targeted medications — Highmark

Initial criteria

• When a benefit, coverage of a targeted medication will be approved if a member meets all of the following criteria:
• A. The medication must be used for an FDA approved indication.
• AND
• B. The member meets one (1) of the following:
• 1. For an Rx with OTC Equivalent medication, the member must try and fail the similar chemical entity product which is available over the counter.
• 2. For a High Cost Low Value medication, the member must try and fail two (2) therapeutic alternatives, if available, which must be from the middle column of the table below for the corresponding targeted medication.
• 3. For a New to Market medication, the member must try and fail two (2) therapeutic alternatives, if available, with one (1) alternative being in the same therapeutic class/category as the requested medication; if none exist in the class/category, both alternatives may be in a different therapeutic class/category, however they must have the same indication.