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Transcript
PDL Effective September 2013 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, placebocontrolled 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 AUGMENTIN1 AMOXICILLIN/POTASSIUM CLA CHEW AUGMENTIN XR TB12 2 1. Chewable 125mg & 250mg and Solution 125mg/5ml and 250mg/5ml available without PA. AMOXICILLIN/POTASSIUM CLA SUSR AMOXICILLIN/POTASSIUM CLA TABS 2. Use preferred generic amoxicillin/clavulanate potassium alternatives. AMPICILLIN BICILLIN L-A SUSP DICLOXACILLIN SODIUM CAPS Use PA Form# 20420 OXACILLIN SODIUM SOLR PENICILLIN V POTASSIUM TIMENTIN SOLR UNASYN SOLR ZOSYN CEPHALOSPORINS CEFADROXIL HEMIHYDRATE CEDAX CEFAZOLIN SODIUM SOLR CEFACLOR1 CEFADROXIL MONOHYDRATE TABS CEFDINIR CEFEPIME HCI CEFPODOXIME CEFTIN FORTAZ CEFPROZIL FORTAZ SOLN CEFTAZIDIME 6MG KEFLEX CAPS Page 1 of 41 1. Both brand and generic are clinically nonpreferred. CEFTIN SUSP OMNICEF CEFTRIAXONE ROCEPHIN CEFUROXIME AXETIL TABS SUPRAX CEPHALEXIN MONOHYDRATE TAZICEF SOLR FORTAZ SOLR TEFLARO Use PA Form# 20420 TAZICEF 6GM MACROLIDES / ERYTHROMYCIN'S BIAXIN XL1 AZITHROMYCIN TABS AZITHROMYCIN POW BIAXIN AZITHROMYCIN SUSP CLARITHROMYCIN SUSP E.E.S. CLARITHROMYCIN TABS ERYPED 200 SUSR ERYPED 400 SUSR DIFICID PCE TBEC ERY-TAB TBEC ZITHROMAX TABS ERYTHROCIN STEARATE TABS ZITHROMAX 1GM PAK ERYTHROMYCIN ZITHROMAX TRI-PAK 1. 7- Day supply per month without PA. Use PA Form# 20420 ZITHROMAX SUSP ZMAX TETRACYCLINES DOXYCYCLINE HYCLATE DECLOMYCIN TABS MINOCYCLINE HCL CAPS DORYX CPEP TETRACYCLINE HCL CAPS DOXYCYCLINE MONO CAPS VIBRAMYCIN SYRP DYNACIN CAPS 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 TOBI PODHALER1 1. Clinical PA to verify appropriate diag NEOMYCIN SULFATE TABS TOBI NEBU Use PA Form# 20420 TOBRAMYCIN SULFATE SOLN ANTI-MYCOBACTERIALS / ANTITUBERCULOSIS ETHAMBUTOL HCL TABS Use PA Form# 20420 MYAMBUTOL TABS MYCOBUTIN CAPS RIFAMPIN ANTIMALARIAL AGENTS CHLOROQUINE PHOSPHATE TABS ARALEN TABS Use PA Form# 20420 DARAPRIM TABS HYDROXYCHLOROQUINE TABS ISONARIF1 MALARONE TABS 1. Ingredients available as preferred without PA. MEFLOQUINE HCL TABS PLAQUENIL TABS QUININE SULFATE ANTHELMINTICS ALBENZA TABS Use PA Form# 20420 BILTRICIDE TABS STROMECTOL TABS ANTIBIOTICS - MISC. AZACTAM SOLR COLISTIMETHATE SODIUM SOLR COLY-MYCIN-M SOLR CAYSTON4 FLAGYL CAPS FUROXONE TABS METRONIDAZOLE PENTAMIDINE ISETHIONATE SOLR FLAGYL TABS PRIMSOL SOLN KETEK TRIMETHOPRIM TABS METRONIDAZOLE 375MG CAPS2 VANCOMYCIN 5GM INJ. METRONIDAZOLE 750MG TABS2 NEBUPENT SOLR 2 FLAGYL ER TBCR TINDAMAX1 Page 2 of 41 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. VANCOMYCIN 10GM INJ. XIFAXAN 3. Please use multiple 5gm which are preferred to obtain dose without PA. 3 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 1 1. Use multiple 150's for Clindamycin instead of 300's. CLINDAMYCIN HCL 150CAPS CLINDAMYCIN HCL 300CAPS 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 SEPTRA/DS TABS SULFAMETHOXAZOLE/TRIMETH TRIMETHOPRIM/SULFAMETHOXA ANTIPROTOZOALS ALINIA 1 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 FLUCONAZOLE1 GRIFULVIN V TABS10 GRISEOFULVIN SUSP 10 GRISEOFULVIN ULTRAMICROSI TABS10 GRIS-PEG TABS 10 KETOCONAZOLE TABS NYSTATIN TERBINAFINE TABS4 8 6 SPORANOX SOLN2 6 SPORANOX PULSEPAK CAPS3 7 SPORANOX CAPS3 8 ERAXIS INJ6 8 DIFLUCAN 8 GRIFULVIN SUSP 8 8 ONMEL 8 NOXAFIL5 VFEND TABS 8 ITRACONAZOLE 1. QL--1/every 7-day period (150mg only). 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 ANTIRETROVIRALS APTIVUS ANTI - VIRALS 8 COMPLERA Use PA Form# 10620 for Fuzeon ATRIPLA1 COMBIVIR TABS 8 DIDANOSINE 8 EDURANT CRIXIVAN CAPS 8 FUZEON3 EMTRIVA 8 INTELENCE EPIVIR / HBV 8 ISENTRESS3,4 RETROVIR 3 EPZICOM 8 INVIRASE CAPS 8 KALETRA 8 SELZENTRY3 ZERIT LEXIVA 9 VIRAMUNE XR NORVIR Page 3 of 41 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. 3. Prescribers with >= 10 ART scripts per quarter and 75% ART PDL compliance will be exempt from PA for these products. 2 PREZISTA RESCRIPTOR TABS 4.Isentress Chewable will only be approved if between the age of 2-12 years old 1 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 Use PA Form# 20420 ACYCLOVIR 8 VALTREX TABS 8 ZOVIRAX 8 VALACYCLOVIR 9 FAMCICLOVIR 1. Must fail Acyclovir and Valtrex before nonpreferred products in step order. 1 1 FAMVIR TABS 1 1 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 HEPATITIS AGENTS COPEGUS TABS VICTRELIS2 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 Use PA Form# 20420 HEPATITIS AGENTS - MISC. HEPATITIS B ONLY 1. Dosing limits apply, please see dosage consolidation list. HEPSERA TABS ACTIMMUNE Use PA Form# 20420 BARACLUDE Use PA Form# 20420 TYZEKA RSV PROPHYLAXIS SYNAGIS1 RSV PROPHYLAXIS Use PA Form #30120 1. MaineCare will approve Synagis PA's for start date of December 2nd for infants who meet the guidelines. PA will be approved for max of 5 doses. Maximum 1 dose/30 days. MS TREATMENTS MULTIPLE SCLEROSIS INTERFERONS AVONEX KIT1 EXTAVIA BETASERON SOLR1 1.Clinical PA is required to establish diagnosis and medical necessity. REBIF SOLN1 Use PA Form# 20430 MULTIPLE SCLEROSIS - NONINTERFERONS COPAXONE2 6 TYSABRI1 8 AUBAGIO 8 8 AMPYRA GILENYA3 1. Providers must be enrolled in the TOUCH Prescribing program, a restricted distribution program. Clinical PA is required to establish diagnosis and medical necessity. 2. Clinical PA is required to establish diagnosis and medical necessity. 3. Dosing limits apply,please see dosing consolidation list. Page 4 of 41 Use PA Form# 20430 ASSORTED NEUROLOGICS NEUROLOGICS - MISC. MESTINON BOTOX ORAP TABS DYSPORT 1. Approval will be limited to Cervical dystonia. PROSTIGMIN TABS MYOBLOC 1 1 Use PA Form# 10210 STEROIDS GLUCOCORTICOIDS/ MINERALOCORTICOIDS CELESTONE SUSP CORTEF 5 BUDESONIDE EC 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 ENTOCORT EC CP24 MILLIPRED ORAPRED SOLN FLUDROCORTISONE ACETATE TABS PEDIAPRED LIQD HYDROCORTISONE PREDNISONE INTENSOL CONC KENALOG STERAPRED TABS METHYLPREDNISOLONE TABS PREDNISOLONE PREDNISONE SOLU-CORTEF SOLR SOLU-MEDROL SOLR HORMONE REPLACEMENT THERAPIES ANDROGENS / ANABOLICS ANDRODERM PT24 ANDROGEL ANADROL-50 ANDRO LA 200 OIL ANDROGEL PUMP ANDROID CAPS ANDROID CAPS AXIRON DANAZOL CAPS DELATESTRYL OIL DEPO-TESTOSTERONE OIL FORTESTA METHITEST TABS HALOTESTIN TABS OXANDRIN TABS OXANDROLONE TESTIM Use PA Form# 20420 Use PA Form# 20600 for Oxandrin requests TESTOSTERONE CYP TESTRED CAPS ESTROGENS - PATCHES / TOPICAL CLIMARA PTWK 5 VIVELLE-DOT PTTW1 8 ESTRADIOL PTWK ALORA PTTW 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 ESTRADIOL ENJUVIA ESTRACE TABS ESTROPIPATE TABS ESTRATAB TABS MENEST TABS ORTHO-EST TABS Must fail preferred products before non-preferred products. PREMARIN TABS ESTROGEN COMBO'S Use PA Form# 20420 PREMPHASE TABS ACTIVELLA TABS1 PREMPRO TABS COMBIPATCH PTTW1 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 1. PA approvals will require two 100 mg caps instead of one 200mg. MAKENA PROGESTERONE POWD PROMETRIUM 100MG CAPS 1 2. Must fail Medroxyprogesterone and Norethidrone products before non-preferred products. PROMETRIUM 200MG1 PROVERA TABS Use PA Form# 20420 CONTRACEPTIVES CONTRACEPTIVES - PROGESTIN ONLY ORTHO MICRONOR TABS CAMILA TABS ERRIN JOLIVETTE Page 5 of 41 If member experienced adverse reactions, consider using Oral Contraceptives from other groups. NORA-BE TABS NOR-QD TABS Use PA Form# 20420 CONTRACEPTIVES INJECTABLE CONTRACEPTIVE - EMERGENCY CONTRACEPTIVES - PATCHES/ VAGINAL PRODUCTS MEDROXYPROGESTERONE ACETATE 150mg IM 1 1 PLAN B ONE STEP 2 ELLA 2 LEVONORGESTREL DEPO-PROVERA 150 mg SUSP Use PA Form# 20420 PLAN - B 1. Allowed 2 tablets per 30 days without PA NEXT CHOICE1 Use PA Form# 20420 NUVARING RING3 Use PA Form# 20420 1.No PA required for users less than 21 years of age. ORTHO EVRA PTWK1,2,4 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 CONTRACEPTIVES - BI-PHASIC COMBINATIONS 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 ZOVIA ORTHO-NOVUM 10/11-28 TABS NECON 10/11-28 TABS NORETHINDRONE-ETH ESTRADIOL TAB 0.535/1-35 KARIVA TABS SEASONIQUE LOSEASONIQUE LOSEASONIQUE MIRCETTE TABS ENPRESSE CYCLESSA TABS NECON 7/7/7 ESTROSTEP FE TABS ORTHO-NOVUM 7/7/7-28 TABS NORTREL 7/7/7 SAFYRAL If member experienced adverse reactions, consider using Oral Contraceptives from other groups. Use PA Form# 20420 CONTRACEPTIVES - TRI-PHASIC COMBINATIONS Page 6 of 41 If member experienced adverse reactions, consider using Oral Contraceptives from other groups. using Oral Contraceptives from other groups. TRI-NORINYL 28 TABS ORTHO TRI-CYCLEN TABS TRI-PREVIFEM ORTHO TRI-CYCLEN LO TABS TRIPHASIL 28 TABS TRI-SPRINTEC TRINESSA TRIVORA-28 TABS Use PA Form# 20420 CONTRACEPTIVES - MULTIPHASIC COMBINATIONS 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 LANTUS SOLOSTAR1 1 APIDRA OPTICLIK PEN HUMALOG KWIK INJ 100/ML LEVEMIR FLEXPEN 1 HUMALOG MIX INJ 75/25 KWP NOVOLIN PENFILL1 HUMALOG MIX INJ 50/50 KWP 1. Clinical PA will be required to establish significant visual or neurological impairment. 1 NOVOLIN 70/30 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 XR 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 DIABETIC - LANCET-LANCET DEVICE ONE TOUCH LANCETS JANUMET1 JENTADUETO KAZANO OSENI 2. Dosing limits apply. Please refer to Dose consolidation list. Use PA Form# 20420 Use PA Form# 20420 DELICA LANCETS UNILET LANCETS UNISTIK LANCING DEVICE AUTOLOT LANCING DEVICE DIABETIC - SYRINGES-NEEDLES BD MICRO-FINE Use PA Form# 20420 BD ULTRA-FINE BD ULTRA-FINE PEN NEEDLES UNIFINE PEN NEEDLES DIABETIC - OTHER CYCLOSET INVOKANA Page 7 of 41 1 Use PA Form# 301501 1.Dosing limits apply please refer to Dose Consolidation List DIABETIC MONITOR FREESTYLE INSULINX FREESTYLE LITE SYSTEM KIT ACCUCHECK FREESTYLE FLASH SYSTEM KIT ASSURE FREESTYLE FREEDOM SYSTEM KIT FREESTYLE FREEDOM LITE KIT CONTOUR BREEZE Z EXACTECH ONE TOUCH ULTRA 2 KIT PRODIGY Use PA Form# 20420 ASCENSIA ONE TOUCH ULTRA MINI KIT ONE TOUCH ULTRA SMART KIT PRECISION XTRA METER DIABETIC TEST STRIPS FREESTYLE ACCUCHECK 1 FREESTYLE LITE ASSURE FREESTYLE INSULINX1 ONE TOUCH BASIC 1. Only 50 ct & 100 ct package size. ASCENSIA 1 EXACTECH 1 ONE TOUCH SURESTEP PRODIGY 1 CONTOUR BREEZE Z ONE TOUCH FAST TAKE ONE TOUCH ULTRA Use PA Form# 20420 1 1 PRECISION XTRA1 PRECISION XTRA BETA KETONE 10 CT INCRETIN MIMETIC 8 8 BYDUREON1 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 8 BYETTA NESINA 9 VICTOZA1 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 AVANDARYL 1 Use PA Form# 20420 1. Requires use of Actos, Metformin, or other preferred anti-diabetics. AVANDAMET TABS1 DIABETIC - / THIAZOL ACTOS TABS 1,3 AVANDIA TABS3 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. 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 PRECOSE TABS DIABETIC - SULFONYLUREA / BIGUANIDE GLYBURIDE/METFORMIN GLUCOVANCE TABS1 Use PA Form# 20420 METAGLIP TABS 1. Use individual ingredients. 1 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 41 Use PA Form# 20420 GLUCOSE ELEVATING AGENTS GLUCAGEN INJ. HYPOKIT GLUCAGON DIAGNOSTIC KIT Use PA Form# 20420 GLUCAGEN DIAGNOSTIC KIT THYROID THYROID HORMONES ARMOUR THYROID TABS LEVOTHYROXINE SODIUM SOLR CYTOMEL TABS LIOTHYRONINE LEVOTHROID TABS SYNTHROID TABS 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. BINOSTO BONIVA INJECTION KIT BONIVA TABS 2,4 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 GENOTROPIN1 HUMATROPE SOLR NORDITROPIN SOLN SOMATOSTATIC AGENTS 1 8 INCRELEX 8 NUTROPIN AQ NUSPIN2 8 Use PA Form# 10710 1 8 NUTROPIN OMNITROPE 8 SAIZEN SOLR 8 TEV-TROPIN OCTREOTIDE INJ SANDOSTATIN 1.Clinical PA is required to establish diagnosis and medical necessity. 2.Established users will be grandfathered. Use PA Form# 10710 SOMATULINE GROWTH HORMONE ANTAGONISTS GH ANTAGONISTS SOMAVERT Use PA Form# 10710 VASOPRESSIN RECEPTOR ANTAGONIST VASOPRESSIN RECEPTOR ANTAGONIST SAMSCA1 Use PA Form# 20420 1. See Criteria Section. 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 Page 9 of 41 Use PA Form# 20420 ANTISPASMODICS DITROPAN URISPAS TABS SANCTURA TROSPIUM ANTISPASMODICS - LONG ACTING OXYBUTYNIN ER TABS 8 DITROPAN XL TBCR TOVIAZ 8 ENABLEX 8 8 MYBRETRIQ OXYTROL 8 TOLTERODINE TAB 8 TROSPIUM 2 DETROL LA CP VESICARE 1 9 9 1,3 Use PA Form# 20420 1. See Criteria Section. 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. SANCTURA XR2 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 1 NITREK PT24 1 NITRO-DUR PT 24 0.8MG1 3 MINITRAN PT241 1 NITRODISC PT24 NITRO-DUR PT24 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 PINDOLOL TABS PROPRANOLOL HCL SOLN1 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 BETAPACE AF 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 ZEBETA TABS TOPROL XL TB24 Page 10 of 41 Use PA Form# 20420 BETA BLOCKERS - ALPHA / BETA LABETALOL HCL TABS TRANDATE TABS Use PA Form# 20420 BETA BLOCKERS & DURECTIC COMBOS CALCIUM CHANNEL BLOCKERS-Amlodipines, Bepridil, Diltiazems, Felodipines, Isradipines, Nifedipines, Nisoldipine, and Verapamils DUTOPROL Use PA Form# 20420 1. Dosing limits apply, please see dose consolidation list. NORVASC TABS1 AMLODIPINE1 Use PA Form# 20420 1 DILTIA XT CP24 5 DILACOR XR CP241 1 DILTIAZEM HCL ER CP24 TAZTIA1 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 TB24 8 CARDIZEM SR CP12 8 DILTIAZEM HCL TABS 8 DILTIAZEM HCL ER CP12 4 4 4 1 CARTIA XT CP24 1 DILTIAZEM CD CP24 DILTIAZEM HCL ER CP24 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. CARDIZEM TABS1 1 1 1 1 1 Use PA Form# 20420 DILTIAZEM XR CP24 1 TIAZAC CP24 PLENDIL TB24 Use PA Form# 20420 FELODIPINE DYNACIRC CAPS Use PA Form# 20420 1. Established users will be grandfathered 1 DYNACIRC CR TBCR CARDENE SR CPCR 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. 1. Established users of Adalat CC are grandfathered. NIFEDIPINE CAPS NIFEDIPINE ER TBCR SULAR CR 1 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 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. ISOPTIN-SR 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 MULTAQ MULTAQ PACERONE NORPACE QUINIDEX PROCAINAMIDE TAMBOCOR PROPAFENONE TIKOSYN1 QUINAGLUTE RYTHMOL SR QUINIDINE GLUCONATE RYTHMOL Use PA Form# 20420 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 TABS RAMIPRIL 8 MOEXIPRIL1 QUINAPRIL 8 MONOPRIL HCT TABS AVAPRO 1 BENICAR TABS 1 1. Non-preferred products must be used in specified order. Use PA Form# 20420 1 1 8 PRINIVIL TABS 8 UNIVASC1 8 VASOTEC TABS1 8 ZESTRIL TABS1 8 ATACAND TABS Use PA Form# 20420 8 COZAAR 1. Preferred products only available without PA if patient on diabetic therapy or prior ACE therapy. Page 11 of 41 1 ANGIOTENSIN RECEPTOR BLOCKER DIOVAN 1 LOSARTAN 1 MICARDIS TABS 1 1. Preferred products only available without PA if patient on diabetic therapy or prior ACE therapy. 8 EDARBI 8 8 IRBESARTAN TEVETEN TABS 8 TRIBENZOR2 2. Use preferred active ingredients which are available without PA. AMTURNIDE 1. Must show failure of single and combination therapy from all preferred antihypertensive categories. DIRECT RENIN INHIBITOR TEKTURNA TEKAMLO 1 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 EXFORGE1 AZOR TWYNSTA EXFORGE HCT1 1. Preferred products only available without PA if patient on diabetic therapy or prior ACE therapy. Use PA Form# 20420 ARB'S AND DIURETICS AVALIDE TABS BENICAR HCT 1 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 Use PA Form# 20420 ARB'S AND DIRECT RENIN INHIBITOR COMBINATION VALTURNA Use PA Form# 20420 ACETAZOLAMIDE TABS ALDACTAZIDE TABS BUMETANIDE ALDACTONE TABS CHLOROTHIAZIDE TABS AMILORIDE HCL 1. Multiples of Spironolactone 25 mg are cheaper than 50 mg strength. Inspra will be approved for severe breast tenderness and male gynecomastia. 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 DIURETICS TORSEMIDE TABS MICROZIDE CAPS Page 12 of 41 Use PA Form# 20420 TRIAMTERENE/HCTZ MIDAMOR TABS ZAROXOLYN TABS NAQUA TABS SPIRONOLACTONE 50MG CCB / LIPID 1 CADUET LIPID DRUGS CHOLESTEROL - BILE SEQUESTRANTS CHOLESTYRAMINE COLESTID COLESTIPOL HCI PREVALITE Use PA Form# 20420 QUESTRAN WELCHOL TABS CHOLESTEROL - FIBRIC ACID DERIVATIVES ANTARA GEMFIBROZIL TABS ANTARA NIASPAN FIBRICOR TRICOR LIPOFEN TRILIPIX LOFIBRA Use PA Form# 20420 LOPID FENOFIBRATE TRIGLIDE CHOLESTEROL - HGM COA + ABSORB INHIBITORS MORE POTENT DRUGS/COMBINATIONS ATORVASTATIN CRESTOR SIMVASTATIN1 VYTORIN LIPITOR ZOCOR 1. Dosing limits apply, please see dosage consolidation list. SIMVASTATIN 80MG 3 2. Only available if component ingredients are unavailable. 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 TABS 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. 1 2. Dosing limits apply, please see dosage consolidation list. Use PA Form# 20420 CHOLESTEROL - HGM COA + ABSORB INHIBITORS STATIN/ NIACIN COMBO SIMCOR FAMILIAL HYPERCHOLESTEROLEMIA ADVICOR TBCR Use PA Form# 20420 JUXTAPID 1. Clinical PA required for appropriate diagnosis KYNAMRO1 PULMONARY ANTI-HYPERTENSIVES PULMONARY ANTIHYPERTENSIVES ADCIRCA FLOLAN 1 VENTAVIS 2 EPOPROSTENOL INJ4 REMODULIN 1. See Criteria Section. 3 REVATIO1 2. See Criteria Section. 3. There will be dosing limits of one 20ml multidose vial/ 30 days supply without pa. 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 LETAIRIS1,2 TRACLEER3,4 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. Page 13 of 41 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 As of January 1, 2006, per CMS (federal govt.), impotence agents are no longer covered. IMPOTENCE AGENTS 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 ONDANSETRON TABS 2,4 ONDANSETRON ODT TBDP ONDANSETRON INJ2,4 2,4 5 GRANISETRON 8 ALOXI 8 ANZEMET TABS 8 CESAMET 8 8 EMEND3 KYTRIL 8 SANCUSO 8 ZOFRAN ODT TBDP 1 8 ZOFRAN TABS 8 ZOFRAN INJ4 ZUPLENZ 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. 4 4 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 CLARINEX TABS1,5 CETIRIZINE TABS 5 5 CLARINEX SYR1,2 CLARITIN (OTC) CLARITIN SYRP (OTC) LORATADINE TAVIST ND (OTC) 5 5 8 8 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 9 LEVOCETIRIZINE LORATADINE ODT4 XYZAL3 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. 5. Pa's for Clarinex RediTabs will only be approved if between the ages of 6-11 years old. Use PA Form# 20530 ANTIHISTIMINES - OTHER Use PA Form# 20530 CLEMASTINE CHLORPHENIRAMINE DIPHENHYDRAMINE ALLERGY / ASTHMA THERAPIES ANAPHYLACTIC DEVICES AUVI- Q EPIPEN ANTIASTHMATIC ANTICHOLINERGICS - INHALER SPIRIVA1,2 TUDORZA Page 14 of 41 Use PA Form# 20420 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. ANTIASTHMATIC ANTICHOLINERGICS - INHALER 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 DALIRESP Use PA Form# 20420 Use PA Form# 20420 ANTIASTHMATIC ANTICHOLINERGICS NEBULIZER IPRATROPIUM BROMIDE SOLN ATROVENT SOLN ANTIASTHMATIC ANTIINFLAMMATORY AGENTS CROMOLYN SODIUM NEBU XOLAIR ANTIASTHMATIC - NASAL STEROIDS FLUTICASONE SPR3 5 BECONASE AQ INHA1,3 Use PA Form# 20420 NASONEX SUSP3 5 8 NASACORT AQ AERS1,3 DYMISTA 1. All preferred drugs must be tried before moving to non preferred steps. 8 FLONASE SUSP2,3 8 FLUNISOLIDE SOLN 8 NASACORT AERS 2,3 8 OMNARIS SPR 1. Need max inhaled steroids and written by pulmonary or allergy specialist. 1 Use PA Form# 20420 ANTIASTHMATIC - NASAL MISC. 2. All step 5 medications need to be tried before moving to step 8's. 3 8 RHINOCORT AERO 8 RHINOCORT AQUA SUSP2,3 8 TRI-NASAL SOLN2,3 8 QNASL 8 VANCENASE POCKETHALER AERS2,3 8 8 VERAMYST2,3 ZETONNA 9 TRIAMCINOLONE NS CROMOLYN NASAL 4% 7 ATROVENT NASAL SOL Use PA Form# 20420 OCEAN 0.65% SALINE NASAL SPRAY 0.65% 7 IPRATROPIUM NASAL SOL1 ASTELIN 1. Ipratropium will be approved if submitted with documentation supporting use of CPAP machine. 7 8 8 ANTIASTHMATIC - BETA ADRENERGICS 2,3 ACCUNEB NEBU MAXAIR ALBUTEROL AER PROAIR HFA 3. Dosing limits apply to whole category, please see dosage consolidation list. ASTEPRO2 PATANASE ALBUTEROL NEB METAPROTERENOL 2,3 2. Utilize Multiple preferred, as well as step therapy Astelin. 1. Xopenex users w/ prior asthma hospitalization due to albuterol nebulizer failure will be grandfathered. ALBUTEROL HFA 3 ALBUTEROL 0.63mg/3ml PROVENTIL HFA ARCAPTA3 SEREVENT BRETHINE TERBUTALINE SULFATE TABS FORADIL AEROLIZER CAPS 2. Quantity Limit: 12 cc/day. VENTOLIN AERS VENTOLIN HFA AERS VOLMAX TBCR 3 3. Dosing limits apply, please see dosage consolidation list. VOSPIRE ER TB12 XOPENEX HFA3 XOPENEX NEBU1,2 ANTIASTHMATIC - ADRENERGIC COMBINATIONS ADVAIR DISKUS/HFA Use PA Form# 20420 1. We ask physicians to write "asthma" on the prescription whenever Advair is primarily being used for that condition. 1,2 DULERA SYMBICORT2 2. Dosing limits apply, please see dosage consolidation list. Use PA Form# 20420 ANTIASTHMATIC - ADRENERGIC ANTICHOLINERGIC ALBUTEROL/IPRATROPIUM NEB. SOLN COMBIVENT RESPIMAT COMBIVENT AERO2 DUONEB SOLN1 1. Please use preferred individual ingredients Albuterol and Ipratropium. 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 Page 15 of 41 Use PA Form# 20420 UNIPHYL TBCR THEOLAIR-SR TB12 THEOPHYLLINE CR TB12 THEOPHYLLINE ELIX THEOPHYLLINE SOLN THEOPHYLLINE ER CP12 THEOPHYLLINE ER TB12 ANTIASTHMATIC - STEROID INHALANTS 5 ASMANEX4,5 FLOVENT DISKUS 4 4 FLOVENT HFA PULMICORT FLEXHALER PULMICORT SUSP QVAR AERS 1,4 1. No PA for Pulmicort susp if under 8 years old. 2,4 BECLOVENT AERS 5 VANCERIL AERS2,4 8 AEROBID-M AERS3,4 8 ALVESCO 8 4 AEROBID AERS 5 2,4 4 VANCERIL DOUBLE STRENGTH AERS 3,4 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. 5. Asmanex 110mcg will be limited to member between the ages of 4-11years old. Use PA Form# 20420 ANTIASTHMATIC - 5Lipoxygenase Inhibitors ANTIASTHMATIC LEUKOTRIENE RECEPTOR ANTAGONISTS ZYFLO CR TABS Use PA Form# 20420 MONTELUKAST SODIUM TAB ACCOLATE TABS Use PA Form# 20420 MONTELUKAST SODIUM CHEW TAB SINGULAIR1 1.Singulair Granules will only be approved if between ages of 6months-5years old. Singulair Chewables 4mg from 2years-5years and Singulair Cheables 5mgs from 6years-14years old. ARALAST ZEMAIRA Use PA Form# 20420 ANTIASTHMATIC - ALPHAPROTEINASE INHIBITOR 8 8 9 9 ANTIASTHMATIC - HYDRO-LYTIC ENZYMES ANTIASTHMATIC - MUCOLYTICS ACETYLCYSTEINE1 GLASSIA PROLASTIN SUSR PULMOZYME SOLN Use PA Form# 20420 MUCOMYST 1. Acetylcysteine is covered with diagnosis of CF. Use PA Form# 20420 ANTIASTHMATIC-CFTR POTENTIATOR KALYDECO 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 Use PA Form# 20420 BENTYL SYRP BENTYL TABS 1.Dosing limits apply please refer to Dose Consolidation List BISMATROL BISMUTH SUBSALICYLATE CUVPOSA FULYZAQ1 CALCIUM CARBONATE (ANTACID) CHEW GLYCOPYRROLATE INJ DICYCLOMINE HCL HYOSCYAMINE SL Page 16 of 41 GLYCOPYRROLATE TABS LEVBID TB12 HAPONAL TABS LEVSIN ELIX HYOSCYAMINE CAPS & TABS LEVSIN TABS HYOSCYAMINE SULFATE LEVSIN/SL SUBL KAOPECTATE NULEV TBDP MAGNESIUM OXIDE TABS ROBINUL INJ MAG-OX 400 TABS ROBINUL 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 Use PA Form# 20420 RANITIDINE NIZATIDINE CAPS RANITIDINE SYRP PEPCID ACID REDUCER TABS PEPCID AC ZANTAC SYRP ZANTAC TABS GI - PROTON PUMP INHIBITOR DEXILANT (KAPIDEX) OMEPRAZOLE 20MG PANTOPRAZOLE 2 2 6 PRILOSEC OTC 4 1. Prevacid Solutabs available without PA for children less than 9 years old. 4 7 ACIPHEX TBEC 8 8 PREVACID CPDR PREVACID SOLUTABS1 8 NEXIUM CPDR4 8 8 PRILOSEC CPDR PROTONIX INJ 8 PROTONIX2 4,5 2. Dosing limits apply, please see dosage consolidation list. 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 PYLERA GI - PROSTAGLANDINS GI - DIGESTIVE ENZYMES MISOPROSTOL TABS CYTOTEC TABS Use PA Form# 20420 LACTRASE CAPS Use PA Form# 20420 LACTASE CHEW PANCREASE LACTASE TAB PERTZYE 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. CREON 1 ZENPEP1 GI - ANTI - FLATULENTS / GI STIMULANTS CALULOSE SYRP CONSTULOSE SYRP ENULOSE SYRP1 GASTROCROM CONC AMITIZA2 CEPHULAC SYRP INFANTS GAS RELIEF SUSP REGLAN TABS GENERLAC SYRP1 Use PA Form# 20420 LACTULOSE SYRP1 METOCLOPRAMIDE HCL 2. Prior failed trials of multiple other preferred GI agents must occur first, Such as OTC senna, docusate, lactulose, polyethylene glycol. 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 GIAZO 1. Current users grandfathered. BALSALAZIDE LIALDA TABS CANASA SUPP PENTASA 500MG2 Page 17 of 41 Use PA Form# 20420 1 COLAZAL CAPS SFROWASA DELZICOL 2. Use multiple Pentasa 250mg. DIPENTUM CAPS PENTASA CPCR 250MG ROWASA ENEM SULFAZINE EC TBEC SULFASALAZINE TABS GI - IRRITABLE BOWEL SYNDROME AGENTS LOTRONEX TABS GI- SHORT BOWL SYNDROME GATTEX Use PA Form# 20420 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 METAMUCIL LINZESS MALTSUPEX MILK OF MAGNESIA SUSP MIRALAX PACK (OTC versions) MINERAL OIL OIL MIRALAX POWD (OTC versions) NULYTELY SOLR PEG 3350/ELECTROLYTES SOLR SENNA SENEXON TABS SENOKOT GRAN SENOKOT TABS SENOKOT SYRP SENOKOT S TABS SENOKOT CHILDRENS SYRP STOOL SOFTENER PLUS CAPS SENOKOT XTRA TABS UNI-CENNA TABS SORBITOL UNI-EASE PLUS CAPS STOOL SOFTENER CAPS V-R NATURAL SENNA LAXATIV TABS SUCRALFATE TABS URSO 250 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 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 FURADANTIN SUSP ELMIRON CAPS1 K-PHOS MF TABS FURADANTIN SUSP MACROBID CAPS METHENAMINE MANDELATE TABS MONUROL PACK NEOSPORIN GU IRRIGANT SOLN MACRODANTIN CAPS NITROFURANTOIN MACR SUSP NITROFURANTOIN MONO CAPS POTASSIUM CITRATE/CITRIC SOLN PHENAZOPYRIDINE HCL TABS PYRIDIUM PLUS TABS PHENAZOPYRIDINE PLUS PYRIDIUM TABS PROSED/DS TABS RENACIDIN SOLN TRICITRATES SYRP URELIEF PLUS UREX TABS URISED TABS UROCIT-K UROQID #2 TABS Page 18 of 41 1. Elmiron requires adequate proof of Dx with supportive testing. Use PA Form# 20420 PHOSPHATE BINDERS PHOSPHATE BINDERS ELIPHOS CALCIUM ACETATE 1 1 MAGNEBIND - 400 PHOSLYRA FOSRENOL RENVELA 1 1 Use PA Form# 20420 1. Diag required. 1 RENAGEL INTRA-VAGINALS VAGINAL - ANTIBACTERIALS CLEOCIN CREA VANDAZOLE METROGEL VAGINAL GEL2 METRONIDAZOLE VAGINAL GEL 2 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 GYNE-LOTRIMIN CREA MICONAZOLE CREA MICONAZOLE 3 COMBO PACK KIT MICONAZOLE 7 CREA AVC CREA CLOTRIMAZOLE 3 DAY CREA 1. Quantity limit: 1/script/2 weeks GYNAZOLE-1 CREA Use PA Form# 20420 GYNE-LOTRIMIN 3 TABS 1 MICONAZOLE 3 SUPP MICONAZOLE NITRATE CREA TERAZOL 3 CREA NYSTATIN TABS TERAZOL 7 CREA TERAZOL 3 SUPP TERCONAZOLE 0.8MG TERCONAZOLE 0.4MG TERCONAZOLE SUPP VAGITROL V-R MICONAZOLE-7 CREA VAGINAL - CONTRACEPTIVES GYNOL II EXTRA STRENGTH GEL DELFEN FOAM Use PA Form# 20420 VAGINAL - ESTROGENS ESTRING RING ESTRACE CREA1 PREMARIN CREA VAGIFEM TABS1 1. Must fail all preferred products before nonpreferred. Use PA Form# 20420 VAGINAL - OTHER ACID JELLY GEL AMINO ACID CERVICAL CREA 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 UROXATRAL4 1. There will be dosing limits of 1 tab per day with out PA. AVODART2,4 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 VISTARIL ANTI-DEPRESSANTS Page 19 of 41 Use PA Form# 20420 Use PA Form# 20420 ANTIDEPRESSANTS - MAO INHIBITORS NARDIL TABS Use PA Form# 20420 PARNATE TABS ANTIDEPRESSANTS - MAO INHIBITORS TOPICAL 1. Dosing limits apply, please refer to Dose consolidation list. 1 EMSAM Use PA Form# 20420 ANTIDEPRESSANTS SELECTED SSRI's BUPROPION HCL TABS 8 APLENZIN7 BUPROPION SR 8 CELEXA4 BUPROPION XL 8 8 CYMBALTA EFFEXOR TABS ESCITALOPRAM FLUOXETINE HCL CAPS 8 EFFEXOR XR CP24 3, 10 8 FLUOXETINE 40 mg AND 60mg CAPS FLUOXETINE HCL LIQD 8 FLUOXETINE HCL 10mg TABS 8 FLUOXETINE 20mg TABS FORFIVO XL FLUVOXAMINE MALEATE TABS 8 MIRTAZAPINE 8 LEXAPRO TABS4 LUVOX TABS NEFAZODONE 8 MAPROTILINE HCL TABS 3 8 MIRTAZAPINE ODT SERTRALINE TRAZODONE HCL TABS 2 8 8 OLEPTRO PAROXETINE CR3 9 8 PAXIL 8 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 8 WELLBUTRIN SR TBCR WELLBUTRIN XL 8 REMERON SOLTAB TBDP 8 SAVELLA 8 8 ZOLOFT 8 VENLAFAXINE TABS9 4 CITALOPRAM 4 PAROXETINE VENLAFAXINE ER CAPS 8 9 1. Use Fluoxetine 20 mg in multiples. 5, 11 2. See Zoloft splitting table. Sertraline requires splitting of scored tabs to avoid PA. 6 3. Strong caution with pediatric population. 4. See Celexa/Citalopram and Lexapro splitting tables. 3 VENLAFAXINE ER TABS VIBRYD 1 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. 9 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. FLUOXETINE 90mg TABS12 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 BUTISOL SODIUM TABS1 LUMINAL SOLN CHLORAL HYDRATE SYRP1 SOMNOTE CAPS 1. PA required for new users of preferred products if over 65 years. MEBARAL TABS1 PHENOBARBITAL1 Use PA Form# 20420 Page 20 of 41 SEDATIVE/HYPNOTICS BENZODIAZEPINES DORAL TABS 1 ESTAZOLAM TABS FLURAZEPAM HCL CAPS 1 TEMAZEPAM CAPS 15 & 30MG SEDATIVE/HYPNOTICS - NonBenzodiazepines 1 TRIAZOLAM TABS MIRTAZAPINE 1 TRAZODONE 1 ZOLPIDEM 2 ZALEPLON 2,3 2 1. Dosing limits apply, please see dosing consolidation list. 1 HALCION TABS MIDAZOLAM HCL SYRP 1 RESTORIL CAPS 1 1 TEMAZEPAM 7.5MG Use PA Form# 30110 1 1 7 AMBIEN1 7 8 ZOLPIDEM ER 8 1. Quantity Limt of 12 per 34 days. AMBIEN CR EDLUAR 8 8 INTERMEZZO 8 8 SONATA CAPS ROZEREM 8 ZOLPIMIST LUNESTA 2. Quantity limits will be allowed up to 30/30, but intermittent therapy is recommended. 1 1 1 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 TABS 4 OLANZAPINE 8 RISPERIDONE TAB4 8 8 GEODON 8 INVEGA SUSTENNA 8 8 LATUDA6 RISPERDAL TAB 8 RISPERDAL CONSA 8 2 3,4 RISPERIDONE SOLN4 QUETIAPINE4,7 ZIPRASIDONE 4 8 ABILIFY DISC TAB, INJ and SOL FANAPT INVEGA RISPERDAL M TAB RISPERDAL SOLN 8 RISPERIDONE ODT 8 SAPHRIS 8 SEROQUEL 50MG TABS1,2 ZYPREXA TABS 8 8 9 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. 2 8 8 8 2 ZYPREXA ZYDIS TBDP 2 ZYPREXA RELPREVV SEROQUEL TABS SEROQUEL XR5 Use PA form# 20440 for Multiple Antipsychotic requests Use PA form# 10130 for non-preferred single therapy atypical requests 1. Please use multiple 25mg tablets. 2. Established users of single therapy atypicals were grandfathered. 3. Abilify requires splitting of tab to avoid PA. Please see Abilify splitting table. 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 Page 21 of 41 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 SYMBYAX 1 1. Only available if component ingredients are unavailable. PERPHENAZINE/AMITRIPTYLIN Use PA Form# 20420 STIMULANTS STIMULANT - AMPHETAMINES SHORT ACTING ADDERALL TABS 1 AMPHETAMINE SALT COMBO DEXTROAMPHET SULF TABS 1,3 1,3 1. Preferred stimulants will be available without PA if diagnosis of ADHD. DEXEDRINE1,3 PROCENTRA 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. 3. Dosing limits apply, please see dosing consolidation list. Use PA Form# 20420 STIMULANT - LONG ACTING AMPHETAMINES SALT VYVANSE2,3,4 8 ADDERALL XR CP241,3,4 Use PA Form# 20420 8 QUILLIVANT XR 9 AMPHETAMINE/DEXTROAMPHET ER 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 FOCALIN TABS METHYLIN CHEWABLES 1,2 METADATE ER TBCR 1,2 RITALIN 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 8 RITALIN LA 8 CONCERTA TBCR METHYLPHENIDATE ER CAPS1,2,4 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. Page 22 of 41 4.Dosing limits applly, please see dosing consolidation list. Use PA Form# 20420 STIMULANT - STIMULANT LIKE 7 STRATTERA1, 2 8 8 CAFCIT SOLN INTUNIV 8 KAPVAY 8 PROVIGIL TABS 3 9 NUVIGIL 9 DESOXYN TABS 9 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. 3 3 DESOXYN CR 3 3 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 WEIGHT LOSS No longer covered: PHENTERMINE, XENICAL,DIDREX, and MERIDIA ALZHEIMER DISEASE ALZHEIMER Cholinomimetics/Others DONEPEZIL HYDROCHLORIDE TABS1 6 DONEPEZIL HYDROCHLORIDE ODT1 ARICEPT TABS2 6 EXELON1 8 8 ARICEPT ODT2 RAZADYNE2 NAMENDA1 9 1. PA is required to establish dementia diagnosis and baseline mental status score. RIVASTIGMINE TARTRATE CAPS2 2. Must fail all preferred products before moving to non-preferred. COGNEX CAPS2 Use PA Form# 20420 SMOKING CESSATION NICOTINE PATCHES / TABLETS CHANTIX1,2,3 Use PA Form# 20420 NICODERM CQ PT243 1. Products are preferred only for use during pregnancy 2,3 NICOTINE DIS PT24 2. As of September 1, 2012 per MaineCare policy, smoking cessation products are no longer covered except for use during pregnancy. 3. See criteria section for exemptions NICOTINE REPLACEMENT OTHER NICOTINE POLACRILEX GUM2 5 COMMIT LOZENGES1,3,4 8 NICOTROL INHALER3,4 8 NICOTROL NASAL SPRAY NICORETTE GUM Use PA Form# 20420 3,4 1. Products are preferred only for use during pregnancy 2. As of September 1, 2012 per MaineCare policy, smoking cessation products are no longer covered except for use during pregnancy. 3. See criteria section for exemptions 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. 1 CAMPRAL DISULFIRAM TABS NALTREXONE HCL TABS Use PA Form# 20420 MISCELLANEOUS ANALGESICS ANALGESICS - MISC. ACETAMINOPHEN AXOCET CAPS Page 23 of 41 Use PA Form# 20420 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 ZORPRIN TBCR LONG ACTING NARCOTICS NARCOTICS - LONG ACTING FENTANYL PATCH5 METHADONE METHADOSE MORPHINE SULFATE ER TB12 OPANA ER 8 ABSTRAL 8 8 AVINZA 8 8 DURAGESIC PT72 EMBEDA 8 EXALGO 8 8 KADIAN 8 MS CONTIN TB12 8 ORAMORPH SR TB12 8 9 OXYCONTIN TB121,4 NUCYNTA 9 OXYCODONE ER3,7 BUTRANS Use PA Form# 20510 5 5 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. MORPHINE SULFATE SUPP 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 7 RYZOLT Use PA Form# 20420 8 BUPRENEX SOLN 8 BUTORPHANOL 1. Only available if component ingredients are unavailable. 8 NALBUPHINE HCL SOLN 8 STADOL NS SOLN 8 8 TRAMADOL ER 8 ULTRACET TABS1 ULTRAM TABS 8 ULTRAM ER 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 CAPITAL AND CODEINE SUSP1 8 DILAUDID-HP SOLN CAPITAL/CODEINE SUSP1 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 Page 24 of 41 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 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 OXECTA OXYCODONE 30MG 8 OXYCODONE 10MG OXYCODONE/ACETAMINOPHEN PENTAZOCINE/NALOXONE TABS 8 OXYCODONE 20MG 8 OXYCODONE/APAP 10/650 PROPOXYPHENE CMPND-65 CAPS 8 OXYCODONE/APAP 7.5/500 PROPOXYPHENE COMPOUND CAPS 8 PENTAZOCINE/ACET TABS PROPOXYPHENE HCL CAPS 8 PERCOCET TABS PROPOXYPHENE/ACET TABS 8 PERCOCET TABS PROPOXYPHENE-N/ACET TABS 8 PHRENILIN W/CAFFEINE/CODE CAPS ROXICET 8 ROXICET 5/500 TABS ROXIPRIN TABS 8 ROXICODONE TABS 8 SYNALGOS-DC CAPS 8 TALACEN TABS 8 8 TREZIX TYLENOL/CODEINE #3 TABS 8 TYLOX CAPS 8 8 XOLOX VICODIN 8 VICOPROFEN TABS 8 ZYDONE TABS 9 ACTIQ LPOP 9 CONZIP 9 OPANA 2,3 OPIOID DEPENDENCE TREATMENTS SUBOXONE FILM2 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. Use PA Form# 20420 SUBOXONE TABS BUPRENORPHINE1 Use PA Form# 10200 for Suboxone Continuation Use PA Form# 10100 for Suboxone for Suboxone Restart 1. Buprenophine will only be approved for use during pregnancy. 2. See Criteria Section NARCOTIC ANTAGONISTS NARCOTIC - ANTAGONISTS NALTREXONE HCL TABS REVIA TABS1 2 VIVITROL INJ Use PA Form# 20420 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 NABUMETONE TABS6 2,3,6 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. Page 25 of 41 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 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 NALFON CAPS 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 ORENCIA 2 HUMIRA1,2 SIMPONI CIMZIA KINERET SOLN REMICADE 2. Dosing limits apply. Please see dose consolidation list. XELJANZ 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 Page 26 of 41 Use PA Form# 20420 LUPUS-SLE MIGRAINE THERAPIES MIGRAINE - ERGOTAMINE DERIVATIVES MIGRANAL SOLN MIGRAINE - CARBOXYLIC ACID DERIVATIVES DIVALPROEX ER TB24 MIGRAINE - SELECTIVE SEROTONIN AGONISTS (5HT)-Tabs NARATRIPTAN HCI TABS D.H.E. 45 SOLN Use PA Form# 10110 DEPAKOTE ER TB24 Use PA Form# 10110 AMERGE TABS1,2 1. All drugs in this category have dosing limits. Please refer to dose consolidation table. SANSERT TABS 1 1 RELPAX SUMATRIPTAN TABS1 AXERT TABS 1,2 FROVA TABS 1,2 IMITREX TABS MAXALT MLT 1,2 2. Must fail all preferred products before nonpreferred. 1,2,3 1,2,3 MAXALT RIZATRIPTAN ZOMIG TABS 3. Established users will be grandfathered 1,2 ZOMIG NASAL SPARY 1,2 ZOMIG ZMT TBDP SUMATRIPTAN SOLN Use PA Form# 10110 TREXIMET1,2 Use PA Form# 10110 1,2 MIGRAINE - SELECTIVE SEROTONIN AGONISTS (5HT)-Injectables IMITREX KIT 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. 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 COLCHICINE TABS ULORIC PROBENECID TABS ZYLOPRIM TABS 1 PROBENECID/COLCHICINE TABS Use PA Form# 20420 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. 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 DEPAKOTE DEPAKOTE ER All non-preferred meds must be used in specified order CLONAZEPAM TABS 8 8 DEPAKOTE SPRINKLES CPSP 8 DIAZEPAM GEL 1. Quantity limit. 5/month DIASTAT1 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 4. Adjunctive therapy 17 and older. LAMOTRIGINE2 8 KLONOPIN TABS LEVETIRACETAM SOLN/TABS MYSOLINE TABS 8 8 LAMICTAL 5. Current users as of 7/30/10 for seizures will be grandfathered. OXCARBAZEPINE PHENYTEK CAPS 8 PHENYTOIN 8 OXTELLAR XR7 POTIGA TEGRETOL 8 PRIMIDONE TABS 8 LYRICA3 ONFI Page 27 of 41 3. Dosing limits apply per strength as well as a maximum daily dose of 600mg. Please see dose consolidation list. 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. the Federal Rebate Program in conjunction with HCR. TOPIRAMATE TOPIRAMATE SPRINKLE CAPS TRILEPTAL SUSP 2 8 SABRIL 8 TOPAMAX 8 TOPAMAX SPRINKLE CAPS TRILEPTAL VALPROIC ACID 8 ZARONTIN CAPS 8 8 VIMPAT 9 KEPPRA XR 5,6 9 NEURONTIN 9 9 TEGRETOL-XR TB12 ZONEGRAN CAPS 9 LAMICTAL XR ZONISAMIDE 7. Max dose 2400mg 2 4 ZARONTIN SYRP 5,6 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 PEDIATRIC BIPOLAR1 DISORDER: STEP ORDER M ~ A 4 ~ 4 4 ~ 4 4 ~ 4 Two-step 1 preferred drugs must be tried before (6-18 YEARS WITH OR WITHOUT PSYCHOSIS) Trileptal. The step orders show the relative strength of LITHIUM evidence for use in bi-polar and will guide prior CARBAMAZEPINE authorization determinations. Step 4 drugs-no PA required. VALPROATE 4 ~ 4 ATYPICAL ANTIPSYCHOTICS EXC.CLOZAPINE 4 ~ 4 LAMICTAL TRILEPTA 5 ~ 5 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 Use PA Form# 20420 8 MIRAPEX TABS1 REQUIP TABS 8 REQUIP XL TABS 8 MIRAPEX ER 8 NEUPRO PATCH 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. CARBIDOPA/LEVODOPA/ENTACA1 Use PA Form# 20420 STALEVO1 1.Clinical PA is required to establish diagnosis and medical necessity. MUSCLE RELAXANTS Page 28 of 41 ALS DRUG RILUTEK TABS MUSCLE RELAXANTS BACLOFEN TABS Use PA Form# 20420 6 7 SKELAXIN TAB ORPHENADRINE CITRATE LIORESAL INTRATHECAL KIT 8 8 AMRIX CARISOPRODOL TABS METHOCARBAMOL TABS 8 DANTRIUM CAPS TIZANIDINE HCL TABS 8 LIORESAL TABS 8 LORZONE 8 8 METAXALONE NORFLEX TBCR 8 ROBAXIN-750 TABS 8 8 VECUROMIUM INJ ZANAFLEX TABS 9 9 CYCLOBENZOPRINE ER SKELAXIN TABX 9 SOMA TABS CHLORZOXAZONE TABS CYCLOBENZAPRINE HCL TABS MUSCLE RELAXANT - COMBO. CARISOPRODOL/ASPIRIN TABS 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. Use PA Form# 20420 Use PA Form# 20420 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 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 CHEWABLE MULTIVIT/FL CHEW CITRANATAL DALYVITE LIQD COD LIVER OIL CAPS EMBREX 600 MISC COMPLETE SENIOR TABS DAILY MULTI VIT/IRON FERRALET 90 IBERET DIALYVITE 1MG MATERNA TABS Page 29 of 41 Use PA Form# 20420 DIALYVITE 800MG MULTIRET FOLIC -500 TBCR FULL SPECTRUM B NATAFORT TABS M.V.I.-12 INJ NATALCARE CFE 60 TABS MULTI-VIT/FLUORIDE NATALCARE GLOSS TABS1 NATALCARE RX TABS NATALCARE PIC TABS1 NEPHRONEX NATALCARE PIC FORTE TABS1 O-CAL PRENATAL ONE DAILY TABS NATALCARE PLUS TABS1 1 ONE-DAILY MULTIVITAMINS NATALCARE THREE TABS NATACHEW CHEW ONE-TABLET-DAILY NATALFIRST TABS POLY-VIT/IRON/FLUORID SOLN NATATAB RX TABS POLY-VITAMIN/FLUORIDE SOLN NEPHPLEX RX TABS POLY-VITAMINS/IRON SOLN NEPHROCAPS CAPS PRENATAL 19 CHEW PRENATAL TABS NEPHRO-VITE TABS 1 NESTABS RX TABS 1 PRENATAL FORMULA 3 TABS1 PRENATAL PLUS TABS 1 POLY-VI-FLOR SOLN PRENATAL PLUS NF TABS1 PRENATAL PLUS/27MG IRON NIFEREX OCUVITE TABS 1 1 POLY-VI-SOL SOLN 1 POLY-VI-SOL/IRON SOLN PRENATAL PLUS/IRON TABS PRENATAL RX/BETA-CAROTENE1 RENA-VITE RX TABS POLY-VITAMIN DROPS SOLN RENAL CAPS RENAPHRO CAPS PREFERA OB PREMESIS RX TABS STRESS TAB NF TABS PRENATABS CBF TABS1 THERAPEUTIC-M TABS PRENATAL CARE TABS1 THERAVITE LIQD PRENATAL MR 90 TBCR TRI-VITAMIN/FLUORIDE SOLN PRENATAL MTR/SELENIUM TABS1 VITA CON FORTE CAPS PRENATAL OPTIMA ADVANCE TABS1 VITAMIN B COMPLEX CAPS PRENATAL PC 40 TABS1 VITAPLEX PLUS TABS PRENATAL RX TABS1 PRECARE 1 PRENATE1 PRENATE ELITE1 PRIMACARE MISC 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 Page 30 of 41 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 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 P.T.E. -5 SOLN 1 SEA-OMEGA CAPS1 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 CASEC POWD1 CHOICE DM LIQD1 DELIVER 2.0 LIQD1 ENFAMIL1 ENSURE1 GLUCERNA1 ISOCAL LIQD1 KINDERCAL TF LIQD1 KINDERCAL TF/FIBER LIQD1 L-CARNITINE CAPS 2. Formerly known as Omacor. 1 LIPISORB LIQD1 LOVAZA1,2 Page 31 of 41 Use PA Form# 20420 MODULEN IBD POWD & SGA Form 1 NUTRAMIGEN POWD1 NUTREN 1 NUTRITIONAL SUPPLEMENT LIQD NUTRIVENT 1.5 LIQD PEPTAMEN 1 1 1 PHENYLADE1 PHENYL-FREE PKU 3 POWD 1 1 PREGESTIMIL POWD PROBALANCE LIQD PROSOBEE 1 1 1 SCANDISHAKE PACK VASCEPA 1 ERYTHROPOEITINS ERYTHROPOEITINS PROCRIT SOLN1 6 EPOGEN SOLN Use PA Form# 10520 8 ARANESP SOLN 8 OMONTYS 1. Clinical PA is required to establish medical necessity and that appropriate lab monitoring is being done. GRANULOCYTE CSF GRANULOCYTE CSF 8 LEUKINE 8 NEUPOGEN SOLN2 1. Must be used in specified step order. 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 ELIQUIS ENOXAPARIN 1. Arixtra, Fragmin and Lovenox therapy durations greater than 7 days require PA. FRAGMIN INJ1 HEPARIN SODIUM/NACL 0.9% SOLN FONDAPARINUX IPRIVASK 2. Use other strengths available to obtain desired dose. HEP-LOCK SOLN JANTOVEN 3. Please refer to Pradaxa PA form for criteria INNOHEP LOVENOX 3002 4.Established users will be grandfathered, new starters must use preferred product Coumadin. 1 LOVENOX SOLN HEPARIN LOCK SOLN PRADAXA HEPARIN LOCK FLUSH SOLN XARELTO 3 WARFARIN SODIUM TABS4 HEPARIN SODIUM SOLN HEPARIN SODIUM LOCK FLUSH SOLN Use PA Form# 20420 Use PA form#20725 for Pradaxa requests 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 KOATE-DVI KOGENATE FS MONARC - M Use PA Form# 20420 MONOCLATE - P MONONINE NOVOSEVEN SOLR PROFILNINE RECOMBINATE SOLR PLATELET AGGREGATION INHIBITORS ASPIRIN 7 TICLOPIDINE HCL TABS DIPYRIDAMOLE TABS 8 8 BRILINTA1,2 CLOPIDOGREL 75MG 8 EFFIENT2 PERSANTINE TABS Page 32 of 41 Use PA Form# 20715 for Plavix, Effient & Brilinta Use PA form# 20420 for other requests 8 PLAVIX TABS 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. 1 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 Use PA Form# 20420 Use PA Form# 20420 Use PA Form# 20420 PROMACTA NPLATE HEMOSTATIC HEMOSTATIC AMICAR Use PA Form# 20420 AMINOCAPROIC ACID OPHTHALMICS OP. - ANTIBIOTICS AK-SPORE OINT AK-POLY-BAC OINT BACITRACIN OINT AK-SULF OINT Use PA Form# 20420 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 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 SOLN REFRESH PM OINT 1 NATURE'S TEARS SOLN REFRESH SOLN REFRESH TEARS SOLN SYSTANE TEARGEN SOLN TEARISOL SOLN TEARS NATURALE TEARS PURE SOLN TEARS RENEWED OINT Page 33 of 41 1 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 OP. - CYCLOPLEGICS OP. - MIOTICS - DIRECT ACTING LATANOPROST SOL 0.005%1 TRAVATAN-Z 7 XALATAN SOLN1 1. All preferreds must be tried. 8 8 LUMIGAN SOLN1 TRAVATAN SOLN Use PA Form# 20420 8 ZIOPTAN AK-PENTOLATE SOLN CYCLOGYL SOLN ATROPINE SULFATE ISOPTO ATROPINE SOLN CYCLOPENTOLATE HCL SOLN ISOPTO HOMATROPINE SOLN ISOPTO HYOSCINE SOLN MUROCOLL-2 SOLN ISOPTO CARBACHOL SOLN Use PA Form# 20420 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 0.15% SOLN ALPHAGAN P 0.1% 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 Page 34 of 41 INHIBITORS/COMBO DORZOLAMIDE/TIMOLOL OP. - NSAID'S FLURBIPROFEN SODIUM SOLN 8 DICLOFENAC OPTH 0.1% 8 KETOROLAC OPTH 0.4% 8 ACULAR SOLN ILEVRO KETOROLAC OPTH 0.5% 8 OCUFEN SOLN1 8 8 NEVANAC PROLENSA 8 XIBROM 8 VOLTAREN SOLN 8 1 9 OP. - OF INTEREST ENUCLENE SOLN ACULAR LS 1. Must fail all preferred products before nonpreferred. 1 1 1 1 1 ACUVAIL BROMFENAC BOTOX SOLR RESTASIS 1 Use PA Form# 20420 1. Must have kerato conjuctivitus sicca and failed other dry eye therapies. Use PA Form# 20420 DERMATOLOGICAL TOPICAL - ORAL CLARAVIS SOTRET1 TOPICAL - ACNE PREPARATIONS 1. Users 24 or under, PA will not be required. AMNESTEEM1 1 Use PA Form# 20420 AZELEX CREA BENZOYL PEROXIDE ACZONE CLINDAMYCIN PHOSPHATE 2 AVITA CREA ERYDERM SOLN ERYTHROMYCIN GEL BENZAC 4 ERYTHROMYCIN PADS BENZACLIN GEL3 BENZAGEL-10 GEL ERYTHROMYCIN SOLN BENZAMYCIN GEL ISOTRETINOIN BENZAMYCINPAK PACK METRONIDAZOLE CREA2 METRONIDAZOLE GEL 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 TRETINOIN GEL1 CLINDETS SWAB TRETINOIN CREA 1. Users 24 or under, PA will not be required. ALTINAC CREA 1,2 4. Dosing limits apply, please see dosing consolidation list Use PA Form# 10220 for Brand Name requests DESQUAM-E GEL DESQUAM-X Use PA Form# 20420 for all other requests DIFFERIN 0.3% GEL DIFFERIN DUAC GEL 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 BACITRACIN OINT BACTROBAN CREA1 BACTROBAN NASAL OINT ALTABAX 1 BACTROBAN OINT. 1. Dosing limits apply, please see dosing consolidation list. TRIPLE ANTIBIOTIC OINT Use PA Form# 20420 CENTANY OINT 2% 1 Page 35 of 41 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 KETOCONAZOLE SHAM LOPROX 1.0 CREA 8 LOPROX 0.77 LOTN 8 LOPROX 0.77 CREA LOPROX 1.O LOTN 8 LOPROX 0.77 SUSP LOPROX GEL 8 LOPROX SHAMPOO SHAM LOPROX TS LOTN 8 LOTRIMIN LOTRISONE CREA 8 LOTRISONE LOT MICONAZOLE NITRATE CREA 8 MENTAX CREA MYCO-TRIACET II CREA 8 MYCOGEN II CREA NYSTATIN 8 NAFTIN NYSTATIN/TRIAMCINOLONE 8 8 NIZORAL SHAM NYSTOP POWD PEDI-DRI POWD 8 OXISTAT TINACTIN 9 PENLAC NAIL LACQUER SOLN Use PA Form# 10120 NYSTAT-RX POWD TRI-STATIN II CREA TOPICAL - ANTIPRURITICS ZONALON CREA TOPICAL - ANTIPSORIATICS SORIATANE CAPS TAZORAC PRUDOXIN CREA Use PA Form# 20420 OXSORALEN ULTRA CAPS PSORIATEC CREA 1 1 1. Must fail all preferred products before nonpreferred. SORIATANE CK KIT1 2. Individual ingredients are available as preferred witout PA. TACLONEX1,2 VECTICAL 1 Use PA Form# 20420 TOPICAL - ANTISEBORRHEICS SELENIUM SULFIDE SHAM CARMOL SCALP TREATMENT KIT Use PA Form# 20420 ZNP BAR TOPICAL - ANTIVIRALS DENAVIR CREA1, 3 ZOVIRAX OINT 1. Must fail oral treatment with Acyclovir or Valtrex. 1,2 2. Approvals limited to 1 tube per 180 days. 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 ACLOVATE Use PA Form# 20420 AMCINONIDE CREA 1. Dosing limits apply, please see dosing consolidation list. SILVER SULFADIAZINE CREA SSD AF CREA TOPICAL - CORTICOSTEROIDS SSD CREA THERMAZENE CREA LOW POTENCY DESOWEN 1 HYDROCORTISONE CREA ANUSOL HC-1 OINT HYDROCORTISONE LOTN CLOBETASOL PROPINATE LOTN LACTICARE-HC LOTN CLODERM CREA NUTRACORT LOTN CORDRAN TEXACORT SOLN CORMAX CUTIVATE CREA / OINT MEDIUM POTENCY DESOXIMETASONE .05% CUTIVATE LOTN ELOCON DERMA-SMOOTHE/FS OIL DERMATOP FLUOCINOLONE ACETONIDE .025-.01% DESONATE GEL FLUROSYN CREA DIPROLENE Page 36 of 41 FLUTICASONE PROPIONATE CREA/OINT ELOCON OINT HYDROCORTISONE BUTYRATE HYDROCORTISONE POWD HYDROCORTISONE OINT KENALOG AERS HYDROCORTISONE VALERATE LIDA MANTLE HC CREA MOMETASONE FUROATE OINT LOCOID TRIAMCINOLONE ACETONIDE .025-.1% LUXIQ FOAM OLUX FOAM HIGH POTENCY PANDEL CREA BETAMETHASONE DIPROPIONATE PROCTOCORT CREA CLOBEX LOTN PSORCON DESOXIMETASONE .25% PSORCON E DESONIDE FLUOCINOLONE ACETONIDE .02% TEMOVATE FLUOCINONIDE TOPICORT LP CREA HALOG ULTRAVATE HALOG-E CREA VERDESO TRIAMCINOLONE ACETONIDE .5% WESTCORT 1 TOPICORT 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% 1 LAC-HYDRIN CREA1 AMMONIUM LACTATE CREA1 LAC-HYDRIN LOTN 12% Use PA Form# 20420 UREACIN-20 CREA MEDERMA GEL VITAMIN A & D MEDICATED OINT MIMYX 1. Dosing limits apply, please see dosing consolidation list. RENOVA CREA 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 8 CONDYLOX1 1. Non-preferred products must be used in specified order. 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. SANTYL OINT TOPICAL - GENITAL WARTS IMIQUIMOD2 TOPICAL IMMUNOMODULATORS 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 LIDOCAINE GEL LIDODERM PTCH 1. Lidocaine/Prilocaine cream and Ela-Max products require PA for users over 18 years of age. PONTOCAINE SOLN SYNERA ZOSTRIX Page 37 of 41 Use PA Form# 20420 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 OVIDE LOTN 1. Dosing limits apply, please see dosing consolidation list LICE KILLING SHAM ULESFIA 2. Will require two failed trails of permethrin 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 SOLN1 MOISTURIN DRY SKIN CREA 1. Dosing limits still apply. Please see dose consolidation list. XERAC AC SOLN PROSHIELD PLUS SKIN PROTE CREA LICE TREATMENT CREME RINS LIQD NATROBA1,2 PERMETHRIN LOTN TOPICAL - WOUND / DECUBITUS CARE TOPICAL - ASTRINGENTS / PROTECTANTS 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 ACETASOL HC SOLN ANTIBIOTIC EAR SUSP ACETIC ACID AURALGAN SOLN ACETIC ACID/HYDROCORTISON ALLERGEN SOLN CETRAXAL CIPRO HC SUSP ANTIPYRINE/BENZOCAINE SOLN COLY-MYCIN-S SUSP AURODEX SOLN CORTISPORIN-TC SUSP AUROGUARD SOLN AUROTO OTIC SOLN DERMOTIC DEBROX SOLN CARBAMIDE PEROXIDE 6.5% OTIC SOLN. PEDIOTIC SUSP CIPRODEX CORTISPORIN SOLN VOSOL-HC SOLN CORTOMYCIN ZOTO-HC SOLN Use PA Form# 20420 ZOTANE HC SOLN 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 NYSTATIN SUSP Page 38 of 41 Use PA Form# 20420 MOUTH ANTISEPTICS CHLORHEXIDINE GLUCONATE APHTHASOL PSTE LIDOCAINE VISCOUS SOLN PERIOGARD SOLN TRIAMCINOLONE IN ORABASE PSTE TRIAMCINOLONE ACETONIDE PSTE Use PA Form# 20420 1 1 1 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 PROCTOFOAM HC FOAM HYDROCORTISONE ENEM PROCTO-KIT CREA 2.5% PROCTOZONE-HC CREA RECTIV OINT Use PA Form# 20420 PROCTOSOL HC CREA PROCTOCREAM-HC CREA T-CELL ACTIVATION INHIBITOR PSORIASIS BIOLOGICALS ENBREL1 HUMIRA 1 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. 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 Page 39 of 41 ANTINEOPLASTIC AGENTS TYROSINE KINASE INHIBITORS SPRYCEL Use PA Form# 20420 1 1. Verification of diagnosis is required. TYKERB2 GLEEVEC 1 2. PA required to confirm FDA approved indication and to monitor for potential drug-drug interactions. ANTINEOPLASTICSMISCELLANEOUS AMIFOSTINE MERCAPTOPURINE Use PA Form# 20420 ETHYOL PURINETHOL ZOLINZA ANTINEOPLASTICSMONOCLONAL ANTIBODIES HERCEPTIN 1. PA required to confirm FDA approved indication. 1 Use PA Form# 20420 CANCER CANCER ALIMTA ARIMIDEX ANASTROZOLE TABS BOSULIF 1. PA required to confirm FDA approved indication AVASTIN ERIVEDGE 2. Avoid CYP3AY drug drug interaction. ERBITUX FOLOTYN ICLUSIG3 3. Clinical PA required for appropriate diagnosis LETROZOLE INLYTA MEGACE ES VIDAZA JAKAFI NEXAVAR1 POMALYST STRIVARGA SUTENT1,2 ZELBORAF SYLATRON FEMARA YERVOY XALKORI XTANDI ZELBORAF ZYTIGA Use PA Form# 20420 IMMUNOSUPPRESSANTS IMMUNOSUPPRESSANTS CYCLOSPORINE MODIFIED CELLCEPT CYCLOSPORINE SOL. MODIFIED GENGRAF CAPS CYCLOSPORINE CAPS 1. Established users will require a one time PA. 2. Established users will require a one time PA NEORAL1,2 MYCOPHENOLATE MYFORTIC Use PA Form# 20420 PROGRAF CAPS RAPAMUNE SANDIMMUNE PURINE ANALOG PURINE ANALOG IMURAN TABS AZASAN TABS Use PA Form# 20420 AZATHIOPRINE TABS K REMOVING RESINS 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 GABITRIL X POST HERPETIC NEURALGIA DIABETIC PERIPHERAL NEUROPATHY MONOTHERAPY BIPOLAR ADJUNCTIVE BIPOLAR 9Page 40 of 41 8 MIGRAINE PROPHYLAXIS FIBROMYALGIA SEIZURES NEURALGIA NEUROPATHY BIPOLAR BIPOLAR GABITRIL X 9 8 LAMICTAL X 4 4 LYRICA X TOPAMAX X 9 6 TRILEPTAL X 5 5 X(2nd line) 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 41 of 41
