Recent Pharmacy PA Form and Criteria Updates

Recently, multiple pharmacy prior approval (PA) forms and criteria have been updated or added. Please see the summary of updates below and make sure you are using the most current PA form. Using an old form can cause the PA to deny.

Form Updates/Additions

  • Mavyret Continuation PA form added (new)
  • Topical Antihistamines temporary PA form added (new)
  • Dupixent Asthma temporary PA form added (new); preexisting Dupixent temporary PA form renamed Dupixent for Atopic Dermatitis
  • Entresto PA form updated
  • Migraine Calcitonin Gene Related Therapy temporary PA form (new)
  • Gocovri temporary PA form (new)

Immunomodulator Form Updates

  • Ankylosing Spondylitis (Enbrel, Humira, Cosentyx, Inflectra, Cimzia, Simponi, Simponi Aria, Remicade, Renflexis)
  • Cryopyrin-Associated Periodic Syndromes including Familial Cold Autoinflammatory Syndrome (FCAS) and Muckle-Wells Syndrome (MWS) (Arcalyst and Ilaris)
  • Crohn’s Disease (Adult) (Humira, Cimzia, Entyvio, Inflectra, Stelara, Remicade, Renflexis)
  • Crohn’s Disease (Pediatric) (Humira, Inflectra, Remicade, Renflexis) (new)
  • Cytokine Release Syndrome (Actemra and Actemra SQ) (new)
  • Familial Mediterranean Fever (FMF) (Ilaris) (new)
  • Giant Cell Arteritis (Actemra and Actemra SQ)
  • Hyperimmunoglobulin D Syndrome (HIDS)/ Mevalonate Kinase Deficiency (MKD) (Ilaris) (new)
  • Hidradenitis Suppurativa (Humira)
  • Neonatal Onset: Multi-System Inflammatory Disease (Kineret)
  • Non-Infectious Intermediate Posterior Panuveitis (Humira) (new)
  • Polyarticular Juvenile Idiopathic Arthritis (Enbrel, Humira, Actemra SQ, Actemra Infusion, Orencia Infusion and Orencia SQ)
  • Plaque Psoriasis (Adult) (Enbrel, Humira, Cosentyx, Cimzia, Ilumya, Inflectra, Otezla, Remicade, Renflexis, Stelara, Taltz, and Tremfya)
  • Plaque Psoriasis (Pediatric) (Enbrel and Stelara)
  • Psoriatic Arthritis (Enbrel, Humira, Inflectra, Cosentyx, Cimzia, Orencia, Orencia Infusion, Otezla, Renflexis, Remicade, Simponi, Simponia Aria, Stelara, Taltz, Xeljanz and Xeljanz XR)
  • Rheumatoid Arthritis (Enbrel, Humira, Actemra Infusion, Actemra SQ, Cimzia, Inflectra, Kevzara, Kineret, Olumiant, Orencia Infusion, Orencia SQ, Remicade, Renflexis, Simponi, Simponi Aria, Xeljanz XR)
  • Systemic Onset Juvenile Idiopathic Arthritis (For Actemra SQ, Actemra Infusion and Ilaris)
  • Tumor Necrosis Factor Receptor Associated Periodic Syndrome (TRAPS) (Ilaris) (new)
  • Ulcerative Colitis (Adult) (Humira, Entyvio, Inflectra, Remicade, Renflexis, Simponi, Xeljanz, Xeljanz XR)
  • Ulcerative Colitis (Pediatric) (Remicade) (new)

Criteria Updates/Additions

  • Hematinics criteria updated
  • Immunomodulator criteria updated
  • Topical antihistamines criteria added (new)
  • Entresto criteria updated (adding continuation criteria)
  • Topical local anesthetics criteria updated (this version added generic)
  • Cystic Fibrosis (Kalydeco, Orkambi, Symdeko) criteria updated (this version changes the minimum age for Kalydeco from age 2 to age 1)
  • Gocovri criteria (new)
  • Migraine Therapy: Calcitonin Gene-Related Inhibitors criteria (new)