CareSource Specialty Pharmacy Prior Authorization List ‐ Effective June 1, 2011
PRIMARY DISEASE CLASS BRAND NAME (POLICY) GENERIC NAME CROHN'S DISEASE / RA Remicade Infliximab Cimzia Certolizumab pegol Humira Adalimumab Tysabriy Natalizumab RHEUMATOID ARTHRITIS (RA) Enbrel Etanercept Kineret Anakinra Orencia Abatacept Rituxan Rituximab Simponip Golimumab Actemra Tocilizumab ALLERGIC ASTHMA Xolair Omalizumab MULTIPLE SCLEROSIS Avonex Interferon beta-1a Betaseron Interferon beta-1b Extavia Interferon beta-1b Rebif Interferon beta-1a Copaxone glatiramer acetate Gilenya Fingolimod Ampyra Dalfampridine PLAQUE PSORIASIS Amevive Alefaceptp Stelara Ustekinumab BOTULINUM TOXIN - SPASTICITY Botulinum Toxin Botox OnabotulinumtoxinA Xeomin IncobotulinumtoxinA Dysportyp AbobotulinumtoxinA Myobloc RimabotulinumtoxinB INFANTILE SPASMS Acthar HP Corticotropin Sabril Vigabatrin CareSource Specialty Pharmacy Prior Authorization List ‐ Effective June 1, 2011
PRIMARY DISEASE CLASS BRAND NAME (POLICY) GENERIC NAME GROWTH HORMONE Somatropin Serostim Somatropin Genotropin Somatropin Humatropep Somatropinp Norditropin Somatropin Nutropin Somatropin Omnitrope Somatropin Saizen Somatropin Tev-Tropinp Somatropinp Zorbtive Somatropin GROWTH HORMONE / IGFD Increlex/Iplex Mecasermin LYOSOMAL STORAGE DISORDERS Makena Hydroxyprogesterone caproate Aldurazyme Laronidase Ceredase Alglucerase Cerezyme Imiglucerase Elaprase Idursulfase Fabrazyme Agalsidase beta Alglucosidase alfa Lumizymey Alglucosidase alfa Myozyme Alglucosidase alfa Galsulfase Naglazyme HEPATITIS C Infergen Interferon Alfacon-1, recombinant Pegylated Interferon PegasysPegasys Pegylated Interferon alfa-2a PEG-Intron Peginterferon alfa-2b Rebetrol soln/caps/tabs Ribavirin HEMATOPOIETICS Procrit Epoetin alfa Aranesp Darbepoetin alfa EpogenEpogen EpoetinEpoetin alfaalfa CareSource Specialty Pharmacy Prior Authorization List ‐ Effective June 1, 2011
PRIMARY DISEASE CLASS BRAND NAME (POLICY) GENERIC NAME IV IMMUNE GLOBULINS IVIG Carimune Immune Globulin Intravenous (Human) Cytomegalovirus immune globulin Flebogamma Immune gglobulin,lobulin, non-lnon lyophilizedyophilized GammaSTANGammaSTAN S/D Gammagard Immune Globulin Intravenous (Human) Gamunex Immune Globulin Intravenous (Human) Octagam Immune globulin, non-lyophilized Polygam S/D Immune globulin, lyophilized Privigen Immune Globulin Intravenous (Human) Gammaplex Immune Globulin Intravenous (Human) Hizentra Immune Globulin Subcutaneous [Human] Cytogam Cytomegalovirus immune globulin Rhophylacpy Rho(D)() immune globulin g (human) ( ) WinRho SDF Rho(D) immune globulin, human, solvent detergent OSTEOARTHRITIS Hyaluronic Acid Derivative EuFlexxa Hyaluronan (sodium hyaluronate or derivative) Hyalgan Hyaluronan (sodium hyaluronate or derivative) OrthoviscOrthovisc HHyaluronanyaluronan ((sodiumsodium hhyaluronateyaluronate or derivativederivative)) Synvisc Hylan G-F 20 Synvisc-One Hylan G-F 20 Supartz Hyaluronan (sodium hyaluronate or derivative) OSTEOPOROSIS Osteoporosis Agents ForteoForteo TeriparatideTeriparatide Reclast Zoledronic acid Boniva Ibandronate sodium CareSource Specialty Pharmacy Prior Authorization List ‐ Effective June 1, 2011
PRIMARY DISEASE CLASS BRAND NAME (POLICY) GENERIC NAME PULMONARY ARTERIAL HTN Pulmonary Hypertension Adcirca Tadalafil Remodulin Treprostinil sodium Letairis Ambrisentan Revatio Sildenafil Tracleer Bosentan Tyvaso Treprostinil Ventavis Iloprost HEMOPHILIA HemophiliaHemophilia FactorsFactors Factor VIII (antihemophiliac factor, recombinant) Advate Factor IX, recombinant Benefix Factor VIII(antihemophiliac factor, recombinant) Helixate FS antihemophilictih hili factor f t (recombinant) ( bi t) Kogenate FS Antihemophilic Factor (Recombinant) Recombinate Antihemophilic Factor (Recombinant) Refacto AAntihemophilicntihemophilic Factor/von Willebrand Factor ComComplexplex Alphanate (Human) Alphanine SD Coagulation Factor IX (Human) Bebulin VH Factor IX Complex Antihemophilic Factor (Human) Method M, Monoclonal Hemofil M Purified Antihemophilic Factor/von Willebrand Factor Complex Humate P (Human) Coagulation Factor IX (Human) Mononine Coagulation Factor VIIa (Recombinant) Novoseven Coagulation Factor IX complex Profilnine SD Proplex T Factor IX complex CareSource Specialty Pharmacy Prior Authorization List ‐ Effective June 1, 2011
PRIMARY DISEASE CLASS BRAND NAME (POLICY) GENERIC NAME BLEEDING DISORDERS Stimate Desmopressin Acetate Xyntha Antihemophilic factor OPIATE ANTAGONISTS Vivitrol Naltrexone ENZYME INHIBITOR ZavescaZavesca MiglustatMiglustat ENZYME REPLACEMENT VPRIV Velaglucerase Alfa