C-5. Revision History

Approved criteria:

• Acetylcholinesterase Inhibitors
• Cyclooxygenase-2 Inhibitors
• Histamine H2- Receptor Antagonists
• Ketorolac (oral)
• Leukotriene Receptor Antagonists
• Mecasermin
• Memantine

Approved criteria:

• Aerosolized Agents - Metered-Dose Inhalers (MDIs): Anti-Cholinergic Drugs
• Aerosolized Agents - Metered-Dose Inhalers (MDIs): Anti-Inflammatory Drugs
• Aerosolized Agents - Metered-Dose Inhalers (MDIs): Beta2 Adrenergic Drugs (long-acting)
• Aerosolized Agents - Metered-Dose Inhalers (MDIs): Beta2 Adrenergic Drugs (short-acting)
• Anti-Depressants, Oral (other)
• Anti-Depressants, Selective Serotonin Reuptake Inhibitors

Approved criteria:

• Angiotensin II Receptor Blockers
• Angiotensin-Converting Enzyme Inhibitors
• Platelet Aggregation Inhibitors
• Proton Pump Inhibitors
• Sedative/Hypnotics
• Serotonin 5-HT_1B/1D Receptor Agonists

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

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

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

Approved criteria:

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

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)

Added July 23, 2021, approved criteria:

• Acetylcholinesterase inhibitors
• Cyclooxygenase-2 inhibitors
• Histamine H2-receptor antagonists
• Ketorolac (oral)
• Leukotriene receptor antagonists
• Mecasermin
• Memantine

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

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