Drug: ACCUTANE - Magellan Health Services || TennCare Portal

Prior Authorization Criteria for Amitiza ®
CRITERIA FOR REVIEW
Approval for Amitiza® will be granted upon documentation of:
Diagnosis of idiopathic chronic constipation AND
o Trial and failure of at least ONE agent from TWO of the following classes (as
confirmed by paid claims by TennCare):
• Osmotic laxatives
• Bulk-forming laxatives
• Stimulant laxatives, OR
Diagnosis of constipation predominate irritable bowel syndrome (IBS) in female, AND
o Trial and failure of at least ONE agent from TWO of the following classes (as
confirmed by paid claims by TennCare):
• Osmotic laxatives
• Bulk-forming laxatives
• Stimulant laxatives, OR
Diagnosis of opioid induced consiptation in chronic non-cancer pain, AND
o Documentation of paid claims by TennCare for opioids for at least 150 out of 180
days, AND
o Trial and failure of both PEG and Lactulose (as confirmed by paid claims by
TennCare)
COMMITTEE VOTE:
APPROVED DISAPPROVED APPROVED with MODIFICATION
Prior Authorization Criteria for Simbrinza ®
Simbrinza ® will be approved if the following criteria is met:
Patient is on simultaneous therapy with brimonidine and Azopt ® for at least 60 days
Clinically valid reason why patient cannot take 2 agent seperately.
COMMITTEE VOTE:
APPROVED DISAPPROVED APPROVED with MODIFICATION
Prior Authorization Criteria for Vecamyl ®
Vecamyl will be approved for patients meeting ALL of the following criteria:
Diagnosis of Essential Hypertension or Malignant Hypertension, AND
Trial and failure, contraindication or intolerance to ALL of the following:
o ACE inhibitor or ARB plus a diuretic; AND
o Beta blocker plus a diuretic, AND
o Clonidine, AND
o Hydralazine
COMMITTEE VOTE:
APPROVED DISAPPROVED APPROVED with MODIFICATION
Quantity Limits
Vecamyl ®
10/day
COMMITTEE VOTE:
APPROVED DISAPPROVED APPROVED with MODIFICATION
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August 13, 2013 Tennessee PAC