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Medication Prior Authorization Criteria

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Medication Prior Authorization Criteria MEDICATION PRIOR AUTHORIZATION CRITERIA These medication prior authorization criteria do not apply to drugs picked up at the pharmacy for State and Local Government members or BadgerCare Plus members. State and Local Government members should call Navitus at (866) 333-2757 or visit www.navitus.com for information about your prescription drug benefits. BadgerCare Plus members must call the Wisconsin Department of Health and Family Services at (800) 362-3002 or visit www.forwardhealth.wi.gov for information about your prescription drug benefits. PRIOR AUTHORIZATION GUIDELINES August 15, 2021 Generic Name Brand Name HICL GCN Exception/Other LASMIDITAN SUCCINATE REYVOW 46082 RIMEGEPANT SULFATE NURTEC ODT 46383 UBROGEPANT UBRELVY 46273 Acute Migraine Treatments Step Therapy Criteria Drug Name Drug Status Quantity Limits/30 Days Approval Limits Lasmiditan (Reyvow) Nonpreferred-Restricted 16 None Rimegepant (Nurtec ODT) Nonpreferred-Restricted 16 None Ubrogepant (Ubrelvy) Nonpreferred-Restricted 16 None CRITERIA FOR COVERAGE: . Trial of at least 3 of the following: sumatriptan, naratriptan, rizatriptan, eletriptan, zolmitriptan, almotriptan, frovatriptan Note: if contraindication to triptan use, trial/failure of 2 non-triptan, prescription strength analgesics that are effective for treatment of migraines by the American Headache Society treatment guidelines is required (ex. nonsteroidal anti- inflammatory drugs (NSAIDs), ergotamine derivatives, etc.) CRITERIA FOR QUANTITY EXCEPTIONS: . The requested dosing schedule cannot be met using commercially available dose forms within the quantity limit and the prescriber provides an evidence-based rationale for using a dose outside of the quantity limit . Use of all commercially available dose forms did not relieve symptoms or caused side effects . Clinical documentation supporting ≥ 2 migraine headaches per week . Documentation of current migraine headache prophylaxis treatment Revised: 7/12/2021 Page 2 Afamelanotide (Scenesse) Prior Authorization Criteria Drug Name Drug Status Quantity Limits Approval Limits Afamelanotide (Scenesse) Medical Benefit-Restricted None-implant every 2 months 12 months CRITERIA FOR COVERAGE: . Diagnosis of Erythropoietic Protoporphyria (EPP) . Adult patients . History of phototoxic reactions due to free light exposure CONTINUATION OF COVERAGE CRITERIA:* . Initial criteria met AND Clinical documentation from the previous 12 months demonstrating objective improvements in pain control related to light exposure *Continuation of therapy/coverage criteria will not be applied to persons who were not previously approved for coverage whose therapy was initiated using a manufacturer-sponsored free drug program, provider samples, and/or vouchers. Revised: 7/12/2021 Page 3 Generic Name Brand Name HICL GCN Exception/Other AGALSIDASE BETA FABRAZYME J0180 Agalsidase Beta (Fabrazyme®) Prior Authorization Criteria Drug Name Drug Status Quantity Limits Approval Limits Agalsidase Beta Medical Benefit-Restricted 1mg/kg IV infusion every two None (Fabrazyme) (Infusion) weeks CRITERIA FOR COVERAGE: . Diagnosis of Fabry's Disease . Prescribed by or in consultation of an expert in the treatment of Fabry's Disease . Will not be used in combination with migalastat Revised: 7/12/2021 Page 4 Alglucosidase alfa (Myozyme/Lumizyme) Prior Authorization Criteria Drug Name Drug Status Quantity Limits Approval Limits Alglucosidase alfa Medical Benefit-Restricted None None (Myozyme, Lumizyme) CRITERIA FOR COVERAGE: . Covered for persons with a diagnosis of Pompe disease Revised: 7/12/2021 Page 5 Generic Name Brand Name HICL GCN Exception/Other ALOSETRON HCL LOTRONEX 20953 Alosetron Prior Authorization Criteria Drug Name Drug Status Quantity Limits Approval Limits Alosetron HCL (Lotronex) Nonpreferred-Restricted 0.5mg-#90/30 days None 1mg-#60/30 days CRITERIA FOR COVERAGE: . Person with diarrhea- predominant irritable bowel syndrome (IBS) . Prescribed by physician certified in the alosetron REMS Program . Failed one-month trial of conventional therapy (such as loperamide or diphenoxylate/atropine) CRITERIA FOR COVERAGE OF QUANTITY EXCEPTIONS: . Therapeutic failure or intolerance to use of the commercially available dose forms within the quantity limits and the prescriber provides an evidence-based clinical rationale or use of a dose outside of the quantity limit CONTINUATION OF COVERAGE CRITERIA:* . Persons new to coverage who are established on therapy will have coverage under their drug benefit for the remainder of the current treatment course. Restrictions to specific network pharmacies and participation in medication management programs may apply. *Continuation of therapy/coverage criteria will not be applied to persons who were not previously approved for coverage whose therapy was initiated using a manufacturer-sponsored free drug program, provider samples, and/or vouchers. Revised: 7/12/2021 Page 6 Alpha1 Proteinase Inhibitors (Aralast NP, Glassia, Prolastin-C, Zemaira) Prior Authorization Criteria Drug Name Drug Status Quantity Limits Approval Limits Alpha-1 Proteinase inhibitor Medical Benefit-Restricted None None (Aralast NP, Glassia, Prolastin-C, Zemaira) CRITERIA FOR COVERAGE: . Alpha-1 proteinase deficient (< 11 mcmol/L) . Evidence of COPD (FEV1 25% to 80% predicted) attributable to emphysema . Person is no longer smoking . Maximized COPD therapy based on GOLD guidelines Revised: 7/12/2021 Page 7 Generic Name Brand Name HICL GCN Exception/Other AMIFAMPRIDINE FIRDAPSE 36930 AMIFAMPRIDINE RUZURGI 46265 Amifampridine (Firdapse, Ruzurgi) Prior Authorization Criteria Drug Name Drug Status Quantity Limit/Day Approval Limits Amifampridine (Firdapse) Nonpreferred-Restricted 8 12 Months Amifampridine (Ruzurgi) Nonpreferred-Restricted 8 12 Months CRITERIA FOR COVERAGE: . Diagnosis of Lambert-Eaton myasthenic syndrome (LEMS) confirmed by neurophysiology studies or a positive anti-P/Q type voltage-gated calcium channel antibody test . Prescribed by or in consult with an expert in the treatment of neuromuscular disorders CRITERIA FOR QUANTITY EXCEPTIONS: . The prescriber provides an evidence-based clinical reason for using a dose outside of the quantity limits CRITERIA FOR CONTINUATION OF COVERAGE:* . Documentation from the previous 12 months of therapy indicating improvement or stabilization in muscle weakness compared to baseline. For members new to plan, the prescriber must provide clinical documentation from the previous 12 months regarding the member's response to therapy with improvement or stabilization in muscle weakness compared to baseline. *Continuation of therapy/coverage criteria will not be applied to persons who were not previously approved for coverage whose therapy was initiated using a manufacturer-sponsored free drug program, provider samples, and/or vouchers. FOR BADGERCARE COVERAGE: Medication must be billed to ForwardHealth under the pharmacy benefit. Refer to the ForwardHealth policy “Select High Cost, Orphan, and Accelerated Approval Drugs” for additional information. Revised: 7/12/2021 Page 8 Generic Name Brand Name HICL GCN Exception/Other AMIKACIN LIPOSOMAL/NEB ARIKAYCE 45435 Amikacin Inhaled (Arikayce) Prior Authorization Criteria Drug Name Drug Status Quantity Limits/Day Approval Limits Amikacin inhaled (Arikayce) Nonpreferred-Restricted 1 Initial: 6 months Renewal: 12 months x1 CRITERIA FOR COVERAGE: . Covered for adults with Mycobacterium avium complex (MAC) lung disease . Prescribed by, or in consultation with, an Infectious Disease expert . Documentation of positive sputum cultures despite at least 6 months of multidrug background guideline-based therapy . Used in combination with guideline-based therapy CRITERIA FOR QUANTITY EXCEPTIONS: . Prescriber provides an evidence-based clinical rationale for using a dose outside of the quantity limit CRITERIA FOR CONTINUATION/RENEWAL:* . Initial criteria were met . Person achieves and/or maintains negative sputum culture status by month 6 *Continuation therapy/coverage criteria will not be applied to persons who were not previously approved for coverage whose therapy was initiated using a manufacturer-sponsored free drug program, provider samples, and/or vouchers. Revised: 7/12/2021 Page 9 Generic Name Brand Name HICL GCN Exception/Other AMLODIPINE SUSPENSION KATERZIA 46652 Amlodipine (Katerzia) Suspension Prior Authorization Criteria Drug Name Drug Status Quantity Limits/Day Approval Limits Amlodipine 1mg/ml Suspension Preferred-Restricted N/A 12 months CRITERIA FOR COVERAGE: . Unable to tolerate solid dose form . Age < 12 years of age CRITERIA FOR RE-APPROVAL/CONTINUATION OF THERAPY:* . Criteria for coverage met. Prescriber provides clinical documentation from the previous 12 months that describes the person’s response as improved while on therapy. *Continuation of therapy/coverage criteria will not be applied to persons who were not previously approved for coverage whose therapy was initiated using a manufacturer-sponsored free drug program, provider samples, and/or vouchers. Revised: 7/12/2021 Page 10 Generic Name Brand Name HICL GCN Exception/Other ANAKINRA KINERET 22953 Anakinra (Kineret) Prior Authorization Criteria Drug Name Drug Status Quantity Limits/Day Approval Limits Anakinra (Kineret) Nonpreferred-Restricted 1 12 months CRITERIA FOR COVERAGE (prescription benefit): . Prescribed by or in consultation with a Rheumatologist . Medication must be self-administered . Not used in combination . A diagnosis of moderate to severely active rheumatoid arthritis (RA), reactive arthritis, juvenile idiopathic arthritis
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