June 7, 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: February 21, 2018
Symdeko™ (tezacaftor/ivacaftor)
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Coverage criteria
Symdeko™ (tezacaftor/ivacaftor) may be considered medically necessary for the treatment of cystic fibrosis (CF) in patients age 12 years and older who are homozygous for the F508del mutation in the CFTR gene or heterozygous for F508del with a residual function mutation. If the patient’s genotype is unknown, an FDA-cleared CF mutation test should be used to detect the presence of the F508del mutation on at least one allele of the CFTR gene. Symdeko™ (tezacaftor/ivacaftor) may also be considered medically necessary for any mutation subsequently added to the FDA approved indication.
Symdeko™ (tezacaftor/ivacaftor) is considered investigational when used in patients that do not meet any of the above criteria.
Effective: March 24, 2018
Ilumya™ (tildrakizumabasmn)
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Coverage criteria
Ilumya™ (tildrakizumab-asmn) may be considered medically necessary as a second-line agent in the treatment of moderate to severe plaque psoriasis when:
- Patient has a diagnosis of chronic plaque psoriasis involving ≥10% his or her body surface area (BSA)
- Exception: This may be granted when any of the following are true:
- There is extensive recalcitrant facial involvement
or
- There is pustular involvement of the hands and feet
or
- There is genital involvement which interferes with normal sexual function
and
- Patient has a history of an adequate trial and treatment failure with ≥1 approved systemic therapy (eg, methotrexate, cyclosporine, Soriatane® (acitretin) unless contraindicated or not tolerated
and
- Patient has had an inadequate response or is intolerant to two of the following agents:
- Adalimumab
- Apremilast
- Secukinuma
- Ustekinumab
Effective: May 1, 2018
Rhopressa® (Netarsudil)
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Coverage criteria
Rhopressa® (Netarsudil) may be considered medically necessary to reduce intraocular pressure in patients with open-angle glaucoma or ocular hypertension when the patient has failed trial of two ophthalmic beta-blockers (e.g. timolol, betaxolol) AND two ophthalmic prostaglandins (eg latanoprost, bimatoprost).
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.
Xiaflex® (collagenase clostridium histolyticum)
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Coverage criteria
Injectable clostridial collagenase may be considered medically necessary for the treatment of Dupuytren contracture in adult patients with a palpable cord, for up to 3 injections at intervals of at least 30 days.
- Physicians should treat no more than 2 joints in the same hand for Dupuytren contracture per treatment visit, consistent with U.S. Food and Drug Administration (FDA) labeling.
Injectable clostridial collagenase is considered investigational for all other indications including, but not limited to, Peyronie disease and adhesive capsulitis.