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Members 19 Years and Older will not require a petition 1). NOTE: In order for previously utilized Tier 1 medications to count as trials toward a Tier 2 authorization, the member's NSAID therapy must have been continuous.
Quantity limits apply on all benzodiazepine anxiolytic products. No request for dosing greater than 3 times daily will be approved unless a specific diagnosis exists; for these diagnoses the maximum allowed dosing is 4 times daily. The maximum covered dosing of benzodiazepine therapy is three times a day if a hypnotic medication is also prescribed. Dates and dosing information for Tier 1 trials must be included on petition for authorization.
Tier 3 authorization requires a 14 day trial with all Tier 2 products within the last 60 days (unless no age-appropriate Tier 2 product exists).
Claims submitted for Singulair will trigger an automatic check for asthma diagnoses and prior fills of inhaled corticosteroids / asthma rescue medications in the member's claims history.
A trial, defined by at least 8 weeks of continuous therapy titrated to recommended dose, of a tier 1 medication that did not yield adequate LDL reduction. Documented adverse effect or contraindication to all available lower tiered products. Clinical exception for atorvastatin 80mg: members hospitalized for recent acute myocardial infarction or acute coronary syndrome. A trial, defined by at least 8 weeks of continuous therapy titrated to recommended dose, of a tier 2 medication that did not yield adequate LDL reduction. Documented adverse effect or contraindication to all available lower tiered products. (Special consideration will be given for a diagnosis of DVT when warfarin is not a viable option) *After the end of 15 months, presrcibers should provide supporting information for the continuation of these products.
Documented unexplained, persistent elevations of serum transaminases. After the first 90 days, the following criteria will apply: Plavix Criteria: 4.
Members 0-18 Years of Age will require a petition: 1). Trials with OTC formulations of Tier 1 products must be dosed at full prescription strength.1.
If prescribed for asthma, member should also be utilizing inhaled corticosteroid therapy for long-term control.
Dose of levalbuterol requested cannot be less than the racemic equivalent documented on the prior authorization request.
Plavix and Effient are available without PA for the first 90 days of therapy for members new to therapy with these medications.Tier 2 authorization requires a documented 14 day trial of all Tier 1 products within the last 30 days.