Pharmacy Prior Authorization Edit Expansion Program

  • March 15, 2018

    The Pharmacy Prior Authorization program is designed to promote appropriate drug selection, length of therapy, and use of specific drugs while improving the overall quality of care.

    Premera has added new review criteria based on clinical best practice and approval by an independent pharmacy and therapeutics committee. Drugs may be added or deleted from this list without notification.

    If you have questions, read more about the Pharmacy Prior Authorization program or call the Pharmacy Services Center at 888-261-1756 or fax us at 888-260-9836, Monday through Friday, 8 a.m. - 5 p.m. Pacific Time.

    Which new edits are included in the Pharmacy Prior Authorization Edit Program?

    Effective: August 8, 2017

    Idhifa® (enasidenib)

    Read the full policy.

    Coverage criteria

    Idhifa® (enasidenib) may be considered medically necessary for the treatment of relapsed or refractory acute myeloid leukemia (AML) in patients with an isocitrate dehydrogenase-2 (IDH2) mutation as detected by an FDA-approved test.

    Effective: August 24, 2017

    Nerlynx® (neratinib)

    Read the full policy.

    Coverage criteria

    Neratinib may be considered medically necessary for use as adjuvant treatment in patients with early stage breast cancer whose tumors overexpress or have amplified HER2 protein (HER2-positive breast cancer). This medication may be medically necessary when all of the following are true:

    • Neratinib is being used as adjuvant therapy
    • Neratinib is used following adjuvant trastuzumab-based therapy
    • Patient has early stage breast cancer (stage I, IIA, IIB, or IIIA)
    • Patient has HER2-positive breast cancer

    Effective: January 1, 2018

    Abilify MyCite® (aripiprazole tablets with sensor)

    Read the full policy.

    Coverage criteria

    Abilify MyCite® may be considered medically necessary when the patient has met all of the following criteria:

    • Documentation of low medication adherence ( less than 80%)

    And

    • Trial and failure of an injectable depot antipsychotic (e.g. Risperdal Constar, Nivea Susitna and Invega Trinza, Abilify Maintena, etc.)

    New edits applicable to Health Exchange Plans

    The following edits will only to our health exchange plans and not to other plans. These are individual, family, and small group plans.

    The following medical policy is applicable to all edits.

    Read the full policy.

    Coverage criteria

    Actimmune® (interferon gamma-1b) may be considered medically necessary for:

    • Chronic granulomatous disease
    • Severe malignant osteopetrosis

    Leukine® (sargramostim) may be considered medically necessary for:

    • Acute myelogenous leukemia (following induction chemotherapy)
    • Mobilization and following transplantation of autologous peripheral blood progenitor cells
    • Myeloid reconstitution after allogenic bone marrow transplantation
    • Bone marrow transplantation (allogenic or autologous) failure or engraftment delay

    Jakafi® (ruxolitinib) may be considered medically necessary for:

    • Myelofibrosis
    • Polycythemia vera, after trial and failure of hydroxyurea

    Ilaris® (canakinumab) may be considered medically necessary for:

    • Periodic fever syndromes
      • Cryopyrin-associated periodic syndromes
      • Familial Mediterranean fever
      • Hyperimmunoglobulin D syndrome/mevalonate kinase deficiency
      • Tumor necrosis factor receptor associated periodic syndrome
    • Systemic juvenile idiopathic arthritis

    Step Therapy Protocol for Health Exchange Plans

    Step Therapy Protocol

    A step therapy edit is a requirement that one or more specified first step agents be tried and failed before coverage will be provided for another second step agent.

    Manual review for medical necessity is required, based on the following criteria:

    • Use of a second step agent may be considered medically necessary when the prescribing provider has documented that the required number of first step agents were tried and these agents were ineffective, not tolerated or contraindicated.

    Or

    • Use of a second step agent may be considered medically necessary when the prescribing provider has documented a patient-specific reason why this agent should be used as first-line therapy. These requests will be evaluated on a case-by-case basis.

    Drugs Subject to the Step Therapy Protocol

    Drug Class Second Step Drugs First Step Agents
    Respiratory Ventolin HFA Proair
    Gout Colchicine Colcrys
    Pain Butrans 1 non-opioid medication (i.e. gaba-analogues, tricyclic antidepressants, SNRI’s, NSAID’s, etc.) and 1 immediate-release opioid (i.e. oxycodone, morphine, hydromorphone, etc.)
    Acne Epiduo forte, Tazorac, tazarotene Generic benzoyl peroxide/clindamycin gel, and generic topical tretinoin cream or gel, and a generic tetracycline (doxycycline or minocycline)
    Anti-platelet Brilinta Clopidogrel
    Anti-hypertensive Bystolic Trial and failure of two preferred medications: metoprolol, atenolol, or bisoprolol
    Anti-lipemic Welchol Trial and failure of two preferred medications: colestipol, cholestyramine, or Prevalite
    Ophthalmic corticosteroids Lotemax Trial and failure of two preferred medications: prednisolone, dexamethasone, or FML eye drops
    Angina Ranexa Trial and failure of at least 2 generic beta-blockers
    Anti-Parkinson’s Emsam Carbidopa/levodopa
    Bowel preps Suprep Generic PEG solution

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