Oregon Medicaid Pharmaceutical Services Prior Authorization Criteria HEALTH SYSTEMS DIVISION Prior authorization (PA) criteria for fee-for-service prescriptions for Oregon Health Plan clients May 1, 2016 Contents Introduction .................................................................................................................................. 6 About this guide .................................................................................................................. 6 How to use this guide .......................................................................................................... 6 Administrative rules and supplemental information ........................................................... 6 Update information ...................................................................................................................... 7 General PA information ............................................................................................................... 9 Overview ............................................................................................................................. 9 Drugs requiring prior authorization (PA) ........................................................................... 9 DUR Plus review ................................................................................................................ 9 How to request PA ............................................................................................................ 10 For prescriptions and oral nutritional supplements ................................................ 10 For emergent or urgent prescriptions that require PA ............................................ 10 For diabetic supplies ............................................................................................... 10 Client hearings and exception requests ............................................................................. 11 DMAP 3978 – Pharmacy PA Request form ..................................................................... 11 Information needed to request PA .......................................................................... 11 Sample form ............................................................................................................ 12 PA criteria for fee-for-service prescriptions ........................................................................... 14 About the PA criteria ........................................................................................................ 14 Contact for questions about PA policy ................................................................... 14 ADHD Safety Edit ............................................................................................................ 15 Analgesics, Non-Steroidal Anti-Inflammatory Drugs ...................................................... 18 Antiemetics ....................................................................................................................... 19 Antifungals ........................................................................................................................ 21 Oregon Medicaid PA Criteria May 1, 2016 Antihistimines ................................................................................................................... 25 Antimigraine – Triptans .................................................................................................... 27 Anti-Parkinsons Agents .................................................................................................... 30 Antiplatelets (replaces “Platelet Inhibitors) ...................................................................... 31 Antivirals – Influenza........................................................................................................ 33 Antivirals – Oral and Topical HSV .................................................................................. 35 Becaplermin (Regranex®) ................................................................................................ 38 Benign Prostatic Hypertrophy (BPH) Medications .......................................................... 39 Benzodiazepines ................................................................................................................ 42 Biologicals RA, Psoriasis, Crohn’s disease ...................................................................... 43 Bone Resorption Suppression and Related Agents .......................................................... 46 Botulinum Toxins (BoNT) ................................................................................................ 48 Buprenorphine and Buprenorphine/ Naloxone Fixed-combinations ................................ 53 Calcium and Vitamin D Supplements .............................................................................. 56 Clobazam (Onfi®) ............................................................................................................ 57 CNS - Central Nervous System ........................................................................................ 58 CNS Sedatives – Sedative Non-Benzodiazepines .................................................. 58 CNS Sedatives – Quantity Limit ............................................................................ 60 CNS Sedative – Therapeutic Duplication ............................................................... 62 Codeine ............................................................................................................................. 63 Conjugated estrogens-bazedoxifene (Duavee®) .............................................................. 64 Cough and Cold Preparations ........................................................................................... 66 Cysteamine Delayed Release (Procysbi®) ....................................................................... 67 Dalfampridine (Ampyra®) ............................................................................................... 68 Dispense As Written 1 (DAW-1) Reimbursement Rate ................................................... 70 DPP4 Inhibitors ................................................................................................................. 72 Dronabinol (Marinol®) ..................................................................................................... 74 Droxidopa (Northera®) ..................................................................................................... 76 Drugs for Constipation ...................................................................................................... 78 Drugs for Manual Review ................................................................................................. 80 Drugs for Non-Funded Conditions ................................................................................... 81 Drugs Used for Non-funded Pain Conditions ................................................................... 82 Erythropoiesis-Stimulating Proteins ................................................................................. 85 Oregon Medicaid PA Criteria May 1, 2016 Estrogen Derivatives ......................................................................................................... 87 Exclusion List ................................................................................................................... 89 Fentanyl Transmucosal and Buccal .................................................................................. 94 Fidaxomicin (Dificid®) .................................................................................................... 96 GLP1 Receptor Antagonists ............................................................................................. 97 GnRH Analogs .................................................................................................................. 99 Growth Hormones ........................................................................................................... 100 Hepatitis B Antivirals...................................................................................................... 103 Hepatitis C Direct-Acting Antivirals .............................................................................. 105 Hydroxyprogesterone caproate ...................................................................................... 110 Idiopathic Pulmonary Fibrosis ........................................................................................ 111 Inhaled Corticosteroids ................................................................................................... 112 Initial Pediatric SSRI ...................................................................................................... 114 Insulins ............................................................................................................................ 116 Intranasal Allergy Drugs (replaces “Nasal Inhalers) ...................................................... 117 Ivabradine ........................................................................................................................ 119 LABA / ICS .................................................................................................................... 121 LABA / LAMA ............................................................................................................... 123 LABAs ...........................................................................................................................