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