CurrentUnitedHealthcarePolicy N/A

Ohio Medicaid Unified Preferred Drug List (UPDL) — Pharmacy PA and Step Therapy Rules

Governs prior authorization, step therapy, and coverage rules for Medicaid Fee-for-Service and Managed Care outpatient prescription drugs in Ohio; affects prescribers, pharmacies, and Medicaid members receiving drugs listed on the UPDL.

Policy Summary

PayerUnitedHealthcare

PolicyOhio Medicaid Unified Preferred Drug List (UPDL) — Pharmacy PA and Step Therapy Rules

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization with required documentation of inadequate trials of preferred drugs and supporting clinical data when requesting non-preferred UPDL agents.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

365common length of authorization (days)

30 MEDinitial opioid limit

120insulin step trial (days)

180MAT authorization (days)

≥70%Afrezza FEV1 requirement

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Coverage Criteria and Class-Specific Rules

inv-01: All Authorizations — general 'Covered when ALL of the following are met' rules across UPDL

Covered when ALL of the following are met:

ALL of the following

For ALL authorizations: trials of preferred agents and documentation per UPDL general rules are met (see General Information and UPDL Format).
Step therapy and non-preferred requirements for this category are satisfied as described below where applicable.

inv-02: Non-Preferred and Step Therapy Criteria — non-preferred covered only when criteria met

Non-preferred agents and step therapy rules (apply when drug is non-preferred or subject to step therapy):

ALL of the following

Non-preferred agent requests must document medical necessity beyond convenience (e.g., allergy, drug-drug interaction, contraindication, intolerance) or inadequate clinical response to preferred agents as specified in class-specific rules.
For non-preferred combination products, must document inadequate clinical response of preferred individual components.
Trials of preferred strengths are required prior to non-preferred strengths (when available).

inv-03: Opioid Authorization Criteria — opioid prescriptions subject to additional requirements

Opioid-specific authorization requirements (additional to general rules):

ALL of the following

Ohio OARRS review required before initial prescribing of controlled substances where applicable.
Initial opioid requests defined as no opioid claims in prior 90 days; initial limits and documentation requirements apply (treatment plan, risk assessment, urine drug screening where required).
Exemptions include active cancer treatment, palliative care, end-of-life/hospice care, sickle cell, severe burns, major trauma, certain surgical events, and patients in LTC for specific requirements (see opioid section).

inv-04: Opioid therapy (short-acting and long-acting) coverage criteria — Covered when ALL of the following are met

Opioid therapy coverage criteria — Covered when ALL of the following are met:

ALL of the following

Short-acting and long-acting opioid requests must meet Ohio law OARRS requirements and demonstrate inadequate response to non-opioid modalities when indicated.
Initial short-acting/long-acting requests may be authorized up to 90 days; subsequent up to 180 days. Initial opioid therapy limited to 30 MED/day and max 7 days without PA to exceed limits unless documented exemptions apply.
Dose escalation >80 MED/day requires specialist involvement or consultation and prescriber attestation of expected functional improvement.
Long-acting opioid initial requests require ≥30 of last 60 days opioid use and treatment plan including risk mitigation (opioid contract, baseline urine drug test, pain/function scores) unless exempted (cancer, palliative, LTC exceptions).

inv-05: Colony stimulating factors (CSFs) coverage criteria

Colony stimulating factors (CSFs) coverage criteria:

ALL of the following

Must provide diagnosis, patient weight for weight-based dosing, and duration of treatment (lengths per regimen).
Non-preferred CSFs require inadequate clinical response of at least 14 days with at least one preferred drug in the UPDL category and indicated for diagnosis.

inv-06: Hematopoietic agents (epoetin/darbepoetin) coverage criteria

Hematopoietic agents (epoetin/darbepoetin) coverage criteria:

ALL of the following

Provide baseline hemoglobin; length of authorization varies (180 days; 365 days for chronic renal failure).
Non-preferred criteria: inadequate response of at least 30 days with at least two preferred drugs in the UPDL category and indicated for diagnosis. Additional darbepoetin criteria and subsequent authorization require current hemoglobin labs.

inv-07: Hemophilia and factor products coverage criteria

Hemophilia and factor products coverage criteria:

ALL of the following

Provide patient weight for weight-based dosing; specify on-hand/on-demand use when applicable.
Non-preferred criteria: inadequate clinical response (increased bleeding, need for more replacement, worsening joint health) of at least 14 days with at least one preferred drug and indicated for diagnosis. Additional EHL factor and specific agent criteria apply (hematologist involvement for certain agents).

inv-08: Anticoagulants and antiplatelet agents coverage criteria

Anticoagulants and antiplatelet agents coverage criteria:

ALL of the following

Lengths of authorization and non-preferred criteria vary by class; non-preferred typically require inadequate clinical response of specified duration with preferred agents (e.g., 14 or 30 days) and indicated for diagnosis.

inv-09: Cardiovascular agents and specialty drug additional criteria

Cardiovascular agents and specialty drug additional criteria:

ALL of the following

Class-specific additional criteria (e.g., vericiguat hospitalization and background therapy requirements) must be met; non-preferred criteria require trials of preferred agents per UPDL rules.

inv-10: Vericiguat (VERQUVO) — Initial criteria

Vericiguat (VERQUVO) — Initial criteria:

ALL of the following

Must provide ejection fraction; hospitalization for heart failure in prior 180 days or outpatient IV diuretic in prior 90 days; must be treated with agents from all listed background classes (ACEi/ARB/ARNI, beta-blocker, aldosterone antagonist and/or SGLT2 inhibitor as appropriate) unless contraindicated.

inv-11: Sotagliflozin (INPEFA) — Prior SGLT2 therapy required

Sotagliflozin (INPEFA) — Prior SGLT2 therapy required:

ALL of the following

Must provide documentation of inadequate clinical response to at least two SGLT2 inhibitors (see Diabetes—NonInsulin class for full list).

inv-12: Amlodipine (NORLIQVA) — Trial requirement

Amlodipine (NORLIQVA) — Trial requirement:

ALL of the following

Must have had inadequate clinical response of at least 30 days with KATERZIA prior to authorization.

inv-13: Pulmonary arterial hypertension — PA criteria

Pulmonary arterial hypertension — PA criteria:

ALL of the following

Must provide NYHA functional class documentation; non-preferred PAH agents require trials of preferred agents per UPDL and one must be a PDE5 inhibitor when available.

inv-14: Lipid-lowering agents — Clinical PA criteria

Lipid-lowering agents — Clinical PA criteria:

ALL of the following

Baseline labs and adherence to 90 days of preferred lipid medications required; inadequate response definitions and LDL goal documentation apply. Non-preferred requires trials per class-specific durations (e.g., 30 or 90 days).

inv-15: Pulmonary Hypertension agents (selexipag, sotatercept, PDE5 inhibitors, prostaglandins)

Pulmonary Hypertension agents (selexipag, sotatercept, PDE5 inhibitors, prostaglandins):

ALL of the following

Selexipag and sotatercept require WHO Group 1 diagnosis and functional class II–III with failure of preferred meds from two subclasses ≥90 days unless contraindicated; tadalafil/sildenafil specific trial requirements apply.

inv-16: Migraine prophylaxis biologics and agents

Migraine prophylaxis biologics and agents (erenumab, fremanezumab, galcanezumab, rimegepant):

ALL of the following

Step therapy: Must have had an inadequate clinical response of at least 30 days with at least two preferred controller migraine drugs (beta-blockers, anticonvulsants, SNRIs, or tricyclic antidepressants). For patients already on a serotonergic medication, only one preferred controller required.
Specific agent rules: Erenumab (AIMOVIG) — must have had inadequate response of at least 60 days at 70 mg dose before dose increase. Fremanezumab (AJOVY) — must demonstrate efficacy for at least 90 days before quarterly dosing is authorized. Galcanezumab (EMGALITY) and rimegepant (NURTEC ODT/QULIPTA) follow class step therapy rules; non-preferred criteria require inadequate response of at least 30 days with three preferred controller migraine drugs and one step therapy drug in this UPDL category where noted.
Documentation required: objective documentation of severity, frequency, type of migraine, and number of headache days per month. Subsequent authorization requires documentation of clinical response (severity, frequency, headache days/month).

inv-17: Anticonvulsant / epilepsy agent criteria (including EPIDIOLEX, DIACOMIT, FINTEPLA, XCOPRI)

Anticonvulsant / epilepsy agent criteria (including EPIDIOLEX, DIACOMIT, FINTEPLA, XCOPRI):

ALL of the following

Class-specific step and non-preferred trial requirements apply; certain agents require specialist prescribing and combination trials as noted (e.g., EPIDIOLEX requires trials of two designated anticonvulsants).

inv-18: Antidepressant categories and psychiatrist exemption

Antidepressant categories and psychiatrist exemption:

ALL of the following

Psychiatrist exemption allows specified mental health prescribers credentialed with ODM to be exempt from PA for non-preferred antidepressants in standard tablet/capsule forms; other dosage forms may still require PA.

inv-19: Psychiatrist prescriber exemption — conditions when exemption applies

Psychiatrist prescriber exemption — conditions when exemption applies:

ALL of the following

Exemption processed when pharmacy submits prescriber's individual NPI on claim; applies to psychiatrists and certified psychiatric nurse practitioners/clinical nurse specialists credentialed with ODM for standard tablet/capsule antidepressants and select antipsychotics per section rules.

inv-20: ADHD step/non-preferred criteria

ADHD step/non-preferred criteria:

ALL of the following

Non-preferred ADHD agents require inadequate response of at least 30 days with at least two preferred drugs in the UPDL category and indicated for diagnosis. Immediate- vs extended-release formulation trials must match formulation type.

inv-21: Paliperidone palmitate criteria

Paliperidone palmitate criteria:

ALL of the following

Must have had 4 months of INVEGA SUSTENNA or 3 months with INVEGA TRINZA prior to paliperidone palmitate initiation; step and non-preferred trials apply as noted.

inv-22: LUCEMYRA criteria

LUCEMYRA criteria:

ALL of the following

May be authorized only if all: medical justification why opioid taper (e.g., buprenorphine/methadone) cannot be used; inadequate response or contraindication to clonidine; documentation if initiated inpatient to exempt above criteria.

inv-23: Pimavanserin (NUPLAZID) criteria

Pimavanserin (NUPLAZID) criteria:

ALL of the following

For Parkinson-related hallucinations/delusions all must be met: psychotic symptoms severe enough for antipsychotic; symptoms not related to dementia/delirium; adjustment of Parkinson's meds attempted or intolerable; inadequate response or contraindication to at least 30 days of quetiapine or clozapine. Neurology prescriber exemption may apply.

inv-24: Movement disorder agent criteria

Movement disorder agent criteria:

ALL of the following

Class-specific step and non-preferred trials apply; certain agents require neurologist/psychiatrist prescribing or documented trials of preferred agents as noted (e.g., tetrabenazine trials for Huntington's).

inv-25: Parkinson 'off' episode agent criteria

Parkinson 'off' episode agent criteria:

ALL of the following

Apomorphine, levodopa inhalation, and istradefylline require inadequate response to at least 30 days with one other drug for 'off' episodes; ONAPGO and VY-ALEV require trials including carbidopa/levodopa and documentation of ≥2.5 hours 'off' time per day using PD diary for authorization.

inv-26: Narcolepsy agent criteria

Narcolepsy agent criteria:

ALL of the following

Non-preferred narcolepsy agents require inadequate clinical response to at least two preferred drugs (specified durations) and indicated for diagnosis; oxybate salts require sodium-restricted diet adherence where applicable.

inv-27: Parkinson's agents - additional PA criteria

Parkinson's agents - additional PA criteria:

ALL of the following

Many Parkinson's class agents require 30-day trials of preferred drugs within same sub-section classification and documentation of indication; specialist consultation may be required for advanced therapies.

inv-28: Diabetes agents - step and safety criteria

Diabetes agents - step and safety criteria:

ALL of the following

Non-preferred diabetes agents generally require inadequate clinical response after at least 120 days with specified numbers of preferred drugs (varies by class); subsequent authorizations require recent A1C and documentation of improvement or stabilization and safety monitoring.

inv-29: EMFLAZA (Duchenne Muscular Dystrophy) criteria

EMFLAZA (Duchenne Muscular Dystrophy) criteria:

ALL of the following

Prescribed by or in consultation with neurologist/specialist; documented DMD via genetic testing or muscle biopsy; prior inadequate response or contraindication to prednisone of specified duration; provide patient weight; non-preferred criteria and subsequent monitoring apply.

inv-30: Sedative-hypnotics PA

Sedative-hypnotics PA:

ALL of the following

Non-preferred sedative-hypnotics require inadequate clinical response of at least 7 days with two preferred drugs and indicated for diagnosis; non-controlled meds may be authorized if prescriber documents history of addiction.

inv-31: Muscle relaxants PA

Muscle relaxants PA:

ALL of the following

Non-preferred muscle relaxants require inadequate response of at least 30 days with two preferred drugs in the UPDL category and indicated for diagnosis; some agents require medical justification (e.g., carisoprodol).

inv-32: Androgens PA

Androgens PA:

ALL of the following

Provide baseline labs supporting need for testosterone; non-preferred require inadequate response of at least 90 days with all preferred drugs in category; subsequent authorization requires testosterone and hematocrit monitoring.

inv-33: Oral acne products PA

Oral acne products PA:

ALL of the following

Non-preferred oral acne products require inadequate response of at least 90 days with at least one preferred topical and one preferred oral antibiotic; length of authorization limited (150 days) with required off period after completion.

inv-34: Diabetes: Initial and Subsequent Authorization — non-preferred diabetes agents examples

Diabetes: Initial and Subsequent Authorization — non-preferred diabetes agents examples and inhaled insulin restrictions:

ALL of the following

Initial/successive authorizations require A1C documentation, patient-specific A1C goal if <7%, and demonstration of inadequate response to preferred agents per class-specific rules. Inhaled insulin (Afrezza) requires spirometry with predicted FEV1 ≥70% prior to initiation, is not authorized for patients with asthma or COPD, and requires nicotine-free status for 180 days.

inv-35: Inhaled insulin (Afrezza) — restrictions and requirements

Inhaled insulin (Afrezza) — restrictions and requirements:

ALL of the following

Spirometry prior to initiation with predicted FEV1 ≥70%; not authorized for patients with asthma or COPD; documentation of nicotine-free status for at least 180 days required.

inv-36: Pancreatic Enzymes — coverage conditions

Pancreatic Enzymes — coverage conditions:

ALL of the following

For cystic fibrosis no trials required; other diagnoses require inadequate response of at least 14 days with at least one preferred drug. Non-preferred require inadequate response of at least 14 days with at least two preferred drugs and indicated for diagnosis.

inv-37: Proton Pump Inhibitors (PPI) — higher-than-once-daily dosing rules

Proton Pump Inhibitors (PPI) — higher-than-once-daily dosing rules:

ALL of the following

For PPI doses > once daily must document inadequate response of at least 30 days of once-daily dosing with requested drug OR provide diagnosis documentation for H. pylori or specified chronic conditions; authorization lengths vary by indication.

inv-38: Genitourinary agents - Subsequent authorization

Genitourinary agents - Subsequent authorization (BPH, 5AR inhibitors, PDE5 inhibitors, combinations):

ALL of the following

Subsequent authorization length generally 365 days. Non-preferred criteria: inadequate clinical response of at least 60 days with at least two preferred drugs, with at least one preferred within same sub-section when available, and indicated for diagnosis.
5-alpha-reductase inhibitors (dutasteride, finasteride): non-preferred require 60-day inadequate response with two preferred drugs; tadalafil for BPH requires inadequate response of at least 30 days to an alpha-1 blocker; if prostate volume >30 cc, PSA >1.5 ng/dL, or palpable enlargement, a 90-day finasteride trial is required prior to combination products.
Alpha blocker/5AR/PDE5 combinations and dutasteride/tamsulosin follow same subsequent authorization rules (365 days) and trial requirements as above.

inv-39: Electrolyte depleter agents - Subsequent and step therapy

Electrolyte depleter agents - Subsequent and step therapy (calcium-, iron-, phosphate-based):

ALL of the following

Length of authorization typically 365 days. Step therapy: must have had inadequate clinical response of at least 7 days with at least one preferred drug in the UPDL category prior to non-preferred step therapy agents.
Non-preferred criteria: must have had inadequate clinical response of at least 14 days with at least one preferred step therapy drug in the category and indicated for diagnosis, if available. Applies to calcium-based (e.g., calcium acetate, carbonate), iron-based, sevelamer, ferric citrate (VELPHORO), lanthanum, and other phosphate binders.

inv-40: Immunomodulators, biologics, JAK inhibitors, TNF inhibitors - Subsequent authorization and step therapy

Immunomodulators, biologics, JAK inhibitors, TNF inhibitors - Subsequent authorization and step therapy:

ALL of the following

Initial lengths often 90 days with subsequent 365 days. Clinical PA criteria require absence of active infection and negative TB test within past 365 days if labeling requires. Step therapy: inadequate response of at least 90 days with at least one preferred TNF inhibitor where applicable. Non-preferred immunomodulators require inadequate response of at least 90 days with at least two preferred drugs that are not biosimilars of same reference product; documentation of response to preferred reference product or biosimilar may be required.

inv-41: Inhaled tobramycin - Subsequent authorization

Inhaled tobramycin - Subsequent authorization:

ALL of the following

Initial: 180 days; subsequent: 365 days. Clinical PA requires cultures demonstrating appropriateness; non-preferred requires inadequate response of at least 28 days with one preferred drug. Subsequent authorization requires documentation of clinical response (culture conversion, symptom improvement).

inv-42: Oral antibiotics - Subsequent authorization

Oral antibiotics - Subsequent authorization (cephalosporins, macrolides, quinolones) and class rules:

ALL of the following

PA lengths based on indication; non-preferred cephalosporins/macrolides/quinolones require inadequate clinical response of at least 3 days with at least one preferred drug in UPDL category and indicated for diagnosis. Requests may be authorized to complete courses started inpatient or prior to Medicaid eligibility for remaining therapy only.
Subsequent authorization requires documentation of patient's clinical response, ongoing safety monitoring, and medical necessity for continued use. Specific age-related AR restrictions apply to certain oral suspension formulations (e.g., cefaclor susp, cefixime susp, cefprozil susp, clarithromycin susp, ciprofloxacin susp, levofloxacin soln).

inv-43: Macrolides - Subsequent Authorization

Macrolides - Subsequent Authorization (see Oral antibiotics section for shared rules):

ALL of the following

Non-preferred macrolides require inadequate response of at least 3 days with a preferred drug; subsequent authorization requires documentation of response and ongoing safety monitoring; age-related ARs apply to suspensions as noted.

inv-44: Quinolones - Subsequent Authorization

Quinolones - Subsequent Authorization (see Oral antibiotics section for shared rules):

ALL of the following

Non-preferred quinolones require inadequate response of at least 3 days with a preferred drug; subsequent authorization requires documentation of response and ongoing safety monitoring; age-related ARs apply to oral suspensions where specified.

Initial Therapy and New-Start Requirements

Prior Authorization

Prior Authorization: General Rule

Prior authorization (PA) is required for all non-preferred drugs and for opioid requests that exceed program limits. Prescribers must submit documentation of required trials, clinical rationale, and supporting clinical data (see items). Failure to provide required trial documentation or clinical justification will result in denial. All authorizations must be prescribed in accordance with FDA labeling or supported compendia.

PA required for non-preferred drugs across therapeutic classes
PA required to exceed initial opioid limits (daily MED >30 for initial short-acting; >30 days/30 MED limit exceptions require PA)
All non-preferred authorizations must include documentation of medical necessity beyond convenience (e.g., allergies, drug–drug interactions, contraindications, intolerances)
For non-preferred strengths, a trial and failure of preferred strengths is required
Authorizations must be prescribed in accordance with FDA labeling or CMS-supported compendia
For any nonsolid oral dosage formulation, document why a solid oral dosage cannot be used
For non-preferred extended-release formulations, document inadequate response to immediate-release formulation
Long-acting opioid requests >80 MED require prescription by or consultation with a pain specialist or anesthesiologist

Continuation, Reauthorization, and Legacy Rules

Prior Authorization

Inhaled tobramycin PA — initial 180 days, subsequent 365 days; supply cultures

Inhaled tobramycin products require prior authorization: initial authorization is for 180 days and subsequent authorizations are 365 days; providers must supply cultures demonstrating the prescription aligns with the approved indication.

LENGTH OF AUTHORIZATIONS: Initial: 180 days; Subsequent: 365 days.
Clinical PA criteria: must provide documentation of cultures demonstrating drug is prescribed in alignment with approved indication.

Documentation Required

Subsequent PA renewals require clinical response and safety monitoring

For renewals of non-preferred agents, including inhaled antibiotics, providers must document the patient’s clinical response and evidence of ongoing safety monitoring (e.g., culture conversion or symptom improvement) to support subsequent authorization.

Subsequent authorizations require documentation of patient's clinical response to treatment and ongoing safety monitoring.

Step Therapy Tables and Trial Requirements

Requirement	Details
Trials may be concurrent for the specified duration	Multiple preferred drugs may be used concurrently for the required trial period (e.g., each drug used for 120 days) per UPDL guidance
Exceptions: 'if available' and limited availability	If only one preferred agent exists in a sub‑section or preferred product is on backorder, the 'if available' exception applies

Documentation requirement	What to include
Documentation of trials and inadequate clinical response required for non‑preferred agents	Must document medical necessity beyond convenience (e.g., allergy, interaction, contraindication, intolerance) per general PA rules
For subsequent authorizations include documentation of patient's clinical response and ongoing safety monitoring	Provide objective response measures where applicable (e.g., A1C for diabetes, pain/function scores and urine drug screening for opioids, culture results for inhaled antibiotics)

Step requirement	Scope
Must trial preferred agents within the UPDL category before non‑preferred authorization	Non‑preferred criteria require inadequate clinical response to specified preferred agents and durations as listed in the category
Cumulative top‑to‑bottom UPDL format applies — follow category/sub‑section placement when identifying required preferred drugs	If preferred agents with the same indication are not available, non‑preferred may be exempt per document guidance

Number of preferred trials required	Prescriber/exemption notes
Typically requires trials of 1–3 preferred agents depending on class and indication (specific categories state exact number)	Examples: migraine biologics require ≥2 preferred controller drugs; some categories require 3 preferred drugs for non‑preferred diabetes agents per examples
Neurologist or psychiatrist prescriber exemptions or specialty requirements apply in some cases (e.g., stiripentol requires neurologist involvement; psychiatrist exemption for antidepressants/antipsychotics)	Psychiatrist exemption requires credentialing and NPI submission; when met, prior authorization/step therapy may be waived for specified formulations

Required demonstrated trials	Examples of preferred agents to trial
Documented trials of specified preferred agents in the UPDL category are required prior to coverage of non‑preferred agents	Trial durations commonly at least 30 days unless category specifies otherwise
Examples: ADHD — trial of atomoxetine or at least one preferred ADHD agent for ≥30 days before non‑preferred; movement disorders — trial of tetrabenazine (90 days) before alternatives	For some CNS agents, trials must match formulation type (IR vs ER) per document guidance

Insulin step requirement	Duration/thresholds
Non‑preferred insulins require trial(s) of preferred insulins of similar duration before authorization	Inadequate clinical response must be documented (inability to reach target A1C) after the trial
Typical required trial duration is at least 120 days with at least one preferred agent of similar duration; some non‑preferred categories require failure of two preferred agents	Afrezza (inhaled insulin) additionally requires spirometry (predicted FEV1 ≥70%) and nicotine‑free status ≥180 days and is not authorized for asthma/COPD
searchable":true},{

Parkinson step requirement	Specific conditions
Trial of one preferred agent (or two for certain agents) in the Parkinson's UPDL category required prior to authorization of non‑preferred agents	Non‑preferred criteria often require trial of two preferred drugs within the same sub‑section for some agents (COMT inhibitors, etc.)
For Onapgo and VyaLev: inadequate response to at least two preferred drugs (one must be carbidopa/levodopa) and documentation of ≥2.5 hours/day 'off' time by PD diary	General 'off' episode agents require ≥30 days inadequate response to a COMT inhibitor, dopamine agonist, or MAO‑B inhibitor

Specified‑indication step requirement	Example (endometriosis)
Trial(s) of specified preferred agents are required before non‑preferred use for certain indications	Documentation must show inadequate clinical response for the category‑specified duration
Endometriosis example: must have had ≥84 days inadequate response with at least one preferred NSAID and one oral contraceptive prior to non‑preferred agents; lifetime duration limits noted for some agents	GI and other categories similarly specify 14–84 day trials depending on sub‑class

Class‑wide step requirement	General rule
Must trial and fail the required number of preferred agents (often at least one or two depending on class) before coverage of non‑preferred agents	Required durations vary by class (examples: 7, 14, 30, 90 days) — follow the category‑specific criteria
For immunomodulators/biologics: typically ≥90 days inadequate response to at least one preferred TNF inhibitor; non‑preferred often require failure of two preferred drugs not biosimilars of same reference product	Antibiotics/ophthalmics: acute agents commonly require ≥3 days inadequate response to a preferred agent; tetracyclines acne require ≥90 days

Preferred trials before non‑preferred	Notes
Preferred agents must be tried and inadequate response documented before non‑preferred authorization	Duration requirements vary; providers must document clinical response and medical necessity
Examples: electrolyte depleters require 7–14 day trials; dry eye treatments require 14 day trial within prior 120 days; ophthalmic acute agents often 3 days	Requests to complete a hospital‑initiated course may be authorized only for the remaining course when appropriate

Topical immunomodulator step therapy	When step may be waived
Step therapy attempt is required prior to coverage of certain topical immunomodulators (e.g., OPZELURA, VTAMA, ZORYVE)	Non‑preferred topical immunomodulators require inadequate response of at least 90 days with at least one preferred drug
Step may be waived if documentation explains why patient cannot use non‑step therapy products (medical contraindication/intolerance)	Age‑based PA requirements apply for some topical agents (e.g., tacrolimus/pimecrolimus PA for <2 years)

Inhaled agent step therapy	Required trials/documentation
Step therapy required before coverage of some inhaled non‑preferred agents	Must document inadequate clinical response to defined inhaled therapies per category before escalation
Example: must have ≥14 days inadequate response to an albuterol product; step may require ≥30 days inadequate response to ICS+LABA+LAMA concurrently if available	Inhaled insulin (Afrezza) requires spirometry with predicted FEV1 ≥70% and nicotine‑free status ≥180 days; Afrezza not authorized for asthma/COPD

Drug Lists, Codes, and Key Clinical Thresholds

Drug lists and categoriesmixed

N/A	Document lists many drug names and categories rather than numeric codes; no CPT/HCPCS/ICD codes present in this section.

Calcium Channel Blockersmixed

amlodipine	listed calcium channel blocker
diltiazem IR	listed calcium channel blocker
verapamil ER	listed calcium channel blocker (generic of VERELAN PM)

Diuretics and related agentsmixed

spironolactone	diuretic listed
furosemide	diuretic listed
torsemide	diuretic listed

Specific branded cardiovascular agentsmixed

VERQUVO	vericiguat; additional criteria including ejection fraction and recent heart failure hospitalization
INPEFA	sotagliflozin; requires prior inadequate response to at least two SGLT2 inhibitors
CAMZYOS	listed cardiovascular agent

PCSK9 inhibitors and other lipid agentsmixed

PRALUENT	PCSK9 inhibitor (PA referenced)
REPATHA	PCSK9 inhibitor (PA referenced)
JUXTAPID	lomitapide (length of authorization noted)

PDE5 inhibitors and related productsmixedCovered

sildenafil	sildenafil (PA / sildenafil susp)
tadalafil	tadalafil (TADLIQ)

Anticonvulsants / epilepsy agentsNDCCovered

EPIDIOLEX	cannabidiol (EPIDIOLEX)
DIACOMIT	stiripentol (DIACOMIT)
FINTEPLA	fenfluramine (FINTEPLA)
XCOPRI	cenobamate (XCOPRI)

Migraine prophylaxis biologics and agentsNDCCovered

AIMOVIG	erenumab
AJOVY	fremanezumab
EMGALITY	galcanezumab
NURTEC ODT	rimegepant (NURTEC ODT)

Antidepressant classesmixed

SSRIs	Selective serotonin reuptake inhibitors (listed examples: citalopram, escitalopram, fluoxetine, paroxetine, sertraline)
SNRIs	Serotonin-norepinephrine reuptake inhibitors (examples listed)

Named drugs and formulations citedmixed

aripiprazole	aripiprazole (multiple formulations listed, preferred and non-preferred variants)
citalopram	citalopram (tablet, solution)
escitalopram	escitalopram (tablet, solution)
fluoxetine	fluoxetine (IR 10/20/40 mg, solution, 60 mg)
sertraline	sertraline (tablet, capsule)
mirtazapine	mirtazapine
tranylcypromine	tranylcypromine
vilazodone	vilazodone
paliperidone palmitate	INVEGA HAFYERA (paliperidone palmitate) — criteria reference
buprenorphine	buprenorphine products (including SUBOXONE, SUBUTEX restrictions)

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Mentioned products (selection)NDC | mixed

BAQSIMI	glucagon emergency kit
GVOKE	glucagon product
ZEGALOGUE	dasiglucagon
JANUMET	sitagliptin/metformin
JANUVIA	sitagliptin
LANTUS	insulin glargine
HUMALOG	insulin lispro

Selected drug names mentionedNDC|mixed

JANUMET	Janumet (sitagliptin/metformin) referenced as non-preferred
JANUVIA	Sitagliptin referenced
MOUNJARO	Tirzepatide referenced (Mounjaro)
CREON	Pancreatic enzyme product
ZENPEP	Pancreatic enzyme product

Antibiotics and age-restricted formulationsmixed

AR	Age restriction / prior authorization required for certain oral suspensions

Authorization modifiersModifier

AR	Prior authorization required / age-restricted PA

Ophthalmic NSAIDs - Non-preferred examplesmixedNot Covered

ACUVAIL	Non-preferred ophthalmic NSAID (example listed)
ILEVRO	Non-preferred ophthalmic NSAID (example listed)

Epinephrine auto-injectorsmixed

EPIPEN	Preferred epinephrine auto-injector (labeler 49502) listed
AUVI-Q	Non-preferred epinephrine auto-injector

Monoclonal antibodies - respiratory (examples)mixed

CINQAIR	Monoclonal antibody - PA required
DUPIXENT	Monoclonal antibody - PA required
FASENRA	Monoclonal antibody - PA required
NUCALA	Monoclonal antibody - PA required
XOLAIR	Monoclonal antibody - PA required
TEZSPIRE	Listed as non-preferred agent

Other respiratory and topical agentsmixed

montelukast	Leukotriene receptor modifier
zafirlukast	Leukotriene receptor modifier
permethrin	Topical antiparasitic (preferred example)
ivermectin	Non-preferred topical antiparasitic example

Preferred-drug Trial Duration Example

Preferred-drug trial duration exampleEach preferred trial drug must be used for 120 days (unless medically inappropriate); concurrent trials may be used if clinically appropriate.

Acceptable concurrent useMultiple preferred drugs may be used concurrently for the 120-day trial period if clinically appropriate.

Exception for limited availability'If available' exceptions apply when only one preferred agent exists in the sub-section or preferred drugs are on backorder.

Provider Requirements, Documentation, and Denial Risks

Prior Authorization

PA required for non-preferred and new-to-market UPDL drugs

Prior authorization is required for UPDL non-preferred drugs and many new-to-market drugs until ODM P&T review; PA requests must follow the UPDL cumulative top-to-bottom criteria and drug-specific rules.

Medications new to market will be non-preferred and PA required until P&T review.
All authorizations must be prescribed in accordance with FDA labeling or listed on a CMS-supported compendia and follow the cumulative UPDL format.

Prior Authorization

PA required for non-preferred agents and opioid exceedance

Prior authorization is required for many non-preferred agents and for opioid prescriptions that exceed initial limits (initial opioid prescriptions limited to 30 MED/day and 7 days for opioid‑naïve patients); initial and reauthorization durations are specified in the UPDL.

Initial opioid limits: 30 MED/day and maximum 7 days for patients with no opioid claims in prior 90 days; PA required to exceed these limits.
Initial requests may be authorized up to 90 days; subsequent/reauthorizations up to 180 days.

Quantity, Dosing, and Authorization Durations

Opioids (Initial) — Quantity Limits

Opioids (initial) — MED limitInitial opioid prescriptions for opioid‑naïve patients are limited to 30 MED per day.

Initial day supplyInitial opioid prescriptions limited to a maximum of 7 days for opioid‑naïve patients; PA required to exceed.

Authorization periodsInitial opioid authorizations may be up to 90 days; subsequent/reauthorizations up to 180 days with required documentation.

Various Agent Categories — Authorization Durations

Common authorization durationsTypical authorization durations vary by category: examples include 30 days, 90 days, 180 days (e.g., MAT agents), and 365 days for many chronic agents.

MAT agent exampleMedication-assisted treatment agents (BRIXADI, SUBLOCADE, VIVITROL) commonly authorized for 180 days initial; some agents noted at 14 days with no renewal.

Site-of-Care Considerations

Note

LTC site-of-care exemption for opioid documentation

Long‑term care site-of-care rules: LTC residents may be exempt from some opioid program requirements; use LTC status to determine which documentation elements (e.g., urine screens, opioid contract) can be omitted.

LTC exemption applies to urine drug screening and opioid contract submission requirements.
Confirm LTC setting on PA to apply the exemption.

Documentation Required

Infusion center documentation can satisfy vericiguat PA criterion

Outpatient IV diuretic treatment within the prior 90 days can satisfy a vericiguat (VERQUVO) criterion for PA; include facility/site-of-care documentation when applicable.

VERQUVO criterion: hospitalization for heart failure in prior 180 days OR need for outpatient IV diuretic in prior 90 days.
Document outpatient infusion/IV diuretic site‑of‑care to meet the criterion.

Terms and Abbreviations

Definitions: PA / ST / AR

PA — definitionPA (Clinical Prior Authorization): a clinical prior authorization is required before the drug will be covered.

ST — definitionST (Step Therapy): drug requires a trial with one or more preferred drugs before being covered.

AR — definitionAR (Age Restriction): an edit allowing claims for members within a defined age range to be covered without PA.

Step Therapy (ST) Definition

ST — Step Therapy definitionStep Therapy requires documented trial(s) of preferred drugs in the UPDL category before coverage of non-preferred agents.

Concurrent trials allowedTrials may be concurrent for the specified duration when indicated.

Background and Scope

Background: The Unified Preferred Drug List (UPDL) groups medications by therapeutic class and designates agents as preferred or non‑preferred. The UPDL structure drives many utilization controls: non‑preferred drugs commonly require prior authorization (PA) and most step‑therapy rules require documented inadequate clinical response to specified numbers and durations of preferred drugs (examples include trial durations such as 120 days for some classes). Legacy category rules permit uninterrupted continuation for members with recent claims, while many new‑to‑market products are initially non‑preferred and PA‑required until P&T committee review.

Biosimilar and Reference Product Notes

Billing Rule

Biologics: document failure of preferred reference product/biosimilar

For non-preferred immunomodulators, providers must document inadequate response to the preferred reference product or biosimilar in the UPDL category when available before a non-preferred biologic will be authorized.

Non-preferred immunomodulators: document inadequate clinical response to preferred reference product or biosimilar.
Initial authorization commonly 90 days; subsequent 365 days — document dosing regimen and safety screening as required.

Policy Summary

PayerUnitedHealthcare

PolicyOhio Medicaid Unified Preferred Drug List (UPDL) — Pharmacy PA and Step Therapy Rules

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization with required documentation of inadequate trials of preferred drugs and supporting clinical data when requesting non-preferred UPDL agents.

SourceLink

On This Page

Opioid Initial Therapy Rules

Opioid Initial Therapy — Required Documentation and Limits

opioid_initial

Selected Drug Classes: PA Triggers and Documentation

Class‑specific PA Triggers and Required Documentation

class_specific

Step Therapy

Step Therapy Requirements

Step therapy is enforced across classes: for initial non‑preferred requests, prescribers must document inadequate clinical response to the required number and duration of preferred drugs (counts and durations vary by class). Failure to meet step therapy requirements or to submit required trial documentation will be a basis for denial. For all non‑preferred authorizations, include clinical notes demonstrating trials, intolerance/allergy documentation, and why switching is not appropriate.

Typical step durations: 7–120+ days depending on class; insulin and diabetes non‑preferred agents commonly require 120 days
Required trials must be documented for preferred drugs of similar duration of action (e.g., IR vs ER formulations)
For combination non‑preferred products, must show inadequate response to preferred individual components
Legacy rules: patients with claims in prior 120 days may be auto‑approved to continue; new Medicaid patients without claims require PA

Denial Risk

Denial Conditions and Common Triggers

Denials will be documentation‑based for non‑preferred agents that lack required trials, lack medical necessity beyond convenience, or fail to meet specific clinical thresholds (e.g., LDL goals, A1C goals, WHO functional class, culture confirmation). Common denial triggers include insufficient trials, missing labs (A1C, baseline labs, TB), missing weight for weight‑based dosing, absent spirometry for inhaled insulin, and absent prescriber attestations for opioid exemptions or pulmonary hypertension indications.

Lipid‑lowering agents: denial if no baseline labs AND no adherence to 90 days of preferred therapy or inability to reach LDL goal documented
Insulin and diabetes agents: denial risk if no recent A1C (within 6 months) or insufficient trials (commonly 120 days)
Pulmonary hypertension: denial if no NYHA/WHO class documentation or no trials of required classes for ≥90 days
Seizure drugs/anticonvulsants: denial risk if required anticonvulsant trials not documented
Paliperidone palmitate, Parkinson agents, and other specialty agents: denial risk if required prior trials or specialist consults not provided
Specific antifungals and antibiotics: denial if culture or diagnostic confirmation not provided

Documentation Required

Checklist: Required Clinical Documentation

When requesting PA for specialty or high‑risk agents, include the following required clinical documentation: diagnosis and indication, relevant lab results (A1C, LDL, CBC, renal/hepatic function), weight for weight‑based dosing, prior medication history including dates and durations of trials with preferred agents, treatment plan and goals (e.g., A1C target), TB testing date for biologics, culture results for antimicrobial agents, spirometry for inhaled insulin, urine drug screening results for opioid continuation, and prescriber attestation when required. For anticonvulsants, include seizure type, prior antiseizure medication history with dates/doses, and neurologist consultation when specified.

Diagnosis, indication, and clinical rationale
Medication trial history with dates, doses, and durations showing inadequate response or intolerance
Relevant labs (A1C within 6 months, baseline lipid labs, CBC when required, renal/hepatic function)
Weight for weight‑based products and body weight documentation for hemophilia/factor products
TB test date within past 365 days for biologics when indicated
Culture results for infectious disease agents when applicable
Spirometry (FEV1 ≥70%) and nicotine‑free documentation for AFREZZA
Urine drug screening and treatment adherence documentation for opioid reauthorizations
Specialty agent-specific: ocrelizumab documentation, buprenorphine documentation, LUCEMYRA inpatient/exemption documentation, HAE diagnostic documentation, EMFLAZA justification

Documentation Required

Opioid‑Specific Documentation and Attestations

For opioid authorizations specifically, prescribers must attest that they reviewed the state PDMP (OARRS) prior to initial controlled substance prescribing, provide treatment plan and risk assessment, document urine drug screen results (unless LTC), and supply evidence of functional improvement or stabilization on reauthorization. Long‑acting opioid and dose escalation requests require additional safety documentation; requests for trans‑mucosal fentanyl and certain formulations must come from oncology, palliative, or pain specialists and show concurrent long‑acting opioid use at defined equianalgesic doses.

OARRS (PDMP) review required before initial prescribing of controlled substances
Prescriber attestation that benefits and risks were discussed with patient for exceedance requests
Concurrent long‑acting opioid at therapeutic dose required for transmucosal fentanyl requests
Urine drug screening results must be documented for subsequent opioid authorizations (LTC residents exempt)
Requests for >80 MED/day require pain specialist involvement

Biologic/Immunomodulator Requirements

Biologic / Immunomodulator PA Rules

biologic_rules

Antibiotics: PA and Culture Documentation

Antibiotics and Inhaled Antibiotics

antibiotics

Examples: culture conversion or symptom improvement for inhaled antibiotics documented for continuation.

Opioid Initial Request Lookback

Opioid initial request lookbackAn 'initial request' is defined as having no opioid claims in the previous 90 days.

OARRS review requirementOhio law requires prescribers to request and review an OARRS report before initially prescribing controlled substances like opioids.

Authorization lengths contextInitial short-acting and long-acting opioid requests may be authorized up to 90 days; subsequent up to 180 days.

Initial Opioid Limits

Initial opioid quantity limit (MED)Initial prescriptions for opioid-naïve patients are limited to 30 MED per day.

Initial day supply capFor patients with no opioid claims in prior 90 days, initial prescriptions are limited to a maximum of 7 days per prescription unless PA obtained.

Authorization requirement to exceedPrior authorization is required to exceed the 30 MED/7-day initial limits.

Long-acting Opioid Initiation Dose Cap

Long-acting opioid initiation dose capInitial long-acting opioid requests must be a daily dose equivalent of ≤ 80 MED.

Initial long-acting request definitionAn 'initial long-acting request' is defined as no opioid claims in the previous 90 days; initial long-acting requests can be authorized up to 90 days with required documentation.

Documentation for long-actingRequests must include treatment plan, baseline urine drug tests, pain/function scores, and opioid contract where required.

Dose escalation consultationRequests for cumulative daily dose >80 MED must be prescribed by or in consultation with a pain or appropriate specialist.

Transmucosal Fentanyl Concurrent Requirement

Transmucosal fentanyl concurrent requirementTransmucosal fentanyl for certain uses must be prescribed by an oncologist, pain specialist, or hospice/palliative prescriber and the patient must be concurrently taking a long-acting opioid at a therapeutic dose for at least 7 days (examples: ≥60 mg oral morphine/day; ≥8 mg oral hydromorphone/day; ≥25 mcg/hr transdermal fentanyl; ≥25 mg oral oxymorphone/day; ≥30 mg oral oxycodone/day).

Prescriber specialty requirementTransmucosal fentanyl must be prescribed by an oncologist, pain specialist, or hospice/palliative prescriber.

Concurrent therapy durationConcurrent long-acting opioid at therapeutic dose must be used for at least 7 days without adequate pain relief before transmucosal fentanyl is authorized.

Triglyceride Threshold

Triglyceride thresholdTriglyceride level threshold: ≥500 mg/dL.

Context of useThreshold used when assessing need for specialty lipid-lowering therapies after inadequate response to fibrates, niacin, and diet/exercise.

Documentation expectationBaseline labs documenting triglyceride level ≥500 mg/dL are required for consideration per agent-specific criteria.

LDL Goals for Familial Hypercholesterolemia

LDL goal — familial hypercholesterolemia (adults)Target LDL ≤100 mg/dL for adults with familial hypercholesterolemia.

LDL goal — familial hypercholesterolemia (<18 years)Target LDL ≤110 mg/dL for patients under 18 years with familial hypercholesterolemia.

Evidence requirementDocumentation of baseline labs and adherence to lipid-lowering therapy for 90 days is required when seeking specialty agent authorization.

LDL Goals for ASCVD

LDL goals — ASCVD (not very high risk)LDL goal ≤70 mg/dL for ASCVD patients not at very high risk.

LDL goals — ASCVD (very high risk)LDL goal ≤55 mg/dL for ASCVD patients at very high risk (requires documentation of multiple major ASCVD events or 1 major event plus multiple high-risk conditions).

DocumentationMust provide baseline labs and documentation that maximally tolerated/high-potency statin, ezetimibe and PCSK9 inhibitor were tried or a clinical reason precluding their use.

Minimum Trial Duration

Common minimum trial durationMinimum trial duration commonly 30 days for many classes (documented inadequate clinical response after specified duration).

Longer minimums for select classesSome classes require longer trials: 60–90 days or 90 days for specified pulmonary hypertension, migraine biologics, or biologic/TNF trials.

Example phrasingPolicies often state 'of at least X days with at least Y preferred drugs' — e.g., 120 days with three preferred drugs in some UPDL categories.

Buprenorphine Dosing Safety Edit

Buprenorphine dosing safety edit thresholdSafety edit triggers for buprenorphine when total dosing exceeds 24 mg buprenorphine equivalents per day.

Formulation restrictionsBuprenorphine sublingual tablets (generic SUBUTEX) are limited to pregnancy, breastfeeding, or allergy/contraindication to preferred products.

Documentation requirementUse beyond safety edit may require medical justification and supporting documentation per PA rules.

Parkinson 'Off' Time Requirement

Parkinson 'off' time requirementMinimum required 'off' time for certain Parkinson's agents: ≥2.5 hours per day as documented by a PD diary.

Associated step requirementMust have had inadequate clinical response of at least 30 days to specified prior therapies (COMT inhibitor, dopamine agonist, or MAO-B inhibitor) and, for some agents, inadequate response to two preferred drugs including carbidopa/levodopa.

DocumentationPD diary evidence of off-time and prescriber documentation required for PA consideration.

Spirometry FEV1 Requirement (Afrezza)

Spirometry FEV1 threshold (Afrezza)Predicted FEV1 must be ≥70% prior to initiation of inhaled insulin (Afrezza).

ContraindicationAfrezza will not be authorized for patients with asthma or COPD.

Nicotine abstinence requirementDocumentation of being nicotine-free for at least 180 days is required for Afrezza initiation.

'Off' Time PD Diary Threshold

'Off' time PD diary thresholdRequire documentation of ≥2.5 hours per day of 'off' time as recorded in a PD diary for authorization of some Parkinson's agents.

Prior therapy requirementAlso require inadequate response of at least 30 days to other 'off' episode treatments (COMT inhibitors, dopamine agonists, MAO-B inhibitors).

Use in PA decisionPD diary documentation is used to substantiate uncontrolled motor symptoms and medical necessity for advanced therapies.

Spirometry FEV1 — Requirement

Spirometry FEV1 requirementSpirometry criterion: predicted FEV1 ≥70% required for initiation of inhaled insulin (Afrezza).

Contraindication reminderAfrezza is not authorized for patients with asthma or COPD; must confirm respiratory status.

Nicotine-free documentationPatient must be nicotine-free for ≥180 days prior to Afrezza initiation.

A1C for Tirzepatide Initiation

A1C threshold for tirzepatide initiationHemoglobin A1C must be >7% prior to initiation of tirzepatide (Mounjaro).

Prior therapy requirementMust have had inadequate clinical response of at least 120 days with OZEMPIC or provide documented medical necessity for inability to use OZEMPIC.

Intolerance mitigation stepsIf OZEMPIC intolerance cited, chart documentation must show dietary changes, prescription antiemetics, and dose adjustments tried for ≥30 days.

Prostate Volume / PSA Thresholds

Prostate volume or PSA thresholdsProstate volume >30 cc OR PSA >1.5 ng/dL are threshold findings referenced when determining need for certain BPH therapies.

Finasteride trial requirementIf prostate volume >30 cc or PSA >1.5 ng/dL (or palpable enlargement), a trial of at least 90 days of finasteride is required prior to some non-preferred therapies.

Non-preferred trial durationsNon-preferred genitourinary agents generally require at least 60 days with two preferred drugs (one within same sub-section) prior to authorization.

Atopic Dermatitis BSA Threshold

Atopic dermatitis BSA thresholdAtopic dermatitis must involve at least 10% body surface area (BSA) to meet additional biologic agent criteria.

Topical steroid trialMust document inadequate clinical response of at least 45 days with two topical therapies or 90 days with topical steroids per agent-specific rules.

Authorization contextThis threshold supports PA decisions for systemic/topical immunomodulators and biologics for atopic dermatitis.

Acne Tetracycline Trial Duration

Acne tetracycline trial durationFor acne, tetracyclines require an inadequate clinical response of at least 90 days to at least one preferred oral drug in the UPDL category.

Acute infection exceptionFor acute infections, a 3-day inadequate response to a preferred drug may be sufficient prior to non-preferred tetracycline authorization.

Authorization lengthLength of authorization for acne indications may be up to 365 days per policy.

Vulvovaginal Candidiasis Recurrence

Recurrent vulvovaginal candidiasis thresholdOteseconazole (VIVJOA) requires documentation of at least 3 symptomatic episodes of vulvovaginal candidiasis in the past 12 months.

Maintenance fluconazole requirementVIVJOA authorization requires documentation of a prior 180-day maintenance fluconazole course with evidence of breakthrough infections.

Non-preferred antifungal trialsNon-preferred antifungals generally require inadequate response of at least 3 days with at least two preferred drugs and indication documentation.

Eosinophil Count for COPD Biologics

Eosinophil count for COPD biologicsEosinophil count threshold: ≥150 cells/μL (cells per mcL) within 12 months prior to initiation for COPD biologic consideration.

COPD exacerbation historyAlso requires history of ≥1 COPD exacerbation resulting in hospitalization despite triple therapy (LAMA+LABA+ICS) for ≥3 months at stable dose for ≥1 month.

Specialist prescriber requirementRespiratory monoclonal antibodies must be prescribed by or in consultation with an applicable specialist (allergist/immunologist, pulmonologist, or otolaryngologist).

Prior Authorization

Oral anticoagulants: PA required; typical auth 365 days

Oral anticoagulants require prior authorization with a typical authorization length of 365 days; non-preferred oral anticoagulants require documentation of inadequate clinical response to preferred agents per the UPDL.

LENGTH OF AUTHORIZATION: 365 days.
Non-preferred criteria: must have had an inadequate clinical response of at least 14 days with at least two preferred drugs in the UPDL category.

Prior Authorization

Follow age-based PA (AR) requirements per product

Certain products have age-based PA rules — examples include INZIRQO solution (PA for patients ≥12 years), LOPRESSOR solution (PA for patients <18 years), and SOTYLIZE solution (PA for patients ≥6 years); follow the UPDL age‑restriction (AR) notes.

AR examples cited in vericiguat section: INZIRQO SOLN: PA required for patients 12 years and older; LOPRESSOR SOLN: PA for patients younger than 18; SOTYLIZE SOLN: PA for patients 6 years and older.
Age‑based PA (AR) annotations appear throughout UPDL and must be followed.

Prior Authorization

PDE5 inhibitors: some formulations require PA (age-based examples)

Some PDE5 inhibitor formulations and suspensions require PA or have age-based ARs (e.g., sildenafil suspension requires a PA for patients 18+; TADLIQ requires PA for patients younger than 18); document prior preferred trials or side effects per class criteria.

ADDITIONAL TADALAFIL (TADLIQ) CRITERIA: must have documented side effect/allergy/failure of at least 30 days with sildenafil suspension.
AR — sildenafil susp: PA required for patients 18 years and older; AR — TADLIQ: PA required for patients younger than 18 years.

Prior Authorization

Anticonvulsants: agent-specific PA and prescriber requirements

Selected anticonvulsants have specific PA or prescriber requirements — EPIDIOLEX requires trials of two listed anticonvulsants within the past 365 days to avoid PA; DIACOMIT requires neurologist prescribing/consult, concurrent clobazam, baseline CBC, weight, and PKU documentation when applicable.

EPIDIOLEX: must have inadequate response to two anticonvulsants (clobazam, levetiracetam, valproic acid, lamotrigine, topiramate, rufinamide, or felbamate) within past 365 days to avoid PA.
DIACOMIT (stiripentol) criteria: must be prescribed by/consult with neurologist; concurrent clobazam; baseline hematologic testing and weight documentation; PKU-specific documentation if applicable.

Note

Psychiatrist exemption for antidepressants (credentialed prescribers)

Psychiatrist prescribers credentialed with Ohio Medicaid (physicians with psychiatry specialty, psychiatric nurse practitioners, psychiatric clinical nurse specialists) are operationally exempt from PA/step therapy for non-preferred antidepressants when the prescriber's NPI is on the claim; other dosage forms may still require PA.

Exemption applies when prescriber specialty credentials and NPI are submitted on the pharmacy claim.
Exemption applies to standard tablet/capsule forms; other dosage forms may still need PA.

Note

Psychiatrist exemption for antipsychotics (operational notes)

Credentialed psychiatric prescribers (same definitions as the antidepressant exemption) are also exempt from PA for second‑generation antipsychotics in standard tablet/capsule and long‑acting injectable forms when NPI is submitted on claim; other forms may still require PA.

Psychiatrist exemption covers standard tablet/capsule and long-acting injectable antipsychotics when prescriber is credentialed and NPI submitted.
Other dosage forms remain subject to PA.

Prior Authorization

Stimulants/non-stimulants: PA and age-based rules

Prior authorization is required for many non-preferred stimulants and non-stimulants; step/PA criteria commonly require at least a 30‑day inadequate response to specified preferred ADHD agents and age-based ARs may apply to certain formulations.

Step therapy: must have had an inadequate clinical response of at least 30 days with atomoxetine OR at least one preferred ADHD agent; non-preferred criteria often require failure of two preferred drugs.
PA age examples: some formulations require PA for patients younger than specified ages (see AR flags).

Billing Rule

Authorization length expectations (365, 180, 14 days examples)

Authorization lengths vary by drug class: many chronic agents commonly receive 365‑day authorizations; MAT agents (BRIXADI/SUBLOCADE/VIVITROL) commonly 180 days; certain products (e.g., LUCEMYRA) may have 14‑day initial authorizations with no renewal.

Common lengths: Initial/Subsequent often 365 days for many classes.
MAT agents: 180 days; LUCEMYRA noted 14 days for some authorizations.

Prior Authorization

CNS agents: PA commonly required; check auth lengths and step rules

Many non-preferred CNS agents require prior authorization; typical lengths include 365 days (most agents) or 180 days for select products — confirm class-specific step/failure and prescriber specialty requirements in the UPDL.

PA required for many non-preferred CNS agents; verify agent-specific step therapy and prescriber requirements.
Length of authorizations commonly 365 days; some agents have 180-day initial authorizations.

Prior Authorization

Testosterone PA: PA for <18 years and baseline labs required

All testosterone products require a PA for patients younger than 18 years; baseline laboratory testing must be provided to justify testosterone supplementation and subsequent authorizations must document clinical response and safety monitoring (testosterone level, hematocrit).

PA required for patients younger than 18 years (AR note).
Provide baseline labs; if baseline testosterone within normal limits, provide clinical justification for replacement; subsequent auths require monitoring (testosterone, hematocrit).

Prior Authorization

Diabetes agents: PA with inadequate-response documentation (commonly 120 days)

Many non-preferred diabetes agents require prior authorization and typically require documentation of inadequate clinical response after defined trial durations (commonly 120 days) plus submission of recent hemoglobin A1C and treatment response.

Non-preferred diabetes agents: must show inadequate clinical response after at least 120 days with required preferred agents.
Subsequent authorizations: submit recent A1C within 6 months and documentation of improvement if not at goal.

Prior Authorization

Pancreatic enzyme PA — CF exception; otherwise ≥14‑day trial required

Pancreatic enzyme products (e.g., CREON, PERTZYE, ZENPEP) require prior authorization; for cystic fibrosis diagnosis no preferred trials are required, otherwise at least a 14‑day inadequate response to a preferred drug is required before non-preferred authorization.

For CF diagnosis: no trials required.
For other diagnoses: inadequate clinical response of at least 14 days with at least one preferred drug required.

Prior Authorization

Biologics/immunomodulators: PA initial 90 days, subsequent 365 days; document dosing/safety

Biologics and immunomodulators require prior authorization with initial authorizations commonly 90 days and subsequent reauthorizations 365 days; dosing regimens (loading/maintenance) and exclusion of active infection (TB test date if required) must be documented on the PA form.

Initial: 90 days; Subsequent: 365 days.
Document requested loading/maintenance dosing, ensure no active infection, and provide date of negative TB test within past 365 days if labeling requires it.

Prior Authorization

Inhaled tobramycin PA: initial 180d, subsequent 365d; culture documentation required

Inhaled tobramycin requires prior authorization with an initial authorization of 180 days and subsequent authorizations of 365 days; providers must submit cultures demonstrating the drug is prescribed in alignment with the approved indication.

LENGTH OF AUTHORIZATIONS: Initial: 180 days; Subsequent: 365 days.
Clinical PA criteria: must provide cultures demonstrating the prescription aligns with approved indication.

Prior Authorization

Antibiotics PA: document prior inadequate response (commonly ≥3 days)

For non-preferred antibiotics, PA requires documentation of inadequate clinical response (typically at least 3 days for macrolides/quinolones) to at least one preferred drug; authorization length is indication‑based and subsequent authorizations require documentation of clinical response and safety monitoring.

Non-preferred criteria: inadequate response of at least 3 days with at least one preferred drug for macrolides/quinolones.
Subsequent auth: provide documentation of clinical response, ongoing safety monitoring, and medical necessity.

Documentation Required

Subsequent PA renewals: clinical response, safety monitoring, medical necessity

Subsequent prior authorizations require documentation of clinical response to therapy, evidence of ongoing safety monitoring, and demonstration of medical necessity; many products list indication‑specific lengths (commonly 30 or 365 days) and may require lab or monitoring data for continuation.

Subsequent auths: document clinical response, safety monitoring, and medical necessity (e.g., culture conversion, symptom improvement, labs).
Many products: subsequent lengths commonly 30 or 365 days depending on class.

Note

PAXLOVID: covered without prior authorization

PAXLOVID is covered without prior authorization and does not require submission of a PA form per UPDL.

All PAXLOVID products are covered without PA (explicitly noted).

Prior Authorization

PA requires trial documentation for many non-preferred agents

Many non-preferred agents require PA with documentation of prior trials and specified auth lengths; providers must supply evidence of inadequate response to required preferred agents as listed in the UPDL for authorization (commonly 30 or 365 days depending on class).

PA required for many listed non-preferred agents with specified lengths of authorization and required documentation of prior inadequate trials.
Document duration and agents tried per UPDL class-specific criteria.

Step Therapy

Step therapy: document inadequate response to required preferred trials

Step therapy requires documentation that the patient had an inadequate clinical response to the required number and duration of preferred drugs in the UPDL category or subsection before a non-preferred agent will be authorized; trials may be concurrent and 'if available' or legacy exceptions apply.

Step therapy language: 'Must have had an inadequate clinical response of at least X days with at least X preferred drugs.'
Trials may be concurrent for specified duration; legacy exceptions apply for continuation.

Step Therapy

Required trials: examples of durations and counts by class

Non-preferred coverage commonly requires documented inadequate response to specified preferred agents — examples include opioid criteria (7 days × 2 preferred drugs), CSFs (14 days × 1 preferred), and hematopoietic agents (30 days × 2 preferred); follow the exact class examples in the UPDL.

Examples: opioids — 7 days with at least two preferred drugs; CSFs — 14 days with at least one preferred drug; hematopoietic agents — 30 days with two preferred drugs.
Ensure documentation states duration and which preferred drugs were tried.

Step Therapy

Step therapy: common 30–90 day inadequate-response expectation

Many non-preferred agents require documented inadequate clinical response to preferred agents with common minimum durations of 30–90 days depending on class; migraine biologics, lipid-lowering, and pulmonary hypertension examples may require longer or multi‑class trials.

Minimum trial durations commonly 30 days; some classes (lipid-lowering, PH, biologics) require 60–90 days or specified multi‑class failures.
Providers must follow per‑agent UPDL criteria for exact durations and required subclasses.

Step Therapy

General rule: inadequate response to preferred drugs usually required (≈30 days)

General step therapy rule: an inadequate clinical response to one or more preferred drugs is typically required (commonly at least 30 days); some classes require longer trials or multiple preferred drug failures as specified in the UPDL.

Typical requirement: inadequate response to one preferred drug for ~30 days; some classes require two preferred drugs or longer (e.g., 90 days).
Exceptions for limited availability or legacy apply per UPDL notes.

Step Therapy

General step therapy expectation: ≥30‑day trial of preferred agent

Generally, step therapy requires documented inadequate response of at least 30 days to one preferred agent in the category; certain agents or indications require multiple trials or longer durations as detailed in the UPDL (e.g., 90 days for specified conditions).

Step therapy commonly: 30-day inadequate response to one preferred agent; exceptions include longer trials for specific conditions (e.g., Huntington's, biologics).
Neurology/psychiatry specialty or credentialing may alter step requirements in some classes.

Step Therapy

Insulin step therapy: ≥120‑day trial required before non‑preferred insulin

For non-preferred insulin products, providers must document inadequate clinical response after at least 120 days with one or more preferred insulins of similar duration before a non-preferred insulin will be authorized; some categories require failure of two or three preferred agents.

Insulin step therapy: inadequate response (inability to reach target A1C) after ≥120 days with at least one preferred drug of similar duration.
Subsequent authorizations require recent A1C (within 6 months) and documentation of response.

Step Therapy

Parkinson's step therapy: ≥30‑day trials; PD diary requirement for some agents

Certain Parkinson's 'off' episode agents require prior trials: at least 30 days with other drugs for off episodes (COMT inhibitor, dopamine agonist, or MAO‑B inhibitor); some agents (Onapgo, VyaLev) require inadequate response to two preferred drugs including carbidopa/levodopa and documentation of ≥2.5 hours/day 'off' time per PD diary.

Step requirement: ≥30 days with other drugs for off episodes.
For ONAPGO/VYALEV: inadequate response to ≥30 days with at least two preferred drugs (one must be carbidopa/levodopa) and PD diary showing ≥2.5 hours/day off time.

Step Therapy

Step therapy examples: endometriosis requires NSAID + OCP trials (84 days)

For some indications (e.g., endometriosis), step therapy mandates specific prior trials — for endometriosis agents, providers must document at least 84 days trial of one NSAID and one oral contraceptive before non-preferred agents will be authorized.

Endometriosis example: ≥84 days trial with at least one preferred NSAID and one oral contraceptive required before non-preferred authorization.
Follow the UPDL per‑indication step therapy durations and counts.

Step Therapy

Step therapy: trial-duration ranges (7–90 days) — follow class guidance

Step therapy requirements vary widely by class — examples in the UPDL range from 7 days to 90 days depending on the drug category and indication; follow the specific class guidance for the exact trial length and number of preferred drugs required.

Ranges shown in UPDL: 7–90 days for various classes (e.g., electrolyte depleters, immunomodulators, inhaled antibiotics).
Verify class-specific required durations and counts on the UPDL entry for the drug.

Step Therapy

Dry eye step therapy: ≥14‑day trial in prior 120 days required

For dry eye treatments, step therapy requires at least a 14‑day inadequate response to one preferred drug within the prior 120 days for authorization of certain products; non-preferred dry eye agents often require failure of two preferred agents.

Step therapy: inadequate response ≥14 days to one preferred drug in prior 120 days required; non-preferred often require failure of two preferred drugs.
Length of authorization commonly 365 days for dry eye agents.

Step Therapy

Tetracycline step therapy: acne ≥90 days; acute infections ≥3 days

For tetracyclines used in acne, providers must document at least a 90‑day inadequate response to at least one preferred oral drug; for acute infections, an inadequate response of at least 3 days to a preferred drug is required.

Acne: ≥90 days inadequate response to at least one preferred oral drug; authorization for acne up to 365 days.
Acute infection: ≥3 days inadequate response to at least one preferred drug.

Step Therapy

Inhaled agents: step therapy durations (14–30 days) — follow UPDL

Step therapy for inhaled agents commonly requires inadequate response durations typically 14–30 days (e.g., 14 days with albuterol-containing product; 30 days for concurrent ICS+LABA+LAMA trials when applicable); follow the inhaled agent UPDL entry for exact requirements.

Must have had inadequate response ≥14 days with an albuterol-containing product before many non-preferred inhaled agents.
Step therapy may require ≥30 days inadequate response to concurrent ICS, LABA, and LAMA where specified.

Documentation Required

Documentation: medical necessity required for non‑preferred authorizations

Providers must document medical necessity beyond convenience for all non-preferred authorizations (e.g., allergies, drug–drug interactions, contraindications, intolerances); subsequent authorizations must include documentation of clinical response and ongoing safety monitoring.

For ALL non-preferred authorizations: supply medical justification why patient cannot be changed to a preferred drug form.
ALL subsequent authorizations: documentation of patient's clinical response and ongoing safety monitoring required.

Documentation Required

Opioid prescriber actions: OARRS review and attestation for exceedance

Before initiating opioid therapy, prescribers must request and review an OARRS report; to exceed acute opioid limits (30 MED/7 days for opioid‑naïve patients) provide diagnosis and prescriber attestation; reauthorization requires treatment plan and documentation (pain/function scores, urine screening) per OP criteria.

Ohio law: prescribers must request/review OARRS before initial controlled substance prescribing.
To exceed acute limits, submit somatic pain diagnosis and prescriber attestation that benefits/risks were discussed; reauthorization requires current treatment plan and monitoring documentation.

Documentation Required

Long‑acting opioid PA: submit treatment plan, urine tests, pain/function scores

For long‑acting opioid PA requests, include a current treatment plan, baseline urine drug tests, pain and function scores, and an opioid contract submitted with the PA form; LTC residents may be exempt from some urine screening or contract requirements.

Baseline urine drug tests, pain/function scores at each visit, opioid contract required with PA form for long-acting opioids.
LTC residents may be exempt from urine drug screening and opioid contract requirements.

Biologic initial vs subsequentBiologics/immunomodulators often have initial authorization ~90 days and subsequent renewals of 365 days.

NURTEC Quantity Limit

NURTEC quantity limitMaximum quantity for NURTEC ODT: 16 tablets per month for migraine prophylaxis.

Authorization lengthsNURTEC-related PA criteria specify initial 180 days and subsequent 365 days for some migraine biologics; quantity limit noted alongside step criteria.

Documentation requirementRequests require objective documentation of migraine severity, frequency, and headache days per month.

Note

LTC exemption for select opioid program requirements

Long‑term care patients are exempt from certain urine drug screening and opioid contract requirements; confirm LTC status when completing opioid-related PA documentation.

LTC exemption: patients in long-term care facilities are exempted from urine drug screening and opioid contract requirements per UPDL.
Apply exemptions when documenting opioid PA requests for LTC residents.

Note

Hospital outpatient: NYHA III/IV may meet inhaled/IV agent PA

Hospital outpatient rule: patients with NYHA class III/IV symptoms may be authorized for inhalation or IV agents — document NYHA/WHO functional class where required for pulmonary hypertension and related inpatient/outpatient site‑of‑care considerations.

Patients with class III or IV NYHA symptoms may be authorized for inhalation or IV agents.
Document NYHA Functional Class or WHO Group/Functional Class when required.

Billing Rule

Infusion center billing rules for MAT agents when pharmacy bills

When pharmacy bills but the product is administered in an infusion center, VIVITROL, SUBLOCADE, and BRIXADI may be billed by the pharmacy but must be released only to the administering provider or their staff per regulations — document the administering provider and site-of-care on the claim.

VIVITROL, SUBLOCADE, BRIXADI may be billed by pharmacy if not dispensed directly to patient but must be released to administering provider/staff.
Ensure claim includes administering provider/site‑of‑care information.

Exceptions'If available' and legacy exceptions apply when preferred agents are not available or limited in supply.

Age Restriction (AR) Definition

AR — Age Restriction definitionAge Restriction allows claims for members within a defined age range to be covered without prior authorization.

Usage examplesApplied to specific suspensions/solutions where PA is required only outside the age range (e.g., ciprofloxacin suspensions, sildenafil suspensions).

Claims processingExemption is processed when prescriber and patient age match AR rules on the claim.

LEGACY — Continuation Rule

LEGACY — continuation ruleLEGACY: patients with a claim for a drug needing PA in the previous 120 days are automatically approved to continue the drug (legacy continuation).

New-to-Medicaid patientsPatients without prior claim history (e.g., new to Medicaid) must submit a prior authorization to continue the drug.

Cumulative top-to-bottom UPDLThe UPDL criteria are cumulative top-to-bottom; follow category order when applying legacy and step rules.

Initial Request (Opioid) Definition

Initial request (opioid) — definitionAn initial opioid request is defined as having no opioid claims in the previous 90 days.

Implication for limitsOpioid-naïve status triggers initial limits (30 MED/day and 7-day max) unless PA obtained.

Documentation requiredTo exceed initial limits, must provide diagnosis code for somatic pain and prescriber attestation of risks/benefits discussion.

MED (Morphine Equivalent Dose) Definition

MED — definitionMED (morphine equivalent dose) is the metric used to limit and evaluate opioid dosing (e.g., 30 MED initial limit; >80 MED consultation requirement).

Uses in policyMED thresholds determine initial limits, long-acting initiation caps, and specialist consultation requirements for dose escalation.

Calculation noteCumulative daily MED is compared against thresholds for authorization and safety edits.

NYHA Functional Class / WHO Group 1 Definition

NYHA Functional Class — useNYHA Functional Class is used to document severity of symptoms for pulmonary hypertension and is required for PA of some PAH agents (e.g., vericiguat, selexipag).

WHO Group 1 attestationSome agents (selexipag, sotatercept) require attestation of WHO Group 1 diagnosis and WHO functional class II or III.

Documentation expectationProvide NYHA/WHO functional class documentation and relevant prior therapy trial history per agent-specific criteria.

WHO Group 1 Pulmonary Arterial Hypertension

WHO Group 1 pulmonary arterial hypertension — definitionWHO Group 1 diagnosis and WHO functional class II or III attestation required for agents like selexipag and sotatercept for PA consideration.

Required trialsMust have tried and failed preferred pulmonary hypertension medications from at least two subclasses for ≥90 days unless contraindicated.

Authorization lengthLength of authorizations commonly 365 days for PAH agents.

Psychiatrist Exemption

Psychiatrist exemption — overviewCredentialed psychiatrists, psychiatric nurse practitioners, and psychiatric clinical nurse specialists identified via their NPI are exempt from PA/step therapy for many non-preferred antidepressants and specified antipsychotics.

Exemption scopeExemption generally applies to standard tablet/capsule forms and certain long-acting injectable antipsychotics; other dosage forms may still require PA.

Claims processingExemption is applied when prescriber NPI (credentialed) is submitted on the pharmacy claim.

Inadequate Clinical Response — Definition

Inadequate clinical response — definitionDocumented lack of sufficient therapeutic effect after the policy‑specified minimum trial duration (commonly at least 30 days); for insulin and some diabetes agents this is inability to reach target A1C after ≥120 days.

Documentation requiredProviders must document the prior trials, durations, adherence, and objective response (e.g., A1C, headache days, PD diary) when claiming inadequate response.

Variable durationsMinimum trial durations vary by class (examples: 3, 7, 14, 30, 60, 90, 120 days) as specified in agent sections.

'Off' Time — Definition

'Off' time definition (Parkinson's)'Off' time is patient‑reported hours per day with uncontrolled motor symptoms documented using a PD diary; some criteria require ≥2.5 hours/day.

Use in PA criteriaPD diary evidence is required for PA of certain Parkinson's 'off' episode agents alongside prior therapy failure documentation.

Associated trial durationsTypically requires inadequate response of at least 30 days to prior agents (COMT, dopamine agonist, or MAO‑B inhibitor).

HAE Diagnostic Criteria

HAE diagnostic criteriaHAE diagnosis requires C4 below the laboratory lower limit of normal plus either low C1‑INH antigenic level or low C1‑INH functional level (or known HAE‑causing C1‑INH mutation).

Attack history requirementAuthorization for HAE agents requires history of moderate or severe attacks (airway swelling, severe abdominal pain, facial swelling, nausea/vomiting, or painful facial distortion).

Prophylaxis restrictionProphylactic HAE agents must not be used in combination with other prophylaxis agents.