Non-formulary medications (Multisource Brand or Non-formulary Generic) — Point32Health

Initial criteria

• Documentation of both of the following: the patient has had a treatment failure of two or more formulary alternative medications within the same therapeutic class (including the therapeutically equivalent generic or preferred brand as applicable)
• The patient has an allergy to an ingredient in the therapeutically equivalent generic product or preferred brand that is not contained in the multi-source brand or non-formulary generic alternative
• OR the medication is requested due to a drug shortage
• OR clinical rationale that a change to the formulary alternative would result in instability of the medical condition (e.g., narrow therapeutic index medications)
• AND if the formulary alternative medication(s) is covered with prior authorization, documentation that the patient meets the current coverage criteria for the formulary alternative medication(s)/therapeutic class