Respiratory

PA Criteria:

Tier 1 products for pediatric members are covered with no authorization necessary. OTC products are only covered for pediatric members.

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 is only covered for members 0-20 years of age. (Syrup is covered from 6 months of age to 6 years 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®)

• OTC levocetirizine (Xyzal®)*

• desloratadine (Clarinex®)
• clemastine

montelukast granules (Singulair®)

PA criteria:

• Montelukast granules require prior authorization for all ages.  Authorization requires patient-specific clinically significant reason why member cannot use montelukast tablets or chewable tablets. Age-appropriate trials of asthma and/or allergic rhinitis medications are required.  

zileuton (Zyflo®, Zyflo CR®)  

• Children age 12 and older with:
• Diagnosis of mild or moderate persistent asthma, AND
• Trial of inhaled corticosteroid AND corticosteroid/LAB2A therapy within the previous 6 months, and reason for trial failure, AND
• Recent trial with at least one other available leukotriene modifier that did not yield adequate response.  

Prior Authorization form  

• 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 (ProAir® HFA) 
• levalbuterol HFA (Xopenex HFA) 

 levalbuterol (Xopenex® Nebulizer Solution) PA criteria:

• 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.
  • 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

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 

omalizumab (Xolair®) Approval Criteria for Asthma:

• Member must be between 6-75 years of age; AND
• Member must have a diagnosis of severe persistent asthma (as per NAEPP guidelines); AND
• Member must have a positive skin test to at least one perennial aeroallergen. Positive perennial allergens must be listed on the prior authorization request; AND
• Member must have a pretreatment serum IgE level between 30-1300 IU/ml (depending on member age); AND
• Member weight must be between 20-150kg; AND
• Member must have been on high dose ICS (≥880mcg/day fluticasone propionate or equivalent daily dose or ≥440mcg/day in ages 12 to 17 years) for at minimum the past three months; AND
• Prescribed Xolair® dose must be an FDA approved regimen per Xolair® prescribing information; AND
• Xolair® must be administered in a healthcare setting by a healthcare professional prepared to manage anaphylaxis; AND
• Xolair® must be prescribed by an allergist, pulmonologist, or pulmonary specialist or the member must have been evaluated by an allergist, pulmonologist, or pulmonary specialist within the last twelve months (or be an advanced care practitioner with a supervising physician who is an allergist, pulmonologist, or pulmonary specialist); AND
• Member must have been in the ER or hospitalized, due to an asthma exacerbation, twice in the past twelve months (date of visits must be listed on the prior authorization request), or have been determined to be dependent on systemic steroids to prevent serious exacerbations; AND
• Both the prior authorization request form and statement of medical necessity form must be submitted for processing.
• 12. Initial approvals will be for the duration of six months after which time compliance will be evaluated for continued approval.

Omalizumab (Xolair®) Approval Criteria for Chronic Idiopathic Uritcaria:

• Member must be > 12 years of age; AND
• Other forms of urticaria must be ruled out; AND
• Other potential causes of urticaria must be ruled out; AND
• Member must have an Urticaria Activity Score (UAS) >16; AND
• Prescriber must be an allergist, immunologist, dermatologist, or be an advanced care practitioner with a supervising physician that is an allergist, immunologist, or dermatologist; AND
• A trial of a second generation H₁antihistamine dosed four times the maximum FDA dose within the last three months for at least four weeks (or less if symptoms are intolerable); AND   
• Initial dosing will only be approved at 150mg every 4 weeks.  If inadequate results at this dose, then the dose may be increased to 300mg every 4 weeks: AND
• Initial approvals will be for the duration of 3 months.
  

For Xolair requests, please submit these forms together:

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