December 6, 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: May 5, 2018
Jynarque™ (tolvaptan)
Read the full policy.
Coverage criteria
Jynarque™ (tolvaptan) may be considered medically necessary for the treatment of progressing autosomal dominant polycystic kidney disease (ADPKD) in patients 18 years and older when:
- Patient is enrolled in the REMS program and all program requirements are being met.
- Patient has been counseled regarding risk of hepatotoxicity.
- ALT, AST, and bilirubin are assessed prior to initiation of Jynarque, at 2 weeks and 4 weeks after initiation, then monthly for 18 months and every 3 months thereafter for the duration of therapy.
- At the onset of signs or symptoms consistent with hepatic injury or if ALT, AST, or bilirubin increase to more than 2 times ULN, therapy must be immediately discontinued. If patient is stabilized, treatment may continue with increased monitoring frequency.
- A maximum quantity limit of 120mg/day applies.
Effective: June 27, 2018
Epidiolex® (cannabidiol)
Read the full policy.
Coverage criteria
Epidiolex® (cannabidiol) may be considered medically necessary for the following labeled indication:
- Treatment of seizures associated with Lennox-Gastaut syndrome or Dravet syndrome in patients 2 years of age and older.
Effective: June 30, 2018
Braftovi™ (encorafenib) and Mektovi™(binimetinib)
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Coverage criteria
The following combination regimens may be considered medically necessary for treatment of unresectable or Metastatic melanoma with a BRAF V600E or V600K mutation:
- Braftovi™ (encorafenib) and Mektovi™(binimetinib)
Testing for BRAF V600 mutations is covered whenever use of BRAF inhibitors is contemplated. Use of BRAF and/or MEK inhibitors for treatment of patients with wild-type BRAF is considered not medically necessary.
All other uses of BRAF and/or MEK inhibitors are considered investigational.
Effective: October 12, 2018
Emgality™ (galcanezumab)
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Coverage criteria
Ajovy ™ (fremanezumab) may be considered medically necessary in patients with an average of more than 4 migraine days per month who have:
- Failed at least three preventive migraine therapies
- Are receiving a maximum monthly supply of abortive migraine treatments
Initial Approval
Initial approval for three months requires all of the following:
- Failure to achieve control during adequate trials of at least three prophylactic medications (at least two months on each therapy)
- Receiving maximum doses of a triptan abortive therapy, unless contraindicated
Reauthorization
Continued therapy will be approved for periods of one year as long as the patient has shown and continues to show a sustained reduction in headache frequency compared to baseline prior to initiation of treatment with erenumab.
Required Documentation
Chart notes describing patient’s diagnosis and progress including headache frequency; medication history, if not documented by our prescription claims record.
Effective: November 15, 2018
Xepi™ (ozenoxacin)
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Coverage criteria
Xepi™ (ozenoxacin) may be considered medically necessary to treat impetigo when the patient has failed a trial of mupirocin.