Kentucky Medicaid will incorporate the following changes to its PDL on June 11, 2014:
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1 Fee-For-Service Pharmacy Provider Notice #179 April Pharmacy Updates May 22, W. Broad Street Glen Allen, VA Dear Kentucky Medicaid Provider: Please be advised that the Department for Medicaid Services has made the following changes to the Kentucky Medicaid Fee-For-Service (FFS) Pharmacy Program: Kentucky Medicaid will require a prior authorization on the following new products to market pending review for placement to the Preferred Drug List (PDL): Beginning: Drugs requiring PA: Preferred Products: 04/11/2014 Otezla Orenitram Letairis sildenafil CC Tracleer Ventavis 04/14/2014 acitretin Absorica 04/18/2014 Lazanda N/A Amnesteem Claravis Soriatane Sotret Zenatane Kentucky Medicaid will incorporate the following changes to its PDL on June 11, 2014: Drug Class The following products will have NON-PREFERRED status and require prior authorization (PA): ACE Inhibitors fosinopril benazepril captopril enalapril lisinopril quinapril ramipril Page 1 of 8 The following products will have PREFERRED status:
2 ACEI + Diuretic Combination quinapril/hctz benazepril/hctz captopril/hctz enalapril/hctz lisinopril/hctz Beta Blockers bisoprolol pindolol atenolol metoprolol tartrate propranolol propranolol LA Toprol XL Calcium Channel Blockers (DHP) felodipine ER amlodipine nifedipine ER/SA/SR Calcium Channel Blockers (Non- DHP) verapamil 360mg capsules diltiazem diltiazem ER Agents for Pulmonary Hypertension Adcirca Letairis sildenafil CC Tracleer Ventavis Lipotropics: Bile Acid Sequestrants, Statins, Niacin Derivatives fluvastatin QL Lescol QL Lescol XL QL Simcor atorvastatin QL lovastatin QL pravastatin QL simvastatin QL Niaspan Platelet Inhibitors ticlopidine Aggrenox Effient Brilinta CC clopidogrel cilostazol dipyridamole Oral Anti-Emetics: Anticholinergics Marinol promethazine 50mg rectal meclizine prochlorperazine promethazine Transderm-Scop Patch trimethobenzamide Laxatives and Cathartics OsmoPrep PEG 3350 Powder Pack PEG 3350/Flavor Pack Solution for reconstitution Amitiza CC lactulose MoviPrep polyethylene glycol Sod Chloride/NaHCO3/KCl/PEGS Irritable Bowel Syndrome Lotronex Linzess Alzheimer s: Cholinesterase galantamine Donepzil Page 2 of 8
3 Inhibitors Antidepressants, SSRI ecitalopram solution fluvoxamine Exelon Patch rivastigmin citalopram HBr QL escitalopram QL fluoxetine HCl fluoxetine ER fluvoxamine paroxetine HCl sertraline QL Stimulants and Related Agents Methylin Solution QL methylphenidate solution QL 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 Methlin Chewable CC,QL Methylphenidate IR/SA/SR CC,QL mixed amphetamin salts IR CC,QL Quillivant XR Strattera CC,QL Vyvanse Narcotics Agonist/Antagonists pentazocine/naloxone butorphanol NS Narcotics, Short-Acting Antibiotics: 3 rd Generation Cephalosporins butalbital/apap/caffeine/codeine butalbitalcompound with codeine hydromorphone suppositories oxymorphone oxycodone/ibuprofen Suprax tablets dihydrocodeine hydrocodone/ibuprofen hydromorphone meperidine morphine IR oxycodone oxycodone/apap MD tramadol cefdinir cefpodoxime Suprax suspension Antibiotics: Macrolides clarithromycin suspension Biaxin suspension azithromycin clarithromycin tablets erythromycin base tablets Page 3 of 8
4 Diabetes: DPP-4 Inhibitors Onglyza Kombiglyze XR ST, QL Oseni ST, QL Janumet Janumet XR Januvia Diabetes: Metformins metformin ER glyburide/metformin metformin metformin XR Bone Resorption Suppression and Related Agents alendronate solution QL alendronate QL tablets Evista Fortical Immunomodulators Cimzia QL Enbrel Humira Multiple Sclerosis Agents Betaseron QL Copaxone 20mg QL Extavia QL Rebif QL Phosphate Binders Otic Anti-Infective and Anesthetics Renvela sevelamer carbonate acetic acid/aluminum otic pramoxine HC otic calcium acetate Fosrenol Renagel acetic acid antipyrine/benzocaine Otic Steroids and Antibiotic Combinations Antiparasitics, Topical Topical Acne Agents Dermatologics: Topical Steroids Cortisporin-TC spinosad malathion clindamycin/benzoyl peroxide clindamycin medicated swabs sulfacetamide cleanser tretinoin microspheres clobetasol lotion clobetasol shampoo fluocinolone oil hydrocortisone/neomycin polymyxin B Eurax Natroba permethrin 5% cream Sklice BenzaClin clindamycin solution gel, lotion Differin cream, gel Duac erythromycin solution, gel sodium sulfacetamide/sulfur cleanser tretinoin betamethasone dipropionate ointment Clobex shampoo cream, lotation betamethasone valerate cream ointment Page 4 of 8
5 clobetasol propionate ointment, cream desonide fluocinolone acetonide fluocinonide fluocinonide emollient fluticasone propionate cream, ointment halobetasol propionate hydrocortisone butyrate cream ointment solution hydrocortisone valerate mometasone furoate ointment, cream, solution triamcinolone acetonide Topical Agents for Psoriasis calcitrene calcipotriene ointment calcipotriene ointment Dovonex cream Lipotropics: Fibric Acid Derivatives TriCor Trilipix fenofibrate nanocrystallized fenofibric acid (choline) Kentucky Medicaid will incorporate the following changes to its PDL on June 11, 2014: Drug Class The following products will have PREFERRED status and will NOT require a prior authorization (PA): The following products currently have PREFERRED status: Lipotropics: Bile Acid Sequestrants colestipol cholestyramine cholestyramine light Anticoagulants Eliquis Fragmin fondaparinux Jantoven Lovenox Pradaxa warfarin Xarelto Antibiotics, Inhaled Bethkis TOBI Antihistamines, Minimally Sedating Cetirizine solution cetirizine OTC (EXCEPT chewable tablets) loratadine OTC loratadine-pseudoephedrine OTC Page 5 of 8
6 Corticosteroids, Inhaled Pulmicort Flexhaler QL Asmanex Twisthaler QL Flovent Diskus QL Flovent HFA QL Pulmicort Respules QVAR QL QL, AE Antidepressants: Other bupropion bupropion XL bupropion bupropion SR nefazodone trazodone Antidepressants: Tricyclics mirtazapine ODT amitriptyline clomipramine desipramine imipramine HCl maprotiline mirtazapine nortriptyline Anti-Migraine: 5 Ht1 Receptor Agonists rizatriptan ODT sumatriptan QL Multiple Sclerosis Agents Extavia QL Betaseron QL Copaxone 20mg QL Rebif QL Antiparasitics, Topical Sklice Eurax Natroba malathion permethrin 5% cream Topical Acne Agents Duac BenzaClin clindamycin solution, medicated swab, gel, lotion Differin cream, gel erythromycin solution, gel sodium sulfacetamide/sulfur cleanser tretinoin tretinoin microspheres Antidepressants: SSRIs Lexapro solution citalopram HBr QL escitalopram QL fluoxetine HCl fluoxetine ER fluvoxamine paroxetine HCl sertraline QL Page 6 of 8
7 Kentucky Medicaid will incorporate the following changes to its PDL on June 11, 2014: Drug Class The following products will have PREFERRED status and require a prior authorization (PA): The following products currently have PREFERRED status: Stimulants and Related Agents Quillivant XR CC, QL Adderall XR CC, QL dexmethylphenidate IR dextroamphetamine IR/ER CC, QL Focalin XR CC, QL Intuniv Metadate CD Metadate ER Methylin Methylin Chewable Methylin ER methylphenidate IR/SA/SR mixed amphetamine salts IR CC, QL Strattera CC, QL Vyvanse CC, QL CC, QL Diabetes: DPP-4 Inhibitors Tradjenta QL Jentadueto QL Janumet Janumet XR Januvia Kombiglyze Onglyza ST, QL Oseni Oral Anti-Emetics: Anticholinergics dronabinol Marinol * Please note: All dates are subject to change. Thank you for helping Kentucky Medicaid members to maintain access to prescription coverage by selecting drugs on the preferred drug list whenever possible. Sincerely, Michael Price Provider Relations Manager Page 7 of 8
8 Kentucky Medicaid Fee-For-Service Pharmacy Program s Contact Information Clinical Support Center (800) Sunday Saturday 24 hours a day Pharmacy Support Center (800) Sunday Saturday 24 hours a day Provider Services (877) Monday Friday 8:00 am 4:30 pm Please contact the Clinical Support Center to request a prior authorization (PA) or to check the status of a request. NOTE: The only drugs that are now required to be submitted via fax are Brand Medically Necessary, Buprenorphine Products, Synagis, and Zyvox. Please contact the Pharmacy Support Center when claims assistance is required. Timely filing, lock-in, and early refill (ER) overrides can be obtained through this call center. Please contact Provider Services if you have questions about enrollment or when updating your license or bank information. Member Services (800) Please contact Member Services if you are a member or if you as the provider have questions regarding the member s benefits or eligibility coverage dates. Page 8 of 8
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