Download VA Medicaid PDL List (effective 07/01/2011)

Virginia Medicaid Preferred Drug List With Service Authorization Criteria
Effective July 1, 2011
Provider Synergies, an affiliate of Magellan Medicaid Administration Phone: 1-800-932-6648 Fax: 1-800-932-6651
NOTE:
Fax requests receive a response within 24 hours.
For urgent requests, please call.
Not all medications listed are covered by all DMAS programs. Check individual program coverage.
For program drug coverage information, visit the following: http://www.VirginiaMedicaidPharmacyServices.com
All new products included in a PDL class are automatically non-preferred until reviewed by the P&T Committee
Within these categories, drugs that are not listed are subject to Service Authorization
This is not an all inclusive list.
Not all classes are part of the PDL
Routine PDL criteria guidelines will be considered as followed below to receive a Service Authorization.
1. Is there any reason the patient cannot be changed to a medication not requiring service approval within the same class?
Acceptable reasons include:
o Allergy to medications not requiring service approval
o Contraindication to or drug-to-drug interaction with medications not requiring service approval
o History of unacceptable/toxic side effects to medications not requiring service approval
o Patient’s condition is clinically unstable; changing to a medication not requiring service approval might cause deterioration
of the patient’s condition.
Document clinically compelling information
2. The requested medication may be approved if both of the following are true:
1. If there has been a therapeutic failure of no less than a one-month trial of at least one medication within the same
class not requiring service approval
2. The requested medications corresponding generic (if a generic is available and covered by the State) has been attempted
and failed or is contraindicated.
If the guidelines differ they will be listed along side the class with specific Service Authorization requirements.
All changes from last posting will be highlighted in Yellow
1
Virginia Medicaid Preferred Drug List With Service Authorization Criteria
Effective July 1, 2011
Preferred Agents
Non-Preferred Agents
SA Criteria
Analgesics
Non-Steroidal Anti-Inflammatory Drug
diclofenac potassium
diclofenac sodium
fenoprofen
ibuprofen
ketorolac
meloxicam
naproxen
naproxen sodium
piroxicam
sulindac
Anaprox®
Anaprox DS®
Ansaid®
Arthrotec®
Cataflam®
Celebrex®*
Clinoril®
Daypro®
diflunisal
Dolobid®
etodolac
etodolac SR
Feldene®
flurbiprofen
Indocin®
Indocin SR®
indomethacin
indomethacin
SR and rectal
ketoprofen
ketoprofen ER
Lodine®
Lodine XL®
meclofenamate
mefenamic
Mobic®
Motrin®
nabumetone
Nalfon®
Naprelan®
Naprosyn®
Orudis®
Oruvail®
oxaprozin
Ponstel®
Prevacid Naprapac®
Relafen®
Sprix® nasal spray
Tolectin DS®
Toradol®
tolmetin sodium
Vimovo®
Voltaren®
Voltaren XR®
Zipsor®
LENGTH OF AUTHORIZATIONS:
1 year
Routine PDL edit with exceptions noted below
Avinza®
Butrans®
Embeda®
Exalgo®
fentanyl
MS Contin®
Opana® ER
Oramorph SR®
oxycodone-long
acting
Oxycontin®
LENGTH OF AUTHORIZATIONS:
6 months
Step edit –Trial and failure of 2 different short acting
narcotics
The Step-Therapy is not required for those patients that
have been stabilized on Long Acting Narcotics or need
relief of moderate to severe pain requiring around-theclock opioid therapy, for an extended period of time. Still
subject to PDL criteria edit.
PDL edit -If patient has failed a preferred narcotic or there
is any reason the patient cannot be changed to a
medication not requiring service approval.
A one-month trial of at least two medications within the same
class not requiring SA
*Step edit required for Celebrex
History of a trial of a minimum of two (2) different nonCOX2 NSAIDs within the past year OR have concurrent
use of anticoagulants (warfarin/ heparin), methotrexate,
oral corticosteroids OR history of previous GI bleed or
conditions associated with GI toxicity risk factors (i.e.,
PUD, GERD, etc.) OR specific indication for Celebrex®,
which medications not requiring service approval are not
indicated.
Long Acting Narcotics
Duragesic®
Kadian®
morphine sulfate tablet SA®
2
Virginia Medicaid Preferred Drug List With Service Authorization Criteria
Effective July 1, 2011
Preferred Agents
Short Acting Narcotics
Narcotic Lozenges
fentanyl citrate
Short-Acting Narcotics
codeine
codeine/APAP
codeine/APAP/caff/butal
codeine/ASA
codeine/ASA/caff/butal
hydrocodone/APAP
hydrocodone/ ASA
hydrocodone/ ibuprofen
hydromorphone
meperidine
morphine IR
nalbuphine
oxycodone/APAP
oxycodone/ASA
oxycodone IR
tramadol HCL
tramadol HCL/APAP
Non-Preferred Agents
Actiq®
Fentora®
Onsolis®
All Brands require a SA
Abstral®
oxymorphone HCl
RyzoltTM
tramadol ER
Ultracet®
Ultram®
Ultram ER®
Zolvit®
SA Criteria
LENGTH OF AUTHORIZATIONS:
Routine PDL edit
Clinical edit for narcotic lozenges ONLY.
Both of the following need to be true:
The patient has a diagnosis of cancer AND the patient is
already receiving and tolerant of opioid therapy for their
underlying persistent cancer pain. Patients considered
opioid tolerant are those who are taking transdermal
fentanyl 25 mcg/h, morphine 60 mg/day or more,
oxycodone 30 mg/day, oral hydromorphone 8 mg/day, or
an equianalgesic dose of another opioid for one week or
longer.
Barbiturate & Non-Salicylates Analgesic Combinations
Phrenilin Forte®
acetaminophen-butalbital
®
Sedapap®
Bupap
®
Cephadyn
Opioid Dependency
buprenorphine SL
Suboxone®
Suboxone®film
3 months
Subutex®
3
Virginia Medicaid Preferred Drug List With Service Authorization Criteria
Effective July 1, 2011
Preferred Agents
Non-Preferred Agents
Topical Agents and Anesthetics
*Flector® patch
*Voltaren® gel
**Lidoderm® patch
*Pennsaid® topical solution
SA Criteria
LENGTH OF AUTHORIZATIONS:
Routine PDL edit
1 year
*Clinical Criteria for Flector®, Voltaren gel®, and
Pennsaid®:
Approval is based on patient failing the oral generic of the
desired product and at least one other preferred NSAID (to
equal a total of at least two preferred). For example, a patient
who failed ibuprofen or naproxen will still need to try oral
generic diclofenac for approval of Flector.
Pennsaid topical solution can only be approved for the FDA
approved indication of osteoarthritis of the knee.
Quantity limit for Flector® Patch of 30 units per RX
**Clinical Criteria for Lidoderm® Patch:
Lidoderm® patches can be approved for relief of pain
associated with post-herpetic neuralgia.
Antibiotic-Anti-Infective
Oral Antifungals for Onychomycosis
Grifulvin V® tablets
Griseofulvin oral ®
suspension
Gris-Peg®
terbinafine
itraconazole
Lamisil®
Lamisil ® granules
Sporanox capsules®
Sporanox solution®
LENGTH OF AUTHORIZATIONS:Duration of the
prescription (up to 6 months)
Routine PDL edit
Sporanox
Indications: Aspergillosis, Candidiasis (oral or esophageal),
Histoplasmosis, Blastomycosis, empiric treatment of febrile
neutropenia
Lamisil ® granules
Indication is tinea capitis and the recipient must be over 4
years of age.
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Virginia Medicaid Preferred Drug List With Service Authorization Criteria
Effective July 1, 2011
Preferred Agents
Oral Cephalosporins
Non-Preferred Agents
Second Generation Cephalosporins
Ceftin® tablets / suspension
cefaclor
cefuroxime axetil suspension
capsule/ER/suspension
cefprozil capsule/suspension Cefzil® tablets / suspension
cefuroxime tablets
Raniclor®
Third Generation Cephalosporins
Cedax® capsule/suspension
cefdinir capsule/suspension
®
cefditoren pivoxil
Spectracef
cefpodoxime proxetil capsule/suspension
Suprax® suspension/tablets
Omnicef®
SA Criteria
LENGTH OF AUTHORIZATIONS: date of service only;
no refills
Potential reasons for SA are:
Infection caused by an organism resistant to medications
not requiring service approval OR a therapeutic failure to
no less than a three-day trial of one medication within
the same class not requiring service approval OR the
patient is completing a course of therapy with a
medication requiring a service authorization, which was
initiated in the hospital.
Oral Macrolides
Macrolides & Ketolides
azithromycin
packet/suspension/tablet
clarithromycin
tablet/suspension
E.E.S. ®*
EryC®*
Eryped®*
erythrocin stearate
erythromycin base
erythromycin ethylsuccinate
erythromycin estolate
suspension
erythromycin stearate
erythromycin / sulfisoxazole
Biaxin®tablet/ suspension/XL®
clarithromycin ER
Dynabac®
Ery-tab®
Ketek®**
PCE®
Zithromax® tablet/suspension
ZMAX suspension®
LENGTH OF AUTHORIZATIONS: date of service only;
no refills
Potential reasons for SA are:
Infection caused by an organism resistant to medications
not requiring service approval OR a therapeutic failure to
no less than a three-day trial of one medication within
the same class not requiring service approval OR the
patient is completing a course of therapy with a
medication requiring a service authorization, which was
initiated in the hospital.
*Generics not available in some strengths/dosage forms
**To receive a SA for Ketek®, a specific Ketek SA request
form must be completed and faxed or mailed to Magellan
Medicaid Administration with the physician's signature.
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Virginia Medicaid Preferred Drug List With Service Authorization Criteria
Effective July 1, 2011
Preferred Agents
Oral Quinolones
Non-Preferred Agents
Second Generation Quinolones
Cipro® IR/ XR
Cipro® suspension
ciprofloxacin suspension/ER
ciprofloxacin tablet
Floxin
Maxaquin®
Noroxin®
ofloxacin
Proquin XR®
SA Criteria
LENGTH OF AUTHORIZATIONS: date of service only;
no refills
Potential reasons for SA are:
Infection caused by an organism resistant to medications
not requiring service approval OR a therapeutic failure to
no less than a three-day trial of one medication within
the same class not requiring service approval OR the
patient is completing a course of therapy with a
medication requiring a service authorization, which was
initiated in the hospital.
Third Generation Quinolones
Factive®
Avelox®
®
Levaquin® tablet/suspension
Avelox ABC PACK
Proquin XR®
Zagam®
Otic Quinolones
Ciprodex®
ofloxacin
Cetraxal®
Cipro HC®
Floxin®
LENGTH OF AUTHORIZATION
Date of service only; no refills
Routine PDL edit
Altabax® *
Bactroban® cream and ointment
CentanyTM
Centany AT® Kit
LENGTH OF AUTHORIZATIONS:
Date of service only; no refills
Routine PDL edit
*Has a 15 gram per 34 day quantity limit
famciclovir
valacyclovir
Zovirax® suspension/tablet
LENGTH OF AUTHORIZATIONS:
Routine PDL edit
Topical
mupirocin ointment
Antivirals
Herpes
acyclovir suspension/tablets
Famvir ®
Valtrex ®
6
1 year
Virginia Medicaid Preferred Drug List With Service Authorization Criteria
Effective July 1, 2011
Preferred Agents
Influenza
Non-Preferred Agents
SA Criteria
amantadine
tablet/capsule/syrup
Relenza Disk®
rimantadine
Tamiflu® capsule/suspension
Flumadine® syrup/tablet
LENGTH OF AUTHORIZATIONS:
For diagnosis of influenza, the authorization is for the date of
service only;
no refills
Routine PDL edit
Interferon for Hepatitis C
Pegasys®
Pegasys Conv.Pack®
Peg-Intron®
Peg-Intron Redipen®
LENGTH OF AUTHORIZATIONS:
All products require a Clinical SA
Clinical SA for initial 16 week SA:
Initial approval periods limited to 16-weeks and viral titer
obtained at week 12 of therapy.
Clinical SA for established HCV reactors:
1) Therapy is approvable for a total of 24 weeks in patients
that are HCV genotypes 2 or 3 who have achieved a
virologic response (either undetectable HCV RNA [<50
IU/mL] or at least a 2-log drop in HCV RNA titer from
baseline) at 12 weeks of treatment.
2) Therapy is approvable for total of 48 weeks in HCV
genotype 1 or 4 patients who have achieved a virologic
response (either undetectable HCV RNA [<50 IU/mL] or
at least a 2-log drop in HCV RNA titer from baseline) at
12 weeks of treatment.
3) If patient fails to achieve a virologic response by 12
weeks, further treatment is not indicated.
Topical: Herpes
Abreva OTC®
Zovirax® ointment
Denavir®
Xerese® cream
Zovirax® cream
LENGTH OF AUTHORIZATIONS:
Routine PDL edit
7
1 year
Virginia Medicaid Preferred Drug List With Service Authorization Criteria
Effective July 1, 2011
Preferred Agents
Non-Preferred Agents
SA Criteria
Cardiac
Anticoagulants
Low Molecular Weight Heparin includes FactorXA Inhibitor
enoxaparin
Arixtra ®
Innohep ®
Fragmin ®
®
Lovenox
Oral Anticoagulants
warfarin
Coumadin®
Jantoven®
Pradaxa®*
LENGTH OF AUTHORIZATION:
1 year
Routine PDL edit
*Oral Anticoagulants Clinical edit
Pradaxa® will be approved if all of the following are true:
Diagnosis of non valvular atrial fibrillation; AND
Patient has at least one risk factor:
o History of stroke, TIA, or systemic embolism; OR
o Age ≥ 75 years; OR
o Diabetes mellitus; OR
o History of left ventricular dysfunction or heart
failure; OR
o Age ≥65 years with the presence of one of the
following: diabetes mellitus, coronary artery disease
(CAD), or hypertension; OR
o Patient does not have access to warfarin
management.
ACE Inhibitors, Angiotensin Receptors Blockers, Beta-Blockers
ACE Inhibitors
benazepril
captopril
enalapril
lisinopril
Accupril®
Aceon®
Altace®capsule/table
Capoten®
Fosinopril
Lotensin®
Mavik®
moexipril
Monopril®
perindopril
Prinivil®
quinapril
ramipril
trandolapril
Univasc®
Vasotec®
Zestril®
LENGTH OF AUTHORIZATION:
Routine PDL edit
8
1 year
Virginia Medicaid Preferred Drug List With Service Authorization Criteria
Effective July 1, 2011
Preferred Agents
Non-Preferred Agents
ACE Inhibitors + Diuretic Combinations
Accuretic®
benazepril/HCTZ
captopril/HCTZ
Capozide®
enalapril/HCTZ
fosinopril/HCTZ
lisinopril/HCTZ
Lotensin HCT®
moexipril/HCTZ
Monopril HCT®
Prinzide®
quinapril/HCTZ
Quinaretic®
SA Criteria
Uniretic®
Univasc®
Vaseretic®
Zestoretic®
ACE Inhibitors + Calcium Channel Blocker Combinations
amlodipine/benazepril (5/50 ;10/40)
amlodipine/benazepril
Lexxel®
(2.5/10, 5/10, 5/20 & 10/20)
®
Lotrel (5/40 and 10/40)
Lotrel® (2.5/10, 5/10, 5/20 & 10/20)
Tarka
Teczem®
trandolapril/verapamil hydrochloride ER
Angiotensin Receptor Blockers
Atacand®
Diovan® *
losartan
Avapro®
Benicar®
Cozaar®
Edarbi®
Micardis®
Teveten®
Angiotensin Receptor Blockers + Diuretic Combinations
Atacand HCT®
Hyzaar®
Diovan HCT®*
Micardis HCT®
losartan/HCTZ
Avalide®
Teveten HCT®
Benicar HCT®
*Step edit requires a trial and failure of losartan
*Step edit requires a trial and failure of losartan/HCTZ
9
Virginia Medicaid Preferred Drug List With Service Authorization Criteria
Effective July 1, 2011
Preferred Agents
Non-Preferred Agents
SA Criteria
Angiotensin Receptor Blockers + Calcium Channel Blocker
Combinations
Azor®
N/A
Exforge®
Exforge®HCT
Tribenzor®
Direct Renin Inhibitors (includes combination)
Amturnide™
Twynsta®
N/A
®
Tekturna
Valturna®
®
Tekturna HCT
Beta Blockers
Betapace®
Kerlone®
acebutaolol
®
Betapace AF
Levatol®
atenolol
betaxolol
Lopressor®
bisoprolol fumarate
®
Blockadren
metoprolol
carvedilol
Bystolic®
succinate
labetalol
Cartrol®
Normodyne®
metoprolol tartrate
®
Coreg
propranolol LA
nadolol
Coreg CR®
Sectral®
pindolol
®
Corgard
Tenormin®
propranolol solution/tablet
®
®
Inderal
Toprol XL®
Sorine
®
Inderal LA
Trandate®
sotalol AF
®
Innopran XL
Visken®
sotalol HCL
Zebeta®
timolol maleate
Beta Blockers + Diuretic Combinations
Corzide®
atenolol/chlorthalidone
Inderide®
bisoprolol/HCTZ
Lopressor HCT®
metoprolol/HCTZ
nadolol/bendroflumethiazide Tenoretic®
Timolide®
propranolol/HCTZ
Ziac®
10
Virginia Medicaid Preferred Drug List With Service Authorization Criteria
Effective July 1, 2011
Preferred Agents
Non-Preferred Agents
SA Criteria
Calcium Channel Blockers: Dihydropyridine CCB &Non-Dihydropyride CCB
Dihydropyridine Calcium Channel Blockers
Adalat ®
Afeditab CR®
Adalat CC®
amlodipine
®
Cardene®
Dynacirc CR
Cardene SR®
felodipine ER
Dynacirc®
nicardipine
®
Dynacirc CR®
Nifediac CC
®
isradipine
Nifedical XL
nisoldipine
nifedipine
Norvasc®
nifedipine ER
Procardia®
nifedipine SA
Procardia XL®
Plendil®
Sular®
Non-Dihydropyridine Calcium Channel Blockers
Calan®
Cartia XT®
®
Calan SR®
Diltia XT
Cardizem®
diltiazem
Cardizem CD®
diltiazem ER q 24hr
Cardizem LA®
diltiazem ER q 12hr
Cardizem SR
diltiazem XR
Covera HS®
Taztia XT®
Dilacor XR®
verapamil
diltiazem SR q 12hr
verapamil SA
Isoptin SR®
verapamil 24hr pellets
Tiazac®
Verelan®
Verelan PM®
LENGTH OF AUTHORIZATIONS:
Routine PDL edit
1 year
There are two main classes of Calcium Channel Blockers
(each with different actions on the peripheral vasculature and
cardiac tissue):
o
o
11
Dihydropyridine Calcium Channel Blockers
(DHPCCB)
Non-Dihydropyridine Calcium Channel Blockers
(NDHPCCB)
Virginia Medicaid Preferred Drug List With Service Authorization Criteria
Effective July 1, 2011
Preferred Agents
Lipotropics
Non-Preferred Agents
HMG CoA Reductase Inhibitors and Combinations (Statins)
Advicor®
lovastatin
Altoprev®
pravastatin
Lescol®
Lescol XL®
Mevacor®
Pravachol®
HMG CoA Reductase Inhibitors and Combinations (High Potency
Statins)
Crestor®
simvastatin
Lipitor®
Livalo®
Vytorin®
Zocor®
Fibric Acid Derivatives
fenofibrate
Lopid®
Antara®
®
Fenoglide
Tricor®
gemfibrozil
®
Lipofen
Triglide®
®
Lofibra
Trilipix™
Niacin Derivatives
Niacor®
Niaspan®
Niacin Derivatives & HMG CoA Reductase Inhibitors (Statins)
Combination
Simcor®*
CAI
Zetia®
Omega 3 Fatty Acid Agent
**Lovaza®
SA Criteria
LENGTH OF AUTHORIZATIONS:
1 year
1) Therapeutic failure to no less than three-month trial of
at least one medication not requiring service
approval.
* Requires a history of either a niacin or simvastatin product
within the past 365 days
**Lovaza®
o Step edit is the trial and failure of any other lipotropic.
o A SA may also be approved without any specific
preferred medication trial, if they have documented very
high triglycerides of (≥ 500 mg/dL) in adult patients.
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Virginia Medicaid Preferred Drug List With Service Authorization Criteria
Effective July 1, 2011
Preferred Agents
Non-Preferred Agents
SA Criteria
Bile Acid Sequestrants
cholestyramine
powder/powder Light
Colestid®
granules/packet/tablet
Colestipol HCl
granules/packet/tablet
Prevalite®
Questran® powder/powder
Light
Welchol ® packet/tablet
Phosphodiesterase 5 Inhibitors for Pulmonary Arterial Hypertension
Adcirca TM
Revatio®
Revatio injection®
LENGTH OF AUTHORIZATIONS:
1 year
1) Diagnosis of Pulmonary Hypertension in patients >18
years is required.
2) The requested medication may be approved if both of the
following are true:
o The prescribing physician is a pulmonary specialist
or cardiologist and will be followed by the
prescribing physician.
3) Must have a rationale for not taking the oral Revatio to
receive a SA for the injectable Revatio.
4) Contraindications where the SA should not be approved:
o Concurrent use of nitrates (e.g., nitroglycerin)
o Hypersensitivity to product
Platelet Inhibitors
Aggrenox®
dipyridamole
Effient®
Plavix®
ticlopidine HCL
Persantine®
LENGTH OF AUTHORIZATION:
Routine PDL edit
13
1 year
Virginia Medicaid Preferred Drug List With Service Authorization Criteria
Effective July 1, 2011
Preferred Agents
Non-Preferred Agents
SA Criteria
Central Nervous System
Non-Ergot Dopamine Receptor Agonist
pramipexole
ropinirole HCl
Mirapex®
Mirapex ER®
Requip®
Requip Dose Pack®
Requip®XR
LENGTH OF AUTHORIZATIONS:
Routine PDL edit
1 year
ADDITIONAL INFORMATION TO AID IN THE
FINAL DECISION
o If requested for treatment of Parkinson’s, may approve
without the necessary trial of a preferred agent if the
patient has swallowing issues that causes them to be
unable to use a preferred product OR if the request is for
continuation of established therapy.
o If requested for treatment of restless legs, forward
request to a pharmacist to be denied.
o An indication that is unique to a non-preferred agent and
is supported by peer-reviewed literature or an FDAapproved indication, or Age specific indication, or
Medical co-morbidity, unique patient circumstance,
other medical complications, or Clinically unacceptable
risk with a change in therapy to preferred agent.
Sedative / Hypnotic
Sedative Hypnotics (Benzodiazepine)
Dalmane®
chloral hydrate syrup
Doral®
estazolam
Halcion®
flurazepam
Prosom®
temazepam
Restoril®
triazolam
LENGTH OF AUTHORIZATIONS:
Length of the prescription (up to 3 months)
Routine PDL edit
1) To receive a non preferred benzodiazepine there must
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Virginia Medicaid Preferred Drug List With Service Authorization Criteria
Effective July 1, 2011
Preferred Agents
Non-Preferred Agents
Sedative Hypnotics (Non-Benzodiazepine) See step edit
Ambien®
Rozerem®
Ambien CR®
zolpidem
EdluarTM
Lunesta®
Somnote®
Sonata®
Zaleplon®
Zolpimist TM oral spray
SA Criteria
have been a therapeutic failure to no less than a onemonth trial of at least one benzodiazepine not requiring
service approval.
2) To receive a preferred non benzodiazepine there must
have been a therapeutic failure to no less than a onemonth trial of a benzodiazepine (step edit)
3) To receive a non preferred non benzodiazepine there
must have been a therapeutic failure to no less than a
one-month trial of first a benzodiazepine (step edit) and
second a therapeutic failure to not less than a one-month
trial of Rozerem®
For patients age 65 and older, Rozerem®, Ambien® or
Lunesta may be approved after a trial of trazodone
(duration = at least one month). It is not necessary for
patient’s ≥ 65 to try a benzodiazepine if they have had a trial
of trazodone.
Antimigraine Agents
Maxalt ® MLT
Relpax®
sumatriptan succinate
cartridge, nasal, pen, tablet,
vial
Amerge®
Axert®
Cambia®
Frova®
Imitrex® cartridge, nasal, pen kit, tablet,
vial
Maxalt®
naratriptan
Treximet
Zomig® tablets, nasal spray, ZMT
LENGTH OF AUTHORIZATIONS:
Routine PDL edit
6 months
CLINICAL CONSIDERATIONS:
Service Authorization will not be given for prophylactic
therapy of migraine headache unless the patient has
exhausted or has contraindications to all other ―controller‖
migraine medications (i.e., beta-blockers, calcium channel
blockers, etc) and the physician and patient are aware of the
adverse risk potential.
15
Virginia Medicaid Preferred Drug List With Service Authorization Criteria
Effective July 1, 2011
Preferred Agents
Non-Preferred Agents
Skeletal Muscle Relaxants
baclofen
carisoprodol
carisoprodol/ASA
carisoprodol/ASA/codeine
chlorzoxazone
cyclobenzaprine HCL
dantrolene sodium
methocarbamol
tizanidine
Amrix®
Dantrium®
Fexmid®
Flexeril®
metaxalone
Norflex®
orphenadrine citrate
orphenadrine/ASA/caffeine
Parafon Forte DSC®
Robaxin®
Skelaxin®
Soma®
Zanaflex®
SA Criteria
LENGTH OF AUTHORIZATIONS:
1 year for chronic conditions
Duration of prescription (up to 3 months) for acute
conditions
Routine PDL edit
ADDITIONAL INFORMATION TO AID IN FINAL
DECISION
1) If there is a specific indication for a medication requiring
service approval, for which medications not requiring
service approval are not indicated, then may approve the
requested medication. This medication should be
reviewed for need at each request for reauthorization.
2) Chronic Conditions:
Multiple Sclerosis
Spasticity
Cerebral Palsy
Muscle rigidity as a result of spinal cord/ brain
injury or disease
3) Acute Conditions:
Muscle spasm associated with acute painful musculoskeletal
conditions (ex. Generalized back, neck, or shoulder pain and
muscle spasms attributed to trauma)
Smoking Cessation
bupropion SR
Chantix®
Chantix® Tab DS PK
Nicotrol® Inhaler
Nicotrol ®NS
nicotine gum
nicotine lozenge
nicotine patch
Commit ®Lozenge
Nicoderm CQ® Patch
Nicorette Gum
Zyban
LENGTH OF AUTHORIZATIONS:
Routine PDL edit
16
6 months
Virginia Medicaid Preferred Drug List With Service Authorization Criteria
Effective July 1, 2011
Preferred Agents
Non-Preferred Agents
Stimulants/ADHD Medications
Amphetamine Products
amphetamine salts combo
dextroamphetamine
Vyvanse®
Methylphenidate Products
Concerta®
Focalin XR®
All methylphenidate generic
IR tablets
Adderall®
Adderall XR®(see criteria)
amphetamine salts combo XR
Desoxyn®
Dexedrine®
dextroamphetamine SR
Dextrostat®
methamphetamine
Daytrana™ transdermal
dexmethylphenidate
Focalin®
Metadate CD®
Metadate ER®
Methylin ER®
Methylin chew®
Methylin solution®
methylphenidate oral solution
methylphenidate SR
Procentra solution®
Ritalin®
Ritalin LA®
Ritalin SR®
SA Criteria
LENGTH OF AUTHORIZATION:
Routine PDL edit
1 year
1) If the patient requires a service authorized medication
based on a specific medical need that is not covered by
the FDA indications of one of the preferred
medications, a SA will be granted for a non-preferred
medication.
2) This should be reviewed for need at each request for
reauthorization.
Adderall XR®If a trial & failure of a preferred product occurs and the
physician requests Adderall XR® or amphetamine salts
combo XR. The brand Adderall XR®- is preferred over
the generic.
Clinical Criteria for Nuvigil/Provigil:
Length of Authorization:
1 year for Sleep Apnea and Narcolepsy;
6 months for Shift work sleep disorder.

Approvable diagnosis’ include:
o Sleep Apnea: Requires
documentation/confirmation via sleep study.
Requires documentation that C-PAP has been
maximized.
o Narcolepsy: Documentation of diagnosis via
sleep study.
o Shift Work Sleep disorder: ONLY
APPROVABLE FOR 6 MONTHS, work
schedule must be verified and documented.
Shift work is defined as working the all night
shift.


Minimum age of 16 Provigil® (modafanil)
Minimum age of 17 Nuvigil (armodafinil)
17
Virginia Medicaid Preferred Drug List With Service Authorization Criteria
Effective July 1, 2011
Preferred Agents
Miscellaneous Products
Strattera®
Non-Preferred Agents
SA Criteria
Intuniv®
Kapvay® SR 12H
Nuvigil TM
Provigil®
Dermatologic
Dermatologic Agents
Combo Benzoyl Peroxide & Clindamycin
Benzaclin®
benzoyl peroxide
Benzaclin ®CareKit
clindamycin
Clindamycin 1%/Benzoyl Peroxide 5%
Duac CS®
Duac® gel
Topical Retinoids/Combinations
adapalene 0.1% cream
Differin® cream 0.1%
adapalene 0.1% topical gel
Differin® gel 0.1% & 0.3%
Altinac®
Retin®-A Micro
®
atralin
Retin -A Micro Pump
Differin® 0.1% topical lotion
tretinoin
Epiduo®
Retin-®A
Tazorac®
Tretin®-X
Ziana®
LENGTH OF AUTHORIZATION:
Routine PDL edit
1 year
1. Failure to respond to a therapeutic trial of at least two
weeks of one preferred medication
ADDITIONAL INFORMATION TO AID IN THE
FINAL DECISION
o Topical retinoids will reject for 21 and older - this
can not be overridden.
o Renova and other products considered to have
only a cosmetic indication are not covered by
Virginia Medicaid.
o If the patient is completing a course of therapy
with a medication requiring service approval,
which was initiated in the hospital or other similar
location, or if the patient has just become
Medicaid eligible and is already on a course of
treatment with a medication requiring service
approval, then the requested medication may be
approve.
18
Virginia Medicaid Preferred Drug List With Service Authorization Criteria
Effective July 1, 2011
Preferred Agents
Topical Agents for Psoriasis
calcipotriene
Dovonex®
Psoriatic®
Non-Preferred Agents
SA Criteria
Anthralin
Calcitrene®
Dovonex® Scalp
Micanol®
Taclonex®
Taclonex® Scalp
Vectical®
Endocrine and Metabolic Agents
Androgenic Agents (Testosterone – Topical)
Androderm
Androgel
Axiron solution
Fortesta
Testim
LENGTH OF AUTHORIZATION:
1 year
Failure to respond to a therapeutic trial of at least one
week of one non-service authorized medication
Contraceptives
LENGTH OF AUTHORIZATION:
Oral Contraceptives
Apri
Junel Fe
Loestrin
Lo-Ovral-28
Micronor
Nor-Q-D
Nortrel
Ortho-Cyclen
Ortho-Novum
Ortho Tri-Cyclen
Ortho Tri-Cyclen Lo
Ovcon-50
Portia
Sprintec
Tri-Sprintec
Yasmin 28
Yaz
All other oral contraceptives
1 year
If there is a specific indication for a medication
requiring service approval, for which medications not
requiring service approval are not indicated, then may
approve the requested medication.
19
Virginia Medicaid Preferred Drug List With Service Authorization Criteria
Effective July 1, 2011
Preferred Agents
Non-Preferred Agents
SA Criteria
Etonogestrel/Ethinyl Estradiol Vaginal Ring
NuvaRing®
Norelgestromin/Ethinyl Estradiol Transdermal
Ortho Evra®
Diabetes Hypoglycemics: Injectable Amylin Analogs
Symlin®
LENGTH OF AUTHORIZATION:
1 year
Clinical edit
1. The recipient must have a history of at least a 90 day
trial of insulin.
2. Symlin is only indicated as adjunct therapy with
insulin.
3. Recipient meeting ALL of the following criteria may
be approved:
Diagnosis of Type 1 or 2 diabetes
On insulin therapy
Failure to achieve adequate glycemic control
(HbA1c ≤ 6.5%)
Diabetes Hypoglycemics: Injectable Incretin Mimetics
Byetta®
Victoza®
LENGTH OF AUTHORIZATION:
Routine PDL edit
1 year
ADDITIONAL INFORMATION TO AID IN FINAL
DECISION
If there is a specific indication for a medication requiring
service approval, for which medications not requiring
service approval are not indicated, then may approve the
requested medication.
Diabetes Hypoglycemics: Injectable Insulins
Long-Acting Insulins
Lantus vial
Levemir pen and vial
Rapid-Acting Insulins
Humalog® cartridge,
Kwikpen, and vial
Novolog® cartridge, Flexpen
Syringe, and vial
Lantus Solostar and cartridge
LENGTH OF AUTHORIZATION:
Routine PDL edit
1.
Apidra cartridge, Solostar, and vial
20
1 year
Therapeutic failure of one non-service authorized
medication. For approval of a non-preferred insulin,
the patient must have a failure on the equivalent
preferred product if one is available (ex. Approval of
Humalog® would require a failure on Novolog®).
Virginia Medicaid Preferred Drug List With Service Authorization Criteria
Effective July 1, 2011
Preferred Agents
Non-Preferred Agents
SA Criteria
Insulin Mix
Humalog Mix 75/25 vial
Humalog Mix 50/50 vial
Humalog Mix 50-50 Kwikpen
Humalog Mix 75-25 Kwikpen
Novolog Mix 70/30 pen and
vial
Humulin 70/30 pen and vial
Novolin 70/30 vial
Insulin N
Humulin N pen and vial
Novolin N vial
Insulin R
Humulin R vial
Novolin R vial
2.
Pens/cartridges should only be approved if there is a
physical reason (such as dexterity problems, vision
impairment) vials cannot be used. Approvals should
not be granted based on issues of convenience or
compliance.
Will be approved for individuals meeting the
following criteria:
o Recipient or caregiver has poor eyesight such that
dosing errors may occur
o Recipient or caregiver has problems with manual
dexterity which may result in dosing errors (i.e.
Parkinson’s disease, rheumatoid arthritis in the
finger/hand joints, multiple sclerosis)
o Recipient is under 18 years of age
Additional information to aid in the final decision:
If Humalog® is authorized and the patient is to mix with
Humulin® (any formulation), then approve the Humulin®
medication(s).
Diabetes Oral Hypoglycemics
Oral Hypoglycemics Alpha-Glucosidase Inhibitors
Precose®
acarbose
®
Glyset
Oral Hypoglycemics Biguanides
Fortamet®
metformin
Glucophage®
metformin ER
Glucophage ®XR
Glutmetza®
Riomet® suspension
Oral Hypoglycemics Biguanide Combination Products
Glucovance®
Avandamet®
Metaglip®
glipizide/metformin
glyburide/metformin
LENGTH OF AUTHORIZATION:
Routine PDL edit
21
1 year
Virginia Medicaid Preferred Drug List With Service Authorization Criteria
Effective July 1, 2011
Preferred Agents
Non-Preferred Agents
SA Criteria
Oral Hypoglycemics DPP-IV Inhibitors and Combination
Kombiglyze XRTM
Janumet®
®
TradjentaTM
Januvia
TM
Onglyza
Oral Hypoglycemics Meglitinides
nateglinide
Starlix®
Prandin®
PrandiMetTM
Oral Hypoglycemics Thiazolidinediones
Actoplus Met®
Actos 15mg®, 30mg, and 45
Avandaryl®
mg
®
Duetact®
Avandamet
®
Avandia
Oral Hypoglycemics Second Generation Sulfonylureas
Amaryl®
glimepiride
Diabeta®
glipizide
Glucotrol®
glipizide ER
Glucotrol XL®
glyburide
Glynase®
glyburide micronized
Micronase®
Antihyperuricemics
allopurinol
Probenecid®
Probenecid and Colchicine
*Colcrys®
Uloric®
LENGTH OF AUTHORIZATION:
Routine PDL edit
1 year
*Clinical Criteria for: Colcrys™
Approve if one of the following is true:
Diagnosis of Familial Mediterranean Fever; OR
For Acute Gout Flare:
o Trial and failure of one of the following:
 NSAID (i.e., indomethacin,
naproxen, ibuprofen, sulindac,
ketoprofen) OR
 Corticosteroid
22
Virginia Medicaid Preferred Drug List With Service Authorization Criteria
Effective July 1, 2011
Preferred Agents
Growth Hormone
Genotropin®
Nutropin AQ® NuSpinTM
Non-Preferred Agents
Humatrope® cartridge and vial
Norditropin cartridge®
Norditropin FlexPro®
Norditropin Nordiflex®
Nutropin®
Nutropin AQ® cartridge and vial
Omnitrope®
Saizen® cartridge and vial
Serostim®
Tev-Tropin®
Zorbtive®
SA Criteria
All Growth Hormones requires a clinical SA
PEDIATRICS
LENGTH OF AUTHORIZATION (pediatrics): 1 year
PEDIATRICS (18 years of age and under) Clinical
Criteria for Approval:
1.
Prescriber is an endocrinologist, nephrologists,
infectious disease specialist or HIV specialist or one
has been consulted on this case,
2. The patient has open epiphysis and one of the
following diagnoses
o Turner Syndrome
o Prader-Willi Syndrome
o Renal insufficiency
o Small for gestational age (SGA) - including
Russell-Silver variant and patient is < 2 years old
o Idiopathic Short Stature (for request for renewal
only (a) information is required to be approved)
o Growth hormone deficiency (physician should
provide the required information below)
o Newborn with hypoglycemia and a diagnosis of
hypopituitarism or panhypopituitarism.
3. Height is more than 2 SD (standard deviations) below
average for the population mean height for age and sex,
and a height velocity measured over one year to be 1
SD below the mean for chronological age, or for
children over two years of age, a decrease in height SD
of more than 0.5 over one year;
AND
4. Growth hormone response of less than 10ng/ml to at
least two provocative stimuli of growth hormone
release: insulin, levodopa, L-Arginine, clonidine, or
glucagon
23
Virginia Medicaid Preferred Drug List With Service Authorization Criteria
Effective July 1, 2011
Preferred Agents
Non-Preferred Agents
SA Criteria
Requests for Renewal (pediatrics):
a. For renewal, a response must be documented. Patient
must demonstrate improved/normalized growth
velocity. (Growth velocity has increased by at least 2
cm in the first year and is greater than 2.5 cm per
year),
AND
b. Patient height is less than 5’ 6" for males or 5' 1" for
females, and is more than 1 standard deviation (2")
below mid-parental height (unless parental height is
diminished due to medical or nutritional reasons).
ADULTS Growth Hormones
LENGTH OF AUTHORIZATION: 1 year (Serostim®
– 3 months * see below)
ADULTS (> 18 years of age) Clinical Criteria for
Approval:
Prescriber is an endocrinologist and has:
Diagnosis of growth hormone deficiency confirmed by
growth hormone stimulation tests and rule-out of other
hormonal deficiency, as follows: growth hormone
response of fewer than five nanograms per mL to at
least two provocative stimuli of growth hormone
release: insulin, levodopa, L-Arginine, clonidine or
glucagon when measured by polyclonal antibody (RIA)
or fewer than 2.5 nanograms per mL when measured
by monoclonal antibody (IRMA);
Cause of growth hormone deficiency is Adult Onset
Growth Hormone Deficiency (AO-GHD), alone or
with multiple hormone deficiencies, such as
hypopituitarism, as a result of hypothalamic or
pituitary disease, radiation therapy, surgery or trauma
Other hormonal deficiencies (thyroid, cortisol or sex
steroids) have been ruled out or stimulation testing
would not produce a clinical response such as in a
diagnosis of panhypopituitarism.
24
Virginia Medicaid Preferred Drug List With Service Authorization Criteria
Effective July 1, 2011
Preferred Agents
Non-Preferred Agents
SA Criteria
Zorbtive®- Diagnosis of short bowel syndrome
Serostim®
o Diagnosis of AIDS Wasting or cachexia
o Patient has a documented failure, intolerance, or
contraindication to appetite stimulants and/or other
anabolic agents (both Megace® and Marinol®)
*Length of Authorization (Serostim® only): 3 months
initial; then 1 year.
Renewal is contingent upon improvement in lean body
mass or weight measurements.
Requests for Renewal (adults)
Renewal is contingent upon prescriber affirmation of
positive response to therapy (improved body composition,
reduced body fat, and increased lean body mass).
Erythropoiesis Stimulating Proteins: Epogen®, Procrit® (Erythropoietin) & Aranesp® (Darbepoetin)
Procrit®
Aranesp®
Epogen®
LENGTH OF AUTHORIZATION: for duration of the
prescription up to 6 months
Routine PDL edit
Clinical Information for Pharmacists;
RENEWAL REQUESTS for patients with anemia due to
chronic renal failure/end stage renal disease should be
approved, even if the Hgb or Hct are above the cutoff point.
Progestational Agents
LENGTH OF AUTHORIZATION:
Routine PDL edit
medroxyprogesterone
acetate (tablet only)
norethindrone acetate
progesterone
Prometrium®
Provera®
1 year
Failure to respond to a therapeutic trial of at least one week
of one non-service authorized medication
Progestins Used For Cachexia
megestrol acetate
Megace®
Megace® ES
LENGTH OF AUTHORIZATION:
Routine PDL edit
25
1 year
Virginia Medicaid Preferred Drug List With Service Authorization Criteria
Effective July 1, 2011
Preferred Agents
Vaginal Estrogens
Non-Preferred Agents
Premarin Vaginal cream
Vagifem Vaginal tablets
Estrace Vaginal cream
Estring Vaginal ring
Femring Vaginal ring
SA Criteria
LENGTH OF AUTHORIZATION:
Routine PDL edit
6 months
LENGTH OF AUTHORIZATION:
Routine PDL edit
1 year
Gastrointestinal
Histamine-2 Receptor Antagonists (H-2 RA)
famotidine
ranitidine capsule, tablet,
and syrup
Axid® capsule and solution
cimetidine tablet and syrup
famotidine oral suspension
nizatidine capsule and suspension
Pepcid ®oral suspension and tablet
Tagamet®
Zantac® syrup and tablet
1.
Patient’s condition is clinically unstable—patient has
had an ER visit or at least two hospitalizations for
asthma in the past thirty days—changing to a
medication not requiring service approval might cause
deterioration of the patient’s condition.
2.
Approve if treatment was initiated in the hospital for
the treatment of a condition such as a GI bleed.
Motility Agents – GI Stimulants
metoclopramide
Metozolv® ODT
Reglan®
LENGTH OF AUTHORIZATION:
Routine PDL edit
12 weeks
This medication should be reviewed for need at each
request for reauthorization.
Black box warning placed on product for TARDIVE
DYSKINESIA 2/27/2009
Proton Pump Inhibitors
pantoprazole*
Prevacid® OTC
Prilosec® OTC
Aciphex®
Dexilant®
lansoprazole
Nexium®
omeprazole RX and OTC 20mg (no SA
required if age < 12yrs)
omeprazole/sodium bicarbonate
Prevacid® RX
Prevacid® susp (no SA required if age <
LENGTH OF AUTHORIZATIONS: dependent on
criteria met
*Step one requires a therapeutic failure of a 60-day trial of
OTC Prilosec® (up to 40mg daily) or OTC Prevacid® (up
to 30mg daily) to be approved for 120 days.
For exceptions to this, see criteria for ―proton pump
inhibitors exception‖.
26
Virginia Medicaid Preferred Drug List With Service Authorization Criteria
Effective July 1, 2011
Preferred Agents
Non-Preferred Agents
12yrs)
Prevacid® solutab (no SA required if age <
12yrs)
Prilosec® Rx form
Prilosec® suspension
Protonix®
Zegerid® capsule
Zegerid® OTC
Zegerid® susp packet
SA Criteria
Step two: the other preferred medication, pantoprazole
must be tried/failed
Routine PDL edit
Proton Pump Inhibitors exceptions
If an exception is met, approve desired product and make
the duration for 1 year. Step therapy requirements detailed
above do not apply.
 Erosive Esophagitis
 Active GI Bleed
 Zollinger-Ellison Syndrome
 Greater than 65 years of age
 If Failed 120 day trial and is under the
care of a Gastroenterologist and has ruled
out a nonsecretory condition
SPECIAL CONSIDERATION:
o pantoprazole is a delayed release tablet and cannot be
crushed or opened.
o For tubed patients or patients with swallowing
difficulties omeprazole, Prevacid®, Prevacid Solutab®,
Prilosec®, Nexium® or Prevacid® granules (if oral
administration) can be used. These Proton Pump
Inhibitors may be opened and the intact granules may
be mixed in apple sauce or orange juice and
administered. Alternatively, the capsules may be
opened and the granules may be dissolved in a small
amount of sodium bicarbonate to form a compounded
suspension for administration. The omeprazole will be
the preferred agent for these circumstances and may be
approved.
o If there has been a therapeutic failure on omeprazole or
there is a clinical contraindication to omeprazole then
another non-preferred agent may be approved.
o Aciphex® is an extended release tablet and should not
be opened or crushed.
27
Virginia Medicaid Preferred Drug List With Service Authorization Criteria
Effective July 1, 2011
Preferred Agents
Non-Preferred Agents
SA Criteria
Ulcerative Colitis Oral and Rectal Preparations (5-ASA DERIVATIVES)
Ulcerative Colitis – Oral
Asacol ®
Apriso ®
balsalazide disodium
Pentasa ®
sulfasalazine DR
sulfasalazine IR
Ulcerative Colitis – Rectal
Canasa® supp. rectal
mesalamine enema
Asacol HD ®
Azulfidine Dr ®
Azulfidine IR®
Azulfidine® susp
Colazal®
Dipentum
Lialda ®
LENGTH OF AUTHORIZATION:
Routine PDL edit
1 year
Fiv-Asa®
Rowasa® Enema
Rowasa® Enema Kit
Rowasa® supp. rect
SFRowasa®
Genitourinary
Alpha-Blockers and Androgen Hormone Inhibitors For Benign Prostatic Hypertrophy (BPH)
LENGTH OF AUTHORIZATION:
Routine PDL edit
1 year
Calcium Acetate 667MG
Eliphos®
Renvela® powder and tablet
LENGTH OF AUTHORIZATION:
Routine PDL edit
1 year
Detrol®
Ditropan®
Ditropan® XL
Gelnique™ gel
oxybutynin ER
Toviaz™
LENGTH OF AUTHORIZATION:
Routine PDL edit
1 year
Alpha-Blockers for BPH
tamsulosin HCL
Flomax ®
Rapaflo®
Uroxatral®
Androgen Hormone Inhibitors for BPH
Jalyn®
Avodart ®
Proscar®
finasteride
Phosphate Binders
Fosrenol®
Phoslo®
Renagel®
Urinary Antispasmodics
Detrol® LA
Enablex®
oxybutynin tablet and syrup
Oxytrol® transdermal
Sanctura®
Sanctura® XR
VESIcare®
28
Virginia Medicaid Preferred Drug List With Service Authorization Criteria
Effective July 1, 2011
Preferred Agents
Non-Preferred Agents
SA Criteria
Immunological Agents
Self Administered Drugs for Rheumatoid Arthritis
Enbrel®
Humira®
Cimzia®
Cimzia® SyringeKit
Kineret®
Simponi®
LENGTH OF AUTHORIZATION:
Routine PDL edit
1 year
Ampyra®*
Extavia®
Gilenya®
LENGTH OF AUTHORIZATION:
Routine PDL edit
1 year
Multiple Sclerosis
Avonex®
Avonex® Adm Pack
Betaseron®
Copaxone®
Rebif®
Gilenya is to be used as monotherapy ONLY
* REQUIRED CLINICAL EDIT SA FOR AMPYRA
LENGTH OF AUTHORIZATION FOR AMPYRA:
Initial 8 weeks then, 1 year after successful trial
Criteria:
o The patient has a diagnosis of MS and a gait disorder
or difficulty walking
o Patient has no history of seizures
o Patient’s Creatinine Clearance [CrCL] ≥ 50 mL/min.
o If patient has a gait disorder, they may receive an 8
week trial of Ampyra
o If after 8 week trial the physician states that the patient
showed improvement or that the drug was effective (by
improved Timed 25-foot Walk), the patient may
receive authorization for Ampyra for one year.
Atopic Dermatitis: Topical
Elidel®*
Protopic®*
LENGTH OF AUTHORIZATION:
1 year
Routine PDL edit
*Requires a clinical SA
A SA may only be given for an FDA approved diagnosis:
o Atopic dermatitis (a type of eczema) - FDA approved:
o Elidel®: mild to moderate for ages > 2 years.
o Protopic® 0.03%: moderate to severe for ages > 2
29
Virginia Medicaid Preferred Drug List With Service Authorization Criteria
Effective July 1, 2011
Preferred Agents
Non-Preferred Agents
SA Criteria
o
years.
Protopic® 0.1%: moderate to severe for ages > 18
years.
Critical information
o Black box warnings are in place for both products as
well a requirement for a patient guide to be given with
each product dispensed.
o Use Elidel and Protopic only as second-line agents for
short-term and intermittent treatment of atopic
dermatitis (eczema) in patients unresponsive to, or
intolerant of other treatments.
o Avoid use of Elidel and Protopic in children younger
than 2 years of age. The effect of Elidel and Protopic
on the developing immune system in infants and
children is not known. In clinical studies, infants and
children younger than 2 years old treated with Elidel
had a higher rate of upper respiratory infections than
did those treated with placebo cream.
o Use Elidel and Protopic only for short periods of time,
not continuously. The long term safety of Elidel and
Protopic are unknown
o Children and adults with a weakened or compromised
immune system should not use Elidel or Protopic.
o Use the minimum amount of Elidel or Protopic needed
to control the patient’s symptoms. In animals,
increasing the dose resulted in higher rates of cancer.
Ophthalmic
Antihistamines/Mast Cell Stabilizers
Antihistamines
Alaway OTC®
ketotifen fumerate
Zaditor® OTC drops
Elestat ®drops
Emadine® drop
epinastine 0.05% eye drops
Lastacaft® drops
Optivar ® drops
Patanol® drops
Pataday® drops
LENGTH OF AUTHORIZATION:
1 year
Routine PDL edit
1. Therapeutic failure to no less than a three-day trial of
one medication within the same class not requiring
service approval
2. If the patient is completing a course of therapy with a
medication requiring service approval, which was
initiated in the hospital, then may approve the
30
Virginia Medicaid Preferred Drug List With Service Authorization Criteria
Effective July 1, 2011
Preferred Agents
Mast Cell Stabilizers
cromolyn sodium
Anti-inflammatory
diclofenac sodium
flurbiprofen sodium
ketorolac 0.4%
ketorolac 0.5%
Nevanac® drops suspension
Non-Preferred Agents
SA Criteria
requested medication to complete the course of
therapy.
Alamast® drops
Alocril® drops
Alomide® drops
Crolom® drops
Acular®
Acular LS®
Acular PF® droperette
Acuvail®
Bromday®
bromfenac 0.09%
Ocufen®
Voltaren®
LENGTH OF AUTHORIZATION: for the date of
service only; no refills
Routine PDL edit
AzaSite™ drop
Besivance® drops
Ciloxan® drops and ointment
Iquix® drops
levofloxacin drops
Moxeza® drops
Ocuflox® drops
Zymaxid® drops
LENGTH OF AUTHORIZATION: for the date of
service only; no refills
Routine PDL edit
1.
2.
Therapeutic failure to no less than a three-day trial of
one medication within the same class not requiring
service approval.
If the patient is completing a course of therapy with a
medication requiring service approval, which was
initiated in the hospital, then may approve the
requested medication to complete the course of
therapy.
Antibiotics
ciprofloxacin drops
ofloxacin drops
Quixin® drops
Vigamox® drops
Zymar® drops®
1.
2.
3.
31
If the infection is caused by an organism resistant to
medications not requiring service approval, then may
approve the requested medication.
Therapeutic failure to no less than a three-day trial of
one medication within the same class not requiring
service approval
If the patient is completing a course of therapy with a
medication requiring service approval, which was
initiated in the hospital, then may approve the
requested medication to complete the course of
therapy.
Virginia Medicaid Preferred Drug List With Service Authorization Criteria
Effective July 1, 2011
Preferred Agents
Glaucoma Agents
Non-Preferred Agents
Prostaglandin Analogs
Lumigan® 0.03% drops
latanoprost
®
Lumigan® 0.01% drops
Travatan Z drops
®
Xalatan® 0.005% drops
Travatan 0.0004% drops
Alpha 2 Adrenergic Agents
brimonidine tartrate (0.15%)
Alphagan P® 0.1% &
0.15% drops
brimonidine 0.2% drops
Iopidine® 0.5% & 1% drops
Beta Blockers
Betagan® 0.25% & 0.5% drops
betaxolol 0.5% drops
®
Istalol® 0.5% drops
Betimol 0.25% &0.5%
Ocupress®1% drops
drops
®
optipranolol 0.3% drops
Betoptic-S 0.25% susp
Timoptic® drops 0.25% & 0.5%
drops
Timoptic® XE 0.25% & 0.5% Sol-Gel
carteolol 1% drops
®
Combigan
levobunolol 0.25% & 0.5%
drops
metipranolol 0.3% drops
timolol maleate drops
0.25% &0.5%
timolol maleate 0.5 % SolGel
Carbonic Anhydrase Inhibitors
Cosopt® 0.5%-2% drops
Azopt® 1% drops
Trusopt® 2% drops
dorzolamide
dorzolamide/timolol
SA Criteria
LENGTH OF AUTHORIZATION:
Routine PDL edit
1 year
LENGTH OF AUTHORIZATION:
Routine PDL edit
1 year
Bone Resorption Suppression and Related Agents
Bisphosphonates
alendronate
Fosamax® solution
Actonel®
Actonel® with CA
Atelvia DR®
Boniva®
*Didronel®
* Indicated only for Treatment of Paget’s disease of bone
OR prevention and treatment of
32
Virginia Medicaid Preferred Drug List With Service Authorization Criteria
Effective July 1, 2011
Preferred Agents
Non-Preferred Agents
SA Criteria
etidronate
Fosamax ®plus D
Fosamax®
heterotopic ossification following
total hip replacement or spinal cord
injury.
Calcitonins
Miacalcin®
calcitonin-salmon nasal
Fortical®
LENGTH OF AUTHORIZATION:
Routine PDL edit
1 year
Forteo®
LENGTH OF AUTHORIZATION:
Initial approval
will be for 1 year with ONE renewal if demonstrated
compliance. Maximum duration of therapy is 24 months
during a patient’s lifetime.
Others
Evista®
Forteo® (teriparatide): Indications
o Treatment of osteoporosis in postmenopausal women
who are at high risk for fracture
o Increase of bone mass in men with primary or
hypogonadal osteoporosis who are at high risk for
fractures
o Treatment of men and women with osteoporosis
associated with sustained systemic glucocorticoid
therapy at high risk for fracture
Forteo is indicated if:
o Bone mineral density of -3 or worse or
o Postmenopausal women with history of non-traumatic
fracture(s) or
o Postmenopausal women with two or more of the
following clinical risk factors:
Family history of non-traumatic fracture(s)
Patient history of non-traumatic fracture(s)
DXA BMD T-score ≤-2.5 at any site
Glucocorticoid use* (≥6 months of use at 7.5 dose
of prednisolone equivalent)
a. Rheumatoid Arthritis
Postmenopausal women with BMD T-score ≤2.5 at any site with any of the following clinical
risk factors:
33
Virginia Medicaid Preferred Drug List With Service Authorization Criteria
Effective July 1, 2011
Preferred Agents
Non-Preferred Agents
SA Criteria
a.
b.
c.
d.
More than 2 units of alcohol per day
Current smoker
Men w/primary or hypogonadal
osteoporosis
Osteoporosis associated w/sustained
systemic glucocorticoid therapy
Respiratory
Antihistamines: First and Second Generation
First Generation Antihistamines
All Brands require a SA
Generic only class
LENGTH OF AUTHORIZATION:
Routine PDL edit
Second Generation Antihistamines and Combinations
Allegra®
cetirizine liquid OTC/RX
®
Allegra ODT®
Claritin OTC
®
Allegra suspension ®
Claritin OTC syrup
®
Allegra-D 12 hr®
Claritin tablets- Reditabs
Allegra-D 24 hr®
OTC
®
cetirizine chew and tablet OTC
Claritin-D 24 hr OTC
cetirizine D tablet OTC
Claritin-D® 12 hr OTC
Clarinex® syrup and tablet
loratadine tablet
(represents all OTC names) Clarinex tablet Rapids®
Clarinex- D® 24 hr
loratadine tab - Rapids (all
Clarinex- D® 12 hr
OTC names)
Claritin-D® - Rx forms
loratadine syrup
(represents all OTC names) Claritin® - Rx forms
Claritin® Chewable
loratadine D 24 hr
(represents all OTC names) fexofenadine
fexofenadine/PSE
loratadine D 12 hr
(represents all OTC names) fexofenadine/PSE 60/120 ER
Xyzal®
Zyrtec tablet OTC/RX ®
Zyrtec tab chew OTC/RX ®
Zyrtec® syrup OTC
Zyrtec-D® OTC/RX
34
1 year
Virginia Medicaid Preferred Drug List With Service Authorization Criteria
Effective July 1, 2011
Preferred Agents
Non-Preferred Agents
Beta-Adrenergic Agents
Short Acting Metered Dose Inhalers or Devices
Maxair Autohaler
Proair® HFA
Xopenex® HFA
Proventil ®HFA
®
Ventolin HFA
Long Acting Metered Dose Inhalers or Nebulizers
Brovana®
Foradil®
®
Perforomist®
Serevent Diskus
Short Acting Nebulizers
Accuneb® pediatric dosing, premixed nebs
albuterol sulfate
albuterol sulfate premix
metaproterenol
levalbuterol 0.125%
Xopenex®
Proventil®
SA Criteria
LENGTH OF AUTHORIZATION:
Routine PDL edit
1 year
Therapeutic failure to no less than a two-week trial of at
least one medication not requiring service approval within
the same class and formulation. (i.e. nebulizers for
nebulizers)
COPD: Anticholinergics
Atrovent HFA®
Combivent® MDI
ipratropium bromide
solution
Spiriva®
Atrovent AER®
Duoneb®
ipratropium/albuterol nebs
LENGTH OF AUTHORIZATION:
Routine PDL edit
1 year
Patient’s condition is clinically unstable—patient has had
an ER visit or at least two hospitalizations for asthma in the
past thirty days—and changing to a medication not
requiring service authorization might cause deterioration of
the patient’s condition.
Corticosteroids: Inhaled and Nasal Steroids
Inhaled Corticosteroids: Metered Dose Inhalers
Alvesco®
Aerobid®
®
Flovent®
Aerobid M
®
Flovent Rotadisk®
Asmanex
®
Pulmicort Flexhaler®
Azmacort
®
Flovent Diskus
Flovent® HFA
QVAR®
Inhaled Corticosteroids: Nebulizer Solution
Budesonide
Pulmicort® Respules
LENGTH OF AUTHORIZATION:
1 year
Routine PDL edit
1. Patient’s condition is clinically unstable—patient has
had an ER visit or at least two hospitalizations for
asthma in the past thirty days—and changing to a
medication not requiring service authorization might
cause deterioration of the patient’s condition.
2. Therapeutic failures to no less than one-month trials of
at least two medications not requiring service
authorization.
3. If the patient is a child <13 years old or a patient with a
significant disability, and unable to use an inhaler
which does not require service approval, or is non-
35
Virginia Medicaid Preferred Drug List With Service Authorization Criteria
Effective July 1, 2011
Preferred Agents
Non-Preferred Agents
SA Criteria
compliant on an inhaler not requiring service approval
because of taste, dry mouth, or infection.
Inhaled Corticosteroids: Combination Products (Glucocorticoid and
Beta Adrenergic)
Advair® Diskus
Advair® HFA
Dulera®
Symbicort®
Nasal Steroids
fluticasone
Nasacort® AQ
Beconase AQ®
Flonase®
flunisolide
Nasacort®
Nasarel®
Nasonex®
Omnaris®
Rhinocort Aqua®
Tri-Nasal®
Veramyst®
Cough and Cold Agents
Drug Name
Ala-Hist DM
Ala-Hist LQ
Cheratussin
AC OTC
Cheratussin
DAC OTC
codeine/
promethazine
Diabetic
Tussin EX
OTC
GNN
brompheniramin/
phenylephrine/
dextromethor
phenylephrine/diphe
nhydramine
guaifenesin/codeine
phosphate
p-ephed hcl/codeine/
guaifenesin
codeine/
promethazine
guaifenesin
All other cough and cold product
are non-preferred
LENGTH OF AUTHORIZATION:
Service
Routine PDL edit
36
Date of
Virginia Medicaid Preferred Drug List With Service Authorization Criteria
Effective July 1, 2011
Preferred Agents
guaifenesin/
codeine
phosphate
guaifenesin/
dextromethor
phan
hydrobromide
OTC
guaifenesin/
phenylephrine
HCl OTC
hydrocodone/
homatropine
Iophen-C NR
Lohist-PEB
Mytussin AC
OTC
Nite Time
Cough OTC
phenylephrine
hcl/promethaz
ine hcl
Poly Hist
DHC
Poly-Tussin
DHC
Q-Tussin
OTC
Robafen-DM
Clear OTC
Robafen-DM
OTC
Non-Preferred Agents
SA Criteria
guaifenesin/codeine
phosphate
guaifenesin/
dextromethorphan
hydrobromide
guaifenesin/
phenylephrine HCl
hydrocodone/
homatropine
guaifenesin/codeine
phosphate
phenylephrine/
brompheniramine
guaifenesin/codeine
phosphate
dextromethorphan
hydrobromide/
doxylamine
phenylephrine
hcl/promethazine
hcl
pyrilamine/
phenylephrine/
dihydrocodeine
brompheniramine/
phenylephrine/
dihydrocodeine
guaifenesin
guaifenesin/
dextromethorphan
hydrobromide
guaifenesin/
dextromethorphan
37
Virginia Medicaid Preferred Drug List With Service Authorization Criteria
Effective July 1, 2011
Preferred Agents
Non-Preferred Agents
SA Criteria
hydrobromide
Robafen OTC
guaifenesin
Robitussin
Long-Acting
OTC
Ryantan
Pediatric
Rymed OTC
dextromethorphan
hbr/chlor-mal
Tessalon perle
Tussin DM
Clear OTC
Tussin OTC
Vicks
Formula 44 D
OTC
phenylephrine/
chlor-tan
dexchlorphenir/
phenylephrine
benzonatate
guaifenesin/
dextromethorphan
hydrobromide
guaifenesin
dextromethorphan/
phenylephrine
Intranasal Antihistamines
Astelin®
Astepro® 0.1% and 0.15%
Patanase®
azelastine 0.1%
LENGTH OF AUTHORIZATION:
Routine PDL edit
1 year
Patient’s condition is clinically unstable—patient has had
an ER visit or at least two hospitalizations for asthma in the
past thirty days—changing to a medication not requiring
service authorization might cause deterioration of the
patient’s condition.
1. Therapeutic failures to no less than one-month trials of
at least two medications not requiring service
authorization
2. If the patient is a child <13 years old or a patient with
a significant disability, and unable to use an inhaler
which does not require service approval, or is noncompliant on an inhaler not requiring service approval
because of taste, dry mouth, infection
The requested medications corresponding generic (if a
38
Virginia Medicaid Preferred Drug List With Service Authorization Criteria
Effective July 1, 2011
Preferred Agents
Non-Preferred Agents
SA Criteria
generic is available) has been attempted and failed or is
contraindicated.
Leukotriene Receptor Antagonists
Accolate®
Singulair®
zafirlukast
Zyflo CR™
LENGTH OF AUTHORIZATION:
Routine PDL edit
1 year
LENGTH OF AUTHORIZATION:
Routine PDL edit
1 year
Self Injectable Epinephrine
epinephrine Autoinjector
EpiPen®
EpiPen® Jr
AdrenaClick®
Twinject®
Twinject Jr.®
39