Currentpriority healthPolicy N/A
Medical Drug Prior Authorization Criteria
Defines prior authorization requirements, clinical criteria, age limits, prescriber specialties, dosing limits, approval timeframes, continuation criteria, and infusion site requirements for specified physician-administered drugs covered under Priority Health Choice Medicaid, Medicaid CSHCS, and Healthy MI medical benefit.
Policy Summary
Payerpriority health
PolicyMedical Drug Prior Authorization Criteria
Policy CodePolicy N/A
Change TypeNo material change
Effective Date
Next Review Date
Key ActionPrescribers must complete clinical prior authorization prior to administration using the Medicaid Medical Authorization form and criteria in this document; check the Medicaid Medical Drug List to confirm PA requirement and payable NDCs.
POLICY UPDATE CHANGES
No material changes
91414Infusion policy referenced
1 yrTypical auth duration
200Detrusor per-treatment cap
8 wksAnal fissure trial
18+Age restriction (many drugs)
Coverage Summary
Initial Therapy Criteria
Adakveo (J0791) initial
Documentation confirming diagnosis of Sickle Cell Disease.
Must provide the patient's current weight.
Documented 6-month trial with hydroxyurea, or record of contraindication or intolerance to hydroxyurea.
Documentation of at least two vaso-occlusive crises (VOCs) in the last year.
Adzynma (J7171) initial
Policy Summary
Payerpriority health
PolicyMedical Drug Prior Authorization Criteria
Policy CodePolicy N/A
Change TypeNo material change
Effective Date
Next Review Date
Key ActionPrescribers must complete clinical prior authorization prior to administration using the Medicaid Medical Authorization form and criteria in this document; check the Medicaid Medical Drug List to confirm PA requirement and payable NDCs.
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