Apple Health (Medicaid): Fee-for-service Preferred Drug List (PDL)

Washington State Health Care Authority sent this bulletin at 03/31/2017 02:08 PM PDT

Apple Health (Medicaid): Provider Alert

Dear Provider,

Effective for claims with dates of service on and after May 1, 2017, the Health Care Authority (agency) will make the following changes to the Apple Health (Medicaid): Fee-for-Service Preferred Drug List (PDL):

Drug Class	Drug Name	Change
Antiemetics	Akynzeo®	Added to class as non-preferred, unstudied, not subject to TIP/DAW.
Antiemetics	Sustol®	Added to class as non-preferred, unstudied, not subject to TIP/DAW.
Attention Deficit Hyperactivity Disorder	Vyvanse® chew	Preferred.
Attention Deficit Hyperactivity Disorder	ProCentra®	Non-Preferred, not subject to TIP/DAW-1 override.
Beta Blockers	Kerlone®	Removed, no longer manufactured.
Estrogens	Entire class	Client must have tried and failed, or is intolerant to, all preferred products before receiving a non-preferred product according to the formulation prescribed for the same indication.
Estrogen – Progestin Combinations	Entire class	Client must have tried and failed, or is intolerant to, all preferred products before receiving a non-preferred product according to the formulation prescribed for the same indication.
Inhaled Beta Agonists	Entire class	Separated this class into two classes: “Asthma – Quick Relief” and “Asthma or COPD – Long-Acting Beta Agonists (LABA).”
Asthma – Quick Relief	Entire class	Client must try all preferred drugs with the same route of administration before a non-preferred drug will be authorized unless contraindicated or not clinically appropriate.
Asthma or COPD – Long-Acting Beta Agonist (LABA)	Entire class	Client must try all preferred drugs with the same route of administration before a non-preferred drug will be authorized unless contraindicated or not clinically appropriate.
Asthma or COPD – Long-Acting Beta Agonist (LABA)	Striverdi®	Non-Preferred, subject to TIP/ DAW-1 override.
Inhaled Corticosteroid	Entire class	Renamed this class “Asthma – Inhaled Corticosteroid.” Client must try all preferred drugs with the same indication before a non-preferred drug will be authorized unless contraindicated or not clinically appropriate.
Asthma - Inhaled Corticosteroid	Arnuity Ellipta®	Non-Preferred, subject to TIP/DAW-1 override.
Asthma - Inhaled Corticosteroid	Pulmicort Respules® 1mg/2ml	Non-Preferred, subject to TIP/DAW-1 override.
Inhaled Corticosteroids – Long-Acting Beta-Agonist Combinations	Entire class	Renamed class to “Asthma or COPD – Inhaled Corticosteroid – Long-Acting Beta Agonist Combinations.” Client must try all preferred drugs with the same indication before a non-preferred drug will be authorized unless contraindicated or not clinically appropriate.
Asthma or COPD –Inhaled Corticosteroids – Long-Acting Beta-Agonist Combinations	Breo Ellipta®	Non-Preferred, subject to TIP/DAW-1 override.
Insulin-Release Stimulant Type Oral Hypoglycemics	Entire class	Changed name of drug class to “Diabetes Drugs – Sulfonylureas.”
Leukotriene Modifiers	Entire class	Renamed class to “Asthma – Leukotriene Modifiers.” Client must try all preferred drugs with the same indication before a non-preferred drug will be authorized unless contraindicated or not clinically appropriate
Long-Acting Beta-Agonist – Long Acting Muscarinic Agent Combinations (LABA – LAMA)	Entire class	Renamed class to “Asthma or COPD - Long-Acting Beta-Agonist – Long Acting Muscarinic Agent Combinations (LABA- LAMA).” Client must try all preferred drugs with the same indication before a non-preferred drug will be authorized unless contraindicated or not clinically appropriate.
Asthma or COPD --Long-Acting Beta-Agonist – Long Acting Muscarinic Agent Combinations (LABA – LAMA)	Anoro Ellipta®	Non-Preferred, subject to TIP/DAW-1 override.
	Stiolto®	Preferred.
	Utibron Neohaler®	Non-Preferred, EA required, subject to TIP/DAW-1 override.
Long-acting Insulins	Entire class	This class is being renamed “Diabetes Drugs – Long-acting Insulins.”
Long Acting Muscarinic Agent Combinations (LAMA)	Entire class	Renamed class to “Asthma or COPD -- Long Acting Muscarinic Agent Combinations (LAMA).” Client must try all preferred drugs with the same indication before a non-preferred drug will be authorized unless contraindicated or not clinically appropriate.
Asthma or COPD -- Long Acting Muscarinic Agent Combinations (LAMA)	Incruse Ellipta®	Non-Preferred, EA required, subject to TIP/DAW-1 override.
	Seebri Neohaler®	Non-Preferred, subject to TIP/DAW-1 override.
Long Acting Opioids	Arymo ER®	Non-preferred, not subject to TIP/DAW-1 override.
Newer Diabetics	Entire class	This class is being separated into several classes, titled “Diabetes Drugs – (subclass).”
Diabetes Drugs – Amylin Agonist	Entire class	EA required. Client must try all preferred drugs with the same route of administration before a non-preferred drug will be authorized unless contraindicated or not clinically appropriate.
Diabetes Drugs – DPP-4 Inhibitors	Entire class	Client must try all preferred drugs with the same route of administration before a non-preferred drug will be authorized unless contraindicated or not clinically appropriate. Removed PA requirement.
	alogliptin benzoate	Preferred.
	alogliptin-metformin	Preferred.
	alogliptin-pioglitazone	Preferred.
	Janumet®	Non-Preferred, subject to TIP/DAW-1 override.
	Janumet XR®	Non-Preferred, subject to TIP/DAW-1 override.
	Jentadueto®	Preferred.
	Jentadueto XR®	Non-Preferred, subject to TIP/DAW-1 override.
	Kazano®	Non-Preferred, subject to TIP/DAW-1 override.
	Kombiglyze XR®	Non-Preferred, subject to TIP/DAW-1 override.
	Oseni®	Non-Preferred, subject to TIP/DAW-1 override.
Diabetes Drugs – GLP-1 Agonists	Entire class	Client must try all preferred drugs with the same route of administration before a non-preferred drug will be authorized unless contraindicated or not clinically appropriate.
	Adlyxin®	Non-preferred, not subject to TIP/DAW-1 override.
	Soliqua®	Non-preferred, not subject to TIP/DAW-1 override.
	Xultophy®	Non-preferred, not subject to TIP/DAW-1 override.
Diabetes Drugs – SGLT-2 Inhibitors	Entire class	Client must try all preferred drugs with the same route of administration before a non-preferred drug will be authorized unless contraindicated or not clinically appropriate.
	Glyxambi®	Non-Preferred, subject to TIP/DAW-1 override.
	Invokamet®	Preferred.
	Invokana®	Preferred.
	Xigduo XR®	Preferred.
	Invokamet XR®	Non-Preferred, subject to TIP/DAW-1 override.
	Synjardy®	Non-Preferred, subject to TIP/DAW-1 override.
Insomnia	Edluar®	Non-preferred, not subject to TIP/DAW-1 override.
	Intermezzo®	Non-preferred, not subject to TIP/DAW-1 override.
	Zolpimist®	Non-preferred, not subject to TIP/DAW-1 override.
Newer Antihistamines	Astelin®	Removed, no longer manufactured.
NSAIDs	Cambia™	Non-Preferred, subject to DAW-1 override.
	Diclofenac sodium topical gel	Non-Preferred, PA required, subject to DAW-1 override.
	Diclofenac sodium topical solution	Non-Preferred, PA required, subject to DAW-1 override.
	Flector®	Non-Preferred, PA required, subject to DAW-1 override.
	Pennsaid®	Non-Preferred, PA required, subject to DAW-1 override.
	Rexaphenac®	Non-Preferred, PA required, subject to DAW-1 override.
	Solaraze®	Non-Preferred, PA required, subject to DAW-1 override.
	Voltaren®	Non-Preferred, PA required, subject to DAW-1 override.
Overactive Bladder/Urinary Incontinence	Entire class	Client must try all preferred drugs with the same route of administration before a non-preferred drug will be authorized unless contraindicated or not clinically appropriate.
PD4I Phosphodiesterase – 4 Inhibitors	Entire class	Renamed class to “Asthma or COPD – PD4I Phosphodiesterase – 4 Inhibitors.” Client must try all preferred drugs with the same route of administration before a non-preferred drug will be authorized unless contraindicated or not clinically appropriate.
Proton Pump Inhibitors	Entire class	Client must try all preferred drugs with the same route of administration before a non-preferred drug will be authorized unless contraindicated or not clinically appropriate.
Second Generation Antidepressants	Irenka®	Removed, no longer manufactured.
Second Generation Antidepressants	Pexeva®	Non-preferred, not subject to TIP/DAW-1 override.
Second Generation Antipsychotics	quetiapine ER	Preferred.
Statins	Livalo®	Non-preferred, not subject to TIP/DAW-1 override.
Thiazolidinediones (TZDs)	Entire class	Changed name of drug class to “Diabetes Drugs – Thiazolidinediones (TZDs).”
Diabetes Drugs – Thiazolidinediones (TZDs)	Avandia®	Removed PA requirement.
Triptans	Zecuity®	Non-preferred, not subject to TIP/DAW-1 override.

For more details, see the agency’s Apple Health Medicaid: Fee-for-Service Preferred Drug List.

Please do not reply directly to this message. If you have feedback or questions, please visit the HCA website for contact information.

About Washington State Health Care Authority
HCA oversees the state’s top two health care purchasers — Washington Apple Health (Medicaid) and the Public Employee Benefits Board Program. We work with partners to help ensure Washingtonians have access to better health and better care at a lower cost. For more information, visit www.hca.wa.gov.

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