Non-formulary medications – Multisource Brand with a Therapeutically Equivalent Generic or Non-formulary Generic Drug — Point32Health

Initial criteria

• Patient has diagnosis that is FDA-approved or medically accepted AND
• Documentation of one (1) of the following: (a) Treatment failure of two (2) or more formulary alternative medications within the same therapeutic class, including the therapeutically equivalent generic or preferred brand, AND the patient has an allergy to an ingredient in the generic/preferred brand not contained in the requested drug; OR (b) Medication is requested due to a drug shortage; OR (c) Clinical rationale that changing to formulary alternative would result in instability of the medical condition
• If formulary alternative medication(s) is covered with prior authorization, documentation that patient meets the current coverage criteria for the formulary alternative(s)/therapeutic class