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PDL Effective April 2012 CATEGORY Step Order PREFERRED DRUGS Physicians' Summarized PDL Step Order NON-PREFERRED DRUGS PA Required Comments General Criteria for all PDL categories- For more information or help using the PDL, providers may call 1-888-445-0497; members should call 1-866-796-2463. To access PDL and PA materials via the internet: www.mainecarepdl.org A: Preferred Drugs- Unless otherwise specified, preferred drugs are available without prior authorization. Step order may apply for preferred drugs in some drug categories as indicated on the PDL. (See item "D" below for explanation of step order.) B: Requests for Non-preferred Drugs- Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the preferred drug(s) exists. C: Adequate Drug Trials- 1. The minimum trial period for each preferred and step order drug is two weeks, unless otherwise stated within specific PDL drug categories; trials with less than a two week duration will be reviewed on a case-by-case basis; 2. A trial will not be considered valid if preferred or non-preferred products were readily available (by override, individual purchase, samples, etc.); 3. Certain drug trials, such as with controlled substances, may require evidence that the preferred drugs were actually tried (example: with random pill counts and with random urine drug tests, using the methods of GC/MS with no lower threshold); 4. Adequate trials require documentation of attempts to titrate dose of preferred agents toward desired clinical response. 5. Adequate trials include prevention/treatment of common adverse effects associated with preferred agents (example: antinausea, antipruritics, etc.) D: Step Order- When numbers appear in the "step order" column, it means drugs in this category must be used in the order specified, with the lower numbers having preference over the higher numbers. Chart notes should be provided to confirm drug trials that do not appear in the member's MaineCare drug profile. E. The Department will institute strategies to ensure cost effectiveness through the use of an enhanced Drug Benefit Preferred brand drugs will no longer be preferred in any PDL drug category where preferred generic drugs are also available. It is expected that preferred generics will be used prior to any preferred brands. This will be operated as a form of step care. Preferred brands in these categories will require prior authorization for these high utilization / high cost members. F: Brand Name Medication Requests- (Must be submitted on the Brand Name PA request form)- According to MaineCare Benefits Manual Chapter II (80.07-5), when medically necessary covered brand-name drugs have an A-rated generic equivalent available, the most cost effective medically necessary version will be approved and reimbursed, since the brand-name and A-rated generic drugs have been determined by the FDA to be chemically and therapeutically equivalent. The Bureau does not make determinations as to whether or not a generic drug is clinically inferior or inequivalent to its brand version. This is the proper role of the FDA. Physicians should submit their reports of generic inequivalence directly to the FDA via the MEDWATCH. G: PA requests for non- FDA Approved Indications- Decisions will be made on a case-by-case basis until the DUR committee is able to review the evidence and make a recommendation. Interim approvals and DUR recommendations for approval of a drug for a non- FDA approved indication will require a minimum of two published, peer reviewed, non contradicted, double- blind, placebo-controlled randomized clinical studies establishing both safety and efficacy. H: Dose Consolidation Requirements- Some drugs may also be affected by dose consolidation requirements. Please see Dose Consolidation List and/or Splitting Tables provided in the PDL. I. Trials from Multiple Drug Classes - Trial/failure/intolerance to preferred agents from multiple classes within the same category or other catagories of drugs may be required prior to the approval of non-preferred agents (e.g., Cymbalta, Zofran, Elidel and others). J. Drug-specific PA Forms- Drug-specific PA forms contain medical necessity documentation requirements and/or criteria that may not be repeated in the PDL. Drug-specific PA forms may be obtained on the web at www.mainecarepdl.org . K. PA Exemptions for Prescribers- According to MaineCare Benefits Manual Chapter II (80.07-4), providers may receive a three (3) month exemption from prior authorization requirement for certain categories of drugs when they demonstrate high compliance with the Department's PDL. The Department will notify providers in writing which drug categories are included and what dates apply to the exemption. If a provider loses his/ her exemption, members who previously were not required to obtain a PA while the prescriber was exempt will be required to do so, and criteria for approval of that medication will need to be met. L: Drug-Drug Interactions (DDI)- The DUR Committee has implemented new drug-drug interation edits requiring prior authorization. Several drug-drug combinations and PDL drug catagories are affected by new PA requirements. These will be indicated in the PDL with DDI notation. Please see the DDI document provided in the PDL. ASSORTED ANTIBIOTICS BETA-LACTAMS / CLAVULANATE COMBO'S AMOXICILLIN AMOXIL 500MG TABS AMOXICILLIN/POTASSIUM CLA CHEW AUGMENTIN3 AMOXICILLIN/POTASSIUM CLA SUSR AUGMENTIN XR TB124 AMOXICILLIN/POTASSIUM CLA TABS PRINCIPEN CAPS2 PRINCIPEN SUSR 1 AMOXIL AMPICILLIN BEEPEN 1. Amoxil 500mg tabs are non-preferred. All other Amoxil products are preferred. 2.Principen 250 mg is available without PA. 3. Chewable 125mg & 250mg and Solution 125mg/5ml and 250mg/5ml available without PA. BICILLIN L-A SUSP DICLOXACILLIN SODIUM CAPS DYNAPEN SUSR OXACILLIN SODIUM SOLR PENICILLIN V POTASSIUM 4. Use preferred generic amoxicillin/clavulanate potassium alternatives. TICAR SOLR TIMENTIN SOLR TRIMOX Use PA Form# 20420 UNASYN SOLR VEETIDS ZOSYN CEPHALOSPORINS CEFADROXIL HEMIHYDRATE CEDAX Page 1 of 40 1. Both brand and generic are clinically nonpreferred. CEFAZOLIN SODIUM SOLR CEFDINIR CEFEPIME HCI CEFACLOR1 CEFADROXIL MONOHYDRATE TABS CEFPODOXIME CEFTIN FORTAZ CEFPROZIL FORTAZ SOLN CEFTAZIDIME 6MG KEFLEX CAPS CEFTIN SUSP MAXIPIME CEFTRIAXONE OMNICEF CEFUROXIME AXETIL TABS ROCEPHIN CEPHALEXIN MONOHYDRATE SUPRAX FORTAZ SOLR TAZICEF SOLR KEFZOL SOLR TEFLARO MAXIPIME SOLR 1. Both brand and generic are clinically nonpreferred. Use PA Form# 20420 TAZICEF 6GM VANTIN 100MG VANTIN SUSP MACROLIDES / ERYTHROMYCIN'S TETRACYCLINES BIAXIN XL1 AZITHROMYCIN TABS AZITHROMYCIN POW BIAXIN AZITHROMYCIN SUSP CLARITHROMYCIN SUSP E.E.S. E-MYCIN TBEC CLARITHROMYCIN TABS ERYPED CHEW ERYPED 200 SUSR PCE TBEC ERYPED 400 SUSR ZITHROMAX TABS ERY-TAB TBEC ZITHROMAX 1GM PAK ERYTHROCIN STEARATE TABS ZITHROMAX TRI-PAK ERYTHROMYCIN ZITHROMAX SUSP ZMAX DOXYCYCLINE HYCLATE DECLOMYCIN TABS MINOCYCLINE HCL CAPS DORYX CPEP TETRACYCLINE HCL CAPS DOXYCYCLINE MONO CAPS VIBRAMYCIN SYRP DYNACIN CAPS 1. 7- Day supply per month without PA. Use PA Form# 20420 Use PA Form# 20420 ORACEA PERIOSTAT SOLODYN ER FLUOROQUINOLONES CIPROFLOXACIN AVELOX SOLN LEVOFLOXACIN AVELOX TABS OFLOXACIN AVELOX ABC PACK TABS CIPRO FACTIVE LEVAQUIN TABS1 LEVAQUIN TABS SOLN/INJ Use PA Form# 20420 1. Dosing limits apply, see Dosage Consolidation List. NOROXIN TABS PROQUIN XR AMINO GLYCOSIDES GENTAMICIN NEOMYCIN SULFATE TABS TOBI NEBU Use PA Form# 20420 TOBRAMYCIN SULFATE SOLN ANTI-MYCOBACTERIALS / ANTITUBERCULOSIS ETHAMBUTOL HCL TABS RIMACTANE CAPS Use PA Form# 20420 CHLOROQUINE PHOSPHATE TABS ARALEN TABS Use PA Form# 20420 DARAPRIM TABS HYDROXYCHLOROQUINE TABS ISONARIF1 MALARONE TABS 1. Ingredients available as preferred without PA. LARIAM TABS PLAQUENIL TABS MYAMBUTOL TABS MYCOBUTIN CAPS RIFAMPIN ANTIMALARIAL AGENTS MEFLOQUINE HCL TABS QUINACRINE HCL POWD QUININE SULFATE ANTHELMINTICS ALBENZA TABS VERMOX CHEW BILTRICIDE TABS MEBENDAZOLE CHEW Page 2 of 40 Use PA Form# 20420 STROMECTOL TABS ANTIBIOTICS - MISC. AZACTAM SOLR COLISTIMETHATE SODIUM SOLR COLY-MYCIN-M SOLR CAYSTON4 FLAGYL CAPS FUROXONE TABS 1. Need to fail other anti-protozoals 2. 375mg caps and 750mg tabs are non-preferred. Please use available preferred strengths(250mg & 500mg tabs) to obtain required dose without PA. METRONIDAZOLE2 PENTAMIDINE ISETHIONATE SOLR FLAGYL TABS PRIMSOL SOLN KETEK TRIMETHOPRIM TABS METRONIDAZOLE 375MG CAPS2 VANCOMYCIN 5GM INJ. METRONIDAZOLE 750MG TABS2 NEBUPENT SOLR FLAGYL ER TBCR TINDAMAX1 VANCOMYCIN 10GM INJ.3 XIFAXAN 3. Please use multiple 5gm which are preferred to obtain dose without PA. 4. Clinical PA is required to establish CF diagnosis and medical necessity. Prior trail and failure of preferred Tobi before approval will be granted. Use PA Form# 20420 CARBAPENEMS INVANZ SOLR Use PA Form# 20420 MERREM SOLR PRIMAXIN LINCOSAMIDES / OXAZOLIDINONES / LEPROSTATICS ANTI INFECTIVE COMBO'S MISC. CLEOCIN SOLN CLEOCIN CAPS CLEOCIN SUSR CLINDAMYCIN HCL 150CAPS CLINDAMYCIN HCL 300CAPS1 VIBATIV DAPSONE TABS ZYVOX SUSR Use PA Form# 30820 for Zyvox & Vibativ ZYVOX TABS Use PA Form# 20420 for all others BACTRIM DS TABS Use PA Form# 20420 ERYTHROMYCIN/SULF SUSR 1. Use multiple 150's for Clindamycin instead of 300's. SEPTRA/DS TABS SULFAMETHOXAZOLE/TRIMETH TRIMETHOPRIM/SULFAMETHOXA ALINIA1 ANTIPROTOZOALS 1. Alina is preferred for children less than 12 years of age. Use PA Form# 20420 ANTIFUNGALS - ASSORTED ANTI - FUNGALS 5 LAMISIL TABS4 ANCOBON CAPS 1. QL--1/every 7-day period (150mg only). FLUCONAZOLE 6 SPORANOX SOLN GRIFULVIN V TABS10 6 SPORANOX PULSEPAK CAPS3 1 2 GRISEOFULVIN SUSP 7 SPORANOX CAPS GRISEOFULVIN ULTRAMICROSI TABS10 8 ERAXIS INJ6 GRIS-PEG TABS10 8 DIFLUCAN KETOCONAZOLE TABS8 NYSTATIN 8 GRIFULVIN SUSP 8 8 NOXAFIL5 VFEND TABS 8 ITRACONAZOLE 10 4 TERBINAFINE TABS 3 2. Sporanox QL 300cc/month with PA. See quantity limit table. 3. Sporanox QL 30/month with PA. See quantity limit table. Non-preferred products must be used in specified step order. Continue to use Anti-Fungal PA form for non-preferred products. 4. Quantity limit of one tablet daily. Please see dosage consolidation list. 5. Approved if immuno suppressed/ HIV or if the member has failed a 7 day trial of a preferred antifungal therapy. 6. Eraxis will be approved if submitting with documentation that it was initiated during a hospitalization and this request is to finish the hospital course. 8. Quantity limits allowing 30 day supply without PA. PA will be required if using > 30 days. 10. For children < 18, quantity limits allows 8 weeks supply without PA. PA will be required if using > than 8 weeks. If 18 and older PA will be required for any quantity. Not approving for Onychomycosis indication. Use PA Form# 10120 Page 3 of 40 ANTIRETROVIRALS APTIVUS ANTI - VIRALS 8 COMPLERA ATRIPLA1 COMBIVIR TABS 8 DIDANOSINE 8 EDURANT CRIXIVAN CAPS 8 FUZEON3 EMTRIVA 8 INTELENCE3 EPIVIR / HBV 8 ISENTRESS3 RETROVIR EPZICOM 8 INVIRASE CAPS 8 KALETRA 8 SELZENTRY3 ZERIT LEXIVA 9 VIRAMUNE XR NORVIR Use PA Form# 10620 for Fuzeon 1. Quantity limit of one per day 2. Only preferred if Norvir script is in member's profile within the past 30 days of filling Prezista 3. Prescribers with >= 10 ART scripts per quarter and 75% ART PDL compliance will be exempt from PA for these products. PREZISTA2 RESCRIPTOR TABS REYATAZ STAVUDINE SUSTIVA TRIZIVIR TABS TRUVADA VIDEX / EC VIRACEPT TABS VIRAMUNE TABS VIREAD TABS ZIAGEN TABS ZIDOVUDINE CYTO-MEGALOVIRUS AGENTS HERPES AGENTS FOSCARNET SODIUM FOSCAVIR VALCYTE TABS GANCICLOVIR ACYCLOVIR 8 FAMVIR TABS1 VALTREX TABS 8 ZOVIRAX1 8 VALACYCLOVIR1 9 FAMCICLOVIR1 Use PA Form# 20420 1. Must fail Acyclovir and Valtrex before nonpreferred products in step order. Use PA Form# 20420 INFLUENZA AGENTS AMANTADINE FLUMADINE TABS RELENZA DISKHALER AEPB FLUMIST RIMANTADINE HCL TABS 1. Tamiflu 10 caps or 60cc's per month. Will be audited for presence of positive influenza tests in patient or family member. TAMIFLU1 Use PA Form# 10610 for Flumist requests Use PA Form# 20420 for all others IMMUNE SERUMS IMMUNE SERUMS HYPERRHO INJ HEPATITIS C AGENTS INCIVEK2 VICTRELIS2 HEPATITIS AGENTS COPEGUS TABS REBETOL CAPS PEGASYS KIT1 PEGASYS SOLN 2. Approvals will require clinical PA to establish genotpye, baseline viral loads and will require periodic SVR's. Must have concurrent peg-a or pegI and ribavirin therapies. PEG-INTRON KIT1 RIBAVIRIN HEPATITIS AGENTS - MISC. HEPATITIS B ONLY HEPSERA TABS 1. Dosing limits apply, please see dosage consolidation list. Use PA Form# 20420 ACTIMMUNE Use PA Form# 20420 BARACLUDE Use PA Form# 20420 TYZEKA RSV PROPHYLAXIS RSV PROPHYLAXIS SYNAGIS1 Use PA Form# 30120 1. MaineCare will approve Synagis PA's for start date of November 23rd for infants who meet the guidelines. PA will be approved for max of 5 doses. Maximum 1 dose/30 days. MS TREATMENTS Page 4 of 40 MULTIPLE SCLEROSIS INTERFERONS AVONEX KIT1 1.Clinical PA is required to establish diagnosis and medical necessity. EXTAVIA 1 BETASERON SOLR REBIF SOLN1 Use PA Form# 20430 MULTIPLE SCLEROSIS - NONINTERFERONS 2 COPAXONE 6 TYSABRI 8 8 AMPYRA 1. Providers must be enrolled in the TOUCH Prescribing program, a restricted distribution program. Clinical PA is required to establish diagnosis and medical necessity. 1 GILENYA3 2. Clinical PA is required to establish diagnosis and medical necessity. 3. Dosing limits apply,please see dosing consolidation list. Use PA Form# 20430 ASSORTED NEUROLOGICS NEUROLOGICS - MISC. MESTINON BOTOX 1. Approval will be limited to Cervical dystonia. ORAP TABS DYSPORT PROSTIGMIN TABS MYOBLOC1 1 Use PA Form# 10210 STEROIDS GLUCOCORTICOIDS/ MINERALOCORTICOIDS CELESTONE SUSP BUDESONIDE EC CORTEF 5 CORTEF 10 and 20 TABS Use PA Form# 20420 CORTISONE ACETATE TABS FLORINEF TABS DELTASONE TABS MEDROL TABS DEPO-MEDROL SUSP MEDROL DOSEPAK TABS DEXAMETHASONE ORAPRED SOLN ENTOCORT EC CP24 PEDIAPRED LIQD FLUDROCORTISONE ACETATE TABS PREDNISONE INTENSOL CONC HYDROCORTISONE STERAPRED TABS KENALOG METHYLPREDNISOLONE TABS PREDNISOLONE PREDNISONE SOLU-CORTEF SOLR SOLU-MEDROL SOLR HORMONE REPLACEMENT THERAPIES ANDROGENS / ANABOLICS ANDRODERM PT24 ANDROGEL ANDRO LA 200 OIL ANDROGEL PUMP DELATESTRYL OIL ANDROID CAPS FORTESTA DANAZOL CAPS HALOTESTIN TABS DEPO-TESTOSTERONE OIL METHITEST TABS TESTOSTERONE PROPIONATE OXANDRIN TABS TESTRED CAPS ESTROGENS - PATCHES / TOPICAL Use PA Form# 20420 AXIRON Use PA Form# 20600 for Oxandrin requests TESTIM CLIMARA PTWK 5 ESTRADERM PTTW1 8 ESTRADIOL PTWK ALORA PTTW VIVELLE-DOT PTTW1 8 DIVIGEL2 8 ELESTRIN 8 EVAMIST2 1. Both preferred drugs must be tried. 2 2. Step order drugs must be used in specified step order. 2 Use PA Form# 20420 ESTROGENS - TABS CENESTIN TABS Must fail preferred products before non-preferred products. ESTRADIOL ENJUVIA ESTRACE TABS ESTROPIPATE TABS ESTRATAB TABS MENEST TABS ORTHO-EST TABS PREMARIN TABS ESTROGEN COMBO'S PREMPHASE TABS PREMPRO TABS Use PA Form# 20420 ACTIVELLA TABS 1 COMBIPATCH PTTW 1 1. Must fail Premphase and Prempro products before non preferred products. FEMHRT 1/5 TABS1 ORTHO-PREFEST TABS1 Use PA Form# 20420 SYNTEST H.S. TABS1 PROGESTINS MEDROXYPROGESTERONE ACETA 2 AYGESTIN TABS NORETHINDRONE ACETATE TABS2 CYCRIN TABS Page 5 of 40 1. PA approvals will require two 100 mg caps instead of one 200mg. 1. PA approvals will require two 100 mg caps instead of one 200mg. MAKENA PROGESTERONE POWD PROMETRIUM 100MG CAPS 1 PROMETRIUM 200MG1 PROVERA TABS 2. Must fail Medroxyprogesterone and Norethidrone products before non-preferred products. Use PA Form# 20420 CONTRACEPTIVES CONTRACEPTIVES PROGESTIN ONLY ORTHO MICRONOR TABS CAMILA TABS ERRIN If member experienced adverse reactions, consider using Oral Contraceptives from other groups. JOLIVETTE NORA-BE TABS NOR-QD TABS Use PA Form# 20420 CONTRACEPTIVES INJECTABLE CONTRACEPTIVE EMERGENCY MEDROXYPROGESTERONE ACETATE 150mg IM DEPO-PROVERA 150 mg SUSP Use PA Form# 20420 1 PLAN B ONE STEP1 PLAN - B 1. Allowed 4 tablets per 30 days without PA 2 ELLA 2 LEVONORGESTREL NEXT CHOICE1 CONTRACEPTIVES - PATCHES/ VAGINAL PRODUCTS Use PA Form# 20420 NUVARING RING3 Use PA Form# 20420 1.No PA required for users less than 21 years of age. 1,2,4 ORTHO EVRA PTWK 2. The FDA has issued a public health warning of the potentials for increased exposure to estrogen with Ortho Eva use, possibly up to 60% estrogen exposoure. 3. Quantity limit allowing 1 every 28 days with out PA. 4. Dose limits apply allowing 3 patches per 28 days supply. Please refer to Dose Consolidation Chart. CONTRACEPTIVES MONOPHASIC COMBINATION O/C'S APRI TABS AVIANE TABS BEYAZ BALZIVA CRYSELLE-28 TABS LESSINA-28 TABS DESOGEN TABS LOESTRIN TABS DESOGESTREL/ ETHINYL ESTRADIOL LOW-OGESTREL TABS LOESTRIN FE TABS MODICON TABS LOESTRIN 1.5/30-21 TABS MONONESSA LOESTRIN 1/20-21 TABS NECON 1/50 LO/OVRAL 21 TABS ORTHO-CEPT-28 TABS LO/OVRAL 28 TABS ORTHO-CYCLEN-28 TABS MICROGESTIN FE TABS ORTHO-NOVUM 1/35-28 TABS NORDETTE-28 TABS OVCON-50 28 TABS NORINYL PREVIFEM NORTREL RECLIPSEN OCELLA OGESTREL TABS SOLIA SPRINTEC 28 TABS BREVICON-28 TABS Use PA Form# 20420 If member experienced adverse reactions, consider using Oral Contraceptives from other groups. LEVORA LOESTRIN FE 1/20 TABS OVCON-35/28 TABS YASMIN 28 TABS OVRAL YAZ SEASONALE PORTIA-28 TABS ZENCHENT SEASONALE SAFYRAL YAZ ZOVIA CONTRACEPTIVES - BI-PHASIC COMBINATIONS ORTHO-NOVUM 10/11-28 TABS NECON 10/11-28 TABS NORETHINDRONE-ETH ESTRADIOL TAB 0.535/1-35 KARIVA TABS SEASONIQUE LOSEASONIQUE MIRCETTE TABS LOSEASONIQUE If member experienced adverse reactions, consider using Oral Contraceptives from other groups. Use PA Form# 20420 Page 6 of 40 CONTRACEPTIVES - TRIPHASIC COMBINATIONS ENPRESSE CYCLESSA TABS NECON 7/7/7 ESTROSTEP FE TABS ORTHO-NOVUM 7/7/7-28 TABS NORTREL 7/7/7 TRI-NORINYL 28 TABS ORTHO TRI-CYCLEN TABS TRI-PREVIFEM ORTHO TRI-CYCLEN LO TABS If member experienced adverse reactions, consider using Oral Contraceptives from other groups. TRIPHASIL 28 TABS TRI-SPRINTEC TRINESSA TRIVORA-28 TABS CONTRACEPTIVES - MULTIPHASIC COMBINATIONS Use PA Form# 20420 NATAZIA Use PA Form# 20420 DIABETES THERAPIES DIABETIC - INSULIN HUMALOG INJ 100/ML APIDRA HUMALOG MIX 75/25 HUMALOG MIX 50/50 HUMULIN N INJ U-100 HUMULIN INJ 50/50 HUMULIN INJ 70/30 HUMULIN R INJ U-500 HUMULIN R U-100 LEVEMIR RELION LANTUS SOLN NOVOLIN NOVOLOG Use PA Form# 20420 NOVOLOG MIX DIABETIC - PENFILLS LANTUS OPTICLIK PEN 1 LANTUS SOLOSTAR1 APIDRA OPTICLIK PEN LEVEMIR FLEXPEN 1 HUMALOG MIX INJ 75/25 KWP NOVOLIN PENFILL1 HUMALOG MIX INJ 50/50 KWP NOVOLIN 70/30 HUMALOG KWIK INJ 100/ML 1. Clinical PA will be required to establish significant visual or neurological impairment. 1 NOVOLOG MIX PENFILL1 NOVOLOG PENFILL SOLN1 Use PA Form# 20420 NOVOLOG MIX FLEXPEN1 NOVOLOG FLEXPEN1 DIABETIC - DPP- 4 ENZYME INHIBITOR 1. Preferred if therapeutic doses of metformin are seen in members drug profile for at least 60 days within the past 18 months or if phosphate binder is currently seen in the members drug profile. JANUVIA1,2 ONGLYZA1,2 TRADJENTA1,2 2. Dosing limits apply. Please refer to Dose consolidation list. Use PA Form# 20420 DIABETIC - DPP- 4 ENZYME INHIBITOR-COMBO JANUMET KOMBIGLYZE 1. Preferred if therapeutic doses of metformin are seen in members drug profile for at least 60 days within the past 18 months or if phosphate binder is currently seen in the members drug profile. Dosing limits apply. Please refer to Dose consolidation list. DPP- 4 ENZYME INHIBITOR/ HMG- COS REDUCTASE INHIBITOR JUVISYNC1,2 1. Please refer to criteria section of PDL 1 2. Dosing limits apply. Please refer to Dose consolidation list. Use PA Form# 20420 DIABETIC - LANCET-LANCET DEVICE ONE TOUCH LANCETS Use PA Form# 20420 DELICA LANCETS FREESTYLE LANCETS UNILET LANCETS UNISTIK LANCING DEVICE AUTOLOT LANCING DEVICE DIABETIC - SYRINGESNEEDLES BD MICRO-FINE Use PA Form# 20420 BD ULTRA-FINE BD ULTRA-FINE PEN NEEDLES UNIFINE PEN NEEDLES Page 7 of 40 DIABETIC - OTHER CYCLOSET Use PA Form# 301501 SYMLIN DIABETIC MONITOR FREESTYLE LITE SYSTEM KIT ACCUCHECK FREESTYLE FLASH SYSTEM KIT ASCENSIA FREESTYLE FREEDOM SYSTEM KIT ASSURE FREESTYLE FREEDOM LITE KIT EXACTECH ONE TOUCH ULTRA 2 KIT PRODIGY Use PA Form# 20420 ONE TOUCH ULTRA MINI KIT ONE TOUCH ULTRA SMART KIT PRECISION XTRA METER DIABETIC TEST STRIPS ACCUCHECK FREESTYLE1 1. Only 50 ct & 100 ct package size. ASCENSIA 1 FREESTYLE LITE ASSURE 1 ONE TOUCH BASIC ONE TOUCH SURESTEP EXACTECH ONE TOUCH FAST TAKE1 PRODIGY 1 Use PA Form# 20420 1 ONE TOUCH ULTRA PRECISION XTRA1 PRECISION XTRA BETA KETONE 10 CT INCRETIN MIMETIC 8 8 BYDUREON 9 VICTOZA1 1. If patient is not responding to oral agents (single or multiple) please look to insulin therapy. Dosing limits apply. Please refer to Dose Consolidation List. 1 BYETTA Use PA Form# 10230 DIABETIC - ORAL SULFONYLUREAS CHLORPROPAMIDE TABS AMARYL TABS GLIMEPIRIDE DIABETA TABS GLIPIZIDE TABS GLUCOTROL TABS GLIPIZIDE ER TABS GLYBURIDE TABS GLUCOTROL XL TBCR GLYBURIDE MICRONIZED TABS MICRONASE TABS Use PA Form# 20420 GLYNASE TABS TOLAZAMIDE TABS TOLBUTAMIDE TABS DIABETIC -ORAL BIGUANIDES METFORMIN HCL TABS GLUCOPHAGE TABS METFORMIN ER GLUCOPHAGE XR TB24 Use PA Form# 20420 FORTAMET METFORMIN ER OSMOTIC DIABETIC - THIAZOL / BIGUANIDE COMBO ACTOPLUS MET1 ACTOPLUS MET XR Use PA Form# 20420 1. Requires use of Actos, Metformin, or other preferred anti-diabetics. AVANDARYL1 AVANDAMET TABS1 DIABETIC - / THIAZOL 1,3 ACTOS TABS 1. Actos is non-preferred as monotherapy. Actos is preferred if therapeutic doses of metformin, sulfonylurea or insulin are seen in members drug profile for at least 60 days within the past 18 months. AVANDIA TABS3 2. Actos 30mg or 45mg - please use multiple 15mg tabs. 3. Current users of Avandia who have tried Actos will be able to continue use of Avandia. Use PA Form# 20420 DIABETIC ALPHAGLUCOSIDASE GLYSET TABS DIABETIC - SULFONYLUREA / BIGUANIDE GLYBURIDE/METFORMIN PRECOSE TABS Use PA Form# 20420 1 GLUCOVANCE TABS 1. Use individual ingredients. 1 METAGLIP TABS DUETACT2 2. Use Actos 15mgs with generic glimepiride. Use PA Form# 20420 DIABETIC - MEGLITINIDES STARLIX TABS PRANDIN TABS NATEGLINIDE GLUCOSE ELEVATING AGENTS Page 8 of 40 Use PA Form# 20420 GLUCOSE ELEVATING AGENTS GLUCAGEN INJ. HYPOKIT THYROID HORMONES ARMOUR THYROID TABS LEVOTHYROXINE SODIUM SOLR CYTOMEL TABS LIOTHYRONINE LEVOTHROID TABS SYNTHROID TABS GLUCAGON DIAGNOSTIC KIT Use PA Form# 20420 GLUCAGEN DIAGNOSTIC KIT THYROID Use PA Form# 20420 LEVOTHYROXINE SODIUM TABS LEVOXYL TABS THYROID TABS THYROLAR UNITHROID TABS ANTITHYROID THERAPIES METHIMAZOLE TABS TAPAZOLE TABS Use PA Form# 20420 PROPYLTHIOURACIL TABS OSTEOPOROSIS/BONE AGENTS OSTEOPOROSIS ACTONEL TABS ALENDRONATE MIACALCIN SOLN2 Use PA Form# 20420 AREDIA SOLR 1. Approval only requires failure of Alendronate. BONIVA INJECTION KIT BONIVA TABS2,4 CALCITONIN NS DIDRONEL TABS 2. Quantity limits apply, please see dosage consolidation list. EVISTA TABS1 FORTEO 3. Please use Alendronate and Vitamin D. FORTICAL FOSAMAX TABS AND PLUS D PROLIA 3 4. Please use other preferred agents. XGEVA ZOMETA CALCIMIMETIC AGENTS CALCIMIMETIC AGENTS SENSIPAR Use PA Form# 30115 GROWTH HORMONE GROWTH HORMONE 5 GENOTROPIN1 NUTROPIN AQ NUSPIN 1 NORDITROPIN CARTRIDGE SOLN1 8 8 8 8 SOMATOSTATIC AGENTS OCTREOTIDE INJ HUMATROPE SOLR2 Use PA Form# 10710 INCRELEX2 1.Clinical PA is required to establish diagnosis and medical necessity. NUTROPIN1 OMNITROPE SAIZEN SOLR2 TEV-TROPIN 2. Products must be used in specified step order. All step 5's must be tried prior to moving to step 8's. SANDOSTATIN Use PA Form# 10710 SOMATULINE GROWTH HORMONE ANTAGONISTS GH ANTAGONISTS SOMAVERT Use PA Form# 10710 VASOPRESSIN RECEPTOR ANTAGONIST VASOPRESSIN RECEPTOR ANTAGONIST SAMSCA Use PA Form# 20420 URINARY INCONTINENCE VASOPRESSINS DESMOPRESSIN TABS 5 DDAVP TABS 6 DDAVP SOLN 6 DESMOPRESSIN SPRAY1 8 DESMOPRESSIN ACETATE SOLN1 8 STIMATE SOLN1,2 1 1. Products must be used in specified step order. Nocturnal enuresis patients will be encouraged to periodically attempt stopping DDAVP. 2. Patients with a diagnosis of hemophilia or Von Willebrands disease will be exempt from prior authorization. Use PA Form# 20420 ANTISPASMODICS OXYBUTYNIN DETROL TABS URISPAS TABS DITROPAN Use PA Form# 20420 SANCTURA TROSPIUM ANTISPASMODICS - LONG ACTING OXYBUTYNIN ER TABS 8 SANCTURA 8 ENABLEX1,3 DITROPAN XL TBCR Page 9 of 40 Use PA Form# 20420 1. See Criteria Section. ANTISPASMODICS - LONG ACTING TOVIAZ 1 VESICARE 8 OXYTROL 8 TOLTERODINE TAB 8 TROSPIUM DETROL LA CP2 9 9 SANCTURA XR2 2. Product is considered line extension of the original product due to Healthcare Reform (HCR). MaineCare will consider these medications nonpreferred and a step 9 because of the impact under the Federal Rebate Program in conjunction with HCR. 3. Use a preferred long acting antispasmodic. CHOLINERGIC URECHOLINE Use PA Form# 20420 BETHANECHOL METABOLIC MODIFIER HERED. TYROSINEMIA ORFADIN Use PA Form# 20420 ANTIHYPERTENSIVES / CARDIAC CARDIAC GLYCOSIDES DIGITEK TABS Use PA Form# 20420 DIGOXIN LANOXIN ANTIANGINALS--Isosorbide Dinitrate/ Mono-Nitrates ISOSORBIDE MONONITRATE TABS DILATRATE SR CPCR ISOSORBIDE MONONITRATE ER ISORDIL TABS Use PA Form# 20420 ISORDIL TITRADOSE TABS ISOSORBIDE DINITRATE SUBL ISOSORBIDE DINITRATE TABS ISOSORBIDE DINITRATE CR TBCR ISOSORBIDE DINITRATE ER TBCR ISOSORBIDE DINITRATE TD TBCR IMDUR TB24 ISMO TABS MONOKET TABS NITRO - OINTMENT/CAP/CR NITROBID OINT Use PA Form# 20420 NITROGLYCERIN CPCR NITROL OINT NITRO-TIME CPCR NITRO - PATCHES 1 NITROGLYCERIN PT241 NITRODISC PT24 1 NITREK PT241 NITRO-DUR PT24 1 NITRO-DUR PT 24 0.8MG1 3 MINITRAN PT241 1. At least 2 step 1's and step 3 of the preferred products must be used in specified order or PA will be required. Use PA Form# 20420 NITRO - SUBLINGUAL/ SPRAY NITROLINGUAL TABS NITROQUICK SUBL NITROSTAT SUBL NITROLINGUAL SOLN Use PA Form# 20420 NITROTAB SUBL BETA BLOCKERS - NON SELECTIVE CARVEDILOL LEVATOL TABS BETAPACE TABS NADOLOL TABS COREG CR3 BETAPACE AF TABS PINDOLOL TABS PROPRANOLOL HCL SOLN 1 COREG TABS CORGARD TABS PROPRANOLOL HCL TABS1 INDERAL TABS PROPRANOLOL LA CAPS INDERAL LA CPCR SOTALOL AF SOTALOL HCL TABS INNOPRAN XL TIMOLOL MALEATE TABS RANEXA ACEBUTOLOL HCL CAPS BYSTOLIC ATENOLOL TABS1 BETAXOLOL HCL TABS KERLONE TABS BISOPROLOL FUMARATE TABS SECTRAL CAPS METOPROLOL TARTRATE TABS1 METOPROLOL ER TENORMIN TABS 1. Recommend using BID since its effects do not last 24 hours. 2. Please use other strengths in combination to obtain this dose. 3. Dosing limits still apply. Please see dose consolidation list PROPRANOLOL HCL 60MG TABS2 Use PA Form# 20420 BETA BLOCKERS - CARDIO SELECTIVE 1. Recommend using Atenolol (and metoprolol) BID since its effects do not last 24 hours. LOPRESSOR TABS Use PA Form# 20420 ZEBETA TABS TOPROL XL TB24 BETA BLOCKERS - ALPHA / BETA BETA BLOCKERS & DURECTIC COMBOS LABETALOL HCL TABS TRANDATE TABS Use PA Form# 20420 DUTOPROL Use PA Form# 20420 Page 10 of 40 CALCIUM CHANNEL BLOCKERS--Amlodipines, Bepridil, Diltiazems, Felodipines, Isradipines, Nifedipines, Nisoldipine, and Verapamils 1. Dosing limits apply, please see dose consolidation list. NORVASC TABS1 AMLODIPINE1 Use PA Form# 20420 1 DILTIA XT CP24 5 1 DILTIAZEM HCL ER CP24 TAZTIA 1 DILTIAZEM HCL XR CP24 6 8 1 DILTIAZEM CD 300MG CP24 8 CARDIZEM CD CP241 1 4 DILTIAZEM CD 360MG CP24 8 CARDIZEM LA TB241 8 CARDIZEM SR CP121 8 DILTIAZEM HCL TABS1 8 DILTIAZEM HCL ER CP121 4 4 4 CARTIA XT CP24 1 DILTIAZEM CD CP24 1 DILTIAZEM HCL ER CP24 DILTIAZEM XR CP24 1 DILACOR XR CP24 1 1 CARDIZEM TABS1 1 1. Products must be used in specified order or PA will be required. Just write "Diltiazem 24-hour"and the pharmacy will use a preferred long acting diltiazem that does not require PA. Use PA Form# 20420 TIAZAC CP241 PLENDIL TB24 Use PA Form# 20420 FELODIPINE DYNACIRC CAPS Use PA Form# 20420 DYNACIRC CR TBCR1 CARDENE SR CPCR 1. Established users will be grandfathered Use PA Form# 20420 NICARDIPINE HCL CAPS AFEDITAB CR NIFEDIAC CC ADALAT CC TBCR1 NIFEDICAL XL TBCR PROCARDIA CAPS NIFEDIPINE TBCR PROCARDIA XL TBCR Use PA Form# 20420 SULAR TB24 1. Established users of 10MG and 20MG strengths are grandfathered. NIFEDIPINE CAPS 1. Established users of Adalat CC are grandfathered. NIFEDIPINE ER TBCR 1 SULAR CR Use PA Form# 20420 1 VERAPAMIL HCL CR TBCR CALAN TABS 1 VERAPAMIL HCL ER TBCR CALAN SR TBCR 1 VERAPAMIL HCL SR TBCR COVERA-HS TBCR ISOPTIN-SR Products must be used in specified order or PA will be required. Just write "Verapamil 24-hour" and the pharmacy will use a preferred long acting generic that does not require PA. VERAPAMIL HCL ER CP24 VERAPAMIL HCL SR CP24 VERAPAMIL HCL TABS VERELAN CP24 ANTIARRHYTHMICS VERELAN PM CP24 Use PA Form# 20420 AMIODARONE CORDARONE 1. Prescription must be written by Cardiologist. FLECAINIDE DISOPYRAMIDE MEXILETINE PACERONE MULTAQ QUINIDEX NORPACE TAMBOCOR PROCAINAMIDE TIKOSYN1 PROPAFENONE RYTHMOL SR QUINAGLUTE RYTHMOL Use PA Form# 20420 QUINIDINE GLUCONATE QUINIDINE SULFATE ACE INHIBITORS ANGIOTENSIN RECEPTOR BLOCKER BENAZEPRIL HCL 5 MAVIK TABS CAPTOPRIL TABS 5 ACCUPRIL TABS ENALAPRIL MALEATE TABS 8 ACEON TABS1 FOSINOPRIL SODIUM 8 ALTACE CAPS1 LISINOPRIL TABS 8 LOTENSIN TABS1 RAMIPRIL 8 MOEXIPRIL1 QUINAPRIL 8 MONOPRIL HCT TABS1 8 PRINIVIL TABS1 8 UNIVASC1 8 VASOTEC TABS1 8 ZESTRIL TABS1 AVAPRO 8 ATACAND TABS Use PA Form# 20420 BENICAR TABS1 8 COZAAR DIOVAN1 8 EDARBI 1. Preferred products only available without PA if patient on diabetic therapy or prior ACE therapy. 8 TEVETEN TABS 8 TRIBENZOR2 1 LOSARTAN1 1 MICARDIS TABS Page 11 of 40 1. Non-preferred products must be used in specified order. Use PA Form# 20420 2. Use preferred active ingredients which are available without PA. DIRECT RENIN INHIBITOR AMTURNIDE TEKTURNA1 TEKAMLO 1. Must show failure of single and combination therapy from all preferred antihypertensive categories. Use PA Form# 20420 ANTIHYPERTENSIVES CENTRAL CATAPRES-TTS CATAPRES TABS CLONIDINE HCL TABS CLONIDINE TTS GUANFACINE HCL TABS GUANABENZ ACETATE TABS HYDRALAZINE HCL TABS ISMELIN TABS HYLOREL TABS MINIPRESS CAPS METHYLDOPA TABS NEXICLON MINOXIDIL TABS TENEX TABS Use PA Form# 20420 PRAZOSIN HCL CAPS RESERPINE TABS ACE INHIBITORS AND CA CHANNEL BLOCKERS 8 LOTREL CAPS 8 9 TARKA TBCR AMLODIPINE/BENAZEPRIL Use individual preferred generic medications. Use PA Form# 20420 ACE AND THIAZIDE COMBO'S BENAZEPRIL HCL/HYDROCHLOR ACCURETIC TABS CAPTOPRIL/HYDROCHLOROTHIA ENALAPRIL MALEATE/HCTZ TABS MONOPRIL HCT TABS LISINOPRIL-HCTZ TABS UNIRETIC TABS LOTENSIN HCT TABS VASERETIC TABS Use PA Form# 20420 PRINZIDE TABS ZESTORETIC TABS BETA BLOCKERS AND DIURETIC COMBO'S ATENOLOL/CHLORTHALIDONE CORZIDE TABS BISOPROLOL FUMARATE/HCTZ LOPRESSOR HCT TABS PROPRANOLOL/HCTZ TENORETIC Use PA Form# 20420 TIMOLIDE 10/25 TABS ZIAC TABS ARB'S AND CA CHANNEL BLOCKERS 1 EXFORGE EXFORGE HCT AZOR TWYNSTA 1 1. Preferred products only available without PA if patient on diabetic therapy or prior ACE therapy. Use PA Form# 20420 ARB'S AND DIURETICS 1 AVALIDE TABS BENICAR HCT HYZAAR TABS 1 DIOVAN HCT TABS1 LOSARTAN HCT ATACAND HCT TABS 1. Preferred products only available without PA if patient on diabetic therapy or prior ACE therapy. TEVETEN HCT TABS 1 MICARDIS HCT TABS1 Use PA Form# 20420 ANGIOTENSIN MODULATORSARB COMBINATION EDARBYCLOR ARB'S AND DIRECT RENIN INHIBITOR COMBINATION VALTURNA DIURETICS ACETAZOLAMIDE TABS ALDACTAZIDE TABS BUMETANIDE ALDACTONE TABS CHLOROTHIAZIDE TABS AMILORIDE HCL CHLORTHALIDONE TABS BUMEX TABS EDECRIN TABS DEMADEX TABS FUROSEMIDE DIAMOX HYDROCHLOROTHIAZIDE DIURIL INDAPAMIDE TABS DYAZIDE CAPS METHAZOLAMIDE TABS ENDURON TABS METHYCLOTHIAZIDE TABS INSPRA SPIRONOLACTONE 25MG TABS LASIX TABS SPIRONOLACTONE/HYDRO MAXZIDE TORSEMIDE TABS MICROZIDE CAPS TRIAMTERENE/HCTZ MIDAMOR TABS Use PA Form# 20420 Use PA Form# 20420 Page 12 of 40 1. Multiples of Spironolactone 25 mg are cheaper than 50 mg strength. Inspra will be approved for severe breast tenderness and male gynecomastia. Use PA Form# 20420 ZAROXOLYN TABS NAQUA TABS SPIRONOLACTONE 50MG1 CCB / LIPID CADUET LIPID DRUGS CHOLESTEROL - BILE SEQUESTRANTS CHOLESTYRAMINE COLESTID COLESTIPOL HCI PREVALITE Use PA Form# 20420 QUESTRAN WELCHOL TABS CHOLESTEROL - FIBRIC ACID DERIVATIVES GEMFIBROZIL TABS ANTARA NIASPAN LOPID TRICOR FIBRICOR TRILIPIX LIPOFEN Use PA Form# 20420 LOFIBRA FENOFIBRATE TRIGLIDE CHOLESTEROL - HGM COA + ABSORB INHIBITORS MORE POTENT DRUGS/COMBINATIONS CRESTOR ATORVASTATIN 1 SIMVASTATIN 1. Dosing limits apply, please see dosage consolidation list. LIPITOR VYTORIN2 ZOCOR 2. Only available if component ingredients are unavailable. SIMVASTATIN 80MG3 3. Current users grandfathered. Use PA Form# 20420 CHOLESTEROL - HGM COA + ABSORB INHIBITORS LESS POTENT DRUGS/COMBINATIONS LESCOL CAPS 8 LESCOL XL TB24 8 ALTOPREV TB24 LIVALO LOVASTATIN TABS2 8 MEVACOR TABS PRAVASTATIN2 8 PRAVACHOL TABS 8 PRAVIGARD 8 ZETIA TABS1 1. Zetia available w/out PA as addition to Lipitor 80mg. Zetia will also be approved with a PA as add on for patients at maximally tolerated doses of statins. 2. Dosing limits apply, please see dosage consolidation list. Use PA Form# 20420 CHOLESTEROL - HGM COA + ABSORB INHIBITORS STATIN/ NIACIN COMBO SIMCOR ADVICOR TBCR Use PA Form# 20420 PULMONARY ANTI-HYPERTENSIVES PULMONARY ANTIHYPERTENSIVES FLOLAN 1 ADCIRCA 2 VENTAVIS EPOPROSTENOL INJ 1. See Criteria Section. REMODULIN 4 REVATIO 3 2. See Criteria Section. 3. There will be dosing limits of one 20ml multidose vial/ 30 days supply without pa. 1 4. PA is required to establish and conferm who group 1 diagnosis of primary PAH (Primary Pulmonary Hypertension) and NYHA functional class 3 & 4. Use PA Form# 20420 ERA / ENDOTHELIN RECEPTOR ANTAGONIST 1,2 LETAIRIS 3,4 TRACLEER 1. Providers must be registered with LEAP Prescribing program, a restricted distribution program. 2. Clinical PA is required to establish diagnosis and medical necessity. 3. 1. Prior trial of Letaris, WHO Group 1 diagnosis of PAH (Primary Pulmonary Hypertension) and NYHA functional class of 3. 4. For members with NYHA functional class of 4, Tracleer approval will be allowed with confirmation of diagnosis and functional class. Use PA Form# 20420 IMPOTENCE AGENTS IMPOTENCE AGENTS Page 13 of 40 As of January 1, 2006, per CMS (federal govt.), impotence agents are no longer covered. As of January 1, 2006, per CMS (federal govt.), impotence agents are no longer covered. ANTI-EMETOGENICS ANTIEMETIC ANTICHOLINERGIC / DOPAMINERGIC MECLIZINE HCL TABS ANTIVERT TABS PROMETHAZINE SUPP PHENERGAN SOLN PROMETHAZINE PROMETHAZINE 50MG SUPP TRANSDERM-SCOP PT72 PROMETHEGAN SUPP Use PA Form# 20420 TORECAN TABS ANTIEMETIC - 5-HT3 RECEPTOR ANTAGONISTS/ SUBSTANCE P NEUROKININ MARINOL CAPS 5 GRANISETRON ONDANSETRON TABS 8 ALOXI ONDANSETRON ODT TBDP2,4 8 ANZEMET TABS 8 CESAMET1 8 8 EMEND3 KYTRIL 8 SANCUSO 8 ZOFRAN ODT TBDP4 8 ZOFRAN TABS4 8 ZOFRAN INJ4 ZUPLENZ 2,4 ONDANSETRON INJ 2,4 8 1. Approvals will require diagnosis of chemoinduced nausea/vomiting and failed trials of all preferred anti-emetics, including 5-HT3 class (Ondansetron) and Marinol. 2. Ondansetron will be preferred with CA diag and dosing limits still apply. 3. Clinical PA is required for members on highly emetic anti-neoplastic agents. 4. Dosing limits apply, please see Dosage Consolidation List Use PA Form# 20610 for Ondansetron requests Use PA Form# 20420 for all others NON-SEDATING ANTIHISTAMINES / DECONGESTANTS ANTIHISTIMINES - NONSEDATING ALAVERT TABS 5 CETIRIZINE TABS 5 5 CLARITIN (OTC) CLARITIN SYRP (OTC) LORATADINE TAVIST ND (OTC) 5 5 8 8 CLARINEX TABS1 1,2 CLARINEX SYR FEXOFENADINE1 ZYRTEC1 ZYRTEC SYR1,2 ALLEGRA3 1. Must fail preferred drugs, OTC loratidine and cetirizine before moving to non-preferred step order drugs. 2. Clarinex and Zyrtec syrp <6 yr w/o PA. CLARITIN3 8 8 DELORATADIN 8 XYZAL3 LORATADINE ODT4 3. Must fail all step 5 drugs (Clarinex, Fexofenadine and Zyrtec) before moving to next step product. 4. All OTC versions of loratadine ODT are now nonpreferred. Pseudoephedrine is available with prescription. Use PA Form# 20530 ANTIHISTIMINES - OTHER Use PA Form# 20530 CLEMASTINE CHLORPHENIRAMINE DIPHENHYDRAMINE ALLERGY / ASTHMA THERAPIES ANTIASTHMATIC ANTICHOLINERGICS INHALER Use PA Form# 20420 SPIRIVA1,2 1. Quantity limit of 1 inhalation daily (1 capsule for inhalation daily) Spiriva will require PA if Combivent or Atrovent nebulizer solution is in member's current drug profile. 2. We ask physicians to write "asthma" on the prescription whenever Sprivia is primarily being used for that condition. ANTIASTHMATIC PHOSPHODIESTERASE 4 INHIBITORS ANTIASTHMATIC ANTICHOLINERGICS NEBULIZER IPRATROPIUM BROMIDE SOLN DALIRESP Use PA Form# 20420 ATROVENT SOLN Use PA Form# 20420 Page 14 of 40 ANTIASTHMATIC ANTIINFLAMMATORY AGENTS CROMOLYN SODIUM NEBU 1. Need max inhaled steroids and written by pulmonary or allergy specialist. XOLAIR1 Use PA Form# 20420 ANTIASTHMATIC - NASAL STEROIDS ANTIASTHMATIC - NASAL MISC. 5 3 FLUTICASONE SPR 3 NASONEX SUSP Use PA Form# 20420 1,3 BECONASE AQ INHA 5 NASACORT AQ AERS 8 FLONASE SUSP2,3 8 FLUNISOLIDE SOLN2,3 8 NASACORT AERS2,3 8 OMNARIS SPR3 8 RHINOCORT AERO2,3 8 RHINOCORT AQUA SUSP2,3 8 TRI-NASAL SOLN2,3 1. All preferred drugs must be tried before moving to non preferred steps. 1,3 2. All step 5 medications need to be tried before moving to step 8's. 3. Dosing limits apply to whole category, please see dosage consolidation list. 8 VANCENASE POCKETHALER AERS 8 9 VERAMYST2,3 TRIAMCINOLONE NS CROMOLYN NASAL 4% 7 ATROVENT NASAL SOL Use PA Form# 20420 OCEAN 0.65% SALINE NASAL SPRAY 0.65% 7 7 IPRATROPIUM NASAL SOL1 ASTELIN 1. Ipratropium will be approved if submitted with documentation supporting use of CPAP machine. 8 ASTEPRO2 2,3 2. Utilize Multiple preferred, as well as step therapy Astelin. ANTIASTHMATIC - BETA ADRENERGICS ALBUTEROL NEB ACCUNEB NEBU MAXAIR ALBUTEROL AER METAPROTERENOL ALBUTEROL HFA PROAIR HFA3 ALBUTEROL 0.63mg/3ml PROVENTIL HFA ARCAPTA3 SEREVENT BRETHINE TERBUTALINE SULFATE TABS FORADIL AEROLIZER CAPS VENTOLIN HFA AERS3 VENTOLIN AERS 1. Xopenex users w/ prior asthma hospitalization due to albuterol nebulizer failure will be grandfathered. 2. Quantity Limit: 12 cc/day. 3. Dosing limits apply, please see dosage consolidation list. VOLMAX TBCR VOSPIRE ER TB12 XOPENEX HFA3 Use PA Form# 20420 XOPENEX NEBU1,2 ANTIASTHMATIC ADRENERGIC COMBINATIONS 1. We ask physicians to write "asthma" on the prescription whenever Advair is primarily being used for that condition. 1,2 ADVAIR DISKUS/HFA DULERA SYMBICORT2 2. Dosing limits apply, please see dosage consolidation list. Use PA Form# 20420 ANTIASTHMATIC ADRENERGIC ANTICHOLINERGIC ALBUTEROL/IPRATROPIUM NEB. SOLN 1. Please use preferred individual ingredients Albuterol and Ipratropium. DUONEB SOLN1 COMBIVENT AERO2 2. We ask physicians to write "asthma" on the prescription whenever Combivent is primarily being used for that condition. Use PA Form# 20420 ANTIASTHMATIC - XANTHINES AMINOPHYLLINE TABS THEO-24 CP24 THEOCHRON TB12 THEOLAIR TABS THEOLAIR-SR TB12 UNIPHYL TBCR Use PA Form# 20420 THEOPHYLLINE CR TB12 THEOPHYLLINE ELIX THEOPHYLLINE SOLN THEOPHYLLINE ER CP12 THEOPHYLLINE ER TB12 ANTIASTHMATIC - STEROID INHALANTS 5 ASMANEX4 1. No PA for Pulmicort susp if under 8 years old. AEROBID AERS2,4 FLOVENT DISKUS 5 BECLOVENT AERS FLOVENT HFA4 5 VANCERIL AERS2,4 PULMICORT SUSP1,4 8 AEROBID-M AERS3,4 QVAR AERS4 8 ALVESCO4 8 VANCERIL DOUBLE STRENGTH AERS3,4 8 PULMICORT FLEXHALER4 4 2,4 Page 15 of 40 2. All preferreds must be tried before moving to non preferred steps. 3. All step 5 medications need to be tried before moving to step 8's. 4. Dosing limits apply to whole category, please see dosage consolidation list. 4. Dosing limits apply to whole category, please see dosage consolidation list. Use PA Form# 20420 ANTIASTHMATIC - 5Lipoxygenase Inhibitors ANTIASTHMATIC LEUKOTRIENE RECEPTOR ANTAGONISTS SINGULAIR ANTIASTHMATIC - ALPHAPROTEINASE INHIBITOR 8 8 9 9 ANTIASTHMATIC - HYDROLYTIC ENZYMES ANTIASTHMATIC MUCOLYTICS ACETYLCYSTEINE1 ZYFLO CR TABS Use PA Form# 20420 ACCOLATE TABS Use PA Form# 20420 ARALAST ZEMAIRA Use PA Form# 20420 GLASSIA PROLASTIN SUSR PULMOZYME SOLN Use PA Form# 20420 MUCOMYST 1. Acetylcysteine is covered with diagnosis of CF. Use PA Form# 20420 COUGH/COLD COUGH/COLD DEXTRO-GUAIF SYRP1 1. All of cough cold preparations are not covered except these preferred products. GUAIFENESIN SYRP1 PSEUDOEPHEDRINE1 ROBITUSSIN DM SYRP1 Use PA Form# 20420 ROBITUSSIN SUGAR FREE SYRP1 DIGESTIVE AIDS / ASSORTED GI GI - ANTIPERISTALTIC AGENTS DIPHENOXYLATE LOFENE TABS DIPHENOXYLATE/ATROPINE LONOX TABS LOPERAMIDE HCL CAPS/LIQ MOTOFEN TABS Use PA Form# 20420 OPIUM TINCTURE TINC PAREGORIC TINC GI - ANTI-DIARRHEAL/ ANTACID - MISC. ATROPINE SULFATE SOLN BELLADONNA ALKALOIDS & OP BENTYL SYRP BENTYL TABS BISMATROL BISMUTH SUBSALICYLATE CUVPOSA GLYCOPYRROLATE INJ CALCIUM CARBONATE (ANTACID) CHEW HYOSCYAMINE SL DICYCLOMINE HCL LEVBID TB12 GLYCOPYRROLATE TABS LEVSIN ELIX HAPONAL TABS LEVSIN TABS HYOSCYAMINE CAPS & TABS LEVSIN/SL SUBL HYOSCYAMINE SULFATE NULEV TBDP KAOPECTATE ROBINUL INJ MAGNESIUM OXIDE TABS ROBINUL TABS Use PA Form# 20420 MAG-OX 400 TABS PAMINE TABS PROPANTHELINE BROMIDE TABS SAL-TROPINE TABS SCOPOLAMINE HYDROBROMIDE SODIUM BICARBONATE TABS TUMS GI - H2-ANTAGONISTS CIMETIDINE AXID CAPS FAMOTIDINE AXID AR TABS RANITIDINE NIZATIDINE CAPS RANITIDINE SYRP PEPCID ACID REDUCER TABS PEPCID AC Use PA Form# 20420 ZANTAC SYRP ZANTAC TABS GI - PROTON PUMP INHIBITOR DEXILANT (KAPIDEX)2 6 PRILOSEC OTC4 2 7 ACIPHEX TBEC4 8 8 PREVACID CPDR4,5 PREVACID SOLUTABS1 8 NEXIUM CPDR4 8 PRILOSEC CPDR OMEPRAZOLE 20MG PANTOPRAZOLE Page 16 of 40 1. Prevacid Solutabs available without PA for children less than 9 years old. 2. Dosing limits apply, please see dosage consolidation list. 2. Dosing limits apply, please see dosage consolidation list. 8 PROTONIX INJ 8 PROTONIX2 2 8 8 OMEPRAZOLE 10MG OMEPRAZOLE-SODIUM BICARBONATE CAPS 8 LANSOPRAZOLE 9 OMEPRAZOLE 40MG3 3. Please use multiple 20mg Capsules to obtain required dose. 4. All preferreds and step therapy must be tried and failed. 5.Established users prior to 10/1/09 may continue to obtain Prevacid until 12/31/09. Use PA Form# 20720 GI - ULCER ANTI-INFECTIVE HELIDAC Use PA Form# 20420 PREVPAC GI - PROSTAGLANDINS GI - DIGESTIVE ENZYMES MISOPROSTOL TABS CYTOTEC TABS Use PA Form# 20420 CREON LACTRASE CAPS Use PA Form# 20420 LACTASE CHEW LIPRAM LACTASE TAB LIPRAM CR ZENPEP1 KU-ZYME CAPS 1. Clinical PA is required to establish CF diagnosis and medical necessity. In all cases except cystic fibrosis patients, objective evidence of pancreatic insufficiency (fat malabsorption test etc...) must be supplied. 1 PANCREASE PANOKASE TABS TRIPASE GI - ANTI - FLATULENTS / GI STIMULANTS CALULOSE SYRP CONSTULOSE SYRP ENULOSE SYRP1 GASTROCROM CONC AMITIZA2 CEPHULAC SYRP INFANTS GAS RELIEF SUSP REGLAN TABS Use PA Form# 20420 1 GENERLAC SYRP 2. Prior failed trials of multiple other preferred GI agents must occur first, Such as OTC senna, docusate, lactulose, polyethylene glycol. 1 LACTULOSE SYRP METOCLOPRAMIDE HCL SIMETHICONE GI - INFLAMMATORY BOWEL AGENTS 1. Diag codes no longer necessary for preferred products. Lactulose has 60cc/day QL ASACOL TBEC 400 ASACOL 800MG HD APRISO AZULFIDINE EN-TABS TBEC AZULFIDINE TABS BALSALAZIDE Use PA Form# 20420 1. Current users grandfathered. CANASA SUPP LIALDA TABS COLAZAL CAPS PENTASA 500MG2 SFROWASA 2. Use multiple Pentasa 250mg. LOTRONEX TABS Use PA Form# 20420 DIPENTUM CAPS 1 PENTASA CPCR 250MG ROWASA ENEM SULFAZINE EC TBEC SULFASALAZINE TABS GI - IRRITABLE BOWEL SYNDROME AGENTS MISCELLANEOUS GI GI - MISC. BISAC-EVAC SUPP ACTIGALL CAPS BISACODYL BENEFIBER BISCOLAX SUPP CARAFATE CINOBAC CAPS CLEARLAX POW CITRATE OF MAGNESIA SOLN COLACE CAPS CITRUCEL COLYTE DIOCTO SYRP DIOCTO-C SYRP DOCUSATE CALCIUM CAPS DOC SOD /CAS CAP DOCUSATE SODIUM DOC-Q-LAX CAPS FIBER LAXATIVE TABS DOCUSATE SODIUM/CAS CAPS FLEET DOK PLUS GENFIBER POWD DULCOLAX SUPP GLYCERIN FIBER CON TABS HIPREX TABS FIBER-LAX TABS KRISTALOSE PACK GOLYTELY SOLR MAALOX MALTSUPEX METAMUCIL MIRALAX PACK (OTC versions) MILK OF MAGNESIA SUSP MIRALAX POWD (OTC versions) MINERAL OIL OIL PEG 3350/ELECTROLYTES SOLR Page 17 of 40 1. Must show evidence of trials of preferred agents that do not require PA, such as OTC senna, docusate, mineral oil and prescription lactulose. Use PA Form# 20420 NULYTELY SOLR SENEXON TABS SENNA SENOKOT TABS SENOKOT GRAN SENOKOT S TABS SENOKOT SYRP STOOL SOFTENER PLUS CAPS SENOKOT CHILDRENS SYRP UNI-CENNA TABS SENOKOT XTRA TABS UNI-EASE PLUS CAPS SORBITOL V-R NATURAL SENNA LAXATIV TABS STOOL SOFTENER CAPS URSO 250 SUCRALFATE TABS UNI-EASE CAPS UNIFIBER POWD URSO FORTE URSODIOL MISC. UROLOGICAL UROLOGICAL - MISC. ACETIC ACID 0.25% SOLN CITRIC ACID/SODIUM CITRAT SOLN CYTRA-K SOLN CYTRA-2 SOLN 1. Elmiron requires adequate proof of Dx with supportive testing. FURADANTIN SUSP ELMIRON CAPS1 MACROBID CAPS Use PA Form# 20420 K-PHOS MF TABS METHENAMINE MANDELATE TABS MONUROL PACK MACRODANTIN CAPS POTASSIUM CITRATE/CITRIC SOLN NEOSPORIN GU IRRIGANT SOLN PYRIDIUM PLUS TABS NITROFURANTOIN MACR CAPS PYRIDIUM TABS NITROFURANTOIN MACR SUSP RENACIDIN SOLN PHENAZOPYRIDINE HCL TABS PHENAZOPYRIDINE PLUS PROSED/DS TABS TRICITRATES SYRP URELIEF PLUS UREX TABS URISED TABS UROCIT-K UROQID #2 TABS PHOSPHATE BINDERS PHOSPHATE BINDERS 1 ELIPHOS MAGNEBIND - 400 RENAGEL 1 CALCIUM ACETATE Use PA Form# 20420 PHOSLYRA 1. Diag required. 1 FOSRENOL1 RENVELA1 INTRA-VAGINALS VAGINAL - ANTIBACTERIALS CLEOCIN CREA VANDAZOLE METROGEL VAGINAL GEL2 METRONIDAZOLE VAGINAL GEL2 1. Step order must be followed to avoid PA. Must fail Cleocin Cream and Metronidazole products before moving to next step product without PA. 2. Dosing limits apply, please see Dosage Consolidation List. CLEOCIN SUPP1 Use PA Form# 20420 VAGINAL - ANTI FUNGALS CLOTRIMAZOLE CREA 1. Quantity limit: 1/script/2 weeks GYNE-LOTRIMIN CREA AVC CREA CLOTRIMAZOLE 3 DAY CREA MICONAZOLE CREA GYNAZOLE-1 CREA Use PA Form# 20420 MICONAZOLE 3 COMBO PACK KIT1 MICONAZOLE 7 CREA GYNE-LOTRIMIN 3 TABS MICONAZOLE NITRATE CREA TERAZOL 3 CREA NYSTATIN TABS TERAZOL 7 CREA TERAZOL 3 SUPP TERCONAZOLE 0.8MG TERCONAZOLE 0.4MG TERCONAZOLE SUPP MICONAZOLE 3 SUPP VAGITROL V-R MICONAZOLE-7 CREA VAGINAL - CONTRACEPTIVES GYNOL II EXTRA STRENGTH GEL DELFEN FOAM Page 18 of 40 Use PA Form# 20420 VAGINAL - ESTROGENS ESTRING RING ESTRACE CREA1 PREMARIN CREA VAGIFEM TABS1 ACID JELLY GEL AMINO ACID CERVICAL CREA 1. Must fail all preferred products before nonpreferred. Use PA Form# 20420 VAGINAL - OTHER Use PA Form# 20420 ACI-JEL GEL CERVICAL AMINO ACID CREA BPH BPH DOXAZOSIN MESYLATE TABS 5 FLOMAX CP24 FINASTERIDE1 TERAZOSIN HCL CAPS 8 8 ALFUZOSIN TAMSULOSIN 8 CARDURA TABS4 8 JALYN3,4 8 PROSCAR TABS4 8 RAPAFLO4 8 1. There will be dosing limits of 1 tab per day with out PA. AVODART2,4 UROXATRAL 4 2. Prior use of preferred agent prior to any approvals. 3. Use of preferred (tamsulosin and finasteride) and (tamsulosin and non-preferred Avodart). 4. Non-preferred products must be used in specified order. Use PA Form# 20420 ANXIOLYTICS ANXIOLYTICS BENZODIAZEPINES ALPRAZOLAM TABS 8 ATIVAN CHLORDIAZEPOXIDE HCL CAPS 8 NIRAVAM CLORAZEPATE DIPOTASSIUM TABS 8 SERAX DIAZEPAM 8 TRANXENE LORAZEPAM 8 XANAX TABS OXAZEPAM CAPS 8 XANAX XR ALPRAZOLAM ER 9 ANXIOLYTICS - MISC. BUSPIRONE HCL TABS BUSPAR TABS HYDROXYZINE HCL SOLN DROPERIDOL SOLN HYDROXYZINE HCL SYRP HYDROXYZINE HCL TABS HYDROXYZINE PAMOATE CAPS HYDROXYZINE PAM 100MG CAPS MEPROBAMATE TABS Use PA Form# 20420 Use PA Form# 20420 VISTARIL ANTI-DEPRESSANTS ANTIDEPRESSANTS - MAO INHIBITORS NARDIL TABS Use PA Form# 20420 PARNATE TABS ANTIDEPRESSANTS - MAO INHIBITORS TOPICAL EMSAM1 1. Dosing limits apply, please refer to Dose consolidation list. Use PA Form# 20420 ANTIDEPRESSANTS SELECTED SSRI's BUPROPION HCL TABS 8 APLENZIN7 BUPROPION SR 8 CELEXA4 BUPROPION XL 8 CITALOPRAM FLUOXETINE HCL CAPS 8 CYMBALTA5, 11 EFFEXOR TABS 8 EFFEXOR XR CP24 3, 10 FLUOXETINE HCL LIQD 8 FLUOXETINE 40 mg AND 60mg CAPS1 FLUOXETINE HCL 10mg TABS 8 FLUVOXAMINE MALEATE TABS 8 FLUOXETINE 20mg TABS6 LUVOX TABS LEXAPRO TABS4 MIRTAZAPINE 8 MAPROTILINE HCL TABS 8 MIRTAZAPINE ODT NEFAZODONE 8 PAROXETINE3 8 OLEPTRO PAROXETINE CR3 2 SERTRALINE TRAZODONE HCL TABS 8 PAXIL 8 9 8 PAXIL CR 3 PRISTIQ 8 PROZAC 8 PROZAC CAPS 8 PROZAC WEEKLY CPDR 8 REMERON TABS 8 SARAFEM CAPS 8 TRAZODONE HCL 300MG TABS 8 WELLBUTRIN TABS 8 WELLBUTRIN SR TBCR 4 VENLAFAXINE ER CAPS 3 Page 19 of 40 1. Use Fluoxetine 20 mg in multiples. 2. See Zoloft splitting table. Sertraline requires splitting of scored tabs to avoid PA. 3. Strong caution with pediatric population. 4. See Celexa/Citalopram and Lexapro splitting tables. 5. Max daily dose allowed is 60mg, only 1 capsule per day allowed for all strengths. Combination of multiple strengths require PA. 6. Use Fluoxetine 10mg tabs or capsules in multiples. 8 WELLBUTRIN XL 8 REMERON SOLTAB TBDP 8 SAVELLA 8 8 ZOLOFT 8 VENLAFAXINE TABS 8 VENLAFAXINE ER TABS9 VIBRYD 8 9 FLUOXETINE 90mg TABS12 7. Provide clinical documentation as to why a preferred generic alternative cannot be used. 8. Dosing limits allowing 2 tabs/day and a max daily limit of 200mg / day applies. Please see dose consolidation list. 9. Dosing limits and max daily dose applies. Limit of 1 tab per day of 37.5mg, 75mg, and 225mg will be allowed without pa, along with limits of 2 tabs per day of the 150mg strength. Max daily dose allowed is 375mg. 10. Use venlafaxine ER tabs. 11. Established users are grandfathered. 12. Non-preferred products must be used in specified step order. Use PA Form# 20420 ANTIDEPRESSANTS TRI-CYCLICS AMITRIPTYLINE HCL TABS 1 AMOXAPINE TABS 1 ANAFRANIL CAPS CLOMIPRAMINE HCL CAPS 1. Users over the age of 65 require a pa. DOXEPIN HCL 150 MG2 NORPRAMIN TABS 2. Use multiples of 50mg. IMIPRAMINE HCL TABS1 PAMELOR Use PA Form# 20420 NORTRIPTYLINE HCL1 TOFRANIL Use PA Form# 10220 for Brand Name requests PROTRIPTYLINE HCL TABS1 VIVACTIL TABS DESIPRAMINE HCL TABS1 DOXEPIN HCL 1 SURMONTIL CAPS1 SEDATIVE / HYPNOTICS SEDATIVE/HYPNOTICS BARBITURATE LUMINAL SOLN 1 BUTISOL SODIUM TABS CHLORAL HYDRATE SYRP SOMNOTE CAPS 1 1. PA required for new users of preferred products if over 65 years. MEBARAL TABS1 PHENOBARBITAL1 Use PA Form# 20420 SEDATIVE/HYPNOTICS BENZODIAZEPINES SEDATIVE/HYPNOTICS - NonBenzodiazepines 1 1 DORAL TABS 1. Dosing limits apply, please see dosing consolidation list. ESTAZOLAM TABS HALCION TABS MIDAZOLAM HCL SYRP FLURAZEPAM HCL CAPS1 RESTORIL CAPS1 TEMAZEPAM CAPS 15 & 30MG1 TEMAZEPAM 7.5MG1 Use PA Form# 30110 1. Quantity Limt of 12 per 34 days. 1 1 TRIAZOLAM TABS1 MIRTAZAPINE 7 AMBIEN1 1 TRAZODONE 8 1 ZOLPIDEM 2 8 AMBIEN CR1 EDLUAR 2 ZALEPLON 2,3 8 LUNESTA1 8 8 SONATA CAPS1 ROZEREM 8 ZOLPIMIST 2. Quantity limits will be allowed up to 30/30, but intermittent therapy is recommended. 3. Only zolpidem trial/failure will be required to obtain Zaleplon. 4. Must fail all preferred products before nonpreferred Use PA Form# 30110 ANTI-PSYCHOTICS ANTIPSYCHOTICS ATYPICALS ABILIFY TABS3,4 8 GEODON OLANZAPINE4 8 ABILIFY DISC TAB, INJ and SOL2 FANAPT 8 INVEGA RISPERIDONE TAB4 8 INVEGA SUSTENNA RISPERIDONE SOLN4 QUETIAPINE4 8 8 LATUDA6 RISPERDAL TAB 8 RISPERDAL CONSA 2 8 8 RISPERDAL M TAB2 RISPERDAL SOLN 8 RISPERIDONE ODT 8 SAPHRIS 8 SEROQUEL 50MG TABS1,2 4 Page 20 of 40 If prescribing 2 or more antipsychotics, PA will be required for both drugs, except if one is Clozapine.This also includes combination of Seroquel with Seroquel XR. Use PA form# 20440 for Multiple Antipsychotic requests Use PA form# 10130 for non-preferred single therapy atypical requests 8 8 8 8 9 ZYPREXA TABS Use PA form# 10130 for non-preferred single therapy atypical requests ZYPREXA ZYDIS TBDP 2 ZYPREXA RELPREVV 1. Please use multiple 25mg tablets. SEROQUEL TABS 2. Established users of single therapy atypicals were grandfathered. 3. Abilify requires splitting of tab to avoid PA. Please see Abilify splitting table. SEROQUEL XR5 4. Prior Authorization will be required for preferred medications for members under the age of 5. 5. Product is considered line extension of the original product due to Healthcare Reform (HCR). MaineCare will consider these medications nonpreferred and a step 9 because of the impact under the Federal Rebate Program in conjunction with HCR. 6. Dosing limits apply, please see dosing consolidation list. 7. Dosing limits apply: quetiapine 25mg, 50mg and 100mg are available without PA if daily doasage is less than 1.5 tablets ANTIPSYCHOTICS - SPECIAL ATYPICALS CLOZAPINE TABS ANTIPSYCHOTICS - TYPICAL CHLORPROMAZINE HCL COMPAZINE Use PA Form# 20420 FLUPHENAZINE DECANOATE COMPRO SUPP FLUPHENAZINE HCL HALDOL DECANOATE If prescribing 2 or more antipsychotics, PA will be required for both drugs, except if one is Clozapine. HALDOL LOXITANE CAPS HALOPERIDOL MELLARIL HALOPERIDOL DECANOATE SOLN NAVANE CAPS HALOPERIDOL LACTATE SOLN PROLIXIN LOXAPINE SUCCINATE CAPS STELAZINE TABS CLOZARIL TABS Use PA Form# 20420 FAZACLO LOXITANE-C CONC MOBAN TABS PERPHENAZINE PROCHLORPERAZINE SERENTIL THIORIDAZINE HCL THIOTHIXENE TRIFLUOPERAZINE HCL TABS LITHIUM LITHIUM LITHIUM CARBONATE ESKALITH CAPS LITHIUM CITRATE SYRP ESKALITH CR TBCR Use PA Form# 20420 COMBINATION - PSYCHOTHERAPEUTIC PSYCHOTHERPEUTIC COMBINATION CHLORDIAZEPOXIDE/AMITRIPT 8 SYMBYAX1 1. Only available if component ingredients are unavailable. PERPHENAZINE/AMITRIPTYLIN Use PA Form# 20420 STIMULANTS STIMULANT - AMPHETAMINES SHORT ACTING 1. Preferred stimulants will be available without PA if diagnosis of ADHD. ADDERALL TABS1 AMPHETAMINE SALT COMBO 1,3 DEXTROAMPHET SULF TABS1,3 DEXEDRINE1,3 2. As per recent FDA alert, Adderal & Dexedrinel should not be used in patients with underlying heart defects since they may be at increased risk for sudden death. DEXTROSTAT TABS1 3. Dosing limits apply, please see dosing consolidation list. Use PA Form# 20420 STIMULANT - LONG ACTING AMPHETAMINES SALT 2,3,4 VYVANSE 8 ADDERALL XR CP24 9 AMPHETAMINE/DEXTROAMPHET ER Page 21 of 40 1,3,4 Use PA Form# 20420 1. As per recent FDA alert, Adderall should not be used in patients with underlying heart defects since they may be at increased risk for sudden death. 2. FDA approval is currently for adults and children 6 or older. Will be available without PA for this age group if within dosing limits. Limit of one capsule daily. Max dose of 70MG daily. 3. Preferred stimulants will be available without PA if diagnosis of ADHD. 4. Dosing limits applly, please see dosing consolidation list. LONG ACTING AMPHETAMINES DEXEDRINE CAP CR1,2,3 DEXTROAMPHET SULF CPCR3 1. Preferred stimulants will be available without PA if diagnosis of ADHD. 2. As per recent FDA alert, Adderall & Dexedrine should not be used in patients with underlying heart defects since they may be at increased risk for sudden death. 3. Dosing limits applly, please see dosing consolidation list. Use PA Form# 20420 STIMULANT METHYLPHENIDATE METHYLIN CHEWABLES 1,2 FOCALIN TABS 1,2 RITALIN METADATE ER TBCR 1. Preferred stimulants will be available without PA if diagnosis of ADHD. METHYLIN ER TBCR1,2 METHYLIN TABS1,2 Use PA Form# 20420 METHYLIN SOL1 2. Dosing limits apply, please see dosing consolidation list. Maximum daily doses are as follows: 72mg daily for methylphenidate and 36mg daily for dexmethylphenidate. METHYLPHENIDATE HCL1,2 STIMULANT METHYLPHENIDATE - LONG ACTING DAYTRANA1,4 5 METADATE CD CPCR FOCALIN XR1 METHYLPHENIDATE ER1,4 8 CONCERTA TBCR RITALIN LA2 8 1. Preferred stimulants will be available without PA if diagnosis of ADHD. 2. Non-preferred products must be used in specified step order. 3. FDA approval currently only for ages 6-16. Limit of one patch daily. Max dose of 30MG daily. 4.Dosing limits applly, please see dosing consolidation list. Use PA Form# 20420 STIMULANT - STIMULANT LIKE INTUNIV 7 STRATTERA1, 2 8 CAFCIT SOLN 3 8 8 INTUNIV 3,4 KAPVAY 8 PROVIGIL TABS3 9 NUVIGIL3 9 DESOXYN TABS3 9 DESOXYN CR3 1. Failure of both an amphetamine and methylphenidate is required for consideration for approval of Strattera, unless history of substance abuse without current use of abusable medication(s). Additionally, for patients >17 years of age, a trial of quanfacine in required before approval of Strattera. 2. Strattera currently has dosing limitations allowing one tablet per day for all strengths if obtain approval. Max daily dose of Strattera is 100mg. Please see dosing consolidation list. 3. Non-preferred products must be used in specified step order. 4. Please use generic Guanfacine. Use PA Form# 20710 for Provigil, Nuvigil and Xyrem Use PA Form# 20420 for all others ANTI-CATAPLECTIC AGENTS PSYCHOTHERAPEUTIC AGENTS - MISC. NUEDEXTA Use PA Form# 20710 for Xyrem XYREM SOL Use PA Form# 20710 for Xenazine XENAZINE WEIGHT LOSS Page 22 of 40 WEIGHT LOSS No longer covered: PHENTERMINE, XENICAL,DIDREX, and MERIDIA ALZHEIMER DISEASE ALZHEIMER Cholinomimetics/Others DONEPEZIL HYDROCHLORIDE TABS1 5 EXELON2 DONEPEZIL HYDROCHLORIDE ODT1 5 ARICEPT TABS NAMENDA1 5 ARICEPT ODT2 RAZADYNE2 8 8 9 2 RIVASTIGMINE TARTRATE CAPS2 COGNEX CAPS2 1. PA is required to establish dementia diagnosis and baseline mental status score. 2. Must fail all preferred products before moving to non-preferred. Use PA Form# 20420 SMOKING CESSATION NICOTINE PATCHES / TABLETS CHANTIX1,2,3 NICOTINE DIS PT24 NICODERM CQ PT243 Use PA Form# 20420 1. Chantix is preferred without PA for up to 6 months of continuous use once per lifetime. 2,3 2. Preferred nicotine replacement therapy and Chantix will become non-preferred and will require PA if they are being used in combination together. 3. Bupropion SR 150 mg is available without a prior authorization. NICOTINE REPLACEMENT OTHER NICOTINE POLACRILEX GUM2 5 COMMIT LOZENGES1,3,4 Use PA Form# 20420 8 NICOTROL INHALER3,4 8 NICOTROL NASAL SPRAY3,4 NICORETTE GUM 1. Will be available to patients unable to tolerate preferred products. 2. Preferred nicotine replacement therapy and Chantix will become non-preferred and will require PA if they are being used in combination together. 3. Must fail all preferred products from smoking cessation category (Nicoderm patch and nicotine gum) before moving to non-preferred. 4. Must use non-preferred products in specified step order. ALCOHOL DETERRENTS ALCOHOL DETERRENTS ANTABUSE TABS 1. Should only be used in conjunction with formal structured outpatient detoxification program. CAMPRAL1 DISULFIRAM TABS NALTREXONE HCL TABS Use PA Form# 20420 MISCELLANEOUS ANALGESICS ANALGESICS - MISC. ACETAMINOPHEN AXOCET CAPS ASPIRIN ESGIC-PLUS ASPRIN/ APAP/ CAFF TAB FIORICET TABS BUTAL/ASA/CAFF FIORINAL CAPS BUTALBITAL COMPOUND FIORTAL CAPS BUTALBITAL/ACET TABS FORTABS TABS BUTALBITAL/APAP CAPS PHRENILIN TABS BUTALBITAL/APAP/CAFFEINE PHRENILIN FORTE CAPS CHOLINE MAGNESIUM TRISALI TRILISATE LIQD DIFLUNISAL TABS TRILISATE TABS EXCEDRIN ZEBUTAL CAPS SALSALATE TABS Use PA Form# 20420 ZORPRIN TBCR LONG ACTING NARCOTICS NARCOTICS - LONG ACTING AVINZA 8 ABSTRAL Use PA Form# 20510 FENTANYL PATCH5 8 BUTRANS5 KADIAN6 METHADONE 8 8 DURAGESIC PT725 EMBEDA METHADOSE 8 EXALGO MORPHINE SULFATE ER TB12 8 MORPHINE SULFATE SUPP 1. Oxycontin will be available without PA for patients treated for or dying from cancer or hospice patients. CA (cancer) or HO (hospice) diag code may be used but store must verify since all scripts will be audited and stores will be liable. 8 MS CONTIN TB12 8 ORAMORPH SR TB12 8 OXYCONTIN TB121,4 Page 23 of 40 9 OXYCODONE ER3,7 9 OPANA ER7 2. Established users are grandfathered. 3. Oxycodone ER allowed only 2 per day for all strengths except 80 mg, where 4 are allowed to achieve max total daily dose of 320mg. 4. Oxycontin 15mg, 30mg & 60mg are new strengths. Any PA request for the new strengths will be required to use combinations of strengths that have previously been available (including 10mg, 20mg, 40mg, & 80mg tablets) to obtain requested dose. 5. Dosing limits apply. Please see dose consolidation list. 6. Kadian 10mg, 80mg & 200mg are non-preferred. 7. Non-preferred products must be used in specific order. NARCOTICS - SELECTED TRAMADOL HCL TABS 8 BUPRENEX SOLN Use PA Form# 20420 8 BUTORPHANOL 8 NALBUPHINE HCL SOLN 1. Only available if component ingredients are unavailable. 8 STADOL NS SOLN 8 8 ULTRACET TABS1 ULTRAM TABS 8 ULTRAM ER 9 RYZOLT MISCELLANEOUS NARCOTICS NARCOTICS - MISC. ACETAMINOPHEN/CODEINE 8 ASCOMP/CODEINE CAPS ASPIRIN/CODEINE TABS 8 BUTALBITAL/APAP/CAFFEINE/ CAPS BUTAL/ASA/CAFF/COD CAPS 8 DEMEROL BUTALBITAL/ASPIRIN/CAFFEI CAPS 8 DILAUDID 8 DILAUDID-HP SOLN CAPITAL/CODEINE SUSP CODEINE PHOSPHATE SOLN 8 FENTANYL CITRATE SOLN 8 FENTORA CODEINE SULFATE TABS 8 FIORICET/CODEINE CAPS ENDOCET TABS3 ENDODAN TABS 8 FIORINAL/CODEINE #3 CAPS 8 FIORTAL/CODEINE CAPS FENTANYL OT LOZ1 8 HYDROCODONE/IBUPROFEN HYDROCODONE BITARTRATE/AP TABS 8 LORCET HYDROCODONE/ACETAMINOPHEN 8 LORTAB HYDROMORPHONE HCL3 MEPERIDINE HCL 8 MAXIDONE TABS 8 NORCO TABS OXYCODONE 5MG 8 ONSOLIS OXYCODONE 15MG 8 OXYCODONE 10MG OXYCODONE 30MG 8 OXYCODONE 20MG OXYCODONE/ACETAMINOPHEN PENTAZOCINE/NALOXONE TABS 8 OXYCODONE/APAP 10/650 8 OXYCODONE/APAP 7.5/500 PROPOXYPHENE CMPND-65 CAPS 8 PENTAZOCINE/ACET TABS PROPOXYPHENE COMPOUND CAPS 8 PERCOCET TABS PROPOXYPHENE HCL CAPS 8 PERCOCET TABS PROPOXYPHENE/ACET TABS 8 PHRENILIN W/CAFFEINE/CODE CAPS PROPOXYPHENE-N/ACET TABS 8 ROXICET 5/500 TABS ROXICET 8 ROXICODONE TABS ROXIPRIN TABS 8 SYNALGOS-DC CAPS 8 TALACEN TABS 8 8 TREZIX TYLENOL/CODEINE #3 TABS 8 TYLOX CAPS 1 CAPITAL AND CODEINE SUSP 1 2,3 Page 24 of 40 1. Fentanyl OT loz (Barr) and Capital and codeine suspension products require PA for users over 18 years of age. PA is not required if under 18 years of age. 2. Oxycodone/acet 10/650 is 8 times more expensive. Use twice as many of oxycod/acet 5/325 instead. You can mix andmatch preferred strengths of oxycodone and oxycodone/acet to minimize acet. dose similar to certain non-preferred drugs. 3. Only preferred manufacturer's products will be available without prior authorization. OPIOID DEPENDENCE TREATMENTS SUBOXONE FILM2 8 VICODIN 8 VICOPROFEN TABS 8 ZYDONE TABS 9 ACTIQ LPOP 9 CONZIP 9 NUCYNTA ER 9 OPANA SUBOXONE TABS Use PA Form# 20420 Use PA Form# 20420 1 BUPRENORPHINE 1. Buprenophine will only be approved for use during pregnancy. 2. See Criteria Section NARCOTIC ANTAGONISTS NARCOTIC - ANTAGONISTS NALTREXONE HCL TABS REVIA TABS1 Use PA Form# 20420 VIVITROL INJ2 Use PA form# 30400 for Vivitrol requests 1. Will only be approved for side effects experienced with generic that are not described in the literature as occurring with the brand version. 2. Please see the criteria listed on the Vivitrrol PA form. Any narcotics attempting to be filled during Vivitrol approval will require prior authorization. COX 2 / NSAIDS COX 2 INHIBITORS SELECTIVE / HIGHLY SELECTIVE CELEBREX CAPS 4,5,6 KETOROLAC TROMETHAMINE 2,3,6 NABUMETONE TABS6 MOBIC6 Use PA Form# 10310 MOBIC SUSP6 RELAFEN TABS6 1. Meloxicam has dosing limits allowing one tablet daily of all strengths without PA. MELOXICAM1,6 2. Ketorolac Tromethamine is indicated for the short term (up to 5 days) managment of moderately severe acute pain that requires analgesic at the opiod level in adults. Not indicated for minor of chronic pain conditions. 3. Ketorolac has dosing limits allowing 24 tablets for a 5 day supply every 30 days. 4. Dosing limits will be set at a maximum of 200mg twice daily for PA requests. 5. Users 60 years of age or older will not require PA. If under 60 years of age, Celebrex will require PA. 6. The FDA has issued a Public Health Advisory warning of the potential for increased cardiovascular risk & GI bleeding with NSAID use. NSAIDS CHILDRENS IBUPROFEN ADVIL TABS DICLOFENAC POTASSIUM TABS ANAPROX TABS DICLOFENAC SODIUM ANAPROX DS TABS ETODOLAC CAMBIA FENOPROFEN CALCIUM TABS CATAFLAM TABS FLURBIPROFEN TABS CHILDRENS ADVIL SUSP IBUPROFEN CHILD'S IBUPROFEN SUSP INDOMETHACIN CHILDREN'S MOTRIN SUSP KETOPROFEN CLINORIL TABS MECLOFENAMATE SODIUM CAPS DAYPRO TABS NAPROSYN SUSP EC-NAPROSYN TBEC NAPROXEN SUSP ETODOLAC ER 600MG NAPROXEN TABS FELDENE CAPS NAPROXEN SODIUM TABS IBU-200 OXAPROZIN TABS INDOCIN SULINDAC TABS LODINE TOLMETIN SODIUM MOTRIN NALFON CAPS Page 25 of 40 The FDA has issued a Public Health Advisory warning of the potential for increased cardiovascular risk & GI bleeding with NSAID use. Use PA Form# 20420 NAPRELAN TBCR NAPROSYN TABS NAPROXEN DR TBEC NAPROXEN SODIUM TBCR PENNSAID PIROXICAM CAPS PONSTEL CAPS SB IBUPROFEN TABS SPRIX TOLECTIN VOLTAREN V-R IBUPROFEN TABS NSAID - PPI PREVACID NAPRA-PAC VIMOVO1 1. Use a preferred NSAID and PPI separately. Use PA Form# 20420 RHEUMATOID ARTHRITIS RHEUMATOID ARTHRITIS 1 AZATHIOPRINE ARAVA Use PA Form# 20900 1 HYDROXYCHLOROQUINE LEFLUNOMIDE ACTEMRA 1 1. Only one step 1 drug is required to obtain Enbrel or Humira without PA. 1 METHOTREXATE 1 2 SULFASALAZINE TABS ENBREL 1,4 2 1,2 HUMIRA CIMZIA KINERET SOLN ORENCIA REMICADE 2. Dosing limits apply. Please see dose consolidation list. SIMPONI 3. Preferred dosage form allowed without PA after trial of step 1 prodcuts is multi-dose vial, with dosing limits allowing 8 injections per 28 days without pa. 4. Established users will be grandfathered for Enbrel and Humira. MISCELLANEOUS ARTHRITIS ARTHRITIS - MISC. RIDAURA CAPS ARTHROTEC1 MYOCHRYSINE SOLN 1. The individual components of Arthrotec are available without PA. Use PA Form# 20420 LUPUS-SLE LUPUS-SLE BENLYSTA Use PA Form# 20420 MIGRAINE THERAPIES MIGRAINE - ERGOTAMINE DERIVATIVES MIGRANAL SOLN MIGRAINE - CARBOXYLIC ACID DERIVATIVES MIGRAINE - SELECTIVE SEROTONIN AGONISTS (5HT)-Tabs D.H.E. 45 SOLN Use PA Form# 10110 DIVALPROEX ER TB24 DEPAKOTE ER TB24 Use PA Form# 10110 MAXALT MLT1 NARATRIPTAN HCI TABS1 AMERGE TABS1,2 1. All drugs in this category have dosing limits. Please refer to dose consolidation table. SUMATRIPTAN TABS1 FROVA TABS1,2 SANSERT TABS MAXALT 1, AXERT TABS1,2 IMITREX TABS1,2 RELPAX1,2 1,2 ZOMIG TABS 2. Must fail all preferred products before nonpreferred. ZOMIG NASAL SPARY1,2 MIGRAINE - SELECTIVE SEROTONIN AGONISTS (5HT)-Injectables IMITREX KIT ZOMIG ZMT TBDP1,2 SUMATRIPTAN SOLN Use PA Form# 10110 TREXIMET1,2 Use PA Form# 10110 Use PA Form# 10110 IMITREX SOLN IMITREX STATDOSE PEN KIT IMITREX STATDOSE REFILL KIT MIGRAINE - SELECTIVE SEROTONIN AGONISTS (5HT)-Combinations 1. Dosing limits apply. Please see dose consolidation list. Page 26 of 40 SEROTONIN AGONISTS (5HT)-Combinations 2. Use preferred Sumatriptan and Naproxen separately. Treximet only available if component ingredients of sumatriptan and naproxen are unavailable. MIGRAINE - MISC. CAFERGOT TABS MIGRAZONE CAPS SPASTRIN TABS BELCOMP-PB SUPP Use PA Form# 10110 MIGERGOT SUP GOUT GOUT ALLOPURINOL TABS COLCRYS Use PA Form# 20420 COLCHICINE TABS ULORIC1 PROBENECID TABS ZYLOPRIM TABS 1. Failure of therapeutic (300mg) dose of Allopurinol (failure define as not being able to get uric acid levels below 6mg/dl) or severe renal disease. PROBENECID/COLCHICINE TABS MISC. ANESTHETICS - MISC. BUPIVACAINE HCL SOLN SENSORCAINE-MPF SOLN LIDOCAINE HCL SOLN MARCAINE SOLN SYNVISC INJ XYLOCAINE SOLN Use PA Form# 30130 ANTI-CONVULSANTS ANTICONVULSANTS CARBAMAZEPINE 8 BANZEL Use PA Form# 20420 CARBATROL CP12 8 DEPAKENE CELONTIN CAPS CLONAZEPAM TABS 8 8 DEPAKOTE DEPAKOTE ER All non-preferred meds must be used in specified order DEPAKOTE SPRINKLES CPSP 8 DIAZEPAM GEL 1. Quantity limit. 5/month DIASTAT DILANTIN 8 DIVALPROEX SODIUM SPRINKLE CAPS 8 EQUETRO 2. Dosing limits apply, please see dose consolidation list. DIVALPROEX SODIUM 8 HORIZANT EPITOL TABS ETHOSUXIMIDE SYRP 8 8 GRALISE GABITRIL TABS FELBATOL 8 KEPPRA TABS GABAPENTIN2 8 KEPPRA SOLN LAMOTRIGINE2 8 KLONOPIN TABS LEVETIRACETAM SOLN/TABS MYSOLINE TABS 8 8 LAMICTAL OXCARBAZEPINE PHENYTEK CAPS 8 LYRICA ONFI 8 PRIMIDONE TABS PHENYTOIN 8 SABRIL TEGRETOL 8 TOPAMAX TOPIRAMATE 8 TOPIRAMATE SPRINKLE CAPS2 TRILEPTAL SUSP 8 TOPAMAX SPRINKLE CAPS2 TRILEPTAL 1 3. Dosing limits apply per strength as well as a maximum daily dose of 600mg. Please see dose consolidation list. 4. Adjunctive therapy 17 and older. 3 VIMPAT4 VALPROIC ACID 8 8 ZARONTIN CAPS 9 KEPPRA XR 5,6 ZONISAMIDE 9 NEURONTIN 9 9 TEGRETOL-XR TB12 5,6 ZONEGRAN CAPS 9 LAMICTAL XR ZARONTIN SYRP 5. Current users as of 7/30/10 for seizures will be grandfathered. 6. Product is considered line extension of the original product due to Healthcare Reform (HCR). MaineCare will consider these medications nonpreferred and a step 9 because of the impact under the Federal Rebate Program in conjunction with HCR. BIPOLAR DISORDER: STEP ORDER M ~ A 4 ~ 4 4 ~ 4 4 ~ 4 4 ~ 4 4 ~ 4 5 ~ 5 SEE ANTICONVULSANT INDICATION CHART AT THE END OF THIS DOCUMENT M= Monotherapy A= Adjunctive 9= No Evidence CARBAMAZEPINE The step orders show the relative strength of VALPROATE evidence for use in bi-polar and will guide prior ATYPICAL ANTIPSYCHOTICS EXC. CLOZAPINE authorization determinations. Step 4 drugs-no PA required. TRILEPTAL LAMICTAL LITHIUM 9 ~ 6 TOPAMAX 9 ~ 7 KEPPRA TABS 9 ~ 8 GABITRIL TABS 9 ~ 9 NEURONTIN 9 ~ 9 ZONEGRAN CAPS Page 27 of 40 PEDIATRIC BIPOLAR1 DISORDER: STEP ORDER M ~ A (6-18 YEARS WITH OR WITHOUT PSYCHOSIS) 4 ~ 4 LITHIUM 4 ~ 4 CARBAMAZEPINE 4 ~ 4 VALPROATE 4 ~ 4 ATYPICAL ANTIPSYCHOTICS EXC.CLOZAPINE 4 ~ 4 LAMICTAL TRILEPTA 5 ~ 5 Two-step 1 preferred drugs must be tried before Trileptal. The step orders show the relative strength of evidence for use in bi-polar and will guide prior authorization determinations. Step 4 drugs-no PA required. ANTI-PARKINSON DRUGS PARKINSONS ANTICHOLINERGICS BENZTROPINE MESYLATE TABS Use PA Form# 20420 COGENTIN SOLN TRIHEXYPHENIDYL PARKINSONS - COMT INHIBITORS COMTAN TABS PARKINSONS - SELECTED DOPAMIN AGONISTS PRAMIPEXOLE 5 ROPINIROLE PARKINSONS DOPAMINERGICS/CARBII/ LEVO TASMAR TABS Use PA Form# 20420 MIRAPEX TABS1 REQUIP TABS Use PA Form# 20420 8 8 REQUIP XL TABS 8 MIRAPEX ER AMANTADINE HCL APOKYN3 BROMOCRIPTINE MESYLATE AZILECT2 CARBIDOPA/LEVODOPA TABS3 CARBIDOPA/LEVODOPA ER ELDEPRYL CAPS LARODOPA TABS PARLODEL CAPS SELEGILINE HCL PARLODEL TABS 1. As of 12/08 users of Mirapex will be grandfathered if diagnosis is Parkinsons. 1. Approvals will require concurrent therapy with Levodopa and failed trials of Selegiline, Comtan, and Stalevo. LODOSYN TABS SINEMET TABS 2. Approvals will require trials of Carbidopa/Levodopa, Selegiline, Comtan, and Stalevo. SINEMET TBCR ZELAPAR1 3. Only preferred manufacturer's products will be available without prior authorization. Use PA Form# 20420 PARKINSONS - COMBO. STALEVO Use PA Form# 20420 MUSCLE RELAXANTS ALS DRUG RILUTEK TABS MUSCLE RELAXANTS BACLOFEN TABS 7 ORPHENADRINE CITRATE CHLORZOXAZONE TABS CYCLOBENZAPRINE HCL TABS 8 8 AMRIX CARISOPRODOL TABS LIORESAL INTRATHECAL KIT 8 DANTRIUM CAPS METHOCARBAMOL TABS 8 LIORESAL TABS TIZANIDINE HCL TABS 8 NORFLEX TBCR 8 ROBAXIN-750 TABS 8 ZANAFLEX TABS 9 9 CYCLOBENZOPRINE ER SKELAXIN TABX 9 SOMA TABS Use PA Form# 20420 CARISOPRODOL/ASPIRIN TABS Use PA Form# 20420 MUSCLE RELAXANT - COMBO. Use PA Form# 20420 Non-preferred drugs will not be approved if members circumventing MaineCare prior authorization requirements by paying (prescribers failed to submit prior authorization prior to cash narcotic scripts being filled by member). Non-preferred products must be used in specified step order. CARISOPRODOL/ASPIRIN/CODE NORGESIC TABS ORPHENADRINE COMPOUND ORPHENADRINE/ASA/CAFF ORPHENGESIC VITAMINS VITAMINS ASCORBIC ACID TABS AQUASOL E SOLN Use PA Form# 20420 BIOTIN AQUAVIT-E SOLN Please refer to OTC list. CYANOCOBALAMIN SOLN DHT SOLN FOLIC ACID TABS NASCOBAL GEL MEPHYTON TABS NIACIN NIACOR TABS NICOTINIC ACID SR CPCR Page 28 of 40 PYRIDOXINE HCL TABS SLO-NIACIN TBCR THIAMINE HCL SOLN VITAMIN B-1 TABS VITAMIN B-12 VITAMIN B-6 TABS VITAMIN C VITAMIN E CAPS VITAMIN E/D-ALPHA CAPS VITAMIN K1 SOLN V-R VITAMIN E CAPS VITAMIN D's CALCITRIOL CAPS1 VITAMIN D DRISDOL CAPS ZEMPLAR TABS HECTOROL (ORAL) 1. Diagnosis of dialysis (renal failure) required. CALCIJEX Use PA Form# 20420 HECTOROL (PARENTERAL) ROCALTROL ZEMPLAR INJ MISC MULTI-VITAMINS VITAMINS - MISC. CENTRUM LIQD ADEKS CENTRUM TABS ADVANCED NATALCARE TABS 1. Diag codes are no longer required on prenatal vitamins. CENTRUM JR/IRON CHEW CENTRUM SILVER TABS AQUADEKS CENTRUM JR/EXTRA C CHEW Please refer to OTC list. CENTRUM-LUTEIN TABS CENTRUM PERFORMANCE TABS CEROVITE ADVANCED FO TABS DALYVITE LIQD CHEWABLE MULTIVIT/FL CHEW EMBREX 600 MISC COD LIVER OIL CAPS IBERET COMPLETE SENIOR TABS MATERNA TABS DAILY MULTI VIT/IRON MULTIRET FOLIC -500 TBCR DIALYVITE 1MG DIALYVITE 800MG NATAFORT TABS FULL SPECTRUM B NATALCARE GLOSS TABS1 M.V.I.-12 INJ NATALCARE PIC TABS1 MULTI-VIT/FLUORIDE NATALCARE PIC FORTE TABS1 NATALCARE RX TABS NATALCARE PLUS TABS1 NEPHRONEX NATALCARE THREE TABS1 NATACHEW CHEW NATALCARE CFE 60 TABS1 O-CAL PRENATAL ONE DAILY TABS NATALFIRST TABS ONE-DAILY MULTIVITAMINS NATATAB RX TABS ONE-TABLET-DAILY NEPHPLEX RX TABS POLY-VIT/IRON/FLUORID SOLN NEPHROCAPS CAPS POLY-VITAMIN/FLUORIDE SOLN NEPHRO-VITE TABS POLY-VITAMINS/IRON SOLN NESTABS RX TABS PRENATAL 19 CHEW 1 NIFEREX PRENATAL TABS OCUVITE TABS PRENATAL FORMULA 3 TABS1 POLY-VI-FLOR SOLN PRENATAL PLUS TABS1 POLY-VI-SOL SOLN PRENATAL PLUS NF TABS1 POLY-VI-SOL/IRON SOLN PRENATAL PLUS/27MG IRON1 POLY-VITAMIN DROPS SOLN PRENATAL PLUS/IRON TABS1 PRECARE PRENATAL RX/BETA-CAROTENE1 RENA-VITE RX TABS PREMESIS RX TABS RENAL CAPS PRENATAL CARE TABS1 RENAPHRO CAPS PRENATAL MR 90 TBCR1 STRESS TAB NF TABS PRENATAL MTR/SELENIUM TABS1 THERAPEUTIC-M TABS PRENATAL OPTIMA ADVANCE TABS1 THERAVITE LIQD PRENATAL PC 40 TABS1 TRI-VITAMIN/FLUORIDE SOLN PRENATAL RX TABS1 VITA CON FORTE CAPS PRENATE1 VITAMIN B COMPLEX CAPS PRENATE ELITE1 PRIMACARE MISC 1 VITAPLEX PLUS TABS PRENATABS CBF TABS1 Page 29 of 40 Use PA Form# 20420 PROTEGRA CAPS STUARTNATAL PLUS 3 TABS1 TRI-VI-SOL SOLN TRI-VI-SOL/IRON SOLN ULTRA NATALCARE TABS ULTRA-NATAL TABS1 VICON FORTE CAPS VINATAL FORTE TABS1 VINATE1 VINATE ADVANCED TABS1 MISCELLANEOUS MINERALS MINERALS CALCARB ANEMAGEN Use PA Form# 20420 CALCI-MIX CAPSULE CAPS CALCET TABS Please refer to OTC list. CALCIQUID SYRP CALCIUM 600-D TABS CALCITRATE/VITAMIN D TABS CALCIUM/VITAMIN D TABS CALCIUM CALTRATE 600 PLUS/VIT D TABS CALCIUM CARBONATE CALTRATE PLUS TABS CALCIUM CITRATE TABS CHROMAGEN CALCIUM GLUCONATE TABS CITRACAL PLUS TABS CALCIUM LACTATE TABS CONTRIN CAPS CALCIUM/MAGNESIUM TABS FEOGEN FORTE CAPS CALCIUM/VITAMIN D TABS FEROCON CAPS CALTRATE 600 TABS FERREX 150 CAPS CHEWABLE CALCIUM CHEW FERRO-SEQUELS TBCR CITRACAL TABS FE-TINIC CAPS CITRACAL + D TABS FE-TINIC 150 FORTE CAPS CITRUS CALCIUM TABS FLUOR-A-DAY SOLN CITRUS CALCIUM 1500 + D TABS K-DUR TBCR MC/DEL KLOR-CON PACK EFFERVESCENT POTASSIUM TBEF K-LYTE FEOSTAT CHEW K-PHOS TABS NEUTRAL FERATAB TABS K-TABS TBCR FER-GEN-SOL SOLN K-VESCENT PACK FER-IN-SOL SOLN MICRO-K 10 MEG CPCR FER-IRON SOLN NU-IRON 150 CAPS FERRONATE TABS OYSTER SHELL CALCIUM/VITA TABS FERROUS SULFATE POLY-IRON 150 CAPS FLUOR-A-DAY CHEW POLYSACCHARIDE IRON CAPS FLUORIDE CHEW POTASSIUM BICARB/CHLORIDE FLUORIDE SODIUM CHEW POTASSIUM CHLORIDE 10MEQ CAPS FLUORITAB CHEW POTASSIUM CHLORIDE 8MEQ CAPS HEMOCYTE TABS SLOW FE TBCR HM CALCIUM TABS TUMS 500 CHEW K+ POTASSIUM PACK VIACTIV CHEW KAON ELIX KAON-CL-10 TBCR KCL 0.075%/D5W/NACL 0.2% SOLN K-EFFERVESCENT TBEF KLOR-CON KLOTRIX TBCR K-PHOS TABS K-VESCENT TBEF LURIDE CHEW MAGNESIUM GLUCONATE TABS MAGNESIUM SULFATE SOLN MAGTABS MICRO-K 8 MEG OS-CAL TABS OS-CAL 500 + D TABS OYSCO Page 30 of 40 OYST-CAL TABS OYST-CAL D TABS OYST-CAL/VITAMIN D TABS OYSTER CALCIUM TABS OYSTER SHELL PHARMA FLUR PHOSPHA 250 NEUTRAL TABS POTASSIUM BICARBONATE TBEF POTASSIUM CHLORIDE 8MEQ POTASSIUM EFFERVESCENT SELENIUM TABS SLOW-MAG TBCR SODIUM FLUORIDE SSKI SOLN V-R CALCIUM V-R OYSTER SHELL CALCIUM ZINC SULFATE CAPS MISC. ELECTROLYTES/NUTRITIONALS ELECTROLYTES/ NUTRITIONALS INTRALIPID EMUL1 1. This list of nutritionals is incomplete. All nutritionals still require a PA except for the miscellaneous products listed as preferred. SGA form required for nutritionals unless member has a G/I tube. BOOST1 1 P.T.E. -5 SOLN CASEC POWD1 SEA-OMEGA CAPS1 CHOICE DM LIQD1 DELIVER 2.0 LIQD1 ENFAMIL1 ENSURE1 GLUCERNA1 ISOCAL LIQD1 KINDERCAL TF LIQD1 KINDERCAL TF/FIBER LIQD1 2. Formerly known as Omacor. L-CARNITINE CAPS1 LIPISORB LIQD1 Use PA Form# 20420 LOVAZA1,2 MODULEN IBD POWD1 & SGA Form 1 NUTRAMIGEN POWD NUTREN1 NUTRITIONAL SUPPLEMENT LIQD1 NUTRIVENT 1.5 LIQD1 PEPTAMEN1 PHENYLADE1 PHENYL-FREE1 PKU 3 POWD1 PREGESTIMIL POWD1 PROBALANCE LIQD1 PROSOBEE1 SCANDISHAKE PACK1 ERYTHROPOEITINS ERYTHROPOEITINS PROCRIT SOLN1 6 EPOGEN SOLN Use PA Form# 10520 8 ARANESP SOLN 1. Clinical PA is required to establish medical necessity and that appropriate lab monitoring is being done. GRANULOCYTE CSF GRANULOCYTE CSF 8 LEUKINE 1. Must be used in specified step order. 2 8 NEUPOGEN SOLN 9 NEULASTA1 2.10 day supply/month may be used without a PA. Use PA Form# 20520 ANTICOAGULANTS / PLATELET AGENTS ANTICOAGULANTS ARIXTRA SOLN1 COUMADIN TABS FRAGMIN INJ1 HEPARIN SODIUM/NACL 0.9% SOLN ENOXAPARIN HEP-LOCK SOLN FONDAPARINUX IPRIVASK Page 31 of 40 1. Arixtra, Fragmin and Lovenox therapy durations greater than 7 days require PA. INNOHEP LOVENOX 3002 LOVENOX SOLN1 WARFARIN SODIUM TABS PRADAXA3 XARELTO 2. Use other strengths available to obtain desired dose. HEPARIN LOCK SOLN HEPARIN LOCK FLUSH SOLN 3. Please refer to Pradaxa PA form for criteria HEPARIN SODIUM SOLN Use PA Form# 20420 HEPARIN SODIUM LOCK FLUSH SOLN Use PA form#20725 for Pradaxa requests JANTOVEN ANTIHEMOPHILIC AGENTS ALPHANATE ADVATE1,2 1. Only if other products unavailable. ALPHANINE SD BENEFIX SOLR HELIXATE FS KIT 2. Advate may be available with PA in cases of large volume dosing in patients with poor venous access. HEMOFIL - M HUMATE-P SOLR KOGENATE FS KONYNE - 80 MONARC - M Use PA Form# 20420 MONOCLATE - P MONONINE NOVOSEVEN SOLR PROFILNINE RECOMBINATE SOLR REFACTO PLATELET AGGREGATION INHIBITORS ASPIRIN 7 TICLOPIDINE HCL TABS DIPYRIDAMOLE TABS 8 8 BRILINTA1,2 CLOPIDOGREL 75MG 8 EFFIENT2 PERSANTINE TABS 8 PLAVIX TABS1 Use PA Form# 20715 for Plavix, Effient & Brilinta Use PA form# 20420 for other requests 1. A special PA may be obtained at the pharmacy for members scheduled for "stent" placement or have had placement if in the last 12months. Please indicate on prescription date of stent placement. 2. Dosing limits apply, please see dose consolidation list PLATELET AGGR. INHIBITORS / COMBO'S - MISC. AGGRENOX AGRYLIN CAPS CILOSTAZOL PLETAL TABS PENTOXIFYLLINE ER TBCR TRENTAL TBCR Use PA Form# 20420 HEMATOLOGICALS MONOCLONAL ANTIBODY SOLIRIS BRADYKININ B2 RECEPTOR ANTAGONIST FIRAZYR HEMATOLOGICAL AGENTSTHROMBOPOIETIN RECEPTOR AGONISTS 7 8 PROMACTA NPLATE Use PA Form# 20420 Use PA Form# 20420 Use PA Form# 20420 HEMOSTATIC HEMOSTATIC AMICAR Use PA Form# 20420 AMINOCAPROIC ACID OPHTHALMICS OP. - ANTIBIOTICS AK-SPORE OINT AK-POLY-BAC OINT BACITRACIN OINT AK-SULF OINT BACITRACIN/NEOMYCIN/POLYM AK-TOB SOLN BACITRACIN/POLYMYXIN B OINT AZASITE CHLOROPTIC SOLN BLEPH-10 SOLN ERYTHROMYCIN OINT GENTAK GENTAMICIN SULFATE ILOTYCIN OINT NEOMYCIN/POLYMYXIN/GRAMIC NEOMYCIN/BACI/POLYM OINT NEOSPORIN SOLN NEOSPORIN OINT POLYSPORIN OCUSULF-10 SOLN SODIUM SULFACETAMIDE SOLN OCUTRICIN SOLN SULFACETAMIDE SODIUM TERAK OINT TOBRAMYCIN SULFATE SOLN TOBREX OINT Page 32 of 40 Use PA Form# 20420 TRIMETHOPRIM SULFATE/POLY TRIFLURIDINE SOLN VIROPTIC SOLN OP. - QUINOLONES CILOXAN OINT CIPROFLOXACIN SOL 0.3% BESIVANCE CILOXAN SOLN OFLOXACIN OCUFLOX SOLN Use PA Form# 20420 QUIXIN SOLN OP.QUINOLONES-4TH GENERATION VIGAMOX MOXEZA ZYMAXID Use PA Form# 20420 OP. - ARTIFICIAL TEARS AND LUBRICANTS AKWA TEARS OINT AKWA TEARS SOLN Use PA Form# 20420 ARTIFICIAL TEARS OINT ARTIFICIAL TEARS SOLN OP ARTIFICIAL TEARS SOLN BION TEARS SOLN 1. Dosing limits apply, please see dose consolidation list. CELLUVISC SOLN DRY EYES OINT EYE LUBRICANT OINT DURATEARS OINT GENTEAL HYPO TEARS LIQUITEARS SOLN ISOPTO TEARS SOLN MAJOR TEARS SOLN LACRI-LUBE PURALUBE OINT LUBRIFRESH P.M. OINT PURALUBE TEARS SOLN MURINE SOLN REFRESH SOLN OP MUROCEL SOLN REFRESH PLUS SOLN1 NATURE'S TEARS SOLN REFRESH PM OINT REFRESH SOLN REFRESH TEARS SOLN1 SYSTANE TEARGEN SOLN TEARISOL SOLN TEARS NATURALE TEARS PURE SOLN TEARS RENEWED OINT THERATEARS SOLN V-R ARTIFICIAL TEARS SOLN OP. - BETA - BLOCKERS BETOPTIC-S SUSP BETAGAN SOLN CARTEOLOL HCL SOLN BETAXOLOL HCL SOLN LEVOBUNOLOL HCL SOLN BETIMOL SOLN METIPRANOLOL SOLN TIMOLOL MALEATE SOLG (GEL) ISTALOL OCUPRESS SOLN TIMOLOL MALEATE SOLN OPTIPRANOLOL SOLN Use PA Form# 20420 TIMOPTIC SOLN TIMOPTIC-XE SOLG OP. - ANTI-INFLAMMATORY / STEROIDS OPHTH. AK-SPORE HC OINT AK-TROL SUSP ALREX SUSP BAC/POLY/NEOMY/HC OINT BLEPHAMIDE SUSP BLEPHAMIDE S.O.P. OINT DEXAMETH SOD PHOS SOLN BROMDAY FLAREX SUSP EFLONE SUSP FLUOROMETHOLONE SUSP FLUOR-OP SUSP FML S.O.P. OINT NEOM/POLIN/DEX LOTEMAX SUSP MAXITROL PRED MILD SUSP NEO/POLY/BAC/HC OINT PREDNISOLONE OZURDEX TOBRADEX PRED FORTE SUSP Use PA Form# 20420 PRED-G SUSP PRED-G S.O.P. OINT SULFACET SOD/PRED SOLN TOBRADEX ST TOBRAMYCIN SUSP DEXAMETHASONE VASOCIDIN SOLN VEXOL SUSP OP. - PROSTAGLANDINS 7 XALATAN SOLN1 1. All preferreds must be tried. 8 LUMIGAN SOLN1 TRAVATAN SOLN Use PA Form# 20420 AK-PENTOLATE SOLN CYCLOGYL SOLN Use PA Form# 20420 ATROPINE SULFATE ISOPTO ATROPINE SOLN CYCLOPENTOLATE HCL SOLN ISOPTO HOMATROPINE SOLN LATANOPROST SOL 0.005% TRAVATAN-Z 1 8 OP. - CYCLOPLEGICS Page 33 of 40 ISOPTO HYOSCINE SOLN OP. - MIOTICS - DIRECT ACTING MUROCOLL-2 SOLN ISOPTO CARBACHOL SOLN Use PA Form# 20420 ISOPTO CARPINE SOLN PILOCAR SOLN PILOCARPINE HCL SOLN PILOPINE HS GEL OP. - ADRENERGIC AGENTS DIPIVEFRIN HCL SOLN PROPINE SOLN Use PA Form# 20420 ALPHAGAN SOLN Use PA Form# 20420 EPIFRIN SOLN OP. - SELECTIVE ALPHA ADRENERGIC AGONISTS ALPHAGAN P SOLN BRIMONIDINE 0.2% IOPIDINE SOLN OP. - ANTI-ALLERGICS PATADAY SOLN 8 ALOCRIL SOLN PATANOL SOLN 8 ALOMIDE SOLN 8 BEPREVE 8 ELESTAT 8 EMADINE SOLN 8 LASTACAFT 8 OPTIVAR 8 OPTICROM SOLN 8 ZADITOR SOLN 9 EPINASTINE OP. ANTI-ALLERGICSMASTCELL STABILIZER CLASS OP. - CARBONIC ANHYDRASE INHIBITORS/COMBO Use PA Form# 20420 ALAMAST SOLN Use PA Form# 20420 AZOPT SUSP COSOPT SOLN Use PA Form# 20420 COMBIGAN TRUSOPT SOLN DORZOLAMIDE DORZOLAMIDE/TIMOLOL OP. - NSAID'S FLURBIPROFEN SODIUM SOLN 8 ACULAR LS1 DICLOFENAC OPTH 0.1% 8 ACULAR SOLN1 KETOROLAC OPTH 0.4% 8 OCUFEN SOLN1 KETOROLAC OPTH 0.5% 8 NEVANAC1 8 XIBROM1 8 VOLTAREN SOLN1 8 ACUVAIL1 BROMFENAC 9 OP. - OF INTEREST ENUCLENE SOLN BOTOX SOLR 1 RESTASIS 1. Must fail all preferred products before nonpreferred. Use PA Form# 20420 1. Must have kerato conjuctivitus sicca and failed other dry eye therapies. Use PA Form# 20420 DERMATOLOGICAL TOPICAL - ORAL 1. Users 24 or under, PA will not be required. AMNESTEEM1 1 CLARAVIS SOTRET1 TOPICAL - ACNE PREPARATIONS Use PA Form# 20420 AZELEX CREA ACZONE BENZOYL PEROXIDE ALTINAC CREA CLINDAMYCIN PHOSPHATE 2 AVITA CREA ERYDERM SOLN ERYTHROMYCIN GEL BENZAC ERYTHROMYCIN PADS BENZACLIN GEL3 BENZAGEL-10 GEL ERYTHROMYCIN SOLN BENZAMYCIN GEL ISOTRETINOIN BENZAMYCINPAK PACK METRONIDAZOLE CREA2 METRONIDAZOLE GEL 1. Users 24 or under, PA will not be required. 2. Dosing limits allowing one package per month. Please refer to Dose Consolidation List. 3. Only available if component ingredients are unavailable. BENZEFOAM BREVOXYL 2 2 METRONIDAZOLE LOTN SODIUM SULFACET/SULF LOTN CLEOCIN-T2 CLINAC BPO GEL TAZORAC CLINDAGEL GEL Use PA Form# 10220 for Brand Name requests CLINDETS SWAB TRETINOIN GEL1 1,2 TRETINOIN CREA DESQUAM-E GEL DESQUAM-X DIFFERIN 0.3% GEL DIFFERIN DUAC GEL Page 34 of 40 Use PA Form# 20420 for all other requests EMGEL GEL EPIDUO ERYCETTE PADS EVOCLIN FINEVIN CREA KLARON LOTN METROCREAM CREA2 METROGEL GEL2 METROLOTION LOTN2 NEOBENZ MICRO NORITATE CREA RETIN-A GEL2 RETIN-A MICRO GEL RETIN-A CREA2 TRIAZ VELTIN ZENCIA WASH ZETACET ZIANA TOPICAL - ANTIBIOTIC BACIT/NEOMYCIN/POLYM OINT ALTABAX 1 BACTROBAN OINT. BACITRACIN OINT 1. Dosing limits apply, please see dosing consolidation list. TRIPLE ANTIBIOTIC OINT BACTROBAN CREA1 BACTROBAN NASAL OINT Use PA Form# 20420 CENTANY OINT 2% 1 GENTAMICIN SULFATE MUPIROCIN1 TOPICAL - ANTIFUNGALS BETAMETHASONE CLOTRIMAZOLE LOT CICLOPIROX 0.77 CREA 8 BETAMETHASONE CLOTRIMAZOLE CREA CICLOPIROX 0.77 SUSP 8 8 CICLOPIROX SOLN EXELDERM CLOTRIMAZOLE 8 FUNGIZONE CREA ECONAZOLE NITRATE CREA KETOCONAZOLE CREA 8 HYDROCORT/IODOQ CREA 8 LAMISIL LOPROX 1.0 CREA 8 LOPROX 0.77 LOTN LOPROX 1.O LOTN 8 LOPROX 0.77 CREA LOPROX GEL 8 LOPROX 0.77 SUSP LOPROX TS LOTN 8 LOPROX SHAMPOO SHAM LOTRISONE CREA 8 LOTRIMIN MICONAZOLE NITRATE CREA 8 LOTRISONE LOT MYCO-TRIACET II CREA 8 MENTAX CREA NIZORAL SHAM 8 MYCOGEN II CREA NYSTATIN 8 NAFTIN NYSTATIN/TRIAMCINOLONE 8 NYSTAT-RX POWD NYSTOP POWD 8 OXISTAT PEDI-DRI POWD 9 PENLAC NAIL LACQUER SOLN Use PA Form# 10120 TINACTIN TRI-STATIN II CREA TOPICAL - ANTIPRURITICS ZONALON CREA PRUDOXIN CREA Use PA Form# 20420 TOPICAL - ANTIPSORIATICS DOVONEX OXSORALEN ULTRA CAPS1 SORIATANE CAPS PSORIATEC CREA1 1. Must fail all preferred products before nonpreferred. TAZORAC SORIATANE CK KIT1 TACLONEX1,2 VECTICAL1 2. Individual ingredients are available as preferred witout PA. Use PA Form# 20420 TOPICAL - ANTISEBORRHEICS SELENIUM SULFIDE SHAM CARMOL SCALP TREATMENT KIT Use PA Form# 20420 ZNP BAR TOPICAL - ANTIVIRALS DENAVIR CREA1, 3 1. Must fail oral treatment with Acyclovir or Valtrex. ZOVIRAX OINT1,2 2. Approvals limited to 1 tube per 180 days. Page 35 of 40 3. Dosing limits apply, please see dosing consolidation list. Use PA Form# 20420 TOPICAL - ANTINEOPLASTICS EFUDEX CARAC CREA FLUOROPLEX CREA FLUOROURACIL Use PA Form# 20420 SOLARAZE GEL ZYCLARA TOPICAL - BURN PRODUCTS FURACIN CREA SILVADENE CREA Use PA Form# 20420 SSD CREA THERMAZENE CREA LOW POTENCY ACLOVATE Use PA Form# 20420 DESOWEN AMCINONIDE CREA HYDROCORTISONE CREA ANUSOL HC-1 OINT HYDROCORTISONE LOTN CLOBEX LACTICARE-HC LOTN CLODERM CREA NUTRACORT LOTN CORDRAN TEXACORT SOLN CORMAX SILVER SULFADIAZINE CREA SSD AF CREA TOPICAL - CORTICOSTEROIDS CUTIVATE CREA / OINT MEDIUM POTENCY CUTIVATE LOTN DESOXIMETASONE .05% DERMATOP ELOCON DESONATE GEL FLUOCINOLONE ACETONIDE .025-.01% DIPROLENE FLUROSYN CREA ELOCON OINT FLUTICASONE PROPIONATE CREA/OINT HYDROCORTISONE POWD HYDROCORTISONE BUTYRATE KENALOG AERS HYDROCORTISONE OINT LIDA MANTLE HC CREA HYDROCORTISONE VALERATE LOCOID MOMETASONE FUROATE OINT LUXIQ FOAM TRIAMCINOLONE ACETONIDE .025-.1% OLUX FOAM PANDEL CREA HIGH POTENCY PROCTOCORT CREA BETAMETHASONE DIPROPIONATE PSORCON DESOXIMETASONE .25% PSORCON E DESONIDE TEMOVATE FLUOCINOLONE ACETONIDE .02% TOPICORT FLUOCINONIDE TOPICORT LP CREA HALOG ULTRAVATE HALOG-E CREA VERDESO TRIAMCINOLONE ACETONIDE .5% WESTCORT VERY HIGH POTENCY AUGMENTED BETA DIP BETAMETHASONE VALERATE BETA-VAL CLOBETASOL PROPIONATE DIFLORASONE DIACETATE HALOBETASOL MISCELLANEOUS CAPEX SHAM DERMA-SMOOTHE/FS OIL PROCTO-KIT CREA 1% TOPICAL - STEROID LOCAL ANESTHETICS EPIFOAM FOAM Use PA Form# 20420 TOPICAL - STEROID COMBINATIONS DERMA-SMOOTHE/FS ATOPIC P KIT CARMOL-HC CREA Use PA Form# 20420 TOPICAL - EMOLLIENTS AMMONIUM LACTATE LOTN 12% AMMONIUM LACTATE CREA Use PA Form# 20420 LAC-HYDRIN CREA LAC-HYDRIN LOTN 12% UREACIN-20 CREA MEDERMA GEL VITAMIN A & D MEDICATED OINT MIMYX RENOVA CREA Page 36 of 40 TOPICAL - ENZYMES / KERATOLYTICS / UREA GRANUL-DERM AERS CARMOL 40 CREA Use PA Form# 20420 GRANULEX AERS SALEX CREA TBC AERS SALEX LOTN Ziox, Panafil and Papain products have been removed from the PDL due to FDA safety concerns regarding drugs containing Papain. 5 PODOFILOX SOLN Use PA Form# 20420 8 ALDARA 1. Non-preferred products must be used in specified order. SANTYL OINT TOPICAL - GENITAL WARTS IMIQUIMOD2 TOPICAL IMMUNOMODULATORS 8 CONDYLOX 8 PICATO2 8 VEREGEN1 8 ZYCLARA1 8 ELIDEL CREA1 Use PA Form# 20420 9 PROTOPIC OINT1,2 1. Non-preferred products must be used in specified order. 1 2. Dosing limits still apply. Please see dose consolidation list 2. The FDA has issued a Public Health Advisory for both Elidel and Protopic concerning the potential cancer risk associated with their use. Use for children less than 2 years of age is not recommended. TOPICAL - LOCAL ANESTHETICS AF CAPSICUM OLEORESIN CREA EMLA PADS CAPSAICIN CREA EMLA CREA ELA-MAX1 LIDA MANTLE CREA LIDOCAINE/PRILOCAINE CREA1 XYLOCAINE LIDODERM PTCH 1. Lidocaine/Prilocaine cream and Ela-Max products require PA for users over 18 years of age. PONTOCAINE SOLN SYNERA Use PA Form# 20420 ZOSTRIX TOPICAL - DEPIGMENTING AGENTS TOPICAL - SCABICIDES AND PEDICULICIDES 8 ALUSTRA CREA 8 EPIQUIN MICRO 8 GLYQUIN CREA 8 HYDROQUINONE CREA 8 HYDROQUINONE/SUNSCREENS 8 SOLAQUIN FORTE CREA 8 TRI-LUMA CREA 9 ELDOQUIN Not covered for cosmetic purposes. Use PA Form# 20420 ACTICIN CREA LINDANE Use PA Form# 20420 ELIMITE CREA EURAX MALATHION 1. Dosing limits apply, please see dosing consolidation list LICE KILLING SHAM NATROBA1 OVIDE LOTN LICE TREATMENT CREME RINS LIQD ULESFIA PERMETHRIN LOTN TOPICAL - WOUND / DECUBITUS CARE TOPICAL - ASTRINGENTS / PROTECTANTS REGRANEX GEL Use PA Form# 20420 REGENECARE RADIAPLEXRX Accuzyme and Ethezyme products have been removed from the PDL due to FDA concerns regarding drugs containing Papain. ALUMINUM CHLORIDE SOLN LOWILA BAR Use PA Form# 20420 DRYSOL SOLN MOISTURIN DRY SKIN CREA XERAC AC SOLN PROSHIELD PLUS SKIN PROTE CREA SURGILUBE GEL TOPICAL - ANTISEPTICS / DISINFECTANTS PHISOHEX LIQD BETADINE OINT POVIDONE-IODINE SOLN FORMALYDE-10 AERS Use PA Form# 20420 IODOSORB LAZERFORMALYDE SOLUTION SOLN MISCELLANEOUS EYE OP. - EYE AK-DILATE SOLN LENS PLUS REWETTING DROPS EYE WASH SOLN MURO 128 NAPHAZOLINE HCL SOLN NEO-SYNEPHRINE SOLN Use PA Form# 20420 PHENYLEPHRINE HCL SOLN PONTOCAINE SOLN SODIUM CHLORIDE MISCELLANEOUS EAR EAR A/B OTIC SOLN AERO OTIC HC SOLN ACETASOL SOLN ANTIBIOTIC EAR SOLN Page 37 of 40 Use PA Form# 20420 ACETASOL HC SOLN ANTIBIOTIC EAR SUSP ACETIC ACID AURALGAN SOLN ACETIC ACID/HYDROCORTISON CIPRO HC SUSP ALLERGEN SOLN COLY-MYCIN-S SUSP ANTIPYRINE/BENZOCAINE SOLN CORTISPORIN-TC SUSP AURODEX SOLN DEBROX SOLN AUROGUARD SOLN PEDIOTIC SUSP AUROTO OTIC SOLN VOSOL-HC SOLN CARBAMIDE PEROXIDE 6.5% OTIC SOLN. ZOTANE HC SOLN CIPRODEX CORTISPORIN SOLN ZOTO-HC SOLN CORTOMYCIN EAR DROPS SOLN EAR DROPS RX SOLN EAR WAX REMOVAL DROPS EAR-GESIC SOLN NEOMYCIN/POLYMYXIN/HC OFLOXACIN 0.3% OTIC OTICAINE OTIC SOLN MOUTH ANTISEPTICS MOUTH ANTI-INFECTIVES NILSTAT SUSP MYCELEX TROC EAR-GESIC SOLN ORAVIG Use PA Form# 20420 NYSTATIN SUSP MOUTH ANTISEPTICS CHLORHEXIDINE GLUCONATE Use PA Form# 20420 APHTHASOL PSTE1 LIDOCAINE VISCOUS SOLN 1 PERIOGARD SOLN TRIAMCINOLONE IN ORABASE PSTE 1 TRIAMCINOLONE ACETONIDE PSTE 1. Must fail all preferred products before nonpreferred. TRIAMCINOLONE ORADENT PSTE DENTAL PRODUCTS DENTAL PRODUCTS ETHEDENT CREA APF GEL GEL GEL-KAM CONC DENTAGEL GEL GEL-KAM GEL 0.4% PHOS-FLUR GEL PHOS FLUR SOLN PREVIDENT CREA PREVIDENT GEL THERA-FLUR-N GEL Use PA Form# 20420 PREVIDENT SOLN SF 5000 PLUS CREA SF GEL STANNOUS FLUORIDE ORAL RI CONC ARTIFICIAL SALIVA/STIMULANTS ARTIFICIAL SALIVA/STIMULANTS SALIVA SUBSTITUTE SOLN EVOXAC CAPS Use PA Form# 20420 RADIACARE SOLR SALAGEN TABS MISCELLANEOUS ANORECTAL ANORECTAL - MISC. COLOCORT ENEM ANUSOL-HC CREA CORTENEMA ENEM CORTIFOAM FOAM ELA-MAX 5 CREA PROCTOCREAM-HC CREA HYDROCORTISONE ENEM PROCTOFOAM HC FOAM PROCTOZONE-HC CREA PROCTO-KIT CREA 2.5% Use PA Form# 20420 PROCTOSOL HC CREA T-CELL ACTIVATION INHIBITOR PSORIASIS BIOLOGICALS ENBREL1 1 HUMIRA AMEVIVE2 STELARA 1. Will not require a PA if at least one systemic drug such as methotrexate, cyclosporine, methoxsalen or acitretin is in members drug profile. Please refer to dose consolidation list. 2. Trial of both preferred drugs are required. 3. Preferred dosage form allowed without PA after trial of step 1 prodcuts is multi-dose vial, with dosing limits allowing 8 injections per 28 days without pa. Page 38 of 40 Use PA Form# 20910 ALTERNATIVE MEDICINES ALTERNATIVE MEDICINES DIMETHYL SULFOXIDE SOLN CO-ENZYME Q-10 Use PA Form# 20420 MELATONIN TABS CHELATING AGENTS CHELATING AGENTS CUPRIMINE CAPS DEPEN TITRATABS TABS Use PA Form# 20420 EXJADE1 1. FDA indication of treatment of chronic iron ovrload due to blood transfustions in membes 2 years of age and older is requried for approval of Exjade. ANTILEPROTIC ANTILEPROTIC THALOMID CAPS1 1. All PA requests for 150mg dosing will require use of Thalomid 100mg and 50mg capsules. Use PA Form# 20420 ANTINEOPLASTIC AGENTS ANTINEOPLASTIC AGENTS ANTIADNDROGENS BICALUTAMIDE CASODEX Use PA Form# 20420 ANTINEOPLASTIC AGENTSLHRH ANALOGS LUPRON DEPOT1 VANTAS2 1. Dosing limits apply, please refer to dosage consolidation list. FIRMAGON2 TRELSTAR 2. PA required to confirm FDA approved indication. Use PA Form# 20420 ANTINEOPLASTIC AGENTS TYROSINE KINASE INHIBITORS SPRYCEL 1 Use PA Form# 20420 1. Verification of diagnosis is required. 2 TYKERB 1 GLEEVEC 2. PA required to confirm FDA approved indication and to monitor for potential drug-drug interactions. ANTINEOPLASTICSMISCELLANEOUS AMIFOSTINE MERCAPTOPURINE ETHYOL PURINETHOL Use PA Form# 20420 ZOLINZA ANTINEOPLASTICSMONOCLONAL ANTIBODIES HERCEPTIN1 1. PA required to confirm FDA approved indication. Use PA Form# 20420 CANCER CANCER ALIMTA ARIMIDEX ANASTROZOLE TABS FOLOTYN AVASTIN INLYTA ERBITUX NEXAVAR1 LETROZOLE SUTENT1,2 ZELBORAF VIDAZA 1. PA required to confirm FDA approved indication 2. Avoid CYP3AY drug drug interaction. SYLATRON FEMARA YERVOY ZYTIGA Use PA Form# 20420 IMMUNOSUPPRESSANTS IMMUNOSUPPRESSANTS CYCLOSPORINE MODIFIED CELLCEPT CYCLOSPORINE SOL. MODIFIED GENGRAF CAPS CYCLOSPORINE CAPS NEORAL1,2 1. Established users will require a one time PA. 2. Established users will require a one time PA MYCOPHENOLATE MYFORTIC Use PA Form# 20420 PROGRAF CAPS RAPAMUNE SANDIMMUNE PURINE ANALOG PURINE ANALOG AZASAN TABS IMURAN TABS AZATHIOPRINE TABS K REMOVING RESINS Page 39 of 40 Use PA Form# 20420 K REMOVING RESINS KAYEXALATE POWD Use PA Form# 20420 KIONEX POWD SODIUM POLYSTYRENE SULFON SPS SUSP SPS 30GM/120ML ENEMA SUSP New drugs are initially non-preferred until reviewed by the DUR Committee and the State. According to State policy, any drug requiring specific diagnosis still requires the specific diagnosis unless otherwise noted within this document. ANTI-CONVULSANTS INDICATION CHART SEIZURES POST HERPETIC NEURALGIA DIABETIC PERIPHERAL NEUROPATHY MONOTHERAPY BIPOLAR ADJUNCTIVE BIPOLAR GABITRIL X 9 8 LAMICTAL X 4 4 LYRICA X TOPAMAX X 9 6 TRILEPTAL X 5 5 X(2nd line) MIGRAINE PROPHYLAXIS X(2nd line) X(2nd line) X (2nd line) PEDIATRIC ANTI-CONVULSANTS INDICATION CHART SEIZURES MONOTHERAPY BIPOLAR LITHIUM FIBROMYALGIA ADJUNCTIVE BIPOLAR 1 1 CARBMAZEPINE X 1 1 VALPROATE X 1 1 ATYPICAL ANTIPSYCHOTICS EXC. CLOZAPINE X 1 1 LAMICTAL X 1 1 TRILEPTAL X 5 5 CLOZAPINE X 6 6 Page 40 of 40
