CurrentMass General Brigham Health PlanPolicy N/A

Pulmicort Flexhaler (budesonide) prior authorization

Defines prior authorization, quantity limit, and continuation criteria for Pulmicort Flexhaler (budesonide) for maintenance/prophylactic treatment of asthma in members aged 6 years and older covered by Mass General Brigham Health Plan.

Policy Summary

PayerMass General Brigham Health Plan

PolicyPulmicort Flexhaler (budesonide) prior authorization

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2024

Next Review DateN/A

Key ActionObtain prior authorization demonstrating member is ≥6 years old, has maintenance/prophylactic asthma, and has trial/failure or intolerance/contraindication to both Arnuity Ellipta and Qvar.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

>=6minimum covered patient age

12 moapproval duration

prior authcoverage type

requiredstep therapy

Coverage Criteria

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Initial Therapy

Covered when ALL of the following are met

Initial Authorization: Member is >= 6 years of age; Member has a diagnosis of maintenance and prophylactic treatment of asthma; Member has had trial and failure, intolerance, or contraindication to BOTH Arnuity Ellipta and Qvar.

Documentation must be provided.

Continuation of Therapy

Reauthorization when ALL met

Reauthorization: Member achieves or maintains positive clinical response as evidenced by low disease activity or improvement in signs and symptoms.

Approvals granted for 12 months; documentation of clinical response required.

Initial Therapy

Initial therapy

Initial authorization requirements

Initial Authorization: Member is >= 6 years of age; Diagnosis of maintenance/prophylactic asthma; Trial and failure, intolerance, or contraindication to BOTH Arnuity Ellipta and Qvar.

Documentation required.

Continuation / Reauthorization

Continuation

Reauthorization criteria

Reauthorization: Member achieves or maintains positive clinical response evidenced by low disease activity or improvement in signs and symptoms.

Reauthorizations and initial approvals will be granted for 12 months; documentation of clinical response required.

Provider Actions and Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for Pulmicort Flexhaler. Requests may be reviewed for members new to the plan who are currently receiving the medication (excluding samples or manufacturer patient assistance program supplies).

Benefit: Pharmacy benefit; Program type: Prior Authorization
Prior authorization applies to Commercial/Exchange and MassHealth UPPL plans
Authorization review may consider current receipt of treatment outside plan (samples or PAP excluded)

Step Therapy

Step Therapy Requirement

Step therapy requires documentation of trial and failure, intolerance, or contraindication to both preferred inhaled corticosteroid options prior to approval of Pulmicort Flexhaler.

Required trials (both): Arnuity Ellipta and Qvar
Documentation must show trial duration and reason for failure (lack of efficacy), intolerance, or contraindication

Documentation Required

Required Documentation

Providers must supply documentation demonstrating that the member meets all listed criteria for authorization.

Member age (must be 36 years of age)
Diagnosis of maintenance and prophylactic treatment of asthma
Documentation of trials and failures, intolerance, or contraindications to BOTH Arnuity Ellipta and Qvar (including dates, dosing, and clinical rationale)
For members new to the plan currently on therapy, evidence of current treatment (prescription history, medical records) should be provided; samples and manufacturer patient assistance program supplies do not substitute for documentation

Denial Risk

Denial Triggers

Authorization may be denied if documentation does not demonstrate that the member meets all listed criteria.

Denial triggers include: member age < 6 years, lack of documented diagnosis for maintenance/prophylactic asthma, or absence of documented trials/failure/intolerance/contraindication to both Arnuity Ellipta and Qvar
Insufficient clinical detail about prior trials (no dates, doses, or reason for discontinuation) may result in denial

Step	Requirement
1	Member must have trial and failure, intolerance, or contraindication to BOTH Arnuity Ellipta and Qvar prior to approval of Pulmicort Flexhaler.

Definitions

Maintenance/prophylactic asthma — definition and explanation

DefinitionMaintenance/prophylactic asthma: ongoing inhaled corticosteroid therapy to control chronic asthma symptoms and prevent exacerbations.

Indication ageIndicated for patients 6 years of age and older

Therapeutic goalReduce airway inflammation and prevent asthma exacerbations as part of chronic asthma management.

Drug classInhaled corticosteroid (budesonide)

Policy Summary

PayerMass General Brigham Health Plan

PolicyPulmicort Flexhaler (budesonide) prior authorization

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2024

Next Review DateN/A

SourceLink

On This Page

OpenPayer

Pulmicort Flexhaler (budesonide) prior authorization

Coverage Criteria

Initial Therapy

Continuation / Reauthorization

Provider Actions and Requirements

NDC / CPT / HCPCS

Step Therapy Requirements

Quantity Limits

Background

Definitions