PA Criteria

Drug Name	Ingredients	Dosage Form	Prior Authorization Group Description	Covered Uses	Exclusion Criteria	Required Medical Information	Age Restrictions	Prescriber Restrictions	Coverage Duration	Other Criteria
ABELCET	AMPHOTERICIN B	SUSP	Part B vs D	Injectable/Infusion - Covered under Part D if dispensed by a pharmacy, regardless of place of administration (i.e. home vs healthcare setting); Covered under Part B if obtained from physician's stock.
ABRAXANE	PACLITAXEL	SUSR	Part B vs D	Injectable/Infusion - Covered under Part D if dispensed by a pharmacy, regardless of place of administration (i.e. home vs healthcare setting); Covered under Part B if obtained from physician's stock.
ACCUNEB	ALBUTEROL SULFATE	NEBU	Part B vs D	Inhalation DME supply drugs (Nebulizer medications) - Covered under Part D if patient is in a Long Term Care facility or if drug is delivered with a metered dose inhaler or other non-nebulized administration. Otherwise covered under Part B.
ACETADOTE	ACETYLCYSTEINE	SOLN	Part B vs D	Injectable/Infusion - Covered under Part D if dispensed by a pharmacy, regardless of place of administration (i.e. home vs healthcare setting); Covered under Part B if obtained from physician's stock.
ACETAZOLAMIDE SODIUM	ACETAZOLAMIDE SODIUM	SOLR	Part B vs D	Injectable/Infusion - Covered under Part D if dispensed by a pharmacy, regardless of place of administration (i.e. home vs healthcare setting); Covered under Part B if obtained from physician's stock.
ACTIMMUNE	INTERFERON GAMMA-1B	SOLN	interferon gamma-1b	All FDA-approved indications not otherwise excluded for Part D.	Hypersensitivity to interferon gamma, E. coli derived proteins, or any component of the formulation	APPROVE as requested for diagnoses listed below. 1) Chronic granulomatous disease 2) Severe, malignant osteoporosis to delay the time to disease progression 3) Idiopathic pulmonary fibrosis 4) Adjuvant treatment of refractory mycobacterium infection due to Mycobacterium avium complex (MAC) in conjunction with traditional antimycobacterial agents 5) Ovarian cancer	None	None	1 year	None
ACYCLOVIR SODIUM	ACYCLOVIR SODIUM	SOLN	Part B vs D	Injectable/Infusion - Covered under Part D if dispensed by a pharmacy, regardless of place of administration (i.e. home vs healthcare setting); Covered under Part B if obtained from physician's stock.
ADAGEN	PEGADEMASE BOVINE	SOLN	pegademase	Adenosine deaminase deficiency - Severe combined immunodeficiency disease	Hypersensitivity to pegademase or any of its components, severe thrombocytopenia , not to be used as preparatory or support therapy for bone marrow transplantation	APPROVE as requested for diagnoses listed below: diagnosis: Adenosine deaminase (ADA) deficiency	None	None	1 year, reevaluate the need for possibe lifetime approval	None
ADRIAMYCIN	DOXORUBICIN HYDROCHLORIDE	SOLN	Part B vs D	Injectable/Infusion - Covered under Part D if dispensed by a pharmacy, regardless of place of administration (i.e. home vs healthcare setting); Covered under Part B if obtained from physician's stock.
ADRIAMYCIN	DOXORUBICIN HYDROCHLORIDE	SOLR	Part B vs D	Injectable/Infusion - Covered under Part D if dispensed by a pharmacy, regardless of place of administration (i.e. home vs healthcare setting); Covered under Part B if obtained from physician's stock.
ALBUTEROL SULFATE	ALBUTEROL SULFATE	NEBU	Part B vs D	Inhalation DME supply drugs (Nebulizer medications) - Covered under Part D if patient is in a Long Term Care facility or if drug is delivered with a metered dose inhaler or other non-nebulized administration. Otherwise covered under Part B.
ALCOHOL 5%/DEXTROSE 5%	ALCOHOL, USP; DEXTROSE (ANHYDROUS)	SOLN	Part B vs D	Parenteral nutrition or intradialytic parenteral nutrition (IDPN) - Covered under Part B if patient has a non-functional digestive tract. Otherwise covered under Part D
ALDURAZYME	LARONIDASE	SOLN	Part B vs D	Injectable/Infusion - Covered under Part D if dispensed by a pharmacy, regardless of place of administration (i.e. home vs healthcare setting); Covered under Part B if obtained from physician's stock.
ALFERON N	INTERFERON ALFA-n3	SOLN	interferon alfa-n3	All FDA-approved indications not otherwise excluded for Part D.	None	APPROVE for the treatment of refractory or recurring external condylomata acuminata (genital or venereal warts): Intralesional dosage: Adults: 0.05 ml (250,000 IU) per wart intralesionally twice weekly for up to 8 weeks. The maximum recommended dose per treatment session is 0.5 ml (2.5 million IU). The minimum effective dose of interferon alfa-n3 has not been established. Genital warts usually begin to disappear after several weeks of treatment. Treatment should be continued for a maximum of 8 weeks. In clinical trials, many patients who had a partial resolution of warts during treatment experienced further resolution of their warts after cessation of treatment. Of the patients who had complete resolution, half had complete resolution by the end of treatment and half had complete resolution of venereal warts during the 3 months after treatment cessation. Thus, it is recommended that no further treatment be given for 3 months after the initial 8-week course unless the lesions enlarge or new warts appear. Studies to determine the efficacy of a second treatment course have not been conducted. Hepatitis C infection (NOTE: Best results seen with pegylated interferon and ribavirin combination):If MD is any of the following specialist: Gastroenterologist, Hepatologist, Transplant specialist, Infectious Disease specialist) AND the following labs are provided: HCV RNA levels, AST/ALT levels, Viral genotype, with or without results of liver biopsy,send to Prof. Services for clinical pharmacist review.	None	None	6mo-1yr (diagnosis dependent)	Coverage Duration: Dx: Chronic Hep C Approve x 24 weeks if: 1) Patient is less than 60 years old, AND 2) MD is a gastroenterologist, infectious disease specialist or hepatologist, AND 3) Persistently elevated ALT (greater than 6 months) (normal 0 -45), AND 4) Positive HCV RNA, AND 5) Liver biopsy showing either portal or bridging fibrosis, and at least moderate degrees of inflammation and necrosis, AND Limit #2 kits per month x 24 weeks (6 months). If requesting for 48 weeks duration, approve if: 1) All above criteria is met (for 24 wk approval), AND 2) Very high HCV RNA level (greater than 2million copies/ml), OR 3) HCV genotype 1, OR 4) Cirrhosis on biopsy (with otherwise high likelihood of response) Limit #2 kits/mo x 48 weeks (12 months).
ALIMTA	PEMETREXED DISODIUM	SOLR	Part B vs D	Injectable/Infusion - Covered under Part D if dispensed by a pharmacy, regardless of place of administration (i.e. home vs healthcare setting); Covered under Part B if obtained from physician's stock.
ALKERAN	MELPHALAN	SOLR	Part B vs D	Injectable/Infusion - Covered under Part D if dispensed by a pharmacy, regardless of place of administration (i.e. home vs healthcare setting); Covered under Part B if obtained from physician's stock.
ALLOPURINOL SODIUM	ALLOPURINOL SODIUM	SOLR	Part B vs D	Injectable/Infusion - Covered under Part D if dispensed by a pharmacy, regardless of place of administration (i.e. home vs healthcare setting); Covered under Part B if obtained from physician's stock.
ALOPRIM	ALLOPURINOL SODIUM	SOLR	Part B vs D	Injectable/Infusion - Covered under Part D if dispensed by a pharmacy, regardless of place of administration (i.e. home vs healthcare setting); Covered under Part B if obtained from physician's stock.
ALOXI	PALONOSETRON HYDROCHLORIDE	SOLN	Part B vs D	Injectable/Infusion - Covered under Part D if dispensed by a pharmacy, regardless of place of administration (i.e. home vs healthcare setting); Covered under Part B if obtained from physician's stock.
AMBISOME	AMPHOTERICIN B	SUSR	Part B vs D	Injectable/Infusion - Covered under Part D if dispensed by a pharmacy, regardless of place of administration (i.e. home vs healthcare setting); Covered under Part B if obtained from physician's stock.
A-METHAPRED	METHYLPREDNISOLONE SODIUM SUCCINATE	SOLR	Part B vs D	Injectable/Infusion - Covered under Part D if dispensed by a pharmacy, regardless of place of administration (i.e. home vs healthcare setting); Covered under Part B if obtained from physician's stock.
AMEVIVE	ALEFACEPT	SOLR	alefacept	Treatment of adult patients with moderate to severe chronic plaque psoriasis who are candidates for systemic therapy or phototherapy, psoriasis with arthropathy	Patients with mild psoriasis, patients also using other immunosuppressive agents, patients currently receiving phototherapy, patients also diagnosed with HIV/AIDs.	The prior authorization should be maintained for a lifetime limit of 180 days due to the lack of available studies of Amevive's safety and effectiveness beyond two treatment cycles. The first and second treatment cycles, each consisting of 12 weeks, must be separated by at least a 12-week interval. Retreatment with the second 12-week course may be initiated provided the CD4+ T-cell count is within the normal range. The physician should monitor CD4+ T-cell counts during treatment, dosing should be withheld if the CD4+ T-cell count is less than 250 /mm3 and treatment should be discontinued if the count remains less than 250 /mm3 for one month. Per manufacturer guidelines, Amevive should not be used concomitantly with other immunosuppressive agents or in patients currently receiving phototherapy. Amevive is contraindicated in patients with HIV/AIDs because it reduces CD4+ T-cell counts and, thus, may accelerate progression of HIV infection or increase complications of the disease.	None	None	1 year, lifetime limit of 180 days	None
AMIKACIN SULFATE	AMIKACIN SULFATE	SOLN	Part B vs D	Injectable/Infusion - Covered under Part D if dispensed by a pharmacy, regardless of place of administration (i.e. home vs healthcare setting); Covered under Part B if obtained from physician's stock.
AMIKIN	AMIKACIN SULFATE	SOLN	Part B vs D	Injectable/Infusion - Covered under Part D if dispensed by a pharmacy, regardless of place of administration (i.e. home vs healthcare setting); Covered under Part B if obtained from physician's stock.
AMINESS	AMINO ACIDS	SOLN	Part B vs D	Parenteral nutrition or intradialytic parenteral nutrition (IDPN) - Covered under Part B if patient has a non-functional digestive tract. Otherwise covered under Part D
AMINOPHYLLINE	AMINOPHYLLINE	SOLN	Part B vs D	Injectable/Infusion - Covered under Part D if dispensed by a pharmacy, regardless of place of administration (i.e. home vs healthcare setting); Covered under Part B if obtained from physician's stock.
AMINOSYN	ACETATE; ALANINE; ARGININE; ASPARTIC ACID; GLUTAMIC ACID HYDROCHLORIDE; GLYCINE; HISTIDINE; ISOLEUCINE; LEUCINE; LYSINE; METHIONINE; PHENYLALANINE; PROLINE; SERINE; SODIUM (+1); THREONINE; TRYPTOPHAN; TYROSINE; VALINE	SOLN	Part B vs D	Parenteral nutrition or intradialytic parenteral nutrition (IDPN) - Covered under Part B if patient has a non-functional digestive tract. Otherwise covered under Part D
AMINOSYN	ACETATE; ALANINE; ARGININE; GLYCINE; HISTIDINE; ISOLEUCINE; LEUCINE; LYSINE; METHIONINE; PHENYLALANINE; POTASSIUM (+1); PROLINE; SERINE; THREONINE; TRYPTOPHAN; TYROSINE; VALINE	SOLN	Part B vs D	Parenteral nutrition or intradialytic parenteral nutrition (IDPN) - Covered under Part B if patient has a non-functional digestive tract. Otherwise covered under Part D
AMINOSYN	ACETATE; ALANINE; ARGININE; GLYCINE; HISTIDINE; ISOLEUCINE; LEUCINE; LYSINE; METHIONINE; PHENYLALANINE; PROLINE; SERINE; THREONINE; TRYPTOPHAN; TYROSINE; VALINE	SOLN	Part B vs D	Parenteral nutrition or intradialytic parenteral nutrition (IDPN) - Covered under Part B if patient has a non-functional digestive tract. Otherwise covered under Part D
AMINOSYN 7%/ELECTROLYTES	ACETATE; ALANINE; ARGININE; CHLORIDE ION; GLYCINE; HISTIDINE; ISOLEUCINE; LEUCINE; LYSINE; MAGNESIUM (+2); METHIONINE; PHENYLALANINE; PHOSPHATE; POTASSIUM (+1); PROLINE; SERINE; SODIUM (+1); THREONINE; TRYPTOPHAN; TYROSINE; VALINE	SOLN	Part B vs D	Parenteral nutrition or intradialytic parenteral nutrition (IDPN) - Covered under Part B if patient has a non-functional digestive tract. Otherwise covered under Part D
AMINOSYN II 3.5%/DEXTROSE25%	ACETATE; ALANINE; ARGININE; ASPARTIC ACID; DEXTROSE (ANHYDROUS); GLUTAMIC ACID HYDROCHLORIDE; GLYCINE; HISTIDINE; ISOLEUCINE; LEUCINE; LYSINE; METHIONINE; PHENYLALANINE; PROLINE; SERINE; SODIUM (+1); THREONINE; TRYPTOPHAN; TYROSINE; VALINE	SOLN	Part B vs D	Parenteral nutrition or intradialytic parenteral nutrition (IDPN) - Covered under Part B if patient has a non-functional digestive tract. Otherwise covered under Part D
AMINOSYN II 3.5%/DEXTROSE5%	ACETATE; ALANINE; ARGININE; ASPARTIC ACID; DEXTROSE (ANHYDROUS); GLUTAMIC ACID HYDROCHLORIDE; GLYCINE; HISTIDINE; ISOLEUCINE; LEUCINE; LYSINE; METHIONINE; PHENYLALANINE; PROLINE; SERINE; SODIUM (+1); THREONINE; TRYPTOPHAN; TYROSINE; VALINE	SOLN	Part B vs D	Parenteral nutrition or intradialytic parenteral nutrition (IDPN) - Covered under Part B if patient has a non-functional digestive tract. Otherwise covered under Part D
AMINOSYN II 3.5/DEXTROSE 25%	ACETATE; ALANINE; ARGININE; ASPARTIC ACID; CALCIUM; CHLORIDE ION; DEXTROSE (ANHYDROUS); GLUTAMIC ACID HYDROCHLORIDE; GLYCINE; HISTIDINE; ISOLEUCINE; LEUCINE; LYSINE; MAGNESIUM (+2); METHIONINE; PHENYLALANINE; PHOSPHATE; POTASSIUM (+1); PROLINE; SERINE; SO	SOLN	Part B vs D	Parenteral nutrition or intradialytic parenteral nutrition (IDPN) - Covered under Part B if patient has a non-functional digestive tract. Otherwise covered under Part D
AMINOSYN II 4.25/DEXTROSE25%	ACETATE; ALANINE; ARGININE; ASPARTIC ACID; CALCIUM; CHLORIDE ION; DEXTROSE (ANHYDROUS); GLUTAMIC ACID HYDROCHLORIDE; GLYCINE; HISTIDINE; ISOLEUCINE; LEUCINE; LYSINE; MAGNESIUM (+2); METHIONINE; PHENYLALANINE; PHOSPHATE; POTASSIUM (+1); PROLINE; SERINE; SO	SOLN	Part B vs D	Parenteral nutrition or intradialytic parenteral nutrition (IDPN) - Covered under Part B if patient has a non-functional digestive tract. Otherwise covered under Part D
AMINOSYN II 5/DEXTROSE 25	ACETATE; ALANINE; ARGININE; ASPARTIC ACID; DEXTROSE (ANHYDROUS); GLUTAMIC ACID HYDROCHLORIDE; GLYCINE; HISTIDINE; ISOLEUCINE; LEUCINE; LYSINE; METHIONINE; PHENYLALANINE; PROLINE; SERINE; SODIUM (+1); THREONINE; TRYPTOPHAN; TYROSINE; VALINE	SOLN	Part B vs D	Parenteral nutrition or intradialytic parenteral nutrition (IDPN) - Covered under Part B if patient has a non-functional digestive tract. Otherwise covered under Part D
AMIODARONE HCL	AMIODARONE HCL	SOLN	Part B vs D	Injectable/Infusion - Covered under Part D if dispensed by a pharmacy, regardless of place of administration (i.e. home vs healthcare setting); Covered under Part B if obtained from physician's stock.
AMPHOTEC	AMPHOTERICIN B	SUSR	Part B vs D	Injectable/Infusion - Covered under Part D if dispensed by a pharmacy, regardless of place of administration (i.e. home vs healthcare setting); Covered under Part B if obtained from physician's stock.
AMPICILLIN SODIUM	AMPICILLIN SODIUM	SOLR	Part B vs D	Injectable/Infusion - Covered under Part D if dispensed by a pharmacy, regardless of place of administration (i.e. home vs healthcare setting); Covered under Part B if obtained from physician's stock.
AMPICILLIN-SULBACTAM	AMPICILLIN SODIUM; SULBACTAM SODIUM	SOLR	Part B vs D	Injectable/Infusion - Covered under Part D if dispensed by a pharmacy, regardless of place of administration (i.e. home vs healthcare setting); Covered under Part B if obtained from physician's stock.
ANTIZOL	FOMEPIZOLE (4-METHYLPYRAZOLE)	SOLN	Part B vs D	Injectable/Infusion - Covered under Part D if dispensed by a pharmacy, regardless of place of administration (i.e. home vs healthcare setting); Covered under Part B if obtained from physician's stock.
ANZEMET	DOLASETRON MESYLATE	SOLN	Part B vs D	Injectable/Infusion - Covered under Part D if dispensed by a pharmacy, regardless of place of administration (i.e. home vs healthcare setting); Covered under Part B if obtained from physician's stock.
ANZEMET	DOLASETRON MESYLATE	TABS	Part B vs D	Oral anti-emetics - If being used in cancer treatment as a full replacement for intravenous treatment, and within 48 hours of cancer treatment, covered under Part B. Otherwise, covered under Part D.
APOKYN	APOMORPHINE HYDROCHLORIDE	SOLN	Part B vs D	Injectable/Infusion - Covered under Part D if dispensed by a pharmacy, regardless of place of administration (i.e. home vs healthcare setting); Covered under Part B if obtained from physician's stock.
ARANESP ALBUMIN FREE	DARBEPOETIN ALFA	SOLN	darbepoetin	Anemia-chronic lymphoid leukemia, anemia in neoplastic disease due to chemotherapy (non-myeloid malignancy), anemia in neoplastic disease, anemia-multiple myeloma, anemia-myelodysplastic syndrome, anemia- Non-Hodgkin's lymphoma, anemia- chronic renal failure	Uncontrolled hypertension, known hypersensitivity to the active substance or any excipients, iron stores are inadequate, pre-treatment Hgb greater than 12 g/dl	Initiation of therapy: 1. Patients do not have uncontrolled hypertension 2. Patients do not have an allergy to any component of epoetin or allergy to mammalian cell derived products 3. Patients do not have an allergy to albumin 4. At least one of the below stated diagnosis and lab values For both epoetin and darbepoetin, patients must have one of the following diagnosis with specified lab values, Chronic renal failure requiring dialysis. Chronic renal failure not requiring dialysis with the following lab values: Hb less than 10g/dL, HCT less than 30%, TSAT greater than 20%, Ferritin greater than 100ng/dL, Non-myeloid malignancies where anemia is due to the effect of concomitantly administered chemotherapy and the following lab values: Hb less than 11g/dL, TSAT greater than 20%, Ferritin greater than 100ng/dL. For epoetin only, patients must have one of the following diagnosis with specified lab values: Zidovudine treated HIV patients with the following lab values: Zidovudine dose less than 4,200mg/week, Endogenous erythropoietin levels less than 500mU/mL, Ferritin greater than 100ng/dL, TSAT greater than 20%, Reduction of allogeneic blood transfusion in patients undergoing elective, non-cardiac, non-vascular surgery with the following lab values: Hb greater than 10g/dL but less than 12g/dL	None	None	3 months	The following information must be submitted in PA request: most recent hemoglobin (Hgb) labs, patient’s weight, dosage, planned duration of therapy, is patient receiving iron supplementation? If not, request iron study lab values
ARANESP ALBUMIN FREE SURECLICK	DARBEPOETIN ALFA	SOLN	darbepoetin	Anemia-chronic lymphoid leukemia, anemia in neoplastic disease due to chemotherapy (non-myeloid malignancy), anemia in neoplastic disease, anemia-multiple myeloma, anemia-myelodysplastic syndrome, anemia- Non-Hodgkin's lymphoma, anemia- chronic renal failure	Uncontrolled hypertension, known hypersensitivity to the active substance or any excipients, iron stores are inadequate, pre-treatment Hgb greater than 12 g/dl	Initiation of therapy: 1. Patients do not have uncontrolled hypertension 2. Patients do not have an allergy to any component of epoetin or allergy to mammalian cell derived products 3. Patients do not have an allergy to albumin 4. At least one of the below stated diagnosis and lab values For both epoetin and darbepoetin, patients must have one of the following diagnosis with specified lab values, Chronic renal failure requiring dialysis. Chronic renal failure not requiring dialysis with the following lab values: Hb less than 10g/dL, HCT less than 30%, TSAT greater than 20%, Ferritin greater than 100ng/dL, Non-myeloid malignancies where anemia is due to the effect of concomitantly administered chemotherapy and the following lab values: Hb less than 11g/dL, TSAT greater than 20%, Ferritin greater than 100ng/dL. For epoetin only, patients must have one of the following diagnosis with specified lab values: Zidovudine treated HIV patients with the following lab values: Zidovudine dose less than 4,200mg/week, Endogenous erythropoietin levels less than 500mU/mL, Ferritin greater than 100ng/dL, TSAT greater than 20%, Reduction of allogeneic blood transfusion in patients undergoing elective, non-cardiac, non-vascular surgery with the following lab values: Hb greater than 10g/dL but less than 12g/dL	None	None	3 months	The following information must be submitted in PA request: most recent hemoglobin (Hgb) labs, patient’s weight, dosage, planned duration of therapy, is patient receiving iron supplementation? If not, request iron study lab values
AREDIA	PAMIDRONATE DISODIUM	SOLR	Part B vs D	Injectable/Infusion - Covered under Part D if dispensed by a pharmacy, regardless of place of administration (i.e. home vs healthcare setting); Covered under Part B if obtained from physician's stock.
ARISTOSPAN INTRALESIONAL	TRIAMCINOLONE HEXACETONIDE	SUSP	Part B vs D	Injectable/Infusion - Covered under Part D if dispensed by a pharmacy, regardless of place of administration (i.e. home vs healthcare setting); Covered under Part B if obtained from physician's stock.
ARRANON	NELARABINE	SOLN	Part B vs D	Injectable/Infusion - Covered under Part D if dispensed by a pharmacy, regardless of place of administration (i.e. home vs healthcare setting); Covered under Part B if obtained from physician's stock.
ATGAM	ANTI-THYMOCYTE GLOBULIN (EQUINE)	INJ	Part B vs D	Transplant - Covered under Part B if transplant covered by Medicare. Otherwise covered under Part D
ATROPINE SULFATE	ATROPINE SULFATE	SOLN	Part B vs D	Injectable/Infusion - Covered under Part D if dispensed by a pharmacy, regardless of place of administration (i.e. home vs healthcare setting); Covered under Part B if obtained from physician's stock.
AVASTIN	BEVACIZUMAB	SOLN	Part B vs D	Injectable/Infusion - Covered under Part D if dispensed by a pharmacy, regardless of place of administration (i.e. home vs healthcare setting); Covered under Part B if obtained from physician's stock.
AVELOX	MOXIFLOXACIN HYDROCHLORIDE; SODIUM CHLORIDE	SOLN	Part B vs D	Injectable/Infusion - Covered under Part D if dispensed by a pharmacy, regardless of place of administration (i.e. home vs healthcare setting); Covered under Part B if obtained from physician's stock.
AVITA	TRETINOIN	GEL	tretinoin (topical)	Acne scar, Acne vulgaris, Acne vulgaris, Combination therapy, Alopecia areata, Black hairy tongue, Chemical peeling of skin lesion, Chloasma, Disorder of skin pigmentation, Dysplasia of cervix, Ephelides, Fine wrinkles on face, With comprehensive skin care and sunlight avoidance programs - Adjunct, Geographic tongue, Hyperkeratosis, Hyperpigmentation of skin, Facial mottling, with comprehensive skin care and sunlight avoidance programs - Adjunct, Kaposi's sarcoma, Keloid scar, Leukoplakia, Malignant melanoma, Osteoma cutis, Miliary, Roughness of skin, Facial tactile roughness, with comprehensive skin care and sunlight avoidance programs - Adjunct, Senile lentigo, Systematized epidermal nevus, Systemic sclerosis, Ultraviolet-induced change in normal skin, Wound finding (Mild), Xerophthalmia	Diagnosis of acne vulgaris without trying and failing at least 1 preferred alternatives (such as generic acne products - erythromycin/benzoyl peroxide, clindamycin, etc), use for cosmetic purposes (hyperpigmentation/age spots, wrinkles, tactile roughness of the skin, sun damage, etc.)	Patients diagnosed with ACNE or other non-cosmetic diagnosis	None	None	1 month (warts/actinic keratosis), open-ended (acne vulgaris)	None
AVONEX	INTERFERON BETA-1A	KIT	interferon beta-1a	All FDA-approved indications not otherwise excluded for Part D.	Hypersensitivity to human albumin (Avonex(R) lyophilized powder vials and Rebif(R) prefilled syringes), hypersensitivity to natural or recombinant interferon	Approvable for treatment of MS when written by or consulted on by a neurologist.	None	Prescribing physician must be a neruologist	1 year, only extend for 1 month at a time beyond this duration	None
AZACTAM	AZTREONAM	SOLR	Part B vs D	Injectable/Infusion - Covered under Part D if dispensed by a pharmacy, regardless of place of administration (i.e. home vs healthcare setting); Covered under Part B if obtained from physician's