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Author: Admin | 2025-04-28
Toxoplasmosis Coverage is provided for the treatment of toxoplasmosis when used conjointly with a sulfonamide. Generic natifine gel 1%, 2% (Naftin®) Preferred Topical antifungal Coverage requires the following: Diagnosis of tinea pedis, tinea cruris or tinea corporis Treatment failure to two topical over-the-counter antifungal agents Treatment failure to two oral generic antifungal agents Naftin® gel 1% Preferred Topical antifungal Coverage requires the following: Diagnosis of tinea pedis, tinea cruris or tinea corporis Treatment failure to two topical over-the-counter antifungal agents Treatment failure to two oral generic antifungal agents Neupro® Preferred Parkinson’s disease Coverage requires the following: Diagnosis of Parkinson’s disease Treatment failure or intolerance to generic pramipexole (Mirapex®) and generic ropinirole (Requip®) Or Diagnosis of restless legs syndrome Treatment failure or intolerance to generic pramipexole (Mirapex®), generic ropinirole (Requip®) and generic gabapentin (Neurontin®) Novarel® Clinical, Custom, Preferred Infertility Coverage requires failure of or intolerance to Pregnyl® Oxtellar XR® Preferred Anticonvulsant Coverage requires the following: Treatment of seizures in patients with epilepsy Treatment failure or intolerance to at least 3 generic alternatives, one of which must be generic oxcarbazepine (Trileptal®) Xifaxan® 550mg Preferred Hepatic encephalopathy, gastrointestinal conditions Coverage requires the following: Diagnosis of irritable bowel syndrome with diarrhea, or IBS-D Trial and treatment failure, contraindication, or intolerance to a tricyclic antidepressant Or Diagnosis of small intestinal bacterial overgrowth, or SIBO, as detected by an appropriate breath test Trial and failure of two generic antibiotics Or Diagnosis of intestinal methanogen overgrowth, or IMO, as detected by an appropriate breath test Using in
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