Pharmacy Prior Authorization Criteria

DAW Override

Indications for Prior Authorization

Criteria

Brand drugs with two or more generic equivalents available

Administrative

Length of Approval: 12 Month(s)

• Patient has tried two generic equivalents of the requested drug from different manufacturers
AND
• One of the following:
• Patient has had an allergic reaction or intolerance to an inactive ingredient
OR
• Patient has experienced an inadequate response to the generic equivalent of the requested drug
AND
• One of the following:
• Requested drug is FDA-approved for the condition being treated
OR
• If requested for an off-label indication, the off-label guideline approval criteria have been met

Brand drugs with only one generic equivalent available

Administrative

Length of Approval: 12 Month(s)

• Patient has tried one generic equivalent of the requested drug from a different manufacturer
AND
• One of the following:
• Patient has had an allergic reaction or intolerance to an inactive ingredient
OR
• Patient has experienced an inadequate response to the generic equivalent of the requested drug
AND
• One of the following:
• Requested drug is FDA-approved for the condition being treated
OR
• If requested for an off-label indication, the off-label guideline approval criteria have been met

P & T Revisions

2024-10-24, 2023-11-01, 2022-10-27, 2022-01-19, 2021-11-25, 2021-09-28, 2021-05-20, 2020-11-03, 2019-10-04

References

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End Notes

1. The standard DAW (brand name) override criteria are for clients who opt for such a program to help manage prescription costs. The criteria is applied when a provider/patient requests for coverage of a brand medication when a generic is available. There must be a clinical reason why the patient cannot take the generic version of the medication. Acceptable clinical reasons include having an inadequate response, an allergic reaction, or intolerance to two generic manufacturers of the branded product (or one if only one generic equivalent is available). Intolerance of the generic version may occur due to excipients in the generic version of the product. In order to receive approval for the prescribed drug, the prescriber will document the clinical reason as to why the patient cannot use a generic version of the product.

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Revision History

• 2024-10-24: Annual review, no changes.
• 2023-11-01: Annual review: Removed UHC formulary.
• 2022-10-27: 2022 Annual Review.
• 2022-01-19: Annual Review - No changes.
• 2021-11-25: Annual Review - No changes.
• 2021-09-28: Addition of EHB formulary to guideline, no changes to criteria
• 2021-05-20: Addition of EHB formulary to guideline, no changes to criteria
• 2020-11-03: 2020 Annual Review: No changes
• 2019-10-04: Annual Review. No changes.

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