Approval of Brand-Name Override
Customize your policy alerts
Sign up for Ambetter Nevada Policy NV.PHAR.03 alerts
Get alerted when Policy NV.PHAR.03 changes without checking for updates manually.
Monitor payer policy activity
Governs requests and authorization process for coverage of brand-name medications when an AB-rated generic is available for Ambetter Nevada Medicaid members; affects prescribers, Envolve Pharmacy Solutions prior authorization staff, and the health plan review team.
No material clinical or coverage changes in this revision.
Brand-name Override Coverage Criteria
Brand-name override approval criteria
Covered when ALL of the following are met
See Attachment A (CP.PMN.22 Brand Name Override) for the detailed required documentation and supporting information.
The pharmacy benefit enforces a generic-first requirement: multi-source, AB-rated products must be dispensed as the generic formulation unless the member meets the brand-name override criteria. Coverage for a brand-name product is available only when the conditions for a brand override are satisfied (see Attachment A: CP.PMN.22 for detailed criteria).
Requests for brand-name coverage that are not accompanied by recent, objective, measurable documentation demonstrating the patient’s inability to use the generic formulation will not be granted. Detailed required documentation is specified in Attachment A: CP.PMN.22.
What Providers Must Do
Submit written or faxed prior authorization to Envolve Pharmacy Solutions
Prescriber must submit a written or faxed request to Envolve Pharmacy Solutions Prior Authorization; a registered clinical pharmacist will review the request and respond to the prescriber within 24 hours. If necessary, Envolve Pharmacy Solutions or NurseWise may enter a temporary override in the claims processing system to allow therapy while the request is reviewed.
Generic-first policy — brand requires override criteria
The pharmacy benefit requires dispensing the generic formulation for multi-source, AB-rated drugs; coverage for a brand-name product is only available if the brand-name override criteria in Attachment A (CP.PMN.22) are met.
Provide required documentation and DAW on prescription
Requests must include recent, objective, measurable information per Attachment A (CP.PMN.22). The prescriber must submit the request in writing or by fax and must write DAW on the prescription (pre-printed box or signature line is not accepted).
- Include documentation meeting the detailed criteria in Attachment A: CP.PMN.22
- Write DAW handwritten on the prescription (pre-printed box or signature line not acceptable)
Denial risk if objective, measurable documentation is missing
A request will be denied if it is not accompanied by recent, objective, measurable information demonstrating the patient is unable to take the generic formulation.
- Lack of the required objective documentation per Attachment A is a basis for denial
- Appeals of denials are forwarded to the health plan for final determination by the health plan pharmacist or Medical Director
Policy Background
This policy reflects the standard pharmacy benefit expectation that when an FDA-designated AB-rated (multisource, bioequivalent) generic exists, the generic product is the appropriate dispensing choice unless there is a documented medical necessity for the brand. Providers seeking a brand override must follow the procedures and provide the documentation described in Attachment A (CP.PMN.22).
Key Definitions
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.