C-4. Revision History

Status Date Description
Revision Oct. 21, 2022

Approved criteria:

  • Anti-Diabetic Agents (oral)
  • Attention Deficit Disorder/Attention Deficit Hyperactivity Disorder Medications
  • Glucagon-like Peptide-1 (GLP-1) Receptor Agonists
  • Pramlintide
  • Serotonin 5-HT3 Receptor Antagonists for Nausea and Vomiting (oral)
  • Substance P/Neurokinin1 Receptor Antagonists
Revision July 21, 2022

Approved criteria:

  • Fluoroquinolones (oral)
  • Hepatitis C
  • Immune globulins
  • Non-sedating antihistamines
  • Non-steroidal anti-inflammatory drugs
  • Rifaximin (Xifaxan)
  • Sickle cell disease products
  • Skeletal muscle relaxants
Revision April 22, 2022

Approved criteria:

  • Benzodiazepines (nonsedative/hypnotics)
  • Complement Inhibitor and Enzyme/Protein Replacement Therapy
  • Direct oral anticoagulants
  • Hydroxy-Methylglutaryl Coenzyme A Reductase Inhibitors
  • Ivacaftor (Kalydeco) and Combination Therapy
  • Low Molecular-Weight Heparins
  • Nebulized Bronchodilators
Revision Jan. 21, 2022

Approved criteria:

  • Fentanyl
  • Gabapentin
  • Hydrocodone Bitartrate/Hydrocodone Polistirex
  • Ivaca por (Kalydeco®) and combination therapy
  • Topical Calcineurin Inhibitors – Pimecrolimus (Elidel®) and Tacrolimus (Protopic®)
  • Tramadol (Utram®)
Revision Oct. 22, 2021

Approved criteria:

  • Atypical antipsychotics (long-acting injectable)
  • Atypical antipsychotics (oral)
  • Exogenous insulin products
  • Nitazoxanide (Alinia®)
  • Promethazine use in children less than 2 years of age
  • Quetiapine (low dose)
Revision Oct. 20, 2021

Added July 23, 2021, approved criteria:

  • Acetylcholinesterase inhibitors
  • Cyclooxygenase-2 inhibitors
  • Histamine H2-receptor antagonists
  • Ketorolac (oral)
  • Leukotriene receptor antagonists
  • Mecasermin
  • Memantine
Revision Oct. 20, 2021

Added April 23, 2021, approved criteria:

  • Aerosolized agents - metered-dose inhalers (MDIs): anticholinergic drugs
  • Aerosolized agents - MDIs: anti-inflammatory drugs
  • Aerosolized agents - MDIs: beta2 agonists (long-acting)
  • Aerosolized agents - MDIs: beta2 agonists (short-acting)
  • Antidepressant drugs – other
  • Antidepressant drugs – SSRIs
Revision Oct. 20, 2021

Added Jan. 22, 2021, approved criteria:

  • Angiotensin-converting enzyme inhibitors
  • Angiotensin II receptor blockers
    • Platelet aggregation inhibitors
  • Proton pump inhibitors
  • Sedative/hypnotics
  • Serotonin 5-HT1B/1D receptor agonists
Revision Oct. 20, 2021 Added July 1, 2021, Compendia update
Baseline Oct. 20, 2021 Initial publication of content as Retrospective Drug Use Criteria Handbook