v Department of Human Services IOWA Medicaid Program Draft PDL for P&T Committee Meeting November 8, 2007 PDL DRUG LIST (Two Drug Columns) Highlighted categories denote new changes to the PDL since previous update Column Header Explanations: B, G or O: P, N, R, or NR: B = Brand P = Preferred G = Generic N = Non-Preferred O = OTC R = Recommended NR = Non-Recommended COM: 1 ANTIVERT 50mg - Use two MECLIZINE HCL 27 PA required for quantities exceeding 12-4mg 25mg instead capsules and 8-80mg capsules. 2 BENZONATATE 200mg - Use two 28 PA REQUIRED FOR QUANTITIES EXCEEDING BENZONATATE 100mg instead 12-4MG TABS, 12-8MG TABS, 4-24 TABS, 3 BUSPIRONE 30mg - Use 2 BUSPIRONE 15mg 50ML/MONTH - ORAL SOL, 4-20ML VIALS, tablets AND 8-2ML VIALS. 4 CLINDAMYCIN HCL 300MG - Use Multiples of 29 PA required for quantities exceeding 12-4mg CLINDAMYCIN HCL 150mg tabs, 12-8mg tabs. 5 Flumist Nasal Vaccine: Preferred 19-49 until 30 PA required for doses exceeding two tablets per 3-15-08. Those 2-18 should be referred to day of the same strength Vaccines for Children Program or for more than two strengths per month. 6 FLUOXETINE HCL 20mg TABS - Use 31 PA required limited to package size of #14 FLUOXETINE HCL 20mg CAPS instead 32 PA required limited to package size of #110 7 Preferred only for children 12 years of age and 33 Established users who have tried preferred under. opthalmic prostaglandins will be grandfathered. 8 A 90 day transition period will be allowed to move 35 PA Required / After 30 days only the generic will established users to a preferred product. be preferred 9 HYDROXYZINE HCL - Use HYDROXYZINE 36 PA Required >= 21 yo. / After 30 days only the PAMOATE generic will be preferred 10 HYDROXYZINE PAMOATE 100mg - Use two 37 Payable for members who are 12 years of age HYDROXYZINE PAMOATE 50mg instead and older. Quantity limitations of 12 packets/4 11 PA Required weeks (28 days) or a total of 48 packets/16 12 PA Required > 60 days weeks (112 days). 13 PA Required > 90 days 38 Restricted to persons 40 years of age and older. 14 PA Required > Quantity Limit 10 Days 39 Payable for children 6-12 years old. 15 PA Required for > 4 Bottles/30 Days 40 Grandfathered 16 PA Required from Day 1 41 Preferred with conditions by POS look-back. 17 PA Required: > 18 Units/30Days Supply Must be currently using Metformin or a 18 Preferred < 14yo phosphate binder. 19 Preferred < 8yo 42 Renagel 800mg - Use two Renagel 400mgs 20 Preferred only for children 12 years of instead. age and under for the first 60 days of therapy. 43 Must have trial of immediate release form prior to 21 PROZAC,FLUOXETINE HCL 40mg CAPS - Use use of extended release form. two FLUOXETINE HCL 20mg CAPS instead 22 RHEUMATREX - Write METHOTREXATE instead 23 ULTRACET - Use Tramadol & Acetaminophen separately 24 PA Required >= 21 yo. 25 PA Required: > 14 Units/30Days Supply 26 After 60 days only the generic will be preferred. NEW DRUG REVIEW PROCESS: See Page 2. PDL IMPLEMENTATION DATE 01-15-05 Iowa Medicaid Preferred Drug List (PDL) New Drug Process 1). Therapeutic classes of drugs already reviewed by the Pharmaceutical and Therapeutics (P&T) Committee · New drug entities (including new generics), and new drug product dosage forms of existing drug entities) in therapeutic classes already reviewed by the P&T Committee will be identified weekly and immediately be coded as "Non-preferred-Prior Authorization required" until presented at the next quarterly scheduled P&T Committee meeting. These prior authorization restrictions will continue through the review process, including while committee recommendations are being made, and lasting until DHS makes a final determination. 2). Therapeutic classes of drugs not yet reviewed by the Pharmaceutical and Therapeutics (P&T) Committee New drug entities for conditions without any available PDL choices in therapeutic classes not yet reviewed by the P&T Committee will remain payable, in effect preferred by default, until the therapeutic class is discussed. Once this review occurs for the new therapeutic class, the non- preferred default policy will apply to subsequent new drug entries. 3). Exceptions to the Non-preferred default policy for new PDL drugs There are two major potential exceptions to the non-preferred default policy for new PDL drugs: A). If a new medication is classified as a priority drug by the FDA, the State may indicate that such a drug is preferred, until the drug is reviewed by the P&T Committee at the nearest scheduled meeting. B). The State may decide to designate a new drug as "draft preferred" and provide immediate access and increased therapeutic choice to physicians until the drug is reviewed by the P&T Committee at the nearest scheduled meeting if: - a new drug is therapeutically equivalent or superior to existing preferred or non-preferred choices, and - is as safe or safer than existing preferred or non-preferred choices, and - the net cost, adjusted for all rebates, is less expensive than all existing preferred choices. 4). Existing PDL Drugs · Although the State discourages supplemental rebate offers on existing PDL drugs between annual bidding periods, it may entertain such bids and may accept them if they are determined to represent significant additional savings or if they would replace a delinquent manufacturer's product or a preferred drug pulled from the marketplace or significantly restricted by the FDA. This interim preferred status will remain in effect until the drug is reviewed by the P&T Committee at the next scheduled meeting. Supplemental rebates will only be invoiced for approved drugs under contract. Draft preferred drugs with supplemental rebates will not be invoiced until approved by the Committee and accepted by the State. At that time, the supplemental rebates will be invoiced back to the effective date of the agreement, which is the date the drug began to benefit from B, COM P , B, COM P , G, N, Therapeutic Category G, N, Therapeutic Category or R, or or R, or O NR O NR PDL Categories B N LEXXEL ACE AND THIAZIDE COMBO'S B P TARKA B N LOTENSIN HCT ACNE PRODUCTS: ISOTRETINOIN G P benazepril & hydrochlorothiazide B N CAPOZIDE B 11 P ACCUTANE G P captopril & hydrochlorothiazide G 11 N isotretinoin B N VASERETIC AGENTS FOR FABRYS DISEASE G P enalapril maleate & hydrochlorothiazide B P MONOPRIL HCT B P FABRAZYME G N fosinopril sodium & hydrochlorothiazide B N PRINZIDE AGENTS FOR GAUCHER DISEASE B N ZESTORETIC G P lisinopril & hydrochlorothiazide B P CEREZYME B P UNIRETIC B N ACCURETIC AGENTS FOR PHEOCHROMOCYTOMA G N quinapril-hydrochlorothiazide B P PHENTOLAMINE MESYLATE ACE INHIBITORS B N DEMSER B N LOTENSIN ALCOHOL DETERRENTS G P benazepril hcl B N CAPOTEN B P CAMPRAL G P captopril B P ANTABUSE B N VASOTEC G P enalapril maleate ALS DRUG B N MONOPRIL B P RILUTEK G P fosinopril sodium B N PRINIVIL ALZHEIMER - CHOLINOMIMETICS B N ZESTRIL G P lisinopril B 38 P ARICEPT G N MOEXIPRIL TAB 7.5MG B 38 P ARICEPT ODT B N UNIVASC B 38 N REMINYL G N MOEXIPRIL TAB 15MG B 38 N RAZADYNE ER B N ACEON B 38 N EXELON DIS 4.6MG/24 B N ACCUPRIL B 38 N EXELON DIS 9.5MG/24 G N quinapril hcl B 38 P EXELON B P ALTACE B 38 P NAMENDA G N TRANDOLAPRIL TAB 1MG B 38 P NAMENDA TITRATION PAK G N TRANDOLAPRIL TAB 2MG B N MAVIK AMINO GLYCOSIDES G N TRANDOLAPRIL TAB 4MG B P AMIKIN ACE INHIBITORS AND CA CHANNEL BLOCKERS G P amikacin sulfate B N GARAMYCIN G N AMLOD/BENAZP CAP 2.5-10MG G P gentamicin sulfate G N AMLOD/BENAZP CAP 5-10MG G P gentamicin in saline G N AMLOD/BENAZP CAP 5-20MG B P KANTREX B P LOTREL G P kanamycin sulfate G N AMLOD/BENAZP CAP 10-20MG DRAFT_Report_rt16920_PDL_14_gpi_WEB 10/11/2007 B, COM P , B, COM P , G, N, Therapeutic Category G, N, Therapeutic Category or R, or or R, or O NR O NR PDL Categories G P butalbital-acetaminophen-caffeine tab 50-500-40 mg AMINO GLYCOSIDES B N DOLGIC PLUS - Continued - B P FIORINAL G P neomycin sulfate G N butalbital-aspirin-caffeine cap 50-325-40 mg B P HUMATIN G P butalbital-aspirin-caffeine tab 50-325-40 mg G P paromomycin sulfate B P STREPTOMYCIN SULFATE ANAPHYLAXIS THERAPY B P TOBI B P EPIPEN-JR B N TOBRAMYCIN SULFATE ADD-VA B P EPIPEN G P tobramycin sulfate ANDROGENS / ANABOLICS ANALGESICS - MISC. G N danazol cap 50 mg O P aspirin tab 81 mg G N danazol cap 100 mg O P aspirin tab 325 mg B P DANOCRINE CAP 200MG O P ASPIRIN TAB 650 MG G N danazol cap 200 mg B N ZORPRIN B P FLUOXYMESTERONE O P aspirin chew tab 81 mg B P ANDROID O P aspirin tab delayed release 81 mg B P TESTRED O P aspirin tab delayed release 325 mg B N METHITEST O P aspirin tab delayed release 650 mg B P ANDROGEL G P aspirin tab delayed release 975 mg B N ANDROGEL PUMP B N DOLOBID B N TESTIM G P diflunisal tab 500 mg B P ANDRODERM G P salsalate tab 500 mg B P DEPO-TESTOSTERONE G P salsalate tab 750 mg G P testosterone cypionate im in oil 200 mg/ml G P aspirin buffered (ca carb-mg carb-mg ox) tab 325 mg B N DELATESTRYL O P aspirin buffered tab 325 mg G P testosterone enanthate im in oil 200 mg/ml G P choline & mag salicylate G N OXANDROLONE TAB 2.5MG B P PRIALT B P OXANDRIN O P acetaminophen tab 325 mg G N OXANDROLONE TAB 10MG O P acetaminophen tab 500 mg B P WINSTROL O P acetaminophen elixir 160 mg/5ml O P acetaminophen soln 100 mg/ml ANGIOTENSIN RECEPTOR BLOCKER O P acetaminophen suppos 120 mg B N DURABAC TAB FORTE B N ATACAND B N DURABAC B N TEVETEN B N PHRENILIN FORTE B P AVAPRO B N PHRENILIN B P COZAAR G P butalbital-acetaminophen tab 50-325 mg B P BENICAR G N butalbital-acetaminophen tab 50-650 mg B P MICARDIS B N EQUAGESIC B P DIOVAN G N phenyltoloxamine w/ mag salicylate tab 25-600 mg B P EXFORGE TAB 5-160MG G P butalbital-acetaminophen-caffeine cap 50-325-40 mg B P EXFORGE TAB 5-320MG G N butalbital-acetaminophen-caffeine cap 50-500-40 mg B P EXFORGE TAB 10-160MG B N ESGIC B P EXFORGE TAB 10-320MG B N FIORICET G P butalbital-acetaminophen-caffeine tab 50-325-40 mg ANORECTAL - MISC.