Generic formoterol fumarate — Medical Mutual

Preferred products

• Generic arformoterol tartrate

Initial criteria

• Approve generic formoterol fumarate if the patient has tried generic arformoterol tartrate
• OR Approve for 1 year if A OR B OR C is met:
• A. The patient has an atypical diagnosis and/or unique patient characteristics which prevent use of all preferred agents (documentation required); OR
• B. The patient has a contraindication to all preferred agents (documentation required); OR
• C. The patient is continuing therapy with the requested non-preferred agent after being stable for at least 90 days AND meets ONE of the following:
• 1. The 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 agent for 90 days within a 130-day look-back period AND there is no generic equivalent available for the requested nonpreferred 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 agent for 90 days via paid claims AND there is no generic equivalent available for the requested nonpreferred product

Reauthorization criteria

• Continuation of therapy may be approved according to the same criteria; all approvals for continuation of therapy are provided for 1 year unless otherwise specified

Approval duration

Initial approval: 2 years; Extended approval: 2 years; Exception approval: 1 year; Continuation approval: 1 year