 1 injection/112 days LUPRON DEPOT (leuprolide) 45 mg (6-month) LUPRON DEPOT-PED (leuprolide) mg & 30 mg (3-month) 1 injection/168 days LUPRON DEPOT-PED (leuprolide) 7.5 mg, mg, & 15 mg SUPPRELIN LA (histrelin acetate) 1 kit/365 days TRELSTAR (triptorelin) 22.5 mg (6-month) TRELSTAR DEPOT (triptorelin) 3.75 mg (1-month) 1 injection/168 days TRELSTAR LA (triptorelin) mg (3-month) VANTAS (histrelin) ZOLADEX (goserelin) 10.8 mg 1 implant/year ZOLADEX (goserelin) 3.6 mg EGRIFTA (tesamorelin) 1 mg 2 vials (1 mg each)/day EGRIFTA (tesamorelin) 2 mg 1 vial (2 mg each)/day GENOTROPIN (somatropin) Updated 10/10/2013 Page 1 of 6
2 Osteoporosis Somatostatins Enzyme-Related Alpha-1 proteinase inhibitor Cystine-depleting Agents Enzyme Replacement Enzyme, Gout Phenylketonuria Treatment Agents Gastroenterology Endocrinology & Metabolism HUMATROPE (somatropin) INCRELEX (mecasermin) NORDITROPIN (somatropin) NUTROPIN (somatropin) NUTROPIN AQ (somatropin) OMNITROPE (somatropin) SAIZEN (somatropin) SEROSTIM (somatropin) SOMAVERT (pegvisomant) TEV-TROPIN (somatropin) ZORBTIVE (somatropin) H.P. ACTHAR (corticotropin) PROLIA (denosumab) 2 syringes/year RECLAST (zoledronic acid) SANDOSTATIN (octreotide) SANDOSTATIN LAR (octreotide) SIGNIFOR (pasireotide) 2 ampules/day SOMATULINE DEPOT (lanreotide) ARALAST (alpha-1 proteinase inhibitor) GLASSIA (alpha-1 proteinase inhibitor) PROLASTIN (alpha-1 proteinase inhibitor) ZEMAIRA (alpha-1 proteinase inhibitor) CYSTARAN (cysteamine) 4 bottles/28 days PROCYSBI (cysteamine bitartrate) ADAGEN (pegademase) ALDURAZYME (laronidase) CARBAGLU (carglumic acid) CEREZYME (imiglucerase) ELAPRASE (idursulfase) ELELYSO (taliglucerase) FABRAZYME (agalsidase beta) LUMIZYME (alglucosidase alfa) MYOZYME (alglucosidase alfa) NAGLAZYME (galsulfase) RAVICTI (glycerol phenylbutyrate) VPRIV (velaglucerase) ZAVESCA (miglustat) KRYSTEXXA (pegloticase) KUVAN (sapropterin) Short Bowel Syndrome GATTEX (teduglutide) Immunology Anti-inflammatory Biologic Agents ACTEMRA (tocilizumab) CIMZIA (certolizumab) ENBREL (etanercept) HUMIRA (adalimumab) KINERET (anakinra) ORENCIA (abatacept) REMICADE (infliximab) SIMPONI (golimumab) Updated 10/10/2013 Page 2 of 6
3 Hematopoietic Agents Hepatitis C Agents Immune Globulins Interleukins Multiple Sclerosis Immunology SIMPONI ARIA (golimumab) STELARA (ustekinumab) XELJANZ (tofacitinib) ARANESP (darbepoetin alfa) EPOGEN (epoetin alfa) LEUKINE (sargramostim) MOZOBIL (plerixafor) 8 vials (9.6 ml) per transplant NEULASTA (pegfilgrastim) NEUMEGA (oprelvekin) NEUPOGEN (filgrastim) NPLATE (romiplostim) OMONTYS (peginesatide) PROCRIT (epoetin alfa) PROMACTA (eltrombopag) 12. 5mg, 25 mg 3 tabs/day PROMACTA (eltrombopag) 50 mg, 75 mg SOLIRIS (eculizumab) INCIVEK (telaprevir) INFERGEN (interferon alfacon-1) PEGASYS (peginterferon alfa-2a) PEG-INTRON (peginterferon alfa-2b) VICTRELIS (boceprevir) BIVIGAM (immune globulin) CARIMUNE (immune globulin) CYTOGAM (cytomegalovirus immune globulin) FLEBOGAMMA (immune globulin) FLEBOGAMMA DIF (immune globulin) GAMASTAN (immune globulin) GAMMAGARD (immune globulin) GAMMAKED (immune globulin) GAMMAPLEX (immune globulin) GAMUNEX (immune globulin) GAMUNEX-C (immune globulin) HIZENTRA (immune globulin) OCTAGAM (immune globulin) PRIVIGEN (immune globulin) VARIZIG (varicella-zoster immune globulin) ARCALYST (rilonacept) ILARIS (canakinumab) BENLYSTA (belimumab) AMPYRA (dalfampridine) AUBAGIO (teriflunomide) AVONEX (interferon beta-1a) 1 kit (4 syringes)/28 days BETASERON (interferon beta-1b) 1 package/28 days COPAXONE (glatiramer) 1 kit/30 days EXTAVIA (interferon beta-1b) 1 package/28 days GILENYA (fingolimod) 1 cap/day NOVANTRONE (mitoxantrone) REBIF (interferon beta-1a) 12 syringes/28 days TECFIDERA (dimethyl fumarate) 120 mg 14 caps/year TECFIDERA (dimethyl fumarate) 240 mg 2 caps/day TECFIDERA (dimethyl fumarate) Starter Pack 2 starter packs/year TYSABRI (natalizumab) 1 injection /28 days Updated 10/10/2013 Page 3 of 6
4 Immunology Transplant NULOJIX (belatacept) ZORTRESS (everolimus) Collagenase XIAFLEX (collagenase clostridium histolyticum) Diagnostic Movement Disorder Agents THYROGEN (thyrotropin alfa) XENAZINE (tetrabenazine) 6 vials/year Toxicology EXJADE (deferasirox) FERRIPROX (deferiprone) Viscosupplements EUFLEXXA (sodium hyaluronate) GEL-ONE (sodium hyaluronate) HYALGAN (sodium hyaluronate) ORTHOVISC (sodium hyaluronate) SUPARTZ (sodium hyaluronate) SYNVISC (sodium hyaluronate) SYNVISC-ONE (sodium hyaluronate) Obstetrics & Gynecology Hormone Replacement MAKENA (hydroxyprogesterone caproate) Oncology Alkylating Agents Antiandrogen Antimicrotubular Interferons Kinase and Molecular Target Inhibitors MYLERAN (busulfan) TEMODAR (temozolomide) XTANDI (enzalutamide ) ZYTIGA (abiraterone) HALAVEN (eribulin) JEVTANA (cabazitaxel) INTRON A (interferon alfa-2b) SYLATRON (peginterferon alfa-2b) AFINITOR (everolimus) AFINITOR DISPERZ (everolimus) BOSULIF (bosutinib) CAPRELSA (vandetanib) 100 mg CAPRELSA (vandetanib) 300 mg No QL for this strength COMETRIQ (carbozantinib) ERIVEDGE (vismodegib) GILOTRIF (afatinib) GLEEVEC (imatinib) ICLUSIG (ponatinib) 15 mg ICLUSIG (ponatinib) 45 mg No QL for this strength INLYTA (axitinib) JAKAFI (ruxolitinib) KYPROLIS (carfilzomib) MEKINIST (trametinib) NEXAVAR (sorafenib) PERJETA (pertuzumab) SPRYCEL (dasatinib) STIVARGA (regorafenib) SUTENT (sunitinib) TAFINLAR (dabrafenib) TARCEVA (erlotinib) TASIGNA (nilotinib) TYKERB (lapatinib) VELCADE (bortezomib) Updated 10/10/2013 Page 4 of 6
5 Monoclonal Antibody Thalidomide-related Agents Respiratory Asthma/COPD Cystic fibrosis Respiratory Syncytial Virus Agents Oncology VOTRIENT (pazopanib) XALKORI (crizotinib) ZALTRAP (ziv-aflibercept) ZELBORAF (vemurafenib) DACOGEN (decitabine) ERWINAZE (asparaginase) ISTODAX (romidepsin) SYNRIBO (omacetaxine) TARGRETIN (bexarotene) VIDAZA (azacitidine) XELODA (capecitabine) ZOLINZA (vorinostat) ZOMETA (zoledronic acid) ADCETRIS (brentuximab) HERCEPTIN (trastuzumab) KADCYLA (ado-trastuzumab emtansine) RITUXAN (rituximab) XGEVA (denosumab) QL Varies* YERVOY (ipilimumab) POMALYST (pomalidomide) REVLIMID (lenalidomide) THALOMID (thalidomide) XOLAIR (omalizumab) BETHKIS (tobramycin) CAYSTON (aztreonam) KALYDECO (ivacaftor) PULMOZYME (dornase alfa) TOBI (tobramycin) TOBI PODHALER (tobramycin) 1 package (224 tabs)/56 days SYNAGIS (palivizumab) Updated 10/10/2013 Page 5 of 6
6 Standard QL Programs Therapeutic Category Drug Name Dispensing Limit Anti-infectives Antiretrovirals, HIV ATRIPLA (efavirenz/emtricitabine/tenofovir) COMPLERA (emtricitabine/rilpivirine/tenofovir) STRIBILD (elvitegravir/cobicistat/emtricitabine/tenofovir) TRIZIVIR (abacavir/lamivudine/zidovudine) Cardiology Anticoagulants, LMWH ARIXTRA (fondaparinux) 35 days supply/180 days FRAGMIN (dalteparin) LOVENOX (enoxaparin) 35 days supply/180 days 35 days supply/180 days Endocrinology & Metabolism Osteoporosis Vasopressin Antagonist FORTEO (teriparatide) SAMSCA (tolvaptan) 1 syringe/28 days 30 days/60 days Obstetrics & Gynecology Fertility Agents BRAVELLE (urofollitropin) CETROTIDE (cetrorelix) 0.25 mg 60 vials/30 days 14 boxes/30 days CETROTIDE (cetrorelix) 3 mg 1 box/30 days Chorionic gonadotropin (chorionic gonadotropin) 20 ml/30 days FOLLISTIM AQ (follitropin beta) 30 vials or 20 cartridges/30 days Ganirelix acetate (ganirelix) 20 syringes (0.5 ml)/30 days GONAL-F (follitropin alfa) 3 vials/30 days GONAL-F RFF (follitropin alfa) OVIDREL (choriogonadotropin) 60 pens or vials/30 days 2 syringes (1 ml)/30 days REPRONEX (menotropins) 60 vials/30 days Hormone Replacement CRINONE (progesterone) 8% 54 applicators/30 days PLEASE NOTE: This drug list is subject to periodic updates and may not be all inclusive. Drugs affected include both brand and generic where applicable and includes all dosage formulations unless otherwise specifically notated. If a new drug is approved and falls into one of the targeted PA categories, the new drug may automatically be added to this list. Quantity limits may also apply. *Quantity limits are built into the PA criteria approval and varies based on indication and/or other clinical factors. Updated 10/10/2013 Page 6 of 6
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