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Fee-For-Service Pharmacy Provider Notice #154 – September Pharmacy Updates
Please be advised that the Department for Medicaid Services has made the following changes to the Kentucky Medicaid Fee-For–Service Pharmacy Program.
On September 5, 2012, Kentucky Medicaid placed brand Binosto® as a non-preferred product
on the Preferred Drug List (PDL) with a Tier 3 co-pay. Similar class quantity limits will be applied. The following product is currently preferred: On September 11, 2012, Kentucky Medicaid placed brand Forfivo XL™ as a non-preferred
product on the Preferred Drug List (PDL) with a Tier 3 co-pay. The following products are budeprion SR bupropion SR bupropion HCl bupropion SA maprotiline mirtazapine mirtazapine rapdis nefazodone HCl trazodone On September 11, 2012, Kentucky Medicaid began to require prior authorization for
Myrbetriq™ pending review for permanent PDL placement by the Kentucky Medicaid
Pharmacy and Therapeutics Advisory Committee. The following products are currently flavoxate (QL)
oxybutynin (QL)
Toviaz™ (QL)
VESIcare® (QL)
On September 11, 2012, Kentucky Medicaid began to require prior authorization for
Tudorza™ Pressair ™ pending review for permanent PDL placement by the Kentucky
Medicaid Pharmacy and Therapeutics Advisory Committee. The following products are albuterol-ipratropium inhalation solution (QL)
Atrovent® HFA (QL)
Combivent® (QL)
Combivent Respimat® (QL)
ipratropium inhalation solution (QL)
Spiriva Handihaler® (QL)
On September 12, 2012, Kentucky Medicaid placed generic pioglitazone as a non-preferred
product on the Preferred Drug List (PDL) with a Tier 3 co-pay. Brand name Actos® will remain
a preferred product with a Tier 1 co-pay. Quantity limits will remain in effect. The following
Actos® (QL)
Avandia® (QL)
On September 12, 2012, Kentucky Medicaid placed generic pioglitazone/metformin as a non-
preferred product on the Preferred Drug List (PDL) with a Tier 3 co-pay. Brand name
ACTOplus Met® will remain a preferred product with a Tier 1 co-pay. Quantity limits will
remain in effect. The following products are currently preferred: ACTOplus Met ® (QL)
Avandamet® (QL)
DuetAct® (QL)
On September 12, 2012, Kentucky Medicaid placed generic fondaparinux as a preferred
product on the Preferred Drug List (PDL) with a Tier 1 co-pay. Brand name Arixtra® was
placed as a non-preferred product with a Tier 3 co-pay. The following products are currently
Fragmin®
fondaparinux
Jantoven®
Lovenox®
Pradaxa® (CC)
warfarin
Xarelto®
Thank you for helping Kentucky Medicaid members to maintain access to prescription coverage by selecting drugs on the preferred drug list whenever possible. * Please note: All dates are subject to change. Kentucky Medicaid Fee-For-Service Pharmacy Program’s Contact Information
Clinical Support Center
Please contact the Clinical Support Center to request a prior authorization (PA) or to check the status of a request. NOTE:
The only drugs that are now required to be submitted via
fax are Brand Medically Necessary, Suboxone/Subutex,
Synagis, and Zyvox.
Pharmacy Support Center
Please contact the Pharmacy Support Center when claims assistance is required. Timely filing, lock-in, and early refill (ER) overrides can be obtained through this call center. Provider Services
Please contact Provider Services if you have questions about enrollment or when updating your license or bank information. Member Services
Please contact Member Services if you are a member or if you as the provider have questions regarding the member’s benefits or eligibility coverage dates.

Source: http://kpa.mcallenweb.net/Portals/112/FeeForService%20PharmacyProviderNotice%20154.pdf