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July 1, 2005
 
MEDICAID INFORMATION RELEASE 2005-25
 
TO:                 Prescribing Providers, Pharmacists, Pharmacies, Hospitals, and Long-Term Care Facilities
 
FROM:           Randy May, Deputy Administrator
 
SUBJECT:      PRIOR AUTHORIZATION CRITERIA FOR INHALED BETA-2 AGONIST DRUG CLASS
 
Drug/Drug Class:
INHALED BETA-2 AGONISTS
Implementation Date:
Effective for dates of service on or after August 1, 2005
 

Idaho Medicaid is designating preferred agents for the Inhaled Beta-2 Agonist therapeutic drug class as part of the Enhanced Prior Authorization Program.   Beginning August 1, 2005, the preferred agents for the Inhaled Beta-2 Agonist drug class will be the following:
 
Preferred Agent(s)
Non-preferred Agents^
  • Albuterol
  • Formoterol (Foradil®)
  • Salmetrol (Serevent®)
  • Serevent® Diskus
  • Acceneb®
  • Alupent®
  • Maxair® Autohaler
  • Metaproterenol Sulfate
  • Xopenex®
^ Use of non-preferred agents must meet prior authorization requirements.
 
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)
Short Acting Agents
Albuterol
100%
Alupent®
330%
Maxair® Autohaler
410%
Metaproterenol Sulfate
510%
Accuneb®
900%
Xopenex® soln
970%
Long Acting Agents
Serevent®
1040%
Serevent® Diskus
1130%
Foradil®
1150%
 
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