COVERED USES:

FDA Approved Indications:

Singulair® is indicated for the prophylaxis and chronic treatment of asthma in adults and pediatric patients 12 months of age and older.

Singulair® is indicated for prevention of exercise-induced bronchoconstriction in patients 15 years of age and older.

Singulair® is indicated for the relief of symptoms of allergic rhinitis (seasonal allergic rhinitis in adults and pediatric patients 2 years of age and older, and perennial allergic rhinitis in adults and pediatric patients 6 months of age and older).

Accolate® is indicated for the prophylaxis and chronic treatment of asthma in adults and children 5 years of age and older.

Requests for a non-FDA approved (off-label) indication requires the proposed indication be listed in either the American Hospital Formulary System (AHFS), USP-DI, or Drugdex and is considered subject to evaluation of the prescriber's medical rationale, formulary alternatives, the available published evidence-based research and whether the proposed use is determined to be experimental/investigational.

AGE RESTRICTIONS:

See covered uses.

PRESCRIBER RESTRICTIONS:

NA

REQUIRED MEDICAL INFORMATION:

For initiation of treatment, a prior authorization form and relevant chart notes documenting medical rationale are required and for continuation of therapy, ongoing documentation of successful response to the medication may be necessary.

CRITERIA:

There is a diagnosis of asthma or contraindication to or documentation of an adequate trial of two second-generation antihistamines (formulary examples: OTC loratadine, cetirizine and prescription fexofenadine.

EXCLUSION CRITERIA:

NA

COVERAGE DURATION:

Initial authorization and reauthorization will be approved for up to one year.