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September 7, 2006
 
 
MEDICAID INFORMATION RELEASE 2006-36
 
 
TO:                 Prescribing Providers, Pharmacies and Hospitals
 
FROM:           Leslie Clement, Administrator
 
SUBJECT:      Preferred Agents for Drug Classes Reviewed at July 21, 2006 and August 18, 2006 Pharmacy and Therapeutics Committee Meetings
 
Drug/Drug Classes:
Noted below
Implementation Date:
Effective for dates of service on or after October 1, 2006
 
Idaho Medicaid is designating preferred agents and prior authorization criteria for the following drug classes as part of the Enhanced Prior Authorization Program. The information is included in the attached Preferred Drug List.
 
The Enhanced PA Program and drug-class specific PA criteria are based on evidence-based clinical criteria and nationally recognized peer-reviewed information. The determination of medications to be considered preferred within a drug class is based primarily on objective evaluations of their relative safety, effectiveness, and clinical outcomes in comparison with other therapeutically interchangeable alternative drugs, and secondarily on cost.
 
Questions regarding the Prior Authorization Program may be referred to Idaho Medicaid Pharmacy at (208) 364-1829.  A current listing of preferred and non-preferred agents and prior authorization criteria for all drug classes is available online at www.medicaidpharmacy.idaho.gov
 
THERAPEUTIC
DRUG CLASS
PREFERRED
AGENTS
NON-PREFERRED
AGENTS*
Beta-Agonist Bronchodilators
albuterol CFC metered dose inhaler, albuterol HFA metered dose inhaler, albuterol inhalation solution, albuterol oral syrup, albuterol tablets, Proventil HFA® metered dose inhaler,  Ventolin HFA® metered dose inhaler,  Xopenex HFA® metered dose inhaler, Maxair Autoinhaler® metered dose inhaler, and terbutaline oral tablets
Alupent ® metered dose inhaler,  metaproterenol inhalation solution, metaproterenol oral syrup, metaproterenol tablets, Alupent® metered dose inhaler, Accuneb ® inhalation solution, Xopenex® inhalation solution, Vospire ER®, Serevent Diskus® dry powder inhaler and Foradil Aerolizer ® metered dose inhaler
Anticholenergic
Bronchodilators
ipratropium nebulizer solution, Combivent®  metered dose inhaler, Atrovent HFA ® metered dose inhaler  and  Spiriva Handihaler® inhalation powder
Duoneb® inhalation solution
Leukotriene Modifiers
none
Accolate® Singulair® and Zyflo®
Intranasal Rhinitis Agents
Astelin®, Nasacort AQ®, Nasonex®, Flonase®, and ipratropium nasal spray
Atrovent® ,  Beconase AQ®, Nasarel®, flunisolide, fluticasone and Rhinocort Aqua®
Inhaled Glucocorticoids
AeroBid ®, AeroBid-M®, Azmacort®, QVAR®, and Asmanex ®
The Committee recommends that current Advair® patients receive a “grandfathered” prior authorization.
The Committee recommends that Pulmicort Respules® not require prior authorization for children 1-8 years of age
Advair Diskus®, Pulmicort Respules®, Flovent®, Flovent HFA®, and Pulmicort Turbuhaler®
Non-Steroidal Anti-Inflammatory Agents
ibuprofen, piroxicam, ketorolac, naproxen, fenoprofen, indomethacin, flurbiprofen, oxaprozin, diclofenac, sulindac, Ponstel® and etodolac
meclofenamate, nabumetone, ketoprofen, tolmetin, Mobic®, meloxicam, Celebrex® and Arthrotec®
 
The Committee recommends that Mobic® , meloxicam and Arthrotec® be added to the therapeutic prior authorization rule currently in place for Celebrex. ®
 
Brand name drugs of preferred generics will still require prior authorization.
 
Platelet Aggregation Inhibitors
Aggrenox®,and Plavix®
dipyridamole and ticlopidine
Anti-Parkinson Agents
benztropine, trihexyphenidyl, Kemadrin® , Requip®, carbidopa/levodopa, selgiline, Mirapex®, StalevoTM and Comtan®
Parcopa®, pergolide and Tasmar®
 
Brand name drugs of preferred generics will still require prior authorization.
 
Bone Resorption Suppression & Related Agents
Fosamax®, Fosamax Plus D®, Boniva®, Miacalcin® nasal and Evista®
Actonel®, Actonel®w/calcium, Didronel®, Fortical®, and Forteo® subcutaneous
Androgenic Agents
Androderm® and Androgel ®
Testim®
Alzheimer Agents
Aricept®, Aricept ODT®, and Exelon®
 
The Committee recommends that Namenda® be designated as a preferred agent for moderate to severe dementia ratings.
The Committee recommends that the current therapeutic prior authorization criteria continue to be required.
 
Cognex®, Razadyne® and Razadyne ER®
SSRI Antidepressants
citalopram, fluoxetine, fluvoxamine, Lexapro®, Paxil CR® and Zoloft
paroxetine, Pexeva®, Prozac® Weekly, Sarafem®, and sertraline
 
The Committee recommends that all individuals currently on paroxetine be “grandfathered.”
 
ADHD Drugs
Adderall® XR, amphetamine salt combo, Concerta®,dextroamphetamine, Focalin®, Focalin® XR, Metadate® CD, methylphenidate,  and methylphenidate ER
pemoline, Ritalin® LA, Strattera® and Provigil®
 
The Committee recommends that the current therapeutic prior authorization guidelines for diagnosis and contraindications remain in effect.
The Committee recommends the following change for the Strattera® therapeutic criteria:
Strattera®
·         Documented trial and failure of at least  one stimulant within two months, or
·         Diagnosis of tics or anxiety disorder or a history of substance abuse.
The Committee recommends that patients on Ritalin® LA be grandfathered.
 
ACE Inhibitors
benazepril, benazepril/HCTZ , catopril, captopril/HCTZ, enalapril, enalapril/HCTZ, lisinopril, lisinopril/HCTZ, Altace® and Aceon®
 Mavik®,fosinopril,fosinopril/HCTZ, quinapril/HCTZ, Uniretic®, and Univasc®
 
Brand name drugs of preferred generics will still require prior authorization.
 
Ophthalmic Antibiotics
erythromycin,tobramycin, sulfacetamide, polymixin B/trimethoprim, gentamicin, bacitracin, bacitacin/polymyxin B, VigamoxTM and neomycin/polymixin B/gramicidin
ofloxacin, ZymarTM, ciprofloxacin solution, Quixin® and Ciloxan® ointment
Ophthalmics for Allergic Conjunctivitis
Alrex®, Elestat®, Acular®, Patanol® and cromolyn sodium
Optivar®, Zaditor®, Emadine®, Alomide®, Alocril® and Almast®
Ophthalmic Glaucoma Agents
Prescriber choice is allowed within this drug class. Levobunolol, dipivefrin, pilocarpine, timolol, Azopt®, Travatan®, Betimol®, metipranolol, Lumigan®, Betoptic® S, Trusopt®, brimonidine, Alphagan P, Istalol®, betaxolol, carteolol, Xalatan and Cosopt ®
No agents are recommended as non-preferred at this time.
Brand name agents not listed as preferred agents will still require prior authorization.
 
Antivirals
Prescriber choice is allowed within this drug class. Acyclovir, amantadine, Famvir, ® ganciclovir, Relenza®, rimantadine, Tamiflu®, Valcyte®, and Valtrex®
No agents are recommended as non-preferred at this time.
Brand name drugs of preferred generics will still require prior authorization.
 
Oral Antifungals
ketoconazole, fluconazole, nystatin, clotrimazole, Ancobon® and Vfend
griseofulvin suspension, Grifulvin® V tablets, Gris-Peg®, itraconazole and Lamisil® be designated as non-preferred and subject to therapeutic prior authorization criteria.
Brand name drugs of preferred generics will still require prior authorization.
 
Topical Antifungals
clotrimazole/betamethasone, econazole, Exelderm®, ketoconazole cream and shampoo, Naftin®, nystatin, nystatin/triamicinolone
ciclopirox cream and suspension, Penlac®, Ertaczo®,  Loprox® gel and shampoo Mentax® , Oxistat®,  and Vusion®
Brand name drugs of preferred generics will still require prior authorization.
The Committee recommends no changes to the current Penlac® prior authorization criteria
Oral Cephalosporins and Related Antibiotics
amoxicillin/clavulanate tablets and suspension, Augmentin XR®, Cedax®, cefaclor, cefadroxil, cefpodoxime, cefuroxime, Cefzil®, cephalexin,  Omnicef®,  Spectracef® , cefprozil and Suprax ®
Panixine®, Raniclor® and Lorabid®
 
Brand name drugs of preferred generics will still require prior authorization.
 
Oral Fluoroquinolones
Avelox®, Cipro® (suspension), and ciprofloxacin generic
Cipro® XR, Factive®, Proquin XR®, Levaquin®, and ofloxacin
Macrolides & Ketolides
Biaxin® XL, clarithromycin generic, erythromycin generic, Zithromax® powder/suspension, azithromycin generic,and  Zmax®
Ketek®
Atopic Dermatitis
Elidel® and Protopic®
None
Insulins
Humulin®, Novolin®, Humalog®, Novolog®, Levemir®, Lantus®, Novolog® mixture ,and Humalog® mixturebe
Apidra®
Diabetes Treatment Injectables
Symlin® and Byetta®
 
The Committee recommends that their use be limited to package label guidelines.
 
None
Cytokine and CAM Antagonists
Provider choice is allowed within this class. Keneret®, Enbrel®, Raptiva®, Orencia®, Humira®, Amevive® and Remicade®
None
Oral Antiemetics
Emend®, Zofran and Zofran ODT ®
The Committee recommends that current therapeutic prior authorization criteria remain in effect for all of these agents.
 
Kytril® and Anzemet®
The Committee recommends that current therapeutic prior authorization criteria remain in effect for all of these agents.
 
*Use of non-preferred agents must meet prior authorization requirements
*Use of any covered product may be subject to prior authorization for quantities or uses outside Food and Drug Administration (FDA) guidelines or indications
 
IDAHO MEDICAID PROVIDER HANDBOOK
 
This Information Release does not replace information in your Idaho