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| General Non-Formulary Request Criteria – Delaware – NSF | |
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| Number: J-0752 | Category: Formulary |
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Line(s) of Business:
Commercial |
Benefit(s):
Not Applicable |
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Region(s):
All |
Additional Restriction(s):
Formulary: NSF |
| Drugs Products |
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| FDA-Approved Indications: |
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| Background: |
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I. Contraceptives When a benefit, a targeted NSF contraceptive may be approved if a member meets one of the following criteria (A. or B.): A. The prescribing physician indicates that the drug is medically necessary. B. The member has tried and failed one alternative listed in the Contraceptive category in Table 1 below. II. Antibiotics, Anti-virals, and Anti-fungals When a benefit, an antibiotic, anti-viral, or anti-fungal may be approved if a member meets the following criteria: A. The member has tried and failed one alternative with the same route of administration listed in the last column of Table 1 below for the corresponding antibiotic, anti-viral, or anti-fungal category. III. Combination Medications When a benefit, a combination product may be approved if a member meets the following criteria: A. The member has tried and failed two alternative products, if available, from the corresponding category listed in the last column of Table 1 below with one being in the same specific class as at least one ingredient in the requested combination product IV. All Other Targeted Medications When a benefit, the requested medication will be approved if a member meets all of the following criteria (A. and B. or C.): A. The medication must be used for a FDA approved indication. B. For targeted medications listed in Table 1 below, the member must have tried and failed two alternative products, if available, listed in the last column in the corresponding category. C. For targeted multisource brands NOT listed below, the member must have tried and failed the generic product.
Table 1. NSF Targeted Medications and Therapeutic Alternatives for Specific Therapeutic Categories
**Must be a covered benefit.
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| Limitations of Coverage |
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I. Coverage of a medication for disease states outside of their FDA-approved indications should be denied based on the lack of clinical data to support their effectiveness and safety in other conditions. II. This policy is to be used in conjunction with other utilization management policies for the requested medication, if applicable, based on the member's benefit.
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| Authorization Duration |
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| Automatic Approval Criteria |
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None
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| Version: J-0752-001 |
| Effective Date Begin: 07/01/2018 |
| Effective End Begin: 12/31/2018 |
| Original Date: 07/01/2018 |
| Review Date: 06/20/2018 |
References:
- Truven Health Analytics Micromedex Solutions. Available at: www.micromedexsolutions.com. Accessed June 11, 2018.
- American Society of Health-System Pharmacists. AHFS Drug Information. Available at: http://www.ahfsdruginformation.com/. Accessed June 11, 2018.
- Clinical Pharmacology. Elsevier. Gold Standard. Available at: http://www.clinicalpharmacology-ip.com/default.aspx. Accessed June 11, 2018.
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Pharmacy policies do not constitute medical advice, nor are they intended to govern physicians' prescribing or the practice of medicine. They are intended to reflect Highmark's coverage and reimbursement guidelines. Coverage may vary for individual members, based on the terms of the benefit contract.
Highmark retains the right to review and update its pharmacy policy at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the pharmacy policies is prohibited; however, limited copying of pharmacy policies is permitted for individual use.
