Washington Preferred Drug List
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Prescription Drug Program Washington Preferred Drug List What is new in this version of the Washington preferred drug list? Effective for dates of service on and after January 19, 2016, the Health Care Authority will make the following changes: Drug Class Drug Name Preferred Status Long-Acting Non-preferred, not subject to Seebri Neohaler® Anticholinergics DAW-1 override/ TIP Long-Acting Beta-Agonist Non-preferred, not subject to Utibron Neohaler® Combinations DAW-1 override/ TIP Non-preferred, not subject to Long-Acting Opioids Belbuca® DAW-1 override NSAIDS Vivlodex® Non-preferred Drug Class Drug Name Change NSAIDs All medications in drug class Removal of EA requirement (Rev. 1/12/16)(Eff. 1/19/2016) - 1 - Washington PDL Prescription Drug Program What is the Washington preferred drug list? The Health Care Authority (agency) and Labor & Industries (L & I) have developed a list of preferred drugs within a chosen therapeutic class that are selected based on clinical evidence of safety, efficacy, and effectiveness. The drugs within a chosen therapeutic class are studied by an evidence-based practice center (EPC). A written report on the comparative safety, efficacy, and effectiveness from the EPC is evaluated by the Washington State Pharmacy and Therapeutic Committee which makes recommendations to the state agencies regarding the selection of the preferred drugs on the Washington Preferred Drug List (PDL). (WAC 182-530-4100) What is the process to obtain drugs on the Washington preferred drug list? 1. Preferred Drugs - Prescription claims for preferred drugs submitted to the agency are reimbursed without authorization requirements unless the drug requires authorization for: a. Safety criteria; b. Special subpopulation criteria; or c. Limits based on age, gender, dose, or quantity. 2. Non-preferred Drugs - Prescription claims for non-preferred drugs submitted to the agency are reimbursed without authorization requirements when written by an Endorsing Practitioner who has indicated “DAW” on the prescription unless the drug requires restrictions for safety. See WAC 182-530-4150. 3. Prescription claims for non-preferred drugs submitted to the agency are reimbursed only after authorizing criteria are met if written by a non-endorsing practitioner. 4. Pharmacies must call the agency for authorization when required. Call 800-848-2842 (Option 1) or fax to 866-668-1214. What are the authorization criteria that must be met to obtain a nonpreferred drug? For most drug classes on the Washington PDL, the authorization criteria is that the client must have tried and failed, or is intolerant to, at least one preferred drug. Drugs may have criteria that go beyond these basic criteria for the reasons stated in #1 on the previous page. Drugs that are in drug classes on the Washington PDL that have not been studied by the evidence-based practice center(s) and have not been reviewed by the P&T committee will be treated as non-preferred drugs and will require authorization. (Rev. 1/12/16)(Eff. 1/19/2016) - 2 - Washington PDL Prescription Drug Program HCA requires pharmacies to obtain authorization for non-preferred drugs when a therapeutic equivalent is on the Washington PDL. The following table shows the preferred and non-preferred drug in each therapeutic drug class on the Washington PDL: Note: The agency changed the format for multiple drug listings. A slash ( / ) is used to denote multiple forms of a drug. For example: “Cardizem® /CD/LA/SR” represents immediate release Cardizem, as well as the CD, LA, and SR forms. A hyphen ( - ) is used to indicate combination products. For example: “benazepril- HCTZ” represents the combination product of benazepril and hydrochlorothiazide, rather than benazepril AND the combination product. (Rev. 1/12/16)(Eff. 1/19/2016) - 3 - Washington PDL Prescription Drug Program Drug Class Preferred Drugs Non-preferred Drugs ACE Inhibitors Generic: Generic: benazepril fosinopril captopril moexipril enalapril perindopril erbumine lisinopril quinapril ramipril trandolapril Brand: Brand: Accupril® (quinapril) Aceon® (perindopril) Altace® (ramipril) Epaned® (enalapril)** Lotensin® (benazepril) Mavik® (trandolapril) Prinivil® (lisinopril) Univasc® (moexipril) Vasotec® (enalapril) Zestril® (lisinopril) **Not subject to TIP or DAW-1 override. Alzheimer's Drugs Generic: Generic: donepezil /ODT rivastigmine tartrate patch (Not subject to galantamine therapeutic galantamine HBR Brand: interchange program memantine Aricept® /ODT (donepezil) (TIP). For more memantine titration pak Exelon® (rivastigmine) patch information on TIP, rivastigmine tartrate capsules Exelon® (rivastigmine) see Theraputic capsule/solution Interchange Program Namenda® XR (memantine)** in the Prescription Brand: Namenda XR Titration Pak® Drug Program Namenda® (memantine) (memantine)** Medicaid Provider Namenda Titration Pak® Namzaric® Guide.) (memantine) (memantine/donepezil)** Razadyne® /ER (galantamine) **Not subject to DAW-1 override. (Rev. 1/12/16)(Eff. 1/19/2016) - 4 - Washington PDL Prescription Drug Program Drug Class Preferred Drugs Non-preferred Drugs Antiemetics Generic: Generic: ondansetron tablet/ injection granisetron tablet/injection* ondansetron solution* ondansetron ODT tablet* Brand: Aloxi® (palonosetron) injection* Brand: Anzemet® (dolasetron) tablet/injection* Granisol® (granisetron) solution* Sancuso® (granisetron) transdermal patch** Zofran® (ondansetron) tablet /injection Zofran® (ondansetron) solution* Zofran® ODT® (ondansetron) tablet* Zuplenz® (ondansetron oral *EA required for age 18 and older soluble)** *EA required **Not subject to TIP or DAW-1 override. Antiplatelets Generic: Generic: clopidogrel (Not subject to TIP. Brand: For more information Brand: Aggrenox® (dipyridamole/aspirin on TIP, see ER) Therapeutic Brilinta® (ticagrelor)** Interchange Program Effient® (prasugrel HCl) in the Prescription Plavix ® (clopidogrel bisulfate) Drug Program Zontivity® (vorapaxar sulfate)** Medicaid Provider Guide.) **Not subject to DAW-1 override. (Rev. 1/12/16)(Eff. 1/19/2016) - 5 - Washington PDL Prescription Drug Program Drug Class Preferred Drugs Non-preferred Drugs Attention Deficit/ Generic: Generic: Hyperactivity amphetamine salt combo clonidine ER Disorder amphetamine salt combo XR dextroamphetamine dexmethylphenidate dextroamphetamine SA Not subject to TIP. dexmethylphenidate XR For more information guanfacine ER Brand: on TIP, see methylphenidate Adderall® (amphetamine salt Therapeutic methylphenidate CD/ER/LA/SR combo) Interchange Program Adderall XR® (amphetamine salt in the Prescription Brand: combo) Drug Program Focalin XR® Aptensio XR® (methylphenidate) Medicaid Provider (dexmethylphenidate) Concerta® (methylphenidate HCl) Guide. Intuniv™ (guanfacine) Daytrana™ (methylphenidate HCl) Strattera® (atomoxetine HCl) transdermal patch EA is required for Vyvanse™ (lisdexamfetamine Dexedrine® (d-amphetamine) stimulants prescribed dimesylate) Evekeo® (amphetamine)** for ADD/ADHD Focalin® (dexmethylphenidate) diagnosis for adults) Kapvay® (clonidine) Metadate CD™ (methylphenidate HCl) Metadate ER™ (methylphenidate HCl) Methylin® (methylphenidate HCl) chewable/solution ProCentra® (d-amphetamine) sol Quillivant® XR (methylphenidate HCl) Ritalin® (methylphenidate HCl) Ritalin LA® (methylphenidate HCl) Ritalin SR® (methylphenidate HCl) **Not subject to DAW-1 override. (Rev. 1/12/16)(Eff. 1/19/2016) - 6 - Washington PDL Prescription Drug Program Drug Class Preferred Drugs Non-preferred Drugs Atypical Generic: Generic: Antipsychotic Drugs aripiprazole clozapine tablet / ODT Brand: Not subject to TIP. olanzapine/ODT/injection Aristada® (aripiprazole For more information paliperidone ER lauroxil)** on TIP, see quetiapine Clozaril® (clozapine) tablet Therapeutic risperidone tablet/ODT/solution Fazaclo® (clozapine) Interchange Program ziprasidone capsules disintegrating tablet in the Prescription Geodon® (ziprasidone HCl) Drug Program Brand: capsule Medicaid Provider Abilify® (aripiprazole) Invega Trinza® (paliperidone)** Guide. tablet/solution/Discmelt® Rexulti® (brexpiprazole)** Abilify® (aripiprazole) IM Risperdal® (risperidone) tablet/M- injection tab®/solution Abilify Maintena® (aripiprazole) Seroquel® (quetiapine) tablet Fanapt® (iloperidone) tablet Versacloz® (clozapine)** Fanapt Titration Pack® Zyprexa® (olanzapine) tablet (iloperidone) Zyprexa Zydis® (olanzapine) Geodon® (ziprasidone mesylate) tablet IM injection Invega™ (paliperidone) tablet Invega Sustenna® (paliperidone) IM injection Latuda® (lurasidone HCL) **Not subject to TIP or DAW-1 Risperdal Consta® (risperidone) override. injection Saphris® (asenapine) sublingual tablet Seroquel® XR (quetiapine) Zyprexa® (olanzapine) IM injection Zyprexa Relprevv® (olanzapine pamoate) injection (Rev. 1/12/16)(Eff. 1/19/2016) - 7 - Washington PDL Prescription Drug Program Drug Class Preferred Drugs Non-preferred Drugs Beta Blockers Generic: Generic: acebutolol atenolol Brand: betaxolol Bystolic® (nebivolol) bisoprolol Coreg® /CR® (carvedilol) carvedilol Corgard® (nadolol) labetalol Inderal® LA (propranolol) metoprolol succinate ER InnoPran XL® (propranolol) metoprolol tartrate Kerlone® (betaxolol) nadolol Levatol® (penbutolol) pindolol Lopressor® (metoprolol tartrate) propranolol/ER Sectral® (acebutolol) timolol Tenormin® (atenolol) Toprol XL (metoprolol succinate) Brand: Trandate® (labetalol) Zebeta® (bisoprolol) Calcium Channel Generic: Generic: Blockers amlodipine isradipine diltiazem /CD/ER/XR nifedipine felodipine ER nicardipine Brand: nifedipine ER Adalat® /CC (nifedipine) nisoldipine