Prior Authorization : Preferred Drug List

Antifungals, Topical

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

Jublia and Tavaborole

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

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

PA requests for Jublia or tavaborole may be submitted on the Portal, by fax, or by mail. PA requests for Jublia or tavaborole may not be submitted using the STAT-PA system.

Clinical Criteria for Jublia and Tavaborole

Clinical criteria that must be documented for approval of a PA request for Jublia or tavaborole are both of the following:

• The member has onychomycosis of the toenails.
• The member has been treated with ciclopirox topical solution for 48 weeks and experienced an unsatisfactory therapeutic response.

In addition to meeting both of the above clinical criteria, one of the following must be true:

• The member has been treated with oral terbinafine and experienced an unsatisfactory therapeutic response or a clinically significant adverse drug reaction.
• There is a clinically significant drug interaction between another drug the member is taking and oral terbinafine.
• The member has a medical condition(s) that prevents the use of oral terbinafine.

Prescribers should indicate the specific details about the unsatisfactory therapeutic response, clinically significant adverse drug reaction, clinically significant drug interaction or the medical condition(s) preventing the member from using oral terbinafine.

PA requests for Jublia or tavaborole may be approved for up 365 days.