PROVIDER BULLETIN No. 18-11

DATE: July 3, 2018

TO: All Providers Participating in Nebraska Medicaid Program

FROM: Matthew A. Van Patton, DHA, Director Division of Medicaid & Long-Term Care

BY: Jenny Minchow, R.P., Pharm. D, Pharmacy Consultant

RE: Preferred Drug List Changes

Please share this information with administrative, clinical, and billing staff.

On May 2, 2018, the Nebraska Medicaid Pharmaceutical and Therapeutics Committee reviewed 62 therapeutic classes of drugs on the Preferred Drug List (PDL). Changes to the reviewed thera- peutic classes will be implemented July 19, 2018. The list that follows includes the changes only. It is not the complete PDL.

CHANGES to the drug classes follow.

PREFERRED NON-PREFERRED PREFERRED NON-PREFERRED ACNE AGENTS, TOPICAL /benzoyl peroxide AVAR (sulfacetamine so- ANALGESICS, OPIOID SHORT-ACTING (generic for Duac) dium/sulfur) butalbital/caffeine/APAP w/co- BENZACLIN W/PUMP deine (clindamycin/benzoyl peroxide) butalbital compound w/codeine benzoxyl peroxide (butalbital/ASA/caffeine/co- CLEANSER, CLEANSING deine) BAR, OTC carisoprodol compound-codeine NEUAC (clindamycin/benzoyl (carisoprodol/ASA/codeine) peroxide) FIORINAL/CODEINE (butal- OVACE PLUS (sulfacetamind bital/ASA/codeine/caffeine) sodium) OXAYDO (oxycodone) ANALGESICS, OPIOID LONG-ACTING ANTIBIOTICS, GASTROINTESTINAL EMBEDA (morphine sulfate/ buprenorphine TRANSDER- paromomycin naltrexone) MAL (generic for Butrans) SOLOSEC (secnidazole) MORPHABOND (morphine ANTIEMETICS/ANTIVERTIGO AGENTS sulfate) BONJESTA (doxylamine/pyri- doxine) SYNDROS (dronabinol) , TOPICAL KERIDYN () OTC OINTMENT, SPRAY tolnaftate SPRAY, OTC ANTIMIGRAINE AGENTS, TRIPTANS sumatriptan KIT (mfr SUN) PREFERRED NON-PREFERRED PREFERRED NON-PREFERRED

ANTIVIRALS, ORAL HIV / AIDS NNRTIs rimantadine (generic for EDURANT (rilpivirine) (generic for Sustiva) Flumadine) INTELENCE (etravirine) VIRAMUNE () BETA BLOCKERS, ORAL nevirapine TAB (generic for VIRAMUNE XR (nevirapine bisoprolol (generic for Zebeta) Viramune) extended release) BLADDER RELAXANT PREPARATIONS nevirapine er (generic for Vira- EPIVIR (lamivudine) flavoxate mune XR) RETROVIR (zidovudine) BONE RESORPTION SUPRESSION AND RELATED RESCRIPTOR (delavirdine) tenofovir disoproxil fumarate DRUGS SUSTIVA CAP, TAB (efavi- (generic for Viread) TYMLOS (abaloparatide) renz) VIDEX EC (didanosine) VIRAMUNE SUSP nevirapine) ZERIT SOLN (stavudine) CALCIUM CHANNEL BLOCKERS, ORAL abacavir SOLN, TAB (generic ZIAGEN (abacavir) (generic for Procar- for Ziagen) dia) didanosine CAP DR (generic CEPHALOSPORINS AND RELATED ANTIBIOTICS, ORAL for SUPRAX CAPSULE, CHEW- amoxicillin/clavulanate, Videx EC) ABLE TABLET (cefixime) CHEWABLE EMTRIVA CAP, SOLN cefixime SUSPENSION (gener- (emtricitabine) icfor Suprax) lamivudine SOLN, TAB DAXBIA (cephalexin) (generic for Epivir) CONTRACEPTIVES, ORAL stavudine CAP, SOLN (generic ethynodiol d-ethinyl estradiol for Zerit) levonorgestrel/ethinyl estradiol VIDEX SOLN (didanosine) melodotta 24 FE (nore- VIREAD (tenofovir disoproxil thindrone-e. estradiol/iron) fumarate) my choice otc (levonorgestrel) zidovudine CAP, SYRUP, TAB CYSTIC FIBROSIS, ORAL (generic for Retrovir) SYMDEKO (tezacaftor/ivacaftor) HIV / AIDS NRTI COMBINATIONS DIURETICS abacavir/lamivudine (generic COMBIVIR CAROSPIR () SUS- for EPZICOM) (zidovudine/lamivudine) PENSION abacavir/lamivudine/zidovudine EPZICOM (abacavir methyclothiazide TABLET (generic for Trizivir) sulfate/lamivudine) FLUOROQUINOLONES, ORAL ATRIPLA (tenofovir disoproxil TRIZIVIR BAXDELA (delafloxacin) fumarate/emtricitabine/efaviren (abacavir/zidovudine/ GI MOTILITY, CHRONIC z) lamivudine) MOVANTIK (naloxegol oxa- SYMPROIC (naldemedine) BIKTARVY late) (bictegravir/emtricitabine/ HEPATITIS B TREATMENTS tenofovir alafenamide) entecavir TABLET adefovir dipivoxil COMPLERA lamivudine hbv TABLET BARACLUDE (entecavir) SO- (rilpivirine/emtricitabine/ LUTION, TABLET tenofovir disoproxil fumarate) EPIVIR HBV (lamivudine) DESCOVY TABLET, SOLUTION (emtricitabine/tenofovir HEPSERA (adefovir dipivoxil) alafenamide) VEMLIDY (tenofovir alafena- lamivudine/zidovudine (generic mide fumarate) for COMBIVIR) HIV / AIDS HIV CCR5 ANTAGONISTS ODEFSEY SELZENTRY SOLN, TAB (emtricitabine/rilpivirine/ (maraviroc) tenofovir alafenamide) HIV / AIDS CYTOCHROME P450 INHIBITORS STRIBILD TYBOST (cobicistat) (elvitegravir/cobicistat/emtricita bine/tenofovir disoproxil HIV / AIDS FUSION INHIBITORS fumarate) FUZEON SUB-Q (enfuvirtide) TRIUMEQ HIV / AIDS INTEGRASE INHIBITORS (dolutegravir/abacavir/lamivudi GENVOYA (elvitegravier/cobi- n) cistat/emtricitabine/tenofovir al- TRUVADA (tenofovir afenamide) disoproxil ISENTRESS CHEW TAB, fumarate/emtricitabine) POWDER PACK, TAB (ralte- gravir)

ISENTRESS HD (raltegravir)

JULUCA (dolutegravir/rilpi- virine)

TIVICAY (dolutegravir)

PREFERRED NON-PREFERRED PREFERRED NON-PREFERRED

HIV / AIDS PROTEASE INHIBITORS IMMUNOSUPPRESSIVES, ORAL APTIVUS CAP, SOLN atazanavir (generic for Reyataz) azothiaprine ASTAGRAF XL () (tipranavir) fosamprenavir TABLET cyclosporine CAPSULE, AZASAN (azathioprine) CRIXIVAN () (generic for Lexiva) cyclosporine, modified CELLCEPT (mycophenolate EVOTAZ(atazanavir ritinovir TAB (generic for CAPSULE mofetil) CAPSULE, sulfate/cobicistat) Norvir) mycophenolate mofetil SUSPENSION, TABLET INVIRASE (saquinavir) KALETRA SOLN CAPSULE, TABLET cyclosporine, modified KALETRA TAB (lopinavir/) RAPAMUNE () SOLUTION, SOFTGEL (lopinavir/ritonavir) SOLUTION ENVARSUS XR (tacrolimus) LEXIVA SUSP, TAB sirolimus IMURAN (azathioprine) (fosamprenavir) tacrolimus mycophenolate mofetil lopinavir/ritonavir SOLN SUSPENSION (generic for Kaletra) mycophenolic acid NORVIR SOLN, TAB (mycophenolate sodium) (ritonavir) MYFORTIC (mycophenolate PREZCOBIX sodium) (darunavir/cobicistat) NEORAL (cyclosporine, PREZISTA SUSP, TAB modified) CAPSULE, (darunavir) SOLUTION REYATAZ CAP, POWDER PROGRAF (tacrolimus) PACK (atazanavir) RAPAMUNE (sirolimus) VIRACEPT (nelfinavir) SANDIMMUNE (cyclosporine) HYPOGLYCEMICS, INCRETIN MIMETICS/ENHANCERS CAPSULE, SOLUTION GLUCAGON-LIKE PEPTIDE-1 RECEPTOR AGONIST (GLP-1 ZORTRESS (everolimus) RA) LINCOSAMIDES / OXAZOLIDINONES / STREPTOGRAMINS BYDUREON BCISE PEN clindamycin CAPSULE CLEOCIN (clindamycin hcl) (exenatide) clindamycin palmitate CAPSULE OZEMPIC (semaglutide) SOLUTION CLEOCIN PALMITATE HYPOGLYCEMICS, INCRETIN MIMETICS/ENHANCERS linezolid TABLET (clindamycin palmitate hcl) DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITOR linezolid SUSPENSION GLYXAMBI QTERN SIVEXTRO (tedizolid (empagliflozin/linagliptin) (dapagliflozin/saxagliptin) phosphate) STEGLUJAN ZYVOX (linezolid) (ertugliflozin/sitagliptin) SUSPENSION, TABLET HYPOGLYCEMICS, INSULIN AND RELATED DRUGS LIPOTROPICS, OTHER FIBRIC ACID DERIVATIVES HUMALOG MIX PEN (insulin ADMELOG (insulin lispro) fenofibric acid (generic for lispro/lispro protamine) PEN, VIAL Trilipix) FIASP (insulin aspart)PEN, LIPOTROPICS, OTHER CHOLESTEROL ABSORPTION IN- VIAL HIBITORS HUMALOG JR. (insulin lispro) ezetimibe (generic for Zetia) U-100 PEN PAH (PULMONARY ARTERIAL HYPERTENSION AGENTS, HYPOGLYCEMICS, SGLT2 ORAL AND INHALED) JARDIANCE (empagliflozin) SEGLUROMET TRACLEER TABLETS FOR (ertugliflozin/metformin) SUSPENSION () STEGLATRO (ertugliflozin) SYNJARDY XR (empagliflozin/ metformin)

PREFERRED NON-PREFERRED PREFERRED NON-PREFERRED

PHOSPHATE BINDERS PEDIATRIC VITAMIN PREPARATIONS PHOSLYRA (calcium acetate) CHILD LITTLE ANIMALS AQUADEKS (pedi multivit PRENATAL VITAMINS VITAMINS CHEW OTC (pedi 40/phytonadione) Pnv2.iron b-g suc-p/fa/omega-3 multivit 91/iron fum) CHEW ESCAVITE (pedi multivit (prenatal 2/iron/folic acid/om3) child multivitamins chew otc 47/iron/fluoride) EXPECTA PRENATAL OTC (pedi multivit 19/folic acid) ESCAVITE D (pedi multivit (Prenatal 116/iron/folic CHEW 78/iron/fluoride) CHEW acid/dha) CHILDREN'S CHEW ESCAVITE LQ (pedi multivit MULTIVIT-IRON OTC (pedi 86/iron/fluoride) XIMINO (minocycline ER) multivit 91/iron fum) CHEW FLORIVA (pedi multivit CAPSULE, children’s chewables otc (pedi 85/fluoride) CHEW multivit 23/folic acid) CHEW FLORIVA PLUS (pedi multivit children’s vitamins with iron otc 130/fluoride) DROPS (pedi multivit/iron) multivit A, B, D, E, K, ZN FLINTSTONES OTC (pedi (pediatric multivit 153/D3/K) multivit) CHEW POLY-VI-FLOR (pedi multivit FLINTSTONES MULTI-VIT 33/fluoride) CHEW OTC (pedi multivit 43/iron fum) POLY-VI-FLOR (pedi multivit GUMMIES 37/fluoride) DROPS fluoride/vitamins A,C,AND D POLY-VI-FLOR w/IRON (pedi (ped multivit A,C,D3, 21/fluoride) multivit 33/fluoride/iron) DROPS CHEW multivitamins with fluoride (pedi POLY-VI-FLOR w/IRON (pedi multivit 2/fluoride) DROPS multivit 37/fluoride/iron) multivits with iron and fluoride DROPS (pedi multivit 45/fluoride/iron) QUFLORA (pedi multivit DROPS 84/fluoride) MVC-FLUORIDE (pedi multivit QUFLORA FE (pedi multivit 12/fluoride) CHEW TAB 142/iron/fluoride) ped mvit A,C,D3,No 21/fluoride TRI-VI-FLORO (ped multivit DROPS A, C, D3, 38/fluoride) pedi mvi no. 16 with fluoride CHEW pedi mvi 17 with fluoride CHEW POLY-VI-SOL OTC (pedi multivit 81) DROPS POLY-VI-SOL WITH IRON (pedi multivit 80/ferrous sulfate) DROPS TRI-VI-SOL OTC (vit A palmitate/vit C/Vit D3) DROPS VITALETS OTC (pedi multivit 36/iron) CHEW

For the complete listing of the PDL with upcoming changes, please see the Pharmacy Magellan Medicaid Administration website at https://nebraska.fhsc.com under the Preferred Drug List Tab: (PDL Changes, effective 07/19/2018). Changes to the reviewed therapeutic classes are listed in italics on the posted PDL to be implemented July 19, 2018.

Prior authorization criteria for certain preferred and non-preferred drugs may also be found on the website named above. Requests for prior authorization should be submitted to the client’s plan:

Nebraska Total Care Phone: 1-844-330-7852, or Fax: 1-866-399-0929, or www.covermymeds.com/epa/envolverx/

UnitedHealthcare Community Plan of Nebraska Phone: 1-800-310-6826, or Fax: 1-866-940-7328, or www.unitedhealthcareonline.com

WellCare of Nebraska Phone: 1-855-599-3811, or Fax: 1-877-276-9630, or www.wellcare.com/en/nebraska

Nebraska Medicaid Fee-For-Service (Magellan Rx) Phone: 1-800-241-8335, or Fax: 1-866-759-4115, or https://nebraska.fhsc.com/Downloads/NEfaxform_MedicalNecessity-201210.pdf

For further information contact Jenny Minchow R.P., Pharm.D at (402) 471-9109, or email at [email protected].

Medicaid Provider Bulletins, such as this one, are posted on the DHHS website at http://dhhs.ne.gov/medicaid/Pages/med_pb_index.aspx. The “Recent Web Updates” page will help you monitor changes to the Medicaid pages.