PACE
Provider Bulletin
December 14, 2010
Prospective Drug Utilization Review (ProDUR)
Criteria Additions
Effective December 14, 2010 the following maximum daily dose, duration, age and step therapy criteria have been added to the Department of Aging’s Prospective Drug Utilization Review program in the following drug classes:
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Drug Name/Class
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Maximum Dose or Duration
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Step Therapy
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Diagnosis
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Bupropion HBr
(Aplenzin®)
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348 mg per day
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Prior use of bupropion tablets will be required prior to reimbursement of Aplenzin®.
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Zolpidem
(Edluar®)
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Claim will be stopped at the point of sale. Documentation showing the need for sublingual tablets will be required.
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Dexlansoprazole
(Dexilant®)
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60 mg per day
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Tapentadol
(Nucynta®)
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600 mg per day
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Saxagliptin
(Onglyza®)
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5 mg per day
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Desvenlafaxine
(Pristiq®)
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50 mg per day
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Milnacipran
(Savella®)
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200 mg per day
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Sumatriptan and naproxen
(Treximet®)
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Not indicated in the elderly.
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Diclofenac potassium (Zipsor®)
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100 mg per day
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Sitagliptin
(Januvia®)
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Prior to approving Januvia® cardholder will have to try and fail metformin, sulfonylurea or insulin.
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Quinine Sulfate capsules (Qualaquin®)
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Approved only when prescribed to treat uncomplicated plasmodium falciprum malaria.
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Teriparatide (Forteo®)
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Not be reimbursed for greater than 24 months.
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Questions should be directed to Provider Services at 1-800-835-4080.