table of contents · utah medicaid provider manual drug criteria and limits - attachment division...

Utah Medicaid Provider Manual Drug Criteria and Limits - Attachment

Division of Medicaid and Health Financing Updated January 2018

Manuals: Pharmacy Services of 44

Table of Contents Explanation of Medicaid Policy .................................................................................................................... 9

Drugs with Criteria and Limits ................................................................................................................. 9

Drugs Requiring Prior Authorization ........................................................................................................ 9

Drugs Requiring Diagnosis Codes ............................................................................................................ 9

The Utah Medicaid Preferred Drug List ..................................................................................................... 10

Psychotropic Medication Classes on the Utah Medicaid Preferred Drug List ........................................ 10

Drugs with Quantity Limits ........................................................................................................................ 11

Analgesics ................................................................................................................................................ 11

Codeine Sulfate ........................................................................................................................................ 11

Codeine + Acetaminophen ...................................................................................................................... 11

(Tylenol #3, Tylenol #4, Tylenol with Codeine) ..................................................................................... 11

(Duragesic) .............................................................................................................................................. 11

Hydrocodone ........................................................................................................................................... 12

(Hysingla ER, Zohydro ER) .................................................................................................................... 12

Hydrocodone+Acetaminophen ................................................................................................................ 12

(Lorcet, Lortab, Norco, Vicodin) ............................................................................................................. 12

Hydromorphone ....................................................................................................................................... 12

(Dilaudid, Exalgo) ................................................................................................................................... 12

Levorphanol ............................................................................................................................................. 12

(Levo-Dromoran) ..................................................................................................................................... 12

Meperidine ............................................................................................................................................... 12

(Demerol) ................................................................................................................................................. 12

Methadone ............................................................................................................................................... 13

(Dolophine, Methadose) .......................................................................................................................... 13

Morphine Sulfate ..................................................................................................................................... 13

(Kadian, MS Contin) ............................................................................................................................... 13

Morphine + Naltrexone............................................................................................................................ 13

(Embeda) ................................................................................................................................................. 13

Oxycodone ............................................................................................................................................... 14

(Oxycontin, Roxicodone) ........................................................................................................................ 14

Oxycodone + Acetaminophen ................................................................................................................. 14

(Percocet, Endocet) .................................................................................................................................. 14




Oxymorphone .......................................................................................................................................... 14

(Opana) .................................................................................................................................................... 14

Pentazocine + Acetaminophen ................................................................................................................ 14

(Talacen) .................................................................................................................................................. 14

Tapentadol ............................................................................................................................................... 14

(Nucynta, Nucynta ER) ........................................................................................................................... 14

Tramadol .................................................................................................................................................. 14

(Ultram, Ultram ER) ................................................................................................................................ 14

Tramadol + Acetaminophen .................................................................................................................... 14

(Ultracet) .................................................................................................................................................. 14

Benzodiazepine not for sedative hypnotic: Alprazolam, Chlodiazopoxide, Chlorazepate, Diazepam,

Lorazepam, Oxazepam........................................................................................................................ 15

(Xanax, Librium, Tranxene, Valium, Ativan, Serax) .............................................................................. 15

Celecoxib ................................................................................................................................................. 15

(Celebrex) ................................................................................................................................................ 15

Diabetic Test Strips.................................................................................................................................. 15

Diphenoxylate Containing Products ........................................................................................................ 15

(Lomotil) .................................................................................................................................................. 15

Flu Vaccine .............................................................................................................................................. 15

Inhalers .................................................................................................................................................... 15

Nasal Anti-Inflammatory Inhalers ........................................................................................................... 15

Beta Agonist Inhalers .............................................................................................................................. 15

Anticholinergic Inhalers .......................................................................................................................... 16

Anti-inflammatory Inhalers ..................................................................................................................... 16

Insulin ...................................................................................................................................................... 17

Laxatives .................................................................................................................................................. 17

Metformin ................................................................................................................................................ 17

(Glucophage, Glumetza) .......................................................................................................................... 17

Migraine Medications: Almotriptan, Eletriptan,Frovatriptan, Naratriptan, Rizatriptan, Sumatriptan,

Zolmitriptan, Diclofenac packet ......................................................................................................... 17

(Axert, Relpax, Frova, Amerge, Maxalt, Imitrex, Zomig, Cambia) ........................................................ 17

Muscle Relaxants: Carisoprodol, Chlorzoxazone, Cyclobenzaprine, Dantrolene, Orphenadrine,

Methocarbamol, Metaxalone .............................................................................................................. 17




(Soma, Lorzone/Parafon Forte, Flexeril, Dantrium, Norflex, Robaxin, Skelaxin) .................................. 17

Emergency Contraceptives ...................................................................................................................... 17

Desvenlafaxine ........................................................................................................................................ 17

(Pristiq) .................................................................................................................................................... 17

Proton Pump Inhibitors: Dexlansoprazole, Esomeprazole, Lansoprazole, Omeprazole, Pantoprazole,

Rabeprazole, ........................................................................................................................................ 17

(Dexilant, Nexium, Prevacid, Prilosec, Zegrid, Protonix, Aciphex) ....................................................... 17

Milnacipran .............................................................................................................................................. 17

(Savella) ................................................................................................................................................... 17

Sedative Hypnotics for sleep: Chloral hydrate, Estazolam, Eszopiclone, Ramelteon, Suvorexant,

Tasimelteon, Temazepam, Triazolam, Zaleplon, Zolpidem, Zopiclone ............................................. 17

(Noctec, ProSom, Lunesta, Rozerem, Belsomra, Hetlioz, Restoril, Halcion, Sonata, Ambien, Zimovane)

............................................................................................................................................................ 17

Lidocaine/tetracaine ................................................................................................................................. 17

(Synera) ................................................................................................................................................... 17

Adult Acne for patients 21 years and older ............................................................................................. 18

Tadalafil ................................................................................................................................................... 18

(Adcirca) .................................................................................................................................................. 18

Dalfampridine .......................................................................................................................................... 18

(Ampyra) ................................................................................................................................................. 18

Androgens ................................................................................................................................................ 18

Bromocriptine .......................................................................................................................................... 19

(Cycloset) ................................................................................................................................................. 19

Anti-Emetics ............................................................................................................................................ 19

Palonosetron ............................................................................................................................................ 19

(Aloxi) ..................................................................................................................................................... 19

Aprepitant ................................................................................................................................................ 19

(Emend) ................................................................................................................................................... 19

Becacizumab ............................................................................................................................................ 19

(Avastin) .................................................................................................................................................. 19

Botulinum Toxins .................................................................................................................................... 20

Brand Name Medication .......................................................................................................................... 20

Butalbital Containing Products ................................................................................................................ 21




Oral Buprenorphine/Naloxone Combination Products, Oral Buprenorphine Single-Agent Products ..... 22

(Suboxone, Zubsolv, Bunavail, Subutex) ................................................................................................ 22

Buprenorphine ......................................................................................................................................... 22

(Butrans) .................................................................................................................................................. 22

Colchicine ................................................................................................................................................ 22

(Colcrys) .................................................................................................................................................. 22

Cytomegalovirus Immune Globulin ........................................................................................................ 24

(Cytogam) ................................................................................................................................................ 24

Covered under the medical benefit using the J code................................................................................ 24

Selegiline ................................................................................................................................................. 24

(Emsam) ................................................................................................................................................... 24

Deflazacort (Emflaza) .............................................................................................................................. 24

Sacubitril/valsartan .................................................................................................................................. 24

(Entresto) ................................................................................................................................................. 24

Enzymes ................................................................................................................................................... 24

Pegademase bovine .................................................................................................................................. 24

(Adagen) .................................................................................................................................................. 24


Laronidase ............................................................................................................................................... 24

(Aldurazyme) ........................................................................................................................................... 24


Alpha 1-proteinase inhibitor .................................................................................................................... 25

(Aralast) ................................................................................................................................................... 25

Imiglucerase, Velaglucerase alfa ............................................................................................................. 25

(Cerezyme/Vpriv) .................................................................................................................................... 25

Agalsidase beta ........................................................................................................................................ 25

(Fabrazyme) ............................................................................................................................................. 25

Eteplirsen (Exondys 51) .......................................................................................................................... 26

Teriparatide .............................................................................................................................................. 26

(Forteo) .................................................................................................................................................... 26

Gabapentin Extended Release Products .................................................................................................. 26

Gabapentin ............................................................................................................................................... 26




(Gralise) ................................................................................................................................................... 26

Gabapentin enacarbil (Horizant) .............................................................................................................. 26

Timothy Grass Pollen Allergen Extract ................................................................................................... 26

(Grastek) .................................................................................................................................................. 26

Growth Hormone for Adults (AIDS Wasting Syndrome Only): Serostim .............................................. 27

Growth Hormone (Children): .................................................................................................................. 28

Genotropin, Humatrope, Norditropin, Nutropin, Omnitrope, Saizen, Zomacton, Zorbtive .................... 28

Hepatitis Medications .............................................................................................................................. 29

Hyaluronic Acid Derivatives: .................................................................................................................. 29

(Durolane; Euflexxa; Gel-One; Gelsyn-3; Genvisc 850; Hyalgan; Hymovis; Monovisc; Orthovisc;

Supartz; Synvisc) ................................................................................................................................ 29

Hydroxyprogesterone Caproate (17-p) (Extemporaneous Compounds and Makena) ............................. 29

Mecasermin ............................................................................................................................................. 30

(Increlex) ................................................................................................................................................. 30

Romidepsin .............................................................................................................................................. 30

(Istodax) ................................................................................................................................................... 30

Ivacaftor ................................................................................................................................................... 30

(Kalydeco) ............................................................................................................................................... 30

Ketorolac (oral dosage forms only) ......................................................................................................... 30

(Toradol) .................................................................................................................................................. 30

Pegloticase ............................................................................................................................................... 31

(Krystexxa) .............................................................................................................................................. 31

Lidocaine ................................................................................................................................................. 31

(Lidoderm, Xylocaine) ............................................................................................................................ 31

Metabolic Supplements (for support of in-born errors of metabolism such as PKU) ............................. 31

Methadone ............................................................................................................................................... 32

New-to-Market Drugs .............................................................................................................................. 32

Sorafenib .................................................................................................................................................. 32

(Nexavar) ................................................................................................................................................. 32

Non-Preferred Combination Product and/or Dosing Kit Authorization Request .................................... 32

Non-Preferred Drug Authorization .......................................................................................................... 33

Armodafinil ............................................................................................................................................. 33

(Nuvigil) .................................................................................................................................................. 33




Sweet Vernal, Orchard, Perennial Rye, Timothy, and Kentucky Blue Grass Mixed Pollens Allergen

Extract ................................................................................................................................................. 33

(Oralair) ................................................................................................................................................... 33

Lumacaftor/ivacaftor (Orkambi).............................................................................................................. 33

Oxandrolone ............................................................................................................................................ 34

(Oxandrin) ............................................................................................................................................... 34

PAMORAs (Peripherally-Acting Mu-Opioid Receptor Antagonists): .................................................... 34

Physician-Administered Drug ................................................................................................................. 34

Proprotein Convertase Subtilisin Kexin Type 9 Inhibitor Antibodies (PCSK9 Inhibitors) ..................... 34

Alirocumab (Praluent) ............................................................................................................................. 34

Evolocumab (Repatha/Repatha Pushtronex) ........................................................................................... 34

Proton Pump Inhibitors: ........................................................................................................................... 35

Dexlansoprazole, Esomeprazole, Lansoprazole, Omeprazole, Pantoprazole, Rabeprazole, ................... 35

(Dexilant, Nexium, Prevacid, Prilosec, Zegrid, Protonix, Aciphex) ....................................................... 35

Modafinil ................................................................................................................................................. 35

(Provigil) .................................................................................................................................................. 35

Quinine .................................................................................................................................................... 35

(Qualaquin) .............................................................................................................................................. 35

Short Ragweed Pollen Allergen Extract .................................................................................................. 36

(Ragwitek) ............................................................................................................................................... 36

Becaplermin ............................................................................................................................................. 36

(Regranex) ............................................................................................................................................... 36

Cyclosporine ............................................................................................................................................ 37

(Restasis) ................................................................................................................................................. 37

Retinoids .................................................................................................................................................. 37

Alitretinoin ............................................................................................................................................... 38

(Panretin) ................................................................................................................................................. 38

Tretinoin .................................................................................................................................................. 39

(Retin-A) .................................................................................................................................................. 39

Sildenafil citrate ....................................................................................................................................... 39

(Revatio) .................................................................................................................................................. 39

Tolvaptan ................................................................................................................................................. 39

(Samsca) .................................................................................................................................................. 39




Maraviroc ................................................................................................................................................. 39

(Selzentry) ............................................................................................................................................... 39

Simvastatin .............................................................................................................................................. 39

(Zocor) ..................................................................................................................................................... 39

Bedaquiline .............................................................................................................................................. 40

(Sirturo) ................................................................................................................................................... 40

Eculizumab .............................................................................................................................................. 40

(Soliris) .................................................................................................................................................... 40


Pegvisomant ............................................................................................................................................. 40

(Somavert) ............................................................................................................................................... 40

Sunitinib ................................................................................................................................................... 40

(Sutent) .................................................................................................................................................... 40

Pramlintide ............................................................................................................................................... 41

(Symlin) ................................................................................................................................................... 41

Palivizumab ............................................................................................................................................. 41

(Synagis) .................................................................................................................................................. 41

Topical Immunomodulators (Elidel, Protopic, pimecrolimus, tacrolimus) ............................................. 42

Lapatinib .................................................................................................................................................. 42

(Tykerb) ................................................................................................................................................... 42

Febuxostat ................................................................................................................................................ 42

(Uloric) .................................................................................................................................................... 42

Panitumumab ........................................................................................................................................... 42

(Vectibix) ................................................................................................................................................. 42


Naltrexone ............................................................................................................................................... 42

(Vivitrol) .................................................................................................................................................. 42

Bromfenac ............................................................................................................................................... 42

(Xibrom) .................................................................................................................................................. 42

Rifaximin ................................................................................................................................................. 43

(Xifaxan) .................................................................................................................................................. 43

Omalizumab ............................................................................................................................................. 43




(Xolair) .................................................................................................................................................... 43

Sodium oxybate ....................................................................................................................................... 43

(Xyrem) ................................................................................................................................................... 43

Miglustat .................................................................................................................................................. 44

(Zavesca) ................................................................................................................................................. 44




Explanation of Medicaid Policy

Drugs with Criteria and Limits

Many drugs in the Medicaid pharmacy program do not require a Prior Authorization (PA), but are still

subject to restrictions that are outlined in the Medicaid Pharmacy Services Manual and the Medicaid

Physician Services Manual. This section serves as a quick reference for the specific policies that govern

coverage of these drugs.

In accordance with the Utah Medicaid Provider Manual for Pharmacy Services, SECTION 3, Chapter 5,

Limitations, some drugs are limited by a quantity in any thirty-day (30) period. The limits listed are those

approved by the Medicaid Drug Utilization Review (DUR) Board. Prescribers who feel that a patient has

specific needs that exceed the limits may submit a prior authorization request using the Quantity Override

Request form that is available online:

https://medicaid.utah.gov/pharmacy/priorauthorization/pdf/Quantity%20Limits.pdf.

All medications remain subject to all other requirements of the Utah Medicaid Pharmacy Program, as

described in the Utah Medicaid Manual for Pharmacy Services.

Unless otherwise stated in this attachment, limits apply to both the brand-name and generic formulations

of the listed drugs.

Drugs Requiring Prior Authorization

Certain drugs that are covered by the Medicaid program may require the patient and prescriber to meet

specific criteria and demonstrate medical necessity in order to receive the requested medication. Detailed

information regarding prior approval criteria for individual medications and classes of medications is

provided in this attachment.

Please note that prior authorization for a medication is Medicaid member specific and product specific.

Prior authorization cannot be transferred to another product, nor to another strength of a product that has

been approved. The prior authorization also cannot be transferred to another Medicaid member.

To initiate a prior authorization request, the prescriber must obtain the most current criteria sheet from the

Medicaid Pharmacy Services Website at https://medicaid.utah.gov/pharmacy/prior-authorization and

gather all of the records that are requested in the criteria set for the medication being prescribed. The

requests can be faxed to (855) 828-4992. The criteria sheet must be completely and legibly filled out and

must be accompanied by all requested information. Incomplete or illegible requests will be returned to

the prescriber without being processed by Medicaid.

Drugs Requiring Diagnosis Codes

Utah Medicaid pharmacy claims requiring a diagnosis code will require a current valid ICD-10 code.

Cumulative limits on narcotic analgesics are waived for the current treatment of cancer-related pain. The

prescriber must provide an appropriate current diagnosis code for cancer on prescriptions for these drugs.

https://medicaid.utah.gov/pharmacy/priorauthorization/pdf/Quantity%20Limits.pdf

https://medicaid.utah.gov/pharmacy/prior-authorization




The prescriber is responsible to provide the current correct diagnosis code on each prescription for a

narcotic analgesic for cancer pain. The current diagnosis code may be hand-written by the prescriber on

the prescription or computer generated by prescribing software. Pharmacy providers may also obtain

current diagnosis codes verbally from prescribers, and note the date, time, and name of the prescriber’s

representative providing the current diagnosis code on the original hard-copy prescription. The

dispensing pharmacist must enter that current diagnosis code into the appropriate diagnoses field when

processing a claim.

A listing of the ICD-10 diagnosis codes accepted by Utah Medicaid by category is included in the ICD-10

Reference Chart that is available on the website: https://medicaid.utah.gov/pharmacy/resource-library.

If a pharmacy fills a narcotic analgesic prescription that does not comply with the requirements above,

funds paid by Medicaid will be recovered through post-payment review.

The Utah Medicaid Preferred Drug List

Many of the drugs and classes listed in this document are also on the Preferred Drug List (PDL).

Any drugs or classes listed herein are also subject to the limitations of the PDL if they are listed

in the current version of the PDL.

See https://medicaid.utah.gov/pharmacy/preferred-drug-list.

Psychotropic Medication Classes on the Utah Medicaid Preferred Drug List

Utah Medicaid has psychotropic drugs on the Preferred Drug List (PDL). For the purposes of

the Preferred Drug List, psychotropic medications are defined as atypical antipsychotics, anti-

depressants, anti-convulsants/mood stabilizers, anti-anxiety medications, and attention deficit

hyperactivity disorder (ADHD) stimulants.

Non-preferred psychotropic medication classes listed on the PDL may bypass the non-preferred

drug prior authorization if a prescriber writes “dispense as written” on a prescription and the

pharmacy submits a Dispense As Written (DAW) Code of “1” on the claim. The prescriber is

expected to provide services of quality that meet professionally recognized standards of care and

can be substantiated by records including evidence of medical necessity.

Note: In accordance with UCA 58-17b-606 (4) and (5), the DAW Code will not allow claims for

the brand-name version of multisource drugs to bypass the prior authorization requirement, even

if the brand-name version of the drug is listed as non-preferred and the prescriber writes

“dispense as written” on the prescription. If the brand-name version is preferred over the generic

formulation due to cost, the non-preferred brand-name drug may bypass the prior authorization

requirement instead of the generic formulation.

https://medicaid.utah.gov/pharmacy/resource-library

https://medicaid.utah.gov/pharmacy/preferred-drug-list




Drugs with Quantity Limits

Note: the information below is accurate at the time of Manual publication. Manuals are

updated quarterly. For the most up to date information, refer to the Prior Authorization

website


Analgesics General Notes / Legend:

In addition to the drug-specific limits below, cumulative limits for any

combination of short-acting opioids and/or opioid/APAP combination products is

180 tablets per 30 days (independent of long-acting opioid accumulation).

In addition to the drug-specific limits below, cumulative limits for any

combination of long-acting opioids is 90 tablets per 30 days (independent of

short-acting and/or opioid/APAP combination product accumulation)

CA (cancer pain): The cumulative limit may be overridden if the prescriber writes

a valid ICD code for cancer on the face of the prescription.

Days: Initial prescriptions for over a 7 day supply require prior authorization. A

prescription is considered “initial” if the drug has not been filled for the patient in

the past 60 days. Subsequent prescriptions may be for a 30 day supply and do not

require prior authorization if the quantity prescribed is less than or equal to the

cumulative limit.

Excl: Fentanyl is mutually exclusive with Methadone and all other long acting

opioids. Methadone is mutually exclusive with Fentanyl and all other long acting

opioids. All other opioids are not mutually exclusive with each other.

Codeine Sulfate Codeine Immediate Release tablets (all strengths):

Cumulative limit of 180 tablets in 30 days.

See General Notes / Legend: CA, Days

Codeine Sulfate oral liquid (all strengths):

Cumulative limit of 1,800mL in 30 days.


Codeine + Acetaminophen (Tylenol

#3, Tylenol #4, Tylenol with

Codeine)

Codeine + Acetaminophen tablets (all strengths):


See General Notes / Legend: Days

Codeine + Acetaminophen oral solution & suspension (all strengths):

Cumulative limit of 450 mL in 30 days.

See General Notes: Days

Fentanyl

(Duragesic)

Fentanyl Patch (all strengths):

Cumulative limit of 12 patches in 30 days

The 100mcg Fentanyl Patch is only a covered benefit with valid ICD code for

cancer.

See General Notes / Legend: CA, Excl

Fentanyl, all other dosage forms (all strengths):

Only a covered benefit if the prescriber provides a valid ICD code for cancer.








website


Hydrocodone

(Hysingla ER, Zohydro ER)

Hydrocodone Extended Release tablets (all strengths):



Hydrocodone+Acetaminophen

(Lorcet, Lortab, Norco, Vicodin)

Hydrocodone + Acetaminophen tablets (all strengths):



Hydrocodone + Acetaminophen 10-300 mg/15mL oral solution:



Hydrocodone + Acetaminophen 10-325 mg/15mL oral solution:



Hydrocodone + Acetaminophen 7.5-325 mg/15mL oral solution:



Hydrocodone + Acetaminophen 7.5-500 mg/15mL oral solution:



Hydromorphone

(Dilaudid, Exalgo)

Hydromorphone Immediate Release 2mg, 4mg & 8mg tablets:



Hydromorphone Extended Release 8mg, 12mg, 16mg & 32mg tablets:



Hydromorphone oral liquid (all strengths):



Hydromorphone 3mg suppository:

Cumulative limit of 90 suppositories in 30 days.


Levorphanol

(Levo-Dromoran)

Levorphanol tablets (all strengths):



Meperidine

(Demerol)

Meperidine tablets (all strengths):


See General Notes / Legend: CA

Meperidine oral solution (all strengths):


See General Notes / Legend: CA







website


Methadone

(Dolophine, Methadose)

Methadone 5mg & 10mg tablets:

Cumulative limit of 60 tablets in 30 days


Methadone 40mg tablets:

Cumulative limits of 30 tablets in 30 days


Methadone 10mg/1mL concentrated oral liquid:

Cumulative limits of 90mL in 30 days


Methadone 1mg/ml oral solution:



Methadone 2mg/ml oral solution:



Morphine Sulfate

(Kadian, MS Contin)

Morphine Sulfate Immediate Relief tablets (all strengths):



Kadian tablets (all strengths):



MS Contin 15mg tablets:



MS Contin tablets, all other strengths:



Morphine Sulfate 20mg/1mL concentrated oral solution:



Morphine Sulfate 2mg/ml oral solution:



Morphine Sulfate 4mg/ml oral solution:



Morphine Sulfate suppositories (all strengths):

Cumulative limit of 90 suppositories in 30 days.

See General Notes / Legend: CA,, Excl

Morphine + Naltrexone

(Embeda)

Morphine + Naltrexone tablets (all strengths):









website


Oxycodone

(Oxycontin, Roxicodone)

Oxycodone Immediate Release 5mg, 7.5mg, 10mg & 15mg tabs/caps:


See General Notes / Legend: CA, Days, Excl

Oxycodone Immediate Release 20mg & 30mg tablets:



Oxycodone Extended Release tablets (all strengths):



Oxycodone 20mg/mL concentrated oral solution:

Cumulative limit of 180mL in 30 days.


Oxycodone 1mg/ml oral solution :

Cumulative limit of 3600mL in 30 days.


Oxycodone + Acetaminophen

(Percocet, Endocet)

Oxycodone + Acetaminophen tablets (all strengths):



Oxycodone + Acetaminophen 5mg-325mg/5mL oral liquid:



Oxymorphone

(Opana)

Oxymorphone Immediate Release tablets (all strengths):



Oxymorphone Extended Release tablets (all strengths):



Pentazocine + Acetaminophen

(Talacen)

Pentazocine + Acetaminophen tablets (all strengths):



Tapentadol

(Nucynta, Nucynta ER)

Tapentadol Immediate Release tablets (all strengths):


See General Notes / Legend: Days, Excl

Tapentadol Extended Release tablets (all strengths):



Tramadol

(Ultram, Ultram ER)

Tramadol Immediate Release tablets (all strengths):



Tramadol Extended Release tablets (all strengths):

Cumulative limit of 30 tablets in 30 days


Tramadol + Acetaminophen

(Ultracet)

Tramadol + Acetaminophen tablets (all strengths):









website


Benzodiazepine not for sedative

hypnotic: Alprazolam,

Chlodiazopoxide, Chlorazepate,

Diazepam, Lorazepam, Oxazepam

(Xanax, Librium, Tranxene,

Valium, Ativan, Serax)

Cumulative limit of 120 tablets/capsules in 30 days.

Celecoxib

(Celebrex)

Cumulative limit of 60 capsules in 30 days.

Diabetic Test Strips Limit of 200 strips in 30 days.

Diphenoxylate Containing Products

(Lomotil)


Flu Vaccine Limited to 0.5ml

Inhalers The cumulative number of inhalers in any 30-day period is limited for a Medicaid

member. When there are more than two sizes or strengths for a given product, the

limit is based on the largest size or strength. There are two groups of inhalers: oral

and nasal. For each group, the limits are stated below.

Inhaler Class Generic Name Common Brand

Names

Product

Size

Doses per

Inhaler

Maximum

No. In 30

Days

Nasal Anti-

Inflammatory

Inhalers beclomethasone

Beconase AQ 25 gm 180 2

Qnasl 8.7 gm 120 1

4.9 gm 60 1

ciclesonide Omnaris 12.5 gm 120 1

Zetonna 6.1 gm 60 1

fluticasone Flonase 16 gm 120 1

Veramyst 10 gm 120 1

flunisolide Nasarel 25 gm 200 2

mometasone Nasonex 17 gm 120 1

budesonide Rhinocort AQUA 8.6 gm 120 1

Beta Agonist Inhalers

albuterol

Proair HFA 8.5 gm 200 4

Proventil HFA 6.7 gm 200 4

Ventolin HFA 18 gm 200 4

8 gm 60 4

levalbuterol Xopenex HFA 15 gm 200 4

8.4 gm 80 4

formoterol

Foradil 12 1

60 1

Perforomist 60 1

30 1

arformoterol Brovana

60 1

indacaterol Arcapta 30 1

olodaterol Striverdi 4 gm 60 1







website


salmeterol Serevent Diskus 60 1

Anticholinergic

Inhalers

ipratropium Atrovent HFA 14 gm 200 2

ipratropium/albuterol Combivent 14.7 gm 200 2

tiotropium Spiriva 30 caps 30 1

Anti-inflammatory

Inhalers beclomethasone

QVAR 40 mg 8.7 gm 120 1

QVAR 80 mg 8.7 gm 120 1

budesonide Pulmicort

Flexhaler

225 mg 120 1

165 mg 60 1

ciclesonide Alvesco 6.1 gm 60 1

flunisolide Aerospan 8.9 gm 120 1

fluticasone furoate Arnuity Ellipta 30 1

fluticasone MDI

Flovent 44 mcg 10.6 gm 120 1

Flovent 110 mcg 12 gm 120 1

Flovent 220 mcg 12 gm 120 1

fluticasone DPI Flovent Diskus 50 mcg, 100 mcg,

250 mcg

60 1

60 1

60 1

Mometasone

Asmanex HFA 100 120 1

Asmanex HFA 200 120 1

Asmanex

Twisthaler 110

60/120 1

Asmanex

Twisthaler 220

60/120 2

triamcinolone MDI Azmacort 110 240 gm 60/120 1

Azmacort 220 240 gm 60/120 1

fluticasone/ salmeterol DPI

Advair Diskus 100/50 60 1









website


Insulin Prescriptions are limited to 60 ml per month.

Higher doses may be overridden with a prior authorization if the prescriber

verifies the medical necessity of the higher dose.

Laxatives Polyethylene Glycol 3350: Cumulative Limit of 1054 gm in 30 days

Metformin

(Glucophage, Glumetza)

The maximum daily dose is 2550mg. Dosage limits are set accordingly.

Migraine Medications: Almotriptan,

Eletriptan,Frovatriptan, Naratriptan,

Rizatriptan, Sumatriptan,

Zolmitriptan, Diclofenac packet

(Axert, Relpax, Frova, Amerge,

Maxalt, Imitrex, Zomig, Cambia)

Cumulative limit of 9 dosage units per 30 days - all forms count towards this

limit.

Muscle Relaxants: Carisoprodol,

Chlorzoxazone, Cyclobenzaprine,

Dantrolene, Orphenadrine,

Methocarbamol, Metaxalone

(Soma, Lorzone/Parafon Forte,

Flexeril, Dantrium, Norflex,

Robaxin, Skelaxin)

Cumulative limits specific to each agent (per maximum FDA-approved doses)

Carisoprodol 120 tablets per 30 days

Chlorzoxazone 120 tablets per 30 days

Cyclobenzaprine 90 tablets per 30 days

Dantrolene 90 tablets per 30 days

Metaxalone 360 tablets per 30 days

Orphenadrine 60 tablets per 60 days

Emergency Contraceptives Cumulative limit of two kits per month.

Desvenlafaxine

(Pristiq)

Limit of 30 tablets in 30 days.

Proton Pump Inhibitors:

Dexlansoprazole, Esomeprazole,

Lansoprazole, Omeprazole,

Pantoprazole, Rabeprazole,

(Dexilant, Nexium, Prevacid,

Prilosec, Zegrid, Protonix, Aciphex)

Limit of 1 unit per day

Milnacipran

(Savella)

Maximum daily dose of 100mg per day.

Doses of 200mg per day may be approved after a minimum two-month trial of the

100mg per day dose.

Sedative Hypnotics for sleep:

Chloral hydrate, Estazolam,

Eszopiclone, Ramelteon,

Suvorexant, Tasimelteon,

Temazepam, Triazolam, Zaleplon,

Zolpidem, Zopiclone

(Noctec, ProSom, Lunesta,

Rozerem, Belsomra, Hetlioz,

Restoril, Halcion, Sonata, Ambien,

Zimovane)

Cumulative limit of 30 units in 30 days.

Lidocaine/tetracaine

(Synera)

Limit of 5 patches per 30 days





Adult Acne for patients 21

years and older

Diagnosis of acne vulgaris AND/OR Nodular acne AND/OR Cystic acne.

AUTHORIZATION: 6 months.

RE-AUTHORIZATION: Documentation indicating patient has had at least a 25%

improvement or more from baseline. Re-authorization is then for 6 months.

Tadalafil

(Adcirca)

Minimum age requirement: 18 years old

Documented diagnosis of pulmonary hypertension

AUTHORIZATION: 1 year

RE-AUTHORIZATION: 1 year with an updated letter of medical necessity

Dalfampridine

(Ampyra)

Minimum age requirement: 18 years old.

Documented diagnosis of Multiple Sclerosis.

No history of seizures.

No history of moderate to severe renal impairment, as evidenced by a creatinine

clearance rate greater than or equal to 51mL/min.

AUTHORIZATION: Initial authorization will be granted for three months. Three

months is sufficient to assess efficacy in each patient.

RE-AUTHORIZATION: Reauthorization period is 1 year. Updated letter of

medical necessity indicating: no seizures, current renal function greater than or

equal to 51ml/min, and documented treatment efficacy (i.e. an increase in walking

speed).

Androgens Danazol® for Females, initial authorization:

only FDA-approved uses will be considered

Please submit appropriate documentation describing one of the following:

Hormone-responsive endometriosis

Trial and failure of at least one other treatment for fibrocystic breast disease

Trial and failure of at least one other treatment for hereditary angioedema

AUTHORIZATION: 6 months

Androgens for Males, initial authorization:

≥ 18 years old

Diagnosis of testicular hypofunction or disorder of the pituitary gland

Symptoms of testosterone deficiency

Two morning testosterone levels below the individual lab’s reference range

(different laboratories use different assays and thus may have different ranges

which are considered low, optimal, or high)


Danazol for Females, re-authorization:

Requests must be accompanied by progress notes or a letter of medical necessity

justifying continued therapy.

Therapy must be for an FDA-approved use.

REAUTHORIZATION: 1 year at a time.

Androgens for males, re-authorization:

Requests must be accompanied by one morning testosterone levels, drawn on

different days while on androgen therapy, in order to verify drug absorption. Labs

drawn while off androgen therapy will not be accepted. If labs are not obtained

while on androgen therapy, the patient must wait 6 months (androgen free) before

re-applying for a new authorization

REAUTHORIZATION: 1 year at a time.





Bromocriptine

(Cycloset)

Age > 18 years.

Diagnosis of Type 2 Diabetes.

Failure on or contraindication to Metformin.

May not be used concurrently with a TZD (i.e. Avandia or Actos) or by lactating

women.

Maximum approved dose is 4.8mg daily.

Initial authorization is for 6 months – renewal periods of 1 year require

documentation of improvement of A1C and/or fasting plasma glucose.

NOTES: This form is for Non-Traditional member only. Traditional member may

receive this medication without a prior authorization.


RE-AUTHORIZATION: Updated letter of medical necessity

Anti-Emetics

Palonosetron

(Aloxi)

Covered under the medical

benefit using the J code.

Aloxi:

Prevention of acute or delayed nausea and vomiting associated with initial and

repeat courses of moderately emetogenic cancer chemotherapy.

Must have failed on Zofran, Anzemet or Kytril (5-HT3’s).

No other 5-HT3 medications are allowed as rescue drugs.

AUTHORIZATION: 6 months. RE-AUTHORIZATION: Repeat course of chemotherapy following initial 6

months requires a new authorization.

Aprepitant

(Emend)

Emend:

Patients receiving cancer chemotherapy regimens that are classified as high emetic

risk may receive Emend as a first-line treatment.

Patients on other cancer chemotherapy regimens require a failure on trial of and

ONE of the 5HT3 medications (e.g. Zofran, Anzemet, Kytril or Aloxi)

INFORMATION: Used in combination with corticosteroid and other 5HT3

agents, is indicated for the prevention of acute and delayed nausea and vomiting

associated with initial and repeat courses of highly emetogenic cancer

chemotherapy including high dose Cisplatin. AUTHORIZATION: 6 months, 3 doses per chemotherapy session.


Becacizumab

(Avastin)



Minimum age - 18 years old.

Documentation of one fo the following diagnoses:

Metastatic colorectal cancer

Non-squamous, non-small cell lung cancer

Glioblastoma

Metastatic renal cell carcinoma

Persistent, recurrent or metastatic carcinoma of the cervix

Platinum-resistant recurrent epithelial ovarian, fallopian tube or primary peritoneal

cancer

INFORMATION: To be given in clinic setting only. Provider will bill with J code

J9035, NDC number, and PA number. Patients with ACO’s will have to make

arrangements with their ACO for coverage.

AUTHORIZATION: Initial prior is for 1 year

RE-AUTHORIZATION: Subsequent PA is for 1 year, with an updated letter of

medical necessity.





Botulinum Toxins



DRUG INDICATION CRITERIA Botox®, Dysport®,

Myobloc®, Xeomin®

Cervical Dysonia Age ≥ 16

Documented disease; provide diagnosis code.

Botox®, Xeomin® Blepharospasm or Strabismus

Age ≥ 12 Documented disease; provide diagnosis code

Must fail Botox® before Xeomin® can be

approved.

Botox® Chronic migraine Age ≥ 18

≥15 migraines per 30 days

Each migraine lasting ≥ 4 hours Must fail at least 1 (or have contraindications

to all) of the following antimigraine

medications: topiramate, propranolol, valproic acid and/or timolol

Botox® Overactive bladder or

urinary incontinence

Age ≥ 18

Documented neurologic disease; provide

diagnosis code Must fail ≥ 1 anticholinergic medication

before Botox® can be approved

Botox®, Dysport® Spasticity Age ≥ 18 Documented disease; provide diagnosis code

Dysport® Lower limb spasticity Age > 2

Documented disease; provide diagnosis code

Xeomin® Upper limb spasticity Age > 18 Documented disease; provide diagnosis code

NOTES:

Botulinum Toxin is not covered for any cosmetic or off-label uses. These include

primary axillary hyperhydrosis, sialorrhea, and gastroparesis.

Botox®: please bill both J0585 and current appropriate CPT code.

Dysport®: please bill both J0586 and current appropriate CPT code.

Mybloc®: please bill J0587 and current appropriate CPT code

Xeomin®: please bill J0588 and current appropriate CPT code

Maximum approved doses per 3 month PA period are:

Botox Dysport Myobloc Xeomin 300 units/3 months 1,000 units/3 months 10,000 units/3 months 120 units/3 months


RE-AUTHORIZATION: 3 months with documentation of favorable therapeutic

outcome(s).

Brand Name Medication Explanation of why treatment was initiated with the branded product

OR

Details of adverse reaction, allergy, or inadequate response to the generic

equivalent. Prior authorizations for brand name medications require physician

evaluated, charted documentation of an allergic reaction, adverse reaction or

inadequate response. Patient complaints of lack of efficacy are not acceptable

reasons for failure such as “member said”, “member reports”, “doesn’t work” or

“causes nausea.”

NOTES: Many extended-release branded products do nay have extended-release

generic equivalents. In these cases, an adequate trial of the short-acting generic

product is required.

AUTHORIZATION: one year






Butalbital Containing

Products

As established in the U.S. Headache Consortium’s evidence-based guidelines for

migraine treatment


Trial and failure of:

one or more non-steroidal anti-inflammatory agent

AND

one or more triptans (any administration route)

AND

intranasal dihydroegotamine

AND

butorphanol

AND

an acetaminophen-codeine combination product

AND

an aspirin-caffeine-acetaminophen combination product

A letter of medical necessity detailing the patient’s unsatisfactory response to each

agent above.


RE-AUTHORIZATION: Written request from physician demonstrating that the

patient’s response to the butalbital-containing product is positive, AND that the

patient’s response to the butalbital-containing product is significantly better than to

products that do not contain butalbital.





Oral

Buprenorphine/Naloxone

Combination Products, Oral

Buprenorphine Single-Agent

Products

(Suboxone, Zubsolv,

Bunavail, Subutex)

QUANTITY LIMITS

Maximum daily limits are as follows and apply to both the brand and generic

formulations:

Suboxone: 24mg/day; not to exceed 3 doses per day

Zubsolv: 17.1mg-4.2mg/day; not to exceed 2 doses per day

Bunavail: 12.6mg-2.1mg/day; not to exceed 2 doses per day

Subutex: 24mg/day; not to exceed 3 doses per day

INITIAL 180-DAY PERIOD –Prior authorization is NOT required.

CRITERIAFOR CONTINUATION (3 years)

If the medication is required beyond the initial 180-day period, on an annual basis,

providers must submit an attestation that the following information is present in the

patient’s medical record:

Diagnosis of opioid dependence

Description of psychosocial support the patient will receive/is receiving

A treatment plan detailing management and potential for tapering/discontinuation

ADDITIONAL CRITERIA FOR SINGLE-AGENT BUPRENORPHINE

PRODUCTS:

Patient must be pregnant

OR

Patient must have a verified naloxone allergy, described in medical record

AUTHORIZATION FOR LONG-TERM THERAPY (following 3 year

continuation)

If the medication is required beyond the 3-year continuation period, on an annual

basis thereafter, providers must submit the following documentation from the

patient’s medical record with this request form:

Diagnosis of opioid dependence

Description of psychosocial support the patient will receive/is receiving

A treatment plan detailing management, tapering efforts, and

reason(s)discontinuation is not possible

ADDITIONAL CRITERIA FOR SINGLE-AGENT BUPRENORPHINE

PRODUCTS:

Patient must be pregnant

OR

Patient must have a verified naloxone allergy, described in medical record

Buprenorphine

(Butrans)


Diagnosis of moderate to severe chronic pain requiring continuous, around-the-

clock opioid analgesic for an extended period of time.

Documented trial and failure of ≥ 1 oral non-opioid agent(s).

Documented trial and failure of ≥ 1 oral opioid agent.

NOTES: Prior authorization will be granted for up to 4 patches per 28 days.

AUTHORIZATION: Initial authorization period is for 3 months.

RE-AUTHORIZATION: Reauthorization periods of up to one year require

documentation that the patient is using the drug appropriately, and documentation

of satisfactory pain control.

Colchicine

(Colcrys) Gout:


Documented failure on allopurinol.

Documented failure on or contraindication to corticosteroids and NSAIDS.

Maximum approved dose is 1.8mg every 3 days.

Familial Mediterranean Fever:






Documented diagnosis of Familiar Mediterranean Fever.

Maximum approved dose is 2.4mg per day.

AUTHORIZATION (for both indications): The initial prior authorization will be

approved for one year

RE-AUTHORIZATION (for both indications): Updated letter of medical

necessity





Cytomegalovirus Immune

Globulin

(Cytogam)



For the prophylaxis of cytomegalovirus

Documented transplantation of kidney, lung, liver, pancreas, or heart.



Selegiline

(Emsam)

Physician documentation from charted progress notes of failure with a minimum of

three other antidepressants, which may include MAOI.

Previous intolerance to an oral trial of MAOI.

No concurrent antidepressant therapy.



Deflazacort (Emflaza) Laboratory confirmation of DMD diagnosis by genetic testing; AND

Patient is male and 5 years of age or older; AND

Patient has tried prednisone for 3 months and experienced unmanageable side

effects:

Weight gain OR

Psychiatric or behavioral issues; AND

Prescribed by neurologist.

Initial Authorization for up to 6 months

Reauthorization every 12 months: Chart notes demonstrating positive response to

therapy.

Sacubitril/valsartan

(Entresto)

An automatic PA will be given at the pharmacy point of sale, with no intervention

from prescriber or pharmacist, if the following are met:

Minimum age requirement 18 years old

Trial on an ACEI or an ARB

NOT taking aliskiren (e.g. Tekturna or Tekturna HCT)

NOT pregnant (if applicable)

OR

Diagnosis of systolic heart failure or reduced left ventricular ejection fraction


REAUTHORIZATION: Updated letter of medical necessity and evidence that

patient is responding to treatment

Enzymes

Pegademase bovine

(Adagen)



Adagen:

Documented diagnosis of Adenosine Deaminase Deficiency (ADA)

Copy of prescription from physician.

Dose must be delivered in pre-filled syringe for exact dosing.

Medicaid must be notified of changes in dosage with a copy of new prescription.

AUTHORIZATION: 1 year.

RE-AUTHORIZATION: Updated letter of medical necessity.

Laronidase

(Aldurazyme)



Aldurazyme:

Documented and confirmed diagnosis of Hurler and Hurler-Scheie.

NOTES: Confirmed diagnosis is defined as Hurler and Hurler Scheie of

mucopolysaccharidosis I (MPS I) in patients with Scheie form who have severe

symptoms. AUTHORIZATION: 6 months.






Alpha 1-proteinase inhibitor

(Aralast)



Aralast:

Diagnosis of emphysema.

Current treatment

Treatment failures.

Explanation of condition that demands augmentation with Aralast.


RE-AUTHORIZATION: 1 year with documentation of sustained improvement.

Imiglucerase, Velaglucerase

alfa

(Cerezyme/Vpriv)



Cerezyme/Vpriv:

Documented diagnosis of Gaucher’s Disease.

Medicaid must be notified of changes in dosage with a copy of new prescription.


RE-AUTHORIZATION: 1 year with documentation of significant improvement.

Agalsidase beta

(Fabrazyme)



Fabrazyme:

Documented deficient plasma or leukocyte a-galactosidase A (a-gal) OR

Documented a-gal deficiency and/or mutation in the a-gal A gene in heterozygous

females.

Covered only for patients with documented ADA deficiency.



Alpha 1-proteinase inhibitor

(Prolastin/Zemaira)



Prolastin/Zemaira:

DOCUMENTED Alpha-1 Antitrypsin deficiency AND

DOCUMENTED Panacinar Emphysema.

Must have stopped smoking for at least 30 days, as documented by physician.







Eteplirsen (Exondys 51)


benefit using the C code.

Laboratory confirmation of DMD gene mutation amenable to exon 51 sking

diagnosis by genetic testing; AND

Patient is male and 4 years of age or older; AND

Prescribed by neurologist; AND

Dosing is in accordance with FDA approved labeling.

Initial Authorization for up to 3 months

Reauthorization every 6 months:

Chart notes demonstrating positive response to therapy; AND

Prescribed by neurologist.

Teriparatide

(Forteo)

Available for the following diagnoses at high risk for bone fracture:

Postmenopausal women diagnosed with osteoporosis.

Women and men diagnosed with osteoporosis likely caused by systemic

glucocorticoid therapy.

Men diagnosed with osteoporosis (primary or hypogonadal).

Quantity limit of one injector every 28 days.

AUTHORIZATION: 24 months with no renewal option.

Gabapentin Extended Release

Products

Gabapentin

(Gralise)

Gralise:


Documented diagnosis of postherpetic neuralgia

Dose limited to less than or equal to 1,800mg daily.

Documented failure of a trial of regular release gabapentin, at therapeutic dose, for

one month.

AUTHORIZATION: Initial authorization will be granted for 1 year.


Gabapentin enacarbil

(Horizant)

Horizant:


Documented diagnosis of restless leg syndrome.

Dose limited to less than or equal to 600mg daily.

Documented failure of a trial of regular release gabapentin, at a therapeutic dose,

for one month.

AUTHORIZATION: Initial authorization will be granted for 1 year.


Timothy Grass Pollen

Allergen Extract

(Grastek)

Member must be between 5 and 65 years of age

Provide documentation of a grass pollen-induced allergic rhinitis, with or without

Conjunctivitis, confirmed by positive skin test or in vitro testing for pollen-specific

IgE antibodies for Timothy grass or cross-reactive grass pollens.

Therapy must be initiated at least 12 weeks before the expected onset of each grass

pollen season. (December 5 to January 10)

AUTHORIZATION: One year

RE-AUTHORIZATION: Three consecutive years

Member age between 5 and 65 years of age.

Initial therapy was approved and initiated at least 12 weeks prior to expected onset

of grass pollen season.

Therapy has been continuous throughout grass pollen season.





Growth Hormone for Adults

(AIDS Wasting Syndrome

Only): Serostim

Adult age 19 and older.

Adult onset - AIDS Wasting indication only.

Body Mass Index is less than 20, BMI = wt. times 704 divided by height squared

(in inches)

Patient must be taking antiretroviral medications.

Provide initial height and weight, weight after 60 day trial.

Rule out other causes of weight loss including hypogonadism, opportunistic

infections, diarrhea, inadequate nutritional intake, malabsorption, and thyroid

abnormalities.

(For men) Rule out hypotestosterone levels since hypogonadism is common among

HIV infected individuals.

Patients must be able to maintain 100% of daily nutritional intake. For patients

receiving enteral or parenteral nutrition, the patient must be weight stable for 2

months.

Patient must not have an untreated or suspected systemic infection or persistent

fever > 101 F during the 30 days prior to evaluation of weight loss.

Patient must not have any signs or symptoms of gastrointestinal malabsorption or

blockage unless on total parenteral nutrition.

Patient must not have active malignancy, except for Kaposi’s Sarcoma.

AUTHORIZATION: Initial trial 60 days.

RE-AUTHORIZATION: Fax copy of current prescription and history and

physical showing weight gain during trial period. With appropriate progress, the

patient may receive an additional four weeks of therapy. If the patient continues to

show progress, additional prior authorizations are granted in 6 weeks periods to a

maximum of 12 weeks per any 6 month episode.





Growth Hormone (Children):

Genotropin, Humatrope,

Norditropin, Nutropin,

Omnitrope, Saizen,

Zomacton, Zorbtive

Criteria for Pan Hypopituitarism:

Approved for ages 0-18; must have started before age 16.

Documented diagnosis of panhypopituitarism.

Criteria for Turner Syndrome: Approved for ages 0-18; must have started before age 16.

Documented diagnosis of Turner Syndrome.

Criteria for Small Gestational Age: Request made before age 3.

Documented diagnosis of small gestational age

Child has normal GH blood levels (may have documented GH resistance)

Must be under the care of or have extensive endocrinologist consultation.

A copy of the prescription signed by the physician must be submitted with

application.

Criteria for all other covered diagnoses: Approved for ages 0-18; must have started before age 16.

Must have a height stature less than the 5th percentile on the Physical Growth

NCHS Percentiles Chart for the correct age and sex.

Growth rate must be documented in centimeters for at least 6 months immediately

before initiation of growth hormone treatment.

Prescribed by endocrinologist or with endocrinology consultation.

One of the following diagnoses:

Documented endogenous growth hormone secretion of < 10ng/ml after provocative

stimulation; OR

Growth failure associated with documented chronic renal insufficiency up to the

time of renal transplantation; OR

Long-term treatment of idiopathic short stature, also called non-growth hormone-

deficient short stature, defined by height SDS (Standard Deviation) < 2.25

(Humatrope) OR

Treatment of short bowel syndrome in patients receiving specialized nutritional

support.

Patients diagnosed with Prader Willi must complete a sleep oximetry study. If the

oximetry is abnormal, a full polysomnography study is required. GH is

contraindicated in patients with sleep apnea – PA will not be granted to members

that have sleep apnea.

AUTHORIZATION: 1 year. Maximum covered time period for small gestational

age only is 2 years.

RE-AUTHORIZATION: Copy of the current prescription, patient’s current

weight (kilograms) and height (centimeters), and chart-documented regarding from

growth in past year. Treated growth rate must exceed untreated rate by 2

centimeters per year (this last sentence does not apply to patients being treated for

small gestational age).





Hepatitis Medications

Diagnosis of Hepatitis C

Patient must undergo Hepatitis C genotype testing and submit a copy of the testing

results. The requested agent must be FDA-approved to treat the patient’s genotype.

FDA-approved genotype indications:

Daklinza (daclatasvir): 1, 3

Epclusa (Sofosbuvir/Velpatasvir): 1, 2, 3, 4, 5, 6

Harvoni (ledipasvir and sofosbuvir): 1, 4, 5, 6

Olysio (Simeprevir): 1, excluding 1a

Sovaldi (Sofosbuvir): 1, 2, 3, 4

Technivie (Ombitasvir, paritaprevir and ritonavir): 4

Viekira and Viekira XR (Dasabuvir, ombitasvir, paritaprevir, and ritonavir): 1a, 1b

Zapatier (Elbasvir-Grazoprevir): 1a, 1b, 4

Prescriber is, or has consulted with, an infectious disease physician, hepatologist,

gastroenterologist or a physician assistant or nurse practitioner who practices with

an infectious disease physician, hepatologist, or gastroenterologist.

Initial Authorization Period: 12 weeks

Reauthorization: Note that, in many cases, the initial authorization will suffice for

a full treatment course. If continued treatment is desired, please re-submit all of the

above and a letter of medical necessity.

Hyaluronic Acid Derivatives:

(Durolane; Euflexxa; Gel-

One; Gelsyn-3; Genvisc 850;

Hyalgan; Hymovis;

Monovisc; Orthovisc;

Supartz; Synvisc)



Criteria for Opthalmic Preparations

Covered only for ophthalmic surgeries (no cosmetic or off-label use). Please

indicate the procedure(s) planned and the patient’s pertinent diagnosis code(s)

AUTHORIZATION is required for each surgical episode (no re-authorization)

Criteria for Topical Preparations

Covered only for wound care (no cosmetic or off-label use). Please indicate the

patient’s pertinent diagnosis code(s)

AUTHORIZATION 3 months

REAUTHORIZATION 3 months, upon submission of a letter of continued

necessity including updated diagnosis codes

Criteria for Intra-Articular Preparations:

Covered only for injection into the knee for the treatment of osteoarthritis (no

cosmetic or off-label use, including other joints). Please indicate the patient’s

pertinent diagnosis codes

Please bill using the appropriate product-specific J code.

AUTHORIZATION: 1 treatment cycle = 1 injection per week, up to 5 weeks

REAUTHORIZATION: Each treatment cycle, upon submission of a letter of

medical necessity, including updated diagnosis codes.

Hydroxyprogesterone

Caproate (17-p)

(Extemporaneous

Compounds and Makena)

Prescribed for the prevention of preterm labor for patients with prior history of

preterm delivery.

Must be prescribed by or consultation with an OBGYN.

Therapy initiated between weeks 16-23 of gestation.

The patient must not be in active labor at the time of administration.

If the compounded product is requested, the pharmacy provider must be certified by

Utah Medicaid as compliant with USP Chapter 797 standards for sterile preparation

of the injection.

AUTHORIZATION: For duration of the pregnancy

RE-AUTHORIZATION: Same as initial





Mecasermin

(Increlex)



Patient age >2 and <18; must start therapy prior to age 16

Diagnosis of growth failure.

Documented diagnosis of Primary IGF-1 Deficiency.

Normal to elevated GH level and IGF-1 level at or below -3.0 standard deviations

from normal levels.

Must have a height stature less than the 5th percentile on the Physical Growth

NCHS Percentiles Chart for correct age and sex.

Secondary forms of IGF-1 deficiency (e.g. malnutrition, hypothyroidism, chronic

anti-inflammatory steroid use) have been ruled out.


RE-AUTHORIZATION: Documented improvement on the Physician Growth

NCHS Percentile Chart for correct age and sex.

Romidepsin

(Istodax)




Documented diagnosis of cutaneous or peripheral T-cell lymphoma.

Documentation of at least one other prior systemic therapy.

To be paid through HCPCS code to an infusion center or physician’s office.

Initial authorization is for one year. Renewal requests require an updated letter of

medical necessity showing maintenance or improvement on Istodax.

Ivacaftor

(Kalydeco)

Must be used for the treatment of cystic fibrosis. Please indicate the diagnosis code.

Age ≥ 2 years

Please include laboratory results verifying any of the following CFTR (conductance

regulator potentiator) gene mutation. Treatment will only be considered for FDA-

acknowledged gene mutations.

Initial Authorization: 6 months

Reauthorization: 6 months

Please submit medical records showing treatment efficacy.

Ketorolac (oral dosage forms

only)

(Toradol)


Available only as continuation of IV/IM therapy.

Documented failure of at least three other NSAIDS.

Limited to a total of five days of use.

AUTHORIZATION: Only one authorization will be granted per acute incident.

RE-AUTHORIZATION: Same as initial





Pegloticase

(Krystexxa)




Documented failure on, or contraindication to allopurinol

Documented failure on, or contraindication to probenecid.

Documented failure on, or contraindication to colchicine.

Prescribed by a rheumatologist or nephrologist informed about proper procedures.

Completion of a G6PD screen before treatment initiation (please submit results).

Dose not to exceed one 8mg infusion every 14 days.

Description of the anaphylactic measures to be taken prior to infusion.

Description of proper resuscitative procedures in place to treat anaphylaxis

NOTES:

Krystexxa is NOT indicated to treat asymptomatic gout or prophylaxis of gouty

attacks. Requests for such indications will be denied.

As per indication, treatment to prevent anaphylaxis MUST be given with EACH

Krystexxa infusion.

This medication is only payable through J-code J2507 to a physician’s office.

Patients with ACO’s will have to make arrangements with their ACO for coverage.

AUTHORIZATION: The initial prior authorization will be approved for 3

months.

RE-AUTHORIZATION:

Documentation from progress notes describing positive response to treatment, and

lack of serious anaphylaxis or side effects.

Reauthorization will not be given if a patient has more than 2 serum uric acid levels

over 6mg/dL after treatment initiation

Reauthorizations will be approved for 6 months

Lidocaine

(Lidoderm, Xylocaine) Transdermal lidocaine patches (Lidoderm®): Patient diagnosis must be postherpetic neuralgia or other peripheral neuropathy.

Maximum of 90 patches per 30 day time period


RE-AUTHORIZATION: 1 year upon submittal of a letter from the prescriber

indicating drug effectiveness

Viscous lidocaine solutions: Patients must be > 3 years old

AUTHORIZATION: One prescription fill

RE-AUTHORIZATION: 3 months upon submittal of a letter from the prescriber

indicating drug effectiveness and rational for continuing therapy

All other topical lidocaine containing products:

Maximum of 60g container topical lidocaine

Authorization:

AUTHORIZATION: One prescription fill

RE-AUTHORIZATION: 3 months upon submittal of a letter from the prescriber

indicating drug effectiveness and rational for continuing therapy

Metabolic Supplements (for

support of in-born errors of

metabolism such as PKU)

Documented diagnosis of condition resulting in in-born error of metabolism.

AUTHORIZATION: 1 year.






Methadone Member Criteria:

Member is > 18 years old;

Member has used a short-acting opiate, including tramadol or tapentadol, within the

past 30 days (i.e., opiate tolerant); OR

Member does not have a paid claim for a benzodiazepine within the past 45 days;

OR

Member does not have a paid claim for any buprenorphine-naloxone combination,

buprenorphine, naloxone or naltrexone medication within the past 18 months.

Prescriber Criteria:

Include a treatment agreement, including discontinuation criteria, signed by the

provider and the member.

Prescriber must hold and provide copy of a current American Board of Medical

Specialties (ABMS) Pain Medicine Subspecialty Certificate or equivalent training

OR must work in continued consultation with a prescriber that holds a current

ABMS Pain Medicine Subspecialty Certificate.

NOTE: If the member is enrolled in a research protocol or clinical trial involving

the long acting opiate, the trial must provide the medication.

Initial Authorization: 3 months

Reauthorization: 6 months

New-to-Market Drugs

If new drug is a stereoisomer, prodrug, active metabolite, new dosage form, new

salt, or a fixed combination of two existing drugs:

Use must follow FDA-approved labeling

Patient must use the innovator or Preferred drug first*

If the new drug is a biologic or orphan drug:

Use must follow FDA-approved labeling

If the drug is specific to certain genes or mutations, appropriate testing must be

completed

If other drugs are available for the same indication, the patient must fail a Preferred

drug*

*Note that the Preferred Drug List is available online at

https://medicaid.utah.gov/pharmacy/preferred-drug-list

Sorafenib

(Nexavar)

Patient must be age 18 or above.

Diagnosis of advanced renal cell carcinoma, OR

Diagnosis of unresectable hepatocellular carcinoma

Diagnosis of locally recurrent or metastatic, progressive, differentiated thyroid

carcinoma refractory to radioactive iodine treatment

AUTHORIZATION: 1 year at a maximum dose of 400mg BID.

RE-AUTHORIZATION: reauthorization for 1 year via an updated letter of

medical necessity

Non-Preferred Combination

Product and/or Dosing Kit

Authorization Request

Combination Products: Utah Medicaid generally requires the use of multiple

single-entity products instead of one combination product. Unless a combination

product is listed as Preferred on Utah Medicaid’s Preferred Drug List, please

provide objective clinical evidence against using the individual agents.

Kits: Utah Medicaid does not generally reimburse for dosing kits (e.g. therapy

initiation dose titration kits). Provide objective clinical evidence regarding the

necessity of a kit.







Non-Preferred Drug

Authorization

A trial and failure of at least one preferred agent in the drug class, including

the name of the preferred drug that was tried, the length of therapy, and the reason

for discontinuation.

Detailed evidence of a potential drug interaction between current medication and

the preferred drug.

Detailed evidence of a condition of contraindication that prevents the use of the

preferred drug.

Objective clinical evidence that a patient is at high risk of adverse events due to a

therapeutic interchange with a preferred drug.



Armodafinil

(Nuvigil)

Failure on a ≥ 6 week trial of, or contraindication to, modafinil (Provigil)


Covered Diagnoses:

Narcolepsy, Amphetamines or Methylphenidate must be tried first. Dose limited to

250mg per day.

Daytime somnolence due to Obstructive Sleep Apnea: must be on CPAP. Dose

limited to 150mg per day.

Shift Work Sleep Disorder, must be working night shifts. Provide documentation

of a treatment plan that demonstrates excessive sleepiness at work, insomnia when

the patient should be sleeping. Patient must have a three-month trial of sleep aids.

Dose is limited to 150mg/day.

NOTES: Modafinil (Provigil) and Nuvigil are mutually exclusive. Patients may

only have a prior authorization for one of these medications at a time



Sweet Vernal, Orchard,

Perennial Rye, Timothy, and

Kentucky Blue Grass Mixed

Pollens Allergen Extract

(Oralair)

Age between 10 and 65 years

Provide documentation of a grass pollen-induced allergic rhinitis, with or without

conjunctivitis, confirmed by positive skin test or in vitro testing for pollen-specific

IgE antibodies for any of the five grass species contained in Oralair (Sweet Vernal,

Orchard, Perennial Rye, Timothy, and Kentucky Blue Grass Mixed Pollens

Therapy must be initiated at least 12 weeks before the expected onset of each grass

pollen season (December 5 to January 10)

First dose must be administered under supervision of a physician with experience in

the diagnosis and treatment of allergic diseases. Letter of medical necessity or

progress notes must document that patient will be observed, in the office for at least

30 minutes following the initial dose.

AUTHORIZATION: One year

RE-AUTHORIZATION: Three consecutive years

Member age between 10 and 65 years of age.


of grass pollen season. has been continuous throughout grass pollen season

Lumacaftor/ivacaftor

(Orkambi)

Must be used for the treatment of cystic fibrosis. Please indicate the diagnosis code.

Age ≥ 12 years

Please include laboratory results verifying that the patient is homozygous for the

F508del mutation in the CFTR gene.





Oxandrolone

(Oxandrin) First 60 day trial period: Age ≥ 18 years

Body Mass Index < 20. Please provide current height, weight and BMI.

Please describe the patient’s nutritional intake. Patient must receive at least partial

nutrition orally.

Please describe concurrent therapies for weight gain (Oxandrin is not approved for

monotherapy).

Authorization after 60 day trial (may approve for an additional 4 months):

All criteria above remain effective. (Age, BMI, nutrition and pertinent concurrent

therapies).

Weight needs to have been maintained or has increased. Please provide current

height, weight and BMI.

If weight has not maintained, Oxandrin will not be re-authorized.

If weight is maintained or has increased, the patient may remain on Oxandrin.

AUTHORIZATION: 60 day trial, if weight is maintained or has increased, an

additional 4 months may be approved.

RE-AUTHORIZATION: 6 months.

PAMORAs (Peripherally-

Acting Mu-Opioid Receptor

Antagonists):

Methylnaltrexone (Relistor);

Naldemedine (Symproic);

Naloxegol (Movantik);

Patient age ≥ 18 year

Diagnosis of opioid-induced constipation. Please indicate diagnosis code.

Note: mechanical GI obstruction or other conditions are not FDA-approved

indications

Patient is receiving opioids

Patient is not taking other drugs that may cause or contribute to constipation

Must fail a trial of stimulant laxative and a stool softener


REAUTHORIZATION: Letter from prescriber indicating drug effectiveness,

duration 1 year

Physician-Administered Drug Please see

https://medicaid.utah.gov/pharmacy/priorauthorization/pdf/Physician%20Administ

ered%20Review%20Request%20Form.pdf

Proprotein Convertase

Subtilisin Kexin Type 9

Inhibitor Antibodies (PCSK9

Inhibitors)

Alirocumab (Praluent)

Evolocumab

(Repatha/Repatha

Pushtronex)

Failure on HMG-CoA reductase inhibitor (“statin”) therapy: at maximum

FDA-approved dose to establish statin insufficiency or at minimum FDA-

approved dose to establish patient intolerability.

Medication should be prescribed by, or in consultation with, an ABCL (or

equivalent) certified lipid specialist.

Cholesterol level before treatment:

LDL ≥ 100 mg/dL or non-HDL ≥ 130 mg/dL For secondary prevention of

cardiovascular events in patients with Heterozygous FH, or Type 2 Diabetes,

or two major risk factors as defined by current guidelines

LDL ≥ 130 mg/dL or non-HDL ≥ 160 mg/dL For primary prevention of

cardiovascular events in patients with Heterozygous FH, or Type 2 Diabetes,

or two major risk factors as defined by current guidelines

LDL ≥ 160 or non HDL ≥ 190 For patients with at least one risk factor as

defined by current guidelines


RE-AUTHORIZATION: 1 year with a letter from the prescriber indicating

drug effectiveness





Proton Pump Inhibitors:

Dexlansoprazole,

Esomeprazole, Lansoprazole,

Omeprazole, Pantoprazole,

Rabeprazole,

(Dexilant, Nexium, Prevacid,

Prilosec, Zegrid, Protonix,

Aciphex)

Hypersecretory Conditions:

Write the appropriate hypersecretory condition or H. pylori diagnostic code on the

face of the prescription. Twice-daily dosing will be reimbursed at the pharmacy

point of sale with no further intervention on your part.

Other Diagnosis:

Evidence of failure on an appropriate dosing regimen

Consultation with a GI, ENT, pulmonary or allergy specialist.

Special Populations:

Liquid and quick-dissolving tablets are available without PA to patients under 12

years old. An automatic PA will occur at the pharmacy point of sale.

Liquid and quick-dissolving tablets are available to patients of any age with any

type of feeding tube. Indicate the tube type on your PA request.

Notes: No compounded solutions will be approved, including omeprazole/sodium

bicarbonate


RE-AUTHORIZATION: 1 year, with an updated letter of medical necessity

Modafinil

(Provigil)

Pt. must be age 9 years or older

Covered for the following diagnoses:

Narcolepsy - Amphetamines or Methylphenidate must be tried first. Dose limited to

400mg daily

Treatment to offset sedation related to multiple sclerosis treatment modalities. Dose

is limited to 200mg daily

Daytime somnolence due to obstructive sleep apnea - must be on C-pap. Dose

limited to 200mg per day

Shift work sleep disorder must be working night shifts. Provide documentation of

a treatment plan that demonstrates excessive sleepiness at work, insomnia when

patient should be sleeping. Patient must have a three month trial of sleep aids.

Dose is limited to 200mg/day

NOTES: Provigil and Nuvigil are mutually exclusive. Patients may only have a

prior authorization for one of these medications at a time


RE-AUTHORIZATION: Update letter of medical necessity

Quinine

(Qualaquin)


Diagnosis of malaria

AUTHORIZATION: One 7 day course up to 42 tablets is approved with each PA

RE-AUTHORIZATION: Same as initial PA





Short Ragweed Pollen

Allergen Extract

(Ragwitek)

Member must be between 18 and 65 years of age

Provide documentation of a diagnosis of ragweed pollen-induced allergic rhinitis

confirmed by positive skin test, or in vitro testing, for pollen-specific IgE antibodies

for short ragweed pollen.

Therapy must be initiated at least 16 weeks before the expected onset of each

ragweed pollen season. (December 5 to January 10)

First dose must be administered under supervision of a physician with experience in

the diagnosis and treatment of allergic diseases. Letter of medical necessity or

progress notes must document that patient will be observed, in the office for at least

30 minutes following the initial dose.


RE-AUTHORIZATION:

Member Age between 18 and 65 years of age.


of ragweed pollen season

Therapy has been continuous throughout ragweed pollen season.

If all other criteria have been met, Ragwiteck may be approved for daily therapy for

three consecutive years.

Becaplermin

(Regranex)

Rule out venous ulcers and/or arterial ulcers

Patient must be diabetic, either type I or type II

Not covered for diabetic ulcers above the ankle

Patient must have stage III or IV diabetic foot or ankle ulcer as defined in the

International Association of Enterostomal therapy guide to chronic wound staging,

1989

Not a benefit for patients in long term care facilities, unless that patient is admitted

from home or hospital with a pre-existing diabetic ulcer of the lower extremity.

LTCF must submit a copy of skin assessment report made within 24 hours of

admission

The member must have had a documented failure on a 60 day regimen of good

ulcer care that includes but is not limited to:

Initial complete sharp debridement

A non-weight bearing regimen

Systemic treatment for wound-related infections

Moist saline dressing changes twice daily

Additional debridement if necessary

The subcutaneous diabetic face ulcer may not exceed 3cm in diameter or total

surface of 9.42cm2 (size and shape must be documented)

Total contact casting is an available method of treatment and must be considered

and rejected before Regranex is to be considered

AUTHORIZATION: 8 weeks (15-30 Grams)

RE-AUTHORIZATION: Documentation of 30% reductions in ulcer size must be

achieved before a second prior is given. Treatment is limited to a maximum of 60

grams of Regranex.





Cyclosporine

(Restasis) Restasis for Post Corneal Transplant: Documentation of diagnosis of post corneal transplant

NOTE: Maximum supply is 1 box of 32 dropperettes/month

AUTHORIZATION: Prior approval is for 1 year


Restasis for Other Diagnoses:

Superficial keratitis, unspecified OR Punctate keratitis OR Keratoconjunctivitis

sicca, not specified as Sjogren’s disease OR Sicca syndrome - Sjogren’s disease

Documentation requirements for the above diagnoses:

Diagnosis

Documented fluorescein test or slit lamp test

Request from ophthalmologists or with documented ophthalmologist consult

AUTHORIZATION: Prior approval for the above diagnoses is for 1 year

RE-AUTHORIZATION: Additional periods require steps 1-3

Retinoids





Alitretinoin

(Panretin)

Panretin:

30-day trial period:

Diagnosis of cutaneous lesions caused by Kaposi’s Sarcoma. Include the following

information:

Primary number of KS lesions.

Estimated total square centimeters.

Number of lesions flat on baseline.

Number of lesions raised on baseline.

Systemic anti-KS therapy is not yet required. Panretin is not indicated when

systemic anti-KS therapy is required. (e.g., more than 10 new KS lesion in a month,

symptomatic lymphedema, symptomatic pulmonary KS, or symptomatic visceral

involvement.)

0.1% Retin-A gel has been tried for a period of 60 days or more and there was less

than a 25% improvement of (both Partial Response Area (PRA) and Partial

Response Height (PRH)).

60 day treatment period:

Patient must sustain partial response defined as a 50% or more improvement from

base line. Include:

Number of KS lesions.


Partial Response Area.

Partial Response Height.

Continued use of Panretin: Updated letter of medical necessity indicating continued improvement. Include:

Number of KS lesions.


Partial Response Area.

Partial Response Height.

INFORMATION: Assessment of lesions is limited to only the cutaneous lesions

treated. Each lesion assessed for height and diameter. The response evaluation of

each KS index will be classified according to the following system:

Complete Response (CR): Decreased in lesion area to zero and biopsy-documented

absence of KS cells.

Clinical Complete Response (CCR): Decrease in lesion area to zero.

Partial Response Area (PRA): Decrease in lesion area by 50% or more from

baseline without concurrent increase in height or lesion form flat (macular) at

baseline to raised (plaque-like or nodular).

Partial Response Height (PRH): Complete flattening of a lesion raised at baseline

(decrease in height f from nodular or plaque-like) without concurrent increase in

lesion area by 25% or more from baseline.

Stable Disease (SD): Lesion does not meet evaluation criteria for CR, CCR, PR, or

PD.

Progressive Disease (PD): Increase in lesion area by 25% or more from baseline

area, or an increase in height from flat (macular) at baseline to raised (Plaque-like

or nodular).

AUTHORIZATION: Initial 30 day trial and 60 day treatment period as described

above.

RE-AUTHORIZATION: 60 day treatment periods are authorized with continued

improvement, as described above.





Tretinoin

(Retin-A)

Retin-A:

Diagnosis of cutaneous lesions caused by Kaposi’s Sarcoma

Pre-panretin use

List number of primary KS lesions

Indicate if lesions are flat or raised

Estimated total square centimeters

INFORMATION:

Not to be used when systemic anti-Kaposi’s Sarcoma therapy is required

For adult acne diagnoses, use the Adult Acne Prior Authorization form

AUTHORIZATION: 60 day trial on a topical tretinoin

RE-AUTHORIZATION: Documentation indicating patient has had at least a 25%

improvement or more from the baseline. Re-authorization is then for 6 months

Sildenafil citrate

(Revatio)

Documented diagnosis of pulmonary hypertension



Tolvaptan

(Samsca)

Documentation that therapy was initiated in the hospital

Documentation that Samsca is required for hypervolemic or euvolemic

hyponatremia associated with heart failure, cirrhosis, or SIADH

Documentation that serum sodium ≤ 125mEq/L

Documentation that hyponatremia is symptomatic if serum sodium >125mEq/L

AND documented failure of other treatments strategies including but not limited to:

Documented failure of fluid restriction

Documented failure of salt administration (for euvolemic hyponatremia only)

Documented failure of demeclocycline (for SIADH only)

Evidence is required that the underlying disease state causing the hyponatremia is

being adequately treated

Dose limited to 60mg daily

AUTHORIZATION: Initial authorization is for 60 days

RE-AUTHORIZATION: Subsequent authorizations will only be granted by

petition to the DUR Board

Maraviroc

(Selzentry)

Minimum age: 16 years old

Documentation of co-receptor tropism assay test indicating CCR5-tropic HIV-1

infection

Documentation of optimized background therapy for the treatment of HIV-1

infection



Simvastatin

(Zocor) Doses that exceed 40mg per day require prior authorization:

The patient has been received greater than 40 mg of simvastatin daily (either as

simvastatin or as Vytorin) for 12 or more months, with no evidence of myopathy.

AND

The patient is not receiving any medications which are contraindicated for use with

simvastatin (at any dose)


RE-AUTHORIZATION: Submission of medical notes indicating therapeutic

efficacy and continued lack of myopathic symptoms





Bedaquiline

(Sirturo) Age ≥ 18 years The patient must have active , pulmonary TB Describe previously tried agents, and the nature of treatment failure Indicate the three or four agents planned to be used adjunctively with Sirturo Describe the arrangements for DOT NOTES: Sirturo is not FDA-approved to treat latent or extra-pulmonary tuberculosis (TB) Sirturo is FDA-approved for adjunctive treatment or multi-drug resistant TB, not

for drug-sensitive TB Sirturo must be used in combination with at least 3 other agents that are active

against the patients specific TB isolate If testing to identify isolate(s) is unavailable, Sirturo must be used in combination

with at least 4 other antitubercular agents

Per the FDA, the administration of each Sirturo tablet must be observed by a health

care professional (Directly Observed Therapy, DOT)

AUTHORIZATION/ DOSE LIMITATIONS: Days 1-14: four 100mg tablets (400mg) once daily; 56 tablets per 14 days Weeks 3 – 24: two 100mg tablets (200mg) three times weekly; 126 tablets for 21

weeks RE-AUTHORIZATION: Subsequent authorizations may only be granted by

petition to the DUR Board

Eculizumab

(Soliris)



Documented diagnosis of atypical hemolytic uremic syndrome (aHUS) OR

paroxysmal nocturnal hemoglobinuria (PNH).

Review by the DUR Board. Please include ample clinical information in support of

your diagnosis-specific request.


J1300, NDC number, and PA number.


RE-AUTHORIZATION: 1 year with updated letter of medical necessity and

documentation of patient progress.

Pegvisomant

(Somavert)

DOCUMENTED acromegaly.

DOCUMENTATION showing inadequate response to either transsphenoidal

adenomectomy or radiotherapy or both.

DOCUMENTED trial on at least one Dopamine agonist such as cabergoline

(Dostinex) or bromocriptine.

DOCUMENTATION that patient has been evaluated for a somatostatin analogue

such as octreotide acetate (sandostatin).



Sunitinib

(Sutent) Minimum age requirement: 18 years old.

Documentation of advanced renal cell carcinoma; OR

Documentation of Gastrointestinal stromal tumor with disease progression or

intolerance to Gleevec.

INFORMATION: Dosing: 50mg daily, 4 weeks on and 2 weeks off. Dose

increase or reduction is in 12.5mg increments.


RE-AUTHORIZATION: Updated letter or progress note showing improvement

or maintenance on Sutent.





Pramlintide

(Symlin)

Is being used for Type 1 or Type 2 adjunct therapy for patient who uses mealtime

insulin.

Patient has failed desired glucose control despite optimal insulin therapy

Patient does not have gastroparesis or hypoglycemia

Is insulin compliant

Does regular insulin monitoring

Has HbA less than 9%

Has not had a hypoglycemic incident requiring assistance in the past 6 months

AUTHORIZATION: 1 Year


Palivizumab

(Synagis) All of the Following are Eligible for a Maximum of Five (5) Doses (the last dose

must be given on or before April 30, regardless of when treatment began): Premature infants (born < 29 weeks, 0 days gestation) during their first year of life

Premature infants (born < 32 weeks, 0 days) who received > 21% oxygen for at

least 28 days immediately after birth

Infants < 12 months of age if they have been diagnosed with

congenital abnormalities of the airway

neuromuscular disease that compromise(s) handling of respiratory secretions

acyanotic heart disease AND currently being treated for CHF AND will undergo a

cardiac procedure

moderate to severe pulmonary hypertension

Children < 24 months of age with chronic lung disease of prematurity and who

required at least 28 days of supplemental oxygen immediately after birth and who

continue to require medical intervention (supplemental oxygen, chronic

corticosteroid, or diuretic therapy).

Children younger than 24 months who will be profoundly immunocompromised

during the RSV season.

PLEASE NOTE:

ALL SYNAGIS (DRUG) MUST BE BILLED VIA PHARMACY POINT OF

SALE. The Utah Medicaid Synagis season is December 1st through April 30th. A

maximum of five monthly Synagis doses may be given during this five month

period.

Synagis is not available to any child with active RSV.

No approval will be given to a child of 24 months or older.

When an infant begins a Synagis series late in the season, they may receive

monthly doses until April 30th, as appropriate, according to the criteria above. A

child who begins the series and then turns two may receive monthly doses until

April 30th, as appropriate, according to the criteria above.

The DUR Board considered recommendations from the American Academy of

Pediatrics, the manufacturer, and the FDA approved indications in developing these

criteria. Therefore, prescribers seeking approval outside the above criteria must

provide literature that demonstrates support for the requested use. Consideration of

the request will not proceed without it. NO EXCEPTIONS.

Updated Guidance for Palivizumab Prophylaxis Among Infants and Young

Children at Increased Risk of Hospitalization for Respiratory Syncytial Virus

Infection. Pediatrics 2014; 134:415. Published online July 28, 2014, at

http://pediatrics.aappublications.org/content/124/415.full.html





Topical Immunomodulators

(Elidel, Protopic,

pimecrolimus, tacrolimus)

INITIAL AUTHORIZATION: 6 weeks

Submit all of the following:

Diagnosis

If atopic dermatitis, please write the diagnosis code on the face of the prescription

If lichen planus or vitiligo, please indicate if the patient has Hepatitis C

Strength, quantity and directions for administration

Physical location of affected area(s)

Documentation (medical notes) of failure on at least one non-calcineurin-inhibiting

agent

RE-AUTHORIZATION: 6 months

Submit updated medical notes indicating improvement while on therapy

Lapatinib

(Tykerb) Patient must be age 18 or above

Diagnosis of advanced or metastatic breast cancer whose tumor overexpresses

HER2.

Documentation of prior therapy, including the following agents:

an anthracycline (e.g. danorubicin, doxorubicin, epirubicin, idarubicin, or

valrubicin);

a taxane (e.g. paclitaxel, docetaxel, or taxotere); and

trastuzumab.

To be given in combination with capecitabine.

AUTHORIZATION: Initial PA is granted for 1 year

RE-AUTHORIZATION: granted in one-year increments with an updated letter of

medical necessity

Febuxostat

(Uloric)


Documented diagnosis of Gout.

Documented failure, contraindication, or intolerance to allopurinol.

No concomitant use of azathioprine, mercaptopurine, or theophylline.

AUTHORIZATION: The initial authorization will be approved for one year


Panitumumab

(Vectibix)




Diagnosis of metastatic colorectal cancer.

Disease progression on or following fluoropyrimidine-, oxplatin-, and inrinoteacan-

containing chemotherapy regimens.


J9303, NDC number, and PA number. Patients with ACO’s will have to make

arrangements with their ACO for coverage.



Naltrexone

(Vivitrol)

Diagnosis of alcohol abuse AND/OR Diagnosis of opioid dependence

No concomitant treatment with Suboxone or Subutex.

Description of the psychosocial support to be received by patient, as indicated by

chart notes or a brief letter of medical necessity.

AUTHORIZATION for both indications: Initial authorization is for 6 months.

RE-AUTHORIZATION for both indications: Updated letter of medical

necessity

Bromfenac

(Xibrom)

Documented prior trial of any indicated medication (diclofenac, ketorolac,

nepafenac, loteprednol, rimexolone, or prednisolone ophthalmic preparations).

AUTHORIZATION: Approved for one bottle for a 2 week period following

procedure or surgery.

RE-AUTHORIZATION: Same as initial authorization





Rifaximin

(Xifaxan)

Traveler’s Diarrhea:

Age ≥ 12 years

For treatment, not for prophylaxis

Trial and failure of, or contraindication to, a fluoroquinolone or azithromycin –

please describe

Must reasonably be believed to be caused by Escherichia coli – please describe

Maximum 200mg three times daily for 3 days

Overt Hepatic Encephalopathy Age ≥ 18 years

For prophylaxis of recurrence – please describe previous occurrences and therapies

Trial and failure of, or contraindication to, properly titrated doses of lactulose –

please describe

Maximum 550mg twice daily

AUTHORIZATION

Traveler’s Diarrhea: 3 days

Overt Hepatic Encephalopathy: 1 year

RE-AUTHORIZATION Letter of medical necessity describing treatment efficacy and rational for

continuation

Omalizumab

(Xolair)




Patient must have tried all other therapies for a time period generously adequate (at

least 4 months) to establish indisputable failure of each.

The request must include the following information:

Documentation of all failed therapies tried, and reason for requesting Xolair.

Include the desired starting dose of Xolair in the request.

Include the patient’s baseline IgE value and weight in the written request.

If requested for allergic asthma, please confirm that a skin test and/or in vitro

reactivity test has/have been done.

NOTES:

This medication is only payable through J-code J2357 to a physician’s office.

Patients with ACOs must make arrangements with their ACO for coverage.

The patient must have regular appointments to receive the medication in the

prescriber’s office.

The patient must remain in the office for a minimum of 90 minutes to allow for

observation and treatment of anaphylaxis, if necessary.

If/when any change of dose is requested, the prescriber must indicate, in writing,

the reasoning for the dose increase.



Sodium oxybate

(Xyrem)

Prescribed by or in consultation with a physician that is board certified in sleep

medicine

Diagnosis: cataplexy associated with narcolepsy

excessive daytime sleepiness with narcolepsy and failed previous treatments with a

stimulant AND either modafinil or armodafinil

Documentation ruling out concomitant use of sedative-hypnotics.

Maximum dose is 9gm/day







Miglustat

(Zavesca)


Diagnosis: moderate type I Gaucher’s disease.

Documentation that enzyme replacement therapy has failed.

Documentation that hemoglobin is >9g/dL.

Platelet count > 50k/ul (fax a copy of the lab work).

Written consultation with a trained specialist (hematologist or geneticist).

INFORMATION:

Cumulative limit of 90 capsules in 30 days.

Dosage: 100mg three times daily recommended. May be decreased to once or twice

a day based on side effects



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