Information for Dates of Service Before January 15, 2010

Clinical Criteria Requirements

Clinical criteria for approval of a non-preferred drug must be documented by the prescriber on the appropriate PA/PDL form. Criteria for approval of a PA request for a non-preferred drug include the following:

• The member has experienced a treatment failure with the preferred drug(s).
• The member has conditions that prevent the use of the preferred drug(s).
• There is a clinically significant drug interaction with another medication and the preferred drug(s).
• The member has experienced intolerable side effects while on the preferred drug(s).

If the member's condition does not meet the previously listed criteria, a paper PA request and peer-reviewed medical literature must be submitted to BadgerCare Plus or SeniorCare with PA requests for non-preferred drugs.

Elidel^® and Protopic^®

Specific PA critieria for prescribing Elidel^® and Protopic^® include the following:

• The prescription is written by a dermatologist.
• The member is over two years of age. (Protopic^® Ointment .1% is not covered for members younger than 16 years of age.)
• The member is not immunocompromised.
• The member has not taken an antiretroviral or antineoplastic drug in the past two years.
• The member has experienced a treatment failure or a clinically significant adverse drug reaction to a topical corticosteroid in the past 90 days.

Hypoglycemics for Adjunct Therapy

Preferred drugs in the hypoglycemic drugs for adjunct therapy require specific PA criteria. To obtain PA for these drugs, providers are required to complete the PA/PDL for Hypoglycemics for Adjunct Therapy form.

Specific PA criteria are required for Januvia^™. The PA/PDL for Hypoglycemics for Adjunct Therapy includes the criteria.

Proton Pump Inhibitor Drugs

PPI drugs have specific PA approval criteria. The PA/PDL for PPI Drugs contains these criteria.

A member is required to try and fail the maximum dose of both Prevacid^® and Nexium^® before a non-preferred PPI drug can be prescribed. The member is also required to try and fail the maximum dose of omeprazole before another non-preferred PPI drug can be prescribed.

Stimulants and Related Agents

For non-preferred stimulants and related agents, prescribers should indicate a stimulant-approved diagnosis code on the PA/PDL for Stimulants and Related Agents from. Drugs in this class are diagnosis restricted.

Approval criteria for non-preferred stimulants and related agents include the following:

• The member has a diagnosis of ADD or ADHD.
• The member experienced a treatment failure or a clinically significant adverse drug reaction with the preferred stimulant(s).

Strattera Approval Criteria

PA is not required for Strattera for members who are 18 years of age and older; however, PA is required for Strattera for members who are younger than 18 years of age.

For approval of a PA request for Strattera, a member must meet one of the following criteria:

• A diagnosis of ADHD and Tourette's Syndrome or a history of tics.
• A diagnosis of ADD or ADHD and obsessive compulsive disorder.
• A medical history of substance abuse or misuse.
• A history or serious risk of diversion (e.g., someone living in the home with a history of substance abuse or misuse).
• A trial and failure of or adverse reaction to a preferred stimulant or related agent.

A PA request for a non-preferred stimulant or related agent will be approved if one of the previously listed criteria is met.