SilverScript: A CaremarkRx Company

Drugs: Atralin Gel, Avita Cream, Avita Gel, Retin-A Cream, Retin-A Gel, Retin-A Micr Gel, Tretinoin Cream, Tretinoin Gel
Covered Uses: Acne vulgaris, keratosis follicularis (Darier's disease, Darier-White disease)
Exclusion Criteria: Cosmetic use
Required Medical Information:
Age Restrictions: Approve for those 12 years of age and older
Prescriber Restrictions:
Coverage Duration: 12 months
Other Criteria:

Drugs: Adderall, Adderall Xr, Amphetamine, Desoxyn, Dexedrine, Dexedrine Cr, Dextroamphetamine, Dextroamphetamine Cr, Dextrostat, Liquadd, Vyvanse
Covered Uses: ADHD, narcolepsy
Exclusion Criteria: MAOI concurrent use or within the last 14 days
Required Medical Information: Sleep studies for narcolepsy diagnosis
Age Restrictions: Approve for those 3 years of age and older
Prescriber Restrictions:
Coverage Duration: 12 months
Other Criteria: Monitor for weight loss, decreased growth velocity in children, increased heart rate and blood pressure, appearance or worsening of aggressive behavior or hostility, sleep disturbances and long-term usefulness of the drug

Drugs: Aranesp
Covered Uses: Anemia associated with chronic renal failure (CRF), including patients on dialysis and patients not on dialysis. Anemia in patients with non-myeloid malignancies where anemia is due to the effect of concomitantly administered chemotherapy.
Exclusion Criteria: CRF - transferrin saturation less than 20% and patient not receiving iron supplementation where clinically appropriate. CRF and anemia in patients with non-myeloid malignancies - hemoglobin level of the patient (not the result of a recent blood transfusion) greater than 13 g/dL. Lack of initial diagnosis of anemia (hematocrit less than 30% and/or hemoglobin less than 10 g/dL and/or symptomatic with hemoglobin 10-11g/dL).
Required Medical Information: CRF - iron status of the patient has been evaluated (serum transferrin saturation). CRF and anemia of cancer - Hemoglobin level of the patient be monitored prior to each dose when initiating therapy, for dose changes, and at regular intervals when the dose is stabilized. Hemoglobin level of the patient will be monitored prior to each dose when initiating therapy, for dose changes, and at regular intervals when the dose is stabilized. Blood pressure of the patient will be monitored throughout therapy. Patient will be monitored for the occurrence of thrombotic events.
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: Initiation of therapy and/or dose changes - 6 weeks. Stable on therapy - 12 weeks.
Other Criteria: Once on therapy, compared to pretreatment baseline, the patient must show an objective clinical response (e.g., hemoglobin rise greater than 1 g/dL and/or hematocrit rise greater than 3%) to an appropriate dose/dose increase and duration of therapy.

Drugs: Accuneb, Acetylcysteine, Albuterol Sulfate, Albuterol Sulfate/Ipratropium Bromide, Aminess, Aminosyn, Anzemet, Azasan, Azathioprine, Brovana, Carimune Nanofiltered, Cellcept, Cesamet, Chorionic Gonadotropin, Climimix, Clinisol Sf 15%, Cromolyn Sodium, Cyclophosphamide, Cyclosporine, Cyclosporine Modified, Cytoxan, Decavac, Diptheria/Tetanus Toxoid Pediatric, Duoneb, Emend, Engerix-B, Flebogamma, Freamine, Gammagard Liquid, Gamunex, Gengraf, Granisetron Hcl, Granisol, Hepatamine, Hepatasol, Imuran, Intal, Intralipid, Intralipid 20%, Ipratropium Bromide, Iveegam En, Kytril, Metaproterenol Sulfate, Myfortic, Nebupent, Neoral, Nephramine, Novamine, Novarel, Octagam, Ondansetron Hcl, Ondansetron Odt, Panglobulin, Panglobulin Nf, Perforomist, Polygam S/D, Pregnyl W/Diluent Benzyl Alcohol/Nacl, Premasol, Procalamine, Prograf, Prosol, Pulmicort, Pulmozyme, Rapamune, Recombivax Hb, Renamin, Sandimmune, Tetanus Toxoid Adsorbed, Tetanus/Diphtheria Toxoids-Adsorbed Adult, Tobi, Travasol, Trexall, Trophamine, Ventavis, Xopenex, Xopenex Concentrate, Zofran, Zofran Odt
Covered Uses: This drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination.
Exclusion Criteria:
Required Medical Information:
Age Restrictions:
Prescriber Restrictions:
Coverage Duration:
Other Criteria:

Drugs: Celebrex
Covered Uses: Juvenile Rheumatoid Arthritis (JRA), Familial Adenomatous Polyposis (FAP), primary dysmenorrhea, acute pain, osteoarthritis (OA), rheumatoid arthritis (RA), ankylosing spondylitis (AS)
Exclusion Criteria: Cardiovascular disease, post-operative pain following CABG surgery, allergic-type reaction to aspirin, NSAIDs, or sulfonamides
Required Medical Information: Evaluation of cardiovascular disease or risk factors for cardiovascular disease
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: 6 months for FAP and JRA, 12 months for dysmenorrhea, OA, RA, AS, 1 month for acute pain
Other Criteria: For all diagnoses except FAP, patient must not be at risk for a severe NSAID-induced GI adverse event such as an NSAID associated gastric ulcer GI, or not taking a gastrointestinal (GI) medication indicating an existing GI condition, or is taking the gastrointestinal medication for clinical reasons unrelated to the use of Celebrex or to prevent/treat an NSAID associated gastric ulcer

Drugs: Differin
Covered Uses: Acne vulgaris
Exclusion Criteria: Cosmetic use
Required Medical Information:
Age Restrictions: Approve for those 12 years of age and older
Prescriber Restrictions:
Coverage Duration: 12 months
Other Criteria:

Drugs: Enbrel
Covered Uses: Rheumatoid arthritis, juvenile rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, plaque psoriasis, reactive arthritis, inflammatory bowel disease arthritis
Exclusion Criteria: Patient must be evaluated for latent TB with a PPD test and be treated if positive. Patients are excluded if they have an active infection or on are on concurrent biologic response modifier. Patient must also be assessed for the risk of hepatitis B and if appropriate, be tested.
Required Medical Information: RA/JRA - patient must demonstrate inadequate response to at least 1 DMARD or intolerance to multiple DMARDs. Psoriasis - patient must be a candidate for systemic therapy or phototherapy. Ankylosing spondylitis - patient must demonstrate inadequate response to at least 2 NSAIDs or intolerance to multiple NSAIDs. If the ankylosing spondylitis is predominantly peripheral arthritis, patient must demonstrate an inadequate response or intolerance to sulfasalazine. Reactive arthritis - patient must demonstrate inadequate response or intolerance to at least 2 NSAIDs, intra-articular steroid injections, sulfasalazine, if indicated. IBDA - patient has to be refractory to standard therapies.
Age Restrictions: Psoriasis - Approve for those 18 years of age or older
Prescriber Restrictions:
Coverage Duration: 12 months
Other Criteria:

Drugs: Epogen, Procrit
Covered Uses: All FDA-approved indications not otherwise excluded from Part D, Anemia associated with chronic renal failure (CRF), including patients on dialysis [end-stage renal disease (ESRD)] and patients not on dialysis. Anemia related to therapy with zidovudine in HIV-infected patients. Anemia in patients with non-myeloid malignancies where anemia is due to the effect of concomitantly administered chemotherapy. Anemia associated with myelodysplastic syndromes. Anemia of chronic disease. Anemia associated with management (Ribavirin with interferon alfa or peginterferon alfa) of hepatitis C, reduction of allogenic blood transfusion in surgery patients (elective, non-cardiac, nonvascular)
Exclusion Criteria: CRF, Hepatitis C, elective surgery, HIV/zidovudine - transferrin saturation less than 20% and patient not receiving iron supplementation where clinically appropriate. CRF, Hepatitis C, elective surgery, HIV/zidovudine, MDS, and anemia in patients with non-myeloid malignancies - hemoglobin level of the patient (not the result of a recent blood transfusion) greater than 13 g/dL. Lack of initial diagnosis of anemia (hematocrit less than 30% and/or hemoglobin less than 10 g/dL and/or symptomatic with hemoglobin 10-11g/dL).
Required Medical Information: CRF, Hepatitis C, elective surgery, HIV/zidovudine - iron status of the patient has been evaluated (serum transferrin saturation). CRF, Hepatitis C, elective surgery, HIV/zidovudine, and anemia of cancer - Hemoglobin level of the patient be monitored prior to each dose when initiating therapy, for dose changes, and at regular intervals when the dose is stabilized. Hemoglobin level of the patient will be monitored prior to each dose when initiating therapy, for dose changes, and at regular intervals when the dose is stabilized. Blood pressure of the patient will be monitored throughout therapy. Patient will be monitored for the occurrence of thrombotic events.
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: Initiation of therapy and/or dose changes - 6 weeks. Stable on therapy - 12 weeks.
Other Criteria: Once on therapy, compared to pretreatment baseline, the patient must show an objective clinical response (e.g., hemoglobin rise greater than 1 g/dL and/or hematocrit rise greater than 3%) to an appropriate dose/dose increase and duration of therapy.

Drugs: Genotropin, Humatrope, Iplex, Norditropin, Nutropin, Nutropin Aq, Saizen, Serostim, Tev-Tropin
Covered Uses: Growth failure in pediatric patients due to inadequate secretion of normal endogenous growth hormone whose epiphyses are not closed, treatment of short stature associated with Turner syndrome, growth failure due to Prader-Willi syndrome, growth failure in children born small for gestational age who fail to manifest catchup growth by 2 years of age, adult patients with growth hormone deficiency either alone or associated with multiple hormone deficiencies (hypopituitarism) as a result of pituitary disease, hypothalamic disease, surgery, radiation therapy or trauma, or who were growth hormone deficient during childhood as a result of congenital, genetic, acquired, or idiopathic causes, idiopathic short stature, short stature or growth failure in children with SHOX (short stature homeobox-containing gene) deficiency whose epiphyses are not closed, children with short stature associated with Noonan syndrome, short stature associated with chronic renal insufficiency up to the time of renal transplantation, treatment of adult AIDS patients with cachexia.
Exclusion Criteria: Severe respiratory impairment or sleep apnea (Prader-Willi syndrome)
Required Medical Information: Growth hormone stimulation tests
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: 6 months
Other Criteria:

Drugs: Humira
Covered Uses: Rheumatoid arthritis, juvenile idiopathic arthritis, psoriatic arthritis, ankylosing spondylitis, Crohn's disease, Plaque psoriasis
Exclusion Criteria: Patients are excluded if they have an active infection or on are on concurrent biologic response modifier.
Required Medical Information: Patient must be evaluated for latent TB with a PPD test and be treated if positive. Patient must also be assessed for the risk of hepatitis B and if appropriate, be tested.
Age Restrictions: Rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, Crohn's disease, plaque psoriasis - Approve for those 18 years of age or older
Prescriber Restrictions:
Coverage Duration: 12 months
Other Criteria: RA/JIA - patient must demonstrate inadequate response to at least 1 DMARD or intolerance to multiple DMARDs. Psoriasis - patient must be a candidate for systemic therapy or phototherapy. Ankylosing spondylitis - patient must demonstrate inadequate response to at least 2 NSAIDs or intolerance to multiple NSAIDs. If the ankylosing spondylitis is predominantly peripheral arthritis, patient must demonstrate an inadequate response or intolerance to sulfasalazine. Crohn's disease - patient must demonstrate an inadequate response to conventional therapy or Remicade.

Drugs: Increlex
Covered Uses: Long-term treatment of growth failure in children with severe primary insulin-like growth factor-1 (IGF-1) deficiency (Primary IGFD) or with growth hormone (GH) gene deletion who have developed neutralizing antibodies to GH.
Exclusion Criteria: Closed epiphyses. Other secondary causes of growth failure. Pre-existing thyroid and/or nutritional deficits. Presence of active or suspected neoplasia.
Required Medical Information: Failure of a growth hormone stimulation test. Genetic testing for growth hormone gene deletion. Lab testing for neutralizing antibodies to growth hormone.
Age Restrictions: Approve for those 2 years of age or older
Prescriber Restrictions:
Coverage Duration: 12 months
Other Criteria: Height of the patient greater than or equal to 3 standard deviations below the norm for children of the same age and gender prior to beginning Increlex therapy. Basal IGF-1 level greater than or equal to 3 standard deviations below the norm for children of the same age and gender prior to beginning Increlex therapy. Increase in height velocity of 2 cm/year within the first year of Increlex therapy.

Drugs: Infergen
Covered Uses: Chronic hepatitis C
Exclusion Criteria:
Required Medical Information: Patient must have compensated liver disease with detectable levels of hepatitis C virus RNA in the serum
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: 3 to 9 months depending on genotype and initial vs. renewal therapy
Other Criteria: 2-log decrease in viral load for renewals

Drugs: Itraconazole, Sporanox Caps
Covered Uses: All FDA-approved indications not otherwise excluded from Part D. Onychomycosis due to dermatophytes (2 months for onychomycosis of fingernails only or 3 months for onychomycosis if toenail involvement), Recalcitrant or very severe disfiguring or disabling infections caused by one of the following that is unresponsive to griseofulvin or topical antifungals (1 month for pityriasis versicolor, tinea corporis, tineas crutis, tinea pedis) and for 6 months in severe fungal infections caused by Blastomycosis, Histoplasmosis, Aspergillosis (in patients who are intolerant of or who are refractory to amphotericin B therapy) Basidiobolomycosis, Chromomycosis, Coccidioidomycosis, Cryptococcosis, Cryptococcal Meningitis (treatment or suppression), Chronic Mucocutaneous Candidiasis, Histoplasmosis suppression in immunocompromised patients, Leishmaniasis (cutaneous treatment), Paracoccidioidomycosis, Paronychia, Penicillium marneffei in adults, Fungal pneumonia and septicemia treatment, Sporotrichosis disseminated (treatment), Tinea manuum, Vulvovaginal Candidiasis
Exclusion Criteria: Congestive heart failure, history of congestive heart failure, evidence of left ventricular dysfunction, For onychomycosis only: no diabetes mellitus, peripheral vascular disease, or redness and swelling in surrounding tissue
Required Medical Information: LFTs, fungal diagnostic test (e.g., KOH preparation, fungal culture, or nail biopsy)
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: 1, 2, 3, or 6 months depending on the diagnosis (see duration in parentheses in covered uses)
Other Criteria:

Drugs: Kineret
Covered Uses: Rheumatoid arthritis
Exclusion Criteria: Active infection or concurrent use of a TNF blocking agent.
Required Medical Information:
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: 12 months
Other Criteria: Patient must demonstrate inadequate response to at least 1 DMARD or intolerance to multiple DMARDs.

Drugs: Concerta, Daytrana, Dexmethylphenidate, Focalin, Focalin Xr, Metadate Er, Metadate Cd, Methylin, Methylin Er, Methylphenidate, Ritalin, Ritalin La, Ritalin Sr
Covered Uses: All FDA-approved indications not otherwise excluded from Part D
Exclusion Criteria: MAOI concurrent use or within the last 14 days
Required Medical Information: Sleep studies for narcolepsy diagnosis
Age Restrictions: Approved for those 6 years of age or older
Prescriber Restrictions:
Coverage Duration: 12 months
Other Criteria: Monitor for weight loss, decreased growth velocity in children, increased heart rate and blood pressure, appearance or worsening of aggressive behavior or hostility, sleep disturbances and long-term usefulness of the drug

Drugs: Neulasta
Covered Uses: To decrease the incidence of infection, as manifested by febrile neutropenia, in patients with non-myeloid malignancies receiving myelosuppressive anti-cancer drugs associated with a clinically significant incidence of febrile neutropenia.
Exclusion Criteria: Neulasta treatment within the last 14 days. Treatment of acute afebrile neutropenia.
Required Medical Information: Current and periodic monitoring of WBC count at initiation of and during therapy.
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: 6 months
Other Criteria: Neulasta administration will be delayed a minimum of 24 hours after the administration of cytotoxic chemotherapy.

Drugs: Neumega
Covered Uses: Prevention of severe thrombocytopenia and the reduction of the need for platelet transfusions following myelosuppressive chemotherapy in adult patients with nonmyeloid malignancies who are at high risk of severe thrombocytopenia.
Exclusion Criteria:
Required Medical Information: Patient's renal function above or below 30 mL/min for dosage adjustment. Any cardiovascular/fluid comorbidities for monitoring of fluid status (if applicable).
Age Restrictions: Approved for those 18 years of age or older
Prescriber Restrictions:
Coverage Duration: 3 months
Other Criteria: Treatment not to exceed 21 days per treatment course. Treatment to be discontinued at least two days prior to starting next round of chemotherapy. Discontinue therapy when post-nadir platelet count (not the result of recent platelet transfusions) is greater than 50,000/µL.

Drugs: Leukine, Neupogen
Covered Uses: Following Induction chemotherapy in acute myelogenous leukemia. Mobilization and following transplantation of autologous peripheral blood progenitor cells (PBPC). Myeloid reconstitution after autologous bone marrow transplantation. Bone marrow transplantation failure or engraftment delay. Cancer patients receiving myelosuppressive chemotherapy. Patients with acute myeloid leukemia (AML) receiving induction or consolidation chemotherapy. Cancer patients receiving bone marrow transplant (BMT). Patients undergoing peripheral blood progenitor cell (PBPC) collection and therapy. Patients with severe chronic neutropenia (SCN). Chemotherapy-induced neutropenia. Neutropenia, AIDS associated with treatment or disease. Myelodysplastic syndromes. Drug-induced neutropenia.
Exclusion Criteria: Treatment of acute afebrile neutropenia. Patients not at at high risk for infection-associated complications or not having prognostic factors that are predictive of poor clinical outcomes.
Required Medical Information: Current and periodic monitoring of WBC count at initiation of and during therapy.
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: 3 months
Other Criteria: Treatment to be halted in the event of excessive leukocytosis.

Drugs: Octreotide, Sandostatin
Covered Uses: Acromegaly, Carcinoid tumor, Vasoactive intestinal peptide tumors (VIPomas)
Exclusion Criteria:
Required Medical Information:
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: 12 months
Other Criteria:

Drugs: Orencia
Covered Uses: All FDA-approved indications not otherwise excluded from Part D
Exclusion Criteria: Patients are excluded if they are on concurrent biologic response modifier.
Required Medical Information: Patient must be evaluated for latent TB with a PPD test and be treated if positive.
Age Restrictions: Approved for those 6 years of age or older
Prescriber Restrictions:
Coverage Duration: 12 months
Other Criteria: Patient must demonstrate inadequate response to at least 1 DMARD or a TNF blocking agent.

Drugs: Forteo
Covered Uses: Primary osteoporosis, hypogonadal osteoporosis
Exclusion Criteria: Paget's disease, unexplained elevation of alkaline phosphatase, open epiphyses, bone cancer or cancer that has metastasized to the bone, history of breat cancer, prior radiation therapy involving the skeleton, hypercalcemia, treatment with Forteo for greater than or equal to 24 months, concurrent bisphosphonate therapy during treatment with Forteo
Required Medical Information:
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: 12 months
Other Criteria: For diagnosis of primary osteoporosis or hypogonadal osteoporosis patient must have at least one of the following: history of osteoporotic fractures, multiple risk factors for fractures, OR has failed or is intolerant to traditional osteoporosis therapy

Drugs: Pegasys
Covered Uses: Chronic hepatitis C, Chronic hepatitis B
Exclusion Criteria:
Required Medical Information: For chronic hepatitis C, patient must have compensated liver disease with detectable levels of HCV RNA in the serum. For chronic hepatitis B, patient must have a positive serum marker for HBV replication, persistently elevated aminotransferase levels greater than 2 times ULN, or signs of chronic hepatitis B on liver biopsy, or cirrhosis of the liver as evidenced by radiological or clinical data, or extrahepatic complications.
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: Chronic hepatitis C - 3 to 9 months. Chronic hepatitis B - 12 months.
Other Criteria: For chronic hepatitis C, patient must have 2-log decrease in viral load for renewals.

Drugs: Pegintron
Covered Uses: Chronic hepatitis C
Exclusion Criteria:
Required Medical Information: Patient must have compensated liver disease with detectable levels of hepatitis C virus RNA in the serum
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: 3 to 9 months depending on genotype and initial vs. renewal therapy
Other Criteria: 2-log decrease in viral load for renewals

Drugs: Provigil
Covered Uses: Narcolepsy, obstructive sleep apnea/hypopnea (OSAHS), Shift work sleep disorder
Exclusion Criteria:
Required Medical Information: Polysomnography required for narcolepsy and OSAHS
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: 12 months
Other Criteria:

Drugs: Revatio
Covered Uses: Pulmonary arterial hypertension (PAH)
Exclusion Criteria: Concurrent nitrate therapy. PAH associated with any of the following: left heart disease, chronic thrombotic disease, embolic disease, compression of pulmonary vessels, lung diseases, hypoxemia, sarcoidosis
Required Medical Information:
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: 12 months
Other Criteria:

Drugs: Revlimid
Covered Uses: Multiple myeloma (MM) and transfusion dependent anemia due to Low- or Intermediate-1-risk myelodysplastic syndromes (MDS) associated with a deletion 5q cytogenetic abnormality
Exclusion Criteria: Pregnancy
Required Medical Information: If female of child bearing potential, pregnancy excluded by 2 negative urine or serum pregnancy tests. For MM requirement of combination therapy with dexamethasone and at least one prior MM treatment. For MDS: diagnosis of anemia due to Low- or Intermediate-1-risk MDS associated with a deletion 5q cytogenetic abnormality, transfusion dependent
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: 12 months
Other Criteria: Instruction regarding importance and proper utilization of appropriate contraceptive methods. Monitor CBC on regular basis.

Drugs: Copegus, Rebetol, Ribapak, Ribasphere, Ribatab, Ribavirin
Covered Uses: Chronic hepatitis C
Exclusion Criteria: History of unstable heart disease, hemoglobin less than 8.5, creatinine clearance less than 50, pregnancy, hemoglobinopathy.
Required Medical Information: Patient must have detectable levels of HCV RNA in the serum and be on an alfa interferon product concurrently.
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: 4 to 8 months, depending on genotype and initial vs. renewal therapy.
Other Criteria: 2-log decrease in viral load for renewals

Drugs: Sandostatin Lar
Covered Uses: Acromegaly, Carcinoid tumor, Vasoactive intestinal peptide tumors (VIPomas)
Exclusion Criteria:
Required Medical Information: Patient had prior therapy with sandostatin injection (not depot form) and treatment was effective and tolerated.
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: 12 months
Other Criteria:

Drugs: Serostim
Covered Uses: Treatment of human immunodeficiency virus (HIV) patients with wasting or cachexia to increase lean body mass and body weight, and improve physical endurance. Concomitant antiretroviral therapy is necessary.
Exclusion Criteria: Weight loss less than 10% of body weight. Body Mass Index (BMI) greater than 18.5. Other causes of weight loss such as inadequate nutritional intake, malabsorption, opportunistic infections, or hypogonadism.
Required Medical Information: BMI, patient weight.
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: 12 weeks
Other Criteria: Continuation of prescribed HIV (anti-viral) therapy.

Drugs: Somatuline
Covered Uses: Acromegaly
Exclusion Criteria:
Required Medical Information:
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: 12 months
Other Criteria: Either surgery and/or radiotherapy is not a therapeutic option for the patient or the patient has had inadequate response to surgery and/or radiotherapy

Drugs: Somavert
Covered Uses: Acromegaly
Exclusion Criteria:
Required Medical Information: Monitor IGF-1 levels at 6 month intervals after IGF-1 levels stabilize within normal range. Monitor LFTs as recommended during therapy.
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: 12 months
Other Criteria: Prior to initiation of therapy IGF-1 levels were above age and gender adjusted normal range. If patient has been on therapy for the past 6 months demonstration of significant decrease in IGF-1 levels required. Patients were considered for/received treatment with surgery, radiation therapy, or medical treatment for acromegaly but rejected as inappropriate or had inadequate response.

Drugs: Oxandrin, Oxandrolone
Covered Uses: All FDA-approved indications not otherwise excluded from Part D
Exclusion Criteria: liver disease, abnormal blood lipids, renal disease, atherosclerosis, hypercalcemia, pregnancy, prostate cancer, breast cancer, warfarin therapy
Required Medical Information:
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: 6 months
Other Criteria:

Drugs: Androderm, Androgel, Striant, Testim
Covered Uses: Primary hypogonadism (congenital or acquired), hypogonadotropic hypogonadism (e.g., idiopathic gonadotropin or LHRH deficiency)
Exclusion Criteria: Female, prostate cancer, breast cancer
Required Medical Information: Before the start of testosterone therapy patient has (or patient currently has) a confirmed low testosterone level (i.e. total testosterone less than 300 ng/dL, free or bioavailable, testosterone less than 5 ng/dL) or absence of endogenous testosterone
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: 12 months
Other Criteria:

Drugs: Thalomid
Covered Uses: Newly diagnosed or advanced, refractory multiple myeloma (MM), moderate to severe erythema nodosum leprosum (ENL)
Exclusion Criteria: Pregnancy
Required Medical Information: If female of child bearing potential, pregnancy excluded by 2 negative urine or serum pregnancy tests. For MM requirement of combination therapy with dexamethasone. For ENL if have moderate to severe neuritis Thalomid can not be used as monotherapy.
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: 12 months
Other Criteria: Instruction regarding importance and proper utilization of appropriate contraceptive methods.

Drugs: Regranex
Covered Uses: Diabetic neuropathic ulcer of the lower extremity
Exclusion Criteria: Neoplasm at intended site of application, active wound infection not under control by way of active treatment
Required Medical Information: Ulcer size after 10 weeks of therapy, does ulcer have adequate blood supply, ulcer extending into subcutaneous tissue or beyond
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: 3 months, then additional 2 months upon renewal
Other Criteria:

Drugs: Zorbtive
Covered Uses: Treatment of Short Bowel Syndrome in patients receiving specialized nutritional support. Zorbtive therapy should be used in conjunction with optimal management of Short Bowel Syndrome.
Exclusion Criteria: Recently diagnosed or recurrent active neoplasia.
Required Medical Information: Tracking of patient weight for continuation/reapproval of therapy.
Age Restrictions:
Prescriber Restrictions:
Coverage Duration: 4 weeks
Other Criteria: Patient is currently receiving and will continue to receive any one or a combination of the following specialized nutritional support: high complex-carbohydrate, low-fat diet, TPN, IPN, PPN, rehydration solutions, electrolyte replacement.