RANOLAZINE Aspruzyo Sprinkle Oral Instructions
- June 3, 2024
- ASPRUZYO SPRINKLE
Table of Contents
STANDARD COMMERCIAL DRUG FORMULARY
PRIOR AUTHORIZATION GUIDELINES
RANOLAZINE Aspruzyo Sprinkle Oral
RANOLAZINE
Generic| Brand| HILL| GCN| Medi-Span|
Exception/Other
---|---|---|---|---|---
RANOLAZINE| ASPRUZYO
SPRINKLE| | 52005
52006| GPI-14
(32200040003020,
32200040003040)|
GUIDELINES FOR USE
- Does the patient have a diagnosis of chronic angina and meet ALL the following criteria?
• The patient had a trial of or contraindication to ranolazine ER tablets
• The patient is unable to swallow ranolazine ER tablets
• The patient had a trial of or contraindication to a nitrate (e.g., nitroglycerin, isosorbide mononitrate, isosorbide dinitrate)
If yes, approve for 12 months by GPID or GPI-14 for the requested strength with the following quantity limits:
- 500mg: #2 per day.
- 1000mg: #2 per day.
If no, do not approve.
DENIAL TEXT: *Some terms are already pre-defined in parenthesis. Please
use these definitions if the particular text you need to use does not already
have a definition(s) in it.
Our guideline named RANOLAZINE (Aspruzyo Sprinkle) requires the following
rule(s) be met for approval:
A. You have chronic angina (a type of heart condition)
B. You had a trial of or contraindication (harmful for) to ranolazine ER
(extended-release) tablets
C. You are unable to swallow ranolazine ER tablets
D. You had a trial of or contraindication (harmful for) to a nitrate (such as
nitroglycerin, isosorbide mononitrate, isosorbide dinitrate)
Your doctor told us [INSERT PT SPECIFIC INFO PROVIDED]. We do not have information showing you [INSERT UNMET CRITERIA]. This is why your request is denied. Please work with your doctor to use a different medication or get us more information if it will allow us to approve this request.
CONTINUED ON THE NEXT PAGE
RANOLAZINE
RATIONALE
For further information, please refer to the Prescribing Information and/or
Drug Monograph for Aspruzyo Sprinkle.
REFERENCES
- Aspruzyo Sprinkle [Prescribing Information]. Cranbury, NJ: Sun Pharmaceutical Industries, Inc.; March 2022.
| Library | Commercial | NSA |
|---|---|---|
| Yes | Yes | No |
Part D Effective: N/A
Commercial Effective: 10/01/22
Created: 08/22
Client Approval: 09/22
P&T Approval: 07/22
Copyright © 2022 MedImpact Healthcare Systems, Inc. All rights reserved. This
document is proprietary to MedImpact. MedImpact maintains the sole and
exclusive ownership, right, title, and interest in and to this document.
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