Provider Bulletin

May 29, 2009

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


Call Help






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.