Plan Year 2014 MercyCare Medicare Advantage Prior Authorization (PA) Criteria Prior Authorization: MercyCare Medicare Advantage requires you (or your physician) to get prior authorization for certain drugs. This means that you will need to get approval from MercyCare Medicare Advantage before you fill your prescriptions. If you don’t get approval MercyCare Medicare Advantage may not cover the drug. PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT OUR PRIOR AUTHORIZATION CRITERIA.
MercyCare Health Plans is an HMO-POS plan with a Medicare contract.
MercyCare Health Plans is an HMO plan with a Medicare and Wisconsin Medicaid contract.
Enrollment in MercyCare Health Plans depends on contract renewal.
2014 Mercy Care Medicare Advantage Formulary Products Affected PA Criteria Criteria Details
All FDA-approved indications not otherwise excluded from Part D
Patient must have tried and failed metformin.
Hemoglobin A1C greater than or equal to 7% within three months preceding Bydureon initiation. Products Affected PA Criteria Criteria Details
All FDA-approved indications not otherwise excluded from Part D
Hemoglobin A1C greater than or equal to 7% within three months preceding Byetta initiation. Products Affected PA Criteria Criteria Details
All FDA-approved indications not otherwise excluded from Part D
Restricted to rheumatology and gastroenterology
If diagnosis is rheumatoid arthritis, must have failure or intolerance to methotrexate. Products Affected PA Criteria Criteria Details
All FDA-approved indications not otherwise excluded from Part D
Requires diagnosis of non-valvular atrial fibrillation AND a CHADS2 score of 1 or higher. Listed below is the CHADS2 scoring tool which indicates the Risk Factor and associated score: Congestive heart failure (score = 1) Hypertension (score = 1) Age greater than or equal to 75 years (score = 1) Diabetes mellitis (score = 1) Stroke / Transient Ischemia Attack (score = 2)
Excluded if meets one or more of the following: 1) Heart valve disorder (e.g., prosthetic heart valve, valvular disease requiring surgery, moderate or severe mitral stenosis) 2) Severe renal impairment (estimated creatinine clearance less than 25 mL/min or on dialysis) 3) Severe hepatic impairment (e.g., LFT elevation greater than 2x ULN, total bilirubin greater than 1.5x ULN) 4) Active pathological bleeding
Products Affected PA Criteria Criteria Details
All FDA-approved indications not otherwise excluded from Part D
If diagnosis is plaque psoriasis, must have moderate to severe plaque psoriasis affecting greater than 5% of the body surface area (BSA) or affecting crucial body areas such as the hands, feet, face or genitals.
Restricted to rheumatology and dermatology
If diagnosis is rheumatoid arthritis, must have failure or intolerance to methotrexate. If diagnosis is plaque psoriasis, must have failure of at least two of the following: potent topical corticosteroids, calcipotriene, tazarotene, phototherapy, acitretin, methotrexate, or cyclosporine. Products Affected PA Criteria Criteria Details
All FDA-approved indications not otherwise excluded from Part D
Serum ferritin level greater than 1,000 mcg/L
Considered as initial therapy for patients with chronic iron overload due to blood transfusions
Products Affected PA Criteria Criteria Details
All FDA-approved indications not otherwise excluded from Part D
For use as first-line therapy: Documentation of osteoporotic fractures AND a T-score of less than -3.0 in the spine, femoral neck, or total hip. For use as second-line therapy: Documentation of fractures while on oral bisphosphonate therapy OR intolerance to oral bisphosphonate therapy. Products Affected PA Criteria Criteria Details
All FDA-approved indications not otherwise excluded from Part D
1) Diagnosis of relapsing multiple sclerosis AND 2) Documented negative pregnancy test (if female) AND 3) Patient has evidence of active disease progression (new symptoms, exam findings, or MRI changes) in the last 12 months or at least 2 documented relapses during the previous 2 years OR Patient develops intolerance to either Copaxone (glatiramer) or interferon beta
Patient to discontinue other therapies for MS (e.g. Avonex, Betaseron, Copaxone, Rebif, Extavia, Tysabri) prior to starting Gilenya
Products Affected PA Criteria Criteria Details
All FDA-approved indications not otherwise excluded from Part D.
Prescribed by Oncologist or Hematologist, or under the direct consultation with an Oncologist or Hematologist.
Approved for duration of contract year subject to formulary change and member eligibility. Products Affected PA Criteria Criteria Details
All FDA-approved indications not otherwise excluded from Part D
If diagnosis is plaque psoriasis, must have moderate to severe plaque psoriasis affecting greater than 5% of the body surface area (BSA) or affecting crucial body areas such as the hands, feet, face or genitals.
Restricted to rheumatology, dermatology and gastroenterology
If diagnosis is rheumatoid arthritis, must have failure or intolerance to methotrexate. If diagnosis is plaque psoriasis, must have failure of at least two of the following: potent topical corticosteroids, calcipotriene, tazarotene, phototherapy, acitretin, methotrexate, or cyclosporine. Products Affected PA Criteria Criteria Details
All FDA-approved indications not otherwise excluded from Part D
Patient must have documented diagnosis of chronic HCV Genotype 1
Restricted to gatroenterology or infectious disease
Incivek must be used with peginterferon alfa and ribavirin. Excluded if meets one or more of the following: 1) Previously treated with Incivek or Victrelis 2) Currently taking potent CYP3A4 inducers that may lead to loss of efficacy of INCIVEK (e.g. carbamazepine, phenobarbital, phenytoin, rifampin or St. John’s Wort) 3) Decompensated cirrhosis 4) Pregnant women or men whose female partners are pregnant
Products Affected PA Criteria Criteria Details
All FDA-approved indications not otherwise excluded from Part D
Diagnosis of rheumatoid arthritis and must have failure or intolerance to methotrexate
Products Affected PA Criteria Criteria Details
All medically accepted indications not otherwise excluded from Part D
Products Affected PA Criteria Criteria Details
All medically accepted indications not otherwise excluded from Part D
A documented BRAF V600E or V600K mutation
Mekinist is not indicated for the treatment of patients who have received prior BRAF-inhibitor therapy (i.e. Zelboraf, Tafinlar). Products Affected PA Criteria Criteria Details
All medically accepted indications not otherwise excluded from Part D
Requires diagnosis of non-Hodgin's lymphoma or multiple myeloma. Requires failure of standard stem cell mobilization using a colony stimulating factor (either G-CSF or GM-CSF) alone or in combination with chemotherapy.
Requires use in combination with one of the following colony stimulating factors: Granulocyte Colony Stimulating Factor (G-CSF) or Granulocyte Macrophage Colony Stimulating Factor (GM-CSF)
Products Affected
ARANESP INJ. 150MCG/0.3ML, 200MCG/0.4ML, 200MCG/ML, 300MCG/0.6ML, 300MCG/ML, 500MCG/ML
PROCRIT INJ. 2000UNIT/ML, 3000UNIT/ML, 4000UNIT/ML
PA Criteria Criteria Details
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. Products Affected PA Criteria Criteria Details
All FDA-approved indications not otherwise excluded from Part D
Products Affected PA Criteria Criteria Details
All medically accepted indications not otherwise excluded from Part D
Products Affected PA Criteria Criteria Details
All FDA-approved indications not otherwise excluded from Part D
Requires failure of methotrexate AND at least one tumor necrosis factor antagonist
Products Affected PA Criteria Criteria Details
All FDA-approved indications not otherwise excluded from Part D
Products Affected PA Criteria Criteria Details
All FDA-approved indications not otherwise excluded from Part D
Products Affected PA Criteria Criteria Details
All FDA-approved indications not otherwise excluded from Part D
Requires diagnosis of non-valvular atrial fibrillation AND a CHADS2 score of 1 or higher. Listed below is the CHADS2 scoring tool which indicates the Risk Factor and associated score: Congestive heart failure (score = 1) Hypertension (score = 1) Age greater than or equal to 75 years (score = 1) Diabetes mellitis (score = 1) Stroke / Transient Ischemia Attack (score = 2)
Excluded if meets one or more of the following: 1) Need for anticoagulation treatment for an indication other than atrial fibrillation 2) Active infective endocarditis 3) Active liver disease (e.g., active hepatitis, LFT elevation greater than 2 times the Upper Limit of Normal) 4) Severe renal impairment (estimated creatinine clearance less than 15 mL/min or on dialysis) 5) Active pathological bleeding
Products Affected PA Criteria Criteria Details
All medically accepted indications not otherwise excluded from Part D
Products Affected PA Criteria Criteria Details
All FDA-approved indications not otherwise excluded from Part D
Products Affected PA Criteria Criteria Details
All FDA-approved indications not otherwise excluded from Part D
Restricted to rheumatology and dermatology
If diagnosis is rheumatoid arthritis, must have failure or intolerance to methotrexate. Products Affected PA Criteria Criteria Details
All medically accepted indications not otherwise excluded from Part D
Products Affected PA Criteria Criteria Details
All FDA-approved indications not otherwise excluded from Part D
If diagnosis is plaque psoriasis, must have moderate to severe plaque psoriasis affecting greater than 5% of the body surface area (BSA) or affecting crucial body areas such as the hands, feet, face or genitals.
If diagnosis is plaque psoriasis, must have failure of at least two of the following: potent topical corticosteroids, calcipotriene, tazarotene, phototherapy, acitretin, methotrexate, or cyclosporine. Products Affected PA Criteria Criteria Details
All medically accepted indications not otherwise excluded from Part D
A documented positive BRAF V600E mutation
Tafinlar should not be used in patients with wild-type BRAF melanoma due to the potential risk of tumor promotion in these patients. Products Affected PA Criteria Criteria Details
All medically accepted indications not otherwise excluded from Part D
Products Affected PA Criteria Criteria Details
All medically accepted indications not otherwise excluded from Part D
Products Affected PA Criteria Criteria Details
All medically accepted indications not otherwise excluded from Part D
Products Affected PA Criteria Criteria Details
All FDA-approved indications not otherwise excluded from Part D
Patient must have documented diagnosis of chronic HCV Genotype 1
Restricted to gatroenterology or infectious disease
Incivek must be used with peginterferon alfa and ribavirin AND Patient has completed (or will complete) 4 weeks of lead in therapy with peginterferon alfa and ribavirin. Excluded if meets one or more of the following: 1) Previously treated with Incivek or Victrelis 2) Currently taking potent CYP3A4 inducers that may lead to loss of efficacy of Victrelis (e.g. carbamazepine, phenobarbital, phenytoin, rifampin or St. John’s Wort) 3) Decompensated cirrhosis 4) Pregnant women or men whose female partners are pregnant 5) Null responders to past dual therapy with peginterferon alfa and ribavirin
Products Affected PA Criteria Criteria Details
All medically accepted indications not otherwise excluded from Part D
Products Affected PA Criteria Criteria Details
All FDA-approved indications not otherwise excluded from Part D
When prescribed for non-valvular atrial fibrillation requires a CHADS2 score of 1 or higher. Listed below is the CHADS2 scoring tool which indicates the Risk Factor and associated score: Congestive heart failure (score = 1) Hypertension (score = 1) Age greater than or equal to 75 years (score = 1) Diabetes mellitus (score = 1) Stroke / Transient Ischemia Attack (score = 2)
Excluded if meets one or more of the following: 1) History of heart valve disorder (e.g., prosthetic heart valve or hemodynamically relevant valve disease) 2) Active infective endocarditis 3) Severe renal impairment (estimated creatinine clearance less than 15 mL/min or on dialysis) 4) Active pathological bleeding
Products Affected PA Criteria Criteria Details
All medically accepted indications not otherwise excluded from Part D
If diagnosis is hepatic encephalopathy, requires ONE of the following criteria be met: 1) Encephalopathy with admission to the hospital while on lactulose, 2) Encephalopathy with uncontrolled diarrhea, 3) Encephalopathy with intolerance to lactulose, or 4) Encephalopathy not improving on lactulose alone. Products Affected PA Criteria Criteria Details
All FDA-approved indications not otherwise excluded from Part D
Requires the following: 1) Serum IgE level prior to initiation. 2) Expected dose of Xolair 3) Poor control of asthma as demonstrated by at least one of the following: one hospital admission in the prior 6 months, or 2 emergency room visits in the prior 6 months, or 2 months of daily oral corticosteroids use without significant tapering or other events which are felt to indicate poor control.
Requires patient be on combined inhaled corticosteroid and long-acting bronchodilator therapy. Products Affected PA Criteria Criteria Details
All medically accepted indications not otherwise excluded from Part D
combi-screen® PLUS Nitrite: - Intended to identify nitrite in urine. Nitrite identifi cation is used in the diagnosis and treatment of urinary tract infections of bacterial origin. The color test is based on the principle of the Griess reaction. Any degree of pinkorange coloration should be interpreted as a positive nitrite test suggestive of ≥105 organisms/ml For In-Vitro Diagnostic
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Plan Year 2014