Prescription Drug Program Prior Authorization Criteria

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1 Prescription Drug Program Prior Authorization Criteria Revised 08/14/2015 This document is an informational listing of the medications requiring a Prior Authorization through the Arkansas Medicaid Pharmacy Program, and a description of the associated criteria. Inclusion in this document does not guarantee market availability and products must meet the Centers for Medicare and Medicaid Services (CMS) definition of a covered outpatient drug and pay CMS rebate to be covered by Arkansas Medicaid. Select covered over the counter medications are covered pursuant to a valid prescription, but are not covered for Long Term Care eligible beneficiaries.

2 Prescription Product or Drug Class 5-HT3 or NK1 Receptor Antagonists Abiraterone Acetate Tablet (Zytiga) Acetic Acid HC Ear Drops Acitretin Capsule (Soriatane) Aclidinium Bromide Inhaler (Tudorza Pressair) Acthar HP Gel Injection Actonel Acyclovir (Xerese and Zovirax Cream) Acyclovir Orally Disintegrating Delayed Release Tablet (Sitavig) Adempas (Riociguat) Tablet Adoxa Afatinib Dimaleate Tablet (Gilotrif) Afinitor Afrezza (Regular Human Inhaled Insulin) Alagesic Liquid Oral Solution /15ml Albuterol Oral Tablets and Syrup Aldara Allergan Extracts Altabax 1% Ointment Amitiza Ammonul 10%-10% Ampyra ER Angiotensin II Receptor Antagonists Anoro Ellipta Antibiotic Ophthalmic Drops (Moxeza,Vigamox, Quixin, Iquix, Azasite, Zymar) Antibiotic-Steroid Fixed-Dose Combination Ophthalmic Drops (Cortisporin, Tobradex ST, Zylet) Antibiotics, Long-acting Antidepressant, Second Generation (SGAD) Antidiabetic Agents Anti-Inflammatory Ophthalmic Drops Anti-Inflammatory Agents, Nonsteroidal Antihistamine Eye Drops, Mast Cell Stabilizers, and Combination Mast Cell Stabilizer-Antihistamine Eye Drops Antihistamines, Second Generation Antifungal Creams (Topical), Lotions, and Shampoos Antipsychotics, Injectable Long-acting Antipsychotics, Oral Aptiom Aranesp Armodafinil (Nuvigil) Aromatase Inhibitors (Femara Tablets and Arimidex) Astragraf XL Attention Deficit (ADD/ADHD) Agents for Children (Age Less than 18 Years) Attention Deficit (ADD/ADHD) Agents for Adults (Age 18 Years or greater)

3 Auranolfin (Ridaura) Axitinib Tablet (Inlyta) Azelaic Acid 15% Gel (Finacea) Azithromycin (Azithromycin Powder Packets and ZMAX Suspension) Aztreonam Inhalation Solution (Cayston) Baraclude Becaplermin (Regranex) Bedaquiline Fumarate (Sirturo) Belimumab (Benlysta) Benign Prostatic Hypertrophy (BPH) Drugs Benzodiazepine Solid Oral Dosage Forms Benzodiazepine Liquid Oral Dosage Forms Benzoic Acid 6%, Salicyclic Acid 3%, Oak Bark Extract (Bensal HP) Ointment Beta Adrenergic Blocking Agents Beta2 Agonists/Corticosteroids, Inhaled Bethkis Bexarotene Gel (Targretin) BiDil Binosto Boniva Bosutinib (Bosulif) Botox Bowel Prep Kits Bronchodilators, Long-Acting Bronchodilators, Short-Acting Budesonide EC Capsule (Entocort EC) Buprenorphine (Subutex) Buprenorphine- Naloxone (Suboxone) Buproprion (Zyban) Butalbital Products C1 Esterase inhibitor (Cinryze) CII Stimulants Calcipotriene Cream, Foam, Ointment, or Scalp Solution (Dovonex, Sorilux) Calcipotriene and Betamethasone Dipropionate Ointment (Taclonex) Calcitonin- Salmon Nasal Spray (Miacalcin or Fortical) Calcitonin-Salmon Injection (Miacalcin) Calcitriol (Vectical) Calcium Channel Blockers Carbidopa (Lodosyn) Carbidopa/Levodopa Enteral Infusion Suspension (Duopa) Carbidopa/Levodopa/Entacapone (Stalevo) Cephalexin 750mg Capsule (Keflex) Cephalosporins 3rd Generation Ceritinib (Zykadia) Chlorpheniramine ER 12mg Cholic Acid (Cholbam) Ciclopirox 8% Kit Cidofovir (Vistide)

4 Cinryze Ciprofloxacin Extended-Release (Cipro XR) Clobazam (Onfi) Clonazepam Oral Disintegrating Tablet Clonidine Clonidine Vials Colchicine 0.6mg Capsules (Colcrys) Colchicine 0.6mg Tablets (Colcrys) Cometriq COPD Agents Corticosteroids, Nasal Inhaled Corticosteroids, Oral Inhaled Corticosteroids, Topical Crizotinib (Xalkori) Cromolyn Sodium Oral Solution (Gastrocrom) Crotamiton Cream and Lotion (Eurax) Cuprimine Cyclosporine 0.05% Eye Emulsion (Restasis) Cyproheptadine 4mg/10ml U.D. Cup Cysteamine Opthalmic Drops (Cystaran) Cysteamine DR Oral Capsule (Procysbi) Dabigatran Etexilate Mesylate (Pradaxa) Dabrafenib (Tafinlar) Dalfampridine ER (Ampyra ER) Daliresp Dasatinib (Sprycel) Tablet Deferasirox (Jadenu) Deferiprone (Ferriprox) Tablet Denosumab (Prolia) Depen Desmopressin Nasal Spray/Solution (DDAVP) Dexamethasone Dose Pack (Dexpak and Zema-Pak) Dextromethorphan Hbr/Quinidine Capsule (Nuedexta) Diclegis DR Dihydroergotamine Mesylate Nasal Spray (Migranal) Direct Renin Inhibitors Disopyramide CR (Norpace CR) Dornase Alfa Inhalation Solution (Pulmozyme) Doryx Dorzolamide-Timolol 2%-0.5% PF (Cosopt PF) Doxepin 5% Cream (Prudoxin, Zonalon) Doxycycline Doxylamine Succinate 5mg Chewable Tablet (Aldex AN) Doxylamine Succinate 10mg and Pyridoxine 10mg (Diclegis DR 10-10) Dronabinol (Marinol) Droxidopa (Northera) Capsule Efinaconazole 10% Solution (Jublia) Eliglustat (Cerdelga)

5 Eliquis Emtricitabine (Emtriva) Entacapone (Comtan) Enzalutamide (Xtandi) Eslicarbazepine (Aptiom) Etanercept (Enbrel) Entecavir (Baraclude) Entocort EC Epogen Erythropoiesis Stimulating Agents Estrogen Replacement Agents Everolimus (Afinitor) Exelon Famotidine Oral Suspension (Pepcid) Febuxostat Tablet (Uloric) Fenofibrate and Fenobibric Acid Products Fentanyl Buccal Tablet (Fentora and Onsolis) Fentanyl Nasal Spray (Lazanda) Fentanyl Citrate Sublingual (Abstral) Fentanyl Citrate Sublingual Spray (Subsys) Fentanyl Citrate Oral Transmucosal (Actiq) Fibromyalgia Agents Fidaxomicin (Dificid) Finasteride Tablet (Proscar) Flagyl ER Fluorouracil 0.5% Cream (Carac) Fluorouracil 1% Cream (Fluoroplex) Fluorouracil 2% and 5% Solution (Efudex) Fluorouracil 5% Cream (Efudex) Fosamax Oral Solution Fosamax Plus D Fosamprenavir (Lexiva) Tablet Fosamprenavir (Lexiva) Suspension Forteo Fulyzaq Galantamine ER (Razadyne ER) Galantamine Solution (Razadyne) Gattex Giazo Glycerol Phenylbutyrate Oral Liquid (Ravicti) Glycophos Glycopyrrolate 0.2mg/ml vial Glycopyrrolate 1.5mg Tablet (Glycate) Guanfacine Hemorrhoid Preparations Hepatitis C Virus Medications

6 HMG-CoA Reductase Inhibitors Hydrocodone ER (Zohydro ER) Capsule Hydroxypropyl 5mg Eye Insert (Lacrisert) Ibrutinib (Imbruvica) Capsule Icatibant Syringe (Firazyr) Iclusig Idelalisib (Zydelig) Tablet Imiquimod (Aldara) Imiquimod (Zyclara) Immunologic Agents (Multiple Sclerosis) Infergen Ingenol Mebutate (Picato Gel) Inhaled Corticosteroid (ICS)/Long-Acting Beta Agonist (LABA) Combination Products Insulin Pens Isosorbide Dinitrate/Hydralazine HCl (BiDil) Isotretinoin (Accutane) Itraconazle 200mg Tablet (Onmel) Itraconazole Oral Solution (Sporanox) Ivabradine HCL Tablet (Corlanor) Ivacaftor Tablet (Kalydeco) Ivermectin 0.5% Lotion (Sklice) Juxtapid Keppra ER Ketorolac (Toradol) Kits Korlym Kynamro Lamotrigine Start Kits (Lamictal Start Kits) Lansoprazole, Amoxicillin, and Clarithromycin Combination (Prevpac) Lenvatinib (Lenvima) Capsule Leukotriene Receptor Antagonists Levetiracetam ER (Keppra ER) Levofloxacin 500mg/20ml U.D. Cup Levoleucovorin Vial Levothyroxine Capsule (Tirosint) Levothyroxine Vial Lexiva Oral Suspension Lexiva Tablets Lidocaine 5% Patch (Lidoderm) Lidocaine-Prilocaine2.5%-2.5% Topical Cream (Emla) Linacoltide (Linzess) Lithium ER Lithobid SA Lindane Lovaza Low Molecular Weight Heparins Lubiprostone (Amitiza) Lupaneta

7 Lupron Malathion (Ovide) Macitentan (Opsumit) Marinol Maraviroc (Selzentry) Mecamylamine HCL Tablet (Vecamyl) Mechlorethamine HCL Gel (Valchlor) Medroxyprogesterone (Depo-Provera) Megestrol (Megace and Megace ES) Mekinist Memantine XR (Namenda XR) Memantine Solution (Namenda) Meprobamate (Equanil) Tablet Mepron Mercaptopurine (Purixan) Mesalamine 1000mg (Canasa) Mestinon Timespan Methoxsalen (Oxsoralen-Ultra, 8-MOP) Metreleptin Vial (Myalept) Metformin Oral Solution(Riomet) Metformin ER (Fortamet ER and Glumetza ER) Methscopolamine (Pamine, Pamine Forte, Pamine FQ) Methotrexate Auto Inj. (Otrexup) Methotrexate (Trexall) Methylnaltrexone Bromide (Relistor) SQ Injection Metozolv Metronidazole 1% Cream (Noritate) Metronidazole 1% Gel (Metrogel) Metronidazole 375mg (Flagyl) Metronidazole ER 750mg (Flagyl) Metronidazole/Tetracycline/Bismuth (Helidac and Pylera) Miconazole 50mg Buccal Tablet (Oravig) Miconazole Nitrate/ Zinc Oxide/White Petrolatum (Vusion) Mifepristone (Korlym) Mig Lustat (Zavesca) Migranal Nasal Spray Millipred Minocycline Mirapex ER Mircera Misoprostol (Cytotec) Modafinil (Provigil) Moxatag Multiple Sclerosis Agents Mycophenolate (Cellcept, Myfortic) Nabilone (Cesamet) Nafarelin Nasal Spray (Synarel)

8 Naloxegol (Movantik) Tablet Naloxone Auto-injector (Evzio) Namenda Namenda XR Nandrolone Decanoate Injection Neo-Synalar (Neomycin Sulfate, Fluocinolone) Cream Neuropathic Pain Agents Nevirapine XR (Viramune XR) Nevirapine Oral Suspension (Viramune) Nicotine Replacement Therapy Nimodipine Solution (Nymalize) Nitisinone (Orfadin) Nitrofurantoin Suspension (Furadantin) Nitroglycerin 0.4% Rectal Ointment (Rective) Nizatadine Oral Solution (Axid) Non-Benzodiazepine Sedative Hypnotics Nonsteroidal Anti-Inflammatory Agents Norpace CR Noxafil Suspension Noxafil DR Tablet Noxafil Vial Nucort Nuzon Gel Octreotide Acetate (Sandostatin LAR Depot) Olapari (Lynparza) Omega-3-acid ethyl esters (Lovaza) Omeprazole/Clarithromycin/Amoxicillin (Omeclamox-Pak) Onabotulinumtoxina (Botox 200 Units) Onfi Opioids, Long-Acting Opioids, Short-Acting Opium Tinture Opsumit (Macitentan) Oracea Orapred ODT Tablets Oseltamivir Suspension (Tamiflu Suspension) Osteoporosis Drugs Otic Preparations Otrexup Overactive Bladder Agents Oxandrolone (Oxandrin) Oxymethalone (Anadrol-50) Pain Medications, Injectable Palbociclib (Ibrance) Panobinostat Lactate (Farydak) Papaverine Injection Parathyroid Hormone (Natpara) Pasireotide Diaspartate (Signifor) Pazopanib (Votrient) Peg Intron

9 Pegasys PegInterferon Alfa-2B (Sylatron) Pegvisomant Injection (Somavert) Penciclovir (Denavir) Penicillamine (Depen 250mg Tablet and Cuprimine 250mg Capsule) Perampanel Tablet (Fycompa) Phenoxybenzamine Capsule (Dibenzyline) Phosphate Removing Agents Pimecrolimus (Elidel) Podofilox (Condylox 0.5% Topical Solution/Gel) Pomalyst Posaconazole (Noxafil) Potassium Chloride Capsule and Packet Pradaxa Pramipexole ER (Mirapex ER) Prednisolone Prednisone (Rayos DR) Procrit Procysbi Prolia Promacta Propafenone SR (Rythmol SR) Proquin Proton Pump Inhibitors Pyridostigmine Timespan (Mestinon Timespan) Quick Relief Medications for Asthma Quinine Sulfate (Qualaquin) Raloxifene (Evista) Ranolazine (Ranexa) Razadyne ER Razadyne Solution Rebetol Ravicti Regorafenib (Stivarga) Requip XL Respiratory Syncytial Virus (RSV) Medications Restasis Ribapak Ribasphere Ribavirin Ridaura Rifaximin Tablet (Xifaxan) Rilonacept Sub-Q Vial (Arcalyst) Riociguat (Adempas) Tablet Risedronate (Actonel) Risedronate DR (Atelvia) Rivaroxaban10mg Tablet (Xarelto) Rivaroxaban 15mg and 20mg Tablet (Xarelto) Rivastigmine Soution (Exelon) Solution Ropinirole XL (Requip XL) Rosacea Treatment

10 Rotigotine (Neupro) Patch Ruxolitinib (Jakafi) Rythmol SR Sapropterin HCL (Kuvan) Scopolamine Transermal Patch Sedative Hypnotics Serostim Serotonin 5-HT1 Receptor Agonists Signifor Sildenafil (Revatio) Siltuximab Vial (Sylvant) Sinecatechins (Veregen Ointment 15%) Skeletal Muscle Relaxants Sodium Chloride 7% Inhalation Solution (Hyper-Sal 7%) Sodium Oxybate (Xyrem) Somatropin (Genotropin) Somatropin (Humatrope) Somatropin (Norditropin) Somatropin (Nutropin) Somatropin (Omnitrope) Somatropin (Saizen) Somatropin (Tev-tropin) Somatropin (Zomacton) Somatropin (Zorbtive) Soriatane Sotalol Spinosad 0.9% Topical Suspension (Natroba) Spiriva Stiolto Respimat Suboxone Subutex Sucralfate Suspension (Carafate) Sulfamethoxazole-Trimethoprim U.D. Cup Sunitinib (Sutent) Symbicort Synagis Syprine Tacrolimus (Astagraf XL) Tacrolimus (Protopic) Tadalafil (Adcirca) Tafinlar Tamiflu Suspension Tamoxifen Solution (Soltamox) Targeted Immune Modulators Targretin Tasimelteon (Hetlioz) Tavaborole (Kerydin) Tazarotene Gel/Cream (Tazorac) Tedizolid (Sivextro) Telithromycin (Ketek)

11 Temazepam 7.5mg and 22.5mg Capsule (Restoril) Tenofovir (Viread) Tenofovir/Emtricitabine (Truvada) Terbinafine (Lamisil) Terbinex Teriparatide (Forteo) Testosterone Replacement Products Tetrabenazine (Xenazine) Timolol Maleate/Dorzolamide HCL (Cosopt PF) Tiotropium Bormide Inhaler (Spiriva) Tirosint Tobacco Cessation Products Tobramycin Inhalation Solution (TOBI - Brand) Tobramycin Inhalation Solution (Generic) (Bethkis) Tobramycin Inhalation Powder (TOBI Podhaler) Topical Corticosteroids Topical Products Topiramate XL (Qudexy XL or Trokendi XL) Tramadol ER Tramadol IR Tramadol-Acetaminophen (Ultracet) Trametinib (Mekinist) Tranexamic Acid (Lysteda) Transdermal Scopolamine Patch Trazodone (Trazodone 300mg, Oleptro ER) Trexall Trientine HCl (Syprine) Tudorza Pressair Inhaler Ulesfia Uloric Valchlor Valcyte Solution Varenicline (Chantix) Vascepa Vecamyl Vemurafenib (Zelboraf) Veregen Veripred Solution Viramune XR Viramune Oral Suspension Vismodegib Capsule (Erivedge) Vorapaxar (Zontivity) Votrient Xarelto 10mg, 15mg & 20mg, Starter Pack Xgeva Xyrem

12 Xolair Zohyrdro ER Appendix A Nil per os (NPO) Appendix B Approved Tracheostomy Codes Appendix C Topical Corticosteroids, No PA Required Appendix D Congestive Heart Failure Diagnoses Appendix E Malignant Cancer Diagnoses Appendix F Antineoplastics to Infer Malignant Cancer Appendix G Chronic Obstruction Pulmonary Disease Diagnoses Appendix H Approved Diagnoses for nonpreferred Antiepileptic Agents in Neuropathic Pain Agent Class Appendix I Approved Endoscopy Code Prescribers may request an override for nonpreferred drugs by calling the UAMS College of Pharmacy Evidence-Based Prescription Drug Program Help Desk at (toll-free) or (local.) The Arkansas Medicaid Preferred Drug List may be found at this link. https://arkansas.magellanrx.com/provider/docs/rxinfo/pdl.xlsx For assistance on all other drugs, prescribers may call the Magellan Pharmacy Unit at The appropriate number is indicated with the associated drug. Please refer to the Arkansas Medicaid Pharmacy Webpage at https://arkansas.magellanrx.com/provider/documents for a complete list of drugs. Other claim edits for age, gender, quantity, dose and/or cumulative quantity may apply. https://arkansas.magellanrx.com/provider/docs/rxinfo/claimedits.xls

13 5- HT3 or NK1 Receptor Antagonists (Implemented 09/14/2009) Prescribers may request an override for nonpreferred drugs by calling the UAMS College of Pharmacy Evidence-Based Prescription Drug Program Help Desk at (toll-free) or (local). Preferred agents with criteria Ondansetron HCl 4mg, 8mg tablet (Zofran) Ondansetron 4mg, 8mg oral-disintegrating tablet (Zofran ODT) Ondansetron 4mg/2ml preservative-free vial (Zofran) Ondansetron 40mg/20ml vial (Zofran) Nonpreferred agents Aprepitant (Emend) Dolasetron (Anzemet) Granisetron (Kytril, Sancuso) Netupitant-Palonosetron HCl (Akynzeo) Ondansetron 24mg tablet (Zofran) Ondansetron 32mg/50ml bag (Zofran) Ondansetron 4mg/2ml ampule and syringe (Zofran) Ondansetron 4mg/5ml solution (Zofran) Ondansetron Soluble Film (Zuplenz) Approval criteria for preferred agents with criteria No therapeutic duplication with other 5-HT3 receptor antagonists Additional criteria Quantity limits apply

14 Abiraterone AcetateTablet (Zytiga) (Implemented 12/10/2013) Drugs that require manual review for prior authorization Zytiga Additional criteria Quantity limits apply

15 Acitretin Capsule (Soriatane) (Implemented 03/26/2008) Drugs that require manual review for prior authorization Soriatane

16 Aclidinium Bromide Inhaler (Tudorza Pressair) (Implemented 12/19/2012) Prescribers may request an override for nonpreferred drugs by calling the UAMS College of Pharmacy Evidence-Based Prescription Drug Program Help Desk at (toll-free) or (local). Approval criteria Diagnosis of COPD in Medicaid history in previous 2 years; AND No therapeutic duplication with overlapping days supply between Anoro Ellipta, Spiriva, and/or Tudorza; AND Medicaid recipient is > 18 years of age; AND Denial criteria Lack of approval criteria; OR Diagnosis of asthma in Medicaid history in previous 2 years Additional criteria Quantity edits apply

17 Acyclovir Cream, Ointment (Implemented 03/19/2013) Drugs that do not require prior authorization Docosanol 10% (Abreva) cream Drugs that require manual review for prior authorization Acyclovir (Zovirax) 5% cream Acyclovir (Zovirax) 5% ointment Acyclovir-Hydrocortisone (Xerese) 5%-1% cream Penciclovir (Denavir) 1% cream 5 gram (Implemented 09/23/2014) Additional criteria Quantity edits apply

18 Acyclovir Orally Disintegrating Delayed Release Tablet (Sitavig) (Implemented 09/23/2014) Drugs that require manual review for prior authorization Sitavig

19 Afatinib Dimaleate Tablet (Gilotrif) (Implemented 12/10/2013) Drugs that require manual review for prior authorization Gilotrif Additional criteria Quantity limits apply

20 Afrezza (Regular Human Insulin) Inhaled Insulin (Implemented 07/22/2015) Drug that requires a manual review for prior authorization Afrezza

21 Alagesic Liquid Oral Solution /15ml (Implemented 01/18/2011) Approval criteria NPO (Appendix A) within past 365 days. Age Edit Recipients must be 12 years of age or greater

22 Albuterol Oral Tablets and Syrup (Implemented 03/18/2014) Drugs that require manual review for prior authorization Albuterol 2mg/5ml Syrup Albuterol 4mg ER Vospire 4mg ER Albuterol 8mg ER Vospire 8mg ER Additional criteria Quantity limits apply

23 Allergan Extracts, (short Ragweed Pollen Allergan Extract) and (Timothy Grass Pollen Allergen Extract) (Implemented 09/23/2014) (Updated 07/17/2015) Drugs that require manual review for prior authorization Ragwitek Grastek

24 Ammonul 10%-10%Vial (Updated 05/20/2015) Drugs that require manual review for prior authorization Ammonul 10%-10%

25 Angiotensin II Receptor Antagonists (Implemented 10/01/2008) (Updated 07/20/2015) Prescribers may request an override for nonpreferred drugs by calling the UAMS College of Pharmacy Evidence-Based Prescription Drug Program Help Desk at (toll-free) or (local). Preferred agents with criteria Diovan (Brand only) Irbesartan (Avapro) Irbesartan/HCTZ (Avalide) Losartan potassium (Cozaar) Losartan potassium/hctz (Hyzaar) Olmesartan medoxomil (Benicar) Olmesartan medoxomil/amlodipine besylate (Azor) Olmesartan medoxomil/amlodipine besylate/hctz (Tribenzor) Olmesartan medoxomil/hctz (Benicar HCT) Valsartan/Amlodipine (Exforge)(Brand Only) Valsartan/Amlodipine/HCTZ (Exforge HCT) (Brand Only) Valsartan/HCTZ (Diovan HCT) (Brand Only) Nonpreferred agents Azilsartan medoxomil (Edarbi) Azilsartan medoxomil/chlorthalidone (Edarbyclor) Candesartan cilexetil/hctz (Atacand HCT) Eprosartan mesylate (Teveten) Eprosartan mesylate/hctz (Teveten HCT) Telmisartan (Micardis) Telmisartan/Amlodipine (Twynsta) Telmisartan/HCTZ (Micardis HCT) Valsartan (generic Diovan) Valsartan/Amlodipine (generic Exforge) Valsartan/Amlodipine/HCTZ (generic Exforge HCT) Valsartan/HCTZ (generic Diovan HCT) Approval criteria for preferred agent with criteria New Starts will require a paid claim in history of an ACE-Inhibitor product (ACE- Inhibitor, ACE-Inhibitor/HCTZ, or ACE-Inhibitor/Calcium Channel Blocker) in the previous days OR Continuation of therapy will require at least one paid claim in history of a Preferred with criteria angiotensin receptor blocker or direct renin inhibitor in the

26 past 60 days

27 Nonpreferred agent with criteria Candesartan cilexetil (Atacand) Approval criteria for nonpreferred agent with criteria Candesartan cilexetil (Atacand) Congestive heart failure (Appendix D)

28 Antibiotic Ophthalmic Drops (Implemented 08/21/2009) (toll-free). Approval criteria History of at least two claims for two different products that do not require prior authorization within the previous 30 days Gentamicin 3mg/ml eye drops, Sulfacetamide 10% eye drops, and Tobramycin 0.3% eye drops are available agents that do not require PA but are not included in this approval criteria. ANTIBIOTIC OPHTHALMIC DROPS GENERIC NAME COMMON TRADE NAME* PA STATUS Ciprofloxacin 0.3% eye drops Ciloxan 0.3% eye drops No PA Neomycin-Polymyxin B-Gramicidin eye drops Neosporin eye drops No PA Ofloxacin 0.3% eye drops Ocuflox 0.3% eye drops No PA GENERIC NAME COMMON TRADE NAME* PA STATUS Azithromycin 1% eye drops Azasite 1% eye drops PA Besifloxacin HCl 0.6% eye drops Besivance 0.6% eye drops PA Gatifloxacin 0.5% eye drops Zymaxid 0.5% eye drops PA Levofloxacin 0.5% eye drops Quixin 0.5% eye drops PA Moxifloxacin 0.5% eye drops Moxeza 0.5% eye drops PA Moxifloxacin HCl 0.5% eye drops Vigamox 0.5% eye drops PA *TRADE NAMES ARE FOR REFERENCE ONLY

29 Antibiotic-Steroid Fixed-Dose Combination Opthalmic Drops (Cortisporin, Tobradex ST, Zylet) (Implemented 10/11/2011) (toll-free). Approval criteria History of at least two claims for two different products that do not require prior authorization within the previous 31 days o One claim must have been in the previous days, AND o One claim must have been in the previous 5-13 days. ANTIBIOTIC OPHTHALMIC DROPS GENERIC NAME COMMON TRADE NAME* PA STATUS Gentamicin-Prednisolone eye drops Pred-G 1% eye drops No PA Neomycin-Polymyxin B-Dexamethasone eye drops Maxitrol eye drops No PA Sodium Sulfacetamide-Prednisolone eye drops Blephamide eye drops No PA Sodium Sulfacetamide-Prednisolone eye drops Sulf-Pred % eye drops No PA Tobramycin/Dexamethasone eye drops Tobradex eye drops No PA GENERIC NAME COMMON TRADE NAME* PA STATUS Neomycin-Polymyxin B-Hydrocortisone eye drops Cortisporin eye drops PA Tobramycin-Dexamethasone eye drops Tobradex ST eye drops PA Tobramycin-Loteprednol eye drops Zylet eye drops PA *TRADE NAMES ARE FOR REFERENCE ONLY

30 Antibiotics, Long-acting (Implemented 09/21/2009 and 8/17/2010) Drugs that do not require prior authorization Generic MAC d short-acting antibiotics are available without a prior authorization. Drugs that require manual review for prior authorization Amoxicillin ER 775mg (Moxatag ER) Ciprofloxacin ER 500mg, 1000mg (Cipro XR, Proquin XR) Metronidazole ER 750mg (Flagyl ER) : Clarithromycin XL, Flagyl ER 750 mg : Removal of manual review for Clarithromycin XL : Ciprofloxacin ER, Proquin, Moxatag

31 Second-generation Antidepressants (SGAD) (Implemented 01/01/2010) (Updated 07/20/2015) Prescribers may request an override for nonpreferred drugs by calling the UAMS College of Pharmacy Evidence-Based Prescription Drug Program Help Desk at (toll-free) or (local). Preferred agents with criteria Bupropion HCl regular-release (Wellbutrin) Bupropion HCl extended-release (Wellbutrin XL) Bupropion HCl sustained-release (Wellbutrin SR) Citalopram hydrobromide (Celexa) Escitalopram oxalate (Lexapro) Fluoxetine HCl 10mg, 20mg capsule, and 20mg/5ml solution (Prozac) Fluvoxamine maleate (Luvox) Mirtazapine 15mg, 30mg, 45mg tablet (Remeron) Paroxetine HCl regular-release tablet (Paxil) Sertraline HCl (Zoloft) Venlafaxine HCl extended-release capsule (Effexor ER) Venlafaxine HCl regular-release tablet (Effexor) Nonpreferred agents with SGAD criteria Bupropion hydrobromide extended-release tablet (Aplenzin) Bupropion HCl exended-release tablet (Forfivo XL) Desvenlafaxine extended-release tablet (Khedezla ER) Desvenlafaxine fumarate extended-release tablet Desvenlafaxine succinate extended-release tablet (Pristiq ER) Duloxetine HCl (Cymbalta, Irenka DR) Fluoxetine HCl 10mg, 15mg, 20mg Tablet; 40mg capsule; and 90mg weekly capsule (Prozac) Fluvoxamine maleate extended-release (Luvox CR) Milnacipran HCl (Savella) Mirtazapine 7.5 mg Tablet, and orally disintegrating tablet (Remeron SolTab) Nefazodone HCl (Serzone) Paroxetine HCl controlled-release tablet, and 10mg/5ml suspension (Paxil) Paroxetine mesylate (Pexeva) Vilazodone HCl (Viibryd) Vortioxetine HBr (Brintellix) Venlafaxine HCl extended-release tablet

32 Nonpreferred agents Levomilnacipran HCl extended-release tablet (Fetzima ER) Paroxetine mesylate (Brisdelle) Exempt SGAD combination agents with criteria Fluoxetine HCL/Olanzapine (Symbyax) Approval criteria for preferred or exempt agents Drug daily dose maximum daily dose (Table 1) Approval criteria for preferred or exempt agents resulting from a therapeutic duplication If applicable for a change in therapy or concomitant therapy of two agents and only one or neither are SSRIs and/or SSNRIs (including combinations) (Table 1.2): Drug in history reflects a minimal therapeutic dose (Table 1) for at least four weeks OR If applicable for a change in therapy for two SSRIs and/or SSNRIs (including combinations) (Table 1.2) Drug in history reflects a minimal therapeutic dose (Table 1) for at least four weeks, AND No prior therapeutic duplication for two different SSRIs and/or SSNRIs (including combinations) (Table 1.2) within the past 365 days. Approval criteria for all nonpreferred agents except milnacipran > 90 days of therapy in the previous 120 days for the same drug, strength, and daily dose with the denial exception of a therapeutic duplication between an SSRI and/or SNRI between incoming claim and history Denial criteria for all agents Preferred agents or exempt agents Therapeutic duplication of three agents Therapeutic duplication of two SSRIs and/or SSNRIs (including combinations) (Table 1.2) more than once per 365 days Nonpreferred drugs for patients who do not meet criteria of >90 days of therapy in the previous 120 days for the same drug, strength, and daily dose See Fibromyalgia agents for additional criteria on select second generation antidepressants Link to PDL Memorandum: Second Generation Antidepressants

33 Table 1 Minimum and maximum dose for second-generation antidepressants Drug Minimal daily therapeutic dose Maximum daily dose Bupropion 200mg 450mg Citalopram 20mg 40mg Desvenlafaxine 50mg 100mg Duloxetine 40mg 60mg Escitalopram 10mg 30mg Fluoxetine 20mg 80mg Fluoxetine/olanzapine* 25mg 75mg Fluvoxamine 100mg 300mg Mirtazapine 30mg 60mg Nefazodone 300mg 600mg Paroxetine 30mg 60mg (CR 62.5mg) Sertraline 100mg 200mg Venlafaxine 150mg 375mg * Minimum therapeutic dose and maximum dose based on SSRI component of the combination agent. Table 1.2 Selective Serotonin (norepinephrine) Reuptake Inhibitors (combinations) SSRI, SSNRI or SSRI Combinations Citalopram Desvenlafaxine Duloxetine Escitalopram Fluoxetine Fluoxetine/olanzapine Fluvoxamine Paroxetine Sertraline Venlafaxine

34 Antidiabetic Agents (Implemented 01/01/2009) Prescribers may request an override for nonpreferred drugs by calling the UAMS College of Pharmacy Evidence-Based Prescription Drug Program Help Desk at (toll-free) or (local). Preferred agents Glimepiride (Amaryl) Glipizide (Glucotrol) Glipizide extended-release (Glucotrol XL) Glipizide/Metformin HCl (Metaglip) Glyburide (Diabeta, Glynase Prestab) Glyburide/Metformin HCl (Glucovance) Nateglinide (Starlix) Non-Preferred agents Albiglutide (Tanzeum) Alogliptin benzoate (Nesina) Alogliptin benzoate/metformin HCl (Kazano) Alogliptin benzoate/pioglitazone (Oseni) Canagliflozin (Invokana) Canagliflozin/Metformin (Invokamet) Dapagliflozin (Farxiga) Dapagliflozin/Metformin HCl (Xigduo XR) Dulaglutide (Trulicity) Empagliflozin (Jardiance) Empagliflozin/Linagliptin (Glyxambi) Exenatide (Byetta) Exenatide microspheres (Bydureon) Linagliptin (Tradjenta) Linagliptin/Metformin HCl (Jentadueto) Liraglutide (Victoza) Pioglitazone HCl (Actos) Pioglitazone HCl/Glimepiride (Duetact) Pioglitazone HCl/ Metformin HCl (Actoplus Met) Pramlintide Acetate (Symlin, SymlinPen) Repaglinide (Prandin) Repaglinide/Metformin HCl (Prandimet) Rosiglitazone (Avandia) Rosiglitazone/Glimepiride (Avandaryl) Rosiglitazone/Metformin HCl (Avandamet)

35 Saxagliptin HCl (Onglyza) Saxagliptin HCl/Metformin HCl (Kombiglyze XR) Sitagliptin Phosphate (Januvia) Sitagliptin phosphate/metformin HCl (Janumet) Sitagliptin phosphate/metformin HCl extended-release (Janumet XR) Sitagliptin phosphate/simvastatin (Juvisync)

36 Anti-inflammatory Ophthalmic Drops (Implemented 01/12/2010) Approval criteria History of at least two claims for two different products that do not require prior authorization within the previous 28 days ANTI-INFLAMMATORY OPHTHALMIC DROPS GENERIC NAME COMMON TRADE NAME* PA STATUS Dexamethasone Sodium Phosphate 0.1% eye drops Decadron 0.1% eye drops No PA Diclofenac 0.1% eye drops Voltaren 0.1% eye drops No PA Fluorometholone 0.1% eye drops FML Liquifilm 0.1% eye drops No PA Fluorometholone 0.25% eye drops FML Forte 0.25% eye drops No PA Flurbiprofen 0.03% eye drops Ocufen 0.03% eye drops No PA Ketorolac 0.5% eye drops Acular 0.5% eye drops No PA Ketorolac 0.4% eye drops Acular LS 0.4% eye drops No PA Prednisolone acetate 1% eye drops Pred Forte 1% eye drops No PA Prednisolone acetate 0.12% eye drops Pred Mild 0.12% eye drops No PA Prednisolone sodium 1% eye drops AK-Pred 1% eye drops No PA GENERIC NAME COMMON TRADE NAME* PA STATUS Bromfenac 0.07% eye drops Prolensa 0.07% eye drops PA Bromfenac 0.09% eye drops Bromday 0.09% eye drops PA Dexamethasone 0.1% suspension eye drops Maxidex 0.1% suspension eye drops PA Difluprednate 0.05% eye drops Durezol 0.05% eye drops PA Fluorometholone 0.1% eye drops Flarex 0.1% eye drops PA Ketorolac 0.45% eye drops Acuvail 0.45% eye drops PA Loteprednol 0.2% eye drops Alrex 0.2% eye drops PA

37 Loteprednol 0.5% eye drops Lotemax 0.5% eye drops PA Loteprednol 0.5% eye gel drops Lotemax 0.5% eye gel drops PA Nepafenac 0.1% eye drops Nevanac 0.1% eye drops PA Nepafenac 0.3% eye drops Ilevro 0.3% eye drops PA Rimexolone 1% eye drops Vexol 1% eye drops PA *TRADE NAMES ARE FOR REFERENCE ONLY

38 Nonsteroidal Anti-inflammatory Agents (Implemented 06/18/2007) (Updated 08/14/2015) Prescribers may request an override for nonpreferred drugs by calling the UAMS College of Pharmacy Evidence-Based Prescription Drug Program Help Desk at (toll-free) or (local). Preferred agents Diclofenac sodium ER 100mg tablet (Voltaren XR) Ibuprofen 100mg/5ml suspension; 400mg, 600mg, 800mg tablet (Motrin) Indomethacin 25mg, 50mg capsule (Indocin) Ketoprofen 50mg, 75mg capsule (Orudis) Meloxicam 7.5mg, 15mg tablet (Mobic) Naproxen 250mg, 375mg, 500mg tablet (Naprosyn) Naproxen 375mg, 500mg enteric-coated tablet (EC-Naprosyn) Naproxen sodium 275mg and 550mg tablet (Anaprox) Salsalate 750mg (Salflex-750) Preferred agent with criteria Ketorolac tablet (Toradol) Nonpreferred agents Celecoxib (Celebrex) Diclofenac epolamine (Flector) Diclofenac potassium (Cambia, Cataflam, Zipsor) Diclofenac sodium 25mg, 50mg, and 75 mg tablet (Voltaren) Diclofenac sodium topical (Pennsaid, Voltaren Gel) Diclofenac sodium/misoprostol (Arthrotec) Diclofenac submicronized (Zorvolex) Diflunisal (Dolobid) Dyloject Etodolac (Lodine) Fenoprofen (Nalfon) Flurbiprofen (Ansaid) Ibuprofen 40mg/ml suspension; 50mg,100mg tablet (Motrin) Ibuprofen/caffeine/B1/B2/B6/B12 (IC400, IC800 Kit) Ibuprofen/famotidine (Duexis) Indomethacin 75mg SA Capsule; 50mg suppository; 25mg/5ml suspension (Indocin), 25mg Capsule (Tivorbex), 20mg and 40mg Capsule Tivorbex Ketoprofen 200mg extended-release capsule (Oruvail) Ketorolac nasal spray (Sprix) Meclofenemate sodium (Meclomen) Mefenamic acid (Ponstel) Meloxicam suspension (Mobic)

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