C-5. Revision History

StatusDateDescription
RevisionApril 26, 2024

Approved criteria:

  • Benzodiazepines (oral, nasal, rectal)
  • Complement inhibitor and enzyme/ protein replacement therapy
  • Direct oral anticoagulants
  • Hydroxy-methylglutaryl coenzyme-A reductase inhibitors (statins)
  • Low molecular weight heparins
  • Nebulized bronchodilators
RevisionJan. 26, 2024

Approved criteria:

  • Fentanyl
  • Gabapentin
  • Hydrocodone Bitartrate/ Hydrocodone Polistirex
  • Ivacaftor (Kalydeco) and Lumacaftor/Ivacaftor (Orkambi)
  • Topical Calcineurin Inhibitors
  • Tramadol
RevisionOct. 13, 2023

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)
RevisionJuly 21, 2023

Approved criteria:

  • Acetylcholinesterase Inhibitors
  • Cyclooxygenase-2 Inhibitors
  • Histamine H2- Receptor Antagonists
  • Ketorolac (oral)
  • Leukotriene Receptor Antagonists
  • Mecasermin
  • Memantine
RevisionApril 28, 2023

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
RevisionJan. 20, 2023

Approved criteria:

  • Angiotensin II Receptor Blockers
  • Angiotensin-Converting Enzyme Inhibitors
  • Platelet Aggregation Inhibitors
  • Proton Pump Inhibitors
  • Sedative/Hypnotics
  • Serotonin 5-HT1B/1D Receptor Agonists
RevisionOct. 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
RevisionJuly 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
BaselineOct. 20, 2021Initial publication of content as the VDP Retrospective Drug Use Criteria Handbook.