Pharmacy Prior Authorization Criteria

DAW Override

Indications for Prior Authorization

Criteria

Brand drugs with two or more generic equivalents available

Administrative

Length of Approval: 12 Month(s)

• Submission of medical records (e.g., chart notes) (document manufacturer, duration, dose and date of use) confirming patient has tried two generic equivalents of the requested drug from different manufacturers
AND
• One of the following:
• Submission of medical records (e.g., chart notes) confirming the patient has experienced intolerance (e.g., allergy to excipient) with two generic equivalents of the requested drug
OR
• Both of the following:
• Submission of medical records confirming two generic equivalents of the requested drug have not been effective after a minimum 3-month trial
AND
• Submission of records (e.g., chart notes) confirming why the Brand is expected to provide benefit when the generic products have not been shown to be effective despite having the same active ingredient
OR
• All of the following:
• Submission of medical records (e.g., chart notes) confirming the patient has experienced intolerance (e.g., allergy to excipient) with at least one generic equivalent of the requested drug
AND
• Submission of medical records confirming at least one other generic equivalent of the requested drug has not been effective after a minimum 3-month trial
AND
• Submission of records (e.g., chart notes) confirming why the Brand is expected to provide benefit when the generic product(s) have not been shown to be effective despite having the same active ingredient
AND
• One of the following:
• Requested drug is FDA-approved for the condition being treated
OR
• If request is for an off-label indication, the off-label guideline approval criteria have been met

Brand drugs with only one generic equivalent available

Administrative

Length of Approval: 12 Month(s)

• Submission of medical records (e.g., chart notes) (document manufacturer, duration, dose and date of use) confirming patient has tried one generic equivalent of the requested drug from a different manufacturer
AND
• One of the following:
• Submission of medical records (e.g., chart notes) confirming the patient has experienced intolerance (e.g., allergy to excipient) with the generic equivalent of the requested drug
OR
• Both of the following:
• Submission of medical records confirming the generic equivalent of the requested drug has not been effective after a minimum 3-month trial
AND
• Submission of records (e.g., chart notes) confirming why the Brand is expected to provide benefit when the generic product has not been shown to be effective despite having the same active ingredient
AND
• One of the following:
• Requested drug is FDA-approved for the condition being treated
OR
• If request is for an off-label indication, the off-label guideline approval criteria have been met

P & T Revisions

2025-12-09, 2025-11-06, 2024-10-24, 2023-11-01, 2022-10-27, 2022-01-19, 2021-11-25, 2021-09-28, 2021-05-20, 2020-11-03, 2019-10-04

References

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End Notes

1. The Dispense as Written (DAW) Override criteria applies to clients who haved opted into the program as a method for managing prescription costs.. The criteria is applied when a provider or patient requests coverage for a brand-name medication that has one or more generic equivalents available. To qualify, there must be a documented clinical justification for why the patient cannot use the generic version. The criteria specify which clinical reasons are considered acceptable.

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Revision History

• 2025-12-09: Addition of submission of medical records/ paid claims to confirm criteria. Where there are two or more generic equivalents available, member must have had an intolerance to 2 generics, or an intolerance to 1 generic and 1 generic has not been effective after a minimum 3 month trial, or, 2 generics have not been effective after the same trial duration. Where the generic has not been effective, provider must confirm why the Brand is expected to provide benefit when the generic has not. Similar updates for Brand drugs with only one generic equivalent available, where an intolerance or non-effectiveness to the generic is required. Where the generic has not been effective, provider must confirm why the Brand is expected to provide benefit when the generic has not.
• 2025-11-06: Addition of submission of medical records/ paid claims to confirm criteria. Where there are two or more generic equivalents available, member must have had an intolerance to 2 generics, or an intolerance to 1 generic and 1 generic has not been effective after a minimum 3 month trial, or, 2 generics have not been effective after the same trial duration. Where the generic has not been effective, provider must confirm why the Brand is expected to provide benefit when the generic has not. Similar updates for Brand drugs with only one generic equivalent available, where an intolerance or non-effectiveness to the generic is required. Where the generic has not been effective, provider must confirm why the Brand is expected to provide benefit when the generic has not.
• 2024-10-24: Annual review, no changes.
• 2023-11-01: Annual review: Removed UHC formulary.
• 2022-10-27: 2022 Annual Review.
• 2022-01-19: Annual Review - No changes.
• 2021-11-25: Annual Review - No changes.
• 2021-09-28: Addition of EHB formulary to guideline, no changes to criteria
• 2021-05-20: Addition of EHB formulary to guideline, no changes to criteria
• 2020-11-03: 2020 Annual Review: No changes
• 2019-10-04: Annual Review. No changes.

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