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Prior Authorization for Medications JANUARY 2016 KMAP PHARMACY & PROFESSIONAL BULLETIN 16006 Prior Authorization for Medications Effective with dates of service on and after February 1, 2016, prior authorization (PA) is required for the following medications. Generic name Brand name Generic name Brand name ® ® abobotulinumtoxin A Dysport dimethyl fumarate Tecfidera ® ® adapalene Differin doxylamine/ Diclegis pyridoxine adapalene/benzoyl Epiduo® dronabinol Marinol® peroxide afatinib Gilotrif® ecallantide Kalbitor® albiglutide Tanzeum® eculizumab Soliris® alemtuzumab Lemtrada® eliglustat Cerdelga® alirocumab Praluent® eltrombopag Promacta® alitretinoin Panretin® empagliflozin Jardiance® alpha 1 proteinase Zemaira® epoprostenol Flolan®, Veletri® inhibitor ® ® alpha 1 proteinase Prolastin C everolimus Afinito inhibitor Glassia® Afinitor Disperz® Aralast NP® ambrisentan Letairis® evolocumab Repatha® aminosalicylate sodium Paser® ezetimibe Zetia® apremilast Otezla® filgrastim Neupogen® azelaic acid Azelex®, fingolimod Gilenya® Finacea® azelastine nasal Astelin®, fluticasone/vilanterol Breo-Ellipta® Astepro® ® ® azelastine ophth Optivar glatiramer Copaxone ® ® belimumab Benlysta glycerol Ravicti phenylbutyrate ® ® bexarotene Targretin histrelin acetate Supprelin LA boceprevir Victrelis® icatibant Firazyr® ® ® bosentan Tracleer iloprost Ventavis ® ® c1 esterase Cinryze imiglucerase Cerezyme ® Ruconest canagliflozin Invokana® incobotulinumtoxinA Xeomin® canakinumab Ilaris® interferon alfa-2b Intron A® capreomycin Capostat® interferon alfacon-1 Infergen® cinacalcet Sensipar® interferon beta-1a Avonex®, Rebif®, Plegridy® clobazam Onfi® interferon beta-1b Betaseron®, Extavia® collagenase clostridium Xiaflex® ledipasvir/sofosbuvir Harvoni® histolyticum cyclosporine Restasis® leuprolide Lupron® KMAP dabrafenib Tafinlar® lidocaine patch Lidoderm® Kansas Medical Assistance Program daclatasvir Daklinza® linaclotide Linzess® • Bulletins dalfampridine Ampyra® lomitapide Juxtapid® • Manuals dapagliflozin Farxiga® lorcaserin Belviq® • Forms dapsone topical Aczone® lubiprostone Amitiza® deferasirox Exjade® lumacaftor/vacaftor Orkambi® Customer Service Jadenu® • 1-800-933-6593 (in-state) deferiprone Ferriprox® macitentan Opsumit® • 785-274-5990 ® ® denosumab Xgeva methotrexate Rasuvo , 8:00 a.m. - 5:00 p.m. Prolia® Otrexup® Monday - Friday Hewlett Packard Enterprise is the fiscal agent of KMAP. Page 1 of 2 Prior Authorization for Medications Generic name Brand name Generic name Brand name mipomersen Kynamro® sofosbuvir Sovaldi® naltrexone/bupropion Contrave® tadalafil Adcirca® nintedanib Ofev® taliglucerase alfa Elelyso® ocriplasmin Jetrea® tasimelteon Hetlioz® ombitasvir/paritaprevir/ Technivie® tazarotene Tazorac®, ritonavir Fabior® ombitasvir/paritaprevir/ Viekira Pak® telaprevir Incivek® ritonavir/dasabuvir oprelvekin Neumega® teriflunomide Aubagio® pegfilgrastim Neulasta® testosterone buccal Striant® ® ® peginterferon alfa-2a Pegasys testosterone Delatestryl enanthate injection peginterferon alfa-2b Pegintron® testosterone gel Vogelxo® ® Sylatron pegloticase Krystexxa® testosterone implant Testopel® ® ® phentermine/topirimate ER Qsymia testosterone nasal Natesto gel ® pirfenidone Esbriet testosterone powder quinine Qualaquin® testosterone topical Androgel® gel Fortesta® gel Testim® radium RA 223 dichloride Xofigo® testosterone topical Axiron® solution ranibizumab Lucentis® testosterone Androderm® transdermal repository corticotropin H.P. Acthar® tofacitinib Xeljanz® injection gel rifaximin Xifaxan® trametinib Mekinist® riluzole Rilutek® trastuzumab Herceptin® riociguat Adempas® treprostinil ER Orientram® romiplostim Nplate® treprostinil inhalation Tyvaso® rufinamide Banzel® treprostinil injection Remodulin® sapropterin Kuvan® tretinoin/clindamycin Veltin®, Ziana® sargramostim Leukine® trientine Syprine® sildenafil Revatio® umeclidinium/ Anoro™ vilanterol Elipta® simeprevir Olysio® velaglucerase alfa VPRIV® sipuleucel-T Provenge® vigabatrin Sabril® ® ® sodium phenylbutyrate Buphenyl ziconotide Prialt intrathecal infusion ® Effective February 1, 2016, Xartemis XR (oxycodone HCI and acetaminophen) Extended Release Tablets require PA above an initial 7-day supply per year (4 tablets per day or a total of 28 tablets per 365 days). Refer to Section 8400 in the Pharmacy Fee-for-Service Provider Manual on the KMAP website under the Publications tab. KMAP Refer to Section 4300 in the General Special Requirements Kansas Medical Assistance Program Fee-for-Service Provider Manual on the KMAP website under the • Bulletins Publications tab. • Manuals • Forms All PA forms are located on the KDHE website under Pharmacy. Customer Service • 1-800-933-6593 (in-state) • For the changes resulting from this provider bulletin, view the updated Pharmacy 785-274-5990 Fee-for-Service Provider Manual, Section 8400, pages 8-20 through 8-23, 8-36 through 8-39, 8:00 a.m. - 5:00 p.m. and 8-56 through 8-58. Monday - Friday Hewlett Packard Enterprise is the fiscal agent of KMAP. Page 2 of 2 .
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