DRUGS REQUIRING PREAUTHORIZATION
The table below outlines the medications requiring a review by the Clinical Pharmacist, and if necessary, a Health Alliance Medical Director. If a provider wished for coverage of a drug designated as preauthorization required (PA), they must provide documentation to meet criteria for that particular medication. Provider must request prior authorization from Health Alliance for drugs on the following list:
Drug Class Drug Name Comments ASTHMA/ COPD Advair® (fluticasone-salmeterol) See Non-Preferred ICS/LABA Combination Breo™ Ellipta® (fluticasone-vilanterol) Inhalers policy Arnuity™ Ellipta® (fluticasone- See Non-Preferred ICS Inhalers policy salmeterol) ArmonAir™ RespiClick® (fluticasone propionate) Daliresp® (roflumilast) See Daliresp policy
BEHAVIORAL Dyanavel™ XR (amphetamine Member aged 6 to 12; documentation of HEALTH: suspension) inability to swallow tablets for members ADHD Quillichew® ER (methylphenidate ER) older than 12 Quillivant XR® (methylphenidate suspension) Vyvanse® chewable (lisdexamfetamine) BEHAVIORAL desvenlafaxine ER See Behavioral Health policy; HEALTH: Fetzima™ (levomilnacipran ER) two Tier 1 SSRIs and two Tier 1 SNRIs Antidepressants Khedezla™ (desvenlafaxine ER) (duloxetine and venlafaxine/venlafaxine ER) Pristiq® (desvenlafaxine) Trintellix® (vortioxetine) Viibryd® (vilazodone) BEHAVIORAL aripiprazole See Behavioral Health policy; HEALTH: Rexulti® (brexpiprazole) as adjunct therapy for Major Depressive Atypical Disorder: TWO Tier 1 SSRIs, AND TWO Tier Antipsychotics 1 SNRIs; for Bipolar Disorder and Schizophrenia: TWO of the following: olanzapine, quetiapine, risperidone or ziprasidone Fanapt® (iloperidone) See Behavioral Health policy; Latuda® (lurasidone) for Bipolar Disorder and Schizophrenia: paliperidone TWO of the following: olanzapine, quetiapine ER quetiapine, risperidone or ziprasidone Saphris® (asenapine) Vraylar™ (cariprazine) BEHAVIORAL Nuplazid™ See Nuplazid policy HEALTH: Parkinson’s Disease Psychosis
continued on next page Drug Class Drug Name Comments CARDIOVASCULAR: Entresto™ (sacubitril/valsartan) See Entresto policy ARNI CARDIOVASCULAR: omega-3-acid ethyl esters See Fish Oil (Lovaza and Vascepa) policy Lipotropics Vascepa® (icosapent ethyl) CARDIOVASCULAR: phenoxybenzamine See phenoxybenzamine policy Miscellaneous Agents CARDIOVASCULAR: Altoprev® (lovastatin ER) See Brand Name Statin policy Statins Lescol® XL (fluvastatin) Livalo® (pitavastatin) Zypitamag™ (pitavastatin) CENTRAL NERVOUS Qudexy™ XR (topiramate ER) See Qudexy XR and Trokendi policy SYSTEM: Trokendi™ XR (topiramate ER) Anticonvulsants DERMATOLOGY: Aczone® (dapsone) Documentation of acne vulgaris; trial of two Miscellaneous Agents Azelex® (azelaic acid) Tier 1 agents Picato® (ingenol mebutate) Documentation of a non-cosmetic diagnosis tazarotene (acne, actinic keratosis, etc.); trial of two Tier Tazorac® (tazarotene) 1 agents Eucrisa® (crisaborole) Documentation of mild to moderate atopic dermatitis; trial of topical corticosteroid; trial of tacrolimus ointment or Elidel Finacea® (azelaic acid) Documentation of rosacea; trial of doxycline Mirvaso® (brimonidine) and metronidazole cream, gel or lotion Rhofade™ (oxymetazoline) Soolantra® (ivermectin) DIABETES: alogliptin See Diabetes Drug Therapies policy DPP4 (Dipeptidyl/ alogliptin/ pioglitazone Peptidase IV) alogliptin/ metformin Kazano™ (alogliptin/ metformin) Kombiglyze™ (saxagliptin/ metformin) Kombiglyze™ XR (saxagliptin- metformin ER) Nesina™ (alogliptin) Onglyza® (saxagliptin) Oseni™ (alogliptin/ pioglitazone) DIABETES: Adlyxin™ (lixisenatide) See Diabetes Drug Therapies policy GLP-1 (Glucagon-like Bydureon® (exenatide) peptide-1) Bydureon® BCise (exenatide multidose) Byetta® (exenatide) Ozempic® (semaglutide) Trulicity™ (dulaglutide) Victoza® (liraglutide) DIABETES: Soliqua™ (insulin glargine and See Diabetes Drug Therapies policy Long-Acting Insulin/ lixisenatide) GLP-1 (Glucagon- Xultophy® (insulin degludec and like peptide-1) liraglutide) Combination Products DIABETES, MISC. Regranex® (becaplermin) Diagnosis of diabetic ulcers with failure on conventional therapy (dressings, soaks, debridement, etc.)
continued on next page Drug Class Drug Name Comments DIABETES: Farxiga™ (dapagliflozin) See Diabetes Drug Therapies policy SGLT-2 (Sodium Xigduo™ XR (dapagliflozin/metformin) glucose co-transporter Segluromet™ (ertugliflozin/metformin) 2 inhibitor) Steglatro™ (ertugliflozin) DIABETES: Glyxambi® (empagliflozin/linagliptin) See Diabetes Drug Therapies policy SGLT-2/DPP4 Qtern® (dapagliflozin/saxagliptin) Combination Products Steglujan™ (ertugliflozin/sitagliptin) ENDOCRINE: Veltassa® (patiromer) See Veltassa policy Potassium Binders ENDOCRINE: All testosterone and testosterone- Use in females requires prior authorization; Testosterone containing medications see Testosterone (Implantable, Topical, Oral, Replacement Therapy and Nasal) policy ENDOCRINE: Androderm® (testosterone transdermal) See Testosterone (Implantable, Topical, Oral, Testosterone Androgel® (testosterone gel) and Nasal) policy Replacement Axiron® (testosterone topical) Fortesta® (testosterone gel) Natesto™ (testosterone nasal) Striant® (testosterone buccal) Testim® (testosterone gel) ENDOCRINE: doxercalciferol See doxercalciferol policy Vitamin D Analogs GOUT AGENTS Duzallo® (lesinurad/allopurinol) See Zurampic and Duzallo policy Zurampic® (lesinurad)
HEMATOLOGICAL Mircera® (methoxy polyethylene glycol- PA required for oncology indication DISORDER epoetin beta)
INFECTIOUS Xifaxan® (rifaximin) See Xifaxan policy DISEASE: Antibacterial, Misc LOWER GI Relistor® (methylnaltrexone) See Relistor policy for opioid induced DISORDERS: constipation Narcotic antagonists LOWER GI Fulyzaq™ (crofelemer) See Fulyzaq policy DISORDERS: other NEUROLOGY: Botox® (onabotulinumtoxinA) See Botox policy Botulinum toxins Myobloc® (rimabotulinumtoxinB) See Myobloc policy Xeomin® (incoboluminumtoxinA) See Xeomin policy NEUROLOGY: Gralise® (gabapentin ER) See Gabapentin Coverage Requirement GABA analogs Horizant® (gabapentin ER) policy; FDA label diagnosis specific to product, and trial of Gabapentin Lyrica® (pregabalin) See Lyrica policy NEUROLOGY: Savella® (milnacipran) Trial of TCA, muscle relaxant, gabapentin, Fibromyalgia agents duloxetine, and non-pharmacologic therapy
continued on next page Drug Class Drug Name Comments ONCOLOGY capecitabine PA follows NCCN Oncology Pathways cyclophosphamide guidance Emcyt® (estramustine) etoposide oral Fareston® (toremifene) flutamide Hexalen® (altretamine) Leukeran™ (chlorambucil) Lysodren™ (mitotane) melphalan topotecan tretinoin PAIN Abstral® (fentanyl sublingual tablet) See Fentanyl® Oral Dosage Formulation MANAGEMENT: fentanyl citrate lozenge policy; limited to cancer diagnosis and Analgesics, Narcotics Fentora® (fentanyl citrate) inability to swallow and concurrent long Onsolis® (fentalyl buccal film) acting agent requiring breakthrough agent Subsys® (fentanyl sublingual spray) UPPER GI Dexilant® (dexlansoprazole) See PPI policy; trial of three generic PPIs DISORDERS: and Nexium® 24HR OTC (at least 14 days in Anti-ulcer preparations duration) in addition to qualifying diagnosis
Note: This is an incomplete list. Products with one year or less from the date of product launch are excluded from coverage.
Please Note: This applies to most Health Alliance plans. If you have questions, please contact the Pharmacy Department at 1-800-851-3379, option 4. ph-preauthdrugs-0618