Gastro Intestinal 2017 Archive
Anti-Ulcer | ||
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Tier 1 products are available with no authorization necessary. Criteria for Approval of a Tier 2 medication:
Criteria for Approval of a Tier 3 medication:
Proton Pump Inhibitors for Pediatric members under the age of 19 approval criteria:
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Special Prior Authorizations of Miscellaneous Products
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Tier 1 |
Tier 2 |
Tier 3 |
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Mandatory Generic Plan Applies: ***Special Formulations including ODTs, Granules, Suspension and Solution for I.V. require special reason for use. |
lubiprostone (Amitiza®) | ||
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PA criteria: Amitiza® (Lubiprostone) Approval Criteria – Chronic Idiopathic Constipation (CIC) or Irritable Bowel Syndrome:
Amitiza® (Lubiprostone) Approval Criteria – Opioid-Induced Constipation (OIC):
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linaclotide (LinzessTM) | ||
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PA criteria:
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difenoxin/atropine (Motofen®) | ||
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PA criteria:
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naldemedine (Symproic®) | ||
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PA criteria:
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naloxegol (Movantik™) | ||
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PA criteria:
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plecanatide (Trulance™) | ||
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PA criteria:
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telotristat ethyl (Xermelo™) | ||
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PA criteria:
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methylnaltrexone bromide (Relistor®) | ||
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PA criteria:
Relistor® (Methylnaltrexone) Injection Approval Criteria (Chronic Non-Cancer Pain Diagnosis):
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lactulose packets for oral solution (Kristalose®) | ||
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Approval Criteria:
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eluxadoline (Viberzi™) | ||
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PA criteria:
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rifaximin (Xifaxan®) | ||
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Xifaxan® (Rifaximin) 200mg Approval Criteria:
Xifaxan® (Rifaximin) 550mg Approval Criteria:
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Ulcerative Colitis |
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balsalazide |
balsalazide (Colazal®) Capsules Quantity Limit Approval Criteria:
balsalazide (Giazo®) Approval Criteria:
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budesonide |
budesonide (Uceris®) Extended-Release Tablets Approval Criteria:
budesonide (Uceris®) Rectal Foam Approval Criteria:
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mesalamine |
mesalamine (Asacol® HD) Delayed-Release Tablets Approval Criteria:
mesalamine (Canasa®) Suppositories Quantity Limit Approval Criteria:
mesalamine (Lialda®) Delayed-Release Capsules Quantity Limit Approval Criteria:
mesalamine (Pentasa®) 250mg Controlled-Release Capsules Quantity Limit Approval Criteria:
mesalamine (Pentasa®) 500mg Controlled-Release Capsules Approval Criteria:
mesalamine (Rowasa®) Rectal Suspension Enema Approval Criteria:
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Pancreatic Enzyme Products | ||
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Pancreaze®, Pertzye®, and Viokace® Approval Criteria:
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bezlotoxumab (Zinplava™) |
bezlotoxumab (Zinplava™) Approval Criteria:
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If you have questions please call the Pharmacy Help Desk at (800) 522-0114 option 4 or (405) 522-6205 option 4.