Prior Authorization 2009

PA Criteria: Tier 1 products are covered with no authorization necessary.

Tier 2 authorization requires:

• documented inadequate response to two Tier 1 medications, or
• adverse drug reaction to all the Tier 1 medications, or
• previous stabilization on the Tier 2 medication, or
• a unique indication for which the Tier 1 antihypertensives are not indicated

Tier 3 authorization requires:

• documented inadequate response to two Tier 1 medications and documented inadequate response to all available Tier 2 medications, or
• adverse drug reaction to all the Tier 1 or all Tier 2 medications, or
• previous stabilization on the Tier 3 medication, or
• a unique indication for which the lower tiered antihypertensives are not indicated
• Prior Authorization form

Tier 1

Tier 2

Tier 3

• quinapril/HCTZ (Accuretic)
• captopril/HCTZ (Capozide)
• benazepril/HCTZ (Lotensin HCT)
• fosinopril/HCTZ (Monopril HCT)
• lisinopril/HCTZ (Prinzide, Zestoretic)
• moexipril/HCTZ (Uniretic)
• enalapril/HCTZ (Vasoretic)

Tier 1

Tier 2

Tier 3

• quinapril (Accupril)
• ramipril (Altace)
• captopril (Capoten)
• benazepril (Lotensin)
• trandolapril (Mavik)
• fosinopril (Monopril) 
• lisinopril (Prinivil, Zestril)
• moexipril (Univasc)
• enalapril (Vasotec)
• enalaprilat (Vasotec IV)

• perindopril erbumine (Aceon)

Tier 1

Tier 2

• nifedipine ER
• nifedipine (Adalat, Procardia)
• nifedipine CC (Adalat CC)
• amlodipine/atorvastatin (Caduet)
• verapamil (Calan, Isoptin, Verelan)
• verapamil SR (Calan SR, Isoptin SR, Verelan PM)
• nicardipine (Cardene)
• diltiazem (Cardizem)
• diltiazem CD (Cardizem CD)
• diltiazem SR (Cardizem SR)
• diltiazem ER (Cartia XT, Diltia XT)
• diltiazem XR (Dilacor XR)
• isradipine (Dynacirc, Dynacirc CR)
• nifedipine XL (Nifedical XL, Procardia XL)
• nimodipine (Nimotop)
• amlodipine (Norvasc)
• felodipine (Plendil)
• diltiazem (Tiazac, Taztia XT)

• nicardipine (Cardene SR)
• diltiazem (Cardizem LA)
• verapamil (Covera HS)
• nisoldipine (Sular)

Tier 1

Tier 2

Tier 3

• Tier 1 ACE + Tier 1 CCB

• enalapril/felodipine (Lexxel)
• benazepril/amlodipine (Lotrel)
• trandolapril/verapamil (Tarka)

PA Criteria:

Tier 1 products are covered with no authorization necessary.

Tier 2 authorization requires inadequate response to two Tier 1 medications or

• adverse drug reaction to all Tier 1 class of medications or
• previous stabilization on the Tier 2 medications, or
• a unique indication for which the Tier 1 antihypertensives are not indicated

Tier 3 authorization requires documented inadequate response to two Tier 1 medications and documented inadequate response to all available tier 2 medications, or

• adverse drug reaction to all Tier 1 or Tier 2 classes of medications, or
• previous stablilization on the Tier 3 medication, or
• a unique indication for which the lower tiered antihypertensives are not indicated.
• Prior Authorization form 

Tier 1

Tier 2

Tier 3

• quinapril (Accupril)
• captopril (Capoten)
• benazepril (Lotensin)
• trandolapril (Mavik)
• fosinopril (Monopril)
• lisinopril (Prinivil, Zestril)
• moexipril (Univasc)
• enalapril (Vasotec, Vasotec IV)

• irbesartan/HCTZ (Avalide)
• irbesartan (Avapro)
• valsartan (Diovan)
• valsartan/HCTZ (Diovan HCT)
• amlodopine/valsartan (Exforge)
• amlodopine/valsartan/HCTZ (Exforge HCT)
• telmisartan (Micardis)
• telmisartan/HCTZ (Micardis HCT)

• candesartan (Atacand)
• candesartan/HCTZ (Atacand HCT)
• amlodipine/olmesartan (Azor)
• olmesartan (Benicar)
• olmesartan/HCTZ (Benicar HCT)
• losartan (Cozaar)
• losartan/HCTZ (Hyzaar)
• eprosartan (Teveten)
• eprosartan/HCTZ (Teveten HCT)

Direct Renin Inhibitors

Tier 3 authorization requires:

• FDA approved indication
• Recent trial, within the previous 6 months and at least 4 weeks in duration, of an ACE Inhibitor (or an ARB if previous trial of an ACEI) and a diuretic, used concomitantly at recommended doses, that did not yield adequate blood pressure control.

Tier 1

Tier 2

Tier 3

• Tier 1 ACE Inhibitor + Diuretic

• ARB + Diuretic

• aliskiren (Tekturna)

PA Criteria:

The following are criteria for approval of a Tier-2 Product:

• Previous failure to achieve desired LDL reduction with a preferred statin - defined by at least 6-8 weeks of continuous therapy at standard to high dose.
• Previous stabilization on non-preferred medication.
• Documented increased risk for drug interactions. Specifically: concurrent immunosuppressant therapy, HIV antiretroviral therapy, and therapy with other potent inhibitors of CYP450 system.
• Documented adverse effect or contraindication to the preferred products

Tier 1

Tier 2

• lovastatin (generic)
• fluvastatin (Lescol & Lescol XL)
• atorvastatin (Lipitor)
• pravastatin (Pravachol)
• simvastatin (Zocor)

• lovastatin/niacin (Advicor)
• lovastatin (Altoprev & Mevacor)
• rosuvastatin (Crestor)
• pravastatin (Pravigard)
• ezetimibe/simvastatin (Vytorin)

PA criteria:

• The approval criteria for a tier 2 medication is as follows:
• Laboratory documented failure with a tier one medication after 6 months trial with a tier one medications.
• Documented adverse effect, drug interaction, or contraindication to tier 1 products.

Tier 1

Tier 2

• clofibrate (Atromid - S)
• fenofibrate (Fenoglide)
• micronized fenofibrates (Lofibra)
• gemfibrozil (Lopid)
• micronized fenofibrates (Tricor)
• fenofibrates (Trilipix)

• micronized fenofibrates (Antara)
• micronized fenofibrates (Lipofen)
• fenofibrates (Triglide)

PA criteria:

Diagnosis

• Hypercholesterolemia, primary
• Hypercholesterolemia, homozygous familial
• Sitosterolemia, homozygous

Laboratory documentation that member has not met (LDL) cholesterol goals after therapeutic lifestyle changes and statin therapy for at least 6 months.

Not a candidate for statin therapy due to:

• Documented active liver disease.
• Documented unexplained, persistent elevations of serum transaminases.
• Documented statin related myopathy.

• Prior Authorization form 

PA criteria:

• Plavix requires prior authorization for all members.
• Plavix therapy will be approved for members meeting approved diagnostic criteria that have failed aspirin therapy (due to either side effects or event recurrence),
• Or have a documented aspirin allergy, or use Plavix concomitantly with aspirin. The approved diagnoses are as follows:
  • Recent Stroke
  • Recent myocardial infarction
  • Established peripheral artery disease
  • Acute coronary syndrome (unstable angina/non-Q-wave MI)
  • Percutaneous coronary intervention with stent placement (aspirin trial not required)
  • Transient ischemic attacks
• All diagnoses get approval for duration of 1 year.
• Prior Authorization form 

PA Criteria:

• Diagnosis and medical supervision by a pulmonary specialist and/or cardiologist
• Pulmonary Arterial Hypertension (early stage, NYHA Class II)

Gender:

• Prior authorization required only for male SoonerCare members.

Quantity Limitations:

• 90 tablets per 30 days

PA Criteria:

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

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

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

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

• Xyzal not covered for members under age 6.
• For all antihistamine authorizations, the diagnosis must be for a chronic allergic condition. 
• Prior Authorization form 

Tier 1

Tier 2

Tier 3

• OTC cetirizine (Zyrtec)
• OTC loratadine (Claritin)

• fexofenadine (Allegra)

• desloratadine (Clarinex)
• fexofenadine (syrup, ODT)
• levocetirizine (Xyzal)

PA criteria:

For members with a diagnosis of asthma the following criteria will apply:

Children age 11 and under:

• Diagnosis of asthma, or
• A claim for inhaled corticosteroid, or
• Use of 3 or more rescue medications
• All claims should be within the member's previous year's history.

Children age 12 and older and adults:

• Diagnosis of mild or moderate persistent asthma, and/or exercise induced asthma, and
• Trial of inhaled corticosteroid AND corticosteroid/LAB, A therapy within the previous 6 months, with inadequate control of asthma.

Claims submitted for Singulair will trigger an automatic check for asthma diagnoses and prior fills of inhaled corticosteroids / asthma rescue medications in the member's claims history.  If the appropriate criteria are detected, these claims will be paid with no prior authorization required.

For members with a diagnosis of allergic rhinitis the following criteria will apply:

For members 2 years of age or older:

• Trials of an antihistamine and nasal corticosteroid, each 14 days in duration, that have failed to relieve allergic rhinitis symptoms.
• Agents may be used concomitantly or consecutively within the past 30 days.

For members less than two years of age:

• Trial of an oral antihistamine, 14 days in duration, which has failed to relieve allergic rhinitis symptoms, (Trial must have occurred within the past 30 days.)
• 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

• ProAir HFA (albuterol HFA)
• Proventil HFA (albuterol HFA)
• Ventolin HFA (albuterol HFA)

• Xopenex HFA (levalbuterol HFA)

PA criteria:

Nasal allergy medications will be included in product-based prior authorization effective 4/28/08.  Tier 1 products will be covered with no prior authorization necessary.

Tier 2 Authorization Requires

• Documented adverse effect or contraindication to the Tier 1 products , or
• Documented trials with all available Tier 1 corticosteroids with no beneficial response with the drug having been titrated to the recommended dose.  Each trial must be at least 3 weeks in duration.
• Prior Authorization form 

PA Criteria:

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

For Xolair requests, please submit these forms together:

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

PA criteria:

Xopenex

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

Criteria for approval:

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

PA Criteria:

1) Diagnosis of COPD, or
2) Diagnosis of Asthma:

• Member must be 4 years of age or older, and
• Member must have used an inhaled corticosteroid ( Aerobid, Alvesco, Asmanex, Azmacort, Flovent, Pulmicort, or QVAR) for at least one month immediately prior to request for authorization, and
• Member’s asthma considered uncontrolled by the prescriber
  •  Requires rescue inhaler more than 2 days per week for reasons other than prevention of exercise induced bronchospasms, and/or requires oral systemic corticosteroids, or
• Clinical situation warranting initiation with combination therapy due to severity of asthma
• Prior Authorization form 

PA Criteria:

• Members must be over 18 years of age and have one of the following diagnoses: COPD, chronic bronchitis, or emphysema.
• Member must have previous trial with Advair, Serevent, or Foradil in the past 45 days. A clinical exception will be given for those members who are unable to effectively use hand-actuated devices or who have become unstable on nebulized short-acting agonist therapy.
• Quantity limit of 120ml for a 30 day supply.
• 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

  Synagis form 

PA Criteria:

• No PA required for First 90 days of therapy. (Exception: Niravam & Xanax XR always require prior authorization.)
• Clarification of dosing schedule and diagnosis are important to assure that the member is not receiving duplicate therapy (e.g. an anxiolytic and hypnotic medications).
• Additional information regarding recent attempts at dose reductions should be included on recurrent PA petitions for high dose anxiolytic medications.
• Prior Authorization form 

• lorazepam (Ativan)
• chlordiazepoxide (Librium)
• oxazepam (Serax)
• clorazepate dipotassium (Tranxene)
• diazepam (Valium)
• alprazolam (Xanax)

Prior Authorization required.

• alprazolam rapdis (Niravam)
• alprazolam XR (Xanax XR)

Tier 1 products are available without prior authorization for members age 18 or older.

Prior authorization is required for all products formembers under age 18.

Tier 2 authorization requires:

• Minimum of 30 day trial with at least two Tier 1 products (one of which must be zolpidem) and clinical documentation of attempts to correct any primary cause for insomnia. 
• FDA approved diagnosis.
• No concurrent anxiolytic benzodiazepine therapy greater than TID dosing and no concurrent ADHD medications.
• Prior Authorization form 

Tier 1

Tier 2

• zolpidem tartrate (Ambien)
• flurazepam (Dalmane)
• triazolam (Halcion)
• estazolam (ProSom)
• temazepam (Restoril) 15mg & 30mg
• zaleplon (Sonata)

• zolpidem tartrate (Ambien CR)
• eszopiclone (Lunesta)
• temazepam (Restoril) 7.5 & 22.5mg
• ramelteon (Rozerem)

PA Criteria:

• Dose not to exceed 1.5 times the FDA approved maximum.
• No concurrent use of multiple products from this category, ie, Strattera + Stimulant, Methylphenidate + Amphetamine
• Prior authorization is required for all stimulants for adults age 21 and older.

Tier 2 authorization requires:

• Documented trial of a longer-acting Tier 1 medication within the last 30 days with inadequate results, and
• Diagnosis of ADHD or Narcolepsy

Tier 3 authorization requires:

• Documented trial of one Tier 1 medication long-acting product and one Tier 2 medication or two trials with either a Tier 1 or a Tier 2 medication with inadequate results (both trials within the last 60 days), and
• Diagnosis of ADHD or Narcolepsy.
• Prior Authorization form 

Tier 1

Tier 2

Tier 3

• amphetamine salt combo (Adderall)
• methylphenidate ER (Concerta)
• dexmethylphenidate (Focalin, Focalin XR)
• methylphenidate IR(Ritalin, Methylin)
• methylphenidate SR (Ritalin SR)
• lisdexamfetamine(Vyvanse)

• amphetamine salt combo (Adderall XR)
• methylphenidate ER (Metadate CD, Metadate ER)
• methylphenidate (Ritalin LA)
• atomoxetine (Strattera)

• methylphenidate patch(Daytrana)
• dextroamphetamine (Dexedrine, Dextrostat)
• methamphetamine (Desoxyn)
• armodafinil (Nuvigil)
• modafinil (Provigil)

PA Criteria:

The following are criteria for approval of a Tier 2 Product:

• Documented adverse effect, drug interaction, or contraindication to the Tier 1 products.
• Failure with a Tier 1 medication defined as no beneficial or minimally beneficial response after at least 4 weeks of continuous use within the last 6 months.
• Unique indication not covered by a Tier 1 product.
• Previously stabilized on Tier 2 product.
• Petition for a tier 2 medication may be submitted for consideration when a unique member specific situation exists or prescription by a psychiatrist.

Tier 3 Authorization Criteria

• Recent trials of a Tier 1 and a Tier 2 medication (within the last 6 months) with inadequate response after a minimum of 4 weeks of continuous therapy at recommended doses, or
• Unique FDA-approved indication for which Tier 1 and Tier 2 medications are not indicated, or
• Documented prior stabilization on the Tier 3 medication within the last 100 days.  A past history of success on the Tier 3 medication will also be considered with adequate documentation.

Tier 1

Tier 2

Tier 3

• citalopram (Celexa)
• fluoxetine (Prozac, Sarafem)
• fluvoxamine (Luvox)
• paroxetine (Paxil, Paxil CR)
• sertraline (Zoloft)

• escitalopram (Lexapro tabs & liquid)
• fluvoxamine (Luvox CR)
• fluoxetine 40mg caps
• fluoxetine (Prozac weekly)
• paroxetine (Pexeva)

Tier 1

Tier 2

Tier 3

Any Tier 1 SSRI or

• trazodone (Desyrel)
• venlafaxine (Effexor)
• mirtazapine (Remeron, Remeron SolTab)
• bupropion (Wellbutrin, Wellbutrin SR,  Wellbutrin XL)

• venlafaxine extended release tablets

• bupropion (Aplenzin)
• duloxetine (Cymbalta)
• venlafaxine (Effexor XR capsules)
• desvenlafaxine (Pristiq)
• nefazodone (Serzone)

Tier 1

Tier 2

Tier 3

• selegiline transderm (Emsam)
• phenelzine (Nardil)
• tranylcypromine(Parnate)
• selegiline (Zelapar)

The following are criteria for approval of a Tier 2 product:

• Tier-1 drug failure (i.e. inadequate clinical response or adverse effect), or
• Contraindication to the tier 1 drugs, or
• Stabilization on the tier 2 drug, or
• A unique indication which the tier 1 drugs lack.

• Patients who are currently stabilized on a Tier 2 medication will be allowed to continue their current treatment without prior authorization.

Tier 1

Tier 2

• tolterodine (Detrol)
• tolterodine extended release (Detrol LA)
• oxybutynin (Ditropan)
• darifenacin (Enablex)
• fesoterodine fumarate tablets (Toviaz)
• flavoxate (Urispas)
• solifenacin (VESIcare)

• oxybutinin extended release (Ditropan XL)
• oxybutynin (Oxytrol)
• trospium (Sanctura, Sanctura XR)

*hyoscyamine can be used as adjuvant therapy only. By itself, it will not count as a tier 1 trial.

PA Criteria:

Tier 1 medications are available without prior authorization.

Tier 2 authorization requires:

• documented 30 day trial/titration period with at least two Tier 1 medications within the last 90 days, or
• clinically appropriate pain therapy requiring time-released medication

Tier 3 authorization requires:

• documented 30 day trial with at least two long-acting Tier 2 medications within the last 90 days, or
• documented allergy or contraindication to all Tier 2 medications

Other criteria for this category:

• Members with an oncology-related diagnosis are exempt from the step therapy process, although quantity and dosage limits still apply.  Actiq and Fentora are approved only for oncology-related diagnoses
• Only one long-acting and one short-acting agent can be used concurrently
• Prior Authorization form 

PA criteria:

• Concurrent use of acetaminophen-containing products.
• Documented renal insufficiency or hepatic impairment or documented need to restrict acetaminophen use.
• Prior Authorization form 

A quantity limit of #180/30 on each of the products also applies.

PA criteria:

• FDA approved diagnosis for the use of Ultram ER.
• Diagnosis indicating that the member has a condition that requires extended pain treatment with an around-the-clock dosing schedule,
• The reason immediate release tramadol is inappropriate, and
• The physician's signature

A quantity limit of #30/30 days also applies.

PA criteria:

• 90 day benefit without PA; does not count towards prescription limit.
• After 90 days will require a PA with proof of behavior modification program enrollment for continued therapy. For example see Smoking Cessation Program or call the Oklahoma Tobacco Helpline at (800) QUIT-NOW.
• Coverage includes Chantix, Zyban and nicotine replacement products with a valid prescription.
• After the patient has had 180 days of treatment in a 365 day period, the patient must wait another 180 days before smoking cessation treatment will be covered again.
• Prior Authorization form

PA Criteria:

• Two consecutive trials with Tier 1 products within the last 120 days that did not yield adequate results.
• Clinical exceptions for NSAIDs in Tier 2 are demonstrated by the following conditions:
  • History of upper GI bleeding, or
  • History of NSAID-induced ulcer, or
  • Active peptic ulcer disease, or
  • Concurrent chronic use of oral corticosteroids, or
  • Chronic NSAID therapy in elderly or debilitated patients, or
  • Indomethacin for management of gout.
  • These clinical conditions are demonstrated by documentation sent by the prescribing physician and pharmacist.
• Prior Authorization form 

Tier 1

Tier 2

• naproxen sodium (Anaprox)
• flurbiprofen (Ansaid)
• diclofenac potassium (Cataflam)
• sulindac (Clinoril)
• oxaprozin (Daypro)
• etodolac (Lodine)
• etodolac ER (Lodine XL)
• meclofenamate (Meclomen)
• meloxicam (Mobic)
• ibuprofen (Motrin)
• fenoprofen (Nalfon)
• naproxen (Naprosyn)
• naproxen EC (Naprosyn EC)
• ketoprofen (Orudis)
• ketoprofen ER (Oruvail)
• mefanamic acid (Ponstel)
• nabumetone (Relafen)
• tolmetin (Tolectin)
• diclofenac ER (Voltaren XR)
• diclofenac sodium (Voltaren)
• diclofenac sodium (Voltaren Gel)

• diclofenac sodium/misoprostol (Arthrotec)
• celecoxib (Celebrex)
• piroxicam (Feldene)
• diclofenac epolamine (Flector)
• indomethacin (Indocin)
• naproxen sodium (Naprelan)
• Diclofenac Potassium (Zipsor)

PA Criteria:

• Tier 1 products are covered with no authorization necessary.

Tier 2 authorization requires:

• Documented trial of two Tier 1 medications within the last 90 days with no beneficial response after a minimum of 2 weeks of continuous therapy during which time the medication has been titrated to the recommended dose.

Tier 1

Tier 2

Special PA

• cyclobenzaprine (Flexeril)
• baclofen (Lioresal)
• orphenadrine (Norflex)
• chlorzoxazone (Parafon Forte, Paraflex)
• methocarbamol (Robaxin)
• tizanidine (Zanaflex)

• metaxolone (Skelaxin)

• carisoprodol 350mg w/aspirin
• carisoprodol 350mg, ASA, codeine
• cyclobenzaprine ER (Amrix) Caps
• cyclobenzaprine 7.5mg (Fexmid) Tabs
• carisoprodol (Soma) 250mg
• tizanidine (Zanaflex) Caps

PA Criteria:

• A cumulative 90 therapy day window per 365 days will be in place for these products, further approval will be based on the following:
• An additional approval for 1 month will be granted to allow titration or change to a Tier1 muscle relaxant. Further authorizations will not be granted.
• Clinical exceptions may be made for members with the following diagnosis and approvals will be granted for the duration of one year:
  • Multiple Sclerosis
  • Cerebral Palsy
  • Muscular Dystrophy
  • Paralysis
• A quantity limit of 120 per 30 days will also apply for the carisoprodol and carisoprodol combination products.

Soma 250 Approval for coverage is based on the following criteria:

• Documentation regarding member's inability to use other skeletal muscle relaxants including carisoprodol 350 mg, and specific reason member cannot be drowsy for even a short time period.   Member must not have other sedating medications in current claims history.
• A diagnosis of acute musculoskeletal pain, in which case, the approval will be for 14 days per 365 day period.  Conditions requiring chronic use will not be approved.

Tier 1

Tier 2

Tier 3

• alendronate (Fosamax)
• calcium + vitamin D

• alendronate +D (Fosamax +D)
• lbandronate (Boniva)
• risedronate (Actonel)

• zoledronic acid (Reclast)
• teriparatide (Forteo)

Forteo Criteria:

• Teriparatide (Forteo) may be used after a minimum 12 month trial with a bisphosphonate plus adequate calcium and vitamin D (unless contraindicated, intolerant, or allergic) and a BMD (T-score at or below -2.5) test within the last month. 
• Prior Authorization form 

PA criteria:

• Approval requires FDA approved indication and clinical documentation of inability to take other generically available forms of cyclobenzaprine hydrochloride.
• A quantity limit of 30 capsules for 30 days placed on Amrix.
• A quantity limited of 90 tablets for 30 days placed on Fexmid.

PA Criteria:

• Trizanidine tablets must be tried prior to consideration of the capsules. The capsules maybe considered for
• approval if there is supporting information as to why the member cannot take the tablets

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

PA Criteria:

FDA approved indication for specific products.

• Treatment of Anemia of Chronic Renal Failure Patients
• Treatment of Anemia of Zidovudine-treated HIV-infected Patients
• Treatment of Anemia of Cancer Patients on Chemotherapy
  • Myelosuppressive Chemotherapy-induced Anemia (Hb 8-10 g/dl) Non-Curative
• Reduction of Allogeneic Blood Transfusion in Surgery Patients

Most recent Hb levels (and date obtained) should be included on petition.  Each approval will be for 8 weeks in duration.  Authorization can be granted for up to 8 weeks following the final dose of myelosuppressive chemotherapy in a chemotherapy regimen.  Authorization for surgery patients will be for a maximum of 4 weeks.

Continuation Criteria:

• Continue dose if Hb is ≤12.0 g/dL.
• If Hb is increasing and approaching 12 g/dL then reduce dose by at least 25%
• If more than 1 g/dL increase (but Hb not greater than upper limits listed below) has occurred in a 2 week period reduce dose by 25 to 50%.

Discontinuation Criteria

• ESRD - Discontinue treatment if Hb is at or above 13.0 g/dL.
• All others - Discontinue treatment if Hb is at or above 12 g/dL
• If a minimum increase of 1 g/dL has not been achieved after initial 8 weeks of therapy.

Reinitiation Criteria:

• If Hb decreases to ≤10 g/dL then therapy may be reinitiated at 25 to 50% of the prior dose.

Once the initial request has been submitted and approved, continuation of therapy may occur with submission of the continuation form.

• Aranesp
• Epogen
• Procrit

PA Criteria:

• Classic Human Growth Hormone hGH Deficiency or,
• Short Stature (including Prader-Willi Syndrome) or,
• Short Stature associated with chronic renal insufficiency or,
• Small for Gestational Age (SGA) or,
• Turner’s Syndrome or 45 X, 46 XY mosiacism in males or,
• Hypoglycemia associated with hGH insufficiency or,
• AIDS wasting (Serostim only)
• SHOX (short stature homeobox-containing gene) deficiency
• Prior Authorization form 

• Genotropin
• Humatrope
• Increlex
• Iplex
• Norditropin
• Norditropin Nordiflex
• Nutropin
• Nutropin AQ
• Protropin
• Saizen
• Serostim
• Tev-Tropin

PA criteria: Byetta

• Patients must have Type 2 diabetes and currently taking metformin, sulfonylurea, thiazolidinedione, or a combination and have not achieved adequate glycemic control (HbA1C ≥ 6.5)
• Members that have been on a sulfonylurea, metformin or thiazolidinedione for 90 of the past 180 days will NOT require prior authorization
• Clinical exception will be allowed if Byetta is prescribed by an endocrinologist

PA criteria: Symlin

Patients with type 1 and 2 diabetes using insulin must:

• Be using basal-bolus insulin regimen (basal insulin plus rapid acting with meals), and
• Have failed to achieve adequate glycemic control on a basal-bolus regimen or are gaining excessive weight on basal-bolus regimen, and
• Receiving ongoing care under the guidance of a health care professional.

Patients meeting the following criteria should NOT be considered for Symlin therapy

• poor compliance with insulin regimen
• poor compliance with self-blood glucose monitoring
• HbA1c>9%
• recurrent severe hypoglycemia requiring assistance in past 6 months
• presence of hypoglycemia unawareness
• diagnosis of gastroparesis
• require use of drugs that stimulate GI motility
• pediatric patients (<15 years old)

PA criteria: Fortamet Glumetza

Approval will be based on clinical documentation of inability to take other forms of generic metformin ER - after slow titration of 500mg ER at 2 week intervals up to 2000mg daily.

PA criteria:

• Clinical Diagnosis: short term and intermittent treatment for mild to moderate atopic dermatitis (eczema).
• The first 90 days of a 12 month period will be covered without a prior authorization.
• After the initial period, authorization will be granted with documentation of one trial of a topical corticosteroid of six weeks duration within the past 90 days.
• Therapy will be approved only once each 90 day period to ensure appropriate short-term and intermittent utilization as advised by the FDA.
• Quantities will be limited to 30 grams for use on the face, neck, and groin, and 100 grams for all other areas.
• Authorizations will be restricted to those patients who are not immunocompromised.
• Exception for age restrictions granted only if prescription is written by a dermatologist.
• Age restrictions:
  • Elidel 1% ≥2 years of age
  • Protopic 0.03% for ≥2 years of age
  • Protopic 0.1% for ≥15 years of age (Approved for adult-use only)

PA criteria:

• Member unable to swallow tablets, and
• FDA-approved indication of tinea capitis, and
• No improvement after at least 3 weeks of therapy with griseofulvin, or
• Intolerance of hypersensitivity to griseofulvin or penicillin
• Prior Authorization form 

Criteria for Tier 2 Product:

• Approval of a Tier 2 product will be granted following trials of at least two Tier 1 topical antifungal products within the last 30 days.
• For treatment of Onychomycosis, a trial of oral antifungals (6 weeks for fingernails and 12 weeks for toenails) will be required in order for approval of Penlac.

Tier 1

Tier 2

• ciclopirox
• clotrimazole
• clotrimazole/betamethasone
• econazole
• ketoconazole
• nystatin
• nystatin/triamcinolone
• hydrocortisone/lodoquinol
• Most other available generic antifungal products

• benzoic acid/salicylic acid (Bensal HP)
• sertaconazole nitrate (Ertaczo)
• sulconazole (Exelderm)
• ketoconazole foam 2% (Extina)
• terbinafine (Lamisil Spray)
• Ciclopirox solution, shampoo & gel (Loprox)
• clotrimazole (Lotrimin Lotion 1%)
• butenafine (Mentax)
• naftifine (Naftin)
• oxiconazole (Oxistat)
• miconazole/zinc oxide/white petrolatum (Vusion)
• ketoconazole gel (Xolegel)
• ketoconazole gel +1% pyrithione zinc shampoo (Xolegel DUO)

PA criteria:

• FDA approved diagnosis (Postherpetic Neuraigia)
• Provide documented treatment attempts at recommended dosing or contraindication to at least one agent from two of the following drug classes:
  • Tricyclic antidepressants
  • Anticonvulsants
  • Topical or Oral Analgesics
• Quantity limit of no more than 3 patches per day with a maximum of 90 patches in a month.
• Prior Authorization form 

Tier 1 products are available without prior authorization.

Tier 2 authorization requires:

• Documented five-day trial of a Tier 1 product within the last 30 days.
• Clinical exception for adverse effects with all Tier 1 products, or unique indication not covered by Tier-1 products.
• Prior authorization will be for 10 days.

Tier 1

Tier 2

• Cortisporin Cream 0.5%
• Cortisporin Ointment 1%
• Gentamicin Cream 0.1%
• Gentamicin Ointment 0.1%
• Gentamicin Powder
• Mupirocin Ointment 2%

• Altabax Ointment 1%
• Bactroban Cream 2%
• Bactroban Nasal Ointment 2%
• Centany Kit 2%

PA Criteria:

• Covered OTC products

Malathion lotion (Ovide): No prior authorization necessary

• Member must be at least 6 years old
• Quantity limit of 60ml for 7 day supply; may be repeated once if needed for current infestation after 7 days from original fill date

PA Criteria:

Lindane lotion & shampoo

• Available only after first-line treatment with an OTC product has failed
• Member must be at least 13 years old or weigh at least 110 pounds
• Quantity limit of 60ml for 7 day supply
• One 7 day supply per 30 days maximum

       Crotamiton lotion & cream (Eurax)

• Available only after treatment with OTC product has failed
• quantity limit of 60 grams or milliliters for 30 day supply
• Covered OTC products 

Criteria for Tier 2 Product:

• FDA approved diagnosis.
• A trial of at least one Tier 1 product of a similar type for a minimum of two weeks in the last 30 days.
• Documentation of clinical need for Tier 2 product over Tier 1 should be noted on the petition.
• Clinical exceptions granted for products with allergic reaction or contraindication.

Tier 1

Tier 2

• ketotifen fumarate (Alaway, Zaditor OTC)
• epinastine (Elestat)
• cromolyn sodium (Opticrom)
• azelastine (Optivar)
• olopatadine (Patanol)

• pemirolast potassium (Alamast)
• nedocromil sodium (Alocril)
• lodoxamide tromethamine (Alomide)
• loteprednol etabonate (Alrex)
• emadastine difumarate (Emadine)
• olopatadine (Pataday)

Tier 1 products are covered with no authorization necessary

Tier 2 authorization requires:

• Comprehensive dilated eye exam within the last 365 day period, and
• FDA-approved indication, and
• Trial of a Tier 1 product for a minimum of 4 weeks with inadequate results within the last 90 days, or
• Documented adverse effect, drug interaction, or contraindication to Tier 1 products, or
• Unique FDA-approved indication for which Tier 1 medications are not indicated

Tier 1

Tier 2

• levobunolol (Betagan)
• timolol maleate (Betimol, Istalol, Timoptic, Timoptic Ocudose, Timoptic XE)
• betaxolol (Betoptic 0.5%)
• dorzolamide/timolol (Cosopt)
• carteolol (Ocupress)
• metipranolol (OptiPranolol)

• betaxolol (Betoptic S)
• brimonidine/timolol (Combigan)
• timolol maleate (Timoptic 0.5% dropperette)

Tier 1

Tier 2

• travoprost (Travatan, Travatan Z)
• latanoprost (Xalatan)

• bimatoprost (Lumigan)

Tier 1

Tier 2

• dipivefrin (Propine)

Tier 1

Tier 2

• brimonidine 0.2%

• brimonidine (Alphagan P 0.1%,0.15%)
• apraclonidine (Iopidine 1%)

Tier 1

Tier 2

• dorzolamide/timolol (Cosopt)
• dichlorphenamide (Daranide)
• acetazolamide (Diamox)
• methazolamide (Neptazane)

*(Indicates Available Oral Products)

• brinzolamide (Azopt)
• dorzolamide (Trusopt)

Tier 1

Tier 2

• pilocarpine (Isopto Carpine, Pilopine HS 0.5%, 1%,2%,4%,6%)

• carbachol (Isopto, Miostat 1.5%, 3%)
• echothiophate iodide (Phospholine lodide)

PA Criteria:

• Used for pre-operative/post-operative prophylaxis
• Prescription written by optometrist / ophthalmologist

• tobramycin/dexamethasone (Tobradex)
• tobramycin/loteprednol (Zylet)
• sulfacetamide/prednisolone (Blephamide)
• gentamicin/prednisolone (Pred-G)
• neomycin/polymyxin/Bac/Hydrocortisone Ointment
• neomycin/polymyxin-B/prednisolone (Poly-Pred)
• neomycin/polymyxin-B/hydrocortisone (Cortisporin)
• neomycin/polymyxin-B/dexamethasone (Maxitrol)

• Prior Authorization form 

• Prior Authorization required for:
• ranitidine (Zantac) capsules, effervescent forms and,
• lansoprazole (Prevacid) granules and solutabs forms.
• lansoprazole/naproxen (Prevacid NapraPac)
• esomeprazole IV (Nexium IV)

Tier 2 authorization requires:

• Documented trial of a Tier 1 medication with inadequate results or adverse effect, or
• Documented contraindication to the Tier 1 medications, or
• Documented FDA-approved indication for which Tier 1 products are not indicated
• Prior Authorization form 

Tier 1

Tier 2

• dexlansoprazole (Kapidex)
• omeprazole (Prilosec) 20mg capsules 
• lansoprazole (Prevacid) capsules *BID dosing requires PA 

• rabeprazole sodium (Aciphex)
• esomeprazole magnesium (Nexium)
• omeprazole (Prilosec) 40mg capsules 
• prantoprazole sodium (Protonix)

PA criteria:

• Chronic Idiopathic Constipation in males and females, or Irritable bowel syndrome in females 18 years of age and older who meet the following criteria:
  • Have documentation that constipating therapies for other disease states have been discontinued (excluding opioid pain medications for cancer patients).
  • Documented and updated Colon Screening. (>50 years of age)
• Hydration and treatment attempts with a minimum of three alternate products must be documented.
• Initial approval for 12 weeks of therapy. An additional year approval may be granted if physician documents member is responding well to treatment.
• Quantity limit of 100 units for a 50 day supply.