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Ssdc pdl_maine-12 10 without criteria.xls

Effective: December 3rd 2010 Physicians' Summarized PDL
NON-PREFERRED DRUGS PA
CATEGORY
Step Order
PREFERRED DRUGS
Step Order
Comments
Required
General Criteria for all PDL categories- For more information or help using the PDL, providers may call 1-888-445-0497; members should call 1-866-796-2463. To access PDL and PA materials via the internet:
www.mainecarepdl.org

A: Preferred Drugs- Unless otherwise specified, preferred drugs are available without prior authorization. Step order may apply for preferred drugs in some drug categories as indicated on the PDL. (See item "D"
below for explanation of step order.)

B: Requests for Non-preferred Drugs- Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the preferred drug(s) exists

C: Adequate Drug Trials- 1. The minimum trial period for each preferred and step order drug is two weeks, unless otherwise stated within specific PDL drug categories; trials with less than a two week duration will
be reviewed on a case-by-case basis; 2. A trial will not be considered valid if preferred or non-preferred products were readily available (by override, individual purchase, samples, etc.); 3. Certain drug trials, such
as with controlled substances, may require evidence that the preferred drugs were actually tried (example: with random pill counts and with random urine drug tests, using the methods of GC/MS with no lower
threshold); 4. Adequate trials require documentation of attempts to titrate dose of preferred agents toward desired clinical response. 5. Adequate trials include prevention/treatment of common adverse effects
associated with preferred agents (example: antinausea, antipruritics, etc.)

D: Step Order- When numbers appear in the "step order" column, it means drugs in this category must be used in the order specified, with the lower numbers having preference over the higher numbers. Chart
notes should be provided to confirm drug trials that do not appear in the member's MaineCare drug profile.

E. The Department will institute strategies to ensure cost effectiveness through the use of an enhanced Drug Benefit Preferred brand drugs will no longer be preferred in any PDL drug category where preferred
generic drugs are also available. It is expected that preferred generics will be used prior to any preferred brands. This will be operated as a form of step care. Preferred brands in these categories will require prior
authorization for these high utilization / high cost members.

F: Brand Name Medication Requests- (Must be submitted on the Brand Name PA request form)- According to MaineCare Benefits Manual Chapter II (80.07-5), when medically necessary covered brand-name drugs
have an A-rated generic equivalent available, the most cost effective medically necessary version will be approved and reimbursed, since the brand-name and A-rated generic drugs have been determined by the
FDA to be chemically and therapeutically equivalent. The Bureau does not make determinations as to whether or not a generic drug is clinically inferior or inequivalent to its brand version. This is the proper role of
the FDA. Physicians should submit their reports of generic inequivalence directly to the FDA via the MEDWATCH.

G: PA requests for non- FDA Approved Indications- Decisions will be made on a case-by-case basis until the DUR committee is able to review the evidence and make a recommendation. Interim approvals and DUR
recommendations for approval of a drug for a non- FDA approved indication will require a minimum of two published, peer reviewed, non contradicted, double- blind, placebo-controlled randomized clinical studies
establishing both safety and efficacy.

H: Dose Consolidation Requirements- Some drugs may also be affected by dose consolidation requirements. Please see Dose Consolidation List and/or Splitting Tables provided in the PDL.
I. Trials from Multiple Drug Classes - Trial/failure/intolerance to preferred agents from multiple classes within the same category or other catagories of drugs may be required prior to the approval of non-preferred
agents (e.g., Cymbalta, Zofran, Elidel and others).

J. Drug-specific PA Forms- Drug-specific PA forms contain medical necessity documentation requirements and/or criteria that may not be repeated in the PDL. Drug-specific PA forms may be obtained on the web
at www.mainecarepdl.org
.
K. PA Exemptions for Prescribers- According to MaineCare Benefits Manual Chapter II (80.07-4), providers may receive a three (3) month exemption from prior authorization requirement for certain categories of
drugs when they demonstrate high compliance with the Department's PDL. The Department will notify providers in writing which drug categories are included and what dates apply to the exemption. If a provider
loses his/ her exemption, members who previously were not required to obtain a PA while the prescriber was exempt will be required to do so, and criteria for approval of that medication will need to be met.

L: Drug-Drug Interactions (DDI)- The DUR Committee has implemented new drug-drug interation edits requiring prior authorization. Several drug-drug combinations and PDL drug catagories are affected by new PA
requirements. These will be indicated in the PDL with DDI notation. Please see the DDI document provided in the PDL.

ASSORTED ANTIBIOTICS
BETA-LACTAMS /
1. Amoxil 500mg tabs are non-preferred. All CLAVULANATE COMBO'S
2. Principen 250 mg is available without PA.
3. Chewable 125mg & 250mg and Solution 125mg/5ml and 250mg/5ml available without PA.
4. Use preferred generic amoxicillin/clavulanate DYNAPEN SUSRGEOCILLIN TABSOXACILLIN SODIUM SOLRPENICILLIN V POTASSIUM TICAR SOLRTIMENTIN SOLRTRIMOX UNASYN SOLRVEETIDS ZOSYN CEPHALOSPORINS
1. Both brand and generic are clinically non- TAZICEF 6GMTAZIDIME VANTIN 100MGVANTIN SUSP MACROLIDES /
1. 7- Day supply per month without PA.
ERYTHROMYCIN'S
TETRACYCLINES
FLUOROQUINOLONES
AMINO GLYCOSIDES
NEOMYCIN SULFATE TABSTOBI NEBUTOBRAMYCIN SULFATE SOLN ANTI-MYCOBACTERIALS / ANTI-
TUBERCULOSIS
ANTIMALARIAL AGENTS
CHLOROQUINE PHOSPHATE TABS
DARAPRIM TABS
HYDROXYCHLOROQUINE TABS
1. Ingredients available as preferred without PA.
LARIAM TABS
PLAQUENIL TABS
MEFLOQUINE HCL TABS
QUINACRINE HCL POWD
QUININE SULFATE
ANTHELMINTICS
BILTRICIDE TABSMEBENDAZOLE CHEWSTROMECTOL TABS ANTIBIOTICS - MISC.
preferred. Please use available preferred strengths(25omg & 500mg tabs) to obtain 3. Please use multiple 5gm which are preferred 4. Clinical PA is required to establish CF diagnosis and medical necessity. Prior trail and failure of preferred Tobi before approval will be CARBAPENEMS
LINCOSAMIDES /
1. Use multiple 150's for Clindamycin instead of OXAZOLIDINONES /
LEPROSTATICS
ANTI INFECTIVE COMBO'S -
SEPTRA/DS TABSSULFAMETHOXAZOLE/TRIMETHTRIMETHOPRIM/SULFAMETHOXA ANTIPROTOZOALS
1. Alina is preferred for children less than 12 years of age. ANTI - FUNGALS
ANTIFUNGALS - ASSORTED
1. QL--1/every 7-day period (150mg only). quantity limit table. Non-preferred products must be used in specified step order. Continue to use 4. Quantity limit of one tablet daily. Please see dosage consolidation list.
5. Approved if immuno suppressed/ HIV or if the member has failed a 7 day trial of a preferred 6. Eraxis will be approved if submitting with documentation that it was initiated during a hospitalization and this request is to finish the hospital course.
8. Quantity limits allowing 30 day supply without PA. PA will be required if using > 30 days.
9. For children < 18, quantity limits allows 8 weeks supply without PA. PA will be required if using > than 8 weeks. If 18 and older PA will be required for any quantity. Not approving for Onychomycosis indication.
Please use PA form #20420 for Noxafil.
ANTI - VIRALS
ANTIRETROVIRALS
2. Only preferred if Norvir script is in member's profile within the past 30 days of filling Prezista.
3. Prescribers with >= 10 ART scripts per quarter and 75% ART PDL compliance will be exempt RESCRIPTOR TABSREYATAZSTAVUDINESUSTIVA TRIZIVIR TABSTRUVADAVIDEX / ECVIRACEPT TABSVIRAMUNE TABSVIREAD TABSZIDOVUDINEZIAGEN TABS CYTO-MEGALOVIRUS AGENTS
HERPES AGENTS
Must fail Acyclovir and Valtrex before non- INFLUENZA AGENTS
IMMUNE SERUMS
IMMUNE SERUMS
HEPATITIS AGENTS
HEPATITIS C AGENTS
1. Dosing limits apply, please see dosage 2. Current users are grandfathered.
HEPATITIS AGENTS - MISC.
HEPATITIS B ONLY
RSV PROPHYLAXIS
RSV PROPHYLAXIS
Use PA Form # 301201. MaineCare will approve Synagis PA's for start date of November 23rd for infants who meet the guidelines. PA will be approved for max of 5 doses and good thru March 31, unless Maine specific data suggests ongoing epidemic RSV activity.
MS TREATMENTS
MULTIPLE SCLEROSIS -
INTERFERONS
BETASERON SOLR1
1.Clinical PA is required to establish diagnosis MULTIPLE SCLEROSIS - NON-
COPAXONE2
1. Providers must be enrolled in the TOUCH INTERFERONS
Prescribing program, a restricted distribution program. Clinical PA is required to establish 2. Clinical PA is required to establish diagnosis and medical necessity ASSORTED NEUROLOGICS
NEUROLOGICS - MISC.
1. Approval will be limited to Cervical dystonia.
STEROIDS
GLUCOCORTICOIDS/
MINERALOCORTICOIDS
MEDROL TABS
KENALOG
METHYLPREDNISOLONE TABS
PREDNISOLONE
PREDNISONE
SOLU-CORTEF SOLR
SOLU-MEDROL SOLR
HORMONE REPLACEMENT THERAPIES
ANDROGENS / ANABOLICS
ESTROGENS - PATCHES /
ESTRADERM PTTW1
ESTRADIOL PTWK
VIVELLE-DOT PTTW1
ALORA PTTW
2. Step order drugs must be used in specified step order. CLIMARA PTWK
ELESTRIN
ESTROGENS - TABS
CENESTIN TABS
Must fail preferred products before non-preferred DELESTROGEN OIL
ESTRACE TABS
ESTRADIOL
ESTROPIPATE TABS
MENEST TABS
PREMARIN TABS

ESTROGEN COMBO'S
PREMPHASE TABS
ACTIVELLA TABS
Must fail Premphase and Prempro products PREMPRO TABS
COMBIPATCH PTTW
FEMHRT 1/5 TABS
ORTHO-PREFEST TABS
SYNTEST H.S. TABS
PROGESTINS
1. PA approvals will require two 100 mg caps Norethidrone products before non-preferred products. CONTRACEPTIVES
CONTRACEPTIVES -
If member experienced adverse reactions, PROGESTIN ONLY
consider using Oral Contraceptives from other groups. CONTRACEPTIVES -
INJECTABLE
CONTRACEPTIVE -
1. Allowed 4 tablets per 30 days without PA EMERGENCY
CONTRACEPTIVES - PATCHES/
1.No PA required for users less than 21 years of VAGINAL PRODUCTS
2. The FDA has issued a public health warning of the potentials for increased exposure to estrogen with Ortho Eva use, possibly up to 60% estrogen exposoure 3. Quantity limit allowing 1 every 28 days with out PA. 4. Dose limits apply allowing 3 patches per 28 days supply. Please refer to Dose Consolidation Chart. CONTRACEPTIVES -
If member experienced adverse reactions, MONOPHASIC COMBINATION
MONOPHASIC COMBINATION
consider using Oral Contraceptives from other CONTRACEPTIVES - BI-PHASIC
If member experienced adverse reactions, COMBINATIONS
NORETHINDRONE-ETH ESTRADIOL TAB 0.5-35/1- consider using Oral Contraceptives from other CONTRACEPTIVES - TRI-
If member experienced adverse reactions, PHASIC COMBINATIONS
consider using Oral Contraceptives from other groups. DIABETES THERAPIES
DIABETIC - INSULIN
LANTUS SOLN
LEVEMIR
NOVOLIN
NOVOLOG
NOVOLOG MIX

DIABETIC - PENFILLS
1. Clinical PA will be required to establish significant visual or neurological impairment. LEVEMIR FLEXPEN 1
NOVOLIN PENFILL1
NOVOLIN 70/301
NOVOLOG PENFILL SOLN1
DIABETIC - DPP- 4 ENZYME
1. Preferred if therapeutic doses of metformin INHIBITOR
are seen in members drug profile for at least 60 days within the past 18 months or if phosphate binder is currently seen in the members drug profile. 2. Dosing limits apply. Please refer to Dose consolidation list. DIABETIC - DPP- 4 ENZYME
1. Preferred if therapeutic doses of metformin INHIBITOR-COMBO
are seen in members drug profile for at least 60 days within the past 18 months or if phosphate binder is currently seen in the members drug profile. Dosing limits apply. Please refer to Dose consolidation list. DIABETIC - LANCET-LANCET
FREESTYLE LANCETSUNILET LANCETSUNISTIK LANCING DEVICEAUTOLOT LANCING DEVICE DIABETIC - SYRINGES-
BD ULTRA-FINEBD ULTRA-FINE PEN NEEDLESUNIFINE PEN NEEDLES DIABETIC - OTHER
DIABETIC MONITOR
Effective October 25th 2007, approvals for all non preferred meters/ test strips will require medical necessity documenting clinically significant features that are not available on any ONE TOUCH ULTRA SMART KITPRECISION XTRA METER DIABETIC TEST STRIPS
Effective October 25th 2007, approvals for all non preferred meters/ test strips will require medical necessity documenting clinically significant features that are not available on any 1. Only 50 ct & 100 ct package size.
INCRETIN MIMETIC
1. If patient is not responding to oral agents (single or multiple) please look to insulin therapy. Dosing limits apply. Please refer to Dose Consolidation List. DIABETIC - ORAL
CHLORPROPAMIDE TABS
AMARYL TABS
SULFONYLUREAS
DIABETA TABS
GLIPIZIDE TABS
GLIPIZIDE ER TABS
GLUCOTROL XL TBCR
GLYBURIDE TABS
GLYNASE TABS
GLYBURIDE MICRONIZED TABS
MICRONASE TABS
TOLAZAMIDE TABS
TOLBUTAMIDE TABS

DIABETIC -ORAL BIGUANIDES
METFORMIN HCL TABS
DIABETIC - THIAZOL /
1. Requires use of Actos, Metformin, or other BIGUANIDE COMBO
AVANDAMET TABS1
DIABETIC - / THIAZOL
ACTOS 15MG TABS1
ACTOS 30MG AND 45MG TABS2
1. Actos is non-preferred as monotherapy. AVANDIA TABS3
Actos is preferred if therapeutic doses of metformin, sulfonylurea or insulin are seen in members drug profile for at least 60 days within the past 18 months. 2. Actos 30mg or 45mg - please use multiple 15mg tabs.
3. Current users of Avandia who have tried Actos will be able to continue use of Avandia.
DIABETIC -
GLYSET TABS
ALPHAGLUCOSIDASE
DIABETIC - SULFONYLUREA /
BIGUANIDE
1. Use Actos 15mgs with generic glimepiride.
DIABETIC - MEGLITINIDES
STARLIX TABS
PRANDIN TABS
GLUCOSE ELEVATING AGENTS
GLUCOSE ELEVATING AGENTS
THYROID HORMONES
ARMOUR THYROID TABS
CYTOMEL TABS
LEVOTHROID TABS
LEVOTHYROXINE SODIUM TABS
LEVOXYL TABS
THYROID TABS
THYROLAR
UNITHROID TABS

ANTITHYROID THERAPIES
METHIMAZOLE TABS
TAPAZOLE TABS
PROPYLTHIOURACIL TABS
OSTEOPOROSIS
OSTEOPOROSIS
ACTONEL TABS
1. Approval only requires failure of Fosamax or FOSAMAX SOLN2
MIACALCIN SOLN2
DIDRONEL TABS
2. Quantity limits apply, please see dosage 3. Please use Alendronate and Vitamin D.
FOSAMAX TABS AND PLUS D3
CALCIMIMETIC AGENTS
CALCIMIMETIC AGENTS
GROWTH HORMONE
GROWTH HORMONE
1.Clinical PA is required to establish diagnosis 2. Products must be used in specified step order. All step 5's must be tried prior to moving to step 8's. SOMATOSTATIC AGENTS
SANDOSTATIN
SOMATULINE
GROWTH HORMONE ANTAGONISTS
GH ANTAGONISTS
VASOPRESSIN RECEPTOR ANTAGONIST
VASOPRESSIN RECEPTOR
ANTAGONIST
URINARY INCONTINENCE
VASOPRESSINS
Products must be used in specified step order. Nocturnal enuresis patients will be encouraged to periodically attempt stopping DDAVP. ANTISPASMODICS
OXYBUTYNIN
CYSTOSPAZ TABS
DETROL TABS
DITROPAN

ANTISPASMODICS - LONG
1. Product is considered line extension of the original product due to Healthcare Reform (HCR). MaineCare will consider these medications non-preferred and a step 9 because of the impact under the Federal Rebate Program in conjunction with HCR.
CHOLINERGIC
BETHANECHOL 25MG & 50MG
URECHOLINE
METABOLIC MODIFIER
HERED. TYROSINEMIA
ANTIHYPERTENSIVES / CARDIAC
CARDIAC GLYCOSIDES
DIGITEK TABS
DIGOXIN
LANOXICAPS
LANOXIN

ANTIANGINALS--Isosorbide Di-
ISOSORBIDE MONONITRATE TABS
nitrate/ Mono-Nitrates
ISOSORBIDE MONONITRATE ER
ISORDIL TITRADOSE TABS
ISOSORBIDE DINITRATE SUBL
ISOSORBIDE DINITRATE TABS
ISOSORBIDE DINITRATE CR TBCR
ISOSORBIDE DINITRATE ER TBCR
ISOSORBIDE DINITRATE TD TBCR
IMDUR TB24
ISMO TABS
MONOKET TABS
NITRO - OINTMENT/CAP/CR
NITROBID OINT
NITROGLYCERIN CPCR
NITROL OINT
NITRO-TIME CPCR
NITRO - PATCHES
NITROGLYCERIN PT24
At least 2 step 1's and step 3 of the preferred NITREK PT24
NITRO-DUR PT24
products must be used in specified order or PA NITRO-DUR PT 24 0.8MG
MINITRAN PT24
NITRO - SUBLINGUAL/ SPRAY
NITROQUICK SUBL
NITROSTAT SUBL
NITROTAB SUBL

BETA BLOCKERS - NON
BETAPACE TABS
1. Recommend using BID since its effects do not SELECTIVE
BETAPACE AF TABS
NADOLOL TABS
COREG CR2
2. Dosing limits still apply. Please see dose PINDOLOL TABS
COREG TABS
PROPRANOLOL HCL SOLN1
CORGARD TABS
3. Please use other strengths in combination to PROPRANOLOL HCL TABS1
INDERAL TABS
PROPRANOLOL LA CAPS
INDERAL LA CPCR
TIMOLOL MALEATE TABS
PROPRANOLOL HCL 60MG TABS2
RANEXA
BETA BLOCKERS - CARDIO
ACEBUTOLOL HCL CAPS
1. Recommend using Atenolol (and metoprolol) SELECTIVE
ATENOLOL TABS1
BID since its effects do not last 24 hours. LOPRESSOR TABS
BISOPROLOL FUMARATE TABS
TOPROL XL TB24
METOPROLOL TARTRATE TABS1
METOPROLOL ER
TENORMIN TABS
ZEBETA TABS

BETA BLOCKERS - ALPHA /
LABETALOL HCL TABS
CALCIUM CHANNEL
NORVASC TABS1
BLOCKERS--Amlodipines,
Bepridil, Diltiazems, Felodipines,
Products must be used in specified order or PA Isradipines, Nifedipines,
DILTIAZEM HCL ER CP24
will be required. Just write "Diltiazem 24- Nisoldipine, and Verapamils
hour"and the pharmacy will use a preferred long DILTIAZEM HCL XR CP24
TIAZAC CP24
acting diltiazem that does not require PA. DILTIAZEM CD 300MG CP24
CARDIZEM TABS
DILTIAZEM CD 360MG CP24
CARDIZEM CD CP24
DILTIAZEM CD CP24
DILTIAZEM HCL ER CP24
DILTIAZEM HCL TABS
DILTIAZEM XR CP24
DILTIAZEM HCL ER CP12
PLENDIL TB24

FELODIPINE
1. Established users will be grandfathered CARDENE SR CPCR
NICARDIPINE HCL CAPS
AFEDITAB CR
NIFEDIAC CC
NIFEDIPINE CAPS
NIFEDICAL XL TBCR
NIFEDIPINE TBCR
PROCARDIA XL TBCR
NIFEDIPINE ER TBCR
Established users of 10MG and 20MG strengths VERAPAMIL HCL CR TBCR
CALAN TABS
Products must be used in specified order or PA VERAPAMIL HCL ER TBCR
CALAN SR TBCR
will be required. Just write "Verapamil 24-hour" VERAPAMIL HCL SR TBCR
COVERA-HS TBCR
and the pharmacy will use a preferred long actinggeneric that does not require PA.
VERAPAMIL HCL ER CP24VERAPAMIL HCL SR CP24 VERAPAMIL HCL TABSVERELAN CP24VERELAN PM CP24 ANTIARRHYTHMICS
AMIODARONE
CORDARONE
1. Prescription must be written by Cardiologist. FLECAINIDE
DISOPYRAMIDE
MEXILETINE
PACERONE
PROCAINAMIDE
PROPAFENONE
QUINIDINE GLUCONATE
QUINIDINE SULFATE

ACE INHIBITORS
BENAZEPRIL HCL
CAPTOPRIL TABS
ACCUPRIL TABS
ENALAPRIL MALEATE TABS
ACEON TABS
FOSINOPRIL SODIUM
ALTACE CAPS
LISINOPRIL TABS
QUINAPRIL
LOTENSIN TABS
MOEXIPRIL
MONOPRIL HCT TABS
PRINIVIL TABS
ZESTRIL TABS
ANGIOTENSIN RECEPTOR
ATACAND TABS
Preferred products only available without PA if BENICAR TABS
COZAAR 50MG & 100MG1
patient on diabetic therapy or prior ACE therapy. COZAAR TABS 25MG2
1. Please use multiple preferred 25mg tabs.
LOSARTAN
MICARDIS TABS
2.Dosing limits apply. Please see dose consolidation list.
DIRECT RENIN INHIBITOR
1. Must show failure of single and combination therapy from all preferred antihypertensive categories.
ANTIHYPERTENSIVES -
CATAPRES-TTS
CATAPRES TABS
CLONIDINE HCL TABS
GUANFACINE HCL TABS
HYDRALAZINE HCL TABS
METHYLDOPA TABS
TENEX TABS
MINOXIDIL TABS
PRAZOSIN HCL CAPS
RESERPINE TABS

ACE INHIBITORS AND CA
LEXXEL TBCR
Use individual preferred generic medications. CHANNEL BLOCKERS
LOTREL CAPS
AMLODIPINE/BENAZEPRIL
ACE AND THIAZIDE COMBO'S
BENAZEPRIL HCL/HYDROCHLOR
ACCURETIC TABS
CAPTOPRIL/HYDROCHLOROTHIA
ENALAPRIL MALEATE/HCTZ TABS
LOTENSIN HCT TABS
LISINOPRIL-HCTZ TABS
MONOPRIL HCT TABS
PRINZIDE TABS
UNIRETIC TABS
VASERETIC TABS
ZESTORETIC TABS
BETA BLOCKERS AND
ATENOLOL/CHLORTHALIDONE
DIURETIC COMBO'S
BISOPROLOL FUMARATE/HCTZ
INDERIDE 40/25 TABS
PROPRANOLOL/HCTZ
LOPRESSOR HCT TABS
TENORETIC
TIMOLIDE 10/25 TABS
ZIAC TABS
ARB'S AND CA CHANNEL
Preferred products only available without PA if BLOCKERS
patient on diabetic therapy or prior ACE therapy. EXFORGE HCT
ARB'S AND DIURETICS
ATACAND HCT TABS
Preferred products only available without PA if BENICAR HCT
patient on diabetic therapy or prior ACE therapy. DIOVAN HCT TABS
HYZAAR TABS

LOSARTAN HCT
MICARDIS HCT TABS
ARB'S AND DIRECT RENIN
VALTURNA
INHIBITOR COMBINATION
DIURETICS
ACETAZOLAMIDE TABS
ALDACTAZIDE TABS
1. Multiples of Spironolactone 25 mg are ALDACTONE TABS
cheaper than 50 mg strength. Inspra will be BUMETANIDE
approved for severe breast tenderness and male gynecomastia.
CHLOROTHIAZIDE TABS
BUMEX TABS
CHLORTHALIDONE TABS
DEMADEX TABS
FUROSEMIDE DIURIL
HYDROCHLOROTHIAZIDE

DYAZIDE CAPS
INDAPAMIDE TABS
METHAZOLAMIDE TABS
METHYCLOTHIAZIDE TABS
LASIX TABS
SPIRONOLACTONE 25MG TABS
SPIRONOLACTONE/HYDRO MAXZIDE
TORSEMIDE TABS

TRIAMTERENE/HCTZ
MIDAMOR TABS
MODURETIC 5-50 TABSNAQUA TABSNATURETIN TABS SPIRONOLACTONE 50MG1
CCB / LIPID
LIPID DRUGS
CHOLESTEROL - BILE
CHOLESTYRAMINE
COLESTID
SEQUESTRANTS
COLESTIPOL HCI
PREVALITE
QUESTRAN
WELCHOL TABS
CHOLESTEROL - FIBRIC ACID
GEMFIBROZIL TABS
DERIVATIVES
CHOLESTEROL - HGM COA +
1. Dosing limits apply, please see dosage ABSORB INHIBITORS MORE
SIMVASTATIN1
VYTORIN 2
DRUGS/COMBINATIONS
CHOLESTEROL - HGM COA +
LESCOL CAPS
1. Zetia available w/0PA as addition to Lipitor ABSORB INHIBITORS LESS
80mg. Zetia will also be approved with a PA as add on for patients at maximally tolerated doses DRUGS/COMBINATIONS
3. Product is considered line extension of the original product due to Healthcare Reform (HCR). MaineCare will consider these medications non-preferred and a step 9 because of the impact under the Federal Rebate Program in conjunction with HCR.
CHOLESTEROL - HGM COA +
ABSORB INHIBITORS STATIN/
ADVICOR TBCR
NIACIN COMBO
PULMONARY ANTI-HYPERTENSIVES
PULMONARY ANTI-
3. There will be dosing limits of one 20ml HYPERTENSIVES
multidose vial/ 30 days supply without pa. 4. Viagra would be approved after a diagnosis of pulmonary hypertension is confirmed.
5. PA is required to establish and conferm who group 1 diagnosis of primary PAH (Primary Pulmonary Hypertension) and NYHA functional class 3 & 4 ERA / ENDOTHELIN RECEPTOR
1. Providers must be registered with LEAP ANTAGONIST
Prescribing program, a restricted distribution program. 2. Clinical PA is required to establish diagnosis and medical necessity.
IMPOTENCE AGENTS
IMPOTENCE AGENTS
As of January 1, 2006, per CMS (federal govt.), impotence agents are no longer covered.
ANTI-EMETOGENICS
ANTIEMETIC -
ANTICHOLINERGIC /
DOPAMINERGIC
ANTIEMETIC - 5-HT3 RECEPTOR
ANTAGONISTS/ SUBSTANCE P
1. Approvals will require diagnosis of chemo- NEUROKININ
induced nausea/vomiting and failed trials of all preferred anti-emetics, including 5-HT3 class (Zofran, Emend) and Marinol.
2. Ondansetron will be preferred with CA diag 3. Clinical PA is required for members on highly Ondansetron: use PA Form # 20610 Others: use PA Form # 20420 NON-SEDATING ANTIHISTAMINES / DECONGESTANTS
ANTIHISTIMINES - NON-
1. Must fail preferred drugs, OTC loratidine and SEDATING
cetirizine before moving to non-preferred step 2. Clarinex and Zyrtec syrup <6 yr w/o PA. 3. Must fail all step 5 drugs (Clarinex, F Fexofenadine and Zyrtec) before moving to next step product. 4. All OTC versions of loratadine ODT are now Pseudoephedrine is available with prescription.
Use PA Form # 20530 ANTIHISTIMINES - OTHER
ALLERGY / ASTHMA THERAPIES
ANTIASTHMATIC -
ATROVENT AERS
ANTICHOLINERGICS - INHALER
ATROVENT HFA
1. Quantity limit of 1 inhalation daily (1 capsule for inhalation daily) Spiriva will require PA if Combivent or Atrovent inhaler/nebulizer solution 2. We ask physicians to write "asthma" on the prescription whenever Sprivia is primarily being used for that condition. ANTIASTHMATIC -
IPRATROPIUM BROMIDE SOLN
ANTICHOLINERGICS -
NEBULIZER
ANTIASTHMATIC -
1. Need max inhaled steroids and written by ANTIINFLAMMATORY AGENTS
ANTIASTHMATIC - NASAL
STEROIDS
Dosing limits apply to whole category, please 1. All preferred drugs must be tried before 2. All step 5 medications need to be tried before ANTIASTHMATIC - NASAL MISC.
1. Ipratropium will be approved if submitted with documentation supporting use of CPAP machine. 2. Utilize Multiple preferred, as well as step therapy Astelin.
ANTIASTHMATIC - BETA -
ALBUTEROL NEB
ACCUNEB NEBU
1. Xopenex users w/ prior asthma hospitalization ADRENERGICS
ALBUTEROL AER
due to albuterol nebulizer failure will be METAPROTERENOL
ALBUTEROL HFA
grandfathered. 2. Quantity Limit: 12 cc/day. PROAIR HFA3
ALBUTEROL 0.63mg/3ml
PROVENTIL HFA AERS3
ALUPENT AERP
SEREVENT BRETHINE
TERBUTALINE SULFATE TABS

FORADIL AEROLIZER CAPS
VENTOLIN HFA AERS3
PROVENTIL
3. Dosing limits apply, please see dosage VENTOLIN AERS
VOLMAX TBCR
VOSPIRE ER TB12
XOPENEX HFA3
XOPENEX NEBU1,2
ANTIASTHMATIC -
ADVAIR DISKUS/HFA1
We ask physicians to write "asthma" on the ADRENERGIC COMBINATIONS
prescription whenever Advair is primarily being used for that condition. 1. Dosing limits apply, please see dosage consolidation list. ANTIASTHMATIC -
ALBUTEROL/IPRATROPIUM NEB. SOLN
1. Please use preferred individual ingredients ADRENERGIC
COMBIVENT AERO2
ANTICHOLINERGIC
ANTICHOLINERGIC
2. We ask physicians to write "asthma" on the prescription whenever Combivent is primarily being used for that condition. ANTIASTHMATIC - XANTHINES
AMINOPHYLLINE TABS
THEOPHYLLINE CR TB12
THEO-24 CP24
UNIPHYL TBCR
THEOPHYLLINE ER CP12
THEOPHYLLINE ER TB12

ANTIASTHMATIC - STEROID
AEROBID AERS2
Dosing limits apply to whole category, please INHALANTS
FLOVENT DISKUS
FLOVENT HFA
1. No PA for Pulmicort susp if under 8 years old. PULMICORT SUSP1
AEROBID-M AERS3
2. All preferreds must be tried before moving to PULMICORT FLEXHALER
3. All step 5 medications need to be tried before moving to step 8's. ANTIASTHMATIC - 5-
ZYFLO CR TABS
Lipoxygenase Inhibitors
ANTIASTHMATIC -
SINGULAIR1
ACCOLATE TABS
1. We ask physicians to write "asthma" on the LEUKOTRIENE RECEPTOR
prescription whenever Singulair is primarily being ANTAGONISTS
ANTIASTHMATIC - ALPHA-
PROTEINASE INHIBITOR
ANTIASTHMATIC - HYDRO-
LYTIC ENZYMES
ANTIASTHMATIC -
1. Acetylcysteine is covered with diagnosis of MUCOLYTICS
COUGH/COLD
COUGH/COLD
All others are a non-covered service (this includes All of cough cold preparations are not covered antihistamines-decongestive combinations).
PSEUDOEPHEDRINEROBITUSSIN DM SYRPROBITUSSIN SUGAR FREE SYRP DIGESTIVE AIDS / ASSORTED GI
**Preferred drugs that used to require diag codes still require diag codes unless indicated otherwise.**
GI - ANTIPERISTALTIC AGENTS
GI - ANTI-DIARRHEAL/ ANTACID
PAMINE TABSPROPANTHELINE BROMIDE TABSSAL-TROPINE TABSSCOPOLAMINE HYDROBROMIDESODIUM BICARBONATE TABS GI - H2-ANTAGONISTS
RANITIDINE SYRUPTAGAMET TABSZANTAC SYRUPZANTAC TABS GI - PROTON PUMP INHIBITOR
1. Prevacid Solutabs available without PA for children less than 9 years old. 2. Dosing limits apply, please see dosage 3. Please use multiple 20mg Capsules to obtain 4. All preferreds and step therapy must be tried 5. Established users prior to 10/1/09 may coninue to obtain Prevacid until 12/31/09.
GI - ULCER ANTI-INFECTIVE
GI - PROSTAGLANDINS
GI - DIGESTIVE ENZYMES
1. Clinical PA is required to establish CF diagnosis and medical necessity. In all cases except cystic fibrosis patients, objective evidence of pancreatic insufficiency (fat malabsorption test etc.) must be supplied.
GI - ANTI - FLATULENTS / GI
Diag codes no longer necessary for preferred STIMULANTS
1. Prior failed trials of multiple other preferred GI agents must occur first, Such as OTC senna, docusate, lactulose, polyethylene glycol.
GI - INFLAMMATORY BOWEL
PENTASA CPCR
ROWASA ENEM
SULFAZINE EC TBEC
SULFASALAZINE TABS

GI - IRRITABLE BOWEL
SYNDROME AGENTS
MISCELLANEOUS GI
**Preferred drugs that used to require diag codes still require diag codes unless indicated otherwise.**
GI - MISC.
1. Must show evidence of trials of preferred agents that do not require PA, such as OTC senna, docusate, mineral oil and prescription lactulose. STOOL SOFTENER CAPSSUCRALFATE TABSUNI-EASE CAPSUNIFIBER POWDURSO FORTEURSODIOL MISC. UROLOGICAL
UROLOGICAL - MISC.
1. Elmiron requires adequate proof of Dx with TRICITRATES SYRPURELIEF PLUSUREX TABSURISED TABSUROCIT-KUROQID #2 TABS PHOSPHATE BINDERS
PHOSPHATE BINDERS
2. Must fail Phoslo, Renagel & Fosrenol before INTRA-VAGINALS
VAGINAL - ANTIBACTERIALS
1. Step order must be followed to avoid PA. Must fail Cleocin Cream and Metronidazole products before moving to next step product 2. Dosing limits apply, please see Dosage Consolidation List. VAGINAL - ANTI FUNGALS
VAGINAL - CONTRACEPTIVES
VAGINAL - ESTROGENS
ESTRING RING
Must fail all preferred products before non- PREMARIN CREA
VAGINAL - OTHER
FLOMAX CP24
DOXAZOSIN MESYLATE TABS
CARDURA TABS
1. There will be dosing limits of 1 tab per day ANXIOLYTICS
ANXIOLYTICS -
BENZODIAZEPINES
DIAZEPAM SERAX LORAZEPAM TRANXENEOXAZEPAM CAPS ANXIOLYTICS - MISC.
HYDROXYZINE PAM 100MG CAPSINAPSINE SOLNVISTARIL ANTI-DEPRESSANTS
ANTIDEPRESSANTS - MAO
INHIBITORS
ANTIDEPRESSANTS - MAO
1. Dosing limits apply, please refer to Dose INHIBITORS TOPICAL
ANTIDEPRESSANTS -
SELECTED SSRI's
2. See Zoloft splitting table. Sertraline requires splitting of scored tabs to avoid PA.
3. Strong caution with pediatric population. 4. See Celexa/Citalopram and Lexapro splitting 5. Max daily dose allowed is 60mg, only 1 capsule per day allowed for all strengths. Combination of multiple strengths require PA. 6. Use Fluoxetine 10mg tabs or capsules in 7. Provide clinical documentation as to why a preferred generic alternative cannot be used.
8. Dosing limits allowing 2 tabs/day and a max daily limit of 200mg / day applies. Please see dose consolidation list.
9. Dosing limits and max daily dose applies. Limit of 1 tab per day of 37.5mg, 75mg, and 225mg will be allowed without pa, along with limits of 2 tabs per day of the 150mg strength. limits of 2 tabs per day of the 150mg strength. Max daily dose allowed is 375mg.
ANTIDEPRESSANTS -
AMITRIPTYLINE HCL TABS
AMOXAPINE TABS
*Users over the age of 65 require a pa.
TRI-CYCLICS
ANAFRANIL CAPS
CLOMIPRAMINE HCL CAPS
DOXEPIN HCL 150mg1
DESIPRAMINE HCL TABS
ELAVIL TABS
DOXEPIN HCL
NORPRAMIN TABS
IMIPRAMINE HCL TABS
NORTRIPTYLINE HCL
SINEQUAN
SEDATIVE / HYPNOTICS
SEDATIVE/HYPNOTICS -
PA required for new users of preferred products BARBITURATE
SEDATIVE/HYPNOTICS -
Previous quantity limits still apply.
BENZODIAZEPINES
SEDATIVE/HYPNOTICS - Non-
Benzodiazepines
Must fail all preferred products before non- 2. Quantity limits will be allowed up to 30/30, but intermittent therapy is recommended.
3. Only zolpidem trial/failure will be required to obtain Zaleplon. ANTI-PSYCHOTICS
ANTIPSYCHOTICS - ATYPICALS
If prescribing 2 or more antipsychotics, PA will be required for both drugs, except if one is Clozapine. This also includes combination of RISPERDAL TAB See Multiple Antipsychotic PA form #20440.
Please use Miscellaneous PA form # 20420 for RISPERDAL SOLN non-preferred single therapy atypical requests.
All atypicals have dosing limitations and maximum daily doses. Please refer to dose consolidation table for any potential dosing limits.
Risperdal- 8mg daily max Seroquel- 800mg daily max Seroquel XR- 800mg daily max Zyprexa- 30mg daily maxUse PA form #10420 for requests exceeding these maximum daily doses. 1. Please use multiple 25mg tablets.
2. Established users of single therapy atypicals were grandfathered. 3. Abilify requires splitting of tab to avoid PA. Please see Abilify splitting table.
4. Prior Authorization will be required for preferred medications for members under the age of 5. 5. Product is considered line extension of the original product due to Healthcare Reform (HCR). MaineCare will consider these medications non-preferred and a step 9 because of the impact under the Federal Rebate Program in conjunction with HCR.
ANTIPSYCHOTICS - SPECIAL
ATYPICALS
ANTIPSYCHOTICS - TYPICAL
If prescribing 2 or more antipsychotics, PA will be required for both drugs, except if one is Clozapine. See Multiple Antipsychotic PA form #20440. For PA requests for non preferred single user antipsychotic medications, please MOBAN TABSPERPHENAZINEPROCHLORPERAZINESERENTILTHIORIDAZINE HCLTHIOTHIXENE THORAZINE SUPPTRIFLUOPERAZINE HCL TABS COMBINATION - PSYCHOTHERAPEUTIC
PSYCHOTHERPEUTIC
COMBINATION
STIMULANTS
Preferred stimulants will be available without PA STIMULANT - AMPHETAMINES -
if diagnosis of ADHD.As per recent FDA alert, SHORT ACTING
Adderal & Dexedrinel should not be used in patients with underlying heart defects since they may be at increased risk for sudden death. Stimulants have dosing limitations per strength and maximum daily doses. Please refer to dose consolidation table for any potential dosing limits per strength. Maximum daily doses are as follows: 50mg daily.
STIMULANT - LONG ACTING
Preferred stimulants will be available without
AMPHETAMINES SALT
PA if diagnosis of ADHD. Stimulants have
dosing limitations per strength and maximum

daily doses. Please refer to dose
consolidation table for any potential dosing
limits per strength.

1. As per recent FDA alert, Adderall should not be used in patients with underlying heart defects since they may be at increased risk for sudden death. 2. FDA approval is currently for adults and children 6 or older. Will be available without PA for this age group if within dosing limits. Limit of one capsule daily. Max dose of 70MG daily. LONG ACTING AMPHETAMINES
Preferred stimulants will be available without PA if diagnosis of ADHD. As per recent FDA alert, Adderall & Dexedrine should not be used in Adderall & Dexedrine should not be used in patients with underlying heart defects since they may be at increased risk for sudden death. Stimulants have dosing limitations per strength and maximum daily doses. Please refer to dose consolidation table for any potential dosing limits per strength. Maximum daily doses are as follows: 50mg daily. STIMULANT -
Preferred stimulants will be available without PA METHYLPHENIDATE
Stimulants have dosing limitations per strength and maximum daily doses. Please refer to dose consolidation table for any potential dosing limits per strength. Maximum daily doses are as follows: 72mg daily for methylphenidate and 36mg daily for dexmethylphenidate.
STIMULANT -
Preferred stimulants will be available without PA METHYLPHENIDATE - LONG
if diagnosis of ADHD. Non-preferred products Stimulants also have dosing limitations per strength and maximum daily doses. Please refer to dose consolidation table for any potential dosing limits per strength. 1. FDA approval currently only for ages 6-16. Limit of one patch daily. Max dose of 30MG daily.
STIMULANT - STIMULANT LIKE
methylphenidate is required for consideration for approval of Strattera, unless history of substance medication(s) 2. Strattera currently has dosing limitations allowing one tablet per day for all strengths if obtain approval. Max daily dose of Strattera is 100mg. Please refer to PDL dosage consolidation chart. 3. Non-preferred products must be used in specified step order. ANTI-CATAPLECTIC AGENTS
PSYCHOTHERAPEUTIC
AGENTS - MISC.
WEIGHT LOSS
WEIGHT LOSS
No longer covered: PHENTERMINE, XENICAL,DIDREX, and MERIDIA ALZHEIMER DISEASE
ALZHEIMER -
Cholinomimetics/Others
diagnosis and baseline mental status score. 2. Must fail all preferred products before moving SMOKING CESSATION
NICOTINE PATCHES / TABLETS
Bupropion SR 150 mg is available without a prior authorization.
1. Chantix is preferred without PA for up to 6
months of continuous use once per lifetime.
2. Preferred nicotine replacement therapy and Chantix will become non-preferred and will require PA if they are being used in combination together. NICOTINE REPLACEMENT -
Must fail all preferred products from smoking cessation category (Nicoderm patch and nicotine gum) before moving to non-preferred. Must use Non-preferred products in specified step order. 1. Will be available to patients unable to tolerate preferred products. 2. Preferred nicotine replacement therapy and Chantix will become non-preferred and will require PA if they are being used in combination together. ALCOHOL DETERRENTS
ALCOHOL DETERRENTS
1. Should only be used in conjunction with formal structured outpatient detoxification MISCELLANEOUS ANALGESICS
ANALGESICS - MISC.
CHOLINE MAGNESIUM TRISALI
DIFLUNISAL TABS
SALSALATE TABS
LONG ACTING NARCOTICS
NARCOTICS - LONG ACTING
Non-preferred products must be used in specific 1. Oxycontin will be available without PA for patients treated for or dying from cancer or hospice patients. CA (cancer) or HO (hospice) diag code may be used but store must verify since all scripts will be audited and stores will be 2. Established users are grandfathered.
3. Oxycodone ER allowed only 2 per day for all strengths except 80 mg, where 4 are allowed to achieve max total daily dose of 320mg. 4. Oxycontin 15mg, 30mg & 60mg are new strengths. Any PA request for the new strengths will be required to use combinations of strengths that have previously been available (including 10mg, 20mg, 40mg, & 80mg tablets) to obtain requested dose.
5. Dosing limits apply. Please see dose consolidation list. 6. Kadian 80mg & 200mg are non-preferred.
NARCOTICS - SELECTED
1. Only available if component ingredients are MISCELLANEOUS NARCOTICS
NARCOTICS - MISC.
1. Fentanyl OT loz (Barr) and Capital and codeine suspension products require PA for users over 18 years of age. PA is not required if 2. Oxycodone/acet 10/650 is 8 times more expensive. Use twice as many of oxycod/acet 5/325 instead. You can mix andmatch preferred strengths of oxycodone and oxycodone/acet to minimize acet. dose similar to certain non- 3. Only preferred manufacturer's products will be available without prior authorization.
OPIOID DEPENDENCE
1. Subutex will only be approved for use during TREATMENTS
NARCOTIC ANTAGONISTS
NARCOTIC - ANTAGONISTS
Use PA form #30400 for Vivitrol requests.
COX 2 / NSAIDS
NSAID - PPI
COX 2 INHIBITORS - SELECTIVE
/ HIGHLY SELECTIVE
The FDA has issued a Public Health Advisory RELAFEN TABS
warning of the potential for increased cardiovascular risk & GI bleeding with NSAID 1. Meloxicam has dosing limits allowing one tablet daily of all strengths without PA. 2. Ketorolac Tromethamine is indicated for the short term (up to 5 days) managment of moderately severe acute pain that requires analgesic at the opiod level in adults. Not indicated for minor of chronic pain conditions.
3. Ketorolac has dosing limits allowing 24 tablets for a 5 day supply every 30 days. 4. Dosing limits will be set at a maximum of 200mg once daily for PA requests. 5. Users 60 years of age or older will not require PA. If under 60 years of age, Celebrex will require PA.
CHILDRENS IBUPROFEN
The FDA has issued a Public Health Advisory DICLOFENAC POTASSIUM TABS
DICLOFENAC SODIUM
cardiovascular risk & GI bleeding with NSAID use. ETODOLAC
FENOPROFEN CALCIUM TABS
CATAFLAM TABS
FLURBIPROFEN TABS
IBUPROFEN
INDOMETHACIN
KETOPROFEN
CLINORIL TABS
MECLOFENAMATE SODIUM CAPS
DAYPRO TABS
EC-NAPROSYN TBEC
ETODOLAC ER 600MG
NAPROXEN TABS
NAPROXEN SODIUM TABS
OXAPROZIN TABS
SULINDAC TABS
TOLMETIN SODIUM
MOTRIN
NALFON CAPS
NAPRELAN TBCR
NAPROSYN TABS
NAPROXEN DR TBEC
NAPROXEN SODIUM TBCR
ORUVAIL CP24
PENNSAID
PIROXICAM CAPS
PONSTEL CAPS
SB IBUPROFEN TABS
TOLECTIN
VOLTAREN
V-R IBUPROFEN TABS
RHEUMATOID ARTHRITIS
RHEUMATOID ARTHRITIS
AZATHIOPRINE
HYDROXYCHLOROQUINE
1. Only one step 1 drug is required to obtain KINERET SOLN
SULFASALAZINE TABS
REMICADE
2. Dosing limits apply. Please see dose consolidation list. ENBREL 50MG3
ENBREL 25MG INJECTIONS ONLY1, 4
HUMIRA1, 2
4. Preferred dosage form allowed without PA after trial of step 1 prodcuts is multi-dose vial, with dosing limits allowing 8 injections per 28 days without pa.
Established users will be grandfathered for Enbrel and Humira.
MISCELLANEOUS ARTHRITIS
ARTHRITIS - MISC.
ARTHROTEC1
1. The individual components of Arthrotec are available without PA. MIGRAINE THERAPIES
MIGRAINE - ERGOTAMINE
DERIVATIVES
MIGRAINE - CARBOXYLIC ACID
DERIVATIVES
MIGRAINE - SELECTIVE
1. Product is considered line extension of the SEROTONIN AGONISTS (5HT)--
original product due to Healthcare Reform medications non-preferred and a step 9 because of the impact under the Federal Rebate Program MIGRAINE - SELECTIVE
SEROTONIN AGONISTS (5HT)--
Injectables
IMITREX STATDOSE PEN KITIMITREX STATDOSE REFILL KIT MIGRAINE - SELECTIVE
SEROTONIN AGONISTS (5HT)--
Combinations
2. Use preferred Sumatriptan and Naproxen separately. Treximet only available if component ingredients of sumatriptan and naproxen are unavailable.
MIGRAINE - MISC.
ALLOPURINOL TABS
COLCHICINE TABS
1. Failure of therapeutic (300mg) dose of PROBENECID TABS
Allopurinol (failure define as not being able to get uric acid levels below 6mg/dl) or severe renal PROBENECID/COLCHICINE TABS
ANESTHETICS - MISC.
ANTI-CONVULSANTS
ANTICONVULSANTS
instead.Pharmaceutical supply issues will delay All non-preferred meds must be used in specified 4. Dosing limits apply per strength as well as a maximum daily dose of 600mg. Please see dose consolidation list.
BIPOLAR DISORDER: STEP ORDER
6. Current users as of 7/30/10 for seizures will be 7. Product is considered line extension of the original product due to Healthcare Reform (HCR). MaineCare will consider these medications non-preferred and a step 9 because of the impact under the Federal Rebate Program in conjunction with HCR.
9= No EvidenceThe step orders show the relative strength of evidence for use in bi-polar and will guide prior authorization determinations.
PEDIATRIC BIPOLAR1 DISORDER: STEP ORDER Step 4 drugs-no PA required.
Two-step 1 preferred drugs must be tried before Trileptal.
The step orders show the relative strength of evidence for use in bi-polar and will guide prior ANTI-PARKINSON DRUGS
PARKINSONS -
ANTICHOLINERGICS
BENZTROPINE MESYLATE TABS
COGENTIN SOLN
KEMADRIN TABS
TRIHEXYPHENIDYL

PARKINSONS - COMT
COMTAN TABS
TASMAR TABS
INHIBITORS
PARKINSONS - SELECTED
PRAMIPEXOLE
MIRAPEX TABS1
DOPAMIN AGONISTS
REQUIP TABS
REQUIP XL TABS
grandfathered if diagnosis is Parkinsons.
MIRAPEX ER
PARKINSONS -
AMANTADINE HCL
* Only preferred manufacturer's products will be DOPAMINERGICS/CARBII/ LEVO
BROMOCRIPTINE MESYLATE
CARBIDOPA/LEVODOPA TABS*
CARBIDOPA/LEVODOPA ER
PARLODEL CAPS
1. Approvals will require concurrent therapy with SELEGILINE HCL
PARLODEL TABS
Levodopa and failed trials of Selegiline, Comtan, 2. Approvals will require trials of Carbidopa/Levodopa, Selegiline, Comtan, and Stalevo.
PARKINSONS - COMBO.
MUSCLE RELAXANTS
RILUTEK TABS
MUSCLE RELAXANTS
BACLOFEN TABS
ORPHENADRINE CITRATE
Non-preferred drugs will not be approved if CHLORZOXAZONE TABS
CARISOPRODOL TABS
CYCLOBENZAPRINE HCL TABS
authorization requirements by paying (prescribers failed to submit prior authorization FLEXERIL TABS
prior to cash narcotic scripts being filled by METHOCARBAMOL TABS
TIZANIDINE HCL TABS
products must be used in specified step order. ZANAFLEX TABS
SKELAXIN TABX
SOMA TABS
MUSCLE RELAXANT - COMBO.
CARISOPRODOL/ASPIRIN/CODENORGESIC TABSORPHENADRINE COMPOUNDORPHENADRINE/ASA/CAFFORPHENGESIC VITAMINS
**Preferred products that used to require diag codes still require diag codes unless indicated otherwise.**
VITAMINS
FOLIC ACID TABSFOLTX TABSMEPHYTON TABSNIACINNIACOR TABSNICOTINIC ACID SR CPCRPYRIDOXINE HCL TABSSLO-NIACIN TBCRTHIAMINE HCL SOLNVITAMIN B-1 TABSVITAMIN B-12 VITAMIN B-6 TABSVITAMIN CVITAMIN E CAPS VITAMIN E/D-ALPHA CAPSVITAMIN K1 SOLNV-R VITAMIN E CAPS VITAMIN D's
CALCITRIOL CAPS1
DRISDOL CAPS
1. Diagnosis of dialysis (renal failure) required. VITAMIN D
HECTOROL (ORAL)
HECTOROL (PARENTERAL)
ROCALTROL
ZEMPLAR INJ
MISC MULTI-VITAMINS
**Preferred products that used to require diag codes still require diag codes unless indicated otherwise.**
VITAMINS - MISC.
Diag codes are no longer required on prenatal PROTEGRA CAPSSTUARTNATAL PLUS 3 TABSTRI-VI-SOL SOLNTRI-VI-SOL/IRON SOLNULTRA NATALCARE TABSULTRA-NATAL TABSVICON FORTE CAPSVINATAL FORTE TABSVINATEVINATE ADVANCED TABS MISCELLANEOUS MINERALS
**Preferred products that used to require diag codes still require diag codes unless indicated otherwise.**
MINERALS
CALCIUM 600-D TABS
CALCIUM/VITAMIN D TABS
OYSTER SHELL CALCIUM/VITA TABS
KAON ELIX
KAON-CL-10 TBCR
KCL 0.075%/D5W/NACL 0.2% SOLN
K-EFFERVESCENT TBEF
KLOR-CON
KLOTRIX TBCR
K-PHOS TABS
K-VESCENT TBEF
LURIDE CHEW
MAGNESIUM GLUCONATE TABS
MAGNESIUM SULFATE SOLN
MAGTABS
MICRO-K 8 MEQ
OS-CAL TABS
OS-CAL 500 + D TABS
OYSCO
OYST-CAL TABS
OYST-CAL D TABS
OYST-CAL/VITAMIN D TABS
OYSTER CALCIUM TABS
OYSTER SHELL
PHARMA FLUR
PHOSPHA 250 NEUTRAL TABS
POTASSIUM BICARBONATE TBEF
POTASSIUM CHLORIDE 8MEQ
POTASSIUM EFFERVESCENT
SELENIUM TABS
SLOW-MAG TBCR
SODIUM FLUORIDE
SSKI SOLN
V-R CALCIUM
V-R OYSTER SHELL CALCIUM
ZINC SULFATE CAPS
MISC. ELECTROLYTES/NUTRITIONALS
ELECTROLYTES/
This list of nutritionals is incomplete. All NUTRITIONALS
nutritionals still require a PA except for the miscellaneous products listed as preferred. SGA form required for nutritionals unless member has ENFAMIL ENSUREGLUCERNAISOCAL LIQDKINDERCAL TF LIQDKINDERCAL TF/FIBER LIQD NUTRAMIGEN POWDNUTRENNUTRITIONAL SUPPLEMENT LIQDNUTRIVENT 1.5 LIQDPEPTAMENPHENYL-FREEPKU 3 POWDPREGESTIMIL POWDPROBALANCE LIQD ERYTHROPOEITINS
ERYTHROPOEITINS
1. Clinical PA is required to establish medical necessity and that appropriate lab monitoring is being done. GRANULOCYTE CSF
GRANULOCYTE CSF
1. 10 day supply/month may be used without a PA. ANTICOAGULANTS / PLATELET AGENTS
ANTICOAGULANTS
durations greater than 7 days require PA.
INNOHEP
LOVENOX SOLN1

WARFARIN SODIUM TABS
HEPARIN LOCK SOLNHEPARIN LOCK FLUSH SOLNHEPARIN SODIUM SOLNHEPARIN SODIUM LOCK FLUSH SOLNJANTOVEN ANTIHEMOPHILIC AGENTS
1. Only if other products unavailable.
2. Advate may be available with PA in cases of large volume dosing in patients with poor venous KONYNE - 80MONARC - MMONOCLATE - PMONONINENOVOSEVEN SOLRPROFILNINEPROPLEX -TRECOMBINATE SOLRREFACTO PLATELET AGGREGATION
Use PA Form # 20715 for Plavix & Effient INHIBITORS
DIPYRIDAMOLE TABS
For all other requests please use form # 20420. 1. As of 10.16.08 all new users of Plavix will require prior authorization.
2. A special PA may be obtained at the pharmacy for members scheduled for "stent" placement or have had placement if in the last 12months. Please indicate on prescription date of stent placement.
PLATELET AGGR. INHIBITORS /
AGGRENOX CP121
COMBO'S - MISC.
1. Asprin and dipyridamole are available AGRYLIN CAPS
PLETAL TABS
2. Aggrenox will be approved if submitted with documentation supporting that it is being used for non-embolic stroke.
HEMATOLOGICALS
MONOCLONAL ANTIBODY
HEMATOLOGICAL AGENTS-
THROMBOPOIETIN RECEPTOR
THROMBOPOIETIN RECEPTOR
AGONISTS
HEMOSTATIC
HEMOSTATIC
OPHTHALMICS
OP. - ANTIBIOTICS
OP. - QUINOLONES
OP.QUINOLONES-4TH
GENERATION
OP. - ARTIFICIAL TEARS AND
LUBRICANTS
REFRESH TEARS SOLN1SYSTANETEARGEN SOLNTEARISOL SOLNTEARS NATURALETEARS PURE SOLNTEARS RENEWED OINTTHERATEARS SOLNV-R ARTIFICIAL TEARS SOLN OP. - BETA - BLOCKERS
BETOPTIC-S SUSP
CARTEOLOL HCL SOLN
BETAXOLOL HCL SOLN
LEVOBUNOLOL HCL SOLN
BETIMOL SOLN
TIMOLOL MALEATE SOLG (GEL)
OCUPRESS SOLN
TIMOLOL MALEATE SOLN
OPTIPRANOLOL SOLN
TIMOPTIC SOLN
TIMOPTIC-XE SOLG

OP. - ANTI-INFLAMMATORY /
STEROIDS OPHTH.
OP. - PROSTAGLANDINS
RESCULA SOLN
TRAVATAN SOLN
XALATAN SOLN
OP. - CYCLOPLEGICS
OP. - MIOTICS - DIRECT ACTING
ISOPTO CARBACHOL SOLN
ISOPTO CARPINE SOLN
PILOCAR SOLN
PILOCARPINE HCL SOLN
PILOPINE HS GEL

OP. - ADRENERGIC AGENTS
DIPIVEFRIN HCL SOLN
OP. - SELECTIVE ALPHA
ADRENERGIC AGONISTS
IOPIDINE SOLN
OP. - ANTI-ALLERGICS
BEPREVEELESTATEMADINE SOLNLIVOSTIN SUSPOPTICROM SOLNZADITOR SOLN OP. ANTI-ALLERGICS-
MASTCELL STABILIZER CLASS
OP. - CARBONIC ANHYDRASE
AZOPT SUSP
INHIBITORS/COMBO
COSOPT SOLN
COMBIGAN
TRUSOPT SOLN
OP. - NSAID'S
Must fail all preferred products before non- OP. - OF INTEREST
1. Must have kerato conjuctivitus sicca and failed other dry eye therapies. DERMATOLOGICAL
TOPICAL - ACNE
1. Users 24 or under, PA will not be required. PREPARATIONS
2. Dosing limits allowing one package per month. Please refer to Dose Consolidation list. 3. Only available if component ingredients are EMGEL GELEPIDUOERYCETTE PADSERYGEL GELEVOCLINFINEVIN CREAKLARON LOTN METROCREAM CREAM2METROGEL GEL2METROLOTION LOTN2NEOBENZ MICRONORITATE CREARETIN-A MICRO GEL TOPICAL - ANTIBIOTIC
1. Dosing limits apply, please see dosing MUPIROCIN1CENTANY OINT 2%1GENTAMICIN SULFATE TOPICAL - ANTIFUNGALS
TOPICAL - ANTIPRURITICS
TOPICAL - ANTIPSORIATICS
Must fail all preferred products before non- preferred. 1. Individual ingredients are available TOPICAL - ANTISEBORRHEICS
TOPICAL - ANTIVIRALS
1. Must fail oral treatment with Acyclovir or 2. Approvals limited to 1 tube per 180 days.
TOPICAL - ANTINEOPLASTICS
TOPICAL - BURN PRODUCTS
SILVER SULFADIAZINE CREASSD AF CREASSD CREA TOPICAL - CORTICOSTEROIDS
LOW POTENCY
MEDIUM POTENCY
HIGH POTENCY
VERY HIGH POTENCY
BETAMETHASONE VALERATE BETA-VALCLOBETASOL PROPIONATE DIFLORASONE DIACETATEHALOBETASOL MISCELLANEOUS
CAPEX SHAM DERMA-SMOOTHE/FS OIL PROCTO-KIT CREA 1% TOPICAL - STEROID LOCAL
ANESTHETICS
TOPICAL - STEROID
COMBINATIONS
TOPICAL - EMOLLIENTS
TOPICAL - ENZYMES /
KERATOLYTICS / UREA
Ziox, Panafil and Papain products have been concerns regarding drugs containing Papain.
TOPICAL - GENITAL WARTS
TOPICAL -
IMMUNOMODULATORS
IMMUNOMODULATORS
Non-preferred products must be used in specified order. The FDA has issued a Public Health Advisory for both Elidel and Protopic concerning the potential cancer risk associated with their use. Use for children less than 2 years of age is not recommended. TOPICAL - LOCAL
1. Lidocaine/Prilocaine cream and Ela-Max ANESTHETICS
products require PA for users over 18 years of TOPICAL - DEPIGMENTING
TOPICAL - SCABICIDES AND
PEDICULICIDES
LICE TREATMENT CREME RINS LIQDPERMETHRIN LOTN TOPICAL - WOUND /
DECUBITUS CARE
Accuzyme and Ethezyme products have been removed from the PDL due to FDA safety concerns regarding drugs containing Papain.
TOPICAL - ASTRINGENTS /
PROTECTANTS
PROSHIELD PLUS SKIN PROTE CREASURGILUBE GEL TOPICAL - ANTISEPTICS /
DISINFECTANTS
MISCELLANEOUS EYE
PHENYLEPHRINE HCL SOLNPONTOCAINE SOLNSODIUM CHLORIDE MISCELLANEOUS EAR
EAR DROPS RX SOLNEAR WAX REMOVAL DROPSEAR-GESIC SOLNNEOMYCIN/POLYMYXIN/HCOFLOXACIN 0.3% OTICOTICAINE OTIC SOLN MOUTH ANTISEPTICS
MOUTH ANTI-INFECTIVES
MOUTH ANTISEPTICS
Must fail all preferred products before non- DENTAL PRODUCTS
DENTAL PRODUCTS
PREVIDENT SOLNSF 5000 PLUS CREASF GELSTANNOUS FLUORIDE ORAL RI CONC ARTIFICIAL SALIVA/STIMULANTS
ARTIFICIAL
SALIVA/STIMULANTS
MISCELLANEOUS ANORECTAL
ANORECTAL - MISC.
T-CELL ACTIVATION INHIBITOR
PSORIASIS BIOLOGICALS
AMEVIVE2
1. Will not require a PA if at least one systemic drug such as methotrexate, cyclosporine, methoxsalen or acitretin is in members drug profile. Please refer to dose consolidation list. 2. Trial of both preferred drugs are required. 3. Use multiple 25mg injections.
4. Preferred dosage form allowed without PA after trial of step 1 prodcuts is multi-dose vial, with dosing limits allowing 8 injections per 28 days without pa.
ALTERNATIVE MEDICINES
ALTERNATIVE MEDICINES
CHELATING AGENTS
CHELATING AGENTS
CUPRIMINE CAPS
ANTILEPROTIC
ANTILEPROTIC
1. All PA requests for 150mg dosing will require use of Thalomid 100mg and 50mg capsules. ANTINEOPLASTIC AGENTS
ANTINEOPLASTIC AGENTS -
ANTIADNDROGENS
ANTINEOPLASTIC AGENTS-
1. Dosing limits apply, please refer to dosage LHRH ANALOGS
ANTINEOPLASTIC AGENTS -
TYROSINE KINASE INHIBITORS
1. Verification of diagnosis and prior trial of at least Gleevec is required. 2. PA required to confirm FDA approved indication and to monitor for potential drug-drug interactions.
ANTINEOPLASTICS-
MISCELLANEOUS
ANTINEOPLASTICS-
MONOCLONAL ANTIBODIES
IMMUNOSUPPRESSANTS
IMMUNOSUPPRESSANTS
1. Established users will require a one time PA.
2. Established users will require a one time PA PURINE ANALOG
PURINE ANALOG
IMURAN TABS
AZATHIOPRINE TABS
K REMOVING RESINS
K REMOVING RESINS
KIONEX POWDSODIUM POLYSTYRENE SULFONSPS SUSPSPS 30GM/120ML ENEMA SUSP New drugs are initially non-preferred until reviewed by the DUR Committee and the State. According to State policy, any drug requiring specific diagnosis still requires the specific diagnosis unless otherwise noted within this document.
ANTI-CONVULSANTS INDICATION CHART
GABITRIL
LAMICTAL
X X(2nd line)
X(2nd line)
X(2nd line)
(2nd line)
TRILEPTAL
PEDIATRIC ANTI-CONVULSANTS INDICATION CHART
SEIZURES MONOTHERAPY BIPOLAR ADJUNCTIVE BIPOLAR SEIZURES MONOTHERAPY BIPOLAR ADJUNCTIVE BIPOLAR CARBMAZEPINE
VALPROATE
ATYPICAL ANTIPSYCHOTICS EXC. CLOZAPINE
LAMICTAL
TRILEPTAL
CLOZAPINE

Source: http://www.mainecarepdl.org/sites/default/files/ghs-files/pdl-archive/2011-01-04/ssdc-pdlmaine-12-10-without-criteria.pdf

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GENERAL HEALTH APPRAISAL FORM PARENT please complete AND SIGN Child’s Name: _______________________________________________________ Birthdate: _ ____________________ Allergies: ‰ None or Describe___________________________________________________________________________________________ Type of Reaction _______________________________________________________________________________

Microsoft word - standard charge terms - 200635 - english - march 2007.doc

Land Registration Reform Act SET OF STANDARD CHARGE TERMS Filed by ALTERNA SAVINGS AND CREDIT UNION LIMITED The following set of standard charge terms shall be deemed to be included in every charge in which the set is referred to by its filing number, as provided in section 9 of the Land Registration Reform Act (the “Act”). The Chargor hereby covenants, represents, wa

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