Medicaid Preferred Drug List & Prior Authorization - · PDF filePage 1 of 34 Last Updated:...

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  • Page 1 of 40 Last Updated: April 1, 2018

    PREFERRED DRUG LIST When a generic product is available, for a preferred or non-preferred agent, the pharmacy will

    receive a lower reimbursement rate for the branded product unless a DAW PA is obtained. Products listed in RED have changed from the previous months publication.

    TABLE OF CONTENTS Inhalation Agents Page 1 - 2

    Intranasal Agents Page 2

    Ophthalmic Agents Page 2 - 3

    Otic Agents Page 3

    Oral/Injectable/Topical Agents Page 3 - 19

    Index (Arranged by Brand Name) Page 20 - 33

    INHALATION AGENTS

    Anticholinergics for the Maintenance Treatment of COPD Preferred Non-Preferred, Prior Authorization Required

    Spiriva Handihaler (tiotropium) Atrovent HFA (ipratropium bromide) Incruse Ellipta (umeclidinium bromide) Lonhala Magnair (glycopyrrolate) effective

    4/15/2018 Seebri Neohaler (glycopyrrolate) Spiriva Respimat (tiotropium) Tudorza PressAir (aclidinium)

    Beta2-Agonists - Long-Acting *Clinical prior authorization may apply

    Preferred Non-Preferred, Prior Authorization Required

    Serevent Diskus (salmeterol) Arcapta (indacaterol) Brovana (arformoterol) Perforomist (formoterol) Striverdi Respimat (olodaterol)

    Beta2-Agonists - Short-Acting Preferred Non-Preferred, Prior Authorization Required

    AccuNeb (albuterol) Maxair (pirbuterol) ProAir HFA (albuterol) ProAir RespiClick (albuterol) Proventil HFA (albuterol) Ventolin HFA (albuterol) Proventil Inhalation Solution (albuterol) Xopenex Inhalation Solution (levalbuterol) Ventolin Inhalation Solution (albuterol) Xopenex HFA (levalbuterol)

    Beta2-Agonists - Long-Acting/Anticholinergics *Clinical prior authorization may apply

    Preferred Non-Preferred, Prior Authorization Required

    Anoro Ellipta (umeclidinium/vilanterol) Utibron Neohaler (indacaterol/glycopyrrolate) Bevespi Aerosphere (glycopyrrolate/formoterol) Stiolto Respimat (tiotropium/olodaterol)

    Beta2-Agonists - Long-Acting/Corticosteroids *Clinical prior authorization may apply Preferred Non-Preferred, Prior Authorization Required

    Advair Diskus (fluticasone/salmeterol) Dulera (formoterol/mometasone)

    Airduo Respiclick (fluticasone/salmeterol) Advair HFA (fluticasone/salmeterol)

    Symbicort (budesonide/formoterol) Breo Ellipta (fluticasone/vilanterol)

  • Page 2 of 40 Last Updated: April 1, 2018

    PREFERRED DRUG LIST When a generic product is available, for a preferred or non-preferred agent, the pharmacy will

    receive a lower reimbursement rate for the branded product unless a DAW PA is obtained. Products listed in RED have changed from the previous months publication.

    INHALATION AGENTS (continued)

    Corticosteroids Preferred Non-Preferred, Prior Authorization Required

    Alvesco (ciclesonide) Aerospan (flunisolide) Arnuity Ellipta (fluticasone) Armonair RespiClick (fluticasone) Asmanex (mometasone) Asmanex HFA (mometasone) Flovent HFA (fluticasone) Flovent Diskus (fluticasone) Pulmicort Flexhaler (budesonide) Pulmicort Respules (budesonide) *> 7 years of age Pulmicort Respules (budesonide) * 6 years of age only QVAR (beclomethasone) QVAR RediHaler(beclomethasone) effective 4/15/2018

    Tobramycin Products Preferred Non-Preferred, Prior Authorization Required

    Bethkis (tobramycin) Tobi (tobramycin) Kitabis pak (tobramycin nebulizer) Tobi Podhaler (tobramycin)

    INTRANASAL AGENTS

    Antihistamines Preferred Non-Preferred, Prior Authorization Required

    Astelin (azelastine) Astepro (azelastine) Patanase (olopatadine)

    Corticosteroids Preferred Non-Preferred, Prior Authorization Required

    Flonase (fluticasone) Beconase AQ (beclomethasone) Qnasl (beclomethasone) Nasacort AQ(triamcinolone) Omnaris (ciclesonide) Nasarel (flunisolide) Nasonex (mometasone) Rhinocort AQ (budesonide) Veramyst (fluticasone) Xhance (fluticasone) effective 4/15/2018 Zetonna (ciclesonide)

    OPHTHALMIC AGENTS

    Antihistamine/Mast Cell Stabilizers Preferred Non-Preferred, Prior Authorization Required

    Alaway (ketotifen) Alocril (nedocromil) Cromolyn (cromolyn) Alomide (lodoxamide) Patanol (olopatadine) Bepreve (bepotastine) Pazeo (olopatadine) Elestat (epinastine) Refresh (ketotifen) Emadine (emedastine) Zaditor (ketotifen) Lastacaft (alcaftadine) Optivar (azelastine) Pataday (olopatadine)

  • Page 3 of 40 Last Updated: April 1, 2018

    PREFERRED DRUG LIST When a generic product is available, for a preferred or non-preferred agent, the pharmacy will

    receive a lower reimbursement rate for the branded product unless a DAW PA is obtained. Products listed in RED have changed from the previous months publication.

    OPHTHALMIC AGENTS (continued)

    Anti-Infective/Steroid Combinations Preferred Non-Preferred, Prior Authorization Required

    Blephamide (sulfacetamide/prednisolone) Blephamide S.O.P. (sulfacetamide/prednisolone) Maxitrol (neomycin/polymyxin/dexamethasone) TobraDex (tobramycin/dexamethasone) Pred-G (prednisolone/gentamicin) TobraDex ST (tobramycin/dexamethasone) Pred-G S.O.P. (prednisolone/Gentamicin) Zylet(Loteprednol/Tobramycin)

    Carbonic Anhydrase Inhibitors Preferred Non-Preferred, Prior Authorization Required

    Azopt (brinzolamide) Trusopt (dorzolamide) Simbrinza (brinzolamide/brimonidine tartrate)

    Non-Steroidal Anti-Inflammatory Drugs - Ophthalmic Preferred Non-Preferred, Prior Authorization Required

    Acuvail (ketorolac) Acular (ketorolac) Ilevro (nepafenac) Acular LS (ketorolac) Ocufen(flurbiprofen) Bromday (bromfenac) Voltaren Ophthalmic (diclofenac) BromSite (bromfenac) Prolensa (bromfenac) Nevanac (nepafenac)

    Prostaglandin Analogs Preferred Non-Preferred, Prior Authorization Required

    Xalatan (latanoprost) Lumigan (bimatoprost) Travatan Z (travoprost) Vyzulta (latanoprostene bunod) effective 4/15/2018 Zioptan (tafluprost)

    OTIC AGENTS

    Anti-Infective/Steroid Combinations Preferred Non-Preferred, Prior Authorization Required

    Cipro HC (ciprofloxacin/hydrocortisone) Acetasol HC (acetic acid/hydrocortisone) Ciprodex (ciprofloxacin/dexameth) Cortisporin Otic Suspension (neomycin/polymyxin B/hc) Cortisporin Otic Solution (neomycin/polymyxin B/hc) Otovel (ciprofloxacin/fluocinolone) Coly-Mycin S

    ORAL/INJECTABLE/TOPICAL AGENTS

    ACE Inhibitors Preferred Non-Preferred, Prior Authorization Required

    Accupril (quinapril) Aceon (perindopril) Altace (ramipril) Capoten (captopril) Lotensin (benazepril) Epaned (enalapril solution) Monopril (fosinopril) Mavik( trandolapril) Prinivil (lisinopril) Zestril (lisinopril)

    Qbrelis (lisinopril solution) Univasc (moexipril)

    Vasotec (enalapril)

  • Page 4 of 40 Last Updated: April 1, 2018

    PREFERRED DRUG LIST When a generic product is available, for a preferred or non-preferred agent, the pharmacy will

    receive a lower reimbursement rate for the branded product unless a DAW PA is obtained. Products listed in RED have changed from the previous months publication.

    ORAL/INJECTABLE/TOPICAL AGENTS (continued)

    ACE Inhibitor/Calcium Channel Blocker Combinations Preferred Non-Preferred, Prior Authorization Required

    Lotrel (benazepril/amlodipine) Tarka (trandolapril/verapamil)

    Acne Agents - Topical *Clinical prior authorization may apply

    Preferred Non-Preferred, Prior Authorization Required

    Aczone (dapsone) gel Acanya (benzoyl peroxide-clindamycin) gel Atralin (tretinoin) gel Avar (sulfacetamide-sulfur) pads Cleocin-T (clindamycin) solution Avar-E Emollient (sulfacetamide-sulfur) cream Duac (benzoyl peroxide-clindamycin) gel Avar-E Green (sulfacetamide-sulfur) cream Epiduo (benzoyl peroxide-adapalene) gel Avar LS (sulfacetamide-sulfur) pads Ery (erythromycin) pads Avita (tretinoin) cream Erythromycin solution Azelex (azelaic acid) cream Retin-A (tretinoin) cream Benzaclin (benzoyl peroxide-clindamycin) gel Sumadan Wash (sulfacetamide-sulfur cleanser) Benzamycin (benzoyl peroxide-erythromycin) gel Tazorac (tazarotene) cream BP 10-1 (sulfacetamide/sulfur cleanser) Tazorac (tazarotene) gel Cerisa (sulfacetamide-sulfur) emulsion Cleocin-T (clindamycin) gel Cleocin-T (clindamycin) lotion Clindacin ETZ (clindamycin) swab Clindacin-P (clindamycin) swab Clindagel (clindamycin) gel Differin (adapalene) cream Differin (adapalene) gel Epiduo Forte (adapalene/benzoyl peroxide) Erygel (erythromycin) gel Evoclin (clindamycin phosphate) foam Fabior (tazarotene) foam Klaron (sulfacetamide) lotion Neuac (clindamycin/benzoyl peroxide) Onexton (benzoyl peroxide-clindamycin) gel Retin-A Micro (tretinoin) gel Rosanil Cleanser (sulfacetamide-sulfur) emulsion Rosula (sulfacetamide-sulfur) pads SSS 10-5 (sulfacetamide-sulfur) cream Sulfacetamide suspension Sulfacetamide-Sulfur lotion Sumadan (sulfacetamide-sulfur) kit Sumaxin (sulfacetamide-sulfur) pads Sumaxin TS (sulfacetamide-sulfur) suspension Sumaxin Wash (sulfacetamide-sulfur) liquid Veltin (clindamycin-tretinoin) Ziana (clindamycin-tretinoin)

  • Page 5 of 40 Last Updated: April 1, 2018

    PREFERRED DRUG LIST When a generic product is available, for a preferred or non-preferred agent, the pharmacy will

    receive a lower reimbursement rate for the branded product unless a DAW PA is obtained. Products listed in RED have changed from the previous months publication.

    ORAL/INJECTABLE/TOPICAL AGENTS (continued)

    Actinic Keratosis Agents (formerly Fluorouracil Agents)

    *Clinical prior authorization may apply Preferred Non-Preferred, Prior Authorization Required

    Efudex (fluorouracil) Carac (fluorouracil) Picato (ingenol mebutate) effective 4/15/2018 Solaraze 3% gel (diclofenac sodium) effective

    4/15/2018 Tolak (fluorouracil)

    ADHD Amphetamine Type P


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