Prior Authorization Drug Treatment Criteria
Prior Authorization Drug Treatment Criteria
To provide access to quality and clinically effective medications, KFHC uses a drug formulary. The KFHC Formulary provides information regarding medications covered under the benefit plans.
Please note that coverage is not limited to only medications on the KFHC Formulary. Medications not listed on the KFHC Formulary may be covered by the prior authorization process.
Prior authorization encourages the appropriate and rational use of medications by allowing coverage only when certain conditions are met.
The prior authorization program is based upon current medical findings, FDA-approved manufacturer labeling information, and recommendation by the KFHC Phamacy and Therapeutics committee.
If the medication is not on the KFHC Formulary, a request must be submitted to KFHC for authorization. If the request is approved, the medication will be covered. If the request is denied, notification of the decision will be issued.
Any medication not on the KFHC Formulary requires prior authorization to be covered by KFHC.
The medications requiring prior authorization are subject to change.
Please view the drugs below to read the criteria or guidelines.
Actiq
Approval of this medication will only be granted if the prescribing doctor is a contracted pain specialist. Should have tried and failed formulary medications such as morphine or oxycodone.
Activella
Should have tried and failed formulary medications such as PremPro or other formulary hormone replacement therapies.
Aricept
Allowed for Alzheimer’s Disease. Will consider if MMSE score is 19 or less. Consider Namenda first.
Arthrotec
Use the components as each are formulary.
Epivir HBV
Epivir is carved out of the plan and is billed directly to fee-for-service Medi-Cal. We cover this only for Hepatitis B. Verify for this diagnosis and not HIV.
Exelon
Allowed for Alzheimer’s Disease. Will consider if MMSE score is 19 or less. Consider Namenda first.
Gabitril
Indicated for seizures. FDA contraindicates for bipolar. Should try and fail formulary medications for seizures.
Imitrex Injection kit
Allow a maximum of 2 injections per 30 days. No tablets (of any triptans) while on the injections. Should be on prophylactic medications or have neurology referral for chronic unresolved migraines.
Keppra
Allow for neurologist. Allowed for seizure disorder. Consider the formulary anticonvulsants first.
Lupron Injection
Restricted to OB/GYN’s for endometriosis. Allow for 3 mons at a time, max 6 mos for osteoporosis issues.
Namenda
Allowed for Alzheimer’s Disease. Will consider if MMSE score is 19 or less.
Nicoderm CQ
Approval of this medication will only be granted if the patient has recently (2 weeks) completed a smoking cessation class. Treatment limited to two courses per year.
Pletal
Allowed for intermittent claudication. Requires one to try and fail pentoxifylline.
Protopic
Requires trial and failure of formulary topical steroids (ie triamcinolone , betamethasone). Should be prescribed by dermatologist. Restricted to individuals older than age 2.
Razadyne
Allowed for Alzheimer’s Disease. Will consider if MMSE score is 19 or less. Consider Namenda first.
Toradol
Indicated for RA or pain. Allowed for maximum of 5 days of therapy. Should have failed formulary NSAIDS.
Tricor
Allowed for management of high triglycerides. Should consider gemfibrozil first. Will allow exceptions if being used with statins.
Xolair
Allowed for severe uncontrolled asthma. Requires monitoring by a pulmonologist. Due to the complexity of the administration and follow up care, the following criteria were established.
Please click below for additional Xolair criteria.
