Prior authorization required for ADL-listed drugs and uses

Prior authorization is required for drugs and uses specified on the Approved Drug List (ADL) and when drug use exceeds established coverage limits; drug-level criteria must be met before coverage and authorizations may be granted up to 12 months. For opioid dose exceptions above 120 MEqD/day, document an opioid treatment agreement, chronic pain diagnosis, taper attempt or rationale, routine validated pain/function assessments showing sustained improvement, trial of non-drug therapy within 18 months (or contraindication), concurrent non-opioid medications when appropriate, naloxone education, and safety documentation when combining with benzodiazepines/sedative-hypnotics/barbiturates. Individual drug quantity limits, step therapy, and other utilization management may also apply.

• Opioid exceptions require documentation listed above when >120 MEqD/day.
• Authorizations generally up to 12 months when approved.
• Nonformulary/nonpreferred drugs do not satisfy step requirements unless otherwise allowed.

Acthar: confirm infantile spasms and age <2 years

Acthar prior authorization requires documentation that the patient has infantile spasms and is less than 2 years of age. Approval duration for Acthar is 1 month with the specified dosing/taper schedule noted in the policy.

• Must document diagnosis of infantile spasms and age <2 years.
• Duration of approval: 1 month (dosing/taper instructions provided in policy).

Adalimumab: specialist prescriber + indication-specific therapy documentation

Adalimumab prior authorization requires that the prescriber is a specialist or has consulted a specialist and that the patient meets the general criteria plus the indication‑specific prior-therapy requirements (e.g., adequate trials of conventional systemic therapies). Adalimumab is not covered in combination with another biologic.

• Prescriber must be a specialist or document specialist consultation.
• Provide evidence of required prior conventional therapy trials per treated diagnosis (examples: steroids, immunomodulators, non-biologic systemics).
• Do not request concomitant use with another biologic (not covered).

Adbry: specialist prescriber and prior topical therapy trial(s)

Adbry (tralokinumab) prior authorization requires the prescriber be a specialist or document specialist consultation and documentation that the patient has moderate to severe atopic dermatitis with prior adequate topical therapy trials. For initiation, the patient must have tried a medium‑to‑high potency topical corticosteroid or a topical calcineurin inhibitor for at least 3 months.

• Prescriber is a specialist or has consulted a specialist for the condition.
• Document moderate to severe atopic dermatitis.
• Document trial of one medium‑to‑high potency topical corticosteroid OR one topical calcineurin inhibitor (tacrolimus or pimecrolimus) for ≥3 months.

PCSK9 inhibitors: high‑intensity statin trial ≥8 weeks before approval

PCSK9 inhibitor prior authorization requires documentation of a continuous minimum 8‑week trial of a high‑intensity statin (atorvastatin ≥40 mg or rosuvastatin ≥20 mg) with LDL‑C remaining above goal. Non-preferred agents require specialist prescribing and trial/failure or intolerance to the preferred agent and additional statin therapy; PCSK9 inhibitors must not be used in combination with another PCSK9 inhibitor, Leqvio, Nexletol, or Nexlizet.

• Document continuous high‑intensity statin trial ≥8 weeks with persistent LDL‑C above goal.
• Non-preferred agent (Praluent) requires cardiologist/endocrinologist/lipidologist prescribing and trial/failure or intolerance to Repatha plus additional statin.
• Do not combine with another PCSK9 inhibitor, Leqvio, Nexletol/Nexlizet.

Acute antimigraine agents: triptan trial and preferred-agent failure for non-preferred products

Prior authorization for acute antimigraine agents requires a diagnosis of migraine, patient age ≥18, and documentation of a trial of one triptan. For non-preferred acute branded products, document trial and failure or intolerance to the preferred agent (Ubrelvy) and an additional triptan as required; duration of approval is typically 12 months.

• Diagnosis of migraine with or without aura and age ≥18 years.
• Document trial of one triptan (e.g., sumatriptan, rizatriptan).
• For non-preferred products, document failure/intolerance to Ubrelvy and an additional triptan.

Products that require prior authorization (listed agents)

Prior authorization is required for the listed products (examples include Aimovig, Ajovy, Emgality, Qulipta, Vyepti, Sunlenca, and Rukobia); follow the product‑specific criteria in the policy when submitting requests.

• Complete product‑specific criteria per the policy for each listed agent.
• Use the Employer Group & MyPriority Plans Pharmacy drug request form or ePA for submission.

Submit PA using the Employer Group & MyPriority Plans Pharmacy drug request form or ePA

Complete the Employer Group & MyPriority Plans Pharmacy (NonOncology) drug request form or submit via Electronic prior authorization (ePA) to initiate a prior authorization request; the policy provides the form link and requires this form for PA processing.

• Use the Employer Group & MyPriority Plans Pharmacy (NonOncology) drug request form or ePA link provided in the policy.
• Include all required clinical documentation as specified for the requested agent.

Approval durations: initial ~6 months; continuation ~12 months (agent-specific exceptions apply)

Initial approvals are generally for 6 months and continuation approvals are generally for 12 months; Arikayce continuation is an example with 12‑month continuation and some agents have specified shorter initial durations (e.g., Cablivi initial 30 days).

• Typical durations: Initial = 6 months; Continuation = 12 months.
• Follow drug-specific duration and quantity limits where provided (e.g., Cablivi initial 30 days / continuation 28 days).

Benlysta: age, autoantibody, and disease‑activity documentation required

Benlysta prior authorization for active, autoantibody‑positive SLE requires the patient be ≥5 years old, be autoantibody‑positive (ANA ≥1:80 or anti‑dsDNA ≥30 IU/mL), and have active SLE demonstrated by SELENA‑SLEDAI >6 while on standard therapy for ≥12 weeks; similar antibody and age criteria apply for biopsy‑proven lupus nephritis with eGFR ≥30 mL/min/1.73m2.

• Age ≥5 years and autoantibody‑positive (ANA ≥1:80 OR anti‑dsDNA ≥30 IU/mL).
• Active SLE: SELENA‑SLEDAI >6 while on standard therapy for ≥12 weeks.
• For lupus nephritis Class III–V: active renal disease requiring standard therapy and eGFR ≥30 mL/min/1.73m2.

Besremi: hematology/oncology prescriber and prior therapy requirements

Besremi prior authorization requires diagnosis of high‑risk polycythemia vera, patient age ≥18, prescribing by or consultation with a hematologist/oncologist, trial and failure of hydroxyurea and pegylated interferon‑alfa 2a, ECOG 0–2, and eGFR ≥30 mL/min/1.73m2.

• Document high‑risk polycythemia vera and supporting records.
• Age ≥18 and hematology/oncology prescriber or documented consultation.
• Document trial and failure of hydroxyurea AND pegylated interferon‑alfa 2a; ECOG 0–2; eGFR ≥30.

Cablivi: aTTP diagnosis and plasma exchange co‑administration required

Cablivi prior authorization for acquired TTP requires documentation of thrombocytopenia and microangiopathic hemolysis, patient age ≥18, and that Cablivi will be administered in addition to plasma exchange and immunosuppressive therapy and continued for 30 days after plasma exchange.

• Document aTTP diagnosis with thrombocytopenia and schistocytes/microangiopathic hemolysis.
• Age ≥18 years.
• Plan to administer Cablivi with plasma exchange plus immunosuppression and continue 30 days post‑exchange.

Cardiac myosin inhibitors: specialist prescribing, step therapy, and durations

Prior authorization is required for cardiac myosin inhibitors (Camzyos, Myqorzo); initial approval is 6 months and continuation is 12 months. These agents must not be used in combination with one another and are to be prescribed by or in consultation with a cardiologist with required baseline eligibility.

• Indication: symptomatic NYHA class II or III obstructive HCM, age ≥18, LVEF ≥55%, cardiologist involvement.
• Document trial and failure/intolerance/contraindication to both beta blocker and calcium channel blocker prior to initiation.
• Initial approval 6 months; continuation 12 months; Camzyos and Myqorzo not used together.

Carglumic acid (Carbaglu): NAGS deficiency documentation required

Prior authorization for carglumic acid (Carbaglu) requires documentation of N‑acetylglutamate synthase (NAGS) deficiency with acute or chronic hyperammonemia; approvals may be granted for up to 12 months with required clinical documentation for continuation.

• Document NAGS deficiency and hyperammonemia.
• Provide clinical documentation for continuation; approval up to 12 months.

Cayston: CF diagnosis, age ≥7, Pseudomonas culture and susceptibility or prior tobramycin failure

Cayston prior authorization requires documentation of cystic fibrosis (submit an approved CF ICD‑10 code within the last 12 months), patient age ≥7 years, a positive Pseudomonas aeruginosa airway culture, and either susceptibility showing aztreonam is the only effective inhaled antibiotic or prior tobramycin failure/intolerance/resistance.

• Submit CF ICD‑10 code (E84.*) within last 12 months and age ≥7.
• Provide positive sputum culture for Pseudomonas aeruginosa and susceptibility results or prior tobramycin failure/intolerance/resistance.
• Continuation requires pulmonologist/CF specialist documentation of stabilization or improvement; dosing cycles 28 days on/28 days off.

Cholbam: diagnosis, VLCFA value, and baseline LFTs required

Cholbam prior authorization requires documentation of a bile acid synthesis disorder due to single enzyme defects (SED) or a peroxisomal disorder, provision of a serum very long chain fatty acid (VLCFA) value, and baseline liver function tests.

• Document diagnosis of SED or peroxisomal disorder.
• Submit serum VLCFA result and baseline LFTs with the PA request.

Cibinqo: specialist prescriber, topical therapy trial(s), and prior systemic agent trials required

Cibinqo prior authorization requires that the prescriber is a specialist or has consulted a specialist, documentation that the patient has moderate to severe atopic dermatitis, prior adequate topical therapy trial(s), and trials of at least two specified systemic/biologic agents as listed.

• Specialist prescriber or documented specialist consultation required.
• Document moderate to severe atopic dermatitis.
• Provide prior topical therapy trial (medium‑to‑high potency steroid or topical calcineurin inhibitor ≥3 months) and trials of at least two systemic/biologic agents each ≥3 months.

Specialist prescriber and indication‑specific prior therapy documentation required

Prior authorization requires that the prescriber is a specialist or has consulted a specialist and that indication‑specific prior therapies and diagnostic criteria are documented per the policy for the requested drug and diagnosis.

• Provide documentation of specialist involvement or consultation.
• Include indication‑specific prior therapy trials and diagnostic evidence (labs, imaging, biopsies) as required by the drug's criteria.

CFTR modulators: submit CF ICD‑10 code and age‑appropriate formulation

CFTR modulator prior authorization requires documentation of cystic fibrosis (submit an approved CF ICD‑10 code within the last 12 months) and that the requested formulation matches FDA‑labeled age for the member.

• Submit CF ICD‑10 code (E84.0, E84.11, E84.19, E84.8, E84.9) within the last 12 months.
• Requested formulation (granules, tablets) must match the FDA label for the member's age.

Diacomit: Dravet diagnosis, adjunctive with clobazam, prior valproate/clobazam failure required

Diacomit (stiripentol) prior authorization requires a diagnosis of Dravet syndrome, patient age ≥2 years, use as adjunctive therapy with clobazam (not monotherapy), and documentation of prior trials and failure with valproate and clobazam.

• Diagnosis of Dravet syndrome and age ≥2 years.
• Use as adjunct to clobazam; Diacomit is not supported as monotherapy.
• Document trial and failure with valproate and clobazam.

Droxidopa: nOH diagnosis, non‑pharmacologic trials, specialist consult, and prior midodrine/fludrocortisone trial

Droxidopa prior authorization requires symptomatic neurogenic orthostatic hypotension due to specified causes with exclusion of other causes, trial of at least two non‑pharmacologic interventions, specialist prescribing or consultation (cardiology, neurology, or nephrology), and trial/failure or intolerance to midodrine and fludrocortisone; initial approval is 3 months with continuation requiring objective response documentation.

• Document nOH diagnosis from listed causes and exclusion of other causes.
• Document trial of ≥2 nonpharmacologic measures and trial/failure/intolerance to midodrine and fludrocortisone (≥30 days).
• Prescribed by or in consultation with cardiologist, neurologist, or nephrologist; initial 3 months, continuation 6 months with documented benefit.

Dupixent: meet indication‑specific criteria and provide response data for continuation

Dupixent prior authorization requires meeting the indication‑specific criteria listed (e.g., for atopic dermatitis document moderate to severe disease and prior topical therapy; for asthma document eosinophilic phenotype and prior controller therapy; for COPD, prurigo nodularis, EoE, chronic urticaria, and bullous pemphigoid meet the specific diagnostic and prior‑therapy requirements). Continuation requires demonstration of clinical response per indication.

• Follow indication‑specific entry criteria (topical/systemic prior trials, objective measures such as eosinophil counts, spirometry, biopsy results, WI‑NRS, BPDAI, etc.).
• Provide documentation of positive clinical response for continuation (examples per indication provided).
• Dupixent is not covered in combination with other biologic drug therapy.

PA submissions must document diagnosis, prior trials, and clinical benefit for continuation

Prior authorization and duration: initial and continuation approvals require documented diagnostic criteria, required prior treatment trials, and demonstration of clinical benefit for continuation; standard duration of approval is 12 months unless otherwise specified.

• Include diagnostic confirmation, prior therapy history, and objective measures as required.
• Continuation approvals generally require evidence of clinical benefit and are typically 12 months.

Enspryng: submit PA form/ePA and AQP4 antibody documentation

Enspryng prior authorization requires completion of the Employer Group & MyPriority Plans Pharmacy drug request form or ePA and submission of supporting documentation including neuromyelitis optica spectrum disorder diagnosis and anti‑AQP4 antibody positivity; duration of approval is 12 months.

• Submit the Employer Group & MyPriority Plans Pharmacy drug request form or use ePA.
• Provide NMOSD diagnosis and anti‑AQP4 antibody positivity documentation.
• Duration of approval: 12 months; neurologist involvement and prior rituximab trial history required per criteria.

Entyvio SC: complete PA form/ePA and provide prior therapy documentation

Entyvio SC prior authorization requires completion of the Employer Group & MyPriority Plans Pharmacy drug request form or ePA and submission of required clinical history and prior therapy trials per the indication before coverage will be approved.

• Complete the Employer Group & MyPriority Plans Pharmacy (NonOncology) drug request form or ePA.
• Provide documentation of prior conventional therapy failure and trials of required biologics/agents (two agents for Crohn's/UC) as specified.

Eohilia: biopsy confirmation and prior therapy documentation required

Eohilia prior authorization requires completion of the Employer Group & MyPriority Plans Pharmacy drug request form or ePA and submission of biopsy confirmation (≥15 intraepithelial eosinophils/hpf) and documentation of prior therapy trials (dietary modification, PPI ≥2 months, topical corticosteroid ≥2 months).

• Submit PA form or ePA and include biopsy showing ≥15 eos/hpf.
• Document prior trials: dietary modification, one PPI ≥2 months, one topical corticosteroid ≥2 months.
• Provide prescriber specialty (gastroenterologist or allergist).

Epidiolex: submit PA form/ePA and seizure diagnosis/prior anticonvulsant history

Epidiolex prior authorization requires completion of the Employer Group & MyPriority Plans Pharmacy drug request form or ePA and supporting documentation of the qualifying diagnosis and prior anticonvulsant treatment history; initial coverage applies to Lennox‑Gastaut, Dravet, or tuberous sclerosis complex per the criteria.

• Complete PA form or ePA for submission.
• Document qualifying diagnosis and trial/failure or intolerance to at least two generic anticonvulsants.
• Patient must be ≥1 year of age for coverage per policy.

Evrysdi: genetic confirmation and baseline motor function testing required

Evrysdi prior authorization requires meeting the listed genetic and clinical criteria (prescriber neurologist, diagnosis of SMA with bi‑allelic SMN1 mutation, SMN2 copy number/onset limits, symptomatic but not advanced disease) and submission of baseline motor function assessment; duration of approval is 6 months for initial authorizations.

• Provide genetic testing confirming bi‑allelic SMN1 mutations and SMN2 copy number/onset criteria.
• Submit baseline motor function assessment (MFM‑32, HINE, or other validated tool).
• Evrysdi authorized per FDA dosing only; initial duration 6 months; not authorized for prior Zolgensma recipients or in combination with Spinraza.

Fasenra: eosinophil counts and prior controller therapy documentation required

Fasenra prior authorization requires condition‑specific criteria be met (e.g., severe eosinophilic asthma requires peripheral eosinophils >150 cells/mcL, prior controller therapy, and exacerbation history); provide peripheral eosinophil counts and prior controller/corticosteroid or immunosuppressive therapy documentation. Continuation requires demonstration of clinical response; duration typically 12 months.

• Submit peripheral blood eosinophil counts and evidence of prior controller/ICS plus additional controller therapy for asthma.
• Provide indication‑specific documentation (EGPA, HES) as required.
• Continuation: document clinical response (reduced exacerbations, decreased steroid use) for ongoing authorization.

Fentanyl lozenge products require prior authorization

Fentanyl citrate buccal lozenge products listed in the policy require prior authorization before coverage; submit the Employer Group & MyPriority Plans Pharmacy drug request form or ePA and include the clinical justification.

• Affected strengths include the listed 200 mcg and 1200 mcg buccal lozenge products.
• Complete PA form or ePA and provide clinical rationale for use.

Step therapy: document trial and failure or intolerance to preferred agents

When step therapy is required, the provider must document a trial and therapeutic failure or intolerance/contraindication to the preferred medication(s); failures must be of plan‑covered or preferred drugs to satisfy the requirement and the policy specifies required durations and examples per drug.

• Document trials of preferred agents (drug names and minimum durations are specified in the policy).
• Provide reasons for failure/intolerance or contraindication; nonformulary/nonpreferred drugs do not satisfy step requirements.

Adalimumab preferred biosimilars listed — step to preferred agents

Preferred adalimumab biosimilars are listed (e.g., adalimumab‑adaz, adalimumab‑adbm, adalimumab‑bwwd, adalimumab‑ryvk); requests should step to the preferred biosimilar/unbranded adalimumab agents where applicable.

• Use preferred adalimumab biosimilar product names as listed when possible.
• If requesting a non‑preferred adalimumab, provide clinical rationale and required prior therapy documentation.

PCSK9 step: try Repatha before Praluent; non‑preferred needs trial/failure and specialist

For PCSK9 inhibitors, the preferred agent (Repatha) should be tried before non‑preferred agents (Praluent); coverage of non‑preferred agents requires documentation of trial and failure or intolerance to the preferred product and additional statin therapy, and specialist prescribing.

• Document trial/failure of Repatha prior to Praluent where required.
• Non‑preferred agent requests should include cardiology/endocrinology/lipidology prescriber documentation.

Acute migraine step: triptan trial and preferred agent (Ubrelvy) trial before non‑preferred

For acute migraine treatment, patients should have tried a triptan and the preferred agent (Ubrelvy) prior to approval of non‑preferred acute branded agents; document the triptan trial and failure or intolerance to preferred agent where applicable.

• Document trial of one triptan and trial/failure or intolerance to Ubrelvy for non‑preferred acute agents.
• Duration of approval typically 12 months for approved acute agents.

Migraine preventive step: try two oral preventives; non‑preferred biologics require preferred biologic failures

For migraine preventive therapy, patients must have tried any two oral preventive medications; non‑preferred agents require failure/intolerance to the preferred biologic CGRPs (Aimovig, Emgality, Ajovy) for 3 continuous months each where specified.

• Document trials of two oral preventive agents (examples provided in policy).
• For non‑preferred preventive biologics, document 3 months each of Aimovig, Emgality, and Ajovy with inadequate response when required.

Arikayce prerequisite: failed ≥6 months multidrug regimen and submit sputum culture

Arikayce requires prior failure to achieve negative sputum cultures after a minimum of 6 months on a multidrug background regimen and must be used as part of a multidrug regimen; submit sputum culture supporting the MAC diagnosis to Priority Health.

• Document failure to obtain negative sputum culture after ≥6 months on multidrug regimen (e.g., macrolide, rifampin, ethambutol).
• Submit positive sputum culture and susceptibility data to Priority Health; Arikayce is not approved as single‑agent therapy.

Bimzelx: document prior systemic and biologic therapy failures per indication

Bimzelx requires prior use/failure of specified systemic and biologic agents per indication before approval (e.g., for plaque psoriasis one traditional non‑biologic systemic ≥3 months plus two biologics each ≥3 months); document the prior agents and durations.

• Provide prior therapy history showing trials of required non‑biologic and biologic agents for the indicated durations.
• Bimzelx will not be covered in combination with another biologic.