PACE PROVIDER BULLETIN

 

March 26, 2004

 

 

ProDUR Edit Revisions

 

Effective March 29, 2004, the following list shows the recommended initial maximum dose, maximum daily dose and duration criteria have been added to the Department of Aging’s Prospective Drug Utilization Review Program for the following class of drugs.

 

·   Aspirin-containing medications                                    · Beta Blocker              · GAO medications

·   Acetaminophen-containing medications                        · Antimigraine

·   Narcotic medications                                                  · Antianxiety

·   Cox-2 Inhibitors                                                          · Misc. Agents

 

 

 

Recommended Criteria

Drug Name/ Class

Initial Maximum Dose

Diagnosis

Maximum Daily Dose

Duration

 

 

 

 

 

Aspirin-containing medications

N/A

 

4000 mg

 

 

 

 

 

 

Acetaminophen-containing medications

N/A

 

4000 mg

 

Narcotic Medications

    Actiq®

    (fentanyl             transmucosal)

 

Verify diagnosis of Cancer

N/A

 

    Oxycontin®     (oxycodone)

N/A

 

320 mg

N/A

 

Beta Blockers

    Innopran® XL

    propranolol (extended release)

N/A

 

120 mg

N/A

   

 

 

 

 

Antimigraine

    Relpax®

    (eletriptan)

 

 

40 mg

3 days

out of 30

   

 

 

 

 

Antianxiety

    Xanax® XR

    (alprazolam)

0.5 mg

Panic Disorder

6 mg

N/A

(OVER)


 

Recommended Criteria

Drug Name/ Class

Initial Maximum Dose

Diagnosis

Maximum Daily Dose

Duration

 

 

 

 

 

Miscellaneous Agents

 

 

 

 

    Actonel®

    (risedronate sodium)

N/A

 

5 mg

N/A

    Zetia®

    (ezetimibe)

N/A

 

10 mg

N/A

    Zelnorm®

    (tegaserod)

N/A

 

12 mg

N/A

    Provigil®

    (modafinil)

N/A

Narcolepsy

200 mg

N/A

 

 

 

 

 

Cox-2 Inhibitors

 

 

 

 

    Vioxx®

    (rofecoxib)

12.5 mg

 

25 mg

 

Unless a cardholder has previously received a medical exception for one of the following medications, no reimbursement will be made until the physician has been contacted.  Pharmacies will be notified if exception has been granted.

Drug Name/ Class

 

Drug Name/ Class

    Librium®

    (chlordiapoxide)

    Vasodilan®

    (isoxsuprine)

    Valium®

    (diazepam)

    Tigan®

     (trimethobenzamide)

    Dalmane®

    (flurazepam)

    Elavil®

     (amitriptyline)

    Soma®

    (carisoprodal)

    Triavil®

     (amitriptyline/perphenazine)

    Norflex®

    (orphenadrine)

    Limbitrol®

     (amitriptyline / chlordiazepoxide)

    Soma® Compound

    (carisoprodal compound)

    Indocin® (greater than 2 weeks)

     (indomethacin)

    Equanil®

    (meprobamate)

    Robaxin®

    (methocarbamol)

    Equanil®

    (meprobamate compound)

    Persantine®

    (dipyridamole)

    Norgesic®

    (orphenadrine/paracetamol)

    Flexeril®

    (cyclobenzaprine)

    Diabinese®

    (chlorpropamide)

 

 

Any Questions should be directed to Provider Services at

1-800-835-4080

 

PPB-04-008