September 20, 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: September 4, 2018
Brand Topical Acne or Rosacea Products
Acanya®, Aczone®, Adapalene®, Aktipak®, Avita®, Azelex®, Benzamycinpak®, Clindagel®, Differin®, Epiduo®, Epiduo Forte®, Fabior®, Onexton®, Retin-A Micro Pump®, Tretin-X®, Veltin®
Read the full policy.
Coverage criteria
Brand topical acne or rosacea products may be considered medically necessary for the treatment of acne or rosacea when patient has had a documented trial and failure (confirmed by medical records) of ALL of the following alternatives for continuous 3 months each:
- Topical generic tretinoin gel or cream (any strength)
- Generic oral tetracycline (minocycline or doxycycline)
- Clindamycin/benzoyl peroxide gel (any strength)
Brand Topical Corticosteroids
Anti-Itch Lotion®, Anti-Itch Spray®, Anti-Itch Plus Cream®, Aveeno®, Capex Shampoo®, Clocortolone Pivalate®, Cloderm®, Cordran®, Cortizone®, Dermasorb TA®, Desonate®, First-Hydrocortisone®, Halog®, Halog®, Impoyz®, Locoid Lipocream®, Noble Formula HC®, Nucort®, Pandel®, Pediaderm TA®, Sernivo®, Synalar®, Texacort®, Topicort®, Topicort®, Ultravate®, Verdeso®
Read the full policy.
Coverage criteria
Topical brand corticosteroids may be considered medically necessary when the following conditions are met:
- Patient must try and fail two generic topical steroids prior to using a branded topical steroid
- A generic alternative is not disqualified if it is not the exact same dosage form
- Policy does not target kit and combination packages
Note: Initial approval can be granted for a period of one year. Further re-authorization would require documentation that the condition for which prescribed demonstrates continued clinical response and that ongoing treatment is required.