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Department of Human Services IOWA Medicaid Program Preferred / Recommended Only Drug List (Two Drug Columns) Effective January 1, 2020

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Department of Human Services IOWA Medicaid Program Preferred / Recommended Only Drug List (Two Drug Columns) Effective January 1, 2020 v Department of Human Services IOWA Medicaid Program Preferred / Recommended Only Drug List (Two Drug Columns) Effective January 1, 2020 Highlighted categories denote new changes to the PDL since previous update Column Header Explanations: B, G or O: P, N, R, or NR: B = Brand P = Preferred G = Generic N = Non-Preferred O = OTC R = Recommended NR = Non-Recommended 3 BUSPIRONE 30mg - Use 2 BUSPIRONE 15mg 94 Preferred product is authorized generic distributed by tablets labeler 61314 6 FLUOXETINE HCL 20mg TABS - Use FLUOXETINE 98 PA required. Preferred for all indicated diagnoses HCL 20mg CAPS instead after step through Humira. 11 PA Required 99 Preferred product is authorized generic of EpiPen PA Required < 6 years of age and > 20 years of age distributed by labeler 49502 PA Required 104 Preferred product is authorized generic distributed by 13 PA Required > 90 days labeler 00406 16 Grandfathered for Existing Users with previous Actos 105 Unit Dose Preferred. No manual PA required if a use or CHF diagnosis preferred artificial tear agent is found in member’s 17 PA Required> 12 Units/30 Days supply pharmacy claims history in past 12 months 19 Preferred < 8yo 106 Preferred for indicated age group (2 to 12 years of 21 PROZAC,FLUOXETINE HCL 40mg CAPS - Use two age) FLUOXETINE HCL 20mg CAPS instead 107 PA required. Preferred for patients with Factor VIII 23 ULTRACET - Use Tramadol & Acetaminophen inhibitors only. Non-preferred for all other diagnoses. separately 110 72-hour emergency supply not available 24 PA Required >= 21 yo. 111 PA required < 6 years of age and > 17 years of age 25 PA Required: > 14 Units/30Days Supply 112 PA Required < 3 years of age and > 20 years of age 27 PA required for quantities exceeding 12-40mg 113 PA Required < 6 years of age and > 20 years of age capsules and 8-80mg capsules 115 PA Required < 6 years of age and > 20 years of age. 28 PA required for quantities exceeding 60-4mg tabs, Preferred product is authorized generic distributed by 60-8mg tabs, 4-20ml vials, and 8-2ml vials. labeler 10147 29 PA required for quantities exceeding 60-4mg tabs, 116 PA Required. Preferred product is authorized generic 60-8mg tabs. distributed by labeler 68682 36 Payable for members who are 12 years of age and 117 PA Required < 12 years of age older. Quantity limitations of 12 packets/4 weeks (28 days) or a total of 48 packets/16 weeks (112 days). 37 Restricted to persons 40 years of age and older. 39 Grandfather Existing Users 43 PA required for concurrent therapy with long acting injectable and oral antispychotics of the same chemical entity after 12 weeks (84 days) of concomitant therapy. 46 Grandfather for seizure disorder. Anticonvulsants Grandfather for seizure disorder. 47 Preferred with Conditions and allow a one time fill. 48 Those 0-18 should be referred to the Vaccines for Children Program. 50 Requires a Selected Brand Name Drug PA 52 Imipramine Pamoate - Use Imipramine HCL 63 Initial fill limited to 15 day supply. 64 Use Multiples of Phenytoin Sodium 100mg Capsules. 69 Payable for members who are 18 years of age and older. Quantity limitations of 30 grams/4 weeks (28 days) or a total of 120 grams/16 weeks (112 days) 70 Payable for members 50 years of age and older without prior authorization 72 Preferred < 2 years of age 74 PA Required < 4 years of age 76 PA Required < 15 years of age 77 PA Required < 6 years of age 78 PA Required < 9 years of age 80 PA Required < 18 years of age 87 No manual PA required if HMG-CoA reductase inhibitor found in member’s pharmacy claims history in past 12 months. 89 PA Required < 7 years of age 90 No manual PA required if a preferred injectable MS agent is found in member’s pharmacy claims history in past 12 months 92 Preferred for ages 19 through 64 93 No PA required for members 6 years of age or older when dosed within established quantity limits Iowa Medicaid Preferred Drug List (PDL) New Drug Process New Drug Entities New drug entities (including new generics), and new drug product dosage forms of existing drug entities) will be identified weekly and immediately be coded as "Non-preferred-Prior Authorization required" until presented at the next scheduled P&T Committee meeting. These prior authorization restrictions will continue through the review process, including while committee recommendations are being made, and lasting until DHS makes a final determination. Exceptions to the Non-preferred default policy for new PDL drugs There are two major potential exceptions to the non-preferred default policy for new PDL drugs: A). If a new medication is classified as a priority drug by the FDA, the State may indicate that such a drug is preferred, until the drug is reviewed by the P&T Committee at the nearest scheduled meeting. B). The State may decide to designate a new drug as "draft preferred" and provide immediate access and increased therapeutic choice to physicians until the drug is reviewed by the P&T Committee at the nearest scheduled meeting if: - a new drug is therapeutically equivalent or superior to existing preferred or non-preferred choices, and - is as safe or safer than existing preferred or non-preferred choices, and - the net cost, adjusted for all rebates, is less expensive than all existing preferred choices. Existing PDL Drugs Although the State discourages supplemental rebate offers on existing PDL drugs between annual bidding periods, it may entertain such bids and may accept them if they are determined to represent significant additional savings or if they would replace a delinquent manufacturer's product or a preferred drug pulled from the marketplace or significantly restricted by the FDA. This interim preferred status will remain in effect until the drug is reviewed by the P&T Committee at the next scheduled meeting. Supplemental rebates will only be invoiced for approved drugs under contract. Draft preferred drugs with supplemental rebates will not be invoiced until approved by the Committee and accepted by the State. At that time, the supplemental rebates will be invoiced back to the effective date of the agreement, which is the date the drug began to benefit from preferred status. B, COM P , B, COM P , G, N, Therapeutic Category G, N, Therapeutic Category or R, or or R, or O NR O NR PDL Categories G P gentamicin sulfate ACE AND THIAZIDE COMBO'S G P gentamicin in saline G P benazepril & hydrochlorothiazide G P neomycin sulfate G P captopril & hydrochlorothiazide G P paromomycin sulfate G P enalapril maleate & hydrochlorothiazide G P streptomycin sulfate G P lisinopril & hydrochlorothiazide G P tobramycin neb solution G P tobramycin sulfate ACE INHIBITORS G P benazepril hcl ANALGESICS - MISC. G P captopril O P aspirin G P enalapril maleate G P diflunisal G P fosinopril sodium G P salsalate G P lisinopril O P aspirin buffered G P quinapril hcl O P acetaminophen G P ramipril G P butalbital-acetaminophen tab 50-325 mg G P trandolapril G P butalbital-acetaminophen-caffeine cap 50-325-40 mg G P butalbital-acetaminophen-caffeine tab 50-325-40 mg ACE INHIBITORS AND CALCIUM CHANNEL BLOCKERS G P butalbital-aspirin-caffeine G P amlodipine besylate-benazepril hcl G P trandolapril-verapamil hcl ANAPHYLAXIS THERAPY G 99 P epinephrine auto-injector ACNE PRODUCTS: ISOTRETINOIN G 11 P isotretinoin ANDROGENS - ANABOLICS G P danazol AGENTS FOR FABRYS DISEASE G 11 P testosterone cypionate B P FABRAZYME G 11 P testosterone enanthate B 11 P GALAFOLD ANDROGENS -TOPICAL AGENTS FOR PHEOCHROMOCYTOMA B 11 P ANDRODERM G P phentolamine mesylate G 11 P testosterone 1% packets ALCOHOL DETERRENTS ANORECTAL - MISC. G P acamprosate calcium G P hydrocortisone (rectal) G P disulfiram G P hydrocortisone (intrarectal) ALPHA-PROTEINASE INHIBITOR ANTHELMINTICS B 11 P PROLASTIN C B P ALBENZA G 106 P benznidazole ALS DRUG G P ivermectin G 11 P riluzole B P BILTRICIDE ALZHEIMER - CHOLINOMIMETICS ANTI INFECTIVE COMBO'S - MISC. G 37 P donepezil hydrochloride G P sulfamethoxazole-trimethoprim G 37 P galantamine tabs G 37 P rivastigmine cap ANTIANGINALS G 37 P memantine G P ranolazine AMINO GLYCOSIDES G P amikacin sulfate RT43025 B, COM P , B, COM P , G, N, Therapeutic Category G, N, Therapeutic Category or R, or or R, or O NR O NR PDL Categories G P terbutaline sulfate tab 5 mg ANTIANGINALS--ISOSORBIDE NITRATE ANTIASTHMATIC - LEUKOTRIENE RECEPTOR ANTAGONISTS G P isosorbide dinitrate G P isosorbide mononitrate G P montelukast sodium chew tab 4 mg (base equiv) G P montelukast sodium chew tab 5 mg (base equiv) ANTIARRHYTHMICS G P montelukast sodium tab 10 mg (base equiv) G P disopyramide phosphate G 72 P montelukast granules G P procainamide hcl ANTIASTHMATIC - MISC. RESPIRATORY INHALANTS G P quinidine gluconate G P quinidine sulfate G P sodium chloride soln nebu 0.9% G P mexiletine hcl ANTIASTHMATIC - MIXED ADRENERGICS G P flecainide acetate G P propafenone hcl G P epinephrine hcl G P amiodarone hcl tab 200 mg G P dofetilide ANTIASTHMATIC - MUCOLYTICS B P MULTAQ G P acetylcysteine ANTIASTHMATIC - ADRENERGIC COMBOS ANTIASTHMATIC - NASAL MISC. G P fluticasone/salmeterol G P ipratropium bromide (nasal) soln 0.03% B P COMBIVENT RESPIMAT G P ipratropium-albuterol ANTIASTHMATIC - STEROID INHALANTS B P SYMBICORT G 19 P budesonide (inhalation) B P BEVESPI AEROSPHERE B P PULMICORT INHALER B P UTIBRON NEOHALER B P FLOVENT HFA B P ADVAIR DISKUS B P FLOVENT DISKUS B P ADVAIR HFA B P ASMANEX B P DULERA B P STIOLTO RESPIMAT ANTIASTHMATIC - XANTHINES G P aminophylline ANTIASTHMATIC - ANTI-CHOLINERGICS B P ELIXOPHYLLIN G P ipratropium bromide B P THEO-24 B P ATROVENT HFA G P theophylline B P SPIRIVA HANDIHALER ANTIASTHMATIC - ANTIINFLAMMATORY AGENTS G P cromolyn sodium ANTIASTHMATIC - BETA - ADRENERGICS G 72 P albuterol sulfate nebu 0.63mg/3 G P albuterol sulfate soln nebu 0.083% (2.5 mg/3ml) G P albuterol sulfate soln nebu 0.5% (5 mg/ml) G P albuterol sulfate syrup 2 mg/5ml G P albuterol sulfate tab sr 12hr 4 mg G P albuterol sulfate tab sr 12hr 8 mg B P PROAIR HFA B P PROVENTIL HFA B P PROAIR RESPICLICK B 74 P SEREVENT DISKUS G P terbutaline sulfate tab 2.5 mg RT43025 B, COM P , B, COM P , G, N, Therapeutic Category G, N, Therapeutic Category or R, or or R, or O NR O NR PDL Categories B P TEGRETOL SUSP ANTIBIOTICS - MISC.
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