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Endocrine/Diabetics

Anti-Diabetic Medications Tier-2 Approval Criteria:  

  • A trial at least 3 months in duration (unless intolerable adverse effects) of metformin titrated up to maximum dose, or a patient-specific, clinically significant reason why a 3-month trial of metformin titrated up to maximum tolerated dose is not appropriate must be provided. 
  • For initiation with dual or triple therapy, additional Tier-2 medications may be approved based on current American Association of Clinical Endocrinologists (AACE) or American Diabetes Association (ADA) guidelines. 
  • A clinical exception will apply for medications with a unique FDA approved indication not covered by all Tier-1 medications. Tier structure rules for unique FDA approved indications will apply.

Anti-Diabetic Medications Tier-3 Approval Criteria:

  • Member must have failed a trial at least 3 months in duration and at recommended dosing (and member must be adherent to therapy) with 1 Tier-2 medication in the same category and have a documented clinical reason why the member cannot continue treatment with the Tier-2 medication.  
    • For members who did not complete a 3 month trial (i.e., due to intolerable adverse effects), the member must have a documented clinical reason why they cannot utilize a different Tier-2 medication in the same category, a Tier-2 medication in a different category, or provide detailed information regarding adverse effects occurring with the Tier-2 medication(s) that are not expected to occur with the requested Tier-3 medication that is in the same category. 
    • For Tier-3 medications that do not have a similar category in Tier-2, a medication from any category in Tier-2 may be used. 
  • A clinical exception will apply for medications with a unique FDA approved indication not covered by all Tier-1 and Tier-2 medications. Tier structure rules for unique FDA approved indications will apply.

Anti-Diabetic Medications Special Prior Authorization (PA) Approval Criteria:

  • Member must be currently stabilized on the requested product or have attempted at least 3 other categories of Tier-2 or Tier-3 medications, or have a documented clinical reason why the requested product is necessary for the member; AND  
  • Use of Invokamet® XR [canagliflozin/metformin extended-release (ER)] will require a patient-specific, clinically significant reason why the member cannot take the immediate-release formulation(s); AND 
  • Use of Adlyxin® (lixisenatide) or Mounjaro® (tirzepatide) will require a patient-specific, clinically significant reason the member cannot use the vial or pen formulation.  

Kerendia® (Finerenone) Approval Criteria:

  • An FDA approved indication to reduce the risk of sustained estimated glomerular filtration rate (eGFR) decline, end stage kidney disease, cardiovascular death, non-fatal myocardial infarction, and hospitalization for heart failure in adult members with chronic kidney disease (CKD) associated with type 2 diabetes mellitus (T2DM); and
  • Member must be receiving a maximum tolerated dose of an angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) or have a contraindication to use; and
  • A patient specific, clinically significant reason why the member cannot use a sodium-glucose cotransporter-2 (SGLT-2) inhibitor must be provided; and
  • Member must not be receiving concomitant treatment with strong CYP3A4 inhibitors (e.g., itraconazole, ketoconazole, ritonavir); and
  • Member must not have adrenal insufficiency; and
  • Member must not have severe hepatic impairment (Child Pugh C); and
  • Prescriber must measure serum potassium and eGFR prior to initiation of Kerendia®; and
  • Prescriber must verify serum potassium is not >5.0mEq/L prior to treatment initiation with Kerendia®; and
  • Prescriber must agree to monitor serum potassium levels 4 weeks after a dose adjustment and throughout treatment and adjust the dose accordingly per package labeling; and
  • Initial authorization will be for 4 weeks, after which time serum potassium levels will be required for continued approval; and
  • A quantity limit of 30 tablets per 30 days will apply. The member’s eGFR should be provided for initiation of treatment to ensure the correct recommended dose per package labeling. The following initial dose will be approved based on eGFR:
    • Kerendia® 10mg once daily in members with eGFR 25 to <60mL/min/1.73m2; or
    • Kerendia® 20mg once daily in members with eGFR ≥60mL/min/1.73m2.

Soliqua® 100/33 (Insulin Glargine/Lixisenatide) Approval Criteria:  

  • An FDA approved diagnosis of type 2 diabetes mellitus; AND  
  • A patient-specific, clinically significant reason why the member cannot use Lantus® (insulin glargine) with an alternative glucagon-like peptide-1 (GLP-1) receptor agonist must be provided.
  • Current Tier-3 criteria will apply. 

Tzield® (Teplizumab-mzwv) Approval Criteria:

  • An FDA approved diagnosis of stage 2 Type 1 diabetes mellitus (DM). Diagnosis must be confirmed by the following:
    • Laboratory testing confirming the presence of ≥2 pancreatic islet autoantibodies; AND
      • Documentation must be submitted with results of autoantibody testing; AND
    • Documented evidence of dysglycemia without overt hyperglycemia as demonstrated by an abnormal oral glucose tolerance test (OGTT) meeting 1 of the following:
      • Fasting plasma glucose ≥100mg/dL and <126mg/dL; OR
      • 2-hour plasma glucose ≥140 mg/dL and <200mg/dL; OR
      • 30-, 60-, or 90-minute value on OGTT ≥200mg/dL; AND
  • Member must be 8 years of age or older; AND
  • Prescriber must confirm that member’s clinical history does not suggest a diagnosis of Type 2 DM; AND
  • Tzield® must be prescribed by an endocrinologist (or an advanced care practitioner with a supervising physician who is an endocrinologist); AND
  • All of the following will be required for initiation of treatment:
    • Verification that female members of reproductive potential are not pregnant and are currently using reliable contraception; AND
    • Verification that the member has no active infection(s); AND
    • Complete blood counts (CBC) and verification that levels are acceptable to the prescriber; AND
    • Liver function tests and verification that levels are acceptable to the prescriber; AND
    • Verification that all age-appropriate vaccinations have been administered prior to treatment; AND
    • Prescriber must agree to premedicate the member for the first 5 days of dosing and as needed with a nonsteroidal anti-inflammatory drug (NSAID) or acetaminophen, an antihistamine, and/or an antiemetic; AND
  • Tzield® must be administered by a health care professional. Approvals will not be granted for self-administration. Prior authorization requests must indicate how Tzield® will be administered; AND
    • Tzield® must be shipped via cold chain supply to the facility where the member is scheduled to receive treatment; OR
    • Tzield® must be shipped via cold chain supply to the member’s home and administered by a home health care provider and the member or member’s caregiver must be trained on the proper storage of Tzield®; AND
  • The member’s recent body surface area (BSA) must be provided on the prior authorization request in order to authorize the appropriate amount of drug required according to package labeling; AND
  • A quantity limit of 28mL per 14 days will apply; AND
  • Approvals will be for (1) 14-day cycle per member per lifetime.

    Tzield PA Form

Xultophy® 100/3.6 (Insulin Degludec/Liraglutide) Approval Criteria:  

  • An FDA approved diagnosis of type 2 diabetes mellitus; AND
  • A patient-specific, clinically significant reason why the member cannot use Lantus® (insulin glargine) with Victoza® (liraglutide) must be provided. Please note: Victoza® (liraglutide) may require prior authorization.
  • Current Tier-3 criteria will apply.  
Diabetic Medications

TIER 1

TIER 2

TIER 3

SPECIAL PA

DDP-4 INHIBITORS

  • EMPAGLIFLOZIN/LINAGLIPTIN (GLYXAMBI®)

BIAGUANIDES

  • METFORMIN (GLUCOPHAGE®)
  • METFORMIN SR (GLUCOPHAGE XR®)
  • METFORMIN-GLYBURIDE (GLUCOVANCE®)
  • METFORMIN-GLIPIZIDE (METAGLIP®)

SULFONYLUREAS

  • GLIMEPIRIDE (AMARYL®)
  • GLYBURIDE (DIABETA®)
  • GLYBURIDE MICRONIZED (MICRONASE®)
  • GLIPIZIDE (GLUCOTROL®)
  • GLIPIZIDE SR (GLUCOTROL XL®)

ALPHA-GLUCOSIDASE INHIBITORS

  • ACARBOSE (PRECOSE®)

 GLINIDES

  • REPAGLINIDE (PRANDIN®)

THIAZOLIDINEDIONES

  • PIOGLITAZONE (ACTOS®)

SGLT-2 INHIBITORS

  • DAPAGLIFLOZIN (FARXIGA®)
  • EMPAGLIFLOZIN (JARDIANCE®)

SGLT-2/DPP-4 INHIBITORS/BIGUANIDES

EMPAGLIFLOZIN/LINAGLIPTIN/ METFORMIN ER (TRIJARDY® XR)

DDP-4 INHIBITORS

  • LINAGLIPTIN (TRADJENTA®)
  • LINAGLIPTIN-METFORMIN (JENTADUETOTM) 
  • LINAGLIPTIN/METFORMIN ER (JENTADUETO® XR)
  • SAXAGLIPTIN (ONGLYZA®)
  • SAXAGLIPTIN/METFORMIN (KOMBIGLYZE®, KOMBIGLYZE XR®)
  • SITAGLIPTIN (JANUVIA®)
  • SITAGLIPTIN-METFORMIN (JANUMET®)
  • SITAGLIPTIN-METFORMIN ER (JANUMET XR®)

SGLT-2 INHIBITORS

  • DAPAGLIFLOZIN-METFORMIN (XIGDUO™ XR)
  • EMPAGLIFLOZIN/METFORMIN (SYNJARDY®)
  • EMPAGLIFLOZIN/METFORMIN ER (SYNJARDY® XR)

GLINIDES

  • NATEGLINIDE (STARLIX®) 
  • REPAGLINIDE-METFORMIN (PRANDIMET®)

GIP/GLP-1 AGONISTS

  • DULAGLUTIDE (TRULICITY®)
  • EXENATIDE (BYETTA®)
  • LIRAGLUTIDE (VICTOZA®)

SGLT-2/DPP-4 INHIBITOR

 SGLT-2/DPP-4 INHIBITORS/BIGUANIDES

 DDP-4 INHIBITORS

  • ALOGLIPTIN-METFORMIN (KAZANO®)
  • ALOGLIPTIN (NESINA®)
  • ALOGLIPTIN-PIOGLITAZONE (OSENI®)

 THIAZOLIDINEDIONES  

  • ROSIGLITAZONE (AVANDIA®) 
  • PIOGLITAZONE-METFORMIN (ACTOPLUS MET®, ACTOPLUS MET XR®)
  • PIOGLITAZONE-GLIMEPIRIDE (DUETACT®)

ALPHA-GLUCOSIDASE INHIBITORS

  • MIGLITOL (GLYSET®)

SGLT-2 INHIBITORS

  • CANAGLIFLOZIN (INVOKANA®)
  • CANAGLIFLOZIN/METFORMIN (INVOKAMETTM )

DOPAMINE AGONIST

  • BROMOCRIPTINE (CYCLOSET®)

SGLT-2/DPP-4 INHIBITOR

GIP/GLP-1 AGONISTS

  • EXENATIDE ER AUTOINJECTOR (BYDUREON BCISE®)
  • SEMAGLUTIDE (OZEMPIC®)
  • SEMAGLUTIDE (RYBELSUS®)

GLP-1 AGONISTS/INSULIN

  • INSULIN DEGLUDEC/ LIRAGLUTIDE (XULTOPHY® 100/3.6) 
  • INSULIN GLARGINE/ LIXISENATIDE (SOLIQUA™ 100/33)

BIAGUANIDES

  • METFORMIN SOLUTION (RIOMET®)
  • METFORMIN LONG ACTING (FORTAMET®, GLUMETZA®)
  • METFORMIN ER SUSPENSION (RIOMET ER™)

AMYLINOMIMETIC

  • PRAMLINTIDE (SYMLIN®)
      

DDP-4 INHIBITORS

  • DAPAGLIFLOZIN/SAXAGLIPTIN (QTERN®)
  • ERTUGLIFLOZIN/SITAGLIPTIN (STEGLUJAN®)

SGLT-2 INHIBITORS

  • BEXAGLIFLOZIN (BRENZAVVY™)**
  • CANAGLIFLOZIN/METFORMIN (INVOKAMETTM XR)
  • ERTUGLIFLOZIN (STEGLATRO®)
  • ERTUGLIFLOZIN/METFORMIN (SEGLUROMET®)

GIP/GLP-1 AGONISTS  

  • LIXISENATIDE (ADLYXIN®)
  • TIRZEPATIDE (MOUNJARO®)

 SGLT-2/DPP-4 INHIBITOR/BIGUANIDES

  • DAPAGLIFLOZIN/SAXAGLIPTIN/METFORMIN ER (QTERNMET® XR)

*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).

**no products available for coverage by SoonerCare currently

+Unique criteria applies.

DPP-4 = dipeptidyl peptidase-4; ER = extended-release; GLP-1 = glucagon-like peptide-1; PA = prior authorization; SGLT-2 = sodium-glucose cotransporter-2; soln = solution; SR = sustained-release; 

susp = suspension

 

INSULIN PRODUCTS

Insulin Lispro (Generic Humalog® U-100), Admelog® and Insulin Lispro(Insulin Lispro)), and Lyumjev™ (Insulin Lispro-aabc 100 Units/mL) Approval Criteria: 

  • An FDA approved diagnosis of diabetes mellitus; AND  
  • A patient-specific, clinically significant reason why the member cannot use Humalog® (insulin lispro) must be provided (the brand formulation of Humalog® U-100 is preferred). 

Afrezza® (Insulin Human) Inhalation Powder Approval Criteria:

  • An FDA approved diagnosis of diabetes mellitus; AND
  • Member must be 18 years of age or older; AND
  • A patient-specific, clinically significant reason why other rapid-acting injectable insulins are not appropriate; AND
  • For the indication of type 1 diabetes, the member must use Afrezza® with a long-acting insulin; AND
  • The member must not smoke or have chronic lung disease such as asthma or chronic obstructive pulmonary disease (COPD).

 Basaglar® (Insulin Glargine) Approval Criteria:

  • An FDA approved diagnosis of diabetes mellitus; AND
  • A patient-specific, clinically significant reason why the member cannot use Lantus® (insulin glargine) or Levemir® (insulin detemir).

Fiasp® (Insulin Aspart) Approval Criteria:  

  • An FDA approved diagnosis of diabetes mellitus; AND
  • A patient-specific, clinically significant reason why the member cannot use NovoLog® (insulin aspart) must be provided.

Humulin® R U-500 Vials (Insulin Human 500 Units/mL) Approval Criteria:  

  • An FDA approved diagnosis of diabetes mellitus; AND
  • A patient-specific, clinically significant reason why the member cannot use the Humulin® R U-500 KwikPen® (insulin human 500units/mL), which is available without prior authorization, must be provided.

Humalog® KwikPen® U-200 (Insulin Lispro 200 Units/mL) and Lyumjev™ (Insulin Lispro-aabc 200 Units/mL) Approval Criteria:

  • An FDA approved diagnosis of diabetes mellitus; and
  • Authorization of the 200 units/mL strength requires a patient-specific, clinically significant reason why the member cannot use the 100 units/mL strength (the brand formulation of Humalog® U-100 is preferred). 

Rezvoglar™ (Insulin Glargine-aglr) and Semglee® (Insulin Glargine-yfgn) Approval Criteria:

  • An FDA approved diagnosis of diabetes mellitus; and
  • A patient-specific, clinically significant reason why the member cannot use Lantus® (insulin glargine) or Levemir® (insulin detemir) must be provided. Biosimilars and/or reference products are preferred based on the lowest net cost product(s) and may be moved to either preferred or non-preferred if the net cost changes in comparison to the reference product and/or other available biosimilar products.

Toujeo® (Insulin Glargine) Approval Criteria:

  • An FDA approved diagnosis of diabetes mellitus; AND
  • A patient-specific, clinically significant reason why member cannot use Lantus® (insulin glargine), and member must be using a minimum of 100 units of Lantus® (insulin glargine) per day. 

Tresiba® (Insulin Degludec) Approval Criteria:

  • An FDA approved diagnosis of diabetes mellitus; AND
  • A patient-specific, clinically significant reason why the member cannot use Lantus® (insulin glargine) or Levemir® (insulin detemir). 

 

PREGABALIN (DIABETIC NEUROPATHY DIAGNOSIS)

pregabalin (Lyrica®) Approval Criteria (Diabetic Neuropathy Diagnosis):

  • For the diagnosis of diabetic neuropathy, a trial of duloxetine and a trial of gabapentin or a patient-specific, clinically significant reason why duloxetine or gabapentin cannot be used must be provided
  • Other criteria for Lyrica® (pregabalin) will continue to apply.
  • Clinical exceptions for Lyrica® (pregabalin) include:
    • Diagnosis of seizures or postherpetic neuralgia 

 

MIFEPRISTONE (KORLYM®)
mifepristone (Korlym®) Approval Criteria:    
  • An FDA approved indication to control hyperglycemia secondary to hypercortisolism in adult patients with endogenous Cushing’s syndrome who have type 2 diabetes mellitus (T2DM) or glucose intolerance; AND
  • Member must have failed surgery intended to correct the cause of endogenous Cushing’s syndrome or not be a candidate for surgery that is expected to correct the cause of endogenous Cushing’s syndrome; AND  
  • Member must be 18 years of age or older; AND
  • Korlym® must be prescribed by, or in consultation with, an endocrinologist (or be an advanced care practitioner with a supervising physician who is an endocrinologist); AND
  • Female members must not be pregnant and must have a negative pregnancy test prior to initiation of therapy; AND
  • Female members of reproductive potential must use a non-hormonal, medically acceptable method of contraception (unless member has undergone surgical sterilization) during treatment with Korlym® and for at least 1 month after discontinuing treatment; AND
  • Member must not have any contraindications to taking Korlym® including the following: 
    • Taking drugs metabolized by CYP3A such as simvastatin, lovastatin, and CYP3A substrates with narrow therapeutic ranges, such as cyclosporine,  dihydroergotamine, ergotamine, fentanyl, pimozide, quinidine, sirolimus, and tacrolimus; AND
    • Receiving systemic corticosteroids for lifesaving purposes (e.g., immunosuppression after organ transplantation); AND
    • Female members must not have a history of unexplained vaginal bleeding or endometrial hyperplasia with atypia or endometrial carcinoma; AND
    • Known hypersensitivity to mifepristone or to any of the product components; AND   
  • Authorizations will be for the duration of 12 months; AND
  • Reauthorization may be granted if the prescriber documents the member is responding well to treatment.  

Prior Authorization Form

*SoonerCare members with Medicare DO NOT need a Prior Authorization*

Procrit® (Epoetin Alfa), Epogen® (Epoetin Alfa), and Retacrit™ (Epoetin Alfa-epbx) Approval Criteria:   

  • An FDA approved diagnosis of 1 of the following:
    • Anemia due to chemotherapy in patients with non-myeloid malignancies; OR
    • Anemia in zidovudine-treated Human Immunodeficiency Virus (HIV)-infected patients; OR
    • The reduction of allogeneic blood transfusion(s) in surgery patients; OR
    • An FDA approved diagnosis of anemia associated with chronic renal failure; AND  
      • For the diagnosis of anemia associated with chronic renal failure: member must not be receiving dialysis [erythropoietin stimulating agents (ESAs) are included in the bundled dialysis payment if member is on any form of dialysis and cannot be billed separately]; AND   
  • Recent hemoglobin levels must be provided; AND
  • Approvals will be for the duration of 16 weeks of therapy. Recent hemoglobin levels must be provided with continuation requests, and further approval may be granted if the member’s recent hemoglobin level is <11g/dL.  
Aranesp® (Darbepoetin Alfa) Approval Criteria:
  • An FDA approved diagnosis of anemia due to chemotherapy in patients with non-myeloid malignancies; or
  • An FDA approved diagnosis of anemia associated with chronic renal failure; and
    • For the diagnosis of anemia associated with chronic renal failure: member must not be receiving dialysis [erythropoietin stimulating agents (ESAs) are included in the bundled dialysis payment if member is on any form of dialysis and cannot be billed separately]; and
  • Recent hemoglobin levels must be provided; and
  •  Approvals will be for the duration of 16 weeks of therapy. Recent hemoglobin levels must be provided with continuation requests, and further approval may be granted if the member’s recent hemoglobin level is less than 11g/dL. 
 

Prior Authorization Forms

        

 

ESTRADIOL/PROGESTERONE CAPSULE (BIJUVA™ )

estradiol/progesterone capsule (Bijuva™) Approval Criteria:  

  • An FDA approved indication for the treatment of moderate-to-severe vasomotor symptoms due to menopause in women with an intact uterus; AND
  • A patient-specific, clinically significant reason why the member cannot use all other available estrogen/progestin products indicated for vasomotor symptoms of menopause must be provided; AND
  • A quantity limit of 30 capsules (1 pack) per 30 days will apply.  

Prior Authorization Form 

PROGESTERONE VAGINAL GEL/INSERTS 

progesterone vaginal gel (Crinone®) Approval Criteria: 

  • Current singleton pregnancy; AND
  • Cervical length of ≤ 25mm; AND
  • Gestational age between 16 weeks, 0 days and 26 weeks, 6 days of gestation; AND
  • A patient-specific, clinically significant reason why the member cannot use Endometrin® (progesterone vaginal insert). 
  • Authorizations will be given for treatment through 36 weeks, 6 days of gestation.  
  • Crinone® will not be covered for use with assisted reproductive technology (ART) for female infertility. 

progesterone vaginal insert (Endometrin®) Approval Criteria:  

  • Current singleton pregnancy; AND
  • Cervical length of ≤ 25mm; AND
  • Gestational age between 16 weeks, 0 days and 26 weeks, 6 days of gestation;  
  • Authorizations will be given for treatment through 36 weeks, 6 days of gestation.  
  • Endometrin® will not be covered for use with assisted reproductive technology (ART) for female infertility.

 Prior Authorization form

elagolix (Orilissa™) Approval Criteria:

  • An FDA approved diagnosis of moderate-to-severe pain associated with endometriosis; AND
  • Member must be 18 years of age or older; AND  
  • Member must not have known osteoporosis; AND
  • Female members must not be pregnant and must have a negative pregnancy test prior to initiation of therapy; AND
  • Female members of reproductive potential must be willing to use effective non-hormonal contraception during treatment with Orilissa™ and for at least one week after discontinuing treatment; AND
  • Member must not have severe hepatic impairment (Child-Pugh C); AND
  • Member must not be taking a strong organic anion transporting polypeptide (OATP) 1B1 inhibitor (e.g., cyclosporine, gemfibrozil); AND
  • Orilissa™ must be prescribed by, or in consultation with, an obstetrician/gynecologist or a specialist with expertise in the treatment of endometriosis; AND
  • A failed trial at least one month in duration with nonsteroidal anti-inflammatory drugs (NSAIDs) or a patient-specific, clinically significant reason why the member cannot use NSAIDs; AND
  • A failed trial at least three months in duration of hormonal contraceptives or a patient-specific, clinically significant reason why the member cannot use hormonal contraceptives; AND
  • Dosing and lifetime approval duration will be limited based on the following:  
    • Coexisting condition of moderate hepatic impairment (Child-Pugh B):
      • 150mg once daily for a maximum of 6 months; AND 
    • Normal liver function or mild hepatic impairment (Child-Pugh A):  
      • 150mg once daily for a maximum of 24 months; OR
      • 200mg twice daily for a maximum of 6 months. 

Myfembree® (Relugolix/Estradiol/Norethindrone) Approval Criteria:

  • An FDA approved diagnosis of 1 of the following: 
    • Heavy menstrual bleeding associated with uterine leiomyomas (fibroids) in premenopausal women; OR
    • Moderate-to-severe pain associated with endometriosis in premenopausal women; AND
  • Member must be 18 years of age or older; AND
  • Member must not have any contraindications to therapy including:
    • Osteoporosis; AND
    • Pregnancy; AND
      • Female members must not be pregnant and must have a negative pregnancy test prior to initiation of therapy; AND
      • Female members of reproductive potential must be willing to use effective non-hormonal contraception during treatment and for at least 1 week after discontinuing treatment; AND
    • Hepatic impairment or disease; AND
    • Undiagnosed abnormal uterine bleeding; AND
    • High risk of arterial, venous thrombotic, or thromboembolic disease, including uncontrolled hypertension; AND
    • Current or history of breast cancer or other hormonally-sensitive malignancies; AND
    • Known hypersensitivity to ingredients in Myfembree®; AND
  • Must be prescribed by, or in consultation with, an obstetrician/gynecologist or a specialist with expertise in the treatment of uterine leiomyomas (fibroids) or endometriosis; AND
  • A failed trial at least 1 month in duration with nonsteroidal anti-inflammatory drugs (NSAIDs) or a patient-specific, clinically significant reason why the member cannot use NSAIDs; AND
  • A failed trial at least 3 months in duration of hormonal contraceptives or a patient-specific, clinically significant reason why the member cannot use hormonal contraceptives; AND
  • A quantity limit of 28 tablets per 28 days will apply; AND
  • Lifetime approval duration will be limited to a maximum of 24 months. For members previously approved for Oriahnn® or Orilissa®, a combined cumulative maximum treatment duration of 24 months will apply.

 

Oriahnn (elagolix/estradiol/norethindrone and elagolix) Approval Criteria:

  • An FDA approved diagnosis of heavy menstrual bleeding associated with uterine leiomyomas (fibroids) in premenopausal women; AND
  • Member must be 18 years of age or older; AND
  • Member must not have any contraindications to therapy including:
    • Osteoporosis; AND
    • Pregnancy; AND
      • Female members must not be pregnant and must have a negative pregnancy test prior to initiation of therapy; and
      • Female members of reproductive potential must be willing to use effective non-hormonal contraception during treatment and for at least 1 week after discontinuing treatment; AND
    • Hepatic impairment or disease; AND
    • Undiagnosed abnormal uterine bleeding; AND
    • High risk of arterial, venous thrombotic, or thromboembolic disease, including uncontrolled hypertension; AND
    • Current or history of breast cancer or other hormonally-sensitive malignicies; AND
    • Known hypersensitivity to ingredients in Oriahnn; AND
    • Prescriber must verify the member will not use Oriahnn® concomitantly with an organic anion transporting polypeptide (OATP) 1B1 inhibitor (e.g., cyclosporine, gemfibrozil); AND
  • Must be prescribed by, or in consultation with, an obstetrician/gynecologist or a specialist with expertise in the treatment of uterine leiomyomas (fibroids); AND
  • A failed trial at least 1 month in duration with nonsteroidal anti-inflammatory drugs (NSAIDs) or a patient-specific, clinically significant reason why the member cannot use NSAIDs; AND
  • A failed trial at least 3 months in duration of hormonal contraceptives or a patient-specific, clinically significant reason why the member cannot use hormonal contraceptives; AND
  • A patient-specific, clinically significant reason why the member cannot use leuprolide depot formulations available without prior authorization must be provided; AND 
  • A patient-specific, clinically significant reason why the member cannot use Myfembree® (relugolix/estradiol/norethindrone) must be provided; AND
  • A quantity limit of 56 tablets per 28 days will apply; AND
  • Lifetime approval duration will be limited to a maximum of 24 months. For members previously approved for Myfembree, a combined cumulative maximum treatment duration of 24 months will apply.
 

leuprolide acetate for Depot Suspension and Norethindrone Acetate Tablets (Lupaneta Pack™) Approval Criteria:

  • A patient-specific, clinically significant reason why the member cannot use the individual components. 
Tier 1 Tier 2 Tier 3
  • histrelin (Supprelin® LA)
  • leuprolide (Fensolvi)™ 
  • leuprolide (Lupron® Depot) 
  • leuprolide  (Lupron Depot-Ped®)
  • nafarelin (Synarel®)
  • triptorelin (Triptodur®)
 
 

Tier structure based on supplemental rebate participation and/or National Average Drug Acquisition Costs (NADAC), or Wholesale Acquisition Costs (WAC) if NADAC unavailable

pegfilgrastim-jmdb (Fulphila®), Neulasta® (Pegfilgrastim), pegfilgrastim-cbqv (Udenyca™) Approval Criteria:  

  • An FDA approved diagnosis; AND  
  • A patient-specific, clinically significant reason why the member cannot use Granix® (tbo-filgrastim), or Neupogen® (filgrastim), Nyvepria™ (pegfilgrastim-apgf), Zarxio® (filgrastim-sndz), or Ziextenzo® (pegfilgrastim-bmez) must be provided. Biosimilars and/or reference products are preferred based on the lowest net cost product(s) and may be moved to either preferred or non-preferred if the net cost changes in comparison to the reference product and/or other available biosimilar products.  

tbo-filgrastim (Granix®), Nivestym™ (Filgrastim-aafi), Releuko™ (Filgrastim-ayow), and filgrastim-sndz (Zarxio™)Approval Criteria:

  • An FDA approved diagnosis; AND
  • A patient-specific, clinically significant reason why the member cannot use Neupogen® (filgrastim), Granix® (tbo-filgrastim), or Zarxio® (filgrastim-sndz) must be provided. Biosimilars and/or reference products are preferred based on the lowest net cost product(s) and may be moved to either preferred or non-preferred if the net cost changes in comparison to the reference product and/or other available biosimilar products.

Prior Authorization Forms 

Pharmacy  

Physician/Outpatient Administered    

Fulphila/Nivestym/Neulasta/Releuko/Udenyca PA  

Growth Hormone Covered Indications (prior to epiphyseal closure)*:

  • Growth hormone deficiency (GHD) of 1 of the following types:
    • Classic GHD as determined by childhood GH stimulation tests; or
    • Panhypopituitarism; or
    • Hypoglycemia with evidence for GHD; or
    • Neurosecretory dysfunction; or
    • Other evidence for GHD submitted for panel review and decision; or
  • Short stature associated with Prader-Willi Syndrome; or
  • Short stature associated with Noonan Syndrome; or
  • Short stature associated with chronic renal insufficiency (pre-transplantation); or
  • Growth failure in children born small for gestational age (SGA) who fail to manifest catch-up growth by 2 years of age; or
  • Idiopathic short stature (ISS) in children with height ≥2.25 SD below the mean for age and gender and who are unlikely to catch up in height; or
  • Turner syndrome or 45X, 46XY mosaicism; or
  • Short-stature homeobox-containing gene (SHOX) deficiency with genetic evidence for SHOX deficiency.

*Please refer to the complete prior authorization criteria for each indication, listed below.

Growth Hormone Tier-2 Approval Criteria:

  • Documented allergic reaction to non-active components of all available Tier-1 products; or
  • A clinical exception applies to members with a diagnosis of acquired immunodeficiency syndrome (AIDS) wasting syndrome, in which case Serostim® can be used regardless of its current Tier status; or
  • A clinical exception applies to members with a diagnosis of short bowel syndrome (SBS), in which case Zorbtive® can be used regardless of its current Tier status. 

Discontinuation of Therapy or Transition to Adult Therapy Criteria:

  • Failure to show improvement in height percentile on growth chart after 1 year of treatment; or
  • Growth velocity <2.5cm/year unless associated with another growth-limiting and treatable medical condition (i.e., hypothyroidism); or
  • Epiphyseal closure; or
  • Covered height has been reached:
    • 152.4cm (60 inches) for girls; or
    • 165.1cm (65 inches) for boys; or
    • The covered height does not apply for members with a diagnosis of growth hormone deficiency (GHD) or panhypopituitarism; or
  • Inadequate compliance; or
  • Significant adverse effects.

Growth Hormone Dosing (doses must be individualized and titrated):

  • Children: 22 to 100mcg/kg/day according to current pediatric guidelines; or
  • Adults:
    • Initial Dosing: 0.1 to 0.5mg per day – Doses should be evaluated and titrated at 1 to 2 month intervals targeting an insulin-like growth factor 1 (IGF-1) level within the age-adjusted reference range provided by the laboratory utilized [IGF-1 standard deviation score (SDS) between -2 and +2]. In general, younger patients may require higher doses than older patients. The following initial doses are suggested by the current American Association of Clinical Endocrinologists/American College of Endocrinology (AACE/ACE) guidelines, but these doses should be titrated based on IGF-1 levels:
      • Age <30 years: 0.4 to 0.5mg per day (may be higher for patients transitioning from pediatric treatment); or
      • Age 30-60 years: 0.2 to 0.3mg per day; or
      • Age >60 years: 0.1 to 0.2mg per day; and
    • Transition Dosing: In patients transitioning from pediatric to adult dosing, resuming GH doses at 50% of the dose last used in childhood is suggested, as they tend to be more tolerant of higher doses.

 

Growth Hormone Deficiency (GHD) Approval Criteria:

  • Initial Approval:
    • Member must be 2 years of age or older (unless hypoglycemia is present); and
    • Growth hormone therapy must be prescribed by an endocrinologist (or an advanced care practitioner with a supervising physician who is an endocrinologist); and
    • Member must meet at least 1 of the following:
      • Member’s growth velocity (GV) must be <10% on a GV curve for gender and age; or
      • Member must have evidence of delayed bone age (undefined delay); and
    • Member must have open epiphyses; and
    • Member’s height must be ≥2.25 standard deviations (SD) below the mean for age and gender; and
    • Member’s growth chart and parental heights must be provided; and
      • If the form is completed, a growth chart is not required; and
      • Parental heights are not always available; and
    • There must be no contributing medical conditions (e.g., cystic fibrosis, malnutrition, psychosocial deprivation); and
    • Member must have suboptimal response of ≤10ng/mL on 2 of the following provocative growth hormone stimulation tests, using the highest level per date of testing. (Stimulation tests are always required for approval unless hypoglycemia is observed, in which case a random low glucose level and low growth hormone level would be acceptable):
      • Propranolol with exercise; or
      • Levodopa; or
      • Insulin hypoglycemia test; or
      • Arginine HCl infusion; or
      • Clonidine; or
      • Glucagon (not approved for use in children); or
    • If hypoglycemia is present and member is growth hormone deficient: request may be approved for 6 months (other criteria above is not applicable). If the member has hypoglycemia, a low glucose level must be submitted along with additional evidence of GHD such as:
      • Low insulin-like growth factor 1 (IGF-1), random growth hormone level, or suboptimal growth hormone stimulation tests; or
      • MRI evidence of congenital anomaly which includes pituitary damage or absence; or
      • Other pituitary hormones also being replaced (e.g., thyroid, cortisol, etc.).
  • Approval Length: 6 months if criteria met, compliant, and not needing to transition to adult dosing.
  • Dosing:
    • Pediatric Dosing: FDA approved dosing varies by product. See the “Growth Hormone Dosing” section above for current guideline-based dosing considerations; OR
    • Adult Dosing: Members with this diagnosis may transition to adult dosing (see “Growth Hormone Dosing” section above for recommendations for adult and transition dosing) after 1 or both of the following:
      • Epiphyseal closure; or
      • GV <2.5cm/year; and
      • If either of the above have occurred and the member has not yet transitioned to adult dosing, may be approved short term (3 months) to allow time for transition to adult dosing.
    • Continuation Approval:
    • Medications and dosing should be appropriate; and
    • Member should have had a recent office visit with new information regarding heights provided; and
    • Member should be compliant; and
    • GV should not be <2.5cm/year if not on adult dosing; and
    • For members on adult dosing, recent IGF-1 level and standard deviation score (SDS) should be submitted and SDS should be between -2 and +2. 

Panhypopituitarism Approval Criteria:

  • Initial Approval:
    • Member must be 2 years of age or older (unless hypoglycemia is present); and
    • Growth hormone therapy must be prescribed by an endocrinologist (or an advanced care practitioner with a supervising physician who is an endocrinologist); and
    • Member must meet at least 1 of the following:
      • Member’s growth velocity (GV) must be <10% on a GV curve for gender and age; or
      • Member must have evidence of delayed bone age (undefined delay); and
    • Member must have open epiphyses; and
    • Member’s height must be ≥2.25 standard deviations (SD) below the mean for age and gender; and
      • For members with secondary panhypopituitarism due to tumor, trauma, or surgery 12 months post trauma or surgery, approval may be granted if no evidence of tumor recurrence and growth has not restarted. The member must still meet all the other criteria; however, authorization would not require height ≥2.25 SD below the mean in these circumstances; and
    • Member’s growth chart and parental heights must be provided; and
      • If the form is completed, a growth chart is not required; and
      • Parental heights are not always available; and
    • Member must have a history of pituitary or hypothalamic injury due to tumor, trauma, surgery, documented whole brain radiation, irradiation, hemorrhage or infarction, or a congenital anomaly; and
      • Deficiency in ≥3 pituitary hormones and insulin-like growth factor 1 (IGF-1) ≥2.5 SD below the mean for member’s age; or
      • No deficiency, or deficiency in <3 pituitary hormones, and IGF-1 <50th percentile and subnormal response of 10ng/mL or less on at least 2 provocative growth hormone stimulation tests, using the highest level per date of testing. (Stimulation tests are always required for approval unless hypoglycemia is observed, in which case a random low glucose level and low growth hormone level would be acceptable); or
    • If member has MRI evidence of pituitary stalk agenesis, empty sella, or ectopic posterior pituitary “bright spot”, member is exempt from height requirement (criteria letter e listed above); and
      • If they lack the hormones testosterone, luteinizing hormone (LH), or follicle-stimulating hormone (FSH) then an MRI is not required; or
    • If hypoglycemia is present and member is growth hormone deficient: request may be approved for 6 months (other criteria above is not applicable). If the member has hypoglycemia, a low glucose level must be submitted along with additional evidence of GHD such as:
      • Low IGF-1, random growth hormone level, or suboptimal growth hormone stimulation tests; or
      • MRI evidence of congenital anomaly which includes pituitary damage or absence; or
      • Other pituitary hormones also being replaced (e.g., thyroid, cortisol); and
  • Approval Length: 6 months if criteria met, compliant, and not needing to transition to adult dosing.
  • Dosing:
    • Pediatric Dosing: FDA approved dosing varies by product. See the “Growth Hormone Dosing” section above for current guideline-based dosing considerations; OR
    • Adult Dosing: Members with this diagnosis may transition to adult dosing (see “Growth Hormone Dosing” section above for recommendations for adult and transition dosing) after 1 or both of the following:
      • Epiphyseal closure; or
      • GV <2.5cm/year; and
      • If either of the above have occurred and the member has not yet transitioned to adult dosing, may be approved short term (3 months) to allow time for transition to adult dosing.    
  • Continuation Approval:
    • Medications and dosing should be appropriate; and
    • Member should have had a recent office visit with new information regarding heights provided; and
    • Member should be compliant; and
    • GV should not be <2.5cm/year if not on adult dosing; and
    • For members on adult dosing, recent IGF-1 level and standard deviation score (SDS) should be submitted and SDS should be between -2 and +2.

Neurosecretory Dysfunction Approval Criteria:

  • Initial Approval:
    • Member must be 2 years of age or older; and
    • Growth hormone therapy must be prescribed by an endocrinologist (or an advanced care practitioner with a supervising physician who is an endocrinologist); and
    • Member’s growth velocity (GV) must be <10% on a GV curve for gender and age; and
    • Member’s height must be ≥2.25 standard deviations (SD) below the mean for age and gender; and
    • Member must have evidence of delayed bone age and open epiphyses; and
    • Member’s growth chart and parental heights must be provided; and
      • If the form is completed, a growth chart is not required; and
      • Parental heights are not always available; and
    • Member’s serum insulin-like growth factor 1 (IGF-1) must be below the mean for member’s age; and
      • Note: Children with profoundly low GV, who are at risk for growth hormone deficiency due to CNS radiation or other organic causes, termed neurosecretory dysfunction, may demonstrate “normal” responses to provocative tests, often for several years, but often benefit from growth hormone therapy.
    • Growth hormone stimulation testing is required; however, growth hormone levels may be normal; and
  • Approval Length: 6 months if criteria met, compliant, and not needing to transition to adult dosing.
  • Dosing:
    • Pediatric Dosing: FDA approved dosing varies by product. See the “Growth Hormone Dosing” section above for current guideline-based dosing considerations; OR
    • Adult Dosing: Members with this diagnosis may transition to adult dosing (see “Growth Hormone Dosing” section above for recommendations for adult and transition dosing) after 1 of the following:
      • Epiphyseal closure; or
      • Covered height [Boys: 165.1cm (65 inches); Girls: 152.4cm (60 inches)]; or
      • GV <2.5cm/year; and
      • If any of the above have occurred and the member has not yet transitioned to adult dosing, may be approved short term (3 months) to allow time for transition to adult dosing.
  • Continuation Approval:
    • Medications and dosing should be appropriate; and
    • Member should have had a recent office visit with new information regarding heights provided; and
    • Member should be compliant; and
    • GV should not be <2.5cm/year if not on adult dosing; and
    • For members on adult dosing, recent IGF-1 level and standard deviation score (SDS) should be submitted and SDS should be between -2 and +2. 

Idiopathic Short Stature Approval Criteria:

  • Initial Approval:
    • Member must be 8 years of age or older; and
    • Growth hormone therapy must be prescribed by an endocrinologist (or an advanced care practitioner with a supervising physician who is an endocrinologist); and
    • Member’s growth velocity (GV) must be <10% on a GV curve for gender and age; and
    • Member’s height must be ≥2.25 standard deviations (SD) below the mean for age and gender; and
    • Member must have evidence of delayed bone age (undefined delay) and open epiphyses; and
    • Member’s growth chart and parental heights must be provided
      • If the form is completed, a growth chart is not required; and
      • Parental heights are not always available; and
  • Approval Length: 6 months if criteria met and compliant. No adult dosing will be approved for this indication. Once epiphyses are closed, covered height has been met, or GV is <2.5cm/year, therapy should be discontinued.
  • Dosing:
    • Pediatric Dosing: FDA approved dosing varies by product. See the “Growth Hormone Dosing” section above for current guideline-based dosing considerations. Treatment may continue until 1 of the following:
      • Epiphyseal closure; or
      • Covered height [Boys: 165.1cm (65 inches); Girls: 152.4cm (60 inches)]; or
      • GV <2.5cm/year; and
    • Adult Dosing: No proven benefit to continuing growth hormone treatment in adulthood.
  • Continuation Approval:
    • Medications and dosing should be appropriate; and
    • Member should have had a recent office visit with new information regarding heights provided; and
    • Member should be compliant; and
    • Epiphyses are open; and
    • GV should not be <2.5cm/year.

Short Stature Associated with Chronic Renal Insufficiency (Pre-Transplantation) Approval Criteria:

  • Initial Approval:
    • Member must be 2 years of age or older; and
    • Member’s estimated creatinine clearance (CrCl) must be <50mL/min; and
    • Member must not be post-kidney transplant; and
    • Growth hormone therapy must be prescribed by an endocrinologist or pediatric nephrologist (or an advanced care practitioner with a supervising physician who is an endocrinologist or pediatric nephrologist); and
    • Member’s growth chart and parental heights must be provided; and
      • If the form is completed, a growth chart is not required; and
      • Parental heights are not always available; and   
    • Members meeting the above criteria are exempt from height requirements.
  • Approval Length: 6 months if criteria met and compliant. No adult dosing will be approved for this indication. Once epiphyses are closed, covered height has been met, growth velocity (GV) is <2.5cm/year, or member has received renal transplant, therapy should be discontinued.
  • Dosing:
    • Pediatric Dosing: Standard dosing applies for members receiving pediatric dosing (0.05mg/kg/day). Treatment may continue until 1 of the following:
      • Renal transplantation; or
      • Epiphyseal closure; or
      • Covered height [Boys: 165.1cm (65 inches); Girls: 152.4cm (60 inches)]; or
      • GV <2.5cm/year; and
    • Adult Dosing: No proven benefit to continuing growth hormone treatment in adulthood.
  • Continuation Approval:
    • Member is still pre-transplant; and
    • Medications and dosing should be appropriate; and
    • Member should have had a recent office visit with new information regarding heights; and
    • Member should be compliant; and
    • Epiphyses are open; and
    • GV should not be <2.5cm/year.

Short Stature Associated with Prader-Willi Syndrome (PWS) Approval Criteria:

  •  Initial Approval:
    • Member must be 2 years of age or older; and
    • Member must have a chromosome analysis confirming the diagnosis of PWS; and
    • Growth hormone therapy must be prescribed by an endocrinologist (or an advanced care practitioner with a supervising physician who is an endocrinologist); and
    • Member’s growth velocity (GV) must be <10% on a GV curve for gender and age; and
    • Member’s height must be ≥2.25 standard deviations (SD) below the mean for age and gender; and
    • Member must have evidence of delayed bone age (undefined delay) and open epiphyses; and
    • Member’s growth chart and parental heights must be provided; and
      • If the form is completed, a growth chart is not required; and
      • Parental heights are not always available; and
  • Approval Length: 6 months if criteria met, compliant, and not needing to transition to adult dosing.
  • Dosing: 
    • Pediatric Dosing: 0.24mg/kg/week. Treatment should continue until 1 of the following:
      • Epiphyseal closure; or
      • Covered height [Boys: 165.1cm (65 inches); Girls: 152.4cm (60 inches)]; or
      • GV <2.5cm/year; and
    • Adult Dosing: After attainment of adult height, adults with PWS may be considered for adult dosing if evidence is submitted documenting adult growth hormone deficiency [e.g., low insulin-like growth factor 1 (IGF-1) level and GH stimulation testing]. 
  • Continuation Approval:
    • Medications and dosing should be appropriate; and
    • Member should have had a recent office visit with new information regarding heights provided; and
    • Member should be compliant; and
    • GV should not be <2.5cm/year; and
    • For members on adult dosing, recent IGF-1 level and standard deviation score (SDS) should be submitted and SDS should be between -2 and +2.

Short Stature Associated with Turner Syndrome or 45X, 46XY Mosaicism Approval Criteria:

  • Initial Approval:
    • Member must be 2 years of age or older; and
    • Member must have a chromosome analysis confirming the diagnosis of Turner Syndrome in females or 45X 46XY mosaicism in males; and
    • Growth hormone therapy must be prescribed by an endocrinologist (or an advanced care practitioner with a supervising physician who is an endocrinologist); and
  • Approval Length: 6 months if criteria met and compliant. No adult dosing will be approved for this indication. Once epiphyses are closed, covered height has been met, or growth velocity (GV) is <2.5cm/year, therapy should be discontinued.
  • Dosing:
    • Pediatric Dosing: FDA approved dosing varies by product. See the “Growth Hormone Dosing” section above for current guideline-based dosing considerations. Treatment should continue until 1 of the following:
      • Epiphyseal closure; or
      • Covered height [Boys: 165.1cm (65 inches); Girls: 152.4cm (60 inches)]; or
      • GV <2.5cm/year; and
    • Adult Dosing: No proven benefit to continuing growth hormone treatment in adulthood.
  • Continuation Approval:
    • Medications and dosing should be appropriate; and
    • Member should have had a recent office visit with new information regarding heights provided; and
    • Member should be compliant; and
    • Epiphyses should be open; and
    • GV should not be <2.5cm/year.

Short Stature Associated with Noonan Syndrome Approval Criteria:

  • Initial Approval:
    • Member must be 2 years or older; and
    • Member must have a chromosome analysis confirming the diagnosis of Noonan Syndrome; and
    • Growth hormone therapy must be prescribed by an endocrinologist (or an advanced care practitioner with a supervising physician who is an endocrinologist); and
  • Approval Length: 6 months if criteria met and compliant. No adult dosing will be approved for this indication. Once epiphyses are closed, covered height has been met, or growth velocity (GV) is <2.5cm/year, therapy should be discontinued.
  • Dosing: 
    • Pediatric Dosing: Standard dosing applies for members receiving pediatric dosing (up to 0.066mg/kg/day). Treatment should continue until 1 of the following:
      • Epiphyseal closure; or
      • Covered height [Boys: 165.1cm (65 inches); Girls: 152.4cm (60 inches)]; or
      • GV <2.5cm/year.
    • Adult Dosing: No proven benefit to continuing growth hormone treatment in adulthood.
  • Continuation Approval:
    • Medications and dosing should be appropriate; and
    • Member should have had a recent office visit with new information regarding heights provided; and
    • Member should be compliant; and
    • Epiphyses should be open; and
    • GV should not be <2.5cm/year.

Short Stature Associated with Short Stature Homeobox-Containing Gene (SHOX) Deficiency Approval Criteria:

  • Initial Approval:
    • Member must be 2 years or older; and
    • Member must have a chromosome analysis confirming the diagnosis of SHOX deficiency; and
    • Growth hormone therapy must be prescribed by an endocrinologist (or an advanced care practitioner with a supervising physician who is an endocrinologist); and
    • Member’s growth velocity (GV) must be <10% on a GV curve for gender and age; and
    • Member’s height must be ≥2.25 standard deviations (SD) below the mean for age and gender; and
    • Member must have evidence of delayed bone age (undefined delay) and open epiphyses; and
    • Member’s growth chart and parental heights must be provided; and
      • If the form is completed, a growth chart is not required; and
      • Parental heights are not always available; and
    • Member must have a normal endocrine screen; and
    • Member must have no evidence of growth hormone deficiency or insensitivity, tumor activity, diabetes mellitus, history of impaired glucose tolerance, or other serious illness known to interfere with growth; and
  • Approval Length: 6 months if criteria met and compliant. No adult dosing will be approved for this indication. Once epiphyses are closed, covered height has been met, or GV is <2.5cm/year, therapy should be discontinued.
  • Dosing:  
    • Pediatric Dosing: Standard dosing applies for members receiving pediatric dosing (up to 0.05mg/kg/day). Treatment should continue until 1 of the following:
      • Epiphyseal closure; or
      • Covered height [Boys: 165.1cm (65 inches); Girls: 152.4cm (60 inches)]; or
      • GV <2.5cm/year; and
    • Adult Dosing: No proven benefit to continuing growth hormone treatment in adulthood.
  • Continuation Approval:
    • Medications and dosing should be appropriate; and
    • Member should have had a recent office visit with new information regarding heights provided; and
    • Member should be compliant; and
    • Epiphyses should be open; and
    • GV should not be <2.5cm/year.

Small for Gestational Age (SGA) Approval Criteria:

  • Initial Approval:
    • Member must be 2 years or age or older; and
    • Documentation of birth weight <2,500 grams at gestational age of more than 37 weeks or birth weight or length below the 3rd percentile for gestational age; and
    • Growth hormone therapy must be prescribed by an endocrinologist (or an advanced care practitioner with a supervising physician who is an endocrinologist); and
    • Member’s growth velocity (GV) must be <10% on a GV curve for gender and age; and
    • Member’s height must be ≥2.25 standard deviations (SD) below the mean for age and gender; and
    • Member must have evidence of delayed bone age (undefined delay) and open epiphyses; and
    • Member’s growth chart and parental heights must be provided; and
      • If the form is completed, a growth chart is not required; and
      • Parental heights are not always available; and
  • Approval Length: 6 months if criteria met and compliant. No adult dosing will be approved for this indication. Once epiphyses are closed, covered height has been met, or GV is <2.5cm/year, therapy should be discontinued.
  • Dosing: 
    • Pediatric Dosing: FDA approved dosing varies by product. See the “Growth Hormone Dosing” section above for current guideline-based dosing considerations. Treatment should continue until 1 of the following:
      • Epiphyseal closure; or
      • Covered height [Boys: 165.1cm (65 inches); Girls: 152.4cm (60 inches)]; or
      • GV <2.5cm/year; and
    • Adult Dosing: No proven benefit to continuing growth hormone treatment in adulthood.
  • Continuation Approval:
    • Medications and dosing should be appropriate; and
    • Member should have had a recent office visit with new information regarding heights provided; and
    • Member should be compliant; and
    • Epiphyses should be open; and
    • GV should not be <2.5cm/year. 

Prior Authorization forms 

PREFERRED

NON-Preferred

  • Genotropin®
  • Humatrope®
  • Norditropin®
  • Norditropin Nordiflex®
  • Nutropin®
  • Nutropin AQ®
  • Omnitrope®
  • Saizen®
  • +Serostim®
  • +Skytrofa (lonapegsomatropin-tcgd) (Ascendis) - Cartridge
  • +Sogroya® (somapacitan-beco) (NovoNordisk) - Pens
  • Zomacton®
  • +Zorbtive®

*Supplementally rebated product(s); 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).

+Additional approval criteria applies.

All products, other than Sogroya®, contain the identical 191 amino acid sequence found in pituitary-derived human growth hormone (hGH). For Sogroya®, 1 amino acid has been substituted and linked to an albumin-binding side chain.

Skytrofa® (Lonapegsomatropin-tcgd) Approval Criteria:

  • Member must have a confirmed diagnosis of growth hormone deficiency (GHD) or panhypopituitarism meeting the initial growth hormone approval criteria (listed under “Initial Approval”) for the member’s specific diagnosis; and
  • Member’s weight must be ≥11.5kg; and
  • A patient-specific, clinically significant reason (beyond convenience) why the member cannot use all Tier-1 product(s) must be provided; and
  • Prescriber must verify the member has been counseled on proper administration and storage of Skytrofa®; and
  • Initial approvals will be for the 0.24mg/kg weekly dose, using the specific dose recommended in the Skytrofa® Prescribing Information; and
  • Initial approvals will be for the duration of 6 months. For additional approval consideration:
    • Dosing should be appropriate; and
    • Member should have had a recent office visit with new information regarding heights provided; and
    • Member should be compliant; and
    • Growth velocity should not be <2.5cm/year; and
    • Prescriber must verify member still has open epiphyses; and
  • Skytrofa® will not be approved following epiphyseal closure. Skytrofa® is contraindicated in children with closed epiphyses.

Voxzogo™ (Vosoritide) Approval Criteria:

  • Member must have an FDA approved diagnosis of achondroplasia; and
    • Diagnosis must be confirmed by genetic testing identifying a pathogenic mutation in the FGFR3 gene; and
  • Member must be 5 years of age or older; and
  • Prescriber must verify member has open epiphyses; and
  • The member’s baseline height and growth velocity (GV) must be provided; and
  • Voxzogo™ must be prescribed by a geneticist, endocrinologist, or other specialist with expertise in the treatment of achondroplasia (or an advanced care practitioner with a supervising physician who is a geneticist, endocrinologist, or other specialist with expertise in the treatment of achondroplasia); and
  • Member’s recent weight (taken within the past 3 weeks) must be provided in order to ensure appropriate dosing in accordance with the Voxzogo™ Prescribing Information; and
  • Prescriber must verify the member or member’s caregiver has been counseled on proper administration and storage of Voxzogo™, including the need for adequate food and fluid intake prior to each dose; and
  • A quantity limit of 30 vials per 30 days will apply; and
  • Initial and subsequent approvals will be for the duration of 6 months. For additional approval consideration:
    • Member’s current height must be provided and must demonstrate an improvement in GV from baseline; and
    • Member’s recent weight must be provided and dosing must be appropriate; and
    • Member should be compliant; and
    • Prescriber must verify member still has open epiphyses; and
  • Voxzogo™ will not be approved following epiphyseal closure. 

 

 

HYDROXYPROGESTERONE CAPROATE (GENERIC DELALUTIN®)

PA Criteria:

  • An FDA approved indication of one of the following in non-pregnant women:
    • For the treatment of advanced adenocarcinoma of the uterine corpus (Stage III or IV); OR
    • For the management of amenorrhea (primary and secondary) or abnormal uterine bleeding due to hormonal imbalance in the absence of organic pathology, such as submucous fibroids or uterine cancer; OR
    • As a test for endogenous estrogen production or for the production of secretory endometrium and desquamation; AND 
  • The quantity approved will be patient-specific depending on patient diagnosis, maximum recommended dosage, and manufacturer packaging.  
  • Requests for the prevention of preterm birth in pregnant women with a history of previous singleton spontaneous preterm delivery (SPTD) prior to 37 weeks gestation will not be approved for generic Delalutin®. 

Insulin-Like Growth Factor-1 (IGF-1) Analog Medications: Increlex® and Iplex® (Mecasermin [rDNA Origin] Injection) Approval Criteria:

  • Therapy initiated by an endocrinologist (or an advanced care practitioner with a supervising physician who is an endocrinologist); and
  • Diagnosis of primary IGF-1 deficiency with all of the following:
    • Height >3 standard deviations (SD) below the mean; and
    • Basal IGF-1 >3 SD below the mean; and
    • Normal or elevated growth hormone (GH); and
  • Documentation of mutation in GH receptor (GHR) or mutation in post-GHR signaling pathway or IGF-1 gene defects (Laron Syndrome); and
  • IGF-1 analog medications will not be approved for use in secondary IGF-1 deficiencies related to GH deficiency, malnutrition, hypothyroidism, or chronic steroid therapy. 

Isturisa® (Osilodrostat) Approval Criteria:  

  • An FDA approved indication for the treatment of adult patients with Cushing’s disease for whom pituitary or adrenal surgery is not an option or has not been curative; 
  • Member must be 18 years of age or older; AND
  • Prescriber must document that the member has had an inadequate response to pituitary or adrenal surgery or is not a candidate for pituitary or adrenal surgery; AND
  • Prescriber must verify that hypokalemia and hypomagnesemia are corrected prior to starting Isturisa®; AND
  • Prescriber must agree to perform and monitor electrocardiogram (ECG) at baseline, 1 week after treatment initiation, and as clinically indicated thereafter; AND
  • Prescriber must verify that dose titration will be followed according to package labeling; AND
  • If the member is taking strong CYP3A4 inhibitors (e.g., itraconazole, clarithromycin) or strong CYP3A4 and/or CYP2B6 inducers (e.g., carbamazepine, rifampin, phenobarbital), the prescriber must verify that the Isturisa® dose will be adjusted according to the package labeling; and
  • For female members, prescriber must verify that the member is not breastfeeding; AND
  • Isturisa® must be prescribed by, or in consultation with, an endocrinologist (or be an advanced care practitioner with a supervising physician who is an endocrinologist); AND
  • A patient-specific, clinically significant reason why the member cannot use ketoconazole tablets and metyrapone capsules must be provided; AND
  • Initial authorizations will be for the duration of 3 months after which time, compliance and 24-hour urine free cortisol levels within the normal range (to demonstrate the effectiveness of this medication) will be required for continued approval. Subsequent approvals will be for the duration of 1 year and will require the prescriber to verify the member is still not a candidate for pituitary or adrenal surgery. 

Prior Authorization Form

Mycapssa® (Octreotide) Approval Criteria:

  • An FDA approved indication for long-term maintenance treatment in members with acromegaly who have responded to and tolerated treatment with octreotide or lanreotide; and
  • Member has elevated insulin-like growth factor-1 (IGF-1) levels for age and/or gender; and
  • Member has a documented trial with injectable octreotide or lanreotide, and the prescriber must verify that the member responded to and tolerated treatment with octreotide or lanreotide; and
  • A patient-specific, clinically significant reason why the member cannot continue treatment with injectable octreotide or lanreotide must be provided; and
  • Mycapssa® must be prescribed by, or in consultation with, an endocrinologist; and
  • Prescriber must document that the member has had an inadequate response to surgery or is not a candidate for surgery; and
  • Initial approvals will be for the duration of 12 months. Reauthorization may be granted if the prescriber documents the member’s IGF-1 level has decreased or normalized since initiating treatment; and
  • A quantity limit of 120 capsules per 30 days will apply.

PA Criteria:

  • An FDA approved diagnosis as an adjunct to calcium and vitamin D to control hypocalcemia in patients with hypoparathyroidism; AND
    • Natpara® is not FDA approved for hypoparathyroidism caused by calcium-sensing receptor mutations.
    • Natpara® is not FDA approved for hypoparathyroidism due to acute post-surgery. 
  • Magnesium deficiency must be ruled out; AND  
  • Member must have pretreatment serum calcium above 7.5mg/dL before starting Natpara®; AND
  • Prescriber must verify the member has sufficient 25-hydroxyvitamin D level per standard of care; AND
  • Member must be unable to be adequately well-controlled on calcium supplements and active forms of vitamin D alone; AND  
  • Health care provider and dispensing pharmacy must be certified through the Natpara® Risk Evaluation and Mitigation Strategies (REMS) Program; AND
  • A quantity limit of two cartridges (each package contains two 14-day cartridges) per 28 days will apply.  The maximum covered dose will be 100mcg per day.

Novarel® and Pregnyl® (Chorionic Gonadotropin) Approval Criteria:

  • An FDA approved diagnosis of prepubertal cryptorchidism not due to anatomic obstruction or hypogonadotropic hypogonadism (hypogonadism secondary to a pituitary deficiency); and
  • Requests for any of the following diagnoses will not be approved:
    • Ovulation induction; or
    • Spermatogenesis induction; or
    • Weight loss; and
  • Member must be male; and
  • For the diagnosis of prepubertal cryptorchidism, member must be 4 to 10 years of age; or
  • For the diagnosis of hypogonadotropic hypogonadism, member must be of peripubertal age; and
    • A patient-specific, clinically significant reason why testosterone therapy is not appropriate must be provided.

Recorlev® (Levoketoconazole) Approval Criteria:

  • An FDA approved indication for the treatment of adult members with Cushing’s disease for whom pituitary or adrenal surgery is not an option or has not been curative; AND
  • Member must be 18 years of age or older; AND
  • Recorlev® must be prescribed by, or in consultation with, an endocrinologist (or an advanced care practitioner with a supervising physician who is an endocrinologist); AND
  • Prescriber must document that the member has had an inadequate response to pituitary or adrenal surgery or is not a candidate for pituitary or adrenal surgery; AND
  • Prescriber agrees to obtain baseline liver test and electrocardiogram (ECG) prior to initiating treatment; AND
  • Prescriber agrees to monitor liver enzymes and bilirubin weekly for at least 6 weeks after initiating treatment, every 2 weeks for the next 6 weeks, monthly for the next 3 months, and then as clinically indicated; AND
  • Prescriber must verify that hypokalemia and hypomagnesemia are corrected prior to starting Recorlev®; AND
  • Member must not be taking medications that cause QT prolongation associated with ventricular arrhythmias, including torsades de pointes (e.g., dofetilide, dronedarone, methadone, quinidine, ranolazine); AND
  • Member must not be taking medications that are sensitive substrates of CYP3A4 and/or P-gp (e.g., digoxin, lovastatin, simvastatin, tacrolimus, triazolam); AND
  • If the member is taking medications that are strong CYP3A4 inhibitors (e.g., ritonavir, mifepristone) or strong CYP3A4 inducers (e.g. isoniazid, carbamazepine, rifampicin, phenytoin), the prescriber must verify the medication will be stopped 2 weeks before and during treatment with Recorlev® per package labeling; AND
  • For female members, prescriber must verify that the member is not breastfeeding; AND
  • A patient-specific, clinically significant reason why the member cannot use ketoconazole tablets and metyrapone capsules must be provided; AND
  • Initial authorizations will be for the duration of 3 months. Continued authorization at that time will require the prescriber to provide a recent 24-hour urine free cortisol (UFC) level within the normal range to demonstrate the effectiveness of this medication, and compliance will also be checked at that time. Subsequent approvals will be for the duration of 1 year and will require the prescriber to verify the member is still not a candidate for pituitary or adrenal surgery.

pasireotide (Signifor® LAR) Approval Criteria:

  • An FDA approved diagnosis of one of the following:
    • Members with acromegaly who have had an inadequate response to surgery or for whom surgery is not an option; OR
    • Members with Cushing’s disease from a pituitary tumor for whom pituitary surgery is not an option or has not been curative; AND 
  • For a diagnosis of acromegaly, the member must have a documented trial with octreotide long-acting or lanreotide depot with an inadequate response or have a patient-specific, clinically significant reason why the other long-acting somatostatin analogs (SSAs) are not appropriate for the member; AND
  • Pasireotide LAR must be prescribed by an endocrinologist or in consultation with an endocrinologist; AND 
  • Pasireotide LAR must be administered by a health care professional; AND
  • Prescriber must document that the member has had an inadequate response to surgery or is not a candidate for surgery; AND
     Prescriber must verify liver function tests (LFTs) (e.g., ALT, AST, bilirubin) will be monitored when starting treatment and periodically thereafter; AND
  • Authorizations will be for the duration of 12 months; AND  
  • Reauthorization may be granted if the prescriber documents the member is responding well to treatment. 

Prior Authorization Form   

*Brand products are subject to the Brand Name Override where generics are available 

 Testosterone replacement products Prior Authorization Criteria

Consideration will be based on both of the following criteria:

  • An FDA approved diagnosis of:
    • Testicular failure due to cryptorchidism, bilateral torsions, orchitis, vanishing testis syndrome, orchidectomy/orchiectomy; OR
    • Idiopathic gonadotropin or luteinizing-hormone-releasing hormone (LHRH) deficiency, or pituitary hypothalamic injury from tumors, trauma, or radiation; OR
    • Delayed puberty; OR
    • Advanced inoperable metastatic mammary cancer in females 1 to 5 years postmenopausal, or premenopausal women with breast cancer benefitting from oophorectomy and have been determined to have a hormone-responsive tumor; AND  
  • The prescriber must verify the member has been evaluated for the presence of a pituitary tumor as the potential cause of low testosterone and the member will receive appropriate follow-up and/or treatment as necessary; and
  • Must include two labs showing pre-medication, morning testosterone(total testosterone) levels below 300ng/dL; AND  
  • Must include one lab showing abnormal gonadotropins and/or other information necessary to demonstrate diagnosis; OR
  • Testosterone and gonadotropin labs are not required for authorization of testosterone therapy if documentation is provided for established hypothalamic pituitary or gonadal disease or if the pituitary gland or testes has/have been removed.

Testosterone replacement products Tier-2 Prior Authorization Criteria:

  • All diagnoses and laboratory requirements listed above must be met; AND
  • A trial of at least two Tier-1 products (must include at least one injectable and one topical formulation) at least 12 weeks in duration; OR
  • A patient-specific, clinically significant reason why member cannot use all available Tier-1 medications; OR
  • Prior stabilization on a Tier-2 medication (within the past 180 days).
  • Approvals will be for the duration of one year; AND
  • For Xyosted™ [testosterone enanthate subcutaneous (sub-Q) auto-injector]:
    • Member must be trained by a health care professional on sub-Q administration and storage of Xyosted™ sub-Q auto-injector.  

Testosterone replacement products Special Prior Authorization Criteria

 Consideration will be based on the following criteria:

  • All diagnoses and laboratory requirements listed above must be met; AND
  • A patient-specific, clinically significant reason why member cannot use all other available formulations of testosterone.
  • Approvals will be for the duration of one year.

*Please note that approval will be for one year.

Prior Authorization Form

 

TIER 1 TIER 2 TIER 3
  • testosterone cypionate IM inj (Depo Testosterone®)
  • testosterone enanthate IM inj (Delatestryl®)
  • testosterone topical gel 1% packet, tube (Testim®, Vogelxo®)
  • testosterone topical gel 1.62% pump (Androgel®) – Brand Preferred
  • testosterone topical solution (Axiron®)
  • testosterone enanthate sub-Q auto-injector (Xyosted®)
  • testosterone nasal gel (Natesto®)
  • testosterone patch (Androderm®
  • testosterone topical gel 1%, 1.62% packet (Androgel®)
  • testosterone topical gel 1% pump (Vogelxo®)
  • testosterone topical gel 2% pump (Fortesta®
  • testosterone undecanoate IM inj (Aveed®)
  • methyltestosterone oral tab/cap (Android®, Methitest®, Testred®
  • testosterone pellets (Testopel®)
  • testosterone undecanoate oral cap (Jatenzo®, Kyzatrex®, Tlando®)

calcifediol er capsules (Rayaldee®) Approval Criteria:

  • An FDA approved indication for treatment of secondary hyperparathyroidism (SHPT) in adults with chronic kidney disease (CKD) stage 3 or 4; AND
  • Member must not have CKD stage 5 or end-stage renal disease on dialysis; AND
  • Member should have a serum total 25-hydroxyvitamin D level less than 30ng/mL before starting treatment; AND  
  • Member should have a serum calcium level below 9.8mg/dL before initiating treatment; AND
  • Rayaldee® must be prescribed by a nephrologist, endocrinologist, or provider who specializes in the treatment of SHPT; AND
  • Member must have a documented failure or clinically-significant reason why the member cannot use available generic vitamin D analogs including calcitriol; AND
  • Initial approval will be for 30mcg daily for three months; AND
    • After three months, approval for 60mcg daily for 12 months can be considered if intact parathyroid hormone (iPTH) is above the treatment goal and serum calcium is below 9.8mg/dL, phosphorus is below 5.5mg/dL, and 25-hydroxyvitamin D is below 100ng/mL. 
    • Additional approvals will not be granted if iPTH is persistently abnormally low, serum calcium is consistently above the normal range, or serum 25-hydroxyvitamin D is consistently above 100ng/mL. 
  • A quantity limit of 60 capsules per 30 days will apply.  

etelcalcetide injection (Parsabiv™) Approval Criteria:

  • An FDA approved indication for the treatment of secondary hyperparathyroidism (SHPT) in adult patients with chronic kidney disease (CKD) on hemodialysis; AND
  • Parsabiv™ will not be approved for parathyroid carcinoma, primary hyperparathyroidism, or in patients with CKD who are not on hemodialysis and is not recommended for use in these populations; AND
  • Member’s corrected serum calcium should be at or above the lower limit of normal (≥ 8.3mg/dL) prior to initiation, dose increase, or re-initiation of Parsabiv™; AND
     Parsabiv™ must be prescribed by a nephrologist, endocrinologist, or provider who specializes in the treatment of SHPT; AND
  • Member must have a documented failure or a clinically-significant reason why the member cannot use available generic vitamin D analogs including calcitriol; AND
  • Member must have a documented failure or a clinically-significant reason why the member cannot use Sensipar® (cinacalcet); AND
  • A quantity limit of 12 vials per month will apply.

paricalcitol capsules (Zemplar®) Approval Criteria:

  • Member must be 10 years of age or older; AND
  • An FDA approved indication for the prevention and treatment of secondary hyperparathyroidism (SHPT) associated with one of the following:
    • Chronic kidney disease (CKD) stage 3 or 4; OR
    • CKD stage 5 in patients on hemodialysis or peritoneal dialysis; AND
    • Members with CKD stage 5 should have a corrected total serum calcium equal to or less than 9.5mg/dL before initiating treatment; AND 
  • Zemplar® must be prescribed by a nephrologist, endocrinologist, or provider who specializes in the treatment of SHPT; AND
  • Member must have a documented failure or a clinically-significant reason why the member cannot use other generic vitamin D analogs available without prior authorization including calcitriol and Zemplar® injection; AND
  • A quantity limit of 30 capsules per 30 days will apply.

doxercalciferol capsules (Hectorol®) Approval Criteria:

  • An FDA approved diagnosis; AND
  • Member must have a documented failure or a clinically-significant reason why the member cannot use calcitriol. 

Prior Authorization Form   

 

If you have questions please call the Pharmacy Help Desk at (800) 522-0114 option 4 or (405) 522-6205 option 4.
Last Modified on Apr 19, 2024
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