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Skeletal System

 

NSAIDs

PA Criteria:

Tier 1 products are covered with no authorization necessary.

Tier 2 authorization criteria:

  • Previous use of at least two Tier 1 NSAIDs (from different product lines) plus a PPI within the last 120 days, or
  • For those with prior GI bleed who must have an NSAIDs, a Tier 2 product may be approved (Celebrex should also be taken with a PPI)

Special PA approval criteria:

  • A unique indication for which a Tier-1 or Tier-2 medication is not appropriate, such as the diagnosis of gout for indomethacin; or
  • Previous use of at least two Tier-1 NSAID products (from different product lines); and 
  • A patient-specific, clinically significant reason why a special formulation is needed over a Tier-1 product.
  • Additionally, use of Tivorbex™ will require a patient-specific, clinically significant reason why member cannot use other available generic indomethacin products. 

Meloxicam suspension for members older than 7 years of age will require a prior authorization.  A prior authorization request can be submitted for members older than 7 years of age requiring meloxicam suspension.  A reason why the member needs the liquid formulation and cannot use the oral tablet formulation should be provided with the prior authorization request.

NOTE: In order for previously utilized Tier 1 medications to count as trials toward a Tier 2 authorization, the member's NSAID therapy must have been continuous. Dates and dosing information for Tier 1 trials must be included on petition for authorization. Trials with OTC formulations of Tier 1 products must be dosed at full prescription strength.

Prior Authorization form

Tier 1

Tier 2

Special PA
  • diclofenac sodium (Voltaren®)
  • diclofenac potassium (Cataflam®)
  • diclofenac ER (Voltaren XR®)
  • etodolac (Lodine®) 400mg and 500mg tabs
  • flurbiprofen (Ansaid®)
  • ibuprofen (Motrin®)
  • ketoprofen (Orudis®)
  • meloxicam (Mobic®)
  • nabumetone (Relafen®)
  • naproxen (Naprosyn®)
  • naproxen EC (Naprosyn EC®)
  • sulindac (Clinoril®)
  • celecoxib (Celebrex®)
  • diclofenac sodium/misoprostol (Arthrotec®)
  • etodolac (Lodine®) 200mg and 300mg cap
  • etodolac ER (Lodine XL®)
  • fenoprofen (Nalfon®)
  • meclofenamate (Meclomen®)
  • naproxen sodium (Anaprox®) 275mg and 550mg tabs
  • oxaprozin (Daypro®)
  • piroxicam (Feldene®)
  • tolmetin (Tolectin®)
  • diclofenac (Zorvolex™)
  • diclofenac epolamine (Flector®)
  • diclofenac potassium (Zipsor®, Cambia®)
  • diclofenac injection (Dyloject™)
  • diclofenac sodium gel (Voltaren Gel®)
  • diclofenac sodium drops (Pennsaid®)
  • ibuprofen/famotidine (Duexis®)
  • indomethacin (Tivorbex™)
  • ketoprofen ER (Oruvail®)
  • mefanamic acid (Ponstel®)
  • meloxicam capsules (Vivlodex™)
  • naproxen sodium (Naprelan®)
  • naproxen/esomeprazole (Vimovo®)

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Gout    

colchicine capsules (Mitigare™) and colchicine tablets (Colcrys®) Approval Criteria:

  • A quantity of six tablets for a three day supply is available without prior authorization for treatment of acute gouty attacks; AND
  • Failure of allopurinol after six months of treatment defined by persistent gouty attacks with serum urate levels greater than 6.0mg/dL; AND
  • Patient-specific, clinically significant reason why colchicine/probenecid would not be a viable option for the member.
  • A quantity limit of 60 tablets per 30 days will apply for gout.  
  • Members with the diagnosis of Familial Mediterranean Fever verified by genetic testing will be approved for up to 2.4mg per day.

Prior Authorization form   

febuxostat (Uloric®) Approval Criteria:

  • Failure of allopurinol defined by persistent gouty attacks with serum urate levels greater than 6.5mg/dL.
  • Clinical reason why allopurinol is not a viable option for the member.
  • Quantity limit of #30 per 30 days will apply.

Prior Authorization form

lesinurad (Zurampic™) Approval Criteria:

  • Member must be 18 years of age or older; AND
  • An FDA approved diagnosis of gout in patients who have not achieved target serum uric acid (sUA) levels with a xanthine oxidase inhibitor (XOI) alone;AND
  • Failure of allopurinol or febuxostat alone defined by serum urate levels greater than 6.0mg/dL; AND
  • Prescriber must verify that member has a creatinine clearance greater than 45mL/min prior to initiating treatment and for continued approval; AND
  • Prescriber must verify that member will take Zurampic™ concomitantly with a XOI; AND
  • Prescriber must document member is not taking more than 325mg of aspirin per day and member is not taking any epoxide hydrolase inhibitors; AND 
  • Prescriber must document member has no contraindications for use of Zurampic™ including any of the following: Tumor lysis syndrome or Lesch-Nyhan syndrome, severe renal impairment (CrCl less than 30mL/min), end stage renal disease, kidney transplant recipients, or patients on dialysis.
  • A quantity limit of one tablet daily will apply.

Prior Authorization form

   

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Skeletal Muscle Relaxants

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.
  • Prior Authorization form

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
  • chlorzoxazone (Lorzone™)
  • carisoprodol (Soma®) 250mg, 350mg
  • tizanidine (Zanaflex®) Caps
Soma

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.
  • Prior Authorization form
Amrix and Fexmid

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.
  • Prior Authorization form
Zanaflex

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
  • Prior Authorization form

Lorzone™

PA Criteria:

  • Generic chlorzoxazone 500mg tablets must be tried prior to consideration of Lorzone™; AND 
  • A patient-specific, clinically significant reason why the member cannot use generic chlorzoxazone 500mg tablets must be provided; AND
  • The following quantity limits apply:
    • Lorzone™ 375mg tablets: 120 tablets for 30 days
    • Lorzone™ 750mg tablets: 120 tablets for 30 days
  • Prior Authorization form  

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Osteoporosis

Tier 1 products are available with no authorization necessary.

PA Criteria:

*Calcitonin and raloxifene are not included as Tier-1 trials.

  • Must be used at recommended doses in conjunction with Tier-1 bisphosphonate for trial to be accepted unless member has a recent laboratory result showing adequate Vitamin D or member is unable to tolerate calcium. OTC Calcium and Vitamin D are only covered for members with osteoporosis. See a list of covered calcium products.


Criteria for Moving to Higher Tiers:

  • Treatment failure with all lower tiered products, or
  • Contraindication to all lower tiered products, or
  • Allergic reaction to all lowered tiered products, or
  • Specific indication not covered by a lower tiered product.
  • No concomitant use of bisphosphonate therapy will be approved.  No additional bisphosphonate therapy may be approved for 365 days following zoledronic acid infusion.

Clinical Exceptions/Additional Criteria:

  • Risedronate may be approved for members with high risk for gastric side effects.
  • Zoledronic acid may be approved for members with a diagnosis of Paget’s disease or for osteoporosis if secondary diagnosis meets criteria below:
  • Severe esophageal disease (e.g., ulcerations, strictures)
  • Inability to take anything by mouth
  • Inability to sit or stand for prolonged periods
  • Inability to take an oral bisphosphonate for other special medical circumstances that justify the method of administration

Tier 1

Tier 2

Special Criteria Apply
  • alendronate (Fosamax®)
  • calcium + vitamin D
  • alendronate +D (Fosamax +D®)
  • lbandronate (Boniva®)
  • risedronate (Actonel®)
  • alendronate (BinostoTM )
  • conjugated estrogens/bazedoxifene (Duavee®)
  • denosumab (Prolia®)
  • ibandronate (BonivaTM IV)
  • risedronate 30mg Tabs (Actonel®)
  • risedronate delayed release (Atelvia®)
  • teriparatide (Forteo®)
  • zoledronic acid (Reclast®)
                                                                                                                          teriparatide (Forteo®)

PA Criteria: 

  • A Bone Mineral Density test (T-score at or below -2.5) within the last month, AND
  • A minimum 12 month trial with a bisphosphonate plus adequate calcium and vitamin D, OR
  • A 12 month trial of Prolia™ (Denosumab), unless contraindicated, intolerant, or allergic, that did not yield adequate results. Quantity Limits apply bases on FDA maximum doses. 

Prior Authorization form
denosumab (Xgeva®) *Medical billing only

Consideration for approval will be based on the following criteria:

  • An FDA approved indication of one of the following:
    • Prevention of skeletal-related events in patients with bone metastases from solid tumors; OR
    • Treatment of adults and skeletally mature adolescents with giant cell tumor of the bone (GCTB) that is unresectable or where surgical resection is likely to result in severe morbidity; OR
      • Prescriber must document that tumor is unresectable or that surgical resection is likely to result in severe morbidity.
    • Treatment of hypercalcemia of malignancy refractory to bisphosphonate therapy.
      • Member must have albumin-corrected calcium of greater than 12.5 mg/dL (3.1 mmol/L) despite treatment with intravenous bisphosphonate therapy in the last 30 days prior to initiation of Xgeva® therapy.  

ProliaTM, Reclast® , Boniva® , IV requires

Prior Authorization Criteria:

  • A minimum 12 month trial with a Tier 1 or Tier 2 bisphosphonate plus adequate calcium and vitamin D, or
  • Contraindication to or intolerable adverse effects with Tier 1 and Tier 2 products.
  • Clinical exceptions may apply for members with
    • Severe esophageal disease (e.g., ulcerations, strictures)
    • Inability to take anything by mouth
    • Inability to sit or stand for prolonged periods
    • Inability to take bisphosphonates orally for other special medical circumstances that justify the method of administration

Prior Authorization form
conjugated estrogens/bazedoxifene (Duavee®)

Consideration for approval will be based on the following criteria:

  • An FDA approved diagnosis of moderate to severe vasomotor symptoms associated with menopause or for prevention of postmenopausal osteoporosis;AND
  • Member must be a female with an intact uterus; AND
  • For a diagnosis of moderate to severe vasomotor symptoms associated with menopause:
    • Member must have at least 7 moderate to severe hot flushes per day or at least 50 per week prior to treatment; AND
  • For a diagnosis of prevention of postmenopausal osteoporosis:
    • A trial of Fosamax® (alendronate), Actonel® (risedronate), Boniva® (ibandronate) or Reclast® (zoledronic acid) compliantly used for at least 6 months concomitantly with calcium + vitamin D, that failed to prevent fracture or improve BMD scores; OR
    • Contraindication to, hypersensitivity to, or intolerable adverse effects with all bisphosphonates indicated for prevention of postmenopausal osteoporosis; and
  • Member must not have any of the contraindications for use of Duavee®; AND
  • Members greater than 65 years of age will generally not be approved without supporting information.
  • Approvals will be for the duration of 6 months to ensure the need for continued therapy is reassessed periodically and the medication is being used for the shortest duration possible.
  • A quantity limit of 30 tablets per 30 days will apply.
Last Modified on Dec 02, 2020
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