Q4 2017 PDL Provider Notification
Date: 12/15/17
The following list of utilization limits and PDL Q4 2017 changes were reviewed and approved by the MHS P&T Committee.
Table 1: New Age Limits for Stimulant Medications Effective 2/1/2018
The following stimulant medications have new age limits as recommended by the Indiana Mental Health Quality Advisory Committee which are aligned with approved FDA labeling.
Name of Medication and Strength | Utilization Edit |
AMPHETAMINE IR, ALL FORMULATIONS | Age 3 years and older |
AMPHETAMINE ER, ALL FORMULATIONS | Age 6 years and older |
AMPHETAMINE-DEXTROAMPHETAMINE IR, ALL FORMULATIONS | Age 3 years and older |
AMPHETAMINE-DEXTROAMPHETAMINE ER, ALL FORMULATIONS | Age 6 years and older |
COTEMPLA XR 8.6MG ODT | 1/DAY; Age 6 years and older |
COTEMPLA XR 17.3MG ODT, 25.9MG ODT | 2/DAY; Age 6 years and older |
DEXMETHYLPHENIDATE HCL IR, ALL FORMULATIONS | Age 3 years and older |
DEXMETHYLPHENIDATE HCL ER, ALL FORMULATIONS | Age 6 years and older |
DEXTROAMPHETAMINE SULFATE IR,ALL FORMULATIONS | Age 3 years and older |
DEXTROAMPHETAMINE SULFATE ER, ALL FORMULATIONS | Age 6 years and older |
LISDEXAMFETAMINE, ALL FORMULATIONS | Age 6 years and older |
METHAMPHETAMINE, ALL FORMULATIONS | Age 6 years and older |
METHYLPHENIDATE IR, ALL FORMULATIONS | Age 3 years and older |
METHYLPHENIDATE ER, ALL FORMULATIONS | Age 6 years and older |
Table 2: PDL Changes Effective 1/1/2018
Drug | Action | Notes |
telmisartan-amlodipine | Add to PDL |
|
trandolapril-verapamil HCl | Add to PDL |
|
famciclovir | Add to PDL |
|
Norethindrone & Ethinyl Estradiol-Fe | Add to PDL | Generic Femcon Fe, Generess Fe, Estrostep Fe |
Norethindrone Acetate-Ethinyl Estradiol | Add to PDL | Generic Femhrt Low Dose |