ALPHA BLOCKERS Products Affected
Transcription
ALPHA BLOCKERS Products Affected
ALPHA BLOCKERS Products Affected Step 2: Cardura 1 mg tablet Cardura 2 mg tablet Cardura 4 mg tablet Cardura 8 mg tablet Cardura XL 4 mg tablet,extended release Cardura XL 8 mg tablet,extended release Flomax 0.4 mg capsule Rapaflo 4 mg capsule Rapaflo 8 mg capsule Uroxatral 10 mg tablet,extended release Details Criteria If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. 1 ANTIDEPRESSANTS - SNRI Products Affected Step 2: Cymbalta 20 mg capsule,delayed release Cymbalta 30 mg capsule,delayed release Cymbalta 60 mg capsule,delayed release desvenlafaxine ER 100 mg tablet,extended release 24 hr desvenlafaxine ER 50 mg tablet,extended release 24 hr Effexor XR 150 mg capsule,extended release Effexor XR 37.5 mg capsule,extended release Effexor XR 75 mg capsule,extended release Fetzima 120 mg capsule,extended release Fetzima 20 mg (2)-40 mg (26) capsule,extended release,24 hr,dose pack Fetzima 20 mg capsule,extended release Fetzima 40 mg capsule,extended release Fetzima 80 mg capsule,extended release Khedezla 100 mg tablet,extended release Khedezla 50 mg tablet,extended release Pristiq 100 mg tablet,extended release Pristiq 50 mg tablet,extended release Details Criteria If the patient has tried a Step 1 drug, then authorization for a drug in Step 2 drug may be given. Authorization may be given for a step 2 drug that does not have a generic equivalent included in step 1, without trial of a step 1 drug, if the patient is currently taking or has taken the drug in the past. Authorization may be given for a step 2 drug that does not have a generic equivalent included in step 1, without a trial of a step 1 drug, if the patient has symptoms of suicidal ideation. 2 DPP-4 INHIBITORS-PST Products Affected Step 2: Jentadueto 2.5 mg-1,000 mg tablet Jentadueto 2.5 mg-500 mg tablet Jentadueto 2.5 mg-850 mg tablet Kazano 12.5 mg-1,000 mg tablet Kazano 12.5 mg-500 mg tablet Nesina 12.5 mg tablet Nesina 25 mg tablet Nesina 6.25 mg tablet Tradjenta 5 mg tablet Details Criteria If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. 3 ENHANCED OVERACTIVE BLADDER Products Affected Step 2: Enablex 15 mg tablet,extended release Enablex 7.5 mg tablet,extended release Myrbetriq 25 mg tablet,extended release Myrbetriq 50 mg tablet,extended release Step 3: Detrol 1 mg tablet Detrol 2 mg tablet Detrol LA 2 mg capsule,extended release Detrol LA 4 mg capsule,extended release Ditropan XL 10 mg tablet,extended release Ditropan XL 15 mg tablet,extended release Toviaz 4 mg tablet,extended release Toviaz 8 mg tablet,extended release Vesicare 10 mg tablet Vesicare 5 mg tablet Ditropan XL 5 mg tablet,extended release Gelnique 10 % (100 mg/gram) transdermal gel packet Gelnique 28 mg/0.92 gram (3 %) transdermal gel pump Oxytrol 3.9 mg/24 hr transdermal patch Sanctura 20 mg tablet Sanctura XR 60 mg capsule,extended release Details Criteria If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. If the patient has tried a Step 1 and a Step 2 drug, then authorization for a Step 3 drug may be given. Authorization for Gelnique or Oxytrol may be given for patients who cannot swallow or who have difficulty swallowing. 4 OPHTHALMIC PROSTAGLANDINS-PST Products Affected Step 2: Rescula 0.15 % eye drops Xalatan 0.005 % eye drops Zioptan (PF) 0.0015 % eye drops in a dropperette Details Criteria If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Authorization for Zioptan may be given if the patient has a known benzalkonium chloride (BAK) sensitivity and a known sensitivity to other ophthalmic preservatives. 5 TETRACYCLINES (ORAL) Products Affected Step 2: Adoxa 150 mg capsule Doryx 150 mg tablet,delayed release Doryx 200 mg tablet,delayed release Oracea 40 mg capsule, extended release Solodyn 105 mg tablet,extended release Solodyn 115 mg tablet,extended release Solodyn 55 mg tablet,extended release Solodyn 65 mg tablet,extended release Solodyn 80 mg tablet,extended release Vibramycin 100 mg capsule Details Criteria If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Authorization for Oracea will be given if it is being used in the treatment of rosacea. 6 TOPICAL CORTICOSTEROIDS Products Affected Step 2: Ala-Scalp 2 % lotion Capex 0.01 % shampoo Clobex 0.05 % lotion Clobex 0.05 % shampoo Clobex 0.05 % topical spray Cloderm 0.1 % topical cream Cordran Tape Large Roll 4 mcg/cm2 Cutivate 0.05 % lotion Cutivate 0.05 % topical cream Dermatop 0.1 % topical cream Dermatop 0.1 % topical ointment Desonate 0.05 % topical gel DesOwen 0.05 % lotion DesOwen 0.05 % topical cream Diprolene 0.05 % lotion Diprolene 0.05 % topical ointment Diprolene AF 0.05 % topical cream Elocon 0.1 % topical cream Elocon 0.1 % topical lotion (solution) Elocon 0.1 % topical ointment Halog 0.1 % topical cream Halog 0.1 % topical ointment Kenalog 0.147 mg/gram topical aerosol Olux 0.05 % topical foam Pandel 0.1 % topical cream Synalar Cream Kit 0.025 % topical Temovate 0.05 % topical cream Temovate 0.05 % topical ointment Topicort 0.05 % topical cream Topicort 0.05 % topical gel Topicort 0.05 % topical ointment Topicort 0.25 % topical cream Topicort 0.25 % topical ointment Topicort 0.25 % topical spray U-Cort 1 %-10 % topical cream Ultravate 0.05 % topical cream Ultravate 0.05 % topical ointment Vanos 0.1 % topical cream Details Criteria If the patient has tried two Step 1 drugs, then authorization for a Step 2 drug may be given. Authorization for a step 2 drug may be given if the patient has tried two step 1 drugs for the current condition. Authorization may be given for Capex shampoo without a trial of two step 1 drugs for the treatment of dermatoses of the scalp. Authorization may be given for Derma-Smoothe FS scalp oil without a trial of two step 1 drugs for the treatment of psoriasis of the scalp. 7 TOPICAL NSAIDS-PST Products Affected Step 2: Pennsaid 1.5 % topical drops Pennsaid 20 mg/gram/actuation (2 %) topical soln in metered-dose pump Details Criteria If the patient has tried one Step 1 drug, then authorization for a Step 2 drug may be given. 8 ULORIC Products Affected Step 2: Uloric 40 mg tablet Uloric 80 mg tablet Details Criteria If the patient has tried a Step 1 drug (brand or generic), then authorization for a Step 2 drug may be given. Authorization may be given for Uloric if the patient has renal insufficiency or decreased renal function. Authorization may be given for Uloric if the patient is receiving concomitant medications that have significant drug-drug interactions with allopurinol, which are not noted with Uloric (eg, cyclosporine, chlorpropamide). 9 Index A Adoxa 150 mg capsule ................................ 6 Ala-Scalp 2 % lotion ................................... 7 C Capex 0.01 % shampoo............................... 7 Cardura 1 mg tablet ..................................... 1 Cardura 2 mg tablet ..................................... 1 Cardura 4 mg tablet ..................................... 1 Cardura 8 mg tablet ..................................... 1 Cardura XL 4 mg tablet,extended release ... 1 Cardura XL 8 mg tablet,extended release ... 1 Clobex 0.05 % lotion .................................. 7 Clobex 0.05 % shampoo ............................. 7 Clobex 0.05 % topical spray ....................... 7 Cloderm 0.1 % topical cream...................... 7 Cordran Tape Large Roll 4 mcg/cm2 ......... 7 Cutivate 0.05 % lotion ................................ 7 Cutivate 0.05 % topical cream .................... 7 Cymbalta 20 mg capsule,delayed release ... 2 Cymbalta 30 mg capsule,delayed release ... 2 Cymbalta 60 mg capsule,delayed release ... 2 D Dermatop 0.1 % topical cream.................... 7 Dermatop 0.1 % topical ointment ............... 7 Desonate 0.05 % topical gel........................ 7 DesOwen 0.05 % lotion .............................. 7 DesOwen 0.05 % topical cream .................. 7 desvenlafaxine ER 100 mg tablet,extended release 24 hr ............................................ 2 desvenlafaxine ER 50 mg tablet,extended release 24 hr ............................................ 2 Detrol 1 mg tablet ....................................... 4 Detrol 2 mg tablet ....................................... 4 Detrol LA 2 mg capsule,extended release .. 4 Detrol LA 4 mg capsule,extended release .. 4 Diprolene 0.05 % lotion .............................. 7 Diprolene 0.05 % topical ointment ............. 7 Diprolene AF 0.05 % topical cream ........... 7 Ditropan XL 10 mg tablet,extended release 4 Ditropan XL 15 mg tablet,extended release 4 Ditropan XL 5 mg tablet,extended release . 4 Doryx 150 mg tablet,delayed release .......... 6 Doryx 200 mg tablet,delayed release .......... 6 E Effexor XR 150 mg capsule,extended release ..................................................... 2 Effexor XR 37.5 mg capsule,extended release ..................................................... 2 Effexor XR 75 mg capsule,extended release ................................................................. 2 Elocon 0.1 % topical cream ........................ 7 Elocon 0.1 % topical lotion (solution) ........ 7 Elocon 0.1 % topical ointment .................... 7 Enablex 15 mg tablet,extended release ....... 4 Enablex 7.5 mg tablet,extended release ...... 4 F Fetzima 120 mg capsule,extended release .. 2 Fetzima 20 mg (2)-40 mg (26) capsule,extended release,24 hr,dose pack 2 Fetzima 20 mg capsule,extended release .... 2 Fetzima 40 mg capsule,extended release .... 2 Fetzima 80 mg capsule,extended release .... 2 Flomax 0.4 mg capsule ............................... 1 G Gelnique 10 % (100 mg/gram) transdermal gel packet ................................................ 4 Gelnique 28 mg/0.92 gram (3 %) transdermal gel pump .............................. 4 H Halog 0.1 % topical cream .......................... 7 Halog 0.1 % topical ointment ..................... 7 J Jentadueto 2.5 mg-1,000 mg tablet ............. 3 Jentadueto 2.5 mg-500 mg tablet ................ 3 Jentadueto 2.5 mg-850 mg tablet ................ 3 K Kazano 12.5 mg-1,000 mg tablet ................ 3 Kazano 12.5 mg-500 mg tablet ................... 3 Kenalog 0.147 mg/gram topical aerosol ..... 7 Khedezla 100 mg tablet,extended release ... 2 Khedezla 50 mg tablet,extended release ..... 2 M Myrbetriq 25 mg tablet,extended release .... 4 Myrbetriq 50 mg tablet,extended release .... 4 N Nesina 12.5 mg tablet ................................. 3 Nesina 25 mg tablet .................................... 3 10 Nesina 6.25 mg tablet ................................. 3 O Olux 0.05 % topical foam ........................... 7 Oracea 40 mg capsule, extended release..... 6 Oxytrol 3.9 mg/24 hr transdermal patch ..... 4 P Pandel 0.1 % topical cream ......................... 7 Pennsaid 1.5 % topical drops ...................... 8 Pennsaid 20 mg/gram/actuation (2 %) topical soln in metered-dose pump ......... 8 Pristiq 100 mg tablet,extended release........ 2 Pristiq 50 mg tablet,extended release.......... 2 R Rapaflo 4 mg capsule .................................. 1 Rapaflo 8 mg capsule .................................. 1 Rescula 0.15 % eye drops ........................... 5 S Sanctura 20 mg tablet.................................. 4 Sanctura XR 60 mg capsule,extended release ..................................................... 4 Solodyn 105 mg tablet,extended release ..... 6 Solodyn 115 mg tablet,extended release ..... 6 Solodyn 55 mg tablet,extended release ....... 6 Solodyn 65 mg tablet,extended release ....... 6 Solodyn 80 mg tablet,extended release ....... 6 Synalar Cream Kit 0.025 % topical ............ 7 T Temovate 0.05 % topical cream.................. 7 Temovate 0.05 % topical ointment ............. 7 Topicort 0.05 % topical cream .................... 7 Topicort 0.05 % topical gel ......................... 7 Topicort 0.05 % topical ointment ............... 7 Topicort 0.25 % topical cream .................... 7 Topicort 0.25 % topical ointment ............... 7 Topicort 0.25 % topical spray ..................... 7 Toviaz 4 mg tablet,extended release ........... 4 Toviaz 8 mg tablet,extended release ........... 4 Tradjenta 5 mg tablet .................................. 3 U U-Cort 1 %-10 % topical cream.................. 7 Uloric 40 mg tablet ..................................... 9 Uloric 80 mg tablet ..................................... 9 Ultravate 0.05 % topical cream ................... 7 Ultravate 0.05 % topical ointment .............. 7 Uroxatral 10 mg tablet,extended release ..... 1 V Vanos 0.1 % topical cream ......................... 7 Vesicare 10 mg tablet.................................. 4 Vesicare 5 mg tablet.................................... 4 Vibramycin 100 mg capsule ....................... 6 X Xalatan 0.005 % eye drops ......................... 5 Z Zioptan (PF) 0.0015 % eye drops in a dropperette .............................................. 5 11