#Chantix free 30 day trial 2018 verification
Verification that blood pressure and symptoms of renal failure are being monitored AND.Verification that female members are not pregnant and still on reliable contraceptive AND.Repeat liver function tests and verification that levels are acceptable to the prescriber AND.Repeat CBC counts and verification that counts are acceptable to the prescriber AND.Approval of Aubagio will be initially for 6 months, after which time, all of the following will be required for further approval:.Verification that members do not have tuberculosis, or completion of standard medical treatment for patients with tuberculosis AND.Blood pressure measurement and verification that blood pressure is being monitored AND.CBC counts and verification that levels are acceptable to the prescriber AND.Verification that member has no active infection(s) AND.Verification that female members are not pregnant and currently on a reliable contraceptive AND.No concurrent use with other disease modifying therapies AND.All of the following will be required for initiation of treatment:.Documented diagnosis of relapsing forms of Multiple Sclerosis AND.Liver function tests and verification that levels are acceptable to the prescriber ANDĬonsideration will be based on all of the following criteria:.Complete blood counts (CBC) and verification that levels are acceptable to the prescriber AND.Verification from the prescriber that member has no active infection(s) AND.The first dose should be observed in the doctor’s office for signs and symptoms of bradycardia for six hours after first dose AND.Approvals will not be granted for concurrent use with other disease-modifying therapies AND.An FDA approved diagnosis of relapsing forms of Multiple Sclerosis (MS) AND.Copaxone 20mg and 40 mg will be Brand preferred. Approvals for the generic formulation of either strength of Copaxone®, including Glatopa®, require a patient-specific, clinically signification reason why the member cannot use the brand formulation.Compliance will be checked for continued approval every six months.Approvals for the 40mg strength of Copaxone® will require a patient-specific, clinically significant reason why the member cannot use the 20mg strength AND.Approvals will not be granted for concurrent use with other disease modifying therapies AND.An FDA approved diagnosis of relapsing, remitting Multiple Sclerosis AND.A quantity limit of 30 capsules for 30 days will apply.For continuation, the prescriber must include information regarding improved response/effectiveness of this medication.
No current anxiolytic benzodiazepine therapy greater than TID.Minimum of 30 day trial with at least two Tier 1 products and clinical documentation of attempts to correct any primary cause for insomnia.Prior authorization is required for all products for members under age 19. Tier 1 products are available without prior authorization for members age 19 or older. For Members 12 or younger the same criteria applies and prescriptions for psychiatric conditions must originally be written by a psychiatrist.No concurrent stimulant ADHD medications, and Members 0-18 Years of Age will require a petition:ġ). The maximum covered dosing of benzodiazepine therapy is three times a day if a hypnotic medication is also prescribed. No request for dosing greater than 3 times daily will be approved unless a specific diagnosis exists for these diagnoses the maximum allowed dosing is 4 times daily.ģ). Quantity limits apply on all benzodiazepine anxiolytic products.Ģ). Members 19 Years and Older will not require a petitionġ). SoonerCare Out-of-State Services Rule Changes.Electronic Health Record Incentive Program.
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