Mercy Care ALBENDAZOLE. Products Affected. ALBENZA TABLET 200 MG ORAL Details. Criteria. Refer to PA Guideline for approval criteria

Transcription

1 ALBENDAZOLE Mercy Care ALBENZA TABLET 200 MG ORAL Refer to PA Guideline for approval criteria 1

2 BRIMONIDINE-TIMOLOL COMBIGAN SOLUTION % OPHTHALMIC Requires use of separate ingredients for at least 30 days in the previous 130 days 2

3 BRINZOLAMIDE OPHTH AZOPT SUSPENSION 1 % OPHTHALMIC Requires use of dorzolamide for at least 30 days in the previous 130 days 3

4 CELECOXIB celecoxib capsule 100 mg oral celecoxib capsule 200 mg oral celecoxib capsule 400 mg oral celecoxib capsule 50 mg oral Refer to PA Guideline for approval criteria 4

5 DIABETES INVOKAMET TABLET MG ORAL INVOKAMET TABLET MG ORAL INVOKAMET TABLET MG ORAL INVOKAMET TABLET MG ORAL INVOKANA TABLET 100 MG ORAL INVOKANA TABLET 300 MG ORAL JARDIANCE TABLET 10 MG ORAL JARDIANCE TABLET 25 MG ORAL SYNJARDY TABLET MG ORAL SYNJARDY TABLET MG ORAL SYNJARDY TABLET MG ORAL SYNJARDY TABLET MG ORAL SYNJARDY XR TABLET EXTENDED RELEASE 24 HOUR MG ORAL SYNJARDY XR TABLET EXTENDED RELEASE 24 HOUR MG ORAL SYNJARDY XR TABLET EXTENDED RELEASE 24 HOUR MG ORAL SYNJARDY XR TABLET EXTENDED RELEASE 24 HOUR MG ORAL Requires use of Metformin for at least 60 days in the previous 130 days 5

6 Differin OTC adapalene cream 0.1 % external tretinoin cream % external tretinoin cream 0.05 % external tretinoin cream 0.1 % external tretinoin gel 0.01 % external tretinoin gel % external Requires use of OTC Differin 0.1% gel for at least 30 days in the previous 130 days 6

7 EZETIMIBE ezetimibe tablet 10 mg oral Requires use of a statin for at least 60 days in the previous 130 days 7

8 FEBUXOSTAT ULORIC TABLET 40 MG ORAL ULORIC TABLET 80 MG ORAL Requires use of allopurinol for at least 30 days in the previous 130 days 8

9 ICS Combination Inhalers ADVAIR DISKUS AEROSOL POWDER BREATH ACTIVATED MCG/DOSE INHALATION ADVAIR DISKUS AEROSOL POWDER BREATH ACTIVATED MCG/DOSE INHALATION ADVAIR DISKUS AEROSOL POWDER BREATH ACTIVATED MCG/DOSE INHALATION ADVAIR HFA AEROSOL MCG/ACT INHALATION ADVAIR HFA AEROSOL MCG/ACT INHALATION ADVAIR HFA AEROSOL MCG/ACT INHALATION DULERA AEROSOL MCG/ACT INHALATION DULERA AEROSOL MCG/ACT INHALATION SYMBICORT AEROSOL MCG/ACT INHALATION SYMBICORT AEROSOL MCG/ACT INHALATION Requires use of a steroid inhaler for at least 30 days in the previous 130 days 9

10 ISOTRETINOIN MYORISAN CAPSULE 10 MG ORAL MYORISAN CAPSULE 20 MG ORAL MYORISAN CAPSULE 30 MG ORAL MYORISAN CAPSULE 40 MG ORAL ZENATANE CAPSULE 10 MG ORAL ZENATANE CAPSULE 20 MG ORAL ZENATANE CAPSULE 30 MG ORAL ZENATANE CAPSULE 40 MG ORAL Requires use of oral minocycline or doxycycline for at least 30 days in the previous 130 days. In addition, cannot have a claim for adapalene or topical tretinoin in the past 30 days 10

11 Lice malathion lotion 0.5 % external SKLICE LOTION 0.5 % EXTERNAL spinosad suspension 0.9 % external Requires use of permethrin or pyrethrin in the previous 30 days 11

12 LINACLOTIDE LINZESS CAPSULE 145 MCG ORAL LINZESS CAPSULE 290 MCG ORAL LINZESS CAPSULE 72 MCG ORAL Requires use of lactulose, PEG3350, or dicyclomine for at least 30 days in the previous 130 days 12

13 MILNACIPRAN SAVELLA TABLET 100 MG ORAL SAVELLA TABLET 12.5 MG ORAL SAVELLA TABLET 25 MG ORAL SAVELLA TABLET 50 MG ORAL SAVELLA TITRATION PACK 12.5 & 25 & 50 MG ORAL Requires use of duloxetine for at least 60 days in the previous 130 days 13

14 MOMETASONE NASAL mometasone furoate suspension 50 mcg/act nasal Requires use of any 2 of the following: fluticasone, triamcinolone, or budesonide for at least 30 days in the previous 130 days 14

15 OMEGA-3-ACID omega-3-acid ethyl esters capsule 1 gm oral Requires use of OTC FISH OIL for at least 60 days in the previous 130 days 15

16 Ophthalmic Antihistamines azelastine hcl solution 0.05 % ophthalmic epinastine hcl solution 0.05 % ophthalmic olopatadine hcl solution 0.1 % ophthalmic olopatadine hcl solution 0.2 % ophthalmic Requires use of ketotifen for at least 15 days in the previous 90 days 16

17 PARICALCITOL paricalcitol capsule 1 mcg oral paricalcitol capsule 2 mcg oral paricalcitol capsule 4 mcg oral Requires use of Calcitriol for at least 30 days in the previous 130 days 17

18 RAMELTEON ROZEREM TABLET 8 MG ORAL Requires use of both zolpidem and temazepam for at least 15 days in the previous 130 days 18

19 ROSIGLITAZONE AVANDIA TABLET 2 MG ORAL AVANDIA TABLET 4 MG ORAL Requires use of Metformin and Pioglitazone for at least 60 days in the previous 130 days 19

20 ROSUVASTATIN rosuvastatin calcium tablet 10 mg oral rosuvastatin calcium tablet 20 mg oral rosuvastatin calcium tablet 40 mg oral rosuvastatin calcium tablet 5 mg oral Requires use of atorvastatin for at least 60 days in the previous 130 days 20

21 TADALAFIL tadalafil (pah) tablet 20 mg oral Requires use of Sildenafil for at least 30 days in the previous 130 days 21

22 Topical Calcinurin Inhibitors ELIDEL CREAM 1 % EXTERNAL tacrolimus ointment 0.03 % external tacrolimus ointment 0.1 % external Requires Requires use of of 2 topical steroids for at least 14 days in the previous 130 days 22

23 URINARY ANTICHOLINERGICS tolterodine tartrate er capsule extended release 24 hour 2 mg oral tolterodine tartrate er capsule extended release 24 hour 4 mg oral tolterodine tartrate tablet 1 mg oral tolterodine tartrate tablet 2 mg oral trospium chloride er capsule extended Requires use of oxybutynin or trospium IR for at least 30 days in the previous 130 days 23

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