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Preferred Drug List with Prior Authorization Criteria

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Preferred Drug List with Prior Authorization Criteria BUREAU FOR MEDICAL SERVICES WEST VIRGINIA MEDICAID PREFERRED DRUG LIST WITH PRIOR AUTHORIZATION CRITERIA REVISED 6/1/05 Posted: 6/6/05 THERAPEUTIC PREFERRED NON-PREFERRED PA DRUG CLASS AGENTS AGENTS CRITERIA ACE INHIBITORS ACE INHIBITORS Four of the preferred agents must be tried for at least 30 days each ACEON (perindopril) ACCUPRIL (quinapril) before a non-preferred agent will be authorized unless one of the exceptions on the PA form is present. Implement 1/3/05 ALTACE (ramipril) CAPOTEN (captopril) benazepril fosinopril captopril LOTENSIN (benazepril) enalapril MONOPRIL (fosinopril) lisinopril PRINIVIL (lisinopril) MAVIK (trandolapril) quinapril moexepril UNIVASC (moexepril) VASOTEC (enalapril) ZESTRIL (lisinopril) ACE INHIBITOR/DIURETIC COMBINATIONS benazepril/HCTZ ACCURETIC (quinapril/HCTZ) captopril/HCTZ CAPOZIDE (captopril/HCTZ) enalapril/HCTZ LOTENSIN HCT (benazepril/HCTZ) lisinopril/HCTZ MONOPRIL HCT (fosinopril/HCTZ) UNIRETIC (moexepril/HCTZ) PRINZIDE (lisinopril/HCTZ) quinapril/HCTZ VASERETIC (enalapril/HCTZ) ZESTORETIC (lisinopril/HCTZ) ACE INHIBITOR/CALCIUM LOTREL (benazepril/amlodipine) LEXXEL (enalapril/felodipine) Each of the preferred agents must be tried for at least two weeks CHANNEL BLOCKER TARKA (trandolapril/verapamil) each before a non-preferred agent in that group will be authorized COMBINATIONS unless one of the exceptions on the PA form is present. Effective 7/1/05 ALZHEIMER’S AGENTS CHOLINESTERASE INHIBITORS Patients starting therapy in this class must show a documented ARICEPT (donepezil) COGNEX (tacrine) allergy to the preferred agents before a non-preferred agent will be authorized. Implement 10/1/04 EXELON (rivastigmine) REMINYL (galantamine) NMDA RECEPTOR ANTAGONIST NAMENDA (memantine) Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. 1 CL - Requires Clinical PA NR – New drug has not been reviewed by P & T Committee BUREAU FOR MEDICAL SERVICES WEST VIRGINIA MEDICAID PREFERRED DRUG LIST WITH PRIOR AUTHORIZATION CRITERIA REVISED 6/1/05 Posted: 6/6/05 THERAPEUTIC PREFERRED NON-PREFERRED PA DRUG CLASS AGENTS AGENTS CRITERIA ANALGESICS, NARCOTIC SHORT ACTING Three of the preferred agents must be tried for at least 72 hours (Non-parenteral) acetaminophen/codeine ACTIQ (fentanyl) before a non-preferred agent will be authorized unless one of the exceptions on the PA form is present. (The three agents tried must aspirin/codeine ANEXSIA (hydrocodone/APAP) include at least one of the long-acting agents when requesting a PA Effective 7/1/05 codeine BANCAP HC (hydrocodone/APAP) for a non-preferred long acting agent.) hydrocodone/APAP butalbital/APAP/caffeine/codeine hydrocodone/ibuprofen butalbital/ASA/caffeine/codeine Limits: Quantities exceeding 240 tablets per 30 days (8 tablets/day) hydromorphone DARVOCET (propoxyphene/APAP) for agents containing 500 mg of acetaminophen will require a prior levorphanol DARVON (propoxyphene) authorization. methadone DARVON N (propoxyphene) morphine DEMEROL (meperidine) oxycodone DILAUDID (hydromorphone) oxycodone/APAP FIORICET W/ CODEINE oxycodone/aspirin (butalbital/APAP/caffeine/codeine) pentazocine/APAP FIORINAL W/ CODEINE pentazocine/naloxone (butalbital/ASA/caffeine/codeine) LORCET, LORTAB (hydrocodone/APAP) propoxyphene/APAP tramadol MAXIDONE (hydrocodone/APAP) meperidine ULTRACET (tramadol/APAP) MSIR (morphine) NORCO (hydrocodone/APAP) OXYFAST, OXYIR (oxycodone) PANLOR (dihydrocodeine/APAP/caffeine) PERCOCET (oxycodone/APAP) PERCODAN (oxycodone/aspirin) PERCOLONE (oxycodone) PHRENILIN W/ CAFFEINE AND CODEINE (butalbital/ASA/caffeine/codeine) propoxyphene propoxyphene/ASA/caffeine propoxyphene napsylate REPREXAIN (hydrocodone/ibuprofen) SYNALGOS-DC (dihydrocodeine/ASA/caffeine) TALACEN (pentazocine/APAP) TALWIN NX (pentazocine/naloxone) TYLENOL W/CODEINE (APAP/codeine) ULTRAM (tramadol) VICODIN (hydrocodone/APAP) Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. 2 CL - Requires Clinical PA NR – New drug has not been reviewed by P & T Committee BUREAU FOR MEDICAL SERVICES WEST VIRGINIA MEDICAID PREFERRED DRUG LIST WITH PRIOR AUTHORIZATION CRITERIA REVISED 6/1/05 Posted: 6/6/05 THERAPEUTIC PREFERRED NON-PREFERRED PA DRUG CLASS AGENTS AGENTS CRITERIA VICOPROFEN (hydrocodone/ibuprofen) ZYDONE (hydrocodone/APAP) LONG-ACTING DURAGESIC (fentanyl) AVINZA (morphine) KADIAN (morphine) fetanyl patches morphine SR MS CONTIN (morphine) ORAMORPH SR (morphine) oxycodone ER OXYCONTIN (oxycodone) PALLADONE (hydromorphone ER) ANGIOTENSIN II RECEPTOR ANGIOTENSIN RECEPTOR BLOCKERS Each of the preferred agents in the corresponding group must be tried BLOCKERS (ARBs) AVAPRO (irbesartan) ATACAND (candesartan) for at least two weeks each before a non-preferred agent in that group will be authorized, unless one of the exceptions on the PA form is COZAAR (losartan) BENICAR (olmesartan) present. Effective 7/1/05 DIOVAN (valsartan) TEVETEN (eprosartan) MICARDIS (telmisartan) ARB/DIURETIC COMBINATIONS AVALIDE (irbesartan/HCTZ) ATACAND-HCT (candesartan/HCTZ) DIOVAN-HCT (valsartan/HCTZ) BENICAR-HCT (olmesartan/HCTZ) HYZAAR (losartan/HCTZ) TEVETEN-HCT (eprosartan/HCTZ) MICARDIS-HCT (telmisartan/HCTZ) ANTICOAGULANTS, FRAGMIN (dalteparin) ARIXTRA (fondaparinux) CL INJECTABLE LOVENOX (enoxaparin) INNOHEP (tinzaparin) Effective 7/1/05 ANTIDEPRESSANTS, OTHER bupropion SR bupropion IR A non-preferred agent will only be authorized if there has been a six- (non-SSRI) CYMBALTA (duloxetine) DESYREL (trazodone) week trial of a preferred agent in this class unless one of the EFFEXOR XR (venlafaxine) EFFEXOR (venlafaxine) exceptions on the PA form is present. Effective 7/1/05 mirtazapine nefazodone trazodone REMERON (mirtazapine) SERZONE (nefazodone) WELLBUTRIN (bupropion) WELLBUTRIN SR (bupropion) WELLBUTRIN XL (bupropion) Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. 3 CL - Requires Clinical PA NR – New drug has not been reviewed by P & T Committee BUREAU FOR MEDICAL SERVICES WEST VIRGINIA MEDICAID PREFERRED DRUG LIST WITH PRIOR AUTHORIZATION CRITERIA REVISED 6/1/05 Posted: 6/6/05 THERAPEUTIC PREFERRED NON-PREFERRED PA DRUG CLASS AGENTS AGENTS CRITERIA ANTIDEPRESSANTS, SSRIs citalopram CELEXA (citalopram) None of the non-preferred dosage forms will be authorized unless fluoxetine LUVOX (fluvoxamine) there is documentation showing that the preferred dosage forms of the corresponding agents are inappropriate for the patient. Implement 1/3/05 fluvoxamine paroxetine LEXAPRO (escitalopram) PAXIL (paroxetine) PAXIL CR (paroxetine) PEXEVA (paroxetine) ZOLOFT (sertraline) PROZAC (fluoxetine) RAPIFLUX (fluoxetine) SARAFEM (fluoxetine) ANTIEMETICS 5HT3 RECEPTOR BLOCKERS A trial of the preferred agent is required before a non-preferred agent (Oral) ZOFRAN (ondansetron) ANZEMET (dolasetron) will be approved unless one of the exceptions on the PA form is present. ZOFRAN ODT (ondansetron) KYTRIL (granisetron) Implement 4/1/04 Quantity limits apply for this drug class. ANTIFUNGALS, ORAL clotrimazole ANCOBON (flucytosine) Non-preferred agents will be approved only if one of the exceptions on fluconazole DIFLUCAN (fluconazole) the PA form is present. Implement 1/3/05 ketoconazoleCL FULVICIN (griseofulvin) LAMISIL (terbinafine)CL GRIFULVIN V (griseofulvin) PA is required when limits are exceeded. MYCOSTATIN (nystatin) GRISACTIN (griseofulvin) nystatin griseofulvin PA is not required for Grifulvin-V Suspension for children up to 6 GRIS-PEG (griseofulvin) years of age. MYCELEX (clotrimazole) NIZORAL (ketoconazole) SPORANOX (itraconazole) VFEND (voriconazole) ANTIFUNGALS, TOPICAL ANTIFUNGALS Three of the preferred agents must be tried for at least two weeks EXELDERM (sulconazole) ciclopirox each before one of the non-preferred agents will be authorized unless one of the exceptions on the PA form is present. Implement 1/3/05 ketoconazole econazole LOPROX Cream, Gel, Shampoo ERTACZO (sertaconazole) (ciclopirox) LOPROX TS (ciclopirox) MENTAX (butenafine) MYCOSTATIN (nystatin) NAFTIN (naftifine) NIZORAL (ketoconazole) nystatin PENLAC (ciclopirox) OXISTAT (oxiconazole) SPECTAZOLE (econazole) ANTIFUNGAL/STEROID COMBINATIONS nystatin/triamcinolone clotrimazole/betamethasone LOTRISONE (clotrimazole/betamethasone) MYCOLOG (nystatin/triamcinolone) Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. 4 CL - Requires Clinical PA NR – New drug has not been reviewed by P & T Committee BUREAU FOR MEDICAL SERVICES WEST VIRGINIA MEDICAID PREFERRED DRUG LIST WITH PRIOR AUTHORIZATION CRITERIA REVISED 6/1/05 Posted: 6/6/05 THERAPEUTIC PREFERRED NON-PREFERRED PA DRUG CLASS AGENTS AGENTS CRITERIA ANTIHISTAMINES, ANTIHISTAMINES A preferred agent must be tried before a non-preferred agent will be MINIMALLY SEDATING loratadine ALLEGRA (fexofenadine) authorized unless one of the exceptions on the PA form is present. CLARINEX Syrup (desloratadine) CLARINEX tablets (desloratadine) Effective 7/1/05 ALAVERT (loratadine) CLARITIN (loratadine) TAVIST-ND (loratadine) ZYRTEC (cetirizine) ANTIHISTAMINE/DECONGESTANT COMBINATIONS ALAVERT D ALLEGRA-D (fexofenadine/pseudoephedrine) (loratadine/psuedoephedrine) CLARITIN-D (loratadine/pseudoephedrine) loratadine/pseudoephedrine ZYRTEC-D (cetirizine/pseudoephedrine) ANTIMIGRAINE AGENTS, AXERT (almotriptan) AMERGE (naratriptan) Two of the oral agents must be tried before a non-preferred agent will TRIPTANS IMITREX Injection (sumatriptan) FROVA
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