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Great-West’s Drug Prior Authorization
Great-West Life’s prior authorization process is designed to provide an effective approach to managing claims for specific prescription drugs. Approval for coverage of certain prescription drugs is required in order to provide plan members with coverage for appropriate drug treatment, and keep your drug plan affordable. Below is a current listing of drugs that require prior authorization by Great-West, along with information about the conditions they are commonly used to treat. This list is provided for general information purposes only. Coverage may not be available under certain group benefits plans offered or administered by Great-West. Coverage for any of the drugs listed below depends on the terms of your group benefits plan. To obtain additional drug information, visit the Health & Wel ness section of GroupNet by clicking Drug Library and searching for the drug name. Great-West Life prior authorization drug listing as of February 28, 2011
This list is subject to change without notice. Abraxane is used for the treatment of patients with metastatic breast cancer after failure of combination chemotherapy for
metastatic disease or relapse within 6 months of adjuvant chemotherapy.
Aldurazyme is used as an enzyme replacement therapy for the treatment of Hurler syndrome (also known as
mucopolysaccharidosis MPS I), an extremely rare genetic enzyme deficiency disease. Hurler syndrome is a highly disabling and
life-threatening disease.
Alertec is used for the treatment of excessive daytime sleepiness due to sleep apnea and narcolepsy.
Alimta is used for the treatment of patients with malignant pleural mesothelioma whose disease has spread and is unable to
be removed with surgery, or who are otherwise not candidates for curative surgery. It is also used for the treatment of non-
small cell lung cancer for patients who have received prior chemotherapy.
Amevive is used to treat adults with moderate to severe chronic plaque psoriasis who are candidates for systemic therapy or
phototherapy.
Avastin is used for the treatment of patients with metastatic colorectal cancer. It is also used for the treatment of patients with
glioblastoma multiforme (GBM) after relapse or disease progression, following prior therapy.
Botox is a neuromuscular paralytic agent and is used to treat conditions that are caused by certain muscles going into spasm.
Catena is used for the symptomatic management of patients with Friedreich’s Ataxia, a rare neuromuscular disease that results
in the degeneration of nerve and muscle tissue.
Camptosar and Irinotecan Hydrochloride are used for the treatment of patients with metastatic colon or rectum cancer.
Cerezyme is used for the treatment of long-term enzyme replacement therapy for adult and pediatric patients with a
confirmed diagnosis of Type 1 Gaucher disease.
Cimzia is used to treat moderate to severe active rheumatoid arthritis.
Elaprase is the first drug used as an enzyme replacement therapy for the treatment of Hunter syndrome (also known as
mucopolysaccharidosis MPS II), an extremely rare genetic enzyme deficiency disease. Hunter syndrome is a highly disabling and
life-threatening disease.
Eloxatin is used in combination with other cancer medications such as 5-fluorouracil (5-FU) and leucovorin (LV) for the
treatment of metastatic colorectal cancer.
Enbrel is used for the treatment of:
• moderately to severely active rheumatoid arthritis in adult patients • moderately to severely active polyarticular-course juvenile rheumatoid arthritis in patients aged four to 17 • psoriatic arthritis in adult patients• ankylosing spondylitis• chronic moderate to severe plaque psoriasis Great-West Life prior authorization drug listing as of February 28, 2011
This list is subject to change without notice. Erbitux is used for the treatment of patients with metastatic colorectal cancer. It is also used in combination with radiation
therapy for the initial treatment of head and neck cancer.
Femara is used in various treatments for postmenopausal women with advanced or metastatic breast cancer.
Flolan is used for the long term intravenous treatment of patients with primary pulmonary hypertension (PAH) and secondary
hypertension (SPH) who did not respond to conventional therapy.
Fludara and Fludarabine are used as a second-line therapy for both chronic lymphocytic leukemia (CLL) and low-grade
non-Hodgkin’s lymphoma (lg-NHL) where the patient has failed first-line therapies.
Forteo is used for the treatment of post-menopausal women with severe osteoporosis who are at high risk of fracture or when
other therapies are deemed inadequate. It is also used to increase bone mass in men with primary or hypogonadal severe
osteoporosis when other therapies are deemed inadequate.
Gleevec is used for the treatment of chronic myeloid leukemia (CML), gastrointestinal stromal tumours (GIST) and
lymphoblastic leukemia.
Growth Hormones (Humatrope; Nutropin; Genotropin; Protropin; Saizen, Omnitrope) are man-made versions of
growth hormones and are used for growth hormone therapy in people who have growth hormone deficiency.
Herceptin is used for the treatment of patients with early stage breast cancer and metastatic breast cancer when tumors
substantially over-express the HER2 protein.
Humira is used for the treatment of:
• moderately to severely active rheumatoid arthritis• moderately to severely active Crohn’s disease Iressa is a third-line treatment for non-small cell lung cancer (NSCLC) in patients who have failed two or more different
chemotherapy regimens.
Kineret, Orencia and Actemra are used for the treatment of moderate to severe rheumatoid arthritis.
Kuvan is used in conjunction with a Phe-restricted diet to reduce blood phenylalanine (phe) levels in patients with
hyperphenylalaninemia (HPA) due to responsive phenylketonuria (PKU).
Mabcampath is used for the treatment of patients with B-cell chronic lymphocytic leukemia when previous treatments have
been unsuccessful.
Myobloc is used for the treatment of cervical dystonia in order to reduce the severity of abnormal head position and neck pain
associated with this condition.
Myozyme is used for the treatment of patients with pompe disease. Pompe disease is a rare hereditary genetic disorder that is
caused by a deficiency in the enzyme acid alpha-glucosidase or known as GAA deficiency.
Nexavar is used for the treatment of locally advanced/metastatic kidney cancer in patients who have failed prior cytokine
therapy or who are considered unsuitable for such therapy.
Pulmozyme is used for the long-term management of patients with cystic fibrosis to reduce the frequency of respiratory
infections requiring antibiotics and to improve pulmonary function.
Remicade is used for the treatment of:
• moderately to severely active rheumatoid arthritis in adult patients• moderately to severely active Crohn’s disease• fistulizing Crohn’s disease in adult patients Remodulin is used for the long term subcutaneous treatment of patients with pulmonary arterial hypertension (PAH) who did
not respond to conventional therapy.
Replagal and Fabrazyme are used for long-term enzyme replacement therapy in patients with a confirmed diagnosis of Fabry
disease. Fabry disease is an extremely rare genetic disorder that can lead to end-stage renal failure, cardiac disease, strokes and
premature death.
Revatio is used for the treatment of pulmonary arterial hypertension (PAH). Revatio contains the same chemical ingredient
found in Viagra.
Revlimid is used for the treatment of multiple myeloma. It is also used for patients with transfusion-dependent anemia.
Rituxan is used for the treatment of patients with CD20 positive, B-cell non-Hodgkin’s lymphoma and CD20 positive, diffuse
large B-cell non-Hodgkin’s lymphoma. It is also used for the treatment of moderate to severe active rheumatoid arthritis.
Sativex is a cannabis-based medicine that is used as adjunctive treatment for the symptomatic relief of neuropathic pain in
patients with multiple sclerosis (MS).
Great-West Life prior authorization drug listing as of February 28, 2011
This list is subject to change without notice. Sensipar is used for the treatment of secondary hyperparathyroidism (secondary HPT) in patients with chronic kidney disease
who are on dialysis. It is also used to lower calcium levels of the parathyroid hormone in people with chronic renal disease who
are on dialysis.
Serostim is a man-made growth hormone that is used to manage HIV wasting (a metabolic disorder resulting in severe weight
loss seen in people with HIV).
Simponi is used to treat moderate to severe active rheumatoid arthritis, active psoriatic arthritis and active ankylosing
spondylitits.
Soliris is the first treatment for patients with paroxysmal nocturnal hemoglobinuria (PNH) to reduce haemolysis.
Somavert is indicated for the treatment of acromegaly in patients who have had an inadequate response to surgery, and/or
radiation therapy, and other medical therapies, or for whom these therapies are not appropriate.
Sprycel is used for the treatment of patients with chronic, accelerated, or blast phase chronic myeloid leukemia (CML).
Stelara is used to treat adults with moderate to severe chronic plaque psoriasis who are candidates for systemic therapy or
phototherapy.
Sutent is used for the treatment of patients with gastrointestinal stromal tumour (GIST). It is also used for the treatment of
metastatic renal cell cancer.
Tarceva is used for the treatment of patients with locally advanced or metastatic non-small cell lung cancer after failure of at
least one prior chemotherapy regimen, and whose epidermal growth factor receptor expression status is positive or unknown.
Taxotere is used for the treatment of: breast cancer; non-small cell lung cancer; ovarian cancer; prostate cancer and head and
neck cancer.
Temodal is used for the treatment of adult patients with Grade III or IV primary tumor of the brain.
Thelin is used for the treatment of primary pulmonary arterial hypertension or pulmonary hypertension secondary to
connective tissue disease, in patients who have not responded to conventional therapy. It is also used for patients who did not
respond to conventional therapy and for whom no appropriate alternative can be identified.
Thyrogen is used as an adjunctive diagnostic tool for thyroid cancer patients.
Tracleer is used for the treatment of pulmonary arterial hypertension (PAH).
Tysabri is indicated as a monotherapy for the treatment of patients with the relapsing-remitting form of multiple sclerosis to
reduce the frequency of clinical relapses, to decrease the number and volume of active brain lesions identified on MRI scans
and to delay the progression of physical disability.
Vectibix is used as monotherapy for the treatment of metastatic colorectal cancer after previous cancer treatments have
failed.
Velcade is used for the treatment of patients with multiple myeloma who have relapsed following first line therapy and those
who are not responding to their most recent therapy.
Volibris is used for the treatment of primary pulmonary arterial hypertension and pulmonary hypertension associated with
connective tissue disease in patients who have not responded to conventional therapy.
Xenical is used for the treatment of obesity and management of Type 2 diabetes.
Xeomin is used for the treatment of muscle or nerve disorders, similar to Botox.
Xolair is used to treat adults and adolescents (12 years and older) with moderate to severe persistent asthma.
Xyrem is an oral solution used for the treatment of cataplexy in patients with narcolepsy.
Zavesca is used for the treatment of adult patients with mild to moderate Type 1 Gaucher disease for whom enzyme
replacement therapy is not a therapeutic option.
For any of the drugs currently requiring prior authorization, plan members must complete the appropriate section(s) of a Request for Information form with their prescribing doctor, and submit the form to Great-West to have their claim considered for reimbursement. Plan members can find these forms in the Client ServicesGroup Benefits Plan MembersForms section of the Great-West website at www.greatwestlife.com. A brochure on Great-West’s prior authorization process is also available for distribution to plan members. For more information, please contact your Great-West group benefits representative.

Source: http://www.mycibp.ca/resources/GWL%20Drug%20Prior%20Authorization%20List.pdf

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