Transcription
Kentucky Medicaid Pharmacy Program Single Preferred Drug List (PDL)Effective: June 3, 2022GENERAL DEFINITION OF TERMSClinical Criteria (CC) – Due to the nature of some medications, prior authorization (PA) is required for the medication to be covered.Medications with this indicator may require prior use of a different medication or drug product, a qualifying diagnosis to be reportedand/or appropriate clinical criteria to be satisfied before prior authorization is approved. Prescriptions exceeding plan limitationssuch as a Quantity Limit (QL), Maximum Duration (MD), or Age Edit (AE), in addition to those subject to Clinical Criteria (CC), willrequire additional approval. All non-preferred agents require prior authorization.Quantity Limits (QL) – Quantity limits have been placed on medications to be consistent with the maximum dosage that the Foodand Drug Administration (FDA) has approved to be both safe and effective. Medications where the quantity exceeds the FDA’smaximum daily dose will require PA. Prescriptions exceeding plan limitations will require PA.Medication with Maximum Duration (MD) – Medications indicated will be available for a defined period (e.g., 60 days) per rollingyear (365 days) before requiring a new or additional PA.Age Edit (AE) – Medications indicated are available for members above or below a given age without PA.Maintenance Drugs – Maintenance drugs are medications that generally require regular, long-term use and are prescribed for thetreatment of a chronic medical condition. The following classes are examples of common maintenance drugs. Maintenance drugs, asdetermined by First Databank (FDB) or Medi-Span, can be processed for up to a 92 days’ supply for KY Medicaid recipients. ACE Inhibitors Beta Blockers COPD Agents Diabetes Drugs Lipotropics Antidepressants Antipsychotics AnticonvulsantsTo view the most current PA criteria, please go to lic/home.xhtml.To request a PA, please submit the Kentucky Medicaid Pharmacy Prior Authorization Form to the member’s plan. 2022 Magellan Health, Inc. All rights reserved.Magellan Medicaid Administration, part of the Magellan Rx Management division of Magellan Health, Inc.
Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/Magellan Medicaid Administration Clinical Support Center: Phone 800-477-3071; Fax 800-365-8835I.CARDIOVASCULARDrug ClassPreferred AgentsACE miprilACEI Angiotensin ReceptorBlockersEntresto irbesartanlosartanolmesartanvalsartanARB mesartan/HCTZvalsartan/HCTZAE Age EditsCC Clinical CriteriaMD Medications withMaximum DurationPage 2 Kentucky Medicaid Single Preferred Drug ListNon-Preferred AgentsAccupril Altace captoprilenalapril solutionEpaned CCfosinoprilLotensin moexiprilperindoprilPrinivil Qbrelis CC, QLtrandolaprilVasotec Zestril Accuretic n HCT quinapril/HCTZVaseretic Zestoretic Atacand Avapro Benicar candesartanCozaar Diovan Edarbi eprosartanMicardis telmisartanAtacand HCT Avalide Benicar HCT candesartan/HCTZDiovan HCT Edarbyclor Hyzaar Micardis HCT telmisartan/HCTZQL Quantity LimitsEffective June 3, 2022
Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/Magellan Medicaid Administration Clinical Support Center: Phone 800-477-3071; Fax 800-365-8835I.CARDIOVASCULARDrug ClassPreferred AgentsNon-Preferred AgentsAngiotensin Modulator amlodipine/benazeprilCCB ne/HCTZAnti-Anginal & AntiIschemic AgentOral Anti-Arrhythmicsranolazine ERDirect Renin InhibitorsN/ABeta Blockersatenololbisoprololmetoprolol tartratemetoprolol succinate ERnadololpropranololpropranolol ERAE Age EditsAzor Exforge Exforge HCT Lotrel ka Tribenzor or CCRanexa amiodarone 400 mgBetapace Betapace AF Multaq Norpace Norpace CRPacerone propafenone SR/ERquinidine gluconate ERRythmol SR Sotylize CCTikosyn aliskirenTekturna Tekturna HCT acebutololbetaxololBystolic Corgard Hemangeol Inderal LAInderal XLInnoPran XL Kapspargo Lopressor nebivololpindololTenormin timololToprol XL amiodarone 100, 200 enonequinidine sulfateSorine sotalolsotalol AFCC Clinical CriteriaMD Medications withMaximum DurationPage 3 Kentucky Medicaid Single Preferred Drug ListQL Quantity LimitsEffective June 3, 2022
Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/Magellan Medicaid Administration Clinical Support Center: Phone 800-477-3071; Fax 800-365-8835I.CARDIOVASCULARDrug ClassPreferred AgentsBeta Blockers lol/HCTZAlpha/Beta BlockerscarvedilollabetalolNon-Preferred AgentsLopressor HCTmetoprolol l/HCTZTenoretic Ziac carvedilol ERCoreg Coreg CR Adalat CC felodipine ERisradipineKaterzia levamlodipinenicardipinenifedipine IR CCnimodipine CCnisoldipine ERNorliqva Norvasc Nymalize CCProcardia Procardia XL Sular ERCalan SRCardizem Cardizem CD Cardizem LA diltiazem ER (generic Cardizem LA )Matzim LA Tiazac ER verapamil ER 360 mg capsulesverapamil ER PMVerelan Verelan PM Adcirca QLAdempas bosentan tabletsLetairis Opsumit Orenitram ER sildenafil CCTracleer 32 mg tablets for suspension CCTyvaso Uptravi QLCalcium Channel Blockers amlodipine(DHP)nifedipine ER/SA/SRCalcium Channel Blockers Cartia XT(Non-DHP)diltiazemdiltiazem ER/CDDilt-XRTaztia XT Tiadylt ER verapamilverapamil ER (except 360 mg capsules)Pulmonary ArterialHypertension (PAH)AgentsAE Age EditsAlyq CC, QLambrisentan CCRevatio CCtadalafil CC, QLTracleer tablets CCVentavis CCCC Clinical CriteriaMD Medications withMaximum DurationPage 4 Kentucky Medicaid Single Preferred Drug ListQL Quantity LimitsEffective June 3, 2022
Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/Magellan Medicaid Administration Clinical Support Center: Phone 800-477-3071; Fax 800-365-8835I.CARDIOVASCULARDrug ClassPreferred AgentsLipotropics: Bile AcidSequestrantscholestyraminecholestyramine lightcolestipol tabletsPrevalite Lipotropics: Fibric AcidDerivativesfenofibrate nanocrystallized (generic Tricor )fenofibric acid (generic Trilipix DR)gemfibrozilLipotropics: Otherezetimibeniacin ERomega-3 acid ethyl estersLipotropics: Statinsatorvastatin QLlovastatin QLpravastatin QLrosuvastatin QLsimvastatin QLPlatelet AggregationInhibitorsBrilinta cilostazolclopidogreldipyridamoleprasugrelAE Age EditsCC Clinical CriteriaMD Medications withMaximum DurationPage 5 Kentucky Medicaid Single Preferred Drug ListNon-Preferred AgentscolesevelamColestid colestipol granules/packetsQuestran Questran Light Welchol Antara fenofibrate (generic Lipofen , Fenoglide )fenofibric acid (generic Fibricor )Fenoglide Fibricor Lipofen Lopid TriCor Trilipix DRicosapent ethylJuxtapid CCLovaza Nexletol CC, AE, QLNexlizet CC, AE, QLNiaspan ERPraluent CCRepatha CCVascepa Zetia Altoprev QLamlodipine/atorvastatin CC, QLCaduet QLCrestor QLEzallor Sprinkle QLezetimibe/simvastatin QLfluvastatin QLfluvastatin ER QLLescol QLLescol XL QLLipitor QLLivalo QLPravachol QLVytorin QLZocor QLZypitamag QLaspirin/dipyridamoleEffient Plavix Zontivity QL Quantity LimitsEffective June 3, 2022
Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/Magellan Medicaid Administration Clinical Support Center: Phone 800-477-3071; Fax 800-365-8835I.CARDIOVASCULARDrug ClassPreferred AgentsAnticoagulantsII.Non-Preferred AgentsEliquis enoxaparinJantoven Pradaxa warfarinXarelto Arixtra fondaparinuxFragmin Lovenox Savaysa Xarelto granules for suspensionGASTROINTESTINALDrug ClassPreferred AgentsAnti-Emetics: OtherNon-Preferred Agentsmeclizinemetoclopramide oral solution, tabletsprochlorperazine tabletspromethazine syrup, tabletspromethazine/Promethegan 12.5, 25 mg suppositoriesscopolamine patchesOral Anti-Emetics: 5-HT3 ondansetronAntagonistsOral Anti-Emetics: NK-1AntagonistsaprepitantQLOral Anti-Emetics: Δ-9dronabinol CC, QLTHC DerivativesH2 Receptor Antagonists famotidineAE Age EditsCC Clinical CriteriaMD Medications withMaximum DurationPage 6 Kentucky Medicaid Single Preferred Drug ListAntivert Bonjesta CCCompro Diclegis CC, QLdoxylamine/pyridoxine CC, QLGimoti CC, QLmetoclopramide ODTprochlorperazine suppositoriespromethazine/Promethegan 50 mg suppositoriesReglan Tigan Transderm-Scop trimethobenzamideAloxi QLgranisetronSancuso CC, QLZofran Zuplenz Akynzeo QLEmend QLVarubi CCMarinol CC, QLcimetidinenizatidinePepcid QL Quantity LimitsEffective June 3, 2022
Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/Magellan Medicaid Administration Clinical Support Center: Phone 800-477-3071; Fax 800-365-8835II.GASTROINTESTINALDrug ClassPreferred AgentsProton Pump InhibitorsAnti-Ulcer ProtectantsH. pylori Treatmentesomeprazole magnesium capsuleslansoprazole capsules QLNexium suspension QLomeprazole capsules QLpantoprazole tablets QLAciphex QLDexilant QLDexlansoprazole DR capsulesesomeprazole suspension QLlansoprazole ODT QLNexium capsules QLomeprazole/sodium bicarbonate QLpantoprazole suspension QLPrevacid QLPrilosec QLProtonix QLrabeprazole QLZegerid QLCarafate tabletsCytotec sucralfate suspensionHelidac QLlansoprazole/amoxicillin/clarithromycin QLOmeclamox-Pak QLTalicia Anaspaz chlordiazepoxide/clidiniumCuvposa Dartisla ODTDonnatal Glycate glycopyrrolate oral solutionHyosyne Levsin Librax Oscimin Phenohytro anthelineActigall Bylvay CC, QLChenodal Cholbam Livmarli CC, QLOcaliva CC, QL, AEReltone Urso , Urso Forte diphenoxylate with atropine liquidLomotil Motofen Mytesi CC, QLopiumCarafate suspensionmisoprostolsucralfate tabletsPylera zglycopyrrolatehyoscyaminemethscopolamineNuLev Bile Saltsursodiol capsules, tabletsAntidiarrhealsdiphenoxylate with atropine tabletsloperamideAE Age EditsNon-Preferred AgentsQLCC Clinical CriteriaMD Medications withMaximum DurationPage 7 Kentucky Medicaid Single Preferred Drug ListQL Quantity LimitsEffective June 3, 2022
Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/Magellan Medicaid Administration Clinical Support Center: Phone 800-477-3071; Fax 800-365-8835II.GASTROINTESTINALDrug ClassPreferred AgentsUlcerative Colitis AgentsLaxatives and CatharticsGI Motility AgentsNon-Preferred AgentsApriso balsalazideLialda mesalamine enema (generic Rowasa )mesalamine suppository (generic Canasa )Pentasa sulfasalazinesulfasalazine EC/DRAsacol HDAzulfidine Azulfidine EN-tabs budesonide ER (generic Uceris )Canasa Colazal Delzicol Dipentum mesalamine oral formulations (generics of Apriso ,Asacol HD, Delzicol , Pentasa and Lialda )Rowasa , sfRowasa Uceris lactulose solution (including Constulose , Enulose , Generlac)alvimopanMoviPrep Clenpiq polyethylene glycol (PEG) 3350 bottleEntereg PEG 3350/electrolyte solution for reconstitution (includingGoLYTELY GaviLyte-C , GaviLyte-G , GaviLyte-N )Kristalose PEG 3350/electrolyte solution with flavor packs (including TriLyte NuLytely with flavor packets)OsmoPrep TabletsPEG 3350 powder packetsPEG-3350, sodium sulfate, sodium chloride,potassium chloride, sodium ascorbate and ascorbicacid for oral solution (generic for MoviPrep )Plenvu powder packetsSuprep Sutab TriLyte Amitiza CC, AE, QLalosetron CC, AE, QLLinzess CC, AE, QLLotronex CC ,AE, QLMovantik CC, AE, QLlubiprostone AE, QLMotegrity AE, QLRelistor CC, AE, QLSymproic CC , AE, QLTrulance AE, QLViberzi CC, AE, ,QLIII.RESPIRATORYDrug ClassAntibiotics, InhaledAE Age EditsPreferred AgentsNon-Preferred AgentsBethkis QLKitabis Pak QLtobramycin inhalation solution (generic for TOBI ) QLCC Clinical CriteriaMD Medications withMaximum DurationPage 8 Kentucky Medicaid Single Preferred Drug ListArikayce CC, QLCayston QLTOBI QLTOBI Podhaler QLtobramycin inhalation solution (generic forBethkis and Kitabis PakTM) QLQL Quantity LimitsEffective June 3, 2022
Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/Magellan Medicaid Administration Clinical Support Center: Phone 800-477-3071; Fax 800-365-8835III.RESPIRATORYDrug ClassPreferred AgentsNon-Preferred AgentsMinimally SedatingAntihistaminescetirizine oral solution/syruplevocetirizine tabletsClarinex Clarinex-D 12 Hrdesloratadinelevocetirizine solutionIntranasal Antihistaminesand AnticholinergicsShort-Acting Beta2Adrenergic Agonistsazelastine 0.1%, 0.15%ipratropium nasal sprayalbuterol inhalation solution QLalbuterol low-dose inhalation solution QLProAir HFA QLterbutaline tablets QLLong-Acting Beta2Adrenergic AgonistsSerevent Diskus QLBeta Agonists:Combination ProductsAdvair Diskus QLAdvair HFA QLDulera QLSymbicort QLCOPD Agentsalbuterol-ipratropium inhalation solution QLAnoro Ellipta QLAtrovent HFA QLBevespi Aerosphere QLCombivent Respimat QLipratropium inhalation solution QLSpiriva HandiHaler QLStiolto Respimat QLInhaled CorticosteroidsAsmanex Twisthaler QLbudesonide inhalation suspension AE, QLFlovent HFA QLolopatadinePatanase albuterol HFA QLalbuterol oral syrup, tablets QLalbuterol ER tablets QLlevalbuterol HFA QLlevalbuterol inhalation solution QLmetaproterenol oral syrup QLProAir Digihaler QLProAir RespiClick QLProventil HFA QLVentolin HFA QLXopenex QLXopenex HFA QLarformoterol CC, QLBrovana CC, QLFormoterol CC, QLPerforomist CC, QLStriverdi Respimat QLAirDuo Digihaler CC, QLAirDuo RespiClick CC, Q, AEBreo Ellipta QLbudesonide/formoterol QLfluticasone/salmeterol QLWixela Inhub QLBreztri Aerosphere QLDaliresp CC, QLDuaklir Pressair Incruse Ellipta QLLonhala Magnair CC, QLSpiriva Respimat QLTrelegy Ellipta CC, QLTudorza Pressair QLYupelri CC, QLAlvesco QLArmonAir Digihaler QLArnuity Ellipta QLAsmanex HFA QLFlovent Diskus QLPulmicort Flexhaler QLPulmicort Respules QLQVAR RediHaler AE Age EditsCC Clinical CriteriaMD Medications withMaximum DurationPage 9 Kentucky Medicaid Single Preferred Drug ListQL Quantity LimitsEffective June 3, 2022
Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/Magellan Medicaid Administration Clinical Support Center: Phone 800-477-3071; Fax 800-365-8835III.RESPIRATORYDrug ClassPreferred AgentsNon-Preferred AgentsQLazelastine/fluticasone QLBeconase AQ QLbudesonideChildren’s Qnasl QLflunisolide QLmometasone QLNasonex QLOmnaris QLQnasl QLXhance CCZetonna QLAccolate QLSingulair QLzileuton ER QLzafirlukast QLZyflo QLZyflo CR QLepinephrine 0.3 mg (generic Adrenaclick ) QLepinephrine 0.15 mg (generic Adrenaclick ) QLEpiPen QLEpiPen Jr. QLSymjepi QLIntranasal Corticosteroids Dymista fluticasone propionate QLLeukotriene Modifiersmontelukast chewables, tablets QLmontelukast granules AE, QLSelf Injectable Epinephrine epinephrine 0.3 mg (generic EpiPen ) QLepinephrine 0.15 mg (generic EpiPen Jr. ) QLIV.CENTRAL NERVOUS SYSTEMDrug ClassAlzheimer’s AgentsAE Age EditsPreferred AgentsNon-Preferred Agentsdonepezil 5 and 10 mg tablets, ODTExelon Patchmemantine tabletsrivastigmine capsulesCC Clinical CriteriaMD Medications withMaximum DurationPage 10 Kentucky Medicaid Single Preferred Drug ListAricept donepezil 23 mg tablets CCgalantaminegalantamine ERmemantine ERmemantine solutionNamzaric Namenda tabletsNamenda XR Razadyne rivastigmine patchQL Quantity LimitsEffective June 3, 2022
Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/Magellan Medicaid Administration Clinical Support Center: Phone 800-477-3071; Fax 800-365-8835IV.CENTRAL NERVOUS SYSTEMDrug ClassPreferred AgentsNon-Preferred AgentsMDAntianxiety Agentsalprazolam IR tabletsbuspironechlordiazepoxide MDdiazepam oral solution, tablets MDlorazepam MDAntidepressants: MAOIsN/AAntidepressants: Otherbupropionbupropion SRbupropion XL 150 mg, 300 mg tabletstrazodoneAntidepressants: SNRIsdesvenlafaxine succinate ER (generic Pristiq )venlafaxinevenlafaxine ER capsulesAE Age EditsCC Clinical CriteriaMD Medications withMaximum DurationPage 11 Kentucky Medicaid Single Preferred Drug Listalprazolam ER/XR MDalprazolam ODT MDalprazolam intensol MDAtivan MDclorazepate MDdiazepam Intensol MDdoxepin QL (generic Silenor )lorazepam intensol/oral concentrate MDLoreev XRMDmeprobamateoxazepam MDSilenor QLTranxene-T MDXanax MDXanax XRMDEmsam Marplan Nardil phenelzinetranylcypromineAplenzin bupropion XL 450 mg tabletsForfivo XL nefazodoneSpravato CC, AE, QLViibryd Trintellix Wellbutrin Wellbutrin SRWellbutrin XLdesvenlafaxine ER basedesvenlafaxine fumarate EREffexor XR Fetzima Khedezla Pristiq venlafaxine ER tabletsQL Quantity LimitsEffective June 3, 2022
Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/Magellan Medicaid Administration Clinical Support Center: Phone 800-477-3071; Fax 800-365-8835IV.CENTRAL NERVOUS SYSTEMDrug ClassPreferred AgentsAntidepressants: SSRIsNon-Preferred Agentscitalopramescitalopram tabletsfluoxetine capsules, solutionfluoxetine ERparoxetine tablets, suspensionsertraline tablets, capsules, solution, oral concentrateAntidepressants: Tricyclics amitriptylineclomipraminedoxepin concentrateimipramine hydrochloridemirtazapinenortriptyline capsuleAnticonvulsants: FirstGenerationAE Age EditsCelontin clobazam QLclonazepam tablets QLdiazepam rectal gel QLdivalproex delayed-releasedivalproex sodium ERdivalproex sprinkleethosuximidefelbamatePeganone phenobarbital CCphenytoin IR/ERprimidone CCvalproatevalproic acidValtoco QLCC Clinical CriteriaMD Medications withMaximum DurationPage 12 Kentucky Medicaid Single Preferred Drug ListCCBrisdelle Celexa escitalopram solutionfluoxetine 90 mg DR, tablets QLfluvoxaminefluvoxamine ERLexapro paroxetine capsulesparoxetine controlled release tabletsparoxetine ER tabletsPaxil tablets, suspensionPaxil CR tabletsPexeva Prozac Sarafem Zoloft tablets, solution, oral concentrateamoxapineAnafranil desipraminedoxepin capsules, tabletsimipramine pamoatemaprotilineNorpramin nortriptyline solutionPamelor protriptylineRemeron Surmontil Tofranil trimipramineclonazepam ODTDepakene Depakote Depakote ER Depakote SprinkleDiastat QLDilantin Felbatol Klonopin QLMysoline Nayzilam CC, QLOnfi QLPhenytek Sympazan CC, QLZarontin QL Quantity LimitsEffective June 3, 2022
Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/Magellan Medicaid Administration Clinical Support Center: Phone 800-477-3071; Fax 800-365-8835IV.CENTRAL NERVOUS SYSTEMDrug ClassPreferred AgentsNon-Preferred AgentsCC, QLAnticonvulsants: SecondGenerationBanzel Gabitril QLlamotrigine chewable tablets, tablets (except dose packs)levetiracetam ER QLlevetiracetam solution, tablets QLSabril CCtopiramate QLzonisamide epine tabletscarbamazepine ER capsules (generic Carbatrol )carbamazepine ER tabletsEquetro oxcarbazepine QLTegretol luoperazineAE Age EditsCC Clinical CriteriaMD Medications withMaximum DurationPage 13 Kentucky Medicaid Single Preferred Drug ListCC, QLBriviact Diacomit CC, QLElepsia XR QLEpidiolex CCEprontia Fintepla CC, QLFycompa QLKeppra solution, tablets QLKeppra XR QLlacosamide QLLamictal Lamictal ODT Lamictal XR QLlamotrigine dose packslamotrigine ER QLlamotrigine ODTQudexy XR QLrufinamide QLSpritam QLtiagabine QLTopamax QLtopiramate ER QLTrokendi XR QLvigabatrinVimpat QLXcopri CC, QLAptiom QLcarbamazepine suspensionCarbatrol Epitol Oxtellar XR QLTegretol tabletsTegretol XRTrileptal QLAdasuve molindonepimozideQL Quantity LimitsEffective June 3, 2022
Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/Magellan Medicaid Administration Clinical Support Center: Phone 800-477-3071; Fax 800-365-8835IV.CENTRAL NERVOUS SYSTEMDrug ClassPreferred AgentsSecond-GenerationAntipsychoticsNon-Preferred Agentstablets CC, QLAbilify oral formulations QLAbilify MyCite CC, QLaripiprazole ODT, oral solutionCaplyta CC, QLclozapine ODT QLClozaril QLFanapt QLFazaClo QLGeodon capsules QLInvega QLLybalvi CC, AE, QLolanzapine/fluoxetine CC, QLNuplazid CC, QLpaliperidone QLRexulti QLRisperdal QLSaphris CC, QLSecuado QLSeroquel QLSeroquel XR QLSymbyax CC, QLVersacloz QLZyprexa QLInvega Hafyera CC, AE, QLHaldol Decanoate QLHaldol Lactate QLPerseris ziprasidone injection QLZyprexa QLZyprexa Relprevv QLaripiprazoleasenapine CC, QLclozapine tablets CC, QLLatuda CC, QLolanzapine CC, QLquetiapine CC, QLquetiapine ER CC, QLrisperidone CC, QLVraylar CC, QLziprasidone capsules CC, QLAntipsychotics: Injectable Abilify Maintena CC, QLAristada ER CC, QLAristada Initio CC, QLfluphenazine decanoate CC, QLGeodon injection CC, QLhaloperidol decanoate CC, QLhaloperidol lactate CC, QLInvega Sustenna CC, QLInvega Trinza CC, QLolanzapine CC, QLRisperdal Consta CC, QLAE Age EditsCC Clinical CriteriaMD Medications withMaximum DurationPage 14 Kentucky Medicaid Single Preferred Drug ListQL Quantity LimitsEffective June 3, 2022
Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/Magellan Medicaid Administration Clinical Support Center: Phone 800-477-3071; Fax 800-365-8835IV.CENTRAL NERVOUS SYSTEMDrug ClassPreferred AgentsStimulants and RelatedAgentsAE Age EditsNon-Preferred AgentsCC, QLQLAdderall XR atomoxetine CC, QLConcerta CC, QLdexmethylphenidate CC, QLdexmethylphenidate ER CC, QLdextroamphetamine CC, QLguanfacine ER CC, QLMethylin solution cc, QLmethylphenidate solution, tablets CC, QLmixed amphetamine salts tablets CC, QLVyvanse capsules, chewable tablets CC, QLCC Clinical CriteriaMD Medications withMaximum DurationPage 15 Kentucky Medicaid Single Preferred Drug ListAdderall Adhansia XR QLAdzenys ER Adzenys XR-ODT QLamphetamine ER suspensionamphetamine sulfate QLAptensio XR QLAzstarys QLclonidine ER QLCotempla XR-ODT AE, QLDaytrana QLDesoxyn QLDexedrine QLdextroamphetamine ER QLdextroamphetamine solution QLdextroamphetamine sulfate tablets (generic forZenzedi ) QLDyanavel XR QLEvekeo QLEvekeo ODT QLFocalin QLFocalin XR QLIntuniv QLJornay PM QLMetadate ER QLmethamphetamine QLmethylphenidate CD (generic Metadate CD ) QLmethylphenidate chewable tablets QLmethylphenidate ER tablets QLmethylphenidate ER OROS (generic Concerta ) QLmethylphenidate LA (generic Ritalin LA ) QLmixed amphetamine salts ER capsules QLMydayis QLProCentra QLQelbree QLQuilliChew ER QLQuillivant XR QLRelexxii QLRitalin QLRitalin LA QLStrattera QLZenzedi QLQL Quantity LimitsEffective June 3, 2022
Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/Magellan Medicaid Administration Clinical Support Center: Phone 800-477-3071; Fax 800-365-8835IV.CENTRAL NERVOUS SYSTEMDrug ClassPreferred AgentsAnti-Migraine: 5-HT1Receptor AgonistsImitrex nasalrizatriptan QLrizatriptan ODT QLsumatriptan syringe, tablet, vial QLAnti-Migraine: CGRPInhibitorsAjovy CC, AE,QLEmgality 120 mg/mL CC, AE, QLUbrelvy CC, AE, QLDopamine Movement DisordersAustedo CC, AE, QLtetrabenazineProvigil CC, QLNarcolepsy AgentsAE Age EditsNon-Preferred AgentsQLCC Clinical CriteriaMD Medications withMaximum DurationPage 16 Kentucky Medicaid Single Preferred Drug Listalmotriptan QLAmerge QLeletriptan QLFrova QLfrovatriptan QLImitrex kit, vial, tablet QLMaxalt QLMaxalt-MLT QLnaratriptan QLOnzetra Xsail CC, AE, QLRelpax QLsumatriptan kit QLsumatriptan nasal spray QLsumatriptan/naproxen QLTreximet QLTosymra Zembrace SymTouch CC, QLzolmitriptan tablet, nasal spray QLzolmitriptan ODT QLZomig QLZomig-ZMT QLAimovig CC, AE, QLEmgality 100 mg/mL CC, AE, QLNurtec ODT CC, AE, QLReyvow CC, AE, QLQulipta CC, AE, QLMirapex ERNeupro Parlodel pramipexole ERropinirole ERIngrezza AE, QLXenazine armodafinil QLmodafinil QLNuvigil QLSunosi CC, QLWakix CC, QLXyrem CC, QLXywav CC, QLQL Quantity LimitsEffective June 3, 2022
Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/Magellan Medicaid Administration Clinical Support Center: Phone 800-477-3071; Fax 800-365-8835IV.CENTRAL NERVOUS SYSTEMDrug ClassPreferred AgentsNeuropathic Painduloxetine DR (generic Cymbalta )gabapentin QLLidoderm QLpregabalin CC, QLParkinson’s bidopalevodopa/carbidopa CRlevodopa/carbidopa henidylAE Age EditsCC Clinical CriteriaMD Medications withMaximum DurationPage 17 Kentucky Medicaid Single Preferred Drug ListNon-Preferred AgentsCymbalta Drizalma Sprinkle duloxetine (generic Irenka )Gralise Horizant lidocaine 5% patch CC, QLLyrica QLLyrica CR QLNeurontin QLpregabalin ER QLSavella ZTlido CC, QLAzilect carbidopaComtan Dhivy Duopa Gocovri Inbrija Kynmobi CC, QLLodosyn Nourianz CC QLOngentys CC, QLOsmolex ERrasagilineRytary Sinemet Sinemet CRStalevo Tasmar tolcaponeXadago CC, QLZelapar QL Quantity LimitsEffective June 3, 2022
Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/Magellan Medicaid Administration Clinical Support Center: Phone 800-477-3071; Fax 800-365-8835IV.CENTRAL NERVOUS SYSTEMDrug ClassPreferred AgentsSedative Hypnotic Agents temazepam 15 mg, 30 mgzolpidem MD, QLNon-Preferred AgentsMD, QLMD, QLAmbien Ambien CR MD, QLBelsomra MD, QLDayvigo MD, QLDoral MD, QLEdluar CC, MD, QLestazolam MD, QLeszopiclone MD, QLflurazepam MD, QLHalcion MD, QLHetlioz CC, QLHetlioz LQ CC, QLIntermezzo MD, QLLunesta MD, QLramelteon CC, MD, QLRestoril MD, QLRozerem CC, MD, QLSonata MD, QLtemazepam 7.5 mg, 22.5 mg MD, QLtriazolam MD, QLzaleplon MD, QLzolpidem ER MD, QLzolpidem SL MD, QLZolpimist MD, QLAmrix QL, MDbaclofen solution QLcarisoprodol QL, MDcarisoprodol compound QL, MDcyclobenzaprine ER QL, MDDantrium QLdantrolene QL, CCFexmid QL, MDFleqsuvyQLLorzone QLLyvispah QLmetaxalone QLNorgesic ForteRobaxin QLSkelaxin QLSoma QL, MDtizanidine capsules QLZanaflex QLEvrysdi CCSpinraza CCZolgensma CCSkeletal Muscle Relaxants baclofen QLchlorzoxazone QLcyclobenzaprine QLmethocarbamol QLorphenadrine QLtizanidine tablets QLSpinal Muscular AtrophyAE Age EditsN/ACC Clinical CriteriaMD Medications withMaximum DurationPage 18 Kentucky Medicaid Single Preferred Drug ListQL Quantity LimitsEffective June 3, 2022
Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/Magellan Medicaid Administration Clinical Support Center: Phone 800-477-3071; Fax 800-365-8835IV.CENTRAL NERVOUS SYSTEMDrug ClassPreferred AgentsTobacco CessationV.Non-Preferred AgentsQLQLbupropion SRChantix AE, QLnicotine buccal/gum/lozenge QLnicotine transdermal system QLNicotrol Inhaler QLNicotrol NS QLvarenicline AE, QLCommit NicoDerm QLNicoDerm CQ QLNicorelief QLNicorette QLNicotrol Patch QLANALGESICSDrug ClassPreferred AgentsNarcotic Agonist/AntagonistsNarcotics: Short-ActingAE Age EditsNon-Preferred AgentsN/Acodeine/APAP CC, AE, MD, QLhydrocodone/APAP CC, MD, QLhydrocodone/ibuprofen CC, MD, QLhydromorphone tablets CC, MD, QLmorphine concentrate, solution, tablets CC, MD, QLoxycodone solution, tablets CC, MD, QLoxycodone/APAP CC, MD, QLtramadol 50 mg CC, MD, AE, QLtramadol/APAP MD, AE, QLCC Clinical CriteriaMD Medications withMaximum DurationPage 19 Kentucky Medicaid Single Preferred Drug Listbutorphanol NSpentazocine/naloxone QLApadaz MD, QLAscomp with codeine CC, AE, QLbenzhydrocodone/APAP MD, QLbutalbital/APAP/caffeine/codeine CC, AE, QLbutalbital compound/codeine CC, AE, QLcarisoprodol/ASA/codeine MD, AE, QLcodeine MD, AE, QLdihydrocodeine bitartrate/APAP/caffeine MD, QLDilaudid MD, QLhydromorphone liquid, suppositories MD, QLlevorphanol MD, QLLortab MD, QLmeperidine solution, tablets MD, QLmorphine suppository MD, QLNucynta MD, QLOxaydo MD, QLoxycodone capsules, concentrate MD, QLoxycodone/APAP (generic for Primlev andProlate)MD, QLoxycodone/ASA MD, QLoxymorphone MD, QLPercocet MD, QLQdolo MD, AE, QLRoxicodone MD, QLSeglentis MD, AE, QLtramadol 100 mg MD, AE, QLtramadol solution MD, AE, QLUltracet MD, AE, QLUltram MD, AE, QLVicodin HP MD, QLQL Quantity LimitsEffective June 3, 2022
Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/Magellan Medicaid Administration Clinical Support Center: Phone 800-477-3071; Fax 800-365-8835V.ANALGESICSDrug ClassPreferred AgentsNarcotics: Long-ActingNon-Preferred AgentsButrans CC, QLAE, QLfentanyl transdermal 12, 25, 50, 75, 100 mcg CC, QLmorphine sulfate ER (generic MS Contin ) CC, QLtramadol ER (generic Ryzolt , Ultram ER) CC, AE, QLNarcotics: Fentanyl Buccal N/AProductsOpiate DependenceTreatmentsAE Age EditsBunavail AE, QLbuprenorphine AE, QLbuprenorphine/naloxone SL films AE, QLbuprenorphine/naloxone SL tablets AE, QLLucemyra AE, QLnaltrexone AEProbuphine AESublocade AE, QLSuboxone films AE, QLVivitrol AEZubsolv AE, QLCC Clinical CriteriaMD Medications withMaximum DurationPage 20 Kentucky Medicaid Single Preferred Drug ListBelbuca buprenorphine film AE, QLbuprenorphine patch QLConZip AE, QLDuragesic QLfentanyl transdermal 37.5, 62.5, 87.5 mcg , QLhydrocodone ER QLhydromorphone ER QLHysingla ER QLmethadone CC, QLmorphine sulfate SA (generic Ka
Page 2 Kentucky Medicaid Single Preferred Drug List Effective June 3, 2022 I. CARDIOVASCULAR Drug Class Preferred Agents Non-Preferred Agents ACE Inhibitors benazepril enalapril lisinopril quinapril ramipril Accupril Altace captopril enalapril solution Epaned CC fosinopril Lotensin moexipril perindopril Prinivil Qbrelis CC, QL
