Topical agents: Topical: Bionect, See detailed document posted separately on website. Intial Approval: Hylira,XClair Burns or dermatitis: When used for treatment of burns, dermal ulcers, wounds, radiation dermatitis: 3 fills of generic Prescriber must be a dermatologist agent Patient must be at least 18 years old Xerosis: Up to 1,000 grams When used for treatment of xerosis: of equivalent Prescriber must be a dermatologist generic agent per and failure of ammonium lactate or a topical corticosteroid 30 days for three Patient must be at least 18 years old months Renewal: 3 months Hyperlipidemia Crestor can be approved when the following criteria are met: Initial Approval: PSCK9 inhibitors: 3 Patient is at least 10 years old; AND Medications months Patient has failed to achieve LDL goal on a compliant regimen of maximum tolerated dose Last reviewed: 6/15/15 Juxtapid, Kynamro: 3 of atorvastatin; OR months Crestor Patient requires a high intensity statin (i.e., diagnosis of familial hypercholesterolemia or All others: 6 months high ASCVD risk per provider evaluation) AND patient had a trial and failure of atorvastatin Zetia Renewal: Zetia requires step therapy: PSCK9 inhibitors: 6 Lovaza If member has filled 2 prescriptions for 2 different statins (specifically atorvastatin, months Vascepa simvastatin or Crestor) within the last 130-days, the prescription will automatically process Juxtapid, Kynamro: 6 Epanova at the pharmacy. months Trial Authorization will be required for prescriptions that do not process automatically at All others: indefinite Repatha the pharmacy. Praluent In cases, Zetia will be authorized upon receipt of documentation to support the Renewals require diagnosis of hyperlipidemia and failure of, or contraindication to atorvastatin, simvastatin, improvement in fasting Juxtapid and Crestor. lipids and documentation Kynamro of recommended safety Non-formulary medications for hypertriglyceridemia (Lovaza, Vascepa, and Epanova) monitoring parameters can be approved when the following criteria are met: (such as enzymes)
Topical: Bionect, Hylira,XClair See detailed document posted separately on website. When used for treatment of burns, dermal ulcers, wounds, radiation dermatitis: Prescriber must be a dermatologist Patient must be at least 18 years old When used for treatment of xerosis: Prescriber must be a dermatologist and failure of ammonium lactate or a topical corticosteroid Patient must be at least 18 years old Topical agents: Intial Approval: Burns or dermatitis: 3 fills of generic agent Xerosis: Up to 1,000 grams of equivalent generic agent per 30 days for three months Renewal: 3 months Hyperlipidemia Medications Last reviewed: 6/15/15 Crestor Zetia Lovaza Vascepa Epanova Repatha Praluent Juxtapid Kynamro Crestor can be approved when the following criteria are met: Patient is at least 10 years old; AND Patient has failed to achieve LDL goal on a compliant regimen of maximum tolerated dose of atorvastatin; OR Patient requires a high intensity statin (i.e., diagnosis of familial hypercholesterolemia or high ASCVD risk per provider evaluation) AND patient had a trial and failure of atorvastatin Zetia requires step therapy: If member has filled 2 prescriptions for 2 different statins (specifically atorvastatin, simvastatin or Crestor) within the last 130-days, the prescription will automatically process at the pharmacy. Authorization will be required for prescriptions that do not process automatically at the pharmacy. In cases, Zetia will be authorized upon receipt of documentation to support the diagnosis of hyperlipidemia and failure of, or contraindication to atorvastatin, simvastatin, and Crestor. Non-formulary medications for hypertriglyceridemia (Lovaza, Vascepa, and Epanova) can be approved when the following criteria are met: Initial Approval: PSCK9 inhibitors: 3 months Juxtapid, Kynamro: 3 months All others: 6 months Renewal: PSCK9 inhibitors: 6 months Juxtapid, Kynamro: 6 months All others: indefinite Renewals require improvement in fasting lipids and documentation of recommended safety monitoring parameters (such as enzymes) Trial
Mercy-Maricopa-Integrated-Care-PA-Guidelines-SMI.docx