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Company Hanson / DepoMed Inc. / / Event FDA Phase / Product Issues / / Facility Yes No CRITERIA FOR APPROVAL Sandostatin LAR Depot / Sandostatin LAR Depot / / IndustryTerm treatment of Hepatitis C / therapy for AIDS / treatment of anemia in cancer / acne products / treatment of anemia associated with chronic renal failure / food / erythropoietin product / topical products / treatment of Attention-Deficit/Hyperactivity Disorder / drug products / dexmethylphenidate/methylphenidate drug products / dexmethylphenidate/methylphenidate products / therapy for allergy / / MedicalCondition HIV / multiple myeloma / seizures / myelodysplastic syndrome / ankylosing spondylitis / vascular thrombosis / Acromegaly / sickle cell anemia / chronic renal failure / Rheumatoid Arthritis / Guidelines Acne / onychomycosis / acute and delayed nausea / leukocytosis / advanced / refractory multiple myeloma / moderately emetogenic cancer / primary psychiatric disorders / insufficient sleep syndrome / Psoriasis / cardiac arrest / vasoactive intestinal peptide tumors / hypersomnolence / Shift Work Sleep Disorder / Asthma / acute bronchospasm / ADHD / cancer / shortness of breath / upper airway resistance syndrome / sleep disorder / ESRD / narcolepsy / neutropenia / stroke / thromboembolism / severe acne / Allergy / onychomycosis infection / vomiting / Chronic continuous use / myelodysplasia / postoperative nausea / AIDS / infection / highly emetogenic cancer / patient’s asthma / ADHD/Narcolepsy / allergy-induced asthma / Irritable Bowel Syndrome / sleep disorders / Circadian Rhythm Sleep Disorders / depression / acute myeloid leukemia / symptomatic anemia / severe neutropenia / disorders / neutropenia resulting / severe erythema nodosum leprosum Yes No / chest pain / carcinoid tumor / obstructive sleep apnea / hyperpigmentation / severe persistent asthma / myelodysplastic syndromes / acquired immune deficiency syndrome / rheumatic disease / nausea / familial adenomatous polyposis / chronic dialysis therapy / Hepatitis C / Acne Vulgaris / fatigue / febrile neutropenia / excessive leukocytosis / Shift Worker Sleep Disorder / Relpax (eletriptan) Osteoporosis / severe persistent allergic asthma / severe chronic neutropenia / infections / established nausea / mental disorders / Attention-Deficit/Hyperactivity Disorder / acute myocardial infarction / another mental disorder / future asthma / congestive heart failure / peripheral vascular disease / peptic ulcer / hemolytic anemia / non-myeloid cancer / hypertension / allergic asthma / acne / disease / gastric ulcer / tinea unguium / low-risk myelodysplastic syndrome / Migraine / Saizen (somatropin) Influenza / osteoarthritis / status asthmaticus / pain / Prilosec (omeprazole) Pulmonary Arterial Hypertension / diabetes mellitus / urticaria / heart attack / chronic myeloid leukemia / liver injury / severe neuritis / obstructive sleep apnea/hypopnea syndrome / leprosy / anemia / / MedicalTreatment Concomitant therapy / surgery / blood transfusions / continuous positive airway pressure / adjunctive therapy / alternate therapies / vascular surgery / dialysis / contraceptive methods / radiation therapy / antiretroviral therapy / antibiotics / Chemotherapy / bone marrow transplant / Hemodialysis / total body irradiation / / Organization Institute for Clinical Systems Improvement / American Society of Clinical Oncology / American Academy of Dermatology / Medicare / FDA / Food and Drug Administration / American Heart Association / / Person Provigil / / Position physician / pharmacist / / Product Tamiflu / cisplatin / sumatriptan / Nexium / Anzemet / Tablets/ODT- 9 / Adderall XR / Lotronex / Dextrostat / Infergen / Aranesp / promethazine / Neupogen / modafinil / Dexedrine / Renova / Zofran Oral Solution- 90 / octreotide acetate / Neulasta / Remicade / Imitrex / Protopic / erythromycin / Kytril / tretinoin / Elidel / Regranex / Phenergan / Somavert / Zofran / Is / Depo-Testosterone / Sandostatin LAR / Nutropin / Compazine / Testim / Ribavirin / Saizen / Forteo / Pegasys / Sandostatin / Rebetol / prochlorperazine / Ranexa / Avita / Xolair / Nutropin AQ / metoclopramide / testosterone cypionate / Humira / zidovudine / granisetron / Emend / Torecan / Exjade / Humatrope / Dexamethasone / leflunomide / Prevacid / Reglan / Ribasphere / doxycycline / COX-2 / Retin-A / Androderm / omeprazole / Protonix / Marinol / Norditropin / Revatio / Celebrex / Azelex / Zelnorm / Enbrel / AcipHex / Prilosec / Arava / Strattera / lansoprazole / Plavix / Genotropin / Aloxi / Differin / Raptiva / Relpax / Maxalt / Lamisil / Provigil / Zofran 24 mg Tablet- 1 / Thalomid / ondansetron / Yes / MDC-1 / sodium retention / Limit / renal perfusion / response / 5HT3 / renal function / increased blood pressure.10 Therefore / / Technology radiation / Chemotherapy / dialysis / Alpha / / SocialTag 
Client Contract Number – Client Name – MA-PD/PDP Prior Authorization Criteria and Guidelines Acne 5 Retinoids, topical (tretinoins) 5-6 Avita