Patient has indications for treatment such as: Systemic symptoms fatigue, weakness, weight loss, fever, night sweats – Symptomatic splenomegaly or adenopathy Significant cytopenias hemoglobin < 12 g/dL, platelet < 100,000/mcL, or ANC – < 1000/mcL Patient is at 18 years old Malignant Melanoma: (Intron A, Sylatron) Prescribed by, or in consultation with a hematologist/oncologist Patient has undergone surgical resection AND is at high risk for recurrence (e.g., primary tumor > 4 mm thick, presence of ulceration, lymph node involvement) Patient is at least 18 years old Chronic Granulomatous Disease: (Actimmune) Prescribed by, or in consultation with an immunologist Patient is also receiving prophylactic antimicrobials (such as itraconazole and trimethoprim/sulfamethoxazole) Malignant Osteopetrosis: (Actimmune) Prescribed for the treatment of severe, malignant osteopetrosis Intravaginal For patients that meet the following: Initial Approval: Progesterone products Prescribed by a provider of obstetrical care Approve as requested Last reviewed: 4/22/15 Patient is not on Makena (17-hydroxyprogesterone) until 37 weeks gestation Patient is pregnant and has 1 of the following: progesterone capsules, Patient has a cervix Crinone, OR Patient is at high risk for pregnancy loss based on other risk factors suppositories Invokana For patients that meet all of the following: Initial Approval:
Patient has indications for treatment such as: Systemic symptoms – fatigue, weakness, weight loss, fever, night sweats Symptomatic splenomegaly or adenopathy Significant cytopenias – hemoglobin < 12 g/dL, platelet < 100,000/mcL, or ANC < 1000/mcL Patient is at 18 years old Malignant Melanoma: (Intron A, Sylatron) Prescribed by, or in consultation with a hematologist/oncologist Patient has undergone surgical resection AND is at high risk for recurrence (e.g., primary tumor > 4 mm thick, presence of ulceration, lymph node involvement) Patient is at least 18 years old Chronic Granulomatous Disease: (Actimmune) Prescribed by, or in consultation with an immunologist Patient is also receiving prophylactic antimicrobials (such as itraconazole and trimethoprim/sulfamethoxazole) Malignant Osteopetrosis: (Actimmune) Prescribed for the treatment of severe, malignant osteopetrosis Intravaginal Progesterone products Last reviewed: 4/22/15 progesterone capsules, Crinone, suppositories For patients that meet the following: Prescribed by a provider of obstetrical care Patient is not on Makena (17-hydroxyprogesterone) Patient is pregnant and has 1 of the following: Patient has a cervix OR Patient is at high risk for pregnancy loss based on other risk factors Initial Approval: Approve as requested until 37 weeks gestation Invokana For patients that meet all of the following: Initial Approval: