Buckeye (OH)Commercial Clinical Policy

30 Day Change Notice Form

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30 Day Change Notice

Indications

(10001) Is the medication Nyvepria being requested? 
(10002) Is Nyvepria a Colony Stimulating Factor? 
(20001) Is the medication Tadliq (Pulmonary Arterial Hypertension) being requested? 
(30001) Is the medication Forteo being requested? 
(30002) Is Forteo an Osteoporosis medication? 

YesNoN/A
YesNoN/A
YesNoN/A

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Effective Date

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Last Reviewed

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Original Document

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Ohio Department of Medicaid

30 Day Change Notice

Effective Date: April 1, 2023

NEW CLINICAL PA REQUIRED PREFERRED DRUGS

THERAPEUTIC CLASS CLINICAL CRITERIA REQUIRED PREFERRED
Blood Formation, Coagulation, and Thrombosis Agents: Colony Stimulating Factors Nyvepria
Cardiovascular Agents: Pulmonary Arterial Hypertension Tadliq
Endocrine Agents: Osteoporosis – Bone Ossification Enhancers Forteo

NEW NON-PREFERRED DRUGS

THERAPEUTIC CLASS PA REQUIRED NON-PREFERRED
Blood Formation, Coagulation, and Thrombosis Agents: Colony Stimulating Factors Fylnetra
Cardiovascular Agents: Angina, Hypertension, and Heart Failure Clonidine ER (generic of Nexiclon XR)
Central Nervous System (CNS) Agents: Anticonvulsants Levamlodipine
Central Nervous System (CNS) Agents: Antidepressants Zonisade Susp
Genitourinary Agents: Benign Prostatic Hyperplasia Ztalmy
Immunomodulator Agents: Systemic Inflammatory Disease Auvelity
Infectious Disease Agents: Antifungals Entadfi
Respiratory Agents: Nasal Preparations Sotyktu
Topical Agents: Immunomodulators Ryaltris
Zoryve

REMOVED FROM UPDL

THERAPEUTIC CLASS
Analgesic Agents: Opioids Oxaydo

THERAPEUTIC CATEGORIES WITH CHANGES IN CRITERIA

  • Blood Formation, Coagulation, and Thrombosis Agents: Colony Stimulating Factors
  • Cardiovascular Agents: Pulmonary Arterial Hypertension
  • Endocrine Agents: Osteoporosis – Bone Ossification Enhancers
  • Genitourinary Agents: Benign Prostatic Hyperplasia
  • Infectious Disease Agents: Antifungals
  • Infectious Disease Agents: Hepatitis C Agents

Ohio Department of Medicaid

30 Day Change Notice

Effective Date: April 1, 2023

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Ohio Department of Medicaid

30 Day Change Notice

Effective Date: April 1, 2023

Infectious Disease Agents: Hepatitis C Agents

OHIO DEPARTMENT OF MEDICAID

PRIOR AUTHORIZATION HEPATITIS C TREATMENT

Request Date Review Requested
STANDARD URGENT
Individual’s Name Prescriber’s Name
Individual’s Medicaid ID Number Prescriber’s NPI Number
Individual’s Date of Birth Prescriber’s Address
Prescriber’s Phone Number
Prescriber’s Fax Number

Only Hepatitis C treatment PA requests for individuals who meet the following guidelines will be approved. This PA form will cover up to the length authorized by the American Association for the Study of Liver Disease (AASLD) guidelines. Please refer to the APPENDIX which lists the various regimens and the clinical situations for which they will be considered medically necessary according to the Ohio Department of Medicaid (OOM) criteria. The PA must be approved prior to the 1st dose and include appropriate supporting documentation.

APPENDIX

Treatment naive
No cirrhosis
Mayvret 100/40 mg, three (3) tablets daily for 8 weeks (for GT5/6 and/or HIV/HCV co-infection, 12 weeks is recommended)
sofosbuvir/velpatasvir 400/100 mg, one tablet daily for 12 weeks
Compensated cirrhosis, HIV negative
Mayvret 100/40 mg, three (3) tablets daily for 8 weeks (GT4 WITH HIV coinfection, IDSA/AASLD guidelines recommend 12 weeks of therapy)
sofosbuvir/velpatasvir 400/100, one tablet daily for 12 weeks (for GT3, add weight based RBV if Y93H positive)
Compensated cirrhosis, HIV positive
Mayvret 100/40 mg, three (3) tablets daily for 12 weeks
sofosbuvir/velpatasvir 400/100 mg, one tablet daily for 12 weeks (for GT2, add weight-based RBV if Y93H positive)
Treatment experienced
Previously failed a Sofosbuvir-based regimen
Mayvret 100/40 mg, three (3) tablets daily for 16 weeks
Vosevi 400/100/100 mg, one tablet daily for 12 weeks (e.g. Zepatier)
Previously failed a NS3/4 protease inhibitor inclusive regimen (e.g. Zepatier)
Vosevi 400/100/100 mg, one tablet daily for 12 weeks (if compensated cirrhosis, add weight-based RBV)
Previously failed Mayvret
Vosevi 400/100/100 mg, one tablet daily for 12 weeks (if compensated cirrhosis, add weight-based RBV for 24 weeks)
Previously failed Vosevi or sofosbuvir + Mayvret
Vosevi 400/100/100 mg, one tablet daily + weight-based RBV for 24 weeks
Previously failed GT 3 only: sofosbuvir/NS5A (e.g. Harvoni)
Vosevi 400/100/100 mg, one tablet daily + weight-based RBV for 12 weeks

Date of Notice: 3/1/2023

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