Edarbi 2 of a first-line agent (or any combination of first-line agents) in the last 130 days OR Documented intolerance to formulary ARBs Age restriction Benicar must be at least 6 years old and weigh at least 20 kg – Edarbi must be at trial 18 years old – Agents include: ACE inhibitors Formulary ARBs: Losartan, losartan/HCTZ Irbesartan, irbesartan/HCTZ Valsartan, valsartan/HCTZ Amlodipine/valsartan, amlodipine/valsartan/HCTZ Diabetes medication Botulinum Toxins Botox, Myobloc, Dysport, Xeomin See Detailed document: Cambia[ii] May be authorized for patients who meet the following criteria: Initial Approval: Last reviewed: 10/21/2015 Diagnosis of migraine headaches Indefinite 18 of age or older Tried and failed at least 2 formulary triptans (e.g., sumatriptan, naratriptan) or has a Limit of 9 packets (1 box contraindication to triptans per month) Tried and failed at least 2 formulary NSAIDs (e.g., Ibuprofen, naproxen, diclofenac) Capecitabine May be authorized when prescribed by an oncologist for patients who are at least 18 years old Initial Approval: 1 year who have ANY of the following indications: Last reviewed: 1/19/2016 Metastatic colorectal cancer Renewal: 3 based on Adjuvant (post-surgery) treatment of Dukes’ C colon cancer therapeutic response. Metastatic breast cancer that is refractory to both paclitaxel and an anthracycline-containing chemotherapy regimen Required: Metastatic breast cancer that is refractory to paclitaxel when the patient is not appropriate for Crcl >30mL/min anthracycline therapy neutrophils >1 × 109/L platelets >50 × 109/L
Edarbi 2 of a first-line agent (or any combination of first-line agents) in the last 130 days OR Documented intolerance to formulary ARBs Age restriction Benicar – must be at least 6 years old and weigh at least 20 kg Edarbi – must be at 18 years old Agents include: ACE inhibitors Formulary ARBs: Losartan, losartan/HCTZ Irbesartan, irbesartan/HCTZ Valsartan, valsartan/HCTZ Amlodipine/valsartan, amlodipine/valsartan/HCTZ Diabetes medication Botulinum Toxins Botox, Myobloc, Dysport, Xeomin See Detailed document: Cambia[ii] Last reviewed: 10/21/2015 May be authorized for patients who meet the following criteria: Diagnosis of migraine headaches 18 of age or older Tried and failed at least 2 formulary triptans (e.g., sumatriptan, naratriptan) or has a contraindication to triptans Tried and failed at least 2 formulary NSAIDs (e.g., Ibuprofen, naproxen, diclofenac) Initial Approval: Indefinite Limit of 9 packets (1 box per month) Capecitabine Last reviewed: 1/19/2016 May be authorized when prescribed by an oncologist for patients who are at least 18 years old who have ANY of the following indications: Metastatic colorectal cancer Adjuvant (post-surgery) treatment of Dukes’ C colon cancer Metastatic breast cancer that is refractory to both paclitaxel and an anthracycline-containing chemotherapy regimen Metastatic breast cancer that is refractory to paclitaxel when the patient is not appropriate for anthracycline therapy Initial Approval: 1 year Renewal: 3 based on therapeutic response. Required: Crcl >30mL/min neutrophils >1 × 109/L platelets >50 × 109/L trial