Special Formulations

PA criteria:

Veripred™ 20 (Prednisolone Sodium Phosphate Oral Solution 20mg/5mL) and Millipred™ (Prednisolone Sodium Phosphate Oral Solution 10mg/5mL) Approval Criteria: 

• Authorization of Veripred™ 20 or Millipred™ requires a patient-specific, clinically significant reason why the member cannot use a tablet or an alternative strength liquid formulations.

Prior Authorization form

nitroglycerin sublingual powder (GoNitro™) Approval Criteria:

• An FDA approved indication of acute relief of an attack or prophylaxis of angina pectoris due to coronary artery disease; AND
  
• A patient-specific, clinically significant reason why the member cannot use nitroglycerin sublingual tablets or nitroglycerin lingual spray.
  

Prior Authorization form

tamoxifen citrate 10mg/5mL oral solution (Soltamox®) Approval Criteria:

• An FDA approved indication of one of the following:
  
  • Treatment of metastatic breast cancer in women and men; OR
    
  • Adjuvant treatment of node-positive breast cancer in postmenopausal women and for the adjuvant treatment of axillary node-negative breast cancer in women following total mastectomy or segmental mastectomy, axillary dissection, and breast irradiation; OR
    
  • The reduction in risk of invasive breast cancer in women with ductal carcinoma in situ (DCIS), following breast surgery and radiation; OR
    
  • To reduce the incidence of breast cancer in women at high risk for breast cancer; AND
    
   
• A patient-specific, clinically significant reason why the member cannot use tamoxifen tablets.
  

Prior Authorization form           

Ximino™ (minocycline extended-release) Approval Criteria: 

• An FDA approved diagnosis of inflammatory lesions of non-nodular moderate to severe acne vulgaris; AND
• Member must be 12 years of age or older; AND
• Ximino™ is not covered for members older than 20 years of age; AND
• A patient-specific, clinically significant reason why the member cannot use the immediate-release capsule formulation or and/or other cost effective therapeutic equivalent medication(s).

Prior Authorization form

norethindrone acetate/ethinyl estradiol capsules & ferrous fumarate capsules (Taytulla™) Approval Criteria:

• An FDA approved indication to prevent pregnancy in women; AND
• A patient-specific, clinically significant reason why the member cannot use all other generic formulations of norethindrone acetate/ethinyl estradiol tablets with ferrous fumarate tablets. 

Prior Authorization form

levothyroxine sodium oral solution (Tirosint®-SOL) Approval Criteria:  

• An FDA approved diagnosis of one of the following:
  
  • Hypothyroidism: As replacement therapy in primary (thyroidal), secondary (pituitary), and tertiary (hypothalamic) congenital or acquired hypothyroidism; OR
  • Pituitary Thyrotropin (Thyroid-Stimulating Hormone, TSH) Suppression: As an adjunct to surgery and radioiodine therapy in the management of thyrotropin-dependent well-differentiated thyroid cancer; AND
   
• A patient-specific, clinically significant reason why the member cannot use all other formulations of levothyroxine sodium in the place of oral solution even when tablets are crushed.

Prior Authorization form  

Approval Criteria:

• An FDA approved indication of nasal polyps in adults 18 years of age and older who have had ethmoid sinus surgery; AND
• Date of ethmoid sinus surgery must be provided; AND
• Sinuva™ must be prescribed and implanted by a physician specializing in otolaryngology; AND
• Failure of intranasal corticosteroids after at least a three month trial at the maximum recommended dose in combination with a 14-day trial of oral corticosteroids within the last six months (if not contraindicated); AND
• Prescriber must confirm the member has recurrent nasal obstruction/congestion symptoms and recurrent bilateral sinusitis or chronic sinusitis due to nasal polyps; AND
• A quantity limit of 2 implants per member will apply. 

Prior Authorization form

Approval Criteria:

• An FDA approved diagnosis of osteoarthritis (OA) pain of the knee; AND
• Zilretta™ will only be approvable for use in the knee(s) for OA pain; AND
• A patient-specific, clinically significant reason why the member cannot use Kenalog-40® (triamcinolone acetonide 40mg injection) and Depo-Medrol® (methylprednisolone injection) must be provided.
• A quantity limit of 1 injection per knee per 12 weeks will apply. 

Prior Authorization form

Approval Criteria:

• A patient-specific, clinically significant reason why the member cannot use Restasis® in the individual dosage formulation (single-use vials) must be provided.

Prior Authorization form