Medicaid Managed Care Prior Authorization List

Transcription

1 Allergen Extracts Alzheimer's Angioedema Anthelmintics Trade Name: GRASTEK, ORALAIR, RAGWITEK Trade Name: NAMZARIC Trade Name: BERINERT, CINRYZE, FIRAZYR, RUCONEST Trade Name: EMVERM Attention Deficit Disorder Blood Cancer Trade Name: ADZENYS XR-ODT, DYANAVEL XR, QUILLICHEW ER, QUILLIVANT XR Antiplatelet Trade Name: ZONTIVITY Blood Cell Stimulation Trade Name: MOZOBIL Antineoplastic Trade Name: AFINITOR, ALECENSA, BEXAROTENE, BOSULIF, CABOMETYX, CAPRELSA, COMETRIQ, COTELLIC, ERIVEDGE, FARYDAK, GILOTRIF, HYCAMTIN, IBRANCE, ICLUSIG, IMBRUVICA, INLYTA, IRESSA, JAKAFI, LENVIMA, LEUPROLIDE ACETATE, LONSURF, LYNPARZA, MEKINIST, NEXAVAR, NINLARO, ODOMZO, POMALYST, PURIXAN, REVLIMID, SOLTAMOX, SPRYCEL, STIVARGA, SUTENT, TAFINLAR, TARCEVA, TASIGNA, TYKERB, VENCLEXTA, VOTRIENT, XALKORI, XTANDI, ZELBORAF, ZOLINZA, ZYDELIG, ZYKADIA, ZYTIGA Cardiovascular / Heart ACE Inhibitors (high blood pressure) Trade Name: EPANED Anti-anginal Agents Trade Name: NITROMIST Antihyperlipidemics Trade Name: JUXTAPID, KYNAMRO, PRALUENT, REPATHA Antihypertensive Combinations / Miscellaneous Trade Name: AMLODIPINE BESYLATE/ATORVASTATIN CALCIUM, AZOR, CADUET, EXFORGE, EXFORGE HCT, TRIBENZOR, TWYNSTA Beta Blockers (high blood pressure) Trade Name: SOTYLIZE Hypotension Trade Name: NORTHERA Central Nervous System Trade Name: ARMODAFINIL, CUVPOSA, MODAFINIL, NUVIGIL, PROVIGIL, XYREM Cryopyrin Associated Periodic Syndromes Trade Name: ARCALYST Cushing's Syndrome Cystic Fibrosis Dermatology Trade Name: KORLYM Trade Name: KALYDECO, ORKAMBI Cancer / Topical Peeling Agents Trade Name: VALCHLOR Psoriasis Products Trade Name: COSENTYX, ENBREL, ENSTILAR, HUMIRA, OTEZLA, SORILUX, STELARA, TACLONEX, TALTZ Topical / Oral Acne Products Trade Name: ABSORICA, ACANYA, FABIOR, MINOCYCLINE HCL ER, ONEXTON, SOLODYN, TRETIN-X, VELTIN, ZIANA Topical / Oral Steroids Trade Name: DERMA SILKRX SDS PAK, DERMACINRX SILAPAK, HALONATE, RAYOS, SANADERMRX SKIN REPAIR SOLUTION, SILAZONE PHARMAPAK, WHYTEDERM TRILASIL PAK Trade Name: DERMAWERX SURGICAL PLUS PAK, WHYTEDERM SURGIPAK Topical Antifungals Endocrine PKU Trade Name: JUBLIA, KERYDIN, NYATA Trade Name: MYALEPT, OMEGA-3/D-3 WELLNESS PACK, SIGNIFOR Trade Name: KUVAN Enzyme Replacements/ Modifiers Eye Topical Antibiotics Enzyme Replacements/ Modifiers Cystinosis Trade Name: PROCYSBI, STRENSIQ Trade Name: CYSTARAN 1

2 Growth Hormone / Factors Trade Name: GENOTROPIN MINIQUICK, HUMATROPE, INCRELEX, NORDITROPIN FLEXPRO, NUTROPIN AQ PEN, OMNITROPE, SAIZEN, SEROSTIM, SOMAVERT, ZORBTIVE Hormonal Agents Hepatitis C HIV Trade Name: ZOMACTON Trade Name: COPEGUS, DAKLINZA, EPCLUSA, HARVONI, OLYSIO, PEGASYS, RIBASPHERE, RIBASPHERE RIBAPAK, RIBAVIRIN, SOVALDI, TECHNIVIE, VICTRELIS, VIEKIRA PAK, ZEPATIER Trade Name: EGRIFTA Huntington's Chorea Hyperammonemia Trade Name: TETRABENAZINE, XENAZINE Trade Name: CARBAGLU Idiopathic Thrombocytopenia Immune System Trade Name: PROMACTA Trade Name: ASTAGRAF XL, ENVARSUS XR Inborn Errors of Metabolism Infantile Spasms Infections Trade Name: CERDELGA, CHOLBAM, ORFADIN, XURIDEN, ZAVESCA Antibiotics Trade Name: SABRIL Trade Name: IMPAVIDO Trade Name: ACTICLATE, LINEZOLID, MOXATAG, SIVEXTRO, ZYVOX Antifungal Drugs (oral) Trade Name: LAMISIL, ONMEL, ORAVIG Antiviral Drugs Malaria Trade Name: SITAVIG, XERESE Trade Name: QUALAQUIN Inflammatory Bowel Trade Name: CIMZIA, GIAZO, HUMIRA PEN, MESALAMINE, ROWASA, UCERIS Intranasal Men's Health Hormones Mental Health Migraine Steroids / Antihistamines / Miscellaneous Trade Name: DERMACINRX TICANASE PAK, DYMISTA Trade Name: ANDRODERM, ANDROGEL, ANDROID, ANDROXY, AXIRON, FIRST-TESTOSTERONE, FIRST-TESTOSTERONE MC COMPOUNDING KIT, FORTESTA, METHITEST, METHYLTESTOSTERONE, NATESTO, STRIANT, TESTIM, TESTOSTERONE, TESTRED, VOGELXO Antidepressants Trade Name: BRINTELLIX, FETZIMA, TRINTELLIX, VIIBRYD Antipsychosis Multiple Sclerosis Osteoporosis Trade Name: NUPLAZID, PALIPERIDONE ER Trade Name: MIGRANOW, ZECUITY Trade Name: AMPYRA, EXTAVIA, H.P. ACTHAR Trade Name: FORTEO Pain / Inflammation Muscle Relaxants NSAIDs Trade Name: AMRIX, CARISOPRODOL, CYCLOBENZAPRINE COMFORT PAC, CYCLOBENZAPRINE HCL 7.5MG, CYCLOBENZAPRINEPAX, FEXMID, FLEXEPAX, LORZONE Trade Name: CAPXIB KIT, DERMA SILKRX DICLOPAK, DERMACINRX INFLAMMATRAL PAK, DERMACINRX LEXITRAL PHARMAPAK, DERMACINRX PHN PAK, DERMACINRX ZRM PAK, INFLAMMATION REDUCTION PACK, LIDOXIB KIT, PREVIDOLRX ANALGESIC PAK, VOPAC MDS, XRYLIX Topical NSAIDs Pain Relievers Narcotic Trade Name: LORVATUS PHARMAPAK Trade Name: ACTIQ, EXALGO, FENTANYL CITRATE ORAL TRANSMUCOSAL, FENTORA, HYDROMORPHONE HCL ER, HYSINGLA ER, LAZANDA, OPANA ER (CRUSH RESISTANT), OXYCODONE HCL ER, OXYCONTIN, OXYMORPHONE HYDROCHLORIDE ER, SUBSYS, XARTEMIS XR, XTAMPZA ER, ZOHYDRO ER 2

3 Parkinson's Disease Trade Name: NEUPRO, RYTARY Post-Herpetic Neuralgia Trade Name: GRALISE Pseudobulbar Affect Trade Name: NUEDEXTA Pulmonary Arterial Hypertension Trade Name: ADCIRCA, ADEMPAS, LETAIRIS, OPSUMIT, ORENITRAM, REVATIO, SILDENAFIL, TRACLEER, TYVASO STARTER, UPTRAVI, VENTAVIS Respiratory Tract Agents Trade Name: ESBRIET, OFEV Restless Leg Syndrome Trade Name: HORIZANT Rheumatoid Arthritis Seizure / Pain Trade Name: ACTEMRA, KINERET, ORENCIA, OTREXUP, RASUVO, SIMPONI, XELJANZ Trade Name: ACTIVE-PAC/GABAPENTIN, APTIOM, BRIVIACT, OXTELLAR XR, QUDEXY XR, SMARTRX GABA KIT, SMARTRX GABA-V KIT, SPRITAM, TROKENDI XR Sleep-Wake Disorder Trade Name: HETLIOZ Stomach / Intestinal Trade Name: OCALIVA Antiemetics (for nausea) Diarrhea Trade Name: DICLEGIS Trade Name: FULYZAQ Short Bowel Syndrome Trade Name: GATTEX Urea Cycle Disorders Wilson's Disease Women's Health Trade Name: RAVICTI Trade Name: CUPRIMINE Menopause Trade Name: BRISDELLE 3

4 Medicaid Managed Care Step Therapy List The following prescription drugs have STEP THERAPY applied Before certain medications are covered, we require that a generic or cost-effective alternative be tried first. For example, if Drug A and Drug B can both be used to treat a medical condition, Drug B may not be covered unless Drug A is tried first. If Drug A does not work, we will then cover Drug B. Attention Deficit Disorder Cancer Trade Name: STRATTERA Antineoplastic Trade Name: XTANDI Cardiovascular / Heart Angiotensin II Receptor Blockers Trade Name: ATACAND, BENICAR, EDARBI, MICARDIS Antihyperlipidemics Trade Name: ALTOPREV, CRESTOR, LIVALO, VYTORIN Antihypertensive Combinations / Miscellaneous Trade Name: AMTURNIDE, ATACAND HCT, BENICAR HCT, EDARBYCLOR, ENTRESTO, MICARDIS HCT, TEVETEN HCT Beta Blockers (high blood pressure) Dermatology Diabetes Eye Trade Name: BYSTOLIC, COREG CR Psoriasis Products Trade Name: COSENTYX, OTEZLA, TACLONEX Trade Name: ACZONE, DIFFERIN, DORYX, DOXYCYCLINE, ORACEA, ZACLIR CLEANSING Topical / Oral Steroids Trade Name: CLOBEX, CLOCORTOLONE PIVALATE, CLODERM, CORDRAN, DESONATE, HALOG, KENALOG, PANDEL, TRIANEX, VERDESO Trade Name: ALTABAX, BACTROBAN Oral Hypoglycemics Glaucoma Fibromyalgia Gout Topical / Oral Acne Products Topical Antibiotics Trade Name: KOMBIGLYZE XR, ONGLYZA Trade Name: BIMATOPROST, LUMIGAN Trade Name: LYRICA, SAVELLA Trade Name: ULORIC Growth Hormone / Factors Hepatitis C Infections Trade Name: GENOTROPIN MINIQUICK, HUMATROPE, NORDITROPIN FLEXPRO, NUTROPIN AQ PEN, SAIZEN, SEROSTIM, ZORBTIVE Antibiotics Trade Name: HARVONI, TECHNIVIE, VIEKIRA PAK Trade Name: DIFICID Inflammatory Bowel Intranasal Trade Name: CIMZIA Steroids / Antihistamines / Miscellaneous Trade Name: PATANASE Men's Health BPH Agents (prostate) Trade Name: AVODART, RAPAFLO Mental Health Migraine Antidepressants Trade Name: APLENZIN, DESVENLAFAXINE ER, EMSAM, KHEDEZLA, LUVOX CR, OLEPTRO, PEXEVA, PRISTIQ, VENLAFAXINE HCL ER Antipsychosis Trade Name: ABILIFY, FANAPT, LATUDA, REXULTI, SAPHRIS, SEROQUEL XR Sedatives / Hypnotics / Anxiety Trade Name: EDLUAR, INTERMEZZO, ROZEREM, SILENOR, ZOLPIMIST Trade Name: CAMBIA Multiple Sclerosis Osteoporosis Pain / Inflammation NSAIDs Trade Name: AUBAGIO, BETASERON, ZINBRYTA Trade Name: FOSAMAX PLUS D Trade Name: ANAPROX DS, ARTHROTEC 75, CATAFLAM, CELEBREX, DAYPRO, DUEXIS, EC-NAPROSYN, FELDENE, INDOCIN, MOBIC, NALFON, NAPROSYN, PONSTEL, SPRIX, TIVORBEX, VIMOVO, VOLTAREN-XR (GT) = Generic Trial Program 4

5 Medicaid Managed Care Step Therapy List The following prescription drugs have STEP THERAPY applied Before certain medications are covered, we require that a generic or cost-effective alternative be tried first. For example, if Drug A and Drug B can both be used to treat a medical condition, Drug B may not be covered unless Drug A is tried first. If Drug A does not work, we will then cover Drug B. Topical NSAIDs Trade Name: FLECTOR, PENNSAID Pain Relievers Narcotic Trade Name: BUTRANS, FENTANYL Parkinson's Disease Trade Name: REQUIP XL, ZELAPAR Respiratory Inhaled Beta Agonists / Inhaled Respiratory Drugs Trade Name: XOPENEX Inhaled Steroids Trade Name: BUDESONIDE, PULMICORT Rheumatoid Arthritis Trade Name: ACTEMRA, CIMZIA, ORENCIA, XELJANZ Seizure / Pain Trade Name: LYRICA Stomach / Intestinal Antiemetics (for nausea) Trade Name: SANCUSO Irritable Bowel Trade Name: AMITIZA Ulcer / Heartburn Trade Name: DEXILANT, ESOMEPRAZOLE MAGNESIUM, NEXIUM (GT) = Generic Trial Program 5