Read 2011 Aetna Medicare Prescription Drugs that Require Prior Authorization text version

2011 Prescription Drugs that Require Prior Authorization Drugs

ACTEMRA

Covered Uses

All FDA-approved indications not otherwise excluded from Part D

Exclusion Criteria

Required Medical Age Prescriber Coverage Other Criteria Info Restrictions Restrictions Duration

Through End Diagnosis of of Plan Rheumatoid Contract Yr Arthritis AND prior inadequate response to ONE TNF antagonist such as one of the following Enbrel or Humira or Cimzia or Simponi or Remicade Covered for members greater than 8 years of age Covered for members greater than 8 years of age Through End of Plan Contract Year Through End of Plan Contract Year Through End Diagnosis of of Plan advanced renal cell Contract Yr carcinoma and prior therapy with Sutent(sunitinib) or Nexavar (sorafenib)

ADOXA

All FDA-approved indications not otherwise excluded from Part D

ADOXA PAK

All FDA-approved indications not otherwise excluded from Part D

AFINITOR

All FDA approved indications not otherwise excluded from Part D

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2011 Prescription Drugs that Require Prior Authorization Drugs

ALIMTA

Covered Uses

All FDA-approved indications not otherwise excluded from Part D All FDA-approved indications not otherwise excluded from Part D

Exclusion Criteria

Required Medical Age Prescriber Coverage Other Criteria Info Restrictions Restrictions Duration

Through End of Plan Contract Yr

AMITIZA 8MG

males

Covered for 18 years of age and older

Through End of Plan Contract Year 6 months

amnesteem

All FDA-approved indications not otherwise excluded from Part D OR Acne vulgaris OR Neuroblastoma OR Rosacea OR Ultraviolet-induced change in normal skin All FDA-approved indications not otherwise excluded from Part D Covered for members less than 65 years of age

amphetamine

Through End of Plan Contract Year Through End of Plan Contract Yr Through End of Plan Contract Year

AMPYRA

All FDA approved indications not otherwise excluded from Part D All FDA approved indications not otherwise excluded from Part D

ANADROL

APOKYN

All FDA approved indications not otherwise excluded from Part D

use for Erectile dysfunction

Through End of Plan Contract Yr

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2011 Prescription Drugs that Require Prior Authorization Drugs

ARANESP

Covered Uses

All FDA approved indications not otherwise excluded from Part D or anemia associated with low or intermediate-1 risk Myelodysplastic syndrome All FDA approved indications not otherwise excluded from Part D

Exclusion Criteria

anemia associated with chronic renal failure and on dialysis

Required Medical Age Prescriber Coverage Other Criteria Info Restrictions Restrictions Duration

12 weeks

ARCALYST

exclusions from coverage include those who have a diagnosis of gout, diabetes mellitus type 1, idiopathic juvenile rheumatoid arthritis

Through End of Plan Contract Year

ARZERRA

All FDA-approved indications not otherwise excluded from Part D All FDA approved indications not otherwise excluded from Part D and Bone marrow transplant All FDA approved indications not otherwise excluded from Part D patient is a recipient of a Medicare covered organ transplant Covered for members less than 65 years of age

Through End of Plan Contract Yr Through End of Plan Contract Yr Through End of Plan Contract Year Through End of Plan Contract Yr Covered for members greater than 8 years of age Through End of Plan Contract Year

ATGAM

atropine sulfate inj

AVASTIN

All FDA-approved indications not otherwise excluded from Part D All FDA-approved indications not otherwise excluded from Part D

avidoxy

Y0001_M_OT_WB_01239_R1 CMS Approved 06/02/2011 ©2011 Aetna Inc.

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2011 Prescription Drugs that Require Prior Authorization Drugs

avita

Covered Uses

All FDA approved indications not otherwise excluded from Part D.

Exclusion Criteria

Cosmetic use

Required Medical Age Prescriber Coverage Other Criteria Info Restrictions Restrictions Duration

Approval will be given to all members using this agent for a medically necessary, FDA approved, noncosmetic indication. Through End of Plan Contract Yr

AVODART

All FDA approved indicatiions not otherwise excluded from Part D

Females

Through End of Plan Contract Year History of a clinical demyelinating event AND MRI-detected brain lesions consistent with MS. Neurologist Through End of Plan Contract Yr

AVONEX

All FDA approved indications not otherwise excluded from Part D

AZASAN

BANZEL

All FDA approved indications not otherwise excluded from Part D AND Atopic dermatitis,Prophylaxis of Cardiac transplant rejection, Inflammatory bowel disease,Prophylaxis of Liver transplant rejection, Myasthenia gravis,Prophylaxis of Rejection of pancreas transplant, Refractory sprue, Systemic lupus erythematosus,Takayasu's disease, Vasculitis All FDA approved indications not otherwise excluded from Part D

patient is a recipient of a Medicare covered organ transplant

Through End of Plan Contract Yr

Through End of Plan Contract Year

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2011 Prescription Drugs that Require Prior Authorization Drugs

BARACLUDE

Covered Uses

All FDA approved indications not otherwise excluded from Part D

Exclusion Criteria

Required Medical Age Prescriber Coverage Other Criteria Info Restrictions Restrictions Duration

Through End of Plan Contract Year Covered for members less than 65 years of age Through End of Plan Contract Year Through End of Plan Contract Year For treatment Through End of opioid of Plan dependenceContract Physician must Year have DATA 2000 waiver with a Unique Identification Number and a DEA number. 6 months Diagnosis of Invasive Aspergillosis AND refractory to or intolerant to one other therapy such as amphotericin B, lipid formulations of amphotericin B, or itraconazole

bentyl

All FDA approved indications not otherwise excluded from Part D

BERINERT

All FDA approved indications not otherwise excluded from Part D

buprenorphine sublingual All FDA-approved indications not otherwise excluded from Part D or Chronic pain

CANCIDAS

All FDA approved indicatiions not otherwise excluded from Part D

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carisoprodol

Covered Uses

All FDA approved indications not otherwise excluded from Part D

Exclusion Criteria

Required Medical Age Prescriber Coverage Other Criteria Info Restrictions Restrictions Duration

Covered for members less than 65 years of age Covered for members less than 65 years of age Covered for members less than 65 years of age Through End of Plan Contract Year Through End of Plan Contract Year Through End of Plan Contract Year Through End of Plan Contract Yr

carisoprodol/aspirin

All FDA approved indications not otherwise excluded from Part D

carisoprodol/aspirin/codei All FDA approved indications not ne otherwise excluded from Part D

CELLCEPT

All FDA approved indications not otherwise excluded from Part D AND Atopic dermatitis,Complication of transplanted pancreas,Graft versus host disease,Idiopathic thrombocytopenic purpura,Myasthenia gravis Nephrotic syndrome, Adjunct Renal transplant rejection Renal transplant rejection, Alternative regimens Wegener's granulomatosis All FDA approved indications not otherwise excluded from Part D

patient is a recipient of a Medicare covered organ transplant

CENESTIN

Covered for members less than 65 years of age Males Covered for Members between the ages of 10 to 25 years of age FID: 11195: version 40 August 2011

Through End of Plan Contract Year 180 days

CERVARIX

All FDA-approved indications not otherwise excluded from Part D

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2011 Prescription Drugs that Require Prior Authorization Drugs

chenodal

Covered Uses

All FDA approved indications not otherwise excluded from Part D

Exclusion Criteria

Required Medical Age Prescriber Coverage Other Criteria Info Restrictions Restrictions Duration

Through End of Plan Contract Year Through End of Plan Contract Year Through End of Plan Contract Year Through End of Plan Contract Year

chlorpropamide

All FDA approved indications not otherwise excluded from Part D

Covered for members less than 65 years of age Covered for members less than 65 years of age

chlorzoxazone

All FDA approved indications not otherwise excluded from Part D

chorionic gonadotropin

All FDA approved indications not otherwise excluded from Part D

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2011 Prescription Drugs that Require Prior Authorization Drugs

ciclodan solution

Covered Uses

All FDA-approved indications not otherwise excluded from Part D

Exclusion Criteria

concurrent use of a systemic (oral) antifungal agent for onychomycosis

Required Medical Age Prescriber Coverage Other Criteria Info Restrictions Restrictions Duration

Diagnosis of Mild to moderate onychomycosis of fingernails or toenails confirmed by either a positive KOH stain OR positive PAS stain (para-aminosalicylic acid) OR positive fungal culture AND one of the following experiencing pain which limits normal activity OR diagnosis of diabetes OR immunosuppressed OR systemic dermatosis with impaired skin integrity OR significant vascular compromise (peripheral) Through End of Plan Contract Year Diagnosis of Mild to moderate onychomycosis of fingernails or toenails AND Failure of an adequate trial of six weeks of one systemic (oral) antifungal alternative such as terbinafine for ONY unless there is presence of hepatic dysfunction or increased risk for liver disease OR Member is female and is pregnant or breastfeeding OR Member is

ciclodan solution (continued)

less than 12 yrs of age

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2011 Prescription Drugs that Require Prior Authorization Drugs

ciclopirox solution

Covered Uses

All FDA-approved indications not otherwise excluded from Part D

Exclusion Criteria

concurrent use of a systemic (oral) antifungal agent for onychomycosis

Required Medical Age Prescriber Coverage Other Criteria Info Restrictions Restrictions Duration

Diagnosis of Mild to moderate onychomycosis of fingernails or toenails confirmed by either a positive KOH stain OR positive PAS stain (para-aminosalicylic acid) OR positive fungal culture AND one of the following experiencing pain which limits normal activity OR diagnosis of diabetes OR immunosuppressed OR systemic dermatosis with impaired skin integrity OR significant vascular compromise (peripheral) Through End of Plan Contract Year Diagnosis of Mild to moderate onychomycosis of fingernails or toenails AND Failure of an adequate trial of six weeks of one systemic (oral) antifungal alternative such as terbinafine for ONY unless there is presence of hepatic dysfunction or increased risk for liver disease OR Member is female and is pregnant or breastfeeding OR Member is

ciclopirox solution (continued)

less than 12 yrs of age

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2011 Prescription Drugs that Require Prior Authorization Drugs

CIMZIA

Covered Uses

All FDA approved indications not otherwise excluded from Part D

Exclusion Criteria

Required Medical Age Prescriber Coverage Other Criteria Info Restrictions Restrictions Duration

Through End Crohn's disease of Plan AND Prior use of Contract Yr one of the followingCorticosteroids (ex. prednisone, budesonide, methylprednisolon e) or mercaptopurine or azathioprine (Imuran) OR Moderate to severe Rheumatoid Arthritis AND Failure of one nonbiological DMARD for 1 month

claravis

All FDA-approved indications not otherwise excluded from Part D OR Acne vulgaris OR Neuroblastoma OR Rosacea OR Ultraviolet-induced change in normal skin

7 months

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colistimethate inj

Covered Uses

All FDA approved indications not otherwise excluded from Part D

Exclusion Criteria

Administration via nebulizer

Required Medical Age Prescriber Coverage Other Criteria Info Restrictions Restrictions Duration

Infectious Disease Specialist 3 months Allow intravenous (IV) use only. CMS endorsed compendia do no support inhalation/nebulizat in of colistimethate.

COPAXONE

All FDA approved indications not otherwise excluded from Part D

History of a clinical demyelinating event AND MRI-detected brain lesions consistent with MS.

Neurologist

Through End of Plan Contract Yr

CUBICIN

All FDA approved indications not otherwise excluded from Part D

Infectious Disease Specialist Covered for members less than 65 years of age Covered for members less than 65 years of age

3 months

cyclobenzaprine

All FDA approved indications not otherwise excluded from Part D

Through End of Plan Contract Year Through End of Plan Contract Year

cyclobenzaprine sr

All FDA approved indications not otherwise excluded from Part D

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cyclosporine

Covered Uses

All FDA approved indications not otherwise excluded from Part D AND Aplastic anemia, Prophylaxis of Graft versus host disease, Treatment and Prophylaxis of Lung transplant rejection, Myasthenia gravis, Nephrotic syndrome, Plaque psoriasis (Severe), Rheumatoid arthritis (Severe), Systemic lupus erythematosus, Ulcerative colitis (Severe)

Exclusion Criteria

patient is a recipient of a Medicare covered organ transplant

Required Medical Age Prescriber Coverage Other Criteria Info Restrictions Restrictions Duration

Through End Plaque psoriasis of Plan (Severe) AND prior Contract Yr therapy of one of the followingcyclosporine or methotrexate or methoxsalen with UVA light (PUVA) OR Rheumatoid arthritis (Severe), AND prior therapy of methotrexate Covered for members less than 65 years of age Through End of Plan Contract Year Through End of Plan Contract Year Covered for members greater than 8 years of age Covered for members less than 65 years of age Through End of Plan Contract Year Through End of Plan Contract Year

cyproheptadine

All FDA approved indications not otherwise excluded from Part D

DALIRESP

All FDA approved indications not otherwise excluded from Part D

demeclocycline

All FDA-approved indications not otherwise excluded from Part D

dexchlorpheniramine

All FDA approved indications not otherwise excluded from Part D

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2011 Prescription Drugs that Require Prior Authorization Drugs

dexmethylphenidate

Covered Uses

All FDA-approved indications not otherwise excluded from Part D

Exclusion Criteria

Required Medical Age Prescriber Coverage Other Criteria Info Restrictions Restrictions Duration

Covered for members less than 65 years of age Covered for members less than 65 years of age Covered for members less than 65 years of age Covered for members less than 65 years of age Through End of Plan Contract Year Through End of Plan Contract Year Through End of Plan Contract Year Through End of Plan Contract Year 3 months

dextroamphetamine

All FDA-approved indications not otherwise excluded from Part D

dextroamphetamine er

All FDA-approved indications not otherwise excluded from Part D

dicyclomine

All FDA approved indications not otherwise excluded from Part D

DIFICID

All FDA approved indications not otherwise excluded from Part D

diphenatol

All FDA approved indicatiions not otherwise excluded from Part D

diphenhydramine

All FDA approved indications not otherwise excluded from Part D

Covered for members less than 65 years of age Covered for members less than 65 years of age Covered for members less than 65 years of age

Through End of Plan Contract Year Through End of Plan Contract Year Through End of Plan Contract Year

diphenoxylate/atropine

All FDA approved indicatiions not otherwise excluded from Part D

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doxycycline hyclate

Covered Uses

All FDA-approved indications not otherwise excluded from Part D

Exclusion Criteria

Required Medical Age Prescriber Coverage Other Criteria Info Restrictions Restrictions Duration

Covered for members greater than 8 years of age Covered for members greater than 8 years of age Covered for members greater than 8 years of age Through End of Plan Contract Year Through End of Plan Contract Year Through End of Plan Contract Year

doxycycline monohydrate All FDA-approved indications not otherwise excluded from Part D

doxy-caps

All FDA-approved indications not otherwise excluded from Part D

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dronabinol

Covered Uses

All FDA-approved indications not otherwise excluded from Part D and postoperative nausea and vomiting

Exclusion Criteria

Required Medical Age Prescriber Coverage Other Criteria Info Restrictions Restrictions Duration

CINV-6 months, PONV-1 month A documented Diagnosis of Nausea and Vomiting Associated with Cancer Chemotherapy (CINV) AND Patient is receiving cancer chemotherapy AND Failure to one 5HT-3 receptor antagonist OR A documented Diagnosis of Postoperative Nausea and Vomiting (PONV) AND Failure to one 5HT-3 receptor antagonist

dynacin

All FDA-approved indications not otherwise excluded from Part D

Covered for members greater than 8 years of age

Through End of Plan Contract Year Through End of Plan Contract Year

EGRIFTA

All FDA-approved indications not otherwise excluded from Part D

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ELIGARD ELITEK

Covered Uses

All FDA approved indications not otherwise excluded from Part D All FDA approved indications not otherwise excluded from Part D All FDA-approved indications not otherwise excluded from Part D

Exclusion Criteria

Required Medical Age Prescriber Coverage Other Criteria Info Restrictions Restrictions Duration

6 months Through End of Plan Contract Yr

EMSAM

exclusions from coverage include those who have a diagnosis of pheochromocytoma and who are taking SSRIs, SNRIs, TCAs, amphetamines, bupropion, carbamazepine /oxcarbazepine, cyclobenzaprine, dextromethorphan, meperidine

Through End of Plan Contract Year

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ENBREL

Covered Uses

All FDA approved indications not otherwise excluded from Part D

Exclusion Criteria

Required Medical Age Prescriber Coverage Other Criteria Info Restrictions Restrictions Duration

Through End Chronic Plaque of Plan psoriasis Contract Yr (moderate to severe) AND Prior use of one of the followingcyclosporine or methotrexate or acitretin or methoxsalen with UVA light (PUVA) OR Psoriatic arthritis or Rheumatoid arthritis AND Failure of one nonbiological DMARD for 1 month Covered for members less than 65 years of age Diagnosis of pulmonary arterial hypertension confirmed by right heart catheterization (RHC) Covered for members less than 65 years of age Through End of Plan Contract Year Pulmonologist Through End or Cardiologist of Plan Contract Year

ENJUVIA

All FDA approved indications not otherwise excluded from Part D

epoprostenol inj

All FDA-approved indications not otherwise excluded from Part D

estropipate

All FDA approved indications not otherwise excluded from Part D

Through End of Plan Contract Year

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EXJADE

Covered Uses

All FDA approved indications not otherwise excluded from Part D.

Exclusion Criteria

Required Medical Age Prescriber Coverage Other Criteria Info Restrictions Restrictions Duration

The patient has a diagnosis of chronic iron overload caused by blood transfusions (transfusional hemosiderosis) History of a clinical demyelinating event AND MRI-detected brain lesions consistent with MS. Neurologist Through End of Plan Contract Yr

EXTAVIA

All FDA approved indications not otherwise excluded from Part D

Through End of Plan Contract Yr

fentanyl lozenges

All FDA-approved indications not otherwise excluded from Part D

Through End of Plan Contract Year

Cancer pain and breakthrough pain in opioid-tolerant patients AND Concomitant use of long acting opioid therapy, such as ONE of thesecontrolled-release morphine or extended-release morphine or controlled-release oxycodone or extended-release oxymorphone or fentanyl transdermal or methadone

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finasteride

Covered Uses

All FDA approved indications not otherwise excluded from Part D

Exclusion Criteria

FEMALES

Required Medical Age Prescriber Coverage Other Criteria Info Restrictions Restrictions Duration

Through End of Plan Contract Year Through End of Plan Contract Year Through End of Plan Contract Yr

FIRMAGON

All FDA approved indications not otherwise excluded from Part D

FEMALES

GABITRIL

All FDA approved indications not otherwise excluded from Part D and generalized anxiety disorder, posttraumatic stress disorder, spasticity due to intractable epilepsy

exclusions from coverage include those who have a diagnosis multiple sclerosis, psychotic disorder, bipolar disorder

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GAMASTAN

Covered Uses

All FDA approved indications not otherwise excluded from Part D or Autoimmune hemolytic anemia , Autoimmune neutropenia, Prevention of bacterial infections in patients with hypogammaglobulinemia and/or recurrent bacterial infections associated with B-cell chronic lymphocytic leukemia, Adjunct therapy in bone marrow transplant recipients, Cytomegalovirus infection Treatment and Prophylaxis, Dermatomyositis as a second-line agent, Guillain-Barre syndrome, Haemophilus influenzae infection- Prophylaxis - Hemopoietic stem cell transplant Hemopoietic stem cell transplant - Streptococcal infectious disease- Prophylaxis, HIV infection in children, Inflammatory demyelinating polyradiculoneuropathy, chronic, Kidney disease, Myasthenia gravis, Neonatal jaundice, Respiratory syncytial virus infection in children, Sepsis, Toxic shock syndrome,

Exclusion Criteria

Required Medical Age Prescriber Coverage Other Criteria Info Restrictions Restrictions Duration

Through End of Plan Contract Year

GAMASTAN (continued)

Uveitis, von Willebrand disorder

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GAMMAGARD

Covered Uses

All FDA approved indications not otherwise excluded from Part D or Autoimmune hemolytic anemia , Autoimmune neutropenia, Prevention of bacterial infections in patients with hypogammaglobulinemia and/or recurrent bacterial infections associated with B-cell chronic lymphocytic leukemia, Adjunct therapy in bone marrow transplant recipients, Cytomegalovirus infection Treatment and Prophylaxis, Dermatomyositis as a second-line agent, Guillain-Barre syndrome, Haemophilus influenzae infection- Prophylaxis - Hemopoietic stem cell transplant Hemopoietic stem cell transplant - Streptococcal infectious disease- Prophylaxis, HIV infection in children, Inflammatory demyelinating polyradiculoneuropathy, chronic, Kidney disease, Myasthenia gravis, Neonatal jaundice, Respiratory syncytial virus infection in children, Sepsis, Toxic shock syndrome,

Exclusion Criteria

Required Medical Age Prescriber Coverage Other Criteria Info Restrictions Restrictions Duration

Through End of Plan Contract Year

GAMMAGARD (continued)

Uveitis, von Willebrand disorder

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GAMMAPLEX

Covered Uses

All FDA approved indications not otherwise excluded from Part D or Autoimmune hemolytic anemia , Autoimmune neutropenia, Prevention of bacterial infections in patients with hypogammaglobulinemia and/or recurrent bacterial infections associated with B-cell chronic lymphocytic leukemia, Adjunct therapy in bone marrow transplant recipients, Cytomegalovirus infection Treatment and Prophylaxis, Dermatomyositis as a second-line agent, Guillain-Barre syndrome, Haemophilus influenzae infection- Prophylaxis - Hemopoietic stem cell transplant Hemopoietic stem cell transplant - Streptococcal infectious disease- Prophylaxis, HIV infection in children, Inflammatory demyelinating polyradiculoneuropathy, chronic, Kidney disease, Myasthenia gravis, Neonatal jaundice, Respiratory syncytial virus infection in children, Sepsis, Toxic shock syndrome,

Exclusion Criteria

Required Medical Age Prescriber Coverage Other Criteria Info Restrictions Restrictions Duration

Through End of Plan Contract Year

GAMMAPLEX (continued)

Uveitis, von Willebrand disorder

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GAMUNEX

Covered Uses

All FDA approved indications not otherwise excluded from Part D or Autoimmune hemolytic anemia , Autoimmune neutropenia, Prevention of bacterial infections in patients with hypogammaglobulinemia and/or recurrent bacterial infections associated with B-cell chronic lymphocytic leukemia, Adjunct therapy in bone marrow transplant recipients, Cytomegalovirus infection Treatment and Prophylaxis, Dermatomyositis as a second-line agent, Guillain-Barre syndrome, Haemophilus influenzae infection- Prophylaxis - Hemopoietic stem cell transplant Hemopoietic stem cell transplant - Streptococcal infectious disease- Prophylaxis, HIV infection in children, Inflammatory demyelinating polyradiculoneuropathy, chronic, Kidney disease, Myasthenia gravis, Neonatal jaundice, Respiratory syncytial virus infection in children, Sepsis, Toxic shock syndrome,

Exclusion Criteria

Required Medical Age Prescriber Coverage Other Criteria Info Restrictions Restrictions Duration

Through End of Plan Contract Year

GAMUNEX (continued)

Uveitis, von Willebrand disorder

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GAMUNEX-C

Covered Uses

All FDA approved indications not otherwise excluded from Part D or Autoimmune hemolytic anemia , Autoimmune neutropenia, Prevention of bacterial infections in patients with hypogammaglobulinemia and/or recurrent bacterial infections associated with B-cell chronic lymphocytic leukemia, Adjunct therapy in bone marrow transplant recipients, Cytomegalovirus infection Treatment and Prophylaxis, Dermatomyositis as a second-line agent, Guillain-Barre syndrome, Haemophilus influenzae infection- Prophylaxis - Hemopoietic stem cell transplant Hemopoietic stem cell transplant - Streptococcal infectious disease- Prophylaxis, HIV infection in children, Inflammatory demyelinating polyradiculoneuropathy, chronic, Kidney disease, Myasthenia gravis, Neonatal jaundice, Respiratory syncytial virus infection in children, Sepsis, Toxic shock syndrome,

Exclusion Criteria

Required Medical Age Prescriber Coverage Other Criteria Info Restrictions Restrictions Duration

Through End of Plan Contract Year

GAMUNEX-C (continued) Uveitis, von Willebrand disorder GARDASIL All FDA approved indications not otherwise excluded from Part D Covered for Members between the ages of 9 to 26 years of age 180 days

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GASTROCROM

Covered Uses

All FDA-approved indications not otherwise excluded from Part D

Exclusion Criteria

exclusions from coverage include those who have a diagnosis of food allergies, Sjogren's syndrome patient is a recipient of a Medicare covered organ transplant

Required Medical Age Prescriber Coverage Other Criteria Info Restrictions Restrictions Duration

Through End of Plan Contract Year

gengraf

All FDA approved indications not otherwise excluded from Part D AND Aplastic anemia, Prophylaxis of Graft versus host disease, Treatment and Prophylaxis of Lung transplant rejection, Myasthenia gravis, Nephrotic syndrome, Plaque psoriasis (Severe), Rheumatoid arthritis (Severe), Systemic lupus erythematosus, Ulcerative colitis (Severe)

Through End Plaque psoriasis of Plan (Severe) AND prior Contract Yr therapy of one of the followingcyclosporine or methotrexate or methoxsalen with UVA light (PUVA) OR Rheumatoid arthritis (Severe), AND prior therapy of methotrexate Through End of Plan Contract Yr Through End of Plan Contract Yr History of a clinical demyelinating event AND MRI-detected brain lesions consistent with MS. Neurologist Through End of Plan Contract Yr

GEODON

All FDA approved indications not otherwise excluded from Part D All FDA approved indications not otherwise excluded from Part D All FDA approved indications not otherwise excluded from Part D

GEODON INJ

GILENYA

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GLEEVEC

Covered Uses

All FDA approved indications not otherwise excluded from Part D.

Exclusion Criteria

Required Medical Age Prescriber Coverage Other Criteria Info Restrictions Restrictions Duration

For children, Diagnosis of Philadelphia chromosome positive (Ph+) chronic phase CML AND One of the following - Not candidates for stem cell transplantation or Disease has recurred after stem cell transplant or resistant to interferon-alfa therapy Oncologist 6 months

HALAVEN

All FDA-approved indications not otherwise excluded from Part D

Through End A documented of Plan Diagnosis of Contract Yr metastatic breast cancer AND documented prior therapy with both an anthracycline (ex. daunorubicin,bleo mycin), and a taxane (ex. Paclitaxel, docetaxel) Through End of Plan Contract Year

HEPSERA

All FDA approved indications not otherwise excluded from Part D

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HEXALEN

Covered Uses

All FDA approved indications not otherwise excluded from Part D All FDA approved indications not otherwise excluded from Part D or Autoimmune hemolytic anemia , Autoimmune neutropenia, Prevention of bacterial infections in patients with hypogammaglobulinemia and/or recurrent bacterial infections associated with B-cell chronic lymphocytic leukemia, Adjunct therapy in bone marrow transplant recipients, Cytomegalovirus infection Treatment and Prophylaxis, Dermatomyositis as a second-line agent, Guillain-Barre syndrome, Haemophilus influenzae infection- Prophylaxis - Hemopoietic stem cell transplant Hemopoietic stem cell transplant - Streptococcal infectious disease- Prophylaxis, HIV infection in children, Inflammatory demyelinating polyradiculoneuropathy, chronic, Kidney disease, Myasthenia gravis, Neonatal jaundice, Respiratory syncytial virus infection in children, Sepsis, Toxic shock syndrome,

Exclusion Criteria

Required Medical Age Prescriber Coverage Other Criteria Info Restrictions Restrictions Duration

Through End of Plan Contract Yr

HIZENTRA

Acquired factor VIII inhibitors OR Acquired von Willebrand's disease OR Acute cardiomyopathy OR Acute idiopathic dysautonomia OR Acute lymphoblastic leukemia OR Adrenoleukodystroph y OR Amyotrophic lateral sclerosis OR Angioedema OR Antiphospholipid syndrome

Through End of Plan Contract Year

HIZENTRA (continued)

Uveitis, von Willebrand disorder

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HUMIRA

Covered Uses

All FDA approved indications not otherwise excluded from Part D

Exclusion Criteria

Required Medical Age Prescriber Coverage Other Criteria Info Restrictions Restrictions Duration

Through End Moderate to severe of Plan Crohn's disease Contract Yr AND Prior use of one of the followingCorticosteroids (ex. prednisone, budesonide, methylprednisolon e) or mercaptopurine or azathioprine (Imuran) OR Chronic moderate to severe Plaque psoriasis AND Prior use of one of the followingcyclosporine or methotrexate or acitretin or methoxsalen with UVA light (PUVA) OR Active Psoriatic

Y0001_M_OT_WB_01239_R1 CMS Approved 06/02/2011 ©2011 Aetna Inc.

FID: 11195: version 40 August 2011

2011 Prescription Drugs that Require Prior Authorization Drugs

HUMIRA (continued)

Covered Uses

Exclusion Criteria

Required Medical Age Prescriber Coverage Other Criteria Info Restrictions Restrictions Duration

arthritis or Rheumatoid arthritis or moderate to severe Juvenile Idiopathic arthritis AND Failure of one nonbiological DMARD for 1 month

hydroxyzine

All FDA approved indications not otherwise excluded from Part D

Covered for members less than 65 years of age Covered for members less than 65 years of age

Through End of Plan Contract Year Through End of Plan Contract Year 12 weeks Diagnosis of chronic hepatitis C genotype 1 AND In combination/conco mitant use of peginterferon alfa and ribavirin therapy

hydroxyzine pamoate

All FDA approved indications not otherwise excluded from Part D

INCIVEK

All FDA approved indications not otherwise excluded from Part D

INCRELEX

All FDA approved indications not otherwise excluded from Part D

Through End of Plan Contract Year

Y0001_M_OT_WB_01239_R1 CMS Approved 06/02/2011 ©2011 Aetna Inc.

FID: 11195: version 40 August 2011

2011 Prescription Drugs that Require Prior Authorization Drugs

INFERGEN

Covered Uses

All FDA approved indications not otherwise excluded from Part D

Exclusion Criteria

Required Medical Age Prescriber Coverage Other Criteria Info Restrictions Restrictions Duration

Hepatitis C, chronic, in adult patients AND compensated liver disease AND who have anti-HCV serum antibodies and/or HCV RNA Through End of Plan Contract Yr

INTRON-A

All FDA approved indications not otherwise excluded from Part D OR Carcinoid tumor or Chronic myeloid leukemia or Multiple myeloma or Ovarian cancer or Renal cell carcinoma or Skin cancer or Hepatitis C, acute or Laryngeal papillomatosis or Polycythemia vera or Thrombocytosis All FDA approved indications not otherwise excluded from Part D All FDA approved indications not otherwise excluded from Part D Oncologist

Through End of Plan Contract Yr

INVEGA TABLETS

Through End of Plan Contract Yr 6 months Non-small cell lung cancer AND failed both platinum and docetaxel-based chemotherapies OR patients have been on and have benefited from gefitinib

IRESSA

isotretinoin capsules

All FDA-approved indications not otherwise excluded from Part D OR Acne vulgaris OR Neuroblastoma OR Rosacea OR Ultraviolet-induced change in normal skin FID: 11195: version 40 August 2011

6 months

Y0001_M_OT_WB_01239_R1 CMS Approved 06/02/2011 ©2011 Aetna Inc.

2011 Prescription Drugs that Require Prior Authorization Drugs

ISTODAX

Covered Uses

All FDA-approved indications not otherwise excluded from Part D

Exclusion Criteria

Required Medical Age Prescriber Coverage Other Criteria Info Restrictions Restrictions Duration

Through End Diagnosis of of Plan Cutaneous T-cell Contract Yr lymphoma AND prior use of one systemic therapy such one of the following, a retinoid (ex.bexarotene (Targretin), alltrans retinoic acid (Vesanoid), acitretin (Soriatane) Diagnosis of Onychomycosis AND A positive laboratory test such as (potassium hydroxideKOH preparation, fungal culture, or nail biopsy) to confirm the diagnosis of onychomycosis 6 months

itraconazole

All FDA approved indications not othewise excluded from Part D.

JALYN

All FDA approved indications not otherwise excluded from Part D

FEMALES

Through End of Plan Contract Year

Y0001_M_OT_WB_01239_R1 CMS Approved 06/02/2011 ©2011 Aetna Inc.

FID: 11195: version 40 August 2011

2011 Prescription Drugs that Require Prior Authorization Drugs

JEVTANA

Covered Uses

All FDA-approved indications not otherwise excluded from Part D

Exclusion Criteria

Required Medical Age Prescriber Coverage Other Criteria Info Restrictions Restrictions Duration

Through End Diagnosis of of Plan hormone-refractory Contract Yr metastatic prostate cancer AND failed a docetaxel-based chemotherapy AND used in combination with prednisone

KALBITOR

All FDA approved indications not otherwise excluded from Part D All FDA approved indications not otherwise excluded from Part D Covered for members less than 65 years of age

ketorolac

Through End of Plan Contract Yr Through End of Plan Contract Year Through End Diagnosis of of Plan moderate to severe Contract Yr Rheumatoid arthritis AND failure of one nonbiological DMARD for 1 month

KINERET

All FDA approved indications not otherwise excluded from Part D

KRYSTEXXA

All FDA approved indications not otherwise excluded from Part D

Through End of Plan Contract Year

Y0001_M_OT_WB_01239_R1 CMS Approved 06/02/2011 ©2011 Aetna Inc.

FID: 11195: version 40 August 2011

2011 Prescription Drugs that Require Prior Authorization Drugs

KUVAN

Covered Uses

All FDA approved indications not otherwise excluded from Part D

Exclusion Criteria

Required Medical Age Prescriber Coverage Other Criteria Info Restrictions Restrictions Duration

hyperphenylalaninemi a caused by tetrahydrobiopterin(BH4-)responsive phenylketonuria AND dosing is within the range of 5 to 20 mg/kg/day 2 months for initial approval followed by an indefinite approval if member responds to therapy Through End of Plan Contract Yr Pulmonologist Through End or Cardiologist of Plan Contract Year

LATUDA

All FDA approved indications not otherwise excluded from Part D All FDA-approved indications not otherwise excluded from Part D Diagnosis of pulmonary arterial hypertension confirmed by right heart catheterization (RHC)

LETAIRIS

LEUKINE

All FDA approved indications not otherwise excluded from Part D All FDA approved indications not otherwise excluded from Part D All FDA approved indications not otherwise excluded from Part D All FDA approved indicatiions not otherwise excluded from Part D Covered for members less than 65 years of age

leuprolide LIDODERM

Through End of Plan Contract Yr 8 months Through End of Plan Contract Yr Through End of Plan Contract Year

lofene

Y0001_M_OT_WB_01239_R1 CMS Approved 06/02/2011 ©2011 Aetna Inc.

FID: 11195: version 40 August 2011

2011 Prescription Drugs that Require Prior Authorization Drugs

lonox

Covered Uses

All FDA approved indicatiions not otherwise excluded from Part D

Exclusion Criteria

Required Medical Age Prescriber Coverage Other Criteria Info Restrictions Restrictions Duration

Covered for members less than 65 years of age Through End of Plan Contract Year 6 months

LOTRONEX

All FDA approved indications not otherwise excluded from Part D

Males

Diagnosis of Severe IBS including diarrhea and 1 or more of the following-A.frequent and severe abdominal pain/discomfort OR B.frequent bowel urgency or fecal incontinence OR C. disability or restriction of daily activities due to IBS

LUPRON DEPOT LUPRON DEPOT-PED LYSTEDA

All FDA approved indications not otherwise excluded from Part D All FDA approved indications not otherwise excluded from Part D All FDA approved indications not otherwise excluded from Part D or Prophylaxis of Hemophilia-Hemorrhage during Tooth extraction, Acute myeloid leukemia-Hemorrhage, Angioedema, Arthroplasty, Dental surgical procedureHemophilia-Hemorrhage, Gastrointestinal hemorrhage, Operation on cervix, Operation on heart, Postoperative hemorrhage

7 months 9 months Through End of Plan Contract Year

Y0001_M_OT_WB_01239_R1 CMS Approved 06/02/2011 ©2011 Aetna Inc.

FID: 11195: version 40 August 2011

2011 Prescription Drugs that Require Prior Authorization Drugs

megestrol

Covered Uses

All FDA-approved indications not otherwise excluded from Part D AND Cachexia - Cancer, Cachexia - Cystic fibrosis,Carcinoma of prostate, Advanced hormonerefractory,Endometrial hyperplasia, Endometriosis, Hot sweats, In women with a history of breast cancer, Malignant melanoma, Malignant neoplasm of liver, Mullerian mixed tumor, Adenosarcoma, Ovarian carcinoma All FDA approved indications not otherwise excluded from Part D

Exclusion Criteria

Required Medical Age Prescriber Coverage Other Criteria Info Restrictions Restrictions Duration

Through End of Plan Contract Yr

menest

Covered for members less than 65 years of age Covered for members less than 65 years of age Covered for members less than 65 years of age Covered for members less than 65 years of age Covered for members less than 65 years of age

Through End of Plan Contract Year Through End of Plan Contract Year Through End of Plan Contract Year Through End of Plan Contract Year Through End of Plan Contract Year

meperidine

All FDA-approved indications not otherwise excluded from Part D

meprobamate

All FDA-approved indications not otherwise excluded from Part D

metadate er

All FDA-approved indications not otherwise excluded from Part D

methamphetamine

All FDA-approved indications not otherwise excluded from Part D

Y0001_M_OT_WB_01239_R1 CMS Approved 06/02/2011 ©2011 Aetna Inc.

FID: 11195: version 40 August 2011

2011 Prescription Drugs that Require Prior Authorization Drugs

methocarbamol

Covered Uses

All FDA approved indications not otherwise excluded from Part D

Exclusion Criteria

Required Medical Age Prescriber Coverage Other Criteria Info Restrictions Restrictions Duration

Covered for members less than 65 years of age Covered for members less than 65 years of age Covered for members less than 65 years of age Covered for members less than 65 years of age Covered for members less than 65 years of age Covered for members greater than 8 years of age Covered for members greater than 8 years of age Through End of Plan Contract Year Through End of Plan Contract Year Through End of Plan Contract Year Through End of Plan Contract Year Through End of Plan Contract Year Through End of Plan Contract Year Through End of Plan Contract Year

methylin

All FDA-approved indications not otherwise excluded from Part D

methylin er

All FDA-approved indications not otherwise excluded from Part D

methylphenidate

All FDA-approved indications not otherwise excluded from Part D

methylphenidate sr

All FDA-approved indications not otherwise excluded from Part D

minocycline

All FDA-approved indications not otherwise excluded from Part D

minocycline er

All FDA-approved indications not otherwise excluded from Part D

Y0001_M_OT_WB_01239_R1 CMS Approved 06/02/2011 ©2011 Aetna Inc.

FID: 11195: version 40 August 2011

2011 Prescription Drugs that Require Prior Authorization Drugs

MOZOBIL

Covered Uses

All FDA-approved indications not otherwise excluded from Part D

Exclusion Criteria

Required Medical Age Prescriber Coverage Other Criteria Info Restrictions Restrictions Duration

Through End Diagnosis of of Plan mobilizing Contract Yr hematopoietic stem cells to the peripheral blood for collection and subsequent autologous transplantation in patients with nonHodgkin's lymphoma and multiple myeloma AND being used in combination with one granulocytecolony stimulating factor (G-CSF) such as Neulasta or Leukine or Neupogen

MYCAMINE

All FDA approved indications not othewise excluded from Part D.

6 months

Y0001_M_OT_WB_01239_R1 CMS Approved 06/02/2011 ©2011 Aetna Inc.

FID: 11195: version 40 August 2011

2011 Prescription Drugs that Require Prior Authorization Drugs

mycophenolate

Covered Uses

All FDA approved indications not otherwise excluded from Part D AND Atopic dermatitis,Complication of transplanted pancreas,Graft versus host disease,Idiopathic thrombocytopenic purpura,Myasthenia gravis Nephrotic syndrome, Adjunct Renal transplant rejection Renal transplant rejection, Alternative regimens Wegener's granulomatosis All FDA approved indications not otherwise excluded from Part D AND Psoriasis All FDA approved indications not otherwise excluded from Part D All FDA approved indications not otherwise excluded from Part D

Exclusion Criteria

patient is a recipient of a Medicare covered organ transplant

Required Medical Age Prescriber Coverage Other Criteria Info Restrictions Restrictions Duration

Through End of Plan Contract Yr

MYFORTIC

patient is a recipient of a Medicare covered organ transplant

Through End of Plan Contract Yr Through End of Plan Contract Yr Through End of Plan Contract Yr

NEUMEGA

NEUPOGEN

Y0001_M_OT_WB_01239_R1 CMS Approved 06/02/2011 ©2011 Aetna Inc.

FID: 11195: version 40 August 2011

2011 Prescription Drugs that Require Prior Authorization Drugs

NEXAVAR

Covered Uses

All FDA approved indications not otherwise excluded from Part D

Exclusion Criteria

Required Medical Age Prescriber Coverage Other Criteria Info Restrictions Restrictions Duration

Documented diagnosis of 1. Stage IV advanced renal cell carcinoma, 2. unresectable hepatocellular carcinoma, 3. advanced metastatic medullary carcinoma (thyroid carcinoma), 4. advanced, clinically progressive papillary tumors and/or symptomatic papillary tumors. Oncologist 6 months

NORDITROPIN

All FDA approved indications not otherwise excluded from Part D

Through End of Plan Contract Year

Y0001_M_OT_WB_01239_R1 CMS Approved 06/02/2011 ©2011 Aetna Inc.

FID: 11195: version 40 August 2011

2011 Prescription Drugs that Require Prior Authorization Drugs

NOXAFIL

Covered Uses

All FDA approved indications not otherwise excluded from Part D.

Exclusion Criteria

Required Medical Age Prescriber Coverage Other Criteria Info Restrictions Restrictions Duration

Diagnosis of 13 years of prophylaxis of age and older invasive Aspergillus and Candida infections AND at high risk of developing these infections due to being severely immunocompromised, such as hematopoietic stem cell transplant (HSCT) recipients with Graft versus Host Disease (GVHD) or those with hematologic malignancies with prolonged neutropenia from chemotherapy. 6 months

NPLATE

All FDA approved indications not otherwise excluded from Part D

Through End thrombocytopenia of Plan with chronic Contract Yr immune(idiopathic) thrombocytopenic purpura (ITP) AND insufficient response to conticosteroids, immunoglobulins, or splenectomy

Y0001_M_OT_WB_01239_R1 CMS Approved 06/02/2011 ©2011 Aetna Inc.

FID: 11195: version 40 August 2011

2011 Prescription Drugs that Require Prior Authorization Drugs

NUEDEXTA

Covered Uses

All FDA approved indications not otherwise excluded from Part D

Exclusion Criteria

Required Medical Age Prescriber Coverage Other Criteria Info Restrictions Restrictions Duration

Through End of Plan Contract Year Through End of Plan Contract Year

NULOJIX

All FDA approved indications not otherwise excluded from Part D

Documented Diagnosis of Prophylaxis of organ rejection in kidney transplant in combination with basiliximab (Simulect) during induction therapy and used concurrently with mycophenolate mofetil and corticosteroids.

Y0001_M_OT_WB_01239_R1 CMS Approved 06/02/2011 ©2011 Aetna Inc.

FID: 11195: version 40 August 2011

2011 Prescription Drugs that Require Prior Authorization Drugs

OCTAGAM

Covered Uses

All FDA approved indications not otherwise excluded from Part D or Autoimmune hemolytic anemia , Autoimmune neutropenia, Prevention of bacterial infections in patients with hypogammaglobulinemia and/or recurrent bacterial infections associated with B-cell chronic lymphocytic leukemia, Adjunct therapy in bone marrow transplant recipients, Cytomegalovirus infection Treatment and Prophylaxis, Dermatomyositis as a second-line agent, Guillain-Barre syndrome, Haemophilus influenzae infection- Prophylaxis - Hemopoietic stem cell transplant Hemopoietic stem cell transplant - Streptococcal infectious disease- Prophylaxis, HIV infection in children, Inflammatory demyelinating polyradiculoneuropathy, chronic, Kidney disease, Myasthenia gravis, Neonatal jaundice, Respiratory syncytial virus infection in children, Sepsis, Toxic shock syndrome,

Exclusion Criteria

Required Medical Age Prescriber Coverage Other Criteria Info Restrictions Restrictions Duration

Through End of Plan Contract Year

OCTAGAM (continued)

Uveitis, von Willebrand disorder

Y0001_M_OT_WB_01239_R1 CMS Approved 06/02/2011 ©2011 Aetna Inc.

FID: 11195: version 40 August 2011

2011 Prescription Drugs that Require Prior Authorization Drugs

octreotide inj

Covered Uses

All FDA approved indications not otherwise excluded from Part D or AIDS - Diarrhea, Bleeding esophageal varices,Cryptosporidiosis, Diabetes mellitus, Dumping syndrome, Hypothalamic obesity ,Lymphorrhea, Adjunct therapy for acute Necrotizing pancreatitis, or adjunct therapy for Neuroendocrine tumor, Non-infective diarrhea, Pituitary adenoma, Polycystic ovary syndrome, Adjunct therapy for Polyostotic fibrous dysplasia of bone,Adjunct therapy for ZollingerEllison syndrome All FDA approved indications not otherwise excluded from Part D

Exclusion Criteria

Required Medical Age Prescriber Coverage Other Criteria Info Restrictions Restrictions Duration

Through End of Plan Contract Yr

ogen

Covered for members less than 65 years of age

Through End of Plan Contract Year

Y0001_M_OT_WB_01239_R1 CMS Approved 06/02/2011 ©2011 Aetna Inc.

FID: 11195: version 40 August 2011

2011 Prescription Drugs that Require Prior Authorization Drugs

ORENCIA

Covered Uses

All FDA approved indications not otherwise excluded from Part D

Exclusion Criteria

concurrent use with TNF antagonists ex such as infliximab, adalimumab, certolizumab

Required Medical Age Prescriber Coverage Other Criteria Info Restrictions Restrictions Duration

Through End Diagnosis of of Plan moderate to severe Contract Yr Rheumatoid Arthritis AND failure of one nonbiological DMARD for 1 month OR Diagnosis of moderate to severe polyarticular juvenile idiopathic arthritis AND failure of one nonbiological DMARD for 1 month

ORFADIN

All FDA approved indications not otherwise excluded from Part D

orphen cpd

All FDA approved indications not otherwise excluded from Part D

orphenadrine er

All FDA approved indications not otherwise excluded from Part D

Covered for members less than 65 years of age Covered for members less than 65 years of age

Through End of Plan Contract Year Through End of Plan Contract Year Through End of Plan Contract Year

Y0001_M_OT_WB_01239_R1 CMS Approved 06/02/2011 ©2011 Aetna Inc.

FID: 11195: version 40 August 2011

2011 Prescription Drugs that Require Prior Authorization Drugs

orphenadrine inj

Covered Uses

All FDA approved indications not otherwise excluded from Part D

Exclusion Criteria

Required Medical Age Prescriber Coverage Other Criteria Info Restrictions Restrictions Duration

Covered for members less than 65 years of age Covered for members less than 65 years of age Through End of Plan Contract Year Through End of Plan Contract Year Through End All FDA approved of Plan indications not Contract Yr otherwise excluded from Part D AND Diagnosis of cardiac transplant rejection or renal transplant rejection AND Steroidresistant

orphenadrine/aspirin/ caffeine

All FDA approved indications not otherwise excluded from Part D

ORTHOCLONE

All FDA approved indications not otherwise excluded from Part D AND Prophylaxis of Cardiac transplant rejection, Graft versus host disease, Prophylaxis of Renal transplant rejection

patient is a recipient of a Medicare covered organ transplant

ortho-est

All FDA approved indications not otherwise excluded from Part D

Covered for members less than 65 years of age

oxandrolone 10mg

All FDA approved indications not otherwise excluded from Part D

Through End of Plan Contract Year Through End of Plan Contract Year Through End of Plan Contract Year

oxandrolone 2.5mg

All FDA approved indications not otherwise excluded from Part D

Y0001_M_OT_WB_01239_R1 CMS Approved 06/02/2011 ©2011 Aetna Inc.

FID: 11195: version 40 August 2011

2011 Prescription Drugs that Require Prior Authorization Drugs

PEGASYS

Covered Uses

All FDA-approved indications not otherwise excluded from Part D

Exclusion Criteria

Required Medical Age Prescriber Coverage Other Criteria Info Restrictions Restrictions Duration

Through End of Plan Contract Year Diagnosis of Hepatitis B treatment, AND who are interferon naïve or who have relapsed or failed to respond to prior non-pegylated interferon therapy or Diagnosis of Hepatitis C (non-A, non-B hepatitis), in members with compensated liver disease who are interferon naïve, OR who have relapsed or failed to respond to prior non-pegylated interferon

PEGASYS (continued)

therapy, either as monotherapy or in combination with ribavirin.

Y0001_M_OT_WB_01239_R1 CMS Approved 06/02/2011 ©2011 Aetna Inc.

FID: 11195: version 40 August 2011

2011 Prescription Drugs that Require Prior Authorization Drugs

PEG-INTRON

Covered Uses

All FDA-approved indications not otherwise excluded from Part D

Exclusion Criteria

Required Medical Age Prescriber Coverage Other Criteria Info Restrictions Restrictions Duration

Through End of Plan Contract Year Diagnosis of Hepatitis B treatment, AND who are interferon naïve or who have relapsed or failed to respond to prior non-pegylated interferon therapy or Diagnosis of Hepatitis C (non-A, non-B hepatitis), in members with compensated liver disease who are interferon naïve, OR who have relapsed or failed to respond to prior non-pegylated interferon

PEG-INTRON (continued)

therapy, either as monotherapy or in combination with ribavirin. All FDA-approved indications not otherwise excluded from Part D Covered for members less than 65 years of age Through End of Plan Contract Year

pentazocine/apap

Y0001_M_OT_WB_01239_R1 CMS Approved 06/02/2011 ©2011 Aetna Inc.

FID: 11195: version 40 August 2011

2011 Prescription Drugs that Require Prior Authorization Drugs

pentazocine/naloxone

Covered Uses

All FDA-approved indications not otherwise excluded from Part D

Exclusion Criteria

Required Medical Age Prescriber Coverage Other Criteria Info Restrictions Restrictions Duration

Covered for members less than 65 years of age Covered for members less than 65 years of age Covered for members less than 65 years of age Through End of Plan Contract Year Through End of Plan Contract Year Through End of Plan Contract Year

phenadoz

All FDA approved indications not otherwise excluded from Part D

phenergan inj

All FDA approved indications not otherwise excluded from Part D

Y0001_M_OT_WB_01239_R1 CMS Approved 06/02/2011 ©2011 Aetna Inc.

FID: 11195: version 40 August 2011

2011 Prescription Drugs that Require Prior Authorization Drugs

POLYGAM S/D

Covered Uses

All FDA approved indications not otherwise excluded from Part D or Autoimmune hemolytic anemia , Autoimmune neutropenia, Prevention of bacterial infections in patients with hypogammaglobulinemia and/or recurrent bacterial infections associated with B-cell chronic lymphocytic leukemia, Adjunct therapy in bone marrow transplant recipients, Cytomegalovirus infection Treatment and Prophylaxis, Dermatomyositis as a second-line agent, Guillain-Barre syndrome, Haemophilus influenzae infection- Prophylaxis - Hemopoietic stem cell transplant Hemopoietic stem cell transplant - Streptococcal infectious disease- Prophylaxis, HIV infection in children, Inflammatory demyelinating polyradiculoneuropathy, chronic, Kidney disease, Myasthenia gravis, Neonatal jaundice, Respiratory syncytial virus infection in children, Sepsis, Toxic shock syndrome,

Exclusion Criteria

Acquired factor VIII inhibitors OR Acquired von Willebrand's disease OR Acute cardiomyopathy OR Acute idiopathic dysautonomia OR Acute lymphoblastic leukemia OR Adrenoleukodystroph y OR Amyotrophic lateral sclerosis OR Angioedema OR Antiphospholipid syndrome

Required Medical Age Prescriber Coverage Other Criteria Info Restrictions Restrictions Duration

Through End of Plan Contract Year

POLYGAM S/D (continued) PRADAXA

Uveitis, von Willebrand disorder All FDA approved indications not otherwise excluded from Part D Through End of Plan Contract Year

Y0001_M_OT_WB_01239_R1 CMS Approved 06/02/2011 ©2011 Aetna Inc.

FID: 11195: version 40 August 2011

2011 Prescription Drugs that Require Prior Authorization Drugs

PREMARIN

Covered Uses

All FDA approved indications not otherwise excluded from Part D

Exclusion Criteria

Required Medical Age Prescriber Coverage Other Criteria Info Restrictions Restrictions Duration

Covered for members less than 65 years of age Covered for members less than 65 years of age Covered for members less than 65 years of age Through End of Plan Contract Year Through End of Plan Contract Year Through End of Plan Contract Year

PREMPHASE

All FDA approved indications not otherwise excluded from Part D

PREMPRO

All FDA approved indications not otherwise excluded from Part D

Y0001_M_OT_WB_01239_R1 CMS Approved 06/02/2011 ©2011 Aetna Inc.

FID: 11195: version 40 August 2011

2011 Prescription Drugs that Require Prior Authorization Drugs

PRIVIGEN

Covered Uses

All FDA approved indications not otherwise excluded from Part D or Autoimmune hemolytic anemia , Autoimmune neutropenia, Prevention of bacterial infections in patients with hypogammaglobulinemia and/or recurrent bacterial infections associated with B-cell chronic lymphocytic leukemia, Adjunct therapy in bone marrow transplant recipients, Cytomegalovirus infection Treatment and Prophylaxis, Dermatomyositis as a second-line agent, Guillain-Barre syndrome, Haemophilus influenzae infection- Prophylaxis - Hemopoietic stem cell transplant Hemopoietic stem cell transplant - Streptococcal infectious disease- Prophylaxis, HIV infection in children, Inflammatory demyelinating polyradiculoneuropathy, chronic, Kidney disease, Myasthenia gravis, Neonatal jaundice, Respiratory syncytial virus infection in children, Sepsis, Toxic shock syndrome,

Exclusion Criteria

Required Medical Age Prescriber Coverage Other Criteria Info Restrictions Restrictions Duration

Through End of Plan Contract Year

PRIVIGEN (continued) procentra

Uveitis, von Willebrand disorder All FDA-approved indications not otherwise excluded from Part D

Covered for members less than 65 years of age

Through End of Plan Contract Year

Y0001_M_OT_WB_01239_R1 CMS Approved 06/02/2011 ©2011 Aetna Inc.

FID: 11195: version 40 August 2011

2011 Prescription Drugs that Require Prior Authorization Drugs

PROCRIT

Covered Uses

All FDA approved indications not otherwise excluded from Part D or Anemia associated with any of the following-Congestive heart failure or radiation or during the puerperium or Hepatitis C or Multiple myeloma or Myelodysplastic syndrome or Myelofibrosis or anemia of prematurity or Rheumatoid arthritis, or beta Thalassemia or Blood unit collection for autotransfusion All FDA approved indications not otherwise excluded from Part D AND Prophylaxis of Corneal graft rejection, Graft versus host disease, Lichen planus, Liver transplant rejectionRescue, Psoriasis, Rejection of pancreas transplant, Prophylaxis of Rejection of pancreas transplant, Prophylaxis of Renal transplant rejection, Rescue of Renal transplant rejection, Rheumatoid arthritis, Prophylaxis of Transplantation of small intestine -Transplanted organ rejection

Exclusion Criteria

anemia associated with chronic renal failure and on dialysis

Required Medical Age Prescriber Coverage Other Criteria Info Restrictions Restrictions Duration

12 weeks

PROGRAF

patient is a recipient of a Medicare covered organ transplant

Through End of Plan Contract Yr

Y0001_M_OT_WB_01239_R1 CMS Approved 06/02/2011 ©2011 Aetna Inc.

FID: 11195: version 40 August 2011

2011 Prescription Drugs that Require Prior Authorization Drugs

PROLIA

Covered Uses

All FDA approved indications not otherwise excluded from Part D

Exclusion Criteria

Required Medical Age Prescriber Coverage Other Criteria Info Restrictions Restrictions Duration

Diagnosis of treatment of postmenopausal women (PMW) with osteoporosis AND A documented Bone mineral density T score of 2.5 or more standard deviations below the mean value (i.e. T score is less than -2.5) AND History of previous osteoporotic fracture Through End of Plan Contract Yr

PROMACTA

All FDA approved indications not otherwise excluded from Part D All FDA approved indications not otherwise excluded from Part D Covered for members less than 65 years of age Covered for members less than 65 years of age Covered for members less than 65 years of age

Through End of Plan Contract Yr Through End of Plan Contract Year Through End of Plan Contract Year Through End of Plan Contract Year

promethazine

promethegan

All FDA approved indications not otherwise excluded from Part D

propantheline

All FDA approved indications not otherwise excluded from Part D

Y0001_M_OT_WB_01239_R1 CMS Approved 06/02/2011 ©2011 Aetna Inc.

FID: 11195: version 40 August 2011

2011 Prescription Drugs that Require Prior Authorization Drugs

PROVIGIL

Covered Uses

All FDA-approved indications not otherwise excluded from Part D

Exclusion Criteria

Required Medical Age Prescriber Coverage Other Criteria Info Restrictions Restrictions Duration

Diagnosis of obstructive sleep apnea/hypopnea syndrome (OSAHS) to improve excessive sleepiness, as an adjunct to standard treatment(s) for the underlying obstruction AND ONE OF THE FOLLOWING-an adequate therapeutic trial of twelve weeks of continuous positive airway pressure (CPAP) treatment and is still experiencing excessive sleepiness despite CPAP use OR Member is currently using an oral/dental appliance OR Through End of Plan Contract Year

PROVIGIL (continued)

Member has undergone a uvulopalatopharyngop lasty (UPPP)

Y0001_M_OT_WB_01239_R1 CMS Approved 06/02/2011 ©2011 Aetna Inc.

FID: 11195: version 40 August 2011

2011 Prescription Drugs that Require Prior Authorization Drugs

QUALAQUIN

Covered Uses

All FDA approved indications not otherwise excluded from Part D

Exclusion Criteria

exclusions from coverage include those who have a diagnosis of restless leg syndrome, muscle cramps Females

Required Medical Age Prescriber Coverage Other Criteria Info Restrictions Restrictions Duration

3 months

RAPAFLO

All FDA approved indicatiions not otherwise excluded from Part D

Through End of Plan Contract Year Through End of Plan Contract Yr Through End of Plan Contract Year Diagnosis of Hepatitis C (non-A, non-B hepatitis) AND compensated liver disease AND in combination with interferon alfa or pegylated interferon alfa

RAPAMUNE

All FDA approved indications not otherwise excluded from Part D AND Renal transplant rejection All FDA-approved indications not otherwise excluded from Part D

patient is a recipient of a Medicare covered organ transplant

REBETOL

REBIF

All FDA approved indications not otherwise excluded from Part D

History of a clinical demyelinating event AND MRI-detected brain lesions consistent with MS.

Neurologist

Through End of Plan Contract Yr

REGRANEX

All FDA approved indications not otherwise excluded from Part D

Through End of Plan Contract Yr

Y0001_M_OT_WB_01239_R1 CMS Approved 06/02/2011 ©2011 Aetna Inc.

FID: 11195: version 40 August 2011

2011 Prescription Drugs that Require Prior Authorization Drugs

REMICADE

Covered Uses

All FDA approved indications not otherwise excluded from Part D

Exclusion Criteria

Required Medical Age Prescriber Coverage Other Criteria Info Restrictions Restrictions Duration

Through End Moderate to severe of Plan active Crohn's Contract Yr disease AND inadequate response to one corticosteroid (ex. prednisone, budesonide, methylprednisolon e) OR Severe chronic plaque psoriasis AND prior use of one of the followingcyclosporine or methotrexate or methoxsalen with UVA light (PUVA) OR Active psoriatic arthritis AND prior use of one corticosteroid (ex. dexamethasone,

Y0001_M_OT_WB_01239_R1 CMS Approved 06/02/2011 ©2011 Aetna Inc.

FID: 11195: version 40 August 2011

2011 Prescription Drugs that Require Prior Authorization Drugs

REMICADE (continued)

Covered Uses

Exclusion Criteria

Required Medical Age Prescriber Coverage Other Criteria Info Restrictions Restrictions Duration

methylprednisolon e) OR Moderate to severe rheumatoid arthritis AND concomitant treatment with methotrexate OR Moderate to severe active ulcerative colitis AND inadequate response to one 5aminosalicylic acid product (5-ASA ex. sulfasalazine, mesalamine, balsalazide) or one corticosteroid (ex. prednisone, methylprednisolon e).

REVATIO TABLET

All FDA-approved indications not otherwise excluded from Part D

concurrent use of organic nitrates (for example, isosorbide mononitrate, isosorbide dinitrate, nitroglycerin)

Diagnosis of pulmonary arterial hypertension confirmed by right heart catheterization (RHC)

Pulmonologist Through End or Cardiologist of Plan Contract Year

Y0001_M_OT_WB_01239_R1 CMS Approved 06/02/2011 ©2011 Aetna Inc.

FID: 11195: version 40 August 2011

2011 Prescription Drugs that Require Prior Authorization Drugs

REVATIO INJ

Covered Uses

All FDA-approved indications not otherwise excluded from Part D

Exclusion Criteria

concurrent use of organic nitrates (for example, isosorbide mononitrate, isosorbide dinitrate, nitroglycerin)

Required Medical Age Prescriber Coverage Other Criteria Info Restrictions Restrictions Duration

Diagnosis of pulmonary arterial hypertension confirmed by right heart catheterization (RHC) Diagnosis of MDS (with or without transfusion dependent anemia), with a deletion 5q chromosomal abnormality (with or without other chromosomal abnormalities present) confirmed by cytogenetic or DNA FISH testing OR The patient has in the past received Revlimid as a study medication within a clinical trial for MDS AND Diagnosis of Multiple Myeloma, Solitary plasmacytoma, or Smoldering multiple myeloma Pulmonologist Through End or Cardiologist of Plan Contract Year

REVLIMID

All FDA approved indications not otherwise excluded from Part D.

Oncologist, hematologist

6 months

Y0001_M_OT_WB_01239_R1 CMS Approved 06/02/2011 ©2011 Aetna Inc.

FID: 11195: version 40 August 2011

2011 Prescription Drugs that Require Prior Authorization Drugs

RIBAPAK PAK 1000/DAY

Covered Uses

All FDA-approved indications not otherwise excluded from Part D

Exclusion Criteria

Required Medical Age Prescriber Coverage Other Criteria Info Restrictions Restrictions Duration

Through End of Plan Contract Year Diagnosis of Hepatitis C (non-A, non-B hepatitis) AND compensated liver disease AND in combination with interferon alfa or pegylated interferon alfa Through End Diagnosis of of Plan Hepatitis C (non-A, Contract non-B hepatitis) Year AND compensated liver disease AND in combination with interferon alfa or pegylated interferon alfa Through End Diagnosis of of Plan Hepatitis C (non-A, Contract non-B hepatitis) Year AND compensated liver disease AND in combination with interferon alfa or pegylated interferon alfa

ribapak pak 800,1200/day All FDA-approved indications not otherwise excluded from Part D

ribasphere

All FDA-approved indications not otherwise excluded from Part D

Y0001_M_OT_WB_01239_R1 CMS Approved 06/02/2011 ©2011 Aetna Inc.

FID: 11195: version 40 August 2011

2011 Prescription Drugs that Require Prior Authorization Drugs

ribatab pak

Covered Uses

All FDA-approved indications not otherwise excluded from Part D

Exclusion Criteria

Required Medical Age Prescriber Coverage Other Criteria Info Restrictions Restrictions Duration

Through End of Plan Contract Year Diagnosis of Hepatitis C (non-A, non-B hepatitis) AND compensated liver disease AND in combination with interferon alfa or pegylated interferon alfa Diagnosis of Hepatitis C (non-A, non-B hepatitis) AND compensated liver disease AND in combination with interferon alfa or pegylated interferon alfa Diagnosis of Hepatitis C (non-A, non-B hepatitis) AND compensated liver disease AND in combination with interferon alfa or pegylated interferon alfa

ribatab tablets

All FDA-approved indications not otherwise excluded from Part D

Through End of Plan Contract Year

ribavirin

All FDA-approved indications not otherwise excluded from Part D

Through End of Plan Contract Year

RILUTEK

All FDA-approved indications not otherwise excluded from Part D

Through End of Plan Contract Year FID: 11195: version 40 August 2011

Y0001_M_OT_WB_01239_R1 CMS Approved 06/02/2011 ©2011 Aetna Inc.

2011 Prescription Drugs that Require Prior Authorization Drugs

RITUXAN

Covered Uses

All FDA approved indications not otherwise excluded from Part D

Exclusion Criteria

Required Medical Age Prescriber Coverage Other Criteria Info Restrictions Restrictions Duration

Diagnosis of NonHodgkin's Lymphoma (NHL) AND evidence of positive CD20 Through End Diagnosis of of Plan Rheumatoid Contract Yr Arthritis AND in combination with methotrexate AND an inadequate response to one or more TNF antagonist therapies ex such as infliximab, adalimumab, certolizumab

SABRIL

All FDA approved indications not otherwise excluded from Part D

Diagnosis of Refractory Complex Partial Seizures AND Initial monotherapy for the management of infantile spasms (West syndrome)AND enrolled in the Sabril SHARE program

Through End of Plan Contract Year

Y0001_M_OT_WB_01239_R1 CMS Approved 06/02/2011 ©2011 Aetna Inc.

FID: 11195: version 40 August 2011

2011 Prescription Drugs that Require Prior Authorization Drugs Covered Uses Exclusion Criteria Required Medical Age Prescriber Coverage Other Criteria Info Restrictions Restrictions Duration

Through End of Plan Contract Yr

SANDOSTATIN KIT LAR All FDA approved indications not otherwise excluded from Part D or AIDS - Diarrhea, Bleeding esophageal varices,Cryptosporidiosis, Diabetes mellitus, Dumping syndrome, Hypothalamic obesity ,Lymphorrhea, Adjunct therapy for acute Necrotizing pancreatitis, or adjunct therapy for Neuroendocrine tumor, Non-infective diarrhea, Pituitary adenoma, Polycystic ovary syndrome, Adjunct therapy for Polyostotic fibrous dysplasia of bone,Adjunct therapy for Zollinger-

SANDOSTATIN KIT LAR Ellison syndrome (continued)

Y0001_M_OT_WB_01239_R1 CMS Approved 06/02/2011 ©2011 Aetna Inc.

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2011 Prescription Drugs that Require Prior Authorization Drugs

SIMPONI

Covered Uses

All FDA approved indications not otherwise excluded from Part D

Exclusion Criteria

Required Medical Age Prescriber Coverage Other Criteria Info Restrictions Restrictions Duration

Through End Moderate to severe of Plan active rheumatoid Contract Yr arthritis used in combination with methotrexate OR Active Psoriatic arthritis AND Failure of one nonbiological DMARD for 1 month

SIMULECT

All FDA approved indications not otherwise excluded from Part D AND Graft versus host disease or Prophylaxis of Liver transplant rejection

patient is a recipient of a Medicare covered organ transplant

SOMATULINE

All FDA approved indications not otherwise excluded from Part D

Through End Diagnosis of of Plan Prophylaxis of Contract Yr Renal transplant rejection in combination with cyclosporine and corticosteroids Through End of Plan Contract Yr

Y0001_M_OT_WB_01239_R1 CMS Approved 06/02/2011 ©2011 Aetna Inc.

FID: 11195: version 40 August 2011

2011 Prescription Drugs that Require Prior Authorization Drugs

SOMAVERT

Covered Uses

All FDA approved indications not otherwise excluded from Part D

Exclusion Criteria

Required Medical Age Prescriber Coverage Other Criteria Info Restrictions Restrictions Duration

A documented diagnosis of acromegaly AND Inadequate response to surgery or radiation therapy or other medical therapies or surgery or radiation therapy or other medical therapies is not an option due to risk or other medical reason Through End of Plan Contract Yr

sotret

SPORANOX SOLN

All FDA-approved indications not otherwise excluded from Part D OR Acne vulgaris OR Neuroblastoma OR Rosacea OR Ultraviolet-induced change in normal skin All FDA approved indications not othewise excluded from Part D.

8 months

6 months

Y0001_M_OT_WB_01239_R1 CMS Approved 06/02/2011 ©2011 Aetna Inc.

FID: 11195: version 40 August 2011

2011 Prescription Drugs that Require Prior Authorization Drugs

SPRYCEL

Covered Uses

All FDA approved indications not otherwise excluded from Part D

Exclusion Criteria

Required Medical Age Prescriber Coverage Other Criteria Info Restrictions Restrictions Duration

Oncologist 6 months Accelerated phase chronic myeloid leukemia OR Acute lymphoid leukemia, Philadelphia chromosomepositive OR Blastic phase chronic myeloid leukemia OR Chronic phase chronic myeloid leukemia AND Resistant or intolerant to prior therapy such as imatinib

STELARA

All FDA-approved indications not otherwise excluded from Part D

Through End Diagnosis of of Plan moderate to severe Contract Yr Plaque Psoriasis AND Prior use of one of the following, cyclosporine, methotrexate,acitre tin, Psoralens (methoxsalen, trioxsalen) with UVA light (PUVA)

Y0001_M_OT_WB_01239_R1 CMS Approved 06/02/2011 ©2011 Aetna Inc.

FID: 11195: version 40 August 2011

2011 Prescription Drugs that Require Prior Authorization Drugs

SUBOXONE

Covered Uses

All FDA-approved indications not otherwise excluded from Part D or Chronic pain

Exclusion Criteria

Required Medical Age Prescriber Coverage Other Criteria Info Restrictions Restrictions Duration

For treatment of opioid dependencePhysician must have DATA 2000 waiver with a Unique Identification Number and a DEA number. Oncologist Through End of Plan Contract Year

SUTENT

All FDA approved indications not otherwise excluded from Part D

6 months

Gastrointestinal stromal tumor AND After disease progression on or intolerance to imatinib OR Metastatic breast cancer AND previously treated with an anthracycline (ex. daunorubicin,bleo mycin)and a taxane( ex.Paclitaxel, docetaxel )

SYLATRON

All FDA approved indications not otherwise excluded from Part D

Through End of Plan Contract Year

Y0001_M_OT_WB_01239_R1 CMS Approved 06/02/2011 ©2011 Aetna Inc.

FID: 11195: version 40 August 2011

2011 Prescription Drugs that Require Prior Authorization Drugs

SYNAGIS

Covered Uses

All FDA approved indications not otherwise excluded from Part D.

Exclusion Criteria

congenital heart disease conditions such as Hemodynamically insignificant heart disease (e.g., secundum atrial septal defect, small ventricular septal defect (VSD), pulm

Required Medical Age Prescriber Coverage Other Criteria Info Restrictions Restrictions Duration

infants and children who need protection against lower respiratory tract infection with respiratory syncytial virus (RSV) AND a. Who are less than 24 months of age at the start of RSV season with bronchopulmonary dysplasia or other chronic lung disease (CLD) who have required medical therapy (supplemental oxygen, bronchodilator, and diuretic or corticosteroid therapy) for their CLD within 6 months before the anticipated RSV season OR b. Through End of Plan Contract Year

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SYNAGIS (continued)

Covered Uses

Exclusion Criteria

Required Medical Age Prescriber Coverage Other Criteria Info Restrictions Restrictions Duration

Infants born at 32 weeks of gestation or earlier (with or without CLD) who are less than 12 months of age at the start of RSV Season OR c. Infants born between 32 to 35 weeks of gestation who are younger than 6 months of age at the start of RSV season with at least two of the following risk factors for RSV Infection-i. Exposure to environmental air pollutants (including tobacco smoke if the family refuses to eliminate the infant's exposure to tobacco smoke in the home) or ii.

Y0001_M_OT_WB_01239_R1 CMS Approved 06/02/2011 ©2011 Aetna Inc.

FID: 11195: version 40 August 2011

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SYNAGIS (continued)

Covered Uses

Exclusion Criteria

Required Medical Age Prescriber Coverage Other Criteria Info Restrictions Restrictions Duration

Child care attendance or iii. School-aged siblings or iv. Severe neuromuscular disease or v. Congenital anomalies of the airways. OR d. Infants and children with severe immunodeficiencies who are less than 2 years of age at the start of the RSV season (e.g., severe combined immunodeficiency or severe acquired immunodeficiency syndrome) OR

Y0001_M_OT_WB_01239_R1 CMS Approved 06/02/2011 ©2011 Aetna Inc.

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2011 Prescription Drugs that Require Prior Authorization Drugs

SYNAGIS (continued)

Covered Uses

Exclusion Criteria

Required Medical Age Prescriber Coverage Other Criteria Info Restrictions Restrictions Duration

e. Infants and children with hemodynamically significant cyanotic or acyanotic congenital heart disease who are 24 months of age or younger at the onset of the RSV season, including the followingi. Infants receiving medication to control congestive heart failure or ii. Infants with moderate to severe pulmonary artery hypertension or iii. Infants with cyanotic congenital heart disease

Y0001_M_OT_WB_01239_R1 CMS Approved 06/02/2011 ©2011 Aetna Inc.

FID: 11195: version 40 August 2011

2011 Prescription Drugs that Require Prior Authorization Drugs

tacrolimus

Covered Uses

All FDA approved indications not otherwise excluded from Part D AND Prophylaxis of Corneal graft rejection, Graft versus host disease, Lichen planus, Liver transplant rejectionRescue, Psoriasis, Rejection of pancreas transplant, Prophylaxis of Rejection of pancreas transplant, Prophylaxis of Renal transplant rejection, Rescue of Renal transplant rejection, Rheumatoid arthritis, Prophylaxis of Transplantation of small intestine -Transplanted organ rejection All FDA-approved indications not otherwise excluded from Part D

Exclusion Criteria

patient is a recipient of a Medicare covered organ transplant

Required Medical Age Prescriber Coverage Other Criteria Info Restrictions Restrictions Duration

Through End of Plan Contract Yr

TALWIN

Covered for members less than 65 years of age Oncologist

Through End of Plan Contract Year 6 months Carcinoma of pancreas, Locally advanced, unresectable, or metastatic, first line treatment AND in combination with gemcitabine OR Non-small cell lung cancer, Locally advanced or metastatic AND failure of any prior chemotherapy

TARCEVA

All FDA approved indications not otherwise excluded from Part D

Y0001_M_OT_WB_01239_R1 CMS Approved 06/02/2011 ©2011 Aetna Inc.

FID: 11195: version 40 August 2011

2011 Prescription Drugs that Require Prior Authorization Drugs

TARGRETIN CAPSULE

Covered Uses

All FDA-approved indications not otherwise excluded from Part D

Exclusion Criteria

Required Medical Age Prescriber Coverage Other Criteria Info Restrictions Restrictions Duration

Oncologist Through End of Plan Contract Year Definite diagnosis of cutaneous T-cell lymphoma (CTCL) AND refractory to any prior systemic therapy (such as methotrexate) Diagnosis of cutaneous lesions in patients with cutaneous T-cell lymphoma (CTCL) (Stage IA and IB) AND refractory or persistent disease after other therapies or who have not tolerated other therapies which can include topical corticosteroids, methoxsalen, phototherapy, topical chemotherapy (mechlorethamine, carmustine)

TARGRETIN GEL

All FDA-approved indications not otherwise excluded from Part D

Oncologist

Through End of Plan Contract Year

Y0001_M_OT_WB_01239_R1 CMS Approved 06/02/2011 ©2011 Aetna Inc.

FID: 11195: version 40 August 2011

2011 Prescription Drugs that Require Prior Authorization Drugs

TASIGNA

Covered Uses

All FDA-approved indications not otherwise excluded from Part D

Exclusion Criteria

Required Medical Age Prescriber Coverage Other Criteria Info Restrictions Restrictions Duration

Oncologist 6 months Diagnosis of Chronic Myelogenous Leukemia in chronic phase or accelerated phase Philadelphia chromosome positive and resistant or intolerant to prior therapy with imatinib

terbinafine

All FDA approved indications not otherwise excluded from Part D OR Chromoblastomycosis OR Cutaneous leishmaniasis OR Cutaneous sporotrichosis OR Paracoccidioidomycosis OR Seborrheic dermatitis

Onychomycosis (Tinea unguium) due to dermatophyte AND A positive laboratory test such as (potassium hydroxideKOH preparation, fungal culture, or nail biopsy) to confirm the diagnosis of onychomycosis Covered for members greater than 8 years of age

6 months

tetracycline

All FDA-approved indications not otherwise excluded from Part D

Through End of Plan Contract Year

Y0001_M_OT_WB_01239_R1 CMS Approved 06/02/2011 ©2011 Aetna Inc.

FID: 11195: version 40 August 2011

2011 Prescription Drugs that Require Prior Authorization Drugs

THALOMID

Covered Uses

All FDA-approved indications not otherwise excluded from Part D and Waldenstrom's Macro-globulinemia (WM), Aphthous stomatitis or ulcers (AS) Crohn's Disease, Graft-versusHost Disease (GVHD) Primary Brain Tumors, AIDS-related cachexia or wasting Renal Cell Carcinoma, prostate cancer

Exclusion Criteria

Required Medical Age Prescriber Coverage Other Criteria Info Restrictions Restrictions Duration

Multiple myelomaOncologist AS-1 month, ENL, MM-1 year, WM, GVHD, and Primary Brain Tumors-6 months, Other Uses3 months A documented New diagnosis of multiple myeloma in combination with dexamethasone or conventional dose chemotherapy OR In combination with high dose chemotherapy with stem cell rescue OR A documented diagnosis of Salvage therapy in refractory or

Y0001_M_OT_WB_01239_R1 CMS Approved 06/02/2011 ©2011 Aetna Inc.

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THALOMID (continued)

Covered Uses

Exclusion Criteria

Required Medical Age Prescriber Coverage Other Criteria Info Restrictions Restrictions Duration

relapsed multiple myeloma after primary therapy OR In combination with dexamethasone, doxorubicin, cyclophosphamide, and etoposide as part of induction regimen prior to autologous transplant OR A documented Diagnosis of Waldenstrom's Macroglobulinemia (WM) AND Disease progression

Y0001_M_OT_WB_01239_R1 CMS Approved 06/02/2011 ©2011 Aetna Inc.

FID: 11195: version 40 August 2011

2011 Prescription Drugs that Require Prior Authorization Drugs

THALOMID (continued)

Covered Uses

Exclusion Criteria

Required Medical Age Prescriber Coverage Other Criteria Info Restrictions Restrictions Duration

on an alkylating agent, nucleoside analog, or rituximab OR A documented Diagnosis of Aphthous stomatitis or ulcers AND One of the following-Diagnosis of HIV-associated aphthous ulcers OR Recurrent aphthous stomatitis in immunocompromis ed patients-AND Refractory to alternative therapies

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FID: 11195: version 40 August 2011

2011 Prescription Drugs that Require Prior Authorization Drugs

THALOMID (continued)

Covered Uses

Exclusion Criteria

Required Medical Age Prescriber Coverage Other Criteria Info Restrictions Restrictions Duration

OR A documented Diagnosis of Crohn's Disease AND refractory to all of the following standard treatment regimensCorticosteroids, 5aminosalicylic acid, Immunomodulators , Remicade OR A documented Diagnosis of chronic or refractory Graftversus-Host Disease AND unresponsive

Y0001_M_OT_WB_01239_R1 CMS Approved 06/02/2011 ©2011 Aetna Inc.

FID: 11195: version 40 August 2011

2011 Prescription Drugs that Require Prior Authorization Drugs

THALOMID (continued)

Covered Uses

Exclusion Criteria

Required Medical Age Prescriber Coverage Other Criteria Info Restrictions Restrictions Duration

to all of the followingCorticosteroids, Azathioprine, Tacrolimus, Cyclosporine, Antithymocyte globulin OR A documented Diagnosis of Primary Brain Tumors AND used as adjuvant therapy to current cytotoxic therapies OR Previous failure to cytotoxic therapies and/or tumor resection OR A documented Diagnosis of AIDS wasting or cachexia (defined as

Y0001_M_OT_WB_01239_R1 CMS Approved 06/02/2011 ©2011 Aetna Inc.

FID: 11195: version 40 August 2011

2011 Prescription Drugs that Require Prior Authorization Drugs

THALOMID (continued)

Covered Uses

Exclusion Criteria

Required Medical Age Prescriber Coverage Other Criteria Info Restrictions Restrictions Duration

chronic unremitting weight loss of more than 10% body weight in the previous 4 months) AND Nutritional evaluation since onset of wasting first occurred AND Screened for hypogonadism AND

Y0001_M_OT_WB_01239_R1 CMS Approved 06/02/2011 ©2011 Aetna Inc.

FID: 11195: version 40 August 2011

2011 Prescription Drugs that Require Prior Authorization Drugs

THALOMID (continued)

Covered Uses

Exclusion Criteria

Required Medical Age Prescriber Coverage Other Criteria Info Restrictions Restrictions Duration

Failure to respond to hormone replacement therapy in patients with hypogonadism AND Failure, contraindication or intolerance to standard treatments (growth hormone, dronabinol, oxandrolone, megestrol) OR A documented Confirmed diagnosis of metastatic renal cell carcinoma AND Patient is refractory to Sutent, Nexavar, Afinitor

THALOMID (continued)

or Avastin OR A documented Diagnosis of androgenindependent prostate cancer AND Thalomid is being used as salvage therapy.

Y0001_M_OT_WB_01239_R1 CMS Approved 06/02/2011 ©2011 Aetna Inc.

FID: 11195: version 40 August 2011

2011 Prescription Drugs that Require Prior Authorization Drugs

THYMOGLOBULIN INJ

Covered Uses

All FDA approved indications not otherwise excluded from Part D AND Cardiac transplant rejection,Prophylaxis of Cardiac transplant rejection, Prophylaxis of Graft versus host disease, Rejection of pancreas transplant, Prophylaxis of Rejection All FDA-approved indications not otherwise excluded from Part D

Exclusion Criteria

patient is a recipient of a Medicare covered organ transplant

Required Medical Age Prescriber Coverage Other Criteria Info Restrictions Restrictions Duration

Through End of Plan Contract Yr

TRACLEER

Diagnosis of pulmonary arterial hypertension confirmed by right heart catheterization (RHC) Cosmetic use Approval will be given to all members using this agent for a medically necessary, FDA approved, noncosmetic indication.

Pulmonologist Through End or Cardiologist of Plan Contract Year

tretin-x

All FDA approved indications not otherwise excluded from Part D.

Through End of Plan Contract Yr

tretinoin capsule

All FDA-approved indications not otherwise excluded from Part D

Through End Diagnosis of acute of Plan promyelocytic Contract Yr leukemia AND refractory to anthracycline chemotherapy

Y0001_M_OT_WB_01239_R1 CMS Approved 06/02/2011 ©2011 Aetna Inc.

FID: 11195: version 40 August 2011

2011 Prescription Drugs that Require Prior Authorization Drugs

tretinoin cream/gel

Covered Uses

All FDA approved indications not otherwise excluded from Part D.

Exclusion Criteria

Cosmetic use

Required Medical Age Prescriber Coverage Other Criteria Info Restrictions Restrictions Duration

Approval will be given to all members using this agent for a medically necessary, FDA approved, noncosmetic indication. Covered for members less than 65 years of age Oncologist Through End of Plan Contract Yr

trimethobenzamide

All FDA approved indications not otherwise excluded from Part D

Through End of Plan Contract Year 6 months Diagnosis of Breast cancer, Advanced or metastatic, HER2 overexpression AND history of prior therapy with an anthracycline (ex. daunorubicin, bleomycin), a taxane (ex. Paclitaxel, docetaxel ), and trastuzumab AND used in combination with capecitabine

TYKERB

All FDA-approved indications not otherwise excluded from Part D

Y0001_M_OT_WB_01239_R1 CMS Approved 06/02/2011 ©2011 Aetna Inc.

FID: 11195: version 40 August 2011

2011 Prescription Drugs that Require Prior Authorization Drugs

TYSABRI

Covered Uses

All FDA approved indications not otherwise excluded from Part D

Exclusion Criteria

concurrent use or in combination with immunosuppressants (eg, azathioprine, cyclosporine, methotrexate, 6mercaptopurine) or inhibitors of TNFinhibitors ex such as infliximab, adalimumab, certolizumab

Required Medical Age Prescriber Coverage Other Criteria Info Restrictions Restrictions Duration

All FDA approved indications not otherwise excluded from Part D AND Diagnosis of Relapsing, remitting multiple sclerosis AND enrolled in the restricted distribution program called the TOUCHTM Prescribing Program Through End Diagnosis of of Plan Relapsing, Contract Yr remitting multiple sclerosis AND Prior use/failure of ONE standard MS therapies such as an interferon or copaxone AND Diagnosis of Crohn's disease (CD) with evidence of inflammation who have had an inadequate response to, or are unable to tolerate ONE

TYSABRI (continued)

conventional CD therapy such as 5ASA drugs, corticosteroids, immunosuppressa nts and ONE TNFinhibitors inhibitors ex such as infliximab, adalimumab, certolizumab

Y0001_M_OT_WB_01239_R1 CMS Approved 06/02/2011 ©2011 Aetna Inc.

FID: 11195: version 40 August 2011

2011 Prescription Drugs that Require Prior Authorization Drugs

TYZEKA

Covered Uses

All FDA approved indications not otherwise excluded from Part D

Exclusion Criteria

Required Medical Age Prescriber Coverage Other Criteria Info Restrictions Restrictions Duration

Through End of Plan Contract Year

VENOGLOBULIN

All FDA approved indications not otherwise excluded from Part D or Autoimmune hemolytic anemia , Autoimmune neutropenia, Prevention of bacterial infections in patients with hypogammaglobulinemia and/or recurrent bacterial infections associated with B-cell chronic lymphocytic leukemia, Adjunct therapy in bone marrow transplant recipients, Cytomegalovirus infection Treatment and Prophylaxis, Dermatomyositis as a second-line agent, Guillain-Barre syndrome, Haemophilus influenzae infection- Prophylaxis - Hemopoietic stem cell transplant Hemopoietic stem cell transplant - Streptococcal infectious disease- Prophylaxis, HIV infection in children, Inflammatory demyelinating polyradiculoneuropathy, chronic, Kidney disease, Myasthenia gravis, Neonatal jaundice, Respiratory syncytial virus infection in children, Sepsis, Toxic shock syndrome, Uveitis, von Willebrand disorder All FDA approved indications not othewise excluded from Part D. Infectious Disease Specialist FID: 11195: version 40 August 2011 6 months

VENOGLOBULIN (continued) VFEND

Y0001_M_OT_WB_01239_R1 CMS Approved 06/02/2011 ©2011 Aetna Inc.

2011 Prescription Drugs that Require Prior Authorization Drugs

VFEND INJ

Covered Uses

All FDA approved indications not othewise excluded from Part D. All FDA-approved indications not otherwise excluded from Part D

Exclusion Criteria

Required Medical Age Prescriber Coverage Other Criteria Info Restrictions Restrictions Duration

Infectious Disease Specialist Covered for members greater than 8 years of age 6 months

VIBRAMYCIN

Through End of Plan Contract Year Through End of Plan Contract Year Diagnosis of chronic hepatitis C genotype 1 AND failure of an adequate trial of 4 weeks of peginterferon alfa and ribavirin therapy AND concomitant use of peginterferon alfa and ribavirin therapy

VICTRELIS

All FDA-approved indications not otherwise excluded from Part D

VIMPAT

All FDA approved indications not otherwise excluded from Part D

Through End of Plan Contract Year Infectious Disease Specialist 6 months

voriconazole tablets

All FDA approved indications not othewise excluded from Part D.

VOTRIENT

All FDA-approved indications not otherwise excluded from Part D

Through End of Plan Contract Yr

Y0001_M_OT_WB_01239_R1 CMS Approved 06/02/2011 ©2011 Aetna Inc.

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2011 Prescription Drugs that Require Prior Authorization Drugs

XENAZINE

Covered Uses

All FDA approved indications not otherwise excluded from Part D and Tourette's syndrome, tardive dyskinesia All FDA-approved indications not otherwise excluded from Part D or hepatic encephalopathy

Exclusion Criteria

Required Medical Age Prescriber Coverage Other Criteria Info Restrictions Restrictions Duration

Through End of Plan Contract Year Through End of Plan Contract Year A documented diagnosis of hepatic encephalopathy AND trial of one month of one preferred alternative agent such as lactulose Through End Diagnosis of of Plan Moderate-severe Contract Yr persistent asthma AND inadequately controlled with one inhaled corticosteroid AND one of the following, one longacting betaagonists (LABAs) or one leukotriene inhibitors AND Persistent daily

XIFAXAN

XOLAIR

All FDA approved indications not otherwise excluded from Part D

Moderate-severe persistent asthma in those who have a positive skin test or in vitro reactivity to a perennial aeroallergen AND baseline serum IgE level is between 30 and 700 IU/mL

XOLAIR (continued)

asthma symtoms and overall poor asthma control

Y0001_M_OT_WB_01239_R1 CMS Approved 06/02/2011 ©2011 Aetna Inc.

FID: 11195: version 40 August 2011

2011 Prescription Drugs that Require Prior Authorization Drugs

XYREM

Covered Uses

All FDA approved indications not otherwise excluded from Part D

Exclusion Criteria

Required Medical Age Prescriber Coverage Other Criteria Info Restrictions Restrictions Duration

Treatment of excessive daytime sleepiness and cataplexy in patients with narcolepsyAND Enrolled in Xyrem Success Program Through End of Plan Contract Yr

YERVOY

All FDA approved indications not otherwise excluded from Part D All FDA approved indications not otherwise excluded from Part D

Through End of Plan Contract Yr Through End of Plan Contract Year Through End of Plan Contract Year Cutaneous T-cell lymphoma who have progressive, persistent or recurrent disease on or following two systemic therapies such as a retinoids or oral bexarotene

ZAVESCA

ZOLINZA

All FDA-approved indications not otherwise excluded from Part D

Y0001_M_OT_WB_01239_R1 CMS Approved 06/02/2011 ©2011 Aetna Inc.

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2011 Prescription Drugs that Require Prior Authorization Drugs

ZORTRESS

Covered Uses

All FDA approved indications not otherwise excluded from Part D

Exclusion Criteria

Required Medical Age Prescriber Coverage Other Criteria Info Restrictions Restrictions Duration

Through End Documented of Plan Diagnosis of of Contract Yr Prophylaxis of organ rejection in kidney transplant in combination with basiliximab (Simulect) during induction therapy and used concurrently with reduced doses of cyclosporine and corticosteroids

Y0001_M_OT_WB_01239_R1 CMS Approved 06/02/2011 ©2011 Aetna Inc.

FID: 11195: version 40 August 2011

2011 Prescription Drugs that Require Prior Authorization Drugs

ZOSTAVAX

Covered Uses

All FDA approved indications not otherwise excluded from Part D

Exclusion Criteria

history of primary or acquired immunodeficiency states including leukemia lymphomas of any type, or other malignant neoplasms affecting the bone marrow or lymphatic system or AIDS or other clinical manifestations of infection with human immunodeficiency viruses or if on immunosuppressive therapy, including high-dose corticosteroids or presence of active untreated tuberculosis

Required Medical Age Prescriber Coverage Other Criteria Info Restrictions Restrictions Duration

Covered for Members at least 60 years of age 30 days

Y0001_M_OT_WB_01239_R1 CMS Approved 06/02/2011 ©2011 Aetna Inc.

FID: 11195: version 40 August 2011

2011 Prescription Drugs that Require Prior Authorization Drugs

ZYVOX

Covered Uses

All FDA-approved indications not otherwise excluded from Part D OR Febrile neutropenia

Exclusion Criteria

Required Medical Age Prescriber Coverage Other Criteria Info Restrictions Restrictions Duration

30 days FDA-approved indication not otherwise excluded from Part D AND trial of three days each of two preferred antibiotics indicated for the members condition such as amoxicillin or moxifloxacin or azithromycin or cephalosporin or clindamycin or dicloxicillin OR Discharge from hospital or medical facility due to a documented diagnosis /COVERED USE AND

Documented initial treatment with vancomycin OR intravenous (IV) Zyvox (linezolid) while in the hospital/ medical facility

Y0001_M_OT_WB_01239_R1 CMS Approved 06/02/2011 ©2011 Aetna Inc.

FID: 11195: version 40 August 2011

2011 Prescription Drugs that Require Prior Authorization

The prescription drugs below 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. acetylcysteine sol ACTEMRA AMINOSYN-HBC AMINOSYN-HF CAMPATH CELLCEPT CEREDASE CEREZYME CESAMET CLINISOL SF cromolyn sodium neb cyclophosphamide tab cyclosporine DOCEFREZ docetaxel/ DOCETAXEL dronabinol EMEND ENGERIX-B foscarnet sod GABLOFEN GAMASTAN S/D GAMMAGARD GAMMAGARD GAMMAPLEX GAMUNEX GAMUNEX/ GAMUNEX-C gemcitabine GEMZAR granisetron granisol HAVRIX HIZENTRA IMOVAX RABIES ipratropium /albuterol sol ipratropium inh soln KEPIVANCE leucovorin /calcium inj levalbuterol soln mannitol inj melphalan inj metaproterenol soln mitoxantrone mycophenolate MYFORTIC NEBUPENT NEB SOLN NEPHRAMINE NULOJIX OCTAGAM ondansetron ORTHOCLONE POLYGAM S/D premasol PROCRIT PROGRAF PROLIA prosol RABAVERT RAPAMUNE PULMOZYME RECOMBIVAX HB REMICADE RENAMIN RITUXAN SANCUSO tacrolimus TAXOTERE terbutaline TETANUS TOXOID TOBI topotecan inj THYMOGLOBULIN trexall TYSABRI VAQTA VENOGLOBULIN YERVOY

albuterol sulfate neb AMINOSYN-PF ALKERAN amifostine AMINOSYN AMINOSYN II AMINOSYN II M/ DEXTROSE AMINOSYN II/LYTES AMINOSYN M AMINOSYN/ DEXTROSE AMINOSYN II/ DEXTROSE ANZEMET TAB ARANESP ATGAM AVASTIN azasan azathioprine tab/inj bleomycin BOTOX budesonide susp

Y0001_M_OT_WB_01239_R1 CMS Approved 06/02/2011 ©2011 Aetna Inc.

FID: 11195: version 40 August 2011

2011 Prescription Drugs that Require Prior Authorization

AMINOSYN/LYTES calcium folinate inj ELOXATIN gengraf methotrexate inj PRIVIGEN SIMULECT ZENAPAX ZOTRESS

Y0001_M_OT_WB_01239_R1 CMS Approved 06/02/2011 ©2011 Aetna Inc.

FID: 11195: version 40 August 2011

2011 Prescription Drugs that Require Prior Authorization

The prescription drugs below fall under the End-Stage Renal Disease (ESRD) prospective payment system for ESRD dialysis patients ONLY. Information may need to be submitted describing the use and setting of the drug to make the determination.

ABBOKINASE INJ

CALCIJEX INJ

CUBICIN INJ

EPOGEN

imferon inj

lidocaine/prilocaine cream

protamine sulfate inj VANCOCIN HCL INJ VANCOMYCIN IN DEXTROSE

ACTIVASE INJ

calcitriol cap/inj/soln cyanocobalamin inj

FERRLECIT INJ

infed inj

lidocaine inj 0.5,1,1.5,2%

REFLUDAN INJ

ARANESP

calcium gluconate inj deferoxamine inj

HECTOROL CAP/INJ

iron dextran inj

MIACALCIN INJ

RETAVASE

INJ

vancomycin inj

AREDIA

CARNITOR INJ/SOLN/TAB

DEXFERRUM INJ

heparin lock inj 10, 100units/ml

KINLYTIC INJ

pamidronate inj

ROCALTROL CAP/SOLN

VENOFER INJ

BONIVA TAB/KIT

CATHFLO ACTIVASE INJ

EMLA

heparin sodium inj 1000units/ml

levocarnitine inj/tab/soln

PROCRIT INJ

SYNERA

ZEMPLAR CAP/INJ

Y0001_M_OT_WB_01239_R1 CMS Approved 06/02/2011 ©2011 Aetna Inc.

FID: 11195: version 40 August 2011

Information

2011 Aetna Medicare Prescription Drugs that Require Prior Authorization

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