Restat Recommended Drug Coverage Standards

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Restat Recommended Drug Coverage Standards Powered By Docstoc
					                                                                                                                                        Updated: 5/1/2012
                                                         Restat
                                            Recommended Drug Coverage Standards

Restat Standard Exclusions - Not Covered
Drug                          Use
Apptrim Kits                  Nutritional Supplement for weight loss.
Arestin                       Periodontal use only
Botox Cosmetic                Wrinkles
Cleeravue-M Kit 50mg          Minocycline and eye lid cleanser. No advantage to previously marketed products and generics
Domperidone powder            Use in compounds- Considered experimental treatment.
Entereg                       Hospital use product only after bowel resection
Estriol powder (Triest)       Use in compounded hormones- Considered experimental treatment.
Femcap                        Cervical Caps, not available at retail pharmacies.
FluMist                       Flu Shot- Medical Claim
GlucoWatch G2                 Diabetic Monitor- Medical Claim
Hydrocodone powder            Use in compounds- manual claim only
Implanon Implant 68mg         Progestin Implant Contraceptive. Medical Claim, not used in retail pharmacies.
IV Drugs                      Rarely if ever used in retail pharmacies
Keflex 750mg                  No advantage to previously marketed products and generics
Mifeprex                      Abortion Pill
Minocin Pak                   Combo of brand Minocin and acne products. No advantage to previously marketed products and generics
Mirena                        IUD- Medical Claim
Naproxen Kit Comfort          Contains generic naproxen and an ointment. No advantage to previously marketed products and generics
Oxycodone powder              Use in compounds- manual claim only
Pedipirox-4 Kit Nail          Topical Antifungal kit with lacquer removal pads and foot powder
Plenaxis                      Cancer drug Manufacturer only sells to physician's offices
                              Lytensopril, Senophylline, Trazamine, Stazepam, Theraproxen, Prazolamine, Appbutamone, Appformin, Gabazolamine,
Phys. Therapeutics Generic /  Gabitidine, Gaboxetine, Hypertensolo, Pulmophyllin, Rimantalist, Sentradine, Sentroxatine, Therafeldami, Therapentin,
Vitamin paks                  Theraprofen, Theratramado paks are blocked. Significantly more expensive without advantage over previously marketed products
Progesterone Suppositories    Not officially marketed in the U.S. Considered experimental treatment.
Rosadan                       Metronidazole cream with cleanser kit
Solodyn                       No advantage to previously marketed products and generics
Sumadan Kit                   Acne kit with skin cleanser
Sumaxin CP Kit                Acne kit with skin cleanser
Toxoids, Vaccines             Administered in physician's office
Restat Exclusions Covered Only With Clinical Prior Authorization (Recommended)
Drug or Category              Notes
Abstral                       Only indicated for Breakthrough cancer pain
Actiq                         Only indicated for Breakthrough cancer pain
Adcirca                       Pulmonary arterial hypertension (PAH)
Afinitor                      Advanced renal cell carcinoma, Renal transplantation
ALL DIET PILLS                BMI >= 30Kg/m2 or >= 27Kg/m2 with other risk factors
Amevive                       Moderate to severe chronic plaque psoriasis
Amitiza                       Chronic Idiopathic Constipation in adults
Amrix                         Long-acting cyclobenzaprine
ANABOLIC STEROIDS             Osteoporosis, HIV wasting, Protein catabolism
ANDROGENS (ex. Androgel)      Hypogonadism, Delayed Puberty, Panhypopituitarism
Aplenzin                      Major depressive disorder (MDD)
Apokyn                        Parkinson's Disease "off" episodes
Arcalyst                      Specialty injectable to treat CAPS, a rare, genetic inflammatory disorder
Aricept 23 mg                 High dose formulation for the treatment of moderate to severe Alzheimer's disease (AD)
BiDil                         For prevention of cardiac events in African Americans
Botox                         Indicated for Axillary hyperhidrosis, Cervical Dystonia, Strabismus and blepharospasm, Upper limb spasticity
Bydureon                      Long-acting version of the diabetes drug Byetta
Byetta                        Injectable for Type II diabetes
Cambia                        Acute treatment of migraine attacks
Celebrex 50 mg                Only indicated for Juvenile Rheumatoid Arthritis (JRA), for patients weighing less than 25Kg (55 lbs)
Celebrex 400 mg               Indicated for Ankylosing spondylitis and Familial adenomatous polyposis (FAP)
Cimzia                        Injectable used for Crohn disease and Rheumatoid arthritis
Cinryze                       Prophylaxis against angioedema attacks with Hereditary angioedema
ConZip                        Extended release formulation of tramadol. Tramadol IR is available generically.
Dificid                       Treatment of Clostridium difficile -associated diarrhea (CDAD)
Doryx 150 mg                  New strength of doxycycline, an antibiotic used to treat many kinds of infections
Dysport                       Newest Botox alternative, approved for the treatment of Cervical Dystonia
Edluar                        Sublingual formulation for Insomnia
Eligard                       Treats Advanced prostatic cancer
Enbrel                        Ankylosing spondylitis, Plaque psoriasis, Polyarticular juvenile idiopathic arthritis, Psoriatic arthritis, Rheumatoid arthritis
Euflexxa                      Intra-articular injection for the treatment of pain in osteoarthritis of the knee
Exjade                        Used to treat chronic iron overload due to blood transfusions.
Fentora                       Only indicated for Breakthrough cancer pain
Ferriprox                     Treats patients with excess iron in the body
Fexmid                        Centrally-acting skeletal muscle relaxant
Forteo                        Specific Osteoporosis Use
Gleevec                       Specific cancer use
Gralise                       Once-a-day tablet formulation of gabapentin
GROWTH HORMONES               Need to see patient's growth chart yearly for dose calculation
Hizentra                      Primary immune deficiency
Humira                        Ankylosing spondylitis, Crohn disease, Juvenile idiopathic arthritis, Plaque psoriasis, Psoriatic arthritis, Rheumatoid arthritis
Hyalgan                       Intra-articular injection for the treatment of pain in osteoarthritis of the knee
Hycamtin                      Relapsed small cell lung cancer
Hylira lotion                 For use as an emollient. Must fail other prescription emollients prior to use of Hylira.
Incivek                       Used to treat certain adults with chronic hepatitis C infection
                                                                                                                                      Updated: 5/1/2012
                                                         Restat
                                            Recommended Drug Coverage Standards

Iressa                             Specific Cancer Use
Jakafi                             First drug approved for rare marrow disease
Jalyn                              Combination product to treat symptomatic benign prostatic hyperplasia (BPH) in men with an enlarged prostate
Kalydeco                           Treats a rare form of Cystic Fibrosis
Kineret                            Rheumatoid arthritis
Korlym                             Controls high blood sugar levels in adults with endogenous Cushing's syndrome
Kuvan                              To treat Phenylketonuria, Specialty Distribution only
Lazanda                            Only indicated for Breakthrough cancer pain
leuprolide acetate                 Treats Advanced prostatic cancer
Letairis                           Oral product, Specialty Pharmacy Only, for Pulmonary artherial hypertension (PAH)
Liqadd                             Liquid brand form of dextroamphetamine
Lotronex                           Females with IBS-diarrhea dominant only
Lupron Depot                       Treats Advanced prostatic cancer, Endometriosis, and Fibroids
Lupron Depot-Ped                   Treats children with central precocious puberty (CPP)
Mozobil                            Peripheral stem cell collection and transplantation
Myobloc                            Cervical dystonia
Nexavar                            For Advanced renal cell carcinoma and Hepatocellular carcinoma
Nuedexta                           Treats Laughing and Crying Outbursts
Oleptro                            Extended release formulation of trazodone for the treatment of MDD
Omontys                            Treats anemia in adult patients on dialysis
Onfi                               Treats severe type of seizures
Onsolis                            Only indicated for Breakthrough cancer pain
Oracea                             For rosacea in adults, must fail other forms of doxycycline prior to Oracea use
Orencia                            Adult rheumatoid arhtritis (RA) and Juvenile idiopathic arthritis
Oforta                             B-cell chronic lymphocytic leukemia
Orthovisc                          Intra-articular injection for the treatment of pain in osteoarthritis of the knee
Pennsaid                           Topical treatment for Osteoarthritis of the knee(s)
Potiga                             An add-on medication to treat seizures associated with epilepsy in adults
Pradaxa                            Oral Anticoagulant, may be an alternative to the generic blood thinner warfarin
Pristiq                            New SNRI antidepressant, which is the active metabolite of venlafaxine (Effexor). No efficacy advantage over Effexor XR
Procentra                          Liquid brand form of dextroamphetamine
Prolia                             Injectable medication for osteoporosis every 6 months
Promacta                           Thrombocytopenia
Reclast                            Used to prevent or treat osteoporosis
Relistor                           Injectable for opioid-causing constipation for patients receiving paliative care
Requip XL                          Long acting ropinrole, indicated only for Parkinson's, not for RLS. Generics are available for immediate release.
Revatio                            Only indicated for Pulmonary arterial hypertension (PAH)
Revlimid                           For Multiple myeloma, Myleodysplastic syndromes (MDS)
Simponi                            Ankylosing spondylitis, Psoriatic arthritis, Rheumatoid arthritis
Solesta                            An injectable therapy for fecal incontinence
Soma 250mg                         New strength when generic 350mg has been available for years.
Somatuline                         Used to treat acromegaly
Sprycel                            For Acute lymphoblastic leukemia and Chronic Mylogenous Leukemia (CML) after Gleevec failure
Stavzor                            For the treatment of the manic episodes associated with bipolar disorder and for prophylaxis of migraine headaches
Stelara                            Plaque psoriasis
Subsys                             Only indicated for Breakthrough cancer pain
Supartz                            Intra-articular injection for the treatment of pain in osteoarthritis of the knee
Sutent                             For renal cell carcinoma (RCC) and GI stromal tumors (GIST)
Symlin                             Injectable for diabetes
Synagis                            For prevention of RSV-induced respiratory disease
Synvisc                            Intra-articular injection for the treatment of pain in osteoarthritis of the knee
Synvisc One                        Intra-articular injection for the treatment of pain in osteoarthritis of the knee
Tarceva                            Lung cancer and Pancreatic cancer
Tasigna                            For Chronic Myelogenous Leukemia (CML) after Gleevec failure and Newly diagnosed Philadelphia chromosome-positive CML
Temodar                            Specific cancer use
Tykerb                             HER2 receptor positive Breast cancer
Uloric                             For the chronic management of hyperuricemia in patients with gout
Ventavis                           Inhalation solution for Pulmonary arterial hypertension (PAH)
Victoza                            Injectable for Type II diabetes
Victrelis                          An antiviral medication used in combination with other medicines to treat chronic hepatitis C
Vidaza                             Specific Cancer Use
Viibryd                            Treats major depressive disorder in adults
Vivaglobin                         Subcutaneous injection of Immunoglobulin
Voltaren Gel                       Topical NSAID treatment for osteoarthritis.
Vyvanse                            Used for ADHD
Xarelto 15 mg & 20 mg              New Anticoagulant for atrial fibrillation
Xeomin                             New Botox alterternative, approved for the treatment of Cervical Dystonia and Blepharospasm
Xgeva                              Bone Metastases Treatment
Xolair                             Indicated for asthma not responsive to inhaled corticosteroids
Zipsor                             Liquid filled capsule formulation of diclofenac
Zolinza                            Specific Cancer Use- Cutaneous T-cell Lymphoma
Zolpimist                          Oral spray for the short-term treatment of insomnia
Zuplenz                            Oral soluble film formulation of ondansetron
Zytaze                             Nutritional support for botulinum toxin injections
Zytopic Kit                        Kit containing triamcinolone cream, a moisturizer and cleanser
Restat will exclude all of these medications. Restat recommends that coverage of medications in this area only be considered with the Restat Clinical
Prior Auth process.
This listing is not all-inclusive.

				
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posted:7/25/2012
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