PA required for A1-PI augmentation products

Prior authorization is required for the listed A1-PI augmentation products; submit required medical information including diagnosis of severe congenital A1-PI deficiency with clinically evident emphysema, patient weight, A1-PI phenotype, and baseline A1-PI level. Prescription must be written by a pulmonologist; coverage duration is 1 year.

• Required medical information: diagnosis, weight, phenotype, baseline A1-PI level
• Prescriber restriction: pulmonologist
• Coverage duration: 1 year

AKEEGA — prior authorization and prescriber requirement

AKEEGA requires prior authorization with documentation of diagnosis (metastatic castration‑resistant prostate cancer with deleterious or suspected deleterious BRCA mutation) and that the prescriber is an oncologist or urologist; beneficiary age must be appropriate per FDA labeling. Coverage duration: 5 years.

• Diagnosis: metastatic castration‑resistant prostate cancer with deleterious or suspected deleterious BRCA mutation
• Prescriber restriction: oncologist or urologist
• Coverage duration: 5 years

ALK TKIs — PA and prescriber restriction

ALK tyrosine kinase inhibitors require prior authorization; submit diagnosis and ensure the prescription is written by an oncologist. Coverage duration is 5 years.

• Products: ALECENSA, XALKORI, ZYKADIA
• Prescriber restriction: oncologist
• Coverage duration: 5 years

ALUNBRIG — ALK confirmation and PA

ALUNBRIG requires prior authorization with documentation that metastatic NSCLC is ALK‑positive as detected by an approved test; prescription must be by or in consultation with an oncologist. Coverage duration: 5 years; continuation of prior therapy may be approved.

• Required: ALK‑positive NSCLC confirmed by an approved test
• Prescriber restriction: oncologist (or consult)
• Coverage duration: 5 years; continuation may be approved

FIRDAPSE — diagnostic confirmation and PA

For FIRDAPSE (amifampridine) prior authorization is required; submit electrodiagnostic studies (including repetitive nerve stimulation) and anti‑P/Q‑type VGCC antibody testing to confirm Lambert‑Eaton diagnosis. Prescription must be written by a neurologist. Coverage duration: 1 year.

• Diagnostic confirmation: electrodiagnostic studies and anti‑P/Q‑type VGCC antibody testing
• Prescriber restriction: neurologist
• Coverage duration: 1 year

Aprepitant — chemotherapy regimen documentation required

Aprepitant requires prior authorization when used with highly or moderately emetogenic chemotherapy; submit the chemotherapy regimen (drug, dose, frequency). For PONV use, provide rationale why preferred agents (e.g., ondansetron) are not appropriate. Coverage duration: 6 months.

• Required documentation: chemotherapy regimen (drug, dose, frequency)
• For PONV: rationale why preferred agents are not appropriate
• Coverage duration: 6 months

Antipsychotics — PA and prior treatment documentation

Selected antipsychotics require prior authorization with documentation of diagnosis and treatment history; for bipolar disorder or schizophrenia, document failure of two atypical antipsychotics or provide rationale. Coverage duration: 3 years.

• Required: diagnosis and treatment history
• Schizophrenia/bipolar: failure of two atypical antipsychotics (or rationale)
• Coverage duration: 3 years

ARIKAYCE — required documentation and PA

ARIKAYCE prior authorization requires medical records supporting the request including sputum culture confirming MAC lung disease; prescriber must be or consult with an infectious disease specialist or pulmonologist. For initial review provide documentation of failure to obtain negative sputum cultures after ≥6 months of multidrug background regimen therapy. Coverage duration: 1 year.

• Required documentation: sputum culture supporting MAC lung disease
• Prior therapy documentation: failure to clear sputum after ≥6 months of multidrug regimen for initial review
• Prescriber restriction: infectious disease specialist or pulmonologist
• Coverage duration: 1 year

ATTRUBY — diagnostic confirmation and PA

ATTRUBY requires prior authorization with confirmation of diagnosis via appropriate testing; prescription must be written by a cardiologist. Coverage duration: 1 year.

• Required documentation: confirmation of diagnosis with appropriate testing
• Prescriber restriction: cardiologist
• Coverage duration: 1 year

AUGTYRO — prior authorization

Prior authorization is required for AUGTYRO (oral capsules); beneficiary age must be appropriate per FDA labeling and other criteria in the product entry must be met.

• Beneficiary age per FDA labeling
• PA required before dispensing

AVMAPKI‑FAKZYNJA — PA and prescriber restriction

AVMAPKI‑FAKZYNJA requires prior authorization; the prescription must be written by an oncologist and coverage duration is 5 years.

• Prescriber restriction: oncologist
• Coverage duration: 5 years

BENLYSTA SC — PA and required documentation

BENLYSTA SUBCUTANEOUS requires prior authorization; submit diagnosis, autoantibody testing, and prior treatments with responses. Prescription must be written by a rheumatologist or nephrologist. Coverage duration: 3 years.

• Required documentation: diagnosis, autoantibody testing, prior treatments and responses
• Prescriber restriction: rheumatologist or nephrologist
• Coverage duration: 3 years

BRIVIACT — PA and prerequisite therapy

BRIVIACT (brivaracetam) requires prior authorization; prerequisite therapy is noted as required and prescriber/age must align with FDA labeling.

• Required: documentation of response to brivaracetam and prerequisite therapy
• Prescriber/age per FDA labeling

BRUKINSA — prior authorization

BRUKINSA oral tablet requires prior authorization; no prerequisite therapy is listed and prescriber/use must follow FDA labeling.

• PA required; Prerequisite Therapy: No
• Prescriber/age per FDA labeling

COBENFY — PA and step therapy requirement

COBENFY requires prior authorization; submit diagnosis and treatment history. For schizophrenia, document failure with two atypical antipsychotics. Coverage duration: 5 years.

• Required documentation: diagnosis and treatment history
• Schizophrenia: failure of two atypical antipsychotics required
• Coverage duration: 5 years

COMETRIQ — PA and prescriber restriction

COMETRIQ requires prior authorization; prescription must be written by an oncologist. Coverage duration: 5 years.

• Prescriber restriction: oncologist
• Coverage duration: 5 years

COPIKTRA — PA and prescriber restriction

COPIKTRA requires prior authorization; prescription must be written by an oncologist or hematologist. Coverage duration: 5 years.

• Prescriber restriction: oncologist or hematologist
• Coverage duration: 5 years

CORLANOR — PA and required clinical documentation

CORLANOR prior authorization requires documentation supporting heart failure in adults: left ventricular ejection fraction ≤35%, heart rate ≥70 bpm in sinus rhythm, and that the patient is on a maximally tolerated beta‑blocker or has a contraindication to beta‑blocker. Prescription should be by a cardiologist; coverage duration: 12 months.

• EF ≤ 35% and HR ≥ 70 bpm in sinus rhythm
• On maximally tolerated beta‑blocker OR contraindication to beta‑blocker
• Prescriber restriction: cardiologist
• Coverage duration: 12 months

COSENTYX — PA, documentation, and combination exclusion

COSENTYX requires prior authorization; prescriber must be a rheumatologist or dermatologist. Submit diagnosis, prior treatments and reasons for failure, and baseline/ongoing TB monitoring. Coverage duration: 1 year; must not be used in combination with other biologic drugs or JAK inhibitors.

• Prescriber restriction: rheumatologist or dermatologist
• Required documentation: diagnosis, prior treatments and failures, TB monitoring
• Coverage duration: 1 year
• Combination therapy exclusion: not used with other biologics or JAK inhibitors

CRESEMBA — prior authorization and prerequisite therapy

CRESEMBA (oral) requires prior authorization; beneficiary age must be appropriate per FDA labeling and prerequisite therapy is noted as required.

• PA required; prerequisite therapy: Yes
• Age per FDA labeling

Cyclobenzaprine — PA, documentation, and age notes

Cyclobenzaprine oral tablets (5 mg, 10 mg) require prior authorization with medical records documenting the diagnosis. Patients under age 65 are approved; patients aged 65 and older must meet additional age‑specific criteria. Coverage duration: 1 year.

• Required documentation: medical records documenting diagnosis
• Patients <65: approved; patients ≥65: additional criteria apply
• Coverage duration: 1 year

CYSTADROPS — prescriber restriction and diagnostic documentation

CYSTADROPS requires prior authorization; prescribing is limited to an ophthalmologist or corneal specialist and documentation of corneal cystine crystals is required before initiation.

• Prescriber restriction: ophthalmologist or corneal specialist
• Required clinical finding: documentation of corneal cystine crystal

GATTEX — PA and required documentation

GATTEX prior authorization requires documentation of diagnosis and prior therapies and responses; for adult patients submit colonoscopy of entire colon with polyp removal before initiation. Prescriber must be a gastroenterologist; discontinue therapy if intestinal malignancy is present. Coverage duration: 3 years.

• Required documentation: diagnosis, prior therapies and responses; adults: colonoscopy with polyp removal documented
• Prescriber restriction: gastroenterologist
• Exclusion: discontinue if intestinal malignancy
• Coverage duration: 3 years

Demser (metyrosine) — PA and surgical candidacy documentation

Demser (metyrosine) prior authorization requires documentation of diagnosis and whether the patient is a candidate for surgery. Coverage duration: 1 year.

• Required documentation: diagnosis and surgical candidacy
• Coverage duration: 1 year

Diabetic supplies — PA and purpose confirmation

Diabetic supplies require prior authorization for a 1‑year duration; prescriber must confirm that the supply is requested for use directly associated with delivering insulin to the patient.

• Prescriber confirmation required: supply is for insulin delivery
• Coverage duration: 1 year

Fidaxomicin — PA and prescriber restriction

Fidaxomicin (DIFICID) requires prior authorization for Clostridium difficile infection and must be prescribed by or in consultation with an infectious disease specialist. Coverage duration: 1 month.

• Required documentation: diagnosis of C. difficile
• Prescriber restriction: infectious disease specialist (or consult)
• Coverage duration: 1 month

DOPTELET — PA, documentation, and prescriber restriction

DOPTELET requires prior authorization with documentation of diagnosis and platelet count; prescribing is limited to an appropriate specialist (e.g., hematologist, oncologist, gastroenterologist). Coverage duration varies by indication (1 month for chronic liver disease; 6 months for chronic immune thrombocytopenia).

• Required medical information: diagnosis and platelet count
• Prescriber restriction: appropriate specialist (hematologist/oncologist/gastroenterologist)
• Coverage duration: indication-specific (1 month CLD; 6 months ITP)

Dronabinol — PA, documentation, and indication limits

Dronabinol requires prior authorization with documentation of diagnosis, previous treatments and outcomes; for cancer‑related weight loss, document failure or intolerance to megestrol. Dronabinol is not covered for treatment of pain. Coverage duration: 1 year.

• Required documentation: diagnosis, prior treatments and outcomes
• Cancer cachexia: failure/intolerance to megestrol required
• Not covered for pain
• Coverage duration: 1 year

Dupixent — PA, documentation, and prescriber restriction

Dupixent requires prior authorization with indication‑specific documentation (e.g., baseline eosinophil count for asthma, mucin/culture for AFRS). Prescribing is limited to specified specialties (allergist, immunologist, pulmonologist, otolaryngologist, dermatologist, gastroenterologist). Coverage duration: 1 year; many indications require prerequisite therapy trials.

• Required: diagnosis and indication‑specific documentation (e.g., eosinophil ≥150 cells/mcL for asthma)
• Prescriber restriction: specified specialties (allergist, immunologist, pulmonologist, otolaryngologist, dermatologist, gastroenterologist)
• Coverage duration: 1 year
• Prerequisite therapy: Yes for many indications

Epidiolex — required prior therapy documentation

Epidiolex prior authorization requires documentation of prior anticonvulsant trials per indication (valproate and lamotrigine for Lennox‑Gastaut; valproate and topiramate for Dravet; two different anticonvulsants from different classes for refractory seizures). Submit diagnosis, prior therapies and outcomes; prescriber must be or consult with a neurologist.

• Lennox‑Gastaut: documentation of valproate and lamotrigine trial/outcomes
• Dravet: documentation of valproate and topiramate trial/outcomes
• Refractory seizures: documentation of two different anticonvulsant trials/outcomes
• Prescriber restriction: neurologist (or consult)

Dihydroergotamine nasal — PA and triptan trial requirement

Dihydroergotamine nasal requires prior authorization; prescriber must be a headache specialist, pain management specialist, or neurologist. For migraine, document trial and failure of two different triptans (one oral tablet and one other formulation) unless contraindicated. Coverage duration: 1 year.

• Required documentation: diagnosis, prior treatments and responses
• Triptan trial: failure of two different triptans (one oral, one other formulation) unless contraindicated
• Prescriber restriction: headache specialist, pain management specialist, or neurologist
• Coverage duration: 1 year

FILSUVEZ — PA and age requirement

FILSUVEZ requires prior authorization; beneficiary must be of appropriate age per FDA labeling and applicable product criteria must be met as listed in the product entry.

• PA required; age per FDA labeling
• Follow product‑specific criteria in PA entry

FINTEPLA — prior authorization

FINTEPLA requires prior authorization; beneficiary must be of appropriate age per FDA labeling and applicable product criteria must be met as listed in the product entry.

• PA required; age per FDA labeling
• Follow product‑specific criteria in PA entry

FORTEO — PA, pretreatment testing and step therapy

FORTEO (teriparatide) prior authorization requires documentation of diagnosis, fracture history, prior therapy and response, and required pretreatment testing (DXA if not in past 2 years; serum calcium, phosphorus, creatinine, alkaline phosphatase, albumin, 25‑OH vitamin D; 24‑hour urine calcium/creatinine or fasting specimen). Prescriber must be an endocrinologist. Prior trials and failure of an oral bisphosphonate (or parenteral if GI intolerant) AND denosumab are required. Coverage duration: 2 years.

• Required pretreatment testing: DXA, serum calcium, phosphorus, creatinine, alkaline phosphatase, albumin, 25‑OH D, 24‑hour urine calcium/creatinine (or fasting specimen)
• Prior therapy: trial/failure of oral bisphosphonate (or parenteral if intolerant) AND trial/failure of denosumab
• Prescriber restriction: endocrinologist
• Coverage duration: 2 years

Fruzaqla — PA and prior therapy documentation

Fruzaqla requires prior authorization with documentation of prior therapies and treatment history consistent with metastatic colorectal cancer previously treated with specified regimens; prescriber must be or consult with a hematologist/oncologist. Coverage duration: 5 years.

• Required documentation: prior chemotherapy regimens and treatment history
• Prescriber restriction: hematologist/oncologist
• Coverage duration: 5 years

GAVRETO — PA and diagnostic confirmation

GAVRETO requires prior authorization; submit diagnosis and verification of RET fusion mutation by an FDA‑approved diagnostic test for NSCLC or thyroid cancer. Prescription must be written by an oncologist or pulmonologist. Coverage duration: 5 years.

• Required documentation: diagnosis and FDA‑approved diagnostic test confirming RET fusion mutation
• Prescriber restriction: oncologist or pulmonologist
• Coverage duration: 5 years

GILOTRIF — PA and prescriber restriction

GILOTRIF requires prior authorization with documented diagnosis; prescription must be written by an oncologist. Coverage duration: 5 years.

• Required documentation: diagnosis
• Prescriber restriction: oncologist
• Coverage duration: 5 years

Ibrance — PA, documentation and step therapy

Ibrance prior authorization requires documentation of diagnosis and previous therapies tried; prescription must be written by an oncologist. A trial of Kisqali or Verzenio is required prior to approval unless the beneficiary has PIK3CA‑mutated HR‑positive, HER2‑negative locally advanced or metastatic breast cancer. Coverage duration: 1 year.

• Required documentation: diagnosis and previous therapies
• Prescriber restriction: oncologist
• Step therapy: trial of Kisqali or Verzenio required unless PIK3CA‑mutated exception
• Coverage duration: 1 year

Idhifa — PA and prescriber restriction

Idhifa requires prior authorization with documentation of diagnosis; prescription must be by or in consultation with a hematologist/oncologist. Coverage duration: 5 years.

• Required documentation: diagnosis
• Prescriber restriction: hematologist/oncologist
• Coverage duration: 5 years

Imbruvica — PA and prescriber restriction

Imbruvica requires prior authorization with documentation of diagnosis; prescription must be written by an oncologist, hematologist, or transplant specialist. Coverage duration: 1 year.

• Required documentation: diagnosis
• Prescriber restriction: oncologist, hematologist, or transplant specialist
• Coverage duration: 1 year

BONSITY — required documentation and exclusion

For BONSITY prior authorization submit diagnosis, fracture history, prior therapy and response, and required pretreatment testing (DXA and labs). Prescriber must be an endocrinologist; BONSITY is not approved for combination therapy with other osteoporosis agents.

• Required: diagnosis, fracture history, prior therapy and response
• Pretreatment testing: DXA (if not in 2 years), serum calcium, phosphorus, creatinine, alkaline phosphatase, albumin, 25‑OH D, 24‑hour urine calcium/creatinine or fasting ratio
• Prescriber restriction: endocrinologist
• Combination therapy exclusion applies

Diacomit — PA and exclusion note

Diacomit requires prior authorization; note that the policy states there is no clinical data to support use of Diacomit alone to treat Dravet syndrome (exclusion noted).

• PA required
• Exclusion note: Diacomit alone for Dravet syndrome lacks supporting clinical data