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    v1.0.30
    OpenPayerPolicy UpdatesPharmacy & Specialty DrugsOHCA Propoxyphene Prior Auth Coverage | OpenPayer
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    CurrentOklahoma Health Care AuthorityPolicy N/A

    Annual Review of Propoxyphene Products

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    This document governs prior authorization approval criteria and quantity limits for selected propoxyphene products administered through the Oklahoma Health Care Authority. It also summarizes utilization and prescriber/member trends for propoxyphene products in fiscal year 2008.

    Policy Summary
    PayerOklahoma Health Care Authority
    PolicyAnnual Review of Propoxyphene Products
    Policy CodePolicy N/A
    Change TypeAnnual review
    Effective DateN/A
    Next Review DateN/A
    Key ActionDocument at least one applicable clinical justification and confirm the requested quantity does not exceed 180 units in 30 days.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    180/30Quantity limit for each approved product
    31,547Total propoxyphene product claims in FY 2008
    16,975Members using propoxyphene products in FY 2008
    $214,117.32Total FY 2008 propoxyphene product cost
    NoneCollege of Pharmacy recommendation for the category
    Policy Summary
    PayerOklahoma Health Care Authority
    PolicyAnnual Review of Propoxyphene Products
    Policy CodePolicy N/A
    Change TypeAnnual review
    Effective DateN/A
    Next Review DateN/A
    Key ActionDocument at least one applicable clinical justification and confirm the requested quantity does not exceed 180 units in 30 days.
    SourceLink
    On This Page
    Propoxyphene Product Approval CriteriaPrior Authorization and Documentation RequirementsProduct Quantity Limits

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    Propoxyphene Product Approval Criteria

    Darvocet A500 and Balacet 325 approval criteria

    Approval requires the documented criteria listed for the requested product.

    Approval criteria

    • Clinical justification: Documented need to restrict acetaminophen use; documented renal insufficiency or hepatic impairment; or concurrent use of acetaminophen-containing products.

    Initial approval

    Approval criteria for Darvocet A500 and Balacet 325

    Clinical justification: At least one of the following documented circumstances is listed: need to restrict acetaminophen use; renal insufficiency or hepatic impairment; or concurrent use of acetaminophen-containing products.

    Prior Authorization and Documentation Requirements

    Prior Authorization

    Prior Authorization and Approval Criteria

    Prior authorization is required for Darvocet A500 and Balacet 325. Approval depends on documentation supporting the applicable approval criteria and the clinical need for therapy.

    • Darvocet A500
    • Balacet 325
    Documentation Required

    Required Clinical Documentation

    The prior authorization request must include clinical documentation addressing the applicable approval criteria.

    • Documented need to restrict acetaminophen use
    • Documented renal insufficiency or hepatic impairment
    • Concurrent use of acetaminophen-containing products

    Product Quantity Limits

    Quantity Limits
    ProductsDarvocet A500 and Balacet 325
    Quantity limit180 units per 30 days
    ApplicationThe limit applies to each product
    Denial Risk

    Documentation Required for Approval

    Requests may be denied when the applicable clinical need or listed approval criteria are not documented.

    Billing Rule

    Quantity Limit

    A quantity limit of 180 units in 30 days applies separately to Darvocet A500 and Balacet 325.

    • Darvocet A500: maximum 180 units per 30 days
    • Balacet 325: maximum 180 units per 30 days