CurrentProvidence Health PlanPolicy N/A

Prior Authorization Criteria — Pharmacy Benefit (Coverage Criteria for Listed Drugs)

Defines clinical prior authorization criteria and lists drugs/groups subject to prior authorization under the pharmacy benefit; intended for providers and pharmacists submitting PA requests to Providence Health Plan.

Policy Summary

PayerProvidence Health Plan

PolicyPrior Authorization Criteria — Pharmacy Benefit (coverage criteria for listed drugs)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a prior authorization request specifying the exact product presentation (brand/strength/device) for any listed drug before coverage will be approved.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

20+drug categories or therapeutic groups listed

100+individual products/formulations enumerated

NCapplicable state

Prior Authorizationpolicy type

Coverage Criteria — Pharmacy Benefit Prior Authorization

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General coverage stance for listed products

Covered when prior authorization is obtained for the listed drugs under the pharmacy benefit as per the plan's clinical criteria.

Listed drug/groups: Drug or drug group appears in the document listing (e.g., Actinic keratosis agents; Acute hereditary angioedema therapy; Acute migraine medications; anticancer medications; CGRP receptor antagonists; CFTR modulators; GIP/GLP‑1 receptor agonists; and others).presence on list

Detailed clinical eligibility criteria per product are in later sections of the full policy.

General PA requirement for listed medications

Covered when prior authorization is obtained for the listed products and formulations

PA required: Prior authorization must be obtained for any of the enumerated medications, strengths, formulations, starter/titration kits, or device presentations listed in this section before coverage/dispensing.

List of products and specific presentations appears across the cited chunks.

Prior authorization — listed products

Medications enumerated in this segment are subject to prior authorization.

PA requirement: The listed medications require prior authorization before coverage is provided.

This portion of the document is a formulary-level list; specific clinical eligibility criteria for individual agents are contained elsewhere in the full policy.

Covered when prior authorization criteria met

Products listed below are subject to prior authorization

Listed product match: Requested drug must match one of the exact product presentations listed in the policy excerpt (brand or biosimilar, strength, and delivery device as specified).

Exact match to the listed presentation (e.g., specific pen, syringe, starter kit, dose pack) is required on the PA request.

Please note that additional restrictions and exclusions to drug coverage may apply; not all drugs listed in this policy are guaranteed to be covered without meeting the plan’s requirements. Coverage for the products in this document is subject to prior authorization and other plan rules, and benefit verification should be performed using the Drug Search formulary tool or by contacting Providence Health Plan Customer Service.

Within the excerpt reviewed there are no explicit coverage exclusions listed; the text presents product and formulation listings that are subject to prior authorization but does not identify specific products that are categorically excluded from coverage.

The excerpt identifies certain items as non-preferred fumarate products (examples given) but does not provide explicit coverage exclusions in these chunks. Non-preferred status is noted without a corresponding statement that the products are excluded from coverage.

No explicit exclusions are provided in this portion of the policy excerpt. The section lists starter and maintenance product presentations that require prior authorization but does not state that any of these items are excluded from coverage.

The document states “This is not a guarantee of coverage or benefits”. In the chunks reviewed, that statement is present but no specific not-medically-necessary (NMN) conditions are enumerated; clinical determinations of medical necessity are made through the prior authorization process and by reference to the member handbook.

In this excerpt there are no specific "not medically necessary" determinations defined. The text focuses on enumerating products and formulations that require prior authorization rather than listing NMN conditions.

Across chunks 36–55 reviewed here, the policy supplies product listings and formulary status but does not include explicit not medically necessary rulings for particular uses or clinical scenarios; coverage is described as dependent on meeting PA and plan criteria.

This excerpt does not list any items explicitly labeled as not medically necessary. Instead, it enumerates starter kits and product presentations that must be requested via prior authorization for coverage consideration.

Coding and Product Listings

Pharmacy products listedNDC|brand_generic

N/A	List enumerates drug names and strengths rather than procedure or billing codes in this portion of the document.

Listed products and formulations (no billing codes provided in this excerpt)mixed

No codes listed

Listed drugs (no CPT/HCPCS/NDC codes present)mixed

N/A	Product and strength listings (no billing codes provided in this segment)

Listed specialty drug presentationsmixed

Hyrimoz 80 MG/0.8 ML	Starter subcutaneous pen injector 80 mg/0.8 mL
HYRIMOZ 40 MG/0.4 ML	Subcutaneous pen injector 40 mg/0.4 mL
HYRIMOZ 20 MG/0.2 ML	Subcutaneous syringe 20 mg/0.2 mL
PYZCHIVA 45 MG/0.5 ML	Subcutaneous solution 45 mg/0.5 mL
ENTYVIO PEN 108 MG/0.68 ML	Subcutaneous pen injector 108 mg/0.68 mL
Idacio Pen 40 mg/0.8 mL	Subcutaneous kit/pen 40 mg/0.8 mL
ADALIMUMAB-AACF 40 MG/0.8 ML	Subcutaneous pen injector kit 40 mg/0.8 mL
OTULFI 45 MG/0.5 ML	Subcutaneous syringe 45 mg/0.5 mL
ustekinumab-aauz 45 MG/0.5 ML	Subcutaneous syringe 45 mg/0.5 mL
KINERET 100 MG/0.67 ML	Subcutaneous syringe 100 mg/0.67 mL

1–10 of 38

1/4

inv-17: XPOVIO dosing examples

XPOVIO — 60 mg twice-weekListed as XPOVIO oral tablet 60 mg twice week = 120 mg/week.

XPOVIO — 80 mg twice-weekListed as XPOVIO oral tablet 80 mg twice week = 160 mg/week.

XPOVIO — 100 mg per week (split doses)Listed as XPOVIO oral tablet 100 mg/week (50 mg x 2).

XPOVIO — 40 mg multiple formatsListed dose presentations include 40 mg twice week (40 mg x 2) and 40 mg/week (10 mg x 4).

Most actionable dosing summaryWhen submitting PA requests, specify the exact XPOVIO weekly regimen as listed (e.g., 60 mg twice-week = 120 mg/week).

inv-18: tovaptan titration examples

Tolvaptan — 15/15 mg scheduleListed sequential dosing: 15 mg (am)/15 mg (pm).

Tolvaptan — 30/15 mg scheduleListed sequential dosing: 30 mg (am)/15 mg (pm).

Tolvaptan — 45/15 mg scheduleListed sequential dosing: 45 mg (am)/15 mg (pm).

Tolvaptan — 60/30 mg and 90/30 mgAlso listed: 60 mg (am)/30 mg (pm) and 90 mg (am)/30 mg (pm) titration sequences.

Tolvaptan — individual strengthsIndividual tablet strengths listed include tolvaptan 15 mg and 30 mg formulations for ADPKD/polycystic kidney disease dosing schedules.

Actions Required by Providers and Pharmacies

Prior Authorization

Actions Required by Providers and Pharmacies

Drugs and device presentations listed in this document require prior authorization under the pharmacy benefit. Requests submitted without the required prior authorization may be denied. Coverage is not guaranteed; additional restrictions and exclusions may apply. Providers and patients should verify coverage via the Providence Health Plan Drug Search formulary tool or contact Providence Health Plan Customer Service at 503-574-7500 or 1-800-878-4445 (TTY: 711).

Prior authorization required for enumerated drugs, doses, and device formulations.
Denial risk if prior authorization is not obtained before claim submission.
Prescribers must submit documentation supporting medical necessity with the prior authorization request.
Submission must specify the exact product presentation (e.g., pen, syringe, autoinjector, kit, packet, dose).
Some entries are marked as "NEW DRUG AWAITING ORPTC REVIEW - PRIOR AUTHORIZATION REQUEST" indicating new-drug review steps may apply.
Some therapeutic classes are grouped but no step therapy details are present in this excerpt; check full policy for any step therapy requirements.

Definitions

inv-36: Prior authorization definition

DefinitionPrior authorization: a plan process requiring approval before coverage is provided for certain pharmacy products.

PurposeEnsures coverage is consistent with plan clinical criteria prior to dispensing.

Provider actionProviders must submit PA requests for listed drugs/formulations before coverage will be approved.

inv-37: Prior Authorization

RequirementPrior authorization is required for the enumerated medications, doses, and device formulations listed in this policy before coverage/dispensing.

ScopeApplies to specific products, strengths, delivery devices (pens, syringes, kits, oral tablets/capsules) named in the formulary sections.

ConsequenceLack of required prior authorization may result in denial of coverage for the requested drug/formulation.

inv-38: Non-preferred fumarate products

TermNON-PREFERRED FUMARATE PRODUCTS refers to specific delayed-release fumarate formulations listed as non-preferred.

ExamplesVUMERITY oral capsule, delayed release (DR/EC) 231 mg; BAFIERTAM oral capsule, delayed release (DR/EC) 95 mg.

ImplicationThese fumarate products are designated non-preferred within the document's formulary listing.

inv-39: starter pack/kit

DefinitionStarter pack / starter kit: a named initial presentation (pen, syringe, or kit) provided for initiation/titration of therapy.

Usage in listingsStarter presentations are enumerated for specific products (examples: Hyrimoz starter subcutaneous pen injector 80 mg/0.8 mL; Hyrimoz pedi Crohn starter syringe 80 mg/0.8 mL).

PA implicationWhen requesting prior authorization for initiation, the exact starter kit/pack presentation listed must be specified in the PA request.

Initial Therapy Prior Authorization Criteria

Initial therapy prior authorization

Initial prior authorization applies to the enumerated drugs/groups.

Initial PA: Provider must request prior authorization for the drug product listed before coverage is approved per plan rules.PA submission

Specific clinical eligibility criteria per drug are not included in these chunks and must be referenced in the full policy when available.

Initial therapy — kits and starter packs

Formulations and dose packs listed (e.g., ORENITRAM titration kits, TYVASO kits) are included in the PA list.

Initial PA listing: Specified starter kits, titration packs, and institutional/start kits for specialty agents require prior authorization when requested.

PA must identify the exact kit or dose pack presentation (e.g., ORENITRAM month titration kits, TYVASO starter/refill kits).

Starter kits/packs

Starter packs/kits are enumerated for certain products.

Starter kit match: When initiating therapy with a product that has a named starter kit or starter pen (examples in the list include Hyrimoz starter presentations; Idacio starter kits; Zeposia starter packs; multiple adalimumab starter kits), the specific starter presentation listed must be requested for prior authorization.

Request must specify the starter or titration presentation exactly as listed (brand/biosimilar and strength/device).

Step Therapy and Prior Failures

Note	Source
Policy states that additional restrictions and exclusions to drug coverage may apply; these additional restrictions may include step therapy edits, but specific step edits are not listed in this excerpt.
PRIOR AUTHORIZATION CRITERIA: Please note that additional restrictions and exclusions to drug coverage may apply.

Observation	Document text
Some newly listed medications are flagged for further review and prior authorization, indicating potential additional review/step requirements.
NEW DRUG AWAITING ORPTC REVIEW - PRIOR AUTHORIZATION REQUEST (example entries include Foundayo, Wegovy HD, Exdensur, etc.).

Implication	Text excerpt
Certain products are designated as non-preferred (e.g., non-preferred fumarate products), which implies alternative or step therapy policies may apply though specifics are not provided here.
NON-PREFERRED FUMARATE PRODUCTS, 1 = VUMERITY ORAL CAPSULE,DELAYED RELEASE(DR/EC) 231 MG, BAFIERTAM ORAL CAPSULE,DELAYED RELEASE(DR/EC) 95 MG.

Therapeutic class	Step therapy detail present?
VMAT2 inhibitors (Austedo, Ingrezza, tetrabenazine) and weight management medications (Zepbound, Vyleesi, etc.) are listed as therapeutic classes.
No specific required prior failures, sequencing, or step-therapy logic for individual products is specified in this excerpt.

OpenPayer

Prior Authorization Criteria — Pharmacy Benefit (Coverage Criteria for Listed Drugs)

Coverage Criteria — Pharmacy Benefit Prior Authorization

Coding and Product Listings

Actions Required by Providers and Pharmacies

Background and Scope

Definitions

Initial Therapy Prior Authorization Criteria

Step Therapy and Prior Failures

Site of Care and Administration Settings

Biosimilar Products