PHARMACY PRIOR AUTHORIZATION

CRITERIA

This criteria document does not supersede any criteria set forth by the Louisiana Department of Health (LDH) Fee for Service Medicaid program. This criteria only applies in the absence of LDH prior authorization criteria.

Field Name Field Description Prior Authorization Group Description Diabetic Testing Supplies

Drugs Diabetic Testing Supplies (e.g. glucometers, test strips, lancets, syringes, pen needles)

Covered Uses Medically accepted indications are defined using the following sources: the Food and Drug Administration (FDA), Micromedex, American Hospital Formulary Service (AHFS), United States Pharmacopeia Drug Information for the Healthcare Professional (USP DI), the Drug Package Insert (PPI), or disease state specific standard of care guidelines.

Exclusion Criteria N/A Required Medical

Information See “other criteria”

Age Restrictions N/A

Prescriber Restrictions N/A

Coverage Duration If the criterion is met, the request will be approved for up to a 12 month duration (depending on the diagnosis and usual treatment duration). If criterion is not met, the request will be referred to a clinician for medical necessity review.

Other Criteria

Revision/Review Date 10/2020

Initial Authorization: Criteria for approval of Non-Preferred products: • Member is legally blind or has reduced visual acuity so that they

are unable to see the numbers on ALL of the preferred products and the requested product has a feature that enables the patient to use the meter that is not available on any of the preferred meters. The member (not a caregiver) must be the one using the monitor/strips OR

• Member is currently using an insulin pump that needs specific meter compatibility to accurately dose insulin OR

• Preferred meter is not compatible with insulin pump recipient is using OR

• Member is unable to change to a preferred meter and strip combination due to a cognitive or developmental disability OR

• Changing to a preferred meter and strip combination would create undue hardship for the member

Medical Director/clinical reviewer must override criteria when, in

his/her professional judgement, the requested item is medically necessary.

Field Name Field Description Prior Authorization

Group Oncology Drugs

Drugs Injectable Oncology Medications (specialty or non-specialty) without medication specific criteria when requested for an oncology diagnosis

Covered Uses Medically accepted indications are defined using the following sources: the Food and Drug Administration (FDA), Micromedex, American Hospital Formulary Service (AHFS), United States Pharmacopeia Drug Information for the Healthcare Professional (USP DI) , and the Drug Package Insert, and/or per the National Comprehensive Cancer Network (NCCN)

Exclusion Criteria N/A Required Medical

Information See “Other Criteria”

Age Restrictions N/A Prescriber Restrictions Prescriber is an oncologist, or specialist in type of cancer being

treated Coverage Duration If the criteria are met, the request will be approved for up to 6

month duration; if the criteria are not met, the request will be referred to a clinical reviewer for medical necessity review.

Other Criteria

All of the following criteria must be met:

The drug is requested through the medical benefit Requested use must be a labeled indication or be supported

by NCCN Category 1 or 2A level of evidence. If the request is for an off-label use supported by NCCN as Category 2B recommendation then medical documentation has been provided as to why member is unable to utilize a treatment regimen with a higher level of evidence (e.g. allergic reaction, contraindication); if such a treatment exists; AND

Documentation has been provided of the results of all required genetic testing where required per drug package insert; AND

Documentation has been provided of the results of all required laboratory values and patient specific information (e.g. weight, ALT/AST, creatine kinase, etc.) necessary to ensure the patient has no contraindications to therapy per drug package insert; AND

The medication is being prescribed at a dose that is within FDA approved/NCCN guidelines.

If the request is for a reference biologic drug with either a biosimilar or interchangeable biologic drug currently available

o The provider has either verbally or in writing submitted a member specific reason why the brand

Revision/Review

7/2020

name biologic is required based on the member’s condition or treatment history;

Medical Director/clinical reviewer must override criteria when,

in his/her professional judgment, the requested item is medically

necessary.

Field Name Field Description Prior Authorization Group Description Remdesivir

Drugs Remdesivir Covered Uses Medically accepted indications are defined using the following

sources: the Food and Drug Administration (FDA), Micromedex, American Hospital Formulary Service (AHFS), United States Pharmacopeia Drug Information for the Healthcare Professional (USP DI), and the Drug Package Insert (PPI).

Exclusion Criteria N/A Required Medical

Information See “Other Criteria”

Age Restrictions N/A Prescriber

Restrictions N/A

Coverage Duration If all of the conditions are met, the request will be approved for a duration consistent with the fact sheet for health care providers associated with the emergency use authorization.

Other Criteria

Revision/Review Date 7/2020

Use is consistent with the terms and conditions of the emergency use authorization granted by the US Food and Drug Administration. FDA Emergency Use Authorization Letter: https://www.gilead.com/-/media/files/pdfs/remdesivir/eua-fda-authorization-letter_01may2020.pdf?la=en&hash=1333AAA128ECE91DDBB9BC4F9467C843 Medical Director/clinical reviewer must override criteria when, in his/her professional judgement, the requested item is medically necessary.

References 1. Remdesivir. Gilead website. Available at https://www.gilead.com/remdesivir.

Accessed July 21, 2020 2. FDA emergency use authorization letter. Available at https://www.gilead.com/-

/media/files/pdfs/remdesivir/eua-fda-authorization-letter_01may2020.pdf?la=en&hash=1333AAA128ECE91DDBB9BC4F9467C843. Accessed July 21, 2020

https://www.gilead.com/-/media/files/pdfs/remdesivir/eua-fda-authorization-letter_01may2020.pdf?la=en&hash=1333AAA128ECE91DDBB9BC4F9467C843https://www.gilead.com/-/media/files/pdfs/remdesivir/eua-fda-authorization-letter_01may2020.pdf?la=en&hash=1333AAA128ECE91DDBB9BC4F9467C843https://www.gilead.com/-/media/files/pdfs/remdesivir/eua-fda-authorization-letter_01may2020.pdf?la=en&hash=1333AAA128ECE91DDBB9BC4F9467C843https://www.gilead.com/-/media/files/pdfs/remdesivir/eua-fda-authorization-letter_01may2020.pdf?la=en&hash=1333AAA128ECE91DDBB9BC4F9467C843https://www.gilead.com/remdesivirhttps://www.gilead.com/-/media/files/pdfs/remdesivir/eua-fda-authorization-letter_01may2020.pdf?la=en&hash=1333AAA128ECE91DDBB9BC4F9467C843https://www.gilead.com/-/media/files/pdfs/remdesivir/eua-fda-authorization-letter_01may2020.pdf?la=en&hash=1333AAA128ECE91DDBB9BC4F9467C843https://www.gilead.com/-/media/files/pdfs/remdesivir/eua-fda-authorization-letter_01may2020.pdf?la=en&hash=1333AAA128ECE91DDBB9BC4F9467C843

Field Name Field Description Prior Authorization Group Description Specialty Drugs

Drugs Oral and injectable specialty drugs without drug or class specific prior authorization criteria *** The Oncology Drugs prior authorization criteria will be applied to oncology drugs without drug or class specific criteria***

Covered Uses Medically accepted indications are defined using the following sources: the Food and Drug Administration (FDA), Micromedex, American Hospital Formulary Service (AHFS), United States Pharmacopeia Drug Information for the Healthcare Professional (USP DI), the Drug Package Insert (PPI), or disease state specific standard of care guidelines.

Exclusion Criteria N/A Required Medical

Information See “Other Criteria”

Age Restrictions According to package insert Prescriber Restrictions N/A

Coverage Duration If all of the conditions are met, requests will be approved for up to 6 months. If the conditions are not met, the request will be sent to a Medical Director/clinical reviewer for medical necessity review.

Other Criteria

Revision/Review Date 7/2020

All of the following criteria must be met: • The drug is requested through the medical benefit • The drug is requested for an appropriate use (per the references

outlined in “Covered Uses” • The dose requested is appropriate for the requested use (per the

references outlined in “Covered Uses”) • Documentation has been provided of a trial and failure of an

appropriate alternative first line therapy, if one exists, for the requested use (per the references outlined in “Covered Uses” or has a medical reason why these drug(s) cannot be used (e.g. intolerance, contraindication)

• If the request is for a reference biologic drug with either a biosimilar or interchangeable biologic drug currently available

o The provider has either verbally or in writing submitted a member specific reason why the reference biologic is required based on the member’s condition or treatment history;

Physician/clinical reviewer must override criteria when, in his/her professional judgment, the requested item is medically necessary.

Field Name Field Description Prior Authorization Group Description Prior Authorization Exception Criteria

Covered Uses All medically accepted indications. Medically accepted indications are defined using the following compendia resources: the Food and Drug Administration (FDA) approved indication(s) (Drug Package Insert), American Hospital Formulary Service Drug Information (AHFS-DI), and DRUGDEX Information System. The reviewer may also reference disease state specific standard of care guidelines.

Scope Requests for exception to the drug’s prior authorization criteria requirements

Criteria • The provider either verbally or in writing has submitted a medical or member specific reason why prior authorization criteria all or in part is not applicable to the member.

o Medical reasons may include but are not limited to: Criteria requirements are not applicable to the

member based on the uniqueness of the member’s condition or other physical characteristics of the member’s condition.

OR

o Member specific reasons may include but are not limited to: Mental and/or physical characteristics of the member

which may inhibit the provider from obtaining all necessary prior authorization criteria requirements.

Medical Director/clinical reviewer may override criteria when, in his/her professional judgement, the requested item is medically necessary.

Coverage Duration 12 months Revision/Review

Date: 5/2020

Field Name Field Description Prior Authorization Group Description Quantity Limit Exception Criteria

Covered Uses All medically accepted indications. Medically accepted indications are defined using the following compendia resources: the Food and Drug Administration (FDA) approved indication(s) (Drug Package Insert), American Hospital Formulary Service Drug Information (AHFS-DI), and DRUGDEX Information System. The reviewer may also reference disease state specific standard of care guidelines.

Scope Requests for formulary drugs exceeding the health plan’s published quantity limits

Criteria • The provider has submitted a medical reason why the plan’s

quantity limit will be inadequate based on the member’s condition and treatment history.

AND

• The member has a documented treatment failure with the drug prescribed at the health plan’s quantity limit AND the dose requested is supported by the Medical Compendia or current treatment guidelines.

OR • The member requires a dose within prescribing guidelines that

exceeds the plan’s quantity limit.

Medical Director/clinical reviewer may override criteria when, in his/her professional judgement, the requested item is medically necessary.

Coverage Duration 12 Months Revision/Review

Date 5/2020

Field Name Field Description Prior Authorization Group Description Safety Edit Exception Criteria

Covered Uses All medically accepted indications. Medically accepted indications are defined using the following compendia resources: the Food and Drug Administration (FDA) approved indication(s) (Drug Package Insert), American Hospital Formulary Service Drug Information (AHFS-DI), and DRUGDEX Information System. The reviewer may also reference disease state specific standard of care guidelines.

Scope Requests for formulary drugs and for previously approved non-formulary drugs:

• Exceeding the Food and Drug Administration (FDA) or compendia max dose recommendations

• Exceeding the FDA dosing or compendia administration frequency recommendations

• Exceeding the FDA or compendia duration of therapy recommendations

• Duplication of therapy error at Point of Service (POS) • Age Restriction error at POS • Concurrent Use error at POS

Criteria Exceeding the Food and Drug Administration (FDA) or compendia maximum dose, administration frequency or duration of therapy recommendations.

• The member must have a documented treatment failure with the drug at the maximum tolerated dose or maximum dose (whichever is the lesser dose), administration frequency or duration of therapy.

AND • The provider must submit a medical reason why the maximum

dose, administration frequency or duration of therapy needs to be exceeded based on the member’s condition or treatment history.

Duplication of therapy

Transition from one agent to another

• If a provider has outlined a plan to transition a member to a similar drug or provided a dose titration schedule, the requested drug is approved for one month*.

Concurrent Therapy with two similar agents

• The provider must submit a medical reason why treatment with more than one drug in the same class is required based on the member’s condition and treatment history.

OR • The provider must submit disease state specific standard of care

guidelines supporting concurrent therapy. Age Restriction

• The provider must submit a medical reason why the drug is needed for a member whose age is outside of the plan’s minimum or maximum age limit.

AND • The indication and dose requested is supported by the Medical

Compendia or current treatment guidelines.

Concurrent Use:

• The provider must submit a medical reason why treatment with both drugs is necessary for the member

Medical Director/clinical reviewer may override criteria when, in his/her professional judgement, the requested item is medically necessary.

Coverage Duration *One month approval for Duplication of therapy when transitioning from one agent to another. All Other Scenarios: 12 months

Revision/Review Date:

5/2020

 

Field Name  Field Description Prior Authorization Group Description 

Step Therapy Exception Criteria 

Covered Uses  All medically accepted indications. Medically accepted indications are defined using the following compendia resources: the Food and Drug Administration (FDA) approved indication(s) (Drug Package Insert), American Hospital Formulary Service Drug Information (AHFS‐DI), and DRUGDEX Information System. The reviewer may also reference disease state specific standard of care guidelines. 

Scope   Requests for drugs on the plan’s formulary with a step therapy restriction which do not meet step therapy requirements 

Criteria  The provider has demonstrated knowledge of step therapy requirements. 

AND  The provider verbally or in writing has submitted a medical reason why 

required step therapy drug(s) would be ineffective or have the potential to cause harm or deterioration of the member’s condition. 

OR   The provider has submitted a medical reason why the requested drug 

would be superior to the required prerequisite trial(s) with formulary drug(s). 

  Medical Director/clinical reviewer may override criteria when, in his/her professional judgement, the requested item is medically necessary. 

 

Coverage Duration   12 Months  Revision/Review Date:  

10/2019 

 

Field Name  Field Description Prior Authorization Group Description 

Diagnosis Code Requirement 

Drugs  Formulary/preferred medications that will pay at point of sale if the required ICD‐10 code is submitted at the pharmacy 

Covered Uses  Medically accepted indications are defined using the following sources: the Food and Drug Administration (FDA), Micromedex, American Hospital Formulary Service (AHFS), United States Pharmacopeia Drug Information for the Healthcare Professional (USP DI), the Drug Package Insert (PPI), or disease state specific standard of care guidelines.  

Exclusion Criteria  N/A 

Required Medical Information  See “other criteria” 

Age Restrictions  According to package insert 

Prescriber Restrictions 

N/A 

Coverage Duration  If the criterion is met, the request will approved for up to a 12 month duration (depending on the diagnosis and usual treatment duration).  If criterion is not met, the request will be referred to a Clinician for medical necessity review. 

Other Criteria 

Revision/Review Date 4/2019 

Provider has submitted a diagnosis that is FDA approved or referenced in disease state specific standard of care guidelines for the requested drug. (Please see covered uses section for appropriate sources) 

Medical Director/clinical reviewer must override criteria when, in his/her professional judgement, the requested item is medically necessary. 

Diagnosis Code Requirement PA Criteria 4.2019