Download doxycycline monohydrate

SUMMACARE COMMERCIAL MEDICATION REQUEST GUIDELINES
Generic
DOXYCYCLINE
MONOHYDRATE,
DELAYED RELEASE TETRACYCLINE PRODUCTS
Brand
HICL
GCN
Exception/Other
ADOXA,
7184,
19107,
40363,
25751,
98818,
DOXYCYCLINE
HYCLATE
DORYX
DOXYCYCLINE
MONOHYDRATE
MONODOX
DOXYCYCLINE
MONOHYDRATE
MINOCYCLINE
HCL
ORACEA
SOLODYN
25283,
25284,
34586,
38752
99828
98271,
40651,
40652
27097
26957,
26958,
26960,
27396,
27397,
29040,
29044,
29045
GUIDELINES FOR USE
1. Is the patient a new enrollee within the past 6 months; (NOTE: Confirm eligibility information that
the patient has enrolled within the past 6 months and document enrollment date.)?
If yes, continue to #2.
If no, continue to #3.
2. Is there medical record documentation (for example, chart notes) or claims history that the patient
has been prescribed and is currently stabilized on this medication; (NOTE: Document that the
patient is a new enrollee and is currently stable on this medication in the PA Comments.)?
If yes, Approve for 12 months.
If no, continue to #3.
3. Does the patient’s prescription history show claims for brand name Adoxa, Doryx, Monodox,
Oracea, or Solodyn within the past 120 days; (NOTE: previous claims for generic products do not
automatically qualify a member for the brand product. Document that the patient's prescription
history shows claims for the requested brand drug (Adoxa, Doryx, Monodox, Oracea, or Solodyn)
within the past 120 days in the PA Comments.)?
If yes, Approve for 12 months.
If no, continue to #4.
CONTINUED ON NEXT PAGE
Revised 12/7/2015
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SUMMACARE COMMERCIAL MEDICATION REQUEST GUIDELINES
DELAYED RELEASE TETRACYCLINE PRODUCTS
GUIDELINES FOR USE (CONTINUED)
4. Can the prescriber provide documentation that the patient has tried and failed treatment (after at
least 6 weeks of continuous therapy) with or has a contraindication to generic doxycycline
monohydrate OR doxycycline hyclate, (Vibramycin, Vibra-Tab), AND minocycline (Minocin, Myrac,
Dynacin); (NOTE: Document prior drugs and dates prescription provided in tried/failed field.)?
If yes, Approve for 12 months.
If no, do not approve.
DENIAL TEXT: Our guideline for Delayed-Released Tetracyclines, requires that the patient
has tried and failed treatment or has a contraindication to generic doxycycline monohydrate,
doxycycline hyclate, (Vibramycin, Vibra-Tab) AND minocycline (Minocin, Myrac, Dynacin).
REFERENCES
• Adoxa prescribing information, Pharma Derm, Melville, NY, March 2008.
• Facts and Comparisons Online Edition, Accessed 12/13/10
• Oracea prescribing information, Galderma Laboratories, Fort Worth, TX, May 2008.
• Solodyn prescribing information, Medicis, Scottsdale, AZ, 2010.
Commercial
X
HIEx
X
Created: 05/05/11
Effective
Revised 12/7/2015
Client Approval:
P&T Approval:
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