Prior Auth Protocol

FDA Approved Indications:

All FDA-approved medications

Health Net Approved Indications and Usage Guidelines:

Formulary exceptions for a non-formulary drug (not applicable to formulary exceptions for a brand name drug when a generic drug equivalent is available) or Tier 3 drug exception (applies to plans where prior authorization is required for all Tier 3 drugs):

Failure or clinically significant adverse effect to:
- Two or more formulary alternatives that are FDA approved or standard pharmacopeias (e.g., DrugDex) support efficacy and safety for the requested indication
- One formulary alternative that is FDA approved or standard pharmacopeias (e.g., DrugDex) support efficacy and safety for the requested indication if only one is available

AND

The indication is FDA approved or standard pharmacopeias (e.g., DrugDex) support efficacy and safety

AND

Chart note documentation may be required

Exceptions for dose limits, quantity and frequency edits:

Patient has been titrated up from the lower dose with partial improvement without adverse reactions

AND

Prescribed dose is FDA approved or standard pharmacopeias (e.g., DrugDex) support efficacy and safety

AND

Patient may be required to try preferred alternatives prior to dose escalation if medically appropriate

Formulary exceptions for a brand-name drug when a generic drug equivalent is available:

Failure or clinically significant adverse effects to the generic equivalent

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.

General Information:

These criteria are to be used only when specific prior authorization criteria does not exist

Therapeutic Alternatives:

Drug	Dosing Regimen	Dose Limit/ Maximum Dose
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* Requires Prior Authorization

Recommended Dosing Regimen and Authorization Limit:

Drug	Dosing Regimen	Authorization Limit
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Product Availability:

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References:

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