Prior Authorization : Brand Medically Necessary Drugs and Brand Before Generic Drugs

Brand Before Generic Drugs

The Brand Medically Necessary Drugs and Brand Before Generic Drugs data table provides the most current list of BBG drugs that require PA.

Clinical Criteria for Brand Before Generic Drugs

Clinical criteria for approval of a BBG drug that requires PA are all of the following:

• The drug has been defined by ForwardHealth as a generic drug that requires BBG PA.
• The member satisfies established coverage and PA policy for the brand equivalent drug.
• The prescriber submits detailed documentation of the member's relevant medication treatment history.
• The member has taken the requested generic drug for at least 30 consecutive days and had a measurable therapeutic response. (Note: Documentation of approximate dates taken may come from the pharmacy or the prescriber.)
• The member has experienced an unsatisfactory therapeutic response or experienced a clinically significant adverse drug reaction to the brand equivalent drug. (Note: Documentation of approximate dates taken may come from the pharmacy or the prescriber.)
• The prescriber includes a description of the unsatisfactory therapeutic response or clinically significant adverse drug reaction that can be directly attributed to the brand equivalent drug.
• The prescriber has indicated how the generic drug will prevent recurrence of an unsatisfactory therapeutic response or clinically significant adverse drug reaction.

Note: Member or prescriber preference for the use of a BBG drug will not be considered as criteria to support the need for a BBG drug.

Submitting Prior Authorization Requests for Brand Before Generic Drugs

PA requests for BBG drugs must be completed and signed by the prescriber and must be submitted using both of the following forms:

• Section VI (Clinical Information for Drugs with Specific Criteria Addressed in the ForwardHealth Online Handbook) of the PA/DGA form
• The PA/RF

Pharmacy providers may submit PA requests for BBG drugs on the Portal, by fax, or by mail (but not using the STAT-PA system).

Brand Before Generic Drugs on the Preferred Drug List

In addition to meeting the clinical criteria for BBG drugs, all existing PDL policies apply to BBG drugs on the PDL. This includes, but is not limited to, policy pertaining to drug classes that require step therapy, drugs that require clinical PA, and drugs that have non-preferred brand equivalents.

In addition to completing the PA/DGA form for BBG drugs, the prescriber is required to complete any other required drug- or drug-class-specific PA form and provide any medical records and/or documentation required for the brand drug or applicable drug class. Examples include, but are not limited to, the following:

• A BBG drug, where the non-preferred brand requires a specific PA form
• A drug or drug class that requires specific medical records and/or documentation to be submitted with the PA request

For example, if a prescriber requests BBG PA for a generic drug and the non-preferred brand drug's PDL PA criteria requires the use of at least two PDL preferred drugs in the same drug class with an unsatisfactory therapeutic response or clinically significant adverse drug reaction, this requirement must also be met before a PA request can be approved for the generic drug.

Submitting Prior Authorization Requests for Brand Before Generic Drugs on the Preferred Drug List

PA requests for BBG drugs on the PDL must be completed and signed by the prescriber and must be submitted using all of the following forms:

• Section VI (Clinical Information for Drugs with Specific Criteria Addressed in the ForwardHealth Online Handbook) of the PA/DGA form
• The PA/RF
• Any other drug- or drug class-specific PA request form that would be required for the brand equivalent drug or applicable drug class

Pharmacy providers may submit PA requests for BBG drugs on the PDL on the Portal, by fax, or by mail (but not using the STAT-PA system).