The following medications are included in this PA program (formulary specific):
MAPD Stars formulary: benztropine tablet, cyproheptadine tablet, dicyclomine tablet/capsule/solution, diphenoxylate/atropine 2.5-0.025 mg tablet, hydroxyzine hydrochloride tablet/syrup, hydroxyzine pamoate capsule (25 mg and 50 mg), Promethegan suppositories (12.5 mg and 25 mg), promethazine tablet, promethazine suppositories (12.5 mg and 25 mg), scopolamine transdermal patch, trihexyphenidyl tablets
Enhanced formulary: benztropine tablet, cyproheptadine tablet, dicyclomine tablet/capsule/solution, diphenoxylate/atropine 2.5-0.025 mg tablet, hydroxyzine hydrochloride tablet/syrup, Promethegan suppositories (12.5 mg and 25 mg), promethazine tablet, promethazine suppositories (12.5 mg), scopolamine transdermal patch, trihexyphenidyl tablets
Basic formulary: benztropine tablet, cyproheptadine tablet, dicyclomine tablet/capsule/solution, diphenoxylate/atropine 2.5-0.025 mg tablet, hydroxyzine hydrochloride tablet (25 mg and 50 mg), promethazine tablet, scopolamine transdermal patch
Prior Authorization Criteria for Approval
Prior Authorization only applies to patients 65 years of age and older
Formulary High Risk Medications will be approved when ALL of the following are met:
- The patient has an FDA labeled indication or an indication that is supported in CMS approved compendia for the requested high-risk medication
AND - The prescriber has indicated that the benefits of the requested high-risk medication outweigh the risks for the patient
AND - The prescriber has indicated that the risks and potential side effects of the requested high-risk medication have been discussed with the patient
Length of Approval: 12 months
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