Special Formulations


prednisolone oral solution (Millipred®, Veripred 20®)

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

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nitroglycerin sublingual powder (GoNitro™)

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®)

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           

      

minocycline extended-release (Ximino™)

 

Ximino™ (minocycline extended-release) Approval Criteria: 

  • An FDA approved diagnosis of inflammatory lesions of non-nodular moderate to severe acne vulgaris; AND
  • Member must be 12 years of age or older; AND
  • Ximino™ is not covered for members older than 20 years of age; AND
  • A patient-specific, clinically significant reason why the member cannot use the immediate-release capsule formulation or and/or other cost effective therapeutic equivalent medication(s).

 

Prior Authorization form

 

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

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)

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  

      

mometason furoate sinus implant (Sinuva™)

Approval Criteria:

  • An FDA approved indication of nasal polyps in adults 18 years of age and older who have had ethmoid sinus surgery; AND
  • Date of ethmoid sinus surgery must be provided; AND
  • Sinuva™ must be prescribed and implanted by a physician specializing in otolaryngology; AND
  • Failure of intranasal corticosteroids after at least a three month trial at the maximum recommended dose in combination with a 14-day trial of oral corticosteroids within the last six months (if not contraindicated); AND
  • Prescriber must confirm the member has recurrent nasal obstruction/congestion symptoms and recurrent bilateral sinusitis or chronic sinusitis due to nasal polyps; AND
  • A quantity limit of 2 implants per member will apply. 

Prior Authorization form

triamcinolone acetonide extended-release (ER) Injection (Zilretta™)

Approval Criteria:

  • An FDA approved diagnosis of osteoarthritis (OA) pain of the knee; AND
  • Zilretta™ will only be approvable for use in the knee(s) for OA pain; AND
  • A patient-specific, clinically significant reason why the member cannot use Kenalog-40® (triamcinolone acetonide 40mg injection) and Depo-Medrol® (methylprednisolone injection) must be provided.
  • A quantity limit of 1 injection per knee per 12 weeks will apply. 

Prior Authorization form

       

cyclosporine 0.05% ophthalmic emulsion (Restasis MultiDose®)

Approval Criteria:

  • A patient-specific, clinically significant reason why the member cannot use Restasis® in the individual dosage formulation (single-use vials) must be provided.

Prior Authorization form

If you have questions please call the Pharmacy Help Desk at (800) 522-0114 option 4 or (405) 522-6205 option 4.