DELAWARE MEDICAL ASSISTANCE PROGRAM (DMAP) PREFERRED DRUG LIST (PDL) Effective: 01/02/2015; Updated: 12/19/2014

Transcription

1 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 ANTIPSYCHOTICS ANTIVIRALS, ORAL ANTIVIRALS, TOPICAL ANXIOLYTICS... 14

2 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 HISTAMINE II RECEPTOR BLOCKERS HIV / AIDS HYPOGLYCEMICS, INCRETIN MIMETICS/ENHANCERS HYPOGLYCEMICS, INSULINS HYPOGLYCEMICS, MEGLITINIDES HYPOGLYCEMICS, METFORMINS HYPOGLYCEMICS, TZDs

3 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 NSAIDs OPHTHALMICS, ALLERGIC CONJUNCTIVITIS OPHTHALMICS, ANTI-INFLAMMATORIES OPHTHALMICS, ANTIBIOTICS OPHTHALMICS, ANTIBIOTIC-STEROID COMBINATIONS OPHTHALMICS, GLAUCOMA AGENTS OPIATE DEPENDENCE TREATMENTS OTIC ANTI-INFECTIVES, ANESTHETICS 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

4 TETRACYCLINES THYROID HORMONES ULCERATIVE COLITIS AGENTS VASODILATORS, CORONARY

5 ACNE AGENTS, TOPICAL Preferred status implementation: 7/18/14 benzoyl peroxide gel clindamycin solution erythromycin solution Azelex Benzaclin with Pump Differin cream, lotion Retin-A cream/gel adapalene adapalene gel/pump benzoyl peroxide cleanser, pad, towelette clindamycin foam, gel, lotion, swab clindamycin/benzoyl peroxide erythromycin gel, swab erythromycin/benzoyl peroxide sod. sulfacetamide sod. sulfacet ER cleanser sod. sulfacetamide/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 Plexion NR Retin-A Micro Retin-A Micro 0.08% NR SE BPO SSS-10 NR Sumadan XLT Kit NR Tazorac Veltin Ziana 2 preferred medications are required before a non-preferred will be approved Class only covered up to 20 years old. Over 20 is considered cosmetic. Medical necessity prior authorization forms available on the web at: ity.pdf Please note: brand name drugs with a generic available are considered ALZHEIMER S AGENTS Clinical criteria apply to class. All agents require a prior authorization. Preferred status implementation: 1/02/15 donepezil tablets Exelon patch donepezil ODT* donepezil 23mg galantamine* / ER* rivastigmine capsules* Aricept ODT Exelon solution* Namenda solution* Namenda tablets, dose pack Namenda XR Prior Authorization forms available on the web at: : nhibitor.pdf Please note: brand name drugs with a generic available are considered * 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 Kadian DELAWARE MEDICAL ASSISTANCE PROGRAM (DMAP) ANALGESICS, NARCOTIC LONG Clinical criteria apply to class. All agents require a prior authorization. hydromorphone ER methadone concentrate, soluble tablet, solution morphine ER caps (Avinza) NR morphine ER caps (Kadian) oxycodone ER oxycodone ER (gen. Oxycontin ) oxymorphone ER tramadol ER Butrans Conzip ER Duragesic Embeda Nucynta ER Zohydro ER NR ANALGESICS, NARCOTIC SHORT Prior Authorization forms available on the web at: Please note: brand name drugs with a generic available are considered butalbital compound /codeine codeine codeine/apap hydrocodone/apap hydrocodone/ibuprofen hydromorphone tablets morphine tablets/ solution oxycodone IR oxycodone/apap pentazocine/apap tramadol butorphanol nasal carisoprodol / codeine dihydrocodeine/apap/ caffeine fentanyl lozenge hydromorphone liquid, suppositories levorphanol meperidine morphine concentrate morphine suppositories oxycodone/asa oxycodone conc. oxycodone/ibuprofen oxymorphone pentazocine/naloxone roxicodone tablet tramadol/apap Abstral Cocet / Plus Fentora Fioricet Codeine caps NR Ibudone Magnacet Nucynta 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 short-acting 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 Testim ANDROGENIC AGENTS Clinical criteria apply to class. All agents require a prior authorization testost (gen Fortesta) Androderm testost (gen. Testim) Axiron testost (gen.vogelxo) Clinical criteria apply. A clinical prior authorization is required despite the medication s status as preferred or nonpreferred: pplementation.pdf 6

7 ANGIOTENSIN MODULATORS Preferred status implementation: 7/18/14 benazepril / HCTZ quinapril / HCTZ enalapril / HCTZ ramipril lisinopril / HCTZ Diovan / HCT losartan / HCTZ candesartan/hctz NR captopril / HCTZ eprosartan fosinopril / HCTZ irbesartan / HCTZ moexipril / 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 / Tribenzor Exforge / HCT telmisartan/amlodipine trandolapril / verapamil valsartan/amlodipine Tekamlo / Amturnide Valturna Dose optimization required when applicable ANTIBIOTICS, GI metronidazole tablets neomycin metronidazole capsules paromycin capsules vancomycin Alinia Dificid Flagyl ER Tindamax Xifaxan 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 approved for appropriate diagnoses. ANTIBIOTICS, INHALED Bethkis Preferred status implementation: 1/16/14 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 Cleocin ovules Metrogel-Vaginal metronidazole Cleocin cream Clindesse Vandazole Please note: brand name drugs with a generic available are considered ANTICOAGULANTS warfarin Eliquis (step-edit) Fragmin Lovenox syringe Pradaxa (step-edit) Xarelto(step-edit) enoxaparin fondaparinux Arixtra Innohep Lovenox vial 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 considered 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 carbamazepine clonazepam tablet divalproex IR / ER ethosuximide syrup gabapentin lamotrigine levetiracetam oxcarbazepine tablets Felbatol Tablets Gabitril Peganone Tegretol Susp. Tegretol XR Trileptal suspension carbamazepine ER carbamazepine susp. carbamazepine XR clonazepam ODT diazepam /device (rectal) divalproex sprinkle ethosuximide caps felbamate lamotrigine ER 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 considered Clinical criteria will still apply: Prior Authorization forms available on the web at: a.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 considered * (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* 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 considered * (grandfathered) clients currently receiving medication at implementation date may continue without prior authorization. ANTIEMETICS ondansetron ODT ondansetron tablets dronabinol granisetron ondansetron solution Akynzeo NR Anzemet Cesamet Diclegis DR NR Emend Marinol Sancuso Zuplenz Clinical criteria will still apply: indicates that a clinical prior authorization is required despite the medication s status as preferred or nonpreferred available at: ANTIFUNGALS, ORAL fluconazole griseofulvin suspension ketoconazole nystatin terbinafine Gris-Peg clotrimazole flucytosine griseofulvin ultramicrosized itraconazole voriconazole Grifulvin V Lamisil granules Noxafil Onmel Sporanox solution Terbinex Vfend 10

11 ANTIFUNGALS, TOPICAL ciclopirox solution clotrimazole econazole ketoconazole cream, shampoo nystatin nystatin/triamcinolone ciclopirox suspension clotrimazole/betameth. ketoconazole foam Bensal HP CNL-8 Ciclodan kit Ecoza NR Ertaczo Mentax Exelderm Naftin Extina Oxistat Jublia NR Pediaderm AF Nerydin Soln. NR Pedipirox-4 Ketodan NR Vusion Lamisil solution Luzu NR 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 considered ANTIHYPERURICEMICS allopurinol probenecid probenecid with colchicine Colcrys Mitigare NR Uloric Zyloprim Colcrys preferred for treatment, not prophylaxis. Quantity limit of 15 tablets per 90 days in place. 11

12 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 Quantity limits in place: Nine (9) tablets per 45 days Please note: Brand name drugs with a generic available are considered ANTIPARASITICS, TOPICAL 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 considered ANTIPARKINSON S AGENTS benztropine carbidopa/levodopa pramipexole ropinirole selegiline tablets trihexyphenidyl Bromocriptine carbidopa carbidopa/levodopa/ entacapone entacapone levodopa/carb ODT ropinirole XL selegiline capsules Azilect Mirapex ER Neupro NR Requip XL Stalevo Tasmar Zelapar ANTIPSORIATIC AGENTS, ORAL Please note: brand name drugs with a generic available are considered Soriatane acitretin methoxsalen rapid 8-MOP Oxsoralen-Ultra Please note: Brand name drugs with a generic available are considered nonpreferred unless listed in bold 12

13 ANTIPSORIATIC AGENTS, TOPICAL calcipotriene cream calcipotriene solution calcipotrieneointment calcipotriene/betamethasone dipropionate ointment calcitriol ointment Dovonex cream Sorilux Taclonex scalp Vectical Please note: Brand name drugs with a generic available are considered nonpreferred unless listed in bold ANTIPSYCHOTICS amitriptyline / perphenazine chlorpromazine clozapine fluphenazine / decanoate Geodon IM haloperidol / decanoate loxapine olanzapine / IM perphenazine quetiapine risperidone solution, tablets thioridazine thiothixene trifluoperazine ziprasidone Abilify tab (step-edit) Latuda (step-edit) Moban Orap Risperdal Consta Seroquel XR (stepedit) 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 Sustenna* Saphris * Versacloz Zyprexa Relprevv DMAP requires prior authorization for the following products for the pediatric patient under six: All long acting injectable antipsychotics are non-preferred, please see prior authorization forms: ction.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 approved ANTIVIRALS, ORAL Preferred status implementation: 7/18/14 acyclovir amantadine capsules rimantadine valacyclovir Relenza Tamiflu amantadine tablets Famciclovir 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 13

14 ANTIVIRALS, TOPICAL Abreva OTC Denavir alprazolam tablets diazepam solution buspirone diazepam tablets chlordiazepoxide lorazepam clorazepate acyclovir ointment Xerese Zovirax cream, ointment ANXIOLYTICS alprazolam ER Ativan tablet alprazolam Intensol Niravam alprazolam ODT Tranxene T-tablet diazepam intensol Valium tablet lorazepam Intensol Xanax tablet meprobamate Xanax XR oxazepam 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 nonpreferred available at: BETA BLOCKERS Preferred status implementation: 7/18/14 atenolol / chlorthalidone bisoprolol / HCTZ carvedilol labetalol propranolol/hctz propranolol ER sotalol timolol Toprol XL acebutolol betaxolol metoprolol / HCTZ metoprolol XL nadolol nadolol/ bendroflumethiazide pindolol Bystolic Coreg CR Dutoprol Hemangeol NR Inderal XL NR Innopran XL Levatol BILE SALTS ursodiol 300mg capsule ursodiol tablets Actigall Chenodal Urso/Urso Forte 14

15 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 Preferred status implementation: 7/18/14 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 considered Clinical criteria will still apply: indicates that a clinical prior authorization is required despite the medication s status as preferred or nonpreferred available at: alfuzosin terazosin doxazosin finasteride tamsulosin Avodart Cardura XL Jalyn Rapaflo Uroxatral 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 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. 15

16 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/clavulanate tabs amoxicillin/clavulanate susp cefaclor capsules cefadroxil capsules, tablets cefdinir cefprozil suspension cefprozil tablets cefuroxime cephalexin capsules Suprax tablets, susp. amoxicillin/clavulanate XR cefaclor tablets cefadroxil suspension cefditoren cefpodoxime ceftibuten tablets/suspension cephalexin tablets Augmentin 125, 250 susp Ceftin suspension Suprax Chew tablets 2 preferred medications are required before a non-preferred will be approved COPD AGENTS albuterol/ipratropium nebulizer ipratropium nebulizer Combivent Respimat Spiriva Anoro Ellipta Atrovent HFA Combivent Daliresp Spiriva Respimat NR Tudorza Clinical criteria will apply 16

17 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 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 * Class is grandfathered, meaning clients currently receiving medication at implementation date may continue without prior authorization. 17

18 CYTOKINE AND CAM ANTAGONISTS Enbrel (diagnosis code required) Humira(diagnosis code required) Actemra Orencia Actemra Syringe Otezla Amevive Remicade Arcalyst Simponi Cimzia Simponi Aria Entyvio Stelara Ilaris Xeljanz Kineret DIABETIC TESTING BLOOD GLUCOSE METERS, TEST STRIPS, LANCETS Approved diagnosis code required on prescription and electronic submissions. 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 DIURETICS amiloride HCTZ bumetanide chlorothiazide chlorthalidone furosemide Preferred status implementation: 7/18/14 hydrochlorothiazide indapamide spironolactone spirololactone HCTZ triamterene HCTZ All other diuretics are non-preferred EPINEPRINE, SELF-INJECTED EpiPen EpiPen Jr. epinephrine injection Auvi-Q 18

19 DELAWARE MEDICAL ASSISTANCE PROGRAM (DMAP) ERYTHROPOIESIS STIMULATING PROTEINS Clinical criteria apply to class. All agents require a prior authorization. Aranesp Procrit Epogen Omontys NR FLUOROQUINOLONES Prior authorization forms available on the web at : df ciprofloxacin tablets levofloxacin tablets ciprofloxacin ER Factive ciprofloxacin suspension levofloxacin solution moxifloxacin ofloxacin 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 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 tablets prednisolone sodium phosphate prednisolone solution prednisone solution / tablets All other oral glucocorticoids are non-preferred 19

20 Norditropin Nutropin / AQ Preferred status implementation: 7/25/14 DELAWARE MEDICAL ASSISTANCE PROGRAM (DMAP) GROWTH HORMONES Clinical criteria apply to class. All agents require a prior authorization. Genotropin Humatrope Omnitrope Saizen Serostim Tev-Tropin Zorbtive Prior authorization available at: e.drug.pdf programs H. PYLORI TREATMENTS Helidac Pylera lansporazole-amoxicillin-clarithromycin Omeclamox Pak HAE TREATMENTS Kalbitor Berinert Cinryze Firazyr Ruconest NR HEPATITIS C AGENTS ribavirin capsules, tablets Incivek Pegasys Victrelis famotidine tablets ranitidine syrup / tablets Harvoni NR Infergen Olysio Peg-Intron / Redipen Ribapak Ribasphere Sovaldi HISTAMINE II RECEPTOR BLOCKERS All other histamine II agents are non-preferred Clinical criteria will still apply. Prior authorization available at: nts.pdf 20

21 HIV / AIDS didanosine nevirapine stavudine zidovudine Atripla Combivir Crixivan Emtriva Epivir Epzicom Invirase Isentress Isentress Chew Tab Kaletra Lexiva Norvir Prezista Reyataz Sustiva Truvada Viread Ziagen abacavir abacavir/lamivudine/zidovudine lamivudine lamivudine/zidovudine nevirapine ER Aptivus* Complera Edurant Fuzeon* Intelence* Isentress Powder Pack NR Prezista Suspension Rescriptor* Selzentry* Stribild Tivicay NR Triumeq NR Trizivir* Tybost NR Viracept* Viramune Please note: brand name drugs with a generic available are considered * class is grandfathered, meaning clients currently receiving medication at implementation date may continue without prior authorization. but DMMA policy states that new products will be non-preferred until reviewed by the Committee. Jentadueto (step-edit) Kombiglyze XR (step-edit) Onglyza (step-edit) Tradjenta (step-edit) HYPOGLYCEMICS, INCRETIN MIMETICS/ENHANCERS Clinical criteria apply to class. All agents require a prior authorization. Bydureon Bydureon Pens NR Byetta * Kazano Janumet / XR Januvia Juvisync Nesina Oseni Symlin * Tanzeum NR 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 Preferred status implementation: 7/4/14 Humulin pens, vials Humalog pens, vials Humalog Mix pens, vials Lantus pens, vials Levemir pens, vials Novolin pens, vials Novolog pens, vials Novolog Mix pens, vials Apidra pens, vials - Levemir will produce an electronic PA for pregnant clients with an appropriate diagnosis code. HYPOGLYCEMICS, MEGLITINIDES Preferred status implementation: 7/4/14 nateglinide Prandin repaglinide Prandimet 21

22 HYPOGLYCEMICS, METFORMINS Preferred status implementation: 7/18/14 glipizide-metformin glyburide-metformin metformin metformin ER (gen Glucophage XR) metformin ER (gen Fortamet) Fortamet Glucophage Glucophage XR Glucovance Glumetza Riomet HYPOGLYCEMICS, TZDs Preferred status implementation: 7/18/14 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: limus.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 considered 22

23 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 Nasacort OTC Nasonex Omnaris Qnasl Zetonna Please note: brand name drugs with a generic available are considered montelukast tablet, chew tabs Accolate LEUKOTRIENE RECEPTOR ANTAGONISTS Clinical criteria apply to class. All agents require a prior authorization. montelukast granules zafirlukast Singulair Gran Pack Zyflo CR Please note: brand name drugs with a generic available are considered Clinical criteria apply. ICD-9 code for asthma indication may create a system-generated approval for montelukast or Accolate Prior authorizations available at: ene.pdf clindamycin capsules clindamycin solution (preferred for client younger than 10) LINCOSAMIDES/OXAZOLIDINONES/STREPTOGRAMINS All other agents are non-preferred 23

24 LIPOTROPICS, OTHER colestipol cholestyramine/aspartame gemfibrozil Niacor 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 Triglide Vascepa Welchol Zetia 2 preferred medications are required before a non-preferred will be approved LIPOTROPICS, STATINS Preferred status implementation: 7/18/14 atorvastatin lovastatin pravastatin simvastatin amlodipine/atorvastatin fluvastatin Advicor Altoprev Crestor Lescol / XL Liptruzet Livalo Simcor Vytorin 2 preferred medications are required before a non-preferred will be approved Once daily dosing required Please note: brand name drugs with a generic available are considered 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 24

25 MULTIPLE SCLEROSIS Avonex Copaxone 20mg Extavia Gilenya (electronic step-edit) Rebif Rebif Rebidose Ampyra Aubagio Betaseron Copaxone 40mg 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 lidocaine 5% patch Cymbalta Gralise Horizant Lyrica Neurontin Qutenza Savella Lidoderm (greater than 2 patches a day requires prior auth) al.patch.pdf Liquid medications require prior authorization for clients over 10 years old Please note: brand name drugs with a generic available are considered NSAIDs flurbiprofen ibuprofen indomethacin ketorolac meloxicam tablets naproxen tablets sulindac diclofenac diclofenac/misoprostol diclofenac solution diflunisal etodolac etodolac SR fenoprofen indomethacin ER ketoprofen meclofenamate mefenamic acid meloxicam suspension nabumetone naproxen EC naproxen suspension oxaprozin piroxicam tolmetin Celebrex Flector Indocin Pennsaid Pump Sprix Vimovo Voltaren gel Zipsor Zorvolex 2 preferred medications are required before a non-preferred will be approved 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 25

26 OPHTHALMICS, ALLERGIC CONJUNCTIVITIS cromolyn Alrex Pataday azelastine epinastine Alamast Alocril Alomide Bepreve Emadine Lastacaft Patanol 2 preferred medications are required before a non-preferred will be approved OPHTHALMICS, ANTI-INFLAMMATORIES dexamethasone diclofenac fluorometholone flurbiprofen Flarex FML Forte FML S.O.P. bacitracin/polymyxin ciprofloxacin erythromycin gentamicin ofloxacin polymyxin/trimethopm sulfacetamide tobramycin Moxeza Terramycin /polymyxin Tobrex ointment Vigamox Lotemax Maxidex Pred Mild bromfenac ketorolac / LS prednisolone acetate prednisolone sod phosphate Acuvail Bromday bacitracin gatifloxacin levofloxacin neomycin / bac / polymyxin neomycin/polymyxin/gramicidin Azasite Durezol FML Ilevro Lotemax Gel Nevanac Ozurdex Prolensa Retisert Triesence Vexol OPHTHALMICS, ANTIBIOTICS Besivance Ciloxan Garamycin Iquix Natacyn Zymar but DMMA policy states that new products will be non-preferred until reviewed by the Committee. 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 considered 26

27 OPHTHALMICS, GLAUCOMA AGENTS 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 brimonidine P phospholine iodide travaprost Cosopt PF Lumigan 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 considered For prior authorization forms, please visit: buprenorphine naltrexone Suboxone film OPIATE DEPENDENCE TREATMENTS Clinical criteria apply to class. All agents require a prior authorization. buprenorphine/naloxone tablets Bunavail NR Suboxone tablets Zubsolv For prior authorization forms, please visit: df OTIC ANTI-INFECTIVES, ANESTHETICS 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 27

28 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 Adcirca Letairis Tracleer Ventavis Adempas NR Opsumit NR Orenitram ER NR Revatio Suspension NR Tyvaso Clinical criteria will still apply. For prior authorization forms, please visit: 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 28

29 PHOSPHATE BINDERS calcium acetate tablets Phoslyra Renagel calcium acetate capsules sevelamer carbonate Eliphos Ferric Citrate NR Fosrenol Magnebind 400 Rx 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: nders.pdf PLATELET AGGREGATION INHIBITORS clopidogrel dipyridamole Aggrenox Brilinta (step-edit) ticlopidine Effient Zontivity NR Step edit on Brilinta require diagnosis code PRENATAL VITAMINS Preferred status implementation: 7/25/14 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 29

30 PROGESTATIONAL AGENTS medroxyprogesterone acetate norethindrone acetate progesterone capsule Makena progesterone capsule 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 nonpreferred. Prior Authorization forms available on the web at: akena.pdf Please note: Brand name drugs with a generic available are considered PROTON PUMP INHIBITORS Preferred status implementation: 7/25/14 omeprazole Rx pantoprazole Nexium suspension (preferred for age 10 and under) Protonix suspension (preferred for age 10 and under) 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 nonpreferred. Prior Authorization forms available on the web at: SEDATIVE HYPNOTICS temazepam 15mg, 30mg zolpidem chloral hydrate eszopiclone estazolam flurazepam temazepam 7.5,22.5mg triazolam zaleplon zolpidem ER 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. 30

31 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: 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 Clobex amcinonide Clodan Kit NR betamethasone, other Cordran formulations Cutivate clobetasol Dermaclocortolone pivalate cream Smoothe-FS desonide Dermasorb TA desoximetasone Dermatop diflorasone diacetate Desonate fluocinonide cream Desonil Plus fluocinolone oil Desowen fluocinonide, other formulations Halac fluocinolone Halog fluticasone propionate Halonate halobetasol prop cr/oi Kenalog hydrocortisone, other Luxiq formulations prednicarbate cream/ointment triamcinolone acetonide lotion Aqua Glycolic HC Momexin Olux -E Pandel Pediaderm HC / TA Synalar Texacort Topicort Trianex Oi. Ultravate/ X Vanos Verdeso 31

32 STIMULANTS AND RELATED AGENTS amphetamine salt combo dexmethylphenidate dextroamphetamine methylphenidate / ER tablets methylphenidate ER (Concerta generic) Adderall XR (stepedit) Focalin / XR Intuniv Metadate CD Provigil Strattera Vyvanse amphetamine salt combo ER clonidine ER dexmethylphenidate ER dexmethylphenidate XR dextroamphetamine ER dextroamphetamine-amphetamine ER dextroamphetamine sulfate 5mg/5ml methamphetamine methylphenidate CD methylphenidate ER cap (ritalin LA generic)* methylphenidate solution * Concerta Daytrana Dexedrine Tabs NR 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 apy.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 considered For Prior Authorization forms, please visit: 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. 32

33 ULCERATIVE COLITIS AGENTS sulfasalazine Apriso Asacol Canasa balsalazide mesalamine Asacol HD Delzicol DR Dipentum Giazo NR Lialda Pentasa sfrowasa Uceris 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 33