Essential Health Benefits Standard Specialty PA and QL List April 2015
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1 Anti-infectives Antiretrovirals, Hepatitis B BARACLUDE (entecavir) BARACLUDE (entecavir) Soln 630 ml/30days HEPSERA (adefovir) TYZEKA (telbivudine ) Antiretrovirals, HIV FUZEON (enfuvirtide) 60 vials or 1 kit/30 days SELZENTRY (maraviroc) TRUVADA (emtricitabine/tenofovir) Cardiology Antilipemic JUXTAPID (lomitapide) 20 mg 3 tabs/day JUXTAPID (lomitapide) 5 mg, 10 mg KYNAMRO (mipomersen) 4 syringes/28 days Pulmonary Arterial Hypertension ADCIRCA (tadalafil) ADEMPAS (riociguat) 90 tabs/30 days FLOLAN (epoprostenol) LETAIRIS (ambrisentan) OPSUMIT (macitentan) REMODULIN (treprostinil) REVATIO (sildenafil) 3 tabs or vials/day REVATIO (sildenafil) Susp QL is 2 bottles/mon. TRACLEER (bosentan) TYVASO (treprostinil) 1 ampule/day VELETRI (epoprostenol) VENTAVIS (iloprost) 9 ampules/day Central Nervous System Anticonvulsants SABRIL (vigabatrin) pack Depressant XYREM (sodium oxybate) 3 bottles (540 ml)/30 days Neurotoxins BOTOX (onabotulinumtoxina) DYSPORT (abobotulinumtoxina) MYOBLOC (rimabotulinumtoxinb) XEOMIN (incobotulinumtoxina) Parkinson's APOKYN (apomorphine) Sleep Disorder HETLIOZ (tasimelteon) 1 cap/day Dermatology Alkylating Agents VALCHLOR (mechlorethamine) Gel Endocrinology & Metabolism Gonadotropins ELIGARD (leuprolide) 22.5 mg (3-month) 1 injection/84 days ELIGARD (leuprolide) 30 mg (4-month) 1 injection/112 days ELIGARD (leuprolide) 45 mg (6-month) 1 injection/168 days ELIGARD (leuprolide) 7.5 mg (1-month) 1 injection/28 days FIRMAGON (degarelix) 120 mg 2 vials/year FIRMAGON (degarelix) 80 mg 1 vial/28 days LUPRON (leuprolide) 1 mg/0.2 ml No QL for this strength LUPRON DEPOT (leuprolide) mg & 22.5 mg (3-month) 1 injection/84 days Updated 4/1/2015 Page 1 of 7
2 Endocrinology & Metabolism LUPRON DEPOT (leuprolide) 3.75 mg & 7.5 mg (1-month) 1 injection/28 days LUPRON DEPOT (leuprolide) 30 mg (4-month) 1 injection/112 days LUPRON DEPOT (leuprolide) 45 mg (6-month) 1 injection/168 days LUPRON DEPOT-PED (leuprolide) mg & 30 mg (3-month) 1 injection/84 days LUPRON DEPOT-PED (leuprolide) 7.5 mg, mg, & 15 mg 1 injection/28 days SUPPRELIN LA (histrelin acetate) 1 kit/365 days TRELSTAR (triptorelin) 22.5 mg (6-month) 1 injection/168 days TRELSTAR DEPOT (triptorelin) 3.75 mg (1-month) 1 injection/28 days TRELSTAR LA (triptorelin) mg (3-month) 1 injection/84 days VANTAS (histrelin) 1 implant/year ZOLADEX (goserelin) 10.8 mg 1 injection/84 days ZOLADEX (goserelin) 3.6 mg 1 injection/28 days Growth Hormones and Related Therapy EGRIFTA (tesamorelin) 1 mg 2 vials (1 mg each)/day EGRIFTA (tesamorelin) 2 mg 1 vial (2 mg each)/day GENOTROPIN (somatropin) HUMATROPE (somatropin) INCRELEX (mecasermin) NORDITROPIN (somatropin) NUTROPIN (somatropin) NUTROPIN AQ (somatropin) OMNITROPE (somatropin) SAIZEN (somatropin) SEROSTIM (somatropin) SOMAVERT (pegvisomant) TEV-TROPIN (somatropin) ZORBTIVE (somatropin) Hormone Modifiers MYALEPT (metreleptin) H.P. ACTHAR (corticotropin) Osteoporosis PROLIA (denosumab) 2 syringes/year RECLAST (zoledronic acid) Somatostatins SANDOSTATIN (octreotide) SANDOSTATIN LAR (octreotide) SIGNIFOR (pasireotide) 2 ampules/day SOMATULINE DEPOT (lanreotide) Enzyme-Related Alpha-1 proteinase inhibitor ARALAST (alpha-1 proteinase inhibitor) GLASSIA (alpha-1 proteinase inhibitor) PROLASTIN (alpha-1 proteinase inhibitor) ZEMAIRA (alpha-1 proteinase inhibitor) Cystine-depleting Agents CYSTARAN (cysteamine) 4 bottles/28 days PROCYSBI (cysteamine bitartrate) Enzyme Replacement ADAGEN (pegademase) ALDURAZYME (laronidase) CARBAGLU (carglumic acid) CEREZYME (imiglucerase) Updated 4/1/2015 Page 2 of 7
3 Enzyme-Related ELAPRASE (idursulfase) ELELYSO (taliglucerase) FABRAZYME (agalsidase beta) LUMIZYME (alglucosidase alfa) MYOZYME (alglucosidase alfa) NAGLAZYME (galsulfase) RAVICTI (glycerol phenylbutyrate) VIMIZIM (elosulfase) VPRIV (velaglucerase) ZAVESCA (miglustat) Enzyme, Gout KRYSTEXXA (pegloticase) Phenylketonuria Treatment Agents KUVAN (sapropterin) Gastroenterology Short Bowel Syndrome GATTEX (teduglutide) Immunology Hematopoietic Agents ARANESP (darbepoetin alfa) EPOGEN (epoetin alfa) LEUKINE (sargramostim) MOZOBIL (plerixafor) 8 vials (9.6 ml) per transplant NEULASTA (pegfilgrastim) NEUMEGA (oprelvekin) NEUPOGEN (filgrastim) NPLATE (romiplostim) OMONTYS (peginesatide) PROCRIT (epoetin alfa) PROMACTA (eltrombopag) SOLIRIS (eculizumab) Hepatitis C Agents HARVONI (ledipasvir-sofosbuvir) PEGASYS (peginterferon alfa-2a) PEG-INTRON (peginterferon alfa-2b) SOVALDI (sofosbuvir) VICTRELIS (boceprevir) Immune Globulins BIVIGAM (immune globulin) CARIMUNE (immune globulin) CYTOGAM (cytomegalovirus immune globulin) FLEBOGAMMA (immune globulin) FLEBOGAMMA DIF (immune globulin) GAMASTAN (immune globulin) GAMMAGARD (immune globulin) GAMMAKED (immune globulin) GAMMAPLEX (immune globulin) GAMUNEX (immune globulin) GAMUNEX-C (immune globulin) HIZENTRA (immune globulin) OCTAGAM (immune globulin) Updated 4/1/2015 Page 3 of 7
4 Immunology PRIVIGEN (immune globulin) Immunomodulators ACTEMRA (tocilizumab) CIMZIA (certolizumab) ENBREL (etanercept) HUMIRA (adalimumab) KINERET (anakinra) ORENCIA (abatacept) REMICADE (infliximab) SIMPONI (golimumab) STELARA (ustekinumab) XELJANZ (tofacitinib) Interleukins ARCALYST (rilonacept) ILARIS (canakinumab) BENLYSTA (belimumab) Multiple Sclerosis AMPYRA (dalfampridine) AUBAGIO (teriflunomide) AVONEX (interferon beta-1a) 1 kit (4 syringes)/28 days BETASERON (interferon beta-1b) 1 package/28 days COPAXONE (glatiramer) SOSY 20 mg/ml 1 kit/30 days COPAXONE (glatiramer) SOSY 40 mg/ml 1 kit/30 days EXTAVIA (interferon beta-1b) 1 package/28 days GILENYA (fingolimod) 1 cap/day NOVANTRONE (mitoxantrone) REBIF (interferon beta-1a) 12 syringes/28 days REBIF (interferon beta-1a) Starter Pack 1 starter pack/year TECFIDERA (dimethyl fumarate) 120 mg 14 caps/year TECFIDERA (dimethyl fumarate) 240 mg 2 caps/day TECFIDERA (dimethyl fumarate) Starter Pack 1 starter pack/year TYSABRI (natalizumab) 1 injection /28 days Transplant NULOJIX (belatacept) ZORTRESS (everolimus) Collagenase XIAFLEX (collagenase clostridium histolyticum) Diagnostic THYROGEN (thyrotropin alfa) 6 vials/year Movement Disorder Agents XENAZINE (tetrabenazine) Toxicology EXJADE (deferasirox) FERRIPROX (deferiprone) Viscosupplements EUFLEXXA (sodium hyaluronate) HYALGAN (sodium hyaluronate) MONOVISC (hyaluronan) ORTHOVISC (sodium hyaluronate) SUPARTZ (sodium hyaluronate) SYNVISC (sodium hyaluronate) SYNVISC-ONE (sodium hyaluronate) Updated 4/1/2015 Page 4 of 7
5 Obstetrics & Gynecology Fertility Agents GONAL-F (follitropin alfa) 1050 IU 10 vials/35 days GONAL-F (follitropin alfa) 450 IU 24 vials/35 days GONAL-F RFF (follitropin alfa) 75 IU 140 vials/35 days GONAL-F RFF (follitropin alfa) Pens 300 IU 35 pens/35 days GONAL-F RFF REDIINJECT (follitropin alfa) Soln 450 IU 24 pens/35 days GONAL-F RFF REDIINJECT (follitropin alfa) Soln 900 IU 12 pens/35 days Hormone Replacement MAKENA (hydroxyprogesterone caproate) Oncology Alkylating Agents MYLERAN (busulfan) TEMODAR (temozolomide) Antiandrogen XTANDI (enzalutamide ) ZYTIGA (abiraterone) Antimicrotubular HALAVEN (eribulin) JEVTANA (cabazitaxel) Interferons INTRON A (interferon alfa-2b) SYLATRON (peginterferon alfa-2b) Kinase and Molecular Target Inhibitors AFINITOR (everolimus) AFINITOR DISPERZ (everolimus) BOSULIF (bosutinib) CAPRELSA (vandetanib) 100 mg CAPRELSA (vandetanib) 300 mg No QL for this strength COMETRIQ (carbozantinib) ERIVEDGE (vismodegib) GILOTRIF (afatinib) GLEEVEC (imatinib) ICLUSIG (ponatinib) 15 mg ICLUSIG (ponatinib) 45 mg No QL for this strength IMBRUVICA (ibrutinib) INLYTA (axitinib) JAKAFI (ruxolitinib) JAKAFI (ruxolitinib) 10 mg KYPROLIS (carfilzomib) MEKINIST (trametinib) NEXAVAR (sorafenib) PERJETA (pertuzumab) SPRYCEL (dasatinib) STIVARGA (regorafenib) SUTENT (sunitinib) TAFINLAR (dabrafenib) TARCEVA (erlotinib) 3 tabs/day TASIGNA (nilotinib) TYKERB (lapatinib) VELCADE (bortezomib) VOTRIENT (pazopanib) XALKORI (crizotinib) Updated 4/1/2015 Page 5 of 7
6 Oncology ZALTRAP (ziv-aflibercept) ZALTRAP (ziv-aflibercept) vial 100 mg/4 ml 2 vials/28 days ZELBORAF (vemurafenib) DACOGEN (decitabine) ERWINAZE (asparaginase) ISTODAX (romidepsin) SYNRIBO (omacetaxine) TARGRETIN (bexarotene) caps TARGRETIN (bexarotene) Gel VIDAZA (azacitidine) XELODA (capecitabine) ZOLINZA (vorinostat) ZOMETA (zoledronic acid) Monoclonal Antibody ADCETRIS (brentuximab) ARZERRA (ofatumumab) GAZYVA (obinutuzumab) HERCEPTIN (trastuzumab) KADCYLA (ado-trastuzumab emtansine) RITUXAN (rituximab) XGEVA (denosumab) QL Varies* YERVOY (ipilimumab) Thalidomide-related Agents POMALYST (pomalidomide) REVLIMID (lenalidomide) THALOMID (thalidomide) Respiratory Asthma/COPD XOLAIR (omalizumab) Cystic fibrosis CAYSTON (aztreonam) KALYDECO (ivacaftor) PULMOZYME (dornase alfa) TOBI (tobramycin) Respiratory Syncytial Virus Agents SYNAGIS (palivizumab) Updated 4/1/2015 Page 6 of 7
7 Standard QL Programs Therapeutic Category Drug Name Dispensing Limit Anti-infectives Antiretrovirals, HIV ATRIPLA (efavirenz/emtricitabine/tenofovir) COMPLERA (emtricitabine/rilpivirine/tenofovir) STRIBILD (elvitegravir/cobicistat/emtricitabine/tenofovir) TRIZIVIR (abacavir/lamivudine/zidovudine) Cardiology Anticoagulants, LMWH ARIXTRA (fondaparinux) 35 days supply/180 days FRAGMIN (dalteparin) 35 days supply/180 days LOVENOX (enoxaparin) 35 days supply/180 days Endocrinology & Metabolism Osteoporosis FORTEO (teriparatide) 1 syringe/28 days Vasopressin Antagonist SAMSCA (tolvaptan) 30 days/60 days Obstetrics & Gynecology Fertility Agents BRAVELLE (urofollitropin) 72 vials/30 days CETROTIDE (cetrorelix) 0.25 mg 14 boxes/30 days CETROTIDE (cetrorelix) 3 mg 1 box/30 days FOLLISTIM AQ (follitropin beta) 150 IU 48 vials/30 days FOLLISTIM AQ (follitropin beta) 300 IU 20 cartridges/30 days FOLLISTIM AQ (follitropin beta) 600 IU 10 cartridges/30 days FOLLISTIM AQ (follitropin beta) 75 IU 96 vials/30 days FOLLISTIM AQ (follitropin beta) 900 IU 7 cartridges/30 days Ganirelix acetate (ganirelix) 14 syringes (0.5 ml)/30 days MENOPUR (menotropins) 120 vials/30 days OVIDREL (choriogonadotropin) 1 syringe (0.5 ml)/30 days REPRONEX (menotropins) 72 vials/30 days Hormone Replacement CRINONE (progesterone) 8% 60 applicators/30 days PLEASE NOTE: This drug list is subject to periodic updates and may not be all inclusive. Drugs affected include both brand and generic where applicable and includes all dosage formulations unless otherwise specifically notated. If a new drug is approved and falls into one of the targeted PA categories, the new drug may automatically be added to this list. Quantity limits may also apply. *Quantity limits are built into the PA criteria approval and varies based on indication and/or other clinical factors. Updated 4/1/2015 Page 7 of 7
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Anti-infectives Antiretrovirals, Hepatitis B BARACLUDE (entecavir) BARACLUDE (entecavir) Soln 630 ml/30days HEPSERA (adefovir) TYZEKA (telbivudine ) Antiretrovirals, HIV FUZEON (enfuvirtide) 60 vials or
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