v Department of Human Services IOWA Medicaid Program Effective Date 1/1/2007 PDL DRUG LIST (Two Drug Columns) Highlighted categories denote new changes to the PDL since previous update Column Header Explanations: P, N, R, or NR: B, G or O: P = Preferred B = Brand N = Non-Preferred G = Generic R = Recommended O = OTC NR = Non-Recommended COM: 20 Preferred only for children 12 years of 1 ANTIVERT 50mg - Use two MECLIZINE HCL age and under for the first 60 days of therapy. 25mg instead 21 PROZAC,FLUOXETINE HCL 40mg CAPS - Use 2 BENZONATATE 200mg - Use two two FLUOXETINE HCL 20mg CAPS instead BENZONATATE 100mg instead 22 RHEUMATREX - Write METHOTREXATE 3 BUSPIRONE 30mg - Use 2 BUSPIRONE 15mg instead tablets 23 ULTRACET - Use Tramadol & Acetaminophen 4 CLINDAMYCIN HCL 300MG - Use Multiples of separately CLINDAMYCIN HCL 150mg 24 PA Required >= 21 yo 5 FLUMIST NASAL VACCINE 200 - Preferred 5 - 25 PA Required: > 14 Units/30Days Supply 49 yo until 3/15/2006. 6 FLUOXETINE HCL 20mg TABS - Use 26 After 30 days only the generic will be preferred. FLUOXETINE HCL 20mg CAPS instead 7 Preferred only for children 12 years of age and 27 PA Required for quantities exceeding 4-125mg under. capsules and 8 - 80mg capsules. 8 A 90 day transition period will be allowed to move established users to a preferred product. 28 PA required for quantities exceeding 12-4mg tabs, HYDROXYZINE HCL - Use HYDROXYZINE 9 12-8mg tabs, 4-24 tabs, 50ml/month - oral sol, 4-20ml PAMOATE vials, and 8-2ml vials. 10 HYDROXYZINE PAMOATE 100mg - Use two HYDROXYZINE PAMOATE 50mg instead 29 PA required for quantities exceeding 12-4mg tabs, 11 PA Required 12-8mg tabs. 30 PA required for doses exceeding two tablets per day 12 PA Required > 60 days of the same strength or for more than two strengths per month. 13 PA Required > 90 days 31 PA required limited to package size of #14. 14 PA Required > Quantity Limit 10 Days 32 PA required limited to package size of #110. 15 PA Required for > 4 Bottles/30 Days 33 Established users who have tried preferred opthalmic 16 PA Required from Day 1 prostaglandins will be grandfathered. 34 Preferred with conditions by POS look-back. Must be 17 PA Required: > 18 Units/30Days Supply 18 years of age or older, fail at least two potent oral 18 Preferred < 14yo antidiabetic medications, no concurrent nicotine replacement therapy, no concurrent inhaled COPD or 19 Preferred < 8yo asthma medications. 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 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 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 preferred status. TABLE OF CONTENTS Page Page CATEGORY DESCRIPTION CATEGORY DESCRIPTION Number Number ACE AND THIAZIDE COMBO'S 7 ANTIHISTAMINES - NON-SEDATING / 12 DECONGESTANTS ACE INHIBITORS 7 ANTIHISTAMINES - OTHER 12 ACE INHIBITORS AND CA CHANNEL BLOCKERS 7 ANTIHISTAMINES/DECONGESTANTS 13 ACNE PRODUCTS: ISOTRETINOIN 7 ANTIHYPERTENSIVE COMBOS 13 AGENTS FOR FABRYS DISEASE 7 ANTIHYPERTENSIVES - CENTRAL 13 AGENTS FOR GAUCHER DISEASE 7 ANTILEPROTIC 13 AGENTS FOR PHEOCHROMOCYTOMA 7 ANTIMALARIAL AGENTS 13 ALCOHOL DETERRENTS 7 ANTIMYCOBACTERIALS / ANTITUBERCULOSIS 13 ALS DRUG 7 ANTINEOPLASTICS - ALKYLATING AGENTS 48 ALZHEIMER - CHOLINOMIMETICS 7 ANTINEOPLASTICS - ANTIADRENALS 48 AMINO GLYCOSIDES 7 ANTINEOPLASTICS - ANTIANDROGENS 48 ANALGESICS - MISC. 7 ANTINEOPLASTICS - ANTIBIOTICS 48 ANAPHYLAXIS THERAPY 8 ANTINEOPLASTICS - ANTIESTROGENS 48 ANDROGENS / ANABOLICS 8 ANTINEOPLASTICS - ANTIMETABOLITES 48 ANGIOTENSIN RECEPTOR BLOCKER 8 ANTINEOPLASTICS - AROMATASE INHIBITORS 48 ANORECTAL - MISC. 8 ANTINEOPLASTICS - CARDIAC PROTECTIVE AGENTS 48 ANTHELMINTICS 8 ANTINEOPLASTICS - COMBINATIONS 48 ANTI INFECTIVE COMBO'S - MISC. 8 ANTINEOPLASTICS - ESTROGEN RECEPTOR 48 ANTIANGINALS--ISOSORBIDE NITRATE 8 ANTAGONIST ANTIARRHYTHMICS 9 ANTINEOPLASTICS - ESTROGENS 48 ANTIASTHMATIC - ADRENERGIC COMBOS 9 ANTINEOPLASTICS - FOLIC ACID ANTAGONISTS 48 ANTIASTHMATIC - ALPHA-PROTEINASE INHIBITOR 9 RESCUE AGENTS ANTIASTHMATIC - ANTI-CHOLINERGICS 9 ANTINEOPLASTICS - IMIDAZOTETRAZINES 48 ANTIASTHMATIC - ANTIINFLAMMATORY AGENTS 9 ANTINEOPLASTICS - INTERLEUKINS 48 ANTIASTHMATIC - BETA - ADRENERGICS 9 ANTINEOPLASTICS - LHRH ANALOGS 49 ANTIASTHMATIC - HYDRO-LYTIC ENZYMES 9 ANTINEOPLASTICS - MISC. 49 ANTIASTHMATIC - LEUKOTRIENE RECEPTOR 9 ANTINEOPLASTICS - MITOTIC INHIBITORS 49 ANTAGONISTS ANTINEOPLASTICS - NITROGEN MUSTARDS 49 ANTIASTHMATIC - MISC. RESPIRATORY INHALANTS 9 ANTINEOPLASTICS - NITROSOUREAS 49 ANTIASTHMATIC - MIXED ADRENERGICSS 9 ANTINEOPLASTICS - PROGESTINS 49 ANTIASTHMATIC - MUCOLYTICS 9 ANTINEOPLASTICS - PROTEIN-TYROSINE KINASE 49 ANTIASTHMATIC - NASAL MISC. 10 INHIBITORS ANTIASTHMATIC - NASAL STEROIDS 10 ANTINEOPLASTICS - RETINOIDS 49 ANTIASTHMATIC - STEROID INHALANTS 10 ANTINEOPLASTICS - SELECTIVE RETINOID X 49 RECEPTOR AGONISTS ANTIASTHMATIC - XANTHINES 10 ANTINEOPLASTICS - TOPOISOMERASE I INHIBITORS 49 ANTIBIOTICS - MISC. 10 ANTINEOPLASTICS - URINARY TRACT PROTECTIVE 49 ANTI-CATAPLECTIC AGENTS 10 AGENTS ANTICOAGULANTS 10 ANTI-PARKINSONIAN DRUGS 14 ANTICONVULSANTS 10 ANTIPROTOZOAL AGENTS 14 ANTIDEPRESSANTS - MAO INHIBITORS 44 ANTI-PSORIATICS - BIOLOGICALS 14 ANTIDEPRESSANTS - SELECTED SSRI'S 44 ANTI-PSORIATICS - NON-BIOLOGICALS 14 ANTIDEPRESSANTS - TRI-CYCLICS 44 ANTIPSYCHOTICS - ATYPICALS 44 ANTIDOTES 11 ANTIPSYCHOTICS - SPECIAL ATYPICALS 45 ANTIDOTES - CHELATING AGENTS 11 ANTIPSYCHOTICS - TYPICAL 45 ANTIEMETIC - 5-HT3 RECEPTOR ANTAGONISTS/ 11 ANTIRETROVIRAL COMBINATIONS 49 SUBSTANCE P NEUROKININ ANTIRETROVIRALS 49 ANTIEMETIC - ANTICHOLINERGIC / DOPAMINERGIC 11 ANTIRETROVIRALS - FUSION INHIBITORS 49 ANTIFUNGALS - ASSORTED 12 ANTIRETROVIRALS - PROTEASE INHIBITORS 49 ANTIHEMOPHILIC AGENTS 48 ANTIRETROVIRALS - RTI-NON-NUCLEOSIDE 49 ANTIHISTAMINES - NON-SEDATING 12 ANALOGUES ANTIRETROVIRALS - RTI-NUCLEOSIDE 49 COUGH/COLD - DECONGESTANT W/ EXPECTORANT 20 ANALOGUES-PURINES COUGH/COLD - DECONGESTANT-ANTIHISTAMINE W/ 20 ANTIRETROVIRALS - RTI-NUCLEOSIDE 50 EXPECTORANT ANALOGUES-PYRIMIDINES COUGH/COLD - 20 ANTIRETROVIRALS - RTI-NUCLEOSIDE 50 DECONGESTANT-ANTIHISTAMINE-ANTICHOLINERGIC ANALOGUES-THYMIDINES COUGH/COLD - EXPECTORANT MIXTURES 20 ANTIRETROVIRALS - RTI-NUCLEOTIDE ANALOGUES 50 COUGH/COLD - EXPECTORANTS 20 ANTISPASMODICS 14 COUGH/COLD - NARCOTIC 20 ANTISPASMODICS - LONG ACTING 14 ANTITUSSIVE-ANTIHISTAMINE ANTITHYROID THERAPIES 14 COUGH/COLD - NARCOTIC 20 ANTITUSSIVE-DECONGESTANT ANXIOLYTICS - BENZODIAZEPINES 45 COUGH/COLD - NARCOTIC 20 ANXIOLYTICS - LONG ACTING 46 ANTITUSSIVE-DECONGESTANT-ANTIHISTAMINE ANXIOLYTICS - MISC. 46 COUGH/COLD - NON-NARC 21 ARB'S AND DIURETICS 14 ANTITUSSIVE-ANTIHISTAMINE ARTHRITIS - MISC. 14 COUGH/COLD - NON-NARC 21 ANTITUSSIVE-DECONGESTANT ARTIFICIAL SALIVA/STIMULANTS 14 COUGH/COLD - NON-NARC 21 BETA BLOCKERS - ALPHA / BETA 14 ANTITUSSIVE-DECONGESTANT-ANTIHISTAMINE BETA BLOCKERS