Gastrointestinal
Anti-Ulcer | ||
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:
Criteria for Approval of Age Appropriate PPIs for Pediatric members under the age of 19:
Special Prior Authorizations of Miscellaneous Products
|
||
Tier 1 |
Tier 2 |
Tier 3 |
|
|
|
*Mandatory Generic Plan Applies: ***Special Formulations including ODTs, Granules, Suspension and Solution for I.V. require special reason for use. |
crofelemer (Fulyzaq™) |
Consideration will be based on ALL of the following PA criteria:
*Please note that initial approval will be for 4 weeks of therapy. An additional 6 month approval may be granted if physician documents member is responding well to treatment. |
lubiprostone (Amitiza®) |
PA criteria:
|
linaclotide (Linzess™) |
PA criteria:
|
Antiemetic |
granisetron (Kytril®, Sancuso®), dolasetron (Anzement®), aprepitant (Emend®) |
Approval Criteria:
|
nabilone (Cesamet®), dronabinol (Marinol®) |
Approval Criteria:
|
doxylamine/pyridoxine (Diclegis®) |
Approval Criteria (Consideration for approval will be based on all of the following criteria):
|
methylnaltrexone bromide (Relistor®) |
PA criteria:
|