Preferred Drug List - Kentucky - Magellan Medicaid Administration
Kentucky Pharmacy Preferred Drug List Effective: February 18, 2015 GENERAL DEFINITION OF TERMS Clinical Criteria (CC) – Due to the nature of some medications, prior authorization may be required for the medication to be covered at any copay tier. Medications that require prior authorization will require that certain clinical criteria be met. Medications may require the use of preferred medications (subject to PDL), in addition to satisfying appropriate clinical criteria, before approval (prior authorization) can be considered. If a medication requires PA, the ordering physician should contact Magellan Medicaid Administration, the plan’s pharmacy benefit administrator. Also, prescriptions exceeding such plan limitations as Quantity Limits (QL), Step Therapy (ST), Maximum Duration (MD), Age Edit (AE), in addition to those subject to Clinical Criteria (CC), will also require PA. Step Therapy (ST) – Step therapy is an electronic PA process that takes place at t he time the pharmacy submits the claim. For example, in the case of medications considered “second‐line” agents, the system will look at the member’s paid claims history, and if a claim(s) for the required “first‐line” medication(s) is located, the system will approve the claim. If “first‐line” medication(s) are not located, the system will not approve the claim, and will return a message to the pharmacy advising that the Step Therapy protocol has not been satisfied and prior authorization is required. At that time, the pharmacy may contact the physician and request that they contact Magellan Medicaid Administration for PA. Quantity Limits (QL) – Quantity limits have been placed on medications to be consistent with the maximum dosage that the Food and Drug Administration (FDA) has approved to be both safe and effective. Medications where the quantity exceeds the FDA’s maximum daily dose will require PA. Prescriptions exceeding plan limitations will require PA. Medication with Maximum Duration (MD) – Medications indicated will be available for a defined period of days per rolling year (365 days) before requiring a new or additional PA. Age Edit (AE) – Medications indicated are available for members above or below XX age without PA. Maintenance Drugs – Maintenance medications in the following classes can be processed for up to a 92 day supply and 100 units: Antianginals Antiarrhythmics Antiarthritics Antidiabetics Antihypertensives Cardiac Glycosides Digestants Diuretics Oral Contraceptives Progesterones Thyroid Preparations Proprietary & Confidential © 2015 Magellan Health Services, Inc. Magellan Medicaid Administration, a Magellan Rx Management company Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/ Magellan Medicaid Administration Clinical Support Center: Phone 800‐477‐3071; Fax 800‐365‐8835 I. CARDIOVASCULAR Drug Class Preferred Agents ACE Inhibitors benazepril captopril enalapril lisinopril quinapril ramipril Accupril® Aceon® Altace® Capoten® Epaned™ fosinopril Lotensin® Mavik® moexipril Monopril® perindopril Prinivil® trandolapril Univasc® Vasotec® Zestril® ACEI + Diuretic Combinations benazepril/HCTZ captopril/HCTZ enalapril/HCTZ lisinopril/HCTZ Accuretic® Capozide® fosinopril HCT Lotensin HCT® moexipril/HCTZ Prinzide® quinapril/HCTZ Quinaretic® Uniretic® Vaseretic® Zestoretic® Angiotensin Receptor Blockers losartan valsartan Atacand® Avapro® Benicar® candesartan Cozaar® Diovan® Edarbi™ eprosartan irbesartan Micardis® telmisartan Teveten® AE = Age Edits CC = Clinical Criteria MD = Medications with Maximum Duration Page 2 | Kentucky Preferred Drug List Non‐Preferred Agents QL = Quantity Limits ST = Step Therapy Effective February 18, 2015 Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/ Magellan Medicaid Administration Clinical Support Center: Phone 800‐477‐3071; Fax 800‐365‐8835 I. CARDIOVASCULAR Drug Class Preferred Agents Angiotensin Modulator + amlodipine/benazepril CCB Combinations Exforge® ST Exforge HCT® ST Azor™ Lotrel® Tarka® Tribenzor® telmisartan/amlodipine Twynsta® valsartan/amlodipine valsartan/amlodipine/HCTZ verapamil/trandolapril ARB + Diuretic Combinations losartan/HCTZ valsartan/HCTZ Atacand HCT® Avalide® Benicar HCT® candesartan/HCTZ Diovan HCT® Edarbyclor™ Hyzaar® irbesartan/HCTZ Micardis HCT® telmisartan/HCTZ Teveten HCT® Anti‐Anginal & Anti‐ Ischemic Ranexa® CC N/A Anti‐Arrhythmics, Oral amiodarone 100, 200 mg disopyramide flecainide mexiletine procainamide propafenone quinidine gluconate quinidine sulfate quinidine sulfate CR Tikosyn® sotalol sotalol AF amiodarone 400 mg Betapace® Betapace® AF Cordarone® Multaq® Norpace® Norpace® CR Pacerone® Pronestyl® propafenone SR Rythmol® Rythmol® SR Tambocor® Direct Renin Inhibitors Tekturna® ST Tekturna HCT® ST Amturnide™ Tekamlo® AE = Age Edits CC = Clinical Criteria MD = Medications with Maximum Duration Page 3 | Kentucky Preferred Drug List Non‐Preferred Agents QL = Quantity Limits ST = Step Therapy Effective February 18, 2015 Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/ Magellan Medicaid Administration Clinical Support Center: Phone 800‐477‐3071; Fax 800‐365‐8835 I. CARDIOVASCULAR Drug Class Preferred Agents Beta Blockers atenolol metoprolol tartrate propranolol propranolol ER Toprol XL® acebutolol betaxolol bisoprolol Bystolic™ Corgard® Hemangeol™ Inderal® Inderal® LA Inderal® XL Innopran XL® Kerlone® Levatol® Lopressor® metoprolol succinate ER nadolol pindolol Sectral® Tenormin® timolol Zebeta® Visken® Beta Blockers + Diuretic Combinations atenolol/chlorthalidone bisoprolol/HCTZ propranolol/HCTZ Corzide® Dutoprol™ Lopressor® HCT metoprolol tartrate/HCTZ nadolol/bendroflumethiazide Tenoretic® Ziac® Alpha/Beta Blockers carvedilol labetalol Coreg® Coreg CR® Trandate® AE = Age Edits CC = Clinical Criteria MD = Medications with Maximum Duration Page 4 | Kentucky Preferred Drug List Non‐Preferred Agents QL = Quantity Limits ST = Step Therapy Effective February 18, 2015 Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/ Magellan Medicaid Administration Clinical Support Center: Phone 800‐477‐3071; Fax 800‐365‐8835 I. CARDIOVASCULAR Drug Class Preferred Agents Calcium Channel Blockers amlodipine (DHP) nifedipine ER/SA/SR Adalat CC® Afeditab™ CR Cardene® Cardene ER® Dynacirc® felodipine ER isradipine nicardipine Nifediac CC® Nifedical XL® nifedipine IR nimodipine nisoldipine ER Norvasc® Nymalize® Plendil® Procardia® Procardia XL® Sular® Calcium Channel Blockers diltiazem (Non‐DHP) diltiazem ER/LA verapamil verapamil ER (EXCEPT 360 mg capsules) Calan® Calan® SR Cardizem® Cardizem CD® Cardizem LA® Cartia XT Covera‐HS® Dilacor XR® Dilt CD Dilt XR Diltia XT® Diltzac ER Matzim LA™ Taztia XT Tiazac® verapamil ER 360 mg capsules verapamil ER PM Verelan® Verelan PM® Vasodilator and Nitrate Combinations N/A AE = Age Edits BiDil® CC = Clinical Criteria MD = Medications with Maximum Duration Page 5 | Kentucky Preferred Drug List Non‐Preferred Agents QL = Quantity Limits ST = Step Therapy Effective February 18, 2015 Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/ Magellan Medicaid Administration Clinical Support Center: Phone 800‐477‐3071; Fax 800‐365‐8835 I. CARDIOVASCULAR Drug Class Preferred Agents Agents for Pulmonary Hypertension Letairis™ sildenafil CC Tracleer® Ventavis® CC Adcirca™ CC Adempas® Opsumit® Orenitram™ CC Revatio™ Tyvaso™ Familial Hypercholesterolemia Agents Kynamro™ CC Juxtapid™ Lipotropics: Bile Acid Sequestrants cholestyramine cholestyramine light colestipol tablets Colestid® colestipol granules/packets Questran® Questran Light® Prevalite® WelChol® Lipotropics: Cholesterol Absorption Inhibitor Zetia® N/A Lipotropics: Fibric Acid Derivatives fenofibric acid (Generic Trilipix™) fenofibrate nanocrystallized (Generic Tricor®) gemfibrozil Antara™ Fenoglide™ fenofibrate (Generic Antara™, Lipofen™, Lofibra®) fenofibric acid (Generic Fibricor™) Fibricor™ Lipofen™ Lofibra® Lopid® TriCor® Triglide™ Trilipix™ Lipotropics: Omega‐3 Fatty Acids Lovaza® ST omega‐3 acid ethyl esters Vascepa® AE = Age Edits CC = Clinical Criteria MD = Medications with Maximum Duration Page 6 | Kentucky Preferred Drug List Non‐Preferred Agents QL = Quantity Limits ST = Step Therapy Effective February 18, 2015 Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/ Magellan Medicaid Administration Clinical Support Center: Phone 800‐477‐3071; Fax 800‐365‐8835 I. CARDIOVASCULAR Drug Class Preferred Agents CC, QL Non‐Preferred Agents QL Advicor™ QL Altoprev® QL Caduet® QL Crestor® QL fluvastatin QL Lescol® Lescol XL® QL QL Lipitor® Liptruzet® QL QL Livalo® Mevacor® QL QL Pravachol® QL Simcor® Vytorin™ QL QL Zocor® Lipotropics: Statins amlodipine/atorvastatin atorvastatin QL lovastatin QL pravastatin QL simvastatin QL Lipotropics: Niacin Derivatives niacin ER Niacor® Niaspan® niacin Platelet Inhibitors Aggrenox® Brilinta™ CC clopidogrel cilostazol dipyridamole Effient™ Persantine® Plavix® Pletal® Ticlopidine CC Zontivity™ Anticoagulants Eliquis® enoxaparin Fragmin® fondaparinux Jantoven® Pradaxa® warfarin Xarelto® Arixtra® Coumadin® Innohep® Lovenox® II. GASTROINTESTINAL Drug Class Preferred Agents Oral Anti‐Emetics: Anticholinergics meclizine prochlorperazine promethazine (EXCEPT 50 mg suppositories) Transderm‐Scop Patch® trimethobenzamide AE = Age Edits CC = Clinical Criteria MD = Medications with Maximum Duration Page 7 | Kentucky Preferred Drug List QL = Quantity Limits Non‐Preferred Agents Antivert® CC, QL Diclegis™ Phenergan® promethazine 50 mg suppositories Tigan® Univert® ST = Step Therapy Effective February 18, 2015 Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/ Magellan Medicaid Administration Clinical Support Center: Phone 800‐477‐3071; Fax 800‐365‐8835 II. GASTROINTESTINAL Drug Class Preferred Agents Non‐Preferred Agents QL QL Oral Anti‐Emetics: 5‐HT3 ondansetron Antagonists Aloxi® QL Anzemet® QL granisetron Granisol™ QL Kytril® CC, QL Sancuso® QL Zofran® Zuplenz® Oral Anti‐Emetics: NK‐1 Antagonists Emend® QL N/A Oral Anti‐Emetics: Δ‐9‐ THC Derivatives dronabinol CC, QL Cesamet® CC, QL CC, QL Marinol® Axid® Pepcid® nizatidine Zantac® H2 Receptor Antagonists cimetidine famotidine ranitidine Proton Pump Inhibitors Nexium® QL omeprazole capsules QL pantoprazole QL Aciphex® QL Aciphex® Sprinkle QL QL Dexilant™ esomeprazole strontium QL QL lansoprazole omeprazole suspension QL QL omeprazole/sodium bicarb Prevacid® QL Prilosec® QL QL Protonix® rabeprazole QL Anti‐Ulcer Protectants misoprostol sucralfate Carafate® Cytotec® Orafate® H. pylori Treatment Helidac® QL Prevpac® QL QL Pylera® lansoprazole/amoxicillin/clarithromycin QL QL Omeclamox‐Pak™ AE = Age Edits CC = Clinical Criteria MD = Medications with Maximum Duration Page 8 | Kentucky Preferred Drug List QL = Quantity Limits ST = Step Therapy Effective February 18, 2015 Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/ Magellan Medicaid Administration Clinical Support Center: Phone 800‐477‐3071; Fax 800‐365‐8835 II. GASTROINTESTINAL Drug Class Preferred Agents Antispasmodics/ Anticholinergics dicyclomine glycopyrrolate hyoscyamine methscopolamine propantheline Anaspaz® Bentyl® Cantil® chlordiazepoxide/clidinium Cuvposa® Librax® Pamine® Pamine® Forte PB‐Hyos® Quadrapax® Robinul® Robinul Forte® Sal‐Tropine® Scopace® 5‐ASA Derivatives Apriso™ balsalazide Canasa® mesalamine enemas sulfasalazine Asacol HD® Azulfidine® Azulfidine EN® Delzicol® Dipentum® Giazo® Lialda™ mesalamine kits Pentasa® Rowasa® sfRowasa® Antidiarrheals diphenoxylate with atropine loperamide QL Fulyzaq™ Lomotil® Motofen® paregoric AE = Age Edits CC = Clinical Criteria MD = Medications with Maximum Duration Page 9 | Kentucky Preferred Drug List Non‐Preferred Agents QL = Quantity Limits ST = Step Therapy Effective February 18, 2015 Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/ Magellan Medicaid Administration Clinical Support Center: Phone 800‐477‐3071; Fax 800‐365‐8835 II. GASTROINTESTINAL Drug Class Preferred Agents Non‐Preferred Agents Laxatives and Cathartics lactulose MoviPrep® PEG 3350/Electrolyte PEG 3350/Na Sulf, Bicarb, Cl/KCl polyethylene glycol Sod Chloride/NaHCO3/KCl/PEGS CoLyte® with flavoring Gavilyte‐C® Gavilyte‐G® Gavilyte‐N® GoLytely® HalfLytely‐Bisacodyl Bowel Kit® Kristalose® Miralax® NuLytely® with Flavor Packs OCL® OsmoPrep® PEG 3350 Powder Pack PEG3350/Flavor Pack Solution Prepopik™ CC Relistor® Suclear™ Bowel Prep Kit Suprep® Trilyte® with Flavor Packets Irritable Bowel Syndrome Amitiza® CC Linzess® CC Lotronex® CC AE = Age Edits CC = Clinical Criteria MD = Medications with Maximum Duration Page 10 | Kentucky Preferred Drug List QL = Quantity Limits ST = Step Therapy Effective February 18, 2015 Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/ Magellan Medicaid Administration Clinical Support Center: Phone 800‐477‐3071; Fax 800‐365‐8835 III. RESPIRATORY Drug Class Preferred Agents Antibiotics, Inhaled Non‐Preferred Agents Bethkis® Cayston® TOBI® TOBI Podhaler® tobramycin inhalation solution Antihistamines, Minimally cetirizine OTC (EXCEPT chewable tablets) Sedating loratadine OTC loratadine‐pseudoephedrine OTC Allegra® ST Allegra‐D® 12 Hr Allegra‐D® 24 Hr ST cetirizine syrup ST Clarinex® Clarinex‐D® 12 Hr Clarinex‐D® 24 Hr desloratadine ST fexofenadine fexofenadine/pseudoephedrine 12‐Hour fexofenadine/pseudoephedrine 24‐Hour ST levocetirizine Semprex D® ST Xyzal® Antihistamines, Intranasal Astepro® Astelin® azelastine olopatadine Patanase™ Anticholinergics, Intranasal ipratropium nasal spray Atrovent® Beta Agonists: Short‐ Acting albuterol inhalation solution QL albuterol oral ProAir HFA® QL Proventil® HFA QL terbutaline levalbuterol inhalation solution QL metaproterenol inhalation solution metaproterenol oral QL Ventolin HFA® QL Xopenex® QL Xopenex HFA® QL Beta Agonists: Long‐Acting Foradil® Aerolizer® QL Beta Agonists: Combination Products Advair Diskus ® QL Advair HFA® QL Dulera® QL Symbicort® QL Breo Ellipta™ QL COPD Agents albuterol‐ipratropium inhalation solution QL Atrovent® HFA QL Combivent Respimat® QL ipratropium inhalation solution QL Spiriva Handihaler® QL Anoro™ Ellipta™ Daliresp™ QL QL DuoNeb® Spiriva Respimat® QL Tudorza™ Pressair™ QL AE = Age Edits CC = Clinical Criteria MD = Medications with Maximum Duration Page 11 | Kentucky Preferred Drug List Arcapta™ Neohaler™ QL QL Brovana® Perforomist™ QL Serevent® Diskus QL QL = Quantity Limits CC, QL ST = Step Therapy Effective February 18, 2015 Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/ Magellan Medicaid Administration Clinical Support Center: Phone 800‐477‐3071; Fax 800‐365‐8835 III. RESPIRATORY Drug Class Preferred Agents Corticosteroids, Inhaled Non‐Preferred Agents QL QL Aerospan™ QL Alvesco® QL Asmanex® HFA AE, QL budesonide respules Asmanex® Twisthaler Flovent Diskus® QL Flovent HFA® QL Pulmicort Flexhaler® QL Pulmicort Respules® QL, AE QVAR™ QL Corticosteroids, Intranasal fluticasone propionate QL Nasonex® QL Leukotriene Modifiers Beconase AQ® QL budesonide QL QL Dymista® QL Flonase® QL flunisolide Nasacort AQ® QL Omnaris™ QL QL Qnasl™ Rhinocort Aqua® QL QL triamcinolone QL Veramyst® Zetonna™ QL montelukast CC, QL zafirlukast CC, QL Accolate® QL CC, QL Singulair® Zyflo CR® Self Injectable Epinephrine Epi Pen® QL Epi Pen® Jr. QL Adrenaclick® QL QL AuviQ® QL self‐injectable epinephrine IV. CENTRAL NERVOUS SYSTEM Drug Class Preferred Agents Alzheimer’s: donepezil Cholinesterase Inhibitors Exelon® Patch rivastigmine Aricept® Aricept ODT® donepezil 23 mg donepezil ODT Exelon® Solution/Capsule galantamine galantamine ER Razadyne® Razadyne ER® Alzheimer’s: NMDA Receptor Antagonists Namenda XR® AE = Age Edits Namenda® CC = Clinical Criteria MD = Medications with Maximum Duration Page 12 | Kentucky Preferred Drug List Non‐Preferred Agents QL = Quantity Limits ST = Step Therapy Effective February 18, 2015 Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/ Magellan Medicaid Administration Clinical Support Center: Phone 800‐477‐3071; Fax 800‐365‐8835 IV. CENTRAL NERVOUS SYSTEM Drug Class Preferred Agents Non‐Preferred Agents acamprosate Antabuse® disulfiram Depade® ReVia® Antialcoholic Preparations Campral® naltrexone oral Vivitrol® Antianxiety Agents alprazolam IR tablets MD buspirone chlordiazepoxide MD clonazepam tablets clorazepate MD diazepam tablets MD lorazepam MD oxazepam MD alprazolam ER MD MD alprazolam ODT MD Ativan® clonazepam ODT CC, MD diazepam liquid® CC meprobamate Klonopin® Niravam® CC, MD CC, MD Tranxene‐T® MD Valium® CC, MD Xanax® CC, MD Xanax XR® Antidepressants: MAOIs N/A Emsam® Marplan® Nardil® Parnate® phenelzine tranylcypromine Antidepressants: Other bupropion bupropion SR/ER/XL nefazodone trazodone Aplenzin™ Brintellix™ Forfivo XL® Oleptro™ Viibryd® Wellbutrin® Wellbutrin® SR Wellbutrin® XL Antidepressants: SNRIs Savella™ CC venlafaxine venlafaxine XR capsules Cymbalta® desvenlafaxine ER desvenlafaxine fumarate XR desvenlafaxine succinate ER CC duloxetine Effexor® Effexor XR® Fetzima™ Khedezla DR® Pristiq® venlafaxine ER tablets AE = Age Edits CC = Clinical Criteria MD = Medications with Maximum Duration Page 13 | Kentucky Preferred Drug List QL = Quantity Limits ST = Step Therapy Effective February 18, 2015 Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/ Magellan Medicaid Administration Clinical Support Center: Phone 800‐477‐3071; Fax 800‐365‐8835 IV. CENTRAL NERVOUS SYSTEM Drug Class Preferred Agents Antidepressants: SSRIs Brisdelle™ Celexa® escitalopram solution QL fluoxetine60 mg, 90 mg fluvoxamine fluvoxamine ER Lexapro™ Luvox® CR paroxetine CR Paxil® Paxil CR® Pexeva® Prozac® QL Prozac Weekly™ Sarafem® Zoloft® citalopram HBr escitalopram fluoxetine HCl Lexapro™ Solution paroxetine HCl sertraline Antidepressants: Tricyclics amitriptyline clomipramine desipramine imipramine HCl maprotiline mirtazapine nortriptyline Anafranil® amoxapine doxepin imipramine pamoate Norpramin® Pamelor® protriptyline Remeron® Surmontil® Tofranil® Tofranil‐PM® trimipramine Vivactil® Anticonvulsants: First Generation clonazepam ODT Depakene® Depakote® Depakote ER® diazepam rectal gel Dilantin® divalproex sodium ER Klonopin® Mebaral® CC Onfi™ Stavzor™ Zarontin® AE = Age Edits Celontin® clonazepam tablets DiaStat® divalproex delayed‐release ethosuximide mephobarbital CC Peganone® phenobarbital CC Phenytek® phenytoin IR/ER primidone valproic acid CC = Clinical Criteria MD = Medications with Maximum Duration Page 14 | Kentucky Preferred Drug List Non‐Preferred Agents CC QL = Quantity Limits ST = Step Therapy Effective February 18, 2015 Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/ Magellan Medicaid Administration Clinical Support Center: Phone 800‐477‐3071; Fax 800‐365‐8835 IV. CENTRAL NERVOUS SYSTEM Drug Class Preferred Agents Anticonvulsants: Second Generation Banzel™ felbamate Gabitril® gabapentin capsules lamotrigine IR levetiracetam IR Lyrica® CC Sabril® CC topiramate IR zonisamide Fanatrex™ Felbatol® Fycompa™ gabapentin tablets Gralise™ Keppra™ Keppra XR™ Lamictal® Lamictal ODT® Lamictal XR® lamotrigine ODT lamotrigine XR levetiracetam XR Neurontin® Potiga® Qudexy XR® tiagabine Topamax® topiramate ER Trokendi XR® Vimpat® Zonegran® Anticonvulsants: Carbamazepine Derivatives Carbatrol® carbamazepine carbamazepine XR Equetro™ oxcarbazepine carbamazepine ER Oxtellar XR® Tegretol® Tegretol‐XR® Trileptal® Antipsychotics: First‐ Generation amitriptyline/perphenazine chlorpromazine fluphenazine haloperidol loxapine Moban® Orap® perphenazine thioridazine thiothixene trifluoperazine Adasuve® Loxitane® AE = Age Edits CC = Clinical Criteria MD = Medications with Maximum Duration Page 15 | Kentucky Preferred Drug List Non‐Preferred Agents CC QL = Quantity Limits ST = Step Therapy Effective February 18, 2015 Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/ Magellan Medicaid Administration Clinical Support Center: Phone 800‐477‐3071; Fax 800‐365‐8835 IV. CENTRAL NERVOUS SYSTEM Drug Class Preferred Agents Antipsychotics: Second‐ Generation CC, QL Abilify® clozapine CC, QL clozapine ODT CC, QL Fanapt™ CC, QL Latuda® CC, QL olanzapine CC, QL quetiapine CC, QL risperidone CC, QL Saphris® CC, QL Seroquel® XR CC, QL ziprasidone CC, QL Clozaril® CC, QL FazaClo ODT® CC, QL Geodon® CC, QL Invega® CC, QL Risperdal® CC, QL Seroquel® Versacloz® CC, QL CC, QL Zyprexa Zydis® CC, QL Zyprexa® Antipsychotics: Injectable Abilify® CC, QL Abilify® Maintena CC, QL fluphenazine decanoate CC, QL Geodon® CC, QL haloperidol decanoate CC, QL Invega® Sustenna® CC, QL olanzapine CC, QL Risperdal® Consta® CC, QL Haldol® Decanoate CC, QL Zyprexa® CC, QL CC, QL Zyprexa® Relprevv™ Atypical Antipsychotic and Symbyax® CC, QL SSRI Comb. olanzapine/fluoxetine CC, QL Stimulants and Related Agents AE = Age Edits Adderall XR® CC, QL dexmethylphenidate IR CC, QL dextroamphetamine IR/ER CC, QL Focalin XR™ CC, QL Intuniv™ CC, QL Metadate CD® CC, QL Metadate ER® CC, QL Methylin® CC, QL Methylin Chewable® CC, QL Methylin ER® CC, QL methylphenidate IR/SA/SR tablets, capsulesCC, QL mixed amphetamine salts IR CC, QL Quillivant® XR CC, QL Strattera® CC, QL Vyvanse™ CC, QL CC = Clinical Criteria MD = Medications with Maximum Duration Page 16 | Kentucky Preferred Drug List Non‐Preferred Agents CC, QL QL = Quantity Limits Adderall® CC, QL CC, QL clonidine 0.1 mg CC, QL Concerta® CC, QL Daytrana™ CC, QL Desoxyn® CC, QL Dexedrine IR/ER® dexmethylphenidate ER CC, QL CC, QL dextroamphetamine solution CC, QL Focalin™ guanfacine CC, QL CC, QL Kapvay™ methamphetamine CC, QL Methylin Solution® methylphenidate (Generic for Metadate CD®)CC, QL CC, QL methylphenidate LA (Generic Ritalin® LA) CC, QL methylphenidate solution mixed amphetamine salts ER CC, QL CC, QL Procentra™ CC, QL Ritalin® IR/LA/SR CC, QL Zenzedi® ST = Step Therapy Effective February 18, 2015 Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/ Magellan Medicaid Administration Clinical Support Center: Phone 800‐477‐3071; Fax 800‐365‐8835 IV. CENTRAL NERVOUS SYSTEM Drug Class Preferred Agents QL Anti‐Migraine: 5‐HT1 Receptor Agonists rizatriptan ODT sumatriptan QL Alsuma™ QL Amerge® QL Axert® QL Cambia™ QL Frova™ QL Imitrex® Maxalt® QL Maxalt‐MLT® QL naratriptan QL QL rizatriptan QL Relpax™ QL Sumavel ™Dosepro™ QL Treximet™ zolmitriptan QL zolmitriptan ODT QL Zomig® QL Zomig‐ZMT® QL Dopamine Receptor Agonists bromocriptine pramipexole ropinirole Mirapex® Mirapex® ER Neupro® Parlodel® Requip® Requip® XL ropinirole ER Narcolepsy Agents Provigil® CC, QL modafinil CC, QL CC, QL Nuvigil® CC, QL Xyrem® Parkinson’s Disease amantadine syrup, tablets benztropine carbidopa Comtan® levodopa/carbidopa levodopa/carbidopa CR levodopa/carbidopa ODT selegiline tablets trihexyphenidyl amantadine capsules Azilect® Duopa™ entacapone levodopa/carbidopa/entacaone Lodosyn® Parcopa™ Rytary™ selegiline capsules Sinemet® Sinemet® CR Stalevo® Tasmar® Zelapar™ AE = Age Edits CC = Clinical Criteria MD = Medications with Maximum Duration Page 17 | Kentucky Preferred Drug List Non‐Preferred Agents QL QL = Quantity Limits ST = Step Therapy Effective February 18, 2015 Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/ Magellan Medicaid Administration Clinical Support Center: Phone 800‐477‐3071; Fax 800‐365‐8835 IV. CENTRAL NERVOUS SYSTEM Drug Class Preferred Agents Non‐Preferred Agents QL Sedative Hypnotic Agents estazolam flurazepam QL temazepam 15 mg, 30 mg QL triazolam QL zolpidem QL Ambien® QL Ambien CR® QL Doral® CC, QL Edluar® QL eszopiclone QL Halcion® CC, QL Hetlioz® QL Intermezzo® Lunesta™ QL QL Restoril® Rozerem® CC, QL QL temazepam 22.5 mg, 7.5 mg QL Silenor® Somnote® QL Sonata® zaleplon QL QL zolpidem ER QL Zolpimist™ Skeletal Muscle Relaxants baclofen QL chlorzoxazone QL cyclobenzaprine QL dantrolene QL methocarbamol QL orphenadrine QL orphenadrine compound QL orphenadrine compound forte QL tizanidine tablets QL Amrix® QL, MD QL, MD carisoprodol carisoprodol compound QL, MD cyclobenzaprine ER QL, MD QL Dantrium® QL, MD Fexmid® QL, MD Flexeril® Lioresal® QL QL Lorzone® metaxalone QL QL methocarbamol/aspirin Parafon Forte DSC® QL Robaxin® QL QL Skelaxin® QL, MD Soma® QL tizanidine capsules QL Zanaflex® Tobacco Cessation AE = Age Edits bupropion SR QL Chantix® QL Nicoderm CQ® QL Nicorette® QL nicotine buccal/gum QL nicotine lozenge QL nicotine transdermal system QL Nicotrol® Inhaler QL Nicotrol® NS QL Zyban® QL CC = Clinical Criteria MD = Medications with Maximum Duration Page 18 | Kentucky Preferred Drug List QL N/A QL = Quantity Limits ST = Step Therapy Effective February 18, 2015 Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/ Magellan Medicaid Administration Clinical Support Center: Phone 800‐477‐3071; Fax 800‐365‐8835 V. ANALGESICS Drug Class Preferred Agents Narcotic Agonist/ Antagonists butorphanol NS pentazocine/APAP pentazocine/naloxone Narcotics: Short‐Acting butalbital/APAP/caffeine CC codeine/APAP MD dihydrocodeine bitartrate/APAP/caffeine hydrocodone/APAP MD hydrocodone/ibuprofen hydromorphone liquid, tablets meperidine morphine IR oxycodone oxycodone/APAP MD tramadol All branded short‐acting narcotics and narcotic combinations CC butalbital/APAP/caffeine/codeine CC butalbital compound/codeine codeine Capital® Demerol® dihydrocodeine bitartrate/ASA/caffeine Dilaudid® Endodan® Hycet® hydromorphone suppositories Ibudone™ levorphanol Margesic H® Maxidone® Norco® Nucynta™ Opana® Oxaydo® MD oxycodone/ASA oxycodone/ibuprofen oxymorphone IR Primlev® Reprexain™ Rybix™ ODT Synalgos DC® tramadolAPAP Trezix® Ultracet® Ultram® Xartemis™ XR Xodol® Xolox® Zamicet™ Zolvit™ AE = Age Edits CC = Clinical Criteria MD = Medications with Maximum Duration Page 19 | Kentucky Preferred Drug List Non‐Preferred Agents QL = Quantity Limits ST = Step Therapy Effective February 18, 2015 Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/ Magellan Medicaid Administration Clinical Support Center: Phone 800‐477‐3071; Fax 800‐365‐8835 V. ANALGESICS Drug Class Preferred Agents Narcotics: Long‐Acting Non‐Preferred Agents CC, QL QL fentanyl transdermal Kadian® QL methadone QL morphine sulfate SA (Generic for MS Contin®) QL Avinza™ CC, QL Butrans™ QL ConZip™ QL Dolophine® CC, QL Duragesic® QL Embeda™ Exalgo™ QL hydromorphone ER QL Hysingla™ ER methadone concentrate morphine sulfate SA (Generic Kadian®, QL Avinza™) MS Contin® QL CC,QL Nucynta® ER QL Opana ER® QL Oramorph® SR oxycodone ER/SR QL QL OxyContin® oxymorphone ER QL Ryzolt™ QL tramadol ER QL Ultram® ER QL Zohydro ER™ CC,QL Abstral® CC, QL Actiq® CC, QL CC, QL fentanyl citrate lollipop CC, QL Fentora® CC, QL Lazanda® Onsolis™ CC, QL Subsys® CC, QL Narcotics: Fentanyl Buccal N/A Products AE = Age Edits CC = Clinical Criteria MD = Medications with Maximum Duration Page 20 | Kentucky Preferred Drug List QL = Quantity Limits ST = Step Therapy Effective February 18, 2015 Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/ Magellan Medicaid Administration Clinical Support Center: Phone 800‐477‐3071; Fax 800‐365‐8835 V. ANALGESICS Drug Class Non‐Steroidal Anti‐ Inflammatory Drugs Preferred Agents Non‐Preferred Agents QL Celebrex® diclofenac potassium etodolac flurbiprofen ibuprofen indomethacin ketoprofen ketorolac tromethamine QL meloxicam tablets naproxen sodium naproxen tablets piroxicam sulindac Anaprox® Anaprox® DS Ansaid® Arthrotec® Cataflam® QL celecoxib Clinoril® Daypro® diclofenac/misoprostol diclofenac topical diclofenac sodium diclofenac SR diflunisal CC Duexis® etodolac SR Feldene® fenoprofen CC Flector® Indocin® indomethacin ER ketoprofen ER meclofenamate mefenamic acid meloxicam suspension Mobic® nabumetone Nalfon® Naprelan® EC naproxen suspension naproxen EC oxaprozin CC Pennsaid® CC Pennsaid® Pump Ponstel® Sprix™ CC Tivorbex® tolmetin QL Vimovo™ Voltaren® Gel CC Voltaren® XR Zipsor™ Zorvolex™ AE = Age Edits CC = Clinical Criteria MD = Medications with Maximum Duration Page 21 | Kentucky Preferred Drug List QL = Quantity Limits ST = Step Therapy Effective February 18, 2015 Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/ Magellan Medicaid Administration Clinical Support Center: Phone 800‐477‐3071; Fax 800‐365‐8835 VI. ANTI‐INFECTIVES Drug Class Preferred Agents Antibiotics: st Cephalosporins 1 Generation cefadroxil capsule cephalexin cefadroxil tablet, suspension Duricef® Keflex® Antibiotics: nd Cephalosporins 2 Generation cefuroxime axetil Ceclor® Ceclor CD® cefaclor cefaclor CD cefprozil Ceftin® Cefzil® Antibiotics: Cephalosporins 3rd Generation cefdinir cefpodoxime Suprax® suspension Cedax® cefditoren pivoxil ceftibuten Omnicef® Spectracef® Suprax® capsules, chewable tablets, tablets Vantin® Antibiotics: GI Alinia® tablets metronidazole tablets paromomycin vancomycin Xifaxan® CC, QL Alinia® suspension Dificid® Flagyl® Flagyl® ER metronidazole capsules neomycin Tindamax® tinidazole Vancocin® Antibiotics: Ketolides Ketek® CC, QL azithromycin clarithromycin erythromycin base tablets N/A Biaxin® Biaxin XL® clarithromycin ER erythromycin base capsule DR PCE® Zithromax® Zmax® Antibiotics: Oxazolidinones Zyvox® CC, QL Sivextro™ QL Antibiotics: Penicillins amoxicillin amoxicillin/clavulanate tablets, suspension ampicillin dicloxacillin penicillin V amoxicillin ER amoxicillin/clavulanate chewable tablets amoxicillin/clavulanate ER Augmentin® Augmentin XR® Moxatag™ Antibiotics: Macrolides AE = Age Edits CC = Clinical Criteria MD = Medications with Maximum Duration Page 22 | Kentucky Preferred Drug List Non‐Preferred Agents QL = Quantity Limits ST = Step Therapy Effective February 18, 2015 Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/ Magellan Medicaid Administration Clinical Support Center: Phone 800‐477‐3071; Fax 800‐365‐8835 VI. ANTI‐INFECTIVES Drug Class Preferred Agents Antibiotics: Quinolones Non‐Preferred Agents ciprofloxacin tablets levofloxacin tablets Antibiotics: Tetracyclines demeclocycline doxycycline hyclate doxycycline monohydrate tablets 50 mg, 75 mg, 100 mg capsules, tablets, suspension minocycline capsules tetracycline Antibiotics: Vaginal AE = Age Edits CC = Clinical Criteria MD = Medications with Maximum Duration Page 23 | Kentucky Preferred Drug List Avelox® ciprofloxacin ER ciprofloxacin suspension Cipro® Cipro XR® Factive® Levaquin® levofloxacin solution moxifloxacin Noroxin® ofloxacin Adoxa® Adoxa® Pak Alodox® Convenience Pak Avidoxy® Doryx® Doxy® doxycycline hyclate DR tablets doxycycline IR‐DR doxycycline monohydrate 150 mg capsules, pack Dynacin® Minocin® minocycline tablets minocycline ER Monodox® Morgidox® Ocudox® ™ Oracea Oraxyl® Solodyn® Vibramycin® Cleoncin® cream clindamycin vaginal 2% cream Clindesse® MetroGel Vaginal® Vandazole® Cleocin® Ovules metronidazole vaginal 0.75% gel QL = Quantity Limits ST = Step Therapy Effective February 18, 2015 Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/ Magellan Medicaid Administration Clinical Support Center: Phone 800‐477‐3071; Fax 800‐365‐8835 VI. ANTI‐INFECTIVES Drug Class Preferred Agents Non‐Preferred Agents Antifungals: Oral clotrimazole fluconazole flucytosine griseofulvin suspension griseofulvin ultramicrosize Noxafil® nystatin terbinafine voriconazole Ancobon® Diflucan® griseofulvin microsize Gris‐PEG® CC itraconazole ketoconazole Lamisil® Mycelex Troche® Nizoral® Onmel™ Oravig™ Sporanox® Terbinex™ Vfend® Antivirals: Herpes acyclovir famciclovir valacyclovir Famvir® Sitavig® Valtrex® Zovirax® Antivirals: Flu Relenza® rimantadine Tamiflu® QL Flumadine® Symmetrel® Anti‐Infective: Sulfonamides, Folate Antagonist trimethoprim trimethoprim/sulfamethoxazole Bactrim® Bactrim DS® Primsol® Septra DS® sulfadiazine Anti‐Infectives: Hepatitis B Baraclude™ Epivir‐HBV® Hepsera® Tyzeka® adefovir entecavir lamivudine HBV Hepatitis C: Oral Protease Incivek™ CC, QL Inhibitors Olysio™ CC, QL Victrelis™ CC, QL Hepatitis C: Interferons PEGASYS® ProClick CC, QL PEGASYS® syringe CC, QL Infergen® CC, QL PEGASYS® vial CC, QL CC, QL PEGIntron™ ® CC, QL PEGIntron™ Redipen Hepatitis C: Ribavirins ribavirin CC Copegus™ CC CC Moderiba™ CC Rebetol® CC Ribasphere™ CC Ribasphere RibaPak™ CC ribavirin dosepack AE = Age Edits CC = Clinical Criteria MD = Medications with Maximum Duration Page 24 | Kentucky Preferred Drug List N/A QL = Quantity Limits ST = Step Therapy Effective February 18, 2015 Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/ Magellan Medicaid Administration Clinical Support Center: Phone 800‐477‐3071; Fax 800‐365‐8835 VI. ANTI‐INFECTIVES Drug Class Preferred Agents Hepatitis C: NS5B Polymerase Inhibitors Sovaldi™ CC, QL Non‐Preferred Agents N/A VII. ENDOCRINE AND METABOLIC AGENTS Drug Class Preferred Agents Diabetes: Injectable Insulins Humalog® Vial Humalog® Mix Vial/Pen Humulin® N Vial Humulin® R Vial Humulin® 70/30 Vial Lantus® Vial Levemir® Vial/Pen Novolog® Vial/Pen/Cartridge Novolog® Mix Vial/Pen Apidra™ Vial/Pen Humalog® Pen/Cartridge Humulin® R 500 Vial Humulin® Pen Humulin® 70/30 Pen Lantus® Solostar Pen Novolin® Vial Novolin® 70/30 Vial Diabetes: Amylin Analogue N/A Symlin® ST Diabetes: DPP‐4 Inhibitors Janumet™ ST, QL Janumet XR™ ST, QL Januvia™ ST, QL Jentadueto™ QL Tradjenta™ QL Kazano® ST, QL Kombiglyze™ XR QL Nesina® Onglyza™ ST, QL Oseni® ST, QL Diabetes: GLP‐1 Receptor Byetta™ ST Agonists Bydureon® Tanzeum™ Victoza® Diabetes: Alpha‐ Glucosidase Inhibitors acarbose Glyset® Precose® Diabetes: Metformins glyburide/metformin metformin metformin XR Fortamet™ glipizide/metformin Glucophage® Glucophage XR® Glumetza™ Metaglip™ metformin ER (Generic Fortamet™) Riomet™ Diabetes: Meglitinides repaglinide Starlix® nateglinide PrandiMet™ Prandin® AE = Age Edits CC = Clinical Criteria MD = Medications with Maximum Duration Page 25 | Kentucky Preferred Drug List Non‐Preferred Agents QL QL = Quantity Limits ST = Step Therapy Effective February 18, 2015 Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/ Magellan Medicaid Administration Clinical Support Center: Phone 800‐477‐3071; Fax 800‐365‐8835 VII. ENDOCRINE AND METABOLIC AGENTS Drug Class Preferred Agents Diabetes: Sulfonylureas chlorpropamide glimepiride glipizide glipizide extended‐release glyburide glyburide micronized tolazamide tolbutamide Amaryl® Diabeta® Glucotrol® Glucotrol XL® Glynase PresTab® Micronase® Diabetes: Thiazolidinediones pioglitazone QL Actos® QL ACTOplus Met® QL QL ActoPlus Met® XR QL Avandamet® Avandia® QL Avandaryl® QL DuetAct™ QL pioglitazone/glimepiride QL pioglitazone/metformin QL Growth Hormones Genotropin® CC Norditropin® CC Norditropin Flexpro® CC Nutropin® CC Nutropin AQ® CC Humatrope® CC Omnitrope® CC Saizen® CC Serostim® Tev‐Tropin™ CC CC Zorbtive® CC Bone Resorption alendronate tabletsQL Suppression and Related Fortical® Agents raloxifene Actonel® QL Actonel with Calcium® QL alendronate solution Atelvia™ QL Binosto® QL QL Boniva® calcitonin‐salmon Didronel® etidronate Evista® Forteo™ QL Fosamax® QL Fosamax Plus D™ QL ibandronate Miacalcin® Prolia™ QL Reclast® risedronate QL QL Skelid® zoledronic acid QL Progestins for Cachexia Megace® Megace ES® AE = Age Edits QL megestrol acetate CC = Clinical Criteria MD = Medications with Maximum Duration Page 26 | Kentucky Preferred Drug List Non‐Preferred Agents QL = Quantity Limits ST = Step Therapy Effective February 18, 2015 Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/ Magellan Medicaid Administration Clinical Support Center: Phone 800‐477‐3071; Fax 800‐365‐8835 VII. ENDOCRINE AND METABOLIC AGENTS Drug Class Preferred Agents Non‐Preferred Agents Pancreatic Enzymes Creon® pancrelipase Zenpep® Pancreaze™ Pertzye™ Ultresa™ Viokace™ Androgenic Agents Androderm® Androgel® Axiron® Fortesta® Testim® testosterone gel Vogelxo® Oral Steroids cortisone dexamethasone solution, tablets Entocort EC® hydrocortisone methylprednisolone dose pack, tablets prednisolone solution prednisolone sodium phosphate prednisone dose pack, tablets, solution Baycadron® budesonide EC Celestone® Celestone® Soluspan Cortef® dexamethasone elixir dexamethasone intensol DexPak® DexPak JR® Flo‐Pred® Medrol® methylprednisolone 8 mg, 16 mg tablets Millipred® AE Orapred® Orapred ODT® AE prednisone intensol prednisolone sodium phosphate ODT Prelone® Rayos® Uceris® Veripred 20® AE = Age Edits CC = Clinical Criteria MD = Medications with Maximum Duration Page 27 | Kentucky Preferred Drug List QL = Quantity Limits ST = Step Therapy Effective February 18, 2015 Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/ Magellan Medicaid Administration Clinical Support Center: Phone 800‐477‐3071; Fax 800‐365‐8835 VIII. IMMUNOLOGIC AGENTS Drug Class Preferred Agents Non‐Preferred Agents CC QL CC, QL Immunomodulators Enbrel® Humira® CC, QL Actemra® CC, QL Cimzia® CC, QL Entyvio™ Kineret® CC, QL CC, QL Orencia® CC, QL Otezla® Remicade® CC, QL CC, QL Simponi™ Simponi™ARI CC, QL CC, QL Stelara™ Xeljanz™ CC, QL Topical Immunomodulators Elidel® Protopic® tacrolimus Multiple Sclerosis Agents Copaxone® 20 mg QL Extavia® QL Rebif® QL Ampyra™ QL, CC QL Aubagio® Avonex® QL QL Avonex Administration Pack® QL Betaseron® QL Copaxone® 40 mg QL Gilenya™ Plegridy® QL Tecfidera™ QL Immunosuppressants Astagraf XL™ Azasan® CellCept® Hecoria® Imuran® mycophenolic acid Neoral® Prograf® Rapamune® Sandimmune® Zortress® azathioprine cyclosporine cyclosporine modified Gengraf® mycophenolate mofetil Myfortic® sirolimus tacrolimus AE = Age Edits CC = Clinical Criteria MD = Medications with Maximum Duration Page 28 | Kentucky Preferred Drug List QL = Quantity Limits ST = Step Therapy Effective February 18, 2015 Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/ Magellan Medicaid Administration Clinical Support Center: Phone 800‐477‐3071; Fax 800‐365‐8835 IX. BLOOD MODIFIERS Drug Class Preferred Agents Non‐Preferred Agents CC N/A Erythropoiesis Stimulating Aranesp® Proteins Epogen® CC Procrit® CC Thrombopoiesis Stimulating Proteins Neumega® CC Promacta® CC Nplate™ CC Antihyperuricemics allopurinol probenecid probenecid/colchicine colchicine CC CC Colcrys® Mitigare® CC Uloric® CC Zyloprim® Phosphate Binders calcium acetate Fosrenol® MagneBind® 400 RX Renagel® Eliphos™ PhosLo® Phoslyra™ sevelamer Renvela™ Velphoro® X. OPHTHALMICS Drug Class Preferred Agents Ophthalmic Antivirals trifluridine Viroptic® Vitrasert® intraocular implant Zirgan® Ophthalmic Antifungals Natacyn® N/A Ophthalmic Quinolones ciprofloxacin ophthalmic solution Moxeza™ ofloxacin Vigamox™ Besivance™ Ciloxan® gatifloxacin levofloxacin 0.5% Ocuflox® Quixin® Zymaxid™ Ophthalmic Macrolides erythromycin 0.5% ointment AzaSite™ Ilotycin® Ophthalmic Antibiotics, Non‐Quinolones bacitracin bacitracin/polymyxin B gentamicin solution/ointment neomycin/polymyxin B/gramicidin polymyxin B/trimethoprim sulfacetamide solution tobramycin solution Bleph®‐10 Garamycin® Neocidin® neomycin/polymyxin B/bacitracin Neosporin® Polytrim® sulfacetamide ointment Tobrex® AE = Age Edits CC = Clinical Criteria MD = Medications with Maximum Duration Page 29 | Kentucky Preferred Drug List Non‐Preferred Agents QL = Quantity Limits ST = Step Therapy Effective February 18, 2015 Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/ Magellan Medicaid Administration Clinical Support Center: Phone 800‐477‐3071; Fax 800‐365‐8835 X. OPHTHALMICS Drug Class Preferred Agents Non‐Preferred Agents Ophthalmic Antibiotic‐ Steroid Combinations Blephamide® Blephamide® S.O.P. dexamethasone/neomycin sulfate/polymyxin B sulfate hydrocortisone/bacitracin zinc/neomycin sulfate/polymyxin B sulfates Pred‐G® Pred‐G® S.O.P. Tobradex® dexamethasone/tobramycin hydrocortisone/neomycin sulfate/polymyxin B sulfate Maxitrol® prednisolone sodium phosphate / sulfacetamide sodium Tobradex® ST Zylet™ Ophthalmic Antihistamines Pataday™ azelastine Bepreve™ Elestat™ Emadine® epinastine Lastacaft™ Optivar® Patanol® Ophthalmic Beta Blockers Betimol® levobunolol timolol maleate Betagan® betaxolol Betoptic S® carteolol Istalol® metipranolol Optipranolol® Timoptic® Timoptic XE® Ophthalmic Carbonic Anhydrase Inhibitors Trusopt® Azopt® dorzolamide Ophthalmic Combinations Combigan™ for Glaucoma dorzolamide/timolol Simbrinza™ Cospot® Cospot PF® Ophthalmic Vasoconstrictors naphazoline phenylephrine Altafrin® Mydfrin® Neofrin® Ophthalmic Mast Cell Stabilizers cromolyn sodium Alocril® Alomide® Cyclogyl® Cyclomydril® Homatropaire® homatropine Isopto Atropine® Isopto Homatropine® Isopto Hyoscine® Mydriacyl® Paremyd® Ophthalmic Mydriatics & atropine sulfate Mydriatic Combinations cyclopentolate tropicamide AE = Age Edits CC = Clinical Criteria MD = Medications with Maximum Duration Page 30 | Kentucky Preferred Drug List QL = Quantity Limits ST = Step Therapy Effective February 18, 2015 Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/ Magellan Medicaid Administration Clinical Support Center: Phone 800‐477‐3071; Fax 800‐365‐8835 X. OPHTHALMICS Drug Class Preferred Agents Ophthalmic NSAIDs Non‐Preferred Agents Acular® Acular LS® Acuvail® bromfenac Ilevro™ Nevanac™ Ocufen® Prolensa™ Voltaren® diclofenac flurbiprofen ketorolac Ophthalmic Prostaglandin latanoprost QL Agonists Lumigan® QL QL Rescula® Travatan Z® QL travoprost QL QL Xalatan® QL Zioptan® Ophthalmic Anti‐ Inflammatory Steroids dexamethasone sodium phosphate Flarex® fluorometholone prednisolone acetate prednisolone sodium phosphate Alrex® Durezol™ FML® FML Forte® FML S.O.P.® Lotemax™ Maxidex® Omnipred™ Ozurdex™ Pred Forte® Pred Mild® Retisert™ Triesence® Vexol® Ophthalmic Glaucoma Direct Acting Miotics pilocarpine Isopto Carpine® Pilopine HS® 4% Ophthalmic Sympathomimetics Alphagan P® 0.15% apraclonidine brimonidine 0.2% Alphagan P® 0.1% brimonidine 0.15% Iopidine® Ophthalmic Immunomodulator Restasis® ST N/A AE = Age Edits CC = Clinical Criteria MD = Medications with Maximum Duration Page 31 | Kentucky Preferred Drug List QL = Quantity Limits ST = Step Therapy Effective February 18, 2015 Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/ Magellan Medicaid Administration Clinical Support Center: Phone 800‐477‐3071; Fax 800‐365‐8835 XI. OTICS Drug Class Preferred Agents Non‐Preferred Agents Otic Antibiotics CiproDex® Otic hydrocortisone 1%/neomycin sulfate 5 mg/polymyxin B 10,000 units solution, suspension ofloxacin 0.3% solution Cetraxal® Cipro HC® Otic ciprofloxacin 0.2% Coly‐mycin® S Cortisporin® solution Cortisporin® – TC Otic Anti‐Infectives, Anesthetics & Anti‐ Inflammatories acetic acid antipyrine/benzocaine Acetasol HC® acetic acid/hydrocortisone acetic acid in aluminum acetate Aralagan® Aurodex® Auroguard® Borofair® chloroxylenol/pramoxine/hydrocortisone Dermotic® Domeboro® fluocinolone 0.01% oil Neotic® Otic Care® Oto‐End 10® Otozin™ Pinnacaine® Pramoxine HC® Trioxin® Vosol® HC XII. RENAL AND GENITOURINARY Drug Class Preferred Agents Alpha Blockers for BPH Non‐Preferred Agents alfuzosin ER doxazosin tamsulosin terazosin Cardura® Cardura XL® Flomax® Rapaflo™ Uroxatral® 5‐Alpha Reductase (5AR) finasteride CC Inhibitors AE = Age Edits CC = Clinical Criteria MD = Medications with Maximum Duration Page 32 | Kentucky Preferred Drug List Avodart® CC CC Jalyn® Proscar® CC QL = Quantity Limits ST = Step Therapy Effective February 18, 2015 Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/ Magellan Medicaid Administration Clinical Support Center: Phone 800‐477‐3071; Fax 800‐365‐8835 XII. RENAL AND GENITOURINARY Drug Class Preferred Agents Non‐Preferred Agents QL Bladder Relaxants QL Detrol® QL Detrol® LA QL Ditropan® XL QL Enablex® QL flavoxate CC, QL Gelnique™ QL Myrbetriq™ QL oxybutynin ER QL Oxytrol® QL Sanctura® Sanctura® XR QL QL tolterodine QL tolterodine ER QL trospium trospium ER QL oxybutynin Toviaz™ QL VESIcare® QL XIII. DERMATOLOGICS Drug Class Preferred Agents Topical Antiviral Agents acyclovir ointment Denavir® Xerese™ Zovirax® cream, ointment Topical Antibiotic Agents bacitracin ointment bacitracin zinc ointment Bactroban® Cream gentamicin 0.1% cream, ointment mupirocin ointment Altabax™ Bactroban® ointment Centany® mupirocin cream Triple Antibiotic® Topical Antiparasitic Agents Elimite™ lindane malathion Natroba® Ovide® Prioderm® Ulesfia® AE = Age Edits Eurax® permethrin 5% cream Sklice® spinosad CC = Clinical Criteria MD = Medications with Maximum Duration Page 33 | Kentucky Preferred Drug List Non‐Preferred Agents QL = Quantity Limits ST = Step Therapy Effective February 18, 2015 Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/ Magellan Medicaid Administration Clinical Support Center: Phone 800‐477‐3071; Fax 800‐365‐8835 XIII. DERMATOLOGICS Drug Class Topical Acne Agents AE = Age Edits Preferred Agents Acanya™ Aczone™ adapalene cream, gel Akne‐Mycin® Atralin™ Avar™ Avar E™ Avar E LS™ Avar LS™ Avita® BenoxylDoxy® Benzac AC® Benzamycin® Benzefoam™ Benzefoam Ultra™ BenzePro™ benzoyl peroxide cleanser, kit, microspheres, gel, foam benzoyl peroxide/sulfur BP 10‐1® BPO® BPO‐5® BPO‐10® BP Wash™ Cerisa™ Clarifoam® EF Cleocin‐T® Clindacin PAC™ Clindagel® clindamycin foam, medicated swab clindamycin/benzoyl peroxide Desquam‐X® Differin® lotion Effaclar Duo® BenzaClin® clindamycin solution, gel, lotion Differin® cream, gel Duac® erythromycin solution, gel sodium sulfacetamide/sulfur cleanser tretinoin CC = Clinical Criteria MD = Medications with Maximum Duration Page 34 | Kentucky Preferred Drug List Non‐Preferred Agents QL = Quantity Limits ST = Step Therapy Effective February 18, 2015 Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/ Magellan Medicaid Administration Clinical Support Center: Phone 800‐477‐3071; Fax 800‐365‐8835 XIII. DERMATOLOGICS Drug Class Topical Acne Agents (continued) AE = Age Edits Preferred Agents See Previous Page CC = Clinical Criteria MD = Medications with Maximum Duration Page 35 | Kentucky Preferred Drug List Non‐Preferred Agents Epiduo™ erythromycin medicated swab erythromycin/benzoyl peroxide Evoclin™ Fabior® Inova™ Inova™ 4/1 Inova™ 8/2 Klaron® Lavoclen™ Neuac® Pacnex® Pacnex® HP Pacnex® LP Pacnex® MX Panoxyl® Persa‐Gel® Prascion® PR‐benzoyl peroxide OC8® Onexton™ Ovace® Ovace Plus® Nu‐Ox® Retin‐A® Retin‐A Micro® SE 10‐5 SS® SE BPO® sodium sulfacetamide 10% CLNSG sodium sulfacetamide/sulfur/urea SSS 10‐4® SSS 10‐5® sulfacetamide cleanser Sumadan™ Sumadan™ XLT Sumaxin® Tazorac® Tretin‐X™ tretinoin microsphere Vanoxide‐HC® Veltin™ Zencia® Ziana™ QL = Quantity Limits ST = Step Therapy Effective February 18, 2015 Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/ Magellan Medicaid Administration Clinical Support Center: Phone 800‐477‐3071; Fax 800‐365‐8835 XIII. DERMATOLOGICS Drug Class Preferred Agents Non‐Preferred Agents Oral Acne Agents Amnesteem® Claravis™ Myorisan™ Sotret® Zenatane™ Absorica™ Topical Rosacea Agents metronidazole cream, gel, lotion Azelex® Finacea® Finacea® Plus MetroCream® MetroGel® MetroLotion® Mirvaso® Noritate® Rosadan® Kit Topical Antifungal Agents clotrimazole cream, solution econazole ketoconazole cream, shampoo nystatin cream, ointment, powder nystatin/triamcinolone cream, ointment AE = Age Edits CC = Clinical Criteria MD = Medications with Maximum Duration Page 36 | Kentucky Preferred Drug List Ciclodan® cream, kit, solution ciclopirox clotrimazole/betamethasone CNL‐8™ Ecoza™ Ertazczo® Exelderm® Extina® CC Jublia® ketoconazole foam Ketodan™ Kuric® Loprox® Lotrimin® Lotrisone® Luzu® Mentax® Naftin® Nizoral Shampoo® Nyamyc® Nystop® Oxistat® Pedi‐Dri® Pediaderm AF® Pedipirox‐4™ Penlac® CC Vusion® Xolegel® QL = Quantity Limits ST = Step Therapy Effective February 18, 2015 Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/ Magellan Medicaid Administration Clinical Support Center: Phone 800‐477‐3071; Fax 800‐365‐8835 XIII. DERMATOLOGICS Drug Class Topical Steroids AE = Age Edits Preferred Agents betamethasone dipropionate ointment, cream, lotion betamethasone valerate cream, ointment clobetasol propionate ointment, cream, solution, gel Clobex® shampoo desonide fluocinolone acetonide cream, ointment, solution fluocinonide fluocinonide emollient fluticasone propionate cream, ointment halobetasol propionate hydrocortisone cream, gel, ointment hydrocortisone butyrate hydrocortisone valerate mometasone furoate ointment, cream, solution triamcinolone acetonide CC = Clinical Criteria MD = Medications with Maximum Duration Page 37 | Kentucky Preferred Drug List Non‐Preferred Agents QL = Quantity Limits Aclovate® alclometasone dipropionate Ala‐Cort® Ala‐Scalp® Aqua Glycolic HC® amcinonide ApexiCon®/ApexiCon E® Balneol for Her® betamethasone dipropionate gel betamethasone dipropionate augmented betamethasone valerate lotion, foam Caldecort® Capex® Shampoo clobetasol emollient clobetasol propionate foam, lotion, shampoo, spray Clobex® lotion, spray clocortolone Clodan® Cloderm® Cordran® Cordran® Tape Cormax® Cutivate® Cyclocort® Derma‐Smoothe/FS® Dermatop® Desonate® Desowen® desoximetasone diflorasone diacetate Diprolene AF® Elocon® fluocinolone acetonide oil fluticasone propionate lotion Halac Kit® Halog® Halonate® hydrocortisone‐aloe hydrocortisone lotion hydrocortisone‐urea Kenalog® Lipocream® Locoid® Luxiq® Momexin™ NuZon™ Olux® Olux‐E® Olux‐Olux E® Complete Pack Pandel® Pediaderm HC™ Pediaderm TA™ ST = Step Therapy Effective February 18, 2015 Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/ Magellan Medicaid Administration Clinical Support Center: Phone 800‐477‐3071; Fax 800‐365‐8835 XIII. DERMATOLOGICS Drug Class Preferred Agents Topical Steroids (continued) See Previous Page prednicarbate Scalacort® Scalacort‐DK® Kit Synalar® Temovate® Temovate E® Texacort® Topicort® Topicort® Topical Spray Triderm® Trianex® Ultravate® Ultravate® PAC Kit Ultravate® X Vanos™ Verdeso™ Westcort® Topical Psoriasis Agents calcipotriene salicylic acid 6% gel, shampoo urea cream Aluvea® Bensal HP® BP® 50% calcipotriene/betamethasone Calcitrene™ calcitriol ointment Cem‐Urea® Dovonex® Keralyt® Latrix® Realo® Remeven® Salacyn® cream, lotion salicylic acid 3%, 6% cream, lotion salicylic acid 26% liquid salicylic acid 27.5% combo pkg, kit, liquid, lotion Salex® combo pkg, kit, shampoo Sorilux™ Taclonex® ointment, suspension Taclonex® Scalp Tazorac® Umecta® emulsion, foam, kit, suspension Umecta PD® emulsion, suspension Uramaxin® Uramaxin® GT Urea emulsion, foam, gel, kit, lotion, nail film suspension, suspension Vectical™ X‐Viate® AE = Age Edits CC = Clinical Criteria MD = Medications with Maximum Duration Page 38 | Kentucky Preferred Drug List Non‐Preferred Agents QL = Quantity Limits ST = Step Therapy Effective February 18, 2015 Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/ Magellan Medicaid Administration Clinical Support Center: Phone 800‐477‐3071; Fax 800‐365‐8835 XIII. DERMATOLOGICS Drug Class Oral Psoriasis Agents XIV. Preferred Agents Non‐Preferred Agents 8‐MOP® acitretin methoxsalen Oxsoralean‐Ultra® Soriatane® ANTINEOPLASTIC AGENTS Drug Class Oral Oncology Agents Preferred Agents Non‐Preferred Agents QL Afinitor Disperz™ QL QL Bosulif® QL capecitabine QL Cometriq™ QL Iclusig™ QL Tasigna® Votrient™ QL Xtandi® QL Afinitor™ oral Caprelsa® QL Erivedge™ CC, QL Gleevec® QL Gilotrif™ CC, QL CC, QL Imbruvica™ CC, QL Inlyta® Iressa® QL Jakafi™ CC, QL Mekinist™ CC, QL Nexavar® QL Sprycel® QL Stivarga® CC, QL Sutent® QL Tafinlar® CC, QL Tarceva® QL Tykerb® QL Xalkori® CC, QL Xeloda® Zelboraf™ CC, QL Zytiga™ QL AE = Age Edits CC = Clinical Criteria MD = Medications with Maximum Duration Page 39 | Kentucky Preferred Drug List QL = Quantity Limits ST = Step Therapy Effective February 18, 2015
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