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Coverage Rule and PDL Updates for 2020:
The 2020 Preferred Drug List (PDL) will be a comprehensive list of product requiring prior authorization (combining the Preferred Drug List and PA Criteria).

The Medicaid expansion population has followed the Preferred Drug List (PDL), but not the PA Criteria document under Sanford Health Plan. The PA Criteria and PDL will both now apply to Medicaid Expansion population since ND Medicaid will be processing the pharmacy claims for the Medicaid Expansion population. There is no longer a need to keep the documents separate so they will be combined into one comprehensive document in the 2020 Preferred Drug List (PDL).
 
Please refer to the 2020 Preferred Drug List (PDL) rather than the PA Criteria document until the link is removed from the website.
 
Smoking Cessation Products:
Effective January 1, 2020 – Smoking cessation products will no longer require prior authorization. Patients are still strongly encouraged to sign up for counseling through NDQuits as smoking cessation is significantly more successful with a counseling component than with medication alone. Patient must be compliant with treatment. Chantix treatment can be extended to 24 weeks of continuous treatment if patient is abstinent.
  • Chantix and Nicotine patch are allowed for 12 weeks every 6 months and are allowed with all other products
  • Nicotine Gum, Lozenge, Inhaler, and Spray are allowed for 90 days every 6 months. They must be used with Nicotine Patch, Chantix, or Bupropion
  • Bupropion is allowed for 90 days every 6 months and is allowed with all other products.
Opioid Dependence Products:
Effective January 1, 2020 –
  • Zubsolv will be a non-preferred product requiring a step through buprenorphine/naloxone generic tablets. 
  • Buprenorphine / Naloxone generic tablets WILL NOT require prior authorization.
 Does not require PA:
  • Buprenorphine / Naloxone SL tablets
  • Naltrexone tablets
  • Sublocade
  • Probuphine
  • Vivitrol
 Requires PA:
  • Zubsolv
  • Suboxone Film (and its generics)
Long Acting Opioids:
Effective January 1, 2020 –
  • Butrans, Belbuca, or Butorphanol do not require prior authorization
  • Oxycontin, Tramadol ER, and Nucynta ER are preferred products with PA
  • Morphine ER is a non-preferred product and requires step through Oxycontin
  • Fentanyl patches requires PA with clinical criteria with inability to swallow or an indication of cancer pain or palliative care pain and a BMI > 18
Correction to 'Coverage Rule Summary' email:
One strength of one medication from each class:
  • Please make the following updates for these common dosages:
    • Fluoxetine 60mg/day: use 3 x 20mg tablets capsules instead of 40mg + 20mg
Alexi Murphy, PharmD
Quality and Operations Manager, Pharmacy Services
701.328.4061 (office)   •   701.328.1544 (fax)
600 E. Boulevard Ave – Dept 325     •     Bismarck, ND  58505-0250
amurphy@nd.gov


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