Prior Authorization and Quantity Limit Criteria for Approval

PA applies to new starts only and only to patients who are 65 YEARS OF AGE AND OVER. Quantity limitations apply to all patients.

Lorazepam will be approved when BOTH of the following are met:

1. ONE of the following:
   1. BOTH of the following:
      1. ONE of the following:
         1. There is evidence of a claim that the patient is currently being treated with the requested medication within the past 180 days
            OR
         2. The prescriber states the patient is currently being treated with the requested medication
            AND
      2. The patient has an FDA labeled indication or an indication that is supported in CMS approved compendia for the requested medication
         OR
   2. BOTH of the following:
      1. The patient has ONE of the following diagnoses:
         1. Anxiety disorder AND ONE of the following:
            1. The patient has tried and had an inadequate response to a formulary selective serotonin reuptake inhibitor (SSRI) or serotonin norepinephrine reuptake inhibitor (SNRI)
               OR
            2. The patient has an intolerance or hypersensitivity to a formulary SSRI or SNRI
               OR
            3. The patient has an FDA labeled contraindication to a formulary SSRI or SNRI
               OR
         2. The patient has an indication that is supported in CMS approved compendia for the requested medication
            AND
      2. The patient does NOT have any FDA labeled contraindications to the requested medication
         AND
2. ONE of the following:
   1. The requested quantity (dose) does NOT exceed the program quantity limit
      OR
   2. ALL of the following:
      1. The requested quantity (dose) is greater than the program quantity limit
         AND
      2. The requested quantity (dose) cannot be achieved with a lower quantity of a higher strength that does not exceed the program quantity limit
         AND
      3. The prescriber has provided information in support of therapy with a higher dose for the requested indication

Length of Approval: 12 months