General PA Definition and Use
General PA Definition and Use: Prior authorization (PA) is required when specified below. Documentation should include diagnosis, prior therapies/trials, relevant test results, and specialist consultation notes when required. For brand drugs where generic available, DAW justification is required. Non-formulary or excluded drugs require a formulary exception request.
ALL of the following
Provider must submit clinical documentation supporting the requested indication, including relevant diagnostic testing, prior medication trials and durations, and specialist consultation when required.
For initial requests, include baseline measures where applicable (e.g., AIMS for tardive dyskinesia, LVEF for HCM, BTT for Bronchitol, genetic/biopsy/radionuclide confirmation for ATTR-CM).
For continuation requests, include documentation of clinical benefit or stability compared to baseline and adherence to REMS or other program enrollment when required.
Quantity limits, step therapy, and preferred alternative requirements apply as listed in specific agent criteria.
Desmopressin nasal spray (Central DI)
Desmopressin nasal spray (Arginine Vasopressin Disorder / Central DI):
ALL of the following
Confirmed diagnosis of central diabetes insipidus (CDI) or other appropriate arginine vasopressin deficiency disorder.
Documentation of clinician assessment distinguishing central vs nephrogenic DI; desmopressin is NOT appropriate for nephrogenic DI.
For initial approval, provide baseline serum sodium and fluid status; prescriber specialty preference: endocrinologist or in consultation with endocrinology if applicable.
Approval duration: standard initial authorization per product labeling; continuation requires documentation of symptomatic improvement and periodic monitoring of serum sodium to avoid hyponatremia.
Increlex (mecasermin)
Increlex (mecasermin) for severe primary IGF-1 deficiency and related indications:
ALL of the following
Diagnosis of severe primary insulin-like growth factor-1 (IGF-1) deficiency (e.g., growth hormone gene deletion or GH receptor mutation) or other FDA‑labeled indication for mecasermin.
Documentation of short stature with growth failure and baseline IGF-1 levels consistent with severe IGF-1 deficiency.
Documentation of prior appropriate growth hormone (GH) therapy trial, if indicated and tolerable, and rationale for use of mecasermin instead of GH (e.g., GH receptor insensitivity).
Prescriber must be pediatric endocrinologist or in consultation with a pediatric endocrinologist; provide growth velocity data and monitoring plan for hypoglycemia risk.
Isotretinoin (oral brands)
Isotretinoin (oral brand variants listed):
ALL of the following
Diagnosis consistent with severe nodular acne or other FDA-approved indication for oral isotretinoin.
Documentation of trial and inadequate response or intolerance to conventional therapies (topical agents, systemic antibiotics) per dermatology standards of care.
For females of childbearing potential: compliance with approved pregnancy prevention program (iPLEDGE), negative pregnancy test prior to initiation and monthly tests during therapy, and documentation of contraception use as required.
Prescriber specialty preference: dermatologist; include baseline labs and follow-up monitoring plan (lipids, liver enzymes).
Topical sirolimus (facial angiofibroma, TSC)
Topical sirolimus (facial angiofibroma, tuberous sclerosis):
ALL of the following
Documented diagnosis of facial angiofibromas associated with tuberous sclerosis complex (TSC).
Prescriber attests topical therapy is clinically indicated and patient has been evaluated for alternative topical or systemic options; pediatric dosing justification if applicable.
Initial approval per product labeling and demonstration of clinical response required for continuation.
Camzyos (mavacamten) for obstructive HCM
Camzyos (mavacamten) for obstructive HCM:
ALL of the following
Diagnosis of symptomatic NYHA class II or III obstructive hypertrophic cardiomyopathy with left ventricular outflow tract obstruction, confirmed by cardiology assessment.
LVEF ≥ 55% at baseline with documentation; prescriber must be a cardiologist or in consultation with a cardiologist.
Attestation patient will not concurrently receive disopyramide, ranolazine, or a combination of beta blocker plus calcium channel blocker while on mavacamten.
For females of childbearing potential, negative pregnancy test prior to initiation and ongoing pregnancy avoidance counseling; enrollment in Camzyos REMS program required.
Initial authorization: 6 months; continuation requires clinician attestation of clinical benefit and LVEF ≥ 50%.
Tetrabenazine / deutetrabenazine (Chorea/Huntington's & Tardive Dyskinesia)
Tetrabenazine / deutetrabenazine (Chorea/Huntington's & Tardive Dyskinesia):
ALL of the following
Approved diagnoses: chorea associated with Huntington's disease OR tardive dyskinesia secondary to use of a dopamine antagonist.
Prescribed by or in consultation with a neurologist or psychiatrist; age ≥ 18 years for these agents unless labeling permits otherwise.
For tardive dyskinesia, documentation that a baseline AIMS exam was completed prior to initiation; include attestation of monitoring schedule.
Initial authorization: up to 1 year; continuation requires documentation of symptomatic improvement and, for tardive dyskinesia, follow-up AIMS showing positive response.
Benznidazole (Chagas disease)
Benznidazole (Chagas disease):
ALL of the following
Confirmed diagnosis of Chagas disease due to Trypanosoma cruzi.
Initial authorization: 60 days; continuation not applicable in most cases.
Provide documentation of diagnostic testing and treatment plan.
Beyfortus (RSV prevention)
Beyfortus (RSV prevention):
ALL of the following
Indication: prevention of RSV lower respiratory tract disease in neonates/infants during first RSV season or children up to 24 months remaining at high risk in second season.
Age limitation: patient must be ≤ 24 months; dosing per planned cardiac surgery (2 doses) vs other (1 dose) scenarios.
Mother did not receive RSV vaccination in 2nd or 3rd trimester AND patient meets age/seasonal and risk-factor criteria (e.g., CLD with recent medical support, CHD, immunocompromised, neuromuscular disorder, severe CF manifestations, Alaska Native / American Indian), and has not received 5 doses of palivizumab for current season.
Bronchitol (cystic fibrosis)
Bronchitol (cystic fibrosis):
ALL of the following
Confirmed diagnosis of cystic fibrosis; prescriber must be a pulmonologist.
Documentation that Bronchitol Tolerance Test (BTT) has been performed and patient is suitable for therapy.
Documented trial and failure of hypertonic saline; Bronchitol to be used as add-on maintenance therapy to improve pulmonary function.
Continuation requires attestation of positive response and absence of hemoptysis; initial authorization: 1 year.
Budesonide EC (Crohn's disease, microscopic colitis)
Budesonide EC (Crohn's disease, microscopic colitis):
ANY of the following
Crohn's disease (mild to moderate)
Active Crohn's disease; must have intolerance to or history of unacceptable side effects to systemic steroids (e.g., prednisone).
Initial authorization up to 8 months per dosing guidance; prescriber should be gastroenterologist or in collaboration with one.
Microscopic colitis
Diagnosis confirmed via endoscopy and biopsy of colonic mucosa; active disease defined as ≥3 stools/day or ≥1 watery stool/day OR diarrhea persistent despite antidiarrheals.
Initial authorization up to 3 months per product limits; prescriber specialty: gastroenterologist.
Topical Vitamin D analogs (psoriasis)
Topical Vitamin D analogs (psoriasis):
ALL of the following
Diagnosis of psoriasis and prescribed for an FDA‑approved topical Vitamin D analog indication.
Documented trial/failure/intolerance of at least one high- or very-high-potency topical steroid OR trial/failure/intolerance of a lower-potency topical steroid with justification for avoiding higher potency; pediatric steroid avoidance acceptable justification.
Quantity limits: amount to cover area up to 34 days. Max weekly limits: age ≥7: 200 g/week; age 2–6: 100 g/week. Prescriber must justify exceeding safe limits.
Initial authorization 6 months; continuation 1 year with prescriber attestation of positive response or stable disease. Therapy may be discontinued for noncompliance or lack of improvement within 6 months.
Palforzia (peanut allergy OIT)
Palforzia (peanut allergy oral immunotherapy) — includes continuation branch:
ALL of the following
Diagnosis of peanut allergy confirmed by appropriate testing and clinical history.
Initial approval requires enrollment in a structured oral immunotherapy program with dosing and monitoring per product labeling.
Continuation - ONE of
Documentation of clinical benefit such as reduced reactivity on supervised oral food challenge, or tolerated maintenance doses with acceptable adverse effects.
Documentation of inability to discontinue therapy based on clinical judgement and patient risk profile with ongoing monitoring plan.
Pretomanid (XDR / treatment-intolerant MDR TB)
Pretomanid (for XDR or treatment‑intolerant/nonresponsive MDR TB):
ALL of the following
Diagnosis of extensively drug-resistant (XDR) TB or multidrug-resistant (MDR) TB that is treatment-intolerant or nonresponsive to standard regimens per infectious disease specialist assessment.
Therapy should be prescribed by or in consultation with an infectious disease or TB specialist; provide drug-susceptibility testing and prior regimen history.
Initial authorization per recommended short-course regimen and specialist documentation; duration and continuation per specialist guidance and TB program protocols.
CFTR modulators (Cystic Fibrosis)
CFTR modulators (Cystic Fibrosis entries):
ALL of the following
Confirmed diagnosis of cystic fibrosis with genotype appropriate for the requested CFTR modulator per FDA labeling and CF care guidelines.
Prescriber should be a CF specialist or pulmonologist and provide genotype documentation and prior CF therapies status.
Initial and continuation authorizations follow product-specific criteria including demonstrated clinical benefit, lack of contraindicated concomitant therapies, and monitoring plan.
Lidocaine 5% patch (selected neuropathic pain)
Lidocaine 5% patch (PHN, diabetic neuropathic pain, peripheral polyneuropathy with SUD concerns):
ALL of the following
Indication: post-herpetic neuralgia (PHN), diabetic peripheral neuropathic pain, or peripheral polyneuropathy where topical therapy is clinically appropriate.
For patients with substance use disorder concerns, topical lidocaine may be preferred to minimize systemic opioid exposure; document SUD history and rationale.
Quantity limits and application instructions per product labeling; provide documentation of prior trials of first-line neuropathic agents unless contraindicated or not tolerated.
JAK inhibitors for severe alopecia areata
JAK inhibitors for severe alopecia areata (non-preferred class considerations):
ALL of the following
Diagnosis of severe alopecia areata confirmed by dermatologist; documentation of disease extent and prior therapy trials (topicals, intralesional corticosteroids, systemic agents) with failure or intolerance.
Prescriber must be dermatologist; JAK inhibitor use limited to cases meeting severity thresholds and after discussion of risks/benefits and baseline laboratory monitoring per labeling.
Non-preferred JAK agents require prior authorization with documentation of trial of preferred alternatives when applicable.
Octreotide (multiple indications)
Octreotide (multiple indications):
ALL of the following
Indication and diagnosis must be specified (e.g., acromegaly adjunct, carcinoid tumor symptom control, variceal bleeding adjunct), with supporting diagnostic and prior therapy documentation.
Prescriber specialty and monitoring plan appropriate to indication (e.g., endocrinology, oncology, hepatology).
Initial authorization and renewal based on demonstrated clinical benefit and tolerability per indication-specific criteria.
Ohtuvayre (COPD)
Ohtuvayre (for COPD):
ALL of the following
Diagnosis of COPD requiring the requested therapy; document exacerbation history and prior inhaled therapy trials per COPD treatment guidelines.
Prescriber attestations regarding inhaler technique education and optimization of background bronchodilator therapy.
Sulopenem (uUTI)
Sulopenem (uncomplicated UTI - uUTI):
ALL of the following
Diagnosis of uncomplicated urinary tract infection; provide urine culture and susceptibility when available and documentation of prior recommended oral therapy failures or contraindications.
Initial authorization aligned with labeling for duration of therapy; consider stewardship and narrowest effective therapy.
Non-Preferred Agent PA Criteria (selected examples)
Non-Preferred Agent PA Criteria and Selected Specifics (consolidated):
ALL of the following
Non-preferred agents require documentation of trial and failure, intolerance, or clinical inappropriateness of preferred alternatives as specified in agent-specific criteria.
Examples of specific agents and notes: ARBLI (losartan) - apply specific criteria where listed; ENTRESTO Sprinkles - require diagnosis and age/weight-based justification; Eliquis (apixaban) formulations and Pradaxa oral pellets - require indication-specific dosing justification and age appropriateness; Akynzeo - approved for CINV with prior antiemetic trial documentation; Brexafemme, Cresemba, Sporanox, Vivjoa, ciclopirox shampoo, econazole foam, tavaborole, Vusion, colchicine products (Colcrys, Gloperba) - follow indicated infection/dermatologic/mycotic or gout criteria and any bypass exceptions listed.
Preferred acute migraine agents (Nurtec ODT, Ubrelvy) require indication for acute migraine; quantity limits for acute migraine therapies apply per plan (see Acute migraine quantity limits).
Non-GLP-1 and Non-preferred GLP-1 anti-obesity agents: require class-level initial criteria including BMI thresholds, documentation of lifestyle interventions, and contraindications to preferred agents; specific non-preferred GLP-1 agents (Wegovy, Saxenda, Zepbound) require prior authorization with documentation per obesity management criteria.
Formulation‑specific and ARBLI specifics
ENTRESTO Sprinkles; ARBLI (losartan) specifics; Eliquis and Pradaxa oral pellet considerations:
ALL of the following
ENTRESTO Sprinkles: require heart failure diagnosis and age/weight-appropriate justification for sprinkle formulation when oral tablets are unsuitable; include prior intolerance or inability to swallow tablets.
ARBLI (losartan): apply ARB-specific criteria including indication (e.g., hypertension, proteinuria) and contraindication checks; document prior ACE inhibitor intolerance when required by protocol.
Eliquis (apixaban) formulations and Pradaxa oral pellets: require indication-specific dosing justification (e.g., VTE prophylaxis, atrial fibrillation) and age/weight appropriateness; pediatric or pellet formulations require documentation why standard formulations are not appropriate.
Antifungal, Dermatologic, Gynecologic Agents
Antifungal, Dermatologic, and Gynecologic Agents (selected):
ALL of the following
Akynzeo (netupitant/palonosetron): for prevention of CINV per guideline-recommended regimens; document emetogenicity of chemotherapy and prior antiemetic prophylaxis if relevant.
Brexafemme (ibrexafungerp), Cresemba (isavuconazole), Sporanox (itraconazole) for onychomycosis, and Vivjoa (oteseconazole): require confirmed diagnosis, prior therapy trials when standard of care dictates, and susceptibility or recurrence documentation as applicable.
Topical antifungal/dermatologic bypass criteria: ciclopirox shampoo bypass may be approved without PA when specified conditions met; econazole nitrate foam, tavaborole, Vusion (miconazole nitrate/zinc oxide/petrolatum) follow topical product-specific criteria and quantity limits.
Colchicine (Colcrys) bypass and Gloperba: apply bypass exceptions or pediatric liquid formulation justifications where listed; document gout diagnosis, attack frequency, or prophylactic rationale per product labeling.
Acute migraine agents and quantity limits
Preferred acute migraine agents PA criteria and quantity limits:
ALL of the following
Preferred acute migraine agents (Nurtec ODT, Ubrelvy) require diagnosis of migraine and documentation that triptans or other first-line agents are contraindicated, not tolerated, or ineffective when policy specifies step therapy.
Acute migraine quantity limits: apply per-claim and per-month limits as listed in plan; prescribers must justify overrides for frequency exceeding limits (e.g., status migrainosus or chronic migraine management).
GLP-1 and Anti-Obesity Agent Criteria
GLP-1 Agonists and Anti-Obesity Agents (preferred and non-preferred class-level criteria):
ALL of the following
GLP-1 agonists preferred agent PA criteria: require BMI threshold per labeling (e.g., BMI ≥30 or ≥27 with comorbidity) and documentation of lifestyle intervention attempts; for diabetes indications follow glycemic control documentation.
Non-preferred GLP-1 anti-obesity agents (e.g., Wegovy, Saxenda, Zepbound): require prior trial/failure or contraindication to preferred agents, BMI criteria, and long-term management plan with monitoring for adverse effects.
Non-GLP-1 anti-obesity class-level initial criteria: similar BMI and lifestyle intervention documentation, contraindication checks, and specialist consultation when appropriate.
Parkinson's disease and movement disorder agents
Parkinson's disease agents and movement disorder specifics:
ALL of the following
Anti-Parkinson non-preferred agent general PA criteria: document diagnosis, specialist (neurology) recommendation, prior trial of preferred therapies, and functional impact justifying use of non-preferred agent.
Gocovri (amantadine ER): specific criteria include diagnosis of levodopa‑induced dyskinesia, prior response to immediate‑release amantadine or other indicated therapies, and attestation of improvement for continuation.
Inbrija (levodopa inhalation): require documentation of OFF episodes despite optimized oral therapy and pulmonology considerations; quantity limits per inhalation dosing schedule.
Ongentys (opicapone) and Xadago (safinamide): require adjunctive use documentation with levodopa/carbidopa for motor fluctuations and prior trials of alternative adjunctive options when specified.
Inhaled agents and Hemangeol pediatric considerations
Beta-adrenergic and combination inhaled agents; Hemangeol (propranolol) pediatric limit:
ALL of the following
Beta-adrenergic and combination inhaled agents: require diagnosis (asthma/COPD), documentation of prior inhaled controller optimization, and age-appropriate device/formulation justification.
Hemangeol (oral propranolol) pediatric dosing limits: adhere to labeled pediatric age and weight limits; prior authorization required for doses or durations exceeding routine pediatric guidance.
Biologic immunomodulators - general and specific patterns
Biologic immunomodulators - preferred vs non-preferred and disease-specific patterns (consolidated):
ALL of the following
Biologic immunomodulators classified as non-preferred require documentation of trial and inadequate response or intolerance to preferred agents and adherence to step therapy sequences where applicable.
Disease-specific criteria examples: Crohn's disease, ulcerative colitis, plaque psoriasis, psoriatic arthritis, rheumatoid arthritis, juvenile idiopathic arthritis, nonradiographic axial spondyloarthritis, hidradenitis suppurativa, uveitis — each require diagnosis confirmation, prior conventional therapy trials, specialist prescribing (e.g., rheumatology, gastroenterology, dermatology, ophthalmology), and objective measures of disease severity and prior treatment response.
ENTYVIO® (vedolizumab) in Crohn's disease: require gastroenterologist documentation, prior conventional therapy trial failures, and objective evidence of active disease (endoscopy, imaging, biomarkers) per Crohn's criteria pattern.
Renewal criteria for biologics: documentation of clinical benefit, safety monitoring, and adherence; discontinuation if noncompliant or no demonstrable improvement.
Class‑level and specialty chronic disease PA patterns
Specialty chronic disease patterns and other class rules (consolidated):
ALL of the following
Inflammatory and autoimmune disease class patterns (psoriasis, psoriatic arthritis, RA, JIA, HS, spondyloarthritis, uveitis): require confirmation of diagnosis, prior conventional therapy trials (topical/systemic/steroids/DMARDs), specialist prescriber, and monitoring plan; biologic selection follows preferred agent hierarchy unless contraindicated.
BPH agents, calcium channel blockers (dihydropyridine and non-dihydropyridine), oral hypoglycemics including DPP-4 combinations: apply class-level preferred agent criteria and step therapy when specified.
Insulin and insulin mixes: general PA rules apply including prior authorization for non-preferred insulin formulations and combination products (Soliqua/Xultophy), with documentation of indication, prior regimen, and clinical rationale for non-preferred products.
Montelukast: age/form-specific PA criteria apply; provide age and indication justification for pediatric approvals when required.
PCSK9 inhibitors (Praluent/Repatha)
Praluent/Repatha (PCSK9 inhibitors) - Initial and Renewal Criteria:
ALL of the following
Indication-specific requirements (e.g., heterozygous familial hypercholesterolemia, clinical atherosclerotic cardiovascular disease) with LDL-C thresholds and documentation of maximally tolerated statin therapy +/- ezetimibe failure or intolerance.
Initial authorization requires lipid panel baseline and adherence plan; renewal requires LDL-C reduction or clinical benefit documentation and continued adherence.
Xhance (chronic rhinosinusitis)
Xhance (fluticasone) - chronic rhinosinusitis:
ALL of the following
Diagnosis of chronic rhinosinusitis with objective findings; documentation of prior intranasal steroid trial and response.
Prescriber specialty (ENT) recommendation when surgical considerations are present; approval based on symptomatic benefit and proper device use training.
Brensocatib (Brinsupri)
Brensocatib (Brinsupri) - Non-cystic fibrosis bronchiectasis:
ALL of the following
Diagnosis of non-cystic fibrosis bronchiectasis with recurrent exacerbations despite guideline-directed therapy; prescriber specialty and exacerbation history required.
Initial and renewal approvals based on reduction in exacerbation frequency and tolerability; include sputum cultures and baseline pulmonary function when available.
NSAID and gastroprotective combination products
Celecoxib / Vyscoca, Vimovo and ibuprofen/famotidine considerations:
ALL of the following
NSAID and COX-2 inhibitor use should follow GI risk assessment; Vimovo and ibuprofen/famotidine combinations require documentation of need for gastroprotection and justification for combination product instead of separate agents when specified.
Celecoxib/Vyscoca PA criteria require indication justification and cardiovascular/GI risk assessment per formulary rules.
Ophthalmic products and renewal rules
Eysuvis (loteprednol) renewal and topical ophthalmic products:
ALL of the following
Eysuvis renewal: require documentation of prior response for short-term use in dry eye disease flares per labeling and avoidance of chronic overuse; provide IOP monitoring plan if prolonged use anticipated.
Other ophthalmic products (e.g., Tyrvaya, cenegermin) require indication-specific documentation and specialty ophthalmology prescribing.
Opioid PA rules and chronic management
Opioids — Long Acting and Short Acting PA rules, MME criteria, and chronic opioid management:
ALL of the following
Opioid prior authorization applies to certain long-acting and non-preferred short-acting formulations. Provide indication, prior therapy attempts, and functional goals; adhere to MME limits and tapering plans as required by policy.
Chronic opioid management requires additional documentation: pain diagnosis, treatment plan, risk assessment (PDMP check), urine drug testing results when indicated, agreements/consent, and monitoring schedule.
Opioid transdermal products: coverage and PA logic follow specific product labeling, with consideration of previous opioid exposure and dose equivalence calculations.
Oral hypoglycemics and combination products
Class-specific Unique Criteria and Oral Hypoglycemics: DPP-4 combinations and preferred agents:
ALL of the following
Oral hypoglycemics containing DPP-4 inhibitors as combinations require indication of type 2 diabetes mellitus and documentation that component therapies are clinically appropriate; preferred agent criteria and step therapy apply.
Soliqua/Xultophy and other combination insulin/GLP products: require documentation of inadequate control on basal insulin and/or GLP-1 monotherapy trials and specialist endorsement when required.
Uterine disorder treatments
Uterine disorder treatments (Myfembree, Oriahnn, Orilissa):
ALL of the following
Indication-specific documentation required for heavy menstrual bleeding, uterine fibroids, or endometriosis per product labeling; include prior therapies and surgical history when applicable.
PA requires reproductive counseling for agents with hormonal effects and documentation of pregnancy avoidance when indicated.