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 30 days in the previous 130 days 2
BRINZOLAMIDE OPHTH AZOPT SUSPENSION 1 % OPHTHALMIC Requires use of dorzolamide for at least 30 days in the previous 130 days 3
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
DIABETES INVOKAMET TABLET 150-1000 MG ORAL INVOKAMET TABLET 150-500 MG ORAL INVOKAMET TABLET 50-1000 MG ORAL INVOKAMET TABLET 50-500 MG ORAL INVOKANA TABLET 100 MG ORAL INVOKANA TABLET 300 MG ORAL JARDIANCE TABLET 10 MG ORAL JARDIANCE TABLET 25 MG ORAL SYNJARDY TABLET 12.5-1000 MG ORAL SYNJARDY TABLET 12.5-500 MG ORAL SYNJARDY TABLET 5-1000 MG ORAL SYNJARDY TABLET 5-500 MG ORAL SYNJARDY XR TABLET EXTENDED RELEASE 24 HOUR 10-1000 MG ORAL SYNJARDY XR TABLET EXTENDED RELEASE 24 HOUR 12.5-1000 MG ORAL SYNJARDY XR TABLET EXTENDED RELEASE 24 HOUR 25-1000 MG ORAL SYNJARDY XR TABLET EXTENDED RELEASE 24 HOUR 5-1000 MG ORAL Requires use of Metformin for at least 60 days in the previous 130 days 5
Differin OTC adapalene cream 0.1 % external tretinoin cream 0.025 % external tretinoin cream 0.05 % external tretinoin cream 0.1 % external tretinoin gel 0.01 % external tretinoin gel 0.025 % external Requires use of OTC Differin 0.1% gel for at least 30 days in the previous 130 days 6
EZETIMIBE ezetimibe tablet 10 mg oral Requires use of a statin for at least 60 days in the previous 130 days 7
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
ICS Combination Inhalers ADVAIR DISKUS AEROSOL POWDER BREATH ACTIVATED 100-50 MCG/DOSE INHALATION ADVAIR DISKUS AEROSOL POWDER BREATH ACTIVATED 250-50 MCG/DOSE INHALATION ADVAIR DISKUS AEROSOL POWDER BREATH ACTIVATED 500-50 MCG/DOSE INHALATION ADVAIR HFA AEROSOL 115-21 MCG/ACT INHALATION ADVAIR HFA AEROSOL 230-21 MCG/ACT INHALATION ADVAIR HFA AEROSOL 45-21 MCG/ACT INHALATION DULERA AEROSOL 100-5 MCG/ACT INHALATION DULERA AEROSOL 200-5 MCG/ACT INHALATION SYMBICORT AEROSOL 160-4.5 MCG/ACT INHALATION SYMBICORT AEROSOL 80-4.5 MCG/ACT INHALATION Requires use of a steroid inhaler for at least 30 days in the previous 130 days 9
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
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
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
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
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
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
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
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
RAMELTEON ROZEREM TABLET 8 MG ORAL Requires use of both zolpidem and temazepam for at least 15 days in the previous 130 days 18
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
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
TADALAFIL tadalafil (pah) tablet 20 mg oral Requires use of Sildenafil for at least 30 days in the previous 130 days 21
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
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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