HEALTH AND HUMAN SERVICES COMMISSION TEXAS ...

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 23, 2013 HEPATITIS C AGENTS Preferred Agents Non‐Preferred Agents PA Criteria Protease Inhibitors INCIVEK (telaprevir) VICTRELIS (boceprevir) REBETOL solution ribavirin Ribavirin COPEGUS RIBAPAK RIBASPHERE 400, 600 mg ■ Treatment failure with preferred drugs within any subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs HYPOGLYCEMICS, INCRETIN MIMETICS/ENHANCERS Preferred Agents Non‐Preferred Agents PA Criteria Amylin Analogs SYMLIN (pramlintide) Patient must meet all of the following criteria: Incretin Enhancers ■ Diagnosis of diabetes mellitus ■ Age >18 years ■ HbA1C in past 6 months ■ No history of gastroparesis, neurologic manifestations of diabetes or recent treatment of hypoglycemia JENTADUETO (linagliptin/metformin) KOMBIGLYZE XR (saxagliptin/metformin) ONGLYZA (saxagliptin) TRADJENTA (linagliptin) JANUMET (sitagliptin/metformin) JANUMET XR (sitagliptin/metformin) JANUVIA (sitagliptin) JUVISYNC (sitagliptin/simvastatin) ■ Treatment failure with preferred drugs within any subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. January 23, 2013 Page 26 of 47
HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 23, 2013 HYPOGLYCEMICS, INCRETIN MIMETICS/ENHANCERS Preferred Agents Non‐Preferred Agents PA Criteria Incretin Mimetics BYETTA (exenatide) SYMLIN (pramlintide) BYDUREON (exenatide ER) VICTOZA (liraglutide) ■ Treatment failure with preferred drugs within any subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs HYPOGLYCEMICS, INSULIN Preferred Agents Non‐Preferred Agents PA Criteria HUMALOG vials (insulin lispro) HUMALOG MIX vials (insulin lispro/lispro protamine) LANTUS (insulin glargine) NOVOLIN (insulin) NOVOLOG (insulin aspart) NOVOLOG MIX (insulin aspart/aspart protamine) APIDRA (insulin glulisine) HUMALOG pens (insulin lispro) HUMALOG MIX pens (insulin lispro/lispro protamine) HUMULIN (insulin) LEVEMIR (insulin detemir) ■ Treatment failure with preferred drugs within any subclass ■ Contraindication to preferred drugs HYPOGLYCEMICS, MEGLITINIDES Preferred Agents Non‐Preferred Agents PA Criteria nateglinide PRANDIN (repaglinide) PRANDIMET (repaglinide/metformin) STARLIX (nateglinide) ■ Separate prescriptions for the individual components should be used instead of the combination drug. HYPOGLYCEMICS, TZD Preferred Agents Non‐Preferred Agents PA Criteria Thiazolinediones ACTOS (pioglitazone) AVANDIA (rosiglitazone) pioglitazone Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. January 23, 2013 Page 27 of 47
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HEALTH AND HUMAN SERVICES COMMISSION TEXAS ...

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