MedStar Family Choice - Maryland HealthChoice Prescribing Guide 2014 (710)

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MedStar Family Choice - Maryland HealthChoice Prescribing Guide 2014 (710) (10/01/2014) INTRODUCTION... 5 PREFACE... 5 PHARMACY AND THERAPEUTICS (P&T) COMMITTEE... 5 PRODUCT SELECTION CRITERIA... 5 GENERIC
MedStar Family Choice - Maryland HealthChoice Prescribing Guide 2014 (710) (10/01/2014) INTRODUCTION... 5 PREFACE... 5 PHARMACY AND THERAPEUTICS (P&T) COMMITTEE... 5 PRODUCT SELECTION CRITERIA... 5 GENERIC AVAILABILITY... 6 GENERIC SUBSTITUTION... 6 DRUG EFFICACY STUDY IMPLEMENTATION (DESI) DRUGS... 6 MEDICAL EXCEPTION... 6 PRIOR AUTHORIZATION (PA)... 7 MANAGED DRUG LIMITATIONS (MDL)... 7 STEP THERAPY (ST)... 8 OVER-THE-COUNTER (OTC) DRUG COVERAGE... 9 EDITOR NOTICE LEGEND ANALGESICS NSAIDs NSAIDs, TOPICAL COX-2 INHIBITORS GOUT OPIOID ANALGESICS NON-OPIOID ANALGESICS VISCOSUPPLEMENTS ANTI-INFECTIVES ANTIBACTERIALS ANTIFUNGALS ANTIMALARIALS ANTIRETROVIRAL AGENTS ANTITUBERCULAR AGENTS ANTIVIRALS MISCELLANEOUS ANTINEOPLASTIC AGENTS ALKYLATING AGENTS ANTIMETABOLITES HORMONAL ANTINEOPLASTIC AGENTS KINASE INHIBITORS TOPOISOMERASE INHIBITORS MISCELLANEOUS CARDIOVASCULAR ACE INHIBITORS ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS ACE INHIBITOR/DIURETIC COMBINATIONS ADRENOLYTICS, CENTRAL ALDOSTERONE RECEPTOR ANTAGONISTS ALPHA BLOCKERS ANGIOTENSIN II RECEPTOR ANTAGONISTS/DIURETIC COMBINATIONS ANTIARRHYTHMICS ANTILIPEMICS BETA-BLOCKERS BETA-BLOCKER/DIURETIC COMBINATIONS CALCIUM CHANNEL BLOCKERS CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS DIGITALIS GLYCOSIDES DIURETICS NITRATES PULMONARY ARTERIAL HYPERTENSION MISCELLANEOUS CENTRAL NERVOUS SYSTEM ANTIANXIETY ANTICONVULSANTS ANTIDEMENTIA ANTIDEPRESSANTS ANTIPARKINSONIAN AGENTS ANTIPSYCHOTICS ATTENTION DEFICIT HYPERACTIVITY DISORDER FIBROMYALGIA HYPNOTICS MIGRAINE MOOD STABILIZERS MULTIPLE SCLEROSIS MUSCULOSKELETAL THERAPY AGENTS MYASTHENIA GRAVIS NARCOLEPSY/CATAPLEXY NEUROMUSCULAR BLOCKING AGENTS PSYCHOTHERAPEUTIC - MISCELLANEOUS ENDOCRINE AND METABOLIC ANDROGENS ANTIDIABETICS CALCIUM RECEPTOR ANTAGONISTS CALCIUM REGULATORS CONTRACEPTIVES ESTROGENS ESTROGEN/PROGESTINS GLUCOCORTICOIDS GLUCOSE ELEVATING AGENTS HUMAN GROWTH HORMONES HYPERPARATHYROID TREATMENT, VITAMIN D ANALOGS PHOSPHATE BINDER AGENTS PROGESTINS SELECTIVE ESTROGEN RECEPTOR MODULATORS THYROID AGENTS VASOPRESSINS MISCELLANEOUS GASTROINTESTINAL ANTACIDS ANTIDIARRHEALS ANTIEMETICS ANTISPASMODICS CHOLELITHOLYTICS H2 RECEPTOR ANTAGONISTS INFLAMMATORY BOWEL DISEASE LAXATIVES/STOOL SOFTENERS PANCREATIC ENZYMES PROSTAGLANDINS PROTON PUMP INHIBITORS STEROIDS, RECTAL ULCER THERAPY COMBINATIONS MISCELLANEOUS GENITOURINARY BENIGN PROSTATIC HYPERPLASIA URINARY ANTISPASMODICS VAGINAL ANTI-INFECTIVES MISCELLANEOUS HEMATOLOGIC ANTICOAGULANTS HEMATOPOIETIC GROWTH FACTORS HEREDITARY ANGIOEDEMA AGENTS PLATELET AGGREGATION INHIBITORS PLATELET SYNTHESIS INHIBITORS IMMUNOLOGIC AGENTS ALLERGEN EXTRACTS BIOLOGIC DISEASE-MODIFYING AGENTS DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs) IMMUNOMODULATORS IMMUNOSUPPRESSANTS NUTRITIONAL/SUPPLEMENTS ELECTROLYTES VITAMINS AND MINERALS RESPIRATORY ANAPHYLAXIS TREATMENT AGENTS ANTICHOLINERGICS ANTICHOLINERGIC/BETA AGONIST COMBINATIONS ANTIHISTAMINES, LOW SEDATING ANTIHISTAMINES, NONSEDATING ANTIHISTAMINES, SEDATING ANTIHISTAMINE/DECONGESTANT COMBINATIONS ANTITUSSIVES ANTITUSSIVE COMBINATIONS BETA AGONISTS CYSTIC FIBROSIS DECONGESTANTS DECONGESTANT/EXPECTORANT COMBINATIONS EXPECTORANTS LEUKOTRIENE RECEPTOR ANTAGONISTS MAST CELL STABILIZERS NASAL ANTIHISTAMINES NASAL STEROIDS RESPIRATORY SYNCYTIAL VIRUS STEROID/BETA AGONIST COMBINATIONS STEROID INHALANTS XANTHINES MISCELLANEOUS TOPICAL DERMATOLOGY MOUTH/THROAT/DENTAL AGENTS OPHTHALMIC OTIC WEBSITES INTRODUCTION PREFACE MedStar Family Choice is pleased to provide the 2014 MedStar Family Choice - Maryland HealthChoice Prescribing Guide to be used when prescribing for patients covered by the pharmacy plan offered by MedStar Family Choice. This is a closed formulary and only those drugs listed in this formulary will be covered by MedStar Family Choice. The drugs listed in the MedStar Family Choice - Maryland HealthChoice Prescribing Guide have been reviewed and approved by the MedStar Family Choice Pharmacy and Therapeutics Committee. The drugs have been selected to provide the most clinically appropriate and cost-effective medications for patients who have drug benefits administered through MedStar Family Choice - Maryland HealthChoice. There may be occasions when an unlisted drug is desired for medical management of a specific patient. In those instances, the unlisted medication may be requested through the Medical Exception process. The information contained in this formulary and its appendices is provided solely for the convenience of medical providers. This formulary is subject to state-specific regulations and rules, including, but not limited to, those regarding generic substitution, controlled substance schedules, preference for brands and mandatory generics whenever applicable. MedStar Family Choice does not warrant or assure accuracy of such information nor is it intended to be comprehensive in nature. This formulary is not intended to be a substitute for the knowledge, expertise, skill and judgment of the medical provider in his or her choice of prescription drugs. MedStar Family Choice does not assume responsibility for the actions or omissions of any medical provider based upon reliance, in whole or in part, on the information contained herein. The medical provider should consult the drug manufacturer's product literature or standard references for more detailed information. The MedStar Family Choice - Maryland HealthChoice Prescribing Guide is organized by sections. Each section includes therapeutic groups identified by either a drug class or disease state. All drugs listed were selected to be on this formulary. Products are listed by generic name. Brand-name products are included as a reference to assist in product recognition. Unless exceptions are noted, generally all dosage forms and strengths of the drug cited are covered. This formulary covers selected over-the-counter (OTC) products. You are encouraged to prescribe them when clinically appropriate. A prescription (written or telephoned) is required and refills are permitted. The prescription expires under Maryland Pharmacy Law in 12 months. Condoms do not require a prescription. For covered products refer to the Over- The-Counter (OTC) Drug Coverage section that is located near the end of the introductory sections of this formulary. PHARMACY AND THERAPEUTICS (P&T) COMMITTEE The MedStar Family Choice P&T Committee includes physicians, pharmacists, and nurses. The Committee meets bimonthly to evaluate drugs for formulary inclusion and to develop policies concerning formulary and drug utilization management. Please visit the MedStar Family Choice website at to view the decisions of the MedStar Family Choice P&T Committee and any applicable changes. The main features of the MedStar Family Choice P&T Policies are also on the website in the FAQs. Please visit to view the MedStar Family Choice - Maryland HealthChoice Prescribing Guide. This Maryland Department of Health and Mental Hygiene (D.H.M.H.) sponsored site contains the formularies of all the Managed Care Organizations (MCO) and is updated frequently. MedStar Family Choice formulary information can also be found online through epocrates. Registration is free and available at PRODUCT SELECTION CRITERIA The MedStar Family Choice Pharmacy and Therapeutics Committee considers clinical information on new-to-market drugs that are typically included in an outpatient pharmacy benefit. The evaluation includes all or part of the following: Safety Efficacy Comparison studies Approved indications Adverse effects Contraindications/Warnings/Precautions Pharmacokinetics Patient administration/compliance considerations 5 When a new drug is considered for formulary inclusion, it will be reviewed relative to similar drugs currently on formulary. In addition, the entire MedStar Family Choice - Maryland HealthChoice Prescribing Guide is reviewed on an annual basis. All the information in the MedStar Family Choice - Maryland HealthChoice Prescribing Guide is provided as a reference for drug therapy selection. Specific drug selection for an individual patient rests solely with the prescriber. GENERIC AVAILABILITY Boldface type of a generic drug name in this book indicates generic availability of that product. However, not all strengths or dosage forms of the generic name in boldface type may be generically available. In some cases, the brand name listed is a generic drug. Examples of the latter include Levoxyl and Trivora. GENERIC SUBSTITUTION Generic substitution is a pharmacy action whereby a generic version is dispensed rather than a prescribed brand-name product. An important consideration for generic substitution is the knowledge that all approvals of generic drugs by the FDA since 1984, and many generic approvals prior to 1984, have a showing of bioequivalence between the generic versions and the reference brand product. To gain FDA approval: 1. The generic drug must contain the same active ingredient(s), be the same strength and the same dosage form as the brand-name product. 2. The FDA has given the generic an A rating compared to the branded product indicating bioequivalence, and has determined the generic is therapeutically equivalent to the reference brand. The ratings of generic drugs are available by referring to the FDA reference, Approved Drug Products with Therapeutic Equivalence Evaluations (Orange Book). When the above two criteria are met, a generic can be substituted with the full expectation that the substituted product will produce the same clinical effect and safety profile as the prescribed product. Drug products that have a narrow therapeutic index (NTI) can also be guided by these principles. It is not necessary for the health care provider to approach any one therapeutic class of drug products (e.g., NTI drugs) differently from any other class, when there has been a determination of therapeutic equivalence by the FDA for the drug products under consideration. Also, additional clinical tests or examinations by the physician are not needed when a therapeutically equivalent generic drug product is substituted for the brand-name product. It is recommended that generic substitution not be exercised by the pharmacist with multisource products that appear in the Orange Book and carry a B rating, indicating that these products cannot be considered therapeutically equivalent to other products in the group. DRUG EFFICACY STUDY IMPLEMENTATION (DESI) DRUGS Drugs first marketed between 1938 and 1962 were approved as safe but required no showing of effectiveness for FDA approval. Beginning in 1962, all new drugs were required to be both safe and effective before they could be marketed. This legislation also applied retroactively to all drugs approved as safe from The DESI program was established by the FDA to review the effectiveness of these pre-1962 drugs for their labeled indications, and a determination of fully effective was made for most of these products and they remain in the marketplace. A few DESI products remain classified as less than fully effective while awaiting final administrative disposition. Also, classified as DESI are many products listed as identical, similar, or related to actual DESI products. Some plans will not pay for DESI less than fully effective drug products. DESI drugs are excluded by MedStar Family Choice. Exceptions: Anusol-HC suppositories, Donnatal and Midrin are covered. MEDICAL EXCEPTION If a non-covered drug is desired for medical management of a patient, a medication exception may be requested by calling MedStar Family Choice at: PRIOR AUTHORIZATION (PA) The following drugs and generic versions, if available, require prior authorization. This list is subject to change. ACTEMRA ADCIRCA ADEMPAS ARAVA AVINZA BENLYSTA BEYAZ BOSULIF BOTOX CAMPRAL CELEBREX CHANTIX COMETRIQ COPEGUS DDAVP spray DIFICID DURAGESIC ELIGARD ENBREL ERWINAZE FIRAZYR FLOLAN FOSRENOL FULYZAQ GAMMAGARD S/D GENERESS FE GILENYA GRASTEK HERCEPTIN HUMIRA HYCAMTIN CAPS ICLUSIG IMBRUVICA INCIVEK MANAGED DRUG LIMITATIONS (MDL) INTRON A isotretinoin JAKAFI JUXTAPID KALYDECO KINERET KORLYM KRYSTEXXA LETAIRIS leuprolide acetate LO LOESTRIN FE LOVAZA LUPRON DEPOT MEKINIST midazolam injection MINASTRIN 24 FE MS CONTIN NAMENDA NATAZIA NICOTROL INHALER NICOTROL NS NORDITROPIN NOXAFIL OLYSIO OPSUMIT ORALAIR ORENCIA PEGASYS PEGINTRON PRADAXA PROLIA PULMOZYME QUARTETTE RAGWITEK REBETOL REMICADE REMODULIN REVATIO SAFYRAL SENSIPAR SEROSTIM SIRTURO SOVALDI STELARA STIMATE STIVARGA SUPPRELIN LA SYNAGIS SYNRIBO SYNVISC SYNVISC-ONE TAFINLAR TARCEVA TASIGNA TYKERB TYVASO VENTAVIS XALKORI XGEVA XOLAIR XYREM ZELBORAF ZEMAIRA ZOLADEX ZONTIVITY ZYDELIG The Managed Drug Limitation program provides for a maximum quantity of drug product that a member may receive per prescription and/or over a specific period of time. Many drug products on the MedStar Family Choice - Maryland HealthChoice Prescribing Guide have quantity limits based upon the dosage described in product labeling. The following drugs are subject to MDL because they are typically not taken on a regular schedule and/or because of potential safety and utilization concerns. This list is subject to change. Contact MedStar Family Choice at for an updated list. Drugs azelastine spray buprenorphine/naloxone sublingual tabs butalbital/acetaminophen butalbital/acetaminophen/caffeine (FIORICET) butalbital/acetaminophen/caffeine/codeine (FIORICET w/codeine) butalbital/aspirin/caffeine (FIORINAL) butalbital/aspirin/caffeine/codeine (FIORINAL w/codeine) CHANTIX ciprofloxacin ext-rel 500 mg (CIPRO XR) dihydroergotamine spray (MIGRANAL) Limits 3 inhalers per 23 days 24 mg buprenorphine per day 30 units per 23 days 30 units per 23 days 30 units per 23 days 30 units per 23 days 30 units per 23 days 24 weeks per 12 months 3 tablets per 23 days 8 ml per 23 days 7 Drugs ELLA enoxaparin (LOVENOX) esomeprazole magnesium delayed-rel (NEXIUM 24HR) FLEET ENEMA fluconazole 150 mg (DIFLUCAN) granisetron 1 mg ketorolac lansoprazole (PREVACID) levonorgestrel 0.75 mg levonorgestrel - Next Choice One Dose (PLAN B ONE-STEP) naratriptan (AMERGE) nicotine transdermal omeprazole 40 mg (PRILOSEC) omeprazole, except 40 mg (PRILOSEC) pantoprazole 20 mg (PROTONIX) pantoprazole 40 mg (PROTONIX) PREVACID SOLUTAB RELENZA rizatriptan orally disintegrating tabs (MAXALT-MLT) rizatriptan (MAXALT) SEREVENT sumatriptan 25 mg, 50 mg, 100 mg (IMITREX) sumatriptan inj (IMITREX) sumatriptan inj (IMITREX) sumatriptan nasal spray (IMITREX) TAMIFLU tramadol (ULTRAM) ZANTAC 75 zolmitriptan 2.5 mg (ZOMIG) zolmitriptan 5 mg (ZOMIG) zolmitriptan orally disintegrating tabs 2.5 mg (ZOMIG-ZMT) zolmitriptan orally disintegrating tabs 5 mg (ZOMIG-ZMT) Limits 3 fills per 365 days 28 prefilled syringes per 23 days 60 capsules per 23 days 2 kits per 72 hours 3 tablets per 23 days 10 tablets per 23 days 20 tablets per 23 days 30 units per 23 days 3 fills per 365 days 3 fills per 365 days 9 tablets per 23 days 90 day supply per calendar year 60 capsules per 23 days 30 capsules per 23 days 30 tablets per 23 days 60 tablets per 23 days 30 tablets per 23 days 1 course of treatment per calendar year 18 tablets per 23 days 18 tablets per 23 days 1 inhaler per 23 days 9 tablets per 23 days 6 vials (6 injections) per 23 days 3 kits (6 injections) per 23 days 6 units (1 package) per 23 days 1 course of treatment per calendar year 120 tablets per 23 days 240 tablets per 23 days 12 tablets per 23 days 6 tablets per 23 days 12 tablets per 23 days 6 tablets per 23 days STEP THERAPY (ST) Drugs indicated with a ST require Step Therapy authorization for coverage. When using drugs within select drug classes, this program requires a certain order to be followed for the ST designated drugs to be covered by your benefit plan. Within the Step Therapy program, drug therapy is begun with the most cost-effective and safest drugs. If this initial therapy proves unsuccessful, treatment may move to other, more costly therapy. Step Therapy helps ensure that a plan member receives clinically appropriate, cost-effective medication. The following drugs are subject to Step Therapy: Drugs ADVAIR DISKUS ADVAIR HFA CARMOL 10, CARMOL 20 CRESTOR DULERA lansoprazole delayed-rel (PREVACID) rizatriptan orally disintegrating tabs (MAXALT-MLT) rizatriptan (MAXALT) SKLICE SYMBICORT 8 Drugs zolmitriptan orally disintegrating tabs (ZOMIG-ZMT) zolmitriptan tabs (ZOMIG) OVER-THE-COUNTER (OTC) DRUG COVERAGE In addition to prescription benefits, all over-the-counter medications on this list are covered by MedStar Family Choice with a written or telephoned prescription. Refills are permitted. Prescriptions may be written for the State limited 12 month maximum. OTC products covered are restricted to generics when available. Brand names are provided as reference only. If both prescription and OTC products are available, you are encouraged to prescribe OTC products when clinically appropriate. Antacids aluminum hydroxide aluminum hydroxide/magnesium hydroxide aluminum hydroxide/magnesium hydroxide/simethicone calcium carbonate AlternaGEL Alamag Maalox Maalox Antibacterial, Topical bacitracin bacitracin/polymyxin B benzoyl peroxide neomycin/bacitracin/polymyxin B Antifungals, Topical butenafine clotrimazole miconazole terbinafine tolnaftate Antifungals, Vaginal clotrimazole miconazole Antihistamines cetirizine chlorpheniramine clemastine diphenhydramine fexofenadine loratadine Antihistamine/Decongestant Combinations cetirizine/pseudoephedrine ext-rel chlorpheniramine/phenylephrine tabs loratadine/pseudoephedrine ext-rel Anti-Inflammatories, Topical hydrocortisone crm, oint 0.5%, 1% Polysporin Panoxyl Neosporin Lotrimin Ultra Lotrimin AF Desenex Lamisil AT Tinactin Gyne-Lotrimin Monistat Zyrtec Chlor-Trimeton Tavist-1 Benadryl Allegra Claritin Zyrtec-D Cold & Allergy Relief Claritin-D Cortizone Antilipemic Agents, Miscellaneous niacin Contraceptives, Barrier condoms spermicide gel Trojan Gynol II 9 Contraceptives, Emergency levonorgestrel 0.75 mg levonorgestrel - Next Choice One Dose Plan B One-Step Cough/Cold/Allergy (OTC products not covered for members under 4 years of age) dextromethorphan gelcaps, liquid Robitussin Long-Acting Cough dextromethorphan/chlorpheniramine liquid Robitussin Children's Cough & Cold, Long-Acting dextromethorphan/guaifenesin ext-rel Mucinex DM dextromethorphan/guaifenesin/pseudoephedrine liq 10 mg/100 mg/30 mg/5 ml dextromethorphan/guaifenesin syrup Robitussin Cough + Chest Congestion DM dextromethorphan/pyrilamine/phenylephrine Codituss DM guaifenesin ext-rel Mucinex guaifenesin liquid Diabetic Tussin guaifenesin liquid Mucinex for Kids guaifenesin/pseudoephedrine ext-rel Mucinex D oxymetazoline Afrin phenylephrine Neo-Synephrine phenylephrine drops PediaCare pseudoephedrine Sudafed sodium chloride solution Ocean sodium chloride solution Simply Saline triamcinolone acetonide spray Nasacort Allergy 24HR Gastrointestinal famotidine Pepcid AC famotidine chewable tabs Pepcid AC lansoprazole delayed-rel Prevacid 24HR omeprazole magnesium delayed-rel Prilosec OTC omeprazole/sodium bicarbonate Zegerid OTC ranitidine 75 mg Zantac 75 ranitidine 150 mg Zantac 150 Gastrointestinal, Miscellaneous bismuth subsalicylate dextrose/fructose/phosphoric acid dimenhydrinate docusate sodium caps docusate sodium liquid loperamide liquid, tabs meclizine simethicone Laxatives bisacodyl glycerin rectal suppository, adult glycerin rectal suppository, pediatric magnesium citrate methylcellulose mineral oil polyethylene glycol 3350 psyllium/aspartame sennosides 8.6 mg tablets sennosides 15 mg tablets sennosides/docusate sodium sodium phosphate/sodium biphosphate enema, adult sodium phosphate/sodium biphosphate enema, pediatric Pepto-Bismol Emetrol Dramamine Colace Anti-Diarrheal Mylicon Dulcolax Citrucel MiraLax Natural Fiber Senokot Ex-Lax Peri-Colace Fleet Enema Fleet Enema 10 Nutritional/Supplements calcium Tums cholecalciferol (D3) Vitamin D3 electrolyte rehydrating soln Pedialyte ergocalcife
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