NOTICES
Medical Assistance Program; Prior Authorization List
[35 Pa.B. 2827] This notice announces that the Department of Public Welfare (Department) will add an item to the Medical Assistance (MA) Program's list of items and services requiring prior authorization.
Section 443.6(b)(7) of the Public Welfare Code (62 P. S. § 443.6(b)(7)) authorizes the Department to add items and services to the list of services requiring prior authorization by publication of notice in the Pennsylvania Bulletin.
The MA Program will require prior authorization of prescriptions, including refills, for the following drugs, dispensed on and after May 16, 2005, when the quantity prescribed exceeds the limit established by the Department, as set for in the following table:
Therapy Class Medication Quantity Limit (QL) Per
30 Day Supply
Ace Inhibitors Altace (ramipril) 1.25mg, 2.5mg, 5mg, 10mg 60 units per 30 days Prinivil (lisinopril) all strengths 30 units per 30 days Univasc (moexipril) 7.5mg, 15mg 30 units per 30 days Vasotec (enalapril) all strengths 60 units per 30 days Zestril (lisinopril) all strengths 30 units per 30 days Angiotensin II Receptor Antagonists Atacand (candesartan) 4mg, 8mg, 16mg, 32mg 30 units per 30 days Atacand-HCT (candesartan/HCTZ) 16/12.5mg 60 units per 30 days Atacand-HCT (candesartan/HCTZ) 32/12.5mg 30 units per 30 days Avalide (irbesartan/HCTZ) 150/12.5mg 60 units per 30 days Avalide (irbesartan/HCTZ) 300/12.5mg 30 units per 30 days Avapro (irbesartan) 75mg, 150mg, 300mg 30 units per 30 days Benicar (olmesartan) 5mg, 20mg, 40mg 30 units per 30 days Benicar-HCT (olmesartan/HCTZ) 30 units per 30 days Cozaar (losartan) 25mg, 50mg, 100mg 30 units per 30 days Diovan (valsartan) 40mg, 80mg, 160mg, 320mg 30 units per 30 days Diovan-HCT (valsartan/HCTZ) 80/12.5mg, 160/25mg 30 units per 30 days Diovan-HCT (valsartan/HCTZ) 160/12.5mg 60 units per 30 days Hyzaar (losartan/HCTZ) 50/12.5mg, 100/25mg 30 units per 30 days Micardis (telmisartan) 20mg, 40mg, 80mg 30 units per 30 days Micardis-HCT(telmisartan/HCTZ) 40/12.5mg, 80/12.5mg, 80/25mg 30 units per 30 days Teveten (eprosartan) 400mg 60 units per 30 days Teveten (eprosartan) 600mg 30 units per 30 days Teveten-HCT (eprosartan/HCTZ) 600/12.5mg, 600/25mg 30 units per 30 days Asthma Agents Accolate (zafirlukast) 10mg, 20mg 60 units per 30 days Advair (fluticasone/salmeterol) 100/50, 250/50, 500/50 1 unit per 30 days Foradil Aerosolizer (formoterol) 1 box of 60 capsules per 30 days Pulmicort (budesonide) 1 unit per 30 days Serevent (salmeterol) Diskus 1 box per 30 days Singulair (montelukast) 4mg, 5mg, 10mg 30 units per 30 days Anticonvulsants Neurontin (gabapentin) 100mg, 300mg, 400mg, 600mg 180 units per 30 days Neurontin (gabapentin) 800mg 120 units per 30 days Neurontin (gabapentin) oral solution 2,160ml per 30 days Antidepressants Celexa (citalopram) 10mg, 20mg, 40mg 30 units per 30 days Celexa (citalopram) 10mg/5 ml solution 600ml per 30 days Cymbalta (duloxetine) 20mg 60 units per 30 days Cymbalta (duloxetine) 30mg, 60mg 30 units per 30 days Effexor (venlafaxine) 25mg, 37.5mg, 50mg, 75mg, 100mg 90 units per 30 days Effexor XR (venlafaxine extended release) 37.5mg 30 units per 30 days Effexor XR (venlafaxine extended release) 75mg 150 units per 30 days Effexor XR (venlafaxine extended release) 150mg 60 units per 30 days *Fluoxetine 10mg, 20mg 30 units per 30 days *Fluoxetine 20mg/5ml solution 600ml per 30 days *Fluoxetine 40mg 60 units per 30 days Lexapro (escitalopram) 5mg, 10mg, 20mg 30 units per 30 days Lexapro (escitalopram) 5mgl/5ml solution 750ml per 30 days *Paroxetine 10mg, 20mg, 40mg 30 units per 30 days *Paroxetine 30mg 60 units per 30 days Paxil (paroxetine) 10mg/5mg suspension 900ml per 30 days Paxil (paroxetine) 30mg 60 units per 30 days Paxil (paroxetine) 10mg, 20mg, 40mg 30 units per 30 days Paxil CR (paroxetine controlled release) 12.5mg 30 units per 30 days Paxil CR (paroxetine controlled release) 25mg, 37.5mg 60 units per 30 days Prozac (fluoxetine) 10mg, 20mg 30 units per 30 days Prozac (fluoxetine) 20mg/5ml solution 600ml per 30 days Prozac (fluoxetine) 40mg 60 units per 30 days Prozac (fluoxetine) 90mg 4 units per 28 days Wellbutrin SR (bupropion sustained release) 100mg,
150 mg, 200 mg60 units per 30 days Wellbutrin XL (bupropion extended release) 150mg, 300mg 30 units per 30 days Zoloft (sertraline) 25mg 30 units per 30 days Zoloft (sertraline) 50mg and 100mg 60 units per 30 days Antilipidemics Advicor (niacin extended release/lovastatin) all strengths 30 units per 30 days Altoprev (lovastatin extended release) 10mg, 20mg,
40mg, 60mg30 units per 30 days Caduet (amlodipine/atorvastatin) all strengths 30 units per 30 days Crestor (rosuvastatin) 5mg, 10mg, 20mg, 40mg 30 units per 30 days Lescol (fluvastatin) 20mg and 40mg 30 units per 30 days Lescol XL (fluvastatin extended release) 80mg 30 units per 30 days Lipitor (atorvastatin) 10mg, 20mg, 40mg, 80mg 30 units per 30 days *Lovastatin 10mg, 20mg 30 units per 30 days *Lovastatin 40mg 60 units per 30 days Mevacor (lovastatin) 10mg, 20mg 30 units per 30 days Mevacor (lovastatin) 40mg 60 units per 30 days Pravachol (pravastatin) 10mg, 20mg, 40mg, 80mg 30 units per 30 days Vytorin (ezetimibe/simvastatin) 10/10mg, 10/20mg,
10/40mg, 10/80mg30 units per 30 days Zetia (ezetimibe) 10mg 30 units per 30 days Zocor (simvastatin) 5mg, 10mg, 20mg, 40mg, 80mg 30 units per 30 days Calcium Channel Blockers Adalat CC (nifedipine) 30mg, 60mg, 90mg 30 units per 30 days Calan SR (verapamil sustained release) 120mg 30 units per 30 days Calan SR (verapamil sustained release) 180mg, 240mg 60 units per 30 days Cardene SR (nicardipine sustained release) 30mg, 60mg 60 units per 30 days Cardene SR (nicardipine sustained release) 45mg 60 units per 30 days Cardizem CD (diltiazem extended release) 120mg,
180mg, 300mg, 360mg30 units per 30 days Cardizem CD (diltiazem extended release) 240mg 60 units per 30 days Cardizem LA (diltiazem extended release) 120mg,
300mg, 360mg, 420mg30 units per 30 days Cardizem LA (diltiazem extended release) 180mg 90 units per 30 days Cardizem LA (diltiazem extended release) 240mg 60 units per 30 days Cardizem SR (diltiazem extended release) 60mg, 90mg 60 units per 30 days Cardizem SR (diltiazem extended release) 120mg 90 units per 30 days Covera HS (verapamil extended release) 180mg, 240mg 60 units per 30 days Dilacor XR (diltiazem extended release) 120mg, 180mg 30 units per 30 days Dilacor XR (diltiazem extended release) 240mg 60 units per 30 days Dynacirc (isradipine) 2.5mg, 5mg 60 units per 30 days Dynacirc CR (isradipine controlled release) 5mg 30 units per 30 days Dynacirc CR (isradipine controlled release) 10mg 60 units per 30 days Isoptin SR (verapamil sustained release) 120mg 30 units per 30 days Isoptin SR (verapamil sustained release) 180mg, 240mg 60 units per 30 days Lotrel (amlodipine/benazapril) 2.5/10mg, 5/10mg,
5/20mg, 10/20mg30 units per 30 days Norvasc (amlodipine) 5mg and 10mg 30 units per 30 days Plendil (felodipine) 2.5mg, 5mg, 10mg 30 units per 30 days Procardia XL (nifedipine extended release) 30mg 30 units per 30 days Procardia XL (nifedipine extended release) 60mg 60 units per 30 days Procardia XL (nifedipine extended release) 90mg 30 units per 30 days Sular (nisoldipine) 10mg, 20mg, 40mg 30 units per 30 days Sular (nisoldipine) 30mg 60 units per 30 days Tarka (trandolapril/verapamil) 1/240mg, 2/180mg,
2/240mg, 4/240mg30 units per 30 days Tiazac (diltiazem extended release) 120mg, 180mg,
240mg, 300mg, 360mg, 420mg30 units per 30 days Verelan (verapamil sustained release) 120mg,
180mg, 360mg30 units per 30 days Verelan (verapamil sustained release) 240mg 60 units per 30 days Verelan PM (verapamil sustained release) 100mg, 300mg 30 units per 30 days Verelan PM (verapamil sustained release) 200mg 60 units per 30 days Diabetes Agents Actos (pioglitazone) 15mg, 30mg, 45mg 30 units per 30 days Avandamet (rosiglitazone/metformin) 1/500mg, 2/500mg, 4/500mg, 2/1,000mg, 4/1,000mg 60 units per 30 days Avandia (rosiglitazone) 2mg, 4mg, 60 units per 30 days Avandia (rosiglitazone) 8mg 30 units per 30 days Gastrointestinal Agents Lotronex (alosetron) 0.5mg, 1mg 60 units per 30 days Zelnorm (tegaserod) 2mg, 6mg 60 units per 30 days Incontinence Agents Oxytrol (oxybutynin) 8 patches per 28 days Low Molecular Weight Heparins Arixtra (fondaparinux) 20 syringes per 30 days Fragmin (dalteparin) 20 syringes per 30 days Innohep (tinzaparin) 10 syringes per 30 days Lovenox (enoxaparin) 20 syringes per 30 days Migraine Amerge (naratriptan) 1mg, 2.5mg 9 units per 30 days Axert (almotriptan) 6.25mg, 12.5mg 6 units per 30 days Frova (frovatriptan) 2.5mg 9 units per 30 days Imitrex (sumatriptan) 0.5ml single-dose vials 10 vials per 30 days Imitrex (sumatriptan) 25mg, 50mg, 100mg tablets 18 units per 30 days Imitrex (sumatriptan) Injection Kit 4 kits (8 syringes) per 30 days Imitrex (sumatriptan) Nasal Spray 2 boxes (12 spray bottles) per 30 days Maxalt 5mg and 10mg, MLT 12 units per 30 days Migranal Nasal Spray (dihydroergotamine) 3 boxes (12ml) per 30 days Relpax (eletriptan) 20mg 12 units per 30 days Relpax (eletriptan) 40mg 6 units per 30 days Zomig (zolmitriptan) Nasal Spray 6 devices per 30 days Zomig, -ZMT (zolmitriptan) 2.5mg 12 units per 30 days Zomig, -ZMT (zolmitriptan) 5mg 6 units per 30 days Narcotic Analgesics Actiq (fentanyl transmucosal lozenges) all strengths 120 lollipops per 30 days *Butorphanol Nasal Spray 2 bottles (5ml) per 30 days Duragesic (fentanyl transdermal) 25mcg, 50mcg,
75mcg, 100mcg20 patches per 30 days Palladone (hydromorphone extended release) all strengths 30 units per 30 days Stadol (butorphanol) Nasal Spray 2 bottles (5ml) per 30 days Osteoporosis/Pagets Disease Actonel (risedronate) 35mg 4 units per 28 days Fosamax (alendronate) 35mg and 70mg tablets 4 units per 28 days Fosamax (alendronate) 70mg/75ml solution 300ml per 28 days Premenstrual Dysphoric Disorder Sarafem (fluoxetine) 10mg, 20mg 30 units per 30 days Psychotropics Abilify (aripiprazole) 5mg, 10mg, 15mg, 20mg, 30mg 30 units per 30 days Clozaril (clozapine) 100mg 270 units per 30 days Clozaril (clozapine) 25mg 90 units per 30 days FazaClo (clozapine) 100mg 270 units per 30 days FazaClo (clozapine) 25mg 90 units per 30 days Geodon (ziprasidone) 20mg, 60mg 90 units per 30 days Geodon (ziprasidone) 40mg, 80mg 60 units per 30 days Risperdal (risperidone) 0.25mg, 0.5mg, 1mg, 2mg,
3mg, 4mg60 units per 30 days Seroquel (quetiapine) 100mg 90 units per 30 days Seroquel (quetiapine) 200mg 120 units per 30 days Seroquel (quetiapine) 25mg 180 units per 30 days Seroquel (quetiapine) 300mg 60 units per 30 days Symbyax (olanzepine/fluoxetine) all strengths 30 units per 30 days Zyprexa (olanzapine) 2.5mg, 5mg, 7.5mg, 10mg,
15mg, 20mg, -Zydis30 units per 30 days Sedatives and Hypnotics Ambien (zolpidem) 5mg, 10mg 30 units per 30 days Lunesta (eszopiclone) 1mg, 2mg, 3mg 30 units per 30 days Sonata (zaleplon) 5mg 30 units per 30 days Sonata (zaleplon) 10mg 60 units per 30 days *Generic drug Fiscal Impact
Due to the claims processing time lag, no savings are anticipated for Fiscal-Year (FY) 2004-2005. For FY 2005-2006, savings are estimated at $1.309 million ($0.602 million in State funds).
Public Comment
Interested persons are invited to submit written comments regarding this notice to the Department of Public Welfare, Office of Medical Assistance Programs, c/o Deputy Secretary's Office, Attention: Regulations Coordinator, Room 515, Health and Welfare Building, Harrisburg, PA 17120. Comments received within 30 days will be reviewed and considered for any subsequent changes to these prior authorization requirements.
Persons with a disability who require an auxiliary aid or service may submit comments using the AT&T Relay Service at (800) 654-5984 (TDD users) or (800) 654-5988 (voice users).
ESTELLE B. RICHMAN,
SecretaryFiscal Note: 14-NOT-420. No fiscal impact; (8) recommends adoption. Implementation of the notice will generate savings to the General Fund beginning in FY 2005-2006. These savings have been included in the Governor's 2005-2006 proposed budget.
[Pa.B. Doc. No. 05-901. Filed for public inspection May 6, 2005, 9:00 a.m.]
No part of the information on this site may be reproduced for profit or sold for profit.This material has been drawn directly from the official Pennsylvania Bulletin full text database. Due to the limitations of HTML or differences in display capabilities of different browsers, this version may differ slightly from the official printed version.
