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Provider Notice 12-12





Dear Provider:



Effective for dates of service on and after April 1, 2012, the Medicaid Program of the Health Care Authority (the Agency) will publish a revised list of drugs with limitations.



The Agency will require authorization for drugs used to treat Alzheimer's when prescribed to clients less than 18 years of age.  These drugs are identified in the table below:





Drug

Limitations

donepezil HCl

Minimum age 18

galantamine

Minimum age 18

rivastigmine tartrate

Minimum age 18

Aricept(r) (donepezil)

Minimum age 18

Aricept ODT(r) (donepezil)

Minimum age 18

Namenda(r) (memantine)

Minimum age 18

Exelon(r) (rivastigmine)

Minimum age 18

Razadyne(r) (galantamine)

Minimum age 18

Razadyne ER(r) (galantamine)

Minimum age 18



To view the Agency's current List of Drugs with Limitations, go to:

http://hrsa.dshs.wa.gov/pharmacy/pdf/List%20of%20Drugs%20with%20Limits.pdf





Thank you.





BC

Provider Publications Team

The Medicaid Program of the Health Care Authority













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