Priority Health Medicare Drug Prior Auth

Medication Coverage Criteria

Initial Therapy and Drug-Specific Coverage Criteria

Covered when the applicable drug-specific initial-therapy criteria below are met.

Initial therapy criteria

Opioid quantity and dose-limit exception
- Requests exceeding 120 MEqD (morphine equivalent dose per day) require an opioid treatment agreement; documented chronic pain due to a medical condition; documented taper or taper attempt, or valid rationale why taper was not attempted; routine validated pain/function assessments showing sustained improvement; non-drug therapy tried within 18 months or contraindicated; concurrent non-opioid medication unless contraindicated; documentation supporting safety when opioids are used with benzodiazepines, sedative-hypnotics, barbiturates, or other harmful interacting drugs; and naloxone education.
- Individual drug quantity limits, step therapy, and other utilization management continue to apply. Non-preferred long-acting opioids require prior authorization.
- When approved, opioid treatment may be authorized for the necessary duration, up to 12 months.
Accrufer initial therapy
- Diagnosis of iron deficiency anemia.
- Baseline pre-treatment hemoglobin and ferritin are documented.
- Inadequate response to two different generic oral iron therapies.
Acthar initial therapy
- Diagnosis of infantile spasms.
- Patient is younger than 2 years of age.
Adalimumab Crohn's disease
- Prescriber is a specialist or has consulted a specialist.
- Moderate-to-severe Crohn's disease.
- Adequate conventional therapy, such as steroids for 7 days or an immunomodulator such as azathioprine for at least 2 months, was tried and failed or is contraindicated or not tolerated.
Adalimumab ulcerative colitis
- Moderate-to-severe ulcerative colitis.
- Adequate conventional therapy, such as steroids for 7 days or an immunomodulator such as azathioprine for at least 2 months, was tried and failed or is contraindicated or not tolerated.
Adalimumab autoimmune and inflammatory indications
- For uveitis, the patient tried one other agent, such as periocular, intraocular, or systemic corticosteroids or an immunosuppressive agent.
- For hidradenitis suppurativa, the patient tried at least one other agent, such as corticosteroids, systemic antibiotics, or isotretinoin.
- For plaque psoriasis, the patient tried one traditional non-biologic systemic agent for at least 3 months.
- For psoriatic arthritis, the patient tried one traditional non-biologic systemic agent for at least 3 months.
- For ankylosing spondylitis, no specific induction criterion applies when the general initiation criteria are met.
- For rheumatoid arthritis, the patient tried one traditional non-biologic systemic agent for at least 3 months.
Adalimumab juvenile idiopathic arthritis
- The patient tried at least one other agent, will start adalimumab concurrently with methotrexate, sulfasalazine, or leflunomide, or has aggressive disease as determined by the prescriber.
Adbry initial therapy
- Prescriber is a specialist or has consulted a specialist.
- Moderate-to-severe atopic dermatitis.
- Tried one medium- to high-potency topical corticosteroid for at least 3 months or one topical calcineurin inhibitor for at least 3 months.
PCSK9 inhibitor coverage
- For hypercholesterolemia with or without ASCVD, HoFH, or HeFH, tried high-intensity atorvastatin at least 40 mg daily or rosuvastatin at least 20 mg daily continuously for at least 8 weeks, with LDL-C remaining above goal.
- Not used with another PCSK9 inhibitor, Leqvio, Nexletol, or Nexlizet.
- For a non-preferred product, prescribed by a cardiologist, endocrinologist, or board-certified lipidologist, with trial and failure or intolerance/contraindication to the preferred product and an additional statin.
Acute migraine treatment
- Migraine with or without aura; patient is at least 18 years old; and has tried one triptan, such as sumatriptan, rizatriptan, naratriptan, or zolmitriptan.
- For a non-preferred product, trial and failure or intolerance/contraindication to the preferred product and an additional triptan.
Migraine initial therapy
- Migraine with or without aura and at least four migraine days per month.
- Tried any two of the following: antidepressants, beta blockers, or antiepileptics.
- For non-preferred therapy, trial and failure, intolerance, or contraindication to Aimovig, Emgality, and Ajovy for 3 continuous months each without adequate reduction in migraines.
Emgality cluster headache initial therapy
- Patient is at least 18 years old and has episodic cluster headache.
- Tried and failed at least two of injectable or intranasal triptans, oxygen therapy, verapamil, topiramate, or valproate.
Non-preferred antimigraine therapy
- Trial and failure, intolerance, or contraindication to the preferred product and required additional triptan or preventive therapy, as applicable.
Miscellaneous antiretroviral initial therapy
- Heavily treatment-experienced adult with multidrug-resistant HIV-1; confirmed HIV infection with failure of the current regimen, baseline HIV-1 RNA at least 400 copies/mL, and no viable combination regimen because of documented resistance to at least two agents in three of four major ARV classes.
- Used with an optimized background ARV regimen and resistance testing documents full susceptibility to at least one other ARV.
- Non-preferred products require trial and failure or intolerance/contraindication to the preferred product.
Arcalyst initial therapy
- Diagnosis of CAPS, including FCAS or MWS, in adults or children at least 12 years; DIRA in adults or children weighing at least 10 kg; or recurrent pericarditis in adults or children at least 12 years.
Arikayce initial therapy
- MAC lung disease documented by sputum culture submitted to Priority Health.
- Failure to obtain a negative sputum culture after at least 6 consecutive months of a multidrug regimen, such as clarithromycin or azithromycin, rifampin, and ethambutol.
- Used only as part of a multidrug regimen and prescribed by or in consultation with an infectious-disease specialist.
Benlysta initial therapy
- For active autoantibody-positive SLE: age at least 5 years, ANA at least 1:80 or anti-dsDNA at least 30 IU/mL, and active disease with SELENA-SLEDAI score greater than 6 despite standard therapy for at least 12 weeks.
- For biopsy-proven lupus nephritis class III-V: age at least 5 years, ANA at least 1:80 or anti-dsDNA at least 30 IU/mL, active renal disease requiring standard therapy, and eGFR at least 30 mL/min/1.73m2.
Besremi initial therapy
- High-risk polycythemia vera, age at least 18 years, prescribed by or in consultation with hematology/oncology.
- Trial and failure of hydroxyurea and pegylated interferon-alfa 2a; ECOG 0-2; and eGFR at least 30 mL/min/1.73m2.
Bimzelx general and diagnosis-specific coverage
- Prescriber is a specialist or has consulted a specialist.
- Plaque psoriasis: traditional non-biologic systemic agent for at least 3 months and at least two of adalimumab, Cosentyx, Enbrel, Otezla/XR, or ustekinumab for at least 3 months each.
- Hidradenitis suppurativa: at least one other agent and at least two of Cosentyx, adalimumab, or infliximab for at least 3 months each.
- Ankylosing spondylitis: at least two of adalimumab, Cosentyx, Enbrel, or Xeljanz/XR for at least 3 months each.
- Non-radiographic axial spondyloarthritis: objective inflammation by elevated CRP and/or MRI sacroiliitis, plus at least two of Cimzia or Cosentyx for at least 3 months each.
- Psoriatic arthritis: traditional non-biologic systemic agent for at least 3 months and at least two of adalimumab, Cosentyx, Enbrel, Otezla/XR, ustekinumab, or Xeljanz/XR for at least 3 months each.
Cablivi initial therapy
- Age at least 18 years and diagnosis of acquired TTP with thrombocytopenia and microscopic red-cell fragmentation.
- Administered with plasma exchange and immunosuppressive therapy and continued for 30 days after plasma exchange ends.
Initial cardiac myosin inhibitor therapy
- Symptomatic NYHA class II or III obstructive hypertrophic cardiomyopathy, age at least 18 years, LVEF at least 55%, and prescribed by or in consultation with a cardiologist.
- Trial and failure for at least 30 days, intolerance, or contraindication to both a beta blocker and a calcium-channel blocker.
Initial carglumic acid therapy
- Deficiency of N-acetylglutamate synthase and acute or chronic hyperammonemia.
Initial Cayston therapy
- Cystic fibrosis with appropriate documentation, age at least 7 years, and Pseudomonas aeruginosa confirmed by positive airway culture.
- Aztreonam is the only sensitive inhaled antibiotic, or tobramycin inhalation solution was unsuccessful, not tolerated, contraindicated, or the isolate is resistant.
Cholbam initial therapy
- Bile-acid synthesis disorder due to a single-enzyme defect or peroxisomal disorder; serum VLCFA and baseline liver-function tests submitted.
Cibinqo initial therapy
- Specialist involvement; moderate-to-severe atopic dermatitis; medium/high-potency topical corticosteroid or topical calcineurin inhibitor for at least 3 months; and at least two of Dupixent, Adbry, or Nemluvio for at least 3 months each.
Cimzia initial therapy
- Specialist involvement and diagnosis-specific criteria: ankylosing spondylitis requires at least two of adalimumab, Cosentyx, Enbrel, or Xeljanz/XR; nr-axSpA requires objective inflammation; Crohn's disease requires moderate-to-severe disease, failed or contraindicated conventional therapy, and at least one of adalimumab, infliximab, or ustekinumab; juvenile idiopathic arthritis requires at least two of adalimumab, Enbrel, tocilizumab, or Xeljanz/XR; psoriatic arthritis, rheumatoid arthritis, and plaque psoriasis require the specified traditional systemic agent plus at least two preferred biologic/targeted agents.
Cobenfy initial therapy
- Schizophrenia, age at least 18 years, failed or cannot use two atypical antipsychotics for at least 28 days each, and specialist involvement.
Cosentyx initial therapy
- Specialist involvement; plaque psoriasis or psoriatic arthritis requires a traditional non-biologic systemic agent for at least 3 months; ankylosing spondylitis has no specific induction criterion beyond general criteria; nr-axSpA requires objective inflammation; hidradenitis suppurativa requires at least one other agent.
Crenessity initial therapy
- Genetically confirmed classic CAH due to 21-hydroxylase deficiency; age at least 4 years; stable and compliant glucocorticoid dose for at least 1 month exceeding 13 mg/m2/day hydrocortisone equivalents; inability and medical necessity to lower the dose; and specialist involvement.
Cresemba initial therapy
- Invasive aspergillosis or mucormycosis; failed, intolerant of, or contraindicated to voriconazole or itraconazole; and specialist involvement.
CFTR modulator initial therapy
- Cystic fibrosis documented within the prior 12 months using an approved CF diagnosis code, and the requested formulation matches the FDA-labeled age formulation.
Dalfampridine ER initial therapy
- Multiple sclerosis, age 18-70 years, receiving immunomodulatory therapy unless not indicated, and significant continuous walking impairment despite optimal MS treatment.
- Does not require a wheelchair; can walk 20 meters without resting; baseline T25FW is 8-45 seconds or EDSS is at least 4.5 and less than 7.
Initial therapy for multiple sclerosis walking impairment
- Meets the MS diagnosis, age, treatment, ambulation, T25FW/EDSS, and functional-impairment requirements above.
Initial Daybue therapy
- Classic/typical Rett syndrome with MECP2 mutation; baseline objective severity assessment; in-depth behavioral assessment by an appropriate specialist; age at least 2 years; and specialist involvement.
Initial Diacomit therapy
- Dravet syndrome, age at least 2 years, adjunctive use with clobazam, and failure of valproate and clobazam.
Initial Droxidopa therapy
- Symptomatic neurogenic orthostatic hypotension from primary autonomic failure, dopamine beta-hydroxylase deficiency, or non-diabetic autonomic neuropathy, excluding other causes.
- Tried at least two non-pharmacologic interventions and trial/failure, intolerance, or contraindication to both midodrine and fludrocortisone; specialist involvement.
Dupixent atopic dermatitis
- Moderate-to-severe atopic dermatitis and trial of a medium/high-potency topical corticosteroid or topical calcineurin inhibitor for at least 3 months.
Dupixent moderate-to-severe asthma
- Eosinophilic asthma with eosinophils over 150 cells/mcL in the prior 12 months or daily oral-corticosteroid dependence; ICS plus another controller; and at least one exacerbation in the prior year.
Dupixent CRSwNP
- Used as add-on maintenance treatment for inadequately controlled chronic rhinosinusitis with nasal polyposis.
Dupixent moderate-to-severe COPD
- COPD with FEV1/FVC less than 0.7 and FEV1 30-70%, eosinophils over 300 cells/mcL, symptoms, failure of LABA/LAMA or triple therapy after at least 3 months, continued background therapy, qualifying exacerbation, and current non-smoking status.
Dupixent prurigo nodularis
- Moderate-to-severe disease with WI-NRS at least 7 and at least 20 nodules, after medium/high-potency topical corticosteroid and topical calcineurin inhibitor each for at least 3 months.
Dupixent eosinophilic esophagitis
- Biopsy-confirmed EoE with at least 15 eos/hpf and failure of dietary modification, a proton-pump inhibitor for at least 2 months, and topical corticosteroid for at least 2 months.
Dupixent chronic urticaria
- Age at least 12 years and failure of either two or more H1 antihistamines or one H1 antihistamine plus an H2 antihistamine, oral corticosteroid, or leukotriene modifier.
Dupixent bullous pemphigoid
- Moderate-to-severe disease with BPDAI at least 24 and weekly Peak Pruritus NRS at least 4; failure of medium/high-potency topical corticosteroid, oral corticosteroid, and a traditional non-biologic systemic agent, each for at least 3 months.
Enbrel general initiation
- Prescriber is a specialist or has consulted a specialist for the condition.
Enbrel indication-specific therapy
- Plaque psoriasis, psoriatic arthritis, ankylosing spondylitis, and rheumatoid arthritis require the specified traditional non-biologic systemic agent for at least 3 months; ankylosing spondylitis has no additional specific induction criterion.
- Juvenile idiopathic arthritis requires one other agent, concurrent methotrexate/sulfasalazine/leflunomide, or aggressive disease.
Enbrel initial therapy
- General and diagnosis-specific Enbrel criteria are met.
Enspryng initial therapy
- NMOSD documented, AQP4 antibody positive, at least one attack requiring rescue therapy in the prior year or two in the prior 2 years, specialist neurologist involvement, progressive disease on a rituximab trial, and EDSS no greater than 7.
Entyvio SC initial therapy
- Specialist involvement; moderate-to-severe Crohn's disease or ulcerative colitis; failed or contraindicated conventional therapy; and failed at least two specified biologic/targeted agents for the applicable indication.
Eohilia initial therapy
- Biopsy-confirmed EoE with at least 15 eos/hpf; failure of dietary modification, PPI for at least 2 months, and topical corticosteroid for at least 2 months; age at least 1 year; and gastroenterologist or allergist involvement.
Epidiolex initial therapy
- Lennox-Gastaut syndrome, Dravet syndrome, or tuberous sclerosis complex; adjunctive seizure treatment; age at least 1 year; and failure, intolerance, or contraindication to at least two generic anticonvulsants.
Evrysdi initial therapy
- SMA diagnosed by genetic testing with biallelic SMN1 mutations, no more than two SMN2 copies or symptoms before 6 months, symptomatic but not advanced disease, baseline validated motor assessment, and prescription by or consultation with an SMA-experienced neurologist.
Fasenra initial therapy
- Severe eosinophilic asthma with eosinophils over 150 cells/mcL, ICS plus another controller, and an exacerbation in the prior year.
- EGPA with eosinophils over 1,000 cells/mcL or at least 10% and trial of systemic corticosteroid or immunosuppressive therapy.
- HES without an identifiable secondary non-hematologic cause, at least two flares in 12 months or eosinophils at least 1,000 cells/mcL, and stable standard therapy.
Fentanyl citrate lozenge initial therapy
- Age at least 16 years; breakthrough cancer pain; and tolerance of around-the-clock opioid therapy for persistent cancer pain.
- Quantity limited to 120 lozenges per 30 days; quantity-limit exception requires the designated request form.
Filsuvez initial therapy
- Recessive dystrophic epidermolysis bullosa with genetic confirmation, open partial-thickness wounds, application only to such wounds during dressing changes, and specialist involvement.
Fintepla initial therapy
- Seizures associated with Lennox-Gastaut or Dravet syndrome, age at least 2 years, failed two of clobazam, valproate/divalproex, or topiramate, and failed or contraindicated to Diacomit for Dravet syndrome.
Firdapse initial therapy
- LEMS confirmed by qualifying electrodiagnostic findings and positive anti-P/Q-type VGCC antibody; symptomatic proximal lower-extremity weakness interfering with daily activities; ambulatory; baseline QMG or 3TUG score; adults failed pyridostigmine; and associated cancer appropriately treated before therapy.

Continuation Therapy

Continuation coverage requires the applicable response, adherence, safety, and monitoring criteria below.

Continuation therapy criteria

Accrufer continuation therapy
- Documentation of improvement from baseline, such as improved tolerance or increased hemoglobin and ferritin.
Adbry continuation therapy
- Positive clinical response, such as reduced BSA, pruritus, flares, or improved activities of daily living.
- Approval duration is 12 months.
Migraine continuation therapy

Exclusions, Non-Covered Combinations, and Operational Restrictions

The following exclusions, non-covered combinations, unsupported-use restrictions, and operational limits apply in addition to the applicable criteria.

Exclusions and denial-risk criteria

Acthar is not medically necessary for corticosteroid-responsive acute MS exacerbations; rheumatic disorders including psoriatic or rheumatoid arthritis and ankylosing spondylitis; collagen diseases including SLE and dermatomyositis; severe erythema multiforme or Stevens-Johnson syndrome; serum sickness; listed ophthalmic inflammatory diseases; symptomatic sarcoidosis; or edematous states. Acthar approval is 1 month, up to 75 units/m2 twice daily for 2 weeks followed by taper.
Adalimumab, Arcalyst, Bimzelx, Cimzia, Cosentyx, Enbrel, and other specified biologic therapies are not covered in combination with another biologic. Unlisted diagnoses, doses, intervals, or indications require case-by-case rationale and pertinent clinical information.
Adbry, Cibinqo, Dupixent, Fasenra, and similar biologics are not covered in combination with other biologic therapy; Dupixent is also not covered with Rhapsido or Ohtuvayre, and Fasenra is not covered with another biologic.

Prior Authorization and Documentation Requirements

Prior Authorization

Request Authorization and Submit Complete Documentation

Use the Approved Drug List (ADL) to determine whether a medication requires prior authorization. Submit the applicable Pharmacy Prior Authorization form (for retail pharmacy drugs), Oncology Pharmacy Drug Request form (for oncology drugs under the pharmacy or medical benefit), or electronic prior authorization (ePA); use the Opioid Quantity/Dose Limit exception form for opioid exceptions. Requests for formulary exceptions, quantity-limit exceptions, age-limit exceptions, or other ADL limitations must include the applicable exception rationale and supporting clinical information.

General request: Submit the diagnosis, requested drug/product, dose, route, quantity, duration, treatment history, relevant laboratory or diagnostic results, response or failure documentation, and prescriber/specialist information.
Off-label or unlisted indication, dose, or route: Provide rationale, all pertinent patient information, and two published peer-reviewed literature articles supporting the requested use. FDA-approved indications, dosing, and routes, or uses recognized in CMS-accepted compendia, do not require this literature exception package.
Step therapy: Document a therapeutic trial and failure, intolerance, or contraindication to each required preferred or prerequisite drug. Trials must involve drugs covered or preferred by the plan; nonformulary and nonpreferred products do not satisfy a preferred-drug prerequisite.
Continuation: Coverage may be discontinued for noncompliance, absence of demonstrable clinically significant improvement, or failure to continue meeting initial criteria. Submit adherence and objective response documentation at renewal.

Preferred Product and Treatment Sequencing

Medication or indication	Step	Required prior therapy	Duration or failure requirement
Accrufer — iron deficiency anemia	1	Two different generic oral iron therapies	Inadequate response; if intolerant, attempt every-other-day dosing and lifestyle or dietary strategies to improve tolerability
Adalimumab — Crohn’s disease	1	Adequate conventional therapy, such as steroids or immunomodulators such as azathioprine	Steroids for 7 days or immunomodulators for at least 2 months; failure, intolerance, or contraindication required
Adalimumab — plaque psoriasis, psoriatic arthritis, or rheumatoid arthritis	1	One traditional non-biologic systemic agent	At least 3 months; failure or required treatment history must be documented
Adalimumab — uveitis or hidradenitis suppurativa	1	One other agent for the condition	Prior trial required; duration not specified
Adalimumab — juvenile idiopathic arthritis	1	One other agent; or concurrent methotrexate, sulfasalazine, or leflunomide; or physician-determined aggressive disease	One prior agent where applicable; alternative pathways may apply
Adbry — atopic dermatitis	1	One medium- to high-potency topical corticosteroid or one topical calcineurin inhibitor (tacrolimus or pimecrolimus)	At least 3 months
PCSK9 inhibitor	1	One high-intensity statin, such as atorvastatin or rosuvastatin	Atorvastatin at least 40 mg daily or rosuvastatin at least 20 mg daily for at least 8 continuous weeks; LDL-C remains above goal
Non-preferred PCSK9 inhibitor	2	Preferred Repatha and an additional statin drug	Trial and failure, intolerance, or contraindication; specialist prescriber required
Acute migraine therapy	1	One triptan drug	Prior trial required
Non-preferred acute migraine product	2	Preferred Ubrelvy and an additional triptan drug	Trial and failure, intolerance, or contraindication to Ubrelvy; additional triptan trial required
Non-preferred preventive antimigraine product	1	Aimovig, Emgality, and Ajovy	Each for 3 continuous months without adequate migraine reduction; failure, intolerance, or contraindication required
Non-preferred miscellaneous antiretroviral product	1	Preferred Sunlenca	Trial and failure, intolerance, or contraindication required
Arikayce — MAC lung disease	1	Multidrug background regimen, such as clarithromycin or azithromycin, rifampin, and ethambutol	At least 6 consecutive months with failure to obtain a negative sputum culture
Benlysta — active SLE	1	Standard therapy, such as corticosteroids, immunosuppressants, or hydroxychloroquine	At least 12 weeks; active SLE remains demonstrated despite therapy
Besremi — high-risk polycythemia vera	1	Hydroxyurea and pegylated interferon-alfa 2a	Trial and failure of both required
Bimzelx — plaque psoriasis	1	One traditional non-biologic systemic agent and at least two of adalimumab, Cosentyx, Enbrel, Otezla/XR, or ustekinumab	Systemic agent and each listed advanced agent for at least 3 months
Bimzelx — hidradenitis suppurativa	1	One other agent and at least two of Cosentyx, adalimumab, or infliximab	Each listed advanced agent for at least 3 months
Bimzelx — ankylosing spondylitis	1	At least two of adalimumab, Cosentyx, Enbrel, or Xeljanz/XR	Each for at least 3 months
Bimzelx — non-radiographic axial spondyloarthritis	1	At least two of Cimzia or Cosentyx	Each for at least 3 months; objective inflammation also required
Bimzelx — psoriatic arthritis	1	One traditional non-biologic systemic agent and at least two of adalimumab, Cosentyx, Enbrel, Otezla/XR, ustekinumab, or Xeljanz/XR	Systemic agent and each listed advanced agent for at least 3 months
Camzyos or Myqorzo	1	Beta blocker and calcium channel blocker	At least 30 days; trial and failure, intolerance, or contraindication to both
Cayston	1	Tobramycin inhalation solution, unless aztreonam is the only sensitive inhaled antibiotic	Qualifying adverse reaction, unsatisfactory response, contraindication, intolerance, or tobramycin resistance required
Cibinqo — atopic dermatitis	1	One topical corticosteroid or calcineurin inhibitor, and at least two of Dupixent, Adbry, or Nemluvio	Topical therapy for at least 3 months; each advanced therapy for at least 3 months
Cimzia — ankylosing spondylitis or juvenile idiopathic arthritis	1	At least two indication-specific agents	Each for at least 3 months
Cimzia — Crohn’s disease	1	Conventional therapy plus at least one of adalimumab, infliximab, or ustekinumab	Conventional therapy failure, intolerance, or contraindication; biologic for at least 3 months
Cimzia — psoriatic arthritis, rheumatoid arthritis, or plaque psoriasis	2	Required conventional systemic therapy and the specified number of biologic or targeted agents	Generally at least 3 months per agent; failure, intolerance, or contraindication where specified
Cosentyx — plaque psoriasis or psoriatic arthritis	1	One traditional non-biologic systemic agent	At least 3 months
Cosentyx — hidradenitis suppurativa	1	At least one other agent, such as corticosteroids, systemic antibiotics, or isotretinoin	Prior treatment trial required; duration not specified
Cobenfy	1	Two atypical antipsychotic drugs	Each used for at least 28 days with failure, intolerance, or contraindication
Cresemba	1	Voriconazole or itraconazole	Trial and failure, intolerance, or contraindication required
Diacomit — Dravet syndrome	1	Valproate and clobazam; Diacomit used with clobazam	Trial and failure of valproate and clobazam required
Droxidopa	1	At least two non-pharmacologic interventions	Prior interventions required; medication step also required
Droxidopa	1	Midodrine and fludrocortisone	Each for at least 30 days with failure, intolerance, or contraindication
Dupixent — COPD	1	LABA/LAMA or triple therapy containing LABA/LAMA/ICS	Try and fail after at least 3 months of consistent use; continue background therapy with Dupixent
Enbrel — plaque psoriasis, psoriatic arthritis, or rheumatoid arthritis	1	One traditional non-biologic systemic agent	At least 3 months
Enbrel — juvenile idiopathic arthritis	1	One other agent; or concurrent methotrexate, sulfasalazine, or leflunomide; or aggressive disease	Alternative pathways may apply; duration not specified
Entyvio — Crohn disease or ulcerative colitis	1	Adequate conventional therapy plus at least two listed biologic or targeted therapies	Conventional therapy failure, intolerance, or contraindication; each prior listed therapy for at least 3 months
Eohilia	1	Dietary modification, one proton pump inhibitor, and one topical corticosteroid	PPI and topical corticosteroid each for at least 2 months; failure required
Epidiolex	1	At least two generic anticonvulsants	Trial and failure, intolerance, or contraindication required
Fasenra — severe eosinophilic asthma	1	One inhaled corticosteroid and one additional asthma controller	Prior trials required; at least one exacerbation in the previous year
Fasenra — EGPA	1	One systemic corticosteroid or one immunosuppressive therapy	Prior trial required
Fintepla	1	Two of clobazam, valproate/divalproex, or topiramate; Diacomit for Dravet syndrome	Failure of two antiseizure drugs; failure or contraindication to Diacomit for Dravet syndrome
Firdapse — adults	1	Pyridostigmine	Failure after use as prescribed at an appropriate dose

Quantity, Dose, and Treatment Duration Limits

Quantity and Dosing Limits

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

VyeptiInitial dosing of 100 mg every 3 months; one-time authorization for 300 mg may be made for patients unresponsive to 100 mg and assessed for incremental efficacy

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

CaystonUse for 28 days followed by 28 days off treatment

Fentanyl citrate lozenge (generic Actiq)120 lozenges per 30 days

Coding and Reference Codes

Referenced diagnosis codingICD-10

ICD-10

Cystic fibrosis diagnosis code; the specific code is not provided in the document.

Approved cystic fibrosis ICD-10 codesICD-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 Operational Criteria

Opioid exception thresholdRequests exceeding 120 MEqD per day require an exception review; approved treatment may be authorized for up to 12 months

Acute migraine minimum ageAt least 18 years, with a trial of one triptan drug

Migraine frequency for preventive therapyAt least 4 migraine days per month

Migraine continuation responseMore than 50% reduction in monthly migraine days

Baseline HIV-1 RNAAt least 400 copies/mL

Benlysta active SLE responseMeet at least 3 of 6 continuation response requirements

Benlysta lupus nephritis renal function

Site-of-Care and Administration Rules

Billing Rule

Follow Entyvio site-of-care rules

For Crohn disease or ulcerative colitis, Entyvio induction consists of two IV doses covered under the medical benefit at weeks 0 and 2. After induction, maintenance may continue as IV dosing under the medical benefit or use subcutaneous pens under the pharmacy benefit.

Initial induction: IV doses at week 0 and week 2 in an infusion-center setting.
Maintenance: continued IV dosing under the medical benefit or subcutaneous Entyvio pens under the pharmacy benefit.

Definitions and Abbreviations

ASCVDAtherosclerotic cardiovascular disease.

Multidrug-resistant HIV-1 infectionDocumented resistance to two or more agents from three of the four main antiretroviral classes.

CAPSCryopyrin-Associated Periodic Syndromes, including Familial Cold Autoinflammatory Syndrome and Muckle-Wells Syndrome.

SELENA-SLEDAISafety of Estrogens in Lupus National Assessment-Systemic Lupus Erythematosus Disease Activity Index.

T25FWTimed 25-foot walk test used to assess walking speed and impairment.

Eosinophilic esophagitis confirmationBiopsy showing at least 15 intraepithelial eosinophils per high-power field.

LEMS

Policy Background

This manual establishes prior authorization requirements for pharmacy medications covered under Priority Health benefits. Authorization may be required when specified clinical criteria must be met before coverage, or when a request exceeds coverage limits listed on the plan’s Approved Drug List (ADL).

Use this manual with the member’s plan-specific Approved Drug List and the applicable pharmacy or oncology drug request form. Requirements may include coverage criteria, quantity-limit exceptions, step therapy, and continuation requirements; coverage may be discontinued if the member is noncompliant, does not show clinically significant improvement, or no longer meets the initial criteria.

Preferred Adalimumab Biosimilars

Billing Rule

Use a preferred adalimumab biosimilar

Use the preferred adalimumab biosimilar products listed by Priority Health when clinically appropriate: adalimumab-adaz, adalimumab-adbm, adalimumab-bwwd (Hadlima), adalimumab-ryvk (Simlandi), or 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.

Documentation Required

Drug-Specific Clinical Criteria and Supporting Records

The request must establish the diagnosis-specific criteria, required specialist involvement, baseline testing, and treatment history for the requested product. Include objective measures and supporting records rather than diagnosis codes alone.

Adbry: Use a specialist or specialist consultation; document moderate-to-severe atopic dermatitis and at least 3 months of medium/high-potency topical corticosteroid or topical calcineurin inhibitor therapy. For an off-label request, provide published literature and rationale for the indication or dose.
Arcalyst: Document CAPS, DIRA, or recurrent pericarditis, including age/weight requirements. For an exception or unlisted use, provide rationale and pertinent information; document specialist involvement when applicable.
Arikayce: Submit MAC sputum culture supporting diagnosis, at least 6 months of multidrug-regimen history, infectious-disease consultation, adherence and tolerability, and continuation response. A negative sputum culture obtained within 30 days is required for continuation; treatment is not authorized beyond 1 year of negative cultures.
Benlysta: Submit age, ANA or anti-dsDNA results, SELENA-SLEDAI activity, standard-therapy history, renal biopsy and renal-function data for lupus nephritis, and continuation evidence such as score reduction, steroid reduction, BILAG/PGA findings, serology, flare status, urinary protein/creatinine ratio, and eGFR. Initial approval is 6 months and continuation is 12 months.
Besremi: Submit high-risk polycythemia vera diagnosis, hematology/oncology documentation, hydroxyurea and pegylated interferon alfa-2a history, ECOG 0–2, and eGFR at least 30 mL/min/1.73 m².
Bimzelx: Submit specialist documentation and diagnosis-specific treatment history: plaque psoriasis requires a traditional nonbiologic systemic agent and two qualifying biologics; hidradenitis suppurativa requires one other agent and two qualifying biologics; ankylosing spondylitis requires two qualifying agents; nr-axSpA requires elevated CRP and/or MRI sacroiliitis plus two qualifying agents; psoriatic arthritis requires a traditional systemic agent plus two qualifying agents. Provide exception rationale for unlisted use.
Cablivi: Document acute acquired TTP with thrombocytopenia and red-cell fragmentation, age 18 years or older, and concurrent plasma exchange and immunosuppressive therapy through 30 days after plasma exchange ends.
Carglumic acid: Document NAGS deficiency and acute or chronic hyperammonemia; for continuation, submit chart notes showing stability or improvement. Approval is 12 months.
Cayston: Submit CF diagnosis and code, age, positive Pseudomonas sputum culture, susceptibility results, and pulmonologist/CF-specialist continuation documentation. Initial approval is 6 months and continuation is 12 months; use 28 days on followed by 28 days off.
Cholbam: Submit SED or peroxisomal-disorder diagnosis, serum VLCFA, baseline liver tests, and continuation weight, ALT/AST, bilirubin, and liver-biopsy findings.
Cibinqo: Document moderate-to-severe atopic dermatitis, topical treatment, two qualifying biologic trials, specialist involvement, and rationale for an exception or unlisted use. Approval is 12 months.
Cimzia and Cosentyx: Submit specialist documentation, diagnosis-specific conventional or biologic treatment history, CRP/MRI evidence for nr-axSpA, and exception rationale where criteria are not met.
Cobenfy: Submit schizophrenia diagnosis, age 18 years or older, two failed or contraindicated atypical antipsychotic trials of at least 28 days, and specialist involvement. Approval is 12 months.
Crenessity: Submit genetic confirmation of classic CAH due to 21-hydroxylase deficiency, age, glucocorticoid dose and compliance, androgen results, medical necessity to reduce glucocorticoid exposure, and specialist documentation. Continuation requires reduced daily glucocorticoid dose; approval is 6 months initially and 12 months thereafter.
Cresemba: Submit invasive aspergillosis or mucormycosis diagnosis, prior azole failure/intolerance/contraindication, and specialist involvement. Continuation requires disease stability or improvement.
CFTR modulators: Submit CF diagnosis and qualifying ICD-10 code within 12 months and verify that granule or tablet formulation matches the FDA-labeled age.
Dalfampridine ER: Submit MS diagnosis, immunomodulatory treatment or rationale, age 18–70, walking impairment, wheelchair status, baseline T25FW or EDSS, and continuation adherence and response. Approval is 6 months initially and 12 months for continuation.
Daybue: Submit classic/typical Rett syndrome with MECP2 mutation, objective baseline severity assessment, in-depth neurologic/genetic/developmental evaluation, age at least 2 years, and specialist involvement. Atypical or variant Rett syndrome is excluded.
Diacomit: Submit Dravet syndrome, age at least 2 years, adjunctive use with clobazam, and failed valproate and clobazam therapy.
Droxidopa: Submit symptomatic neurogenic orthostatic hypotension, exclusion of other causes, at least two nonpharmacologic measures, cardiology/neurology/nephrology involvement, failed or contraindicated midodrine and fludrocortisone, and continuation response. Initial approval is 3 months and continuation is 6 months.
Dupixent: Submit indication-specific diagnosis and therapy history for atopic dermatitis, asthma, COPD, CRSwNP, prurigo nodularis, EoE, chronic urticaria, or bullous pemphigoid, including required topical, controller, dietary, antihistamine, PPI, corticosteroid, or systemic-agent trials and objective severity results.
Enspryng: Submit NMOSD diagnosis, AQP4 antibody positivity, qualifying attacks, neurologist involvement, progressive disease despite rituximab, and EDSS ≤7.
Entyvio SC: Submit specialist documentation, Crohn’s disease or ulcerative colitis diagnosis, conventional therapy failure, and two required biologic or targeted-therapy trials. Document whether IV induction and maintenance are billed under the medical benefit or SC maintenance under the pharmacy benefit.
Eohilia: Submit biopsy-confirmed EoE with at least 15 eos/hpf, failed dietary modification, PPI for at least 2 months, topical corticosteroid for at least 2 months, age at least 1 year, and gastroenterology/allergy consultation. Approval is 12 weeks.
Epidiolex: Submit Lennox-Gastaut syndrome, Dravet syndrome, or tuberous sclerosis complex diagnosis, adjunctive seizure use, age at least 1 year, and failure, intolerance, or contraindication to at least two generic anticonvulsants.
Evrysdi: Submit neurologist involvement, SMA diagnosis, SMN1 bi-allelic mutation testing, qualifying SMN2 copy number or early symptoms, symptomatic but not advanced disease, and baseline MFM-32, HINE, or validated measure. Continuation requires repeat objective assessment and clinically significant stability or improvement.
Fasenra: Submit eosinophilic asthma, EGPA, or HES criteria; required eosinophil counts or flare history; standard therapy; and continuation response. Approval is 12 months.
Fentanyl citrate lozenge: Submit age at least 16 years, breakthrough cancer pain, tolerance of around-the-clock opioid therapy, and quantity justification. The standard limit is 120 lozenges per 30 days; use the opioid quantity/dose exception form when exceeding it.
Filsuvez: Submit genetic confirmation of recessive dystrophic epidermolysis bullosa, open partial-thickness wounds, specialist involvement, application limited to wounds during dressing changes, and continuation wound response. Initial approval is 3 months and continuation is 6 months.
Fintepla: Submit Lennox-Gastaut or Dravet syndrome, age at least 2 years, failed clobazam, valproate/divalproex, or topiramate trials, and failed or contraindicated Diacomit for Dravet syndrome.
Firdapse: Submit electrodiagnostic confirmation of LEMS, positive P/Q-type VGCC antibody, clinically significant proximal weakness, ambulatory status, baseline QMG or 3TUG, failed pyridostigmine for adults, and appropriate treatment of associated cancer before initiation.

Pharmacy Drug Prior Authorization Criteria

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