AETNA BETTER HEALTH Prior Authorization guidelines for Step Therapy

Transcription

1 AETNA BETTER HEALTH Prior Authorization guidelines for Step Therapy Definition A form of automated Prior Authorization whereby one or more prerequisite medications, which may or may not be in the same drug class, must be tried first before a Step Therapy medication will be approved Automated Setup If there are fills for the first line drug in the prescription drug history within the specified last # of days AND with the applicable # of filled claims of the first line drug, the second-line drug will automatically process. Please review each step therapy rule for the details on the system set up as it may differ between rules. Authorization guidelines Refer to Automated Setup requirements Approval If the above requirements are met, the request will be approved for a minimum of 3 months depending upon the diagnosis and usual treatment therapies. If the above conditions are not met, the request will be referred to a Medical Director for medical necessity review and for final determination. Drug Compendia 1. FDA-approved drug monographs 2. American Medical Hospital Formulary Service Drug Information 3. Drug Facts and Comparisons 4. American Medical Association Drug Evaluations 5. Clinical Pharmacology Authorization and Limitations If the above requirements are met, the request will be approved for a minimum of 3 months depending upon the diagnosis and usual treatment therapies. If the above conditions are not met, the request will be referred to a Medical Director for medical necessity review and for final determination. Additional Information: Specific drugs listed above are NOT covered for members with the following criteria: Use not approved by the FDA; AND Revised April 2014

2 The use is unapproved and not supported by the literature or evidence as an accepted off-label use. Medically Necessary A service or benefit is Medically Necessary if it is compensable under the MA Program and if it meets any one of the following standards: The service or benefit will, or is reasonably expected to, prevent the onset of an illness, condition or disability. The service or benefit will, or is reasonably expected to, reduce or ameliorate the physical, mental or developmental effects of an illness, condition, injury or disability. The service or benefit will assist the Member to achieve or maintain maximum functional capacity in performing daily activities, taking into account both the functional capacity of the Member and those functional capacities that are appropriate for Members of the same age. Determination of Medical Necessity for covered care and services, whether made on a Prior Authorization, Concurrent Review, Retrospective Review, or exception basis, must be documented in writing. The determination is based on medical information provided by the Member, the Member s family/caretaker and the Primary Care Practitioner, as well as any other Providers, programs, agencies that have evaluated the Member. All such determinations must be made by qualified and trained Health Care Providers. A Health Care Provider who makes such determinations of Medical Necessity is not considered to be providing a health care service under this Agreement. 2

3 Asthma Step Therapy Program # Days for claims review for select or first line drugs: The system will look for 1 asthma medication prescription that was filled within the last 90 days. Singulair Accolate Grandfathering: Yes, if there is history of Singulair or Accolate use in the last 120 days, then the patient will be able to continue receiving the specific target drug. On-line Pharmacy Message: PA Required Advair Advair HFA Aerobid Albuterol (all forms) Aminophylline (all forms) Asmanex Atrovent Azmacort Combivent Cromolyn Inhaler Duoneb Flovent HFA/Powder Foradil Ipratropium Ipratropium/albuterol Maxair ProAir HFA Proventil HFA Pulmicort Flexhaler Pulmicort Respules QVAR Serevent Symbicort Theophylline Ventolin HFA Xolair Xopenex 3

4 ARB Step Therapy Program # Days for claims review for select or first line: 90 # Generics or specific drug claims: 1 or more (Includes any combination of drugs in 1 st line drug group or on a drug for Diabetes.) # Utilization Days of the first line drugs: 60 # Days to review for first line drug utilization: 90 Benicar Benicar HCT utilizing the same 2 nd line drug in the past 130 days and do not count emergency prescriptions (<6 days supply On-line Pharmacy Message: Use GEN ACE 1 st ACE Inhibitors Benzapril/HCTZ Captopril/HCTZ Enalapril/HCTZ Fosinopril/HCTZ Lisinopril/HCTZ Moexipril/HCTZ Quinapril/HCTZ Trandolapril/Verapamil Benazepril/Amlodipine Enalapril/Felodipine Oxymorphone Step Therapy Program # Days for claims review for select or first line drugs: 90 # Different first line drugs: 2 Morphine ER tabs or capsules Fentanyl Patch Methadone Oxymorphone ER Grandfathering: 130 days (Mbr will be grandfathered if utilizing the same 2 nd Line drug in the past 130 days and do not count emergency prescriptions (<6 days supply with PA). Spiriva Step Therapy Program # Days for claims review for select or first line drugs: 90 # Claims: 2 Ipratropium Atrovent Combivent Spiriva 4

5 Grandfathering: 130 days (Mbr will be grandfathered if utilizing the same 2 nd Line drug in the past 130 days and do not count emergency prescriptions (<6 days supply with PA). On-line Pharmacy Message: Call Dr, Step use 2 claims for iprtrop, Atrovnt or Combivnt First Elidel Step Therapy program # Days for claims review for first line drugs: 90 # Different first line drugs: 1 # Claims: 2 Grandfathering: 130 days (Mbr will be grandfathered if utilizing the same 2 nd Line drug in the past 130 days and do not count emergency prescriptions (<6 days supply with pa). On-line Pharmacy Message: Call Dr, Step Use 2 claims gen topical steroid first Topical corticosteroids aclometasone dipropionate cream and ointment (Aclovate ) amcinonide cream, lotion, and ointment (Cyclocort ) betamethasone diproprionate, augmented gel, lotion, ointment, and cream (Diprolene /Diprolene AF) clobetasone propionate cream, gel, and ointment (Temovate ) clocortolone pivalate cream (Cloderm ) desoximetasone cream, gel, and ointment (Topicort ) diflorasone diacetate cream and ointment (Florone /Florone E) diflorasone diacetate cream and ointment (Psorcon E ) flurandrenolide lotion, ointment, and cream (Cordran ) fluticasone propionate cream and ointment (Cutivate ) halcinonide cream, ointment, and solution (Halog/Halog E) halobetasol propionate cream and ointment (Ultravate ) hydrocortisone buteprate cream (Pandel ) hydrocortisone butyrate cream, ointment, and solution (Locoid ) mometasone furoate cream, lotion, and pimecrolimus cream (Elidel ) 5

6 Zetia Step Therapy program ointment (Elocon ) triamcinolone acetonide cream, lotion and ointment (Kenalog ; Aristocort ) # Days for claims review for first line drugs: 90 # Claims: 2 HMG CoA Reductase Inhibitors HMG CoA Combinations Zetia Grandfathering: 130 days (Mbr will be grandfathered if utilizing the same 2 nd Line drug in the past 130 days and do not count emergency prescriptions (<6 days supply On-line Pharmacy Message: Use 2 FORMULARY HMG PRIOR TO ZETIA Nasonex Step Therapy program # Days for claims review for select or first line drugs: 90 Nasacort OCT/triamcinolone mometasone nasal # Different generics or specific drug claims: 1O nasal spray. spray (Nasonex) # Claims in the last 90 days: 2 # Days between step 1 fill and step 2 claim: 60 Flonase OTC/fluticasone spray fluticasone propionate nasal spray (RX version) flunisolide nasal spray (RX version) On-line Pharmacy Message: Use 2 fills of fluticasone or flunisolide first 6

7 Uloric Step Therapy program utilizing the same 2 nd Line drug in the past 130 days and do not count emergency prescriptions (<6 days supply allopurinol probenecid colchicine/probenecid colchicine Uloric On-line Pharmacy Message: Use allopurinol/colchicine first Celebrex Step Therapy program utilizing the same 2 nd Line drug in the past 130 days and do not count emergency prescriptions (<16 days supply PPI/H2 agent warfarin prednisone 2 fills of formulary NSAIDs Celebrex On-line Pharmacy Message: Must Use 2 generic NSAIDs 1st Escitolapram Step Therapy Program # Days for claims review for select or first line drugs: 90 # Generics or specific drug claims: 2 utilizing the same 2 nd Line drug in the past 130 days and do not count emergency prescriptions (<15 days supply On-line Pharmacy Message: Use citalopram and generic SSRIs First citalopram fluoxetine paroxetine sertraline escitalopram 7

8 Ranexa Step Therapy program # Different first line drugs: 2 # Claims: 2 utilizing the same 2 nd Line drug in the past 130 days and do not count emergency prescriptions (<16 days supply Ranexa On-line Pharmacy Message: Must Use 2 generic formulary agents 1st Januvia/Janumet Step Therapy program acebutolol atenolol carvedilol metoprolol nadolol nifedipine felodipine amlodipine diltiazem verapamil isosorbide dinitrate, isosorbide mononitrate, nitroglycerin Grandfathering: 120 days (Mbr will be grandfathered if utilizing the same 2 nd Line drug in the past 130 days and do not count emergency prescriptions (<16 days supply Metformin Januvia/Janumet On-line Pharmacy Message: Must Use generic metformin 1st Byetta Step Therapy program Grandfathering: 120 days (Mbr will be grandfathered if utilizing the same 2 nd Line drug in the past 130 days and do not count emergency prescriptions (<16 days supply Metformin Byetta On-line Pharmacy Message: Must Use generic metformin formulary agents 1st 8

9 Savella Step Therapy program # Different first line drugs: 3 Grandfathering: 120 days (Mbr will be grandfathered if utilizing the same 2 nd Line drug in the past 130 days and do not count emergency prescriptions (<16 days supply Savella On-line Pharmacy Message: Must use formulary agents 1st amitriptyline gabapentin cyclobenazeprine tramadol tramadol/ acetaminohen, fluoxetine duloxetine 9