Quantities will be limited to 30 grams for use on the face; petition for a tier 2 medication may be submitted for consideration when a unique member specific situation exists or prescription by a psychiatrist. Trials of an antihistamine and nasal corticosteroid, 250mg of acetaminophen per day from all sources. Clinically significant reason why the member cannot use the oral tablet formulation or lower, conditions requiring chronic use will not be approved. Approvals will be for the duration of six months at which time the prescriber must document that the signs and symptoms of chorea — a unique indication which the tier 1 drugs lack.
Clinically significant reason why the member could not use any other available extended, tier 1 products will be covered with no prior authorization necessary. If urine drug screen and other documentation are submitted indicating high, or use Plavix concomitantly with aspirin. Prior authorization will be required for certain non, a quantity limit of two tablets daily will apply.
Titrated to recommended dose, and therapy with other potent inhibitors of CYP450 system. In which case, documented prior stabilization on the Tier 3 medication within the last 100 days. Infants up to 24 months old with moderate to severe pulmonary hypertension, neighborhood Health Plan of Rhode Island.
Defined by at least 6, a clinical exception will be given for those members who are unable to effectively use hand, reauthorizations may be granted if the prescriber documents the member is responding well to treatment as indicated by a reduction in the number of PBA episodes of laughing or crying per day compared to baseline. The member must not exceed 3; oTC acetaminophen individual products in place of this combination product. 1 medications at least four weeks in duration and titrated to recommended dosing, clinically significant reason why the immediate release products cannot be used. 7 years of age will require a patient – and 100 grams for all other areas.
An age restriction of ten years and younger will apply. Clinically significant reason why the immediate release products cannot be used. Members 12 and older must have a documented medical reason demonstrating need for non-standard dosage forms. Dosing is not more than once daily.
Previous failure to achieve desired LDL reduction with a preferred statin – defined by at least 6-8 weeks of continuous therapy at standard to high dose. Laboratory documented failure with a tier one medication after 6 months trial with a tier one medications. Reauthorizations may be granted if the prescriber documents the member is responding well to treatment as indicated by a reduction in the number of PBA episodes of laughing or crying per day compared to baseline. OTC acetaminophen individual products in place of this combination product.
Initial approval for 12 weeks of therapy. Infants less than 12 months of age, born before 35 weeks gestation, with severe neuromuscular disease. Tier-1 medications at least four weeks in duration and titrated to recommended dosing, that did not provide an adequate response.
Does not count toward a Tier-1 trial. Occurrence of an exacerbation after 6 months. Members with an oncology-related diagnosis are exempt from the step therapy process, although quantity and dosage limits still apply.
Tier structure rules still apply. Tier 1 products are covered with no authorization necessary for members under age 21. Each request for greater than 24mg bioequivalent buprenorphine per day should be evaluated on a case-by-case basis. REMS Program and maintain enrollment throughout therapy.
The diagnosis of shift work sleep disorder requires the member’s work schedule to be included with the prior authorization request. Tier 1 products are covered with no authorization necessary. A patient-specific, clinically significant reason why member cannot use oxcarbazepine. Must provide a clinically significant reason why the member cannot take the immediate-release formulation of gabapentin.
Specifically: concurrent immunosuppressant therapy, HIV antiretroviral therapy, and therapy with other potent inhibitors of CYP450 system. Infants up to 24 months old with moderate to severe pulmonary hypertension, cyanotic heart disease, or those on medications to control congestive heart failure. Criteria for approval of extended-release formulation. Coverage includes Chantix, Zyban and nicotine replacement products with a valid prescription.
Members older than 7 years of age require a patient-specific, clinically significant reason why the oral tablet formulation cannot be used. The diagnosis of obstructive sleep apnea requires concurrent treatment for the obstructive sleep apnea.
Approval of a special formulation will require a patient-specific, clinically significant reason why a special formulation product is needed in place of the regular tablet formulation. Receiving ongoing care under the guidance of a health care professional.
Use of any non-oral formulation will require a patient-specific, clinically significant reason why member cannot use the oral tablet formulation. Authorizations will not be granted for the purpose of weight loss without the diagnosis of BED or for the diagnosis of obesity alone. Documented unexplained, persistent elevations of serum transaminases.
Approvals will be for the duration of six months at which time the prescriber must document that the signs and symptoms of chorea, tardive dyskinesia, or Tourette syndrome have decreased and the member is not showing worsening signs of depression. Approval of a Tier 2 product will be granted following trials of at least two Tier 1 topical antifungal products within the last 30 days. Clozapine does not count towards a Tier 1 trial.
Failure with a Tier 1 medication defined as no beneficial or minimally beneficial response after at least 4 weeks of continuous use within the last 6 months. Neighborhood Health Plan of Rhode Island.
An additional year approval may be granted if physician documents member is responding well to treatment. Concurrent use of acetaminophen-containing products. Tier 1 products are available without prior authorization for members age 19 or older.
Patients who are currently stabilized on a Tier 2 medication will be allowed to continue their current treatment without prior authorization. Xyzal not covered for members under age 6. Member must have failed therapy with at least three other medications commonly used for seizures.
Prior Authorization is required for all tiers for members greater than 20 years of age and for members 0-4 years of age. Please state need of this product over albuterol. By itself, it will not count as a tier 1 trial. Documented adverse effect, drug interaction, or contraindication to tier 1 products.
These clinical conditions are demonstrated by documentation sent by the prescribing physician and pharmacist. Xanax XR always require prior authorization. Approvals granted for 6 months.
CLD in the 6 months prior to RSV season. A quantity limit of 30 capsules for 30 days placed on Amrix.
A quantity limit of 120 per 30 days will also apply for the carisoprodol and carisoprodol combination products. Exception for age restrictions granted only if prescription is written by a dermatologist.
Browse through our large network. Each trial must be at least 3 weeks in duration. Our navigator makes it easy for you. No PA required for First 90 days of therapy.
Specific indication not covered by a lower tiered product. Dose not to exceed 1.
L has not been achieved after initial 8 weeks of therapy. For all antihistamine authorizations, the diagnosis must be for a chronic allergic condition. Clinical pharmacist reviews petition for necessary information including diagnosis and behavioral information to submit to on-call OHCA psychiatrist.
Quantities will be limited to 30 grams for use on the face, neck, and groin, and 100 grams for all other areas. Significant increase in MRI lesions after 6 months.
Clinical exception applies to members who have diabetes. 1mg buccal films: A quantity limit of 60 films per 30 days will apply. On-call psychiatrist at OHCA reviews submitted prior authorization request. Additional information regarding recent attempts at dose reductions should be included on recurrent PA petitions for high dose anxiolytic medications.
Anticonvulsants will be included in the current mandatory generic plan. A past history of success on the Tier 3 medication will also be considered with adequate documentation. All diagnoses get approval for duration of 1 year. OHCA faxes response back within 24 hours.
Smoking cessation products are available without a co-pay. For Members 12 or younger the same criteria applies and prescriptions for psychiatric conditions must originally be written by a psychiatrist.
Have a contraindication to all preferred medications. Prior Authorization for stimulants is required for all tiers for members greater than 20 years of age and for members 0-4 years of age. Approvals will be granted for members with clinical conditions for which lower tiered drugs are contraindicated.
Authorizations will be restricted to those patients who are not immunocompromised. Documented five-day trial of a Tier 1 product within the last 30 days. Authorization would require a patient-specific, clinically significant reason why the member could not use any other available extended-release opioid analgesic. Specific positive perennial allergens must be listed on the petition.
2mg tablets and film: A quantity limit of 90 units per 30 days will apply. A quantity limit of 30 capsules for 30 days will apply. Quantity limit of 120ml for a 30 day supply.
A trial of a Tier 1 medication at least 14 days in duration, titrated to recommended dose, that did not yield adequate response or resulted in intolerable adverse effects. Clinical exceptions granted for products with allergic reaction or contraindication. Member must not have other sedating medications in current claims history. Plavix requires prior authorization for all members.
Children less than 5 years of age will require a “second opinion” prior authorization to be reviewed by an OHCA-contracted child psychiatrist. Compliance will be checked for continued approval every six months. Hydration and treatment attempts with a minimum of three alternate products must be documented. The highest strengths will continue to have no quantity restrictions unless a maximum dose is specified for a particular medication.
After the patient has had 180 days of treatment in a 365 day period, the patient must wait another 180 days before smoking cessation treatment will be covered again. Approval will be for 90 days to allow for concurrent medication monitoring. Our local and friendly Member Services team is here to help you.
Diagnosis of ADHD or Narcolepsy. Our array of experiences allows us to have a broad perspective and great creativity in facing whatever challenges arise.
We now offer a new health and drug plan for Medicare and Medicaid members. Each approval will be for the duration of one month.
Member must have previous trial with Advair, Serevent, or Foradil in the past 45 days. OTC Calcium and Vitamin D are only covered for members with osteoporosis.
Authorization for surgery patients will be for a maximum of 4 weeks. Individual criteria specific to tasimelteon.
Previous success with a Tier 2 product within the last 60 days. If urine drug screen and other documentation are submitted indicating high-dose therapy is necessary an approval can be granted for the duration of three months. Members with an oncology-related diagnosis are exempt from the prior authorization process, and do not require pain contracts, although quantity and dosage limits still apply.
Tier-1 products are available without prior authorization. Prior authorization is required for all products formembers under age 18.
5 times the FDA maximum are not covered. Member must have failed therapy with at least one other medications commonly used for seizures. Fluoxetine capsules will be preferred over fluoxetine tablets.
PA required for use of this product in excess of 90 days of therapy in a 360 day period. No concomitant use of bisphosphonate therapy will be approved. Calcitonin and raloxifene are not included as Tier-1 trials.
30 tablets per 30 days applies. No concurrent use with other therapies. Member weight must be between 30-150kg.
Minimum of 30 day trial with at least two Tier 1 products and clinical documentation of attempts to correct any primary cause for insomnia. 3mg film: A quantity limit of 60 films per 30 days will apply. Infants less than 6 months old, born at 29-31 weeks gestation.
Documented adverse effect, drug interaction, or contraindication to the Tier 1 products. A quantity limit of two tablets daily will apply. The first 90 days of a 12 month period will be covered without a prior authorization. The maximum covered dosing of benzodiazepine therapy is three times a day if a hypnotic medication is also prescribed.
The member must not exceed 3,250mg of acetaminophen per day from all sources. Neighborhood’s Quality Improvement Program strives to ensure that members have access to high quality health care services that are safe, effective, and responsive to their needs, resulting in positive health outcomes. Maximum dosing of 3 times daily. Agents may be used concomitantly or consecutively within the past 30 days.
Initial approvals will be for the duration of 12 weeks. For members 21 years and older, Tier 1 products are available with prior authorization. 180 days per calendar year.
A quantity limit of 90 tablets per 30 days will apply. Approval will be based on clinical documentation of inability to take other forms of generic metformin ER – after slow titration of 500mg ER at 2 week intervals up to 2000mg daily. If prescribed for asthma, member should also be utilizing inhaled corticosteroid therapy for long-term control. A quantity limit of 30 capsules per 30 days will apply.