Great-West s Drug Prior Authorization

Transcription

1 Great-West s Drug Prior Authorization Great-West Life s prior authorization process is designed to provide an effective approach to managing claims for specific prescription drugs. Approval for coverage of certain prescription drugs is required in order to provide plan members with coverage for appropriate drug treatment, and keep your drug plan affordable. Below is a current listing of drugs that require prior authorization by Great-West, along with information about the conditions they are commonly used to treat. This list is provided for general information purposes only. Coverage may not be available under certain group benefits plans offered or administered by Great-West. Coverage for any of the drugs listed below depends on the terms of your group benefits plan. To obtain additional drug information, visit the Health & Wellness section of GroupNet by clicking Drug Library and searching for the drug name. Great-West Life prior authorization drug listing as of June Actemra is used for the treatment of moderate to severe rheumatoid arthritis. Adcirca is used for the treatment of idiopathic (primary) pulmonary arterial hypertension (PAH). Afinitor is used for the treatment of subependymal giant cell astrocytoma (SEGA) associated with tuberous sclerosis complex (TSC), and for the treatment of metastatic renal cell carcinoma (RCC) of clear cell morphology. Aldurazyme is used as an enzyme replacement therapy for the treatment of Hurler syndrome (also known as mucopolysaccharidosis MPS I), an extremely rare genetic enzyme deficiency disease. Hurler syndrome is a highly disabling and life-threatening disease. Alertec is used for the treatment of excessive daytime sleepiness due to sleep apnea and narcolepsy. Alimta is used for the treatment of patients with malignant pleural mesothelioma whose disease has spread and is unable to be removed with surgery, or who are otherwise not candidates for curative surgery. It is also used for the treatment of nonsmall cell lung cancer for patients who have received prior chemotherapy. Aubagio is used to reduce flare-ups in people with relapsing-remitting multiple sclerosis (MS). Avastin is used for the treatment of patients with metastatic colorectal cancer. It is also used for the treatment of patients with glioblastoma multiforme (GBM) after relapse or disease progression, following prior therapy. Benlysta is used to treat systemic lupus erythematosus (SLE), in addition to standard therapy for reducing disease activity in adult patients with active, autoantibody-positive. Bosulif is used to treat a type of blood cancer called Philadelphia chromosome positive chronic myelogenous leukemia (CML). Botox is a neuromuscular paralytic agent and is used to treat conditions that are caused by certain muscles going into spasm. Caprelsa is used for the treatment of patients with medullary thyroid cancer. Cerezyme is used for the treatment of long-term enzyme replacement therapy for adult and pediatric patients with a confirmed diagnosis of Type 1 Gaucher disease. Cimzia is used to treat moderate to severe active rheumatoid arthritis. Cosentyx is used to treat moderate to severe plaque psoriasis. Duodopa is used to treat Parkinson s disease in people who have tried other types of Parkinson s disease medication combinations but continue to have symptoms. Elaprase is the first drug used as an enzyme replacement therapy for the treatment of Hunter syndrome (also known as mucopolysaccharidosis MPS II), an extremely rare genetic enzyme deficiency disease. Hunter syndrome is a highly disabling and life-threatening disease.

2 Enbrel is used for the treatment of: moderately to severely active rheumatoid arthritis in adult patients moderately to severely active polyarticular-course juvenile rheumatoid arthritis in patients aged four to 17 psoriatic arthritis in adult patients ankylosing spondylitis chronic moderate to severe plaque psoriasis Entyvio is used to treat adults with moderately to severely active ulcerative colitis. Erivedge is used to treat adults with a type of skin cancer, called basal cell carcinoma, that has spread to other parts of the body or that has come back after surgery or cannot be treated with surgery or radiation. Esbriet is used to treat mild to moderate idiopathic pulmonary fibrosis (IPF). IPF is a long term-disease in which hard fibrous tissue continuously forms in the lungs, causing persistent cough, frequent lung infections and severe shortness of breath. Eylea is used to treat wet age-related macular degeneration. Exjade is used for the management of chronic iron overload in patients with transfusion-dependent anemias. Fabrazyme is used for long-term enzyme replacement therapy in patients with a confirmed diagnosis of Fabry disease. Fabry disease is an extremely rare genetic disorder that can lead to end-stage renal failure, cardiac disease, strokes and premature death. Fampyra is used to improve walking ability in adult patients with multiple sclerosis (MS) who have a walking disability. Flolan is used for the long term intravenous treatment of patients with primary pulmonary hypertension (PAH) and secondary hypertension (SPH) who did not respond to conventional therapy. Forteo is used for the treatment of post-menopausal women with severe osteoporosis who are at high risk of fracture or when other therapies are deemed inadequate. It is also used to increase bone mass in men with primary or hypogonadal severe osteoporosis when other therapies are deemed inadequate. Galexos is used to treat chronic hepatitis C infection. Genotropin is a man-made version of growth hormones and is used for growth hormone therapy in people who have growth Gilenya is the first and only oral treatment for patients with the relapsing-remitting form of multiple sclerosis (MS). Giotrif is used to treat non small cell lung cancer that has outside the lung or to other parts of the body. Gleevec is used for the treatment of chronic myeloid leukemia (CML), gastrointestinal stromal tumours (GIST) and lymphoblastic leukemia. Harvoni is used to treat chronic hepatitis C (CHC) virus genotype 1 infection in adults. Humatrope is a man-made version of growth hormones and is used for growth hormone therapy in people who have growth Humira is used for the treatment of: moderately to severely active rheumatoid arthritis moderately to severely active Crohn s disease Ilaris reduces the effects of a substance in the body that can cause inflammation. It is used to treat rare genetic conditions such as Familial Cold Autoinflammatory Syndrome (FCAS) and Muckle-Wells Syndrome (MWS). Ilaris is also used for the treatment of active Systemic Juvenile Idiopathic Arthritis (SJIA) in patients 2 years and older. Imbruvica is used to treat chronic lymphocytic leukemia (CLL) in people who have already received at least one other cancer medicine. It is also used to treat CLL in people with 17p deletion, even if they have never received prior treatment. Inflectra is used to treat Rheumatoid arthritis, Ankylosing spondylitis, Psoriatic arthritis, and Plaque psoriasis. Inlyta is used to treat kidney cancer (advanced renal cell carcinoma) in patients who have received at least one cancer treatment that did not work. Jakavi is used to treat myelofibrosis, a bone marrow disorder that affects the body s ability to produce blood cells. Jetrea is used to treat symptomatic vitreomacular adhesion. Symptomatic vitreomacular adhesion is an eye condition related to aging that may lead to blurring of vision or blindness. Juxtapid is indicated as an adjunct to a low-fat diet and other lipid-lowering treatment to manage cholesterol in adult patients with homozygous familial hypercholesterolemia (HoFH)(an inherited type of high cholesterol).

3 Kadcyla is used to treat a certain type of breast cancer that has spread to other parts of the body. It is usually given after other cancer medications have been tried without success. Kalydeco is used for the treatment of Cystic Fibrosis (CF) in patients age 6 years and older who have a certain mutation in their CF gene called the G551D mutation. Kineret is used for the treatment of moderate to severe rheumatoid arthritis. Kuvan is used in conjunction with a Phe-restricted diet to reduce blood phenylalanine (phe) levels in patients with hyperphenylalaninemia (HPA) due to responsive phenylketonuria (PKU). Lemtrada is used to reduce flare-ups in people with relapsing-remitting multiple sclerosis (MS). Lucentis is used to treat the wet form of age-related macular degeneration (AMD). It is also used to treat macular edema following retinal vein occlusion (RVO) and diabetic macular edema (DME). Mekinist is used to treat a certain type of metastatic melanoma (skin cancer that has spread to other parts of the body). Mozobil may help to increase stem cells in the blood that can be collected for autologous stem cell transplant (stem cell transplant using a patient s own stem cells) in patients with non-hodgkin s lymphoma (NHL) or multiple myeloma (MM). Myobloc is used for the treatment of cervical dystonia in order to reduce the severity of abnormal head position and neck pain associated with this condition. Myozyme is used for the treatment of patients with pompe disease. Pompe disease is a rare hereditary genetic disorder that is caused by a deficiency in the enzyme acid alpha-glucosidase or known as GAA deficiency. Nexavar is used for the treatment of locally advanced/metastatic kidney cancer in patients who have failed prior cytokine therapy or who are considered unsuitable for such therapy. Nplate is a man-made form of a protein used to treat low blood platelet (blood clotting cells) counts in adults with chronic immune (idiopathic) thrombocytopenia purpura (ITP-a bleeding condition caused by lack of platelets in the blood), when certain other medicines, or surgery to remove the spleen, have not been effective. Nutropin is a man-made version of growth hormones and is used for growth hormone therapy in people who have growth Omnitrope is a man-made version of growth hormones and is used for growth hormone therapy in people who have growth Opsumit is used to treat Pulmonary Arterial Hypertension. Orencia is used for the treatment of moderate to severe rheumatoid arthritis. Otezla is used to treat moderate to severe plaque psoriasis in adult patients who are candidates for phototherapy or systemic therapy. Ozurdex is used to treat macular edema (swelling of the back of the eye) and uveitis (swelling in the middle part of the eye). Perjeta is a cancer medication that interferes with the growth and spread of cancer cells in the body. It is used together with Herceptin and Taxotere to treat breast cancer that has spread to other parts of the body. Pomalyst is used to treat multiple myeloma. Prolastin is used to treat lung problems (emphysema) caused by a certain inherited disease (alpha-1-proteinase inhibitor deficiency). Protropin is a man-made version of growth hormones and is used for growth hormone therapy in people who have growth Remicade is used for the treatment of: moderately to severely active rheumatoid arthritis in adult patients moderately to severely active Crohn s disease fistulizing Crohn s disease in adult patients Remodulin is used for the long term subcutaneous treatment of patients with pulmonary arterial hypertension (PAH) who did not respond to conventional therapy. Replagal is used for long-term enzyme replacement therapy in patients with a confirmed diagnosis of Fabry disease. Fabry disease is an extremely rare genetic disorder that can lead to end-stage renal failure, cardiac disease, strokes and premature death. Retisert is an ophthalmic implant used to treat inflammation within the eye.

4 Revatio is used for the treatment of pulmonary arterial hypertension (PAH). Revatio contains the same chemical ingredient found in Viagra. Revlimid is used for the treatment of multiple myeloma. It is also used for patients with transfusion-dependent anemia. Revolade is an adult chronic immune (idiopathic) thrombocytopenic purpura (ITP) to increase platelet counts in spenectomized patients who are refractory to first-line treatments. Rituxan is used for the treatment of patients with CD20 positive, B-cell non-hodgkin s lymphoma and CD20 positive, diffuse large B-cell non-hodgkin s lymphoma. It is also used for the treatment of moderate to severe active rheumatoid arthritis. Saizen is a man-made version of growth hormones and is used for growth hormone therapy in people who have growth Samsca is used for the treatment of clinically important, non-hypovolemic hyponatremia. Sativex is a cannabis-based medicine that is used as adjunctive treatment for the symptomatic relief of neuropathic pain in patients with multiple sclerosis (MS). Serostim is a man-made growth hormone that is used to manage HIV wasting (a metabolic disorder resulting in severe weight loss seen in people with HIV). Signifor is used to treat Cushing s disease which is a relatively rare hormonal disorder caused by prolonged exposure of the body s tissues to high levels of the hormone cortisol. Simponi is used to treat moderate to severe active rheumatoid arthritis, active psoriatic arthritis and active ankylosing spondylitits. Soliris is the first treatment for patients with paroxysmal nocturnal hemoglobinuria (PNH) to reduce haemolysis. Somavert is indicated for the treatment of acromegaly in patients who have had an inadequate response to surgery, and/or radiation therapy, and other medical therapies, or for whom these therapies are not appropriate. Sovaldi is used to treat chronic hepatitis C infection. Sprycel is used for the treatment of patients with chronic, accelerated, or blast phase chronic myeloid leukemia (CML). Stelara is used to treat adults with moderate to severe chronic plaque psoriasis who are candidates for systemic therapy or phototherapy. Stivarga is used to treat colorectal cancer. It is also used to treat a rare type of tumor that can affect the esophagus, stomach, or intestines. Sutent is used for the treatment of patients with gastrointestinal stromal tumour (GIST). It is also used for the treatment of metastatic renal cell cancer. Tafinlar is used to treat a certain type of metastatic melanoma (skin cancer that has spread to other parts of the body). Tasigna is used to treat Philadelphia chromosome positive chronic myeloid leukemia (Ph+CML). Tecfidera is used to treat patients with relapsing forms of Multiple Sclerosis (MS). Temodal is used for the treatment of adult patients with Grade III or IV primary tumor of the brain. Tracleer is used for the treatment of pulmonary arterial hypertension (PAH). Tysabri is indicated as a monotherapy for the treatment of patients with the relapsing-remitting form of multiple sclerosis to reduce the frequency of clinical relapses, to decrease the number and volume of active brain lesions identified on MRI scans and to delay the progression of physical disability. Volibris is used for the treatment of primary pulmonary arterial hypertension and pulmonary hypertension associated with connective tissue disease in patients who have not responded to conventional therapy. Votrient is used for the treatment of patients with metastatic renal cell (clear cell) carcinoma (mrcc). Vpriv is used for the treatment of long-term enzyme replacement therapy for adult and pediatric patients with a confirmed diagnosis of Type 1 Gaucherdisease. Xalkori is used to treat non-small cell lung cancer (NSCLC) that is advanced or spread to other parts of the body and is caused by a defect in a gene called ALK (anaplastic lymphoma kinase). Xenical is used for the treatment of obesity and management of Type 2 diabetes. Xeljanz is indicated for reducing the signs and symptoms of rheumatoid arthritis (RA). Xeomin is used for the treatment of muscle or nerve disorders, similar to Botox.

5 Xolair is used to treat adults and adolescents (12 years and older) with moderate to severe persistent asthma. Xtandi is used to treat prostate cancer. Xyrem is an oral solution used for the treatment of cataplexy in patients with narcolepsy. Yervoy is used to treat unresectable or metastatic melanoma in patients who have failed or do not tolerate other systemic therapy for advanced melanoma. Zavesca is used for the treatment of adult patients with mild to moderate Type 1 Gaucher disease for whom enzyme replacement therapy is not a therapeutic option. Zelboraf is used to treat a type of skin cancer called melanoma, that has spread to other parts of the body or cannot be removed by surgery, and that has a certain type of abnormal BRAF gene. Zolinza is used for the treatment of cutaneous manifestations in patients with advanced cutaneous T-cell lymphoma (CTCL). Zytiga is used for the treatment of patients with castration resistant metastic prostate cancer. For any of the drugs currently requiring prior authorization, plan members must complete the appropriate section(s) of a Request for Information form with their prescribing doctor, and submit the form to Great-West to have their claim considered for reimbursement. Plan members can find these forms in the Client Services Group Benefits Plan Members Forms section of the Great-West website at A brochure on Great-West s prior authorization process is also available for distribution to plan members. For more information, please contact your Great-West group benefits representative.