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Medications listed are available on OH EPIC Formulary, unless otherwise noted.
Not all formulary medications are available at each facility. Please refer to your local pharmacy for available inventory.
Search results for:

polidocanol

polidocanol
  • Ambulatory: Vascular Clinics
Drug Name Form Strength Infusion Center Available Restricted Non-formulary Ambulatory Available Interchange REMS
Varithena FOAM, INJECTABLE 1%        
Asclera SOLUTION, INJECTABLE 1%        
VIEW MORE alpha-Adrenergic Blocking Agents
CLASS
241600
Additional Information and Links

Varithena criteria of use:

  • Service Line: All
  • Formulary Location: Ambulatory
  • Service location: Ambulatory clinics, procedural area
  • Patient Population: Adults 18 and older
  • Prior Authorization Required: Yes
  • Restriction/Criteria of Use:
    • Provider trained/certified on use of Varithena (training provided by Boston Scientific company)
    • Veins > 3 mm in diameter
    • Trial and failure, intolerance or contraindication to Asclera for the treatment of varicose vein ≤ 3 mm in diameter
Last updated: Feb. 23, 2024

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