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NON-INJECTABLE MEDICATIONS THAT REQUIRE AUTHORIZATION PRIOR TO COVERAGE UNDER THE
ENROLLEE’S RXPRIME BENEFIT.
Brand Name
Requires documentation of diagnosis of angina Requires documentation of diagnosis of testosteronedeficiency in men Requires documentation of diagnosis of Osteoarthritis orRheumatoid Arthritis and evidence of risk of gastrointestinaladverse reaction to other NSAIDs. Requires documentation of diagnosis of thrombocytosis Requires documentation of use in chronic pain managementprotocols Requires PA for the treatment of onychomycosis of thefingernail or toenail if the patient has evidence of diabetes orAIDS or other illness/treatment which causes immunecompromise. Requires documentation of impotence of organic origin andis limited to 6 units per 30 days per copay.
Requires documentation of diagnosis of diabetic foot ulcer PA required for diagnosis of systemic fungal infection. Useof Sporanox for the treatment of onychomycosis of thefingernail or toenail requires evidence of diabetes, AIDS, orother illness/treatment which causes immune compromise. PA required for diagnosis of bleeding disorders such asHemophilia A or von Willebrand's disease PA required for diagnosis of intestinal parasitic infectionssuch as onchocerciasis, or strongyloidiasis. Use ofivermectin for head lice is not approved.
PA required for diagnosis of endometriosis or precociouspuberty PA required for diagnosis of testosterone deficiency in men.
PA required for diagnosis of pseudomonas infection in apatient with cystic fibrosis.
PA required to use as a follow up to treatment with injectableToradol. QL is 20 tablets. (Longer treatments causegastrointestinal adverse reactions) NON-INJECTABLE MEDICATIONS THAT REQUIRE AUTHORIZATION PRIOR TO COVERAGE UNDER THE
ENROLLEE’S RXPRIME BENEFIT.
Brand Name
PA required for approved diagnoses as a follow up toinjectable Trovan. (Trovan has been restricted by the FDAand cannot be dispensed without drug company approval PA required for the treatment of organic impotence; druginduced impotence is not covered; QL is 6 tablets per 30days. Requires documentation of diagnosis of Osteoarthritis orRheumatoid Arthritis and evidence of risk of gastrointestinaladverse reaction to other NSAIDs. Only covered if the account covers smoking cessation.
For use only where there is documented methicillin andvancomycin resistant bacteria.
NON-INJECTABLE MEDICATIONS WHICH REQUIRE AUTHORIZATION FOR COVERAGE IF MEMBER IS
OUTSIDE SPECIFIED AGE RANGE:
Brand Name
Requires PA if member over age 17 to document continued ADHD.
Requires PA if member over age 17 to document continued ADHD.
Requires PA if member over age 17 to document continued ADHD.
Requires PA if member over age 17 to document continued ADHD.
Prior auth required if the member is < 40 years of age. The appropriatediagnosis for approval of Proscar is benign prostatic hypertrophy.
Finasteride is also used for male baldness but is not a covered use.
Requires PA for patients > 36 years of age to document diagnosis ofadult acne. Tretinoin is also used for wrinkles, which is not covered.
Requires PA for patients > 36 years of age to document diagnosis ofadult acne. Tretinoin is also used for wrinkles, which is not covered.
Requires PA if member over age 17 to document continued ADHD.
PA required if patient is < 4 years of age; QL is 13 grams per month PA required if patient is < 4 years of age; QL is 13 grams per month NON-INJECTABLE MEDICATIONS WHICH REQUIRE AUTHORIZATION FOR COVERAGE AFTER AN INITIAL
TIME PERIOD:
Brand Name
Authorization is required for use beyond 8 weeks. The initialprescription and one refill are allowed at the retail pharmacy beforeauthorization is required. Letters are sent to both member andphysician after the initial fill and the first refill. Authorization is required for use beyond 8 weeks. The initialprescription and one refill are allowed at the retail pharmacy beforeauthorization is required. Letters are sent to both member andphysician after the initial fill and the first refill.
Authorization is required for use beyond 8 weeks. The initialprescription and one refill are allowed at the retail pharmacy beforeauthorization is required. Letters are sent to both member andphysician after the initial fill and the first refill.
Authorization is required for use beyond 8 weeks. The initialprescription and one refill are allowed at the retail pharmacy beforeauthorization is required. Letters are sent to both member andphysician after the initial fill and the first refill.
Authorization is required for use beyond 8 weeks. The initialprescription and one refill are allowed at the retail pharmacy beforeauthorization is required. Letters are sent to both member andphysician after the initial fill and the first refill. NON-INJECTABLE MEDICATIONS WHICH REQUIRE AUTHORIZATION FOR COVERAGE OF QUANTITIES
GREATER THAN LISTED BELOW:
Brand Name
Limited to 150 days of therapy in a calendar year QL applies to the 150mg tablet used for the treatment of vaginal yeastinfection - limit is two tablets per month per copay.
QL is 8 tablets per 30 days for the treatment of hyperprolactinemia Injectable: 3 kits per 30 days per copay; Tablets: 9 per 30 days percopay; Nasal Spray: 6 per 30 days per copay QL is 6 tablets per 30 days for a copay.
QL is 84 days of therapy in calendar year for narcotic withdrawal QL is 8 tablets per 30 days for the treatment of emesis related tochemotherapy. PA is required for quantities > 8 tablets per 30 days.
QL is 8 tablets per 30 days for the treatment of emesis related tochemotherapy. PA is required for quantities > 8 tablets per 30 days.
2.5mg tablets: QL is 6 tablets per 30 days for a copay;5mg tablets: QL is 3 tablets per 30 days for a copay

Source: http://www.vmcnet.org/Contribution/Providers/Provider_Relations/Operational_Tools/Payer_Matrices/FAP_and_FAP_Plus/Rx%20Prime%20Prior%20Auth%201.pdf

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