1. Amphetamine products covered are agents used to treat learning disorders and narcolepsy.
2. Modafinil can only be approved for patients >16 years of age with a diagnosis of narcolepsy. Prescriptions for excessive daytime sleepiness due to shift/time changes or sleep apnea can not be approved. Prescriptions for modafinil for learning disorder can not be approved for payment.
3. No obesity control products will be covered.
4. Amphetamines ordered for depression will only be covered after a documentation of multiple failure of other anti-depressants.

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1. Preferred Drug Lists

1. WVBMS allows a maximum days supply of fourteen days and one refill on antibiotic prescriptions.
2. Claims for antibiotics with a greater than 14 day sypply will require prior approval.
3. Some exemptions:
   1. Low dose antibiotics for urinary tract prophylaxis.
   2. Anti-tuberculosis agents
   3. Anti-viral agents for HIV.
4. Each request is reviewed with current literature to determine its appropriateness.

1. Growth Hormones for Adults

1. Growth Hormones for Children

1. All Home IV therapy will require prior approval.
2. Criteria requires that if the patient is currently taking other oral medications, justification will be needed as to why the patient cannot take oral medications. With the current broad spectrum, highly bioavailable agents there should be few Home IV antibiotic therapy needs.
3. Examples of drug classifications considered equally effective orally as to IV therapy:
   1. Fluoroquinolone
   2. Fluconazole
   3. Penicillin's / Cephalosporins
   4. Metronidazole



For Home IV Therapy the following infromation will be required:

1. Drug dosage and length of time
2. Diagnosis
3. Cultures and sensitivities



For Home IV Pain Therapy the following information will be required

1. Drug dosage and length of therapy
2. Diagnosis
3. Assessment of concurrent oral pain therapies



For Home IV Chemo Therapy the following information will be required

1. Drug dosage and length of time
2. Diagnosis



For Home IV Hydration Therapy the following information will be required

1. Clinical justification for therapy exceeding 72 hours.


4. Specialty therapies will be reviewed on an individual basis.

1. All injectable medications must have prior approval before dispensing.
2. Medications are checked for appropriate diagnosis, appropriate dose and if there are any oral alternatives to the particular agent. Provider must justify why a patient cannot use or take oral therapy.
3. Exemptions to the policy are:
   1. Haloperidol
   2. Fluphenazine
   3. Medroxy-progesterone
   4. Cyanocobalamin
   5. Insulins
   6. Epinephrine syringes for allergic reaction
   7. Glucagons emergency kit

1. Mandatory generic substitution is required for all Brand Medically Necessary prescriptions that have both:
   1. A Federal MAC price
   2. An "AA" or "AB" rated generic
2. To get approval, the physician must send a letter (Fax or mail) to RDTP explaining the request for exception.

Exemption Criteria

1. Allergic Reaction to excipients in the generic products. If multiple generics are available then a history of multiple companies must exist.
2. A therapeutic failure to the generic product. A history of previous purchases will be reviewed to determine dosing and compliance issues.
3. Tegretol / Depakene, and/or patients stabilized on brand name anti-psychotics.
4. Patient requests for brand will not be accepted.