CurrentAdvanced HealthPolicy N/A

Injectable Epinephrine Drug Use Criteria

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This policy governs Advanced Health coverage of injectable epinephrine products for Oregon members, including annual quantity limits, formulary selection, prior authorization requirements, documentation, and exclusions for convenience or multiple-site storage.

Policy Summary

PayerAdvanced Health

PolicyInjectable Epinephrine Drug Use Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Last ReviewMar 25, 2024

Next Review DateN/A

Key ActionUse the least costly alternative formulation of a formulary injectable epinephrine product.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4Maximum prescriptions per year without prior authorization

8Maximum injections per year without prior authorization

12 monthsPrior authorization lookback period

ExcludedAdditional doses for multiple-site storage

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CurrentAdvanced HealthPolicy N/A

Injectable Epinephrine Drug Use Criteria

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Sign up for all advancedhealth policy alerts

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Policy Summary

PayerAdvanced Health

PolicyInjectable Epinephrine Drug Use Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Last ReviewMar 25, 2024

Next Review DateN/A

Key ActionUse the least costly alternative formulation of a formulary injectable epinephrine product.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4Maximum prescriptions per year without prior authorization

8Maximum injections per year without prior authorization

12 monthsPrior authorization lookback period

ExcludedAdditional doses for multiple-site storage

Standard formulary quantity allowance

Covered without prior authorization when all of the following are met:

Standard annual allowance: The member receives no more than four prescriptions of a formulary injectable epinephrine product in a 12-month period; commercially packaged products generally contain two injections per box, allowing up to eight injections per year.<= 4 prescriptions per 12 months; typically <= 8 injections per year

The least costly alternative formulation must be used.

Additional fills requiring prior authorization

Covered with prior authorization when all of the following are met:

Additional clinical need: More than four injectable epinephrine prescriptions are required within a 12-month period.> 4 fills per 12 months

A prior authorization request is required.

Clinical documentation: A current chart note is submitted with the prior authorization request, supporting that the patient's condition has been evaluated by the provider or a specialist.Current chart note

Additional doses for storage at multiple sites or locations, including schools or daycares, are not approved. School districts have employees trained to administer epinephrine on site and maintain their own supply.

Convenience items are not a covered benefit under the Oregon Health Plan.

Provider Requirements and Actionable Rules

Prior Authorization

Prior Authorization Required After Four Fills

Submit prior authorization when an Advanced Health member requires more than four formulary injectable epinephrine fills within a 12-month period. The request must include a current chart note supporting that the patient's condition has been evaluated by the provider or specialist.

Up to four prescriptions per 12 months are allowed without prior authorization.
Because injectable epinephrine is commercially packaged with two injections per box, up to eight injections per year are allowed without prior authorization.
Providers and pharmacists are encouraged to educate members on proper storage and handling and to confirm the product expiration date is 12 months or greater before the prescription is accepted.

Billing Rule

Use the Least Costly Formulary Formulation

Use the least costly alternative formulation of a formulary injectable epinephrine product whenever prescribing or dispensing the medication.

Documentation Required

Current Clinical Evaluation Documentation

Requests for more than four injectable epinephrine fills within 12 months must include current clinical documentation showing that the patient's condition has been evaluated by the provider or specialist.

Submit a current chart note with the prior authorization request.

Denial Risk

More Than Four Annual Fills Require Prior Authorization

Claims exceeding four injectable epinephrine prescriptions within a 12-month period may not be approved without prior authorization.

The four-fill limit applies within each 12-month period.
Up to eight injections per year are allowed without prior authorization because each commercial package contains two injections.

Denial Risk

No Additional Doses for Multiple-Site Storage

Additional injectable epinephrine doses will not be approved solely for storage at multiple sites or locations, including schools or daycares. Convenience quantities are not a covered benefit under the Oregon Health Plan; school districts have trained employees and maintain their own epinephrine supply.

Denial Risk

Failure to Use the Least Costly Alternative

The least costly alternative formulary formulation must be used when obtaining injectable epinephrine.

Failure to use the least costly formulary alternative may result in nonapproval or denial.

Standard Injectable Epinephrine Therapy

Standard injectable epinephrine therapy

Initial or standard therapy is covered when all of the following apply:

Formulary product and quantity: The member receives a formulary injectable epinephrine product within the standard annual allowance of four prescriptions, generally equivalent to eight injections because products are packaged with two injections per box.<= 4 prescriptions or typically <= 8 injections per year

The least costly alternative formulation must be used.

Injectable Epinephrine Drug Use Criteria

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Injectable Epinephrine Drug Use Criteria

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Injectable Epinephrine Coverage Criteria

Provider Requirements and Actionable Rules

Clinical and Packaging Context

Operational Definitions

Standard Injectable Epinephrine Therapy

Formulary Product Selection

Annual Injectable Epinephrine Limits