Pharmacy Prior Authorization Criteria

Healthcare Reform Copay Waiver Review

Indications for Prior Authorization

Criteria

Fluoride supplementation products

*Benefit exclusion if age not met. **The HCR preventive drug list is posted at: https://uhgazure.sharepoint.com/sites/CST/CSDM/Shared%20Documents/UMCS%20Guidelines/Healthcare%20Reform%20Supporting%20Document.

Administrative

Length of Approval: 12 Month(s)

• Patient is between 6 months of age to 4 years of age*
AND
• Requested product is a prescription (single ingredient only) oral fluoride supplementation product (does not include topical fluoride products such as toothpaste or rinses, etc.)
AND
• There is a clinical reason why the patient cannot take two products on the HCR preventive drug list** (e.g., the patient has had an allergic reaction or intolerance to an inactive ingredient or has experienced an inadequate response)

Folic acid supplementation products

*Benefit exclusion if not for childbearing or for multivitamins without folic acid. **Greater than 0.8mg is allowed for medical necessity. ***The HCR preventive drug list is posted at: https://uhgazure.sharepoint.com/sites/CST/CSDM/Shared%20Documents/UMCS%20Guidelines/Healthcare%20Reform%20Supporting%20Document.

Administrative

Length of Approval: 12 Month(s)

• Patient is of childbearing potential who is planning pregnancy*
AND
• Requested product is a prescription or OTC folic acid product (with prescription), including prenatal vitamins containing folic acid*
AND
• Requested product contains between 0.4 mg to 0.8 mg of folic acid**
AND
• There is a clinical reason why the patient cannot take two products on the HCR preventive drug list** (e.g., the patient has had an allergic reaction or intolerance to an inactive ingredient or has experienced an inadequate response)

Smoking Cessation products

*Benefit exclusion if age not met or not used for smoking cessation or used beyond 180 days.

Administrative

Length of Approval: 6 months per 12 months for zero copay with deductible bypass

• Patient is 18 years of age or older*
AND
• For use as an aid to smoking cessation treatment*
AND
• Any requested HCR $0 Rx or OTC smoking cessation product and quantity requested does not exceed the following quantities:
• Maximum of 180 days of therapy per year for all smoking cessation products
• Varenicline/Apo-Varenicline: starter kits limited to one 53 tablet starter kit; Maximum Daily Dose (MDD) = 2 units per day for remainder of therapy
• Nicotrol NS: MDD = 4 mL per day
• Nicotrol Inhaler: MDD = 16 units per day
• Bupropion 150 mg SR: MDD = 2
• Brand or Generic OTC Nicotine replacement patch: MDD = 1
• Brand or Generic OTC Nicotine replacement gum: MDD = 24
• Brand or Generic OTC Nicotine replacement lozenge: MDD = 20
AND
• If request is for Nicotrol inhaler, Nicotrol NS, or Apo-Varenicline, a history of both of the following:
• Generic Zyban (bupropion)
AND
• One of the following smoking cessation therapies:
• Nicotine gum
• Nicotine lozenge
• Nicotine transdermal patch
• Generic varenicline

Aspirin

*Benefit exclusion if any criterion is not met.

Administrative

Length of Approval: 12 Month(s)

• Patient meets the following*:
• Patient is using 81 mg aspirin for the prevention of morbidity and mortality from preeclampsia
AND
• Requested product is a single agent oral OTC aspirin product (with prescription) (but does not include prescription aspirin products, non-oral aspirin products, or aspirin strengths greater than 81 mg)

Immunizations

*Benefit exclusion if age not met. **This list excludes vaccines not listed in the Advisory Committee on Immunization Practices (ACIP) Immunization Schedules (http://www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/index.html). ***For updated guidance on dengue endemic areas and pre-vaccination laboratory testing see: https://www.cdc.gov/mmwr/volumes/70/rr/rr7006a1.htm and https://www.cdc.gov/dengue/vaccine/hcp/index.html ^For risk factors for Mpox infection see: Use of JYNNEOS (Smallpox and Monkeypox Vaccine, Live, Nonreplicating) for Preexposure Vaccination of Persons at Risk for Occupational Exposure to Orthopoxviruses: Recommendations of the Advisory Committee on Immunization Practices — United States, 2022 | MMWR (cdc.gov) OR Adult Immunization Schedule Notes | CDC

Administrative

Length of Approval: 12 Month(s)

• Requested product is a single-entity or combination vaccination for one of the following:**
• Diphtheria
• Haemophilus influenzae type B (applies only to children less than 6 years of age)*
• Hepatitis A
• Hepatitis B (Heplisav B applies only to adults ages 18 years and older)*
• Herpes zoster (Shingrix applies to adults ages 19 years and older)*
• Human papillomavirus (applies only to children and adults 9 years to 45 years of age)*
• Polio
• Influenza (Flumist applies only to children and adults 2 years through 49 years of age. Fluzone HD Quad, Fluad Quad applies only to adults ages 65 years and older)*
• Measles
• Mumps
• Rubella
• Meningococcal infections
• Pertussis
• Pneumococcal infections
• Respiratory Syncytial Virus ([Abrysvo applies to pregnant individuals at 32 through 36 weeks gestational age AND adults 60 years and older] [Arexvy applies only to adults 60 years and older])
• Rotavirus (applies only to children less than 8 months)*
• Tetanus
• Varicella
OR
• All of the following:
• Requested product is for Dengvaxia vaccine:
AND
• Member is between ages 9-16 living in a dengue endemic area (endemic areas include Puerto Rico, American Samoa, US Virgin Islands, Federated States of Micronesia, Republic of Marshall Islands, and the Republic of Palau)***
AND
• Member has a laboratory confirmation of a previous dengue infection
OR
• All of the following:
• Requested product is for Monkey Pox (JYNNEOS) vaccine
AND
• Member is 18 years of age or older and has risk factors for Mpox infection^

Bowel preparation agents for colorectal cancer screening [E]

*Benefit exclusion if not for cancer screening. **The HCR preventive drug list is posted at: https://uhgazure.sharepoint.com/sites/CST/CSDM/Shared%20Documents/UMCS%20Guidelines/Healthcare%20Reform%20Supporting%20Document. ***If a patient has an intolerance, allergic reaction, or an inadequate response to one of the products on the HCR preventative drug list, then the quantity limits will not apply for one time only per drug category (to allow for another product to be tried on the HCR preventative drug list).

Administrative

Length of Approval: 12 Month(s)

• Requested product is a prescription bowel preparation agent used for primary preventative colorectal cancer screening (e.g., patient does not have a previous history of adenomatous polyps or previous colorectal cancer)*
AND
• There is a clinical reason why the patient cannot take two generic products on the HCR preventive drug list** (e.g., the patient has had an allergic reaction or intolerance to an inactive ingredient or has experienced an inadequate response). (Some examples of generic bowel prep products include: TriLyte, Gavilyte, PEG-3350/electrolytes)
AND
• Quantity requested does not exceed the QL of two primary preventive bowel prep products per year***

Arimidex (anastrozole) 1 mg, Aromasin (exemestane) 25 mg, Evista (raloxifene) 60 mg, Soltamox (tamoxifen) solution, Tamoxifen 20 mg tablets

*Benefit exclusion if age not met or has prior cancer diagnosis or has thromboembolic events or less than 3% risk factor or requesting a different strength. This program is designed to meet Health Care Reform requirements which require coverage of tamoxifen tablets, Soltamox (tamoxifen) solution, Evista (raloxifene), Aromasin (exemestane), and Arimidex (anastozole) at zero dollar cost share if being used for primary prevention of breast cancer and criteria are met.

Administrative

Length of Approval: 60 Months: Authorization will be issued for zero copay with deductible bypass for a total of up to 60 months (please determine if member has already received some length of therapy and if so subtract from total approval period).

• Member is greater than or equal to 35 years of age*
AND
• Member has no prior diagnosis of any of the following:*
• breast cancer
• ductal carcinoma in situ (DCIS)
AND
• Member has no history of thromboembolic events (e.g.- deep venous thrombosis, pulmonary embolus, stroke or transient ischemic attack)*
AND
• Member has an estimated 5 year risk of breast cancer based on a breast cancer risk assessment tool of greater than or equal to 3% [11]*
AND
• One of the following:
• Request is for tamoxifen 20 mg once daily
OR
• Both of the following:
• Member is post-menopausal
AND
• One of the following:
• Request is for raloxifene 60 mg once daily, exemestane 25 mg once daily, or anastrozole 1 mg once daily
OR
• Request is for brand name Evista 60 mg, Aromasin 25 mg, and Arimidex 1 mg once daily and member has had failure, contraindication or adverse reaction to generic raloxifene, exemestane, or anastrozole
OR
• Both of the following:
• Request is for Soltamox 20 mg once daily*
AND
• Member has had failure, contraindication or adverse reaction to tamoxifen tablets

Generic Statins

*Benefit exclusion if any criterion not met. The HCR preventive drug list is posted at: https://uhgazure.sharepoint.com/sites/CST/CSDM/Shared%20Documents/UMCS%20Guidelines/Healthcare%20Reform%20Supporting%20Document.

Administrative

Length of Approval: 24 Month(s)

• One of the following:
• Request is for atorvastatin 10 mg or 20 mg, simvastatin 5 mg, 10 mg, 20 mg, or 40mg*
OR
• Both of the following:
• Request is for another moderate or low dose statin (pravastatin 10 mg, 20 mg, 40 mg, or 80 mg; fluvastatin 20 mg or 40 mg; fluvastatin ER 80 mg; pitavastatin 1 mg, 2 mg, or 4 mg; rosuvastatin 5 mg or 10 mg) (D)*
AND
• Patient is unable to take all of the following:
• atorvastatin 10 mg or 20 mg
• simvastatin 5 mg, 10 mg, 20 mg, or 40 mg
• lovastatin (any strength)
AND
• Patient is at least 40 years old and younger than 75 years old*
AND
• Medication is being used for primary prevention of cardiovascular disease (CVD) (e.g., member has no history of cardiovascular events)*
AND
• Patient has one or more risk factors for CVD (e.g., dyslipidemia, diabetes, hypertension, or smoking)*
AND
• Patient has an estimated 10-year risk of a cardiovascular event of 10% or greater*

Erythromycin 0.5% ophthalmic ointment

*Please note, requests may be submitted before the infant’s birth, and could be requested under the mother’s account. **Benefit exclusion if age exceeded. This program is designed to meet Health Care Reform requirements which require coverage of erythromycin 0.5% ophthalmic ointment at zero dollar cost share if being used for primary prevention of gonococcal ophthalmia neonatorum (GON) and criteria are met. [H] The HCR preventive drug list is posted at: https://uhgazure.sharepoint.com/sites/CST/CSDM/Shared%20Documents/UMCS%20Guidelines/Healthcare%20Reform%20Supporting%20Document.

Administrative

Length of Approval: 1 Month: Authorization will be issued for zero copay with deductible bypass for up to 1 month

• Member or health care provider intends to administer medication to newborn for the prophylaxis of gonococcal ophthalmia*
OR
• Newborn is 0-1 month of age**

Brand Truvada 200-300 mg, Generic emtricitabine-tenofovir disoproxil fumarate 200-300 mg, Brand Viread 300mg, generic tenofovir disoproxil fumarate 300mg, Descovy 200-25mg

This program is designed to meet Health Care Reform requirements which require coverage of effective HIV Prep regimens at zero dollar cost share if being used for pre-exposure prophylaxis (PrEP) and criteria are met. [I] *The HCR preventive drug list is posted at: https://uhgazure.sharepoint.com/sites/CST/CSDM/Shared%20Documents/UMCS%20Guidelines/Healthcare%20Reform%20Supporting%20Document.

Administrative

Length of Approval: 12 Months: Authorization will be issued for zero copay with deductible bypass for 12 months

• Member is taking as effective antiretroviral therapy for pre-exposure prophylaxis (PrEP)
AND
• One of the following:
• Request is for generic emtricitabine-tenofovir disoproxil fumarate 200-300 mg or generic tenofovir disoproxil fumarate 300mg or Descovy 200-25mg
OR
• History of contraindication or intolerance to generic emtricitabine-tenofovir disoproxil fumarate 200-300 mg (Applies to Brand Truvada 200-300 mg only)
OR
• History of contraindication or intolerance to generic tenofovir disoproxil fumarate 300mg (Applies to Brand Viread 300mg only)

Apretude

This program is designed to meet Health Care Reform requirements which require coverage of effective HIV Prep regimens at zero dollar cost share if being used for pre-exposure prophylaxis (PrEP) and criteria are met. [I] *The HCR preventive drug list is posted at: https://uhgazure.sharepoint.com/sites/CST/CSDM/Shared%20Documents/UMCS%20Guidelines/Healthcare%20Reform%20Supporting%20Document.

Administrative

Length of Approval: 12 Months: Authorization will be issued for zero copay with deductible bypass for 12 months

• Member is taking as effective antiretroviral therapy for pre-exposure prophylaxis (PrEP)

P & T Revisions

2024-11-20, 2024-06-20, 2023-11-01, 2023-09-19, 2023-08-24, 2023-07-21, 2023-01-05, 2023-01-05, 2022-12-15, 2022-10-13, 2022-09-07, 2022-07-22, 2022-03-29, 2022-01-19, 2021-09-28, 2021-07-07, 2021-05-20, 2021-05-04, 2021-04-15, 2020-10-12, 2020-09-30, 2020-06-30, 2020-05-18, 2020-05-15, 2020-05-14, 2020-02-11, 2019-12-17, 2019-11-26, 2019-10-25

References

1. Barnes A. Colonoscopy: Screening or Surveillance? Available at http://news.aapc.com/index.php/2013/03/colonoscopy-screening-or-surveillance/. Updated March 1, 2014. Accessed October 25, 2018.
2. Rex DK, Johnson DA, Anderson JC, et al. American College of Gastroenterology guidelines for colorectal cancer screening. Am J Gastroenterol. 2009; 104(3):739-50.
3. U.S. Department of Health and Human Services. Recommended Preventive Services. Available online at https://www.hhs.gov/healthcare/about-the-aca/preventive-care/index.html. Accessed October 25, 2018.
4. U.S. Department of Health and Human Services Health Resources and Services Administration. Women's Preventive Services: Required Health Plan Coverage Guidelines. Available online at https://www.hrsa.gov/womens-guidelines. Accessed October 25, 2018.
5. U.S. Preventive Services Task Force. Medications for risk reduction of primary breast cancer in women: U.S. Preventive Services Task Force recommendation statement. https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryDraft/breast-cancer-medications-for-risk-reduction1. Accessed February 11, 2020.
6. U.S. Preventive Services Task Force. Screening for colorectal cancer: U.S. Preventive Services Task Force recommendation statement. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/colorectal-cancer-screening.
7. Nicotrol Inhaler Prescribing Information. Pfizer, Inc. December 2009.
8. Nicotrol NS Prescribing Information. Pharmacia and Upjohn Company. June 2018.
9. U.S. Preventive Services Task Force http://www.uspreventiveservicestaskforce.org/ Accessed 6/2022
10. Assessment of Breast Cancer Risk Status. U.S. Preventive Services Task Force https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/breast-cancer-medications-for-risk-reduction. Accessed 10/2018
11. Tamoxifen Prescribing Information. Actavis Pharma. Parsippany, NJ. January 2017.
12. Soltamox Prescribing Information. Meditech Pharma US Inc. Raleigh, NC. October 2018.
13. Evista Prescribing Information. Eli Lily. Indianapolis, IN. January 2018.
14. Stone NJ, Robinson JG, Lichtenstein AH, Bairey Merz CN, Blum CB, Eckel RH, Goldberg AC, Gordon D, Levy D, Lloyd-Jones DM, McBride P, Schwartz JS, Shero ST, Smith SC Jr, Watson K, Wilson PWF. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines. Circulation. 2014;129(suppl 2):S1–S45.
15. Cardiovascular Risk Calculator: http://www.cvriskcalculator.com/
16. Ocular Prophylaxis for Gonococcal Ophthalmia Neonatorum. U.S. Preventive Services Task Force https://jamanetwork.com/journals/jama/fullarticle/2722778. Accessed 5/2019.
17. Erythromycin ophthalmic ointment prescribing information. Bausch + Lomb, a division of Valeant Pharmaceuticals North America LLC. Bridgewater, NJ. July 2016.
18. U.S. Preventive Services Task Force Final Recommendation Statement Prevention of Human Immunodeficiency Virus (HIV) Infection: Pre-exposure Prophylaxis https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/prevention-of-human-immunodeficiency-virus-hiv-infection-pre-exposure-prophylaxis#consider. Accessed July 22, 2019.
19. Truvada Prescribing Information. Gilead Sciences, Inc. Foster City, CA. May 2018.
20. Descovy Prescribing Information. Gilead Sciences, Inc. Foster City, CA. October 2019.
21. Aromasin Prescribing Information. Pfizer. New York, NY. Revised October 2016.
22. Arimidex Prescribing Information. AstraZeneca Pharmaceuticals LP. Wilmington, DE. Revised October 2010.
23. Recommendation: Prevention of Dental Caries in Children Younger Than 5 Years: Screening and Interventions | United States Preventive Services Taskforce (uspreventiveservicestaskforce.org) Accessed May 22, 2024.

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End Notes

1. Important Risk Factors for Breast Cancer [5]: (1) Family history of breast or ovarian cancer (especially among first-degree relatives and onset before age 50 years); (2) History of atypical hyperplasia; (3) Non-malignant high-risk breast lesions; (4) Previous breast biopsy; (5) Extremely dense breast tissue; (6) Increasing age; (7) Race or ethnicity; (8) Age at menarche; (9) Age at first live childbirth; (10) Ductal carcinoma in situ (DCIS); (11) Lobular carcinoma in situ (LCIS); (12) Body mass index; (13) Menopause status or age; (14) Estrogen and progestin use; (15) Smoking; (16) Alcohol use; (17) Physical activity; (18) Diet.
2. The Affordable Care Act (ACA) requires private insurers to cover certain preventive services without any patient cost-sharing (i.e., copayments) when they are delivered by a network provider. The Department of Health and Human Services (HHS) has recognized several recommending bodies (e.g., United States Preventive Services Task Force [USPSTF], Advisory Committee on Immunization Practices [ACIP] http://www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/index.html, Health Resources and Services Administration [HRSA]) who have identified several medication categories that fall within the preventive health mandate.
3. OptumRx has developed a Healthcare Reform Preventative Drug List posted at: https://uhgazure.sharepoint.com/sites/CST/CSDM/Shared%20Documents/UMCS%20Guidelines/Healthcare%20Reform%20Supporting%20Document that identifies which products are eligible for coverage without patient copayment. Some products may be excluded (such as brand oral contraceptives) unless the patient meets the criteria in this exceptions policy.
4. Here is a brief summary of the exceptions allowed in this policy (provided the patient meets all of the specified criteria): (1) The fluoride supplementation exception allows for brand name products at no cost-share, but not combination products; (2) The folic acid exception allows for brand name and Rx products at no cost-share; (3) The smoking cessation exception allows for Nicotrol Inhaler, Nicotrol NS, and brand Zyban at no cost-share, but not additional quantities beyond the QLs; all other covered tobacco cessation products for members ages 18 years and older and not to exceed listed QLs; (4) The contraceptives exception allows for brand name products at no cost-share; (5) The bowel preparation agent exception allows for brand name Rx products at no cost-share but not beyond the QL; and (6) The statin exception allows for atorvastatin 10 mg or 20 mg, or simvastatin 5 mg, 10 mg, 20 mg, or 40mg generics at no cost-share. Other moderate to low dose statins include: pravastatin 10 mg, 20 mg, 40 mg, or 80 mg, fluvastatin 20 mg or 40 mg, pitavastatin 1 mg or 2 mg or 4 mg, rosuvastatin 5 mg or 10 mg.
5. Bowel Preparation Agents: It is important to distinguish between a screening and a surveillance or diagnostic colonoscopy. Screening is performed in asymptomatic patients with no history of colon cancer, polyps, and/or gastrointestinal disease. [1] Whereas, a surveillance colonoscopy can be performed at varying ages and intervals based on the patient’s personal history of colon cancer, polyps, and/or gastrointestinal disease. Patients with a history of colon polyp(s) are not recommended for a screening colonoscopy, but for a surveillance colonoscopy. Per the USPSTF, when the screening test results in the diagnosis of clinically significant colorectal adenomas or cancer, the patient will be followed by a surveillance regimen, and recommendations for screening are no longer applicable. [6] According to the USPSTF, routine colorectal cancer screening is now recommended in adults beginning at age 45 and continuing only until age 75. The American Cancer Society, the U.S. Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology jointly recommended screening for colorectal cancer beginning at 45 years of age by 1) high-sensitivity FOBT or fecal immunochemical testing annually, 2) flexible sigmoidoscopy every 5 years, 3) CT colonography (virtual colonoscopy) every 5 years, 4) colonoscopy every 10 years, or 5) fecal DNA at an unspecified interval. Based on the collective information above, we have a quantity limit in place of two bowel preparation agents per year. (This quantity limit will not apply if patient was intolerant to, had an allergic reaction, or an inadequate response to one of the bowel prep products on the HCR preventative drug list.)
6. Breast Cancer Prevention: The USPSTF recommends that clinicians engage in shared, informed decision-making with women who are at increased risk for breast cancer about medications to reduce their risk. [5] For women who are at an increased risk for breast cancer and at low risk for adverse medication effects, clinicians should offer to prescribe risk-reducing medications, such as tamoxifen or raloxifene. The USPSTF recommends against the routine use of medications, such as tamoxifen or raloxifene, for risk reduction of primary breast cancer in women who are not at increased risk for breast cancer. The updated STAR trial results show diminished benefits of raloxifene compared to tamoxifen after cessation of therapy, making it a preferred risk reduction choice for most post-menopausal women desiring non-surgical risk reduction therapy. However, consideration of toxicity (e.g., endometrial cancer or uterine bleeding) may still lead to the choice of raloxifene over tamoxifen in some women.
7. Gonococcal Ophthalmia Neonatorum (GON) Prevention: The USPSTF recommends prophylactic ocular topical medication for all newborns to prevent gonococcal ophthalmia neonatorum (GON). [17] GON can cause corneal scarring, ocular perforation, and blindness as early as 24 hours after birth. Erythromycin ophthalmic ointment is the only FDA approved drug for the prophylaxis of GON. Ocular prophylaxis of newborns is mandated in most states and is considered standard neonatal care.
8. The USPSTF recommends that clinicians offer preexposure prophylaxis (PrEP) with effective antiretroviral therapy to persons who are at high risk of HIV acquisition. [19] Once-daily oral treatment with Truvada is the only formulation of PrEP approved by the US Food and Drug Administration (FDA) for use in the United States in persons at risk of sexual acquisition of HIV infection. However, several studies reviewed by the USPSTF found that tenofovir disoproxil fumarate alone was also effective as PrEP, and CDC guidelines note that, given these trial data, tenofovir disoproxil fumarate alone can be considered as an alternative regimen for high-risk heterosexually active men and women and persons who inject drugs. [19, 20]
9. The USPSTF recommends that clinicians offer to prescribe risk-reducing medications, such as tamoxifen, raloxifene, or aromatase inhibitors, to women who are at increased risk for breast cancer and at low risk for adverse medication effects. (B recommendation) The USPSTF recommends against the routine use of risk-reducing medications, such as tamoxifen, raloxifene, or aromatase inhibitors, in women who are not at increased risk for breast cancer. (D recommendation) This recommendation applies to asymptomatic women 35 years and older, including women with previous benign breast lesions on biopsy (such as atypical ductal or lobular hyperplasia and lobular carcinoma in situ). This recommendation does not apply to women who have a current or previous diagnosis of breast cancer or ductal carcinoma in situ.
10. The USPSTF recommends for children younger than 5 years of age, that primary care clinicians prescribe oral fluoride supplementation starting at age 6 months for children whose water supply is deficient in fluoride.

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Revision History

• 2024-11-20: Guideline was revised to remove step through requirements.
• 2024-06-20: Per Formulary Strategy team request, updated age criterion for flouride supplementation products section, removed obsolete Buproban and Zyban, updated criteria for immunizations, added fluvastatin ER 80mg as a moderate statin dose option. Updated endnotes and references.
• 2023-11-01: Addition of Apretude
• 2023-09-19: Removed Contraceptives criteria and moved to its own HCR - Contraceptives guideline.
• 2023-08-24: Updated to remove VARENICLINE STARTING MONTH BOX from HIV Prep criteria box.
• 2023-07-21: Annual review - no updates.
• 2023-01-05: Update to change aspirins strength from 325 MG to 81 MG
• 2023-01-05: Consolidated multiple active guidelines to one guideline, combined changes from GL-118432 with GL-114810.
• 2022-12-15: Annual Review
• 2022-10-13: GPI Reclassification
• 2022-09-07: Updated background
• 2022-07-22: Revised contraceptive criteria to allow approval pathway if medically necessary. Minor update to "Generic Statins" criteria changing "i.e." to "e.g."
• 2022-03-29: Updated criteria and background
• 2022-01-19: Added Apo-Varenicline and updated smoking cessation products criteria.
• 2021-09-28: TSK003774440
• 2021-07-07: Annual review - updated criteria for Immunizations section per formulary strategy team request.
• 2021-05-20: Addition of EHB formulary to guideline, no changes to criteria
• 2021-05-04: Reformatted criteria for HIV PrEP for additional clarity, no change to clinical intent
• 2021-04-15: Updated criteria for HIV PrEP per formulary request.
• 2020-10-12: updated criteria for HIV PrEp section per formulary request
• 2020-09-30: copied previous guideline as generic generic emtricitabine-tenofovir disoproxil fumarate is not yet available
• 2020-06-30: Revised language to "Smoking Cessation Products" vs. "Tobacco Cessation Products". Added age limits for influenza vaccines.
• 2020-05-18: Per PA request, added pravastatin, fluvastatin, pitavastatin, and rosuvastatin into product list.
• 2020-05-15: Per PA request, removed "e.g." from the list of statins that are not covered.
• 2020-05-14: Removed non-statin products from the statin criteria per PA request. SL 05/14/20
• 2020-02-11: Updated criteria and notes, and added Aromasin and Arimidex (brand, generic) to guideline.
• 2019-12-17: Updated guideline name to "Healthcare Reform Copay Waiver Review"
• 2019-11-26: Added GON prophylaxis (erythromycin) criteria and PrEP (Truvada, generic tenofovir, Descovy) criteria.
• 2019-10-25: Updated background info and statin criteria.

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