Prior Authorization Criteria
CW 2014
Last Updated: 02/25/2014
ACITRETIN
Products Affected
•
•
Soriatane
Acitretin
PA Criteria
Criteria Details
Covered Uses
All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
Pregnancy or intent to become pregnant in the next three years.
Required
Medical
Information
N/A
Age Restrictions
N/A
Prescriber
Restrictions
Dermatologist
Coverage
Duration
6 months
Other Criteria
N/A
Partnership HMO SNP
1
AFATINIB (GILOTRIF)
Products Affected
•
Gilotrif
PA Criteria
Criteria Details
Covered Uses
All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
N/A
Required
Medical
Information
N/A
Age Restrictions
N/A
Prescriber
Restrictions
N/A
Coverage
Duration
1 year
Other Criteria
N/A
Partnership HMO SNP
2
ALOSETRON (LOTRONEX)
Products Affected
•
Lotronex
PA Criteria
Criteria Details
Covered Uses
All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
Failure of alosetron after 4 weeks of taking 1mg twice a day.
Required
Medical
Information
Enrollment in the Glaxo-SmithKline Prescribing Program.
Age Restrictions
N/A
Prescriber
Restrictions
Only physicians enrolled in the GlaxoSmithKline Prescribing Program.
Coverage
Duration
1 year
Other Criteria
N/A
Partnership HMO SNP
3
ANAGRELIDE
Products Affected
•
Anagrelide Hydrochloride
PA Criteria
Criteria Details
Covered Uses
All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
N/A
Required
Medical
Information
N/A
Age Restrictions
N/A
Prescriber
Restrictions
Hematologist
Coverage
Duration
1 year
Other Criteria
N/A
Partnership HMO SNP
4
ARIPIPRAZOLE (ABILIFY)
Products Affected
•
•
Abilify Discmelt
Abilify ORAL SOLN
PA Criteria
Criteria Details
Covered Uses
All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
N/A
Required
Medical
Information
Unable to take a solid oral dosage form
Age Restrictions
N/A
Prescriber
Restrictions
N/A
Coverage
Duration
1 year
Other Criteria
N/A
Partnership HMO SNP
5
BECAPLERMIN (REGRANEX)
Products Affected
•
Regranex
PA Criteria
Criteria Details
Covered Uses
All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
N/A
Required
Medical
Information
Diagnosis of diabetic neuropathic ulcers during a wound care consult.
Reasses treatment if ulcer fails to decrease in size by 30% after 10 weeks
or fails to completely heal in 20 weeks.
Age Restrictions
N/A
Prescriber
Restrictions
Wound care specialist (MD, NP, or RN)
Coverage
Duration
1 year
Other Criteria
N/A
Partnership HMO SNP
6
BEDAQUILINE (SIRTURO)
Products Affected
•
Sirturo
PA Criteria
Criteria Details
Covered Uses
All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
N/A
Required
Medical
Information
Member must have observed therapy for 24 weeks.
Age Restrictions
N/A
Prescriber
Restrictions
N/A
Coverage
Duration
1 year
Other Criteria
N/A
Partnership HMO SNP
7
BEER'S LIST HIGHLY ANTICHOLINERGIC MEDICATIONS
Products Affected
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Amitriptyline Hcl
Amoxapine
Benztropine Mesylate ORAL TABS
Chlorpromazine Hcl INJ
Chlorpromazine Hcl ORAL TABS
Clomipramine Hcl
Cyclobenzaprine Hcl
Desipramine Hcl
Dicyclomine Hcl
Diphenhydramine Hcl CAPS 50MG
Diphenhydramine Hcl INJ
Diphenoxylate/atropine
Doxepin Hcl
Fluphenazine Decanoate
Fluphenazine Hcl
Hydroxyzine Hcl
Hydroxyzine Pamoate
Imipramine Hcl
Imipramine Pamoate
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Loxapine Succinate
Meclizine Hcl ORAL TABS
Nortriptyline Hcl ORAL CAPS
Olanzapine
Orap
Paroxetine Hcl
Paroxetine Hcl Er
Perphenazine
Prochlorperazine
Prochlorperazine Edisylate
Prochlorperazine Maleate
Promethazine Hcl
Promethazine Vc
Protriptyline Hcl
Thioridazine Hcl
Thiothixene
Tizanidine Hcl ORAL TABS
Trifluoperazine Hcl
Trihexyphenidyl Hcl
Trimipramine Maleate
PA Criteria
Criteria Details
Covered Uses
All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
N/A
Required
Medical
Information
Prescriber must certify that member is appropriate for this highly
anticholinergic medication.
Age Restrictions
N/A
Prescriber
Restrictions
N/A
Coverage
Duration
1 year
Partnership HMO SNP
8
Other Criteria
These medications have been identified by the 2012 Beer's Criteria as
highly anticholinergic and potentially inappropriate for use in older
adults. Beneficiaries should be evaluated for falls risk and other risks
before initiation of treatment and monitored closely for side effects during
treatment.
Partnership HMO SNP
9
BEER'S LIST HIGHLY ANTICHOLINERGIC MEDICATIONS
LIQUID
Products Affected
•
Nortriptyline Hcl SOLN
PA Criteria
Criteria Details
Covered Uses
All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
N/A
Required
Medical
Information
Unable to take a solid oral dosage form
Age Restrictions
N/A
Prescriber
Restrictions
N/A
Coverage
Duration
1 year
Other Criteria
N/A
Partnership HMO SNP
10
BOCEPRIVIR (VICTRELIS)
Products Affected
•
Victrelis
PA Criteria
Criteria Details
Covered Uses
All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
N/A
Required
Medical
Information
Confirmed HCV genotype 1 and compensated liver disease. Must be used
with peg interferon alfa and ribavirin. HCV-RNA levels must be less than
or equal to 100 IU/mL at treament week 12 for PA renewal. HCV-RNA
levels must be confirmed undetectable at treatment week 24 for PA
renewal.
Age Restrictions
N/A
Prescriber
Restrictions
Hepatologist, infectious disease specialist, or gastroenterologist
Coverage
Duration
3 months
Other Criteria
Must be taken with peginterferon alfa and ribavirin
Partnership HMO SNP
11
CABOZANTINIB S-MALATE (COMETRIQ)
Products Affected
•
Cometriq ORAL KIT 0, 0, 20MG
PA Criteria
Criteria Details
Covered Uses
All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
N/A
Required
Medical
Information
N/A
Age Restrictions
N/A
Prescriber
Restrictions
Endocrinologist or Oncologist
Coverage
Duration
1 year
Other Criteria
N/A
Partnership HMO SNP
12
CARGLUMIC ACID (CARBAGLU)
Products Affected
•
Carbaglu
PA Criteria
Criteria Details
Covered Uses
All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
N/A
Required
Medical
Information
N/A
Age Restrictions
N/A
Prescriber
Restrictions
N/A
Coverage
Duration
1 year
Other Criteria
N/A
Partnership HMO SNP
13
CLOBAZAM (ONFI)
Products Affected
•
Onfi ORAL TABS
PA Criteria
Criteria Details
Covered Uses
All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
N/A
Required
Medical
Information
N/A
Age Restrictions
N/A
Prescriber
Restrictions
Neurologist
Coverage
Duration
1 year
Other Criteria
N/A
Partnership HMO SNP
14
CLOBAZAM LIQUID (ONFI)
Products Affected
•
Onfi SUSP
PA Criteria
Criteria Details
Covered Uses
All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
N/A
Required
Medical
Information
Unable to take a solid oral dosage form
Age Restrictions
N/A
Prescriber
Restrictions
Neurologist
Coverage
Duration
1 year
Other Criteria
N/A
Partnership HMO SNP
15
CLONIDINE TRANSDERMAL (CATAPRES-TTS)
Products Affected
•
Clonidine Hcl TRANSDERMAL
PTWK
PA Criteria
Criteria Details
Covered Uses
All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
N/A
Required
Medical
Information
Unable to take a solid oral dosage form
Age Restrictions
N/A
Prescriber
Restrictions
N/A
Coverage
Duration
1 year
Other Criteria
N/A
Partnership HMO SNP
16
CLOZAPINE (VERSACLOZ)
Products Affected
•
Versacloz
PA Criteria
Criteria Details
Covered Uses
All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
N/A
Required
Medical
Information
Unable to take a solid oral dosage form.
Age Restrictions
N/A
Prescriber
Restrictions
N/A
Coverage
Duration
1 year
Other Criteria
N/A
Partnership HMO SNP
17
COLLAGENASE (SANTYL)
Products Affected
•
Santyl
PA Criteria
Criteria Details
Covered Uses
All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
N/A
Required
Medical
Information
N/A
Age Restrictions
N/A
Prescriber
Restrictions
Wound care specialist (MD, NP, or RN) or Infectious Disease Specialist
or Dermatologist
Coverage
Duration
1 year
Other Criteria
N/A
Partnership HMO SNP
18
CRIZOTINIB (XALKORI)
Products Affected
•
Xalkori
PA Criteria
Criteria Details
Covered Uses
All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
N/A
Required
Medical
Information
N/A
Age Restrictions
N/A
Prescriber
Restrictions
Oncologist
Coverage
Duration
1 year
Other Criteria
N/A
Partnership HMO SNP
19
CYCLOSPORINE (RESTASIS)
Products Affected
•
Restasis
PA Criteria
Criteria Details
Covered Uses
All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
Non-functioning lacriminal gland
Required
Medical
Information
N/A
Age Restrictions
N/A
Prescriber
Restrictions
Opthalmologist
Coverage
Duration
1 year
Other Criteria
N/A
Partnership HMO SNP
20
DARBEPOETIN ALFA (ARANESP)
Products Affected
•
Aranesp Albumin Free INJ
100MCG/0.5ML, 100MCG/ML,
150MCG/0.3ML, 200MCG/0.4ML,
200MCG/ML, 25MCG/0.42ML,
25MCG/ML, 300MCG/0.6ML,
300MCG/ML, 40MCG/0.4ML,
40MCG/ML, 500MCG/ML,
60MCG/0.3ML, 60MCG/ML
PA Criteria
Criteria Details
Covered Uses
All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
Anemia of chronic disease OR bleeding OR autoimmune hemolytic
anemia OR uncontrolled HTN OR cancer patients receiving radiation
alone OR inadequate iron or Vitamin B stores as determined by blood
testing OR failure to respond (hemoglobin greater than 10 g/dL)
Required
Medical
Information
N/A
Age Restrictions
N/A
Prescriber
Restrictions
N/A
Coverage
Duration
6 months
Other Criteria
N/A
Partnership HMO SNP
21
DEXTROMETHORPHAN HYDROBROMIDE/QUINIDINE
SULFATE (NEUDEXTA)
Products Affected
•
Nuedexta
PA Criteria
Criteria Details
Covered Uses
All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
N/A
Required
Medical
Information
N/A
Age Restrictions
N/A
Prescriber
Restrictions
N/A
Coverage
Duration
1 year
Other Criteria
N/A
Partnership HMO SNP
22
DICLOFENAC (SOLARAZE)
Products Affected
•
•
Solaraze
Diclofenac Sodium GEL
PA Criteria
Criteria Details
Covered Uses
All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
Use for topical relief of joint pain.
Required
Medical
Information
N/A
Age Restrictions
N/A
Prescriber
Restrictions
Dermatologist or oncologist
Coverage
Duration
1 year
Other Criteria
N/A
Partnership HMO SNP
23
DORNASE ALFA (PULMOZYME)
Products Affected
•
Pulmozyme
PA Criteria
Criteria Details
Covered Uses
All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
N/A
Required
Medical
Information
N/A
Age Restrictions
N/A
Prescriber
Restrictions
Pulmonologist
Coverage
Duration
1 year
Other Criteria
N/A
Partnership HMO SNP
24
DRONABINOL (MARINOL)
Products Affected
•
Dronabinol
PA Criteria
Criteria Details
Covered Uses
All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
N/A
Required
Medical
Information
N/A
Age Restrictions
N/A
Prescriber
Restrictions
Oncologist or Infectious Disease specialist.
Coverage
Duration
6 months
Other Criteria
N/A
Partnership HMO SNP
25
DULOXETINE (CYMBALTA)
Products Affected
•
•
Duloxetine Hcl
Cymbalta
PA Criteria
Criteria Details
Covered Uses
All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
Creatinine clearance less than 30mL/min
Required
Medical
Information
If prescribed for depression, beneficiary should have tried two other
SSRIs/SNRIs. If for painful neuropathy, beneficiary should have tried
gabapentin.
Age Restrictions
N/A
Prescriber
Restrictions
N/A
Coverage
Duration
1 year
Other Criteria
maximum dose of 120mg/day
Partnership HMO SNP
26
ELTROMBOPAG OLAMINE (PROMACTA)
Products Affected
•
Promacta
PA Criteria
Criteria Details
Covered Uses
All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
N/A
Required
Medical
Information
N/A
Age Restrictions
N/A
Prescriber
Restrictions
N/A
Coverage
Duration
1 year
Other Criteria
N/A
Partnership HMO SNP
27
EPOETIN (EPOGEN/PROCRIT)
Products Affected
•
•
Procrit
Epogen
PA Criteria
Criteria Details
Covered Uses
All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
Anemia of chronic disease OR bleeding OR autoimmune hemolytic
anemia OR uncontrolled HTN OR cancer patients receiving radiation
alone OR inadequate iron or Vitamin B stores as determined by blood
testing OR failure to respond (hemoglobin greater than 10 g/dL)
Required
Medical
Information
N/A
Age Restrictions
N/A
Prescriber
Restrictions
N/A
Coverage
Duration
6 months
Other Criteria
N/A
Partnership HMO SNP
28
ESTERIFIED ESTROGENS (MENEST)
Products Affected
•
Menest
PA Criteria
Criteria Details
Covered Uses
All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
N/A
Required
Medical
Information
N/A
Age Restrictions
N/A
Prescriber
Restrictions
Oncologist or endocrinologist
Coverage
Duration
1 year
Other Criteria
N/A
Partnership HMO SNP
29
ESTRADIOL TRANSDERMAL (CLIMERA)
Products Affected
•
Estradiol TRANSDERMAL PTWK
PA Criteria
Criteria Details
Covered Uses
All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
N/A
Required
Medical
Information
Unable to take a solid oral dosage form
Age Restrictions
N/A
Prescriber
Restrictions
N/A
Coverage
Duration
1 year
Other Criteria
N/A
Partnership HMO SNP
30
FENTANYL LOZENGES
Products Affected
•
Fentanyl Citrate Oral Transmucosal
PA Criteria
Criteria Details
Covered Uses
All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
N/A
Required
Medical
Information
Unable to tolerate a transdermal patch
Age Restrictions
N/A
Prescriber
Restrictions
N/A
Coverage
Duration
1 year
Other Criteria
Opioid tolerant beneficiaries only.
Partnership HMO SNP
31
FIDAXOMICIN (DIFICID)
Products Affected
•
Dificid
PA Criteria
Criteria Details
Covered Uses
All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
N/A
Required
Medical
Information
Confirmed gastrointestinal infection with Clostridium difficile.
Age Restrictions
N/A
Prescriber
Restrictions
N/A
Coverage
Duration
1 year
Other Criteria
N/A
Partnership HMO SNP
32
FINGOLIMOD (GILENYA)
Products Affected
•
Gilenya
PA Criteria
Criteria Details
Covered Uses
All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
N/A
Required
Medical
Information
N/A
Age Restrictions
N/A
Prescriber
Restrictions
Neurologist
Coverage
Duration
1 year
Other Criteria
N/A
Partnership HMO SNP
33
GABAPENTIN ENCARBIL XR (HORIZANT)
Products Affected
•
Horizant TB24 600MG
PA Criteria
Criteria Details
Covered Uses
All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
N/A
Required
Medical
Information
Diagnosis of Restless Legs Syndrome
Age Restrictions
N/A
Prescriber
Restrictions
N/A
Coverage
Duration
1 year
Other Criteria
N/A
Partnership HMO SNP
34
GUANFACINE (INTUNIV)
Products Affected
•
Intuniv
PA Criteria
Criteria Details
Covered Uses
All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
N/A
Required
Medical
Information
N/A
Age Restrictions
Under the age of 18 years
Prescriber
Restrictions
N/A
Coverage
Duration
1 year
Other Criteria
N/A
Partnership HMO SNP
35
IMIQUIMOD (ALDARA)
Products Affected
•
Imiquimod
PA Criteria
Criteria Details
Covered Uses
All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
N/A
Required
Medical
Information
N/A
Age Restrictions
N/A
Prescriber
Restrictions
Dermatologist or oncologist
Coverage
Duration
4 months
Other Criteria
N/A
Partnership HMO SNP
36
LOMITAPIDE (JUXTAPID)
Products Affected
•
Juxtapid
PA Criteria
Criteria Details
Covered Uses
All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
N/A
Required
Medical
Information
Diagnosis of homozygous familial hypercholesterolemia.
Age Restrictions
N/A
Prescriber
Restrictions
N/A
Coverage
Duration
1 year
Other Criteria
N/A
Partnership HMO SNP
37
MEGESTROL (MEGACE ES)
Products Affected
•
Megace Es
PA Criteria
Criteria Details
Covered Uses
All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
N/A
Required
Medical
Information
Unable to take a solid oral dosage form
Age Restrictions
N/A
Prescriber
Restrictions
N/A
Coverage
Duration
1 year
Other Criteria
N/A
Partnership HMO SNP
38
MODAFINAL (PROVIGIL)
Products Affected
•
Modafinil
PA Criteria
Criteria Details
Covered Uses
All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
Dose over 400mg per day
Required
Medical
Information
In obstructive sleep apnea or hypopnea syndrome: must also submit
history regarding continuous positive airway pressure (CPAP) use.
Age Restrictions
N/A
Prescriber
Restrictions
N/A
Coverage
Duration
1 year
Other Criteria
N/A
Partnership HMO SNP
39
NAFARELIN (SYNAREL)
Products Affected
•
Synarel
PA Criteria
Criteria Details
Covered Uses
All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
N/A
Required
Medical
Information
N/A
Age Restrictions
N/A
Prescriber
Restrictions
N/A
Coverage
Duration
1 year
Other Criteria
N/A
Partnership HMO SNP
40
NASAL FENTANYL (LAZANDA)
Products Affected
•
Lazanda
PA Criteria
Criteria Details
Covered Uses
All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
N/A
Required
Medical
Information
Beneficiary must have a diagnosis of cancer. Beneficiary must be opioid
tolerant.
Age Restrictions
N/A
Prescriber
Restrictions
N/A
Coverage
Duration
3 months
Other Criteria
N/A
Partnership HMO SNP
41
NATALIZUMAB (TYSABRI)
Products Affected
•
Tysabri
PA Criteria
Criteria Details
Covered Uses
All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
Beneficiary is positive anti-JC virus antibodies or a diagnosis of
Progressive Multifocal Leukoencephalopathy.
Required
Medical
Information
N/A
Age Restrictions
N/A
Prescriber
Restrictions
Neurologist enrolled in the TOUCH program or Gastroenterologist
enrolled in the TOUCH program
Coverage
Duration
6 months
Other Criteria
N/A
Partnership HMO SNP
42
NEUPOGEN (FILGRASTIM)
Products Affected
•
Neupogen INJ 300MCG/0.5ML,
480MCG/0.8ML, 480MCG/1.6ML
PA Criteria
Criteria Details
Covered Uses
All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
Afebrile neutropenia
Required
Medical
Information
N/A
Age Restrictions
N/A
Prescriber
Restrictions
N/A
Coverage
Duration
6 months
Other Criteria
N/A
Partnership HMO SNP
43
NICOTINE (NICOTROL NS)
Products Affected
•
Nicotrol Ns
PA Criteria
Criteria Details
Covered Uses
All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
N/A
Required
Medical
Information
Patient must be enrolled in a smoking cessation program.
Age Restrictions
N/A
Prescriber
Restrictions
N/A
Coverage
Duration
12 weeks
Other Criteria
Progress toward cessation (75% or greater reduction in cigarette use from
the beginning of the PA period) is required for PA renewal.
Partnership HMO SNP
44
NICOTINE (NICOTROL)
Products Affected
•
Nicotrol Inhaler
PA Criteria
Criteria Details
Covered Uses
All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
N/A
Required
Medical
Information
Patient must be enrolled in a smoking cessation program.
Age Restrictions
N/A
Prescriber
Restrictions
N/A
Coverage
Duration
12 weeks
Other Criteria
Progress toward cessation (75% or greater reduction in cigarette use from
the beginning of the PA period) is required for PA renewal.
Partnership HMO SNP
45
NITROFURANTOIN
Products Affected
•
•
Nitrofurantoin Monohydrate
Nitrofurantoin Macrocrystals CAPS
50MG
PA Criteria
Criteria Details
Covered Uses
All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
Renal impairment (creatinine clearance of less than 60mL/min)
Required
Medical
Information
Member must have diagnosis of urinary tract infection with a susceptible
organism. Prescriber must certify that member is appropriate for this
medication, due to its potential for pulmonary toxicity and reduced
efficacy in low creatinine clearance.
Age Restrictions
N/A
Prescriber
Restrictions
N/A
Coverage
Duration
1 month
Other Criteria
This medication has been identified by the 2012 Beer's Criteria as
potentially inappropriate for use in older adults. Beneficiaries should be
evaluated for pulmonary risks or low creatinine clearance before initiation
of treatment and monitored closely for side effects during treatment.
Partnership HMO SNP
46
OLANZAPINE (ZYPREXA ZYDIS)
Products Affected
•
Olanzapine Odt
PA Criteria
Criteria Details
Covered Uses
All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
N/A
Required
Medical
Information
Unable to take a solid oral dosage form. Prescriber must certify that
member is appropriate for this highly anticholinergic medication.
Age Restrictions
N/A
Prescriber
Restrictions
N/A
Coverage
Duration
1 year
Other Criteria
This medication has been identified by the 2012 Beer's Criteria as highly
anticholinergic and potentially inappropriate for use in older adults.
Beneficiaries should be evaluated for falls risk and other risks before
initiation of treatment and monitored closely for side effects during
treatment.
Partnership HMO SNP
47
OMACETAXINE MEPESUCCINATE (SYNRIBO)
Products Affected
•
Synribo
PA Criteria
Criteria Details
Covered Uses
All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
N/A
Required
Medical
Information
N/A
Age Restrictions
N/A
Prescriber
Restrictions
Oncologist
Coverage
Duration
1 year
Other Criteria
N/A
Partnership HMO SNP
48
OPRELVEKIN (NEUMEGA)
Products Affected
•
Neumega
PA Criteria
Criteria Details
Covered Uses
All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
N/A
Required
Medical
Information
N/A
Age Restrictions
N/A
Prescriber
Restrictions
Oncologist
Coverage
Duration
1 year
Other Criteria
N/A
Partnership HMO SNP
49
PANTOPRAZOLE ORAL SUSPENSION (PROTONIX)
Products Affected
•
Pantoprazole Sodium INJ
PA Criteria
Criteria Details
Covered Uses
All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
N/A
Required
Medical
Information
Unable to take a solid oral dosage form
Age Restrictions
N/A
Prescriber
Restrictions
N/A
Coverage
Duration
1 year
Other Criteria
N/A
Partnership HMO SNP
50
PAROXETINE (PAXIL)
Products Affected
•
Paxil SUSP
PA Criteria
Criteria Details
Covered Uses
All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
N/A
Required
Medical
Information
Unable to take a solid oral dosage form. Prescriber must certify that
member is appropriate for this highly anticholinergic medication.
Age Restrictions
N/A
Prescriber
Restrictions
N/A
Coverage
Duration
1 year
Other Criteria
This medication has been identified by the 2012 Beer's Criteria as highly
anticholinergic and potentially inappropriate for use in older adults.
Beneficiaries should be evaluated for falls risk and other risks before
initiation of treatment and monitored closely for side effects during
treatment.
Partnership HMO SNP
51
PENTAMIDINE
Products Affected
•
•
Pentam 300
Nebupent
PA Criteria
Criteria Details
Covered Uses
All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
N/A
Required
Medical
Information
N/A
Age Restrictions
N/A
Prescriber
Restrictions
Pulmonologist or Infectious Disease Specialist
Coverage
Duration
6 months
Other Criteria
N/A
Partnership HMO SNP
52
RANOLAZINE (RANEXA)
Products Affected
•
Ranexa
PA Criteria
Criteria Details
Covered Uses
All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
N/A
Required
Medical
Information
N/A
Age Restrictions
N/A
Prescriber
Restrictions
Cardiologist
Coverage
Duration
1 year
Other Criteria
Monitor for QT prolongation
Partnership HMO SNP
53
RILUZOLE (RILUTEK)
Products Affected
•
Riluzole
PA Criteria
Criteria Details
Covered Uses
All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
N/A
Required
Medical
Information
N/A
Age Restrictions
N/A
Prescriber
Restrictions
N/A
Coverage
Duration
1 year
Other Criteria
N/A
Partnership HMO SNP
54
ROFLUMILAST (DALIRESP)
Products Affected
•
Daliresp
PA Criteria
Criteria Details
Covered Uses
All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
N/A
Required
Medical
Information
N/A
Age Restrictions
N/A
Prescriber
Restrictions
Pulmonologist
Coverage
Duration
1 year
Other Criteria
N/A
Partnership HMO SNP
55
SAPROPTERIN (KUVAN)
Products Affected
•
Kuvan
PA Criteria
Criteria Details
Covered Uses
All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
N/A
Required
Medical
Information
Failure of PKU diet to control blood Phe levels or a medical
contraindication to adhering to the PKU diet
Age Restrictions
N/A
Prescriber
Restrictions
N/A
Coverage
Duration
1 year
Other Criteria
N/A
Partnership HMO SNP
56
SARGRAMOSTIM (LEUKINE)
Products Affected
•
Leukine
PA Criteria
Criteria Details
Covered Uses
All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
N/A
Required
Medical
Information
N/A
Age Restrictions
N/A
Prescriber
Restrictions
Oncologist, immunologist, or transplant specialist
Coverage
Duration
1 year
Other Criteria
N/A
Partnership HMO SNP
57
SELEGILINE (EMSAM)
Products Affected
•
Emsam
PA Criteria
Criteria Details
Covered Uses
All FDA-approved indications not otherwise excluded from Part D
Exclusion
Criteria
N/A
Required
Medical
Information
Unable to take a solid oral dosage form
Age Restrictions
N/A
Prescriber
Restrictions
N/A
Coverage
Duration
1 year
Other Criteria
N/A
Partnership HMO SNP
58
SEVELAMER (RENVELA)
Products Affected
•
Renvela ORAL PACK
PA Criteria
Criteria Details
Covered Uses
All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
N/A
Required
Medical
Information
Unable to take a solid oral dosage form
Age Restrictions
N/A
Prescriber
Restrictions
N/A
Coverage
Duration
1 year
Other Criteria
N/A
Partnership HMO SNP
59
SILDENAFIL (REVATIO)
Products Affected
•
Sildenafil Citrate
PA Criteria
Criteria Details
Covered Uses
All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
Erectile dysfunction
Required
Medical
Information
Pulmonary hypertension
Age Restrictions
N/A
Prescriber
Restrictions
N/A
Coverage
Duration
1 year
Other Criteria
N/A
Partnership HMO SNP
60
SOMATROPIN
Products Affected
•
•
•
•
•
•
•
Genotropin
Genotropin Miniquick
Humatrope INJ 12MG, 24MG, 6MG
Humatrope Combo Pack
Norditropin Flexpro
Norditropin Nordiflex Pen
Nutropin
•
•
•
•
•
•
•
•
Nutropin Aq Nuspin 5
Nutropin Aq Pen
Omnitrope
Saizen INJ 5MG
Saizen Click.easy
Serostim
Tev-tropin
Zorbtive
PA Criteria
Criteria Details
Covered Uses
All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
N/A
Required
Medical
Information
N/A
Age Restrictions
N/A
Prescriber
Restrictions
Endocrinologist
Coverage
Duration
1 year
Other Criteria
N/A
Partnership HMO SNP
61
TADALAFIL (ADCIRCA)
Products Affected
•
Adcirca
PA Criteria
Criteria Details
Covered Uses
All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
Erectile dysfunction
Required
Medical
Information
Pulmonary hypertension
Age Restrictions
N/A
Prescriber
Restrictions
N/A
Coverage
Duration
1 year
Other Criteria
N/A
Partnership HMO SNP
62
TELAPREVIR (INCIVEK)
Products Affected
•
Incivek
PA Criteria
Criteria Details
Covered Uses
All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
N/A
Required
Medical
Information
Confirmed HCV genotype 1 and compensated liver disease. Must be used
with peg interferon alfa and ribavirin. HCV RNA levels must be under
1000 units/mL at treatment week 4 for PA renewal.
Age Restrictions
N/A
Prescriber
Restrictions
Hepatologist, infectious disease specialist, or gastroenterologist
Coverage
Duration
1 year
Other Criteria
Must be taken with peginterferon alfa and ribavirin
Partnership HMO SNP
63
TELITHROMYCIN (KETEK)
Products Affected
•
Ketek
PA Criteria
Criteria Details
Covered Uses
All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
Congenital prolongation of QTc interval OR ongoing proarrhythmic
condition, such as hypokalemia or hypomagnesemia or concurrent
treatment with a Class IA or Class III antiarrythmic agent OR diagnosis of
myasthenia gravis.
Required
Medical
Information
N/A
Age Restrictions
N/A
Prescriber
Restrictions
N/A
Coverage
Duration
1 year
Other Criteria
N/A
Partnership HMO SNP
64
TESTOSTERONE (ANDRODERM)
Products Affected
•
Androderm
PA Criteria
Criteria Details
Covered Uses
All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
N/A
Required
Medical
Information
For PA renewal, improvement must be seen and maintained after 3
months.
Age Restrictions
N/A
Prescriber
Restrictions
N/A
Coverage
Duration
3 months
Other Criteria
N/A
Partnership HMO SNP
65
TETRABENAZINE (XENAZINE)
Products Affected
•
Xenazine
PA Criteria
Criteria Details
Covered Uses
All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
N/A
Required
Medical
Information
N/A
Age Restrictions
N/A
Prescriber
Restrictions
N/A
Coverage
Duration
1 year
Other Criteria
N/A
Partnership HMO SNP
66
TOBRAMYCIN (TOBI)
Products Affected
•
•
Tobramycin
Tobi
PA Criteria
Criteria Details
Covered Uses
All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
N/A
Required
Medical
Information
N/A
Age Restrictions
N/A
Prescriber
Restrictions
Pulmonologist or infectious disease specialist
Coverage
Duration
1 year
Other Criteria
N/A
Partnership HMO SNP
67
TOFACITINIB (XELJANZ)
Products Affected
•
Xeljanz
PA Criteria
Criteria Details
Covered Uses
All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
N/A
Required
Medical
Information
N/A
Age Restrictions
N/A
Prescriber
Restrictions
N/A
Coverage
Duration
1 year
Other Criteria
N/A
Partnership HMO SNP
68
TOPRIAMATE (TOPAMAX SPRINKLE)
Products Affected
•
Topiramate ORAL CPSP
PA Criteria
Criteria Details
Covered Uses
All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
N/A
Required
Medical
Information
Unable to take a solid oral dosage form
Age Restrictions
N/A
Prescriber
Restrictions
N/A
Coverage
Duration
1 year
Other Criteria
N/A
Partnership HMO SNP
69
VARENICILINE (CHANTIX)
Products Affected
•
•
Chantix Starting Month Pak
Chantix
PA Criteria
Criteria Details
Covered Uses
All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
N/A
Required
Medical
Information
Patient must be enrolled in a smoking cessation program.
Age Restrictions
N/A
Prescriber
Restrictions
N/A
Coverage
Duration
12 weeks
Other Criteria
Progress toward cessation (75% or greater reduction in cigarette use from
the beginning of the PA period) is required for PA renewal. Up to two PA
periods allowed per year.
Partnership HMO SNP
70
VEMURAFENIB (ZELBORAF)
Products Affected
•
Zelboraf
PA Criteria
Criteria Details
Covered Uses
All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
N/A
Required
Medical
Information
N/A
Age Restrictions
N/A
Prescriber
Restrictions
Oncologist
Coverage
Duration
1 year
Other Criteria
N/A
Partnership HMO SNP
71
VORTIOXETINE (BRINTELLIX)
Products Affected
•
Brintellix
PA Criteria
Criteria Details
Covered Uses
All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
N/A
Required
Medical
Information
N/A
Age Restrictions
N/A
Prescriber
Restrictions
N/A
Coverage
Duration
1 year
Other Criteria
N/A
Partnership HMO SNP
72
ZOLEDRONIC ACID (ZOMETA)
Products Affected
•
Zoledronic Acid INJ 4MG/5ML
PA Criteria
Criteria Details
Covered Uses
All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
N/A
Required
Medical
Information
N/A
Age Restrictions
N/A
Prescriber
Restrictions
N/A
Coverage
Duration
1 year
Other Criteria
N/A
Partnership HMO SNP
73
INDEX
T
To create the index select this text and press the
function key, F9................................................. 1
Partnership HMO SNP
74