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July 1, 2005
 
MEDICAID INFORMATION RELEASE 2005-29
 
TO:                 Prescribing Providers, Pharmacists, Pharmacies, Hospitals, and Long-Term Care Facilities
 
FROM:           Randy May, Deputy Administrator
 
SUBJECT:      PRIOR AUTHORIZATION CRITERIA FOR ALZHEIMER’S DRUG CLASS
 
Drug/Drug Class:
ALZHEIMER’S AGENTS
Implementation Date:
Effective for dates of service on or after August 1, 2005
 

Idaho Medicaid is designating preferred agents and therapeutic criteria for the Alzheimer’s drug class as part of the Enhanced Prior Authorization Program.   Beginning August 1, 2005, the preferred agents for the Alzheimer’s drug class will be the following:
 
Preferred Agent(s)
Non-preferred Agents^
Aricept® (For mild to moderate dementia ratings.)
Namenda® (For moderate to severe dementia ratings)
Cognex®
Exelon®
Reminyl® / RazadyneTM
    ^ Use of non-preferred agents must meet additional prior authorization
       requirements.
 
Therapeutic Criteria
1)      Alzheimer’s agent use will be limited to individuals with an approved dementia diagnosis.
2)      Alzheimer’s agent use will require the use and documentation of an objective dementia rating scale such as the Mini-Mental State Examination (MMSE).
3)      Individuals with an approved diagnosis who are currently stable on their medication will not be required to transition to a preferred agent.
The Department requests that providers use the following relative cost ranking table as a secondary factor when determining the most appropriate drug therapy for their patients.
 
Lowest to Highest Relative Cost
(Cost to Medicaid after rebates)
Namenda®
100%
Aricept®
110%
Reminyl® / RazadyneTM
130%
Exelon®
140%
 
Questions regarding the Prior Authorization program may be referred to Medicaid Pharmacy at (208) 364-1829.

 
A current listing of all the preferred agents by drug class and prior authorization criteria is also available online at www.medicaidpharmacy.idaho.gov.
 
IDAHO MEDICAID PROVIDER HANDBOOK
This Information Release does not replace information in your Idaho Medicaid Handbook.
 
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