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Drugs That Require Prior Authorization (PA) Before Being Approved for CoverageYou will need authorization by AvMed Medicare Choice and AvMed Medicare Choice Elect before filling prescriptions for thedrugs listed below. AvMed Medicare Choice and AvMed Medicare Choice Elect will only provide coverage after it determinesthat the drug is being prescribed according to the criteria specified in the chart.You, your appointed representative, or your prescriber can request prior authorization by calling AvMed at 1-800-782-8633,October 1 - February 14, 8:00 AM-8:00 PM, seven days a week, and February 15 - September 30, 8:00 AM - 8:00 PM Monday- Friday, 9:00 AM - 1:00 PM Saturday. Customer Service is available in English and other languages. TTY/TDD users shouldcall 1-800-955-8771 or 711.PA CriteriaPrior Authorization GroupDrug NamesCovered UsesExclusion CriteriaRequired Medical InformationAge RestrictionsPrescriber RestrictionsCoverage DurationOther CriteriaUpdated 09/01/2015ACTEMRAACTEMRAAll FDA-approved indications not otherwise excluded from Part D.Tocilizumab should not be given in combination with tumor necrosis factor (TNF)antagonists (adalimumab, certolizumab pegol, etanercept, golimumab, infliximab),abatacept, anakinra, rituximab, or tofacitinib.Coverage for adults with RA is provided in situations where the patient experiencedintolerance/failure to Humira AND Enbrel. Coverage for Systemic-onset JIA is providedin situations where the patient have tried a systemic corticosteroid or MTX, leflunomide,or sulfasalazine or another DMARD such as etanercept, adalimumab, infliximab, oranakinra OR have systemic arthritis with active systemic features and features of poorprognosis (eg, arthritis of the hip, radiographic damage).For rheumatoid arthritis (RA), patient must be 18 years of age or olderPrescribed by or in consultation with a rheumatologist.Authorization will be for 12 months.1
Prior Authorization GroupDrug NamesCovered UsesExclusion CriteriaRequired Medical InformationAge RestrictionsPrescriber RestrictionsCoverage DurationOther CriteriaACTHAR HPH.P. ACTHARAll FDA-approved indications not otherwise excluded from Part D.Use in patients with multiple sclerosis (MS) as pulse therapy on a monthly basis.MS exacerbation, history of corticosteroid use.Infantile spasms, prescribed by or in consultation with a neurologist or an epileptologist.MS exacerbation, prescribed by or in consultation with a neurologist or physician thatspecializes in the treatment of MS.Infantile spasms, 12 months. MS exacerbation, approve 1 month.For MS exacerbation, approve if the patient cannot use high-dose IV corticosteroidsbecause IV access is not possible or if the patient has tried high-dose corticosteroidsadministered IV for an acute MS exacerbation and has experienced a severe or limitingadverse effect.Prior Authorization GroupDrug NamesCovered UsesExclusion CriteriaRequired Medical InformationAge RestrictionsPrescriber RestrictionsCoverage DurationOther CriteriaACTIMMUNEACTIMMUNEAll FDA approved indications not otherwise excluded from Part D.Prior Authorization GroupDrug NamesCovered UsesExclusion CriteriaRequired Medical InformationAge RestrictionsPrescriber RestrictionsADEMPASADEMPASAll FDA-approved indications not otherwise excluded from Part D.Coverage DurationOther CriteriaUpdated 09/01/201512 monthsPAH and CTEPH- must be precribed by or in consultation with a cardiologist or apulmonologist.12 monthsFor PAH - must have PAH (WHO Group 1) and had a right heart catheterization toconfirm the diagnosis of PAH (WHO Group 1). Right heart cathererization is not requiredin pts who are currently receiving Adempas or another agent indicated for WHO group 1.2
Prior Authorization GroupDrug NamesCovered UsesExclusion CriteriaRequired Medical InformationAge RestrictionsPrescriber RestrictionsCoverage DurationOther CriteriaPrior Authorization GroupDrug NamesCovered UsesExclusion CriteriaRequired Medical InformationAge RestrictionsPrescriber RestrictionsCoverage DurationOther CriteriaUpdated 09/01/2015AFINITORAFINITOR, AFINITOR DISPERZAll FDA approved indications not otherwise excluded from Part D. Additional off-labeluses covered are the treatment of advanced, unresectable neuroendocrine tumors.Combination use with sorafenib or sunitinib.Coverage for RCC is provided after failure of treatment with sunitinib or sorafenib.Coverage for SEGA is provided for patients who are not candidates for curative surgicalresection.12 monthsALPHA-1 PROTEINASE INHIBITORSARALAST NP, GLASSIA, PROLASTIN-C, ZEMAIRAAll FDA-approved indications not otherwise excluded from Part D. Alpha-1 antitrypsin(AAT) deficiency-associated panniculitis.For AAT deficiency with emphysema (or COPD), approve in patients with baseline(pretreatment) alpha1-antitrypsin serum concentration less than 11 microM (11micromol/L) or 80 mg/dL.Authorization will be for 12 months, unless otherwise specified.For all covered uses, the patient is required to try Aralast NP first line. For AAT deficiencywith emphysema (or COPD), approve in patients with baseline (pretreatment)alpha1-antitrypsin serum concentration less than 11 microM (11 micromol/L) or 80mg/dL.3
Prior Authorization GroupDrug NamesCovered UsesExclusion CriteriaRequired Medical InformationAge RestrictionsPrescriber RestrictionsCoverage DurationOther CriteriaPrior Authorization GroupDrug NamesCovered UsesExclusion CriteriaRequired Medical InformationAge RestrictionsPrescriber RestrictionsCoverage DurationOther CriteriaPrior Authorization GroupDrug NamesCovered UsesExclusion CriteriaRequired Medical InformationAge RestrictionsPrescriber RestrictionsCoverage DurationOther CriteriaUpdated 09/01/2015AMPYRAAMPYRAAll FDA-approved indications not otherwise excluded from Part D.History of seizures/evidence of epileptiform activity on EEG, moderate to severe renalimpairment (CrCl less than or equal to 50 ml/min), patient not able to walk 25 feet in 8 45 secondsDiagnosis of multiple sclerosisGreater than or equal to 18 years of agelifetimeANDROGENSANDRODERM, ANDROGEL, ANDROGEL PUMP, DEPO-TESTOSTERONEAll FDA approved indications not otherwise excluded from Part D.Coverage is provided for females for the palliative treatment of breast cancer. Coverageis provided for males for delayed puberty or the treatment of hypogonadism in situationswhere the patient has a baseline (pre-treatment) serum testosterone level of less than orequal to 300 ng/dL (less than 10.4 nmol/L) OR has symptoms suggestive of androgendeficiency with a baseline free testosterone levels below the lower limit of normal.All indications 5 years, except delayed puberty: 6 monthsANTIEMETICSPHENADOZ, PHENERGAN, PROMETHAZINE HCL, PROMETHEGAN,TRIMETHOBENZAMIDE HCLAll FDA-approved indications not otherwise excluded from Part D.Patient must have tried and failed one formulary non high risk medication alternative(prochlorperazine, ondansetron, granisetron ) or have a documented contraindication toall of these alternatives.PA required for age 65 years and older. Coverage is provided immediately in situationswhere the patient is younger than 65 years of age.1 year4
Prior Authorization GroupDrug NamesCovered UsesExclusion CriteriaRequired Medical InformationAge RestrictionsPrescriber RestrictionsCoverage DurationOther CriteriaPrior Authorization GroupDrug NamesCovered UsesExclusion CriteriaRequired Medical InformationAge RestrictionsPrescriber RestrictionsCoverage DurationOther CriteriaUpdated 09/01/2015ANTIFUNGAL THERAPYITRACONAZOLEAll FDA-approved indications not otherwise excluded from Part D.Onychomycosis in patients with evidence of ventricular dysfunction such as CHF or ahistory of CHF. Coadministration with certain drugs metabolized by the cytochromeP-450 3A4 isoenzyme system (CYP3A4), cisapride, oral midazolam, pimozide,quinidine, dofetilide, triazolam, HMG-CoA reductase inhibitors metabolized by CYP3A4,such as lovastatin and simvastatin, and ergot alkaloids metabolized by CYP3A4, such asdihydroergotamine, ergotamine, ergonovine, and methylergonovine.KOH smear, or dermatophyte test medium, or fungal culture. For Sporanox foronychomycosis: diagnosis of onychomycosis of the toenail and/or fingernail determinedby the presence of dermatophytes that must be verified by 1 of the following: KOH smearor dermatophyte test medium or fungal culture. Immunosppression as identified by anyof the following: diabetes mellitus, concurrent cancer chemotherapy, concurrent chronicoral corticosteroid use, history of solid organ transplant, HIV, or severe peripheralvascular disease. For Sporanox for a topical fungal infection other than onychomycosis:failed an adequate trial of topical antifungal therapy. For Sporanox for a systemic fungalinfection: a systemic fungal infection including, but not limited to: blastomycosis,histoplasmosis, aspergillosis, candidiasis, sporotrichosis, paracoccidioidomycosisN/AN/A12 weeks for onychomycosisANTIHISTAMINESCYPROHEPTADINE HCL, HYDROXYZINE HCL, HYDROXYZINE PAMOATEAll FDA-approved indications not otherwise excluded from Part D.Patient must have tried and failed one formulary non high risk medication alternative(cetirizine, desloratadine, levocetirizine) or have a documented contraindication to all ofthese alternatives.PA required for age 65 years and older. Coverage is provided immediately in situationswhere the patient is younger than 65 years of age.1 year5
Prior Authorization GroupDrug NamesCovered UsesExclusion CriteriaRequired Medical InformationAge RestrictionsPrescriber RestrictionsCoverage DurationOther CriteriaUpdated 09/01/2015ANTIPSYCHOTICSABILIFY, ABILIFY MAINTENA, ARIPIPRAZOLE, INVEGAAll medically accepted indications not otherwise excluded from Part DFor paliperidone: diagnosis must be schizoaffective disorder OR for other indicationspatient must have intolerance/failure with the use of Seroquel XR, Risperdal Consta, or ageneric atypical antipsychotic. For aripiprazole: patient must have intolerance/failure withthe use of Seroquel XR, Risperdal Consta, or a generic atypical antipsychotic.Patients younger than 18 years of age are exempt from the required medical informationLifetime6
Prior Authorization GroupDrug NamesCovered UsesExclusion CriteriaRequired Medical InformationARANESPARANESP ALBUMIN FREEAll FDA-approved indications not otherwise excluded from Part D.Age RestrictionsPrescriber RestrictionsCoverage DurationOther CriteriaFor CKD not on dialysis for initial therapy:inadequate response to epoetin alfa therapy asdefined as failure to achieve target H/H in the presence of adequate iron stores within 4to 6 months or failure to maintain target H/H subsequently at that dose, and diagnosis ofCKD defined as GFR less than 60mL/min or creatinine greater than 1.8mg/dL and labvalues within the past 30 days indicating H/H less than 10g/dL/30% or H/H greater than9.9g/dL/29.9% with documentation of S/Sx of anemia, and transferrin saturation greaterthan 20% and ferritin greater than 100ng/ml. For CKD not on dialysis continuationtherapy: current progress notes indicating symptomatic response to therapy and labvalues in the past 30 days indicating: H/H less than 12g/dL/36% and iron panelequivalent to initiation criteria. For anemia due to chemotherapy for nonmyeloidmalignancies initial therapy: received chemotherapy within the past 8 weeks andinadequate response to epoetin alfa therapy, as defined previously, diagnosis ofnon-excluded cancer type, chemotherapy regimen noted, and lab values in the past 30days indicating: H/H less than 10 g/dL/30% or H/H greater than 9.9 g/dL /29.9% withdocumentation of S/Sx of anemia. For anemia due to chemotherapy for nonmyeloidmalignancies continuation therapy: received chemotherapy within the past 8 weeks andlab values within the past 30 days indicating H/H less than 12g/dL/36% and symptomaticresponse noted. For anemia associated with MDS initial therapy: inadequate response toepoetin alfa therapy, as defined previously, and diagnosis of MDS confirmed by bonemarrow aspiration or biopsy and lab values within the past 30 days indicating: H/H lessthan 10g/dL/30% or H/H greater than 9.9g/dL/29.9% with documentation of S/Sx ofanemia. For anemia associated with MDS continuation therapy:lab values in the past 30days indicating H/H less than 12g/dL/36% and symptomatic response noted. Doseshould be based upon maintaining Hgb level between 10-12 g/dL.N/AN/AInitial therapy 3 months. Continuation therapy 3 months.Drug Part B vs D coverage determination may applyUpdated 09/01/20157
Prior Authorization GroupDrug NamesCovered UsesExclusion CriteriaRequired Medical InformationAge RestrictionsPrescriber RestrictionsCoverage DurationOther CriteriaPrior Authorization GroupDrug NamesCovered UsesExclusion CriteriaRequired Medical InformationAge RestrictionsPrescriber RestrictionsCoverage DurationOther CriteriaUpdated 09/01/2015ARCALYSTARCALYSTAll FDA-approved indications not otherwise excluded from Part D. Plus patient alreadystarted on rilonacept for Muckle Wells Syndrome (MWS) or Familial ColdAutoinflammatory Syndrome (FCAS).Rilonacept should not be given in combination with tumor necrosis factor (TNF) blockingagents (eg, adalimumab, certolizumab pegol, etanercept, golimumab, infliximab),anakinra, or canakinumab.Greater than or equal to 12 years of age.Prescribed by, or in consultation with, a rheumatologist, geneticist, or dermatologist.Initial approval of MWS/FCAS, 2 mos. Subsequent authorization for 12 mos if patient hada response.Patients already started on rilonacept for MWS/FCAS may receive authorization if theyhave had a response and are continuing therapy to maintain response/remission.AUBAGIOAUBAGIOAll FDA-approved indications not otherwise excluded from Part D.Concurrent use of Aubagio with other disease-modifying agents used for multiplesclerosis (MS) [eg, Avonex, Rebif, Betaseron, Copaxone, or Gilenya].The prescriber has considered and screened for the presence of latent TB infection priorto starting teriflunomide. The patient must still either be able to walk at least a few stepsor alternatively must have some functional arm/ hand use consistent with performingactivities of daily living. Patient must have inadequate response or intolerance to RebifAND Copaxone . Aubagio will not be used in combination with an interferon, Copaxoneor Gilenya. Coverage will not be provided for the treatment of primary progressive MS.12 months8
Prior Authorization GroupDrug NamesB VS. DABELCET, ACETYLCYSTEINE, ACYCLOVIR SODIUM, AKYNZEO, ALBUTEROLSULFATE, AMBISOME, AMINOSYN 8.5%/ELECTROLYTE, AMINOSYN II, AMINOSYNII 8.5%/ELECTROL, AMINOSYN M, AMINOSYN-HBC, AMINOSYN-PF, AMINOSYN-PF7%, AMPHOTERICIN B, ASTAGRAF XL, ATGAM, AZATHIOPRINE, BICNU,BLEOMYCIN SULFATE, BROVANA, BUDESONIDE, CELLCEPT, CELLCEPTINTRAVENOUS, CESAMET, CLADRIBINE, CLINIMIX 2.75%/DEXTROSE 5, CLINIMIX4.25%/DEXTROSE 1, CLINIMIX 4.25%/DEXTROSE 2, CLINIMIX 4.25%/DEXTROSE 5,CLINIMIX 5%/DEXTROSE 15%, CLINIMIX 5%/DEXTROSE 20%, CLINIMIX5%/DEXTROSE 25%, CLINISOL SF 15%, CLOLAR, CROMOLYN SODIUM,CYCLOSPORINE, CYCLOSPORINE MODIFIED, CYTARABINE AQUEOUS,DAUNORUBICIN HCL, DOXORUBICIN HCL, DRONABINOL, EMEND, ENGERIX-B,FLUOROURACIL, FOSCARNET SODIUM, GENGRAF, GRANISETRON HCL,HEPATAMINE, IDARUBICIN HCL, INTRALIPID, IPRATROPIUM BROMIDE,IPRATROPIUM BROMIDE/ALBUT, LEVALBUTEROL, LEVALBUTEROL HCL,LIPOSYN III, METHOTREXATE, METHYLPREDNISOLONE, MORPHINE SULFATE,MYCOPHENOLATE MOFETIL, MYCOPHENOLIC ACID DR, NEBUPENT, NEORAL,NEPHRAMINE, NULOJIX, NUTRILIPID, ONDANSETRON HCL, ONDANSETRONODT, OXALIPLATIN, PENTAM 300, PERFOROMIST, PREDNISONE, PREDNISONEINTENSOL, PREMASOL, PROCALAMINE, PROGRAF, PROSOL, PULMICORT,PULMOZYME, RAPAMUNE, RECOMBIVAX HB, SANDIMMUNE, SIMULECT,SIROLIMUS, TACROLIMUS, TOBRAMYCIN, TRAVASOL, TROPHAMINE,VINBLASTINE SULFATE, ZORTRESSCovered UsesExclusion CriteriaRequired Medical InformationAge RestrictionsPrescriber RestrictionsCoverage DurationOther CriteriaPrior Authorization GroupDrug NamesCovered UsesExclusion CriteriaRequired Medical InformationAge RestrictionsPrescriber RestrictionsCoverage DurationOther CriteriaUpdated 09/01/2015BELEODAQBELEODAQAll FDA-approved indications not otherwise excluded from Part D.Prescribed by or in consultation with an oncologist12 months9
Prior Authorization GroupDrug NamesCovered UsesExclusion CriteriaRequired Medical InformationAge RestrictionsPrescriber RestrictionsCoverage DurationOther CriteriaPrior Authorization GroupDrug NamesCovered UsesExclusion CriteriaRequired Medical InformationAge RestrictionsPrescriber RestrictionsCoverage DurationOther CriteriaUpdated 09/01/2015BENLYSTABENLYSTAAll FDA-approved indications not otherwise excluded from Part D.Members with severe active lupus nephritis or severe active central nervous systemlupus or members with concommitant use of other biologic products or IVcyclophosphamide or member receiving therapy for chronic infectionDiagnosis of active, autoantibody-positive systemic lupus erythematous(SLE) evidencedby ANA greater than 1:80 or anti-ds DNA greater than 30IU/ml. Member showsintolerance/failure to any 2 of the following: Corticosteroids,Immunosuppressive/cytotoxic agents or antimalarials. Must be used in combination withstandard therapy excluding IV cyclophosphamide.12 monthsBOSULIFBOSULIFAll FDA approved indications not otherwise excluded from Part D.Coverage is not provided in those that have the BCR-ABL1 T315I mutation and useBosulif in combination with other kinase inhibitors (for example sorafenib, sunitinib, etc.)Coverage is provided for the treatment of chronic, accelerated, or blast phasePhiladelphia chromosome-positive chronic myelogenous leukemia (CML) in situationswhere the patient has experienced resistance or intolerance to prior therapy withimatinib.Coverage is only provided in patients at least 18 years of age and older12 months10
Prior Authorization GroupDrug NamesCovered UsesExclusion CriteriaRequired Medical InformationAge RestrictionsPrescriber RestrictionsCoverage DurationOther CriteriaBOTULINUM TOXINSBOTOX, DYSPORT, XEOMINAll FDA-approved indications not otherwise excluded from Part D.Infection at injection siteAbobotulinumtoxinA diagnosis of cervical dystonia. Incobotulinumtoxin diagnosis mustbe blepharospasm or cervical dystonia. OnabotulinumtoxinA diagnosis must beblepharospasm, cervical dystonia, migraine prophylaxis, neurogenic or overactivebladder, spasticity, strabismus or urinary incontinence.12monthsPrior Authorization GroupDrug NamesCovered UsesExclusion CriteriaRequired Medical InformationAge RestrictionsPrescriber RestrictionsCoverage DurationOther CriteriaCAPRELSACAPRELSAAll FDA-approved indications not otherwise excluded from Part D.Prior Authorization GroupDrug NamesCovered UsesExclusion CriteriaRequired Medical InformationCELEBREXCELEBREXAll medically accepted indications not otherwise excluded from Part DCoverage is not provided for the treatment/prevention of Alzheimer's disease or cancer.Coverage is provided when the pt has previously been unable to tolerate therapy with atleast two other different NSAIDs OR is at high risk of NSAID induced adverse GI eventsevidenced by any of the following: 1. history of peptic ulcer disease, history of NSAIDrelated ulcer, or history of clinically significant GI bleeding or 2. Concomitant therapy withanticoagulants (e.g. warfarin, heparin, or LMWH), chronic use of oral corticosteroids, orNon-aspirin anti-platelet agents (e.g. clopidogrel, ticagrelor, or prasugrel).Patients 65 years of age and older are exempt from the required medical information. ForJRA, pt must be 2 years of age or olderAge RestrictionsPrescriber RestrictionsCoverage DurationOther CriteriaUpdated 09/01/2015Dx: metastatic or unresectable medullary thyroid cancerOncologist1 yearLifetime for JRA/ 12 months for all other indications11
Prior Authorization GroupDrug NamesCovered UsesExclusion CriteriaRequired Medical InformationAge RestrictionsPrescriber RestrictionsCoverage DurationOther CriteriaPrior Authorization GroupDrug NamesCovered UsesExclusion CriteriaRequired Medical InformationAge RestrictionsPrescriber RestrictionsCoverage DurationOther CriteriaUpdated 09/01/2015CERDELGACERDELGAAll FDA-approved indications not otherwise excluded from Part D.Biochemical assay of glucocerebrosidase activity in member's WBC or skin fibroblast isless than 30% of normal activity and genotype mutation of two mutant alleles of theglucocerebrosidase geneand member experiencing symptomatic manifestations of the disease. Member hasFDA-approved genotyping test that has determined that the member is a CYP2D6extensive metabolizer, intermediate metabolizer or poor metabolizer.18 years of age or older12 monthsCHANTIXCHANTIX, CHANTIX CONTINUING MONTH, CHANTIX STARTING MONTH PAAll FDA-approved indications not otherwise excluded from Part D.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 older6 months12
Prior Authorization GroupDrug NamesCovered UsesExclusion CriteriaRequired Medical InformationAge RestrictionsPrescriber RestrictionsCoverage DurationOther CriteriaPrior Authorization GroupDrug NamesCovered UsesExclusion CriteriaRequired Medical InformationAge RestrictionsPrescriber RestrictionsCoverage DurationOther CriteriaPrior Authorization GroupDrug NamesCovered UsesExclusion CriteriaRequired Medical InformationAge RestrictionsPrescriber RestrictionsCoverage DurationOther CriteriaUpdated 09/01/2015CIALISCIALISAll FDA approved indications not otherwise excluded from Part DIndication for which Taladafil is being prescribed. Coverage for Benign ProstaticHyperplasia (BPH) is provided in situations where the the patient experiencedintolerance/failure with two of the preferred medications such as tamsulosin, alfuzosin,terazosin, doxazosin, finasteride, dutasteride (Avodart), dutasteride plus tamsulin(Jalyn).Up to 1 yearCIMZIACIMZIAAll FDA-approved indications not otherwise excluded from Part DCoverage is not provided for use of Cimzia in combination with other biologics e.g.,Humira, Kineret, Remicade, etcCoverage is provided in situations where the patient has been evaluated and screenedfor the presence of latent TB infection, where warranted, prior to initiating treatment withCimzia. Coverage for Crohn's disease is provided in situations where the patientexperienced intolerance/failure to Humira. Coverage for rheumatoid arthritis is providedin situations where the patient experienced intolerance/failure to Humira AND EnbrelPatient must be 18 years of age or olderCrohn's - 12 months, Rheumatoid arthritis - 5 yearsRenewal coverage is provided in situations where treatment has provided clinical benefit.CINRYZECINRYZEAll FDA-approved indications not otherwise excluded from Part D.Diagnosis of hereditary angioedema as evidenced by C4 and C1 inhibitor assays.Prescribed by an allergist or immunologist12 months13
Prior Authorization GroupDrug NamesCovered UsesExclusion CriteriaRequired Medical InformationAge RestrictionsPrescriber RestrictionsCoverage DurationOther CriteriaPrior Authorization GroupDrug NamesCovered UsesExclusion CriteriaRequired Medical InformationAge RestrictionsPrescriber RestrictionsCoverage DurationOther CriteriaUpdated 09/01/2015COMETRIQCOMETRIQAll FDA approved indications not otherwise excluded from Part D. Plus patients alreadystarted on Cometriq for a Covered Use.Diagnosis of progressive, metastatic medullary thyroid cancer.Authorization will be for 12 months.COSENTYXCOSENTYX SENSOREADY PENAll FDA-approved indications not otherwise excluded from Part D.Latent TB screening with either a TB skin test or an interferon gamma release assay(e.g., QFT-GIT, T-SPOT.TB) must be performed prior to initiating Cosentyx (or otherbiologic). Member has a diagnosis of moderate to severe plaque psoriasis. At least 5%BSA is affected or crucial body areas (eg, feet, hands, face, neck and/or groin) areaffected at the time of diagnosis. For new starts, ALL of the following criteria must bemet: 1) Member has experienced an inadequate response to phototherapy (e.g., UVB,PUVA), methotrexate, cyclosporine, or acitretin, unless contraindicated or intolerant tosuch therapies, 2) Member will be assessed for continuation of therapy after 3 months oftreatment. For continuation, member must have achieved positive clinical response after3 months of treatment or has maintained positive clinical response as evidenced by lowdisease activity or improvement in signs and symptoms.18 years of age or olderInitial: 4 months. Continuation: 1 Year14
Prior Authorization GroupDrug NamesCovered UsesExclusion CriteriaRequired Medical InformationAge RestrictionsPrescriber RestrictionsCoverage DurationOther CriteriaPrior Authorization GroupDrug NamesCovered UsesExclusion CriteriaRequired Medical InformationAge RestrictionsPrescriber RestrictionsCoverage DurationOther CriteriaPrior Authorization GroupDrug NamesCovered UsesExclusion CriteriaRequired Medical InformationAge RestrictionsPrescriber RestrictionsCoverage DurationOther CriteriaUpdated 09/01/2015CRESEMBACRESEMBAAll FDA-approved indications not otherwise excluded from Part D.Familial Short QT SyndromeCoverage is provided in the treatment of invasive aspergillosis and invasivemucormycosis.18 years of age or older1 YearDALIRESPDALIRESPAll FDA-approved indications not otherwise excluded from Part D.Coverage is provided in patients who meet all of the following conditions: Patients hassevere COPD (defined as an FEV1 less than 50% predicted) or very severe COPD(defined as FEV1 less than 30% predicted), AND Patient has chronic bronchitis, ANDPatient has a history of exacerbations, AND Patient has tried a medication from two ofthe three following drug categories: long-acting beta2-agonist (LABA) [eg, salmeterol,formoterol], long-acting anticholinergic (eg, tiotropium), inhaled corticosteroid (eg,fluticasone).Adult patients 18 years or older1 yearDIFICIDDIFICIDAll FDA-approved indications not otherwise excluded from Part D.Required Medical information: -Diagnosis of severe Clostridium difficile-associateddiarrhea -Oral vancomycin trial firstAdult patients 18 years or older30 days for each treatment15
Prior Authorization GroupDrug NamesCovered UsesExclusion CriteriaRequired Medical InformationAge RestrictionsPrescriber RestrictionsCoverage DurationOther CriteriaUpdated 09/01/2015ENBRELENBRELAll FDA-approved indications not otherwise excluded from Part D.Concurrent use of more than 1 biological response modifier including, but not limited to:adalimumab, infliximab. Diagnosis of guttate, erythrodermic, or pustular psoriasis.Individual experiencing acute infection or significant chronic infection.RA, Tried 1 DMARD for 3 mos or is also receiving MTX, has a contraindication orintolerance to MTX and leflunomide, or has early RA (defined as disease duration of lessthan 6 months) with at least one of the following features of poor prognosis: functionallimitation, extraarticular disease such as rheumatoid nodules, RA vasculitis, or Felty¿ssyndrome, positive rheumatoid factor or anti-CCP antibodies, or bony erosions byradiograph. JIA/JRA, approve if the pt has aggressive disease or the pt has tried oneother agent for this condition (eg, MTX, sulfasalazine, leflunomide, NSAID, biologicDMARD or the pt will be started on Enbrel concurrently with MTX, sulfasalazine, orleflunomide or the pt has an absolute contraindication to MTX (eg, pregnancy, breastfeeding, alcoholic liver disease, immunodeficiency syndrome, blood dyscrasias),sulfasalazine, or leflunomide.Plaque psoriasis (PP). Approve if the patient has tried atleast one of the following agents for at least 3 months for plaque psoriasis: an oraltherapy for psoriasis (eg, MTX, cyclosporine, Soriatane), oral methoxsalen plus PUVA,or a biologic agent OR the patient had intolerance to a trial of at least one oral or biologictherapy for plaque psoriasis OR the patient has a contraindication to one oral agent forpsoriasis such as MTX.Must be greater than or equal to 2 years of age. For JRA: must be between 2 and 17years of age. For Ankylosing Spondylitis and Psoriatic Arthritis: must be greater than orequal to 18 years of age.For RA, JRA, Ankylosing Spondylitis: provider must be a rheumatologist. For PsoriaticArthritis: provider must be a rheumatologist or dermatologist. For Plaque Psoriasis:provider must be a dermatologist.May approve for up to 1 year.16
Prior Authorization GroupDrug NamesCovered UsesExclusion CriteriaRequired Medical InformationAge RestrictionsPrescriber RestrictionsCoverage DurationOther CriteriaUpdated 09/01/2015EPOETIN ALFAEPOGEN, PROCRITAll medically accepted indications not otherwise excluded from Part DFor CKD and not on dialysis: hypersensitivity to mammalian-cell derived products or tohuman albumin, untreated iron or folate deficiencies, hemolysis, or GI bleeding,uncontrolled hypertension, or in need of immediate correction of severe anemia. Forcovered indications other than CKD/ESRD: Anemia that is secondary to the malignancy,hypersensitivity to mammalian-cell derived products, or to human albumin, untreatediron or folate deficiencies, hemolysis, or GI bleeding, uncontrolled hypertension, need forimmediate correction of severe anemia, inadequate iron stores including transferrinsaturation less than 20% and ferritin less than 100ng/mL, endogenous erythropoietinlevels greater than 500 mU/mL for zidovudine induced anemia or greater than 200mU/mL for anemia secondary to cancer.Required Medical Information: Diagnosis of CKD: GFR, creatinine, lab values Hgb/Hct(H/H), transferrin saturation and ferritin level within the past 30 days, current bodyweight, cancer and chemotherapy history. Criteria for anemia secondary to CKD not ondialysis, anemia due to chemotherapy for nonmyeloid malignancies, anemia associatedwith MDS equivalent to criteria outlined in the Aranesp prior authorization criteria.
drugs listed below. AvMed Medicare Choice and AvMed Medicare Choice Elect will only provide coverage after it determines that the drug is being prescribed according to the criteria specified in the chart. You, your appointed representative, or your prescriber can request prior authorization by calling AvMed at 1-800-782-8633,
