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Prior Authorization : Services Requiring Prior Authorization

Topic #1414

Drugs That Require Paper Prior Authorization

Paper PA request submission is required to determine medical necessity for the following drugs. Diagnosis and information regarding the medical requirements for these drug categories must be provided on the PA request for members enrolled in the BadgerCare Plus Standard Plan, Medicaid, and SeniorCare.

Drug Products That Require Paper PA Submission

Alitretinoin gel (when used to treat Kaposi's sarcoma lesions)

Brand medically necessary drugs

Diagnosis-restricted drugs that require PA outside approved diagnoses

Drugs without signed manufacturer rebate agreements*

Fertility enhancement drugs (when used to treat conditions other than infertility)

Impotence treatment drugs (when used for a condition other than impotence)

Unlisted or investigational drugs*

* SeniorCare does not cover prescription drugs, even with a PA request, that do not have a signed rebate agreement between the DHS and the manufacturer; however, these drug products may be covered for BadgerCare Plus or Wisconsin Medicaid members if a paper PA request is submitted.

Submitting Paper Prior Authorization Requests

Paper PA requests that are faxed to ForwardHealth will receive an adjudication response via telephone one business day after they are received. Providers who submit PA requests by mail should be aware that this option requires additional time for the PA request to reach ForwardHealth and for ForwardHealth to complete the adjudication process.

To avoid delayed adjudication, do not fax and mail duplicate copies of the same PA request forms.

Pharmacy providers may contact Provider Services to determine the status of any PA request that has been submitted.

Approved, Returned, and Denied Paper Requests

A paper PA request submitted to ForwardHealth may be approved, returned, or denied.

When a PA request is approved:

  • The "approved" box on the PA/RF is checked.
  • The grant and expiration dates are indicated.
  • A signature and a date signed are indicated.
  • A specific days' supply is indicated.

When a PA request is returned:

  • The "return" box on the PA/RF is checked.
  • An explanation for the return is indicated.

A PA request is returned because additional information is needed or because information on the request must be corrected. A returned PA request is not the same as a denied request. Providers should correct or add the missing information to the original PA request and resubmit it to BadgerCare Plus or SeniorCare.

When a PA request is denied:

  • The "denied" box on the PA/RF is checked and an explanation is given.
  • A signature and date signed are indicated.
Topic #13678

Fertility and Impotence Drugs

According to DHS 107.10(2)(f) and 107.10(2)(g), Wis. Admin. Code, the following drugs require PA:

  • Drugs identified by the DHS that are sometimes used to enhance the prospect of fertility in males or females, when proposed to be used for treatment of a condition not related to fertility.
  • Drugs identified by the DHS that are sometimes used to treat impotence, when proposed to be used for the treatment of a condition not related to impotence.

These types of drugs are not covered unless a paper PA request is submitted on the PA/DGA and the drug is being used to treat a condition unrelated to fertility or impotence.

Topic #13677

Kalydeco

Kalydeco (ivacaftor) requires PA and is only indicated for the treatment of a rare form of cystic fibrosis with a G551D mutation in the CFTR gene. Prescribers are required to complete the appropriate section(s) of the PA/DGA as it pertains to the drug being requested.

Clinical criteria for approval of a PA request for Kalydeco are the following:

  • The member has a diagnosis of cystic fibrosis.
  • The member is 6 years of age or older.
  • The prescriber has confirmed the member has a G551D mutation in the CFTR gene. (Note: A copy of the test results should be included with an initial PA request.)
  • The prescriber has confirmed the member does not have a homozygous F508del mutation in the CFTR gene.
  • The prescriber has confirmed liver function testing is being periodically monitored. (Note: A copy of the test results completed within the last 90 days should be included with initial and renewal PA requests.)

PA requests for Kalydeco may be approved for a maximum approval period of 365 days.

Topic #7877

Prior Authorization Requests and Amendments for Synagis

Synagis® requires PA. Prescribers, not pharmacy providers, are required to submit PA requests for Synagis®. Members who have previously been administered Synagis® will not be grandfathered and are required to have a valid PA on file for Synagis® for each treatment season. If the first dose of Synagis® is administered in a hospital, the dose does not require PA.

PA requests for Synagis® may be submitted beginning September 15 of each year.

When requesting PA for Synagis®, the prescribing provider must identify the name and NPI of the provider who intends to submit a claim for reimbursement for Synagis® (i.e., the billing provider).

If the prescribing provider intends to submit the claim, the prescribing provider must list his or her name and NPI on the PA request as the billing provider.

If the prescribing provider's clinic or group intends to submit the claim, the prescribing provider must list the clinic or group's name and NPI on the PA request as the billing provider.

If, instead, a pharmacy provider intends to submit the claim, the prescribing provider must list the pharmacy provider's name and NPI on the PA request as the billing provider. In this case, it is the prescribing provider's responsibility to acquire the pharmacy provider's name and NPI.

Prescribers or their designees must request PA for Synagis® using only one of the following options:

If prescribers call the DAPO Center to obtain PA, they may complete, sign, and date the PA request form and keep it in a member's medical records.

PA requests for Synagis® submitted through the Portal or by mail or fax will not be processed as 24-hour drug PA requests because providers may call the DAPO Center to obtain an immediate decision about a PA request.

Prior Authorization Requests Submitted by Fax or Mail

If a prescriber or his or her designee chooses to submit a paper PA request for Synagis® by fax or mail, the following must be completed and submitted to ForwardHealth:

The Prior Authorization Fax Cover Sheet is available for providers submitting the forms and documentation by fax.

Prior Authorization Amendments

Prescribing providers and billing providers may amend approved PAs for Synagis® if a member's weight changes, resulting in an increase in Synagis® units during a treatment season. Providers have 30 days from the date of administering each dose change to amend an approved PA for Synagis®.

If the prescribing provider is not also the billing provider, the prescribing provider may only amend the PA by contacting the DAPO Center.

Billing providers may amend PA requests through the following:

  • By calling the DAPO Center.
  • On the Portal.
  • By submitting a PA/RF by mail or fax.

To amend a PA request for Synagis®, providers are required to provide the following information:

  • The member's most recent weight and the date it was measured.
  • The member's weight at the time the dose change occurred and the date it was measured.
  • The requested start date for the dose change.
  • The new Synagis® dose calculation.

Change in Billing Provider

If during the course of Synagis® treatment the billing provider changes, the prescribing provider (i.e., the provider who submitted the original PA request) is responsible for amending the PA. To amend the billing provider information, the prescribing provider must call the DAPO Center. The prescribing provider will be required to give the new billing provider's name and NPI.

Clinical Criteria

To be approved, PA requests must document that the member meets the following clinical criteria:

  • For chronic lung disease, the member is a child younger than 24 months of age at the start of the RSV season with chronic lung disease who requires medical therapy (i.e., supplemental oxygen, bronchodilators, diuretics, or corticosteroid therapy) within six months of the start of the RSV season. In this case, a maximum of five doses of Synagis® will be approved.
  • For congenital heart disease, the member is a child younger than 24 months of age at the start of the RSV season with hemodynamically significant cyanotic or acyanotic congenital heart disease and is receiving medication to control congestive heart failure, has moderate to severe pulmonary hypertension, or has cyanotic heart disease. In this case, a maximum of five doses of Synagis® will be approved.
  • For immunocompromised children, the member is a child younger than 24 months of age at the start of the RSV season with a severe immunodeficiency (i.e., SCID or advanced AIDS). In this case, a maximum of five doses of Synagis® will be approved.

To be approved, PA requests for pre-term infants must document that the member meets the following clinical criteria:

  • The member is an infant born before 29 weeks gestation (i.e., zero days through 28 weeks, six days) who is less than 12 months of age at the start of the RSV season. In this case, a maximum of five doses of Synagis® will be approved.
  • The member is an infant born at or greater than 29 weeks gestation but less than 32 weeks gestation (i.e., 29 weeks, zero days through 31 weeks, six days) who is less than six months of age at the start of the RSV season. In this case, a maximum of five doses of Synagis® will be approved.
  • The member is an infant born at or greater than 32 weeks gestation but less than 35 weeks gestation (i.e., 32 weeks, zero days through 34 weeks, six days) who is less than three months of age at the start of the RSV season or is born during the RSV season and has at least one of the following risk factors:
    • Infant attends child care.
    • Infant has siblings younger than five years of age.

The member should receive prophylaxis only until he or she reaches 3 months of age. The member should only receive a maximum of three monthly doses; many members will receive only one or two doses until they reach 3 months of age.

  • The member is an infant born before 35 weeks gestation (i.e., 34 weeks, six days) who is less than 12 months of age at the start of the RSV season with either congenital abnormalities of the airway or a neuromuscular condition that compromises handling of respiratory secretions. In this case, a maximum of five doses of Synagis® will be approved.

PA requests will be approved only for the Synagis® treatment season of November through March. ForwardHealth will not approve more than five doses of Synagis® per season.

Topic #7837

Prior Authorization for Anti-Obesity Drugs

PA requests for the following anti-obesity drugs may be submitted on the Prior Authorization Drug Attachment for Anti-Obesity Drugs:

  • Benzphetamine.
  • Diethylpropion.
  • Phentermine.
  • Phendimetrazine.
  • Belviq.
  • Qysmia.
  • Xenical®.

Anti-obesity drugs are covered for dual eligibles enrolled in a Medicare Part D PDP.

A 34-day supply is the maximum amount of any anti-obesity drug that may be dispensed each month.

Clinical Criteria for Anti-obesity Drugs

Clinical criteria for approval of a PA request for anti-obesity drugs require one of the following:

  • The member has a BMI greater than or equal to 30.
  • The member has a BMI greater than or equal to 27 but less than 30 and two or more of the following risk factors:
    • Coronary heart disease.
    • Dyslipidemia.
    • Hypertension.
    • Sleep apnea.
    • Type II diabetes mellitus.

In addition, all of the following must be true:

  • The member is 16 years of age or older. (Note: Members need only to be 12 years of age or older to take Xenical®.)
  • The member is not pregnant or nursing.
  • The member does not have a history of an eating disorder (e.g., anorexia, bulimia).
  • The prescriber has evaluated and determined that the member does not have any medical or medication contraindications to treatment with the anti-obesity drug being requested.
  • For controlled substance anti-obesity drugs, the member does not have a medical history of substance abuse or misuse.
  • The member has participated in a weight loss treatment plan (e.g., nutritional counseling, an exercise regimen, a calorie-restricted diet) in the past six months and will continue to follow the treatment plan while taking an anti-obesity drug.

PA requests for anti-obesity drugs will not be renewed if a member's BMI is below 24.

Note: ForwardHealth does not cover the brand name (i.e., innovator) anti-obesity drugs if an FDA-approved generic equivalent is available. ForwardHealth does not cover any brand name innovator phentermine products. In addition, ForwardHealth does not cover OTC anti-obesity drugs.

ForwardHealth will return PA requests for OTC and brand name anti-obesity drugs with generic equivalents and brand name phentermine products as noncovered services.

Clinical Criteria for Benzphetamine, Diethylpropion, Phendimetrazine, and Phentermine

If clinical criteria for anti-obesity drugs are met, initial PA requests for benzphetamine, diethylpropion, phendimetrazine, and phentermine will be approved for up to a maximum of three months. If the member meets a weight loss goal of at least 10 pounds of his or her weight from baseline during the initial three-month approval, PA may be requested for an additional three months of treatment. The maximum length of continuous drug therapy for benzphetamine, diethylpropion, phendimetrazine, and phentermine is six months.

If the member does not meet a weight loss goal of at least 10 pounds of his or her weight from baseline during the initial three-month approval, or if the member has completed six months of continuous benzphetamine, diethylpropion, phendimetrazine, or phentermine treatment, the member must wait six months before PA can be requested for any controlled substance anti-obesity drug.

ForwardHealth allows only two weight loss attempts with this group of drugs (benzphetamine, diethylpropion, phendimetrazine, and phentermine) during a member's lifetime. Additional PA requests will not be approved. ForwardHealth will return additional PA requests to the provider as noncovered services. Members do not have appeal rights for noncovered services.

Clinical Criteria for Belviq

If clinical criteria for anti-obesity drugs are met, initial PA requests for Belviq will be approved for up to a maximum of three months. If the member meets a weight loss goal of at least five percent of his or her weight from baseline during the first three months of treatment, PA may be requested for an additional six months of treatment. If the member's weight remains below baseline, subsequent PA renewal periods for Belviq are a maximum of six months. PA requests for Belviq may be approved for a maximum treatment period of 24 continuous months of drug therapy.

If the member does not meet a weight loss goal of at least five percent of his or her weight from baseline during the initial three-month approval, or if the member's weight does not remain below baseline, or if the member has completed 24 months of continuous Belviq treatment, the member must wait six months before PA can be requested for any controlled substance anti-obesity drug.

ForwardHealth allows only two weight loss attempts with Belviq during a member's lifetime. Additional PA requests will not be approved. ForwardHealth will return additional PA requests to the provider as noncovered services. Members do not have appeal rights for noncovered services.

Clinical Criteria for Qysmia

If clinical criteria for anti-obesity drugs are met, initial PA requests for Qysmia will be approved for up to a maximum of six months. If the member meets a weight loss goal of at least five percent of his or her weight from baseline, PA may be requested for an additional six months of treatment. PA requests for Qysmia may be approved for a maximum treatment period of 12 continuous months of drug therapy.

If the member does not meet a weight loss goal of at least five percent of his or her weight from baseline during the initial six-month approval, or if the member has completed 12 months of continuous Qysmia treatment, the member must wait six months before PA can be requested for any controlled substance anti-obesity drug.

ForwardHealth allows only two weight loss attempts with Qysmia during a member's lifetime. Additional PA requests will not be approved. ForwardHealth will return additional PA requests to the provider as noncovered services. Members do not have appeal rights for noncovered services.

Clinical Criteria for Xenical®

If clinical criteria for anti-obesity drugs are met, initial PA requests for Xenical® will be approved for up to a maximum of six months. If the member meets a weight loss goal of at least 10 pounds of his or her weight from baseline during the first six months of treatment, PA may be requested for an additional six months of treatment. If the member's weight remains below baseline, subsequent PA renewal periods for Xenical® are a maximum of six months. PA requests for Xenical® may be approved for a maximum treatment period of 24 continuous months of drug therapy.

If the member does not meet a weight loss goal of at least 10 pounds during the initial six-month approval, or if the member's weight does not remain below baseline, or if the member has completed 24 months of continuous Xenical® treatment, the member must wait six months before PA can be requested for Xenical®.

ForwardHealth allows only two weight loss attempts with Xenical® during a member's lifetime. Additional PA requests will not be approved. ForwardHealth will return additional PA requests to the provider as noncovered services. Members do not have appeal rights for noncovered services.

Submitting Prior Authorization Requests for Anti-obesity Drugs

PA requests for anti-obesity drugs must be submitted using the Prior Authorization Drug Attachment for Anti-Obesity Drugs form and must be submitted by prescribers or their designees, not pharmacy providers.

Prior Authorization requests for anti-obesity drugs may be submitted through the following:

Note: PA requests for anti-obesity drugs submitted by mail or fax will not be processed as 24-hour drug PA requests If an immediate decision is needed for a PA request, providers should call the DAPO Center. during the noted business hours. If prescribers choose not to use the DAPO Center, the prescriber is required to submit a PA/RF along with the applicable PA drug attachment form with the additional medical documentation.

Prior authorization request submission procedures apply to members enrolled in the BadgerCare Plus Standard Plan, Medicaid, and SeniorCare.

Topic #16537

Prior Authorization for Antipsychotic Drugs for Children 7 Years of Age and Younger

All antipsychotic drugs prescribed for oral use for all children 7 years of age and younger require PA.

PA requests must meet the criteria for children 7 years of age and younger to maintain coverage of an antipsychotic drug.

PA requests for antipsychotic drugs for children 7 years of age and younger must be submitted on the Prior Authorization Drug Attachment for Antipsychotic Drugs for Children 7 Years of Age and Younger.

Claims submitted for an antipsychotic drug for children 7 years of age and younger without an approved Prior Authorization Drug Attachment for Antipsychotic Drugs for Children 7 Years of Age and Younger on file will be denied.

Providers should refer to the Preferred Drug List Quick Reference for a list of covered antipsychotic drugs for members enrolled in the BadgerCare Plus Standard Plan or Medicaid. Prescribers are encouraged to write prescriptions for preferred antipsychotic drugs.

Background

In 2007, a consortium of state Medicaid medical directors for 16 states and the Rutgers Center for Education and research on Mental Health Therapeutics collaborated on an analysis of antipsychotic medication use among a combined enrollment of 12 million children and adolescents. This collaboration concluded the following:

  • Many children receive mental health care that is largely limited to medications without adequate evaluations and other therapy services.
  • The signs, symptoms, and diagnostic criteria for bipolar disorder in children are highly controversial and often lead to antipsychotic use in children and adolescents.
  • There are many concerns about the use of multiple psychoactive medications simultaneously (polypharmacy) within and between drug classes.
  • Off-label prescribing of antipsychotic medications in children occurs and some children are prescribed doses that may exceed maximum limits.
  • Antipsychotic prescribing occurs in young children with questionable diagnoses and without child psychiatric consultation.
  • There is limited knowledge about the long-term effects of antipsychotic medications.
  • Children in foster care appear to have significantly higher rates of antipsychotic medication use.
  • There are significant metabolic risks including weight gain and diabetes associated with the use of second generation antipsychotic medications.

The consortium surveyed 36 states regarding the possible approaches to monitoring antipsychotic use among children and adolescents. States have adopted many different approaches singularly or in combinations including PAs, PDLs, restrictions by provider types, step therapy protocols, guidelines, limited refills, second opinions, age restrictions, dose restrictions, polypharmacy restrictions, cost restrictions, and generic preferences. There is growing concern particularly regarding the use of antipsychotic medications in children placed in foster care and in very young (7 and under) preschool-age children.

The increased use of antipsychotic medications in young children over the past decade has been associated with the frequent use of the diagnosis of Bipolar Disorder, NOS (296.80) per the DSM-5 in many of these children. A discussion and review of the issues in differentiating Bipolar Disorder, NOS and DMDD can be found in the Journal of the American Academy of Child and Adolescent Psychiatry, Volume 52, Issue 5, May 5, 2013, pp.466-481 (Towbin, K. MD, Axelson, D. MD, Leibenluft, E. MD, Birmaher, B. MD. "Differentiating Bipolar Disorder-Not Otherwise Specified and Severe Mood Dysregulation."). There has been some progress in the research of these clinical issues in recent years. Specifically the DSM-5 addresses the inclusion of DMDD (296.99). This evolved out of the observation that many children with a diagnosis of bipolar disorder do not progress to having bipolar disorder, NOS as adults thus bringing into question the use of antipsychotic medications for these children. Many of the children with DMDD (or severe mood dysregulation as referenced in several research studies) respond to stimulants and/or SSRI antidepressants. Clinicians who prescribe antipsychotic medications to children with bipolar disorder, NOS diagnoses will need to become familiar with the details of the current research on differentiating DMDD from bipolar disorder, NOS.

Topic #16538

Prescriber Responsibilities for Antipsychotic Drugs for Children 7 Years of Age and Younger

If the child is 7 years of age or younger and requires an antipsychotic drug, the prescriber is required to complete the Prior Authorization Drug Attachment for Antipsychotic Drugs for Children 7 Years of Age and Younger form. PA request forms must be faxed, mailed, or sent with the member to the pharmacy provider.

The pharmacy provider will use the completed form to submit a PA request to ForwardHealth. Prescribers should not submit the Prior Authorization Drug Attachment for Antipsychotic Drugs for Children 7 Years of Age and Younger form directly to ForwardHealth. Prescribers are required to retain a completed and signed copy of the PA form.

PA requests for covered antipsychotic drugs for children 7 years of age and younger are approved at the active ingredient level. Therefore, an approved PA allows any covered NDC with the same active ingredient of the prior authorized drug to be covered with the same PA. For example, if a member has an approved PA for risperidone 1 mg tablets and the prescriber orders a new prescription for risperidone 2 mg tablets, an amended PA request or new PA request is not required.

Topic #16539

Required Documentation

The following factors will be considered for the approval of a PA request for antipsychotics for children 7 years of age and younger and should be documented on the PA request:

  • Diagnoses — There are appropriate indications for the use of antipsychotic medications in young children with certain diagnoses including autism spectrum disorders, psychotic disorders, and tic disorders. Antipsychotic medications may also be helpful for severe symptoms of irritability, aggression, anger, or defiance that may accompany severe mood disorders, developmental disorders, or attention-deficit/hyperactivity disorders.
  • BMI — Antipsychotic medications can have profoundly adverse effects on weight, glucose, and lipids. Because of these well-documented side effects, the Prior Authorization Drug Attachment for Antipsychotic Drugs for Children 7 Years of Age and Younger requires the submission of a BMI percentile measurement with each PA request. The BMI percentile measurement is required because it is the standard for stratifying individuals as obese or at-risk for obesity and therefore requiring closer monitoring and active intervention. Children who have a BMI percentile measurement greater than or equal to 85 percent are at risk for diabetes and the metabolic syndrome associated with many antipsychotic medications. If the child's BMI percentile is 85 percent or greater, the PA must include a fasting lipid panel and a fasting glucose drawn within the past six months for the PA to be approved. A BMI calculator is available and may be found on the CDC Web site.
  • Target symptoms — To appropriately prescribe and track the use of antipsychotic medications, the prescriber needs to carefully identify the primary target symptom (or target symptom cluster) so that the family, mental health clinicians, teachers, and all involved adults can help clarify and determine the efficacy of the medication.
  • Polypharmacy — The Prior Authorization Drug Attachment for Antipsychotic Drugs for Children 7 Years of Age and Younger requires the notation of any psychoactive medications, concurrent medications, as well as previous medication trials in the preceding 12 months.
  • Specialty/Consultation information — Wisconsin Medicaid and BadgerCare Plus are interested in tracking the availability of sub-specialty consultations from Child Psychiatrists for children receiving antipsychotic medications as these medications are complicated and have many side effects, and the children often present with very complicated diagnostic considerations.
  • PDL — If the prescriber is requesting a non-preferred antipsychotic medication, clinical justification must be provided (e.g., failed trials of preferred medications including doses, length of treatment, clinical response, side effects, and/or target symptoms).
Topic #16540

Pharmacy Responsibilities for Antipsychotic Drugs for Children 7 Years of Age and Younger

Pharmacy providers should ensure that they have received the completed Prior Authorization Drug Attachment for Antipsychotic Drugs for Children 7 Years of Age and Younger from the prescriber.

Pharmacy providers should determine the ForwardHealth benefit plan in which the member is enrolled. After the benefit plan is confirmed, pharmacy providers should review the program-specific covered drug or product list.

For Standard Plan and Medicaid members, pharmacy providers should review the Preferred Drug List Quick Reference for the most current list of preferred and non-preferred drugs.

If a Standard Plan or Medicaid member presents a prescription for a non-preferred antipsychotic drug, the pharmacy provider is encouraged to contact the prescriber to discuss preferred drug options. The prescriber may choose to change the prescription to a preferred antipsychotic drug, if medically appropriate for the member.

It is important that pharmacy providers work with prescribers to ensure that members are given appropriate assistance regarding coverage information and the PA request submission process for antipsychotic drugs. Pharmacy providers are responsible for the submission of the Prior Authorization Drug Attachment for Antipsychotic Drugs for Children 7 Years of Age and Younger to ForwardHealth. Pharmacy providers are required to retain a completed and signed copy of the PA form.

Brand name antipsychotic drugs prescribed to children 7 years of age and younger that are brand medically necessary require a PA Drug Attachment for Antipsychotic Drugs for Children 7 Years of Age and Younger to be submitted on the ForwardHealth Portal, by fax, or by mail with the PA/BMNA and the PA/RF.

Two unique PA numbers will be assigned for a brand medically necessary antipsychotic drug. One PA number will be assigned to the Prior Authorization Drug Attachment for Antipsychotic Drugs for Children 7 Years of Age and Younger and the other will be assigned to the PA/BMNA.

Prior Authorization Request Submission Methods

Pharmacy providers are encouraged to use the STAT-PA system to submit antipsychotic PA requests for members diagnosed with one of the following conditions:

  • ADHD (ICD-9-CM codes 314.0-314.9).
  • Autism Spectrum Disorder (ICD-9-CM codes 299.0-299.91).
  • Tic disorder (ICD-9-CM codes 307.20-307.23).

PA requests cannot be submitted using the STAT-PA system if at least one of the following is true:

  • The diagnosis code for the child is something other than ADHD, Autism Spectrum Disorder, or tic disorder.
  • The drug being requested is a non-preferred antipsychotic drug.
  • The member is 2 years of age or younger.
  • The PA is for a brand medically necessary antipsychotic drug.
  • The child's BMI percentile is greater than or equal to the 85th percentile for the age of the child.

If the PA is not approved through the STAT-PA system, pharmacy providers are required to submit the Prior Authorization Drug Attachment for Antipsychotic Drugs for Children 7 Years of Age and Younger form, and a PA/RF, and any supporting documentation from the prescriber via the FowardHealth Portal, by fax, or by mail.

Topic #16541

Approved Prior Authorization Requests for Antipsychotic Drugs for Children 7 Years of Age and Younger

Neither a new PA request nor a PA amendment is needed if the antipsychotic drug the child is taking has changed and the new drug contains the same active ingredient as the original drug approved or if the child is taking multiple strengths of the same drug.

PA decision notice letters for antipsychotic drugs for children 7 years of age and younger will include a message stating: "The prior authorization for this drug has been approved at the active ingredient level instead of the drug strength and dosage form level. Additional PAs are not needed for a different strength of this same drug."

Topic #12997

Prior Authorization for Drugs Outside ForwardHealth-Allowed Diagnoses

PA requests for drugs outside the ForwardHealth-allowed diagnoses must be submitted on paper using a PA/RF and a PA/DGA. The prescriber is required to complete the appropriate section(s) of the PA/DGA as it pertains to the drug being requested and submit peer-reviewed medical literature to support the proven efficacy of the requested use of the drug to the pharmacy where the prescription will be filled.

Topic #7817

Prior Authorization for Lipotropics, Omega-3 Acids

Note: For the most current list of preferred and non-preferred drugs in this drug class, refer to the Preferred Drug List Quick Reference.

Clinical PA is required for all omega-3 acids, including preferred omega-3 acids. PA requests for omega-3 acids must be submitted by prescribers or their designees, not pharmacy providers.

PA requests for Lovaza® and Vascepa® for BadgerCare Plus Standard Plan, Medicaid, and SeniorCare members should be submitted using the Prior Authorization Drug Attachment for Lipotropics, Omega-3 Acids.

PA requests for omega-3 acids may be submitted through the following:

Note: PA requests for omega-3 acids submitted by fax or mail will not be processed as 24-hour drug PA requests because providers may call the DAPO Center to obtain an immediate decision about a PA request.

Prior Authorization Requests Submitted by Fax or Mail

If a prescriber or his or her designee chooses to submit a PA request for an omega-3 acid by fax or mail, the following must be completed and submitted to ForwardHealth:

  • A PA/RF (which should be completed using the instructions for prescribers for drugs).
  • The Prior Authorization Drug Attachment for Lipotropics, Omega-3 Acids form.
  • Supporting documentation, as appropriate.

The Prior Authorization Fax Cover Sheet is available for providers submitting the forms and documentation by fax.

Clinical Criteria for Lovaza®

Clinical criteria for approval of a PA request for Lovaza® for members who are not currently taking Lovaza® are all of the following:

  • The member is 18 years of age or older.
  • The member does not have an allergy or sensitivity to fish.
  • One of following is true:
    • The member currently has a triglyceride level of 500 mg/dL or greater.
    • The member currently has a triglyceride level below 500 mg/dL and both of the following are true:
      • The member has had a triglyceride level of 500 mg/dL or greater in the past.
      • The member has a current triglyceride level between 200 and 499 mg/dL while taking a fibrate or niacin. (If a member's triglyceride level is below 200mg/dL, the PA request will be denied.)

Clinical criteria for approval of a PA request for Lovaza® for members who are currently taking Lovaza® are all of the following:

  • The member is 18 years of age or older.
  • The member does not have an allergy or sensitivity to fish.
  • The member's current triglyceride level has decreased by at least 20 percent from the baseline level.
  • The member has had a triglyceride level of 500 mg/dL or greater in the past.

Clinical Criteria for Non-Preferred Omega-3 Acids

Clinical criteria for approval of a PA request for a non-preferred omega-3 acid for members not currently taking a non-preferred omega-3 acid are all of the following:

  • The member is 18 years of age or older.
  • The member does not have an allergy or sensitivity to fish.
  • In the past year, the member has taken the maximum dose of Lovaza® for at least four consecutive months and one of the following is true:
    • The member failed to achieve at least a 30 percent decrease in triglyceride level from baseline.
    • The member's triglyceride level remained at 500 mg/dL or greater.
  • One of following is true:
    • The member currently has a triglyceride level of 500 mg/dL or greater.
    • The member currently has a triglyceride level below 500 mg/dL and both of the following are true:
      • The member has had a triglyceride level of 500 mg/dL or greater in the past.
      • The member has a current triglyceride level between 200 and 499 mg/dL while taking a fibrate, niacin, or Lovaza®. (If a member's triglyceride level is below 200mg/dL, the PA request will be denied.)

Clinical criteria for approval of a PA request for a non-preferred omega-3 acid for members currently taking a non-preferred omega-3 acid are all of the following:

  • The member is 18 years of age or older.
  • The member does not have an allergy or sensitivity to fish.
  • The member's current triglyceride level has decreased by at least 20 percent from the baseline level.
  • The member has had a triglyceride level of 500 mg/dL or greater in the past.

Approved Prior Authorization Requests for Omega-3 Acids

PA requests for omega-3 acids may be initially approved for four months. Renewal PA requests may be approved for up to a maximum of one year. For an initial renewal PA request to be approved, the member's triglyceride levels must decrease by at least 20 percent from the baseline triglyceride level. For subsequent renewal PA requests to be approved, the member must continue to maintain the improved triglyceride level.

Lipid panels, including triglyceride levels, within the previous three months are required for each yearly PA renewal request thereafter.

Topic #13017

Types of Drugs that Require Prior Authorization

The following are types of drugs that require PA:

  • Brand medically necessary drugs.
  • Diagnosis-restricted drugs.
  • Drugs outside approved diagnoses.
  • PDL drugs.


 
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Wisconsin Department of Health Services
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