South Carolina Medicaid Preferred Drug List

 

The following revisions to the Preferred Drug List (PDL) are effective with dates of service on or after August 1, 2012.

 

ANTICONVULSANTS, RECTAL PREPARATIONS

Preferred

Non-Preferred

DIASTAT                                                Added as Preferred

DIAZEPAM RECTAL

ATYPICAL ANTIPSYCHOTICS, LONG ACTING INJECTABLES

Preferred

Non-Preferred

INVEGA SUSTENNA                            Added as Preferred

ZYPREXA RELPREVV

RISPERDAL CONSTA                           Added as Preferred

 

ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS

Preferred

Non-Preferred

ADDERALL XR

AMPHETAMINE SALT COMBO ER

AMPHETAMINE SALT COMBO

DAYTRANA

CONCERTA

DESOXYN

DEXMETHYLPHENIDATE

DEXEDRINE SPANSULE

DEXTROAMPHETAMINE TABLET

FOCALIN

DEXTROAMPHETAMINE CAP ER

KAPVAY

FOCALIN XR

METHAMPHETAMINE

 

 



 

 

ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS (continued)

INTUNIV

METHYPHENIDATE ER (Generic Concerta)

METADATE CD

METHYPHENIDATE ER (Generic Ritalin LA)

METHYLPHENIDATE

METHYLIN                             Changed to Non-Preferred

METHYLPHENIDATE ER

NUVIGIL

RITALIN LA

PROCENTRA

STRATTERA

PROVIGIL

VYVANSE

RITALIN

 

RITALIN SR

LIPOTROPICS, STATINS

Preferred

Non-Preferred

ATORVASTATIN                                   Added as Preferred

ADVICOR                               Changed to Non-Preferred

LESCOL

ALTOPREV                             Changed to Non-Preferred

LESCOL XL

AMLODIPINE-ATORVASTATIN

LOVASTATIN

CADUET                                 Changed to Non-Preferred

PRAVASTATIN

CRESTOR†                             Changed to Non-Preferred

SIMCOR

LIPITOR                                  Changed to Non-Preferred

SIMVASTATIN

LIVALO

 

MEVACOR

 

PRAVACOL

 

VYTORIN

 

ZOCOR

 

Those patients already on Crestor® will be grandfathered.

CHOLESTEROL ABSORPTION INHIBITORS

Preferred

Non-Preferred

 

ZETIA‡                                    Changed to Non-Preferred

 

No PA required for Zetia®  if statin or fenofibrate within 90 days in patient history

BILE ACID SEQUESTERING RESINS  

Preferred

Non-Preferred

CHOLESTYRAMINE

COLESTID

CHOLESTYRAMINE LIGHT

COLESTIPOL GRANULES      Changed to Non-Preferred

COLESTIPOL TABLET

QUESTRAN

 

QUESTRAN LIGHT

 

WELCHOL‡                            Changed to Non-Preferred

 

No PA required for Welchol® if concurrent statin or intolerance to statin within 90 days in patient history.

 

 



 

 

FIBRIC ACID DERIVATIVES

Preferred

Non-Preferred

GEMFIBROZIL

TRICOR

ANTARA

FENOFIBRATE

TRILIPIX

FENOFIBRIC ACIDE

 

FIBRICOR

 

LIPOFEN

 

LOPID

 

LOVAZA‡                               Changed to Non-Preferred

 

TRIGLIDE

 

No PA required for Lovaza® if intolerance of Fenofibrate, Gemfibrozil or Niacin within 90 days in patient history.

BETA ADRENERGIC DEVICES, LONG ACTING METERED DOSE INHALERS

Preferred

Non-Preferred

FORADIL                                               Added as Preferred

ARCAPTA

SEREVENT

 

PANCREATIC ENZYMES

Preferred

Non-Preferred

CREON

PANCREAZE

PANCRELIPASE

 

ZENPEP                                                 Added as Preferred

 

PROTON PUMP INHIBITORS

Preferred

Non-Preferred

PANTOPRAZOLE

ACIPHEX

OMEPRAZOLE OTC

DEXILANT

OMEPRAZOLE RX

LANSOPRAZOLE

 

NEXIUM

 

PREVACID

 

PRILOSEC OTC

 

PROTONIX

 

ZEGERID OTC

 

 

 

 

 

 

 

 

 

 

 

 

GROWTH HORMONES

Preferred

Non-Preferred

NORDITROPIN

GENOTROPIN†                     Changed to Non-Preferred

NUTROPIN

HUMATROPE

 

OMNITROPE

 

SAIZEN

 

SEROSTIM

 

TEV-TROPIN

 

ZORBTIVE

 

Those patients already on Genotropin® will be grandfathered

 

 

The list above only reflects changes to the PDL.  To view the complete PDL, please refer to our website at http://southcarolina.fhsc.comPlease note that the Topical Acne Agents therapeutic class has been combined for your convenience and Topical Steroids are a new therapeutic class.

 

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

 

PA requests may be submitted online, via telephone, or fax to the Magellan Medicaid Administration Clinical Call Center.  To access the WebPA tool for online PA submission, visit http://southcarolina.fhsc.com, click on "Prescribers", then "WebPA".  New users will need to click on “UAC” in the right hand corner to request a User ID and Password.  The toll-free telephone and fax numbers for the Clinical Call Center are 866-247-1181 and 888-603-7696, respectively.  The Magellan Clinical Call Center telephone number is reserved for use by healthcare professionals and should not be provided to beneficiaries.  Magellan’s Beneficiary Call Centertelephone number for Pharmacy Services is 800-834-2680.

 

Any questions regarding this bulletin should be directed to your Program Representative in the Division of Pharmacy Services at (803) 898-2876.

 

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