Kentucky Pharmacy Preferred Drug List
Effective December 5, 2012
GENERAL DEFINITION OF TERMS
st
1 Tier Medications ($) – Typically preferred generic medications. A generic medication is identified by its chemical name, while a
manufacturer assigns a brand name. Also, the price of the generic medication is usually lower than that of a brand name medication.
Both generic and brand name medications may require PA.
nd
2 Tier Medications ($$) – Typically preferred brand medications. Preferred brand medications may have generic equivalents. Once
a branded medication is available as a generic alternative, the branded medication may move to non-preferred status and the
generic medication may become the preferred medication. Some Tier 2 medications may require PA.
rd
3 Tier Medications ($$$) – Typically, branded medications which are not 1st or 2nd Tier. Non-preferred medications are usually
available at the highest copay tier for members. Prior authorization is required for all non-preferred medications.
Clinical Criteria (CC) – Due to the nature of some medications, prior authorization may be required for the medication to be covered
at any copay tier. Medications that require prior authorization will require that certain clinical criteria be met. Medications may
require the use of preferred medications (subject to PDL), in addition to satisfying appropriate clinical criteria, before approval
(prior authorization) can be considered. If a medication requires PA, the ordering physician should contact Magellan Medicaid
Administration, the plan’s pharmacy benefit administrator. Also, prescriptions exceeding such plan limitations as Quantity Limits
(QL), Step Therapy (ST), Maximum Duration (MD), Age Edit (AE), in addition to those subject to Clinical Criteria (CC), will also
require PA.
Step Therapy (ST) – Step therapy is an electronic PA process that takes place at t he time the pharmacy submits the claim. For
example, in the case of medications considered “second-line” agents, the system will look at the member’s paid claims history, and if
a claim(s) for the required “first-line” medication(s) is located, the system will approve the claim. If “first-line” medication(s) are not
located, the system will not approve the claim, and will return a message to the pharmacy advising that the Step Therapy protocol
has not been satisfied and prior authorization is required. At that time, the pharmacy may contact the physician and request that
they contact Magellan Medicaid Administration for PA.
Quantity Limits (QL) – Quantity limits have been placed on medications to be consistent with the maximum dosage that the Food
and Drug Administration (FDA) has approved to be both safe and effective. Medications where the quantity exceed the FDA’s
maximum daily dose will require PA. Prescriptions exceeding plan limitations will require PA.
Medication with Maximum Duration (MD) – Medications indicated will be available for a defined period of days per rolling year
(365 days) before requiring a new or additional PA.
Age Edit (AE) – Medications indicated are available for members above or below XX age without PA.
Maintenance Drugs – Maintenance medications in the following classes can be processed for up to a 92 day supply and 100 units:
Antianginals
Antiarrhythmics
Antiarthritics
Antidiabetics
Antihypertensives
Cardiac Glycosides
Digestants
Diuretics
Oral Contraceptives
Progesterones
Thyroid Preparations
AE – Age Edit
Rev 11/28/2012
CC – Clinical Criteria
MD – Medications with Maximum Duration
QL – Quantity Limit
ST – Step Therapy
Page 1 of 32
Kentucky Pharmacy Preferred Drug List
Effective December 5, 2012
MAGELLAN MEDICAID ADMINISTRATION/KENTUCKY WEBSITE: HTTPS://KENTUCKY.MAGELLANMEDICAID.COM/
MAGELLAN MEDICAID ADMINISTRATION CLINICAL SUPPORT CENTER: PHONE 800-477-3071; FAX 800-365-8835
I.
CARDIOVASCULAR
Drug Class
Preferred Agents
ACE Inhibitors
benazepril
captopril
enalapril
fosinopril
lisinopril
quinapril
ramipril
Angiotensin Modulators Lotrel®
+ CCB Combinations
ACEI + Diuretic
Combination
benazepril/HCTZ
captopril/HCTZ
enalapril/HCTZ
lisinopril/HCTZ
quinapril/HCTZ
Quinaretic®
Angiotensin Receptor
Blockers
Diovan®
losartan
Angiotensin Receptor
Blockers + CCB (DHP)
Exforge®
ST
Exforge HCT®
AE – Age Edit
Rev 11/28/2012
ST
ST
CC – Clinical Criteria
Relative Cost
Non-Preferred Agents
Relative Cost of
Most Agents
$
$
$
$
$
$
$
Accupril®
Aceon®
Altace®
Capoten®
Lotensin®
Mavik®
moexipril
perindopril
Prinivil®
trandolapril
Univasc®
Vasotec®
Zestril®
$$$
$
amlodipine/benazepril
Tarka®
verapamil/trandolapril
$$$
$
$
$
$
$
$
Accuretic®
Capozide®
fosinopril HCT
Lotensin HCT®
moexipril/HCTZ
Prinzide®
Uniretic®
Vaseretic®
Zestoretic®
$$$
$$
$
Atacand®
Avapro®
Benicar®
Cozaar®
Edarbi™
eprosartan
irbesartan
Micardis®
Teveten®
$$$
$$
$$
Azor™
Tribenzor®
Twynsta®
$$$
MD – Medications with Maximum Duration
QL – Quantity Limit
ST – Step Therapy
Page 2 of 32
Kentucky Pharmacy Preferred Drug List
Effective December 5, 2012
MAGELLAN MEDICAID ADMINISTRATION/KENTUCKY WEBSITE: HTTPS://KENTUCKY.MAGELLANMEDICAID.COM/
MAGELLAN MEDICAID ADMINISTRATION CLINICAL SUPPORT CENTER: PHONE 800-477-3071; FAX 800-365-8835
I.
CARDIOVASCULAR
Drug Class
Preferred Agents
ST
Relative Cost
Non-Preferred Agents
Relative Cost of
Most Agents
Angiotensin Receptor
Blockers + Diuretic
Diovan HCT®
losartan/HCTZ
$
$
Atacand HCT®
Avalide®
Benicar HCT®
Edarbyclor™
Hyzaar®
irbesartan/HCTZ
Micardis HCT®
Teveten HCT®
valsartan/HCTZ
$$$
Anti-Arrhythmics, Oral
amiodarone 200 mg
disopyramide
flecainide
mexiletine
procainamide
propafenone
quinidine gluconate
quinidine sulfate
quinidine sulfate CR
Tikosyn®
$
$
$
$
$
$
$
$
$
$$
amiodarone 400 mg
Cordarone®
Multaq®
Norpace®
Norpace® CR
Pacerone®
Pronestyl®
propafenone SR
Rythmol®
Rythmol® SR
Tambocor®
$$$
Direct Renin Inhibitors
Amturnide™
ST
Tekturna®
ST
Tekturna HCT®
ST
Tekamlo®
$$
$$
$$
$$
N/A
Beta Blockers
acebutolol
atenolol
betaxolol
bisoprolol fumerate
metoprolol succinate ER
metoprolol tartrate
nadolol
pindolol
propranolol
propranolol LA
sotalol
timolol
$
$
$
$
$
$
$
$
$
$
$
$
Betapace®
Betapace® AF
Bystolic®
Corgard®
Inderal® LA
InnoPran XL®
Kerlone®
Levatol®
Lopressor®
Sectral®
Sorine®
Tenormin®
Toprol XL®
Zebeta®
$$$
Beta Blockers + Diuretic
atenolol/chlorthalidone
bisoprolol/HCTZ
metoprolol/HCTZ
nadolol/endroflumethiazide
propranolol/HCTZ
$
$
$
$
$
Corzide®
Dutoprol™
Lopressor® HCT
Tenoretic®
Ziac®
$$$
AE – Age Edit
Rev 11/28/2012
ST
CC – Clinical Criteria
MD – Medications with Maximum Duration
QL – Quantity Limit
ST – Step Therapy
Page 3 of 32
Kentucky Pharmacy Preferred Drug List
Effective December 5, 2012
MAGELLAN MEDICAID ADMINISTRATION/KENTUCKY WEBSITE: HTTPS://KENTUCKY.MAGELLANMEDICAID.COM/
MAGELLAN MEDICAID ADMINISTRATION CLINICAL SUPPORT CENTER: PHONE 800-477-3071; FAX 800-365-8835
I.
CARDIOVASCULAR
Drug Class
Preferred Agents
Alpha/Beta Blockers
carvedilol
labetalol
Relative Cost
Non-Preferred Agents
Relative Cost of
Most Agents
$
$
Coreg CR®
Coreg®
Trandate®
$$$
Calcium Channel Blockers Afeditab® CR
(DHP)
amlodipine
felodipine ER
isradipine
nicardipine HCl
Nifediac® CC
Nifedical® XL
nifedipine IR
nifedipine ER/SA/XL
nimodipine
$
$
$
$
$
$
$
$
$
$
Adalat CC®
Cardene SR®
Dynacirc CR®
Nimotop®
nisoldipine
Norvasc®
Plendil®
Procardia XL®
Procardia®
Sular®
$$$
Calcium Channel Blockers diltiazem
(Non-DHP)
diltiazem ER
verapamil
verapamil ER
$
$
$
$
Calan®
Calan SR®
Cardizem®
Cardizem CD®
Cardizem LA®
Covera-HS®
Dilacor XR®
Diltia XT®
Tiazac®
verapamil ER PM
Verelan®
Verelan PM®
$$$
$$
N/A
Vasodilator and Nitrate
Combinations
BiDil®
Agents for Pulmonary
Hypertension
Adcirca™
Letairis™
Tracleer®
Ventavis®
CC
$$
$$
$$
$$
Revatio™
Tyvaso™
Lipotropics: Bile Acid
Sequestrants
cholestyramine
cholestyramine light
WelChol®
$
$
$$
Colestid®
colestipol
Prevalite®
Questran®
Questran Light®
Lipotropics: Cholesterol
Absorption Inhibitors
Zetia®
$$
N/A
Lipotropics: Fibric Acid
Derivatives
gemfibrozil
TriCor®
Trilipix™
$
$$
$$
Antara™
fenofibrate
Fibricor™
Lipofen™
Lofibra®
Triglide™
AE – Age Edit
Rev 11/28/2012
CC – Clinical Criteria
MD – Medications with Maximum Duration
CC
$$$
$$$
$$$
QL – Quantity Limit
ST – Step Therapy
Page 4 of 32
Kentucky Pharmacy Preferred Drug List
Effective December 5, 2012
MAGELLAN MEDICAID ADMINISTRATION/KENTUCKY WEBSITE: HTTPS://KENTUCKY.MAGELLANMEDICAID.COM/
MAGELLAN MEDICAID ADMINISTRATION CLINICAL SUPPORT CENTER: PHONE 800-477-3071; FAX 800-365-8835
I.
CARDIOVASCULAR
Drug Class
Preferred Agents
Lipotropics: Omega-3
Fatty Acids
Lovaza®
ST
QL
Lipotropics: High Potency atorvastatin
QL
Statins
simvastatin
Lipotropics: Statins
QL
fluvastatin
QL
Lescol XL®
QL
lovastatin
QL
pravastatin
Lipotropics: Statin + CCB amlodipine/atorvastatin
Combination
CC
Relative Cost
Non-Preferred Agents
Relative Cost of
Most Agents
$$
N/A
$
$
Crestor®
QL
Lipitor®
QL
Livalo®
QL
Vytorin™
QL
Zocor®
$$$
$
$$
$
$
Advicor™
QL
Altoprev®
QL
Lescol®
QL
Mevacor®
QL
Pravachol®
QL
$$$
$$
Caduet®
$$$
QL
Lipotropics: Niacin
Derivatives
Niaspan®
Simcor®
$$
$$
Niacor®
$$$
Platelet Inhibitors
Aggrenox®
CC
Brilinta™
clopidogrel
cilostazol
dipyridamole
Effient™
ticlopidine
$$
$$
$
$
$
$$
$
Persantine®
Plavix®
Pletal®
$$$
Anticoagulants
Fragmin®
fondaparinux
Jantoven®
Lovenox®
CC
Pradaxa®
warfarin
Xarelto®
$$
$
$$
$
$$
$
$$
Arixtra®
Coumadin®
enoxaparin
Innohep®
$$$
II.
GASTROINTESTINAL
Drug Class
Oral Anti-Emetics:
Anticholinergics
AE – Age Edit
Rev 11/28/2012
Preferred Agents
meclizine
prochlorperazine
promethazine
Transderm-Scop Patch®
trimethobenzamide
CC – Clinical Criteria
Relative Cost
$
$
$
$$
$
Non-Preferred Agents
Antivert®
Phenergan®
Tigan®
Univert®
MD – Medications with Maximum Duration
Relative Cost of
Most Agents
$$$
QL – Quantity Limit
ST – Step Therapy
Page 5 of 32
Kentucky Pharmacy Preferred Drug List
Effective December 5, 2012
MAGELLAN MEDICAID ADMINISTRATION/KENTUCKY WEBSITE: HTTPS://KENTUCKY.MAGELLANMEDICAID.COM/
MAGELLAN MEDICAID ADMINISTRATION CLINICAL SUPPORT CENTER: PHONE 800-477-3071; FAX 800-365-8835
II.
GASTROINTESTINAL
Drug Class
Preferred Agents
Oral Anti-Emetics: 5-HT3 ondansetron
Antagonists
QL
QL
Oral Anti-Emetics: NK-1
Antagonists
Emend®
Oral Anti-Emetics: Δ-9THC Derivatives
dronabinol
CC, QL
H2 Receptor Antagonists cimetidine
famotidine
ranitidine
QL
Relative Cost
Non-Preferred Agents
QL
Relative Cost of
Most Agents
$
Aloxi®
QL
Anzemet®
QL
granisetron
Granisol™
QL
Kytril®
CC, QL
Sancuso®
QL
Zofran®
Zuplenz®
$$
N/A
$
Cesamet®
CC, QL
Marinol®
$$$
$
$
$
Axid®
Pepcid®
nizatidine
Zantac®
$$$
CC, QL
QL
$$$
Proton Pump Inhibitors
Nexium®
QL
omeprazole
QL
pantoprazole
$$
$
$
Aciphex®
QL
Dexilant™
QL
lansoprazole
QL
omeprazole/sodium bicarb
QL
Prevacid®
QL
Prilosec®
QL
Protonix®
$$$
Anti-Ulcer Protectants
misoprostol
sucralfate
$
$
Carafate®
Cytotec®
$$$
Combination Products
for H. pylori
Helidac®
QL
Prevpac®
QL
Pylera™
$$
$$
Omeclamox-Pak®
$$$
Antispasmodics/
Anticholinergics
atropine sulfate
dicyclomine
glycopyrrolate
hyoscyamine
methscopolamine
propantheline
$
$
$
$
$
$
Anaspaz®
Bentyl®
Cantil®
chlordiazepoxide/clidinium
Cuvposa®
Librax®
Pamine®
Pamine® Forte
PB-Hyos®
Quadrapax®
Robinul®
Robinul Forte®
Sal-Tropine®
Scopace®
$$$
AE – Age Edit
Rev 11/28/2012
QL
CC – Clinical Criteria
MD – Medications with Maximum Duration
QL – Quantity Limit
ST – Step Therapy
Page 6 of 32
Kentucky Pharmacy Preferred Drug List
Effective December 5, 2012
MAGELLAN MEDICAID ADMINISTRATION/KENTUCKY WEBSITE: HTTPS://KENTUCKY.MAGELLANMEDICAID.COM/
MAGELLAN MEDICAID ADMINISTRATION CLINICAL SUPPORT CENTER: PHONE 800-477-3071; FAX 800-365-8835
II.
GASTROINTESTINAL
Drug Class
Preferred Agents
Relative Cost
Non-Preferred Agents
Relative Cost of
Most Agents
5-ASA Derivatives
Apriso™
Asacol®
balsalazide
Canasa®
mesalamine enemas
sfRowasa®
sulfasalazine
$$
$$
$
$$
$
$$
$
Asacol HD®
Azulfidine®
Azulfidine EN®
Dipentum®
Lialda™
Pentasa®
Rowasa®
$$$
Antidiarrheals
diphenoxylate with atropine
loperamide
$
$
Lomotil®
Motofen®
paregoric
$$$
$$
$
$$
$$
$
$
$
$
$$
CoLyte® with flavoring
Gavilyte-C®
Gavilyte-G®
Gavilyte-N®
GoLytely®
HalfLytely-Bisacodyl Bowel Kit®
Kristalose®
Miralax®
NuLytely® with Flavor Packs
OCL®
CC
Relistor®
Suprep®
Trilyte® with Flavor Packets
$$$
CC
Laxatives and Cathartics Amitiza®
lactulose
MoviPrep®
OsmoPrep®
PEG 3350/Electrolyte
PEG 3350/Na Sulf, Bicarb, Cl/KCl
polyethylene glycol
Sod Chloride/NaHCO3/KCl/PEGS
Visicol®
III.
RESPIRATORY
Drug Class
Antibiotics, Inhaled
Antihistamines,
Minimally Sedating
AE – Age Edit
Rev 11/28/2012
Preferred Agents
TOBI®
$$
cetirizine OTC (EXCEPT chewable
tablets)
loratadine OTC
loratadine-pseudoephedrine OTC
CC – Clinical Criteria
Relative Cost
$
$
$
Non-Preferred Agents
Cayston®
$$$
ST
Allegra®
Allegra-D® 12 Hr
Allegra-D® 24 Hr
ST
cetirizine syrup
ST
Clarinex®
Clarinex-D® 12 Hr
Clarinex-D® 24 Hr
desloratadine
ST
fexofenadine
fexofenadine/pseudoephedrine 12Hour
fexofenadine/pseudoephedrine 24Hour
ST
levocetirizine
Semprex D®
ST
Xyzal®
MD – Medications with Maximum Duration
Relative Cost of
Most Agents
QL – Quantity Limit
$$$
ST – Step Therapy
Page 7 of 32
Kentucky Pharmacy Preferred Drug List
Effective December 5, 2012
MAGELLAN MEDICAID ADMINISTRATION/KENTUCKY WEBSITE: HTTPS://KENTUCKY.MAGELLANMEDICAID.COM/
MAGELLAN MEDICAID ADMINISTRATION CLINICAL SUPPORT CENTER: PHONE 800-477-3071; FAX 800-365-8835
III.
RESPIRATORY
Drug Class
Preferred Agents
Relative Cost
Non-Preferred Agents
Relative Cost of
Most Agents
Antihistamines,
Intranasal
Astepro®
azelastine
$$
$
Astelin®
Patanase™
$$$
Anticholinergics,
Intranasal
ipratropium nasal spray
$
Atrovent®
$$$
Beta Agonists: ShortActing
albuterol inhalation solution
albuterol oral
QL
ProAir HFA®
QL
Proventil® HFA
terbutaline
$
$
$$
$$
$
levalbuterol inhalation solution
QL
Maxair Autohaler®
QL
metaproterenol inhalation solution
metaproterenol oral
QL
Ventolin HFA®
QL
Xopenex®
QL
Xopenex HFA®
Beta Agonists: LongActing
Foradil® Aerolizer®
QL
Serevent® Diskus
$$
$$
Arcapta™
QL
Brovana®
QL
Perforomist®
Beta Agonists:
Combination Products
Advair Diskus ®
QL
Advair HFA®
QL
Dulera®
QL
Symbicort®
$$
$$
$$
$$
N/A
COPD Agents
albuterol-ipratropium inhalation
QL
solution
QL
Atrovent® HFA
QL
Combivent®
QL
Combivent Respimat®
QL
ipratropium inhalation solution
QL
Spiriva Handihaler®
$
Daliresp™
QL
DuoNeb®
QL
QL
QL
Corticosteroids, Inhaled
Asmanex® Twisthaler
AE, QL
budesonide respules
QL
Flovent Diskus®
QL
Flovent HFA®
QL
QVAR™
Corticosteroids,
Intranasal
fluticasone propionate
QL
Nasonex®
Leukotriene Modifiers
montelukast
CC, QL
zafirlukast
AE – Age Edit
Rev 11/28/2012
CC – Clinical Criteria
QL
CC, QL
QL
QL
$$$
QL
$$$
QL
$$$
$$
$$
$$
$
$$
QL
$$
$
$$
$$
$$
Alvesco®
QL
Pulmicort Flexhaler®
QL
Pulmicort Respules®
$
$$
Beconase AQ®
QL
Flonase®
QL
flunisolide
QL
Nasacort AQ®
QL
Omnaris™
QL
Qnasl™
QL
Rhinocort Aqua®
QL
triamcinolone
QL
Veramyst®
QL
Zetonna®
$
$
Accolate®
CC, QL
Singulair®
Zyflo CR®
QL
MD – Medications with Maximum Duration
QL
QL – Quantity Limit
$$$
$$$
$$$
ST – Step Therapy
Page 8 of 32
Kentucky Pharmacy Preferred Drug List
Effective December 5, 2012
MAGELLAN MEDICAID ADMINISTRATION/KENTUCKY WEBSITE: HTTPS://KENTUCKY.MAGELLANMEDICAID.COM/
MAGELLAN MEDICAID ADMINISTRATION CLINICAL SUPPORT CENTER: PHONE 800-477-3071; FAX 800-365-8835
III.
RESPIRATORY
Drug Class
Preferred Agents
Epi Pen®
Epi Pen® Jr.
Self Injectable
Epinephrine
IV.
Relative Cost
$$
$$
Non-Preferred Agents
Relative Cost of
Most Agents
Non-Preferred Agents
Relative Cost of
Most Agents
N/A
CENTRAL NERVOUS SYSTEM
Drug Class
Preferred Agents
Relative Cost
Alzheimer’s:
Cholinesterase
Inhibitors
Exelon® Patch/Solution
donepezil
rivastigmine
$$
$
$
Aricept®
Aricept ODT®
galantamine
Exelon®
galantamine ER
Cognex®
Razadyne®
Razadyne ER®
Alzheimer’s: NMDA
Receptor Antagonists
Namenda®
$$
N/A
Antialcoholic
Preparations
naltrexone oral
Depade®
ReVia®
Antabuse®
Campral®
CC
Vivitrol®
$
$
$
$$
$$
$$
N/A
Antianxiety Agents
alprazolam IR/ER
buspirone
chlordiazepoxide
clonazepam
clorazepate
diazepam tablets
halazepam
hydroxyzine capsules
oxazepam
$
$
$
$
$
$
$
$
$
diazepam liquid®
Buspar®
Klonopin®
Librium®
CC
Niravam®
Serax®
CC
Tranxene®
Valium®
Vistaril®
CC
Xanax®
CC
Xanax XR®
AE – Age Edit
Rev 11/28/2012
CC – Clinical Criteria
MD – Medications with Maximum Duration
$$$
CC
QL – Quantity Limit
$$$
ST – Step Therapy
Page 9 of 32
Kentucky Pharmacy Preferred Drug List
Effective December 5, 2012
MAGELLAN MEDICAID ADMINISTRATION/KENTUCKY WEBSITE: HTTPS://KENTUCKY.MAGELLANMEDICAID.COM/
MAGELLAN MEDICAID ADMINISTRATION CLINICAL SUPPORT CENTER: PHONE 800-477-3071; FAX 800-365-8835
IV.
CENTRAL NERVOUS SYSTEM
Drug Class
Preferred Agents
Antidepressants: SSRIs
citalopram HBr
fluoxetine HCl
fluvoxamine
paroxetine HCl
QL
sertraline
ST
Viibryd®
Antidepressants: SNRIs
QL
Relative Cost
Non-Preferred Agents
QL
Relative Cost of
Most Agents
$
$
$
$
$
$$
Celexa®
QL
escitalopram
QL
fluoxetine weekly
QL
Lexapro®
Luvox®
Luvox™ CR
paroxetine CR
Paxil®
Paxil CR®
Pexeva®
Prozac®
QL
Prozac Weekly®
Sarafem®
QL
Zoloft®
Savella™
venlafaxine
venlafaxine XR
$$
$
$
Cymbalta®
Effexor®
Effexor XR®
Pristiq™
venlafaxine ER tablets
$$$
Antidepressants: New
Generation
budeprion SR
bupropion SR
bupropion HCl
bupropion SA
maprotiline
mirtazapine
mirtazapine rapdis
nefazodone HCl
trazodone
$
$
$
$
$
$
$
$
$
bupropion XL
budeprion XL
Aplenzin™
Forfivo XL®
Desyrel®
Oleptro®
Remeron®
Remeron SolTab®
Wellbutrin®
Wellbutrin SR®
Wellbutrin XL®
$$$
Antidepressants:
Tricyclics
amitriptyline
amoxapine
clomipramine
desipramine
doxepin
imipramine
nortriptyline
protriptyline
Anafranil®
Norpramin®
Pamelor®
Sinequan®
$
$
$
$
$
$
$
$
$$
$$
$$
$$
Asendin®
Aventyl®
Elavil®
Surmontil®
Tofranil®
Tofranil-PM®
Vivactil®
$$$
Antidepressants: MISC.
N/A
AE – Age Edit
Rev 11/28/2012
CC
CC – Clinical Criteria
CC
EMSAM®
MD – Medications with Maximum Duration
QL
$$$
$$$
QL – Quantity Limit
ST – Step Therapy
Page 10 of 32
Kentucky Pharmacy Preferred Drug List
Effective December 5, 2012
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IV.
CENTRAL NERVOUS SYSTEM
Drug Class
Preferred Agents
Non-Preferred Agents
Relative Cost of
Most Agents
$$
$
$
$
$
$
$
$$
$
$$
$
$
$
Depakene®
Depakote®
Depakote ER®
diazepam rectal gel
Dilantin®
Klonopin®
Mebaral®
Onfi™
Stavzor™
Zarontin®
$$
CC
$$
$
$
$
$
$
$$
$$
$
$
Felbatol®
Keppra®
Keppra XR®
Lamictal™
Lamictal ODT™
Lamictal XR™
levetiracetam ER
Neurontin®
Potiga™
tiagabine
Topamax®
Vimpat®
Zonegran®
$$
Anticonvulsants:
Carbamazepine
Derivatives
Carbatrol®
carbamazepine
carbamazepine XR
Equetro®
oxcarbazepine
$
$
$
$$
$
carbamazepine ER
Tegretol®
Tegretol-XR®
Trileptal®
$$
Antipsychotics: Typical
amitriptyline/perphenazine
chlorpromazine
fluphenazine
haloperidol
loxapine
Moban®
Orap®
perphenazine
thioridazine
thiothixene
trifluoperazine
$
$
$
$
$
$$
$$
$
$
$
$
Loxitane®
Navane®
$$$
Anticonvulsants: First
Generation
Celontin®
clonazepam
DiaStat®
divalproex sodium
divalproex sodium ER
ethosuximide
CC
mephobarbital
Peganone®
CC
phenobarbital
Phenytek®
phenytoin
primidone
valproic acid
Relative Cost
Anticonvulsants: Second Banzel®
Generation
felbamate
Gabitril®
gabapentin
lamotrigine
levetiracetam
CC
Lyrica®
CC
Sabril™
topiramate
zonisamide
AE – Age Edit
Rev 11/28/2012
CC – Clinical Criteria
MD – Medications with Maximum Duration
QL – Quantity Limit
ST – Step Therapy
Page 11 of 32
Kentucky Pharmacy Preferred Drug List
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IV.
CENTRAL NERVOUS SYSTEM
Drug Class
Preferred Agents
Antipsychotics: Atypical
Clozaril®
CC, QL
Geodon®
CC, QL
Invega®
CC, QL
Latuda®
CC, QL
Risperdal®
CC, QL
Seroquel®
CC, QL
Zyprexa Zydis®
CC, QL
Zyprexa®
CC, QL
$
$
$
$
$
$
$
$
Haldol® Decanoate
CC, QL
Zyprexa®
CC, QL
Zyprexa® Relprevv™
$
$
olanzapine/fluoxetine
$$$
$
$
$
$
$
$$
$$
$$
$$
$$
$$
$$
$$
$$
Adderall®
CC, QL
Concerta®
CC, QL
Daytrana®
CC, QL
Desoxyn®
CC, QL
Dexedrine IR/ER®
CC, QL
Focalin®
CC, QL
Kapvay™
CC, QL
Methylin Solution®
CC, QL
mixed amphetamine salts ER
methylphenidate (Generic for
CC, QL
Metadate CD®)
methylphenidate LA (Generic Ritalin®
CC, QL
LA)
CC, QL
modafinil
CC, QL
Nuvigil®
CC, QL
Procentra™
CC, QL
Provigil®
CC, QL
Ritalin® IR/LA/SR
Symbyax®
CC, QL
CC, QL
Rev 11/28/2012
CC – Clinical Criteria
CC, QL
Relative Cost of
Most Agents
$
$
$
$
$
$
$
$
$
$
Antihyperkinesis Agents dexmethylphenidate IR
CC, QL
dextroamphetamine IR/ER
CC, QL
methylphenidate IR/SA/SR
CC, QL
mixed amphetamine salts IR
CC, QL
Adderall XR®
CC, QL
Dextrostat®
CC, QL
Focalin XR®
CC, QL
Intuniv™
CC, QL
Metadate CD/ER®
CC, QL
Methylin®
CC, QL
Methylin Chewable®
CC, QL
Methylin ER®
CC, QL
Strattera®
CC, QL
Vyvanse™
AE – Age Edit
Non-Preferred Agents
CC, QL
Abilify®
CC, QL
clozapine
CC, QL
Fanapt™
CC, QL
FazaClo ODT®
CC, QL
olanzapine
CC, QL
quetiapine
CC, QL
risperidone
CC, QL
Saphris®
CC, QL
Seroquel XR®
CC, QL
ziprasidone
Antipsychotics: Injectable Abilify®
CC, QL
chlorpromazine
CC, QL
fluphenazine decanoate
CC, QL
Geodon®
CC, QL
haloperidol decanoate
CC, QL
Invega® Sustenna™
CC, QL
olanzapine
CC, QL
Risperdal Consta®
Atypical Antipsychotic
and SSRI Comb.
Relative Cost
$
CC, QL
MD – Medications with Maximum Duration
CC, QL
QL – Quantity Limit
$$$
ST – Step Therapy
Page 12 of 32
Kentucky Pharmacy Preferred Drug List
Effective December 5, 2012
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IV.
CENTRAL NERVOUS SYSTEM
Drug Class
Preferred Agents
QL
Non-Preferred Agents
QL
Relative Cost of
Most Agents
$
Amerge®
QL
Alsuma®
QL
Axert®
QL
Cambia™
QL
Frova™
QL
Imitrex®
QL
Maxalt®
QL
Maxalt MLT®
QL
naratriptan
QL
Relpax™
QL
Sumavel ™Dosepro™
QL
Treximet™
QL
Zomig®
$$$
pramipexole
Non-Ergot Dopamine
Receptor Agonists
ropinirole
The Preferred/NonPreferred status above is
applicable to use for
Restless Leg Syndrome
ONLY. Both Requip and
Mirapex are available
without prior
authorization when used
for Parkinson's Disease.
$
$
Mirapex®
Mirapex ER®
Requip®
Requip® XL
ropinirole XL
$$$
Sedative Hypnotic Agents chloral hydrate
QL
estazolam
QL
flurazepam
QL
temazepam 15 mg, 30 mg
QL
triazolam
QL
zolpidem
$
$
$
$
$
$
Ambien®
QL
Ambien CR®
QL
Doral®
CC, QL
Edluar®
QL
Halcion®
QL
Intermezzo®
QL
Lunesta™
QL
Restoril®
CC, QL
Rozerem®
QL
temazepam 22.5 mg, 7.5 mg
QL
Silenor®
Somnote®
QL
Sonata®
QL
zaleplon
QL
zolpidem ER
QL
Zolpimist™
$$
N/A
Anti-Migraine: 5-HT1
Receptor Agonists
Miscellaneous CNS
Agents
AE – Age Edit
Rev 11/28/2012
sumatriptan
Relative Cost
Xyrem®
QL
CC – Clinical Criteria
QL
MD – Medications with Maximum Duration
QL – Quantity Limit
$$$
ST – Step Therapy
Page 13 of 32
Kentucky Pharmacy Preferred Drug List
Effective December 5, 2012
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IV.
CENTRAL NERVOUS SYSTEM
Drug Class
Preferred Agents
QL
Skeletal Muscle
Relaxants
baclofen
QL
chlorzoxazone
QL
cyclobenzaprine
QL
dantrolene
QL
methocarbamol
QL
orphenadrine
QL
orphenadrine compound
QL
orphenadrine compound forte
QL
tizanidine
Tobacco Cessation
bupropion SR
QL, MD
Chantix®
QL, MD
nicotine gum
QL, MD
nicotine lozenge
QL, MD
nicotine transdermal system
V.
Relative Cost
Non-Preferred Agents
QL, MD
$
$
$
$
$
$
$
$
$
Amrix®
QL, MD
carisoprodol
QL, MD
carisoprodol compound
ER QL, MD
cyclobenzaprine
QL
Dantrium®
QL, MD
Fexmid®
QL, MD
Flexeril®
QL
Gablofen®
QL
Lioresal®
QL
metaxalone
QL
Norflex®
QL
Norgesic®
QL
Robaxin®
QL
Skelaxin®
QL, MD
Soma®
QL
tizanidine capsules
QL
Zanaflex®
QL, MD
Relative Cost of
Most Agents
$$$
QL, MD
Commit Lozenge®
QL, MD
Nicoderm CQ®
QL, MD
Nicorette®
QL, MD
Nicorette Mini Lozenge®
QL, MD
Nicotrol® Inhaler
QL, MD
Nicotrol® NS
QL, MD
Zyban®
ANALGESICS
Drug Class
Narcotic Agonist/
Antagonists
AE – Age Edit
Rev 11/28/2012
Preferred Agents
butorphanol NS
pentazocine/APAP
pentazocine/naloxone
CC – Clinical Criteria
Relative Cost
$
$
$
Non-Preferred Agents
Stadol NS®
Talacen®
Talwin®
Talwin NX®
Zanaflex®
MD – Medications with Maximum Duration
Relative Cost of
Most Agents
$$$
QL – Quantity Limit
ST – Step Therapy
Page 14 of 32
Kentucky Pharmacy Preferred Drug List
Effective December 5, 2012
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V.
ANALGESICS
Drug Class
Preferred Agents
Narcotics: Short-Acting
AE – Age Edit
Rev 11/28/2012
butalbital compound/codeine
MD
codeine/APAP
dihydrocodeine
bitartrate/APAP/caffeine
MD
hydrocodone/APAP
hydrocodone/ibuprofen
hydromorphone
meperidine
morphine IR
oxycodone
MD
oxycodone/APAP
oxycodone/ibuprofen
oxymorphone IR
tramadol
CC – Clinical Criteria
Relative Cost
CC
$
$
$
$
$
$
$
$
$
$
$
$
$
Non-Preferred Agents
Relative Cost of
Most Agents
All branded short-acting narcotics and $$$
narcotic combinations
codeine
Capital®
Demerol®
Dilaudid®
Endodan®
Hycet®
Ibudone™
levorphanol
Margesic H®
Maxidone®
Norco®
Nucynta™
Opana®
Oxecta®
MD
oxycodone/ASA
Primlev®
Reprexain™
Rybix™ ODT
Synalgos DC®
tramadolAPAP
Trezix®
Ultracet®
Ultram®
Xodol®
Xolox®
Zamicet™
Zolvit™
MD – Medications with Maximum Duration
QL – Quantity Limit
ST – Step Therapy
Page 15 of 32
Kentucky Pharmacy Preferred Drug List
Effective December 5, 2012
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MAGELLAN MEDICAID ADMINISTRATION CLINICAL SUPPORT CENTER: PHONE 800-477-3071; FAX 800-365-8835
V.
ANALGESICS
Drug Class
Preferred Agents
CC, QL
Narcotics: Long-Acting
fentanyl transdermal
QL
Kadian®
QL
methadone
QL
morphine sulfate SA
Narcotics: Fentanyl
Buccal Products
N/A
AE – Age Edit
Rev 11/28/2012
CC – Clinical Criteria
Relative Cost
$
$$
$
$
Non-Preferred Agents
QL
Avinza™
CC, QL
Butrans™
QL
ConZip™
QL
Dolophine®
CC, QL
Duragesic®
QL
Embeda™
QL
Exalgo™
methadone concentrate
morphine sulfate SA (Generic
QL
Kadian®)
QL
MS Contin®
QL
Nucynta® ER
QL
Opana ER®
QL
Oramorph® SR
QL
oxycodone SR
QL
OxyContin®
QL
oxymorphone ER
QL
Ryzolt™
QL
tramadol ER
QL
Ultram® ER
fentanyl citrate lollipop
CC, QL
Abstral®
CC, QL
Actiq®
CC, QL
Fentora®
CC, QL
Onsolis™
MD – Medications with Maximum Duration
CC, QL
QL – Quantity Limit
Relative Cost of
Most Agents
$$$
$$$
ST – Step Therapy
Page 16 of 32
Kentucky Pharmacy Preferred Drug List
Effective December 5, 2012
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MAGELLAN MEDICAID ADMINISTRATION CLINICAL SUPPORT CENTER: PHONE 800-477-3071; FAX 800-365-8835
V.
ANALGESICS
Drug Class
Non-Steroidal AntiInflammatory Drugs
VI.
Preferred Agents
Celebrex®
diclofenac potassium
etodolac
flurbiprofen
ibuprofen
indomethacin
ketoprofen
QL
ketorolac tromethamine
meloxicam tablets
naproxen sodium
naproxen tablets
piroxicam
sulindac
Relative Cost
$$
$
$
$
$
$
$
$
$
$
$
$
$
Non-Preferred Agents
Anaprox®
Anaprox® DS
Ansaid®
Arthrotec®
Cataflam®
Clinoril®
Daypro®
diclofenac sodium
diclofenac SR
diflunisal
CC
Duexis®
etodolac SR
Feldene®
fenoprofen
CC
Flector®
Indocin®
indomethacin ER
ketoprofen ER
meclofenamate
mefenamic acid
meloxicam suspension
Mobic®
nabumetone
Nalfon®
Naprelan® EC
naproxen suspension
naproxen EC
oxaprozin
CC
Pennsaid®
Ponstel®
CC
Sprix™
tolmetin
QL
Vimovo™
CC
Voltaren® Gel
Voltaren® XR
Zipsor™
Relative Cost of
Most Agents
$$$
ANTI-INFECTIVES
Drug Class
Antibiotics:
st
Cephalosporins 1
Generation
AE – Age Edit
Rev 11/28/2012
Preferred Agents
cefadroxil
cephalexin
CC – Clinical Criteria
Relative Cost
$
$
Non-Preferred Agents
Duricef®
Keflex®
MD – Medications with Maximum Duration
Relative Cost of
Most Agents
$$$
QL – Quantity Limit
ST – Step Therapy
Page 17 of 32
Kentucky Pharmacy Preferred Drug List
Effective December 5, 2012
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MAGELLAN MEDICAID ADMINISTRATION CLINICAL SUPPORT CENTER: PHONE 800-477-3071; FAX 800-365-8835
VI.
ANTI-INFECTIVES
Drug Class
Preferred Agents
Relative Cost
Non-Preferred Agents
Relative Cost of
Most Agents
Antibiotics:
nd
Cephalosporins 2
Generation
cefaclor
cefprozil
cefuroxime
$
$
$
Ceclor®
cefaclor ER
Ceftin®
Cefzil®
Raniclor™
$$$
Antibiotics:
rd
Cephalosporins 3
Generation
cefdinir
cefditoren
cefpodoxime
Suprax®
$
$
$
$$
Cedax®
Omnicef®
Spectracef®
Suprax® chewable tablets
Vantin®
$$$
Antibiotics: GI
Alinia® tablets
metronidazole tablets
vancomycin
$$
$
$
Alinia® suspension
Dificid®
Flagyl®
Flagyl® ER
metronidazole capsules
neomycin
Neo-Fradin®
Tindamax®
tinidazole
CC, QL
Xifaxan®
Vancocin®
$$$
Antibiotics: Ketolides
Ketek®
$$
N/A
Antibiotics: Macrolides
azithromycin
azithromycin pack
azithromycin suspension
clarithromycin
clarithromycin suspension
erythromycin
erythromycin liquid
erythromycin suspension
erythromycin tablet ER/SA
$
$
$
$
$
$
$
$
$
clarithromycin ER
Biaxin®
Biaxin® Suspension
Biaxin XL®
Zithromax®
CC
Dificid™
Zithromax® Pack
Zithromax® Suspension
Zmax®
Antibiotics:
Oxazolidinones
Zyvox®
$$
N/A
Antibiotics: Penicillins
amoxicillin
amoxicillin/clavulanate
amoxicillin/clavulanate ES-600
ampicillin
dicloxacillin
penicillin V
$
$
$
$
$
$
All branded penicillins
amoxicillin/clavulanate XR
Amoxil®
Amoclan®
Augmentin®
Augmentin ES-600®
Augmentin XR®
Moxatag™
Trimox®
Veetids®
AE – Age Edit
Rev 11/28/2012
CC, QL
CC, QL
CC – Clinical Criteria
MD – Medications with Maximum Duration
QL – Quantity Limit
$$$
$$$
ST – Step Therapy
Page 18 of 32
Kentucky Pharmacy Preferred Drug List
Effective December 5, 2012
MAGELLAN MEDICAID ADMINISTRATION/KENTUCKY WEBSITE: HTTPS://KENTUCKY.MAGELLANMEDICAID.COM/
MAGELLAN MEDICAID ADMINISTRATION CLINICAL SUPPORT CENTER: PHONE 800-477-3071; FAX 800-365-8835
VI.
ANTI-INFECTIVES
Drug Class
Preferred Agents
Antibiotics: Quinolones
Non-Preferred Agents
Relative Cost of
Most Agents
$
$
Avelox®
ciprofloxacin ER
Cipro®
Cipro XR®
Factive®
Levaquin®
levofloxacin solution
Noroxin®
ofloxacin
Antibiotics: Tetracyclines demeclocycline
doxycycline
minocycline
tetracycline
$
$
$
$
All branded tetracyclines
$$$
Adoxa®/Adoxa®Pak
Adoxa® CK/Adoxa®TT
Declomycin®
Doryx®
Dynacin®
Minocin®/Minocin® Convenience Pack
Monodox®
Morgidox®
Myrac®
Nutri Dox®
AE
Oracea®
MD
Solodyn®
Sumycin®
Vibra-Tabs®
Vibramycin®
Antifungals: Oral
clotrimazole
fluconazole
flucytosine
griseofulvin
CC
itraconazole
ketoconazole
nystatin
terbinafine
Gris-Peg®
Noxafil®
voriconazole
$
$
$
$
$
$
$
$
$
$$
$$
Ancobon®
Diflucan®
Diflucan®
Grifulvin V®
griseofulvin ultramicrosize
Lamisil®
Mycelex Troche®
Mycostatin®
Nizoral®
Oravig®
Sporanox®
Vfend®
$$$
Antivirals: Herpes
acyclovir
valacyclovir
$
$
famciclovir
Famvir®
Valtrex®
Zovirax®
$$$
Antivirals: Influenza
amantadine
rimantadine
Relenza®
QL
Tamiflu®
$
$
$$
$$
Flumadine®
$$$
AE – Age Edit
Rev 11/28/2012
ciprofloxacin
levofloxacin tablets
Relative Cost
CC – Clinical Criteria
MD – Medications with Maximum Duration
QL – Quantity Limit
$$$
ST – Step Therapy
Page 19 of 32
Kentucky Pharmacy Preferred Drug List
Effective December 5, 2012
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MAGELLAN MEDICAID ADMINISTRATION CLINICAL SUPPORT CENTER: PHONE 800-477-3071; FAX 800-365-8835
VI.
ANTI-INFECTIVES
Drug Class
Preferred Agents
Relative Cost
Non-Preferred Agents
Anti-Infective:
Sulfonamides, Folate
Antagonist
sulfadiazine
trimethoprim
trimethoprim/sulfamethoxazole
$
$
$
Bactrim®
Bactrim DS®
Primsol®
Septra®
Septra DS®
Sulfatrim®
Anti-Infectives:
Hepatitis B
Baraclude®
Epivir-HBV®
Hepsera®
Tyzeka®
$$
$$
$$
$$
N/A
Hepatitis C: Oral Protease Incivek™
CC, QL
Inhibitors
Victrelis™
$$
$$
N/A
CC, QL
$$
$$
$$
$$
Infergen
$$
$
Copegus®
CC
Rebetol®
CC
Ribasphere™ 600 mg
CC
RibaPak™
CC
ribavirin capsules
CC, QL
Hepatitis C: Interferons
PEGASYS®
CC, QL
PEGASYS ProClick®
CC, QL
PEGIntron™
CC, QL
PEGIntron Redipen™
Hepatitis C: Ribavirins
Ribasphere™ 400 mg
CC
ribavirin tablets
VII.
CC
Relative Cost of
Most Agents
$$$
® CC, QL
CC
$$
$$$
ENDOCRINE AND METABOLIC AGENTS
Drug Class
Diabetes: Injectable
Insulins
Preferred Agents
Lantus® Vials
Levemir®
Novolin N® Vials
Novolin R® Vials
Novolin 70/30® Vials
Novolog®
Novolog Mix 70/30®
Diabetes: Amylin Analog N/A
AE – Age Edit
Rev 11/28/2012
CC – Clinical Criteria
Relative Cost
$$
$$
$$
$$
$$
$$
$$
Non-Preferred Agents
Apidra®
Humalog®
Humalog 50/50® Pen/KwikPen
Humalog 75/25®
Humulin N®
Humulin R®
Humulin 70/30®
CC
Lantus Solostar®
Relion N®
Relion R®
Relion 70/30®
Symlin®
MD – Medications with Maximum Duration
ST
Relative Cost of
Most Agents
$$$
$$$
QL – Quantity Limit
ST – Step Therapy
Page 20 of 32
Kentucky Pharmacy Preferred Drug List
Effective December 5, 2012
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MAGELLAN MEDICAID ADMINISTRATION CLINICAL SUPPORT CENTER: PHONE 800-477-3071; FAX 800-365-8835
VII.
ENDOCRINE AND METABOLIC AGENTS
Drug Class
Preferred Agents
ST, QL
Diabetes: DPP-4
Inhibitors
Januvia®
ST, QL
Janumet®
ST, QL
Janumet® XR
ST, QL
Jentadueto™
ST, QL
Juvisync™
ST, QL
Kombiglyze™ XR
ST, QL
Onglyza™
ST, QL
Tradjenta™
Diabetes: Incretin
Mimetic
Byetta®
Diabetes: AlphaGlucosidase Inhibitors
Relative Cost
Non-Preferred Agents
Relative Cost of
Most Agents
$$
$$
$$
$$
$$
$$
$$
$$
N/A
$$
Bydureon®
Victoza®
$$$
acarbose
Glyset®
$
$$
Precose®
$$$
Diabetes: Biguanides
metformin
metformin ER
$
$
Fortamet®
Glucophage®
Glucophage XR®
Glumetza®
Riomet®
$$$
Diabetes: Meglitinides
nateglinide
Prandin®
$
$$
Prandimet®
Starlix®
$$$
Diabetes: Sulfonylureas
and Combinations
chlorpropamide
glimepiride
glipizide
glipizide ER/XL
glipizide/metformin
glyburide
glyburide micronized
glyburide/metformin
tolazamide
tolbutamide
$
$
$
$
$
$
$
$
$
$
Amaryl®
Diabeta®
Glucotrol®
Glucotrol XL®
Glucovance®
Glynase PresTab®
Metaglip®
Micronase®
$$$
Diabetes:
Thiazolidinediones
Actos®
QL
Avandia®
$$
$$
pioglitazone
Diabetes:
Thiazolidinedione
Combination
ACTOplus Met®
QL
Avandamet®
QL
DuetAct®
$$
$$
$$
Avandaryl®
QL
ActoPlus Met XR®
pioglitazone/metformin
Growth Hormones
Genotropin®
CC
Norditropin®
CC
Norditropin Flexpro®
CC
Saizen®
$$
$$
$$
$$
Humatrope®
CC
Nutropin®
CC
Nutropin AQ®
CC
Omnitrope®
CC
Serostim®
CC
Tev-Tropin®
CC
Zorbtive®
AE – Age Edit
Rev 11/28/2012
ST
QL
CC
CC – Clinical Criteria
QL
QL
MD – Medications with Maximum Duration
CC
QL – Quantity Limit
$$$
$$$
ST – Step Therapy
Page 21 of 32
Kentucky Pharmacy Preferred Drug List
Effective December 5, 2012
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VII.
ENDOCRINE AND METABOLIC AGENTS
Drug Class
Preferred Agents
Bone: Bisphosphonates
alendronate
Bone: Calcitonin
QL
Relative Cost
Non-Preferred Agents
QL
Relative Cost of
Most Agents
$
Actonel®
QL
Actonel with Calcium®
QL
Atelvia®
QL
Boniva®
QL
Binosto®
QL
Boniva I.V.®
Didronel®
etidronate
QL
Fosamax®
QL
Fosamax Plus D®
QL
ibandronate
Reclast® QL
Skelid® QL
$$$
Miacalcin®
calcitonin-salmon
$$
$
Fortical®
$$$
Progestins for Cachexia
megestrol acetate
$
Megace®
Megace® ES
$$$
Pancreatic Enzymes
Creon®
pancrelipase
Zenpep®
$$
$
$$
Pancreaze™
$$$
Androgenic Agents
Androderm®
Androgel®
$$
$$
Axiron®
Fortesta®
Testim®
$$$
Oral Steroids
cortisone
dexamethasone
budesonide
hydrocortisone
methylprednisolone
prednisolone
prednisolone sodium phosphate
prednisone
Zema-Pak®
$
$
$
$
$
$
$
$
$$
Baycadron®
Celestone®
Cortef®
DexPak®
DexPak JR®
Entocort EC®
Millipred®
AE
Orapred ®
AE
Orapred ODT®
Pediapred®
Prelone®
Veripred 20®
$$$
AE – Age Edit
Rev 11/28/2012
CC – Clinical Criteria
MD – Medications with Maximum Duration
QL – Quantity Limit
ST – Step Therapy
Page 22 of 32
Kentucky Pharmacy Preferred Drug List
Effective December 5, 2012
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MAGELLAN MEDICAID ADMINISTRATION CLINICAL SUPPORT CENTER: PHONE 800-477-3071; FAX 800-365-8835
VIII.
IMMUNOLOGIC AGENTS
Drug Class
Preferred Agents
CC, QL
Relative Cost
Non-Preferred Agents
CC, QL
Relative Cost of
Most Agents
Immunomodulators
Cimzia®
CC QL
Enbrel®
CC, QL
Humira®
$$
$$
$$
Actemra®
CC, QL
Amevive®
CC, QL
Kineret®
CC, QL
Orencia®
CC, QL
Remicade®
CC, QL
Simponi™
CC, QL
Stelara™
$$$
Topical
Immunomodulators
Elidel®
$$
Protopic®
$$$
Multiple Sclerosis Agents Avonex®
QL
Avonex Administration Pack®
QL
Betaseron®
QL
Copaxone®
QL
Rebif®
$$
$$
$$
$$
$$
Ampyra™
QL
Extavia®
QL
Gilenya™
QL, CC
$$$
Immunosuppressants
$
$
$$
$
$$
$$
$
Azasan®
Cellcept®
Hecoria®
Imuran®
Neoral®
Prograf®
Sandimmune®
Zortress®
$$$
QL
IX.
azathioprine
cyclosporine
Gengraf®
mycophenolate mofetil
Myfortic®
Rapamune®
tacrolimus
BLOOD MODIFIERS
Drug Class
Preferred Agents
CC
Hematopoietic Agents
Aranesp®
CC
Epogen®
CC
Procrit®
Thrombopoiesis
Stimulating Agents
Relative Cost
Non-Preferred Agents
$$
$$
$$
Omontys®
Neumega®
CC
Promacta®
$$
$$
Nplate™
Antihyperuricemics
allopurinol
probenecid
probenecid/colchicine
$
$
$
Phosphate Binders
calcium acetate
Fosrenol®
Renagel®
$
$$
$$
AE – Age Edit
Rev 11/28/2012
CC
CC – Clinical Criteria
CC
Relative Cost of
Most Agents
$$$
CC
$$$
Colcrys™
CC
Uloric®
Zyloprim®
CC
$$$
Eliphos®
PhosLo®
Phoslyra™
Renvela™
$$$
MD – Medications with Maximum Duration
QL – Quantity Limit
ST – Step Therapy
Page 23 of 32
Kentucky Pharmacy Preferred Drug List
Effective December 5, 2012
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MAGELLAN MEDICAID ADMINISTRATION CLINICAL SUPPORT CENTER: PHONE 800-477-3071; FAX 800-365-8835
X.
OPHTHALMICS
Drug Class
Preferred Agents
Relative Cost
Non-Preferred Agents
Relative Cost of
Most Agents
Ophthalmic Antivirals
trifluridine
Viroptic®
Zirgan™
$
$$
$$
N/A
Ophthalmic Antifungals
Natacyn®
$$
N/A
Ophthalmic Antibiotics,
Quinolone
ciprofloxacin ophthalmic
Moxeza™
ofloxacin
Vigamox®
$
$$
$
$$
Besivance™
Ciloxan®
CC
Iquix®
levofloxacin
Ocuflox®
Quixin®
Zymar®
Zymaxid™
Ophthalmic Antibiotics,
Macrolides
erythromycin 0.5% ointment
$
AzaSite®
Romycin®
$$$
Ophthalmic Antibiotics,
Non-Quinolone
bacitracin
bacitracin/poly B
gentamicin
neomycin/bac/poly B
neomycin/poly B/HC
neomycin/bac/poly B/HC
neomycin/poly B/dexamethasone
neomycin/poly B/gramicidin
polymyxin B/TMP
sulfacetamide sodium
tobramycin
tobramycin/dexamethasone
Blephamide®
Pred-G®
TobraDex® Ointment
Zylet®
$
$
$
$
$
$
$
$
$
$
$
$
$$
$$
$$
$$
AK-Poly Bac®
AK-Trol®
Bleph-10®
Gentak®
Gentasol®
Maxitrol®
Methadex®
Neocidin®
Neosporin®
Polydex®
Polytrim®
sulfacetamide/prednisolone
Sulfamide®
Tobrex®
TobraDex® Suspension
TobraDex® ST
$$$
Ophthalmic
Antihistamines
Alaway OTC®
Pataday™
Zaditor OTC®
$$
$$
$$
azelastine
Bepreve™
Elestat™
Emadine®
epinastine
Lastacaft™
Optivar®
Patanol®
$$$
AE – Age Edit
Rev 11/28/2012
CC – Clinical Criteria
$$$
CC
MD – Medications with Maximum Duration
QL – Quantity Limit
ST – Step Therapy
Page 24 of 32
Kentucky Pharmacy Preferred Drug List
Effective December 5, 2012
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X.
OPHTHALMICS
Drug Class
Preferred Agents
Relative Cost
Non-Preferred Agents
Relative Cost of
Most Agents
Ophthalmic Beta
Blockers
betaxolol HCl
carteolol HCl
levobunolol
metipranolol
timolol maleate
Betimol®
Betoptic S®
Combigan®
Istalol®
$
$
$
$
$
$$
$$
$$
$$
Betagan®
OptiPranolol®
Timoptic®
Timoptic XE®
$$$
Ophthalmic Carbonic
Anhydrase Inhibitors
dorzolamide
dorzolamide/timolol
Azopt®
$
$
$$
Cosopt®
Cosopt® PF
Trusopt®
$$$
Ophthalmic
Decongestants
phenylephrine
tetrahydrozoline
$
$
AK-Con®
AK-Dilate®
Mydfrin®
$$$
Ophthalmic Mast Cell
Stabilizers
cromolyn sodium
$
Alamast®
Alocril®
Alomide®
$$$
Ophthalmic Mydriatics & atropine
Mydriatic Combos
cyclopentolate
Isopto Hyoscine®
tropicamide
$
$
$$
$
AK-Pentolate®
Cyclogyl®
Cyclomydril®
Isopto Atropine®
Isopto Homatropine®
Mydriacyl®
Paremyd®
Tropicacyl®
$$$
Ophthalmic NSAIDs
diclofenac
flurbiprofen
ketorolac
$
$
$
Acular®
Acular LS®
Acuvail™
Bromday®
bromfenac
Nevanac®
Ocufen®
Voltaren®
$$$
Ophthalmic
Prostaglandin Agonists
latanoprost
$
Lumigan®
QL
Travatan Z®
QL
Xalatan®
QL
Zioptan®
AE – Age Edit
Rev 11/28/2012
QL
CC – Clinical Criteria
MD – Medications with Maximum Duration
QL
QL – Quantity Limit
$$$
ST – Step Therapy
Page 25 of 32
Kentucky Pharmacy Preferred Drug List
Effective December 5, 2012
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X.
OPHTHALMICS
Drug Class
Preferred Agents
Relative Cost
Non-Preferred Agents
Relative Cost of
Most Agents
Ophthalmic AntiInflammatory Steroids
dexamethasone
fluorometholone
prednisolone acetate
prednisolone sodium phosphate
Flarex®
Lotemax®
Maxidex®
Vexol®
$
$
$
$
$$
$$
$$
$$
Alrex®
Durezol™
FML®
FML Forte®
FML S.O.P.®
Omnipred™
Pred Forte®
Pred Mild®
Retisert™
Triesence®
$$$
Ophthalmic Glaucoma
Direct Acting Miotics
pilocarpine
$
Isopto Carpine®
Pilopine HS®
$$$
Ophthalmic
Sympathomimetics
apraclonidine
brimonidine tartrate
$
$
Alphagan P®
Iopidine®
$$$
Ophthalmic
Immunomodulators
Restasis®
$$
N/A
XI.
ST
OTICS
Drug Class
Preferred Agents
Relative Cost
Non-Preferred Agents
Relative Cost of
Most Agents
Otic: Quinolone
Antibiotics
ofloxacin otic
CiproDex®
$
$$
Cetraxal™
Cipro HC®
$$$
Otic: Anti-Infective &
Anesthetic
acetic acid
acetic acid in aluminum acetate
antipyrine/benzocaine
pramoxine/hydrocortisone
$
$
$
$
acetic acid/hydrocortisone
Neotic®
Otic Care®
Otozin™
Pramotic® HC
PR Otic®
Tregan®
Vosol® HC
Zinotic®
Zinotic® ES
$$$
Coly-mycin® S
Cortisporin®
Cortisporin® – TC
Cortomycin®
fluocinolone otic
$$$
hydrocortisone/neomycin/polymyxinB $
Otic: Steroid and
Antibiotic Combinations
AE – Age Edit
Rev 11/28/2012
CC – Clinical Criteria
MD – Medications with Maximum Duration
QL – Quantity Limit
ST – Step Therapy
Page 26 of 32
Kentucky Pharmacy Preferred Drug List
Effective December 5, 2012
MAGELLAN MEDICAID ADMINISTRATION/KENTUCKY WEBSITE: HTTPS://KENTUCKY.MAGELLANMEDICAID.COM/
MAGELLAN MEDICAID ADMINISTRATION CLINICAL SUPPORT CENTER: PHONE 800-477-3071; FAX 800-365-8835
XII.
RENAL AND GENITOURINARY
Drug Class
Preferred Agents
Alpha Blockers for BPH
alfuzosin
doxazosin
tamsulosin
terazosin
Androgen Hormone
Inhibitors
finasteride
Urinary Tract
Antispasmodics
flavoxate
QL
oxybutynin
QL
Toviaz™
QL
VESIcare®
XIII.
CC
QL
Relative Cost
Non-Preferred Agents
$
$
$
$
Cardura®
Cardura XL®
Flomax®
Hytrin®
Rapaflo™
Uroxatral®
$
Avodart®
CC
Jalyn®
CC
Proscar®
$
$
$$
$$
Detrol®
QL
Detrol LA®
QL
Ditropan XL®
QL
Enablex®
CC, QL
Gelnique™
QL
oxybutynin ER
QL
Oxytrol™
QL
Sanctura®
QL
Sanctura XR®
QL
tolterodine
QL
trospium
Relative Cost of
Most Agents
$$$
CC
$$$
QL
$$$
DERMATOLOGICS
Drug Class
Preferred Agents
Relative Cost
Non-Preferred Agents
Relative Cost of
Most Agents
Dermatologics: AntiVirals
Abreva®
Zovirax® ointment
$$
$$
Denavir® cream
Zovirax® cream
Xerese®
$$$
Dermatologics:
Antiseborrheic Agents
selenium sulfide
Carmol®
$
$$
Ovace®
Ovace Plus®
Seb-Prev®
Selenos®
Selseb®
Scalp Treatment Kit®
$$$
$
$
$
Altabax™
Bactroban®
Centany®
$$$
Dermatologics: Antibiotic bacitracin ointment
Agents
bacitracin zinc ointment
bacitracin/neomycin/polymyxin B
ointment
bacitracin/neomycin/polymyxin B/
pramoxine ointment
bacitracin/polymyxin B ointment
gentamicin 0.1% cream, ointment
mupirocin
neomycin/polymyxin/pramoxine
AE – Age Edit
Rev 11/28/2012
CC – Clinical Criteria
$
$
$
$
$
MD – Medications with Maximum Duration
QL – Quantity Limit
ST – Step Therapy
Page 27 of 32
Kentucky Pharmacy Preferred Drug List
Effective December 5, 2012
MAGELLAN MEDICAID ADMINISTRATION/KENTUCKY WEBSITE: HTTPS://KENTUCKY.MAGELLANMEDICAID.COM/
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XIII.
DERMATOLOGICS
Drug Class
Preferred Agents
Relative Cost
Non-Preferred Agents
Relative Cost of
Most Agents
Dermatologics:
Antiparasitics, Topical
Eurax®
malathion
permethrin 5% cream
$$
$
$
Acticin®
Elimite®
lindane
Ovide®
Natroba™
spinosad
Ulesfia™
Miscellaneous Topical
Treatments for Acne
benzoyl peroxide
benzoyl peroxide/clindamycin
benzoyl peroxide/erythromycin
clindamycin
erythromycin
salicylic acid
sodium sulfacetamide
sodium sulfacetamide/sulfur
BenzaClin®
Benzamycin®
Lavoclen™
$
$
$
$
$
$
$
$
$$
$$
$
All brand benzoyl peroxide products
$$$
All brand benzoyl
peroxide/clindamycin products
All brand benzoyl
peroxide/erythromycin products
All brand clindamycin products
All brand erythromycin products
All brand salicylic acid products
All brand sodium sulfacetamide
products
All brand sodium sulfacetamide/sulfur
products
Acanya™
Aczone™
Avar®
Azelex®
Benprox®
Benzac® AC/W
BenzaClin CareKit®
Benzashave®
Benziq®
benzoyl peroxide/urea
BP® 10
BPO®
Brevoxyl®
Cerisa®
Clarifoam® EF
Claris®
Clenia®
Cllinac BPO®
Clindacin Pac®
Clinda-Derm®
Clindagel®
Clindamax®
ClindaReach™
Desquam-X®
Duac CS®QL
Emgel®
Evoclin™
AE – Age Edit
Rev 11/28/2012
CC – Clinical Criteria
MD – Medications with Maximum Duration
$$$
QL – Quantity Limit
ST – Step Therapy
Page 28 of 32
Kentucky Pharmacy Preferred Drug List
Effective December 5, 2012
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XIII.
DERMATOLOGICS
Drug Class
Preferred Agents
Relative Cost
Non-Preferred Agents
Relative Cost of
Most Agents
Finacea®/Finacea Plus®
Inova™
Klaron®
NuOx®
Oscion®
Pacnex®
Plexion®
Prascion® RA
Rosac®
Rosaderm®
Rosanil®
Rosula® CLK
Salkera® Foam
Salacyn®
Salvax®
sodium sulfacetamide/sulfur/
urea/meradimate/titanium
Suphera®
Sumadan®
Sumaxin®
Topisulf®
Triaz®
Zacare™
Zaclir®
Zetacet®
Zoderm®
AE – Age Edit
Rev 11/28/2012
CC – Clinical Criteria
MD – Medications with Maximum Duration
QL – Quantity Limit
ST – Step Therapy
Page 29 of 32
Kentucky Pharmacy Preferred Drug List
Effective December 5, 2012
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XIII.
DERMATOLOGICS
Drug Class
Preferred Agents
Relative Cost
Non-Preferred Agents
Dermatologics:
Antifungal Agents
clotrimazole
econazole
ketoconazole shampoo
nystatin cream/ointment
nystatin/triamcinolone
$
$
$
$
$
ciclopirox
ciclopirox/nail lacquer remover
Ciclodan Kit®
CNL8™ Nail Kit
clotrimazole/betamethasone
Ertazczo®
Exelderm®
Extina®
ketoconazole cream
Ketodan®
Kuric®
Lamisil®
Loprox®
Lotrimin®
Lotrisone®
Mentax®
Monistat-Derm®
Myconel®
Mycostatin®
Naftin®
Nizoral®
Nyamyc®
nystatin powder
Nystop®
Oxistat®
Pedi-Dri®
Pediaderm AF®
Pedipirox-4 Nail®
Penlac®
Spectazole®
CC
Vusion®
Xolegel®
Xolegel Corepack®
Xolegel Duo®
Dermatologics: Oral
Retinoids
Amnesteem®
Claravis®
Soriatane® CK
Sotret®
$$
$$
$$
$$
N/A
AE – Age Edit
Rev 11/28/2012
CC – Clinical Criteria
MD – Medications with Maximum Duration
QL – Quantity Limit
Relative Cost of
Most Agents
$$$
ST – Step Therapy
Page 30 of 32
Kentucky Pharmacy Preferred Drug List
Effective December 5, 2012
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XIII.
DERMATOLOGICS
Drug Class
Preferred Agents
Relative Cost
Non-Preferred Agents
Relative Cost of
Most Agents
Dermatologics: Topical
Retinoids
adapalene
Retin-A Micro®
tretinoin
$
$$
$
Atralin™
Avita®
Differin®
Epiduo™
Retin-A®
Retin-A Micro® Pump
CC
Tazorac®
Veltirn™
Ziana™
$$$
Dermatologics: Topical
Steroids
alclometasone
amcinonide
betamethasone dipropionate
betamethasone valerate
clobetasol propionate
desonide
fluocinolone
fluocinonide
fluticasone
halobetasol
hydrocortisone
hydrocortisone butyrate
hydrocortisone valerate
mometasone
nystatin-triamcinolone
prednicarbate
triamcinolone
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
Aclovate®
ApexiCon®/ApexiCon E®
Beta-Val®
Capex® Shampoo
Clobeta + Plus®
Clobex®
Cloderm®
Cordran® Tape
Cormax®
clotrimazole/betamethasone
Cutivate®
Derma-Smoothe/FS®
Dermatop®
Desowen®
desoximetasone
diflorasone diacetate
Diprolene®/Diprolene AF®
Elocon®
fluocinolone scalp oil
Halog®
Halonate®
Ketocon + Plus®
Lokara®
Lotrisone®
Luxiq®
Momexin™
Olux®/Olux-E®
Olux-Olux E® Complete Pack
Pandel®
Temovate®
Texacort®
Topicort®
Topicort LP®
Ultravate®
Vanos™
Verdeso™
Westcort®
$$$
AE – Age Edit
Rev 11/28/2012
CC – Clinical Criteria
MD – Medications with Maximum Duration
QL – Quantity Limit
ST – Step Therapy
Page 31 of 32
Kentucky Pharmacy Preferred Drug List
Effective December 5, 2012
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XIII.
DERMATOLOGICS
Drug Class
Preferred Agents
Dermatologics: Topical
Agents for Psoriasis
XIV.
calcipotriene scalp solution
calcipotriene ointment
Dovonex® cream
Relative Cost
$
$
$
Non-Preferred Agents
Calcitriol
calcipotriene cream
Dovonex® solution/ointment
Psoriatec®
Sorilux®
Taclonex®
CC
Tazorac®
Vectical™
Zithranol®
Relative Cost of
Most Agents
$$$
ANTINEOPLASTIC AGENTS
Drug Class
Preferred Agents
Oral Oncology Agents
AE – Age Edit
Rev 11/28/2012
QL
Caprelsa®
CC, QL
Erivedge™
QL
Gleevec®
CC, QL
Inlyta®
QL
Iressa®
CC, QL
Jakafi™
QL
Nexavar®
QL
Sprycel®
QL
Sutent®
QL
Tarceva®
QL
Tykerb®
CC, QL
Xalkori®
QL
Xeloda®
CC, QL
Zelboraf™
CC, QL
Zytiga™
CC – Clinical Criteria
Relative Cost
$$
$$
$$
$$
$$
$$
$$
$$
$$
$$
$$
$$
$$
$$
$$
Non-Preferred Agents
QL
Afinitor™
QL
Tasigna®
QL
Votrient™
MD – Medications with Maximum Duration
Relative Cost of
Most Agents
$$
QL – Quantity Limit
ST – Step Therapy
Page 32 of 32