New Pharmacy Prior Authorization Programs for October 3, 2011
August 19, 2011 - On October 3, 2011, the State Health Plan will begin pharmacy prior authorization programs for Cambia® (diclofenac potassium powder for oral solution), topical tretinoin products and Tazorac® (tazarotene).
Cambia®(diclofenac potassium powder for oral solution) is indicated for the treatment of acute migraine attacks (with or without aura) in adults 18 and over. The Plan currently has quantity limits on medications used to treat migraines; therefore, Cambia will also have quantity limits.
Coverage of Cambia will also require prior authorization with the following criteria:
- Patient is 18 years of age or older
- For migraines - the patient has migraine headaches that have responded to NSAIDs and requires this dosage form to achieve a faster onset of pain relief.
- For other pain - has previously experienced failure/intolerance to treatment with at least 3 different oral non-selective NSAIDs and patient is not taking concurrent oral, topical, intranasal or injectable non-selective NSAID therapy or Celebrex.
If the coverage review is approved, coverage will be provided for a quantity up to 9 sachets per 60 days (which is sufficient to treat 4 migraine headaches per month at the maximum daily recommended dose) with no further coverage review needed.
For members requiring additional quantities, either for the treatment of additional migraine headaches per month or for the treatment of other types of pain, an additional coverage review is available.
Topical tretinoin (Retin-A® and others), tretinoin combination products and tazarotene (Tazorac®) are used in the treatment of acne and other skin conditions. These products will require prior authorization for members age 30 years and older. Patients under 30 will not require a review.
According to Plan benefits, prescription drugs are not covered for cosmetic purposes. Therefore, the prior authorization requirement will ensure the utilization of tretinoin and tazarotene is for non-cosmetic purposes. Examples of uses that are considered cosmetic include (but are not limited to) photo-aging, wrinkling, hyperpigmentation, sun damage and melasma.
In addition for tazarotene, if the non-cosmetic use is the treatment of acne, the member must have experienced treatment failure or intolerance to a topical form of generic tretinoin first.
Members or providers can request a coverage review by calling Medco toll-free at 800-417-1764, 8 a.m. to 9 p.m., Eastern Time, Monday through Friday. If the review is approved, you will pay the appropriate copay for the prescription. If approval is not obtained after October 3, 2011, you will be responsible for the entire cost of the prescription.
You may call Medco Member Services at 800-336-5933 for more information.
