Keystone 65 Select Rx HMO Keystone 65 Preferred Rx HMO
Keystone 65 Select Rx HMOKeystone 65 Preferred Rx HMOPersonal Choice 65SM Rx PPO2020 Utilization ManagementCriteria: Prior AuthorizationPLEASE READ: THIS DOCUMENT CONTAINS INFORMATIONABOUT SOME OF THE DRUGS WE COVER IN THIS PLANThis document was updated on 12/01/2020. For more recent information or other questions,please contact our Member Help Team: Keystone 65 at 1-800-645-3965, Personal Choice 65 at1-888-718-3333, Select Option at 1-888-678-7009 or, for TTY/TDD users, 711, seven days aweek from 8 a.m. to 8 p.m. Please note that on weekends and holidays from April 1 throughSeptember 30, your call may be sent to voicemail. Or, visit www.ibxmedicare.com to use ourFormulary (List of Covered Drugs) search tool or view a downloadable document.When this document refers to “we,” “us,” or “our,” it means Independence Blue Cross. When itrefers to “plan” or “our plan,” it means Keystone 65 Rx, Personal Choice 65 Rx, and SelectOption Rx.You must generally use network pharmacies to use your prescription drug benefit. Benefits,formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2021,and from time to time during the year.Independence Blue Cross offers Medicare Advantage plans with a Medicare contract.Enrollment in Independence Medicare Advantage plans depends on contract renewal.Keystone 65: Benefits underwritten by Keystone Health Plan East, a subsidiary ofIndependence Blue Cross — independent licensees of the Blue Cross and Blue ShieldAssociation.Personal Choice 65: Benefits underwritten by QCC Insurance Company, a subsidiary ofIndependence Blue Cross — independent licensees of the Blue Cross and Blue ShieldAssociation.Y0041 HM 18 70813IBC9390 (12/20)
There may be restrictions to your drug coverageSome covered drugs may have additional requirements or limits on coverage. We call this“utilization management.” These requirements and limits may include: Prior Authorization (PA): Our plan requires you or your physician to get prior authorizationfor certain drugs. This means that you will need to get approval from our plan before you fillyour prescriptions. If you don’t get approval, our plan may not cover the drug. Drugs thatrequire Prior Authorization are listed in this document. Step Therapy (ST): In some cases, our plan requires you to first try certain drugs to treatyour medical condition before we will cover another drug for that condition. Drugs thatrequire Step Therapy are listed in 2020 Utilization Management Criteria: Step Therapy. Quantity Limits (QL): For certain drugs, our plan limits the amount of the drug that our planwill cover. Drugs that have Quantity Limits are listed in the Keystone 65 Select Rx, Keystone65 Preferred Rx, and Personal Choice 65 Rx Formulary (List of Covered Drugs).You can find out if your drug has any additional requirements or limits by looking in your planFormulary (List of Covered Drugs). You can also get more information about the restrictionsapplied to specific covered drugs by visiting www.ibxmedicare.com.You can ask our plan to make an exception to these restrictions or limits, or for a list of othersimilar drugs that may treat your health condition. Your Formulary (List of Covered Drugs) andEvidence of Coverage will have more information about the exception request process.How to use this documentThis document, along with 2020 Utilization Management Criteria: Step Therapy, is intended tobe used with your Formulary (List of Covered Drugs). If your prescription drug has the note“PA” in the “Requirements” column of the Keystone 65 Select Rx, Keystone 65 Preferred Rx,and Personal Choice 65 Rx Formulary (List of Covered Drugs), you can find more informationon the restriction(s) in this document.Locate your drug in the index on page 161. The restriction information includes: Prior AuthorizationoCovered usesoExclusion criteriaoRequired medical informationoAge restrictionsoPrescriber restrictionsoCoverage durationoOther criteriaBe sure to read all the information listed for your affected drug. If you have any questions, orneed assistance with the information contained in this document, please call our Member HelpTeam: Keystone 65 at 1-800-645-3965, Personal Choice 65 at 1-888-718-3333.2
ABILIFY MYCITEProducts Affected ABILIFY MYCITEPA CriteriaCriteria DetailsExclusion CriteriaRequired MedicalInformationAge RestrictionsDeny if less than 18 years of eOther CriteriaBoth of the following (1) inadequate response or inability to tolerate genericaripiprazole and (2) attestation that tracking ingestion of the medication ismedically necessaryIndicationsAll Medically-accepted Indications.Off Label Uses3
ABUSE DETERRENT OPIOIDProducts Affectedhydrocodone bitartrate er oral capsule extendedrelease 12 hourXTAMPZA ER PA CriteriaCriteria DetailsExclusion CriteriaRequired MedicalInformationAge Remainder of contract yearOther CriteriaDocumentation of one of the following: (1) Prior use of TWO generic opioidsOR (2) BOTH of the following: (a) there is a history of or a potential for drugabuse among the individual or a member of the individual's household AND (b)documentation of current patient-prescriber opioid treatment agreementIndicationsAll Medically-accepted Indications.Off Label Uses4
ACTEMRA SQProducts Affected ACTEMRA ACTPENACTEMRA SUBCUTANEOUSPA CriteriaCriteria DetailsExclusion CriteriaConcurrent therapy with any other biologic disease modifying anti-rheumaticdrug (DMARD), e.g. tumor necrosis factor antagonists.Required MedicalInformationDocumentation for evaluation of active or latent Tuberculosis (TB). For newstarts only: at least 2 weeks passed since administration of Herpes Zostervaccine prior to start of therapy.Age RestrictionsDeny if age is less than 2 years for Polyarticular and Systemic juvenilerheumatoid arthritis. Deny if less than 18 years for all other Indications.PrescriberRestrictionsPrescribed by a RheumatologistCoverageDurationIndefiniteOther CriteriaONE of the following: (1) For Polyarticular Juvenile rheumatoid arthritis:inadequate response or inability to tolerate BOTH adalimumab (Humira) andetanercept (Enbrel) OR documentation demonstrating that a trial may beinappropriate, (2) Systemic onset Juvenile chronic arthritis, (3) For moderateto severe rheumatoid arthritis: Inadequate response or inability to tolerate toTWO of the following: (a) Humira, (b) Enbrel, (c) Rinvoq, (d) Xeljanz/Xeljanz XROR documentation demonstrating that a trial may be inappropriate, (4)ForGiant Cell Arteritis: documentation of inadequate response/inability totolerate oral corticosteroidsIndicationsAll Medically-accepted Indications.Off Label Uses5
ACTHAR HPProducts AffectedACTHAR PA CriteriaCriteria DetailsExclusion CriteriaScleroderma, osteoporosis, systemic fungal infections, ocular herpes simplex,recent surgery, history of or the presence of peptic ulcer, congestive heartfailure, uncontrolled hypertension, primary adrenocortical insufficiency,adrenocortical hyperfunction, sensitivity to proteins or porcine origin, orwhere congenital infections are suspected in infants. OR Administration oflive or live attenuated vaccines in patients receiving immunosuppressivedoses of H.P. Acthar Gel. Concurrent primary adrenocortical insufficiency oradrenocortical hyperfunction.Required MedicalInformationAge RestrictionsFor diagnosis of IS: 2 years of age and younger, for diagnosis of MS: 18 yearsof age and older, for all other indications: 2 years of age and olderPrescriberRestrictionsInfantile spasms: pediatric neurologist or neonatologist, all other indications:neurologist, rheumatologist, nephrologist, pulmonologist, ophthalmologist,dermatologist, allergist, immunologist.CoverageDurationInfantile Spasms 1 yr. All Other 1 monthOther CriteriaSubject to Part B vs Part D review. Part D is medically necessary when ONE ofthe following is present: infantile spasms OR there has been inadequateresponse or inability to tolerate two systemic steroids (e.g. prednisone,methylprednisolone) and ONE of the following (1) acute exacerbation ofmultiple sclerosis currently receiving maintenance treatment for MS (e.g.Avonex, Betaseron, Copaxone, Tecfidera, etc.) (2) acute exacerbation ofpsoriatic arthritis, rheumatoid arthritis, juvenile rheumatoid arthritis orankylosing spondylitis currently receiving DMARD (3) nephrotic syndrome andALL of the following (a) proteinuria greater than3.5g/ 24 hours AND (b) serumalbumin less than 3 mg/dL AND (c) peripheral edema (4) systemic lupuserythematosus, systemic dermatomyositis, severe erythema multiforme,Stevens-Johnson syndrome, serum sickness, inflammatory ophthalmicdisease, or symptomatic sarcoidosis6
PA CriteriaCriteria DetailsIndicationsAll Medically-accepted Indications.Off Label Uses7
ACUTE HAE AGENTSProducts AffectedBERINERTFIRAZYRicatibant acetate PA CriteriaCriteria DetailsExclusion CriteriaRequired MedicalInformationAge RestrictionsPrescriberRestrictionsPrescribed by an allergist or immunologistCoverageDurationLifetimeOther CriteriaSubject to Part B vs Part D review. Part D is medically necessary when thefollowing inclusion criterion is met: documentation of treatment of acuteabdominal, facial or laryngeal attacks of hereditary angioedema (HAE)IndicationsAll Medically-accepted Indications.Off Label Uses8
ACUTE SEIZURE ACTIVITY AGENTSProducts Affected VALTOCO 10 MG DOSEVALTOCO 15 MG DOSEVALTOCO 20 MG DOSEVALTOCO 5 MG DOSEPA CriteriaCriteria DetailsExclusion CriteriaRequired MedicalInformationAge RestrictionsPrescriberRestrictionsPrescriber is a neurologist/epilepsy specialistCoverageDurationIndefiniteOther CriteriaIndicationsAll Medically-accepted Indications.Off Label Uses9
ADEMPASProducts AffectedADEMPAS PA CriteriaCriteria DetailsExclusion CriteriaConcurrent use of phosphodiesterase inhibitors, nitrates or nitric oxidedonors, pregnancyRequired MedicalInformationAge RestrictionsDeny if age is less than 18 yearsPrescriberRestrictionsCoverageDuration6 month for initial authorization and 12 months for renewal authorizationsOther CriteriaDocumentation of ONE of the following: (1) Diagnosis of pulmonary arterialhypertension (PAH) WHO Group I with New York Heart Association (NYHA)Functional Class II - IV AND (a) Diagnosis confirmed by catheterization (rightheart or Swan-Ganz) or echocardiography (b) Mean pulmonary artery pressuregreater than or equal to 25 mm Hg at rest or greater than 30 mm Hg withexertion, OR (2) Diagnosis of persistent/recurrent Chronic ThromboembolicPulmonary Hypertension (CTEPH) (WHO Group 4) after surgical treatment orinoperable CTEPH. Re-authorization: Documentation of stabilization orimprovement as evaluated by a cardiologist or pulmonologist.IndicationsAll Medically-accepted Indications.Off Label Uses10
ALLERGEN SPECIFIC IMMUNOTHERAPY (SL)Products Affected GRASTEKPA CriteriaCriteria DetailsExclusion CriteriaDeny with documentation of any of the following: (1) Severe, unstable oruncontrolled asthma (2) History of eosinophilic esophagitisRequired MedicalInformationAge RestrictionsPrescriberRestrictionsPrescriber is an allergist or immunologist.CoverageDurationRemainder of contract yearOther CriteriaPatient has a positive skin test or in vitro test for the listed pollen-specific IgEantibody AND Inadequate response or inability to tolerate intranasalcorticosteroid and an antihistamine. Re-authorization criteria: Patient hasexperienced improvement in the symptoms of their allergic rhinitis or adecrease in the number of medications needed to control allergy symptomsIndicationsAll Medically-accepted Indications.Off Label Uses11
AMPYRAProducts AffectedAMPYRAdalfampridine er PA CriteriaCriteria DetailsExclusion CriteriaDeny if patient has history of seizure or moderate to severe renal impairment(CrCL less than or equal to 50 mL/min)Required MedicalInformationAge Remainder of contract yearOther CriteriaDiagnosis of multiple sclerosis. REAUTHORIZATION CRITERIA: documentationof improvement in walking speedIndicationsAll Medically-accepted Indications.Off Label Uses12
ANADROLProducts Affected ANADROL-50PA CriteriaCriteria DetailsExclusion CriteriaRequired MedicalInformationAge Remainder of contract yearOther CriteriaDocumentation of ONE of the following: (1) Acquired aplastic anemia (2)Anemia of chronic renal failure (3) Antineoplastic adverse reaction Myelosuppression (4) Fanconi's anemia (5) Pure red cell aplasia OR (6)Cachexia associated with AIDSIndicationsAll Medically-accepted Indications.Off Label Uses13
ARIKAYCEProducts AffectedARIKAYCE PA CriteriaCriteria DetailsExclusion CriteriaRequired MedicalInformationAge RestrictionsDeny if less than 18 years of agePrescriberRestrictionsDeny if not prescribed by a pulmonologist or an infectious disease specialistCoverageDurationIndefiniteOther CriteriaIndicationsOff Label Uses14All Medically-accepted Indications.
ARMODAFINIL/MODAFINILProducts Affected armodafinilmodafinilPA CriteriaCriteria DetailsExclusion CriteriaRequired MedicalInformationAge RestrictionsPrescriberRestrictionsFor Narcolepsy, shift work sleep disorder or obstructive sleep apnea:prescribed by a neurologist or sleep specialist.CoverageDurationNarcolepsy, shift work sleep disorder or obstructive sleep apnea: IndefiniteOther CriteriaFOR NARCOLEPSY: Documentation of a diagnosis of Narcolepsy. FOROBSTRUCTIVE SLEEP APNEA/HYPOPNEA SYNDROME (OSAHS): diagnosisconfirmed by a sleep study (unless prescriber provides justification confirmingthat a sleep study is not feasible), and documentation that the medication isbeing used as an adjunct treatment for the underlying obstruction. FOR SHIFTWORK SLEEP DISORDER (SWSD): 1)symptoms of excessive sleepiness orinsomnia for at least 3 months, which is associated with a work period (usuallynight work) that occurs during the normal sleep period, OR 2) A sleep studydemonstrating loss of a normal sleep-wake pattern (i.e., disturbedchronobiologic rhythmicity), AND 3) Documentation that the member has nomedical or mental disorder accounting for the symptomsIndicationsAll Medically-accepted Indications.Off Label Uses15
BENLYSTA SCProducts AffectedBENLYSTA SUBCUTANEOUS PA CriteriaCriteria DetailsExclusion CriteriaRequired MedicalInformationAge IndefiniteOther CriteriaSubject to Part B vs Part D review. Part D is medically necessary when BOTH ofthe following are met: (1) documentation of active, autoantibody-positive,systemic lupus erythematosus (SLE) AND (2) patient is receiving concurrenttreatment with at least ONE of the following: steroids, antimalarials,immunosuppressants, nonsteroidal anti-inflammatory drugs (NSAIDS)IndicationsAll Medically-accepted Indications.Off Label Uses16
BRAND ORAL FENTANYLProducts Affected fentanyl citrate buccalFENTORA BUCCAL TABLET 100 MCG, 200 MCG,400 MCG, 600 MCG, 800 MCGSUBSYS SUBLINGUAL LIQUID 100 MCG, 200PA CriteriaMCG, 400 MCG, 600 MCG, 800 MCGCriteria DetailsExclusion CriteriaRequired MedicalInformationAge RestrictionsPrescriberRestrictionsPrescribed by one of the following: Pain specialist, Oncologist, Hematologist,Hospice care specialist, or Palliative care specialist.CoverageDurationRemainder of contract yearOther CriteriaDocumentation of ALL of the following: (1) pain associated with cancer, (2)long-acting pain medication regimen, (3) member is opioid tolerant asdemonstrated by adherence for one week or more of any of the followingregimens: at least 25mcg of transdermal fentanyl hourly, 30mg of oxycodonedaily, 60mg of oral morphine daily, 8mg of oral hydromorphone daily, 25mg oforal oxymorphone daily or an equianalgesic dose of another opioid AND (4)inadequate response to a generic oral transmucosal fentanyl citrate productIndicationsAll Medically-accepted Indications.Off Label Uses17
CARBAGLUProducts AffectedCARBAGLU PA CriteriaCriteria DetailsExclusion CriteriaRequired MedicalInformationAge IndefiniteOther CriteriaHyperammonemia due to the deficiency of the hepatic enzyme Nacetylglutamate synthase (NAGS)IndicationsAll Medically-accepted Indications.Off Label Uses18
CAYSTONProducts Affected CAYSTONPA CriteriaCriteria DetailsExclusion CriteriaRequired MedicalInformationAge RestrictionsDeny if less than 7 er of contract yearOther CriteriaDocumentation of all of the following: (1) cystic fibrosis, (2) PseudomonasAeruginosa in the lungs, (3) Susceptibility results indicating that thePseudomonas aeruginosa is sensitive to aztreonam AND (4) FEV1 between25% and 75% of predictedIndicationsAll Medically-accepted Indications.Off Label Uses19
CERDELGAProducts AffectedCERDELGA PA CriteriaCriteria DetailsExclusion CriteriaPatient is CYP2D6 Ultra Rapid Metabolizer (URM), concurrent use of Class 1Aor Class III anti-arrhythmic, long QT syndrome, patient has pre-existingcardiac diseaseRequired MedicalInformationAge RestrictionsDeny if less than 18 iteOther CriteriaDiagnosis of Type 1 Gaucher disease and patient is CYP2D6 extensivemetabolizer (EM), intermediate metabolizer (IM), or poor metabolizer (PM) asdetected by an FDA-cleared test for determining CYP2D6 genotypeIndicationsAll Medically-accepted Indications.Off Label Uses20
CGRP ANTAGONISTSProducts Affected AIMOVIGAJOVYEMGALITYPA CriteriaCriteria DetailsExclusion CriteriaRequired MedicalInformationAge RestrictionsDeny if less than 18 years of agePrescriberRestrictionsPrescribed by or in consultation with a neurologist or headache specialistcertified by the United Council for Neurologic Subspecialties, or pain specialistCoverageDuration6 months for initial authorization, 12 months for reauthorization21
PA CriteriaCriteria DetailsOther CriteriaFor Migraines (Initial): Approved when ONE of the following inclusion criteriaare met: (1) Diagnosis of episodic migraines defined as 4 to 14 headache daysper month AND inadequate response or inability to tolerate a 4 week trial ofTWO of the following prophylactic medications (a) topiramate (b) divalproexsodium/ valproic acid (c) beta-blocker: metoprolol, propranolol, timolol,atenolol, nadolol (d) tricyclic antidepressants: amitriptyline, nortriptyline(e)SNRI antidepressants: venlafaxine, duloxetine OR (2) Diagnosis of chronicmigraines defined as greater than or equal to 15 headache days per monthAND inadequate response or inability to tolerate a 4 week trial of TWO of thefollowing prophylactic medications (i) topiramate (ii) divalproex sodium/valproic acid (iii) beta-blocker: metoprolol, propranolol, timolol, atenolol,nadolol (iv) tricyclic antidepressants: amitriptyline, nortriptyline (v)SNRIantidepressants: venlafaxine, duloxetine (REAUTHORIZATION criteria): BOTHof the following: (1) Prescribed by or in consultation with a neurologist orheadache specialist (2) Documentation of response to therapy as defined by areduction in headache days per month (defined as at least 4 hours durationand moderate intensity) For Episodic Cluster Headaches (Initial): Diagnosis ofepisodic cluster headaches (Applies only to Emgality). Diagnosis of episodiccluster headache and ALL of the following: (a) Member has experienced atleast 2 cluster periods lasting 6 days to 365 days, separated by pain-freeperiods lasting at least three months, (b) Emgality 100mg/ml will not be usedin combination with another CGRP inhibitor. (REAUTHORIZATION CRITERIA):BOTH of the following: (1) Prescribed by or in consultation with a neurologistor headache specialist (2) Documentation of response to therapy as definedby a reduction in weekly cluster headache attacksIndicationsAll Medically-accepted Indications.Off Label Uses22
CHOLBAMProducts Affected CHOLBAMPA CriteriaCriteria DetailsExclusion CriteriaDeny if there is documentation of extrahepatic manifestations of bile acidsynthesis disorders due to single enzyme defects or peroxisomal disordersincluding Zellweger spectrum disordersRequired MedicalInformationAge Initial criteria: 3 months. Re-authorization criteria: indefiniteOther CriteriaDocumentation of One of the following: (a) Treatment of bile acid synthesisdisorder due to single enzyme defect (b) Adjunctive treatment of peroxisomaldisorder including Zellweger spectrum disorder in patients who exhibitmanifestations of liver disease, steatorrhea, or complications from decreasedfat soluble vitamin absorption. Re-authorization criteria: Documentation ofimproved liver function tests from the start of treatment.IndicationsAll Medically-accepted Indications.Off Label Uses23
CIALISProducts Affectedtadalafil oral tablet 2.5 mg, 5 mg PA CriteriaCriteria DetailsExclusion CriteriaConcurrent use of nitrates.Required MedicalInformationAge IndefiniteOther CriteriaDiagnosis of BPH and an inadequate response or inability to tolerate an alphablocker (e.g. tamsulosin, terazosin) or a 5-alpha reductase inhibitor (e.g.,dutasteride, finasteride).IndicationsAll Medically-accepted Indications.Off Label Uses24
CIMZIAProducts Affected CIMZIA PREFILLEDCIMZIA SUBCUTANEOUS KIT 2 X 200 MGPA CriteriaCriteria DetailsExclusion CriteriaConcurrent therapy with biological DMARDs or other tumor necrosis factorantagonistsRequired MedicalInformationDocumentation for evaluation of active or latent Tuberculosis (TB). For newstarts only: at least 2 weeks passed since administration of Herpes Zostervaccine prior to start of therapy.Age RestrictionsDeny if less than 18 yearsPrescriberRestrictionsCD: Prescribed by or in consultation with a gastroenterologist. RA, AS, nraxSpA: Prescribed by or in consultation with a rheumatologist. PsA:prescribed by or in consultation with a dermatologist or rheumatologist.Plaque psoriasis: Prescribed by or in consultation with a dermatologist.CoverageDurationIndefiniteOther CriteriaDocumentation of ONE of the following: (1) for diagnosis of AnkylosingSpondylitis: inadequate response or inability to tolerate both adalimumab(Humira) AND etanercept (Enbrel) or documentation demonstrating that atrial may be inappropriate, (2) for Psoriatic Arthritis: inadequate response orinability to tolerate TWO of the following: Humira, Xeljanz/Xeljanz XR, Enbrelor documentation demonstrating that a trial may be inappropriate, (3) forPlaque Psoriasis: inadequate response or inability to tolerate to BOTH of thefollowing: (a) ONE of the following: (i) Humira, (ii) Enbrel, or (iii) Skyrizi AND (b)Cosentyx OR documentation demonstrating that a trial may be inappropriate,(4) for Rheumatoid Arthritis: inadequate response or inability to tolerate toTWO of the following: (a) Humira, (b) Enbrel, (c) Rinvoq, (d) Xeljanz/Xeljanz XROR documentation demonstrating that a trial may be inappropriate, (5) fordiagnosis of Crohn's Disease: inadequate response or inability to tolerateadalimumab (Humira) or documentation demonstrating that a trial may beinappropriate, (6) Diagnosis of Non-radiographic axial Spondyloarthritis ANDinadequate response or inability to tolerate two NSAIDs OR Cosentyx ORdocumentation demonstrating that a trial may be inappropriate.IndicationsAll Medically-accepted Indications.25
PA CriteriaOff Label Uses26Criteria Details
CINRYZEProducts Affected CINRYZEPA CriteriaCriteria DetailsExclusion CriteriaRequired MedicalInformationAge RestrictionsDeny if less than 6 years of agePrescriberRestrictionsPrescribed by an allergist or immunologistCoverageDurationIndefiniteOther CriteriaSubject to Part B vs Part D review. Part D is medically necessary when ALL ofthe following criteria are met: (1) Diagnosis of hereditary angioedema (HAE)(2) history of laryngeal edema or airway compromise with an episode of HAEor a history of at least 2 HAE attacks per month, AND (3) inadequate responseor inability to tolerate 17 alpha-alkylated androgens (e.g. danazol,oxandrolone, stanozolol) or anti-fibrinolytic agents (e.g. epsilon aminocaproicacid, tranexamic acid) for HAE prophylaxisIndicationsAll Medically-accepted Indications.Off Label Uses27
CORLANORProducts AffectedCORLANOR PA CriteriaCriteria DetailsExclusion CriteriaRequired MedicalInformationChronic Heart Failure: (1)Diagnosis of chronic heart failure. (2) stable,symptomatic chronic heart failure (3) left ventricular ejection fraction lessthan or equal to 35% and (4) sinus rhythm with resting heart rate greater thanor equal to 70 beats per minute. Chronic Heart Failure due to DilatedCardiomyopathy in pediatric patients ages 6 months and older: (1) Diagnosisof chronic heart failure due to dilated cardiomyopathy (2) Patient is in sinusrhythm.Age RestrictionsPrescriberRestrictionsPrescribed by a cardiologistCoverageDurationIndefiniteOther CriteriaPatient is clinically stable for at least 4 weeks on an optimized regimen whichincludes: (a) maximally tolerated doses of beta blockers or inability to toleratebeta blockers, (b) ACE inhibitors or ARBs or inability to tolerate ACE inhibitoror ARBIndicationsAll Medically-accepted Indications.Off Label Uses28
COSENTYXProducts Affected COSENTYX (300 MG DOSE)COSENTYX SENSOREADY (300 MG)PA CriteriaCriteria DetailsExclusion CriteriaConcurrent therapy with biological DMARDs or other tumor necrosis factorantagonistsRequired MedicalInformationDocumentation for evaluation of active or latent Tuberculosis (TB). For newstarts only: at least 2 weeks passed since administration of Herpes Zostervaccine prior to start of therapy.Age RestrictionsDeny if less than 18 yearsPrescriberRestrictionsPlaque psoriasis : Prescribed by a dermatologist. PsA: Prescribed by arheumatologist or dermatologist. AS, nr-axSpA: Prescribed by arheumatologist.CoverageDurationIndefiniteOther CriteriaONE of the following: (1) For diagnosis of plaque psoriasis: Inadequateresponse or inability to tolerate to ONE of the following: (a) Humira, (b) Enbrel,(c) Skyrizi OR documentation demonstrating that a trial may be inappropriate,(2) for psoriatic arthritis: inadequate response or inability to tolerate to bothadalimumab (Humira) AND etanercept (Enbrel) or documentationdemonstrating that a trial may be inappropriate, (3) ankylosing spondylitis:inadequate response or inability to tolerate to both adalimumab (Humira)AND etanercept (Enbrel) or documentation demonstrating that a trial may beinappropriate, or (4) for non-radiographic axial spondyloarthritis (nr-axSpA):inadequate response or inability to tolerate two NSAIDsIndicationsAll Medically-accepted Indications.Off Label Uses29
CRESEMBA [ORAL]Products AffectedCRESEMBA ORAL PA CriteriaCriteria DetailsExclusion CriteriaRequired MedicalInformationAge RestrictionsDeny if less than 18 yearsPrescriberRestrictionsPrescribed by or in consultation with an infectious disease specialistCoverageDurationRemainder of contract yearOther CriteriaDocumentation of either of the following: (1) for use in the treatment ofinvasive aspergillosis after inadequate response or inability to tolerate oralVoriconazole (oral Vfend) OR (2) for a diagnosis of mucormycosis.IndicationsAll Medically-accepted Indications.Off Label Uses30
CYSTARANProducts Affected CYSTARANPA CriteriaCriteria DetailsExclusion CriteriaRequired MedicalInformationAge Remainder of contract yearOther CriteriaDocumentation of BOTH of the following: (1) diagnosis of cystinosis AND (2)patient has corneal cystine crystal accumulationIndicationsAll Medically-accepted Indications.Off Label Uses31
DAYVIGOProducts AffectedDAYVIGO PA CriteriaCriteria DetailsExclusion CriteriaRequired MedicalInformationInsomnia: (1) Diagnosis of insomnia. (2) Inadequate response or inability totolerate generic ramelteon (Rozerem).Age Restrictions(Insomnia): Apply if member is greater than or equal to 65 ia): Remainder of contract yearOther CriteriaIndicationsOff Label Uses32All Medically-accepted Indications.
DEFERASIROXProducts Affected deferasiroxdeferasirox granulesJADENUJADENU SPRINKLEPA CriteriaCriteria DetailsExclusion CriteriaCrCl less than 40 mL/min or serum creatinine more than 2 times the ageappropriate ULN, platelet counts less than 50,000/mLRequired MedicalInformationSerum ferritin levels consistently greater than 300 mcg/L (as demonstratedwith at least two lab values within the previous two months)Age RestrictionsIron Overload Due to Blood Transfusions: 2 years of age or older. NTDT: 10years of age or olderPrescriberRestrictionsCoverageDurationInitial approval 3 months, Reauthorization 6 monthsOther CriteriaDocumentation of ONE of the following diagnoses: (1) Chronic iron overloadin nontransfusion-dependent thalassemia syndromes and all of the following:(a) patient 10 years and older (b) liver iron concentration (LIC) of at least 5 mgof iron per gram of liver dry weight (mg Fe/g dw) and (c) serum ferritin greaterthan 300 mcg/L OR (2) For the treatment of chronic iron overload caused byblood transfusions (transfusional hemosiderosis) in patients 2 years and olderReauthorization criteria: One of the following: (1) Documentation of adecreased serum ferritin level compared with the baseline level fortransfusion- dependent anemia or (2) Documentation of a decreased serumferritin level compared with the baseline level or reduction in LIC (liver ironconcentration) for Non-transfusion dependent thalassemia syndromeIndicationsAll Medically-accepted Indications.Off Label Uses33
DOPTELETProducts AffectedDOPTELET ORAL TABLET 20 MG PA CriteriaCriteria DetailsExclusion CriteriaRequired MedicalInformationDocumentation of baseline platelet count less than 50,000/mcLAge For Chronic Liver Disease 1 month. For Chronic Immune Thrombocytopenia 12 mo
Keystone 65 Select Rx HMO Keystone 65 Preferred Rx HMO Personal Choice 65SM Rx PPO 2020 Utilization Management Criteria: Prior Authorization PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION
Medical-Only HMO, Keystone 65 Select Medical-Only HMO, and Keystone 65 Select Rx HMO have networks of doctors, hospitals, pharmacies, and other providers. Keystone 65 Basic Rx HMO, Keystone 65 Liberty Medical-Only HMO, Keystone 65 Select Medical-Only HMO, and Keystone 65 Select Rx HMO: If you use providers that are not in
Medical-Only HMO and Keystone 65 Preferred Rx HMO cover and what you pay. Keystone 65 Preferred Medical-Only HMO and Keystone 65 Preferred Rx HMO are Medicare Advantage HMO (Health Maintenance Organization) plans. With an HMO plan, members choose a family doctor, called a primary c
Keystone 65 Basic Rx HMO, Keystone 65 Focus Rx HMO-POS, and Keystone 65 Select Rx HMO have a preferred pharmacy network; cost-sharing for drugs may vary depending on the pharmacy you use. To view our lists of network providers and pharmacies (Provider
Keystone 65 Preferred Medical-Only HMO and Keystone 65 Preferred Rx HMO have a network of doctors, hospitals, pharmacies, and other providers. If you use providers that are not in our network, we may not pay for these services. Keystone 65 Preferred Rx HMO also has a preferred pharmacy network; cost-sharing for drugs may vary depending on the
Keystone 65 Preferred Medical-Only HMO and Keystone . 65 Preferred Rx HMO are Medicare Advantage HMO (Health Maintenance Organization) plans. With an HMO plan, members choose a family doctor, called a primary care physician (PCP), who provides the services they need. Whe
Para afiliados a Health Net Seniority Plus (HMO)*, Health Net Healthy Heart (HMO), Health Net Ruby Select (HMO), Health Net Gold Select (HMO), Health Net Jade (HMO SNP) y Health Net Seniority Plus (Employer HMO). Su examen de la vista de rutina está cubierto como un beneficio médico básico a través de su plan médico.
My Avatar - Financial Eligibility Guide . 10 Baycare Medical Group 44 HMO Insurance 11 BC Freedom Blue MDC HMO 42 HMO Insurance (MDC) 12 Benefit and Risk Management Services 45 HMO Insurance 13 Benesight 46 HMO Insurance 14 Blue Cross of CA 4 HMO Insurance (MDC) 15 Blue Shield Federal Emp Program 47 HMO Insurance
Adolf Hitler was born on 20 April 1889 at the Gasthof zum Pommer, an inn located at Salzburger Vorstadt 15, Braunau am Inn , Austria -Hungary , a town on the border with Bavaria , Germany. [10 ] He was the fourth of six children to Alois Hitler and .ODUD3 O]O (1860 1907). Hitler's older siblings ² Gustav, Ida, and Otto ² died in infancy. [11 ] When Hitler was three, the family moved to .
