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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


 Actonel 150mg tabalendronate

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 TherapyVictozaByetta, 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, InjectionLansoprazole ODT, omeprazole, pantoprazole

Table 2: Miscellaneous PDL Revisions

Narcan NS (naloxone nasal spray)Add to PreferredQuantity Limit 2 per 90 days
Evzio (naloxone auto injector)Add Prior AuthorizationNarcan NS, naloxone inj preferred without PA
Vancomycin Oral CapsAdd to PreferredQL 125mg 4 caps/day; 250mg 8 caps/day
SurfaxinRemove from PDLNot commercially available
Renagel (sevelamer)Remove from PDL, add STPrefer PhosLo generic (calcium actetate) first line
Fosrenol (lanthanum carbonate)Remove from PDL, add STPrefer PhosLo generic (calcium actetate) first line
Phoslyra (calcium acetate)Remove from PDL, add STPrefer PhosLo generic (calcium actetate) first line
Gralise (gabapentin)Remove from PDLPrefer gabapentin generic
Horizant (gabapentin)Remove from PDLPrefer gabapentin generic


Table 3: Additions of new or modified utilization edits

Drug NameUtilization Edit
Xarelto 15mg tabRemove Max Supply of 21 tabs/180 days
Cilostazol 50mg, 100mg tabsAdd MDD 2 tabs/day
Ondansteron 4mg, 8mg tabsRemove QL
Effient 5mg, 10mg tabsAdd MDD 1 tab/day
Apidra penQL 30ml/30 days
Apidra VialsQL 40ml/30 days
Humalog Vials and PensQL 30ml/30 days
Novolog PensQL 30ml/30 days
Novolog VialQL 40ml/30 days
Lantus vials and pensQL 30ml/30 days
Levemir Vials and PenQL 30ml/30 days
Humulin 70/30  PensQL 30ml/30 days
Humulin 70/30 VialsQL 40ml/30 days
Novolin 70/30 vialsQL 40ml/30 days
Humalog Mix 50/50 and 75/25 vialsQL 40ml/30 days
Humalog Mix 50/50 and 75/25 PensQL 30ml/30 days
Novolog Mix 70/30 PensQL 30ml/30 days
Novolog Mix 70/30 VialsQL 40ml/30 days
Byetta 5mcgQL 1.2 ml/30 days
Byetta 10mcgQL 2.4 ml/30 days
Symlin 60QL 6 ml/30 days
Symlin 120QL 10.8ml/30 days
montelukast  – all strengthsQL 1 tab/day
pioglitazone – All strengthsQL 1 tab/day
pioglitazone/metformin – All strengthsQL 2 tabs/day
Jentadueto – All StrengthsQL 2 tabs/day
atorvastatin – all strengthsQL 1 tab/day
pravastatin – all strengthsQL 1 tab/day
simvastatin – all strengthsQL 1 tab/day

Last Updated: 04/15/2020