Priority Health Medicare Prior Auth

Medication Coverage Criteria

Fasenra Initial Therapy

Before Fasenra is covered, the patient must meet all applicable criteria below.

ONE of the following indications

Severe eosinophilic asthma
- Eosinophilic asthma confirmed by a peripheral blood eosinophil count greater than 150 cells/mcL in the past 12 months.
- Patient has tried one inhaled corticosteroid (ICS) and one additional asthma controller medication, such as a long-acting beta agonist, long-acting anti-muscarinic agent, or leukotriene receptor antagonist.
- Patient has had at least one asthma exacerbation in the previous year.
Eosinophilic granulomatosis with polyangiitis (EGPA or Churg-Strauss)
- Diagnosis of EGPA confirmed by a peripheral blood eosinophil count greater than 1,000 cells/mcL or at least 10% of leukocytes.
- Patient has tried one systemic corticosteroid or one immunosuppressive therapy.
Hypereosinophilic syndrome (HES)
- Diagnosis of HES without an identifiable secondary non-hematologic cause.
- Disease activity
  - Patient has had at least two HES flares in the last 12 months, defined as signs or symptoms of HES requiring an increase in steroid dosing or addition of another therapy.
  - Blood eosinophil count is at least 1,000 cells/mcL.
- Patient is stable on standard HES therapy, including steroid therapy such as prednisone or other immunosuppressive therapies such as methotrexate or hydroxyurea.

Fasenra Continuation Therapy

For continuation of Fasenra coverage, the patient must demonstrate a positive clinical response for the applicable indication.

ONE of the following response criteria

For severe eosinophilic asthma: positive clinical response, such as decreased exacerbation frequency, improved asthma symptoms, or decreased oral corticosteroid use.
For eosinophilic granulomatosis with polyangiitis (EGPA or Churg-Strauss): positive clinical response, with a Birmingham Vasculitis Activity Score (BVAS) of 0 and prednisolone or prednisone dose less than or equal to 4 mg/day.
For hypereosinophilic syndrome (HES): positive clinical response, documented by decreased exacerbation frequency and/or decreased oral corticosteroid use and improvement in HES symptoms.

Eohilia Continuation Therapy

For continuation of Eohilia coverage, documentation must support ongoing clinical appropriateness and response to therapy.

ALL of the following

Continuation is within the 12-week approval duration.
Failure is defined as the inability to achieve and maintain remission of low or mild disease activity.

Fentanyl Citrate Lozenge Initial Therapy

Before fentanyl citrate lozenge is covered, the patient must meet all of the following requirements:

ALL of the following

Patient is at least 16 years of age.
Fentanyl citrate lozenge will be used to manage breakthrough pain in a patient with cancer.
Patient is receiving and tolerant to around-the-clock opioid therapy for persistent cancer pain.

Filsuvez Initial Therapy

Before Filsuvez is covered, the patient must meet all of the following requirements:

ALL of the following

Diagnosis of recessive dystrophic epidermolysis bullosa (RDEB), with documentation of genetic testing confirming mutation(s).
Patient has open, partial-thickness skin wounds.
Application is limited to open, partial-thickness skin wounds during dressing changes.
Prescriber is a specialist or has consulted with a specialist for the condition being treated.

Filsuvez Continuation Therapy

For continuation of Filsuvez coverage, the patient must demonstrate clinical benefit from treatment.

At least one documented clinical benefit

Complete wound closure.
Decrease in wound size.
Reduced body surface area affected by wounds.
Increase in granulation tissue.
Decrease in pain.
Decrease in infection.

Fintepla Initial Therapy

Before Fintepla is covered, the patient must meet all of the following requirements:

ALL of the following

Patient has a diagnosis of seizures associated with Lennox-Gastaut syndrome or Dravet syndrome, with supporting documentation submitted to Priority Health.
Patient is at least 2 years of age.
Patient has tried and failed two of the following drugs, alone or in combination: clobazam, valproate/divalproex, or topiramate.
Dravet syndrome only
- Patient has tried and failed Diacomit (stiripentol).
- Patient has a contraindication to Diacomit (stiripentol).

Initial Authorization Criteria

Evrysdi continuation therapy

Continuation requires documented maintenance or improvement.

Repeat validated motor-function assessment shows improvement or stability; HINE shows more improved than worsened motor-milestone categories when used; and members over age 2 show clinically significant improvement compared with predicted natural history.

Continuation Authorization Criteria

Continuation criteria by medication

Continuation criteria are grouped below by medication or medication class.

Accrufer: Improvement from baseline, including tolerance or hemoglobin/ferritin improvement.

Adbry: Positive clinical response in body-surface area, pruritus/flares, or activities of daily living.

Migraine: >50% reduction in monthly migraine days.

Emgality cluster headache: Significant decrease in cluster-headache frequency/intensity and current cluster period.

Preferred Products and Prerequisite Therapy

Product or indication	Required prior therapy	Trial or failure standard
General step therapy rule	Preferred or plan-covered prerequisite medication	Document therapeutic failure, intolerance, or contraindication; nonformulary and nonpreferred drugs do not satisfy the requirement.
Accrufer	Two different generic oral iron therapies	Inadequate response. If intolerance is cited, attempt every-other-day dosing and dietary or lifestyle tolerability strategies first.
Adalimumab — Crohn’s disease	Adequate conventional therapy, such as steroids or an immunomodulator such as azathioprine	Failure, intolerance, or contraindication; steroids generally for 7 days or azathioprine for at least 2 months.
Adalimumab — ulcerative colitis	Adequate conventional therapy and listed preferred adalimumab alternatives	Failure, intolerance, or contraindication to conventional therapy and the listed alternatives.
Adalimumab — uveitis or hidradenitis suppurativa	At least one other agent	Tried and failed or otherwise not tolerated or contraindicated.
Adalimumab — plaque psoriasis, psoriatic arthritis, or rheumatoid arthritis	One traditional non-biologic systemic agent	Trial for at least 3 months.
Adalimumab — juvenile idiopathic arthritis	At least one other agent; alternatively, concurrent methotrexate, sulfasalazine, or leflunomide	Prior therapy must be tried unless the concurrent-treatment or aggressive-disease pathway applies.
Adbry — atopic dermatitis	One medium- to high-potency topical corticosteroid or topical calcineurin inhibitor	Trial for at least 3 months.
PCSK9 inhibitors — nonpreferred products	Preferred Repatha plus an additional statin drug	Trial and failure, intolerance, or contraindication to Repatha and the additional statin; nonpreferred prescribing requires a cardiologist, endocrinologist, or board-certified lipidologist.
Acute migraine — nonpreferred products	Preferred Ubrelvy plus an additional triptan	Trial and failure, intolerance, or contraindication to Ubrelvy and the additional triptan.
Preventive migraine — nonpreferred products	Aimovig, Emgality, and Ajovy	Trial and failure, intolerance, or contraindication to each for 3 continuous months, without adequate migraine reduction.
Preventive migraine — all products	Any two oral preventive classes: antidepressants, beta blockers, or anti-epileptics	Trial of two classes is required before coverage.
Emgality — episodic cluster headache	At least two of injectable or intranasal triptans, oxygen therapy, verapamil, topiramate, or valproate	Tried and failed at least two treatments.
Nonpreferred antiretroviral products	Preferred Sunlenca	Trial and failure, intolerance, or contraindication to the preferred product.
Arikayce — MAC lung disease	Multidrug background regimen, such as clarithromycin or azithromycin, rifampin, and ethambutol	Failure to obtain a negative sputum culture after at least 6 consecutive months.
Besremi	Hydroxyurea and pegylated interferon-alfa 2a	Both therapies must be tried and failed.
Bimzelx — plaque psoriasis	One traditional non-biologic systemic agent plus at least two of adalimumab, Cosentyx, Enbrel, Otezla/XR, or ustekinumab	Traditional agent and each of two specified agents generally require at least 3 months.
Bimzelx — hidradenitis suppurativa	At least one other agent plus at least two of Cosentyx, adalimumab, or infliximab	Each specified biologic generally requires at least 3 months.
Bimzelx — ankylosing spondylitis	At least two of adalimumab, Cosentyx, Enbrel, or Xeljanz/XR	Each agent generally requires at least 3 months.
Bimzelx — non-radiographic axial spondyloarthritis	Cimzia or Cosentyx	Try at least two agents for at least 3 months each and document objective inflammation.
Bimzelx — psoriatic arthritis	One traditional non-biologic systemic agent plus at least two specified biologic or targeted agents	Traditional agent and each of two specified agents generally require at least 3 months.
Cardiac myosin inhibitors	One beta blocker and one calcium channel blocker, such as metoprolol and verapamil or diltiazem	Trial and failure for at least 30 days, intolerance, or contraindication for both classes.
Cayston	Aztreonam-only susceptibility or qualifying prior tobramycin history	Aztreonam must be the only sensitive inhaled antibiotic, or tobramycin must have caused significant adverse effects, unsatisfactory response, contraindication, intolerance, or resistance.
Cibinqo — atopic dermatitis	One qualifying topical therapy plus at least two of Dupixent, Adbry, or Nemluvio	Topical therapy and each biologic must generally be tried for at least 3 months.
Cimzia — ankylosing spondylitis	At least two of adalimumab, Cosentyx, Enbrel, or Xeljanz/XR	Each agent for at least 3 months.
Cimzia — Crohn’s disease	Conventional therapy plus at least one of adalimumab, infliximab, or ustekinumab	Failure, intolerance, or contraindication to conventional therapy; specified biologic for at least 3 months.
Cimzia — juvenile idiopathic arthritis	At least two of adalimumab, Enbrel, tocilizumab, or Xeljanz/XR	Each agent for at least 3 months.
Cimzia — psoriatic arthritis	One traditional non-biologic systemic agent plus at least two of Cosentyx, Enbrel, adalimumab, Xeljanz/XR, Otezla/XR, or ustekinumab	Each required therapy for at least 3 months.
Cimzia — rheumatoid arthritis	One traditional non-biologic systemic agent plus at least two of tocilizumab, Enbrel, adalimumab, or Xeljanz/XR	Each required therapy for at least 3 months.
Cimzia — plaque psoriasis	One traditional non-biologic systemic agent plus at least two of Cosentyx, Enbrel, adalimumab, Otezla/XR, or ustekinumab	Each required therapy for at least 3 months.
Cobenfy	Two atypical antipsychotic drugs	Trial and failure, intolerance, or contraindication after at least 28 days for each drug.
Cosentyx — plaque psoriasis or psoriatic arthritis	One traditional non-biologic systemic agent	Trial for at least 3 months.
Cosentyx — hidradenitis suppurativa	At least one other agent, such as corticosteroids, systemic antibiotics, or isotretinoin	Prior agent must be tried before coverage.
Cresemba	Voriconazole or itraconazole	Trial and failure, intolerance, or contraindication.
Diacomit	Valproate and clobazam; Diacomit is used with clobazam	Trial and failure with both valproate and clobazam.
Droxidopa	Midodrine and fludrocortisone, plus at least two specified nonpharmacologic interventions	Each medication requires at least 30 days of trial and failure, intolerance, or contraindication; nonpharmacologic interventions must also be tried.
Dupixent	Indication-specific topical, inhaled, systemic, dietary, antihistamine, or controller therapy	Complete the applicable prerequisite pathway; duration varies by indication, generally 2 to 3 months where specified.
Enbrel — plaque psoriasis, psoriatic arthritis, or rheumatoid arthritis	Traditional non-biologic systemic agent	Trial generally for at least 3 months.
Enbrel — juvenile idiopathic arthritis	At least one other agent; alternatively, concurrent methotrexate, sulfasalazine, or leflunomide	Prior therapy is not required when the concurrent-treatment or aggressive-disease pathway applies.
Enspryng	Rituximab	Progressive disease during a therapeutic trial of rituximab; trial duration is not specified.
Entyvio — Crohn’s disease	Conventional therapy plus at least two of adalimumab, Cimzia, infliximab, or ustekinumab	Failure, intolerance, or contraindication to conventional therapy; each selected agent for at least 3 months.
Entyvio — ulcerative colitis	Conventional therapy plus at least two of adalimumab, infliximab, Omvoh, Simponi, ustekinumab, or Xeljanz/XR	Failure, intolerance, or contraindication to conventional therapy; each selected agent for at least 3 months.
Eohilia	Dietary modification, one proton pump inhibitor, and one topical corticosteroid	Failure of dietary modification; medication trials for at least 2 months each.
Epidiolex	At least two generic anticonvulsants	Trial and failure, intolerance, or contraindication to at least two agents.
Fasenra — severe eosinophilic asthma	One inhaled corticosteroid plus one additional asthma controller	Required prior treatment must be tried before coverage.
Fasenra — EGPA	One systemic corticosteroid or one immunosuppressive therapy	Required prior treatment must be tried before coverage.
Fintepla	Two of clobazam, valproate/divalproex, or topiramate; Diacomit for Dravet syndrome	Failure of two specified antiseizure drugs; for Dravet syndrome, failure or contraindication to Diacomit is also required.

Prior Authorization, Documentation, and Denial Risks

Prior Authorization

Submit the correct prior authorization request

Use the Approved Drug List to determine whether the requested medication requires prior authorization. When required, submit the applicable Pharmacy Prior Authorization form, Oncology Pharmacy Drug Request form, or electronic prior authorization request with the clinical information supporting the requested medication and indication.

Prior authorization may also apply when use exceeds an established coverage limit on the Approved Drug List.
For products addressed in the pharmacy criteria, complete the Employer Group & MyPriority Plans Pharmacy (NonOncology) drug request form or submit an ePA.
Non-preferred long-acting opioids require prior authorization and may also be subject to quantity limits, step therapy, and other utilization-management requirements.

Step Therapy

Document prerequisite treatment history

Document the required therapeutic failure, intolerance, or contraindication to the preferred medication before requesting a product subject to step therapy. Prerequisite trials must involve drugs covered or preferred by the plan; nonformulary and nonpreferred drugs do not satisfy the step requirement.

Clinical Thresholds and Approved Codes

Approved ICD-10 codes for cystic fibrosisICD-10Covered

E84.0	Cystic fibrosis with pulmonary manifestations
E84.11	Cystic fibrosis with meconium ileus
E84.19	Cystic fibrosis with other intestinal manifestations
E84.8	Cystic fibrosis with other manifestations
E84.9	Cystic fibrosis, unspecified

Clinical Thresholds and Response Measures

Opioid dose exception thresholdMore than 120 MEqD per day

Migraine continuation responseMore than 50% reduction in monthly migraine days

Benlysta active SLE continuationAt least 3 of 6 response requirements

Benlysta lupus nephritis continuationUrinary protein-creatinine ratio no greater than 0.7; eGFR no greater than 20% below pre-flare or at least 60 mL/min/1.73m2

Cardiac myosin inhibitor ventricular functionLeft ventricular ejection fraction of at least 55%

Cardiac myosin inhibitor continuation responsepVO2 improvement of at least 1.5 mL/kg/min plus at least one NYHA class reduction, or at least 3 mL/kg/min with stable NYHA class

Quantity, Dose, and Authorization Limits

Quantity Limits and Duration Rules

Opioid medications120 MEqD per day

ActharUp to 75 units/m2 twice daily for two weeks, followed by a tapering schedule for an additional two weeks

Vyepti100 mg every 3 months for initial dosing; one-time authorization for 300 mg may be made for patients unresponsive to 100 mg

CabliviInitial: 31 vials per 30 days; continuation: 28 vials per 28 days

CaystonUse for 28 days followed by 28 days off

Cobenfy12-month approval duration

Fentanyl citrate lozenge120 lozenges per 30 days

Prescriber and Administration Requirements

Note

Obtain cardiologist involvement

Ensure that the cardiac myosin inhibitor is prescribed by or used in consultation with a cardiologist. The request must also document symptomatic NYHA class II or III obstructive hypertrophic cardiomyopathy, age 18 or older, left ventricular ejection fraction of at least 55%, and the required beta-blocker and calcium-channel-blocker treatment history.

Document trial and failure for at least 30 days, intolerance, or contraindication to both medication classes.
Examples include metoprolol for the beta blocker and verapamil or diltiazem for the calcium channel blocker.

Documentation Required

Submit specialist documentation for Cayston continuation

For Cayston continuation, provide documentation from a pulmonologist or cystic fibrosis specialist showing that treatment of Pseudomonas aeruginosa infection remains necessary and that the patient has stabilized or improved.

Document the ongoing need for treatment.

Policy Definitions

Key Definitions

Prior authorizationA utilization management process requiring specified criteria to be met before a medication is covered; it may also apply when use exceeds established coverage limits on the Approved Drug List.

Drug failureA lack of adequate therapeutic response when the medication was used appropriately, consistently with its labeling and applicable drug compendia or guidelines, with adherence and for an adequate assessment period.

High-intensity statinAtorvastatin at least 40 mg daily or rosuvastatin at least 20 mg daily.

No viable antiretroviral combination therapyDocumented resistance to two or more agents from three of the four main antiretroviral classes: nucleoside reverse transcriptase inhibitors, non-nucleoside reverse transcriptase inhibitors, protease inhibitors, and integrase strand-transfer inhibitors.

Active autoantibody-positive SLESystemic lupus erythematosus with autoantibody positivity and active disease demonstrated by a SELENA-SLEDAI score greater than 6 while receiving standard therapy.

Policy Background

This pharmacy medication prior authorization manual establishes coverage requirements for medications under Priority Health pharmacy benefits. Requirements may include prior authorization, step therapy, quantity limits, documentation for nonstandard uses, and evidence of clinical benefit for continuation. Coverage is subject to the member’s prescription drug plan and should be reviewed with the Approved Drug List and applicable request forms.

Preferred Adalimumab Agents

Billing Rule

Select a preferred adalimumab biosimilar

Use a preferred adalimumab biosimilar when selecting therapy under this policy. The listed preferred agents are adalimumab-adaz, adalimumab-adbm, adalimumab-bwwd (Hadlima), adalimumab-ryvk (Simlandi), and adalimumab-aaty.

Adalimumab-adaz — unbranded by Sandoz
Adalimumab-adbm — unbranded by Boehringer Ingelheim
Adalimumab-bwwd (Hadlima) — by Organon
Adalimumab-ryvk (Simlandi) — by Teva
Adalimumab-aaty — unbranded by Celltrion

Priority Plans Pharmacy Drug Prior Authorization Criteria

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Priority Plans Pharmacy Drug Prior Authorization Criteria

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Medication Coverage Criteria

Initial Authorization Criteria

Continuation Authorization Criteria

Preferred Products and Prerequisite Therapy

Prior Authorization, Documentation, and Denial Risks

Clinical Thresholds and Approved Codes

Quantity, Dose, and Authorization Limits

Prescriber and Administration Requirements

Policy Definitions

Policy Background

Preferred Adalimumab Agents