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 29, 2017 Contents Contents ................................................................................................................................................................ 2 Introduction........................................................................................................................................................... 6 About this guide ......................................................................................................................................... 6 How to use this guide ................................................................................................................................. 6 Administrative rules and supplemental information .................................................................................. 6 Update information .............................................................................................................................................. 7 Effective March 29, 2017 .......................................................................................................................... 7 Substantive updates and new criteria ............................................................................................. 7 Clerical changes ............................................................................................................................. 7 General PA information ....................................................................................................................................... 8 Overview .................................................................................................................................................... 8 Drugs requiring PA - See OAR 410-121-0040 for more information ....................................................... 8 DUR Plus review ....................................................................................................................................... 8 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) ......................... 9 Client hearings and exception requests .................................................................................................... 10 DMAP 3978 - Pharmacy Prior Authorization Request............................................................................ 10 Information needed to request PA ............................................................................................... 10 PA criteria for fee-for-service prescriptions .................................................................................................... 13 About the PA criteria ............................................................................................................................... 13 Contact for questions about PA policy .................................................................................................... 13 Attention Deficit Hyperactivity Disorder (ADHD) Safety Edit ......................................................................... 14 Analgesics, Non-Steroidal Anti-Inflammatory Drugs ...................................................................................... 17 Antiemetics ......................................................................................................................................................... 18 Antifungals .......................................................................................................................................................... 20 Oregon Medicaid PA Criteria 2 March 29, 2017 Antihistamines .................................................................................................................................................... 24 Antimigraine - Triptans ...................................................................................................................................... 26 Anti-Parkinson’s Agents .................................................................................................................................... 29 Antiplatelets ........................................................................................................................................................ 30 Antivirals for Herpes Simplex Virus ................................................................................................................. 32 Antivirals - Influenza .......................................................................................................................................... 34 Becaplermin (Regranex®) .................................................................................................................................. 36 Benign Prostatic Hypertrophy (BPH) Medications .......................................................................................... 37 Benzodiazepines ................................................................................................................................................ 39 Biologics for Autoimmune Diseases ................................................................................................................ 40 Bone Resorption Inhibitors and Related Agents............................................................................................. 45 Botulinum Toxins ............................................................................................................................................... 47 Buprenorphine and Buprenorphine/Naloxone ................................................................................................ 52 Calcium and Vitamin D Supplements ............................................................................................................... 55 Clobazam............................................................................................................................................................. 56 Codeine ............................................................................................................................................................... 57 Conjugated Estrogens/Bazedoxifene (Duavee®) ............................................................................................. 58 Cough and Cold Preparations ........................................................................................................................... 60 Cysteamine Delayed-release (PROCYSBI®) ..................................................................................................... 61 Daclizumab (Zinbryta™) .................................................................................................................................... 62 Dalfampridine...................................................................................................................................................... 63 Dispense as Written-1 (DAW-1) Reimbursement Rate .................................................................................... 65 Dipeptidyl Peptidase-4 (DPP-4) Inhibitors........................................................................................................ 67 Dronabinol (Marinol®) ........................................................................................................................................ 68 Droxidopa (Northera®) ....................................................................................................................................... 70 Drugs for Constipation ...................................................................................................................................... 72 Drugs Selected for Manual Review by Oregon Health Plan ........................................................................... 74 Drugs for Non-funded Conditions .................................................................................................................... 75 Erythropoiesis Stimulating Agents (ESAs) ...................................................................................................... 76 Estrogen Derivatives .......................................................................................................................................... 78 Exclusion List ..................................................................................................................................................... 80 Fidaxomicin (Dificid®) ....................................................................................................................................... 85 Glucagon-like Peptide-1 (GLP-1) Receptor Agonists...................................................................................... 86 Gonadotropin-Releasing Hormone (GnRH) Analogs ...................................................................................... 88 Agents for Gout .................................................................................................................................................