Kentucky Medicaid External Clinical Criteria

1 2023 by Magellan Rx Management, LLC. All Rights Reserved. Kentucky Medicaid Single PDL Prior authorization (PA) Criteria Effective: July 6, 2023 TABLE OF CONTENT S INTRODUCTION .. 6 CARDIOVASCULAR: ANGIOTENSIN RECEPTOR MODULATORS .. 7 ANGIOTENSIN CONVERTING ENZYME (ACE) INHIBITORS .. 7 ANGIOTENSIN CONVERTING ENZYME (ACE) INHIBITORS + DIURETIC COMBINATIONS .. 8 ANGIOTENSIN RECEPTOR BLOCKERS (ARB) .. 8 ANGIOTENSIN RECEPTOR BLOCKERS (ARB) + DIURETIC COMBINATIONS .. 8 DIRECT RENIN INHIBITORS .. 9 CARDIOVASCULAR: ANTI-ANGINAL & ANTI-ISCHEMIC AGENTS .. 10 CARDIOVASCULAR: ANTIARRHYTHMICS (ORAL ANTI-ARRHYTHMICS) .. 11 CARDIOVASCULAR: BETA BLOCKERS .. 12 BETA BLOCKERS .. 12 BETA BLOCKERS + DIURETIC 13 ALPHA/BETA BLOCKER .. 13 CARDIOVASCULAR: CALCIUM CHANNEL BLOCKERS.

2 14 CALCIUM CHANNEL BLOCKERS; DIHYDROPYRIDINES (DHP) .. 14 CALCIUM CHANNEL BLOCKERS; NON-DIHYDROPYRIDINES (NON-DHP) .. 15 ANGIOTENSIN MODULATOR AND CALCIUM CHANNEL BLOCKER COMBINATIONS .. 15 CARDIOVASCULAR: ANTICOAGULANTS .. 16 CARDIOVASCULAR: PLATELET AGGREGATION INHIBITORS .. 17 CARDIOVASCULAR: PULMONARY ARTERIAL HYPERTENSION (PAH) AGENTS, ORAL AND INHALED .. 18 CARDIOVASCULAR: LIPOTROPICS .. 20 LIPOTROPICS: BILE ACID SEQUESTRANTS .. 21 LIPOTROPICS: FIBRIC ACID DERIVATIVES .. 22 LIPOTROPICS: OTHER .. 22 LIPOTROPICS: STATINS .. 22 GASTROINTESTINAL: ANTIEMETICS AND ANTIVERTIGO 24 ANTIEMETICS: OTHER .. 25 ORAL ANTI-EMETICS: 5-HT3 ANTAGONISTS .. 26 ORAL ANTI-EMETICS: NK-1 ANTAGONISTS .. 26 ORAL ANTI-EMETICS: -9-THC DERIVATIVES.

3 26 GASTROINTESTINAL: ANTIDIARRHEALS .. 27 GASTROINTESTINAL: ANTISPASMODICS/ANTICHOLINERGICS .. 28 AE = Age Edits CC = Clinical Criteria MD = Medications with Maximum Duration QL = Quantity Limits Page 2 | Kentucky Medicaid Single PDL Prior authorization (PA) Criteria Effective July 6, 2023 GASTROINTESTINAL: ANTI-ULCER PROTECTANTS .. 29 GASTROINTESTINAL: BILE SALTS .. 30 GASTROINTESTINAL: H. PYLORI 32 GASTROINTESTINAL: HISTAMINE II (H2) RECEPTOR BLOCKERS .. 33 GASTROINTESTINAL: LAXATIVES AND CATHARTICS .. 34 GASTROINTESTINAL: GI MOTILITY AGENTS .. 35 GASTROINTESTINAL: PROTON PUMP INHIBITORS .. 39 GASTROINTESTINAL: ULCERATIVE COLITIS AGENTS .. 40 RESPIRATORY: ANTIBIOTICS, INHALED .. 41 RESPIRATORY: MINIMALLY SEDATING ANTIHISTAMINES.

4 43 RESPIRATORY: TOBACCO CESSATION .. 44 RESPIRATORY: INTRANASAL RHINITIS AGENTS .. 45 INTRANASAL ANTIHISTAMINES AND ANTICHOLINERGICS .. 45 INTRANASAL CORTICOSTEROIDS .. 45 RESPIRATORY: LEUKOTRIENE INHIBITORS .. 47 RESPIRATORY: BETA-ADRENERGIC AGENTS .. 48 BETA AGONISTS: COMBINATION 48 LONG-ACTING BETA2 ADRENERGIC AGONISTS .. 49 SHORT-ACTING BETA2 ADRENERGIC AGONISTS .. 49 RESPIRATORY: SELF-INJECTABLE 50 RESPIRATORY: COPD AGENTS .. 51 RESPIRATORY: IMMUNOMODULATORS, 52 RESPIRATORY: INHALED CORTICOSTEROIDS .. 54 CENTRAL NERVOUS SYSTEM: ALZHEIMER S AGENTS .. 55 CENTRAL NERVOUS SYSTEM: ANTIANXIETY AGENTS .. 56 CENTRAL NERVOUS SYSTEM: 58 ANTICONVULSANTS: FIRST GENERATION .. 59 ANTICONVULSANTS: SECOND GENERATION .. 60 ANTICONVULSANTS: CARBAMAZEPINE DERIVATIVES.

5 61 CENTRAL NERVOUS SYSTEM: ANTIPSYCHOTICS: FIRST GENERATION (TYPICAL).. 62 CENTRAL NERVOUS SYSTEM: ANTIPSYCHOTICS: SECOND GENERATION (ATYPICAL) AND INJECTABLE .. 63 ANTIPSYCHOTICS: SECOND GENERATION (ATYPICAL) .. 68 ANTIPSYCHOTICS: 69 CENTRAL NERVOUS SYSTEM: DOPAMINE RECEPTOR AGONISTS .. 69 CENTRAL NERVOUS SYSTEM: PARKINSON S DISEASE (ANTIPARKINSON S AGENTS) .. 71 CENTRAL NERVOUS SYSTEM: MOVEMENT 74 CENTRAL NERVOUS SYSTEM: ANTIDEPRESSANTS .. 76 ANTIDEPRESSANTS: OTHER .. 77 ANTIDEPRESSANTS: SNRIS .. 77 ANTIDEPRESSANTS: 78 ANTIDEPRESSANTS: TRICYCLICS .. 78 AE = Age Edits CC = Clinical Criteria MD = Medications with Maximum Duration QL = Quantity Limits Kentucky Medicaid Single PDL Prior authorization (PA) Criteria Effective July 6, 2023 | Page 3 CENTRAL NERVOUS SYSTEM: ANTI-MIGRAINE: SEROTONIN 5HT1 RECEPTOR AGONISTS.

6 80 CENTRAL NERVOUS SYSTEM: ANTI-MIGRAINE: CGRP INHIBITORS .. 82 CENTRAL NERVOUS SYSTEM: STIMULANTS AND RELATED AGENTS .. 86 CENTRAL NERVOUS SYSTEM: NARCOLEPSY 90 CENTRAL NERVOUS SYSTEM: NEUROPATHIC PAIN .. 93 CENTRAL NERVOUS SYSTEM: SEDATIVE HYPNOTICS .. 95 CENTRAL NERVOUS SYSTEM: SKELETAL MUSCLE RELAXANTS .. 98 SPINAL MUSCULAR ATROPHY .. 100 ANALGESICS, NARCOTICS LONG (LONG-ACTING OPIOIDS) .. 104 ANALGESICS, NARCOTICS SHORT (SHORT-ACTING OPIOIDS).. 108 Clinical Criteria FOR SHORT ACTING AND LONG ACTING OPIOIDS .. 114 NARCOTIC ANALGESICS: FENTANYL CITRATE PRODUCTS .. 116 NARCOTIC AGONISTS/ANTAGONISTS .. 117 NON-STEROIDAL ANTI-INFLAMMATORY DRUGS (NSAIDS) .. 118 OPIOID DEPENDENCE TREATMENTS .. 121 ANTIFUNGALS, ORAL .. 122 ANTIVIRALS, ORAL.

7 125 ANTIVIRALS: HERPES .. 125 ANTIVIRALS: INFLUENZA .. 126 ORAL ANTIBIOTICS .. 127 ANTIBIOTICS: CEPHALOSPORINS 1ST GENERATION .. 130 ANTIBIOTICS: CEPHALOSPORINS 2ND GENERATION .. 130 ANTIBIOTICS: CEPHALOSPORINS 3RD GENERATION .. 130 ANTIBIOTICS: GASTROINTESTINAL (GI) .. 130 ANTIBIOTICS: MACROLIDES .. 130 ANTIBIOTICS: OXAZOLIDINONES .. 131 ANTIBIOTICS: PENICILLINS .. 131 ANTIBIOTICS: PLEUROMUTILINS .. 131 ANTIBIOTICS: QUINOLONES .. 131 ANTIBIOTICS: SULFONAMIDES, FOLATE ANTAGONIST .. 132 ANTIBIOTICS: TETRACYCLINES .. 132 ANTIBIOTICS, VAGINAL .. 133 ANTIRETROVIRALS: HIV/AIDS .. 134 HEPATITIS B AGENTS .. 138 HEPATITIS C AGENTS: INTERFERONS AND RIBAVIRINS .. 139 HEPATITIS C: INTERFERONS .. 139 HEPATITIS C: RIBAVIRINS .. 139 HEPATITIS C AGENTS: DIRECT-ACTING ANTIVIRALS.

8 140 DIABETES: INSULINS AND RELATED AGENTS .. 142 RAPID- AND SHORT-ACTING INSULINS .. 142 INTERMEDIATE-ACTING INSULINS .. 143 AE = Age Edits CC = Clinical Criteria MD = Medications with Maximum Duration QL = Quantity Limits Page 4 | Kentucky Medicaid Single PDL Prior authorization (PA) Criteria Effective July 6, 2023 LONG-ACTING INSULINS .. 143 DIABETES: GLP-1 RECEPTOR AGONISTS .. 144 DIABETES: DPP-4 INHIBITORS .. 145 DIABETES: SGLT2 INHIBITORS .. 146 DIABETES: ALPHA-GLUCOSIDASE INHIBITORS .. 147 DIABETES: METFORMINS .. 148 DIABETES: MEGLITINIDES .. 149 DIABETES: SULFONYLUREAS .. 150 DIABETES: THIAZOLIDINEDIONES (TZDS) .. 151 ENDOCRINE AND METABOLIC AGENTS: GLUCAGON AGENTS .. 152 ENDOCRINE AND METABOLIC AGENTS: GROWTH HORMONES.

9 153 ENDOCRINE AND METABOLIC AGENTS: GLUCOCORTICOIDS, ORAL (ORAL STEROIDS) .. 155 ENDOCRINE AND METABOLIC AGENTS: PANCREATIC ENZYMES .. 157 ENDOCRINE AND METABOLIC AGENTS: PROGESTINS FOR CACHEXIA .. 158 ENDOCRINE AND METABOLIC AGENTS: ANDROGENIC AGENTS .. 159 ENDOCRINE AND METABOLIC AGENTS: BONE RESORPTION SUPPRESSION AND RELATED AGENTS .. 160 ENDOCRINE AND METABOLIC AGENTS: UTERINE DISORDER TREATMENTS .. 161 162 MULTIPLE SCLEROSIS AGENTS .. 165 CYTOKINE AND CAM ANTAGONISTS .. 171 IMMUNOMODULATORS, ATOPIC DERMATITIS .. 186 BLOOD MODIFIERS: ANTIHYPERURICEMICS .. 190 BLOOD MODIFIERS: COLONY STIMULATING FACTORS .. 191 BLOOD MODIFIERS: ERYTHROPOIESIS STIMULATING AGENTS .. 192 BLOOD MODIFIERS: PHOSPHATE BINDERS .. 193 BLOOD MODIFIERS: THROMBOPOIESIS STIMULATING AGENTS.

10 195 OPHTHALMIC ANTIBIOTICS AND ANTIVIRALS .. 197 OPHTHALMIC ANTIVIRALS .. 197 OPHTHALMIC QUINOLONES .. 197 OPHTHALMIC ANTIBIOTICS, NON-QUINOLONES .. 198 OPHTHALMIC ANTIBIOTIC-STEROID COMBINATIONS .. 198 OPHTHALMICS FOR ALLERGIC CONJUNCTIVITIS .. 199 OPHTHALMIC ANTIHISTAMINES .. 199 OPHTHALMIC MAST CELL STABILIZERS .. 199 OPHTHALMICS, GLAUCOMA AGENTS .. 200 OPHTHALMIC PROSTAGLANDIN AGONISTS .. 200 OPHTHALMIC BETA BLOCKERS .. 201 OPHTHALMIC CARBONIC ANHYDRASE INHIBITORS .. 201 OPHTHALMIC COMBINATIONS FOR 201 OPHTHALMIC SYMPATHOMIMETICS .. 201 OPHTHALMICS, GLAUCOMA AGENTS (OTHER) .. 202 AE = Age Edits CC = Clinical Criteria MD = Medications with Maximum Duration QL = Quantity Limits Kentucky Medicaid Single PDL Prior authorization (PA) Criteria Effective July 6, 2023 | Page 5 OPHTHALMICS, ANTI-INFLAMMATORIES.