Prior authorization required for AAT augmentation products

Prior authorization is required for ARALAST NP, GLASSIA, PROLASTIN‑C, and ZEMAIRA; the prescription must be written by a pulmonologist and include documentation of diagnosis of severe congenital A1‑PI deficiency with clinically evident emphysema, patient weight, A1‑PI phenotype, and baseline A1‑PI level. Coverage is authorized for 1 year.

• Prescriber must be a pulmonologist.
• Include diagnosis, weight, A1‑PI phenotype, and baseline A1‑PI level.

Prescriber must be a pulmonologist

The prescriber must be a pulmonologist for AAT augmentation product requests; prescriptions from other specialties risk denial for failure to meet the prescriber restriction.

Firdapse prior authorization and diagnostic confirmation

Firdapse (amifampridine) requires prior authorization and must be prescribed by a neurologist; submit electrodiagnostic testing (repetitive nerve stimulation) and anti‑P/Q‑type VGCC antibody testing to confirm Lambert‑Eaton diagnosis. Coverage is for 1 year.

• Prescriber must be a neurologist.
• Provide electrodiagnostic studies and anti‑P/Q‑type VGCC antibody testing.

ARIKAYCE — submit sputum culture and prior multidrug therapy documentation

For ARIKAYCE prior authorization, submit medical records including sputum culture confirming Mycobacterium avium complex (MAC) lung disease and documentation of failure to obtain negative sputum cultures after ≥6 months of a multidrug background regimen.

• Prescriber must be or consult with an infectious disease specialist or pulmonologist.
• Include sputum culture results and ≥6 months of prior multidrug therapy documentation.

ATTRUBY prescriber restriction and required diagnostic confirmation

ATTRUBY requires prior authorization and the prescription must be written by a cardiologist; include confirmation of diagnosis with appropriate testing. Coverage is for 1 year.

• Prescription must be written by a cardiologist.
• Provide diagnostic confirmation documentation.

Document prior therapy trials when prerequisite therapy is required

Some products in this document require documentation of prior therapy trials (Prerequisite Therapy: Yes); when indicated, prior therapy failure or intolerance must be documented before approval.

• When an entry lists Prerequisite Therapy: Yes, include clinical records showing trials and outcomes of specified prior agents.

Products that indicate no prerequisite therapy

Where the product entry indicates no prerequisite therapy, prior therapy trials are not required for approval but prior authorization criteria and required documentation still apply.

Antidepressant step‑therapy: document two prior antidepressant trials

For listed antidepressants used to treat major depressive disorder, the member must have tried two generic antidepressants from different classes (e.g., SSRIs, SNRIs, TCAs, bupropion) before certain agents will be approved; document the trials and outcomes.

• List the two different generic antidepressants tried and reason for failure/intolerance.
• Include dates and doses of prior trials.

Antipsychotic step‑therapy: document two atypical antipsychotic failures

For listed antipsychotics treating bipolar disorder or schizophrenia, prior authorization requires documentation of treatment failure with two atypical antipsychotics (or rationale why alternatives are unsuitable); include treatment history.

• Document the two atypical antipsychotics tried and reasons for failure.
• Provide diagnosis and treatment timeline.

Document trials of required alternatives per step‑therapy rules

When step therapy is specified, providers must document trial and failure (or contraindication) of the required alternative agents or formulations before requesting the listed product.

• Provide clinical notes showing trials, durations, and outcomes of alternative agents.
• If dosing frequency escalation is requested (e.g., Cosentyx every‑2‑week dosing), document failure of the lower‑frequency regimen.

Oncology products — PA, prescriber restrictions, and diagnostic testing

Prior authorization is required for many oncology agents in this section; prescriptions generally must be written by or in consultation with an oncologist and include diagnosis documentation and any diagnostic testing required (e.g., PDGFRA mutation for GIST, RET fusion testing). Coverage durations are listed per product (commonly 5 years).

• Ensure prescriber specialty matches the product's restriction (oncologist, hematologist, cardiologist, etc.).
• Include disease‑specific diagnostic testing when specified (e.g., PDGFRA D842V, RET fusions).

Examples: BALVERSA and BRAFTOVI — oncologist prescription and diagnosis documentation required

Examples: BALVERSA, BRAFTOVI and similar oncology agents require prior authorization with prescription by an oncologist and are typically authorized for up to 5 years; include documented diagnosis and any specified biomarker testing.

• Confirm prescriber is an oncologist.
• Attach diagnostic reports and biomarker test results.

BENLYSTA Subcutaneous — prescriber restriction and documentation

BENLYSTA Subcutaneous requires prior authorization; prescriber should be a rheumatologist or nephrologist and required documentation includes diagnosis, autoantibody testing, prior therapies and responses. Coverage duration is 3 years.

• Provide autoantibody test results and prior treatment history with outcomes.
• Confirm prescriber specialty (rheumatologist or nephrologist).

BRIVIACT — PA with prerequisite therapy noted

Brivaracetam (BRIVIACT) requires prior authorization with prerequisite therapy noted as 'Yes'; include age‑appropriate information per FDA labeling and documentation of prior therapy trials and response.

• Provide prior anticonvulsant trial history and response.
• Confirm beneficiary age per FDA labeling.

Targeted oncology agents — prescriber and baseline testing requirements

CABOMETYX, CALQUENCE, CAPRELSA and similar targeted agents require prior authorization; ensure the prescriber is or consults with an oncologist and submit required baseline testing where specified (e.g., ECG/electrolytes/TSH for CAPRELSA).

• Attach diagnostic and baseline monitoring tests as listed for each product.
• Confirm oncologist prescriber or consult note.

CINQAIR — prescriber restriction, baseline testing, and administration setting

CINQAIR (reslizumab) requires prior authorization with prescriber restricted to pulmonology or immunology, baseline testing including allergen test and FEV1 measures, and administration must occur in a setting prepared to manage anaphylaxis (self‑administration will not be approved).

• Do not request self‑administration; document plan for supervised administration.
• Provide allergen test, baseline FEV1 and post‑bronchodilator FEV1, asthma history, and baseline eosinophil count.

COBENFY — document diagnosis and treatment history

COBENFY (and COBENFY STARTER PACK) prior authorization requests must include documentation of diagnosis and treatment history; prerequisite therapy is required for some indications and coverage duration is commonly 5 years.

• Include treatment history demonstrating prior trials and outcomes.
• Document beneficiary age per FDA labeling.