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 1, 2020 Contents Contents ................................................................................................................................................................ 2 Introduction........................................................................................................................................................... 7 About this guide ......................................................................................................................................... 7 How to use this guide ................................................................................................................................. 7 Administrative rules and supplemental information .................................................................................. 7 Update information............................................................................................................................................... 8 Effective March 1, 2020 ............................................................................................................................ 8 Substantive updates and new criteria ............................................................................................. 8 Clerical changes ............................................................................................................................. 8 General PA information ....................................................................................................................................... 9 Overview .................................................................................................................................................... 9 Drugs requiring PA - See OAR 410-121-0040 for more information ....................................................... 9 DUR Plus review ....................................................................................................................................... 9 How to request PA ..................................................................................................................................... 9 For prescriptions and oral nutritional supplements ...................................................................... 10 For emergent or urgent prescriptions that require PA ................................................................. 10 For diabetic supplies (lancets, test strips, syringe and glucose monitor supplies) ....................... 10 Client hearings and exception requests .................................................................................................... 10 DMAP 3978 - Pharmacy Prior Authorization Request............................................................................ 11 Information needed to request PA ............................................................................................... 11 PA criteria for fee-for-service prescriptions .................................................................................................... 14 About the PA criteria ............................................................................................................................... 14 Contact for questions about PA policy .................................................................................................... 14 Acne Medications ............................................................................................................................................... 15 Amifampridine .................................................................................................................................................... 16 Amikacin Liposome Inhalation Suspension .................................................................................................... 19 Analgesics, Non-Steroidal Anti-Inflammatory Drugs ...................................................................................... 21 Oregon Medicaid PA Criteria 2 March 1, 2020 Antiemetics ......................................................................................................................................................... 22 Antifungals .......................................................................................................................................................... 24 Antihistamines .................................................................................................................................................... 28 Antimigraine – Serotonin Agonists .................................................................................................................. 30 Anti-Parkinson’s Agents .................................................................................................................................... 33 Antiplatelets ........................................................................................................................................................ 35 Antivirals - Influenza .......................................................................................................................................... 37 Antivirals for Herpes Simplex Virus ................................................................................................................. 39 Atopic Dermatitis and Topical Antipsoriatics .................................................................................................. 41 Attention Deficit Hyperactivity Disorder (ADHD) Safety Edit ......................................................................... 44 Drugs for Transthyretin-Mediated Amyloidosis (ATTR) ................................................................................. 47 Becaplermin (Regranex®) .................................................................................................................................. 50 Belimumab (Benlysta®) ...................................................................................................................................... 51 Benign Prostatic Hypertrophy (BPH) Medications .......................................................................................... 54 Benzodiazepines ................................................................................................................................................ 56 Bezlotoxumab (Zinplava™) ............................................................................................................................... 60 Biologics for Autoimmune Diseases ................................................................................................................ 61 Bone Metabolism Agents................................................................................................................................... 68 Botulinum Toxins ............................................................................................................................................... 72 Brexanolone (Zulresso) ..................................................................................................................................... 77 Buprenorphine and Buprenorphine/Naloxone ................................................................................................ 78 Calcium and Vitamin D Supplements ............................................................................................................... 80 Cannabidiol ......................................................................................................................................................... 81 Calcitonin Gene-Related Peptide (CGRP) antagonists ................................................................................... 84 Cholic Acid (Cholbam™) .................................................................................................................................... 86 Clobazam............................................................................................................................................................. 88 Codeine ............................................................................................................................................................... 89 Conjugated Estrogens/Bazedoxifene (Duavee®) ............................................................................................. 90 Cough and Cold Preparations ........................................................................................................................... 92 Cysteamine Delayed-release (PROCYSBI®) ..................................................................................................... 93 Oral Cystic Fibrosis Modulators ....................................................................................................................... 94 Daclizumab (Zinbryta™) and Ocrelizumab (Ocrevus™) ............................................................................... 100 Dalfampridine.................................................................................................................................................... 103 Dispense as Written-1 (DAW-1) Reimbursement Rate .................................................................................. 105 Dichlorphenamide ...........................................................................................................................................