Virginia Medicaid Preferred Drug List With Service Authorization Criteria
Effective January 1, 2012
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 PDL 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 and not all classes are part of the PDL
The following “routine” PDL criteria guidelines will be applied to non-preferred drugs requiring a Service Authorization.
Some drug classes will have additional criteria that will be listed along side the drug class.
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 stable; changing to a medication not requiring service approval might cause deterioration of
the patient’s condition.
2. The requested medication may be approved if both of the following are true:
A. 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
B. The requested medications corresponding generic (if a generic is available and covered by the State) has been attempted
and failed or is contraindicated.
All changes from last posting will be highlighted in Yellow
1
Virginia Medicaid Preferred Drug List With Service Authorization Criteria
Effective January 1, 2012
Preferred Agents Non-Preferred Agents SA Criteria
Analgesics
Non-Steroidal Anti-Inflammatory Drugs
diclofenac potassium Anaprox® meclofenamate LENGTH OF AUTHORIZATIONS: 1 year
diclofenac sodium Anaprox DS® mefenamic Routine PDL edit with exceptions noted below
fenoprofen Ansaid® Mobic®
ibuprofen Arthrotec® Motrin® A one-month trial of at least two medications within the same
ketorolac Cataflam® nabumetone class not requiring SA
meloxicam Celebrex® Nalfon®
naproxen Clinoril® Naprelan® *Step edit required for Celebrex®
naproxen sodium Daypro® Naprosyn® History of a trial of a minimum of two (2) different
piroxicam diflunisal Orudis® non-COX2 NSAIDs within the past year, OR
sulindac Dolobid® Oruvail® have concurrent use of anticoagulants (warfarin/
etodolac oxaprozin heparin), methotrexate, oral corticosteroids, OR
etodolac SR Ponstel® history of previous GI bleed or conditions associated
Feldene® Prevacid Naprapac® with GI toxicity risk factors (i.e., PUD, GERD, etc.),
flurbiprofen Relafen® OR specific indication for Celebrex®, which
Indocin® Sprix® nasal spray medications not requiring Service Approval are not
Indocin SR® Tolectin DS® indicated.
Indomethacin IR, Toradol®
SR and rectal tolmetin sodium
ketoprofen IR& Vimovo®
ER Voltaren®
Lodine®IR & XL Voltaren XR®
Zipsor®
Narcotics -Long Acting
Duragesic® Avinza® Opana® ER LENGTH OF AUTHORIZATIONS: 6 months
Kadian® Butrans® Oramorph ® SR Routine PDL edit
morphine sulfate tablet SA® Embeda® oxycodone-long acting
Exalgo® Oxycontin® Step Edit –Trial and failure of 2 different short acting
fentanyl oxymorphone ER narcotics. The step edit is not required for those patients
MS Contin® that have been stabilized on Long Acting Narcotics or need
Nucynta® ER relief of moderate to severe pain requiring around-the-
clock 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.
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Virginia Medicaid Preferred Drug List With Service Authorization Criteria
Effective January 1, 2012
Preferred Agents Non-Preferred Agents SA Criteria
Narcotics - Short Acting
Barbiturate & Non-Salicylates Analgesic Combinations LENGTH OF AUTHORIZATIONS: 3 months
acetaminophen-butalbital Phrenilin Forte® Routine PDL edit
Bupap ®
Sedapap®
®
Cephadyn
Lozenges- Narcotic Clinical edit for narcotic lozenges ONLY.
fentanyl citrate Actiq® Both of the following need to be true:
Fentora® o the patient has a diagnosis of cancer, AND
Onsolis® o the patient is already receiving and tolerant of opioid
therapy for their underlying persistent cancer pain.
Patients considered opioid tolerant are those who are
Opioid Dependency taking transdermal fentanyl 25 mcg/h, morphine 60
buprenorphine SL Subutex® mg/day or more, oxycodone 30 mg/day, oral
Suboxone® hydromorphone 8 mg/day, or an equianalgesic dose of
Suboxone®film another opioid for one week or longer.
Short-Acting Narcotics
codeine All Brands require a SA
codeine/APAP Abstral®
codeine/APAP/caff/butal Conzip ® ER
codeine/ASA Nucynta®
codeine/ASA/caff/butal oxymorphone HCl
hydrocodone/APAP RyzoltTM
hydrocodone/ ASA tramadol ER
hydrocodone/ ibuprofen Ultracet®
hydromorphone Ultram®
meperidine Ultram ER®
morphine IR Zolvit®
nalbuphine
oxycodone/APAP
oxycodone/ASA
oxycodone IR
tramadol HCL
tramadol HCL/APAP
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Virginia Medicaid Preferred Drug List With Service Authorization Criteria
Effective January 1, 2012
Preferred Agents Non-Preferred Agents SA Criteria
Topical Agents and Anesthetics
*Flector® patch **Lidoderm® patch LENGTH OF AUTHORIZATIONS: 1 year
*Voltaren® gel *Pennsaid® topical solution Routine PDL edit
*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 itraconazole LENGTH OF AUTHORIZATIONS: Duration of the
Griseofulvin ® suspension Lamisil® prescription (up to 6 months)
Gris-Peg® Lamisil ® granules Routine PDL edit
terbinafine Sporanox® capsules
Sporanox® solution 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 January 1, 2012
Preferred Agents Non-Preferred Agents SA Criteria
Oral Cephalosporins
Second Generation Cephalosporins LENGTH OF AUTHORIZATIONS: date of service only;
cefaclor Ceftin® tablets / suspension no refills
capsule/ER/suspension cefuroxime axetil suspension Routine PDL edit
cefprozil capsule/suspension Cefzil® tablets / suspension
cefuroxime tablets Potential reasons for SA are:
Raniclor® o infection caused by an organism resistant to medications
not requiring service approval
Third Generation Cephalosporins o a therapeutic failure to no less than a three-day trial of
cefdinir capsule/suspension Cedax® capsule/suspension one medication within the same class not requiring
®
Spectracef cefditoren pivoxil service approval
Suprax® suspension/tablet cefpodoxime proxetil capsule/suspension o the patient is completing a course of therapy with a
Omnicef ® medication requiring a service authorization, which was
initiated in the hospital.
Oral Macrolides
Macrolides & Ketolides LENGTH OF AUTHORIZATIONS: date of service only;
® no refills
azithromycin Biaxin tablet/ suspension/XL
packet/suspension/tablet clarithromycin ER Routine PDL edit
clarithromycin Dynabac®
tablet/suspension Ery-tab® Potential reasons for SA are:
*E.E.S.® **Ketek® o infection caused by an organism resistant to medications
*EryC® PCE® not requiring service approval
*Eryped® Zithromax® tablet/suspension o a therapeutic failure to no less than a three-day trial of
erythrocin stearate ZMAX suspension® one medication within the same class not requiring
erythromycin base service approval
erythromycin ethylsuccinate o the patient is completing a course of therapy with a
erythromycin estolate medication requiring a service authorization, which was
suspension initiated in the hospital.
erythromycin stearate
erythromycin / sulfisoxazole *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 January 1, 2012
Preferred Agents Non-Preferred Agents SA Criteria
Oral Quinolones
Second Generation Quinolones LENGTH OF AUTHORIZATIONS: date of service only;
Cipro® suspension Cipro® IR/ XR no refills.
ciprofloxacin tablet ciprofloxacin suspension/ER Routine PDL edit
Floxin®
Maxaquin® Potential reasons for SA are:
Noroxin® o Infection caused by an organism resistant to medications
ofloxacin not requiring service approval
Proquin XR® o a therapeutic failure to no less than a three-day trial of
one medication within the same class not requiring
service approval
o the patient is completing a course of therapy with a
medication requiring a service authorization, which was
initiated in the hospital.
Third Generation Quinolones
Avelox® Factive®
®
Avelox ABC PACK Levaquin® tablet/suspension
levofloxacin tablet/suspension
Proquin XR®
Zagam®
Otic Quinolones
Ciprodex® Cetraxal® LENGTH OF AUTHORIZATION
ofloxacin Cipro HC® Date of service only; no refills
Floxin® Routine PDL edit
Topical
mupirocin ointment Altabax® * LENGTH OF AUTHORIZATIONS:
Bactroban® cream and ointment Date of service only; no refills
CentanyTM Routine PDL edit
Centany AT® Kit *Has a 15 gram per 34 day quantity limit
Antivirals
Hepatitis C Agents
Interferon LENGTH OF AUTHORIZATIONS:
Pegasys® All products require a Clinical SA
Pegasys Conv.Pack® Interferon Clinical SA
Peg-Intron®
Peg-Intron Redipen® Clinical SA for initial 16 week SA:
Initial approval periods limited to 16-weeks and viral titer
obtained at week 12 of therapy.
6
Virginia Medicaid Preferred Drug List With Service Authorization Criteria
Effective January 1, 2012
Preferred Agents Non-Preferred Agents SA Criteria
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 [ 2 log reduction
at week 12 in previous treatment – Approve for 44
weeks
c) If none of above in a or b, then evaluate below to
determine duration of therapy.
3) At initial prescription fill, confirmed diagnosis of HCV
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Virginia Medicaid Preferred Drug List With Service Authorization Criteria
Effective January 1, 2012
Preferred Agents Non-Preferred Agents SA Criteria
with genotype 1 and completed 4 weeks of peginterferon
and ribavirin with continuing therapy – approve for 24
weeks.
4) After 24 weeks – require labs drawn at weeks 8 and 24.
Depending on the result – determine the duration of
approval:
a) Treatment naïve patients:
i. If week 8 and 24 are both undetectable – triple
therapy is completed. No further Victrelis
therapy.
ii. If week 8 results are detectable and week 24
results are undetectable – then approve Victrelis
for 8 more weeks.
iii. If week 24 results are detectable, discontinue all
3 therapies (Victrelis and peginterferon/
ribavirin).
b) Previously treated or relapsed patients:
i. If week 8 and 24 are both undetectable – approve
for 8 more weeks for Victrelis and
peginterferon/ribavirin (then discontinue all 3)
ii. If week 8 results are detectable and week 24
results are undetectable – then approve Victrelis
for 8 more weeks.
iii. If week 24 results are detectable, discontinue all
3 therapies (Victrelis and
peginterferon/ribavirin).
5) For ALL patients –If at week 12, the HCV-RNA level is >
100 IU/mL, do not approve Victrelis.
6) For ALL patients - If at week 24 HCV-RNA results are
detectable, discontinue all 3 therapies (Victrelis and
peginterferon/ribavirin).
Lab work needs to be done at 8, 12, and 24 weeks.
Herpes oral
acyclovir suspension/tablets famciclovir LENGTH OF AUTHORIZATIONS: 1 year
Famvir ® valacyclovir Routine PDL edit
Valtrex ® Zovirax® suspension/tablet
Herpes Topical
Abreva OTC® Denavir® Zovirax® cream LENGTH OF AUTHORIZATIONS: 1 year
Zovirax® ointment Xerese® cream Routine PDL edit
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Virginia Medicaid Preferred Drug List With Service Authorization Criteria
Effective January 1, 2012
Preferred Agents Non-Preferred Agents SA Criteria
Influenza
amantadine tab/cap/syrup Flumadine® syrup/tablet LENGTH OF AUTHORIZATIONS:
Relenza Disk® For diagnosis of influenza, the authorization is for the date of
rimantadine service only; no refills
Tamiflu® capsule/suspension Routine PDL edit
Bone Resorption Suppression and Related Agents
Bisphosphonates
alendronate Actonel® etidronate LENGTH OF AUTHORIZATION: 1 year
Fosamax® solution Actonel® with CA Fosamax ®plus D Routine PDL edit
Atelvia DR® Fosamax®
Boniva® * Indicated only for treatment of Paget’s disease of bone
*Didronel® OR prevention and treatment of heterotopic ossification
following total hip replacement or spinal cord injury
Calcitonins
Miacalcin® calcitonin-salmon nasal LENGTH OF AUTHORIZATION: 1 year
Fortical® Routine PDL edit
Others
Evista® 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.
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
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Virginia Medicaid Preferred Drug List With Service Authorization Criteria
Effective January 1, 2012
Preferred Agents Non-Preferred Agents SA Criteria
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:
a. More than 2 units of alcohol per day
b. Current smoker
c. Men w/primary or hypogonadal osteoporosis
d. Osteoporosis associated w/sustained systemic
glucocorticoid therapy
Cardiac
Anticoagulants
Low Molecular Weight Heparin includes FactorXA Inhibitor LENGTH OF AUTHORIZATION: 1 year
Arixtra ® enoxaparin Routine PDL edit
Fragmin ® fondaparinux
Lovenox ® Innohep ® *Oral Anticoagulants Clinical edit
Pradaxa® will be approved if all of the following are true:
Diagnosis of non valvular atrial fibrillation; AND
Oral Anticoagulants Patient has at least one risk factor:
warfarin Coumadin® o History of stroke, TIA, or systemic embolism; OR
Pradaxa®* o Age ≥ 75 years; OR
Xarelto® 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.
10
Virginia Medicaid Preferred Drug List With Service Authorization Criteria
Effective January 1, 2012
Preferred Agents Non-Preferred Agents SA Criteria
ACE Inhibitors, Angiotensin Receptors Blockers, Beta-Blockers
ACE Inhibitors LENGTH OF AUTHORIZATION: 1 year
® Routine PDL edit
benazepril Accupril perindopril
captopril Aceon® Prinivil®
enalapril Altace®capsule/table quinapril
lisinopril Capoten® ramipril
fosinopril trandolapril
Lotensin® Univasc®
Mavik® Vasotec®
moexipril Zestril®
Monopril®
ACE Inhibitors + Diuretic Combinations
benazepril/HCTZ Accuretic® quinapril/HCTZ
captopril/HCTZ Capozide® Quinaretic®
enalapril/HCTZ Uniretic®
fosinopril/HCTZ
lisinopril/HCTZ Univasc®
Lotensin HCT®
moexipril/HCTZ Vaseretic®
Monopril HCT® Zestoretic®
Prinzide®
ACE Inhibitors + Calcium Channel Blocker Combinations
amlodipine/benazepril amlodipine/benazepril (5/50 ;10/40)
(2.5/10, 5/10, 5/20 & 10/20) Lexxel®
®
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
Diovan® * Atacand® Edarbi®
losartan Avapro ® Micardis® *Step edit requires a trial and failure of losartan
Benicar® Teveten®
®
Cozaar
Angiotensin Receptor Blockers + Diuretic Combinations
Diovan HCT®* Atacand HCT® Hyzaar®
losartan/HCTZ Avalide® Micardis HCT® *Step edit requires a trial and failure of losartan/HCTZ
Benicar HCT® Teveten HCT®
11
Virginia Medicaid Preferred Drug List With Service Authorization Criteria
Effective January 1, 2012
Preferred Agents Non-Preferred Agents SA Criteria
Angiotensin Receptor Blockers + Calcium Channel Blocker Combinations
N/A Azor® Exforge®HCT
Exforge® Tribenzor®
Direct Renin Inhibitors (includes combination)
N/A Amturnide™ Twynsta®
Tekturna® Valturna®
Tekturna HCT®
Beta Blockers
atenolol acebutaolol Lopressor®
carvedilol Betapace®IR / AF® metoprolol succinate
labetalol betaxolol Normodyne®
metoprolol tartrate bisoprolol fumarate pindolol
nadolol Blockadren® propranolol LA
propranolol solution/tablet Bystolic® Sectral®
Sorine® Cartrol® Tenormin®
sotalol AF Coreg® IR & CR® timolol maleate
sotalol HCL Corgard® Toprol XL®
Inderal® IR & LA Trandate®
Innopran ® XL Visken®
Kerlone® Zebeta®
Levatol®
Beta Blockers + Diuretic Combinations
atenolol/chlorthalidone Corzide® Tenoretic®
bisoprolol/HCTZ Inderide® Timolide®
nadolol/bendroflumethiazide Lopressor HCT® Ziac®
propranolol/HCTZ metoprolol/HCTZ
Calcium Channel Blockers: Dihydropyridine CCB &Non-Dihydropyride CCB
Dihydropyridine Calcium Channel Blockers LENGTH OF AUTHORIZATIONS: 1 year
Afeditab CR® Adalat ® nisoldipine Routine PDL edit
amlodipine Adalat CC® nicardipine
®
Nifediac CC Cardene® Norvasc® There are two main classes of Calcium Channel Blockers
®
Nifedical XL Cardene SR® Procardia® (each with different actions on the peripheral vasculature and
nifedipine Dynacirc® IR & CR® Procardia XL® cardiac tissue):
nifedipine ER felodipine ER Plendil® o Dihydropyridine Calcium Channel Blockers
nifedipine SA isradipine Sular® o Non-Dihydropyridine Calcium Channel Blockers
12
Virginia Medicaid Preferred Drug List With Service Authorization Criteria
Effective January 1, 2012
Preferred Agents Non-Preferred Agents SA Criteria
Non-Dihydropyridine Calcium Channel Blockers
Cartia XT® Calan® IR & SR Tiazac®
®
Diltia XT Cardizem® IR & CD verapamil ER
diltiazem Cardizem LA® & SR capsule
diltiazem ER q 24hr Covera HS® Verelan®
diltiazem ER q 12hr Dilacor XR® Verelan PM®
diltiazem XR diltiazem SR q 12hr
Taztia XT® Isoptin SR®
verapamil tablet
verapamil tablet ER
Lipotropics
HMG CoA Reductase Inhibitors and Combinations (Statins) LENGTH OF AUTHORIZATIONS: 1 year
lovastatin Advicor® Lescol XL® 1) Therapeutic failure to no less than three-month trial of
®
pravastatin Altoprev Mevacor® at least one medication not requiring service
®
Lescol Pravachol® approval.
FDA has announced (on June 8, 2011) new safety
HMG CoA Reductase Inhibitors and Combinations (High Potency restrictions (including contraindications & dose
Statins) limitations) for high-dose simvastatin.
simvastatin Crestor® Vytorin® FDA recommendations:
®
Lipitor Zocor® Maintain patients on simvastatin 80 mg or Vytorin 10/80
®
Livalo mg ONLY if they have been taking this dose chronically
Fibric Acid Derivatives (for 12 months or more) without evidence of muscle
gemfibrozil Antara® Lofibra® toxicity.
Tricor ®
fenofibrate Lopid® Do not start new patients on simvastatin 80 mg or
®
Fenoglide Triglide® Vytorin 10/80 mg.
®
Lipofen Trilipix™ Place patients who do not meet their LDL-C goal on
simvastatin 40 mg or Vytorin 10/40 mg on alternative
Niacin Derivatives LDL-C lowering treatment(s) that provides greater LDL-
Niacor® C lowering.
Niaspan® Follow the recommendations in the simvastatin-
containing medicines labels regarding drugs that may
Niacin Derivatives & HMG CoA Reductase Inhibitors (Statins) increase the risk for muscle injury when used with
Combination simvastatin.
Simcor®* Switch patients who need to be initiated on a drug that
interacts with simvastatin to an alternative statin with less
CAI potential for the drug-drug interaction.
Zetia®
* Requires a history of either a niacin or simvastatin product
within the past 365 days
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Virginia Medicaid Preferred Drug List With Service Authorization Criteria
Effective January 1, 2012
Preferred Agents Non-Preferred Agents SA Criteria
Omega 3 Fatty Acid Agent
**Lovaza Clinical edit **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
Bile Acid Sequestrants high triglycerides of (≥ 500 mg/dL) in adult patients.
cholestyramine powder cholestyramine powder Light
Colestid® packet/tablet Colestid® granule
colestipol packet/tablet colestipol HCl granules
Prevalite® Questran® powder/powder Light
Welchol ® tablet Welchol ® packet
Pulmonary Arterial Hypertension Agents
Phosphodiesterase 5 Inhibitors LENGTH OF AUTHORIZATIONS: 1 year
Adcirca TM Revatio injection® Routine PDL edit
®
Revatio
Clinical edit for PD5
1) Diagnosis of Pulmonary Hypertension in patients >18
Inhaled Prostacyclin Analogues years is required.
Tyvaso® 2) The requested medication may be approved if both of the
Ventavis® following are true:
o The prescribing physician is a pulmonary specialist
Oral Endothelin Receptor Antagonist or cardiologist and will be followed by the
prescribing physician.
Letairis®
3) Must have a rationale for not taking the oral Revatio to
Tracleer®
receive a SA for the injectable Revatio.
4) PDE-5 contraindications where the SA should not be
approved:
o Concurrent use of nitrates (e.g., nitroglycerin)
o Hypersensitivity to product
Platelet Inhibitors
Aggrenox® Brilinta® LENGTH OF AUTHORIZATION: 1 year
dipyridamole Persantine® Routine PDL edit
Effient®
Plavix®
ticlopidine HCL
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Virginia Medicaid Preferred Drug List With Service Authorization Criteria
Effective January 1, 2012
Preferred Agents Non-Preferred Agents SA Criteria
Central Nervous System
Non-Ergot Dopamine Receptor Agonist
pramipexole Mirapex® LENGTH OF AUTHORIZATIONS: 1 year
ropinirole HCl Mirapex® ER Routine PDL edit
Requip®
Requip® Dose Pack ADDITIONAL INFORMATION TO AID IN THE
Requip®XR 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 FDA-
approved 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
chloral hydrate syrup Dalmane® LENGTH OF AUTHORIZATIONS:
flurazepam Doral® Length of the prescription (up to 3 months)
temazepam 15mg & 30mg estazolam Routine PDL edit
Halcion®
Prosom® For patients age 65 and older, Rozerem®, Ambien® or
Restoril® Lunesta may be approved after a trial of trazodone (duration
temazepam 7.5 mg & 22.5 mg = at least one month). It is not necessary for patient’s ≥ 65 to
triazolam try a benzodiazepine if they have had a trial of trazodone.
Chloral hydrate syrup may be approved for
Children for the following doses up to according to
Sedative Hypnotics (Non-Benzodiazepine) weight
Rozerem® Ambien® IR & CR Sonata® As a h ypnotic 1 g/day PO
zolpidem EdluarTM Zaleplon® As a sedative 1.5 g/day PO.
Lunesta® Zolpimist TM oral Clinical reason as to why preferred medications are not
Somnote® spray appropriate. (I.e. patient has hx of substance abuse, patient on
another benzo for another disorder).
15
Virginia Medicaid Preferred Drug List With Service Authorization Criteria
Effective January 1, 2012
Preferred Agents Non-Preferred Agents SA Criteria
Antimigraine Agents
Maxalt ® MLT Amerge® LENGTH OF AUTHORIZATIONS: 6 months
Relpax® Axert® Routine PDL edit
sumatriptan succinate Cambia®
cartridge, nasal, pen, tablet, Frova® CLINICAL CONSIDERATIONS:
vial Imitrex® cartridge, nasal, pen kit, tablet, vial Service Authorization will not be given for prophylactic
Maxalt® therapy of migraine headache unless the patient has exhausted
naratriptan or has contraindications to all other ―controller‖ migraine
Treximet® medications (i.e., beta-blockers, calcium channel blockers,
Zomig® tablets, nasal spray, ZMT etc) and the physician and patient are aware of the adverse
risk potential.
Skeletal Muscle Relaxants
baclofen Amrix® LENGTH OF AUTHORIZATIONS:
carisoprodol cyclobenzaprine ER 1 year for chronic conditions
carisoprodol/ASA Dantrium® Duration of prescription (up to 3 months) for acute
carisoprodol/ASA/codeine Fexmid® conditions
chlorzoxazone Flexeril® Routine PDL edit
cyclobenzaprine HCL metaxalone
dantrolene sodium Norflex® Additonal Information to Aid in Final Decision
methocarbamol orphenadrine citrate 1) If there is a specific indication for a medication requiring
tizanidine orphenadrine/ASA/caffeine service approval, for which medications not requiring
Parafon Forte® DSC service approval are not indicated, then may approve the
Robaxin® requested medication. This medication should be
Skelaxin® reviewed for need at each request for reauthorization.
Soma®
Zanaflex® 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)
16
Virginia Medicaid Preferred Drug List With Service Authorization Criteria
Effective January 1, 2012
Preferred Agents Non-Preferred Agents SA Criteria
Smoking Cessation
bupropion SR Commit ®Lozenge LENGTH OF AUTHORIZATIONS: 6 months
Chantix® Nicoderm CQ® Patch Routine PDL edit
Chantix® Tab DS PK Nicorette® Gum
Nicotrol® Inhaler& NS Zyban®
nicotine gum, lozenge &
patch
Stimulants/ADHD Medications
Amphetamine Products LENGTH OF AUTHORIZATION: 1 year
amphetamine salts combo Adderall® IR & XR®(see criteria) Routine PDL edit
dextroamphetamine amphetamine salts combo XR
Vyvanse® Desoxyn® 1) If the patient requires a service authorized medication
Dexedrine® based on a specific medical need that is not covered by
dextroamphetamine SR the FDA indications of one of the preferred
Dextrostat® medications, a SA will be granted for a non-preferred
Methamphetamine medication.
2) This should be reviewed for need at each request for
reauthorization.
Methylphenidate Products Adderall XR®-
Concerta® Daytrana™ Methylin solution® If a trial & failure of a preferred product occurs and the
Focalin XR® transdermal methylphenidate oral physician requests Adderall XR® or amphetamine salts
All methylphenidate generic dexmethylphenidate solution combo XR. The brand Adderall XR®- is preferred over
IR tablets Focalin® methylphenidate SR the generic.
Metadate CD® Procentra solution® Clinical Criteria for Nuvigil TM /Provigil®:
Metadate ER® Ritalin® Length of Authorization:
Methylin ER® Ritalin LA® 1 year for sleep apnea and narcolepsy;
Methylin chew® Ritalin SR® 6 months for shift work sleep disorder.
Approvable diagnosis’ include:
Miscellaneous Products o Sleep Apnea: Requires documentation/confirmation
Strattera® Intuniv® via sleep study.
Kapvay® SR 12H o Requires documentation that C-PAP has been
Nuvigil TM maximized.
Provigil® 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 TM (armodafinil)
17
Virginia Medicaid Preferred Drug List With Service Authorization Criteria
Effective January 1, 2012
Preferred Agents Non-Preferred Agents SA Criteria
Dermatologic
Dermatologic Agents
Combination Benzoyl Peroxide & Clindamycin LENGTH OF AUTHORIZATION: 1 year
benzoyl peroxide Benzaclin® Routine PDL edit
clindamycin Benzaclin ®CareKit
Clindamycin 1%/Benzoyl Peroxide 5% 1. Failure to respond to a therapeutic trial of at least two
Duac CS® weeks of one preferred medication
Duac® gel
Additonal Information to Aid in Final Decision
o Topical retinoids will reject for 21 and older - this
Topical Retinoids/Combinations can not be overridden.
Differin® cream 0.1% adapalene 0.1% cream o Renova and other products considered to have only
Differin® gel 0.1% & 0.3% adapalene 0.1% topical gel a cosmetic indication are not covered by Virginia
Retin®-A Micro Altinac® Medicaid.
®
Retin -A Micro Pump atralin o If the patient is completing a course of therapy
tretinoin Differin® 0.1% topical lotion with a medication requiring service approval,
Epiduo® which was initiated in the hospital or other similar
Retin-®A location, or if the patient has just become Medicaid
Tazorac® eligible and is already on a course of treatment
Tretin®-X with a medication requiring service
Ziana® o Approval, then the requested medication may be
Topical Agents for Psoriasis approving.
calcipotriene anthralin
Dovonex® Calcitrene®
®
Psoriatic Dovonex® Scalp
Micanol®
Taclonex®
Taclonex® Scalp
Vectical®
Endocrine and Metabolic Agents
Androgenic Agents (Testosterone – Topical)
Androderm Axiron solution LENGTH OF AUTHORIZATION: 1 year
Androgel Fortesta Routine PDL edit
Testim
Failure to respond to a therapeutic trial of at least one week
of one non-service authorized medication
18
Virginia Medicaid Preferred Drug List With Service Authorization Criteria
Effective January 1, 2012
Preferred Agents Non-Preferred Agents SA Criteria
Contraceptives
Oral Contraceptives LENGTH OF AUTHORIZATION: 1 year
Ortho Tri- All other oral contraceptives Routine PDL edit
Apri
Junel Fe Cyclen
If there is a specific indication for a medication requiring
Loestrin Ortho Tri-
service approval, for which medications not requiring
Lo-Ovral-28 Cyclen Lo
service approval are not indicated, then request may be
Micronor Ovcon -50 approved.
Nor-Q-D Portia
Nortrel Sprintec
Ortho- Tri-
®
Cyclen Sprintec
Ortho- Yasmin 28
Novum Yaz
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: 1 year
Routine PDL edit
19
Virginia Medicaid Preferred Drug List With Service Authorization Criteria
Effective January 1, 2012
Preferred Agents Non-Preferred Agents SA Criteria
Diabetes Hypoglycemics: Injectable Insulins
Long-Acting Insulins LENGTH OF AUTHORIZATION: 1 year
Lantus vial Lantus Solostar® and cartridge Routine PDL edit
Levemir pen and vial
Rapid-Acting Insulins 1. Therapeutic failure of one non-service authorized
Humalog® cartridge, ®
Apidra cartridge, Solostar, and vial medication. For approval of a non-preferred insulin,
Kwikpen®, and vial the patient must have a failure on the equivalent
Novolog® cartridge, Flexpen preferred product if one is available (ex. Approval of
Syringe, and vial Humalog® would require a failure on Novolog®).
Insulin Mix
2. Pens/cartridges should only be approved if there is a
Humalog Mix 75/25 vial
physical reason (such as dexterity problems, vision
Humalog Mix 50/50 vial
impairment) vials cannot be used. Approvals should
Humalog® Mix 50-50
not be granted based on issues of convenience or
Kwikpen®
compliance.
Humalog® Mix 75-25
Kwikpen
Will be approved for individuals meeting the
Novolog Mix 70/30 pen & following criteria:
vial o Recipient or caregiver has poor eyesight such that
Humulin 70/30 pen and vial dosing errors may occur
Novolin 70/30 vial o Recipient or caregiver has problems with manual
Insulin N dexterity which may result in dosing errors (i.e.
Humulin N pen and vial Parkinson’s disease, rheumatoid arthritis in the
Novolin N vial finger/hand joints, multiple sclerosis)
Insulin R o Recipient is under 18 years of age
Humulin R vial
Novolin R vial 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 LENGTH OF AUTHORIZATION: 1 year
acarbose Precose® Routine PDL edit
®
Glyset
Oral Hypoglycemics Biguanides
metformin Fortamet®
metformin ER Glucophage® IR & ®XR
Glutmetza®
Riomet® suspension
20
Virginia Medicaid Preferred Drug List With Service Authorization Criteria
Effective January 1, 2012
Preferred Agents Non-Preferred Agents SA Criteria
Oral Hypoglycemics Biguanide Combination Products
Avandamet® Glucovance®
glipizide/metformin Metaglip®
glyburide/metformin
Oral Hypoglycemics DPP-IV Inhibitors and Combination
Janumet® Kombiglyze XRTM
®
Januvia
OnglyzaTM
TradjentaTM
Oral Hypoglycemics Meglitinides
Starlix® nateglinide
Prandin®
PrandiMetTM
Oral Hypoglycemics Thiazolidinediones
Actos® Actoplus Met® Rosiglitazone REMS Program-
®
Avandamet Avandaryl® After November 18, 2011 rosiglitazone medicines will be
®
Avandia Duetact® withdrawn from local pharmacies, and the distribution of
Oral Hypoglycemics Second Generation Sulfonylureas rosiglitazone-containing medicines will be limited to only
glimepiride Amaryl® specially-certified, mail-order pharmacies.
glipizide Diabeta® To receive a rosiglitazone-containing medicines (Avandia®,
glipizide ER Glucotrol® Avandame®t, and Avandaryl®). The physician must be
glyburide Glucotrol XL® enrolled in the Avandia®-Rosiglitazone Medicines Access
glyburide micronized Glynase® Program and adhere to the new restrictions to obtain the
Micronase® products if they wish to prescribe rosiglitazone medicines to
outpatients or patients in long-term care facilities after
November 18, 2011. These products are not included as
preferred or nonprefered on DMAS’ PDL
Antihyperuricemics
allopurinol *Colcrys® LENGTH OF AUTHORIZATION: 1 year
probenecid Uloric® Routine PDL edit
probenecid and colchicine
*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
21
Virginia Medicaid Preferred Drug List With Service Authorization Criteria
Effective January 1, 2012
Preferred Agents Non-Preferred Agents SA Criteria
Growth Hormone
Genotropin® Humatrope® cartridge and vial All Growth Hormones require a clinical SA
Nutropin AQ® NuSpinTM Norditropin cartridge®
Norditropin FlexPro®& Nordiflex® PEDIATRICS
Nutropin® LENGTH OF AUTHORIZATION (pediatrics): 1 year
Nutropin AQ® cartridge and vial PEDIATRICS (18 years of age and under) Clinical
Omnitrope® Criteria for Approval:
Saizen® cartridge and vial
Serostim® 1. Prescriber is an endocrinologist, nephrologists,
Tev-Tropin® infectious disease specialist or HIV specialist or one
Zorbtive® 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 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.
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®)
23
Virginia Medicaid Preferred Drug List With Service Authorization Criteria
Effective January 1, 2012
Preferred Agents Non-Preferred Agents SA Criteria
*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® LENGTH OF AUTHORIZATION: for duration of the
Epogen® 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
medroxyprogesterone LENGTH OF AUTHORIZATION: 1 year
acetate (tablet only) Routine PDL edit
norethindrone acetate
progesterone Failure to respond to a therapeutic trial of at least one week
Prometrium® of one non-service authorized medication
Provera®
Progestins Used For Cachexia
megestrol acetate Megace® LENGTH OF AUTHORIZATION: 1 year
Megace® ES Routine PDL edit
Vaginal Estrogens
Premarin® vaginal cream Estrace ®Vaginal cream LENGTH OF AUTHORIZATION: 6 months
Vagifem® Vaginal tablets Estring® Vaginal ring Routine PDL edit
Femring® Vaginal ring
Gastrointestinal
24
Virginia Medicaid Preferred Drug List With Service Authorization Criteria
Effective January 1, 2012
Preferred Agents Non-Preferred Agents SA Criteria
Histamine-2 Receptor Antagonists (H-2 RA)
famotidine OTC & RX Axid® capsule and solution OTC & RX LENGTH OF AUTHORIZATION: 1 year
ranitidine tablet, & syrup cimetidine tablet and syrup OTC & RX Routine PDL edit
OTC & RX famotidine oral suspension OTC & RX
nizatidine capsule and suspension 1. Patient’s condition is clinically unstable—patient has
Pepcid ®oral suspension and tablet OTC & RX had an ER visit or at least two hospitalizations for
ranitidine capsule OTC & RX asthma in the past thirty days—changing to a
Tagamet® OTC & RX medication not requiring service approval might cause
Zantac® syrup and tablet OTC & RX 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 LENGTH OF AUTHORIZATION: 12 weeks
Reglan® Routine PDL edit
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
omeprazole OTC 20mg Aciphex® LENGTH OF AUTHORIZATIONS:
pantoprazole Dexilant® 12 weeks; unless recipient meets an exception; then 1 year
Prevacid® OTC lansoprazole Routine PDL edit
Nexium®
omeprazole RX 20mg Additional PDL edit criteria
omeprazole/sodium bicarbonate 1. The requested medication may be approved if both of
Prevacid® RX the following are true:
Prevacid® susp (no SA required if age 2 years.
o Protopic® 0.03%: moderate to severe for ages > 2
years.
®
o Protopic 0.1%: moderate to severe for ages > 18
years.
o Failure to topical corticosteroids (i.e., desonide,
fluticasone propionate, hydrocortisone butyrate, etc.)
Critical information
o Black box warnings are in place for both products as
well as 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 to topical corticosteroids (i.e., desonide,
fluticasone propionate, hydrocortisone butyrate, etc.)
® ®
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.
28
Virginia Medicaid Preferred Drug List With Service Authorization Criteria
Effective January 1, 2012
Preferred Agents Non-Preferred Agents SA Criteria
Ophthalmic
Antihistamines/Mast Cell Stabilizers
Antihistamines LENGTH OF AUTHORIZATION: 1 year
Alaway OTC® Elestat ®drops Routine PDL edit
ketotifen fumerate Emadine® drop
Zaditor® OTC drops epinastine 0.05% eye drops 1. Therapeutic failure to no less than a three-day trial of
Lastacaft® drops one medication within the same class not requiring
Optivar ® drops service approval
Patanol® drops 2. If the patient is completing a course of therapy with a
Pataday® drops medication requiring service approval, which was
initiated in the hospital, then may approve the requested
Mast Cell Stabilizers medication to complete the course of therapy.
cromolyn sodium Alamast® drops Alomide® drops
Alocril® drops Crolom® drops
Anti-inflammatory
diclofenac sodium Acular® LENGTH OF AUTHORIZATION: for the date of
flurbiprofen sodium Acular LS® service only; no refills
ketorolac 0.4% Acular PF® droperette Routine PDL edit
ketorolac 0.5% Acuvail®
Nevanac® drops suspension Bepreve 1. Therapeutic failure to no less than a three-day trial of
Bromday® one medication within the same class not requiring
bromfenac 0.09% service approval.
Ocufen® 2. If the patient is completing a course of therapy with a
Voltaren® 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 AzaSite™ drop LENGTH OF AUTHORIZATION: for the date of
ofloxacin drops Besivance® drops service only; no refills
Quixin® drops Ciloxan® drops and ointment Routine PDL edit
Vigamox® drops Iquix® drops
Zymar® drops® levofloxacin drops 1. If the infection is caused by an organism resistant to
Moxeza® drops medications not requiring service approval, then may
Ocuflox® drops approve the requested medication.
Zymaxid® drops 2. Therapeutic failure to no less than a three-day trial of
one medication within the same class not requiring
service approval
3. If the patient is completing a course of therapy with a
29
Virginia Medicaid Preferred Drug List With Service Authorization Criteria
Effective January 1, 2012
Preferred Agents Non-Preferred Agents SA Criteria
medication requiring service approval, which was
initiated in the hospital, then may approve the requested
medication to complete the course of therapy.
Glaucoma Agents
Alpha 2 Adrenergic Agents LENGTH OF AUTHORIZATION: 1 year
Alphagan P® 0.1 & 0.15% brimonidine tartrate (0.15%) Routine PDL edit
brimonidine 0.2% drops
Iopidine® 0.5% & 1%
drops
Beta Blockers
betaxolol 0.5% drops Betagan® 0.25% & 0.5% drops
Betimol® 0.25% &0.5% Istalol® 0.5% drops
Betoptic-S® 0.25% susp Ocupress®1% drops
carteolol 1% drops optipranolol 0.3% drops
Combigan® Timoptic® drops 0.25% & 0.5%
levobunolol 0.25% & 0.5% Timoptic® XE 0.25% & 0.5% Sol-Gel
metipranolol 0.3% drops
timolol maleate drops
0.25% &0.5%
timolol maleate 0.5 % Sol-
Gel
Carbonic Anhydrase Inhibitors
Azopt® 1% drops Cosopt® 0.5%-2% drops
dorzolamide Trusopt® 2% drops
dorzolamide/timolol
Prostaglandin Analogs
latanoprost Lumigan® 0.03% drops
Travatan Z® drops Lumigan® 0.01% drops
Travatan® 0.0004% drops Xalatan® 0.005% drops
Respiratory
Antihistamines: First and Second Generation
First Generation Antihistamines LENGTH OF AUTHORIZATION: 1 year
Generic only class All Brands require a SA Routine PDL edit
30
Virginia Medicaid Preferred Drug List With Service Authorization Criteria
Effective January 1, 2012
Preferred Agents Non-Preferred Agents SA Criteria
Second Generation Antihistamines and Combinations LENGTH OF AUTHORIZATION: 1 year
cetirizine liquid & tablets Allegra® tab , suspension & ODT Routine PDL edit
OTC Allegra-D® 12 h & 24 hr
loratadine tab, Rapidtabs & cetirizine chew and tablet OTC
syrup OTC cetirizine D tablet OTC
Clarinex® syrup, tablet & Rapid Tab
Clarinex- D® 24 & 12 hr
Claritin-D® -Rx & OTC forms
Claritin® tab & Chewable Rx/ OTC forms
fexofenadine
fexofenadine/PSE & 60/120 ER
loratadine D 12 &24 HR
Xyzal®
Zyrtec tablet, chew & syrup OTC/RX ®
Zyrtec-D® OTC/RX
Beta-Adrenergic Agents
Short Acting Metered Dose Inhalers or Devices LENGTH OF AUTHORIZATION: 1 year
Proventil ®HFA Maxair Autohaler Routine PDL edit
Proair® HFA
Ventolin® HFA Therapeutic failure to no less than a two-week trial of at
Xopenex® HFA least one medication not requiring service approval within
the same class and formulation. (i.e. nebulizers for
Long Acting Metered Dose Inhalers or Nebulizers nebulizers)
Foradil® Arcapta Neohaler®
®
Serevent Diskus Brovana®
Perforomist®
Short Acting Nebulizers
albuterol sulfate Accuneb® pediatric dosing, premixed nebs
metaproterenol albuterol sulfate premix
Xopenex® levalbuterol 0.125%
Proventil®
COPD: Bronchodilators and phosphodiesterase 4 (PDE4) inhibitors
Atrovent HFA® Atrovent AER® LENGTH OF AUTHORIZATION: 1 year
Combivent® MDI Daliresp® Routine PDL edit
ipratropium bromide Duoneb®
solution ipratropium/albuterol nebs Patient’s condition is clinically unstable—patient has had an
Spiriva® 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.
31
Virginia Medicaid Preferred Drug List With Service Authorization Criteria
Effective January 1, 2012
Preferred Agents Non-Preferred Agents SA Criteria
Corticosteroids: Inhaled and Nasal Steroids
Inhaled Corticosteroids: Metered Dose Inhalers LENGTH OF AUTHORIZATION: 1 year
Aerobid® Alvesco® Routine PDL edit
®
Aerobid M Flovent®
Asmanex ®
Flovent Rotadisk® 1) Patient’s condition is clinically unstable—patient has
Azmacort ®
Pulmicort Flexhaler® had an ER visit or at least two hospitalizations for
®
Flovent Diskus asthma in the past thirty days—and changing to a
Flovent® HFA medication not requiring service authorization might
QVAR® cause deterioration of the patient’s condition.
Inhaled Corticosteroids: Nebulizer Solution 2) Therapeutic failures to no less than one-month trials of
Pulmicort® Respules Budesonide at least two medications not requiring service
authorization
3) If the patient is a child <13 years old or a patient with a
Inhaled Corticosteroids: Combination Products (Glucocorticoid and Beta
significant disability, and unable to use an inhaler
Adrenergic)
which does not require service approval, or is non-
Advair® Diskus & HFA
compliant on an inhaler not requiring service approval
Dulera®
because of taste, dry mouth, or infection.
Symbicort®
Nasal Steroids
fluticasone Beconase AQ®
®
Nasacort AQ Flonase®
flunisolide
Nasacort®
Nasarel®
Nasonex®
Omnaris®
Rhinocort Aqua®
triamcinolone acetonide
Tri-Nasal®
Veramyst®
Cough and Cold Agents
Drug Name GNN All other cough and cold product are LENGTH OF AUTHORIZATION: Date of Service
non-preferred Routine PDL edit
Ala-Hist DM brompheniramine/
Removed from phenylephrine/
market dextromethorphan
32
Virginia Medicaid Preferred Drug List With Service Authorization Criteria
Effective January 1, 2012
Preferred Agents Non-Preferred Agents SA Criteria
ala-hist LQ phenylephrine/
diphenhydramine
cheratussin guaifenesin/
AC OTC codeine phosphate
cheratussin p-ephed hcl/
DAC OTC codeine/
guaifenesin
codeine/ codeine/
promethazine promethazine
Diabetic ® guaifenesin
Tussin EX
OTC
Diabetic ® guaifenesin/
Tussin Max- d-methorphan hb
Strength
guaifenesin/ guaifenesin/
codeine codeine phosphate
phosphate
guaifenesin/ guaifenesin/
dextromethor dextromethorphan
phan hydrobromide
hydrobromide
OTC
guaifenesin/ guaifenesin/
phenylephrine phenylephrine
HCl OTC HCl
hydrocodone/ hydrocodone/
homatropine homatropine
iophen-C NR guaifenesin/
codeine phosphate
lohist-PEB phenylephrine/
brompheniramine
Mytussin® AC guaifenesin/
OTC codeine phosphate
Nite Time dextromethorphan
Cough OTC hydrobromide/
doxylamine
phenylephrine phenylephrine hcl/
hcl/promethaz promethazine hcl
ine hcl
33
Virginia Medicaid Preferred Drug List With Service Authorization Criteria
Effective January 1, 2012
Preferred Agents Non-Preferred Agents SA Criteria
poly hist DHC pyrilamine/
phenylephrine/
dihydrocodeine
poly-tussin brompheniramine/
DHC phenylephrine/
dihydrocodeine
q-tussin OTC guaifenesin
robafen-DM guaifenesin/
clear OTC dextromethorphan
hydrobromide
robafen-DM guaifenesin/
OTC dextromethorphan
hydrobromide
robafen OTC guaifenesin
Robitussin dextromethorphan
Long-Acting® hbr/chlor-mal
OTC
Ryantan® phenylephrine/
Pediatric chlor-tan
Rymed OTC dexchlorphenir/
phenylephrine
Tessalon ® benzonatate
perle
Tussin DM guaifenesin/
Clear OTC dextromethorphan
hydrobromide
Tussin OTC guaifenesin
Vicks dextromethorphan
Formula ® 44 / phenylephrine
D OTC
Intranasal Antihistamines
Astelin® azelastine 0.1% LENGTH OF AUTHORIZATION: 1 year
Astepro® 0.1% Astepro® 0.15%
Patanase® Routine PDL edit
Patient’s condition is clinically unstable—patient has had an
ER visit or at least two hospitalizations for asthma in the
34
Virginia Medicaid Preferred Drug List With Service Authorization Criteria
Effective January 1, 2012
Preferred Agents Non-Preferred Agents SA Criteria
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 non-
compliant on an inhaler not requiring service approval
because of taste, dry mouth, infection
The requested medications corresponding generic (if a
generic is available) has been attempted and failed or is
contraindicated.
Leukotriene Receptor Antagonists
Accolate® zafirlukast LENGTH OF AUTHORIZATION: 1 year
Singulair® Zyflo CR™ Routine PDL edit
Self Injectable Epinephrine
EpiPen® Twinject® LENGTH OF AUTHORIZATION: 1 year
EpiPen® Jr Twinject Jr.® Routine PDL edit
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