Pharmacy Prior Authorization Criteria

Non-Essential Drug Program – PA, NF

Indications for Prior Authorization

Criteria

Drugs included on the Non-Essential Drug List*

* If being used for any other indication, deny the case for medical necessity and do not review for off-label use. **Alternatives on the same tier refers to a requested drug on tier 1. ^OTC equivalents refers to any covered or non-covered OTC equivalent product.

Prior Authorization

Length of Approval: 14 Day(s)

• All of the following:
• Requested drug is FDA-approved for the condition being treated
AND
• Additional requirements listed in the "Indications and Usage" sections of the prescribing information (or package insert) have been met (e.g., first line therapies have been tried and failed, any testing requirements have been met, etc.)
AND
• Requested drug will be used at a dose which is within FDA recommendations
AND
• One of the following:
• If the requested drug has an alternative(s) on the same or lower tier** with the same active ingredient, both of the following:
• Patient has experienced intolerance (e.g., allergy to excipient) with all same and lower tier alternative(s) that has the same active ingredient if applicable
AND
• Patient has tried and failed all same and lower tier alternative(s) within the same therapeutic class. If there are no same or lower tier alternatives within the same therapeutic class, the patient must have failed or had contraindication or intolerance to all same and lower tier alternatives if applicable
OR
• If the requested drug is a fixed-dose combination product with each individual ingredients available on same or lower tier**, both of the following:
• Patient has experienced intolerance (e.g., allergy to excipient) with the individual ingredients in the combination product
AND
• Patient has tried and failed all same and lower tier alternatives if applicable
OR
• If only Over-The-Counter (OTC) equivalents^ are available, patient has tried and failed or has contraindications or intolerance to all available OTC equivalents. [document drug(s), dose, duration of trial]
OR
• If alternative(s) on the same or lower tier** available and do not meet above scenarios, patient has tried and failed, or has contraindication or intolerance to all same and lower tier alternatives
AND
• Submission of records (e.g., chart notes) confirming why the requested drug is expected to provide benefit when the same and lower tier alternative(s) or OTC equivalent(s) has not shown to be effective

Drugs included on the Non-Essential Drug List*

* If being used for any other indication, deny the case for non-formulary and do not review for off-label use. ^OTC equivalents refers to any covered or non-covered OTC equivalent product.

Non Formulary

Length of Approval: 14 Day(s)

• All of the following:
• Requested drug is FDA-approved for the condition being treated
AND
• Additional requirements listed in the "Indications and Usage" sections of the prescribing information (or package insert) have been met (e.g., first line therapies have been tried and failed, any testing requirements have been met, etc.)
AND
• Requested drug will be used at a dose which is within FDA recommendations
AND
• One of the following:
• If the requested drug has a lower tier alternative(s) with the same active ingredient, both of the following:
• Submission of medical records (e.g., chart notes) confirming patient has experienced intolerance (e.g., allergy to excipient) with all lower tier alternative(s) that has the same active ingredient
AND
• Submission of medical records (e.g., chart notes) or paid claims confirming patient has tried and failed all lower tier alternative(s) within the same therapeutic class. If there are no lower tier alternatives within the same therapeutic class, the patient must have failed or had contraindication or intolerance to all lower tier alternatives
OR
• If the requested drug is a fixed-dose combination product with each individual ingredients available on lower tier, both of the following:
• Submission of medical records (e.g., chart notes) confirming patient has experienced intolerance (e.g., allergy to excipient) with the individual ingredients in the combination product
AND
• Submission of medical records (e.g., chart notes) or paid claims confirming patient has tried and failed all lower tier alternatives
OR
• If only Over-The-Counter (OTC) equivalents^ are available, patient has tried and failed or has contraindications or intolerance to all available OTC equivalents. [document drug(s), dose, duration of trial]
OR
• If lower tier alternatives are available and do not meet above scenarios, submission of medical records (e.g., chart notes) or paid claims confirming patient has tried and failed, or has contraindication or intolerance to all lower tier alternatives
AND
• Submission of records (e.g., chart notes) confirming why the requested drug is expected to provide benefit when the lower tier alternative(s) or OTC equivalent(s) has not shown to be effective

P & T Revisions

2024-07-05, 2024-06-05

References

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Revision History

• 2024-07-05: Program update.
• 2024-06-05: New Program.

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