Pharmacy Prior Authorization Criteria

Quantity Limit General

Indications for Prior Authorization

Criteria

Drugs subjected to Quantity Limits (in the absence of a drug-specific guideline)*

*This guideline only applies in the absence of a drug-specific quantity limit override guideline. No override requests will be permitted for acetaminophen, alone or in combination with other agents, which will exceed a total of 4 grams of acetaminophen per day. **Commercially available strength/dose requires a formulary drug.

Administrative

Length of Approval: 6 Month(s) (except for titration or loading-dose purposes)

• One of the following:
• Requested drug is being used for a Food and Drug Administration (FDA)-approved indication
OR
• If requested for an off-label indication, the off-label guideline approval criteria have been met
AND
• One of the following:
• For titration or loading-dose purposes (one time authorization or per FDA labeling)
OR
• Requested strength/dose is commercially unavailable**
OR
• Patient is on a dose alternating schedule
OR
• For topical applications, member has tried the dose under the quantity limit restriction for an adequate period of time and it has been deemed ineffective or insufficient in the treatment of the member's disease or medical condition
AND
• For the indication being requested, the higher dose, frequency of administration, and quantity are supported in one of the following:
• The dosage and administration section of the manufacturer's prescribing information
OR
• One of following compendia:
• American Hospital Formulary Service Drug Information
• Micromedex DRUGDEX System
OR
• Supported as being generally safe and effective by clinical research in two articles from peer reviewed medical journals

P & T Revisions

2024-10-02, 2024-06-05, 2023-09-27, 2023-04-05, 2023-01-12, 2022-08-05, 2022-06-15, 2022-04-06, 2022-01-19, 2021-11-15, 2021-06-30, 2021-05-21, 2020-07-14, 2019-10-10

References

Revision History

• 2024-10-02: Added "patient is on a dose alternating schedule" as an acceptable reason for QL override. Clarified the ineffective or insufficient quantity allowance applies to topical applications. Minor verbiage updates.
• 2024-06-05: 2024 Annual Review - Consolidated criteria.
• 2023-09-27: Updated criteria for requested quantities that are less than or equal to the maximum dose as specified in the product prescribing information.
• 2023-04-05: No criteria change. Removed UHC Core formulary.
• 2023-01-12: Per PA Team request, added keyword (quantity)
• 2022-08-05: Per PA team feedback, add operational note to clarify process if requested strength/dose is commercially unavailable.
• 2022-06-15: Updated second criteria bucket to include peer-reviewed journals
• 2022-04-06: 2022 Annual Review- No changes
• 2022-01-19: Update to criteria section headings
• 2021-11-15: Update to criteria section headings
• 2021-06-30: Annual review - no changes
• 2021-05-21: Addition of EHB formulary to guideline, no changes to criteria
• 2020-07-14: 2020 Annual Review, no changes to criteria.
• 2019-10-10: Annual review. No changes.