PA Criteria Proposal - PDF document

1 PA Criteria Proposal  2013 ACS,
PA Criteria Proposal  2013 ACS, A Xerox Company All Rights Reserved. D D r r u u g g M M o o n n o o g g r r a a p p h h Drug/Drug Class: Virt - Vite Plus (Vitamins C, B 1 , B 2 , B 6 , B 12 , folic acid, niacin, pantothenic acid and biotin ) Tablets / Multiple Vitamin Agent Prepared for: MO HealthNet Prepared by: ACS, A Xerox Company New Criteria Revision of Existing Criteria E E x x e e c c u u t t i i v v e e S S u u m m m m a a r r y y Purpose: The purpose of this monograph is to provide a review of new therapy to determine whether the reviewed drug should be made available on an open access basis to prescribers, require a clinical edit or require prior authorization for use. Dosage Forms: Each tablet of Virt - Vite Plus contains Vitamin C 60 mg , Vitamin B 1 1.5 mg , Vitamin B 2 1.5 mg , Vitamin B 6 50 mg, Vitamin B 12 1 m g , Folic Acid 5 mg, Niacin 20 mg, Pantothenic Acid 10 mg and Biotin 300 mcg. Manufacturer: Virtus Pharmaceuticals, LLC . Tampa, FL 33619 Indications: Virt - Vite Plus tablets are indicated for the distinct nutritional requirements of patients in need of dietary supplementation as determined by a licensed medical practitioner. Costs: $0.42433 per tablet of Virt - Vite Plus W holesale A cquisition C ost Summary of Findings: MO HealthNet Division recommends Open Access status for this product . Status Recommendation: Prior Authorization (PA) Required Clinical Edit Open Access PDL Type of PA Criteria: Increased Risk of ADE Appropriate Indications Preferred Agent No PA Required Prepared By: Mark Roaseau, BS Pharmacy, MD Date: February 15 , 201 3