Medicaid Prescription Drug Coverage – June 2020
Posted on June 2, 2020
Step Therapy Drug changes effective July 1, 2020:
For Health New England to cover the step therapy drugs listed here, you first must try the corresponding first line drugs. If Health New England has paid a claim for the first line drug within the previous 180 or 360 days (depending on the first line drug), then you are eligible for coverage of the step therapy drug.
The use of samples does not satisfy the requirements of documented usage of a first line drug or medical necessity for a step therapy drug.
If it is medically necessary for you to use a step therapy drug before trying a first line drug, then your provider can contact Health New England to request a medical review.
All new Step Therapy requirements apply only to new prescriptions.
| You must try: | First Line Drugs: | · Clobazam |
| Before HNE will cover: | Step Therapy Drug(s): | · Banzel |
| You must try: | First Line Drug(s): | · Dorzolomide |
| Before HNE will cover: | Step Therapy Drug(s): | · Azopt |
| You must try both: | First Line Drug(s): | · Latanoprost
· Travoprost |
| Before HNE will cover: | Step Therapy Drug(s): | · Zioptan |
Quantity Limit Additions
Starting July 1, 2020, Health New England will add Quantity Limits to the drugs below.
| Drug Name | Quantity Limit per 30-day supply
(unless otherwise specified) |
| · Banzel | 240 ML |
| · Zioptan | 30 ML |
| · Azopt | 10 ML |
New Prior Authorizations (PA) Effective July 1, 2020
• Nuplazid: PA thru Optum
• Eylea, Lucentis, Macugen: PA thru Magellan
New Prior Authorizations (PA) Effective July 1, 2020
• Betoptic S. Alternative is timolol
• Brimonidine 0.15%. Alternative is brimonidine 0.2%
• Calcitriol ointment. Alternative is calcipotriene
• Cephalexin 750mg. Alternative is cephalexin 250mg
• Cyclobenzaprine 7.5mg. Alternative is cyclobenzaprine 5mg or 10mg
• Desloratadine ODT. Alternative is desloratadine tablets
• Desonate gel. Alternative is desonide cream
• Evzio. Alternative is generic Evzio (naloxone injector)
• Fenoprofen. Alternative is ibuprofen
• Gralise. Alternative is gabapentin
• Horizant. Alternative is gabapentin
• Imiquimod 3.75%. Alternative is imiquimod 5%
• Indocin suppository. Alternative is indomethacin
• Lidocaine/hydrocortisone rectal kit. Alternative is lidocaine 5% ointment and hydrocortisone separately
• Lyrica CR. Alternative is pregabalin
• Urea 41%. Alternative is urea 40%
