MEDICAL ASSISTANCE BULLETIN

Transcription

1 ISSUE DATE July 12, 2012 SUBJECT EFFECTIVE DATE August 13, 2012 MEDICAL ASSISTANCE BULLETIN NUMBER *See below BY Drug List (PDL) Update August 2012 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 August 13, 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. DISCUSSION: The P&T Committee made the following recommendations during the most recent semiannual meeting on May 23, 2012, which were reviewed and approved by the Department. * 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 1. Classes of drugs subject to the PDL with no changes: Analgesics, Narcotics Long Androgenic Agents Angiotensin Modulator Combinations Antibiotics, Inhaled Antibiotics, Topical Antimigraine Agents Antivirals, Topical Colony Stimulating Factors Erythropoiesis Stimulating Proteins Fluoroquinolones, Oral Hypoglycemics, Meglitinides Immunosuppressives, Oral Multiple Sclerosis Agents PAH Agents, Oral and Inhaled Phosphate Binders Skeletal Muscle Relaxants 2. Classes of drugs added to the PDL: Growth Factors Pituitary Suppressive Agents, LHRH 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 Acne Agents, Topical Akne-Mycin Benzaclin w/pump Benzoyl Peroxide Med. Pad Clindagel Differin Gel Epiduo Inova Retin-A Micro Pump 10-1 Benzac AC Benzac W Wash Benzoyl Peroxide 5% Wash Benzoyl Peroxide 6% Cleanser

3 3 OTC Acne Agents, Topical, Benzoyl Peroxide 7% Wash continued OTC Benzoyl Peroxide Cleanser Benzoyl Peroxide Kit Benzoyl Peroxide OTC Benzoyl Peroxide Towelette Benzoyl Peroxide/Urea Cleanser BP Cleanser OTC BP Suspension OTC BPO Kit Cerisa Clenia Clindamycin Phosphate Foam Clindamycin Phosphate Med. Swab Clindamycin/Benzoyl Peroxide Desquam- Erythromycin Med. Swab Nuox SE BPO 7-5.5% Wash Kit SSS 10-4 Sulfacetamide/Sulfur Cleanser Sulfacetamide/Sulfur Cleansing Cloths Sulfacetamide/Sulfur Lotion Sulfacetamide/Sulfur Med. Pad Sulfacetamide/Sulfur Suspension Sulfacetamide/Sulfur/Urea Analgesics, Narcotics Short Codeine Zydone Cleanser TL 4.25% BPO M Cleanser OTC Carisoprodol Compound- Codeine Cocet Cocet Plus Hydromorphone Suppositories

4 4 Pentazocine/Naloxone Angiotensin Fosinopril/HCTZ Modulators Quinapril/HCTZ Antibiotics, GI Alinia Tablet Metronidazole Capsule Antibiotics, Vaginal Metronidazole Anticoagulants Arixtra Lovenox Syringe arelto Enoxaparin Syringe Antiemetics/Antivertigo Dimenhydrinate Injection Agents Metoclopramide Ampul Ondansetron Ampul Phenergan Ampul Prochlorperazine Injection Prochlorperazine Rectal Promethazine 50mg Rectal Antifungals, Oral Nystatin Powder Antifungals, Topical Lotrimin Ultra OTC Naftin Cream Naftin Gel Clotrimazole-Betamethasone Lotion Fungoid Kit OTC Antiparasitics, Topical Eurax Lotion Lice Egg Remover OTC Antivirals, Oral Tamiflu Suspension Beta Blockers Inderal LA Toprol L Acebutolol Metoprolol L Metoprolol/HCTZ Nadolol/Bendroflumethiazide Propranolol ER Timolol Bladder Relaxants Ditropan L Oxytrol Sanctura R Toviaz VESIcare

5 5 Flavoxate Bone Resorption Suppression & Related Agents Aredia BPH Agents Cialis Uroxatral Calcium Channel Dynacirc CR Blockers Norvasc Verapamil 360mg Capsule Cephalosporins & Augmentin 250 Related Agents Suspension Cefaclor Tablet ER Cefadroxil Tablet Cefadroxil Suspension Contraceptives, Oral Femcon FE Leena Loestrin Loestrin FE Lo-Ovral-28 Micronor Nordette-28 Ortho Tri-Cyclen Ortho Tri-Cyclen Lo Ortho-Cyclen Ortho-Novum Seasonique Trinessa Yasmin 28 Yaz Aviane Caziant Cryselle Errin Heather Junel FE Lutera Microgestin FE Necon Norethindrone

6 6 Norgestimate-Ethinyl Estradiol Ovcon-35 Reclipsen Sronyx Tri-Previfem Contraceptives, Oral, Tri-Sprintec continued Trivora-28 Velivet Growth Factors Increlex Growth Hormones Norditropin Pen Saizen Cartridge Saizen Vial Serostim Vial Hepatitis C Agents Peg-Intron Peg-Intron Redipen HIV/AIDS Complera Hypoglycemics, Bydureon Incretin Mimetics/ Jentadueto Enhancers Juvisync Tradjenta Victoza Hypoglycemics, Insulin Levemir Pens & Related Agents Levemir Vial Hypoglycemics, TZD Duetact Lipotropics, Other Antara Colestipol Granules Fenofibrate Capsule Niacin Tablet OTC Niacin Tablet ER OTC Niacin (Inositol Niacinate) OTC Niacin Capsule ER OTC Lipotropics, Statins Crestor Atorvastatin Macrolides/Ketolides E.E.S. 200 Suspension Eryped 200 Suspension Eryped 400 Suspension Erythromycin Erythromycin Base Capsule DR Opiate Dependence Treatments Suboxone Tablet **

7 7 Pancreatic Enzymes Pancreaze Pituitary Suppressive Eligard Agents, LHRH Lupron Depot Lupron Depot Kit Lupron Depot-Ped Pituitary Suppressive Lupron Depot-Ped Agents, LHRH, Kit continued Supprelin LA Kit Synarel Trelstar Trelstar Depot Trelstar LA Vantas Kit Zoladex Leuprolide Acetate Platelet Aggregation Inhibitors Brilinta Prenatal Vitamins Prenata Complete Natal DHA Complete-RF Prenatal Maxinate PNV with CA, No.71/Iron/FA Poly Iron PN Forte Prenafirst Prenatal 19 Tab Chew Prenatal Vit 15/Iron CB/FA/DSS Prenatal-U PureFE OB Plus PureFE Plus Select-OB + DHA SE-Natal 19 Tab Chew Stuart Prenatal + DHA OTC Taron-BC Taron-Duo EC Triveen-Duo DHA Triveen-U Vinate AZ Vitafol-OB + DHA Vitaspire Vol-Nate

8 8 Vol-Tab Rx Proton Pump Inhibitors Aciphex omeprazole Tetracyclines Vibramycin Syrup Ulcerative Colitis Canasa Agents Colazal Ulcerative Colitis Mesalamine Agents, continued Mesalamine Kit ** Effective September 10, New Drugs that require clinical prior authorization: Increlex 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. 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: mitslist/index.htm

9 9 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