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Page 1
Updated May 30, 2018
Alzheimer's Agents Antimigraine Agents Growth HormonesCholinesterase Inhibitors Triptans H. Pylori TreatmentNMDA Receptor Antagonist Antiparkinson's Agents Hepatitis C AgentsAndrogenic Agents Dopamine Receptor Agonists Pegylated InterferonsAngiotensin Modulators Antipsychotics, Atypical RibavirinsAce Inhibitors Antivirals Hepatitis C Agents, OtherAce Inhibitor/Diuretic Combo Herpes HypoglycemicsAngiotensin Receptor Blocker Influenza Agents Alpha-Glucosidase InhibitorsAngiotensin II Receptor Blocker/Diuretic Combo Beta Blockers Incretin Mimetics/EnhancersRenin Inhibitor Bile Salts Amylin AnalogsRenin Inhibitor/Diuretic Combo Bladder Relaxants DPP-IV InhibitorsAngiotensin Modulator/Calcium Channel Blocker Combinations
Bone Resorption Suppression and Related Agents GLP-1 Receptor Agonists
Ace Inhibitor/Calcium Channel Blocker Combo Bisphosphonates InsulinsAngiotensin II Receptor Blocker/CCB Combo Other Related Agents Insulins, Long ActingAnti-Allergens BPH Agents Insulins, Short ActingAntianginal & Anti-Ischemic Alpha Blockers, Selective MeglitinidesAntibiotics, GI 5-Alpha Reductase Inhibitors MetforminsAntibiotics, Inhaled Bronchodilators Metformins ComboAntibiotics, Tetracyclines Beta Agonist SGLT2Antibiotics, Topical Inhalers, Long Acting SulfonylureasAntibiotics, Vaginal Inhalers, Short Acting TZDsAnticoagulants Nebulizers, Long Acting TZD/Metformin ComboAnticonvulsants Nebulizers, Short Acting TZD/Sulfonylurea Combo
Carbamazepine Derivatives Calcium Channel Blockers Immunomodulators, Atopic DermatitisFirst Generation Dihydropyridines Immunomodulators, TopicalSecond Generation Non-Dihydropyridines Intranasal RhinitisAntidepressants Cephalosporins AntihistaminesAntidepressants, Other Second Generation Leukotriene ModifiersAntidepressants, SSRI Third Generation Lipotropics, OtherAntiemetics COPD Agents Bile Acid ResinsAntiemetics, Oral Cytokine & CAM Antagonists Cholesterol Absorption InhibitorsNKI1 Receptor Antagonist Epinephrine, Self-Injected Fibric Acid DerivativesAntifungals Erythropoiesis Stimulating Proteins NiacinsAntihistamines, Minimally Sedating Fluoroquinolones Omega-3 Fatty Acids
GI Motility Agents MTP Inhibitor
Antihistamines Glucocorticoids, InhaledAntihyperlipidemic APOB-100 Synthesis Inhibitor
Antihistamine/Decongestant Combo Glucocorticoids Antihypertensives, Sympatholytics Glucocorticoid/Beta-Agonist Lipotropics, StatinsAntihyperuricemics Glucocorticoids, Oral Statins
Statin Combo
Executive Office of Health and Human ServicesRhode Island Medicaid Fee for Service
Preferred Drug List (PDL)
Page 2
Macrolides/Ketolides SteroidsMethotrexate Topical HighMultiple Sclerosis Topical LowNarcotic Analgesics, Long Acting Topical MediumNarcotic Analgesics, Short Acting Topical Very HighFentanyl Oral Products Stimulants and Related AgentsOther Topical AcneNeuropathic Pain Miscellaneous TopicalsNSAIDS and Combination Products RetnoidsOral Topical AntiviralsTopical Topical PsoriasisOphthalmics Ulcerative ColitisAllergic Conjunctivitis OralAntibiotics TopicalGlaucomaAlpha-2 Adrenegic AgonistsBeta BlockersCarbonic Anhydrase InhibitorsProstaglandin AgonistsOphthalmic Antibiotic-Steroid ComboOphthalmics Anti-InflammatoryOphthalmics Anti-Inflammatory/ImmunomodulatorsOpiate Dependence TreatmentsOtic AntibioticsPancreatic EnzymesPhosphate BindersPlatelet InhibitorsProgestins for CachexiaProton Pump InhibitorsPulmonary Arterial Hypertension AgentsRosacea Agents, TopicalSedative HypnoticsSkeletal Muscle Relaxants
Page 3
Contact Information
Prior Authorization Call CenterPA RequestsFax: 1-401-784-3889
DXC TechnologyCustomer Service Help DeskTelephone: 1-401-784-8100Toll Free: 1-800-964-6211
Request for a Non-Preferred Drug Prior Authorization Form
Rhode Island Medicaid Fee for Service Preferred Drug List
Note: Most fax requests are responded to within 24 hours
The general rule to receive a non-preferred agent is to try a preferred agent in the same therapeutic class in the past 90 days.
The exceptions to this general rule are drugs that require a clinical prior authorization of some kind or a step edit. These drugs are identified below in the appropriate class listing and are highlighted in green.
http://www.eohhs.ri.gov/ProvidersPartners/GeneralInformation/ProviderDirectories/Pharmacy/PharmacyPriorAuthorizationProgram.aspx
Prior Authorization Program Forms
The Preferred Drug List (PDL) is a listing of therapeutic classes and associated drugs that are managed by the Medicaid Fee-for-Service Pharmacy and Therapeutics Committee. It is not an all inclusive list of covered medications in the Medicaid Fee-for-Service program. If you have an NDC, please check the NDC lookup on the EOHHS healthcare portal to determine coverage.
Page 4
Alzheimer's AgentsLength of Authorization: 1 Year Status Implementation: 1/15/2008
Current Review Date: 10/24/2017No PA Required PA RequiredCholinesterase Inhibitors Cholinesterase Inhibitorsdonepezil 5 and 10 mg tablet donepezil 23 mgdonepezil ODT galantamine ER/solutionrivastigmine capsule galantamine tabletExelon Patch rivastigmine transdermal
Aricept/ODT/23 mgExelon capsulesRazadyne tablet/ER/solution
NMDA Receptor Antagonist and Combinations
NMDA Receptor Antagonist and Combinations
memantine tablet memantine solutionmemantine HCL ERNR
Namenda Solution/XRNamenda TabletNamenda dose packNamzaric Namzaric dose pack
Androgenic AgentsLength of Authorization: 1 Year Status Implementation: 10/15/2008
Current Review Date: 10/24/2017No PA Required PA RequiredAndrogenic Agents Androgenic AgentsAndroderm testosteroneAndrogel Axiron
FortestaNatestoTestimVogelxo gelVogelxo gel packetVogelxo gel pump
Angiotensin ModulatorsLength of Authorization: 1 Year Status Implementation: 1/15/2007
Current Review Date: 1/22/2018No PA Required PA RequiredAce Inhibitors Ace Inhibitorsbenazepril fosinoprilcaptopril moexiprilenalapril perindoprillisinopril quinapril
ramipriltrandolaprilAccuprilAceonAltaceEpanedEpaned solutionLotensinMavikPrinivilVasaotec
Return to Index Zestril
Page 5
Length of Authorization: 1 Year Status Implementation: 1/15/2007Current Review Date: 1/22/2018
No PA Required PA RequiredACE Inhibitor/Diuretic ACE Inhibitor/Diureticbenazepril HCTZ fosinopril HCTZcaptopril HCTZ moexipril HCTZenalapril HCTZ quinapril HCTZlisinopril HCTZ Accuretic
Lotensin HCTVasereticZestoretic
Angiotensin Receptor Blockers Angiotensin Receptor Blockerslosartan candesartanDiovan eprosartan
irbesartanolmesartan medoxomiltelmisartan valsartanAtacandAvaproBenicarCozaarEdarbiMicardisQbrelis
Angiotensin II Receptor Blocker/Diuretic
Angiotensin II Receptor Blocker/Diuretic
losartan HCTZ candesartan HCTZvalsartan HCTZ irbesartan HCTZ Micardis HCT olmesartan HCTZ
olmesartan-medoxomil HCTZtelmisartan HCTZ Atacand HCTAvalideBenicar HCTDiovan HCTEdarbyclorHyzaar
No PA Required PA Required (failure of ARB)Renin Inhibitor Renin Inhibitor
Tekturna
Renin Inhibitor Combinations Renin Inhibitor CombinationsTekturna HCT
Return to Index
Angiotensin Modulators - Continued
Page 6
Authorization: 1 Year Status Implementation: 1/15/2007Current Review Date: 1/22/2018
No PA Required PA RequiredAce Inhibitor/Calcium Channel Blocker Combo
Ace Inhibitor/Calcium Channel Blocker Combo
amlodipine/benazepril trandolapril/verapamil ERLotrelPrestaliaTarka
Angiotensin II Receptor Blocker/Calcium Channel Blocker Combo
Angiotensin II Receptor Blocker/Calcium Channel Blocker Combo
Entresto amlodipine-olmesartanExforge/HCT amlodipine/valsartan
olmesartan-amlodipine HCTZtelmisartan/amlodipine AzorTribenzorTwynsta
Length of Authorization: 1 Year Status Implementation: 7/5/2017Current Review Date: 7/5/2017
No PA Required PA RequiredAnti-Allergens Anti-Allergens
GrastekOralairRagwitek
Length of Authorization: 1 Year Status Implementation: 1/3/2014Current Review Date: 1/22/2018
No PA Required PA Required
Antianginal & Anti-Ischemic Agents Antianginal & Anti-Ischemic AgentsRanexa
Return to Index
Anti-Allergens
Angiotensin Modulators/Calcium Channel Blocker Combinations
Antianginal & Anti-Ischemic Agents
Page 7
Antibiotics, GILength of Authorization: 1 Year Status Implementation: 7/1/2013
Most Current Review Date: 7/5/2017No PA Required PA RequiredAntibiotics, GI Antibiotics, GImetronidazole tablet metronidazole capsule
paromomycintinidazolevancomycin HCLAlinia suspensionAlinia tabletDificidFlagyl capsule/tabletFlagyl ERNeomycinSolosecNR
TindamaxVancocin Xifaxan *
* Diagnosis of Hepatic Encephalopathy and 1 paid claim for lactulose in the past 30 days or inadequate respone or contraindication to lactulose documented
Antibiotics, InhaledLength of Authorization: 1 Year Status Implementation: 5/11/2012
Current Review Date: 7/5/2017No PA Required PA RequiredAntibiotics, Inhaled Antibiotics, InhaledBethkis tobramycin Kitabis Pak Cayston
TobiTobi Podhaler
Antibiotics, TetracyclinesLength of Authorization: 1 Year Status Implementation: 7/1/2013
Current Review Date: 7/5/2017No PA Required PA RequiredAntibiotics, Tetracyclines Antibiotics, Tetracyclinesdoxycycline hyclate capsule demeclycyclinedoxycycline hyclate tablet doxycycline hyclate tablet DRdoxycycline monohydrate 100mg generic capsule doxycycline monohydrate (oracea)doxycycline monohydrate 50mg generic capsule
doxycycline monohydrate 50mg brand capsule
minocycline capsulesdoxycycline monohydrate 150mg capsule
tetracyclinedoxycycline monohydrate 75mg capsule
Morgidox 100mg capsule doxycycline monohydrate suspensiondoxycycline monohydrate tabletminocycline ER/tabletDoryxDoryx MPCMorgidox kitOracea
Return to Index SolodynVibramycin cap/suspensionVibramycin syrupXimino ERNR
Page 8
Antibiotics, TopicalLength of Authorization: 1 Year Status Implementation: 7/1/2013
Current Review Date: 7/5/2017No PA Required PA RequiredAntibiotics, Topical Antibiotics, Topicalmupirocin ointment mupirocin cream
AltabaxBactroban cream/ointmentCentanyCentany kit
Antibiotics, VaginalLength of Authorization: 1 Year Status Implementation: 7/1/2013
Current Review Date: 7/5/2017No PA Required PA RequiredAntibiotics, Vaginal Antibiotics, Vaginalmetronidazole clindamycin Cleocin Ovules Cleocin creamClindesse MetrogelVandazole Return to Index Nuvessa
Page 9
AnticoagulantsLength of Authorization: 1 Year Status Implementation: 1/15/2008
Current Review Date: 2/01/2017No PA Required PA RequiredAnticoagulants Anticoagulantswarfarin coumadinFragmin enoxaparin Lovenox fondaparinux Pradaxa* ArixtraXarelto BevyxxaNR
Eliquis Eliquis dose packNR
Savaysa* Diagnosis of Atrial Fibrillation in the past year. Xarelto dose pack
AnticonvulsantsLength of Authorization: 1 Year Status Implementation: 1/15/2008
Current Review Date: 1/22/2018No PA Required PA Requiredcarbamazepine derivatives carbamazepine derivativescarbamazepine chewable tablet carbamazepine XRcarbamazepine ER carbamazepine suspensioncarbamazepine tablet Carbatroloxcarbazepine tablet/susp EquetroEpitol Oxtellar XRTegretol suspension Tegretol tablet/chewable tabletTegretol XR Trileptal suspension
Trileptal tabletFirst Generation First Generationdivalproex sprinkles felbamatedivalproex tablet/ER phenytoin chew tabethosuximide Celontinphenytoin capsule/suspension Depakene capsulesprimidone Depakote/ERvalproate syrup Depakote Sprinklevalproic acid capsules/syrup Dilantin capsules/suspensionDepakene syrup FelbatolDilantin chew tab Mysoline
PeganonePhenytekZarontin capsules/syrup
Return to Index
Page 10
No PA RequiredSecond Generationlamotrigine tablets lamotrigine tablet dose pack Fycompalevetiracetam lamotrigine XR Keppra/XR *roweepra lamotrigine ODT Lamictal/ODT/XR/DStopiragen levetiracetam ER Qudexy XRtopiramate tablet/sprinkle tiagabine Sabrilzonisamide topirmate ER SpritamGabitril vigabatrinNR Topamax tablet/sprinkle *
Aptiom Trokendi XRBanzel Vimpat/dose packBriviact Zonegran
Other Phenobarbital elixir OtherPhenobarbital tablet diazepam (rectal/device)Diastat (rectal/Acudial) Onfi
Potiga
AntidepressantsLength of Authorization: 1 Year Status Implementation: 1/15/2008
Current Review Date: 1/22/2018No PA RequiredOtherbupropion/SR desvenlafaxine ER Effexor XR *bupropion XL desvenlafaxine fumarate ER Fetzimamirtazapine/ODT maprotiline Forfivo XLtrazodone nefazodone Khedezlavenlafaxine venlafaxine ER tabs Oleptrovenlafaxine ER caps Aplenzin PristiqWellbutrin XL Brintellix Remeron/ODT
Cymbalta TrintellixEffexor Viibryd
Wellbutrin/SR
SSRI SSRIcitalopram tablet citalopram solutionescitalopram tablet escitalopram solutionfluoxetine capsule fluoxetine tabletfluoxetine solution fluoxetine 60mg tablet paroxetine fluoxetine capsules DRsertraline tablet fluvoxamine/ER
paroxetine (generic Brisdelle)NR
paroxetine CRsertaline concentrateBrisdelleCelexaLexapro(failure of citalopram)Paxil/CRPexevaProzac/Weekly
Return to Index SarafemZoloft
* History of a paid claim for a preferred antidepressant at least 28 days prior to the current date of service
PA RequiredSecond Generation
PA RequiredOther
* Diagnosis of epilepsy, convulsions or seizure disorder and a claim for Keppra or Topamax in the past 60 days or a claim for a preferred agent in the past 90
days
Page 11
AntiemeticsLength of Authorization: 1 Year Status Implementation: 1/15/2008
Current Review Date: 5/30/2018No PA Required PA RequiredSerotonin Antagonists Serotonin Antagonistsmetoclopramide solution granisetronmetoclopramide tablet metoclopramide ODTondansetron ODT Akynzeoondansetron solution Anzemetondasetron tablet BonjestaNR
DiclegisSancuso patchSustolSyndrosZofran/ODTZuplenz
NK1 Receptor Antagonist NK1 Receptor Antagonistaprepitant capsuleaprepitant packetEmendEmend powder packetVarubi
AntifungalsLength of Authorization: 1 Year Status Implementation: 7/1/2007
Current Review Date: 7/5/2017No PA RequiredOralfluconazole tablet clotrimazole Cresemba capsule griseofulvin suspension fluconazole suspension Diflucan tablet/suspensiongriseofulvin ultra tabs flucytosine Grifulvin V tabletsnystatin suspension griseofulvin micro tablet Gris-Pegterbinafine itraconazole Lamisil
ketoconazole oral Noxafilnystatin oral powder/tablet Onmel
voriconazole SporanoxAncobon Vfend tablet/suspension
Topicalclotrimazole-betamethasone cream butenafine cream Extinaclotrimazole cream (Rx) ciclopirox cream/gel/kit Fungoid Kitketoconazole cream ciclopirox shampoo Jubliaketoconazole shampoo ciclopirox solution/suspension Kerydinmiconazole cream clotrimazole solution Lamisil cream/gel/spraynystatin cream/ointment clotrimazole-betamethasone lotion Loprox cream/gel/kit/shampoo
nystatin-triamcinolone cream/ointment econazole Loprox suspensionNR
terbinafine cream ketoconazole foam Lotrimintolnaftate cream/powder miconazole oint/powder/spray Lotrisone
naftifine Luzunystatin powder Mentax
oxiconazole nitrate cream Naftin cream/geltolnaftate solution/spray/aero powder Nizoral shampoo
Aloe Vesta Oxistat cream/lotionBensal HP Pediaderm AF
Ciclodan cream/kit PenlacCNL-8 Vusion
Dermacinrx Therazole PakNR ZeasorbDesenex Aero Powder
ErtaczoExelderm cream/solution
Return to Index
Topical
PA RequiredOral
Page 12
Length of Authorization:1 Year Status Implementation: 7/1/2007Current Review Date: 7/5/2017
No PA Required PA RequiredAntihistamines Antihistaminescetirizine tab/solution desloratadine/ODTlevocetirizine fexofenadine suspensionloratadine tablet loratadine ODT /solution
Clarinex (tab, syrup, rapdis)Xyzal
Antihistamine/Decongestant Combinations
Antihistamine/Decongestant Combinationsloratadine-D 12/24 hour tabletsClarinex-D 12 hour tabletSemprex-D
Length of Authorization: 1 Year Status Implementation: 1/3/2014Current Review Date: 10/24/2017
No PA Required PA Required
Antihypertensives, Sympatholytics Antihypertensives, Sympatholyticsclonidine tablet (oral) clonidine (transderm)guanfacine methyldopa HCTZmethyldopa methyldopate HCLCatapres-TTS (transderm) Catapres tablet (oral)
Return to Index
Antihistamines, Minimally Sedating
Antihypertensives, Sympatholytics
Page 13
Length of Authorization: 1 Year Status Implementation: 5/27/2015Current Review Date: 5/30/2018
No PA Required PA RequiredAntihyperuricemics Antihyperuricemicsallopurinol colchicine capsulecolchicine tablet Colcrysprobencid Duzalloprobencid/colchicine Mitigare
UloricZurampicZyloprim
Antimigraine AgentsLength of Authorization: 1 Year Status Implementation: 7/1/2007
Current Review Date: 7/5/2017No PA RequiredAntimigraine Agentsrizatriptan tablet/ODT almotriptan malate Frovasumatriptan (oral, nasal, vial) eletriptanNR Imitrex (oral, nasal, subcutaneous)Relpax frovatriptan Maxalt (oral)/MLT
naratriptan Migranowsumatriptan (syringe) Onzetra Xsail
sumatriptan/naproxenNR Sumavelzolmitriptan tablet/ODT Treximet
Amerge ZembraceAxert Zomig (oral, nasal, ZMT)
Cambia
Antiparkinson's Agents
Length of Authorization: 1 Year Status Implementation: 1/15/2008Current Review Date: 10/24/2017
No PA Required PA RequiredDopamine Receptor Agonists Dopamine Receptor Agonistsamantadine capsule pramipexole ERamantadine syrup ropinirole ERamantadine tablet GocovriNR
pramipexole IR Mirapex*/ERropinirole IR Neupro
Requip/XL
Return to Index
* Diagnosis of Parkinson's in the past 12 months or Diagnosis of Restless Leg Syndrome in the past 12 months and a claim for ropinirole in the past 90 days
Antihyperuricemics
PA RequiredAntimigraine Agents
Page 14
AntipsychoticsLength of Authorization: 1 Year Status Implementation: 10/15/2008
Current Review Date: 7/5/2017No PA Required PA RequiredAtypical Atypicalaripiprazole tablet aripiprazole solution/ODTclozapine tablet clozapine ODTolanzapine tablet olanzapine ODTpaliperidone ER olanzapine/fluoxetinequetiapine Abilify tabletquetiapine ER Adasuverisperidone Aristadaziprasidone ClozarilAbilify Maintena Fanapt tritration packInvega Sustenna FazacloInvega Trinza * GeodonLatuda InvegaRisperdal Consta Nuplazid
Rexulti Risperdal tablet/solution/ODTSaphrisSeroquelSeroquel XRSymbyaxVersaclozVraylarZyprexa/ZydisZyprexa Relprevv
AntiviralsLength of Authorization: 1 Year Status Implementation: 10/15/2007
Current Review Date: 5/1/2017No PA Required PA RequiredHerpes Herpesacyclovir capsule Sitavigacyclovir suspension Valtrexacyclovir tablet Zovirax capsulefamciclovir Zovirax suspensionvalacyclovir Zovirax tablet
Influenza Agents Influenza AgentsRelenza oseltamivir phosphate suspensionTamiflu rimantadine
Flumadine
Return to Index
* 4 claims in the last 120 days for Invega Sustenna
Page 15
Beta BlockersLength of Authorization: 1 Year Status Implementation: 1/15/2007
Current Review Date: 1/22/2018No PA Required PA RequiredBeta Blockers Beta Blockersatenolol acebutololatenolol/chlorthalidone betaxololcarvedilol bisoprolol/HCTZlabetolol metoprolol HCTZmetoprolol nadolol/bendroflumethazidemetoprolol XL pindololpropranolol HCTZ propranolol HCL ERNR
propranolol tablet propranolol cap SA 24H/solutionsotaloltimololBetapace/AFBystolicByvalsoncarvedilol ERNR
Coreg/CRCorgardCorzideDutoprolHemangeolInderal/ LA/XLInnopran XLLevatolLopressor/HCTSotylizeTenoreticTenorminToprol XLZiac
Bile SaltsLength of Authorization: 1 Year Status Implementation: 1/22/2018
Current Review Date: 1/22/2018No PA Required PA RequiredBile Salts Bile Saltsursodiol tablet chenodal
ursodiol 300mg capsuleActigallCholbamOcalivaUrso/Urso Forte tablet
Bladder RelaxantsLength of Authorization: 1 Year Status Implementation: 10/15/2007
Current Review Date: 10/24/2017No PA Required PA RequiredBladder Relaxants Bladder Relaxantsoxybutynin ER darifenacin ERoxybutynin IR tolterodineEnablex tolterondine ERToviaz trospium/ERVesicare Detrol/LA
Ditropan/XLGelniqueGelnique gel pumpMyrbetriqOxytrol
Return to Index
Page 16
Length of Authorization: 1 Year Status Implementation: 5/1/2007Current Review Date: 5/30/2018
No PA Required PA RequiredBisphosphonates Bisphosphonatesalendronate tablet alendronate solution
etidronateibandronaterisedronate sodium DRActonelAtelviaBinostoBonivaFosamax/Plus D
Other Related Agents Other Related Agentsraloxifene HCL calcitonin salmon
EvistaForteo *Prolia*Tymlos*
* History of Bisphosphonates in 12 Months
BPH Agents
Length of Authorization:1 Year Status Implementation: 10/15/2007Current Review Date: 10/24/2017
No PA Required PA RequiredAlpha Blockers, Selective Alpha Blockers, Selectivealfuzosin Flomaxtamsulosin HCL Rapaflo
Uroxatral
5-Alpha Reductase Inhibitors 5-Alpha Reductase Inhibitorsfinasteride dutasteride
dutasteride/tamsulosinAvodartJalynProscar
Return to Index
Bone Resorption Suppression Related Agents
Page 17
Bronchodilators, Beta AgonistLength of Authorization: 1 Year Status Implementation: 7/1/2007
Current Review Date: 7/5/2017No PA Required PA Required
Beta Agonist Inhalers, Long Acting Beta Agonist Inhalers, Long ActingForadil (step edit-use of inhaled corticosteroid in past 45 days) Striverdi RespimatSerevent (step edit-use of inhaled corticosteroid in past 45 days)
Beta Agonist Inhalers, Short Acting Beta Agonist Inhalers, Short ActingProAir HFA levalbuterol tartrate HFAProventil HFA Arcapta
ProAir RespiclickVentolin HFAXopenex HFA
Beta Agonist Nebulizers, Long Acting
Beta Agonist Nebulizers, Long Acting
n/aBrovana (step edit for failure of long acting inhaler and corticoid steroid)
Perforomist (step edit for failure of long acting inhaler and corticoid steroid)
Beta Agonist Nebulizers, Short Acting
Beta Agonist Nebulizers, Short Acting
albuterol nebulizer solutionalbuterol nebulizer solution low-dose (accuneb)levalbuterolXopenex
Return to Index
Page 18
Calcium Channel Blockers
Length of Authorization: 1 Year Status Implementation: 1/15/2007Current Review Date: 1/22/2018
No PA Required PA RequiredDihydropyridines Dihydropyridinesamlodipine felodipine ER
isradipinenicardipinenifedipine/SAnifedipine ERnimodipinenisoldipineAdalat CCAfeditab CRDynacirc CRNifedical XLNorvascNymalizePlendilProcardia/XLSular
Non-Dihydropyridines Non-Dihydropyridinesdiltiazem diltiazem CD/ERverapamil tablet/ER verapamil capsule ER/PM
Calan/SRCardizem/CD/LACartia XTDilacor XRDilt CD/XRDiltzac ERMatzim LATaztia XTTiazacVerelan/PM
CephalosporinsLength of Authorization: 1 Year Status Implementation: 7/1/2007
Current Review Date: 7/5/2017No PA Required PA RequiredSecond Generation Second Generationcefaclor capsule, suspension cefaclor tablet ERcefprozil tablet, suspension Ceftin tablet, suspensioncefuroxime tablet
Third Generation Third Generationcefdinir capsule, suspension cefixime suspensioncefpodoxime tablet cefpodoxime suspensionSuprax capsules/tablets/chewables Suprax suspension
Return to Index
Page 19
COPD AgentsLength of Authorization: 1 Year Status Implementation: 7/1/2007
Current Review Date: 7/5/2017No PA Required PA RequiredCOPD Agents COPD Agents
albuterol/ipratropium nebulizer solution Anoro Elliptaipratropium nebulizer solution Bevespi AerosphereAtrovent HFA Combivent RespimatSpiriva Handihaler DalirespStiolto Respimat Incruse Ellipta
Lonhala MagnairNR
Seebri NeohalerSpiriva RespimatTudorza pressairUtibron Neohaler
Cytokine & CAM Antagonists
Length of Authorization:1 Year Status Implementation: 10/15/2007Current Review Date: 10/24/2017
No PA Required PA RequiredCytokine & CAM Antagonist Cytokine & CAM AntagonistEnbrel/cartridge ActemraHumira Arcalyst
CimziaCosentyxEntyvioIlarisInflectraKevzaraKineretOrencia/ clickjetOtezlaRemicadeRenflexisSiliqSimponiSimponi AriaStelaraTaltzTremfyaXeljanz/XR
Epinephrine, Self-InjectedLength of Authorization:1 Year Status Implementation: 7/1/2013
Current Review Date: 7/5/2017No PA Required PA RequiredEpinephrine, Self-Injected Epinephrine, Self-Injectedepinephrine 0.15mg (AG Epipen Jr) epinephrine 0.15mg (AG Adrenaclick)epinephrine 0.3mg (AG Epinpen) epinephrine 0.3mg (AG Adrenaclick)
EpipenEpipen Jr
Return to Index
Page 20
Length of Authorization: 1 Year Status Implementation: 10/15/2007Current Review Date: 10/24/2017
No PA Required PA Required
Erythropoiesis Stimulating Proteins Erythropoiesis Stimulating ProteinsProcrit Aranesp
Aranesp disp syringeEpogenMircera
FluoroquinolonesLength of Authorization: 1 Year Status Implementation: 7/1/2007
Current Review Date: 7/5/2017No PA Required PA RequiredFluoroquinolones Fluoroquinolonesciprofloxacin tablet ciprofloxacin ER/suspensionlevofloxacin tablet levofloxacin solutionCipro suspension moxifloxacin
ofloxacinAveloxBaxdelaNR
Cipro TabletCipro XRLevaquin
GI Motility AgentsLength of Authorization: 1 Year Status Implementation: 9/2/2015
Current Review Date: 7/5/2017No PA Required PA RequiredGI Motility Agents GI Motility AgentsAmitiza alosetronLinzess Relistor Lotronex SymproicNR
Movantik TrulanceViberzi
Glucocorticoids, InhaledLength of Authorization: 1 Year Status Implementation: 7/1/2007
Current Review Date: 7/5/2017No PA Required PA RequiredGlucocorticoids GlucocorticoidsAsmanex budesonide 0.25,0.5 mg respules
Flovent HFA AerospanPulmicort 0.25, 0.5 mg respules AlvescoPulmicort 1mg respules ArmonAir RespiclickNR
QVAR Arnuity ElliptaAsmanex HFAFlovent DiskusPulmicort FlexhalerQVAR RedihalerNR
Glucocorticoid/Beta-Agonist Combo Glucocorticoid/Beta-Agonist ComboAdvair Diskus Advair HFADulera Breo-ElliptaSymbicort Return to Index Trelegy ElliptaNR
Erythropoiesis Stimulating Proteins
Page 21
Glucocorticoids, OralLength of Authorization: 1 Year Status Implementation: 7/1/2007
Current Review Date: 7/5/2017No PA Required PA RequiredGlucocorticoids Glucocorticoidsbudesonide EC dexamethasone elixircortisone dexamethasone intensoldexamethasone solution/tablet methylprednisolone 8mg, 16mg tabhydrocortisone prednisone intensol
methylprednisolone 4mg &32mg tabletprednisolone sodium phosphate solution
methylprednisolone tab ds pk Cortefprednisolone sodium phosphate Dexpak prednisolone solution Entocort EC prednisone solution prednisone tab ds pk Medrol tab DS pk prednisone tablet Medrol tablet
Millipred solutionMillipred DP tab DS pkOrapred/ODTPediapredRayos tablet DRTaperdexNR
VeripredZodexNR
Growth HormoneLength of Authorization: 1 Year Status Implementation: 5/15/2008
Current Review Date: 5/30/2018No PA Required PA RequiredGrowth Hormone Growth HormoneGenotropin cartridge Humatrope cartridgeGenotropin dis syringe Humatrope vialNorditropin pen Nutropin AQ Pen
Omnitrope cartridgeOmnitrope vialSaizen cartridgeSaizen vialSerostim vialZomacton vialZorbtive vial
If recipient is over 21 years of age a manual clinical PA is required for preferred agents.
If recipient is over 21 years of age a manual clinical PA (specific form is available on the OHHS website) is required as well as a claim for a preferred agent in the past 90 days for a non-preferred agents. If the recipient is under 21 years of age a claim for a preferred agent in the past 90 days is required is required for a non-preferred agent.
Specific form is available on the OHHS website.
Specific form is available on the OHHS website.
H. Pylori TreatmentLength of Authorization: 1 Year Status Implementation: 5/27/2015
Current Review Date: 5/30/2018No PA Required PA RequiredH. Pylori Treatment H. Pylori TreatmentPylera lansoprazole/amoxicillin/clarithromycin
Return to Index Omeclamox-PakPrevpac
Page 22
Hepatitis C AgentsLength of Authorization: 1 Year Status Implementation: 10/15/2007
Current Review Date: 5/1/2017No PA Required PA RequiredPegylated Interferons Pegylated InterferonsPegasys Peg-Intron
Ribavirins Ribavirinsribavirin ribarivin dosepak
RebetolRibapakRibasphere 400 Ribasphere 600
Hepatitis C Agents, OtherLength of Authorization: 1 Year Status Implementation: 10/15/2007
Current Review Date: 1/22/2018
Other Hepatitis C Agents Other Hepatitis C AgentsMavyret DaklinzaVosevi Epclusa (genotypes 2 & 3 only)
HarvoniOlysioSovaldiTechnivieViekira PakViekira XRZepatier
HypoglycemicsLength of Authorization: 1 Year Status Implementation: 5/1/2007
Current Review Date: 5/30/2018No PA Required PA RequiredAlpha-Glucosidase Inhibitors Alpha-Glucosidase Inhibitorsacarbose miglitol
GlysetPrecose
Incretin Mimetics/Enhancers Incretin Mimetics/EnhancersAmylin Analogs Amylin Analogs
n/aSymlin/pen (History of use of mealtime Insulin)
DPP-IV Inhibitors DPP-IV InhibitorsGlyxambi alogliptinJanumet algliptin/metforminJanumet XR alogliptin/pioglitazoneJanuvia Jentadueto XRJentadueto Kazano Tradjenta Kombiglyze XR
Nesina OnglyzaOseni Q-ternSteglujanNR
Return to Index
Clinical Criteria Applies to this Class/Requires Manual Prior Authorization
Clinical Criteria for DPP-IV Inhibitors - History of either metformin or TZD therapy in the past 90 days
Page 23
Hypoglycemics - ContinuedLength of Authorization: 1 Year Status Implementation: 5/1/2007
Current Review Date: 5/30/2018
GLP-1 Receptor Agonists GLP-1 Receptor AgonistsBydureon/pen AdlyxinByetta Bydureon BciseVictoza Ozempic
SoliquaTanzeumTrulicity
Insulins InsulinsInsulins Long Acting Insulins Long ActingLantus vial Basaglar Kwikpen U-100Lantus solostar Toujeo Solostar Levemir pen Toujeo Max SolostarNR
Levemir vial Tresiba
No PA Required PA RequiredInsulins Short Acting Insulins Short ActingHumulin vial AdmelogNR
Humalog pen/vial Admelog SolostarNR
Humalog Mix pen/vial AfrezzaNovolog vial/pen Afrezza cartridgeNovolog Mix pen Apidra vial/solostar
FiaspFiasp FlextouchHumalog cartridge Humalog Jr KwikpenHumulin penHumulin 500Humulin R U-500 kwikpenNovolin vialNovolog Mix vial
Meglitinides Meglitinidesnateglinide repaglinide/metforminrepaglinide Prandin
Starlix
MetforminsMetformins metformin ER (generic Fortamet)metformin metformin ER (generic for Glumetza)metformin ER (generic Glucophage XR) Fortamet
Glucophage/XR
GlumetzaRiomet
No PA Required PA RequiredMetformins Combinations Metformins Combinationsglyburide/metformin glipizide/metformin
Glucovance
SGLT2 and Combinations SGLT2 and CombinationsFarxiga* Invokamet Invokana* Invokamet XRJardiance* Segluromet
Steglatro* 2 single metformin agents or 1 combination metformin agent in the past 30 days Synjardy
Synjardy XRReturn to Index Xigduo XR
Clinical Criteria for GLP-1 Receptor Agonists - History of either metformin or TZD therapy in the past 90 days
Page 24
Hypoglycemics - ContinuedLength of Authorization: 1 Year Status Implementation: 5/1/2007
Current Review Date: 5/30/2018Sulfonylureas Sulfonylureasglimepiride chlorpropamideglipizide/ER/XL tolazamideglyburide/micronized tolbutamide
AmarylGlucotrol/XLGlynaseTZD
TZD Actospioglitazone Avandia
TZD/Metformin Combinations TZD/Metformin Combinationspioglitazone-metforminActoplus MetActoplus Met XR
TZD/Sulfonylurea Combinations TZD/Sulfonylurea Combinationspioglitazone-glimepride Duetact
Immunomodulators, Atopic DermatitisLength of Authorization: 1 Year Status Implementation: 10/15/2007
Current Review Date: 5/30/2018No PA Required PA RequiredImmunomodulators, Atopic Dermatitis
Immunomodulators, Atopic Dermatitis
Elidel tacrolimus Protopic Dupixent
Eucrisa
Immunomodulators,TopicalLength of Authorization: 1 Year Status Implementation: 5/27/2015
Current Review Date: 5/30/2018No PA Required PA RequiredImmunomodulators, Topical Immunomodulators, Topicalimiquimod Aldara
Zyclara
Return to Index
Step Edit - Failure of topical medium/high anti-inflammatory steroid in the last 3 months. Excludes hydrocortisone.
The use of single agents are preferred in these sub categories
Page 25
Intranasal RhinitisLength of Authorization:1 Year Status Implementation: 7/1/2007
Current Review Date: 7/5/2017No PA Required PA RequiredSteroids Steroidsfluticasone flunisolide
mometasone nasalBeconase AQDymista NasonexOmnarisQNasl SinuvaNR
TicanaseVeramystXhanceNR
Zetonna
Antihistamines & Other Antihistamines & Otheripratropium (nasal) azelastinePatanase olopatadine
Astepro
Leukotriene ModifiersLength of Authorization: 1 Year Status Implementation: 7/1/2007
Current Review Date: 7/5/2017No PA Required PA RequiredLeukotriene Modifiers Leukotriene Modifiersmontelukast tab/chew montelukast granuleszafirlukast Accolate
SingulairZyflo CR
Lipotropics, OtherLength of Authorization: 1 Year Status Implementation: 5/1/2007
Current Review Date: 1/22/2018No PA Required PA RequiredBile Acid Resins Bile Acid Resinscholestyramine light colestipol granules/packetcolestipol tablet Colestid tablet/granules/packetPrevalite Questran
Welchol
Cholesterol Absorption Inhibitors Cholesterol Absorption InhibitorsZetia ezetimibe
Fibric Acid Derivatives Fibric Acid Derivatives
fenofibrate (Antara,Lipofen,Lofibra)
gemfibrozil fenobibric acid (generic Fibricor,Trilipix)AntaraFenoglideFibricorLofibraLipofenLopidTricor
Return to Index TrilipixTriglide
PCSK9 Inhibitors PCSK9 InhibitorsPraluent pen/syringe (manual PA req'd)
Repatha(manual PA req'd)
fenofibrate tablet 48 and 145mg (generic Tricor)
Page 26
Lipotropics, Other - ContinuedLength of Authorization: 1 Year Status Implementation: 5/1/2007
Current Review Date: 1/22/2018Niacins Niacinsniacin/ER OTC niacin ERNiaspan Niacor
Omega-3 Fatty Acids Omega-3 Fatty Acidsn/a omega-3 acid ethyl esters
LovazaVascepa
Antihyperlipidemic APOB-100 Synthesis Inhibitor
Antihyperlipidemic APOB-100 Synthesis InhibitorKynamro
MTP Inhibitor MTP InhibitorJuxtapid
Lipotropics, StatinsLength of Authorization: 1 Year Status Implementation: 1/15/2007
Current Review Date: 1/22/2018No PA Required PA RequiredStatins Statinsatorvastatin fluvastatin/ERlovastatin Altoprevpravastatin Crestorrousuvastatin Lescol/XLsimvastatin Lipitor (failure on Crestor)
LivaloPravacholZocorZypitamagNR
Statin Combinations Statin Combinationsamlodipine-atorvastatin ezetimibe-simvastatinNR
CaduetVytorin
Macrolides/KetolidesLength of Authorization: 1 Year Status Implementation: 7/1/2007
Current Review Date: 7/5/2017No PA Required PA RequiredMacrolides/Ketolides Macrolides/Ketolidesazithromycin suspension, tablet erythrocinclarithromycin ER azithromycin packetclarithromycin suspension, tablet erythromycin base tabletE.E.S. 200 suspension erythromycin ethylsuccinate 200 susp
E.E.S. 400 tabletEryped 200 suspensionEryped 400 suspensionEry-tabPCEZithromaxZmax
Return to Index
Page 27
MethotrexateLength of Authorization: 1 Year Status Implementation: 9/2/2015
Current Review Date: 7/5/2017No PA Required PA RequiredMethotrexate Methotrexatemethotrexate PF vial Otrexup Auto Injectormethotrexate tablet Rasuvo Auto Injectormethotrexate vial Trexall Tablet
Xatmep
Multiple SclerosisLength of Authorization: 1 Year Status Implementation: 5/15/2008
Current Review Date: 5/30/2018No PA Required PA RequiredMultiple Sclerosis Multiple SclerosisAvonex glatiramer 20 mg/mlAvonex pen glatiramer 40 mg/mlBetaseron kit AmpyraCopaxone 20mg/ml syringe kit AubagioGilenya Copaxone 40mg/mlRebif Extavia kitRebif Rebidose Pen Extavia vial
GlatopaLemtrada OcrevusPlegridy TecfideraZinbryta
Length of Authorization: 1 Year Status Implementation: 7/1/2007Current Review Date: 5/1/2017
No PA Required PA RequiredNarcotic Analgesics, Long-Acting
fentanyl transdermal 12,25,20,75,100mg buprenorphine transdermal
methadone tab fentanyl transdermal 37.5,62.5,87.5mgmorphine ER tab hydromorphone ERButrans methadone conc/sol tab/solutionEmbeda morphine ER cap
morphine ER (Avinza)oxycodone HCL ERoxymorphone ER tramadol ER/SR 24HArymo ERBelbucaConzip ER DuragesicExalgoHysingla ERKadianMorphabond ERNR
MS ContinNucynta EROpana EROxyContinXtampza ERZohydro ER
Return to Index
Narcotic Analgesics, Long-Acting
Clinical Criteria Applies to this Class/Requires Manual Prior Authorization
Narcotic Analgesics, Long-Acting
Page 28
Length of Authorization: 1 Year Status Implementation: 10/15/2009Current Review Date: 5/1/2017
No PA RequiredFentanyl Oral Products
fentanyl (buccal)Abstral
ActiqFentoraOnsolisUltracetUltram
OtherAPAP/codeine elixir butalbital cmpd w/codeine HycetAPAP/codeine tablet butorphanol tartrate (nasal) Ibudonehydrocodone/APAP tablet codeine oral Lazandahydrocodone/ibuprofen dihydrocodeine/ASA/caffeine Norcohydromorphone tablet fentanyl (buccal) Nucyntamorphine concentrate solution hydrocodone/APAP solution Opanamorphine IR tablet levorphanol Percocetmorphine solution meperidine solution/tablet Primlevoxycodone/APAP tablet morphine suppositories Primalevoxycodone tablet oxycodone/ASA Roxicodonetramadol oxycodone/ibuprofen Subsys
oxycodone capsule Synalogs-DCoxycodone conc Tylenol-Codeine
oxycodone solution Vicoprofenoxymorphone Xartemis XR
panlorNR Xodolpentazocine/naloxone Xolox
reprexain Zamicettramadol/APAP
Capital w/codeineDemerol
Dilaudid liquid/tablets
Return to Index
PA RequiredFentanyl Oral Products
Other
Narcotic Analgesics, Short Acting
Page 29
Neuropathic PainLength of Authorization: 1 Year Status Implementation: 1/17/2013
Current Review Date: 1/22/2018No PA Required PA RequiredOral Oralduloxetine (generic Cymbalta) duloxetine (generic Irenka)gabapentin capsule/solution gabapentin tablet
CymbaltaGraliseHorizant/ER**Lyrica**Lyrica CR**NR
NeurontinSavella*
Topical Topicalcapsaicin dermacinrx phn pakNR
lidocaine patchLidoderm***Qutenza Kit***
* Diagnosis of Fibromyalgia in the past year and a claim for a preferred agent ** Diagnosis of Epilepsy or Convulsions in the past year and a claim for a preferred agent OR Diagnosis of Fibromyalgia in the past year and a claim for Lyrica or Savella in the past 60 days OR Diagnosis of Diabetic Peripheral Neuropathy or Post Herpetic Neuralgia
***Step edit failure on one oral NSAID
Return to Index
Page 30
NSAIDS and Combination ProductsLength of Authorization: 1 Year Status Implementation: 10/15/2007
Current Review Date: 1/22/2018No PA RequiredNSAIDS and Combo Productsdiclofenac sodium celecoxib*** Celebrex***flurbiprofen diclofenac potassium Dayproibuprofen susp/tablet diclofenac sodium gel Dermacinrx Lexitralindomethacin capsule diclofenac SR Duexisketorolac (oral) diclotral Feldenemeloxicam tablet diflunisal **Flectornaproxen tablet etodolac Indocin supp/suspensionpiroxicam fenoprofen Mobicsulindac indomenthacin capsule ER NalfonVoltaren (topical)* ketoprofen/ER Naprelan
meclofenamate Naprosyn tab/EC/suspensionmefenamic acid **Pennsaid
meloxicam suspension **Pennsaid solution packetNR
nabumetone Ponstelnaproxen EC Sprix
naproxen sodium Tivorbex naproxen suspension Vimovo
oxaprozin Vivlodextolmetin sodium caps/tabs Vopac MDS (topical)
Arthrotec Xrylix kitZipsor
Zorvolex
* Failure of an oral NSAID ** Failure of Voltaren gel
*** Claim for a preferred agent in the past 90 days and a claim for an anticoagulant in the past 30 days or a diagnosis of a gastrointestinal hemorrhage in the past year.
Ophthalmics
Length of Authorization: 1 Year Status Implementation: 10/15/2007Current Review Date: 10/24/2017
No PA Required PA RequiredAllergic Conjunctivitis Allergic Conjunctivitiscromolyn sodium azelastine ophth 0.05%Pazeo epinastine
ketotifenolopatadineAlawayAlocrilAlomideAlrex BepreveElestatEmadineLastacaftPatadayPatanolZaditor
Return to Index
NSAIDS and Combo ProductsPA Required
Page 31
Ophthalmics - Continued
Length of Authorization: 1 Year Status Implementation: 10/15/2007Current Review Date: 10/24/2017
No PA Required PA RequiredAntibiotics Antibioticsbacitracin/polymixin ointment Azasiteciprofloxacin solution bacitracin ointmenterythromycin ophth gatifloxacingentamicin drops/ointment levofloxacin dropspolymixin/trimethoprim moxifloxacin HCL-BSSsulfacetamide solution neomycin/bacitracin/polymixin ointtobramycin ophth neomycin-polymixin-gramicidinMoxeza ofloxacinOcuflox sulfacetamide ointmentTobrex ointment BesivanceVigamox Bleph-10
Ciloxan Solution, OintmentNatacynPolytrmTobrex dropsZymaxid
No PA Required PA RequiredGlaucoma GlaucomaAlpha-2 Adrenergic Agonists Alpha-2 Adrenergic Agonistsbrimonidine 0.2% apradondineAlphagan P brimonidine 0.15%
lopidineBeta Blockers Beta Blockerstimolol/XE betaxololCombigan betimol
carteolollevobunololtimolol maleateNR
AkbetaBetaganBetopic SIstalolOcupressRhopressaNR
Timoptic/XE
Carbonic Anhydrase Inhibitors Carbonic Anhydrase Inhibitorsdorzolamide Cosoptdorzolamide/timolol Cosopt PF Azopt TrusoptSimbrinzaProstaglandin Agonists Prostaglandin Agonistslatanoprost bimatoprostTravatan/Z travoprost
LumiganVyzultaNR
XalatanZioptan
Return to Index
Page 32
Ophthalmics, Antibiotic-Steroid CombinationsLength of Authorization: 1 Year Status Implementation: 1/22/2018
Current Review Date: 1/22/2018No PA Required PA RequiredAntibiotic-Steroid Combinations Antibiotics-Steroid Combinationsneomycin/polymyxin/desamethasone neomycin/bacitracin/poly/HCTobradex suspension neomycin/polymyxin/HC
sulfacetamide/prednisolonetobramycin/dexamethasone suspensionBlephamideBlephamide S.O.P.Maxitrol drops suspensionMaxitrol ointmentPred-G drops suspensionPred-G ointmentTobradex ointmentTobradex STZylet
Length of Authorization: 1 Year Status Implementation: 5/15/2008Current Review Date: 10/24/2017
No PA Required PA RequiredOphthalmic Anti-Inflammatory Ophthalmic Anti-Inflammatorydiclofenac sodium bromfenacfluorometholone dexamethasoneflurbiprofen sodium ketorolac ophth 0.4 (LS)ketorolac ophth 0.5 prednisolone sod phosphateprednisolone acetate Acular/LSDurezol AcuvailIlevro BromsiteNR
Lotemax drops FlarexMaxidex FMLNevanac FML FortePred Mild FML SOP
IluvienLotemax gel/ointmentOmnipredOzurdexPred ForteProlensa
Ophthalmic Anti-Inflammatories
Page 33
Return to Index
Length of Authorization: 1 Year Status Implementation: 1/22/2018Current Review Date: 1/22/2018
Ophthalmic Anti-Inflammatory/Immunomodulators
Ophthalmic Anti-Inflammatory/Immunomodulators
No PA Required PA RequiredRestasis XiidraRestasis multidose
Opiate Dependence TreatmentLength of Authorization: 1 Year Status Implementation: 9/2/2015
Current Review Date: 7/5/2017No PA Required PA Required
Buprenorphine and Related Agents Buprenorphine and Related Agentsbuprenorphine HCL buprenorphine/naloxone tabSuboxone Film Bunavail
ProbuphineZubsolv
No PA Required PA RequiredOpiate Dependence, Other Opiate Dependence, Othernaltrexone HCL SublocadeNR
Naloxone Syringe VivitrolNarcan SprayNarcan Spray
Otic Antibiotics Status Implementation: 10/15/2007Length of Authorization: 1 Year Current Review Date: 10/24/2017No PA Required PA RequiredOtic Antibiotics Otic Antibioticsciprofloxacin otic ofloxacinneomycin/polymixin/HC soln/susp floxin 0.3%Ciprodex Cipro HC
Coly-mycin SOtioprioOtovel
Pancreatic EnzymesLength of Authorization: 1 Year Status Imlementation: 5/11/2012
Current Review Date: 5/30/2018No PA Required PA RequiredPancreatic Enzymes Pancreatic EnzymesCreon PancreazeZenpep Pertzye
Viokace
Return to Index
Ophthalmic Anti-Inflammatories/Immunomodulators
Page 34
Phosphate BindersLength of Authorization: 1 Year Status Implementation: 10/15/2007
Current Review Date: 10/24/2017No PA Required PA RequiredPhosphate Binders Phosphate Binderscalcium acetate capsule/tablet lanthanum carbonateRenagel sevelamer carbonateRenvela tablets Auryxia
EliphosFosrenol powder packFosrenol tablet chewablePhoslyra Renvela powder packsevelamer carbonate powder packVelphoro
Platelet InhibitorsLength of Authorization: 1 Year Status Implementation: 1/5/2009
Current Review Date: 1/22/2018No PA Required PA RequiredPlatelet Inhibitors Platelet Inhibitorsclopidrogel aspirin-dipyridamoledipyridamole prasugrelticlopidine AggrenoxBrilinta Effient
PlavixYospralaZontivity
Progestins for CachexiaLength of Authorization: 1 Year Status Implementation: 1/22/2018
Current Review Date: 1/22/2018No PA Required PA RequiredProgestins for Cachexia Progestins for Cachexiamegestrol suspension Megace ESmegestrol tablets megestrol suspension (Megace ES)
Proton Pump InhibitorsLength of Authorization: 1 Year Status Implementation: 5/1/2007
Current Review Date: 5/30/2018No PA Required PA RequiredProton Pump Inhibitors Proton Pump Inhibitorsomeprazole esomeprazole magnesiumpantoprazole esomeprazole strontium
lansoprazole capsulesNexium suspension rabeprazole sodium tabletProtonix suspension Aciphex tablet/sprinkle
DexilantEsomep-EZSNR
Nexium capsulesPrevacid capsules/solutabsPrilosec suspension
Page 35
PrilosecReturn to Index Protonix
Zegerid
Length of Authorization: 1 Year Status Implementation: 1/5/2009Current Review Date: 1/22/2018
No PA Required PA RequiredPulmonary Arterial Hypertension Agents
Pulmonary Arterial Hypertension Agents
sildenafil AdcircaLetairis Adempas
OpsumitOrentram ERRevatioTracleerTyvasoUptraviVentavis
Clinical PA over 21 years of age. Specific PA form is on the EOHHS website.
Clinical PA over 21 years of age. Specific PA form is on the EOHHS website. If the recipient is under 21 years of age a claim for a preferred agent is required.
Rosacea Agents, Topical
Length of Authorization: 1 Year Status Implementation: 01/02/2018Current Review Date: 01/02/2018
No PA Required PA RequiredFinacea metronidazole creamMetrocream metronidazole gel (AG)Metrogel metronidazole gel
metronidazole lotionFinacea foamMetrolotionMirvasoNoritateRhofadeRosadan kitSoolantra
Sedative HypnoticsLength of Authorization: 1 Year Status Implementation: 7/1/2007
Current Review Date: 7/5/2017No PA Required PA RequiredSedative Hypnotics Sedative Hypnoticstemazepam 15 & 30 mg eszopiclonezolpidem estazolam
flurazepamtemazepam 7.5 & 22.5 mgzaleplonzolpidem ERzolpidem SLAmbien/CRBelsomraDoralEdluarHalcionHetloizIntermezzo LunestaRestorilRozerem
Pulmonary Arterial Hypertension Agents
**triazolam - no longer covered by RI Medicaid
Page 36
SilenorSonata
Return to Index Zolpimist
Skeletal Muscle RelaxantsLength of Authorization: 1 Year Status Implementation: 7/6/2009
Current Review Date: 7/5/2017No PA Required PA RequiredSkeletal Muscle Relaxants Skeletal Muscle Relaxantsbaclofen dantrolenechlorzoxazone metaxallNR
cyclobenzaprine metaxalonemethocarbamol orphenadrine citrate ER
tizanidine cap/tabAmrixDantriumFexmidLorzone RobaxinSkelaxinZanaflex**carisoprodol and Soma - no longer covered by RI Medicaid
SteroidsLength of Authorization: 1 Year Status Implementation: 5/31/2013
Current Review Date: 5/30/2018No PA Required PA RequiredTopical High Topical Highbetamethasone dipropionate cream/lotion amcinonide cream, lotion, ointmentbetamethasone valerate cream, ointment
betamethasone dipropionate gel, ointment
fluocinonide cream 0.05%betamethasone dipropionate/prop gly cream, lotion, ointment
triamcinolone acetonide cream, lotion, ointment betamethasone valerate lotion
dermazone
desoximetasone cream, gel, ointment
diflorasone diacetate cream, ointmentfluocinonide emollient, gel, ointment, solutiontriamcinolone/dimethiconeDermacinrx SilazoneDermasorb TADiprolene AFDiprolene lotion, ointmentEllzia PakHalog cream, ointmentKenalog aerosolPsorconSanaderm RxSemivo spraySilazone-IITopicort cream, ointment, sprayTrianexVanos
Return to Index
Page 37
Steroids - ContinuedLength of Authorization: 1 Year Status Implementation: 5/31/2013
Current Review Date: 5/30/2018
No PA Required PA RequiredTopical Low Topical Lowalclometasone dipropionate ointment alclometasone diproponate creamhydrocortisone cream 1% rx desonide creamhydrocortisone lotion 1% rx desonide lotionhydrocortisone ointment 1% rx desonide ointment
fluocinolone 0.01% oilhydrocortisone acetate/urea 1%hydrocortisone/aloe gel 1%hydrocortisone/min oil/pet oint 1%micort-HC 2.5% creamNR
tridesilonAqua-Glycolic HCCapex ShampooDermasorb HCDerma-Smoothe-FSDesonate gelTexacortVerdeso
Return to Index
Page 38
Steroids - ContinuedLength of Authorization: 1 Year Status Implementation: 5/31/2013
Current Review Date: 5/30/2018No PA Required PA RequiredTopical Medium Topical Medium
betamethasone valerate foamfluticasone propionate cream clocortolonefluticasone propionate ointment fluocinolone acetonide creammometasone furoate cream fluocinolone acetonide ointmentmometasone furoate ointment fluocinolone acetonide solutionmometasone furoate solution fluticasone propionate lotion
hydrocortisone valerate creamhydrocortisone valerate ointmenthydrocortisone butyrate cream, emollient,lotion, ointment, solutionClodermCordran tape/ointmentCutivate lotion/creamDermatop cream, ointmentElocon cream, ointment, solutionLuxiq foamPandelPrednicarbate creamPrednicarbate ointment
Synalar cream & ointment kit, solutionSynalar TS kit
No PA Required PA RequiredTopical Very High Topical Very Highclobetasol propionate cream,gel clobetasol emollientclobetasol propionate ointment clobetasol lotionclobetasol solution clobetasol shampoohalobetasol propionate cream clobetasol propionate foamhalobetasol propionate ointment clobetasol propionate sprayhalobetasol propionate ointment Apexicon E
Clobex lotion, shampoo, sprayClodan/kitOluxOlux ETemovate ointmentUltravate ointment, lotionUltravate X PAC cream, ointment
Return to Index
Page 39
Length of Authorization: 1 Year Status Implementation: 1/15/2008Current Review Date: 10/24/2017
No PA Required PA RequiredStimulants and Related Agents
amphetamine salt combo amphetamine salt combo ERatomoxetine armodafinildextroamphetamine tab/cap ER clonidine ERguanfacine ER dexmethylphenidatemethylphenidate IR dexmethylphenidate XRAdderall XR dextroamphetamine solutionAptensio XR methamphetamine
Concerta methylphenidate CD
Daytranamethylphenide ER cap (generic Ritalin LA)
Focalin methylphenidate ER 18,27,36,54 mg
Focalin XRmethylphenidate ER 18,27,36,54 mg (AG)
Kapvay methylphenidate ER tabletProcentra methylphenidate solution/chewableProvigil modafanil Quillichew ER Adzenys XR ODT/suspensionQuillivant XR Cotempla XR ODTRitalin LA DesoxynVyvanse capsule Dexedrine
Dyanavel XREvekeoIntunivMetadate ERMethylin solutionMydayisNuvigilRitalinStratteraVyvanse chewableZenzedi
* If the recipient is over 21 years of age a diagnosis of ADD, ADHD, Narcolepsy or Depression in the past year or evidence of stimulant treatment greater than 210 days or 7 stimulant claims in the past year is required for the clinical PA for a preferred agent. If the recipient is under 21 years of age the claim will process with no PA required.
* If the recipient is over 21 years of age a claim for a preferred agent AND a diagnosis of ADD, ADHD, Narcolepsy or Depression in the past year or evidence of stimulant treatment greater than 210 days or 7 stimulant claims in the past year is required for the clinical PA for a preferred agent. If the recipient is under 21 years of age a claim for a preferred agent is required.
Return to Index
Stimulants and Related Agents
Stimulants and Related Agents*
Page 40
Topical AcneLength of Authorization: 1 Year Status Implementation: 5/15/2008
Current Review Date: 5/30/2018No PA RequiredMiscellaneous Topicalsclindamycin/benzoyl peroxide (generic Duac) Acne clearing system erythromycin med swabclindamycin/benzoyl peroxide w/pump (general Benzaclin Pump) Aczone erythromycin-benzoly peroxideclindamycin phosphate solution Aczone gel/w pump Evoclinerythromycin solution Avar Cleanser Fabior
Avar LS KlaronAvar-E Neuac
Avar-E LS OnextonAzelex Ovace/Ovace Plus
Benzaclin RosulaBenzaclin w/pump Seb-Prev
Benzamycin SSS 10-5benzoyl peroxide foam sodium sulfacetamide/sulfur
BP-10-1 sulfacetamide cleanserBP Cleasning Wash sulfacetamide/sulfur cleanser
Cleocin-T gel/lotion/med swab/solution sulfacetamide/sulfur med padCleocin-T lotion sulfacetamide/sulfur suspension
Cleocin-T med swab sulfacetamide/sulfur/ureaCleocin-T solution Sumadan kit, wash, cleanser
Clindacin ETZ Sumadan cleansing padsClindacin P Sumaxin CP kit
Clindacin Pac Kit Sumaxin med padbenzoyl peroxide gel Sumaxin TS
clindamycin phosphate gel, foam, lotion tazoratene 0.1% creamNR
clindamycin phosphate med swabDuac
erythromycin gel
Retinoids and Combinations Retinoids and CombinationsDifferin lotion adapaleneRetin-A cream adapalene-benzoyl peroxideTazorac cream clindamycin phos-tretinoin
tretinoin (Atralin)tretinoin (generic Retin-A)tretinoin microspheresAcanyaAtralinAvitaDifferin cream, gel, pumpEpiduoEpiduo ForteRetin-A gelRetin-A Micro
Return to Index Retin-A Micro PumpTazorac gelZiana
PA RequiredMiscellaneous Topicals
Page 41
Topical AntiviralsLength of Authorization: 1 Year Status Implementation: 10/15/2008
Current Review Date: 5/1/2017No PA Required PA RequiredTopical Antivirals Topical AntiviralsZovirax cream acyclovir ointment
DenavirXereseZovirax ointment
Topical AntipsoriaticsLength of Authorization: 1 Year Status Implementation: 5/4/2009
Current Review Date: 5/30/2018No PA Required PA RequiredTopical Antipsoriatics Topical Antipsoriaticscalcipotriene solution calcipotriene/betamethasone ointcalcipotriene cream calcitriol ointmentcalcipotriene ointment Calcitrene
Dovonex creamEnstilar foamSoriluxTaclonex ointmentTaclonex scalpVectical
Ulcerative ColitisLength of Authorization: 1 Year Status Implmentation: 7/1/2008
Current Review Date: 7/5/2017No PA Required PA RequiredOral Oralsulfazine balsalazidesulfasalazine/DR mesalamineApriso Asacol HDDelzicol Azulfidine
ColazalDipentumGiazoLialdaPentasaUceris ERUceris rectal foam
Topical Topicalmesalamine enema mesalamine kitCanasa suppository Rowasa
SF RowasaReturn to Index
NR indicates that a product has not been reviewed by the P & T Committee, but EOHHS policy states that new products