Skeletal System

Osteoporosis Medications
Tier-1	Tier-2	Special PA¥
alendronate tabs (Fosamax®)	alendronate + vitamin D tabs (Fosamax® + D)	abaloparatide inj (Tymlos®)
calcium + vitamin D†	risedronate tabs (Actonel®)	alendronate effervescent tabs (Binosto®)
ibandronate tabs (Boniva®)		alendronate soln (Fosamax®)
zoledronic acid inj (Reclast®)		alendronate 40mg tabs (Fosamax®)
		denosumab inj (Prolia®)
		ibandronate inj (Boniva® IV)
		risedronate 30mg tabs (Actonel®)
		risedronate DR tabs (Atelvia®)
		romosozumab-aqqg (Evenity®)
		teriparatide inj (Forteo®) – Brand Preferred
		teriparatide inj (Bonsity®)
		denosumab-bmwo inj (Stoboclo®)
		denosumab-bnht inj (Conexxence®)
		denosumab-nxxp inj (Bildyos®)

*Tier structure based on supplemental rebate participation and/or National Average Drug Acquisition Costs (NADAC), Wholesale Acquisition Costs (WAC), or State Maximum Allowable Costs (SMAC).

^†OTC calcium + vitamin D must be used at recommended doses in conjunction with Tier-1 bisphosphonates for trial to be accepted unless member has a recent laboratory result showing adequate vitamin D or member is unable to tolerate calcium. OTC calcium + vitamin D are only covered for members with osteoporosis who are being treated with a bisphosphonate.

^¥Unique criteria applies to medications in the Special PA Tier.

DR = delayed-release; inj = injection; PA = prior authorization; soln = solution; tabs = tablets

 

Osteoporosis Medications Tier-2 Approval Criteria:

• A trial of at least 1 Tier-1 bisphosphonate medication, compliantly used for at least 6 months concomitantly with calcium and vitamin D, that failed to prevent fracture or improve bone mineral density (BMD) scores; or
• Hypersensitivity to or intolerable adverse effect(s) with all Tier-1 bisphosphonate medications (including oral and intravenous routes of administration); and
• Quantity limits apply based on FDA approved maximum doses.

 

Actonel^® (Risedronate 30mg Tablets), Atelvia^® [Risedronate Delayed-Release (DR) Tablets], and Binosto^® (Alendronate Effervescent Tablets) Approval Criteria:

• A patient-specific, clinically significant reason why the member cannot use all other available Tier-1 and Tier-2 bisphosphonate medications must be provided; or
• Members with a diagnosis of Paget’s disease in claims history will not require prior authorization.

 

Bildyos^® (Denosumab-nxxp), Boniva^® [Ibandronate Intravenous (IV) Solution], Conexxence^® (Denosumab-bnht),  Jubbonti^® (Denosumab-bbdz), Prolia^® (Denosumab), and Stoboclo^® (Denosumab-bmwo) Approval Criteria:

• A minimum of a 12-month trial with a Tier-1 or Tier-2 bisphosphonate medication plus adequate calcium and vitamin D; or
• Contraindication to or intolerable adverse effects with Tier-1 and Tier-2 bisphosphonate medications (including oral and intravenous routes of administration); and
• For Bildyos^®, Conexxence^®, and Stoboclo^® a patient-specific, clinically significant reason why the member cannot use Jubbonti^® or Prolia^® must be provided. 
  • Biosimilars and/or reference products are preferred based on the lowest net cost product(s) and may be moved to either preferred or non-preferred if the net cost changes in comparison to the reference product and/or other available biosimilar products. 

 

Bonsity® (Teriparatide) and Forteo^® (Teriparatide) and Teriparatide Approval Criteria:

• Diagnosis of 1 of the following:
  • Treatment of postmenopausal women with osteoporosis at high risk for fracture; or
  • To increase bone mass in men with primary or hypogonadal osteoporosis at high risk for fracture; or
  • Treatment of men and women with osteoporosis associated with sustained systemic corticosteroid therapy at high risk for fracture; or
  • Treatment of non-healing fracture (this indication only pertains to Forteo^®); and
• A minimum 12-month trial with a bisphosphonate plus adequate calcium and vitamin D or a patient-specific, clinically significant reason why the member cannot use a bisphosphonate must be provided; and
• Use of generic teriparatide will require a patient-specific, clinically significant reason why the member cannot use the brand formulation, Forteo^® (teriparatide); and
• Use of Bonsity® (teriparatide) will require a patient-specific, clinically significant reason why the member cannot use Forteo® (teriparatide) or generic teriparatide formulations; and
• The diagnosis of non-healing fracture may be approved for 6 months; and
• Treatment duration including other parathyroid hormone analogs has not exceeded a total of 24 months during the patient’s lifetime; and
• Approval will be for a maximum of 2 years of parathyroid hormone analog therapy.

 

Evenity^® (Romosozumab-aqqg) Approval Criteria:

• An FDA approved diagnosis of osteoporosis in postmenopausal women at high-risk for fracture; and
• Member meets 1 of the following:
  • History of osteoporotic fracture; or
  • Multiple risk factors for fracture (e.g., T-score ≤-2.5 at the total hip or femoral neck, smoking, corticosteroid use, rheumatoid arthritis); or 
  • Failure of or intolerance to other available osteoporosis therapies; and
• Prescriber must verify member has not had a myocardial infarction or stroke within the preceding year; and
• Prescriber must verify calcium levels will be monitored and pre-existing hypocalcemia will be corrected prior to starting therapy; and
• Prescriber must verify that the member will take adequate calcium and vitamin D supplements during treatment with Evenity^® to reduce the risk of hypocalcemia; and
• Evenity^® must be administered by a health care provider; and
• Approval will be limited to a total duration of 1 year of therapy. 

 

Fosamax^® (Alendronate Oral Solution) Approval Criteria:

• An FDA approved diagnosis of osteoporosis or Paget’s disease; and
• A patient-specific, clinically significant reason why the member cannot use the oral tablet formulation must be provided.

 

Fosamax^® (Alendronate 40mg Tablets) Approval Criteria:

• A patient-specific, clinically significant reason why the member cannot use all other available Tier-1 and Tier-2 bisphosphonate medications including a 35mg alendronate tablet in combination with a 5mg alendronate tablet to achieve a 40mg dose must be provided; or
• Members with a diagnosis of Paget’s disease in claims history will not require prior authorization.

 

Tymlos^® (Abaloparatide) Approval Criteria:

• Diagnosis of postmenopausal osteoporosis confirmed by the following:
  • History of vertebral fracture(s) or low trauma or fragility fracture(s) (e.g., prior fracture from minor trauma such as falling from standing height or less) within the past 5 years; or
  • A bone mineral density (BMD) test (T-score at or below -2.5) within the last month in the spine, femoral neck, total hip, or 33% radius; or
  • A T-score between -1.0 and -2.5 in the spine, femoral neck, total hip, or 33% radius, with a FRAX^® 10-year probability for major osteoporotic fracture ≥20% or the 10-year probability of hip fracture ≥3%; and
• One of the following [if a 12-month bisphosphonate trial is inappropriate for the member, the member must have a trial of Prolia^® or a selective estrogen receptor modulator (SERM) or a patient-specific, clinically significant reason why Prolia^® or a SERM is not appropriate must be provided]:
  • A minimum 12-month trial with a bisphosphonate medication plus adequate calcium and vitamin D; or
  • A 12-month trial of Prolia^® (denosumab), unless contraindicated, intolerant, or allergic, that did not yield adequate results; or
  • A 12-month trial of a SERM, unless contraindicated, intolerant, or allergic, that did not yield adequate results; and
• A patient-specific, clinically significant reason why the member cannot use Forteo^® (teriparatide) must be provided; and
• Treatment duration including other parathyroid hormone analogs has not exceeded a total of 24 months during the member’s lifetime; and
• Approval will be for a maximum of 2 years of parathyroid hormone analog therapy; and
• A quantity limit of 1 pen per 30 days will apply.

Bilprevda® (Denosumab-nxxp), Bomyntra® (Denosumab-bnht), Osenvelt® (Denosumab-bmwo), Wyost^® (Denosumab-bbdz) and Xgeva^® (Denosumab) Approval Criteria:

• An FDA approved indication of 1 of the following:
  • Prevention of skeletal-related events in members with multiple myeloma and in members with bone metastases from solid tumors; or
  • Treatment of adults and skeletally mature adolescents with giant cell tumor of the bone (GCTB) that is unresectable or where surgical resection is likely to result in severe morbidity; and
    • Prescriber must document that tumor is unresectable or that surgical resection is likely to result in severe morbidity; or
  • Treatment of hypercalcemia of malignancy refractory to bisphosphonate therapy; and
    • Member must have albumin-corrected calcium of >12.5mg/dL (3.1mmol/L) despite treatment with intravenous bisphosphonate therapy in the last 30 days prior to initiation of therapy.
• For Bilprevda^®, Bomyntra^®, and Osenvelt^® a patient-specific, clinically significant reason why the member cannot use Wyost^® or Xgeva^® must be provided. 
  • Biosimilars and/or reference products are preferred based on the lowest net cost product(s) and may be moved to either preferred or non-preferred if the net cost changes in comparison to the reference product and/or other available biosimilar products. 
• These products will be covered as a medical benefit only.

Allopurinol 200mg Tablet Approval Criteria:

• An FDA approved diagnosis; and
• A patient-specific, clinically significant reason why the member cannot use 2 allopurinol 100mg tablets in place of allopurinol 200mg must be provided. 

Gloperba® (Colchicine Oral Solution) and Mitigare® (Colchicine Capsules) Approval Criteria:

• Member must have failure of allopurinol after 6 months of treatment defined by persistent gouty attacks with serum urate levels >6.0mg/dL; and
• Patient-specific, clinically significant reason why colchicine tablets (generic Colcrys^®) or colchicine/probenecid would not be a viable option for the member must be provided; and
• For authorization of Gloperba®, a patient-specific, clinically significant reason why the member cannot use colchicine tablets or capsules must be provided; and
• A quantity limit of 60 capsules per 30 days or 300 mL per 30 days will apply for gout; and   
• Members with the diagnosis of Familial Mediterranean Fever verified by genetic testing will be approved for up to 2.4mg per day.

Krystexxa® (Pegloticase) Approval Criteria:

• An FDA approved diagnosis of gout; and  
• Member must have symptomatic gout confirmed by at least 1 of the following:
  • ≥3 gout flares in the previous 18 months; or
  • ≥1 gout tophus; or
  • Gouty arthritis; and
• Member must have failure of the following urate lowering therapies titrated to the maximum tolerable dose for at least 3 months
  • Allopurinol; and
  • Febuxostat; and
  • Probenecid; and
• Pegloticase must be administered in a health care setting by a health care provider prepared to manage anaphylaxis; and
• Prescriber must attest that the member will be pre-medicated with antihistamines and corticosteroids to reduce the risk of anaphylaxis; and
• Prescriber must document that member does not have glucose-6-phosphate dehydrogenase (G6PD) deficiency prior to starting pegloticase; and
• Member must discontinue oral urate-lowering agents prior to starting pegloticase; and
• Member must receive gout flare prophylaxis with non-steroidal anti-inflammatory drug(s) (NSAIDs) or colchicine at least 1 week before initiation of pegloticase therapy and continue for at least 6 months unless medically contraindicated or member is unable to tolerate therapy.
• Approvals will be for the duration of 6 months. Reauthorizations may be granted if the prescriber documents the member is responding well to treatment, and member has not exceeded >4 consecutive weeks without therapy.  

Uloric® (Febuxostat) Approval Criteria:

• Member must have failure of allopurinol defined by persistent gouty attacks with serum urate levels >6.5 mg/dL; and
• A patient-specific, clinically significant reason why allopurinol is not a viable option for the member.
  
• A quantity limit of 30 tablets per 30 days will apply.

Prior Authorization form

 

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)
Tier-1	Tier-2	Special PA
celecoxib (Celebrex®) caps	diclofenac ER (Voltaren® XR)	celecoxib (Elyxyb®) oral solution
diclofenac potassium (Cataflam®)	diclofenac sodium/misoprostol (Arthrotec®)	Diclofenac epolamine (generic Flector® Patch)
diclofenac sodium (Voltaren®) 50mg & 75mg tabs	diclofenac sodium (Voltaren®) 25mg tabs	diclofenac potassium (Cambia®) powder pack
diclofenac sodium 1% (Voltaren® Gel)	diflunisal 500mg tabs	diclofenac potassium (Lofena™) tabs
etodolac (Lodine®) tabs	etodolac ER (Lodine® XL)	diclofenac potassium (Zipsor®) caps
ibuprofen (Motrin®) 400mg, 600mg, & 800mg tabs	flurbiprofen (Ansaid®)	diclofenac sodium (Pennsaid®) topical drops
indomethacin (Indocin®) caps	indomethacin (Indocin®) ER caps	diflunisal (Dolobid™) 250mg & 375mg tabs
meloxicam (Mobic®)	mefenamic acid (Ponstel®)	fenoprofen (Nalfon®)
nabumetone (Relafen®)	Naproxen DR (EC-Naprosyn®)	ibuprofen (Caldolor®) inj
naproxen* (Naprosyn®)	naproxen sodium (Anaprox®) 275mg & 550mg tabs	ibuprofen/acetaminophen (Combogesic® IV) inj+
piroxicam (Feldene®)	oxaprozin (Daypro®) 600mg tabs	ibuprofen/famotidine (Duexis®)
sulindac (Clinoril®)		indomethacin (Indocin®) supp & susp
		ketoprofen (Orudis®) caps
		ketoprofen ER (Oruvail®)
		ketorolac tromethamine (Sprix®) nasal spray
		meclofenamate (Meclomen®)
		meloxicam (Vivlodex®) caps
		nabumetone 1,000mg (Relafen DS®)
		naproxen sodium ER (Naprelan®)
		naproxen/esomeprazole (Vimovo®)
		tolmetin (Tolectin®)
		celecoxib (Vyscoxa™) susp
		ibuprofen (Motrin®) 300mg tabs
		meloxicam (Xifyrm™) inj+
		oxaprozin (Coxanto®) 300mg caps

Tier structure based on supplemental rebate participation and/or National Average Drug Acquisition Costs (NADAC), or Wholesale Acquisition Costs (WAC) if NADAC unavailable.
*Naproxen oral suspension is available without prior authorization for members 12 years of age and younger. Members older than 12 years of age require a reason why a special formulation product is needed in place of the regular tablet formulation.
⁺Unique criteria applies.
caps = capsules; DR = delayed-release; ER = extended-release; EC = enteric-coated; inj = injection; ODT = orally disintegrating tablet; PA = prior authorization; supp = suppository; susp = suspension; tabs = tablets

NSAIDs Tier-2 Approval Criteria:

• Previous use of at least 2 Tier-1 NSAID products (from different product lines) plus a proton pump inhibitor (PPI) within the last 120 days.

 

NSAIDs Special Prior Authorization (PA) Approval Criteria:

• A unique indication for which a Tier-1 or Tier-2 medication is not appropriate; or
• Previous use of at least 2 Tier-1 NSAID products (from different product lines); and
• A patient-specific, clinically significant reason why a special formulation is needed over a Tier-1 product; and
• Additionally, use of Coxanto^® (oxaprozin) 300mg capsule will require a patient-specific, clinically significant reason why the member cannot use generic oxaprozin 600mg tablets, which can be split to achieve the requested dose, must be provided; and
• Additionally, use of Dolobid™ (diflunisal) 250mg or 375mg tablet will require a patient-specific, clinically significant reason why the member cannot use generic diflunisal 500mg tablets; and
• Additionally, use of Elyxyb^® (celecoxib oral solution) will require a diagnosis of acute migraine treatment in adults 18 years of age and older and a patient-specific, clinically significant reason why the member cannot use Cambia^® (diclofenac potassium powder); and
• Additionally, use of ibuprofen 300mg tablets will require a patient-specific, clinically significant reason why the member cannot use all Tier-1 strengths of ibuprofen tablets and all other lower-tiered NSAIDs; and
• Additionally, use of Lofena™ (diclofenac potassium) will require a patient-specific, clinically significant reason why the member cannot use all other available generic diclofenac products; and
• Additionally, use of Vyscoxa™ (celecoxib oral suspension) will require a patient-specific, clinically significant reason why the member cannot use Tier-1 celecoxib capsules, which can be opened and sprinkled on applesauce for members with difficulties swallowing, must be provided.

 

Combogesic^® IV (Ibuprofen/Acetaminophen Injection) Approval Criteria:

• An FDA approved indication in members where an intravenous (IV) route of administration is considered clinically necessary for 1 of the following:
  • Relief of mild-to-moderate pain; or
  • Management of moderate-to-severe pain as an adjunct to opioid analgesics; and
• Member must be 18 years of age or older; and
• A patient-specific, clinically significant reason why the member requires IV administration and cannot use Tier-1 oral and/or topical alternatives must be provided; and
• A quantity limit of 2,000mL (20 vials) per 5 days will apply; and
• A maximum approval duration of 5 days will apply, as Combogesic^® IV is only indicated for short-term use of 5 days or less.

Xifyrm™ (Meloxicam Injection) Approval Criteria:

• An FDA approved diagnosis of management of moderate-to-severe pain, alone or in combination with non-NSAID analgesics; and
• Member must be 18 years of age or older; and
• Member must be well hydrated before administration to reduce the risk of renal toxicity; and
• Should be used for the shortest duration consistent with individual patient treatment goals; and
• A patient-specific, clinically significant reason the member cannot use oral meloxicam tablets or other Tier-1 NSAID products must be provided; and
• A quantity limit of 3 vials per 3 days will apply; and
• For consideration of a longer duration of use, a patient-specific, clinically significant reason why the member cannot transition to an oral Tier-1 NSAID product must be provided, along with the anticipated duration of treatment.

Tier 1 products are covered with no authorization necessary.

Muscle Relaxant Medications Tier 2 Approval Criteria: 

• Member must have failure with at least 2 Tier-1 medications within the last 90 days defined as no beneficial response after at least 2 weeks of use during which time the medication has been titrated to the recommended dose; and
• Approvals will be for the duration of 3 months, except for members with chronic diseases such as multiple sclerosis, cerebral palsy, muscular dystrophy, paralysis, or other chronic musculoskeletal diagnosis confirmed with diagnostic results, in which case authorizations will be for the duration of 1 year; and
• For repeat authorizations, there must be documentation of a failed withdrawal attempt within the past 3 months defined as increase in pain and debilitating symptoms when medication was discontinued.

Amrix® [Cyclobenzaprine Extended-Release (ER) Capsule] and Fexmid® (Cyclobenzaprine 7.5mg Tablet) Approval Criteria:

• Authorization requires clinical documentation of inability to take other generically available forms of cyclobenzaprine tablets; and
• The following quantity limits apply:
  • Amrix® 15mg and 30mg capsules: 30 capsules per 30 days; or
  • Fexmid® 7.5mg tablets: 90 tablets per 30 days.

Baclofen 5mg Tablet and Baclofen 15mg Tablet Approval Criteria:

• A patient-specific, clinically significant reason why the member cannot use other appropriate Tier-1 products including splitting a baclofen 10mg tablet to achieve a 5mg or 15mg dose must be provided.
  

Chlorzoxazone 250mg Tablet Approval Criteria:

• A patient-specific, clinically specific reason why the member cannot split a 500mg chlorzoxazone tablet to achieve the 250mg dose must be provided.

Fleqsuvy™ 25mg/5mL (Baclofen Oral Suspension), Lyvispah™ (Baclofen Oral Granules) ,Ozobax^® 5mg/5mL (Baclofen Oral Solution), and Ozobax^® DS [Baclofen Double Strength (DS) 10mg/5mL Oral Solution] Approval Criteria:

• An FDA approved diagnosis of spasticity resulting from multiple sclerosis (relief of flexor spasms and concomitant pain, clonus, and muscular rigidity) or spinal cord injuries/diseases; and
• Members older than 10 years of age require a patient-specific, clinically significant reason why the member cannot use baclofen oral tablets, even when tablets are crushed.

Lorzone® (Chlorzoxazone) Approval Criteria:

• Generic chlorzoxazone 500mg tablets must be tried prior to consideration of Lorzone®; and 
• A patient-specific, clinically significant reason why the member cannot use generic chlorzoxazone 500mg tablets must be provided; and
• The following quantity limits apply:
  • Lorzone® 375mg tablets: 120 tablets for 30 days; or
  • Lorzone® 750mg tablets: 120 tablets for 30 days

Metaxalone 640mg Tablet and Skelaxin^® (Metaxalone 400mg Tablet) Approval Criteria:

• A patient-specific, clinically significant reason why the member cannot use all other appropriate lower-tiered products, including metaxalone 800mg tablets, must be provided; and
• For metaxalone 400mg tablets, a patient-specific, clinically significant reason why the member cannot split an 800mg metaxalone tablet to achieve the requested dose must be provided.

Norgesic^®, Norgesic^® Forte, and Orphengesic^® Forte (Orphenadrine/ Aspirin/Caffeine) Approval Criteria:

• A patient-specific, clinically significant reason why the member cannot use all lower-tiered products must be provided.

Soma® (Carisoprodol 250mg or 350mg) Approval Criteria:

• A patient-specific, clinically significant reason why the member cannot use all other appropriate lower-tiered products must be provided; and
• Requests for carisoprodol 250mg will require a patient-specific, clinically significant reason why the member cannot use carisoprodol 350mg; and
• Requests will be approved for a maximum duration of 3 months; or
  • Clinical exceptions may be made for members with the following diagnosis and approvals will be granted for the duration of 1 year: multiple sclerosis, cerebral palsy, muscular dystrophy, paralysis, or cancer pain; and
• A quantity limit of 120 tablets per 30 days will apply for carisoprodol and carisoprodol combination products.

Tanlor^® (Methocarbamol 1,000mg Tablet) Approval Criteria:

• A patient-specific, clinically significant reason why the member cannot use other appropriate Tier-1 products, including using methocarbamol 500mg or 750mg tablets to achieve the requested dose, must be provided.

Zanaflex® (Tizanidine Capsule) Approval Criteria:

• Trizanidine tablets must be tried prior to consideration of tizanidine capsules; and.
• The capsule formulation may be considered for approval only if there is supporting information as to why the member cannot take the tablets; and
• For Zanaflex^® 8mg capsule, a patient-specific, clinically significant reason (beyond convenience) why the member cannot use generic tizanidine 2mg, 4mg, or 6mg capsules to achieve the requested dose must be provided.

Prior Authorization form

Tier 1	Tier 2	Special PA
cyclobenzaprine (Flexeril®) baclofen 10mg, 20mg (Lioresal®) orphenadrine (Norflex®) chlorzoxazone (Parafon Forte®) methocarbamol (Robaxin®) tizanidine tabs (Zanaflex®)	metaxolone 800mg tabs (Skelaxin®)	baclofen 5mg, 15mg baclofen oral granules (Lyvispah™) baclofen oral suspension (Fleqsuvy™) baclofen 10mg/5mL oral soln (Ozobax® DS) cyclobenzaprine ER (Amrix®) Caps cyclobenzaprine 7.5mg (Fexmid®) Tabs chlorzoxazone 250mg, 375mg, 750mg  carisoprodol (Soma®) 250mg, 350mg metaxalone 400mg tabs (Skelaxin®) metaxalone 640mg tabs methocarbamol 1,000mg tabs (Tanlor®) orphenadrine/ASA/caffeine tabs (Norgesic®, Norgesic® Forte, Orphengesic® Forte) tizanidine (Zanaflex®) Caps