North Carolina Prior Authorization Program                             

Therapeutic Class Code: Z2Q

Therapeutic Class Description: Second Generation Antihistamines

Medication

Generic Code Number(s)

National Drug Code(s)

Allegra, Fexofenadine

46594, 37198, 97779, 46593, 98722

 

Clarinex

25439, 23883, 19716, 12762

 

Xyzal

 

14901, 97950

 

Zyrtec, Cetirizine

  

00069073166, 00069553093,

00069553047, 00069144003,

00069073266, 00069145003,

00069551066, 00093630016, 00093630012, 45802062626, 60258086004, 60258086016,

60505038503, 60505038505,

63304093604

 

Early Periodic Screening, Diagnostic and Treatment Provision

Early Periodic Screening, Diagnostic and Treatment (EPSDT) allows a recipient less than 21 years of age to receive services in excess of the limitations or restrictions below and without meeting the specific criteria in this section when such services are medically necessary health care services to correct or ameliorate a defect, physical or mental illness, or a condition [health problem]; that is, documentation shows how the service product or procedure will correct or improve or maintain the recipient’s health in the best condition possible, compensate for a health problem, prevent it from worsening, or prevent the development of additional health problems.

EPSDT DOES NOT ELIMINATE THE REQUIREMENT FOR PRIOR APPROVAL IF PRIOR APPROVAL IS REQUIRED.  Additional information on EPSDT guidelines may be access at http://www.ncdhhs.gov/dma/EPSDTprovider.htm.

 

 

Step therapy for Second Generation Antihistamines:

1) All Loratadine OTC, Claritin OTC, Cetirizine OTC, and Zyrtec OTC formulations will not require prior approval.

 

2) Criteria to use generic Fexofenadine

Documented failure with a 30-day trial of Claritin OTC/Loratadine OTC AND
30-day trial of Zyrtec OTC/Cetirizine OTC during a 12 month time period.
May be approved for 12 months.

3) Criteria to use other liquid formulations:

Documented failure with 30-day trial of Claritin OTC/Loratadine OTC syrup AND
30-day trial of Zyrtec OTC/Cetirizine OTC during a 12 month time period. 
May be approved for 12 months.

4) Criteria to use of all other second generation antihistamines

Documented failure with a 30-day trial of Claritin OTC/Loratadine OTC AND
failure with a 30-day trial of Zyrtec OTC/Cetirizine OTC AND
failure with a 30-day trial of fexofenadine during a 12 month time period.
May be approved for 12 months. 

Exemptions:

Patient has a contraindication or allergy to loratadine, cetirizine, or fexofenadine

Procedures:

May be approved for 12 months.

Pharmacist may override the prior authorization edit at point-of-sale if the prescriber writes on the face of the prescription in his/her own handwriting:

For generic fexofenadine

  1. “Failed loratadine and failed cetirizine for 30 days”
  2. “Allergy to loratadine and cetirizine”

For liquid formulations other than loratadine and cetirizine syrup

  1. “Failed loratadine and failed cetirizine syrup for 30 days”
  2. Allergy to loratadine and cetirizine syrup”           

For all other second generation antihistamines

  1. “Failed loratadine for 30 days, failed cetirizine for 30 days and failed fexofenadine for 30 days”
  1. “Allergy to fexofenadine, loratadine, and cetirizine”.

This information may also be entered in the comment block on e-prescriptions.

References:

Drug Class Review on Newer Antihistamines. Final Report Update 1. April 2006. http://www.ohsu.edu/drugeffectiveness/reports/final.cfm