2015 Cigna-HealthSpring Prior Authorization Criteria ... · PDF file2015 Cigna-HealthSpring...

Drug NamePrior Authorization

Type DescriptionProduct Group Covered Uses Exclusion Criteria Required Medical Information

Age

Restrictions

Prescriber

Restrictions

Coverage

DurationOther Criteria

Excluded

Drug

Criteria

ABELCETPrior Authorization

Appliesantifungals, polyene

All medically accepted

indications not otherwise

excluded from Part D.

6 months B vs D coverage determination

ABRAXANEPart D vs. Part B Prior

Authorization Only12 months

ACAMPROSATE

CALCIUM DR

Prior Authorization

Applies

alcohol dependence

agents

All FDA-approved



Documentation of alcohol dependence 12 months

ACETYLCYSTEINEPart D vs. Part B Prior


ACITRETINPrior Authorization

Appliesacitretin



excluded from Part D

Documentation of diagnosis 12 months

ACTIMMUNE

Prior Authorization

Applies to New Starts

Only

actimmune




12 months

ADAGENPrior Authorization

Appliesimmune stimulants





ADRIAMYCINPart D vs. Part B Prior


ADRUCILPart D vs. Part B Prior


AFINITOR

Prior Authorization


Only

afinitor




Documentation of diagnosis and past medication history 12 months

Afinitor is considered medically necessary for

the treatment of patients with advanced renal

cell carcinoma after failure of treatment with

Sutent (sunitinib) OR Nexavar (sorafenib).

AFINITOR DISPERZ

Prior Authorization


Only

afinitor





Afinitor is considered medically necessary for

the treatment of patients with advanced renal

cell carcinoma after failure of treatment with

Sutent (sunitinib) OR Nexavar (sorafenib).

ALBUTEROL SULFATEPart D vs. Part B Prior


ALDURAZYMEPrior Authorization

Applies

enzyme

replacement/modifiers





ALIMTAPart D vs. Part B Prior


ALORAPrior Authorization

AppliesHRM - Estrogens




The physician has documented the indication for the continued

use of the HRM (high risk med) with an explanation of the

specific benefit established with the medication and how that

benefit outweighs the potential risk, AND the physician has

documented the ongoing monitoring plan for the agent, AND

the physician has documented that the patient has tried and

failed two (2) safer formulary alternatives or provided clinical

rationale why two safer formulary alternatives are not

appropriate for the patient.

Automatic

approval if

member is less

than 65 years of

age.Prior Auth

required for age

65 or older.

12 months

Safer alternatives to the estrogen high risk

medications depend on the indication. For Hot

Flashes, safer alternatives are: Estradiol

Valerate, Depo-Estradiol, SSRIs, venlafaxine,

gabapentin, and Femring. For Vaginal

Symptoms, safer alternatives are: Premarin

Cream, Estring, Femring, and Estradiol

Valerate. For Bone Density, safer alternatives

are: alendronate, risedronate, Evista, and

Prolia.

ALOSETRONPrior Authorization

Applieslotronex




Alosetron (Lotronex) will not be

approved for use in men, as

safety and efficacy in men has

not been established.

Prescriber must be

enrolled in the

prescribing

program for

alosetron.

12 months

ALOXI (Non-formulary

for Cigna-HealthSpring

Secure (PDP) and Cigna-

HealthSpring Secure-

XTRA (PDP))

Part D vs. Part B Prior


AMBISOMEPrior Authorization






AMIFOSTINEPart D vs. Part B Prior


AMINO ACIDSPart D vs. Part B Prior


2015 Cigna-HealthSpring Prior Authorization Criteria

(Updated December 2015)



Age

Restrictions

Prescriber

Restrictions

Coverage


Excluded

Drug

Criteria

AMINOSYNPart D vs. Part B Prior


AMINOSYN

7%/ELECTROLYTES



AMINOSYN

8.5%/ELECTROLYTES



AMINOSYN IIPart D vs. Part B Prior


AMINOSYN II

4.25/DEXTROSE25%



AMINOSYN II

5/DEXTROSE 25



AMINOSYN II

8.5%/ELECTROLYTES



AMINOSYN MPart D vs. Part B Prior


AMINOSYN-HBCPart D vs. Part B Prior


AMINOSYN-HFPart D vs. Part B Prior


AMINOSYN-PFPart D vs. Part B Prior


AMINOSYN-PF 5.2 %Part D vs. Part B Prior


AMINOSYN-PF 7%Part D vs. Part B Prior


AMITRIPTYLINE HCL

Prior Authorization


Only

HRM - Tricyclic

Antidepressants













Automatic

approval if

member is less

than 65 years of

age.Prior Auth

required for age

65 or older.

12 months

Safer alternatives depend on indication. For

Depression, safer alternatives are:

Nortriptyline, Protriptyline, Desipramine,

Amoxapine, Citalopram, Venlafaxine,

Fluoxetine, Paroxetine, Sertraline, Duloxetine,

and Bupropion. For headache prophylaxis,

safer alternatives are: Propranolol, Topiramate,

and Divalproex sodium. For headache

treatment, safer alternatives are: Sumatriptan,

Naratriptan, and Dihydroergotamine. For

Pain/Neuropathy, safer alternatives are:

Duloxetine, Lyrica, and Gabapentin.

AMPHOTECPrior Authorization






AMPHOTERICIN BPrior Authorization






AMPYRAPrior Authorization

Appliesampyra




Documentation of diagnosis. 12 months

Ampyra is considered medically necessary for

patients with multiple sclerosis with medical

documentation of impaired walking ability.

ANADROL-50Prior Authorization

Applies

anabolic steroids,

androgens





ANDROGEL (Non-

formulary for Cigna-

HealthSpring Secure

(PDP) and Cigna-


XTRA (PDP))

Prior Authorization

Applies

anabolic steroids,

androgens





ANDROGEL PUMP

(Non-formulary Cigna-

HealthSpring Secure

(PDP) and Cigna-


XTRA (PDP))

Prior Authorization

Applies

anabolic steroids,

androgens





ANDROXYPrior Authorization

Applies

anabolic steroids,

androgens





APOKYNPrior Authorization

Appliesapokyn




12 months

ARALAST NPPart D vs. Part B Prior




Age

Restrictions

Prescriber

Restrictions

Coverage


Excluded

Drug

Criteria

ARANESP ALBUMIN

FREE

Prior Authorization

Applieshematopoietics




For the indication of anemia, documentation of Hemoglobin

less than 11, transferrin saturation greater than 20%, and

ferritin levels greater than 100 obtained over the last 3 months

6 months BvD Determination

ARCALYSTPrior Authorization

Appliesarcalyst




Documentation of diagnosis of Cryopyrin-Associated Periodic

Syndromes (CAPS), including Familial Cold Auto-

inflammatory Syndrome (FCAS) and Muckle-Wells Syndrome

(MWS)

12 years of age

and older12 months B vs D coverage determination

ARZERRAPart D vs. Part B Prior


ASCOMP/CODEINEPrior Authorization

Applies

HRM - Butalbital

Combinations













Automatic

approval if

member is less

than 65 years of

age.Prior Auth

required for age

65 or older.

12 monthsSafer alternatives are: naproxen sodium and

ibuprofen.

ASTAGRAF XLPart D vs. Part B Prior


ATGAMPart D vs. Part B Prior


AVASTINPart D vs. Part B Prior


AVONEXPrior Authorization

Appliesimmunomodulators




12 months

AVONEX PENPrior Authorization





12 months

AZACITIDINEPart D vs. Part B Prior


AZASANPart D vs. Part B Prior


AZATHIOPRINEPart D vs. Part B Prior


BANZEL

Prior Authorization


Only

banzel





BELEODAQ

Prior Authorization


Only

Beleodaq





BENZTROPINE

MESYLATE

Prior Authorization

AppliesHRM - Benztropine












appropriate for the patient. If only one (1) safer formulary

alternative is available, then only that particular medication

would need to be documented as tried and failed or clinical

rationale provided as to why that one safer formulary

alternative is not appropriate for the patient.

Automatic

approval if

member is less

than 65 years of

age. Prior Auth

required for age

65 or older.

12 months


Parkinsonism, safer alternatives are:

Carbidopa/Levodopa, Pramipexole,

Ropinirole, Bromocriptine, Amantadine, and

Selegiline. For extrapyramidal symptoms, a

safer alternative is: Amantadine.

BICNUPart D vs. Part B Prior


BIVIGAMPart D vs. Part B Prior


BLEOMYCIN SULFATEPart D vs. Part B Prior


BOSULIF

Prior Authorization


Only

molecular target

inhibitors




12 months

BUDESONIDE SUSPart D vs. Part B Prior




Age

Restrictions

Prescriber

Restrictions

Coverage


Excluded

Drug

Criteria

BUPRENORPHINE HCLPrior Authorization

Applies

opioid agonist-antagonist

analgesics

All FDA-approved



Documentation of opioid dependence. Documentation that

patient is involved in a comprehensive addiction care program

that incorporates non drug therapy

Buprenorphine-3d

supply, or 6 mo if

pregnant/hypersen

sitive to naloxone.

Suboxone

(bup/naltrex)-6

The use of buprenorphine for maintenance

therapy should be limited to patients who have

experienced a hypersensitivity reaction to

naloxone or require buprenorphine during

pregnancy.

BUPRENORPHINE

HCL/NALOXONE HCL

Prior Authorization

Applies


analgesics

All FDA-approved






Buprenorphine-3d

supply, or 6 mo if

pregnant/hypersen

sitive to naloxone.

Suboxone

(bup/naltrex)-6





pregnancy.

BUSULFEXPart D vs. Part B Prior


BUTAL/ASA/CAFFPrior Authorization

Applies

HRM - Butalbital

Combinations













Automatic

approval if

member is less

than 65 years of

age.Prior Auth

required for age

65 or older.


ibuprofen.

BUTALBITAL/ACETA

MINOPHEN/CAFFEINE

Prior Authorization

Applies

HRM - Butalbital

Combinations













Automatic

approval if

member is less

than 65 years of

age.Prior Auth

required for age

65 or older.


ibuprofen.

BUTALBITAL/ACETA

MINOPHEN/CAFFEINE

/CODEINE

Prior Authorization

Applies

HRM - Butalbital

Combinations













Automatic

approval if

member is less

than 65 years of

age.Prior Auth

required for age

65 or older.


ibuprofen.

BUTALBITAL/ASPIRIN

/CAFFEINE/CODEINE

Prior Authorization

Applies

HRM - Butalbital

Combinations













Automatic

approval if

member is less

than 65 years of

age.Prior Auth

required for age

65 or older.


ibuprofen.

CALCITRIOL SOLNPart D vs. Part B Prior


CANCIDASPrior Authorization

Applies

antifungals, superficial

and systemic




up to 3 months

For the treatment of tinea versicolor or

ptyriasis, use of oral ketoconazole or a topical

antifungal agent is required prior to the use of

Itraconazole For candidiasis infections (unless

specified C. glabrata or C. krusei) use of

fluconazole is required prior to the use of

CAPRELSA

Prior Authorization


Only

caprelsa





CARBOPLATINPart D vs. Part B Prior


CELLCEPTPart D vs. Part B Prior




Age

Restrictions

Prescriber

Restrictions

Coverage


Excluded

Drug

CriteriaCELLCEPT

INTRAVENOUS



CEREZYMEPart D vs. Part B Prior


CERUBIDINEPart D vs. Part B Prior


CHANTIXPrior Authorization

Applieschantix




The patient must be enrolled in a behavioral support/

modification program (e.g., community program,

manufacturer sponsored program, counseling by the physician,

internet, or telephone quitline).

The patient must

be 18 years of age

or older

6 months

CHANTIX

CONTINUING MONTH

PAK

Prior Authorization

Applieschantix








The patient must

be 18 years of age

or older

6 months

CHANTIX STARTING

MONTH PAK

Prior Authorization

Applieschantix








The patient must

be 18 years of age

or older

6 months

CHLORZOXAZONEPrior Authorization

Applies

HRM - Skeletal Muscle

Relaxants








documented the ongoing monitoring plan for the agent.

Automatic

approval if

member is less

than 65 years of

age.Prior Auth

required for age

65 or older.

12 months

CHORIONIC

GONADOTROPIN

Prior Authorization

Applies

hormonal agents,

gonadotropins





CINRYZEPrior authorization

appliesCinryze




Patient must have a confirmed diagnosis of HAE as evidenced

by a C4 level below the lower limit of normal as defined by

the laboratory performing the test AND EITHER of the

following: 1) C1 inhibitor (C1INH) antigenic level below the

lower limit of normal as defined by the laboratory performing

the test 2) C1INH functional level below the lower limit of

normal as defined by the laboratory performing the test or 3)

known HAE-causing C1INH mutation.

12 months

The patient must have a history of more than

one severe event per month and have failure,

contraindication or intolerance to one

conventional therapy for HAE prophylaxis such

as aminocaproic acid, danazol or tranexamic

acid.

CISPLATINPart D vs. Part B Prior


CLADRIBINEPart D vs. Part B Prior


CLINIMIX

2.75%/DEXTROSE 5%



CLINIMIX

4.25%/DEXTROSE 10%



CLINIMIX

4.25%/DEXTROSE 20%



CLINIMIX

4.25%/DEXTROSE 25%



CLINIMIX

4.25%/DEXTROSE 5%



CLINIMIX

5%/DEXTROSE 15%



CLINIMIX

5%/DEXTROSE 20%



CLINIMIX

5%/DEXTROSE 25%



CLINIMIX E 4.25%Part D vs. Part B Prior


CLINIMIX E

4.25%/DEXTROSE 25%



CLINIMIX E 5%Part D vs. Part B Prior


CLINISOL SF 15%Part D vs. Part B Prior


CLOLARPart D vs. Part B Prior




Age

Restrictions

Prescriber

Restrictions

Coverage


Excluded

Drug

Criteria

CLOMIPRAMINE HCL

Prior Authorization


Only

HRM - Tricyclic

Antidepressants













Automatic

approval if

member is less

than 65 years of

age.Prior Auth

required for age

65 or older.

12 months













COMETRIQ

Prior Authorization


Only

molecular target

inhibitors




12 months

COSMEGENPart D vs. Part B Prior


CROMOLYN SODIUMPart D vs. Part B Prior


CUBICINPart D vs. Part B Prior


CYCLOBENZAPRINE

HCL

Prior Authorization

Applies


Relaxants









Automatic

approval if

member is less

than 65 years of

age.Prior Auth

required for age

65 or older.

12 months

CYCLOPHOSPHAMIDEPart D vs. Part B Prior


CYCLOPHOSPHAMIDEPart D vs. Part B Prior


CYCLOSPORINEPart D vs. Part B Prior


CYCLOSPORINE

MODIFIED



CYRAMZA

Prior Authorization


Only

Antineoplastics,

monoclonal antibodies





CYTARABINEPart D vs. Part B Prior


CYTARABINE

AQUEOUS



DACARBAZINEPart D vs. Part B Prior


DACTINOMYCINPart D vs. Part B Prior


DALIRESPPrior Authorization

Applies

phosphodiesterase type 4

(pde4) inhibitors




12 months

DAUNORUBICIN HCLPart D vs. Part B Prior


DAUNOXOMEPart D vs. Part B Prior


DEPADEPrior Authorization

Appliesnaltrexone

All FDA-approved



Documentation of opioid or alcohol dependance 12 months

DEXRAZOXANEPart D vs. Part B Prior


DEXTROSE 10%/NACL

0.45%



DEXTROSE 5%

/ELECTROLYTE #48

VIAFLEX



DEXTROSE 10% FLEX

CONTAINER



DEXTROSE 10%/NACL

0.2%



DEXTROSE 2.5%/NACL

0.45%





Age

Restrictions

Prescriber

Restrictions

Coverage


Excluded

Drug

CriteriaDEXTROSE

2.5%/SODIUM

CHLORIDE 0.45%



DEXTROSE 5%Part D vs. Part B Prior


DEXTROSE 5%/NACL

0.2%



DEXTROSE 5%/NACL

0.225%



DEXTROSE 5%/NACL

0.33%



DEXTROSE 5%/NACL

0.45%



DEXTROSE 5%/NACL

0.9%



DEXTROSE

5%/POTASSIUM

CHLORIDE 0.15%



DEXTROSE

5%/SODIUM

CHLORIDE 0.2%



DEXTROSE

5%/SODIUM

CHLORIDE 0.45%



DIGITEKPrior Authorization

AppliesHRM - Digoxin









the physician has documented that the patient has tried

digoxin 0.125mg daily or provided clinical rationale as to why

the lower dose is not appropriate for the patient

Automatic

approval if

member is less

than 65 years of

age.Prior Auth

required for age

65 or older.

12 months

DIGOXPrior Authorization













Automatic

approval if

member is less

than 65 years of

age.Prior Auth

required for age

65 or older.

12 months

DIGOXINPrior Authorization













Automatic

approval if

member is less

than 65 years of

age.Prior Auth

required for age

65 or older.

12 months

DIPYRIDAMOLE (Cigna-

HealthSpring Secure

(PDP) and Cigna-


XTRA (PDP) ONLY)

Prior Authorization

Applies

HRM - Platelet

Modifying Agents













Automatic

approval if

member is less

than 65 years of

age.Prior Auth

required for age

65 or older.

12 monthsSafer alternatives are: Clopidogrel, Warfarin,

Jantoven, and Aggrenox.

DOCEFREZPart D vs. Part B Prior


DOCETAXELPart D vs. Part B Prior




Age

Restrictions

Prescriber

Restrictions

Coverage


Excluded

Drug

Criteria

DOXEPIN HCL

Prior Authorization


Only

HRM - Tricyclic

Antidepressants













Automatic

approval if

member is less

than 65 years of

age.Prior Auth

required for age

65 or older.

12 months













DOXERCALCIFEROLPart D vs. Part B Prior


DOXORUBICIN HCLPart D vs. Part B Prior


DOXORUBICIN HCL

LIPOSOME



DRONABINOLPrior Authorization

Appliesdronabinol




Documentation of diagnosis Up to 6 months

Use of Dronabinol is considered medically

necessary for the treatment of patients with

anorexia associated with weight loss in patients

with AIDS and nausea and vomiting associated

with cancer chemotherapy.

ELAPRASEPrior Authorization

Applies

enzyme






ELIGARD

Prior Authorization


Only

pituitary hormones




12 months

ELIQUIS (Cigna-

HealthSpring Secure

(PDP) and Cigna-


XTRA (PDP) ONLY))

Prior authorization

applies

Oral Factor Xa

Inhibitors/Oral DTIs




Documentation of Diagnosis 1 to 12 months

ELITEKPart D vs. Part B Prior


ELLENCEPart D vs. Part B Prior


ELSPARPart D vs. Part B Prior


EMENDPart D vs. Part B Prior


ENBRELPrior Authorization

Appliesimmune suppressants





Use of Humira, Enbrel, or Remicade is considered medically

necessary for the treatment of: 1. Rheumatoid Arthritis in

patients that have tried and failed methotrexate OR at least 2

alternative disease modifying antirheumatic drugs (DMARDs).

2. Juvenile Rheumatoid Arthritis in patients that have tried and

failed at least 2 DMARDs. 3. Ankylosing Spondylitis in patients

that have tried and failed at least 1 non-steroidal anti-

inflammatory drug (NSAID), corticosteroid, OR sulfasalazine.

4. Plaque Psoriasis in patients that have: a) moderate to severe

chronic disease, b) minimum body surface area (BSA)

involvement of greater than or equal to 5% OR involvement of

the palms, soles, head, neck or genitalia, c) tried and failed at

least 1 topical agent (topical steroid, calcipotriene, or

tazarotene) , AND d) tried and failed at least 1 systemic therapy

(cyclosporine, methotrexate, or acitretin) OR phototherapy. 5.

Psoriatic Arthritis in patients with active disease. In addition,

use of Humira or Remicade is considered medically necessary

for the treatment of: 1. Moderate to severe CrohnÂ¿s Disease in

patients that have tried and failed at least 2 of the following:

immunomodulators, corticosteroids, or aminosalicylates. 2.

Treatment of moderately to severely active ulcerative colitis in

patients who have had inadequate response to at least 2 of the

following: corticosteroids, sulfasalazine, mesalamine,

azathioprine, 6-mercaptopurine. Use of Remicade will also be

considered medically necessary for the treatment of fistulizing

Crohn's disease. B vs D determination required for Remicade.



Age

Restrictions

Prescriber

Restrictions

Coverage


Excluded

Drug

Criteria

ENBREL SURECLICKPrior Authorization
































ENGERIX-BPart D vs. Part B Prior


EPIRUBICIN HCLPart D vs. Part B Prior


ERBITUXPart D vs. Part B Prior


ERGOLOID

MESYLATES

Prior Authorization

Applies

HRM - Antidementia

Agents













Automatic

approval if

member is less

than 65 years of

age.Prior Auth

required for age

65 or older.

12 monthsSafer alternatives are: donepezil, galantamine

and rivastigmine.

ERIVEDGE

Prior Authorization


Only

erivedge




12 months

ERWINAZEPart D vs. Part B Prior


ESGICPrior Authorization

Applies

HRM - Butalbital

Combinations













Automatic

approval if

member is less

than 65 years of

age.Prior Auth

required for age

65 or older.


ibuprofen.

ESTRADIOLPrior Authorization














Automatic

approval if

member is less

than 65 years of

age.Prior Auth

required for age

65 or older.

12 months










Prolia.



Age

Restrictions

Prescriber

Restrictions

Coverage


Excluded

Drug

Criteria

ESTRADIOL/NORETHI

NDRONE ACETATE

Prior Authorization














Automatic

approval if

member is less

than 65 years of

age.Prior Auth

required for age

65 or older.

12 months










Prolia.

ETOPOPHOSPart D vs. Part B Prior


ETOPOSIDEPart D vs. Part B Prior


FABRAZYMEPart D vs. Part B Prior


FARYDAK

Prior Authorization


Only

Farydak




12 months

FASLODEXPart D vs. Part B Prior


FENTANYL CITRATEPart D vs. Part B Prior


FENTANYL CITRATE

ORAL

TRANSMUCOSAL

Prior Authorization

Applies

transmucosal fentanyl

citrate

All FDA-approved



Documentation from the medical record of diagnosis.

16 years of age

and older for

fentanyl citrate

(lozenge/troche).

18 years of age

and older for

Lazanda

Enrollment in the

Transmucosal

Immediate-

Release Fentanyl

(TIRF) REMS

Access program

12 months

Transmucosal fentanyl products will only be

covered with documentation of breakthrough

cancer pain. The patient must be currently

receiving and be tolerant to opioid therapy for

persistent cancer pain.The patient must be

enrolled in the TIRF REMS Access program.

FIRAZYRPrior Authorization

Appliesfirazyr




Patient must have a confirmed diagnosis of HAE as evidenced

by a C4 level below the lower limit of normal as defined by

the laboratory performing the test AND EITHER of the

following: 1) C1 inhibitor (C1INH) antigenic level below the

lower limit of normal as defined by the laboratory performing

the test 2) C1INH functional level below the lower limit of

normal as defined by the laboratory performing the test.

12 months

The patient must have a history of a moderate

or severe attack (e.g., airway swelling, severe

abdominal pain, facial swelling, nausea and

vomiting, painful facial distortion).

FIRMAGONPart D vs. Part B Prior


FLEBOGAMMAPart D vs. Part B Prior


FLEBOGAMMA DIFPart D vs. Part B Prior


FLUDARABINE

PHOSPHATE



FLUOROURACILPart D vs. Part B Prior


FOLOTYNPart D vs. Part B Prior


FORTEOPrior Authorization

Applies

metabolic bone disease

agents




BMD T-Score, Medical documentation reflecting high risk for

a fracture, medication history regarding the prior use of

bisphosphonates

12 months

Patients with a BMD T-score indicating high

risk despite therapy with a

bisphosphonateÂ¿for six months OR Patients

with a history of osteoporotic fracture while

receiving treatment with bisphosphonates OR

Patients unable to tolerate oral

bisphosphonates due to gastrointestinal

comorbidities or is unable to adhere to dosing

requirements (i.e., unable to remain upright for

30 minutes). For the diagnosis of

postmenopausal osteoporosis patients unable

to tolerate oral bisphosphonates must have

tried and failed Prolia for a total duration of at

least 6 months prior to the use of Forteo.

FREAMINE HBC 6.9%Part D vs. Part B Prior


FREAMINE IIIPart D vs. Part B Prior


FREAMINE III 3%Part D vs. Part B Prior


GAMASTAN S/DPart D vs. Part B Prior




Age

Restrictions

Prescriber

Restrictions

Coverage


Excluded

Drug

Criteria

GAMMAGARD LIQUIDPart D vs. Part B Prior


GAMMAKEDPart D vs. Part B Prior


GAMMAPLEXPart D vs. Part B Prior


GAMUNEXPart D vs. Part B Prior


GAMUNEX-CPart D vs. Part B Prior


GANCICLOVIRPart D vs. Part B Prior


GAZYVA

Prior Authorization


Only

antineoplastics,






GEMCITABINEPart D vs. Part B Prior


GEMCITABINE HCLPart D vs. Part B Prior


GENGRAFPart D vs. Part B Prior


GILOTRIF

Prior Authorization


Only

molecular target

inhibitors




12 months

GLEEVEC

Prior Authorization


Only

molecular target

inhibitors




12 months

GLYBURIDE/METFOR

MIN HCL

Prior Authorization

Applies

HRM -

Glyburide/Metformin










failed glipizide-metformin or provided clinical rationale as to

why that safer formulary alternative is not appropriate for the

patient.

Automatic

approval if

member is less

than 65 years of

age.Prior Auth

required for age

65 or older.

12 months

GRANISETRON HCLPart D vs. Part B Prior


HALAVEN

Prior Authorization


Only

halaven




Documentation of prior treatment with an anthracycline and a

taxane.12 months

Use of Halaven is considered medically


metastatic breast cancer who have previously

received at least two chemotherapeutic

regimens for the treatment of metastatic

disease. B vs D determination

HARVONIPrior authorization

appliesHARVONI




Previous failure of HarvoniGenotype, HCV RNA viral levels prior to treatment,

documentation of presence/absence of cirrhosis

Hepatologist,

gastroenterologist,

infectious disease

specialist or

managed by a liver

transplant center

12 to 24 weeks

based on

indication and

established

treatment

guidelines

HECORIAPart D vs. Part B Prior


HEPATAMINEPart D vs. Part B Prior


HEPATASOLPart D vs. Part B Prior


HERCEPTINPart D vs. Part B Prior




Age

Restrictions

Prescriber

Restrictions

Coverage


Excluded

Drug

Criteria

HUMIRAPrior Authorization
































HUMIRA PENPrior Authorization
































HUMIRA PEN-CROHNS

DISEASESTARTER

Prior Authorization


































Age

Restrictions

Prescriber

Restrictions

Coverage


Excluded

Drug

Criteria

HUMIRA PEN-

PEDIATRIC CROHNS

DISEASESTARTER

Prior Authorization
































HUMIRA-PSORIASIS

DISEASESTARTER

Prior Authorization
































IBRANCE

Prior Authorization


Only

molecular target

inhibitors




12 months

ICLUSIG

Prior Authorization


Only

molecular target

inhibitors




12 months

IDARUBICIN HCLPart D vs. Part B Prior


IFOSFAMIDEPart D vs. Part B Prior


IFOSFAMIDE/MESNAPart D vs. Part B Prior


ILARISPrior Authorization

Appliesilaris




12 months B vs D determination

IMBRUVICA

Prior Authorization


Only

molecular target

inhibitors




12 months



Age

Restrictions

Prescriber

Restrictions

Coverage


Excluded

Drug

Criteria

IMIPRAMINE HCL

Prior Authorization


Only

HRM - Tricyclic

Antidepressants













Automatic

approval if

member is less

than 65 years of

age.Prior Auth

required for age

65 or older.

12 months













IMIPRAMINE

PAMOATE

Prior Authorization


Only

HRM - Tricyclic

Antidepressants













Automatic

approval if

member is less

than 65 years of

age.Prior Auth

required for age

65 or older.

12 months













INCIVEKPrior Authorization

Appliesincivek




Documentation from the medical record of diagnosis including

genotype, current medication regimen, and HCV-RNA levels12 weeks

Concurrent therapy with peginterferon alfa and

ribavirin is required for Incivek

INCRELEXPrior Authorization

Appliesinsulin-like growth factor




Documentation of diagnosis. Documentation of lab data

reflecting height standard deviation score, basal IGF-1 score,

and growth hormone level.

Prescribing

physician must be

an endocrinologist

12 months

Height standard deviation score must be less

than or equal to -3.0 AND the basal IGF-1

score must be below the lower limits of normal

for the reporting lab AND the patient must

have a normal or elevated growth hormone

level (excluding patients with growth hormone

gene deletion) AND epiphyses must be

confirmed as open in patients greater than or

equal to 10 years of age.

INFERGENPrior Authorization

Applies

immune stimulants, non-

vaccine




Documentation of genotype to determine length of therapy 6 months

INLYTA

Prior Authorization


Only

molecular target

inhibitors




12 months

INTRALIPIDPart D vs. Part B Prior


INVEGA TRINZA

Prior Authorization


Only

Invega Trinza





Use of Invega Sustenna for a minimum of 4

months is required prior to use of Invega

Trinza. IPRATROPIUM

BROMIDE



IPRATROPIUM

BROMIDE/ALBUTERO

L SULFATE



IRESSA

Prior Authorization


Only

molecular target

inhibitors




12 months

IRINOTECANPart D vs. Part B Prior


ISOLYTE-

M/DEXTROSE 5%



ISOLYTE-SPart D vs. Part B Prior

Authorization Only

ISTODAX

Prior Authorization


Only

istodax




Documentation of diagnosis and past medication history

Prescribing

physician must be

an oncologist.

12 months

Use of Istodax is considered medically

necessary for the treatment of cutaneous T-cell

lymphoma in patients that have tried and failed

at least 1 prior therapy. B vs D coverage

determination.



Age

Restrictions

Prescriber

Restrictions

Coverage


Excluded

Drug

Criteria

ITRACONAZOLEPrior Authorization

Applies


and systemic




up to 3 months







Itraconazole.

IXEMPRA KITPart D vs. Part B Prior


JAKAFI

Prior Authorization


Only

molecular target

inhibitors




12 months

JEVTANAPart D vs. Part B Prior


KABIVENPart D vs. Part B Prior

Authorization Only

KADCYLA

Prior Authorization


Only

antineoplastics,






KCL

0.075%/D5W/NACL



KCL 0.15%/D5W/ NACL

0.3%



KCL 0.15%/D5W/LRPart D vs. Part B Prior


KCL 0.15%/D5W/NACL

0.2%



KCL 0.15%/D5W/NACL

0.45%



KCL 0.15%/D5W/NACL

0.9%



KCL 0.3%/D5W/NACL

0.45%



KEYTRUDA

Prior Authorization


Only

Antineoplastics,






KUVANPrior Authorization

Applieskuvan





KYPROLIS

Prior Authorization


Only

kuvan





LANOXIN (Cigna-

HealthSpring Secure

(PDP) and Cigna-


XTRA (PDP) ONLY)

Prior Authorization













Automatic

approval if

member is less

than 65 years of

age.Prior Auth

required for age

65 or older.

12 months

LANOXIN PEDIATRICPrior Authorization













Automatic

approval if

member is less

than 65 years of

age.Prior Auth

required for age

65 or older.

12 months

LAZANDAPrior Authorization

Applies

transmucosal fentanyl

citrate

All FDA-approved



Documentation from the medical record of diagnosis.

17 years of age

and older for

fentanyl citrate

(lozenge/troche).

18 years of age

and older for

Enrollment in the

Transmucosal

Immediate-

Release Fentanyl

(TIRF) REMS

Access program

12 months

Transmucosal fentanyl products will only be

covered with documentation of breakthrough

cancer pain. The patient must be currently

receiving and be tolerant to opioid therapy for

persistent cancer pain.The patient must be

enrolled in the TIRF REMS Access program.

LENVIMA

Prior Authorization


Only

molecular target

inhibitors




12 months



Age

Restrictions

Prescriber

Restrictions

Coverage


Excluded

Drug

Criteria

LETAIRISPrior Authorization

Appliesletairis





LEUKINEPrior Authorization

Applies

colony stimulating

factors




Documentation of diagnosis and either CBC with differential

or ANC.6 months

LEUPROLIDE

ACETATE

Prior Authorization


Only

pituitary hormones




12 months

LEVOCARNITINE

SOLN



LIDOCAINE 5%

PATCH

Prior Authorization

Applieslidocaine patch




12 months

For the FDA-labeled indication of post-

herpetic neuralgia, no additional criteria are

required to be met. For OTHER types of off-

labeled neuropathic pain: the patient must have

previous use and inadequate response or

intolerance to any ONE neuropathic pain

medication, including (but not limited to)

Cymbalta (duloxetine) and Lyrica that are

labeled for neuropathic pain.

LINEZOLIDPrior Authorization

AppliesAntibacterials, other




Documentation from the medical record of diagnosis, site of

infection, recent culture and sensitivity data, current or

previous treatment for infection.

1 to 3 months

Use of Zyvox (linezolid) is considered

medically necessary for use in infections

resulting from VRE and MRSA. Zyvox

(linezolid) is also considered medically

accepted for other clinically appropriate

infections when drug allergies prevent the use

of clinically appropriate 1st-line agents in other

infections.

LIPODOXPart D vs. Part B Prior


LIPODOX 50Part D vs. Part B Prior


LIPOSYN IIPart D vs. Part B Prior

Authorization Only

LIPOSYN IIIPart D vs. Part B Prior


LONSURF

Prior Authorization


Only

LONSURF




12 months

LOPREEZAPrior Authorization














Automatic

approval if

member is less

than 65 years of

age.Prior Auth

required for age

65 or older.

12 months










Prolia.

LOTRONEXPrior Authorization

Applieslotronex




Alosetron (Lotronex) will not be

approved for use in men, as

safety and efficacy in men has

not been established.

Prescriber must be

enrolled in the

prescribing

program for

alosetron.

12 months

LUMIZYMEPrior authorization

appliesLumizyme





Use of Lumizyme is considered medically

necessary for the treatment of late-onset Pompe

disease with no evidence of cardiac

hypertrophy. B vs D.

LUPRON DEPOT

Prior Authorization


Only

pituitary hormones




12 months

LUPRON DEPOT-PED

Prior Authorization


Only

pituitary hormones




12 months

LYNPARZA

Prior Authorization


Only

molecular target

inhibitors




12 months

MAGNESIUM

SULFATE





Age

Restrictions

Prescriber

Restrictions

Coverage


Excluded

Drug

Criteria

MARGESICPrior Authorization

Applies

HRM - Butalbital

Combinations













Automatic

approval if

member is less

than 65 years of

age.Prior Auth

required for age

65 or older.


ibuprofen.

MEGESTROL

ACETATE

SUSPENSION

Prior Authorization


Only

HRM - Megestrol

Suspension










failed dronabinol or provided clinical rationale as to why that

safer formulary alternative is not appropriate for the patient.

Automatic

approval if

member is less

than 65 years of

age.Prior Auth

required for age

65 or older.

12 months

MEGESTROL

ACETATE TABS

Prior Authorization


Only

HRM - Megestrol Tabs









Automatic

approval if

member is less

than 65 years of

age.Prior Auth

required for age

65 or older.

12 months

MEKINIST

Prior Authorization


Only

molecular target

inhibitors




12 months

MELPHALAN

HYDROCHLORIDE



MENEST

Prior Authorization


Only

HRM - Menest










failed one (1) safer formulary alternative or provided clinical

rationale why the safer formulary alternative is not appropriate

for the patient. For palliative therapy of metastatic breast

cancer, no trial of a formulary alternative is required.

Automatic

approval if

member is less

than 65 years of

age.Prior Auth

required for age

65 or older.

12 months

For vasomotor symptoms of menopause, safer

alternatives are: SSRIs, venlafaxine,

gabapentin, and Femring. For vaginal

symptoms of menopause, safer alternatives are:

Premarin Cream, Estring, and Femring. For all

other indications, no formulary alternative is

required.

MENOSTARPrior Authorization














Automatic

approval if

member is less

than 65 years of

age.Prior Auth

required for age

65 or older.

12 months










Prolia.

MESNAPart D vs. Part B Prior




Age

Restrictions

Prescriber

Restrictions

Coverage


Excluded

Drug

Criteria

METHYLDOPATE HCLPrior Authorization

Applies HRM - Methyldopa













Automatic

approval if

member is less

than 65 years of

age.Prior Auth

required for age

65 or older.

12 months

Safer alternatives are: ACE inhibitors

(Benazepril, Captopril, Enalapril, Lisinopril,

Quinapril, and Ramipril), ARBs (Candesartan,

Irbesartan, Losartan, and Telmisartan), Beta-

blockers (Atenolol, Metoprolol, Nadolol,

Pindolol, and Propranolol), Calcium channel

blockers (Verapamil, Diltiazem, Amlodipine,

Felodipine, and Nifedipine ER), and Thiazide

diuretics (Hydrochlorothiazide, Chorthalidone,

and Indapamide)

MIMVEYPrior Authorization














Automatic

approval if

member is less

than 65 years of

age.Prior Auth

required for age

65 or older.

12 months










Prolia.

MIMVEY LOPrior Authorization














Automatic

approval if

member is less

than 65 years of

age.Prior Auth

required for age

65 or older.

12 months










Prolia.

MINIVELLEPrior Authorization














Automatic

approval if

member is less

than 65 years of

age.Prior Auth

required for age

65 or older.

12 months










Prolia.

MITOMYCINPart D vs. Part B Prior


MITOXANTRONE HCLPart D vs. Part B Prior


MODAFINILPrior Authorization

Applies

non-amphetamine central

nervous system agents




Documentation of diagnosis and sleep study for the diagnosis

of sleep apnea or narcolepsy12 months

MODERIBAPrior Authorization

Applies


vaccine





MUSTARGENPart D vs. Part B Prior


MYCOPHENOLATE

MOFETIL



MYCOPHENOLIC

ACID DR



NAGLAZYMEPrior Authorization

Applies

enzyme






NALTREXONE HCLPrior Authorization

Appliesnaltrexone

All FDA-approved



Documentation of opioid or alcohol dependance 12 months

NEBUPENTPart D vs. Part B Prior


NEULASTAPrior Authorization

Applies

colony stimulating

factors





or ANC.6 months



Age

Restrictions

Prescriber

Restrictions

Coverage


Excluded

Drug

Criteria

NEUMEGAPrior Authorization

Appliesneumega




Documentation of diagnosis and lab data reflecting platelet

count.

Certified

Hematologist

and/or Oncologist

Up to 6 months

Neumega is considered medically necessary for

patients that have experienced severe

thrombocytopenia (platelet count less than or

equal to 20,000 mcg/L) from previous

chemotherapy OR patients cosidered to be at

high risk for the development of severe

thrombocytopenia. B vs D coverage

determination

NEUPOGENPrior Authorization

Applies

colony stimulating

factors





or ANC.6 months

NEUPROPrior Authorization

Appliesneupro





The member must have documentation of

previous trial and failure of either ropinirole or

pramipexole

NEXAVAR

Prior Authorization


Only

molecular target

inhibitors




12 months

NICOTROL INHALERPrior Authorization

Appliessmoking deterrents








The patient must

be 18 years of age

or older

12 months

NICOTROL NSPrior Authorization

Appliessmoking deterrents








The patient must

be 18 years of age

or older

12 months

NIPENTPart D vs. Part B Prior


NORMOSOL-M IN D5WPart D vs. Part B Prior


NORMOSOL-RPart D vs. Part B Prior


NORMOSOL-R IN D5WPart D vs. Part B Prior


NOVARELPrior Authorization

Applies

hormonal agents,

gonadotropins





NOXAFILPrior Authorization

Appliesantifungals, triazole




6 months

NUEDEXTAPrior Authorization

Appliesnuedexta





NULOJIX

Prior Authorization


Only

nulojix




Documentation of Epstein-Barr virus serology and current

medication regimen12 months

B vs D determination. Documentation of use in

combination with basiliximab induction,

mycophenolate mofetil, and corticosteroids.

NUTRILIPID 20% IV

FAT EMULSION



OCTAGAMPart D vs. Part B Prior


OCTREOTIDE

ACETATE

Prior Authorization

Applies

hormonal agents,

somatostatin analogs





ODOMZO

Prior Authorization


Only

ODOMZO




12 months

OLYSIOPrior Authorization

Appliesolysio




Previous failure to respond to

treatment with other HCV direct-

acting protease inhibitors or

repeated courses of simeprevir

will result in exclusion of

coverage for Olysio.


genotype, current medication regimen, and HCV-RNA levels

12 to 24 weeks

based on

indication and

established

treatment

guidelines

Concurrent therapy with peginterferon alfa and

ribavirin is required for Olysio (unless Olysio

is being used in combination with sofosbuvir).

ONCASPARPart D vs. Part B Prior


ONDANSETRON HCLPart D vs. Part B Prior


ONDANSETRON ODTPart D vs. Part B Prior


OPDIVO

Prior Authorization


Only

Antineoplastics,








Age

Restrictions

Prescriber

Restrictions

Coverage


Excluded

Drug

Criteria

ORPHENADRINE

CITRATE ER

Prior Authorization

Applies


Relaxants (2015)









Automatic

approval if

member is less

than 65 years of

age.Prior Auth

required for age

65 or older.

12 months

OXALIPLATINPart D vs. Part B Prior


OXANDROLONEPrior Authorization

Applies

anabolic steroids,

androgens





OXYCONTINPrior Authorization

Applieslong acting opioids




Documentation from the medical record of diagnosis & prior

medication history12 months

OxyContin will be covered with documentation

of chronic pain due to a malignant condition.

For chronic non-malignant pain: demonstrated

intolerance to two (2) preferred formulary long-

acting opioids or trial and failure of optimal

dosing of two (2) preferred formulary long-

acting opioids for 30 days.

PACLITAXELPart D vs. Part B Prior


PAMIDRONATE

DISODIUM



PEG-INTRONPrior Authorization

Applies


vaccine





PEG-INTRON KITPrior Authorization

Applies


vaccine





PEG-INTRON REDIPENPrior Authorization

Applies


vaccine





PEG-INTRON REDIPEN

PAK 4

Prior Authorization

Applies


vaccine





PENTOSTATINPart D vs. Part B Prior


PERFOROMISTPart D vs. Part B Prior


PERIKABIVENPart D vs. Part B Prior

Authorization Only

PERJETA

Prior Authorization


Only

perjeta




Documentation of previous and current treatment 12 months B vs D coverage determination

PERPHENAZINE/AMIT

RIPTYLINE

Prior Authorization


Only

HRM -

Perphenazine/Amitriptyli

ne













Automatic

approval if

member is less

than 65 years of

age.Prior Auth

required for age

65 or older.

12 months

Safer alternatives are: Nortriptyline,

Protriptyline, Desipramine, Amoxapine,

Citalopram, Venlafaxine, Fluoxetine,

Paroxetine, Sertraline, Duloxetine, and

Bupropion.

PHENADOZPrior Authorization

AppliesHRM - Promethazine










failed one (1) safer formulary alternative if available or

provided clinical rationale why the safer formulary alternative

is not appropriate for the patient.

Automatic

approval if

member is less

than 65 years of

age.Prior Auth

required for age

65 or older.

12 months

For nausea and vomiting, the safer alternative

is ondansetron (QL = 90/30). For perennial

and seasonal allergic rhinitis, safer alternatives

are: levocetirizine and desloratadine. For any

other indications, trial of a formulary

alternative is not required.

PHYSIOLYTEPart D vs. Part B Prior




Age

Restrictions

Prescriber

Restrictions

Coverage


Excluded

Drug

Criteria

POMALYST

Prior Authorization


Only

molecular target

inhibitors




12 months

POTASSIUM

CHLORIDE



POTASSIUM

CHLORIDE 0.15%

D5W/NACL 0.33%



POTASSIUM

CHLORIDE 0.15%

D5W/NACL 0.45%



POTASSIUM

CHLORIDE 0.15%

D5W/NACL 0.45%

VIAFLEX



POTASSIUM

CHLORIDE

0.15%/D5W/NACL 0.9%

VIAFLEX



POTASSIUM

CHLORIDE

0.15%/NACL 0.9%



POTASSIUM

CHLORIDE 0.22%

D5W/NACL 0.45%



POTASSIUM

CHLORIDE

0.224%/D5W/NACL

0.45%



POTASSIUM

CHLORIDE 0.3%/

NACL 0.9%



POTASSIUM

CHLORIDE 0.3%/D5W



POTASSIUM

CHLORIDE 0.3%/NACL

0.9%/VIAFLEX



POTIGA

Prior Authorization


Only

potiga





PRADAXA (Cigna-

HealthSpring Secure

(PDP) and Cigna-


XTRA (PDP) ONLY)

Prior authorization

applies

Oral Factor Xa






PREGNYL W/DILUENT

BENZYL

ALCOHOL/NACL

Prior Authorization

Applies

hormonal agents,

gonadotropins





PREMARINPrior Authorization














Automatic

approval if

member is less

than 65 years of

age.Prior Auth

required for age

65 or older.

12 months










Prolia.

PREMASOLPart D vs. Part B Prior


PRIVIGENPart D vs. Part B Prior


PROCALAMINEPart D vs. Part B Prior


PROCRITPrior Authorization

Applieshematopoietics




For the indication of anemia, documentation of Hemoglobin

less than 11, transferrin saturation greater than 20%, and

ferritin levels greater than 100 obtained over the last 3 months

6 months BvD Determination

PROGRAFPart D vs. Part B Prior


PROLASTINPart D vs. Part B Prior


PROLASTIN-CPart D vs. Part B Prior




Age

Restrictions

Prescriber

Restrictions

Coverage


Excluded

Drug

Criteria

PROLEUKINPart D vs. Part B Prior


PROMACTAPrior Authorization

Appliespromacta




Documentation of diagnosis of: a) thrombocytopenia in

patients with chronic hepatitis C, or b) chronic immune

(idopathic) thrombocytopenic purpura (ITP) with

documentation of previous therapy with corticosteroids OR

intravenous immune globuline (IVIG) therapy over a period of

at least 30 days OR insufficient response to a splenectomy.

12 months

Use of Promacta for the treatment of

thrombocytopenia is considered medically

necessary in: a) patients with chronic hepatitis

C, or b) patients with chronic immune

(idopathic) thrombocytopenic purpura (ITP)

that have failed corticosteroid OR intravenous

immune globuline (IVIG) therapy OR have had

an insufficient response to a splenectomy.

PROMETHAZINE HCLPrior Authorization














Automatic

approval if

member is less

than 65 years of

age.Prior Auth

required for age

65 or older.

12 months







PROMETHAZINE HCL

PLAIN

Prior Authorization














Automatic

approval if

member is less

than 65 years of

age.Prior Auth

required for age

65 or older.

12 months







PROMETHEGANPrior Authorization














Automatic

approval if

member is less

than 65 years of

age.Prior Auth

required for age

65 or older.

12 months







PROSOLPart D vs. Part B Prior


PROVENGEPart D vs. Part B Prior


PULMOZYMEPart D vs. Part B Prior


PURIXAN

Prior Authorization


Only

Purixan




12 monthsDocumentation of trial, contraindication, or

failure to mercaptopurine tablets

RAPAMUNEPart D vs. Part B Prior


REBETOLPrior Authorization

Applies


vaccine





REBIFPrior Authorization





12 months

REBIF REBIDOSEPrior Authorization





12 months

REBIF REBIDOSE

TITRATION PACK

Prior Authorization





12 months

REBIF TITRATION

PACK

Prior Authorization





12 months

RECOMBIVAX HBPart D vs. Part B Prior




Age

Restrictions

Prescriber

Restrictions

Coverage


Excluded

Drug

Criteria

REGRANEXPrior Authorization

Applies

dermatological wound

care agents




Documentation of wound type and wound care therapy

provided.12 months

Regranex must be used as adjunctive therapy to

clinically appropriate ulcer wound care

including debridement, infection control, and/or

pressure relief.

RELISTORPrior Authorization

Appliesrelistor




Documentation of diagnosis and past medication history. 6 months

Use of Relistor is considered medically

necessary for the treatment of opioid-induced

constipation in patients with advanced illnesses

who are receiving palliative care AND have

tried and failed laxative therapy with lactulose

or polyethylene glycol. Relistor is also

considered medically necessary for the

treatment of opioid-induced constipation in

adult patients with chronic non-cancer pain

who have tried and failed laxative therapy with

lactulose or polyethylene glycol.

REMICADEPrior Authorization
































REMODULINPart D vs. Part B Prior


REVLIMID

Prior Authorization


Only

revlimid





RIBASPHEREPrior Authorization

Applies


vaccine





RIBASPHERE

RIBAPAK

Prior Authorization

Applies


vaccine





RIBATABPrior Authorization

Applies


vaccine





RIBAVIRINPrior Authorization

Applies


vaccine





RITUXAN

Prior Authorization


Only

antineoplastics,






SABRIL

Prior Authorization


Only

sabril




Documentation from the medical record of diagnosis and past

medication history.12 months

Sabril is considered medically necessary in

patients that have failed to receive a clinically

appropriate response from optimal doses and

administration of at least two of the following:

phenytoin, Depakote (divalproex),

Lamotrigine, and Keppra (levetiracetam). For

the indication of Infantile Spasms failure of

another drug(s) is not required.

SAIZENPrior Authorization

Appliespituitary hormones




12 months



Age

Restrictions

Prescriber

Restrictions

Coverage


Excluded

Drug

Criteria

SAIZEN CLICK.EASYPrior Authorization





12 months

SAMSCAPrior Authorization

Appliessamsca




Documentation of diagnosis

Initial therapy 60

days. Continuation

of therapy 12

months.

Samsca is considered medically necessary for

the treatment of patients with significant

hypervolemic and euvolemic hyponatremia

(serum sodium less than 125 mEq/L) or

symptomatic hyponatremia that has not been

corrected with restriction of fluids including

heart failure and Syndrome of Inappropriate

Antidiuretic Hormone (SIADH).

SANDIMMUNE ORAL

SOLN


Authorization Only

SANDOSTATIN LAR

DEPOT

Prior Authorization

Applies

hormonal agents,






SILDENAFILPrior Authorization

Applies

phosphodiesterase type 5

(pde5) inhibitors

All FDA approved



Medical documentation of pulmonary arterial hypertension 12 months

SIMULECTPart D vs. Part B Prior


SIROLIMUSPart D vs. Part B Prior


SIRTUROPrior Authorization

Appliessirturo




Documentation from the medical record required indicating

the patient has multi-drug resistant tuberculosis resistant to

isoniazid and rifampin

The patient must

be 18 years of age

or older.

6 months

Use of Sirturo for the treatment of multi-drug

resistant tuberculosis is considered medically

necessary in patients with multi-drug resistant

tuberculosis in combination with at least 3

other agents.

SODIUM CHLORIDEPart D vs. Part B Prior


SODIUM CHLORIDE

0.45% VIAFLEX



SODIUM LACTATEPart D vs. Part B Prior


SOMATULINE DEPOT

60MG/0.2ML &

90MG/0.3ML

Prior Authorization

Applies

hormonal agents,






SOMATULINE DEPOT

120MG/0.5ML

Prior Authorization


Only

hormonal agents,






SOMAVERTPrior Authorization

Applies

endocrine and metabolic

agents





SOVALDIPrior Authorization

appliesSOVALDI





genotype, current medication regimen, and HCV-RNA levels

12 to 48 weeks,

based on

indication and

established

treatment

guidelines

Concurrent therapy with ribavirin, with or

without peginterferon alfa, depending on

clinical indication, is required for Sovaldi

(unless being used in combination with

simeprevir).

SPORANOXPrior Authorization

Applies


and systemic




up to 3 months







Itraconazole.

SPRYCEL

Prior Authorization


Only

molecular target

inhibitors




12 months

STIVARGA

Prior Authorization


Only

molecular target

inhibitors




12 months

SUBOXONEPrior Authorization

Applies


analgesics

All FDA-approved






Buprenorphine-3d

supply, or 6 mo if

pregnant/hypersen

sitive to naloxone.

Suboxone

(bup/naltrex)-6





pregnancy.



Age

Restrictions

Prescriber

Restrictions

Coverage


Excluded

Drug

Criteria

SURMONTIL

Prior Authorization


Only

HRM - Tricyclic

Antidepressants













Automatic

approval if

member is less

than 65 years of

age.Prior Auth

required for age

65 or older.

12 months













SUTENT

Prior Authorization


Only

molecular target

inhibitors




12 months

SYLATRON

Prior Authorization


Only

sylatron




Documentation of Diagnosis 12 months

Sylatron is considered medically necessary in

patients with a diagnosis of malignant

melanoma

SYMLINPEN 120 (Non-


HealthSpring Secure

(PDP) and Cigna-


XTRA (PDP))

Prior Authorization

Appliesamylin analog




Hemoglobin A1C less than 7%

prior to initiating Amylin

Analog therapy

Documentation of past and current medication history 12 months


previous insulin failure and documentation of

continuation of insulin therapy concomitantly

with the requested drug

SYMLINPEN 60 (Non-


HealthSpring Secure

(PDP) and Cigna-


XTRA (PDP))

Prior Authorization

Appliesamylin analog




Hemoglobin A1C less than 7%

prior to initiating Amylin

Analog therapy

Documentation of past and current medication history 12 months


previous insulin failure and documentation of

continuation of insulin therapy concomitantly

with the requested drug

SYNAGISPrior Authorization

Appliessynagis





SYNARELPrior Authorization





12 months

SYNRIBO

Prior Authorization


Only

molecular target

inhibitors




12 months

TACROLIMUSPart D vs. Part B Prior


TAFINLAR

Prior Authorization


Only

molecular target

inhibitors




12 months

TARCEVA

Prior Authorization


Only

molecular target

inhibitors




12 months

TASIGNA

Prior Authorization


Only

molecular target

inhibitors




12 months

TAXOTEREPart D vs. Part B Prior


TEMODARPart D vs. Part B Prior


TESTIMPrior Authorization

Applies

anabolic steroids,

androgens





TESTOSTERONE

CYPIONATE

Prior Authorization

Applies

anabolic steroids,

androgens





TESTOSTERONE

ENANTHATE

Prior Authorization

Applies

anabolic steroids,

androgens





TETRABENAZINE TABPrior Authorization

AppliesXenazine




Documentation of diagnosis of chorea associated with

Huntington's Disease. CYP 2D6 genotype must be provided

for doses greater than 50mg/day.

12 months

THALOMID

Prior Authorization


Only

thalidomide (thalomid)




12 months



Age

Restrictions

Prescriber

Restrictions

Coverage


Excluded

Drug

Criteria

THIORIDAZINE HCL

Prior Authorization


Only

HRM - 1st Generation

Antipsychotics













Automatic

approval if

member is less

than 65 years of

age.Prior Auth

required for age

65 or older.

12 months

Safer alternatives are: Risperidone, Quetiapine,

Aripiprazole, Abilify, Olanzapine, Saphris, and

Ziprasidone.

THIOTEPA

Prior Authorization


Only

Thiotepa




Documentation of diagnosis 12 months B vs D coverage determination

THYMOGLOBULINPart D vs. Part B Prior


TOBRAMYCINPart D vs. Part B Prior


TOBRAMYCIN

SULFATE



TOPOSARPart D vs. Part B Prior


TORISELPart D vs. Part B Prior


TPN ELECTROLYTESPart D vs. Part B Prior


TRACLEERPrior Authorization

Appliesvasodilators

All FDA-approved



Documentation of pulmonary arterial hypertension 12 months

TRANEXAMIC ACIDPrior Authorization

Applies

coagulants, protease

inhibitors




10 days

TRAVASOLPart D vs. Part B Prior


TREANDAPart D vs. Part B Prior


TRELSTAR DEPOTPrior Authorization





12 months

TRELSTAR DEPOT

MIXJECT

Prior Authorization





12 months

TRELSTAR LA

Prior Authorization


Only

pituitary hormones




12 months

TRELSTAR LA

MIXJECT

Prior Authorization


Only

pituitary hormones




12 months

TRELSTAR MIXJECT

Prior Authorization


Only

pituitary hormones




12 months

TRETINOINPrior Authorization

Appliesdermatological retinoids




12 months

TRETINOIN

MICROSPHERE

Prior Authorization





12 months

TRETINOIN

MICROSPHERE PUMP

Prior Authorization





12 months

TRIHEXYPHENIDYL

HCL

Prior Authorization

AppliesHRM - Trihexyphenidyl









Automatic

approval if

member is less

than 65 years of

age.Prior Auth

required for age

65 or older.

12 months



Age

Restrictions

Prescriber

Restrictions

Coverage


Excluded

Drug

Criteria

TRIMIPRAMINE

MALEATE

Prior Authorization


Only

HRM - Tricyclic

Antidepressants













Automatic

approval if

member is less

than 65 years of

age.Prior Auth

required for age

65 or older.

12 months













TRISENOXPart D vs. Part B Prior


TROPHAMINEPart D vs. Part B Prior


TYKERB

Prior Authorization


Only

molecular target

inhibitors




12 months

TYSABRIPrior authorization

appliesTYSABRI



excluded from part D.

12 months

Treatment of relapsing forms of multiple

sclerosis (MS) when EITHER of the following

criteria is met: 1) history of beneficial clinical

response to Tysabri® (natalizumab) for MS or

failure, contraindication or intolerance to one

formulary alternative (eg. Avonex®,

Copaxone® or Rebif®). Treatment of

moderately to severely active Crohn’s disease

(CD) when EITHER of the following criteria is

met: 1) history of beneficial clinical response to

Tysabri® (natalizumab) for CD or 2) failure,

contraindication, intolerance, or inadequate

response to one conventional therapy (eg.

aminosalicylate, corticosteroids, or

immunomodulators) AND failure or intolerance

to Humira®.

TYZEKA

Prior Authorization


Only

tyzeka




Documentation of diagnosis.

Adults and

adolescents 16

years of age and

older

12 months Coverage is provided for Chronic Hepatitis B.

UNITUXIN

Prior Authorization


Only

antineoplastics,






UVADEXPart D vs. Part B Prior


VALCHLOR

Prior Authorization


Only

Valchlor gel




Documentation of diagnosis and past medical history. 12 months

Valchlor Topical Gel is considered medically


Stage 1A and 1B mycosis fungoides-type

cutaneous T-cell lymphoma who have received

prior skin-directed therapy.

VECTIBIXPart D vs. Part B Prior


VELCADEPart D vs. Part B Prior


VICTRELISPrior authorization

appliesVictrelis

All medically accepted uses

not otherwise excluded from

Part D


genotype, current medication regimen, and HCV-RNA levelsUp to 44 weeks

For Victrelis for Previously Treated patients:

Documentation of HCV-RNA level decline at

Week 12 during prior treatment is required 44

weeks of therapy. Diagnosis of compensated

cirrhosis is required for 44 weeks of

therapy.Concurrent therapy with peginterferon

alfa and ribavirin is required for Victrelis

VINBLASTINE

SULFATE



VINCASAR PFSPart D vs. Part B Prior




Age

Restrictions

Prescriber

Restrictions

Coverage


Excluded

Drug

CriteriaVINCRISTINE

SULFATE



VINORELBINE

TARTRATE



VIRAZOLEPart D vs. Part B Prior


VIVELLE-DOTPrior Authorization














Automatic

approval if

member is less

than 65 years of

age.Prior Auth

required for age

65 or older.

12 months










Prolia.

VORICONAZOLEPrior authorization

appliesAntifungals, Azole




Documented fungal culture and or notes from medical record

suggestive of a serious fungal infection1 to 6 months

VOTRIENT

Prior Authorization


Only

antiangiogenic agents





Votrient is considered medically necessary for

the treatment of patients with a diagnosis of 1.)

advanced renal cell carcinoma or 2.)advanced

soft tissue sarcoma who have received prior

chemotherapy

VPRIVPrior Authorization

Appliesvpriv




Documentation of diagnosis 12 months BvD Determination.

XALKORI

Prior Authorization


Only

molecular target

inhibitors




12 months

XARELTO (Cigna-

HealthSpring Secure

(PDP) and Cigna-


XTRA (PDP) ONLY)

Prior authorization

applies

Oral Factor Xa






XARELTO START

PACK (Cigna-

HealthSpring Secure

(PDP) and Cigna-


XTRA (PDP) ONLY)

Prior authorization

applies

Oral Factor Xa






XENAZINEPrior Authorization

Appliesxenazine




Documentation of diagnosis of chorea associated with

Huntington's Disease. CYP 2D6 genotype must be provided

for doses greater than 50mg/day.

12 months

XGEVAPrior Authorization

Appliesxgeva




12 Months

XIFAXANPrior Authorization

Appliesxifaxan




12 months

XOLAIRPrior Authorization

Appliesmonoclonal antibodies




Laboratory data reflecting IgE levels greater than 30 but less

than 700 IU/mL , medical history documenting previous trial

and response to inhaled corticosteroids and a leukotriene

receptor antagonist.

12 months

XTANDI

Prior Authorization


Only

xtandi




Documentation from medical records of diagnosis 12 months

Xtandi is considered medically necessary in

patients who have a diagnosis of metastatic

castration-resistant prostate cancer.

XYREMPrior Authorization

Appliesxyrem

All FDA-approved



Documentation of diagnosis, sleep study, and enrollment in

Xyrem Success Program.

Must be 16 years

of age or older.12 months

Use of Xyrem is considered medically

necessary in patients with narcolepsy

experiencing excessive daytime sleepiness and

cataplexy. The patient must not be taking any

sedative hypnotic agents or other CNS

YERVOYPart D vs. Part B Prior


ZALTRAP

Prior Authorization


Only

antineoplastics,








Age

Restrictions

Prescriber

Restrictions

Coverage


Excluded

Drug

Criteria

ZANOSARPart D vs. Part B Prior


ZEBUTALPrior Authorization

Applies

HRM - Butalbital

Combinations













Automatic

approval if

member is less

than 65 years of

age.Prior Auth

required for age

65 or older.


ibuprofen.

ZELBORAF

Prior Authorization


Only

zelboraf




Documentation of accepted genetic test results 12 months

ZEMAIRAPart D vs. Part B Prior


ZINECARDPart D vs. Part B Prior


ZOLEDRONIC ACIDPart D vs. Part B Prior


ZOLPIDEM

TARTRATE (Applies to

all EXCEPT Cigna-

HealthSpring Secure

(PDP) and Cigna-


XTRA (PDP))

Prior Authorization

Applies

HRM - Sedative

Hypnotics













Automatic

approval if

member is less

than 65 years of

age.Prior Auth

required for age

65 or older.

12 months Safer alternatives are: Rozerem and Silenor.

ZOMETAPart D vs. Part B Prior


ZORTRESSPart D vs. Part B Prior


ZYDELIG

Prior Authorization


Only

molecular target

inhibitors




12 months

ZYKADIA

Prior Authorization


Only

molecular target

inhibitors




12 months

ZYTIGA

Prior Authorization


Only

zytiga




Documentation of diagnosis 12 monthsZytiga is approved for use in combination with

prednisone.

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