Department of Medical Assistance Services 600 East Broad Street, Suite 1300

Richmond, Virginia 23219

http://www.dmas.state.va.us

MEDICAID MEMO

TO: All Prescribing Providers, Pharmacists, and Managed Care Organizations (MCOs)

Participating in the Virginia Medical Assistance Programs

FROM: Cynthia B. Jones, Acting Director Department of Medical Assistance Services (DMAS)

MEMO: Special

DATE: 6/9/2010 SUBJECT: Changes to the Estimated Acquisition Cost (EAC) for Single Source, Innovator Drugs—Effective July 1, 2010; Contractor Changes for DMAS Pharmacy Services

including pharmacy claims processing, Drug Utilization Review (DUR), Preferred Drug List (PDL), Maximum Allowable Cost (MAC) and Specialty Maximum Allowable Cost (SMAC) programs—Effective June 28, 2010; and Modifications to the Virginia Medicaid Preferred Drug List (PDL) Program—Effective July 1, 2010

The purpose of this memorandum is to inform providers about changes in the estimated acquisition cost (EAC) for single source, innovator drugs effective on July 1, 2010, and to announce changes in DMAS’ contractors effective June 28, 2010, for pharmacy claims processing, Drug Utilization Review (DUR), Preferred Drug List (PDL), Maximum Allowable Cost (MAC) and Specialty Maximum Allowable Cost (SMAC) programs. Lastly, this memorandum describes modifications to Virginia Medicaid’s Preferred Drug List (PDL) Program effective July 1, 2010. Change to the Estimated Acquisition Cost (EAC) for Single Source Innovator Drugs-Effective July 1, 2010 As a result of actions by the 2010 Virginia General Assembly, the estimated acquisition cost for single source innovator drugs will change from Average Wholesale Price (AWP) minus 10.25% to AWP minus 13.1%. This change will go into effect for all applicable drugs dispensed on or after July 1, 2010. A change in state regulations governing the EAC for single source innovator drugs (12VAC30-80-40) is currently being promulgated to reflect the actions of the Virginia General Assembly. This change only impacts the cost of prescription drugs under the DMAS fee-for-service program. It does not impact the price paid for prescription drugs by DMAS’ contracted Managed Care Organizations (MCOs). ACS State Healthcare (ACS) to Provide Pharmacy Claims Processing Services and the DUR Program, including RetroDUR and ProDUR Programs on June 28, 2010 and Associated Outages Effective June 28, 2010, ACS State Healthcare, in addition to providing Virginia Medicaid Fiscal Agent services (claims processing services), will become DMAS’ new DUR contractor.

Medicaid Memo: Special June 9, 2010 Page 2 The ACS Technical Call Center will assist with questions regarding claims processing including transmission errors, claim reversals, etc., as well as calls relating to prospective DUR edits, the generic drug program, drug rebate and obsolete date issues, generic drugs priced as brand name drugs and the tamper resistant prescription pad requirement. The phone number for the ACS Clinical Call Center is 800-774-8481. Any questions related to service authorizations (SAs - formerly referred to as PAs or prior authorizations) involving proDUR edits such as early refill and dose optimization are to be directed to Provider Synergies’(formerly First Health Services) clinical call center at 800-932-6648. Due to the transition from FHS to ACS, Virginia Medicaid has scheduled downtime for the Medicaid Point of Sale (POS) system from 5:00 PM Sunday, June 27, 2010 until 7:00 AM Monday, June 28, 2010. This means that POS claims cannot be processed during this time. Please hold all Medicaid POS claims until after 7:00 AM on June 28, 2010, when the POS system will be operational again. If the system is not available by 9:00 AM on Monday, June 28, 2010, AND eligibility cannot be verified through the Automated Response System (ARS) at www.virginiamedicaid.dmas.virginia.gov or MediCall at 800-552-8627, providers should follow the Virginia Medicaid Emergency fill provisions as detailed below: A pharmacist should verify Medicaid eligibility and fee-for-service enrollment through patient information at the store level or obtain a copy of the current Medicaid identification card and dispense a 72-hour supply of the prescribed medication. The pharmacist must call Provider Synergies at 800-932-6648 if the drug dispensed is a non-preferred drug on the Preferred Drug List (PDL). The patient will be charged a co-payment for the 72-hour supply. A co-payment should not be charged for the completion fill. The prescription must be processed as a “partial” and “completion” fill in order for only one co-payment to be computed for the prescription. If a provider dispenses a “partial” and a “completion” prescription as defined by NCPDP, the provider is entitled to an additional $3.75 dispensing fee when filling the completion portion of a 72-hour supply prescription. The completion fill claim should be submitted with a “03” in the Level of Service (NCPDP data element 418-DI) field. If the pharmacy’s software application does not have the capability to create a “partial” and a “completion” claim, please submit one claim for the full amount dispensed when the system becomes available. A second dispensing fee will not apply. Contact the ACS Call Center at 800-774-8481 for other pharmacy services concerns related to pharmacy claims submissions. New PDL, MAC and SMAC Contractor – Effective June 28, 2010 Effective June 28, 2010, Provider Synergies will become DMAS’ contractor for the Preferred Drug List Program (formerly managed by First Health Services) as well as the Maximum Allowable Cost Program (MAC) and the Specialty Maximum Allowable Cost (SMAC) Program, formally managed by Optima Health. The phone and fax numbers for the PDL program and the MAC and SMAC programs will remain the same as well as the email address for questions and disputes arising from the MAC and SMAC programs. The phone and fax numbers are provided below:

Medicaid Memo: Special June 9, 2010 Page 3 PDL Program Ph# 1-800-932-6648 Fax# 1-800-932-6651 MAC and SMAC Programs Ph# 1-866-312-8467 Fax# 1-866-312-8470 Email: disputeresolution@dmas.virginia.gov The Provider Synergies’ call center will address questions regarding drugs subject to the PDL program, including requests for SAs for drugs not on the PDL and SAs for drugs subject to prospective DUR edits such as early refill and dose optimization. Provider Synergies will also begin operating a new web site for the PDL, MAC and SMAC programs on June 28, 2010. The URL for the web site will be www.virginiamedicaidpharmacyservices.com. The web site will contain information about the PDL program, links to relevant web sites for eligibility, enrollment and claims information, the web SA process, and the MAC and SMAC drug lists. Appendix 1 provides a table summarizing the contractor changes and contact information. Preferred Drug List (PDL) Updates — Effective July 1, 2010 The PDL is a list of preferred drugs, by select therapeutic class, for which the Medicaid program allows payment without requiring service authorization (SA). Please note that not all drug classes are subject to the Virginia Medicaid PDL. In the designated classes, drug products classified as non-preferred will be subject to SA. In some instances, other additional clinical criteria may apply to a respective drug class which could result in the need for a SA. The PDL program aims to provide clinically effective and safe drugs to its clients in a cost-effective manner. Your continued compliance and support of this program is critical to its success. The PDL is effective for the Medicaid, MEDALLION, and FAMIS Plus fee-for-service populations. The PDL does not apply to members enrolled in a Managed Care Organization. The DMAS Pharmacy and Therapeutics (P&T) Committee recently conducted its annual review of the PDL Phase II drug classes listed below. Specific drug additions within the following PDL categories are identified in bold type in the attached PDL Quicklist.

• Analgesics • Antibiotics/Anti-infectives • Antivirals • Asthma / Allergy • Central Nervous System • Dermatologic • Immunologic Agents • Ophthalmics • Hypoglycemics (oral) • Please note that Actos® will continue to be a preferred agent on the PDL but only in the 15 mg strength (Actos® 30 mg and 45 mg tablets will be non-preferred) • Osteoporosis

Medicaid Memo: Special June 9, 2010 Page 4

• Serotonin Receptor Agonists • Gout Suppressants

In addition, the P&T Committee added several new classes and/or categories of drugs to the PDL as of July, 1 2010, which are identified below. The new drug classes and/or category as well as the specific drug within each new class are also highlighted in bold text in the attached Quicklist.

• Analgesics (lozenges and short acting) • Contraceptives (oral, non-oral, injectable) • Cough and Cold • Estrogens (vaginal) • Injectable Hypoglycemic Agents (incretin mimetics) • GI Stimulants • Platelet Inhibitors • Skeletal Muscle Relaxants • Smoking Cessation Aids

The revised PDL Quicklist is attached to this memo and reflects all the changes that will become effective on July 1, 2010. Please note that the revised PDL Quicklist only includes “preferred” drugs (no SA required). A SA is required if the drug requested from one of these select therapeutic classes is not on the list. You may also access the complete list of pharmaceutical products included on the Virginia PDL by visiting http://www.dmas.virginia.gov/pharm-pdl_program.htm or https://virginiamedicaidpharmacyservices.com. Additional information and Provider Manual updates will be posted as necessary. Comments and questions regarding this program may be emailed to pdlinput@dmas.virginia.gov. PDL Service Authorization (SA) Process A message indicating that a drug requires a SA will be displayed at the point of sale (POS) when a non-preferred drug is dispensed. Pharmacists should contact the patient’s prescribing provider to request that they initiate the SA process. Prescribers can initiate SA requests by letter; faxing to 1-800-932-6651; contacting the Provider Synergies Clinical Call Center at 1-800-932-6648 (available 24 hours a day, seven days a week); or by using the web-based service authorization process (Web SA) at virginiamedicaidpharmacyservices.com. Faxed and mailed SA requests will receive a response within 24 hours of receipt. SA requests can be mailed to:

Provider Synergies ATTN: MAP Department/ VA Medicaid 4300 Cox Road Glen Allen, Virginia 23060

A copy of the SA form is available online at http://www.dmas.virginia.gov/pharm-pdl_program.htm and http://www.virginiamedicaidpharmacyservices.com. The PDL criteria for SA purposes are also available on both websites. The telephone number and mailing address will remain the same after Provider Synergies takes over the PDL contract on July 1, 2010.

Medicaid Memo: Special June 9, 2010 Page 5 PDL 72-Hour-Supply Processing Policy and Dispensing Fee Process The PDL program provides a process where the pharmacist may dispense a 72-hour supply of a non-preferred, prescribed medication if the prescriber is not available to consult with the pharmacist (after-hours, weekends, or holidays), AND the pharmacist, in his/her professional judgment, consistent with current standards of practice, feels that the patient’s health would be compromised without the benefit of the drug. A phone call by the pharmacy provider to Provider Synergies at 1-800-932-6648 (available 24 hours a day, seven days a week) is required for processing a 72-hour supply. The patient will be charged a co-payment applicable for this 72-hour supply (partial fill). However, a co-payment will not be charged for the completion fill. The prescription must be processed as a “partial” fill and then a “completion” fill. For unit-of-use drugs (i.e., inhalers, drops, etc.), the entire unit should be dispensed and appropriate action taken to prevent similar situations in the future. Pharmacy providers are entitled to an additional $3.75 dispensing fee when filling the completion of a 72-hour-supply prescription for a non-preferred drug. To receive the additional dispensing fee, the pharmacist must submit the 72-hour supply as a partial fill and, when submitting the claim for the completion fill, enter “03” in the “Level of Service” (data element 418-DI) field. The additional dispensing fee is only available (one time per prescription) to the pharmacist after dispensing the completion fill of a non-preferred drug when a partial (72-hour supply) prescription was previously filled. Personal Digital Assistant (PDA) Download for PDL Quicklist There are two ways to download the PDL list for PDA users. There is a link on the DMAS website (http://www.dmas.virginia.gov/pharm-pdl_program.htm) which enables providers to download the PDL Quicklist to their PDAs. This page will have complete directions for the download and HotSync operations. ePocrates® users may also access Virginia Medicaid’s PDL through the ePocrates® formulary link at www.epocrates.com. ePocrates® is a leading drug information software application for handheld computers (PDAs) and desktop computers. For more information and product registration, please visit the ePocrates® website at www.eprocrates.com. To download the Virginia Medicaid PDL via the ePocrates® website to your PDA, please follow these steps:

1. Ensure that you have the most recent version of ePocrates Rx® installed on your PDA. 2. Connect to the Internet and go to www.epocrates.com. 3. Click the “Add Formularies” link at the top of the page. 4. Log in to the website using your user name and password. 5. Select “Virginia” from the “Select State” menu. 6. Select “Virginia Medicaid-PDL” under “Available Formularies.” 7. Click on “Add to My List” and then click on “Done.” 8. Auto Update your PDA to install the “Virginia Medicaid-PDL” to your PDA.

REQUESTS FOR DUPLICATE REMITTANCE ADVICES In an effort to reduce operating expenditures, requests for duplicate provider remittance advices are no longer printed and mailed free of charge. Duplicate remittance advices are now processed and sent

Medicaid Memo: Special June 9, 2010 Page 6 via secure email. A processing fee for generating duplicate paper remittance advices has been applied to paper requests, effective July 1, 2009. ALTERNATE METHODS TO LOOK UP INFORMATION As of August 1, 2009, DMAS authorized users now have the additional capability to look up service limits by entering a procedure code with or without a modifier. Any procedure code entered must be part of a current service limit edit to obtain any results. The service limit information returned pertains to all procedure codes used in that edit and will not be limited to the one procedure code that is entered. This is designed to enhance the current ability to request service limits by Service Type, e.g., substance abuse, home health, etc. Please refer to the appropriate Provider Manual for the specific service limit policies. ELIGIBILITY VENDORS DMAS has contracts with the following eligibility verification vendors offering internet real-time, batch and/or integrated platforms. Eligibility details such as eligibility status, third party liability, and service limits for many service types and procedures are available. Contact information for each of the vendors is listed below. Passport Health Communications,

Inc. www.passporthealth.comsales@passporthealth.com

Telephone: 1 (888) 661-5657

SIEMENS Medical Solutions – Health Services

Foundation Enterprise Systems/HDX www.hdx.com

Telephone: 1 (610) 219-2322

Emdeon www.emdeon.com

Telephone: 1 (877) 363-3666

“HELPLINE” The “HELPLINE” is available to answer questions Monday through Friday from 8:30 a.m. to 4:30 p.m., except on state holidays. The “HELPLINE” numbers are:

1-804-786-6273 Richmond area and out-of-state long distance 1-800-552-8627 All other areas (in-state, toll-free long distance)

Please remember that the “HELPLINE” is for provider use only. Please have your Medicaid Provider Identification Number available when you call. Attached Number of Pages: (7)

Appendix 1

Virginia Department of Medical Assistance Services Pharmacy Contractors

Activity Old Vendor New Vendor New Vendor Contact Information

Pharmacy Claims Processing First Health Services ACS 800-774-8481 www.virginiamedicaid.dmas.virginia.gov

Drug Utilization Review Program (proDUR and retroDUR) First Health Services ACS 800-774-8481

www.virginiamedicaid.dmas.virginia.gov

Service Authorizations First Health Services Provider Synergies 800-932-6648 www.virginiamedicaidpharmacyservices.com

Preferred Drug List (PDL) First Health Services Provider Synergies P: 800-932-6648 F: 800-932-6651 www.virginiamedicaidpharmacyservices.com

MAC/SMAC Programs Optima Health Provider Synergies P: 866-312-8467 F: 866-312-8470 E-mail: disputeresolution@dmas.virginia.gov

Virginia Medicaid Preferred Drug List Effective July 1, 2010 Phone: .

Bold font indicates drug added since last up-date ® = Registered Trade name * A step edit is required for this class **Clinical Service Authorization required Page 1 of 6

Provider Synergies, an affiliate of Magellan Medicaid Administration Phone: 1-800-932-6648 Fax: 1-800-932-6651

Within these categories, drugs that are not listed are subject to Service Authorization ANALGESICS BARBITURATE & NON-SALICYLATE ANALGESIC COMBINATIONS acetaminophen-butalbital Bupap®

Cephadyn®

Sedapap®

NON-STEROIDAL ANTI-INFLAMMATORY DRUGS Celebrex®** diclofenac potassium diclofenac sodium diflunisal etodolac etodolac SR fenoprofen flurbiprofen ibuprofen indomethacin indomethacin SR ketoprofen ketoprofen SR ketorolac meclofenamate sodium meloxicam nabumetone naproxen naproxen sodium oxaprozin piroxicam sulindac tolmetin sodium

NARCOTICS: * LONG-ACTING Duragesic® (Brand Only) *Kadian ® *morphine sulfate tablets SA* NARCOTIC LOZENGES fentanyl citrate** NARCOTICS: SHORT-ACTING AND COMBINATIONS Generic only class OPIOID ANALGESICS tramadol HCL tramadol HCL/APAP OPIOID DEPENDENCY Suboxone® buprenorphine SL TOPICAL AGENTS & ANESTHETICS* Flector® Patch* Voltaren® Gel* ANTIBIOTICS – ANTIINFECTIVES ORAL ANTIFUNGALS – Grifulvin V® Tablets Gris-Peg®

griseofulvin oral susp terbinafine

CEPHALOSPORINS: 2ND & 3RD GENERATION cefaclor capsule

cefaclor ER cefaclor suspension cefdinir capsules cefdinir suspension cefprozil tablet cefprozil suspension cefuroxime Raniclor®

Spectracef®

Suprax Suspension® MACROLIDES azithromycin tablet azithromycin packet azithromycin suspension clarithromycin tablet clarithromycin suspension E.E.S®

EryC®

Eryped®

Erythrocin® stearate erythromycin base erythromycin ethylsuccinate erythromycin stearate suspension erythromycin stearate erythromycin w/sulfisoxazole QUINOLONES: 2ND & 3RD GENERATION Avelox®

Avelox ABC pack®

ciprofloxacin tablet Cipro suspension®

OTIC QUINOLONES Ciprodex®

ofloxacin TOPICAL ANIBIOTICS Altabax®

mupirocin ANTIVIRALS HEPATITIS C** Pegasys Conv.Pack®** Pegasys®** PegIntron®** PegIntron Redipen®** HERPESacyclovir tablets acyclovir suspension Famvir®

Valtrex®

INFLUENZAamantadine amantadine syrup Relenza Disk ®

rimantadine

Tamiflu®

Tamiflu suspension®

TOPICAL ANTIVIRALS Abreva OTC®

Zovirax Oint®

Virginia Medicaid Preferred Drug List Effective July 1, 2010 Phone: .

Bold font indicates drug added since last up-date ® = Registered Trade name * A step edit is required for this class **Clinical Service Authorization required Page 2 of 6

Provider Synergies, an affiliate of Magellan Medicaid Administration Phone: 1-800-932-6648 Fax: 1-800-932-6651

Within these categories, drugs that are not listed are subject to Service Authorization

CARDIAC MEDICATIONS ACE INHIBITORS benazepril benazepril /HCTZ captopril captopril/HCTZ enalapril enalapril/HCTZ lisinopril lisinopril/HCTZ ACE OR ARB INHIBITORS W/ CALCIUM CHANNEL BLOCKERS amlodipine/benazepril (2.5/10, 5/10, 5/20 & 10/20 generic preferred) Lotrel® (5/40 and 10/40 brand preferred) ANGIOTENSIN RECEPTOR ANTAGONISTS Cozaar®

Diovan®* Diovan HCT®* Hyzaar® (Once generic Cozaar/Hyzaar are available and there is a financial advantage, a step edit will be placed on this class. Diovan/Diovan HCT will require a step try of generic) BETA BLOCKERS acebutolol atenolol atenolol/chlorthalidone betaxolol bisoprolol fumarate bisoprolol/HCTZ carvedilol labetalol HCL metoprolol tartrate

metoprolol/HCTZ nadolol pindolol propranolol propranolol solution propranolol/HCTZ Sorine® sotalol sotalol AF timolol maleate CALCIUM CHANNEL BLOCKERS: DIHYDROPYRIDINEAfeditab CR®

amlodipine Dynacirc®CR felodipine ER nicardipine Nifediac CC®

Nifedical XL®

nifedipine nifedipine ER nifedipine SA CALCIUM CHANNEL BLOCKERS: NON-DIHYDROPYRIDINE Cartia XT®

Diltia XT®

diltiazem ER diltiazem HCL diltiazem XR Taztia XT®

verapamil verapamil SA verapamil 24 hr pellets

LIPOTROPICS: BILE ACID SEQUESTRANTS cholestyramine light cholestyramine Colestid® packet Colestid® tablet colestipol HCl tablet colestipol HCl packet Prevalite®

WelChol®

WelChol packet®

LIPOTROPICS: CAI Zetia® LIPOTROPICS: FIBRIC ACID Antara®gemfibrozil LIPOTROPICS: NIACIN DERIVATIVES Niacor®

Niaspan®

LIPOTROPICS: NIACIN & STATIN COMBINATIONS Simcor®* LIPOTROPICS: OMEGA 3 AGENT Lovaza®* LIPOTROPICS: STATINS lovastatin pravastatin

simvastatin

LOW MOLECULAR WEIGHT HEPARIN Arixtra®

Fragmin®

Lovenox® PDE-5 INHIBITORS - PAH** Revatio®** PLATELET INHIBITORS Aggrenox® dipyridamole Plavix®

ticlopidine HCl CENTRAL NERVOUS SYSTEM NON-ERGOT DOPAMINE RECEPTOR AGONISTS Mirapex®

ropinirole HCL SEDATIVE HYPNOTIC chloral hydrate syrup estazolam flurazepam temazepam triazolam SEDATIVE HYPNOTIC OTHER * Rozerem® * zolpidem

Virginia Medicaid Preferred Drug List Effective July 1, 2010 Phone: .

s drug added since last up-date ® = Registered Trade name * A step edit is required for this class **Clinical Service Authorization required Page 3 of 6

Bold font indicate

Provider Synergies, an affiliate of Magellan Medicaid Administration Phone: 1-800-932-6648 Fax: 1-800-932-6651

Within these categories, drugs that are not listed are subject to Service Authorization SEROTONIN RECEPTOR AGONISTS (Triptans) Maxalt-MLT®

sumatriptan succinate Cartridge sumatriptan succinate Nasal sumatriptan succinate Pen Kit sumatriptan succinate Tablet sumatriptan succinate Vial

SKELETAL MUSCLE RELAXANTS baclofen carisoprodol carisoprodol/ASA carisoprodol/ASA/codeine chlorzoxazone cyclobenzapine dantrolene methocarbamol orphenadrine orphenadrine/ASA/caffeine tizanidine STIMULANTS/ADHD MEDICATIONS amphetamine salt combo Concerta®

dextroamphetamine tablet Focalin XR®

methylphenidate Strattera®

Vyvanse®

SMOKING CESSATION bupropion SR nicotine gum nicotine lozenge nicotine patch DERMATOLOGIC ACNE AGENTS clindamycin benzoyl peroxide ACNE AGENTS: TOPICAL RETINOIDS Differin® cream 1% Differin® gel (1% & 0.3%) Retin-A Micro®

Retin-A Micro Pump®tretinoin TOPICAL AGENTS FOR PSORIASIS calcipotriene Dovonex®

Psoriatec®

ENDOCRINE AND METABOLIC AGENTS ANDROGENIC AGENTS Androderm® Androgel® Testim®

CONTRACEPTIVES ORAL Generic only class with YAZ® included

INTRA-VAGINAL Nuvaring®

TRANSDERMAL Ortho Evra®

GROWTH HORMONE** Genotropin® ** NuSpin™ ** Nutropin® ** Nutropin AQ® Cartridge ** Nutropin AQ® Vial ** HEMATOPOIETIC AGENTS Aranesp® Epogen® Procrit® INJECTABLE HYPOGLYCEMICS INCRETIN MIMETICS Byetta®

INSULINS LONG-ACTING Lantus® Vial Levemir® Vial Levemir® Pen INSULIN MIX Humalog® Mix 50/50 Vial Humalog® Mix 50/50 Pen Humalog® Mix 75/25 Vial Humalog® Mix 75/25 Pen

Novolog® Mix 70/30 Vial Novolog® Mix 70/30 Pen INSULIN 70/30 Humulin® 70/30 Vial Humulin® 70/30 Pen Novolin® 70/30 Vial INSULIN N Humulin® N Vial Humulin® N Pen Novolin® N Vial INSULINS RAPID-ACTING Humalog® Cartridge Humalog® Pen Humalog® Vial Novolog® Cartridge Novolog® Flexpen Syringe Novolog® Vial INSULIN R Humulin® R Vial Novolin® R Vial ORAL HYPOGLYCEMICS ALPHAGLUCOSIDASE INHIBITORS acarbose Glyset®

BIGUANIDES metformin metformin ER

Virginia Medicaid Preferred Drug List Effective July 1, 2010 Phone: .

Bold font indicates drug added since last up-date ® = Registered Trade name * A step edit is required for this class **Clinical Service Authorization required

Within these categories, drugs that are not

Provider Synergies, an affiliate of Magellan Medicaid Administration Phone: 1-800-932-6648 Fax: 1-800-932-6651

listed are subject to Service Authorization BIGUANIDE COMBINATIONS Avandamet® glipizide–metformin

glyburide–metformin DPP-IV INHIBITORS AND COMBINATIONS Janumet®

Januvia®

Onglyza®

MEGLITINIDES Starlix®

2ND GENERATION SULFONYLUREAS glimepiride glipizide glipizide ER glyburide glyburide micronized THIAZOLIDINEDIONES Actos 15 mg only®

Avandia®

ORAL AGENTS FOR GOUT allopurinol colchicine probenecid probenecid-colchicine PROGESTATIONAL AGENTS medroxyprogesterone acetate norethindrone acetate

progesterone Prometrium® Provera® PROGESTINS FOR CACHEXIA megestrol acetate VAGINAL ESTROGENS Premarin® Vagifem®

GASTROINTESTINAL HISTAMINE-2 RECEPTOR ANTAGONISTS (H-2RA) famotidine ranitidine ranitidine syrup MOTILITY AGENTS metoclopramide** PROTON PUMP INHIBITORS * omeprazole (No SA required. under age 12) Prevacid® (No SA required. under age 12) Prevacid® suspension (No SA required. under age 12) Prevacid® solutab

(No SA required. under age 12) Prilosec® OTC Protonix® *

ULCERATIVE COLITIS (5-ASA) ORALAsacol®

balsalazide disodium Lialda™ Pentasa®

sulfasalazine IR & DR ULCERATIVE COLITIS (5-ASA) RECTALCanasa® suppository mesalamine enema GENITOURINARYALPHA BLOCKERS FOR BPH Flomax®

ANDROGEN HORMONE INHIBITORS Avodart®

finasteride ELECTROLYTE DEPLETERS Fosrenol®

Phoslo®

Renagel®

URINARY ANTISPASMODICS Detrol® LA Enablex®

oxybutynin tablet oxybutynin syrup

Oxytrol® Transdermal

Sanctura®

Sanctura XR®

VESIcare®

IMMUNOLOGIC AGENTS SELF ADMINISTERED DRUGS FOR RHEUMATOID ARTHRITIS Enbrel®

Humira®

MULTIPLE SCLEROSIS AGENTS Avonex®

Avonex® Adm Pack Betaseron®

Copaxone®

Rebif®

TOPICAL IMMUNOMODULATORS** Elidel® ** Protopic® **

OPHTHALMIC ANTIBIOTIC: QUINOLONES ciprofloxacin drops

ofloxacin drops

Quixin®

Vigamox®

Zymar®

ANTIHISTAMINES Alaway OTC ®

Page 4 of 6

Virginia Medicaid Preferred Drug List Effective July 1, 2010 Phone: .

Bold font indicates drug added since last up-date * A step edit is required for this class **Clinical Service Authorization required Page 5 of 6

® = Registered Trade name

Provider Synergies, an affiliate of Magellan Medicaid Administration Phone: 1-800-932-6648 Fax: 1-800-932-6651

Within these categories, drugs that are not listed are subject to Service Authorization ANTI-INFLAMMATORY Acular®

Acular LS®

diclofenac sodium drops flurbiprofen sodium drops

Nevanac®

Xibrom®

GLAUCOMA: ALPHA-2 ADRENERGICS Alphagan P®

brimonidine tartrate Iopidine®

GLAUCOMA: BETA-BLOCKERS betaxolol HCl Betimol®

Betoptic S®

carteolol HCl Combigan®

levobunolol HCl metipranolol timolol maleate drops timolol maleate Sol-Gel GLAUCOMA: CARBONIC ANHYDRASE INHIBITORS Azopt®

Cosopt®

Trusopt®

GLAUCOMA: PROSTAGLANDIN ANALOGS Travatan®

Travatan Z®

Xalatan®

MAST CELL STABLIZERS Alamast®

Alocril®

Alomide®

cromolyn OSTEOPOROSIS BISPHOSPHONATES alendronate tablet

Fosamax® Solution CALCITONINS Miacalcin®

RESPIRATORY ANTIHISTAMINES: 1ST GENERATION Generic only class ANTIHISTAMINES: 2ND GENERATION cetirizine solution (SA required, except for children under age 2) Claritin tablets OTC ® Claritin Reditabs® OTC Claritin Syrup OTC ® Claritin-D 12 hr OTC®

Claritin-D 24 hr OTC®

loratadine tablet (All OTCs names) loratadine tablets- Rapids (All OTCs names) loratadine syrup (All OTCs names) loratadine-D 12 hr (All OTCs names) loratadine-D 24 hr (All OTC names)

ANTIHISTAMINE & DECONGESTANT COMBINATIONS Generic only class ANTIHISTAMINE 1ST GENERATION & DECONGESTANT COMBINATIONS Generic only class BETA2 ADRENERGIC & CORTICOSTEROID INHALER COMBINATIONS Advair Diskus®

Advair HFA®

BETA2 ADRENERGICS FOR NEBULIZERS albuterol sulfate metaproterenol Xopenex®

BETA2 ADRENERGICS: LONG ACTING Foradil®

Serevent® Diskus BETA2 ADRENERGIC: SHORT ACTING METERED-DOSE INHALERS Proventil® HFA Ventolin® HFA

COPD ANTICHOLINERGICS Atrovent HFA®

Combivent MDI® ipratropium bromide Spiriva®

DECONGESTANT & EXPECTORANT COMBINATIONS Generic only class EXPECTORANTS Generic only class INHALED CORTICOSTEROIDS AeroBid®

AeroBid M®

Asmanex®

Azmacort® Flovent HFA®

Pulmicort Respules®

QVAR® INTRANASAL ANTIHISTAMINES Astelin®

Astepro®

LEUKOTRIENE INHIBITORS Accolate®

Singulair®

NARCOTIC ANTITUSSIVE & DECONGESTANT COMBOS Generic only class

Virginia Medicaid Preferred Drug List Effective July 1, 2010 Phone: .

Bold font indicates drug added since last up-date ® = Registered Trade name * A step edit is required for this class **Clinical Service Authorization required Page 6 of 6

Provider Synergies, an affiliate of Magellan Medicaid Administration Phone: 1-800-932-6648 Fax: 1-800-932-6651

Within these categories, drugs that are not listed are subject to Service Authorization NARCOTIC ANTITUSSIVE & EXPECTORANT COMBOS Generic only class NASAL STEROIDS flunisolide fluticasone Nasacort AQ®

Nasonex® NON-NARCOTIC ANTITUSSIVES Generic only class NON- NARCOTIC ANTITUSSIVE & DECONGESTANT COMBOS Generic only class NON -NARCOTIC ANTITUSSIVE & EXPECTORANT COMBOS Generic only class NON -NARCOTIC ANTITUSSIVE & 1ST GENERATION ANTIHISTAMINE DECONGESTANT COMBOS Generic only class SELF-INJECTABLE EPINEPHRINE EpiPen®

EpiPen® Jr

NOTE: • Fax requests receive a

response within 24 hours. • For urgent requests, please

call. • Not all medications listed

are covered by all DMAS programs. Check individual program coverage.

For program drug coverage information, visit the following: http://www.virginiamedicaidpharmacyservices.com