AKLIEF — Highmark
any/all FDA-approved indication(s)
Preferred products
- METFORMIN HCL ER (GENERIC OF GLUCOPHAGE XR)
- METFORMIN HCL IR (GENERIC OF GLUCOPHAGE)
- METRONIDAZOLE 125 MG
- METRONIDAZOLE 250 MG
- AZELAIC ACID
- ONDANSETRON HCL 8 MG TABLET
- ONDANSETRON ODT 8 MG TABLET
- ONDANSETRON 4 MG/5 ML SOLUTION
- OXYBUTYNIN 5 MG TABLET
- POTASSIUM CHLORIDE CAPSULE
- POTASSIUM CHLORIDE TABLET
- PREDNISOLONE SODIUM PHOSPHATE OPHTHALMIC SUSPENSION 1%
- PREDNISOLONE ACETATE 1%
- FLOUROMETHOLONE SUSPENSION 0.1%
- PREDNISONE
- RIZTRIPTAN + MELOXICAM
- SUMATRIPTAN + MELOXICAM
- ZOLMITRIPTAN + MELOXICAM
- TETRACYCLINE CAPSULE
- TRAMADOL HCL 50 MG TABLETS
- TRAMADOL ORAL SOLUTION
- TRAMADOL 25 MG TABLETS
- TRAMADOL 75 MG TABLETS
- TRETINOIN
- VENLAFAXINE HCL ER CAPSULE
- ZOLPIDEM TABLETS
- CYCLOBENZAPRINE HCL
- METHOCARBAMOL 500 MG OR 750 MG
- BUSPIRONE TABLETS
Initial criteria
- Member must have a documented trial and failure, contraindication, or intolerance to the therapeutic alternative(s) listed in the policy (preferred products).
Reauthorization criteria
- Continuation of therapy may be approved if the member continues to meet initial criteria and the medication remains clinically appropriate.
Approval duration
12 months