Medications Requiring Prior Authorization For Medical .
January 2017Medications Requiring Prior Authorization for MedicalNecessityBelow is a list of medicines by drug class that will not be covered without a prior authorization for medical necessity, effective January1, 2017. If you continue using one of these drugs without prior approval for medical necessity, you may be required to pay the full cost.If you are currently using one of the drugs requiring prior authorization for medical necessity, ask your doctor to choose one of thegeneric or brand formulary options listed below.Bolded products represent drugs requiring prior authorization for medical necessity that are new for the 2017 plan year.Category *Drug ClassDrugs Requiring PriorAuthorization forMedical Necessity 1Formulary OptionsAllergic Reaction(Anaphylaxis) Treatment *ADRENACLICKEPIPEN, EPIPEN JRAllergies *Nasal Steroids / CombinationsBECONASE AQOMNARISQNASLRHINOCORT AQUAVERAMYSTZETONNAflunisolide spray, fluticasone spray, triamcinolone spray, DYMISTAAllergies *OphthalmicLASTACAFTazelastine, cromolyn sodium, olopatadine, PATADAY, PAZEOAnti-infectives, Antivirals *Cytomegalovirus AgentsVALCYTEvalganciclovirAnti-infectives, Antivirals *Hepatitis C AgentsDAKLINZAOLYSIOTECHNIVIEVIEKIRA PAKZEPATIEREPCLUSA, HARVONI, SOVALDIAnti-infectives, Antivirals *Herpes AgentsVALTREXacyclovir, valacyclovirAntiobesity Agents *Newer AgentsQSYMIABELVIQ, CONTRAVE, SAXENDAAsthma *Beta Agonists, Short-ActingPROVENTIL HFAVENTOLIN HFAXOPENEX HFAPROAIR HFA, PROAIR RESPICLICKAsthma *Steroid InhalantsAEROSPANALVESCOASMANEX, FLOVENT, PULMICORT FLEXHALER, QVARAsthma * or ChronicObstructive PulmonaryDisease (COPD) *Steroid / Beta AgonistCombinationsSYMBICORTADVAIR, BREO ELLIPTA, DULERAAttention Deficit HyperactivityDisorder Agents *ADDERALL XRINTUNIVamphetamine-dextroamphetamine mixed salts,amphetamine-dextroamphetamine mixed salts ext-rel, guanfacine ext-rel, methylphenidate,methylphenidate ext-rel, APTENSIO XR, QUILLIVANT XR, STRATTERA, VYVANSECancer *Chronic MyelogenousLeukemia AgentsGLEEVECTASIGNAimatinib mesylate, BOSULIF, SPRYCEL
Category *Drug ClassDrugs Requiring PriorAuthorization forMedical Necessity 1Formulary OptionsCancer *ProstateHormonal Agents,AntiandrogensNILANDRONXTANDIbicalutamide, ZYTIGACardiovascularAntilipemics *FibratesTRICORfenofibrate, fenofibric acidCardiovascularAntilipemics *HMG-CoA ReductaseInhibitors (HMGs or Statins) /CombinationsADVICORALTOPREVCRESTORLESCOL XLLIPITORLIPTRUZETLIVALOatorvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin, VYTORINCardiovascularPotassium Supplements *KLOR-CON/25potassium chloride liquidCardiovascular PulmonaryArterial Hypertension Agents *EndothelinReceptor AntagonistsOPSUMITLETAIRIS, TRACLEERCarnitine Deficiency Agents *CARNITORCARNITOR SFlevocarnitineChronic ObstructivePulmonary Disease (COPD) *AnticholinergicsINCRUSE ELLIPTATUDORZASPIRIVACystic Fibrosis *Inhaled AntibioticsTOBITOBI PODHALERtobramycin inhalation solution, BETHKISDepression *Antidepressants, SelectiveNorepinephrine ReuptakeInhibitors (SNRIs)venlafaxine ext-rel tablet(except 225 mg)CYMBALTAduloxetine, venlafaxine, venlafaxine ext-rel capsule, PRISTIQDepression *Antidepressants,Miscellaneous AgentsOLEPTROtrazodoneDepression *, Schizophrenia *Antipsychotics, AtypicalsABILIFYaripiprazole, clozapine, olanzapine, quetiapine, risperidone, ziprasidone, LATUDA,SEROQUEL XRDermatologyActinic Keratosis *fluorouracil cream 0.5%CARACfluorouracil cream 5%, fluorouracil solution, imiquimod, PICATO, ZYCLARADermatologyRosacea *NORITATEmetronidazole, sulfacetamide-sulfur, FINACEA, SOOLANTRADermatologySkin Inflammation and Hives *Corticosteroidsclobetasol sprayCLOBEX SPRAYOLUX-Eclobetasol foamAPEXICON Edesoximetasone, fluocinonideALCORTIN ADermatologyMiscellaneous Skin Conditions ALOQUINNOVACORT*hydrocortisone
Category *Drug ClassDrugs Requiring PriorAuthorization forMedical Necessity 1Formulary OptionsDiabetes *BiguanidesFORTAMETGLUMETZARIOMETmetformin, metformin ext-relDiabetes *Dipeptidyl Peptidase-4(DPP-4) InhibitorsNESINAONGLYZAJANUVIA, TRADJENTAKAZANODiabetes *KOMBIGLYZE XRDipeptidyl Peptidase-4OSENI(DPP-4) Inhibitor CombinationsJANUMET, JANUMET XR, JENTADUETO, JENTADUETO XRDiabetes *Injectable Incretin MimeticsBYDUREONBYETTATRULICITY, VICTOZADiabetes *InsulinsAPIDRAHUMALOGNOVOLOGHUMALOG MIX 50/50NOVOLOG MIX 70/30HUMALOG MIX 75/25NOVOLOG MIX 70/30HUMULIN 70/30 2NOVOLIN 70/30 2HUMULIN N 2NOVOLIN N 2HUMULIN R 2NOVOLIN R 2NOTE: Humulin R U-500 concentrate vial willnot be subject to prior authorization and willcontinue to be covered.Diabetes *Long Acting InsulinsLANTUSTOUJEOBASAGLAR, LEVEMIR, TRESIBADiabetes *Insulin SensitizersACTOSpioglitazoneDiabetes *Sodium-GlucoseCo-transporter 2 (SGLT2)InhibitorsINVOKANAFARXIGA, JARDIANCEDiabetes *Sodium-GlucoseCo-transporter 2 (SGLT2)Inhibitor / BiguanideCombinationsINVOKAMETXIGDUO XRDiabetes *Supplies, Pen NeedlesALLISON MEDICAL PEN NEEDLESNOVO NORDISK PEN NEEDLESULTIMED PEN NEEDLESAll other insulin pen needles that are not BDbrandBD PEN NEEDLESDiabetes *Supplies, SyringesALLISON MEDICAL INSULIN SYRINGESTRIVIDIA INSULIN SYRINGESULTIMED INSULIN SYRINGESAll other insulin syringes that are not BD brandBD INSULIN SYRINGES
Category *Drug ClassDrugs Requiring PriorAuthorization forMedical Necessity 1Formulary OptionsDiabetes *Supplies, Test Strips andKits 3, 4ACCU-CHEK STRIPS AND KITSBREEZE 2 STRIPS AND KITSCONTOUR NEXT STRIPS AND KITSCONTOUR STRIPS AND KITSFREESTYLE STRIPS AND KITSAll other test strips that are not ONETOUCHbrandONETOUCH ULTRA STRIPS AND KITS 3, ONETOUCH VERIO STRIPS AND KITS 3Erectile Dysfunction *Phosphodiesterase InhibitorsLEVITRAVIAGRACIALISGastrointestinal Agents *Opioid-induced ConstipationRELISTORMOVANTIKGastrointestinal Agents *Proton Pump Inhibitors (PPIs)NEXIUMPREVACIDPROTONIXZEGERIDesomeprazole, lansoprazole, omeprazole, omeprazole-sodium bicarbonate capsule,pantoprazole, DEXILANTGlaucoma *Prostaglandin AnalogsLUMIGANlatanoprost, travoprost, TRAVATAN Z, ZIOPTANGrowth Hormones *GENOTROPINNUTROPIN AQOMNITROPESAIZENHUMATROPE, NORDITROPINHematologicAnticoagulants (oral) *PRADAXAwarfarin, ELIQUIS, XARELTOHematologicHemophilia Agents *HELIXATE FSKOGENATE FSHematologic *Neutropenia ColonyStimulating FactorsNEUPOGENZARXIOHematologic *Platelet Aggregation InhibitorsPLAVIXclopidogrel, BRILINTA, EFFIENTHigh Blood Pressure *Angiotensin II sartan, eprosartan, irbesartan, losartan, telmisartan, valsartan, BENICARHigh Blood Pressure *Angiotensin II ReceptorAntagonist / DiureticCombinationsATACAND HCTDIOVAN HCTEDARBYCLORTEVETEN HCTcandesartan-hydrochlorothiazide, irbesartan-hydrochlorothiazide, losartanhydrochlorothiazide, telmisartan-hydrochlorothiazide, valsartan-hydrochlorothiazide,BENICAR HCTHigh Blood Pressure *Angiotensin II ReceptorAntagonist / Calcium ChannelBlocker CombinationsEXFORGEamlodipine-telmisartan, amlodipine-valsartan, AZORHigh Blood Pressure *Angiotensin II ReceptorAntagonist / Calcium ChannelBlocker / DiureticCombinationsEXFORGE HCTamlodipine-valsartan-hydrochlorothiazide, TRIBENZORHigh Blood Pressure *Beta-blocker CombinationsDUTOPROLmetoprolol succinate ext-rel WITH hydrochlorothiazide
Category *Drug ClassDrugs Requiring PriorAuthorization forMedical Necessity 1Formulary OptionsHigh Blood Pressure *Calcium Channel BlockersNORVASCamlodipineCARDIZEMCARDIZEM CDCARDIZEM LA (and its generics)Matzim LAdiltiazem ext-rel (except generic of CARDIZEM LA)Huntington's Disease Agents *XENAZINEtetrabenazineInflammatory Bowel Disease(IBD), Ulcerative Colitis *AminosalicylatesASACOL HDDELZICOLbalsalazide, sulfasalazine, sulfasalazine delayed-rel, APRISO, LIALDA,PENTASA, UCERISKidney Disease *Phosphate BindersFOSRENOLcalcium acetate, PHOSLYRA, RENVELA, VELPHOROMultiple Sclerosis Agents *AVONEXEXTAVIAPLEGRIDYglatiramer, AUBAGIO, BETASERON, COPAXONE 40 MG, GILENYA, REBIF, TECFIDERAMusculoskeletal Agents *AMRIXcyclobenzaprineOpioid Dependence Agents *ZUBSOLVbuprenorphine-naloxone sublingual tablet, SUBOXONE FILMOpioid Reversal Agents *EVZIONARCAN NASAL SPRAYOsteoarthritis *ViscosupplementsEUFLEXXAMONOVISCORTHOVISCGEL-ONE, HYALGAN, SUPARTZ FXOveractive Bladder /Incontinence *Urinary AntispasmodicsDETROL LAENABLEXGELNIQUEOXYTROLoxybutynin ext-rel, tolterodine, tolterodine ext-rel, trospium, trospium ext-rel,MYRBETRIQ, TOVIAZ, VESICAREPain *Headache Agentsbutalbital-acetaminophen-caffeine capsulenaratriptan, rizatriptan, sumatriptan, zolmitriptan, RELPAX, ZOMIG NASAL SPRAYPain *Transmucosal Immediaterelease Fentanyl AgentsABSTRALfentanyl transmucosal lozenge, FENTORA, SUBSYSPain and Inflammation *CorticosteroidsDEXPAKMILLIPREDRAYOSdexamethasone, methylprednisolone, prednisonePain and Inflammation *Nonsteroidal Antiinflammatory Drugs (NSAIDs) /CombinationsARTHROTECcelecoxib; diclofenac sodium, meloxicam or naproxen WITH esomeprazole, lansoprazole,omeprazole, omeprazole-sodium bicarbonate capsule, pantoprazole or DEXILANTPENNSAIDdiclofenac sodium, diclofenac sodium solution, meloxicam, naproxen, VOLTAREN GELNAPRELANcelecoxib, diclofenac sodium, meloxicam, naproxenProstate Condition *Benign Prostatic HyperplasiaAgents / CombinationsJALYNdutasteride or finasteride WITH alfuzosin ext-rel, doxazosin, tamsulosin, terazosin orRAPAFLOSleep *Hypnotics, one, zolpidem, zolpidem ext-rel, SILENORTestosterone Replacement *Androgenstestosterone gel 1% 5ANDROGELFORTESTANATESTOTESTIMVOGELXOANDRODERM, AXIRON
Category *Drug ClassFormulary OptionsAutoimmune and Hepatitis C *For Autoimmune and Hepatitis C, CVS Caremark will be implementing an Indication Based Formulary for 2017 which may result in additionalexclusions announced in both classes.GenericsLimited source generics may be evaluated when appropriate and potentially excluded.HyperinflationProducts with significant cost inflation throughout the year may be evaluated and potentially excluded.New-to-Market Agents 1New-to-market products and new variations of products already in the marketplace will not be added to the formulary until the product hasbeen evaluated, determined to be clinically appropriate and cost-effective, and approved by the CVS Caremark Pharmacy and TherapeuticsCommittee (or other appropriate reviewing body).SpecialtyAs new specialty products launch, all existing products in the class will be re-evaluated to determine appropriate formulary placement andpotentially excluded, added back to formulary or not listed.The listed formulary options are subject to change.List of Drugs Requiring Prior Authorization for Medical Necessity - Carry Over from 2016ABILIFYACCU-CHEK STRIPS AND KITS 4ACTOSADDERALL DROGELAPEXICON EAPIDRAARTHROTECASACOL HDATACANDATACAND HCTAVONEXBECONASE AQBREEZE 2 STRIPS AND KITS 4BYDUREONBYETTACARACCARDIZEMCARDIZEM CDCARDIZEM LA (and its generics)clobetasol sprayCLOBEX SPRAYCONTOUR NEXT STRIPS AND KITS 4CONTOUR STRIPS AND KITS 4CYMBALTADELZICOLDETROL LADIOVANDIOVAN HCTEDARBIEDARBYCLOREUFLEXXAEXFORGEEXFORGE HCTEXTAVIAfluorouracil cream 0.5%FORTAMETFORTESTAFOSRENOLFREESTYLE STRIPS AND KITS 4GENOTROPINGLUMETZAHUMALOGHUMALOG MIX 50/50HUMALOG MIX 75/25HUMULIN 70/30 2HUMULIN N 2HUMULIN R 2INCRUSE NOKOMBIGLYZE XRLASTACAFTLESCOL m OPIN SLQSYMIARAYOSRELISTORRHINOCORT AQUARIOMETROZEREMSAIZENSYMBICORTTESTIMtestosterone gel 1% 5TEVETENTEVETEN A PAKVOGELXOXOPENEX HFAZETONNAZUBSOLV
List of Drugs Requiring Prior Authorization for Medical Necessity - New for 2017ABSTRALALCORTIN AALOQUINALLISON MEDICAL INSULIN SYRINGESALLISON MEDICAL PEN NEEDLESbutalbital-acetaminophen-caffeine capsuleCARNITORCARNITOR EGLEEVECHELIXATE NNOVACORTNOVO NORDISK PEN NEEDLESOLYSIOOPSUMITPRADAXAPROVENTIL HFATASIGNATECHNIVIETOBITOBI PODHALERTOUJEOTRIVIDIA INSULIN SYRINGESULTIMED INSULIN SYRINGESULTIMED PEN NEEDLESvenlafaxine ext-rel tablets (except for 225 mg)VENTOLIN HFAXENAZINEXTANDIZEGERIDZEPATIER
There may be additional drugs subject to prior authorization or other plan design restrictions. Please consult your plan for further information.This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics. This is not an all-inclusive list of available drugoptions. Log in to www.caremark.com to check coverage and copay information for a specific drug. Discuss this information with your doctor or health care provider. This information isnot a substitute for medical advice or treatment. Talk to your doctor or health care provider about this information and any health-related questions you have. CVS Caremark assumes noliability whatsoever for the information provided or for any diagnosis or treatment made as a result of this information. This list is subject to change.Subject to applicable laws and regulations.*12345This list indicates the common uses for which the drug is prescribed. Some drugs are prescribed for more than one condition.If your doctor believes you have a specific clinical need for one of these products, he or she should contact the Prior Authorization department at: 1-855-240-0536.Rebranded or private label formulations are not covered without a prior authorization for medical necessity (i.e., RELION).A ONETOUCH blood glucose meter may be provided at no charge by the manufacturer to those individuals currently using a meter other than ONETOUCH. For more information onhow to obtain a blood glucose meter, call: 1-800-588-4456.ONETOUCH brand test strips are the only preferred options.Listing reflects the authorized generics for TESTIM and VOGELXO.Your privacy is important to us. Our employees are trained regarding the appropriate way to handle your private health information.This document contains confidential and proprietary information of CVS Caremark and cannot be reproduced, distributed or printed without written permission from CVS Caremark. CVSCaremark may receive rebates, discounts and service fees from pharmaceutical manufacturers for certain listed products. This document contains references to brand-name prescriptiondrugs that are trademarks or registered trademarks of pharmaceutical manufacturers not affiliated with CVS Caremark. Listed products are for informational purposes only and are notintended to replace the clinical judgment of the doctor. 2016 CVS Caremark. All rights reserved.Document date: August 1, 2016106-25923B 010117www.caremark.com
Supplies, Pen Needles ALLISON MEDICAL PEN NEEDLES NOVO NORDISK PEN NEEDLES ULTIMED PEN NEEDLES All other insulin pen needles that are not BD brand BD PEN NEEDLES . HUMATROPE, NORDITROPIN Hematologic Anticoagulants (oral) * PRADAXA warfarin, ELIQUIS, XARELT
Bruksanvisning för bilstereo . Bruksanvisning for bilstereo . Instrukcja obsługi samochodowego odtwarzacza stereo . Operating Instructions for Car Stereo . 610-104 . SV . Bruksanvisning i original
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Forteo (Teriparatide) Clinical Criteria Information Included in this Document Forteo (Teriparatide) Drugs requiring prior authorization: the list of drugs requiring prior authorization for this clinical criteria Prior authorization criteria logic: a description of how the prior
4 For services described in this policy, see below for products where prior authorization might be required if the procedure is performed outpatient. Outpatient Commercial Managed Care (HMO and POS) Prior authorization is not required. Commercial PPO and Indemnity Prior authorization is not required. Medicare HMO BlueSM Prior authorization is not required.
Gold-Carding Gold-carding: A process that exempts providers with a record of consistent adherence to prior authorization criteria from prior authorization submission requirements Promotes more timely access to care by eliminating unnecessary obstacles between patients and treatments. Allows health plans to focus prior authorization on
