Prior Authorization : Preferred Drug List

Anticonvulsants

Note: The Preferred Drug List Quick Reference provides the most current list of preferred and non-preferred drugs in this drug class.

Expedited Emergency Supply for Anticonvulsants

ForwardHealth strongly encourages pharmacy providers to utilize the expedited emergency supply process for anticonvulsant drugs when it is determined that the member should begin taking the medication immediately, but the PA request submission and adjudication process would delay dispensing the medication to the member. This may occur if the member receives a prescription for a covered anticonvulsant drug and the prescriber has not completed the necessary PA form or the PA request is still in process.

Expedited emergency supply requests for anticonvulsant drugs will be approved for up to a 14-day supply. Members will be limited to receiving two 14-day expedited emergency supply approvals of the same drug from one pharmacy provider within a six-month time period. A PA is not required to be in process when the first expedited emergency supply request is submitted.

If a second expedited emergency supply is necessary for a member, there must be a PA request for the drug submitted to ForwardHealth, and it must be in the process of being adjudicated. The second expedited emergency supply request may be approved if a PA request is in process for the same drug and strength and the PA is submitted by the pharmacy that submitted the first expedited emergency supply request.

If a PA request for the drug has been approved, the second expedited emergency supply request will not be approved.

Requests for a second expedited emergency supply request may be submitted seven to 21 days after the initial request was submitted. Second expedited emergency supply requests will not be approved if they are submitted before day seven or after day 21.

For example, if an initial expedited emergency supply request was submitted on March 4 and a PA request for the drug was submitted on March 7 and a second expedited emergency supply is necessary for the member because the PA request had not yet been adjudicated, the second expedited emergency request may be submitted on March 10 or as late as March 24.

Vigadrone and Vigpoder

PA requests for Vigadrone and Vigpoder must be completed, signed, and dated by the prescriber. PA requests for Vigadrone and Vigpoder must be submitted using Section VI (Clinical Information for Drugs With Specific Criteria Addressed in the ForwardHealth Online Handbook) of the PA/DGA form.

The PA form must be sent to the pharmacy where the prescription will be filled. The prescriber may send the PA form to the pharmacy, or the member may carry the PA form with the prescription to the pharmacy. The pharmacy provider will use the completed PA form to submit a PA request to ForwardHealth. Prescribers should not submit the PA form to ForwardHealth.

Pharmacy providers are required to submit the completed PA/DGA form and a completed PA/RF to ForwardHealth.

PA requests for Vigadrone and Vigpoder may be submitted may be submitted on the Portal, by fax, or by mail (but not using the STAT-PA system).

For information about general ForwardHealth PA policy for drugs that require PA approval, prescribers and pharmacy providers may refer to the Standard Pharmacy Policy for Covered and Noncovered Drugs topic. Providers may also refer to this topic for information about what may not be considered criteria to support the need for a drug.

Clinical Criteria for Vigadrone and Vigpoder

The clinical criteria that must be documented for approval of a PA request for Vigadrone or Vigpoder includes both of the following:

• The prescriber has submitted detailed clinical justification for prescribing Vigadrone or Vigpoder instead of Sabril or vigabatrin (generic Sabril).
• The clinical information must document why the member cannot use Sabril or vigabatrin (generic Sabril), including why it is medically necessary that the member receive Vigadrone or Vigpoder instead of Sabril or vigabatrin (generic Sabril).

Supporting clinical documentation and a copy of the member's current medical records must be submitted with the PA request to support the member's need for Vigadrone or Vigpoder. Initial PA requests for Vigadrone or Vigpoder may be approved for up to 183 days.

Renewal PA requests may be approved for up to 365 days. Medical records must be submitted demonstrating clinical improvement and must reflect member compliance with Vigadrone or Vigpoder.

Note: Vigadrone and Vigpoder are not available through expedited emergency supply.