Prior Authorization (PA)
There are three reasons for the use of prior authorization: scope
controls, utilization controls and product based controls. This section
includes the list of medications requiring Prior Authorization (PA). PA forms
can be found in the Pharmacy
Forms section. Incomplete forms will result in either a delay or
denial. Please ensure all forms are submitted with all the necessary information
to efficiently process the request for the member.
Oklahoma Health Care Authority (OHCA) administers two types of PA programs:
Scope and Utilization-based Prior Authorization
Scope controls refer to constraints used to insure a drug is used for
approved indications and is therapeutically appropriate. Utilization controls
are used to limit the quantity of medication dispensed or to limit the duration
of use.
The Drug Utilization and Review (DUR) Board recommends clinical criteria
for medications that require a PA.
Product Based Prior Authorization (PBPA)
This program divides certain therapeutic categories of drugs into two or
more levels called Tiers. Tier 1 medications are preferred as the first step
for treating a member’s health condition. They are cost effective and are
usually available without PA. Members that do not achieve a clinical success
with Tier 1 medications may qualify to obtain a Tier 2 or Tier 3
medication. Most of these categories are set up so that if a member meets the
step therapy criteria, their claim for the next highest tier will process
without a PA. Alternately, a PA may be required so that OHCA will have
documentation of the step therapy and/or other clinical information necessary
to approve the use of a Tier 2 or higher medication.
Providers may request a step therapy exception to
skip the step therapy process and receive the Tier 2 or higher drug
immediately. An exception can be requested following a denial of a prior
authorization or can be submitted at the onset of the request. Criteria for a
step therapy exception can be found in OHCA rules 317:30-5-77.4. Step therapy
exception requests must be submitted on form PHARM – 136. Please see each
therapeutic category for specific clinical criteria required to bypass the step
therapy protocol.
Therapeutic Categories:
- Anti-Infectives - Cephaloporins, Ketoconazole Oral Tablets, Skin and Soft Tissue, Special Formulations
- Biologics - Botulinum toxins, Hematopoetic, Immunomodulating, Replacement Therapy, Respiratory, Skeletal
- Cardiovascular - Anticoagulants, Antihypertensives, Antiplatelet, Antihyperlipidemics, Clonidine Products, Hereditary Angioedema, Pulmonary Arterial Hypertension, Revatio
- Central Nervous System/Behavioral Health - ADHD & Narcolepsy, Alzheimer's, Antidepressants, Anti-Migraine, Anxiolytic/Hypnotic, Atypical Antipsychotics, Fibromyalgia, Multiple Sclerosis, Narcotic Analgesics, Parkinson's, Restless Leg Syndrome, Requip XL/Mirapex ER, Smoking Cessation, Substance Abuse Treatment
- Chelating/Binding Agents: Ferriprox, Jadenu
- Diabetes/Endocrine - Diabetic Medications, Erythropoietin Stimulating Agents, Growth Hormone, Makena®, Testosterone, Vitamin D Analogs
- Gastro-Intestinal - Amitiza, Anti-emetic, Anti-Ulcer, Bowel Prep, Pancreatic Enzymes
- Genetic Disorders - Cerdelga®, Cerezyme®, Elelyso®, Exondys 51™, Spinraza™, Vpriv®, Zavesca®
- Genitourinary System - Benign Prostatic Hyperplasia (BPH), Bladder Control Drugs
- Hemophilia - Adynovate, Alprolix, Coagadex, Corifact, Eloctate, Idelvion, Obizur, Tretten
- Hepatic Disorders - Daklinza, Harvoni, Incivek, Olysio, Sovaldi, Technivie, Victrelis, Viekira Pak, Zepatier
- HIV Medications
- Metabolic Disorders- Cholbam, Kanuma, Keveyis, Myalept, Procysbi, Ravicti, Strensiq
- Ocular/Otic - Ocular Allergy, Opthalmic Anti-Infective/Steroid, Ophthalmic Corticosteroid, Ophthalmic NSAIDs, Ophthalmic Glaucoma, Otic Anti-Infective
- Oncologic Therapies - Afinitor, Breast Cancer, Prostate Cancer, Skin Cancer
- Respiratory - Asthma & COPD Inhalation Medications, Antihistamines, Leukotriene Modifiers, Nasal Allergy Sprays, Pulmonary Arterial Hypertension, Pulmonary Fibrosis, Synagis, Tobi/Pulmozyme, Xolair
- Skeletal System - Amrix & Fexmid, Bisphosphonates, Forteo, Gout, NSAIDs, Skeletal Muscle Relaxants, Soma
- Special Formulations - Millipred®, Veripred 20®
- Topical - Antifungal, Elidel/Protopic, Pediculicides, Topical Antibiotic Medications, Topical Corticosteroids