Mercy Care RBHA ALBENDAZOLE Products Affected • albendazole tablet 200 mg oral Details
Criteria Refer to PA Guideline for approval criteria
1 BRIMONIDINE-TIMOLOL Products Affected • COMBIGAN SOLUTION 0.2-0.5 % OPHTHALMIC Details
Criteria Requires use of separate ingredients for at least 30 days in the previous 130 days
2 BRINZOLAMIDE OPHTH Products Affected • AZOPT SUSPENSION 1 % OPHTHALMIC Details
Criteria Requires use of dorzolamide for at least 30 days in the previous 130 days
3 CELECOXIB Products Affected • celecoxib capsule 100 mg oral • celecoxib capsule 400 mg oral • celecoxib capsule 200 mg oral • celecoxib capsule 50 mg oral Details
Criteria Refer to PA Guideline for approval criteria
4 Differin OTC Products Affected • adapalene cream 0.1 % external • tretinoin cream 0.1 % external • tretinoin cream 0.025 % external • tretinoin gel 0.01 % external • tretinoin cream 0.05 % external • tretinoin gel 0.025 % external Details
Criteria Requires use of OTC Differin 0.1% gel for at least 30 days in the previous 130 days
5 EZETIMIBE Products Affected • ezetimibe tablet 10 mg oral Details
Criteria Requires use of a statin for at least 60 days in the previous 130 days
6 FEBUXOSTAT Products Affected • ULORIC TABLET 40 MG ORAL • ULORIC TABLET 80 MG ORAL Details
Criteria Requires use of allopurinol for at least 30 days in the previous 130 days
7 ICS Combination Inhalers Products Affected • ADVAIR DISKUS AEROSOL POWDER MCG/ACT INHALATION BREATH ACTIVATED 100-50 • ADVAIR HFA AEROSOL 45-21 MCG/DOSE INHALATION MCG/ACT INHALATION • ADVAIR DISKUS AEROSOL POWDER • DULERA AEROSOL 100-5 MCG/ACT BREATH ACTIVATED 250-50 INHALATION MCG/DOSE INHALATION • DULERA AEROSOL 200-5 MCG/ACT • ADVAIR DISKUS AEROSOL POWDER INHALATION BREATH ACTIVATED 500-50 • SYMBICORT AEROSOL 160-4.5 MCG/DOSE INHALATION MCG/ACT INHALATION • ADVAIR HFA AEROSOL 115-21 • SYMBICORT AEROSOL 80-4.5 MCG/ACT INHALATION MCG/ACT INHALATION • ADVAIR HFA AEROSOL 230-21 Details
Criteria Requires use of a steroid inhaler for at least 30 days in the previous 130 days
8 ISOTRETINOIN Products Affected • MYORISAN CAPSULE 10 MG ORAL • ZENATANE CAPSULE 10 MG ORAL • MYORISAN CAPSULE 20 MG ORAL • ZENATANE CAPSULE 20 MG ORAL • MYORISAN CAPSULE 30 MG ORAL • ZENATANE CAPSULE 30 MG ORAL • MYORISAN CAPSULE 40 MG ORAL • ZENATANE CAPSULE 40 MG ORAL Details
Criteria 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
9 Lice Products Affected • malathion lotion 0.5 % external • spinosad suspension 0.9 % external • SKLICE LOTION 0.5 % EXTERNAL Details
Criteria Requires use of permethrin or pyrethrin in the previous 30 days
10 LINACLOTIDE Products Affected • LINZESS CAPSULE 145 MCG ORAL • LINZESS CAPSULE 72 MCG ORAL • LINZESS CAPSULE 290 MCG ORAL Details
Criteria Requires use of lactulose, PEG3350, or dicyclomine for at least 30 days in the previous 130 days
11 MILNACIPRAN Products Affected • SAVELLA TABLET 100 MG ORAL • SAVELLA TABLET 50 MG ORAL • SAVELLA TABLET 12.5 MG ORAL • SAVELLA TITRATION PACK 12.5 & 25 • SAVELLA TABLET 25 MG ORAL & 50 MG ORAL Details
Criteria Requires use of duloxetine for at least 60 days in the previous 130 days
12 MOMETASONE NASAL Products Affected • mometasone furoate suspension 50 mcg/act nasal Details
Criteria Requires use of any 2 of the following: fluticasone, triamcinolone, or budesonide for at least 30 days in the previous 130 days
13 OMEGA-3-ACID Products Affected • omega-3-acid ethyl esters capsule 1 gm oral Details
Criteria Requires use of OTC FISH OIL for at least 60 days in the previous 130 days
14 Ophthalmic Antihistamines Products Affected • azelastine hcl solution 0.05 % ophthalmic • olopatadine hcl solution 0.1 % ophthalmic • epinastine hcl solution 0.05 % ophthalmic • olopatadine hcl solution 0.2 % ophthalmic Details
Criteria Requires use of ketotifen for at least 15 days in the previous 90 days
15 PARICALCITOL Products Affected • paricalcitol capsule 1 mcg oral • paricalcitol capsule 4 mcg oral • paricalcitol capsule 2 mcg oral Details
Criteria Requires use of Calcitriol for at least 30 days in the previous 130 days
16 RAMELTEON Products Affected • ROZEREM TABLET 8 MG ORAL Details
Criteria Requires use of both zolpidem and temazepam for at least 15 days in the previous 130 days
17 ROSIGLITAZONE Products Affected • AVANDIA TABLET 2 MG ORAL • AVANDIA TABLET 4 MG ORAL Details
Criteria Requires use of Metformin and Pioglitazone for at least 60 days in the previous 130 days
18 ROSUVASTATIN Products Affected • rosuvastatin calcium tablet 10 mg oral • rosuvastatin calcium tablet 40 mg oral • rosuvastatin calcium tablet 20 mg oral • rosuvastatin calcium tablet 5 mg oral Details
Criteria Requires use of atorvastatin for at least 60 days in the previous 130 days
19 SGLT2 Inhibitor Products Affected • SEGLUROMET TABLET 2.5-1000 MG ORAL ORAL • SEGLUROMET TABLET 7.5-500 MG • SEGLUROMET TABLET 2.5-500 MG ORAL ORAL • STEGLATRO TABLET 15 MG ORAL • SEGLUROMET TABLET 7.5-1000 MG • STEGLATRO TABLET 5 MG ORAL Details
Criteria Use of metformin or combination metformin products for at least 60 days in the previous 130 days
20 TADALAFIL Products Affected • tadalafil (pah) tablet 20 mg oral Details
Criteria Requires use of Sildenafil for at least 30 days in the previous 130 days
21 Topical Calcinurin Inhibitors Products Affected • tacrolimus ointment 0.03 % external • tacrolimus ointment 0.1 % external Details
Criteria Requires Requires use of of 2 topical steroids for at least 14 days in the previous 130 days
22 URINARY ANTICHOLINERGICS Products Affected • tolterodine tartrate er capsule extended • tolterodine tartrate tablet 1 mg oral release 24 hour 2 mg oral • tolterodine tartrate tablet 2 mg oral • tolterodine tartrate er capsule extended • trospium chloride er capsule extended release 24 hour 4 mg oral Details
Criteria Requires use of oxybutynin or trospium IR for at least 30 days in the previous 130 days
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