DELAWARE MEDICAL ASSISTANCE PROGRAM (DMAP) PREFERRED DRUG LIST (PDL) Effective: 07/10/2015; Updated: 07/10/2015

Transcription

1 PREFERRED DRUG LIST (PDL) Effective: 07/10/2015; Updated: 07/10/2015 Contents ACNE AGENTS, TOPICAL... 5 ALZHEIMER S AGENTS... 5 ANALGESICS, NARCOTIC LONG... 6 ANALGESICS, NARCOTIC SHORT... 6 ANDROGENIC AGENTS... 6 ANGIOTENSIN MODULATORS... 7 ANGIOTENSIN MODULATORS/CALCIUM CHANNEL BLOCKER COMBINATIONS... 7 ANTIBIOTICS, GI... 7 ANTIBIOTICS, INHALED... 7 ANTIBIOTICS, TOPICAL... 8 ANTIBIOTICS, VAGINAL... 8 ANTICOAGULANTS... 8 ANTICONVULSANTS... 9 ANTIDEPRESSANTS, OTHER... 9 ANTIDEPRESSANTS, SSRIs ANTIEMETICS ANTIFUNGALS, ORAL ANTIFUNGALS, TOPICAL ANTIHISTAMINES, MINIMALLY SEDATING ANTIHYPERTENSIVES, SYMPATHOLYTIC ANTIHYPERURICEMICS ANTIMIGRAINE AGENTS, TRIPTANS ANTIPARASITICS, TOPICAL ANTIPARKINSON S AGENTS ANTIPSORIATIC AGENTS, ORAL ANTIPSORIATIC AGENTS, TOPICAL... 13

2 ANTIPSYCHOTICS ANTIVIRALS, ORAL ANTIVIRALS, TOPICAL ANXIOLYTICS BETA BLOCKERS BILE SALTS BLADDER RELAXANT PREPARATIONS BONE RESORPTION SUPPRESSION AND RELATED AGENTS BPH TREATMENTS BRONCHODILATORS, BETA AGONIST CALCIUM CHANNEL BLOCKERS CEPHALOSPORINS AND RELATED ANTIBIOTICS COPD AGENTS COUGH and COLD COLONY STIMULATING FACTORS CONTRACEPTIVES, ORAL CYTOKINE AND CAM ANTAGONISTS DIABETIC TESTING BLOOD GLUCOSE METERS, TEST STRIPS, LANCETS DIURETICS EPINEPRINE, SELF-INJECTED ERYTHROPOIESIS STIMULATING PROTEINS FLUOROQUINOLONES GLUCOCORTICOIDS, INHALED GLUCOCORTICOIDS, ORAL GROWTH HORMONES H. PYLORI TREATMENTS HAE TREATMENTS HEPATITIS C AGENTS

3 HISTAMINE II RECEPTOR BLOCKERS HYPOGLYCEMICS, ALPHA-GLUCOSIDASE INHIBITORS HYPOGLYCEMICS, INCRETIN MIMETICS/ENHANCERS HYPOGLYCEMICS, INSULINS HYPOGLYCEMICS, MEGLITINIDES HYPOGLYCEMICS, METFORMINS HYPOGLYCEMICS, SGLT2s HYPOGLYCEMICS, TZDs IMMUNOMODULATORS, ATOPIC DERMATITIS IMMUNOMODULATORS, TOPICAL IRON AGENTS, ORAL INTRANASAL RHINITIS AGENTS LEUKOTRIENE RECEPTOR ANTAGONISTS LINCOSAMIDES/OXAZOLIDINONES/STREPTOGRAMINS LIPOTROPICS, OTHER LIPOTROPICS, STATINS MACROLIDES/KETOLIDES MULTIPLE SCLEROSIS NEUROPATHIC PAIN NITROFURAN DERIVATIVES NSAIDs OPHTHALMICS, ALLERGIC CONJUNCTIVITIS OPHTHALMICS, ANTI-INFLAMMATORIES OPHTHALMICS, ANTIBIOTICS OPHTHALMICS, ANTIBIOTIC-STEROID COMBINATIONS OPHTHALMICS, GLAUCOMA AGENTS OPIATE DEPENDENCE TREATMENTS OTIC ANTI-INFECTIVES, ANESTHETICS

4 OTIC FLUOROQUINOLONES PAH AGENTS, ORAL & INHALED PANCREATIC ENZYMES PENICILLINS PHOSPHATE BINDERS PLATELET AGGREGATION INHIBITORS PRENATAL VITAMINS PROGESTATIONAL AGENTS PROTON PUMP INHIBITORS SEDATIVE HYPNOTICS SKELETAL MUSCLE RELAXANTS STEROIDS, TOPICAL STIMULANTS AND RELATED AGENTS TETRACYCLINES THYROID HORMONES ULCERATIVE COLITIS AGENTS VASODILATORS, CORONARY

5 ACNE AGENTS, TOPICAL clindamycin solution erythromycin solution erythromycin/benzoyl peroxide Azelex Benzaclin with Pump Differin cream, lotion Retin-A cream/gel adapalene adapalene gel/pump benzoyl peroxide cleanser, pad, towelette benzoyl peroxide gel clindamycin foam, gel, lotion, swab clindamycin/benzoyl peroxide erythromycin gel, swab sod. sulfacetamide sod. sulfacet ER cleanser sod. sulfacetamide/sulfur sod. sulfacet/sulfur % tretinoin cream/gel tretinoin micro gel 10-1 Acanya Aczone Akne-Mycin APOP Gel NR Atralin AvarPads NR Avar LS NR Benoxyl-CR NR Benoxyldoxy NR Benzaclin Benzepro Clarifoam EF Cleanse & Treat Clinac BPO Clindagel Delos Duac Epiduo Evoclin Fabior 0.1% NR Garimide Inova Klaron NR Neuac NR Nuox Onexton nr Plexion NR Retin-A Micro Retin-A Micro 0.08% NR SE BPO SSS-10 NR Sumadan XLT Kit NR Tazorac Veltin Ziana Class only covered up to 20 years old. Over 20 is considered cosmetic. Medical necessity prior authorization forms available on the web at: cessity.pdf Please note: brand name drugs with a generic available are Preferred status implementation: 1/02/15 ALZHEIMER S AGENTS Clinical criteria apply to class. All agents require a prior authorization. donepezil tablets Exelon patch donepezil ODT* donepezil 23mg galantamine* / ER* rivastigmine capsules* Aricept ODT Exelon solution* Namenda solution* Namenda tablets, dose pack Namenda XR Namzaric nr Prior Authorization forms available on the web at: : ase.inhibitor.pdf Please note: brand name drugs with a generic available are considered nonpreferred unless listed in bold. * class is grandfathered, meaning clients currently receiving medication at implementation date may continue without prior authorization. 5

6 fentanyl transdermal methadone tablets morphine ER tablets tramadol ER Kadian DELAWARE MEDICAL ASSISTANCE PROGRAM (DMAP) ANALGESICS, NARCOTIC LONG Clinical criteria apply to class. All agents require a prior authorization. fentanyl transdermal 37.5mg,62.5mg & 87.5mg hydromorphone ER methadone concentrate, soluble tablet, solution morphine ER (Avinza) NR morphine ER (Kadian) oxycodone ER oxycodone ER (gen. Oxycontin ) oxymorphone ER tramadol ER (gen.conzip) Butrans Duragesic Embeda Hysingla ER nr Nucynta ER Zohydro ER NR Prior Authorization forms available on the web at: Please note: brand name drugs with a generic available are considered nonpreferred unless listed in bold. ANALGESICS, NARCOTIC SHORT butalbital compound /codeine morphine tabs/soln codeine oxycodone IR codeine/apap oxycodone/apap hydrocodone/apap pentazocine/apap hydrocodone/ibuprofen tramadol hydromorphone tablets butorphanol nasal roxicodone tablet carisoprodol / codeine tramadol/apap dihydrocodeine/apap Abstral / caffeine Cocet / Plus fentanyl lozenge Fentora hydromorphone liquid, Fioricet Codeine caps NR suppositories Ibudone levorphanol Magnacet meperidine Nucynta morphine concentrate morphine suppositories oxycodone/asa oxycodone conc. oxycodone/ibuprofen oxymorphone pentazocine/naloxone Onsolis Oxecta Opana Reprexain Rybix ODT Subsys Xartemis XR NR Zamicet Zolvit Zydone Quantity limits in place: oxycodone 15mg maximum of 240 units a year oxycodone 20mg maximum of 120 units a year oxycodone 30 mg maximum of 60 units a year July 2012 implementation of a quantity limit for all short-acting narcotics in addition to the limits noted above: 120 short-acting units per 30 days with a total of 720 shortacting units a year. For patients starting on a new pain medication, DMMA recommends that initial dispensing quantities be limited to a 15 day supply for the first fill. Clinical criteria apply. A clinical prior authorization is required: Androgel packet, pump ANDROGENIC AGENTS Clinical criteria apply to class. All agents require a prior authorization testost (gen Androgel) Androderm testost (gen Fortesta) Axiron testost (gen. Testim) Natesto nr testost (gen.vogelxo) Testim Clinical criteria apply. A clinical prior authorization is required despite the medication s status as preferred or nonpreferred: e.supplementation.pdf 6

7 ANGIOTENSIN MODULATORS benazepril / HCTZ ramipril enalapril / HCTZ Diovan / HCT lisinopril / HCTZ losartan / HCTZ candesartan/hctz NR captopril / HCTZ eprosartan fosinopril / HCTZ irbesartan / HCTZ moexipril / HCTZ quinapril / HCTZ perindopril telmisartan/hctz trandolapril valsartan/hctz Benicar / HCT Edarbi / Edarbyclor Epaned NR Tekturna / HCT Teveten / HCT Dose optimization required when applicable ANGIOTENSIN MODULATORS/CALCIUM CHANNEL BLOCKER COMBINATIONS amlodipine/benazepril Azor Exforge / HCT telmisartan/amlodipine trandolapril / verapamil valsartan/amlodipine valsartan/amlodpipne/hctz Tekamlo / Amturnide Tribenzor Valturna Dose optimization required when applicable ANTIBIOTICS, GI metronidazole tablets neomycin metronidazole capsules paromomycin capsules vancomycin Alinia Dificid Flagyl ER Tindamax Xifaxan ANTIBIOTICS, INHALED Clinical criteria apply. A clinical prior authorization is required despite the medication s status as preferred or nonpreferred. Patients must try and fail lactulose before Xifaxan is for appropriate diagnoses. Bethkis Kitabis Pak Preferred status implementation: 07/01/15 tobramycin inhaled tobramycin inhaled (gen. TOBI) Cayston TOBI TOBI Podhaler 7

8 ANTIBIOTICS, TOPICAL gentamicin mupirocin ointment Altabax Bactroban cream mupirocin cream neomycin / polymyxin / pramoxine ANTIBIOTICS, VAGINAL clindamycin metronidazole Cleocin ovules Cleocin cream Clindesse Metrogel-Vaginal Nuvessa nr Vandazole Please note: brand name drugs with a generic available are ANTICOAGULANTS enoxaparin warfarin Fragmin Pradaxa (step-edit) Xarelto(step-edit) fondaparinux Arixtra Eliquis Innohep Lovenox Savaysa nr Xarelto Dose Pack NR Quantity limits in place on injectable formulations: 10 days allowed without prior authorization Please note: Brand name drugs with a generic available are Step edit on Pradaxa and Xarelto require diagnosis code 8

9 ANTICONVULSANTS phenobarbital phenytoin primidone topiramate topiramate sprinkle valproic acid zonisamide Carbatrol Celontin Depakote Sprinkle Diastat / Acudial Dilantin 50mg chewable carbamazepine clonazepam tablet divalproex IR / ER ethosuximide syrup gabapentin lamotrigine levetiracetam oxcarbazepine tablets Felbatol Tabs Gabitril Peganone Tegretol Susp. Tegretol XR Trileptal susp carbamazepine ER carbamazepine susp. carbamazepine XR clonazepam ODT diazepam /device (rectal) divalproex sprinkle ethosuximide caps felbamate lamotrigine ER lamotrigine ODT levetiracetam ER oxcarbazepine suspension phenytoin chew tabs tiagabine tablets topiramate ER (gen. Qudexy XR) Aptiom NR Banzel Dilantin 30 mg cap Dilantin Susp. Equetro Fanatrex Felbatol Suspension Fycompa Gralise Lamictal ODT Lyrica Onfi Oxtellar XR Phenytek Potiga Sabril Stavzor Trokendi XR Vimpat Vimpat Dose Pack NR Quantity limits in place: 240 Adjunctive anticonvulsants per 30 days. Greater quantities require prior authorization. Brand name narrow therapeutic drugs automatically pay for seizure clients with seizure diagnosis in medical history Please note: brand name drugs with a generic available are Clinical criteria will still apply: Prior Authorization forms available on the web at: Lyrica.pdf ANTIDEPRESSANTS, OTHER bupropion IR bupropion SR bupropion XL mirtazapine tab trazodone venlafaxine venlafaxine ER caps Marplan Parnate Desvenlafaxine ER NR * desvenlafaxine fumarate ER* mirtazapine ODT* nefazodone* phenelzine* tranylcypromine* venlafaxine ER tablets* Aplenzin* Brintellix* Emsam* Fetzima* Forfivo XL* Oleptro* Viibryd* DMAP requires prior authorization for the following products for the pediatric patient under six (6) years of age. Prior authorization forms available on the web at: Please note: Brand name drugs with a generic available are * (grandfathered) clients currently receiving medication at implementation date may continue without prior authorization. 9

10 ANTIDEPRESSANTS, SSRIs citalopram escitalopram tablet fluoxetine capsules fluvoxamine paroxetine tablets sertraline escitalopram solution* Brisdelle* fluoxetine tablets* Pexeva* fluoxetine 60mg* fluoxetine weekly* fluvoxamine ER nr * paroxetine CR* paroxetine suspension* ANTIEMETICS DMAP requires prior authorization for the following products for the pediatric patient under six (6) years of age. Prior authorization forms available on the web at: Liquid medications require prior authorization for clients over 10 years old. Please note: brand name drugs with a generic available are * (grandfathered) clients currently receiving medication at implementation date may continue without prior authorization. ondansetron ODT ondansetron tablets dronabinol granisetron ondansetron solution Akynzeo NR Anzemet Cesamet Diclegis DR NR Emend Marinol Sancuso Zuplenz ANTIFUNGALS, ORAL Clinical criteria will still apply: indicates that a clinical prior authorization is required despite the medication s status as preferred or non-preferred available at: fluconazole griseofulvin ultramicrosized griseofulvin suspension ketoconazole nystatin terbinafine clotrimazole flucytosine itraconazole tinidazole voriconazole Cresemba nr Grifulvin V Gris-Peg Lamisil granules Noxafil Onmel Sporanox solution Terbinex Vfend 10

11 ANTIFUNGALS, TOPICAL ciclopirox solution clotrimazole ketoconazole cream, shampoo nystatin nystatin/triamcinolone ciclopirox suspension clotrimazole/betameth. econazole ketoconazole foam miconazole naftifine Bensal HP CNL-8 Ciclodan kit Ecoza NR Ertaczo Exelderm Extina Jublia NR Kerydin Soln. NR Ketodan NR Lamisil solution Luzu NR Mentax Oxistat Pediaderm AF Pedipirox-4 Vusion ANTIHISTAMINES, MINIMALLY SEDATING cetirizine solution OTC / Rx cetirizine tablets OTC loratadine tablets OTC, ODT, solution cetirizine chewable cetirizine-d OTC desloratadine desloratadine ODT fexofenadine OTC fexofenadine / fexofenadine-d levocetirizine syrup, tablets loratadine-d OTC Allegra / Allegra-D Clarinex-D Claritin OTC Semprex-D ANTIHYPERTENSIVES, SYMPATHOLYTIC clonidine guanfacine methyldopa / HCTZ Catapres-TTS clonidine transdermal reserpine Please note: Brand name drugs with a generic available are 11

12 ANTIHYPERURICEMICS allopurinol probenecid probenecid with colchicine Colcrys colchicine capsules colchicine tablets Mitigare NR Uloric Zyloprim Colcrys preferred for treatment, not prophylaxis. Quantity limit of 15 tablets per 90 days in place. ANTIMIGRAINE AGENTS, TRIPTANS sumatriptan oral Imitrex nasal Relpax rizatriptan rizatriptan ODT naratriptan sumatriptan nasal, injection zolmitriptan/odt Axert Cambia Frova Imitrex Kit, vial Sumavel Dosepro Treximet Zomig nasal ANTIPARASITICS, TOPICAL Quantity limits in place: Nine (9) tablets per 45 days Please note: Brand name drugs with a generic available are permethrin (Rx and OTC) Natroba Sklice Ulesfia lindane malathion Eurax Lycelle Ovace plus Lotion NR Ovide Spinosad Please note: brand name drugs with a generic available are ANTIPARKINSON S AGENTS benztropine carbidopa/levodopa pramipexole ropinirole selegiline tablets trihexyphenidyl Bromocriptine carbidopa carbidopa/levodopa/ entacapone entacapone levodopa/carb ODT pramipexole ER ropinirole XL selegiline capsules tolcapone Azilect Duopa nr Neupro NR Requip XL Rytary nr Stalevo Zelapar Please note: brand name drugs with a generic available are 12

13 ANTIPSORIATIC AGENTS, ORAL Soriatane acitretin methoxsalen rapid 8-MOP Oxsoralen-Ultra Please note: Brand name drugs with a generic available are considered nonpreferred unless listed in bold ANTIPSORIATIC AGENTS, TOPICAL calcipotriene cream calcipotriene solution calcipotrieneointment calcipotriene/betamethasone dipropionate ointment calcitriol ointment Dovonex cream Sorilux Taclonex scalp Vectical ANTIPSYCHOTICS Please note: Brand name drugs with a generic available are considered nonpreferred unless listed in bold amitriptyline / perphenazine chlorpromazine clozapine fluphenazine / decanoate Geodon IM haloperidol / decanoate loxapine olanzapine / IM perphenazine quetiapine risperidone solution, tablets thioridazine thiothixene trifluoperazine ziprasidone Abilify tab (stepedit) Latuda (step-edit) Moban Orap Risperdal Consta Seroquel XR (stepedit) aripiprazole tablets clozapine ODT* haloperidol lactate INJ olanzapine ODT* olanzapine / fluoxetine* risperidone ODT* Abilify Discmelt Abilify IM Abilify Maintena Adasuve Fanapt* Fazaclo* Geodon caps Haldol INJ Invega Invega Sustenna* Invega Trina nr Saphris * Seroquel XR Kit nr Versacloz Zyprexa Relprevv DMAP requires prior authorization for the following products for the pediatric patient under six: All long acting injectable antipsychotics require prior authorization, forms are available at the following link: e.injection.pdf Please note: Brand name drugs with a generic available are considered nonpreferred unless listed in bold * (grandfathered) clients currently receiving medication at implementation date may continue without prior authorization. Abilify, Latuda, Seroquel XR new starts will pay electronically if a client has tried and failed a generic atypical antipsychotic first. - indicates oral therapy is required before injectable will be 13

14 ANTIVIRALS, ORAL acyclovir amantadine capsules famciclovir rimantadine valacyclovir Relenza Tamiflu amantadine tablets Famvir nr Sitavig nr Liquid medications require prior authorization for clients over 10 years old Quantity limits in place for Tamiflu and Relenza Please note: Brand name drugs with a generic available are considered nonpreferred unless listed in bold indicates that manufacturer does not participate in all DMMA ANTIVIRALS, TOPICAL Abreva OTC Denavir alprazolam tablets buspirone chlordiazepoxide clorazepate diazepam solution diazepam tablets lorazepam acyclovir ointment Xerese Zovirax cream, ointment alprazolam ER alprazolam Intensol alprazolam ODT diazepam intensol lorazepam Intensol meprobamate oxazepam ANXIOLYTICS Ativan tablet Niravam Tranxene T-tablet Valium tablet Xanax tablet Xanax XR BETA BLOCKERS Quantity Limits of 120 units of benzodiazepines per 30 days. Clinical criteria will still apply: indicates that a clinical prior authorization is required despite the medication s status as preferred or non-preferred available at: atenolol / chlorthalidone bisoprolol / HCTZ carvedilol Labetalol metoprolol XL propranolol/hctz propranolol ER sotalol acebutolol betaxolol metoprolol / HCTZ nadolol nadolol/bendroflu pindolol timolol Bystolic Coreg CR Dutoprol Hemangeol NR Inderal XL NR Innopran XL Levatol Sotylize nr Toprol XL 14

15 BILE SALTS ursodiol 300mg capsule ursodiol tablets Actigall Chenodal Cholbam nr Urso/Urso Forte BLADDER RELAXANT PREPARATIONS oxybutynin IR oxybutynin ER Toviaz Vesicare tolterodine tolterodine ER trospium trospium ER Detrol LA Enablex Gelnique Myrbetriq Oxytrol Oxytrol for Women OTC NR BONE RESORPTION SUPPRESSION AND RELATED AGENTS alendronate tablets calcitonin-salmon alendronate solution etidronate Ibandronate risedronate raloxifene Atelvia Binosto Boniva Didronel Forteo Fortical Fosamax Plus D Miacalcin Prolia BPH TREATMENTS Please note: brand name drugs with a generic available are Clinical criteria will still apply: indicates that a clinical prior authorization is required despite the medication s status as preferred or non-preferred available at: alfuzosin terazosin doxazosin finasteride tamsulosin Avodart Cardura XL Jalyn Rapaflo Uroxatral 15

16 BRONCHODILATORS, BETA AGONIST albuterol tablets albuterol nebulizer terbutaline ProAir HFA Proventil HFA Foradil (ICD-9 code for COPD indication may create a systemgenerated approval ) Serevent (ICD-9 code for COPD indication may create a systemgenerated approval ) albuterol ER levalbuterol nebulizer metaproteranol Arcapta Brovana Maxair Perforomist ProAir Respiclick nr Striverdi Respimat Ventolin HFA Xopenex HFA Xopenex nebulizer Submit ICD-9 code for COPD on prescriptions for Foradil and Serevent for COPD clients. Drugs contraindicated in asthma. CALCIUM CHANNEL BLOCKERS amlodipine diltiazem nicardipine nifedipine IR / ER verapamil diltiazem LA felodipine isradipine nimodipine (ICD-9 code for SAH indication may create a systemgenerated approval ) nisoldipine verapamil ER PM Cardene SR Dynacirc CR Matzim LA Nymalize NR Requires dose optimization when applicable programs CEPHALOSPORINS AND RELATED ANTIBIOTICS amoxicillin/clav tabs amoxicillin/clav susp cefaclor capsules cefadroxil capsules, tablets cefdinir cefprozil susp cefprozil tabs cefuroxime cephalexin caps Suprax susp. amoxicillin/clavulanate XR cefaclor tablets cefadroxil suspension cefditoren cefixime suspension cefpodoxime ceftibuten tablets/suspension cephalexin tablets Augmentin 125, 250 susp Ceftin suspension Suprax tablets Suprax Chew tablets 16

17 COPD AGENTS albuterol/ipratropium nebulizer ipratropium nebulizer Combivent Respimat Spiriva Anoro Ellipta Atrovent HFA Combivent Daliresp Incruse Ellipta nr Spiriva Respimat nr Stiolto Respimat nr Tudorza Clinical criteria will apply COUGH and COLD guaifenesin liquid OTC guaifenesin DM liquid OTC guaifenesin tablet 600 mg OTC guaifenesin/codeine syrup guaifenesin/codeine syrup OTC hydrocodone/chlorpheniramine susp hydrocodone/homatropine syrup nasal decongestant OTC promethazine DM syrup promethazine/codeine syrup Bromfed DM syrup Mucinex ER tablet OTC All other cough/cold products non-preferred COLONY STIMULATING FACTORS Quantity limits are still in place: 240ml of narcotic cough suppressants per 30 days and 480ml per 90 days without a comorbid diagnosis. 120ml per 84 days and 900ml/year for Tussionex Neupogen Granix NR Leukine Neulasta Zarxio nr 17

18 CONTRACEPTIVES, ORAL Brevicon Desogen Loseasonique Mircette Nor-Q-D Ortho Tri-Cyclen Lo Seasonique Tri-Norinyl Yasmin Yaz All other oral contraceptives are non-preferred All emergency oral contraceptives are covered without any prior authorization. * Class is grandfathered, meaning clients currently receiving medication at implementation date may continue without prior authorization. CYTOKINE AND CAM ANTAGONISTS Enbrel (diagnosis code required) Humira(diagnosis code required) Actemra Actemra Syringe Amevive Arcalyst Cimzia Cosentyx Pen/Syringe nr Entyvio Ilaris Kineret Orencia Otezla Remicade Simponi Simponi Aria Stelara Xeljanz Approved diagnosis code required on prescription and electronic submissions. DIABETIC TESTING BLOOD GLUCOSE METERS, TEST STRIPS, LANCETS Preferred Status implementation 1/1/15 FreeStyle Freedom Lite meter FreeStyle Lite meter FreeStyle Lite test strips Freestyle InsuLinx Meter Freestyle InsuLinx Strips FreeStyle test strips FreeStyle lancets Precision Xtra Meter Precision Xtra Test Strips Precision Xtra Ketone Strips All other diabetic meters and test strips are non-preferred 18

19 DIURETICS amiloride HCTZ bumetanide chlorothiazide furosemide hydrochlorothiazide indapamide spironolactone spirololactone HCTZ triamterene HCTZ All other diuretics are non-preferred EPINEPRINE, SELF-INJECTED EpiPen EpiPen Jr. epinephrine injection Auvi-Q ERYTHROPOIESIS STIMULATING PROTEINS Clinical criteria apply to class. All agents require a prior authorization. Procrit Aranesp Epogen Mircera NR Prior authorization forms available on the web at : ha.pdf FLUOROQUINOLONES ciprofloxacin tablets levofloxacin tablets ciprofloxacin ER Factive ciprofloxacin suspension levofloxacin solution moxifloxacin ofloxacin 19

20 GLUCOCORTICOIDS, INHALED Advair (step-edit) Asmanex Flovent / HFA QVAR Pulmicort Flexhaler Pulmicort Respules 0.25 mg & 0.5 mg (age 6 and under or clients with diagnoses on file indicating developmental delays may create a system generated approval) Symbicort (step-edit) budesonide respules 0.25 mg & 0.5 mg Advair HFA Aerospan Alvesco Asmanex HFA nr Arnuity Ellpita nr Breo Ellipta Dulera Pulmicort Respules 1 mg GLUCOCORTICOIDS, ORAL Clinical criteria will still apply age 6 and under or clients with diagnoses on file indicating developmental delays may create a system generated approval for budesonide respules indicates that a prior authorization will generate if client has previously failed single agent corticosteroid or long-acting beta agonist inhaler in previous 90 days. Other information and form available on the web at: dexamethasone solution / tablet Entocort EC hydrocortisone Orapred ODT methylprednisolone dose pack methylprednisolone 4mg tablets prednisolone sodium phosphate prednisolone solution prednisone solution / tablets All other oral glucocorticoids are non-preferred Norditropin Nutropin / AQ GROWTH HORMONES Clinical criteria apply to class. All agents require a prior authorization. Genotropin Humatrope Omnitrope Saizen Serostim Tev-Tropin Zorbtive H. PYLORI TREATMENTS Prior authorization available at: mone.drug.pdf programs Pylera lansporazole-amoxicillin-clarithromycin Omeclamox Pak 20

21 Kalbitor DELAWARE MEDICAL ASSISTANCE PROGRAM (DMAP) HAE TREATMENTS Clinical criteria apply to class. All agents require a prior authorization. Berinert Cinryze Firazyr Ruconest NR HEPATITIS C AGENTS Preferred status implementation: 1/1/15 ribavirin capsules, tablets Harvoni Pegasys Peg-Intron / Redipen Viekira Incivek Infergen Olysio Ribapak Ribasphere Sovaldi Victrelis Clinical criteria will still apply. Prior authorization available at: Prior.Authorization.Form.pdf HISTAMINE II RECEPTOR BLOCKERS famotidine tablets ranitidine syrup / tablets All other histamine II agents are non-preferred HYPOGLYCEMICS, ALPHA-GLUCOSIDASE INHIBITORS acarbose Glyset Precose 21

22 Bydureon(step-edit) Bydureon Pens (step-edit) Byetta (step-edit) Jentadueto (step-edit) Kombiglyze XR (step-edit) Onglyza (step-edit) Tanzeum (step-edit) Tradjenta (step-edit) DELAWARE MEDICAL ASSISTANCE PROGRAM (DMAP) HYPOGLYCEMICS, INCRETIN MIMETICS/ENHANCERS Clinical criteria apply to class. All agents require a prior authorization. Kazano Janumet / XR Januvia Juvisync Nesina Oseni Symlin * Trulicity NR Victoza Step-edit : For preferred products, no PA required if client has Type II diagnosis and metformin use in last 90 days. Clinical criteria apply for non-preferred products. Forms available at: * (grandfathered) clients currently receiving medication at implementation date may continue without prior authorization. HYPOGLYCEMICS, INSULINS Humulin pens, vials Humalog cartridges, pens, vials Humalog Mix pens, vials Lantus pens, vials Levemir pens, vials Novolin pens, vials Novolog pens, vials Novolog Mix pens, vials Afrezza nr Apidra pens, vials Toujeo Solostar nr - Levemir will produce an electronic PA for pregnant clients with an appropriate diagnosis code. HYPOGLYCEMICS, MEGLITINIDES nateglinide repaglinide Prandin Prandimet HYPOGLYCEMICS, METFORMINS glipizide-metformin glyburide-metformin metformin metformin ER (gen Glucophage XR) metformin ER (gen Fortamet) Glucophage Glucophage XR Glucovance Glumetza Riomet 22

23 HYPOGLYCEMICS, SGLT2s Invokana (step-edit) Farxiga Invokamet Jardiance Xigduo XR HYPOGLYCEMICS, TZDs Step-edit : For preferred products, no PA required if client has Type II diagnosis and metformin use in last 90 days. pioglitazone Actoplus Met XR Avandamet Avandia Avandaryl pioglitazone/glimep pioglitaz/metformin IMMUNOMODULATORS, ATOPIC DERMATITIS Clinical criteria apply to class. All agents require a prior authorization. Elidel tacrolimus Clinical criteria will still apply. Prior authorizations available at: ecrolimus.and.tacrolimus.pdf Quantity limits are in place: 400 grams per year IMMUNOMODULATORS, TOPICAL imiquimod Aldara Zyclara Please note: brand name drugs with a generic available are 23

24 IRON AGENTS, ORAL ferrous gluconate OTC ferrous sulfate OTC ferrous sulfate solution OTC iron 45mg tablet OTC iron polysaccharides complex OTC iron PS cmplx/vit B12/FA Fe C OTC Ferate OTC Feragon Slow Release Iron All other oral iron products are non-preferred INTRANASAL RHINITIS AGENTS fluticasone ipratropium Astepro Patanase Veramyst (patients 2 to 4 years of age only) azelastine azelastine HCl budesonide flunisolide olopatadine triamcinolone Beconase AQ Dymista Flonase Nasal OTC nr Nasacort OTC Nasonex Omnaris Qnasl Zetonna Please note: brand name drugs with a generic available are montelukast tablet, chew tabs Accolate clindamycin capsules clindamycin solution (preferred for client younger than 10) LEUKOTRIENE RECEPTOR ANTAGONISTS montelukast granules zafirlukast Singulair Gran Pack Zyflo CR LINCOSAMIDES/OXAZOLIDINONES/STREPTOGRAMINS All other agents are non-preferred Please note: brand name drugs with a generic available are Clinical criteria apply. ICD-9 code for asthma indication may create a system-generated approval for montelukast or Accolate Prior authorizations available at: kotriene.pdf 24

25 LIPOTROPICS, OTHER colestipol cholestyramine/aspartame gemfibrozil Niaspan Tricor Trilipix cholestyramine/sucrose fenofibrate fenofibrate (gen Lipofen) fenofibric acid fenofibric acid 45mg & 135mg (gen Trilipix) niacin ER omega-3 acid ethyl esters Antara Fibricor Juxtapid Kynamro Niacor Triglide Vascepa Welchol Zetia LIPOTROPICS, STATINS atorvastatin lovastatin pravastatin simvastatin amlodipine/atorvastatin fluvastatin Advicor Altoprev Crestor Lescol / XL Liptruzet Livalo Simcor Vytorin Once daily dosing required Please note: brand name drugs with a generic available are MACROLIDES/KETOLIDES azithromycin clarithromycin tabs E.E.S. 200 suspension (preferred for client younger than 6) Erythrocin clarithromycin suspension clarithromycin ER erythromycin E.E.S. 400 tablets Eryped 200, 400 suspension Ery-Tab PCE Ketek Zmax 25

26 MULTIPLE SCLEROSIS Preferred status implementation: 7/01/14 Avonex Betaseron Copaxone 20mg Gilenya (electronic step-edit) Rebif Rebif Rebidose Ampyra Aubagio Copaxone 40mg Extavia Lemtrada NR Plegridy NR Tecfidera Capsules Gilenya has an electronic step edit through a preferred injectable. If client has tried and failed preferred injectable, PA will generate electronically for Gilenya Ampyra has a clinical prior authorization that is required despite the medication s status as preferred or non-preferred. Forms available on the web at: NEUROPATHIC PAIN duloxetine gabapentin Lidoderm duloxetine DR (gen. Irenka) lidocaine 5% patch Cymbalta Gralise Horizant Irenka nr Lyrica Neurontin Qutenza Savella Lidoderm (greater than 2 patches a day requires prior auth) opical.patch.pdf Liquid medications require prior authorization for clients over 10 years old Please note: brand name drugs with a generic available are Preferred status implementation: 07/01/15 nitrofurantoin macrocrystals capsules nitrofurantoin mono-macro capsules nitrofurantoin suspension NITROFURAN DERIVATIVES Furadantin suspension Macrobid Macrodantin capsules 26

27 NSAIDs flurbiprofen ibuprofen indomethacin ketorolac meloxicam tablets naproxen tablets sulindac celecoxib diclofenac diclofenac/misoprostol diclofenac solution diflunisal etodolac etodolac SR fenoprofen indomethacin ER ketoprofen meclofenamate mefenamic acid meloxicam suspension nabumetone naproxen CR naproxen EC naproxen suspension oxaprozin piroxicam tolmetin Flector Indocin Pennsaid Pump Sprix Tivorbex nr Vimovo Voltaren gel Zipsor Zorvolex indicates that a clinical prior authorization is required despite the medication s status as preferred or non-preferred. Forms available on the web at: 2.Celecoxib.valdecoxib.pdf OPHTHALMICS, ALLERGIC CONJUNCTIVITIS cromolyn Alrex Pataday azelastine epinastine Alamast Alocril Alomide Bepreve Emadine Lastacaft Patanol Pazeo nr OPHTHALMICS, ANTI-INFLAMMATORIES dexamethasone diclofenac fluorometholone flurbiprofen prednisolone acetate Flarex FML Forte FML S.O.P. Lotemax Maxidex Pred Mild bromfenac ketorolac / LS prednisolone sod phosphate Acuvail Bromday Durezol FML Ilevro Lotemax Gel Nevanac Ozurdex Prolensa Retisert Triesence Vexol 27

28 OPHTHALMICS, ANTIBIOTICS bacitracin/polymyxin ciprofloxacin erythromycin gentamicin ofloxacin polymyxin/trimethopm sulfacetamide tobramycin Moxeza Terramycin /polymyxin Tobrex ointment Vigamox bacitracin gatifloxacin levofloxacin neomycin / bac / polymyxin neomycin/polymyxin/gramicidin Azasite Besivance Ciloxan Garamycin Iquix Natacyn Zymar OPHTHALMICS, ANTIBIOTIC-STEROID COMBINATIONS neomycin/polymyxin/ dexamethasone sulfacetamide/ prednisolone Blephamide / S.O.P. Pred-G ointment, drops Tobradex suspension neomycin/polymyxin/hc neomycin/bacitracin/ polymyxin/hc tobramycin/dexamethasone suspension Tobradex ointment Tobradex ST Zylet Please note: Brand name drugs with a generic available are OPHTHALMICS, GLAUCOMA AGENTS Preferred status implementation: 01/01/15 brimonidine carteolol dorzolamide dorzolamide / timolol latanoprost levobunolol metipranolol pilocarpine timolol Alphagan P 0.15% Azopt Betimol Betoptic S Combigan Istalol Simbrinza Travatan / Z apraclonidine betaxolol bitamoprost brimonidine P phospholine iodide travaprost Cosopt PF Rescula Zioptan Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. Please note: Brand name drugs with a generic available are For prior authorization forms, please visit: 28

29 Buprenorphine naloxone syringe, vial naltrexone Suboxone film Vivitrol DELAWARE MEDICAL ASSISTANCE PROGRAM (DMAP) OPIATE DEPENDENCE TREATMENTS Clinical criteria apply to class. All agents require a prior authorization. buprenorphine/naloxone tablets Bunavail NR Suboxone tablets Zubsolv OTIC ANTI-INFECTIVES, ANESTHETICS For prior authorization forms, please visit: ine.pdf acetic acid / aluminum antipyrine / benzocaine acetic acid acetic acid / antipyrine / benzocaine / aluminum Aurax Myoxin Neotic Otic Care Otozin Pinnacaine PR Otic Solution Pramotic Treagan Otic Trioxin Zinotic / ES OTIC FLUOROQUINOLONES neomycyin / polymyxin / hydrocortisone ofloxacin otic Ciprodex ciprofloxacin Cetraxal Cipro HC Coly-Mycin S Cortisporin-TC PAH AGENTS, ORAL & INHALED Clinical criteria apply to class. All agents require a prior authorization. sildenafil Letairis Tracleer Ventavis Adcirca Adempas nr Opsumit nr Orenitram ER nr Revatio Suspension nr Tyvaso Clinical criteria will still apply. For prior authorization forms, please visit: df 29

30 PANCREATIC ENZYMES pancrelipase Creon Zenpep Pancreaze Pertzye Viokace Ultressa PENICILLINS amoxicillin ampicillin caps, susp dicloxacillin penicillin G procaine penicillin V potassium suspension, tablet Bicillin CR Bicillin LA All other agents are non-preferred PHOSPHATE BINDERS calcium acetate tablets Phoslyra Renagel Renvela tablet calcium acetate capsules sevelamer carbonate Auryxia Eliphos Fosrenol Magnebind 400 Rx Renvela Powder Pack Velphoro NR Clinical criteria will still apply: indicates that a prior authorization is required despite the medication s status as preferred or non-preferred. Forms available: at: us.binders.pdf PLATELET AGGREGATION INHIBITORS clopidogrel dipyridamole Aggrenox Brilinta (step-edit) ticlopidine Effient Zontivity NR Step edit on Brilinta require diagnosis code 30

31 PRENATAL VITAMINS Citranatal 90 DHA Citranatal Assure Citranatal Harmony PNV with Ca, No.71/iron/fa PNV with Ca, No.72/iron/fa Prenatabs FA Prenatal 19 chewable Prenatal Vit 15/iron cb/fa/dss Prenatal vita 18/iron cb/fa/dss Prenatal Vit27& calcium/iron/fa Prenatal vit/fe fumarate/fa otc Se-Natal 19 tab Se-Natal 19 tab chewable Vinate GT Vinate-M Vol-Tab All other prenatal products non-preferred medroxyprogesterone acetate norethindrone acetate progesterone capsule Makena PROGESTATIONAL AGENTS Aygestin Crinone Depo-Provera 400mg/ml INJ Progesterone IM Prometrium Provera Clinical criteria will still apply: indicates that a clinical prior authorization is required despite the medication s status as preferred or non-preferred. Prior Authorization forms available on the web at: ap.makena.pdf Please note: Brand name drugs with a generic available are PROTON PUMP INHIBITORS omeprazole Rx pantoprazole Nexium suspension (preferred for age 10 and under) Protonix suspension (preferred for age 10 and under) esomeprazole magnesium esomeprazole strontium lansoprazole omeprazole OTC tablets omeprazole / sodium bicarbonate (Rx / OTC) omeprazole suspension omeprazole magnesium OTC rabeprazole tablets Aciphex Dexilant Nexium Nexium OTC NR Prevacid Solutab Prilosec packets Zegerid OTC For non-preferred products, max of 60 days approval for GERD Clinical criteria will still apply: indicates that a clinical prior authorization is required despite the medication s status as preferred or non-preferred. Prior Authorization forms available on the web at: 31

32 SEDATIVE HYPNOTICS temazepam 15mg, 30mg zolpidem chloral hydrate eszopiclone estazolam flurazepam temazepam 7.5,22.5mg triazolam zaleplon zolpidem ER Belsomra nr Doral Edluar Hetlioz Intermezzo Rozerem* Silenor Zolpimist Dose optimization when applicable: total quantity limit of one daily covered. * (grandfathered) clients currently receiving medication at implementation date may continue without prior authorization. SKELETAL MUSCLE RELAXANTS baclofen chlorzoxazone cyclobenzaprine methocarbamol tizanidine tablets carisoprodol / compound cyclobenzaprine 7.5 mg cyclobenzaprine ER dantrolene metaxolone orphenadrine / compound tizanidine capsules Fexmid Lorzone Soma Total quantity limit of 120 units of muscle relaxants per 30 rolling days. Clinical criteria will still apply: indicates that a clinical prior authorization is required. Prior Authorization forms available on the web at: ol.pdf 32

33 STEROIDS, TOPICAL betamethasone dipropionate cream, lotion betamethasone diprop/prop gly cream betamethasone valerate cream fluocinonide emollient cream hydrocortisone cream, ointment hydrocortisone butyrate hydrocortisone valerate mometasone furoate triamcinolone acetonide cream, ointment Apexicon E Capex shampoo alclometasone dipropionate Aqua Glycolic amcinonide HC betamethasone, other Clobex formulations Clodan Kit NR clobetasol Cordran clocortolone pivalate cream Cutivate desonide Dermadesoximetasone Smoothe-FS diflorasone diacetate Dermasorb TA fluocinonide cream Dermatop fluocinolone oil Desonate fluocinonide, other formulations Desonil Plus fluocinolone Desowen fluticasone propionate Halac halobetasol prop cr/oi Halog hydrocortisone, other Halonate formulations Kenalog prednicarbate cream/ointment Luxiq triamcinolone acetonide aerosol triamcinolone acetonide lotion Momexin Olux -E Pandel Pediaderm HC / TA Synalar Texacort Topicort Trianex Oi. Ultravate/ X Vanos Verdeso STIMULANTS AND RELATED AGENTS Preferred status implementation: 7/10/15 amphetamine salt combo dexmethylphenidate dextroamphetamine guanfacine ER methylphenidate / ER tablets methylphenidate ER (Concerta generic) Adderall XR (stepedit) Focalin / XR Metadate CD Provigil Strattera Vyvanse amphetamine salt combo ER clonidine ER dexmethylphenidate AG dexmethylphenidate ER dexmethylphenidate XR dextroamphetamine ER dextroamphetamine-amphetamine ER dextroamphetamine sulfate 5mg/5ml methamphetamine methylphenidate CD methylphenidate chew tablets methylphenidate ER cap (ritalin LA generic)* methylphenidate solution * Aptensio XR nr Concerta Daytrana Dexedrine Tabs NR Evekeo nr Intuniv Kapvay * Methylin Chew, Soln Nuvigil* Procentra Quillivant XR Ritalin LA * Zenzedi Dose optimization required. -Indicates that clinical criteria applies for all ages for drugs Clinical criteria applies for clients over age Therapy.pdf Adult clients will no longer be grandfathered. Adderall XR new starts will pay electronically if the client has tried and failed Vyvanse first. Please note: Brand name drugs with a generic available are For Prior Authorization forms, please visit: 33

34 TETRACYCLINES doxycycline hyclate doxycycline monohydrate 50, 100mg capsules doxycycline monohydrate tablets minocycline capsules tetracycline demeclocycline doxycycline hyclate DR doxycycline monohydrate (other strengths) minocycline ER minocycline tablets Acticlate NR Adoxa CK / TT Doryx Morgidox kit Oracea Solodyn Vibramycin levothyroxine sodium tablets liothyronine sodium tablets thyroid, pork tablets Cytomel THYROID HORMONES levothyroxine sodium injection liothyronine sodium injection Synthroid tablets Thyrolar Tirosint * class is grandfathered, meaning clients currently receiving medication at implementation date may continue without prior authorization. ULCERATIVE COLITIS AGENTS mesalamine rectal sulfasalazine Apriso Asacol Canasa balsalazide Uceris Asacol HD Delzicol DR Dipentum Giazo NR Lialda Pentasa sfrowasa Uceris Foam nr 34

35 VASODILATORS, CORONARY isosorbide dinitrate isosorbide mononitrate isosorbide mononitrate SR nitroglycerin transdermal Nitrostat sublingual Isosorbide dinitrate ER isosorbide dinitrate sublingual nitroglycerin ER nitroglycerin translingual Dilatrate SR Imdur Isordil Nitro-Bid ointment Nitro-Bid patch Nitrolingual spray Nitromist ***Be advised this criterion is for FEE-FOR-SERVICE CLIENTS ONLY. Prior authorizations for clients enrolled with a Managed Care Organization (MCO) should be processed through the MCO following MCO criteria. HighMark Health Options criteria can be reviewed at UnitedHealthcare Community Plan criteria can be reviewed at 35