Pharmacy Prior Authorization Criteria

Hemangeol (propranolol hydrochloride oral solution)

Indications for Prior Authorization

Hemangeol (propranolol hydrochloride oral solution)

• For diagnosis of Infantile hemangioma
  Indicated for the treatment of proliferating infantile hemangioma requiring systemic therapy.

Criteria

Hemangeol

Prior Authorization (Initial Authorization)

Length of Approval: 6 Month(s) [A]

• Diagnosis of proliferating infantile hemangioma
AND
• Patient is less than or equal to 12 months of age [A]

Hemangeol

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)

• Patient demonstrates positive clinical response to therapy (e.g., reduction in size, absence of functional impact, tissue softening)
AND
• Patient is less than or equal to 18 months of age [A]

P & T Revisions

2024-01-04

References

1. Hemangeol Prescribing Information. Pierre Fabre Pharmaceuticals, Inc. Parsippany, NJ. June 2021.
2. Krowchuk DP, Frieden IJ, Mancini AJ, et al. Clinical Practice Guideline for the Management of Infantile Hemangiomas. Pediatrics. 2018;143(1):e20183475.

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End Notes

1. Treatment typically is continued for at least 6 months and often is maintained until 12 months of age (occasionally longer). [2]

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Revision History

• 2024-01-04: New Program

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