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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

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