|
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. |
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|
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. |
|
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|
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. |
|
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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. |
|
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|
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. |
|
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|
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. |
|
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|
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. |
|
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|
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. |
|
|
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|
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. |
|
|
|
|
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|
|
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 |
|
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|
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. |
|
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|
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. |
|
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|
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. |
|
|
|
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|
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|
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. |
|
|
|
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|
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|
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. |
|
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|
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. |
|
|
|
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|
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|
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 |
|
|
|
|
|
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|
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. |
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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. |
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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 |