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July 1, 2005
 
MEDICAID INFORMATION RELEASE 2005-27
 
TO:                 Prescribing Providers, Pharmacists, Pharmacies, Hospitals, and Long-Term Care Facilities
 
FROM:           Randy May, Deputy Administrator
 
SUBJECT:     PRIOR AUTHORIZATION CRITERIA FOR LEUKOTRIENE DRUG CLASS
 
Drug/Drug Class:
LEUKOTRIENES
Implementation Date:
Effective for dates of service on or after August 1, 2005
 

Idaho Medicaid is designating preferred agents and therapeutic criteria for the Leukotriene therapeutic drug class as part of the Enhanced Prior Authorization Program. Beginning August 1, 2005, the preferred agents for the Leukotriene drug class will be the following:
 
Preferred Agent(s)*
Non-preferred Agents*
  • Accolate®
  • Singulair®
  • None as of 8/1/2005
* Use of any Leukotriene must meet therapeutic prior authorization criteria.
 
To meet the therapeutic requirements the patient must have an asthma or allergic rhinitis diagnosis. Individuals over age 16 with an asthma diagnosis must also show documented concurrent use or failure of an Inhaled Corticosteroid.
The Department requests that providers use the relative cost ranking table below as a secondary factor when determining the most appropriate drug therapy for their patients.
 
 
Lowest to Highest Relative Cost
(Cost to Medicaid after rebates)
Accolate®
100%
Singulair®
130%
 
 
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.
 
Thank you for your continued participation in the Idaho Medicaid program.
 
IDAHO MEDICAID PROVIDER HANDBOOK
This Information Release does not replace information in your Idaho Medicaid Provider handbook.
 
RM/cb