Pharmacy Prior Authorization Criteria

Generic-First Step Program

Indications for Prior Authorization

Criteria

Brand contraceptive drug which has a generic counterpart

*Examples of non-contraception uses: (1) Abnormal or excessive bleeding disorders (eg, amenorrhea, oligomenorrhea, menorrhagia, dysfunctional uterine bleeding); (2) Acne; (3) Decrease in bone mineral density; (4) Dysmennorrhea; (5) Endometriosis; (6) Hirsutism; (7) Irregular menses / cycles; (8) Ovarian cysts; (9) Perimenopausal symptoms; (10) History of Pelvic Inflammatory Disease (PID); (11) Polycystic Ovarian Syndrome (PCO or PCOS); (12) Premenstrual Syndrome (PMS); (13) Premenstrual Dysphoric Disorder (PMDD); (14) Prevention of endometrial and/or ovarian cancer; (15) Prevention of menstrual migraines; (16) Turner’s syndrome; (17) Uterine fibroids or adenomyosis. **Any justification of medical necessity/appropriateness provided by the prescriber is adequate to approve access.

Step Therapy

Length of Approval: 12 Month(s)

One of the following:

Both of the following:

Patient is using the prescribed drug for contraception or other FDA-approved condition*
The requested product is medically necessary**

Both of the following:

Patient is using the prescribed drug for contraception or other FDA-approved condition*
Trial and failure of a minimum 30 day supply, or intolerance to target's generic counterpart

Brand drug which has a generic counterpart

Step Therapy

Length of Approval: 12 Month(s)

Requested drug is being used for a Food and Drug Administration (FDA)-approved indication

AND

Trial and failure of a minimum 30 day supply, or intolerance to target's generic counterpart

Guideline ID
GL-146859
Formulary
Premium
Effective date
Jul 1, 2024
P&T approval date
Nov 14, 2019

P & T Revisions

2024-04-30, 2024-04-30, 2024-04-11, 2023-10-24, 2023-09-25, 2023-08-29, 2023-04-20, 2023-04-17, 2023-03-31, 2023-03-21, 2023-03-08, 2023-02-19, 2023-02-02, 2023-01-06, 2022-10-24, 2022-09-20, 2022-08-21, 2022-07-22, 2022-03-24, 2022-02-18, 2022-01-14, 2021-12-01, 2021-11-04, 2021-10-06, 2021-09-28, 2021-05-21, 2020-11-19, 2020-10-29, 2020-07-22, 2020-01-22, 2020-01-15, 2019-12-20, 2019-12-05, 2019-11-07

References

Revision History

2024-04-30: Added Risperdal Consta and Alphagan P 0.1% ophth soln as targets to guideline.
2024-04-30: update guideline
2024-04-11: 2024 Annual Review.
2023-10-24: update guideline
2023-09-25: 2023 Annual Review
2023-08-29: Removal of Pentasa from guideline
2023-04-20: Added Effexor XR, brand Arimidex, Depakote and Plaquenil as target drugs to guideline
2023-04-17: Removed Baraclude as a target drug from the guideline
2023-03-31: Updated GPIs
2023-03-21: UPDATE GUIDELINE
2023-03-08: Guideline Update
2023-02-19: Removed Arimidex, Depakote IR tablets, Tamiflu suspension, and Plaquenil due to drug shortages
2023-02-02: update guideline
2023-01-06: UPDATE GUIDELINE
2022-10-24: guideline update
2022-09-20: 2022 Annual Review.
2022-08-21: 2022 Guideline Update
2022-07-22: Create contraceptive specific generic-first criteria.
2022-03-24: Product List Update
2022-02-18: 2022 UM Product Updates
2022-01-14: Program update to remove Exforge HCT
2021-12-01: Program update to remove Exforge HCT
2021-11-04: 2021 Annual Review. Program update to remove progesterone, glucophage/xr, golytely sol, and ortho-cyclen as targets
2021-10-06: Program updated to add Bystolic
2021-09-28: Added Brand Azopt and Brand Travatan Z as targets
2021-05-21: Addition of EHB formulary to guideline, no changes to criteria
2020-11-19: Program updated to remove Finacea gel and Metrogel as they will have drug-specific guidelines on 1/1/2021.
2020-10-29: 2020 Annual Review, no changes to criteria.
2020-07-22: Program updated to add Vanadom as target.
2020-01-22: Program updated to remove Cardizem LA 120mg, Delestrogen 10mg/ml, and Lamictal XR Kits.
2020-01-15: Program updated to remove Carnitor injection as it does not have generic equivalent
2019-12-20: Program updated to remove Clarinex syrup and Clarinex-D as they do not have generic equivalents
2019-12-05: Program updated to remove Latisse and Propecia as targets
2019-11-07: New program