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2017 Cigna-HealthSpring Prior Authorization Criteria

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Name ABELCET Product Group Covered Uses Exclusion Required Medical Information Antifungals, Polyene 2017 Cigna-HealthSpring 6 months B vs D coverage determination ABILIFY MAINTENA to new starts only Abilify
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Name ABELCET Product Group Covered Uses Exclusion Required Medical Information Antifungals, Polyene 2017 Cigna-HealthSpring 6 months B vs D coverage determination ABILIFY MAINTENA to new starts only Abilify Maintena Patient must have failure, contraindication or intolerance to Aristada before Abilify Maintena is authorized. ABRAXANE ACAMPROSATE CALCIUM DR ACETYLCYSTEINE ACITRETIN ACTEMRA IV ACTEMRA SC ACT ACYCLOVIR SODIUM ADAGEN ADEMPAS ADRUCIL AFINITOR to new starts only to new starts only Alcohol Dependence nts Acitretin Actemra Actemra Actimmune STIMULANTS ADEMPAS Afinitor All FDA-approved Documentation of alcohol dependence and past medication history. and past medication history. and past medication history Use of Actemra is considered medically necessary for the treatment of rheumatoid arthritis (RA) when BOTH of the following criteria are met: 1) inadequate response, intolerance, or contraindication to at least one disease-modifying anti-rheumatic drug (DMARD) (i.e., Methotrexate (MTX) Azathioprine, gold, Hydroxychloroquine, Penicillamine, Sulfasalazine and 2) failure, contraindication or intolerance to Enbrel or Humira. B vs D coverage determination required for Actemra IV. Use of Actemra is considered medically necessary for the treatment of rheumatoid arthritis (RA) when BOTH of the following criteria are met: 1) inadequate response, intolerance, or contraindication to at least one disease-modifying anti-rheumatic drug (DMARD) (i.e., Methotrexate (MTX) Azathioprine, gold, Hydroxychloroquine, Penicillamine, Sulfasalazine and 2) failure, contraindication or intolerance to Enbrel or Humira. B vs D coverage determination required for Actemra IV. 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 to new starts only Afinitor and past medication history 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 SULFATE ALDURAZYME ALECENSA to new starts only Enzyme Replacement/Modifiers Name ALIMTA Product Group Covered Uses Exclusion Required Medical Information ALORA HRM - Estrogens Safer alternatives to the estrogen high risk medications depend on the indication. For Hot Flashes, safer alternatives are: Depo-Estradiol, SSRIs, venlafaxine, gabapentin, and Femring. For Vaginal Symptoms of menopause, safer alternatives are: Premarin Cream, Estring, and Femring. For Bone Density, safer alternatives are: alendronate, raloxifene, and Prolia. ALOSETRON HYDROCHLORIDE ALOXI (Non-formulary for PDP Secure, PDP Secure-Extra) AMBISOME AMIFOSTINE AMINOSYN AMINOSYN 7%/ELECTROLYTES AMINOSYN 8.5%/ELECTROLYTES AMINOSYN II AMINOSYN II 8.5%/ELECTROLYTES AMINOSYN M AMINOSYN-HBC AMINOSYN-PF AMINOSYN-PF 7% AMINOSYN-RF Alosetron Antifungals, Polyene Alosetron will not be approved for use in men, as safety and efficacy in men has not been established. 6 months B vs D coverage determination AMITRIPTYLINE HCL to new starts only HRM - Tricyclic Antidepressants continue to monitor for side effects. AMPHOTERICIN B AMPYRA ANADROL-50 ANDROXY APOKYN ARALAST NP Antifungals, Polyene Ampyra ANABOLIC STEROIDS, ANDROGENS ANABOLIC STEROIDS, ANDROGENS Apokyn 6 months B vs D coverage determination Ampyra is considered medically necessary for patients with multiple sclerosis with medical documentation of impaired walking ability. Name ARANESP ALBUMIN FREE Product Group Covered Uses Exclusion Required Medical Information HEMATOPOIETICS For initial treatment of anemia, documentation of Hemoglobin less than 10, transferrin saturation greater than 20%, and ferritin levels greater than 100 obtained over the last 3 months. For res, approvals granted if Hemoglobin does not exceed 10-12g/dL or approvals granted if Hemoglobin does not exceed 10-13g/dL for the indication of reduction of allogeneic red cell transfusions in patients undergoing elective, noncardiac, nonvascular surgery. 6 months B vs D coverage determination ARCALYST ARMODAFINIL ARZERRA Arcalyst Non-amphetamine Central Nervous System nts of Cryopyrin-Associated Periodic Syndromes (CAPS), including Familial Cold Autoinflammatory Syndrome (FCAS) and Muckle-Wells Syndrome and sleep study for the diagnosis of sleep apnea or narcolepsy 12 years of age and older B vs D coverage determination ASCOMP/CODEINE HRM - Butalbital Combinations Safer alternatives are: naproxen sodium and ibuprofen. ASTAGRAF XL ATGAM AVASTIN AVONEX (Nonformulary for PDP Secure) AVONEX PEN (Nonformulary for PDP Secure) AZACITIDINE AZASAN AZATHIOPRINE BANZEL BELEODAQ BENDEKA to new starts only to new starts only to new starts only to new starts only to new starts only to new starts only Immunomodulators Immunomodulators Banzel Beleodaq Patient must have failure, contraindication or intolerance to Betaseron and Copaxone 40mg/ml before Avonex or Rebif will be authorized. Patient must have failure, contraindication or intolerance to Betaseron and Copaxone 40mg/ml before Avonex or Rebif will be authorized. B vs D coverage determination B vs D coverage determination B vs D coverage determination B vs D coverage determination B vs D coverage determination Name BENLYSTA Product Group Covered Uses Exclusion Required Medical Information BENLYSTA The patient must have a positive autoantibody test (i.e., antinuclear antibody [ANA] greater than or equal to 1:80 and/or anti-double-stranded DNA [anti-dsdna] greater than or equal to 30 IU/ml) AND active disease state as documented by a SELENA-SLEDAI score of 6 or greater on the current treatment regimen. The patient must be receiving one standard therapy for SLE with any of the following: corticosteroids, hydroxychloroquine, immunosuppressives (cyclophosphamide, azathioprine, mycophenolate, methotrexate, cyclosporine) or nonsteroidal anti-inflammatory drugs AND there must be an absence of severe active lupus nephritis or severe active central nervous system lupus before Benlysta is authorized. B vs D coverage determination. BENZTROPINE MESYLATE HRM - Benztropine formulary alternatives if two are available or provided clinical rationale why two safer formulary alternatives are not 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. Safer alternatives depend on indication. For Parkinsonism, safer alternatives are: Carbidopa/Levodopa, Pramipexole, Ropinirole, Bromocriptine, Amantadine, and Selegiline. For extrapyramidal symptoms, a safer alternative is: Amantadine. BETASERON BICNU BLEOMYCIN SULFATE BOSULIF BUDESONIDE to new starts only Immunomodulators BUPRENORPHINE HCL Opioid Agonist- Antagonist Analgesics All FDA-approved Documentation of opioid dependence. Buprenorphine-3d The use of buprenorphine for maintenance supply, or 6 mo if therapy should be limited to patients who have pregnant/hypersen experienced a hypersensitivity reaction to sitive to naloxone. naloxone or require buprenorphine during Zubsolv and pregnancy. bup/nalox-6 mo BUPRENORPHINE HCL/NALOXONE HCL Opioid Agonist- Antagonist Analgesics All FDA-approved Documentation of opioid dependence. Buprenorphine-3d The use of buprenorphine for maintenance supply, or 6 mo if therapy should be limited to patients who have pregnant/hypersen experienced a hypersensitivity reaction to sitive to naloxone. naloxone or require buprenorphine during Zubsolv and pregnancy. bup/nalox-6 mo BUSULFEX BUTALBITAL/ACETA MINOPHEN/CAFFEINE HRM - Butalbital Combinations Safer alternatives are: naproxen sodium and ibuprofen. Name Product Group Covered Uses Exclusion Required Medical Information BUTALBITAL/ACETA MINOPHEN/CAFFEINE /CODEINE HRM - Butalbital Combinations Safer alternatives are: naproxen sodium and ibuprofen. BUTALBITAL/ASPIRIN /CAFFEINE HRM - Butalbital Combinations Safer alternatives are: naproxen sodium and ibuprofen. BUTALBITAL/ASPIRIN /CAFFEINE/CODEINE HRM - Butalbital Combinations Safer alternatives are: naproxen sodium and ibuprofen. CABOMETYX to new starts only CANCIDAS Antifungals, Superficial and Systemic 3 to, depending on indication 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 Itraconazole. CAPACET HRM - Butalbital Combinations Safer alternatives are: naproxen sodium and ibuprofen. CAPRELSA to new starts only Caprelsa Name CARBOPLATIN CAYSTON CELLCEPT INTRAVENOUS CEREZYME CHORIONIC GONADOTROPIN to new starts only Product Group Covered Uses Exclusion Required Medical Information CAYSTON Hormonal nts, Gonadotropins 7 years and older B vs D coverage determination CINRYZE Cinryze Patient must have a confirmed diagnosis of HAE. 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. B vs D coverage determination. CISPLATIN CLADRIBINE 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 2.75%/DEXTROSE 10% CLINIMIX E 4.25%/DEXTROSE 10% CLINIMIX E 4.25%/DEXTROSE 25% CLINIMIX E 5%/DEXTROSE 25% CLINISOL SF 15% CLOLAR CLOMIPRAMINE HCL to new starts only HRM - Tricyclic Antidepressants continue to monitor for side effects. COMETRIQ COPAXONE COSMEGEN COTELLIC CROMOLYN SODIUM CUBICIN to new starts only to new starts only Immunomodulators Patient must have failure, contraindication or intolerance to Betaseron and Copaxone 40mg/ml before Avonex or Rebif will be authorized. Name CYCLOBENZAPRINE HCL CYCLOPHOSPHAMIDE CYCLOSPORINE CYCLOSPORINE MODIFIED CYRAMZA CYSTARAN CYTARABINE CYTARABINE AQUEOUS DACARBAZINE DALIRESP DARZALEX to new starts only to new starts only to new starts only to new starts only DAUNORUBICIN HCL DAUNOXOME DEXRAZOXANE DEXTROSE 10%/NACL 0.45% DEXTROSE 5% /ELECTROLYTE #48 VIAFLEX DEXTROSE 10% DEXTROSE 10% FLEX CONTAINER DEXTROSE 10%/NACL 0.2% DEXTROSE 2.5%/NACL 0.45% DEXTROSE 2.5%/SODIUM CHLORIDE 0.45% DEXTROSE 20% DEXTROSE 25% DEXTROSE 30% DEXTROSE 40% DEXTROSE 5% DEXTROSE 5%/LACTATED RINGERS DEXTROSE 5%/NACL 0.2% DEXTROSE 5%/NACL 0.225% DEXTROSE 5%/NACL 0.3% DEXTROSE 5%/NACL 0.33% Product Group Covered Uses Exclusion Required Medical Information HRM - Skeletal Muscle Relaxants Antineoplastics, Monoclonal Antibodies CYSTARAN Phosphodiesterase Type 4 (PDE4) Antineoplastics, Monoclonal Antibodies continue to monitor for side effects. B vs D coverage determination B vs D coverage determination B vs D coverage determination B vs D coverage determination Name 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% DEXTROSE 50% DEXTROSE 70% Product Group Covered Uses Exclusion Required Medical Information DIGITEK HRM - Digoxin documented that the patient has tried and failed digoxin 0.125mg daily or provided clinical rationale as to why the lower dose is not appropriate for the patient. DIGOX HRM - Digoxin documented that the patient has tried and failed digoxin 0.125mg daily or provided clinical rationale as to why the lower dose is not appropriate for the patient. DIGOXIN HRM - Digoxin documented that the patient has tried and failed digoxin 0.125mg daily or provided clinical rationale as to why the lower dose is not appropriate for the patient. DIPYRIDAMOLE (only covered on PDP Secure, PDP Secure-Extra) HRM - Platelet Modifying nts Safer alternatives are: Clopidogrel, Warfarin, Jantoven, and Aggrenox. DOCEFREZ DOCETAXEL DOXEPIN HCL to new starts only HRM - Tricyclic Antidepressants continue to monitor for side effects. DOXORUBICIN HCL DOXORUBICIN HCL LIPOSOME Name DRONABINOL ELAPRASE ELIGARD ELITEK EMEND EMPLICITI to new starts only to new starts only Product Group Covered Uses Exclusion Required Medical Information Dronabinol Enzyme Replacement/Modifiers Pituitary Hormones Empliciti and current medication regimen 6 months Empliciti is approved with concurrent use of dexamethasone and lenalidomide. B vs D coverage determination. ENBREL Immune Suppressants and past medication history 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 antiinflammatory 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 Crohn 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 coverage determination required for Remicade. ENBREL SURECLICK ENGERIX-B ENTRESTO ENVARSUS XR EPIRUBICIN HCL ERBITUX to new starts only Immune Suppressants ENTRESTO and past medication history 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 antiinflammatory 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 Crohn 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 coverage determination required for Remicade. The patient must have a diagnosis of chronic heart failure (NYHA Class II IV), have left ventricular ejection fraction less than or equal to 40%, and have no concomitant therapy with an ACE inhibitor, ARB, or direct renin inhibitor when starting on Entresto. B vs D coverage determination Name Product Group Covered Uses Exclusion Required Medical Information ERGOLOID MESYLATES HRM - Antidementia nts Safer alternatives are: donepezil, galantamine and rivastigmine. ERIVEDGE ERWINAZE ESBRIET to new starts only Erivedge ESBRIET All FDA-approved excluded from part D. Other known causes of interstitial lung disease e.g., domestic and occupational environmental exposures, connective tissue disease, and drug toxicity. Diagnosis confirmed by 1.) in patients without surgical lung biopsy: Usual interstitial pneumonia (UIP) pattern on high resolution computed tomography (HRCT) is indicative of IPF or 2.) in patients with surgical lung biopsy: The combination of HRCT and biopsy pattern is indicative of IPF. Documented forced vital capacity (% FVC) greater than or equal to 50% performed within the last 6 months. Prescribed by pulmonologist. Esbriet will be used as monotherapy. ESGIC HRM - Butalbital Combinations Safer alternatives are: naproxen sodium and ibuprofen. ESTRADIOL PATCH HRM - Estrogens Safer alternatives to the estrogen high risk medications depend on the indication. For Hot Flashes, safer alternatives are: Depo-Estradiol, SSRIs, venlafaxine, gabapentin, and Femring. For Vaginal Symptoms of menopause, safer alternatives are: Premarin Cream, Estring, and Femring. For Bone Density, safer alternatives are: alendronate, raloxifene, and Prolia. ESTRADIOL TABS HRM - Estrogens Safer alternatives to the estrogen high risk medications depend on the indication. For Hot Flashes, safer alternatives are: Depo-Estradiol, SSRIs, venlafaxine, gabapentin, and Femring. For Vaginal Symptoms of menopause, safer alternatives are: Premarin Cream, Estring, and Femring. For Bone Density, safer alternatives are: alendronate, raloxifene, and Prolia. ETOPOSIDE EVOMELA FABRAZYME FARYDAK FASLODEX FENTANYL CITRATE to new starts only to new starts only EVOMELA FARYDAK B vs D coverage determination Name FENTANYL CITRATE ORAL TRANSMUCOSAL FERRIPROX FIRAZYR Product Group Covered Uses Exclusion Required Medical Information Transmucosal Fentanyl Citrate FERRIPROX Firazyr All FDA-approved Documentation from the medical record of diagnosis Patient must have a confirmed diagnosis of HAE. 16 years of age and older for fentanyl citrate (lozenge/troche). Enrollment in the Transmucosal Immediate- Release Fentanyl (TIRF) REMS Access program 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. 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). FIRMAGON FLUDARABINE PHOSPHATE FLUOROURACIL FOLOTYN FORTEO FREAMINE HBC 6.9% FREAMINE III Metabolic Bone Disease agents 1.) Pediatric patients or young 1.) Bone mineral density (BMD) by DEXA at hip and spine. adults with open epiphyses. 2.) 2.) Confirmation of normal serum alkaline phosphatase or History of prior external beam provider statement that Paget s disease has been excluded. 3.) or implant radiation involving Treatment history related to bisphosphonates and Prolia. the skeleton For the diagnoses of treatment of postmenopausal osteoporosis and treatment of primary or hypogonadal male osteoporosis, patient must have 1.) failure, contraindication, or intolerance to one oral bisphosphonate with failure or contraindication defined as any one of the following: a.) creatinine clearance less than 35 ml/min, b.) inability to remain upright for 30 minutes after
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