SilverScript: A CaremarkRx Company

Drugs: AVITA CREAM, AVITA GEL, RETIN-A MICR GEL, TRETINOIN CREAM, TRETINOIN GEL
Covered Uses: All FDA-approved indications not otherwise excluded from Part D, keratosis follicularis (Darier's disease, Darier-White disease)
Exclusion Criteria: Cosmetic use
Required Medical Information:
Age Restrictions: Approve for those 12 years of age and older
Prescriber Restrictions:
Coverage Duration: 12 months
Other Criteria:

Drugs: ACTEMRA
Covered Uses: All FDA-approved indications not otherwise excluded from Part D
Exclusion Criteria: Active infection (including tuberculosis), concurrent use with other biologics
Required Medical Information: Screening for latent tuberculosis is required. If results are positive, patient must have completed treatment or must currently be receiving treatment for latent tuberculosis. Evaluate for HBV risk and initiate treatment if appropriate.
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: 12 months
Other Criteria: Must have an inadequate response to at least one nonbiologic DMARD or intolerance/contraindication to at least 2 nonbiologic DMARDs. Must have an inadequate response or intolerance/contraindication to TNF therapy. For renewals, patient must have responded to Actemra therapy (e.g., condition improved or stabilized).

Drugs: ADCIRCA
Covered Uses: All FDA-approved indications not otherwise excluded from Part D
Exclusion Criteria: Concurrent nitrate therapy. PAH associated with any of the following: left heart disease, chronic thrombotic disease, embolic disease, compression of pulmonary vessels, lung diseases, hypoxemia, sarcoidosis
Required Medical Information:
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: 12 months
Other Criteria:

Drugs: AFINITOR
Covered Uses: All FDA-approved indications not otherwise excluded from Part D
Exclusion Criteria:
Required Medical Information:
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: 6 months
Other Criteria:

Drugs: AMITIZA
Covered Uses: All FDA-approved indications not otherwise excluded from Part D
Exclusion Criteria: Known or suspected mechanical gastrointestinal obstruction
Required Medical Information:
Age Restrictions: 18 years of age or older
Prescriber Restrictions:
Coverage Duration: 12 months
Other Criteria:

Drugs: AMPHETAMINE, DEXTROAMPHETAMINE
Covered Uses: All FDA-approved indications not otherwise excluded from Part D
Exclusion Criteria: MAOI concurrent use or within the last 14 days
Required Medical Information: Sleep studies for narcolepsy diagnosis
Age Restrictions: Approve for those 3 years of age and older
Prescriber Restrictions:
Coverage Duration: 12 months
Other Criteria: Monitor for weight loss, decreased growth velocity in children, increased heart rate and blood pressure, appearance or worsening of aggressive behavior or hostility, sleep disturbances and long-term usefulness of the drug

Drugs: ARANESP
Covered Uses: All FDA-approved indications not otherwise excluded from Part D
Exclusion Criteria: CRF - transferrin saturation less than 20% and patient not receiving iron supplementation where clinically appropriate. CRF and anemia in patients with non-myeloid malignancies - hemoglobin level of the patient (not the result of a recent blood transfusion) greater than 13 g/dL. Lack of initial diagnosis of anemia (hematocrit less than 30% and/or hemoglobin less than 10 g/dL and/or symptomatic with hemoglobin 10-11g/dL).
Required Medical Information: CRF - iron status of the patient has been evaluated (serum transferrin saturation). CRF and anemia of cancer - Hemoglobin level of the patient be monitored prior to each dose when initiating therapy, for dose changes, and at regular intervals when the dose is stabilized. Hemoglobin level of the patient will be monitored prior to each dose when initiating therapy, for dose changes, and at regular intervals when the dose is stabilized. Blood pressure of the patient will be monitored throughout therapy. Patient will be monitored for the occurrence of thrombotic events.
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: Initiation of therapy and/or dose changes - 6 weeks. Stable on therapy - 12 weeks.
Other Criteria: Once on therapy, compared to pretreatment baseline, the patient must show an objective clinical response (e.g., hemoglobin rise greater than 1 g/dL and/or hematocrit rise greater than 3%) to an appropriate dose/dose increase and duration of therapy.

Drugs: AVONEX
Covered Uses: All FDA-approved indications not otherwise excluded from Part D
Exclusion Criteria:
Required Medical Information: For first clinical episode, diagnosis must be confirmed by MRI
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: 12 months
Other Criteria:

Drugs: ACETYLCYSTEINE, ALBUTEROL SULFATE, ALBUTEROL SULFATE/IPRATROPIUM BROMIDE, AMINESS, AMINOSYN, AZASAN, AZATHIOPRINE, CELLCEPT, CHORIONIC GONADOTROPIN, CLIMIMIX , CLINISOL SF 15%, COLISTIMETHATE SODIUM, CROMOLYN SODIUM, CYCLOPHOSPHAMIDE, CYCLOSPORINE, CYCLOSPORINE MODIFIED, DECAVAC, DIPTHERIA/TETANUS TOXOID PEDIATRIC, EMEND, ENGERIX-B, FREAMINE , GENGRAF, GRANISETRON HCL, GRANISOL, HEPATAMINE, HEPATASOL, INTRALIPID, IPRATROPIUM BROMIDE, MYCOPHENOLATE, MYFORTIC, NEORAL, NEPHRAMINE, NOVAMINE, NOCAREL, ONDANSETRON HCL, ONDANSETRON ODT, PREGNYL, PREMASOL, PROCALAMINE, PROGRAF, PROSOL, PULMICORT, PULMOZYME, RAPAMUNE, RECOMBIVAX HB, RENAMIN, SANDIMMUNE, TACROLIMUS, TETANUS TOXOID ADSORBED, TETANUS/DIPHTHERIA TOXOIDS-ADSORBED, TOBI, TRAVASOL, TROPHAMINE
Covered Uses: This drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination.
Exclusion Criteria:
Required Medical Information:
Age Restrictions:
Prescriber Restrictions:
Coverage Duration:
Other Criteria:

Drugs: BETASERON
Covered Uses: All FDA-approved indications not otherwise excluded from Part D
Exclusion Criteria:
Required Medical Information: For first clinical episode, diagnosis must be confirmed by MRI
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: 12 months
Other Criteria:

Drugs: SUBOXONE, SUBUTEX
Covered Uses: All FDA-approved indications not otherwise excluded from Part D
Exclusion Criteria: Patients who are unwilling to follow the safety precautions for treatment with Subutex/Suboxone.
Required Medical Information:
Age Restrictions: 16 years of age or older
Prescriber Restrictions: Prescribers must be registered with the Substance Abuse and Mental Health Services Administration and must not treat more than 100 patients with Subutex/Suboxone at one time.
Coverage Duration: Subutex - One fill only. Suboxone - 12 months.
Other Criteria: Subutex/Suboxone should be part of an overall treatment program. The patient should be willing to comply with treatment and be monitored periodically.

Drugs: CELEBREX
Covered Uses: All FDA-approved indications not otherwise excluded from Part D
Exclusion Criteria: Post-operative pain following CABG surgery, allergic-type reaction to aspirin, NSAIDs, or sulfonamides
Required Medical Information: Evaluation of cardiovascular disease or risk factors for cardiovascular disease
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: 6 months for FAP and JRA, 12 months for dysmenorrhea, OA, RA, AS, 1 month for acute pain
Other Criteria: For all diagnoses, patient must undergo determination of risk versus benefit of treatment with celecoxib for an NSAID-related gastrointestinal (GI) adverse event such as an NSAID-associated gastric ulcer or gastrointestinal bleeding

Drugs: CHANTIX
Covered Uses: All FDA-approved indications not otherwise excluded from Part D
Exclusion Criteria: Concurrent Zyban use
Required Medical Information:
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: 12 weeks initial, 12 weeks additional upon renewal
Other Criteria:

Drugs: Cimzia
Covered Uses: All FDA-approved indications not otherwise excluded from Part D
Exclusion Criteria: Patient must be evaluated for latent TB with a PPD test and be treated if positive. Patients are excluded if they have an active infection or on are on concurrent biologic response modifier. Patient must also be assessed for the risk of hepatitis B and if appropriate, be tested.
Required Medical Information: Patient must demonstrate inadequate response to at least 1 conventional therapy for Crohn's disease (i.e., prednisone, budesonide, sulfasalazine, azathioprine, mesalamine, infliximab or adalimumab)
Age Restrictions: Approve for those 18 years of age or older
Prescriber Restrictions:
Coverage Duration: 12 months
Other Criteria:

Drugs: COPAXONE
Covered Uses: All FDA-approved indications not otherwise excluded from Part D
Exclusion Criteria:
Required Medical Information: For first clinical episode, diagnosis must be confirmed by MRI
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: 12 months
Other Criteria:

Drugs: DIFFERIN
Covered Uses: All FDA-approved indications not otherwise excluded from Part D
Exclusion Criteria: Cosmetic use
Required Medical Information:
Age Restrictions: Approve for those 12 years of age and older
Prescriber Restrictions:
Coverage Duration: 12 months
Other Criteria:

Drugs: DRONABINOL
Covered Uses: All FDA-approved indications not otherwise excluded from Part D
Exclusion Criteria:
Required Medical Information: Nausea and vomiting associated with chemotherapy: The patient must be on moderately to severely emetogenic chemotherapy and failed two conventional antiemetic treatments such as prochlorperazine, promethazine or 5-HT3 receptor antagonists. For anorexia and weight loss in patients with AIDS: The patient must have an involuntary weight loss of greater than 10% of pre-illness baseline body weight or a body mass index (BMI) less than 20kg/m2 in the absence of a concurrent illness or medical condition other than HIV that may cause weight loss.
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: 6 months
Other Criteria:

Drugs: ENBREL
Covered Uses: All FDA-approved indications not otherwise excluded from Part D, reactive arthritis, inflammatory bowel disease arthritis
Exclusion Criteria: Patient must be evaluated for latent TB with a PPD test and be treated if positive. Patients are excluded if they have an active infection or on are on concurrent biologic response modifier. Patient must also be assessed for the risk of hepatitis B and if appropriate, be tested.
Required Medical Information: Rheumatoid Arthritis/Juvenile Rheumatoid Arthritis - patient must demonstrate inadequate response to at least 1 DMARD or intolerance to 2 DMARDs. Psoriasis - patient must be a candidate for systemic therapy or phototherapy. Ankylosing spondylitis - patient must demonstrate inadequate response or intolerance to at least 2 NSAIDs. Reactive arthritis - patient must demonstrate inadequate response or intolerance to at least 2 of the following, NSAIDs, intra-articular steroid injections, or sulfasalazine, if indicated.
Age Restrictions: Psoriasis - Approve for those 18 years of age or older
Prescriber Restrictions:
Coverage Duration: 12 months
Other Criteria:

Drugs: PROCRIT
Covered Uses: All FDA-approved indications not otherwise excluded from Part D
Exclusion Criteria: CRF, Hepatitis C, elective surgery, HIV/zidovudine - transferrin saturation less than 20% and patient not receiving iron supplementation where clinically appropriate. CRF, Hepatitis C, elective surgery, HIV/zidovudine, MDS, and anemia in patients with non-myeloid malignancies - hemoglobin level of the patient (not the result of a recent blood transfusion) greater than 13 g/dL. Lack of initial diagnosis of anemia (hematocrit less than 30% and/or hemoglobin less than 10 g/dL and/or symptomatic with hemoglobin 10-11g/dL).
Required Medical Information: CRF, Hepatitis C, elective surgery, HIV/zidovudine - iron status of the patient has been evaluated (serum transferrin saturation). CRF, Hepatitis C, elective surgery, HIV/zidovudine, and anemia of cancer - Hemoglobin level of the patient will be monitored prior to each dose when initiating therapy, for dose changes, and at regular intervals when the dose is stabilized. Blood pressure of the patient will be monitored throughout therapy. Patient will be monitored for the occurrence of thrombotic events.
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: Initiation of therapy and/or dose changes - 6 weeks. Stable on therapy - 12 weeks.
Other Criteria: Once on therapy, compared to pretreatment baseline, the patient must show an objective clinical response (e.g., hemoglobin rise greater than 1 g/dL and/or hematocrit rise greater than 3%) to an appropriate dose/dose increase and duration of therapy.

Drugs: EXJADE
Covered Uses: All FDA-approved indications not otherwise excluded from Part D
Exclusion Criteria: 1.) Age younger than 2 years, 2.) Patients who will NOT be monitored for LFTs, SCr, CBC, serum ferritin.
Required Medical Information: 1) Baseline and monthly serum creatinine and LFT montoring required, 2) Baseline and periodic monitoring of CBC with differential and serum ferritin.
Age Restrictions: Must be at least 2 years of age
Prescriber Restrictions:
Coverage Duration: 12 months
Other Criteria: Dose of Exjade may be adjusted (if necessary) every three to six months based on serum ferritin trends

Drugs: EXTAVIA
Covered Uses: All FDA-approved indications not otherwise excluded from Part D
Exclusion Criteria:
Required Medical Information: For first clinical episode, diagnosis must be confirmed by MRI
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: 12 months
Other Criteria:

Drugs: GLEEVEC
Covered Uses: All FDA-approved indications not otherwise excluded from Part D, Adult pts with newly diagnosed Ph+ALL as part of combination chemotherapy.
Exclusion Criteria: Pregnancy
Required Medical Information: 1. CML and ALL must express either BCR-ABL fusion gene or the Philadelphia chromosome. 2. ALL must be either relapsed or refractory. 3. Combination chemotherapy required for newly diagnosed ALL. 4. MDS/MPD must be associated with PDGFR gene rearrangements. 5. DFSP classified as being unresectable, recurrent, and/or metastatic. 6. GIST must be metastatic and/or unresectable.
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: 12 months
Other Criteria: Instruction on appropriate contraceptive methods.

Drugs: NORDITROPIN, SAIZEN, TEV-TROPIN
Covered Uses: All FDA-approved indications not otherwise excluded from Part D
Exclusion Criteria: Severe respiratory impairment or sleep apnea (Prader-Willi syndrome)
Required Medical Information: Growth hormone stimulation tests
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: 6 months
Other Criteria:

Drugs: HUMIRA
Covered Uses: All FDA-approved indications not otherwise excluded from Part D
Exclusion Criteria: Patients are excluded if they have an active infection or on are on concurrent biologic response modifier.
Required Medical Information: Patient must be evaluated for latent TB with a PPD test and be treated if positive. Patient must also be assessed for the risk of hepatitis B and if appropriate, be tested.
Age Restrictions: Rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, Crohn's disease, plaque psoriasis - Approve for those 18 years of age or older
Prescriber Restrictions:
Coverage Duration: 12 months
Other Criteria: RA/JIA - patient must demonstrate inadequate response to at least 1 DMARD or intolerance to 2 DMARDs. Psoriasis - patient must be a candidate for systemic therapy or phototherapy. Ankylosing spondylitis - patient must demonstrate inadequate response or intolerance to at least 2 NSAIDs. Crohn's disease - patient must demonstrate an inadequate response to 2 conventional therapies such as glucocorticosteroids, sulfasalazine, balsalazide, mesalamine, azathioprine, cyclosporine, methotrexate or 6-mercaptopurine, or to Remicade.

Drugs: INCRELEX
Covered Uses: All FDA-approved indications not otherwise excluded from Part D
Exclusion Criteria: Closed epiphyses. Other secondary causes of growth failure. Pre-existing thyroid and/or nutritional deficits. Presence of active or suspected neoplasia.
Required Medical Information: Failure of a growth hormone stimulation test. Genetic testing for growth hormone gene deletion. Lab testing for neutralizing antibodies to growth hormone.
Age Restrictions: Approve for those 2 years of age or older
Prescriber Restrictions:
Coverage Duration: 12 months
Other Criteria: Height of the patient greater than or equal to 3 standard deviations below the norm for children of the same age and gender prior to beginning Increlex therapy. Basal IGF-1 level greater than or equal to 3 standard deviations below the norm for children of the same age and gender prior to beginning Increlex therapy. Increase in height velocity of 2 cm/year within the first year of Increlex therapy.

Drugs: INFERGEN
Covered Uses: All FDA-approved indications not otherwise excluded from Part D
Exclusion Criteria:
Required Medical Information: Patient must have compensated liver disease with detectable levels of hepatitis C virus RNA in the serum
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: 3 to 9 months depending on genotype and initial vs. renewal therapy
Other Criteria: 2-log decrease in viral load for renewals

Drugs: ITRACONAZOLE CAPS
Covered Uses: All FDA-approved indications not otherwise excluded from Part D
Exclusion Criteria: Congestive heart failure, history of congestive heart failure, evidence of left ventricular dysfunction.
Required Medical Information: LFTs, fungal diagnostic test (e.g., KOH preparation, fungal culture, or nail biopsy)
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: Onychomycosis-2 months fingernails, 3 months toenails, all others uses 6 months
Other Criteria:

Drugs: GAMMAGARD, GAMUNEX
Covered Uses: All FDA-approved indications not otherwise excluded from Part D
Exclusion Criteria:
Required Medical Information: HSCT - IVIG is to be used in patients that have developed severe hypogammaglobulinemia (IgG less than 400) within the first 100 days post transplant.
Age Restrictions: BMT - patients have to be 20 years of age or older. HIV - patient has to be younger than 13 years of age.
Prescriber Restrictions:
Coverage Duration: 4 months- CIDP, BMT, HSCT 6 months - ITP, Kawasaki, Parvovirus B19 12 months - remaining covered uses
Other Criteria: Kawasaki disease - IVIG is to be used in conjunction with high dose aspirin. BMT - IVIG is to be used within the first 100 days after BMT. Dermatomyositis - IVIG is to be used only if corticosteroid is not a therapeutic option. GBS - IVIG is to be used for patients who require aid to walk within 2 or 4 weeks from the onset of neuropathic symptoms. Hyperimmunoglobulinemia E syndrome - diagnosis has to be coincident with eczema and atopic dermatitis. RRMS - IVIG is to be used as 2nd line treatment.

Drugs: LETAIRIS
Covered Uses: All FDA-approved indications not otherwise excluded from Part D
Exclusion Criteria: Patients with baseline aminotransferase (AST, ALT) level 3x the upper limit of normal , women who are or who may become pregnant
Required Medical Information: 1. Baseline serum AST, ALT, and bilirubin and monthly thereafter. 2. Hemoglobin and hematocrit at baseline, at one month of treatment, and periodically thereafter. 3. Pregnancy excluded by a negative urine or serum pregnancy test prior to therapy and monthly during Letairis therapy.
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: 12 months
Other Criteria: 1. Letairis to be discontinued if liver aminotransferase becomes greater than 5x ULN or if elevations are accompanied by bilirubin greater than 2x ULN or by symptoms of liver dysfunction. 2. Women of childbearing potential must consistently utilize either an intrauterine device or 2 appropriate contraceptive methods for the duration of therapy. 3. Pt to avoid consumption of grapefruit and grapefruit-containing products during the therapy. 4. Pt must have WHO Class II or III symptoms.

Drugs: LIDODERM
Covered Uses: All FDA-approved indications not otherwise excluded from Part D
Exclusion Criteria: Sensitivity to local anesthetics of the amide type (e.g., procaine, tetracaine, benzocaine), skin is broken or inflamed where the patch is to be applied.
Required Medical Information:
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: 12 months
Other Criteria:

Drugs: LOTRONEX
Covered Uses: All FDA-approved indications not otherwise excluded from Part D
Exclusion Criteria: 1. Male 2. Chronic or severe constipation or sequelae from constipation 3. Intestinal obstruction, stricture, toxic megacolon, gastrointestinal perforation, and/or adhesions 4. Ischemic colitis, impaired intestinal circulation, thrombophlebitis or hypercoagulable state 5. Crohn's disease or ulcerative colitis 6. Diverticulitis 7. Severe hepatic impairment.
Required Medical Information: Patient must have severe diarrhea-predominant IBS with one or more of the following: 1. frequent and severe abdominal pain/discomfort 2. Frequent bowel urgency or fecal incontinence 3. Disability or restriction of daily activity due to IBS.
Age Restrictions: 18 years of age and older
Prescriber Restrictions:
Coverage Duration: 1 month initial, 12 months on renewal
Other Criteria:

Drugs: LUPRON DEP-PED, LUPRON DEPOT
Covered Uses: All FDA-approved indications not otherwise excluded from Part D
Exclusion Criteria: 1) Diagnosis of uterine fibroids (uterine leiomyomata) exclusions are male, less than 18 years of age, pregnant and/or breast feeding, no diagnosis of anemia (e.g., hematocrit less than 30% and/or hemoglobin less than 10 g/dL), not being used in conjunction with iron therapy. 2) Diagnosis of endometriosis exclusions are male, less than 18 years of age, pregnancy and/or breast feeding, (renewal exclusions for endometriosis) are no recurrence of symptoms, bone mineral density not within normal limits, more than one prior course of Lupron therapy for endometriosis, no add-back therapy prescribed with Lupron Depot. 3) Diagnosis of advanced prostatic cancer exclusions are female, non-advanced prostate cancer. 4) Diagnosis of central precocious puberty (CPP) exclusions are no confirmation of CPP by a pubertal response to a GnRH agonist test, bone age of patient is not advanced more than one year beyond the chronological age of the patient, intracranial tumor, onset of secondary sexual characteristics must be prior to eight years of age for females and nine yrs of age for males, therapy must be completed by 11yrs of age for females and 12 yrs of age for males, pregnancy.
Required Medical Information: CPP diagnosis only 1) FSH, LH, estradiol/testosterone monitoring at baseline and after 1-2 months of therapy, initiation or dose change, height, weight, and bone age of the patient be assessed at baseline and every 6 to 12 months of therapy, 2) appropriate diagnostic imaging of the head been done to exclude an intracranial tumor. 3) The following been evaluated, if indicated: a. adrenal steroid levels to exclude congenital adrenal hyperplasia, b. appropriate diagnostic imaging to exclude a steroid secreting tumor, c. beta human chorionic gonadotropin level to exclude a chorionic gonadotropin secreting tumor (in males).
Age Restrictions: 1. ) Uterine Fibroids/Endometriosis - 18 years of age and older 2.) CPP - therapy must be completed by 11years of age for females and 12 years of age for males.
Prescriber Restrictions:
Coverage Duration: 3 months-Uter Fibrds, Initial CPP, 6 months- Endometrosis, 12 months- Prostate CA, renewal for CPP
Other Criteria: Patient and/or the patient's guardian been informed of the potential dangers to a fetus from Lupron therapy and the importance of not conceiving a child during Lupron therapy

Drugs: MEGACE ES
Covered Uses: All FDA-approved indications not otherwise excluded from Part D, cachexia in patients with a diagnosis of cancer.
Exclusion Criteria: All Part D-excluded indications
Required Medical Information:
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: 12 months
Other Criteria:

Drugs: CONCERTA, DEXMETHYLPHENIDATE, METADATE, METADATE CD, METHYLIN, METHYLPHENIDATE, RITALIN LA
Covered Uses: All FDA-approved indications not otherwise excluded from Part D
Exclusion Criteria: MAOI concurrent use or within the last 14 days
Required Medical Information: Sleep studies for narcolepsy diagnosis
Age Restrictions: Approved for those 6 years of age or older
Prescriber Restrictions:
Coverage Duration: 12 months
Other Criteria: Monitor for weight loss, decreased growth velocity in children, increased heart rate and blood pressure, appearance or worsening of aggressive behavior or hostility, sleep disturbances and long-term usefulness of the drug

Drugs: NEULASTA
Covered Uses: All FDA-approved indications not otherwise excluded from Part D
Exclusion Criteria: Neulasta treatment within the last 14 days. Treatment of acute afebrile neutropenia.
Required Medical Information: Current and periodic monitoring of WBC count at initiation of and during therapy.
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: 6 months
Other Criteria: Neulasta administration will be delayed a minimum of 24 hours after the administration of cytotoxic chemotherapy.

Drugs: NEUPOGEN
Covered Uses: All FDA-approved indications not otherwise excluded from Part D, bone marrow transplantation failure or engraftment delay. Neutropenia AIDS associated with treatment or disease, myelodysplastic syndromes, drug-induced neutropenia.
Exclusion Criteria: Treatment of acute afebrile neutropenia. Patients not at at high risk for infection-associated complications or not having prognostic factors that are predictive of poor clinical outcomes.
Required Medical Information: Current and periodic monitoring of WBC count at initiation of and during therapy.
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: 3 months
Other Criteria: Treatment to be halted in the event of excessive leukocytosis.

Drugs: OCTREOTIDE
Covered Uses: All FDA-approved indications not otherwise excluded from Part D.
Exclusion Criteria:
Required Medical Information:
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: 12 months
Other Criteria:

Drugs: FENTANYL OT LOZENGE
Covered Uses: All FDA-approved indications not otherwise excluded from Part D.
Exclusion Criteria:
Required Medical Information:
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: 1 month for initial or titrating patients, 3 months for all others
Other Criteria:

Drugs: FORTEO
Covered Uses: All FDA-approved indications not otherwise excluded from Part D
Exclusion Criteria: Paget's disease, unexplained elevation of alkaline phosphatase, open epiphyses, bone cancer or cancer that has metastasized to the bone, history of breat cancer, prior radiation therapy involving the skeleton, hypercalcemia, treatment with Forteo for greater than or equal to 24 months, concurrent bisphosphonate therapy during treatment with Forteo
Required Medical Information:
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: 12 months
Other Criteria: For diagnosis of primary osteoporosis or hypogonadal osteoporosis patient must have at least one of the following: history of osteoporotic fractures, multiple risk factors for fractures, OR has failed or is intolerant to traditional osteoporosis therapy

Drugs: PEGASYS
Covered Uses: All FDA-approved indications not otherwise excluded from Part D
Exclusion Criteria:
Required Medical Information: For chronic hepatitis C, patient must have compensated liver disease with detectable levels of HCV RNA in the serum. For chronic hepatitis B, patient must have a positive serum marker for HBV replication, persistently elevated aminotransferase levels greater than 2 times ULN, or signs of chronic hepatitis B on liver biopsy, or cirrhosis of the liver as evidenced by radiological or clinical data, or extrahepatic complications.
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: Chronic hepatitis C - 3 to 9 months. Chronic hepatitis B - 12 months.
Other Criteria: For chronic hepatitis C, patient must have 2-log decrease in viral load for renewals.

Drugs: PEGINTRON
Covered Uses: All FDA-approved indications not otherwise excluded from Part D
Exclusion Criteria:
Required Medical Information: Patient must have compensated liver disease with detectable levels of hepatitis C virus RNA in the serum
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: 3 to 9 months depending on genotype and initial vs. renewal therapy
Other Criteria: 2-log decrease in viral load for renewals

Drugs: PROVIGIL
Covered Uses: All FDA-approved indications not otherwise excluded from Part D
Exclusion Criteria:
Required Medical Information: Polysomnography required for narcolepsy and OSAHS
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: 12 months
Other Criteria:

Drugs: REBIF
Covered Uses: All FDA-approved indications not otherwise excluded from Part D
Exclusion Criteria:
Required Medical Information: For first clinical episode, diagnosis must be confirmed by MRI
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: 12 months
Other Criteria:

Drugs: REMICADE
Covered Uses: All FDA-approved indications not otherwise excluded from Part D
Exclusion Criteria: Patients are excluded if they have an active infection or moderate to severe CHF
Required Medical Information: Patient must be evaluated for latent TB with a PPD test and be treated if positive. Patient must also be assessed for the risk of hepatitis B and if appropriate, be tested.
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: 12 months
Other Criteria: RA - patient must demonstrate inadequate response to at least 1 DMARD or intolerance to 2 DMARDs. Remicade is to be used in combination with methotrexate. Crohn's disease - patient must demonstrate an inadequate response to at least 2 first-line agents such as glucocorticosteroids, sulfasalazine, balsalazide, mesalamine, azathioprine, cyclosporine, methotrexate, or 6-mercaptopurine unless the patient has multiple draining enterocutaneous or rectovaginal fistulae, which would make Remicade first-line therapy. Ulcerative colitis - patient must demonstrate an inadequate response to at least 2 first-line agents such as oral or rectal 5-ASA products or glucocorticosteroids. Ankylosing spondylitis - patient must demonstrate inadequate response to at least 2 NSAIDs or intolerance to 2 NSAIDs. Psoriasis - patient must be a candidate for systemic therapy or phototherapy. Reactive arthritis - patient must demonstrate inadequate response to at least 2 first-line agents such as NSAIDs or DMARDs. IBDA - patient must demonstrate an inadequate response to at least 2 first-line agents such as sulfasalazine, azathioprine, 6-mercaptopurine, MTX or oral steroids.

Drugs: REVATIO
Covered Uses: All FDA-approved indications not otherwise excluded from Part D
Exclusion Criteria: Concurrent nitrate therapy. PAH associated with any of the following: left heart disease, chronic thrombotic disease, embolic disease, compression of pulmonary vessels, lung diseases, hypoxemia, sarcoidosis
Required Medical Information:
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: 12 months
Other Criteria:

Drugs: REVLIMID
Covered Uses: All FDA-approved indications not otherwise excluded from Part D
Exclusion Criteria: Pregnancy
Required Medical Information: If female of child bearing potential, pregnancy excluded by 2 negative urine or serum pregnancy tests. For MM requirement of combination therapy with dexamethasone and at least one prior MM treatment. For MDS: diagnosis of anemia due to Low- or Intermediate-1-risk MDS associated with a deletion 5q cytogenetic abnormality, transfusion dependent
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: 12 months
Other Criteria: Instruction regarding importance and proper utilization of appropriate contraceptive methods. Monitor CBC on regular basis.

Drugs: REBETOL SOLN, RIBAPAK, RIBASPHERE, RIBAVIRIN
Covered Uses: All FDA-approved indications not otherwise excluded from Part D
Exclusion Criteria: History of unstable heart disease, hemoglobin less than 8.5, creatinine clearance less than 50, pregnancy, hemoglobinopathy.
Required Medical Information: Patient must have detectable levels of HCV RNA in the serum and be on an alfa interferon product concurrently.
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: 4 to 8 months, depending on genotype and initial vs. renewal therapy.
Other Criteria: 2-log decrease in viral load for renewals

Drugs: RITUXAN
Covered Uses: All FDA-approved indications not otherwise excluded from Part D, Chronic lymphocytic leukemia (CLL). Immune thrombocytopenic purpura (ITP). Waldenstrom's macroglobulinemia.
Exclusion Criteria: RA - Rituxan cannot be used concomitantly with another biologic DMARD.
Required Medical Information: Prescriber has to asses the patient for the risk of hepatitis B, and if clinically indicated, test the patient for hepatitis B infection before initiation or continuation of therapy with Rituxan.
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: NHL, RA, CLL, Waldenstrom's macroglobulinemia - 12 months. ITP - 1 month.
Other Criteria: For NHL, the diagnosis must fall into one of the following categories of CD20-positive B-cell NHL: - relapsed or refractory, low-grade or follicular - previously untreated follicular, in combination with CVP chemotherapy - low grade in patients with stable disease or who achieve a partial or complete response following first-line treatment with CVP chemotherapy - diffuse large B-cell, treated first line in combination with CHOP or other anthracycline-based chemotherapy - relapsed or refractory diffuse large B-cell lymphoma. For ITP, patient has to be refractory to first line treatment with corticosteroids and/or IVIG.

Drugs: SANCUSO
Covered Uses: All FDA-approved indications not otherwise excluded from Part D, Chronic lymphocytic leukemia (CLL). Immune thrombocytopenic purpura (ITP). Waldenstrom's macroglobulinemia.
Exclusion Criteria:
Required Medical Information:
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: 6 months
Other Criteria: The patient must be unable to tolerate oral therapy.

Drugs: SANDOSTATIN LAR
Covered Uses: All FDA-approved indications not otherwise excluded from Part D
Exclusion Criteria:
Required Medical Information: Patient had prior therapy with sandostatin injection (not depot form) and treatment was effective and tolerated.
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: 12 months
Other Criteria:

Drugs: SOMATULINE DEPOT
Covered Uses: All FDA-approved indications not otherwise excluded from Part D
Exclusion Criteria:
Required Medical Information:
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: 12 months
Other Criteria: Either surgery and/or radiotherapy is not a therapeutic option for the patient or the patient has had inadequate response to surgery and/or radiotherapy

Drugs: SOMAVERT
Covered Uses: All FDA-approved indications not otherwise excluded from Part D
Exclusion Criteria:
Required Medical Information: Monitor IGF-1 levels at 6 month intervals after IGF-1 levels stabilize within normal range. Monitor LFTs as recommended during therapy.
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: 12 months
Other Criteria: Prior to initiation of therapy IGF-1 levels were above age and gender adjusted normal range. If patient has been on therapy for the past 6 months demonstration of significant decrease in IGF-1 levels required. Patients were considered for/received treatment with surgery, radiation therapy, or medical treatment for acromegaly but rejected as inappropriate or had inadequate response.

Drugs: STELARA
Covered Uses: All FDA-approved indications not otherwise excluded from Part D
Exclusion Criteria: Active infection (including tuberculosis), concurrent use with other biologics
Required Medical Information: Screening for latent tuberculosis is required. If results are positive, patient must have completed treatment or must currently be receiving treatment for latent tuberculosis.
Age Restrictions: 18 years of age and older
Prescriber Restrictions:
Coverage Duration: 12 months
Other Criteria:

Drugs: OXANDRIN, OXANDROLONE
Covered Uses: All FDA-approved indications not otherwise excluded from Part D
Exclusion Criteria: Known or suspected carcinoma of the prostate or breast (in male patients), carcinoma of the breast in women with hypercalcemia, pregnancy, nephrosis (the nephrotic phase of nephritis), hypercalcemia.
Required Medical Information:
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: 6 months
Other Criteria:

Drugs: STRATTERA
Covered Uses: All FDA-approved indications not otherwise excluded from Part D
Exclusion Criteria: MAOI concurrent use or within the last 14 days
Required Medical Information:
Age Restrictions: Approved for those 6 years of age or older
Prescriber Restrictions:
Coverage Duration: 12 months
Other Criteria: monitor for suicidality, clinical worsening, changes in behavior, blood pressure changes, heart rate changes, weight loss, decreased growth velocity in children, sleep disturbances, liver injury

Drugs: SUTENT
Covered Uses: All FDA-approved indications not otherwise excluded from Part D
Exclusion Criteria: Pregnancy
Required Medical Information: Pregnancy excluded by a negative urine or serum pregnancy test.
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: 6 months
Other Criteria: Pt to be instructed on appropriate contraceptive methods.

Drugs: TERBINAFINE
Covered Uses: All FDA-approved indications not otherwise excluded from Part D
Exclusion Criteria:
Required Medical Information: LFTs, fungal diagnostic test (e.g., KOH preparation, positive fungal culture, or nail biopsy)
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: 2 months for fingernails only, 3 months if toenail involvement
Other Criteria:

Drugs: ANDRODERM, ANDROGEL, TESTIM
Covered Uses: All FDA-approved indications not otherwise excluded from Part D
Exclusion Criteria: Female, prostate cancer, breast cancer
Required Medical Information: Before the start of testosterone therapy patient has (or patient currently has) a confirmed low testosterone level (i.e. total testosterone less than 300 ng/dL, free or bioavailable, testosterone less than 5 ng/dL) or absence of endogenous testosterone
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: 12 months
Other Criteria:

Drugs: THALOMID
Covered Uses: All FDA-approved indications not otherwise excluded from Part D
Exclusion Criteria: Pregnancy
Required Medical Information: If female of child bearing potential, pregnancy excluded by 2 negative urine or serum pregnancy tests. For MM requirement of combination therapy with dexamethasone. For ENL if have moderate to severe neuritis Thalomid can not be used as monotherapy.
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: 12 months
Other Criteria: Instruction regarding importance and proper utilization of appropriate contraceptive methods.

Drugs: REGRANEX
Covered Uses: All FDA-approved indications not otherwise excluded from Part D
Exclusion Criteria: Neoplasm at intended site of application, active wound infection not under control by way of active treatment
Required Medical Information: Ulcer size after 10 weeks of therapy, does ulcer have adequate blood supply, ulcer extending into subcutaneous tissue or beyond
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: 3 months, then additional 2 months upon renewal
Other Criteria:

Drugs: TRACLEER
Covered Uses: All FDA-approved indications not otherwise excluded from Part D
Exclusion Criteria: 1. Pulmonary hypertension (Group 2-5) associated with: -Left heart disease -Chronic thromboembolic disease -Compression of pulmonary vessels (e.g., adenopathy, tumor, fibrosing mediastinitis) -Lung diseases and/or hypoxemia (e.g., COPD, sleep disorders) -Sarcoidosis 2. Pregnancy 3. Co-administration with cyclosporine A 4. Co-administration with glyburide
Required Medical Information: 1. Baseline serum aminotransferase levels (AST, ALT) and monthly thereafter. 2. Pregnancy excluded prior to therapy and monthly during the therapy. 3. Monitor hemoglobin level after 1 and 3 months of therapy and then every 3 months during the therapy.
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: 12 months
Other Criteria: Pt to use more than one method of contraception and not rely upon hormonal contraception alone.

Drugs: VENTAVIS
Covered Uses: All FDA-approved indications not otherwise excluded from Part D
Exclusion Criteria: Pulmonary hypertension (Group 2-5) associated with: 1. Left heart disease 2. Chronic thromboembolic disease 3. Compression of pulmonary vessels (e.g., adenopathy, tumor, fibrosing mediastinitis) 4. Lung diseases and/or hypoxemia (e.g., COPD, sleep disorders) 5. Sarcoidosis
Required Medical Information: 1. Pt must have NYHA Class III or IV symptoms (e.g., noticeable limitations of physical activity, unable to carry out any physical activity without discomfort, symptoms of cardiac insufficiency at rest) 2. Pt must have SBP greater than 85 mmHg
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: 12 months
Other Criteria:

Drugs: VOTRIENT
Covered Uses: All FDA-approved indications not otherwise excluded from Part D
Exclusion Criteria: Concurrent elevations of alanine transaminase (ALT) more than 3 times the upper limit of normal (ULN) and bilirubin greater than 2 times ULN
Required Medical Information: Serum liver tests should be monitored before initiation of treatment and at least once every 4 weeks for at least the first 4 months of treatment or as clinically indicated.
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: 12 months
Other Criteria:

Drugs: XENAZINE
Covered Uses: All FDA-approved indications not otherwise excluded from Part D
Exclusion Criteria: Actively suicidal, untreated or inadequately treated depression, impaired hepatic function, current use of monoamine oxidase inhibitors or reserpine.
Required Medical Information: Ulcer size after 10 weeks of therapy, does ulcer have adequate blood supply, ulcer extending into subcutaneous tissue or beyond
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: 12 months
Other Criteria: In patients who are taking reserpine, at least 20 days should elapse after stopping reserpine before initiation of Xenazine therapy.

Drugs: XOLAIR
Covered Uses: All FDA-approved indications not otherwise excluded from Part D
Exclusion Criteria: Xolair is not to be used as monotherapy.
Required Medical Information: Positive aeroallergen skin or blood test. Pre-treatment IgE level to be between 30 and 700 IU/mL
Age Restrictions: 12 years of age and above
Prescriber Restrictions:
Coverage Duration: 12 months
Other Criteria: Patient must be inadequately controlled on inhaled corticosteroids.

Drug Names

FANAPT, INVEGA, SAPHRIS

Step Therapy Criteria

The member has filled a prescription for risperidone, Geodon, Seroquel, Seroquel XR or Zyprexa for at least a 30 day supply OR The member has a documented contraindication to or a potential drug interaction with generic risperidone OR The member is intolerant to or had a confirmed adverse event with generic risperidone, Geodon, Seroquel, Seroquel XR or Zyprexa OR The member has had an inadequate treatment response to at least a 30 day trial of generic risperidone, Geodon, Seroquel, Seroquel XR or Zyprexa.

Drug Names

FLOMAX, UROXATRAL

Step Therapy Criteria

The member has filled a prescription for generic doxazosin or terazosin for at least a 15 day supply OR The member has a documented contraindication to or a potential drug interaction with a generic alpha-1 receptor antagonist (doxazosin or terazosin) OR The member is intolerant to or had a confirmed adverse event with generic doxazosin or terazosin OR The member has had an inadequate treatment response to at least a 15 day trial of generic doxazosin or terazosin.

Drug Names

VYTORIN

Step Therapy Criteria

The member has filled a prescription for generic lovastatin, pravastatin or simvastatin for at least a 30 day supply OR The member has a documented contraindication to or a potential drug interaction with a generic HMG (lovastatin, pravastatin or simvastatin) OR The member is intolerant to or had a confirmed adverse event with a generic statin OR The member has had an inadequate treatment response to at least a 30 day trial of a generic statin.

Drug Names	INVEGA SUSTENNA
Step Therapy Criteria	The member has filled a prescription for risperidone extended-release injection for at least a 30 day supply OR The member has had an inadequate treatment response to at least a 30 day trial of risperidone extended-release injection.

Drug Names

NASONEX, RHINOCORT

Step Therapy Criteria

The member has filled a prescription for generic fluticasone or flunisolide nasal for at least a 15 day supply OR The member has a documented contraindication to or a potential drug interaction with a generic nasal steroid (fluticasone or flunisolide) OR The member is intolerant to or had a confirmed adverse event with a generic nasal steroid (fluticasone or flunisolide) OR The member has had an inadequate treatment response to at least a 15 day trial of generic nasal steroid (fluticasone or flunisolide).

Drug Names	PANTOPRAZOLE
Step Therapy Criteria	The member has filled a prescription for generic omeprazole for at least a 15 day supply OR The member has a documented contraindication to or a potential drug interaction with generic omeprazole OR The member is intolerant to or had a confirmed adverse event with generic omeprazole OR The member has had an inadequate treatment response to at least a 15 day trial of generic omeprazole.

Drug Names

ELIDEL, PROTOPIC

Step Therapy Criteria

Elidel - member must be 2 years of age or older and failed any one medium- or higher-potency corticosteroid (14 day minimum therapy) within the previous six months. Protopic 0.03% - member must be 2 years of age or older and failed any one medium- or higher-potency corticosteroid (14 day minimum therapy) within the previous six months. Protopic 0.1% - member must be over 15 years of age and failed any one medium- or higher-potency corticosteroid (14 day minimum therapy) within the previous six months.

Drug Names	ULORIC
Step Therapy Criteria	The member has filled a prescription for generic allopurinol for at least a 30 day supply OR The member has a documented contraindication to or a potential drug interaction with generic allopurinol OR The member is intolerant to or had a confirmed adverse event with generic allopurinol OR The member has had an inadequate treatment response to at least a 30 day trial of generic allopurinol.