Download Drug Name Criteria Drug Available at Pharmacy Drug Available at

Drug Name
Criteria
Amevive
Coverage is provided for intralesional treatment of refractory or recurring external
condylomata acuminata inpatient 18 years of age or older
Coverage is provided for treatment of adults with moderate to severe plaque psoriasis
Botox Dysport Myobloc Xeomin
Botulinum Toxins A and B Drug Policy
Alferon
Celebrex
Cerezyme
Coverage is provided for patients who have tried and failed at least two Tier 1 NSAIDs
Exceptions exist if the Customer is at high risk of a NSAID-induced adverse GI event
Coverage is provided for Enzyme Replacement
Epogen Procrit Aranesp
Anemia Drugs: Darbepoetin Alfa and Epoetin Alfa Drug Policy
Neupogen/ Neulasta
Coverage is provided for treatment of neutropenia and in bone marrow transplantation
Prolastin
Remicade Orencia
ADHD, Adderall, Adderall XR, Concerta,
Daytrana, Desoxyn, Dexedrine, Dextrostat,
Focalin, Focalin XR, Liquadd, Ritalin, Ritalin SR,
Ritalin LA, Metadate CD, Methylin ER, Strattera,
Vyvanse, and Intuniv
Sodium Hyaluronic Acid Synvisc, Synvisc-One,
Euflexxa, Othovisc Hyalgan & Supartz
Drug Available at
Pharmacy
X
X
X
X
X If dispensed
through
pharmacy
X If dispensed
through
pharmacy
Coverage is provided for a diagnosis of congenital alpha 1-antitrypsin deficiency with
emphysema
Remicade (infliximab) Drug Policy Orencia (abatacept) Drug Policy
Coverage is provided for treatment of attention deficit hyperactivity disorder, narcolepsy
and idiopathic somnolence, fatigue associated with multiple sclerosis, and refractory
depression
Drug Available at
Physician Office
Only
X
X If dispensed
through MD
office
X If dispensed
through MD
office
X
X
X
Sodium Hyaluronate For The Treatment of Arthritis List as preferred Buy and Bill or
Specialty Pharmacy Obtain through Specialty Pharmacy
X
Synagis
Synagis® (palivizumab) Drug Policy Required to obtain through Specialty Pharmacy
X
Xolair
Xolair® (omalizumab) Drug Policy Obtain through Specialty Pharmacy
Coverage is provided for treatment of infections caused by susceptible strains of
Vancomycin-Resistant Enterococcus faecium; nosocomial pneumonia caused by
Staphylococcus aureus or Streptococcus pneumoniae; complicated skin and skin
structure infections, including diabetic foot infections, without concomitant osteomyelitis,
caused by Staphylococcus aureus, Streptococcus pyogenes, or Streptococcus
agalactiae; uncomplicated skin and skin structure infections caused by Staphylococcus
aureus (methicillin-susceptible only) or Streptococcus pyogenes; community-acquired
pneumonia caused by Streptococcus pneumoniae, or Staphylococcus aureus
(methicillin-susceptible strains only)
X
Zyvox
X