Airsupra — try budesonide/formoterol first

Member must be trialed on a budesonide/formoterol product (for example, Breyna) before Airsupra will be authorized unless the prescriber provides adequate justification why a budesonide/formoterol formulation cannot be used. See Quantity Limit Policy (Pharmacy-43) for quantity limits.

• Use budesonide/formoterol first; document clinical justification if not feasible

Consensi — document diagnoses and generic alternative use

For Consensi, document diagnoses of BOTH hypertension and osteoarthritis and the patient’s age (must be ≥18). The provider must also document use of separate generic amlodipine and celecoxib (as individual tablets) unless there is adequate justification why separate generics are inappropriate; include quantity request details (30 tablets/30 days).

• Diagnosis: hypertension AND osteoarthritis
• Age ≥18 years
• Trial/use of generic amlodipine and celecoxib as separate pills or justification why not appropriate
• Quantity limit: 30 tablets per 30 days

Prior authorization required — follow product-specific prerequisites

Prior authorization is required for the listed low clinical impact drugs per formulary rules. Requests must meet the drug‑specific prerequisites such as appropriate prescriber specialty, documented diagnosis, required prior trials of preferred or component agents, and applicable quantity limits as specified for each product.

• Confirm prescriber specialty when required (e.g., dermatologist for Duobrii)
• Provide diagnosis and age where required
• Document prior trials or component-agent trials as specified
• Request quantity consistent with stated limits

Prior auth approvals typically 1 year; recertification requires ongoing benefit

Unless otherwise stated in an individual drug entry, prior authorizations are issued for a 1‑year period. At recertification, the provider must submit documentation demonstrating ongoing benefit (improvement or stability) and that dosing remains consistent with FDA or guideline-supported recommendations.

• Default approval period: 1 year
• Recertification requires objective/subjective documentation of ongoing benefit (progress notes, imaging, labs)

Dymista — must try azelastine and fluticasone separately first

Dymista (azelastine/fluticasone combination) will only be approved if the member has tried azelastine and fluticasone as separate products and either failed those trials or the prescriber documents a valid medical reason for combination therapy.

• Document prior trials of azelastine and fluticasone as separate products and outcomes or provide medical justification for combination use
• Quantity limit: 23 grams per 30 days

Step therapy — trial separate components and preferred agents first

Step‑therapy expectations require trialing separate component products or preferred agents before approving combination or higher‑cost formulations. Providers must document prior trials (or provide justification) per the product-specific rules (e.g., separate azelastine/fluticasone before Dymista; multiple triptans and combinations before specified migraine products; lactulose solutions before packets).

• Try separate components before combination sprays
• Attempt all listed generic/solution alternatives before brand/specialty formulations
• Document each trial and outcome in progress notes

Preferred‑drug trial requirements and NY law exceptions

When a trial of a preferred drug is required, providers must document a trial of the preferred agent(s) unless an exception under NY Insurance Law §4903(c-1) or Public Health Law §4903(3‑a) applies (e.g., contraindication, likely adverse reaction, prior failure, expected ineffectiveness, adherence barrier, or patient stability). Note: the NY law exceptions do not apply when a brand has an AB‑rated generic — a generic trial may still be required.

• If claiming an exception under NY law, include supporting clinical rationale
• Be aware AB‑rated generic trials may still be required despite exceptions

Atoncy — swallowing disorder and speech/swallow evaluation required

For Atoncy oral solution, submit documentation that the patient has a swallowing disorder preventing use of oral pills and include a speech and swallow evaluation in the medical record.

• Provide speech and swallow evaluation documenting inability to use oral pills
• Confirm patient age meets product criteria (≥6 years) and include quantity requested (100 mL/30 days)

Cardizem CD 360 mg — document failure/intolerance to generics

For Cardizem CD 360 mg (diltiazem CD 360 mg), document that lower‑cost generic alternatives (diltiazem LA/ER) are inappropriate and provide evidence of serious side effects or failure of diltiazem CD 180 mg to justify use of the 360 mg product.

• Document trials and failures or serious adverse effects with lower‑cost generics
• If citing 180 mg failure, note that a 360 mg daily dose can be obtained with two 180 mg capsules

Required documentation — trials, swallowing evaluations, and product‑specific evidence

Providers must include required supporting documentation in progress notes for any requested exceptions or when prior trials are required — examples include trial documentation for lactulose solutions before packets, trials of mometasone and olopatadine separately before Ryaltris, speech and swallow evaluations for oral suspensions, and documentation of prior medication failures or side effects.

• Attach progress notes documenting each prior trial and outcome
• Include evaluations (e.g., speech/swallow) where required
• List specific prior medications tried, dates, and reasons for discontinuation

Documentation to support missing claims history and recertification

If a required preferred‑agent trial is not found in claims history, submit supportive documentation of previous drug use (chart notes, medication lists, or discharge summaries). For recertification, provide documentation demonstrating ongoing clinical benefit (progress notes, imaging, labs, or other objective/subjective measures).

• When claims do not show prior trial, include clinical records verifying the trial and outcome
• At recertification, document continued benefit and adherence to formulary/dosing guidance

Non‑preferred status and no coverage for non‑FDA indications

Drugs listed as low clinical impact are non‑preferred and will not be approved for non‑FDA indications. Brand requests with AB‑rated generics may still require a generic trial. Providers should not expect coverage for listed products when the indication is not an FDA‑approved use.

• Listed drugs are non‑preferred
• Requests for non‑FDA indications will not be approved

Denial triggers — missing trials, non‑FDA uses, incorrect formulations

Common denial triggers include absence of required trials of specified lower‑cost or alternative formulations (e.g., lactulose solutions before packets, separate azelastine/fluticasone trials), requests for non‑FDA indications, or requests for formulations that do not meet the product‑specific criteria (such as lacking required prescriber specialty or age).

• Missing documentation of required prior trials
• Requesting non‑FDA indications
• Failure to meet prescriber, age, or quantity criteria

Contract‑dependent denial risk — verify member benefit language

Coverage and utilization management requirements are contract dependent. Providers should verify member benefit/contract language because contract‑specific criteria or exclusions may lead to denial even if policy criteria are otherwise met.

• Check specific contract/benefit language for exclusions or differing requirements
• Understand that utilization rules may change with contract renewal