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Wyo pdl eff 1-01-11_draft_121410 with sr info.xls

Anticipated Preferred Drug List (PDL) - January 1, 2011 Drug classes not included on this list are not managed through a Preferred Drug List (PDL). HOWEVER, THIS EXCLUSION IS NOT A GUARANTEE OF PAYMENT OR COVERAGE. Dosage limits and other requirements may apply. Please refer to the Additional Therapeutic Criteria Chart, Dosage Limitation List, Epocrates, and the Wyoming EqualityCare Provider Manual at http://wyequalitycare.org for Drugs new to market are non-preferred until a clinical review has been completed. PA criteria will apply to both the pediatric population, as well as the adult population for those plans where PA/PDL limits are allowed.
Unless otherwise noted on the PDL, generic substitution is mandatory.
*Indicates BRAND is Preferred. May Use DAW 5.
Contact the GHS PA Helpdesk @ 877-207-1126 for prior authorization if client has primary insurance that will not cover the brand name medication.
PREFERRED AGENTS REQUIRING
GENERIC MANDATORY POLICY APPLIES
THIS LIST IS NOT ALL INCLUSIVE
PLEASE CONTACT GHS FOR QUESTIONS
ALLERGY / ASTHMA
ANTIHISTAMINES, MINIMALLY SEDATING
Trial and failure of a preferred agent greater than or equal to a 14 day supply in the last 12 months will be required before approval can be levocetirizine given for a non-preferred agent.
Trial and failure of a preferred agent greater than or equal to a 14 day supply in the last 12 months will be required before approval can be CLARINEX-D given for a non-preferred agent.
ANTICHOLINERGIC BRONCHODILATORS
Trial and failure of a preferred agent greater than or equal to 30 days in the last 12 months will be required before approval can be given for a non-preferred agent.
Spiriva 5 day package will be allowed one (1) time per recipient.
CORTICOSTEROID / BRONCHODILATOR COMBO'S
Trial and failure of a preferred agent greater than or equal to 30 days in the last 12 months will be required before approval can be given for a non-preferred agent.
Advair 7 and 14-day package will be allowed one (1) time per recipient.
Trial and failure of preferred agent greater than SINGULAIR GRANULES (use preferred) or equal to 30 days in the last 12 months will be zafirlukast LONG ACTING BRONCHODILATORS
Trial and failure of preferred agent greater than FORADIL or equal to 30 days in the last 12 months will be Serevent 14-day package will be allowed one (1) time per recipient.
Trial and failure of preferred agent greater than ASTEPRO or equal to 90 days in the last 12 months will be PATANASErequired before approval can be given for a non-preferred agent.
Trial and failure of two (2) preferred agents greater than or equal to 30 days in the last 12 months will be required before approval can be OMNARIS given for a non-preferred agent. Rhinocort will be approved for pregnancy.
SHORT ACTING BRONCHODILATORS - INHALERS
Trial and failure of a preferred agent greater than or equal to 30 days in the last 12 months will be required before approval can be given for a non-preferred agent.
SHORT ACTING BRONCHODILATORS - NEBULIZERS
Trial and failure of a preferred agent greater than or equal to 30 days in the last 12 months will be required before approval can be given for a non-preferred agent.
Trial and failure of three (3) preferred agents greater than or equal to 30 days in the last 12 months will be required before approval can be ASMANEX STARTER PACK given for a non-preferred agent.
Alvesco will be approved for a history of oral thrush with steroid inhalants.
Client must have a diagnosis of dementia.
ARICEPT 23MG (use preferred) ARICEPT ODT (use preferred) donepezil (BRAND IS PREFERRED) rivastigmine (BRAND IS PREFERRED) Last Updated 12/14/10 Anticipated Preferred Drug List (PDL) - January 1, 2011 PREFERRED AGENTS REQUIRING
GENERIC MANDATORY POLICY APPLIES
THIS LIST IS NOT ALL INCLUSIVE
PLEASE CONTACT GHS FOR QUESTIONS
Only one (1) narcotic prescription will be allowed between fills.
Subutex will be approved for pregnancy.
Dosage limits apply.
LONG-ACTING C-IIs
Trial and failure of a preferred agent(s) greater AVINZA than or equal to a 14 day supply in the last 12 months will be required before approval can be KADIANgiven for a non-preferred agent.
OPANA EROXYCONTIN/CR Fentanyl patches are limited to one patch every 72 hours.
C-IIIs and C-IVs are not included and are available without prior authorization (generic substitution is mandatory).
**Embeda requires trial of preferred and client must have diagnosis of drug/substance abuse Trial and failure of three (3) preferred agents greater than or equal to a 6 day supply in the last 90 days will be required before approval can be given for a non-preferred agent.
Trial and failure of a preferred agent(s) greater RYBIX ODT than or equal to a 14 day supply in the last 12 months will be required before approval can be tramadol/apapgiven for a non-preferred agent.
Quantity and dosage limits apply.
TESTOSTERONE TOPICAL GELS
Testosterone agents are only allowed for ANDROGEL PUMP (use preferred) diagnosis of hypogonadism or insufficient ANGIOTENSIN
Trial and failure of a preferred agent greater than or equal to a 14 day supply in the last 12 months will be required before approval can be given for a non-preferred agent.
fosinopril lisinopril moexiprilperindoprilquinapril ramipril trandolapril ACE INHIBITORS AND DIURETICS
Trial and failure of a preferred agent greater than or equal to a 14 day supply in the last 12 months will be required before approval can be given for a non-preferred agent.
ANGIOTENSIN RECEPTOR BLOCKERS (ARBs)
Trial and failure of an ACE Inhibitor greater than ATACAND or equal to a 14 day supply in the last 12 months will be required before approval can be given for preferred ARB. Non-preferred ARBs and ARB/diuretic combinations also require a history of ALL preferred ARBs before approval ARBs AND DIURETICS
can be given.
BENICAR HCT DIOVAN HCT losartan HCTMICARDIS HCT ARB COMBINATIONS
TWYNSTA (use separate agents) AZOR EXFORGE/EXFORGE-HCT Last Updated 12/14/10 Anticipated Preferred Drug List (PDL) - January 1, 2011 PREFERRED AGENTS REQUIRING
GENERIC MANDATORY POLICY APPLIES
THIS LIST IS NOT ALL INCLUSIVE
PLEASE CONTACT GHS FOR QUESTIONS
LOW MOLECULAR WEIGHT HEPARIN (LMWH)
enoxaparin (BRAND IS PREFERRED) LOVENOX 300MG/3ML (USE PREFERRED)
DIAZEPAM RECTAL GEL
diazepam gel (BRAND IS PREFERRED) Trazodone, buspirone, fluvoxamine, MAO fluoxetine 20mg tablets (USE PREFERRED)
inhibitors, TCA's, bupropion IR and venlafaxine mirtazapine 7.5mg and mirtazapine rapid-
IR do not require prior authorization but will
dissolve tablets (USE PREFERRED)
not count towards meeting Step Therapy
mirtazapine 15, 30, and 45mg paroxetine IRsertraline Step 2 agents require a trial and failure of a Step
1 agent greater than or equal to six (6) weeks prior to approval.
venlafaxine ER tablets Step 3 agents require a trial and failure of a Step
1 AND Step 2 agent greater than or equal to six (6) weeks EACH prior to approval.
*Cymbalta will be approved for a diagnosis of Venlafaxine ER capsules peripheral neuropathy and osteoarthritis of the knee. **Lexapro will be approved for adolescents between the ages of 12 - 17.
Non-preferred agents (Fanapt, Latuda, and ABILIFY ODT (USE PREFERRED) Saphris) require a trial of ALL preferred agents at max doses.
Dosing limits apply.
SEROQUEL XR (USE PREFERRED; CURRENT USERS WILL BE GRANDFATHERED) SPECIAL ATYPICAL ANTIPSYCHOTICS
valacyclovir (BRAND IS PREFERRED) STATINS, LOW POTENCY
Trial and failure of a preferred agent greater than or equal to a 90 day supply in the last 12 months will be required before approval can be given for a non-preferred agent.
If client's current medication therapy is contraindicated with the preferred statin(s) due to a drug-drug interaction, a non-preferred agent may be obtained with a prior authorization.
STATINS, HIGH POTENCY
Trial and failure of a preferred agent greater than or equal to a 90 day supply in the last 12 months will be required before approval can be given for a non-preferred agent.
If client's current medication therapy is contraindicated with the preferred statin(s) due to a drug-drug interaction, a non-preferred agent may be obtained with a prior authorization.
Last Updated 12/14/10 Anticipated Preferred Drug List (PDL) - January 1, 2011 PREFERRED AGENTS REQUIRING
GENERIC MANDATORY POLICY APPLIES
THIS LIST IS NOT ALL INCLUSIVE
PLEASE CONTACT GHS FOR QUESTIONS
Trial and failure of a preferred agent greater ADVICOR (use separate agents) than or equal to a 90 day supply in the last 12 months will be required before approval can be PRAVIGARDgiven for a non-preferred agent.
VYTORIN (use separate agents) TRIGLYCERIDE LOWERING AGENTS
Trial and failure of a preferred agent greater than or equal to a 90 day supply in the last 12 months will be required before approval can be FENOGLIDE given for a non-preferred agent.
INTESTINAL CHOLESTEROL ABSORPTION INHIBITOR
BILE ACID SEQUESTRANT
Trial and failure of ALL preferred agents greater WELCHOL than or equal to six (6) months in the last 12 months will be required before approval can be given for a non-preferred agent.
BIPHASIC ORAL CONTRACEPTIVES
Monophasic and triphasic oral contraceptives are not included and are available without prior authorization. (generic substitution is COUGH AND COLD
Trial and failure of metformin and a preferred agent greater than or equal to a 90 day supply in the last 12 months will be required before approval can be given for a non-preferred agent.
Trial and failure of metformin and a preferred nateglinide (BRAND IS PREFERRED) agent greater than or equal to a 90 day supply in the last 12 months will be required before approval can be given for a non-preferred agent.
Trial and failure of metformin and a preferred ACTOS 30MG, 45MG ( use ACTOS 15mg) agent greater than or equal to a 90 day supply ACTOSPLUS MET (use separate agents) in the last 12 months will be required before approval can be given for a non-preferred AVANDAMET (use separate agents) Trial and failure of metformin and a preferred agent greater than or equal to a 90 day supply in the last 12 months will be required before approval can be given for a non-preferred agent.
DIPEPTIDYL PEPTIDASE 4 (DPP-4) INHIBITORS
Trial and failure of metformin greater than or KOMBIGLYZE (use separate agents) equal to a 90 day supply in the last 12 months will be required before approval can be given for a preferred agent.
DIABETIC METERS/TEST STRIPS
ALL OTHER METERS AND TEST STRIPS FREESTYLE LITEFREESTYLE FREEDOM LITEONE TOUCH ULTRAONE TOUCH ULTRA 2ONE TOUCH ULTRA MINIONE TOUCH ULTRASMARTPRECISION XTRA CETRAXALCIPRODEXCIPRO HCCOLY-MYCIN SCORTISPORIN-TCNeomycin/Polymyxin B Sulfates/Hydrocortisone Last Updated 12/14/10 Anticipated Preferred Drug List (PDL) - January 1, 2011 PREFERRED AGENTS REQUIRING
GENERIC MANDATORY POLICY APPLIES
THIS LIST IS NOT ALL INCLUSIVE
PLEASE CONTACT GHS FOR QUESTIONS
Trial and failure of a Step 1 agent greater than or equal to six (6) weeks in the last 12 months is required for approval of a Step 2 agent.
Trial and failure of a Step 1 agent and a Step 2 agent greater than or equal to six (6) weeks in the last 12 months is required for approval of a Step 3 agent.
Prior authorization required.
CREON 6000, 12000, 24000 UNIT PROTON PUMP INHIBITORS
Trial and failure of a preferred agent greater than or equal to a 14 day supply in the last 12 months will be required before approval can be NEXIUMgiven for a non-preferred agent.
Lansoprazole solutabs will be approved for children less than or equal to 8 years of age.
VIMOVO (use separate agents) Lansoprazole capsules will be approved for children less than 1 year of age.
Pantoprazole will be allowed for clients on concurrent Plavix therapy.
MESALAMINE
Trial and failure of a preferred agent greater than or equal to a 14 day supply in the last 12 months will be required before approval can be LIALDA PENTASA 250MG ONLY given for a non-preferred agent.
PENTASA 500MG (use Pentasa 250mg)ROWASA PA is required for use outside of FDA-approved HUMATROPE indications. Evaluation by an endocrinologist is OMNITROPE Clinical evidence of improved growth will be required on a yearly basis to support ongoing Clinical evidence of need for growth hormone will be required for adult growth hormone deficiency and pediatric growth failure due to inadequate endogenous growth hormone.
Trial and failure of two (2) preferred agents within the last 12 months will be required for the following indications: Pediatric: Growth failure due to inadequate endogenous growth hormone, Prader-Willi syndrome, children born small for gestation. Turner syndrome. Adult: Replacement for those with growth hormone deficiency.
HEPATITIS C
Trial and failure of preferred agent greater than PEG-INTRON or equal to 30 day supply in the last 12 months will be required before approval can be given for a non-preferred agent. Peg-Intron will be approved for pediatric patients (aged 18 and under), for retreatment, and for dosage adjustments that cannot be achieved with Pegasys.
Last Updated 12/14/10 Anticipated Preferred Drug List (PDL) - January 1, 2011 PREFERRED AGENTS REQUIRING
GENERIC MANDATORY POLICY APPLIES
THIS LIST IS NOT ALL INCLUSIVE
PLEASE CONTACT GHS FOR QUESTIONS
IMMUNOMODULATORS (DIAGNOSIS REQUIRED)
Client must have diagnosis prior to approval
for preferred agents (outlined below) :
Enbrel : Ankylosing Spondylitis (AS), Juvenile
Idiopathic Arthritis (JIA), Plaque Psoriasis (PP), HUMIRA CROHN'S KIT Psoriatic Arthritis (PA), Rheumatoid Arthritis Humira : AS, Crohn's, JIA, PP, PA, RA**
**60-day trial and failure of methotrexate required prior to approval of Enbrel or Humira for diagnosis of Rheumatoid Arthritis (RA) For non-preferred agents , 60-day trial and TYSABRI (additional criteria applies) failure of a preferred agent is required and client must have diagnosis prior to approval (outlined below):Actemra : RA (60-day trial of methotrexate is required)Amevive : PPCimzia : Crohn's***, RA Kineret : RAOrencia : JIA, RARemicade : AS, Crohn's, PP, PA, RA, Ulcerative Colitis****Rituxan : RASimponi : AS, PA, RA Stelara : PPTysabri : Crohn's (additional PA criteria applies)***Cimzia will be allowed without a preferred trial for diagnosis of Crohn's****Remicade will be allowed without a preferred trial for diagnosis of Ulcerative Colitis Trial and failure of a preferred agent greater than or equal to a 14 day supply in the last 12 months will be required before approval can be ROZEREM given for a non-preferred agent. Rozerem is non-preferred without a history of substance abuse. Dosing limits apply.
Trial and failure of a preferred agent will be required before approval can be given for a non- FROVA preferred agent. Quantity limits apply. MULTIPLE SCLEROSIS AGENTS
Trial and failure of one (1) interferon agent AND EXTAVIA failure of Copaxone.
TYSABRI (additional criteria applies) For Gilenya, in addition to the above criteria, a trial and failure of Tysabri is required.
For Tysabri, in addition to the above criteria, additional prior authorization criteria applies.
Trial and failure of two (2) preferred agents each greater than or equal to a 14 day supply in CAMBIA POWDER the last 12 months will be required before approval can be given for a non-preferred FLECTOR (additional criteria applies) Dosing limits apply for ketorolac.
PENNSAID (additional criteria applies) SOLARAZE (additional criteria applies) VOLTAREN (additional criteria applies) meloxicamnabumetone naproxenoxaprozin sulindac tolmetin Last Updated 12/14/10 Anticipated Preferred Drug List (PDL) - January 1, 2011 PREFERRED AGENTS REQUIRING
GENERIC MANDATORY POLICY APPLIES
THIS LIST IS NOT ALL INCLUSIVE
PLEASE CONTACT GHS FOR QUESTIONS
OP. -ANTIBIOTICS- QUINOLONES
Trial and failure of a preferred agent greater CELEBREX
than or equal to 5 days in the last 12 months will be required before approval can be given for a non-preferred agent.
Azasite will be approved for pregnancy.
OP. -ANTI-INFLAMMATORY- NSAIDS
Trial and failure of ALL preferred agents each ACULAR/LS/PF (USE PREFERRED) CELEBREX
greater than or equal to 5 day supply in the last ACUVAIL 12 months will be required before approval can BROMDAY be given for a non-preferred agent.
Trial and failure of three (3) preferred agents each greater than or equal to 30 days in the last BETOPTIC S 12 months will be required before approval can ISTALOL be given for a non-preferred agent.
Betoptic S will be approved for those with heart and lung conditions.
OP. -CARBONIC ANHYDRASE INHIBITOR
Trial and failure of a preferred agent greater than or equal to 30 days in the last 12 months will be required before approval can be given for a non-preferred agent.
OP. -CARBONIC ANHYDRASE INHIBITOR COMBO
Trial and failure of a preferred agent greater than or equal to 30 days in the last 12 months will be required before approval can be given for a non-preferred agent.
OP. -MAST CELL STABILIZERS
Trial and failure of two (2) preferred agents greater than or equal to 30 days in the last 12 months will be required before approval can be ALOCRIL given for a non-preferred agent.
Emadine, Alomide, and Alocril will be approved BEPREVEfor pregnancy.
CLARITIN OTCELESTAT Alomide will be approved for children under the EMADINEage of 3.
Trial and failure of ALL preferred agents each greater than or equal to 30 days in the last 12 months will be required before approval can be given for a non-preferred agent.
Trial of a preferred agent greater than or equal to 30 days in the last 12 months will be required before approval can be given for a non- preferred agent.
OP. -SYMPATHOMIMETIC COMBO
Trial of a preferred agent greater than or equal to 30 days in the last 12 months will be required before approval can be given for a non-preferred agent.
Trial and failure of a preferred agent greater than or equal to 12 months will be required before approval can be given for a non- preferred agent.
Fosamax liquid will be approved for clients that have difficulty swallowing.
OVERACTIVE BLADDER
OVERACTIVE BLADDER AGENTS
Trial and failure of a preferred agent greater than or equal to a 14 day supply in the last 12 months will be required before approval can be GELNIQUE GEL 10% given for a non-preferred agent. Oxytrol will be approved for clients that have an inability to swallow.
Last Updated 12/14/10 Anticipated Preferred Drug List (PDL) - January 1, 2011 PREFERRED AGENTS REQUIRING
GENERIC MANDATORY POLICY APPLIES
THIS LIST IS NOT ALL INCLUSIVE
PLEASE CONTACT GHS FOR QUESTIONS
Trial and failure of a preferred agent greater JALYN (use separate agents) than or equal to a 30 day supply in the last 12 months will be required before approval can be given for a non-preferred agent.
Trial and failure of a preferred agent greater JALYN (use separate agents) than or equal to a 30 day supply in the last 12 months will be required before approval can be given for a non-preferred agent.
PULMONARY
ENDOTHELIN RECEPTOR ANTAGONISTS
SKELETAL MUSCLE
Trial and failure of a preferred agent greater than or equal to a 14 day supply in the last 12 months, along with a medical diagnosis of muscle spasticity will be required before approval can be given for a non-preferred Generic bupropion SR needs to be an AB rated nicotine gum, lozenges, and patches generic of Zyban. Concomitant use of Chantix with bupropion SR or other nicotine replacement therapies will not be allowed.
Quantity limits apply. Clients must have a diagnosis for ADD, ADHD, LONG ACTING AMPHETAMINES
narcolepsy, obstructive sleep apnea, shift work amphetamine salts combo ER (BRAND IS PREFERRED) ADDERALL XR WILL ONLY BE PREFFERRED
ADDERALL XR *
sleep disturbance, MS fatigue (see MS Fatigue FOR THOSE CLIENTS CURRENTLY ON THE MEDICATION. criteria below), or refractory depression (see dextroamphetamine CR refractory depression criteria below).
IMMEDIATE RELEASE AMPHETAMINES
Diagnosis of MS fatigue will require a fatigue amphetamine salts combo severity scale score of 5.0, a 60-day trial of amantadine and discontinuation of medications STIMULANT LIKE
that may contribute to drowsiness and fatigue. Diagnosis of refractory depression will require a LONG ACTING METHYLPHENIDATES
dexmethylphenidate/ER (BRAND IS PREFERRED) 6-week trial and failure of an antidepressant (monotherapy) and continued concomitant use of an antidepressant with the stimulant.
FOCALIN XRmethylin ER Prior Authorization will be required for clients methylphenidate ER/CR/SR under the age of 5.
IMMEDIATE RELEASE METHYLPHENIDATES
Claims will require Prior Authorization if clients have a history of the following: glaucoma, cardiac arrhythmias, arteriosclerosis, untreated hypertension, untreated hyperthyroidism, substance abuse, or current MAO inhibitor use.
Dosing limits apply (150% of labeled max).
Trial and failure of two (2) preferred agents (each from a different class: methylphenidate, amphetamine, stimulant like) greater than or equal to a 30 day supply in the last 12 months will be required before approval can be given for a non-preferred agent. Last Updated 12/14/10 Anticipated Preferred Drug List (PDL) - January 1, 2011 PREFERRED AGENTS REQUIRING
GENERIC MANDATORY POLICY APPLIES
THIS LIST IS NOT ALL INCLUSIVE
PLEASE CONTACT GHS FOR QUESTIONS
SELECTIVE ALPHA-ADRENERGIC AGONIST
To obtain the non-preferred agent, client must INTUNIV
meet the following criteria:
Client must have a diagnosis of ADHD or ADD.
Prior authorization will be required for clients
under the age of 5.
Client must have a trial and failure of a
stimulant greater than or equal to a 14
OR a trial and failure of Strattera greater than
or equal to a 30 day supply AND
trial and benefit of guanfacine (Tenex) in the
previous 12 months
OR a contraindication to ADHD medications
(including stimulant and non-stimulant)
OR a TIC disorder associated with stimulants
(trial of stimulant required).
Trial and failure of ALL preferred agents greater ALTABAX than or equal to 7 days in the past 90 days.
Use smallest size appropriate for 7 day trial.
BENZOYL PEROXIDE/CLINDAMYCIN COMBOs
Acne combinations are limited to clients under ACANYA the age of 21.
Trial and failure of ALL preferred agents greater PANDEL C=CREAM; G=GEL; L=LOTION; O=OINTMENT
than or equal to 14 days in the last 90 days.
LOW POTENCY
alclometasonedesonidefluocinolone 0.01%hydrocortisone butyrate 0.1% (C) hydrocortisone 1%, 2.5% (C,L,O) Trial and failure of ALL preferred agents greater CLODERM betamethasone valerate than or equal to 14 days in the last 90 days.
desoximetasone 0.05% (C)fluocinolone 0.025%fluticasone 0.05% (C)hydrocortisone butyrate 0.1% (O) hydrocortisone probutate 0.1% (C) mometasonetriamcinolone 0.025%, 0.1% HIGH POTENCY
Trial and failure of ALL preferred agents greater HALOG than or equal to 14 days in the last 90 days.
betamethasone dipropionateclobetasoldesoximetasone 0.25%, 0.05% (G) Trial and failure of a preferred agent greater imiquimod (BRAND IS PREFERRED) than or equal to 28 days in the last 12 months will be required before approval can be given for a non-preferred agent.
MISC TOPICAL
Tazorac is allowed for clients with the diagnosis of psoriasis for all ages. For the treatment of acne vulgaris, acne combinations are limited to those clients under the age of 21.
Last Updated 12/14/10

Source: http://www.wymedicaid.org/sites/default/files/ghs-files/pdl-archive/2010-12-21/wyo-anticipated-pdleff-010110.pdf

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