SelectHealth Advantage 2015 Prior Authorization Criteria
SelectHealth Advantage 2015 Prior Authorization Criteria ACROMEGALY Drugs Somatuline Depot, Somavert Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information 1. Pt has had surgical resection of the pituitary gland OR is not a candidate for surgery/radiation therapy, 2. Patient has tried at least ONE of the following: a. Bromocriptine, b. Cabergoline, c. Octreotide Age Restrictions N/A Prescriber Restrictions Endocrinologist or consult Coverage Duration Plan Year Other Criteria N/A 1 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria ACTEMRA Drugs Actemra Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information 1. For rheumatoid arthritis dx: a. Pt has previous trial on at least ONE of the following: i. Enbrel, ii. Humira, b. Pt has previous trial on Cimzia, 2. For juvenile rheumatoid arthritis dx: a. Pt has failed on at least ONE of the following: i. methotrexate, ii. leflunomide, iii. hydroxychloroquine, iv. sulfasalazine, v. injectable gold, vi. oral gold, vii. azathioprine, viii. penicillamine, ix. cyclosporine, b. Pt has previous trial on at least ONE of the following: a. Enbrel, b. Humira Age Restrictions N/A Prescriber Restrictions Rheumatologist Coverage Duration Plan Year Other Criteria N/A 2 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria ACTHAR Drugs H.P. Acthar Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information 1. For Infantile Spasms: a. Dx is confirmed by EEG, b. Pt has tried at least ONE of the following: i. Prednisone, ii. Prednisolone, iii. Hydrocortisone, iv. Dexamethasone, c. Pt has tried at least ONE of the following: i. Vigabatrin, ii. Cosyntropin, 2. For MS: Pt has failed at least TWO courses of treatment with Solu-Medrol for two different multiple sclerosis exacerbations, 3. For Nephrotic Syndrome: a. Pt has tried at least TWO corticosteroids, b. Pt has tried at least ONE of the following: i. Cyclophosphamide, ii. Cyclosporine, 4. For Rheumatic Disorders: a. Pt has tried at least ONE oral corticosteroid, b. Pt has tried at least ONE oral DMARD, 5. For Dermatologic Disorders: a. Pt has failed therapy with methylprednisolone Age Restrictions Infantile Spasms: 24 months old or younger Prescriber Restrictions 1. Infantile Spasms: Neurologist, 2. MS: Neurologist, 3. Nephrotic Syndrome: Nephrologist, 4. Rheumatic Disorders: Rheumatologist, 5. Dermatologic Disorders: Dermatologist Coverage Duration 1 mo Other Criteria N/A 3 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria ACTIMMUNE Drugs Actimmune Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria 1. Hypersensitivity to Actimmune or E. coli derived products Required Medical Information N/A Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration Plan Year Other Criteria N/A 4 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria ADEMPAS Drugs Adempas Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information 1. PAH: a. Pt has previous failure on sildenafil, 2. CTPH: a. Pt has failed endarterectomy OR b. Pt considered inoperable for pulmonary endarterectomy AND c. Pt been compliant on full anticoagulation for at least 90 days Age Restrictions 18 years old or older Prescriber Restrictions Specialist in pulmonary hypertension Coverage Duration Plan Year Other Criteria N/A 5 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria ALIMTA Drugs Alimta Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information 1. For mesothelioma: a. Unresectable disease OR not candidate for surgery, b. Used in combination with cisplatin or carboplatin, 2. For NSCLC a. Initial: used in combo with cisplatin or carboplatin, b. Maintenance tx: Used after failure of four cycles of platinum-based first-line chemotherapy, c. After prior chemotherapy: Alimta used as single chemotherapeutic agent Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration Plan Year Other Criteria N/A 6 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria AMIFOSTINE Drugs Amifostine Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information 1. For ovarian cancer: a. Pt receiving treatment with a cisplatin-containing regimen, 2. For head and neck cancer: a. Pt is undergoing post-operative radiation treatment, b. At least 75% of both parotid glands are in the radiation field Age Restrictions N/A Prescriber Restrictions Oncologist or Nephrologist Coverage Duration Plan Year Other Criteria N/A 7 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria AMPHOB Drugs Ambisome, Amphotericin B Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information 1. For use of brand Ambisome: Pt must have previous failure or contraindication to generic Amphotericin B, 2. If using for empiric therapy: a. Patient must be febrile AND neutropenic Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration Plan Year Other Criteria BvsD determination 8 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria AMPYRA Drugs Ampyra Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria 1. Pt confined to wheelchair, 2. Hx of seizures, 3. Moderate to severe renal impairment (CrCl is less than 50 mL/min) Required Medical Information 1. Initial: a. Currently taking at least one other MS drug, b. EDSS score between 3.5 and 6.0, c. Documented 25 foot walk time, 2. Reauth: Same as 1.a and 1.b above AND improvement in 25 foot walk time Age Restrictions N/A Prescriber Restrictions Neurologist Coverage Duration Initial: 2 mo, Reauth: Plan Year Other Criteria N/A 9 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria ANDROGENS Drugs Androderm, Axiron, Testosterone Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information 1. Total tesosterone level below 300 ng/dL, 2. Pt experiences at least ONE of the following: malaise, fatigue, lethargy, muscle loss, depression, decreased libido, 3. Previous trial on Androgel Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration Plan Year Other Criteria If request NOT for Androgel: Previous trial of Androgel, 10 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria APO B Drugs Juxtapid, Kynamro Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria Pt has none of the following health conditions or health concerns: a. Congestive heart failure, b. History of significant renal or hepatic disease, c. Alcohol abuse Required Medical Information 1. Pt has untreated, fasting LDL cholesterol greater than 500 mg/dL AND triglycerides less than 300 mg/dL, 2. Pt meets a OR b AND c of the following: a. Pt has documented mutations in both alleles of the LDL receptor or of other genes known to affect LDL receptor function, b. Both of pt's parents have a hx of untreated total cholesterol of greater than 250 mg/dL, c. Pt has xanthomas present before age 10, 3. Pt abides by a low-fat diet in addition to all other lipid-lowering therapies, 4. Patient has failed or is currently taking at least ONE of the following: a. Atorvastatin 40 mg or higher, b. Rosuvastatin 20mg or higher, c. Simvastatin 40mg or higher, AND ONE of the following: a. Niacin, b. Ezemitibe, c. Gemfibrozil, d. Fenofibrate, e. Cholestyramine, f. Colesevelam, g. Colestipol, 5. Pt previously failed lipid apheresis therapy. Age Restrictions N/A Prescriber Restrictions Specialist in lipid disorders Coverage Duration 1. Initial: 6 mo, 2. Reauthorization: 12 mo Other Criteria N/A 11 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria APOKYN Drugs Apokyn Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information 1. Pt suffering from end of dose wearing off episodes, 2. Apokyn initiated with a concomitant antiemetic (not a 5HT3) Age Restrictions N/A Prescriber Restrictions Neurologist Coverage Duration Plan Year Other Criteria N/A 12 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria ARCALYST Drugs Arcalyst Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria 1. Combination use with a TNF-inhibitor Required Medical Information N/A Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration Plan Year Other Criteria N/A 13 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria ARZERRA Drugs Arzerra Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information 1. For refractory chronic leukemia dx: Pt is refractory to BOTH fludarabine and alemtuzumab, 2. For untreated chronic lymphocytic leukemia: a. Used in combination with chlorambucil, b. Fludarabine-based therapy is inappropriate for the pt Age Restrictions N/A Prescriber Restrictions Oncologist Coverage Duration Plan Year Other Criteria N/A 14 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria AUBAGIO Drugs Aubagio Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria Combination therapy with other MS agents Required Medical Information 1. initial: a. LFT within last 6 months, b. CBC within last 6 months, c. Tuberculosis screening, d. No live vaccination within previous 2 months, 2. If pt is female: negative pregnancy test AND reliable contraception method is being used, 3. Previous trial on at least ONE of the following: a. Extavia, b. Gilenya, c. Rebif Age Restrictions N/A Prescriber Restrictions Neurologist Coverage Duration Plan Year Other Criteria N/A 15 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria AVASTIN Drugs Avastin Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information 1. For metastatic, colon, or rectal cancer dx: Used in combination with 5-flurouracil OR capecitabine, 2. For NSCLC dx: Used in combination with carboplatin/paclitaxel OR erlotinib, 3. For glioblastoma multiforme: Previous failure on temozolomide, 4. For RCC dx: Used in combination with interferon alpha, 5. For cervical cancer dx: Used in combination with paclitaxel/cisplatin OR paclitaxel/topotecan Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration Plan Year Other Criteria N/A 16 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria BELEODAQ Drugs Beleodaq Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information N/A Age Restrictions N/A Prescriber Restrictions Oncologist Coverage Duration Plan Year Other Criteria N/A 17 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria BOSULIF Drugs Bosulif Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information 1. Pt's CML is in chronic phase, accelerated phase, or blast phase, 2. Pt has previous failure or intolerance to Gleevec (imatinib) Age Restrictions N/A Prescriber Restrictions Oncologist Coverage Duration Plan Year Other Criteria N/A 18 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria CANCIDAS Drugs Cancidas Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information 1. For invasive aspergillosis: a. Pt has failure on at least ONE other systemic antifungal, 2. If using for empiric therapy: a. Patient must be febrile AND neutropenic Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration Plan Year Other Criteria BvsD determination 19 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria CAPASTAT Drugs Capastat Sulfate Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information Pt has previous failure on at least ONE of the following: 1. Isoniazid, 2. Rifampin, 3. Ethambutol, 4. Pyrazinamide Age Restrictions N/A Prescriber Restrictions Infectious Disease Specialist Coverage Duration 10 Months Other Criteria BvsD determination 20 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria CAPRELSA Drugs Caprelsa Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information N/A Age Restrictions N/A Prescriber Restrictions Oncologist, Hematologist, Endocrinologist Coverage Duration Plan Year Other Criteria N/A 21 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria CERDELGA Drugs Cerdelga Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information 1. Pt was diagnosed by a Clinical Biomedical Geneticist, 2. Pt is unable to use intravenous enzyme replacement, 3. The CYP2D6 genotype has been determined Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration Plan Year Other Criteria N/A 22 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria CHORIONIC GONADOTROPIN Drugs Chorionic Gonadotropin Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria Fertillity Use Required Medical Information For hypogonadism dx: Pt previously failed on testosterone replacement therapy Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration Plan Year Other Criteria N/A 23 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria CIMZIA Drugs Cimzia Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria Combination therapy with TNF antagonist Required Medical Information 1. RA dx: Pt has failed on at least ONE of the following: a. methotrexate, b. leflunomide, c. hydroxychloroquine, d. sulfasalazine, e. injectable gold, f. oral gold, g. azathioprine, h. penicillamine, i. cyclosporine, 2. All dx: Pt has failed at least ONE of the following: a. Enbrel, b. Humira Age Restrictions N/A Prescriber Restrictions Rheumatologist, Gastroenterologist Coverage Duration Plan Year Other Criteria N/A 24 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria CINRYZE Drugs Cinryze Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information 1. Dx is verified by low C1-INH and/or low C1-INH functional levels on two separate occasions, 2. Therapy is required as follows: a. Pt has history of 2 or more facial, laryngeal, and/or gastroinestinal HAE attacks per month, AND b. Pt is compliant with trigger avoidance, AND c. Pt has tried or has contraindication to a 6 months trial of attenuated androgen therapy OR a. Pt is scheduled to undergo a major medical procedure that requires propylaxis, 3. Reauth: Pt has had a significant decrease in the frequency of attacks per month OR had a significant decrease in the severity or duration of attacks Age Restrictions N/A Prescriber Restrictions Allergist, Immunologist Coverage Duration 6 Months Other Criteria N/A 25 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria COMETRIQ Drugs Cometriq Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria Diagnosis of indolent medullary thyroid cancer Required Medical Information N/A Age Restrictions N/A Prescriber Restrictions Oncologist Coverage Duration Plan Year Other Criteria N/A 26 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria COSENTYX Drugs Cosentyx Pen (2 Pens) Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information 1. Plaque psoriasis involves 10% or more of the body surface area, 2. If less than 10% of body surface area there is scalp, palmer, foot, or groin involvement causing significant disability, 3. Pt has failed therapy of at least 12 weeks with at least ONE of the following: i. methotrexate, ii. cyclosporine, iii. acitretin, 4. Pt has failed treatment with Enbrel OR Humira Age Restrictions N/A Prescriber Restrictions Dermatologist Coverage Duration Plan Year Other Criteria N/A 27 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria CUBICIN Drugs Cubicin Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information 1. For complicated bacterial skin and skin structure infections: Pt has had a positive culture within the past month for ANY of the following (mark all that apply): a. Staphylococcus aureus (MSSA or MRSA), b. Streptococcus pyogenes, c. Streptococcus agalactia, d. Streptococcus dysgalactiae subspecies equisimilis, e. Enterococcus faecalis (vancomycin susceptible strains only), 2. For blood stream infections: Pt has had a positive culture within the past month for Staphylococcus aureus (MSSA or MRSA) Age Restrictions N/A Prescriber Restrictions Infectious Disease Specialist Coverage Duration 2 Months Other Criteria BvsD determination 28 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria CYSTARAN Drugs Cystaran Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information 1. Initial: Pt has corneal cysteine accumulation that has been confirmed by slit-lamp photography, 2. Reauth: Pt had a reduction of 1 or more units in the Corneal Cystine Crystal Score (CCCS) after 6 months of treatment with Cystaran. Age Restrictions N/A Prescriber Restrictions Corneal Specialist Coverage Duration 6 Months Other Criteria N/A 29 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria CYSTIC FIBROSIS Drugs Bethkis, Cayston, Tobi Podhaler, Tobramycin Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information Pt has had at least ONE positive culture for Pseudomonas aeruginosa Age Restrictions N/A Prescriber Restrictions Pulmonologist, Infectious Disease Specialist Coverage Duration Plan Year Other Criteria BvsD determination 30 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria DALVANCE Drugs Dalvance Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information Chart notes and bacterial susceptibility reports have been submitted showing need for medication Age Restrictions N/A Prescriber Restrictions Infectious Disease Specialist Coverage Duration 14 Days Other Criteria BvsD determination 31 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria DIFICID Drugs Dificid Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information 1. Pt has had a positive C. difficile toxin assay within the past month, 2. Pt has tried as least TWO of the following treatments: a. Metronidazole for 10-14 days, b. Vancomycin for 10-14 days, c. Vancomycin extended taper, d. Rifaximin for 14 days. Age Restrictions N/A Prescriber Restrictions Gastroenterologist, Infectious Disease Specialist Coverage Duration Plan Year Other Criteria N/A 32 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria ENDOTHELIN ANTAGONIST Drugs Letairis, Opsumit, Tracleer Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information 1. Exclusion of all secondary causes of pulmonary hypertension, 2. Must be dx with PAH with WHO class II, III, or IV Age Restrictions N/A Prescriber Restrictions Pulmonoligist, Cardiologist Coverage Duration Plan Year Other Criteria N/A 33 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria ERBITUX Drugs Erbitux Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information 1. For colorectal cancer dx: a. Failure of BOTH irinotecan- and oxaliplatin- based regimens OR intolerant to irinotecan-based chemotherapy, b. Tumor must bear wild-type (non-mutated) K-ras gene, 2. For head and neck cancer dx: Used as a single agent in recurrent cancer where platinumbased therapy has failed OR Used in combination with radiation therapy for local or regionally advanced cancer, 3. For ALL dx: Patient has no previous failure on Vectibix Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration Plan Year Other Criteria N/A 34 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria ERIVEDGE Drugs Erivedge Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information 1. For basal cell carcinoma: a. Pt has lesions that are greater than or equal to 10 mm in diameter, b. Pt has recurring lesions after radiation therapy OR radiation therapy is contraindicated or inappropriate, c. Pt has recurring lesions after surgical excision OR surgery is contraindicated or inappropriate Age Restrictions N/A Prescriber Restrictions Dermatologist, Oncologist Coverage Duration Plan Year Other Criteria N/A 35 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria ERWINAZE Drugs Erwinaze Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information 1. Erwinaze is used in combination with chemotherapy for treatment, 2. Pt has demonstrated a hypersensitivity to an E. Coli derived asparaginase Age Restrictions N/A Prescriber Restrictions Oncologist Coverage Duration Plan Year Other Criteria N/A 36 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria EVZIO Drugs Evzio Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information 1. Initial: a. Pt's use of opioids is limited to legally prescribed medications for legitamate medical conditions, b. Pt is at a high risk for opioid overdose, c. Must meet ONE of the following: i. The current prescription contains sufficient doses to manage ONE overdose event, ii. Pt is prescribed and taking methadone tablets for pain, iii. Pt has experienced an opioid overdose in the past, 2. Reauth: a. Pt experienced an overdose that required administration of Evzio, b. Emergency medical care was immediately sought after Evzio was administered, c. Pt's use of opioids was limited to legally prescribed prescription medications for a legitimate medical condition, d. The current prescription contains sufficient doses to manage ONE overdose event, e. A Narcotics Abuse Specialist has been consulted Age Restrictions N/A Prescriber Restrictions Addiction Specialist (if 1.c.i, 1.c.ii, and 1.c.iii are not met) Coverage Duration Plan Year Other Criteria N/A 37 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria FARYDAK Drugs Farydak Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information 1. Used in combination with bortezomib and dexamethasone, 2. Pt has previous trial on at least TWO regimens including bortezomib and an immunomodulatory agent Age Restrictions N/A Prescriber Restrictions Oncologist, Hematologist Coverage Duration Plan Year Other Criteria N/A 38 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria FENTANYL Drugs Abstral, Fentanyl Citrate, Fentora, Lazanda Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria Non-cancer pain use Required Medical Information 1. Must have documented maintenance therapy with a long-acting opioid, 2. Documented failure with a short-acting opioid for breakthrough pain Age Restrictions N/A Prescriber Restrictions Oncologist, Pain Specialist Coverage Duration 6 Months Other Criteria Previous trial on generic fentanyl citrate 39 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria FIRAZYR Drugs Firazyr Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information 1. For HAE type I and II and aquired angioedema: Dx has been verified by low C1-INH and/or low C1-INH function levels on two separate occasions, 2. For HAE with normal C1-INH: Pt has failed a trial with high-dose non-sedating antihistamines for at least 3 months to rule-out idiopathic angioedema Age Restrictions N/A Prescriber Restrictions Allergist, Immunologist Coverage Duration Initial: 3 mo, Reauth: 1 year Other Criteria N/A 40 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria FLECTOR Drugs Flector Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information Pt has failed at least a 14-day trial with an oral NSAID in combination with a PPI Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration Plan Year Other Criteria N/A 41 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria FOLOTYN Drugs Folotyn Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information Treatment with prior systemic therapy Age Restrictions N/A Prescriber Restrictions Oncologist Coverage Duration Plan Year Other Criteria N/A 42 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria FORTEO Drugs Forteo Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria 1. Treatment for longer than 2 years, 2. Increased baseline risk for osteosarcoma Required Medical Information 1. For osteoporosis dx: a. T-score less than or equal to -2.5, b. Pt meets at least ONE of the follwing: 1. Must have previous trial on bisphosphonate therapy and experienced a fragility fracture, ii.Pt is intolerant to bisphosphonate therapy due to musculoskeletal pain, iii. GFR less than 35 ml/min AND pt is at high risk for fracture based on FRAX score Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration Plan Year Other Criteria N/A 43 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria GILOTRIF Drugs Gilotrif Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information The tumor has an epidermal growth factor receptor (EGFR) exon 19 deletion or exon 21 (L858R) substitution mutation Age Restrictions N/A Prescriber Restrictions Oncologist Coverage Duration Plan Year Other Criteria N/A 44 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria GROWTH HORMONE Drugs Saizen, Tev-Tropin Covered Uses 1. All medically accepted indications not otherwise excluded from Part D Exclusion Criteria For Ped GHD: Male at bone age of 16 yo, Female at bone age of 14 yo, 2. Growth velocity is less than 2 cm/yr, 3. Fusion of epiphyses Required Medical Information 1. Ped GHD: Initial: a. Meet criteria i, ii, iii, iv, AND either iv(a), or iv(b), or v: i) Ht more than 2 SD below the pop mean OR less than 3rd percentile, ii) Ht velocity less than 4cm/yr OR less than 5th percentile of bone age and gender for at least 6 mo iii) Evidence of other causes of growth failure have been ruled out AND iv) (a) Failure of at least TWO stim tests (peak GH concentration less than 10mcg/L) OR iv) (b) IGF-1 2 SD or more below the mean standardized for bone age AND IGF-BP3 is in the lowest quartile for bone age and gender AND other causes of low IGF have been excluded, OR v) Pt has more than 3 pituitary hormone deficiencies requiring replacement therapy, Reauth: Growth velocity of 4cm/year or more, 2. Adult GHD: Initial: a. Pts must meet any of the criteria i-ii: i) Pt has GH deficiency as a result of hypothalamic or pituitary disease or is dxed with acquired GH deficiency (1) Secondary to any of the following: (a) Pituitary tumor, (b) Pituitary surgical damage, (c) Hypothalamic disease, (d) Pituitary irradiation, (e) Pituitary trauma, (f) Sheehan’s syndrome, (g) Autoimmune hypophytis, (h) Hypophytis associated with an inflammatory condition, (i) Deficiency of 3 or more anterior pituitary hormones AND (2) Pt is receiving active supplementation of deficient hormones as necessary AND (3) (a) Pt has a low IGF-1 level and other causes of low IGF have been excluded OR (b) Pt has failed standardized provocative testing as demonstrated by serum GH conc less than 5mcg/L when measured by RIA or less than 2.5mcg/L when measured by IRMA, ii) Adult dxed with childhood GHD (1) Retesting using the parameters in 2(i)(3)(b) indicates GHD persists OR (2) Pt is dxed with panhypopituitarism and IGF-I deficiencies exist as outlined in 2(i)(3)(c), Reauth: Continued efficacy both clinically and by lab testing. Age Restrictions N/A Prescriber Restrictions Ped GHD AND Adult GHD: Endocrinologist Coverage Duration 45 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria 1. Ped GHD: Initial: 6 mo, Reauth: 12 mo, 2. HIV wasting: 12 wks LIFETIME, 3. All others: Plan Year Other Criteria 1. Chronic Renal Insufficiency: a. Meet ALL of the following: i) Pt dxed with CRI AND has not yet received renal transplant, ii) Existing metabolic disorders have been corrected, iii) Ht more than 2 SD below the population mean OR less than 3rd percentile, iv) Height velocity less than 4cm/yr or less than 10th percentile of normal for age and gender, 2. Turner Syndrome: a. Meet ALL of the following: i) Dx of TS confirmed by blood karotype or fibroblast studies, ii) Ht of female pt plotted on TS-specific growth curve AND pt is less than 5th percentile of normal growth curve for girls, 3. Prader-Willi Syndrome: a. Meet ALL of the following: i) Dx of PWS confirmed by appropriate genetic testing, ii) Ht more than 2 SD below the pop mean OR less than 3rd percentile, iii) Ht velocity less than 3cm/yr or less than 10th percentile of normal for age and gender, 4. Small for Gestational Age: a. Meet ALL of the following: i) Dx of SGA as defined as one of the following: (1) Birth weight of less than 2,500g at gestational age of greater than 37 weeks, (2) OR birth weight or length less than 3rd percentile for gestational age, ii) Pt has failed to catch up in ht by 2 yo, 5. AIDS-Related Wasting: a. Meet ALL of the following: i) Involuntary weight loss of more than 10% pre-illness body weight or a BMI less than 20, ii) Failure to respond to dronabinol (Marinol™) OR megesterol acetate (Megace™), iii) Chronic diarrhea (defined as more than 3 loose stools/day for more than 30 days) OR Chronic weakness and documented fever (30 days, intermittent or constant) in the absence of concurrent illness or condition other than HIV infection that would otherwise explain the symptoms. 46 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria HALAVEN Drugs Halaven Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information 1. Previous failure of at least TWO chemotherapeutic regimens, 2. Previous treament includes an anthracycline AND a taxane Age Restrictions N/A Prescriber Restrictions Oncologist Coverage Duration Plan Year Other Criteria N/A 47 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria HARVONI Drugs Harvoni Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information 1. Chart notes showing genotype, 2. Pt has previous trial on Viekira Age Restrictions N/A Prescriber Restrictions Gastroenterologist, Infectious Disease Specialist, Transplant Specialist Coverage Duration Maximum 24 weeks Other Criteria N/A 48 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria HEPATITIS C Drugs Pegasys, Pegasys Proclick, Pegintron, Pegintron Redipen, Victrelis Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria 1. Previous treatment with a protease inhibitor, 2. For treatment without protease inhibitor: prior treatment with pegylated interferon Required Medical Information 1. For Hep C dx (includes Incivek and Victrelis): a. Initial: i. HCV genotype, ii. HCV RNA viral load, b. For reauth: i. Genotype 1: 1) Interferon: No detectable HCV-RNA at treatment week 24, 2) Victrelis: HCV-RNA is 100 IU/ml or less at treatment week 12 and patient is undetectable at week 24, 3) Incivek: HCV-RNA is 1000 IU/mL or less at treatment week 12, ii. Genotype 4, 5, and 6: 2 log reduction in HCV RNA compared to baseline, iii. Genotype 2,3: No reauth available, 2. For Hep B dx (does not include Incivek and Victrelis): a. Pre-treatment HBV DNA levels are greater than 20,000 IU/ml, b. Must be used as monotherapy Age Restrictions N/A Prescriber Restrictions Gastroenterologist, Infectious Disease Coverage Duration Interferon: Initial: 24 Wks, Re: 24 Wks, Incivek: 12 Wks, Victrelis: Initial: 24 Wks, Re: 8-20 Wks Other Criteria 1. Pegylated interferon and Victrelis: For reauth: Must provide HCV viral load at 24 weeks, 2. Peg-Intron, Victrelis, and Incivek must be accompanied by letter of medical necessity explaining why the preferred agents Pegasys, Olysio, and Sovaldi cannot be used 49 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria HETLIOZ Drugs Hetlioz Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information 1. Pt is totally blind without light perception, 2. Pt has previous trial on Rozerem, 3. Pt has previous tiral on at least ONE of the following: a. zolpidem, b. zolpidem ER, c. zaleplon Age Restrictions N/A Prescriber Restrictions Sleep specialist Coverage Duration Plan Year Other Criteria N/A 50 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria HRM Drugs Cyclobenzaprine Hcl, Diphenhydramine Hcl, Duavee, Ergoloid Mesylates, Phenobarbital, Thioridazine Hcl Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information N/A Age Restrictions 1. Approved for 64 years of age and younger, 2. 65 years and older use OTHER criteria Prescriber Restrictions N/A Coverage Duration Plan Year Other Criteria If the patient is 65 years of age or older, the benefit of therapy with the prescribed medication outweighs the potential risk. 51 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria IBRANCE Drugs Ibrance Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria Prior therapy for metastatic disease Required Medical Information Used in combination with letrozole Age Restrictions N/A Prescriber Restrictions Oncologist Coverage Duration Plan Year Other Criteria N/A 52 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria ICLUSIG Drugs Iclusig Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information 1. CML dx: Pt's CML is in chronic phase, accelerated phase, or blast phase, 2. All dx: Pt has previous trial on Gleevec Age Restrictions N/A Prescriber Restrictions Oncologist, Hematologist Coverage Duration Plan Year Other Criteria N/A 53 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria ILARIS Drugs Ilaris Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria Combination therapy with TNF antagonist Required Medical Information 1. For all dx EXCEPT CAPS: Pt has had prior trial on BOTH of the following: 1. Kineret, 2. Actemra Age Restrictions N/A Prescriber Restrictions Rheumatologist Coverage Duration 6 Months Other Criteria N/A 54 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria IMBRUVICA Drugs Imbruvica Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information Pt has failed at least ONE prior therapy Age Restrictions N/A Prescriber Restrictions Oncologist, Hematologist Coverage Duration Plan Year Other Criteria N/A 55 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria INCRELEX Drugs Increlex Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information 1. Height standard deviation score of less than -3 based on age and gender, 2. Basal IGF-1 standard deviation score of less than -3 based on age and gender, 3. Normal or elevated growth hormone levels, 4. Pt must have open epiphyses, 5. Gh stimulation test of greater than 10 mcg/L. Age Restrictions 2 years old or older Prescriber Restrictions Endocrinologist or consult Coverage Duration Plan Year Other Criteria N/A 56 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria INLYTA Drugs Inlyta Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information Pt has failed prior systemic therapy Age Restrictions N/A Prescriber Restrictions Oncologist Coverage Duration Plan Year Other Criteria N/A 57 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria ISTODAX Drugs Istodax Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information Pt received at least ONE previous systemic therapy Age Restrictions N/A Prescriber Restrictions Oncologist Coverage Duration Plan Year Other Criteria N/A 58 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria IVIG Drugs Bivigam, Carimune Nf Nanofiltered, Flebogamma Dif, Gamastan S-D, Gammagard Liquid, Gammaked, Gammaplex, Gamunex-C, Privigen Covered Uses 1. All medically accepted indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information 1. For Kawasaki disease dx: IF pt after 10 days of illness: persistent fever without explanation OR aneurysms and ongoing systemic inflammation, 2. For HIV dx: CD4 count of less than 200 cells/mL, 3. For blistering disease dx: failure on at least TWO of the following: azathioprine, mycophenolate, cyclophosphmaide, cyclosporine, methotrexate, 4. For Thrombo dx: platelet count less than 20,000, 5. For CLL dx: hypogammaglobulinemia shown by less than 500 mg/dL, 6. For Transplant dx: within 100 days of transplant OR hypogammaglobulinemia after 100 days, 7. For stiff person dx: Failure on corticosteroids, 8. For RRMS dx: Failure to at least TWO fo the following: Betaseron, Avonex, Rebif, Copaxone, Gilenya, 9. For Dermatomyositis dx: Failure to IV steroids AND failure to azathoprine OR methotrexate Age Restrictions For Kawasaki disease dx: less than 18 years old Prescriber Restrictions N/A Coverage Duration Plan Year Other Criteria BvsD determination 59 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria IXEMPRA Drugs Ixempra Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information 1. Ixempra monotherapy: Previous failure to ALL the following: anthracycline, taxane, capecitabine, 2. Ixempra in combination with capecitabine: Previous failure to BOTH anthracycline AND taxane Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration Initial: 6 mo, Reauth: plan year Other Criteria N/A 60 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria JAKAFI Drugs Jakafi Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information 1. Pt has enlarged spleen shown by MRI or CT, 2. Platelet count greater than or equal to 50X10(9)/L Age Restrictions N/A Prescriber Restrictions Oncologist, Hematologist Coverage Duration Plan Year Other Criteria N/A 61 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria JEVTANA Drugs Jevtana Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information 1. Previous treatment with docetaxel-containing regimen, 2. Combination therapy with prednisone Age Restrictions N/A Prescriber Restrictions Oncologist, Urologist Coverage Duration Plan Year Other Criteria N/A 62 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria KADCYLA Drugs Kadcyla Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria Combination therapy Required Medical Information 1. Pt has previously received BOTH of the following: a. Taxane therapy, b. Herceptin Age Restrictions N/A Prescriber Restrictions Oncologist Coverage Duration Plan Year Other Criteria BvsD determination 63 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria KALYDECO Drugs Kalydeco Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information 1. Pt is being managed at a cystic fibrosis clinic, 2. Pt genotyped by an FDA-cleared CF mutation test, 3. Pt has ONE of the following mutations: a. G551D, b. G551S, c. S549R, d. G1244E, e. S1251N, f. G1349D, g. S1255P, h. G178R, i. S549N, j. R117H Age Restrictions Tablet: 6 years old or older, Granules: 2 years old to 5 years old Prescriber Restrictions Pulmonologist Coverage Duration Plan Year Other Criteria N/A 64 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria KEPIVANCE Drugs Kepivance Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information 1. Pt will be undergoing a bone marrow transplant, 2. Pt will be undergoing total-body irradiation, 3. Pt's chemotherapy regimen consists of at least ONE medication that is predicted to result in greater than WHO Grade 3 mucositis, 4. The patien will NOT be receiving a high dose of melphalan preparative regimen Age Restrictions N/A Prescriber Restrictions Hematologist, Oncologist Coverage Duration Plan Year Other Criteria BvsD determination 65 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria KEYTRUDA Drugs Keytruda Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information 1. Pt has previous trial on Yervoy and experienced disease progression within 24 weeks following the last dose of Yervoy, 2. Pt did NOT experience an immune-mediated adverse reaction to Yervoy requiring use of corticosteroids, 3. Pt is NOT positive for BRAF V600E or V600K mutation OR 4. Pt is BRAF V600E or V600K mutation positive AND has previously tried at least ONE of the following: a. Mekinist, b. Tafinlar, c. Zelboraf Age Restrictions N/A Prescriber Restrictions Oncologist, Hematologist Coverage Duration Plan Year Other Criteria BvsD determination 66 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria KINERET Drugs Kineret Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information 1. For rheumatoid arthritis dx: a. Pt has previous trial on at least ONE of the following: i. Enbrel, ii. Humira, b. Pt has previous trial on Cimzia, 2. For juvenile rheumatoid arthritis dx: a. Pt has failed on at least ONE of the following: i. methotrexate, ii. leflunomide, iii. hydroxychloroquine, iv. sulfasalazine, v. injectable gold, vi. oral gold, vii. azathioprine, viii. penicillamine, ix. cyclosporine, b. Pt has previous trial on at least ONE of the following: a. Enbrel, b. Humira Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration Plan Year Other Criteria N/A 67 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria KORLYM Drugs Korlym Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria Pt using long-term corticosteroid Required Medical Information 1. Pt has previously failed surgery or chemotherapy to correct Cushing's disease OR is ineligible for surgery, 2. Pt with type II diabetes diagnosis, 3. HgA1c is 8.0% or greater, 4. Pt has treatment failure with at least TWO of the following: a. Insulin, b. metformin, c. meglitinides, d. sulfonylureas, e. thiazolidinediones, f. DPP4 inhibitors, g. GLP-1 agonists, 5. If pt is female: a. Pt has negative pregnancy test within past 14 days, b. Pt is currently using non-hormonal form of birth control Age Restrictions N/A Prescriber Restrictions Endocrinologist Coverage Duration Initial: 6 months, Reauth: Plan Year Other Criteria N/A 68 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria LENVIMA Drugs Lenvima Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information 1. Tumor is refractory to treatment with radioactive iodine, 2. Used as monotherapy Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration Plan Year Other Criteria N/A 69 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria LIDODERM Drugs Lidocaine Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information N/A Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration Plan Year Other Criteria N/A 70 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria LYNPARZA Drugs Lynparza Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria Combination therapy Required Medical Information Pt has previous trial on at least TWO prior lines of chemotherapy Age Restrictions N/A Prescriber Restrictions Oncologist Coverage Duration Plan Year Other Criteria N/A 71 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria MEKINIST Drugs Mekinist Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria Previous use of Zelboraf OR Tafinlar Required Medical Information 1. Pt is BRAF(V600E or V600K) mutation positive, 2. Monotherapy or in combination with Tafinlar Age Restrictions N/A Prescriber Restrictions Oncologist, Hematolgist, Dermatologist Coverage Duration Plan Year Other Criteria N/A 72 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria MS Drugs Avonex, Avonex Administration Pack Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information Previous trial on at least ONE of the following: 1. Extavia, 2. Gilenya, 3. Rebif Age Restrictions N/A Prescriber Restrictions Neurologist Coverage Duration Plan Year Other Criteria N/A 73 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria MYALEPT Drugs Myalept Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information 1. Pt has baseline leptin levels of less than 8 ng/mL for males OR less than 12 ng/mL for females, 2. Pt has ONE of the following: a. Diagnosis of diabetes and is being treated with Metformin AND at least one other antidiabetic agent, b. Diagnosis of hypertriglyceridemia and is being treated with at least ONE antihyperlipidemic agent, 3. Reauth: a. Pt has been screened for the presence of anti-metreleptin antibodies, b. If presence of antimetreleptin antibodies, pt must still be receiving benefit from Myalept therapy, c. Pt shows improvement in hemoglobin A1c OR fasting triglyceride level Age Restrictions N/A Prescriber Restrictions Endocrinologist Coverage Duration Initial: 6 months, Reauth: Plan Year Other Criteria N/A 74 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria NAFCILLIN Drugs Nafcillin, Nafcillin Sodium Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information N/A Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration Plan Year Other Criteria BvsD determination 75 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria NATPARA Drugs Natpara Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information 1. Pt has failed oral vitamin D and oral calcium, 2. Pt's Ionized Ca2+ is greater than 1.10 mmol/L, 3. Pt is symptomatic with presence of at least ONE of the following: a. tetany, b. carpopedal spasm, c. seizures, d. hypotension, e. prolongation of QT interval, 4. Pt's vitamin D level is greater than 30 ng/ml Age Restrictions N/A Prescriber Restrictions Endocrinologist Coverage Duration Plan Year Other Criteria N/A 76 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria NEXAVAR Drugs Nexavar Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information 1. Used as monotherapy, 2. For HCC dx: Treatment for unresectable tumor or recurrent disease Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration Plan Year Other Criteria N/A 77 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria NUEDEXTA Drugs Nuedexta Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information Pt has score of 13 or greater on Center for Neurologic Study-Liability Scale (CNS-LS) for pseudobulbar affect (PBA) Age Restrictions N/A Prescriber Restrictions Neurologist Coverage Duration 6 Months Other Criteria N/A 78 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria OCTREOTIDE Drugs Octreotide Acetate Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information 1. For acromegaly: a. Has patient failed at least TWO of the following: i. Surgical resection, ii. Pituitary irradiation, iii. Bromocriptine, b. Pt has elevated levels of growth hormone and IGF-1, 2. For carcinoid: a. Pt is suffering from severe diarrhea and flushing episodes associated with disease, 3. For VIPoma: a. Pt has profuse water diarrhea associated with disease Age Restrictions N/A Prescriber Restrictions Endocrinologist or Oncologist Coverage Duration 1. For acromegaly: 6 mo, 2. For others: Plan year Other Criteria BvsD determination 79 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria OLYSIO Drugs Olysio Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria 1. Previous treatment with a protease inhibitor, 2. Genotype 1a: Screening revealed presence of the NS3 Q80K polymorphism Required Medical Information 1. Used in combination with pegylated interferon-alfa and ribavirin OR 2. Used in combination with Sovaldi Age Restrictions N/A Prescriber Restrictions Gastroenterolgist, Infectious Disease Specialist, Transplant Specialist Coverage Duration 12 Weeks Other Criteria N/A 80 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria ONCASPAR Drugs Oncaspar Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information 1. Oncaspar is being used in combination with chemotherapy AND 2. Oncaspar is being used first-line OR 3. Pt has demonstrated a past hypersensitivity to L-asparaginase therapy Age Restrictions N/A Prescriber Restrictions Oncologist Coverage Duration Plan Year Other Criteria N/A 81 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria OPDIVO Drugs Opdivo Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information 1. Pt has previous trial on Yervoy and experienced disease progression within 24 weeks following the last dose of Yervoy, 2. Pt did NOT experience an immune-mediated adverse reaction to Yervoy requiring use of corticosteroids, 3. Pt is NOT positive for BRAF V600E or V600K mutation OR 4. Pt is BRAF V600E or V600K mutation positive AND has previously tried at least ONE of the following: a. Mekinist, b. Tafinlar, c. Zelboraf Age Restrictions N/A Prescriber Restrictions Oncologist, Hematologist Coverage Duration Plan Year Other Criteria BvsD determination 82 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria ORENCIA Drugs Orencia Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information 1. Pt has failed treament with Enbrel OR Humira, 2. Pt has failed treatment with Cimzia Age Restrictions N/A Prescriber Restrictions Rheumatologist or consult Coverage Duration Plan Year Other Criteria N/A 83 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria ORFADIN Drugs Orfadin Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information 1. Pt's plasma tyrosine level is greater than 200 microcol/L Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration Plan Year Other Criteria N/A 84 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria OTEZLA Drugs Otezla Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information 1. Pt has previous trial on Enbrel OR Humira, 2. Pt has previous trial on Cimzia Age Restrictions N/A Prescriber Restrictions Rheumatologist, Dermatologist Coverage Duration Plan Year Other Criteria N/A 85 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria PAH Drugs Adcirca, Sildenafil Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information 1. Exclusion of all secondary causes of pulmonary hypertension, 2. Must be dx with PAH with WHO class II or III Age Restrictions N/A Prescriber Restrictions Pulmonoligist, Cardiologist Coverage Duration Plan Year Other Criteria Adcirca requests: previous trial on sildenafil 86 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria PLEGRIDY Drugs Plegridy, Plegridy Pen Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information 1. Pt has previous trial on Avonex AND 2. Pt has previous trial on at least ONE of the following: a. Aubagio, b. Betaseron, c. Copaxone, d. Extavia, e. Gilenya, f. Rebif, g. Tecfidera, h. Tysabri Age Restrictions N/A Prescriber Restrictions Neurologist Coverage Duration Plan Year Other Criteria N/A 87 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria POMALYST Drugs Pomalyst Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information 1. Pt has tried BOTH of the following: a. Revlimid, b. Velcade, 2. Pt has demonstrated disease progression within 60 days of completion of prior therapy Age Restrictions N/A Prescriber Restrictions Oncologist, Hematologist Coverage Duration Plan Year Other Criteria N/A 88 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria PRIMAXIN Drugs Imipenem-Cilastatin Sodium Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria Pt has had a positive culture within the past month indicating a MRSA infection Required Medical Information 1. For infections of the lower respiratory tract, urinary tract, intra-abdominal, gynecologic, bone and joint, skin and skin structure, polymicrobic infections, or bacterial septicemia: Pt has had a positive culture within the past month for ANY of the following (mark all that apply): a. Staphylococcus aureus (MSSA), b. Streptococcus spp., c. Escherichia coli, d. Klebsiella spp., e. Enterobacter, f. Pseudomonas aeruginosa, g. Other resistant gram-negative bacilli, h. Other anaerobes, 2. Pt must meet ONE of the following: a. Pt has a CrCl greater than or equal to 5 mL/minute/1.73 m2, b. Pt will be on hemodialysis within 48 hours of therapy, 3. Pt has failed at least ONE previous antibacterial and/or other antimicrobial therapy Age Restrictions N/A Prescriber Restrictions Infectious Disease Specialist Coverage Duration 1 Month Other Criteria BvsD determination 89 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria PROLIA Drugs Prolia Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information 1. For Osteoporosis: a. Must meet at least ONE of the following: i. Pt has experienced a fragility fracture AND Pt has intolerance or contraindication on oral or IV bisphosphonate therapy, OR ii. WHO fracture risk score completed AND Pt qualifies for pharmacologic treatment with a 10 year hip fracture probability of greater than 3% OR a 10 year major osteoporosis-related all fracture probability of greater than 20% AND Pt has intolerance or contraindication on oral or IV bisphosphonate therapy, OR iii. WHO fracture risk score completed AND Pt qualifies for pharmacologic treatment with a 10 year hip fracture probability of greater than 3% OR a 10 year major osteoporosis-related all fracture probability of greater than 20% AND Pt had a decline in bone mineral density (BMD) of greater than 10% while on IV bisphosphonate therapy for at least 2 years AND Pt has been compliant on calcium and vitamin D supplementation AND Other causes of low BMD have been evaluated, 2. For Nonmetastatic prostate cancer: a. Pt has a BMD T-score at the lumbar spine, total hip or femoral neck of -1.0 or less OR b. Pt had an osteoporotic fracture, 3. For Women at high risk for fracture receiving adjuvant aromatase inhibitor therapy for breast cancer: a. Pt has a BMD T-score at the lumbar spine, total hip or femoral neck between -1.0 and -2.5 Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration Plan Year Other Criteria 90 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria N/A 91 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria PROMACTA Drugs Promacta Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information 1. For ITP dx: a. Previous failure to corticosteroids, immunoglubulins, OR splenectomy, b. Initial: Evidence of bleeding OR platelet count less than 20,000/microL, c. For reauth: Platelet count less than 400,000/microL, 2. For Hep C with Thrombocytopenia dx: a. Platelet count less than 75,000/microL, b. Pt is not receiving concurrent protease inhibitor treatment Age Restrictions N/A Prescriber Restrictions Oncologist, Hematologist, Gastroenterologist, Hepatologist Coverage Duration 6 Months Other Criteria N/A 92 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria PULMONARY FIBROSIS Drugs Esbriet, Ofev Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information 1. Initial: a. All other causes of IPF have been eliminated, b. Diagnosis has been confirmed via high-resolution computed tomography scan and/or lung biopsy, c. Pt Forced Vital Capacity (FVC) is between 50-79% predicted value, d. Pt carbon monoxide diffusing capacity is between 30-79% predicted value, e. Liver function test has been completed prior to initiating therapy, f. Patient is not a current smoker, g. FOR OFEV: Patient is not receiving anticoagulation therapy, 2. Reauth: a. A repeat liver function teast has been performed after 3 months of therapy has been completed Age Restrictions N/A Prescriber Restrictions Pulmonoligist Coverage Duration Initial: 3 mo, Reauth: 1 year Other Criteria N/A 93 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria PURIXAN Drugs Purixan Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information 1. Used in conjunction with a combination chemotherapy treatment regimen for ALL, 2. Pt has previous failure on mercaptopurine tablets Age Restrictions N/A Prescriber Restrictions Oncologist, Hematologist Coverage Duration Plan Year Other Criteria N/A 94 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria RAVICTI Drugs Ravicti Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria Diagnosis of hyperammonemia OR N-acetylglutamate synthase deficiency Required Medical Information 1. Pt has been compliant with dietary protein restriction OR amino acid supplementation, 2. Previous trial on sodium phenylbutyrate Age Restrictions 2 years old or older Prescriber Restrictions Medical Geneticist, Metabolic Specialist Coverage Duration Plan Year Other Criteria N/A 95 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria RCC Drugs Afinitor, Afinitor Disperz Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information 1. Previous failure on either Sutent or Nexavar, 2. For SEGA or TS dx: Patient must require therapeutic intervention and not be a candidate for surgical resection Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration Plan Year Other Criteria N/A 96 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria RELISTOR Drugs Relistor Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information 1. Pt has advanced illness, 2. Pt has tried at least TWO of the following: a. Miralax, b. Lactulose, c. Senna, d. Bisacodyl, e. Milk of Magnesia Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration Plan Year Other Criteria BvsD determination 97 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria REMICADE Drugs Remicade Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information 1. For rheumatoid arthritis, psoriatic arthritis, Crohn's, ankylosing spondylitis dxs : a. Pt has previous trial on at least ONE of the following: i. methotrexate, ii. leflunomide, iii. hydroxychloroquine, iv. sulfasalazine, v. injectable gold, vi. oral gold, vii. azathioprine, viii. penicillamine, ix. cyclosporine, b. Pt has previous trial on at least ONE of the following: a. Enbrel, b. Humira, 2. For Crohn's dx: a. Pt has previous trial on at least ONE of the following: i. Enbrel, ii. Humira, b. Pt has previous trial on Cimzia, 3. For ulcerative colitis and plaque psoriasis dxs: Pt has previous trial on at least ONE of the following: a. Enbrel, b. Humira, 4. For ankylosing spondylitis dxs: Pt has previous trial on Cimzia Age Restrictions N/A Prescriber Restrictions Rheumatologist, Gastroenterologist, OR Dermatologist Coverage Duration Plan Year Other Criteria BvsD determination 98 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria REVLIMID Drugs Revlimid Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information N/A Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration Plan Year Other Criteria N/A 99 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria SABRIL Drugs Sabril Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information 1. For solution: Must be used as monotherapy for infantile spasms, 2. For tablets: a. Must be used as adjunctive therapy, b. Must have tried at least TWO of the following: i. Banzel, ii. Carbamazepine, iii. Celontin, iv. Depakene, v. Depakote, vi. Dilantin, vii. Divalproex, viii. Epitol, ix. Equetro, x. Ethosuximide, xi. Felbamate, xii. Gabitril, xiii. Keppra, xiv. Lamictal, xv. Lamotrigine, xvi. Levetiracetam, xvii. Lyrica, xviii. Mysoline, xix. Oxcarbazepine, xx. Peganone, xxi. Phenytoin, xxii. Potiga, xxiii. Stavzor, xxiv. Tegretol, xxv. Topamax, xxvi. Topiramate, xxvii. Trileptal, xxviii. Valproic Acid, xxix. Vimpat, xxx. Zonegran, xxxi. Zonisamide Age Restrictions N/A Prescriber Restrictions Neurologist Coverage Duration Plan Year Other Criteria Periodic vision testing 100 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria SIGNIFOR Drugs Signifor, Signifor Lar Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information 1. Initial: a. Pt is NOT a candidate for pituitary surgery, b. If pt previously had pituitary surgery: Pt continues to have 24-hour urinary free crotisol levels of: i. 90 micrograms or greater if male, ii. 67 micrograms or greater if female, 2. Reauth: a. Pt's 24-hour urinary free cortisol level is: i. 60 micrograms or lower if male, ii. 45 micrograms or lower if female OR has decreased by at least 50% from initial Signifor therapy Age Restrictions N/A Prescriber Restrictions Endocrinologist Coverage Duration Initial: 2 mo, Reauth: Plan Year Other Criteria N/A 101 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria SIMPONI Drugs Simponi, Simponi Aria Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria Combination treatment with TNF antagonist Required Medical Information 1. For rheumatoid arthritis, psoriatic arthritis dxs: a. Pt has previous trial on at least ONE of the following: i. methotrexate, ii. leflunomide, iii. hydroxychloroquine, iv. sulfasalazine, v. injectable gold, vi. oral gold, vii. azathioprine, viii. penicillamine, ix. cyclosporine, b. Pt has previous trial on at least ONE of the following: a. Enbrel, b. Humira, 2. For ankylosing spondylitis dx: a. Pt has previous trial on at least ONE of the following: i. Enbrel, ii. Humira, b. Pt has previous trial on Cimzia, 3. for ulcerative colitis dx: Pt have previous trial on at least ONE of the following: a. Enbrel, b. Humira Age Restrictions N/A Prescriber Restrictions Rheumatologist, Gastroenterologist Coverage Duration Plan Year Other Criteria N/A 102 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria SIRTURO Drugs Sirturo Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information Pt has previous failure on at least TWO of the following: 1. Ethambutol, 2. Streptomycin, 3. Pyrazinamide, 4. Amikacin/kanamycin, 5. Cycloserine/terizidone, 6. Ethionamide, 7. Capreomycin, 8. Levofloxacin, 9. Moxifloxacin, 10. Ofloxacin Age Restrictions N/A Prescriber Restrictions Pulmonologist, Infectious Disease Specialist Coverage Duration 6 Months Other Criteria N/A 103 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria SIVEXTRO Drugs Sivextro Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information Chart notes and bacterial susceptibility reports have been submitted showing need for medication Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration 1 month Other Criteria N/A 104 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria SOVALDI Drugs Sovaldi Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information 1. Genotype 1 and 4: a. Used in combination with pegylated interferon-alfa and ribavirin OR b. Used in combination with Olysio, 2. Liver transplant: Pt is a candidate for liver transplant and on the transplant waiting list, 3. Pt must display at least ONE of the following: a. Extrahepatic complications of HCV as shown by any of the following: i. HCV-related renal disease, ii. Vasculitis, iii. Porphyria cutanea tarda, b. Status post liver transplant for HCV, c. HCV with chronic kidney disease (greater than or equal to stage 2), d. Status post renal transplantation Age Restrictions N/A Prescriber Restrictions Gastroenterolgist, Infectious Disease Specialist, Transplant Specialist Coverage Duration 1. Genotype 1, 2, 4: 12 Weeks, 2. Genotype 3: 24 Weeks, 3. Liver transplant: 48 Weeks Other Criteria N/A 105 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria SPRYCEL Drugs Sprycel Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information 1. For blast or chronic phase CML dx : Previous trial on Gleevec, 2. For ALL dx: Resistance or intolerance to at least ONE prior therapy, 3. Efficacy testing will be conducted in accordance with NCCN recommended treatment guidelines, 4. After failure of treatment per NCCN CML guideline testing patient does NOT have a T315I mutation based BCR-ABL kinase domain testing Age Restrictions N/A Prescriber Restrictions Oncologist, Hematologist Coverage Duration Plan Year Other Criteria N/A 106 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria STELARA Drugs Stelara Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria Treatment initiation during an active infection Required Medical Information 1. For PsA dx: a. Pt has failed treatment with Enbrel OR Humira, b. Pt has failed treatment with Cimzia, 2. For plaque psoriasis dx: a. Plaque psoriasis involves 10% or more of the body surface area, b. If less than 10% of body surface area there is scalp, palmer, foot, or groin involvement causing significant disability, c. Pt has failed therapy of at least 12 weeks with at least ONE of the following: i. methotrexate, ii. cyclosporine, iii. acitretin, d. Pt has failed treatment with Enbrel OR Humira Age Restrictions N/A Prescriber Restrictions Dermatologist or consult Coverage Duration Plan Year Other Criteria N/A 107 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria STIMULANTS Drugs Modafinil, Nuvigil Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information 1. For OSAHS dx: Pt has history of CPAP in which pt showed compliance with CPAP, 2. For SWSD dx: 1. Expressed symptoms of excessive sleepiness for at least 3 months 2. The work shift meets at least ONE of the following: a. Six (6) or more hours of the shift between 10pm and 8am, b. Twelve (12) or less hours per shift, c. Five (5) or more alternative shifts per month, d. Three (3) or more consecutive shifts per month Age Restrictions N/A Prescriber Restrictions Sleep specialist Coverage Duration Plan Year Other Criteria N/A 108 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria STIVARGA Drugs Stivarga Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information N/A Age Restrictions N/A Prescriber Restrictions Oncologist Coverage Duration Plan Year Other Criteria N/A 109 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria SUTENT Drugs Sutent Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria Sutent used as combination therapy with other chemotherapies Required Medical Information 1. For GIST dx: Disease progression or intolerance to Gleevec, 2. For pNET dx: Tumor is unresectable locally advanced or metastatic Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration Plan Year Other Criteria N/A 110 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria SYLATRON Drugs Sylatron Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information 1. Pt has stage III melanoma with previous surgical resection, 2. Surgical resection (including lymphadenectomy) were less than 84 days prior to request Age Restrictions N/A Prescriber Restrictions Oncologist or Dermatologist Coverage Duration Plan Year Other Criteria N/A 111 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria SYNAGIS Drugs Synagis Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information 1. For less than 2 years of age: a. Pt with CLD requiring medical therapy (such as supplemental oxygen, bronchodilator, diuretic or corticosteroid therapy) within 6 months before start of RSV season, To meet a dx of CLD with a recent history of oxygen use, infants should have the following: i. Required supplemental oxygen for at least 28 postnatal days to be classified as having mild, moderate, or severe BPD/CLD according to United States National Institute of Child Health and Human Development (NICHD), b. 2nd season authorization: Pt continues to require medical therapy for respiratory or cardiac dysfunction, 2. Infants born at 32 weeks of gestation or before with or without CLD: a. Gestational age and chronologic age at start of season, b. Born less than 29 weeks GA and less than 12 months of age during the RSV season, c. Born 29 to 32 weeks GA and less than 6 months of age before start of RSV season, 3. Infants with a gestational age 32 weeks 0 days to 34 weeks 6 days, with one of the risk factors below: a. Daycare attendance, b. Sibling(s) younger than 5 years of age, 4. Infants less than one (1) year of age with severe neuromuscular disease or congenital abnormalities of the airways that compromise handling of respiratory secretions, 5. Children less than 24 months (2 years) old with hemodynamically significant congenital heart disease who have any of the following: a. Are receiving medication to control congestive heart failure (diuretics, antihypertensives), b. Diagnosed with moderate to severe pulmonary hypertension, c. Diagnosed with cyanotic heart disease Age Restrictions 2 years old or younger Prescriber Restrictions N/A Coverage Duration Plan Year 112 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria Other Criteria BvsD determination 113 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria SYNERCID Drugs Synercid Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information 1. For complicated bacterial skin and skin structure infections: Pt has had a positive culture within the past month for either of the following (mark all that apply): a. Staphylococcus aureus (MSSA only), b. Streptococcus pyogenes Age Restrictions N/A Prescriber Restrictions Infectious Disease Specialist Coverage Duration 1 Month Other Criteria BvsD determination 114 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria SYNRIBO Drugs Synribo Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information Pt has resistance and/or intolerance to TWO or more of the following: 1. Gleevec, 2. Sprycel, 3. Tasigna, 4. Bosulif Age Restrictions N/A Prescriber Restrictions Hematologist, Oncologist Coverage Duration Plan Year Other Criteria BvsD determination 115 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria TAFINLAR Drugs Tafinlar Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria Disease progression with Zelboraf OR Mekanist Required Medical Information Pt is BRAF(V600E or V600K) mutation positive Age Restrictions N/A Prescriber Restrictions Oncologist, Hematologist, Dermatologist Coverage Duration Plan Year Other Criteria N/A 116 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria TARCEVA Drugs Tarceva Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information 1. For NSCLC dx: a. Pt with EGFR mutation, b. Tarceva is not used in combination with platinum-based chemotherapy, 2. For pancreatic cancer dx: Combination with gemcitabine Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration Plan Year Other Criteria N/A 117 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria TASIGNA Drugs Tasigna Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information Documented resistance or intolerance to gleevec for chronic phase or accelerated phase CML Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration Plan Year Other Criteria N/A 118 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria TECFIDERA Drugs Tecfidera Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information 1. Pt has failed at least TWO of the following: a. Aubagio, b. Avonex, c. Betaseron, d. Copaxone, e. Extavia, f. Gilenya, g. mitoxantrone, h. Rebif, i. Tysabri, 2. Pt has normal CBC (within last 6 months) Age Restrictions N/A Prescriber Restrictions Neurologist Coverage Duration Plan Year Other Criteria N/A 119 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria TEFLARO Drugs Teflaro Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information 1. For acute bacterial skin and skin structure infections: Pt has had a positive culture within the past month for ANY of the following (mark all that apply): a. Staphylococcus aureus (MSSA and MRSA), b. Streptococcus pyogenes, c. Streptococcus agalactiae, d. Escherichia coli, e. Klebsiella pneumonia, f. Klebsiella oxytoca, 2. For community-acquired bacterial pneumonia: Pt has had a positive culture within the past month for ANY of the following (mark all that apply): a. Staphylococcus aureus (MSSA only), b. Streptococcus pneumoniae, c. Haemophilus influenzae, d. Escherichia coli, e. Klebsiella pneumonia, f. Klebsiella oxytoca Age Restrictions N/A Prescriber Restrictions Infectious Disease Specialist Coverage Duration 1 Month Other Criteria BvsD determination 120 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria TORISEL Drugs Torisel Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria Combination chemotherapy Required Medical Information N/A Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration Plan Year Other Criteria N/A 121 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria TREANDA Drugs Treanda Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information For NHL dx: Disease progression during or within six months of treatment with rituximab OR rituximab-containing regimen Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration Plan Year Other Criteria N/A 122 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria TROKENDI Drugs Topiramate Er, Trokendi Xr Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information Pt has previous failure on immediate release topiramate, 2. Pt has previous failure with at least ONE other antiepileptic drug Age Restrictions 6 years old or older Prescriber Restrictions Neurologist Coverage Duration Plan Year Other Criteria N/A 123 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria TYGACIL Drugs Tygacil Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information 1. For complicated bacterial skin and skin structure infections: Pt has had a positive culture within the past month for ANY of the following (mark all that apply): a. Staphylococcus aureus (MSSA or MRSA), b. Escherichia coli, c. Enterococcus faecalis (vancomycin susceptible strains only), d. Enterobacter cloacae, e. Klebsiella pneumonia, f. Bacteroides fragilis, g. Streptococcus agalactia, h. S.pyogenes, i. S.anginosus group (including S. anginosus, S. intermedius, and S. constellatus), 2. For community acquired bacterial pneumonia: Pt has had a positive culture within the past month for ANY of the following (mark all that apply): a. Streptococcus pneumonia (penicillin-susceptible isotales), b. Haemophilus influenza (betalactamase negative isolates), c. Legionella pneumophila, 3. For complicated bacterial intra-abdominal infections: Pt has had a positive culture within the past month for ANY of the following (mark all that apply): a. Staphylococcus aureus (MSSA or MRSA), b. Escherichia coli, c. Enterococcus faecalis (vancomycin susceptible strains only), d. Enterobacter cloacae, e. Klebsiella pneumonia, f. K.oxytoca, g. Bacteroides fragilis, h. B.thetaiotaomicron, i. B.uniformis, j. B.fragilis, k. Citrobacter freundii, l. Clostridium perfringens, m. Peptostreptococcus micros Age Restrictions 18 years old or older Prescriber Restrictions Infectious Disease Specialist Coverage Duration 1 Month Other Criteria BvsD determination 124 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria 125 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria TYKERB Drugs Tykerb Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information 1. For advanced or metastatic HER-2 positive breast cancer dx: a. Previous failure on anthracycline, taxane, and trastuzumab AND b. Combination therapy with capecitabine OR c. Combination therapy with trastuzumab, 2. For postmenopausal HER-2 receptor hormone receptor positive breast cancer dx: Combination therapy with aromatase inhibitor Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration Plan Year Other Criteria N/A 126 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria TYSABRI Drugs Tysabri Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information 1. For MS: a. Pt has been compliant on at least ONE of the following: i. Avonex, ii. Betaseron, iii. Copaxone, iv. Rebif, b. Anti-natalizumab assay is required after 12 weeks and 24 weeks of therapy, 2. For Crohn's: a. Pt has tried at least ONE of the following: i. Humira, ii. Remicade Age Restrictions N/A Prescriber Restrictions Neurologist, Gastroenterologist Coverage Duration Initial: 12 Weeks, Reauth: 6 Months Other Criteria N/A 127 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria VALCHLOR Drugs Valchlor Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information Pt has previous trial on at least ONE previous skin directed therapy of the following: 1. Topical corticosteroid, 2. Topical carmustine, 3. Topical retinoid, 4. Radiation therapy, 5. Phototherapy Age Restrictions N/A Prescriber Restrictions Oncologist, Dermatologist Coverage Duration Plan Year Other Criteria N/A 128 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria VASODILATORS Drugs Orenitram Er, Remodulin, Tyvaso, Ventavis Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information 1. For NYHA functional class II or III: Previous trial on at least one of the following: Adcirca, Letairis, Opsumit, sildenafil, Tracleer, 2. Presence of functional class IV Age Restrictions N/A Prescriber Restrictions Pulmonologist, Cardiologist Coverage Duration Plan Year Other Criteria N/A 129 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria VECTIBIX Drugs Vectibix Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information 1. Failure of irinotecan-, oxaliplatin-, and 5-FU- based regimens, 2. Tumor must bear wild-type (non-mutated) K-ras gene, 3. Patient has no previous failure on Erbitux Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration Plan Year Other Criteria N/A 130 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria VELCADE Drugs Velcade Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information For mantle cell lymphoma dx: Pt has failed prevous chemotherapy Age Restrictions N/A Prescriber Restrictions Oncologist Coverage Duration Plan Year Other Criteria N/A 131 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria VERSACLOZ Drugs Versacloz Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information 1. Pt has had an inadequate response to at least TWO antipsychotic medications, a. At least one medication must be a long-acting depot, OR 2. Pt has medical condition that prohibits the use of tablets Age Restrictions N/A Prescriber Restrictions Psychiatrist Coverage Duration Plan Year Other Criteria N/A 132 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria VIEKIRA Drugs Viekira Pak Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information 1. Chart notes showing genotype Age Restrictions N/A Prescriber Restrictions Gastroenterologist, Infectious Disease Specialist, Transplant Specialist Coverage Duration Maximum 24 weeks Other Criteria N/A 133 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria VIRAZOLE Drugs Virazole Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information 1. Pt has had an RSV infection confirmed or quantified by antibody, antigen, or viral RNA assays in the last month, 2. Pt has an underlying compromising condition (i.e. prematurity, cardiopulmonary disease, or immunosuppression) Age Restrictions 3 years old or younger Prescriber Restrictions Infectious Disease Specialist Coverage Duration 7 Days Other Criteria N/A 134 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria XALKORI Drugs Xalkori Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria Combination therapy with other chemotherapy agents Required Medical Information NSCLC must be anaplastic lymphoma kinase (ALK)-positive Age Restrictions N/A Prescriber Restrictions Oncologist Coverage Duration Plan Year Other Criteria N/A 135 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria XELJANZ Drugs Xeljanz Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria Combination with biologic DMARD or potent immunosuppressant Required Medical Information 1. Pt has failed treament with Enbrel OR Humira, 2. Pt has failed treatment with Cimzia Age Restrictions N/A Prescriber Restrictions Rheumatologist or consult Coverage Duration Plan Year Other Criteria N/A 136 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria XENAZINE Drugs Xenazine Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information N/A Age Restrictions N/A Prescriber Restrictions Neurologist Coverage Duration Plan Year Other Criteria N/A 137 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria XGEVA Drugs Xgeva Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria 1. Use in pt with multiple myeloma Required Medical Information 1. Must meet at least ONE of the following: a. Pt has giant cell tumor of the bone that is unresectable or where surgical resection is likely to result in severe morbidity, b. Pt has a diagnosis of bone metasteses related to a solid tumor, c. Pt has a diagnosis of metastatic breast or prostate cancer, d. Pt has severe renal impairment (CrCl less than 35mL/min), e. Pt has previously been treated with Zometa or Aredia and had disease progression OR adverse reaction to the treatment Age Restrictions N/A Prescriber Restrictions Oncologist Coverage Duration Plan Year Other Criteria BvsD determination 138 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria XIFAXAN Drugs Xifaxan Covered Uses 1. All FDA-approved indications not otherwise excluded from Part D, 2. Diarrhea or Mixed Type Irritable Bowel Syndrome, 3. Clostridium difficile infection Exclusion Criteria N/A Required Medical Information 1. For traveler's diarrhea dx: Previous trial on sulfamethoxazole-trimethoprim, azithromycin, ciprofloxacin, or levofloxacin, 2. For hepatic encephalopathy dx: Previous failure on lactulose therapy, 3. For irritable bowel syndrome dx: Failure on at least ONE antispasmodic therapy AND at least ONE antibiotic therapy, 4. For Clostridium difficile dx: Failure on at least TWO other antibiotic therapies Age Restrictions N/A Prescriber Restrictions Gastroenterologist OR Infectious Disease Specialist Coverage Duration Plan Year Other Criteria N/A 139 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria XOLAIR Drugs Xolair Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information 1. FEV1 baseline between 40 and 80% of predicted, 2. Pt has been taking for at least 3 months on at least ONE of the following: a. Medium dose ICS and inhaled long-acting bronchodilator, b. Medium dose ICS and leukotriene antagonist, c. Medium dose ICS and theophylline, d. High dose ICS and inhaled long-acting bronchodilator, e. Low dose ICS and inhaled long-acting bronchodilator, 3. Pt has had need for frequent intermittent use of oral corticosteroids, 4. Pt has at least ONE of the following: 1 ER visit or hospitalization for asthma within past 6 months OR Need for frequent office visits due to asthma evaluation, 5. Pt's IgE level is greater than or equal to 30, 6. Pt is less than 330 lbs Age Restrictions N/A Prescriber Restrictions Allergist, Pulmonologist Coverage Duration Plan Year Other Criteria Pt weighs 330 lbs or less 140 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria XTANDI Drugs Xtandi Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information 1. Pt's prostate cancer is castration resistant, 2. Pt has previous trial on docetaxel therapy AND Zytiga therapy Age Restrictions N/A Prescriber Restrictions Oncologist, Urologist Coverage Duration Plan Year Other Criteria N/A 141 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria XYREM Drugs Xyrem Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information 1. Narcolepsy dx confirmed by PSG and MSLT tests, 2. Pt must have at least ONE of the following: a. Pt exhibits symptoms of cataplexy OR b. Pt has previous treatment with Provigil or Nuvigil Age Restrictions N/A Prescriber Restrictions Board certified in Sleep, Pulmonology, or Neurology Coverage Duration Plan Year Other Criteria N/A 142 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria ZELBORAF Drugs Zelboraf Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria 1. Combination therapy, 2. Disease progression with prior Mekinist or Tafinlar therapy Required Medical Information Pt is BRAF(V600E or V600K) mutation positive Age Restrictions N/A Prescriber Restrictions Oncologist, Hematologist Coverage Duration Plan Year Other Criteria N/A 143 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria ZOLINZA Drugs Zolinza Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information 1. Pt has progressive, persistent, or recurrent disease, 2. Pt has tried at least TWO prior systemic therapies Age Restrictions N/A Prescriber Restrictions N/A Coverage Duration Plan Year Other Criteria N/A 144 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria ZYDELIG Drugs Zydelig Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information 1. CLL dx: Used in combination with Rituxan, 2. Non-Hodgkin dx: Pt has failure of two prior systemic therapies, 3. Small Lymphocytic Lymphoma dx: Pt has failure of two prior systemic therapies Age Restrictions N/A Prescriber Restrictions Oncologist, Hematologist Coverage Duration Plan Year Other Criteria N/A 145 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria ZYKADIA Drugs Zykadia Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria Combination therapy Required Medical Information Pt has previous trial on Xalkori Age Restrictions N/A Prescriber Restrictions Oncologist Coverage Duration Plan Year Other Criteria N/A 146 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria ZYTIGA Drugs Zytiga Covered Uses All FDA-approved indications not otherwise excluded from Part D Exclusion Criteria N/A Required Medical Information Zytiga is given in combination with prednisone 5mg twice daily Age Restrictions N/A Prescriber Restrictions Oncologist, Urologist Coverage Duration Plan Year Other Criteria N/A 147 Updated 7/1/2015 SelectHealth Advantage 2015 Prior Authorization Criteria Index Abstral .......................................... 39 Actemra .......................................... 2 Actimmune .................................... 4 Adcirca ......................................... 86 Adempas ........................................ 5 Afinitor ......................................... 95 Afinitor Disperz .......................... 95 Alimta ............................................. 6 Ambisome ...................................... 8 Amifostine ..................................... 7 Amphotericin B ............................. 8 Ampyra........................................... 9 Androderm ................................... 10 Apokyn ......................................... 12 Arcalyst ........................................ 13 Arzerra.......................................... 14 Aubagio ........................................ 15 Avastin ......................................... 16 Avonex ......................................... 73 Avonex Administration Pack .... 73 Axiron .......................................... 10 Beleodaq ...................................... 17 Bethkis ......................................... 30 Bivigam ........................................ 59 Bosulif .......................................... 18 Cancidas ....................................... 19 Capastat Sulfate .......................... 20 Caprelsa........................................ 21 Carimune Nf Nanofiltered ......... 59 Cayston ........................................ 30 Cerdelga ....................................... 22 Chorionic Gonadotropin ............ 23 Cimzia .......................................... 24 Cinryze ......................................... 25 Cometriq ...................................... 26 Cosentyx Pen (2 Pens) ............... 27 Cubicin ......................................... 28 Cyclobenzaprine Hcl .................. 51 Cystaran ....................................... 29 Dalvance ...................................... 31 Dificid .......................................... 32 Diphenhydramine Hcl ................ 51 Duavee ......................................... 51 Erbitux.......................................... 34 Ergoloid Mesylates ..................... 51 Erivedge ....................................... 35 Erwinaze ...................................... 36 Esbriet .......................................... 92 Evzio............................................. 37 Farydak ........................................ 38 Fentanyl Citrate........................... 39 Fentora ......................................... 39 Firazyr .......................................... 40 Flebogamma Dif ......................... 59 Flector .......................................... 41 Folotyn ......................................... 42 148 Updated 7/1/2015 Forteo ........................................... 43 Gamastan S-D ............................. 59 Gammagard Liquid .................... 59 Gammaked................................... 59 Gammaplex ................................. 59 Gamunex-C ................................. 59 Gilotrif.......................................... 44 H.P. Acthar .................................... 3 Halaven ........................................ 47 Harvoni ........................................ 48 Hetlioz .......................................... 50 Ibrance.......................................... 52 Iclusig ........................................... 53 Ilaris .............................................. 54 Imbruvica ..................................... 55 Imipenem-Cilastatin Sodium .... 89 Increlex ........................................ 56 Inlyta ............................................ 57 Istodax .......................................... 58 Ixempra ........................................ 60 Jakafi ............................................ 61 Jevtana.......................................... 62 Juxtapid ........................................ 11 Kadcyla ........................................ 63 Kalydeco ...................................... 64 Kepivance .................................... 65 Keytruda ...................................... 66 Kineret.......................................... 67 SelectHealth Advantage 2015 Prior Authorization Criteria Korlym ......................................... 68 Kynamro ...................................... 11 Lazanda ........................................ 39 Lenvima ....................................... 69 Letairis.......................................... 33 Lidocaine ..................................... 70 Lynparza ...................................... 71 Mekinist ....................................... 72 Modafinil ................................... 107 Myalept ........................................ 74 Nafcillin ....................................... 75 Nafcillin Sodium ......................... 75 Natpara ......................................... 76 Nexavar ........................................ 77 Nuedexta ...................................... 78 Nuvigil ....................................... 107 Octreotide Acetate ...................... 79 Ofev .............................................. 92 Olysio ........................................... 80 Oncaspar ...................................... 81 Opdivo .......................................... 82 Opsumit ........................................ 33 Orencia ......................................... 83 Orenitram Er .............................. 127 Orfadin ......................................... 84 Otezla ........................................... 85 Pegasys ......................................... 49 Pegasys Proclick ......................... 49 Pegintron ...................................... 49 Pegintron Redipen ...................... 49 Phenobarbital............................... 51 Plegridy ........................................ 87 Plegridy Pen ................................ 87 Pomalyst....................................... 88 Privigen ........................................ 59 Prolia ............................................ 90 Promacta ...................................... 91 Purixan ......................................... 93 Ravicti .......................................... 94 Relistor ......................................... 96 Remicade ..................................... 97 Remodulin ................................. 127 Revlimid....................................... 98 Sabril ............................................ 99 Saizen ........................................... 45 Signifor ...................................... 100 Signifor Lar ............................... 100 Sildenafil ...................................... 86 Simponi ...................................... 101 Simponi Aria ............................. 101 Sirturo......................................... 102 Sivextro ...................................... 103 Somatuline Depot ......................... 1 Somavert ........................................ 1 Sovaldi ....................................... 104 Sprycel ....................................... 105 149 Updated 7/1/2015 Stelara......................................... 106 Stivarga ...................................... 108 Sutent ......................................... 109 Sylatron ...................................... 110 Synagis ....................................... 111 Synercid ..................................... 113 Synribo ....................................... 114 Tafinlar....................................... 115 Tarceva....................................... 116 Tasigna ....................................... 117 Tecfidera .................................... 118 Teflaro ........................................ 119 Testosterone ................................ 10 Tev-Tropin................................... 45 Thioridazine Hcl ......................... 51 Tobi Podhaler .............................. 30 Tobramycin ................................. 30 Topiramate Er ........................... 122 Torisel ........................................ 120 Tracleer ........................................ 33 Treanda ...................................... 121 Trokendi Xr ............................... 122 Tygacil ....................................... 123 Tykerb ........................................ 124 Tysabri ....................................... 125 Tyvaso ........................................ 127 Valchlor ..................................... 126 Vectibix ...................................... 128 SelectHealth Advantage 2015 Prior Authorization Criteria Velcade....................................... 129 Ventavis ..................................... 127 Versacloz ................................... 130 Victrelis ........................................ 49 Viekira Pak ................................ 131 Virazole ...................................... 132 Xalkori........................................ 133 Xeljanz ....................................... 134 Xenazine .................................... 135 Xgeva ......................................... 136 Xifaxan ....................................... 137 Xolair .......................................... 138 Xtandi ......................................... 139 Xyrem ......................................... 140 Zelboraf ...................................... 141 Zolinza........................................ 142 Zydelig ....................................... 143 Zykadia....................................... 144 Zytiga ......................................... 145 150 Updated 7/1/2015
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