2016 Prior Authorization Requirements

Transcription

1 Group Health Medicare Advantage HMO 2016 PLEASE READ: Group Health requires you to get prior authorization for certain drugs. This means that you will need to get approval from Group Health before you fill your prescriptions. If you don t get approval, Group Health may not cover the drug. The medications in this document have requirements that must be met for coverage to be considered. Beneficiaries must use network pharmacies to access their prescription drug benefit. Group Health Cooperative Medicare Advantage is an HMO plan with a Medicare contract. Enrollment in Group Health HMO depends on contract renewal. Y0033_RXPAWEB_2016v2 Formulary ID Version 7 Last updated:11/ MED

2 Y0033_RXPAWEB_2016v2 Formulary ID Version 7 Last updated:11/ MED

3 ADCIRCA ADCIRCA

4 AMITRIPTYLINE AMITRIPTYLINE HCL CHLORDIAZEPOXIDE-AMITRIPTYLINE PERPHENAZINE- AMITRIPTYLINE ALL MEDICALLY ACCEPTED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D. APPLIES TO PATIENTS 64 YEARS OF AGE AND OLDER. PA NOT REQUIRED FOR AGE 0-63 YEARS. FOR DEPRESSION: PATIENTS MUST TRY AND FAIL NORTRIPTYLINE AND AN SSRI SUCH AS FLUOXETINE, CITALOPRAM, OR SERTRALINE. FOR SLEEP: PATIENTS MUST TRY AND FAIL LOW-DOSE DOXEPIN (LESS THAN OR EQUAL TO 6MG/DAY) AND PRESCRIBER MUST ATTEST THAT THE BENEFIT OF USING AMITRIPTYLINE OUTWEIGHS THE RISKS. AMITRIPTYLINE IS CONSIDERED A HIGH RISK MEDICATION IN THE ELDERLY. FOR NEUROPATHIC PAIN: AFTER FAILURE OF 2 PREFERRED AGENTS, ONE OF WHICH IS NORTRIPTYLINE (E.G., GABAPENTIN, VENLAFAXINE).

5 ANAKINRA KINERET ALL MEDICALLY ACCEPTED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D. COVERED FOR PATIENTS WITH RHEUMATOID ARTHRITIS WHO HAVE FAILURE, SIGNIFICANT SYSTEMIC INTOLERANCE, OR CONTRAINDICATION TO 1) ADALIMUMAB, ETANERCEPT, OR INFLIXIMAB, AND 2) ABATACEPT. COVERED FOR ACTIVE SYSTEMIC JUVENILE IDIOPATHIC ARTHRITIS.

6 ARMODAFINIL NUVIGIL ALL MEDICALLY ACCEPTED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D.

7 AVONEX AVONEX AVONEX ADMINISTRATION PACK AVONEX PEN COVERED FOR PATIENTS WHO HAVE FAILURE, CONTRAINDICATION, OR INTOLERANCE TO TWO OR MORE OF THE FOLLOWING: REBIF, EXTAVIA, OR COPAXONE.

8 AZTREONAM INHALATION CAYSTON

9 BETASERON BETASERON COVERED FOR PATIENTS WHO HAVE FAILURE OR INTOLERANCE TO TWO OR MORE OF THE FOLLOWING: REBIF, EXTAVIA, OR COPAXONE.

10 BOTULINUM TOXIN BOTOX DYSPORT XEOMIN

11 CARISOPRODOL CARISOPRODOL CARISOPRODOL-ASPIRIN CARISOPRODOL-ASPIRIN-CODEINE SOMA 30 DAYS MEMBERS 65 YEARS OR OLDER WILL BE EVALUATED FOR MORE THAN ONE FILL WITHIN THE CURRENT PLAN YEAR. THE PRESCRIBER MUST ATTEST THAT THEY ARE AWARE THAT THE MEDICATION IS CONSIDERED A HIGH RISK MEDICATION IN THE ELDERLY AND THAT THE BENEFITS OUTWEIGH THE RISKS.

12 CERTOLIZUMAB CIMZIA COVERED FOR PATIENTS WITH RHEUMATOID ARTHRITIS, PSORIATIC ARTHRITIS, AND ANKYLOSING SPONDYLITIS WHO HAVE FAILURE, SIGNIFICANT SYSTEMIC INTOLERANCE, OR CONTRAINDICATION TO TWO FORMULARY ANTI-TNF AGENTS (ADALIMUMAB, ETANERCEPT, INFLIXIMAB). COVERED FOR PATIENTS WITH CROHN'S DISEASE WHO HAVE FAILED INFLIXIMAB AND ADALIMUMAB.

13 CORTICOTROPIN H.P. ACTHAR CONTRAINDICATION TO CORTICOSTEROIDS WHEN USED FOR THE TREATMENT OF ACUTE EXACERBATIONS OF MULTIPLE SCLEROSIS.

14 CYSTEAMINE DELAYED-RELEASE PROCYSBI A TRIAL OF CYSTEAMINE BITARTRATE (CYSTAGON).

15 DALFAMPRIDINE AMPYRA NOT COVERED FOR PATIENTS WITH MODERATE TO SEVERE RENAL IMPAIRMENT (CRCL LESS THAN 50 ML/MIN) OR A HISTORY OF SEIZURES. COVERED FOR PATIENTS WITH A DIAGNOSIS OF MULTIPLE SCLEROSIS, AND 1) IF DIAGNOSIS IS RELAPSING, REMITTING MULTIPLE SCLEROSIS (RRMS), PATIENT IS RECEIVING CONCOMITANT THERAPY WITH A DISEASE MODIFYING DRUG (E.G. INTERFERON, GLATIRAMER, FINGOLIMOD, TERIFLUNOMIDE, DIMETHYL FUMARATE), AND 2) PATIENT IS EXPERIENCING SIGNIFICANT LIMITATIONS IN CORE DAILY ACTIVITIES (E.G. MEAL PREPARATION, HOUSEHOLD CHORES) ATTRIBUTABLE TO SLOW AMBULATION, AND 3) PATIENT HAS THE ABILITY TO AMBULATE AT LEAST 25 FEET AND HAS A DOCUMENTED 25-FOOT WALK TEST.

16 DICLOFENAC TRANSDERMAL FLECTOR ALL MEDICALLY ACCEPTED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D.

17 DIMETHYL FUMARATE TECFIDERA ACTIVE INFECTION OR WBC LESS THAN LOWER LIMIT OF NORMAL (LESS THAN 500,000,000/L). 1) DIAGNOSIS OF RELAPSING-REMITTING OR RELAPSING FORMS OF SECONDARY PROGRESSIVE MS BASED ON MCDONALD CRITERIA, AND 2) EDSS SCORE LESS THAN OR EQUAL TO 5.0. FAILURE OR INTOLERANCE TO INTERFERON OR GLATIRAMER. MINOR INJECTION SITE REACTIONS ALONE ARE NOT CONSIDERED MEDICATION FAILURE OR INTOLERANCE QUALIFIED FOR COVERAGE APPROVAL.

18 DRUGS WITH PRIOR AUTHORIZATION FOR PURPOSE OF VERIFYING B VS D COVERAGE A-HYDROCORT ACETYLCYSTEINE AKYNZEO ALBUTEROL SULFATE ANZEMET ARANESP ASTAGRAF XL AZASAN AZATHIOPRINE BCG (TICE STRAIN) BONIVA BROVANA BUDESONIDE CALCITRIOL CARNITOR CARNITOR SF CELLCEPT CORTEF CORTISONE ACETATE CROMOLYN SODIUM CUBICIN CYCLOPHOSPHAMIDE CYCLOSPORINE CYCLOSPORINE MODIFIED DEPO- MEDROL DEXAMETHASONE DEXAMETHASONE SODIUM PHOSPHATE DIPHTHERIA-TETANUS TOXOIDS-PED DOXERCALCIFEROL EMEND EMLA ENGERIX-B ADULT ENGERIX-B PEDIATRIC-ADOLESCENT EPOGEN GABLOFEN GENGRAF GRANISETRON HCL HECTOROL HEPARIN SODIUM HYDROCORTISONE IBANDRONATE SODIUM IMOVAX RABIES VACCINE IMURAN IPRATROPIUM BROMIDE IPRATROPIUM-ALBUTEROL LEVALBUTEROL HCL LEVOCARNITINE LIDOCAINE LIDOCAINE HCL LIDOCAINE-PRILOCAINE LIORESAL INTRATHECAL MARINOL MEDROL METHYLPREDNISOLONE METHYLPREDNISOLONE ACETATE METHYLPREDNISOLONE SOD SUCC MIACALCIN MILLIPRED MIRCERA MYCOPHENOLATE MOFETIL MYCOPHENOLIC ACID MYFORTIC NEBUPENT NEORAL NULOJIX OCTAGAM ONDANSETRON HCL ONDANSETRON ODT ORAPRED ODT PAMIDRONATE DISODIUM PARICALCITOL PERFOROMIST PREDNISOLONE SODIUM PHOSPHATE PREDNISONE PREDNISONE INTENSOL PROCRIT PROGRAF PULMICORT PULMOZYME RABAVERT RAPAMUNE RAYOS RECOMBIVAX HB REMODULIN ROCALTROL SANDIMMUNE SIMULECT SIROLIMUS SOLU-CORTEF SOLU- MEDROL TACROLIMUS TENIVAC TETANUS DIPHTHERIA TOXOIDS TYVASO VANCOMYCIN HCL VENTAVIS VERIPRED 20 VIRAZOLE XOPENEX XYLOCAINE ZEMPLAR ZOFRAN ZOFRAN ODT ZORTRESS ZUPLENZ THIS DRUG MAY BE COVERED UNDER MEDICARE PART B OR D DEPENDING UPON THE CIRCUMSTANCES. INFORMATION MAY NEED TO BE SUBMITTED DESCRIBING THE USE AND SETTING OF THE DRUG TO MAKE THE DETERMINATION.

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20 ESTROGENS ACTIVELLA ALORA ANGELIQ CLIMARA CLIMARA PRO COMBIPATCH DELESTROGEN DEPO-ESTRADIOL DIVIGEL DUAVEE ELESTRIN ENJUVIA ESTRACE ESTRADIOL ESTRADIOL VALERATE ESTRADIOL-NORETHINDRONE ACETAT ESTROPIPATE EVAMIST FEMHRT JINTELI LOPREEZA MENEST MENOSTAR MIMVEY MIMVEY LO MINIVELLE PREFEST PREMARIN PREMPHASE PREMPRO VIVELLE-DOT All FDA-approved indications not otherwise excluded from Part D. Applies to patients 64 years of age and older. Prior authorization not required for patients age 0 to 63 years. One year Members 64 years of age and older will be evaluated for more than one fill within the current plan year. For vaginal/vulvar atrophy, patient must try and fail two of the following: Estrace vaginal cream, Premarin vaginal cream, Estring, Vagifem. For postmenopausal osteoporosis, patient must try and fail two of the following: alendronate, ibandronate, raloxifene. For abnormal vasomotor function, patients must try and fail Femring. Use in cancer, palliative care, or hypoestrogenism due to hypogonadism, castration or primary ovarian failure will be approved.

21 FENTANYL TRANSMUCOSAL ABSTRAL ACTIQ FENTANYL CITRATE FENTORA LAZANDA SUBSYS

22 FINGOLIMOD GILENYA NOT COVERED FOR PATIENTS WITH 1) ACTIVE INFECTION OR IMMUNOSUPPRESSION, 2) SECOND DEGREE OR HIGHER AV BLOCK, SICK SINUS SYNDROME, 3) PROLONGED QT INTERVAL, ISCHEMIC HEART DISEASE, CONGESTIVE HEART FAILURE, ARRHYTHMIA REQUIRING CLASS IA OR CLASS III ANTI-ARRHYTHMIC DRUG, 4) PULMONARY DISEASE (E.G. COPD, ASTHMA), OR 5) MACULAR EDEMA. COVERED FOR PATIENTS WITH 1) DIAGNOSIS OF RELAPSING-REMITTING OR RELAPSING FORMS OF SECONDARY PROGRESSIVE MULTIPLE SCLEROSIS BASED ON MCDONALD CRITERIA, AND 2) EDSS (EXPANDED DISABILITY STATUS SCALE) SCORE LESS THAN OR EQUAL TO 5.5, AND 3) WITH FAILURE OR INTOLERANCE TO INTERFERON OR GLATIRAMER - MINOR INJECTION SITE REACTIONS ALONE ARE NOT CONSIDERED MEDICATION FAILURE OR INTOLERANCE QUALIFIED FOR COVERAGE.

23 GLATIRAMER 40 MG COPAXONE COVERED FOR PATIENTS WITH 1) DIAGNOSIS OF RELAPSING-REMITTING OR RELAPSING FORMS OF SECONDARY PROGRESSIVE MS BASED ON MCDONALD CRITERIA, AND 2) EDSS (EXPANDED DISABILITY STATUS SCALE) SCORE LESS THAN OR EQUAL TO 5.5, AND 3) WITH FAILURE OR INTOLERANCE TO GLATIRAMER 20 MG/ML AND ONE OTHER DISEASE MODIFYING DRUG (E.G. INTERFERON, FINGOLIMOD, TERIFLUNOMIDE, DIMETHYL FUMARATE). MINOR INJECTION SITE REACTIONS ALONE ARE NOT CONSIDERED MEDICATION FAILURE OR INTOLERANCE QUALIFIED FOR COVERAGE.

24 GOLIMUMAB SIMPONI SIMPONI ARIA COVERED FOR PATIENTS WITH RHEUMATOID ARTHRITIS WHO HAVE FAILURE, SIGNIFICANT SYSTEMIC INTOLERANCE, OR CONTRAINDICATION TO 1) ADALIMUMAB, ETANERCEPT, OR INFLIXIMAB, AND 2) ABATACEPT. COVERED FOR PATIENTS WITH ULCERATIVE COLITIS WHO HAVE FAILED INFLIXIMAB AND ADALIMUMAB.

25 HIGH-RISK NSAIDS INDOCIN INDOMETHACIN KETOROLAC TROMETHAMINE SPRIX TIVORBEX APPLIES TO PATIENTS 64 YEARS OF AGE AND OLDER. PRIOR AUTHORIZATION NOT REQUIRED FOR PATIENTS AGE 0 TO 63 YEARS. MEMBERS 64 YEARS OF AGE AND OLDER WILL BE EVALUATED FOR MORE THAN ONE FILL WITHIN THE CURRENT PLAN YEAR. PATIENTS MUST TRY AND FAIL NAPROXEN AND IBUPROFEN.

26 HYDROCODONE ER HYSINGLA ER ZOHYDRO ER TRIAL AND INTOLERANCE OF MORPHINE EXTENDED-RELEASE AND OXYCODONE EXTENDED-RELEASE.

27 IVACAFTOR KALYDECO IVACAFTOR WILL NOT BE COVERED FOR: 1) CF PATIENTS HOMOZYGOUS FOR THE F508-DEL MUTATION IN THE CFTR GENE. 2) PATIENTS ON CONCOMITANT THERAPY WITH STRONG CYP3A INDUCERS (E.G., RIFAMPIN, ST. JOHN S WORT). 3) PATIENTS WITH ELEVATED TRANSAMINASES (ALT OR AST) MORE THAN 5 TIMES THE UPPER LIMIT OF NORMAL. ORAL GRANULES ARE COVERED FOR PATIENTS 2 YEARS OF AGE OR OLDER. ORAL TABLETS ARE COVERED FOR PATIENTS 6 YEARS OF AGE OR OLDER. CYSTIC FIBROSIS WITH AT LEAST ONE COPY OF THE G551D MUTATION IN THE CYSTIC FIBROSIS TRANSMEMBRANE CONDUCTANCE REGULATOR (CFTR) GENE.

28 LEDIPASVIR-SOFOSBUVIR HARVONI MUST BE PRESCRIBED BY OR IN CONSULTATION WITH INFECTIOUS DISEASE SPECIALIST, GASTROENTEROLOGY SPECIALIST, OR HEPATOLOGIST. 12WK UNLESS: GT1/4 TX-EXP AND CIRRHOTIC, GT1/4 POST-TRANSPLANT AND INELIGIBLE FOR RBV 24WK PROVIDER ATTESTS THAT MEDICATION ADHERENCE HAS BEEN DISCUSSED AND HE/SHE IS CONFIDENT IN THE PATIENT'S ABILITY TO MAINTAIN MEDICATION ADHERENCE.

29 LIDOCAINE TRANSDERMAL LIDOCAINE LIDODERM ALL MEDICALLY ACCEPTED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D.

30 LOMITAPIDE JUXTAPID

31 MIFEPRISTONE 300MG KORLYM PREGNANCY.

32 MIPOMERSEN KYNAMRO

33 MODAFINIL MODAFINIL PROVIGIL ALL MEDICALLY ACCEPTED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D.

34 NINTEDANIB OFEV MUST BE PRESCRIBED BY OR IN CONSULTATION WITH A PULMONOLOGIST.

35 NON BENZODIAZEPINE HYPNOTICS AMBIEN AMBIEN CR EDLUAR ESZOPICLONE INTERMEZZO LUNESTA SONATA ZALEPLON ZOLPIDEM TARTRATE ZOLPIDEM TARTRATE ER ZOLPIMIST APPLIES TO PATIENTS 64 YEARS OF AGE AND OLDER. PA NOT REQUIRED FOR AGE 0-63 YEARS. MEMBERS 64 YEARS OR OLDER WILL BE EVALUATED FOR MORE THAN ONE FILL WITHIN THE CURRENT PLAN YEAR. FOR INSOMNIA, PATIENTS MUST HAVE TRIAL, FAILURE, OR CONTRAINDICATION TO TRAZODONE AND EITHER LOW DOSE DOXEPIN (LESS THAN OR EQUAL TO 6 MG/DAY) OR MIRTAZAPINE.

36 OTEZLA OTEZLA STARTER PACK WILL BE APPROVED FOR NEW STARTS TO REDUCE GASTROINTESTINAL SIDE EFFECTS. WILL NOT BE APPROVED FOR USE IN COMBINATION WITH BIOLOGIC THERAPY (E.G. HUMIRA, ENBREL, STELARA, COSENTYX).

37 PEGINTERFERON BETA-1A (PLEGRIDY) PLEGRIDY ALL FDA-APPROVED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D COVERED FOR PATIENTS WHO HAVE FAILURE OR INTOLERANCE TO TWO OR MORE OF THE FOLLOWING: REBIF, EXTAVIA, OR COPAXONE.

38 PIRFENIDONE ESBRIET MUST BE PRESCRIBED BY OR IN CONSULTATION WITH A PULMONOLOGIST.

39 REVATIO REVATIO

40 SECUKINUMAB COSENTYX (2 SYRINGES) COSENTYX PEN (2 PENS) COVERED FOR THE TREATMENT OF MODERATE TO SEVERE PLAQUE PSORIASIS IN PATIENTS WHO HAVE TRIED AND FAILED TWO ANTI-TNF AGENTS (ADALIMUMAB, ETANERCEPT, INFLIXIMAB).

41 SILDENAFIL REVATIO SILDENAFIL

42 SIMEPREVIR OLYSIO MUST BE PRESCRIBED BY OR IN CONSULTATION WITH INFECTIOUS DISEASE SPECIALIST, GASTROENTEROLOGY SPECIALIST, OR HEPATOLOGIST. 12WKS UNLESS CIRRHOTIC: 24WKS, POST-LIVER TRANSPLANT: 24 WKS COVERED FOR PATIENTS 1) WITH CHRONIC HEPATITIS C GENOTYPE 1, AND 2) WHO HAVE CONTRAINDICATION OR INTOLERANCE TO HARVONI. NOT COVERED IN PATIENTS WHO HAVE FAILED PREVIOUS TREATMENT WITH EITHER BOCEPREVIR/TELAPREVIR.

43 SKELETAL MUSCLE RELAXANTS AMRIX CYCLOBENZAPRINE HCL FEXMID MEPROBAMATE METAXALONE METHOCARBAMOL ORPHENADRINE CITRATE SKELAXIN APPLIES TO PATIENTS 65 YEARS OF AGE AND OLDER. PA NOT REQUIRED FOR PATIENTS AGE 0 TO 64 YEARS. 30 DAYS EXCEPT MEPROBAMATE 4 MONTHS MEMBERS 65 YEARS OR OLDER WILL BE EVALUATED FOR MORE THAN ONE FILL WITHIN THE CURRENT PLAN YEAR. THE PRESCRIBER MUST ATTEST THAT THEY ARE AWARE THAT THE MEDICATION IS CONSIDERED A HIGH RISK MEDICATION IN THE ELDERLY AND THAT THE BENEFITS OUTWEIGH THE RISKS.

44 SODIUM OXYBATE XYREM COVERED FOR PATIENTS 1) WITH NARCOLEPSY WITH CATAPLEXY WHO ARE ON CONCURRENT THERAPY WITH A STIMULANT (AMPHETAMINE, AMPHETAMINE/DEXTROAMPHETAMINE, ARMODAFINIL, DEXTROAMPHETAMINE, METHYLPHENIDATE, MODAFINIL) OR WHO HAVE CONTRAINDICATION, INTOLERANCE, OR FAILURE TO A STIMULANT. OR 2) WITH EXCESSIVE DAYTIME SLEEPINESS IN NARCOLEPSY WHO HAVE CONTRAINDICATION, INTOLERANCE, OR FAILURE TO A STIMULANT.

45 SOFOSBUVIR SOVALDI ALL FDA-APPROVED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D MUST BE PRESCRIBED BY OR IN CONSULTATION WITH INFECTIOUS DISEASE SPECIALIST, GASTROENTEROLOGY SPECIALIST, OR HEPATOLOGIST. 12WK UNLESS GT2 CIRRHOSIS (C) 16WK, GT1-C, GT2/4 TX-EX, GT3, GT2/3 POST-TX 24WK, GT2/3 DECOMP 48WK COVERED FOR 1) WITH CHRONIC HEPATITIS C GENOTYPE 1,2,3,4,5 OR 6. NOT COVERED 1) IN COMBINATION WITH SIMEPREVIR OR DACLATASVIR UNLESS THE PATIENT IS GENOTYPE 1 AND HAS A CONTRAINDICATION OR INTOLERANCE TO HARVONI OR THE PATIENT IS GENOTYPE 2 AND HAS A CONTRAINDICATION OR INTOLERANCE TO RIBAVIRIN OR THE PATIENT IS GENOTYPE 3 AND HAS A CONTRAINDICATION OR INTOLERANCE TO RIBAVIRIN OR INTERFERON, OR 2) PATIENT HAS CRCL LESS THAN 30 ML/MIN.

46 SOMATROPIN GENOTROPIN HUMATROPE NORDITROPIN FLEXPRO NORDITROPIN NORDIFLEX NUTROPIN AQ NUSPIN OMNITROPE SAIZEN SEROSTIM ZOMACTON ZORBTIVE

47 TADALAFIL CIALIS COVERED FOR TREATMENT OF THE SIGNS AND SYMPTOMS OF BENIGN PROSTATIC HYPERPLASIA AT THE FDA-APPROVED DOSE FOR THIS INDICATION (DOSE MAY NOT EXCEED 5MG/DAY), PROVIDED THAT THE PATIENT HAS HAD FAILURE, INTOLERANCE OR CONTRAINDICATION TO ONE FORMULARY ALPHA-1 ADRENERGIC BLOCKING AGENTS (E.G. PRAZOSIN, DOXAZOSIN, TERAZOSIN, TAMSULOSIN), AND HAS HAD FAILURE, INTOLERANCE OR CONTRAINDICATION TO ONE 5-ALPHA-REDUCTASE INHIBITOR (E.G. FINASTERIDE, DUTASTERIDE).

48 TEDUGLUTIDE GATTEX

49 TERIFLUNOMIDE AUBAGIO NOT COVERED FOR 1) PATIENTS WITH ACTIVE INFECTION, OR 2) WOMEN OF CHILDBEARING AGE (YOUNGER THAN 50 YEARS OF AGE UNLESS CONFIRMED MENOPAUSE) WHO ARE NOT ON AT LEAST ONE RELIABLE CONTRACEPTIVE METHOD. DOCUMENTED BASELINE LABS/TESTS WITHIN NORMAL LIMITS FOR 1) SERUM ALT LESS THAN 2 TIMES ULN OF BASELINE LEVELS OF LESS THAN 35 U/L, 2) TOTAL BILIRUBIN LESS THAN 2 TIMES THE ULN OF BASELINE LEVELS OF MG/DL, 3) WBC 4,400 TO 11,3000 CELLS/MICROLITER, 4) NEGATIVE PREGNANCY TEST OR DOCUMENTED RELIABLE CONTRACEPTION FOR WOMEN OF CHILDBEARING AGE, AND 5) NEGATIVE TUBERCULIN SKIN TEST.

50 Group Health Medicare Advantage Part D COVERED FOR PATIENTS WITH 1) DIAGNOSIS OF RELAPSING-REMITTING OR RELAPSING FORMS OF SECONDARY PROGRESSIVE MS BASED ON MCDONALD CRITERIA. AND 2) EDSS (EXTENDED DISABILITY STATUS SCALE) SCORE LESS THAN OR EQUAL TO 5.5. AND 3) WITH FAILURE OR INTOLERANCE TO INTERFERON OR GLATIRAMER (MINOR INJECTION SITE REACTIONS ALONE ARE NOT CONSIDERED MEDICATION FAILURE OR INTOLERANCE QUALIFIED FOR COVERAGE).

51 TOBRAMYCIN INHALATION BRAND BETHKIS TOBI TOBI PODHALER TRIAL AND FAILURE OF GENERIC TOBRAMYCIN INHALATION SOLUTION.

52 TOBRAMYCIN INHALATION GENERIC TOBRAMYCIN

53 TOCILIZUMAB ACTEMRA COVERED FOR PATIENTS WITH RHEUMATOID ARTHRITIS WHO HAVE FAILURE, SIGNIFICANT SYSTEMIC INTOLERANCE, OR CONTRAINDICATION TO 1) ADALIMUMAB, ETANERCEPT, OR INFLIXIMAB, AND 2) ABATACEPT. COVERED FOR PATIENTS WITH ACTIVE SYSTEMIC JUVENILE IDIOPATHIC ARTHRITIS.

54 TOFACITINIB XELJANZ COVERED FOR PATIENTS WITH RHEUMATOID ARTHRITIS WHO HAVE FAILURE, SIGNIFICANT SYSTEMIC INTOLERANCE, OR CONTRAINDICATION TO 1) ADALIMUMAB, ETANERCEPT, OR INFLIXIMAB, AND 2) ABATACEPT

55 USTEKINUMAB STELARA COVERED FOR ADULT PATIENTS WITH PLAQUE PSORIASIS OR PSORIATIC ARTHRITIS WHO HAVE TRIED AND FAILED TWO ANTI-TNF AGENTS.

56 VIEKIRA PAK VIEKIRA PAK MUST BE PRESCRIBED BY OR IN CONSULTATION WITH INFECTIOUS DISEASE SPECIALIST, GASTROENTEROLOGY SPECIALIST, OR HEPATOLOGIST. GT 1A: NON CIRRHOTIC 12 WK, CIRRHOTIC 24 WK, GT 1B AND GT 4: 12 WK, POST LIVER TX: 24 WK COVERED FOR PATIENTS 1) WITH CHRONIC HEPATITIS C GENOTYPE 1 OR 4, AND 2) WHO HAVE CONTRAINDICATION OR INTOLERANCE TO HARVONI, AND 3) PROVIDER ATTESTS THAT MEDICATION ADHERENCE HAS BEEN DISCUSSED AND HE/SHE IS CONFIDENT IN THE PATIENT'S ABILITY TO MAINTAIN MEDICATION ADHERENCE