Alvesco — Medical Mutual

Preferred products

• Arnuity Ellipta
• Asmanex HFA
• Asmanex Twisthaler
• Qvar RediHaler

Initial criteria

• Patient has tried one preferred product

Reauthorization criteria

• Patient has an atypical diagnosis and/or unique patient characteristics which prevent use of all preferred products; OR
• Patient has a contraindication to all preferred products; OR
• Patient is continuing therapy with the requested non-preferred product after being stable for at least 90 days AND meets ONE of the following:
• 1. Patient has at least 130 days of prescription claims history on file and claims history supports that the patient has received the requested non-preferred product for 90 days within a 130-day look-back period AND there is no generic equivalent available for the requested non-preferred product; OR
• 2. When 130 days of the patient’s prescription claims history file is unavailable, the prescriber must verify that the patient has been receiving the requested non-preferred product for 90 days AND that the patient has been receiving it via paid claims (not samples/coupons/waivers) AND there is no generic equivalent available for the requested non-preferred product

Approval duration

1 year