SHORT ACTING BETA2 AGONISTS |
- Tier-1 products are available without prior authorization.
- Tier-2 authorization requires:
- An FDA approved or clinically accepted indication, and
- A patient-specific, clinically significant reason why the member cannot use all available Tier-1 products; and
- Approval of generic levalbuterol HFA requires a patient-specific, clinically significant reason the member cannot use the brand formulation.
Airsupra™ (Albuterol/Budesonide) Approval Criteria:
- An FDA approved diagnosis of asthma; AND
- Member must be 18 years of age or older; AND
- Member must be using maintenance therapy per the Global Initiative for Asthma (GINA) guidelines; AND
- A patient-specific, clinically significant reason why the member cannot use a long-acting beta2 agonist (LABA), inhaled corticosteroid (ICS)/LABA combination, or specific individual ICS and short-acting beta2 agonist (SABA) components must be provided; AND
- Initial approvals will be for the duration of 3 months. For continued consideration, prescriber must verify the member has had a positive clinical response to therapy; AND
- Subsequent approvals will be for the duration of 1 year.
ProAir® Digihaler® (Albuterol Sulfate Inhalation Powder) Approval Criteria::
- An FDA approved or clinically accepted indication; AND
- A patient-specific, clinically significant reason why the member requires the ProAir® Digihaler™ formulation over all available Tier-1 medications must be provided; AND
- The prescriber agrees to closely monitor member adherence; AND
- The member should be capable and willing to use the Companion Mobile App and follow the Instructions for Use and ensure the ProAir® Digihaler™ Companion Mobile App is compatible with their specific smartphone; AND
- The member’s phone camera must be functional and able to scan the inhaler QR code and register the ProAir® Digihaler™ inhaler; AND
- Approvals will be for the duration of 3 months. For continuation consideration, documentation demonstrating positive clinical response and member compliance greater than 80% with prescribed maintenance therapy must be provided. In addition, a patient-specific, clinically significant reason why the member cannot transition to Tier-1 medications must be provided. Tier structure rules continue to apply.
Xopenex® (Levalbuterol) Nebulizer Solution Approval Criteria:
- A free-floating 90 days therapy per 365 days will be in place.
- Use of this product in excess of 90 days of therapy in 365 day period will require a patient-specific, clinically significant reason why the member is unable to use long-acting bronchodilators and/or inhaled corticosteroids (ICS) therapy for long-term control as recommended in the National Asthma Education and Prevention Program (NAEPP) guidelines; and
- A patient-specific, clinically significant reason why the member cannot use a metered-dose inhaler (MDI); and
- Clinical exceptions will be made for clients with chronic obstructive pulmonary disease (COPD); and
- A quantity limit of 288mL per 30 days will apply.
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Tier 1
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Tier 2
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- ProAir HFA® (brand only)
- Proventil HFA® (brand only)
- Ventolin HFA® (brand only)
- albuterol sulfate (ProAir® RespiClick)
- Xopenex HFA® (brand only)
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- albuterol HFA (ProAir® HFA) (generic)
- albuterol HFA (Proventil® HFA) (generic)
- albuterol HFA (Ventolin® HFA) (generic)
- albuterol sulfate inhalation powder (ProAir® Digihaler™)
- levalbuterol HFA (Xopenex HFA) (generic)
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Tier-1 products are covered without authorization |
Maintenance Asthma and COPD Medications:
Long-Acting Beta2 Agonist (LABA) and Long-Acting Muscarinic Antagonist (LAMA) Tier-2 Approval Criteria:
- Member must be 18 years of age or older; and
- An FDA approved diagnosis of chronic obstructive pulmonary disease (COPD), chronic bronchitis, or emphysema; and
- A 4-week trial of at least 1 LABA and a 4-week trial of 1 LAMA within the past 90 days; or
- A documented adverse effect, drug interaction, or contraindication to all available Tier-1 products; or
- A clinical exception may apply for members who are unable to effectively use hand-actuated devices, such as Spiriva® HandiHaler®, or who are stable on nebulized therapy.
Prior Authorization form
Long-Acting Beta2 Agonists (LABA) and Long-Acting Anticholinergics (LAMA) |
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Long-Acting Beta2 Agonists (LABA)
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- salmeterol inhalation powder (Serevent®)
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- arformoterol nebulizer solution Brovana®)
- formoterol nebulizer solution (Perforomist®)
- olodaterol inhalation spray Striverdi® Respimat®)
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Long-Acting Anticholinergics (LAMA)
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- aclidinium inhalation powder (Tudorza® PressAir®)
- tiotropium inhalation powder (Spiriva® HandiHaler®) – Brand Preferred
- tiotropium soft mist inhaler (Spiriva® Respimat®)
- umeclidinium inhalation powder (Incruse® Ellipta®)
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- revefenacin inhalation solution (Yupelri™)
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*Combination agents that contain a Tier-1 ingredient qualify as Tier-1 agents.
Tier-1 medications do not require prior authorization.
QVAR® RediHaler™ (Beclomethasone Dipropionate) Approval Criteria:
- An FDA approved diagnosis of asthma; and
- Member must be at the age indicated for the requested product:
- QVAR® RediHaler™: Member must be 4 years of age or older; and
- A trial of all available Tier-1 inhaled corticosteroids or a patient-specific, clinically significant reason why they are not appropriate for the member must be provided.
AirDuo RespiClick® (Fluticasone Propionate/Salmeterol) Approval Criteria:
- An FDA approved diagnosis of asthma; and
- Member must be at or above the minimum age indicated; and
- Failure of Advair®, Dulera®, and Symbicort® or a reason why Advair®, Dulera®, and Symbicort® are not appropriate for the member; and
- Member must have used an inhaled corticosteroid for at least 1 month immediately prior; and
- Member must be considered uncontrolled by provider [required rescue medication >2 days a week (not for prevention of exercise induced bronchospasms) and/or needed oral systemic corticosteroids]; or
- A clinical situation warranting initiation with combination therapy due to severity of asthma.
Breo® Ellipta® (Fluticasone Furoate/Vilanterol) Approval Criteria:
- An FDA approved diagnosis of chronic obstructive pulmonary disease (COPD) or chronic bronchitis and/or emphysema associated with COPD; and
- For a diagnosis of COPD or chronic bronchitis and/or emphysema associated with COPD, trials of Advair® and Symbicort®, consisting of at least 30 days each within the last 90 days that did not adequately control COPD symptoms; or
- An FDA approved diagnosis of asthma in members 5 years of age and older; and
- For a diagnosis of asthma, trials of Advair®, Dulera®, and Symbicort® consisting of at least 30 days each within the last 120 days that did not adequately control asthma symptoms; and
- Requests for generic fluticasone furoate/vilanterol will require a patient-specific, clinically significant reason why brand name Breo® Ellipta® cannot be used.
Breyna™ (Budesonide/Formoterol Fumarate) Approval Criteria:
- A patient-specific, clinically significant reason why the member cannot use brand name Symbicort® must be provided (brand formulation is preferred and does not require a prior authorization).
Daliresp® (Roflumilast) Approval Criteria:
- An FDA approved diagnosis of chronic obstructive pulmonary disease (COPD) with history of chronic bronchitis; and
- Forced expiratory volume (FEV) ≤50% of predicted; and
- Member is inadequately controlled on long-acting bronchodilator therapy (must have 3 or more claims for long-acting bronchodilators in the previous 6 months)
Dulera® (Mometasone Furoate/Formoterol) 50mcg/5mcg Approval Criteria:
- An FDA approved diagnosis of asthma; and
- Member must be between 5 and 11 years of age; and
- Failure of Advair® and Symbicort® or a reason why Advair® and Symbicort® are not appropriate for the member must be provided; and
- Member must have used an inhaled corticosteroid for at least 1 month immediately prior; and
- Member must be considered uncontrolled by provider [required rescue medication >2 days a week (not for prevention of exercise induced bronchospasms) and/or needed oral systemic corticosteroids]; or
- A clinical situation warranting initiation with combination therapy due to severity of asthma.
AirDuo® Digihaler® (Fluticasone Propionate/Salmeterol Inhalation Powder) Approval Criteria:
- An FDA approved diagnosis of asthma; and
- Member must be 12 years of age or older; and
- A patient-specific, clinically significant reason why the member requires AirDuo® Digihaler® over AirDuo RespiClick® and all preferred Tier-1 inhaled corticosteroid and long-acting beta2-agonist (ICS/LABA) products (Advair®, Dulera®, and Symbicort®) must be provided; and
- Failure of Advair®, Dulera®, and Symbicort® or a reason why Advair®, Dulera®, and Symbicort® are not appropriate for the member must be provided; and
- Member must have used an ICS for at least 1 month immediately prior; and
- Member must be considered uncontrolled by provider [required rescue medication >2 days a week (not for prevention of exercise induced bronchospasms) and/or needed oral systemic corticosteroids]; or
- A clinical situation warranting initiation with combination therapy due to severity of asthma; and
- The prescriber agrees to closely monitor member adherence; and
- The member should be capable and willing to use the Companion Mobile App and to follow the Instructions for Use, and member must ensure the Digihaler® Companion Mobile App is compatible with their specific smartphone; and
- The member’s phone camera must be functional and able to scan the inhaler QR code and register the AirDuo® Digihaler® inhaler; and
- Approvals will be for the duration of 3 months. For continuation consideration, documentation demonstrating positive clinical response and member compliance >80% with prescribed maintenance therapy must be provided. In addition, a patient-specific, clinically significant reason why the member cannot transition to Tier-1 medications must be provided. Tier structure rules continue to apply.
ArmonAir® Digihaler® (Fluticasone Propionate Inhalation Powder) Approval Criteria:
- An FDA approved diagnosis of asthma; and
- Member must be 12 years of age or older; and
- A patient-specific, clinically significant reason why Flovent® (fluticasone propionate) or other preferred monotherapy inhaled corticosteroid (ICS) is not appropriate for the member must be provided; and
- The prescriber agrees to closely monitor member adherence; and
- The member should be capable and willing to use the Companion Mobile App and to follow the Instructions for Use, and member must ensure the Digihaler® Companion Mobile App is compatible with their specific smartphone; and
- The member’s phone camera must be functional and able to scan the inhaler QR code and register the ArmonAir® Digihaler® inhaler; and
- Approvals will be for the duration of 3 months. For continuation consideration, documentation demonstrating positive clinical response and member compliance >80% with prescribed maintenance therapy must be provided. In addition, a patient-specific, clinically significant reason why the member cannot transition to Tier-1 medications must be provided. Tier structure rules continue to apply.
Anoro® Ellipta® (Umeclidinium/Vilanterol), Bevespi Aerosphere® (Glycopyrrolate/Formoterol Fumarate), Duaklir® Pressair® (Aclidinium Bromide/Formoterol Fumarate), and Stiolto® Respimat® (Tiotropium/Olodaterol) Approval Criteria:
- Member must be 18 years of age or older; and
- An FDA approved diagnosis of chronic obstructive pulmonary disease (COPD); and
- A patient-specific, clinically significant reason why the member cannot use Tier-1 long-acting beta2 agonist (LABA) and long-acting muscarinic antagonist (LAMA) individual components must be provided.
Breztri Aerosphere™ (Budesonide/Glycopyrrolate/Formoterol) and Trelegy Ellipta (Fluticasone Furoate/Umeclidinium/Vilanterol) Approval Criteria:
- An FDA approved diagnosis; and
- Member must be 18 years of age or older; and
- A 4-week trial of at least 1 long-acting beta2 agonist (LABA) and a 4-week trial of 1 long-acting muscarinic antagonist (LAMA) within the past 90 days used concomitantly with an inhaled corticosteroid (ICS); and
- A patient-specific, clinically significant reason why the member requires the triple combination therapy in place of the individual components or use of a LABA/ICS combination with a LAMA must be provided.
Symbicort Aerosphere® (Budesonide/Formoterol Fumarate) Approval Criteria:
- An FDA approved diagnosis of chronic obstructive pulmonary disease (COPD); and
- A patient-specific, clinically significant reason why the member cannot use brand name Symbicort® and Advair® must be provided.
Wixela Inhub (Fluticasone/Salmeterol Inhalation Powder) Approval Criteria:
- A patient-specific, clinically significant reason why the member cannot use the brand formulation (Advair Diskus) or other generic formulations (fluticasone/salmeterol) must be provided (brand formulation and other generics are preferred and do not require prior authorization).
PRIOR AUTHORIZATION FORM
INHALED CORTICOSTEROIDS (ICS) and Combination products |
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Tier 1
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Tier 2
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- budesonide (Pulmicort Flexhaler®)
- budesonide/formoterol (Symbicort®)β - Brand Preferred
- Budesonide suspension (Pulmicort®) (Age Restriction of 0 to 8 years old does not require prior authorization)
- ciclesonide (Alvesco®)
- fluticasone furoate (Arnuity® Ellipta®)
- fluticasone propionate (Flovent®)
- fluticasone/salmeterol (Advair®)α
- mometasone furoate/formoterol (Dulera®)◊
- mometasone furoate (Asmanex®)
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- beclomethasone dipropionate (QVAR® RediHaler™)
- budesonide/formoterol (Symbicort Aerosphere®)
- fluticasone furoate/vilanterol (Breo® Ellipta®) – Brand Preferred
- fluticasone propionate (ArmonAir™ RespiClick®)
- fluticasone propionate (ArmonAir™ Digihaler®)
- fluticasone propionate/salmeterol (AirDuo Digihaler ®)
- mometasone furoate/formoterol 50mcg/5mcg (Dulera®)
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Tier-1 products indicated for the member’s age are covered with no prior authorization required.
Tier structure based on supplemental rebate participation and/or National Average Drug Acquisition Costs (NADAC), Wholesale Acquisition Costs (WAC), or State Maximum Allowable Costs (SMAC).
*Unique criteria apply to each Tier-2 product.
βDoes not include Breyna™; authorization of Breyna™ requires a reason why the member cannot use the brand formulation (Symbicort®).
αDoes not include Wixela Inhub®; authorization of Wixela Inhub® requires a reason why the member cannot use the brand formulation (Advair®) or other generic formulations of fluticasone propionate/ salmeterol.
◊Includes all strengths other than Dulera® 50mcg/5mcg.