August 16, 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: April 27, 2018
Crysvita® (burosemab)
Read the full policy.
Coverage criteria
Crysvita® (burosemab) may be considered medically necessary when the following are met:
- The patient must be 1 year of age or older
- The patient must be diagnosed with X-linked hypophosphatemia (XLH), as documented by radiographic evidence of rickets and a genetic test confirming presence of a PHEX (PHosphate regulating Endopeptidase on the X chromosome) mutation.
Approval is for a period of one year.
Reauthorization requires evidence of continuing benefit from therapy.
Effective: May 25, 2018
Palynziq™ (pegvaliase pqpz)
Read the full policy.
Coverage criteria
Initial approval for 4 months requires all of the following:
- Age greater than or equal to 18 years old
- Phenylalanine level greater than or equal to 600 micromoles/liter on a Phenylketonuria (PKU) diet which includes an average of 65 grams of protein daily (combined natural food and medical food content)
- Failure to achieve control (phenylalanine level greater than or equal to 600 micromoles/liter) during an adequate trial of sapropterin (Kuvan).
Continued therapy will be approved for periods of two years as long as the above conditions are met, and the patient has shown and continues to show phenylalanine level less than 600 micromoles/liter while on treatment.
Effective: August 1, 2018
Tavalisse™ (fostamatinib disodium hexahydrate)
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Coverage criteria
Fostamatinib may be considered medically necessary for treatment of chronic immune thrombocytopenic purpura (ITP) in adults when all of the following criteria are met:
- The patient has a platelet count of less than 30,000 μL
- The patient has had an insufficient response to corticosteroids
- The patient has had an insufficient response to an immune globulin (IVIg) or splenectomy.
- The patient has had an insufficient response to Thrombopoietin Receptor Agonist (TPO-RA) such as romiplostim or eltrombopag.
*Note: Discontinue Tavalisse if platelet response is insufficient to prevent clinically important bleeding after 12 weeks.
Olumiant® (baricitinib)
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Coverage criteria
Baricitinib may be considered medically necessary as a second-line agent in the treatment of moderate to severe rheumatoid arthritis when:
- Patient has had an inadequate response or intolerance to methotrexate, and two of the following agents:
- etanercept, adalimumab, tocilizumab, or tofacitinib
Lucemyra (lofexidine)
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Coverage criteria
Lucemyra (lofexidine) may be considered medically necessary when medical records show lofexidine is used for adults currently experiencing or expecting acute opioid withdrawal symptoms who have tried and failed clonidine.
- Adirca® (tadalafil) (oral)
Note: Duration of approval is 14 days per episode of treatment.
Xifaxan® (rifaximin)
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Coverage criteria
TXifaxan® (rifaximin) may be considered medically necessary when medical records show rifaximin will be used for the following indications:
- Adult patients with Hepatic Encephalopathy
- Quantity may be approved up to 60 tablets per 30 days
- Treatment of Traveler’s Diarrhea (TD) in adult and pediatric patients 12 years of age and older when the patient has tried and failed three antibiotic for TD (e.g. ciprofloxacin, levofloxacin, sulfamethoxazole/trimethoprim)
- Quantity may be approved up to up to a three-day supply
- Adult patients with Irritable Bowel Disease with Diarrhea (IBS-D) when the patient has tried and failed two other anti-diarrheal agents (e.g. loperamide, atropine/diphenoxylate)
- Quantity may be approved up to a 14-day supply with two refills
Erivedge® (vismodegib)
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Coverage criteria
Erivedge® (vismodegib) may be considered medically necessary for the treatment of adults with metastatic basal cell carcinoma, or with locally advanced basal cell carcinoma that has recurred following surgery or who aren’t candidates for surgery, and who aren’t candidates for radiation.
Revatio® (Revatio)
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Coverage criteria
Combination therapy for the treatment of pulmonary arterial hypertension (PAH/ WHO Group 1) may be considered medically necessary when ALL of the following conditions are met:
- Patients have failed to demonstrate an adequate response to a single medication
- Medications are from different therapeutic classes
- Each medication may be considered medically necessary for the treatment of PAH