hawk-i Wellmark Drug List

Medical Exception Criteria

Effective Date: July 1, 2002 
Revision Dates: N/A 
Approval: Clinical Advisory Committee

Applies to: hawk-i Program

Purpose: To establish medical exception criteria for branded medications excluded from coverage.

Policy: Wellmark will only reimburse for non-formulary medications excluded from coverage under the hawk-i Program if the criteria stated below are met.

Each exception request will be reviewed by the medical or pharmacy director for clinical appropriateness. Exceptions to the following criteria may be made based on a patient-specific review. This list is not intended to be all-inclusive.

ANTIBIOTICS (BRANDED) 

1. Patient has failed two generic antibiotics from different therapeutic classes within the past three months. 
2. Patient presents with a situation where ONLY a branded antibiotic is indicated (e.g. Cipro for pseudomonal coverage in cystic fibrosis patients, etc.).

STIMULANTS

1. Patient has failed two different generic CNS Stimulants - (amphetamine/dextroamphetamine, dextroamphetamine (immediate or extended release), methylphenidate (immediate or extended release)) with a trial of 1 month each. 
2. Medical records may be required to demonstrate past failure.

PROTON PUMP INHIBITORS (PPI's) 

1. Patient has failed on one generic H2 Antagonist (maximum dose) with a trial of 2 months. 
2. If discontinuation is due to side effects or drug interaction, another generic H2 Antagonist must be utilized.

NON-SEDATING ANTIHISTAMINES 

(all of the following criteria must be met for this class to be approved) 

1. Patient has failed on one generic prescription antihistamine with a trial of 7 days. 
2. Patient has failed on one generic prescription antihistamine/decongestant combination product with a trial of 7 days. 3. Patient has failed a nasal steroid with a trial of 2 months, unless contraindicated.

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