Provider Manual

Injectable drug list

Notes:

Emergency Room, skilled nursing facility or inpatient use of these medications does not require prior authorization.
All medications billed with miscellaneous codes will require authorization if line charge is greater than $500.
Click a medication name to open its prior authorization/medical necessity form.
Drugs in boldface must be ordered through a specialty pharmacy.
Go to the specialty pharmacy fax order form (739KB PDF).

No authorization required when Botulinum toxin is billed by neurologists, rehabilitation medicine or physical medicine.
Once criteria are met, review for annual renewal of authorization. Documentation should not need to be submitted.
Covered only with prescription benefit. Must be purchased through a specialty pharmacy.
No authorization required when Euflexxa billed by orthopedic specialists, physiatrists, or rheumatologists.
No authorization required for Rituxan for Non-Hodgkin's Lymphoma and other CD20-expressing neoplasm (e.g. chronic lymphocytic leukemia, Waldenström macroglobulinemia, hairy cell leukemia, mantle cell lymphoma).
No authorization required for Medicare. Must use CPT code outlined in the CMS local coverage determination (LCD) available at www.cms.hhs.gov/mcd/search.asp?from2=search.asp&
Priority Health Medicare applies CMS local coverage determination criteria when available for Part B drugs.

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Injectable drugs requiring prior authorization all plans Updated January 2012
Click the drug name to get the PA form	Code	Benefit	Use	Criteria for coverage
Actemra (tocolizumab)	J3262	Medical	Rheumatoid arthritis	Moderate to severe rheumatoid arthritis in adults Trial of at least one self-injectable anti-TNF Negative TB test (must be done yearly) Pretreatment labs completed and within normal limits (CBC with diff, LFTs, Lipid panel) Patient must not be receiving Actemra in combination with and other biologic drug
Acthar (corticotrophin)	J0800	Pharmacy	Up to 40 units; treatment for infantile spasms Length of initial authorization: 2 weeks Length of continuation authorization: 4 weeks	Diagnosis of infantile spasms
Adcetris (brentuximab)	J9999 C9287	Medical	Treatment of Hodgkins lymphoma and anaplastic large cell lymphoma	One of the following diagnoses: Adult patients with Hodgkin lymphoma after failure of autologous stem cell transplant (ASCT) or after failure of at least two prior multi-agent chemotherapy regimens Adult patients with Systemic anaplastic large cell lymphoma (ALCL) after failure of at least one prior multi-agent chemotherapy regimen
Aloxi (palonosetron)	J2469	Medical	Per 10 mg; antiemetic; PA required ONLY for home infusion providers
Amevive (alefacept)²	J0215	Medical	Per 10mg; biologic treatment for moderate to severe chronic plaque psoriasis Length of initial authorization: 3 months Length of continuation authorization: 1 year Two courses of therapy must be separated by at least 3 months	Diagnosis of chronic moderate-to-severe plaque psoriasis affecting >10% of BSA (unless hands, feet, head and neck, or genitalia) Documented trial of one topical agent, one systemic treatment, AND phototherapy
Anzemet (dolasetron)	J1260	Medical	Per 10 mg; antiemetic; PA required ONLY for home infusion providers	See PA form for Medicare
Aralast (alpha 1 proteinase inhibitor - human)	J0256	Medical	Alpha-antitrypsin deficiency	Diagnosis of congenital alpha 1-antitrypsin deficiency Clinically evident emphysema FEV1 30-65% predicted Serum AAT level < 11mM/L (< 60 mg/dL)
Arzerra (ofatumumab)	J9032	Medical	Treatment of refractory CLL	Diagnosis of CLL Trial and failure of fludarabine (Fludara) and alemtuzumab (Campath)
Benlysta (belimumab)	J0490	Medical	Treatment of SLE	Active, auto-antibody positive SLE Baseline SELENA-SLEDAI score of 6 or more Free of severe nephritis, CNS manifestations, and chronic infections Currently receiving standard therapy for at least 3 months Not receiving any biologic therapy or intravenous cyclophosphamide
Click the drug name to get the PA form	Code	Benefit	Use	Criteria for coverage
Boniva (ibandronate sodium)⁷	J1740	Medical	Injection 1 mg for treatment of osteoporosis Length of authorization: 2 years (given one injection every 3 months)	Diagnosis of postmenopausal osteoporosis (T-score < -2.5) Clinical trial of Fosamax, Actonel, and Reclast See PA form for Medicare
Botox (Botulinum toxin type A)¹	J0585	Medical	Per unit, for various neuro-muscular uses: see PA form for covered conditions Length of authorization: 1 year (given one injection every 3 months) Injections must be separated by at least 90 days	See PA form for a list of covered indications Treatment for anal fissures and headache diagnoses require a clinical trial of conventional therapies See PA form for Medicare
Cimzia (certolizumab)	J0718	Medical or Pharmacy	Per 1mg; treatment of moderate to severe Crohn's disease and rheumatoid arthritis Medical coverage if administered by health professional Pharmacy coverage if self-injected	Documented therapeutic trial and clinical failure with either Enbrel or Humira Diagnosis of Rheumatoid arthritis with documented therapeutic trial of at least one DMARD AND documented therapeutic trial and clinical failure with either Enbrel or Humira Diagnosis of Crohn's Disease with documented therapeutic trial of at least two of the following formulary alternatives: corticosteroids, sulfasalazine, osalazine, and mesalamine AND documented therapeutic trial and clinical failure with Humira Negative TB test (must be done yearly) See Medical necessity form for complete details.
Dysport (abobotulinumtoxin A)¹	J0586	Medical	Per 5 units, for various neuro-muscular uses: see PA form for covered conditions Length of authorization: 1 injection Injections must be separated by at least 90 days	See PA form for a list of covered indications Treatment for anal fissures and headache diagnoses require a clinical trial of conventional therapies See PA form for Medicare
Enbrel (etanercept)³	J1438	Pharmacy	Treatment of rheumatoid arthritis, juvenile RA, ankylosing spondylosis, plaque psoriasis, psoriatic arthritis, and ankylosing spondylitis Length of initial authorization: 3 months Length of continuation authorization: 1 year (3 months for plaque psoriasis)	Diagnosis of rheumatoid arthritis, juvenile RA, ankylosing spondylosis, plaque psoriasis, psoriatic arthritis, or ankylosing spondylitis Negative TB test (provided on an annual basis) Treatment failure with one or more DMARD (except ankylosing spondylitis and plaque psoriasis) Ankylosing spondylitis requires failure of at least 2 NSAIDs, intra-articular steroids, and sulfasalazine in patients with peripheral arthritis Plaque psoriasis affecting > 10% of BSA (unless hands, feet, head and neck, or genitalia) and a documented trial of one topical agent, one systemic treatment, and phototherapy
Erbitux (cetuximab)	J9055	Medical	Treatment of advanced metastatic colorectal cancer and head and neck cancer Length of authorization: 4 injections	Patient is 18 years of age Diagnosis of metastatic colorectal cancer or sqamous cell carcinoma of the head and neck Documented KRAS negative mutation status for colorectal cancer Used in combination with other therapy or as a single agent in members that have failed or been intolerant to other therapy
Extavia (interferon beta 1b)	J1830	Pharmacy	Treatment of multiple sclerosis	Requires a trial and failure with both Rebif and Copaxone
Fabrazyme (agalsidase beta)	J0180	Medical	Treatment of Fabry disease Length of authorization: 1 year	Diagnosis of Fabry disease
Firmagon (degrelix)	J9155	Medical	Treatment of prostate cancer	Diagnosis of prostate cancer Trial and failure with leuprolide (Lupron Depot), goserelin (Zoladex) or triptorelin (Trelstar Depot) with or without anti-androgen therapy for the first 30 days
Click the drug name to get the PA form	Code	Benefit	Use	Criteria for coverage
Forteo (teriparatide)^2,³	J3110	Pharmacy	Treatment of osteoporosis Length of authorization: 2 years	Diagnosis of postmenopausal osteoporosis in women or primary or hypogonadal osteoporosis in men Clinical trial and failure with Fosamax (alendronate) and Actonel
Glassia (alpha 1 proteinase inhibitor - human)	J0257	Medical	Alpha-antitrypsin deficiency	Diagnosis of congenital alpha 1-antitrypsin deficiency Clinically evident emphysema FEV1 30-65% predicted Serum AAT level < 11mM/L (< 60 mg/dL)
Human growth hormone³: Preferred: Norditropin Other: Nutropin Nutropin AQ Humatrope Saizen Genotropin Serostim Zorptive (somatropin)³ Protropin	J2941 J2940 (Protropin)	Pharmacy	Per 1 mg; human growth hormone (HGH) Length of initial authorization: 1 year Authorization of a non-preferred agent requires a clinical failure of a preferred agent	Pediatrics: Diagnosis of idiopathic growth hormone deficiency (requires submission of appropriate lab tests) or Turner's syndrome Adults: Documented growth hormone deficiency and hypothalamic pituitary disease, history of cranial radiation, pituitary surgery, or continued treatment of childhood growth hormone deficiency
Humira (adalimumab)^2,3	J0135	Pharmacy	Treatment of rheumatoid arthritis, juvenile idiopathic arthritis, ankylosing spondylitis, Crohn's disease, and plaque psoriasis Length of initial authorization: 3 months Length of continuation authorization: 1 year (3 months for plaque psoriasis)	Diagnosis of rheumatoid arthritis, juvenile RA, ankylosing spondylosis, Crohn's disease, plaque psoriasis, psoriatic arthritis, or ankylosing spondylitis Negative TB test (provided on an annual basis) Treatment failure with one or more DMARD (except Crohn's disease, ankylosing spondylitis and plaque psoriasis) Crohn's disease requires treatment failure with two or more conventional therapies Ankylosing spondylitis requires failure of at least 2 NSAIDs, intra-articular steroids, and sulfasalazine in patients with peripheral arthritis Plaque psoriasis affecting > 10% of BSA (unless hands, feet, head and neck, or genitalia) and a documented trial of one topical agent, one systemic treatment, AND phototherapy
Hyaluronic acid derivatives⁴ Preferred: Euflexxa (no PA required for Euflexxa) PA does not apply to Priority Health Medicare plans	J7323	Medical	Euflexxa: Treatment of osteoarthritis of the knee(s)	Diagnosis of osteoarthritis of the knee(s) Clinical trial and failure of at least two other pharmacologic therapies (NSAIDs, COX-2 selective NSAIDs, acetaminophen, IA corticosteroids, tramadol) Euflexxa is the preferred product. All other hyaluronic acid derivative products require a therapeutic trial and clinical failure with Euflexxa. Prior authorization is not required for Euflexxa
	J7321	Medical	Hyalgan or Supartz: Treatment of osteoarthritis of the knee(s) Length of authorization: 3-5 injections
	J7322	Medical	Synvisc or Synvisc One: Treatment of osteoarthritis of the knee(s) Length of authorization: 1-5 injections
	J7324	Medical	Orthovisc: Treatment of osteoarthritis of the knee(s) Length of authorization: 3-5 injections
	J7326	Medical	Gel-One: Treatment of osteoarthritis of the knee(s)
Ilaris (canakinumab)	J0638	Medical	Medical treatment of Familial Cold Autoinflammatory Syndrome (FCAS) and Muckle-Wells Syndrome (MWS) C-code billable by facility only	One of the following diagnoses: Cryopyrin-Associated Periodic Syndromes (CAPS): including Familial Cold Autoinflammatory Syndrome (FCAS) and Muckle-Wells Syndrome (MWS) in patients ≥ 4 years old.
Click the drug name to get the PA form	Code	Benefit	Use	Criteria for coverage
Increlex	J2170	Medical	Treatment of insulin-like growth factor-1 deficiency Length of authorization: 1 year	Diagnosis of severe primary insulin-like growth factor-1 deficiency or growth hormone gene deletion who have developed neutralizing antibodies to GH Must be evaluated by a pediatric endocrinologist
IVIG (immune globulin) - various brand names⁷	J1561	Medical	Gamunex	See PA form for covered indications
	J1566		Immune globulin, lyophilized (e.g., powder), 500 mg IV
	J1568		Injection, immune globulin (Octagam), intravenous, non-lyphilized (e.g. liquid), 500 mg
	J1569		Gammagard liquid
	J1572		Flebogamma
	90283		Immune globulin, 100 mg subcutaneous
	J1459		Privigen
	J1562/90284		Vivaglobin (SC1g), 100 mg, subcutaneous
	J1559		Hizentra
	J1557		Gammaplex
Jevtana (carbazitaxel)	J9043	Medical	Treatment of hormone-refractor metastatic prostate cancer	Diagnosis of hormone-refractory metastatic prostate cancer Prior use of a docetaxel-containing treatment regimen Serum prostate-specific antigen (PSA) ≥ 5 ng/mL Two sequential rising PSA levels obtained 2–3 weeks apart or other evidence of disease progression Eastern Cooperative Oncology Group (ECOG) performance status of 0-2 Serum testosterone < 50 ng/dL Jevtana will not be authorized for patients with any of the following: Congestive heart failure Myocardial infarction within the last 6 months Uncontrolled cardiac arrhythmias, angina pectoris, and/or hypertension ECOG performance status ≥ 3
Kineret (anakinra)³	J3490	Pharmacy	For treatment of moderate to severe symptoms of rheumatoid arthritis Length of initial authorization: 3 months Length of continuation authorization: 1 year	Diagnosis of moderate to severe rheumatoid arthritis Negative TB test (provided on an annual basis) Treatment failure with one or more DMARD Treatment failure with Enbrel
Krystexxa (pegloticase)	J2507	Medical	For treatment of chronic gout refractory to conventional therapy Length of initial authorization: 3 months Length of continuation authorization: 1 year	Symptomatic gout and has experienced three or more flares within the past 18 months Patient has at least one gout tophus or has gouty arthritis Therapeutic trial (at least 6 months) and clinical failure of conventional therapy Continuation requires SUA level ≤ 6 mg/dL
Lucentis (ranibizumab)⁶	J2778	Medical	Treatment of AMD and RVO	Documented therapeutic trial and clinical failure with Avastin (bevacizumab)
Macugen (pegaptinib)⁶	J2503	Medical	Treatment of AMD	Documented therapeutic trial and clinical failure with Avastin (bevacizumab)
Makena (hydroxyprogesterone caproate)⁷	J1725	Medical	Prevention of preterm birth	Not covered Compounded 17P (17 alpha-hydroxyprogesterone caproate) is covered, no PA required
Myobloc (Botulinum toxin type B)¹	J0587	Medical	Per 100 units; for treatment of cervical dystonia Length of authorization: 1 year, given as 1 injection every 3 months Injections must be separated by at least 90 days	See PA form for a list of covered indications Treatment for anal fissures and headache diagnoses require a clinical trial of conventional therapies See PA form for Medicare
Nplate (romiplostim)	J2796	Medical	For treatment of chronic immune (idiopathic) thrombocyctopenia (ITP) Starting Dose 1 mck/kg SC weekly. Median dose to achieve response: 2-3 mcg/kg weekly. (Max dose 10 mcg/kg weekly). Dose to achieve platelet count above 50 x 109/L (not to normal platelet levels). Length of initial authorization: 4 injections Length of continuation authorization: If platelet count increases to a level sufficient to avoid clinically important bleeding, approved for an additional 4 injections	Diagnosis of chronic immune (idiopathic) thrombocytopenic purpura (ITP) Patient has had an insufficient response to corticosteroids, immunoglobulins or splenectomy Current platelet count < 50 x 109/L with clinical risk of bleeding
Nulojix (belatacept)	C9286 J3590	Medical	For treatment of Hodgkins lymphoma and anaplastic large cell lymphoma	New kidney transplant (started Day 1 after transplant), given in combination with basiliximab induction, mycophenolate mofetil, and corticosteroids Seropositive for Epstein-Barr virus (EBV) Allergy or intolerance to tacrolimus and/or cyclosporine
Click the drug name to get the PA form	Code	Benefit	Use	Criteria for coverage
Orencia (abatacept)⁶	J0129	Medical	For treatment of moderate to severe symptoms of rheumatoid arthritis Length of initial authorization: 3 months Length of continuation authorization: 1 year	Diagnosis of moderate to severe rheumatoid arthritis Negative TB test (provided on an annual basis) Treatment failure with one or more self-injectable TNF antagonists (Enbrel, Humira) Patient must not have moderate to severe heart failure Cannot be used in combination with TNF antagonists or Kineret
PEG-Intron (interferon alpha 2b)³	S0148	Pharmacy	Hepatitis C Length of initial authorization: 3 months Length of continuation authorization: 3-9 months (dependent on genotype)	Diagnosis of chronic hepatitis C with liver disease No alcohol use within the past 6 months Cannot have decompensated liver disease Continued therapy will be approved if RNA titer is undetectable or < 100 times the original titer
Prolastin (alpha 1 proteinase inhibitor)	J0256	Medical	Alpha-antitrypsin deficiency	Diagnosis of congenital alpha 1-antitrypsin deficiency Clinically evident emphysema FEV1 30-65% predicted Serum AAT level < 11mM/L (< 60 mg/dL)
Prolia (denosumab)	J0897	Medical	Treatment of postmenopausal osteoporosis	Diagnosis of postmenopausal osteoporosis Documented therapeutic trial of alendronate (step 1) and Actonel (step 2)
Provenge (sipuleucel-T)⁷	Q2043	Medical	Treatment of advanced prostate cancer	Diagnosis of asymptomatic or minimally symptomatic metastatic castrate resistant (hormone refractory) prostate cancer Eastern Cooperative Oncology Group (ECOG) performance status of 0-1 Life expectancy greater than 6 months Serum prostate-specific antigen (PSA) ≥ 5 ng/mL Two sequential rising PSA levels obtained 2–3 weeks apart or other evidence of disease progression Serum testosterone < 50 ng/dL Prior use of docetaxel every 3 weeks and steroids (NCCN category 1 recommendation) Provenge will not be authorized for patients with any of the following: Requirement for systemic corticosteroid use Use of opioid analgesics for cancer-related pain Visceral metastases ECOG performance status ≥ 2 Pathologic long-bone fractures Spinal cord compression See PA form for Medicare
Qutenza (capsaicin 8% patch)	J7335	Medical	Post-herpetic neuralgia	Diagnosis of post-herpetic neuralgia Trial and failure of all of the following: Gabapentin Lyrica (requires step therapy with gabapentin) Generic tricyclic antidepressant (TCA) oxycodone CR or morphine CR Lidoderm Patch (requires prior authorization)
Click the drug name to get the PA form	Code	Benefit	Use	Criteria for coverage
Reclast (zoledronic acid)⁶	J3488	Medical	Per 1 mg; treatment of osteoporosis Length of authorization: 2 years, given as 1 infusion per year	Diagnosis of Paget's disease or postmenopausal osteoporosis (T-score < -2.5) Documented trial and failure with both Fosamax (alendronate) and Actonel
Remicade (infliximab)⁷	J1745	Medical	Per 10 mg; for treatment of rheumatoid arthritis, ankylosing spondylosis, Crohn's disease, ulcerative colitis, plaque psoriasis, psoriatic arthritis, or ankylosing spondylitis Length of initial authorization: 14 weeks Length of continuation authorization: 1 year (3 months for psoriasis)	Diagnosis of rheumatoid arthritis, ankylosing spondylosis, Crohn's disease, ulcerative colitis, plaque psoriasis, psoriatic arthritis, or ankylosing spondylitis Negative TB test (provided on an annual basis) Rheumatoid arthritis requires treatment failure with steroids and methotrexate Crohn's disease requires treatment failure with two or more conventional therapies Ankylosing spondylitis requires BASDAI of at least 4, failure of at least 2 NSAIDs, intra-articular steroids, and sulfasalazine in patients with peripheral arthritis Psoriatic arthritis requires treatment failure with one or more DMARD Ulcerative colitis requires therapeutic trial of conventional therapy Plaque psoriasis affecting > 10% of BSA (unless hands, feet, head and neck, or genitalia) and a documented trial of one topical agent, one systemic treatment, and phototherapy The following indications require treatment failure with a self-injectable anti-TNF agent (e.g. Enbrel, Humira, Raptiva): Rheumatoid arthritis Psoriatic arthritis Plaque psoriasis Crohn's disease Ankylosing spondylitis See PA form for Medicare
Remodulin (treprostinil sodium)	J3285	Medical	Per 1 mg; for treatment of pulmonary hypertension Length of initial authorization: 3 months Length of continuation authorization: 1 year	Diagnosis of pulmonary arterial hypertension Trial of Tracleer Trial of Flolan Completion of six-minute walk
Rituxan (rituximab)^5,7	J9310	Medical	10mg/mL Length of initial authorization: 3 months Length of continuation authorization	Treatment of Non-Hodgkins Lymphoma Treatment of CD20-expressing neoplasm (e.g. chronic lymphocytic leukemia, Waldenström macroglobulinemia, hairy cell leukemia, mantle cell lymphoma) Treatment of Thrombocytopenic purpura. One of the following is required: Patient did not respond to plasma exchange; Patient developed worsening disease in spite of continuing plasma exchange plus glucocorticoids; Patient has relapsing disease Treatment of Rheumatoid Arthritis. Requires one or more DMARDs AND prior use of self-injectable anti-TNF. See PA form for Medicare
Simponi (golimumab)	J3590	Pharmacy	Treatment of Ankylosing spondylitis, Psoriatic arthritis and Rheumatoid arthritis	Requires a trial and failure of preferred agents, Enbrel and Humira. (PA required for preferred agents)
Soliris (golimumab)	J1300	Medical	Treatment of paroxysmal nocturnal hemoglobinemia (PNH)	Diagnosis of paroxysmal nocturnal hemoglobinuria (PNH) Age ≥ 18 years At least four or more transfusions in the last 12 months Flow cytometric confirmation or at least 10% PNH cells Platelet counts at least 100,000/mm3 Meningococcal vaccinated at least 2 weeks before treatment initiation
Stelara (ustekinumab)	J3357	Medical	Treatment of moderate to severe plaque psoriasis	Moderate to Severe Plaque Psoriasis (BSA ≥10%) who are candidates for phototherapy or systemic therapy. Patient age ≥ 18 years Documented therapeutic trial of at one self-injectable biologic agent (Enbrel, Humira) Trial of topical, systemic and phototherapy for at least 3 months. Negative TB test (must be done yearly) Patient cannot take in combination with other biologics (Enbrel, Humira, Cimzia, Simponi, Remicade, Kineret, Amevive)
Synagis (palvizumab)	90378	Medical	Immune globulin for respiratory syncytial virus (RSV) Length of authorization: 5 infusions (given monthly November - March)	See PA form for complete details coverage information
Teflaro (ceftaroline fosamil)	J0712	Medical	Medical Treatment of CABP and ABSSSI	Diagnosis of community-acquired bacterial pneumonia (CABP) requires trial and failure with ceftriaxone Diagnosis of acute bacterial skin and skin structure infection requires trial and failure with vancomycin
Click the drug name to get the PA form	Code	Benefit	Use	Criteria for coverage
Tysabri (natalizumab)	J2323	Medical	Per 1 mg; for treatment of multiple sclerosis Length of authorization: Indefinite	Diagnosis of relapsing-remitting form of multiple sclerosis > 18 years of age Previous use of Copaxone Previous use of Interferon product
Vectibix (panitumumab)⁶	J9303	Medical	Treatment of advanced metastatic colorectal cancer Length of authorization: 4 injections	Documented negative KRAS mutation status for colorectal cancer Previous treatment with fluoropyridimine-containing chemo, oxaliplatin-containing chemo, or irinotecan-containing chemo
Vibativ (telavancin)	C9399 J3490	Medical	Treatment of complicated skin and skin structure infections	Diagnosis of suspected or confirmed MRSA Trial/failure with IV vancomycin (unless contraindicated)
Xeomin (incobotulinumtoxin A)¹	J0588	Medical	Per unit, for various neuro-muscular uses: see PA form for covered conditions Length of authorization: 1 injection Injections must be separated by at least 90 days	See PA form for a list of covered indications Treatment for anal fissures and headache diagnoses require a clinical trial of conventional therapies See PA form for Medicare
Xgeva (denosumab)	J0897	Medical	Treatment of metastatic breast and prostate cancer	Diagnosis of bone metastases. Documented therapeutic trial and clinical failure with Zometa® (not required if the patient has advanced breast or prostate cancer).
Xiaflex (collagenase clostridium histolyticum)	J0775	Medical	Treatment of adult Dupuytren's contracture	Diagnosis of Dupuytren's contracture Flexion contracture of at least one finger, other than the thumb, of ≥ 20 degrees at the MP or PIP joints Patient is free of a chronic muscular, neurological, or neuromuscular disorder affecting the hands Patient is not a candidate for surgical palmar fasciotomy
Xolair (omalizumab)^2,7	J2357	Medical or Pharmacy	Anti-IgE therapy for treating moderate to severe allergic asthma Length of initial authorization: 6 months Length of continuation authorization: 1 year	Diagnosis of allergic asthma requiring daily inhaled corticosteroids Compliant and persistent use of inhaled corticosteroids (75% adherence) Steroid dependency > 3 months, > 2 steroid bursts in last 12 months, or > 2 ED visits in last 12 months Positive perennial aeroallergen test IgE level 30-700 IU/ml > 12 years of age No tobacco use See PA form for Medicare
Yervoy (ipilimumab)	J9228	Medical	Treatment of unresectable or metastatic melanoma	Diagnosis of unresectable or metastatic melanoma Agreement to permanently discontinue Yervoy if the patient experiences any severe adverse reactions Prescriber must communicate directly, face-to-face, with patient to provide both verbal and printed materials regarding the safety risks associated with the use of Yervoy.
Zemaira (alpha 1 proteinase inhibitor)	J0256	Medical	Alpha-antitrypsin deficiency	Diagnosis of congenital alpha 1-antitrypsin deficiency Clinically evident emphysema FEV1 30-65% predicted Serum AAT level < 11mM/L (< 60 mg/dL)
Zevalin (ibritumomab tiuxetan)	A9543	Medical	Radioimmunotherapy; indicated for the treatment of relapsed or refractory low-grade, follicular, or transformed B-cell non-Hodgkin's lymphoma (NHL)	Diagnosis of relapsed or refractory low grade, follicular, or transformed B-cell non-Hodgkin's lymphoma or rituximab refractory follicular B-cell Hodgkin's lymphoma Platelet count > 100,000/mm3 < 25% bone marrow involvement Neutrophil count > 1500/mm3 Cannot have had prior myeloablative therapies with autologous bone marrow transplantation or peripheral stem cell collection Cannot have history of failed stem cell collection Cannot have history of prior external radiation to > 25% of active marrow
Zyvox IV	J2020	Medical	2mg/mL in 100, 200, and 300ml single use bags	Patient was started on Zyvox oral or IV in the hospital, or other inpatient setting and will be continuing therapy Patient has vancomycin-resistant Enterococcus faecium infection Patient has a documented methicillin-resistant staph aureus (MRSA) infection See PA form for complete details

Last modified: 12/29/2011

Provider Manual

Injectable drug list

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