Prior authorization required for specified pediatric age groups

Prior authorization is required for codeine-, tramadol-, and hydrocodone-containing medications in the specified pediatric age groups due to FDA labeling: codeine-containing medications for pain are contraindicated in pediatric patients younger than 12 years and in patients <18 years for post-tonsillectomy/post-adenoidectomy pain; tramadol-containing medications are not indicated for pain in patients <18 years (contraindicated <12 years and <18 years for post-tonsillectomy/post-adenoidectomy); and codeine- and hydrocodone-containing cough products are not indicated in pediatric patients <18 years.

Approval duration rules by indication

Approval durations vary by indication: approvals for non-cancer pain are limited to 7 days, while approvals for cancer, sickle cell disease, or palliative care are granted for 12 months.

Use age/weight dosing guidance when requesting an override

Age- and weight-based dosing regimens and dose limits are provided in the policy as therapeutic-alternative guidance and may be used to support an override request; providers should reference those dosing tables when proposing dose-based justification.

Step therapy: failure of ≥2 non-opioid agents required

For pain, prior authorization requires documented failure of at least two non-opioid ancillary treatments at up to maximally indicated doses unless clinically significant adverse effects or contraindications exist; for cough, failure of at least two agents (dextromethorphan, benzonatate, guaifenesin) at maximally indicated doses is required unless contraindicated.

• Pain examples: NSAIDs, acetaminophen, anticonvulsants, antidepressants at maximally indicated doses
• Cough examples: dextromethorphan, benzonatate, guaifenesin at maximally indicated doses

Step therapy redirection and state-specific bypasses

Step therapy redirection/bypass exceptions apply where state regulations prohibit step therapy in certain oncology settings (see Appendix D); additionally, Illinois HIM requests are exempt from the step therapy requirements effective 1/1/2026 per IL HB 5395.

• See Appendix D for the list of states and specific cancer-stage notes
• IL HIM bypass per IL HB 5395 (effective 1/1/2026)

Required clinical documentation for prior authorization

Providers must submit clinical documentation (such as office chart notes, laboratory results, or other clinical information) demonstrating that the member has met all approval criteria.

• Include documentation of failed therapies, dosing history, and clinician specialty consults when applicable

Ensure documentation aligns with product labeling

Refer to the respective package inserts for dosing and administration; any documentation submitted to support a request should align with the product labeling.

Triggers for denial if approval criteria are unmet

Requests that do not meet the listed approval criteria will be denied — examples include lack of required prior therapies, doses exceeding the health plan's approved quantity limit, non‑FDA indications without off-label documentation, and use for post-tonsillectomy/post-adenoidectomy pain.

• Failure to document ≥2 failed non-opioid agents (pain) or ≥2 failed cough agents (cough)
• Requests that exceed the plan's approved quantity limits
• Non‑FDA indications without appropriate off-label justification per referenced off-label policies

High-risk pediatric/postoperative uses flagged as non-authorized

Use in high‑risk pediatric and postoperative populations is contraindicated and will be considered not authorized: children younger than 12 years (codeine/tramadol contraindications) and postoperative management in children younger than 18 years following tonsillectomy and/or adenoidectomy are expressly flagged as non-authorized.

• Children <12 years: contraindicated for codeine and tramadol
• Post-tonsillectomy/post-adenoidectomy in patients <18 years: not authorized