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2015 bcn advantage prior auth criteria

2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014

Drugs Requiring Prior Authorization
BCN AdvantageSM is a n HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
Acthar HP
Effective Date: January 1, 2015

Covered uses
All FDA-approved indications not otherwise excluded from Part D. Exclusion criteria
Required med info
Age restrictions
Prescriber restrictions
Coverage duration
Other criteria
BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
Adempas
Effective Date: January 1, 2015

Covered uses
All FDA-approved indications not otherwise excluded from Part D. Exclusion criteria
Required med info
Age restrictions
Prescriber restrictions
Coverage duration
Other criteria
BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
Afinitor
Effective Date: January 1, 2015

Covered uses
All FDA-approved indications not otherwise excluded from Part D. Exclusion criteria
Required med info
Age restrictions
Prescriber restrictions
Prescriber is an oncologist Coverage duration
Other criteria
Coverage is not provided when Affinitor® is used in combination with Nexavar® or BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014

Amitzia
Effective Date: January 1, 2015

Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Required med info
1. Chronic idiopathic constipation (CIC) in adults or
2. Opioid-induced constipation in adults with chronic, non-cancer pain or
3. Irritable bowel syndrome (IBS) with constipation in women Age restrictions
18 years of age and older Prescriber restrictions
Prescribed by or in consultation with a dermatologist or oncologist. Coverage duration
Other criteria
Documentation of trial/failure within the last 12 months of: 1. A fiber laxative and
2. One of the fol owing: a stimulant laxative or an osmotic laxative BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014

Ampyra
Effective Date: January 1, 2015

Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Patients with a history of seizure or moderate to severe renal impairment defined by a CrCl of 50ml/min or less Required med info
Initial requests require documentation of a 25 foot timed walk test.
Renewal requests require documentation of improvement in walking distance of a
25 foot timed walk test compared to pretreatment. Age restrictions
Prescriber restrictions
Prescriber is a neurologist Coverage duration
Initial approval is Three Months
Renewal approvals are for one year
Other criteria
Initial coverage is provided to improve walking distance in patients with a
diagnosis of multiple sclerosis who have the ability to walk a timed 25 foot walk Renewal criteria: documentation that the member has shown an improvement in
walking distance of a 25 foot timed walk test compared to pretreatment. BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
Trandermal Androgens
Androgel, Androderm, Testim, Testipel, Testosterone
Effective Date: January 1, 2015

Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Required med info
Documentation of androgen deficiency syndrome confirmed by two morning testosterone levels less than 300 ng/dL and at least 2 clinical signs or symptoms specific to androgen deficiency Age restrictions
Prescriber restrictions
Coverage duration
Other criteria
BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
Androxy
Effective Date: January 1, 2015

Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Required med info
Age restrictions
Prescriber restrictions
Coverage duration
Other criteria
BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
Arcalyst
Effective Date: January 1, 2015

Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Required med info
Age restrictions
12 years of age and older Prescriber restrictions
Coverage duration
Other criteria
BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
Aubagio
Effective Date: January 1, 2015
Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Required med info
Age restrictions
Prescriber restrictions
Prescriber is a neurologist Coverage duration
Other criteria
Requires documentation of a trial/failure of either Glatiramer or an Interferon BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
Avonex
Effective Date: January 1, 2015
Covered uses
All FDA-approved indications not otherwise excluded from Part D. Exclusion criteria
Required med info
Multiple Sclerosis (MS): 1. Relapsing forms of MS or 2. High risk of developing clinical y definite MS defined by both of the following: a) Recent history of a first clinical demyelinating event AND
b) MRI-detected brain lesions consistent with MS Age restrictions
Prescriber restrictions
Coverage duration
Other criteria
BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
Bosulif
Effective Date: January 1, 2015

Covered uses
All FDA-approved indications not otherwise excluded from Part D. Exclusion criteria
Required med info
Diagnosis of chronic, accelerated, or blast phase Philadelphia chromosome- positive (Ph+) chronic myelogenous leukemia (CML) Age restrictions
Prescriber restrictions
Coverage duration
Other criteria
BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
Cimzia
Effective Date: January 1, 2015
Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Required med info
Requires documentation of diagnosis and medication history or intolerance(s) Age restrictions
Prescriber restrictions
Crohn's Disease: Prescribed or recommended by a gastroenterologist RA: Prescribed or recommended by a rheumatologist. Coverage duration
Other criteria
Rheumatoid arthritis requires the member has tried and failed Humira® or
Enbrel®, except if not tolerated due to documented clinical side effects. Crohn's disease, requires:
1) Treatment with an adequate course of systemic corticosteroids (e.g., 40 mg to 60 mg prednisone per day for 7 to 14 days) has been ineffective or is contraindicated or 2) The patient has been unable to taper off an adequate course of systemic corticosteroids without experiencing worsening of disease or 3) The patient is experiencing breakthrough disease (e.g., active disease flares) while stabilized for at least 2 months on an immunomodulatory medication (such as azathioprine, mercaptopurine, cyclosporine, or methotrexate) and 4) Adalimumab (Humira®) is not effective after at least an initial 3-dose induction period, except if not tolerated due to documented clinical side effects. BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
Cinryze
Effective Date: January 1, 2015
Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Required med info
Age restrictions
Prescriber restrictions
Prescribed by an immunologist, allergist, or rheumatologist Coverage duration
Other criteria
BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
Cometriq
Effective Date: January 1, 2015
Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Required med info
Diagnosis of progressive, metastatic medullary thyroid cancer Age restrictions
Prescriber restrictions
Coverage duration
Other criteria
BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
Copaxone
Effective Date: January 1, 2015
Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Required med info
Multiple Sclerosis (MS): 1. Relapsing forms of MS OR 2. High risk of developing clinically definite MS defined by both of the fol owing: a) Recent history of a first clinical demyelinating event AND b) MRI-detected brain lesions consistent with MS Age restrictions
Prescriber restrictions
Coverage duration
Other criteria
BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
HIGH RISK IN THE ELDERLY MEDICATION

Cyclobenzaprine
Effective Date: January 1, 2015
Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Required med info
Age restrictions
Authorization is required for members 65 years of age and older Prescriber restrictions
Coverage duration
Other criteria
When used for treating fibromyalagia, requires: Trial/failure of two safer alternatives (gabapentin, pregabalin, duloxetine, nortriptyline, tramadol, tizandine or baclofen) (unless not appropriate or contraindicated for the intended use). For all other indications, at least one safer alternative (tizanidine or baclofen) should be tried and failed (unless not appropriate or contraindicated for the BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
Daliresp
Effective Date: January 1, 2015
Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Required med info
Diagnosis and patient medication history Age restrictions
Prescriber restrictions
Coverage duration
Other criteria
Coverage is provided for the treatment of severe chronic obstructive pulmonary disease (COPD) associated with chronic bronchitis in patients with a history of exacerbations and patient is receiving: 1. inhaled long-acting beta-2 agonist [for example, Formoterol, Salmeterol] AND
2. inhaled long-acting anticholinergic agent [for example, Tiotropium] AND
3. inhaled corticosteroid [for example, Fluticasone] OR
4. Patient experienced intolerance or has contraindications to use of these BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
Dysport
Effective Date: January 1, 2015
Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Wil not be covered for cosmetic purposes Required med info
Age restrictions
Prescriber restrictions
Coverage duration
Other criteria
BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
Erythropoesis Stimulating Agents:
Arnesp, Epogen, Procrit
Effective Date: January 1, 2015
Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Anemia due to folate, vitamin B12, iron deficiencies, hemolysis, bleeding, or bone marrow fibrosis. Anemia associated with treatment of acute and chronic myelogenous leukemias or erythroid cancers. Anemia due to cancer treatment in patients with uncontrol ed hypertension. Anemia not associated with cancer treatment or renal disease under inclusions. Anemia associated only with radiotherapy. Prophylactic use to prevent chemotherapy induced anemia. Prophylactic use to reduce tumor hypoxia. Erythropoietin-type resistance due to neutralizing antibodies. Required med info
Hemoglobin less than 13 for prophylactic use during some major surgeries Hemoglobin less than 12mg/dl for remaining covered uses Age restrictions
Prescriber restrictions
Coverage duration
Other criteria
Erythropoesis stimulating agents are subject to Part B vs Part D review BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
Erivedge
Effective Date: January 1, 2015
Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Required med info
Age restrictions
Prescriber restrictions
Prescribed by or in consultation with a dermatologist or oncologist Coverage duration
Other criteria
BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
Estrogens (Menest)
Effective Date: January 1, 2015
Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Required med info
Age restrictions
Authorization is required for members 65 years of age and older Prescriber restrictions
Coverage duration
Other criteria
Oral Estrogen (Menest) wil be approved when used as part of a cancer treatment For all other uses, Menest wil be approved if two of the fol owing safer alternatives as been tried and failed or are not appropriate or contraindicated.
Safer alternatives include: e.g., SSRIs, venlafaxine ER, Premarin vaginal cream,
Estrace vaginal creams, Estring or Femring Vaginal Rings, Vagifem vaginal tablets BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014

Forteo
Effective Date: January 1, 2015
Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Coverage is not provided for hypocalcemia Required med info
1) A Diagnosis of: a. Postmenopausal women with osteoporosis, or
b. Glucocorticoid induced osteoporosis, or
c. Males with primary or hypogonadal osteoporosis, all of who are at high risk for 2) Bone mineral density that is 2.5 standard deviations or more below the mean (t-score at or below -2.5) Age restrictions
Prescriber restrictions
Coverage duration
One year with maximum two years of therapy Other criteria
Forteo is subject to Part B vs Part D review. Coverage approval requires: Trial and failure to at least one bisphosphonate except when: 1. Contraindication to an oral and intravenous bisphosphonate (such as a stricture or aclasia, inability to stand or sit upright for at least 30 minutes and increased risk 2. Documented intolerance to a bisphosphonate BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
Fulyzaq
Effective Date: January 1, 2015
Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Required med info
Age restrictions
Prescriber restrictions
Coverage duration
Other criteria
BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
Gattex
Effective Date: January 1, 2015
Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Required med info
Age restrictions
Prescriber restrictions
Coverage duration
Other criteria
BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
Gilenya
Effective Date: January 1, 2015
Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Required med info
Age restrictions
Prescriber restrictions
Prescribed by a neurologist Coverage duration
Other criteria
Requires documentation of trial/failure of either Glatiramer or an Interferon beta BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
Giltorif
Effective Date: January 1, 2015
Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Required med info
Age restrictions
Prescriber restrictions
Coverage duration
Other criteria
BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
Growth Hormone:
Genotropin, Humatrope, Increlex, Norditropin, Nutropin, Nutropin AQ, Omnitrope,
Saizen, Serostim, Somavert, Tev-Tropin, Zorbtive
Effective Date: January 1, 2015
Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Required med info
Covered for the replacement of endogenous growth hormone in adults with growth hormone deficiency of childhood onset or adult onset. Covered if initial diagnosis based on two growth hormone stimulation tests and that the patient does not have edema, arthralgias, or carpal tunnel syndrome. Serostim is covered for aids wasting cachexia.
Norditropin is covered for Noonan syndrome, Turner syndrome, and adult growth
hormone deficiency. Nutropin is covered for Turner syndrome, and adult growth hormone deficiency.
Omnitrope and Saizen are covered for adult growth hormone deficiency.
Zorbtive is covered for the treatment of short-bowel syndrome in patients
receiving specialized nutritional support. Somavert is covered for acromegaly.
Age restrictions
Prescriber restrictions
Coverage duration
Other criteria
BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
Hetlioz
Effective Date: January 1, 2015 June 1, 2014
Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Required med info
Documentation of patient visual capabilities Age restrictions
Prescriber restrictions
Coverage duration
Other criteria
BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014

Hepatitis Treatments:
Infergen, Intron-A, Pegasys, Pegasys proclick, Peg-Intron
Peg-Intron Redipen
Effective Date: January 1, 2015
Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Required med info
Documentation of concomitant Ribavarin use (or contraindications) is required when requesting initial use for Hepatitis C. Documentation of viral genotype is required for Hepatitis C. Documentation of response to therapy is required for requests for continuation of therapy for Hepatitis C Age restrictions
Prescriber restrictions
Coverage duration
Initiation Of Therapy: 12 weeks Continuation Therapy: 24 to 48 weeks Other criteria
BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
High Risk in the Elderly Medications:
Diphenhydramine
Effective Date: January 1, 2015
Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Required med info
Age restrictions
Prior authorization is required for formulary high risk medications for members 65 years of age and older Prescriber restrictions
Coverage duration
Other criteria
Requires documentation of intolerance, contraindications, or trial with failure with at least one other safer formulary alternative. Diphenhydramine is approved if patient has failed or is intolerant to at least one
other safer alternative sedative agent such as Trazodone or Rozeram or if patient
has failed or is intolerant to at least one other safer alternative antihistamine such as fexofenadine.
BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
High Risk in the Elderly Medications:
Tricyclic Antidepressants: Amitriptyline, Clomipramine, Doxepin, Imipramine,
Surmontil
Effective Date: January 1, 2015

Covered uses
All FDA-approved indications not otherwise excluded from Part D. Exclusion criteria
Required med info
Age restrictions
Authorization is required for formulary high risk medications for members 65 years of age and older Prescriber restrictions
Coverage duration
Other criteria
High Risk Tricyclic Antidepressants are approved if patient has a history of use.
For patients initiating therapy, the high risk tricyclic antidepressant is approved if at least one of the suggested alternatives (nortriptyline, desipramine, citalopram,
escitalopram, mirtazapine, sertraline, venlafaxine) with less sedation and fewer
anticholinergic effects have been tried and failed or is not appropriate or contraindicated for the intended use. BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
High Risk in the Elderly Medications
Megace (Megesterol)
Effective Date: January 1, 2015

Covered uses
All FDA-approved indications not otherwise excluded from Part D. Exclusion criteria
Required med info
Age restrictions
Authorization is required for formulary high risk medications for members 65 years of age and older Prescriber restrictions
Coverage duration
Other criteria
Megace (megesterol) is approved if at least one of the suggested alternatives
(mirtazipine, oxandrolone or dronabinol) have been tried and failed or are not
appropriate or contraindicated for the intended use. BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
High Risk in the Elderly Medications:
Zaleplon
Effective Date: January 1, 2015

Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Required med info
Age restrictions
Authorization is required for formulary high risk medications for members 65 years of age and older Prescriber restrictions
Coverage duration
Other criteria
Lunesta (Zaleplon) is approved if at least one of the suggested alternatives, (low
dose Trazodone (25-50mg) or Rozerem), has been tried and failed or is not
appropriate or contraindicated for the intended use. BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
High Risk in the Elderly Medications
Thioridiazine
Effective Date: January 1, 2015

Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Required med info
Age restrictions
Prior authorization is required for formulary high risk medications for members 65 years of age and older Prescriber restrictions
Coverage duration
Other criteria
Requires documentation of intolerance, contraindications, or trial with failure with at least one other safer formulary alternative. Thioridizine is covered for patients who have a history of use. For patients
initiating therapy, thioridizine is covered if patient has a failure of or intolerance to at least one other safer alternative antipsychotics such as Abilify or Seroquel.
BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014

High Risk in the Elderly Medications:
Cyproheptadine
Effective Date: January 1, 2015

Covered uses
All FDA-approved indications not otherwise excluded from Part D. Exclusion criteria
Required med info
Age restrictions
Authorization is required for formulary high risk medications for members 65 years of age and older Prescriber restrictions
Coverage duration
Other criteria
Cyproheptadine is approved if at least one suggested alternative such as a second
generation antihistamine (e.g., Cetirizine, Desloratadine, Loratadine,
Fexofenadine) or low dose Trazodone (25-50mg) or Rozerem, if using for sleep,
have been tried and failed or not appropriate or contraindicated for the intended BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
Iclusig
Effective Date: January 1, 2015
Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Required med info
Age restrictions
Prescriber restrictions
Coverage duration
Other criteria
BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
Imbruvica
Effective Date: January 1, 2015
Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Required med info
Age restrictions
Prescriber restrictions
Coverage duration
Other criteria
BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
Injectable Diabetic Medications:
Byetta, Bydureon, Victoza, Symlin
Effective Date: January 1, 2015
Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Not covered for non Type 2 diabetes diagnosis.
Not covered for weight loss in patients with or without diabetes.
Required med info
Requires documentation of diagnosis and medication history or intolerance(s). Age restrictions
Prescriber restrictions
Coverage duration
Other criteria
Byetta, Bydureon, Victoza:
Approved as adjunctive therapy to improve glycemic control in patients who have a diagnosis of Type II Diabetes Mel itus and are currently taking or have tried and failed at least One of the fol owing:
Metformin, a Sulfonylurea, or a Thiazolidinedione, or
One of the fol owing: a combination of metformin and a sulfonylurea or a
combination of Metformin and a Thiazolidinedione. In addition to the above criteria the patient must have a hemoglobin A1c of greater than 7 per cent. Symlin is covered for patients that have failed intensive treatment with insulin
monotherapy and for concurrent use with an insulin product BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
Inlyta
Effective Date: January 1, 2015
Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Coverage is not provided for combination use with other tyrosine kinase inhibitors such as Sorafenib, Sunitinib Required med info
Coverage for the treatment of renal cell carcinoma is provided after failure with one prior systemic therapy Age restrictions
Prescriber restrictions
Coverage duration
Other criteria
BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
Jakafi
Effective Date: January 1, 2015
Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Required med info
Age restrictions
Prescriber restrictions
Prescribed by a hematologist / oncologist Coverage duration
Other criteria
BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
Juxtapid
Effective Date: January 1, 2015
Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Required med info
Requires documentation of diagnosis of homozygous familial hypercholesterolemia. Age restrictions
Prescriber restrictions
Coverage duration
Other criteria
Requires trial and failure of Kynamro BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
Kalydeco
Effective Date: January 1, 2015
Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Required med info
Diagnosis of Cystic Fibrosis and confirmed G551D mutation Age restrictions
Prescriber restrictions
Coverage duration
Other criteria
BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
Kineret
Effective Date: January 1, 2015
Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Required med info
Requires documentation of diagnosis and medication history or intolerance(s). Age restrictions
Prescriber restrictions
Prescribed by a rheumatologist Coverage duration
Other criteria
Rheumatoid arthritis: requires a treatment failure or contraindication to Enbrel®
BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
Korlym
Effective Date: January 1, 2015
Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Required med info
Age restrictions
Prescriber restrictions
Coverage duration
Other criteria
BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
Kynamro
Effective Date: January 1, 2015
Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Required med info
Requires documentation of diagnosis of homozygous familial hypercholesterolemia. Age restrictions
Prescriber restrictions
Coverage duration
Other criteria
BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
Lidocaine Transdermal Patch
Effective Date: January 1, 2015
Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Required med info
Age restrictions
Prescriber restrictions
Coverage duration
Other criteria
BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
Linzess
Effective Date: January 1, 2015
Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Required med info
Age restrictions
18 years of age and older Prescriber restrictions
Coverage duration
Other criteria
Chronic idiopathic constipation (CIC) requires documentation of failure within the
last 12 months of use of a fiber laxative and one of the fol owing: a stimulant laxative or an osmotic laxative. Drug-induced constipation must be ruled out. BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
Mekinist
Effective Date: January 1, 2015
Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Required med info
Confirmation of the presence of BRAF V600E or V600K mutation in tumor Age restrictions
Prescriber restrictions
Coverage duration
Other criteria
BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
Modafinil, Nuvigil
Effective Date: January 1, 2015
Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Required med info
Age restrictions
Prescriber restrictions
Coverage duration
Other criteria
Nuvigil: Requires a treatment failure or contraindication to modafinal BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
Mozobil
Effective Date: January 1, 2015
Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Required med info
Requires documentation of diagnosis and that granulocyte colony stimulating factor is administered concomitantly, and documentation of poor response to apheresis with granulocyte colony stimulating factor alone. Age restrictions
Prescriber restrictions
Coverage duration
Duration requested up to one month Other criteria
BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
Namenda
Effective Date: January 1, 2015
Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Coverage is not provided for diagnosis of Autism Required med info
Age restrictions
Prescriber restrictions
Coverage duration
Other criteria
BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014

Narcotic Analgesics:
Abstral, Fentanyl Citrate Oral Transmucosal, Fentora, Lazanda, Onsolis, Subsys
Effective Date: January 1, 2015
Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Required med info
Requires documentation of diagnosis and medication history Age restrictions
Prescriber restrictions
Coverage duration
Other criteria
Covered for cancer or cancer related diagnosis in patients already receiving long BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
Nexavar
Effective Date: January 1, 2015
Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Required med info
Age restrictions
Prescriber restrictions
Hepato-cel ular carcinoma: Prescribed by an oncologist, hepatologist, or
gastroenterologist Al other indications: Prescribed by an oncologist
Coverage duration
Other criteria
BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
Nuedexta
Effective Date: January 1, 2015
Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Required med info
Requires diagnosis of pseudobulbar affect (PBA). Age restrictions
Prescriber restrictions
Coverage duration
Other criteria
Coverage is provided for the treatment of pseudobulbar affect in patients with underlying neurologic condition. BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
Olysio
Effective Date: January 1, 2015
Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Required med info
Chronic Hepatitis C genotype 1 with compensated liver disease (including Age restrictions
18 years and older Prescriber restrictions
Coverage duration
Other criteria
For interferon eligible patients: must be used in combination with peg-interferon alpha and ribavirin. for interferon ineligble patients: may be used in combination with Sovaldi with or without ribavirin. BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014

Orencia
Effective Date: January 1, 2015
Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Required med info
Verification that the patient has been evaluated for TB and treated accordingly Age restrictions
Rheumatoid Arthritis: 18 years and older. Prescriber restrictions
Prescribed by a rheumatologist Coverage duration
Other criteria
Coverage is provided if: 1) Failed methotrexate or one DMARD and
2) Failure to at least one preferred biologic (Enbrel or Humira) BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
Orenitram
Effective Date: January 1, 2015
Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Required med info
Age restrictions
Prescriber restrictions
Coverage duration
Other criteria
BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
Otezla
Effective Date: January 1, 2015
Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Required med info
Requires documentation of diagnosis and medication history or intolerance(s). Requires verification that the patient has been evaluated for TB and has been treated accordingly. Age restrictions
Prescriber restrictions
Coverage duration
Other criteria
Coverage is provided if: 1) Failed methotrexate or one DMARD and
2) Failure to at least one preferred biologic (Enbrel or Humira) BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
Oxandrolone
Effective Date: January 1, 2015
Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Weight gain not related to AIDS wasting/cachexia Required med info
Diagnosis of bone pain due to osteoporosis Diagnosis of AIDS wasting/cachexia Age restrictions
Prescriber restrictions
Coverage duration
Other criteria
BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
Pomalyst
Effective Date: January 1, 2015
Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Required med info
Diagnosis of multiple myeloma Age restrictions
Prescriber restrictions
Coverage duration
Other criteria
Coverage is provided if: 1) Patient has received at least two prior therapies including Lenalidomide and 2) Demonstrated disease progression on or within 60 days of completion of the BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
Prolia
Effective Date: January 1, 2015
Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Coverage is not provided for hypocalcemia Required med info
1.Postmenopausal osteoporosis with a high risk of fracture or 2. Males with risk for fracture receiving androgen deprivation therapy for nonmetastatic prostate cancer or to increase bone mass for osteoporosis or 3. Female at high risk of fracture receiving adjuvant aromatase inhibitor therapy for nonmetastatic breast cancer Age restrictions
Prescriber restrictions
Coverage duration
Other criteria
Prolia is subject to Part B versus Part D review
Requirements: Patient has tried and failed at least one bisphosphonate except
1. Contraindication to a bisphosphonate (oral and intravenous) such as a stricture or aclasia, inability to stand or sit upright for at least 30 minutes and increased risk 2. Documented intolerance to a bisphosphonate BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
Promacta
Effective Date: January 1, 2015
Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Required med info
Requires documentation of diagnosis, medication history or intolerance(s), platelet counts. Age restrictions
18 years of age and older Prescriber restrictions
Prescribed or recommended by a hematologist, hepatologist or gastroenterologist. Coverage duration
Initiation of therapy: 12 weeks
Continuation therapy: One Year
Other criteria
Initial Coverage approval requires: 1) Treatment of thrombocytopenia in patients with chronic immune thrombocytopenia (ITP) at risk for bleeding who have had insufficient response to corticosteroids, immune globulin, or splenectomy; or
2) Treatment of thrombocytopenia in patients with chronic hepatitis C in order to allow and maintain interferon-based therapy Renewal of therapy is covered for patients who meet the following criteria:
Recent platelet count of 30,000 to 150,000 mcl. BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
Hepatitis Therapies:
Incivik, Victrelis
Effective Date: January 1, 2015
Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Coverage is not provided in situations where patients have previously not responded to therapy that included either Boceprevir or Telaprevir. Required med info
Diagnosis: Chronic hepatitis C, genotype 1 with compensated liver disease (including cirrhosis) and recent HCV-RNA level. Renewal for Victrelis: Detectable HCV-RNA level/viral load or HCV-RNA level/viral
load greater than or equal to 100 IU/ml after total treatment week 12 and 24. Age restrictions
Covered for patients 18 years of age or older Prescriber restrictions
Coverage duration
Incivek: 12 weeks.
Victrelis: Initial: 12 weeks.
1st Renewal: 12 weeks. 2nd Renewal: 20 weeks. Other criteria
Incivek and Victrelis: Coverage is provided in situations where patients are
receiving combination therapy with either Boceprevir or Telaprevir and a Peg
interferon alfa product with Ribavirin. Victrelis: Incivek must be contraindicated or not recommended do the patients'
clinical history (history of severe skin reactions or dermatologic conditions, moderate to severe hepatic impairment, drug-drug interactions not associated with boceprevir) BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
Pulmonary Agents:
Adcirca, Letairis, Opsumit, Sildenafil Citrate 20mg, Remodulin, Tracleer, Tyvaso,
Ventavis
Effective Date: January 1, 2015
Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Coverage for Sildenafil and Adcirca is not provided in situations where patients are receiving nitrate therapy. Required med info
Age restrictions
Prescriber restrictions
Coverage duration
Other criteria
BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
Ravicti
Effective Date: January 1, 2015
Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Required med info
Age restrictions
Prescriber restrictions
Coverage duration
Other criteria
BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
Rebif
Effective Date: January 1, 2015
Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Required med info
Multiple Sclerosis (MS): 1. Relapsing forms of MS OR 2. High risk of developing clinical y definite MS defined by both of the fol owing: a) Recent history of a first clinical demyelinating event AND b) MRI-detected brain lesions consistent with MS Age restrictions
Prescriber restrictions
Coverage duration
Other criteria
BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
Regranex
Effective Date: January 1, 2015
Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Required med info
Requires documentation of adequate tissue oxygenation at the site of the neuropathic diabetic ulcer, and that there is a full thickness ulcer (for example stage three or four) extending through the dermis into subcutaneous tissue. In addition, requires documentation that the patient is participating in a comprehensive wound care treatment plan including such modalities as debridement, pressure relief (for example, non weight bearing) and infection Age restrictions
Prescriber restrictions
Coverage duration
Other criteria
BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
Relistor
Effective Date: January 1, 2015
Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Required med info
Age restrictions
Prescriber restrictions
Coverage duration
Other criteria
Requires adequate treatment consisting of 5 days duration of treatment of agents for constipation, including at least any two of the fol owing:
Bulk laxatives, saline laxatives or osmotic laxatives. Coverage may not be provided if there are contraindications to Methylnaltrexone BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
Revlimid
Effective Date: January 1, 2015
Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Required med info
Age restrictions
Prescriber restrictions
Prescribed by or in consultation with an oncologist or hematologist Coverage duration
Other criteria
BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
Remicade
Effective Date: January 1, 2015
Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Required med info
Verification that the patient has been evaluated for TB and treated accordingly Age restrictions
Crohn's Disease: 6 years and older All other indications: 18 years and older Prescriber restrictions
Coverage duration
Other criteria
BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
Remodulin
Effective Date: January 1, 2015
Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Required med info
Age restrictions
Prescriber restrictions
Coverage duration
Other criteria
BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014

Samsca
Effective Date: January 1, 2015
Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Required med info
Documentation that patient does not have underlying liver disease Age restrictions
Prescriber restrictions
Coverage duration
Other criteria
BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
Sancuso
Effective Date: January 1, 2015
Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Sancuso is not covered for hyperemesis gravidarum, nausea and vomiting of pregnancy and post-operative nausea and vomiting. Required med info
Age restrictions
Prescriber restrictions
Coverage duration
Other criteria
Covered if treatment with generic Ondansetron and oral Granisetron is not effective or is not tolerated. BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
Kuvan (Sapropterin hydrochloride)
Effective Date: January 1, 2015
Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Required med info
Initial approval requires documentation of dietary restrictions and diagnosis.
For renewal requires documentation in reduction of phenylalanine from baseline.
Age restrictions
Prescriber restrictions
Coverage duration
Initial - 2 months Authorization wil be extended for 1 year if documented
response after initial therapy Other criteria
Renewal criteria: after initial therapy of 2 months, a 30% or greater reduction in
phenylalanine from baseline BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
Simponi
Effective Date: January 1, 2015
Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Required med info
Requires documentation of diagnosis and medication history or intolerance(s). Requires verification that the patient has been evaluated for TB and treated Age restrictions
Prescriber restrictions
Coverage duration
Other criteria
Rheumatoid Arthritis Trial and failure with Humira® or Enbrel®, except if not
tolerated due to documented clinical side effects. Psoriatic Arthritis requires trial and failure of Humira® or Enbrel®, except if not
tolerated due to documented clinical side effects. Alkylosing spondylitis, requires trial and failure of Humira® or Enbrel®, except if
contraindicated or not tolerated due to documented clinical side effects. Ulcerative Colitis requires trial and failure of Humira® except if contraindicated or
not tolerated due to documented clinical side effects. BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
Sirturo
Effective Date: January 1, 2015
Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Required med info
Age restrictions
Prescriber restrictions
Coverage duration
Other criteria
Must be used in combination with at least 3 other agents BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
Sovaldi
Effective Date: January 1, 2015
Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Required med info
Initial: Documentation of chronic hepatitis C genotype 1-6, including patients with hepatocellular carcinoma awaiting liver transplant. Renewal: HCV RNA level at 24 weeks and documentation of hepatocel ular carcinoma awaiting liver transplant. Age restrictions
18 years and older Prescriber restrictions
Coverage duration
Initial: 24 weeks, Renewal: 24 weeks Other criteria
For patients with genotype 1, 4, 5 and 6 who are interferon eligible: must be used in combination with peg-interferon alpha and ribavirin. For patients with genotype 1 who are interferon ineligible may be used in combination with Olysio with or without ribavirin or with ribavirin alone. For patients with genotype 4 who are interferon ineligible must be used in combination with ribavirin. For patients with genotype 2 or 3, and patients with hepatocel ular carcinoma: must be used in combination with ribavirin. BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014

Sprycel
Effective Date: January 1, 2015
Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Required med info
Age restrictions
Prescriber restrictions
Prescribed by oncologist Coverage duration
Other criteria
BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
Stelara
Effective Date: January 1, 2015

Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Not covered for diagnosis of Crohn's disease or Psoriatic Arthritis Required med info
Requires documentation of diagnosis and medication history or intolerance(s). Requires verification that the patient has been evaluated for TB and has been treated accordingly. Age restrictions
Prescriber restrictions
Coverage duration
Other criteria
Covered for treatment of Psoriasis when there is documented:
1. Trial and failure of at least one other oral systemic agent for psoriasis unless all are contraindicated. (E.g. cyclosporine, methotrexate, acitretin). 2. A trial and failure any one of the following: a) Infliximab (Remicaide) after at least an initial induction period (5 mg/kg on weeks 0,2, 6), except if not tolerated due to documented clinical side effects -or-
b) Humira® -or- Enbrel® after at least a 12 week treatment course, except if not
tolerated due to documented clinical side effects. BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
Sutent
Effective Date: January 1, 2015
Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Required med info
Age restrictions
Prescriber restrictions
Prescribed by oncologist Coverage duration
Other criteria
BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
Sylatron
Effective Date: January 1, 2015
Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Required med info
Age restrictions
Prescriber restrictions
Prescribed by oncologist Coverage duration
Other criteria
BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
Sylvant
Effective Date: January 1, 2015
Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Required med info
Age restrictions
Prescriber restrictions
Coverage duration
Other criteria
BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
Tabloid
Effective Date: January 1, 2015
Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Required med info
Age restrictions
Prescriber restrictions
Prescribed by oncologist or hematologist Coverage duration
Other criteria
BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
Tafinlar
Effective Date: January 1, 2015
Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Required med info
Confirmation of the presence of BRAF V600E mutation in tumor specimen Age restrictions
Prescriber restrictions
Coverage duration
Other criteria
BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
Tarceva
Effective Date: January 1, 2015
Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Required med info
Age restrictions
Prescriber restrictions
Prescribed by oncologist Coverage duration
Other criteria
BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
Targretin
Effective Date: January 1, 2015
Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Required med info
Age restrictions
Prescriber restrictions
Prescribed by oncologist or dermatologist Coverage duration
Other criteria
BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
Tasigna
Effective Date: January 1, 2015
Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Required med info
Age restrictions
Prescriber restrictions
Coverage duration
Other criteria
BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
Ticfidera
Effective Date: January 1, 2015
Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Required med info
Age restrictions
Prescriber restrictions
Coverage duration
Other criteria
BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
Thalomid
Effective Date: January 1, 2015
Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Required med info
Age restrictions
Prescriber restrictions
Coverage duration
Other criteria
BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
Treanda
Effective Date: January 1, 2015
Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Required med info
Age restrictions
Prescriber restrictions
Coverage duration
Other criteria
BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
Vecamyl
Effective Date: January 1, 2015
Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Required med info
Age restrictions
Prescriber restrictions
Coverage duration
Other criteria
BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
Victibex
Effective Date: January 1, 2015
Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Required med info
Age restrictions
Prescriber restrictions
Prescribed by an oncologist Coverage duration
Other criteria
BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
Votrient
Effective Date: January 1, 2015
Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Required med info
Documentation of advanced renal cell carcinoma Age restrictions
Prescriber restrictions
Prescribed by an oncologist Coverage duration
Other criteria
BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
Regranex
Effective Date: January 1, 2015
Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Required med info
Requires adequate tissue oxygenation at the site of the neuropathic diabetic ulcer, and that there is a full thickness ulcer (for example stage three or four) extending through the dermis into subcutaneous tissue. Requires that the patient is participating in a comprehensive wound care treatment plan including such modalities as debridement, pressure relief (for example, non weight bearing) and infection control. Age restrictions
Prescriber restrictions
Coverage duration
Other criteria
BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
Xalkori
Effective Date: January 1, 2015
Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Required med info
Diagnosis of locally advanced or metastatic non-small cell lung cancer (NSCLC) that is anaplastic lymphoma kinase (alk)-positive as detected by a FDA-approved test. Age restrictions
Prescriber restrictions
Coverage duration
Other criteria
BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
Xeljanz
Effective Date: January 1, 2015
Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Required med info
Requires documentation of diagnosis and medication history or intolerance(s). Age restrictions
Prescriber restrictions
Prescribed or recommended by a rheumatologist Coverage duration
Other criteria
Requires a treatment failure or contraindication to Enbrel and Humira. BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
Xenazine
Effective Date: January 1, 2015
Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Coverage for Xenazine wil not be provided for patients who have hepatic function impairment, patients who are actively suicidal or who have untreated or inadequately treated depression, or patients taking monoamine oxidase inhibitors Required med info
Age restrictions
Prescriber restrictions
Coverage duration
Other criteria
BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
Xgeva
Effective Date: January 1, 2015
Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Required med info
Age restrictions
Prescriber restrictions
Coverage duration
Other criteria
BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
Xolair
Effective Date: January 1, 2015
Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Required med info
Age restrictions
12 years of age and older Prescriber restrictions
Prescribed by a pulmonologist or allergist/immunologist Coverage duration
Other criteria
BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
Xtandi
Effective Date: January 1, 2015
Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Required med info
Coverage is provided for the treatment of metastatic castration-resistant prostate cancer where the patient has had prior treatment with docetaxel. Age restrictions
Prescriber restrictions
Prescribed or recommended by an oncologist or urologist Coverage duration
Other criteria
BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
Xyrem
Effective Date: January 1, 2015
Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Required med info
Age restrictions
Prescriber restrictions
Coverage duration
Other criteria
BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
Yervoy
Effective Date: January 1, 2015
Covered uses
All FDA-approved indications not otherwise excluded from Part D. Exclusion criteria
Required med info
Age restrictions
Prescriber restrictions
Prescribed by an oncologist Coverage duration
Other criteria
BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
Zelboraf
Effective Date: January 1, 2015
Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Will not be covered in combination with Yervoy Required med info
Diagnosis of unresectable or metastatic melanoma with BRAF V600E mutation as detected by a FDA-approved test. Age restrictions
Prescriber restrictions
Prescribed by an oncologist Coverage duration
Other criteria
BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
Zolinza
Effective Date: January 1, 2015
Covered uses
All FDA-approved indications not otherwise excluded from Part D. Exclusion criteria
Required med info
Age restrictions
Prescriber restrictions
Prescribed by an oncologist or hematologist Coverage duration
Other criteria
BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
Zykadia
Effective Date: January 1, 2015
Covered uses
All FDA-approved indications not otherwise excluded from Part D. Exclusion criteria
Required med info
Age restrictions
Prescriber restrictions
Coverage duration
Other criteria
BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013 2015 BCN Advantage Prior Authorization Criteria

Last updated: October, 2014
Zytiga
Effective Date: January 1, 2015
Covered uses
All FDA-approved indications not otherwise excluded from Part D Exclusion criteria
Required med info
Age restrictions
Prescriber restrictions
Coverage duration
Other criteria
BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_T_PAlist CMS Approved 12022013

Source: https://bcbsm.com/content/dam/public/Providers/Documents/help/faqs/bcna-prior-authorization-criteria.pdf