excluded anti-virals — Highmark

Initial criteria

• When a benefit, coverage of an excluded antibiotic, anti-viral, or anti-fungal may be approved if a member has tried and failed one (1) alternative with the same route of administration:
• 1. For an Rx with OTC Equivalent medication, the alternative must be the similar chemical entity product which is available over the counter.
• 2. For a High Cost Low Value medication, the alternative must be from the middle column of the table below for the corresponding targeted medication.
• 3. For a New to Market medication, the alternative must be in the same therapeutic class/category as the requested medication; if none exist in the class/category, the alternative may be in a different therapeutic class/category, however it must have the same indication.