Q3 2015 MHS Preferred Drug List (PDL) Provider Notice
Date: 12/30/15
Click here for a PDF version of this notice.
The Managed Health Services (MHS) Pharmacy and Therapeutics (P&T) Committee approved the following medications for addition to the MHS PDLs for Healthy Indiana Plan 2.0 (HIP) and Hoosier Care Connect members. These additions are effective 12/1/2015.
Therapeutic Class | Medication | Comments |
|---|---|---|
Acne Products | erythromycin 2% gel | MPL 1/ claim |
| Sulfacetamide sodium wash | ||
Antiadrenergic Agents – Centrally Acting | Reserpine | |
Beta Blockers | timolol maleate oral tab | |
| Coreg® CR (carvedilol) | MDD 1/day | |
Contraceptives | ELLA (ulipristal 30mg tab) | QL 4/365 DAYS |
Hormone Replacement Therapy
| progesterone vaginal insert | |
| estradiol vaginal cream | QL 43/30 DAYS
| |
| progesterone vaginal suppositories | ||
Multiple Sclerosis Agents
| Avonex (Interferon Beta-1a) | PA Required |
| Plegridy (Peginterferon beta-1a) | PA Required | |
| Tecfidera (dimethy fumarate0 | PA Required | |
| Copaxone (Glatiramer 40mg Inj.) | PA Required | |
NSAIDs
| choline magnesium trisalicylate | |
| salsalate tab | ||
| aspirin 81mg Tab | ||
Topical Corticosteroids
| augmented betamethasone dipropionate 0.05% cream | MPL 1/ claim |
| betamethasone valerate 0.1% cream, lotion and ointment | MPL 1/ claim | |
| clobetasol propionate emulsion 0.05% foam | MPL 1/ claim | |
Bile Acid Agent | Cholbam (cholic acid) | PA Required, QL = 5/day |
Respiratory Agent (CF) | Orkambi (lumacaftor, ivacaftor) | PA Required |
Atypical Antipsychotic
| Rexulti (brexpiprazole) | MDD 1/day |
| Aristada (aripiprazole) | QL 1/28 days, Age 18 and older | |
Anticonvulsants | Qudexy XR (topiramate) | MDD 1/day |
Vitamin/Supplement | Vitamin B12 injection (cyanocobalamin) |
The following clinical edits were approved by the P&T Committee with an effective date of 2/1/2016. MHS will attempt to convert members to preferred alternatives or obtain the necessary authorization by working directly with the prescriber and only as approval is granted.
Medication | Edit | Comment |
|---|---|---|
Celecoxib (Celebrex) | Prior Authorization |
|
Ranexa (Ranolazine) | Prior Authorization | A. Diagnosis of chronic anginaB. Age ≥18 years;
C. Failure of concurrent use of a beta- blocker and long-acting nitrate OR failure of concurrent use of a calcium channel blocker and long-acting nitrate, unless contraindicated; |
Hemangeol (propranolol HCL Soulution) | Prior Authorization | A. Patient with documented diagnosis of proliferating infantile hemangioma.B. For infants younger than 2 months of age, the patient must be hospitalized for monitoring during induction of treatment if patient has PHACE syndrome.
C. Patient must weigh less than 12.5 kg in weight. |
Regranex (becaplermin) | Prior Authorization | A. Diagnosis of diabetes;B. Chronic lower extremity ulcer present ≥8 weeks;
C. Diagnosis of Stage III or IV lower extremity ulcer(s) as defined in the IAET guideline to chronic wound staging; D. Age ≥16 years; E. Failure of wound care, including initial sharp debridement, pressure relief, and infection control; F. Documentation of proper and adequate wound care, wound devoid of infection. |
Sodium Glucose Co Transporter-2 (SGLT-2) | Step Therapy | Initial Approval Criteria (must meet all):
|
The P&T Committee has approved the following list of medications to be moved to non-preferred status on the HIP and Hoosier Care Connect PDLs. These medications will remain available through the prior authorization process. MHS will attempt to convert members to preferred alternatives by working directly with the prescriber and only as approval is granted. The effective date of these changes is 2/1/2016.
Therapeutic Class | Medication Moving | Preferred Alternative(s) |
|---|---|---|
Acne and Rosacea Products | Azelex (azelaic acid) | clindamycin topical, erythromycin, metronidazole, sulfacetaminde sodium, benzyl peroxide, tretinoin (generics), nezoyl peroxide/clindamycin |
| Noritate (metronidazole) | ||
| Sulfacetamide sodium 10% | ||
| benzoyl peroxide Foam (BenzEFoam) | ||
| Zaclir (benzoyl peroxide) | ||
| Avar LS, Avar E- LS (sulfacetamide/sulfur cleanser) | ||
| Sumaxin, Sumaxin TS(sulfacetamide/sulfur) | ||
| Epiduo (benzoyl peroxide, adapalene) | ||
| Panretin (alitretinoin) | ||
| Avita, Atralin (tretinoin) | ||
| Acanya (benzoyl peroxide/clindamycin) | ||
| benzoyl peroxid/erythromycin | ||
| Ziana (Clindamycycin/tretinoin) | ||
| Benziq LS, Benziq, Benziq Wash (benzoyl peroxide/ aloe vera) | ||
Antimalarial Preparations | Quinine sulfate (Qualaquin) | chloroquine, hydroxychloroquine, primaquine, Coartem, Malarone, mefloquine |
| Daraprim (pyrimethamine) | ||
Antituberculosis Agents | Paser (aminosalicylic acid) | ethambutol, Trecator (ethionamide), isoniazid, pyrazinamide, rifampin |
| Cycloserine (Seromycine) | ||
| Rifabutin (Mycobutin) | ||
| Priftin (rifapentine) | ||
| Rifater (rifampin,isoniazid,pyrazinamide) | ||
| Rifamate (rifampin, isoniazid) | ||
Beta Blockers | Bystolic (nebivolol) | acebutolol, atenolol, bisoprolol, levatol (penbutolol), nadolol, metoprolol (IR/ER), pindolol, propranolol (IR/ER), sotalol, carvedilol, labetalol |
Calcium Channel Blockers | Cardene SR (nicardipine) | amlodipine, diltiazem, felodipine, nicardipine, nifedipine (IR/ER), verapamil (IR/ER) |
| Isradipine | ||
| Nimodipine (Nimotop) | ||
| Nisoldipine (Sular) | ||
| Verelan PM (verapamil ER) |
Therapeutic Class | Medication Moving | Preferred Alternative(s) |
|---|---|---|
Contraceptives | Falessa Kit (Ethinyl estradiol, levonorgestrel, folic acid, levomefolate) | Multiple products |
Hormone Replacement Therapy | Cenestin, Enjuvia(conjugated estrogens, synthetic) | estradiol tabs, estropipate, Premarin, Estratest, Femhrt, Prempro, Premphase, Provera, Aygestin, Prometrium, Combipatch, Climara |
| Menest(esterified estrogens) | ||
| Angeliq(estradiol/ drospirenone) | ||
| Duavee(conjugated estrogen/bazedoxifene) | ||
| Activella(estradiol/ norethindrone) | ||
| Jinteli(ethinyl estradiol/ norethindrone) | ||
| Prefest(estradiol/ norgestimate) | ||
| Climara Pro(estradiol/ levonorgestrel) | ||
| Menostar(estradiol) | ||
| Divigel, Elestrin(estradiol gel) | ||
| Estrasorb(estradiol Emulsion) | ||
| Evamist(estradiol Spray) | ||
| Vagifem(estradiol vaginal tablets) | ||
| Premarin Injection(conjugated estrogens) | ||
| Overactive Bladder Agents | Enablex (darifenacin) | tolterodine (IR/ER), oxybutynin (IR/ER tabs), Sanctura (trospium), flavoxate |
| Gelnique (oxybutynin topical Gel) | ||
| Oxytrol (oxybutynin Patch) | ||
| Sanctura XR (trospium ER) | ||
| Toviaz (fesoterodine) | ||
| Vesicare (solifenacin) | ||
Muscle Relaxants | Dantrolene (Dantrium) | baclofen, chlorzoxazone, cyclobenzaprine (5mg,10mg tab), methocarbamol, orphenadrine |
| Fexmid, Amrix (Cyclobenzaprine) | ||
| Metaxalone (Skelaxin) | ||
| Tizanidine (Zanaflex) |
Therapeutic Class | Medication Moving | Preferred Alternative(s) |
|---|---|---|
NSAIDs | diclofenac Na(Pennsaid transdermal soln.) | diclofenac sodium, diclofenac potassium, etodoloac, flurbiprofen, ibuprofen, indomethacin, ketoprofen, ketorolac, nabumetone, naproxen (IR/EC), oxaprozin, piroxicam, sulindac, aspirin, diflunisal, salsalate |
| Zipsor(diclofenac potassium liquid cap) | ||
| Flector (diclofenac patch) | ||
| Indocin (indomethacin suppository, Suspension) | ||
| meclofenamate | ||
| Ponstel (mefanamic acid) | ||
| Mobic Suspension(meloxicam suspension) | ||
| Naprelan (naproxen ER tabs) | ||
| Sprix (ketorolac nasal spray) | ||
| Tolmetin (Tolectin) | ||
| Voltaren gel (diclofenac gel) | ||
| Zorvolex (diclofenac tabs) | ||
| Diclofenac sodium/ misoprostol (Arthrotec) | ||
Topical Corticosteroids | alclometasone dipropionate 0.05% cream, ointment (Aclovate) | Very High Potency: aug. betamethasone 0.05% oint, lotion clobetasol 0.05% oint, soln, cream ,gel, foam High Potency: aug. betamethasone 0.05% cream diflorasone 0.05% cream fluocinonide 0.05% emulisified cream, gel betamethasone 0.05% oint triamcinolone 0.5% oint Medium Potency: triamcinolone 0.025%, 0.1%, 0.5% ointment, cream, 0.025%,0.1% lotion betamethasone 0.05% cream, lotion fluocinolone 0.025% cream, 0.025% oint Low Potency: fluocinolone 0.01% cream, soln hydrocortisone 0.5%, 1%, 2.5% cream, ointment, lotion Combination: betamethasone/clotrimazole cr, lot triamcinolone/nystatin cream, ointment Rectal: hydrocortisone rectal cream 1%, 2.5%, suppository 25mg hydrocortisone/pramoxine cream, lotion, ointment |