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Oregon Medicaid Pharmaceutical Services Prior Authorization Criteria

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Oregon Medicaid Pharmaceutical Services Prior Authorization Criteria Oregon Medicaid Pharmaceutical Services Prior Authorization Criteria HEALTH SYSTEMS DIVISION Prior authorization (PA) criteria for fee-for-service prescriptions for Oregon Health Plan clients March 1, 2021 Contents Contents ................................................................................................................................................................ 2 Introduction........................................................................................................................................................... 7 About this guide ......................................................................................................................................... 7 How to use this guide ................................................................................................................................. 7 Administrative rules and supplemental information .................................................................................. 7 Update information............................................................................................................................................... 8 Effective March 1, 2021 ............................................................................................................................ 8 Substantive updates and new criteria ............................................................................................. 8 Clerical changes ............................................................................................................................. 8 General PA information ....................................................................................................................................... 8 Overview .................................................................................................................................................... 8 Drugs requiring PA - See OAR 410-121-0040 for more information ....................................................... 9 DUR Plus review ....................................................................................................................................... 9 How to request PA ..................................................................................................................................... 9 For prescriptions and oral nutritional supplements ........................................................................ 9 For emergent or urgent prescriptions that require PA ................................................................... 9 For diabetic supplies (lancets, test strips, syringe and glucose monitor supplies) ....................... 10 Client hearings and exception requests .................................................................................................... 10 DMAP 3978 - Pharmacy Prior Authorization Request............................................................................ 10 Information needed to request PA ............................................................................................... 11 PA criteria for fee-for-service prescriptions .................................................................................................... 14 About the PA criteria ............................................................................................................................... 14 Contact for questions about PA policy .................................................................................................... 14 Acne Medications ............................................................................................................................................... 15 Amifampridine .................................................................................................................................................... 16 Amikacin Liposome Inhalation Suspension .................................................................................................... 19 Analgesics, Non-Steroidal Anti-Inflammatory Drugs ...................................................................................... 21 Oregon Medicaid PA Criteria 2 March 1, 2021 Antiemetics ......................................................................................................................................................... 22 Antifungals .......................................................................................................................................................... 24 Antihistamines .................................................................................................................................................... 28 Antimigraine – Serotonin Agonists .................................................................................................................. 30 Anti-Parkinson’s Agents .................................................................................................................................... 33 Antiplatelets ........................................................................................................................................................ 35 Antivirals - Influenza .......................................................................................................................................... 37 Antivirals for Herpes Simplex Virus ................................................................................................................. 39 Atopic Dermatitis and Topical Antipsoriatics .................................................................................................. 41 Attention Deficit Hyperactivity Disorder (ADHD) Safety Edit ......................................................................... 44 Drugs for Transthyretin-Mediated Amyloidosis (ATTR) ................................................................................. 47 Becaplermin (Regranex®) .................................................................................................................................. 50 Belimumab (Benlysta®) ...................................................................................................................................... 51 Bempedoic Acid ................................................................................................................................................. 54 Benign Prostatic Hypertrophy (BPH) Medications .......................................................................................... 58 Benzodiazepines ................................................................................................................................................ 60 Bezlotoxumab (Zinplava™) ............................................................................................................................... 64 Biologics for Autoimmune Diseases ................................................................................................................ 65 Bone Metabolism Agents................................................................................................................................... 73 Botulinum Toxins ............................................................................................................................................... 77 Brexanolone (Zulresso) ..................................................................................................................................... 81 Buprenorphine and Buprenorphine/Naloxone ................................................................................................ 82 Calcium and Vitamin D Supplements ............................................................................................................... 83 Cannabidiol ......................................................................................................................................................... 84 Cenegermin-bkbj (Oxervate™) .......................................................................................................................... 87 Calcitonin Gene-Related Peptide (CGRP) antagonists ................................................................................... 88 Cholic Acid (Cholbam™) .................................................................................................................................... 92 Clobazam............................................................................................................................................................. 94 Codeine ............................................................................................................................................................... 95 Conjugated Estrogens/Bazedoxifene (Duavee®) ............................................................................................. 96 Drugs for Constipation ...................................................................................................................................... 98 Cough and Cold Preparations ......................................................................................................................... 100 Cysteamine Delayed-release (PROCYSBI®) ................................................................................................... 101 Oral Cystic Fibrosis Modulators ..................................................................................................................... 102 Dalfampridine...................................................................................................................................................
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