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Preferred Drug List for FL, HI, IA, MS CHIP, NM, NY, OH, and PA

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Preferred Drug List for FL, HI, IA, MS CHIP, NM, NY, OH, and PA UnitedHealthcare Community Plan of Virginia 1st Quarter 2019 Preferred Drug List Update UnitedHealthcare Community Plan’s Preferred Drug List (PDL) is updated quarterly by our Pharmacy and Therapeutics Committee. Please review the changes and update your references as necessary. You may also view the changes at UHCprovider.com > Health Plans by State > Choose Your State > Medicaid (Community Plan) > Pharmacy Resources and Physician Administered Drugs. We provided a list of available alternatives to UnitedHealthcare Community Plan members whose current treatment includes a medication removed from the PDL. Please provide affected members a prescription for a preferred alternative in one of the following ways: Call or fax the pharmacy. Use e-Script. Write a new prescription and give it directly to the member. If a preferred alternative is not appropriate, please call 800-310-6826 for prior authorization for the UnitedHealthcare Community Plan member to remain on their current medication. Changes effective November 1, 2018 PDL Additions Brand Name Generic Name Comments Basaglar KwikPen® Insulin glargine Indicated for the treatment of type-1 diabetes in adults and injection children and type-2 diabetes in adults. Changes will be effective January 1, 2019 PDL Additions Brand Name Generic Name Comments ErleadaTM Apalutamide tablet Indicated for the treatment of non-metastatic castration resistant prostate cancer. Prior authorization required. Available through specialty pharmacy. Nocdurna® Desmopressin Indicated for the treatment of nocturnal polyuria. Prior acetate sublingual authorization required. tablet Vandazole™ gel Metronidazole Indicated in the treatment of bacterial vaginosis. vaginal gel 0.75% carbamazepine XR carbamazepine XR Extended-release anticonvulsant diazepam (rectal) diazepam (rectal) For rectal use when oral diazepam is contraindicated diazepam device diazepam device For rectal use when oral diazepam is contraindicated (rectal) (rectal) primidone primidone Oral anticonvulsant Aristada™ Initio aripiprazole lauroxil Indicated for use as a single dose to initiate ARISTADA® (aripiprazole lauroxil) treatment or as a single dose to reinitiate ARISTADA treatment following a missed dose of ARISTADA®. Doc#: PCA-1-009402-01182018_01292018_VA_PDL_Q4_2018 © 2018 United HealthCare Services, Inc. olanzapine (IM) olanzapine (IM) Injectable antitypical antipsychotic indicated in the treatment of acute agitation associated with schizophrenia and bipolar I mania bisoprolol, bisoprolol, Antihypertensive propranolol ER propranolol ER oxybutynin ER oxybutynin ER Indicated for the treatment of overactive bladder. Anoro® Ellipta® umeclidinium and Once-daily maintenance treatment of airflow obstruction in vilanterol inhalation patients with chronic obstructive powder pulmonary disease (COPD), including chronic bronchitis and/or emphysema. Stiolto® Respimat® tiotropium bromide Indicated for the long‑term, once‑daily maintenance treatment and olodaterol of airflow obstruction in patients with chronic obstructive pulmonary disease (COPD), including chronic bronchitis and/or emphysema. ezetimibe ezetimibe Generic substitution for Zetia® bacitracin/polymyxin bacitracin/polymyxi Topical antibiotic B sulfate oint n B sulfate oint PDL Modifications Brand Name Generic Name Comments Regranex® Becaplermin gel Remove prior authorization. Diagnosis required. PDL Deletions Brand Name Generic Name Comments Diastat® Diazepam Diazepam rectal gel preferred Diastat®AcuDial™ Diazepam Diazepam rectal device preferred. Dilantin® Infatab Phenytoin Phenytoin chew tab preferred Phenytek®, Phenytoin Generic phenytoin caps preferred. Tegretol® XR Carbamazepine XR Carbamazepine XR preferred. aripiprazole oral aripiprazole oral Current utilizers grandfathered for 1 year, then prior solution solution authorization will be required. Geodon® (IM), Ziprasidone Current utilizers grandfathered for 1 year, then prior authorization will be required. Nuplazid® Pimavanserin Current utilizers grandfathered for 1 year, then prior authorization will be required. olanzapine/ olanzapine/ Current utilizers grandfathered for 1 year, then prior fluoxetine fluoxetine authorization will be required. Kapspargo™ metoprolol Extended-release sprinkle formulation of metoprolol succinate Sprinkle (NEW DRUG) indicated for treatment of patients with Hypertension, Angina Pectoris and Heart Failure. Oxytrol® for Women Transdermal Oxybutin ER preferred. OTC (transdermal) Oxybutin QVAR® beclomethasone Product discontinued by manufacturer. dipropionate Patanase® Olopatadine Azelastine 0.1% preferred. Zetia® ezetimibe Ezetimibe preferred. Betoptic S® Betaxolol Use preferred agents (ophthalmic) Doc#: PCA-1-009402-01182018_01292018_VA_PDL_Q4_2018 © 2018 United HealthCare Services, Inc. Tracleer® susp Bosentan Use Tracleer tablet for suspension PDL Update Training on UHC On Air On UHC On Air, we have an on-demand video highlighting this quarter’s more impactful PDL changes. UnitedHealthcare Link users can access UHC On Air by selecting the UHC On Air tile on their Link dashboard. From there, go to Virginia, and click on UHC Community Plan. You’ll find the Preferred Drug List Q1 Update in the videos listings. To access Link, go to UHCprovider.com and sign in by clicking the Link button in the top right corner. If you don’t have access to Link, select the New User button. To learn more about Link, please visit UHCprovider.com/link. If you have any questions, please call UnitedHealthcare Community Plan’s Pharmacy Department at 800-310-6826. Thank you. Doc#: PCA-1-009402-01182018_01292018_VA_PDL_Q4_2018 © 2018 United HealthCare Services, Inc. .
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