Affected Medications: Lidocaine Patch Effective Date: 01/01/2014
Last Review Date: 04/08/2015
Covered Uses: All FDA approved indications not otherwise excluded by benefit design. Neuropathic pain
Required Medical Information:
Diagnosis of post-herpetic neuralgia: requires trial of gabapentin All medications tried/failed for indicated diagnosis
Appropriate Treatment
Regimen & Other Criteria:
Neuropathic pain:
Documented inadequate treatment response or intolerance to a minimum of 3 other pharmacologic therapies commonly used to treat neuropathic pain such as gabapentin, tricyclic antidepressants (TCAs), serotonin receptor inhibitors (SSRIs, SNRIs) Exclusion Criteria: Age Restriction: Prescriber Restrictions: Coverage Duration:
135 POLICY NAME:
LONSURF
Affected Medications: Trifluridine/Tipiracil Effective Date: 12/15/2015
Last Review Date: 11/11/2015
Covered Uses: All FDA-approved indications not otherwise excluded by plan design. NCCN indications with evidence level of 2A or higher
Required Medical Information:
Documentation of performance status, disease staging, all prior therapies used, planned treatment course, and KRAS/NRAS mutation status
Documentation of progression with at least 2 lines of standard therapies includes: fluoropyrimidine-, oxaliplatin-, and irinotecan-based chemotherapy, an anti-VEGF biological therapy, and if RAS wild-type and an anti-EGFR therapy
Documentation of complete blood counts (CBC) will be monitored at baseline and throughout therapy
Appropriate Treatment
Regimen & Other Criteria:
Reauthorization requires documentation of disease responsiveness to therapy
Exclusion Criteria: Consider holding therapy if Karnofsky Performance Status ≤50% or ECOG performance score ≥3 Age Restriction: Prescriber Restrictions: Oncologist Coverage Duration:
Initial approval: 3 months
136 POLICY NAME:
LYNPARZA
Affected Medications: LYNPARZA (olaparib) Effective Date: 03/08/2015
Last Review Date: 10/14/2015
Covered Uses: All FDA approved indications not otherwise excluded by benefit design. NCCN indications with evidence level of 2A or higher
Required Medical Information:
Documentation of disease staging, all prior therapies used, and anticipated treatment course AND
Documentation of CYP3A4 inhibitor medication being taken (ex. telithromycin, clarithromycin, ketoconazole, voriconazole, nefazodone, ritinovir) AND
Documentation of ECOG performance status of 1 or 2 OR Karnofsky performance score greater than 50%
Advanced ovarian cancer
Documentation of BRCA status AND
Documentation of confirmed deleterious germline BRCA mutated advanced ovarian cancer with progression on 3 or more prior chemotherapies
Appropriate Treatment
Regimen & Other Criteria:
Appropriate dose reduction if using with CYP3A4 inhibitors
Reauthorization: documentation of disease responsiveness to therapy
Exclusion Criteria:
Age Restriction:
Prescriber Restrictions:
Oncologist
Coverage Duration: Initial: 3 months
137 POLICY NAME:
LYRICA
Affected Medications: LYRICA (pregabalin) Effective Date: 04/01/2010
Last Review Date: 08/07/2015
Covered Uses: All FDA approved indications not otherwise excluded by benefit design. Required Medical
Information:
Initial approval requires documented failure, intolerance, or clinical rationale for avoidance to the following:
Neurontin (gabapentin)
Appropriate Treatment Regimen & Other
Criteria:
Subsequent approval requires documentation of treatment success.
Exclusion Criteria: Prior intolerance or allergic reaction to requested medication Age Restriction:
Prescriber Restrictions:
138 POLICY NAME:
MAKENA
Affected Medications: MAKENA (Hydroxyprogesterone Caproate) *Brand Name only (J1725) Effective Date: 08/01/2011
Last Review Date: 06/8/2011
Covered Uses: All FDA approved indications not otherwise excluded by benefit design. Required Medical
Information:
Singleton pregnant patient
history of singleton spontaneous preterm birth (<37 weeks) Appropriate Treatment
Regimen & Other Criteria:
Initial approval requires documented failure, intolerance, or clinical rationale for avoidance to one of the following:
Generic 17 alpha hydroxyprogesterone Vaginal progesterone
Exclusion Criteria: Current or history of any of the following:
multiple gestations or other risk factors for preterm birth. Thrombosis or thromboembolic disorders
Known or suspected breast cancer or other hormone-sensitive cancer, or history of these conditions
Undiagnosed abnormal vaginal bleeding unrelated to pregnancy Cholestatic jaundice of pregnancy
Liver tumors, benign or malignant, or active liver disease Uncontrolled hypertension.
Age Restriction: ≥ 16 years of age Prescriber Restrictions:
139 POLICY NAME:
MEKINIST
Affected Medications: MEKINIST (trametinib) Effective Date: 09/01/2014
Last Review Date: 05/13/2015
Covered Uses: All FDA approved indications not otherwise excluded by benefit design. NCCN indications with evidence level of 2A or higher
Required Medical Information:
Documentation of performance status, all prior therapies used, and prescribed treatment regimen
Documentation that Mekinist is being used as a NCCN 2A level of evidence regimen
Documentation of BRAF V600 mutant
Appropriate Treatment Regimen & Other Criteria:
Reauthorization requires documentation of treatment success Exclusion Criteria: Karnofsky Performance Status ≤50% or ECOG performance score ≥3 Age Restriction:
Prescriber Restrictions: Oncologist
Coverage Duration: Initial approval: 3 months Reauthorization: 12 months
140 POLICY NAME:
MOZOBIL
Affected Medications: MOZOBIL (plerixafor) (J2562) Effective Date: 01/01/2014
Last Review Date: 08/12/2015
Covered Uses: All FDA-approved indications and doses not otherwise excluded by plan design. Required Medical
Information:
Patient diagnosed with either non-Hodgkin’s lymphoma or multiple myeloma. Appropriate
Treatment
Regimen & Other Criteria:
Mozobil will be used to mobilize hematopoietic stem cells for collection prior to autologous transplantation and used in combination with granulocyte- colony stimulating factor (G-CSF)
Patient must have received C-CSF for four days prior to starting Mozobil Dosing: 0.24 mg/kg given subcutaneously
Exclusion Criteria: Age Restriction: Prescriber Restrictions:
141 POLICY NAME: