Authorization requirements added for select Medicare medical drugs starting Dec. 1, 2021

Our Priority Health Pharmacy and Therapeutics committee meets throughout the year to review formulary and medical drugs to ensure our members have access to safe, effective and affordable drugs. 

 

Effective Dec. 1, 2021, prior authorization requirements will be added to the following medical drugs for members newly starting these drugs:

 

 Drug Common Use  Change Type
 Dalvance (dalbavancin)  Antibiotic  

Prior authorization required- refer to the Glycopeptide Antibiotic prior authorization form

 

For specific criteria, visit the Medical Benefit Drug List on our website

 Kimyrsa  (oritavancin)

Antibiotic  

Prior authorization required- refer to the Glycopeptide Antibiotic prior authorization form

 

For specific criteria, visit the Medical Benefit Drug List on our website

 Orbactiv (oritavancin)  Antibiotic

Prior authorization required- refer to the Glycopeptide Antibiotic prior authorization form

 

For specific criteria, visit the Medical Benefit Drug List on our website

 Vibativ (telavancin)  Antibiotic

Prior authorization required- refer to the Glycopeptide Antibiotic prior authorization form

 

For specific criteria, visit the Medical Benefit Drug List on our website


 Istodax (romidepsin-lyophilized)  Chemotherapy

Prior Authorization required – Refer to the Oncology drug request form

 

For specific criteria, visit the Medical Benefit Drug List on our website

 

 Romidepsin (non-Istodax-non-lyophilized)  Chemotherapy

Prior Authorization required – Refer to the Oncology drug request form

 

For specific criteria, visit the Medical Benefit Drug List on our website

 

 

Why are we making the change?

Authorization requirements were added to ensure our members get the right care, at the right time.

 

Impact to members

Members with a claim on file for the above drugs within the last 365 days are exempt from this authorization requirement. This prior authorization requirement is for members newly starting the drug.