For Crohn’s Disease, all of the following: Additional Renewals: Trial and failure of a compliant regimen of oral corticosteroids (for moderate to severe CD) or For Multiple Sclerosis: intravenous corticosteroids (for severe and fulminant CD) for one month (or documented Approve for 6 months, contraindication or intolerance to PO or IV corticosteroids); and up to 2 total, if Trial and failure of a compliant regimen of azathioprine or mercaptopurine for three patient is responding consecutive months (or documented contraindication or intolerance to azathioprine or For Crohn’s Disease: mercaptopurine); and If member is unable to Trial and failure of a compliant regimen of Humira OR Remicade for at least 3 months taper off of steroids in the first 6-months, d/c natalizumab If patient has responded, approve for 6 months Velphoro For patients that meet all of the following: Initial Approval: Diagnosis of hyperphosphatemia 1 year At least 18 years old Receiving dialysis Renewal: Failed at least 2 formulary phosphate binding agents such as calcium acetate capsules or 1 year tablets, sevelamer carbonate (Renvela), or Renagel Weight Reduction For patients who meet all of the following: Initial Approval: Medications BMI 30 kg/m2 (obese) 3 months ≥ Xenical OR Renewal: Belviq BMI 27kg/m2 (overweight) and one of the following obesity-related chronic diseases and Xenical and Belviq: ≥ Bontril risk factors: 3 months Didrex Coronary heart disease Requires documentation of phentermine Dyslipidemia: a weight loss of at least 4 Tenuate HDL <35mg/dl or pounds per month Qsymia LDL 160mg/dL, or ≥ Contrave Triglycerides 400mg/dl All others: ≥ Controlled hypertension (less than> 140/90mm Hg) Treatment beyond 3 months is not Type II diabetes mellitus Sleep apnea
For Crohn’s Disease, all of the following: Trial and failure of a compliant regimen of oral corticosteroids (for moderate to severe CD) or intravenous corticosteroids (for severe and fulminant CD) for one month (or documented contraindication or intolerance to PO or IV corticosteroids); and Trial and failure of a compliant regimen of azathioprine or mercaptopurine for three consecutive months (or documented contraindication or intolerance to azathioprine or mercaptopurine); and Trial and failure of a compliant regimen of Humira OR Remicade for at least 3 months Additional Renewals: For Multiple Sclerosis: Approve for 6 months, up to 2 total, if patient is responding For Crohn’s Disease: If member is unable to taper off of steroids in the first 6-months, d/c natalizumab If patient has responded, approve for 6 months Velphoro For patients that meet all of the following: Diagnosis of hyperphosphatemia At least 18 years old Receiving dialysis Failed at least 2 formulary phosphate binding agents such as calcium acetate capsules or tablets, sevelamer carbonate (Renvela), or Renagel Initial Approval: 1 year Renewal: 1 year Weight Reduction Medications Xenical Belviq Bontril Didrex phentermine Tenuate Qsymia Contrave For patients who meet all of the following: BMI ≥ 30 kg/m2 (obese) OR BMI ≥ 27kg/m2 (overweight) and one of the following obesity-related chronic diseases and risk factors: Coronary heart disease Dyslipidemia: HDL <35mg/dl or LDL ≥ 160mg/dL, or Triglycerides ≥ 400mg/dl Controlled hypertension (less than> 140/90mm Hg) Type II diabetes mellitus Sleep apnea Initial Approval: 3 months Renewal: Xenical and Belviq: 3 months Requires documentation of a weight loss of at least 4 pounds per month All others: Treatment beyond 3 months is not
MMIC-PA-SMI-Guidelines.docx