Pharmacy Prior Authorization Criteria

Non-Solid Oral Dosage Forms

Indications for Prior Authorization

Criteria

Norliqva

Prior Authorization

Length of Approval: 12 Month(s)

• One of the following:
• Requested drug is FDA-approved for the condition being treated
OR
• If requested for an off-label indication, the off-label guideline approval criteria have been met
AND
• Patient is unable to swallow a solid dosage form (e.g., oral tablet, capsule) due to one of the following:
• Age
• Physical impairment (e.g., difficulties with motor or oral coordination)
• Dysphagia
• Patient is using a feeding tube or nasal gastric tube

Atorvaliq, Gloperba, Inzirqo, Likmez, generic spironolactone suspension

Prior Authorization

Length of Approval: 12 Month(s)

• One of the following:
• Requested drug is FDA-approved for the condition being treated
OR
• If requested for an off-label indication, the off-label guideline approval criteria have been met
AND
• One of the following:
• Trial and failure, or intolerance to a generic equivalent of the requested drug in a solid dosage form
OR
• Patient is unable to swallow a solid dosage form (e.g., oral tablet, capsule) due to one of the following:
• Age
• Physical impairment (e.g., difficulties with motor or oral coordination)
• Dysphagia
• Patient is using a feeding tube or nasal gastric tube

Jylamvo, Xatmep, Zonisade

Prior Authorization

Length of Approval: 12 Month(s)

• One of the following:
• Requested drug is FDA-approved for the condition being treated
OR
• If requested for an off-label indication, the off-label guideline approval criteria have been met
AND
• One of the following:
• Trial and failure, or intolerance to a generic equivalent of the requested drug in a solid dosage form
OR
• Patient is unable to swallow a solid dosage form (e.g., oral tablet, capsule) due to one of the following:
• Age
• Physical impairment (e.g., difficulties with motor or oral coordination)
• Dysphagia
• Patient is using a feeding tube or nasal gastric tube
OR
• For continuation of prior therapy

P & T Revisions

2025-04-04, 2024-09-11, 2024-06-28, 2024-05-06, 2024-01-31, 2024-01-03, 2023-11-29, 2023-08-28, 2023-03-27, 2022-10-24, 2022-10-05

References

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Revision History

• 2025-04-04: Addition of Inzirqo as a target drug
• 2024-09-11: 2024 UM Annual Review. Addition of COT option for Jylamvo, Xatmep and Zonisade due to COT policy. Removal of PA from Myhibbin
• 2024-06-28: Addition of Myhibbin to guideline
• 2024-05-06: Addition of Xatmep as a target agent
• 2024-01-31: Addition of Gloperba as target
• 2024-01-03: Addition of Jylamvo
• 2023-11-29: Addition of Likmez and generic Carospir (spironolactone suspension)
• 2023-08-28: 2023 UM Annual Review. No changes
• 2023-03-27: update guideline
• 2022-10-24: update guideline
• 2022-10-05: New PA program.

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