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.

SourceLink

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

SourceLink

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Botulinum toxin initial/diagnosis-specific initial criteria

Botulinum toxin (J0585-J0588) — Approved Diagnoses and Initial Authorization Requirements

Approved Diagnoses (coverage when diagnosis is one of the following)

Anal fissures
Detrusor overactivity associated with a neurologic condition
Primary axillary hyperhidrosis
Palmar hyperhidrosis
Chronic migraine
Ptyalism/sialorrhea

General Initial Criteria

Documentation confirming the specific diagnosis for which botulinum toxin is being requested.
Documentation of prior conservative or first-line therapies trialed and failed when applicable to the diagnosis (see diagnosis-specific initial criteria).
Documentation of current weight when dosing is weight-based or required by the product labeling.
Prescriber specialty and age requirements met for the specific indication (as applicable).

Indication-specific Initial Authorization Requirements

Anal fissures - Specific Initial Criteria: documentation of chronic anal fissure refractory to medical therapy (e.g., topical nitrates or calcium channel blockers) and consideration of surgical options; documentation of failure of at least one course of conservative therapy.
Detrusor overactivity associated with a neurologic condition - Specific Initial Criteria: documentation of diagnosis with neurogenic detrusor overactivity, prior inadequate response or intolerance to anticholinergic or beta-3 agonist therapy, and objective bladder assessment as appropriate.
Primary axillary hyperhidrosis - Specific Initial Criteria: documentation of focal, bilateral axillary hyperhidrosis for at least 6 months with impairment of daily activities and failure of topical therapies (e.g., aluminum chloride).
Palmar hyperhidrosis - Specific Initial Criteria: documentation of focal, bilateral palmar hyperhidrosis for at least 6 months with impairment of daily activities and failure of topical therapies.
Chronic migraine - Specific Initial Criteria: documentation of chronic migraine diagnosis (>=15 headache days per month with >=8 migraine days), and documented trials of and inadequate response or intolerance to at least two oral preventive agents from different classes.

Dose & Frequency Constraint

Dose and frequency limited to FDA-approved dosing by indication and product labeling; ensure cumulative dose limits and minimum intervals between administrations are met.

Authorization Timeframes and Other Administrative Criteria

Initial authorization timeframes vary by indication (typical initial authorization: 3 to 6 months depending on diagnosis) — refer to the specific indication rules.
Therapy may be discontinued if patient is noncompliant or there is no demonstrable clinically significant improvement after initiation of therapy.
Some botulinum toxin uses require administration in specified settings per infusion/administration policies; document infusion location when applicable.

Applicable Codes

AdakveoHCPCSCovered

J0791

Crizanlizumab-tmca (Adakveo)

AdzynmaHCPCSCovered

J7171

ADAMTS13, recombinant-krhn (Adzynma)

AldurazymeHCPCSCovered

J1931

Laronidase (Aldurazyme)

Alpha1-proteinase inhibitor productsHCPCSCovered

J0256	Alpha1-proteinase inhibitor (Prolastin, Prolastin-C, Zemaira)
J0257	Alpha1-proteinase inhibitor (Glassia)

Botulinum toxin HCPCS codesHCPCS

J0584	Botulinum toxin type A
J0585	Botulinum toxin type A, first 5 units
J0586	Botulinum toxin type A, additional units
J0587	Botulinum toxin type A, other
J0588	Botulinum toxin type B
J0589	Botulinum toxin other

Immune globulin HCPCS codesHCPCSCovered

J1551	Immune globulin, intravenous, human, non-lyophilized (10%): 10 grams
J1555	Immune globulin, human, intramuscular
J1557	Immune globulin, human, subcutaneous
J1558	Immune globulin, human, subcutaneous, hyaluronidase facilitated
J1559	Immune globulin, human, other
J1561	Immune globulin, human, 5%
J1568	Immune globulin, human, 20%
J1569	Immune globulin, human, 10%
J1572	Immune globulin, human, IV, different descriptor

Other physician-administered drugs referencedHCPCS

J0567	Injection, unspecified
J0875	Injection, unspecified
J1202	Drug code J1202
J1203	Drug code J1203
J0129	Injection code J0129
J0178	Injection code J0178
J0180	Injection code J0180
J0218	Injection code J0218
J0219	Injection code J0219
J0221	Injection code J0221

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Q-code and miscellaneous HCPCS referencesmixed

Q5124	Miscellaneous Q-code Q5124
Q5128	Miscellaneous Q-code Q5128
Q5133	Miscellaneous Q-code Q5133
Q5135	Miscellaneous Q-code Q5135
Q5147	Miscellaneous Q-code Q5147
Q5151	Miscellaneous Q-code Q5151
Q5152	Miscellaneous Q-code Q5152
Q5156	Miscellaneous Q-code Q5156
Q5098	Miscellaneous Q-code Q5098
Q5098 JA	Miscellaneous Q-code Q5098 with modifier JA

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OpenPayer

Medical Drug Prior Authorization Criteria

Coverage Summary

Initial Therapy Criteria

Continuation Therapy Criteria

Unproven / Exclusions

Applicable Codes

Provider Actions & Operational Requirements