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Prior Authorization Criteria June 2021

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Prior Authorization Criteria June 2021 Prior Authorization Criteria June 2021 Prior Authorization Criteria The following is the listing of Prescryptive Health prior authorization criteria that will be used to evaluate prior authorization requests. Prescryptive Health’s prior authorization criteria are based on clinical monographs and National Pharmacy and Therapeutics guidelines. Prior Authorization Criteria will be updated regularly to reflect ongoing changes and is subject to change without notice. Prior Authorization Requests for Tier 4 Medications and Non-Preferred Medications Tier 4 and non-preferred medications may be authorized when there is clinical justification for doing so. Clinicians can submit a prior authorization (PA) request to initiate a review with the following steps: 1. 1. Download the Prior Authorization Request Form. This form can be found at: www.prescryptive.com/prescriber 2. Fax the completed form with supporting documentation to 1-(848) 456-5463 for both standard and urgent requests. Note: Urgent requests should be clearly labeled “URGENT” at the top of the prior authorization request form Prescryptive | PRIOR AUTHORIZATION CRITERIA | AS OF JUNE 23, 2021| 1 Prior Authorization Criteria June 2021 Contents OFF-LABEL USES ................................................................................................................. 7 STEP THERAPY EXCEPTION ............................................................................................... 8 QUANTITY LIMIT EXCEPTION .............................................................................................. 9 SAFETY EDIT EXCEPTION ..................................................................................................10 ORAL and SELF INJECTABLE ONCOLYTICS .....................................................................11 COMPOUNDED MEDICATIONS ...........................................................................................13 SHORT-ACTING ANALGESIC NARCOTICS ........................................................................14 LONG-ACTING OPIOIDS ......................................................................................................17 BUTORPHANOL (STADOL NS) ............................................................................................19 PULMONARY HYPERTENSION ............................................. Error! Bookmark not defined. DUPILUMAB (DUPIXENT) ....................................................................................................20 ACITRETIN (SORIATANE) ....................................................................................................22 SUCCIMER (CHEMET) .........................................................................................................24 DEFERASIROX (JADENU & EXJADE) & DEFERIPRONE (FERRIPROX) ...........................25 WILSON’S DISEASE .............................................................................................................27 NON-FORMULARY TEST STRIPS/QUANTITY LIMIT EXCEPTION .....................................28 NON-FORMULARY BLOOD GLUCOSE METERS................................................................30 SOMATROPIN (GROWTH HORMONE PREPARATIONS) ...................................................31 TESAMORELIN INJECTION (EGRIFTA) ..............................................................................35 OCTREOTIDE (BYNFEZIA, MYCAPSSA) & PEGVISOMANT (SOMAVERT) .......................36 TERIPARATIDE (FORTEO) ..................................................................................................38 DENOSUMAB (PROLIA & XGEVA) ......................................................................................39 ROMOSOZUMAB (EVENITY) ...............................................................................................40 MIGLUSTAT (ZAVESCA) AND ELIGLUSTAT (CERDELGA) ................................................41 DEFLAZACORT (EMFLAZA) ................................................................................................43 CONSTIPATION AGENTS ....................................................................................................45 CHOLIC ACID (CHOLBAM) ..................................................................................................47 OBETICHOLIC ACID (OCALIVA) ..........................................................................................49 THROMBOCYTOPENIA........................................................................................................50 WHITE BLOOD CELL STIMULATORS .................................................................................52 ERYTHROPOIETIN STIMULATING AGENTS (ESAs) ..........................................................54 HEREDITARY ANGIOEDEMA ..............................................................................................56 NITISINONE (ORFADIN AND NITYR)...................................................................................58 PYRIMETHAMINE (DARAPRIM) ...........................................................................................59 Prescryptive | PRIOR AUTHORIZATION CRITERIA | AS OF JUNE 23, 2021| 2 Prior Authorization Criteria June 2021 AZOLE ANTIFUNGALS .........................................................................................................60 HEPATITIS C ........................................................................................................................62 BEDAQUILINE (SIRTURO) ...................................................................................................65 SODIUM OXYBATE (XYREM) & OXYBATE SALTS (XYWAV) ..................................................66 DRUGS FOR MOVEMENT DISORDERS .............................................................................68 DEXTROMETHORPHAN/QUINIDINE (NUEDEXTA) ............................................................70 PHOSPHATE BINDERS........................................................................................................71 GLUTAMINE (ENDARI) .........................................................................................................72 HYDROXYPROGESTERONE CAPROATE (MAKENA .........................................................73 IDIOPATHIC PULMONARY FIBROSIS .................................................................................74 CYSTIC FIBROSIS................................................................................................................75 LEUKOTRIENE RECEPTOR ANTAGONISTS ......................................................................78 NARCOTIC WITHDRAWAL THERAPY AGENTS .................................................................79 NAFARELIN (SYNAREL) & ELAGOLIX (ORILISSA) .............................................................80 INGENOL (PICATO) ..............................................................................................................82 ASFOTASE ALFA (STRENSIQ) ............................................................................................83 TEDUGLITIDE (GATTEX) .....................................................................................................85 PREDNISONE DR (RAYOS) .................................................................................................86 NALOXONE AUTO-INJECTOR (EVZIO) ...............................................................................87 DROXIDOPA (NORTHERA) ..................................................................................................88 PARATHYROID HORMONE (NATPARA) .............................................................................90 METRELEPTIN (MYALEPT) .................................................................................................92 MIFEPRISTONE (KORLYM) .................................................................................................93 INTERLEUKIN 1 ANTAGONISTS .........................................................................................94 FAMILIAL HYPERCHOLESTEROLEMIA ..............................................................................97 EMICIZUMAB-KXWH (HEMLIBRA) .......................................................................................99 MIGALASTAT (GALAFOLD) ...............................................................................................102 UREA CYCLE DISORDERS ...............................................................................................104 CANNABIDIOL (EPIDIOLEX ...............................................................................................105 BELIMUMAB (BENLYSTA) ................................................................................................. 106 APOMORPHINE (APOKYN, KYNMOBI) .............................................................................108 AMIKACIN (ARIKAYCE) ......................................................................................................109 CARGLUMIC ACID (CARBAGLU) .......................................................................................110 CHENODIOL (CHENODAL) ................................................................................................111 Prescryptive | PRIOR AUTHORIZATION CRITERIA | AS OF JUNE 23, 2021| 3 Prior Authorization Criteria June 2021 BUROSUMAB-TWZA (CRYSVITA) .....................................................................................112 BETAINE (CYSTADANE) ....................................................................................................113 AMIFAMPRIDINE (RUZURGI,FIRDAPSE) ..........................................................................114
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