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Prior Authorization Protocol

(Brand name drugs that require prior authorization and a generic drug equivalent is available or Brand name drugs that require prior authorization without a generic equivalent or any drug with electronic step therapy criteria)

ASTAGRAF XL (tacrolimus extended-release capsules), BEPREVE (bepotastine besilate), BRIVIACT (brivaracetam), CORDRAN LOTION/OINT (flurandrenolide 0.05%), ENVARSUS XR (tacrolimus extended-release tablets), LOCOID (hydrocortisone butyrate lotion 0.1%), risedronate (generic Actonel), PATADAY, PAZEO (olopatadine hcl), TACLONEX SUSPENSION (calcipotriene 0.005% and betamethasone dipropionate 0.064%), WELLBUTRIN XL (bupropion hcl), ZOVIRAX (acyclovir cream 5%), XERESE (acyclovir-hydrocortisone cream 5-1%), ZYCLARA (imiquimod cream 2.5% and 3.75%), ZYFLO (zileuton), ZYFLO CR (zileuton extended-release)



NATL


Coverage of drugs is first determined by the member’s pharmacy or medical benefit. Please consult with or refer to the Evidence of Coverage document.
  1. FDA Approved Indications:
    • All FDA-approved medications
  2. Health Net Approved Indications and Usage Guidelines:
    Brand-name drugs that require prior authorization and a generic drug equivalent is available:
    • Medical justification must be provided why the generic equivalent cannot be used (use of a copay card or discount card does not constitute medical necessity)
    AND
    • Failure or clinically significant adverse effect to two or more (or one if only one exists) formulary alternatives that are FDA approved or standard pharmacopeias (e.g. DrugDex) support efficacy and safety for the requested indication

    Brand-name drugs that require prior authorization and generic drug equivalent does not exist:
    • Failure or clinically significant adverse effect to two or more (or one if only one exists) formulary alternatives that are FDA approved or standard pharmacopeias (e.g. DrugDex) support efficacy and safety for the requested indication

    Drugs requiring electronic step therapy:

    • Patient meets drug requirements listed in the formulary viewer messaging
  3. Coverage is Not Authorized For:
    • Non-FDA approved indications, which are not listed in the Health Net Approved Indications and Usage Guidelines section, unless there is sufficient documentation of efficacy and safety in the published literature.
  4. General Information:
    • These criteria are to be used only when specific prior authorization criteria do not exist.
  5. Therapeutic Alternatives:
    Drug Dosing Regimen Dose Limit/ Maximum Dose
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    * Requires Prior Authorization
  6. Recommended Dosing Regimen and Authorization Limit:
    Drug Dosing Regimen Authorization Limit
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  7. Product Availability:
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  8. References:
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The material provided to you are guidelines used by this plan to authorize, modify or determine coverage for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under your contract.