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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
