Preferred Drug List Update, Exceptions to Prescription Limit, Update to Synagis® (palivizumab) Reimbursement, Preferred Brand Medications and Certificate of Medical Necessity for Home Infusion Pharmacies

I. Preferred Drug List Update

The following revisions to the South Carolina Department of Health and Human Services (SCDHHS) Preferred Drug List (PDL) are effective with dates of service on or after January 1, 2014:

 

ANTIPARASITICS, TOPICAL

Preferred

Non-Preferred

PERMETHRIN, OTC†

EURAX®, CREAM/LOTION‡

ULESFIA®†

LINDANE‡

PERMETHRIN 5% CREAM†

MALATHION‡

SKLICE®†

NATROBA™‡

 

OVIDE®‡

 

SPINOSAD‡

Added as Preferred

Added as Non-Preferred

 

 

 

PANCREATIC ENZYMES

Preferred

Non-Preferred

CREON®

PANCREAZE®

PANCRELIPASE

PERTZYE®

ULTRESA®†

VIOKACE®

ZENPEP

 

 

 

Added as Preferred

 

SODIUM-GLUCOSE TRANSPORTER 2 (SGLT2) INHIBITORS

Preferred

Non-Preferred

INVOKANA™†

 

 

 

PA required if no claim for metformin in history.

 

ANTIFUNGALS, TOPICAL

Preferred

Non-Preferred

CICLOPIROX, CREAM/SOLUTION/SUSP†

BENSAL HP‡

CLOTRIMAZOLE,  CREAM/SOLUTION (RX)†

CNL 8 KIT‡

CLOTRIMAZOLE/BETAMETHASONE,CREAM/LOTION†

CICLODAN‡

ECONAZOLE†

CICLOPIROX, KIT/GEL/SHAMPOO‡

KETOCONAZOLE, CREAM/SHAMPOO†

ERTACZO‡

NYSTATIN, CREAM/OINTMENT†

EXELDERM‡

NYSTATIN/TRIAMCINOLONE, CREAM/OINTMENT†

EXTINA‡

 

KETOCONAZOLE FOAM‡

 

KETODAN ‡

 

LOPROX ‡

 

LOTRISONE CREAM‡

 

MENTAX‡

 

NAFTIN ‡

 

NIZORAL SHAMPOO‡

 

NYSTATIN POWDER‡

 

OXISTAT ‡

 

PEDIPIROX-4‡

 

PEDIADERM AF‡

 

PENLAC‡

 

VUSION‡

 

XOLEGEL‡

Added as Preferred

Added as Non-Preferred

 

 

GLUCOCORTICOIDS, ORAL   

Preferred

Non-Preferred

BUDESONIDE EC†

DEXAMETHASONE ELIXIR‡

CORTEF®†

DEXAMETHASONE INTENSOL‡

CORTISONE†

DEXPAK®‡

DEXAMETHASONE †

ENTOCORT® EC‡

HYDROCORTISONE†

FLO-PRED‡

METHYLPREDNISOLONE †

MEDROL ‡

ORAPRED/ORAPRED ODT† (Covered for ages 0-12 only)

MILLIPRED ‡

PREDNISOLONE SOLN†

RAYOS® TABLET DR‡

PREDNISOLONE SODIUM PHOSPHATE†

PREDNISONE INTENSOL‡

PREDNISONE †

VERIPRED™ 20‡

 

ZEMA-PAK‡

   

Added as Preferred

Added as Non-Preferred



ATTENTION DEFICIT HYPERACTIVITY DISORDER (ADHD) AGENTS

Preferred

Non-Preferred

ADDERALL XR®

ADDERALL®

AMPHETAMINE SALT COMBO

AMPHETAMINE SALTS COMBO XR

DEXMETHYLPHENIDATE IR

CONCERTA®

DEXTROAMPHETAMINE

DAYTRANA®

DEXTROAMPHETAMINE SR

DESOXYN®

FOCALIN XR®*

DEXEDRINE

INTUNIV®**

DEXTROSTAT

METADATE CD®

FOCALIN®

METHYLPHENIDATE

METHAMPHETAMINE

METHYLPHENIDATE ER/SR

METHYLIN® CHEW/SOLUTION

QUILLIVANT XR™†**

METHYLPHENIDATE LA

RITALIN LA®*

PROCENTRA SOLN/DEXTROAMPHET

STRATTERA®

ZENZEDI®

VYVANSE®*

 

 

 

Added as Preferred

*Generic Agents considered first line when appropriate

 

**Preferred for ages 6 years and older

 

 

 

 

BLADDER RELAXANTS, ANTISPASMODICS

Preferred

Non-Preferred

OXYBUTYNIN

DETROL

OXYTROL® TRANSDERMAL

DETROL LA®‡

TOVIAZ®

DITROPAN XL®

VESICARE®

ENABLEX®

 

FLAVOXATE‡

 

GELNIQUE® TRANSDERMAL

 

MYBETRIQ®

 

SANCTURA®

 

SANCTURA XR®

 

TOLTERODINE

 

TROSPIUM

 

TROSPIUM ER

 

‡Changed to Non-Preferred

 

 

The list above only reflects changes to the Preferred Drug List (PDL).  To view the complete Preferred Drug List (PDL), please refer to our website http://southcarolina.fhsc.com

Prescribers are strongly encouraged to write prescriptions for "preferred" products.  However, if a prescriber deems that a patient’s clinical status requires therapy with a PA-required drug, the prescriber (or his/her designated office personnel) is responsible for initiating the PA request.  A prospective, approved PA request will prevent rejection of prescription claims at the pharmacy due to the PA requirement.

All PA requests should be submitted via WebPA, telephone, or fax to the Magellan Medicaid Administration Clinical Call Center by the prescriber or the prescriber’s designated office personnel.  To access the WebPA tool, visit http://southcarolina.fhsc.com .  The toll-free telephone and fax numbers for the Clinical Call Center are 866-247-1181 and 888-603-7696, respectively.  The Magellan Medicaid Administration Clinical Call Center telephone number is reserved for use by healthcare professionals and should not be provided to beneficiaries.  (Magellan Medicaid Administration’s SC Medicaid beneficiary call centertelephone number for Pharmacy Services is 800-834-2680.  Providers may furnish the beneficiary call center telephone number to Medicaid beneficiaries for Pharmacy Services-related issues only.)

A pharmacy claim submitted for a PA-required product that has not been approved for Medicaid reimbursement will reject.  If this occurs, the pharmacist should contact the prescriber so that a determination can be made regarding whether a drug not requiring PA is clinically appropriate for the patient.

Questions regarding the PDL should be directed to Magellan Medicaid Administration’s Call Center at 866-254-1669.  

 

II.         Exceptions to Prescription Limit

In an effort to encourage adherence to high-value medications, SCDHHS will exempt the following classes of medications from the monthly prescription limit effective January 1, 2014.  Claims submitted for medications in these classes after January 2, 2014 will not accumulate to the base prescription limit of four (4) claims or the override limit of three (3) claims.  Pharmacies need not submit a “5” in the Prior Authorization Type Code field for these claims to pay.  Drug classes exempted from the prescription limit include:

  • Diabetic Therapies (Insulin, metformin, sulfonylureas, thiazolidinediones, DPP-4 inhibitors, GLP-1 receptor antagonists).
  • Cardiovascular Medications (Statins and other lipid lowering agents, antihypertensives, diuretics, antiarrhythmics, anticoagulants).
  • Behavioral Health Medications (Antipsychotics, antidepressants).
  • Anticonvulsants
  • Systemic Antibiotics and Antivirals

A complete list of the specific medications included will be available at http://southcarolina.fhsc.com .  SCDHHS will continue to evaluate additional medication classes, and other high value medication classes may be added in the future.

III.     Update to Synagis® (palivizumab) Reimbursement

 

SCDHHS has updated the reimbursement rate for Synagis® (palivizumab) for the 2013-2014 respiratory syncytial virus (RSV) season to AverageWholesale Price (AWP) minus 16%.  The new rate for the 100mg vial will be $2,488.43 and $1,317.82 for the 50mg vial.  This rate will be applied to all claims submitted for dates of service on or after October 15, 2013.  Future changes to the Synagis reimbursement rate will be communicated via the standard fee schedule update process and posted at www.scdhhs.gov .

 

SCDHHS will continue to cover Synagis only in accordance with the most recent edition of the American Academy of Pediatrics (AAP) guidelines for dates of service October 15 through March 31 every year.

 

IV.    Preferred Brand Medications

Effective with dates of service on or after January 1, 2014, SCDHHS will no longer require that the brand medication be dispensed when a generic is available for the following medications:

Avapro & Avalide

Phoslo

Diovan HCT

Prograf

Kadian

Tricor

Lescol

Valtrex

V. Certificate of Medical Necessity for Home Infusion Pharmacies

 

Effective for dates of service on or after January 1, 2014, home infusion pharmacies are no longer required to obtain a Medicaid Certificate of Medical Necessity (MCMN) for the following services, so long as the pharmacy obtains a valid prescription that includes the diagnosis for which therapy is being provided. 

 

  • Supplies or per diems related to IV/parenteral drug administration
  • Parenteral or enteral nutrition

The announcements in this Bulletin apply to services provided to beneficiaries who are enrolled in fee-for-service Medicaid or a Medical Home Network (MHN). Questions regarding specific authorization and coverage of this service by one of the Medicaid Managed Care Organizations (MCOs) should be directed to the managed care plan.  Claims for participants enrolled in either a Medical Homes Network or the fee-for-service program should be billed directly to Medicaid. 

If you have any questions regarding this policy, please contact the Provider Service Center at (888) 289-0709.  Thank you for your continued support of the South Carolina Healthy Connections Medicaid Program.

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