Mercy Care Plan. Acyclovir Ointment. Products Affected. acyclovir ointment 5 % external Details. Criteria. Requires use of oral Acyclovir
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1 Acyclovir Ointment Mercy Care Plan acyclovir ointment 5 % external Requires use of oral Acyclovir 1
2 Adcirca ADCIRCA TABLET 20 MG ORAL Requires use of Sildenafil 2
3 Albenza ALBENZA TABLET 200 MG ORAL Requires use of Pyrantel or Ivermectin. When ST therapy requirements are not met, the criteria in the PA guideline must be met for approval. 3
4 Azopt ALBENZA TABLET 200 MG ORAL Requires use of Dorzolamide or Dorzolamide-Timolol for at least 30 days 4
5 Celecoxib celecoxib capsule 100 mg oral celecoxib capsule 200 mg oral celecoxib capsule 400 mg oral celecoxib capsule 50 mg oral Requires use of 3 different NSAID's. When ST therapy requirements are not met, the criteria in the PA guideline must be met for approval. 5
6 Combigan COMBIGAN SOLUTION % OPHTHALMIC Requires use of Brimonidine or Timolol for at least 15 days 6
7 Diabetes BYDUREON PEN-INJECTOR 2 MG SUBCUTANEOUS BYDUREON SUSPENSION RECONSTITUTED ER 2 MG SUBCUTANEOUS BYETTA 10 MCG PEN SOLUTION PEN-INJECTOR 10 MCG/0.04ML SUBCUTANEOUS BYETTA 5 MCG PEN SOLUTION PEN- INJECTOR 5 MCG/0.02ML SUBCUTANEOUS GLYXAMBI TABLET 10-5 MG ORAL GLYXAMBI TABLET 25-5 MG ORAL INVOKANA TABLET 100 MG ORAL INVOKANA TABLET 300 MG ORAL JANUMET TABLET MG ORAL JANUMET TABLET MG ORAL JANUMET XR TABLET EXTENDED RELEASE 24 HOUR MG ORAL JANUMET XR TABLET EXTENDED RELEASE 24 HOUR MG ORAL JANUMET XR TABLET EXTENDED RELEASE 24 HOUR MG ORAL JANUVIA TABLET 100 MG ORAL JANUVIA TABLET 25 MG ORAL JANUVIA TABLET 50 MG ORAL JARDIANCE TABLET 10 MG ORAL JARDIANCE TABLET 25 MG ORAL JENTADUETO TABLET MG ORAL JENTADUETO TABLET MG ORAL JENTADUETO TABLET MG ORAL KOMBIGLYZE XR TABLET EXTENDED RELEASE 24 HOUR MG ORAL KOMBIGLYZE XR TABLET EXTENDED RELEASE 24 HOUR MG ORAL KOMBIGLYZE XR TABLET EXTENDED RELEASE 24 HOUR MG ORAL ONGLYZA TABLET 2.5 MG ORAL ONGLYZA TABLET 5 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 TRADJENTA TABLET 5 MG ORAL VICTOZA SOLUTION PEN-INJECTOR 18 MG/3ML SUBCUTANEOUS Requires use of Metformin, or a Metformin-containing product, for at least 60 days. 7
8 Ezetimibe ezetimibe tablet 10 mg oral Requires use of a both Atorvastatin and Simvastatin 8
9 ICS/LABA 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 Qvar HFA, Pulmicort Flexhaler, Flovent HFA, or Asmanex Twisthaler. 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 Doxycycline or Minocycline 10
11 Lice/Scabicides malathion lotion 0.5 % external spinosad suspension 0.9 % external Requires use of Permethrin or Pyrethrin 11
12 Linzess LINZESS CAPSULE 145 MCG ORAL LINZESS CAPSULE 290 MCG ORAL LINZESS CAPSULE 72 MCG ORAL Requires use of Lactulose, Dicyclomine or Miralax 12
13 Nasal Steroids mometasone furoate suspension 50 mcg/act nasal Requires use of 2 of the following: Fluticasone OTC, Budesonide OTC, or Triamcinolone OTC. Members age 2-3 years old are not subject to the step requirement 13
14 Omega 3 omega-3-acid ethyl esters capsule 1 gm oral Use of OTC Fish Oil for at least 60 days in the previous 130 days. 14
15 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 ophthalmic 15
16 Overactive Bladder 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 Use of oxybutynin IR/ER for at least 30 days within the previous 130 days. 16
17 Paricalcitol paricalcitol capsule 1 mcg oral paricalcitol capsule 2 mcg oral paricalcitol capsule 4 mcg oral Requires use of Calcitriol 17
18 Rosiglitazone AVANDIA TABLET 2 MG ORAL AVANDIA TABLET 4 MG ORAL Requires use of Metformin in combination with Pioglitazone for at least 60 days 18
19 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. 19
20 Rozerem ROZEREM TABLET 8 MG ORAL Requires use of Zolpidem and Temazepam in the last 130 days. 20
21 Savella 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 21
22 Sklice SKLICE LOTION 0.5 % EXTERNAL Requires use of Malathion 22
23 Timolol Ophth Gel timolol maleate gel forming solution 0.25 % ophthalmic timolol maleate gel forming solution 0.5 % ophthalmic Requires use of Timolol Solution for at least 15 days 23
24 Topical Calcineurin Inhibitors ELIDEL CREAM 1 % EXTERNAL tacrolimus ointment 0.03 % external tacrolimus ointment 0.1 % external Requires use of 2 different topical Corticosteroids 24
25 Topical Retinoids 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 25
26 Uloric ULORIC TABLET 40 MG ORAL ULORIC TABLET 80 MG ORAL Requires use of Allopurinol, Colchicine, or Probenicid 26
Mercy Care ALBENDAZOLE. Products Affected. ALBENZA TABLET 200 MG ORAL Details. Criteria. Refer to PA Guideline for approval criteria
ALBENDAZOLE Mercy Care ALBENZA TABLET 200 MG ORAL Refer to PA Guideline for approval criteria 1 BRIMONIDINE-TIMOLOL COMBIGAN SOLUTION 0.2-0.5 % OPHTHALMIC Requires use of separate ingredients for at least
Acyclovir Ointment. Aetna Better Health Pennsylvania. Products Affected. acyclovir ointment 5 % external Details. Criteria
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JANUVIA 50 MG TABLET BYDUREON 2 MG/0.65 ML JARDIANCE 10 MG TABLET SUBCUTANEOUS PEN INJECTOR JARDIANCE 25 MG TABLET BYDUREON BCISE 2 MG/0.
ANTI DIABETICS BYDUREON 2 MG SUBCUTANEOUS JANUVIA 25 MG TABLET EXTENDED RELEASE SUSPENSION JANUVIA 50 MG TABLET BYDUREON 2 MG/0.65 ML JARDIANCE 10 MG TABLET SUBCUTANEOUS PEN INJECTOR JARDIANCE 25 MG TABLET
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