BUREAU FOR MEDICAL SERVICES WEST VIRGINIA MEDICAID EFFECTIVE PREFERRED DRUG LIST WITH PRIOR AUTHORIZATION CRITERIA 01/01/13 This is not an all-inclusive list of available covered drugs and includes only managed categories. Refer to cover page for complete list of rules governing this PDL. Version 2013.1i Prior authorization for a non-preferred agent in any category will be given only if there has been a trial of the preferred brand/generic equivalent or preferred formulation of the active ingredient, at a therapeutic dose, that resulted in a partial response with a documented intolerance. Prior authorization of a non-preferred isomer, pro-drug, or metabolite will be considered with a trial of a preferred parent drug of the same chemical entity, at a therapeutic dose, that resulted in a partial response with documented intolerance or a previous trial and therapy failure, at a therapeutic dose, with a preferred drug of a different chemical entity indicated to treat the submitted diagnosis. (The required trial may be overridden when documented evidence is provided that the use of these preferred agent(s) would be medically contraindicated.) Unless otherwise specified, the listing of a particular brand or generic name includes all legend forms of that drug. OTC drugs are not covered unless specified. PA criteria for non-preferred agents apply in addition to general Drug Utilization Review policy that is in effect for the entire pharmacy program, including, but not limited to, appropriate dosing, duplication of therapy, etc. The use of pharmaceutical samples will not be considered when evaluating the members’ medical condition or prior prescription history for drugs that require prior authorization. Acronyms CL - Requires clinical PA. For detailed clinical criteria, please refer to: http://www.dhhr.wv.gov/bms/Pharmacy/Pages/PriorAuthorizationCriteria.aspx NR - New drug has not been reviewed by P & T Committee AP - Non-preferred and selected preferred drugs, where indicated, are subject to auto-PA criteria. See PA criteria column. 1 BUREAU FOR MEDICAL SERVICES WEST VIRGINIA MEDICAID EFFECTIVE PREFERRED DRUG LIST WITH PRIOR AUTHORIZATION CRITERIA 01/01/13 This is not an all-inclusive list of available covered drugs and includes only managed categories. Refer to cover page for complete list of rules governing this PDL. Version 2013.1i THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS ACNE AGENTS (Topical)AP ANTI-INFECTIVE AZELEX (azelaic acid) ACZONE (dapsone) Thirty (30) day trials each of one clindamycin gel, lotion, medicated swab, AKNE-MYCIN (erythromycin) preferred retinoid and two unique solution CLEOCIN-T (clindamycin) chemical entities in two other erythromycin gel, solution CLINDACIN PAC (clindamycin) subclasses, including the generic sulfacetamide suspension CLINDAGEL (clindamycin) version of a requested non- clindamycin foam preferred product, are required erythromycin medicated swab before a non-preferred agent will be EVOCLIN (clindamycin) authorized unless one of the KLARON (sodium sulfacetamide) exceptions on the PA form is OVACE/PLUS (sulfacetamide) present. (In cases of pregnancy, a sulfacetamide cleanser trial of retinoids will not be required.) RETINOIDS RETIN A MICRO (tretinoin) adapalene PA required after 17 years of age TAZORAC (tazarotene) ATRALIN (tretinoin) for tretinoin products. AVITA (tretinoin) DIFFERIN (adapalene) RETIN-A (tretinoin) tretinoin cream, gel KERATOLYTICS benzoyl peroxide cleanser OTC, 10% cream BENZEFOAM (benzoyl peroxide) Acne kits are non-preferred. OTC, gel Rx & OTC, lotion OTC, 5% & BENZEFOAM ULTRA (benzoyl peroxide) 10% wash OTC BENZEPRO (benzoyl peroxide) TL 4.25% BPO MX (benzoyl peroxide) benzoyl peroxide cloths, medicated pads benzoyl peroxide/aloe OTC benzoyl peroxide/urea BPO (benzoyl peroxide) DELOS (benzoyl peroxide) DESQUAM-X (benzoyl peroxide) LAVOCLEN (benzoyl peroxide) PACNEX/HP/LP (benzoyl peroxide) PANOXYL-4, -8 OTC (benzoyl peroxide) PERSA-GEL OTC (benzoyl peroxide) SASTID (sulfur) SE-BPO (benzoyl peroxide) SULPHO-LAC (sulfur) 2 BUREAU FOR MEDICAL SERVICES WEST VIRGINIA MEDICAID EFFECTIVE PREFERRED DRUG LIST WITH PRIOR AUTHORIZATION CRITERIA 01/01/13 This is not an all-inclusive list of available covered drugs and includes only managed categories. Refer to cover page for complete list of rules governing this PDL. Version 2013.1i THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS COMBINATION AGENTS erythromycin/benzoyl peroxide 10-1 (sulfacetamide/sulfur) Thirty (30) day trials each of one sulfacetamide solution ACANYA (clindamycin phosphate/benzoyl preferred retinoid and two unique sulfacetamide/sulfur wash/cleanser peroxide) chemical entities in two other subclasses, including the generic AVAR/-E/LS (sulfur/sulfacetamide) version of a requested non- BENZACLIN GEL (benzoyl peroxide/ preferred product, are required clindamycin) before a non-preferred agent will be BENZAMYCIN PAK (benzoyl peroxide/ authorized unless one of the erythromycin) exceptions on the PA form is benzoyl peroxide/clindamycin gel present. (In cases of pregnancy, a benzoyl peroxide/urea trial of retinoids will not be required.) CERISA (sulfacetamide sodium/sulfur) CLARIFOAM EF (sulfacetamide/sulfur) In addition, thirty (30) day trials of CLENIA (sulfacetamide sodium/sulfur) combinations of the corresponding DUAC (benzoyl peroxide/ erythromycin) preferred single agents available EPIDUO (adapalene/benzoyl peroxide) are required before non-preferred GARIMIDE (sulfacetamide/sulfur) combination agents will be INOVA 4/1, 5/2 (benzoyl peroxide/salicylic authorized. acid) NUOX (benzoyl peroxide/sulfur) PRASCION (sulfacetamide sodium/sulfur) SE 10-5 SS (sulfacetamide/sulfur) SSS 10-4 (sulfacetamide /sulfur) sulfacetamide sodium/sulfur cloths, lotion, pads, suspension sulfacetamide sodium/sulfur/ urea SUMADAN (sulfacetamide/sulfur) SUMAXIN/TS (sulfacetamide sodium/sulfur) VELTIN (clindamycin/tretinoin) ZIANA (clindamycin/tretinoin) ALZHEIMER’S AGENTSAP CHOLINESTERASE INHIBITORS donepezil ARICEPT (donepezil) A thirty (30) day trial of a preferred ARICEPT 23mg (donepezil) agent is required before a non- ARICEPT ODT(donepezil) preferred agent in this class will be COGNEX (tacrine) authorized unless one of the donepezil ODT exceptions on the PA form is EXELON CAPSULE (rivastigmine) present. EXELON PATCH (rivastigmine) 3 BUREAU FOR MEDICAL SERVICES WEST VIRGINIA MEDICAID EFFECTIVE PREFERRED DRUG LIST WITH PRIOR AUTHORIZATION CRITERIA 01/01/13 This is not an all-inclusive list of available covered drugs and includes only managed categories. Refer to cover page for complete list of rules governing this PDL. Version 2013.1i THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS galantamine Aricept 23mg tablets will be galantamine ER approved when there is a diagnosis RAZADYNE (galantamine) of moderate-to-severe Alzheimer’s RAZADYNE ER (galantamine) Disease, a trial of donepezil 10mg rivastigmine daily for at least three (3) months, and donepezil 20mg daily for an additional one (1) month. Aricept and donepezil ODT will be approved only when the oral dosage form is not appropriate for the patient. NMDA RECEPTOR ANTAGONIST NAMENDA (memantine) ANALGESICS, NARCOTIC - SHORT ACTING (Non-parenteral)AP APAP/codeine ABSTRAL (fentanyl) Six (6) day trials of at least four (4) ASA/codeine ACTIQ (fentanyl) chemically distinct preferred agents butalbital/APAP/caffeine/codeine butalbital/ASA/caffeine/codeine (based on narcotic ingredient only), codeine butorphanol including the generic formulation of hydrocodone/APAP COMBUNOX (oxycodone/ibuprofen) a requested non-preferred product, hydrocodone/ibuprofen DEMEROL (meperidine) are required before a non-preferred hydromorphone tablets dihydrocodeine/ APAP/caffeine agent will be authorized unless one morphine DILAUDID (hydromorphone) of the exceptions on the PA form is oxycodone fentanyl present. oxycodone/APAP FENTORA (fentanyl) pentazocine/APAP FIORICET W/ CODEINE Fentanyl lozenges and Onsolis will pentazocine/naloxone (butalbital/APAP/caffeine/codeine) only be approved for a diagnosis of ROXICET (oxycodone/acetaminophen) FIORINAL W/ CODEINE cancer and as an adjunct to a long- tramadol (butalbital/ASA/caffeine/codeine) acting agent. Neither will be tramadol/APAP hydromorphone liquid approved for monotherapy. hydromorphone suppositories LAZANDA (fentanyl) Limits: Unless the patient has levorphanol escalating cancer pain or another LORCET (hydrocodone/APAP) diagnosis supporting increased LORTAB (hydrocodone/APAP) quantities of short-acting opioids, all MAGNACET (oxycodone/APAP) short acting solid forms of the meperidine narcotic analgesics are limited to NUCYNTA (tapentadol) 120 tablets per 30 days for the OPANA (oxymorphone) purpose of maximizing the use of ONSOLIS (fentanyl) longer acting medications to oxycodone/ASA prevent unnecessary breakthrough 4 BUREAU FOR MEDICAL SERVICES WEST VIRGINIA MEDICAID EFFECTIVE PREFERRED DRUG LIST WITH PRIOR AUTHORIZATION CRITERIA 01/01/13 This is not an all-inclusive list of available covered drugs and includes only managed categories. Refer to cover page for complete list of rules governing this PDL. Version 2013.1i THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS oxycodone/ibuprofen pain in chronic pain therapy. OXECTA (oxycodone) OXYFAST (oxycodone) OXYIR (oxycodone) PANLOR (dihydrocodeine/ APAP/caffeine) PERCOCET (oxycodone/APAP) PERCODAN (oxycodone/ASA) PRIMLEV (oxycodone/APAP) ROXANOL (morphine) RYBIX ODT (tramadol) SUBSYS (fentanyl) TALACEN (pentazocine/APAP)