N/A N/A N/A. Supporting statement of diagnosis from the N/A. physician and documented trial of 1 generic. formulary alternative

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1 Actimmune Amlodipine Androderm Anticonvulsant Antidepressants Antineoplastics Antipsychotics Arcalyst Butalbital Colony Stimulating Factors ESRD Therapy Actimmune Norvasc Androderm Banzel Keppra Mysoline Neurontin Sabril Abilify Abilify Discmelt Pamelor Prozac Afinitor Avastin Gleevac Istodax Nexavar Revlimid Rituxan Spyrcel Sutent Tarceva Targretin Tasigna Thalomid Tretinoin Tykerb Velcade Vidaza Votrient Fanapt Arcalyst Fioricet w/cod Leukine Mozobil Neulasta Neupogen Procrit Supporting statement of diagnoisis from the and ANC requirement (less than or equal to 1000 cells/mm3). For PA extension, need to provide new labs (WBC Hemogloblin less than 10 g/dl for patients receiving Cancer Chemotherapy and Hemoglobin less than 12 and Hematacrit less than 33 for other approved FDA indications in addition to supporting statement of diagnosis from 3 months 3 months Exjade Exjade Fenofibrate Lipofen Lofibra 12/31/2012 Last Updated: 09/21/2011 Page 1 of 7

2 Fentanyl Fentanyl Lozenge Fentora Firmagon Fosamax Gamunex Growth Hormone Hepatitis C Hydrocodone Imitrex Imuran Kuvan Fentora Onsolis Firmagon Fosamax Gamunex Humatrope Nutropin Nutropin AQ Omnitrope Saizen Serostim Infergan Pegasys Pegintron Ribapak Ribavirin Lorcet Lortab Norco Imitrex Imuran Kuvan, submission of pretreatment viral titers (HCV RNA) and genotype. For genotypes 1 and 4 submission of documentation of RNA load at 12 weeks 12/31/ weeks Letairis Letairis Lidoderm Lidoderm Loprox Lupron Marinol Mestinon Minocycline Mirapex Loprox Leuprolide Acetate Lupron Depot Lupron Depot-Ped Marinol Mestinon Minocin Oracea Solodyn Mirapex 12/31/2012 Last Updated: 09/21/2011 Page 2 of 7

3 Mobic Mobic MS Contin Multiple Sclerosis Nifedipine Noxafil Octreotide Oxandrolone Oxycodone Parlodel Pravachol Prilosec Privigen Proscar Provigil Razadyne Revatio Rheumatoid Ritalin Samsca MS Contin Ampyra Avonex Betaseron Rebif Rebif Titration Pack Procardia Noxafil Octreotide Acetate Sandostatin Oxandrin Oxycontin Percocet Percodan Roxicodone Parlodel Pravachol Prilosec Privigen Proscar Nuvigil Provigil Razadyne Revatio Enbrel Humira Humira Pen-Crohns Kineret Orencia Simponi Ritalin Samsca 12/31/ /31/ /31/2012 Last Updated: 09/21/2011 Page 3 of 7

4 Sinemet Sinemet Soma Somatuline Fexmid Soma Somatuline Somavert Somavert Sonata Sporanox Symlin Terbinafine Sonata Sporanox Sporanox Pulsepack Symlin Symlinpen Terbinafine 12/31/2012 Tracleer Tracleer Uloric Uloric Xenazine Xenazine Xolair Xolair Zolinza Zolinza Last Updated: 09/21/2011 Page 4 of 7

5 Albuterol Sulfate Albuterol/Ipratropium Alimta Amifostine Aminosyn Aminosyn/Electrolyte Aminosyn/Dextrose Aminosyn M Aminosyn-HBC Aminosyn-HF Aminosyn-PF AMPHOTERICIN B Ampicillin/Sulbactam Arzerra Atgam Azathioprine Bleomycin Sulfate Busuflex This drug may be covered under Calcitonin-Salmon Medicare Part B or D depending Calcitrol upon the circumstances. Part B/D Drugs Cellcept Information may need to be Drugs A through F Cerezyme submitted describing the use and Chlorpromazine hcl setting of the drug to make the Clinimix/Dextrose determination. Clinimix E/Dextrose Clinisol SF Colistimathate Sodium Copaxone Cromolyn Sodium Cyclophosphamide Cyclosporine Cyclosporine Modified Dextrose/NACL Doxycyline Dronabinol Etoposide Fabrazyme Fluconazole Fortical Foscarnet Sodium Freamine III Last Updated: 09/21/2011 Page 5 of 7

6 Gamastan S/D Gammagard Liquid Gemzar Gengraf Granisetron hcl Granisol Hectoral HECTOROL Heparin Sodium Heparin Sodium DCU Hepatamine Hycamtin Idamycin Idarubicin hcl Ifex Ifosfamide/Mesna Ifosfamide Ipratropium Bromide KCL/D5W/LR Leucovorin Leustatin Levalbuterol This drug may be covered under Levocartine Medicare Part B or D depending Melphalan upon the circumstances. Part B/D Drugs Mesna Information may need to be Drugs G through P Mesnex submitted describing the use and Miacalcin setting of the drug to make the Mitoxantrone hcl determination. Mustargen Mycophenolate Mofetil Myfortic Nebupent Neoral Nephramine Nipent Novantrone Ondansetron, Ondandestron ODT Orthoclone Oxaliplatin Paclitaxel Pentam Pentostatin Performist Premasol Procalamine Prochlorperazine Maleate Prograf Prosol Pulmicort Pulmozyme Last Updated: 09/21/2011 Page 6 of 7

7 Rapamune Rocaltrol Sancuso Sandimmune Simulect Sodium Chloride Tacrolimus This drug may be covered under Thymoglobulin Medicare Part B or D depending Tobi upon the circumstances. Part B/D Drugs Torisel Information may need to be Drugs R through Z Travasol submitted describing the use and Trisenox setting of the drug to make the Vancocin hcl determination. Vancomycin hcl Ventavis Vivaglobin Zemplar Zometa Zortress Last Updated: 09/21/2011 Page 7 of 7

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