Colorado Rocky Mountain Health Plans Prior Auth | OpenPayer

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Colorado Rocky Mountain Health Plans Prior Auth | OpenPayer

Coverage criteria for non-solid oral & suppository dosage forms

Initial approval for listed products

Covered when ONE of the following is met

Primary approval conditions: Patient is unable to ingest a solid dosage form (e.g. an oral tablet or capsule) due to one of the following: (a) age; (b) oral/motor difficulties; (c) dysphagia

Applies to listed non-solid oral and suppository products; authorization will be issued for 12 months.

Zegerid (omeprazole + sodium bicarbonate) suspension

Covered when BOTH of the following are met

Zegerid suspension criteria: (1) ONE of the following: (a) patient is unable to ingest a solid dosage form (e.g., due to age, oral/motor difficulties, or dysphagia) OR (b) patient utilizes a feeding tube for medication administration; AND (2) patient has a history of trial and failure, intolerance, or contraindication to BOTH Nexium suspension (esomeprazole) and lansoprazole orally disintegrating tablets (Prevacid SoluTabs).

Authorization will be issued for 12 months.

Eprontia (topiramate) sprinkles

Covered when ONE of the following is met

Eprontia criteria: Either: (a) BOTH: patient is unable to ingest a solid dosage form (e.g., due to age, oral/motor difficulties, or dysphagia) AND patient has a history of trial and failure, intolerance, or contraindication to topiramate sprinkles (Topamax Sprinkle); OR (b) patient utilizes a feeding tube for medication administration.

Authorization will be issued for 12 months.

Valsartan oral solution

Covered when BOTH of the following are met

Valsartan oral solution: (1) Patient is unable to ingest a solid dosage form (e.g., due to age, oral/motor difficulties, dysphagia) or utilizes a feeding tube for medication administration; AND (2) patient has a history of trial and failure, intolerance, or contraindication to one of the following: enalapril oral solution (Epaned) OR Qbrelis (lisinopril) oral solution.

Authorization will be issued for 12 months.

Xelstrym (dextroamphetamine transdermal) approval

Covered when BOTH of the following are met

Xelstrym criteria: (1) Patient is unable to ingest a solid dosage form (e.g., due to age, oral/motor difficulties, dysphagia) or utilizes a feeding tube for medication administration; AND (2) history of trial and failure, intolerance, or contraindication to BOTH: (a) amphetamine/dextroamphetamine extended-release (generic Adderall XR) opened and sprinkled on soft food (e.g., applesauce); AND (b) one of: methylphenidate extended-release capsules (generic Metadate CD or Ritalin LA) opened and sprinkled on soft food OR dexmethylphenidate extended-release (generic Focalin XR) opened and sprinkled on soft food.

Authorization will be issued for 12 months.

Sympazan

Covered when BOTH of the following are met

Sympazan criteria: (1) Patient is unable to ingest a solid dosage form (e.g., due to age, oral/motor difficulties, dysphagia) or utilizes a feeding tube for medication administration; AND (2) patient has a history of trial and failure or intolerance to clobazam oral suspension (generic Onfi).

Authorization will be issued for 12 months.

Imkeldi (imatinib) granules

Covered when BOTH of the following are met

Imkeldi criteria: (1) Patient is less than 19 years of age; AND (2) patient is unable to achieve desired dose by dissolving imatinib 100 mg or 400 mg tablets in water or apple juice.

Authorization will be issued for 12 months.

Vyscoxa (celecoxib) oral solution

Covered when BOTH of the following are met

Vyscoxa criteria: (1) Patient is unable to ingest a solid dosage form (e.g., due to age, oral/motor difficulties, dysphagia) or utilizes a feeding tube for medication administration; AND (2) patient is unable to achieve desired dose by opening celecoxib capsules and adding to applesauce.

Authorization will be issued for 12 months.

Vyscoxa (oral solution) initial criteria

Vyscoxa will be approved based on BOTH of the following:

Vyscoxa approval: 1. Patient is unable to ingest a solid dosage form due to age, oral/motor difficulties, dysphagia, or use of a feeding tube; AND 2. Patient is unable to achieve desired dose by opening celecoxib capsules and adding to applesauce.

Authorization will be issued for 12 months.

Subvenite (oral solution) initial criteria

Subvenite will be approved based on BOTH of the following:

Subvenite approval: 1. Patient is unable to ingest a solid dosage form due to age, oral/motor difficulties, dysphagia, or use of a feeding tube; AND 2. Patient is unable to achieve desired dose with lamotrigine chewable tablet.

Authorization will be issued for 12 months.

Imatinib dose modification criteria

Imatinib workaround: Patient is unable to achieve desired dose by dissolving imatinib 100 mg or 400 mg tablets in water or apple juice.

See Imkeldi criteria for age requirement where applicable.

Claims for many of the listed non‑solid oral and suppository products may be set to auto‑process based on the member’s age. Examples in the policy include automatic adjudication for patients under 6 years for a defined list of products (e.g., Alkindi Sprinkle, Arbli, Brynovin, Carospir, chlorpromazine oral solution, Epaned, Fleqsuvy, Flolipid, Indocin formulations, Inzirqo, Jylamvo, Khindivi, Lopressor oral solution, Meloxicam suspension, Naprosyn suspension, Nexium suspension, Norliqva, Ozobax DS, Prevacid SoluTab, Prograf Granules, Qbrelis, Raldesy, Simvastatin oral suspension, Sotylize, Subvenite, Tezruly, Tirosint‑Sol, Vyscoxa, Xatmep, and Xromi), under 8 years for Pradaxa oral pellets, and under 19 years for Imkeldi. These operational age thresholds are an exception to normal prior authorization workflow and should be considered when reviewing claims or submitting authorization requests.

The policy notes that certain products are typically excluded from coverage. Specifically, Feqsuvy, Indocin Suspension, Indocin Suppositories, and Nexium Suspension are listed in the references/history as typically excluded. Where an item is marked as typically excluded, coverage will follow the member’s benefit plan and any applicable state or federal mandates.

Some referenced products may be excluded from coverage on a brand‑only basis as noted in the policy references. The document indicates that brand‑only designations and other exclusions are detailed in the references and may affect coverage determinations alongside plan benefits and regulatory requirements.

Prior authorization, documentation, and provider requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for the listed non-solid oral and suppository products. Approvals are generally issued for 12 months for the referenced products unless otherwise noted.

PA required for listed non-solid oral and suppository products
Standard authorization duration: 12 months

Prior Authorization

Prior Authorization Duration

Approvals and reauthorizations are typically issued for 12 months for Vyscoxa, Subvenite, and the other listed products. Specific products noted in the criteria (e.g., Zegerid suspension, Eprontia, Valsartan oral solution, Xelstrym, Sympazan, Imkeldi) follow the same standard 12‑month authorization unless explicitly stated otherwise.

Standard PA duration = 12 months for Vyscoxa, Subvenite, and referenced products

Initial therapy conditions for specified products

Initial therapy criteria

Initial approval conditions for specific oral solution products

Initial Vyscoxa: Patient unable to ingest solid dosage form (age, oral/motor difficulties, dysphagia, or feeding tube) AND unable to achieve desired dose by opening celecoxib capsules and adding to applesauce.

12-month authorization.

Initial Subvenite: Patient unable to ingest solid dosage form (age, oral/motor difficulties, dysphagia, or feeding tube) AND unable to achieve desired dose with lamotrigine chewable tablet.

12-month authorization.

Imatinib: Patient unable to achieve desired dose by dissolving imatinib 100 mg or 400 mg tablets in water or apple juice.

Reauthorization and continuation rules

Reauthorization duration and conditions

Reauthorization rules for listed products

Reauthorization: Authorization will be issued for 12 months for Vyscoxa and Subvenite.

Reauthorization may be granted based on previous claim/medication history and claim logic per program rules.

Step therapy requirements and historical step notes

Product	Required prior trial(s) (documented trial and failure, intolerance, or contraindication)	Authorization duration
Zegerid suspension (omeprazole + sodium bicarbonate)
History of trial and failure, intolerance, or contraindication to BOTH Nexium suspension (esomeprazole) AND lansoprazole orally disintegrating tablets (Prevacid SoluTabs).
12 months

Product	Required prior trial(s) (documented trial and failure, intolerance, or contraindication)	Authorization duration
Eprontia (topiramate) sprinkles
History of trial and failure, intolerance, or contraindication to topiramate sprinkles (Topamax Sprinkle) OR patient utilizes a feeding tube for medication administration.
12 months

Background and scope

These coverage criteria apply to members who are unable to ingest solid oral dosage forms (examples include young age, oral/motor difficulties, or dysphagia) or who require administration via a feeding tube. Operational rules within the program allow automatic claim processing by age for many products (for example, automatic processing under age 6 for a long list of items, under age 8 for Pradaxa oral pellets, and under age 19 for Imkeldi). When automatic processing does not apply, prior authorization is required and approvals are managed per the product‑specific criteria.

Key definitions used in criteria

Inability to ingest solid oral dosage form (examples: age, oral/motor difficulties, dysphagia)

DefinitionUnable to ingest a solid oral dosage form (e.g., oral tablet or capsule)

Common clinical examplesAge-related limitations

Common clinical examplesOral or motor difficulties affecting swallowing

Common clinical examplesDysphagia

Documentation requiredClinical record must indicate reason the patient cannot ingest solid oral dosage forms (age, oral/motor difficulties, or dysphagia)

Inability to ingest solids (examples provided)

Definition

References, package inserts, and excluded products

Feqsuvy, Indocin Suspension, Indocin Suppositories, and Nexium Suspension are identified in the policy references as products that are typically excluded from coverage. The reference notes also record changes to the policy history (for example, additions of Subvenite and Vyscoxa in 2/2026) and remind readers that state mandates and benefit plan terms may further influence coverage.

The policy calls out that some products may be excluded from coverage as brand‑only exclusions or marked as typically excluded in the references. Providers should consult the policy references and the member’s specific benefit plan to determine whether a brand‑only exclusion or other exception applies before submitting an authorization request.

Policy changes and revision history

2026-02additionLatest

Subvenite and Vyscoxa were added to the coverage criteria.

2025-06addition

Imkeldi, Inzirqo, Raldesy and Xromi were added to the coverage criteria.