Bardzo tanie apteki z dostawą w całej Polsce kupic cialis i ogromny wybór pigułek.

Csr clinical reference-2.xls

Number of
generics
override
needed B4
approval of
Category and rejected Drug
covered in category
Grandfathering
Overrides
Scriptwise Message
2 Antihypertensives - brand ARBs
Cozaar (Losartan)
Hyzaar (Losartan Hydrochlorothiazide)
Teveten HCT (Eprosartan/Hydrochlorothiazide) · Exforge
· Valturna
3 niacin containing products- not covered AT ALL
· Advicor
brand Antihistamine Eye Drops
brand Migraine (Triptans) Medications
〈 Relpax
6 Enlarged prostate A
Step Therapy Category B (only after Category A has be

de) iled):
6B Enlarged prostate B
Step Therapy Category B (only after Category A has

all brands in the category (rapaflo, uroxatral) 7 alzheimers
Step Therapy Category B (only after Category A has b

incontinence
Step Therapy Category B (only after 2 of Category A has been tried and failed):
vesicare
Lantus/levemir
Step Therapy Category B (only after 2 of Category A has been tried and failed):
Lantus
anti inflammatory/nsaid eye drops
Step Therapy Category B (only after 2 of Category A has been tried and failed):
Nevanac
Opthalmic Prostaglandins etc…
Step Therapy Category B (only after 3 of Category A has been tried and failed):
Lumigan
Use Xalataan PA 866-718-2375
Use Xalataan PA 866-718-2375
Use Cosopt PA 866-718-2375
Use trusopt PA 866-718-2375
Use timolol PA 866-718-2375
Use alphagan P0.15% PA 866-718-2375
sleep aids/insomnia
Step Therapy Category B PA required for approval
Ambien (Zolpidem)
Edluar
Diabetes
Step Therapy Category B (only after 2 of Category A has been tried and failed)one of which must be metformin:
byetta
sulfonylureas (glyburide, tolazamide, glimepiride, Glipizide, asthma
Step Therapy Category B (only after 1of Category A has been tried and failed):
Combivent
albuterol inhaler (proventil/proair/ventolin) Step Therapy Category B (only after all of Category
l en tried and failed):
all generic Fenofibrates under this gpi
all generic Fenofibrates under this gpi
all generic Fenofibrates under this gpi
all generic Fenofibrates under this gpi
all generic Fenofibrates under this gpi
Neuropathic pain (lyrica)
gabapentin
Step Therapy Category B (only after all of Category A
e tried and failed):
Nortriptylline
Desipramine
Carbamazepine

Osteoporosis
Step Therapy Category B (only after one of Category A has been tried and failed):

fosamax (Alendronate)
Boniva (Ibandronate)
3. Antihistamines - Non-Sedating- UPDATE
NO ANTIHISTAMINES TO BE PAID- FULL COST OF DRUG SHOULD BE MEMBERS COPAY
〈 OTC Loratadine
〈 Generic Fexofenadine - termed 5/30/11 〈 OTC Allegra (Fexofenadine) - Effective 5/31/11 〈 Brand Allegra (not a protocol for Xyzal) - termed 5/30/11 Step Therapy Category C (only after Category B has been tried and failed): 〈 Fexofenadine (effective 12/1/09) - (termed 5/30/11) 〈 OTC Allegra-D/Fexofenadine-D (effective 5/31/11) Step Therapy Category B (only after Category A has been tried and failed): 〈 Allegra-D (effective 12/1/09) - (termed 5/30/11) 〈 Allegra-D (effective 12/1/09)- (termed 5/30/11) 〈 Allegra-D (effective 12/1/09)- (termed 5/30/11) 〈 Allegra-D (effective 12/1/09)- (termed 5/30/11) NO PPIS TO BE PAID- FULL COST OF DRUG SHOULD BE MEMBERS COPAY
1. Proton Pump Inhibitors- COPAY= COST OF
DRUG

Source: http://www.bmr-inc.com/files/Medications-Requiring-Prior-Auth.pdf

Untitled

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