Pharmacy Prior Authorization Criteria

High Cost, Low Value Non-Formulary Program

Indications for Prior Authorization

Criteria

A Non-Preferred Non-Formulary or Excluded Medication* (Brand Absorica, Absorica LD, Brand Aczone, Brand Adapalene 0.1% pads, Anusol-HC suppository, Arazlo, Atopaderm, Azesco, Bensal HP, Cabtreo, generic chlorzoxazone, Coxanto, Brand Oxaprozin, Brand Diclofenac Epolamine, Brand Doryx, Brand Doryx MPC, generic doxepin cream, Epiceram, generic fenoprofen calcium, Flector, Fluovix, Folic-K, Genicin Vita-S, Brand Inderal XL, Innopran XL, Kamdoy, Kelarx, Licart, Brand Lidocaine-tetracaine cream, Brand Naprosyn, generic naproxen-esomeprazole, Brand Oracea, Ortho DF, Brand Pennsaid, Pliaglis, Pokonza, Pregenna, Prodigen, Promethazine VC syrup, Promethazine/codeine syrup, Brand Prudoxin, Rayos, Relafen DS, Sajazir, Sitavig, Sprix, Tivorbex, Tolsura, Brand Vimovo, Winlevi, Xerese, Xhance, Yosprala, Zipsor, Brand Zonalon, Zorvolex, ZT Lido, Brand Zyclara, Zyflo)

*See table in background section for a list of the Non-Formulary or Excluded Medications and their preferred formulary alternatives. Please double check plan formulary for coverage. For off-label use, do not review against the off-label administration guideline. Deny per guideline criteria. ^OTC equivalents refers to any covered or non-covered OTC equivalent product.

Non Formulary

Length of Approval: 6 Month(s)

• Submission of medical records (e.g., chart notes) confirming request is for an FDA-approved indication
AND
• Submission of medical records (e.g., chart notes) (document drug, duration, dose and date of use) confirming history of use of ALL available formulary alternative(s) and over-the-counter (OTC) equivalents*^ (if request is for a combination product, member must have documentation indicating concurrent use of separate agents)
AND
• Both of the following:
• Documentation provided stating the formulary alternative(s) and over-the-counter (OTC) equivalents*^ has/have not been effective
AND
• Justification/rationale provided explaining how the Non-Formulary or Excluded Medication is expected to provide benefit when the formulary alternative product(s) and over-the-counter (OTC) equivalents*^ has/have not been shown to be effective despite having the same active ingredient and/or same mechanism of action

P & T Revisions

2024-10-30, 2024-10-30, 2024-10-17, 2024-08-26, 2024-08-23, 2024-07-03, 2024-06-10, 2024-05-21, 2024-05-13, 2024-04-03, 2024-03-07, 2023-12-22, 2023-05-04, 2022-10-04, 2022-04-15, 2022-02-01, 2022-01-14, 2021-11-01, 2021-10-13, 2021-08-16, 2021-07-23, 2021-06-28, 2021-05-26, 2021-05-25, 2021-05-05, 2021-03-01, 2021-01-04, 2020-12-31, 2020-11-16, 2020-02-25, 2019-11-01

References

Revision History

• 2024-10-30: Minor update
• 2024-10-30: Minor update
• 2024-10-17: Minor update
• 2024-08-26: Addition of Licart, Oracea, Aczone, and Anusol-HC suppository as targets to guideline. Update criteria to add "OTC equivalent" language. Updated background table.
• 2024-08-23: update guideline
• 2024-07-03: Addition of Licart, Oracea, Aczone, and Anusol-HC suppository as targets to guideline. Update criteria to add "OTC equivalent" language
• 2024-06-10: Corrected spelling errors in background section.
• 2024-05-21: Addition of Promethazine VC/codeine syrup; promethazine VC syrup.
• 2024-05-13: 2024 Annual Review. Addition of new target drugs. Updated alternatives for target drugs to have a minimum of three formulary/ OTC alternatives.
• 2024-04-03: Addition of Arazlo as a target drug, update to guideline name, background table, and verbiage change from "documenting to confirming" within criteria.
• 2024-03-07: Addition of adapalene 0.1% pads, Doryx MPC, Pokonza, Sajazir, and Winlevi as target drugs
• 2023-12-22: No changes to criteria. Created stand alone guideline.
• 2023-05-04: Removed Evzio and Sil-K pad large from guideline as products are obsolete.
• 2022-10-04: Update to Pennsaid formulary alternatives
• 2022-04-15: Update Product List
• 2022-02-01: Removed all insulin products from the guideline (product section, background, etc.)
• 2022-01-14: Added ABA Semglee and ABA Flector as targets. Changed Flector/ABA preferred alts to oral formulations.
• 2021-11-01: Added ABA Semglee and ABA Flector as targets. Changed Flector/ABA preferred alts to oral formulations.
• 2021-10-13: Updated product name verbiage per PA Team feedback.
• 2021-08-16: Added Xhance as target
• 2021-07-23: Added new targets, updated table.
• 2021-06-28: Added additional targets (Insulin products) to guideline and table
• 2021-05-26: Renamed guideline to Non-Preferred Non-Formulary & Excluded Medications, updated verbiage where applicable to align. No change to clinical criteria.
• 2021-05-25: Addition of EHB formulary. No changes to criteria
• 2021-05-05: Non-Formulary Non-Preferred criteria removed from NF admin guideline, new guideline created.
• 2021-03-01: Removed Aplenzin as target, moved to Non-Formulary Drugs of Clinical Concern
• 2021-01-04: Updated Formulary alternatives table
• 2020-12-31: Added targets to Non-Form Non-Preferred criteria for 1.1.21 eff date and updated alternative table in background section.
• 2020-11-16: Attached Non-Form Non-Preferred criteria to NF admin guideline per PA team request to facilitate proper NF reviews.
• 2020-02-25: Added keywords "non", "non-form", and "non-formulary" to criteria section per PA request.
• 2019-11-01: Updated to add criteria for when there are only OTC equivalents.