ABATACEPT - MetroPlus Health Plan

METROPLUS MEDICARE ADVANTAGE PLAN
2011 PRIOR AUTHORIZATION CRITERIA
EFFECTIVE 1/1/11
ABATACEPT
Products Affected
Orencia
Details
Covered Uses All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
Required
Medical
Information
Age Restrictions
Prescriber
Restrictions
Coverage
Duration
Other Criteria
Coverage is not provided for juvenile rheumatoid arthritis, treatment or
prophylaxis of systemic lupus erythematous.
Diagnosis of moderate to severe Rheumatoid Arthritis OR moderate to
severe Juvenile Idiopathic Arthritis AND member must have a negative
tuberculin skin test, or if positive, have initiated treatment for latent TB
prior to treatment with Orencia, AND member does not have an active
infection that would put the patient at risk if receiving Orencia AND
treatment will not be prescribed along with another biologic DMARD
(i.e., Enbrel, Rituxan, Humira, Remicade, etc.) AND member has had an
inadequate response to one or more nonbiologic disease modifying
antirheumatic drugs OR member has had an inadequate response to one or
more biologic disease modifying antirheumatic drugs.
Patient is 18 years of age or older for RA. Patient is 6-17 years of age for
juvenile idiopathic arthritis.
N/A
12 months
N/A
Version 10, Last updated 8/18/10 1

METROPLUS MEDICARE ADVANTAGE PLAN
2011 PRIOR AUTHORIZATION CRITERIA
EFFECTIVE 1/1/11
ADALIMUMAB
Products Affected
Humira INJ 40MG/0.8ML
Details
Covered Uses All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
Required
Medical
Information
Age Restrictions
Prescriber
Restrictions
Coverage
Duration
Other Criteria
Coverage is not provided for use of Humira in combination with other
biologics e.g., Enbrel, Kineret or Remicade.
Diagnosis
N/A
N/A
12 months
N/A
Version 10, Last updated 8/18/10 2

METROPLUS MEDICARE ADVANTAGE PLAN
2011 PRIOR AUTHORIZATION CRITERIA
EFFECTIVE 1/1/11
ANABOLIC STEROIDS
Products Affected
Anadrol-50
Details
Covered Uses All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
Required
Medical
Information
Age Restrictions
Prescriber
Restrictions
Coverage
Duration
Other Criteria
Known or suspected carcinoma of the prostate or male breast, carcinoma
of the breast in females with hypercalcemia, pregnancy, nephrosis,
hypercalcemia, severe hepatic impairment
Approve if treatment is for: anemia caused by deficient red cell
production (documented hematocrit less than 33 or hemoglobin less than
12), hereditary angioedema, involuntary weight loss following extensive
surgery, chronic infections, or severe trauma, failure to gain or maintain at
least 90% of ideal body weight without definite pathophysiologic reasons,
chronic corticosteroid administration, osteoporosis related bone pain
N/A
N/A
6 months
N/A
Version 10, Last updated 8/18/10 3

METROPLUS MEDICARE ADVANTAGE PLAN
2011 PRIOR AUTHORIZATION CRITERIA
EFFECTIVE 1/1/11
ANAKINRA
Products Affected
Kineret
Details
Covered Uses All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
Required
Medical
Information
Age Restrictions
Prescriber
Restrictions
Coverage
Duration
Other Criteria
N/A
Diagnosis of moderate to severe Rheumatoid Arthritis AND patient must
have neutrophil counts assessed prior to beginning therapy, monthly for 3
months and then quarterly thereafter for up to a year AND patient does
not have an active infection AND treatment will not be prescribed with
another biologic DMARD. Patient must also have had an inadequate
response to at least one biologic and nonbiologic DMARD
Patient must be 18 years or older
N/A
12 months
N/A
Version 10, Last updated 8/18/10 4

METROPLUS MEDICARE ADVANTAGE PLAN
2011 PRIOR AUTHORIZATION CRITERIA
EFFECTIVE 1/1/11
CERTOLIZUMAB
Products Affected
Cimzia
Details
Covered Uses All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
Required
Medical
Information
Age Restrictions
Prescriber
Restrictions
Coverage
Duration
Other Criteria
N/A
Approve for FDA approved indications AND patient does not have a
documented active infection, patient has been evaluated for tuberculosis
risk factors and tested for latent infection prior to initiation of therapy and
will be assessed periodically during therapy AND patient has failed to
achieve symptom control after an adherent trial to conventional therapy
AND patient has failed Remicade or Humira for Crohn's disease or Enbrel
and Humira for rheumatoid arthritis
Patient must be 18 years or older
N/A
3 months, then reassess for extension of PA x 1 yr.
N/A
Version 10, Last updated 8/18/10 5

METROPLUS MEDICARE ADVANTAGE PLAN
2011 PRIOR AUTHORIZATION CRITERIA
EFFECTIVE 1/1/11
DEGARELIX
Products Affected
Firmagon
Details
Covered Uses All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
Required
Medical
Information
Age Restrictions
Prescriber
Restrictions
Coverage
Duration
Other Criteria
Coverage not provided for females
Diagnosis of advanced or metastatic prostate cancer OR patient has as an
intermediate to high risk of disease recurrence AND orchiectomy is not
indicated or not acceptable to the patient AND estrogen therapy is not
indicated or not acceptable to the patient
Patient must be at least 18 years of age
N/A
12 months
N/A
Version 10, Last updated 8/18/10 6

METROPLUS MEDICARE ADVANTAGE PLAN
2011 PRIOR AUTHORIZATION CRITERIA
EFFECTIVE 1/1/11
DICLOFENAC PATCH
Products Affected
Flector
Details
Covered Uses All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
Required
Medical
Information
Age Restrictions
Prescriber
Restrictions
Coverage
Duration
Other Criteria
N/A
Approve if used for the topical treatment of acute pain due to minor
strains, sprains, and contusions AND documented trial and failure of an
oral NSAID or documented swallowing disorder
N/A
N/A
12 months
N/A
Version 10, Last updated 8/18/10 7

METROPLUS MEDICARE ADVANTAGE PLAN
2011 PRIOR AUTHORIZATION CRITERIA
EFFECTIVE 1/1/11
ELTROMBOPAG
Products Affected
Promacta TABS 25MG, 50MG
Details
Covered Uses All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
Required
Medical
Information
Age Restrictions
Prescriber
Restrictions
Coverage
Duration
Other Criteria
Concomitant use with other platelet-stimulating agents such as
romiplostim or oprelvekin, Patient has failed to respond to therapy with
eltrombopag following at least 4 weeks at the maximum dose,
Eltrombopag is being used to normalize platelet count rather than to
reduce the risk of bleeding in patients with chronic ITP,
Chemotherapy/drug-induced thrombocytopenia, Treatment of
thrombocytopenia due to causes other than chronic ITP, Patients who
have previously failed therapy with eltrombopag
Patient has a diagnosis of relapsed/refractory chronic ITP (greater than 6
months) AND Prescriber and patient are enrolled in the Promacta Cares
program (1-877-9-PROMACTA) AND Patient’s baseline platelet count is
less than 50,000/mcL AND Patient’s degree of thrombocytopenia and
clinical condition increases the risk for bleeding AND Patient is intolerant
to splenectomy, and has had an insufficient response or is intolerant to
corticosteroids and immune globulin OR Patient had a splenectomy with
an inadequate response and had an insufficient response or is intolerant to
corticosteroids and immune globulin.
Patient is 18 years of age or older.
N/A
3 months
N/A
Version 10, Last updated 8/18/10 8

METROPLUS MEDICARE ADVANTAGE PLAN
2011 PRIOR AUTHORIZATION CRITERIA
EFFECTIVE 1/1/11
ERYTHROPOIETINS
Products Affected
Aranesp Albumin Free
Epogen
Procrit
Details
Covered Uses All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
Required
Medical
Information
Age Restrictions
Prescriber
Restrictions
Coverage
Duration
Other Criteria
Coverage not provided for prophylactic use to prevent chemotherapyinduced
anemia or tumor hypoxia, sickle cell anemia, anemia associated
only with radiotherapy or treatment of acute or chronic myelogenous
leukemias or erythroid cancers, anemia of cancer not related to cancer
treatment, anemia associated with iron deficiency, folate deficiency, B-12
deficiency, hemolysis, or bone marrow fibrosis
Pretreatment hemoglobin (Hgb) level must be less than 13 in anemic
patients at high risk for perioperative blood loss and less than 10 for all
other indications AND patient must have adequate iron stores prior to
therapy AND patient must not have uncontrolled hypertension AND
patient has not been diagnosed with antibody-mediated pure red cell
aplasia AND other causes of anemia have been ruled out
N/A
N/A
12 months
Part B vs D Determination - if patient has end stage renal disease and is
on dialysis, covered under Part B. Otherwise covered under Part D.
Version 10, Last updated 8/18/10 9

METROPLUS MEDICARE ADVANTAGE PLAN
2011 PRIOR AUTHORIZATION CRITERIA
EFFECTIVE 1/1/11
FENTANYL CITRATE BUCCAL
Products Affected
Fentora
Details
Covered Uses All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
Required
Medical
Information
Age Restrictions
Prescriber
Restrictions
Coverage
Duration
Other Criteria
Coverage not provided in the management of acute or postoperative pain,
opiod non-tolerant patients, patients with known intolerance or
hypersensitivity to the drug or fentanyl
Diagnosis of cancer and use is for breakthrough cancer pain AND other
formulary short acting narcotics have been ineffective, not tolerated, or
contraindicated AND patient is opioid tolerant and taking at least 60 mg
morphine/day or an equianalgesic dose of another opioid for a week or
longer
Patient must be at least 18 years of age
N/A
6 months
N/A
Version 10, Last updated 8/18/10 10

METROPLUS MEDICARE ADVANTAGE PLAN
2011 PRIOR AUTHORIZATION CRITERIA
EFFECTIVE 1/1/11
GOSERELIN
Products Affected
«TableStart:Rx1»«Tradename»
«DosageForm»
«Strength»«TableEnd:Rx1»
«TableStart:Rx2»«Tradename»
«DosageForm»
«Strength»«TableEnd:Rx2»
Details
Covered Uses All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
Required
Medical
Information
Age Restrictions
Prescriber
Restrictions
Coverage
Duration
Coverage is not provided for carcinoma of pancreas, chronic pelvic pain
of female, In vitro fertilization, ovarian cancer, precocious puberty,
uterine leiomyoma, females who are pregnant or lactating,the 10.8 mg
dose is not indicated for use in women, continued therapy or restarted
after malignant disease progression constituting treatment failure,
concomitant use with other LHRH agents, experimental/investigational
uses including indications not supported by CMS recognized compendia
Diagnosis of advanced or metastatic prostate cancer OR patient has as an
intermediate to high risk of disease recurrence AND orchiectomy is not
indicated or not acceptable to the patient AND estrogen therapy is not
indicated or not acceptable to the patient. Diagnosis of hormone receptor
(ER and/or PR +) positive advanced breast cancer in pre- or
perimenopausal female or male patient, only the 3.6 mg dosage form is
approved for advanced breast cancer. Diagnosis of endometriosis AND
patient has had an inadequate pain control response or intolerance to:
Danazol (six month trial) OR Combination [estrogen/progesterone] Oral
Contraceptives (six month trial) OR Progestins (six month trial), only the
3.6 mg dosage form is approved for endometriosis.Diagnosis of
dysfunctional uterine bleeding AND Patient is scheduled for endometrial
ablation, only the 3.6 mg is approved for Endometrial
Thinning/Endometrial Hypoplasia for Dysfunctional Uterine Bleeding
Patient must be 18 years or older.
For oncology uses only, prescriber is an oncologist or an individual highly
familiar with prescribing and monitoring of oncology related medications
Adv Prostate Cancer, Invasive Breast Cancer 12 mth. Endometriosis 6
mth. Endometrial thinning 2 mth
Version 10, Last updated 8/18/10 11

METROPLUS MEDICARE ADVANTAGE PLAN
2011 PRIOR AUTHORIZATION CRITERIA
EFFECTIVE 1/1/11
Other Criteria
N/A
Version 10, Last updated 8/18/10 12

METROPLUS MEDICARE ADVANTAGE PLAN
2011 PRIOR AUTHORIZATION CRITERIA
EFFECTIVE 1/1/11
GROWTH HORMONES
Products Affected
Genotropin
Genotropin Miniquick
Humatrope
Humatrope Combo Pack
Norditropin Cartridge
Norditropin Nordiflex Pen INJ
10MG/1.5ML
Nutropin
Nutropin Aq
Nutropin Aq Pen
Omnitrope INJ 5.8MG
Saizen INJ 5MG
Saizen Click.easy
Serostim
Tev-tropin
Zorbtive
Details
Covered Uses All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
Required
Medical
Information
Age Restrictions
Prescriber
Restrictions
Coverage
Duration
Other Criteria
Coverage is not provided for constitutional delayed growth
Diagnosis
N/A
N/A
12 months
N/A
Version 10, Last updated 8/18/10 13

METROPLUS MEDICARE ADVANTAGE PLAN
2011 PRIOR AUTHORIZATION CRITERIA
EFFECTIVE 1/1/11
IMMUNE GLOBULIN
Products Affected
Carimune Nanofiltered INJ 3GM
Gamastan S/d
Gammagard Liquid
Gamunex
Octagam
Vivaglobin
Details
Covered Uses All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
Required
Medical
Information
Age Restrictions
Prescriber
Restrictions
Coverage
Duration
Other Criteria
Coverage is not provided in patients with selective IgA deficiency, history
of anaphylactic reaction or hypersensitivity to immune globulin
preparations
Diagnosis
N/A
N/A
6 months
N/A
Version 10, Last updated 8/18/10 14

METROPLUS MEDICARE ADVANTAGE PLAN
2011 PRIOR AUTHORIZATION CRITERIA
EFFECTIVE 1/1/11
MECASERMIN
Products Affected
Increlex
Details
Covered Uses All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
Required
Medical
Information
Age Restrictions
Prescriber
Restrictions
Coverage
Duration
Other Criteria
Coverage is not provided in the presence of: Concurrent treatment with
growth hormone or Pharmacologic doses of corticosteroids, Allergy to
mecasermin (ICF-1) or any component of the formulation, growth
promotion in patients with closed epiphyses, active or suspected
neoplasia, diagnosis of growth failure in adults
1) diagnosis of growth failure due to severe primary IGFD with (a)height
standard deviation less than-3.0, (b) basal IGF-1 standard deviation
scoreless than-3.0 and (c) normal or elevated growth hormone levels OR
(2) diagnosis of growth failure due to growth hormone deletion with
neutralizing antibodies to growth hormone AND (3) treating physician is
an endocrinologist or has consulted with an endocrinologist AND (4)
patient does NOT have any of the following conditions: growth hormone
deficiency, malnutrition, hypothyroidism or chronic treatmetn with
pharmacologic doses of anti-inflammatory steroids.
Patient must be a pediatric patient that is at least 2 years of age
Prescribing physician must be an endocrinologist
12 months
N/A
Version 10, Last updated 8/18/10 15

METROPLUS MEDICARE ADVANTAGE PLAN
2011 PRIOR AUTHORIZATION CRITERIA
EFFECTIVE 1/1/11
METHYLNALTREXONE
Products Affected
Relistor
Details
Covered Uses All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
Required
Medical
Information
Age Restrictions
Prescriber
Restrictions
Coverage
Duration
Other Criteria
Coverage is not provided for use nausea, vomiting, pruritis, or urinary
retention related to morphine or other opioids.
Diagnosis of opioid-induced constipation in patients with advanced illness
AND patient is receiving palliative care AND documented trial and
insufficient response to laxative therapy AND no known or suspected
mechanical gastrointestinal obstruction (contraindication) AND no severe
or persistent diarrhea (therapy should be discontinued in cases of severe
or persistent diarrhea)
N/A
N/A
4 months
Use of methylnaltrexone in this diagnosis has not been studied beyond
four months.
Version 10, Last updated 8/18/10 16

METROPLUS MEDICARE ADVANTAGE PLAN
2011 PRIOR AUTHORIZATION CRITERIA
EFFECTIVE 1/1/11
NABILONE
Products Affected
Cesamet
Details
Covered Uses All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
Required
Medical
Information
Age Restrictions
Prescriber
Restrictions
Coverage
Duration
Other Criteria
N/A
Diagnosis of cancer with chemotherapy-induced nausea/vomitting AND
failure to reach desired outcomes with use of two conventional
antiemetics
Patient must be at least 18 years of age
N/A
6 months
N/A
Version 10, Last updated 8/18/10 17

METROPLUS MEDICARE ADVANTAGE PLAN
2011 PRIOR AUTHORIZATION CRITERIA
EFFECTIVE 1/1/11
PAZOPANIB
Products Affected
Votrient
Details
Covered Uses All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
Required
Medical
Information
Age Restrictions
Prescriber
Restrictions
Coverage
Duration
Other Criteria
Coverage is not provided for Patients on concomitant tyrosine kinase
inhibitors, Patients who have experienced significant disease progression
while on pazopanib, Indications not supported by CMS-recognized
compendia.
Diagnosis of advanced renal cell carcinoma
Patient is 18 years of age or older
Prescriber is an oncologist or a healthcare provider highly familiar with
prescribing and monitoring of oncology medications
6 months
N/A
Version 10, Last updated 8/18/10 18

METROPLUS MEDICARE ADVANTAGE PLAN
2011 PRIOR AUTHORIZATION CRITERIA
EFFECTIVE 1/1/11
PEGFILGRASTIM
Products Affected
Neulasta
Details
Covered Uses All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
Required
Medical
Information
Age Restrictions
Prescriber
Restrictions
Coverage
Duration
Other Criteria
N/A
Approve if anticipated that patient will require at least 10 days of white
blood cell CSF therapy AND drug will be used as primary prophylaxis of
febrile neutropenia associated with myelosuppresive chemotherapy OR
patient's risk of febrile neutropenia is as least 20% or has risk factors if
less than 20%, OR patient is receiving a dose density chemotherapy
regimen OR patient had neutropenic complication from a prior cycle of
chemotherapy OR patient had an autologous BMT or PBPC OR patient
has diffuse aggressive lymphoma, is at least 65 years old, and being
treated with curative chemotherapy OR patient is receiving radiation
therapy, not on chemotherapy, and expected to have prolonged delays in
treatment secondary to neutropenia
N/A
Patient is under the care of a physician with experience in prescribing
pegfilgrastim
4 months
N/A
Version 10, Last updated 8/18/10 19

METROPLUS MEDICARE ADVANTAGE PLAN
2011 PRIOR AUTHORIZATION CRITERIA
EFFECTIVE 1/1/11
PEGVISOMANT
Products Affected
Somavert
Details
Covered Uses All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
Required
Medical
Information
Age Restrictions
Prescriber
Restrictions
Coverage
Duration
Other Criteria
Coverage not provided for Cancer, Insulin resistance, McCune-Albright
syndrome, Turner syndrome
Patient has a diagnosis of acromegaly AND Patient has had inadequate
response to surgery and/or radiation therapy and/or other medical
therapies, or these therapies are not appropriate.
Patient is 18 years of age or older
Prescriber is an endocrinologist or an individual familiar with prescribing
and monitoring acromegaly related medications
12 months
N/A
Version 10, Last updated 8/18/10 20

METROPLUS MEDICARE ADVANTAGE PLAN
2011 PRIOR AUTHORIZATION CRITERIA
EFFECTIVE 1/1/11
RILONACEPT
Products Affected
Arcalyst
Details
Covered Uses All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
Required
Medical
Information
Age Restrictions
Prescriber
Restrictions
Neonatal-Onset Multisystem Inflammatory Disease (NOMID), also
referred to as Chronic Infantile Neurologic Cutaneous Articular
Syndrome (CINCA), Familial Mediterranean Fever (FMF), TNF
Receptor-Associated Periodic Syndromes (TRAPS),
Hyperimmunoglobulinemia D with periodic fever syndrome [HIDS] (also
known as Hyper-IgD syndrome with periodic fever), Pyogenic arthritis,
pyoderma gangrenosum, and acne syndrome [PAPA], Pediatric
granulomatous arthritis (which encompasses familial Blau syndrome and
the sporadic early-onset sarcoidosis), Deficiency of IL-1 receptor
antagonist (DIRA), Pseudogout, Schnitzler syndrome, Systemic Juvenile
Idiopathic Arthritis (SJIA), Gout (acute, chronic), Majeed syndrome,
Cherubism, Adult-onset Still disease, Asthma, Chronic obstructive
pulmonary disorder (COPD), Diabetes (type 1 or type 2), Prediabetes,
Atherosclerosis, Rheumatoid arthritis, Wet age-related macular
degeneration
Patient has diagnosis of Familial Cold Autoinflammatory Syndrome
(FCAS) OR Muckle-Wells Syndrome (MWS) diagnosed by, or upon
consultation with or recommendation of, an immunologist, allergist,
dermatologist, rheumatologist, neurologist or other medical specialist
(medical specialty should be indicated by prescriber) AND Patient has
been screened for latent tuberculosis (TB) infection and is negative or if
positive, has been treated by standard medical practice for TB AND
Patient has received all recommended vaccinations AND Patient is not
receiving concomitant therapy with TNF inhibitors (i.e., certolizumab
[CIMZIA], etanercept [ENBREL], adalimumab [HUMIRA], infliximab
[REMICADE]) or other IL-1 blockers (i.e. anakinra [KINERET],
canakinumab [ILARIS])
Patient must be at least 12 year of age
Diagnosed by, or upon consultation with or recommendation of, an
immunologist, allergist, dermatologist, rheumatologist, neurologist or
Version 10, Last updated 8/18/10 21

METROPLUS MEDICARE ADVANTAGE PLAN
2011 PRIOR AUTHORIZATION CRITERIA
EFFECTIVE 1/1/11
other medical specialist (medical specialty should be indicated by
prescriber)
Coverage
Duration
Other Criteria
12 months
N/A
Version 10, Last updated 8/18/10 22

METROPLUS MEDICARE ADVANTAGE PLAN
2011 PRIOR AUTHORIZATION CRITERIA
EFFECTIVE 1/1/11
SARGRAMOSTIM
Products Affected
Leukine
Details
Covered Uses All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
Required
Medical
Information
Age Restrictions
Prescriber
Restrictions
Coverage
Duration
Other Criteria
N/A
Diagnosis
N/A
Physician with experience in prescribing sargramostim
4 months
N/A
Version 10, Last updated 8/18/10 23

METROPLUS MEDICARE ADVANTAGE PLAN
2011 PRIOR AUTHORIZATION CRITERIA
EFFECTIVE 1/1/11
SILDENAFIL
Products Affected
Revatio
Details
Covered Uses All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
Required
Medical
Information
Age Restrictions
Prescriber
Restrictions
Coverage
Duration
Other Criteria
Coverage not provided for Sexual dysfunction as a result of
antidepressant drug adverse reaction, Depression - Erectile Dysfunction,
Diabetes mellitus - Erectile dysfunction, Dialysis procedure - Erectile
dysfunction, Drug-induced impotence, Erectile dysfunction - Generalized
atherosclerosis, Erectile dysfunction - Lower urinary tract symptoms, In
combination with alfuzosin, Erectile dysfunction - Parkinson's disease,
Erectile dysfunction - Peyronie's disease, Erectile dysfunction -
Prostatectomy, Erectile dysfunction - Radiation therapy, Erectile
dysfunction - Resection of rectum, Erectile dysfunction - Spina bifida,
Erectile dysfunction - Spinal cord injury, Female sexual arousal disorder,
Secondary Raynaud's phenomenon, Sexual dysfunction - Spinal cord
injury.
Diagnosis of Pulmonary Arterial Hypertension [PAH] (WHO Group I,
WHO/NYHA functional class II, III or IV) AND Patient has undergone
acute vasoreactivity testing and had a negative response or an initial
positive response with subsequent failure of therapy with an oral calcium
channel blocker (CCB) or the patient is unstable or has severe right-heart
failure or a contraindication to CCB therapy AND Patient is not taking
any of the following drugs concomitantly: organic nitrates in any form,
ritonavir or other potent CYP3A4 inhibitors, Viagra or any other PDE5
inhibitors AND Patients with hypoxia should receive concomitant oxygen
therapy.
N/A
Prescription is written by a pulmonologist or cardiologist or
documentation of consultation with pulmonologist or cardiologist
Initial approval in new patients 6 months. Renewals annually thereafter.
N/A
Version 10, Last updated 8/18/10 24

METROPLUS MEDICARE ADVANTAGE PLAN
2011 PRIOR AUTHORIZATION CRITERIA
EFFECTIVE 1/1/11
SODIUM OXYBATE
Products Affected
Xyrem
Details
Covered Uses All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
Required
Medical
Information
Age Restrictions
Prescriber
Restrictions
Coverage
Duration
Other Criteria
Coverage is not provided for patients being treated with sedative hypnotic
agents, patients with succinic semialdehyde dehydrogenase deficiency, a
rare disorder is an inborn error of metabolism variably characterized by
mental retardation, hypotonia, and ataxia.
Documented (i.e., multiple sleep latency test) diagnosis of narcolepsy
with excessive daytime sleepiness, cataplexy, or both. For a diagnosis of
fibromyalgia, patients must try/fail two FDA approved drugs used for the
treatment of fibromyalgia.
Patients greater than 16 years of age.
N/A
Approval given for up to 3 years
N/A
Version 10, Last updated 8/18/10 25

METROPLUS MEDICARE ADVANTAGE PLAN
2011 PRIOR AUTHORIZATION CRITERIA
EFFECTIVE 1/1/11
TERIPARATIDE
Products Affected
Forteo
Details
Covered Uses All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
Required
Medical
Information
Age Restrictions
Prescriber
Restrictions
Coverage
Duration
Other Criteria
N/A
Postmenopausal female with a diagnosis of osteoporosis OR male with
diagnosis of hypogonadal osteoporosis with one of the following: history
of osteoporotic fracture, multiple risk factors for fracture, trial and failure
of oral bisphophonate, documented contraindication or intolerance to oral
bisphophonate therapy
Patient must be 18 years or older.
N/A
12 months
N/A
Version 10, Last updated 8/18/10 26

METROPLUS MEDICARE ADVANTAGE PLAN
2011 PRIOR AUTHORIZATION CRITERIA
EFFECTIVE 1/1/11
TREPROSTINIL-INJ
Products Affected
Remodulin
Details
Covered Uses All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
Required
Medical
Information
Age Restrictions
Prescriber
Restrictions
Coverage
Duration
Other Criteria
Coverage not provided for Heart failure and Peripheral ischemia (Severe).
Diagnosis of Pulmonary Arterial Hypertension [PAH] (WHO Group I) in
Class III - IV patients OR Diagnosis of PAH (WHO Group I) in Class II
patients who do not respond adequately to or are unable to tolerate
conventional therapy, such as REVATIO (sildenafil), ADCIRCA
(tadalafil), TRACLEER (bosentan) or LETAIRIS (ambrisentan) AND
Patient has undergone acute vasoreactivity testing and had a negative
response or an initial positive response with subsequent failure of therapy
with an oral calcium channel blocker (CCB) or the patient is unstable or
has severe right-heart failure or a contraindication to CCB therapy AND
Patients with hypoxia should receive concomitant oxygen therapy.
N/A
Prescription is written by a pulmonologist or cardiologist or
documentation of consultation with pulmonologist or cardiologist
Initial approval in new patients 6 months. Renewals annually thereafter.
N/A
Version 10, Last updated 8/18/10 27

METROPLUS MEDICARE ADVANTAGE PLAN
2011 PRIOR AUTHORIZATION CRITERIA
EFFECTIVE 1/1/11
ZICONOTIDE
Products Affected
«TableStart:Rx1»«Tradename»
«DosageForm»
«Strength»«TableEnd:Rx1»
«TableStart:Rx2»«Tradename»
«DosageForm»
«Strength»«TableEnd:Rx2»
Details
Covered Uses All FDA-approved indications not otherwise excluded from Part D.
Exclusion
Criteria
Required
Medical
Information
Age Restrictions
Prescriber
Restrictions
Coverage
Duration
Other Criteria
Coverage not included for chronic cancer pain, ischemia, post-operative
pain history of psychosis, known hypersensitivity to ziconotide or any of
its formulation components, OR Patients with concomitant treatment or
medical conditions that would render IT administration hazardous such as
the presence of infection at the microinfusion injection site, uncontrolled
bleeding diathesis, or spinal canal obstruction that impairs circulation of
cerebrospinal fluid.
Diagnosis of severe chronic, intractable pain related or unrelated to
cancer, AND The patient has documented inadequate response,
intolerable adverse events, or contraindications to IT morphine or IT
hydromorphone (see Note). AND The patient with non-cancer pain has
documented failure or intolerance (over a 6-month period) of other
conservative treatment modalities such as: pharmacologic, surgical,
psychological, physical. AND The patient with non-cancer pain has had a
documented psychological evaluation both to rule-out that the pain is not
psychological in nature and that the patient will benefit and be able to
cope with the demands of an IDDS and IT drug therapy AND Ziconotide
will be infused via an implanted Medtronic SynchroMed® EL,
SynchroMed® II infusion system, or Smiths Medical MD CADD-Micro®
ambulatory infusion pump.
The patient is 18 years of age or older.
Prescribed by a pain specialist or anesthesiologist who has experience
with the use of IT pain medications.
6 months
Note: According to the American Academy of Pain Medicine proposed
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EFFECTIVE 1/1/11
guidelines for the management of chronic pain, IT therapy should be
administered through a permanently implanted drug-delivery system
(IDDS). An IDDS for the administration of IT pain medications is
considered medically necessary in the following types of patients
experiencing pain: Cancer-pain patients who: Have documented failure or
intolerance of opioids or other analgesics, AND Have a life expectancy of
greater than 3 months, AND Do not have tumor encroachment on the
thecal sac, AND Have no contraindications to implantation of the device
Non-cancer patients who: Have documented failure or intolerance (over a
6-month period) of other conservative treatment modalities such as:
pharmacologic, surgical, psychological, physical, AND Had a
psychological evaluation performed to determine that the pain is not
psychological in origin and that benefit would occur with implantation of
a device, AND Have no contraindications to the implantation of the
device.
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EFFECTIVE 1/1/11
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