Prior authorization and non-formulary drugs

Botulinum
Toxin A
(BTX-A)

Botox®
Xeomin®
Dysport TherapeuticTM

Botox®:
50 U/Vial
100 U/Vial
200 U/Vial

Xeomin®:
50 U/Vial
100 U/Vial

Dysport TherapeuticTM:
300 U/Vial
500 U/Vial

BTX-A may be approved for the following conditions:

• Cervical dystonia
• Blepharospasm/hemifacial spasm
• Focal spasticity (including upper and lower limb spasticity)
• Neurogenic detrusor overactivity
• Prophylaxis of chronic migraine

Additionally, the injured worker must meet the following criteria:

• Product being prescribed has an official indication for use in the above condition(s)
• Doses for each product should reflect product monograph recommendations

For neurogenic detrusor overactivity, the following additional criteria must also be met:

• Patient has a subcervical spinal cord injury; AND
• Patient has not responded to behavioral modifications or anticholinergic medications, and/or is intolerant of anticholinergic medications; AND
• Subsequent injections are no less than 36 weeks apart and initial injection must have demonstrated a positive clinical response.

For chronic migraine, the following additional criteria must also be met:

• Patient is experiencing chronic migraine (≥15 days/month, with continuous headache lasting ≥4 hours and ≥4 distinct headache episodes each lasting ≥4 hours); AND
• Patient has failed* 3+ oral prophylactic medicationsꝉ; AND
• Botox® is being requested by a physician with training in management of headache, and will be administered by a physician with appropriate qualifications & experience.

*failure defined as <30% reduction in frequency of headache days to an adequate dose and duration of 3 prophylactic therapies (2 treatments must be of different classes, and contraindications or intolerable adverse effects considered for only 1 of 3 medications)
ꝉBeta-blockers, TCAs, verapamil/flunarizine, sodium valproate/divalproex sodium, topiramate, gabapentin

Notes regarding continued therapy with Botox® for chronic migraine prophylaxis:

• Patients with an inadequate response (<50% reduction in headache days per month) after 2 treatment cycles should be discontinued from further therapy.
• Patients with an adequate response who transition from chronic to episodic migraine should also be discontinued off Botox® within 3 months of that transition.

Criteria for resumption of Botox® for chronic migraine prophylaxis (Renewal Criteria):

• Objective evidence (i.e. headache diary) that the patient has obtained an adequate treatment response; AND
• Confirmation that the patient has reverted back to chronic migraine upon trial discontinuation.

Duration of authorization is determined on a case-by-case basis.

Buprenorphine / Naloxone

*Suboxone® + generics

2 mg/0.5 mg
8 mg/2 mg

Buprenorphine / Naloxone may be approved for:

• Treatment of opioid use disorder (OUD)
• Opioid tapering in individuals currently taking high-dose opioids for their work-related injury or illness (MED ≥90/day)

Duration of authorization is determined on case-by-case basis. 

Diclofenac
sodium solution

*Pennsaid® + generics

1.5% w/w in solution

Diclofenac sodium solution may be approved if all of the following conditions are met:

• Use will be strictly limited to a local / superficial joint [e.g., knee, wrist, elbow, etc.]
• Use will be limited to 12 weeks
• An NSAID / COX-2 inhibitor will not be used concurrently
• High risk of GI adverse events OR failed trial of an oral NSAID

Diclofenac diethylamine
gel

Voltaren® Emulgel

Voltaren® Emulgel Joint Pain

Voltaren® Emulgel Extra Strength

1.16% w/w
2.32% w/w

Diclofenac diethylamine may be approved for treatment if all of the following conditions are met:

• use is strictly limited to relief of pain associated with recent (acute), localized muscle or joint injuries such as sprains, strains or sports-like injuries (e.g. sprained ankle, strained shoulder or back muscles)
• use will be limited to 7 days
• an NSAID / COX-2 inhibitor will not be used concurrently

Tramadol

Short-acting:
Tramacet® and generics

Ultram® and generics

Long-acting:
Ralivia®
Tridural®
Zytram XL®
Durela® and generics

Tramadol 37.5mg/Acetaminophen 325mg tablets

Tramadol 50mg tablets

Tramadol 100mg, 200mg, 300mg ER tablets
Tramadol 75mg, 100mg, 150mg, 200mg, 300mg, 400mg XL tablets

Tramadol may be approved in the following situations:

• Short-acting tramadol: after failure of non-pharmacological treatment of pain and when non-opioids (e.g., acetaminophen, non-steroidal anti-inflammatory drugs-NSAIDs and short-acting opioids (e.g., codeine, Tylenol 3®) have been trialed and are not effective or are contraindicated.
• Long-acting tramadol: for treatment of chronic musculoskeletal or neuropathic pain when first and second-line agents have been trialed and are not effective or are contraindicated. Prescriber must also provide rationale for use of tramadol over other opioid analgesics.

Duration of authorization is determined on a case-by-case basis.  Renewal will be granted if objective evidence supports improvement in pain and function.