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Request for a Non-Preferred Drug Prior Authorization Form
Rhode Island Medicaid Fee for Service Preferred Drug List
Note: Most fax requests are responded to within 24 hours
The general rule to receive a non-preferred agent is to try a preferred agent in the same therapeutic class in the past 90 days.
The exceptions to this general rule are drugs that require a clinical prior authorization of some kind or a step edit. These drugs are identified below in the appropriate class listing and are highlighted in green.
The Preferred Drug List (PDL) is a listing of therapeutic classes and associated drugs that are managed by the Medicaid Fee-for-Service Pharmacy and Therapeutics Committee. It is not an all inclusive list of covered medications in the Medicaid Fee-for-Service program. If you have an NDC, please check the NDC lookup on the EOHHS healthcare portal to determine coverage.
Androgenic AgentsLength of Authorization: 1 Year Status Implementation: 10/15/2008
Current Review Date: 10/24/2017No PA Required PA RequiredAndrogenic Agents Androgenic AgentsAndroderm testosteroneAndrogel Axiron
FortestaNatestoTestimVogelxo gelVogelxo gel packetVogelxo gel pump
Angiotensin ModulatorsLength of Authorization: 1 Year Status Implementation: 1/15/2007
Current Review Date: 1/22/2018No PA Required PA RequiredAce Inhibitors Ace Inhibitorsbenazepril fosinoprilcaptopril moexiprilenalapril perindoprillisinopril quinapril
* Diagnosis of Hepatic Encephalopathy and 1 paid claim for lactulose in the past 30 days or inadequate respone or contraindication to lactulose documented
Antibiotics, InhaledLength of Authorization: 1 Year Status Implementation: 5/11/2012
Current Review Date: 7/5/2017No PA Required PA RequiredAntibiotics, Inhaled Antibiotics, InhaledBethkis tobramycin Kitabis Pak Cayston
TobiTobi Podhaler
Antibiotics, TetracyclinesLength of Authorization: 1 Year Status Implementation: 7/1/2013
Return to Index SolodynVibramycin cap/suspensionVibramycin syrupXimino ERNR
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Antibiotics, TopicalLength of Authorization: 1 Year Status Implementation: 7/1/2013
Current Review Date: 7/5/2017No PA Required PA RequiredAntibiotics, Topical Antibiotics, Topicalmupirocin ointment mupirocin cream
AltabaxBactroban cream/ointmentCentanyCentany kit
Antibiotics, VaginalLength of Authorization: 1 Year Status Implementation: 7/1/2013
Current Review Date: 7/5/2017No PA Required PA RequiredAntibiotics, Vaginal Antibiotics, Vaginalmetronidazole clindamycin Cleocin Ovules Cleocin creamClindesse MetrogelVandazole Return to Index Nuvessa
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AnticoagulantsLength of Authorization: 1 Year Status Implementation: 1/15/2008
Current Review Date: 2/01/2017No PA Required PA RequiredAnticoagulants Anticoagulantswarfarin coumadinFragmin enoxaparin Lovenox fondaparinux Pradaxa* ArixtraXarelto BevyxxaNR
Eliquis Eliquis dose packNR
Savaysa* Diagnosis of Atrial Fibrillation in the past year. Xarelto dose pack
AnticonvulsantsLength of Authorization: 1 Year Status Implementation: 1/15/2008
Current Review Date: 1/22/2018No PA Required PA Requiredcarbamazepine derivatives carbamazepine derivativescarbamazepine chewable tablet carbamazepine XRcarbamazepine ER carbamazepine suspensioncarbamazepine tablet Carbatroloxcarbazepine tablet/susp EquetroEpitol Oxtellar XRTegretol suspension Tegretol tablet/chewable tabletTegretol XR Trileptal suspension
paroxetine CRsertaline concentrateBrisdelleCelexaLexapro(failure of citalopram)Paxil/CRPexevaProzac/Weekly
Return to Index SarafemZoloft
* History of a paid claim for a preferred antidepressant at least 28 days prior to the current date of service
PA RequiredSecond Generation
PA RequiredOther
* Diagnosis of epilepsy, convulsions or seizure disorder and a claim for Keppra or Topamax in the past 60 days or a claim for a preferred agent in the past 90
days
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AntiemeticsLength of Authorization: 1 Year Status Implementation: 1/15/2008
Current Review Date: 5/30/2018No PA Required PA RequiredSerotonin Antagonists Serotonin Antagonistsmetoclopramide solution granisetronmetoclopramide tablet metoclopramide ODTondansetron ODT Akynzeoondansetron solution Anzemetondasetron tablet BonjestaNR
Length of Authorization:1 Year Status Implementation: 7/1/2007Current Review Date: 7/5/2017
No PA Required PA RequiredAntihistamines Antihistaminescetirizine tab/solution desloratadine/ODTlevocetirizine fexofenadine suspensionloratadine tablet loratadine ODT /solution
Length of Authorization: 1 Year Status Implementation: 5/27/2015Current Review Date: 5/30/2018
No PA Required PA RequiredAntihyperuricemics Antihyperuricemicsallopurinol colchicine capsulecolchicine tablet Colcrysprobencid Duzalloprobencid/colchicine Mitigare
UloricZurampicZyloprim
Antimigraine AgentsLength of Authorization: 1 Year Status Implementation: 7/1/2007
Length of Authorization: 1 Year Status Implementation: 1/15/2008Current Review Date: 10/24/2017
No PA Required PA RequiredDopamine Receptor Agonists Dopamine Receptor Agonistsamantadine capsule pramipexole ERamantadine syrup ropinirole ERamantadine tablet GocovriNR
pramipexole IR Mirapex*/ERropinirole IR Neupro
Requip/XL
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* Diagnosis of Parkinson's in the past 12 months or Diagnosis of Restless Leg Syndrome in the past 12 months and a claim for ropinirole in the past 90 days
Antihyperuricemics
PA RequiredAntimigraine Agents
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AntipsychoticsLength of Authorization: 1 Year Status Implementation: 10/15/2008
Current Review Date: 7/5/2017No PA Required PA RequiredAtypical Atypicalaripiprazole tablet aripiprazole solution/ODTclozapine tablet clozapine ODTolanzapine tablet olanzapine ODTpaliperidone ER olanzapine/fluoxetinequetiapine Abilify tabletquetiapine ER Adasuverisperidone Aristadaziprasidone ClozarilAbilify Maintena Fanapt tritration packInvega Sustenna FazacloInvega Trinza * GeodonLatuda InvegaRisperdal Consta Nuplazid
Bile SaltsLength of Authorization: 1 Year Status Implementation: 1/22/2018
Current Review Date: 1/22/2018No PA Required PA RequiredBile Salts Bile Saltsursodiol tablet chenodal
ursodiol 300mg capsuleActigallCholbamOcalivaUrso/Urso Forte tablet
Bladder RelaxantsLength of Authorization: 1 Year Status Implementation: 10/15/2007
Current Review Date: 10/24/2017No PA Required PA RequiredBladder Relaxants Bladder Relaxantsoxybutynin ER darifenacin ERoxybutynin IR tolterodineEnablex tolterondine ERToviaz trospium/ERVesicare Detrol/LA
Ditropan/XLGelniqueGelnique gel pumpMyrbetriqOxytrol
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Length of Authorization: 1 Year Status Implementation: 5/1/2007Current Review Date: 5/30/2018
No PA Required PA RequiredBisphosphonates Bisphosphonatesalendronate tablet alendronate solution
etidronateibandronaterisedronate sodium DRActonelAtelviaBinostoBonivaFosamax/Plus D
Other Related Agents Other Related Agentsraloxifene HCL calcitonin salmon
EvistaForteo *Prolia*Tymlos*
* History of Bisphosphonates in 12 Months
BPH Agents
Length of Authorization:1 Year Status Implementation: 10/15/2007Current Review Date: 10/24/2017
No PA Required PA RequiredAlpha Blockers, Selective Alpha Blockers, Selectivealfuzosin Flomaxtamsulosin HCL Rapaflo
Bronchodilators, Beta AgonistLength of Authorization: 1 Year Status Implementation: 7/1/2007
Current Review Date: 7/5/2017No PA Required PA Required
Beta Agonist Inhalers, Long Acting Beta Agonist Inhalers, Long ActingForadil (step edit-use of inhaled corticosteroid in past 45 days) Striverdi RespimatSerevent (step edit-use of inhaled corticosteroid in past 45 days)
Beta Agonist Inhalers, Short Acting Beta Agonist Inhalers, Short ActingProAir HFA levalbuterol tartrate HFAProventil HFA Arcapta
ProAir RespiclickVentolin HFAXopenex HFA
Beta Agonist Nebulizers, Long Acting
Beta Agonist Nebulizers, Long Acting
n/aBrovana (step edit for failure of long acting inhaler and corticoid steroid)
Perforomist (step edit for failure of long acting inhaler and corticoid steroid)
If recipient is over 21 years of age a manual clinical PA is required for preferred agents.
If recipient is over 21 years of age a manual clinical PA (specific form is available on the OHHS website) is required as well as a claim for a preferred agent in the past 90 days for a non-preferred agents. If the recipient is under 21 years of age a claim for a preferred agent in the past 90 days is required is required for a non-preferred agent.
Specific form is available on the OHHS website.
Specific form is available on the OHHS website.
H. Pylori TreatmentLength of Authorization: 1 Year Status Implementation: 5/27/2015
Current Review Date: 5/30/2018No PA Required PA RequiredH. Pylori Treatment H. Pylori TreatmentPylera lansoprazole/amoxicillin/clarithromycin
Antihistamines & Other Antihistamines & Otheripratropium (nasal) azelastinePatanase olopatadine
Astepro
Leukotriene ModifiersLength of Authorization: 1 Year Status Implementation: 7/1/2007
Current Review Date: 7/5/2017No PA Required PA RequiredLeukotriene Modifiers Leukotriene Modifiersmontelukast tab/chew montelukast granuleszafirlukast Accolate
SingulairZyflo CR
Lipotropics, OtherLength of Authorization: 1 Year Status Implementation: 5/1/2007
Current Review Date: 1/22/2018No PA Required PA RequiredBile Acid Resins Bile Acid Resinscholestyramine light colestipol granules/packetcolestipol tablet Colestid tablet/granules/packetPrevalite Questran
Lipotropics, StatinsLength of Authorization: 1 Year Status Implementation: 1/15/2007
Current Review Date: 1/22/2018No PA Required PA RequiredStatins Statinsatorvastatin fluvastatin/ERlovastatin Altoprevpravastatin Crestorrousuvastatin Lescol/XLsimvastatin Lipitor (failure on Crestor)
MethotrexateLength of Authorization: 1 Year Status Implementation: 9/2/2015
Current Review Date: 7/5/2017No PA Required PA RequiredMethotrexate Methotrexatemethotrexate PF vial Otrexup Auto Injectormethotrexate tablet Rasuvo Auto Injectormethotrexate vial Trexall Tablet
Xatmep
Multiple SclerosisLength of Authorization: 1 Year Status Implementation: 5/15/2008
Neuropathic PainLength of Authorization: 1 Year Status Implementation: 1/17/2013
Current Review Date: 1/22/2018No PA Required PA RequiredOral Oralduloxetine (generic Cymbalta) duloxetine (generic Irenka)gabapentin capsule/solution gabapentin tablet
CymbaltaGraliseHorizant/ER**Lyrica**Lyrica CR**NR
NeurontinSavella*
Topical Topicalcapsaicin dermacinrx phn pakNR
lidocaine patchLidoderm***Qutenza Kit***
* Diagnosis of Fibromyalgia in the past year and a claim for a preferred agent ** Diagnosis of Epilepsy or Convulsions in the past year and a claim for a preferred agent OR Diagnosis of Fibromyalgia in the past year and a claim for Lyrica or Savella in the past 60 days OR Diagnosis of Diabetic Peripheral Neuropathy or Post Herpetic Neuralgia
***Step edit failure on one oral NSAID
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NSAIDS and Combination ProductsLength of Authorization: 1 Year Status Implementation: 10/15/2007
Current Review Date: 1/22/2018No PA RequiredNSAIDS and Combo Productsdiclofenac sodium celecoxib*** Celebrex***flurbiprofen diclofenac potassium Dayproibuprofen susp/tablet diclofenac sodium gel Dermacinrx Lexitralindomethacin capsule diclofenac SR Duexisketorolac (oral) diclotral Feldenemeloxicam tablet diflunisal **Flectornaproxen tablet etodolac Indocin supp/suspensionpiroxicam fenoprofen Mobicsulindac indomenthacin capsule ER NalfonVoltaren (topical)* ketoprofen/ER Naprelan
* Failure of an oral NSAID ** Failure of Voltaren gel
*** Claim for a preferred agent in the past 90 days and a claim for an anticoagulant in the past 30 days or a diagnosis of a gastrointestinal hemorrhage in the past year.
Ophthalmics
Length of Authorization: 1 Year Status Implementation: 10/15/2007Current Review Date: 10/24/2017
No PA Required PA RequiredAllergic Conjunctivitis Allergic Conjunctivitiscromolyn sodium azelastine ophth 0.05%Pazeo epinastine
No PA Required PA RequiredGlaucoma GlaucomaAlpha-2 Adrenergic Agonists Alpha-2 Adrenergic Agonistsbrimonidine 0.2% apradondineAlphagan P brimonidine 0.15%
Ophthalmics, Antibiotic-Steroid CombinationsLength of Authorization: 1 Year Status Implementation: 1/22/2018
Current Review Date: 1/22/2018No PA Required PA RequiredAntibiotic-Steroid Combinations Antibiotics-Steroid Combinationsneomycin/polymyxin/desamethasone neomycin/bacitracin/poly/HCTobradex suspension neomycin/polymyxin/HC
Length of Authorization: 1 Year Status Implementation: 1/22/2018Current Review Date: 1/22/2018
Ophthalmic Anti-Inflammatory/Immunomodulators
Ophthalmic Anti-Inflammatory/Immunomodulators
No PA Required PA RequiredRestasis XiidraRestasis multidose
Opiate Dependence TreatmentLength of Authorization: 1 Year Status Implementation: 9/2/2015
Current Review Date: 7/5/2017No PA Required PA Required
Buprenorphine and Related Agents Buprenorphine and Related Agentsbuprenorphine HCL buprenorphine/naloxone tabSuboxone Film Bunavail
ProbuphineZubsolv
No PA Required PA RequiredOpiate Dependence, Other Opiate Dependence, Othernaltrexone HCL SublocadeNR
Naloxone Syringe VivitrolNarcan SprayNarcan Spray
Otic Antibiotics Status Implementation: 10/15/2007Length of Authorization: 1 Year Current Review Date: 10/24/2017No PA Required PA RequiredOtic Antibiotics Otic Antibioticsciprofloxacin otic ofloxacinneomycin/polymixin/HC soln/susp floxin 0.3%Ciprodex Cipro HC
Coly-mycin SOtioprioOtovel
Pancreatic EnzymesLength of Authorization: 1 Year Status Imlementation: 5/11/2012
Current Review Date: 5/30/2018No PA Required PA RequiredPancreatic Enzymes Pancreatic EnzymesCreon PancreazeZenpep Pertzye
Viokace
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Ophthalmic Anti-Inflammatories/Immunomodulators
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Phosphate BindersLength of Authorization: 1 Year Status Implementation: 10/15/2007
Current Review Date: 10/24/2017No PA Required PA RequiredPhosphate Binders Phosphate Binderscalcium acetate capsule/tablet lanthanum carbonateRenagel sevelamer carbonateRenvela tablets Auryxia
Platelet InhibitorsLength of Authorization: 1 Year Status Implementation: 1/5/2009
Current Review Date: 1/22/2018No PA Required PA RequiredPlatelet Inhibitors Platelet Inhibitorsclopidrogel aspirin-dipyridamoledipyridamole prasugrelticlopidine AggrenoxBrilinta Effient
PlavixYospralaZontivity
Progestins for CachexiaLength of Authorization: 1 Year Status Implementation: 1/22/2018
Current Review Date: 1/22/2018No PA Required PA RequiredProgestins for Cachexia Progestins for Cachexiamegestrol suspension Megace ESmegestrol tablets megestrol suspension (Megace ES)
Proton Pump InhibitorsLength of Authorization: 1 Year Status Implementation: 5/1/2007
Current Review Date: 5/30/2018No PA Required PA RequiredProton Pump Inhibitors Proton Pump Inhibitorsomeprazole esomeprazole magnesiumpantoprazole esomeprazole strontium
Clinical PA over 21 years of age. Specific PA form is on the EOHHS website.
Clinical PA over 21 years of age. Specific PA form is on the EOHHS website. If the recipient is under 21 years of age a claim for a preferred agent is required.
Rosacea Agents, Topical
Length of Authorization: 1 Year Status Implementation: 01/02/2018Current Review Date: 01/02/2018
No PA Required PA RequiredFinacea metronidazole creamMetrocream metronidazole gel (AG)Metrogel metronidazole gel
Skeletal Muscle RelaxantsLength of Authorization: 1 Year Status Implementation: 7/6/2009
Current Review Date: 7/5/2017No PA Required PA RequiredSkeletal Muscle Relaxants Skeletal Muscle Relaxantsbaclofen dantrolenechlorzoxazone metaxallNR
cyclobenzaprine metaxalonemethocarbamol orphenadrine citrate ER
tizanidine cap/tabAmrixDantriumFexmidLorzone RobaxinSkelaxinZanaflex**carisoprodol and Soma - no longer covered by RI Medicaid
SteroidsLength of Authorization: 1 Year Status Implementation: 5/31/2013
Current Review Date: 5/30/2018No PA Required PA RequiredTopical High Topical Highbetamethasone dipropionate cream/lotion amcinonide cream, lotion, ointmentbetamethasone valerate cream, ointment
No PA Required PA RequiredTopical Very High Topical Very Highclobetasol propionate cream,gel clobetasol emollientclobetasol propionate ointment clobetasol lotionclobetasol solution clobetasol shampoohalobetasol propionate cream clobetasol propionate foamhalobetasol propionate ointment clobetasol propionate sprayhalobetasol propionate ointment Apexicon E
Length of Authorization: 1 Year Status Implementation: 1/15/2008Current Review Date: 10/24/2017
No PA Required PA RequiredStimulants and Related Agents
amphetamine salt combo amphetamine salt combo ERatomoxetine armodafinildextroamphetamine tab/cap ER clonidine ERguanfacine ER dexmethylphenidatemethylphenidate IR dexmethylphenidate XRAdderall XR dextroamphetamine solutionAptensio XR methamphetamine
Concerta methylphenidate CD
Daytranamethylphenide ER cap (generic Ritalin LA)
Focalin methylphenidate ER 18,27,36,54 mg
Focalin XRmethylphenidate ER 18,27,36,54 mg (AG)
Kapvay methylphenidate ER tabletProcentra methylphenidate solution/chewableProvigil modafanil Quillichew ER Adzenys XR ODT/suspensionQuillivant XR Cotempla XR ODTRitalin LA DesoxynVyvanse capsule Dexedrine
* If the recipient is over 21 years of age a diagnosis of ADD, ADHD, Narcolepsy or Depression in the past year or evidence of stimulant treatment greater than 210 days or 7 stimulant claims in the past year is required for the clinical PA for a preferred agent. If the recipient is under 21 years of age the claim will process with no PA required.
* If the recipient is over 21 years of age a claim for a preferred agent AND a diagnosis of ADD, ADHD, Narcolepsy or Depression in the past year or evidence of stimulant treatment greater than 210 days or 7 stimulant claims in the past year is required for the clinical PA for a preferred agent. If the recipient is under 21 years of age a claim for a preferred agent is required.
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Stimulants and Related Agents
Stimulants and Related Agents*
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Topical AcneLength of Authorization: 1 Year Status Implementation: 5/15/2008
Current Review Date: 5/30/2018No PA RequiredMiscellaneous Topicalsclindamycin/benzoyl peroxide (generic Duac) Acne clearing system erythromycin med swabclindamycin/benzoyl peroxide w/pump (general Benzaclin Pump) Aczone erythromycin-benzoly peroxideclindamycin phosphate solution Aczone gel/w pump Evoclinerythromycin solution Avar Cleanser Fabior
