preferred drug list - magellan rx management · 2019-12-31 · 1/1/2020 allergy-asthma opiate...

1/1/2020

ALLERGY-ASTHMA OPIATE DEPENDENCE ANTIHYPERLIPIDEMICS

ANTIHISTAMINES -- NASAL & NONSEDATING OPIATE DEPENDENCE TREATMENTS HMG-CoA REDUCTASE INHIBITORS

ORIGINAL POSTED PREFERRED STATUS: 1/25/2005 ORIGINAL POSTED PREFERRED STATUS: 2/3/2017 ORIGINAL POSTED PREFERRED STATUS: 3/30/2005

ORIGINAL EDIT EFFECTIVE DATE: 3/25/2005 ORIGINAL EDIT EFFECTIVE DATE: 4/1/2017 ORIGINAL EDIT EFFECTIVE DATE: 6/8/2005

RE-REVIEW POSTED PREFERRED STATUS: 11/2007 RE-REVIEW: 8/10/18 RE-REVIEW POSTED PREFERRED STATUS: 4/11/2008

RE-REVIEW POSTED PREFERRED STATUS: 10/26/2010 REVISED EDIT EFFECTIVE DATE: 6/10/2008

REVISED EDIT EFFECTIVE DATE 12/28/2010 PREFERRED RE-REVIEW POSTED PREFERRED STATUS: 5/27/2014

RE-REVIEW POSTED PREFERRED STATUS: 2/14/18 SUBOXONE FILM (BRAND) REVISED EDIT EFFECTIVE DATE: 5/30/2014

REVISED EDIT EFFECTIVE DATE: 4/1/2018 BUPRENORPHINE SUBLINGUAL TABLETS

VIVITROL* PREFERRED

NON-PREFERRED – ATORVASTATIN (LIPITOR) Effective 5/30/2014

INCLUDE BUT NOT LIMITED TO PRAVASTATIN (PRAVACHOL)

PREFERRED BUNAVAIL* SIMVASTATIN (ZOCOR)

CETIRIZINE 1MG/ML SOL, 10MG SWALLOW TAB (ZYRTEC) BUPRENORPHINE/NALOXONE SUBLINGUAL TAB *

LORATADINE (CLARITIN) BUPRENORPHINE/NALOXONE SUBLINGUAL FILM (GENERIC)* NON-PREFERRED –

AZELASTINE NASAL SPRAY (ASTELIN, ASTEPRO) -effective 4/1/18 ZUBSOLV * INCLUDE BUT NOT LIMITED TO

OLOPATADINE NASAL SPRAY (PATANASE) -effective 4/1/18 ATORVASTATIN (LIPITOR) Effective 5/30/2014

ATORVASTATIN/EZETIMIBE (LIPTRUZET)

NON-PREFERRED – MEDICAL BILLING ONLY FLUVASTATIN (LESCOL)

INCLUDE BUT NOT LIMITED TO PROBUPHINE LOVASTATIN (MEVACOR)

ACRIVASTINE/PSEUDOEPHEDRINE (SEMPREX-D) SUBLOCADE LOVASTATIN/NIACIN (ADVICOR)

AZELASTINE NASAL SPRAY (ASTELIN, ASTEPRO) effective 4/1/18 PITAVASTATIN (LIVALO)

AZELASTINE/FLUTICASONE NASAL SPRAY (DYMISTA) ROSUVASTATIN (CRESTOR)

CETIRIZINE 5MG, 10MG CHEWABLE TAB (ZYRTEC)* SIMVASTATIN/EZETIMIBE (VYTORIN)

CETIRIZINE/PSEUDOEPHEDRINE (ZYRTEC-D)* SIMVASTATIN/NIACIN (SIMCOR)

DESLORATADINE (CLARINEX)* Criteria discontinued 12/28/10 SIMVASTATIN/SITAGLIPTIN (JUVISYNC)

DESLORATADINE/PSEUDOEPHEDRINE (CLARINEX-D)*

FEXOFENADINE (ALLEGRA)*

FEXOFENADINE/PSEUDOEPHEDRINE (ALLEGRA-D)*

LEVOCETIRIZINE (XYZAL)*

LORATADINE/PSEUDOEPHEDRINE (CLARITIN-D)*

OLOPATADINE NASAL SPRAY (PATANASE) -effective 4/1/18

*Please refer to the PDL Criteria Overview for more detail GENERIC (SAMPLE BRAND) LISTED FOR REFERENCE ONLY Strikethrough indicates change in PDL Status

For the most up-to-date Preferred Drug List visit https://arkansas.magellanrx.com/provider/documents

Preferred Drug ListPrescribers may request an override for non-preferred drugs by calling the Magellan Medicaid Administration (MMA) Help Desk at: Toll Free 1-

800-424-7895 and choose the PDL option. This Preferred Drug List is subject to change without notice. New products in a reviewed drug class

are considered NON-PREFERRED until the committee has reevaluated the evidence for the drug class. The effective implementation date stated

for each drug class is the date claims will be edited at point-of-sale.

https://arkansas.magellanrx.com/provider/docs/rxinfo/PACriteria.pdf

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ANTIHYPERTENSIVE AGENTS ANTIHYPERTENSIVE AGENTS ANTIHYPERTENSIVE AGENTS

ANGIOTENSIN-CONVERTING ENZYME INHIBITORS ANGIOTENSIN-CONVERTING ENZYME INHIBITORS ANGIOTENSIN II RECEPTOR ANTAGONISTS



REVISED POSTED PREFERRED STATUS: 11/21/2007 REVISED POSTED PREFERRED STATUS: 11/21/2007 REVISED POSTED PREFERRED STATUS: 8/12/2011

REVISED EDIT EFFECTIVE DATE: 1/23/2008 REVISED EDIT EFFECTIVE DATE: 1/23/2008 REVISED EDIT EFFECTIVE DATE: 10/12/2011

RE-REVIEW POSTED PREFERRED STATUS: 6/17/2010 RE-REVIEW POSTED PREFERRED STATUS: 6/17/2010 RE-REVIEW POSTED PREFERRED STATUS: 3/6/2013


RE-REVIEW POSTED PREFERRED STATUS: 11/10/17 RE-REVIEW POSTED PREFERRED STATUS: 11/10/17 REVISED EDIT EFFECTIVE DATE: 02/15/2016

REVISED EDIT EFFECTIVE DATE: 1/1/18 REVISED EDIT EFFECTIVE DATE: 1/1/18 RE-REVIEW POSTED PREFERRED STATUS: 11/10/17

REVISED EDIT EFFECTIVE DATE: 1/1/18

PREFERRED NON-PREFERRED – PREFERRED

BENAZEPRIL (LOTENSIN) INCLUDE BUT NOT LIMITED TO IRBESARTAN

BENAZEPRIL/HCTZ (LOTENSIN HCT) BENAZEPRIL/AMLODIPINE (LOTREL) IRBESARTAN/HCTZ

ENALAPRIL (VASOTEC) CAPTOPRIL (CAPOTEN)-effective 1/1/18 LOSARTAN

ENALAPRIL/HCTZ (VASERETIC) CAPTOPRIL/HCTZ (CAPOZIDE)-effective 1/1/18 LOSARTAN/HCTZ

LISINOPRIL (PRINIVIL) ENALAPRIL SOLUTION (EPANED) VALSARTAN

LISINOPRIL/HCTZ (PRINZIDE) FOSINOPRIL (MONOPRIL) VALSARTAN/HCTZ

QUINAPRIL (ACCUPRIL) FOSINOPRIL/HCTZ (MONOPRIL HCT) VALSARTAN/AMLODIPINE

QUINAPRIL/HCTZ (ACCURETIC) MOEXIPRIL (UNIVASC) EXFORGE HCT (BRAND ONLY) effective 1/1/18

RAMIPRIL CAPSULES (ALTACE CAPSULES) MOEXIPRIL/HCTZ (UNIRETIC)

CAPTOPRIL (CAPOTEN)-effective 1/1/18 PERINDOPRIL (ACEON)

CAPTOPRIL/HCTZ (CAPOZIDE)-effective 1/1/18 RAMIPRIL TABLETS (ALTACE TABLETS)

TRANDOLAPRIL (MAVIK)

NON-PREFERRED – TRANDOLAPRIL/VERAPAMIL (TARKA)

NON-PREFERRED AGENTS LISTED IN NEXT COLUMN



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ANTIHYPERTENSIVE AGENTS ANTIHYPERTENSIVE AGENTS ANTIHYPERTENSIVE AGENTS

ANGIOTENSIN II RECEPTOR ANTAGONISTS BETA ADRENERGIC BLOCKERS CALCIUM CHANNEL BLOCKERS

ORIGINAL POSTED PREFERRED STATUS: 7/18/2005 ORIGINAL POSTED PREFERRED STATUS: 5/12/2005

ORIGINAL POSTED PREFERRED STATUS: 12/20/2005 ORIGINAL EDIT EFFECTIVE DATE: 10/5/2005 ORIGINAL EDIT EFFECTIVE DATE: 7/12/2005

ORIGINAL EDIT EFFECTIVE DATE: 2/21/2006 RE-REVIEW POSTED PREFERRED STATUS: 10/17/2007 RE-REVIEW POSTED PREFERRED STATUS: 6/17/2010

REVISED POSTED PREFERRED STATUS: 8/12/2011 RE-REVIEW POSTED PREFERRED STATUS: 11/15/2018 REVISED EDIT EFFECTIVE DATE: 8/17/2010

REVISED EDIT EFFECTIVE DATE: 10/12/2011 RE-REVIEW EFFECTIVE DATE: 02/15/2016

RE-REVIEW POSTED PREFERRED STATUS: 3/6/2013 PREFERRED PREFERRED

REVISED EDIT EFFECTIVE DATE: 5/7/2013 ATENOLOL AMLODIPINE (NORVASC)

REVISED EDIT EFFECTIVE DATE: 02/15/2016 METOPROLOL TARTRATE AMLODIPINE/OLMESARTAN (AZOR)* 02/15/2016

RE-REVIEW POSTED PREFERRED STATUS: 11/10/17 PROPRANOLOL IMMEDIATE RELEASE AMLODIPINE/OLMESARTAN/HCTZ (TRIBENZOR)* 02/15/2016

REVISED EDIT EFFECTIVE DATE: 1/1/18 BISOPROLOL DILTIAZEM ER 120MG, 180MG, 240MG CAPSULE (DILACOR XR)

CARVEDILOL DILTIAZEM ER 120MG, 180MG, 240, 300MG (TIAZAC) Eff 10/1/2016

METOPROLOL SUCCINATE EXFORGE* (Brand only) 02/15/2016

TIMOLOL EXFORGE HCT* 02/15/2016

NON-PREFERRED – ACEBUTOLOL NIFEDIPINE CC, ER (ADALAT CC, PROCARDIA XL)

INCLUDE BUT NOT LIMITED TO PINDOLOL VALSARTAN/AMLODIPINE (EXFORGE)* Effective 02/15/2016

AZILSARTAN (EDARBI) SOTALOL VERAPAMIL SR TABLETS 120MG, 180MG, AND 240MG

AZILSARTAN/CHLORTHALIDONE (EDARBYCLOR) BETAXOLOL (CALAN SR)

AMLODIPINE/OLMESARTAN LABETALOL NON-PREFERRED –

AMLODIPINE/OLMESARTAN/HCTZ PROPRANOLOL SOLUTION INCLUDE BUT NOT LIMITED TO

BYVALSON PROPRANOLOL/HCTZ AMLODIPINE/ATORVASTATIN (CADUET)

CANDESARTAN BISOPROLOL/HCTZ AMLODIPINE/OLMESARTAN (AZOR)* 02/15/2016

CANDESARTAN/HCTZ ATENOLOL/CHLORTHALIDONE AMLODIPINE/OLMESARTAN/HCTZ (TRIBENZOR)* 02/15/2016

EPROSARTAN NON-PREFERRED – DILTIAZEM CD, ER, LA, XR, OR XT (CARDIZEM)

EPROSARTAN/HCTZ INCLUDE BUT NOT LIMITED TO FELODIPINE ER (PLENDIL)

OLMESARTAN CARVEDILOL ER ISRADIPINE (DYNACIRC)

OLMESARTAN/AMLODIPINE NADOLOL ISRADIPINE CR (DYNACIRC CR)

OLMESARTAN/HCTZ NEBIVOLOL (BYSTOLIC) NICARDIPINE (CARDENE)

OLMESARTAN/AMLODIPINE/HCTZ PENBUTOLOL NICARDIPINE ER (CARDENE SR)

TELMISARTAN PROPRANOLOL ER (INDERAL LA, INNOPRAN XL) NISOLDIPINE ER (SULAR ER)

TELMISARTAN/AMLODIPINE PROPRANOLOL SOLUTION (HEMANGEOL) OLMESARTAN/AMLODIPINE/HCTZ (TRIBENZOR) Eff 02/15/2016

TELMISARTAN/HCTZ SOTALOL (SOTYLIZE) VALSARTAN/AMLODIPINE (EXFORGE-Generic only) Eff 02/15/2016

VALSARTAN/AMLODIPINE/HCTZ NADOLOL/BENDROFLUMETHAZIDE VALSARTAN/AMLODIPINE/HCTZ (EXFORGE HCT) Eff 02/15/2016

METOPROLOL/HCTZ VERAPAMIL SR CAPSULES (VERELAN)



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ANTIHYPERTENSIVE AGENTS ANTI-INFECTIVES ANTI-INFECTIVES

DIRECT RENIN INHIBITORS ANTI-INFECTIVE & OTIC ANTIBIOTIC/CORTICOSTEROID COMBINATIONS HEPATITIS C AGENTS

ORIGINAL POSTED PREFERRED STATUS: 6/17/2010

ORIGINAL EDIT EFFECTIVE DATE: 8/17/2010


ORIGINAL EDIT EFFECTIVE DATE: 10/1/2016 ORIGINAL EDIT EFFECTIVE DATE: 10/1/2016

RE-REVIEW POSTED PREFERRED STATUS: 10/1/2019 RE-REVIEW POSTED PREFERRED STATUS: 2/14/18

PREFERRED PREFERRED REVISED EDIT EFFECTIVE DATE: 4/1/2018

ALISKIREN (TEKTURNA)* Effective 02/15/2016 ACETIC ACID 2% OTIC (ACETASOL)

ALISKIREN/HCTZ (TEKTURNA HCT)* Effective 02/15/2016 ACETIC ACID/HC OTIC DROPS (ACETASOL HC) PREFERRED, MANUAL REVIEW PA

ALISKIREN/VALSARTAN (VALTURNA)* CIPROFLOXACIN 0.3%/DEXAMETHASONE 0.1% (CIPRODEX) ELBASVIR/GRAZOPREVIR (ZEPATIER)*

NEOMYCIN/POLYMIXIN/HC SOLN/SUSP (CORTISPORIN) SOFOSBUVIR/VELPATASVIR (EPCLUSA)*

NON-PREFERRED – OFLOXACIN 0.3% SOLUTION (FLOXIN OTIC) RIBAVIRIN TABLETS OR CAPSULES 200MG*

INCLUDE BUT NOT LIMITED TO GLECAPREVIR/PIBRENTASVIR (MAVYRET)*

ALISKIREN/AMLODIPINE (AMTURNIDE) NON-PREFERRED –

ALISKIREN/AMLODIPINE (TEKAMLO) INCLUDE BUT NOT LIMITED TO NON-PREFERRED –

ALISKIREN (TEKTURNA)* Effective 02/15/2016 CIPROFLOXACIN OTIC 0.2% INCLUDE BUT NOT LIMITED TO

ALISKIREN/HCTZ (TEKTURNA HCT)* Effective 02/15/2016 CIPROFLOXACIN 0.2%/HC 1% (CIPRO HC OTIC) DACLATASVIR (DAKLINZA)*

HC/NEOMYCIN/COLISTIN/THONZONIUM (COLY-MYCIN S) LEDIPASVIR/ SOFOSBUVIR (HARVONI)*

HC/NEOMYCIN/COLISTIN/THONZONIUM (CORTISPORIN TC) OMBITASVIR/ PARITAPREVIR/ RITONAVIR (TECHNIVIE)*

OMBITASVIR/ PARITAPREVIR/ RITONAVIR/ DASABUVIR

(VIEKIRA PAK)*

SIMEPREVIR (OLYSIO)*

SOFOSBUVIR (SOVALDI)*

SOFOSBUVIR/VELPATASVIR/VOXILAPREVIR (VOSEVI)*



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BIOLOGIC AND IMMUNOLOGIC AGENTS BIOLOGIC AND IMMUNOLOGIC AGENTS CARDIOVASCULAR AGENTS

IMMUNOLOGIC AGENTS IMMUNOLOGIC AGENTS PULMONARY HYPERTENSION TREATMENTS

Disease-modifying Drugs for Multiple Sclerosis Targeted Immune Modulators ORAL INHALED INJECTED


ORIGINAL POSTED PREFERRED STATUS: 7/28/2011 ORIGINAL POSTED PREFERRED STATUS: 4/14/2006 ORIGINAL EDIT EFFECTIVE DATE: 4/1/2017

ORIGINAL EDIT EFFECTIVE DATE: 9/27/2011 ORIGINAL EDIT EFFECTIVE DATE: 6/13/2006 RE-REVIEW POSTED PREFERRED STATUS: 10/1/2019

ORIGINAL POSTED PREFERRED STATUS: 5/6/2014 RE-REVIEW POSTED PREFERRED STATUS: 8/22/2007

ORIGINAL EDIT EFFECTIVE DATE: 7/8/2014 REVISED EDIT EFFECTIVE DATE: 10/17/2007 PREFERRED

RE-REVIEW: 11/09/2016 RE-REVIEW POSTED PREFERRED STATUS: 5/31/2012 AMBRISENTAN TABLETS (LETAIRIS)* BRAND ONLY

REVISED EDIT EFFECTIVE DATE: 7/1/2012 BOSENTAN TABLETS (TRACLEER)* BRAND ONLY

PREFERRED RE-REVIEW POSTED PREFERRED STATUS: 11/10/17 EPOPROSTENOLVIALS* -GENERIC ONLY

DIMETHYL FUMARATE (TECFIDERA AND TECFIDERA STARTER PAK)* REVISED EDIT EFFECTIVE DATE: 1/1/18 SILDENAFIL TABLETS (REVATIO)*

GLATIRAMER 20MG (COPAXONE) -BRAND ONLY PREFERRED TADALAFIL TABLETS (ADCIRCA)*

INTERFERON BETA - 1A (AVONEX) ADALIMUMAB (HUMIRA)* TREPROSTINIL VIAL* - GENERIC ONLY

ETANERCEPT (ENBREL)*

NON-PREFERRED –

NON-PREFERRED – NON-PREFERRED – INCLUDE BUT NOT LIMITED TO INCLUDE BUT NOT LIMITED TO

INCLUDE BUT NOT LIMITED TO ABATACEPT (ORENCIA)

CERTOLIZUMAB (CIMZIA) Effective 7/1/2012 ANAKINRA (KINERET) AMBRISENTAN TABLETS* -GENERIC ONLY

GLATIRAMER 40MG (COPAXONE) BRAND AND GENERIC APREMILAST (OTEZLA) BOSENTAN TABLETS* - GENERIC ONLY

FINGOLIMOD (GILENYA) CERTOLIZUMAB (CIMZIA) EPOPROSTENOL VIALS* (FLOLAN) - BRAND ONLY

INTERFERON BETA - 1A/ALBUMIN (REBIF) GOLIMUMAB (SIMPONI) EPOPROSTENOL VIALS* (VELETRI)

INTERFERON BETA - 1B (BETASERON) Effective 7/8/2014 INFLIXIMAB (REMICADE, INFLECTRA,RENFLEXIS ) ILOPROST INHALATION (VENTAVIS)*

INTERFERON BETA - 1B KIT (EXTAVIA) IXEKIZUMAB (TALTZ) MACITENTAN (OPSUMIT)*

TERIFLUNOMIDE (AUBAGIO) SECUKINUMAB (COSENTYX) RIOCIGUAT(ADEMPAS)*

GLATIRAMER 20MG (GLATOPA) Effective 06/18/2015 TOCILIZUMAB (ACTEMRA) SELEXIPAG(UPTRAVI)*

GLATIRAMER 20MG -GENERIC ONLY TOFACITINIB (XELJANZ) SILDENAFIL SUSPENSION (REVATIO)*

SIPONIMOD (MAYZENT) USTEKINUMAB (STELARA) SILDENAFIL VIAL*

CLADRIBINE (MAVENCLAD) GUSELKUMAB (TREMFYA) TREPROSTINIL TABLETS (ORENITRAM ER)*

SARILUMAB (KEVZARA) TREPROSTINIL INHALATION (TYVASO)*

BRODALUMAB (SILIQ) TREPROSTINIL VIAL (REMODULIN) * BRAND ONLY

CANAKINUMAB (ILARIS)

RILONACEPT (ARCALYST)

RISANKIZUMAB-RZAA (SKYRIZI)



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CENTRAL NERVOUS SYSTEM AGENTS CENTRAL NERVOUS SYSTEM AGENTS CENTRAL NERVOUS SYSTEM AGENTS

ANTIDEPRESSANTS ANTIDEPRESSANTS ADHD

SSRIs, SSNRIs, SNRIs SSRIs, SSNRIs, SNRIs Amphetamine Salts, Amphetamine-Like Drugs, and

Norepinephrine Reuptake Inhibitors


ORIGINAL EDIT EFFECTIVE DATE: 4/10/2007 ORIGINAL EDIT EFFECTIVE DATE: 4/10/2007 ORIGINAL POSTED PREFERRED STATUS: 5/7/2007

RE-REVIEW POSTED PREFERRED STATUS: 10/8/2009 RE-REVIEW POSTED PREFERRED STATUS: 10/8/2009 ORIGINAL EDIT EFFECTIVE DATE: 7/10/2007

REVISED EDIT EFFECTIVE DATE: 1/1/2010 REVISED EDIT EFFECTIVE DATE: 1/1/2010 REVISED POSTED PREFERRED STATUS: 5/11/2009






PREFERRED NON-PREFERRED --

BUPROPION EXTENDED RELEASE (WELLBUTRIN XL)* INCLUDE BUT NOT LIMITED TO PREFERRED

BUPROPION REGULAR RELEASE (WELLBUTRIN)* BUPROPION HBR ER TABLET (APLENZIN)* ADDERALL XR* (Brand only) Effective 4/17/2012

BUPROPION SUSTAINED RELEASE (WELLBUTRIN SR)* BUPROPION HCL ER TABLET (FORFIVO XL)* ATOMOXETINE (STRATTERA)-effective 1/1/18

CITALOPRAM (CELEXA)* DESVENLAFAXINE ER (KHEDEZLA ER, PRISTIQ ER)* AMPHETAMINE SALTS TABLET (ADDERALL)*

ESCITALOPRAM 5MG TABLET, 5MG/5ML SOL'N (LEXAPRO)* DULOXETINE (CYMBALTA)* Effective1/1/19 DEXTROAMPHETAMINE 5MG, 10MG TABLET*

ESCITALOPRAM 10MG, 20MG TABLET (LEXAPRO)* FLUOXETINE 10MG, 15MG, 20MG TABLET, 40MG CAPSULE, FOCALIN* (Brand only) Effective 4/17/2012

FLUOXETINE 10MG, 20MG CAPSULE, AND 20MG/5ML AND 90MG DELAYED RELEASE (PROZAC)* FOCALIN XR* (Brand only)

SOLUTION (PROZAC)* FLUVOXAMINE EXTENDED RELEASE (LUVOX CR) VYVANSE CAPSULES (LISDEXAMFETAMINE CAPSULES)*

FLUVOXAMINE (LUVOX)* LEVOMILNACIPRAN (FETZIMA ER)* METHYLPHENIDATE SWALLOW TABLET (RITALIN)*

MIRTAZAPINE 7.5MG (REMERON)* Effective 6/5/2014 MILNACIPRAN (SAVELLA)* STRATTERA (brand only)-effective 1/1/18

MIRTAZAPINE 15MG, 30MG, 45MG TABLET (REMERON)* MIRTAZAPINE 7.5MG (REMERON)* Effective 6/5/2014 GUANFACINE ER TABLET- effective 1/1/18*

PAROXETINE HCL TABLET (PAXIL)* MIRTAZAPINE ODT TABLET (REMERON SOLTAB)*

SERTRALINE (ZOLOFT)* NEFAZODONE (SERZONE)*

VENLAFAXINE ER CAPSULES (EFFEXOR XR)* Effective 6/5/14 PAROXETINE CR TABLET; SUSPENSION (PAXIL)* NON-PREFERRED –

VENLAFAXINE REGULAR RELEASE TABLET (EFFEXOR)* PAROXETINE MESYLATE (BRISDELLE) NON-PREFERRED AGENTS LISTED IN NEXT COLUMN

DULOXETINE (CYMBALTA) Effective 1/1/19 PAROXETINE MESYLATE (PEXEVA)*

VENLAFAXINE ER CAPSULES (EFFEXOR XR)* Effective 6/5/14

VENLAFAXINE ER TABLET (EFFEXOR XR)*

NON-PREFERRED – VILAZODONE (VIIBRYD)*

NON-PREFERRED AGENTS LISTED IN NEXT COLUMN VORTIOXETINE (BRINTELLIX)*



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ATTENTION DEFICIT DISORDER/HYPERACTIVITY DISORDER FIBROMYALGIA AGENTS FIBROMYALGIA AGENTS

Amphetamine Salts, Amphetamine-Like Drugs, and ORIGINAL POSTED PREFERRED STATUS 7/20/2011 ORIGINAL POSTED PREFERRED STATUS 7/20/2011

Norepinephrine Reuptake Inhibitors ORIGINAL EDIT EFFECTIVE DATE: 9/20/2011 ORIGINAL EDIT EFFECTIVE DATE: 9/20/2011

ORIGINAL POSTED PREFERRED STATUS: 5/7/2007 PREFERRED NON-PREFERRED – CONTINUED FROM PREVIOUS CLM

ORIGINAL EDIT EFFECTIVE DATE: 7/10/2007 AMITRIPTYLINE (ELAVIL) INCLUDE BUT NOT LIMITED TO

REVISED POSTED PREFERRED STATUS: 5/11/2009 CITALOPRAM (CELEXA)* ETHOTOIN TABLET (PEGANONE)*

REVISED EDIT EFFECTIVE DATE: 7/21/2009 CYCLOBENAZAPRINE 10MG TABLET (FLEXERIL) FLUOXETINE 10MG, 15MG, 20MG TABLET, 40MG CAPSULE &

RE-REVIEW POSTED PREFERRED STATUS: 2/16/2012 FLUOXETINE 10MG, 20MG CAPSULE, 20MG/5ML SOLUTION 90MG DELAYED RELEASE (PROZAC, SARAFEM)*

REVISED EDIT EFFECTIVE DATE: 4/17/2012 (PROZAC)* FLUVOXAMINE EXTENDED RELEASE CAPSULE (LUVOX CR)*

GABAPENTIN CAPSULE (NEURONTIN) FLUVOXAMINE TABLET (LUVOX)*

NON-PREFERRED – NORTRIPTYLINE (PAMELOR) GABAPENTIN 250MG/5ML SOLUTION (NEURONTIN)*

INCLUDE BUT NOT LIMITED TO PAROXETINE HCL TABLET (PAXIL)* GABAPENTIN 600MG, 800MG TABLET (NEURONTIN)*

AMPHETAMINE SALTS ER CAPSULE (ADDERALL XR - Generic DULOXETINE (CYMBALTA)* Effective 1/1/19 IMIPRAMINE (TOFRANIL)*

only) LACOSAMIDE (VIMPAT)*

ATOMOXETINE (STRATTERA)* brand only- effective 1/1/18 NON-PREFERRED – LAMOTRIGINE (LAMICTAL)*

DEXMETHYLPHENIDATE ER CAPSULE (FOCALIN XR - Generic only) INCLUDE BUT NOT LIMITED TO LEVETIRACETAM (KEPPRA)*

DEXMETHYLPHENIDATE TABLET (FOCALIN - Generic only) BUPROPION HBR ER TABLET (APLENZIN)* MILNACIPRAN (SAVELLA)*

CLONIDINE ER SUSPENSION (NEXICLON XR) BUPROPION EXTENDED RELEASE (WELLBUTRIN XL)* MIRTAZAPINE (REMERON)*

CLONIDINE ER TABLET (KAPVAY ER, NEXICLON XR) BUPROPION REGULAR RELEASE (WELLBUTRIN)* NEFAZODONE (SERZONE)*

DEXTROAMPHETAMINE CAPSULE (DEXEDRINE SPANSULE) BUPROPION SUSTAINED RELEASE (WELLBUTRIN SR)* OXCARBAZEPINE (TRILEPTAL)*

DEXTROAMPHETAMINE SOLUTION (PROCENTRA) CARBAMAZEPINE CHEWABLE TABLET (TEGRETOL CHEW TAB)* PAROXETINE EXTENDED RELEASE & SUSPENSION (PAXIL)*

DEXTROAMPHETAMINE 2.5MG, 7.5MG, 15MG, 20MG, 30MG CARBAMAZEPINE EXTENDED RELEASE CAPSULE PAROXETINE MESYLATE (PEXEVA)*

TABLET (ZENZEDI) (CARBATROL ER, EQUETRO)* PHENYTOIN 100MG ER CAPSULE (DILANTIN)*

LISDEXAMFETAMINE CHEWABLE (VYVANSE CHEWABLE TABS) CARBAMAZEPINE IMMEDIATE RELEASE TABLET (TEGRETOL)* PREGABALIN (LYRICA)*

METHAMPHETAMINE TABLET (DESOXYN) CARBAMAZEPINE SUSPENSION (TEGRETOL)* SERTRALINE (ZOLOFT)*

METHYLPHENIDATE CHEWABLE TABLET (METHYLIN) CYCLOBENZAPRINE 5MG, 7.5MG TABLET (FEXMID, FLEXERIL) TIAGABINE (GABITRIL)*

METHYLPHENIDATE ER CAPSULE (METADATE CD, RITALIN LA, APTENSIO XR) CYCLOBENZAPRINE ER CAPSULE (AMRIX) TOPIRAMATE (TOPAMAX)*

METHLYPHENIDATE ER PATCH (DAYTRANA)* DESIPRAMINE (NORPRAMIN)* VALPROIC ACID (DEPAKENE, STAVZOR)*

METHYLPHENIDATE ER SUSPENSION (QUILLIVANT XR) DESVENLAFAXINE (PRISTIQ)* VENLAFAXINE TABLET (EFFEXOR)*

METHYLPHENIDATE ER TABLET (METADATE ER, RITALIN SR) DIVALPROEX SODIUM (DEPAKOTE)* VENLAFAXINE EXTENDED RELEASE CAPSULES (EFFEXOR XR)*

METHYLPHENIDATE SOLUTION (METHYLIN) DULOXETINE (CYMBALTA)* Effective 1/1/19 VENLAFAXINE EXTENDED RELEASE TABLET*

METHYLPHENIDATE (COTEMPLA XR-ODT) ESCITALOPRAM (LEXAPRO)* ZONISAMIDE (ZONEGRAN)*

METHYLPHENIDATE ER (CONCERTA) NON-PREFERRED AGENTS CONTINUED IN NEXT COLUMN ***SEE DISCLAIMER ON LAST PAGE***



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MIGRAINE AGENTS NARCOTIC AGONIST ANALGESICS NEUROPATHIC PAIN AGENTS

Serotonin 5-HT1 Receptor Agonist LONG-ACTING OPIOIDS ORIGINAL POSTED PREFERRED STATUS: 4/3/2008



REVISED POSTED PREFERRED STATUS: 7/25/2007 REVISED POSTED PREFERRED STATUS: 8/4/2008 REVISED EDIT EFFECTIVE DATE: 12/13/2011

REVISED EDIT EFFECTIVE DATE: 10/1/2007 REVISED EDIT EFFECTIVE DATE: 8/1/2008

RE-REVIEW POSTED PREFERRED STATUS: 4/26/2010 RE-REVIEW POSTED PREFERRED STATUS: 10/14/2011 PREFERRED

REVISED EDIT EFFECTIVE DATE: 7/1/2010 REVISED EDIT EFFECTIVE DATE: 1/10/2012 AMITRIPTYLINE (ELAVIL)

RE-REVIEW POSTED PREFERRED STATUS: 1/1/2020 REVISED EDIT EFFECTIVE DATE: 05/13/2016 CARBAMAZEPINE CHEWABLE TABLET (TEGRETOL CHEW TAB

REVISED EDIT EFFECTIVE DATE: 04/01/2019 CARBAMAZEPINE IMMEDIATE RELEASE TABLET (TEGRETOL)

PREFERRED GABAPENTIN CAPSULE (NEURONTIN)

RIZATRIPTAN (MAXALT) PREFERRED GABAPENTIN 600MG, 800MG TAB (NEURONTIN) Eff 12/13/11

RIZATRIPTAN DISINTEGRATING (MAXALT MLT) BUPRENORPHINE PATCH (BUTRANS)*-Brand Only NORTRIPTYLINE (PAMELOR)

SUMATRIPTAN 4MG/0.5ML KIT REFILL (IMITREX)* HYDROCODONE ER (HYSINGLA ER) EFFECTIVE 04/01/2019 PREGABALIN (LYRICA)* Effective 12/13/2011

SUMATRIPTAN 6MG/0.5ML KIT REFILL (IMITREX)* METHADONE (DOLOPHINE)* VENLAFAXINE REGULAR RELEASE TABLET (EFFEXOR)*

SUMATRIPTAN 6MG/0.5ML VIAL (IMITREX)* MORPHINE/NALTREXONE (EMBEDA)*Effective 05/13/2016 DULOXETINE (CYMBALTA)* Effective 1/1/19

SUMATRIPTAN 20MG NASAL SPRAY (IMITREX)* -BRAND ONLY MORPHINE SULFATE LA TABLET (MS CONTIN, ORAMORPH)*

SUMATRIPTAN TABLET (IMITREX)* OXYMORPHONE ER TABLET (OPANA ER)* Effective 1/10/2012 NON-PREFERRED –

ZOMIG NASAL SPRAY TRAMADOL ER TABLET* INCLUDE BUT NOT LIMITED TO

CARBAMAZEPINE EXTENDED RELEASE CAPSULE & TABLET

NON-PREFERRED –INCLUDE BUT NOT LIMITED TO NON-PREFERRED – (CARBATROL ER, EQUETRO, TEGRETOL XR)*

AMLOTRIPTAN (AXERT) INCLUDE BUT NOT LIMITED TO CARBAMAZEPINE SUSPENSION (TEGRETOL)*

ELETRIPTAN (RELPAX) BUPRENORPHINE PATCH (BUTRANS) DIVALPROEX SODIUM (DEPAKOTE)*

FROVATRIPTAN (FROVA) BUPRENORPHINE (BELBUCA)* DULOXETINE (CYMBALTA)* Effective 1/1/19

NARATRIPTAN (AMERGE) FENTANYL PATCH (DURAGESIC)* GABAPENTIN 250MG/5ML SOLUTION (NEURONTIN)*

SUMATRIPTAN 6MG/0.5ML KIT SYRINGE (IMITREX)* HYDROMORPHONE ER TABLET (EXALGO ER)* GABAPENTIN TABLET (NEURONTIN)* Effective 12/13/2011

SUMATRIPTAN 6MG/0.5ML INJECTION (SUMAVEL DOSEPRO) MORPHINE SULFATE ER CAPSULE (AVINZA, KADIAN)* GABAPENTIN EXTENDED RELEASE CAPSULE (GRALISE)

SUMATRIPTAN NASAL POWDER (ONZETRA XSAIL) MORPHINE/NALTREXONE (EMBEDA)* GABAPENTIN EXTENDED RELEASE TABLET (HORIZANT)

SUMATRIPTAN NASAL SPRAY (TOSYMRA) OXYCODONE-ACETAMINOPHEN ER TABLET (XARTEMIX XR)* LACOSAMIDE (VIMPAT)*

SUMATRIPTAN/NAPROXEN (TREXIMET) OXYCODONE ER TABLET (OXYCONTIN)* LAMOTRIGINE (LAMICTAL)*

SUMATRIPTAN AUTOINJECTOR (ZEMBRACE SYMTOUCH) OXYMORPHONE ER TABLET (OPANA ER)* Effective 1/10/2012

SUMATRIPTAN 5MG NASAL SPRAY (IMITREX)*-GENERIC ONLY TAPENTADOL ER TABLET (NUCYNTA ER)* NON-PREFERRED AGENTS CONTINUED IN NEXT COLUMN

SUMATRIPTAN 20MG NASAL SPRAY (IMITREX)* -GENERIC ONLY BUPRENORPHINE PATCH (BUTRANS)*-generic only

ZOLMITRIPTAN (ZOMIG) ODT AND TABLETS HYDROCODONE ER (HYSINGLA ER) EFFECTIVE 04/01/2019 ***SEE DISCLAIMER ON LAST PAGE***



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NEUROPATHIC PAIN AGENTS NON-BENZODIAZEPINE SEDATIVE HYNOTICS NONSTEROIDAL

ANTIINFLAMMATORY AGENTS



RE-REVIEW POSTED PREFERRED STATUS: 10/14/2011 REVISED POSTED PREFERRED STATUS: 12/15/2008 ORIGINAL EDIT EFFECTIVE DATE: 6/18/2007



NON-PREFERRED – CONTINUED FROM PREVIOUS COLUMN REVISED EDIT EFFECTIVE DATE: 2/28/2012

INCLUDE BUT NOT LIMITED TO PREFERRED

PREFERRED CELECOXIB CAPSULES (CELEBREX)

LIDOCAINE PATCH (LIDODERM)* RAMELTEON (ROZEREM)* Effective 2/28/2012 DICLOFENAC SODIUM DR 25MG, 50MG, 75MG TABLETS

OXCARBAZEPINE (TRILEPTAL)* ZALEPLON (SONATA)* DICLOFENAC SODIUM 1% TOPICAL GEL (VOLTAREN)

PREGABALIN (LYRICA)* Effective 12/13/2011 ZOLPIDEM TABLET (AMBIEN)* IBUPROFEN 100MG/5ML SUSPENSION, 400MG, 600MG,

TOPIRAMATE (TOPAMAX)* 800MG TABLET (MOTRIN)

VALPROIC ACID (DEPAKENE, STAVZOR)* NON-PREFERRED – INDOMETHACIN 25MG, 50MG CAPSULE (INDOCIN)

VENLAFAXINE ER CAPSULE (EFFEXOR XR)* INCLUDE BUT NOT LIMITED TO KETOROLAC TABLET (TORADOL)*

VENLAFAXINE ER TABLET (EFFEXOR XR)* DOXEPIN (SILENOR) MELOXICAM 7.5MG, 15MG TABLET (MOBIC)

ESZOPICLONE (LUNESTA) NABUMETONE (RELAFEN)

RAMELTEON (ROZEREM) Effective 2/28/2012 NAPROXEN 250MG, 375MG, 500MG TABLET (NAPROSYN)

ZOLPIDEM CR TABLET (AMBIEN CR) NAPROXEN 375MG, 500MG EC TABLET (EC-NAPROSYN)

ZOLPIDEM ORAL SPRAY (ZOLPIMIST) NAPROXEN SODIUM 275MG, 550MG TABLET (ANAPROX)

ZOLPIDEM SL TABLET (EDLUAR, INTERMEZZO)

NON-PREFERRED –

INCLUDE BUT NOT LIMITED TO

DICLOFENAC EPOLAMINE (FLECTOR)

DICLOFENAC POTASSIUM (CAMBIA, CATAFLAM, ZIPSOR)

DICLOFENAC SODIUM/MISOPROSTOL (ARTHROTEC)

DICLOFENAC SODIUM ER 100MG TABLETS (VOLTAREN XR)

DICLOFENAC SUBMICRONIZED (ZORVOLEX)

DICLOFENAC SODIUM 1.5% , 2% , AND 3% TOPICAL (PENNSAID, SOLARAZE)

DIFLUNISAL (DOLOBID)

***SEE DISCLAIMER ON LAST PAGE*** NON-PREFERRED AGENTS CONTINUED IN NEXT COLUMN



1/1/2020






CENTRAL NERVOUS SYSTEM AGENTS CENTRAL NERVOUS SYSTEM AGENTS DERMATOLOGY

NONSTEROIDAL SKELETAL MUSCLE RELAXANTS TOPICAL ANTIFUNGALS

ANTIINFLAMMATORY AGENTS


ORIGINAL POSTED PREFERRED STATUS: 4/13/2007 ORIGINAL EDIT EFFECTIVE DATE: 3/20/2006 ORIGINAL EDIT EFFECTIVE DATE: 4/1/2017


RE-REVIEW POSTED PREFERRED STATUS: 4/07/2011 PREFERRED PREFERRED

REVISED EDIT EFFECTIVE DATE: 6/7/2011 BACLOFEN TABLETS (LIORESAL)*

NON-PREFERRED – CONTINUED FROM PREVIOUS COLUMN CHLORZOXAZONE 500MG (PARAFON) TOLNAFTATE 1% TOPICAL CREAM OTC

INCLUDE BUT NOT LIMITED TO CYCLOBENZAPRINE 10MG TABLET (FLEXERIL) TOLNAFTATE 1% TOPICAL POWDER OTC

METHOCARBAMOL (ROBAXIN) TOLNAFTATE 1% TOPICAL SOLUTION OTC

ETODOLAC (LODINE) TIZANIDINE TABLET (ZANAFLEX)* CLOTRIMAZOLE RX CREAM

FENOPROFEN (NALFON) CLOTRIMAZOLE-BETAMETHASONE RX CREAM

FLURBIPROFEN (ANSAID) NON-PREFERRED – KETOCONAZOLE 2% RX SHAMPOO

IBUPROFEN/FAMOTIDINE (DUEXIS) INCLUDE BUT NOT LIMITED TO NYSTATIN (OINTMENT, CREAM, POWDER)

INDOMETHACIN 75MG SA CAPSULE CARISOPRODOL (SOMA)

INDOMETHACIN 20MG, 25MG and 40MG CAPSULE (TIVORBEX) CARISOPRODOL/ASA (SOMA COMPOUND) NON-PREFERRED –

INDOMETHACIN 25MG/5ML SUSPENSION (INDOCIN) CARISOPRODOL/ASA/CODEINE (SOMA COMPOUND W/ COD) INCLUDE BUT NOT LIMITED TO

INDOMETHACIN 50MG SUPPOSITORY CHLORZOXAZONE 375MG, 750MG (LORZONE)

KETOPROFEN CAPSULES CYCLOBENZAPRINE 5MG, 7.5MG TABLET (FLEXERIL, FEXMID) CLOTRIMAZOLE / BETAMETHASONE (LOTRISONE)

KETOROLAC NASAL SPRAY (SPRIX) CYCLOBENZAPRINE ER CAPSULE (AMRIX) ECONAZOLE CREAM

MECLOFENAMATE (MECLOMEN) DANTROLENE (DANTRIUM) ECONAZOLE FOAM (ECOZA)

MEFENAMIC ACID (PONSTEL) METAXOLONE (SKELAXIN) KETOCONAZOLE CREAM

NABUMETONE DS (RELAFEN DS) ORPHENADRINE CITRATE (NORFLEX) KETOCONAZOLE FOAM(EXTINA)

NAPROXEN/ESOMEPRAZOLE (VIMOVO) ORPHENADRINE/ASPIRIN/CAFFEINE (NORGESIC) LULICONAZOLE CREAM (LUZU)

NAPROXEN SUSPENSION (NAPROSYN) TIZANIDINE CAPSULES (ZANAFLEX) OXICONAZOLE (OXISTAT)

NAPROXEN ER 375MG, 500MG TABLET (NAPRELAN) SERTACONAZOLE (ERTACZO)

OXAPROZIN (DAYPRO) SULCONAZOLE (EXELDERM)

PIROXICAM (FELDENE) MICONAZOLE /ZINC OXIDE/PETROLATUM (VUSION)

QMIZ ODT (MELOXICAM) MICONAZOLE CREAM

SULINDAC (CLINORIL) NAFTIFINE (NAFTIN)

TOLMETIN (TOLECTIN) BUTENAFINE (MENTAX)

NYSTATIN/EMOLLIENT (PEDIADERM AF)

NYSTATIN / TRIAMCINOLONE



1/1/2020






DERMATOLOGY DERMATOLOGY ENDOCRINE AND METABOLIC AGENTS

TOPICAL ANTIFUNGALS TOPICAL ANTIPARASITICS ANTIDIABETIC AGENTS

DPP-4 Enzyme Inhibitors




NON-PREFERRED – ONYCHOMYCOSIS PREFERRED

INCLUDE BUT NOT LIMITED TO PIP BUTOXIDE/PYRETHRINS/PERMETHRIN KIT OTC PREFERRED

[LICE SOLUTION, COMPLETE LICE TREATMENT] SITAGLIPTIN/METFORMIN (JANUMET)*

CICLOPIROX (PENLAC NAIL LACQUER) PIPERONYL BUTOXIDE/PYRETHRINS SHAMPOO OTC

EFINACONAZOLE (JUBLIA) [LICE KILLING SHAMPOO, LICE TREATMENT]

TAVABOROLE (KERYDIN) PERMETHRIN 1% LIQUID OTC NON-PREFERRED –

PERMETHRIN 5% CREAM (ELIMITE) INCLUDE BUT NOT LIMITED TO

NATROBA (BRAND NAME ONLY) -SPINOSAD 0.9% ALOGLIPTIN (NESINA)

ALOGLIPTIN/METFORMIN (KAZANO)

ALOGLIPTIN/PIOGLITAZONE (OSENI)

NON-PREFERRED –INCLUDE BUT NOT LIMITED TO LINAGLIPTIN (TRADJENTA)

BENZYL ALCOHOL (ULESFIA) LINAGLIPTIN/EMPAGLIFLOZIN (GLYXAMBI)

CROTAMITON (EURAX) LINAGLIPTIN/METFORMIN (JENTADUETO)

IVERMECTIN (SKLICE) SAXAGLIPTIN (ONGLYZA)

LINDANE SAXAGLIPTIN/METFORMIN ER (KOMBIGLYZE XR)

MALATHION (OVIDE) SITAGLIPTIN/METFORMIN EXTENDED RELEASE (JANUMET XR)

SPINOSAD (NATROBA)-GENERIC ONLY SITAGLIPTIN (JANUVIA)



1/1/2020






ENDOCRINE AND METABOLIC AGENTS ENDOCRINE AND METABOLIC AGENTS ENDOCRINE AND METABOLIC AGENTS

ANTIDIABETIC AGENTS ANTIDIABETIC AGENTS ANTIDIABETIC AGENTS

GLP-1 Receptor Agonists Meglitinides SGLT2 Inhibitors



REVISED POSTED PREFERRED STATUS: 11/12/2008

PREFERRED REVISED EDIT EFFECTIVE DATE: 1/1/2009 PREFERRED

EXENATIDE (BYETTA)* RE-REVIEW POSTED PREFERRED STATUS: 9/7/2011 DAPAGLIFLOZIN (FARXIGA)*

EXENATIDE ER (BYDUREON PEN & VIAL)* REVISED EDIT EFFECTIVE DATE: 1/1/2012 DAPAGLIFLOZIN/METFORMIN ER (XIGDUO XR)*

LIRAGLUTIDE (VICTOZA)* REVISED POSTED PREFERRED STATUS: 8/11/2017 EMPAGLIFLOZIN (JARDIANCE)*

REVISED EDIT EFFECTIVE DATE: 10/1/2017 EMPAGLIFLOZIN/METFORMIN (SYNJARDY)*

NON-PREFERRED –

INCLUDE BUT NOT LIMITED TO PREFERRED NON-PREFERRED –

ALBIGLUTIDE (TANZEUM) NATEGLINIDE INCLUDE BUT NOT LIMITED TO

DULAGLUTIDE (TRULICITY) REPAGLINIDE CANAGLIFLOZIN (INVOKANA)

EXENATIDE ER (BYDUREON BCISE) CANAGLIFLOZIN/METFORMIN (INVOKAMET)

LIRAGLUTIDE/INSULIN DEGLUDEC (XULTOPHY) NON-PREFERRED – CANAGLIFLOZIN/METFORMIN (INVOKAMET XR)

LIXISENATIDE (ADLYXIN) INCLUDE BUT NOT LIMITED TO EMPAGLIFLOZIN/METFORMIN ER (SYNJARDY XR)

LIXISENATIDE/INSULIN GLARGINE (SOLIQUA) REPAGLINIDE/ METFORMIN (PRANDIMET)

SEMAGLUTIDE (OZEMPIC)



1/1/2020






ENDOCRINE AND METABOLIC AGENTS ENDOCRINE AND METABOLIC AGENTS ENDOCRINE AND METABOLIC AGENTS

ANTIDIABETIC AGENTS ANTIDIABETIC AGENTS ESTROGEN REPLACEMENT AGENTS

Sulfonylurea Thiazolidinediones




REVISED POSTED PREFERRED STATUS: 11/12/2008 REVISED POSTED PREFERRED STATUS: 11/12/2008 REVISED EDIT EFFECTIVE DATE: 7/11/2008

REVISED EDIT EFFECTIVE DATE: 1/1/2009 REVISED EDIT EFFECTIVE DATE: 1/1/2009

RE-REVIEW POSTED PREFERRED STATUS: 9/7/2011 RE-REVIEW POSTED PREFERRED STATUS: 9/7/2011 PREFERRED

REVISED EDIT EFFECTIVE DATE: 1/1/2012 REVISED EDIT EFFECTIVE DATE: 1/1/2012 ESTRADIOL 0.5MG, 1MG, 2MG ORAL TABLET (ESTRACE)

RE-REVIEW POSTED PREFERRED STATUS: 8/11/17 ESTROPIPATE ORAL TABLET (OGEN)

PREFERRED REVISED EDIT EFFECTIVE DATE: 10/1/17

CHLORPROPAMIDE (DIABINESE) NON-PREFERRED –

GLIMEPIRIDE (AMARYL) INCLUDE BUT NOT LIMITED TO

GLIPIZIDE (GLUCOTROL) PREFERRED ESTRADIOL ACETATE TABLET (FEMTRACE)

GLYBURIDE (DIABETA) PIOGLITAZONE* ESTRADIOL ACETATE VAGINAL RING (FEMRING)

GLYBURIDE MICRONIZED (GLYNASE) ESTRADIOL ORAL 1.5MG TABLET (ESTRACE)

METFORMIN/GLIPIZIDE (METAGLIP) NON-PREFERRED – ESTRADIOL SPRAY (EVAMIST)

METFORMIN/GLYBURIDE (GLUCOVANCE) INCLUDE BUT NOT LIMITED TO ESTRADIOL TOPICAL GEL (DIVIGEL)

PIOGLITAZONE/GLIMEPIRIDE (DUETACT) Effective 1/1/2012 ROSIGLITAZONE (AVANDIA) ESTRADIOL TRANSDERMAL (ALORA, CLIMARA)

TOLAZAMIDE (TOLINASE) ROSIGLITAZONE/METFORMIN (AVANDAMET) ESTRADIOL VAGINAL RING (ESTRING)

PIOGLITAZONE/GLIMEPIRIDE (DUETACT) ESTRADIOL VAGINAL TABLET (VAGIFEM, YUVAFEM)

NON-PREFERRED – PIOGLITAZONE/METFORMIN ESTRADIOL/DROSPIRENONE (ANGELIQ)*

INCLUDE BUT NOT LIMITED TO PIOGLITAZONE/METFORMIN EXTENDED-RELEASE ESTRADIOL/LEVONORGESTREL (CLIMARA PRO)*

PIOGLITAZONE/GLIMEPIRIDE (DUETACT)* Effective 1/1/2012 (ACTOPLUS MET XR) ESTRADIOL/NORETHINDRONE ACETATE (ACTIVELLA)*

ESTRADIOL/NORGESTIMATE (PREFEST)*

ESTROGENS, CONJUGATED (CENESTIN, ENJUVIA, PREMARIN)

ESTROGENS, CONGUATED/BAZEDOXIFENE (DUAVEE)

ESTROGENS, CONJUGATED/MEDROXYPROGESTERONE

(PREMPHASE, PREMPRO)*

ESTROGENS, ESTERIFIED (MENEST)

ETHINYL ESTRADIOL/NORETHINDRONE ACETATE

(FEMHRT)*



1/1/2020






ENDOCRINE AND METABOLIC AGENTS ENDOCRINE AND METABOLIC AGENTS GASTROINTESTINAL

GROWTH HORMONE PANCREATIC ENZYMES ANTIEMETICS

5-HT3 & NK1 Receptor Antagonists





SOMATROPIN (GENOTROPIN)* PREFERRED

PANCRELIPASE (CREON) PREFERRED

NON-PREFERRED – PANCRELIPASE (ZENPEP) ONDANSETRON 4MG, 8MG ORAL DISINTEGRATING

INCLUDE BUT NOT LIMITED TO TABLET (ZOFRAN)*

SOMATROPIN (HUMATROPE)* NON-PREFERRED – ONDANSETRON 4MG, 8MG TABLET (ZOFRAN)*

SOMATROPIN (NORDITROPIN)* INCLUDE BUT NOT LIMITED TO ONDANSETRON 4MG/2ML PRESERVATIVE FREE VIAL*

SOMATROPIN (NUTROPIN AQ)* PANCRELIPASE (PANCREAZE) ONDANSETRON 40MG/20ML VIAL (ZOFRAN)*

SOMATROPIN (OMNITROPE)* PANCRELIPASE (PERTZYE)

SOMATROPIN (SAIZEN)* PANCRELIPASE (ULTRESA) NON-PREFERRED –

SOMATROPIN (SEROSTIM)* PANCRELIPASE (VIOKACE) INCLUDE BUT NOT LIMITED TO

SOMATROPIN (ZOMACTON)* APREPITANT (EMEND)

SOMATROPIN (ZORBTIVE)* DOLASETRON (ANZEMET)

GRANISETRON (KYTRIL, SANCUSO)

NETUPITANT-PALONOSETRON (AKYNZEO)

PALONOSETRON (ALOXI)

ONDANSETRON 24MG TABLET (ZOFRAN)

ONDANSETRON 32MG/50ML BAG (ZOFRAN)

ONDANSETRON 4MG/2ML AMPULE/SYRINGE (ZOFRAN)

ONDANSETRON 4MG/5ML SOLUTION (ZOFRAN)

ONDANSETRON SOLUBLE FILM (ZUPLENZ)

ETHINYL ESTRADIOL/NORETHINDRONE ACETATE

(FEMHRT)*



1/1/2020






GASTROINTESTINAL NASAL INHALANT PRODUCTS RENAL AND GENITOURINARY AGENTS

PROTON PUMP INHIBITORS CORTICOSTEROIDS OVERACTIVE BLADDER AGENTS



RE-REVIEW POSTED PREFERRED STATUS: 1/31/2008 REVISED POSTED PREFERRED STATUS: 6/25/2009 REVISED POSTED PREFERRED STATUS: 5/14/2009



REVISED EDIT EFFECTIVE DATE: 7/9/2013 RE-REVIEW EDIT EFFECTIVE DATE: 7/16/2012 REVISED EDIT EFFECTIVE DATE: 5/8/2012

RE-REVIEW POSTED PREFERRED STATUS: 7/1/2019 RE-REVIEW POSTED PREFERRED STATUS: 5/21/2014


PREFERRED RE-REVIEW: 11/09/16

OMEPRAZOLE CAPSULES FLUTICASONE FUROATE (VERAMYST) Effective 7/16/2012

PANTOPRAZOLE TABLETS (PROTONIX) FLUTICASONE PROPIONATE (FLONASE) PREFERRED

MOMETASONE (NASONEX) Effective 7/16/2012 FESOTERODINE (TOVIAZ) Effective 5/30/2014

NON-PREFERRED – NASACORT AQ (brand only) Effective 1/1/2014 OXYBUTYNIN 5MG/5ML SYRUP, 5MG TABLET (DITROPAN)

INCLUDE BUT NOT LIMITED TO OXYBUTYNIN ER (DITROPAN XL)*

DEXLANSOPRAZOLE (DEXILANT) NON-PREFERRED – SOLIFENACIN (VESICARE) BRAND ONLY

ESOMEPRAZOLE CAPSULE (NEXIUM) Effective 7/9/2013 INCLUDE BUT NOT LIMITED TO

ESOMEPRAZOLE/NAPROXEN (VIMOVO) AZELASTINE/FLUTICASONE NASAL SPRAY (DYMISTA) NON-PREFERRED –

ESOMEPRAZOLE PACKET (NEXIUM PACKET)* BECLOMETHASONE (BECONASE AQ, QNASAL) INCLUDE BUT NOT LIMITED TO

ESOMEPRAZOLE STRONTIUM DR CAPSULE BUDESONIDE (RHINOCORT AQUA) DARIFENACIN (ENABLEX)

LANSOPRAZOLE CAPSULE (PREVACID CAPSULE) CICLESONIDE (OMNARIS, ZETONNA) FESOTERODINE (TOVIAZ) Effective 5/30/2014

LANSOPRAZOLE SOLUTAB (PREVACID SOLUTAB)* FLUTICASONE FUROATE (VERAMYST) Effective 7/16/2012 FLAVOXATE (URISPAS)

OMEPRAZOLE 10MG, 40MG CAPSULE (PRILOSEC) MOMETASONE (NASONEX) Effective 7/16/2012 OXYBUTYNIN GEL (GELNIQUE)

OMEPRAZOLE SUSPENSION (PRILOSEC SUSPENSION) NASACORT AQ (brand only) Effective 1/1/2014 OXYBUTYNIN PATCH (OXYTROL)

OMEPRAZOLE/SODIUM BICARBONATE (ZEGERID) TRIAMCINOLONE (NASOCORT AQ-generic only) Eff 7/16/2012 MIRABEGRON ER (MYRBETRIQ)

RABEPRAZOLE (ACIPHEX) TOLTERODINE IMMEDIATE RELEASE TABLET (DETROL)

TOLTERODINE LA CAPSULE (DETROL LA)

TROSPIUM (SANCTURA)

TROSPIUM ER (SANCTURA XR) Effective 5/8/2012

SOLIFENACIN GENERIC



1/1/2020






RESPIRATORY AGENTS RESPIRATORY AGENTS RESPIRATORY AGENTS

BRONCHODILATORS, SHORT-ACTING BETA AGONISTS BRONCHODILATORS, SHORT-ACTING ANTICHOLINERGICS BRONCHODILATORS, LONG-ACTING BETA AGONISTS (LABA)

Quick Relief Medications for Asthma AND COMBINATION PRODUCTS Controller Medications for Asthma/COPD

Quick Relief Medications for Asthma


ORIGINAL EDIT EFFECTIVE DATE: 5/29/2007 ORIGINAL POSTED PREFERRED STATUS: 3/30/2007 ORIGINAL EDIT EFFECTIVE DATE: 5/29/2007

RE-REVIEW POSTED PREFERRED STATUS: 11/09/2016 ORIGINAL EDIT EFFECTIVE DATE: 5/29/2007 RE-REVIEW POSTED PREFERRED STATUS: 5/11/2009

RE-REVIEW EDIT EFFECTIVE DATE: 1/01/2017 RE-REVIEW POSTED PREFERRED STATUS: 11/09/2016 RE-REVIEW EDIT EFFECTIVE DATE: 8/11/2009

RE-REVIEW EDIT EFFECTIVE DATE: 1/01/2017 RE-REVIEW POSTED PREFERRED STATUS: 7/21/2014

RE-REVIEW EDIT EFFECTIVE DATE: 1/1/2020 RE-REVIEW EDIT EFFECTIVE DATE: 9/23/2014

RE-REVIEW POSTED PREFERRED STATUS: 11/09/2016

PREFERRED PREFERRED RE-REVIEW EDIT EFFECTIVE DATE: 1/01/2017

ALBUTEROL 100MG/20ML, 2.5MG/0.5ML & 2.5MG/3ML SOL. IPRATROPIUM HFA(ATROVENT HFA)* RE-REVIEW EDIT EFFECTIVE DATE: 1/1/2020

ALBUTEROL INHALER HFA (PROAIR HFA) -BRAND ONLY IPRATROPIUM INHALATION SOLUTION*

ALBUTEROL INHALER HFA (PROVENTIL HFA) -BRAND ONLY IPRATROPIUM/ALBUTEROL (COMBIVENT RESPIMAT) PREFERRED

SALMETEROL INHALER (SEREVENT DISKUS)

NON-PREFERRED –

INCLUDE BUT NOT LIMITED TO NON-PREFERRED –

IPRATROPIUM/ALBUTEROL (NEBULIZER SOLUTION) INCLUDE BUT NOT LIMITED TO

ARFOMOTEROL (BROVANA)

NON-PREFERRED – FORMOTEROL INHALATION SOLUTION (PERFOROMIST)

INCLUDE BUT NOT LIMITED TO FORMOTEROL INHALER (FORADIL)

ALBUTEROL 0.21MG/ML, 0.42MG/ML SOLUTION (ACCUNEB) INDACATEROL MALEATE (ARCAPTA NEOHALER)

ALBUTEROL INHALER HFA (PROAIR RESPICLICK) OLODATEROL (STRIVERDI RESPIMAT)

ALBUTEROL INHALER HFA (VENTOLIN HFA) -BRAND AND GENERIC

ALBUTEROL INHALER HFA (PROVENTIL/PROAIR) - GENERIC ONLY

LEVALBUTEROL HFA INHALER (XOPENEX HFA)

LEVALBUTEROL SOLUTION (XOPENEX)



1/1/2020






RESPIRATORY RESPIRATORY AGENTS RESPIRATORY AGENTS

BRONCHODILATORS, LONG-ACTING ANTICHOLINERGICS BRONCHODILATORS, COMBINATION INHALED CORTICOSTEROIDS

(LAMA) LONG ACTING ANTICHOLINERGIC/LONG ACTING BETA AGONIST (ICS)

Controller Medications for COPD (LAMA/LABA) Controller Medications for Asthma

Controller Medications for Asthma/COPD

REVISED POSTED PREFERRED STATUS: 1/1/2020 ORIGINAL POSTED PREFERRED STATUS: 5/12/2006

ORIGINAL POSTED PREFERRED STATUS: 3/30/2007 ORIGINAL EDIT EFFECTIVE DATE: 7/11/2006

PREFERRED REVISED POSTED PREFERRED STATUS: 1/1/2020 REVISED POSTED PREFERRED STATUS: 11/9/2016

TIOTROPIUM INHALER (SPIRIVA HANDIHALER)* REVISED EDIT EFFECTIVE DATE: 1/1/17

PREFERRED RE-REVIEWED: 2/14/18

FORMOTEROL/GLYCOPYRROLATE (BEVESPI AEROSPHERE)* REVISED EDIT EFFECTIVE DATE: 1/1/2020

NON-PREFERRED –

INCLUDE BUT NOT LIMITED TO NON-PREFERRED – PREFERRED


ACLIDINIUM INHALER (TUDORZA PRESSAIR)* FLUTICASONE (FLOVENT HFA)*

GLYCOPYRROLATE CAPSULE (SEEBRI NEOHALER)* INDACATEROL/GLYCOPYRROLATE (UTIBRON NEOHALER)* MOMETASONE (ASMANEX TWISTHALER )*

GLYCOPYRROLATE SOLUTION (LONHALA MAGNAIR)* TIOTROPIUM/OLODATEROL (STIOLTO RESPIMAT)* BUDESONIDE AMPULE (GENERIC ONLY)*

REVEFENACIN SOLUTION (YUPELRI)* UMECLIDINIUM/VILANTEROL INHALER (ANORO ELLIPTA)*

TIOTROPIUM INHALER (SPIRIVA RESPIMAT)*

UMECLIDINIUM BROMIDE INHALER (INCRUSE ELLIPTA)*

NON-PREFERRED –


BECLOMETHASONE (QVAR REDIHALER) *

BUDESONIDE AMPULE (PULMICORT RESPULES ) BRAND ONLY*

BUDESONIDE INHALER (PULMICORT FLEXHALER) *

CICLESONIDE (ALVESCO)*

FLUNISOLIDE (AEROSPAN)*

FLUTICASONE DISK WITH DEVICE (FLOVENT DISKUS)*

FLUTICASONE FUROATE INHALATION POWDER (ARNUITY ELLIPTA)*

FLUTICASONE PROPRIONATE (ARMONAIR RESPICLICK)*

MOMETASONE HFA (ASMANEX HFA)*

TRIAMCINOLONE (AZMACORT)*



1/1/2020






RESPIRATORY AGENTS RESPIRATORY AGENTS RESPIRATORY AGENTS

INHALED CORTICOSTEROIDS AND LONG ACTING BETA AGONISTS LEUKOTRIENE RECEPTOR ANTAGONISTS INHALED ANTIBIOTICS

(ICS/LABA) Controller Medications for Asthma CF AGENTS

Controller Medications for Asthma/COPD




PREFERRED

BUDESONIDE/FORMOTEROL (SYMBICORT)* MONTELUKAST (SINGULAIR)* PREFERRED

FLUTICASONE/SALMETEROL (ADVAIR DISKUS)- BRAND ONLY* TOBRAMYCIN (BETHKIS)*- BRAND ONLY

MOMETASONE/FORMOTEROL (DULERA)* NON-PREFERRED – TOBRAMYCIN (KITABIS PAK)* -BRAND ONLY


ZAFIRLUKAST (ACCOLATE) NON-PREFERRED –

NON-PREFERRED – ZILEUTON (ZYFLO) INCLUDE BUT NOT LIMITED TO

INCLUDE BUT NOT LIMITED TO AZTREONAM (CAYSTON)*

TOBRAMYCIN (TOBI)*

FLUTICASONE/SALMETEROL HFA (ADVAIR HFA) * TOBRAMYCIN (TOBI PODHALER)*

FLUTICASONE/VILANTEROL (BREO ELLIPTA)*

FLUTICASONE/SALMETEROL (AIRDUO)*

FLUTICASONE/SALMETEROL (WIXELA)*

FLUTICASONE/SALMETEROL (ADVAIR) GENERIC ONLY*

NON-PREFERRED –ICS/LABA/LAMA

FLUTICASONE/UMECLIDINIUM/VILANTEROL (TRELEGY)*

NON-PREFERRRED PDE4 INHIBITORS

ROFLUMILAST (DALIRESP)



1/1/2020






DERMATOLOGY DERMATOLOGY DERMATOLOGY

TOPICAL STEROIDS TOPICAL STEROIDS TOPICAL STEROIDS

Class 1 (Superpotent) Class 2 (Potent) Class 3 (Upper-Mid)

ORIGINAL POSTED PREFERRED STATUS: 5/12/17 ORIGINAL POSTED PREFERRED STATUS: 5/12/17 ORIGINAL POSTED PREFERRED STATUS:5/12/17


PREFERRED CLASS 1 (SUPERPOTENT) PREFERRED CLASS 2 (POTENT) PREFERRED CLASS 3 (UPPER-MID STRENGTH)

CLOBETASOL PROPIONATE 0.05% CREAM-EMOLLIENT (15, 30, 60 gm) BETAMETHASONE DP/PROP GLYC (AUG) 0.05% CREAM (15gm, 50gm) BETAMETHASONE DP 0.05% LOT (not augmented) 60ml

CLOBEX (BRAND ONLY) CLOBETASOL PROP. 0.05% LOTION (59ML) FLUOCINONIDE 0.05% CREAM (15gm, 30gm, 60gm) BETAMETHASONE VAL 0.1% OINTMENT (15gm, 45gm)

HALOBETASOL PROP 0.05% CREAM (15gm, 50gm) FLUOCINONIDE 0.05% OINTMENT (15gm, 30gm) ELOCON OINTMENT (BRAND ONLY) MOMETASONE 0.1% OINT (15, 45gm)

HALOBETASOL PROP 0.05% OINT (15gm, 50gm) TRIAMCINOLONE 0.5% OINTMENT (15 gm) TRIAMCINOLONE 0.5% CREAM (15gm)

NON-PREFERRED – NON-PREFERRED

INCLUDE BUT NOT LIMITED TO NON-PREFERRED – INCLUDE BUT NOT LIMITED TO

BETAMETHASONE DP/PROP GLYC (AUG) 0.05% GEL INCLUDE BUT NOT LIMITED TO AMCINONIDE 0.1% CREAM

BETAMETHASONE DP/PROP GLYC (AUG) 0.05% OINT (Diprolene) AMCINONIDE 0.1% LOTION

BETAMETHASONE DP/PROP GLYC (AUG) 0.05% LOTION AMCINONIDE 0.1% OINTMENT BETAMETHASONE DIPROPIONATE 0.05% CREAM (not augmented)

BRYHALI 0.01% LOTION (HALOBETASOL PROP) DESOXIMETASONE 0.05% GEL BETAMETHASONE DIPROPIONATE 0.05% OINTMENT (not augmented)

CLOBETASOL PROPIONATE 0.05% CREAM DESOXIMETASONE 0.25% CREAM, OINTMENT BETAMETHASONE DIPROPIONATE 0.05% SPRAY EMULSION (not aug.)

CLOBETASOL PROPIONATE 0.05% EMOLL FOAM (e.g., OLUX-E) DIFLORASONE 0.05% CREAM BETAMETHASONE VALERATE 0.12% FOAM

CLOBETASOL PROPIONATE 0.05% FOAM (e.g., OLUX) FLUOCINONIDE 0.05% GEL, SOLUTION FLUOCINONIDE 0.05% EMOLLIENT CREAM

CLOBETASOL PROPIONATE 0.05% GEL FLUOCINONIDE 0.05% CREAM (120 gm) FLUTICASONE PROPIONATE 0.005% OINTMENT

CLOBETASOL PROPIONATE 0.05% OINTMENT FLUOCINONIDE 0.05% OINTMENT (60gm) TRIAMCINOLONE 0.1% OINTMENT

CLOBETASOL PROPIONATE 0.05% LOTION (59ML, 118ML) HALCINONIDE (HALOG) 0.1% CREAM, OINTMENT

CLOBETASOL PROPIONATE 0.05% SHAMPOO

CLOBETASOL PROPIONATE 0.05% SPRAY ( CLOBEX)

CLOBETASOL 0.05% SOLUTION

DESOXIMETASONE 0.25% SPRAY TOPICAL (TOPICORT)

DIFLORASONE diacetate 0.05% OINTMENT

FLUOCINONIDE 0.1% CREAM (e.g., VANOS)

HALOBETASOL PROP 0.05% LOTION (ULTRAVATE LOTION)

LEXETTE 0.05% FOAM (HALOBETASOL)



1/1/2020






DERMATOLOGY DERMATOLOGY DERMATOLOGY

TOPICAL STEROIDS TOPICAL STEROIDS TOPICAL STEROIDS

Class 4 (Mid) Class 5 (Lower-Mid) Class 6 (Mild)

ORIGINAL POSTED PREFERRED STATUS:5/12/17 ORIGINAL POSTED PREFERRED STATUS:5/12/17 ORIGINAL POSTED PREFERRED STATUS: 5/12/17


PREFERRED CLASS 4 (MID-STRENGTH) PREFERRED CLASS 5 (LOWER-MID STRENGTH) PREFERRED CLASS 6 (MILD)

ELOCON CREAM (BRAND ONLY) MOMETASONE 0.1% CREAM (15, 45gm) FLUOCINOLONE 0.01% CREAM (15, 60gm) ALCLOMETASONE DIPR 0.05% OINTMENT (15gm, 45gm, 60gm)

MOMETASONE FUROATE 0.1% SOLN, LOTION (30 ML) BETAMETHASONE VAL 0.1% CREAM (15gm, 45gm) TRIAMCINOLONE 0.025% CREAM (15 gm, 60 gm, 80 gm)

FLUOCINOLONE 0.025% OINT (15gm, 60gm, 120gm) FLUOCINOLONE 0.025% CREAM (15gm, 60gm, 120gm) SYNALAR (BRAND ONLY) FLUOCINOLONE 0.01% SOLUTION (60ml)

TRIAMCINOLONE 0.1% CREAM (15gm, 28.4gm, 30gm, 45gm, 80gm, 85.2gm) FLUTICASONE PROP 0.05% CREAM (15gm, 30gm, 60gm)

HYDROCORTISONE BUTYRATE 0.1% SOLUTION NON-PREFERRED

NON-PREFERRED TRIAMCINOLONE 0.025% LOTION, OINTMENT (60ml, 15gm, 80gm) INCLUDE BUT NOT LIMITED TO

INCLUDE BUT NOT LIMITED TO TRIAMCINOLONE 0.1% LOTION (60ml) ALCLOMETASONE DIPROPIONATE 0.05% CREAM

CLOCORTOLONE PIVALATE 0.1% CREAM AND CREAM PUMP NON-PREFERRED DESONIDE 0.05% CREAM

DESOXIMETASONE 0.05% CREAM INCLUDE BUT NOT LIMITED TO DESONIDE 0.05% GEL

DESOXIMETASONE 0.05% OINTMENT BETAMETHASONE VALERATE 0.1% LOTION FLUOCINOLONE 0.01% SOLUTION (90 ML)

HYDROCORTISONE VALERATE 0.2% OINTMENT DESONIDE 0.05% LOTION FLUOCINOLONE SCALP OIL 0.01%

FLURANDRENOLIDE 0.05% OINTMENT DESONIDE 0.05% OINTMENT TRIAMCINOLONE 0.025% CREAM (453.6 GM, 454 GM)

MOMETASONE FUROATE 0.1% SOLUTION OR LOTION (60 ML) FLUOCINOLONE SHAMPOO

TRIAMCINOLONE ACETONIDE 0.1% AEROSOL SPRAY FLURANDRENOLIDE 0.05% CREAM

FLURANDRENOLIDE 0.05% LOTION

FLURANDRENOLIDE 4 MCG/SQ. CM TAPE, SMALL AND LARGE SIZE

FLUTICASONE PROPIONATE 0.05% LOTION

HYDROCORTISONE BUTYRATE 0.1% CREAM

HYDROCORTISONE BUTYRATE 0.1% CREAM EMOLLIENT

HYDROCORTISONE BUTYRATE 0.1% OINTMENT

HYDROCORTISONE VALERATE 0.2% CREAM

HYDROCORTISONE PROBUTATE 0.1% CREAM

PREDNICARBATE 0.1% CREAM EMOLLIENT

PREDNICARBATE 0.1% OINTMENT

TRIAMCINOLONE 0.025% OINTMENT, 453.6 GM, 430 GM

TRIAMCINOLONE 0.05% OINTMENT, 430 GM



1/1/2020






DERMATOLOGY CENTRAL NERVOUS SYSTEM AGENTS CENTRAL NERVOUS SYSTEM AGENTS

TOPICAL STEROIDS NARCOTIC AGONIST ANALGESICS NARCOTIC AGONIST ANALGESICS

Class 7 (Least Potent) SHORT-ACTING OPIOIDS SHORT-ACTING OPIOIDS



PREFERRED CLASS 7 (LEAST POTENT) PREFERRED NON-PREFERRED – (continued)

HYDROCORTISONE ACETATE 0.5% (covered OTC) 28.4gm APAP/CODEINE ELIXIR INCLUDE BUT NOT LIMITED TO

HYDROCORTISONE 0.5% CREAM (covered OTC) 28.4gm, 28.35gm APAP/CODEINE TABLET (300-15 mg, 300-30 mg, 300-60 mg) DIHYDROCODEINE/APAP/CAFFEINE (TABLET, CAPSULE)

HYDROCORTISONE 0.5% OINTMENT (covered OTC) 28.35gm CODEINE TABLET (15 mg, 30 mg, 60 mg) FIORICET/CODEINE

HYDROCORTISONE 1% CREAM (28.35gm, 28.4gm) HYDROMORPHONE TABLET (2 mg, 4 mg, 8 mg) FIORINAL/CODEINE

HYDROCORTISONE 1% OINTMENT (28.35gm, 28.4gm) HYDROCODONE/APAP SOLUTION (7.5-325 mg/15 ml) HYDROMORPHONE LIQUID, RECTAL SUPP

HYDROCORTISONE 2.5% CREAM (20gm, 28gm, 28.35gm, 30gm) HYDROCODONE/APAP TABLET (5-325 mg,7.5-325 mg, 10-325 mg) HYDROCODONE/APAP TABLET (2.5-325, 5-300, 7.5-300, 10-300 mg)

HYDROCORTISONE 2.5% OINTMENT (20gm, 28.35gm, 28.4gm) HYDROCODONE/IBUPROFEN (7.5-200 mg) HYDROCODONE/APAP SOLUTION (unit dose cups)

MEPERIDINE SOLUTION HYDROCODONE/IBUPROFEN (5-200mg, 10-200mg)

NON-PREFERRED – MEPERIDINE TABLET (50 MG) MEPERIDINE TABLET (100 MG)

INCLUDE BUT NOT LIMITED TO MORPHINE CONC. SOLUTION (100 mg/5 ml) NUCYNTA

HYDROCORTISONE 1% CREAM (453.6 GM) MORPHINE IR TABLET (15 mg, 30 mg) OPANA

HYDROCORTISONE 1% OINTMENT (453.6 GM) MORPHINE SOLUTION (10 mg/5 ml, 20 mg/5 ml) OXYCODONE/ASA

HYDROCORTISONE 1% OINTMENT IN ABSORBASE OXYCODONE/APAP SOLUTION (5-325 mg/5 ml) OXYCODONE CAPSULE

HYDROCORTISONE 2.5% CREAM (453.6 GM) OXYCODONE/APAP TABLET (5-325 mg, 7.5-325 mg 10-325 mg) OXYCODONE CONCENTRATED ORAL SOLUTION

HYDROCORTISONE 2.5% LOTION OXYCODONE SOLUTION (5 mg/5 ml) OXYCODONE/IBUPROFEN

HYDROCORTISONE 2.5% OINTMENT (453.6 GM, 454 GM) OXYCODONE TABLET OXYCODONE/APAP TABLET (2.5-325mg)

HYDROCORTISONE 2.5% SOLUTION TRAMADOL TABLET OXYMORPHONE

TRAMADOL/APAP TABLET PENTAZOCINE/NALOXONE

NON-PREFERRED – PRIMLEV (5-300mg, 7.5-300mg, 10-300mg)

INCLUDE BUT NOT LIMITED TO REPREXAIN

APAP/CODEINE (unit dose cups) ZAMICET

BUTALBITAL/CAFFEINE/APAP W/CODEINE

BUTALBITAL COMPOUND W/CODEINE

BUTORPHANOL TARTRATE

CAPITAL W-CODEINE

CARISOPRODOL COMPOUND W/CODEINE



1/1/2020






OPHTHALMOLOGY OPHTHALMOLOGY OPHTHALMOLOGY

OPHTHALMIC ANTIBIOTICS OPHTHALMIC ANTIBIOTICS-STEROID COMBINATIONS GLAUCOMA AGENTS



PREFERRED PREFERRED PREFERRED

BACITRACIN/ POLYMYXIN B DEXAMETHASONE/NEOMYCIN SULFATE/POLYMYXIN B SULFATE ALPHAGAN P 0.15% (BRAND ONLY) BRIMONIDINE

CIPROFLOXACIN SOLUTION TOBRADEX (DEXAMETHASONE/TOBRAMYCIN) CARTEOLOL DROPS

ERYTHROMYCIN OINT DEXAMETHASONE/TOBRAMYCIN SUSPENSION (GENERIC) COMBIGAN (BRIMONIDINE/TIMOLOL)

GENTAMICIN (SOLUTION/OINTMENT) PREDNISOLONE SODIUM PHOSPHATE/SULFACETAMIDE SODIUM DORZOLAMIDE

POLYMYXIN B /TRIMETHOPRIM DROPS SOLUTION DORZOLAMIDE/TIMOLOL (generic)

TOBRAMYCIN DROPS LATANOPROST

VIGAMOX (BRAND ONLY) MOXIFLOXACIN NON-PREFERRED – LEVOBUNOLOL

INCLUDE BUT NOT LIMITED TO LUMIGAN 0.01% 2.5ML, 5ML ( BIMATOPROST)

NON-PREFERRED – BLEPHAMIDE, BLEPHAMIDE S.O.P. (PREDNISOLONE ACETATE/ SIMBRINZA (BROMONIDINE/BRINZOLAMIDE)

INCLUDE BUT NOT LIMITED TO SULFACETAMIDE SODIUM) SUSPENSION & OINTMENT) TIMOLOL (GENERIC TIMOPTIC DROPS)

AZASITE (AZITHROMYCIN) HYDROCORTISONE/NEOMYCIN SULFATE/BACITRACIN ZINC/ TRAVATAN Z (TRAVOPROST)

BACITRACIN POLYMYXIN B SULFATES NON-PREFERRED –

BESIVANCE (BESIFLOXACIN) HYDROCORTISONE/NEOMYCIN SULFATE/POLYMYXIN B SULFATE INCLUDE BUT NOT LIMITED TO

CILOXAN (CIPROFLOXACIN OINTMENT) PRED-G, PRED-G S.O.P. (PREDNISOLONE ACETATE/ BRIMONIDINE 0.1% (ALPHAGAN P), BRIMONIDINE 0.2%

LEVOFLOXACIN GENTAMICIN SULFATE) APRACLONIDINE

MOXEZA(MOXIFLOXACIN) TOBRADEX ST (DEXAMETHASONE/TOBRAMYCIN) AZOPT (BRINZOLAMIDE)

NATACYN (NATAMYCIN) ZYLET(LOTEPREDNOL/TOBRAMYCIN) BETAXOLOL

NEOMYCIN/POLYMYXIN B/ BACITRACIN BETOPIC S (BETAXOLOL)

NEOMYCIN/POLYMYXIN B/ GRAMICIDIN IOPIDINE (APRACLONIDINE)

OFLOXACIN ISTALOL (TIMOLOL LA)

SULFACETAMIDE LUMIGAN 7.5ML (BIMATOPROST)

TOBREX (TOBRAMYCIN OINTMENT) METIPRANOLOL

ZYMAXID (GATIFLOXACIN) PILOCARPINE

ROCKLATAN (NETARSUDIL MESYLAT/LATANOPROST)

TIMOPTIC IN OCUDOSE, TIMOLOL XE (TIMOLOL)

XELPROS (LATANOPROST)

ZIOPTAN (TAFLUPROST)



1/1/2020






CENTRAL NERVOUS AGENTS CENTRAL NERVOUS AGENTS CENTRAL NERVOUS AGENTS

Long Acting Injectable Antipsychotics Oral Antipsychotics Oral Antipsychotics (continued)

NEW PDL CATEGORY STARTING 7/1/19 NEW PDL CATEGORY STARTING 7/1/19



PREFERRED PREFERRED NON-PREFERRED

ARIPIPRAZOLE ER (ABILIFY MAINTENA)* AMITRIPTYLINE/PERPHENAZINE TABLETS INCLUDE BUT NOT LIMITED TO

ARIPIPRAZOLE LAUROXIL ER (ARISTADA)* ARIPIPRAZOLE TABLETS ARIPIPRAZOLE ODT

FLUPHENAZINE DECANOATE* CLOZAPINE TABLETS ARIPIRAZOLE SOLUTION

HALOPERIDOL DECANOATE* FLUPHENAZINE TABLETS CHLORPROMAZINE TABLETS

OLANZAPINE(ZYPREXA RELPREVV)* HALOPERIDOL LACTATE CONC CLOZAPINE ODT

RISPERIDONE MICROSPHERES(RISPERDAL CONSTA)* HALOPERIDOL TABLETS FANAPT (ILOPERIDONE) TABLETS

LOXAPINE TABLETS FAZACLOZ (CLOZAPINE) ODT

OLANZAPINE TABLETS FLUPHENAZINE ELIXIR/SOLUTION

OLANZAPINE ODT LATUDA (LURASIDONE) TABLETS

NON-PREFERRED – PERPHENAZINE TABLETS MOLINDONE TABLETS

INCLUDE BUT NOT LIMITED TO PIMOZIDE TABLETS OLANZAPINE/FLUOXETINE (SYMBYAX) CAPSULE

PALIPERIDONE PALMITATE (INVEGA SUSTENNA)* QUETIAPINE TABLETS PALIPERIDONE TABLETS (INVEGA BRAND AND GENERIC)

PALIPERIDONE PALMITATE (INVEGA TRINZA)* RISPERIDONE TABLETS REXULTI (BREXPIPRAZOLE) TABLETS

RISPERIDONE ODT SAPHRIS SL TABLETS(ASENAPINE)

RISPERIDONE SOLUTION ZYREXA ZYDIS

THIORIDAZINE TABLETS VERSACLOZ (CLOZAPINE ODT)

THIOTHIXENE TABLETS VRAYLAR (CARIPRAZINE)

TRIFLUOPERAZINE TABLETS

ZIPRASIDONE CAPSULES



1/1/2020






INSULINS INSULINS



PREFERRED NON-PREFERRED –

REGULAR/INTERMEDIATE ACTING INCLUDE BUT NOT LIMITED TO

HUMULIN 500 U/M VIAL

HUMULIN VIAL HUMALOG CARTRIDGE

NOVOLIN VIAL HUMALOG JR QUICKPEN

LONG ACTING HUMALOG 200 PEN

LEVEMIR PENS & VIALS AFREZZA

LANTUS SOLOSTAR PEN NOVOLIN 70/30 VIAL OTC

LANTUS VIAL HUMULIN 70/30 PEN OTC

RAPID ACTING HUMULIN PEN OTC

HUMALOG VIAL (BRAND ONLY) HUMULIN 500 U/M PEN

APIDRA SOLOSTAR PEN TRESIBA PEN

APIDRA VIAL BASAGLAR KWIKPEN

NOVOLOG PEN TOUJEO SOLOSTAR PEN

NOVOLOG VIAL TRESIBA FLEXTOUCH PEN

NOVOLOG CARTRIDGE FIASP

HUMALOG PEN INSULIN LISPRO VIALS (GENERIC ONLY)

COMBINATION

HUMALOG MIX VIAL

HUMALOG MIX PEN

NOVOLOG MIX PEN

NOVOLOG MIX VIAL

HUMULIN 70/30 VIAL



1/1/2020






ANTICOAGULANTS CHRONIC GI MOTILITY AGENTS ANTIHYPERURICEMICS




ENOXAPARIN-GENERIC VIAL, SYRINGE LUBIPROSTONE (AMITIZA) MITIGARE CAPSULE-BRAND ONLY

WARFARIN ALLOPURINOL

DABIGATRAN (PRADAXA) PROBENECID

APIXIBAN (ELIQUIS) NON-PREFERRED – PROBENECID/COLCHICINE

RIVAROXABAN (XARELTO) INCLUDE BUT NOT LIMITED TO

ALOSETRON (LOTRONEX)

ELUXADOLINE (VIBERZI) NON-PREFERRED –

NON-PREFERRED – PLECANATIDE (TRULANCE) INCLUDE BUT NOT LIMITED TO

INCLUDE BUT NOT LIMITED TO METHYLNALTREXONE (RELISTOR) COLCHICINE TABLET (COLCRYS)

DALTEPARIN (FRAGMIN) NALDEMEDINE (SYMPROIC) COLCHICINE CAPSULE-GENERIC

FONDAPARINUX (ARIXTRA) LINACLOTIDE (LINZESS) FEBUXOSTAT (ULORIC)

EDOXABAN (SAVAYSA) NALEXEGOL (MOVANTIK) LESINURAD/ALLOPURINOL (DUZALLO)

BETRIXABAN (BEVYXXA) PRUCALOPRIDE (MOTEGRITY) ZURAMPIC (ZURAMPIC)



1/1/2020






CIII STIMULANTS FOR NARCOLEPSY COLONY STIMULATING FACTORS ERYTHROPOIESIS STIMULATING AGENTS

PROVIGIL & NUVIGIL


ORIGINAL POSTED PREFERRED STATUS: 5/10/18 ORIGINAL EDIT EFFECTIVE DATE: 7/1/18 ORIGINAL POSTED PREFERRED STATUS: 5/10/18


PREFERRED

PREFERRED NEUPOGEN DISP SYRIN PREFERRED

NUVIGIL (BRAND ONLY)* NEUPOGEN VIAL EPOGEN*

GRANIX PROCRIT*

NON-PREFERRED – NEULASTA SYRINGE


PROVIGIL

ARMODAFINIL (GENERIC) NON-PREFERRED –

MODAFINIL INCLUDE BUT NOT LIMITED TO NON-PREFERRED –

LEUKINE INCLUDE BUT NOT LIMITED TO

NEULASTA KIT ARANESP DISP SYRIN

ZARXIO ARANESP VIAL

FULPHILA MIRCERA



1/1/2020






PLATELET AGGREGATION INHIBITORS PHOSPHATE BINDERS FOR CKD LIPOTROPICS-OTHER

BILE ACID SEQUESTRANTS, FIBRATES


ORIGINAL POSTED PREFERRED STATUS: 5/10/18 ORIGINAL EDIT EFFECTIVE DATE: 7/1/18 ORIGINAL POSTED PREFERRED STATUS: 5/10/18


PREFERRED

PREFERRED SEVELAMER HCL (GENERIC RENAGAEL) PREFERRED FIBRATES

AGGRENOX (BRAND ONLY) RENVELA TABLET (BRAND ONLY) GEMFIBROZIL

DIPYRIDAMOLE CALCIUM ACETATE CAPSULE FENOFIBRATE TABLET (TRICOR)

PRASUGREL CALCIUM ACETATE TABLET FENOFIBRATE TABLET (LOFIBRA)

CLOPIDOGREL PREFERRED BILE ACID SEQUESTRANTS

BRILINTA COLESTID TABLET

CILOSTAZOL NON-PREFERRED – COLESTIPOL GRANULES

INCLUDE BUT NOT LIMITED TO CHOLESTYRAMINE/ASPARTAME

NON-PREFERRED – CHOLESTYRAMINE/SUCROSE

INCLUDE BUT NOT LIMITED TO AURYXIA

ELIPHOS NON-PREFERRED –

ASPIRIN/DIPYRIDAMOLE (GENERIC) FOSRENOL CHEWABLE TABLET INCLUDE BUT NOT LIMITED TO

EFFIENT (BRAND) LANTHANUM CARBONATE CHEWABLE TABLET FENOFIBRATE (ANTARA)

PLAVIX (BRAND) PHOSLYRA FENOFIBRATE (FENOGLIDE)

TICLOPIDINE RENVELA POWDER PACK FENOFIBRATE CAPSULE (LIPOFEN, LOFIBRA)

ZONTIVITY SEVELAMER CARBONATE POWDER PACK FENOFIBRIC ACID (FIBRICOR)

YOSPRALA SEVELAMER CARBONATE TABLET FENOFIBRIC ACID (TRILIPIX)

VELPHORO FENOGLIDE

RENAGEL (BRAND ONLY) FIBRICOR

LIPOFEN

TRICOR

TRIGLIDE

TRILIPIX

WELCHOL POWDER PACK

WELCHOL TABLET



1/1/2020






CYSTINE-DEPLETING AGENTS BOWEL PREP AGENTS ANTIMIGRAINE AGENTS-CGRP ANTAGONISTS

NEW PDL CATEGORY STARTING 1/1/19 NEW PDL CATEGORY STARTING 10/1/19




POTASSIUM CITRATE COLYTE SOLUTION EMGALITY PEN 120 MG

COLYTE W/ FLAVOR PACKS EMGALITY SYRINGE 120 MG

PREFERRED –WITH CRITERIA GAVILYTE-C

CUPRIMINE NULYTELY NON-PREFERRED

DEPEN GAVILYTE-N INCLUDE BUT NOT LIMITED TO

THIOLA GOLYTELY SOLUTION

GAVILYTE-G EMGALITY PEN 100 MG

MOVIPREP EMGALITY SYRINGES 100 MG

PEG-3350 AND ELECTROLYTE SOLUTION AIMOVIG AUTOINJECTOR 70 MG

PEG-3350 WITH FLAVOR PACKS SOLUTION AIMOVIG AUTOINJECTOR 140 MG

TRILYTE AJOVY SYRINGE 255 MG

NON-PREFERRED


OSMOPREP

CLENPIQ

PREPOPIK

SUPREP

PLENVU

GOLYTELY POWDER PACK

*Please refer to the PDL Criteria Overview for more detail GENERIC (SAMPLE BRAND) LISTED FOR REFERENCE ONLY GENERIC (SAMPLE BRAND) LISTED FOR REFERENCE ONLY


1/1/2020






OSTEOPOROSIS DISCLAIMER ANAPHYLAXIS AGENTS

NEW PDL CATEGORY STARTING 10/1/19 FIBROMYALGIA & NEUROPATHIC PAIN AGENTS SELF INJECTED EPINEPHRINE




PREFERRED ORIGINAL EDIT EFFECTIVE DATE: 6/5/2008 ORIGINAL EDIT EFFECTIVE DATE: 1/1/17

ALENDRONATE REVISED POSTED PREFERRED STATUS: 11/10/17

REVISED EDIT EFFECTIVE DATE: 1/1/18

PREFERRED

GENERIC EPIPEN & EPIPEN Jr.

NON-PREFERRED NON-PREFERRED –

INCLUDE BUT NOT LIMITED TO INCLUDE BUT NOT LIMITED TO

ABALOPARATIDE (TYMLOS) EPINEPHRINE 0.15MG (ADRENACLICK)

ALENDRONATE Plus D (FOSAMAX + D) EPINEPHRINE 0.3MG (ADRENACLICK)

ALENDRONATE ORAL SOLUTION (FOSAMAX) EPIPEN (brand )

ALENDRONATE EFFERVESCENT TABLET (BINOSTO) EPIPEN JR. (brand)

CALCITONIN-SALMON (MIACALCIN/FORTICAL)

DENOSUMAB (PROLIA)

ETIDRONATE

IBANDRONATE (BONIVA) TABLET

IBANDRONATE (BONIVA) INJECTION

RALOXIFENE (EVISTA)

RISEDRONATE (ACTONEL)

RISEDRONATE (ATELVIA)

ROMOSOZUMAB-AQQG (EVENITY) INJECTION

TERIPARATIDE (FORTEO)

Strikethrough indicates change in PDL Status GENERIC (SAMPLE BRAND) LISTED FOR REFERENCE ONLY

*Please refer to the PDL Criteria Overview for more detail

The non-preferred antiepileptic medications will be considered non-preferred for

treating fibromyalgia and neuropathic pain only. Medications listed as either

preferred or non-preferred status in this category may or may not include an FDA

approved indication for fibromyalgia or neuropathic pain. Use of these

medications for fibromyalgia, neuralgias, and neuropathic pain has been reviewed

through the evidence-based review process. Medications listed in this category as

either preferred or non-preferred status are not to be construed as endorsements

for marketing of off-label use by the manufacturer or by Medicaid.


preferred drug list - magellan rx management · 2019-12-31 · 1/1/2020 allergy-asthma opiate...

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