Kentucky Medicaid Pharmacy Preferred Drug List

1 2021 Magellan Health, Inc. All rights reserved. Magellan Medicaid Administration, part of the Magellan Rx Management division of Magellan Health, Inc. Kentucky Medicaid Pharmacy Program Single Preferred drug List (PDL) Effective: December 14, 2021 GENERAL DEFINITION OF TERMS Clinical 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 reported and/or appropriate clinical criteria to be satisfied before prior authorization is approved.

2 Prescriptions exceeding plan limitations such as a Quantity Limit (QL), Maximum Duration (MD), or Age Edit (AE), in addition to those subject to Clinical Criteria (CC), will require 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 Food and drug Administration (FDA) has approved to be both safe and effective. Medications where the quantity exceeds the FDA s maximum daily dose will require PA.

3 Prescriptions exceeding plan limitations will require PA. Medication with Maximum Duration (MD) Medications indicated will be available for a defined period ( , 60 days) per rolling year (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 the treatment of a chronic medical condition.

4 The following classes are examples of common maintenance drugs. Maintenance drugs, as determined by First Databank (FDB) or Medi-Span, can be processed for up to a 92 days supply for KY Medicaid recipients. ACE Inhibitors Lipotropics Beta Blockers Antidepressants COPD Agents Antipsychotics Diabetes Drugs Anticonvulsants To view the most current PA criteria, please go to To request a PA, please submit the Kentucky Medicaid Pharmacy Prior Authorization Form to the member s plan. Magellan Medicaid Administration/ Kentucky Website: Magellan Medicaid Administration Clinical Support Center: Phone 800-477-3071; Fax 800-365-8835 AE = Age Edits CC = Clinical Criteria MD = Medications with Maximum Duration QL = Quantity Limits Page 2 | Kentucky Medicaid Single Preferred drug List Effective December 14, 2021 I.

5 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 trandolapril Vasotec Zestril ACEI + Diuretic Combinations benazepril/HCTZ lisinopril/HCTZ Accuretic captopril/HCTZ enalapril/HCTZ fosinopril/HCTZ Lotensin HCT quinapril/HCTZ Vaseretic Zestoretic Angiotensin Receptor Blockers Entresto irbesartan losartan olmesartan valsartan Atacand Avapro Benicar candesartan Cozaar Diovan Edarbi eprosartan Micardis telmisartan ARB + Diuretic Combinations irbesartan/HCTZ losartan/HCTZ olmesartan/HCTZ valsartan/HCTZ Atacand HCT Avalide Benicar HCT

6 Candesartan/HCTZ Diovan HCT Edarbyclor Hyzaar Micardis HCT telmisartan/HCTZ Magellan Medicaid Administration/ Kentucky Website: Magellan Medicaid Administration Clinical Support Center: Phone 800-477-3071; Fax 800-365-8835 AE = Age Edits CC = Clinical Criteria MD = Medications with Maximum Duration QL = Quantity Limits Page 3 | Kentucky Medicaid Single Preferred drug List Effective December 14, 2021 I. CARDIOVASCULAR drug Class Preferred Agents Non- Preferred Agents Angiotensin Modulator + CCB Combinations amlodipine /benazepril valsartan/ amlodipine valsartan/ amlodipine /HCTZ Azor Exforge Exforge HCT Lotrel olmesartan/ amlodipine olmesartan/ amlodipine /HCTZ Tarka Tribenzor telmisartan/ amlodipine verapamil/trandolapril Anti-Anginal & Anti-Ischemic Agent ranolazine ER Corlanor CC Ranexa Oral Anti-Arrhythmics amiodarone 100.

7 200 mg disopyramide dofetilide flecainide mexiletine propafenone quinidine sulfate Sorine sotalol sotalol AF amiodarone 400 mg Betapace Betapace AF Multaq Norpace Norpace CR Pacerone propafenone SR/ER quinidine gluconate ER Rythmol SR Sotylize CC Tikosyn Direct Renin Inhibitors N/A aliskiren Tekturna Tekturna HCT Beta Blockers atenolol bisoprolol metoprolol tartrate metoprolol succinate ER nadolol propranolol propranolol ER acebutolol betaxolol Bystolic Corgard Hemangeol Inderal LA Inderal XL Innopran XL Kapspargo Lopressor nebivolol pindolol Tenormin timolol Toprol XL Magellan Medicaid Administration/ Kentucky Website: Magellan Medicaid Administration Clinical Support Center: Phone 800-477-3071; Fax 800-365-8835 AE = Age Edits CC = Clinical Criteria MD = Medications with Maximum Duration QL = Quantity Limits Page 4 | Kentucky Medicaid Single Preferred drug List Effective December 14, 2021 I.

8 CARDIOVASCULAR drug Class Preferred Agents Non- Preferred Agents Beta Blockers + Diuretic Combinations atenolol/chlorthalidone bisoprolol/HCTZ Lopressor HCT metoprolol tartrate/HCTZ nadolol/bendroflumethiazide propranolol/HCTZ Tenoretic Ziac Alpha/Beta Blockers carvedilol labetalol carvedilol ER Coreg Coreg CR Calcium Channel Blockers (DHP) amlodipine nifedipine ER/SA/SR Adalat CC felodipine ER isradipine Katerzia nicardipine nifedipine IR CC nimodipine CC nisoldipine ER Norvasc Nymalize CC Procardia Procardia XL Sular ER Calcium Channel Blockers (Non-DHP) Cartia XT diltiazem diltiazem ER/CD Dilt-XR Taztia XT Tiadylt ER verapamil verapamil ER (except 360 mg capsules) Calan SR Cardizem Cardizem CD Cardizem LA diltiazem ER (generic Cardizem LA )

9 Matzim LA Tiazac ER verapamil ER 360 mg capsules verapamil ER PM Verelan Verelan PM Pulmonary Arterial Hypertension (PAH) Agents Alyq CC, QL ambrisentan CC sildenafil CC tadalafil CC, QL Tracleer tablets CC Ventavis CC Adcirca QL Adempas bosentan tablets Letairis Opsumit Orenitram ER Revatio Tracleer 32 mg tablets for suspension CC Tyvaso Uptravi QL Magellan Medicaid Administration/ Kentucky Website: Magellan Medicaid Administration Clinical Support Center: Phone 800-477-3071; Fax 800-365-8835 AE = Age Edits CC = Clinical Criteria MD = Medications with Maximum Duration QL = Quantity Limits Page 5 | Kentucky Medicaid Single Preferred drug List Effective December 14, 2021 I.

10 CARDIOVASCULAR drug Class Preferred Agents Non- Preferred Agents Lipotropics: Bile Acid Sequestrants cholestyramine cholestyramine light colestipol tablets Prevalite colesevelam Colestid colestipol granules/packets Questran Questran Light WelChol Lipotropics: Fibric Acid Derivatives fenofibrate nanocrystallized (generic Tricor ) fenofibric acid (generic Trilipix DR) gemfibrozil Antara fenofibrate (generic Lipofen , Fenoglide ) fenofibric acid (generic Fibricor ) Fenoglide Fibricor Lipofen Lopid TriCor Trilipix DR Lipotropics: Other ezetimibe niacin ER omega-3 acid ethyl esters icosapent ethyl Juxtapid CC Lovaza Nexletol CC, AE, QL Nexlizet CC, AE, QL Niaspan ER Praluent CC Repatha CC Vascepa Zetia Lipotropics.