Silverback Care Management CARE N' CARE Specialty Drug Preauthorization List 2016 The medications listed below require preauthorization when delivered in the physician office, clinic, outpatient or home setting Preauthorization is NOT required when administered as an Inpatient or in the ED or Urgent Care Clinic
Brand Name Generic Name Abraxane® Paclitaxel Protein-bound, paclitaxel-nab Actemra tocilizumab Acthar Gel corticotropin Adcetris brentuximab vedotin Aldurazyme laronidase Alimta® Pemetrexed Aloxi palonosetron HCl Aralast NP alpha 1-proteinase inhibitor Aranesp darbepoetin alfa Arcalyst rilonacept Arranon nelarabine Arzerra ofatumumab Atgam lymphocyte immune globulin Avastin®* Bevacizumab Beleodaq belinostat Benlysta belimumab Berinert c1 esterase inhibitor Blincyto blinatumomab Boniva ibandronate sodium Botox onabotulinumtoxinA Brovana arformoterol Carimune NF®, Panglobulin NF® and Gammagard SD® Immune Globulin, Intravenous Cerezyme imiglucerase Chemotherapy Chemotherapy Agents Supportive and Drugs Symptom Chemotherapy Chemotherapy Agents Supportive and Drugs Symptom Management Drugs Management Drugs Cimzia certolizumab pegol Cinryze c1 esterase inhibitor Cyklokapron tranexamic acid Cyramza ramucirumab CytoGam cytomegalovirus immune globulin Dacogen decitabine Duopa carbidopa / levodopa Dysport abobotulinumtoxin A Elaprase idursulfase Elelyso taliglucerase alfa Elitek rasburicase Eloxatin oxaliplatin Emend IV aprepitant Entyvio vedolizumab Epogen epoetin alfa Erbitux® Cetuximab Erwinaze asparaginase Erwinia chrysanthemi Eylea aflibercept Fabrazyme agalsidase beta Firazyr icatibant Flebogamma® Immune Globulin, Intravenous Flolan epoprostenol (injection) Folotyn pralatrexate Fusilev levoleucovorin Gammagard® Immune Globulin, Intravenous Gammaplex® Immune Globulin, Intravenous Gamunex® Immune Globulin, Intravenous Gattex teduglutide Gazyva obinutuzumab Gemzar® Gemcitabine HCl Gilenya fingolimod Glassia alpha 1-proteinase inhibitor Growth Hormones: Genotropin, Humatrope, Norditropin, Nutropin, somatropin Nutropin AQ, Omnitrope, Saizen, Serostim, Tev-Tropin, Zorbtive
Halaven eribulin mesylate Herceptin® Trastuzumab IImmune Globulin, Intravenous Immune Globulin, Intravenous Ilaris canakinumab Iluvien fluocinolone acetonide Immune Globulin: Carimune NF, Flebogamma 5%, Gamastan, immune globulin Gammagard S/D, Gammagard Liquid, Gamunex, Hizentra, Octagam, Privigen, Vivaglobin Istodax romidepsin Ixempra ixabepilone Jetrea ocriplasmin Jevtana cabazitaxel Kadcyla ado-trastuzumab emtansine Kalbitor ecallantide Kineret anakinra Krystexxa pegloticase Kynamro mipomersen sodium
Specialty Drug Preauthorization List 1 of 2 Last Approved August 2015 Silverback Care Management CARE N' CARE Specialty Drug Preauthorization List 2016 The medications listed below require preauthorization when delivered in the physician office, clinic, outpatient or home setting Preauthorization is NOT required when administered as an Inpatient or in the ED or Urgent Care Clinic
Brand Name Generic Name Kyprolis carfilzomib Lemtrada alemtuzumab Lucentis ranibizumab Lumizyme alglucosidase alfa Macugen pegaptanib sodium Makena hydroxyprogesterone caproate Marqibo vincristine sulfate Mozobil plerixafor Myobloc rimabotulinumtoxinB Myozyme alglucosidase alfa Naglazyme galsulfase Neulasta pegfilgrastim Nplate romiplostim Nulojix belatacept Opdivo nivolumab Octagam® Immune Globulin, Intravenous Omontys peginesatide Ontak denileukin diftitox Orencia abatacept Ozurdex dexamethasone intravitreal implant Perjeta pertuzumab Prialt ziconotide Privigen® Immune Globulin, Intravenous Procrit epoetin alfa Prolastin-C alpha 1-proteinase inhibitor Prolia denosumab Provenge® Sipuleucel -T Provenge®*** Sipuleucel -T Qutenza capsaicin/skin cleanser Reclast zoledronic acid Remicade infliximab Remodulin treprostinil (injection) Revatio sildenafil citrate (injection) Rituxan® Rituximab Ruconest c1 esterase inhibitor Sandostatin LAR octreotide Signifor LAR pasireotide Simponi golimumab Simponi ARIA golimumab Soliris eculizumab Somatuline Depot lanreotide Stelara ustekinumab Sylatron peginterferon alfa-2b Synagis palivizumab Synribo omacetaxine mepesuccinate Temodar temozolomide Testopel testosterone pellet Torisel temsirolimus Treanda bendamustine HCI Tysabri natalizumab Tyvaso treprostinil (inhaled) Valstar valrubicin Varizig varicella zoster immune globulin Vectibix® Panitumumab Velcade® Bortezomib Veletri epoprostenol Ventavis iloprost (inhaled) Vidaza® Azacitidine Vimizim elosulfase alfa Visudyne verteporfin Vpriv velaglucerase alfa Xeomin incobotulinumtoxin A Xgeva®** Denosumab Xofigo radium Ra 223 dichloride Xolair omalizumab Yervoy® Ipilimumab Zaltrap ziv-aflibercept Zemaira alpha 1-proteinase inhibitor Zevalin ibritumomab tiuxetan Zometa zoledronic acid Zyprexa Relprevv olanzapine
Specialty Drug Preauthorization List 2 of 2 Last Approved August 2015