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DIVISION OF MEDICAID AND LONG-TERM CARE
PHARMACEUTICAL AND THERAPEUTICS COMMITTEE MEETING MINUTES
May 13, 2015 at 9 a.m., CST Mahoney State Park, Peter Kiewit Lodge Claire Baker, M.D. Jenny Minchow, Pharm.D. Stacie Bleicher, M.D. Abigail Anderson, M.C.R.P. Kristie Bohac, M.D. Shelly Nickerson, Pharm.D. Chris Caudill, M.D. Yvonne Davenport, M.D. Magellan Rx Management Allison Dering-Anderson, Pharm.D. James Dubé, Pharm.D. Julie Pritchard, Pharm. D., M.B.A Gary Elsasser, Pharm.D. Sabrina Hellbusch, R.N., B.S.N Jeffrey Gotschall, M.D. Nancy Haberstich, R.N., M.S. Mary Hammond, Pharm.D. Nathan Green D.O. Laurie Humphries, M.D. Kevin Reichmuth M.D. Eileen Rock, M.D. Joyce Juracek Pharm.D. Ken Saunders, Pharm.D. Christopher Sorensen, Pharm.D. Linda Sobeski, Pharm. D. Eric Thomsen, M.D. Call to Order: Chairperson, Jeff Gotschall, called the meeting to order at 9:00am. The agenda was posted on the Nebraska Medicaid Pharmacy MMA website on April 9, 2015. A copy of the Open Meetings Act was posted at the back of the meeting room and materials distributed to members were on display. Introduction of Magellan Rx Management staff: Julie Pritchard, Pharm. D., M.B.A Roll Call: see list above Conflict of Interest: No new conflicts of interest were reported. Approval of November 2014 Minutes: The November 12, 2014 meeting minutes were unanimously approved. Department information: Governor Pete Ricketts has appointed Courtney Phillips as the new Chief Execute Officer of the Nebraska Department of Health and Human Services. Calder Lynch assumes the position of Director, Division of Medicaid and Long-Term Care. Shelly Nickerson, Pharm.D has been appointed as the new Pharmacy Unit Manager for the Division of Medicaid and Long-Term Care. Other: There are two openings on the DHHS Pharmaceutical and Therapeutics Committee as Nathan Green, M.D. and Kevin Reichmuth, M.D. have submitted their resignations. Officer election will take place at the November 2015 meeting. Public Testimony Classes with changes
DRUG CLASS
Drug Name
Speaker Name
Affiliation
Jennifer Stoffel Hepatitis C Agents Gilead Sciences, Inc. DRUG CLASS
Drug Name
Speaker Name
Affiliation
Hepatitis C Agents Gilead Sciences, Inc. Hypoglycemics, Incretin Memetics/Enhancers Hypoglycemics, SGLT2 Hypoglycemics, SGLT2 Hypoglycemics, SGLT2 Multiple Sclerosis Agents Multiple Sclerosis Agents Multiple Sclerosis Agents Teva Pharmaceuticals IX. A motion to move into closed session was made by Baker and seconded. Moved into closed session at 9:59am. Roll call vote was taken and the motion passed:
Votes as follows: Baker-yes, Bleicher-yes, Bohac-yes, Caudill-yes, Davenport-yes, Dering-Anderson-
yes, Dubé-yes, Elsasser-yes, Haberstitch-yes, Hammond-yes, Humphries-yes, Rock-yes, Saunders-
yes, Sobeski-yes, Sorensen-yes, Thomsen-yes.
Motion Carried.
Chairperson, Jeff Gotschal restated the reason for closed session, which is (a): "Strategy session with respect to collective bargaining". Cost issues discussed in Closed Session. X. A motion was made by Dering-Andersen, seconded, and unanimously passed to move back into open session at 11:15. XI. Consent Agenda (Therapeutic Categories with Unchanged Recommendations):
ANTIBIOTICS, GASTROINTESTINAL Note: Although azithromycin, ciprofloxacin, and
trimethoprim/sulfamethoxazole are not included in this review, they are available without prior authorization.
PREFERRED DRUGS
NON-PREFERRED DRUGS
PDL EXCEPTION CRITERIA:
metronidazole TABLETS
ALINIA (nitazoxanide) DIFICID (fidaxomicin) If giardiasis; require treatment failure vancomycin compounded oral FLAGYL ER (metronidazole)
with metronidazole or tindazole. metronidazole CAPSULES
If cryptosporidium: no treatment failure tinidazole (generic for Tindamax) required with other agent. vancomycin capsules (generic for XIFAXAN (rifaximin)* For diagnosis of Clostridium difficile 2 BRAND PRODUCTS IN UPPER CASE generic names in lower case. If only the generic name is listed as preferred, then the
BRAND name of that product is non-preferred; unless the brand name product is ALSO listed as preferred. *Indicates that a clinical prior authorization is required despite the medication's status as preferred or non-preferred. QL indicates quantity limits. NR indicates product was not reviewed. New Drug criteria will apply. diarrhea; require contraindication to or
treatment failure with oral vancomycin
or metronidazole.
FLAGYL ER:
Requires trial on metronidazole or
tindazole.
tindazole:
For treatment of Giardia, amebiasis
intestinal or liver abscess, bacterial
vaginosis or trichomoniasis:
 Treatment failure with or Contraindication to metronidazole. VANCOCIN: May bypass metronidazole if initial episode of SEVERE c. difficile colitis or recurrence. Severe defined as: 1. Leukocytosis w/WBC ≥15,000 cells/microliter 2. Serum creatinine ≥1.5 x premorbid level XIFAXAN: 1. Diagnosis of Travelers Diarrhea resistant to quinolone. 2. Hepatic encephalopathy with treatment failure of lactulose or neomycin. ANTIBIOTICS, TOPICAL
PREFERRED DRUGS
NON-PREFERRED DRUGS
PDL EXCEPTION CRITERIA:
bacitracin ointment ALTABAX (retapamulin) Non-preferred agents will be approved bacitracin/polymyxin (generic for CENTANY (mupirocin ointment) only after documented failure of the gentamicin OINTMENT, CREAM
preferred agents. mupirocin OINTMENT (generic for mupirocin CREAM (generic for
Mupirocin CREAM: Requires clinical reason the mupirocin (generic for Neosporin, Triple ointment cannot be used. ALTABAX® (retapamulin):  Diagnosis impetigo due to Staphylococcus aureus (methicillin-susceptible isolates only) or Streptococcus pyogenes in adults 3 BRAND PRODUCTS IN UPPER CASE generic names in lower case. If only the generic name is listed as preferred, then the
BRAND name of that product is non-preferred; unless the brand name product is ALSO listed as preferred. *Indicates that a clinical prior authorization is required despite the medication's status as preferred or non-preferred. QL indicates quantity limits. NR indicates product was not reviewed. New Drug criteria will apply. and children ≥ 9 months of age  Clinical reason that topical mupirocin ointment (generic Bactroban®) cannot be used.  ALTABAX® is not approved for MRSA and has not been proven any more
effective than Bactroban®.
ANTIVIRALS, TOPICAL
PREFERRED DRUGS
NON-PREFERRED DRUGS
PDL EXCEPTION CRITERIA:
acyclovir OINTMENT (generic for 1. Adverse reaction to, allergy, or contraindication to preferred oral DENAVIR (penciclovir) antiherpetic agent. XERESE (acyclovir/hydrocortisone) ZOVIRAX Cream (acyclovir) 2. Documentation of treatment failure with a preferred oral antiherpetic drug. BLADDER RELAXANT PREPARATIONS
PREFERRED DRUGS
NON-PREFERRED DRUGS
PDL EXCEPTION CRITERIA:
oxybutynin (generic for Ditropan) ENABLEX (darifenacin) The non-preferred agent will be oxybutynin ER (generic for GELNIQUE (oxybutynin) approved only after documented MYRBETRIQ (mirabegron) failure of a preferred agent. TOVIAZ (fesoterodine ER) OXYTROL (oxybutynin) VESICARE (solifenacin) tolterodine (generic for Detrol) tolterodine ER (generic for Detrol LA) Allow when anticholinergic agent is trospium (generic for Sanctura) contraindicated. trospium ER (generic for Sanctura BONE RESORPTION SUPPRESSION AND RELATED DRUGS
PREFERRED DRUGS
NON-PREFERRED DRUGS
PDL EXCEPTION CRITERIA:
alendronate (generic for Fosamax) ATELVIA DR (risedronate) 1. Adverse reaction to, allergy, or (daily and weekly formulations) BINOSTO (alendronate effervescent) contraindication to preferred drugs, etidronate disodium (generic for 2. Documentation of treatment failure FOSAMAX Oral Solution with preferred drug. ibandronate (generic for Boniva) Clinical reason can't take alendronate risedronate (generic for Actonel) on empty stomach. Note: products with calcium or vitamin D will be prescribed separately. OTHER BONE RESORPTION SUPPRESSION AND RELATED DRUGS
4 BRAND PRODUCTS IN UPPER CASE generic names in lower case. If only the generic name is listed as preferred, then the
BRAND name of that product is non-preferred; unless the brand name product is ALSO listed as preferred. *Indicates that a clinical prior authorization is required despite the medication's status as preferred or non-preferred. QL indicates quantity limits. NR indicates product was not reviewed. New Drug criteria will apply. EVISTA (raloxifene) calcitonin-salmon nasal 1. Adverse reaction to, allergy or FORTICAL (calcitonin) nasal FORTEO (teriparatide) contraindication to preferred drugs. MIACALCIN (calcitonin) nasal 2. Documentation of treatment failure raloxifene (generic for Evista) with preferred drug. Forteo® (teriparatide) Criteria:
May approve if the client is unable to use preferred products (i.e. intolerance,
contraindication, allergy, and previous trial/failure) OR the client is at high risk
of fracture as defined below.
Patients at high risk of fracture include:  Bone mineral density of -3 or worse  Postmenopausal women with history of non-traumatic fracture(s)  Postmenopausal women with two or more of the following clinical risk 1. Family history of non-traumatic fracture(s) 2. Patient history of non-traumatic fracture(s) 3. DXA BMD T-score ≤-2.5 at any site 4. Glucocorticoid use* (≥6 months of use at 7.5 mg dose of prednisolone equivalent) 5. Rheumatoid Arthritis  Postmenopausal women with BMD T-score ≤-2.5 at any site with any of the following clinical risk factors: 1. More than 2 units of alcohol per day 2. Current smoker  Men w/primary or hypogonadal osteoporosis  Osteoporosis associated w/sustained systemic glucocorticoid therapy* Initial approval will be for 1 year with ONE renewal if demonstrated compliance. Maximum duration of therapy is 24 months during a patient's lifetime. Approval does not require trial and failure on calcitonin nasal. Quantity limit of 2.4ml per claim for a 30 day supply. Combination therapy with bisphosphonates (Actonel®, Boniva®, Didronel®, Fosamax®, alendronate) is not recommended and will NOT be approved. Not approved for pediatric patients or young adults with open epiphyses. Injection must be administered by patient or caregivers. BPH - BENIGN PROSTATIC HYPERPLASIA TREATMENTS
PREFERRED DRUGS
NON-PREFERRED DRUGS
PDL EXCEPTION CRITERIA:
ALPHA BLOCKERS
alfuzosin (generic for Uroxatral) CARDURA XL (doxazosin) Treatment failure with one preferred doxazosin (generic for Cardura) JALYN (dutasteride/tamsulosin) tamsulosin (generic for Flomax) RAPAFLO (silodosin) terazosin (generic for Hytrin) UROXATRAL (alfuzosin) Must meet criteria for approval of Avodart and clinical reason can't take individual agents. 5 BRAND PRODUCTS IN UPPER CASE generic names in lower case. If only the generic name is listed as preferred, then the
BRAND name of that product is non-preferred; unless the brand name product is ALSO listed as preferred. *Indicates that a clinical prior authorization is required despite the medication's status as preferred or non-preferred. QL indicates quantity limits. NR indicates product was not reviewed. New Drug criteria will apply. 5-ALPHA-REDUCTASE (5AR) INHIBITORS
finasteride (generic for Proscar) AVODART (dutasteride) JALYN (dutasteride/tamsulosin)
CALCIUM CHANNEL BLOCKERS (Oral)
PREFERRED DRUGS
NON-PREFERRED DRUGS
PDL EXCEPTION CRITERIA:
nifedipine (generic for Procardia) isradipine (generic for Dynacirc) nicardipine (generic for Cardene) The non-preferred agent will be nimodipine (generic for Nimotop) approved only after documented NYMALIZE (nimodipine solution) failure of a preferred agent. diltiazem (generic for Cardizem) verapamil (generic for Calan, Requires the diagnosis of subarachnoid hemorrhage or cerebrovascular spasm. LONG-ACTING
Non-preferred agents will be approved amlodipine (generic for Norvasc) CARDENE SR (nicardipine) only after documented failure of a nifedipine ER (generic for Adalat felodipine ER (generic for Plendil) preferred agent. CC, Procardia XL) nisoldipine (generic for Sular) diltiazem ER (generic for Cardizem CALAN SR (verapamil) diltiazem LA (generic for Cardizem verapamil ER TABLET
verapamil ER PM (generic for MATZIM LA (diltiazem) TIAZAC (diltiazem)
verapamil ER CAPSULE
verapamil 360mg capsule
CEPHALOSPORINS (Oral) and RELATED ANTIBIOTICS
PREFERRED DRUGS
NON-PREFERRED DRUGS
PDL EXCEPTION CRITERIA:
BETA LACTAM/BETA-LACTAMASE INHIBITOR COMBINATIONS
amoxicillin/clavulanate TABLETS,
amoxicilline/claquante XR (generic for 1. Adverse reaction or contraindication CHEW TABLETS, SUSPENSION
to preferred drugs. AUGMENTIN 125MG/5ML
AUGMENTIN 250MG/5ML
SUSPENSION
2. Documentation of treatment failure AUGMENTIN (amoxicilline/claquante) with preferred drug. CEPHALOSPORINS – First Generation
cefadroxil CAPSULE,
cefadroxil TABLET (generic for
1. Adverse reaction or contraindication SUSPENSION (generic for Duricef)
to preferred drugs. cephalexin CAPSULE,
cephalexin TABLET
SUSPENSION (generic for Keflex)
2. Documentation of treatment failure with preferred drug. CEPHALOSPORINS – Second Generation
6 BRAND PRODUCTS IN UPPER CASE generic names in lower case. If only the generic name is listed as preferred, then the
BRAND name of that product is non-preferred; unless the brand name product is ALSO listed as preferred. *Indicates that a clinical prior authorization is required despite the medication's status as preferred or non-preferred. QL indicates quantity limits. NR indicates product was not reviewed. New Drug criteria will apply. cefprozil (oral) (generic for Cefzil) cefaclor (oral) (generic for Ceclor) 1. Adverse reaction or contraindication cefuroxime (oral tablet) (generic for CEFTIN (cefuroxime) tablets, to preferred drugs. 2. Documentation of treatment failure with preferred drug. CEPHALOSPORINS – Third Generation
cefdinir (oral) (generic for Omnicef) CEDAX (ceftibuten) 1. Adverse reaction or contraindication SUPRAX SUSPENSION, CAPSULE cefditoren (generic for Spectracef)
to preferred drugs. cefixime (generic for Suprax 2. Documentation of treatment failure cefpodoxime (oral) (generic for with preferred drug. SUPRAX CHEWABLE TABLET,
TABLET (cefixime)
COLONY STIMULATING FACTORS (Entire class requires prior authorization when administered outside
physician office or hospital)
PREFERRED DRUGS
NON-PREFERRED DRUGS
PDL EXCEPTION CRITERIA:
NEUPOGEN (filgrastim) VIAL*
NEUPOGEN (filgrastim) DISP SYR
Entire class requires place of service determination. Only approved for self administration or administration by care giver in home. (not approved thru Pharmacy program for administration in office, clinic or hospital)  Documented myelosuppressive chemotherapy, bone marrow transplant, peripheral blood progenitor cell collection, severe chronic neutropenia;  Documented ANC < 750 cells/microliter in patients with Hepatitis C who are being treated with Interferon.  Not covered for AIDS, hairy cell leukemia, myelodysplasia, drug-induced congenital agranulocytosis, alloimmune neonatalneutropenia. Initial authorization is granted for six months. ERYTHROPOIESIS STIMULATING PROTEINS (Entire class requires prior authorization when administered
outside physician office or hospital)
PREFERRED DRUGS
NON-PREFERRED DRUGS
PDL EXCEPTION CRITERIA:
EPOGEN (rHuEPO)* Entire class requires place of service PROCRIT (rHuEPO)* determination. Only approved for self administration or administration by 7 BRAND PRODUCTS IN UPPER CASE generic names in lower case. If only the generic name is listed as preferred, then the
BRAND name of that product is non-preferred; unless the brand name product is ALSO listed as preferred. *Indicates that a clinical prior authorization is required despite the medication's status as preferred or non-preferred. QL indicates quantity limits. NR indicates product was not reviewed. New Drug criteria will apply. care giver in home. (not approved thru Pharmacy program for administration in office, clinic or hospital) Length of authorization: varies  Anemia associated with chronic renal failure APPROVAL ONE YEAR  Anemia with chemotherapy, need length of chemo regimen auth 30 days longer  Anemia in HIV infected clients FLUOROQUINOLONES, ORAL
PREFERRED DRUGS
NON-PREFERRED DRUGS
PDL EXCEPTION CRITERIA:
ciprofloxacin (generic for Cipro) ciprofloxacin ER 1. Adverse reaction to, allergy, or levofloxacin TABLETS (generic for
ciprofloxacin suspension (generic for contraindication to preferred drugs, Cipro Suspension) levofloxacin oral solution 2. Documentation of treatment failure moxifloxacin (generic for Avelox) with preferred drug. Ofloxacin: May be approved drug without trial on preferred with diagnosis of: Pelvic Inflammatory Disease Or Acute Epididymitis not caused by gonorrhea. Non-preferred quinolone: May be approved upon inpatient hospital discharge to complete a course of antibiotic therapy initiated during inpatient care. GROWTH HORMONE
Entire class requires prior authorization based on clinical criteria.
PREFERRED DRUGS
NON-PREFERRED DRUGS
PDL EXCEPTION CRITERIA:
NORDITROPIN (somatropin) GENOTROPIN (somatropin) See clinical criteria. NUTROPIN AQ (somatropin) HUMATROPE (somatropin) SAIZEN (somatropin) OMNITROPE (somatropin) SEROSTIM (somatropin) TEV-TROPIN (somatropin) ZORBTIVE (somatropin) H.PYLORI TREATMENTS
PREFERRED DRUGS
NON-PREFERRED DRUGS
PDL EXCEPTION CRITERIA:
8 BRAND PRODUCTS IN UPPER CASE generic names in lower case. If only the generic name is listed as preferred, then the
BRAND name of that product is non-preferred; unless the brand name product is ALSO listed as preferred. *Indicates that a clinical prior authorization is required despite the medication's status as preferred or non-preferred. QL indicates quantity limits. NR indicates product was not reviewed. New Drug criteria will apply. PYLERA (bismuth, metronidazole, OMECLAMOX-PAK (omeprazole, 1. Adverse reaction to, allergy, or clarithromycin, amoxicillin) contraindication to preferred drugs. PREVPAC (lansoprazole, amoxicillin, lansoprazole/amoxicillin/clarithromycin (generic for Prevpac) 2. Documentation of treatment failure with preferred drug. HYPOGLYCEMICS, ALPHA-GLUCOSIDASE INHIBITORS
PREFERRED DRUGS
NON-PREFERRED DRUGS
PDL EXCEPTION CRITERIA:
acarbose (generic for Precose) Glyset (miglitol) HYPOGLYCEMICS, MEGLITINIDES
PREFERRED DRUGS
NON-PREFERRED DRUGS
PDL EXCEPTION CRITERIA:
nateglinide (generic for Starlix)  Compliance demonstrated with PRANDIMET (repaglinide/metformin) metformin trial and have not repaglinide (generic for Prandin) received adequate glycemic control with metformin;  Intolerance to metformin  HbA1C >7 HYPOGLYCEMICS, METFORMINS
PREFERRED DRUGS
NON-PREFERRED DRUGS
PDL EXCEPTION CRITERIA:
glipizide/metformin metformin ER (generic for Fortamet) Fortamet and GLUMETZA require glyburide/metformin (generic for GLUMETZA (metformin extended documentation of why generic for Glucophage XR not appropriate for metformin (generic for Glucophage) RIOMET (metformin oral solution) metformin ER (generic for RIOMET:  Liquid for ages < 6 years of age do not require a prior authorization.  The liquid formulation should only be approved for clients 6 years of age and older if medical necessity is documented. HYPOGLYCEMICS, TZDS
PREFERRED DRUGS
NON-PREFERRED DRUGS
PDL EXCEPTION CRITERIA:
THIAZOLIDINEDIONES (TZDs)
pioglitazone (generic for Actos) AVANDIA (rosiglitazone)  Compliance demonstrated with metformin trial and have not received adequate glycemic control with metformin;  Intolerance to metformin; TZD COMBINATIONS
 Combination agents will require (pioglitazone/metformin ER) clinical reason separate agents 9 BRAND PRODUCTS IN UPPER CASE generic names in lower case. If only the generic name is listed as preferred, then the
BRAND name of that product is non-preferred; unless the brand name product is ALSO listed as preferred. *Indicates that a clinical prior authorization is required despite the medication's status as preferred or non-preferred. QL indicates quantity limits. NR indicates product was not reviewed. New Drug criteria will apply. AVANDARYL (rosiglitazone/glipizide) pioglitazone/glimepiride (generic for pioglitazone/metformin generic for IRRITABLE BOWEL SYNDROME
PREFERRED DRUGS
NON-PREFERRED DRUGS
PDL EXCEPTION CRITERIA:
AMITIZA (lubiprostone) LOTRONEX (alosetron) LINZESS (linaclotide)  Diagnosis of irritable bowel syndrome, severe diarrhea-predominant. LIPOTROPICS, STATINS
PREFERRED DRUGS
NON-PREFERRED DRUGS
PDL EXCEPTION CRITERIA:
atorvastatin (generic for Lipitor) ALTOPREV (lovastatin) Non-preferred agents may be approved CRESTOR (rosuvastatin)* fluvastatin (generic for Lescol) if the patient has a history of two lovastatin (generic for Mevacor) LESCOL / XL (fluvastatin) preferred agents in the last 12 months. pravastatin (generic for Pravachol) LIVALO (pitavastatin) simvastatin (generic for Zocor) ALTOPREV AND LESCOL XL: Requires documentation of medical necessity of long acting form. STATIN COMBINATIONS
ADVICOR (lovastatin/niacin ER) VYTORIN and LIPTRUZET: atorvastatin/ amlodipine (generic for Will be approved for patients failing a minimum 3 month trial of standard dose LIPTRUZET (ezetimibe/atorvastatin) SIMCOR (simvastatin/niacin ER) VYTORIN (simvastatin/ezetimibe) PANCREATIC ENZYMES
PREFERRED DRUGS
NON-PREFERRED DRUGS
PDL EXCEPTION CRITERIA:
PANCREAZE (pancrelipase) 1. Adverse reaction to, allergy, or PANCRELIPASETM (pancrelipase) PERTYZE (pancrelipase) contraindication to preferred drugs. ZENPEP (pancrelipase) ULTRESA (pancrelipase) VIOKACE (pancrelipase) 2. Documentation of treatment failure with two preferred drugs. PROTON PUMP INHIBITORS (ORAL)
PREFERRED DRUGS
NON-PREFERRED DRUGS
PDL EXCEPTION CRITERIA:
omeprazole (generic for Prilosec) DEXILANT (dexlansoprazole) pantoprazole (generic for Protonix) esomeprazole strontium lansoprazole (generic for Prevacid) 10 BRAND PRODUCTS IN UPPER CASE generic names in lower case. If only the generic name is listed as preferred, then the
BRAND name of that product is non-preferred; unless the brand name product is ALSO listed as preferred. *Indicates that a clinical prior authorization is required despite the medication's status as preferred or non-preferred. QL indicates quantity limits. NR indicates product was not reviewed. New Drug criteria will apply. esomeprazole magnesium (generic NEXIUM SUSPENSION omeprazole/sodium bicarbonate (generic for Zegerid RX) PREVACID Rx, SOLU-TAB PRILOSEC (omeprazole) rabeprazole (generic for Aciphex) SKELETAL MUSCLE RELAXANTS
PREFERRED DRUGS
NON-PREFERRED DRUGS
PDL EXCEPTION CRITERIA:
baclofen (generic for Lioresal) AMRIX (cyclobenzaprine)* 1. The non-preferred agents will be chlorzoxazone (generic for Parafon) carisoprodol (generic for Soma) approved for patients with documented cyclobenzaprine (generic for Flexeril) carisoprodol compound failure of at least a one week trial each methocarbamol (generic for Robaxin) dantrolene (generic for Dantrium) of two preferred agents. tizanidine TABLETS (generic for
RZONE (chlorzoxazone)* 2. Concurrent use with opioids requires metaxalone (generic for Skelaxin) prior authorization orphenadrine (generic for Norflex) orphenadrine compound For carisoprodol: SOMA (carisoprodol)*  Use will be limited to no more than 30 tizanidine CAPSULES
ZANAFLEX (tizanidine) (brand name  Additional authorization will not be tablets and capsules) granted for at least six months following the last day of the previous course of therapy  Approval will not be granted for patients with a history of meprobamate use in the previous two years AMRIX: Clinical reason regular release cannot be used. Only for short term use. ZANAFLEX: Clinical reason generic cannot be used. PREFERRED DRUGS
NON-PREFERRED DRUGS
PDL EXCEPTION CRITERIA:
doxycycline hyclate IR (generic for Demeclocycline:* DORYX (doxycycline pelletized) Treatment of Syndrome of Inappropriate doxycycline monohydrate CAPSULES
doxycycline hyclate DR (generic for Antidiuretic Hormone (SIADH) 50mg, 100mg
minocycline HCl capsules (generic for
doxycycline monohydrate TABLET,
1. Adverse reaction to, allergy or Minocin, Dynacin) SUSPENSION, 75MG and
contraindication to preferred drugs, tetracycline HCl (generic for Sumycin) 150MG CAPSULES (Monodox,
2. Documentation of treatment failure 11 BRAND PRODUCTS IN UPPER CASE generic names in lower case. If only the generic name is listed as preferred, then the
BRAND name of that product is non-preferred; unless the brand name product is ALSO listed as preferred. *Indicates that a clinical prior authorization is required despite the medication's status as preferred or non-preferred. QL indicates quantity limits. NR indicates product was not reviewed. New Drug criteria will apply. doxycycline monohydrate (generic with two preferred drugs. minocycline HCl tablets (generic for
minocycline HCl extended release (generic for Solodyn) ORACEA (doxycycline monohydrate) SOLODYN (minocycline HCl) VIBRAMYCIN SUSPENSION

It was moved by Dubé and seconded to accept recommendations as published for the Therapeutic
Classes on the Consent Agenda. Roll Call vote was taken and the motion passed.
Votes as follows: Baker-yes, Bleicher-yes, Bohac-yes, Caudill-yes, Davenport-yes, Dering-Anderson-yes, Dubé-yes, Elsasser-yes, Haberstitch-yes, Hammond-yes, Humphries-yes, Rock-yes, Saunders-yes, Sobeski-yes, Sorensen-yes, Thomsen-yes. Motion Carried.
XII. Therapeutic Class Review: (Therapeutic Categories with New Recommendations)
ACNE AGENTS, TOPICAL
PREFERRED DRUGS
NON-PREFERRED DRUGS
PDL EXCEPTION CRITERIA:
AZELEX (azelaic acid) ACANYA (clindamycin and benzoyl Treatment failure with three preferred BENZACLIN W/PUMP (clindamycin/benzoyl peroxide) ACZONE (dapsone) benzoyl peroxide generic OTC adapalene gel, cream (generic benzoyl peroxide generic Rx clindamycin phosphate SOLUTION
AKNE-MYCIN (erythromycin) DIFFERIN GEL
ATRALIN (tretinoin) DIFFERIN LOTION, CREAM
AVITA (tretinoin) BENZACLIN GEL (clindamycin/ DUAC (clindamycin/benzoyl peroxide) benzoyl peroxide) erythromycin GEL, SOLUTION
BENZEPRO (benzoyl peroxide) tretinoin CREAM
benzoyl peroxide foam (generic for benzoyl peroxide gel Rx
CLINDAGEL (clindamycin) clindamycin GEL, LOTION, FOAM
clindamycin/benzoyl peroxide (generic for Benzaclin) EPIDUO (adapalene/benzoyl erythromycin-benzoyl peroxide (generic for Benzamycin and EVOCLIN (clindamycin) FABIOR (tazarotene foam) 12 BRAND PRODUCTS IN UPPER CASE generic names in lower case. If only the generic name is listed as preferred, then the
BRAND name of that product is non-preferred; unless the brand name product is ALSO listed as preferred. *Indicates that a clinical prior authorization is required despite the medication's status as preferred or non-preferred. QL indicates quantity limits. NR indicates product was not reviewed. New Drug criteria will apply. INOVA (benzoyl peroxide) KLARON (sulfacetamide) NEUAC (clindamycin/benzoyl RETIN-A GEL, CREAM RETIN-A MICRO (tretinoin sulfacetamide/sulfur SUMADAN (sulfacetamide/sulfur) TAZORAC (tazarotene) tretinoin GEL
tretinoin microspheres (generic for
VELTIN (clindamycin and tretinoin) ZIANA (clindamycin and tretinoin) It was moved by Dering- Anderson and seconded to accept recommendations as published. Roll Call vote was taken and the motion passed. Votes as follows: Baker-yes, Bleicher-yes, Bohac-yes, Caudill-yes, Davenport-yes, Dering-Anderson-yes, Dubé-yes, Elsasser-yes, Haberstitch-yes, Hammond-yes, Humphries-yes, Rock-yes, Saunders-yes, Sobeski-yes, Sorensen-yes, Thomsen-yes. Motion Carried.

ANALGESICS, OPIATE LONG-ACTING
PREFERRED DRUGS
NON-PREFERRED DRUGS
PDL EXCEPTION CRITERIA:
fentanyl patches 25, 50, 75, 100mcg BUTRANS (buprenorphine, Non-preferred agents will be KADIAN (morphine ER capsule) approved for patients meeting the DURAGESIC MATRIX (fentanyl) following criteria: morphine ER TABLET (generic for
EMBEDA (morphine/naltrexone) MS Contin, Oramorph SR) fentanyl patch 37.5, 62.5, 87.5 mcg  Documented failure of at least a 30
OXYCONTIN (oxycodone ER) hydromorphone ER (generic for day trial of two preferred agents within previous 6 months. HYSINGLA ER (hydrocodone) morphine ER capsule (generic for Patient must meet all of the following morphine ER capsule (generic for  Diagnosis of moderate to severe NUCYNTA ER (tapentadol)* oxycodone ER (generic for re-  Require < 80mg morphine formulated Oxycontin) equivalents per day oxymorphone ER (generic for OPANA  Require continuous around-the- tramadol extended release* (generic  Need analgesic medication for an extended period of time ZOHYDRO ER (hydrocodone  Patient is 18 years or older  Inability to take oral medication 13 BRAND PRODUCTS IN UPPER CASE generic names in lower case. If only the generic name is listed as preferred, then the
BRAND name of that product is non-preferred; unless the brand name product is ALSO listed as preferred. *Indicates that a clinical prior authorization is required despite the medication's status as preferred or non-preferred. QL indicates quantity limits. NR indicates product was not reviewed. New Drug criteria will apply. Adequate trial with 3 preferred long or
short acting opiate analgesic agents
NOT approved for substance abuse
or addiction.
CONZIP, EXALGO, HYSLINGA ER,
ULTRAM ER, and ZOHYDRO ER:
Must document clinical reason why
short-acting product with same active
ingredient cannot be used.
It was moved by Dering- Anderson and seconded to accept recommendations as published with the exception of OXYCONTIN, which will remain on the Preferred Drug List. Roll call vote was taken and the motion passed. Votes as follows: Baker-yes, Bleicher-yes, Bohac-yes, Caudill-yes, Davenport-yes, Dering-Anderson-yes, Dubé-yes, Elsasser-yes, Haberstitch-yes, Hammond-yes, Humphries-yes, Rock-yes, Saunders-yes, Sobeski-yes, Sorensen-yes, Thomsen-yes. Motion Carried.

ANALGESICS, OPIATE SHORT-ACTING
PREFERRED DRUGS
NON-PREFERRED DRUGS
PDL EXCEPTION CRITERIA:
acetaminophen/codeine codeine ORAL SOLUTION
Non-preferred agents will be codeine ORAL
approved only after documented hydrocodone/APAP (generic for Synalgos DC) failure of 3 preferred agents. hydrocodone/ibuprofen hydromorphone TABLETS
Note: NUCYNTA only approved for morphine ORAL
hydromorphone ORAL LIQUID, short term use for acute pain. Not oxycodone TABLET
SUPPOSITORIES (generic for approved for chronic pain. ROXICET SOLUTION
IBUDONE (hydrocodone/ibuprofen) meperidine (generic for Demerol) morphine SUPPOSITORIES
NUCYNTA (tapentadol)* oxycodone CAPSULE
oxycodone CONCENTRATE
oxycodone/aspirin
oxycodone/ibuprofen (generic for
oxymorphone (generic for Opana) pentazocine/APAP pentazocine/naloxone PRIMLEV ROXICODONE TABLET (oxycodone)
tramadol/APAP –generic for Ultracet
14 BRAND PRODUCTS IN UPPER CASE generic names in lower case. If only the generic name is listed as preferred, then the
BRAND name of that product is non-preferred; unless the brand name product is ALSO listed as preferred. *Indicates that a clinical prior authorization is required despite the medication's status as preferred or non-preferred. QL indicates quantity limits. NR indicates product was not reviewed. New Drug criteria will apply. (note: separate ingredients preferred) (hydrocodone/ibuprofen) butorphanol nasal spray ABSTRAL (fentanyl transmucosal)* Diagnosis of cancer. fentanyl transmucosal* (generic for Current use of long-acting opiate. NOT approved for acute pain, FENTORA (fentanyl)* migraine, or fibromyalgia. SUBSYS (fentanyl spray)* It was moved by Dering- Anderson and seconded to accept recommendations as published, roll call vote was taken and the motion passed. Votes as follows: Baker-yes, Bleicher-yes, Bohac-yes, Caudill-yes, Davenport-yes, Dering-Anderson-yes, Dubé-yes, Elsasser-yes, Haberstitch-yes, Hammond-yes, Humphries-yes, Rock-yes, Saunders-yes, Sobeski-yes, Sorensen-yes, Thomsen-yes. Motion Carried.

ANDROGENIC DRUGS (Topical)
PREFERRED DRUGS
NON-PREFERRED DRUGS
PDL EXCEPTION CRITERIA:
ANDROGEL (testosterone) ANDRODERM (testosterone) 1. 1. Adverse reaction to, allergy, or AXIRON (testosterone) contraindication to preferred drugs. FORTESTA (testosterone) TESTIM (testosterone) 2. 2. Documentation of treatment failure testosterone (generics for Androgel, with preferred drug. Fortesta, Testim, and Vogelxo) VOGELXO (testosterone) It was moved by Thomsen and seconded to accept recommendations as published, roll call vote was taken and the motion passed. Votes as follows: Baker-yes, Bleicher-yes, Bohac-yes, Caudill-yes, Davenport-yes, Dering-Anderson-yes, Dubé-yes, Elsasser-yes, Haberstitch-yes, Hammond-yes, Humphries-yes, Rock-yes, Saunders-yes, Sobeski-yes, Sorensen-yes, Thomsen-yes. Motion Carried.

ANGIOTENSIN MODULATORS
PREFERRED DRUGS
NON-PREFERRED DRUGS
PDL EXCEPTION CRITERIA:
ACE INHIBITORS
benazepril (generic for Lotensin) captopril (generic for Capoten) Non-preferred agents may be enalapril (generic for Vasotec) EPANED (enalapril) oral solution approved if the patient has a history lisinopril (generic for Prinivil/Zestril) fosinopril (generic for Monopril) of two preferred agents in the last 15 BRAND PRODUCTS IN UPPER CASE generic names in lower case. If only the generic name is listed as preferred, then the
BRAND name of that product is non-preferred; unless the brand name product is ALSO listed as preferred. *Indicates that a clinical prior authorization is required despite the medication's status as preferred or non-preferred. QL indicates quantity limits. NR indicates product was not reviewed. New Drug criteria will apply. quinapril (generic for Accupril) moexepril (generic for Univasc) ramipril (generic for Altace) perindopril (generic for Aceon) trandolapril (generic for Mavik) EPANED: Requires documentation of ACE INHIBITOR/DIURETIC COMBINATIONS
why an oral tablet or compounded benazepril/HCTZ (generic for Lotensin captopril/HCTZ (generic for product are not appropriate for enalapril/HCTZ (generic for Vaseretic) fosinopril/HCTZ (generic for Monopril lisinopril/HCTZ (generic Prinzide/Zestoretic) moexepril/HCTZ (generic for Uniretic) quinapril/HCTZ (generic for ANGIOTENSIN RECEPTOR BLOCKERS
irbesartan (generic for Avapro) BENICAR (olmesartan) Non-preferred agents may be losartan (generic for Cozaar) candesartan (generic for Atacand) approved if the patient has a history valsartan (generic for Diovan) DIOVAN (valsartan) of two preferred agents in the last EDARBI (azilsartan medoxomil) eprosartan (generic for Teveten) telmisartan (generic for Micardis) ANGIOTENSIN RECEPTOR BLOCKER/DIURETIC COMBINATIONS
irbesartan/HCTZ (generic for Avalide) BENICAR-HCT (olmesartan/HCTZ) losartan/HCTZ (generic for Hyzaar) candesartan/HCTZ (generic for valsartan-HCTZ (generic for Diovan- DIOVAN-HCT (valsartan/HCTZ) telmisartan/HCTZ (generic for TEVETEN-HCT (eprosartan/HCTZ) DIRECT RENIN INHIBITORS
TEKTURNA (aliskiren) Non-preferred agents may be approved if the patient has a history of two preferred ACE inhibitors or angiotensin receptor blockers in the last 12 months. DIRECT RENIN INHIBITOR COMBINATIONS
Individual prescriptions for the components of these products TEKAMLO (aliskiren/amlodipine)
should be used for patients TEKTURNA/HCT (aliskiren/HCTZ) requiring these drug combinations. Documentation of medical necessity required for use of combination product. It was moved by Thomsen and seconded to accept recommendations as published, roll call vote was taken and the motion passed. 16 BRAND PRODUCTS IN UPPER CASE generic names in lower case. If only the generic name is listed as preferred, then the
BRAND name of that product is non-preferred; unless the brand name product is ALSO listed as preferred. *Indicates that a clinical prior authorization is required despite the medication's status as preferred or non-preferred. QL indicates quantity limits. NR indicates product was not reviewed. New Drug criteria will apply. Votes as follows: Baker-yes, Bleicher-yes, Bohac-yes, Caudill-yes, Davenport-yes, Dering-Anderson-yes, Dubé-yes, Elsasser-yes, Haberstitch-yes, Hammond-yes, Humphries-yes, Rock-yes, Saunders-yes, Sobeski-yes, Sorensen-yes, Thomsen-yes. Motion Carried.

ANGIOTENSIN MODULATOR/CALCIUM CHANNEL BLOCKER COMBINATIONS
PREFERRED DRUGS
NON-PREFERRED DRUGS
PDL EXCEPTION CRITERIA:
benazepril/amlodipine (generic for Individual prescriptions for the AZOR (olmesartan/amlodipine) components of these products EXFORGE (valsartan/amlodipine) should be used for patients TEKAMLO (aliskiren/amlodipine)
requiring these drug combinations. telmisartan/amlodipine (generic for Documentation of medical necessity trandolapril/verapamil (generic for required for use of combination valsartan/amlodipine (generic for valsartan/amlodipine/HCTZ (generic for Exforge HCT) It was moved by Saunders and seconded to accept recommendations as published, roll call vote was taken and the motion passed. Votes as follows: Baker-yes, Bleicher-yes, Bohac-yes, Caudill-yes, Davenport-yes, Dering-Anderson-yes, Dubé-yes, Elsasser-yes, Haberstitch-yes, Hammond-yes, Humphries-yes, Rock-yes, Saunders-yes, Sobeski-yes, Sorensen-yes, Thomsen-yes. Motion Carried.

ANTIBIOTICS, INHALED
PREFERRED DRUGS
NON-PREFERRED DRUGS
PDL EXCEPTION CRITERIA:
BETHKIS (tobramycin) CAYSTON (aztreonam lysine)QL, * Cayston:
KITABIS PAK (tobramycin) TOBI (tobramycin) 1. Adverse reaction to, allergy, TOBI-PODHALER (tobramycin)* tobramycin (generic for TOBI) treatment failure, or contraindication to preferred drugs. 2. Previous therapy with tobramycin via nebulizer, AND 3. Demonstration of TOBI compliance, AND 4. Diagnosis of cystic fibrosis, and 5. Quantity limits of 84ml per 28 days' supply. Tobi-Podhaler® (tobramycin
inhalation powder)
 Step thru with solution
17 BRAND PRODUCTS IN UPPER CASE generic names in lower case. If only the generic name is listed as preferred, then the
BRAND name of that product is non-preferred; unless the brand name product is ALSO listed as preferred. *Indicates that a clinical prior authorization is required despite the medication's status as preferred or non-preferred. QL indicates quantity limits. NR indicates product was not reviewed. New Drug criteria will apply. It was moved by Dering-Anderson and seconded to accept recommendations as published, roll Call vote was taken and the motion passed. Votes as follows: Baker-yes, Bleicher-yes, Bohac-yes, Caudill-yes, Davenport-yes, Dering-Anderson-yes, Dubé-yes, Elsasser-yes, Haberstitch-yes, Hammond-yes, Humphries-yes, Rock-yes, Saunders-yes, Sobeski-yes, Sorensen-yes, Thomsen-yes. Motion Carried.

ANTIBIOTICS, VAGINAL
PREFERRED DRUGS
NON-PREFERRED DRUGS
PDL EXCEPTION CRITERIA:
CLEOCIN OVULES (clindamycin, CLINDESSE (clindamycin vaginal) 1. Adverse reaction to, allergy, or vaginal suppositories) METROGEL (metronidazole, vaginal) contraindication to preferred drugs. clindamycin (vaginal) (generic for NUVESSA (metronidazole gel) VANDAZOLE (metronidazole) 2. Documentation of treatment metronidazole (vaginal) failure with preferred drug. It was moved by Sobeski and seconded to accept recommendations as published, roll call vote was taken and the motion passed. Votes as follows: Baker-yes, Bleicher-yes, Bohac-yes, Caudill-yes, Davenport-yes, Dering-Anderson-yes, Dubé-yes, Elsasser-yes, Haberstitch-yes, Hammond-yes, Humphries-yes, Rock-yes, Saunders-yes, Sobeski-yes, Sorensen-yes, Thomsen-yes. Motion Carried.
XIII. An all in favor motion was made to move break for lunch at 12:10p, Resumed open session at 1:05pm. PREFERRED DRUGS
NON-PREFERRED DRUGS
PDL EXCEPTION CRITERIA:
ELIQUIS (apixaban) fondaparinux (generic for Arixtra) 1. Non-preferred agents will be enoxaparin (generic for Lovenox) SAVAYSA (edoxaban) approved only after documented FRAGMIN (dalteparin) XARELTO DOSE PACK failure of a preferred agent. PRADAXA (dabigatran) warfarin (generic for Coumadin) 2. Allergy/ inability to control INR XARELTO (rivaroxaban) 3. Contraindication to preferred agent. It was moved by Saunders and seconded to approve the recommendation but also include Eliquis as preferred. After further discussion, it was moved by Dering-Anderson and seconded to amend the main motion by changing the PDL exception criteria from requiring a treatment failure with a preferred agent to "contraindication to preferred agent." Further discussion ensued. It was then moved by Baker to amend the amendment to remove Pradaxa from the Preferred Drug List, except for individuals who are already prescribed the drug. As the public testimony had been deferred, an offer was extended to the public to testify to this motion. DRUG CLASS
Drug Name
PDL Status
Speaker Name
Affiliation
18 BRAND PRODUCTS IN UPPER CASE generic names in lower case. If only the generic name is listed as preferred, then the
BRAND name of that product is non-preferred; unless the brand name product is ALSO listed as preferred. *Indicates that a clinical prior authorization is required despite the medication's status as preferred or non-preferred. QL indicates quantity limits. NR indicates product was not reviewed. New Drug criteria will apply. Votes as follows for the amendment to the amendment: Baker-yes, Bleicher-no, Bohac-no, Caudill-no, Davenport-no, Dering-Anderson-yes, Dubé-yes, Elsasser-no, Haberstitch-no, Hammond-no, Humphries-yes, Rock-no, Saunders-no, Sobeski-yes, Sorensen-no, Thomsen-no. Motion Failed.

Discussion was then reopened on the amendment to the main motion and after further discussion, roll call vote was taken and the amendment passed. The main motion as amended was read aloud, "to accept the amendment to the main motion by changing the PDL exception criteria from requiring a treatment failure with a preferred agent to contraindication to preferred agent." Votes as follows: Baker-yes, Bleicher-yes, Bohac-yes, Caudill-yes, Davenport-yes, Dering-Anderson-yes, Dubé-yes, Elsasser-yes, Haberstitch-no, Hammond-yes, Humphries-yes, Rock-yes, Saunders-yes, Sobeski-no, Sorensen-yes, Thomsen-yes. Motion Carried.
The amended motion was read aloud, " to accept recommendations as published with the addition of
ELIQUIS to the Preferred Drug List and to add to the PDL Exception Criteria - contraindication to
preferred agent". Rol call vote was taken on the amended motion and passed.
Votes as follows: Baker-yes, Bleicher-yes, Bohac-yes, Caudill-yes, Davenport-yes, Dering-Anderson-yes, Dubé-yes, Elsasser-yes, Haberstitch-yes, Hammond-yes, Humphries-yes, Rock-yes, Saunders-yes, Sobeski-yes, Sorensen-yes, Thomsen-yes. Motion Carried.

ANTIEMETICS /ANTIVERTIGO AGENTS
PREFERRED DRUGS
NON-PREFERRED DRUGS
PDL EXCEPTION CRITERIA:
dronabinol (generic for Marinol) CESAMET (nabilone) 1. Adverse reaction to, allergy, or MARINOL (dronabinol) contraindication to preferred drugs. 2. Documentation of treatment failure with preferred drug. 5HT3 RECEPTOR BLOCKERS
ondansetron (generic for Zofran) ANZEMET (dolasetron) 1. Adverse reaction to, allergy or ondansetron ODT (generic for Zofran) granisetron (generic for Kytril) contraindication to preferred SANCUSO (granisetron) ZUPLENZ (ondansetron) 2. Documentation of treatment failure with preferred drug. --------------------------------------- SANCUSO and ZUPLENZ: Unable to tolerate oral. NK-1 RECEPTOR ANTAGONIST
AKYNZEO (netupitant/palonosetron) Does NOT require treatment 19 BRAND PRODUCTS IN UPPER CASE generic names in lower case. If only the generic name is listed as preferred, then the
BRAND name of that product is non-preferred; unless the brand name product is ALSO listed as preferred. *Indicates that a clinical prior authorization is required despite the medication's status as preferred or non-preferred. QL indicates quantity limits. NR indicates product was not reviewed. New Drug criteria will apply. EMEND (aprepitant)QL, * failure with preferred drugs when used for moderately or highly emetogenic chemotherapy. TRADITIONAL ANTIEMETICS
DICLEGIS (doxylamine/pyridoxine)* COMPRO (prochlorperazine rectal) 1. Adverse reaction to, allergy or METOZOLV ODT (metoclopramide) contraindication to 2 preferred dimenhydrinate (generic for prochlorperazine rectal (generic for hydroxyzine (generic for Vistaril) promethazine suppositories 50mg 2. Documentation of treatment meclizine (generic for Antivert) trimethobenzamide oral (generic for failure with 2 preferred drugs. metoclopramide (generic for Reglan) phosphoric acid/dextrose/fructose solution (generic for Emetrol) Inablilty to swallow or clinical prochlorperazine oral (generic for reason can't utilize oral liquid. promethazine oral (generic for promethazine suppositories 12.5mg, TRANSDERM-SCOP (scopolamine) It was moved by Dering-Anderson and seconded to accept recommendations as published, roll call vote was taken and the motion passed. Votes as follows: Baker-yes, Bleicher-yes, Bohac-yes, Caudill-yes, Davenport-yes, Dering-Anderson-yes, Dubé-yes, Elsasser-yes, Haberstitch-yes, Hammond-yes, Humphries-yes, Rock-yes, Saunders-yes, Sobeski-yes, Sorensen-yes, Thomsen-yes. Motion Carried.

ANTIFUNGALS, ORAL
PREFERRED DRUGS
NON-PREFERRED DRUGS
PDL EXCEPTION CRITERIA:
clotrimazole (mucous membrane flucytosine (generic for Ancobon)* 1. Adverse reaction to, allergy, or GRIFULVIN V (griseofulvin) contraindication to preferred drugs, fluconazole (generic for Diflucan) griseofulvin tablets griseofulvin suspension
griseofulvin ultramicrosize 2. Documentation of treatment GRIS-PEG (griseofulvin) itraconazole (generic for Sporanox) failure with two preferred drugs. nystatin TABLET, SUSPENSION
ketoconazole (generic for Nizoral) terbinafine (generic for Lamisil) LAMISIL GRANULES (terbinafine) NOXAFIL (posaconazole)* nystatin POWDER for reconstitution
These meds do not necessarily
ONMEL (itraconazole) require trial and failure on a
ORAVIG (miconazole buccal) preferred medication, if clinical
SPORANOX (itraconazole)* criteria are met. Tech: may
voriconazole (generic for VFEND)* approve:
All: allow if immunocompromised

ANCOBON: diagnosis of:
 Candida: septicemia, 20 BRAND PRODUCTS IN UPPER CASE generic names in lower case. If only the generic name is listed as preferred, then the
BRAND name of that product is non-preferred; unless the brand name product is ALSO listed as preferred. *Indicates that a clinical prior authorization is required despite the medication's status as preferred or non-preferred. QL indicates quantity limits. NR indicates product was not reviewed. New Drug criteria will apply. endocarditis, UTI  Cryptococcus: meningitis, pulmonary infections. ITRACONAZOLE: diagnosis of:
 Aspergillosis  Blastomycosis  Histoplasmosis  Onychomycosis resistant to  Oropharyngeal/esophageal candidiasis refractory to fluconazole.  SPORANOX liquid only if unable to take capsules.  ONMEL only FDA approved for NOXAFIL: minimum age of 13.
Prevention of infection with diagnosis of:  Neutropenic Myelodysplastic  Neutropenic hematologic  Graft vs. Host disease  Immunosuppression following hematopoetic stem cell transplant  Oropharyngeal/esophageal candidiasis refractory to itraconazole and/or fluconazole  Myelodysplastic Syndrome  Neutropenic Acute Myeloid  Graft versus Host Disease  Candidemia (candida krusei), Esophageal Candidiasis  Pulmonary or invasive  Blastomycosis  Serious fungal infections caused by Scedosporium apiospermum (asexual form of 21 BRAND PRODUCTS IN UPPER CASE generic names in lower case. If only the generic name is listed as preferred, then the
BRAND name of that product is non-preferred; unless the brand name product is ALSO listed as preferred. *Indicates that a clinical prior authorization is required despite the medication's status as preferred or non-preferred. QL indicates quantity limits. NR indicates product was not reviewed. New Drug criteria will apply. Pseudallescheria boydii) and Fusarium spp., including Fusarium solani, in patients intolerant of, or refractory to other therapy.  Oropharyngeal/esophageal candidiasis refractory to fluconazole. It was moved by Sorensen and seconded to accept recommendations as published, roll call vote was taken and the motion passed. Votes as follows: Baker-yes, Bleicher-yes, Bohac-yes, Caudill-yes, Davenport-yes, Dering-Anderson-yes, Dubé-yes, Elsasser-yes, Haberstitch-yes, Hammond-yes, Humphries-yes, Rock-yes, Saunders-yes, Sobeski-yes, Sorensen-yes, Thomsen-yes. Motion Carried.

ANTIFUNGALS, TOPICAL
PREFERRED DRUGS
NON-PREFERRED DRUGS
PDL EXCEPTION CRITERIA:
ANTIFUNGAL
clotrimazole (generic for Lotrimin) RX, ALEVAZOL (clotrimazole)NR 1. Adverse reaction to, allergy, or BENSAL HP (salicylic acid) contraindication to preferred drugs. ketoconazole cream (generic for Nizoral) ciclopirox cream/gel/suspension ketoconazole shampoo (generic for (generic for Ciclodan, Loprox) 2. Documentation of treatment ciclopirox nail lacquer (solution) failure of two preferred drugs within LAMISIL AT CREAM (terbinafine) OTC (generic for Penlac) the last 6 months. LAMISIL AT GEL (terbinafine) OTC ciclopirox shampoo (generic for LAMISIL SPRAY OTC (terbinafine) miconazole OTC CREAM, SPRAY, DESENEX AERO POWDER OTC NUZOLE (miconazole) econazole (generic for Spectazole) ERTACZO (sertaconazole) selenium sulfide 2.5% EXELDERM (sulconazole) terbinafine OTC (generic for Lamisil AT) EXTINA (ketoconazole) tolnaftate OTC (generic for Tinactin) FUNGOID OTC
JUBLIA (efinaconazole)
ketoconazole FOAM (generic for
LOTRIMIN AF CREAM OTC LOTRIMIN ULTRA
LUZU (luliconazole)
MENTAX (butenafine)
miconazole OTC OINTMENT
NAFTIN (naftifine)
OXISTAT (oxiconazole)
selenium sulfide 2.25%
TINACTIN AERO POWDER
(tolnaftate) OTC
22 BRAND PRODUCTS IN UPPER CASE generic names in lower case. If only the generic name is listed as preferred, then the
BRAND name of that product is non-preferred; unless the brand name product is ALSO listed as preferred. *Indicates that a clinical prior authorization is required despite the medication's status as preferred or non-preferred. QL indicates quantity limits. NR indicates product was not reviewed. New Drug criteria will apply. TINACTIN CREAM (tolnaftate) OTC VUSION (miconazole/ zinc oxide) ANTIFUNGAL/STEROID COMBINATIONS
clotrimazole/betamethasone CREAM
(gen. Lotrisone) LOTION (gen. Lotrisone)
nystatin/triamcinolone (gen. for
It was moved by Rock and seconded to accept recommendations as published, roll call vote was taken and the motion passed. Votes as follows: Baker-yes, Bleicher-yes, Bohac-yes, Caudill-yes, Davenport-yes, Dering-Anderson-yes, Dubé-yes, Elsasser-yes, Haberstitch-yes, Hammond-yes, Humphries-yes, Rock-yes, Saunders-yes, Sobeski-yes, Sorensen-yes, Thomsen-yes. Motion Carried.

ANTIMIGRAINE DRUGSQL, TRIPTANS Note: There are Quantity Limits for entire class.
PREFERRED DRUGS
NON-PREFERRED DRUGS
PDL EXCEPTION CRITERIA:
RELPAX (eletriptan) AXERT (almotriptan) Non-preferred agents will be rizatriptan ODT (generic for Maxalt MLT) FROVA (frovatriptan) approved only if patient has sumatriptan generic oral IMITREX oral (sumatriptan) tried and failed therapy with all naratriptan (generic for Amerge) preferred agents. rizatriptan (generic for Maxalt) TREXIMET (sumatriptan/naproxen) zolmitriptan (generic for Zomig/Zomig IMITREX (sumatriptan) sumatriptan generic nasal ZOMIG (zolmitriptan) INJECTABLE
IMITREX (sumatriptan) PEN,
IMITREX (sumatriptan) VIAL
CARTRIDGE
sumatriptan SYRINGE, KIT
sumatriptan generic VIAL
SUMAVEL DOSEPRO (sumatriptan) It was moved by Thomsen and seconded to accept recommendations as published, roll call vote was taken and the motion passed. Votes as follows: Baker-yes, Bleicher-yes, Bohac-yes, Caudill-yes, Davenport-yes, Dering-Anderson-yes, Dubé-yes, Elsasser-yes, Haberstitch-yes, Hammond-yes, Humphries-yes, Rock-yes, Saunders-yes, Sobeski-yes, Sorensen-yes, Thomsen-yes. Motion Carried.

ANTIPARASITICS, TOPICAL
PREFERRED DRUGS
NON-PREFERRED DRUGS
PDL EXCEPTION CRITERIA:
NATROBA (spinosad) EURAX (crotamiton) CREAM
1. Adverse reaction to, allergy, or permethrin 1% OTC (generic for Nix) EURAX (crotamiton) LOTION
contraindication to preferred drugs. permethrin 5% RX (generic for Elimite) 23 BRAND PRODUCTS IN UPPER CASE generic names in lower case. If only the generic name is listed as preferred, then the
BRAND name of that product is non-preferred; unless the brand name product is ALSO listed as preferred. *Indicates that a clinical prior authorization is required despite the medication's status as preferred or non-preferred. QL indicates quantity limits. NR indicates product was not reviewed. New Drug criteria will apply. pyrethrin/piperonyl butoxide (generic malathion (generic for Ovide) 2. Documentation of treatment spinosad (generic for Natroba) failure with one preferred drug. SKLICE (ivermectin) ULESFIA (benzyl alcohol) Note: Lindane will process in claims system automatically without prior authorization if 2 preferred products have been filled within the previous 60 days. ULESFIA: Quantity limits based on hair length. It was moved by Saunders and seconded to accept recommendations as published, roll call vote was taken and the motion passed. Votes as follows: Baker-yes, Bleicher-yes, Bohac-yes, Caudill-yes, Davenport-yes, Dering-Anderson-yes, Dubé-yes, Elsasser-yes, Haberstitch-yes, Hammond-yes, Humphries-yes, Rock-yes, Saunders-yes, Sobeski-yes, Sorensen-yes, Thomsen-yes. Motion Carried.

ANTIVIRALS, ORAL
PREFERRED DRUGS
NON-PREFERRED DRUGS
PDL EXCEPTION CRITERIA:
ANTI-HERPETIC DRUGS
acyclovir (generic for Zovirax) SITAVIG (acyclovir buccal) 1. Adverse reaction to, allergy, or famciclovir (generic for Famvir) contraindication to preferred drugs. valacyclovir (generic for Valtrex) 2. Documentation of treatment failure with a preferred drug. ANTI-INFLUENZA DRUGS
RELENZA (zanamivir) inhalationQL rimantadine (generic for Flumadine) TAMIFLU (oseltamivir) QL It was moved by Dering-Anderson and seconded to accept recommendations as published, roll call vote was taken and the motion passed. Votes as follows: Baker-yes, Bleicher-yes, Bohac-yes, Caudill-yes, Davenport-yes, Dering-Anderson-yes, Dubé-yes, Elsasser-yes, Haberstitch-yes, Hammond-yes, Humphries-yes, Rock-yes, Saunders-yes, Sobeski-yes, Sorensen-yes, Thomsen-yes. Motion Carried.

BETA BLOCKERS (Oral)
PREFERRED DRUGS
NON-PREFERRED DRUGS
PDL EXCEPTION CRITERIA:
BETA BLOCKERS
atenolol (generic for Tenormin) acebutolol (generic for Sectral) Non-preferred agent will be atenolol/chlorthalidone(generic for betaxolol (generic for Kerlone) approved only after documented bisoprolol (generic for Zebeta) failure of two preferred agents bisoprolol/HCTZ (generic for Ziac) BYSTOLIC (nebivolol) within the past 12 months. metoprolol (generic for Lopressor) DUTOPROL (metoprolol XR and 24 BRAND PRODUCTS IN UPPER CASE generic names in lower case. If only the generic name is listed as preferred, then the
BRAND name of that product is non-preferred; unless the brand name product is ALSO listed as preferred. *Indicates that a clinical prior authorization is required despite the medication's status as preferred or non-preferred. QL indicates quantity limits. NR indicates product was not reviewed. New Drug criteria will apply. metoprolol XL (generic for Toprol XL) Drug Interactions: propranolol (generic for Inderal) HEMANGEOL (propranolol oral Non-preferred beta blocker may be propranolol extended release (Inderal approved if necessary to avoid drug interaction with preferred INNOPRAN XL (propranolol) agent. Such as allow pindolol OK LEVATOL (penbutolol) with MAO inhibitor or SSRI. metoprolol/HCTZ (generic for nadolol (generic for Corgard) Non-preferred agent will be nadolol/bendroflumethiazide (generic approved only after documented failure of one preferred agent within pindolol (generic for Viskin) the past 12 months in patients with obstructive lung disease. timolol (generic for Blocadren) TOPROL XL (metoprolol) BETA- AND ALPHA- BLOCKERS
carvedilol (generic for Coreg) COREG CR (carvedilol) labetalol (generic for Trandate) Clinical reason the generic regular-release cannot be used. Labetalol: Allow without trial on preferred agent for pregnancy induced hypertension. sotalol (generic for Betapace) SOTYLIZE (sotalol oral solution) It was moved by Dubé and seconded to accept recommendations as published, roll call vote was taken and the motion passed. Votes as follows: Baker-yes, Bleicher-yes, Bohac-yes, Caudill-yes, Davenport-yes, Dering-Anderson-yes, Dubé-yes, Elsasser-yes, Haberstitch-yes, Hammond-yes, Humphries-yes, Rock-yes, Saunders-yes, Sobeski-yes, Sorensen-yes, Thomsen-yes. Motion Carried.

HEPATITIS C AGENTS
PREFERRED DRUGS
NON-PREFERRED DRUGS
CRITERIA FOR USE OF NON-
PREFERRED PRODUCTS
INTERFERON
See clinical criteria. (pegylated interferon alfa-2a)* (pegylated interferon alfa-2b)* RIBAVIRIN
ribavirin 200mg tablets and capsules* REBETOL SOLUTION (ribavirin) NUCLEOTIDE ANALOG POLYMERASE INHIBITOR
VIEKIRA PAK * (ombitasvir, HARVONI (sofosbuvir/ledipasvir)* 25 BRAND PRODUCTS IN UPPER CASE generic names in lower case. If only the generic name is listed as preferred, then the
BRAND name of that product is non-preferred; unless the brand name product is ALSO listed as preferred. *Indicates that a clinical prior authorization is required despite the medication's status as preferred or non-preferred. QL indicates quantity limits. NR indicates product was not reviewed. New Drug criteria will apply. paritaprevir, ritonavir, dasabuvir) SOVALDI (sofosbuvir)* PROTEASE INHIBITOR
PREFERRED DRUGS
NON-PREFERRED DRUGS
PDL EXCEPTION CRITERIA:
OLYSIO (simeprevir) It was moved by Bohac and seconded to accept recommendations as published, roll call vote was taken and the motion passed. Votes as follows: Baker-yes, Bleicher-yes, Bohac-yes, Caudill-yes, Davenport-yes, Dering-Anderson-yes, Dubé-yes, Elsasser-yes, Haberstitch-yes, Hammond-yes, Humphries-yes, Rock-yes, Saunders-yes, Sobeski-yes, Sorensen-yes, Thomsen-yes. Motion Carried.

HYPOGLYCEMICS, INCRETIN MIMETICS/ENHANCERS
PREFERRED DRUGS
NON-PREFERRED DRUGS
PDL EXCEPTION CRITERIA:
Glucagon-Like Peptide-1 Receptor Agonist (GLP-1 RA)
BYDUREON (exenatide ER) TRULICITY (dulaglutide) VICTOZA (liraglutide) subcutaneous BYDUREON PEN (exenatide ER)
BYETTA (exenatide) subcutaneous**
TANZEUM (albiglutide)**
** Requires metformin trial and
diagnosis of diabetes.
Amlyn Analog
SYMLIN (pramlintide) subcutaneous* Dipeptidyl peptidase-4 (DPP-4) Inhibitor
JANUMET (sitagliptin/metformin)QL
GLYXAMBI (empagliflozin/linagliptin) Trial on sitagliptin or linagliptin. JANUMET XR(sitagliptin/metformin)QL KAZANO (alogliptin/metformin)QL JANUVIA (sitagliptin)QL JENTADUETO (linagliptin/metformin)QL (saxagliptin/metformin)QL TRADJENTA (linagliptin)QL NESINA (alogliptin)QL ONGLYZA (saxagliptin)QL OSENI (alogliptin/pioglitazone)QL It was moved by Sorensen and seconded to accept recommendations as published, roll call vote was taken and the motion passed. Votes as follows: Baker-yes, Bleicher-yes, Bohac-yes, Caudill-yes, Davenport-yes, Dering-Anderson-yes, Dubé-yes, Elsasser-yes, Haberstitch-yes, Hammond-yes, Humphries-yes, Rock-yes, Saunders-yes, Sobeski-yes, Sorensen-yes, Thomsen-yes. Motion Carried.

HYPOGLYCEMICS, INSULIN AND RELATED DRUGS
PREFERRED DRUGS
NON-PREFERRED DRUGS
PDL EXCEPTION CRITERIA:
HUMALOG (insulin lispro) AFREZZA (insulin human regular) 1. Adverse reaction to, allergy, or 26 BRAND PRODUCTS IN UPPER CASE generic names in lower case. If only the generic name is listed as preferred, then the
BRAND name of that product is non-preferred; unless the brand name product is ALSO listed as preferred. *Indicates that a clinical prior authorization is required despite the medication's status as preferred or non-preferred. QL indicates quantity limits. NR indicates product was not reviewed. New Drug criteria will apply. HUMALOG MIX (insulin lispro/lispro APIDRA (insulin glulisine) contraindication to preferred drugs, NOVOLIN (insulin) HUMULIN (insulin) NOVOLOG (insulin aspart) 2 .Documentation of treatment LANTUS (insulin glargine) NOVOLOG MIX (insulin aspart/aspart failure with preferred drug. LEVEMIR (insulin detemir) Insulin pens /cartridges* Insulin pens/cartridges :
TOUJEO SOLOSTAR PEN (insulin 1. Physical reasons, such as dexterity problems, vision impairment. 2. Must be Self Administered. 3. NOT just for convenience. 4. Low dose (≤40 units per day) It was moved by Sorensen and seconded to accept recommendations as published, roll call vote was taken and the motion passed. Votes as follows: Baker-yes, Bleicher-yes, Bohac-yes, Caudill-yes, Davenport-yes, Dering-Anderson-yes, Dubé-yes, Elsasser-yes, Haberstitch-yes, Hammond-yes, Humphries-yes, Rock-yes, Saunders-yes, Sobeski-yes, Sorensen-yes, Thomsen-yes. Motion Carried.

HYPOGLYCEMICS, SGLT2
PREFERRED DRUGS
NON-PREFERRED DRUGS
PDL EXCEPTION CRITERIA:
INVOKANA (canagliflozin) FARXIGA (dapagliflozin)*  Compliance demonstrated with Metformin trial and have not received adequate glycemic JARDIANCE (empagliflozin) control with Metformin. XIGDUO XR (dapagliflozin/metformin)  Intolerance to Metformin It was moved by Dering-Anderson and seconded to accept recommendations as published and the motion passed. Votes as follows: Baker-yes, Bleicher-yes, Bohac-yes, Caudill-yes, Davenport-yes, Dering-Anderson-yes, Dubé-yes, Elsasser-yes, Haberstitch-yes, Hammond-yes, Humphries-yes, Rock-yes, Saunders-yes, Sobeski-yes, Sorensen-yes, Thomsen-yes. Motion Carried.

Hypoglycemics: Additional Classes
The following hypoglycemic class and the drugs noted are not reviewed by the PDL process but are covered
without prior authorization.
HYPOGLYCEMICS, SULFONYLUREAS
PREFERRED DRUGS
NON-PREFERRED DRUGS
PDL EXCEPTION CRITERIA:
27 BRAND PRODUCTS IN UPPER CASE generic names in lower case. If only the generic name is listed as preferred, then the
BRAND name of that product is non-preferred; unless the brand name product is ALSO listed as preferred. *Indicates that a clinical prior authorization is required despite the medication's status as preferred or non-preferred. QL indicates quantity limits. NR indicates product was not reviewed. New Drug criteria will apply. glimepiride (generic for Amaryl) glipizide (generic for Glucotrol) glipizide ER (generic for Glucotrol XL) glyburide/micronized (generic for Diabeta, Glynase) tolazamide tolbutamide
LIPOTROPICS, OTHER (non-statins)
Note: Several other forms of OTC niacin and fish oil are also covered under Medicaid with a prescription without
prior authorization.
PREFERRED DRUGS
NON-PREFERRED DRUGS
PDL EXCEPTION CRITERIA:
BILE ACID SEQUESTRANTS
The non-preferred agent will be cholestyramine (generic for Questran) colestipol (generic for Colestid) approved only after documented colestipol (generic for Colestid) GRANULES
failure of the preferred agents. QUESTRAN LIGHT (cholestyramine) WELCHOL (colesevalam) FIBRIC ACID DERIVATIVES
gemfibrozil (generic for Lopid) fenofibrate (generic for Antara) TRICOR (fenofibrate) fenofibrate (generic for Lofibra) TRILIPIX (fenofibric acid) fenofibrate (generic for Tricor) fenofibric acid (generic for Fibricor) fenofibric acid (generic for Trilipix) LIPOFEN (fenofibrate) TRIGLIDE (fenofibrate) NIASPAN (niacin ER) ADVICOR (lovastatin/niacin ER) niacin ER (generic for Niaspan) NIACOR (niacin IR) OMEGA-3 FATTY ACIDS
omega-3 fatty acids* (generic for *May approve if TG ≥500. (Verified by faxed copy of lab report). If TG VASCEPA (icosapent)* <500, OTC fish oils covered without prior authorization. CHOLESTEROL ABSORPTION INHIBITORS
28 BRAND PRODUCTS IN UPPER CASE generic names in lower case. If only the generic name is listed as preferred, then the
BRAND name of that product is non-preferred; unless the brand name product is ALSO listed as preferred. *Indicates that a clinical prior authorization is required despite the medication's status as preferred or non-preferred. QL indicates quantity limits. NR indicates product was not reviewed. New Drug criteria will apply. ZETIA (ezetimibe) ZETIA:  Only approved as an adjunct to concurrent statin therapy unless there is a documented intolerance to the statins.  Will be approved for patients who have a diagnosis of hypercholesterolemia and have: either failed statin monotherapy  Have a documented intolerance APOLIPOPROTEIN B SYNTHESIS INHIBITORS
JUXTAPID (lomitapide)* KYNAMRO (mipomersen)* JUXTAPID™ (lomitapide)
Patient must have a diagnosis of homozygous familial hypercholesterolemia (HoFH).  Prescriber must be certified with the Juxtapid™ REMS program.  Must fax a copy of the completed Juxtapid™ REMS Program Prescription Authorization Form.  Minimum age restriction of 18 years of age.  Patient has had treatment failure, maximized dosing with, or contraindication to all of the following,(document name of medication, date of trial and outcome, dose if maximized, or reason for contraindication): o statins o ezetimibe o niacin o fibric acid derivatives o omega-3 agents o bile acid sequestrants o See PDL Lipotropic (other) criteria for examples of the above and PDL Lipotropic: Statins.  Maximum daily dose: 60 mg  Juxtapid™ REMS program: Because of the risk of hepatotoxicity associated with lomitapide therapy,
lomitapide is available through a restricted program under the REMS. Under the JuxtapidTM REMS, only certified
health care providers and pharmacies may prescribe and distribute lomitapide. Further information is available

 Prescribers must use a REMS Program Prescription Authorization Form for each new prescription to ensure
safe use of JUXTAPID™.

KYNAMRO™Subcutaneous Injection (mipomersen sodium)
 Patient must have a diagnosis of homozygous familial hypercholesterolemia (HoFH).  Prescriber must be certified with the Kynamro™ REMS program.  Must fax a copy of the completed Kynamro™ REMS Program Prescription Authorization Form.  Minimum age restriction of 18 years of age.  Patient has had treatment failure, maximum dosing with or contraindication to: statins, ezetimibe, niacin, fibric acid derivatives, omega-3 agents, and bile acid sequestrants. 29 BRAND PRODUCTS IN UPPER CASE generic names in lower case. If only the generic name is listed as preferred, then the
BRAND name of that product is non-preferred; unless the brand name product is ALSO listed as preferred. *Indicates that a clinical prior authorization is required despite the medication's status as preferred or non-preferred. QL indicates quantity limits. NR indicates product was not reviewed. New Drug criteria will apply. Kynamro™ REMS program: Because of the risk of hepatotoxicity, Kynamro™ is available only through a limited
program under the REMS. Under the Kynamro™ REMS, only certified healthcare providers and pharmacies may
prescribe and distribute Kynamro™. Further information is available rescribers must use
a REMS Program Prescription Authorization Form for each new prescription to ensure safe use of KYNAMRO™.
It was moved by Caudill and seconded to accept recommendations as published, roll call vote was taken and the motion passed. Votes as follows: Baker-yes, Bleicher-yes, Bohac-yes, Caudill-yes, Davenport-yes, Dering-Anderson-yes, Dubé-yes, Elsasser-yes, Haberstitch-yes, Hammond-yes, Humphries-yes, Rock-yes, Saunders-yes, Sobeski-yes, Sorensen-yes, Thomsen-yes. Motion Carried.

MACROLIDES AND KETOLIDES (Oral)
PREFERRED DRUGS
NON-PREFERRED DRUGS
PDL EXCEPTION CRITERIA:
KETOLIDES
KETEK (telithromycin) 1. Documentation of any antibiotic use within the last 28 days. 2. Diagnosis is Community Acquired Pneumonia. 3. 18 years of age or older. MACROLIDES
azithromycin (generic for Zithromax) clarithromycin ER (generic for Biaxin 1. Adverse reaction to, allergy, or clarithromycin IR (generic for Biaxin) contraindication to preferred drugs. clarithromycin suspension EES 200 SUSPENSION 2. Documentation of treatment failure ERYPED 200 SUSPENSION EES 400 TABLET
with preferred drug. ERYPED 400 SUSPENSION erythromycin base PCE (erythromycin) erythromycin base CAPSULE DR ZMAX (azithromycin ER) ZITHROMAX (azithromycin) It was moved by Saunders and seconded to accept recommendations as published, roll call vote was taken and the motion passed. Votes as follows: Baker-yes, Bleicher-yes, Bohac-yes, Caudill-yes, Davenport-yes, Dering-Anderson-yes, Dubé-yes, Elsasser-yes, Haberstitch-yes, Hammond-yes, Humphries-yes, Rock-yes, Saunders-yes, Sobeski-yes, Sorensen-yes, Thomsen-yes. Motion Carried.

MULTIPLE SCLEROSIS DRUGS
PREFERRED DRUGS
NON-PREFERRED DRUGS
PDL EXCEPTION CRITERIA:
AVONEX (interferon beta-1a) AMPYRA (dalfampridine)* 1. Adverse reaction to, allergy, or BETASERON (interferon beta-1b) AUBAGIO (teriflunomide) contraindication to preferred drug. COPAXONE 20mg (glatiramer)
COPAXONE 40mg Syringe
GILENYA (fingolimod) 2. Documentation of treatment failure REBIF (interferon beta-1a) EXTAVIA (interferon beta-1b) with one preferred drug PLEGRIDY (peginterferon beta-1a) 30 BRAND PRODUCTS IN UPPER CASE generic names in lower case. If only the generic name is listed as preferred, then the
BRAND name of that product is non-preferred; unless the brand name product is ALSO listed as preferred. *Indicates that a clinical prior authorization is required despite the medication's status as preferred or non-preferred. QL indicates quantity limits. NR indicates product was not reviewed. New Drug criteria will apply. TECFIDERA (dimethyl fumarate)  Initial authorization for 12 weeks, requiring gait disorder associated with MS, no seizure diagnosis, no moderate or severe renal impairment, and baseline 25 foot, timed walk.  Additional prior authorizations every 6 months, based on maintained 20% improvement of baseline in 25-foot walk. EDSS score not greater than 7. It was moved by Dering-Anderson and seconded to accept recommendations as published, roll call vote was taken and the motion passed. Votes as follows: Baker-yes, Bleicher-yes, Bohac-yes, Caudill-yes, Davenport-yes, Dering-Anderson-yes, Dubé-yes, Elsasser-yes, Haberstitch-yes, Hammond-yes, Humphries-yes, Rock-yes, Saunders-yes, Sobeski-yes, Sorensen-yes, Thomsen-yes. Motion Carried.

(PAH) PULMONARY ARTERIAL HYPERTENSION AGENTS (Oral and inhaled)
PREFERRED DRUGS
NON-PREFERRED DRUGS
PDL EXCEPTION CRITERIA:
LETAIRIS (ambrisentan) ADCIRCA (tadalafil) (for PAH only)* Trial on a preferred agent or sildenafil (generic for Revatio) (for PAH ADEMPAS (riociguat) documentation of why not OPSUMIT (macitentan) appropriate for patient. TRACLEER (bosentan) ORENITRAM ER (treprostinil) TYVASO INHALATION (treprostinil) REVATIO SUSPENSION (for PAH Sildenafil and ADCIRCA: VENTAVIS INHALATION (iloprost) Require diagnosis of PAH. It was moved by Bohac and seconded to accept recommendations as published, roll call vote was taken and the motion passed. Votes as follows: Baker-yes, Bleicher-yes, Bohac-yes, Caudill-yes, Davenport-yes, Dering-Anderson-yes, Dubé-yes, Elsasser-yes, Haberstitch-yes, Hammond-yes, Humphries-yes, Rock-yes, Saunders-yes, Sobeski-yes, Sorensen-yes, Thomsen-yes. Motion Carried.

PHOSPHATE BINDERS
PREFERRED DRUGS
NON-PREFERRED DRUGS
PDL EXCEPTION CRITERIA:
calcium acetate TABLET
AURYXIA (ferric citrate) Non-preferred agents may be CALPHRON OTC (calcium acetate) calcium acetate CAPSULE
approved if the patient has a history PHOSLYRA (calcium acetate) ELIPHOS (calcium acetate) of one preferred agent in the last 6 RENAGEL (sevelamer HCl) FOSRENOL (lanthanum) PHOSLO (calcium acetate) RENVELA (sevelamer carbonate) VELPHORO (sucroferric 31 BRAND PRODUCTS IN UPPER CASE generic names in lower case. If only the generic name is listed as preferred, then the
BRAND name of that product is non-preferred; unless the brand name product is ALSO listed as preferred. *Indicates that a clinical prior authorization is required despite the medication's status as preferred or non-preferred. QL indicates quantity limits. NR indicates product was not reviewed. New Drug criteria will apply. It was moved by Sobeski and seconded to accept recommendations as published, roll call vote was taken and the motion passed. Votes as follows: Baker-yes, Bleicher-yes, Bohac-yes, Caudill-yes, Davenport-yes, Dering-Anderson-yes, Dubé-yes, Elsasser-yes, Haberstitch-yes, Hammond-yes, Humphries-yes, Rock-yes, Saunders-yes, Sobeski-yes, Sorensen-yes, Thomsen-yes. Motion Carried.

PLATELET AGGREGATION INHIBITORS
PREFERRED DRUGS
NON-PREFERRED DRUGS
PDL EXCEPTION CRITERIA:
AGGRENOX (dipyridamole/aspirin) ticlopidine (generic for Ticlid) 1. Adverse reaction to, allergy, or ZONTIVITY (vorapaxar) contraindication to preferred drugs. BRILINTA (ticagrelor) clopidogrel (generic for Plavix) 2. Documentation of treatment failure dipyridamole (generic for Persantine) with preferred drug. EFFIENT (prasugrel) It was moved by Dering-Anderson and seconded to accept recommendations as published, roll call vote was taken and the motion passed. Votes as follows: Baker-yes, Bleicher-yes, Bohac-yes, Caudill-yes, Davenport-yes, Dering-Anderson-yes, Dubé-yes, Elsasser-yes, Haberstitch-yes, Hammond-yes, Humphries-yes, Rock-yes, Saunders-yes, Sobeski-yes, Sorensen-yes, Thomsen-yes. Motion Carried.

ULCERATIVE COLITIS
PREFERRED DRUGS
NON-PREFERRED DRUGS
PDL EXCEPTION CRITERIA:
APRISO (mesalamine) ASACOL HD 800mg (mesalamine)
1. Adverse reaction to, allergy, or balsalazide (generic for Colazal) DELZICOL DR (mesalamine) contraindication to preferred drugs. sulfasalazine (generic for Azulfidine) DIPENTUM (olsalazine) sulfasalazine DR (generic for Azulfidine GIAZO (balsalazide) 2. Documentation of treatment failure LIALDA (mesalamine) with one preferred drug. PENTASA (mesalamine) UCERIS ORAL (budesonide)
ASACOL HD, DELZICOL DR, AND
LIALDA:
Clinical reason cannot use the
preferred form of mesalamine.
GIAZO: Clinical reason required as to
why the preferred generic balsalazide
cannot be used. GIAZO is most
likely used in males and will deny if
claim is for a female patient
(effectiveness in female patients was
not demonstrated in clinical trials).
CANASA (mesalamine) 1. Adverse reaction to, allergy, or 32 BRAND PRODUCTS IN UPPER CASE generic names in lower case. If only the generic name is listed as preferred, then the
BRAND name of that product is non-preferred; unless the brand name product is ALSO listed as preferred. *Indicates that a clinical prior authorization is required despite the medication's status as preferred or non-preferred. QL indicates quantity limits. NR indicates product was not reviewed. New Drug criteria will apply. SFROWASA (mesalamine) contraindication to preferred drugs. UCERIS RECTAL FOAM
2. Documentation of treatment failure with one preferred drug. It was moved by Sobeski and seconded to accept recommendations as published and the motion passed. Votes as follows: Baker-yes, Bleicher-yes, Bohac-yes, Caudill-yes, Davenport-yes, Dering-Anderson-yes, Dubé-yes, Elsasser-yes, Haberstitch-yes, Hammond-yes, Humphries-yes, Rock-yes, Saunders-yes, Sobeski-yes, Sorensen-yes, Thomsen-yes. Motion Carried.
Committee members requested the following information be made available to committee members: the number of requests and approvals for non-preferred drugs (specifically drugs that are prescribed to treat/prevent acute life threatening conditions). Committee members expressed concerns that prescribers fail to understand the following: 1) Medicaid's Preferred vs. Non-Preferred drug list is different than the private sector's Formulary vs. Non-formulary drug list. This difference makes every drug available to a Medicaid member, which is not the case for members served by the private sector. Dering-Anderson suggested that use of a pharmacy student to develop educational material for providers. 2) The PDL may not be easily accessible for prescribers. However, it was also noted that the PDL is the top result when "Nebraska Medicaid PDL" is typed into Google search. An all in favor motion was made to conclude the meeting at 1:52 p.m. Next meeting: The next meeting of the Nebraska Medicaid Pharmaceutical and Therapeutics Committee is scheduled for: Monday November 11, 2015 at 9:00a.m. CST Mahoney State Park, Ashland, NE Recorded by: Sabrina Hellbusch, R.N., B.S.N., Recovery Care Management, Magellan Medicaid Administration and Abigail Anderson, M.R.C.P., Program Specialist, Nebraska Medicaid & Long-Term Care, DHHS. 33 BRAND PRODUCTS IN UPPER CASE generic names in lower case. If only the generic name is listed as preferred, then the
BRAND name of that product is non-preferred; unless the brand name product is ALSO listed as preferred. *Indicates that a clinical prior authorization is required despite the medication's status as preferred or non-preferred. QL indicates quantity limits. NR indicates product was not reviewed. New Drug criteria will apply.

Source: https://nebraska.fhsc.com/Downloads/NE_PTminutes-20150513a.pdf