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Louisiana Healthcare Connections Appropriate Use and Safety Edits
he health and safety of our members is a priority for Louisiana Healthcare Connections. One of the ways
T we address patient safety is through point-of sale (POS) edits at the time a prescription is processed
at the pharmacy. These edits are based on Food and Drug Administration (FDA) recommendations and
promote safe and effective medication utilization of our memberrs. Quantity Limits: Restrictions on claim quantity per day implemented to prevent doses above the FDA approved guidelines. Multiple medications within different drug classes have quantity limit requirements. Lower Age Limits: Restrictions on age implemented to prevent children below the FDA approved age of receiving medications off-label. Current drug classes with lower age limits include, but are not limited to:
Long-Acting ADHD Medications (Stimulants & Non-Stitimulants)
Migraine Rescue Medications (Triptans and Non-Triptans)
Short-Acting ADHD Medications (Stimulants only)
Upper Age Limits: Restrictions on age implemented to prevent adults from receiving medications commonly indicated for pediatric use only (without proper documentation of diagnosis). Current drug classes with upper age limits include, but are not limited to:
Long-Acting ADHD Medications (Stimulants and Non-Stimulants)
Short-Acting ADHD Medications (Stimulants only)
Duplicate Thherapy Edits: Restrictions on claims implemented to prevent members from receiving excessive medication regimens within the same (or similar) drug classes. Current drug classes with duplicate therapy edits include, but are not limited to:
ACE Inhibitor/Angiotensin Receptor Blockers
Diabetic Medications (Sulfonylurea/Meglitinides)
Human Immunodeficiency Virus Medications
Long-Acting ADHD Medications (Stimulants & Non-Stitimulants)
Selective Serotonin Receptor Inhibitors and Serotonin Norepinephrine Receptor Inhibitors
Short-Acting ADHD Medications (Stimulants only)
For specific drug quantity limits and age limits please refer tto the Louisiana Healthcare Connections Preferred Drug List (PDL). Appropriate Use and Safety Edits
Dose Consolidation Edits: Restrictions on claims implemented to prevent members from receiving multiple strengths of the same medication. Current drug classes with dose consolidation edits include:
Long-Acting ADHD Medications (Stimulants and Non Stimulants)
Selective Serotonin Receptor Inhibitors and Serotonin Norepinephrine Receptor Inhibitors
Short-Acting ADHD Medications (Stimulants only)
Step Therapy Edits: Restrictions on claims implemented to steer members toward the preferred medication in the drug class. Current drug classes with step therapy restrictions include, but are not limited to:
Teratogenic Edits: Restrictions on claims implemented to prevent female members from receiving potentially harmful medications prior to confirmation of pregnancy status. Multiple medications within different drug classes have teratogenic requirements. Safety Edits: Restrictions on claims implemented to prevent members from receiving combination drug regimens that are contraindicated or have been deemed toxic and potentially life threatening.
Human Immunodeficiency Virus (HIV) Medications
For specific drug quantity limits and age limits please refer to the Louisiana Healthcare Connections Preferred Drug List (PDL). Appropriate Use and Safety Edits
Duplicate Therapy Edit Medications
PDL: Abilify, Clozaril (clozapine), Geodon (ziprasidone), Risperdal
(risperidone), Seroquel (quetiapine), Seroquel-XR, Zyprexa (olanzapine)
Non-PDL: Abilify Discmelt, Fanapt, Fazaclo, Invega, Invega Sustenna,
Latuda, Risperdal Consta, Saphris, Zyprexa Zydis (olanzapine)
PDL: Adderall XR (amphetamine-dextroamphetamine ER), Concerta
(methylphenidate ER), Dexedrine SR (dextroamphetamine ER), Metadate
CD (methyphenidate CR), Ritalin SR (methylphenidate ER)
Non-PDL: Daytrana, Focalin XR, Ritalin LA (methylphenidate ER),
PDL: Adderall (amphetamine-dextroamphetamine), Dexedrine
(dextroamphetamine), Methylin/Ritalin (methylphenidate)
PDL: Catapres (clonidine), Tenex (guanfacine)
(one drug regimen) Applies only to age <
PDL: Celexa (citalopram), Effexor (venlafaxine), Effexor XR (venlafaxine
ER), Luvox (fluvoxamine), Paxil (paroxetine), Paxil CR (paroxetine ER),
Prozac (fluoxetine), Zoloft (sertraline)
Non-PDL: Cymbalta, Lexapro (escitalopram), Luvox CR, Pexeva, Pristiq
PDL: Anafranil (clomipramine), Elavil (amitriptyline), Norpramin
(desipramine), Pamelor (nortiptyline), Sinequan (doxepin), Tofranil
Non-PDL: Surmontil (trimipramine), Vivactil (protriptyline)
PDL: Ativan (lorazepam), Dalmane (flurazepam), Halcion (triazolam),
Klonopin (clonazepam), Librium (chlordiazepoxide), Restoril (temazepam),
Serax (oxazepam), Tranxene (clorazepate), Valium (diazepam), Xanax
Sedative-Hypnotics PDL: Ambien (zolpidem), Chloral Hydrate, Dalmane (flurazepam), Halcion
(triazolam), Restoril (temazepam), Sonata (zaleplon).
Non-PDL: Ambien CR (zolpidem ER), Doral, Prosom (estazolam), Lunesta, (one drug regimen)
Please refer to the safety edit section (NOTE: All HIV medications are
PDL: Accupril (quinapril), Altace (ramipril), Capoten (captopril), Cozaar
(losartan), Diovan, Lotensin (benazepril), Mavik (trandolapril), Monopril
(fosinopril), Vasotec (enalapril), Zestril (lisinopril), plus any of the following
drugs in combination with HCTZ Non-PDL: Aceon (perindopril), Atacand, Avapro (irbesartan), Benicar,
Edarbi, Micardis, Teveten, Univasc (moexipril), plus any of the following drugs in combination with HCTZ or other cardiovascular medications
PDL: Amaryl (glimepiride), Diabeta (glyburide), Glucotrol (glipizide),
Glucotrol XL (glipizide SR), Glucovance (glyburide-metformin), Glynase
(glyburide micronized), Metaglip (glipizide-metformin)
Non-PDL: Avandaryl, Diabinese (chlorpropamide), Duetact, Dymelor (acetohexamide), Orinase (tolbutamide), Prandimet, Prandin, Starlix
For specific drug quantity limits and age limits please refer to the Louisiana Healthcare Connections Preferred Drug List (PDL). Appropriate Use and Safety Edits
Step Therapy Edit Medications
Claritin (loratadine), Zyrtec (cetirizine)
Teratogenic Edit Programming Details
Is member between 11 – 50 years of age?
Does the member have an active claim for contraception or hormone replacement therapy?
Is the member pregnant? (Pharmacist to ask member at POS)
Is the drug labeled as pregnancy category X?
Is the drug labeled as pregnancy category D (risk outweighs benefit)?
Is the drug labeled as pregnancy category D (benefits may outweigh risk)?
Call prescriber. Does benefit outweigh risks?
Teratogenic Edit Medications
5-Alpha Reductase Inhibitors, Anabolic Steroids, Androgens, Anorexiants, Antineoplastics,
Coumadin Anticoagulants, Endothelin Receptor Antagonists, Hepatitis Agents, HMG CoA Reductase Inhibitors, Non-Barbiturate Hypnotics, Migraine Agents, Non-Steroidal
Antiinflammatory, Progesterone Receptor Antagonists, Progestins, Prostaglandins, Retinoids, Stimulant Laxatives, Etc.
ACE Inhibitors, Alkylating Agents, Aminoglycosides, Antiandrogents, Antiestrogens,
Antineoplastics, Beta Blockers, Gout Agents, Mitiotic Inhibitors, Potassium Sparing Diuretics, Sickle Cell Anemia Agents, Selective Serotonin Reuptake Inhibitors, Smoking Deterrents,
Tetracyclines, Thiazide & Thiazide Like Diuretics, Trycyclic Antidepressants, Etc.
Anticonvulsants, Antithyroid Agents, Antiretrovirals, Antispasmodics, Barbiturate Hypnotics,
Benzodiazepines, Glucocorticoids, Hydantoins, Imidazole Antifungals, Immunosuppressives,
Lithiums, Non-Barbiturate Hypnotics, Etc.
NOTE: These lists are not all inclusive of drugs in pregnancy category X and/or D drugs. Furthermore, not all drugs within
the therapeutic categories listed above are categorized as pregnancy X and/or D.
For specific drug quantity limits and age limits please refer to the Louisiana Healthcare Connections Preferred Drug List (PDL). Appropriate Use and Safety Edits
Safety Edit
Regimens deemed toxic or potentially life threatening are prevented from adjudicating
concurrently (see table below for restricted regimens)
Low dose Seroquel regimens (<150mg/day) are allowed for titration purposed only, as per FDA approved indications (adult restrictions only)
Suboxone/Subutex regimens are prevented from adjudicating in members with active narcotic
claims (Subxoone/Subutex are only approved for opiate withdrawal indications)
Safety Edit HIV Medications
Atripla (efavirenz, emtricitabine, tenofovir), Emtriva (emtricitabine), Truvada (emtricitabine, tenofovir)
Epzicom (abacavir, lamivudine), Ziagen (abacavir), Trizivir (abacavir, lamivudine, zidovudine)
Combivir (lamivudine, zidovudine), Epivir (lamivudine), Trizivir (abacavir, lamivudine, zidovudine)
Truvada (emtricitabine, tenofovir), Viread (tenofovir)
Reyataz (Atazanavir), Crixivan (Indinavir).
Emtriva (emtricitabine), Epivir (lamivudine)
Zerit (stavudine), Trizivir (abacavir, lamivudine, zidovudine)
Atripla (efavirenz, emtricitabine, tenofovir), Videx (didanosine)
Videx (didanosine), Truvada (emtricitabine, tenofovir)
Truvada (emtricitabine, tenofovir), Epivir (lamivudine)
Truvada (emtricitabine, tenofovir), Epzicom (abacavir, lamivudine)
Truvada (emtricitabine, tenofovir), Trizivir (abacavir, lamivudine, zidovudine)
Truvada (emtricitabine, tenofovir), Combivir (lamivudine, zidovudine)
Atripla (efavirenz, emtricitabine, tenofovir), Epivir (lamivudine)
Atripla (efavirenz, emtricitabine, tenofovir), Epzicom (abacavir, lamivudine)
Atripla (efavirenz, emtricitabine, tenofovir), Trizivir (abacavir, lamivudine, zidovudine)
Atripla (efavirenz, emtricitabine, tenofovir), Combivir (lamivudine, zidovudine)
Epzicom (abacavir, lamivudine), Emtriva (emtricitabine)
Emtriva (emtricitabine), Trizivir (abacavir, lamivudine, zidovudine)
Combivir (lamivudine, zidovudine), Emtriva (emtricitabine)
(Delavirdine), Sustiva (Efavirenz), INTELENCE (Etravirine), Viramune (Nevirapine), Atripla
(Efavirenz, Emtricitabine, Tenofovir), Edurant (Rilpivirine)
All Louisiana Healthcare Connections covered products are listed in the PDL. For the most current PDL please contact Louisiana Healthcare Connections at 1-866-595-8133 (TTY/TDD 1-877-285-4514) or visit www.LouisianaHealthConnect.com. For specific drug quantity limits and age limits please refer to the Louisiana Healthcare Connections Preferred Drug List (PDL).
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