Clinical Criteria have been established for some of the medications on the Preferred Drug List to insure that they are used in an efficacious, cost effective and safe manner.

Cymbalta®, step therapy required except for patients with diabetes Strattera®, step therapy required Zyprexa®, step therapy required

 

Cymbalta®

 

• No prior authorization required if a recipient has a diagnosis of diabetes, or a history of receiving hypoglycemic agents within the past 90 days.

• Recipients currently receiving Cymbalta^® for any diagnosis are grandfathered and may continue on Cymbalta^®

• Clinical prior authorization is required unless a recipient has a diagnosis of major depressive disorder or general anxiety disorder AND has had an 8-week trial of an SSRI (e.g. citalopram, fluoxetine, fluvoxamine, paroxetine, sertraline, Lexapro^®, Paxil^® CR, Pexeva^®, etc.) in the past 90 days.

• Quantities for all strengths are limited to 68 in a 34-day period.

To ensure patient safety, a 2-week trial of 60mg per day dose of Cymbalta^® is required before a 120mg per day regimen will be authorized.  (According to the labeling, there is no evidence that doses greater that 60 mg/day confer any additional benefits.  Also, the increased dosage may pose an increased risk of hepatotoxicity.  The maximum FDA approved daily dose is 60mg.)

Strattera®

Strattera® is a Tier Two product on the Preferred Drug List for recipients age 17 and under. If there is no history of use of Strattera® or a Tier One agent in the recipient’s most recent 90-day drug history, Strattera® will require a preauthorization. However, Strattera® claims may be adjudicated without a preauthorization based upon the following exceptions: 

1. Strattera® is considered a mental health drug, and therefore, grandfathered for all recipients who are currently receiving it. 

2. If a claim for Strattera® is submitted and the recipient (age 17 and under) has had a history of receiving a Tier One Agent within the previous 90-day period, the claim will adjudicate without a preauthorization. 

3. If the recipient is age 18 and over, the claim will adjudicate without a preauthorization.

Zyprexa®

Zyprexa^® has been designated a Tier Two atypical antipsychotic agent on the Preferred Drug List, due to the manufacturer's warnings about possible harmful metabolic side-effects.   If there is no history of use of Zyprexa^® OR no history of at least 42 days use of a Tier One agent in the recipient's most recent 90-day drug history (looking only at claims paid by Maryland Medical Assistance), Zyprexa^® will require preauthorization.  At the time of preauthorization, the call center will ascertain from the prescriber the indication for Zyprexa's^® use, including off-label indications.   

• The following atypical antipsychotic agents are Tier One drugs:

  • Abilify^®

  • Geodon^®

  • Invega^®

  • Risperdal^®

  • Seroquel^®

  • Seroquel XR^®

  • clozapine (generic)