Prior Authorization : Preferred Drug List

H. Pylori Drugs

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

Voquenza

Voquenza requires clinical PA.

PA requests for Voquenza must be completed, signed, and dated by the prescriber. PA requests for Voquenza 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 Voquenza 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 Voquenza

• The member's age must be consistent with FDA-approved product labeling for Voquenza.
• One of the following is true:
  • The member has erosive esophagitis.
  • The member has healed erosive esophagitis.
• The member has experienced an unsatisfactory therapeutic response or a clinically significant adverse drug reaction with at least two proton pump inhibitors.

Supporting clinical information and a copy of the member's current medical records must be submitted with the PA request to support the member's condition and outline the member's current treatment plan.

If the clinical criteria for Voquenza are met, PA requests may be approved for up to 56 days (20 mg) or 183 days (10 mg).