Medications not yet evaluated by P&T are considered NON-FORMULARY . . . . . Always check 2 unique patient identifiers - NAME and DATE OF BIRTH - at every step! . . . . . Please be sure to document all clinical activities daily.
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polidocanol

polidocanol
  • Restricted Asclera & Varithena --> Restricted to the THC Vein Treatment Center and Madison Hospital Vein Center.
  • Restricted Miscellaneous Programs
Drug Name Form Strength Formulary Unrestricted Formulary Restricted Non-Formulary Interchange
Varithena FOAM, INJECTABLE 180 mg/18 mL      
Asclera SOLUTION, INJECTABLE 0.5%, 1%      
Comments:

ASCLERA is classified as formulary, restricted to the THC Vein Treatment Center and Madison Hospital Vein Center.

VARITHENA is classified as formulary, restricted to the THC Vein Treatment Center for administration by certified cardiologists.

Reviewed: May 22, 2012 (Asclera), and 28 June 2016 (Varithena)

Last updated: May. 2, 2017






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