PACE
Provider Bulletin
Prospective Drug Utilization Review
(ProDUR)
Criteria Additions
The
following list contains recommended initial maximum dose, maximum daily dose
and duration criteria which have been added to the Department of Aging’s
Prospective Drug Utilization Review program in the following drug classes:
|
Drug
Name/Class |
Maximum
Dose |
Duration |
Call Help
Desk |
|
|
|
|
|
|
Palperidone
(Invega®) |
12 mg per
day * |
|
|
|
|
|
|
|
|
Pioglitazone
and glimepride (Duetact®) |
30 mg per
day of glimepride * |
|
|
|
|
|
|
|
|
Fentanyl
buccal tablets (Fentora®) |
Doses of greater than 100 mcg of
Fentora® will be stopped at the point of sale unless cardholder is being
switched from Actiq® |
|
|
|
|
|
|
|
|
Rifaximin
(Xifanax®) |
|
3 days
out of every 180 |
|
|
|
|
|
|
|
Budesonide
(Pulmicort) |
1 mg/day * |
|
|
|
Eltrombopag
(Promacta®) |
|
|
Verify
diagnosis |
|
|
|
|
|
|
Tinzaparin
(Innohep®) |
|
|
Reimbursement
will be made only if no other alternatives are available |
*NOTE: Claims exceeding the maximum
dose may be eligible for a 1 time Medical Exception IF Provider Services is called.
Questions should be directed to
Provider Services at 1-800-835-4080.