Mercy Care Plan

Acyclovir OintmentProducts Affected• acyclovir ointment 5 % externalDetails

Criteria Requires use of oral Acyclovir

1

AlbendazoleProducts Affected• albendazole tablet 200 mg oralDetails

Criteria Requires use of Pyrantel or Ivermectin. When ST therapy requirements are not met, the criteria in the PA guideline must be met for approval.

2

CelecoxibProducts Affected• celecoxib capsule 100 mg oral• celecoxib capsule 200 mg oral

• celecoxib capsule 400 mg oral• celecoxib capsule 50 mg oral

Details

Criteria Requires use of 3 different NSAID's. When ST therapy requirements are not met, the criteria in the PA guideline must be met for approval.

3

CombiganProducts Affected• COMBIGAN SOLUTION 0.2-0.5 %

OPHTHALMICDetails

Criteria Requires use of Brimonidine or Timolol for at least 15 days

4

DiabetesProducts Affected• BYDUREON PEN-INJECTOR 2 MG

SUBCUTANEOUS• BYDUREON SUSPENSION

RECONSTITUTED ER 2 MG SUBCUTANEOUS

• BYETTA 10 MCG PEN SOLUTION PEN-INJECTOR 10 MCG/0.04ML SUBCUTANEOUS

• BYETTA 5 MCG PEN SOLUTION PEN-INJECTOR 5 MCG/0.02ML SUBCUTANEOUS

• GLYXAMBI TABLET 10-5 MG ORAL• GLYXAMBI TABLET 25-5 MG ORAL• INVOKANA TABLET 100 MG ORAL• INVOKANA TABLET 300 MG ORAL• JANUMET TABLET 50-1000 MG ORAL• JANUMET TABLET 50-500 MG ORAL• JANUMET XR TABLET EXTENDED

RELEASE 24 HOUR 100-1000 MG ORAL

• JANUMET XR TABLET EXTENDED RELEASE 24 HOUR 50-1000 MG ORAL

• JANUMET XR TABLET EXTENDED RELEASE 24 HOUR 50-500 MG ORAL

• JANUVIA TABLET 100 MG ORAL• JANUVIA TABLET 25 MG ORAL• JANUVIA TABLET 50 MG ORAL• JARDIANCE TABLET 10 MG ORAL• JARDIANCE TABLET 25 MG ORAL• JENTADUETO TABLET 2.5-1000 MG

ORAL• JENTADUETO TABLET 2.5-500 MG

ORAL

• JENTADUETO TABLET 2.5-850 MG ORAL

• KOMBIGLYZE XR TABLET EXTENDED RELEASE 24 HOUR 2.5-1000 MG ORAL

• KOMBIGLYZE XR TABLET EXTENDED RELEASE 24 HOUR 5-1000 MG ORAL

• KOMBIGLYZE XR TABLET EXTENDED RELEASE 24 HOUR 5-500 MG ORAL

• ONGLYZA TABLET 2.5 MG ORAL• ONGLYZA TABLET 5 MG ORAL• SYNJARDY TABLET 12.5-1000 MG

ORAL• SYNJARDY TABLET 12.5-500 MG

ORAL• SYNJARDY TABLET 5-1000 MG ORAL• SYNJARDY TABLET 5-500 MG ORAL• SYNJARDY XR TABLET EXTENDED

RELEASE 24 HOUR 10-1000 MG ORAL• SYNJARDY XR TABLET EXTENDED

RELEASE 24 HOUR 12.5-1000 MG ORAL

• SYNJARDY XR TABLET EXTENDED RELEASE 24 HOUR 25-1000 MG ORAL

• SYNJARDY XR TABLET EXTENDED RELEASE 24 HOUR 5-1000 MG ORAL

• TRADJENTA TABLET 5 MG ORAL• VICTOZA SOLUTION PEN-INJECTOR

18 MG/3ML SUBCUTANEOUS

Details

Criteria Requires use of Metformin, or a Metformin-containing product, for at least 60 days.

5

EzetimibeProducts Affected• ezetimibe tablet 10 mg oralDetails

Criteria Requires use of a both Atorvastatin and Simvastatin

6

ICS/LABA InhalersProducts Affected• ADVAIR DISKUS AEROSOL POWDER

BREATH ACTIVATED 100-50 MCG/DOSE INHALATION

• ADVAIR DISKUS AEROSOL POWDER BREATH ACTIVATED 250-50 MCG/DOSE INHALATION

• ADVAIR DISKUS AEROSOL POWDER BREATH ACTIVATED 500-50 MCG/DOSE INHALATION

• ADVAIR HFA AEROSOL 115-21 MCG/ACT INHALATION

• ADVAIR HFA AEROSOL 230-21

MCG/ACT INHALATION• ADVAIR HFA AEROSOL 45-21

MCG/ACT INHALATION• DULERA AEROSOL 100-5 MCG/ACT

INHALATION• DULERA AEROSOL 200-5 MCG/ACT

INHALATION• SYMBICORT AEROSOL 160-4.5

MCG/ACT INHALATION• SYMBICORT AEROSOL 80-4.5

MCG/ACT INHALATION

Details

Criteria Requires use of Qvar HFA, Pulmicort Flexhaler, Flovent HFA, or Asmanex Twisthaler.

7

IsotretinoinProducts Affected• MYORISAN CAPSULE 10 MG ORAL• MYORISAN CAPSULE 20 MG ORAL• MYORISAN CAPSULE 30 MG ORAL• MYORISAN CAPSULE 40 MG ORAL

• ZENATANE CAPSULE 10 MG ORAL• ZENATANE CAPSULE 20 MG ORAL• ZENATANE CAPSULE 30 MG ORAL• ZENATANE CAPSULE 40 MG ORAL

Details

Criteria Requires use of Doxycycline or Minocycline

8

Lice/ScabicidesProducts Affected• malathion lotion 0.5 % external • spinosad suspension 0.9 % externalDetails

Criteria Requires use of Permethrin or Pyrethrin

9

LinzessProducts Affected• LINZESS CAPSULE 145 MCG ORAL• LINZESS CAPSULE 290 MCG ORAL

• LINZESS CAPSULE 72 MCG ORAL

Details

Criteria Requires use of Lactulose, Dicyclomine or Miralax

10

Nasal SteroidsProducts Affected• mometasone furoate suspension 50 mcg/act

nasalDetails

Criteria Requires use of 2 of the following: Fluticasone OTC, Budesonide OTC, or Triamcinolone OTC . Members age 2-3 years old are not subject to the step requirement

11

Omega 3Products Affected• omega-3-acid ethyl esters capsule 1 gm oralDetails

Criteria Use of OTC Fish Oil for at least 60 days in the previous 130 days.

12

Ophthalmic AntihistaminesProducts Affected• azelastine hcl solution 0.05 % ophthalmic• epinastine hcl solution 0.05 % ophthalmic

• olopatadine hcl solution 0.1 % ophthalmic• olopatadine hcl solution 0.2 % ophthalmic

Details

Criteria Requires use of Ketotifen ophthalmic

13

Overactive BladderProducts Affected• tolterodine tartrate er capsule extended

release 24 hour 2 mg oral• tolterodine tartrate er capsule extended

release 24 hour 4 mg oral

• tolterodine tartrate tablet 1 mg oral• tolterodine tartrate tablet 2 mg oral• trospium chloride er capsule extended

Details

Criteria Use of oxybutynin IR/ER for at least 30 days within the previous 130 days.

14

ParicalcitolProducts Affected• paricalcitol capsule 1 mcg oral• paricalcitol capsule 2 mcg oral

• paricalcitol capsule 4 mcg oral

Details

Criteria Requires use of Calcitriol

15

RosiglitazoneProducts Affected• AVANDIA TABLET 2 MG ORAL • AVANDIA TABLET 4 MG ORALDetails

Criteria Requires use of Metformin in combination with Pioglitazone for at least 60 days

16

RosuvastatinProducts Affected• rosuvastatin calcium tablet 10 mg oral• rosuvastatin calcium tablet 20 mg oral

• rosuvastatin calcium tablet 40 mg oral• rosuvastatin calcium tablet 5 mg oral

Details

Criteria Requires use of atorvastatin for at least 60 days.

17

RozeremProducts Affected• ROZEREM TABLET 8 MG ORALDetails

Criteria Requires use of Zolpidem and Temazepam in the last 130 days.

18

SavellaProducts Affected• SAVELLA TABLET 100 MG ORAL• SAVELLA TABLET 12.5 MG ORAL• SAVELLA TABLET 25 MG ORAL

• SAVELLA TABLET 50 MG ORAL• SAVELLA TITRATION PACK 12.5 & 25

& 50 MG ORALDetails

Criteria Requires use of Duloxetine for at least 60 days

19

SkliceProducts Affected• SKLICE LOTION 0.5 % EXTERNALDetails

Criteria Requires use of Malathion

20

TadalafilProducts Affected• tadalafil (pah) tablet 20 mg oralDetails

Criteria Requires use of Sildenafil

21

Timolol Ophth GelProducts Affected• timolol maleate gel forming solution 0.25 %

ophthalmic• timolol maleate gel forming solution 0.5 %

ophthalmicDetails

Criteria Requires use of Timolol Solution for at least 15 days

22

Topical Calcineurin InhibitorsProducts Affected• ELIDEL CREAM 1 % EXTERNAL• tacrolimus ointment 0.03 % external

• tacrolimus ointment 0.1 % external

Details

Criteria Requires use of 2 different topical Corticosteroids

23

Topical RetinoidsProducts Affected• adapalene cream 0.1 % external• tretinoin cream 0.025 % external• tretinoin cream 0.05 % external

• tretinoin cream 0.1 % external• tretinoin gel 0.01 % external• tretinoin gel 0.025 % external

Details

Criteria Requires use of OTC Differin 0.1% Gel

24

UloricProducts Affected• ULORIC TABLET 40 MG ORAL • ULORIC TABLET 80 MG ORALDetails

Criteria Requires use of Allopurinol, Colchicine, or Probenicid

25

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