Last reviewed: 04/08/15 The patient has failed latanoprost Lumigan Travoprost Travatan Z Oral Platelet Effient or Brilinta can be approved for patients who meet the following: Initial Inhibitors and Diagnosis of ACS (unstable angina, STEMI, NSTEMI) Last reviewed: 07/1/15 12 Failure or contraindication/intolerance to clopidogrel, including patients identified as CYP2C19 poor metabolizers No active pathological bleeding, history of intracranial hemorrhage, or planned CABG Effient In addition, for Effient: Brilinta be Age <75 unless patient is considered high thromboembolic risk Zontivity a Taking concomitant 75-325mg/day aspirin No history of TIA or stroke In addition, for Brilinta: Initial Taking concomitant 75-100mg/day aspirin No severe hepatic impairment No concomitant use with medications known to interact with Brilinta (i.e., potent CYP3A4 inhibitors/inducers and simvastatin or lovastatin in doses >40mg/day) without provider documentation that benefit outweighs the risk Zontivity can be approved for patients who meet the following: 12 Prescribed for the secondary prevention of atherothrombosis in patients with PAD or history of MI (drug NOT indicated for ACS) Must be used with aspirin and/or clopidogrel according to the standard of care for the patient’s diagnosis No evidence of contraindications: history of stroke, transient ischemic attack (TIA), or intracranial hemorrhage (ICH); or active pathological bleeding General authorization criteria for all indications: Orencia[viii] Initial Prescribed by a rheumatologist Last reviewed: 10/22/2015 Patient is NOT on another biological DMARD Patient is up to date with all recommended vaccinations Patient has been screened for latent TB and hepatitis B
Last reviewed: 04/08/15 Lumigan Travoprost Travatan Z The patient has failed latanoprost Oral Platelet Inhibitors Last reviewed: 07/1/15 Effient Brilinta Zontivity Effient or Brilinta can be approved for patients who meet the following: Diagnosis of ACS (unstable angina, STEMI, NSTEMI) Failure or contraindication/intolerance to clopidogrel, including patients identified as CYP2C19 poor metabolizers No active pathological bleeding, history of intracranial hemorrhage, or planned CABG In addition, for Effient: Age <75 unless patient is considered high thromboembolic risk Taking concomitant 75-325mg/day aspirin No history of TIA or stroke In addition, for Brilinta: Taking concomitant 75-100mg/day aspirin No severe hepatic impairment No concomitant use with medications known to interact with Brilinta (i.e., potent CYP3A4 inhibitors/inducers and simvastatin or lovastatin in doses >40mg/day) without provider documentation that benefit outweighs the risk Zontivity can be approved for patients who meet the following: Prescribed for the secondary prevention of atherothrombosis in patients with PAD or history of MI (drug NOT indicated for ACS) Must be used with aspirin and/or clopidogrel according to the standard of care for the patient’s diagnosis No evidence of contraindications: history of stroke, transient ischemic attack (TIA), or intracranial hemorrhage (ICH); or active pathological bleeding Initial and 12 be a Initial 12 Orencia[viii] Last reviewed: 10/22/2015 General authorization criteria for all indications: Prescribed by a rheumatologist Patient is NOT on another biological DMARD Patient is up to date with all recommended vaccinations Patient has been screened for latent TB and hepatitis B Initial
2016%20Illinois%20Medicaid%20PA%20Guideline%20Chart.v5.docx