Department of Human Services IOWA Medicaid Program Draft PDL for March 9, 2006 P & T Committee Meeting PDL DRUG LIST (Two Drug Columns)
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Department of Human Services IOWA Medicaid Program Draft PDL for March 9, 2006 P & T Committee Meeting PDL DRUG LIST (Two Drug Columns) Highlighted categories denote new changes to the PDL since previous update Column Header Explanations: P, N, R, or NR: B, G or O: P = Preferred B = Brand N = Non-Preferred G = Generic R = Recommended O = OTC NR = Non-Recommended COM: 13 PA Required > 90 days 1 ANTIVERT 50mg - Use two MECLIZINE HCL 25 mg instead 14 PA Required > Quantity Limit 10 Days 2 BENZONATATE 200mg - Use two BENZONATATE 100mg instead 15 PA Required for > 4 Bottles/30 Days 3 BUSPIRONE 30mg - Use 2 BUSPIRONE 15mg tablets 16 PA Required from Day 1 4 CLINDAMYCIN HCL 300MG - Use Multiples of CLINDAMYCIN HCL 150mg 17 PA Required: > 18 Units/30Days Supply 5 FLUMIST NASAL VACCINE 200 - Preferred 5 - 49 yo until 3/15/2006. 18 Preferred < 14yo 6 FLUOXETINE HCL 20mg TABS - Use 19 Preferred < 8yo FLUOXETINE HCL 20mg CAPS instead 7 Grandfather 21 PROZAC,FLUOXETINE HCL 40mg CAPS - Use 8 Grandfather for Seizure Disorder two FLUOXETINE HCL 20mg CAPS instead 22 RHEUMATREX - Write METHOTREXATE 9 HYDROXYZINE HCL - Use HYDROXYZINE instead PAMOATE 23 ULTRACET - Use Tramadol & Acetaminophen 10 HYDROXYZINE PAMOATE 100mg - Use two separately HYDROXYZINE PAMOATE 50mg instead 24 PA Required >= 21 yo 11 PA Required 25 PA Required: > 14 Units/30Days Supply 12 PA Required > 60 days 26 Levaquin: Levaquin is non-preferred except for continuation of a verified course of therapy started in the hospital. An in-patient hospital stay must be verified by reviewing the member’s hospital discharge order. Then, the pharmacy may override the non-preferred status with a Medical Certification Code = 2 and a PA Type Code= 6. 27 Oxycodone ER: Effective April 16, 2006 only the ENDO Brand (NDC# 60951) of oxycodone ER will be preferred. 28 After 30 days only the generic will be preferred. NEW DRUG REVIEW PROCESS: See Page 2. PDL IMPLEMENTATION DATE 01-15-05 Iowa Medicaid Preferred Drug List (PDL) New Drug Process 1). Therapeutic classes of drugs already reviewed by the Pharmaceutical and Therapeutics (P&T) Committee · New drug entities (including new generics), and new drug product dosage forms of existing drug entities) in therapeutic classes already reviewed by the P&T Committee will be identified weekly and immediately be coded as "Non-preferred-Prior Authorization required" until presented at the next quarterly 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. 2). Therapeutic classes of drugs not yet reviewed by the Pharmaceutical and Therapeutics (P&T) Committee · New drug entities in therapeutic classes not yet reviewed by the P&T Committee will remain payable, in effect preferred by default, until the therapeutic class is discussed. Once this review occurs for the class, the non- preferred default policy will apply to subsequent new drug entries. 3). 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. 4). 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. TABLE OF CONTENTS Page Page CATEGORY DESCRIPTION CATEGORY DESCRIPTION Number Number ACE AND THIAZIDE COMBO'S 7 ANTIHISTAMINES - NON-SEDATING / 12 DECONGESTANTS ACE INHIBITORS 7 ANTIHISTAMINES - OTHER 12 ACE INHIBITORS AND CA CHANNEL BLOCKERS 7 ANTIHISTAMINES/DECONGESTANTS 13 ACNE PRODUCTS: ISOTRETINOIN 7 ANTIHYPERTENSIVE COMBOS 13 AGENTS FOR FABRYS DISEASE 7 ANTIHYPERTENSIVES - CENTRAL 13 AGENTS FOR GAUCHER DISEASE 7 ANTILEPROTIC 14 AGENTS FOR PHEOCHROMOCYTOMA 7 ANTIMALARIAL AGENTS 14 ALCOHOL DETERRENTS 7 ANTIMYCOBACTERIALS / ANTITUBERCULOSIS 14 ALS DRUG 7 ANTINEOPLASTICS - ALKYLATING AGENTS 49 ALZHEIMER - CHOLINOMIMETICS 7 ANTINEOPLASTICS - ANTIADRENALS 49 AMINO GLYCOSIDES 7 ANTINEOPLASTICS - ANTIANDROGENS 49 ANALGESICS - MISC. 7 ANTINEOPLASTICS - ANTIBIOTICS 49 ANAPHYLAXIS THERAPY 8 ANTINEOPLASTICS - ANTIESTROGENS 49 ANDROGENS / ANABOLICS 8 ANTINEOPLASTICS - ANTIMETABOLITES 49 ANGIOTENSIN RECEPTOR BLOCKER 8 ANTINEOPLASTICS - AROMATASE INHIBITORS 49 ANORECTAL - MISC. 8 ANTINEOPLASTICS - CARDIAC PROTECTIVE AGENTS 49 ANTHELMINTICS 8 ANTINEOPLASTICS - COMBINATIONS 49 ANTI INFECTIVE COMBO'S - MISC. 8 ANTINEOPLASTICS - ESTROGEN RECEPTOR 49 ANTIANGINALS--ISOSORBIDE NITRATE 8 ANTAGONIST ANTIARRHYTHMICS 9 ANTINEOPLASTICS - ESTROGENS 49 ANTIASTHMATIC - ADRENERGIC COMBOS 9 ANTINEOPLASTICS - FOLIC ACID ANTAGONISTS 49 ANTIASTHMATIC - ALPHA-PROTEINASE INHIBITOR 9 RESCUE AGENTS ANTIASTHMATIC - ANTI-CHOLINERGICS 9 ANTINEOPLASTICS - IMIDAZOTETRAZINES 49 ANTIASTHMATIC - ANTIINFLAMMATORY AGENTS 9 ANTINEOPLASTICS - INTERLEUKINS 49 ANTIASTHMATIC - BETA - ADRENERGICS 9 ANTINEOPLASTICS - LHRH ANALOGS 49 ANTIASTHMATIC - HYDRO-LYTIC ENZYMES 9 ANTINEOPLASTICS - MISC. 50 ANTIASTHMATIC - LEUKOTRIENE RECEPTOR 9 ANTINEOPLASTICS - MITOTIC INHIBITORS 50 ANTAGONISTS ANTINEOPLASTICS - NITROGEN MUSTARDS 50 ANTIASTHMATIC - MISC. RESPIRATORY INHALANTS 9 ANTINEOPLASTICS - NITROSOUREAS 50 ANTIASTHMATIC - MIXED ADRENERGICSS 9 ANTINEOPLASTICS - PROGESTINS 50 ANTIASTHMATIC - MUCOLYTICS 10 ANTINEOPLASTICS - PROTEIN-TYROSINE KINASE 50 ANTIASTHMATIC - NASAL MISC. 10 INHIBITORS ANTIASTHMATIC - NASAL STEROIDS 10 ANTINEOPLASTICS - RETINOIDS 50 ANTIASTHMATIC - STEROID INHALANTS 10 ANTINEOPLASTICS - SELECTIVE RETINOID X 50 RECEPTOR AGONISTS ANTIASTHMATIC - XANTHINES 10 ANTINEOPLASTICS - TOPOISOMERASE I INHIBITORS 50 ANTIBIOTICS - MISC. 10 ANTINEOPLASTICS - URINARY TRACT PROTECTIVE 50 ANTI-CATAPLECTIC AGENTS 10 AGENTS ANTICOAGULANTS 10 ANTI-PARKINSONIAN DRUGS 14 ANTICONVULSANTS 10 ANTIPROTOZOAL AGENTS 14 ANTIDEPRESSANTS - MAO INHIBITORS 45 ANTI-PSORIATICS - BIOLOGICALS 14 ANTIDEPRESSANTS - SELECTED SSRI'S 45 ANTI-PSORIATICS - NON-BIOLOGICALS 14 ANTIDEPRESSANTS - TRI-CYCLICS 45 ANTIPSYCHOTICS - ATYPICALS 45 ANTIDOTES 11 ANTIPSYCHOTICS - SPECIAL ATYPICALS 45 ANTIDOTES - CHELATING AGENTS 11 ANTIPSYCHOTICS - TYPICAL 45 ANTIEMETIC - 5-HT3 RECEPTOR ANTAGONISTS/ 11 ANTIRETROVIRAL COMBINATIONS 50 SUBSTANCE P NEUROKININ ANTIRETROVIRALS 50 ANTIEMETIC - ANTICHOLINERGIC / DOPAMINERGIC 11 ANTIRETROVIRALS - FUSION INHIBITORS 50 ANTIFUNGALS - ASSORTED 11 ANTIRETROVIRALS - PROTEASE INHIBITORS 50 ANTIHEMOPHILIC AGENTS 49 ANTIRETROVIRALS - RTI-NON-NUCLEOSIDE 50 ANTIHISTAMINES - NON-SEDATING 12 ANALOGUES ANTIRETROVIRALS - RTI-NUCLEOSIDE ANALOGUES- 50 COUGH/COLD - DECONGESTANT W/ EXPECTORANT 20 PURINES COUGH/COLD - DECONGESTANT-ANTIHISTAMINE W/ 21 ANTIRETROVIRALS - RTI-NUCLEOSIDE ANALOGUES- 50 EXPECTORANT PYRIMIDINES COUGH/COLD - DECONGESTANT-ANTIHISTAMINE- 21 ANTIRETROVIRALS - RTI-NUCLEOSIDE ANALOGUES- 51 ANTICHOLINERGIC THYMIDINES COUGH/COLD - EXPECTORANT MIXTURES 21 ANTIRETROVIRALS - RTI-NUCLEOTIDE ANALOGUES 51 COUGH/COLD - EXPECTORANTS 21 ANTISPASMODICS 14 COUGH/COLD - NARCOTIC ANTITUSSIVE- 21 ANTISPASMODICS - LONG ACTING 14 ANTIHISTAMINE ANTITHYROID THERAPIES 14 COUGH/COLD - NARCOTIC ANTITUSSIVE- 21 DECONGESTANT ANXIOLYTICS - BENZODIAZEPINES 46 COUGH/COLD - NARCOTIC ANTITUSSIVE- 21 ANXIOLYTICS - LONG ACTING 46 DECONGESTANT-ANTIHISTAMINE ANXIOLYTICS - MISC. 46 COUGH/COLD - NON-NARC ANTITUSSIVE- 21 ARB'S AND DIURETICS 14 ANTIHISTAMINE ARTHRITIS - MISC. 14 COUGH/COLD - NON-NARC ANTITUSSIVE- 22 DECONGESTANT ARTIFICIAL SALIVA/STIMULANTS 15 COUGH/COLD - NON-NARC ANTITUSSIVE- 22 BETA BLOCKERS - ALPHA / BETA 15 DECONGESTANT-ANTIHISTAMINE BETA BLOCKERS - CARDIO SELECTIVE 15 COUGH/COLD - SYSTEMIC DECONGESTANTS 22 BETA BLOCKERS - NON SELECTIVE 15 COUGH/COLD - TOPICAL DECONGESTANTS 22 BETA BLOCKERS AND DIURETIC COMBO'S 15 COX 2 INHIBITORS - HIGHLY SELECTIVE 22 BETA-LACTAMS / CLAVULANATE COMBO'S 15 COX 2 INHIBITORS - SELECTIVE 22 BPH 16 CYTO-MEGALOVIRUS AGENTS 22 CALCIUM CHANNEL BLOCKERS--AMLODIPINES 16 DENTAL PRODUCTS 22 CALCIUM CHANNEL BLOCKERS--DILTIAZEMS 16 DIABETIC - ALPHAGLUCOSIDASE 22 CALCIUM CHANNEL BLOCKERS--FELODIPINES 16 DIABETIC - INSULIN 22 CALCIUM CHANNEL