MEDICAL ASSISTANCE BULLETIN

Transcription

1 ISSUE DATE December 18, 2013 SUBJECT EFFECTIVE DATE January 22, 2014 MEDICAL ASSISTANCE BULLETIN NUMBER *See Below BY Drug List (PDL) Update January 22, 2014 Pharmacy Services Vincent D. Gordon, Deputy Secretary Office of Medical Assistance Programs PURPOSE: The purpose of this bulletin is to inform providers about updates to the Drug List (PDL), effective January 22, SCOPE: This bulletin applies to all licensed pharmacies and prescribers enrolled in the Medical Assistance (MA) Program and providing services in the fee-for-service (FFS) delivery system, including pharmacy services to residents of long term care facilities. BACKGROUND: The Department of Public Welfare s (Department) Pharmacy and Therapeutics (P&T) Committee meets semi-annually to review published peer-reviewed clinical literature and make recommendations relating to new drugs in therapeutic classes already included in the PDL, changes in the status of drugs on the PDL from preferred to non-preferred and non-preferred to preferred, new quantity limits, and new classes of drugs to be added to or deleted from the PDL. The P&T Committee also recommends new guidelines or modifications to existing guidelines to evaluate requests for prior authorization of prescriptions for medical necessity. * COMMENTS AND QUESTIONS REGARDING THIS BULLETIN SHOULD BE DIRECTED TO: The appropriate toll free number for your provider type Visit the Office of Medical Assistance Programs Web site at

2 2 DISCUSSION: The P&T Committee s most recent semi-annual meeting was held on November 5, The update to the PDL resulting from that meeting and a final review by the Department is as follows; 1. Classes of drugs subject to the PDL with no changes: Antihypertensives, Sympatholytics Antihyperuricemics Antipsoriatics, Topical Bile Salts Botulinum Toxins Diabetic Supplies Enzyme Replacement, Gauchers Disease Glucocorticoids, Oral Immunomodulators, Atopic Dermatitis Oncology Agents, Breast Cancer Ophthalmic Antibiotic-Steroid Combinations Ophthalmics, Allergic Conjunctivitis Otic Antibiotics Otic Anti-Infectives & Anesthetics Sedative Hypnotics Steroids, Topical Very High 2. Classes of drugs added to the PDL: Antipsoriatics, Oral Anxiolytics Epinephrine, Self-Injected Histamine II Receptor Blockers Immunomodulators, Topical Iron, Oral Progestational Agents 3. Classes of drugs or drugs removed from the PDL None 4. PDL status of new drug classes, new drugs, drugs not previously reviewed, and drugs with a change in status Class Brand Name Generic Name Alzheimer s Agents Exelon Capsules Namenda R donepezil 23mg Anticonvulsants Banzel Suspension Depakote Anticonvulsants, Depakote Sprinkle

3 3 Class Brand Name Generic Name continued Dilantin Infatab Onfi Suspension Trokendi R lamotrigine R phenytoin chewable tab tiagabine Antidepressants, Other Forfivo L desvenlafaxine ER Antidepressants, Brisdelle SSRIs escitalopram tablet fluoxetine tablet fluvoxamine ER Antihistamines, cetirizine capsule OTC Minimally Sedating desloratadine ODT Antiparkinson s Agents Lodosyn entacapone Antipsoriatics, Oral 8-Mop Oxsoralen-Ultra Soriatane acitretin Antipsychotics Abilify Maintena Haldol (Injection) clozapine ODT Anxiolytics Ativan Tablet Niravam Tranxene T-Tab Valium Tablet anax Tablet anax R alprazolam ER alprazolam intensol alprazolam ODT alprazolam tablet buspirone chlordiazepoxide clorazepate diazepam intensol diazepam solution diazepam syringe Anxiolytics, continued diazepam tablet diazepam vial

4 4 Class Brand Name Generic Name lorazepam intensol lorazepam tablet meprobamate oxazepam Bronchodilators, Beta Agonists openex Nebulizing Solution Concentrate COPD Agents Tudorza Pressair Cytokine and CAM Simponi Aria Vial Antagonists eljanz Emollients Cerave PM OTC Epinephrine, Self- Auvi-Q Injected Epipen Epipen Jr epinephrine Glucocorticoids, Inhaled Pulmicort Respules 0.25mg, 0.5mg Histamine II Receptor Axid Solution Blockers Pepcid AC Tablet OTC Pepcid Suspension Pepcid Tablet Zantac (Injection) Zantac 75 Tablet OTC Zantac Syrup Zantac Tablet Zantac Tablet OTC cimetidine solution cimetidine tablet cimetidine tablet OTC famotidine (intravenous) famotidine piggyback famotidine suspension famotidine tablet famotidine tablet OTC famotidine vial nizatidine capsule nizatidine solution ranitidine (injection) ranitidine capsule ranitidine syrup Histamine II Receptor ranitidine tablet ranitidine tablet OTC

5 5 Class Brand Name Generic Name Blockers, continued Immunomodulators, Aldara Topical Zyclara imiquimod Intranasal Rhinitis Agents Nasacort AQ Iron, Oral Bifera Rx Feosol OTC Ferate OTC Ferralet 90 Dual-Iron Ferrimin 150 OTC Fusion Plus Hemocyte Plus Hemocyte-F Integra F Integra OTC Integra Plus Niron Komplete Tandem Dual Action OTC Tandem Plus Vitron-C OTC Active Fe Centratex Corvita 150 Corvite 150 Corvite Fe Duofer Fe C OTC Fe fumarate/vit C/B12- IF/FA Fe fumarate/vit C/vit B12/FA Feriva Ferraplus 90 Ferrex 150 Plus OTC Ferrex 28 Ferrocite Plus ferrous gluconate OTC ferrous sulfate 65mg OTC Iron, Oral (continued) ferrous sulfate OTC ferrous sulfate solution

6 6 Class Brand Name Generic Name OTC Folitab 500 OTC Folivane-F Folivane-Plus hematogen hematogen FA hemetab Icar-C OTC Iferex 150 forte iron 45mg OTC iron carbonyl/ascorbic acid OTC iron polysaccharides complex OTC iron PS cmplx/vit B12/FA Irospan Maxaron Forte Multigen Multigen Folic Multigen Plus MV comb18/fefm-fepol CB1/FA Natalvirt FLT Nephron FA Novaferrum Novaferrum 50 OTC Novaferrum Drops OTC Novaferrum Liquid OTC SE-Tan Plus slow release iron Taron Forte TL-Fol 500 TL-Hem 150 Vitafol Iron, Parenteral Injectafer Leukotriene Modifiers montelukast granules Neuropathic Pain Lyrica Solution Savella Savella Dose Pack gabapentin solution NSAIDs diclofenac sodium/

7 7 Class Brand Name Generic Name misoprostol Oncology Agents, Oral Afinitor Disperz Bosulif Cometriq Gilotrif Mekinist Stivarga Tafinlar Temodar eloda tandi Zolinza temozolomide Ophthalmic Antibiotics Besivance Ophthalmics, Anti- Acular Inflammatories Durezol Ilevro Lotemax Gel Prolensa Ophthalmics, Istalol Glaucoma Agents Lumigan Pilopine HS Rescula Simbrinza travoprost Progestational Agents Crinone Depo-Provera 400mg/ml Makena Prometrium Provera Aygestin medroxyprogesterone acetate norethindrone acetate progesterone (intramuscular) progesterone capsule Smoking Cessation Nicorette Lozenge OTC nicotine lozenge OTC Steroids, Topical High fluocinonide ointment Steroids, Topical High, trianex ointment

8 8 Class Brand Name Generic Name continued Steroids, Topical Low fluocinolone 0.01% oil Steroids, Topical Medium betamethasone valerate foam Stimulants and Methylin Chewable Tabs Related Agents Methylin Solution Quillivant R Ritalin dextroamphetamine solution methylphenidate CD Procentra Zenzedi 5. New Drugs that require clinical prior authorization: Afinitor Disperz Bosulif Cometriq Gilotrif Mekinist Stivarga Tafinlar Temodar eloda tandi Zolinza PROCEDURE: The procedures for prescribers to request prior authorization of non-preferred drugs, preferred drugs that require prior authorization, and drugs not subject to the PDL that require prior authorization and for pharmacies to dispense an emergency supply of medication when necessary and without prior authorization are located In SECTION I of the Prior Authorization of Pharmaceutical Services Handbook. The Department will take into account the elements specified in the clinical review guidelines (which are included in the provider handbook pages in the SECTION II chapters related to specific therapeutic classes of drugs) in reviewing the prior authorization request to determine medical necessity. The requirements for prior authorization and clinical review guidelines to determine medical necessity of non-preferred and preferred drugs listed above and updated handbook chapters will be published in separate MA Bulletins.

9 9 As set forth in 55 Pa. Code (a), the procedures described in the handbook pages must be followed to ensure appropriate and timely processing of prior authorization requests for drugs that require prior authorization. ATTACHMENTS: Prior Authorization of Pharmaceutical Services Handbook - Updated pages SECTION I Providers can view the most recent PDL at: Providers can view the most recent Quantity Limits List at: antitylimitslist/index.htm NOTE: Providers may call , Option 1 to request a hard copy of the most recent PDL and Quantity Limits List SECTION II Table of Contents