Paramount Advantage Preferred Drug List

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Paramount Advantage Preferred Drug List (04/01/2018) INTRODUCTION... 4 NOTICE OF NONDISCRIMINATION AND ACCESSIBILITY: DISCRIMINATION IS AGAINST THE LAW... 4 HOW TO SEARCH THIS DOCUMENT... 5 PREFACE... 5 PHARMACY AND THERAPEUTICS COMMITTEE... 5 DRUG LIST PRODUCT DESCRIPTIONS... 5 GENERIC SUBSTITUTION... 6 PLAN DESIGN... 6 PRIOR AUTHORIZATION... 6 QUANTITY LIMITATIONS... 6 STEP THERAPY... 7 LEGEND... 7 NOTICE... 7 ANALGESICS... 8 NSAIDs... 8 NSAIDs, TOPICAL... 8 COX-2 INHIBITORS... 8 GOUT... 8 OPIOID ANALGESICS... 9 NON-OPIOID ANALGESICS... 9 ANTI-INFECTIVES... 9 ANTIBACTERIALS ANTIFUNGALS ANTIMALARIALS ANTIRETROVIRAL AGENTS ANTITUBERCULAR AGENTS ANTIVIRALS MISCELLANEOUS ANTINEOPLASTIC AGENTS ALKYLATING AGENTS ANTIMETABOLITES HORMONAL ANTINEOPLASTIC AGENTS IMMUNOMODULATORS 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 DIGITALIS GLYCOSIDES DIURETICS HEART FAILURE NITRATES PULMONARY ARTERIAL HYPERTENSION MISCELLANEOUS CENTRAL NERVOUS SYSTEM ANTIANXIETY ANTICONVULSANTS ANTIDEMENTIA ANTIDEPRESSANTS ANTIPARKINSONIAN AGENTS ANTIPSYCHOTICS ATTENTION DEFICIT HYPERACTIVITY DISORDER FIBROMYALGIA HUNTINGTON'S DISEASE AGENTS HYPNOTICS MIGRAINE MOOD STABILIZERS MULTIPLE SCLEROSIS AGENTS MUSCULOSKELETAL THERAPY AGENTS MYASTHENIA GRAVIS NARCOLEPSY/CATAPLEXY PSYCHOTHERAPEUTIC-MISCELLANEOUS MISCELLANEOUS ENDOCRINE AND METABOLIC ANDROGENS ANTIDIABETICS CALCIUM RECEPTOR ANTAGONISTS CALCIUM REGULATORS CONTRACEPTIVES ENDOMETRIOSIS ESTROGENS ESTROGEN/PROGESTINS FERTILITY REGULATORS GLUCOCORTICOIDS GLUCOSE ELEVATING AGENTS HUMAN GROWTH HORMONES HYPERPARATHYROID TREATMENT, VITAMIN D ANALOGS INSULIN-LIKE GROWTH FACTORS PHENYLKETONURIA TREATMENT AGENTS PHOSPHATE BINDER AGENTS POTASSIUM-REMOVING AGENTS PRE-TERM BIRTH RISK REDUCTION PROGESTINS THYROID AGENTS VASOPRESSIN RECEPTOR ANTAGONISTS VASOPRESSINS MISCELLANEOUS GASTROINTESTINAL ANTIDIARRHEALS ANTIEMETICS ANTISPASMODICS CHOLELITHOLYTICS H2 RECEPTOR ANTAGONISTS INFLAMMATORY BOWEL DISEASE IRRITABLE BOWEL SYNDROME LAXATIVES/STOOL SOFTENERS PANCREATIC ENZYMES PROSTAGLANDINS PROTON PUMP INHIBITORS SALIVA STIMULANTS STEROIDS, RECTAL ULCER THERAPY COMBINATIONS MISCELLANEOUS GENITOURINARY BENIGN PROSTATIC HYPERPLASIA URINARY ANTISPASMODICS VAGINAL ANTI-INFECTIVES MISCELLANEOUS HEMATOLOGIC ANTICOAGULANTS HEMATOPOIETIC GROWTH FACTORS HEMOPHILIA, VON WILLEBRAND DISEASE AND RELATED BLEEDING DISORDERS HEREDITARY ANGIOEDEMA AGENTS IDIOPATHIC THROMBOCYTOPENIC PURPURA AGENTS PAROXYSMAL NOCTURNAL HEMOGLOBINURIA (PNH) AGENTS PLATELET AGGREGATION INHIBITORS PLATELET SYNTHESIS INHIBITORS STEM CELL MOBILIZERS MISCELLANEOUS IMMUNOLOGIC AGENTS AUTOIMMUNE AGENTS DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs) IMMUNE GLOBULINS IMMUNOMODULATORS IMMUNOSUPPRESSANTS VACCINES 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 DECONGESTANT/EXPECTORANT COMBINATIONS LEUKOTRIENE MODULATORS MAST CELL STABILIZERS MEDICAL SUPPLIES NASAL ANTIHISTAMINES NASAL STEROIDS RESPIRATORY SYNCYTIAL VIRUS STEROID/BETA AGONIST COMBINATIONS STEROID INHALANTS XANTHINES MISCELLANEOUS TOPICAL DERMATOLOGY MOUTH/THROAT/DENTAL AGENTS OPHTHALMIC OTIC WEBSITES INDEX INTRODUCTION We are pleased to provide the 2018 Paramount Advantage Preferred Drug List as a useful reference and informational tool. This is a list of medications which are preferred by Paramount Advantage and commonly prescribed. Additionally, all other Medicaid-covered medications are covered for Paramount Advantage members, but some may require prior authorization (PA) for medical necessity. See the Advantage Drug Prior Authorization List. If you have questions about your prescription benefit or covered medications, please call Paramount Member Services at (800) , TTY users (888) The drugs represented have been reviewed by Paramount's Pharmacy and Therapeutics (P&T) Committee and are approved for inclusion on this formulary. The document is reflective of current medical practice as of the date of review. The information contained in this document and its appendices is provided solely for the convenience of medical providers. We do not warrant or assure accuracy of such information nor is it intended to be comprehensive in nature. This document 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. All the information in the document is provided as a reference for drug therapy selection. Specific drug selection for an individual patient rests solely with the prescriber. The document 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. We assume no 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. National guidelines can be found on the National Guideline Clearinghouse site at on the websites listed under each therapeutic class and on the sites listed in the Websites section of this publication. NOTICE OF NONDISCRIMINATION AND ACCESSIBILITY: Discrimination is Against the Law Paramount complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. Paramount does not exclude people or treat them differently because of race, color, national origin, age, disability or sex. Paramount provides: Free aids and services to people with disabilities to communicate effectively with us, such as: o Qualified sign language interpreters o Written information in other formats (large print, audio, accessible electronic formats, other formats Free language services to people whose primary language is not English, such as: o Qualified interpreters o Information written in other languages If you need these services, contact Member Services at If you believe that Paramount has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability or sex, you can file a grievance. You can file a grievance in person or by mail, fax or . Member Services 1901 Indian Wood Circle, Maumee OH Phone: Toll Free: TTY: Fax: If you need help filing a grievance, Member Services is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at: or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue SW Room 509F, HHH Building Washington, D.C , (TDD) Complaint forms are available at: HOW TO SEARCH THIS DOCUMENT PREFACE To search this document for a specific medication or word, follow these steps: 1. With the PDF open, click on the Edit menu, choose Find. 2. In the Find box (in the upper right corner), type the name of the medication you want to find. 3. Click Find Next button until you find the medications you're looking for. The document is organized by sections. Each section is divided by therapeutic drug class primarily defined by mechanism of action. Products are listed by generic name with brand name for reference only. Unless the cited drug is available as an injectable or an exception is specifically noted, generally, all applicable dosage forms and strengths of the drug cited are included in the document. Generics should be considered the first line of prescribing subject to applicable rules. Paramount Advantage members do not have copays or cost sharing for drug coverage. PHARMACY AND THERAPEUTICS COMMITTEE Paramount's P&T Committee serves to approve safe and clinically effective drug therapies for inclusion on the formulary, with or without clinical limits. The P&T Committee is an advisory body of clinical professionals which includes physicians, specialists, pharmacists, etc. Voting members of the P&T Committee must disclose any financial relationship or conflicts of interest with any pharmaceutical manufacturers. DRUG LIST PRODUCT DESCRIPTIONS To assist in understanding which specific strengths and dosage forms on the document are covered, examples are noted below. The general principles shown in the examples can usually be extended to other entries in the document. Any exceptions are noted. Listed products on the document generally include all strengths and dosage forms of the cited brand-name product. pregabalin Lyrica Oral capsules, oral solution and all strengths of Lyrica would be included in this listing. When a strength or dosage form is specified, only the specified strength and dosage form is on the document. Other strengths/dosage forms, including injectable dosage forms of the reference product are not. ciprofloxacin tabs Cipro tabs The oral tablet dosage form of ciprofloxacin is on the document. From this entry, the oral suspension cannot be assumed to be on the list unless there is a separate entry. 5 Extended-release and delayed-release products require their own entry. carbamazepine Tegretol The immediate-release product listing of Tegretol alone would not include the extended-release product Tegretol-XR. carbamazepine ext-rel Tegretol-XR A separate entry for Tegretol-XR confirms that the extended-release product is on the document. Dosage forms on the document will be consistent with the category and use where listed. neomycin/polymyxin B/hydrocortisone Cortisporin Since Cortisporin is listed only in the OTIC section, it is limited to the otic solution and suspension. From this entry the topical cream cannot be assumed to be on the list unless there is an entry for this product in the DERMATOLOGY section of the document. GENERIC SUBSTITUTION Generic substitution is a pharmacy action whereby a generic version is dispensed rather than a prescribed brand-name product. Boldface type indicates generic availability. However, not all strengths or dosage forms of the generic name in boldface type may be generically available. Branded medications on this list may no longer be preferred if generic equivalents become available. However, the document is subject to state specific regulations and rules regarding generic substitution and mandatory generic rules apply where appropriate. Generic drugs are usually priced lower than their brand-name equivalents. Prescription generic drugs are: Approved by the U.S. Food and Drug Administration for safety and effectiveness, and are manufactured under the same strict standards that apply to brand-name drugs. Tested in humans to assure the generic is absorbed into the bloodstream in a similar rate and extent compared to the brand-name drug (bioequivalence). Generics may be different from the brand in size, color and inactive ingredients, but this does not alter their effectiveness or ability to be absorbed just like the brand-name drug. Manufactured in the same strength and dosage form as the brand-name drugs. PLAN DESIGN When a generic drug is substituted for a brand-name drug, you can expect the generic to produce the same clinical effect and safety profile as the brand-name drug (therapeutic equivalence). Certain medications on the list are covered if utilization management criteria are met (i.e., Step Therapy, Prior Authorization, Quantity Limits, etc.); requests for use of such medications outside of their listed criteria will be reviewed for medical necessity. If a medication is not listed on the document, a formulary exception may be requested for coverage. Medical necessity or formulary exception requests will be reviewed based on drug-specific prior authorization criteria or standard non-formulary prescription request criteria. PRIOR AUTHORIZATION Some medications on this list require prior authorization and are marked with PA. Your doctor may request prior authorization and provide evidence of medical necessity for these medications by obtaining a request form at or by faxing the request to Paramount at (844) Members may contact Paramount by calling (800) , TTY (888) Prior authorization requests must be completed by your prescribing physician. QUANTITY LIMITATIONS Some drugs on this list may have quantity limits and are marked with QL. Most quantity limits are based on FDA guidelines for maximum dose. Your doctor may request prior authorization by providing evidence of medical necessity to exceed the limits by obtaining a request form at or by calling Paramount at (419) Members may contact Paramount by calling (800) , TTY (888) Prior authorization requests must be completed by your prescribing physician. 6 STEP THERAPY LEGEND Some medications on this list are part of what is called Step Therapy , and are marked with ST. Paramount wants your doctor to prescribe a step-one medication for you before using a step-two or step-three medication. The step-one drugs can be found on the Paramount Advantage Drug Prior Authorization list. AL OTC PA PA, QL QL SP ST boldface delayed-rel ext-rel Age Limit Over the counter Prior Authorization Quantity Limit is applied after Prior Authorization approval Quantity Limit Specialty Drug Step Therapy Indicates generic availability; boldface may not apply to every strength or dosage form under the listed generic name Delayed-release (also known as enteric-coated), refer to the reference brand listed for clarification Extended-release (also known as sustained-release), refer to the reference brand listed for clarification NOTICE The information contained in this document is proprietary. The information may not be copied in whole or in part without written permission All rights reserved. This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers. Paramount Advantage does not operate the websites/organizations listed here, nor is it responsible for the availability or reliability of the websites' content. These listings do not imply or constitute an endorsement, sponsorship or recommendation by Paramount Advantage. Plan member privacy is important to us. Our employees are trained regarding the appropriate way to handle members' private health information. 7 ANALGESICS Practice guidelines of pain management are available at: Treatment recommendations for osteoarthritis are available at: NSAIDs choline magnesium trisalicylate diclofenac potassium diclofenac sodium delayed-rel diclofenac sodium ext-rel diflunisal etodolac etodolac ext-rel fenoprofen flurbiprofen ibuprofen indomethacin ketoprofen ketorolac meclofenamate meloxicam nabumetone naproxen naproxen sodium oxaprozin piroxicam salsalate sulindac tolmetin NALFON MOBIC NAPROSYN ANAPROX DAYPRO FELDENE NSAIDs, TOPICAL PA diclofenac sodium gel 1% VOLTAREN PA diclofenac sodium soln COX-2 INHIBITORS ST celecoxib CELEBREX GOUT allopurinol ZYLOPRIM ST colchicine COLCRYS colchicine/probenecid ST febuxostat ULORIC probenecid 8 OPIOID ANALGESICS Practice Guidelines for Cancer Pain Management (includes WHO analgesic ladder) are available at: Opioid guidelines in the management of chronic non-malignant pain are available at: The quantity of opioid products covered (including those that are combined with acetaminophen, aspirin or ibuprofen) will be limited to up to 60 morphine milligram equivalents (MME) per day based on a 30-day supply. Members who are opioid-naïve may be subject to additional quantity limit restrictions including prescriptions limited to 7 days or less or a cumulative of 14 days' supply in the past 45 days. To exceed these limits, a prior authorization request may be required. QL belladonna alkaloids/opium PA, QL buprenorphine transdermal BUTRANS QL butalbital/acetaminophen/caffeine/codeine QL butalbital/aspirin/caffeine/codeine QL butorphanol nasal spray QL codeine sulfate QL codeine/acetaminophen TYLENOL w/codeine PA, QL fentanyl transdermal DURAGESIC QL hydrocodone/acetaminophen NORCO QL hydrocodone/ibuprofen VICOPROFEN QL hydromorphone supp QL hydromorphone tabs DILAUDID QL meperidine soln DEMEROL QL meperidine tabs DEMEROL PA, QL methadone soln PA, QL methadone tabs 5 mg, 10 mg DOLOPHINE QL morphine PA, QL morphine ext-rel MS CONTIN QL morphine supp QL oxycodone QL oxycodone/acetaminophen PERCOCET QL oxycodone/acetaminophen soln QL oxycodone/aspirin PERCODAN QL tramadol ULTRAM PA, QL tramadol ext-rel ULTRAM ER QL tramadol/acetaminophen ULTRACET NON-OPIOID ANALGESICS butalbital/acetaminophen butalbital/acetaminophen/caffeine caps, tabs 50/325/40 mg butalbital/aspirin/caffeine ESGIC FIORINAL ANTI-INFECTIVES Practice guidelines and statements developed and endorsed by the Infectious Diseases Society of America are available at: Hepatitis: CDC recommendations on the treatment of hepatitis are available at: Guidelines for the management of chronic hepatitis by the American Association for the Study of Liver Disease are available at: HIV/AIDS: Guidelines for the treatment of HIV patients by the U.S. Department of Health and Human Services are available at: 9 Infective Endocarditis: American Heart Association recommendations for the prevention of bacterial endocarditis are available at: Influenza: Recommendations of the Advisory Committee on Immunization Practices are available at: International Travel: CDC recommendations for international travel are available at: Respiratory Tract Infection/Antibiotic Use/Community Acquired Pneumonia/Other: Principles of appropriate antibiotic use for treatment of nonspecific upper respiratory tract infection in adults are available at: Sexually Transmitted Diseases: CDC Sexually Transmitted Diseases Guidelines are available at: ANTIBACTERIALS Aminoglycosides neomycin Cephalosporins First Generation cefadroxil cephalexin Second Generation cefaclor cefprozil cefuroxime axetil Third Generation cefdinir cefixime cefpodoxime ceftibuten Erythromycins/Macrolides azithromycin clarithromycin erythromycin base erythromycin delayed-rel - Ery-tab erythromycin dispertabs erythromycin ethylsuccinate erythromycin ethylsuccinate erythromycin stearate Fluoroquinolones ciprofloxacin ext-rel ciprofloxacin tabs levofloxacin ofloxacin KEFLEX CEFTIN SUPRAX VANTIN CEDAX ZITHROMAX BIAXIN PCE E.E.S. ERYPED CIPRO LEVAQUIN Penicillins amoxicillin amoxicillin/clavulanate chew tabs, susp, tabs ampicillin AUGMENTIN 10 dicloxacillin penicillin VK Sulfonamides Tetracyclines sulfadiazine sulfamethoxazole/trimethoprim sulfamethoxazole/trimethoprim DS doxycycline hyclate caps 50 mg, 100 mg doxycycline hyclate tabs 20 mg, 100 mg doxycycline monohydrate susp minocycline tetracycline VIBRAMYCIN VIBRAMYCIN MINOCIN ANTIFUNGALS clotrimazole troches fluconazole griseofulvin microsize susp ketoconazole nystatin terbinafine tabs ANTIMALARIALS chloroquine mefloquine primaquine DIFLUCAN LAMISIL ARALEN ANTIRETROVIRAL AGENTS Antiretroviral Adjuvants PA cobicistat TYBOST Antiretroviral Combinations QL abacavir/dolutegravir/lamivudine TRIUMEQ QL abacavir/lamivudine EPZICOM QL abacavir/lamivudine/zidovudine TRIZIVIR QL atazanavir/cobicistat EVOTAZ QL darunavir/cobicistat PREZCOBIX QL efavirenz/emtricitabine/tenofovir ATRIPLA QL elvitegravir/cobicistat/emtricitabine/tenofovir S
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