Therapeutic Categories:

Cardiovascular

Respiratory

Central Nervous System/Behavioral Health

Skeletal System

Endocrine

Topical

Ocular/Otic

Gastro Intestinal

Biologics

Antihypertensives

PA Criteria: Tier 1 products are covered with no authorization necessary.

Tier 2 authorization requires:

  • documented inadequate response to two Tier 1 medications, or
  • adverse drug reaction to all the Tier 1 medications, or
  • previous stabilization on the Tier 2 medication, or
  • a unique indication for which the Tier 1 antihypertensives are not indicated

Tier 3 authorization requires:

  • documented inadequate response to two Tier 1 medications and documented inadequate response to all available Tier 2 medications, or
  • adverse drug reaction to all the Tier 1 or all Tier 2 medications, or
  • previous stabilization on the Tier 3 medication, or
  • a unique indication for which the lower tiered antihypertensives are not indicated
  • Prior Authorization form 
ACE/HCTZ

Tier 1

Tier 2

Tier 3

  • quinapril/HCTZ (Accuretic)
  • captopril/HCTZ (Capozide)
  • benazepril/HCTZ (Lotensin HCT)
  • fosinopril/HCTZ (Monopril HCT)
  • lisinopril/HCTZ (Prinzide, Zestoretic)
  • moexipril/HCTZ (Uniretic)
  • enalapril/HCTZ (Vasoretic)

 

ACE Inhibitors

Tier 1

Tier 2

Tier 3

  • quinapril (Accupril)
  • ramipril (Altace)
  • captopril (Capoten)
  • benazepril (Lotensin)
  • trandolapril (Mavik)
  • fosinopril (Monopril) 
  • lisinopril (Prinivil, Zestril)
  • moexipril (Univasc)
  • enalapril (Vasotec)
  • enalaprilat (Vasotec IV)
  • perindopril erbumine (Aceon)

back to top

CCB (Calcium Channel Blockers)

Tier 1

Tier 2

  • nifedipine ER
  • nifedipine (Adalat, Procardia)
  • nifedipine CC (Adalat CC)
  • verapamil (Calan, Isoptin, Verelan)
  • verapamil SR (Calan SR, Isoptin SR, Verelan PM)
  • nicardipine (Cardene)
  • diltiazem (Cardizem)
  • diltiazem CD (Cardizem CD)
  • diltiazem SR (Cardizem SR)
  • diltiazem ER (Cartia XT, Diltia XT)
  • diltiazem XR (Dilacor XR)
  • isradipine (Dynacirc, Dynacirc CR)
  • nifedipine XL (Nifedical XL, Procardia XL)
  • nimodipine (Nimotop)
  • amlodipine (Norvasc)
  • felodipine (Plendil)
  • diltiazem (Tiazac, Taztia XT)
  • amlodipine/atorvastatin (Caduet)
  • nicardipine (Cardene SR)
  • diltiazem (Cardizem LA)
  • verapamil (Covera HS)
  • nisoldipine (Sular)
ACE/CCB

Tier 1

Tier 2

Tier 3

  • Tier 1 ACE + Tier 1 CCB
  • enalapril/felodipine (Lexxel)
  • benazepril/amlodipine (Lotrel)
  • trandolapril/verapamil (Tarka)

back to top

ARBs (Angiotensin Receptor Blockers) Medication

PA Criteria:

Tier 1 products are covered with no authorization necessary.

Tier 2 authorization requires inadequate response to two Tier 1 medications or

  • adverse drug reaction to all Tier 1 class of medications or
  • previous stabilization on the Tier 2 medications, or
  • a unique indication for which the Tier 1 antihypertensives are not indicated

Tier 3 authorization requires documented inadequate response to two Tier 1 medications and documented inadequate response to all available tier 2 medications, or

  • adverse drug reaction to all Tier 1 or Tier 2 classes of medications, or
  • previous stablilization on the Tier 3 medication, or
  • a unique indication for which the lower tiered antihypertensives are not indicated.
  • Prior Authorization form 
* Clinical exception applies to members who have diabetes.

Tier 1

Tier 2

Tier 3

  • quinapril (Accupril)
  • captopril (Capoten)
  • benazepril (Lotensin)
  • trandolapril (Mavik)
  • fosinopril (Monopril)
  • lisinopril (Prinivil, Zestril)
  • moexipril (Univasc)
  • enalapril (Vasotec, Vasotec IV)
  • ramipril
  • irbesartan/HCTZ (Avalide)
  • irbesartan (Avapro)
  • amlodipine/olmesartan (Azor)
  • olmesartan (Benicar)
  • olmesartan/HCTZ (Benicar HCT)
  • valsartan (Diovan)
  • valsartan/HCTZ (Diovan HCT)
  • amlodopine/valsartan (Exforge)
  • amlodopine/valsartan/HCTZ (Exforge HCT)
  • olmesarten med/amlodipine/HCTZ (Tribenzor)
  • candesartan (Atacand)
  • candesartan/HCTZ (Atacand HCT)
  • losartan (Cozaar)
  • losartan/HCTZ (Hyzaar)
  • telmisartan (Micardis)
  • telmisartan/HCTZ (Micardis HCT)
  • eprosartan (Teveten)
  • eprosartan/HCTZ (Teveten HCT)
  • telmisartan/amlodipine (Twinsta)

Direct Renin Inhibitors

Tier 3 authorization requires:

  • FDA approved indication
  • Recent trial, within the previous 6 months and at least 4 weeks in duration, of an ACE Inhibitor (or an ARB if previous trial of an ACEI) and a diuretic, used concomitantly at recommended doses, that did not yield adequate blood pressure control.
  • Clinical exceptions will be granted for members already currently on aliskiren and valsartan at the available doses of Valturna.

Tier 1

Tier 2

Tier 3

  • Tier 1 ACE Inhibitor + Diuretic
  • ARB + Diuretic
  • aliskiren (Tekturna)
  • aliskiren/HCTZ (Tekturna HCT)
  • aliskiren/valsartan (Valturna)

back to top

HMG-CoA Reductase inhibitors (Statins)

PA Criteria:

The following are criteria for approval of a Tier-2 Product:

To qualify for a Tier 2 medication, there must be:

1. A trial, defined by at least 8 weeks of continuous therapy titrated to recommended dose, of a tier 1 medication that did not yield adequate LDL reduction.
2. Documented adverse effect or contraindication to all available lower tiered products.
3. Clinical exception for atorvastatin 80mg: members hospitalized for recent acute myocardial  infarction or acute coronary syndrome.

To qualify for a Tier 3 medication, there must be:

1. A trial, defined by at least 8 weeks of continuous therapy titrated to recommended dose, of a tier 2 medication that did not yield adequate LDL reduction.
2. Documented adverse effect or contraindication to all available lower tiered products.
3. Clinical exceptions for Ezetimibe:
   a. Documented active liver disease.
   b. Documented unexplained, persistent elevations of serum transaminases.
   c. Documented statin related myopathy.

Tier 1

Tier 2

Tier 3

  • fluvastatin (Lescol & Lescol XL)
  • lovastatin (Mevacor)
  • pravastatin (Pravachol)
  • simvastatin (Zocor)
  • rosuvastatin (Crestor)
  • atorvastatin (Lipitor)
  • pitavastatin (Livalo)
  • lovastatin (Brand Altoprev)
  • simvastatin/ezetimibe (Vytorin)
  • ezetimibe (Zetia)
   Statin/Niaspan Combination Products     
Tier 1 Statins and/or Niaspan
  • lovastatin/niacin CR (Advicor)
  • simvastatin/niacin CR (Simcor)
Comparable LDL Reductions in Statins

%LDL Reduction

Pravastatin (Pravachol)

Simvastatin (Zocor)

Atorvastatin (Lipitor)

Rosuvastatin (Crestor)

Pitavastatin (Livalo)

25-32%
31-39%
37-45%
48-52%
55-60%
60-63%

20mg
40mg
80mg
10mg
20mg
40mg
80mg

10mg
20mg
40mg
80mg



5mg
0mg
20mg
40mg

1mg
2mg
4mg

back to top

Fibric Acid Derivatives

PA criteria:

  • The approval criteria for a tier 2 medication is as follows:
  • Laboratory documented failure with a tier one medication after 6 months trial with a tier one medications.
  • Documented adverse effect, drug interaction, or contraindication to tier 1 products.

Tier 1

Tier 2

  • clofibrate (Atromid - S)
  • micronized fenofibrates (Lofibra)
  • gemfibrozil (Lopid)
  • micronized fenofibrates (Tricor)
  • fenofibrates (Trilipix)
  • micronized fenofibrates (Antara)
  • fenofibrate (Fenoglide)
  • micronized fenofibrates (Lipofen)
  • fenofibrates (Triglide)

back to top

Lovaza (Omega-3-Acid Ethyl Esters)

PA criteria:

  • Laboratory documentation of severe hypertriglyceridemia (fasting triglycerides ≥500 mg/dL).
  • Previous failure with both nicotinic acid and fibric acid medications.

back to top

Plavix/Effient

Plavix and Effient are available without PA for the first 90 days of therapy for members new to therapy with these medications.  After the first 90 days, the following criteria will apply:

Plavix Criteria:

1. Plavix therapy will be approved for members who meet diagnostic criteria. The approve diagnoses are

  • Recent Stroke
  • Recent myocardial infarction
  • Established peripheral artery disease
  • Acute coronary syndrome (unstable angina/non-Q-wave MI)
  • Percutaneous coronary intervention with stent placement 
  • Transient ischemic attacks (CVA, Stroke)

2. Length of approval: 1 year.

Effient Criteria:

1. Effient therapy will be approved for members who meet approved diagnostic criteria:
  • The approved diagnoses are UA/NSTEMI and STEMI patients who are to be managed with percutaneous coronary intervention (PCI), primary or delay.

2. Length of approval: 1 year.

3. Effient will not be approved for members with the following situation:

  • CABG surgery
  • Members with a history of TIA or stroke

4. Members greater than 75 years of age will generally not be approved without supporting information.

*After the end of 15 months, presrcibers should provide supporting information for the continuation of these products. 

back to top

Revatio

PA Criteria:

  • Diagnosis and medical supervision by a pulmonary specialist and/or cardiologist
  • Pulmonary Arterial Hypertension (early stage, NYHA Class II)

Gender:

  • Prior authorization required only for male SoonerCare members.

Quantity Limitations:

  • 90 tablets per 30 days

back to top

Antihistamines

PA Criteria:

Tier 1 products are covered with no authorization necessary for members under age 21. 

  • For members 21 years and older, Tier 1 products are available with prior authorization.

Tier 2 authorization requires a documented 14 day trial of all Tier 1 products within the last 30 days.

Tier 3 authorization requires a 14 day trial with all Tier 2 products within the last 60 days (unless no age-appropriate Tier 2 product exists).

  • Xyzal Tabs not covered for members under age 6. (Syrup down to 6 mos)
  • For all antihistamine authorizations, the diagnosis must be for a chronic allergic condition. 
  • Prior Authorization form 

Tier 1

Tier 2

Tier 3

  • OTC cetirizine 5mg & 10mg tablets, syrup  (Zyrtec)
  • OTC loratadine (Claritin)
  • fexofenadine (Allegra)
  • desloratadine (Clarinex)
  • fexofenadine (syrup, ODT)
  • levocetirizine (Xyzal)

back to top

Singulair

PA criteria:

For members with a diagnosis of asthma the following criteria will apply:

Children age 11 and under:

  • Diagnosis of asthma, or
  • A claim for inhaled corticosteroid, or
  • Use of 3 or more rescue medications
  • All claims should be within the member's previous year's history.

Children age 12 and older and adults:

  • Diagnosis of mild or moderate persistent asthma, and/or exercise induced asthma, and
  • Trial of inhaled corticosteroid AND corticosteroid/LAB2A therapy within the previous 6 months, with inadequate control of asthma.

Claims submitted for Singulair will trigger an automatic check for asthma diagnoses and prior fills of inhaled corticosteroids / asthma rescue medications in the member's claims history.  If the appropriate criteria are detected, these claims will be paid with no prior authorization required.

For members with a diagnosis of allergic rhinitis the following criteria will apply:

For members 2 years of age or older:

  • Trials of an antihistamine and nasal corticosteroid, each 14 days in duration, that have failed to relieve allergic rhinitis symptoms.
  • Agents may be used concomitantly or consecutively within the past 30 days.

For members less than two years of age:

  • Trial of an oral antihistamine, 14 days in duration, which has failed to relieve allergic rhinitis symptoms, (Trial must have occurred within the past 30 days.)
  • Prior Authorization form 

back to top

HFA Rescue Inhalers
  • Tier-1 products are available without prior authorization.
  • Tier-2 authorization requires:

       1) Approved or clinically accepted indication, and
       2) Specific reason member cannot use all available tier-1 products

Tier 1

Tier 2

  • ProAir HFA (albuterol HFA)
  • Proventil HFA (albuterol HFA)
  • Ventolin HFA (albuterol HFA)
  • Xopenex HFA (levalbuterol HFA)
*Xopenex authorization requests should document why the member is unable to use racemic albuterol. If prescribed for asthma, member should also be utilizing inhaled corticosteroid therapy for long-term control. Dose of levalbuterol requested cannot be less than the racemic equivalent documented on the prior authorization request.

back to top

Nasal Allergy

PA criteria:

Nasal allergy medications will be included in product-based prior authorization effective 4/28/08.  Tier 1 products will be covered with no prior authorization necessary.

Tier 2 Authorization Requires

  • Documented adverse effect or contraindication to the Tier 1 products , or
  • Documented trials with all available Tier 1 corticosteroids with no beneficial response with the drug having been titrated to the recommended dose.  Each trial must be at least 3 weeks in duration.

    Tier 3 Authorization Requires

  • Documented adverse effect or contraindication to the Tier 2 products , or
  • Documented trials with all available Tier 2 corticosteroids with no beneficial response with the drug having been titrated to the recommended dose. Each trial must be at least 3 weeks in duration.
  • Prior Authorization form 

Tier 1

Tier 2

Tier 3

Corticosteroids 

  • fluticasone (Flonase)
  • flunisolide (Nasalide, Nasarel™)
  • beclomethasone (Beconase AQ)
  • triamcinolone  (Nasacort® AQ)
  • mometasone (Nasonex)
  • azelastine (Astelin, Astepro)
  • ciclesonide (Omnaris)
  • budesonide (Rhinocort AQ)
  • fluticasone (Veramyst™)

Other

 

  • olapatadine (Patanase)

back to top

Xolair

PA Criteria:

  • Member must be between 12-75 years of age.
  • Member must have a diagnosis of severe persistent asthma (as per NAEPP guidelines).
  • Member must have a positive skin test to at least one perennial aeroallergen. Specific positive perennial allergens must be listed on the petition.
  • Member must have a pretreatment serum IgE level between 30-700 IU/ml.
  • Member weight must be between 30-150kg.
  • Member must have been on high dose ICS (as per NAEPP Guidelines) for a minimum of 3 months.
  • Medication must be prescribed by either a pulmonary or an allergy/asthma specialist.
  • Member must have been in the ER or hospitalized, due to an asthma exacerbation, twice in the past 6 months. Date of visits must be listed on petition, or
  • Have been determined to be dependent on systemic steroids to prevent serious exacerbations.

For Xolair requests, please submit these forms together:

back to top

Xopenex

PA criteria:

Xopenex

  • PA required for use of this product in excess of 90 days of therapy in a 360 day period.
  • A quantity limit of 288 units every 30 days will apply to Xopenex solution.
  • Please state need of this product over albuterol.

Criteria for approval:

  • In the prior authorization request, the prescriber should explain why the member is unable to use long acting bronchodilators and/or inhaled corticosteroid (ICS) therapy for long-term control as recommended in the NAEPP guidelines.
  • Prior Authorization form 

back to top

Advair / Symbicort and Dulera

PA Criteria:

1) Diagnosis of COPD, or
2) Diagnosis of Asthma:

  • Member must be 4 years of age or older, and
  • Member must have used an inhaled corticosteroid ( Aerobid, Alvesco, Asmanex, Azmacort, Flovent, Pulmicort, or QVAR) for at least one month immediately prior to request for authorization, and
  • Member’s asthma considered uncontrolled by the prescriber
    •  Requires rescue inhaler more than 2 days per week for reasons other than prevention of exercise induced bronchospasms, and/or requires oral systemic corticosteroids, or
  • Clinical situation warranting initiation with combination therapy due to severity of asthma
  • Prior Authorization form 

back to top

Brovana

PA Criteria:

  • Members must be over 18 years of age and have one of the following diagnoses: COPD, chronic bronchitis, or emphysema.
  • Member must have previous trial with Advair, Serevent, or Foradil in the past 45 days. A clinical exception will be given for those members who are unable to effectively use hand-actuated devices or who have become unstable on nebulized short-acting agonist therapy.
  • Quantity limit of 120ml for a 30 day supply.
  • Prior Authorization form 

back to top

Synagis

PA Criteria:

  • Members must be included in one of the following age groups at the beginning of RSV season:
  • Infants and children less than 24 months old with Chronic Lung Disease (CLD) (formerly bronchopulmonary dysplasia) who have required medical treatment (O2, bronchodilator, corticosteroid, or diuretic therapy) for CLD in the 6 months prior to RSV season.
  • Infants up to 24 months old with moderate to severe pulmonary hypertension, cyanotic heart disease, or those on medications to control congestive heart failure.
  • Infants less than 12 months of age, born at 28 weeks gestation or earlier.
  • Infants less than 6 months old, born at 29-31 weeks gestation.
  • Infants less than 12 months of age, born before 35 weeks gestation, with congenital abnormalities of the airway.
  • Infants less than 12 months of age, born before 35 weeks gestation, with severe neuromuscular disease.
  • Infants, up to 3 months old at the start of the season, born at 32-34 weeks gestation, who have one of the following risk factors:
    • Child care attendance
    • Siblings younger than 5 years of age
  • The maximum duration of therapy is five (5) doses, with a dose to be administered no more often than every 30 days. Infants born at 32-34 weeks gestation will receive a maximum of three doses. Members given doses more frequently than every 30 days will not be authorized for additional doses.  Doses administered prior to the member's discharge from a hospital will be counted as one of the approved total. 

    Synagis form 

back to top

Anxiolytic

Members 19 Years and Older will not require a petition

1). Quantity limits apply on all benzodiazepine anxiolytic products.
2). No request for dosing greater than 3 times daily will approved unless a specific diagnosis exists; for these diagnoses the maximum allowed dosing would be 4 times daily.
3). The maximum covered dosing of benzodiazepine therapy is three times a day if a hypnotic medication is also prescribed.

Members 0-18 Years of Age will require a petition:

1). No concurrent stimulant ADHD medications, and
2). No Contraindicated Conditions, and
3). Maximum dosing of 3 times daily.

  • For Members 12 or younger the same criteria applies and prescription must originally be written by a psychiatrist.

Prior Authorization form

  • lorazepam (Ativan)
  • chlordiazepoxide (Librium)
  • oxazepam (Serax)
  • clorazepate dipotassium (Tranxene)
  • diazepam (Valium)
  • alprazolam (Xanax)

Prior Authorization required.

  • alprazolam rapdis (Niravam)
  • alprazolam XR (Xanax XR)
Insomnia

Tier 1 products are available without prior authorization for members age 18 or older.

Prior authorization is required for all products formembers under age 18.

Tier 2 authorization requires:

  • Minimum of 30 day trial with at least two Tier 1 products (one of which must be zolpidem) and clinical documentation of attempts to correct any primary cause for insomnia. 
  • FDA approved diagnosis.
  • No concurrent anxiolytic benzodiazepine therapy greater than TID dosing and no concurrent ADHD medications.
  • Special formulation of zolpidem requires special reason for use.
  • Prior Authorization form 

Tier 1

Tier 2

  • zolpidem tartrate (Ambien)
  • flurazepam (Dalmane)
  • triazolam (Halcion)
  • estazolam (ProSom)
  • temazepam (Restoril) 15mg & 30mg
  • zaleplon (Sonata)
  • zolpidem tartrate (Ambien CR)
  • zolpidem SL tabs (Edluar)
  • eszopiclone (Lunesta)
  • temazepam (Restoril) 7.5mg & 22.5mg
  • ramelteon (Rozerem)

back to top

Multiple Sclerosis

Prior Authorization of Ampyra (dalfampridine)

PA Criteria:

  • Member must have a diagnosis of Multiple Sclerosis
  • Kurtzke Expanded Disability Status Scale (EDSS) score between 4 and 7.5
  • A 90 day trial will be approved. If member has responded well to treatment and physician states that the member has shown improvement or the drug was effective, member may receive authorization for one year.

Quantity Limit of 60 for 30 days

back to top

ADHD and Narcolepsy

PA Criteria:

  • Dose not to exceed 1.5 times the FDA approved maximum.
  • No concurrent use of multiple products from this category, ie, Strattera + Stimulant, Methylphenidate + Amphetamine
  • Prior authorization is required for all stimulants for adults age 21 and older.

Tier 2 authorization requires:

  • Documented trial of a longer-acting Tier 1 medication within the last 30 days with inadequate results, and
  • Diagnosis of ADHD or Narcolepsy

Tier 3 authorization requires:

  • Documented trial of one Tier 1 medication long-acting product and one Tier 2 medication or two trials with either a Tier 1 or a Tier 2 medication with inadequate results (both trials within the last 60 days), and
  • Diagnosis of ADHD or Narcolepsy.
  • Prior Authorization form 

Tier 1

Tier 2

Tier 3

  • amphetamine salt combo (Adderall)
  • amphetamine salt combo (Adderall XR)
  • methylphenidate ER (Concerta)
  • dexmethylphenidate (Focalin, Focalin XR)
  • methylphenidate IR(Ritalin, Methylin)
  • methylphenidate SR (Ritalin SR)
  • atomoxetine (Strattera)
  • methylphenidate ER (Metadate CD, Metadate ER)
  • guanfacine (Intuniv)
  • methylphenidate (Ritalin LA)
  • lisdexamfetamine (Vyvanse)
  • methylphenidate patch(Daytrana)
  • dextroamphetamine (Dexedrine, Dextrostat)
  • methamphetamine (Desoxyn)
  • armodafinil (Nuvigil)
  • dextroamphetamine solution (Procentra®)
  • modafinil (Provigil)

back to top

Requip XL (ropinirole) and Mirapex ER (pramipexole)

PA criteria:

  • Diagnosis of Parkinson's Disease, and
  • Clinically significant reason why the immediate release products cannot be used.

back to top

Atypical Antipsychotics 

Tier 1 products are available without prior authorization.

No member co-pay for risperidone at pharmacy.

Tier 2 Authorization Criteria

1.) Current users/inpatient discharge:

  • Members currently stabilized on a higher tiered medication in the past 90 days will be approved.
  • Members being released from an inpatient facility and stabilized on a higher tier medication will be approved.

2.) Clinical conditions:

  • Approvals will be granted for members with clinical conditions for which lower tiered drugs are contraindicated.
  • Approvals will be granted for members whose current regimen includes drugs known to adversely interact with all lower tiered drugs.

3.) Step therapy:

  • A trial of risperidone, at least 14 days in duration, titrated to recommended dose, that did not yield adequate response or resulted in intolerable adverse effects.

Tier 3 Authorization Criteria

1.) Current users/inpatient discharge:

  • Members currently stabilized on a higher tiered medication the past 90 days will be approved.
  • Members being released from an inpatient facility and stabilized on a higher tier medication will be approved.

2.) Clinical conditions:

  • Approvals will be granted for members with clinical conditions for which lower tiered drugs are contraindicated.
  • Approvals will be granted for members whose current regimen includes drugs known to adversely interact with all lower tiered drugs.

3.) Step therapy:

  • A trial of risperidone, at least 14 days in duration, titrated to recommended dose, that did not yield adequate response or resulted in intolerable adverse effects, and
  • A trial of both Tier 2 medications, at least 14 days in duration, titrated to recommended dose, that did not yield adequate response or resulted in intolerable adverse effects.

Other Authorization Criteria

  • For aripiprazole and quetiapine extended release: a diagnosis of depression requires concurrent use of an antidepressant, and previous trials with at least two other antidepressants. *Tier structure rules still apply. 

Tier 1

Tier 2

Tier 3

  • clozapine (Clozaril®)
  • risperidone (Risperdal®)

 

  • aripiprazole (Abilify®)
  • iloperidone (FanaptTM)
  • ziprasidone (Geodon®)
  • quetiapine ER (Seroquel XR®)
  • clozapine (Fazaclo®)
  • paliperidone (Invega®)
  • asenapine (Saphris®)
  • quetiapine (Seroquel®)
  • olanzapine/fluoxetine (Symbyax®)
  • olanzapine (Zyprexa®)

back to top

Anti-Migraine

PA Criteria:

To qualify for tier 2 products the member must meet one of the following criteria:

  • Trial of all available tier 1 products with inadequate response, or
  • Documented adverse effect to all the tier 1 products, or
  • Previous success with a tier 2 product within the last 60 days.

To qualify for tier 3 products the member must meet one of the following criteria:

  • Trial of all available tier 2 products with inadequate response, or
  • Documented adverse effect to all available tier 2 products, or
  • Previous success with a tier 3 medication within the last 60 days.

Tier 1

Tier 2

  • sumatriptan (Imitrex)

 

  • naratriptan (Amerge)
  • almotriptan (Axert)
  • eletriptan (Relpax)
  • frovatriptan (Frova)
  • rizatriptan (Maxalt, Maxalt MLT)
  • sumatriptan/naproxen (Treximet)
  • zolmitriptan (Zomig, Zomig ZMT)

back to top

Fibromyalgia

PA Criteria:

  • Recent trials (within the last six months) of two tier 1 medications at least 3 weeks in duration that did not provide adequate response, or resulted in intolerable adverse effects, or
  • Contraindications(s) to all available lower tiered medications,
  • Current stabilization on a tier 2 medications (samples will not be accepted if member has not appropriate lower tiered trials).

Tier 1

Tier 2

  • Amitriptyline
  • Cyclobenzaprine
  • Fluoxetine
  • Tramadol
  • cymbalta (Duloxetine HCI)
  • savella (Milnacipran)
  • lyrica (Pregabalin)

back to top

Antidepressants

PA Criteria:

Tier 2 Authorization Criteria:

  • A documented, recent (within 6 months) trial of a tier 1 medication at least 4 weeks in duration and titrated to recommended dosing, that did not provide an adequate response.  Tier 1 selection can be from any classification. 
  • Prior stabilization on the tier 2 medication documented within the last 100 days.  A past history of success on the tier 2 medication will also be considered with adequate documentation.
  • A unique FDA-approved indication not covered by tier 1 product or other products from a different therapeutic class.
  • A petition may be submitted for consideration whenever a unique member specific situation exists.

Tier 3 Authorization Criteria

  • A documented, recent (within 6 months) trial of a tier 1 and a tier 2 medication at least 4 weeks in duration and titrated to recommended dose, that did not provide an adequate response.  Tier 1 and tier 2 selection can be from any classification. 
  • Prior stabilization on the tier 3 medication documented within the last 100 days.  A past history of success on the tier 3 medication will also be considered with adequate documentation.
  • A unique FDA-approved indication not covered by a lowered tiered product or other products from a different therapeutic class.
  • A petition may be submitted for consideration whenever a unique member specific situation exists.

Tier 1

Tier 2

Tier 3

SSRIs (Selective Serotonin Reuptake Inhibitors)
  • citalopram (Celexa)
  • fluoxetine 40mg caps
  • fluoxetine (Prozac, Sarafem)
  • fluvoxamine (Luvox)
  • paroxetine (Paxil, Paxil CR)
  • sertraline (Zoloft)
  • escitalopram (Lexapro tabs & liquid)
  • fluvoxamine (Luvox CR)
  • fluoxetine (Prozac weekly)
  • paroxetine (Pexeva)
Dual Acting Antidepressants

Tier 1

Tier 2

Tier 3

Any Tier 1 SSRI or

  • trazodone (Desyrel)
  • venlafaxine (Effexor)
  • mirtazapine (Remeron, Remeron SolTab)
  • bupropion (Wellbutrin, Wellbutrin SR,  Wellbutrin XL)
  • duloxetine (Cymbalta)
  • bupropion (Aplenzin)
  • venlafaxine (Effexor XR capsules)
  • desvenlafaxine (Pristiq)
  • nefazodone (Serzone)
  • venlafaxine extended release tablets
Monoamine Oxidase Inhibitors

Tier 1

Tier 2

Tier 3

 

  • selegiline transderm (Emsam)
  • phenelzine (Nardil)
  • tranylcypromine(Parnate)
  • selegiline (Zelapar)

back to top

Bladder Control Drugs

Tier 2 Authorizaion Criteria:

  • Trial of one tier-1 medication that yielded inadequate clinical response or adverse effects, or
  • A unique indication which the tier 1 drugs lack.

Tier 3 Authorization Criteria:

  • Trial of all tier 2 medication that yielded inadequate clinical response or adverse effects, or
  • A unique indication which the Tier 2 drugs lack.

Tier 1

Tier 2

Tier 3

  • tolterodine (Detrol)
  • oxybutynin (Ditropan)
  • flavoxate (Urispas)
  • trospium (Sanctura, Sanctura XR)
  • tolterodine ER tabs (Detrol LA)
  • oxybutinin ER tabs (Ditropan XL)
  • darifenacin (Enablex)
  • oxybutinin patch (Oxytrol)
  • oxybutinin gel (Gelnique)
  • fesoterodine (Toviaz)
  • solifenacin (VESIcare)

*hyoscyamine can be used as adjuvant therapy only. By itself, it will not count as a tier 1 trial.

back to top

Narcotic Analgesics

PA Criteria:

Tier 1 medications are available without prior authorization.

Tier 2 authorization requires:

  • documented 30 day trial/titration period with at least two Tier 1 medications within the last 90 days, or
  • clinically appropriate pain therapy requiring time-released medication

Tier 3 authorization requires:

  • documented 30 day trial with at least two long-acting Tier 2 medications within the last 90 days, or
  • documented allergy or contraindication to all Tier 2 medications

Other criteria for this category:

  • Members with an oncology-related diagnosis are exempt from the step therapy process, although quantity and dosage limits still apply.  Actiq and Fentora are approved only for oncology-related diagnoses
  • Only one long-acting and one short-acting agent can be used concurrently
  • Prior Authorization form 

Tier 1

Tier 2

Tier 3

Oncology Only

Immediate Release   Long Acting
  • All immediate Release Narcotics Not Listed in Higher Tier*
  • morphine ER
  • Duragesic patches
  • Exalgo
  • Kadian
  • Avinza
  • Opana ER
  • Oxycontin
  • Embeda
  • Ultram ER
  • Ryzolt
                                                                        Short Acting     
  • Xodol
  • Opana
  • Nucynta
  • Zamicet
  • Actiq
  • Fentora
  • Onsolis buccal film

back to top

Darvocet A500/Balacet 325

PA criteria:

  • Concurrent use of acetaminophen-containing products.
  • Documented renal insufficiency or hepatic impairment or documented need to restrict acetaminophen use.
  • Prior Authorization form 

A quantity limit of #180/30 on each of the products also applies.

back to top

Smoking Cessation

PA criteria:

  • Smoking cessation products are covered, including OTC products.
  • Smoking cessation products are covered without prior authorization for the first 90 days.
  • After 90 days of use in a 365 day period, further use of smoking cessation products requires prior authorization.
  • Member must be enrolled in a smoking cessation behavior modification program and the name of the program must be stated on the petition.
  • For example see Smoking Cessation Program or call the Oklahoma Tobacco Helpline at (800) QUIT-NOW.
  • Length of approval: PA can be approved for another 90 days.
  • After the patient has had 180 days of treatment in a 365 day period, the patient must wait another 180 days before smoking cessation treatment will be covered again.
  • Smoking cessation products do not count against the 6 prescription per month limit.
  • Prior Authorization form 

back to top

NSAIDs

PA Criteria:

Tier 1 products are covered with no authorization necessary.

Tier 2 authorization criteria:

  • Previous use of at least two Tier 1 NSAID (from different product lines) plus a PPI within the last 120 days, or
  • For those with prior GI bleed who must have an NSAID, a Tier 2 product may be approved (Celebrex should also be taken with a PPI)

Special PA approval criteria:

  • Special indications, such as the diagnosis of gout for indomethacin, or
  • Previous use of at least two Tier 1 NSAID (from different product lines) and reason why a special formulation is needed over a Tier 1 product.

NOTE: In order for previously utilized Tier 1 medications to count as trials toward a Tier 2 authorization, the client's NSAID therapy must have been continuous. Dates and dosing information for Tier 1 trials must be included on petition for authorization. Trials with OTC formulations of Tier 1 products must be dosed at full prescription strength.

Tier 1

Tier 2

Special PA

  • naproxen sodium (Anaprox)
  • flurbiprofen (Ansaid)
  • diclofenac potassium (Cataflam)
  • sulindac (Clinoril)
  • oxaprozin (Daypro)
  • etodolac (Lodine)
  • etodolac ER (Lodine XL)
  • meclofenamate (Meclomen)
  • meloxicam (Mobic)
  • ibuprofen (Motrin)
  • fenoprofen (Nalfon)
  • naproxen (Naprosyn)
  • naproxen EC (Naprosyn EC)
  • ketoprofen (Orudis)
  • ketoprofen ER (Oruvail)
  • nabumetone (Relafen)
  • tolmetin (Tolectin)
  • diclofenac ER (Voltaren XR)
  • diclofenac sodium (Voltaren)
  • diclofenac sodium/misoprostol (Arthrotec)
  • celecoxib (Celebrex)
  • piroxicam (Feldene)
  • diclofenac epolamine (Flector)
  • diclofenac sodium drops (Pennsaid)
  • indomethacin (Indocin)
  • mefanamic acid (Ponstel)
  • naproxen sodium (Naprelan)
  • diclofenac sodium drops (Pennsaid)
  • diclofenac sodium gel (Voltaren Gel)
  • diclofenac potassium (Zipsor, Cambia)

back to top

Skeletal Muscle Relaxants

PA Criteria:

  • Tier 1 products are covered with no authorization necessary.

Tier 2 authorization requires:

  • Documented trial of two Tier 1 medications within the last 90 days with no beneficial response after a minimum of 2 weeks of continuous therapy during which time the medication has been titrated to the recommended dose.

Tier 1

Tier 2

Special PA

  • cyclobenzaprine (Flexeril)
  • baclofen (Lioresal)
  • orphenadrine (Norflex)
  • chlorzoxazone (Parafon Forte, Paraflex)
  • methocarbamol (Robaxin)
  • tizanidine (Zanaflex)
  • metaxolone (Skelaxin)
  • carisoprodol 350mg w/aspirin
  • carisoprodol 350mg, ASA, codeine
  • cyclobenzaprine ER (Amrix) Caps
  • cyclobenzaprine 7.5mg (Fexmid) Tabs
  • carisoprodol (Soma) 250mg
  • tizanidine (Zanaflex) Caps
Soma

PA Criteria:

  • A cumulative 90 therapy day window per 365 days will be in place for these products, further approval will be based on the following:
  • An additional approval for 1 month will be granted to allow titration or change to a Tier1 muscle relaxant. Further authorizations will not be granted.
  • Clinical exceptions may be made for members with the following diagnosis and approvals will be granted for the duration of one year:
    • Multiple Sclerosis
    • Cerebral Palsy
    • Muscular Dystrophy
    • Paralysis
  • A quantity limit of 120 per 30 days will also apply for the carisoprodol and carisoprodol combination products.

Soma 250 Approval for coverage is based on the following criteria:

  • Documentation regarding member's inability to use other skeletal muscle relaxants including carisoprodol 350 mg, and specific reason member cannot be drowsy for even a short time period.   Member must not have other sedating medications in current claims history.
  • A diagnosis of acute musculoskeletal pain, in which case, the approval will be for 14 days per 365 day period.  Conditions requiring chronic use will not be approved.

back to top

Osteoporosis

Tier 1

Tier 2

Tier 3

  • alendronate (Fosamax)
  • calcium + vitamin D
  • alendronate +D (Fosamax +D)
  • lbandronate (Boniva)
  • risedronate (Actonel)
  • zoledronic acid (Reclast)
  • teriparatide (Forteo)

Bisphosphonate

PA Criteria:

*Calcitonin and raloxifene are not included as Tier-1 trials.

  • †Must be used at recommended doses in conjunction with Tier-1 bisphosphonate for trial to be accepted unless member has a recent laboratory result showing adequate Vitamin D or member is unable to tolerate calcium. OTC Calcium and Vitamin D are only covered for members with osteoporosis. See a list of covered calcium products.


Criteria for Moving to Higher Tiers:

1. Treatment failure with all lower tiered products, or
2. Contraindication to all lower tiered products, or
3. Allergic reaction to all lowered tiered products, or
4. Specific indication not covered by a lower tiered product.
5. No concomitant use of bisphosphonate therapy will be approved.  No additional bisphosphonate  may be approved for 365 days following zoledronic acid infusion.
6. Clinical Exceptions:
 

  • Risedronate (Actonel) may be approved for members with high risk for gastric side effects.
  • Zoledronic acid (Reclast)may be approved for members with a diagnosis of Paget’s disease or for osteoporosis if secondary diagnosis meets criteria below:

  • Severe esophageal disease (e.g., ulcerations, strictures)
  • Inability to take anything by mouth
  • Inability to sit or stand for prolonged periods
  • Inability to take an oral bisphosphonate for other special medical circumstances that justify the method of administration

Forteo Criteria:

  • Teriparatide (Forteo) may be used after a minimum 12 month trial with a bisphosphonate plus adequate calcium and vitamin D (unless contraindicated, intolerant, or allergic) and a BMD (T-score at or below -2.5) test within the last month. 
  • Prior Authorization form 

back to top

Amrix and Fexmid

PA criteria:

  • Approval requires FDA approved indication and clinical documentation of inability to take other generically available forms of cyclobenzaprine hydrochloride.
  • A quantity limit of 30 capsules for 30 days placed on Amrix.
  • A a quantity limited of 90 tablets for 30 days placed on Fexmid.
Zanaflex

PA Criteria:

  • Trizanidine tablets must be tried prior to consideration of the capsules. The capsules maybe considered for approval if there is supporting information as to why the member cannot take the tablets

back to top

Erythropoietin Stimulating Agents

*SoonerCare members with Medicare DO NOT need a Prior Authorization*

PA Criteria:

FDA approved indication for specific products.

  • Treatment of Anemia of Chronic Renal Failure Patients
  • Treatment of Anemia of Zidovudine-treated HIV-infected Patients
  • Treatment of Anemia of Cancer Patients on Chemotherapy
    • Myelosuppressive Chemotherapy-induced Anemia (Hb 8-10 g/dl) Non-Curative
  • Reduction of Allogeneic Blood Transfusion in Surgery Patients

Most recent Hb levels (and date obtained) should be included on petition.  Each approval will be for 8 weeks in duration.  Authorization can be granted for up to 8 weeks following the final dose of myelosuppressive chemotherapy in a chemotherapy regimen.  Authorization for surgery patients will be for a maximum of 4 weeks.

Continuation Criteria:

  • Continue dose if Hb is 12.0 g/dL.
  • If Hb is increasing and approaching 12 g/dL then reduce dose by at least 25%
  • If more than 1 g/dL increase (but Hb not greater than upper limits listed below) has occurred in a 2 week period reduce dose by 25 to 50%.

Discontinuation Criteria

  • ESRD - Discontinue treatment if Hb is at or above 13.0 g/dL.
  • All others - Discontinue treatment if Hb is at or above 12 g/dL
  • If a minimum increase of 1 g/dL has not been achieved after initial 8 weeks of therapy.

Reinitiation Criteria:

  • If Hb decreases to 10 g/dL then therapy may be reinitiated at 25 to 50% of the prior dose.

Once the initial request has been submitted and approved, continuation of therapy may occur with submission of the continuation form.

  • Aranesp
  • Epogen
  • Procrit

back to top

Growth Hormone

PA Criteria:

  • Classic Human Growth Hormone hGH Deficiency or,
  • Short Stature (including Prader-Willi Syndrome) or,
  • Short Stature associated with chronic renal insufficiency or,
  • Small for Gestational Age (SGA) or,
  • Turner’s Syndrome or 45 X, 46 XY mosiacism in males or,
  • Hypoglycemia associated with hGH insufficiency or,
  • AIDS wasting (Serostim only)
  • SHOX (short stature homeobox-containing gene) deficiency
  • Prior Authorization form 

Preferred

 

  • Nutropin
  • Nutropin AQ
  • Genotropin
  • Humatrope
  • Increlex
  • Iplex
  • Norditropin
  • Norditropin Nordiflex
  • Protropin
  • Saizen
  • Serostim
  • Tev-Tropin

back to top

Diabetic Medications

Byetta (exenatide) and Victoza (liraglutide)

PA criteria:

  • Authorization will be based on the following criteria:
  • Patients must have Type 2 diabetes and currently taking metformin, sulfonylurea, thiazolidinedione, or a combination, for at least 90 days within the last 180 days, and have not achieved adequate glycemic control.
  • Quantity limit of 3 cartrdiges per 30 days applies (3.6 mls & 7.2 mls) for Byetta
  • Quantity limit of 3 penpaks (9 mls) per 30 days for Victoza.

PA criteria: Symlin

Patients with type 1 and 2 diabetes using insulin must:

  • Be using basal-bolus insulin regimen (basal insulin plus rapid acting with meals), and
  • Have failed to achieve adequate glycemic control on a basal-bolus regimen or are gaining excessive weight on basal-bolus regimen, and
  • Receiving ongoing care under the guidance of a health care professional.

Patients meeting the following criteria should NOT be considered for Symlin therapy

  • poor compliance with insulin regimen
  • poor compliance with self-blood glucose monitoring
  • HbA1c>9%
  • recurrent severe hypoglycemia requiring assistance in past 6 months
  • presence of hypoglycemia unawareness
  • diagnosis of gastroparesis
  • require use of drugs that stimulate GI motility
  • pediatric patients (<15 years old)

PA criteria: Fortamet Glumetza

Approval will be based on clinical documentation of inability to take other forms of generic metformin ER - after slow titration of 500mg ER at 2 week intervals up to 2000mg daily.

Elidel / Protopic

PA criteria:

  • Clinical Diagnosis: short term and intermittent treatment for mild to moderate atopic dermatitis (eczema).
  • The first 90 days of a 12 month period will be covered without a prior authorization.
  • After the initial period, authorization will be granted with documentation of one trial of a topical corticosteroid of six weeks duration within the past 90 days.
  • Therapy will be approved only once each 90 day period to ensure appropriate short-term and intermittent utilization as advised by the FDA.
  • Quantities will be limited to 30 grams for use on the face, neck, and groin, and 100 grams for all other areas.
  • Authorizations will be restricted to those patients who are not immunocompromised.
  • Exception for age restrictions granted only if prescription is written by a dermatologist.
  • Age restrictions:
    • Elidel 1% ≥2 years of age
    • Protopic 0.03% for ≥2 years of age
    • Protopic 0.1% for ≥15 years of age (Approved for adult-use only)

back to top

Lamisil Granules

PA criteria:

  • Member unable to swallow tablets, and
  • FDA-approved indication of tinea capitis, and
  • No improvement after at least 3 weeks of therapy with griseofulvin, or
  • Intolerance of hypersensitivity to griseofulvin or penicillin
  • Prior Authorization form 

back to top

Antifungal Step Therapy

Criteria for Tier 2 Product:

  • Approval of a Tier 2 product will be granted following trials of at least two Tier 1 topical antifungal products within the last 30 days.
  • For treatment of Onychomycosis, a trial of oral antifungals (6 weeks for fingernails and 12 weeks for toenails) will be required in order for approval of Penlac.

Tier 1

Tier 2

  • ciclopirox
  • clotrimazole
  • clotrimazole/betamethasone
  • econazole
  • ketoconazole
  • nystatin
  • nystatin/triamcinolone
  • Most other available generic antifungal products
  • benzoic acid/salicylic acid (Bensal HP)
  • sertaconazole nitrate (Ertaczo)
  • sulconazole (Exelderm)
  • ketoconazole foam 2% (Extina)
  • terbinafine (Lamisil Spray)
  • Ciclopirox solution, shampoo & gel (Loprox)
  • clotrimazole (Lotrimin Lotion 1%)
  • butenafine (Mentax)
  • naftifine (Naftin)
  • oxiconazole (Oxistat)
  • miconazole/zinc oxide/white petrolatum (Vusion)
  • ketoconazole gel (Xolegel)
  • ketoconazole gel +1% pyrithione zinc shampoo (Xolegel DUO)

back to top

Lidoderm Patch

PA criteria:

  • FDA approved diagnosis (Postherpetic Neuraigia)
  • Provide documented treatment attempts at recommended dosing or contraindication to at least one agent from two of the following drug classes:
    • Tricyclic antidepressants
    • Anticonvulsants
    • Topical or Oral Analgesics
  • Quantity limit of no more than 3 patches per day with a maximum of 90 patches in a month.
  • Prior Authorization form 

back to top

Topical Antibiotic Medications

Tier 1 products are available without prior authorization.

Tier 2 authorization requires:

  • Documented five-day trial of a Tier 1 product within the last 30 days.
  • Clinical exception for adverse effects with all Tier 1 products, or unique indication not covered by Tier-1 products.
  • Prior authorization will be for 10 days.

Tier 1

Tier 2

  • Cortisporin Cream 0.5%
  • Cortisporin Ointment 1%
  • Gentamicin Cream 0.1%
  • Gentamicin Ointment 0.1%
  • Gentamicin Powder
  • Mupirocin Ointment 2%
  • Altabax Ointment 1%
  • Bactroban Cream 2%
  • Bactroban Nasal Ointment 2%
  • Centany Kit 2%

back to top

Pediculicide

Approval Criteria:

  • Approval of Tier 2 medications requires a trial with one Tier 1 medication with inadequate response or adverse effect.
  • Age and Quantity Limits based on FDA labeling may apply

Tier 1

Tier 2

  • Covered OTC Permethrin Products
  • lindane lotion & shampoo
  • crotamiton (Eurax)lotion
  • malathion (Ovide)
  • benzoyl alcohol (Ulesfia)lotion

back to top

Ocular Allergy

Criteria for Tier 2 Product:

  • FDA approved diagnosis.
  • A trial of at least one Tier 1 product of a similar type for a minimum of two weeks in the last 30 days.
  • Documentation of clinical need for Tier 2 product over Tier 1 should be noted on the petition.
  • Clinical exceptions granted for products with allergic reaction or contraindication.

Tier 1

Tier 2

Tier 3

  • ketotifen fumarate (Alaway, Zaditor OTC)
  • cromolyn sodium (Crolom)
  • olopatadine (Patanol)
  • pemirolast potassium (Alamast)
  • nedocromil sodium (Alocril)
  • lodoxamide tromethamine (Alomide)
  • loteprednol etabonate (Alrex)
  • bepotastine (Bepreve)
  • epinastine (Elestat)
  • emadastine difumarate (Emadine)
  • azelastine (Optivar)
  • olopatadine (Pataday)

back to top

Otic Anti-Infective

PA Criteria:

  • Members must have adequate 14 day trial of at least two tier 1 medications, or
  • Approval may be granted if there is a unique FDA approved indication not covered by tier 1 products or infection by organism not known to be covered by any of the tier 1 agents.
  • A ciprofloxacin combination product may be approved when a steriod containing product is required for severe otitis externa and the tympanic membrane is not intact.

A form containing the tier 1 products will be included in the fax back to aid in product selection.

Tier 1

Tier 2

Tier 3

  • ofloxacin (Floxin Otic)
  • neomycin, polymixin B, HC(Cortisporin, Cortomycin, Pediotic)
  • chloroxylenol/pramoxine (Pramotic)
  • acetic acid (Vosol, Acetasol)

 

  • ciprofloxacin, Dex or HC  (Ciprodex, Cipro HC, Cetraxal Drop)
  • neomycin, colistin, HC (Coly-Mycin, & Coly Mycin-ES)
  • neomycin, polymixin B, HC, thonzonium (Cortisporin,TC)
  • chloroxylenol, benzocaine & HC (Trioxin)
  • chloroxylenol/pramoxine/zinc (Zinotic, Zinotic ES, Chlorpram Z)
  • acetic acid, antipyrine, benzocaine, glycerin (Auralgan)
  • acetic acid, antpy bcain polico al acet 5.4%-1.4% drops
  • acetic acid, HC (Acetasol HC, Vosol HC)
  • antipyrine, benzocaine, glycerin,zinc 5.4-1-2-1% (Neotic)

back to top

Ophthalmic Glaucoma Medications

Tier 1 products are covered with no authorization necessary

Tier 2 authorization requires:

  • Comprehensive dilated eye exam within the last 365 day period, and
  • FDA-approved indication, and
  • Trial of a Tier 1 product for a minimum of 4 weeks with inadequate results within the last 90 days, or
  • Documented adverse effect, drug interaction, or contraindication to Tier 1 products, or
  • Unique FDA-approved indication for which Tier 1 medications are not indicated
Beta-Blockers

Tier 1

Tier 2

  • levobunolol (Betagan)
  • timolol maleate (Betimol, Istalol, Timoptic, Timoptic Ocudose, Timoptic XE)
  • betaxolol (Betoptic 0.5%)
  • dorzolamide/timolol (Cosopt)
  • carteolol (Ocupress)
  • metipranolol (OptiPranolol)
  • betaxolol (Betoptic S)
  • brimonidine/timolol (Combigan)
  • timolol maleate (Timoptic 0.5% dropperette)
Prostaglandin Analogs

Tier 1

Tier 2

  • travoprost (Travatan, Travatan Z)
  • bimatoprost (Lumigan)
  • latanoprost (Xalatan)
Adrenergic Agonists

Tier 1

Tier 2

  • dipivefrin (Propine)
Alpha-2 Adrenergic Agonists

Tier 1

Tier 2

  • brimonidine 0.2%
  • brimonidine (Alphagan P 0.1%,0.15%)
  • apraclonidine (Iopidine 1%)
Carbonic Anhydrase Inhibitors

Tier 1

Tier 2

  • dorzolamide/timolol (Cosopt)
  • dichlorphenamide (Daranide)
  • acetazolamide (Diamox)
  • methazolamide (Neptazane)

*(Indicates Available Oral Products)

  • brinzolamide (Azopt)
  • dorzolamide (Trusopt)
Cholinergic Agonists/Cholinesterase Inhibitors

Tier 1

Tier 2

  • pilocarpine (Isopto Carpine, Pilopine HS 0.5%, 1%,2%,4%,6%)
  • carbachol (Isopto, Miostat 1.5%, 3%)
  • echothiophate iodide (Phospholine lodide)

back to top

Ophthalmic Anti-Infective/Steroid Combinations

All steroid combinations listed below will require a petition for use and the PA Criteria is as follows:

  • Used for pre-operative/post-operative prophylaxis
  • Prescription written by optometrist / ophthalmologist

  • tobramycin/dexamethasone (Tobradex)
  • tobramycin/loteprednol (Zylet)
  • sulfacetamide/prednisolone (Blephamide)
  • gentamicin/prednisolone (Pred-G)
  • neomycin/polymyxin/Bac/Hydrocortisone Ointment
  • neomycin/polymyxin-B/prednisolone (Poly-Pred)
  • neomycin/polymyxin-B/hydrocortisone (Cortisporin)
  • neomycin/polymyxin-B/dexamethasone (Maxitrol)
  • Prior Authorization form  

Ophthalmic Antibiotics: Liquids

Tier 1

Tier 2

Tier 3

  • gentak (Gentamicin)
  • natacyn (Natamycin)
  • ak-spore (Neomycin/PolymyxinB/Gramacidin)
  • polytrim (PolymyxinB/Trimethoprim)
  • bleph-10 sodium sulamyd (Sodium Sulfacetamide)
  • ak-tob (tobramycin)
  • viroptic (Trifluridine)
  • ciloxan solution (Ciprofloxacin)
  • ocuflox (Ofloxacin)
  • azasite (Azithromycin)
  • besifloxacin HCL (Besivance)
  • gatifloxacin (Zymaxid) 0.5% ophthalmic drops
  • zymar (Gatifoxacin)
  • quixin (Levofloxacin)
  • lquix (Levofloxacin)
  • vigamox (Moxifloxacin)
Ophthalmic Antibiotics: Ointments

Tier 1

Tier 2

  • ak-tracin (Bacitracin)
  • ak-poly-bac (Bacitracin/PolymyximB)
  • A/T/S, llotycin, roymicin (Erythromycin)
  • gentak (Gentamicin)
  • neosporin (Neomycin/Polymyxin B/Bacitracin)
  • bleph-10, sodium sulyamyd (Sodium Sulfacetamide)
  • tobrex (Tobramycin)
  • ciloxan ointment (Ciprofloxacin)

Criteria for a Tier 2 medication:

  • Approved indication/suspected infection by organism not know to be covered by tier 1 products,or failure of a tier 1 products
  • Known contraindication to all indicated tier 1 medication.
  • Prescription written by optometrists/ophthalmologists, or
  • When used for pre/post-operative prophylaxis.

Criteria for a Tier 3 medication:

  • Approved indication/suspected infection by organism not know to be covered by tier 2 products, or failure of a tier 2 product.
  • Known contraindication to all indicated tier 2 medication.
  • Prescription written by optometrists/ophthalmologists, or
  • When used for pre/post-operative prophylaxis.

back to top

Anti-Ulcer

Criteria for Approval of a Tier 2 medication:

  • A 14 day trial of omeprazole dosed up to 40mg per day (two 20mg caps) that has resulted in inadequate relief of symptoms or intolerable adverse effects.
  • Contraindication to all available tier 1 medications.
  • An indication not covered by lower tiered medications.

Criteria for Approval of a Tier 3 medication:

  • A 14 day trial all available tier 2 medications that has resulted in inadequate relief of symptoms or intolerable adverse effects.
  • Contraindication to all available tier 2 medications.
  • An indication not covered by lower tiered medications.

Criteria for Approval of Age Appropriate PPIs for Pediatric members under the age of 19:

  • A recent 14 day trial of an H2 receptor antagonist that has resulted in inadequate relief of symptoms or intolerable adverse effects.
  • Recurrent or severe disease such as:
    • GI Bleed
    • Zollinger-Ellison or similar disease
  • Prior Authorization form 

Special Prior Authorizations of Miscellaneous Products

  • ranitidine (Zantac Effervescent Tabs) - must have reason why member cannot take other dosage forms.
  • famotidine (Pepcid Suspension) - reserved for members less than 1 month old.

Tier 1

Tier 2

Tier 3

  • omeprazole (Prilosec 10 mg, 20 mg & 40 mg caps)
  • dexlansoprazole (Dexilant)
  • lansoprazole (Prevacid® Caps and ODT)*
  • pantoprazole (Protonix Tabs)
  • omeprazole/antacid 
  • esomeprazole (Nexium® Caps and I.V.)*
  • omeprazole (Prilosec ® Susp)*
  • pantoprazole (Protonix® Susp & I.V.)*
  • rabeprazole sodium (Aciphex® Tabs)

Mandatory Generic Plan Applies:

***Special Formulations including ODTs, Granules, Suspension and Solution for I.V. require special reason for use.

back to top

Amitiza

PA criteria:

  • Chronic Idiopathic Constipation in males and females, or Irritable bowel syndrome in females 18 years of age and older who meet the following criteria:
    • Have documentation that constipating therapies for other disease states have been discontinued (excluding opioid pain medications for cancer patients).
    • Documented and updated Colon Screening. (>50 years of age)
  • Hydration and treatment attempts with a minimum of three alternate products must be documented.
  • Initial approval for 12 weeks of therapy. An additional year approval may be granted if physician documents member is responding well to treatment.
  • Quantity limit of 100 units for a 50 day supply.

back to top

Anti - emetic

 

Granisetron (Kytril, Sancuso), Dolasetron (Anzement), Aprepitant (Emend)

Approval Criteria:

  • Approved Diagnosis
  • A recent (within the past 6 months) trial of ondansetron used for at least 3 days or one cycle that resulted in inadequate response.

Nabilone (Cesamet), Dronabinol (Marinol)

Approval Criteria:

  • For the diagnosis of HIV related loss of appetite: approve for 6 months
  • For chemotherapy induced nausea and vomiting: A recent (within the past 6 months) trial of ondansetron used for at least 3 days or one cycle that resulted in inadequate response.

      

back to top

Ilaris

PA Criteria:

  • FDA approved indication of Cryopyrin-Associated Periodic Syndromes (CAPS) verified by genetic testing. This includes Familial Cold Auto-inflammatory Syndrome (FCAS) and Muckle-Wells Syndrome (MWS) in adults and children 4 and older.
  • The member should not be using a tumor necrosis factor blocking agent (e.g. adalimumab, etanercept, and infliximab) or anakinra.
  • Should not be initiated in patients with active or chronic infection including hepatitis B, hepatitis C, human immunodeficiency virus, or tuberculosis.
  • Dosing should not be more often than once every 8 weeks.
  • Approved dosing schedule based on weight:
       a. Body weight >40 kg: 150mg
       b. Body weight 15 kg – 40 kg: 2mg/kg. If inadequate response, may be increased to 3mg/kg.
  • Approval period is for one year.

back to top

Mozobil (plerixafor)

PA Criteria:

  • FDA approved indication of use in combination with granulocyte-colony stimulating factor (G-CSF) to mobilize hematopoietic stem cells to the peripheral blood for collection and subsequent autologous transplantation in patients with non-Hodgkin’s lymphoma (NHL) and multiple myeloma (MM).
  • MUST have a cancer diagnosis of non-Hodgkins’s lymphoma (NHL) or multiple myeloma (MM).  This medication is NOT covered for the diagnosis of leukemia.
  • Prescribed by an oncologist only.
  • Patient must be at least 18 years of age.
  • Must be given in combination with the granulocyte-colony stimulating factor (G-CSF) Neupogen® (filgrastim).
  • Dosing (requires current body weight in kilograms):
    • Recommended dose is 0.24 mg/kg, maximum dose is 40mg/day, administered 11 hours prior to apheresis for up to 4 consecutive days. (USE ACTUAL BODY WEIGHT).
    • Dosing for renal impairment:
      • Creatinine clearance ≤ 50 mL/min:  0.16 mg/kg, maximum of 27 mg/day.
  • Approval period will be for two months.

 

back to top

Nplate (romiplostim)

PA Criteria:

  • FDA approved indication of chronic immune (idiopathic) thrombocytopenia purpura (ITP) in adults 18 and over.
  • Previous insufficient response with at least two of the following treatments: corticosteroids, immunoglobulins, or splenectomy.
  • Recent platelet count of < 50 x 109/L.
  • Initial dosing of 1 mcg/kg once weekly as a subcutaneous injection with recent patient weight in kilograms provided.
  • Continuation criteria:
    • Weekly CBCs with platelet count and peripheral blood smears until stable platelet count (≥ 50 x 109/L for at least 4 weeks without dose adjustment) has been achieved; then obtain monthly thereafter.
  • Dosing adjustments:
    • i. Platelets < 50 x 109/L, increase dose by 1 mcg/kg
    • ii. Platelets > 200 x 109/L for 2 consecutive weeks, reduce dose by 1 mcg/kg
    • iii. Platelets > 400 x 109/L, do not dose. Continue to assess platelet count weekly. When platelets < 200 x 109/L, resume at a dose reduced by 1 mcg/kg
  • Discountinuation criteris:
    • Platelet count does not increase to a level sufficient to avoid clinically important bleeding after 4 weeks of therapy at the maximum weekly dose of 10 mcg/kg
  • Approval period will be for four weeks initially, and then quarterly.

back to top

Arcalyst (rilonacept)

PA Criteria:

  • FDA approved indication of Cryopyrin-Associated Periodic Syndromes (CAPS) verified by genetic testing.  This includes Familial Cold Auto-inflammatory Syndrome (FCAS) and Muckle-Wells Syndrome (MWS) in adults and children 12 and older.
  • The member should not be using a tumor necrosis factor blocking agent (e.g. adalimumab, etanercept, and infliximab) or anakinra.
  • Should not be initiated in patients with active or chronic infection including hepatitis B, hepatitis C, human immunodeficiency virus, or tuberculosis.
  • Dosing should not be more often than once weekly.
  • Approved dosing schedule for adults 18 and over:
    • Initial treatment: loading dose of 320 mg delivered as two 2mL subcutaneous injections of 160 mg each given on the same day at two different injection sites.
    • Continued treatment is one 160 mg injection given once weekly.
  • Approved dosing schedule for pediatric patients aged 12-17 years (must have patient weight in kilograms):
    • Initial treatment: loading dose of 4.4 mg/kg, up to a maximum of 320 mg, delivered as one or two subcutaneous injections with a maximum single-injection volume of 2mL.
    • Continued treatment is 2.2 mg/kg, up to a maximum of 160 mg, given once weekly.
  • Approval period is for one year.

back to top

If you have questions please call the Pharmacy Help Desk at (800) 522-0114 option 4 or (405) 522-6205 option 4.