5-ASA. Products Affected Dipentum 250 mg capsule. Details. Lialda 1.2 gram tablet,delayed release

Transcription

1 5-ASA Dipentum 250 mg capsule Lialda 1.2 gram tablet,delayed release You are required to have previous therapy with balsalazide, Delzicol, Apriso, or Asacol HD before we will cover Lialda or Dipentum. 1

2 ANTIEMETICS Anzemet 100 mg tablet Anzemet 50 mg tablet granisetron 1 mg tablet Granisol 1 mg/5 ml oral solution Sancuso 3.1 mg/24 hour transdermal patch You are required to have previous therapy with oral ondansetron before we will cover granisetron oral tablet, granisetron transdermal (Sancuso), granisol, or dolasetron (Anzemet). 2

3 BETA AGONIST INHALERS ProAir HFA 90 mcg/actuation aerosol inhaler Proventil HFA 90 mcg/actuation aerosol inhaler Xopenex HFA 45 mcg/actuation aerosol inhaler You are required to have previous therapy with Ventolin HFA before we will cover ProAir HFA, Proventil HFA, or Xopenex HFA. 3

4 BETASERON Betaseron 0.3 mg subcutaneous kit You are required to have previous therapy with inteferon beta-1a (Avonex) before we will cover interferon beta-1b (Betaseron). 4

5 CLONAZEPAM ODT clonazepam mg disintegrating tablet clonazepam 0.25 mg disintegrating tablet clonazepam 0.5 mg disintegrating tablet clonazepam 1 mg disintegrating tablet clonazepam 2 mg disintegrating tablet You are required to have previous therapy with clonazepam before we will cover clonazepam ODT. 5

6 CLOZAPINE ODT FazaClo 150 mg disintegrating tablet FazaClo 200 mg disintegrating tablet You are required to have previous therapy with clozapine tablets before we will cover clozapine ODT (Fazaclo). 6

7 DESVENLAFAXINE Khedezla 100 mg tablet,extended release Khedezla 50 mg tablet,extended release Pristiq 100 mg tablet,extended release Pristiq 50 mg tablet,extended release You are required to have previous therapy with venlafaxine (IR or ER) AND 1 selective serotonin reuptake inhibitor (SSRI) such as sertraline (Zoloft) or paroxetine (Paxil) before we will cover desvenlafaxine ER (Khedezla, Pristiq). 7

8 FEBUXOSTAT Uloric 40 mg tablet Uloric 80 mg tablet You are required to have previous therapy with allopurinol before we will cover febuxostat (Uloric). 8

9 FIDAXOMICIN Dificid 200 mg tablet You are required to have previous therapy with oral or intravenous vancomycin or oral metronidazole before we will cover fidaxomicin (Dificid). 9

10 GLATIRAMER Copaxone 20 mg/ml subcutaneous syringe kit You are required to have previous therapy with inteferon beta-1a (Avonex) before we will cover glatiramer (Copaxone). 10

11 HYPNOTIC zaleplon 10 mg capsule zaleplon 5 mg capsule zolpidem 10 mg tablet zolpidem 5 mg tablet You are required to have previous therapy with 2 of the following medications before we will cover zolpidem or zaleplon: lorazepam, trazodone, Rozerem, or Silenor. 11

12 LAMOTRIGINE ODT Lamictal ODT 100 mg disintegrating tablet Lamictal ODT 200 mg disintegrating tablet Lamictal ODT 25 mg disintegrating tablet Lamictal ODT 50 mg disintegrating tablet You are required to have previous therapy with generic lamotrigine before we will cover lamotrigine ODT (Lamictal ODT). 12

13 LEVALBUTEROL NEBULIZER SOLUTION levalbuterol 0.31 mg/3 ml solution for nebulization levalbuterol 0.63 mg/3 ml solution for nebulization levalbuterol 1.25 mg/0.5 ml solution for nebulization You are required to have previous therapy with a generic beta-agonist (i.e. albuterol solution) before we will cover levalbuterol nebulizer solution. 13

14 OPHTHALMIC PROSTAGLANDINS Rescula 0.15 % eye drops Travatan Z % eye drops travoprost (benzalkonium) % eye drops Zioptan (PF) % eye drops in a dropperette You are required to have previous therapy with latanoprost before we will cover travoprost, Travatan Z, unoprostone (Rescula), or tafluprost (Zioptan). 14

15 PROTON PUMP INHIBITORS Dexilant 30 mg capsule, delayed release Dexilant 60 mg capsule, delayed release You are required to have previous therapy with prescription omeprazole, lansoprazole, or pantoprazole before we will cover dexlansoprazole (Dexilant). 15

16 SYMLIN SymlinPen 120 2,700 mcg/2.7 ml subcutaneous pen injector SymlinPen 60 1,500 mcg/1.5 ml subcutaneous pen injector You are required to have previous therapy with insulin before we will cover Symlin. 16

17 TEKTURNA Amturnide 150 mg-5 mg-12.5 mg tablet Amturnide 300 mg-10 mg-12.5 mg tablet Amturnide 300 mg-10 mg-25 mg tablet Amturnide 300 mg-5 mg-12.5 mg tablet Amturnide 300 mg-5 mg-25 mg tablet Tekamlo 150 mg-10 mg tablet Tekamlo 150 mg-5 mg tablet Tekamlo 300 mg-10 mg tablet Tekamlo 300 mg-5 mg tablet Tekturna 150 mg tablet Tekturna 300 mg tablet Tekturna HCT 150 mg-12.5 mg tablet Tekturna HCT 150 mg-25 mg tablet Tekturna HCT 300 mg-12.5 mg tablet Tekturna HCT 300 mg-25 mg tablet You are required to have previous therapy with an angiotensinconverting enzyme (ACE) inhibitor (e.g. lisinopril), or an ACE inhibitor combination product (e.g. lisinopril-hctz), or an angiotensin II Receptor Blocker (ARB)(e.g. Losartan), or an ARB combination product (e.g. Losartan-HCT) before we will cover Tekturna, Tekturna HCT, Tekamlo, or Amturnide. 17

18 TERIPARATIDE Forteo 20 mcg/dose (600 mcg/2.4 ml) subcutaneous pen injector You are required to have previous therapy with a bisphosphonate (e.g. alendronate) or raloxifene before we will cover teriparatide (Forteo). 18

19 VYTORIN Liptruzet 10 mg-10 mg tablet Liptruzet 10 mg-20 mg tablet Liptruzet 10 mg-40 mg tablet Liptruzet 10 mg-80 mg tablet Vytorin 10 mg-10 mg tablet Vytorin 10 mg-20 mg tablet Vytorin 10 mg-40 mg tablet Vytorin 10 mg-80 mg tablet You are required to have previous therapy with a statin (e.g. simvastatin or pravastatin) before we will cover Vytorin or Liptruzet. 19

20 Index A Amturnide 150 mg-5 mg-12.5 mg tablet.. 17 Amturnide 300 mg-10 mg-12.5 mg tablet 17 Amturnide 300 mg-10 mg-25 mg tablet Amturnide 300 mg-5 mg-12.5 mg tablet.. 17 Amturnide 300 mg-5 mg-25 mg tablet Anzemet 100 mg tablet... 2 Anzemet 50 mg tablet... 2 B Betaseron 0.3 mg subcutaneous kit... 4 C clonazepam mg disintegrating tablet 5 clonazepam 0.25 mg disintegrating tablet.. 5 clonazepam 0.5 mg disintegrating tablet... 5 clonazepam 1 mg disintegrating tablet... 5 clonazepam 2 mg disintegrating tablet... 5 Copaxone 20 mg/ml subcutaneous syringe kit D Dexilant 30 mg capsule, delayed release.. 15 Dexilant 60 mg capsule, delayed release.. 15 Dificid 200 mg tablet... 9 Dipentum 250 mg capsule... 1 F FazaClo 150 mg disintegrating tablet... 6 FazaClo 200 mg disintegrating tablet... 6 Forteo 20 mcg/dose (600 mcg/2.4 ml) subcutaneous pen injector G granisetron 1 mg tablet... 2 Granisol 1 mg/5 ml oral solution... 2 K Khedezla 100 mg tablet,extended release... 7 Khedezla 50 mg tablet,extended release... 7 L Lamictal ODT 100 mg disintegrating tablet Lamictal ODT 200 mg disintegrating tablet Lamictal ODT 25 mg disintegrating tablet 12 Lamictal ODT 50 mg disintegrating tablet 12 levalbuterol 0.31 mg/3 ml solution for nebulization levalbuterol 0.63 mg/3 ml solution for nebulization levalbuterol 1.25 mg/0.5 ml solution for nebulization Lialda 1.2 gram tablet,delayed release... 1 Liptruzet 10 mg-10 mg tablet Liptruzet 10 mg-20 mg tablet Liptruzet 10 mg-40 mg tablet Liptruzet 10 mg-80 mg tablet P Pristiq 100 mg tablet,extended release... 7 Pristiq 50 mg tablet,extended release... 7 ProAir HFA 90 mcg/actuation aerosol inhaler... 3 Proventil HFA 90 mcg/actuation aerosol inhaler... 3 R Rescula 0.15 % eye drops S Sancuso 3.1 mg/24 hour transdermal patch 2 SymlinPen 120 2,700 mcg/2.7 ml subcutaneous pen injector SymlinPen 60 1,500 mcg/1.5 ml subcutaneous pen injector T Tekamlo 150 mg-10 mg tablet Tekamlo 150 mg-5 mg tablet Tekamlo 300 mg-10 mg tablet Tekamlo 300 mg-5 mg tablet Tekturna 150 mg tablet Tekturna 300 mg tablet Tekturna HCT 150 mg-12.5 mg tablet Tekturna HCT 150 mg-25 mg tablet Tekturna HCT 300 mg-12.5 mg tablet Tekturna HCT 300 mg-25 mg tablet Travatan Z % eye drops travoprost (benzalkonium) % eye drops U Uloric 40 mg tablet... 8 Uloric 80 mg tablet... 8 V Vytorin 10 mg-10 mg tablet Vytorin 10 mg-20 mg tablet

21 Vytorin 10 mg-40 mg tablet Vytorin 10 mg-80 mg tablet X Xopenex HFA 45 mcg/actuation aerosol inhaler... 3 Z zaleplon 10 mg capsule zaleplon 5 mg capsule Zioptan (PF) % eye drops in a dropperette zolpidem 10 mg tablet zolpidem 5 mg tablet