Pharmacy Prior Authorization Criteria - Keystone First

2y ago
28 Views
3 Downloads
2.95 MB
445 Pages
Last View : 22d ago
Last Download : 2m ago
Upload by : Grady Mosby
Transcription

Pharmacy Prior Authorization CriteriaApril 05, 2021

StatewidePDL Policies

Requirements for Prior Authorization of Acne Agents, OralA.Prescriptions That Require Prior AuthorizationAll prescriptions for Acne Agents, Oral must be prior authorized.B.Review of Documentation for Medical NecessityIn evaluating a request for prior authorization of a prescription for an Acne Agent, Oral,the determination of whether the requested prescription is medically necessary will takeinto account whether the beneficiary:1. Is being treated for a diagnosis that is indicated in the U.S. Food and DrugAdministration (FDA)-approved package labeling OR a medically acceptedindication; AND2. Is age-appropriate according to FDA-approved package labeling, nationallyrecognized compendia, or peer-reviewed medical literature; AND3. Is prescribed a dose and duration of therapy that is consistent with FDA-approvedpackage labeling, nationally recognized compendia, or peer-reviewed medicalliterature; AND4. Is prescribed the Acne Agent, Oral by or in consultation with a dermatologist; AND5. For an indication of acne, has a documented history of therapeutic failure,contraindication, or intolerance to all of the following:a. An oral antibiotic recommended for the treatment of acne,b. A topical antibiotic recommended for the treatment of acne,c. A topical tretinoin;AND6. For a non-preferred Acne Agent, Oral, has a history of therapeutic failure,contraindication, or intolerance of the preferred Acne Agents, Oral. See thePreferred Drug List (PDL) for the list of preferred Acne Agents, Oral at:https://papdl.com/preferred-drug-list.NOTE: If the beneficiary does not meet the clinical review guidelines above but, in theprofessional judgement of the physician reviewer, the services are medically necessary tomeet the medical needs of the beneficiary, the request for prior authorization will beapproved.

C.Clinical Review ProcessPrior authorization personnel will review the request for prior authorization and apply theclinical guidelines in Section B. above to assess the medical necessity of the request fora prescription for an Acne Agent, Oral. If the guidelines in Section B. are met, thereviewer will prior authorize the prescription. If the guidelines are not met, the priorauthorization request will be referred to a physician reviewer for a medical necessitydetermination. Such a request for prior authorization will be approved when, in theprofessional judgment of the physician reviewer, the services are medically necessaryto meet the medical needs of the beneficiary.D.References1. Zaenglein, AL, Pathy, AL, et.al. Guidelines of care for the management of acnevulgaris. Journal of the American Academy of Dermatology 2016;74:945-73.2. Isotretinoin Prescribing Information. Bridgewater, NJ. Amneal Pharmaceuticals LLC.April 2018.

Requirements for Prior Authorization of Acne Agents, TopicalA. Prescriptions That Require Prior AuthorizationPrescriptions for Acne Agents, Topical that meet any of the following conditions must be priorauthorized:1. A non-preferred Acne Agent, Topical. See the Preferred Drug List (PDL) for the list ofpreferred Acne Agents, Topical at: https://papdl.com/preferred-drug-list.2. An Acne Agent, Topical that contains a topical retinoic acid derivative or azelaic acid whenprescribed for a beneficiary age 21 years or older.3. An Acne Agent, Topical with a prescribed quantity that exceeds the quantity limit. The list ofdrugs that are subject to quantity limits, with accompanying quantity limits, is available /quantitylimitslist/index.htm.B. Review of Documentation for Medical NecessityIn evaluating a request for prior authorization of a prescription for an Acne Agent, Topical, thedetermination of whether the requested prescription is medically necessary will take intoaccount the whether the beneficiary:1. For a non-preferred Acne Agent, Topical, has a history of therapeutic failure,contraindication, or intolerance to the preferred Acne Agents, Topical; AND2. For specified preferred and non-preferred Acne Agents, Topical listed in Section A.2. whenprescribed for a beneficiary age 21 years or older, has a diagnosis that confirms thetreatment is for a non-cosmetic indication, such as, but not limited to, acne, rosacea, orplaque psoriasis; AND3. If a prescription for an Acne Agent, Topical is for a quantity that exceeds the quantity limit,the determination of whether the prescription is medically necessary will also take intoaccount the guidelines set forth in the Quantity Limits Chapter.NOTE: If the beneficiary does not meet the clinical review guidelines listed above but, in theprofessional judgment of the physician reviewer, the services are medically necessary tomeet the medical needs of the beneficiary, the request for prior authorization will beapproved.C. Clinical Review ProcessPrior authorization personnel will review the request for prior authorization and apply theclinical guidelines in Section B. above to assess the medical necessity of a prescription for anAcne Agent, Topical. If the guidelines in Section B. are met, the reviewer will prior authorizethe prescription. If the guidelines are not met, the prior authorization request will be referred toa physician reviewer for a medical necessity determination. Such a request for prior

authorization will be approved when, in the professional judgment of the physician reviewer,the services are medically necessary to meet the medical needs of the beneficiary.D. Automated Prior AuthorizationPrior authorization of an Acne Agent, Topical will be automatically approved when one of thefollowing is met:1. A non-preferred Acne Agent, Topical is prescribed for a beneficiary under the age of 21years and the Point-of-Sale On-Line Claims Adjudication System verifies a record of a paidclaim(s) within 180 days prior to the date of service that documents that the guidelines todetermine medical necessity have been met. NOTE: Automated prior authorization doesnot apply to non-preferred Acne Agents, Topical combination products that contain anantibiotic and benzoyl peroxide.2. An Acne Agent, Topical with the potential for cosmetic use, such as those with an activeingredient of tretinoin, adapalene, azelaic acid, or tazarotene, is prescribed for a beneficiaryage 21 years or older and the Point-of-Sale On-Line Claims Adjudication System verifies arecord of a paid claim within 180 days prior to the date of service that documents that theguidelines to determine medical necessity listed in Section B. have been met.

Requirements for Prior Authorization of Alzheimer’s AgentsA. Prescriptions That Require Prior AuthorizationPrescriptions for Alzheimer’s Agents that meet any of the following conditions must be priorauthorized:1. A prescription for a preferred or non-preferred Alzheimer’s Agent. See Preferred Drug List(PDL) for the list of preferred Alzheimer’s Agents at: https://papdl.com/preferred-drug-list.2. A prescription for an Acetylcholinesterase Inhibitor when there is a record of a recent paidclaim for another Acetylcholinesterase Inhibitor in Point-of-Sale On-Line ClaimsAdjudication System (therapeutic duplication).3. A prescription for an Alzheimer Agent with a prescribed quantity that exceeds the quantitylimit. See Quantity Limits for the list of drugs with quantity limits /quantitylimitslist/index.htm.B. Review of Documentation for Medical NecessityIn evaluating a request for prior authorization of a prescription for an Alzheimer’s Agent, thedetermination of whether the requested prescription is medically necessary will take intoaccount the following:1. For either a preferred or non-preferred Alzheimer’s Agent:a. Whether the recipient’s diagnosis is:i.Indicated in the package insertORii. Listed in nationally recognized compendia for the determination of medicallyaccepted indications for off-label usesORiii. Supported by peer reviewed medical literature provided by the prescriberAND2. For a non-preferred Alzheimer’s Agent, whether the recipient has a history of therapeuticfailure, contraindication, or intolerance of the preferred Alzheimer’s Agents.AND3. For therapeutic duplication, whether:a. The recipient is being titrated to, or tapered from, another Acetylcholinesterase Inhibitor

ORb. Supporting peer reviewed literature or national treatment guidelines corroborateconcomitant use of the medications being requestedOR4. Whether the recipient does not meet the clinical review guidelines listed above, but, in theprofessional judgment of the physician reviewer, the services are medically necessary tomeet the medical needs of the recipient.5. In addition, if a prescription for either a preferred or non-preferred Alzheimer’s Agent is in aquantity that exceeds the quantity limit, the determination of whether the prescription ismedically necessary will also take into account the guidelines set forth in the QuantityLimits Chapter.FOR RENEWALS OF PRESCRIPTIONS for an Alzheimer’s Agent - The determination ofmedical necessity of requests for prior authorization of renewals of prescriptions forAlzheimer’s Agents that were previously approved will take into account whether the recipienthas a documented rationale for continuing the medication.C . Clinical Review ProcessPrior authorization personnel will review the request for prior authorization and apply theclinical guidelines in Section B. above, to assess the medical necessity of the request for aprescription for an Alzheimer’s Agent. If the guidelines in Section B are met, the reviewer willprior authorize the prescription. If the guidelines are not met, the prior authorization requestwill be referred to a physician reviewer for a medical necessity determination. Such a requestfor prior authorization will be approved when, in the professional judgment of the physicianreviewer, the services are medically necessary to meet the medical needs of the recipient.

Requirements for Prior Authorization of Analgesics, Non-Opioid Barbiturate CombinationsA. Prescriptions That Require Prior AuthorizationAll prescriptions for Analgesics, Non-Opioid Barbiturate Combinations must be priorauthorized.B. Review of Documentation for Medical NecessityIn evaluating a request for prior authorization of an Analgesic, Non-Opioid BarbiturateCombination, the determination of whether the requested prescription is medically necessarywill take into account whether the beneficiary:1.Is prescribed the Analgesic, Non-Opioid Barbiturate Combination for an indication that isincluded in the U.S. Food and Drug Administration (FDA)-approved package labeling OR amedically accepted indication; AND2.Is age-appropriate according to FDA-approved package labeling, nationally recognizedcompendia, or peer-reviewed medical literature; AND3.If age 65 years or older, both of the following:a. Received a risk assessment by the prescriber and the prescriber indicated that thebenefits of the requested medication outweigh the risks for the beneficiaryb. Has documentation of prescriber counseling regarding the potential increased risks ofthe requested medication;AND4.Is not taking primidone or other medication(s) containing a barbiturate; AND5.Is prescribed a dose and duration of therapy that is consistent with FDA-approved packagelabeling, nationally recognized compendia, or peer-reviewed medical literature; AND6.Will not be taking the requested medication on more than three (3) days per month; AND7.Has a diagnosis of headache based on the current International Headache SocietyClassification of Headache Disorders; AND8.Has a history of trial and failure, intolerance, or contraindication of standard abortivemedication based on headache classification as recommended by the most recentAmerican Academy of Neurology, American Academy of Family Physicians, World HealthOrganization, or European Academy of Neurology treatment guidelines; AND9.If being treated for chronic daily headache, defined as the presence of headache on 15days or more per month for at least three (3) months, all of the following:January 5, 2021

a. Has documentation of results of a physical examination and complete neurologicexamination to rule out secondary causes of headache,b. Has documentation of an evaluation for the overuse of abortive medications, includingbut not limited to acetaminophen, NSAIDs, triptans, butalbital, caffeine, and opioids,c. Has documentation of prescriber counseling regarding behavioral modifications, suchas cessation of caffeine and tobacco use, improved sleep hygiene, diet changes, andregular mealtimes,d. One of the following:i.Is taking preventive drug therapy based on headache classification asrecommended by the most recent American Academy of Neurology, AmericanAcademy of Family Physicians, World Health Organization, or European Academy ofNeurology treatment guidelinesii. Has a contraindication or intolerance of standard preventive drug therapies,e. Has documentation of prescriber counseling regarding the potential adverse effects ofAnalgesics, Non-Opioid Barbiturate Combinations, including the risk of medicationoveruse headache, misuse, abuse, and addiction,f. For a beneficiary with a history of substance use disorder, has results of a recent urinedrug screen (UDS) testing for licit and illicit drugs with the potential for abuse (includingspecific testing for oxycodone, fentanyl, and tramadol) that is consistent with prescribedcontrolled substances;AND10. Is being treated by a prescribing provider who confirms that he/she, or the prescribingprovider’s delegate, conducted a search of the Pennsylvania Prescription Drug MonitoringProgram (PDMP) for the beneficiary’s controlled substance prescription history beforeprescribing the Analgesic, Non-Opioid Barbiturate Combination; AND11. For a non-preferred Analgesic, Non-Opioid Barbiturate Combination, has a history oftherapeutic failure, contraindication, or intolerance of the preferred Analgesic, Non-OpioidBarbiturate Combinations. See the Preferred Drug List (PDL) for the list of preferredAnalgesics, Non-Opioid Barbiturate Combinations at: https://papdl.com/preferred-drug-list;AND12. If a prescription for an Analgesic, Non-Opioid Barbiturate Combination is for a quantity thatexceeds the quantity limit, the determination of whether the prescription is medicallynecessary will also take into account the guidelines set forth in the Quantity Limits Chapter.The list of drugs that are subject to quantity limits, with accompanying quantity limits, isavailable at: OTE: If the beneficiary does not meet the clinical review guidelines listed above but, in theprofessional judgment of the physician reviewer, the services are medically necessary toJanuary 5, 2021

meet the medical needs of the beneficiary, the request for prior authorization will beapproved.C. Clinical Review ProcessPrior authorization personnel will review the request for prior authorization and apply theclinical guidelines in Section B. above to assess the medical necessity of a prescription for anAnalgesic, Non-Opioid Barbiturate Combination. If the guidelines in Section B. are met, thereviewer will prior authorize the prescription. If the guidelines are not met, the priorauthorization request will be referred to a physician reviewer for a medical necessitydetermination. Such a request for prior authorization will be approved when, in the professionaljudgment of the physician reviewer, the services are medically necessary to meet the medicalneeds of the beneficiary.January 5, 2021

Requirements for Prior Authorization of Analgesics, Opioid Long-ActingA.Prescriptions That Require Prior AuthorizationAll prescriptions for Analgesics, Opioid Long-Acting must be prior authorized.B.Review of Documentation for Medical NecessityIn evaluating a request for prior authorization of a prescription for an Analgesic, Opioid-LongActing, the determination of whether the requested prescription is medically necessary will takeinto account whether the beneficiary:1.For a non-preferred Analgesic, Opioid Long-Acting, has a history of therapeutic failure,contraindication, or intolerance of the preferred Analgesics, Opioid Long-Acting. See thePreferred Drug List for the list of preferred Analgesics, Opioid Long-Acting at:https://papdl.com/preferred-drug-list; AND2.For an Analgesic, Opioid Long-Acting when the beneficiary has a concurrent prescriptionfor a buprenorphine agent indicated for the treatment of opioid use disorder OR naltrexonefor extended‐release injectable suspension (Vivitrol), both of the following:a. Is prescribed both prescriptions by the same prescriber or, if prescribed by differentprescribers, all prescribers are aware of the other prescription(s)b. Has a need for therapy with an Analgesic, Opioid Long-Acting, and the other therapywill be suspended during the treatment for pain;AND3.One of the following:a. One of the following:i.For a beneficiary under 18 years of age, both of the following:a) Has a diagnosis of active cancer, sickle cell with crisis, or neonatal abstinencesyndrome or is receiving palliative care or hospice servicesb) The Analgesic, Opioid Long-Acting does not contain codeine or tramadolii.For a beneficiary 18 years of age or older, has a diagnosis of active cancer or sicklecell with crisis or is receiving palliative care or hospice servicesb. All of the following:i.Has documentation of pain that is all of the following:a) Caused by a medical condition,b) Not migraine in type,January 5, 2021

c) Severe as documented by a pain assessment tool measurement (e.g., a numericor visual analog scale),ii.Has documentation of the anticipated duration of therapy,iii.Has documentation of therapeutic failure, contraindication, or intolerance to both ofthe following pain management modalities:a) Non-pharmacologic techniques (i.e., behavioral, cognitive, physical, and/orsupportive therapies)b) Non-opioid analgesics (e.g., acetaminophen, NSAIDs, gabapentinoids,duloxetine, tricyclic antidepressants),iv.Has documentation that the Analgesic, Opioid Long Acting will be used incombination with tolerated non-pharmacologic therapy and non-opioidpharmacologic therapy,v.Has documentation of a trial of Analgesics, Opioid Short-Acting,vi.Is opioid-tolerant (for adults, is defined as taking at least morphine 60 mg/day,transdermal fentanyl 25 mcg/hour, oxycodone 30 mg/day, oral hydromorphone 8mg/day or an equi-analgesic dose of another opioid for one week or longer),vii. Is prescribed a medication and dose that is appropriate based on the beneficiary’sage, weight, and concurrent medical conditions and is consistent with FDA-approvedpackage labeling, nationally recognized compendia, or peer-reviewed medicalliterature,viii. Was assessed for potential risk of misuse, abuse, or addiction based on family andsocial history obtained by the prescribing provider,ix.One of the following:a) For a beneficiary under 21 years of age, has documentation that the beneficiaryor parent/guardian has been educated about the potential adverse effects ofopioid analgesics, including the risk for misuse, abuse, and addictionb) For a beneficiary 21 years of age or older, has documentation of education aboutthe potential adverse effects of opioid analgesics, including the risk for misuse,abuse, and addiction,x.Was evaluated for risk factors for opioid-related harm; if beneficiary is identified to beat high risk for opioid-related harm, the prescriber considered prescribing naloxone,xi.Was assessed for recent use (within the past 60 days) of an opioid,xii. Is not taking a benzodiazepine, unless the benzodiazepine or opioid is being taperedor concomitant use is determined medically necessary,January 5, 2021

xiii. Has results of a recent urine drug screen (UDS) testing for licit and illicit drugs withthe potential for ab

C. Clinical Review Process Prior authorization personnel will review the request for prior authorization and apply the clinical guidelines in Section B.

Related Documents:

Medical-Only HMO, Keystone 65 Select Medical-Only HMO, and Keystone 65 Select Rx HMO have networks of doctors, hospitals, pharmacies, and other providers. Keystone 65 Basic Rx HMO, Keystone 65 Liberty Medical-Only HMO, Keystone 65 Select Medical-Only HMO, and Keystone 65 Select Rx HMO: If you use providers that are not in

Added KeyStone II specifics to SRTP examples (Page 3-8) Added mention of KeyStone II engine to Protocol Descriptions. (Page 2-5) Added Specifics for IPsec in KeyStone II devices at IPsec Examples. (Page 3-3) Included SRTP KeyStone II Updates (Page 2-21) Put KeyStone II specification in IPSEC Use (Page 2-11)

KE01053 Keystone Literature - English as a Second Language X KV01053 Keystone Literature - Visually Impaired X KH01053 Keystone Literature - Hearing Impaired X KAE01053 Keystone Literature - Alternative Education X K01005 Keystone – AP English Language and Composition X X X K01006 Keystone – AP Engl

Keystone First Keystone First . July 1, 2018 P.O. Box 7307 P.O. Box 7316 London, KY 40742 London, KY 40742 . Keystone First will send the Health Care Provider a letter acknowledging Keystone First's receipt of the request for a First Level Appeal Review within ten business days of Keystone .

Prior Authorizations —Time Frames Keystone First VIP Choice has up to fourteen (14) calendar days to complete a standard request for prior authorization and notify the provider of the organization determination. Keystone First VIP Choice has seventy-two (72) hours to complete an expedited request.

Keystone 65 Select Rx HMO Keystone 65 Preferred Rx HMO Personal Choice 65SM Rx PPO 2020 Utilization Management Criteria: Prior Authorization PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION

Forteo (Teriparatide) Clinical Criteria Information Included in this Document Forteo (Teriparatide) Drugs requiring prior authorization: the list of drugs requiring prior authorization for this clinical criteria Prior authorization criteria logic: a description of how the prior

Agile software development refers to a group of software development methodologies based on iterative development, where requirements and solutions evolve through collaboration between self-organizing cross-functional teams. The term was coined in 2001 when the Agile Manifesto was formulated. Different types of agile management methodologies can be employed such as Extreme Programming, Feature .