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Download Clinical Pharmacy Program Guidelines for Cough and Cold
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Clinical Pharmacy Program Guidelines for Cough and Cold Medications Program Medication 1. Prior Authorization Cough and Cold Medications Background: Drugs Requiring Prior Authorization ALA-HIST PE TABLET APRODINE TABLET BROTAPP LIQUID CHEST CONGESTION RELIEF PE CHEST CONGESTION RELIEF TABLET CHL MUCINEX® CHEST CONGEST LIQ CHLD MUCINEX STUFFY NOSE-COLD CHLO TUSS EX LIQUID CHLO TUSS LIQUID MUCINEX COUGH MINI-MELT PACK MUCINEX D ER 1,200-120 MG TAB MUCINEX D ER 600-60 MG TABLET MAXIPHEN DEXTROMETHORPHAN TABLET M-END DEXTROMETHORPHANX LIQUID MUCINEX COUGH MINI-MELT PACK MUCINEX D ER 1,200-120 MG TAB MUCINEX D ER 600-60 MG TABLET MUCINEX DEXTROMETHORPHAN ER 600-30 MG TABLET MUCINEX ER 1,200 MG TABLET COUGH DEXTROMETHORPHAN ER 30 MG/5 ML SUSP DECONEX IR TABLET DELSYM® 30 MG/5 ML SUSPENSION DEXTROMETHORPHAN ER 30 MG/5 ML MUCINEX ER 600 MG TABLET MUCINEX FAST-MAX CONGEST-COUGH MUCINEX FAST-MAX DEXTROMETHORPHAN MAX LIQUID MUCINEX SINUS-MAX NASAL SPRAY MUCUS ER 600 MG TABLET NASAL DECONGESTANT 0.05% SPRAY NASOPEN PE LIQUID NINJACOF LIQUID NOHIST-DEXTROMETHORPHAN LIQUID NOHIST-LQ LIQUID NRS-NASAL RELIEF NOSE SPRAY PEDIATRIC COUGH-COLD LIQUID PHENYLEPHRINE-PYRILAMINE 10-25 POLY-HIST DEXTROMETHORPHAN LIQUID POLY-HIST PD LIQUID POLY-VENT DEXTROMETHORPHAN TABLET PRO-CHLO LIQUID PROMETHAZINE-DEXTROMETHORPHAN SYRUP Q-TUSSIN DEXTROMETHORPHAN SYRUP RESCON TABLET RESCON-DEXTROMETHORPHAN LIQUID ROBAFEN CF LIQUID ROBAFEN DEXTROMETHORPHAN COUGH LIQUID ROBAFEN-DEXTROMETHORPHAN SYRUP DIMAPHEN ELIXIR ED BRON GP LIQUID ED-A-HIST PSE TABLET EXEFEN IR TABLET GUAIFENESIN 100 MG/5 ML SYRUP HISTEX-PE SYRUP IOPHEN NR LIQUID J-MAX SYRUP J-TAN D PD DROPS KID'S MUCINEX MINI-MELTS PACK LODRANE® D CAPSULE LORTUSS LQ LIQUID MAXIPHEN TABLET MUCAPHED TABLET MUCUS RELIEF 400 MG TABLET MUCUS RELIEF SINUS TABLET NOSE DROPS ORGAN-I NR 200 MG TABLET POLY-VENT IR TABLET PROMETHAZINE VC SYRUP Q-TUSSIN 100 MG/5 ML SOLUTION UHCTX000321j 1 RESCON-GUAIFEN LIQUID RESPAIRE-30 CAPSULE ROBAFEN 100 MG/5 ML SYRUP RYMED TABLET RYNEX DEXTROMETHORPHAN LIQUID SILTUSSIN DEXTROMETHORPHAN COUGHSYP SM NASAL SPRAY 0.05% SM NASAL SPRAY 0.05% SM TUSSIN DEXTROMETHORPHAN SYRUP SUDOGEST SINUS & ALLERGY TAB TUSSIN DEXTROMETHORPHAN CLEAR LIQUID TUSSIN DEXTROMETHORPHAN SYRUP VANACOF DEXTROMETHORPHAN LIQUID VANACOF LIQUID VANACOF-8 LIQUID VIRDEC DEXTROMETHORPHAN DROPS VIRDEC DROPS BENZONATATE 100 MG CAPSULE RU-HIST D 10-4 MG TABLET RYNEX PE LIQUID RYNEX PSE LIQUID SILTUSSIN SA 100 MG/5 ML SYR SM TUSSIN 100 MG/5 ML LIQUID STAHIST AD LIQUID STAHIST AD TABLET TUSSIN 100 MG/5 ML SYRUP ALA-HIST DEXTROMETHORPHAN LIQUID ALLFEN DEXTROMETHORPHAN TABLET AP-HIST DEXTROMETHORPHAN LIQUID BROMFED DEXTROMETHORPHAN COUGH SYRUP BROMPHENIR-PSEUDOEPHEDRINEEDDEXTROMETHORPHAN SYR BROTAPP DEXTROMETHORPHAN LIQUID CHILD DELSYM COUGH+CHEST DEXTROMETHORPHAN LQ CHILD MUCINEX CONGEST-COUGH LQ CHILD MUCINEX MULTI-SYMPTOM LQ CHILDREN COLD & COUGH DEXTROMETHORPHAN ELIXI CHILDREN'S MUCINEX COUGH LIQ DALLERGY 1-2.5 MG/ML DROPS DALLERGY 1-5 MG TABLET DECONEX DEXTROMETHORPHANX TABLET DELSYM COUGH+CHEST CNGST DEXTROMETHORPHAN LQ DIMAPHEN DEXTROMETHORPHAN ELIXIR ED A-HIST DEXTROMETHORPHAN TABLET ED A-HIST LIQUID ED CHLORPED D PEDIATRIC DROPS ED-A-HIST 4 MG-10 MG TABLET ED-A-HIST DEXTROMETHORPHAN LIQUID ED-CHLORTAN 4 MG TABLET ENDACOF-DEXTROMETHORPHAN LIQUID EXTRA ACTION COUGH SYRUP GUAIFENESIN ER 600 MG TABLET HISTEX-DEXTROMETHORPHAN SYRUP IOPHEN DEXTROMETHORPHAN-NR LIQUID KIDKARE COUGH & COLD LIQUID LOHIST PEB DEXTROMETHORPHAN LIQUID LOHIST-D LIQUID BENZONATATE 200 MG CAPSULE ZONATUSS 150 MG CAPSULE CHERATUSSIN AC SYRUP CHERATUSSIN DAC SYRUP CODEINE-GUAIFEN 10-100 MG/5 ML ENDACOF-C LIQUID GUAIATUSSIN AC LIQUID GUAIFENESIN AC COUGH SYRUP GUAIFENESIN-CODEINE SYRUP HYDROCOD-CPM-PSEUDOEP 5-4-60/5ML HYDROCOD-HOMATROP 5-1.5 MG TAB HYDROCODONE-CHLORPHEN ER SUSP HYDROCODONE-HOMATROPINE SYRUP HYDROMET SYRUP IOPHEN-C NR LIQUID LORTUSS EX LIQUID M-END MAX D LIQUID M-END WC LIQUID NINJACOF-XG LIQUID PHENYLHISTINE DH LIQUID POLY-TUSSIN D LIQUID POLY-TUSSIN LIQUID PRO-CLEAR AC SYRUP PROMETHAZINE VC-CODEINE SYRUP PROMETHAZINE-CODEINE SYRUP REZIRA® SOLUTION UHCTX000321j 2 LOHIST-DEXTROMETHORPHAN SYRUP LORTUSS DEXTROMETHORPHAN LIQUID MAXIPHEN DEXTROMETHORPHAN TABLET M-END DEXTROMETHORPHANX LIQUID 2. TUSSIONEX PENNKINETIC SUSP VIRTUSSIN AC LIQUID VITUZ® SOLUTION ZUTRIPRO® SOLUTION Coverage Criteria: A. Authorization Criteria 1. The patient is at least 2 years of age. Authorization will be issued for 30 days. Program Date August 1, 2016 Program type – Prior Authorization Change Control Change New program UHCTX000321j 3
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