2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

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Abstral Adcirca Adempas Afinitor Alecensa

Alunbrig Amitiza Amitriptyline Ampyra Androgel Androderm

Aralast NP Aranesp Arcalyst Armodafinil Aubagio

Avonex Bavencio Beleodaq

Berinert Betaseron

Bexarotene Bosulif Briviact Bydureon Byetta

Cabometyx

Cayston

Cholbam

Chorionic Gonadotropin Cimzia Cinryze Clomipramine

Cometriq

Copaxone

Cotellic

Crinone Cyramza Daklinza

Daliresp

Darzalex Doxepin Duopa Dysport Empliciti Epclusa Epogen

Erivedge Esbriet Estradiol

Extavia Farydak

Fentanyl Oral Fentora

Firazyr Forteo Gattex Genotropin

Gilenya Giltorif Glassia Harvoni Hetlioz Humatrope Ibrance Iclusig Idhifa

Ilaris

Imbruvica Imfinzi

Imipramine

Increlex Inflectra Inlyta Jakafi Juxtapid Kalydeco

Kanuma Kineret Kisqali Korlym Kuvan Kynamro Kyprolis Lartruvo

Lazanda

Lenvima Letairis Lidocaine Transdermal Linzess Lonsurf Lynparza Mavyret Mekinist Menest Methamphetamine

Modafinil Movantik

Mozobil Myalept Natapara

Nexavar

Nerlynx

Ninlaro Norditropin Novarel Nuplazid Nutropin Nutropin Aq Odomzo Ofev

Olysio Omnitrope Opsumit Orencia, Orencia Clickject Orenitram

Orkambi Otezla Oxandrolone

Oxymetholone Pegasys Peg-Intron Phenergan/Phenado Plegridy

Pomalyst Procrit Procysbi Prolastin C Prolia Promacta

Promethazine Promethegan Radicava

Ravicti Rebif

Relistor Remicade

Remodulin

Repatha Revatio

Revlimid Rubraca Rydapt

Saizen Samsca Serostim Sildenafil Simponi Sirturo Somavert Sovaldi Sprycel Stelara

Strensiq

Subsys Surmontil Sutent Sylatron Sylvant Symlin Tabloid

Tafinlar Tagrisso Tarceva Targretin Tasigna Tecentriq Tecfidera

Technivie

Testim Testosterone

Tetrabenazine

Thalomid

Thioridazine Topiramate Tracleer Treanda

Trimipramine Uptravi Vecamyl Vectibix

Venclexta Victoza

Viekira

Votrient Xalkori Xeljanz

Xgeva

Xolair Xtandi Xyrem Yondelis

Yervoy

Zaleplon

Zelboraf Zemaira Zejula Zepatier Zolinza Zonisamide

Zorbtive Zurampic Zydelig Zykadia

Zytiga

H5883_Ph_Nov17PAlist_NM 10262017

2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

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Adempas

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration One Year

Other criteria None

Back to Prior Authorization Drug List

Afinitor

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions Prescriber is an oncologist

Coverage duration One Year

Other criteria Coverage is not provided when Affinitor® is used in combination with Nexavar® or Sutent®

Back to Prior Authorization Drug List

2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

3 of 99

Alecensa

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration Lifetime

Other criteria None

Back to Prior Authorization Drug List

Alunbrig

Effective Date: August 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration One Year

Other criteria None

Back to Prior Authorization Drug List

2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

4 of 99

Amitzia

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info Diagnosis: 1. Chronic idiopathic constipation (CIC) in adults or 2. Opioid-induced constipation in adults with chronic, non-cancer pain or 3. Irritable bowel syndrome (IBS) with constipation in women

Age restrictions 18 years of age and older

Prescriber restrictions None

Coverage duration One Year

Other criteria Documentation of trial/failure within the last 12 months of: 1. A fiber laxative and 2. One of the following: a stimulant laxative or an osmotic laxative

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Ampyra

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion criteria Patients with a history of seizure or moderate to severe renal impairment defined by a crcl of 50ml/min or less

Required med info Initial requests require documentation of a 25 foot timed walk test. Renewal requests require documentation of improvement in walking distance of a 25 foot timed walk test compared to pretreatment.

Age restrictions None

Prescriber restrictions Prescriber is a neurologist

Coverage duration INITIAL = Three Months RENEWAL = One Year

2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

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Other criteria Initial coverage is provided to improve walking distance in patients with a diagnosis of multiple sclerosis who have the ability to walk a timed 25 foot walk test. renewal criteria: documentation that the member has shown an improvement in walking distance of a 25 foot timed walk test compared to pretreatment.

Back to Prior Authorization Drug List

2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

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Transdermal Androgens

Androgel, Androderm, Testim, Testipel, Testosterone

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info Documentation of androgen deficiency syndrome confirmed by two morning testosterone levels less than 300 ng/dL and at least 2 clinical signs or symptoms specific to androgen deficiency

Age restrictions None

Prescriber restrictions None

Coverage duration One Year

Other criteria None

Back to Prior Authorization Drug List

ALPHA-1-PROTEINASE INHIBITOR (Aralast NP, Glassia, Prolastin C, Zemaira)

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration One Year

Other criteria None

Back to Prior Authorization Drug List

2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

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Arcalyst

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info None

Age restrictions 12 years of age and older

Prescriber restrictions None

Coverage duration One Year

Other criteria None

Back to Prior Authorization Drug List

Aubagio

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration One Year

Other criteria None

Back to Prior Authorization Drug List

2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

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Avonex

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration Lifetime

Other criteria None

Back to Prior Authorization Drug List

Bavencio

Effective Date: July 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration Lifetime

Other criteria None

Back to Prior Authorization Drug List

2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

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Beleodaq

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration One Year

Other criteria None

Back to Prior Authorization Drug List

2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

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Berinert

Effective Date: January 1, 2017

Covered uses For acute attacks of hereditary angioedema (HAE). All FDAapproved indications not otherwise excluded from Part D.

Exclusion criteria None

Required med info None

Age restrictions 13 years or older.

Prescriber restrictions None

Coverage duration One Year

Other criteria Diagnosis of hereditary angioedema (HAE) established by an immunologist or hematologist

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Betaseron

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration Lifetime

Other criteria None

Back to Prior Authorization Drug List

2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

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Bosulif

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration One Year

Other criteria None

Back to Prior Authorization Drug List

Briviact

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration One Year

Other criteria None

Back to Prior Authorization Drug List

2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

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Cabometyx

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration One Year

Other criteria None

Back to Prior Authorization Drug List

Cayston

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration One Year

Other criteria Cayston is subject to Part B versus Part D coverage review

Back to Prior Authorization Drug List

2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

13 of 99

Cholbam

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration One Year

Other criteria None

Back to Prior Authorization Drug List

Chorionic Gonadotropin

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration One Year

Other criteria None

Back to Prior Authorization Drug List

2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

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Cimzia

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info Requires documentation of diagnosis and medication history or intolerance(s)

Age restrictions None

Prescriber restrictions Crohn's Disease: Prescribed or recommended by a gastroenterologist RA: Prescribed or recommended by a rheumatologist.

Coverage duration One Year

Other criteria Rheumatoid arthritis requires the member has tried and failed Humira® or Enbrel®, except if not tolerated due to documented clinical side effects. Crohn's disease, requires: 1) Treatment with an adequate course of systemic corticosteroids (e.g., 40 mg to 60 mg prednisone per day for 7 to 14 days) has been ineffective or is contraindicated or 2) The patient has been unable to taper off an adequate course of systemic corticosteroids without experiencing worsening of disease or 3) The patient is experiencing breakthrough disease (e.g., active disease flares) while stabilized for at least 2 months on an immunomodulatory medication (such as azathioprine, mercaptopurine, cyclosporine, or methotrexate) and 4) Adalimumab (Humira®) is not effective after at least an initial 3-dose induction period, except if not tolerated due to documented clinical side effects.

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2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

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Cinryze

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions Prescribed by an immunologist, allergist, or rheumatologist

Coverage duration One Year

Other criteria None

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Cometriq

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration One Year

Other criteria None

Back to Prior Authorization Drug List

2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

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Copaxone

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration Lifetime

Other criteria None

Back to Prior Authorization Drug List

Cotellic

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration Lifetime

Other criteria None

Back to Prior Authorization Drug List

2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

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Crinone

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration One Year

Other criteria None

Back to Prior Authorization Drug List

Cyramza

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration Lifetime

Other criteria None

Back to Prior Authorization Drug List

2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

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Daklinza

Effective Date: January 1, 2017

Covered uses All medically accepted indications not otherwise excluded from Part D.

Exclusion criteria None

Required med info Criteria will be applied consistent with current AASLD/IDSA guidance

Age restrictions None

Prescriber restrictions None

Coverage duration Criteria will be applied consistent with current AASLD/IDSA guidance

Other criteria Criteria will be applied consistent with current AASLD/IDSA guidance

Back to Prior Authorization Drug List

2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

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Daliresp

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info Diagnosis and patient medication history

Age restrictions None

Prescriber restrictions None

Coverage duration One Year

Other criteria Coverage is provided for the treatment of severe chronic obstructive pulmonary disease (COPD) associated with chronic bronchitis in patients with a history of exacerbations and patient is receiving: 1. inhaled long-acting beta-2 agonist [for example, Formoterol, Salmeterol] AND 2. inhaled long-acting anticholinergic agent [for example, Tiotropium] AND 3. inhaled corticosteroid [for example, Fluticasone] OR 4. Patient experienced intolerance or has contraindications to use of these medications

Back to Prior Authorization Drug List

2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

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Darzalex

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration Lifetime

Other criteria None

Back to Prior Authorization Drug List

Duopa

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration One Year

Other criteria Subject to Part B versus D coverage review. Duopa may be covered under Medicare Part B if the patient is receiving enteral suspension administered as a continuous infusion using a portable infusion pump. It may be covered under Medicare Part D if the patient is receiving enteral suspension short-term via a naso-jejunal tube

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2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

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Dysport

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria Will not be covered for cosmetic purposes

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration One Year

Other criteria None

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Empliciti

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration Lifetime

Other criteria None

Back to Prior Authorization Drug List

2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

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Epclusa

Effective Date: March 1, 2017

Covered uses All medically accepted indications not otherwise excluded from Part D.

Exclusion criteria None

Required med info CRITERIA WILL BE APPLIED CONSISTENT WITH CURRENT AASLD/IDSA GUIDANCE

Age restrictions None

Prescriber restrictions None

Coverage duration CRITERIA WILL BE APPLIED CONSISTENT WITH CURRENT AASLD/IDSA GUIDANCE

Other criteria CRITERIA WILL BE APPLIED CONSISTENT WITH CURRENT AASLD/IDSA GUIDANCE

Back to Prior Authorization Drug List

2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

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Erythropoesis Stimulating Agents:

Arnesp, Epogen, Procrit

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion criteria Anemia due to folate, vitamin b12, iron deficiencies, hemolysis, bleeding, or bone marrow fibrosis. Anemia associated with treatment of acute and chronic myelogenous leukemias or erythroid cancers. Anemia due to cancer treatment in patients with uncontrolled hypertension. Anemia not associated with cancer treatment or renal disease under inclusions. Anemia associated only with radiotherapy. Prophylactic use to prevent chemotherapy induced anemia. Prophylactic use to reduce tumor hypoxia. Erythropoietin-type resistance due to neutralizing antibodies.

Required med info

Age restrictions

Prescriber restrictions

Coverage duration 3 months

Other criteria Erythropoesis stimulating agents are subject to Part B vs Part D review.

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2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

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Erivedge

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions Prescribed by or in consultation with a dermatologist or oncologist

Coverage duration One Year

Other criteria None

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Esbriet

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration One Year

Other criteria None

Back to Prior Authorization Drug List

2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

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Estrogens (Estradiol, Menest)

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info None

Age restrictions Authorization is required for members 65 years of age and older

Prescriber restrictions None

Coverage duration One Year

Other criteria Oral Estrogen (Menest) will be approved when used as part of a cancer treatment regimen. For all other uses, Menest will be approved if two of the following safer alternatives as been tried and failed or are not appropriate or contraindicated. Safer alternatives include: e.g., SSRIs, venlafaxine ER, Premarin vaginal cream, Estrace vaginal creams, Estring or Femring Vaginal Rings, Vagifem vaginal tablets

Back to Prior Authorization Drug List

2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

26 of 99

Extavia

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration Lifetime

Other criteria None

Back to Prior Authorization Drug List

Farydak

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration One Year

Other criteria None

Back to Prior Authorization Drug List

2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

27 of 99

Firazyr

Effective Date: January 1, 2017

Covered uses For acute attacks of hereditary angioedema (HAE). All FDA approved indications not otherwise excluded from Part D.

Exclusion criteria None

Required med info None

Age restrictions 18 years of age or older

Prescriber restrictions None

Coverage duration One Year

Other criteria Diagnosis of hereditary angioedema (HAE) established by an immunologist or hematologist

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2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

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Forteo

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria Coverage is not provided for hypocalcemia

Required med info 1) A Diagnosis of: a. Postmenopausal women with osteoporosis, or b. Glucocorticoid induced osteoporosis, or c. Males with primary or hypogonadal osteoporosis, all of who are at high risk for fracture 2) Bone mineral density that is 2.5 standard deviations or more below the mean (t-score at or below -2.5)

Age restrictions None

Prescriber restrictions None

Coverage duration One year with maximum two years of therapy

Other criteria Forteo is subject to Part B vs Part D review. Coverage approval requires: Trial and failure to at least one bisphosphonate except when: 1. Contraindication to an oral and intravenous bisphosphonate (such as a stricture or aclasia, inability to stand or sit upright for at least 30 minutes and increased risk of aspiration) 2. Documented intolerance to a bisphosphonate

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2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

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Gattex

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration Lifetime

Other criteria None

Back to Prior Authorization Drug List

Gilenya

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration One Year

Other criteria None

Back to Prior Authorization Drug List

2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

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Giltorif

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration One Year

Other criteria None

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Harvoni

Effective Date: January 1, 2017

Covered uses All medically accepted indications not otherwise excluded from Part D.

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration Criteria will be applied consistent with current AASLD/IDSA guidance

Other criteria Criteria will be applied consistent with current AASLD/IDSA guidance

Back to Prior Authorization Drug List

2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

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Growth Hormone:

Genotropin, Humatrope, Increlex, Norditropin, Nutropin, Nutropin AQ, Omnitrope,

Saizen, Serostim, Somavert, Zorbtive

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info Covered for the replacement of endogenous growth hormone in adults with growth hormone deficiency of childhood onset or adult onset. Covered if initial diagnosis based on two growth hormone stimulation tests and that the patient does not have edema, arthralgias, or carpal tunnel syndrome. Serostim is covered for aids wasting cachexia. Norditropin is covered for Noonan syndrome, Turner syndrome, and adult growth hormone deficiency. Nutropin is covered for Turner syndrome, and adult growth hormone deficiency. Omnitrope and Saizen are covered for adult growth hormone deficiency. Zorbtive is covered for the treatment of short-bowel syndrome in patients receiving specialized nutritional support. Somavert is covered for acromegaly.

Age restrictions None

Prescriber restrictions None

Coverage duration One Year

Other criteria None

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2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

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Hetlioz

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info Documentation of patient visual capabilities

Age restrictions None

Prescriber restrictions None

Coverage duration Lifetime

Other criteria None

Back to Prior Authorization Drug List

2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

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Hepatitis Treatments:

Pegasys, Pegasys proclick, Peg-Intron

Peg-Intron Redipen

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info Documentation of concomitant Ribavarin use (or contraindications) is required when requesting initial use for Hepatitis C. Documentation of viral genotype is required for Hepatitis C. Documentation of response to therapy is required for requests for continuation of therapy for Hepatitis C

Age restrictions None

Prescriber restrictions None

Coverage duration Initiation Of Therapy: 12 weeks Continuation Therapy: 24 to 48 weeks

Other criteria None

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2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

34 of 99

High Risk in the Elderly Medications:

Tricyclic Antidepressants: Amitriptyline, Clomipramine, Doxepin, Imipramine,

Trimipramine

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion criteria None

Required med info None

Age restrictions Authorization is required for formulary high risk medications for members 65 years of age and older

Prescriber restrictions None

Coverage duration One Year

Other criteria High Risk Tricyclic Antidepressants are approved if patient has a history of use. For patients initiating therapy, the high risk tricyclic antidepressant is approved if at least one of the suggested alternatives (nortriptyline, desipramine, citalopram, escitalopram, mirtazapine, sertraline, venlafaxine) with less sedation and fewer anticholinergic effects have been tried and failed or is not appropriate or contraindicated for the intended use.

Back to Prior Authorization Drug List

2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

35 of 99

High Risk in the Elderly Medications:

Zaleplon

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info None

Age restrictions Authorization is required for formulary high risk medications for members 65 years of age and older

Prescriber restrictions None

Coverage duration One Year

Other criteria Lunesta (Zaleplon) is approved if at least one of the suggested alternatives, (low dose Trazodone (25-50mg) or Rozerem), has been tried and failed or is not appropriate or contraindicated for the intended use.

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2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

36 of 99

High Risk in the Elderly Medications

Thioridiazine

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info None

Age restrictions Prior authorization is required for formulary high risk medications for members 65 years of age and older

Prescriber restrictions None

Coverage duration One Year

Other criteria Requires documentation of intolerance, contraindications, or trial with failure with at least one other safer formulary alternative. Thioridizine is covered for patients who have a history of use. For patients initiating therapy, thioridizine is covered if patient has a failure of or intolerance to at least one other safer alternative antipsychotics such as Abilify or Seroquel.

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2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

37 of 99

Ibrance

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration One Year

Other criteria None

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Iclusig

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration One Year

Other criteria None

Back to Prior Authorization Drug List

2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

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Idhifa

Effective Date: November 1, 2017

Covered uses All medically accepted indications not otherwise excluded from Part D.

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration One Year

Other criteria None

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Ilaris

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion criteria None

Required med info Requires documentation of diagnosis.

Age restrictions None

Prescriber restrictions None

Coverage duration One Year

Other criteria None

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2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

39 of 99

Imbruvica

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration One Year

Other criteria None

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Imfinzi

Effective Date: August 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration One Year

Other criteria None

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2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

40 of 99

Inflectra

Effective Date: March 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration One Year

Other criteria None

Back to Prior Authorization Drug List

2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

41 of 99

Injectable Diabetic Medications:

Byetta, Bydureon, Victoza, Symlin

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria Not covered for non Type 2 diabetes diagnosis. Not covered for weight loss in patients with or without diabetes.

Required med info Requires documentation of diagnosis and medication history or intolerance(s).

Age restrictions None

Prescriber restrictions None

Coverage duration Lifetime

Other criteria Byetta, Bydureon, Victoza: Approved as adjunctive therapy to improve glycemic control in patients who have a diagnosis of Type II Diabetes Mellitus and are currently taking or have tried and failed at least One of the following: Metformin, a Sulfonylurea, or a Thiazolidinedione, or One of the following: a combination of metformin and a sulfonylurea or a combination of Metformin and a Thiazolidinedione. In addition to the above criteria the patient must have a hemoglobin A1c of greater than 7 per cent. Symlin is covered for patients that have failed intensive treatment with insulin monotherapy and for concurrent use with an insulin product

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2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

42 of 99

Inlyta

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria Coverage is not provided for combination use with other tyrosine kinase inhibitors such as Sorafenib, Sunitinib

Required med info Coverage for the treatment of renal cell carcinoma is provided after failure with one prior systemic therapy

Age restrictions None

Prescriber restrictions None

Coverage duration One Year

Other criteria None

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Jakafi

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions Prescribed by a hematologist / oncologist

Coverage duration One Year

Other criteria None

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2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

43 of 99

Juxtapid

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info Requires documentation of diagnosis of homozygous familial hypercholesterolemia.

Age restrictions None

Prescriber restrictions None

Coverage duration Lifetime

Other criteria Requires trial and failure of Kynamro

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Kalydeco

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info Diagnosis of Cystic Fibrosis and confirmed G551D mutation

Age restrictions None

Prescriber restrictions None

Coverage duration One Year

Other criteria None

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2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

44 of 99

Kanuma

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration One Year

Other criteria None

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Kineret

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration One Year

Other criteria Rheumatoid arthritis requires a treatment failure or contraindication to Enbrel or Humira.

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2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

45 of 99

Kisqali

Effective Date: June 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration One Year

Other criteria None

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Korlym

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration One Year

Other criteria None

Back to Prior Authorization Drug List

2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

46 of 99

Kynamro

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration Lifetime

Other criteria None

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Kyprolis

Effective Date: March 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration Lifetime

Other criteria None

Back to Prior Authorization Drug List

2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

47 of 99

Lartruvo

Effective Date: March 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration Lifetime

Other criteria None

Back to Prior Authorization Drug List

2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

48 of 99

Lenvima

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration One Year

Other criteria None

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Lidocaine Transdermal Patch

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration One Year

Other criteria None

Back to Prior Authorization Drug List

2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

49 of 99

Linzess

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info None

Age restrictions 18 years of age and older

Prescriber restrictions None

Coverage duration One Year

Other criteria Chronic idiopathic constipation (CIC) requires documentation of failure within the last 12 months of use of a fiber laxative and one of the following: a stimulant laxative or an osmotic laxative. Drug-induced constipation must be ruled out.

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Lonsurf

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration Lifetime

Other criteria None

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2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

50 of 99

Lynparza

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration One Year

Other criteria None

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Mavyret

Effective Date: November 1, 2017

Covered uses All medically accepted indications not otherwise excluded from Part D.

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration Criteria will be applied consistent with current AASLD/IDSA guidance

Other criteria Criteria will be applied consistent with current AASLD/IDSA guidance

Back to Prior Authorization Drug List

2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

51 of 99

Mekinist

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info Confirmation of the presence of BRAF V600E or V600K mutation in tumor specimen

Age restrictions None

Prescriber restrictions None

Coverage duration One Year

Other criteria None

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Methamphetamine HCL

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration One Year

Other criteria None

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Modafinil, Armodafinil

2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

52 of 99

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration One Year

Other criteria None

Back to Prior Authorization Drug List

2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

53 of 99

Movantik

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration One Year

Other criteria None

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Mozobil

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info Requires documentation of diagnosis and that granulocyte colony stimulating factor is administered concomitantly, and documentation of poor response to apheresis with granulocyte colony stimulating factor alone.

Age restrictions None

Prescriber restrictions None

Coverage duration Duration requested up to one month

Other criteria None

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2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

54 of 99

Myalept

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria Coverage is not provided for the following: general obesity, HIV-related lipodystrophy, partial lipodystrophy, metabolic disease (without concurrent generalized lipodystrophy) or liver disease.

Required med info Diagnosis of congenital or acquired generalized lipodystrophy

Age restrictions None

Prescriber restrictions Prescribing physician is an endocrinologist

Coverage duration Initial = 3 months Renewal = 1 year

Other criteria Renewal requires adherence to therapy and no signs or symptoms of pancreatic disease, lymphoma or events suggesting neutralizing antibody formation.

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2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

55 of 99

Narcotic Analgesics:

Abstral, Fentanyl Citrate Oral Transmucosal, Fentora, Lazanda, Onsolis, Subsys

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info Requires documentation of diagnosis and medication history

Age restrictions None

Prescriber restrictions None

Coverage duration One Year

Other criteria Covered for cancer or cancer related diagnosis in patients already receiving long acting opioids

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Natapara

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration One Year

Other criteria None

Back to Prior Authorization Drug List

2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

56 of 99

Nerlynx

Effective Date: November 1, 2017

Covered uses All medically accepted indications not otherwise excluded from Part D.

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration One Year

Other criteria None

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Nexavar

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions Hepato-cellular carcinoma: Prescribed by an oncologist, hepatologist, or gastroenterologist All other indications: Prescribed by an oncologist

Coverage duration One Year

Other criteria None

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2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

57 of 99

Ninlaro

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration Lifetime

Other criteria None

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2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

58 of 99

Nuplazid

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration One Year

Other criteria None

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Odomzo

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration Lifetime

Other criteria None

Back to Prior Authorization Drug List

2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

59 of 99

Ofev

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration One year

Other criteria None

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Olysio

Effective Date: January 1, 2017

Covered uses All medically accepted indications not otherwise excluded from Part D.

Exclusion criteria None

Required med info None

Age restrictions 18 years and older

Prescriber restrictions None

Coverage duration Criteria will be applied consistent with current AASLD/IDSA guidance

Other criteria Criteria will be applied consistent with current AASLD/IDSA guidance

Back to Prior Authorization Drug List

2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

60 of 99

Orencia, Orencia Clickject

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info Verification that the patient has been evaluated for TB and treated accordingly

Age restrictions Rheumatoid Arthritis: 18 years and older.

Prescriber restrictions Prescribed by a rheumatologist

Coverage duration One Year

Other criteria Coverage is provided if: 1) Failed methotrexate or one DMARD and 2) Failure to at least one preferred biologic (Enbrel or Humira)

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Orenitram

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration Lifetime

Other criteria None

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2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

61 of 99

Orkambi

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration Lifetime

Other criteria None

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Otezla

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration One Year

Other criteria Coverage is provided when there has been a trial and failure or contraindication to 1) At least one DMARD and 2) Enbrel or Humira

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2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

62 of 99

Oxandrolone

Effective Date: January 1, 2017

Covered uses All medically accepted indications not otherwise excluded from Part D

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration One Year

Other criteria None

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2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

63 of 99

Oxymetholone

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion criteria Coverage will not be provided if anabolic steroids are used to enhance athletic performance or for anti-aging purposes

Required med info Oxymetholone: Documentation that use is 1) for therapy to offset protein catabolism associated with prolonged use of corticosteroids. 2) for bone pain associated with osteoporosis. 3) as prophylactic therapy in patients with hereditary angioedema. anadrol-50 requires documentation of:1) HIV associated wasting.2) prophylactic therapy for hereditary angioedema.3) clinically diagnosed anemia.

Age restrictions None

Prescriber restrictions None

Coverage duration One Year

Other criteria None

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2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

64 of 99

Plegridy

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration One Year

Other criteria None

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Pomalyst

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info Diagnosis of multiple myeloma

Age restrictions None

Prescriber restrictions None

Coverage duration One Year

Other criteria Coverage is provided if: 1) Patient has received at least two prior therapies including Lenalidomide and Bortezomib and 2) Demonstrated disease progression on or within 60 days of completion of the last therapy.

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2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

65 of 99

Procysbi

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration Lifetime

Other criteria None

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2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

66 of 99

Prolia

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria Coverage is not provided for hypocalcemia

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration One Year

Other criteria Prolia is subject to Part B versus Part D review Requirements: Patient has tried and failed at least one bisphosphonate except when: 1. Contraindication to a bisphosphonate (oral and intravenous) such as a stricture or aclasia, inability to stand or sit upright for at least 30 minutes and increased risk of aspiration 2. Documented intolerance to a bisphosphonate

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2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

67 of 99

Promacta

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion criteria None

Required med info Requires documentation of diagnosis, medication history or intolerance(s), platlet counts.

Age restrictions None

Prescriber restrictions Prescribed or recommended by a hematologist, hepatologist or gastroenterologist.

Coverage duration Initiation of therapy - 12 weeks approval, continuation therapy - 12 months approval

Other criteria None

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2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

68 of 99

Promethazine/Promethegan/Phenergan/Phenadoz

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info None

Age restrictions Authorization is required for members 65 years of age and older

Prescriber restrictions None

Coverage duration One Year

Other criteria Promethazine will be approved when used as part of an analgesia regimen. Promethazine is approved for other uses if at least one safer alternative has been tried and failed unless the alternative is not appropriate or contraindicated. Alternatives for allergic conditions: second generation antihistamine (e.g., cetirizine, desloratadine, loratadine, fexofenadine). Alternatives for sleep include low dose trazodone (25-50mg) , rozerem or melatonin. For nausea or vomiting or motion sickness, alternatives include prochlorperazine, ondansetron, granisetron and meclizine.

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2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

69 of 99

Pulmonary Agents:

Adcirca, Letairis, Opsumit, Revatio oral suspension, Sildenafil Citrate 20mg,

Remodulin, Tracleer

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration One Year

Other criteria Coverage for Revatio and Adcirca is not provided in situations where patients are receiving nitrate therapy.

Back to Prior Authorization Drug List

Radicava

Effective Date: November 1, 2017

Covered uses All medically accepted indications not otherwise excluded from Part D.

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration One Year

Other criteria None

Back to Prior Authorization Drug List

2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

70 of 99

Ravicti

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration One Year

Other criteria None

Back to Prior Authorization Drug List

2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

71 of 99

Rebif

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration Lifetime

Other criteria None

Back to Prior Authorization Drug List

Relistor

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration Three Months

Other criteria Requires adequate treatment consisting of 5 days duration of treatment of agents for constipation, including at least any two of the following: Bulk laxatives, saline laxatives or osmotic laxatives. Coverage may not be provided if there are contraindications to Methylnaltrexone therapy.

Back to Prior Authorization Drug List

2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

72 of 99

Remicade

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion criteria None

Required med info Verification that the patient has been evaulated for TB and treated accordingly

Age restrictions None

Prescriber restrictions None

Coverage duration One Year

Other criteria None

Back to Prior Authorization Drug List

Remodulin

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration One Year

Other criteria None

Back to Prior Authorization Drug List

2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

73 of 99

Repatha

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration One Year

Other criteria None

Back to Prior Authorization Drug List

Revlimid

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions Prescribed by or in consultation with an oncologist or hematologist

Coverage duration One Year

Other criteria None

Back to Prior Authorization Drug List

2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

74 of 99

Rubraca

Effective Date: March 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration One Year

Other criteria None

Back to Prior Authorization Drug List

Rydapt

Effective Date: August 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration One Year

Other criteria None

Back to Prior Authorization Drug List

2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

75 of 99

Samsca

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info Documentation that patient does not have underlying liver disease

Age restrictions None

Prescriber restrictions None

Coverage duration One Month

Other criteria None

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Kuvan (Sapropterin hydrochloride)

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration Initial - 2 months auth will be extended for 1 year if documented response after initial therapy

Other criteria Renewal criteria: after initial therapy of 2 months. a 30% or greater reduction in phenylalanine from baseline

Back to Prior Authorization Drug List

2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

76 of 99

Simponi

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion criteria None

Required med info Requires verification that the patient has been evaluated for TB and treated accordingly

Age restrictions None

Prescriber restrictions None

Coverage duration One Year

Other criteria For ulcerative colitis, coverage is provided when the member has tried and failed Humira unless contraindicated or not tolerated due to documented clinical side effects. All other indications for use require the member has tried and failed Humira or Enbrel, except if contraindicated or not tolerated due to documented clinical side effects.

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Sirturo

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info Diagnosis

Age restrictions None

Prescriber restrictions None

Coverage duration One Year

Other criteria Must be used in combination with at least 3 other agents

Back to Prior Authorization Drug List

2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

77 of 99

Sovaldi

Effective Date: January 1, 2017

Covered uses All medically accepted indications not otherwise excluded from Part D.

Exclusion criteria None

Required med info None

Age restrictions 18 years and older

Prescriber restrictions None

Coverage duration Criteria will be applied consistent with current AASLD/IDSA guidance

Other criteria Criteria will be applied consistent with current AASLD/IDSA guidance

Back to Prior Authorization Drug List

Sprycel

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions Prescribed by oncologist

Coverage duration One Year

Other criteria None

Back to Prior Authorization Drug List

2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

78 of 99

Stelara

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion criteria Crohn's disease

Required med info Requires verification that the patient has been evaluated for TB and has been treated accordingly.

Age restrictions None

Prescriber restrictions None

Coverage duration One Year

Other criteria Psoriasis 1) trial and failure of at least one other oral systemic agent for psoriasis unless all are contraindicated. (e.,g cyclosporine, methotrexae, acitretin). 2) a trial and failure any one of the following: Infliximab (Remicaide) after at least an initial induction period (5 mg/kg on weeks 0,2, 6), except if not tolerated due to documented clinical side effects -or- Humira -or- Enbrel after at least a 12 week treatment course, except if not tolerated due to documented clinical side effects.

Back to Prior Authorization Drug List

Strensiq

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration One Year

Other criteria None

Back to Prior Authorization Drug List

2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

79 of 99

2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

80 of 99

Sutent

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions Prescribed by oncologist

Coverage duration One Year

Other criteria None

Back to Prior Authorization Drug List

Sylatron

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions Prescribed by oncologist

Coverage duration One Year

Other criteria None

Back to Prior Authorization Drug List

2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

81 of 99

Sylvant

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration One Year

Other criteria None

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Tabloid

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions Prescribed by oncologist or hematologist

Coverage duration One Year

Other criteria None

Back to Prior Authorization Drug List

2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

82 of 99

Tafinlar

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion criteria None

Required med info Confirmation of the presence of BRAF V600E or BRAF V600K mutation in tumor specimen as detected by an FDA-approved test

Age restrictions None

Prescriber restrictions None

Coverage duration One Year

Other criteria None

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Tagrisso

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration Lifetime

Other criteria None

Back to Prior Authorization Drug List

2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

83 of 99

Tarceva

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions Prescribed by oncologist

Coverage duration One Year

Other criteria None

Back to Prior Authorization Drug List

Targretin/Bexarotene

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions Prescribed by oncologist or dermatologist

Coverage duration One Year

Other criteria None

Back to Prior Authorization Drug List

2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

84 of 99

Tasigna

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration One Year

Other criteria None

Back to Prior Authorization Drug List

Ticfidera

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration Lifetime

Other criteria None

Back to Prior Authorization Drug List

2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

85 of 99

Technivie

Effective Date: January 1, 2017

Covered uses All medically accepted indications not otherwise excluded from Part D.

Exclusion criteria None

Required med info None

Age restrictions 18 years and older

Prescriber restrictions None

Coverage duration Criteria will be applied consistent with current AASLD/IDSA guidance

Other criteria Criteria will be applied consistent with current AASLD/IDSA guidance

Back to Prior Authorization Drug List

Tecentriq

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration One Year

Other criteria None

Back to Prior Authorization Drug List

2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

86 of 99

Thalomid

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration One Year

Other criteria None

Back to Prior Authorization Drug List

Topiramate

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration One Year

Other criteria None

Back to Prior Authorization Drug List

2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

87 of 99

Treanda

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration One Year

Other criteria None

Back to Prior Authorization Drug List

Uptravi

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration One Year

Other criteria None

Back to Prior Authorization Drug List

2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

88 of 99

Vecamyl

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration One Year

Other criteria None

Back to Prior Authorization Drug List

Vectibex

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions Prescribed by an oncologist

Coverage duration One Year

Other criteria None

Back to Prior Authorization Drug List

2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

89 of 99

Venclexta

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration One Year

Other criteria None

Back to Prior Authorization Drug List

Vikeria

Effective Date: January 1, 2017

Covered uses All medically accepted indications not otherwise excluded from Part D.

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration Criteria will be applied consistent with current AASLD/IDSA guidance

Other criteria Criteria will be applied consistent with current AASLD/IDSA guidance

Back to Prior Authorization Drug List

2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

90 of 99

Votrient

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info Documentation of advanced renal cell carcinoma

Age restrictions None

Prescriber restrictions Prescribed by an oncologist

Coverage duration One Year

Other criteria None

Back to Prior Authorization Drug List

Xalkori

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info Diagnosis of locally advanced or metastatic non-small cell lung cancer (NSCLC) that is anaplastic lymphoma kinase (alk)-positive as detected by a FDA-approved test.

Age restrictions None

Prescriber restrictions None

Coverage duration One Year

Other criteria None

Back to Prior Authorization Drug List

2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

91 of 99

Xeljanz

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info Requires documentation of diagnosis and medication history or intolerance(s).

Age restrictions None

Prescriber restrictions Prescribed or recommended by a rheumatologist

Coverage duration One Year

Other criteria Requires a treatment failure or contraindication to Enbrel or Humira.

Back to Prior Authorization Drug List

Xenazine (Tetrabenazine)

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria Coverage for Xenazine or Tetrabenazine will not be provided for patients who have hepatic function impairment, patients who are actively suicidal or who have untreated or inadequately treated depression, or patients taking monoamine oxidase inhibitors or reserpine.

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration Lifetime

Other criteria None

Back to Prior Authorization Drug List

2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

92 of 99

Xgeva

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration One Year

Other criteria None

Back to Prior Authorization Drug List

Xolair

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration One Year

Other criteria None

Back to Prior Authorization Drug List

2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

93 of 99

Xtandi

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info Coverage is provided for the treatment of metastatic castration-resistant prostate cancer where the patient has had prior treatment with docetaxel.

Age restrictions None

Prescriber restrictions Prescribed or recommended by an oncologist or urologist

Coverage duration One Year

Other criteria None

Back to Prior Authorization Drug List

Xyrem

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration One Year

Other criteria None

Back to Prior Authorization Drug List

2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

94 of 99

Yervoy

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions Prescribed by an oncologist

Coverage duration One Year

Other criteria None

Back to Prior Authorization Drug List

Yondelis

Effective Date: March 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration One Year

Other criteria None

Back to Prior Authorization Drug List

2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

95 of 99

Zejula

Effective Date: August 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration One Year

Other criteria None

Back to Prior Authorization Drug List

Zelboraf

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria Will not be covered in combination with Yervoy

Required med info Diagnosis of unresectable or metastatic melanoma with BRAF V600E mutation as detected by a FDA-approved test.

Age restrictions None

Prescriber restrictions Prescribed by an oncologist

Coverage duration One Year

Other criteria None

Back to Prior Authorization Drug List

2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

96 of 99

Zepatier

Effective Date: January1, 2017

Covered uses All medically accepted indications not otherwise excluded from Part D.

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions

Coverage duration Criteria will be applied consistent with current AASLD/IDSA guidance

Other criteria Criteria will be applied consistent with current AASLD/IDSA guidance

Back to Prior Authorization Drug List

Zolinza

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration One Year

Other criteria None

Back to Prior Authorization Drug List

2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

97 of 99

Zonisamide

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration One Year

Other criteria None

Back to Prior Authorization Drug List

Zurampic

Effective Date: March 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration One Year

Other criteria None

Back to Prior Authorization Drug List

2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

98 of 99

Zydelig

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration One Year

Other criteria None

Back to Prior Authorization Drug List

Zykadia

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D.

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration One Year

Other criteria None

Back to Prior Authorization Drug List

2017 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

99 of 99

Zytiga

Effective Date: January 1, 2017

Covered uses All FDA-approved indications not otherwise excluded from Part D

Exclusion criteria None

Required med info None

Age restrictions None

Prescriber restrictions None

Coverage duration One Year

Other criteria None

Back to Prior Authorization Drug List

The formulary may change at any time. You will receive notice when necessary.