March 15, 2018
The Pharmacy Prior Authorization program is designed to promote appropriate drug selection, length of therapy, and use of specific drugs while improving the overall quality of care.
Premera has added new review criteria based on clinical best practice and approval by an independent pharmacy and therapeutics committee. Drugs may be added or deleted from this list without notification.
If you have questions, read more about the Pharmacy Prior Authorization program or call the Pharmacy Services Center at 888-261-1756 or fax us at 888-260-9836, Monday through Friday, 8 a.m.-5 p.m. Pacific time.
Which new edits are included in the Pharmacy Prior Authorization Edit Program?
Effective: August 8, 2017
Idhifa® (enasidenib)
Read the full policy.
Coverage criteria
Idhifa® (enasidenib) may be considered medically necessary for the treatment of relapsed or refractory acute myeloid leukemia (AML) in patients with an isocitrate dehydrogenase-2 (IDH2) mutation as detected by an FDA-approved test.
Effective: August 24, 2017
Nerlynx® (neratinib)
Read the full policy.
Coverage criteria
Neratinib may be considered medically necessary for use as adjuvant treatment in patients with early stage breast cancer whose tumors overexpress or have amplified HER2 protein (HER2-positive breast cancer). This medication may be medically necessary when all of the following are true:
- Neratinib is being used as adjuvant therapy
- Neratinib is used following adjuvant trastuzumab-based therapy
- Patient has early stage breast cancer (stage I, IIA, IIB, or IIIA)
- Patient has HER2-positive breast cancer
Effective: January 1, 2018
Abilify MyCite® (aripiprazole tablets with sensor)
Read the full policy.
Coverage criteria
Abilify MyCite® may be considered medically necessary when the patient has met all of the following criteria:
- Documentation of low medication adherence ( less than 80%)
And
- Trial and failure of an injectable depot antipsychotic (e.g. Risperdal Constar, Nivea Susitna and Invega Trinza, Abilify Maintena, etc.)
New edits applicable to Health Exchange Plans
The following edits will only to our health exchange plans and not to other plans. These are individual, family, and small group plans.
The following medical policy is applicable to all edits.
Read the full policy.
Coverage criteria
Actimmune® (interferon gamma-1b) may be considered medically necessary for:
- Chronic granulomatous disease
- Severe malignant osteopetrosis
Leukine® (sargramostim) may be considered medically necessary for:
- Acute myelogenous leukemia (following induction chemotherapy)
- Mobilization and following transplantation of autologous peripheral blood progenitor cells
- Myeloid reconstitution after allogenic bone marrow transplantation
- Bone marrow transplantation (allogenic or autologous) failure or engraftment delay
Jakafi® (ruxolitinib) may be considered medically necessary for:
- Myelofibrosis
- Polycythemia vera, after trial and failure of hydroxyurea
Ilaris® (canakinumab) may be considered medically necessary for:
- Periodic fever syndromes
- Cryopyrin-associated periodic syndromes
- Familial Mediterranean fever
- Hyperimmunoglobulin D syndrome/mevalonate kinase deficiency
- Tumor necrosis factor receptor associated periodic syndrome
- Systemic juvenile idiopathic arthritis
Step Therapy Protocol for Health Exchange Plans
Step Therapy Protocol
A step therapy edit is a requirement that one or more specified first step agents be tried and failed before coverage will be provided for another second step agent.
Manual review for medical necessity is required, based on the following criteria:
- Use of a second step agent may be considered medically necessary when the prescribing provider has documented that the required number of first step agents were tried and these agents were ineffective, not tolerated or contraindicated.
Or
- Use of a second step agent may be considered medically necessary when the prescribing provider has documented a patient-specific reason why this agent should be used as first-line therapy. These requests will be evaluated on a case-by-case basis.
Drugs Subject to the Step Therapy Protocol
Drug Class |
Second Step Drugs |
First Step Agents |
Respiratory |
Ventolin HFA |
Proair |
Gout |
Colchicine |
Colcrys |
Pain |
Butrans |
1 non-opioid medication (i.e. gaba-analogues, tricyclic antidepressants, SNRI’s, NSAID’s, etc.) and 1 immediate-release opioid (i.e. oxycodone, morphine, hydromorphone, etc.) |
Acne |
Epiduo forte, Tazorac, tazarotene |
Generic benzoyl peroxide/clindamycin gel, and generic topical tretinoin cream or gel, and a generic tetracycline (doxycycline or minocycline) |
Anti-platelet |
Brilinta |
Clopidogrel |
Anti-hypertensive |
Bystolic |
Trial and failure of two preferred medications: metoprolol, atenolol, or bisoprolol |
Anti-lipemic |
Welchol |
Trial and failure of two preferred medications: colestipol, cholestyramine, or Prevalite |
Ophthalmic corticosteroids |
Lotemax |
Trial and failure of two preferred medications: prednisolone, dexamethasone, or FML eye drops |
Angina |
Ranexa |
Trial and failure of at least 2 generic beta-blockers |
Anti-Parkinson’s |
Emsam |
Carbidopa/levodopa |
Bowel preps |
Suprep |
Generic PEG solution |