Children with cystic fibrosis (unless the child has clinical evidience of CLD and/or nutrional compromise in the first year of life) or Down Syndrome (unless qualifying heart disease or prematuity) Can be authorized for patients who meet ONE the following: Initial: Tarceva Locally advanced, unresectable or metastatic pancreatic cancer when used in combination with gemcitabine Last reviewed: 10/01/14 (Gemzar) for the first-line treatment benefit First-line treatment of advanced or metastatic NSCLC with epidermal growth factor receptor (EGFR) exon 19 growth deletions or exon 21 (L858R) substitution mutations as detected by an FDA-approved test (e.g. cobas® EGFR of Mutation Test) Locally advanced or metastatic NSCLC after failure of at least one prior chemotherapy regimen report Maintenance therapy in locally advanced or metastatic NSCLC where disease has not progressed after 4 cycles of first-line chemotherapy Topical NSAIDs Criteria for Approval: Initial A. Age 18 or older Flector Voltaren gel B History of or high risk for adverse GI effects associated with oral NSAID use AND trial and failure of celecoxib; OR All Pennsaid C High risk for other adverse effects associated with oral NSAID use (i.e., CHF, renal failure, concomitant use of lithium); OR Flector patch D. Failure on TWO formulary NSAIDs E. Diagnosis of OA of knee or hand for Voltaren gel Flector F. Diagnosis of OA of knee for Pennsaid All Note: Flector patch is only FDA approved for acute pain. Requests for Flector patch for chronic pain should be denied. If patient meets all other criteria above, offer Voltaren Gel or Pennsaid as an alternative. The risk factors that correlate strongly to adverse GI effects of oral NSAID use are: History of GERD, GI bleed, or ulcer Chronic oral use Current anticoagulant or antiplatelet use Age 65 or greater
Children with cystic fibrosis (unless the child has clinical evidience of CLD and/or nutrional compromise in the first year of life) or Down Syndrome (unless qualifying heart disease or prematuity) Tarceva Last reviewed: 10/01/14 Can be authorized for patients who meet ONE the following: Locally advanced, unresectable or metastatic pancreatic cancer when used in combination with gemcitabine (Gemzar) for the first-line treatment First-line treatment of advanced or metastatic NSCLC with epidermal growth factor receptor (EGFR) exon 19 deletions or exon 21 (L858R) substitution mutations as detected by an FDA-approved test (e.g. cobas® EGFR Mutation Test) Locally advanced or metastatic NSCLC after failure of at least one prior chemotherapy regimen Maintenance therapy in locally advanced or metastatic NSCLC where disease has not progressed after 4 cycles of first-line chemotherapy Initial: benefit growth of report Topical NSAIDs Voltaren gel Pennsaid Flector patch Criteria for Approval: A. Age 18 or older B History of or high risk for adverse GI effects associated with oral NSAID use AND trial and failure of celecoxib; OR C High risk for other adverse effects associated with oral NSAID use (i.e., CHF, renal failure, concomitant use of lithium); OR D. Failure on TWO formulary NSAIDs E. Diagnosis of OA of knee or hand for Voltaren gel F. Diagnosis of OA of knee for Pennsaid Note: Flector patch is only FDA approved for acute pain. Requests for Flector patch for chronic pain should be denied. If patient meets all other criteria above, offer Voltaren Gel or Pennsaid as an alternative. The risk factors that correlate strongly to adverse GI effects of oral NSAID use are: History of GERD, GI bleed, or ulcer Chronic oral use Current anticoagulant or antiplatelet use Age 65 or greater Initial Flector All Flector All
2016%20Illinois%20Medicaid%20PA%20Guideline%20Chart.v5.docx