MHS Preferred Drug List (PDL) Updates - Q1 2016
Date: 05/31/16
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MHS routinely reviews the medications available on the Preferred Drug List (PDL). Items are added, removed or modified periodically due to industry standards, market availability, and assessment of use. Below is a list of changes that were approved by the MHS P&T Committee this quarter. MHS will transition members to preferred alternatives by working directly with the prescriber and only as approval is granted.
Table 1: Summary of Medicaid PDL changes based upon therapeutic class review.
Add to Preferred | Move to Non-Preferred | Preferred Options |
|---|---|---|
ADHD Medications | ||
| Evekeo (amphetamine) | ||
Antiplatelet, Anticoagulant Therapy | ||
| Eliquis (apixaban) MDD 4 tab/dayAnagrelide (Agrylin)Brilinta (ticagrelor) MDD 2 tab/day | Warfarin injectable Aspirin/dipyridamole ER (Aggrenox) Fondaparinux (Arixtra) Fragmin (dalteparin) Heparin premix solutions | warfarin, Eliquis, Xarelto, cilostazol, pentoxyfylline, clopidogrel, Effient, brilinta, ticlodipine, aspirin, dipyridamole, heparin inj., enoxaparin |
Bisphosphonates | ||
| Actonel 150mg tab | alendronate | |
COPD Agents | ||
| Incruse Elipta (umeclidinium) | Serevent, Atrovent, ipratropium bromide, Spiriva Handihaler, Combivent, Tudorza, Anoro Ellipta, Advair, Symbicort, Breo Ellipta | |
Injectable Diabetic Agents | ||
| Bydureon (exenatide) QL 4/30 days; Step Therapy | Victoza | Byetta, Bydureon, Symlin |
Oral Antidiabetic | ||
| Riomet (metformin solution)Janumet (sitagliptin/metformin)Janumet XR (sitagliptin/metformin ER) | Jentadueto (linagliptin/metformin)Kombiglyze XR (saxagliptin/metformin) | |
Proton Pump Inhibitors | ||
| Nexium 24HR (OTC)Prevacid 24HR (OTC) | Protonix Granule Packet, Injection | Lansoprazole ODT, omeprazole, pantoprazole |
Table 2: Miscellaneous PDL Revisions
| Medication | Change | Notes |
|---|---|---|
| Narcan NS (naloxone nasal spray) | Add to Preferred | Quantity Limit 2 per 90 days |
| Evzio (naloxone auto injector) | Add Prior Authorization | Narcan NS, naloxone inj preferred without PA |
| Vancomycin Oral Caps | Add to Preferred | QL 125mg 4 caps/day; 250mg 8 caps/day |
| Surfaxin | Remove from PDL | Not commercially available |
| Renagel (sevelamer) | Remove from PDL, add ST | Prefer PhosLo generic (calcium actetate) first line |
| Fosrenol (lanthanum carbonate) | Remove from PDL, add ST | Prefer PhosLo generic (calcium actetate) first line |
| Phoslyra (calcium acetate) | Remove from PDL, add ST | Prefer PhosLo generic (calcium actetate) first line |
| Gralise (gabapentin) | Remove from PDL | Prefer gabapentin generic |
| Horizant (gabapentin) | Remove from PDL | Prefer gabapentin generic |
Table 3: Additions of new or modified utilization edits
| Drug Name | Utilization Edit |
|---|---|
| Xarelto 15mg tab | Remove Max Supply of 21 tabs/180 days |
| Cilostazol 50mg, 100mg tabs | Add MDD 2 tabs/day |
| Ondansteron 4mg, 8mg tabs | Remove QL |
| Effient 5mg, 10mg tabs | Add MDD 1 tab/day |
| Apidra pen | QL 30ml/30 days |
| Apidra Vials | QL 40ml/30 days |
| Humalog Vials and Pens | QL 30ml/30 days |
| Novolog Pens | QL 30ml/30 days |
| Novolog Vial | QL 40ml/30 days |
| Lantus vials and pens | QL 30ml/30 days |
| Levemir Vials and Pen | QL 30ml/30 days |
| Humulin 70/30 Pens | QL 30ml/30 days |
| Humulin 70/30 Vials | QL 40ml/30 days |
| Novolin 70/30 vials | QL 40ml/30 days |
| Humalog Mix 50/50 and 75/25 vials | QL 40ml/30 days |
| Humalog Mix 50/50 and 75/25 Pens | QL 30ml/30 days |
| Novolog Mix 70/30 Pens | QL 30ml/30 days |
| Novolog Mix 70/30 Vials | QL 40ml/30 days |
| Byetta 5mcg | QL 1.2 ml/30 days |
| Byetta 10mcg | QL 2.4 ml/30 days |
| Symlin 60 | QL 6 ml/30 days |
| Symlin 120 | QL 10.8ml/30 days |
| montelukast – all strengths | QL 1 tab/day |
| pioglitazone – All strengths | QL 1 tab/day |
| pioglitazone/metformin – All strengths | QL 2 tabs/day |
| Jentadueto – All Strengths | QL 2 tabs/day |
| atorvastatin – all strengths | QL 1 tab/day |
| pravastatin – all strengths | QL 1 tab/day |
| simvastatin – all strengths | QL 1 tab/day |