BUREAU FOR MEDICAL SERVICES WEST VIRGINIA MEDICAID Effective 9/2/08 PREFERRED DRUG LIST WITH PRIOR AUTHORIZATION CRITERIA Version 2008.7

THERAPEUTIC PREFERRED NON-PREFERRED PA DRUG CLASS AGENTS AGENTS CRITERIA AGENTS, TOPICAL ANTI-INFECTIVE A trial of at least 30 days each with at least one AKNE-MYCIN () CLEOCIN-T () preferred and two unique chemical entities AZELEX () EVOCLIN (clindamycin) in at least two other subclasses, including the clindamycin KLARON (sodium ) generic version of a requested non-preferred erythromycin product, will be required before a non-preferred sodium sulfacetamide agent will be authorized unless one of the exceptions on the PA form is present. (In cases of RETIN A liquid & Micro () AVITA pregnancy, a trial of retinoids will not be required.) TAZORAC () DIFFERIN () tretinoin cream, gel RETIN-A cream, gel (tretinoin) PA required after 17 years of age for tretinoin products.

KERATOLYTICS (Benzoyl Peroxides) With the exception of Duac CS, acne kits are non- BENZAC WASH () BREVOXYL (benzoyl peroxide) preferred benzoyl peroxide DESQUAM (benzoyl peroxide) ETHEXDERM (benzoyl peroxide) LAVOCLEN (benzoyl peroxide) OSCION (benzoyl peroxide) TRIAZ (benzoyl peroxide) COMBINATION AGENTS benzoyl peroxide/urea BENZACLIN GEL DUAC CS (benzoyl peroxide/ (benzoyl peroxide/clindamycin) clindamycin) BENZAMYCIN PAK erythromycin/benzoyl peroxide (benzoyl peroxide/erythromycin) sulfacetamide sodium/ CLENIA (sulfacetamide sodium/sulfur) wash/cleanser INOVA 4/1 (benzoyl peroxide/) NUOX (benzoyl peroxide/sulfur) PLEXION (sulfacetamide sodium/sulfur) PRASCION (sulfacetamide sodium/sulfur) ROSAC (sulfacetamide sodium/avobenzone/sulfur) ROSADERM (sulfacetamide sodium/sulfur) ROSANIL (sulfacetamide sodium/sulfur) ROSULA (sulfacetamide sodium/sulfur/urea) sulfacetamide sodium/sulfur lotion, gel SULFOXYL (benzoyl peroxide/sulfur) SULFATOL (sulfacetamide sodium/sulfur/urea) ZIANA (clindamycin/tretinoin)

Unless otherwise specified, the listing of a particular brand or generic name includes all legend forms of that drug. OTC are not covered unless specified. 1 CL – Requires Clinical PA NR – New drug has not been reviewed by P & T Committee BUREAU FOR MEDICAL SERVICES WEST VIRGINIA MEDICAID Effective 9/2/08 PREFERRED DRUG LIST WITH PRIOR AUTHORIZATION CRITERIA Version 2008.7

THERAPEUTIC PREFERRED NON-PREFERRED PA DRUG CLASS AGENTS AGENTS CRITERIA ALZHEIMER’S AGENTS CHOLINESTERASE INHIBITORS A trial of a preferred agent will be required before a ARICEPT (donepezil) COGNEX (tacrine) non-preferred agent In this class will be authorized. ARICEPT ODT(donepezil) RAZADYNE (galantamine) EXELON (rivastigmine) RAZADYNE ER (galantamine) NMDA RECEPTOR ANTAGONIST NAMENDA (memantine)

Unless otherwise specified, the listing of a particular brand or generic name includes all legend forms of that drug. OTC are not covered unless specified. 2 CL – Requires Clinical PA NR – New drug has not been reviewed by P & T Committee BUREAU FOR MEDICAL SERVICES WEST VIRGINIA MEDICAID Effective 9/2/08 PREFERRED DRUG LIST WITH PRIOR AUTHORIZATION CRITERIA Version 2008.7

THERAPEUTIC PREFERRED NON-PREFERRED PA DRUG CLASS AGENTS AGENTS CRITERIA ANALGESICS, NARCOTIC - APAP/codeine ACTIQ (fentanyl) A trial of at least four (4) chemically distinct (based on SHORT ACTING ASA/codeine butalbital/APAP/caffeine/codeine narcotic ingredient only) preferred agents, including (Non-parenteral) codeine butalbital/ASA/caffeine/codeine the generic formulation of a requested non-preferred dihydrocodeine/ APAP/caffeine butorphanol product, must be tried before a non-preferred agent hydrocodone/APAP COMBUNOX (oxycodone/) will be authorized unless one of the exceptions on the hydrocodone/ibuprofen DARVOCET (propoxyphene/APAP) PA form is present. hydromorphone DARVON (propoxyphene) levorphanol DEMEROL (meperidine) Fentanyl lozenges will only be approved as an adjunct morphine DILAUDID (hydromorphone) to a long-acting agent. Fentanyl lozenges will not be oxycodone fentanyl approved for monotherapy. oxycodone/APAP FENTORA (fentanyl) oxycodone/ASA FIORICET W/ CODEINE Limits: Quantities exceeding 240 tablets per 30 days pentazocine/APAP (butalbital/APAP/caffeine/codeine) (8 tablets/day) for agents containing 500 mg of pentazocine/naloxone FIORINAL W/ CODEINE acetaminophen will require a prior authorization. propoxyphene/APAP (butalbital/ASA/caffeine/codeine)

ROXICET (oxycodone/acetaminophen) LORCET (hydrocodone/APAP) . tramadol LORTAB (hydrocodone/APAP) tramadol/APAP LYNOX (oxycodone/APAP) VOPAC (codeine/acetaminophen) meperidine OPANA (oxymorphone) oxycodone/ibuprofen OXYFAST (oxycodone) OXYIR (oxycodone) PANLOR (dihydrocodeine/ APAP/caffeine) PERCOCET (oxycodone/APAP) PERCODAN (oxycodone/ASA) propoxyphene ROXANOL (morphine) TALACEN (pentazocine/APAP) TALWIN NX (pentazocine/naloxone) TYLENOL W/CODEINE (APAP/codeine) ULTRACET (tramadol/APAP) ULTRAM (tramadol) VICODIN (hydrocodone/APAP) VICOPROFEN (hydrocodone/ibuprofen) XODOL (hydrocone/acetaminophen) ZAMICET (hydrocodone/APAP) ZYDONE (hydrocodone/acetaminophen)

Unless otherwise specified, the listing of a particular brand or generic name includes all legend forms of that drug. OTC are not covered unless specified. 3 CL – Requires Clinical PA NR – New drug has not been reviewed by P & T Committee BUREAU FOR MEDICAL SERVICES WEST VIRGINIA MEDICAID Effective 9/2/08 PREFERRED DRUG LIST WITH PRIOR AUTHORIZATION CRITERIA Version 2008.7

THERAPEUTIC PREFERRED NON-PREFERRED PA DRUG CLASS AGENTS AGENTS CRITERIA ANALGESICS, NARCOTIC - fentanyl AVINZA (morphine) A total of four (4) preferred narcotic analgesics, LONG ACTING KADIAN (morphine) DURAGESIC (fentanyl) including at least one long-acting agent, must be tried (Non-parenteral) methadone MS CONTIN (morphine) for at least six (6) days before a non-preferred agent morphine ER OPANA ER (oxymorphone) will be authorized unless one of the exceptions on the ORAMORPH SR (morphine) PA form is present. The generic form of the oxycodone ER requested non-preferred agent, if available, must be OXYCONTIN (oxycodone) tried before the non-preferred agent will be approved. ULTRAM ER (tramadol) Exception: Oxycodone ER will be authorized if a diagnosis of cancer is submitted without a trial of the preferred agents. ANDROGENIC AGENTS ANDRODERM (testosterone) TESTIM (testosterone) The non-preferred agents will be approved only if one ANDROGEL (testosterone) of the exceptions on the PA form is present. ANGIOTENSIN MODULATORS ACE INHIBITORS Each of the preferred agents in the corresponding ALTACE (ramipril) ACCUPRIL (quinapril) group and the generic formulation of the requested benazepril ACEON (perindopril) non-preferred agent, with the exception of Direct captopril CAPOTEN (captopril) Renin Inhibitors, must be tried for at least two enalapril LOTENSIN (benazepril) weeks each before a non-preferred agent in that fosinopril MAVIK (trandolapril) group will be authorized unless one of the lisinopril moexipril exceptions on the PA form is present. quinapril MONOPRIL (fosinopril) PRINIVIL (lisinopril) ramipril trandolapril UNIVASC (moexipril) VASOTEC (enalapril) ZESTRIL (lisinopril) ACE INHIBITOR COMBINATION DRUGS

benazepril/amlodipine ACCURETIC (quinapril/HCTZ) benazepril/HCTZ CAPOZIDE (captopril/HCTZ) captopril/HCTZ LEXXEL (enalapril/felodipine) enalapril/HCTZ LOTENSIN HCT (benazepril/HCTZ) fosinopril/HCTZ LOTREL (benazepril/amlodipine) lisinopril/HCTZ moexipril/HCTZ quinapril/HCTZ MONOPRIL HCT (fosinopril/HCTZ) PRINZIDE (lisinopril/HCTZ) TARKA (trandolapril/verapamil) UNIRETIC (moexipril/HCTZ) VASERETIC (enalapril/HCTZ) ZESTORETIC (lisinopril/HCTZ)

Unless otherwise specified, the listing of a particular brand or generic name includes all legend forms of that drug. OTC are not covered unless specified. 4 CL – Requires Clinical PA NR – New drug has not been reviewed by P & T Committee BUREAU FOR MEDICAL SERVICES WEST VIRGINIA MEDICAID Effective 9/2/08 PREFERRED DRUG LIST WITH PRIOR AUTHORIZATION CRITERIA Version 2008.7

THERAPEUTIC PREFERRED NON-PREFERRED PA DRUG CLASS AGENTS AGENTS CRITERIA ANGIOTENSIN MODULATORS ANGIOTENSIN II RECEPTOR BLOCKERS (ARBs)

AVAPRO (irbesartan) ATACAND (candesartan)

BENICAR (olmesartan) TEVETEN (eprosartan)

COZAAR (losartan)

DIOVAN (valsartan)

MICARDIS (telmisartan)

ARB COMBINATIONS AVALIDE (irbesartan/HCTZ) ATACAND-HCT (candesartan/HCTZ) BENICAR-HCT (olmesartan/HCTZ) AZOR (olmesartan/amlodipine) DIOVAN-HCT (valsartan/HCTZ) TEVETEN-HCT (eprosartan/HCTZ) EXFORGE (valsartan/amlodipine) HYZAAR (losartan/HCTZ) MICARDIS-HCT (telmisartan/HCTZ) DIRECT RENIN INHIBITORS A thirty-day trial of one of the preferred ACE, ARB, or combination agents, at the maximum tolerable TEKTURNA (aliskiren) dose, is required before Tekturna will be approved. ANTICOAGULANTS, ARIXTRA (fondaparinux) INNOHEP (tinzaparin) A trial of each of the preferred agents will be INJECTABLE CL FRAGMIN (dalteparin) required before a non-preferred agent will be LOVENOX (enoxaparin) approved unless one of the exceptions on the PA form is present.

Unless otherwise specified, the listing of a particular brand or generic name includes all legend forms of that drug. OTC are not covered unless specified. 5 CL – Requires Clinical PA NR – New drug has not been reviewed by P & T Committee BUREAU FOR MEDICAL SERVICES WEST VIRGINIA MEDICAID Effective 9/2/08 PREFERRED DRUG LIST WITH PRIOR AUTHORIZATION CRITERIA Version 2008.7

THERAPEUTIC PREFERRED NON-PREFERRED PA DRUG CLASS AGENTS AGENTS CRITERIA ANTICONVULSANTS ADJUVANTS Treatment naive patients must have a trial of a preferred agent before a non-preferred agent in its carbamazepine DEPAKENE (valproic acid) corresponding class will be authorized. Additions CARBATROL (carbamazepine) Divalproex EC to that therapy will require a trial of preferred agent DEPAKOTE (divalproex) EQUETRO (carbamazepine) in its respective class unless one of the exceptions DEPAKOTE ER (divalproex) lamotrigine on the PA form is present. DEPAKOTE SPRINKLE (divalproex) NEURONTIN (gabapentin)

FELBATOL (felbamate) oxcarbazepine

gabapentin STAVZOR (valproic acid) - NR

GABITRIL (tiagabine) TEGRETOL (carbamazepine) KEPPRA (levetiracetam) TEGRETOL XR (carbamazepine) LAMICTAL (lamotrigine) ZONEGRAN (zonisamide) LYRICA (pregabalin) TOPAMAX (topiramate) TRILEPTAL (oxcarbazepine) valproic acid zonisamide BARBITURATES mephobarbital MEBARAL (mephobarbital) phenobarbital MYSOLINE (primidone) primidone BENZODIAZEPINES clonazepam KLONOPIN (clonazepam) DIASTAT (diazepam rectal) diazepam HYDANTOINS DILANTIN INFATABS (phenytoin) CEREBYX (fosphenytoin) PEGANONE (ethotoin) DILANTIN (phenytoin) phenytoin EPITOL (phenytoin) PHENYTEK (phenytoin) SUCCINIMIDES CELONTIN (methsuximide) ZARONTIN (ethosuximide) ethosuximide

Unless otherwise specified, the listing of a particular brand or generic name includes all legend forms of that drug. OTC are not covered unless specified. 6 CL – Requires Clinical PA NR – New drug has not been reviewed by P & T Committee BUREAU FOR MEDICAL SERVICES WEST VIRGINIA MEDICAID Effective 9/2/08 PREFERRED DRUG LIST WITH PRIOR AUTHORIZATION CRITERIA Version 2008.7

THERAPEUTIC PREFERRED NON-PREFERRED PA DRUG CLASS AGENTS AGENTS CRITERIA ANTIDEPRESSANTS, OTHER bupropion SR bupropion IR A non-preferred agent will only be authorized if (second generation, non-SSRI) CYMBALTA (duloxetine) bupropion XL there has been a six-week trial of an SSRI and a EFFEXOR XR (venlafaxine) DESYREL (trazodone) preferred agent in this class unless one of the mirtazapine EFFEXOR (venlafaxine) exceptions on the PA form is present. trazodone EMSAM (selegiline) nefazodone PRISTIQ (desvenlafaxine) REMERON (mirtazapine) venlafaxine WELLBUTRIN (bupropion) WELLBUTRIN SR (bupropion) WELLBUTRIN XL (bupropion) ANTIDEPRESSANTS, SSRIs citalopram CELEXA (citalopram) A trial of two of the preferred agents will be fluoxetine LEXAPRO (escitalopram) required, for at least 30 days, before a non- fluvoxamine LUVOX (fluvoxamine) preferred agent will be approved unless one of the paroxetine LUVOX CR (fluvoxamine) exceptions on the PA form is present. Upon sertraline PAXIL (paroxetine) hospital discharge, patients admitted with a PAXIL CR (paroxetine) primary mental health diagnosis and have been paroxetine ER stabilized on a non-preferred SSRI will receive PEXEVA (paroxetine) authorization to continue that drug. PROZAC (fluoxetine) RAPIFLUX (fluoxetine) SARAFEM (fluoxetine) ZOLOFT (sertraline)

Unless otherwise specified, the listing of a particular brand or generic name includes all legend forms of that drug. OTC are not covered unless specified. 7 CL – Requires Clinical PA NR – New drug has not been reviewed by P & T Committee BUREAU FOR MEDICAL SERVICES WEST VIRGINIA MEDICAID Effective 9/2/08 PREFERRED DRUG LIST WITH PRIOR AUTHORIZATION CRITERIA Version 2008.7

THERAPEUTIC PREFERRED NON-PREFERRED PA DRUG CLASS AGENTS AGENTS CRITERIA ANTIEMETICS, ORAL 5HT3 RECEPTOR BLOCKERS A trial of the preferred agent is required before a non-preferred agent will be authorized unless one ondansetron ANZEMET (dolasetron) of the exceptions on the PA form is present. PA is ondansetron ODT KYTRIL (granisetron) required when limits are exceeded. granisetron ZOFRAN (ondansetron) ZOFRAN ODT (ondansetron) CANNABINOIDS Cesamet will be authorized only for the treatment of nausea and vomiting associated with cancer CESAMET (nabilone) chemotherapy for patients who have failed to MARINOL (dronabinol) respond adequately to conventional treatments such as promethazine or ondansetron and are over 18 years of age. Marinol will be authorized only for the treatment of anorexia associated with weight loss in patients with AIDS or cancer and unresponsive to megestrol, the prophylaxis of chemotherapy induced nausea and vomiting unresponsive to ondansetron or promethazine and for patients between the ages of 18 and 65 years of age. SUBSTANCE P ANTAGONISTS PA is required when limits are exceeded. EMEND (aprepitant) ANTIFUNGALS, ORAL clotrimazole ANCOBON (flucytosine) Non-preferred agents will be approved only if one fluconazole* DIFLUCAN (fluconazole) of the exceptions on the PA form is present. ketoconazole CL GRIFULVIN V (griseofulvin) nystatin griseofulvin *PA is required when limits are exceeded. terbinafine CL GRIS-PEG (griseofulvin) itraconazole PA is not required for Grifulvin-V Suspension for LAMISIL (terbinafine) children up to 6 years of age for the treatment of MYCELEX (clotrimazole) tinea capitis. MYCOSTATIN Tablets (nystatin) NIZORAL (ketoconazole) NOXAFIL (posaconazole) SPORANOX (itraconazole) VFEND (voriconazole)

Unless otherwise specified, the listing of a particular brand or generic name includes all legend forms of that drug. OTC are not covered unless specified. 8 CL – Requires Clinical PA NR – New drug has not been reviewed by P & T Committee BUREAU FOR MEDICAL SERVICES WEST VIRGINIA MEDICAID Effective 9/2/08 PREFERRED DRUG LIST WITH PRIOR AUTHORIZATION CRITERIA Version 2008.7

THERAPEUTIC PREFERRED NON-PREFERRED PA DRUG CLASS AGENTS AGENTS CRITERIA ANTIFUNGALS, TOPICAL ANTIFUNGALS Two of the preferred agents must be tried for at least two weeks each before one of the non- econazole ciclopirox preferred agents will be authorized unless one of ketoconazole ERTACZO (sertaconazole) the exceptions on the PA form is present. MENTAX (butenafine) EXELDERM (sulconazole) NAFTIN (naftifine) LOPROX (ciclopirox) nystatin MYCOSTATIN (nystatin) NIZORAL (ketoconazole) OXISTAT (oxiconazole) PENLAC (ciclopirox) SPECTAZOLE (econazole) VUSION (miconazole/petrolatum/zinc oxide) XOLEGEL (ketoconazole) ANTIFUNGAL/STEROIDCOMBINATIONS clotrimazole/betamethasone LOTRISONE nystatin/triamcinolone (clotrimazole/betamethasone) MYCOLOG (nystatin/triamcinolone) ANTIHISTAMINES, MINIMALLY ANTIHISTAMINES A trial of at least 2 chemically distinct preferred SEDATING agents, in the age appropriate form, including the ALAVERT (loratadine) ALLEGRA (fexofenadine) generic formulation of a requested non-preferred cetirizine (OTC) CLARINEX Tablets (desloratadine) product, must be tried before a non-preferred loratadine CLARINEX REDITABS (desloratadine) agent will be authorized unless one of the TAVIST-ND (loratadine) CLARINEX Syrup (desloratadine) exceptions on the PA form is present. CLARITIN (loratadine) fexofenadine XYZAL (levocetirizine) ZYRTEC (Rx and OTC) (cetirizine) ZYRTEC SYRUP (Rx and OTC) (cetirizine) ANTIHISTAMINE/DECONGESTANT COMBINATIONS ALAVERT-D ALLEGRA-D (loratadine/pseudoephedrine) (fexofenadine/pseudoephedrine) cetirizine /pseudoephedrine (OTC) CLARINEX-D loratadine/pseudoephedrine (desloratadine/pseudoephedrine) SEMPREX-D CLARITIN-D (acrivastine/ pseudoephedrine) (loratadine/pseudoephedrine) ZYRTEC-D (Rx and OTC) (cetirizine/pseudoephedrine)

Unless otherwise specified, the listing of a particular brand or generic name includes all legend forms of that drug. OTC are not covered unless specified. 9 CL – Requires Clinical PA NR – New drug has not been reviewed by P & T Committee BUREAU FOR MEDICAL SERVICES WEST VIRGINIA MEDICAID Effective 9/2/08 PREFERRED DRUG LIST WITH PRIOR AUTHORIZATION CRITERIA Version 2008.7

THERAPEUTIC PREFERRED NON-PREFERRED PA DRUG CLASS AGENTS AGENTS CRITERIA ANTIMIGRAINE AGENTS, TRIPTANS All of the preferred agents must be tried before a TRIPTANS AMERGE (naratriptan) AXERT (almotriptan) non-preferred agent will be approved unless one of IMITREX (sumatriptan) FROVA (frovatriptan) the exceptions on the PA form is present. Quantity MAXALT (rizatriptan) ZOMIG (zolmitriptan) limits apply for this drug class. RELPAX (eletriptan)

TRIPTAN COMBINATIONS TREXIMET (sumatriptan/naproxen sodium)

ANTIPARKINSON’S AGENTS ANTICHOLINERGICS Patients starting therapy on drugs in this class (Oral) must show a documented to all of the benztropine COGENTIN (benztropine) preferred agents, in the corresponding class, KEMADRIN (procyclidine) before a non-preferred agent will be authorized. trihexyphenidyl COMT INHIBITORS COMTAN (entacapone) TASMAR (tolcapone) DOPAMINE AGONISTS ropinirole MIRAPEX (pramipexole) REQUIP (ropinirole) REQUIP XL (ropinirole) OTHER ANTIPARKINSON’S AGENTS carbidopa/levodopa AZILECT (rasagiline) selegiline ELDEPRYL (selegiline) STALEVO PARCOPA (levodopa/carbidopa) (levodopa/carbidopa/entacapone) SINEMET (levodopa/carbidopa) ZELAPAR (selegiline)

Unless otherwise specified, the listing of a particular brand or generic name includes all legend forms of that drug. OTC are not covered unless specified. 10 CL – Requires Clinical PA NR – New drug has not been reviewed by P & T Committee BUREAU FOR MEDICAL SERVICES WEST VIRGINIA MEDICAID Effective 9/2/08 PREFERRED DRUG LIST WITH PRIOR AUTHORIZATION CRITERIA Version 2008.7

THERAPEUTIC PREFERRED NON-PREFERRED PA DRUG CLASS AGENTS AGENTS CRITERIA ANTIPSYCHOTICS, ATYPICAL ORAL Treatment naïve patients for this class of drugs will (Oral) be required to try a preferred agent for two weeks clozapine ABILIFY (aripiprazole) unless one of the exceptions on the PA form is GEODON (ziprasidone) CLOZARIL (clozapine) present. Upon discharge, hospitalized patients INVEGA (paliperidone) FAZACLO (clozapine) stabilized on non-preferred agents will receive RISPERDAL (risperidone) risperidone authorization to continue these drugs for labeled SEROQUEL (quetiapine) ZYPREXA (olanzapine) indications and at recommended dosages. SEROQUEL XR (quetiapine)

ATYPICAL ANTIPSYCHOTIC/SSRI COMBINATIONS Abilify will be prior authorized for MDD if the SYMBYAX (olanzapine/fluoxetine) following criteria are met:

1. The patient is at least 18 year of age.

2. Diagnosis of Major Depressive Disorder (MDD) not responsive to other antidepressants.

3. Evidence of trials of appropriate therapeutic duration at a maximum tolerable dose of at least two (2) of the following agents: Selective Serotonin Reuptake Inhibitors (SSRI), Norepinephrine Reuptake Inhibitors, or bupropion.

4. Prescribed in conjunction with an SSRI, SNRI or bupropion.

The daily dose does not exceed 15 mg. ANTIVIRALS (Oral) ANTI HERPES All of the appropriate preferred agents must be tried before the non-preferred agents will be acyclovir FAMVIR (famciclovir) authorized unless one of the exceptions on the PA VALTREX (valacyclovir) ZOVIRAX (acyclovir) form is present. ANTI INFLUENZA All of the appropriate preferred agents must be tried before the non-preferred agents will be amantadine FLUMADINE (rimantadine) authorized unless one of the exceptions on the PA RELENZA (zanamivir) form is present. rimantadine SYMMETREL (amantadine) TAMIFLU (oseltamivir) ATOPIC DERMATITIS ELIDEL (pimecrolimus) PROTOPIC (tacrolimus)

Unless otherwise specified, the listing of a particular brand or generic name includes all legend forms of that drug. OTC are not covered unless specified. 11 CL – Requires Clinical PA NR – New drug has not been reviewed by P & T Committee BUREAU FOR MEDICAL SERVICES WEST VIRGINIA MEDICAID Effective 9/2/08 PREFERRED DRUG LIST WITH PRIOR AUTHORIZATION CRITERIA Version 2008.7

THERAPEUTIC PREFERRED NON-PREFERRED PA DRUG CLASS AGENTS AGENTS CRITERIA BETA BLOCKERS (Oral) BETA BLOCKERS A trial of three chemically distinct preferred agents, including the generic formulation of a requested acebutolol BETAPACE (sotalol) non-preferred product, is required before one of atenolol BLOCADREN (timolol) the non-preferred agents will be approved unless betaxolol BYSTOLIC (nebivolol) one of the exceptions on the PA form is present. bisoprolol CARTROL (carteolol) Toprol XL will be approved after a trial of an metoprolol CORGARD (nadolol) equivalent generic formulation when there is a metoprolol ER INDERAL LA (propranolol) diagnosis of cardiovascular complications, asthma, nadolol INNOPRAN XL (propranolol) chronic bronchitis, COPD, or failure to achieve the pindolol KERLONE (betaxolol) desired outcomes on the generic formulation. propranolol LEVATOL (penbutolol)

propranolol ER LOPRESSOR (metoprolol) sotalol SECTRAL (acebutolol) timolol TENORMIN (atenolol) TOPROL XL (metoprolol) ZEBETA (bisoprolol) BETA BLOCKER/DIURETIC COMBINATION DRUGS atenolol/chlorthalidone CORZIDE (nadolol/bendroflumethiazide) bisoprolol/HCTZ INDERIDE (propranolol/HCTZ) metoprolol/HCTZ LOPRESSOR HCT (metoprolol/HCTZ) nadolol/bendroflumethiazide TENORETIC (atenolol/chlorthalidone) propranolol/HCTZ ZIAC (bisoprolol/HCTZ) BETA- AND ALPHA-BLOCKERS

carvedilol COREG (carvedilol) labetalol COREG CR (carvedilol) TRANDATE (labetalol) BLADDER RELAXANT ENABLEX (darifenacin) DETROL (tolterodine) A trial of at least one of each of the chemically PREPARATIONS oxybutynin DETROL LA (tolterodine) distinct preferred agents must be tried before a oxybutynin ER DITROPAN (oxybutynin) non-preferred agent will be authorized unless one OXYTROL (oxybutynin) DITROPAN XL (oxybutynin) of the exceptions on the PA form is present. SANCTURA (trospium) SANCTURA XR (trospium) VESICARE (solifenacin)

Unless otherwise specified, the listing of a particular brand or generic name includes all legend forms of that drug. OTC are not covered unless specified. 12 CL – Requires Clinical PA NR – New drug has not been reviewed by P & T Committee BUREAU FOR MEDICAL SERVICES WEST VIRGINIA MEDICAID Effective 9/2/08 PREFERRED DRUG LIST WITH PRIOR AUTHORIZATION CRITERIA Version 2008.7

THERAPEUTIC PREFERRED NON-PREFERRED PA DRUG CLASS AGENTS AGENTS CRITERIA BONE RESORPTION BISPHOSPHONATES One of the preferred agents must be tried for at SUPPRESSION AND alendronate ACTONEL (risedronate) least one month before a non-preferred agent will RELATED AGENTS FOSAMAX PLUS D ACTONEL WITH CALCIUM be authorized unless one of the exceptions on the (alendronate/vitamin D) (risedronate/calcium) PA form is present. BONIVA (ibandronate) DIDRONEL (etidronate) FOSAMAX (alendronate)

OTHER BONE RESORPTION SUPPRESSION AND RELATED AGENTS Evista will be approved for postmenopausal MIACALCIN (calcitonin) EVISTA (raloxifene) women with osteoporosis or at high risk for FORTEO (teriparatide) invasive breast cancer. FORTICAL (calcitonin) BPH AGENTS 5-ALPHA-REDUCTASE (5AR) INHIBITORS A trial of at least two (2) chemically distinct preferred agents, including the generic formulation AVODART (dutasteride) finasteride of a requested non-preferred agent, must be tried PROSCAR (finasteride) before a non-preferred agent will be authorized ALPHA BLOCKERS unless one of the exceptions on the PA form is present. doxazosin CARDURA (doxazosin) FLOMAX (tamsulosin) CARDURA XL (doxazosin) terazosin HYTRIN (terazosin) UROXATRAL (alfuzosin) BRONCHODILATORS, ANTICHOLINERGIC The preferred agents in the class must be tried ANTICHOLINERGIC ATROVENT HFA (ipratropium) ATROVENT Inhalation Solution before the non-preferred agent will be authorized ipratropium (ipratropium) unless one of the exceptions on the PA form is SPIRIVA (tiotropium) present.

ANTICHOLINERGIC-BETA AGONIST COMBINATIONS For severely compromised patients, COMBIVENT (albuterol/ipratropium) albuterol/ipratropium albuterol/ipratropium will be approved if the DUONEB (albuterol/ipratropium) combined volume of albuterol and ipratropium nebules is inhibitory.

Unless otherwise specified, the listing of a particular brand or generic name includes all legend forms of that drug. OTC are not covered unless specified. 13 CL – Requires Clinical PA NR – New drug has not been reviewed by P & T Committee BUREAU FOR MEDICAL SERVICES WEST VIRGINIA MEDICAID Effective 9/2/08 PREFERRED DRUG LIST WITH PRIOR AUTHORIZATION CRITERIA Version 2008.7

THERAPEUTIC PREFERRED NON-PREFERRED PA DRUG CLASS AGENTS AGENTS CRITERIA BRONCHODILATORS, BETA INHALATION SOLUTION All of the preferred agents in a group must be tried AGONIST before a non-preferred agent in that group will be albuterol ACCUNEB (albuterol)** NR authorized unless one of the exceptions on the PA BROVANA (arformoterol) form is present. metaproterenol NR PERFOROMIST (formoterol) Xopenex Inhalation Solution will be approved for PROVENTIL (albuterol) 12 months for a diagnosis of asthma or COPD for XOPENEX (levalbuterol) patients on concurrent asthma controller therapy INHALERS, LONG-ACTING (either oral or inhaled) with documentation of FORADIL (formoterol) SEREVENT (salmeterol) failure on a trial of albuterol or documented intolerance of albuterol, or for concurrent diagnosis INHALERS, SHORT-ACTING of heart disease.

albuterol CFC ALUPENT (metaproterenol) **No PA is required for ACCUNEB for children up MAXAIR (pirbuterol) PROVENTIL (albuterol) to 5 years of age. PROAIR HFA (albuterol) PROVENTIL HFA (albuterol) VENTOLIN HFA (albuterol) XOPENEX HFA (levalbuterol) ORAL albuterol BRETHINE (terbutaline) terbutaline metaproterenol VOSPIRE ER (albuterol)

Unless otherwise specified, the listing of a particular brand or generic name includes all legend forms of that drug. OTC are not covered unless specified. 14 CL – Requires Clinical PA NR – New drug has not been reviewed by P & T Committee BUREAU FOR MEDICAL SERVICES WEST VIRGINIA MEDICAID Effective 9/2/08 PREFERRED DRUG LIST WITH PRIOR AUTHORIZATION CRITERIA Version 2008.7

THERAPEUTIC PREFERRED NON-PREFERRED PA DRUG CLASS AGENTS AGENTS CRITERIA CALCIUM CHANNEL LONG-ACTING The preferred agents must be tried before a non- BLOCKERS (Oral) amlodipine ADALAT CC (nifedipine) preferred agent will be approved. CARDIZEM LA (diltiazem) CALAN SR (verapamil) diltiazem CARDENE SR (nicardipine) DYNACIRC CR (isradipine) CARDIZEM CD (diltiazem) felodipine ER CARDIZEM SR (diltiazem) nifedipine ER COVERA-HS (verapamil) nisoldipine DILACOR XR (diltiazem) verapamil ER ISOPTIN SR (verapamil) VERELAN PM (verapamil) NORVASC (amlodipine) PLENDIL (felodipine) PROCARDIA XL (nifedipine) SULAR (nisoldipine) TIAZAC (diltiazem) VERELAN (verapamil) SHORT-ACTING diltiazem ADALAT (nifedipine) verapamil CALAN (verapamil) CARDENE (nicardipine) CARDIZEM (diltiazem) DYNACIRC (isradipine) isradipine nicardipine nimodipine nifedipine NIMOTOP (nimodipine) PROCARDIA (nifedipine) CEPHALOSPORINS AND BETA LACTAM/BETA-LACTAMASE INHIBITOR COMBINATIONS The preferred agents must be tried before a non- RELATED (Oral) amoxicillin/clavulanate preferred agent will be authorized unless one of the exceptions on the PA form is present. CEPHALOSPORINS cefaclor CECLOR (cefaclor) cefadroxil CEDAX (ceftibuten) cefdinir CEFTIN (cefuroxime) cefpodoxime CEFZIL (cefprozil) cefprozil DURICEF (cefadroxil) cefuroxime KEFLEX (cephalexin) cephalexin OMNICEF (cefdinir) SPECTRACEF (cefditoren) PANIXINE (cephalexin) RANICLOR (cefaclor) SUPRAX (cefixime) VANTIN (cefpodoxime)

Unless otherwise specified, the listing of a particular brand or generic name includes all legend forms of that drug. OTC are not covered unless specified. 15 CL – Requires Clinical PA NR – New drug has not been reviewed by P & T Committee BUREAU FOR MEDICAL SERVICES WEST VIRGINIA MEDICAID Effective 9/2/08 PREFERRED DRUG LIST WITH PRIOR AUTHORIZATION CRITERIA Version 2008.7

THERAPEUTIC PREFERRED NON-PREFERRED PA DRUG CLASS AGENTS AGENTS CRITERIA CYTOKINE & CAM ENBREL (etanercept) CIMZIA (certolizumab/pegol)NR ANTAGONISTS CL HUMIRA (adalimumab) KINERET (anakinra) RAPTIVA (efalizumab) ERYTHROPOIESIS ARANESP (darbepoetin) EPOGEN (rHuEPO) The preferred agents must be tried before a non- STIMULATING PROTEINS CL PROCRIT (rHuEPO) preferred agent will be authorized unless one of the exceptions on the PA form is present. FLUOROQUINOLONES, ORAL AVELOX (moxifloxacin) CIPRO (ciprofloxacin) Tablets One of the preferred agents must be tried before a CIPRO (ciprofloxacin) Suspension CIPRO XR (ciprofloxacin) non-preferred agent will be authorized unless one ciprofloxacin FACTIVE (gemifloxacin) of the exceptions on the PA form is present. ciprofloxacin ER FLOXIN (ofloxacin) LEVAQUIN (levofloxacin) NOROXIN (norfloxacin) ofloxacin PROQUIN XR (ciprofloxacin) GENITAL WARTS AGENTS ALDARA (imiquimod) CONDYLOX (podofilox) The preferred agent must be tried before a non- podofilox preferred agent will be authorized unless on of the VEREGEN (sinecatechins) exceptions on the PA form is present. GLUCOCORTICOIDS, GLUCOCORTICOIDS All of the preferred agents of a dosage form must INHALED be tried before a non-preferred agent of that AEROBID (flunisolide) PULMICORT (budesonide) dosage form will be authorized unless one of the AEROBID-M (flunisolide) exceptions on the PA form is present. ASMANEX (mometasone)

AZMACORT (triamcinolone) Pulmicort Respules do not require a prior FLOVENT HFA (fluticasone) authorization for children through 8 years of age or QVAR (beclomethasone) for individuals unable to use an MDI. When GLUCOCORTICOID/BRONCHODILATOR COMBINATIONS children who have been stabilized on Pulmicort Respules reach age 9, prescriptions for the ADVAIR (fluticasone/salmeterol) Pulmicort inhaler will be authorized for them. ADVAIR HFA (fluticasone/salmeterol) SYMBICORT(budesonide/formoterol) GROWTH HORMONE CL GENOTROPIN (somatropin) HUMATROPE (somatropin) The preferred agents must be tried before a non- NORDITROPIN (somatropin) INCRELEX (mecasermin) preferred agent will be authorized unless one of NUTROPIN (somatropin) OMNITROPE (somatropin) the exceptions on the PA form is present. NUTROPIN AQ (somatropin) SEROSTIM (somatropin) SAIZEN (somatropin) ZORBTIVE (somatropin) Patients already on a non-preferred agent will TEV-TROPIN (somatropin) receive authorization to continue therapy on that agent for the duration of the existing PA. HEPATITIS B TREATMENTS EPIVIR HBV (lamivudine) BARACLUDE (entecavir) One of the preferred agents must be tried before HEPSERA (adefovir) the non-preferred agent will be authorized unless TYZEKA (telbivudine) one of the exceptions on the PA form is present.

Unless otherwise specified, the listing of a particular brand or generic name includes all legend forms of that drug. OTC are not covered unless specified. 16 CL – Requires Clinical PA NR – New drug has not been reviewed by P & T Committee BUREAU FOR MEDICAL SERVICES WEST VIRGINIA MEDICAID Effective 9/2/08 PREFERRED DRUG LIST WITH PRIOR AUTHORIZATION CRITERIA Version 2008.7

THERAPEUTIC PREFERRED NON-PREFERRED PA DRUG CLASS AGENTS AGENTS CRITERIA HEPATITIS C TREATMENTS CL PEGASYS (pegylated interferon) COPEGUS (ribavirin) Patients starting therapy in this class must try the ribavirin INFERGEN (consensus interferon) preferred agent of a dosage form before a non- PEG-INTRON (pegylated interferon) preferred agent of that dosage form will be REBETOL (ribavirin) authorized. HYPOGLYCEMICS, INCRETIN BYETTA (exenatide) Byetta and Symlin are both subject to the following MIMETICS/ENHANCERS JANUMET (sitagliptin/metformin) step therapy edits: JANUVIA (sitagliptin) SYMLIN (amylin) Byetta-Current history of therapy with a sulfonylurea, thiazolidinedione (TZD), and/or metformin. No gaps of therapy greater than 30 days in the past 180 days.

Symlin- History of insulin utilization in the past 90 days. No gaps in therapy of greater than 30 days. HYPOGLYCEMICS, INSULINS HUMALOG (insulin lispro) APIDRA (insulin glulisine) To receive Apidra, patients must meet the HUMALOG MIX HUMALOG KWIKPEN (insulin lispro) following criteria: (insulin lispro/lispro protamine) 1. be 18 years or older; HUMULIN (insulin) 2. be currently on a regimen LANTUS (insulin glargine) including a longer-acting or basal insulin. LEVEMIR (insulin detemir) 3. have had a trial of a similar preferred agent, NOVOLIN (insulin) Novolog or Humalog, with documentation NOVOLOG (insulin aspart) that the desired results were not achieved. NOVOLOG MIX (insulin aspart/aspart protamine) HYPOGLYCEMICS, STARLIX (nateglinide) PRANDIN (repaglinide) The preferred agent must be tried before a non- MEGLITINIDES preferred agent will be authorized, unless one of the exceptions on the PA form is present.

HYPOGLYCEMICS, TZDS THIAZOLIDINEDIONES ACTOS (pioglitazone) AVANDIA (rosiglitazone) TZD COMBINATIONS ACTOPLUS MET (pioglitazone/metformin) AVANDAMET (rosiglitazone/metformin) AVANDARYL (rosiglitazone/glimepiride) DUETACT (pioglitazone/glimepiride)

Unless otherwise specified, the listing of a particular brand or generic name includes all legend forms of that drug. OTC are not covered unless specified. 17 CL – Requires Clinical PA NR – New drug has not been reviewed by P & T Committee BUREAU FOR MEDICAL SERVICES WEST VIRGINIA MEDICAID Effective 9/2/08 PREFERRED DRUG LIST WITH PRIOR AUTHORIZATION CRITERIA Version 2008.7

THERAPEUTIC PREFERRED NON-PREFERRED PA DRUG CLASS AGENTS AGENTS CRITERIA IMPETIGO AGENTS, TOPICAL ALTABAX (retapamulin) BACTROBAN (mupirocin) A trial of one of at least one preferred agent, mupirocin CORTISPORIN including the generic formulation of a requested bacitracin (bacitracin/neomycin/polymyxin/HC) non-preferred agent, must be tried for 10 days gentamycin sulfate before a non-preferred agent will be authorized unless one of the exceptions on the PA form is present. INTRANASAL RHINITIS ANTICHOLINERGICS All of the preferred agents, in corresponding AGENTS categories, must be tried before a non-preferred ATROVENT(ipratropium) agent will be authorized unless one of the ipratropium exceptions on the PA form is present. ANTIHISTAMINES ASTELIN (azelastine) CORTICOSTEROIDS fluticasone propionate BECONASE AQ (beclomethasone) NASACORT AQ (triamcinolone) flunisolide NASONEX (mometasone) FLONASE (fluticasone propionate) VERAMYST (fluticasone furoate) NASALIDE (flunisolide) NASAREL (flunisolide) RHINOCORT AQUA (budesonide) LEUKOTRIENE MODIFIERS ACCOLATE (zafirlukast) ZYFLO (zileuton) The preferred agents must be tried before a non- SINGULAIR (montelukast) preferred agent will be authorized unless one of the exceptions on the PA form is present.

Unless otherwise specified, the listing of a particular brand or generic name includes all legend forms of that drug. OTC are not covered unless specified. 18 CL – Requires Clinical PA NR – New drug has not been reviewed by P & T Committee BUREAU FOR MEDICAL SERVICES WEST VIRGINIA MEDICAID Effective 9/2/08 PREFERRED DRUG LIST WITH PRIOR AUTHORIZATION CRITERIA Version 2008.7

THERAPEUTIC PREFERRED NON-PREFERRED PA DRUG CLASS AGENTS AGENTS CRITERIA LIPOTROPICS, OTHER BILE ACID SEQUESTRANTS One of the preferred agents must be tried before a (non-statins) cholestyramine COLESTID (colestipol) non-preferred agent in the corresponding category colestipol QUESTRAN (cholestyramine) will be authorized. WELCHOL (colesevelam) Zetia, as monotherapy, will only be approved for CHOLESTEROL ABSORPTION INHIBITORS patients who cannot take statins or other preferred ZETIA (ezetimibe) agents.

FATTY ACIDS Zetia and Welchol will be approved for add-on OMACOR (omega-3-acid ethyl esters) therapy only after an insufficient response to the LOVAZA (omega-3-acid ethyl esters) maximum tolerable dose of a statin after 12 weeks FIBRIC ACID DERIVATIVES of therapy. fenofibrate ANTARA (fenofibrate) gemfibrozil fenofibrate, micronized TRICOR (fenofibrate) LOFIBRA (fenofibrate) LOPID (gemfibrozil) TRIGLIDE (fenofibrate) NIACIN niacin NIACELS (niacin) NIASPAN (niacin) NIADELAY (niacin) SLO-NIACIN (niacin LIPOTROPICS, STATINS STATINS One of the preferred statins, including the generic CRESTOR (rosuvastatin) ALTOPREV (lovastatin) formulation of a requested non-preferred agent, LESCOL (fluvastatin) MEVACOR (lovastatin) must be tried for 12 weeks before a non-preferred LESCOL XL (fluvastatin) PRAVACHOL (pravastatin) agent will be authorized unless one of the LIPITOR (atorvastatin) ZOCOR (simvastatin) exceptions on the PA form is present lovastatin pravastatin Vytorin will be approved only after an insufficient simvastatin response to the maximum tolerable dose of Lipitor STATIN COMBINATIONS (atorvastatin) or Crestor (rosuvastatin) after 12 ADVICOR (lovastatin/niacin) VYTORIN (simvastatin/ ezetimibe) weeks, unless one of the exceptions on the PA CADUET (atorvastatin/amlodipine) form is present. SIMCOR (simvastatin/niacin ER) Members on Vytorin 10/80 will be grandfathered on that therapy. Members on all other strengths of Vytorin will be grandfathered until 6/30/08 on that therapy, but their prescriptions will require prior authorization after that period. (See letter to providers.)

Unless otherwise specified, the listing of a particular brand or generic name includes all legend forms of that drug. OTC are not covered unless specified. 19 CL – Requires Clinical PA NR – New drug has not been reviewed by P & T Committee BUREAU FOR MEDICAL SERVICES WEST VIRGINIA MEDICAID Effective 9/2/08 PREFERRED DRUG LIST WITH PRIOR AUTHORIZATION CRITERIA Version 2008.7

THERAPEUTIC PREFERRED NON-PREFERRED PA DRUG CLASS AGENTS AGENTS CRITERIA MACROLIDES/KETOLIDES KETOLIDES Requests for telithromycin will be authorized if (Oral) there is documentation of the use of any KETEK (telithromycin) within the past 28 days. MACROLIDES azithromycin BIAXIN (clarithromycin) clarithromycin BIAXIN XL (clarithromycin) erythromycin clarithromycin ER E.E.S. (erythromycin ethylsuccinate) E-MYCIN (erythromycin) ERYC (erythromycin) ERYPED (erythromycin ethylsuccinate) ERY-TAB (erythromycin) ERYTHROCIN (erythromycin stearate) erythromycin estolate PCE (erythromycin) The preferred agents must be tried before a non- ZITHROMAX (azithromycin) preferred agent will be authorized unless one of ZMAX (azithromycin) the exceptions on the PA form is present. MULTIPLE SCLEROSIS AVONEX (interferon beta-1a) TYSABRI (natalizumab) A trial of a preferred agent will be required before a AGENTS CL BETASERON (interferon beta-1b) trial of a non-preferred agent will be approved. COPAXONE (glatiramer) Tysabri will only be approved for members who REBIF (interferon beta-1a) meet the conditions and are enrolled the TOUCH Prescribing Program.

Unless otherwise specified, the listing of a particular brand or generic name includes all legend forms of that drug. OTC are not covered unless specified. 20 CL – Requires Clinical PA NR – New drug has not been reviewed by P & T Committee BUREAU FOR MEDICAL SERVICES WEST VIRGINIA MEDICAID Effective 9/2/08 PREFERRED DRUG LIST WITH PRIOR AUTHORIZATION CRITERIA Version 2008.7

THERAPEUTIC PREFERRED NON-PREFERRED PA DRUG CLASS AGENTS AGENTS CRITERIA NSAIDS NONSELECTIVE The preferred agents must be tried before a non- preferred agent will be authorized unless one of diclofenac ADVIL (ibuprofen) the exceptions on the PA form is present. etodolac ANAPROX (naproxen) fenoprofen ANSAID (flurbiprofen) flurbiprofen CATAFLAM (diclofenac) ibuprofen (Rx and OTC) CLINORIL (sulindac) INDOCIN (indomethacin) (suspension DAYPRO (oxaprozin) only) FELDENE (piroxicam) indomethacin FLECTOR PATCH (diclofenac)NR ketorolac INDOCIN (indomethacin) naproxen (Rx only) ketoprofen oxaprozin LODINE (etodolac) piroxicam meclofenamate sulindac mefenamic acid MOTRIN (ibuprofen) nabumetone NALFON (fenoprofen) NAPRELAN (naproxen) NAPROSYN (naproxen) NUPRIN (ibuprofen) ORUDIS (ketoprofen) PONSTEL (meclofenamate) tolmetin VOLTAREN (diclofenac) VOLTAREN GEL (diclofenac)NR NSAID/GI PROTECTANT COMBINATIONS ARTHROTEC (diclofenac/misoprostol) PREVACID/NAPRAPAC (naproxen/lansoprazole) COX-II SELECTIVE CL COX-II selective NSAIDs will be approved for patients with a GI Risk Score of ≥13. CELEBREX (celecoxib) meloxicam MOBIC (meloxicam) OPHTHALMIC ANTIBIOTICS ciprofloxacin AZASITE (azithromycin) All of the preferred agents must be tried before ofloxacin CILOXAN (ciprofloxacin) non-preferred agents will be authorized unless one VIGAMOX (moxifloxacin) OCUFLOX (ofloxacin) of the exceptions on the PA form is present. QUIXIN (levofloxacin) ZYMAR (gatifloxacin)

Unless otherwise specified, the listing of a particular brand or generic name includes all legend forms of that drug. OTC are not covered unless specified. 21 CL – Requires Clinical PA NR – New drug has not been reviewed by P & T Committee BUREAU FOR MEDICAL SERVICES WEST VIRGINIA MEDICAID Effective 9/2/08 PREFERRED DRUG LIST WITH PRIOR AUTHORIZATION CRITERIA Version 2008.7

THERAPEUTIC PREFERRED NON-PREFERRED PA DRUG CLASS AGENTS AGENTS CRITERIA OPHTHALMIC NSAIDS ACULAR LS (ketorolac) diclofenac All of the preferred agents must be tried before a ACULAR PF (ketorolac) non-preferred agent will be approved unless one of flurbiprofen the exceptions on the PA form is present. NEVANAC (nepafenac) XIBROM (bromfenac) OPHTHALMICS FOR ACULAR (ketorolac) ALAMAST (pemirolast) Two of the preferred agents must be tried before ALLERGIC ALAWAY (ketotifen) ALOCRIL (nedocromil) non-preferred agents will be authorized, unless CONJUNCTIVITIS ALREX (loteprednol) ALOMIDE (lodoxamide) one of the exceptions on the PA form is present. cromolyn CROLOM (cromolyn) ELESTAT (epinastine) EMADINE (emedastine) OPTIVAR (azelastine) ketotifen PATADAY (olopatadine) OPTICROM (cromolyn) PATANOL (olopatadine) ZADITOR OTC (ketotifen)

Unless otherwise specified, the listing of a particular brand or generic name includes all legend forms of that drug. OTC are not covered unless specified. 22 CL – Requires Clinical PA NR – New drug has not been reviewed by P & T Committee BUREAU FOR MEDICAL SERVICES WEST VIRGINIA MEDICAID Effective 9/2/08 PREFERRED DRUG LIST WITH PRIOR AUTHORIZATION CRITERIA Version 2008.7

THERAPEUTIC PREFERRED NON-PREFERRED PA DRUG CLASS AGENTS AGENTS CRITERIA OPHTHALMICS, GLAUCOMA COMBINATION AGENTS Authorization for a non-preferred agent will only be AGENTS COSOPT (dorzolamide/timolol) given if there is an allergy to the preferred agents.

BETA BLOCKERS Betaxolol BETAGAN (levobunolol) BETIMOL (timolol) OPTIPRANOLOL (metipranolol) BETOPTIC S (betaxolol) TIMOPTIC (timolol) carteolol ISTALOL (timolol) levobunolol metipranolol timolol CARBONIC ANHYDRASE INHIBITORS AZOPT (brinzolamide) TRUSOPT (dorzolamide) PARASYMPATHOMIMETICS CARBOPTIC (carbachol) ISOPTO CARPINE (pilocarpine) ISOPTO CARBACHOL (carbachol) PILOPINE HS (pilocarpine) PHOSPHOLINE IODIDE (echothiophate iodide) pilocarpine PROSTAGLANDIN ANALOGS LUMIGAN (bimatoprost) XALATAN (latanoprost) TRAVATAN (travoprost) TRAVATAN-Z (travoprost) SYMPATHOMIMETICS ALPHAGAN P (brimonidine) ALPHAGAN (brimonidine) brimonidine PROPINE (dipivefrin) dipivefrin OTIC FLUOROQUINOLONES CIPRODEX CIPRO HC Each of the preferred agents must be tried before (ciprofloxacin/dexamethasone) (ciprofloxacin/hydrocortisone) a non-preferred agent will be approved unless one Ofloxacin FLOXIN (ofloxacin) of the exceptions on the PA form is present.

Unless otherwise specified, the listing of a particular brand or generic name includes all legend forms of that drug. OTC are not covered unless specified. 23 CL – Requires Clinical PA NR – New drug has not been reviewed by P & T Committee BUREAU FOR MEDICAL SERVICES WEST VIRGINIA MEDICAID Effective 9/2/08 PREFERRED DRUG LIST WITH PRIOR AUTHORIZATION CRITERIA Version 2008.7

THERAPEUTIC PREFERRED NON-PREFERRED PA DRUG CLASS AGENTS AGENTS CRITERIA PANCREATIC ENZYMES CREON KUZYME A trial of at least 3 preferred agents, for at least 30 PANCRECARB LIPRAM days each, is required before a non-preferred ULTRASE PALCAPS agent will be authorized unless one of the ULTRASE MT PANCREASE exceptions on the PA form is present. VIOKASE PANGESTYME Non-preferred agents will be approved for PANOKASE members with cystic fibrosis. In all cases except PLARETASE cystic fibrosis, objective evidence of pancreatic insufficiency (fat malabsorption, etc.) must be documented. PARATHYROID AGENTS ergocalciferol DRISDOL (ergocalciferol) A trial of a non-preferred agent will be required, for calcitriol ROCALTROL (calcitriol) at least 30 days, before a non-preferred agent will HECTOROL (doxercalciferol) SENSIPAR (cinacalcet) be approved. Prescriptions for Sensipar will be ZEMPLAR (paricalcitol) grandfathered. PEDICULICIDES/ EURAX (crotamiton) lindane A trial of all three pediculicides (Ovide, SCABICIDES, TOPICAL OVIDE (malathion) permethrins, and pyrethrins-piperonyl butoxide) is permethrins (Rx and OTC) required before lindane will be approved unless pyrethrins-piperonyl butoxide one of the exceptions on the PA form is present.

PHOSPHATE BINDERS FOSRENOL (lanthanum) RENVELA (sevelamer carbonate) NR A trial of at least two preferred agents will be required PHOSLO (calcium acetate) unless one of the exceptions on the PA form is RENAGEL (sevelamer) present.

PLATELET AGGREGATION AGGRENOX (dipyridamole/ASA) dipyridamole All of the preferred agents must be tried before a INHIBITORS PLAVIX (clopidogrel) PERSANTINE (dipyridamole) non-preferred agent will be approved unless one of TICLID (ticlopidine) the exceptions on the PA form is present. ticlopidine

PROTON PUMP INHIBITORS NEXIUM (esomeprazole) ACIPHEX (rabeprazole) The preferred agents must be tried before a non- PREVACID Capsules (lansoprazole) NEXIUM PACKETS (esomeprazole) preferred agent will be approved unless one of the omeprazole exceptions on the PA form is present. pantoprazole PREVACID Solu-Tabs (lansoprazole) Prior authorization is not required for Prevacid PREVACID Suspension (lansoprazole) Solu-Tabs for patients ≤8 years of age. PRILOSEC (omeprazole) PROTONIX (pantoprazole) ZEGERID (omeprazole/sodium bicarbonate)

Unless otherwise specified, the listing of a particular brand or generic name includes all legend forms of that drug. OTC are not covered unless specified. 24 CL – Requires Clinical PA NR – New drug has not been reviewed by P & T Committee BUREAU FOR MEDICAL SERVICES WEST VIRGINIA MEDICAID Effective 9/2/08 PREFERRED DRUG LIST WITH PRIOR AUTHORIZATION CRITERIA Version 2008.7

THERAPEUTIC PREFERRED NON-PREFERRED PA DRUG CLASS AGENTS AGENTS CRITERIA SEDATIVE HYPNOTICS BENZODIAZEPINES The preferred agent must be tried for 14 days before a nonpreferred agent will be authorized temazepam DALMANE (flurazepam) unless one of the exceptions on the PA form is DORAL (quazepam) present. estazolam flurazepam HALCION (triazolam) PROSOM (estazolam) RESTORIL (temazepam) triazolam OTHERS zolpidem AMBIEN (zolpidem) AMBIEN CR (zolpidem) AQUA CHLORAL (chloral hydrate) chloral hydrate LUNESTA (eszopiclone) ROZEREM (ramelteon) SOMNOTE (chloral hydrate) SONATA (zaleplon) zaleplon NR STIMULANTS AND RELATED AMPHETAMINES Except for Strattera, PA is required for adults >18 AGENTS years. ADDERALL XR ADDERALL

(amphetamine salt combination) (amphetamine salt combination) One of the preferred agents in each group amphetamine salt combination DESOXYN (methamphetamine) (amphetamines and non-amphetamines) must be dextroamphetamine DEXEDRINE (dextroamphetamine) tried before a non-preferred agent will be VYVANSE (lisdexamphetamine) DEXTROSTAT (dextroamphetamine) authorized. NON-AMPHETAMINE CONCERTA (methylphenidate) dexmethylphenidate Amphetamines will be authorized for the treatment DAYTRANA (methylphenidate) METADATE ER (methylphenidate) of depression only after documented failure of FOCALIN (dexmethylphenidate) pemoline multiple antidepressants. FOCALIN XR (dexmethylphenidate) PROVIGIL (modafinil) METADATE CD (methylphenidate) RITALIN (methylphenidate) Provigil will only be approved for patients >16 methylphenidate RITALIN LA (methylphenidate) years of age with a diagnosis of narcolepsy. methylphenidate ER RITALIN-SR (methylphenidate) STRATTERA (atomoxetine) Strattera will not be approved for concurrent administration with amphetamines or methylphenidates, except for 30 days or less for tapering purposes. Only two doses of each strength, or two concurrent doses of any strength, and a maximum of one dose of a 60 mg capsule, will be approved in a 34-day period.

Unless otherwise specified, the listing of a particular brand or generic name includes all legend forms of that drug. OTC are not covered unless specified. 25 CL – Requires Clinical PA NR – New drug has not been reviewed by P & T Committee BUREAU FOR MEDICAL SERVICES WEST VIRGINIA MEDICAID Effective 9/2/08 PREFERRED DRUG LIST WITH PRIOR AUTHORIZATION CRITERIA Version 2008.7

THERAPEUTIC PREFERRED NON-PREFERRED PA DRUG CLASS AGENTS AGENTS CRITERIA ULCERATIVE COLITIS ORAL The preferred agents of a dosage form must be AGENTS tried before a non-preferred agent of that dosage ASACOL (mesalamine) AZULFIDINE (sulfasalazine) form will be authorized unless one of the COLAZAL (balsalazide) LIALDA (mesalamine) exceptions on the PA form is present. DIPENTUM (olsalazine) PENTASA (mesalamine) sulfasalazine RECTAL CANASA (mesalamine) ROWASA (mesalamine) mesalamine MISC SANDOSTATIN (octreotide) octreotide The preferred agent must be tried before the non- BRAND/GENERIC preferred agent will be authorized unless one of the exceptions on the PA form is present.

Unless otherwise specified, the listing of a particular brand or generic name includes all legend forms of that drug. OTC are not covered unless specified. 26 CL – Requires Clinical PA NR – New drug has not been reviewed by P & T Committee