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Central Nervous System/Behavioral Health

 Anxiolytic Medications

Members 19 Years and Older will not require a petition

  • Quantity limits apply on all benzodiazepine anxiolytic products.
  • No request for dosing greater than 3 times daily will be approved unless a specific diagnosis exists; for these diagnoses the maximum allowed dosing is 4 times daily.
  • The maximum covered dosing of benzodiazepine therapy is three times a day if a hypnotic medication is also prescribed.  

Members 0-18 Years of Age will require a petition:

  • No concurrent stimulant ADHD medications, and
  • No Contraindicated Conditions, and
  • Maximum dosing of 3 times daily. For Members 12 or younger the same criteria applies and prescription must originally be written by a psychiatrist.

Prior Authorization form

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

Prior Authorization required.

  • alprazolam rapdis (Niravam®)
Insomnia Medications

Tier 1 products are available without prior authorization for members age 18 or older.Prior authorization is required for all products for members under age 18.

Tier 2 approval Criteria:

  • Minimum of 30 day trial with at least two Tier 1 products 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.
  • Approvals granted for 6 months.
Tier 3 approval Criteria:
  • Minimum of 30 day trial with all available Tier 2 products 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.
  • Approvals granted for 6 months.
  • Prior Authorization form
Tier 1
Tier 2
Tier 3
  • zolpidem tartrate (Ambien®)
  • flurazepam (Dalmane®)
  • triazolam (Halcion®)
  • estazolam (ProSom®)
  • temazepam (Restoril®) 15mg & 30mg
  • zaleplon (Sonata®)    
  • zolpidem tartrate (Ambien CR®)  
  •  tartrate (Ambien CR®)
  • zolpidem SL tabs  (Edluar®)
  • zolpidem SL tabs (Intermezzo®)
  • eszopiclone (Lunesta®)
  • temazepam (Restoril®) 7.5mg & 22.5mg
  • ramelteon (Rozerem®)
  • doxepin (Silenor®)
  • Zolpidem Oral Spray (Zolpimist®)
Multiple Sclerosis
dalfampridine (Ampyra®)

PA Criteria:

  • Member must have a diagnosis of Multiple Sclerosis
  • Kurtzke Expanded Disability Status Scale (EDSS) score between 3 and 7.5
  • A 90 day trial will be approved. If member has responded well to treatment and physician states that the member has shown improvement or the drug was effective, member may receive authorization for one year.
  • Quantity Limit of 60 for 30 days
Interferon

PA Criteria

  • Documented diagnosis of relasping remitting MS.
  • Tier 2 medications require failure of the preferred tier 1 product defined as:
    • Occurrence of an exacerbation after 6 months.
    • Significant increase in MRI lesions after 6 months.
    • Adverse reactions or intolerable side effects.
  • No concurrent use with other therapies.
  • Compliance will be checked for continued aproval every 6 months.
Tier 1
Tier 2
  • interferon β 1b (Betaseron®)
  • interferon β 1a (Rebif®)
  • interferon β 1a (Avonex®)
  • interferon β 1b (Extavia®)
Glatiramer Acetate (Copaxone®)

Prior Authorization of glatiramer acetate (Copaxone®):

  • FDA approved diagnosis.
  • No concurrent use with other therapies
  • Compliance will be checked for continued approval every 6 months.
Fingolimod (Gilenya®)
  • Documented diagnosis of relapsing remitting MS with at least one relapse in the previous 12 months, or transitioning from existing MS therapy.
  • No concurrent use with other therapies.
  • Compliance will be checked for continued approval every 6 months.
teriflumomide (Aubagio®)

PA Criteria
Consideration will be based on all of the following criteria:

  • Documented diagnosis of relapsing forms of Multiple Sclerosis; AND
  • All of the following will be required for initiation of treatment:
    • No concurrent use with other disease modifying therapies; AND
    • Verification that female members are not pregnant and currently on a reliable contraceptive; AND
    • Verification that member has no active infection(s); AND
    • CBC counts and verification that levels are acceptable to the prescriber; AND
    • Liver function tests and verification that levels are acceptable to the prescriber; AND
    • Blood pressure measurement and verification that blood pressure is being monitored; AND
    • Verification that members do not have tuberculosis, or completion of standard medical treatment for patients with tuberculosis; AND
  • Approval of Aubagio will be initially for 6 months, after which time,  all of the following will be required for further approval:
    • Medication compliance; AND
    • Repeat CBC counts and verification that counts are acceptable to the prescriber; AND
    •  Repeat liver function tests and verification that levels are acceptable to the prescriber; AND
    • Verification that female members are not pregnant and still on reliable contraceptive; AND
    • Verification that blood pressure and symptoms of renal failure are being monitored; AND
  • Compliance will be checked every 6 months there-after for continuation of therapy; AND
  • Quantity limit of #30 tablets per 30 days applies.
dimethyl fumarate (Tecfidera™ )  

PA Criteria
Consideration will be based on all of the following criteria:

  • A documented diagnosis of relapsing forms of Multiple Sclerosis; AND
  • All of the following will be required for initiation of treatment:
    • No concurrent use with other disease modifying therapies; AND
    • Verification from the prescriber that member has no active infection (s); AND
    • CBC counts and verification that levels are acceptable to the prescriber; AND
  • Compliance will be checked every 6 months there-after for continuation of therapy; AND
  • Quantity limit of #60 tablets per 30 days applies
ADHD and Narcolepsy

Tier 1

  • NO PRIOR AUTHORIZATION REQUIRED FOR MEMBERS AGE 5-20.
  • Dosing in excess of 1.5 times the FDA approved maximum is not covered.
  • Prior Authorization form
Amphetamine
Methylphenidate Non-Stimulant
  • amphetamine salt combo (Adderall®)
  • Adderall XR (brand only)
  • lisdexamfetamine (Vyvanse®)
  • methylphenidate ER (Concerta®)
  • dexmethylphenidate (Focalin®)
  • dexmethylphenidate (Focalin XR®)
  • methylphenidate IR (Ritalin, Methylin®)
  • methylphenidate SR (Ritalin SR®)
  • Methylphenidate solution
  • Methylphenidate chewable tablets
  • guanfacine ER (Intuniv®)
  • atomoxetine (Strattera®)
  • Clonidine

Tier 2

  • FDA approved diagnosis
  • Use of Tier 2 amphetamine or methylphenidate products requires documented Tier 1 trials of long acting medications from both the amphetamine and methylphenidate categories that did not yield adequate response.
  • Use of Kapvay requires recent 14 day trial with immediate release clonidine and clinically significant reason why member cannot use immediate release products.
Amphetamine Methylphenidate Non-Stimulant
  • methamphetamine patch (Daytrana®)
  • amphetamine/dextro amphetamine XR (generic only)
  • methylphenidate ER (Metadate CD®)
  • methylphenidate ER (Metadate ER®)
  • methylphenidate SR (Ritalin LA®)
  • clonidine ER (Kapvay®)  

Tier 3

  • FDA approved diagnosis
  • Tier trials required for applicable FDA approved diagnosis..
  • The diagnosis of obstructive sleep apnea requires concurrent treatment for the obstructive sleep apnea
  • The diagnosis of shift work sleep disorder requires the member's work schedule to be included with the petition.
  • Use of Xyrem requires recent trials with Tier 1 and Tier 2 stimulants from different chemical categories, and trials with both Provigil and Nuvigil within the past 6 months, unless contraindicated, that did not yield adequate results.
  • dextroamphetamine (Dexedrine, Dextrostat®)
  • dextroamphetamine solution (Procentra®)
  • methamphetamine (Desoxyn®)
  • methylphenidate HCL (Quillivant® XR)
  • modafinil (Provigil®)
  • armodafinil (Nuvigil®)
  • sodium oxybate (Xyrem®)
Second Opinion Process for Children 0-4 Years of Age and Unusual Dosing Requests

Children less than 5 years of age will require a "second opinion" prior authorization to be reviewed by an OHCA-contracted child psychiatrist. Current users will be allowed to remain on current medication until the petition is submitted and reviewed. The  second opinion process is as follows:

  • Prior authorization for the requested medication is received by the prior authorization unit.
  • Clinical pharmacist checks appropriate box to fax to OHCA.
  • On-call psychiatrist at OHCA contacts physician who submitted prior authorization request.
  • OHCA faxes response back within 24 hours.
  • Clinical pharmacist issues appropriate response for petition based on the results.
ropinirole (Requip XL®) and pramipexole (Mirapex ER®)

PA criteria:

  • Diagnosis of Parkinson's Disease, and
  • Clinically significant reason why the immediate release products cannot be used.
Atypical Antipsychotics

Tier 1 products are available without prior authorization.

  • No member co-pay for risperidone at pharmacy.

Tier 2 Authorization Criteria

  • Current users/inpatient discharge:
    • Members currently stabilized on a higher tiered medication in the past 90 days will be approved.
    • Members being released from an inpatient facility and stabilized on a higher tier medication will be approved.
  • Clinical conditions:
    • Approvals will be granted for members with clinical conditions for which lower tiered drugs are contraindicated.
    • Approvals will be granted for members whose current regimen includes drugs known to adversely interact with all lower tiered drugs.
  • Step therapy:
    • A trial of risperidone, quetiapine or olanzapine at least 14 days in duration, titrated to recommended dose, that did not yield adequate response or resulted in intolerable adverse effects.
Tier 3 Authorization Criteria
  • Current users/inpatient discharge:
    • Members currently stabilized on a higher tiered medication the past 90 days will be approved.
    • Members being released from an inpatient facility and stabilized on a higher tier medication will be approved.
  • Clinical conditions:
    • Approvals will be granted for members with clinical conditions for which lower tiered drugs are contraindicated.
    • Approvals will be granted for members whose current regimen includes drugs known to adversely interact with all lower tiered drugs.
  • Step therapy:
    • A trial of risperidone, quetiapine or olanzapine at least 14 days in duration, titrated to recommended dose, that did not yield adequate response or resulted in intolerable adverse effects, and
    • A trial of two Tier 2 medications, at least 14 days in duration, titrated to recommended dose, that did not yield adequate response or resulted in intolerable adverse effects.
 
Approval Criteria for Atypical Antipsychotics as Adjunctive Treatment for Depression:
Consideration for aripiprazole (Abilify®) quetiapine extended release (Seroquel XR®), or olanzapine/fluoxetine (Symbyax®) will be based on the following criteria:
  • A diagnosis of depression; AND
  • Concurrent use of an antidepressant;
  • AND Previous trials with at least two other antidepressants from both categories (an SSRI and a dual acting antidepressant) that did not yield adequate response.
*Please Note: Tier structure still applies.
Tier 1
Tier 2 Tier 3
  • clozapine (Clozaril®)
  • quetiapine (Seroquel®)*
  • risperidone (Risperdal®)
  • olanzapine (Zyprexa®)*    
  • aripiprazole (Abilify®)
  • iloperidone (FanaptTM)
  • ziprasidone (Geodon®)
  • lurasidone (Latuda®)
  • asenapine (Saphris®)
  • quetiapine ER (Seroquel XR®)
  • clozapine (Fazaclo®)
  • paliperidone (Invega®)
  • olanzapine/fluoxetine (Symbyax®)
  • clozapine (Versacloz®)

Second Opinion Process for Children 0-4 Years of Age and Unsual Dosing Requests

Children less than 5 years of age will require a "second opinion" prior authorization to be reviewed by an OHCA-contracted child psychiatrist. Current users will be allowed to remain on current medication until the petition is submitted and reviewed. The  second opinion process is as follows:

  • Prior authorization for the requested medication is received by the prior authorization unit.
  • Clinical pharmacist checks appropriate box to fax to OHCA.
  • On-call psychiatrist at OHCA contacts physician who submitted prior authorization request.
  • OHCA faxes response back within 24 hours.
  • Clinical pharmacist issues appropriate response for petition based on the results.
Anti-Migraine

PA Criteria:

Tier 1 products are covered with no authorization necessary.

Tier 2 authorization requires:

  • Trial of all available tier 1 products with inadequate response, or
  • Documented adverse effect to all the tier 1 products, or
  • Previous success with a tier 2 product within the last 60 days.
Tier 3 authorization requires:

  • Trial of all available tier 2 products with inadequate response, or
  • Documented adverse effect to all the tier 2 products, or
  • Previous success with a tier 3 medication within the last 60 days
  • Use of Sumavel DosePro also requires clinical reason why member cannot use all other available formulations of sumatriptan.  
Tier 1
Tier 2
Tier 3
  • sumatriptan (Imitrex®)  
  • naratriptan (Amerge®)  
  • almotriptan (Axert®)
  • eletriptan (Relpax®)
  • frovatriptan (Frova®)
  • rizatriptan (Maxalt®, Maxalt MLT®)
  • sumatriptan (Sumavel DosePro®)
  • sumatriptan/naproxen (Treximet®)
  • zolmitriptan (Zomig®, Zomig ZMT®)
  • Xarelto® 10mg: One prescription for up to 35 days of therapy is allowed without prior authorization every 6 months.
  • Xarelto® 15mg and 20mg: diagnosis of non valvular atrial fibrillation, deep vein thrombosis (DVT), pulmonary embolism (PE), or to reduce the risk of recurrent DVT and PE will be required.
  • Eliquis® diagnosis of nonvalvular atrial fibrillation will be required.
  • Prior Authorization form
Fibromyalgia

PA Criteria:

Tier 1 products are covered with no authorization necessary.

  • Recent trials (within the last six months) of two tier 1 medications at least 3 weeks in duration that did not provide adequate response, or resulted in intolerable adverse effects, or
  • Contraindications(s) to all available lower tiered medications,
  • Current stabilization on a tier 2 medication (samples will not be accepted if member has not had appropriate lower tiered trials).  
Tier 1
Tier 2
  • amitriptyline
  • cyclobenzaprine
  • fluoxetine
  • tramadol
  • duloxetine HCI (Cymbalta ®)
  • milnacipran (Savella ®)
  • pregabalin (Lyrica ®)
Antidepressants

PA Criteria:

Tier 1 products available with no authorization necessary

Tier 2 Authorization Criteria:

  • Recent trial of tier 1 medications (within the last 6 months) with inadequate response after a minimum of 4 weeks of continuous therapy at recommended dose. Tier 1 selection must include at least one medication from the SSRI category and one medication  from the dual acting category.
  • Unique FDA-approved indication for which tier 1 medications are not indicated, or
  • Prior stabilization on the tier 2 medication within the last 100 days. A past history of success on the tier 2 medication will also be considered with adequate documentation.
  • Special criteria apply for authorization of Prozac Weekly®.

Tier 3 Authorization Criteria

  • Recent trials of two tier 1 medications (one from each category) and a tier 2 medications (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 medications within the last 100 days. A past history of success on the tier 3 medications will also be considered with adequate documentation.

Approval Criteria for Atypical Antipsychotics as Adjunctive Treatment for Depression:

  • Consideration for aripiprazole (Abilify®) quetiapine extended release (Seroquel XR®), or olanzapine/fluoxetine (Symbyax®) will be based on the following criteria:
    • A diagnosis of depression; AND
    • Concurrent use of an antidepressant; AND
    • Previous trials with at least two other antidepressants from both categories (an SSRI and a dual acting antidepressant) that did not yield adequate response.  

*Please Note: Tier structure still applies.  

Tier 1
Tier 2
Tier 3
SSRIs (Selective Serotonin Reuptake Inhibitors)
  • citalopram (Celexa®)
  • escitalopram (Lexapro® tabs & liquid)
  • fluoxetine (Prozac®, Sarafem®)
  • fluvoxamine (Luvox®)
  • paroxetine (Paxil®, Paxil CR®)
  • sertraline (Zoloft®)
  • fluvoxamine (Luvox CR®)
  • fluoxetine 60mg
  • fluoxetine (Prozac weekly®)
  • paroxetine (Pexeva®)
 
Dual Acting Antidepressants

Any Tier 1 SSRI or

  • trazodone (Desyrel®)
  • venlafaxine (Effexor®)
  • venlafaxine (Effexor XR® capsules)
  • mirtazapine (Remeron®, Remeron SolTab®)
  • bupropion (Wellbutrin®, Wellbutrin SR®,  Wellbutrin XL®)
  • duloxetine (Cymbalta®)
  • venlafaxine extended release tablets
  • bupropion (Aplenzin®, Forfivo®)
  • levomilnacipran (FetzimaTM)
  • trazodone ER (Oleptro®)
  • desvenlafaxine (Pristiq®, Khedezla®)
  • nefazodone (Serzone®)
  • vilazodone (Viibryd®)
Monoamine Oxidase Inhibitors
   
  • selegiline transderm (Emsam®)
  • phenelzine (Nardil®)
  • tranylcypromine(Parnate®)
  • selegiline (Zelapar®)
Anticonvulsants

Anticonvulsants will be included in the current mandatory generic plan.

  • All brand-name anticonvulsants (with a generic equivalent) will require prior authorization.

Prior authorization will be required for certain non-standard dosage forms of medications when the drug is available in standard dosage forms.

  • Members 12 and older must have a documented medical reason demonstrating need for non-standard dosage forms.
  • Criteria for approval of extended-release formulation.
    • Previously stabilized on the short-acting formulation.
    • Dosing is not more than once daily.
    • Member must provide a reason why the short-acting formulation is not adequate.
  • Dosepacks will not be approved if standard dosage forms are available.

Quantity limit restrictions will be placed on lower strength tablets and capsules. The highest strengths will continue to have no quantity restrictions unless a maximum dose is specified for a particular medication.  

felbamate (Felbatol®)
PA criteria:
  • Initial prescription written by a neurologist
  • Member has failed therapy with at least three other medications commonly used for seizures.
clobazam (Onfi®)

PA Criteria

  • Diagnosis of generalized tonic, atonic or myoclonic seizures; and
  • Previous failure of at least two non-benzodiazepine anticonvulsants; and
  • Previous failure of clonazepam.
  • For continuation prescriber must include information regarding improved response/effectiveness of this medication.
vigabatrin (Sabril®)

PA Criteria
Consideration will be based on all of the following criteria:

  • FDA approved diagnosis of refractory complex seizures in adults, and pediatric patients 10 years or older, OR
  • infantile spasms in children ages 1 month to 2 years of age; AND
  • Members with refractory complex seizures must have previous trials of at least three other antiepileptic medications; OR
  • Members with infantile spams must have had a previous trial with adrenocorticotropic hormone (ACTH) OR have a diagnosis of infantile spasms with tuberous sclerosis; AND
  • Prescription must be written by a neurologist; AND
  • Member, prescriber, and pharmacy must all register in the SHARE program and maintain enrollment throughout therapy
Narcotic Analgesics

PA Criteria

Only one long-acting and one short-acting agent can be used concurrently.

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 

Oncology Only Products:

  • Members with an oncology-related diagnosis are exempt from the prior authorization process, although quantity and dosage limits still apply. These products are covered only for members with an oncology diagnosis.
  • Prior Authorization form
Tier 1
Tier 2
Tier 3
Oncology Only
Immediate Release Long Acting
  • codeine
  • hydromorphone(Dilaudid®)
  • methadone(Dolophine®)
  • ASA/butalbital/caffeine/ codeine(Fiorinal with Codeine®)
  • hydrocodone/APAP(Lortab®)
  • morphine-immediate release (MSIR®)
  • oxycodone-immediate release (OxylR®)
  • oxycodone/APAP(Percocet®)
  • oxycodone/ASA(Percodan®)
  • tramadol/APAP (Ultracet®)
  • hydrocodone/IBU (Vicoprofen®)
  • morphine ER (MS Cotin)
  • fentanyl patches (Duragesic®)
  • morphine sulfate(Avinza®)
  • buprenorphine(Butrans®)
  • morphine sulfate/naltrexone(Embeda®)
  • hydromorphone(Exalgo®)
  • morphine sulfate(Kadian®)
  • oxymorphone(Opana ER®)
  • oxycodone(Oxycontin®)
  • tramadol ER (Ryzolt® Ultram® ER)
  • tapentadol ER(Nucynta ER®)
 
Short Acting
 
  • tapentadol(Nucynta®)
  • oxymorphone (Opana® IR)
  • Hycet®
  • Liquicet®
  • oxycodone (Oxecta®) oxycodone/APAP (Primlev®, Xolox®,)
  • tramadol ODT (Rybix®)
  • Trezix®
  • hydrocodone/APAP (Xodol®, Zamicet®)
  • fentanyl(Abstral®, Lazanda®)
  • fentanyl (Actiq®)
  • fentanyl (Fentora®)
  • fentanyl (Onsolis®) buccal film
  • fentanyl sublingual spray(Subsys®)
buprenorphine/naloxone (Suboxone®), buprenorphine (Subutex®)

PA criteria:

  • Products must be prescribed by a licensed physician who qualifies for a waiver under the Drug Addiction Treatment Act (DATA) and has notified the Center for Substance Abuse Treatment of the intention to treat addiction patients and has been assigned a DEA  (X) number.
  • Diagnosis of opiate abuse/dependence.
  • Combination with benzodiazepines, hypnotics, and opioids (including tramadol) will be denied.
  • Approval will be for 90 days to allow for concurrent medication monitoring.
  • The following limitations will apply:
    • Suboxone® 2mg/0.5mg and 8mg/2mg tablets and film: Quantity limit of 90 per 30 days.
    • Subutex® 2mg tablets and 8mg tablets will only be approved if the member is pregnant (product may be used for the duration of the pregnancy only), or has a documented serious allergy or adverse reaction to naloxone.
  • Prior Authorization form
Smoking Cessation

PA criteria:

  • Smoking cessation products do not count against the 6 prescriptions/month limit.
  • Nicotine patches and Zyban® do not require prior authorization. Each product may be used for up to 180 days per calendar year.
  • Other nicotine replacement products and Chantix® may be used for up to 90 days per year without prior authorization. An additional 90 days can be covered with prior authorization.

Criteria for Approval after the First 90 Days:

  • Member must be enrolled in a smoking cessation behavior modification program and the name of the program must be stated on the petition.
  • Petition may be approved for another 90 days
  • After the member has had 180 days of treatment in a 365 day period, the member must wait another 180 days before smoking cessation treatment will be covered again

Smoking Cessation Program
Prior Authorization form

Alzheimer's Medications

PA criteria:

  • Prior Authorization is required for the following special formulation products:
    • donepezil (Aricept®) and 23 mg tablets
    • rivastigmine (Exelon®) solution and patch
    • memantine (Namenda®) solution and tablets
    • galantamine (Razadyne®) solution and extended release capsules    
  • Member must have a documented reason why the special formulation is clinically necessary over the regular formulation
  • Application of Age Restriction for ages 0-50 with the following approval criteria.
    • FDA approved diagnosis

Prior Authorization form

Neupro Medications

PA criteria:

Parkinson's Disease

  • FDA approved indication for the treatment of signs and symptoms of Parkinson's Disease
  • Must be 18 years old or older
  • Failed treatment, intolerance, or clinically significant reason why member cannot use oral dopamine agonists  

Restless Leg Syndrome

  • FDA approved indication of Restless Leg Syndrome
  • Must be 18 years or older
  • Must provide documented treatment attempts at recommended dose with at least two of the following that did not yield adequate relief:
    • carbidopo/levodopa
    • pramipexole
    • ropinirole

Prior Authorization form

gabapentin (Gralise®)

PA criteria:

  • FDA-approved indication of postherpetic neuralgia.
  • Must provide documented treatment attempts at recommended dosing or contraindications to at least one agent from two of the following drug classes:
    • Tricyclic antidepressants
    • Anticonvulsants
    • Topical or oral analgesics
  • Must provide a clinically significant reason why the member cannot take the immediate-release formulation of gabapentin.
  • Prior Authorization form
dextromethorphan/quinidine (Nuedexta®)

PA criteria:

  • FDA approved diagnosis.
  • Member must be 18 years of age or older.
  • Quantity limit of #60 tablets per 30 days will apply.
  • Approvals will be for the duration of a year.
  • Prior Authorization form
Last Modified on Jun 21, 2021
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