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No additional bisphosphonate may be approved for 365 days following zoledronic acid infusion. Clinical Exceptions: Most recent Hb levels (and date obtained) should be included on petition. Authorization can be granted for up to 8 weeks following the final dose of myelosuppressive chemotherapy in a chemotherapy regimen.
PA criteria: Nasal allergy medications will be included in product-based prior authorization effective 4/28/08.
Tier 1 products will be covered with no prior authorization necessary. Treatment failure with all lower tiered products, or 2.
Contraindication to all lower tiered products, or 3.
For members with a diagnosis of allergic rhinitis the following criteria will apply: For members 2 years of age or older: *Xopenex authorization requests should document why the member is unable to use racemic albuterol.
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If prescribed for asthma, member should also be utilizing inhaled corticosteroid therapy for long-term control.Gastrointestinal : Altered taste, loss of appetite, constipation, diarrhea, indigestion, flatulence, hiccups, increased appetite, loose stools and vomiting. Psychiatric : Agitation, memory loss, confusion, decreased sexual drive, depression, impaired concentration, sleeplessness and irritability.
