PRIOR AUTHORIZATION DETAIL September 2021 GENERAL DISCLAIMER: Bright Health does not recognize the use of drug samples to meet clinical criteria requirements for prior drug use for drugs covered under the pharmacy benefit or drugs administered in the physician office or other outpatient setting. A physician’s statement that samples have been used cannot be used as documentation of prior drug use. ABILIFY Products Affected • ABILIFY • aripiprazole oral solution • ABILIFY MAINTENA • aripiprazole oral tablet dispersible PA Criteria Criteria Details Covered Uses Schizophrenia, Acute bipolar mania, including manic and mixed episodes associated with bipolar disorder, Major Depressive Disorder, autistic disorder, Tourette’s disorder, Medically accepted indications will also be considered for approval. Exclusion None Criteria Required A. SCHIZOPHRENIA (1) Prescriber attests patient has a diagnosis of Medical Schizophrenia, AND (2) Tried and failed, intolerance or contraindication Information of the formulary alternative risperidone, AND (3) Tried and failed, intolerance or contraindication of the formulary alternative Aripiprazole tablet, OR B. ACUTE BIPOLAR MANIA (1) Prescriber attests patient has a diagnosis of Acute bipolar mania, including manic and mixed episodes associated with bipolar disorder, AND (2) Tried and failed, intolerance or contraindication of the formulary alternative risperidone, AND (3) Tried and failed, intolerance or contraindication of the formulary alternative Aripiprazole tablet, OR C. MAJOR DEPRESSIVE DISORDER (1) Prescriber attests patient has a diagnosis of Major Depressive Disorder, AND (2) Tried and failed, intolerance or contraindication of the formulary alternatives fluoxetine, paroxetine, sertraline, citalopram, Venlafaxine and bupropion (medication usage must be supported by documentation from the patients chart notes/medical records/electronic claim history), AND (3) Trial and failure, intolerance or contraindication of the alternatives escitalopram and desvenlafaxine (Pristiq) (medication usage must be supported by documentation from the patients chart notes/medical records/electronic claim history), AND (4) Tried and failed, intolerance or contraindication of the formulary alternative risperidone, AND (5) Tried and failed, intolerance or contraindication of the formulary alternative Aripiprazole tablet, AND (6) Must be used as adjunctive or add-on treatment to ADT and not as monotherapy, OR 1 PA Criteria Criteria Details Age Restrictions Schizophrenia-13 years of age and older. Acute bipolar mania-10 years of age and older. MDD- 18 years of age and older. Autistic disorder, Tourettes-6 years of age and older. Prescriber None Restrictions Coverage 12 months Duration Other Criteria D. AUTISTIC DISORDER (1) Prescriber attests patient has a diagnosis of autistic disorder, AND (2) Tried and failed, intolerance or contraindication of the formulary alternative risperidone, AND (3) Tried and failed, intolerance or contraindication of the formulary alternative Aripiprazole tablet, AND (4) Tried and failed, intolerance, or contraindication to formulary stimulant medications methylphenidate, dextroamphetamine, amphetamine/dextroamphetamine (medication usage must be supported by documentation from the patients chart notes/medical records/electronic claim history) OR E. TOURETTES DISORDER (1) Prescriber attests patient has a diagnosis of Tourette’s disorder AND (2) Tried and failed, intolerance or contraindication of the formulary alternative risperidone, AND (3) Tried and failed, intolerance or contraindication of the formulary alternative Aripiprazole tablet 2 ABILIFY MYCITE NON FORMULARY Products Affected • ABILIFY MYCITE • ABILIFY MYCITE STARTER KIT • ABILIFY MYCITE MAINTENANCE KIT PA Criteria Criteria Details Covered Uses Schizophrenia, Bipolar I Disorder, including manic and mixed episodes associated with bipolar disorder, Major Depressive Disorder, FDA Approved indications will also be considered for approval. Exclusion None Criteria Required A. SCHIZOPHRENIA (1) Patient has a diagnosis of Schizophrenia, AND Medical (2) Patient has a medical necessity for tracking medication ingestion Information (documentation and clinical reasoning must be provided) OR B. BIPOLAR I DISORDER (1) Patient has a diagnosis of bipolar I disorder AND (2) One of the following: (2a) Drug will be used for treatment of manic and mixed episodes as monotherapy or as an adjunct to lithium or valproate OR (2b) Drug will be used as maintenance treatment as monotherapy or as adjunct to lithium or valproate AND (3) Patient has a medical necessity for tracking medication ingestion (documentation and clinical reasoning must be provided) OR C. MAJOR DEPRESSIVE DISORDER (1) Patient has a diagnosis of Major Depressive Disorder, AND (2) Drug will be used as an adjunctive treatment AND (3) Patient has a medical necessity for tracking medication ingestion (documentation and clinical reasoning must be provided) Age Restrictions 18 years of age or older Prescriber Prescribed by or in consultation with a psychiatrist Restrictions Coverage 12 months Duration Other Criteria None 3 ABSORICA NON FORMULARY Products Affected • ABSORICA • ABSORICA LD PA Criteria Criteria Details Covered Uses Treatment of severe recalcitrant nodular acne in non-pregnant patients 12 years of age and older with multiple inflammatory nodules with a diameter of 5 mm or greater who are unresponsive to conventional therapy, including systemic antibiotics Exclusion Known hypersensitivity to isotretinoin (vitamin A, given the chemical Criteria similarity to isotretinoin), Known or suspected pregnancy Required A. RECALCITRANT NODULOCYSTIC ACNE (1) Patient has diagnosis Medical of severe recalcitrant nodular acne characterized by multiple inflammatory Information nodules with a diameter of 5 mm or greater, AND (2) Patient has documented intolerance to, or treatment failure with, an adequate trial of ONE (1) systemic antibiotic AND (3) Patient has a documented intolerance to, or treatment failure with, an adequate trial of ONE (1) generic isotretinoin preparations (Amnesteem, Claravis, Myorisan) AND (4) Confirmation of the use 2 effective contraception methods or continuous abstinence for 1 month prior, during, and 1 month after isotretinoin therapy Age Restrictions 12 years of age or older Prescriber Prescribed by, or in consultation with, a dermatologist Restrictions Coverage 12 months Duration Other Criteria None 4 ABSTRAL/FENTORA/LAZANDA/ONSOLIS/SUBSY S NON FORMULARY Products Affected • fentanyl citrate buccal • LAZANDA • FENTORA • SUBSYS PA Criteria Criteria Details Covered Uses Diagnosis (including any applicable labs and /or tests) of breakthrough cancer pain in patients with malignancies who are already receiving and who are tolerant to opioid therapy (at least: 60 mg morphine/day or an equianalgesic dose of another opioid for a week or longer) for underlying persistent cancer pain, Medically accepted indications will also be considered for approval. Exclusion None Criteria Required A. BREAKTHROUGH CANCER PAIN (1) Prescriber attests patient has Medical a diagnosis (including any applicable labs and /or tests) of breakthrough Information cancer pain in patients with malignancies who are already receiving and who are tolerant to opioid therapy (at least: 60 mg morphine/day or an equianalgesic dose of another opioid for a week or longer) for underlying persistent cancer pain AND (2) Must be on an adequate dose of a long- acting (maintenance, around-the-clock) opioid AND (3) An inadequate response, intolerance, or contraindication to a trial of immediate-release morphine at maximum tolerated dose for breakthrough pain AND (4) An inadequate response, intolerance, or contraindication to a trial of immediate-release oxycodone at maximum tolerated dose for breakthrough pain AND (5) An inadequate response or intolerance to a trial of fentanyl lozenge (Actiq) AND (6) Must be able to comply with instructions to keep medication out of the reach of children and to discard open units properly Age Restrictions 18 years of age or older Prescriber Must be prescribed by oncologist or pain specialist Restrictions 5 PA Criteria Criteria Details Coverage 12 months Duration Other Criteria None 6 ACITRETIN Products Affected • acitretin PA Criteria Criteria Details Covered Uses Moderate to severe Psoriasis , Medically accepted indications will also be considered for approval Exclusion None Criteria Required A. PSORIASIS (1) Prescriber attests patient has a diagnosis of moderate Medical to severe Psoriasis AND (2) Trial and failure, intolerance, or Information contraindication to, 90 day trial of Methotrexate AND (3) Trial and failure, intolerance, or contraindication to, 90 day trial of high dose topical steroid (i.e. betamethasone augmented, halobetasol) AND (4) Maximum of 2 capsules per day AND (5) For continuation of therapy, requires documentation of a positive response to therapy Age Restrictions None Prescriber Must be prescribed by, or in consultation with, a Dermatologist Restrictions Coverage Initial=3 months, Renewal=1 year Duration Other Criteria None 7 ACTEMRA (TOCILIZUMAB) (SP) NON FORMULARY Products Affected • ACTEMRA • ACTEMRA ACTPEN PA Criteria Criteria Details Covered Uses Moderate to Severely active Rheumatoid Arthritis (RA), Giant Cell Arteritis (GCA), Systemic Juvenile Idiopathic Arthritis (SJIA), Polyarticular Juvenile Idiopathic Arthritis (PIJA), Cytokine Release Syndrome (CRS) Exclusion Concurrent use with a biologic DMARD Criteria Required A. Moderate to Severely