Escolar Documentos
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Cultura Documentos
page ANALGESICS
Drug Class
Narcotics Long Acting
Preferred Agents
Kadian methadone morphine sulfate SA tablets
Non-Preferred Agents
Avinza Conzip ER Exalgo morphine sulfate ER caps (generic Kadian) MS Contin Nucynta ER Opana ER Oramorph SR Oxycontin oxymorphone ER Ryzolt ER Ultram ER Abstral butorphanol Capital w/ Codeine Demerol all forms Dilaudid all forms Fentora Fioricet w/ Codeine Fiorinal w/ Codeine Lorcet Lortab Norco Nucynta Onsolis Opana opium Oxecta Oxydose Oxyfast OxyIR oxymorphone pentazocine/naloxone Percocet Percodan Primlev Roxanol Rybix ODT Roxicodone Stadol, Stadol NS Subsys Talwin, Talwin NX tramadol/APAP Tylenol #2
Actiq codeine codeine / APAP codeine / APAP/caffeine /butalbital Codeine / APAP/caffeine codeine / ASA codeine / ASA /caffeine /butalbital codeine phosphate hydrocodone / APAP hydromorphone oral tablets meperidine morphine sulfate tabs / soln oxycodone (immediate release) oxycodone / APAP oxycodone / ASA tramadol
1 Prior Authorization Not Required for Beneficiaries Under the Age of 12. 2 Quantity limits apply See MPPL on website for details 3 Prior Authorization Required if Beneficiary is Over the Age of 65. 4 Prior Authorization Required for Beneficiaries Under Age of 6. 5 PA required if a benzodiazepine is found in beneficiary drug history 7 Providers should consult yearly CDC guidelines for Influenza 8 Electronic Step edit: at least 1 component of the product must be in beneficiary drug history
9 PA required if no history of oral antinausea drugs in beneficiary drug history 10 Prior Authorization Required for Beneficiaries Under Age of 15. 11 Prior Authorization Required for Beneficiaries Under Age of 18. 12 Components of product must be in drug history APAP = Acetaminophen ASA = Aspirin CR, ER, SR, XL, XR, SA, LA = Extended Release, HCT = Hydrochlorothiazide Clinical PA required; refer to MPPL, MI Provider Manual or michigan.fhsc.com for other restrictions Version 07162013v1 Page 1 of 17
Effective 07/16/2013 Preferred Agents do not require prior authorization, except as noted in the chart at the bottom of the page ANALGESICS
Drug Class Preferred Agents Non-Preferred Agents
Tylenol #3 Tylenol #4 Tylenol w/ Codeine Elixir Tylox Ultracet Ultram Vicodin Vopac Wygesic Xodol 5/300 Zolvit Zydone Narcotics Transdermal Non-Steroidal Anti-Infammatory Cox II Inhibitors fentanyl Patches (generic only) Butrans Celebrex
2
Duragesic
ANTIBIOTICS / ANTI-INFECTIVES
Drug Class
Antifungals Oral
Preferred Agents
fluconazole griseofulvin griseofulvin microsize griseofulvin ultramicrosize Gris-Peg nystatin oral susp terbinifine
Non-Preferred Agents
clotrimazole troches Diflucan itraconazole ketoconazole Lamisil Mycelex Mycostatin Nizoral Noxafil nystatin tablets Onmel Sporanox Vfend voriconzaole
1 Prior Authorization Not Required for Beneficiaries Under the Age of 12. 2 Quantity limits apply See MPPL on website for details 3 Prior Authorization Required if Beneficiary is Over the Age of 65. 4 Prior Authorization Required for Beneficiaries Under Age of 6. 5 PA required if a benzodiazepine is found in beneficiary drug history 7 Providers should consult yearly CDC guidelines for Influenza 8 Electronic Step edit: at least 1 component of the product must be in beneficiary drug history
9 PA required if no history of oral antinausea drugs in beneficiary drug history 10 Prior Authorization Required for Beneficiaries Under Age of 15. 11 Prior Authorization Required for Beneficiaries Under Age of 18. 12 Components of product must be in drug history APAP = Acetaminophen ASA = Aspirin CR, ER, SR, XL, XR, SA, LA = Extended Release, HCT = Hydrochlorothiazide Clinical PA required; refer to MPPL, MI Provider Manual or michigan.fhsc.com for other restrictions Version 07162013v1 Page 2 of 17
Effective 07/16/2013 Preferred Agents do not require prior authorization, except as noted in the chart at the bottom of the page ANTIBIOTICS / ANTI-INFECTIVES
Drug Class
Antifungals Topical
Preferred Agents
clotrimazole clotrimazole / betamethasone econazole nitrate ketoconazole miconazole nitrate nystatin nystatin / triamcinolone tolnaftate
Non-Preferred Agents
Ciclodan ciclopirox Ertaczo Exelderm Extina ketoconazole foam Ketodan Loprox Lotrimin AF Lotrisone Mentax Naftin Nizoral Oxistat Pedipirox-4 Penlac Vusion Xolegel Famvir Valtrex Zovirax
Antivirals Herpes
Relenza Tamiflu Denavir Zovirax Ointment cefadroxil cephalexin acyclovir ointment Xerese Zovirax Cream cephradine Duricef Keflex Velosef Ceclor / Ceclor CD cefaclor / cefaclor ER cefprozil Ceftin tabs, suspension Cefzil Lorabid Cedax Spectracef Suprax tablets, chew tabs Vantin
1 Prior Authorization Not Required for Beneficiaries Under the Age of 12. 2 Quantity limits apply See MPPL on website for details 3 Prior Authorization Required if Beneficiary is Over the Age of 65. 4 Prior Authorization Required for Beneficiaries Under Age of 6. 5 PA required if a benzodiazepine is found in beneficiary drug history 7 Providers should consult yearly CDC guidelines for Influenza 8 Electronic Step edit: at least 1 component of the product must be in beneficiary drug history
9 PA required if no history of oral antinausea drugs in beneficiary drug history 10 Prior Authorization Required for Beneficiaries Under Age of 15. 11 Prior Authorization Required for Beneficiaries Under Age of 18. 12 Components of product must be in drug history APAP = Acetaminophen ASA = Aspirin CR, ER, SR, XL, XR, SA, LA = Extended Release, HCT = Hydrochlorothiazide Clinical PA required; refer to MPPL, MI Provider Manual or michigan.fhsc.com for other restrictions Version 07162013v1 Page 3 of 17
Effective 07/16/2013 Preferred Agents do not require prior authorization, except as noted in the chart at the bottom of the page ANTIBIOTICS / ANTI-INFECTIVES
Drug Class
Hepatitis C Pegasys Peg-Intron ribavirin
Preferred Agents
Non-Preferred Agents
Copegus Infergen Intron A Rebetol Rebetron Ribapak Ribasphere Roferon-A
Incivek Victrelis azithromycin clarithromycin erythromycin base erythromycin estolate erythromycin ethylsuccinate erythromycin stearate erythromycin w/ sulfisoxazole Biaxin / Biaxin XL / Biaxin Susp clarithromycin ER Dificid Dynabac E.E.S. EryPed Ery-Tab PCE Zithromax tablets 1 Zithromax suspension Zmax
Oxalodinones Quinolones
Zyvox ciprofloxacin levofloxacin Avelox ciprofloxacin ER Cipro XR Factive Floxin Levaquin Maxaquin NegGram Noroxin ofloxacin Tequin Trovan Besivance Ciloxan levofloxacin Ocuflox Zymaxid
Ophthalmic Fluoroquinolones
Ophthalmic Macrolides
1 Prior Authorization Not Required for Beneficiaries Under the Age of 12. 2 Quantity limits apply See MPPL on website for details 3 Prior Authorization Required if Beneficiary is Over the Age of 65. 4 Prior Authorization Required for Beneficiaries Under Age of 6. 5 PA required if a benzodiazepine is found in beneficiary drug history 7 Providers should consult yearly CDC guidelines for Influenza 8 Electronic Step edit: at least 1 component of the product must be in beneficiary drug history
9 PA required if no history of oral antinausea drugs in beneficiary drug history 10 Prior Authorization Required for Beneficiaries Under Age of 15. 11 Prior Authorization Required for Beneficiaries Under Age of 18. 12 Components of product must be in drug history APAP = Acetaminophen ASA = Aspirin CR, ER, SR, XL, XR, SA, LA = Extended Release, HCT = Hydrochlorothiazide Clinical PA required; refer to MPPL, MI Provider Manual or michigan.fhsc.com for other restrictions Version 07162013v1 Page 4 of 17
Effective 07/16/2013 Preferred Agents do not require prior authorization, except as noted in the chart at the bottom of the page ANTIBIOTICS / ANTI-INFECTIVES
Drug Class
Otic Quinolones Topical Antibiotics Gastrointestinal Antibiotics Ciprodex ofloxacin otic mupiricin ointment metronidazole tablets Vancocin
Preferred Agents
Cetraxal Cipro HC Bactroban Altabax
Non-Preferred Agents
Alinia Dificid Flagyl tablets and capsules Flagyl ER metronidazole capsules neomycin tablets Tindamax tinidazole vancomycin Xifaxan
Preferred Agents
Atrovent / Atrovent HFA Combivent Combivent RESPIMAT ipratropium Spiriva cetirizine loratadine / loratadine ODT
Non-Preferred Agents
Daliresp Tudorza Pressair
Allegra / Allegra Suspension cetirizine chewable tablets Clarinex/ Clarinex ODT Claritin tablets, syrup Claritin Redi-Tab desloratadine fexofenadine Xyzal Zyrtec azelastine Dymista Patanase Nasal Alupent Maxair Autohaler Xopenex HFA Ventolin HFA - effective 9/17/2013 Arcapta Brovana nebulizer soln. Perforomist Serevent
Antihistamines - Nasal
Foradil
1 Prior Authorization Not Required for Beneficiaries Under the Age of 12. 2 Quantity limits apply See MPPL on website for details 3 Prior Authorization Required if Beneficiary is Over the Age of 65. 4 Prior Authorization Required for Beneficiaries Under Age of 6. 5 PA required if a benzodiazepine is found in beneficiary drug history 7 Providers should consult yearly CDC guidelines for Influenza 8 Electronic Step edit: at least 1 component of the product must be in beneficiary drug history
9 PA required if no history of oral antinausea drugs in beneficiary drug history 10 Prior Authorization Required for Beneficiaries Under Age of 15. 11 Prior Authorization Required for Beneficiaries Under Age of 18. 12 Components of product must be in drug history APAP = Acetaminophen ASA = Aspirin CR, ER, SR, XL, XR, SA, LA = Extended Release, HCT = Hydrochlorothiazide Clinical PA required; refer to MPPL, MI Provider Manual or michigan.fhsc.com for other restrictions Version 07162013v1 Page 5 of 17
Effective 07/16/2013 Preferred Agents do not require prior authorization, except as noted in the chart at the bottom of the page ASTHMA / ALLERGY / COPD
Drug Class
Beta Adrenergics For Nebulizers albuterol sulfate
Preferred Agents
Non-Preferred Agents
Accuneb Duoneb levalbuterol metaproterenol Xopenex
Advair Diskus / Advair HFA Dulera Symbicort Asmanex Azmacort Flovent Diskus / Flovent HFA Pulmicort Flexihaler Pulmicort Respules QVAR montelukast tablets, chew tabs zafirlukast Singulair granules fluticasone Nasonex AeroBid Alvesco budesonide nebulizer soln.- effective 9/17/2013
Inhaled Glucocorticoids
Leukotriene Inhibitors
Accolate montelukast granules Singulair tablets, chew tabs Zyflo/ Zyflo CR Beconase AQ Dymista Flonase flunisolide Nasacort Nasacort AQ Nasarel Omnaris Qnasl Rhinocort and Rhinocort Aqua Tri-Nasal Veramyst Zetonna
Nasal Steroids
1 Prior Authorization Not Required for Beneficiaries Under the Age of 12. 2 Quantity limits apply See MPPL on website for details 3 Prior Authorization Required if Beneficiary is Over the Age of 65. 4 Prior Authorization Required for Beneficiaries Under Age of 6. 5 PA required if a benzodiazepine is found in beneficiary drug history 7 Providers should consult yearly CDC guidelines for Influenza 8 Electronic Step edit: at least 1 component of the product must be in beneficiary drug history
9 PA required if no history of oral antinausea drugs in beneficiary drug history 10 Prior Authorization Required for Beneficiaries Under Age of 15. 11 Prior Authorization Required for Beneficiaries Under Age of 18. 12 Components of product must be in drug history APAP = Acetaminophen ASA = Aspirin CR, ER, SR, XL, XR, SA, LA = Extended Release, HCT = Hydrochlorothiazide Clinical PA required; refer to MPPL, MI Provider Manual or michigan.fhsc.com for other restrictions Version 07162013v1 Page 6 of 17
Effective 07/16/2013 Preferred Agents do not require prior authorization, except as noted in the chart at the bottom of the page BEHAVIORAL HEALTH
Drug Class
Atypical Antipsychotics Abilify clozapine Clozaril Fanapt Fazaclo Geodon Invega Latuda olanzapine quetiapine risperidone Risperdal Saphris Seroquel Seroquel XR ziprasidone Zyprexa Symbyax
Preferred Agents
Non-Preferred Agents
Antipsychotic-Antidepressant Comb.
Antidepressants Newer Generations Aplenzin bupropion buproprion hydrobromide ER citalopram Cymbalta Emsam escitalopram fluoxetine fluvoxamine Forfivo XL Luvox CR mirtazapine nefazodone Oleptro paroxetine Pexeva Pristiq Prozac Weekly sertraline trazodone venlafaxine venlafaxine ER Viibryd
1 Prior Authorization Not Required for Beneficiaries Under the Age of 12. 2 Quantity limits apply See MPPL on website for details 3 Prior Authorization Required if Beneficiary is Over the Age of 65. 4 Prior Authorization Required for Beneficiaries Under Age of 6. 5 PA required if a benzodiazepine is found in beneficiary drug history 7 Providers should consult yearly CDC guidelines for Influenza 8 Electronic Step edit: at least 1 component of the product must be in beneficiary drug history
9 PA required if no history of oral antinausea drugs in beneficiary drug history 10 Prior Authorization Required for Beneficiaries Under Age of 15. 11 Prior Authorization Required for Beneficiaries Under Age of 18. 12 Components of product must be in drug history APAP = Acetaminophen ASA = Aspirin CR, ER, SR, XL, XR, SA, LA = Extended Release, HCT = Hydrochlorothiazide Clinical PA required; refer to MPPL, MI Provider Manual or michigan.fhsc.com for other restrictions Version 07162013v1 Page 7 of 17
Effective 07/16/2013 Preferred Agents do not require prior authorization, except as noted in the chart at the bottom of the page CARDIAC MEDICATIONS
Drug Class
ACE Inhibitors
Preferred Agents
benazepril/ benazepril HCT captopril/ captopril HCT enalapril/ enalapril HCT lisinopril/ lisinopril HCT
Non-Preferred Agents
Accupril Accuretic Aceon Altace Capoten / Capozide fosinopril/ fosinopril HCT Lotensin / Lotensin HCT Mavik moexipril / moexipril HCT Monopril / Monopril HCT Prinivil / Prinzide quinapril / quinapril HCT trandolapril Univasc / Unirectic Vasotec / Vaseretic Zestril / Zestoretic Catapres Catapres TTS Nexiclon XR Tenex Lotrel trandolapril / verapamil
clonidine clonidine / chlorthalidone guanfacine methyldopa methyldopa / HCTZ amlodipine / benazepril Tarka Azor Exforge / Exforge HCT Tribenzor Twynsta Benicar Benicar HCT Diovan Diovan HCT losartan/ losartan HCT Micardis / Micardis HCT
Atacand / Atacand HCT Avalide Avapro candesartan HCT Cozaar Edarbi Edarbyclor Hyzaar Teveten / Teveten HCT valsartan HCT Amturnide Tekamlo Tekturna Tekturna HCT Valturna
1 Prior Authorization Not Required for Beneficiaries Under the Age of 12. 2 Quantity limits apply See MPPL on website for details 3 Prior Authorization Required if Beneficiary is Over the Age of 65. 4 Prior Authorization Required for Beneficiaries Under Age of 6. 5 PA required if a benzodiazepine is found in beneficiary drug history 7 Providers should consult yearly CDC guidelines for Influenza 8 Electronic Step edit: at least 1 component of the product must be in beneficiary drug history
9 PA required if no history of oral antinausea drugs in beneficiary drug history 10 Prior Authorization Required for Beneficiaries Under Age of 15. 11 Prior Authorization Required for Beneficiaries Under Age of 18. 12 Components of product must be in drug history APAP = Acetaminophen ASA = Aspirin CR, ER, SR, XL, XR, SA, LA = Extended Release, HCT = Hydrochlorothiazide Clinical PA required; refer to MPPL, MI Provider Manual or michigan.fhsc.com for other restrictions Version 07162013v1 Page 8 of 17
Effective 07/16/2013 Preferred Agents do not require prior authorization, except as noted in the chart at the bottom of the page CARDIAC MEDICATIONS
Drug Class
Beta Blockers
Preferred Agents
acebutolol atenolol atenolol / chlorthalidone betaxolol bisoprolol fumarate bisoprolol fumarate / HCT Bystolic carvedilol Coreg CR labetalol metoprolol / metoprolol HCT metoprolol succinate metoprolol tartrate nadolol pindolol propranolol / propranolol LA/ propranolol HCT sotalol / sotalol AF timolol Maleate Afeditab CR amlodipine besylate Dynacirc CR felodipine isradipine nicardipine Nifediac CC Nifedical XL nifedipine / nifedipine SA nisoldipine diltiazem / diltiazem XR, ER Taztia XT verapamil / verapamil SR verapamil cap 24-hr pellet
Non-Preferred Agents
Betapace / Betapace AF Blocadren Coreg Corgard Dutoprol Inderal Inderal LA Inderide Innopran XL Kerlone Levatol Lopressor Normodyne Sectral Tenormin Toprol XL Trandate Visken Zebeta Adalat CC Cardene / Cardene SR Dynacirc Norvasc Plendil Procardia / Procardia XL Sular
Calan Cardizem LA, SR, CD Covera-HS Dilacor XR Isoptin Verelan / Verelan PM Caduet
Lipotropic-Antihypertensive Combination
amlodipine / atorvastatin
1 Prior Authorization Not Required for Beneficiaries Under the Age of 12. 2 Quantity limits apply See MPPL on website for details 3 Prior Authorization Required if Beneficiary is Over the Age of 65. 4 Prior Authorization Required for Beneficiaries Under Age of 6. 5 PA required if a benzodiazepine is found in beneficiary drug history 7 Providers should consult yearly CDC guidelines for Influenza 8 Electronic Step edit: at least 1 component of the product must be in beneficiary drug history
9 PA required if no history of oral antinausea drugs in beneficiary drug history 10 Prior Authorization Required for Beneficiaries Under Age of 15. 11 Prior Authorization Required for Beneficiaries Under Age of 18. 12 Components of product must be in drug history APAP = Acetaminophen ASA = Aspirin CR, ER, SR, XL, XR, SA, LA = Extended Release, HCT = Hydrochlorothiazide Clinical PA required; refer to MPPL, MI Provider Manual or michigan.fhsc.com for other restrictions Version 07162013v1 Page 9 of 17
Effective 07/16/2013 Preferred Agents do not require prior authorization, except as noted in the chart at the bottom of the page CARDIAC MEDICATIONS
Drug Class
Lipotropics: Fibric Acid Derivatives
Preferred Agents
fenofibrate, micronized capsules gemfibrozil Tricor Trilipix
Non-Preferred Agents
Antara fenofibrate, nanocrystallized (generic Tricor) Fenoglide Fibricor Lofibra Lopid Lipofen Triglide Colestid Questran Light Questran Advicor Altoprev Crestor Lipitor Livalo Mevacor Pravachol Zocor
Lipotropics: Non-Statins
cholestyramine cholestyramine light colestipol Welchol atorvastatin Lescol Lescol XL lovastatin pravastatin 8 Simcor simvastatin 8 Vytorin niacin and niacin ER Niacor Niaspan Zetia
Lipotropics: Statins
Lipotropics: Other
Preferred Agents
donepezil Exelon capsule and patch galantamine Namenda
Non-Preferred Agents
Aricept Cognex Razadyne rivastigmine capsules
1 Prior Authorization Not Required for Beneficiaries Under the Age of 12. 2 Quantity limits apply See MPPL on website for details 3 Prior Authorization Required if Beneficiary is Over the Age of 65. 4 Prior Authorization Required for Beneficiaries Under Age of 6. 5 PA required if a benzodiazepine is found in beneficiary drug history 7 Providers should consult yearly CDC guidelines for Influenza 8 Electronic Step edit: at least 1 component of the product must be in beneficiary drug history
9 PA required if no history of oral antinausea drugs in beneficiary drug history 10 Prior Authorization Required for Beneficiaries Under Age of 15. 11 Prior Authorization Required for Beneficiaries Under Age of 18. 12 Components of product must be in drug history APAP = Acetaminophen ASA = Aspirin CR, ER, SR, XL, XR, SA, LA = Extended Release, HCT = Hydrochlorothiazide Clinical PA required; refer to MPPL, MI Provider Manual or michigan.fhsc.com for other restrictions Version 07162013v1 Page 10 of 17
Effective 07/16/2013 Preferred Agents do not require prior authorization, except as noted in the chart at the bottom of the page CENTRAL NERVOUS SYSTEM DRUGS
Drug Class
Anti-Anxiety General
Preferred Agents
alprazolam buspirone 3 chlordiazepoxide clorazepate 3 diazepam hydroxyzine HCL hydroxyzine pamoate lorazepam oxazepam
Non-Preferred Agents
alprazolam extended release Atarax Ativan Buspar meprobamate 3 Miltown Niravam Serax Tranxene Vistaril Vistaril suspension Xanax / Xanax XR Adderall amphetamine salts XR (generic Adderall XR) Concerta Cylert Daytrana Dexedrine Methylin chewable / soln. methylphenidate CD (generic Metadate CD) methylphenidate LA (generic Ritalin LA) Procentra Ritalin Ritalin SR
Adderall XR amphetamine salts dexmethylphenidate dextroamphetamine Dextrostat Focalin Focalin XR Metadate CD Methylin / Methylin ER methylphenidate methylphenidate ER (generic Concerta) methylphenidate SR (generic Ritalin SR) Ritalin LA 2 Vyvanse Kapvay 2 Kapvay DosePack Intuniv Strattera Avonex Betaseron Copaxone Gilenya Rebif Mirapex ER pramipexole Requip XL ropinirole
Aubagio Extavia
1 Prior Authorization Not Required for Beneficiaries Under the Age of 12. 2 Quantity limits apply See MPPL on website for details 3 Prior Authorization Required if Beneficiary is Over the Age of 65. 4 Prior Authorization Required for Beneficiaries Under Age of 6. 5 PA required if a benzodiazepine is found in beneficiary drug history 7 Providers should consult yearly CDC guidelines for Influenza 8 Electronic Step edit: at least 1 component of the product must be in beneficiary drug history
9 PA required if no history of oral antinausea drugs in beneficiary drug history 10 Prior Authorization Required for Beneficiaries Under Age of 15. 11 Prior Authorization Required for Beneficiaries Under Age of 18. 12 Components of product must be in drug history APAP = Acetaminophen ASA = Aspirin CR, ER, SR, XL, XR, SA, LA = Extended Release, HCT = Hydrochlorothiazide Clinical PA required; refer to MPPL, MI Provider Manual or michigan.fhsc.com for other restrictions Version 07162013v1 Page 11 of 17
Effective 07/16/2013 Preferred Agents do not require prior authorization, except as noted in the chart at the bottom of the page CENTRAL NERVOUS SYSTEM DRUGS
Drug Class
Sedative Hypnotic Non-Barbiturates
Preferred Agents
estazolam 10 flurazepam 3 temazepam (excluding 7.5mg and 22.5mg) 3 triazolam 11 zolpidem
Non-Preferred Agents
Ambien / Ambien CR Doral Edluar Halcion Intermezzo Lunesta ProSom 3 Restoril 5 Rozerem Silenor Somnote 2 Sonata 2, 3 temazepam 7.5mg and 22.5mg Zolpimist Amerge Axert Frova Imitrex Maxalt rizatriptan rizatriptan ODT (generic Maxalt MLT) Sumavel Treximet zolmitriptan, zolmitriptan ODT Zomig / Zomig ZMT
DIABETES
Drug Class
Amylin Analogs Secretin Mimetics Symlin Bydureon Byetta Victoza Lantus Levemir Apidra Humalog Novolog Humalog 50/50 Humalog 75/25 Humulin 50/50 Humulin 70/30 Novolin 70/30 Novolog 70/30
9 PA required if no history of oral antinausea drugs in beneficiary drug history 10 Prior Authorization Required for Beneficiaries Under Age of 15. 11 Prior Authorization Required for Beneficiaries Under Age of 18. 12 Components of product must be in drug history APAP = Acetaminophen ASA = Aspirin CR, ER, SR, XL, XR, SA, LA = Extended Release, HCT = Hydrochlorothiazide Clinical PA required; refer to MPPL, MI Provider Manual or michigan.fhsc.com for other restrictions Version 07162013v1 Page 12 of 17
Preferred Agents
Non-Preferred Agents
Insulin, Mixes
1 Prior Authorization Not Required for Beneficiaries Under the Age of 12. 2 Quantity limits apply See MPPL on website for details 3 Prior Authorization Required if Beneficiary is Over the Age of 65. 4 Prior Authorization Required for Beneficiaries Under Age of 6. 5 PA required if a benzodiazepine is found in beneficiary drug history 7 Providers should consult yearly CDC guidelines for Influenza 8 Electronic Step edit: at least 1 component of the product must be in beneficiary drug history
Effective 07/16/2013 Preferred Agents do not require prior authorization, except as noted in the chart at the bottom of the page DIABETES
Drug Class
Insulins, Traditional
Preferred Agents
Humulin R 500-U Novolin N Novolin R Acarbose Glyset metformin / metformin XR Humulin N Humulin R Precose
Non-Preferred Agents
Glucophage Glucophage XR Fortamet Glumetza Actoplus Met Avandamet Avandaryl Glucovance 12 Juvisync Metaglip pioglitazone/glimepride
Actoplus Met XR Duetact glyburide / metformin glipizide / meformin Kombiglyze XR Janumet/Janumet XR Jentadueto pioglitazone/metformin Prandimet Cycloset
Oral Hypoglycemics DPP4 Inhibitors Januvia Onglyza Tradjenta Oral Hypoglycemics Meglitinides nateglinide Prandin Starlix Amaryl Glucotrol Glucotrol XL Glynase Micronase Actos Avandia
Oral Hypoglycemics 2nd Generation glimepiride Sulfonylureas glipizide / glipizide ER glyburide glyburide micronized Oral Hypoglycemics Thiazolidineiones pioglitazone
GASTROINTESTINAL
Drug Class
Nausea Agents Oral granisetron ondansetron 9 Sancuso Emend
Preferred Agents
Non-Preferred Agents
Anzemet Kytril Brand Zofran / Zofran ODT Brand Zuplenz
1 Prior Authorization Not Required for Beneficiaries Under the Age of 12. 2 Quantity limits apply See MPPL on website for details 3 Prior Authorization Required if Beneficiary is Over the Age of 65. 4 Prior Authorization Required for Beneficiaries Under Age of 6. 5 PA required if a benzodiazepine is found in beneficiary drug history 7 Providers should consult yearly CDC guidelines for Influenza 8 Electronic Step edit: at least 1 component of the product must be in beneficiary drug history
9 PA required if no history of oral antinausea drugs in beneficiary drug history 10 Prior Authorization Required for Beneficiaries Under Age of 15. 11 Prior Authorization Required for Beneficiaries Under Age of 18. 12 Components of product must be in drug history APAP = Acetaminophen ASA = Aspirin CR, ER, SR, XL, XR, SA, LA = Extended Release, HCT = Hydrochlorothiazide Clinical PA required; refer to MPPL, MI Provider Manual or michigan.fhsc.com for other restrictions Version 07162013v1 Page 13 of 17
Effective 07/16/2013 Preferred Agents do not require prior authorization, except as noted in the chart at the bottom of the page GASTROINTESTINAL
Drug Class
Proton Pump Inhibitors
Preferred Agents
Nexium capsules pantoprazole Prilosec OTC
Non-Preferred Agents
Aciphex Dexilant (formerly Kapidex) lansoprazole Nexium Susp Pkts 1 omeprazole Prevacid / Prevacid 24HR Prilosec Protonix Zegerid / Zegerid OTC Asacol HD Azulfidine DR balsalazide Colazal Dipentum Giazo Lialda
OPHTHALMICS
Drug Class
Glaucoma Alpha-2 Adrenergics
Preferred Agents
Alphagan P apraclonidine brimonidrine tartrate betaxolol Betimol carteolol levobunolol metipranolol timolol maleate latanoprost Travatan Z Iopidine
Non-Preferred Agents
Betagan Betoptic S Istalol Ocupress Optipranolol Timoptic Timoptic XE Lumigan Rescula travoprost (generic for Travatan) Xalatan Zioptan Cosopt Trusopt
1 Prior Authorization Not Required for Beneficiaries Under the Age of 12. 2 Quantity limits apply See MPPL on website for details 3 Prior Authorization Required if Beneficiary is Over the Age of 65. 4 Prior Authorization Required for Beneficiaries Under Age of 6. 5 PA required if a benzodiazepine is found in beneficiary drug history 7 Providers should consult yearly CDC guidelines for Influenza 8 Electronic Step edit: at least 1 component of the product must be in beneficiary drug history
9 PA required if no history of oral antinausea drugs in beneficiary drug history 10 Prior Authorization Required for Beneficiaries Under Age of 15. 11 Prior Authorization Required for Beneficiaries Under Age of 18. 12 Components of product must be in drug history APAP = Acetaminophen ASA = Aspirin CR, ER, SR, XL, XR, SA, LA = Extended Release, HCT = Hydrochlorothiazide Clinical PA required; refer to MPPL, MI Provider Manual or michigan.fhsc.com for other restrictions Version 07162013v1 Page 14 of 17
Effective 07/16/2013 Preferred Agents do not require prior authorization, except as noted in the chart at the bottom of the page OPHTHALMICS
Drug Class
Ophthalmic Antihistamines
Preferred Agents
ketotifen fumarate (OTC Only) Pataday Patanol Zaditor
Non-Preferred Agents
Bepreve Elestat Emadine ketotifen fumarate (RX Only) Lastacaft Livostin Optivar Alomide Acular / Acular LS Acuvail Bromday Ilevro Nevanac Voltaren
MISCELLANEOUS
Drug Class
Anticoagulants Arixtra Fragmin Lovenox Pradaxa warfarin Xarelto Enbrel Humira Cimzia Simponi Avodart finasteride prazosin tamsulosin terazosin Uroxatral Benzaclin clindamycin / benzoyl peroxide calcium acetate Fosrenol Renagel Renvela tablets and powder
Preferred Agents
Coumadin Eliquis enoxaparin fondaparinux Innohep
Non-Preferred Agents
Biologic Immunomodulators
Kineret Orencia SC Xeljanz alfuzosin Flomax Jalyn Proscar Rapaflo Acanya gel Duac CS Eliphos Phoslo Phoslyra
BPH Agents
1 Prior Authorization Not Required for Beneficiaries Under the Age of 12. 2 Quantity limits apply See MPPL on website for details 3 Prior Authorization Required if Beneficiary is Over the Age of 65. 4 Prior Authorization Required for Beneficiaries Under Age of 6. 5 PA required if a benzodiazepine is found in beneficiary drug history 7 Providers should consult yearly CDC guidelines for Influenza 8 Electronic Step edit: at least 1 component of the product must be in beneficiary drug history
9 PA required if no history of oral antinausea drugs in beneficiary drug history 10 Prior Authorization Required for Beneficiaries Under Age of 15. 11 Prior Authorization Required for Beneficiaries Under Age of 18. 12 Components of product must be in drug history APAP = Acetaminophen ASA = Aspirin CR, ER, SR, XL, XR, SA, LA = Extended Release, HCT = Hydrochlorothiazide Clinical PA required; refer to MPPL, MI Provider Manual or michigan.fhsc.com for other restrictions Version 07162013v1 Page 15 of 17
Effective 07/16/2013 Preferred Agents do not require prior authorization, except as noted in the chart at the bottom of the page MISCELLANEOUS
Drug Class
Fibromyalgia Agents Cymbalta Lyrica Savella Genotropin Norditropin Norditropin Flexpro Norditropin Nordiflex Nutropin Nutropin AQ Aranesp Epogen Procrit alendronate Sodium Actonel Atelvia Boniva Binosto Didronel etidronate Fosamax Fosamax Plus D ibandronate Forteo Fortical Miacalcin Aggrenox Brilinta dipyridamole Effient Persantine Plavix Ticlid ticlopidine Humatrope Omnitrope Saizen Serostim Tev-Tropin Zorbtive
Preferred Agents
Non-Preferred Agents
Growth Hormones
Hematopoietic Agents
calcitonin
Evista clopidogrel
1 Prior Authorization Not Required for Beneficiaries Under the Age of 12. 2 Quantity limits apply See MPPL on website for details 3 Prior Authorization Required if Beneficiary is Over the Age of 65. 4 Prior Authorization Required for Beneficiaries Under Age of 6. 5 PA required if a benzodiazepine is found in beneficiary drug history 7 Providers should consult yearly CDC guidelines for Influenza 8 Electronic Step edit: at least 1 component of the product must be in beneficiary drug history
9 PA required if no history of oral antinausea drugs in beneficiary drug history 10 Prior Authorization Required for Beneficiaries Under Age of 15. 11 Prior Authorization Required for Beneficiaries Under Age of 18. 12 Components of product must be in drug history APAP = Acetaminophen ASA = Aspirin CR, ER, SR, XL, XR, SA, LA = Extended Release, HCT = Hydrochlorothiazide Clinical PA required; refer to MPPL, MI Provider Manual or michigan.fhsc.com for other restrictions Version 07162013v1 Page 16 of 17
Effective 07/16/2013 Preferred Agents do not require prior authorization, except as noted in the chart at the bottom of the page MISCELLANEOUS
Drug Class
Skeletal Muscle Relaxants
Preferred Agents
baclofen chlorzoxazone cyclobenzaprine methocarbamol orphenadrine citrate tizanidine tablets
Non-Preferred Agents
Amrix cyclobenzaprine ER Dantrium dantrolene sodium Fexmid Lorzone metaxolone Norflex orphenadrine compound Parafon Forte DSC Robaxin Skelaxin Zanaflex capsules and tablets
Elidel Protopic Detrol LA oxybutynin / oxybutynin ER Toviaz Vesicare Detrol Ditropan / Ditropan XL Enablex flavoxate HCL Gelnique Myrbetriq Oxytrol Sanctura / Sanctura XR tolterodine trospium Urispas
Note: Not all medications listed are covered by all MDCH Programs. Check individual program coverage. For program drug coverage information, go to michigan.fhsc.com, open Drug Coverage and click on MPPL Including Coverage Information for all programs. Michigan Department of Community Health, in conjunction with Magellan Medicaid Administration, is pleased to offer an alternative means to submit pharmacy prior authorization (PA) requests for prescription drugs. This web-based process is designed to save prescribers time by providing a real-time pharmacy prior authorization. This process will supplement the more traditional means of requesting PAs by phone or fax, which will still be available to providers. In order to use Web PA, provider designees will need to register to receive a logon and password for the Web PA system. Detailed information on user registration and Web PA, including a web based tutorial, and a complete instruction is available at michigan.fhsc.com. For questions or assistance with registration, call the Magellan Medicaid Administration Web Support Call Center at 800-241-8726.
1 Prior Authorization Not Required for Beneficiaries Under the Age of 12. 2 Quantity limits apply See MPPL on website for details 3 Prior Authorization Required if Beneficiary is Over the Age of 65. 4 Prior Authorization Required for Beneficiaries Under Age of 6. 5 PA required if a benzodiazepine is found in beneficiary drug history 7 Providers should consult yearly CDC guidelines for Influenza 8 Electronic Step edit: at least 1 component of the product must be in beneficiary drug history
9 PA required if no history of oral antinausea drugs in beneficiary drug history 10 Prior Authorization Required for Beneficiaries Under Age of 15. 11 Prior Authorization Required for Beneficiaries Under Age of 18. 12 Components of product must be in drug history APAP = Acetaminophen ASA = Aspirin CR, ER, SR, XL, XR, SA, LA = Extended Release, HCT = Hydrochlorothiazide Clinical PA required; refer to MPPL, MI Provider Manual or michigan.fhsc.com for other restrictions Version 07162013v1 Page 17 of 17