Non-formulary medications – Single Source Brand — Point32Health

Initial criteria

• Documentation of treatment failure of two (2) or more formulary alternative medications within the same therapeutic class (where coverage is listed on the formulary as applicable)
• Documentation of one (1) of the following (when applicable): (a) If the formulary alternative medication(s) is covered with prior authorization, documentation the patient meets the current coverage criteria for those medication(s)/therapeutic class; OR (b) If there are no formulary alternatives and if the plan has drug specific coverage criteria, patient meets those criteria; OR (c) If the non-formulary drug is a novel agent, documentation that all other available, guideline-consistent lines of treatment have been exhausted; OR (d) For non-formulary diabetic test strip or insulin requests, documentation that the patient uses a continuous subcutaneous insulin infusion pump requiring the nonformulary product as medically necessary