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MMCP Clinical Criteria
  

·         Diagnosis of pulmonary arterial hypertension

·         Failure of optimal therapy with the vasodilators and diuretics

·         Dose limitation of 40mg/day

 

Completion of prior authorization form found at the link below is required.

 

https://mmcp.dhmh.maryland.gov/pap/docs/PAH-Drugs-PA-form.pdf

  

For use in Postmenopausal Women for the following diagnosis:

·         Advanced hormone receptor-positive, HER2- negative breast cancer in combination with exemestane after failure of treatment with letrozole or anastrozole

 

For use in adults for the following diagnoses:

·         Progressive neuroendocrine tumors of pancreatic origin that are unresectable, locally advanced or metastatic

·         Advanced renal cell carcinoma after failure of treatment with sunitinib or sorafenib

·         Renal angiomyolipoma and tuberous sclerosis complex, not requiring immediate surgery

 

For use in children and adults for the following diagnosis:

·         Tuberous sclerosis complex with subependymal giant cell astrocytoma that requires therapeutic intervention but cannot be curatively resected

  

·         Diagnosis of multiple sclerosis

·         CrCl at least 50mL/min

·         Currently receiving therapy with an agent to reduce progression of multiple sclerosis, such as Rebif®, Avonex®, Betaseron® or Copaxone®

·         No history of seizure disorder

·         Dosing of 2 tablets per day

  

Prior authorization is required for use of all antipsychotic agents in patients < 18 years of age. Prior authorization is also required for the use of non-preferred or Tier II antipsychotics.

 

Details of the prior authorization procedures for antipsychotics can be found at the link below.

Antipsychotic review program:

https://mmcp.dhmh.maryland.gov/pap/Pages/Antipsychotics-Review-Programs.aspx

 

 

  

·         Diagnosis of partial-onset seizures     

 ·     4 years of age or older

·         No evidence of severe hepatic impairment

·         Once daily dosing

 

  

·         Diagnosis of relapsing form of multiple sclerosis

·         Female patient is not pregnant

·         Prior therapy with one of the following preferred agents:

o    Rebif®

o    Avonex®

o    Betaseron®

o    Copaxone®

·         No evidence of severe hepatic impairment

·         No concurrent therapy with leflunomide (Arava®)

·         Dose of 1 tablet per day

  

·         Diagnosis of Lennox-Gastaut Syndrome

·         Patient also receiving at least one other anticonvulsant

·     1 year of age and older

·         No evidence of severe hepatic impairment

·         No history of familial short QT syndrome

·         Prior trial of at least two other anticonvulsants

·         Maximum dose of 3200 mg per day

 

  

Cosmetic use of Botox® or Myobloc® will not be approved.

Botox® use in adults 18 years of age or older

·         Diagnosis of overactive bladder (OAB) and urinary incontinence associated with a neurologic condition and an inadequate response to or intolerance to an anticholinergic medication

·         Diagnosis of chronic migraine

·         Diagnosis of upper limb spasticity

·         Diagnosis of cervical dystonia (16 years and older)

·         Diagnosis of axillary hyperhidrosis with inadequate response to topical agents

Botox® use in patients 12 years of age or older

·         Diagnosis of blepharospasm associated with dystonia

·         Diagnosis of strabismus

Use of Myobloc® in adults 18 years of age or older

·         Diagnosis of cervical dystonia

 

Completion of prior authorization form found at the link below is required.

https://mmcp.dhmh.maryland.gov/pap/docs/BotoxPAFormJun08.pdf

  

·         Patient must be postmenopausal female

·         Patient experiencing moderate to severe vasomotor symptoms associated with menopause

·         Approval for 6 months

Quantity limit of 1 capsule per day

  

·         Diagnosis of cystic fibrosis CF) with Pseudomonas aeruginosa infection

·         Ages 7 years and older

·         Limit of 3 ampules per day, 28 days supply

  

·         Diagnosis of Type 1 Gaucher disease.

·         Diagnosis of one of the following complications associated with Type 1 Gaucher disease:

o    anemia

o    thrombocytopenia

o    bone disease

o    hepatomegaly

o    splenomegaly

·         Patient 2 years of age or older.

·         Quantity limited to no more than three times weekly administration.

  

·         Diagnosis of Hemophilia A or B or Von Willebrand disease

·         Requirements for submitting claims for clotting factors include:

o    Submission of a standard invoice

o    Dispensing log

o    Patient infusion log

 

These forms can be found at the link below.

 

https://mmcp.dhmh.maryland.gov/pap/SitePages/Pharmacy%20Program%20Forms.aspx

  
  •        No prior authorization required if a recipient has a diagnosis of diabetes,fibromyalgia, chronic musculoskeletal pain, or a history of receiving hypoglycemic agents within the past year.

 

  •   No prior authorization required if a recipient has history of duloxetine use in the last 90 days.

·         Clinical prior authorization is required unless a recipient has a diagnosis of major depressive disorder or general anxiety disorder and has had an 8-week trial of an SSRI (e.g. citalopram,  fluoxetine, fluvoxamine, paroxetine, sertraline, Lexapro®, Paxil® CR, Pexeva®, etc.) in the past   90 days

·         Quantities for all strengths are limited to 68 in a 34-day period

  •                   To ensure patient safety, a 2-week trial of 60mg per day dose of duloxetine (Cymbalta®) is required before a 120mg per day regimen will be authorized. (According to the labeling, there is no evidence that doses greater than 60 mg/day confer any additional benefits. Also, the increased dosage may pose an increased risk of hepatotoxicity. The maximum FDA approved daily dose is 60mg)

 

  

Prior authorization is only required when medroxyprogesterone is used for the treatment of adult males with certain diagnosed behavioral disorders and will be paid fee-for-service if approved. Preauthorization through the University of Maryland School of Pharmacy CAMP program at

410-706-3431 is required.

  

·         Nausea and vomiting during pregnancy

·         Not diagnosed with hyperemesis gravidarum

·         Failure of conservative management for nausea and vomiting

·         No more than 2 tablets per day

·         PA approval is for 90 days

 

  

·         Diagnosis of acne vulgaris

·         Diagnosis of sebaceous cysts

·         Ages 12 to 25 years

  

·         Confirmed diagnosis of Clostridium difficile-associated diarrhea

·         18 years of age or older

·         Prior trial metronidazole or oral vancomycin

·         Dose of 1 tablet BID for 10 days

  

·         Diagnosis of Type 1 Gaucher disease

·         18 years of age or older

·         Quantity limited to every other week administration

  

·         A valid prescription is required

·         Orders verified or recommended by a licensed nutritionist or dietician

 

Completion of prior authorization form found at the link below is required.

https://mmcp.dhmh.maryland.gov/pap/docs/Nutritionals_3495_Apr07.pdf

  

·         Diagnosis of hormone receptor positive metastatic breast cancer

·         Patient must be postmenopausal female

·         History of trial of antiestrogen therapy

·         Dose of 500mg on days 1, 15, 29 and then monthly

  

·         Diagnosis of cancer

·         Age 18 years or older (Actiq® 16 years)

·         Under the care of an oncologist or pain specialist who is experienced in the use of Schedule II opioids to treat cancer pain

·         Does not have any of the following contraindications:

o    hypersensitivity to opiates

o    hypoxia/hypercarbia

o    severe asthma

o    chronic obstructive pulmonary disease

o    paralytic ileus

·         Currently receiving and tolerant to long-acting opioid therapy

·         Limit of 4 doses per day

 

Completion of prior authorization form found at the link below is required.

 

 https://mmcp.dhmh.maryland.gov/pap/docs/MD_FENTANYAL%20BUCCAL%20Rev%20Feb08.pdf

  

·         Diagnosis of HIV/AIDS.

·         Currently on antiretroviral therapy

·         Infective causes of diarrhea have been ruled out

·         Prior history of antidiarrheal therapy

·         Dosing of 2 tablets per day

  

  •             Partial-onset seizures
  •        Primary generalized tonic-clonic seizures
  •             Receiving at least one other antiepileptic drug
  •            12 years of age or older
  •           No evidence of severe renal or hepatic impairment
  • Once daily dosing

 

  

·         Diagnosis of relapsing forms of multiple sclerosis

·         Prior therapy with a preferred agent: interferon beta (Rebif®, Avonex®, Betaseron® or Copaxone®)

Dosing of 1 tablet per day

  

·         Diagnosis of metastatic non-small cell lung cancer

·         Tumors with epidermal growth factor receptor exon 19 deletions or exon 21 substitution detected by an FDA approved test

·         Dosing of 1 tablet per day

  

Completion of prior authorization form found at the link below is required:

https://mmcp.health.maryland.gov/pap/docs/GrowthHormonePARequest0207.pdf

Pediatric use approved for the following:

·         Documented growth hormone deficiency

·         Turner syndrome confirmed by karyotyping

·         Prader-Willi syndrome confirmed by appropriate chromosomal testing

·         G​rowth deficiency due to chronic/irreversible renal insufficiency

  Adult use approved for the following:

·         Adult with childhood onset of growth hormone deficiency

·         Adult onset of growth hormone deficiency with no other hormone deficiencies

·         Adult onset of growth hormone deficiency with other pituitary hormone deficiencies

 

 

  

·         Adjuvant treatment of HER2 overexpressing node positive or node 26 negative (ER/PR negative or with one high risk feature) breast cancer as part of a treatment regimen consisting of either:

o    doxorubicin, cyclophosphamide, and either paclitaxel

                                or docetaxel

o    with docetaxel and carboplatin

o    as a single agent following multi-modality

o    anthracycline based therapy

·         In combination with paclitaxel for first-line treatment of HER2-overexpressing metastatic breast cancer

·         As a single agent for treatment of HER2-overexpressing breast cancer in patients who have received one or more chemotherapy regimens for metastatic disease

·         In combination with cisplatin and capecitabine or 5-fluorouracil, for the treatment of patients with HER2 overexpressing metastatic gastric or gastroesophageal junction adenocarcinoma, who have not received prior treatment for metastatic disease

  

·         Patient is legally blind

·         18 years of age or older

·         Diagnosis of Non-24-Hour Sleep-Wake Disorder (Non-24)

·         No known hepatic impairment

·         Dosing of  1 capsule/day

  

·         Diagnosis of chronic lymphoid leukemia (CLL) or mantle cell lymphoma with trial of at least 1 prior therapy

Quantity limit of 4 tablets per day

  

·         Diagnosis of genotype 1 chronic hepatitis C in adult patients with compensated liver disease

·         Prescriber is an infectious disease specialist, gastroenterologist or hepatologist

·         Patient must be 18 years of age or older

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