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Effective January 1, 2017, new preferred products were updated in all of the following policies: |
| Drugs/Biologics Not Covered Unless Approved Under Medical Necessity Review – Employer Group Plans: Standard Prescription Drug List and Performance Prescription Drug List - (1601) |
Modified |
- Important changes in coverage criteria:
- Added several products consistent with the general criteria approach outlined below:
- Drugs or biologics with a significantly higher cost compared to their therapeutic alternatives (where all other clinical factors are the same): a maximum of five therapeutic alternatives required.
- Non-preferred products: alternatives limited to the preferred product(s).
- Multisource brand drugs: alternatives include generic equivalents, as well as therapeutic alternatives.
- Single-source combination products: alternatives include the individual components taken separately.
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| Drugs/Biologics Not Covered Unless Approved Under Medical Necessity Review – Employer Group Plans: Value Prescription Drug List and Advantage Prescription Drug List - (1602) |
Modified |
- Important changes in coverage criteria:
- Added several products consistent with the general criteria approach outlined below:
- Drugs or biologics with a significantly higher cost compared to their therapeutic alternatives (where all other clinical factors are the same): a maximum of five therapeutic alternatives required.
- Non-preferred products: alternatives limited to the preferred product(s).
- Multisource brand drugs: alternatives include generic equivalents, as well as therapeutic alternatives.
- Single-source combination products: alternatives include the individual components taken separately.
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| Oncology Medications - (1403) |
Modified |
- Important changes in coverage criteria:
- Updated medical necessary criteria for Gleevec® to require documented intolerance to generic imatinib tablets.
- Added Lartruvo® (olaratumab) to support medical precertification.
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| Pharmacy Prior Authorization – (1407) |
Modified |
- Important changes in coverage criteria:
- Added the following to be consistent with FDA-approved indication and AHFS off-label indications:
- Evzio® (naloxone)
- Addyi (flibanserin).
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| Pulmonary Hypertension (PH) Therapy – (6121) |
Modified |
- Important changes in coverage criteria:
- Updated medical necessary criteria for Revatio:
- Will require documented intolerance to generic sildenafil.
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| Somatropin (Genotropin®, Humatrope®, Norditropin FlexPro®, Nutropin®, Nutropin® AQ, Omnitrope®, Saizen®, Serostim®, Zomacton™, Zorbtive®) – (4012) |
Modified |
- Important changes in coverage criteria:
- Updated preferred products:
- Employer Group Benefit Plans: Preferred product will be Humatrope exclusively.
- Individual and Family Benefit Plans: Preferred products will continue to be Humatrope and Saizen.
- Serostim and Zorbtive will continue to be preferred products for their unique indications.
- Updated experimental, investigational, or unproven (EIU) list to include:
- Celiac disease
- Glucocorticoid-induced growth failure.
- Added clarifying statement that the presence of a comorbid condition found on the EIU list does not exclude an individual from therapy if criteria is otherwise met.
- Added separate not covered statement for growth hormone in combination in GnRH for clarity.
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| Step Therapy – (1109) |
Modified |
- Important changes in coverage criteria:
- Added or removed several medications with significant changes happening in the following areas:
- New oral narcotic step therapy class.
- Increase in the number of required generic prerequisites from one to two in the following classes:
- Clearly defined clinical exemption to the step therapy requirements as being an individual who is stabilized on therapy where therapeutic interchange is not appropriate in several classes.
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| Step Therapy Individual and Family Plan – (1603) |
Modified |
- Important changes in coverage criteria:
- Added or removed several medications with significant changes happening in the following areas:
- New oral narcotic step therapy class.
- New long-acting insulin class.
- Clearly defined clinical exemption to the step therapy requirements as being an individual who is stabilized on therapy where therapeutic interchange is not appropriate in several classes.
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Effective January 15, 2017, the following policies were modified: |
| Dimercaprol (BAL in Oil®) and Edetate Calcium Disodium (Calcium Disodium Versenate®) - (6019) |
Modified |
- Important changes in coverage criteria:
- Changed title from “Chelation Therapy” to current title.
- Added lead blood levels to criteria requirement for both dimercaprol and edetate calcium disodium.
- Added treatment of mercury toxicity from dental amalgam fillings as EIU.
- Added HCPCS code, J3520 “edetate disodium” as EIU.
- Added statement that edetate disodium is not an FDA-approved agent.
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| Lomitapide Mesylate (Juxtapid®) , Mipomersen Sodium (Kynamro®) - (1507) |
Modified |
- Important changes in coverage criteria:
- Added minimum three month trial for inadequate response with Repatha criteria.
- Added inability to use Repatha to Juxtapid criteria due to differences in administration:
- Repatha is subcutaneous and Juxtapid is oral.
- Removed prescriber specialist requirement.
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| Tesamorelin (Egrifta®) - (1112) |
Modified |
- Important changes in coverage criteria:
- Removed requirement of CT scan demonstrating an increase in visceral adipose tissue.
- Decreased authorization approval duration from 12 to 6 months.
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| Vascular Endothelial Growth Factor (VEGF) Inhibitors for Ocular Use - (1206) |
Modified |
- Important changes in coverage criteria:
- Added statement that use of more than one VEGF inhibitor in the same eye is considered EIU.
- Clarified that coverage of Lucentis® for diabetic retinopathy with diabetic macular edema includes:
- Non-proliferative diabetic retinopathy (NPDR) and proliferative diabetic retinopathy (PDR) based on FDA-labeled indication.
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