Select Formulary
Group	Covered Uses	Exclusion Criteria	Required Medical Information	Age Restriction	Prescriber Restrictions	Coverage Duration	Other Criteria
ACROMEGALY DRUGS	All medically accepted indications not otherwise excluded from Part D.		Obtain current medical records with labs: TSH, free T-4, IGF-I, zinc levels, Vitamin B-12 levels, ALT, AST, TBIL, and ALP and confirm appropriate diagnosis and dosing.			May approve through contract year.	Confirm no significant arrhythmias, preexisting cardiac conditions, cardiac monitoring during and after subsequent infusions and Confirm no DI: Amitriptyline, Clarithromycin, Cyclosporine, Desipramine, Dolasetron, Doxepin, Droperidol, Erythromycin, Flecainide, Fluconazole, Fluoxetine, Nortriptyline, Promethazine, Thioridazine, Trifluoperazine, Triflupromazine, Trimethoprim, Ziprasidone, and Zolmitriptan.
ACTIMMUNE	Chronic granulomatous disease, Osteopetrosis (Severe), Malignant.		Obtain medical records CBC with differential, blood chemistries and renal function tests, and hepatic function tests to confirm appropriate diagnosis and dosing.			May approve through contract year.	Confirm no current Rotavirus Vaccine.
ADDERALL XR	Attention Deficit Hyperactivity Disorder and narcolepsy.		Supporting statement by the prescriber.	Exclude if less than 3 years old.		May approve through the contract year.	Confirm FDA approve diagnosis, dosage, no presence of advance arteriosclerosis, symptom Cardiovascular Disease, moderate to severe hypertension, hyperthyroidism, known hypersensitivity or idiosyncrasy to the sympathomimetic amines, glaucoma, or agitated states and confirm fail or intolerance of amphetamine salts and at least one other generic.
AFINITOR	FDA approved indications A. All FDA approved indications not otherwise excluded from Part D.		The following copies of chart notes/laboratory reports are required: A. Confirm no concurrent use with Amprenavir,Aprepitant, Atazanavir,Clarithromycin, Delavirdine,Diltiazem, Erythromycin,Fluconazole, Fosamprenavir,Indinavir, Itraconazole,Ketoconazole, N	The patient is 18 years of age or older.	Oncologist	May approve up to 8 weeks initially then may approve thru plan year.	COVERAGE POLICY Afinitor is covered for members who meet the following criteria: A. Renal cell carcinoma, advanced disease after failure of treatment with sunitinib or sorafenib: 10 mg ORALLY once daily
ALDURAZYME	Mucopolysaccharidosis, Type I (Hurler and Hurler-Scheie forms) and Scheie form with moderate to severe symptoms.		Obtain current medical records to confirm appropriate diagnosis and dosing.	Exclude if younger than 5 years old.		May approve through the contract year.	Confirm moderate to severe symptoms (not mild).
ANTI-INFECTIVES	All medically accepted indications not otherwise excluded from Part D.					Approved compendia or FDA duration.	Confirm FDA or compendia approved diagnosis and dosing.
ANTITRYPSIN DEFICIENCY DRUGS	Alpha-1-antitrypsin deficiency.		Obtain last office visit notes and verify FDA approved diagnosis and verify yearly physician appointments occurred measuring elevations in serum and lung fluid levels of alpha-1 antitrypsin.	Exclude in children.		May approve through contract year.
CA DRUGS	All medically accepted indications not otherwise excluded from Part D.					May approve per prescribers request or end of the contract year.	Confirm FDA-approved indication and dosing is appropriate. Request current cholesterol, triglycerides, and glucose.
CANCIDAS	All medically accepted indications not otherwise excluded from Part D.					May approve up to 14 - 30 days.	Confirm no concurrent use with Cyclosporine and Tacrolimus.
CHORIONIC GONAD	Cryptorchidism,Hypogonadotropic hypogonadism.		Obtain currrent medical records, triglycerides, serum testosterone, dihydrotestosterone levels to confirm appropriate diagnosis and dosing.	Exclude in 4 years or younger.		May approve up to 6-9 months or end of contract year.	Confirm no precocious puberty, prostate cancer or other androgen dependent cancer.
CICLOPIROX	Onychomycosis due to dermatophyte (Mild to Moderate), Fingernails and toenails.		Positive potassium hydroxide (KOH) stain, para-aminosalicylic acid (PAS) stain, positive dermatophyte testing medium (DTM) or positive fungal culture.			May approve to end of contract year or 6 months.	If diabetic or immunocompromised, approve upon positive fungal culture. If not, must also experience pain or limiting normal activity or have significant peripheral vascular compromise. No approval if requesting drug due to failed treatment of Terbinafine, itraconazole, or pregnant.
COPAXONE	Copaxone is indicated for reduction of the frequency of relapses in patients with relapsing-remitting multiple sclerosis.		Ensure multiple sclerosis, relapsing-remitting with evidence of a neurological exam.	Exclude if less than 18 years old.		May approve through the Contract Year.	Confirm diagnosis is Relapsing or Remitting MS. Probable and possible diagnoses do not meet criteria, must be definitive diagnosis of Relapsing or Remitting MS. Confirm not allergic to mannitol and not Chronic Progressive MS.
CUBICIN	Infection of skin or subcutaneous tissue, Complicated,Staphylococcus aureus bacteremia, including right-sided endocarditis.		Obtain current medical records, CBC and liver panel to confirm appropriate diagnosis and dosing and current culture and sensitivity results listing causative organism.	Exclude if under 18 years old.		May approve 7 days to 16 weeks.	Confirm not treating pneumonia.
CUPRIMINE	Cystinuria, RA (Severe), Active disease that has failed to respond to conventional therapy, Wilson's disease. Non-FDA approved uses in CMS approved Compendia with favorable efficacy include Copper measurement, urine.		Obtain medical records and C-reactive protein levels, erythrocyte sedimentation rate (for RA) to confirm appropriate diagnosis and dosing. Confirm current 24-hour baseline copper excretion level.			May approve through contract year.	Confirm no concurrent use of gold therapy, antimalarial or cytotoxic drugs, oxyphenbutazone or phenylbutazone, and confirm no renal dysfunction.
ELAPRASE	Hunter syndrome: For patients with Hunter syndrome (mucopolysaccharidosis type II).		Obtain medical records to confirm appropriate diagnosis and dosing.	Exclude if under 4 years old.		May approve through contract year.
ERYTHROPOIETIN DRUGS	All medically accepted indications not otherwise excluded from Part D.		Request most current hematrocrit and hemoglobin levels.			May cover up to 12 weeks or end of the contract year.
EXJADE	Transfusional hemosiderosis.		Obtain current medical records with current serum Ferritin Levels.			May approve through the contract year.	Confirm FDA approved diagnosis and appropriate dosage and elevated serum Ferritin Levels greater than 500mcg per liter.
FABRAZYME	Fabry's disease.		Obtain current office visit notes to confirm appropriate diagnosis and dosing.	Exclude if younger than 8 years old.		May approve through contract year.
FORTEO	Osteoporosis, Primary or hypogonadal. Non-FDA approved uses in CMS approved Compendia with favorable efficacy include Postmenopausal osteoporosis.		Documented history of osteoporotic fracture, or who have multiple risk factors for fracture based upon MD assessment.DEXA T-score of less than or = to -2.5 at spine, hip, femoral neck in last 6 mo or radiographically-confirmed fragility fracture.			Through the contract year.	Confirm one or more of the following: try or fail or intolerant to previous osteoporosis meds including bisphosphonates, Evista. Confirm no documented baseline risk for osteosarcoma (Paget's disease) or Hyperparathyroid Disease, and no concurrent use of Bisphosphonate.
G-CSF DRUGS	All medically accepted indications not otherwise excluded from Part D.		Obtain current medical records and ANC levels (less than 1,000) or febrile neutropenia rate of 20 percet or higher to confirm appropriate diagnosis and dosing.			May approve up to 4 weeks per approval.	Confirm not currently taking Lithium and not administering between 14 days prior to and 24 hours after the administration of chemotherapy.
GAUCHER DRUGS	Non-neuropathic Gaucher's disease, chronic, Gaucher's disease, Type 1, symptomatic.		Request current medical records to confirm appropriate diagnosis and dosing. Obtain hematologic parameters, including hemoglobin, hematocrit, erythrocyte, platelet counts and IgG antibody formation.	If Cerezyme and Zavesca, adults only.		May approve through the contract year.	Note: In most patients, an increase in serum hemoglobin is the first indication of therapeutic effect.
GLEEVEC	All medically accepted indications not otherwise excluded from Part D.		Current Complete Blood Count with Liver Function Testing.	Exclude if less than 2 years old.		New starts, approve up to 60 days to ensure tolerability, then if tolerated, may approve through con	Confirm FDA approved diagnosis and appropriate dosage and no concurrent use of alfuzosin, aprepitant, carbamazepine, clarithromycin, cyclosporine, dexamethasone, eletriptan, erythromycin, itraconazole, ketoconazole, phenobarbital, phenytoin, pimozide, rifabutin, rifampin, rifapentine, St. John's Wort, voriconazole, warfarin.
GROWTH HORMONES	All medically accepted indications not otherwise excluded from Part D.		Obtain current medical records, glucose levels, serum levels of inorganic phosphorus, alkaline phosphatase, and parathyroid hormone to confirm appropriate diagnosis and dosing and growth hormone stimulation test.			May approve through contract year.	No stimulation testing is required where it would not be expected to produce a clinical response, e.g., for a diagnosis of panhypopituitarism, defined by the absence of all anterior pituitary hormones.
HEPSERA	Type B viral hepatitis, chronic.		Obtain medical records, evidence of Active Viral Replication, history of persistent elevations of serum aminotransferases (ALT or AST) to confirm appropriate diagnosis.	Exclude if less than 12 years old.		May approve through the end of the contract year, if requested.	Confirm no lactic acidosis or concurrent use with Ibuprofen.
HEXALEN	Ovarian CA, Non FDA approved uses in CMS approved Compendia with favorable efficacy include: Breast, Colon, Endometrial, Small cell lung CA, Malignant lymphoma, Multiple myeloma.		Current office visit notes and WBC less than 2000/mm3 or granulocyte count less than 1000/mm3 and platelet count less than 75,000/mm3.	Excluded in children.		Approve 21 days initially then if tolerated, may approve through contract year.	Obtain current office visit notes to confirm first-line therapy with a cisplatin- or alkylating agent-based combination.
IMMUNOSUPPRESSANTS	All medically accepted indications not otherwise excluded from Part D.		Confirm all FDA approved and favorable compendia indications with supporting statement.			May approve through contract year.	Determine if Part B or Part D for correct member cost share.
INFERGEN	Hepatitis C, chronic, in adult patients with compensated liver disease who have anti-HCV serum antibodies or HCV RNA.			Exclude if less than 18 years old.		Genotype 1 - 6, approve 16 weeks as initial authorization then up to 48 weeks depending on viral loa	Confirm no lactic acidosis or concurrent use with Ibuprofen.
INTRON A	All medically accepted indications not otherwise excluded from Part D.		Obtain current medical records with CBC with differential, liver panel, WBC with differential and confirm appropriate diagnosis and dosing.			May approve up to 6 months or end of the contract year.	Confirm no autoimmune liver disease, decompensated.If diagnosis is Hepatitis C, must have tried or failed or intolerant to Peg-interferons. Refer to the Hepatitis C Treatment criteria. If diagnosis is hairy cell leukemia, if no response in 6 months, discontinue tx.
ITRACONAZOLE	All FDA approved and favorable compendia indications.		Positive potassium hydroxide (KOH) stain, para-aminosalicylic acid (PAS) stain, positive dermatophyte testing medium (DTM) or positive fungal culture.			Approve 12 weeks toenail and 6 weeks fingernail onychomycosis. All others per prescriber request.	For Diabetic or immunocompromised, approve if positive fungal culture. If not, must experience pain or limiting normal activity OR have peripheral vascular compromise. No approval if requesting drug due to failed treatment of Terbinafine or itraconazole or pregnant. Do not approve if requesting drug due to failed treatment of Terbinafine. For aspergillosis, histoplasmosis, sporotrichosis, Paracoccidioidomycosis, Chromomycosis, Blastomycosis: CST or proof by biopsy of histopathology. Tinea corporis, cruris, pedis/pityriasis versicolor: CST, failed treatment of 1 OTC Product and Grisfulvin/Ketoconazole(last 30d). Oral/esophageal candidiasis: Failed treatment 2 of (last 30 days): Nystatin, Griseofulvin, Ketoconazole, Diflucan.
KINERET	Rheumatoid arthritis.Non-FDA approved uses in CMS approved Compendia with favorable efficacy include Chronic infantile neurological, cutaneous and articular syndrome, Treatment-refractory.		Obtain medical records and neutrophil count to confirm appropriate diagnosis and dosing.	Exclude if child.		May approve through contract year.	Fail/intolerant to one - MTX, Enbrel or Humira. Confirm no concurrent use of Live Vaccines.
LEUPROLIDE	Anemia or Preoperative hematologic, Preoperatively, with iron therapy, Central precocious puberty, Endometriosis, Prostate Cancer, Advanced (palliative treatment).Non-FDA approved uses in CMS approved Compendia with favorable efficacy include: Amenorrhea,		For prostate cancer: serum testosterone and prostate specific antigen For precocious puberty: GnRH stimulation test. For Uterine leiomyoma - Hematocrit	Endometriosis -exclude if under 18 years old.		Approve 6-12 months/through contract year depending on diagnosis.	Confirm advanced Prostate Cancer, then approve. Confirm central precocious puberty: Onset - 8 years females/9 years males and bone age advance 1 year past chronological age. Endometriosis, failed treatement within the last 6 months of NSAIDS/OC for 3 months. No retreatment, approve no more than 6 months. Uterine leiomyomata (fibroids), failed treatment within 6 months NSAIDS/DepoProvera. Approve no more than 3 months.Uterine leiomyomata/anemia, HCT less than 37%.
LMWH	All medically accepted indications not otherwise excluded from Part D.		Confirm appropriate diagnosis and dosing. Platelet Count not below 100,000mm.			Approve up to recommended duration for medically accepted indications.	Confirm following drugs are NOT currently being taken salicylates, dipyridamole, or sulfinpyrazone. Confirm no major bleeding.
LOTRONEX	Irritable bowel syndrome, Severe diarrhea-predominant and Non-FDA approved uses in CMS approved Compendia with favorable efficacy include Indigestion, Non-ulcer.		Obtain current medical records.	Exclude if a child.		May approve 4 weeks, then after 3 months, approve through contract year.	Ensure no ischemic colitis and Ensure no coadministration of Lotronex with fluvoxamine.
LOVAZA	Hypertriglycerides. Non-FDA approved uses in CMS approved Compendia with favorable efficacy include Familial combined hyperlipidemia and Coronary arteriosclerosis - Hypertriglyceridemia.		Current Triglyceride Level.	Exclude if less than 16 years old.		If meets criteria, may approve through the Contract Year.	Confirm failure or intolerance to generically available statins (i.e. lovastatin, pravastatin, or simvastatin). Confirm failure or intolerance to generically available fibrates (i.e. gemfibrozil, fenofibrate, etc).
LYRICA	Fibromyalgia, Diabetic peripheral neuropathy, Partial-onset seizures, Postherpetic neuralgia, Non-FDA approved uses in CMS approved Compendia with favorable efficacy include: Generalized anxiety disorder.		May obtain office visit notes confirming appropriate diagnosis listed above.			May approved for up to 8 weeks initially then may approve thru contract year.
LYSODREN	Adrenal cortical carcinoma.		Request current office visit notes to ensure FDA approved indication and dosage.			Through contract year.	Confirm not currently taking Warfarin.
MARINOL	AIDS - Loss of appetite,Chemothrapy induced Nausea and Vomiting, Prophylaxis. Non-FDA approved uses in CMS approved Compendia with favorable efficacy include Gilles de la Tourette's syndrome, Nausea and Vomiting, Disease-related, treatment refractory Naus		Obtain office visit notes to confirm appropriate diagnosis and dosing.			May approve up to five months or end of contract year.	Confirm no history of substance abuse, including alcohol abuse or dependence or major cardiac disease.For Nausea/Vomiting, confirm tried/failed intolerant to prochlorperazine and promethazine.
MATULANE	Hodgkin's disease, Stages III and IV, in combination with other anticancer drugs.Non-FDA approved uses in CMS approved Compendia with favorable efficacy include Intracranial tumor, Malignant, Multiple myeloma, Non-Hodgkin's lymphoma.		Obtain current medical records and the following Labs CBC with differential, renal and liver function.			May approve through contract year.	Confirm approved diagnosis and ensure appropriate dosing.
MEPRON	Pneumocystis pneumonia, Prophylaxis, Pneumocystis pneumonia (Mild to Moderate). Non-FDA approved uses in CMS approved Compendia with favorable efficacy include Babesiosis, Toxoplasmosis.		Obtain current medical records to confirm appropriate diagnosis and dosing. Obtain culture and sensitivity results listing causative organism.	Exclude if less than 13 years old.		May approve through contract year.	Confirm no concurrent use with Rifampin.
MESNEX	Prophylaxis of Ifosfamide-induced hemorrhagic cystitis. Non-FDA approved uses in CMS approved Compendia with favorable efficacy include Prevent or reduce hemorrhagic cystitis associated with high-dose cyclophosphamide therapy, Respiratory obstruction, Muc		Obtain current medical records to confirm proper diagnosis and dosing.	Exclude Children.		Through Contract Year.	Confirm not allergic to Mesna or related medicines (such as thimerosal, spironolactone, Purinethol, Tapazole, Aldactone)
MULTIPLE SCLEROSIS DRUGS	Multiple sclerosis. Safety and efficacy in patients with chronic progressive MS have not been established. Non FDA approved uses in CMS approved Compendia with favorable efficacy include Condyloma acuminatum and Ulcerative colitis.		Confirm current Complete Blood Counts (including liver function tests) have been obtained.	Exclude if less than 18 years old.		If meets criteria, may approve through the Contract Year.	Confirm diagnosis of Relapsing or Remitting MS. Probable and possible diagnoses do not meet criteria, must be definitive diagnosis of Relapsing or Remitting MS.
NAGLAZYME	Maroteaux-Lamy syndrome.		Obtain current medical records to confirm appropriate diagnosis and dosing.	Exclude if under 5 years old.		Through the end of the current contract year.
NEUTREXIN	Pneumocystis pneumonia.Non-FDA approved uses in CMS approved Compendia with favorable efficacy include Breast, Head and Neck, Colorectal, Esophagus and Non-small cell lung cancer.		Obtain current medical records to confirm appropriate diagnosis and dosing. Laboratory culture and sensitivities listing causative organism.	Exclude if less than 18 years old.		May approve for 6 months or end of contract year.	Confirm no concurrent use of methotrexate, zidovudine and Rotavirus Vaccine, Live.Documented failure or adverse reaction with trimethoprim-sulfamethoxazole use.
NEXAVAR	Advanced renal cell carcinoma and Hepatocellular carcinoma.		Request current office visit notes to ensure FDA approved indication and dosage.	Exclude Children.		May approve through contract year.	Ensure no painful erythema and swelling of the hands or feet or discomfort affecting normal activities, and ensure no moist desquamation, ulceration, blistering, or severe pain of the hands or feet, or severe discomfort that causes inability to work or perform activities of daily living.
NOXAFIL ORAL SUSPENSION	Oropharyngeal candidiasis: For the treatment of oropharyngeal candidiasis, including oropharyngeal candidiasis refractory to itraconazole and/or fluconazole. Prophylaxis of invasive fungal infection Prophylaxis of invasive Aspergillus and Candida infectio		Office visit notes with current Current Culture Sensitivity Testing (CST).	Exclude if 13 years or younger.		Approve through contract year.	Documented failure or intolerance to itraconazole and fluconazole.Confirm appropriate dosing.
ORENCIA	Rheumatoid arthritis (Moderate to Severe), in patients who have had an inadequate response to one or more disease-modifying anti-rheumatic drugs (adult only) Juvenile Idiopathic arthritis. Non-FDA approved uses in CMS approved Compendia with favorable eff		Obtain C-reactive protein levels, erythrocyte sedimentation rate (for RA).			May approve through contract year.	Confirm try or fail or intolerant to Enbrel or Humira.Confirm try or fail or intolerant to 6 months of therapy with methotrexate.Confirmed TB screening, and confirmation of no serious infection.
ORFADIN	Tyrosinemia type I, Adjunct.		Obtain medical records, liver/renal panel, plasma tyrosine concentration (below 500 mcmol/L) to confirm appropriate diagnosis and dosing.			May approve through contract year.
PAMIDRONATE	Bone metastasis, Osteolytic, associated with metastatic breast cancer or multiple myeloma, Hypercalcemia of malignancy (Moderate to Severe), With adequate hydration (adult only), Paget's disease (Moderate to Severe) (adult only) Non-FDA approved uses in C		Obtain current medical records to confirm appropriate diagnosis and dosing and disease progression and request serum calcium, electrolytes, potassium, magnesium, and phosphate levels, complete blood counts with differential and hematocrit-hemoglobin.			May approve through contract year.
PEG-INTRON	Hepatitis C, chronic.		Obtain current Medical Records with lab values to verify compensated liver disease: Viral Load (Serum HCV-RNA = Hepatitis C ribonucleic acid), ALT levels, genotype.	Exclude if less than 18 years old.		Geno 1 - 6 approve 16 weeks as initial authorization then up to 48 weeks depending on viral load.	Between week 12/16, evaluate positive viral response. Approve per the following: Genotype 1, if less 2 log decrease in HCV RNA, do not extend approval, without approve additional 32 weeks (total 48 weeks). Genotype 2 approve therapy 24 total weeks. Genotype 3 approve for 24 total weeks except patients with steatosis/initial high viral loads (patients than 600,000 IU/mL) approve for total 48 weeks. For Genotype 4, 5, or 6, approve for 48 total weeks. HIV receive therapy for 48 weeks. Treatment of chronic Hepatitis B in patients who have liver disease 48 weeks.
PEGASYS	Active type B viral hepatitis, chronic and Hepatitis C, chronic. In patients with compensated liver disease HIV infection.		Obtain current Medical Records with lab values to verify compensated liver disease: Viral Load (Serum HCV-RNA = Hepatitis C ribonucleic acid), ALT levels, genotype.	Exclude if less than 18 years old.		Geno 1 - 6 approve 16 weeks as initial authorization then up to 48 weeks depending on viral load.	Between week 12/16, evaluate positive viral response. Approve per the following: Genotype 1, if less 2 log decrease in HCV RNA, do not extend approval, without approve additional 32 weeks (total 48 weeks). Genotype 2 approve therapy 24 total weeks. Genotype 3 approve for 24 total weeks except patients with steatosis/initial high viral loads (patients than 600,000 IU/mL) approve for total 48 weeks. For Genotype 4, 5, or 6, approve for 48 total weeks. HIV receive therapy for 48 weeks. Treatment of chronic Hepatitis B in patients who have liver disease 48 weeks.
PROMACTA	FDA APPROVED INDICATION: Promacta is indications for A. Thrombocytopenia due to cirrhosis associated with hepatitis C Virus and B. Idiopathic thrombocytopenic purpura (chronic, relapsed or refractory)		Current Chart Notes including CBC, Platlet count, LFT, Peripheral blood differential	Patient must be 18 years or greater	"Enrolled in Promacta FDA REMS long term safety monitoring program"	6 months	CBC wnl, Platlet Count less than 50 x 10(9)/L ALT/AST/Bilirubin WNL, Intolerant to splenectomy, insufficient response/intolerant to corticosteroids AND immunoglobulins OR had splenectomy with inadequate response AND had an insufficient response/intolerant to post-splenectomy corticosteroids.
PROTONIX IV	All medically accepted indications not otherwise excluded from Part D.		Current medical records that confirm appropriate diagnosis and dosing.			May approve up to 4 weeks.	Member must have had failure with oral Omeprazole or generic Protonix or documented reason why the Injectable form is the preferred dosage form.
REGRANEX	All FDA approved and favorable compendia indications.		Obtain current medical records to confirm appropriate diagnosis and dosing and disease progression.	Exclude if under 16 years old.		May approve through contract year.
REMICADE	All medically accepted indications not otherwise excluded from Part D.		For RA only, obtain C-reactive protein levels, erythrocyte sedimentation rate.			May approve through contract year.	RA,PS - failed/intolerant to one - MTX, Enbrel or Humira. Confirm TB screening. Severe Plaque Psoriasis - confirm greater than 10% of BSA and failed/intolerant to one - calcipotriene, tazarotene or UVB. Crohns - confirm failed/intolerant to one - corticosteroids, 5-aminosalicylates, 6-mercaptopurine or azathioprine. AS-failed/intolerant to Enbrel or Humira.
REVATIO	Pulmonary hypertension.		Obtain current medical records, Liver Function Tests (LFTs), Hemoglobin and Hematocrit documenting FDA Indication and ensure appropriate dosing and compliance.			May approve through contract year.	Confirm no current nitrates therapy.
RIBAVIRIN	Hemopoietic stem cell transplant - Respiratory syncytial virus infection and Hepatitis C, chronic, In patients with compensated liver disease and Hepatitis C, chronic, In patients with compensated liver disease - HIV infection and Respiratory syncytial vi		Verify current Ccr is greater than 50mL/min.	None.		Same duration as the interferon or the end of the contract year, whichever comes first.	May approve the following dosages to through the end of the Contract year or weeks approved of Interferon: Genotype 1, 4 less than 75kg = 1,000mg per day or Genotype 1, 4 greater than 75kg = 1,200mg per day or Genotype 2, 3 800mg per day or Genotype 5, 6 between 800mg and 1,200mg per day or Chronic HCV with HIV coinfection - 800 mg/day tablets or Respiratory syncytial virus infection: (severe cases) 20 mg/mL solution aerosolized over 12-18 hr once daily for 3 to 7 days.
RITUXAN	All medically accepted indications not otherwise excluded from Part D.		Obtain current medical records with labs (CBC and platelet counts). Confirm screening patients HBV infection.	Exclude if child.		May approved through contract year.	Confirm Pneumovax administration, no significant arrhythmias or preexisting cardiac conditions. Confirm no Drug Interactions with Rotavirus Vaccine.
SMOKING CESSATION	Smoking cessation.		Office Documentation to include educational materials and counseling to support the quit attempt, target smoking quit date.	Exclude if for children.		Approve up to 4 wks. Re-eval progress then approve up to 16 weeks per contract year.	Verify if Inhaler is requested, completely stop smoking as they begin using the inhaler. OTC treatments are excluded from Part D.
SOLIRIS	Paroxysmal nocturnal hemoglobinuria.		Obtain current medical records with labs (complete blood counts (CBCs) with platelet count and serum chemistries (including LDH) to confirm appropriate diagnosis and dosing.	Exclude if 18 years or younger.		May approve through contract year.	Confirm administration of meningococcal vaccine at least 2 weeks prior to initiation of eculizumab therapy. Confirm no infection.
SOLTAMOX	Adjuvant treatment breast Cancer, High-risk Prophylaxis Breast Cancer, Intraductal Cancer breast situation, Metastatic Malignant neoplasm male breast, Metastatic breast Cancer. Non-FDA approved uses in CMS approved Compendia with favorable efficacy includ		Obtain current medical records and hepatic function labs.			May approve through the contract year.	Confirm appropriate diagnosis and dosing and confirm patient is unable to take oral tablet formulation through medical record documentation.
SPASM DRUGS	All medically accepted indications not otherwise excluded from Part D.		Confirm diagnosis with supporting statement.			May approve through contract year.	Confirm traditional methods of treatments have been tried or failed or intolerant. Confirm dosage and frequency of injections and the sites injected.
SPRYCEL	Accelerated phase chronic myeloid leukemia, Resistant or intolerant to imatinib, Acute lymphoid leukemia, Philadelphia chromosome-positive, resistant or intolerant to prior therapy, Blastic phase chronic myeloid leukemia, Resistant or intolerant to imatin		Obtain current medical records.	Exclude for children.		May approve up to 3 months, then if tolerated, may approve thru contract year.	Confirm appropriate diagnosis and dosing and resistant or intolerant to imatinib with current medical records.
SUBOXONE	Opioid dependence.		Obtain medical records and liver panel to confirm appropriate diagnosis and dosing.	Exclude if 16 years old or younger.		May approve up to 3 months or end of contract year.	Confirm no concurrent use of CNS depressants or alcohol.
SUCRAID	Sucrase-isomaltase deficiency, Congenital.		Obtain medical records to confirm appropriate diagnosis and dosing.			May approve through the contract year.	Confirm no hypersensitivity to sacrosidase, yeast, glycerol.
SUTENT	Gastrointestinal stromal tumor, after disease progression on or intolerance to imatinib and Renal cell carcinoma, Advanced.		Obtain medical records.	Exclude for children.		May approve 3 months, then if tolerated, may approve through the contract year.	Obtain medical records to confirm appropriate diagnosis and dosing and disease progression on or intolerant to Gleevec (imatinib).
TABLOID	Acute myeloid leukemia, Induction and consolidation therapy only. Non-FDA approved uses in CMS approved Compendia with favorable efficacy include: Crohn's disease, Intracranial tumor, Non-Hodgkin's lymphoma, Psoriasis.		Obtain current medical records and lab values including hematocrit, hemoglobin, and liver function tests.			May approve through contract year.	Obtain current medical records to confirm appropriate diagnosis and dosing, and current lab values including hematocrit, hemoglobin, and liver function tests.
TARCEVA	Non-small cell lung cancer (NSCLC) and Pancreatic cancer.		Obtain current medical records.	Exclude for children.		May approve through the contract year.	Obtain current medical records to confirm appropriate diagnosis/dosing and no use of: atazanavir, carbamazepine, clarithromycin, dicumarol, fosphenytoin, indinavir ,itraconazole, ketoconazole, nefazodone, nelfinavir, phenobarb, phenytoin, rifabutin, rifampin, ritonavir, saquinavir, st. john's wort, telithromycin, troleandomycin, voriconazole,warfarin, and for NSCLC, documentation of 1 prior chemo regimen.
TARGRETIN	All medically accepted indications not otherwise excluded from Part D.		Obtain medical records and triglyceride levels.			May approve through contract year.	Obtain medical records or triglycerides to confirm appropriate diagnosis and dosing. For Primary cutaneous T-cell lymphoma, confirm 1 prior systemic therapy. No use of Gemfibrozil. No pregnancy.
TERBINAFINE	Onychomycosis: treatment of onychomycosis of the toenail or fingernail and Tinea capitis. Non-FDA approved uses in CMS approved Compendia with favorable efficacy include: Chromoblastomycosis, Cutaneous leishmaniasis and sporotrichosis, Paracoccidioidomyco		Positive potassium hydroxide (KOH) stain, para-aminosalicylic acid (PAS) stain, positive dermatophyte testing medium (DTM) or positive fungal culture.			Approve up to 12 weeks of therapy for toenail onychomycosis and 6 weeks for fingernail onychomycosis	Diabetic/immunocompromised, approve upon positive Culture Sensitivity Testing. If not, must experience pain/limiting normal activity OR significant peripheral vascular compromise. No approve due to failed treatment of Itraconazole/pregnant.For Tinea capitis, confirm by positive fungal culture/failed/intolerate to conventional therapy.
TESTOSTERONE DRUGS	All medically accepted indications not otherwise excluded from Part D.		Obtain current medical records, lab results (Testosterone, HB/HCT,surveillance for prostate ca, total and HDL cholesterol) to confirm appropriate diagnosis and dosing.	Confirm 18 years or older.		May approve through contract year.	Inform provider of potential Drug Interaction with Warfarin.
THALOMID	All medically accepted indications not otherwise excluded from Part D.		Medical records with ANC.	Exclude if younger than 12 years old.		New starts, may approve 2 weeks ensure tolerability, then approve through end of contract year.	Confirm has no history of seizures or risk factors for seizures, and Confirm patient is not concurrently taking: darbepoetin alfa, docetaxel, zoledronic acid, and for newly diagnosed multiple myeloma confirm concurrent use of dexamethasone.
TNF DRUGS	All medically accepted indications not otherwise excluded from Part D.		Obtain medical records to confirm appropriate diagnosis/dosing and C-reactive protein levels, erythrocyte sedimentation rate (for RA).			Approve through the contract year.	Confirm tried/failed/intolerant to 6 months of MTX. Confim TB screening/no serious infection. Severe Plaque Psoriasis must have greater than 10% of body surface area for more than 12 month and failed treatment 6-month trial of topical (calcipotriene/tazarotene) and UVB unless contraindicated.Crohn's Disease- tried/failed/intolerant to conventional treatment.
TRACLEER	Pulmonary hypertension.Non-FDA approved uses in CMS approved Compendia with favorable efficacy include: Eisenmenger's syndrome, World Health Organization functional class III pulmonary arterial hypertension, Hypertension.		Obtain current medical records, Liver Function Tests (LFTs), Hemoglobin and Hematocrit documenting FDA Indication and ensure appropriate dosing and compliance.			May approve through the contract year.	Confirm Revatio been tried, failed or intolerant and no fluid retention noted in MR and not pregnant and no concurrent use of Atorvastatin, cyclosporine, desogestrel, estradiol, cypionate, etonogestrel, glyburide, levonorgestrel, lovastatin, medroxyprogesterone, norethindrone, norgestrel, simvastatin, warfarin.
TRETINOIN	All medically accepted indications not otherwise excluded from Part D.		Obtain current medical records and Lipid panel (oral only) to confirm appropriate diagnosis and dosing.			Approve through contract year.	Confirm failed/intolerant to one of the following: topical clindamycin, erythromycin, benzoyl peroxide, erythromycin, minocycline or tetracycline. Confirm no pregnancy.
TYKERB	Breast Cancer, Advanced or metastatic, HER2 overexpression, in combo with capecitabine after prior therapies. Non-FDA approved uses in CMS approved Compendia with favorable efficacy include: Metastatic breast Cancer, HER2 overexpression, refractory, first		Obtain current medical records to confirm appropriate diagnosis and dosing and hepatic function tests and left ventricular ejection fraction.	Excluded in children.		May approve through the contract year.	Confirm tried/failed/intolerant standard treatment protocol.
TYZEKA	Type B viral hepatitis, chronic.		Obtain current medical records and serum aminotransferases (ALT or AST)	Exclude children.		May approved up to 3 months.	Confirm appropriate diagnosis and dosing.Tried and failed treatment to Epivir and Emtriva.
XENAZINE	All FDA approved indications not otherwise excluded from Part D. OR Patient must be diagnosed with Huntingtons chorea ANDPatient must have previous trial/failure of Haloperidol					Plan Year
XOLAIR	Allergic asthma. Non-FDA approved uses in CMS approved Compendia with favorable efficacy include Allergic rhinitis, Prophylaxis, Allergy to peanuts, Latex allergy, SQ immunotherapy, Adjunct.		Confirm positive skin test (IgE RAST) or in vitro reactivity to at least one perennial aeroallergen and Serum IgE level.			May approve through contract year.	Confirm failed/intolerant to one of the following: corticosteroids, leukotriene receptor antagonist, or long acting beta-agonist. Confirm not for seasonal allergic rhinitis.
ZEMPLAR	Renal impairment, chronic - Secondary hyperparathyroidism, Treatment and Prophylaxis.		Obtain current medical records to confirm appropriate diagnosis and dosing and most recent parathyroid hormone levels (for baseline).			Initial approvals - 3 months, take PTH levels, then through contract year.
ZYVOX	Community acquired pneumonia, skin/SQ tissue infection, Nosocomial pneumonia, Vancomycin-resistant Enterococcus faecium infection. Non-FDA approved uses in CMS approved Compendia with favorable efficacy include: Febrile neutropenia, Methicillin resistant		Current CSTor medical record indication of nosocomial pneumonia. Zyvox,OXALODINONES, LINEZOLID must be noted susceptible.			May approve up to 14-28 day supply depending on diagnosis.	If other drugs besides Zyvox are equally susceptable, request medical necessity reason as to why Zyvox is being prescribed over an equally susceptible medication.Confirm no concurrent use of Adrenergic agents (eg, dopamine and epinephrine), Serotonergic agents (eg, fluoxetine, paroxetine, sertraline).Ensure appropriate dosage.