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Sucralfate Suspension Prior Authorization with Quantity Limit Program Summary
Policy Number: PH-1099
This prior authorization applies to Blue Partner, Commercial, GenPlus, NetResults A series, SourceRx and Health Insurance Marketplace formularies.
POLICY REVIEW CYCLE
Effective Date |
Date of Origin |
10/1/2022 |
|
FDA APPROVED INDICATIONS AND DOSAGE
Agent(s) |
FDA Indication(s) |
Notes |
Ref# |
Carafate® (sucralfate) Oral suspension Tablet |
Oral suspension:
Tablet:
|
ª- Generic equivalent available |
1 ; 2 |
See package insert for FDA prescribing information: https://dailymed.nlm.nih.gov/dailymed/index.cfm
CLINICAL RATIONALE
Safety |
Carafate is contraindicated in patients with known hypersensitivity reactions to the active substance or to any of the excipients.(1,2) |
REFERENCES
Number |
Reference |
1 |
Carafate suspension prescribing information. Allergan USA, Inc. August 2017. |
2 |
Carafate tablet prescribing information. Allergan USA, Inc. April 2013. |
POLICY AGENT SUMMARY PRIOR AUTHORIZATION
Agent Names |
Strength |
Targeted MSC |
Available MSC |
Effective Date |
|
||||
CARAFATE*sucralfate susp ; SUCRALFATE*sucralfate susp |
1 GM/10ML |
M ; N ; O ; Y |
N ; O ; Y |
|
POLICY AGENT SUMMARY QUANTITY LIMIT
Target Agent GPI |
Agent Names |
Strength |
QL Amount |
Dose Form |
Days Supply |
Duration |
Addtl QL Info |
Allowed Exceptions |
Targeted NDCs When Exclusions Exist |
Effective Date |
|
||||||||||
49300010001820 |
SUCRALFATE*Sucralfate Susp 1 GM/10ML |
1 GM/10ML |
1200.0 |
MLS |
30 |
Days |
|
|
|
|
CLIENT SUMMARY – PRIOR AUTHORIZATION
Agent Names |
Strength |
Client Formulary |
CARAFATE*sucralfate susp ; SUCRALFATE*sucralfate susp |
1 GM/10ML |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
CLIENT SUMMARY – QUANTITY LIMITS
Agent Names |
Strength |
Client Formulary |
SUCRALFATE*Sucralfate Susp 1 GM/10ML |
1 GM/10ML |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
PRIOR AUTHORIZATION CLINICAL CRITERIA FOR APPROVAL
Module |
Clinical Criteria for Approval |
|
Target Agent(s) will be approved when BOTH of the following are met:
Length of Approval: 12 months NOTE: If Quantity Limit applies, please refer to Quantity Limit Criteria. |
QUANTITY LIMIT CLINICAL CRITERIA FOR APPROVAL
Module |
Clinical Criteria for Approval |
|
Quantity Limit for the Target Agent(s) will be approved when ONE of the following is met:
Length of Approval: 12 months
|
This program applies to Blue Partner, Commercial, GenPlus, NetResults A series, SourceRx and Health Insurance Marketplace formularies.
This pharmacy policy is not an authorization, certification, explanation of benefits or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All pharmacy policies are based on (i) information in FDA approved package inserts (and black box warning, alerts, or other information disseminated by the FDA as applicable); (ii) research of current medical and pharmacy literature; and/or (iii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.
The purpose of Blue Cross and Blue Shield of Alabama’s pharmacy policies are to provide a guide to coverage. Pharmacy policies are not intended to dictate to physicians how to practice medicine. Physicians should exercise their medical judgment in providing the care they feel is most appropriate for their patients.
Neither this policy, nor the successful adjudication of a pharmacy claim, is guarantee of payment.
BCBSAL _ PS _ Sucralfate Suspension Prior Authorization with Quantity Limit _ProgSum_ 10/1/2022 _