PROLIA SOLUTION 60 MG/ML SUBCUTANEOUS Details Criteria Patient needs to have a paid claim for one Step 1 drug (alendronate, ibandronate, pamidronate, or zolendronic acid) prior to filling a Prolia. For osteoporosis prophylaxis in men at high risk for bone fractures after receiving androgen deprivation therapy for nonmetastatic prostate cancer and in women at high risk for bone fractures after receiving adjuvant aromatase inhibitor therapy for breast cancer, Prolia will be approved. RHEUMATOID ARTHRITIS Products Affected Step 2: ACTEMRA SOLUTION 200 MG/10ML ORENCIA SOLUTION PREFILLED INTRAVENOUS SYRINGE 125 MG/ML ACTEMRA SOLUTION 400 MG/20ML SUBCUTANEOUS INTRAVENOUS ORENCIA SOLUTION PREFILLED ACTEMRA SOLUTION 80 MG/4ML SYRINGE 50 MG/0.4ML INTRAVENOUS SUBCUTANEOUS ACTEMRA SOLUTION PREFILLED ORENCIA SOLUTION PREFILLED SYRINGE 162 MG/0.9ML SYRINGE 87.5 MG/0.7ML SUBCUTANEOUS SUBCUTANEOUS CIMZIA KIT 2 X 200 MG ORENCIA SOLUTION SUBCUTANEOUS RECONSTITUTED 250 MG CIMZIA PREFILLED KIT 2 X 200 INTRAVENOUS MG/ML SUBCUTANEOUS SIMPONI ARIA SOLUTION 50 COSENTYX 300 DOSE SOLUTION MG/4ML INTRAVENOUS PREFILLED SYRINGE 150 MG/ML SIMPONI SOLUTION SUBCUTANEOUS 100 MG/ML COSENTYX SENSOREADY 300 DOSE SUBCUTANEOUS SOLUTION AUTO-INJECTOR 150 SIMPONI SOLUTION MG/ML SUBCUTANEOUS 50 MG/0.5ML KINERET SOLUTION PREFILLED SUBCUTANEOUS SYRINGE 100 MG/0.67ML SIMPONI SOLUTION PREFILLED SUBCUTANEOUS SYRINGE 100 MG/ML ORENCIA CLICKJECT SOLUTION SUBCUTANEOUS AUTO-INJECTOR 125 MG/ML SIMPONI SOLUTION PREFILLED SUBCUTANEOUS SYRINGE 50 MG/0.5ML SUBCUTANEOUS
PROLIA SOLUTION 60 MG/ML SUBCUTANEOUS Details Criteria Patient needs to have a paid claim for one Step 1 drug (alendronate, ibandronate, pamidronate, or zolendronic acid) prior to filling a Prolia. For osteoporosis prophylaxis in men at high risk for bone fractures after receiving androgen deprivation therapy for nonmetastatic prostate cancer and in women at high risk for bone fractures after receiving adjuvant aromatase inhibitor therapy for breast cancer, Prolia will be approved. RHEUMATOID ARTHRITIS Products Affected Step 2: ACTEMRA SOLUTION 200 MG/10ML INTRAVENOUS ACTEMRA SOLUTION 400 MG/20ML INTRAVENOUS ACTEMRA SOLUTION 80 MG/4ML INTRAVENOUS ACTEMRA SOLUTION PREFILLED SYRINGE 162 MG/0.9ML SUBCUTANEOUS CIMZIA KIT 2 X 200 MG SUBCUTANEOUS CIMZIA PREFILLED KIT 2 X 200 MG/ML SUBCUTANEOUS COSENTYX 300 DOSE SOLUTION PREFILLED SYRINGE 150 MG/ML SUBCUTANEOUS COSENTYX SENSOREADY 300 DOSE SOLUTION AUTO-INJECTOR 150 MG/ML SUBCUTANEOUS KINERET SOLUTION PREFILLED SYRINGE 100 MG/0.67ML SUBCUTANEOUS ORENCIA CLICKJECT SOLUTION AUTO-INJECTOR 125 MG/ML SUBCUTANEOUS ORENCIA SOLUTION PREFILLED SYRINGE 125 MG/ML SUBCUTANEOUS ORENCIA SOLUTION PREFILLED SYRINGE 50 MG/0.4ML SUBCUTANEOUS ORENCIA SOLUTION PREFILLED SYRINGE 87.5 MG/0.7ML SUBCUTANEOUS ORENCIA SOLUTION RECONSTITUTED 250 MG INTRAVENOUS SIMPONI ARIA SOLUTION 50 MG/4ML INTRAVENOUS SIMPONI SOLUTION 100 MG/ML SUBCUTANEOUS SIMPONI SOLUTION 50 MG/0.5ML SUBCUTANEOUS SIMPONI SOLUTION PREFILLED SYRINGE 100 MG/ML SUBCUTANEOUS SIMPONI SOLUTION PREFILLED SYRINGE 50 MG/0.5ML SUBCUTANEOUS