Drugs Requiring Prior Authorization - LA Care Health Plan

REGORAFENIB STIVARGA ALL MEDICALLY ACCEPTED INDICATIONS NOTOTHERWISE EXCLUDED FROM PART D.RIFAXIMIN XIFAXAN ALL FDA APPROVED INDICATIONS NOTOTHERWISE EXCLUDED FROM PART D.RITUXIMAB RITUXAN ALL MEDICALLY ACCEPTED INDICATIONS NOTOTHERWISE EXCLUDED FROM PART D.Drugs Requiring Prior Authorization Effective 08/01/2013RENEWAL: ACTIVE RHEUMATOID ARTHRITIS/PSORIATICARTHRITIS: GREATER THAN 20% IMPROVEMENT INTENDER JOINT COUNT AND SWOLLEN JOINT COUNT.TRAVELERS' DIARRHEA:12 YEARS OR OLDER.HEPATICENCEPHALOPATHY: 18YEARS OR OLDER.PRESCRIBED BY ORSUPERVISED BY: FORRHEUMATOIDARTHRITIS ARHEUMATOLOGIST.FOR NHL OR CLL ANONCOLOGIST.12 MONTHS TRIAL OR CONTRAINDICATION TO ANTI-EGFRTHERAPY SUCH AS ERBITUX OR VECTIBIX. TRIALOR CONTRAINDICATION TO ANTI-VEGF THERAPYSUCH AS AVASTIN OR ZALTRAP AND AFLUOROPYRMIDE-, OXAPLATIN- AND IRINOTECAN-BASED CHEMOTHERAPY SUCH AS FOLFOX,FOLFIRI,CAPEOX, INFUSIONAL 5-FU/LV ORCAPECITABINE, AND FOLFOXIRI.TRAVELERS' DIARRHEA:1 FILL IN 1 MONTH.HEPATICENCEPHALOPATHY: 12MONTHS.TRAVELERS' DIARRHEA: TRIAL OF CIPROFLOXACINOR AZITHROMYCIN. HEPATIC ENCEPHALOPATHY:TRIAL OF LACTULOSE MONOTHERAPY.RA: INITIAL AND INITIAL: RHEUMATOID ARTHRITIS: CURRENTLYRENEWAL 4 MO. HNL: 1 TAKING OR HAVE A CONTRAINDICATION TO THEYEAR. CLL: 6 MO. WG, USE OF METHOTREXATE AND TRIAL/FAILURE OFMPA: 1 MO.ONE TNF BLOCKER (ENBREL, HUMIRA, SIMPONI,CIMZIA). NON HODGKIN'S LYMPHOMA/CHRONICLYMPHOCYTIC LEUKEMIA: USED IN COMBINATIONWITH CHEMOTHERAPY. WEGNER'SGRANULOMATOSIS/MICROSCOPIC POLYANGIITIS:CONCURRENT GLUCOCORTICOID USE.ROMIDEPSIN ISTODAX ALL FDA APPROVED INDICATIONS NOTOTHERWISE EXCLUDED FROM PART D.12 MONTHS TRIAL OF OR CONTRAINDICATION TO VORINOSTAT(ZOLINZA) AND NOT ABLE TO TOLERATE ORALMEDICATIONS, OR IS ABLE TO TOLERATE ORALMEDICATIONS AND HAS TRIED AT LEAST ONESYSTEMIC THERAPY (RETINOID, INTERFERON,EXTRACORPOREAL PHOTOPHERESIS, DENILEUKINDIFTITOX, METHOTREXATE, LIPOSOMALDOXORUBICIN, GEMCITABINE, CHLORAMBUCIL,PENTOSTATIN, ETOPOSIDE, CYCLOPHOSPHAMIDE,TEMOZOLOMIDE, BORTEZOMIB).RUXOLITINIB JAKAFI ALL MEDICALLY ACCEPTED INDICATIONS NOTOTHERWISE EXCLUDED FROM PART D.SOMATROPINGENOTROPIN | HUMATROPE | NORDITROPIN ALL MEDICALLY ACCEPTED INDICATIONS NOTFLEXPRO | NORDITROPIN NORDIFLEX | NUTROPIN | OTHERWISE EXCLUDED FROM PART D.NUTROPIN AQ | NUTROPIN AQ NUSPIN | OMNITROPE| SAIZEN | SEROSTIM | TEV-TROPIN | ZORBTIVERENEWAL: IMPROVEMENT OR MAINTENANCE OFSYMPTOM IMPROVEMENT SUCH AS A 50% OR GREATERREDUCTION IN TOTAL SYMPTOM SCORE ON THEMODIFIED MYELOFIBROSIS SYMPTOM ASSESSMENT FORM(MFSAF) V2.0 OR 50% OR GREATER REDUCTION INPALPABLE SPLEEN LENGTH, OR REDUCTION OF 35% ORGREATER FROM BASELINE SPLEEN VOLUME AFTER 6MONTHS OF THERAPY.FOR GROWTH FAILURE DUE TO (CRI): PATIENT HAS NOTUNDERGONE A RENAL TRANSPLANT, PATIENT'S HEIGHTAT LEAST 2 STANDARD DEVIATIONS (SD) BELOW THEMEAN HEIGHT FOR NORMAL CHILDREN OF THE SAME AGEAND GENDER, LACK OF RESPONSE FROM PREVIOUS YEAR,PATIENT HAS REACHED 50TH PERCENTILE FOR TARGETHEIGHT FOLLOWING GROWTH HORMONE THERAPY. FORHIV/WASTING: THE PATIENT ON ANTIRETROVIRALTHERAPY, MEETS CRITERA OF WEIGHT LOSS: 10%UNINTENTIONAL WEIGHT LOSS OVER 12 MONTHS, 7.5%OVER 6 MONTHS, 5% BODY CELL MASS (BCM) LOSSWITHIN 6 MONTHS, OR A BCM LESS THAN 35% (MEN) OR23% (WOMEN) OF TOTAL BODY WT. AND A BODY MASSINDEX (BMI) LESS THAN 27KG/M2, OR BMI LESS THAN20KG/M2. IF CURRENTLY ON GROWTH HORMONE,PATIENT HAS SHOWN CLINICAL BENEFIT IN MUSCLE MASSAND WEIGHT OR IF NOT ON GROWTH HORMONE, PATIENTHAS HAD INADEQUATE RESPONSE TO PREVIOUSTHERAPY. (I.E. EXERCISE TRAINING, NUTRITIONALSUPPLEMENTS, APPETITE STIMULANTS OR ANABOLICSTEROIDS). FOR SHORT-BOWEL SYNDROME: CURRENTLYON SPECIALIZED NUTRITIONAL SUPPORT.INITIAL: 6 MONTHS.RENEWAL: 12 MONTHSHIV/AIDS: 3 MONTHS. ATHLETIC ENHANCEMENT, ANTI-AGING PURPOSESSHORT BOWEL: 4 WEEK OR GROWTH FAILURE DUE TO CHRONIC RENALONCE. ALL OTHER INSUFFICIENCY(CRI) IF PATIENT HAS HAD A RENALDIAGNOSES: 12 TRANSPLANT ARE NOT ACCEPTABLE DIAGNOSESMONTHS.FOR APPROVAL.SORAFENIB TOSYLATE NEXAVAR ALL MEDICALLY ACCEPTED INDICATIONS NOTOTHERWISE EXCLUDED FROM PART D.SUNITINIB MALATE SUTENT ALL MEDICALLY ACCEPTED INDICATIONS NOTOTHERWISE EXCLUDED FROM PART D.12 MONTHS12 MONTHS GASTROINTESTIONAL STROMAL TUMORS (GIST):TRIAL OF OR CONTRAINDICATION TO GLEEVEC.TELAPREVIR INCIVEK ALL FDA APPROVED INDICATIONS NOTOTHERWISE EXCLUDED FROM PART D.CHRONIC HEPATITIS C, GENOTYPE 1. HCV RNALEVEL/VIRAL LOAD OF LESS THAN 1,000 IU/ML AT 4WEEKS OF TELAPREVIR THERAPY.PATIENT 18 YEARS OFAGE OR OLDER.GASTROENTEROLOGIST 12 WEEKS CONCURRENT USE OF RIBAVIRIN AND, INFECTIOUS DISEASEPEGINTERFERON ALFA. PATIENT HAS NOT FAILEDSPECIALIST, PHYSICIANPRIOR THERAPY WITH TELAPREVIR (INCIVEK) ORSPECIALIZING IN THEBOCEPREVIR (VICTRELIS). CURRENTLY NOTTREATMENT OFTAKING RIFAMPIN. DOES NOT CURRENTLY HAVE AHEPATITIS (E.G.CO-INFECTION WITH HEPATITIS B, OR HISTORY OFHEPATOLOGIST) ORPREVIOUS SOLID ORGAN TRANSPLANT.SPECIALLY TRAINEDGROUP (E.G.EXTENSION FORCOMMUNITYHEALTHCAREOUTCOMES).TERIFLUNOMIDE AUBAGIO ALL FDA APPROVED INDICATIONS NOTOTHERWISE EXCLUDED FROM PART D.TERIPARATIDE FORTEO ALL FDA APPROVED INDICATIONS NOTOTHERWISE EXCLUDED FROM PART D.GREATER THAN 24 MONTHS OF THERAPY.A PATIENT WITH EITHER A DIAGNOSIS OF SEVEREOSTEOPOROSIS (T-SCORE LESS THAN -2.5 WITH FRAGILITYFRACTURE) OR A T SCORE EQUAL TO OR LESS THAN -2.5AND MULTIPLE RISK FACTORS FOR FRACTURE (E.G.HISTORY OF MULTIPLE RECENT LOW TRAUMAFRACTURES, CORTICOSTEROID USE, OR USE OF GNRHANALOGS), OR FAILED AN ADEQUATE TRIAL OFBISPHOSPHONATES, IS INTOLERANT, OR HAS ACONTRAINDICATION TO BISPHOSPHONATES.12 MONTHS TRIAL OF OR CONTRAINDICATION TO ONEINTERFERON THERAPY (SUCH AS AVONEX,BETASERON, EXTAVIA, OR REBIF) AND TOCOPAXONE.12 MONTHSH2643_5015_PA_01 CMS Approved 01102013 Page 8 L.A. Care Health Plan is a Coordinated Care Plan with a Medicare contract and a contract with the California Medicaid program

TESTOSTERONETESTOSTERONE CYPIONATE | TESTOSTERONEENANTHATEALL FDA APPROVED INDICATIONS NOTOTHERWISE EXCLUDED FROM PART D.Drugs Requiring Prior Authorization Effective 08/01/2013CURRENTLY RECEIVING TESTOSTERONE REPLACMENT.MALE HYPOGONADISM CONFIRMED BY EITHER: 1)LABORATORY CONFIRMED TOTAL SERUM TESTOSTERONELEVEL OF LESS THAN 300 NG/DL OR 2) A LOW TOTALSERUM TESTOSTERONE LEVEL AS INDICATED BY A LABRESULT WITH A REFERENCE RANGE OBTAINED WITHIN 90DAYS, OR 3) A FREE SERUM TESTOSTERONE LEVEL OFLESS THAN 50NG/L OR 4) MALE DELAYED PUBERTY NOTSECONDARY TO PATHOLOGY.12 MONTHS RENEWAL: MALE HYPOGONADISM:CONTINUATION OF THERAPY WITH FDAAPPROVED INDICATION AND RECORDED HISTORYOF PREVIOUS TESTOSTERONE REPLACEMENTTHERAPY.TETANUS TOXOIDVACCINE BVDDETERMINATIONTETANUS TOXOID ADSORBEDTHIS DRUG MAY BE COVERED UNDER MEDICAREPART B OR D DEPENDING UPON THECIRCUMSTANCES. INFORMATION MAY NEED TO BESUBMITTED DESCRIBING THE USE AND SETTINGOF THE DRUG TO MAKE THE DETERMINATION.TETRABENAZINE XENAZINE ALL FDA APPROVED INDICATIONS NOTOTHERWISE EXCLUDED FROM PART D.THIAZOLIDINEDIONE AVANDAMET | AVANDARYL | AVANDIA ALL FDA APPROVED INDICATIONS NOTOTHERWISE EXCLUDED FROM PART D.TOCILIZUMAB ACTEMRA ALL FDA APPROVED INDICATIONS NOTOTHERWISE EXCLUDED FROM PART D.TOFACITINIB XELJANZ ALL FDA APPROVED INDICATIONS NOTOTHERWISE EXCLUDED FROM PART D.DIAGNOSIS: ACTIVE RHEUMATOID ARTHRITIS. RENEWAL:AT LEAST 20% IMPROVEMENT IN TENDER JOINT COUNTAND SWOLLEN JOINT COUNT.RHEUMATOID ARTHRITIS RENEWAL: PATIENT HASEXPERIENCED OR MAINTAINED A 20% IMPROVEMENT INTENDER OR SWOLLEN JOINT COUNT WHILE ON THERAPY.NEUROLOGISTRHEUMATOLOGIST12 MONTHS12 MONTHS APPLIES TO NEW STARTS ONLY. TRIAL ORCONTRAINDICATION TO METFORMIN, METFORMINER, GLYBURIDE/METFORMIN,GLIPIZIDE/METFORMIN OR A SULFONYLUREA ANDPIOGLITAZONE.INITIAL: 6 MONTHS.RENEWAL: 6 MONTHSINITIAL: 3 MONTHS.RENEWAL: 12 MONTHSTRIAL OF OR CONTRAINDICATION TO AT LEASTONE OF THE FOLLOWING: ENBREL, HUMIRA,REMICADE, SIMPONI OR CIMZIA.RHEUMATOID ARTHRITIS INITIAL THERAPY: TRIALOR CONTRAINDICATION TO HUMIRA(ADALIMUMAB) AND CIMZIA (CERTOLIZUMABPEGOL).TOPICAL TRETINOIN AVITA | TRETINOIN ALL FDA APPROVED INDICATIONS NOTOTHERWISE EXCLUDED FROM PART D.WRINKLES, PHOTOAGING, MELASMA. 12 MONTHS BRAND TRETINON WILL REQUIRE TRIAL OFGENERIC TOPICAL TRETINOIN.TOTAL PARENTARAL AMINOSYN | AMINOSYN II | AMINOSYN M | THIS DRUG MAY BE COVERED UNDER MEDICARENUTRITION AGENT BVD AMINOSYN-HBC | AMINOSYN-PF | CLINIMIX | PART B OR D DEPENDING UPON THEDETERMINATION CLINIMIX E | CLINISOL | DEXTROSE IN WATER | CIRCUMSTANCES. INFORMATION MAY NEED TO BEFREAMINE III | FREAMINE III WITH ELECTROLYTES | SUBMITTED DESCRIBING THE USE AND SETTINGHEPATAMINE | HEPATASOL | INTRALIPID | LIPOSYN OF THE DRUG TO MAKE THE DETERMINATION.III | NEPHRAMINE | PREMASOL | PROCALAMINE |PROSOL | TRAVASOL | TROPHAMINETRASTUZUMAB KADCYLA ALL MEDICALLY ACCEPTED INDICATIONS NOTOTHERWISE EXCLUDED FROM PART D.USTEKINUMAB STELARA ALL FDA APPROVED INDICATIONS NOTOTHERWISE EXCLUDED FROM PART D.INITIAL: PLAQUE PSORIASIS: MODERATE TO SEVEREPLAQUE PSORIASIS INVOLVING GREATER THAN OR EQUALTO 10 PERCENT BODY SURFACE AREA OR PASI SCOREGREATER THAN OR EQUAL TO 12. PATIENT'S WEIGHT.DERMATOLOGIST ORRHEUMATOLOGIST12 MONTHSINITIAL: 4 MONTHS. FOR SEVERE PLAQUE PSORIASIS COVERING 10%RENEWAL: 12 MONTHS BSA: TRIAL/FAILURE/INTOLERABLE SIDE AFFECTSTO AT LEAST ONE PREFERRED THERAPY (PUVA,UVB, ACITRETIN, METHOTREXATE ORCYCLOSPORINE). RENEWAL: PHYSICIAN'S GLOBALASSESMENT EQUAL TO ZERO OR ONE OR ADECREASE OF PASI OF AT LEAST 50% OR GREATER.VANDETANIB CAPRELSA ALL FDA APPROVED INDICATIONS NOT12 MONTHS CRITERIA APPLIES TO NEW STARTS ONLY.OTHERWISE EXCLUDED FROM PART D.VEMURAFENIB ZELBORAF ALL MEDICALLY ACCEPTED INDICATIONS NOTBRAFV600E MUTATION12 MONTHSOTHERWISE EXCLUDED FROM PART D.VILAZODONE VIIBRYD ALL FDA APPROVED INDICATIONS NOTOTHERWISE EXCLUDED FROM PART D.12 MONTHS TRIAL OF OR CONTRAINDICATION TO A SSRI(PAROXETINE, SERTARLINE, CITALOPRAM,FLUOXETINE, OR ESCITALOPRAM) AND A SECONDAGENT (BUPROPION HCL (IR, SR, OR XL),MIRTAZAPINE, OR VENLAFAXINE (IR OR XR)).VISMODEGIB ERIVEDGE ALL MEDICALLY ACCEPTED INDICATIONS NOTOTHERWISE EXCLUDED FROM PART D.12 MONTHS* 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.This document may be available in a different format or language. For additional information, call customer service at 1‐888‐522‐1298. TTY/TDD users call: 1‐888‐212‐4460H2643_5015_PA_01 CMS Approved 01102013 Page 9 L.A. Care Health Plan is a Coordinated Care Plan with a Medicare contract and a contract with the California Medicaid program