Hemangeol (propranolol hydrochloride oral solution) - PA, NF
Indications for Prior Authorization
Hemangeol (propranolol hydrochloride oral solution)
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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] AND
- One of the following:
- Trial or intolerance to generic propranolol oral solution OR
- Provider attestation that there is potential for an allergic reaction due to a non-active ingredient that is contained in generic propranolol oral solution but not included in the requested product
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] AND
- One of the following:
- Trial or intolerance to generic propranolol oral solution OR
- Provider attestation that there is potential for an allergic reaction due to a non-active ingredient that is contained in generic propranolol oral solution but not included in the requested product
Hemangeol
Non Formulary (Initial Authorization)
Length of Approval: 6 Month(s) [A]
- Submission of medical records (e.g., chart notes) confirming diagnosis of proliferating infantile hemangioma AND
- Patient is less than or equal to 12 months of age [A] AND
- Submission of medical records (e.g., chart notes) confirming one of the following:
- Trial or intolerance to generic propranolol oral solution OR
- There is potential for an allergic reaction due to a non-active ingredient that is contained in generic propranolol oral solution but not included in the requested product
Hemangeol
Non Formulary (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] AND
- Submission of medical records (e.g., chart notes) confirming one of the following:
- Trial or intolerance to generic propranolol oral solution OR
- There is potential for an allergic reaction due to a non-active ingredient that is contained in generic propranolol oral solution but not included in the requested product
P & T Revisions
2026-08-10, 2026-07-08, 2026-06-03, 2026-01-08, 2024-12-23, 2024-01-04
References
- Hemangeol Prescribing Information. Pierre Fabre Pharmaceuticals, Inc. Parsippany, NJ. June 2021.
- Krowchuk DP, Frieden IJ, Mancini AJ, et al. Clinical Practice Guideline for the Management of Infantile Hemangiomas. Pediatrics. 2018;143(1):e20183475.
End Notes
- Treatment typically is continued for at least 6 months and often is maintained until 12 months of age (occasionally longer). [2]
Revision History
- 2026-08-10: Addition of NF criteria
- 2026-07-08: Addition of NF criteria
- 2026-06-03: Addition of trial requirement
- 2026-01-08: 2026 Annual Review. No criteria changes.
- 2024-12-23: 2025 Annual Review - no criteria changes
- 2024-01-04: New Program
HEALTHY LIVING