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Special Formulations

Absorica LD™ (Isotretinoin Capsule) Approval Criteria:

  •  An FDA approved diagnosis of severe recalcitrant nodular acne in non-pregnant patients 12 years of age and older with multiple inflammatory nodules with a diameter of 5mm or greater; AND
  • Absorica LD™ is not covered for members older than 20 years of age; AND
  • Prescriber must verify member is enrolled in the iPLEDGE REMS program; AND
  • Prescriber must verify lipid profile and liver function tests will be monitored prior to initiation of Absorica LD™ and at regular intervals during treatment in accordance with the prescribing information; AND
  • A patient-specific, clinically significant reason why the member cannot use other isotretinoin capsules available without prior authorization must be provided; AND
  • A recent patient weight must be provided on the prior authorization request in order to authorize the appropriate amount of medication according to drug labeling.

Approval Criteria:

  • An FDA approved indication to increase tear production in patients with keratoconjunctivitis sicca (dry eye); AND
  • A patient-specific, clinically significant reason why the member cannot use Restasis® (cyclosporine 0.05% ophthalmic emulsion), which is available without a prior authorization, must be provided; AND
  • A quantity limit of 60 single-use vials (1 box) per 30 days will apply. 

Prior Authorization form

Erythromycin 2% Swabs and 2% Topical Gel Approval Criteria:

  • A patient-specific, clinically significant reason why the member cannot use erythromycin 2% topical solution must be provided

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

levoleucovorin injection (Khapzory™) Approval Criteria:  

  • An FDA approved indication of 1 of the following:
    • Rescue after high-dose methotrexate (MTX) therapy in patients with osteosarcoma; OR  
    • Diminishing the toxicity associated with overdosage of folic acid antagonists or impaired MTX elimination; OR
    • Treatment of patients with metastatic colorectal cancer in combination with fluorouracil; AND  
  • A patient-specific, clinically significant reason why the member cannot use generic leucovorin injection or generic levoleucovorin calcium injection must be provided.  

Prior Authorization form

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

Pyridostigmine 30mg Tablet Approval Criteria:

  • A patient-specific, clinically significant reason why the member cannot use pyridostigmine 60mg tablets, which are available without prior authorization, must be provided.

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

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

Slynd™ (Drospirenone Tablet) Approval Criteria:

  • A patient-specific, clinically significant reason why the member cannot use alternative formulations of hormonal contraceptives, which are available without a prior authorization, must be provided.

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

Talicia® (Omeprazole/Amoxicillin/Rifabutin Capsule) Approval Criteria:

  • An FDA approved diagnosis; AND
  • A patient-specific, clinically significant reason why the member cannot use the individual components of other triple-therapy treatments approved for the same diagnosis (e.g., omeprazole, amoxicillin, and clarithromycin), which are available without prior authorization, must be provided; AND
  • A quantity limit of 168 capsules per 14 days will apply.

dexamethasone tablet (TaperDex™) Approval Criteria:

  • A patient-specific, clinically significant reason why the member cannot use dexamethasone 1.5mg individual tablets, which are available without a prior authorization, must be provided.  

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 capsule and oral solution (Tirosint® and 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 must be provided. For the oral solution, a reason why the member cannot use the levothyroxine tablet formulation, even when the tablets are crushed, must be provided; AND
  • Prescriber must verify member has been compliant with levothyroxine tablets at a maximum dose for at least 8 weeks; AND
  • Prescriber must verify that member has not been able to achieve normal thyroid lab levels despite maximum dosing and compliance with levothyroxine tablets.  

Prior Authorization form

Xiidra® (Lifitegrast) Approval Criteria:

  • Member must be 17 years of age or older and have an FDA approved diagnosis of dry eye disease (DED); AND
  • Prescriber must verify that environmental factors (e.g. humidity, fans) have been addressed; AND
  • Member must have trials with at least 3 over-the-counter (OTC) products for 3 days in the last 30 days that failed to relieve signs and symptoms of dry eyes; AND
  • A patient-specific, clinically significant reason why the member cannot use Restasis® (cyclosporine ophthalmic emulsion), which is available without a prior authorization; AND
  • A quantity limit of 2 vials per day will apply.

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

If you have questions please call the Pharmacy Help Desk at (800) 522-0114 option 4 or (405) 522-6205 option 4.

Last Modified on Mar 29, 2021
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