Multaq Multaq will be authorized when prescribed by, or in consultation with a cardiologist. If not Initial Approval: prescribed by or in consultation with a cardiologist, the following must be met: Indefinite Diagnosis is atrial fibrillation Patient has tried and failed amiodarone Age restriction: must be at least 18 years old Multiple Sclerosis Aubagio, Avonex, Betaseron, Copaxone, Extavia, Gilenya, Glatopa, glatiramer, Lemtrada, Agents Mitoxantrone, Plegridy, Tecfidera, Tysabri See Detailed document: Neumega May be authorized for the treatment of chemotherapy-induced thrombocytopenia when the Initial Approval: following are met: Up to 21 days’ Last reviewed: 10/22/2015 Prescribed by a hematologist/oncologist supply Patient is at least 12 years old Refills if number of Patient has a non-myeloid malignancy and is receiving myelosuppressive chemotherapy cycles provided Patient is at high risk of severe thrombocytopenia or has experienced severe thrombocytopenia with a previous chemotherapy Renewal: Administered 6 24 hours after the completion of chemotherapy Approval up to 1 – NOT being used in the following situations: year myeloablative therapy Requires recent platelet Chemotherapy regimen longer than 5 days count Concurrently with agents associated with delayed myelosuppression (e.g., nitrosoureas, mitomycin C) Nexavar Nexavar, when prescribed by an oncologist for patients at 18 years old, can be authorized for Initial: 1 year Last reviewed: 1/19/2016 the following indications: Treatment of relapsed or unresectable stage IV predominantly clear cell renal cell carcinoma Renewal: 3 years if (RCC) after treatment failure with Sutent or Votrient evidence of stable disease
Multaq Multaq will be authorized when prescribed by, or in consultation with a cardiologist. If not prescribed by or in consultation with a cardiologist, the following must be met: Diagnosis is atrial fibrillation Patient has tried and failed amiodarone Age restriction: must be at least 18 years old Initial Approval: Indefinite Multiple Sclerosis Agents Aubagio, Avonex, Betaseron, Copaxone, Extavia, Gilenya, Glatopa, glatiramer, Lemtrada, Mitoxantrone, Plegridy, Tecfidera, Tysabri See Detailed document: Neumega Last reviewed: 10/22/2015 May be authorized for the treatment of chemotherapy-induced thrombocytopenia when the following are met: Prescribed by a hematologist/oncologist Patient is at least 12 years old Patient has a non-myeloid malignancy and is receiving myelosuppressive chemotherapy Patient is at high risk of severe thrombocytopenia or has experienced severe thrombocytopenia with a previous chemotherapy Administered 6 – 24 hours after the completion of chemotherapy NOT being used in the following situations: myeloablative therapy Chemotherapy regimen longer than 5 days Concurrently with agents associated with delayed myelosuppression (e.g., nitrosoureas, mitomycin C) Initial Approval: Up to 21 days’ supply Refills if number of cycles provided Renewal: Approval up to 1 year Requires recent platelet count Nexavar Last reviewed: 1/19/2016 Nexavar, when prescribed by an oncologist for patients at 18 years old, can be authorized for the following indications: Treatment of relapsed or unresectable stage IV predominantly clear cell renal cell carcinoma (RCC) after treatment failure with Sutent or Votrient Initial: 1 year Renewal: 3 years if evidence of stable disease
Mercy-Maricopa-Integrated-Care-PA-Guidelines-SMI.docx