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C:\Documents and Settings\Ms785a\Desktop\Web BUREAU FOR MEDICAL SERVICES WEST VIRGINIA MEDICAID PREFERRED DRUG LIST WITH PRIOR AUTHORIZATION CRITERIA PA-Prior Authorization REVISED 4/7/03 DRUG CLASS PREFERRED NON-PREFERRED CRITERIA PROTON PUMP lansoprazole (Prevacid)** esomeprazole (Nexium) PA Criteria: Both of the preferred INHIBITORS rabeprazole (AcipHex)** omeprazole (Prilosec) drugs must be tried before a non- Effective 10/1/02 pantoprazole (Protonix) preferred agent will be approved, Implement 1/7/03 unless one of the exceptions on the PA form is present. MINIMALLY SEDATING desloratadine (Clarinex) cetirizine (Zyrtec) PA Criteria: Both Claritin (or a ANTIHISTAMINES AND loratadine (Claritin) cetirizine/pseudoephedrine (Zyrtec-D) decongestant combination) and COMBINATIONS loratadine/pseudoephedrine (Claritin-D fexofenadine (Allegra) Clarinex must be tried before a Effective 10/1/02 12 hour, Claritin-D 24 hour) fexofenadine/pseudoephedrine non-preferred agent will be Implement 1/7/03 (Allegra-D) authorized, unless one of the exceptions on the PA form is present for each agent. LEUKOTRIENE montelukast (Singulair) zafirlukast (Accolate) PA Criteria: The preferred agent RECEPTOR AGONISTS zileuton (Zyflo) must be tried before the non- Effective 10/1/02 preferred agents will be approved, Implement 1/7/03 unless one of the exceptions on the PA form is present. BETA AGONISTS albuterol/ipratropium MDI (Combivent) albuterol/ipratropium inhalation solution PA Criteria: The preferred agents (INHALED & PERORAL) albuterol HFA MDI (Proventil HFA) (Duoneb) must be tried before non- Effective 10/1/02 albuterol syrup, tablets, CFC MDI, albuterol HFA MDI (Ventolin HFA) preferred agents will be Implement 1/7/03 inhalation solution # albuterol inhalation solution (Accuneb) authorized, unless one of the metaproterenol syrup, tablets, inhalation albuterol SR tablets (Volmax) exceptions on the PA form is solution # formoteral MDI (Foradil) present. pirbuterol MDI (Maxair, Maxair metaproterenol MDI (Alupent) Autohaler) salmeterol (Serevent, Serevent Diskus) terbutaline # levalbuterol inhalation solution (Xopenex) Bureau for Medical Services West Virginia Medicaid Preferred Drug List Page 1 of 12 DRUG CLASS PREFERRED NON-PREFERRED CRITERIA HISTAMINE 2 cimetidine (Tagamet)# famotidine orally disintegrating (Pepcid PA Criteria: The preferred agents ANTAGONISTS famotidine (Pepcid)# RPD) must be tried before a non- Effective 10/1/02 nizatidine (Axid)# famotidine suspension (Pepcid) preferred agent will be authorized, Implement 1/7/03 ranitidine (Zantac)# ranitidine 150mg (Zantac EFFERdose) unless one of the exceptions on ranitidine syrup (Zantac) the PA form is present. ANTIMIGRAINE almotriptan (Axert) frovatriptan (Frova) PA Criteria: All of the preferred (TRIPTANS) sumatriptan (Imitrex) all forms naratriptan (Amerge) agents must be tried before a Effective 10/1/02 rizatriptan (Maxalt) non-preferred agent will be Implement 1/7/03 zolmitriptan (Zomig) approved, unless one of the eletriptan (Relpax)<> exceptions on the PA form is present. (Quantity limits still apply in this category) ANTIINCONTINENCE flavoxate (Urispas) oxybutynin XL (Ditropan XL) PA Criteria: All of the preferred AGENTS oxybutynin (Ditropan)# agents in this category must be Effective 10/1/02 tolterodine (Detrol) tried before a non-preferred agent Implement 1/7/03 tolterodine LA (Detrol LA) will be authorized, unless one of the exceptions on the PA form is present. GLUCOCORTICOIDS, beclomethasone CFC (Vanceril) beclomethasone HFA (QVAR) PA Criteria: All of the preferred INHALED flunisolide (Aerobid, Aerobid M) budesonide (Pulmicort Turbuhaler) agents (in one dosage form) must Effective 10/1/02 fluticasone (Flovent, Flovent Rotadisk) budesonide (Pulmicort Respules)*** be tried before a non-preferred Implement 1/7/03 fluticasone/salmeterol (Advair) triamcinolone (Azmacort) agent will be authorized, unless one of the exceptions on the PA form is present. LIPOTROPICS, OTHER cholestyramine (Questran)# colesevelam (WelChol) PA Criteria: The preferred agents Effective 10/1/02 cholestyramine light (Questran Light)# niacin ER/lovastatin (Advicor) must be tried before a non- Implement 1/7/03 colestipol (Colestid) ezetimibe (Zetia)(Implement 2/5/03) preferred agent will be authorized, gemfibrozil (Lopid)# unless one of the exceptions on niacin ER (Niaspan) the PA form is present. Zetia, as fenofibrate (Tricor) monotherapy, will only be approved for patients who cannot take statins or other available agents. Zetia and Welchol will be approved for add-on therapy only after an insufficient response to the maximum tolerable dose of a statin for 12 weeks of therapy and failure of a binding agent. Bureau for Medical Services West Virginia Medicaid Preferred Drug List Page 2 of 12 DRUG CLASS PREFERRED NON-PREFERRED CRITERIA BETA-ADRENERGIC acebutolol (Sectral)# carteolol (Cartrol) PA Criteria: If one of the RECEPTOR BLOCKING atenolol (Tenormin)# penbutolol (Levatol) exceptions on the PA form is AGENTS betaxolol (Kerlone)# sotalol (Betapace AF) present or if the physician feels Effective 10/1/02 bisoprolol (Zebeta)# that the patient cannot be Implement 1/7/03 carvedilol (Coreg) stabilized with any of the labetalol (Normodyne, Trandate)# preferred agents, one of the non- metoprolol (Lopressor)# preferred agents will be approved. metoprolol XL (Toprol XL) nadolol (Corgard)# pindolol (Visken)# propranolol (Inderal)# propranolol LA (Inderal LA) sotalol (Betapace)# timolol (Blocadren)# CORTICOSTEROIDS, flunisolide (Nasalide)# flunisolide (Nasarel) PA Criteria: All of the preferred NASAL fluticasone (Flonase) beclomethasone (Beconase, Vancenase) agents must be tried before a Effective 10/1/02 mometasone (Nasonex) beclomethasone AQ (Beconase AQ, non-preferred agent will be Implement 1/7/03 Vancenase AQ) authorized, unless one of the budesonide (Rhinocort) exceptions on the PA form is budesonide aqua (Rhinocort Aqua) present. triamcinolone (Nasacort) triamcinolone AQ (Nasacort AQ) CALCIUM CHANNEL diltiazem (Cardizem)# amlodipine (Norvasc) PA Criteria: If one of the BLOCKERS diltiazem SR ( Cardizem SR, Cardizem bepridil (Vascor) preferred agents on the list has Effective 10/1/02 CD, Dilacor XR)# nicardipine SR (Cardene SR) already been tried or if one of the Implement 2/5/03 felodipine (Plendil) nifedipine (Adalat, Procardia) generic and exceptions on the PA form is isradipine (Dynacirc) brand present, a non-preferred agent isradipine SR (Dynacirc CR) verapamil ER (Covera-HS) will be authorized. nicardipine (Cardene)# verapamil SR (Verelan) nifedipine SR (Adalat CC, Procardia diltiazem SR (Tiazac) XL)# nimodipine (Nimotop) nisoldipine (Sular) verapamil (Calan, Isoptin)# verapamil ER (Verelan PM) verapamil SR (Calan SR, Isoptin SR)# Bureau for Medical Services West Virginia Medicaid Preferred Drug List Page 3 of 12 DRUG CLASS PREFERRED NON-PREFERRED CRITERIA HMG-CoA REDUCTASE fluvastatin (Lescol) atorvastatin (Lipitor) PA Criteria: One of the preferred INHIBITORS fluvastatin XL (Lescol XL) pravastatin (Pravachol) agents must be tried before a Effective 10/1/02 lovastatin (Mevacor)# non-preferred agent will be Implement 2/5/03 lovastatin ER (Altocor) authorized, unless one of the simvastatin (Zocor) exceptions on the PA form is present. NARCOTIC all generics aspirin/caffeine/dihydrocodeine bitartrate PA Criteria: Three of the ANALGESICS acetaminophen/caffeine/dihydrocodeine (Synalgos-DC) preferred agents must be tried, Effective 12/1/02 bitartrate (Panlor) fentanyl citrate (Actiq) for at least 72 hours, before a Implement 2/5/03 fentanyl transdermal (Duragesic) hydrocodone bitartrate/ibuprofen non-preferred agent will be hydrocodone/acetaminophen (Vicoprofen) authorized, unless one of the (Maxidone) oxycodone (Roxicodone Intensol) exceptions on the PA form is morphine sulfate ER (Kadian) oxycodone CR (OxyContin) present. morphine sulfate ER (Avinza) propoxyphene napsylate (Darvon-N) oxycodone (Roxicodone) tablets oxycodone/acetaminophen (Roxicet) tramadol/acetaminophen (Ultracet)† NSAIDS all generics celecoxib (Celebrex) PA Criteria: A two-week trial of Effective 12/1/02 rofecoxib (Vioxx)** diclofenac/misoprostol (Arthrotec) Vioxx and Bextra is required Implement 2/5/03 valdecoxib (Bextra)** meloxicam (Mobic) before Celebrex will be meclofenamic acid (Ponstel) authorized, unless one of the exceptions on the PA form is present. HYPOGLYCEMICS, glipizide/metformin (Metaglip) (Effective BIGUANIDES 2/1/03) Effective 12/1/02 rosiglitazone/metformin (Avandamet) Implement 2/5/03 (Effective 2/1/03) metformin (Glucophage)# metformin XR (Glucophage XR) metformin/glyburide (Glucovance) HYPOGLYCEMICS, human insulin (Novolin, Novolog) human insulin (Humulin, Humalog) PA Criteria: Lilly products will be INSULINS human insulin (Relion) all insulin pens and devices available for pediatric patients Effective 12/1/02 insulin glargine (Lantus) requiring diluted doses. Non- Implement 2/5/03 preferred insulins will only be authorized with documented proof of an allergic reaction to the preferred insulins. Bureau for Medical Services West Virginia Medicaid Preferred Drug List Page 4 of 12 DRUG CLASS PREFERRED NON-PREFERRED CRITERIA HYPOGLYCEMICS, nateglinide (Starlix) POST-PRANDIAL repaglinide (Prandin) Effective 12/1/02 Implement 2/5/03 HYPOGLYCEMICS, glimepiride (Amaryl) glipizide XL (Glucotrol XL) PA Criteria: A two-month trial of SULFONYLUREAS glipizide (Glucotrol)# acetohexamide (Dymelor and generics) the maximum dose of glimepiride, Effective 12/1/02 glyburide (Micronase, DiaBeta)# chlorpropamide (Diabinese and generics) glipizide, and glyburide is Implement 2/5/03 glyburide
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