Pharmacy Prior Authorization Criteria

Prior Authorization Administrative Guideline

Indications for Prior Authorization

Criteria

Drugs with a prior authorization requirement for which a guideline is unavailable, OR new FDA-approved indications which are not addressed in the existing drug-specific prior authorization guideline

This guideline should not be used to address step therapy.

Administrative

Length of Approval: 12 Month(s)

• One of the following:
• Both of the following:
• Requested drug is FDA-approved for the condition being treated
AND
• Both of the following:
• Additional requirements listed in the "Indications and Usage" sections of the prescribing information (or package insert) have been met (e.g., first line therapies have been tried and failed, any testing requirements have been met, etc.)
AND
• Requested drug will be used at a dose which is within FDA recommendations
OR
• If requested for an off-label indication, the off-label guideline approval criteria have been met

P & T Revisions

2024-09-27, 2023-11-03, 2022-09-21, 2022-01-14, 2021-10-24, 2021-05-21, 2020-10-01, 2019-10-04

References

Revision History

• 2024-09-27: 2024 UM Annual Review. Rephrased criteria without changing clinical intent.
• 2023-11-03: 2023 UM Annual Review.
• 2022-09-21: 2022 Annual Review
• 2022-01-14: Annual review
• 2021-10-24: Annual review
• 2021-05-21: Addition of EHB formulary to guideline, no changes to criteria
• 2020-10-01: 2020 Annual Review, no changes to criteria
• 2019-10-04: Annual Review. No changes.