Special Formulations 2017 Archives

PA criteria:

Veripred™ 20 (Prednisolone Sodium Phosphate Oral Solution 20mg/5mL) and Millipred™ (Prednisolone Sodium Phosphate Oral Solution 10mg/5mL) Approval Criteria:

• Authorization of Veripred™ 20 or Millipred™ requires a patient-specific, clinically significant reason why the member cannot use a tablet or an alternative strength liquid formulations.

Prior Authorization form

methotrexate oral solution (Xatmep™) Approval Criteria:

• An FDA approved indication of  one of the following:
  
  • Treatment of pediatric patients with acute lymphoblastic leukemia (ALL) as a component of a combination chemotherapy maintenance regimen; OR
  • Management of pediatric patients with active polyarticular juvenile idiopathic arthritis (pJIA) who are intolerant of or had an inadequate response to first-line therapy; AND
• A patient-specific, clinically significant reason why the oral tablets or generic injectable formulation cannot be used.  

Prior Authorization form

nitroglycerin sublingual powder (GoNitro™) Approval Criteria:

• An FDA approved indication of acute relief of an attack or prophylaxis of angina pectoris due to coronary artery disease; AND
• A patient-specific, clinically significant reason why the member cannot use nitroglycerin sublingual tablets or nitroglycerin lingual spray.

Prior Authorization form

tamoxifen citrate 10mg/5mL oral solution (Soltamox®) Approval Criteria:

• An FDA approved indication of one of the following:
  
  • Treatment of metastatic breast cancer in women and men; OR
  • Adjuvant treatment of node-positive breast cancer in postmenopausal women and for the adjuvant treatment of axillary node-negative breast cancer in women following total mastectomy or segmental mastectomy, axillary dissection, and breast irradiation; OR
  • The reduction in risk of invasive breast cancer in women with ductal carcinoma in situ (DCIS), following breast surgery and radiation; OR
  • To reduce the incidence of breast cancer in women at high risk for breast cancer; AND
• A patient-specific, clinically significant reason why the member cannot use tamoxifen tablets.

Prior Authorization form

norethindrone acetate/ethinyl estradiol capsules & ferrous fumarate capsules (Taytulla™) Approval Criteria:

• An FDA approved indication to prevent pregnancy in women; AND
• A patient-specific, clinically significant reason why the member cannot use all other generic formulations of norethindrone acetate/ethinyl estradiol tablets with ferrous fumarate tablets. 

Prior Authorization form

levothyroxine sodium oral solution (Tirosint®-SOL) Approval Criteria:

• An FDA approved diagnosis of one of the following:
  
  • Hypothyroidism: As replacement therapy in primary (thyroidal), secondary (pituitary), and tertiary (hypothalamic) congenital or acquired hypothyroidism; OR
  • Pituitary Thyrotropin (Thyroid-Stimulating Hormone, TSH) Suppression: As an adjunct to surgery and radioiodine therapy in the management of thyrotropin-dependent well-differentiated thyroid cancer; AND
• A patient-specific, clinically significant reason why the member cannot use all other formulations of levothyroxine sodium in the place of oral solution even when tablets are crushed.

Prior Authorization form