Pharmacy Prior Authorization Criteria

High-Cost Brand with Generics Program

Indications for Prior Authorization

Criteria

Drugs included on the High Cost Brand with Generics List for which a Drug-Specific Prior Authorization Guideline is Unavailable*

*Drug should be reviewed using the drug-specific Prior Authorization guideline if available. If no drug-specific Prior Authorization guideline is available, proceed with the criteria above. **Please use the ORx Commercial grid to identify covered formulary generic alternatives for the requested target drug

Prior Authorization

Length of Approval: 6 Month(s)

• One of the following:
• 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
OR
• If requested for an off-label indication, the off-label guideline approval criteria have been met
AND
• All of the following:
• Patient has experienced intolerance (e.g., allergy to excipient) with the generic of the requested Brand
AND
• If the requested drug is a Brand fixed-dose combination product, patient has experienced intolerance (e.g., allergy to excipient) with the individual generics in the combination product separately
AND
• Submission of records (e.g., chart notes) confirming why the Brand is expected to provide benefit when the generic product has not been shown to be effective despite having the same active ingredient
AND
• One of the following:**
• Patient has tried and failed at least 2 additional lower tier alternatives within the same therapeutic class. If only 1 lower tier alternative within the therapeutic class is available, the patient must have tried the lower tier alternative within the therapeutic class AND 1 additional lower tier alternative. If there are no lower tier alternatives within the same therapeutic class, the patient must have failed or had contraindication or intolerance to 2 lower tier alternatives
OR
• No lower tier alternative is available to treat the patient's condition

P & T Revisions

2024-06-20

References

Revision History

• 2024-06-20: New Program