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Special Formulations

prednisolone oral solution (Millipred®, Veripred 20®)

PA criteria:

Veripred™ 20 (Prednisolone Sodium Phosphate Oral Solution 20mg/5mL) and Millipred™ (Prednisolone Sodium Phosphate Oral Solution 10mg/5mL) Approval Criteria: 

  • Authorization of Veripred™ 20 or Millipred™ requires a patient-specific, clinically significant reason why the member cannot use a tablet or an alternative strength liquid formulations.

Prior Authorization form

   

nitroglycerin sublingual powder (GoNitro™)

nitroglycerin sublingual powder (GoNitro™) Approval Criteria:

  • An FDA approved indication of acute relief of an attack or prophylaxis of angina pectoris due to coronary artery disease; AND  
  • A patient-specific, clinically significant reason why the member cannot use nitroglycerin sublingual tablets or nitroglycerin lingual spray. 

Prior Authorization form

       

tamoxifen citrate 10mg/5mL oral solution (Soltamox®)

tamoxifen citrate 10mg/5mL oral solution (Soltamox®) Approval Criteria:

  • An FDA approved indication of one of the following: 
    • Treatment of metastatic breast cancer in women and men; OR
    • Adjuvant treatment of node-positive breast cancer in postmenopausal women and for the adjuvant treatment of axillary node-negative breast cancer in women following total mastectomy or segmental mastectomy, axillary dissection, and breast irradiation; OR
       The reduction in risk of invasive breast cancer in women with ductal carcinoma in situ (DCIS), following breast surgery and radiation; OR
    • To reduce the incidence of breast cancer in women at high risk for breast cancer; AND 
  • A patient-specific, clinically significant reason why the member cannot use tamoxifen tablets.

Prior Authorization form           

      

 

levoleucovorin injection (Khapzory™)

levoleucovorin injection (Khapzory™) Approval Criteria:  

  • An FDA approved indication of 1 of the following:
    • Rescue after high-dose methotrexate (MTX) therapy in patients with osteosarcoma; OR  
    • Diminishing the toxicity associated with overdosage of folic acid antagonists or impaired MTX elimination; OR
    • Treatment of patients with metastatic colorectal cancer in combination with fluorouracil; AND  
  • A patient-specific, clinically significant reason why the member cannot use generic leucovorin injection or generic levoleucovorin calcium injection must be provided.  

Prior Authorization form

 

norethindrone acetate/ethinyl estradiol capsules & ferrous fumarate capsules (Taytulla™)

norethindrone acetate/ethinyl estradiol capsules & ferrous fumarate capsules (Taytulla™) Approval Criteria:

  • An FDA approved indication to prevent pregnancy in women; AND
  • A patient-specific, clinically significant reason why the member cannot use all other generic formulations of norethindrone acetate/ethinyl estradiol tablets with ferrous fumarate tablets. 

Prior Authorization form

        

levothyroxine sodium capsule and oral solution (Tirosint® and Tirosint®-SOL)

levothyroxine sodium capsule and oral solution (Tirosint® and Tirosint®-SOL) Approval Criteria:  

  • An FDA approved diagnosis of one of the following: 
    • Hypothyroidism: As replacement therapy in primary (thyroidal), secondary (pituitary), and tertiary (hypothalamic) congenital or acquired hypothyroidism; OR
    • Pituitary Thyrotropin (Thyroid-Stimulating Hormone, TSH) Suppression: As an adjunct to surgery and radioiodine therapy in the management of thyrotropin-dependent well-differentiated thyroid cancer; AND
  • A patient-specific, clinically significant reason why the member cannot use all other formulations of levothyroxine sodium must be provided. For the oral solution, a reason why the member cannot use the levothyroxine tablet formulation, even when the tablets are crushed, must be provided; AND
  • Prescriber must verify member has been compliant with levothyroxine tablets at a maximum dose for at least 8 weeks; AND
  • Prescriber must verify that member has not been able to achieve normal thyroid lab levels despite maximum dosing and compliance with levothyroxine tablets.  

Prior Authorization form  

      

mometason furoate sinus implant (Sinuva™)

Approval Criteria:

  • An FDA approved indication of nasal polyps in adults 18 years of age and older who have had ethmoid sinus surgery; AND
  • Date of ethmoid sinus surgery must be provided; AND
  • Sinuva™ must be prescribed and implanted by a physician specializing in otolaryngology; AND
  • Failure of intranasal corticosteroids after at least a three month trial at the maximum recommended dose in combination with a 14-day trial of oral corticosteroids within the last six months (if not contraindicated); AND
  • Prescriber must confirm the member has recurrent nasal obstruction/congestion symptoms and recurrent bilateral sinusitis or chronic sinusitis due to nasal polyps; AND
  • A quantity limit of 2 implants per member will apply. 

Prior Authorization form

       

dexamethasone tablet (TaperDex™)
dexamethasone tablet (TaperDex™) Approval Criteria:
  • A patient-specific, clinically significant reason why the member cannot use dexamethasone 1.5mg individual tablets, which are available without a prior authorization, must be provided.  

Prior Authorization form

       

riluzole (Exservan™ and Tiglutik™)

riluzole film or suspension (Exservan™ and Tiglutik™) Approval Criteria:

  • An FDA approved indication for the treatment of amyotrophic lateral sclerosis (ALS); AND
  • A patient-specific, clinically significant reason why the member cannot use riluzole tablets, even when tablets are crushed, must be provided; AND
  • A quantity limit of 20mL per day or 600mL per 30 days will apply for Tiglutik®; AND
  • A quantity limit of 2 films per day or 60 films per 30 days will apply for Exservan™.

Prior Authorization form

         

triamcinolone acetonide extended-release (ER) Injection (Zilretta™)

Approval Criteria:

  • An FDA approved diagnosis of osteoarthritis (OA) pain of the knee; AND
  • Zilretta™ will only be approvable for use in the knee(s) for OA pain; AND
  • A patient-specific, clinically significant reason why the member cannot use Kenalog-40® (triamcinolone acetonide 40mg injection) and Depo-Medrol® (methylprednisolone injection) must be provided.
  • A quantity limit of 1 injection per knee per 12 weeks will apply. 

Prior Authorization form

    

cyclosporine 0.05% ophthalmic emulsion (Restasis MultiDose®)

Approval Criteria:

  • A patient-specific, clinically significant reason why the member cannot use Restasis® in the individual dosage formulation (single-use vials) must be provided.

Prior Authorization form

       

cyclosporine 0.09% ophthalmic solution (Cequa™)

Approval Criteria:

  • An FDA approved indication to increase tear production in patients with keratoconjunctivitis sicca (dry eye); AND
  • A patient-specific, clinically significant reason why the member cannot use Restasis® (cyclosporine 0.05% ophthalmic emulsion), which is available without a prior authorization, must be provided; AND
  • A quantity limit of 60 single-use vials (1 box) per 30 days will apply. 

Prior Authorization form

 

If you have questions please call the Pharmacy Help Desk at (800) 522-0114 option 4 or (405) 522-6205 option 4.

Last Modified on Dec 29, 2020
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