Authorization requirements added for select Medicare medical drugs starting Dec. 1, 2021

Our Priority Health Pharmacy and Therapeutics committee meets throughout the year to review formulary and medical drugs to ensure our members have access to safe, effective and affordable drugs.

Effective Dec. 1, 2021, prior authorization requirements will be added to the following medical drugs for members newly starting these drugs. For specific criteria, download the Medical Benefit Drug List.

Drug	Common Use	Change Type
Dalvance (dalbavancin)	Antibiotic	Prior authorization required: Glycopeptide antibiotic PA form
Kimyrsa (oritavancin)	Antibiotic	Prior authorization required: Glycopeptide antibiotic PA form
Orbactiv (oritavancin)	Antibiotic	Prior authorization required: Glycopeptide antibiotic PA form
Vibativ (telavancin)	Antibiotic	Prior authorization required: Glycopeptide antibiotic PA form
Istodax (romidepsin-lyophilized)	Chemotherapy	Prior Authorization required: Oncology drug request form
Romidepsin (non-Istodax-non-lyophilized)	Chemotherapy	Prior Authorization required: Oncology drug request form

Why are we making the change?

Authorization requirements were added to ensure our members get the right care, at the right time.

Impact to members

Members with a claim on file for the above drugs within the last 365 days are exempt from this authorization requirement. This prior authorization requirement is for members newly starting the drug.