Connecticut Medicaid P&T Meeting Minutes

October 23, 2013

The meeting started at 6:00pm

Attendance

Present Members: DSS:

Carl Sherter, MD Jason Gott, RPh

Charles Thompson, MD James Zakszewski, RPh

Emmett Sullivan, RPh

Cynthia Conrad, MD

Manage Nissanka, MD

Kevin Chamberlin, PharmD

Karen McMillan, RN

Jeffrey Kamradt, MD

Absent Members: HP/Magellan:

Mark Defrancesco, MD Deborah Gallagher

Angelo DeFazio, RPh Jason Young, PharmD

Elizabeth Rodriguez, RN Margaret Stroczkowski

Andrew Lustbader, MD Melissa Chandler

Hilda Slivka, MD Heather Kissinger, PharmD (HID)

Stella Cretella Kathy Novak, RPh (Magellan)

Opening remarks:

Dr. Carl Sherter thanked the attendees for coming and called meeting to order at 6:00 pm. The

minutes from the previous meeting, held May 8, 2013, were unanimously approved by the

committee members present.

Public Presentations:

CT Psychiatric Society Testimony Paul Desan, MD, PhD

National Alliance on Mental Illness Testimony Daniela Giordano, MSW

Antidepressants, Other

- Pristiq Aniello Marotta, PharmD MBA

Pfizer

- Viibryd Bassam Awwa, M.D.

Anticonvulsants

- Vimpat Amy Dalsania, PharmD UCB

COPD Agents

- Tudorza and Daliresp Morris Papernik, MD FACP

Cytokine and CAM Antagonists

- Xeljanz Aniello Marotta, PharmD MBA

Pfizer

- Cimzia Amy Dalsania, PharmD UCB

Intranasal Rhinitis Agents

- QNASL Kristen Kau, MBA, PhD Teva

Oncology Agents, Oral

- Sutent, Bosulif, Inlyta, Xalkori Aniello Marotta, PharmD MBA

Pfizer

The rest of the scheduled speakers waived their right to speak because their product was

recommended as preferred on the PDL.

Therapeutic Class Reviews:

Note: Brand name drugs listed in bold font.

Antidepressants, Other

Dr. Paul Desan and Daniela Giordano provided public testimony, on behalf of CT Psychiatric

Society and NAMI respectively, for open access to mental health drugs. Aniello Marotta

testified to the committee for the inclusion of Pristiq, and Dr. Bassam Awwa spoke on behalf of

Viibryd. Cynthia Conrad motioned to accept the recommendations of Magellan, along with the

addition of Pristiq and Viibryd, as preferred. Charles Thompson seconded this motion, and it

passed unanimously.

ON Medicaid PDL: BUPROPION (ORAL), BUPROPION SR (ORAL), BUPROPION XL

(ORAL), MARPLAN (ORAL), MIRTAZAPINE ODT (ORAL), MIRTAZAPINE TABLET

(ORAL), PARNATE (ORAL), PHENELZINE (ORAL), PRISTIQ (ORAL), TRAZODONE

(ORAL), VENLAFAXINE ER CAPSULES (ORAL), VIIBRYD (ORAL), VIIBRYD DOSE

PACK (ORAL)

OFF Medicaid PDL: APLENZIN (ORAL), DESVENLAFAXINE ER (ORAL), EFFEXOR

XR (ORAL), EMSAM (TRANSDERMAL), FORFIVO XL (ORAL), NARDIL (ORAL),

NEFAZODONE (ORAL), OLEPTRO ER (ORAL), REMERON ODT (ORAL), REMERON

TABLET (ORAL), TRANYLCYPROMINE SULFATE (ORAL), VENLAFAXINE (ORAL),

VENLAFAXINE ER TABLETS (GENERIC) (ORAL), VENLAFAXINE ER TABLETS

(SCHWARZ) (ORAL), VENLAFAXINE ER TABLETS (UPSTATE) (ORAL),

WELLBUTRIN (ORAL), WELLBUTRIN SR (ORAL), WELLBUTRIN XL (ORAL)

Antipsychotics

Carl Sherter reminded the committee of their decision last year to have open access for this class

of medications. Cynthia Conrad motioned to make all drugs in this class preferred, and her

motion was seconded and passed unanimously by the committee.

ON Medicaid PDL: ABILIFY (INTRAMUSC), ABILIFY DISCMELT (ORAL), ABILIFY

MAINTENA (INTRAMUSC.), ABILIFY SOLUTION (ORAL), ABILIFY TABLET

(ORAL), AMITRIPTYLINE / PERPHENAZINE (ORAL), CHLORPROMAZINE (ORAL),

CLOZAPINE (ORAL), CLOZAPINE ODT (ORAL), CLOZARIL (ORAL), FANAPT

TABLET (ORAL), FANAPT TITRATION PACK (ORAL), FAZACLO (ORAL),

FLUPHENAZINE DECANOATE (INJECTION), FLUPHENAZINE ELIXIR/SOLN (ORAL),

FLUPHENAZINE TABLET (ORAL), GEODON (INTRAMUSC), GEODON (ORAL),

HALDOL (INJECTION), HALDOL DECANOATE (INTRAMUSC), HALOPERIDOL

(ORAL), HALOPERIDOL DECANOATE (INJECTION), HALOPERIDOL LACTATE

(INJECTION), HALOPERIDOL LACTATE CONC (ORAL), INVEGA (ORAL), INVEGA

SUSTENNA (INTRAMUSC), LATUDA (ORAL), LOXAPINE (ORAL), OLANZAPINE

(INTRAMUSC), OLANZAPINE ODT (ORAL), OLANZAPINE TABLET (ORAL),

OLANZAPINE/FLUOXETINE (ORAL), ORAP (ORAL), PERPHENAZINE (ORAL),

QUETIAPINE TABLETS (ORAL), RISPERDAL CONSTA (INTRAMUSC.), RISPERDAL

ODT (ORAL), RISPERDAL SOLUTION (ORAL), RISPERDAL TABLET (ORAL),

RISPERIDONE ODT (ORAL), RISPERIDONE SOLUTION (ORAL), RISPERIDONE

TABLET (ORAL), SAPHRIS (SUBLINGUAL), SEROQUEL (ORAL), SEROQUEL XR

(ORAL), SYMBYAX (ORAL), THIORIDAZINE (ORAL), THIOTHIXENE (ORAL),

TRIFLUOPERAZINE (ORAL), ZIPRASIDONE CAPSULE (ORAL), ZYPREXA

(INTRAMUSC), ZYPREXA (ORAL), ZYPREXA RELPREVV (INTRAMUSC),

ZYPREXA ZYDIS (ORAL)

OFF Medicaid PDL: NONE

Anticonvulsants

Amy Dalsania provided public testimony for the inclusion of Vimpat on the PDL. Emmett

Sullivan motioned to accept the recommendations as presented by Magellan. Cynthia Conrad

seconded, and the committee passed the motion unanimously.

ON Medicaid PDL: CARBAMAZEPINE CHEWABLE TABLET (ORAL),

CARBAMAZEPINE ER (GENERIC CARBATROL) (ORAL), CARBAMAZEPINE

SUSPENSION (ORAL), CARBAMAZEPINE TABLET (ORAL), CARBAMAZEPINE XR

(ORAL), CARBATROL (ORAL), CELONTIN (ORAL), CLONAZEPAM (ORAL),

DIASTAT (RECTAL), DIASTAT ACUDIAL (RECTAL), DILANTIN INFATAB (ORAL),

DIVALPROEX ER (ORAL), DIVALPROEX SPRINKLE (ORAL), DIVALPROEX TABLET

(ORAL), ETHOSUXIMIDE SYRUP (ORAL), FELBAMATE SUSPENSION (ORAL),

GABITRIL (ORAL), LAMOTRIGINE TABLET (ORAL), LAMOTRIGINE TABLET DOSE

PACK (ORAL), LEVETIRACETAM SOLUTION (ORAL), LEVETIRACETAM TABLETS

(ORAL), OXCARBAZEPINE SUSPENSION (ORAL), OXCARBAZEPINE TABLETS

(ORAL), PEGANONE (ORAL), PHENOBARBITAL ELIXIR (ORAL), PHENOBARBITAL

TABLET (ORAL), PHENYTOIN CAPSULE (ORAL), PHENYTOIN EXT CAPSULE

(GENERIC PHENYTEK) (ORAL), PHENYTOIN SUSPENSION (ORAL), PRIMIDONE

(ORAL), TOPIRAMATE SPRINKLE (ORAL), TOPIRAMATE TABLETS (ORAL),

VALPROATE SYRUP (ORAL), VALPROIC ACID (ORAL), VIMPAT SOLUTION

(ORAL), VIMPAT TABLET (ORAL), ZONISAMIDE (ORAL)

OFF Medicaid PDL: BANZEL SUSPENSION (ORAL), BANZEL TABLET (ORAL),

CLONAZEPAM ODT (ORAL), DEPAKENE CAPSULE (ORAL), DEPAKENE SYRUP

(ORAL), DEPAKOTE (ORAL), DEPAKOTE ER (ORAL), DEPAKOTE SPRINKLE

(ORAL), DIAZEPAM (RECTAL), DIAZEPAM DEVICE (RECTAL), DILANTIN (ORAL),

DILANTIN 30 MG CAPSULE (ORAL), DILANTIN SUSPENSION (ORAL), EQUETRO

(ORAL) ETHOSUXIMIDE CAPSULE (ORAL), FELBAMATE TABLET (ORAL), FELBATOL

SUSPENSION (ORAL), FELBATOL TABLET (ORAL), KEPPRA SOLUTION (ORAL),

KEPPRA TABLETS (ORAL), KEPPRA XR (ORAL), KLONOPIN TABLET (ORAL),

LAMICTAL ODT (ORAL), LAMICTAL ODT DOSE PACK (ORAL), LAMICTAL

TABLET (ORAL), LAMICTAL TABLET DOSE PACK (ORAL), LAMICTAL XR

(ORAL), LAMICTAL XR DOSE PACK (ORAL), LAMOTRIGINE XR (ORAL),

LEVETIRACETAM ER (ORAL), MYSOLINE (ORAL), ONFI SUSPENSION (ORAL),

ONFI TABLET (ORAL), OXTELLAR XR (ORAL), PHENYTEK (ORAL), PHENYTOIN

CHEWABLE TABLET (ORAL), POTIGA (ORAL), SABRIL POWDER PACK (ORAL),

SABRIL TABLET (ORAL), STAVZOR (ORAL), TEGRETOL SUSPENSION (ORAL),

TEGRETOL TABLET (ORAL), TEGRETOL XR (ORAL), TIAGABINE (ORAL),

TOPAMAX SPRINKLE (ORAL), TOPAMAX TABLETS (ORAL), TRILEPTAL

SUSPENSION (ORAL), TRILEPTAL TABLETS (ORAL), TROKENDI XR (ORAL),

ZARONTIN CAPSULE (ORAL), ZARONTIN SYRUP (ORAL), ZONEGRAN (ORAL)

Botulinum Toxins

Kevin Chamberlin motioned to accept the recommendations as presented for this class, and his

motion was seconded by Charles Thompson. The motion passed unanimously.

ON Medicaid PDL: BOTOX (INTRAMUSC)

OFF Medicaid PDL: BOTOX COSMETIC (INTRAMUSC), DYSPORT (INTRAMUSC),

MYOBLOC (INTRAMUSC), XEOMIN (INTRAMUSC)

COPD Agents

Morris Papernik provided testimony for the inclusion of Tudorza and Daliresp on the PDL. Carl

Sherter noted the benefits of Daliresp. Carl Sherter motioned to accept the recommendations as

presented, along with the addition of Daliresp to the PDL. His motion was seconded and passed

unanimously by the committee.

ON Medicaid PDL: ATROVENT HFA (INHALATION), COMBIVENT RESPIMAT

(INHALATION), DALIRESP (ORAL), DUONEB (INHALATION), IPRATROPIUM /

ALBUTEROL (INHALATION), IPRATROPIUM NEBULIZER (INHALATION), SPIRIVA

(INHALATION)

OFF Medicaid PDL: COMBIVENT (INHALATION), TUDORZA PRESSAIR

(INHALATION)

Cytokine and CAM Antagonists

Aniello Marotta provided public testimony in support of Xeljanz, and Amy Dalsania spoke in

support of Cimzia. Kevin Chamberlin motioned to accept the recommendations as presented by

Magellan. His motion was seconded by Emmett Sullivan and the motion passed unanimously.

ON Medicaid PDL: ENBREL KIT (INJECTION), ENBREL PEN (INJECTION),

ENBREL SYRINGE (INJECTION), HUMIRA KIT (INJECTION), HUMIRA PEN KIT

(INJECTION)

OFF Medicaid PDL: ACTEMRA (INJECTION), CIMZIA KIT (INJECTION), CIMZIA

SYRINGE KIT (INJECTION), KINERET (INJECTION), ORENCIA SYRINGE

(SUBCUT.), ORENCIA VIAL (INJECTION), REMICADE (INJECTION), SIMPONI

ARIA VIAL (INTRAVEN.), SIMPONI PEN INJECTER (INJECTION), SIMPONI

SYRINGE (INJECTION), STELARA SYRINGE (INJECTION), XELJANZ (ORAL)

Epinephrine, Self-Injected

Kathy Novak introduced Auvi-Q as a new medication to this class. Charles Thompson

questioned how including Auvi-Q on the PDL would affect cost savings, and Kathy noted there

would be a negative savings in the scenario. Cynthia Conrad motioned to accept the

recommendations as presented, and her motion was seconded and passed unanimously by the

committee.

ON Medicaid PDL: EPIPEN (INTRAMUSC), EPIPEN JR (INTRAMUSC)

OFF Medicaid PDL: AUVI-Q (INTRAMUSC), EPINEPHRINE (INJECTION)

Glucocorticoids, Inhaled

Kevin Chamberlin motioned to accept the recommendations as presented for this class. His

motion was seconded by Manage Nissanka and passed unanimously by the committee.

ON Medicaid PDL: ADVAIR DISKUS (INHALATION), ADVAIR HFA (INHALATION),

ASMANEX (INHALATION), DULERA (INHALATION), FLOVENT DISKUS

(INHALATION), FLOVENT HFA (INHALATION), PULMICORT 0.25, 0.5 MG

RESPULES (INHALATION), PULMICORT FLEXHALER (INHALATION), QVAR

(INHALATION), SYMBICORT (INHALATION)

OFF Medicaid PDL: ALVESCO (INHALATION), BUDESONIDE 0.25, 0.5 MG

RESPULES (INHALATION), PULMICORT 1 MG RESPULES (INHALATION)

Intranasal Rhinitis Agents

Kristen Kau provided public testimony for the inclusion of QNASL on the PDL. Kevin

Chamberlin motioned to accept the recommendations as presented, and was seconded by Charles

Thompson. The motion passed unanimously.

ON Medicaid PDL: ASTELIN (NASAL), ASTEPRO (NASAL), FLUNISOLIDE (NASAL),

FLUTICASONE (NASAL), IPRATROPIUM (NASAL), NASONEX (NASAL), PATANASE

(NASAL)

OFF Medicaid PDL: ATROVENT (NASAL), AZELASTINE (NASAL), BECONASE AQ

(NASAL), DYMISTA (NASAL), FLONASE (NASAL), NASACORT AQ (NASAL),

OMNARIS (NASAL), QNASL (NASAL), RHINOCORT AQUA (NASAL), TRIAMCINOLONE (NASAL), VERAMYST (NASAL), ZETONNA (NASAL)

Neuropathic Pain Agents

Cynthia Conrad motioned to accept the recommendations as presented for this class. Emmett

Sullivan seconded her motion, and it was passed unanimously by the committee.

ON Medicaid PDL: CYMBALTA (ORAL), GABAPENTIN CAPSULE (ORAL),

LIDODERM (TOPICAL), LYRICA CAPSULE (ORAL)

OFF Medicaid PDL: GABAPENTIN SOLUTION (ORAL), GABAPENTIN TABLET

(ORAL), GRALISE (ORAL), HORIZANT (ORAL), LYRICA SOLUTION (ORAL),

NEURONTIN CAPSULE (ORAL), NEURONTIN SOLUTION (ORAL), NEURONTIN

TABLET (ORAL), QUTENZA KIT (TOPICAL), SAVELLA (ORAL), SAVELLA DOSE

PACK (ORAL)

NSAIDs

Kevin Chamberlin motioned to accept the recommendations as presented for this class. Manage

Nissanka seconded the motion, and the committee passed it unanimously.

ON Medicaid PDL: ETODOLAC TAB SR (ORAL), FLECTOR (TOPICAL),

FLURBIPROFEN (ORAL), IBUPROFEN SUSPENSION (ORAL), IBUPROFEN TABLET

(ORAL), INDOCIN SUSPENSION (ORAL), INDOMETHACIN (ORAL/RECTAL),

INDOMETHACIN CAPSULE (ORAL), KETOPROFEN (ORAL), KETOROLAC (ORAL),

MELOXICAM SUSPENSION (ORAL), MELOXICAM TABLET (ORAL), MOBIC

SUSPENSION (ORAL), NABUMETONE (ORAL), NAPROXEN SODIUM (ORAL),

NAPROXEN SUSPENSION (ORAL), NAPROXEN TABLET (ORAL), PIROXICAM

(ORAL), SULINDAC (ORAL), VOLTAREN (TOPICAL)

OFF Medicaid PDL: ADVIL MIGRAINE CAPSULE OTC (ORAL), ADVIL OTC

(ORAL), ADVIL TAB CHEW OTC (ORAL), ALEVE CAPSULE OTC (ORAL), ALEVE

TABLET OTC (ORAL), ANAPROX (ORAL), ARTHROTEC (ORAL), CATAFLAM

TABLET (ORAL), CELEBREX (ORAL), CHILDREN'S MOTRIN ORAL SUSP OTC

(ORAL), DAYPRO (ORAL), DICLOFENAC POTASSIUM (ORAL), DICLOFENAC

SODIUM (ORAL), DICLOFENAC SODIUM/MISOPROSTOL (ORAL), DICLOFENAC SR

(ORAL), DIFLUNISAL (ORAL), DUEXIS (ORAL), ETODOLAC (ORAL), FENOPROFEN

(ORAL), IBUPROFEN CAPSULE OTC (ORAL), IBUPROFEN DROPS SUSPENSION OTC

(ORAL), IBUPROFEN SUSPENSION OTC (ORAL), IBUPROFEN TAB CHEW OTC

(ORAL), IBUPROFEN TABLET OTC (ORAL), INDOCIN (RECTAL), INDOMETHACIN

CAPSULE ER (ORAL), INFANT'S MOTRIN DROPS SUSP OTC (ORAL), KETOPROFEN

ER (ORAL), MECLOFENAMATE (ORAL), MEFENAMIC ACID (ORAL), MIDOL

TABLET OTC (ORAL), MOBIC TABLET (ORAL), MOTRIN TABLET OTC (ORAL),

NALFON (ORAL), NAPRELAN (ORAL), NAPROSYN EC (ORAL), NAPROSYN

SUSPENSION (ORAL), NAPROSYN TABLET (ORAL), NAPROXEN EC (ORAL),

NAPROXEN SODIUM OTC (ORAL), OXAPROZIN (ORAL), PENNSAID (TOPICAL),

PONSTEL (ORAL), SPRIX (NASAL), TOLMETIN SODIUM CAPSULE (ORAL),

TOLMETIN SODIUM TABLET (ORAL), VIMOVO (ORAL), ZIPSOR (ORAL)

Oncology Agents, Oral

Aniello Marotta provided testimony for open access to all drugs in this therapeutic category. The

committee agreed that none of the chemical entities in this class should be subject to prior

authorization. Kathy Novak noted the higher cost for generic of Temodar, and suggested that the

committee allow all chemical entities to be preferred, and allow the state to determine if brand or

generic is preferred based on cost. At this time, the brand Temodar will be preferred and the

generic non-preferred. Cynthia motioned to make all entities preferred, with the lower cost of

either brand or generic for each entity being preferred. Kevin Chamberlin seconded and the

committee passed the motion unanimously.

ON Medicaid PDL: AFINITOR (ORAL), AFINITOR DISPERZ (ORAL), ALKERAN

(ORAL), BOSULIF (ORAL), CAPRELSA (ORAL), COMETRIQ (ORAL), ERIVEDGE

(ORAL), FLUTAMIDE (ORAL), GILOTRIF (ORAL), GLEEVEC (ORAL), HYDREA

(ORAL), HYDROXYUREA (ORAL), ICLUSIG (ORAL), INLYTA (ORAL), JAKAFI

(ORAL), MEKINIST (ORAL), MERCAPTOPURINE (ORAL), NEXAVAR (ORAL),

SPRYCEL (ORAL), STIVARGA (ORAL), SUTENT (ORAL), TAFINLAR (ORAL),

TARCEVA (ORAL), TASIGNA (ORAL), TEMODAR (ORAL), TYKERB (ORAL),

VOTRIENT (ORAL), XALKORI (ORAL), XELODA (ORAL), XTANDI (ORAL),

ZELBORAF (ORAL), ZOLINZA (ORAL), ZYTIGA (ORAL)

OFF Medicaid PDL: TEMOZOLOMIDE (AG) (ORAL), TEMOZOLOMIDE (ORAL)

Smoking Cessation

Kevin Chamberlin motioned to accept the recommendations as presented for this class. Charles

Thompson seconded the motion, and it was passed unanimously.

ON Medicaid PDL: BUPROPION SR (ORAL), CHANTIX (ORAL), CHANTIX DOSE

PACK (ORAL), NICOTINE GUM OTC (BUCCAL), NICOTINE LOZENGE OTC

(BUCCAL), NICOTINE PATCH OTC (TRANSDERMAL)

OFF Medicaid PDL: NICODERM CQ (TRANSDERMAL), NICORETTE GUM OTC

(BUCCAL), NICORETTE LOZENGE OTC (BUCCAL), NICOTROL (INHALATION),

NICOTROL NS (NASAL), ZYBAN (ORAL)

Stimulants and Related Agents

Charles Thompson acknowledged the need for a liquid dosage form in this class for pediatric

populations. He motioned to accept the recommendations as presented, along with the addition

of Methylin solution to the PDL. His motion was seconded by Cynthia Conrad and passed

unanimously.

ON Medicaid PDL: ADDERALL XR (ORAL), AMPHETAMINE SALT COMBO (ORAL),

DAYTRANA (TRANSDERMAL), DEXMETHYLPHENIDATE (ORAL),

DEXTROAMPHETAMINE TABLET (ORAL), FOCALIN (ORAL), FOCALIN XR (ORAL),

INTUNIV (ORAL), METADATE CD (ORAL), METHYLIN SOLUTION (ORAL),

METHYLPHENIDATE (ORAL), METHYLPHENIDATE ER (CONCERTA) (ORAL),

METHYLPHENIDATE ER (ORAL), MODAFINIL (ORAL), PROCENTRA (ORAL),

QUILLIVANT XR (ORAL), STRATTERA (ORAL), VYVANSE (ORAL)

OFF Medicaid PDL: ADDERALL (ORAL), AMPHETAMINE SALT COMBO ER (ORAL),

AMPHETAMINE SALT COMBO ER (TEVA, GLOBAL) (ORAL), CONCERTA (ORAL),

DESOXYN (ORAL), DEXEDRINE SPANSULE (ORAL), DEXTROAMPHETAMINE

CAPSULE ER (ORAL), DEXTROAMPHETAMINE SOLUTION (ORAL), KAPVAY

(ORAL), KAPVAY DOSE PACK (ORAL), METHAMPHETAMINE (ORAL), METHYLIN

CHEWABLE TABLETS (ORAL), METHYLPHENIDATE CD (AG) (ORAL),

METHYLPHENIDATE CD (ORAL), METHYLPHENIDATE ER (GEN RITALIN LA)

(ORAL), METHYLPHENIDATE SOLUTION (ORAL), NUVIGIL (ORAL), PROVIGIL

(ORAL), RITALIN (ORAL), RITALIN LA (ORAL), RITALIN LA 10 MG CAPSULE

(ORAL), RITALIN SR (ORAL), ZENZEDI (ORAL)

Alzheimer’s Agents

Kathy Novak introduced Namenda XR as a new drug to the class, and that Exelon is available in

a new strength. Kevin Chamberlin motioned to accept the recommendations as presented by

Magellan, and Emmett Sullivan seconded. The motion was passed unanimously.

ON Medicaid PDL: DONEPEZIL ODT (ORAL), DONEPEZIL TABLET (ORAL), EXELON

(TRANSDERM.), EXELON CAPSULES (ORAL), NAMENDA SOLUTION (ORAL),

NAMENDA TABLET (ORAL), NAMENDA TABLET DOSE PACK (ORAL)

OFF Medicaid PDL: ARICEPT (ORAL), ARICEPT 23 MG (ORAL), ARICEPT ODT

(ORAL), DONEPEZIL 23 MG (ORAL), EXELON SOLUTION (ORAL), GALANTAMINE

ER (ORAL), GALANTAMINE SOLUTION (ORAL), GALANTAMINE TABLET (ORAL),

NAMENDA XR (ORAL), RIVASTIGMINE CAPSULES (ORAL)

Antidepressants, SSRIs

Emmett Sullivan motioned to accept the recommendations as presented for this class. Cynthia

Conrad seconded the motion and it was passed unanimously by the committee.

ON Medicaid PDL: CITALOPRAM SOLUTION (ORAL), CITALOPRAM TABLET (ORAL),

ESCITALOPRAM TABLET (ORAL), FLUOXETINE CAPSULE (ORAL), FLUOXETINE

SOLUTION (ORAL), FLUOXETINE TABLET (ORAL), FLUVOXAMINE (ORAL),

LEXAPRO SOLUTION (ORAL), PAROXETINE TABLET (ORAL), SERTRALINE CONC

(ORAL), SERTRALINE TABLET (ORAL)

OFF Medicaid PDL: BRISDELLE (ORAL), CELEXA TABLET (ORAL),

ESCITALOPRAM SOLUTION (ORAL), FLUOXETINE 60 MG (ORAL), FLUOXETINE

CAPSULE DR (ORAL), FLUVOXAMINE ER (ORAL), LEXAPRO TABLET (ORAL),

LUVOX CR (ORAL), PAROXETINE CR (ORAL), PAXIL (ORAL), PAXIL CR (ORAL),

PAXIL SUSPENSION (ORAL), PEXEVA (ORAL), PROZAC CAPSULE (ORAL),

PROZAC WEEKLY (ORAL), SARAFEM (ORAL), ZOLOFT CONC (ORAL), ZOLOFT

TABLET (ORAL)

Antihistamines, minimally sedating

Emmett Sullivan motioned to accept the recommendations as presented for this class. His

motion was seconded by Manage Nissanka, and was passed unanimously by the committee.

ON Medicaid PDL: CETIRIZINE SOLUTION (ORAL), CETIRIZINE SOLUTION 5MG/5ML

OTC, CETIRIZINE SOLUTION OTC (ORAL), CETIRIZINE-D OTC (ORAL),

FEXOFENADINE 60, 180 MG OTC (ORAL), FEXOFENADINE D 12-HOUR OTC (ORAL),

FEXOFENADINE D 24-HOUR OTC (ORAL), , LORATADINE ODT OTC (ORAL),

LORATADINE SOLUTION OTC (ORAL), LORATADINE TABLETS OTC (ORAL),

LORATADINE-D OTC (ORAL)

OFF Medicaid PDL: ALLEGRA ALLERGY OTC (ORAL), ALLEGRA ALLERGY

SUSPENSION OTC (ORAL), ALLEGRA ODT (ORAL), ALLEGRA-D 12 HOUR OTC

(ORAL), ALLEGRA-D 24 HOUR OTC (ORAL), ALLEGRA-D 24-HOUR (ORAL),

CETIRIZINE CAPSULE OTC (ORAL), CETIRIZINE CHEWABLE OTC (ORAL),

CETIRIZINE TABLETS OTC (ORAL), CLARINEX SYRUP (ORAL), CLARINEX

TABLET (ORAL), CLARINEX-D 12 HOUR (ORAL), CLARINEX-D 24 HOUR (ORAL),

CLARITIN CAPSULE OTC (ORAL), CLARITIN CHEW OTC (ORAL), CLARITIN

ODT OTC (ORAL), CLARITIN SOLUTION OTC (ORAL), CLARITIN TABLET OTC

(ORAL), CLARITIN-D 12 HOUR OTC (ORAL), CLARITIN-D 24 HOUR OTC (ORAL),

DESLORATADINE (ORAL), DESLORATADINE ODT (ORAL), FEXOFENADINE 30 MG

(ORAL), FEXOFENADINE 30 MG OTC (ORAL), FEXOFENADINE 60, 180 MG (ORAL),

FEXOFENADINE ODT OTC (ORAL), FEXOFENADINE-D 24-HOUR (ORAL),

LEVOCETIRIZINE SOLUTION (ORAL), LEVOCETIRIZINE TABLETS (ORAL),

SEMPREX-D (ORAL), XYZAL SOLUTION (ORAL), XYZAL TABLET (ORAL),

ZYRTEC (ORAL), ZYRTEC CHEWABLET TABLET OTC (ORAL), ZYRTEC OTC

(ORAL), ZYRTEC SOLUTION OTC (ORAL), ZYRTEC-D OTC (ORAL)

Antihypertensives, sympatholytic

Emmett Sullivan motioned to accept the recommendations as presented for this class. His

motion was seconded by Manage Nissanka and passed unanimously by the committee.

ON Medicaid PDL: CATAPRES-TTS (TRANSDERM), CLONIDINE (ORAL),

GUANFACINE (ORAL), METHYLDOPA (ORAL), METHYLDOPA/

HYDROCHLOROTHIAZIDE (ORAL)

OFF Medicaid PDL: CATAPRES (ORAL), CLONIDINE (TRANSDERM), CLORPRES

(ORAL), METHYLDOPATE HCL (INTRAVEN), RESERPINE (ORAL), TENEX (ORAL)

Antihyperuricemics, Oral

Kevin Chamberlin motioned to accept the recommendations as presented for this class. Emmett

Sullivan seconded the motion and the committee passed it unanimously.

ON Medicaid PDL: ALLOPURINOL (ORAL), PROBENECID (ORAL), PROBENECID /

COLCHICINE (ORAL)

OFF Medicaid PDL: COLCRYS (ORAL), KRYSTEXXA (INTRAVEN), ULORIC

(ORAL)

Antiparkinson’s Agents

Cynthia Conrad motioned to accept this class as recommended by Magellan. Her motion was

seconded by Kevin Chamberlin and passed unanimously by the committee.

ON Medicaid PDL: BENZTROPINE (ORAL), BROMOCRIPTINE (ORAL), CARBIDOPA /

LEVODOPA (ORAL), CARBIDOPA / LEVODOPA ER (ORAL), CARBIDOPA /

LEVODOPA ODT (ORAL), CARBIDOPA/LEVODOPA/ENTACAPONE (ORAL),

PRAMIPEXOLE (ORAL), ROPINIROLE (ORAL), SELEGILINE CAPSULE (ORAL),

SELEGILINE TABLET (ORAL), TRIHEXYPHENIDYL ELIXIR (ORAL),

TRIHEXYPHENIDYL TABLET (ORAL)

OFF Medicaid PDL: AZILECT (ORAL), COMTAN (ORAL), ENTACAPONE (ORAL),

LODOSYN (ORAL), MIRAPEX (ORAL), MIRAPEX ER (ORAL), NEUPRO

(TRANSDERM), PARCOPA (ORAL), PARLODEL CAPSULE (ORAL), REQUIP

(ORAL), REQUIP XL (ORAL), ROPINIROLE ER (ORAL), SINEMET (ORAL),

SINEMET CR (ORAL), STALEVO (ORAL), TASMAR (ORAL), ZELAPAR (ORAL)

Antipsoriatics, Oral

Kathy Novak introduced this as a new category for the Connecticut PDL. Kathy explained that

cost savings derive from using the lower cost brand medications in this class. Cynthia Conrad

motioned to accept the recommendations as presented, and Kevin Chamberlin seconded the

motion. The committee unanimously approved the motion.

ON Medicaid PDL: OXSORALEN-ULTRA (ORAL), SORIATANE (ORAL)

OFF Medicaid PDL: 8-MOP (ORAL), ACITRETIN (AG) (ORAL), ACITRETIN (ORAL)

Antipsoriatics, Topical

Kevin Chamberlin motioned to accept the recommendations as presented for this class. The

motion was seconded by Charles Thompson and passed unanimously by the committee.

ON Medicaid PDL: CALCIPOTRIENE CREAM (TOPICAL), CALCIPOTRIENE

OINTMENT (TOPICAL), CALCIPOTRIENE SOLUTION (TOPICAL), CALCITRIOL

OINTMENT (TOPICAL), DOVONEX CREAM (TOPICAL)

OFF Medicaid PDL: CALCITRENE (TOPICAL), SORILUX (TOPICAL), TACLONEX

OINTMENT (TOPICAL), TACLONEX SCALP (TOPICAL), VECTICAL (TOPICAL)

Anxiolytics

Kathy Novak introduced this as a new class for the Connecticut PDL. She informed the

committee that all chemical entities were represented in their recommendations. Emmett

Sullivan suggested the addition of the lorazepam intensol dosage form for hospice settings. He

motioned to accept the recommendations as presented, along with the addition of lorazepam

intensol. The motion was seconded by Cynthia Conrad and passed unanimously by the

committee.

ON Medicaid PDL: ALPRAZOLAM TABLET (ORAL), BUSPIRONE (ORAL),

CHLORDIAZEPOXIDE (ORAL), CLORAZEPATE (ORAL), DIAZEPAM SOLUTION

(ORAL), DIAZEPAM TABLET (ORAL), LORAZEPAM INTENSOL (ORAL), LORAZEPAM

TABLET (ORAL)

OFF Medicaid PDL: ALPRAZOLAM ER (ORAL), ALPRAZOLAM INTENSOL (ORAL),

ALPRAZOLAM ODT (ORAL), ATIVAN TABLET (ORAL), DIAZEPAM INTENSOL

(ORAL), DIAZEPAM SYRINGE (INJECTION), DIAZEPAM VIAL (INJECTION),

MEPROBAMATE (ORAL), NIRAVAM (ORAL), OXAZEPAM (ORAL), TRANXENE T-

TAB (ORAL), VALIUM TABLET (ORAL), XANAX TABLET (ORAL), XANAX XR

(ORAL)

Bile Salts

Kevin Chamberlin motioned to accept the recommendations as presented for this class. The

motion was seconded by Jeffrey Kamradt and passed unanimously by the committee.

ON Medicaid PDL: URSODIOL 300 MG CAPSULE (ORAL)

OFF Medicaid PDL: ACTIGALL (ORAL), CHENODAL (ORAL), URSO/URSO FORTE

TABLET (ORAL), URSODIOL TABLET (ORAL)

Bronchodilators, Beta Agonists

Kathy Novak informed the committee there were no changes to this class from the previous

review. Kevin Chamberlin motioned to accept the recommendations as presented. The motion

was seconded by Emmett Sullivan and passed unanimously by the committee.

ON Medicaid PDL: ALBUTEROL NEB SOLN 0.63, 1.25 MG (INHALATION),

ALBUTEROL NEB SOLN 100 MG/20 ML (INHALATION), ALBUTEROL NEB SOLN 2.5

MG/3 ML (INHALATION), ALBUTEROL SYRUP (ORAL), ALBUTEROL TABLET

(ORAL), PROAIR HFA (INHALATION), PROVENTIL HFA (INHALATION),

TERBUTALINE (ORAL)

OFF Medicaid PDL: ACCUNEB (INHALATION), ALBUTEROL ER (ORAL),

ALBUTEROL NEB SOLN 2.5 MG/0.5 ML (INHALATION), ARCAPTA NEOHALER

(INHALATION), BROVANA (INHALATION), FORADIL (INHALATION),

LEVALBUTEROL NEB SOLN (INHALATION), LEVALBUTEROL NEB SOLN CONC

(INHALATION), MAXAIR (INHALATION), METAPROTERENOL SYRUP (ORAL),

METAPROTERENOL TABLET (ORAL), PERFOROMIST (INHALATION), SEREVENT

(INHALATION), VENTOLIN HFA (INHALATION), VOSPIRE ER (ORAL), XOPENEX

HFA (INHALATION), XOPENEX NEB SOLN (INHALATION), XOPENEX NEB SOLN

CONC (INHALATION)

Emollients

Kathy Novak informed committee of two new products to this class. Cynthia Conrad motioned

to accept the recommendations as presented, and her motion was seconded by Kevin

Chamberlin. The motion was passed unanimously by the committee.

ON Medicaid PDL: AMMONIUM LACTATE CREAM/LOTION (TOPICAL), LACTIC ACID

CREAM/LOTION (TOPICAL)

OFF Medicaid PDL: ATOPICLAIR (TOPICAL), BIAFINE (TOPICAL), ELETONE

(TOPICAL), EMOLLIENT COMBINATION NO.10 (TOPICAL), EMOLLIENT

COMBINATION NO.32 (TOPICAL), EMOLLIENT COMBO 35 CREAM (TOPICAL),

EMOLLIENT FOAM (TOPICAL), EMOLLIENT FOAM PLUS (TOPICAL), EPICERAM

(TOPICAL), HPR PLUS (TOPICAL), HPR PLUS-MB HYROGEL (TOPICAL),

HYLATOPIC (TOPICAL), HYLATOPIC PLUS (TOPICAL), LAC-HYDRIN

CREAM/LOTION (TOPICAL), MB HYDROGEL (TOPICAL), PRUCLAIR (TOPICAL), TL

TRISEB (TOPICAL), TROPAZONE CREAM (TOPICAL), TROPAZONE LOTION

(TOPICAL)

Histamine II Receptor Blockers

Kathy Novak introduced this as a new class to the Connecticut PDL. Charles Thompson

motioned to accept as recommended along with the addition of ranitidine syrup and Pepcid

suspension as they are needed for use in pediatric populations. Karen McMillan seconded the

motion and the committee passed it unanimously.

ON Medicaid PDL: CIMETIDINE TABLET (ORAL), CIMETIDINE TABLET OTC (ORAL),

FAMOTIDINE TABLET (ORAL), FAMOTIDINE TABLET OTC (ORAL), PEPCID

SUSPENSION (ORAL), RANITIDINE SYRUP (ORAL), RANITIDINE TABLET (ORAL),

RANITIDINE TABLET OTC (ORAL)

OFF Medicaid PDL: AXID SOLUTION (ORAL), CIMETIDINE SOLUTION (ORAL),

FAMOTIDINE (INTRAVEN), FAMOTIDINE PIGGYBACK (INJECTION), FAMOTIDINE

SUSPENSION (ORAL), FAMOTIDINE VIAL (INJECTION), NIZATIDINE CAPSULE

(ORAL), NIZATIDINE SOLUTION (ORAL), PEPCID AC TABLET OTC (ORAL),

PEPCID TABLET (ORAL), RANITIDINE (INJECTION), RANITIDINE CAPSULE (ORAL),

ZANTAC (INJECTION), ZANTAC 25 (ORAL), ZANTAC 75 TABLET OTC (ORAL),

ZANTAC SYRUP (ORAL), ZANTAC TABLET (ORAL), ZANTAC TABLET OTC

(ORAL)

Immunomodulators, Atopic Dermatitis

Jeffrey Kamradt motioned to accept the recommendations as presented for this class. Cynthia

Conrad seconded, and the motion was passed unanimously.

ON Medicaid PDL: ELIDEL (TOPICAL)

OFF Medicaid PDL: PROTOPIC (TOPICAL)

Immunomodulators, Topical

Kathy Novak introduced this as a new category for the Connecticut PDL. Kathy stated all agents

are the same active ingredient and cost savings are derived by pushing to the specific branded

product Aldara. Kevin Chamberlin motioned to approve the recommendations as presented.

The motion was seconded and passed unanimously by the committee.

ON Medicaid PDL: ALDARA (TOPICAL)

OFF Medicaid PDL: IMIQUIMOD (TOPICAL), ZYCLARA (TOPICAL)

Iron, Oral

Kathy Novak introduced this as a new category for the Connecticut PDL. Cynthia Conrad

motioned to accept the recommendations as presented. Charles Thompson seconded the motion

and it was passed unanimously by the committee.

ON Medicaid PDL: CENTRATEX (ORAL), FE C OTC (ORAL), FE FUMARATE/VIT

C/B12-IF/FA (ORAL), FEOSOL OTC (ORAL), FERATE OTC (ORAL), FERRALET 90

DUAL-IRON (ORAL), FERRAPLUS 90 (ORAL), FERRIMIN 150 OTC (ORAL),

FERROCITE PLUS (ORAL), FERROUS GLUCONATE OTC (ORAL), FERROUS

SULFATE 65 MG TABLET OTC (ORAL), FERROUS SULFATE OTC (ORAL), FERROUS

SULFATE SOLUTION OTC (ORAL), FOLITAB 500 OTC (ORAL), FOLIVANE-F

(ORAL), FOLIVANE-PLUS (ORAL), HEMATOGEN (ORAL), HEMATOGEN FA

(ORAL), HEMOCYTE PLUS (ORAL), HEMOCYTE-F (ORAL), IFEREX 150 FORTE

(ORAL), INTEGRA F (ORAL), INTEGRA OTC (ORAL), INTEGRA PLUS (ORAL), IRON 45 MG TABLET OTC (ORAL), IRON POLYSACCHARIDES COMPLEX OTC

(ORAL), IRON PS CMPLX/VIT B12/FA (ORAL), IRON,CARBONYL/ASCORBIC ACID

OTC (ORAL), MV COMB18/FEFM-FEPOL CB1/FA (ORAL), NEPHRON FA (ORAL),

NOVAFERRUM 50 CAPSULE OTC (ORAL), NOVAFERRUM DROPS OTC (ORAL),

SE-TAN PLUS (ORAL), SLOW RELEASE IRON (ORAL), TANDEM DUAL ACTION

OTC (ORAL), TANDEM PLUS (ORAL), TARON FORTE (ORAL), TL-FOL 500

(ORAL), TL-HEM 150 (ORAL), VITRON-C OTC (ORAL)

OFF Medicaid PDL: ACTIVE FE (ORAL), BIFERA RX (ORAL), CHROMAGEN

(ORAL), CORVITA 150 (ORAL), CORVITE 150 (ORAL), CORVITE FE (ORAL),

DUOFER (ORAL), FE FUMARATE/VIT C/VIT B12/FA (ORAL), FERIVA (ORAL),

FERREX 150 PLUS OTC (ORAL), FERREX 28 (ORAL), FERROFLEX 150 FORTE

(ORAL), FUSION PLUS (ORAL), HEMETAB (ORAL), ICAR-C OTC (ORAL),

IROSPAN (ORAL), MAXARON FORTE (ORAL), MULTIGEN (ORAL), MULTIGEN

FOLIC (ORAL), MULTIGEN PLUS (ORAL), NATALVIRT FLT (ORAL), NIRON

KOMPLETE (ORAL), NOVAFERRUM (ORAL), NOVAFERRUM LIQUID OTC

(ORAL), VITAFOL (ORAL)

Leukotriene Modifiers

Kathy Novak advised that the montelukast chewable tablets could be crushed, and such the

granules were not recommended as preferred. Carl Sherter motioned to accept the

recommendations as presented. Charles Thompson seconded the motion and it was passed

unanimously by the committee.

ON Medicaid PDL: ACCOLATE (ORAL), MONTELUKAST CHEWABLE TABLET

(ORAL), MONTELUKAST TABLET (ORAL)

OFF Medicaid PDL: MONTELUKAST GRANULES (ORAL), SINGULAIR CHEWABLE

TABLET (ORAL), SINGULAIR GRANULES (ORAL), SINGULAIR TABLET (ORAL),

ZAFIRLUKAST (ORAL), ZYFLO (ORAL), ZYFLO CR (ORAL)

Oncology Agents, Breast Cancer

Cynthia Conrad motioned to accept the recommendations as presented for this class. Kevin

Chamberlin seconded the motion and the committee passed it unanimously.

ON Medicaid PDL: ARIMIDEX (ORAL), EXEMESTANE (ORAL), LETROZOLE (ORAL),

TAMOXIFEN CITRATE (ORAL)

OFF Medicaid PDL: ANASTROZOLE (ORAL), AROMASIN (ORAL), FARESTON

(ORAL), FEMARA (ORAL)

Ophthalmic Antibiotics

The committee unanimously voted to accept the recommendations as presented for this drug

category.

ON Medicaid PDL: BACITRACIN/POLYMYXIN B SULFATE OINT. (OPHTHALMIC),

CIPROFLOXACIN SOLUTION (OPHTHALMIC), ERYTHROMYCIN (OPHTHALMIC),

GENTAMICIN DROPS (OPHTHALMIC), GENTAMICIN OINT. (OPHTHALMIC),

LEVOFLOXACIN (OPHTHALMIC), MOXEZA (OPHTHALMIC), NEOMYCIN-

POLYMYXIN-GRAMICIDIN (OPHTHALMIC), OFLOXACIN (OPHTHALMIC),

POLYMYXIN/TRIMETHOPRIM (OPHTHALMIC), SULFACETAMIDE SOLUTION

(OPHTHALMIC), TOBRAMYCIN (OPHTHALMIC), TOBREX OINTMENT

(OPHTHALMIC), VIGAMOX (OPHTHALMIC)

OFF Medicaid PDL: AZASITE (OPHTHALMIC), BACITRACIN (OPHTHALMIC),

BESIVANCE (OPHTHALMIC), BLEPH-10 (OPHTHALMIC), CILOXAN DROPS

(OPHTHALMIC), CILOXAN OINTMENT (OPHTHALMIC), GARAMYCIN DROPS

(OPHTHALMIC), GARAMYCIN OINT. (OPHTHALMIC), NATACYN

(OPHTHALMIC), NEOMYCIN/BACITRACIN/POLYMYXIN OINT (OPHTHALMIC),

POLYTRIM (OPHTHALMIC), SULFACETAMIDE OINTMENT (OPHTHALMIC),

TOBREX DROPS (OPHTHALMIC), ZYMAR (OPHTHALMIC), ZYMAXID

(OPHTHALMIC)

Ophthalmic Antibiotic/Steroid Combinations

Kathy Novak advised there were no changes to this drug category from previous review. Charles

Thompson motioned to accept the recommendations as presented. Kevin Chamberlin seconded

the motion and it was passed unanimously.

ON Medicaid PDL: BLEPHAMIDE (OPHTHALMIC), BLEPHAMIDE S.O.P.

(OPHTHALMIC), NEOMYCIN/BACITRACIN/POLY/HC (OPHTHALMIC),

NEOMYCIN/POLYMYXIN/DEXAMETHASONE (OPHTHALMIC), PRED-G DROPS

SUSP (OPHTHALMIC), PRED-G OINT. (OPHTHALMIC), SULFACETAMIDE /

PREDNISOLONE (OPHTHALMIC), TOBRADEX OINTMENT (OPHTHALMIC),

TOBRADEX SUSPENSION (OPHTHALMIC)

OFF Medicaid PDL: MAXITROL DROPS SUSP (OPHTHALMIC), MAXITROL OINT.

(OPHTHALMIC), NEOMYCIN/POLYMYXIN/HC (OPHTHALMIC), TOBRADEX ST

(OPHTHALMIC), TOBRAMYCIN / DEXAMETHASONE SUSPENSION (OPHTHALMIC),

ZYLET (OPHTHALMIC)

Ophthalmics for Allergic Conjunctivitis

The committee voted unanimously to accept the recommendations as presented for this category.

ON Medicaid PDL: ALREX (OPHTHALMIC), CROMOLYN SODIUM (OPHTHALMIC),

PATADAY (OPHTHALMIC)

OFF Medicaid PDL: ALAMAST (OPHTHALMIC), ALOCRIL (OPHTHALMIC),

ALOMIDE (OPHTHALMIC), AZELASTINE (OPHTHALMIC), BEPREVE

(OPHTHALMIC), ELESTAT (OPHTHALMIC), EMADINE (OPHTHALMIC),

EPINASTINE (OPHTHALMIC), KETOTIFEN OTC (OPHTHALMIC), LASTACAFT

(OPHTHALMIC), OPTIVAR (OPHTHALMIC), PATANOL (OPHTHALMIC),

ZADITOR OTC (OPHTHALMIC)

Ophthalmic Anti-inflammatories

Cynthia Conrad motioned to accept the recommendations as presented for this category. Kevin

Chamberlin seconded the motion and it was passed unanimously.

ON Medicaid PDL: DEXAMETHASONE (OPHTHALMIC), DICLOFENAC

(OPHTHALMIC), DUREZOL (OPHTHALMIC), FLAREX (OPHTHALMIC),

FLUOROMETHOLONE (OPHTHALMIC), FLURBIPROFEN (OPHTHALMIC), FML

FORTE (OPHTHALMIC), FML S.O.P. (OPHTHALMIC), LOTEMAX DROPS

(OPHTHALMIC), MAXIDEX (OPHTHALMIC), PRED MILD (OPHTHALMIC), PREDNISOLONE ACETATE (OPHTHALMIC), PREDNISOLONE SOD PHOSPHATE

(OPHTHALMIC)

OFF Medicaid PDL: ACULAR (OPHTHALMIC), ACULAR LS (OPHTHALMIC),

ACUVAIL (OPHTHALMIC), BROMDAY (OPHTHALMIC), BROMFENAC

(OPHTHALMIC), FML (OPHTHALMIC)

ILEVRO (OPHTHALMIC), KETOROLAC (OPHTHALMIC), KETOROLAC LS

(OPHTHALMIC), LOTEMAX GEL (OPHTHALMIC), LOTEMAX OINTMENT

(OPHTHALMIC), NEVANAC (OPHTHALMIC), OMNIPRED (OPHTHALMIC),

OZURDEX (INTRAOCULR), PRED FORTE (OPHTHALMIC), PROLENSA

(OPHTHALMIC), RETISERT (INTRAOCULR), TRIESENCE (INTRAOCULR),

VEXOL (OPHTHALMIC)

Ophthalmic Glaucoma Agents

Cynthia Conrad motioned to accept the recommendations as presented for this category. Charles

Thompson seconded the motion and it was passed unanimously by the committee.

ON Medicaid PDL: ALPHAGAN P 0.15% (OPHTHALMIC), AZOPT (OPHTHALMIC), BETAXOLOL (OPHTHALMIC), BETIMOL (OPHTHALMIC), BETOPTIC S

(OPHTHALMIC), BRIMONIDINE (OPHTHALMIC), CARTEOLOL (OPHTHALMIC),

DORZOLAMIDE (OPHTHALMIC), DORZOLAMIDE / TIMOLOL (OPHTHALMIC),

ISTALOL (OPHTHALMIC), LATANOPROST 2.5 ML (OPHTHALMIC), LEVOBUNOLOL

(OPHTHALMIC), METIPRANOLOL (OPHTHALMIC), PILOCARPINE (OPHTHALMIC),

SIMBRINZA (OPHTHALMIC), TIMOLOL (OPHTHALMIC), TRAVATAN Z 2.5 ML

(OPHTHALMIC), TRAVATAN Z 5 ML (OPHTHALMIC)

OFF Medicaid PDL: ALPHAGAN P 0.1% (OPHTHALMIC), APRACLONIDINE

(OPHTHALMIC), BETAGAN (OPHTHALMIC), BRIMONIDINE P 0.15%

(OPHTHALMIC), COMBIGAN (OPHTHALMIC), COSOPT (OPHTHALMIC), COSOPT

PF (OPHTHALMIC), IOPIDINE (OPHTHALMIC), LUMIGAN 2.5ML

(OPHTHALMIC), LUMIGAN 5ML (OPHTHALMIC), LUMIGAN 7.5ML

(OPHTHALMIC), PILOPINE HS (OPHTHALMIC), RESCULA (OPHTHALMIC),

TIMOPTIC (OPHTHALMIC), TIMOPTIC OCUDOSE (OPHTHALMIC), TIMOPTIC-

XE (OPHTHALMIC), TRAVOPROST 2.5 ML (OPHTHALMIC), TRAVOPROST 5 ML

(OPHTHALMIC), TRUSOPT (OPHTHALMIC), XALATAN 2.5 ML (OPHTHALMIC),

ZIOPTAN (OPHTHALMIC)

Otic Antibiotics

Kevin Chamberlin motioned to accept the recommendations as presented for this category.

Manage Nissanka seconded the motion and it was passed unanimously by the committee.

ON Medicaid PDL: CIPRODEX (OTIC), CORTISPORIN SOLUTION (OTIC),

NEOMYCIN/POLYMYXIN/HC SOLN/SUSP (OTIC), OFLOXACIN (OTIC)

OFF Medicaid PDL: CIPRO HC (OTIC), CIPROFLOXACIN (OTIC), COLY-MYCIN S

(OTIC), CORTISPORIN-TC (OTIC)

Otic Anti-infectives & Anesthetics

Karen McMillan motioned to accept the recommendations as presented for this class. Cynthia

Conrad seconded the motion and it was passed unanimously by the committee.

ON Medicaid PDL: ACETIC ACID (OTIC), ACETIC ACID/ALUMINUM (OTIC),

ANTIPYRINE / BENZOCAINE (OTIC)

OFF Medicaid PDL: ACETIC ACID HC (OTIC), AURAX (OTIC), MYOXIN (OTIC),

OTIC CARE (OTIC), OTO-END 10 (OTIC), OTOZIN (OTIC), PINNACAINE (OTIC),

PRAMOXINE-HC (OTIC), VOSOL HC (OTIC)

Sedative Hypnotics

Kathy Novak advised there were no changes to the recommendations from last review for this

category. She informed the committee of the updated dosing recommendations for zolpidem use

in female patients. Manage Nissanka motioned to accept the recommendations as presented.

Kevin Chamberlin seconded the motion and it was passed unanimously by the committee.

ON Medicaid PDL: FLURAZEPAM (ORAL), TEMAZEPAM (ORAL), ZOLPIDEM (ORAL)

OFF Medicaid PDL: AMBIEN (ORAL), AMBIEN CR (ORAL), EDLUAR

(SUBLINGUAL), ESTAZOLAM (ORAL), INTERMEZZO (SUBLINGUAL), LUNESTA

(ORAL), RESTORIL (ORAL), ROZEREM (ORAL), SILENOR (ORAL), SONATA

(ORAL), TEMAZEPAM 22.5 MG (ORAL), TEMAZEPAM 7.5 MG (ORAL), TRIAZOLAM

(ORAL), ZALEPLON (ORAL), ZOLPIDEM ER (ORAL), ZOLPIMIST (ORAL)

Steroids, Topical Low

Emmett Sullivan motioned to accept the recommendations as presented for this class. Charles

Thompson seconded the motion and it was passed unanimously by the committee.

ON Medicaid PDL: CAPEX SHAMPOO (TOPICAL), DESONIDE CREAM (TOPICAL),

DESONIDE LOTION (TOPICAL), DESONIDE OINTMENT (TOPICAL), DESOWEN

LOTION (TOPICAL), FLUOCINOLONE 0.01% OIL (TOPICAL), HYDROCORTISONE /

MIN OIL / PET OINTMENT (TOPICAL), HYDROCORTISONE CREAM (TOPICAL),

HYDROCORTISONE GEL (TOPICAL), HYDROCORTISONE OINTMENT (TOPICAL)

OFF Medicaid PDL: ALCLOMETASONE DIPROPIONATE CREAM (TOPICAL),

ALCLOMETASONE DIPROPIONATE OINTMENT (TOPICAL), AQUA GLYCOLIC HC

(TOPICAL), DERMA-SMOOTHE-FS (TOPICAL), DESONATE GEL (TOPICAL),

HYDROCORTISONE ACETATE / UREA (TOPICAL), HYDROCORTISONE LOTION

(TOPICAL), HYDROCORTISONE/ALOE GEL (TOPICAL), PEDIADERM HC (TOPICAL),

PEDIADERM TA (TOPICAL), TEXACORT (TOPICAL), VERDESO (TOPICAL)

Steroids, Topical Medium

The committee voted unanimously to accept the recommendations as presented for this category.

ON Medicaid PDL: FLUOCINOLONE ACETONIDE CREAM (TOPICAL),

FLUOCINOLONE ACETONIDE OINTMENT (TOPICAL), FLUOCINOLONE ACETONIDE

SOLUTION (TOPICAL), FLUTICASONE PROPIONATE CREAM (TOPICAL),

FLUTICASONE PROPIONATE OINTMENT (TOPICAL), HYDROCORTISONE

BUTYRATE CREAM (TOPICAL), HYDROCORTISONE BUTYRATE CREAM BRAND

(TOPICAL), HYDROCORTISONE BUTYRATE OINTMENT (TOPICAL),

HYDROCORTISONE BUTYRATE OINTMENT BRAND (TOPICAL), HYDROCORTISONE

BUTYRATE SOLUTION (TOPICAL), HYDROCORTISONE BUTYRATE SOLUTION

BRAND (TOPICAL), HYDROCORTISONE VALERATE CREAM (TOPICAL),

HYDROCORTISONE VALERATE OINTMENT (TOPICAL), MOMETASONE FUROATE

CREAM (TOPICAL), MOMETASONE FUROATE OINTMENT (TOPICAL),

MOMETASONE FUROATE SOLUTION (TOPICAL), PREDNICARBATE CREAM

(TOPICAL), PREDNICARBATE OINTMENT (TOPICAL)

OFF Medicaid PDL: BETAMETHASONE VALERATE FOAM (TOPICAL), CLODERM

(TOPICAL), CORDRAN TAPE (TOPICAL), CUTIVATE CREAM (TOPICAL),

CUTIVATE LOTION (TOPICAL), DERMATOP OINTMENT (TOPICAL), ELOCON

CREAM (TOPICAL), ELOCON OINTMENT (TOPICAL), ELOCON SOLUTION

(TOPICAL), FLUTICASONE PROPIONATE LOTION (TOPICAL), LUXIQ (TOPICAL),

MOMEXIN (TOPICAL), PANDEL (TOPICAL), SYNALAR CREAM (TOPICAL),

SYNALAR CREAM KIT (TOPICAL), SYNALAR OINTMENT (TOPICAL), SYNALAR

OINTMENT KIT (TOPICAL), SYNALAR SOLUTION (TOPICAL), SYNALAR TS KIT

(TOPICAL)

Steroids, Topical High

Cynthia Conrad motioned to accept the recommendations as presented for this category. Manage

Nissanka seconded the motion and it was passed unanimously by the committee.

ON Medicaid PDL: BETAMETHASONE DIPROPIONATE CREAM (TOPICAL),

BETAMETHASONE DIPROPIONATE LOTION (TOPICAL), BETAMETHASONE

VALERATE CREAM (TOPICAL), BETAMETHASONE VALERATE OINTMENT

(TOPICAL), BETA-VAL CREAM (TOPICAL), FLUOCINONIDE CREAM (TOPICAL),

FLUOCINONIDE EMOLLIENT (TOPICAL), FLUOCINONIDE SOLUTION (TOPICAL),

TRIAMCINOLONE ACETONIDE CREAM (TOPICAL), TRIAMCINOLONE ACETONIDE

LOTION (TOPICAL), TRIAMCINOLONE ACETONIDE OINTMENT (TOPICAL),

TRIANEX OINTMENT (TOPICAL)

OFF Medicaid PDL: AMCINONIDE CREAM (TOPICAL), AMCINONIDE LOTION

(TOPICAL), AMCINONIDE OINTMENT (TOPICAL), BETAMET DIPROP / PROP GLY

CREAM (TOPICAL), BETAMET DIPROP / PROP GLY LOTION (TOPICAL), BETAMET

DIPROP / PROP GLY OINTMENT (TOPICAL), BETAMETHASONE DIPROPIONATE GEL

(TOPICAL), BETAMETHASONE DIPROPIONATE OINTMENT (TOPICAL),

BETAMETHASONE VALERATE LOTION (TOPICAL), DESOXIMETASONE CREAM

(TOPICAL), DESOXIMETASONE GEL (TOPICAL), DESOXIMETASONE OINTMENT

(TOPICAL), DIFLORASONE DIACETATE CREAM (TOPICAL), DIFLORASONE

DIACETATE OINTMENT (TOPICAL), DIPROLENE AF CREAM (TOPICAL),

DIPROLENE LOTION (TOPICAL), DIPROLENE OINTMENT (TOPICAL), FLUOCINONIDE GEL (TOPICAL), FLUOCINONIDE OINTMENT (TOPICAL), HALOG

CREAM (TOPICAL), HALOG OINTMENT (TOPICAL), KENALOG AEROSOL

(TOPICAL), TOPICORT CREAM (TOPICAL), TOPICORT LP CREAM (TOPICAL),

TOPICORT OINTMENT (TOPICAL), TOPICORT SPRAY (TOPICAL), VANOS

(TOPICAL)

Steroids, Topical Very High

Cynthia Conrad motioned to accept the recommendations as presented for this category. Manage

Nissanka seconded the motion and it was passed unanimously by the committee.

ON Medicaid PDL: CLOBETASOL EMOLLIENT (TOPICAL), CLOBETASOL

PROPIONATE CREAM (TOPICAL), CLOBETASOL PROPIONATE GEL (TOPICAL),

CLOBETASOL PROPIONATE OINTMENT (TOPICAL), CLOBETASOL PROPIONATE

SOLUTION (TOPICAL), CLOBEX SHAMPOO (TOPICAL), HALOBETASOL

PROPIONATE CREAM (TOPICAL), HALOBETASOL PROPIONATE OINTMENT

(TOPICAL)

OFF Medicaid PDL: APEXICON E (TOPICAL), CLOBETASOL LOTION (TOPICAL),

CLOBETASOL PROPIONATE FOAM (TOPICAL), CLOBETASOL SHAMPOO (TOPICAL),

CLOBEX LOTION (TOPICAL), CLOBEX SPRAY (TOPICAL), HALAC (TOPICAL),

HALONATE (TOPICAL), OLUX (TOPICAL), OLUX-E (TOPICAL), ULTRAVATE

CREAM (TOPICAL), ULTRAVATE OINTMENT (TOPICAL), ULTRAVATE X PAC

CREAM (TOPICAL), ULTRAVATE X PAC OINTMENT (TOPICAL)

Recommendations for next class reviews:

Magellan recommended the following classes be reviewed at the May P&T meeting:

ACNE AGENTS, TOPICAL

ANALGESICS, NARCOTICS LONG

ANALGESICS, NARCOTICS SHORT

ANDROGENIC AGENTS

ANGIOTENSIN MODULATOR COMBINATIONS

ANGIOTENSIN MODULATORS

ANTIBIOTICS, GI

ANTIBIOTICS, INHALED

ANTIBIOTICS, TOPICAL

ANTIBIOTICS, VAGINAL

ANTICOAGULANTS

ANTIEMETIC/ANTIVERTIGO AGENTS

ANTIFUNGALS, ORAL

ANTIFUNGALS, TOPICAL

ANTIMIGRAINE AGENTS

ANTIPARASITICS, TOPICAL

ANTIVIRALS, ORAL

ANTIVIRALS, TOPICAL

BETA-BLOCKERS

BLADDER RELAXANT PREPARATIONS

BONE RESORPTION SUPPRESSION AND RELATED AGENTS

BPH TREATMENTS

CALCIUM CHANNEL BLOCKERS

CEPHALOSPORINS AND RELATED ANTIBIOTICS

COLONY STIMULATING FACTORS

CONTRACEPTIVES, ORAL

ERYTHROPOIESIS STIMULATING PROTEINS

FLUOROQUINOLONES, ORAL

GROWTH FACTORS

GROWTH HORMONE

H. PYLORI TREATMENT

HEPATITIS C AGENTS

HYPOGLYCEMICS, INCRETIN MIMETICS/ENHANCERS

HYPOGLYCEMICS, INSULIN AND RELATED AGENTS

HYPOGLYCEMICS, MEGLITINIDES

HYPOGLYCEMICS, TZD

IMMUNOSUPPRESSIVES, ORAL

IRRITABLE BOWEL SYNDROME

LIPOTROPICS, OTHER

LIPOTROPICS, STATINS

MACROLIDES/KETOLIDES

MULTIPLE SCLEROSIS AGENTS

OPIATE DEPENDENCE TREATMENTS

PAH AGENTS, ORAL AND INHALED

PANCREATIC ENZYMES

PHOSPHATE BINDERS

PITUITARY SUPPRESSIVE AGENTS, LHRH

PLATELET AGGREGATION INHIBITORS

PRENATAL VITAMINS

PROTON PUMP INHIBITORS

SKELETAL MUSCLE RELAXANTS

TETRACYCLINES

ULCERATIVE COLITIS AGENTS

VASODILATORS, CORONARY

New Generics:

Kathy Novak presented to the committee members the following new generic products which

would be non-preferred on the Medicaid formulary:

SULFACETAMIDE SHAMPOO (TOPICAL)

DONEPEZIL 23 MG (ORAL)

CANDESARTAN (ORAL)

MUPIROCIN CREAM (TOPICAL)

GRISEOFULVIN ULTRAMICROSIZE (ORAL)

VORICONAZOLE SUSPENSION (ORAL)

ZOLMITRIPTAN TABLET (ORAL)

ZOLMITRIPTAN ODT (ORAL)

ACITRETIN (ORAL)

CALCIPOTRIENE CREAM (TOPICAL)

ACYCLOVIR OINTMENT (TOPICAL)

ALENDRONATE SOLUTION

LANSOPRAZOLE/AMOXICILLIN/CLARITHROMYCIN (ORAL)

REPAGLINIDE (ORAL)

PIOGLITAZONE/GLIMEPIRIDE (ORAL)

NIACIN ER (ORAL)

FENOFIBRIC ACID (TRILIPIX) (ORAL)

LIDOCAINE (TOPICAL)

TEMOZOLOMIDE (ORAL)

GATIFLOXACIN (OPHTHALMIC)

BUPRENORPHINE/NALOXONE TAB (SUBLINGUAL)

QUAZEPAM

HYDROCORTISONE BUTYRATE

DEXTROAMPHETAMINE SOLUTION (ORAL)

DOXYCYCLINE MONOHYDRATE SUSPENSION (ORAL)

Schedule next meeting:

Committee members suggested that a set of available dates be emailed to committee members

for review. The first week of May was suggested to be avoided due to a conflicting conference

for some committee members. Available dates will be sent to the committee by Jason Young.

Meeting adjourned at 7:21pm