Rx PA Drug Treatment Criteria

Prescription Drug Prior Authorization (Rx PA) Drug Treatment Criteria

Medicare:
For Medicare Dual Choice Cal MediConnect Plan (Medicare-Medicaid Plan) Formulary and Criteria information, please visit the page here:
https://ww3.iehp.org/en/members/plans/cal-mediconnect/prescription-drugs/2017-drugs-covered/

Non-Medicare:
To provide access to quality and clinically effective medications, IEHP uses a drug formulary. The IEHP Formulary provides information regarding medications covered under the benefit plans.

Please note that coverage is not limited only to drugs on the IEHP Formulary.  Many drugs not listed on the Formulary are covered through the Rx Prior Authorization Process.

  • Rx prior authorization encourages the appropriate and rational use of medications by allowing coverage only when certain conditions are met.
  • The Rx prior authorization program is based upon current medical findings, FDA-approved manufacturer labeling information, and recommendation by the IEHP Pharmacy and Therapeutics Subcommittee.
  • If the medication you prescribe  is not on IEHP Formulary, you or the pharmacist may request authorization for the medication by submitting an IEHP Prescription Drug Prior Authorization Request Form (Rx PA)  to IEHP. If the request is approved, you will be notified and the medication will be covered. If the request is denied, you and your patient will be notified of the decision.

Any medication not on the IEHP Formulary requires Rx Prior Authorization to be covered by IEHP.

The medications requiring Rx Prior Authorization are subject to change.

First line Formulary medications should be used instead of the Non-Formulary medications.  Drugs with specific criteria / guidelines are listed here:

Medi-Cal PA Drug Criteria Summary Table - Click Here

To view Drug Criteria Referenced in Summary Table - Click Links Below:

Clinical Practice Guidelines - CPGs

Drug Monographs

  • HP Acthar (repository corticotrophin injection)Ver »

  • Nucala (mepolizumab)Ver »

  • Spinraza (Nusinersen)Ver »

  • Synagis (Palivizumab)Ver »

  • Xolair (Omalizumab)Ver »

Drug Class Monographs

  • Adult Enteral Nutritional SupplementVer »

  • Alzheimer Disease AgentVer »

  • Aminosalicylates (5-ASA) AgentsVer »

  • Anti-depressantsVer »

  • Antineoplastic AgentsVer »

  • Anti-obesityVer »

  • Anti-parkinson AgentsVer »

  • Basal InsulinVer »

  • Botulinum ToxinVer »

  • Chronic Hepatitis BVer »

  • CNS StimulantsVer »

  • COPD Respiratory Antimuscarinics Ver »

  • Dermatophyte and Onychomycosis AgentsVer »

  • Dipeptidyl-Peptidase 4 (DPP-4) InhibitorsVer »

  • Erythropoieses-stimulating Agents (ESAs)Ver »

  • GlaucomaVer »

  • Glucagon-like peptide-1 (GLP-1)Ver »

  • Gonadotropin Releasing Hormone (GnRH) AnalogsVer »

  • GoutVer »

  • Hereditary AngioedemaVer »

  • Growth HormoneVer »

  • Hepatitis CVer »

  • Homozygous CholesterolemiaVer »

  • HyaluronansVer »

  • HypnoticsVer »

  • Hyperammonenia AgentsVer »

  • Immune GlobulinsVer »

  • Inhaled CorticosteriodsVer »

  • Intranasal Steroid AgentsVer »

  • Intrauterine and Subdermal Contraceptive DevicesVer »

  • Irritable Bowel Syndrome AgentsVer »

  • Iron ChelatorsVer »

  • Multiple SclerosisVer »

  • Non Steroidal Anti-Inflammatory AgentsVer »

  • Nutritional Supplement Infant FormulaVer »

  • Opioid AnalgesicVer »

  • Opioid AntitussivesVer »

  • OsteoporosisVer »

  • Overactive Bladder AgentsVer »

  • Phosphate BinderVer »

  • Proprotein Convertase Subtilisin/Kexin Type 9 (PCSK9) InhibitorVer »

  • Proton Pump InhibitorsVer »

  • Pediatric Standard Nutritional SupplementsVer »

  • Pulmonary Arterial Hypertension AgentsVer »

  • Skeletal Muscle RelaxantsVer »

  • Sodium-Glucose Co-Transporter 2 (SGLT-2)Ver »

  • Testosterone Hormone ReplacementVer »

  • Therapeutic Agents in Rheumatic and Inflammatory DiseasesVer »

  • Topical PediculicidesVer »

  • Transplant ImmunosuppressantsVer »

  • Serotonin 5-HT Receptor AgonistVer »

  • Vascular Endothelial Growth Factor (VEGF) Inhibitors for Ocular UseVer »

  • WBC Growth FactorsVer »

Drug Policy

  • Antibiotic Stewardship Policy Ver »

  • Automatic Blood Pressure Monitor Coverage PolicyVer »

  • Brand Name Drug PolicyVer »

  • Continuous Glucose Monitoring DevicesVer »

  • External Insulin Pump PolicyVer »

  • Genetic Testing MedicationsVer »

  • Hepatitis B & C Center of Excellence (COE)Ver »

  • High Daily Morphine Equivalent DoseVer »

  • Non-Formulary Drug Policy (Non-Medicare)Ver »

  • Non-Sterile Compounded Medication (Medicare)Ver »

  • Non-Sterile Compounded Medication (Non-Medicare)Ver »

  • Off-Label Indication of Non-Formulary DrugsVer »

  • Pain ManagementVer »

  • Pharmacy Adult VaccineVer »

  • Quantity LimitsVer »

  • Small Volume Nebulizer PolicyVer »

  • Transgender Hormonal Treatment for AdultsVer »

  • Transgender Hormonal Treatment for PediatricsVer »

  • Wound CareVer »