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Maryland
Medicaid Pharmacy Program |
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Clinical Criteria |
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Clinical criteria have been established for some of the
medications on the Preferred Drug List as well as the
Non-Preferred List to insure that they are used in an
efficacious, cost effective and safe manner. Dose
optimization should be adhered to when applicable.
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No prior
authorization required if a recipient has a diagnosis of
diabetes, or a history of receiving hypoglycemic agents within
the past 90 days.
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Recipients
currently receiving Cymbalta® for any diagnosis are
grandfathered and may continue on Cymbalta®
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Clinical prior authorization is required
unless a recipient has a
diagnosis of major depressive disorder or general anxiety
disorder AND has had an 8-week trial of an SSRI (e.g.
citalopram, fluoxetine, fluvoxamine, paroxetine, sertraline,
Lexapro®, Paxil® CR, Pexeva®,
etc.)
in the past 90 days.
To ensure
patient safety, a 2-week trial of 60mg per day dose of Cymbalta®
is required before a 120mg per day regimen will be
authorized. (According to the labeling, there is no evidence that
doses greater that 60 mg/day confer any additional benefits. Also,
the increased dosage may pose an increased risk of hepatotoxicity.
The maximum FDA approved daily dose is 60mg.)
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Strattera® is a
Tier Two product on the Preferred Drug List for recipients age 17
and under. If there is no history of use of Strattera® or a Tier One
agent in the recipient’s most recent 90-day drug history, Strattera®
will require a preauthorization. However, Strattera® claims may be
adjudicated without a preauthorization based upon the following
exceptions:
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Strattera®
is considered a mental health drug, and therefore, grandfathered
for all recipients who are currently receiving it.
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If a claim
for Strattera® is submitted and the recipient (age 17 and under)
has had a history of receiving a Tier One Agent within the
previous 90-day period, the claim will adjudicate without a
preauthorization.
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If the
recipient is age 18 and over, the claim will adjudicate without
a preauthorization.
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Zyprexa®,
Zyprexa® IM
Zyprexa® and
ZyprexaÃ’
IM has been designated a Tier Two antipsychotic agent on the
Preferred Drug List, due to the manufacturer's warnings about
possible harmful metabolic side-effects. If there is no history of
use of ZyprexaÃ’
or ZyprexaÃ’
IM in the
recipient's most recent 120-day history OR if there is no
history of at least 42 days use of a Tier One agent in the
recipient's most recent 120-day drug history (looking only at claims
paid by Maryland Medical Assistance), Zyprexa® and
Zyprexa® IM will require prior authorization (PA). At the time of
PA, the call center will ascertain from the prescriber the
indication for Zyprexa's® use, including off-label
indications.
Abilify®
Abilify® has been
designated a Tier Two antipsychotic agent on the Preferred Drug
List. If there is no history of use of Abilify® in the
recipient’s most recent 120-day history OR if there is no history of
at least 42 days use of a Tier One agent in the recipient's most
recent 120-day drug history (looking only at claims paid by Maryland
Medical Assistance), Abilify® will require PA. At the
time of PA, the call center will ascertain from the prescriber the
indication for Abilify® use, including off-label
indications.
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Lunesta® is a non-preferred drug. However, no
prior authorization will be required if a recipient has a
history of at least 14 days of a preferred sedative hypnotic
drug during the preceding 30 days and there has been an interval
of at least 10 days between the Date of Service of the claim for
the preferred agent and the Date of Service of the new Lunesta®.
Refer to Page 8 of the Preferred Drug List for "Preferred"
options at:
http://www.providersynergies.com/services/documents/MDM_PDL.pdf
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Clinical prior authorization is required if
recipient doesn't meet the clinical criteria stated above.
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Recipients currently receiving Lunesta® will not
be required to meet the above clinical criteria as this class of
drugs is grandfathered.
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Quantities for all strengths are limited to one
per day for up to a 34-day supply.
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