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DRC REVIEW May 13, 2020 Arkansas Medicaid Drug Review Committee (DRC) Meetings 2020 PDL REVIEW CALENDAR LOCATION DRC MEETING DATE DHS 700 Main Street May 13, 2020 Little Rock, AR 72201 Conference Room A THERAPEUTIC CLASSES UNDER REVIEW MAY 2020 MEETING • Analgesics-Short-Acting: Apadaz tablets, APAP/Codeine elixir, APAP/Codeine tablets, Benzhydrocodone/APAP tablets, Butalbital Compound w/Codeine Capsules, Butalbital/Caffeine/APAP/Codeine Capsule, Butorphanol nasal, Carisoprodol compound w/Codeine tablets, Codeine tablets, Demerol tablets, Dilaudid liquid, Dilaudid tablets, Fioricet w/Codeine capsules, Fiorinal w/Codeine capsules, HC/APAP Solution, HC/APAP tablets, HC/Ibuprofen tablets, Hydromorphone liquid, Hydromorphone tablets, Ibudone tablets, Levorphanol tablets, Lorcet tablets, Lortab solution, Meperidine solution, Meperidine tablets, Morphine Conc solution, Morphine syringe, Morphine tablets, Nalocet tablets, Norco tablets, Nucynta tablets, Opana tablets, Oxaydo tablets, Oxycodone capsules, Oxycodone Conc solution, Oxycodone solution, Oxycodone syringe, Oxycodone/APAP solution, Oxycodone/APAP tablets, Oxycodone/ASA tablets, Oxycodone/Ibuprofen tablets, Oxymorphone tablets, Pentazocine/Naloxone tablets, Percocet tablets, Roxicodone tablets, Roxybond tablets, Synalgos-DC capsule, Tramadol tablets, Tramadol/APAP tablets, Tylenol w/codeine tablets, Ultracet tablets, Ultram tablets, Vicodin tablets, Xodol tablets • Contraceptives-Oral: Affirmelle, Altavera, Alyacen Monophasic, Alyacen Triphasic, Amethia, Amethia Lo, Amethyst, Apri, Aranelle, Ashlyna, Aubra, Aubra EQ, Aurovela, Aurovela 24 FE, Aurovela FE, Aviane, Ayuna, Azurette, Balcoltra, Balzvia, Bekyree, Beyaz, Blisovi 24 FE, Blisovi FE, Briellyn, Camila, Camrese, Camrese Lo, Caziant, Chateal, Chateal EQ, Cryselle, Cyclafem Monophasic, Cyclafem Triphasic, Cyred, Cyred EQ, Dasetta, Daysee, Deblitane, Desogestrel/Ethinyl Estradiol, Drospirenone / Ethinyl Estradiol, Drospirenone / Ethinyl Estradiol/Levomefolate, Elinest, Ella, Emoquette, Enpresse, Enskyce, Errin, Estarylla, Estrostep FE, Ethynodiol D-Ethinyl Estradiol, Ethynodiol/ Ethinyl Estradiol, Falmina, Fayosim, Femynor, Generesse FE, Gianvi, Hailey, Hailey 24 FE, Heather, Incassia, Introvale, Isibloom, Jaimiess, Jasmiel, Jencylca, Jolessa, Jolivette, Juleber, Junel, Junel FE, Kaitlib FE, Kalliga, Kariva, Kelnor 1-35, Kelnor 1-50, Kurvelo, Larin, Larin 24 FE, Larin FE, Larissia, Layolis FE, Leena, Lessina, Levonest, Levonorgestrel/Ethinyl Estradiol, Levonorgestrel/Ethinyl Estradiol Extended Cycle, Levonorgestrel, Levonorgestrel/Ethinyl Estradiol Lo, Levonorgestrel/Ethinyl Estradiol Monophasic, Levonorgestrel/Ethinyl Estradiol Triphasic, Levora, Lillow, Lo Loestrin FE, Loestrin, Loestrin FE, LoJaimiess, Loryna, LoSeasonique, Low-Ogestrel, Lo-Zumandimine, Lutera, Lyza, Marlissa, Melodetta 24 FE, Mibelas 24 FE, Microgestin, Microgestin FE, Mili, Minastrin 24 FE, Mircette, Mono-Linyah, Mononessa, Myzilra, Natazia, Necon, Nikki, Nora-B, Norethindrone, Norethindrone/ Ethinyl Estradiol, Norethindrone/ Ethinyl Estradiol FE, Norethindrone/ Ethinyl Estradiol FE Monophasic, Norgestimate/ Ethinyl Estradiol Monophasic, Norgestimate/ Ethinyl Estradiol Triphasic, Norlyda, Nortrel, Ocella, Ogestrel, Orsythia, Ortho-Micronor, Ortho Tri-cyclen, Ortho Tri-cyclen Lo, Ortho Cyclen, Ortho Novum Monophasic, Ortho Novum Triphasic, Philith, Pimtrea, Pirmella, Portia, Previfem, Quartette, Reclipsen, Rivelsa, Safyral, Seasonique, Setlakin, Sharobel, Simliya, Simpesse, Slynd, Sprintec, Sronyx, Syeda, Tarina 24 FE, Tarina FE, Tarine FE 1-20, Taytulla, Tilia FE, Tri-Estarylla, , Tri-Legest FE, Tri-Linyah, Tri-Lo-Estarylla, Tri-Lo-Marzia, Tri-Lo-Mili, Tri-Lo-Sprintec, Tri-Mili, Tri-Norinyl, Tri-Previfem, Tri-Sprintec, Tri-Vylibra, Tri-Vylibra Lo, Trivora-28, Tulana, Tydemy, Velivet, Vienva, Viorele, Volnea, Vyfemla, Vylibra, Wera, Wymzya FE, Yasmin 28, Yaz, Zarah, Zovia 1-35E, Zumandimine • Ophthalmics, Allergic Conjunctivitis: Alocril drops, Alomide drops, Alrex suspension, Azelastine drops, Bepreve drops, Cromolyn Sodium drops, Elestat drops, Emadine drops, Epinastine drops, Ketotifen OTC drops, Lastacaft drops, Olopatadine 0.1% drops, Olopatadine 0.2% drops, Pataday drops, Patanol drops, Pazeo drops, Zaditor OTC drops, Zerviate droperette • Ophthalmics, Antibiotics: Azasite drops, Bacitracin ointment, Bacitracin/Polymyxin B ointment, Besivance suspension, Bleph-10 drops, Ciloxan drops, Ciloxan ointment, Ciprofloxacin drops, Erythromycin ointment, Garamycin drops, Garamycin ointment, Gatifloxacin drops, Gentamycin drops, Gentamycin ointment, Levofloxacin drops, Moxeza drops, Moxifloxacin drops, Natacyn suspension, Neomycin/Bacitracin/Polymyxin B ointment, Neomycin/Bacitracin/Gramicidin drops, Ocuflox drops, Ofloxacin drops, Polymyxin/Trimethoprim drops, Polytrim drops, Sulfacetamide drops, Sulfacetamide ointment, Tobramycin drops, Tobrex drops, Tobrex ointment, Vigamox drops, Zymaxid drops • Ophthalmics, Antibiotics-Steroid Combinations: Blephamide suspension, Blephamide S.O.P. ointment, Cortisporin ointment, Maxitrol ointment, Maxitrol suspension, Neomycin/Bacitracin/Polymyxin B ointment, Neomycin/Polymyxin B/Dexamethasone ointment, Neomycin/Polymyxin B/Dexamethasone suspension, Neomycin/Polymyxin B/HC drops, Neomycin/Polymyxin B/HC ointment, Neomycin/Polymyxin B/HC suspension, Pred-G ointment, Pred-G suspension, Sulfacetamide/Prednisolone drops, Tobradex ointment, Tobradex suspension, Tobramycin/Dexamethasone suspension, Zylet suspension • Ophthalmics, Anti-Inflammatory: Acuvail droperette, Bromfenac drops, Bromsite drops, Dexamethasone drops, Diclofenac drops, Durezol drops, Flarex suspension, Fluorometholone suspension, Flurbiprofen drops, FML suspension, FML Forte suspension, FML S.O.P ointment, Ilevro suspension, Inveltys suspension, Ketorolac drops, Ketorolac LS drops, Lotemax drops, Lotemax gel, Lotemax ointment, Loteprednol drops, Maxidex drops, Maxidex ointment, Nevanac suspension, Ocufen drops, Pred-Forte suspension, Pred-Mild suspension, Prednisol drops, Prednisolone AC suspension, Prednisolone Sodium Phosphate drops, Prolensa drops, Vexol suspension • Ophthalmics, Glaucoma: Alphagan P 0.1% drops, Alphagan P 0.15% drops, Apraclonidine drops, Azopt suspension, Betaxolol drops, Betoptic S suspension, Bimatoprost drops, Brimonidine P 0.15% drops, Brimonidine 0.2% drops, Brimondine/Dorzolamide PF drops, Carteolol drops, Combigan drops, Cosopt drops, Cosopt PF droperette, Dorzolamide, Dorzolamide/Timolol drops, Dorzolamide/Timolol PF droperette, Iopidine 0.5% drops, Iopidine 1% droperette, Istalol drops, Latanoprost drops, Levobunolol drops, Lumigan drops, Metipranolol drops, Phospholine Iodide drops, Pilocarpine drops, Rhopressa drops, Rocklatan drops, Simbrinza suspension, Timolol drops, Timolol gel, Timoptic drops, Timoptic droperette, Timoptic Ocudose, Timoptic XE gel, Travatan Z drops, Travoprost drops, Trusopt drops, Vyzulta drops, Xalatan drops, Xelpros emulsion, Zioptan droperette • Steroids, Topical – Low potency: Ala-Cort cream, Ala-Scalp lotion, Aclometasone diproprionate cream, Aclometasone diproprionate ointment, Capex shampoo, Derma-Smoothe FS oil, Desonate gel, Desonide cream, Desonide lotion, Desonide ointment, Desowen cream, Desowen lotion, Desowen ointment, Fluocinolone oil, Hydrocortisone Cream OTC, Hydrocortisone Ointment OTC, Hydrocortisone Cream Rx, Hydrocortisone Ointment Rx, Hydrocortisone gel Rx, Hydrocortisone lotion Rx, Texacort solution • Steroids, Topical – Medium potency: Beser lotion, Betamethasone Valerate foam, Clocortolone cream, Cloderm cream, Cordran tape, Cutivate cream, Cutivate lotion, Dermatop ointment, Elocon cream, Fluocinolone cream, Fluocinolone oil, Fluocinolone ointment, Fluocinolone solution, Fluandrenolide cream, Fluandrenolide lotion, Fluandrenolide ointment, Fluticasone cream, Fluticasone lotion, Fluticasone ointment, Hydrocortisone Butyrate Cream, Hydrocortisone Butyrate lotion, Hydrocortisone Butyrate ointment, Hydrocortisone Butyrate solution, Hydrocortisone Valerate cream, Hydrocortisone Valerate ointment, Locoid cream, Locoid lotion, Locoid solution, Luxiq foam, Mometasone cream, Mometasone ointment, Mometasone solution, Pandel cream, Prednicarbate cream, Prednicarbate ointment, Synalar cream, Synalar solution • Steroids, Topical –High potency: Amcinonide cream, Amcinonide lotion, Amcinonide ointment, Betamethasone Dipropionate Augmented cream, Betamethasone Dipropionate Augmented gel, Betamethasone Dipropionate Augmented lotion, Betamethasone Dipropionate Augmented ointment, Betamethasone Dipropionate cream, Betamethasone Dipropionate gel, Betamethasone Dipropionate lotion, Betamethasone Dipropionate ointment, Desoximetasone cream, Desoximetasone gel, Desoximetasone ointment, Desoximetasone spray, Diflorasone cream, Diflorasone ointment, Diprolene ointment, Fluocinonide cream, Fluocinonide emollient, Fluocinonide gel, Fluocinonide ointment, Fluocinonide solution, Halcinonide cream, Halog cream, Halog ointment, Kenalog aerosol, Sernivo spray, Topicort cream, Topicort gel, Topicort LP cream, Topicort ointment, Topicort spray, Triamcinolone aerosol, Triamcinolone cream, Triamcinolone lotion, Triamcinolone ointment, Vanos cream, • Steroids, Topical-Very High Potency: Apexicon emollient, Bryhali lotion, Clobetasol emollient, Clobetasol lotion, Clobetasol shampoo, Clobetasol propionate cream, Clobetasol propionate foam, Clobetasol propionate gel, Clobetasol propionate ointment, Clobetasol propionate solution, Clobetasol propionate spray, Clobex lotion, Clobex shampoo, Clobex Spray, Halobetasol cream, Halobetasol foam, Halobetasol ointment, Lexette foam, Olux foam, Olux E foam, Temovate cream, Temovate ointment, Ultravate cream, Ultravate lotion, Ultravate ointment DHS 700 Main Street August 12, 2020 @ 0900–1200 Little Rock, AR 72201 Conference Room A THERAPEUTIC CLASSES UNDER REVIEW AT August 2020 MEETING **TO BE DETERMINED** .
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  • Steroids, Topical Therapeutic Class Review

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    Steroids, Topical Therapeutic Class Review (TCR) May 14, 2019 No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, digital scanning, or via any information storage or retrieval system without the express written consent of Magellan Rx Management. All requests for permission should be mailed to: Magellan Rx Management Attention: Legal Department 6950 Columbia Gateway Drive Columbia, Maryland 21046 The materials contained herein represent the opinions of the collective authors and editors and should not be construed to be the official representation of any professional organization or group, any state Pharmacy and Therapeutics committee, any state Medicaid Agency, or any other clinical committee. This material is not intended to be relied upon as medical advice for specific medical cases and nothing contained herein should be relied upon by any patient, medical professional or layperson seeking information about a specific course of treatment for a specific medical condition. All readers of this material are responsible for independently obtaining medical advice and guidance from their own physician and/or other medical professional in regard to the best course of treatment for their specific medical condition. This publication, inclusive of all forms contained herein, is intended to be educational in nature and is intended to be used for informational purposes only. Send comments and suggestions to [email protected]. May 2019
  • Drug Tariff Part VIIIA December 2019

    Drug Tariff Part VIIIA December 2019

    12/2019 Part VIIIA BASIC PRICES OF DRUGS Drug Quantity Basic Price Category Part VIIIA - Basic Prices of Drugs Product List Part VIIIA products A Abacavir 600mg / Lamivudine 30 19000 C Lupin Healthcare 300mg tablets (UK) Ltd Abatacept 125mg/1ml solution for 4 120960 C Orencia ClickJect injection pre-filled disposable devices Abatacept 125mg/1ml solution for 4 120960 C Orencia injection pre-filled syringes Acacia spray dried powder 250 g 1632 C J M Loveridge Ltd Acamprosate 333mg gastro- 168 3770 K A resistant tablets Acarbose 100mg tablets 90 2529 A Acarbose 50mg tablets 90 1458 A Acebutolol 100mg capsules 84 1497 C Sectral Acebutolol 200mg capsules 56 1918 C Sectral Acebutolol 400mg tablets 28 1862 C Sectral Aceclofenac 100mg tablets 60 962 A Acenocoumarol 1mg tablets 100 462 C Sinthrome Acetazolamide 250mg modified- 30 1666 C Diamox SR release capsules Acetazolamide 250mg tablets 112 1029 M Acetic acid 2% ear spray S 5ml 410 C EarCalm Acetone liquid 50 ml 112 A Acetylcysteine 200mg oral powder 30 11250 A sachets sugar free Acetylcysteine 2g/10ml solution for 10 2126 C Martindale infusion ampoules Pharmaceuticals Ltd Acetylcysteine 5% eye drops S 10 ml 3346 C Ilube Acetylcysteine 600mg capsules 30 3998 A Acetylcysteine 600mg effervescent 30 550 C tablets sugar free Aciclovir 200mg dispersible tablets 25 147 A Aciclovir 200mg tablets 25 133 M Aciclovir 200mg/5ml oral 125 ml 3578 A suspension sugar free Aciclovir 3% eye ointment S 4.5 g 934 C Zovirax Aciclovir 400mg dispersible tablets 56 1199 A Aciclovir 400mg tablets 56 310 M Aciclovir