Acitretin — prior authorization required

Acitretin is subject to prior authorization. Clinical and/or administrative PA criteria must be met before coverage is provided; coverage duration when authorized is one year.

Alecensa — PA and duration

Alecensa requires prior authorization; indications are listed as all medically-accepted and coverage duration is 1 year.

Alosetron — PA and duration

Alosetron (alosetron hydrochloride) is subject to prior authorization; indications are listed as all medically-accepted and coverage duration is 1 year.

Prolastin‑c — required diagnostic documentation and age restriction

Prolastin‑c (alpha‑1‑proteinase inhibitor) requires prior authorization and documentation must include a diagnosis of necrotizing panniculitis or alpha‑1 antitrypsin deficiency with FEV1 < 80% predicted; patients must be 18 years or older.

• Document diagnosis of necrotizing panniculitis or AAT deficiency with FEV1 < 80% predicted
• Document congenital AAT phenotype consistent with PiZZ, PiZ (null), or Pi(null,null)
• Patient age ≥ 18 years

Alunbrig — prerequisite crizotinib required

Alunbrig is subject to prior authorization for ALK‑positive metastatic disease and requires a prior trial of crizotinib as prerequisite therapy.

• Prior trial of crizotinib required

Arcalyst — combination prerequisite therapy required

Arcalyst requires prior authorization and coverage for the recurrent inflammatory indication requires prior use of an inflammatory drug in combination with colchicine.

• Document trial of an inflammatory drug used in combination with colchicine

Benlysta — PA and one‑year duration

Benlysta is subject to prior authorization and, when authorized, coverage duration is one year for medically-accepted indications.

Betaseron — PA and one‑year duration

Betaseron requires prior authorization; when authorized, coverage duration is one year for medically‑accepted indications.

Brukinsa — PA, duration, and prerequisite therapies

Brukinsa is subject to prior authorization with a coverage duration of one year and requires documented trials of specified prior therapies depending on indication (e.g., Calquence for MCL; anti‑CD20 regimen for MZL; Calquence or Imbruvica for CLL/SLL).

• MCL: trial of Calquence required
• MZL: trial of at least one anti‑CD20–based regimen required
• CLL/SLL: trial of Calquence or Imbruvica required

Prior authorization and coverage duration — common provider actions

Prior authorization is required for many listed products; coverage durations are commonly set to one year and some products require documented trials of specified prerequisite therapies prior to approval.

• Obtain PA where product is marked (PA) on formulary
• Prepare documentation of prerequisite therapy trials when required
• Coverage durations commonly authorized for 1 year

Cayston — PA summary

Cayston requires prior authorization; indications are listed as all medically‑accepted and coverage duration is 1 year with no prerequisite Part D drug required.

Cerdelga — PA and duration

Cerdelga is subject to prior authorization for medically‑accepted indications with a one‑year coverage duration; no prerequisite Part D drug is required.

Cholbam — PA and one‑year duration

Cholbam requires prior authorization for medically‑accepted indications; coverage duration is one year and no prerequisite Part D drug is required.

Clomiphene — PA and duration

Clomiphene products are subject to prior authorization for medically‑accepted indications; coverage duration is one year and no prerequisite Part D drug is required.

Cobenfy — prerequisite antipsychotic trial required

Cobenfy requires prior authorization for schizophrenia and mandates prior antipsychotic therapy (prerequisite Part D drug) before coverage will be approved.

• Document prior antipsychotic therapy

Copiktra — prior therapies required

Copiktra requires prior authorization for relapsed or refractory CLL and requires documentation of at least two prior therapies as prerequisite treatment.

• Document at least two prior therapies

Prerequisite Part D drug — confirm and document prior Part D therapy

Some product entries require use of a prerequisite Part D drug prior to authorization; confirm and document prior Part D therapy when specified in the product PA note.

• Verify whether product PA notes list a prerequisite Part D drug
• Provide documentation of prior Part D drug trials when required

Cotellic — vemurafenib prerequisite

Cotellic coverage for unresectable or metastatic melanoma requires prior authorization and lists vemurafenib as prerequisite therapy; document prior vemurafenib use when applicable.

• Document prior vemurafenib therapy where indicated

Deferasirox — one‑year coverage

Deferasirox is subject to prior authorization and, when authorized, coverage duration is limited to one year.

Drizalma Sprinkle — one‑year coverage

Drizalma Sprinkle requires prior authorization and coverage duration when authorized is one year.

Dupixent — PA, duration, and reauthorization documentation

Dupixent requires prior authorization with indication‑specific criteria; when authorized, coverage duration is one year and reauthorization requires documentation of positive clinical response.

• Document indication‑specific prior therapies/biomarkers as required
• Provide evidence of positive clinical response for reauthorization

Doptelet — PA required

Doptelet is subject to prior authorization for treatment of chronic immune thrombocytopenia; follow the PA criteria and provide required clinical information per the product note.

Ebglyss — PA, age/weight prerequisites, and Part D requirement

Ebglyss requires prior authorization and is limited to patients weighing at least 40 kg and aged ≥12 years; coverage duration is one year and some indications require prior Part D drug trials.

• Document patient weight ≥ 40 kg
• Document patient age ≥ 12 years
• Provide evidence of specified prior Part D drug trials when required

Emgality — PA and duration

Emgality requires prior authorization for medically‑accepted indications; coverage duration is one year and no prerequisite Part D drug is required.

Ensacove — PA and duration

Ensacove is subject to prior authorization for medically‑accepted indications; coverage duration is one year and no prerequisite Part D drug is required.

Epidiolex — PA and required prior trials for seizure indications

Epidiolex requires prior authorization for medically‑accepted indications; coverage duration is one year and certain seizure indications require documented trials of specified generic alternatives (e.g., two generics for Lennox‑Gastaut; valproic acid/clobazam/topiramate for Dravet).

• Lennox‑Gastaut: trial of two generic alternatives required
• Dravet: trial of two of valproic acid, clobazam, or topiramate required
• TSC‑associated seizures: trial of two generic alternatives required

Prior authorization and coverage duration — provider checklist

Prior authorization applies to many products and coverage durations are commonly one year; ensure PA is obtained and document prerequisite therapies or other required clinical information as noted per product.

• Obtain PA before dispensing when product is marked (PA)
• Include documentation of prerequisite therapies when product notes require them
• Note common one‑year authorization duration

Eulexin — generic bicalutamide trial required

Eulexin requires prior authorization and a documented trial of generic bicalutamide prior to approval; coverage duration when authorized is one year.

• Document trial of generic bicalutamide

Fanapt — two‑agent antipsychotic trial required

Fanapt requires prior authorization for schizophrenia and mandates trial of two generic formulary atypical antipsychotics (examples include quetiapine, risperidone, ziprasidone) prior to approval.

• Document trial/failure of two generic atypical antipsychotics

Fasenra — eosinophil thresholds and reauthorization

Fasenra prior authorization includes numeric eosinophil thresholds for initiation (≥150 cells/µL for eosinophilic asthma; ≥1000 cells/µL for HES) and coverage duration is one year; reauthorization requires documentation of positive clinical response.

• Eosinophilic asthma: eosinophils ≥ 150 cells/µL at initiation
• HES: eosinophils ≥ 1000 cells/µL at initiation
• Document clinical response for reauthorization

Firazyr — age ≥18 documented for PA

Firazyr (icatibant) is subject to prior authorization and is limited to patients aged 18 years or older; coverage duration when authorized is one year.

• Document patient age ≥ 18 years

Fotivda — prior systemic therapy trials required

Fotivda requires prior authorization for advanced renal cell carcinoma and coverage requires documented trials of two or more prior systemic therapies; provide documentation of prior systemic therapy trials.

• Document trials of two or more prior systemic therapies for advanced RCC

Fruzaqla — prior chemotherapy and anti‑VEGF required

Fruzaqla requires prior authorization for metastatic colorectal cancer and coverage requires documented trials of fluoropyrimidine‑, oxaliplatin‑, and irinotecan‑based chemotherapy and an anti‑VEGF therapy; provide required prior chemotherapy documentation.

• Document prior fluoropyrimidine‑, oxaliplatin‑, and irinotecan‑based chemotherapy
• Document prior anti‑VEGF therapy

Fulphila — PA and one‑year duration

Fulphila requires prior authorization; when authorized, coverage duration is one year and no prerequisite Part D drug is required.

GLP‑1 agonists — PA and documentation requirements

GLP‑1 agonists are subject to prior authorization; they are excluded if used for weight‑loss only and require submission of medical records confirming a T2DM diagnosis or qualifying laboratory values (A1c ≥6.5%, FPG ≥126 mg/dL, or 2‑hour PG ≥200 mg/dL).

• Provide chart notes confirming T2DM or lab evidence (A1c ≥6.5% or FPG ≥126 mg/dL or 2‑hour PG ≥200 mg/dL)
• Do not request coverage if indication is weight loss only

Prior authorization required — general notice

Prior authorization is required for the listed products; PA summaries indicate indications are limited to medically‑accepted uses and coverage durations are commonly one year — obtain PA and submit required documentation as specified per product.

• Obtain PA when product is designated (PA) on formulary
• Submit required medical information per product PA note

PA applies — product list

Prior authorization applies to the listed products and coverage durations are commonly one year; follow each product's PA criteria details and provide requested documentation.

PA requires prerequisite or combination therapy (examples)

Some prior authorizations require demonstration of specific combination therapies or prior Part D drug trials (examples include Ibrance and Iclusig); document prior combination or prerequisite therapy where required.

• Ibrance: document combination use with aromatase inhibitor or fulvestrant as specified
• Iclusig: document prior kinase inhibitor trials or chemotherapy combination per indication

PA applies — include criteria details

Prior authorization applies to the listed products; several entries specify 'PA Criteria = Criteria Details' and note coverage duration commonly of one year — ensure PA submission includes the criteria details requested.

Inlyta — combination immunotherapy and prior therapy requirements

Inlyta prior authorization for first‑line advanced renal cell carcinoma requires combination use with avelumab or pembrolizumab; other Inlyta indications may require a trial of one prior systemic therapy — document combination immunotherapy or prior systemic therapy as applicable.

• Document combination use with avelumab or pembrolizumab for first‑line advanced RCC
• Document trial of one prior systemic therapy when applicable

Ivermectin TABS 3MG — PA and one‑year duration

Ivermectin 3 mg tablets are subject to prior authorization for FDA‑approved indications; coverage duration when authorized is one year and no prerequisite Part D drug is required.

Step therapy overview — verify and document prior trials

Step therapy is applied to specified drugs: providers must document trials of required formulary agents (steps) before a PA will be approved when the product's ST requirement is listed.

• Verify whether the drug is designated (ST) on the formulary
• Provide documentation of prior formulary drug trials per ST requirements

Balversa — prior systemic therapy trial required

Balversa requires prior authorization and a documented trial of at least one prior systemic therapy before coverage will be approved.

• Document trial of at least one prior systemic therapy

Auvelity — generic antidepressant trial required

Auvelity requires a prior trial of another generic formulary antidepressant as prerequisite therapy before authorization will be granted.

• Document trial of a generic formulary antidepressant

Braftovi — combination therapy prerequisites

Braftovi coverage for certain indications requires combination use with specified agents (e.g., vemurafenib + cobimetinib; binimetinib; cetuximab + fluorouracil‑based chemotherapy); document combination regimens when applicable.

• Document required combination regimens per indication (e.g., vemurafenib + cobimetinib)

Step therapy examples — document specified prior agents

Step or prerequisite therapy is required for certain products (examples include Brukinsa, Cabometyx); document trials of specified agents (e.g., Calquence for Brukinsa; sorafenib for Cabometyx) when noted.

• Brukinsa (MCL): trial of Calquence required
• Cabometyx (HCC): trial of sorafenib required
• Calquence (MCL): prior therapy required

Prerequisite therapy requirements — document prior trials

Some products require documented prior therapies before authorization (e.g., Cobenfy requires prior antipsychotics; Copiktra requires at least two prior therapies); include prior therapy documentation in the PA request.

• Cobenfy: document prior antipsychotic use
• Copiktra: document at least two prior therapies

Cotellic — vemurafenib prerequisite (provider action)

Cotellic lists vemurafenib as a prerequisite therapy for coverage in unresectable or metastatic melanoma; document prior vemurafenib use where applicable to support PA.

• Provide records showing prior vemurafenib therapy

Deferasirox — one‑year PA duration

Deferasirox is authorized for a one‑year duration when PA criteria are met; ensure PA includes required clinical information to support a one‑year authorization.

Drizalma Sprinkle — one‑year PA duration

Drizalma Sprinkle prior authorization is authorized for one year; include required medical information with the PA request.

Dupixent — PA, one‑year duration, and reauthorization

Dupixent PA requires indication‑specific documentation and is commonly authorized for one year; for reauthorization submit documentation of positive clinical response.

• Submit indication‑specific diagnostic and prior‑therapy documentation
• Provide evidence of clinical response for reauthorization

Doptelet — PA required

Doptelet requires prior authorization for its indicated use; include clinical information per the PA note to support authorization.

Ebglyss — PA: age, weight, and prerequisite therapy documentation

Ebglyss PA requires documentation that the patient is ≥12 years of age and weighs at least 40 kg; some indications require prior Part D drug trials — include age, weight, and prior therapy documentation as applicable.

• Document patient age ≥ 12 years
• Document patient weight ≥ 40 kg
• Provide prior therapy documentation when indicated

Emgality — PA and one‑year duration

Emgality requires prior authorization and is commonly authorized for one year; no prerequisite Part D drug is required for coverage.

Ensacove — PA and duration

Ensacove requires prior authorization for medically‑accepted indications with a one‑year coverage duration and does not require a prerequisite Part D drug.

Epidiolex — PA and required seizure‑trial documentation

Epidiolex prior authorization requires documentation of prerequisite trials for specific seizure indications (see product PA: two generic alternatives for Lennox‑Gastaut; two of valproic acid/clobazam/topiramate for Dravet), and coverage duration is one year.

• Provide trial documentation of required generic alternatives or specified agents per seizure syndrome

Prior authorization and coverage duration — avoid missing documentation

Prior authorization is commonly required and coverage duration is often one year across many products; include product‑specific prerequisite therapy documentation when requested to avoid denial.

• Confirm PA designation on formulary
• Include prior therapy documentation when specified

Eulexin — document bicalutamide trial (denial risk)

Eulexin requires prior authorization and a documented trial of generic bicalutamide prior to approval; failure to document the bicalutamide trial may lead to denial.

• Document generic bicalutamide trial to support PA

Fanapt — two‑agent trial required (denial risk if missing)

Fanapt prior authorization requires documented trials of two generic formulary atypical antipsychotics for schizophrenia; lack of these trials may result in denial.

• Provide records of two generic atypical antipsychotic trials (e.g., quetiapine, risperidone, ziprasidone)

Forteo — prior osteoporosis therapy documentation required

Forteo prior authorization requires documented trials of specified prior osteoporosis therapies (e.g., oral bisphosphonate or IV bisphosphonate if intolerant) before approval.

• Document trials of required prior osteoporosis therapies or inability to tolerate them

Fycompa — two‑agent trial required

Fycompa (perampanel) requires prior authorization and documentation of trials of two generic agents prior to approval.

• Document trials of two generic antiepileptic agents

GLP‑1 agonists — documentation required; weight‑loss use excluded

GLP‑1 agonist PA requires submission of medical records confirming T2DM diagnosis or qualifying lab values; requests for weight‑loss–only use are excluded and will not be authorized.

• Submit chart notes or lab evidence confirming T2DM (A1c ≥6.5% or FPG ≥126 mg/dL or 2‑hour PG ≥200 mg/dL)
• Do not submit PA for weight‑loss–only indication

PA requires documentation of combination/prerequisite therapies

When a product's PA note specifies prerequisite or combination therapy (e.g., Ibrance, Iclusig), document the required combination or prior Part D drug trials to support the authorization request.

• Ibrance: document combination endocrine therapy as specified
• Iclusig: document prior kinase inhibitor trials or chemotherapy combination per indication

Inlyta — combination immunotherapy and prior therapy documentation

Inlyta prior authorization for first‑line advanced RCC requires combination use with avelumab or pembrolizumab and may require a prior systemic therapy trial for other indications; document combination immunotherapy or prior systemic therapy as applicable.

• Provide evidence of combination use with avelumab or pembrolizumab for first‑line advanced RCC
• Document prior systemic therapy trials when required

Bronchitol — tolerance test documentation required

Some products list specific clinical documentation requirements (e.g., Bronchitol requires documentation that the member has passed the Bronchitol tolerance test); include such test documentation with the PA request.

• Attach Bronchitol tolerance test results when requesting PA for Bronchitol

Document prior therapies — required when PA notes specify

Document prior therapies when the PA note requires them (examples: Calquence, anti‑CD20 regimens, Imbruvica for Brukinsa indications); absence of documented prior therapy may result in denial.

• Provide records of prior Calquence, anti‑CD20 regimens, or Imbruvica where applicable

Dalfampridine — baseline T25FW and exclusion for wheelchair‑bound patients

For Dalfampridine, prior authorization requires documentation of a baseline Timed 25‑Foot Walk (T25FW) prior to initiation; requests for patients who are wheelchair‑bound (or become wheelchair‑bound) are excluded.

• Include baseline T25FW test results with the PA request
• Do not authorize if patient is wheelchair‑bound