Veozah Prior Authorization Criteria - Medicare Part D

Prior Authorization Criteria for Approval

Veozah will be approved when ALL the following are met:

1. The patient has an FDA labeled indication for the requested medication
   AND

2. The patient does NOT have any FDA labeled contraindications to the requested medication
   AND

3. 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