Subject:

 Specific Special Authority Requests:

APIXABAN   Reason: DVT or PE ACETAMINOPHEN   Reason: Osteoarthritis    Monotherapy Adjunct to NSAID ACLIDINIUM ALENDRONATE / RISEDRONATE   Reason:    Osteoporotic fracture Steroid-induced osteoporosis ANGIOTENSIN-2 RECEPTOR BLOCKER (ARB) ANTIFUNGALS-TOPICAL   Reason: lower extremity dermatomycosis with    Diabetes Mellitus Peripheral vascular disease BUPROPION CARVEDILOL CELECOXIB   Reason:    Osteoarthritis Rheumatoid Arthritis CIPRO/DEXAMETHASONE   Reason:    AOM + vent tube AOE + vent tube    AOE + perforation    Failure/Intolerance to aminoglycoside CLOPIDOGREL   Reason:    Secondary Prevention (indefinite)    High risk ACS, and ASA use (up to 12 mo)    Post-PCI (up to 12 mo) DETEMIR / GLARGINE   Reason:    Nocturnal hypoglycemia    Allergic reaction- need to document DUTASTERIDE / FINASTERIDE

FORMOTEROL GLICLAZIDE GLYCOPYRRONIUM INDAPAMIDE LEVETIRACETAM INDACATEROL INH CORTICOSTEROID/LABA       (Advair/ Symbicort/ Breo/ Zenhale)   Reason:    Asthma    COPD LMW HEPARIN METHYLPHENIDATE LONG-ACTING MOMETASONE NASAL PAMIDRONATE PERINDOPRIL RALOXIFENE   Reason: osteoporotic fracture and    Intolerance Treatment failure RIVAROXABAN   Reason: DVT or PE SALMETEROL   Reason:    Asthma    COPD TACROLIMUS TERBINAFINE TESTOSTERONE INJECTION TIOTROPIUM VANCOMYCIN ZOPICLONE   Reason:    HIV-AIDS Depression    Failed Benzodiazepine/hypnotic    Alcohol-Drug Addiction Elderly

Refresh (F5) to re-open menu   SA Reference   RDP Reference   Formulary Search   RDP Reference

 Links to other Special Authority Forms:




  ACLIDINIUM / GLYCOPYRRONIUM / TIOTROPIUM


(Hepatitis C products)