To: Pharmacy Providers
To: MaineCare Providers
Date: June 26, 2008
Re: PDL updates effective 07/03/08
The following medications will be non-preferred and will require prior authorization:
Lo/Ovral 28 and 21 tabs
Requip
Xopenex HFA inhaler
Oxycodone 10 and 20mg tabs
The following medications will be preferred and will not require prior authorization:
Low-Ogestrel
ProAir HFA inhaler
Cryselle
Ventolin HFA inhaler
Proventil HFA inhaler
Ropinirole
The following medications will be preferred with dosing limitations:
Treximet: 12 tablets every 30 days without pa (Acute Migraine PA form updated)
Duragesic: 11 patches every 33 days without pa (Narcotics PA form updated)
The following are miscellaneous PDL changes:
Fentanyl will now be non-preferred step 8. Since Duragesic will now be preferred, the HO Diag and CA Diag will not be required to be utilized with Duragesic patch and will not be able to be utilized with the fentanyl patch.
Since Duragesic is now preferred, it will now be one of the preferred medications needed to be tried prior to consideration for a non-preferred drug, in addition to prior trials of morphine sulfate product, a methadone product, and oxycodone ER.
Epoprostenol inj will be preferred but will require PA to confirm WHO Group 1 diagnosis of primary pulmonary hypertension and NYHA functional class 3 and 4.
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