Bcn advantagesm step therapy and prior authorization requirements outlined

BCN Advantage HMO-POSSM 2012 Step
Therapy and Prior Authorization
requirements outlined for Providers
The goal of the BCN Pharmacy department is to ensure that all members receive high-quality, cost-effective pharmaceutical care. To meet this objective, BCN Advantage requires prior authorization for certain medications, and clinical criteria must be met before coverage is approved. Clinical criteria are based on current medical information and recommendations of BCBSM/BCN’s Pharmacy and Therapeutics Committee. In addition, as required by the Centers for Medicare & Medicaid Services, drugs that can be processed under either Part B or Part D may require prior authorization in order to determine how to process the claim. Drugs that are covered under Part B, based on the member’s circumstance, cannot be processed as a Part D claim. To request an override of one of BCN’s drug utilization management tools, health care providers should contact the Clinical Pharmacy Help Desk at 800-437-3803, Monday-Friday, 24 hours a day, 7 days a week. Responses to requests for coverage determinations are made within 72 hours. The provider should alert the Pharmacy Help Desk if the request is urgent. Urgent requests include requests for drugs without which the BCN Advantage member’s life, health or ability to regain maximum function would be jeopardized or that, in the opinion of the prescriber with knowledge of the member’s condition, would subject the member to severe pain that cannot be adequately managed without the care or treatment requested. The provider should consider these criteria when providing documentation if the request is urgent. A response to these requests will be provided within 24 hours.
ST = Step Therapy. If prior authorization criteria are met in member’s medication pharmacy
claims history, the medication will process at the pharmacy without need for further authorization.
PA = Prior Authorization. Medications must be prior authorized using the procedure described
above before the medication will process at the pharmacy.
Medication / Drug Class
Criteria
Administrative PA (Part D vs Part B processing)
PART B VERSUS PART D
COVERAGE DETERMINATION
REQUIRED FOR MEMBERS WITH
END STAGE RENAL DISEASE
UNDER THE PART D BENEFIT IF THEY ARE BEING (ESRD) WITH RENAL DIALYSIS
AND PRESCRIPTIONS FOR:
BONIVA®
CUBICIN®
HECTOROL®
LEVOCARNITINE
MICALCIN®
PAMINDRONATE
VANCOMYCIN IV
ZEMPLAR
PROCRIT®
EPOGEN®
ARANESP®
REQUIRES DOCUMENTATION
THAT THE DRUG IS NOT COVERED
UNDER PART B
REQUIRED FOR ALL MEMBERS
WITH PRESCRIPTIONS FOR:
ARZERRA®
AZASAN®
CELLCEPT®
GENGRAF®
METHOTREXATE TABS
MYCOPHENOLATE
MYFORTIC®
ORTHOCLONE® OKT3
PROGRAF®
RAPAMUNE®
RHEUMATREX
SANDIMMUNE®
TACROLIMUS
TREANDA
TRELSTAR MIXJECT
TREXALLTM
ZORTRESS®
Medication / Drug Class
Criteria
ANZEMET
EMEND®
GRANISETRON
ONDANSETRON
NEUMEGA®
CARIMUNE
ENGERIX-B®
GAMASTAN® S/D
GAMMAGARD LIQUID
GAMUNEX®
IMOVAX RABIES
VIVAGLOBIN®
Anti-emetic (PA)
SANCUSO®
TREATMENT OF NAUSEA AND OR VOMITING ASSOCIATED WITH CHEMOTHERAPY AND OR RADIATION. SANCUSO® IS REQUIRES DOCUMENTATION OF TREATMENT
FAILURE/INTOLERANCE WITH ZOFRAN® (g), AND
ORAL KYTRIL® (g).
NOT COVERED FOR HYPEREMESIS GRAVIDARUM,
NAUSEA AND VOMITING OF PREGNANCY, AND
POST-OPERATIVE NAUSEA AND VOMITING.
Antidepressants (ST)
For members in the Individual BCN
PEXEVA, SARAFEM®, LUVOX CR, AND VIIBRYD
Advantage benefit, the following
Antidepressants require authorization:
FAILURE OF OR INTOLERANCE TO AT LEAST ONE GENERIC ANTIDEPRESSANT, SUCH AS CELEXA® (g), PAXIL® (g), PROZAC® (g), OR WELLBUTRIN/SR™ PRISTIQTM
LEAST 30 DAYS OF AT LEAST ONE GENERIC ANTIDEPRESSANT AND 30 DAYS TRIAL OF
Antineoplastics (PA)
1) DOCUMENTED ADVANCED RENAL CELL CARCINOMA AND FAILURE OF TREATMENT OR DISEASE PROGRESSION WITH NEXAVAR® OR SUTENT®. 2) TREATMENT OF PROGRESSIVE NEUROENDOCRINE TUMORS (PNET) OF PANCREATIC ORIGIN THAT IS UNRESECTABLE, LOCALLY ADVANCED OR METASTATIC. 3) PATIENTS WITH SUBEPENDYMAL GIANT CELL ASTROCYTOMA (SEGA) ASSOCIATED WITH TUBEROUS SCLEROSIS (TS) WHO REQUIRE THERAPEUTIC INTERVENTION BUT ARE NOT CANDIDATES FOR CURATIVE SURGICAL RESECTION. COVERAGE IS NOT PROVIDED IN COMBINATION WITH NEXAVAR® OR SUTENT®. COVERED FOR THE TREATMENT OF PATIENTS WITH RENAL CELL CARCINOMA WHO HAVE FAILED OTHER SYSTEMIC THERAPIES COVERED FOR THE TREATMENT OF PATIENTS WITH 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. COVERAGE FOR ZELBORAF REQUIRES DOCUMENTATION OF DIAGNOSIS OF UNRESECTABLE OR METASTATIC MELANOMA WITH BRAF V600E MUTATION AS DETECTED BY A FDA-APPROVED TEST. WILL NOT BE COVERED IN COMBINATION WITH YERVOY Arthritis/Psoriasis/Crohn’s (PA)
TNF-alpha agents (self-
LENGTH OF APPROVALS FOR ALL TNF AGENTS: 1

injectables)
YEAR
CIMZIA® (Crtolizumab pegol)
ENBREL ® (Etanerept)
ENBREL:
HUMIRA® (Adalimumab)
FOR RHEUMATOID ARTHRITIS, JUVENILE RA OR
KINERET® (Anakinra)
PSORIATIC ARTHRITIS:
THREE MONTH TRIAL ON TWO CONCURRENT NONBIOLOGIC DISEASE MODIFYING ANTI-RHEUMATIC FOR MODERATE TO SEVERE PSORIASIS:
FOR ALKYLOSING SPONDYLITIS, REQUIRES
THERAPY IS BEING SUPERVISED BY A
HUMIRA:
FOR RHEUMATOID ARTHRITIS, JUVENILE RA OR
PSORIATIC ARTHRITIS:
HUMIRA REQUIRES A TRIAL ON TWO CONCURRENT NONBIOLOGIC DISEASE MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS), ONE OF WHICH MUST BE METHOTREXATE UNLESS CONTRAINDICATED. MODERATE TO SEVERE PSORIASIS:
IN ADDITION TO ABOVE, THERAPY MUST ALSO BE MODERATELY TO SEVERELY ACTIVE CROHN'S
DISEASE:
WITH A HISTORY OF INADEQUATE RESPONSE TO CONVENTIONAL THERAPY, [DEFINED BY ANY ONE OF THE FOLLOWING (a-c) AND (d)]: (a) INEFFECTIVE TREATMENT WITH DAILY SYSTEMIC CORTICOSTEROIDS (e.g., 40 mg to 60 mg PREDNSIONE PER DAY FOR 7 TO 14 DAYS) OR
CONTRAINDICATED OR
(c) THE PATIENT HAS BEEN UNABLE TO TAPER OFF SYSTEMIC CORTICOSTEROIDS WITHOUT EXPERIENCING WORSENING OF DISEASE AND (d) THE PATIENT IS EXPERIENCING
BREAKTHROUGH DISEASE (e.g., ACTIVE DISEASE azathioprine, mercaptopurine, cyclosporine, or methotrexate) UNLESS TREATMENT WITH THESE FOR ALKYLOSING SPONDYLITIS:
DOCUMENTATION OF PREVIOUS TREATMENT WITH A TOPICAL STEROID AND TREATMENT WITH PUVA (UNLESS PUVA CONTRAINDICATED) KINERET:
RHEUMATOID ARTHRITIS:
SIMPONITM :
FOR RHEUMATOID ARTHRITIS, PSORIATIC ARTHRITIS
AND ALKYLOSING SPONDYLITIS:
REQUIRES THE MEMBER HAS TRIED AND FAILED BOTH HUMIRA® AND ENBREL®, EXCEPT IF NOT
TOLERATED DUE TO DOCUMENTED CLINICAL SIDE
RHEUMATOID ARTHRITIS:
REQUIRES THE MEMBER HAS TRIED AND FAILED BOTH HUMIRA® AND ENBREL®, EXCEPT IF NOT TOLERATED DUE TO DOCUMENTED CLINICAL SIDE CROHN's DISEASE:
IMMUNOMODULATOR MEDICATION (such as azathioprine, mercaptopurine, cyclosporine, or 2) AT LEAST AN INITIAL 3-DOSE INDUCTION PERIOD TOLERATED DUE TO DOCUMENTED CLINCIAL SIDE STELARATM
CHRONIC PLAQUE PSORIASIS
1) TREATMENT WITH ONE ORAL SYSTEMIC AGENT FOR PSORIASIS THAT IS INEFFECTIVE OR NOT TOLERATED, UNLESS ALL ARE CONTRAINDICATED. (E.,G CYCLOSPORINE, METHOTREXATE, ACITRETIN). 2) 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) ADALIMUMAB (HUMIRA) -or- (ENBREL) AFTER AT
LEAST A 12 WEEK TREATMENT COURSE, EXCEPT IF NOT TOLERATED DUE TO DOCUMENTED CLINICAL SIDE EFFECTS Cardiovascular
Beta-Blockers (ST)
Members enrolled in a BCN
BYSTOLIC™ THERAPY REQUIRES DOCUMENTATION
Advantage GROUP benefit
THAT THE MEMBER HAS EXPERIENCED FAILURE OF BYSTOLIC™ (Nebivolol)
OR INTOLERANCE TO AT LEAST TWO GENERIC CARDIOSELECTIVE BETA-BLOCKERS, SUCH AS SECTRAL® (g), TENORMIN® (g), KERLONE® (g), ZEBETA® (g), LOPRESSOR® (g), OR TOPROL XL® (g). BYSTOLIC is non formulary for members enrolled in an individual Medicare Advantage Product. Hyperlipidemia (ST)
For members enrolled in a BCN
ALTOPREV®, CRESTOR® REQUIRE DOCUMENTATION Advantage INDIVIDUAL benefit
OF FAILURE WITH OR INTOLERANCE TO GENERIC LOVASTATIN, SIMVASTATIN, PRAVASTATIN OR ATORVASTATIN COVERAGE OF ADVICOR® REQUIRES DOCUMENTATION OF STABLE THERAPY OF LOVASTATIN AND EXTENDED RELEASE NIACIN, AS DEMONSTRATED BY TRIALS OF AT LEAST 30 DAYS SIMVASTATIN AND EXTENDED RELEASE NIACIN, AS DEMONSTRATED BY TRIALS OF AT LEAST 30 DAYS OF THE INDIVIDUAL AGENTS. ATORVASTATIN IS AVAILABLE
WITHOUT authorization
BRAND LIPITOR® is NON
FORMULARY (not covered)
FENOFIBRATE AND GEMFIBROZIL, AS DEMONSTRATED BY TRIALS OF AT LEAST 30 DAYS CADUET IS NON FORMULARY
(not covered)
Generic Caduet is available
without authorization
DOCUMENTATION OF STABLE THERAPY OF SIMVASTATIN AND ZETIA®, AS DEMONSTRATED BY TRIALS OF AT LEAST 30 DAYS OF THE INDIVIDUAL AGENTS. Diabetic Agents (Oral) (ST)
COVERAGE FOR AVANDIA®, ACTOS® OR JANUVIA® AVANDIA® (Rosiglitazone maleate) REQUIRES DOCUMENTATION THAT THE MEMBER HAS EXPERIENCED FAILURE WITH GLUCOPHAGE® (g), DOCUMENTATION THAT THE MEMBER HAS HAD A 30 DOCUMENTATION THAT THE MEMBER HAS HAD A 30 DAY TRIAL OF ACTOS® AND METFORMIN. JANUMET® (Sitagliptin phos/ metformin hcl) DOCUMENTATION THAT THE MEMBER HAS HAD A 30 DAY TRIAL OF AVANDARYL® AND GLIMEPIRIDE. DOCUMENTATION THAT THE MEMBER HAS HAD A 30 DAY TRIAL OF ACTOS® AND GLIMEPIRIDE COVERAGE FOR JANUMET® AND JANUMET XR REQUIRE DOCUMENTATION THAT THE MEMBER HAS HAD A 30 DAY TRIAL OF JANUVIA® AND METFORMIN. COVERAGE FOR PRANDIMET® REQUIRES DOCUMENTATION THAT THE MEMBER HAS HAD A 30 DAY TRIAL OF PRANDIN® AND METFORMIN. Endocrine Agents (PA)
BYETTA, VICTOZA and BYDUREON ARE COVERED
FOR PATIENTS WHO HAVE TYPE 2 DIABETES WHO ARE CURRENTLY TAKING, OR HAVE TRIED, (OR HAVE (A TRIAL OF AT LEAST TWO OF THESE THREE AGENTS IS REQUIRED) IN ADDITION TO THE ABOVE CRITERIA THE PATIENT
MUST HAVE A HEMOGLOBIN A1C OF GREATER THAN
7 PER CENT.
BYETTA, VICTOZA and BYDUREON WILL NOT BE COVERED FOR WEIGHT LOSS IN PATIENTS WITH OR WITHOUT DIABETES. SYMLIN IS COVERED FOR PATIENTS THAT HAVE
FAILED INTENSIVE TREATMENT WITH INSULIN
MONOTHERAPY.
SYMLIN IS COVERED FOR CONCURRENT USE WITH Hematopoietic Agents (PA)
Erythropoesis stimulating
agents (ESAs)
INCLUDING PATIENTS ON DIALYSIS (END-STAGE RENAL DISEASE) AND PATIENTS NOT ON DIALYSIS, TO ELEVATE OR MAINTAIN THE RBC LEVEL (AS DETERMINATIONS) AND TO DECREASE THE NEED FOR TRANSFUSIONS IN THESE PATIENTS. ALSO COVERED FOR ANEMIA SECONDARY TO ACTIVE CHEMOTHERAPY OF SOLID TUMORS, ANEMIA SECONDARY TO ACTIVE ZIDOVUDINE (AZT) THERAPY, ANEMIA IN MYELODYSPLASTIC DISORDERS, AND PROPHYLACTIC USE DURING MAJOR SURGERIES. ARANESP AND EPOGEN USE REQUIRES TRIAL AND FAILURE OF PROCRIT. COVERED FOR ALL FDA APPROVED USES NOT OTHERWISE EXCLUDED BY PART D. EXCLUSIONS:
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 UNCONTROLLED 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 DURE TO NEUTRALIZING ANTIBODIES. DOCUMENTATION OF HEMOGLOBIN MAY BE REQUIRED: HEMOGLOBIN LESS THAN 13 FOR PROPHYLACTIC USE DURING SOME MAJOR SURGERIES FOR EPOGEN. HEMOGLOBIN LESS THAN 12MG/DL FOR REMAINING COVERED USES AUTOLOGOUS TRANSPLANTATION, WHEN POOR RESPONSE IS DOCUMENTED TO APHERESIS WITH GRANULOCYTE COLONY STIMULATING FACTOR ALONE. DOCUMENTATION OF DIAGNOSIS AND THAT GRANULOCYTE COLONY STIMULATING FACTOR IS ADMINISTERED CONCOMITANTLY DOCUMENTATION OF POOR RESPONSE TO APHERESIS WITH GRANULOCYTE COLONY STIMULATING FACTOR INITIAL COVERAGE IS PROVIDED FOR PROMACTA IN PATIENTS WHO MEET THE FOLLOWING CRITERIA: DIAGNOSIS OF CHRONIC IMMUNE THROMBOCYTOPENIA PURPURA, PERSISTENT THROMBOCYTOPENIA DEFINED BY PLATELET COUNT LESS THAN 150,000 MCL FOR MINIMUM 2 MONTHS, AND INADEQUATE RESPONSE OR DOCUMENTED INTOLERANCE FOR THERAPY WITH CORTICOSTEROIDS, IMMUNOGLOBULINS, OR SPLENECTOMY AND CURRENT PLATELET COUNT OF LESS THAN OR EQUAL TO 50,000 MCL AND A PRESCRIBED DAILY DOSE OF 75MG OR LESS. RENEWAL OF THERAPY IS COVERED FOR PATIENTS WHO MEET THE FOLLOWING CRITERIA: RECENT PLATELET COUNT OF 30,000 TO 150,000 MCL, AND A DAILY DOSE OF 75MG OR LESS. LENGTH OF APPROVAL: INITIATION OF THERAPY - 12 WEEKS, CONTINUATION THERAPY - 12 MONTHS Gastrointestinal agents
Misc GI Agents (PA)
RELISTOR™
ILLNESS WHO ARE RECEIVING PALLIATIVE CARE, WHEN RESPONSE TO LAXATIVE THERAPY HAS NOT BEEN SUFFICIENT. REQUIRES ADEQUATE TREATMENT CONSISTING OF 5 DAYS DURATION OF TREATMENT OF AGENTS FOR CONSTIPATION, INCLUDING AT LEAST ANY TWO OF THE FOLLOWING: BULK LAXATIVES, SALINE LAXATIVES OR OSMOTIC LAXATIVES. COVERAGE MAY NOT BE PROVIDED IF THERE ARE CONTRAINDICATIONS TO METHYLNALTREXONE THERAPY. COVERED FOR WOMEN 18 YEARS OR OLDER AND DIAGNOSED WITH IBS WITH CONSTIPATION. COVERED FOR ADULTS WITH FOR THE TREATMENT OF CHRONIC IDIOPATHIC CONSTIPATION. DOCUMENTATION OF FAILURE WITHIN THE LAST 12 MONTHS OF USE OF A FIBER LAXATIVE AND ONE OF THE FOLLOWING: A STIMULANT LAXATIVE OR AN OSMOTIC LAXATIVE. DRUG INDUCED CONSTIPATION MUST BE RULED OUT. Proton Pump Inhibitors
For members enrolled in a BCN
Advantage INDIVIDUAL benefit
PPIs are NONFORMULARY (not
covered) EXCEPT Omeprazole,
Pantoprazole and Lansoprazole.
ACIPEX, NEXIUM, DEXILANT
AND ZEGERID ARE NON-
FORMULARY (NOT COVERED)
Members enrolled in a BCN
ACIPHEX® AND ZEGERID® (g) REQUIRE
ADVANTAGE GROUP benefit
require authorization for the
following PPIs:
NEXIUM® IS COVERED AFTER A 30 DAY TRIAL OF
PANTOPRAZOLE OR OMEPRAZOLE. HIGH DOSE THERAPY IS REQUIRED OF ONE DRUG TRIAL, FOR DEXILANT™ (Dexlansoprazole)
OMEPRAZOLE OR 80MG OR GREATER PER DAY OF DEXILANTTM REQUIRES DOCUMENTATION OF
FAILURE WITH OR INTOLERANCE TO AT LEAST TWO (OMEPRAZOLE AND PANTOPRAZOLE). AT LEAST ONE OF THESE THERAPIES MUST BE TRIED TWICE DAILY. Gout Therapy (ST)
CLAIMS FOR ULORIC WILL APPROVE IF PREVIOUS CLAIMS HAVE BEEN FILLED FOR AT LEAST 30 DAYS OF ALLOPURINOL 300 MG PER DAY IN PREVIOUS 120 DAYS, OTHERWISE PRIOR AUTH WILL BE REQUIRED. IF PA REQUIRED: LENGTH OF APPROVAL: 1 YEAR Growth Hormone (PA)
COVERED FOR THE REPLACEMENT OF ENDOGENOUS GROWTH HORMONE IN ADULTS WITH COVERED IF INITIAL DIAGNOSIS BASED ON TWO GROWTH HORMONE STIMULATION TESTS AND THAT THE PATIENT DOES NOT HAVE EDEMA, 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. INITIAL
APPROVAL FOR 1 YEAR AND RENEWAL CAN BE
OBTAINED IF CLINICAL RESPONSE WITH THERAPY.
Hepatitis (PA)
COVERED FOR HEPATITIS C VIRUS INFECTION. CONCOMITANT RIBAVARIN ARE UTILIZED FOR THE DOCUMENTATION OF CONCOMITANT RIBAVARIN USE DOCUMENTATION OF VIRAL GENOTYPE IS REQUIRED REQUIRED FOR REQUESTS FOR CONTINUATION OF LENGTH OF APPROVAL: INITIATION OF THERAPY - 12 WEEKS, CONTINUATION THERAPY - 24 TO 48 WEEKS INCIVEK™
INCIVEK AND VICTRELIS:
VICTRELIS™
COVERED FOR PATIENTS 18 YEARS OF AGE OR OLDER COVERED FOR CHRONIC HEPATITIS C, GENOTYPE 1 WITH COMPENSATED LIVER DISEASE (INCLUDING CIRRHOSIS) AND RECENT HCV-RNA LEVEL
COVERAGE IS PROVIDED IN SITUATIONS WHERE
PATIENTS ARE RECEIVING COMBINATION THERAPY
WITH EITHER BOCEPREVIR OR TELAPREVIR AND A
PEGINTERFERON ALFA PRODUCT WITH RIBAVIRIN.
COVERAGE IS NOT PROVIDED FOR MONOTHERAPY
COVERAGE IS NOT PROVIDED IN SITUATIONS WHERE
PATIENTS HAVE PREVIOUSLY NOT RESPONDED TO
THERAPY THAT INCLUDED EITHER BOCEPREVIR OR
TELAPREVIR
INCIVEK: NOT COVERED IN PATIENTS WHO HAVE
BEEN TREATED FOR 3 MONTHS OR MORE.
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)
FOR AUTHORIZATION. RENEWAL OF VICTRELIS:

RENEWAL REQUIRES DOCUMENATION OF HCV RNA
LEVEL/VIRAL LOAD LESS THAN OR EQUAL TO 100
IU/ML AFTER TOTAL TREATMENT WEEK 12 AND 24
LENGTH OF INITIAL APPROVAL- VICTRELIS: 12 WEEKS. LENGTH OF RENEWAL- VICTRELIS: FIRST RENEWAL: 12 WEEKS. SECOND RENEWAL: 20 WEEKS. High Risk Drugs in the Elderly (PA)
DIPHENHYDRAMINE IS APPROVED IF PATIENT HAS
ALTERNATIVE SEDATIVE OR ANXIOLYTIC AGENTS SUCH AS ZOLPIDEM OR IF PATIENT HAS FAILED OR IS INTOLERANT TO OTHER SAFER ALTERNATIVE ANTIHISTAMINES SUCH AS FEXOFENADINE. THIORIDIZINE IS COVERED FOR PATIENTS WHO HAVE
A HISTORY OF USE.
FOR THOSE PATIENTS INITITATING THERAPY, THIORIDIZINE IS COVERED IF PATIENT HAS A FAILURE OF OR INTOLERANCE TO SAFER ALTERNATIVE ANTIPSYCHOTICS SUCH AS ABILIFY OR SEROQUEL. NITROFURANTOIN MONOHYDRATE or MACROCRYSTALS ARE COVERED IF 1. DOCUMENTATION IS PROVIDED THAT RENAL
FUNCTION IS GREATER THAN OR EQUAL TO
60ML/MIN. AND
2. PATIENT HAS AN ALLERGY TO SAFER
ALTERNATIVES OR HAS TRIED AND FAILED SAFER
ALTERNATIVES SUCH AS CEPHALOSPORINS,
BACTRIM, QUINOLONES, ETC.
Miscellaneous CNS (ST)
FAILURE, INTOLERANCE TO, OR CONTRAINDICATION TO A METHYLPHENIDATE CONTAINING PRODUCT CLAIMS FOR INTUNIV WILL PROCESS IF CLAIMS FOR
30 DAY OF A METHYLPHENIDATE CONTAINING
PRODUCT AND AN AMPHETAMINE CONTAINING
PRODUCT ARE PROCESSED IN THE PAST 180 DAYS.
LENGTH OF APPROVAL, OTHERWISE PA IS
REQUIRED.
Migraine Therapy (ST)
AXERT® (Aalmotriptan)
NARATRIPTAN, AXERT, MAXALT, FROVA, RELPAX, and ZOMIG WILL PROCESS IF PREVIOUS CLAIMS HAVE BEEN FILLED FOR AT LEAST 6 DAYS OF THERAPY NOTE: SUMAVEL DOSEPRO IS
NONFORMULARY
Multiple Sclerosis (ST)
REQUIRES A LEAST A 30 DAY TRIAL OF EXTAVIA HISTORY WITH A 30 DAY SUPPLY OF EXTAVIA WITHIN THE PAST 120 DAYS. OTHERWISE, PRIOR AUTH IS GILENYNA REQUIRES THE TRIAL AND FAILURE OF EITHER GLATIRAMER OR AN INTERFERON BETA
INITIAL REQUESTS FOR AMPYRA 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. AMPYRA IS NOT COVERED FOR PATIENTS WITH A HISTORY OF SEIZURE OR MODERATE TO SEVERE RENAL IMPAIRMENT DEFINED BY A CRCL OF 50ML/MIN OR LESS Narcotic Analgesics (PA)
ACTIQ® (GEQ) FENTORA® AND ONSOLIS TM ARE
DIAGNOSIS IN PATIENTS ALREADY RECEIVING LONG ACTING OPIOIDS DOCUMENTATION OF DIAGNOSIS AND MEDICATION OXYCONTIN® is NON
FORMULARY (NOT COVERED)
Nasal Steroids (ST)
CLAIMS FOR ALVESCO, BECONASE AQ, VERAMYST, NASACORT, NASACORT AQ, NASONEX, OMNARIS AND RHINOCORT AQUA WILL PROCESS IF A CLAIM FOR AT
LEAST 30 DAYS OF FLUNISOLIDE OR FLUTICASONE
NASAL SPRAY HAS PROCESSED IN THE PAST 120 Non-Sedating Antihistamines
Non-Sedating Antihistamines are not covered for BCNA members
Pulmonary Hypertension (PA)
LETAIRIS, REVATIO, ADCIRCA, TRACLEER AND VENTAVIS ARE COVERED FOR ALL FDA APPROVED INDICATIONS NOT OTHERWISE EXCLUDED FROM PROVIDED IN SITUATIONS WHERE PATIENTS ARE RECEIVING NITRATE THERAPY. Sedative/Hypnotic Agents (ST)
For members enrolled in a BCN
ROZEREM REQUIRES THAT THE PATIENT HAVE TRIED Advantage INDIVIDUAL benefit
AT LEAST 14 DAYS OF ZOLPIDEM (AMBIEN) OR CLAIMS WILL PROCESS AUTOMATICALLY AT THE PHARMACY IF THERE IS A MEDICATION HISTORY OF A 14 DAY SUPPLY OF ZOLPIDEM OR ZALEPLON IN THE PAST 120 DAYS. OTHERWISE, PRIOR AUTH IS LUNESTA AND EDULAR ARE
NONFORMULARY (NOT
COVERED)
Members enrolled in a BCN
ADVANTAGE GROUP benefit
LUNESTA WILL PROCESS AT THE PHARMACY WHEN
THE MEMBER HAS A MEDICATION HISTORY FOR AT benefit. They still require
authorization.
ZALEPLON USE IN THE PAST 120 DAYS, OTHERWISE Wound Care (PA)
COVERED FOR PATIENTS WITH CHRONIC
NEUROPATHIC DIABETIC ULCER OF THE LOWER
EXTREMITY
ADEQUATE TISSUE OXYGENATION AT THE SITE OF THE NEUROPATHIC DIABETIC ULCER FULL THICKNESS ULCER (FOR EXAMPLE STAGE THREE OR FOUR) EXTENDING THROUGH THE DERMIS INTO SUBCUTANEOUS TISSUE. PATIENT IS PARTICIPATING IN A COMPRESHENSIVE WOUND CARE TREATMENT PLAN INCLUDING SUCH MODALITIES AS DEBRIDEMENT, PRESSURE RELIEF (FOR EXAMPLE, NON WEIGHT BEARING) AND INFECTION CONTROL. Miscellaneous (PA)
ARCALYST® (Rilonacept)
COVERAGE IS PROVIDED FOR A DIAGNOSIS OF
CRYOPYRIN-ASSOCIATED PERIODIC SYNDROMES
(CAPS), INCLUDING FAMILIAL COLD AUTO-
PATIENTS SHOULD BE 12 YEARS OF AGE AND OLDER NUDEXTA COVERAGE IS PROVIDED FOR THE TREATMENT OF PSEUDOBULBAR AFFECT IN NUDEXTA® ((dextromethorphan
XENAZINE IS COVERED FOR THE TREATMENT OF CHOREA ASSOCIATED WITH HUNTINGTONS DISEASE
XENAZINE®
FOR DOSES ABOVE 50MG PER DAY:
DOCUMENTATION OF PATIENT CYP2D6 GENOTYPE COVERAGE FOR XENAZINE WILL 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 MONAMINE OXIDASE INHIBITORS OR RESERPINE. KUVAN® (Sapropterin)
HYPERPHENYLALANINEMIA (HPA) DUE TO
TETRAHYDROBIOPTERIN (BH4) RESPONSIVE
PHENYLKETONURIA (PKU).
DOCUMENTATION OF DIETARY RESTRICTIONS AND DIAGNOSIS FOR INITIAL APPROVAL. FOR RENEWAL:
REQUIRES DOCUMENTATION IN REDUCTION OF PHENYLALANINE FROM BASELINE. LENGTH OF APPROVAL: INITIAL - 2 MONTHS AUTH WILL BE EXTENDED FOR 1 YEAR IF DOCUMENTED 30% OR MORE RESPONSE AFTER INITIAL THERAPY.

Source: http://www.bcbsmi.net/pdf/bcna_quality_interchange.pdf