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Introduction
| Browse policies by brand name | Browse
policies by generic name | View recent medication policy
updates (PDF) | View past medication policy
updates | Medicare
drug coverage
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Policy
Name
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Revised
|
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A
|
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Abilify®,
aripiprazole
|
11/18/2011
|
|
|
Abstral®, fentanyl sublingual
tablets
|
09/16/2011
|
|
|
Accretropin®, somatropin
|
07/18/2008
|
|
|
Aciphex®,
rabeprazole
|
02/01/2012
|
|
|
Actemra®, tocilizumab
|
11/18/2012
|
|
|
Actiq®, fentanyl citrate oral
transmucosal lozenges
|
09/16/2011
|
|
|
Actonel®, risedronate-Containing
Medications (Actonel®, Actonel® with Calcium, Atelvia™)
|
07/08/2011
|
|
|
Actos®, pioglitazone-Containing
Medications (Actos®, ACTOplus met®, Duetact™)
|
05/13/2011
|
|
Adcetris™,
brentuximab
|
11/18/2011
|
|
|
Adcirca®, tadalafil 20 mg
|
11/18/2011
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|
|
Afinitor®, everolimus
|
03/18/2011
|
|
|
Alimta®, pemetrexed
|
05/13/2011
|
|
|
Alsuma®, sumatriptan
|
01/13/2012
|
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Altinac®, tretinoin topical
|
08/11/2010
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|
Ambien CR® , zolpidem MR
|
05/13/2011
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|
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Amerge®, naratriptan
|
01/13/2012
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Amevive®, alefacept
|
11/18/2011
|
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Amphetamine-dextroamphetamine
ER capsules
|
05/13/2011
|
|
|
Ampyra™, dalfampridine
|
09/16/2011
|
|
|
Antineoplaston Cancer Therapy
|
03/18/2008
|
|
|
Arcalyst®, rilonacept
|
07/08/2011
|
|
|
Arzerra™, ofatumumab
|
01/13/2012
|
|
|
Atacand®/Atacand® HCT,
candesartan-containing medications (Atacand, Atacand® HCT)
|
03/18/2011
|
|
Atorvastatin
(generic)
|
11/18/2011
|
|
|
Atralin®, tretinoin topical
|
07/08/2011
|
|
|
Avalide®, irbesartan-containing
medications (Avapro, Avalide®)
|
04/10/2010
|
|
|
Avandamet®, rosiglitizone/metformin
|
05/13/2011
|
|
|
Avandaryl®,
rosiglitazone/glimepiride
|
05/13/2011
|
|
|
Avandia®, rosiglitazone-Containing
Medications (Avandia®, Avandamet®, Avandaryl®)
|
05/13/2011
|
|
|
Avapro®, irbesartan-containing
medications (Avapro, Avalide®)
|
03/18/2011
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|
|
Avastin®, bevacizumab
|
07/08/2011
|
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Avita®, tretinoin topical
|
07/08/2011
|
|
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Axert®, almotriptan
|
02/01/2012
|
|
B
|
|
|
|
Beconase AQ®, beclomethasone nasal
|
07/08/2011
|
|
|
Benicar®/Benicar HCT®,
olmesartan-containing medications (Benicar, Benicar HCT®, AZOR® ,
Tribenzor™)
|
03/18/2011
|
|
|
Benlysta®, belimumab
|
09/16/2011
|
|
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Betaseron®, interferon beta-1b
|
11/18/2011
|
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Boniva®, ibandronate injection
|
11/18/2011
|
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Boniva®, ibandronate oral
|
07/08/2011
|
|
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Botox®, onabotulinumtoxinA
Injection
|
01/14/2011
|
|
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Byetta®, exenatide
|
05/13/2011
|
|
C
|
|
|
|
Caprelsa®,
vandetanib
|
07/08/2011
|
|
|
Carimune NF (Immune Globulin
Replacement Therapy)
|
05/13/2011
|
|
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Celebrex®, celecoxib
|
11/18/2011
|
|
|
Cerezyme®, imiglucerase -
VPRIV™, velaglucerase alfa
|
05/12/2010
|
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Cialis®, tadalafil
|
11/18/2011
|
|
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Cimzia®, certolizumab pegol
|
11/18/2011
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|
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Cinryze™, C1 inhibitor (human)
|
11/18/2011
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Compounded Medications
|
02/01/2012
|
|
|
Contraceptives for Medical Conditions,
Self-administered
|
03/18/2011
|
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Crestor®, rosuvastatin
|
03/18/2011
|
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Cymbalta®, duloxetine
|
05/13/2011
|
|
D
|
|
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Diabetic Test Supply: Abbott Blood
Glucose Meters and Testing Strips; (Including, but not limited to
FreeStyle Lite, FreeStyle Freedom Lite, and Precision Xtra)
|
11/18/2011
|
|
|
Diabetic Test Supply: LifeScan (OneTouch) Blood Glucose
Meters and Testing Strips (including, but not limited to OneTouch
Ultra, OneTouch Select, OneTouch SureStep, and OneTouch FastTake)
|
11/18/2011
|
|
|
Diabetic Test Supply: Roche Blood Glucose Meters and
Testing Strips (including, but not limited to Accu-Chek)
|
11/18/2011
|
|
|
Diovan®/Diovan HCT®,
valsartan-containing medications (Diovan, Diovan HCT®, Exforge®,
Exforge HCT®, Valturna®, Amturnide™)
|
03/18/2011
|
|
|
Dexilant®, dexlansoprazole
|
02/01/2012
|
|
|
Doxil®, doxorubicin liposomal
Injection
|
02/01/2012
|
|
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Dysport®, abobotulinumtoxinA
Injection
|
01/14/2011
|
|
E
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Edarbi™, azilsartan
|
03/18/2011
|
|
|
Edluar®, zolpidem sublingual tablets
|
05/13/2011
|
|
|
Egrifta™, tesamorelin
|
01/13/2012
|
|
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Eloxatin®, oxaliplatin
|
11/18/2011
|
|
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Embeda™, morphine/naltrexone
|
09/16/2011
|
|
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Enbrel®, etanercept
|
11/18/2011
|
|
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Erbitux®, cetuximab
|
09/16/2011
|
|
Erwinaze®,
erwinia chrysanthemi
|
02/01/2012
|
|
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Euflexxa®, (1% sodium hyaluronate),
effective July 14, 2011
|
05/13/2011
|
|
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Exalgo™, hydromorphone,
Extended-Release
|
11/18/2011
|
|
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Exforge®/Exforge HCT®, valsartan-containing
medications (Diovan, Diovan HCT®, Exforge®, Exforge HCT®, Valturna®)
|
04/10/2010
|
|
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Extavia®, interferon beta-1b
|
11/18/2011
|
|
Eylea™,
aflibercept
|
02/01/2012
|
|
F
|
|
|
Fanapt®,
iloperidone
|
11/18/2011
|
|
|
Fentora®, fentanyl citrate buccal
tablet
|
09/16/2011
|
|
Firazyr®, icatibant
|
11/18/2011
|
|
|
Flebogamma® DIF (Immune Globulin Replacement
Therapy)
|
05/13/2011
|
|
|
Folotyn™, pralatrexate
|
02/01/2012
|
|
|
Forteo®, teriparatide
|
07/08/2011
|
|
|
Frova®, frovatriptan
|
02/01/2012
|
|
G
|
|
|
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Gammagard® (Immune Globulin
Replacement Therapy)
|
05/13/2011
|
|
|
Gammagard S/D®, (Immune Globulin
Replacement Therapy)
|
05/13/2011
|
|
|
Gammaplex®,
(Immune Globulin Replacement Therapy)
|
05/13/2011
|
|
|
Gamunex® (Immune Globulin
Replacement Therapy)
|
05/13/2011
|
|
|
Genotropin®, somatropin
|
11/18/2011
|
|
Geodon®,
ziprasidone
|
11/18/2011
|
|
|
Gilenya™, fingolimod
|
09/16/2011
|
|
|
Gleevec®, imatinib mesylate
|
01/13/2012
|
|
|
Growth Hormone
|
11/18/2011
|
|
H
|
|
|
|
Halaven™, eribulin
|
02/01/2012
|
|
|
Hizentra™ (SQ preparation) (Immune Globulin
Replacement Therapy)
|
05/13/2011
|
|
|
Hyzaar®, losartan-containing
medications (Cozaar®, Hyzaar®)
|
04/10/2010
|
|
|
Humatrope®, somatropin
|
11/18/2011
|
|
|
Humira®, adalimumab
|
11/18/2011
|
|
|
Hyalgan®, (sodium hyaluronate),
effective July 14, 2011
|
07/08/2011
|
|
I
|
|
|
|
Illaris®,
canakinumab
|
07/08/2011
|
|
|
Imitrex®, sumatriptan
|
02/01/2012
|
|
|
Imitrex® Injectable, sumatriptan
|
01/13/2012
|
|
|
Immune Globulin Replacement Therapy
(IVIG, SQ)
|
05/13/2011
|
|
|
Incivek™, telaprevir
|
09/30/2011
|
|
|
Increlex®, mecasermin
|
01/13/2012
|
|
|
Infergen®, interferon alfacon-1
|
05/13/2011
|
|
Invega®,
paliperidone
|
11/18/2011
|
|
|
Istodax®, romidepsin
|
02/01/2012
|
|
J
|
|
|
Jakafi™,
ruxolitinib
|
02/01/2012
|
|
|
Januvia®,
sitagliptin-Containing Medications (Januvia, Janumet®)
|
11/18/2011
|
|
|
Jevtana®, cabazitaxel
|
02/01/2012
|
|
K
|
|
|
|
Kapidex™, dexlansoprazole
|
01/14/2011
|
|
|
Kineret®, anakinra
|
11/18/2011
|
|
|
Kombiglyze XR®, saxagliptin
|
05/13/2011
|
|
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Krystexxa™, pegloticase
|
01/14/2011
|
|
L
|
|
|
|
Lamisil®, terbinafine oral
|
07/08/2011
|
|
Latuda®,
lurasidone
|
11/18/2011
|
|
|
Lazanda™, fentanyl nasal spray
|
09/16/2011
|
|
|
Letairis®, ambrisentan
|
07/08/2011
|
|
|
Levitra®, vardenafil
|
01/13//2012
|
|
|
Lexapro®, escitalopram
|
05/13/2011
|
|
|
Lipitor®, atorvastatin
|
11/18/2011
|
|
|
Livalo®, pitacastatin
|
03/18/2011
|
|
|
Lucentis®, ranibizumab, effective
July 1, 2011
|
05/13/2011
|
|
|
Lunesta®, eszopiclone
|
05/13/2011
|
|
|
Lyrica®, pregabalin
|
01/13/2012
|
|
M
|
|
|
|
Macugen®, pegaptanib, effective July
1, 2011
|
05/13/2011
|
|
|
Makena™, hydroxyprogesterone caproate
|
09/16/2011
|
|
|
Maxalt®, Maxalt MLT®,
rizatriptan
|
02/01/2012
|
|
|
Maximum Drug Dosage
|
02/01/2012
|
|
|
Medication Policy Manual
Introduction
|
9/10/2010
|
|
|
Micardis®/Micardis HCT®,
telmisartan-containing medications (Micardis, Micardis® HCT)
|
03/18/2011
|
|
|
Mirena®, levonorgestrel-containing
Intrauterine System
(LNG-IUS) for Medical Conditions
|
03/18/2011
|
|
|
Myobloc®, rimabotulinumtoxin
B
|
03/18/2011
|
|
N
|
|
|
|
Nasonex®, mometasone nasal
|
07/08/2011
|
|
|
Nexavar®, sorafenib
|
01/13/2013
|
|
|
Nexium®, esomeprazole
|
02/01/2012
|
|
|
Non-Formulary Medications, Medical
Exception Criteria for Closed Pharmacy Benefit Designs
|
02/01/2012
|
|
|
Norditropin®, somatropin
|
11/18/2011
|
|
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Nplate®, romiplostim
|
05/13/2011
|
|
|
Nutropin®, somatropin
|
11/18/2011
|
|
|
Nutropin AQ®, somatropin
|
11/18/2011
|
|
|
Nuvigil®, armodafinil
|
09/16/2011
|
|
O
|
|
|
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Off-Label Use of FDA Approved
Drugs
|
02/01/2012
|
|
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Omnaris™, ciclesonide nasal
|
07/08/2011
|
|
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Omnitrope®, somatropin
|
11/18/2011
|
|
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Onglyza®, saxagliptin
|
05/13/2011
|
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Onsolis™, fentanyl buccal soluble film
|
09/16/2011
|
|
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Opana® ER, oxymorphone,
Extended-Release
|
09/16/2011
|
|
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Opioids for Chronic Non-Cancer
Pain
|
09/16/2011
|
|
|
Orencia®, abatacept
|
11/18/2011
|
|
|
Orthovisc®, (high molecular weight
hyaluronan)
|
07/08/2011
|
|
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OxyContin®, oxycodone CR
|
02/01/2012
|
|
P
|
|
|
|
Pegasys®, peginterferon alfa-2a
|
08/30/2011
|
|
|
PEG-Intron®, peginterferon
alfa-2b
|
08/30/2011
|
|
|
Penlac®, ciclopirox
|
07/08/2011
|
|
|
Prevacid®, lansoprazole
|
02/01/2012
|
|
|
Pristiq™, desvenlafaxine
|
05/13/2011
|
|
|
Privigen® (Immune Globulin
Replacement Therapy)
|
05/13/2011
|
|
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Prolia™, denosumab
|
11/18/2011
|
|
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Promacta®, eltrombopag
|
05/13/2011
|
|
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Provenge®, sipuleucel-T
|
07/08/2011
|
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Provigil®, modafinil
|
09/16/2011
|
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Q
|
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Qualaquin®, quinine
|
11/18/2011
|
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Qutenza®, capsaicin 8% patch
|
07/08/2011
|
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R
|
|
|
|
Reclast®, Zometa®, zoledronic acid
|
11/18/2011
|
|
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Refissa™, tretinoin topical
|
07/08/2011
|
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Relenza®, zanamivir
|
07/08/2011
|
|
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Relpax®, eletriptan
|
02/01/2012
|
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Relistor®, methylnaltrexone
|
09/16/2011
|
|
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Remicade®, infliximab
|
11/18/2011
|
|
|
Remodulin®, treprostinil injectable
|
07/08/2011
|
|
|
Renova®, tretinoin topical
|
07/08/2011
|
|
|
Retin
A®, tretinoin topical
|
07/08/2011
|
|
|
Retin
A Micro®, tretinoin topical
|
07/08/2011
|
|
|
Revatio®, sildenafil 20mg
|
07/08/2011
|
|
|
Revlimid®, lenalidomide
|
09/16/2011
|
|
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Rhinocort Aqua®, budesonide nasal
|
07/08/2011
|
|
|
Rituxan®, rituximab
|
02/01/2012
|
|
|
Rozerem™, ramelteon
|
05/13/2011
|
|
S
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Saizen®, somatropin
|
11/18/2011
|
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Saphris®,
asenapine
|
11/18/2011
|
|
|
Savella™, milnacipran
|
05/13/2011
|
|
|
Self-administered Contraceptives for
Medical Conditions
|
02/01/2012
|
|
|
Self-Administered Injectables
|
01/11/2011
|
|
|
Serostim®, somatropin
|
11/18/2011
|
|
|
Serostim LQ®, somatropin
|
11/18/2011
|
|
|
Simponi®, golimumab
|
09/16/2011
|
|
|
Solage®, tretinoin topical
|
08/11/2010
|
|
|
Sporanox®, itraconazole oral
|
07/08/2011
|
|
|
Sprycel®, dasatinib
|
01/13/2012
|
|
Staxyn®,
vardenafil
|
01/13/2012
|
|
|
Stelara™, ustekinumab
|
11/18/2011
|
|
|
Sumavel™, DosePro™,
sumatriptan
|
01/13/2012
|
|
|
Supartz®, (sodium hyaluronate)
|
07/08/2011
|
|
|
Sutent®, sunitinib
|
01/13/2012
|
|
|
Sylatron™, peginterferon alfa-2b
|
07/08/2011
|
|
|
Synagis®, palivizumab, respiratory
syncytial virus immune prophylaxis
|
02/01/2012
|
|
|
Synvisc®/Synvisc-One® (hylan G-F 20)
|
05/13/2011
|
|
T
|
|
|
|
Tarceva®, erlotinib
|
07/08/2011
|
|
|
Tasigna®, nilotinib
|
02/01/2012
|
|
|
Tamiflu®, oseltamivir
|
07/08/2011
|
|
|
Tekturna®/Tekturna HCT®, alisksartan-containing medications (Tekturna,
Tekturna HCT®, Valturna®, Amturnide™ , Tekamlo™ )
|
03/18/2011
|
|
|
Tev-Tropin®, somatropin
|
11/18/2011
|
|
|
Teveten®/Teveten HCT®, eprosartan-containing
medications (Teveten, Teveten HCT®)
|
03/18/2011
|
|
|
Tracleer®, bosentan
|
07/08/2011
|
|
|
Tradjenta®, linagliptin
|
05/13/2011
|
|
|
Treximet™, sumatriptan/naproxen
|
02/01/2012
|
|
|
Tykerb®, lapatinib
|
09/16/2011
|
|
|
Tysabri®, natalizumab
|
09/16/2011
|
|
|
Tyvaso®, treprostinil inhalation
|
07/08/2011
|
|
V
|
|
|
|
Valturna®, alisksartan-containing
medications (Tekturna, Tekturna HCT®, Valturna®)
|
04/10/2010
|
|
|
Valturna®, valsartan-containing
medications (Diovan, Diovan HCT®, Exforge®, Exforge HCT®, Valturna®)
|
04/10/2010
|
|
|
Velcade®, bortezomib
|
09/16/2011
|
|
|
Ventavis®, iloprost inhalation
|
07/08/2011
|
|
|
Veramyst®, fluticasone furoate nasal
|
07/08/2011
|
|
|
Viagra®, sildenafil
|
09/01/2010
|
|
|
Victoza®, liraglutide
|
05/13/2011
|
|
|
Victrelis™, boceprevir
|
09/28/2011
|
|
|
Viibryd™, vilazodone
|
05/13/2011
|
|
|
Vimovo™, esomeprazole-containing
medications
|
02/01/2012
|
|
|
Votrient™, pazopanib
|
02/01/2012
|
|
|
VPRIV™, velaglucerase alfa - Cerezyme®,
imiglucerase
|
05/12/2010
|
|
|
Vytorin®, simvastatin/ezetimibe
|
03/18/2011
|
|
X
|
|
|
Xalkori®, crizotinib
|
11/18/2011
|
|
|
Xenazine®, tetrabenazine
|
03/18/2011
|
|
|
Xeomin®, incobotulinumtoxinA
Injection
|
01/14/2011
|
|
|
Xgeva™, denosumab
|
11/18/2011
|
|
|
Xolair®, omalizumab
|
07/08/2011
|
|
|
Xyrem®, sodium oxybate
|
09/16/2011
|
|
Y
|
|
|
|
|
Yervoy™, ipilimumab, effective July 1, 2011
|
05/13/2011
|
|
Z
|
|
|
|
Zavesca®, miglustat
|
08/11/2010
|
|
Zelboraf™, vemurafenib
|
11/18/2011
|
|
|
Zegerid®, omeprazole/sod.
bicarbonate
|
02/11/2012
|
|
|
Zolinza™, vorinostat
|
02/01/2012
|
|
|
Zometa®, Reclast®, zoledronic acid
|
11/18/2011
|
|
|
Zomig®, Zomig ZMT®,
zolmitriptan
|
02/01/2012
|
|
|
ZolpiMist®,
zolpidem
|
05/13/2011
|
|
|
Zorbtive®, somatropin
|
11/18/2011
|
|
|
Zytiga™, abiraterone
|
02/01/2012
|
|
|
|
|
|
|
|
|
|
|
|
