excluded combination products — Highmark

Initial criteria

• When a benefit, an excluded combination product may be approved if a member has tried and failed two (2) therapeutic alternative products, if available, with one (1) being in the same specific class as at least one ingredient in the requested combination product:
• 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(s) 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.