Pharmacy Clinical Prior Authorization Assistance Chart Effective February 2018

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1 About Pharmacy Clinical Prior Authorizations Clinical prior authorizations (PA) are based on evidence-based clinical criteria and nationally recognized peer-reviewed information. The PA may apply to an individual drug or a drug class on the formulary, including some preferred and non-preferred drugs. Clinical PAs approved by the Texas Drug Utilization Review Board are available for use by the Vendor Drug Program (VDP) for traditional Medicaid (or fee-for-service, FFS) and by managed care organizations (MCO). There are certain clinical PAs that all MCOs are required to perform. Usage of all other clinical PA will vary between MCO at the discretion of each MCO. FFS: txvendordrug.com/formulary/prior-authorization/ffs-clinical-pa MCO: txvendordrug.com/formulary/prior-authorization/mco-clinical-pa Obtaining Prior Authorization for Medicaid Managed Care Prescribing providers or their representatives must contact the MCO. Call center phone numbers vary by MCO, and the Prescriber MCO Assistance Chart identifies prior authorization and member call center phone numbers for each MCO. txvendordrug.com/sites/txvendordrug/files/docs/managed-care/prescriber-assistancechart.pdf About the CPA Assistance Chart Each prior authorization guide includes a description of how the prior authorization requests are evaluated. All these steps apply to FFS Medicaid claims processed by VDP. This assistance chart identifies which prior authorizations are utilized by each MCO and how those prior authorizations relate to those used by VDP. VDP AET AGP BCS CMC HLT CFT CHC CKC DEL DRC EPF FCR MHT PRK SCW SND SUP TXC UHC Abbreviations Vendor Drug Program / FFS Aetna Amerigroup Blue Cross Blue Shield Children's Medical Center Cigna HealthSpring Community First Community Health Choice Cook Children's Dell Children's Health Plan Driscoll Children's El Paso First Premier FirstCare Molina Healthcare of Texas Parkland Scott & White Sendero Superior HealthPlan Texas Children's United Healthcare Symbol Definition Follows all steps of the prior authorization Does not follows all steps of the prior authorization Prior authorization does not apply Rev. 02/2018 mco-pcpaac TxVendorDrug.com PAGE 1 OF 7

2 February 2018 Revisions Added Dupixent Added Diclofenac Gel & Topical Solution Removed methylnatrexone bromide (Relistor) due to combination with other GI motility agents Brand Names Included Within Categories Prior Authorization Aliskiren Agents Cystic Fibrosis Cytokine and CAM Agonists Gaucher s Disease Gastrointestinal (GI) Motility Fentanyl Agents Hereditary Angioedema Injectable Pulmonary Hypertension Agents Leukotreine Modifiers Topical Immunomodulators Drugs Tekamlo, Tekturna, Tekturna HCT Kalydeco, Orkambi* Actemra, Cimzia, Ilaris, Kineret, Orencia, Simponi, Stelara, Xeljanz Cerezyme, Elelyso, Vpriv, Zavesca Amitiza, Linzess, Lotronex, Movantik, Relistor Abstral, Lazanda, Subsys, Actiq, Duragesic, Fentora Cinryze, Firazyr Flolan, Remodulin, Veletri Singulair (montelukast), Acccolate (zafirlukast), Zyflo (zileuton) Elidel, Protopic, Eucrisa Rev. 02/2018 mco-pcpaac TxVendorDrug.com PAGE 2 OF 7

3 Prior Authorization Information ADDADHD Medications Alinia (Nitazoxanide) Aliskiren-Containing Agents Allergen Extracts - Grastek/Oralair/Ragwitek Altabax (Retapamulin) Androgenic agents Antiemetics Antipsychotics* Anxiolytics and Sedatives/Hypnotics Byetta (Exenatide Injection) Carisoprodol Colcrys Contraceptives for CHIP clients Copaxone (Glatiramer) Cough/Cold Medications COX-2 Inhibitors Cymbalta Cystic Fibrosis (incl. Orkambi*) Cytokine and CAM Antagonists Rev. 02/2018 mco-pcpaac TxVendorDrug.com PAGE 3 OF 7

4 Desmopressin Dextromethorphan Overutilization Diabetic Test Strips Diclofenac Gel & Topical Solution Drug Regimen Optimization Dupixent Duplicate Therapy Emflaza Enzymes Erythropoiesis- Stimulating Agents Flexeril/Amrix (Cyclobenzaprine) Fentanyl Agents Forteo (Teriparatide) Fosrenol (Lanthanum) Gaucher s Disease Agents GI Motility Agents Growth Hormones H.P. Acthar Hepatitis C Virus (Initial)* Hepatitis C Virus (Refill)* Hereditary Angioedema Agents Rev. 02/2018 mco-pcpaac TxVendorDrug.com PAGE 4 OF 7

5 Imiquimod (Aldara/Zyclara) Increlex (Mecasermin) Inj. Pulmonary Hypertension Agents Ketorolac (Toradol) Leukotriene Modifiers Lidocaine Patches Lovaza Capsules Lyrica Makena Nuedexta Neurontin (Gabapentin) Nuplazid Opiate Overutilization Opiate/Benzo/Muscle Relaxant Combinations OxyContin (Oxycodone) PCSK9 Inhibitors Phenergan/Phenergan Containing Products* Plavix Propylthiouracil Provigil (Modafinil) Ranexa Revatio (Sildenafil) Rev. 02/2018 mco-pcpaac TxVendorDrug.com PAGE 5 OF 7

6 Savella Sitagliptin (Januvia) Suboxone/Subutex Symlin (Pramlintide Acetate) Synagis (Palivizumab) Thiazolidinediones Topical Acne Agents (Non Retinoid) Topical Immunomodulators Tyvaso Starter Kit (CHIP) Victoza (Liraglutide) Solution for Injection Xenical (Orlistat) Xenazine Xifaxan (Rifaximin) Xyrem Zelboraf Rev. 02/2018 mco-pcpaac TxVendorDrug.com PAGE 6 OF 7

7 Some MCOs have a preferred brand of glucose monitoring test strips as shown below. If no brand is listed, the prescriber may choose any brand on VDP formulary. MCO AET AGP BCS CMC HLT CFT CHC CKC DEL DRC EPF FCR MHT PRK SCW SND SUP TXC UHC Preferred Product Name OneTouch TRUETEST and TRUE METRIX TEST STRIPS - Nipro Freestyle, Truetuest, Precision Xtra, Truetrack Nipro and Abbott (Freestyle and Precision). TRUE METRIX - Nipro OneTouch Rev. 02/2018 mco-pcpaac TxVendorDrug.com PAGE 7 OF 7