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Effective 07/20/21 Alphabetical by Brand Name (when applicable) PA Medical Assistance Fee-for-Service Quantity Limits & Daily Dose Limits Maximum Therapy Class Brand Name Generic Name Daily Dose Limit Antipsychotics, Atypical ABILIFY 1 MG/ML SOLUTION ARIPIPRAZOLE 25 Antipsychotics, Atypical ABILIFY 10 MG DISCMELT ARIPIPRAZOLE 2 Antipsychotics, Atypical ABILIFY 10 MG TABLET ARIPIPRAZOLE 1 Antipsychotics, Atypical ABILIFY 15 MG DISCMELT ARIPIPRAZOLE 2 Antipsychotics, Atypical ABILIFY 15 MG TABLET ARIPIPRAZOLE 1 Antipsychotics, Atypical ABILIFY 2 MG TABLET ARIPIPRAZOLE 2 Antipsychotics, Atypical ABILIFY 20 MG TABLET ARIPIPRAZOLE 1 Antipsychotics, Atypical ABILIFY 30 MG TABLET ARIPIPRAZOLE 1 Antipsychotics, Atypical ABILIFY 5 MG TABLET ARIPIPRAZOLE 1.5 Antipsychotics, Atypical ABILIFY 9.75 MG/1.3 ML INJECTION VIAL ARIPIPRAZOLE 3.9 Antipsychotics, Atypical ABILIFY MAINTENA ER 300 MG SYRINGE ARIPIPRAZOLE 0.04 Antipsychotics, Atypical ABILIFY MAINTENA ER 300 MG VIAL ARIPIPRAZOLE 0.04 Antipsychotics, Atypical ABILIFY MAINTENA ER 400 MG SYRINGE ARIPIPRAZOLE 0.04 Antipsychotics, Atypical ABILIFY MAINTENA ER 400 MG VIAL ARIPIPRAZOLE 0.04 Antipsychotics, Atypical ABILIFY MYCITE 10 MG KIT ARIPIPRAZOLE 1 Antipsychotics, Atypical ABILIFY MYCITE 15 MG KIT ARIPIPRAZOLE 1 Antipsychotics, Atypical ABILIFY MYCITE 2 MG KIT ARIPIPRAZOLE 1 Antipsychotics, Atypical ABILIFY MYCITE 20 MG KIT ARIPIPRAZOLE 1 Antipsychotics, Atypical ABILIFY MYCITE 30 MG KIT ARIPIPRAZOLE 1 Antipsychotics, Atypical ABILIFY MYCITE 5 MG KIT ARIPIPRAZOLE 1 Antivirals, Herpes ABREVA 10% CREAM DOCASONAL 1 Analgesics, Opioid Short-Acting ABSTRAL 100 MCG SUBLINGUAL TABLET FENTANYL CITRATE SUBLINGUAL 4 Analgesics, Opioid Short-Acting ABSTRAL 200 MCG SUBLINGUAL TABLET FENTANYL CITRATE SUBLINGUAL 4 Analgesics, Opioid Short-Acting ABSTRAL 300 MCG SUBLINGUAL TABLET FENTANYL CITRATE SUBLINGUAL 4 Analgesics, Opioid Short-Acting ABSTRAL 400 MCG SUBLINGUAL TABLET FENTANYL CITRATE SUBLINGUAL 4 Analgesics, Opioid Short-Acting ABSTRAL 600 MCG SUBLINGUAL TABLET FENTANYL CITRATE SUBLINGUAL 4 Analgesics, Opioid Short-Acting ABSTRAL 800 MCG SUBLINGUAL TABLET FENTANYL CITRATE SUBLINGUAL 4 Leukotriene Modifiers ACCOLATE 10 MG TABLET ZAFIRLUKAST 2 Leukotriene Modifiers ACCOLATE 20 MG TABLET ZAFIRLUKAST 2 Blood Glucose Test Strips ACCU-CHECK ACTIVE BLOOD GLUCOSE TEST STRIPS BLOOD GLUCOSE TEST STRIPS 3.34 Blood Glucose Meters ACCU-CHECK ACTIVE CARE BLOOD GLUCOSE METER BLOOD GLUCOSE METER See footnote2 Blood Glucose Meters ACCU-CHECK ADVANTAGE BLOOD GLUCOSE METER BLOOD GLUCOSE METER See footnote2 Blood Glucose Meters ACCU-CHECK AVIVA PLUS BLOOD GLUCOSE METER BLOOD GLUCOSE METER See footnote2 Blood Glucose Test Strips ACCU-CHECK AVIVA PLUS BLOOD GLUCOSE TEST STRIPS BLOOD GLUCOSE TEST STRIPS 3.34 Blood Glucose Test Strips ACCU-CHECK COMFORT CURVE BLOOD GLUCOSE STRIPS BLOOD GLUCOSE TEST STRIPS 3.34 Blood Glucose Test Strips ACCU-CHECK COMPACT BLOOD GLUCOSE TEST STRIPS BLOOD GLUCOSE TEST STRIPS 3.34 Effective 07/20/21 Alphabetical by Brand Name (when applicable) Blood Glucose Meters ACCU-CHECK COMPACT PLUS BLOOD GLUCOSE METER BLOOD GLUCOSE METER See footnote2 Diabetic Supplies, Miscellaneous ACCU-CHECK FASTCLIX LANCET KIT BLOOD GLUCOSE LANCING DEVICE 1 Diabetic Supplies, Miscellaneous ACCU-CHECK MULTICLIX LANCET KIT BLOOD GLUCOSE LANCING DEVICE 1 Blood Glucose Meters ACCU-CHECK NANO SMARTVIEW BLOOD GLUCOSE METER BLOOD GLUCOSE METER See footnote2 Blood Glucose Test Strips ACCU-CHECK SMARTVIEW BLOOD GLUCOSE TEST STRIPS BLOOD GLUCOSE TEST STRIPS 3.34 Diabetic Supplies, Miscellaneous ACCU-CHECK SOFTCLIX LANCING KIT BLOOD GLUCOSE LANCING DEVICE 1 Blood Glucose Meters ACCU-CHECK VOICEMATE BLOOD GLUCOSE METER BLOOD GLUCOSE METER See footnote2 Angiotensin Modulators ACCUPRIL 10 MG TABLET QUINAPRIL 2 Angiotensin Modulators ACCUPRIL 20 MG TABLET QUINAPRIL 2 Angiotensin Modulators ACCUPRIL 40 MG TABLET QUINAPRIL 2 Angiotensin Modulators ACCUPRIL 5 MG TABLET QUINAPRIL 2 Angiotensin Modulators ACCURETIC 10 MG/12.5 MG TABLET QUINAPRIL/HYDROCHLOROTHIAZIDE 1 Angiotensin Modulators ACCURETIC 20 MG/12.5 MG TABLET QUINAPRIL/HYDROCHLOROTHIAZIDE 2 Angiotensin Modulators ACCURETIC 20 MG/25 MG TABLET QUINAPRIL/HYDROCHLOROTHIAZIDE 1 Angiotensin Modulators ACEON 2 MG TABLET PERINDOPRIL 2 Angiotensin Modulators ACEON 4 MG TABLET PERINDOPRIL 2 Angiotensin Modulators ACEON 8 MG TABLET PERINDOPRIL 2 Analgesics, Opioid Short-Acting ACETAMIN/CAFF/DIHYDROCODEINE 320.5 MG/30 MG/16 MG ACETAMINOPHEN/CAFFEINE/DIHYDROCODEINE 10 Analgesics, Opioid Short-Acting ACETAMIN-CODEIN 300-30 MG/12.5 ML ACETAMINOPHEN/CODEINE 90 Analgesics, Non-Salicylates ACETAMINOPHEN 120 MG TAB/CAP/SUPPOSITORY ACETAMINOPHEN 20 Analgesics, Non-Salicylates ACETAMINOPHEN 160 MG TAB/CAP/SUPPOSITORY ACETAMINOPHEN 20 Analgesics, Non-Salicylates ACETAMINOPHEN 160 MG/5 ML LIQUID ACETAMINOPHEN 75 Analgesics, Non-Salicylates ACETAMINOPHEN 320 MG/10 ML LIQUID ACETAMINOPHEN 100 Analgesics, Non-Salicylates ACETAMINOPHEN 325 MG TAB/CAP/SUPPOSITORY ACETAMINOPHEN 10 Analgesics, Non-Salicylates ACETAMINOPHEN 325 MG/10.15 ML LIQUID ACETAMINOPHEN 100 Analgesics, Non-Salicylates ACETAMINOPHEN 500 MG CAP/TAB/SUPPOSITORY ACETAMINOPHEN 6 Analgesics, Non-Salicylates ACETAMINOPHEN 500 MG/15 ML LIQUID ACETAMINOPHEN 90 Analgesics, Non-Salicylates ACETAMINOPHEN 650 MG TAB/CAP/SUPPOSITORY ACETAMINOPHEN 6 Analgesics, Non-Salicylates ACETAMINOPHEN 650 MG/20.3 ML ACETAMINOPHEN 100 Analgesics, Non-Salicylates ACETAMINOPHEN 80 MG TAB/CAP/SUPPOSITORY ACETAMINOPHEN 30 Analgesics, Opioid Short-Acting ACETAMINOPHEN/CAFF/DIHYDROCOD 325-30-16 MG ACETAMINOPHEN/CAFF/DIHYDROCODONE 10 Proton Pump Inhibitors ACIPHEX 10 MG SPRINKLE DR CAPSULE RABEPRAZOLE 2 Proton Pump Inhibitors ACIPHEX 20 MG TABLET EC RABEPRAZOLE 2 Proton Pump Inhibitors ACIPHEX 5 MG SPRINKLE DR CAPSULE RABEPRAZOLE 1 Cytokine & CAM Antagonists ACTEMRA 162 MG/0.9 ML SYRINGE TOCILIZUMAB 0.13 Cytokine & CAM Antagonists ACTEMRA 200 MG/10 ML VIAL TOCILIZUMAB 1.5 Cytokine & CAM Antagonists ACTEMRA 400 MG/20 ML VIAL TOCILIZUMAB 1.5 Cytokine & CAM Antagonists ACTEMRA 80 MG/4 ML VIAL TOCILIZUMAB 1.5 Cytokine & CAM Antagonists ACTEMRA ACTPEN 162 MG/0.9 ML TOCILIZUMAB 0.13 Bile Salts ACTIGALL 300 MG CAPSULE URSODIOL 4 Analgesics, Opioid Short-Acting ACTIQ 1200 MCG LOZENGE FENTANYL CITRATE 4 Effective 07/20/21 Alphabetical by Brand Name (when applicable) Analgesics, Opioid Short-Acting ACTIQ 1600 MCG LOZENGE FENTANYL CITRATE 4 Analgesics, Opioid Short-Acting ACTIQ 200 MCG LOZENGE FENTANYL CITRATE 4 Analgesics, Opioid Short-Acting ACTIQ 400 MCG LOZENGE FENTANYL CITRATE 4 Analgesics, Opioid Short-Acting ACTIQ 600 MCG LOZENGE FENTANYL CITRATE 4 Analgesics, Opioid Short-Acting ACTIQ 800 MCG LOZENGE FENTANYL CITRATE 4 Estrogens ACTIVELLA 0.5-0.1 MG TABLET ESTRADIOL/NORETHINDRONE ACET 1 Estrogens ACTIVELLA 1MG-0.5 MG TABLET ESTRADIOL/NORETHINDRONE ACET 1 Bone Density Regulators ACTONEL 150 MG TABLET RISEDRONATE 0.04 Bone Density Regulators ACTONEL 30 MG TABLET RISEDRONATE 1 Bone Density Regulators ACTONEL 35 MG TABLET RISEDRONATE 0.15 Bone Density Regulators ACTONEL 5 MG TABLET RISEDRONATE 1 Hypoglycemics, TZDs ACTOPLUS MET 15 MG/500 MG TABLET PIOGLITAZONE/METFORMIN 3 Hypoglycemics, TZDs ACTOPLUS MET 15 MG/850 MG TABLET PIOGLITAZONE/METFORMIN 3 Hypoglycemics, TZDs ACTOS 15 MG TABLET PIOGLITAZONE 1 Hypoglycemics, TZDs ACTOS 30 MG TABLET PIOGLITAZONE 1 Hypoglycemics, TZDs ACTOS 45 MG TABLET PIOGLITAZONE 1 Vaccines ADACEL TDAP VACCINE SYRINGE DIPHTHERIA, PERTUSSIS (ACELL), TETANTUS VACCINE 0.5 Vaccines ADACEL TDAP VACCINE VIAL DIPHTHERIA, PERTUSSIS (ACELL), TETANTUS VACCINE 0.5 Calcium Channel Blockers ADALAT CC 30 MG TABLET NIFEDIPINE 1 Calcium Channel Blockers ADALAT CC 60 MG TABLET NIFEDIPINE 2 Calcium Channel Blockers ADALAT CC 90 MG TABLET NIFEDIPINE 1 Antipsychotics ADASUVE 10 MG INHALATION POWDER LOXAPINE 0.2 Oncology, Other ADCETRIS 50 MG VIAL BRENTUXIMAB VEDOTIN 0.22 PAH Agents, Oral & Inhaled ADCIRCA 20 MG TABLET TADALAFIL 2 Stimulants & Related Agents ADDERALL 10 MG TABLET AMPHETAMINE MIXED SALTS 3 Stimulants & Related Agents ADDERALL 12.5 MG TABLET AMPHETAMINE MIXED SALTS 3 Stimulants & Related Agents ADDERALL 15 MG TABLET AMPHETAMINE MIXED SALTS 3 Stimulants & Related Agents ADDERALL 20 MG TABLET AMPHETAMINE MIXED SALTS 3 Stimulants & Related Agents ADDERALL 30 MG TABLET AMPHETAMINE MIXED SALTS 2 Stimulants & Related Agents ADDERALL 5 MG TABLET AMPHETAMINE MIXED SALTS 3 Stimulants & Related Agents ADDERALL 7.5 MG TABLET AMPHETAMINE MIXED SALTS 3 Stimulants & Related Agents ADDERALL XR 10 MG CAPSULE AMPHETAMINE MIXED SALTS 1 Stimulants & Related Agents ADDERALL XR 15 MG CAPSULE AMPHETAMINE MIXED SALTS 1 Stimulants & Related Agents ADDERALL XR 20 MG CAPSULE AMPHETAMINE MIXED SALTS 2 Stimulants & Related Agents ADDERALL XR 25 MG CAPSULE AMPHETAMINE MIXED SALTS 2 Stimulants & Related Agents ADDERALL XR 30 MG CAPSULE AMPHETAMINE MIXED SALTS 2 Stimulants & Related Agents ADDERALL XR 5 MG CAPSULE AMPHETAMINE MIXED SALTS 1 PAH Agents, Oral & Inhaled ADEMPAS 0.5 MG TABLET RIOCIGUAT 3 PAH Agents, Oral & Inhaled ADEMPAS 1 MG TABLET RIOCIGUAT 3 PAH Agents, Oral & Inhaled ADEMPAS 1.5 MG TABLET RIOCIGUAT 3 PAH Agents, Oral & Inhaled ADEMPAS 2 MG TABLET RIOCIGUAT 3 Effective 07/20/21 Alphabetical by Brand Name (when applicable) PAH Agents, Oral & Inhaled ADEMPAS 2.5 MG TABLET RIOCIGUAT 3 Stimulants & Related Agents ADHANSIA XR 25 MG CAPSULE METHYLPHENIDATE ER 1 Stimulants & Related Agents ADHANSIA XR 35 MG CAPSULE METHYLPHENIDATE ER 1 Stimulants & Related Agents ADHANSIA XR 45 MG CAPSULE METHYLPHENIDATE ER 1 Stimulants & Related Agents ADHANSIA XR 55 MG CAPSULE
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    University of South Florida Masthead Logo Scholar Commons School of Information Faculty Publications School of Information 7-2015 A Comparative Effectiveness Meta-Analysis of Drugs for the Prophylaxis of Migraine Headache Authors: Jeffrey L. Jackson, Elizabeth Cogbill, Rafael Santana-Davila, Christina Eldredge, William Collier, Andrew Gradall, Neha Sehgal, and Jessica Kuester OBJECTIVE: To compare the effectiveness and side effects of migraine prophylactic medications. DESIGN: We performed a network meta-analysis. Data were extracted independently in duplicate and quality was assessed using both the JADAD and Cochrane Risk of Bias instruments. Data were pooled and network meta-analysis performed using random effects models. DATA SOURCES: PUBMED, EMBASE, Cochrane Trial Registry, bibliography of retrieved articles through 18 May 2014. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: We included randomized controlled trials of adults with migraine headaches of at least 4 weeks in duration. RESULTS: Placebo controlled trials included alpha blockers (n = 9), angiotensin converting enzyme inhibitors (n = 3), angiotensin receptor blockers (n = 3), anticonvulsants (n = 32), beta-blockers (n = 39), calcium channel blockers (n = 12), flunarizine (n = 7), serotonin reuptake inhibitors (n = 6), serotonin norepinephrine reuptake inhibitors (n = 1) serotonin agonists (n = 9) and tricyclic antidepressants (n = 11). In addition there were 53 trials comparing different drugs. Drugs with at least 3 trials that were more effective than placebo for episodic migraines
  • Gabapentinoids: Pharmacokinetics, Pharmacodynamics and Considerations for Clinical Practice

    Gabapentinoids: Pharmacokinetics, Pharmacodynamics and Considerations for Clinical Practice

    912496BJP British Journal of PainChincholkar Special Issue Article British Journal of Pain 1 –11 Gabapentinoids: pharmacokinetics, © The British Pain Society 2020 Article reuse guidelines: sagepub.com/journals-permissions pharmacodynamics and considerations DOI:https://doi.org/10.1177/2049463720912496 10.1177/2049463720912496 for clinical practice journals.sagepub.com/home/bjp Mahindra Chincholkar Abstract The gabapentinoids are often recommended as first-line treatments for the management of neuropathic pain. The differing pharmacodynamic and pharmacokinetic profiles can have implications for clinical practice. This article has summarised these key differences. In addition to their use in managing neuropathic pain, gabapentinoids are increasingly being used for off-label conditions despite the lack of evidence. Prescription rates for off-label conditions have overtaken that for on-label use. Similarly, the use of gabapentinoids in the perioperative period is now embedded in clinical practice despite conflicting evidence. This article summarises the risks associated with this increasing use. There is increasing evidence of the potential to cause harm in vulnerable populations such as the elderly and increasing prevalence of abuse. The risk of respiratory depression in combination with opioids is of particular concern in the context of the current opioid crisis. This article describes the practical considerations involved that might help guide appropriate prescribing practices. Keywords Gabapentin, pregabalin, pain management, adverse effects, pharmacology Introduction movement, sleep disorders, headaches, alcohol with- drawal syndrome, chronic back pain, fibromyalgia, vis- The gabapentinoid drugs gabapentin and pregabalin ceral pain and acute postoperative pain.4,5 The rate of are antiepileptic drugs that are considered as first-line new prescriptions is increasing and tripled in England 1 treatments for the management of neuropathic pain.
  • DESCRIPTION Vantas™ (Histrelin Implant) Is a Sterile Non-Biodegradable, Diffusion-Controlled Reservoir Drug Delivery System De

    DESCRIPTION Vantas™ (Histrelin Implant) Is a Sterile Non-Biodegradable, Diffusion-Controlled Reservoir Drug Delivery System De

    Vantas™ (histrelin implant) PACKAGE INSERT DESCRIPTION Vantas™ (histrelin implant) is a sterile non-biodegradable, diffusion-controlled reservoir drug delivery system designed to deliver histrelin continuously for 12 months upon subcutaneous implantation. The Vantas implant contains 50 mg of histrelin acetate. Histrelin acetate is a synthetic nonapeptide analogue of the naturally occurring gonadotropin releasing hormone (GnRH) or luteinizing hormone releasing hormone (LH-RH). The sterile Vantas implantation device (provided with the implant) is used to insert the implant subcutaneously in the inner aspect of the upper arm. After 12 months, the implant must be removed. At the time the implant is removed, another implant may be inserted to continue therapy. The sterile Vantas ™ implant consists of a 50-mg histrelin acetate drug core inside a non- biodegradable, 3 cm by 3.5 mm cylindrically shaped hydrogel reservoir (Figure A). The drug core also contains the inactive ingredient stearic acid NF. The hydrogel reservoir is a hydrophilic polymer cartridge composed of 2-hydroxyethyl methacrylate, 2-hydroxypropyl methacrylate, trimethylolpropane trimethacrylate, benzoin methyl ether, Perkadox-16, and Triton X-100. The hydrated implant is packaged in a glass vial containing 2.0 mL of 1.8% NaCl solution. The implant is primed for release of the drug upon insertion. Figure A. Vantas Histrelin Implant diagram (not to scale) Hydrogel Reservoir Drug Formulation Histrelin acetate is chemically described as 5-oxo-L-prolyl-L-histidyl-L-tryptophyl-L-seryl-L- tyrosyl-Nt-benzyl-D-histidyl-L-leucyl-L-arginyl-N-ethyl-L-prolinamide acetate (salt) [C66H86N18O12. (1.7-2.8 moles) CH3COOH, (0.6-7.0 moles) H2O], with the molecular weight of 1443.70 (or 1323.50 as histrelin base.