Respiratory

PA Criteria:

Tier 1 products are covered with no authorization necessary for members under age 21. 

• For members 21 years and older, Tier 1 products are available with prior authorization.

Tier 2 authorization requires a documented 14 day trial of all Tier 1 products within the last 30 days.

Tier 3 authorization requires a 14 day trial with all Tier 2 products within the last 60 days (unless no age-appropriate Tier 2 product exists).

• Xyzal Tabs are not covered for members under age 6. (Syrup is covered down to 6 months of age)
• For all antihistamine authorizations, the diagnosis must be for a chronic allergic condition. 
• Prior Authorization form

Tier 1

Tier 2

Tier 3

• OTC cetirizine 5mg & 10mg tablets, syrup  (Zyrtec®)
• OTC loratadine (Claritin®)

• levocetirizine (Xyzal®)

• desloratadine (Clarinex®)

• Tier-1 products are available without prior authorization.
• Tier-2 authorization requires:

       1) Approved or clinically accepted indication, and
       2) Specific reason member cannot use all available tier-1 products

Tier 1

Tier 2

• albuterol HFA (ProAir HFA®)
• albuterol HFA (Proventil HFA®)

• albuterol HFA (Ventolin HFA®)
• levalbuterol HFA (Xopenex HFA®)

levalbuterol (Xopenex® nebulizer solution)

PA criteria:

Xopenex

• PA required for use of this product in excess of 90 days of therapy in a 360 day period.
• A quantity limit of 288 units every 30 days will apply to Xopenex solution.
• Please state need of this product over albuterol.

Criteria for approval:

• In the prior authorization request, the prescriber should explain why the member is unable to use long acting bronchodilators and/or inhaled corticosteroid (ICS) therapy for long-term control as recommended in the NAEPP guidelines.
• Prior Authorization form

salmetrol (Serevent®)
formoterol (Foradil®)

PA Criteria:

LABA single products will require a prior authorization with the following approval criteria:

1) Diagnosis of COPD, Approved for one year

2) Diagnosis of Asthma:

• Member must be 12 years of age or older, AND
• Must have used an inhaled corticosteroid for at least one month immediately prior with inadequate results and plan to continue using ICS concomitantly with the LABA.
• Reason why member cannot use and ICS/LADA combination product.
• Approval will be for only 3 months to ensure use for the shortest duration of time require to achieve control of asthma symptoms.
• Prior Authorization form

arformoterol (Brovana®)
indacaterol (Arcapta®)

PA Criteria:

• Members must be over 18 years of age and have one of the following diagnoses: COPD, chronic bronchitis, or emphysema.
• Member must have previous trial with Advair, Serevent, or Foradil in the past 45 days. A clinical exception will be given for those members who are unable to effectively use hand-actuated devices or who have become unstable on nebulized short-acting agonist therapy.
• Quantity limit of 30 day supply.
• Prior Authorization form

PA criteria:

1). The following criteria are required for approval of a Tier 2 product:

• Documented adverse effect or contraindication to the preferred products.
• Failure with all tier 1 medications defined as no beneficial response after at least three weeks use at the maximum recommended dose. 

2). The following criteria are required for approval of a Tier 3 product:

• All tier 2 criteria must be met.
• Failure with all available tier 2 products defined as no beneficial response after at least three weeks use at the maximum recommended dose. 

3). Approvals will be for the duration of three months, except for members with chronic diseases such as asthma or COPD, in which case authorizations will be for the duration of one year.

4). No grandfathering of tier 2 or tier 3 products will be allowed for this category.

5). For 2 to 4 year olds, the age appropriate lower-tiered generic products must be used prior to the use of higher tiered products.

• Prior Authorization form

PA Criteria:

Members must be included in one of the following age groups at the beginning of RSV season:

• Infants and children less than 24 months old with Chronic Lung Disease (CLD) (formerly bronchopulmonary dysplasia) who have required medical treatment (O2, bronchodilator, corticosteroid, or diuretic therapy) for CLD in the 6 months prior to RSV season.
• Infants up to 24 months old with moderate to severe pulmonary hypertension, cyanotic heart disease, or those on medications to control congestive heart failure.
• Infants less than 12 months of age, born at 28 weeks gestation or earlier.
• Infants less than 6 months old, born at 29-31 weeks gestation.
• Infants less than 12 months of age, born before 35 weeks gestation, with congenital abnormalities of the airway.
• Infants less than 12 months of age, born before 35 weeks gestation, with severe neuromuscular disease.
• Infants, up to 3 months old at the start of the season, born at 32-34 weeks gestation, who have one of the following risk factors:
  • Child care attendance
  • Siblings younger than 5 years of age
• The maximum duration of therapy is five (5) doses, with a dose to be administered no more often than every 30 days. Infants born at 32-34 weeks gestation will receive a maximum of three doses. Members given doses more frequently than every 30 days will not be authorized for additional doses.  Doses administered prior to the member's discharge from a hospital will be counted as one of the approved total. 

  Synagis form 

PA Criteria:

• Member must be between 12-75 years of age.
• Member must have a diagnosis of severe persistent asthma (as per NAEPP guidelines).
• Member must have a positive skin test to at least one perennial aeroallergen. Specific positive perennial allergens must be listed on the petition.
• Member must have a pretreatment serum IgE level between 30-700 IU/ml.
• Member weight must be between 30-150kg.
• Member must have been on high dose ICS (as per NAEPP Guidelines) for a minimum of 3 months.
• Medication must be prescribed by either a pulmonary or an allergy/asthma specialist.
• Member must have been in the ER or hospitalized, due to an asthma exacerbation, twice in the past 6 months. Date of visits must be listed on petition, or
• Have been determined to be dependent on systemic steroids to prevent serious exacerbations.

For Xolair requests, please submit these forms together:

• Xolair Statement of Medical Necessity
• Universal Petition for Medication Authorization

PA criteria:

• FDA approval indication of Cystic Fibrosis with a G551D mutation in the CFTR gene detected by genetic testing.
• Age of 6 years or older.
• Quantity limit of two tablets per day, #60 per 30 days will apply.
• Initial approval will be for 6 months, after which time, compliance and information regarding efficacy, such as improvement in FEV1, will be required for continued approval.