Download pdf - 2018 BCN Advantage Prior Authorization Criteria - bcbsm.com · 2018 BCN Advantage Prior Authorization Criteria Last updated: April, 2018 BCN AdvantageSM is an HMO-POS and HMO plan

2018 BCN Advantage Prior Authorization Criteria Last updated: May, 2018

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 Actemra Adcirca Adempas Aliqopa Afinitor Afinitor- Disperz Alecensa Alunbrig Amitiza Amitriptyline Ampyra Anadrol-50 Androgel Androderm Aralast NP Aranesp Arcalyst Armodafinil Aubagio Avonex Bavencio Beleodaq Berinert Betaseron Bexarotene Bosulif Briviact Bydureon Byetta Cabometyx Calquence Cayston Cholbam Chorionic Gonadotropin

Cimzia Cinryze Clomipramine Cometriq Copaxone Cotellic Crinone Cyramza Daliresp Darzalex Doxepin Duopa Dysport Empliciti Epclusa Epogen Erivedge Erleada Esbriet Estradiol Extavia Farydak Fentanyl Oral Fentora Firazyr Forteo Gattex Genotropin Gilenya Gilotrif Glassia Harvoni Hetlioz Humatrope Ibrance Iclusig Idhifa

Ilaris Imbruvica Imfinzi Imipramine Increlex Inflectra Inlyta Jakafi Juxtapid Kalydeco Kanuma Kineret Kisqali Kisqali Femara Korlym Kuvan Kynamro Kyprolis Lartruvo Lazanda Lenvima Letairis Lidocaine Transdermal Linzess Lonsurf Lynparza Mavyret Mekinist Menest Modafinil Movantik Mozobil Myalept Mylotarg Natpara Nexavar

Nerlynx Ninlaro Norditropin Novarel Nuplazid Nutropin Nutropin Aq Odomzo Ofev Omnitrope Opsumit Orencia, Orencia Clickject Orenitram Orkambi Otezla Oxandrolone Oxymetholone Pegasys Plegridy Pomalyst Praluent Procrit Procysbi Prolastin C Prolia Promacta Radicava Ravicti Rebif Relistor Remicade Remodulin Repatha Revatio

Revlimid Rubraca Rydapt Saizen Samsca Serostim Sildenafil Simponi Sirturo Somavert Sovaldi Sprycel Stelara Strensiq Subsys Sutent Sylatron Sylvant SymlinPen Tabloid Tafinlar Tagrisso Tarceva Targretin Tasigna Tecentriq Tecfidera Testim Testosterone Tetrabenazine Thalomid Thioridazine Tracleer Treanda Trimipramine Tysabri

Uptravi Vecamyl Vectibix Vemlidy Venclexta Verzenio Victoza Vosevi Votrient Xalkori Xeljanz Xgeva Xolair Xtandi Xyrem Yondelis Yervoy Zaleplon Zelboraf Zemaira Zejula Zolinza Zorbtive Zurampic Zydelig Zykadia Zytiga

H5883_Ph_Apr18PAlist_NM 04262018



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Actemra Effective Date: January 1, 2018

Covered uses All medically accepted indications not otherwise excluded from Part D. Exclusion criteria None Required med info None Age restrictions None Prescriber restrictions Prescribing physician is a rheumatologist

Coverage duration One Year Other criteria Requires trial of etanercept (Enbrel) and adalimumab (Humira) when these

medications are FDA labeled for the Part D coverable medically accepted indication.

Back to Prior Authorization Drug List Adempas Effective Date: January 1, 2018

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



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Afinitor Effective Date: January 1, 2018

Covered uses All medically accepted 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 Aliqopa Effective Date: March 1, 2018

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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Alecensa Effective Date: January 1, 2018

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 Lifetime Other criteria None


Alunbrig Effective Date: January 1, 2018





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Amitzia Effective Date: January 1, 2018

Covered uses All medically accepted 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


Ampyra Effective Date: January 1, 2018

Covered uses All medically accepted 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



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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 Transdermal Androgens Androgel, Androderm, Testim, Testipel, Testosterone Effective Date: January 1, 2018

Covered uses All medically accepted 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




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ALPHA-1-PROTEINASE INHIBITOR (Aralast NP, Glassia, Prolastin C, Zemaira) Effective Date: January 1, 2018


Back to Prior Authorization Drug List Arcalyst Effective Date: January 1, 2018

Covered uses All medically accepted 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




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Aubagio Effective Date: January 1, 2018



Avonex Effective Date: January 1, 2018





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Bavencio Effective Date: January 1, 2018


Back to Prior Authorization Drug List Beleodaq Effective Date: January 1, 2018





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Berinert Effective Date: January 1, 2018

Covered uses All medically accepted indications not otherwise excluded from Part D. Exclusion criteria None Required med info None Age restrictions None Prescriber restrictions Prescribing physician is an immunologist or hematologist Coverage duration One Year Other criteria None


Betaseron Effective Date: January 1, 2018





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Bosulif Effective Date: January 1, 2018


Back to Prior Authorization Drug List Briviact Effective Date: January 1, 2018





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Cabometyx Effective Date: January 1, 2018


Back to Prior Authorization Drug List Calquence Effective Date: March 1, 2018





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Cayston Effective Date: January 1, 2018

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 Cayston is subject to Part B versus Part D coverage review


Cholbam Effective Date: January 1, 2018





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Chorionic Gonadotropin Effective Date: January 1, 2018





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Cimzia Effective Date: January 1, 2018

Covered uses All medically accepted 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, ankylosing spondylitis and psoriatic arthritis requires the

member has tried and failed Humira and 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 stabilzed 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 clincial side effects.




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Cinryze Effective Date: January 1, 2018

Covered uses All medically accepted 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

Back to Prior Authorization Drug List Cometriq Effective Date: January 1, 2018





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Copaxone Effective Date: January 1, 2018


Back to Prior Authorization Drug List Cotellic Effective Date: January 1, 2018





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Crinone Effective Date: January 1, 2018


Back to Prior Authorization Drug List Cyramza Effective Date: January 1, 2018





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Daliresp Effective Date: January 1, 2018

Covered uses All medically accepted 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 Darzalex Effective Date: January 1, 2018





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Duopa Effective Date: January 1, 2018

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 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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Dysport Effective Date: January 1, 2018

Covered uses All medically accepted 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


Empliciti Effective Date: January 1, 2018





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Epclusa Effective Date: January 1, 2018

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 Erythropoesis Stimulating Agents: Aranesp, Epogen, Procrit Effective Date: January 1, 2018

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




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Erivedge Effective Date: January 1, 2018

Covered uses All medically accepted 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


Erleada Effective Date: May 1, 2018





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Esbriet Effective Date: January 1, 2018





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Estrogens (Estradiol, Menest) Effective Date: January 1, 2018

Covered uses All medically accepted 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




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Extavia Effective Date: January 1, 2018

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 Lifetime Other criteria Requires a trial of at least one of the following: Betaseron, Avonex, Plegridy or

Rebif. Back to Prior Authorization Drug List

Farydak Effective Date: January 1, 2018





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Firazyr Effective Date: January 1, 2018

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 Prescribing physician is an immunologist or hematologist Coverage duration One Year Other criteria None

Back to Prior Authorization Drug List Forteo Effective Date: January 1, 2018

Covered uses All medically accepted 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 with maximum two years of therapy Other criteria Requires patient has tried and failed 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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Gattex Effective Date: January 1, 2018


Back to Prior Authorization Drug List Gilenya Effective Date: January 1, 2018





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Giltorif Effective Date: January 1, 2018


Back to Prior Authorization Drug List Harvoni Effective Date: January 1, 2018

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




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Growth Hormone: Genotropin, Humatrope, Increlex, Norditropin, Nutropin, Nutropin AQ, Omnitrope, Saizen, Serostim, Somavert, Zorbtive Effective Date: January 1, 2018

Covered uses All medically accepted 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.





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Hetlioz Effective Date: January 1, 2018

Covered uses All medically accepted 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 Hepatitis Treatments: Pegasys, Pegasys proclick Effective Date: January 1, 2018

Covered uses All medically accepted 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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High Risk in the Elderly Medications: High Risk in the Elderly Drugs: Tricyclic Antidepressants: Amitriptyline, Clomipramine, Doxepin, Imipramine, Trimipramine Effective Date: January 1, 2018

Covered uses All medically accepted 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.




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High Risk in the Elderly Medications: Zaleplon Effective Date: January 1, 2018

Covered uses All medically accepted 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.

Back to Prior Authorization Drug List High Risk in the Elderly Medications: Thioridiazine Effective Date: January 1, 2018

Covered uses All medically accepted 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 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 antipsychotic such as aripiprazole or quetiapine.



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Ibrance Effective Date: January 1, 2018



Iclusig Effective Date: January 1, 2018





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Idhifa Effective Date: March 1, 2018


Back to Prior Authorization Drug List Ilaris Effective Date: January 1, 2018

Covered uses All medically accepted 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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Imbruvica Effective Date: January 1, 2018



Imfinzi Effective Date: January 1, 2018





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Inflectra Effective Date: January 1, 2018





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Injectable Diabetic Medications: Byetta, Bydureon, Victoza, SymlinPen Effective Date: January 1, 2018

Covered uses All medically accepted 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 None 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. SymlinPen is covered for patients that have failed intensive treatment with insulin monotherapy and for concurrent use with an insulin product




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Inlyta Effective Date: January 1, 2018

Covered uses All medically accepted 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

Back to Prior Authorization Drug List Jakafi Effective Date: January 1, 2018

Covered uses All medically accepted 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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Juxtapid Effective Date: January 1, 2018

Covered uses All medically accepted 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

Back to Prior Authorization Drug List Kalydeco Effective Date: January 1, 2018





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Kanuma Effective Date: January 1, 2018


Back to Prior Authorization Drug List Kineret Effective Date: January 1, 2018

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 Rheumatoid arthritis requires a treatment failure or contraindication to Enbrel

or Humira. Back to Prior Authorization Drug List



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Kisqali, Kisqali Femara Effective Date: January 1, 2018


Back to Prior Authorization Drug List Korlym Effective Date: January 1, 2018





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Kynamro Effective Date: January 1, 2018


Back to Prior Authorization Drug List Kyprolis Effective Date: January 1, 2018





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Lartruvo Effective Date: March 1, 2018


Back to Prior Authorization Drug List Lenvima Effective Date: January 1, 2018





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Lidocaine Transdermal Patch Effective Date: January 1, 2018


Back to Prior Authorization Drug List Linzess Effective Date: January 1, 2018

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 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, 2018


Back to Prior Authorization Drug List Lynparza Effective Date: January 1, 2018





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Mavyret Effective Date: March 1, 2018


Back to Prior Authorization Drug List Mekinist Effective Date: January 1, 2018

Covered uses All medically accepted 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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Modafinil, Armodafinil Effective Date: January 1, 2018


Back to Prior Authorization Drug List Movantik Effective Date: January 1, 2018





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Mozobil Effective Date: January 1, 2018

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 Duration requested up to one month Other criteria None


Myalept Effective Date: January 1, 2018

Covered uses All medically accepted 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 None




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Mylotarg Effective Date: March 1, 2018


Back to Prior Authorization Drug List Narcotic Analgesics: Abstral, Fentanyl Citrate Oral Transmucosal, Fentora, Lazanda, Onsolis, Subsys Effective Date: January 1, 2018

Covered uses All medically accepted 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 Back to Prior Authorization Drug List



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Natpara Effective Date: January 1, 2018



Nerlynx Effective Date: March 1, 2018





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Nexavar Effective Date: January 1, 2018

Covered uses All medically accepted 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

Back to Prior Authorization Drug List Ninlaro Effective Date: January 1, 2018





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Nuplazid Effective Date: January 1, 2018


Back to Prior Authorization Drug List Odomzo Effective Date: January 1, 2018





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Ofev Effective Date: January 1, 2018

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


Orencia, Orencia Clickject Effective Date: January 1, 2018

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 Coverage is provided when there has been a trial and failure or contraindication

to Enbrel or Humira




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Orenitram Effective Date: January 1, 2018


Back to Prior Authorization Drug List Orkambi Effective Date: January 1, 2018





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Otezla Effective Date: January 1, 2018

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 Coverage is provided for moderate to severe plaque psoriasis or psoriatic

arthritis when there has been a trial and failure or contraindication to Enbrel or Humira

Back to Prior Authorization Drug List Oxandrolone Effective Date: January 1, 2018

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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Oxymetholone, Anadrol-50 Effective Date: January 1, 2018

Covered uses All medically accepted 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.


Back to Prior Authorization Drug List Plegridy Effective Date: January 1, 2018





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Pomalyst Effective Date: January 1, 2018

Covered uses All medically accepted 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.

Back to Prior Authorization Drug List Praluent Effective Date: January 1, 2018





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Procysbi Effective Date: January 1, 2018





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Prolia Effective Date: January 1, 2018

Covered uses All medically accepted 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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Promacta Effective Date: January 1, 2018

Covered uses All medically accepted 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 week approval

Continuation therapy - 12 month approval Other criteria None

Back to Prior Authorization Drug List Pulmonary Agents: Adcirca, Letairis, Opsumit, Revatio oral suspension, Sildenafil Citrate 20mg, Remodulin, Tracleer Effective Date: January 1, 2018

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 Coverage for Revatio and Adcirca is not provided in situations where patients

are receiving nitrate therapy. Back to Prior Authorization Drug List



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Radicava Effective Date: March 1, 2018


Back to Prior Authorization Drug List Ravicti Effective Date: January 1, 2018





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Rebif Effective Date: January 1, 2018


Back to Prior Authorization Drug List Relistor Effective Date: January 1, 2018

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 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.




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Remicade Effective Date: January 1, 2018

Covered uses All medically accepted 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 None Prescriber restrictions None Coverage duration One Year Other criteria None

Back to Prior Authorization Drug List Remodulin Effective Date: January 1, 2018





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Repatha Effective Date: January 1, 2018


Prescriber restrictions None Coverage duration One Year Other criteria None

Back to Prior Authorization Drug List Revlimid Effective Date: January 1, 2018

Covered uses All medically accepted 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




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Rubraca Effective Date: January 1, 2018



Back to Prior Authorization Drug List Rydapt Effective Date: January 1, 2018






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Samsca Effective Date: January 1, 2018

Covered uses All medically accepted 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

Back to Prior Authorization Drug List Kuvan (Sapropterin hydrochloride) Effective Date: January 1, 2018

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 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



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Simponi Effective Date: January 1, 2018

Covered uses All medically accepted 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 and Enbrel, except if contraindicated or not tolerated due to documented clinical side effects.

Back to Prior Authorization Drug List Sirturo Effective Date: January 1, 2018

Covered uses All medically accepted 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




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Sovaldi Effective Date: January 1, 2018

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


Sprycel Effective Date: January 1, 2018

Covered uses All medically accepted 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




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Stelara Effective Date: January 1, 2018

Covered uses All medically accepted 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 For Crohn's, 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 and Enbrel, except if contraindicated or not tolerated due to documented clinical side effects.

Back to Prior Authorization Drug List Strensiq Effective Date: January 1, 2018





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Sutent Effective Date: January 1, 2018


Back to Prior Authorization Drug List Sylatron Effective Date: January 1, 2018





72 of 89

Sylvant Effective Date: January 1, 2018


Back to Prior Authorization Drug List Tabloid Effective Date: January 1, 2018

Covered uses All medically accepted 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




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Tafinlar Effective Date: January 1, 2018

Covered uses All medically accepted 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

Back to Prior Authorization Drug List Tagrisso Effective Date: January 1, 2018





74 of 89

Tarceva Effective Date: January 1, 2018


Back to Prior Authorization Drug List Targretin/Bexarotene Effective Date: January 1, 2018

Covered uses All medically accepted 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




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Tasigna Effective Date: January 1, 2018


Back to Prior Authorization Drug List Ticfidera Effective Date: January 1, 2018





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Tecentriq Effective Date: January 1, 2018


Back to Prior Authorization Drug List Tetrabenazine Effective Date: January 1, 2018

Covered uses All medically accepted 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




77 of 89

Thalomid Effective Date: January 1, 2018


Back to Prior Authorization Drug List Treanda Effective Date: January 1, 2018





78 of 89

Tysabri Effective Date: January 1, 2018

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 Coverage is provided for relapsing-remitting form of multiple sclerosis when

there is documentation of a trial of Copaxone and at least one other interferon beta product unless contraindicated. For Crohns disease coverage is provided with documentation of a trial and failure of Humira and either Cimzia or Stelara

Back to Prior Authorization Drug List Uptravi Effective Date: January 1, 2018





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Vecamyl Effective Date: January 1, 2018


Back to Prior Authorization Drug List Vectibex Effective Date: January 1, 2018

Covered uses All medically accepted 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




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Vemlidy Effective Date: April 1, 2018


Back to Prior Authorization Drug List Venclexta Effective Date: January 1, 2018



Verzenio



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Effective Date: March 1, 2018


Back to Prior Authorization Drug List Vosevi Effective Date: March 1, 2018

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 None

Back to Prior Authorization Drug List Votrient Effective Date: January 1, 2018



82 of 89

Covered uses All medically accepted 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, 2018

Covered uses All medically accepted 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.





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Xeljanz Effective Date: January 1, 2018

Covered uses All medically accepted 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 and Humira.


Xgeva Effective Date: January 1, 2018





84 of 89

Xolair Effective Date: January 1, 2018


Back to Prior Authorization Drug List Xtandi Effective Date: January 1, 2018

Covered uses All medically accepted 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




85 of 89

Xyrem Effective Date: January 1, 2018


Back to Prior Authorization Drug List Yervoy Effective Date: January 1, 2018

Covered uses All medically accepted 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



86 of 89

Effective Date: January 1, 2018


Back to Prior Authorization Drug List Zejula Effective Date: January 1, 2018


Back to Prior Authorization Drug List Zelboraf



87 of 89

Effective Date: January 1, 2018

Covered uses All medically accepted indications not otherwise excluded from Part D. Exclusion criteria Will not be covered in combination with Yervoy 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 Zolinza Effective Date: January 1, 2018


Back to Prior Authorization Drug List Zurampic Effective Date: January 1, 2018



88 of 89


Back to Prior Authorization Drug List Zydelig Effective Date: January 1, 2018


Back to Prior Authorization Drug List Zykadia Effective Date: January 1, 2018



89 of 89


Back to Prior Authorization Drug List Zytiga Effective Date: January 1, 2018

