Prior Authorization Archives
Therapeutic Categories:
Cardiovascular
Respiratory
Central Nervous System/Behavioral Health
Skeletal System
Enodocrine
Topical
Ocular
Gastro Intestinal
Antihypertensives | ||
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PA Criteria: Tier 1 products are covered with no authorization necessary. Tier 2 authorization requires:
Tier 3 authorization requires:
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ACE/HCTZ | ||
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Tier 2 |
Tier 3 |
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ACE Inhibitors | ||
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Tier 2 |
Tier 3 |
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CCB (Calcium Channel Blockers) | ||
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Tier 1 |
Tier 2 |
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ARBs (Angiotensin Receptor Blockers) Medication | ||
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PA Criteria: Tier 1 products are covered with no authorization necessary. Tier 2 authorization requires inadequate response to two Tier 1 medications or
Tier 3 authorization requires documented inadequate response to two Tier 1 medications and documented inadequate response to all available tier 2 medications, or
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* Clinical exception applies to members who have diabetes. | ||
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Tier 2 |
Tier 3 |
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Direct Renin Inhibitors |
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Tier 3 authorization requires:
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Tier 1 |
Tier 2 |
Tier 3 |
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*Use of the brand name products when generic is available is subject to the brand name override process. |
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Plavix | ||
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PA criteria:
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Antihistamines | ||
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PA Criteria: Tier 1 products are covered with no authorization necessary for members under age 21.
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).
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Tier 2 |
Tier 3 |
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Singulair | ||
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PA criteria: For members with a diagnosis of asthma the following criteria will apply: Children age 11 and under:
Children age 12 and older and adults:
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:
For members less than two years of age:
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*Xopenex authorization requests should document why the member is unable to use racemic albuterol. If prescribed for asthma, member should also be utilizing inhaled corticosteroid therapy for long-term control. Dose of levalbuterol requested cannot be less than the racemic equivalent documented on the prior authorization request. |
Nasal Allergy | ||
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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
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Xopenex | ||
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PA criteria: Xopenex
Criteria for approval:
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Advair and Symbicort | ||
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PA Criteria: 1) Diagnosis of COPD, or
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Brovana | ||
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PA Criteria:
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Anxiolytic | ||
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PA Criteria:
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Prior Authorization required.
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Insomnia | ||
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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:
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Tier 1 |
Tier 2 |
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ADHD and Narcolepsy | ||
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PA Criteria:
Tier 2 authorization requires:
Tier 3 authorization requires:
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Tier 1 |
Tier 2 |
Tier 3 |
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Tier 1 |
Tier 2 |
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*hyoscyamine can be used as adjuvant therapy only. By itself, it will not count as a tier 1 trial. |
Narcotic Analgesics | ||
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PA Criteria: Tier 1 medications are available without prior authorization. Tier 2 authorization requires:
Tier 3 authorization requires:
Other criteria for this category:
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Darvocet A500/Balacet 325 | ||
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PA criteria:
A quantity limit of #180/30 on each of the products also applies. |
Ultram ER | ||
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PA criteria:
A quantity limit of #30/30 days also applies. |
Smoking Cessation | ||
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PA criteria:
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NSAIDs | ||
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PA Criteria:
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Tier 1 |
Tier 2 |
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Forteo Criteria:
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Growth Hormone | ||
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PA Criteria:
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Lamisil Granules | ||
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PA criteria:
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Lidoderm Patch | ||
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PA criteria:
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Pediculicides | ||
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PA Criteria:
PA Criteria:
Crotamiton lotion & cream (Eurax)
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Anti-Ulcer | ||
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Tier 2 authorization requires:
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Tier 1 |
Tier 2 |
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If you have questions please call the Pharmacy Help Desk at (800) 522-0114 option 4 or (405) 522-6205 option 4.