determined that medication non-adherence is not the reason for the dose escalation. Supporting documentation indicates that use of the medication at a lower dose (or within the plan quantity limit) has been ineffective and a clinically significant was completed. The BHMP has ruled out a non-response due to an unrecognized or co-morbid disorder. The treatment plan must include ongoing safety monitoring. Brand Name Behavioral Health Medications Aplenzin Edluar Emsam Fanapt Gralise Horizant Intermezzo SL Intuniv Lamictal XR Pexeva Quillivant XR Saphris Seroquel XR Silenor Suboxone Film Viibryd Zolpimist FDA Approved Indication: For adults, BHR has a diagnosis for which requested medication is an FDA approved treatment indication. For individuals under the age of 18, the BHR must have a diagnosis for which the requested medication meets the community standard of care. Guidelines for Approval: 1. Documentation of intolerance, nonresponse or non-adherence to a formulary generic equivalent formulation of the requested medication at maximal tolerated for at least 4 weeks. 2. Documentation of intolerance, nonresponse or non-adherence to a formulary generic pharmaceutical alternative formulation of the requested medication at maximal tolerated for at least 4 weeks. 3. Documentation of intolerance, non-adherence, or non-response to at least two generic formulary medications in the same medication class at maximal tolerated doses for at least 4 weeks. Guidelines for Exceptions: 1. Documentation of intolerance/contraindication to other formulary medications (including documentation of the risk of metabolic syndrome, obesity, diabetes), and documentation for the reason why the requested medication will ameliorate the risks 2. Documentation that the individual has responded to a generic immediate release formulary medication, but requires the brand name extended release formulation to maintain adherence. Additional Requirements: Hospital Discharge: 60 days Initial Approval Indefinite treated
Debonnel G; Saint-Andre E; Hebert C; et al. Differential Physiological Effects of a Low Dose and High Doses of Venlafaxine in Major Depression. Int J Neuropsychopharmacol. 2007 Feb; 10(1):51-61 Concomitant Antipsychotic Treatment Approved Indications: Treatment Refractory 1. Schizophrenia spectrum disorders or 2. Bipolar disorder, with psychosis and/or severe symptoms Special Considerations: Cross tapers will automatically be approved for 60 days. Providers must submit a prior authorization request for continued utilization of concomitant use of any 2 antipsychotics beyond the 60 days allowed for cross tapering. Guidelines for Approval for refractory schizophrenia spectrum disorder: 1. Evidence of adequate trials of at three (3) individual formulary antipsychotics, one of which is clozapine, 4-6 weeks of maximum tolerated doses, and failure due to: a. Inadequate response to maximum tolerated dose b. Adverse reaction(s), c. Break through symptoms Guidelines for Approval for refractory bipolar disorder with psychosis and/or severe symptoms: 1. Evidence of adequate trials of at least four (4) evidence based treatment options dependent upon the episode type. Trials may include lithium, divalproex, atypical antipsychotic monotherapy, carbamazepine, haloperidol, lamotrigine, lithium + an anticonvulsant, lithium + an antipsychotic, or an anticonvulsant + an antipsychotic. Trials should be 4-6 weeks of maximum tolerated doses, with failure due to: a. Inadequate response to maximum tolerated dose b. Adverse reaction(s), c. Break through symptoms Additional Requirements: Hospital Discharge: 60 days Initial Approval: 60 days for cross taper 6 months for taper Renewal: 1 year trial
Topical: Bionect, Hylira,XClair See detailed document posted separately on website. When used for treatment of burns, dermal ulcers, wounds, radiation dermatitis: Prescriber must be a dermatologist Patient must be at least 18 years old When used for treatment of xerosis: Prescriber must be a dermatologist and failure of ammonium lactate or a topical corticosteroid Patient must be at least 18 years old Topical agents: Intial Approval: Burns or dermatitis: 3 fills of generic agent Xerosis: Up to 1,000 grams of equivalent generic agent per 30 days for three months Renewal: 3 months Hyperlipidemia Medications Last reviewed: 6/15/15 Crestor Zetia Lovaza Vascepa Epanova Repatha Praluent Juxtapid Kynamro Crestor can be approved when the following criteria are met: Patient is at least 10 years old; AND Patient has failed to achieve LDL goal on a compliant regimen of maximum tolerated dose of atorvastatin; OR Patient requires a high intensity statin (i.e., diagnosis of familial hypercholesterolemia or high ASCVD risk per provider evaluation) AND patient had a trial and failure of atorvastatin Zetia requires step therapy: If member has filled 2 prescriptions for 2 different statins (specifically atorvastatin, simvastatin or Crestor) within the last 130-days, the prescription will automatically process at the pharmacy. Authorization will be required for prescriptions that do not process automatically at the pharmacy. In cases, Zetia will be authorized upon receipt of documentation to support the diagnosis of hyperlipidemia and failure of, or contraindication to atorvastatin, simvastatin, and Crestor. Non-formulary medications for hypertriglyceridemia (Lovaza, Vascepa, and Epanova) can be approved when the following criteria are met: Initial Approval: PSCK9 inhibitors: 3 months Juxtapid, Kynamro: 3 months All others: 6 months Renewal: PSCK9 inhibitors: 6 months Juxtapid, Kynamro: 6 months All others: indefinite Renewals require improvement in fasting lipids and documentation of recommended safety monitoring parameters (such as enzymes) Trial
Multaq Multaq will be authorized when prescribed by, or in consultation with a cardiologist. If not prescribed by or in consultation with a cardiologist, the following must be met: Diagnosis is atrial fibrillation Patient has tried and failed amiodarone Age restriction: must be at least 18 years old Initial Approval: Indefinite Multiple Sclerosis Agents Aubagio, Avonex, Betaseron, Copaxone, Extavia, Gilenya, Glatopa, glatiramer, Lemtrada, Mitoxantrone, Plegridy, Tecfidera, Tysabri See Detailed document: Neumega Last reviewed: 10/22/2015 May be authorized for the treatment of chemotherapy-induced thrombocytopenia when the following are met: Prescribed by a hematologist/oncologist Patient is at least 12 years old Patient has a non-myeloid malignancy and is receiving myelosuppressive chemotherapy Patient is at high risk of severe thrombocytopenia or has experienced severe thrombocytopenia with a previous chemotherapy Administered 6 – 24 hours after the completion of chemotherapy NOT being used in the following situations: myeloablative therapy Chemotherapy regimen longer than 5 days Concurrently with agents associated with delayed myelosuppression (e.g., nitrosoureas, mitomycin C) Initial Approval: Up to 21 days’ supply Refills if number of cycles provided Renewal: Approval up to 1 year Requires recent platelet count Nexavar Last reviewed: 1/19/2016 Nexavar, when prescribed by an oncologist for patients at 18 years old, can be authorized for the following indications: Treatment of relapsed or unresectable stage IV predominantly clear cell renal cell carcinoma (RCC) after treatment failure with Sutent or Votrient Initial: 1 year Renewal: 3 years if evidence of stable disease