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A past history of success on the tier 2 medication will also be considered with adequate documentation. Search for generic or brand product names using this interactive page. Dosing should not be more often than once every 8 weeks.
Clinically significant reason why the immediate release products cannot be used. Members must be over 18 years of age and have one of the following diagnoses: COPD, chronic bronchitis, or emphysema. Members currently stabilized on a higher tiered medication the past 90 days will be approved.
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Sandoz in the US also publishes a generic-to-brand pocket guide which is available via mail. A ciprofloxacin combination product may be approved when a steriod containing product is required for severe otitis externa and the tympanic membrane is not intact. The maximum covered dosing of benzodiazepine therapy is three times a day if a hypnotic medication is also prescribed. OTC Calcium and Vitamin D are only covered for members with osteoporosis. No member co-pay for risperidone at pharmacy.
Prior authorization will be for 10 days. Hydration and treatment attempts with a minimum of three alternate products must be documented. Infants up to 24 months old with moderate to severe pulmonary hypertension, cyanotic heart disease, or those on medications to control congestive heart failure. 2mg tablets and film: Quantity limit of 90 per 30 days.
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Member weight must be between 30-150kg. A past history of success on the tier 3 medication will also be considered with adequate documentation. Agents may be used concomitantly or consecutively within the past 30 days. Approval may be granted if there is a unique FDA approved indication not covered by tier 1 products or infection by organism not known to be covered by any of the tier 1 agents.
Patients must have Type 2 diabetes and currently taking metformin, sulfonylurea, thiazolidinedione, or a combination, for at least 90 days within the last 180 days, and have not achieved adequate glycemic control. An additional approval for 1 month will be granted to allow titration or change to a Tier1 muscle relaxant. A unique FDA-approved indication not covered by a lowered tiered product or other products from a different therapeutic class. Tier 1 products will be covered with no prior authorization necessary. Specific indication not covered by a lower tiered product. All tier 2 criteria must be met.
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A trial of risperidone, at least 14 days in duration, titrated to recommended dose, that did not yield adequate response or resulted in intolerable adverse effects. Clinical exceptions will be granted for members already currently on aliskiren and valsartan at the available doses of Valturna. Calcitonin and raloxifene are not included as Tier-1 trials. Each approval will be for 16 weeks in duration. NOTE: In order for previously utilized Tier 1 medications to count as trials toward a Tier 2 authorization, the member’s NSAID therapy must have been continuous.
Smoking cessation products are covered without prior authorization for the first 90 days. Use of Intuniv requires recent 14 day trial with immediate release clonidine or guanfacine and clinically significant reason why member cannot use immediate release products. An additional year approval may be granted if physician documents member is responding well to treatment. Risedronate may be approved for members with high risk for gastric side effects. Quantity Limtis apply bases on FDA maximum doses. Approval period will be for two months.
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Approval period will be for four weeks initially, and then quarterly. 3 days or one cycle that resulted in inadequate response. A 90 day trial will be approved.
If member has responded well to treatment and physician states that the member has shown improvement or the drug was effective, member may receive authorization for one year. Members greater than 75 years of age will generally not be approved without supporting information. By itself, it will not count as a tier 1 trial.
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Must be used at recommended doses in conjunction with Tier-1 bisphosphonate for trial to be accepted unless member has a recent laboratory result showing adequate Vitamin D or member is unable to tolerate calcium. Ihr Browser kann diese Seite leider nicht anzeigen! At Sandoz, we discover new ways to improve and extend people’s lives. Quantities will be limited to 30 grams for use on the face, neck, and groin, and 100 grams for all other areas. Recent 4-week trial of at least two Tier 1 medications from different pharmacological classes within the last 90 days.
Infants less than 12 months of age, born before 35 weeks gestation, with congenital abnormalities of the airway. Recent trial with at least one other available leukotriene modifier that did not yield adequate response. Members with an oncology-related diagnosis are exempt from the step therapy process, although quantity and dosage limits still apply. Documentation regarding member’s inability to use other skeletal muscle relaxants including carisoprodol 350 mg, and specific reason member cannot be drowsy for even a short time period.
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A trial of two Tier 2 medications, at least 14 days in duration, titrated to recommended dose, that did not yield adequate response or resulted in intolerable adverse effects. Minimum of 30 day trial with at least two Tier 1 products and clinical documentation of attempts to correct any primary cause for insomnia. Dates and dosing information for Tier 1 trials must be included on petition for authorization. No additional bisphosphonate therapy may be approved for 365 days following zoledronic acid infusion.
A trial, defined by at least 8 weeks of continuous therapy titrated to recommended dose, of a tier 1 medication that did not yield adequate LDL reduction. For members 21 years and older, Tier 1 products are available with prior authorization. Approval will be for 90 days to allow for concurrent medication monitoring.
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Approval of a Tier 2 product will be granted following trials of at least two Tier 1 topical antifungal products within the last 30 days. Tier 1 products are covered with no authorization necessary for members under age 21. Should not be initiated in patients with active or chronic infection including hepatitis B, hepatitis C, human immunodeficiency virus, or tuberculosis. Infants less than 12 months of age, born at 28 weeks gestation or earlier.
Member must have previous trial with Advair, Serevent, or Foradil in the past 45 days. For all other inquiries, visit Contact Us. For Members 12 or younger the same criteria applies and prescription must originally be written by a psychiatrist. Clinical exception applies to members who have diabetes. Contraindication to all available tier 2 medications.
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Further authorizations will not be granted. If prescribed for asthma, member should also be utilizing inhaled corticosteroid therapy for long-term control. After the member has had 180 days of treatment in a 365 day period, the member must wait another 180 days before smoking cessation treatment will be covered again.
Include your name, address, phone number, and number of copies requested. Approval will be based on clinical documentation of inability to take other forms of generic metformin ER – after slow titration of 500mg ER at 2 week intervals up to 2000mg daily. Minimum of 30 day trial with all available Tier 2 products and clinical documentation of attempts to correct any primary cause for insomnia. Continued treatment is one 160 mg injection given once weekly. A quantity limit of 288 units every 30 days will apply to Xopenex solution.
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Documented unexplained, persistent elevations of serum transaminases. FDA approved indication for specific products. ESRD – Discontinue treatment if Hb is at or above 13. Approvals will be granted for members with clinical conditions for which lower tiered drugs are contraindicated. Approval will be for only 3 months to ensure use for the shortest duration of time require to achieve control of asthma symptoms. A 14 day trial all available tier 2 medications that has resulted in inadequate relief of symptoms or intolerable adverse effects.
NO PRIOR AUTHORIZATION REQUIRED FOR MEMBERS AGE 5-20. Exception for age restrictions granted only if prescription is written by a dermatologist. Dose of levalbuterol requested cannot be less than the racemic equivalent documented on the prior authorization request. CLD in the 6 months prior to RSV season. For all antihistamine authorizations, the diagnosis must be for a chronic allergic condition. After the end of 15 months, presrcibers should provide supporting information for the continuation of these products.