PDL Changes
Date: 02/18/20
The following list of utilization limits and PDL changes were reviewed and approved by the MHS P&T Committee.
Table 1: New Utilization Edit for Stimulant Medications Effective 4/01/2020
The following medications will need a Prior Authorization for adults (19 years of age & greater) unless there is an appropriate behavior health diagnoses as recommended by the Indiana Mental Health Quality Advisory Committee which are aligned with approved FDA labeling.
Name of Medication | Utilization Edit |
AMPHETAMINE ER | Must have FDA-Labeled Diagnoses or Approved Compendia Diagnoses |
AMPHETAMINE SULFATE | Must have FDA-Labeled Diagnoses or Approved Compendia Diagnoses |
DEXMETHYLPHENIDATE HCL
| Must have FDA-Labeled Diagnoses or Approved Compendia Diagnoses |
DEXTROAMPHETAMINE SULFATE | Must have FDA-Labeled Diagnoses or Approved Compendia Diagnoses |
LISDEXAMFETAMINE DIMESYLATE | Must have FDA-Labeled Diagnoses or Approved Compendia Diagnoses |
METHAMPHETAMINE HCL | Must have FDA-Labeled Diagnoses or Approved Compendia Diagnoses |
METHYLPHENIDATE (patch) | Must have FDA-Labeled Diagnoses or Approved Compendia Diagnoses |
METHYLPHENIDATE HCL (oral products) | Must have FDA-Labeled Diagnoses or Approved Compendia Diagnoses |
Table 2: New Utilization Edit for Clonidine/Guafacine Effective 4/01/2020
The following medications will need a Prior Authorization when taken together as recommended by the Indiana Mental Health Quality Advisory Committee.
Name of Medication | Utilization Edit |
CLONIDINE | PA needed if taken with Guanfacine |
GUANFACINE | PA needed if taken with Clonidine |