Minnesota Fee-for-Service and Managed Care Medicaid Uniform Preferred Drug List effective January 15, 2020

PROVIDER: PLEASE READ Uniform preferred drug list (PDL) and preferred drug list changes

Managed Care Organizations (MCOs) that offer drug benefits to Minnesota Health Care Programs (MHCP) members must use the Minnesota Department of Human Services’ (DHS) Uniform PDL beginning July 1, 2019. The Uniform PDL will ensure a more consistent drug benefit for all members and minimize disruptions if a member’s health plan changes. The Uniform PDL was reviewed and recommended by the Drug Formulary Committee and includes many commonly used medications. Members enrolled with an MCO will have access to all of the preferred drugs on the PDL as well as the other drugs on their plan’s List of Covered Drugs (formulary). This change does not apply to members with dual Medicare and Medicaid coverage. See the Minnesota Uniform Preferred Drug List below. DHS has created a Frequently Asked Questions for Providers Regarding the Uniform Preferred Drug List (PDF) guide to assist you in understanding your role in helping members remain on a nonpreferred drug or transition to a preferred drug on or after July 1, 2019. If a member is currently using a nonpreferred drug, you must do one of the following before July 1, 2019:

Request a one-time continuation of therapy override if the member meets the Continuation of Therapy prior authorization criteria (PA) for coverage of the nonpreferred drug for 90 days. Make your request to DHS if the member has fee-for-service coverage or to the MCO responsible for the member’s coverage.

Request prior authorization (PA) for the Nonpreferred Drug from DHS, if the member has fee-for-service coverage, or the MCO responsible for the member’s coverage. You may request the PA before July 1, 2019, or during the 90-day continuation of therapy period.

If a member currently has an approved PA for a nonpreferred drug, DHS or the member’s MCO will honor the approved PA until the PA expires. After the PA expires, you must request a new PA to continue coverage or transition the member to a preferred drug. If you have additional questions, please contact:

MHCP Provider Call Center (for members in fee-for-service Medicaid) at 800-366-5411 or 651-431-2700

MCO responsible for the member’s coverage (for members in Managed Care Medicaid or MinnesotaCare). See the table below.

MCO Plan Pharmacy Contact Number(s)

Blue Plus – Prime Therapeutics 800-821-4795

HealthPartners 952-883-5813 800-492-7259

Hennepin Health – Navitus 612-596-1036 800-647-0550

Itasca Medical Care – Caremark 800-345-5413

MCO Plan Pharmacy Contact Number(s)

Medica – CVSH 800-364-6331

Primewest Heatlth – MedImpact 800-788-2949

South Country Health Alliance – PerformRX 866-935-8874

UCare – Express Scripts, Inc. (ESI) 877-558-7523 (physician authorizations) 800-595-7140 (Fairview Specialty – specialty medications)

ACNE AGENTS, TOPICAL section updated 4-22-2019 Preferred Nonpreferred AZELEX BENZOYL PEROXIDE 10% WASH OTC (TOPICAL) BENZOYL PEROXIDE 3% CLEANSER OTC (TOPICAL) BENZOYL PEROXIDE 5% WASH OTC (TOPICAL) BENZOYL PEROXIDE 6% CLEANSER OTC (TOPICAL) BENZOYL PEROXIDE 9% CLEANSER OTC (TOPICAL) BENZOYL PEROXIDE GEL (TOPICAL) BENZOYL PEROXIDE LOTION OTC (TOPICAL) CLINDAMYCIN / BENZOYL PEROXIDE (ACANYA) W/PUMP (AG) (TOPICAL) CLINDAMYCIN / BENZOYL PEROXIDE (BENZACLIN) (TOPICAL) CLINDAMYCIN / BENZOYL PEROXIDE (DUAC) (TOPICAL) CLINDAMYCIN PHOSPHATE GEL (TOPICAL) CLINDAMYCIN PHOSPHATE LOTION (TOPICAL) CLINDAMYCIN PHOSPHATE MED. SWAB (TOPICAL) CLINDAMYCIN PHOSPHATE SOLUTION (TOPICAL) DIFFERIN CREAM (TOPICAL) DIFFERIN GEL (TOPICAL) DIFFERIN GEL PUMP (TOPICAL) DIFFERIN LOTION (TOPICAL) ERYTHROMYCIN GEL (TOPICAL) ERYTHROMYCIN MED. SWAB (TOPICAL) ERYTHROMYCIN SOLUTION (TOPICAL) ERYTHROMYCIN-BENZOYL PEROXIDE (TOPICAL) SULFACETAMIDE/SULFUR CLEANSER (TOPICAL SULFACETAMIDE SODIUM/SULFUR (TOPICAL) SULFACETAMIDE SUSPENSION (TOPICAL) TAZORAC CREAM (TOPICAL) TAZORAC GEL (TOPICAL) TRETINOIN CREAM (TOPICAL) TRETINOIN GEL (AVITA, RETIN-A) (TOPICAL)

ACANYA W/PUMP (TOPICAL) ADAPALENE / BENZOYL PEROXIDE (EPIDUO) (TOPICAL) ADAPALENE CREAM (TOPICAL) ADAPALENE GEL (TOPICAL) ADAPALENE GEL PUMP (TOPICAL) ADAPALENE SOLUTION (TOPICAL) ATRALIN (TOPICAL) AVITA CREAM (TOPICAL) AVITA GEL (TOPICAL) BENZACLIN (TOPICAL) BENZACLIN W/PUMP (TOPICAL) BENZOYL PEROXIDE CLEANSER OTC (TOPICAL) BENZOYL PEROXIDE FOAM OTC (TOPICAL) BENZOYL PEROXIDE TOWELETTE OTC (TOPICAL) BP 10-1 (TOPICAL) CLEOCIN T GEL (TOPICAL) CLEOCIN LOTION (TOPICAL) CLINDACIN PAC KIT CLINDAGEL (TOPICAL) CLINDAMYCIN / BENZOYL PEROXIDE (BENZACLIN) W/PUMP (TOPICAL) CLINDAMYCIN / TRETINOIN (TOPICAL) CLINDAMYCIN PHOSPHATE FOAM (TOPICAL) DAPSONE GEL DUAC (TOPICAL) EPIDUO (TOPICAL) EPIDUO FORTE GEL W/PUMP (TOPICAL) FABIOR (TOPICAL) NEUAC (TOPICAL) NEUAC KIT (TOPICAL) ONEXTON GEL (TOPICAL) ONEXTON W/PUMP (TOPICAL) RETIN-A CREAM (TOPICAL) RETIN-A GEL (TOPICAL) RETIN-A MICRO 0.04%, 0.1% (TOPICAL) RETIN-A MICRO 0.04%, 0.1% PUMP (TOPICAL) RETIN-A MICRO 0.06% PUMP (TOPICAL) RETIN-A MICRO 0.08% PUMP (TOPICAL) TAZAROTENE CREAM (TOPICAL) TRETINOIN GEL (ATRALIN) (TOPICAL) TRETINOIN MICROSPHERES GEL 0.04%, 0.1% (TOPICAL) TRETINOIN MICROSPHERES GEL 0.04%, 0.1% PUMP (TOPICAL) ZIANA (TOPICAL)

ALZHEIMER'S AGENTS section updated 3-28-2019 Preferred Nonpreferred DONEPEZIL ODT (ORAL) ARICEPT (ORAL)

Preferred Nonpreferred DONEPEZIL TABLET (ORAL) MEMANTINE TABLET (ORAL)

ARICEPT 23 MG (ORAL) ARICEPT ODT (ORAL) DONEPEZIL 23 MG (ORAL) EXELON (TRANSDERM.) EXELON CAPSULES (ORAL) GALANTAMINE ER (ORAL) GALANTAMINE SOLUTION (ORAL) GALANTAMINE TABLET (ORAL) MEMANTINE ER (ORAL) MEMANTINE SOLUTION (ORAL) NAMENDA TABLET (ORAL) NAMENDA TABLET DOSE PACK (ORAL) NAMENDA XR (ORAL) NAMZARIC (ORAL) NAMZARIC DOSE PACK (ORAL) RAZADYNE ER (ORAL) RAZADYNE TABLET (ORAL) RIVASTIGMINE (AG) (TRANSDERM.) RIVASTIGMINE (TRANSDERM.) RIVASTIGMINE CAPSULES (ORAL)

ANALGESICS, NARCOTICS LONG section updated 10-1-2019 Preferred Nonpreferred MORPHINE ER TABLET (ORAL) BUTRANS (TRANSDERM) FENTANYL (25, 50MCG) TRANSDERM

ARYMO ER (ORAL) BELBUCA (BUCCAL) ) BUPRENORPHINE (TRANSDERM) DURAGESIC MATRIX (TRANSDERM.) EMBEDA (ORAL) EXALGO (ORAL) FENTANYL (12, 37.5, 62.5, 87.5 MG, 75, 100MCG) (TRANSDERM) HYDROMORPHONE ER (ORAL) HYSINGLA ER (ORAL) KADIAN (ORAL) METHADONE TABLET (ORAL) MORPHABOND ER (ORAL) MORPHINE ER CAPSULE (AVINZA) (ORAL) MORPHINE ER CAPSULE (KADIAN) (ORAL) MS CONTIN (ORAL) NUCYNTA ER (ORAL) OPANA ER (ORAL) OXYCONTIN (ORAL) OXYCODONE ER (ORAL) OXYMORPHONE ER (ORAL) XTAMPZA ER (ORAL) ZOHYDRO ER (ORAL)

ANDROGENIC AGENTS section updated 7-11-2018 Preferred Nonpreferred ANDRODERM (TRANSDERM) ANDROGEL GEL PACKET (TRANSDERM.)

AXIRON (TRANSDERM) FORTESTA (TRANSDERM)

Preferred Nonpreferred ANDROGEL GEL PUMP (TRANSDERM)

NATESTO (NASAL) STRIANT (BUCCAL) TESTIM (TRANSDERM.) TESTOSTERONE GEL (VOGELXO) (TRANSDERM) TESTOSTERONE GEL PACKET (ANDROGEL) (TRANSDERM) TESTOSTERONE GEL PUMP (ANDROGEL) (TRANSDERM) TESTOSTERONE GEL PUMP (AXIRON) (TRANSDERM) VOGELXO GEL (TRANSDERM) VOGELXO GEL PACKET (TRANSDERM) VOGELXO GEL PUMP (TRANSDERM)

ANGIOTENSIN MODULATOR COMBINATIONS section updated 3-28-2019 Preferred Nonpreferred AMLODIPINE / BENAZEPRIL (ORAL) AMLODIPINE / VALSARTAN (ORAL) AMLODIPINE / VALSARTAN / HCTZ (ORAL)

AMLODIPINE / OLMESARTAN (ORAL) AMLODIPINE / OLMESARTAN / HCTZ (ORAL) AZOR (ORAL) BYVALSON (ORAL) EXFORGE (ORAL) EXFORGE HCT (ORAL)LOTREL (ORAL) LOTREL (ORAL) PRESTALIA (ORAL) TARKA (ORAL) TELMISARTAN / AMLODIPINE (ORAL) TRIBENZOR (ORAL) TWYNSTA (ORAL)

ANGIOTENSIN MODULATORS section updated 10-1-2018 Preferred Nonpreferred BENAZEPRIL (ORAL) BENAZEPRIL HCTZ (ORAL) CAPTOPRIL (ORAL) CAPTOPRIL HCTZ (ORAL) ENALAPRIL (ORAL) ENALAPRIL HCTZ (ORAL) FOSINOPRIL (ORAL) FOSINOPRIL HCTZ (ORAL) IRBESARTAN (ORAL) IRBESARTAN HCTZ (ORAL) LISINOPRIL (ORAL) LISINOPRIL HCTZ (ORAL) LOSARTAN (ORAL) LOSARTAN HCTZ (ORAL) MOEXIPRIL (ORAL) MOEXIPRIL HCTZ (ORAL) PERINDOPRIL (ORAL) QUINAPRIL (ORAL) QUINAPRIL HCTZ (ORAL) RAMIPRIL (ORAL) TEKTURNA HCT (ORAL) TRANDOLAPRIL (ORAL) VALSARTAN (ORAL)

ACCUPRIL (ORAL) ACCURETIC (ORAL) ACEON (ORAL) ALISKIREN (ORAL) ALTACE (ORAL) ATACAND (ORAL) ATACAND HCT (ORAL) AVALIDE (ORAL) AVAPRO (ORAL) BENICAR (ORAL) BENICAR HCT (ORAL) CANDESARTAN (ORAL) CANDESARTAN HCTZ (ORAL) COZAAR (ORAL) DIOVAN (ORAL) DIOVAN HCT (ORAL) EDARBI (ORAL) EDARBYCLOR (ORAL) ENTRESTO (ORAL) EPANED POWDER (ORAL) EPANED SOLUTION (ORAL) EPROSARTAN (ORAL) HYZAAR (ORAL)

Preferred Nonpreferred VALSARTAN HCTZ (ORAL) LOTENSIN (ORAL)

LOTENSIN HCT (ORAL) MAVIK (ORAL) MICARDIS (ORAL) MICARDIS HCT (ORAL) OLMESARTAN (ORAL) OLMESARTAN HCTZ (ORAL) PRINIVIL (ORAL) QBRELIS SOLUTION (ORAL) TEKTURNA (ORAL) TELMISARTAN (ORAL) TELMISARTAN HCTZ (ORAL) VASERETIC (ORAL) VASOTEC (ORAL) ZESTORETIC (ORAL) ZESTRIL (ORAL)

ANTIBIOTICS, INHALED section updated 7-11-2018 Preferred Nonpreferred BETHKIS (INHALATION) KITABIS PAK (INHALATION)

CAYSTON (INHALATION) TOBI (INHALATION) TOBI PODHALER (INHALATION) TOBRAMYCIN SOLUTION (INHALATION)

ANTIBIOTICS, TOPICAL section updated 4-22-2019 Preferred Nonpreferred MUPIROCIN OINTMENT (TOPICAL) CENTANY (TOPICAL)

CENTANY KIT (TOPICAL) MUPIROCIN CREAM (TOPICAL)

ANTICOAGULANTS section updated 1-1-2020 Preferred Nonpreferred ENOXAPARIN SODIUM VIAL (SUBCUTANEOUS) ENOXAPARIN SYRINGE (SUBCUTANEOUS) FRAGMIN VIAL (SUBCUTANEOUS) JANTOVEN (ORAL) PRADAXA (ORAL) WARFARIN (ORAL) XARELTO 10 MG, 15MG, 20 MG(ORAL)

ARIXTRA (SUBCUTANE.) BEVYXXA (ORAL) COUMADIN (ORAL) ELIQUIS (ORAL) ELIQUIS DOSE PACK (ORAL) FONDAPARINUX (SUBCUTANE.) FRAGMIN DISP SYRIN (SUBCUTANE.) LOVENOX SYRINGE (SUBCUTANE.) LOVENOX VIAL (SUBCUTANE.) SAVAYSA (ORAL) XARELTO 2.5MG (ORAL) XARELTO DOSE PACK (ORAL)

ANTICONVULSANTS section updated 10-1-2019 Preferred Nonpreferred CARBAMAZEPINE CHEWABLE TABLET (ORAL) CARBAMAZEPINE SUSPENSION (ORAL) CARBAMAZEPINE TABLET (ORAL)

APTIOM (ORAL) BANZEL SUSPENSION (ORAL) BANZEL TABLET (ORAL)

Preferred Nonpreferred CARBAMAZEPINE XR (ORAL) CELONTIN (ORAL) CLOBAZAM TABLET (ORAL) DIASTAT (RECTAL) DILANTIN (ORAL) DILANTIN 30 MG CAPSULE (ORAL) DIVALPROEX ER (ORAL) DIVALPROEX SPRINKLE (ORAL) DIVALPROEX TABLET (ORAL) ETHOSUXIMIDE CAPSULE (ORAL) ETHOSUXIMIDE SYRUP (ORAL) FELBAMATE SUSPENSION (ORAL) FELBAMATE TABLET (ORAL) FELBATOL SUSPENSION (ORAL) GABITRIL (ORAL) LAMOTRIGINE CHEWABLE TABLET (ORAL) LAMOTRIGINE TABLET (ORAL) LAMOTRIGINE TABLET DOSE PACK (ORAL) LAMOTRIGINE XR (ORAL) LEVETIRACETAM ER (ORAL) LEVETIRACETAM SOLUTION (ORAL) LEVETIRACETAM TABLETS (ORAL) OXCARBAZEPINE SUSPENSION (ORAL) OXCARBAZEPINE TABLETS (ORAL) PEGANONE (ORAL) PHENYTEK (ORAL) PHENYTOIN CAPSULE (ORAL) PHENYTOIN CHEWABLE TABLET (ORAL) PHENYTOIN EXT CAPSULE (GENERIC PHENYTEK) (ORAL) PHENYTOIN SUSPENSION (ORAL) PRIMIDONE (ORAL) ROWEEPRA TABLET (ORAL) ROWEEPRA XR (ORAL) TOPIRAMATE SPRINKLE (ORAL) TOPIRAMATE TABLETS (ORAL) VALPROIC ACID CAPSULE (ORAL) VALPROIC ACID SOLUTION (ORAL) ZONISAMIDE (ORAL)

BRIVIACT SOLUTION (ORAL) BRIVIACT TABLET (ORAL) CARBAMAZEPINE ER (GENERIC CARBATROL) (ORAL) CARBATROL (ORAL) CLOBAZAM SUSPENSION (ORAL) DEPAKENE CAPSULE (ORAL) DEPAKENE SYRUP (ORAL) DEPAKOTE (ORAL) DEPAKOTE ER (ORAL) DEPAKOTE SPRINKLE (ORAL) DIACOMIT (ORAL) DIAZEPAM (RECTAL) DIAZEPAM DEVICE (RECTAL) DILANTIN INFATAB (ORAL) DILANTIN SUSPENSION (ORAL) EPIDIOLEX SOLUTION (ORAL) FELBATOL TABLET (ORAL) FYCOMPA SUSPENSION (ORAL) FYCOMPA TABLET (ORAL) FYCOMPA TABLET DOSE PACK (ORAL) KEPPRA SOLUTION (ORAL) KEPPRA TABLETS (ORAL) KEPPRA XR (ORAL) LAMICTAL CHEWABLE TABLET (ORAL) LAMICTAL ODT (ORAL) LAMICTAL ODT DOSE PACK (ORAL) LAMICTAL TABLET (ORAL) LAMICTAL TABLET DOSE PACK (ORAL) LAMICTAL XR (ORAL) LAMICTAL XR DOSE PACK (ORAL) LAMOTRIGINE ODT (ORAL) LAMOTRIGINE ODT DOSE PACK (ORAL) MYSOLINE (ORAL) ONFI SUSPENSION (ORAL) ONFI TABLET (ORAL) OXTELLAR XR (ORAL) POTIGA (ORAL) QUDEXY XR (ORAL) SABRIL POWDER PACK (ORAL) SABRIL TABLET (ORAL) SPRITAM (ORAL) TEGRETOL SUSPENSION (ORAL) TEGRETOL TABLET (ORAL) TEGRETOL XR (ORAL) TIAGABINE (ORAL) TOPAMAX SPRINKLE (ORAL) TOPAMAX TABLETS (ORAL) TRILEPTAL SUSPENSION (ORAL) TRILEPTAL TABLETS (ORAL) TROKENDI XR (ORAL) VIGABATRIN POWDER PACK (ORAL)

Preferred Nonpreferred VIGABATRIN TABLET (ORAL) VIMPAT SOLUTION (ORAL) VIMPAT TABLET (ORAL) VIMPAT TABLET DOSE PACK (ORAL) ZARONTIN CAPSULE (ORAL) ZARONTIN SYRUP (ORAL) ZONEGRAN (ORAL)

ANTIDEPRESSANTS, OTHER section updated 7-11-2018 Preferred Nonpreferred BUPROPION (ORAL) BUPROPION SR (ORAL) BUPROPION XL (ORAL) MIRTAZAPINE ODT (ORAL) MIRTAZAPINE TABLET (ORAL) NEFAZODONE (ORAL) TRAZODONE (ORAL) VENLAFAXINE (ORAL) VENLAFAXINE ER CAPSULES (ORAL) VENLAFAXINE ER CAPSULES (ORAL)

APLENZIN (ORAL) DESVENLAFAXINE ER (NO BRAND) (ORAL) DESVENLAFAXINE ER (PRISTIQ) (ORAL) DESVENLAFAXINE FUMARATE ER (ORAL) EFFEXOR XR (ORAL) FETZIMA (ORAL) FORFIVO XL (ORAL) KHEDEZLA (ORAL) OLEPTRO ER (ORAL) PRISTIQ (ORAL) REMERON ODT (ORAL) REMERON TABLET (ORAL) TRINTELLIX (ORAL) VENLAFAXINE ER TABLETS (ORAL) VIIBRYD (ORAL) VIIBRYD DOSE PACK (ORAL) WELLBUTRIN SR (ORAL) WELLBUTRIN XL (ORAL)

ANTIDEPRESSANTS, SSRIs section updated 3-28-2019 Preferred Nonpreferred CITALOPRAM SOLUTION (ORAL) CITALOPRAM TABLET (ORAL) ESCITALOPRAM SOLUTION (ORAL) ESCITALOPRAM TABLET (ORAL) FLUOXETINE CAPSULE (ORAL) FLUOXETINE SOLUTION (ORAL) FLUVOXAMINE (ORAL) PAROXETINE TABLET (ORAL) SERTRALINE CONC (ORAL) SERTRALINE TABLET (ORAL)

BRISDELLE (ORAL) CELEXA TABLET (ORAL) FLUOXETINE CAPSULE DR (ORAL) FLUOXETINE TABLET (ORAL) FLUOXETINE 60 MG (ORAL) FLUVOXAMINE ER (ORAL) LEXAPRO TABLET (ORAL) PAROXETINE (BRISDELLE) (AG) (ORAL) PAROXETINE (BRISDELLE) (ORAL) PAROXETINE CR (ORAL) PAXIL (ORAL) PAXIL CR (ORAL) PAXIL SUSPENSION (ORAL) PEXEVA (ORAL) PROZAC CAPSULE (ORAL) SARAFEM (ORAL) ZOLOFT CONC (ORAL) ZOLOFT TABLET (ORAL)

ANTIEMETIC/ANTIVERTIGO AGENTS section updated 4-22-2019 Preferred Nonpreferred ONDANSETRON ODT (ORAL) ONDANSETRON SOLUTION (ORAL) ONDANSETRON TABLETS (ORAL)

AKYNZEO (ORAL) ANZEMET (ORAL) CESAMET (ORAL) GRANISETRON (ORAL) SANCUSO (TRANSDERMAL) ZOFRAN ODT (ORAL) ZOFRAN SOLUTION (ORAL) ZOFRAN TABLETS (ORAL) ZUPLENZ (ORAL)

ANTIFUNGALS, ORAL section updated 1-1-2020 Preferred Nonpreferred FLUCONAZOLE SUSPENSION (ORAL) FLUCONAZOLE TABLET (ORAL) NYSTATIN SUSPENSION (ORAL) TERBINAFINE (ORAL)

ANCOBON (ORAL) CRESEMBA (ORAL) DIFLUCAN TABLET (ORAL) DIFLUCAN SUSPENSION (ORAL) FLUCYTOSINE (ORAL) GRIS-PEG (ORAL) GRISEOFULVIN SUSPENSION (ORAL) GRISEOFULVIN TABLETS (ORAL) GRISEOFULVIN ULTRAMICROSIZE (ORAL) ITRACONAZOLE (ORAL) KETOCONAZOLE (ORAL) NOXAFIL SUSPENSION (ORAL) NOXAFIL TABLETS (ORAL) NYSTATIN TABLET (ORAL) ONMEL (ORAL) ORAVIG (BUCCAL) POSACONAZOLE TABLET AND SUSPENSION (ORAL) SPORANOX CAPSULE (ORAL) SPORANOX SOLUTION (ORAL) TOLSURA (ORAL)

ANTIHISTAMINES, MINIMALLY SEDATING section updated 3-28-2019 Preferred Nonpreferred CETIRIZINE CHEWABLE OTC (ORAL) CETIRIZINE SOLUTION (ORAL) CETIRIZINE SOLUTION OTC (ORAL) CETIRIZINE TABLETS OTC (ORAL) CETIRIZINE-D OTC (ORAL) LEVOCETIRIZINE SOLUTION (ORAL) LEVOCETIRIZINE TABLETS (ORAL) LORATADINE ODT OTC (ORAL) LORATADINE SOLUTION OTC (ORAL) LORATADINE TABLETS OTC (ORAL) LORATADINE-D OTC (ORAL)

* Allegra OTC, fexofenadine OTC, Allegra-D OTC and fexofenadine-D OTC are excluded from coverage

** Not all OTC products are covered. Please consult the

CLARINEX SYRUP (ORAL) CLARINEX TABLET (ORAL) CLARINEX-D 12 HOUR (ORAL) DESLORATADINE (ORAL) DESLORATADINE ODT (ORAL) SEMPREX-D (ORAL)

Preferred Nonpreferred NDC lookup website for specific NDC coverage information

ANTIMIGRAINE AGENTS, OTHER section updated 10-1-2019 Preferred Nonpreferred EMGALITY 120 MG/ML (PEN) EMGALITY 120 MG/ML (SYRINGE)

AIMOVIG AJOVY

ANTIMIGRAINE AGENTS, TRIPTANS section updated 4-22-2019 Preferred Nonpreferred RELPAX (ORAL) RIZATRIPTAN ODT (ORAL) RIZATRIPTAN TABLET (ORAL) SUMATRIPTAN (NASAL) SUMATRIPTAN (ORAL)

ALMOTRIPTAN (ORAL) AMERGE (ORAL) ELETRIPTAN (ORAL) FROVA (ORAL) FROVATRIPTAN (ORAL) IMITREX (NASAL) IMITREX (ORAL) MAXALT MLT (ORAL) MAXALT TABLET (ORAL) NARATRIPTAN (ORAL) ONZETRA XSAIL (NASAL) SUMATRIPTAN/NAPROXEN (ORAL) TREXIMET (ORAL) ZECUITY (TRANSDERM) ZEMBRACE SYMTOUCH (SUBCUTANE.) ZOLMITRIPTAN ODT (ORAL) ZOLMITRIPTAN TABLET (ORAL) ZOMIG (NASAL) ZOMIG TABLET (ORAL) ZOMIG ZMT (ORAL)

ANTIPARASITICS, TOPICAL section updated 10-1-2019 Preferred Nonpreferred NATROBA (TOPICAL) PERMETHRIN CREAM (TOPICAL) PERMETHRIN OTC (TOPICAL) PIP BUTOXIDE/PYRETHRINS/PERMETHRIN KIT OTC (TOPICAL) PIPERONYL BUTOXIDE/PYRETHRINS SHAMPOO OTC (TOPICAL)

LINDANE LOTION (TOPICAL) LINDANE SHAMPOO (TOPICAL) MALATHION BRAND (TOPICAL) OVIDE (TOPICAL) SKLICE (TOPICAL) SPINOSAD (TOPICAL)

ANTIPARKINSON'S AGENTS section updated 10-1-2019 Preferred Nonpreferred CARBIDOPA / LEVODOPA (ORAL) CARBIDOPA / LEVODOPA ER (ORAL) CARBIDOPA / LEVODOPA ODT (ORAL) PRAMIPEXOLE (ORAL) ROPINIROLE (ORAL)

GOCOVRI (ORAL) INBRIJA (ORAL) MIRAPEX (ORAL) MIRAPEX ER (ORAL) PRAMIPEXOLE ER (ORAL) REQUIP (ORAL)

Preferred Nonpreferred REQUIP XL (ORAL) ROPINIROLE ER (ORAL) RYTARY (ORAL) SINEMET (ORAL) SINEMET CR (ORAL) XADAGO (ORAL)

ANTIPSYCHOTICS section updated 7-11-2018 Preferred Nonpreferred ABILIFY MAINTENA (INTRAMUSC.) ARIPIPRAZOLE SOLUTION (ORAL) ARIPIPRAZOLE TABLET (ORAL) CLOZAPINE (ORAL) CLOZAPINE ODT (AG) (ORAL) CLOZAPINE ODT (ORAL) FANAPT TABLET (ORAL) FANAPT TITRATION PACK (ORAL) INVEGA SUSTENNA (INTRAMUSC) DX INVEGA TRINZA (INTRAMUSC) LATUDA (ORAL) OLANZAPINE (INTRAMUSC) OLANZAPINE TABLET (ORAL) QUETIAPINE ER (ORAL) QUETIAPINE TABLETS (ORAL) RISPERDAL CONSTA (INTRAMUSC.) RISPERIDONE ODT (ORAL) RISPERIDONE SOLUTION (ORAL) RISPERIDONE TABLET (ORAL) SAPHRIS (SUBLINGUAL) ZIPRASIDONE CAPSULE (ORAL)

ABILIFY TABLET (ORAL) ARIPIPRAZOLE ODT (ORAL) ARISTADA (INTRAMUSC) CLOZARIL (ORAL) FAZACLO (ORAL) GEODON (INTRAMUSC) GEODON (ORAL) INVEGA (ORAL) NUPLAZID (ORAL) OLANZAPINE ODT (ORAL) OLANZAPINE/FLUOXETINE (ORAL) PALIPERIDONE (ORAL) REXULTI (ORAL) RISPERDAL ODT (ORAL) RISPERDAL SOLUTION (ORAL) RISPERDAL TABLET (ORAL) SEROQUEL (ORAL) SEROQUEL XR (ORAL) SYMBYAX (ORAL) VERSACLOZ (ORAL) VRAYLAR (ORAL) ZYPREXA (INTRAMUSC) ZYPREXA (ORAL) ZYPREXA RELPREVV (INTRAMUSC) ZYPREXA ZYDIS (ORAL)

ANTIVIRALS, ORAL section updated 4-22-2019 Preferred Nonpreferred ACYCLOVIR CAPSULE (ORAL) ACYCLOVIR SUSPENSION (ORAL) ACYCLOVIR TABLET (ORAL) VALACYCLOVIR (ORAL)

FAMCICLOVIR (ORAL) SITAVIG (BUCCAL) VALTREX (ORAL) ZOVIRAX CAPSULE (ORAL) ZOVIRAX SUSPENSION (ORAL) ZOVIRAX TABLET (ORAL)

ANTIVIRALS, TOPICAL section updated 4-22-2019 Preferred Nonpreferred ACYCLOVIR OINTMENT (TOPICAL) DENAVIR (TOPICAL)

ACYCLOVIR CREAM (TOPICAL) XERESE (TOPICAL) ZOVIRAX CREAM (TOPICAL) ZOVIRAX OINTMENT (TOPICAL)

BETA-BLOCKERS section updated 4-22-2019 Preferred Nonpreferred ATENOLOL (ORAL) BISOPROLOL (ORAL) CARVEDILOL (ORAL) LABETALOL (ORAL) METOPROLOL (ORAL) METOPROLOL XL (ORAL) NADOLOL (ORAL) PINDOLOL (ORAL) PROPRANOLOL ER (ORAL) PROPRANOLOL SOLUTION (ORAL) PROPRANOLOL TABLET (ORAL) SOTALOL (ORAL)

ACEBUTOLOL (ORAL) BETAPACE / AF (ORAL) BETAXOLOL (ORAL) BYSTOLIC (ORAL) CARVEDILOL ER (ORAL) COREG (ORAL) COREG CR (ORAL) CORGARD (ORAL) CORZIDE (ORAL) DUTOPROL (ORAL) HEMANGEOL (ORAL) INDERAL LA (ORAL) INDERAL XL (ORAL) INNOPRAN XL (ORAL) LEVATOL (ORAL) LOPRESSOR (ORAL) LOPRESSOR HCT (ORAL) SOTYLIZE (ORAL) TENORETIC (ORAL) TENORMIN (ORAL) TIMOLOL (ORAL) TOPROL XL (ORAL) ZIAC (ORAL)

BLADDER RELAXANT PREPARATIONS section updated 10-1-2019 Preferred Nonpreferred OXYBUTYNIN ER (ORAL) OXYBUTYNIN SYRUP (ORAL) OXYBUTYNIN TABLET (ORAL) OXYTROL (TRANSDERM.) TOLTERODINE (ORAL) TOLTERODINE ER (ORAL) TOVIAZ (ORAL) VESICARE (ORAL)

DARIFENACIN ER (ORAL) DETROL (ORAL) DETROL LA (ORAL) DITROPAN XL (ORAL) ENABLEX (ORAL) GELNIQUE (TRANSDERM.) GELNIQUE GEL PUMP (TRANSDERMAL) MYRBETRIQ (ORAL) OXYBUTYNIN ER (AG) (ORAL) SOLIFENACIN (ORAL) TROSPIUM (ORAL) TROSPIUM ER (ORAL)

BONE RESORPTION SUPPRESSION AND RELATED AGENTS section updated 3-28-2019 Preferred Nonpreferred ALENDRONATE SOLUTION (ORAL) ALENDRONATE TABLETS (ORAL) CALCITONIN SALMON (NASAL) FORTEO (SUBCUTANEOUS) IBANDRONATE TABLETS (ORAL) MIACALCIN (NASAL) RALOXIFENE (ORAL)

ACTONEL (ORAL) ATELVIA (ORAL) BINOSTO (ORAL) BONIVA (ORAL) ETIDRONATE DISODIUM (ORAL) EVISTA (ORAL FORTICAL (NASAL) FOSAMAX (ORAL) FOSAMAX PLUS D (ORAL)

Preferred Nonpreferred PROLIA (SUBCUTANE.) RISEDRONATE (ACTONEL) (ORAL) RISEDRONATE (ATELVIA) (ORAL) TYMLOS (SUBCUTANE.)

BPH TREATMENTS section updated 3-28-2019 Preferred Nonpreferred ALFUZOSIN (ORAL) DOXAZOSIN (ORAL) DUTASTERIDE (ORAL FINASTERIDE (ORAL) TAMSULOSIN (ORAL) TERAZOSIN (ORAL)

AVODART (ORAL) CARDURA (ORAL) CARDURA XL (ORAL) DUTASTERIDE/TAMSULOSIN (ORAL) FLOMAX (ORAL) JALYN (ORAL) PROSCAR (ORAL) RAPAFLO (ORAL) SILODOSIN (ORAL) UROXATRAL (ORAL)

BRONCHODILATORS, BETA AGONIST section updated 10-1-2019 Preferred Nonpreferred ALBUTEROL HFA (VENTOLIN) (AG) (INHALATION) ALBUTEROL NEB SOLN 0.63, 1.25 MG (INHALATION) ALBUTEROL NEB SOLN 100 MG/20 ML (INHALATION) ALBUTEROL NEB SOLN 2.5 MG/0.5 ML (INHALATION) ALBUTEROL NEB SOLN 2.5 MG/3 ML (INHALATION) ALBUTEROL SYRUP (ORAL) METAPROTERENOL SYRUP (ORAL) PROAIR HFA (INHALATION) PROVENTIL HFA (INHALATION) SEREVENT (INHALATION)

ARCAPTA NEOHALER (INHALATION) ALBUTEROL ER (ORAL) ALBUTEROL HFA (PROAIR HFA) (AG) (INHALATION) ALBUTEROL HFA (PROVENTIL HFA) (AG) (INHALATION) ALBUTEROL TABLET (ORAL) BROVANA (INHALATION) LEVALBUTEROL NEB SOLN (INHALATION) LEVALBUTEROL NEB SOLN CONC (INHALATION) METAPROTERENOL TABLET (ORAL) PERFOROMIST (INHALATION) PROAIR RESPICLICK (INHALATION) STRIVERDI RESPIMAT (INHALATION) VENTOLIN HFA (INHALATION) XOPENEX HFA (INHALATION) XOPENEX NEB SOLN (INHALATION) XOPENEX NEB SOLN CONC (INHALATION)

CALCIUM CHANNEL BLOCKERS section updated 7-11-2018 Preferred Nonpreferred AMLODIPINE (ORAL) DILTIAZEM CAPSULE ER (ORAL) DILTIAZEM TABLET (ORAL) FELODIPINE ER (ORAL) ISRADIPINE (ORAL) MATZIM LA (ORAL) NICARDIPINE (ORAL) NIFEDIPINE ER (ORAL) NIFEDIPINE IR (ORAL) VERAPAMIL 360 MG CAPSULE (ORAL) VERAPAMIL CAPSULE ER (ORAL) VERAPAMIL ER PM (ORAL)

ADALAT CC (ORAL) CALAN (ORAL) CALAN SR (ORAL) CARDIZEM (ORAL) CARDIZEM CD (ORAL) CARDIZEM CD 360 MG (ORAL) CARDIZEM LA (ORAL) NIMODIPINE (ORAL) NISOLDIPINE (ORAL) NORVASC (ORAL) NYMALIZE (ORAL) PROCARDIA (ORAL)

Preferred Nonpreferred VERAPAMIL TABLET (ORAL) VERAPAMIL TABLET ER (ORAL)

PROCARDIA XL (ORAL) SULAR (ORAL) TIAZAC (ORAL) TIAZAC 420 MG (ORAL) VERELAN (ORAL) VERELAN PM (ORAL)

CEPHALOSPORINS AND RELATED ANTIBIOTICS section updated 10-1-2019 Preferred Nonpreferred AMOXICILLIN/CLAV SUSPENSION (ORAL) AMOXICILLIN/CLAV TABLET (ORAL) CEDAX CAPSULE (ORAL) CEDAX SUSPENSION (ORAL) CEFACLOR CAPSULE (ORAL) CEFACLOR SUSPENSION (ORAL) CEFADROXIL CAPSULE (ORAL) CEFADROXIL SUSPENSION (ORAL) CEFDINIR CAPSULE (ORAL) CEFDINIR SUSPENSION (ORAL) CEFDINIR SUSPENSION (ORAL) CEFPROZIL SUSPENSION (ORAL) CEFPROZIL TABLET (ORAL) CEFUROXIME TABLET (ORAL) CEPHALEXIN CAPSULE (ORAL) CEPHALEXIN SUSPENSION (ORAL) SUPRAX CAPSULE (ORAL) SUPRAX SUSPENSION (ORAL)

AMOXICILLIN/CLAV CHEW TABLET (ORAL) AMOXICILLIN/CLAV XR (ORAL) AUGMENTIN 125 SUSPENSION (ORAL) AUGMENTIN 250 SUSPENSION (ORAL) AUGMENTIN XR (ORAL) CEFACLOR TABLET ER (ORAL) CEFADROXIL TABLET (ORAL) CEFIXIME CAPSULE (ORAL) CEFIXIME SUSPENSION (ORAL) CEFPODOXIME SUSPENSION (ORAL) CEFPODOXIME TABLET (ORAL) CEFTIN SUSPENSION (ORAL) CEFTIN TABLET (ORAL) DAXBIA (ORAL) KEFLEX (ORAL) SUPRAX TAB CHEW (ORAL)

COPD AGENTS section updated 10-1-2019 Preferred Nonpreferred ATROVENT HFA (INHALATION) COMBIVENT RESPIMAT (INHALATION) IPRATROPIUM / ALBUTEROL (INHALATION) IPRATROPIUM NEBULIZER (INHALATION) SPIRIVA (INHALATION) SPIRIVA RESPIMAT (INHALATION) STIOLTO RESPIMAT (INHALATION) TUDORZA PRESSAIR (INHALATION)

ANORO ELLIPTA (INHALATION) BEVESPI AEROSPHERE (INHALATION) DALIRESP (ORAL) INCRUSE ELLIPTA (INHALATION) LONHALA MAGNAIR (INHALATION) SEEBRI NEOHALER (INHALATION) UTIBRON NEOHALER (INHALATION) YUPELRI (INHALATION)

CYTOKINE AND CAM ANTAGONISTS section updated 7-11-2018 Preferred Nonpreferred ENBREL KIT (INJECTION) ENBREL PEN (INJECTION) ENBREL SYRINGE (INJECTION) HUMIRA KIT (INJECTION) HUMIRA PEN KIT (INJECTION) HUMIRA PEN KIT (INJECTION)

ACTEMRA VIAL (INJECTION) CIMZIA KIT (INJECTION) CIMZIA SYRINGE KIT (INJECTION) COSENTYX PEN INJECTER (SUBCUTANE.) COSENTYX SYRINGE (SUBCUTANE.) ENBREL CARTRIDGE (SUBCUTANE.) ENTYVIO (INJECTION) INFLECTRA VIAL (INTRAVEN.) KEVZARA (SUBCUTANE.) NPDF KINERET (INJECTION)

Preferred Nonpreferred ORENCIA CLICKJECT (SUBCUTANE.) ORENCIA SYRINGE (SUBCUTANE.) ORENCIA VIAL (INJECTION) OTEZLA (ORAL) REMICADE (INJECTION) RENFLEXIS (INTRAVEN.) SILIQ (SUBCUTANE.) SIMPONI ARIA VIAL (INTRAVEN.) SIMPONI PEN INJECTER (INJECTION) SIMPONI SYRINGE (INJECTION) STELARA SYRINGE (INJECTION) STELARA VIAL (INJECTION) TALTZ AUTOINJECTOR (SUBCUTANE.) TALTZ SYRINGE (SUBCUTANE.) TREMFYA (SUBCUTANE.) XELJANZ (ORAL) XELJANZ XR (ORAL)

DIABETES METERS section updated 10-1-2019 Preferred Nonpreferred ACCU-CHEK AVIVA PLUS ACCU-CHEK GUIDE ACCU-CHEK GUIDE ME ACCU-CHEK NANO SMARTVIEW CONTOUR CONTOUR NEXT CONTOUR NEXT EZ CONTOUR NEXT ONE

FORA G20 FREESTYLE FREEDOM LITE FREESTYLE INSULINX FREESTYLE LITE METER GLUCOCARD EXPRESSION GLUCOCARD SHINE GLUCOCARD SHINE XL ONETOUCH ULTRA2 ONETOUCH ULTRAMINI ONETOUCH VERIO ONETOUCH VERIO FLEX ONETOUCH VERIO IQ PRECISION XTRA PRODIGY PRODIGY POCKET PRODIGY VOICE TRUE METRIX AIR GLUCOSE METER TRUE METRIX BLOOD GLUCOSE MTR WAVESENSE PRESTO

DIABETES TEST STRIPS section updated 10-1-2019 Preferred Nonpreferred ACCU-CHEK AVIVA PLUS ACCU-CHEK COMPACT PLUS ACCU-CHEK GUIDE ACCU-CHEK SMARTVIEW CONTOUR CONTOUR NEXT

FORA G20 FREESTYLE INSULINX FREESTYLE INSULINX TEST STRIPS FREESTYLE LITE STRIPS FREESTYLE TEST STRIPS GLUCOCARD EXPRESSION GLUCOCARD SHINE ONETOUCH ULTRA BLUE TEST STRP ONETOUCH VERIO

Preferred Nonpreferred PRECISION XTRA PRODIGY NO CODING TRUE METRIX GLUCOSE TEST STRIP WAVESENSE PRESTO

EPINEPHRINE, SELF-INJECTED section updated 10-1-2019 Preferred Nonpreferred EPINEPHRINE AUTOINJECTOR (INTRAMUSC), AUTHORIZED GENERIC OF EPIPEN & EPIPEN JR SYMJEPI

EPIPEN (INTRAMUSC) EPIPEN JR (INTRAMUSC) EPINEPHRINE AUTOINJECTOR (INTRAMUSC), AUTHORIZED GENERIC OF ADRENACLICK EPINEPHRINE AUTOINJECTOR, TEVA PHARMACEUTICALS

ERYTHROPOIESIS STIMULATING PROTEINS section updated 7-11-2018 Preferred Nonpreferred ARANESP DISP SYRIN (INJECTION) ARANESP VIAL (INJECTION) PROCRIT (INJECTION)

EPOGEN (INJECTION)

FLUOROQUINOLONES, ORAL section updated 3-28-2019 Preferred Nonpreferred CIPROFLOXACIN TABLET (ORAL) LEVOFLOXACIN SOLUTION (ORAL) LEVOFLOXACIN TABLET (ORAL)

AVELOX (ORAL) BAXDELA (ORAL) CIPRO SUSPENSION (ORAL) CIPRO TABLET (ORAL) CIPROFLOXACIN ER (ORAL) CIPROFLOXACIN SUSPENSION (ORAL) CIPRO XR TABLET LEVAQUIN TABLET (ORAL) MOXIFLOXACIN (ORAL) OFLOXACIN (ORAL)

GLUCOCORTICOIDS, INHALED section updated 10-1-2019 Preferred Nonpreferred ADVAIR HFA (INHALATION) ASMANEX (INHALATION) BUDESONIDE 0.25, 0.5 MG RESPULES (INHALATION) BUDESONIDE 1 MG RESPULES (INHALATION) DULERA (INHALATION) FLOVENT DISKUS (INHALATION) FLOVENT HFA (INHALATION) PULMICORT FLEXHALER (INHALATION) SYMBICORT (INHALATION) WIXELA INHUB (INHALATION)

ADVAIR DISKUS (INHALATION) AEROSPAN (INHALATION) AIRDUO RESPICLICK (INHALATION) ALVESCO (INHALATION) ARMONAIR RESPICLICK (INHALATION) ) ARNUITY ELLIPTA (INHALATION) ASMANEX HFA (INHALATION) BREO ELLIPTA (INHALATION) FLUTICASONE/SALMETEROL (ADVAIR) (AG) (INHALATION) FLUTICASONE/SALMETEROL (AIRDUO) (AG) (INHALATION) PULMICORT 0.25, 0.5 MG RESPULES (INHALATION) PULMICORT 1 MG RESPULES (INHALATION) QVAR REDIHALER (INHALATION) TRELEGY ELLIPTA (INHALATION)

GROWTH HORMONE section updated 7-11-2018 Preferred Nonpreferred NORDITROPIN PEN (INJECTION) NUTROPIN AQ PEN (INJECTION)

GENOTROPIN CARTRIDGE (INJECTION) GENOTROPIN DISP SYRIN (INJECTION) HUMATROPE CARTRIDGE (INJECTION) HUMATROPE VIAL (INJECTION) OMNITROPE CARTRIDGE (INJECTION) OMNITROPE VIAL (INJECTION) SAIZEN CARTRIDGE (INJECTION) SAIZEN VIAL (INJECTION) SEROSTIM VIAL (INJECTION) ZOMACTON VIAL (INJECTION) ZORBTIVE VIAL (INJECTION)

HAE TREATMENTS section updated 10-1-2019 Preferred Nonpreferred BERINERT (INTRAVEN) CINRYZE (INTRAVEN)

FIRAZYR (SUB-Q) HAEGARDA (SUB-Q) ICATIBANT (SUB-Q) KALBITOR (SUB-Q) RUCONEST (INTRAVEN)

HEPATITIS B AGENTS section updated 4-22-2019 Preferred Nonpreferred EPIVIR HBV SOLUTION (ORAL) EPIVIR HBV TABLET (ORAL) LAMIVUDINE HBV TABLET (ORAL) ADEFOVIR DIPIVOXIL (ORAL) BARACLUDE SOLUTION (ORAL) BARACLUDE TABLET (ORAL) ENTECAVIR TABLET (ORAL) HEPSERA (ORAL)

VEMLIDY (ORAL)

HEPATITIS C AGENTS section updated 4-22-2019 Preferred Nonpreferred MAVYRET (ORAL) PEGASYS PROCLICK (SUB-Q) PEGASYS SYRINGE (SUB-Q) PEGASYS VIAL (SUBCUTANE.) RIBAVIRIN CAPSULE (ORAL) RIBAVIRIN TABLET (ORAL) RIBAVIRIN TABLET (ORAL) VOSEVI (ORAL)

DAKLINZA (ORAL) EPCLUSA (ORAL) HARVONI (ORAL) LEDIPASVIR/SOFOSBUVIR (AG) (ORAL) OLYSIO (ORAL) PEG-INTRON (SUBCUTANE.) PEG-INTRON REDIPEN (SUBCUTANE.) REBETOL SOLUTION (ORAL) RIBAPAK (ORAL) RIBASPHERE 400 MG (ORAL) RIBASPHERE 600 MG (ORAL) RIBAVIRIN DOSE PACK (ORAL) SOFOSBUVIR/VELPATASVIR (AG) (ORAL) SOVALDI (ORAL) TECHNIVIE (ORAL)

Preferred Nonpreferred VIEKIRA PAK (ORAL) VIEKIRA XR (ORAL) ZEPATIER (ORAL)

HYPOGLYCEMICS, ALPHA-GLUCOSIDASE INHIBITORS section 3-28-2019 Preferred Nonpreferred ACARBOSE (ORAL) GLYSET (ORAL)

MIGLITOL (ORAL) PRECOSE (ORAL)

HYPOGLYCEMICS, INCRETIN MIMETICS/ENHANCERS section updated 10-1-2019 Preferred Nonpreferred BYDUREON PENS (SUBCUTANE.) BYETTA PENS (SUBCUTANE.) JANUMET (ORAL) JANUVIA (ORAL) JENTADUETO (ORAL) KOMBIGLYZE XR (ORAL) ONGLYZA (ORAL) SYMLIN PENS (SUBCUTANE.) TRADJENTA (ORAL) VICTOZA (SUBCUTANE.)

ADLYXIN (SUBCUTANE.) ALOGLIPTIN (AG) (ORAL) ALOGLIPTIN/METFORMIN (ORAL) ALOGLIPTIN/PIOGLITAZONE (ORAL) BYDUREON BCISE (SUBCUTANE.) GLYXAMBI (ORAL) JANUMET XR (ORAL) JENTADUETO XR (ORAL) KAZANO (ORAL) NESINA (ORAL) OSENI (ORAL) OZEMPIC (SUBCUTANE.) QTERN (ORAL) SOLIQUA (SUBCUTANE.) STEGLUJAN (ORAL) TRULICITY (SUBCUTANE.) XULTOPHY (SUBCUTANE.)

HYPOGLYCEMICS, INSULIN AND RELATED AGENTS section updated 1-1-2020 Preferred Nonpreferred HUMALOG VIAL (SUBCUTANE.) HUMALOG MIX VIAL (SUBCUTANE.) HUMULIN 500 U/M VIAL (SUBCUTANE.) HUMULIN 70/30 VIAL OTC (SUBCUTANE.) HUMULIN VIAL OTC (SUBCUTANE.) LANTUS SOLOSTAR PEN (SUBCUTANE.) LANTUS VIAL (SUBCUTANE.) LEVEMIR PENS (SUBCUTANE.) LEVEMIR VIAL (SUBCUTANE.) NOVOLIN 70/30 VIAL OTC (SUBCUTANE.) NOVOLIN VIAL OTC (SUBCUTANE.) NOVOLOG CARTRIDGE (SUBCUTANE.) NOVOLOG MIX PEN (SUBCUTANE.) NOVOLOG MIX VIAL (SUBCUTANE.) NOVOLOG PEN (SUBCUTANE.) NOVOLOG VIAL (SUBCUTANE.)

ADMELOG SOLOSTAR PEN (SUBCUTANE.) ADMELOG VIAL (SUBCUTANE.) AFREZZA CARTRIDGE (INHALATION) APIDRA SOLOSTAR PEN (SUBCUTANE.) APIDRA VIAL (SUBCUTANE.) BASAGLAR KWIKPEN (SUBCUTANE.) FIASP FLEXTOUCH PEN (SUBCUTANE.) FIASP PENFILL (SUBCUTANE.) FIASP VIAL (SUBCUTANE.) HUMALOG 200 U/ML PEN (SUBCUTANE.) HUMALOG CARTRIDGE (SUBCUTANE.) HUMALOG JUNIOR KWIKPEN (SUBCUTANE.) HUMALOG MIX PEN (SUBCUTANE.) HUMALOG PEN (SUBCUTANE.) HUMULIN 500 U/M PEN (SUBCUTANE.) HUMULIN 70/30 PEN OTC (SUBCUTANE.) HUMULIN PEN OTC (SUBCUTANE.) INSULIN LISPRO PEN (SUBCUTANE.) INSULIN LISPRO VIAL (SUBCUTANE.) NOVOLIN 70/30 PEN OTC (SUBCUTANE.)

Preferred Nonpreferred TOUJEO MAX SOLOSTAR PEN (SUBCUTANE.) TOUJEO SOLOSTAR PEN (SUBCUTANE.) TRESIBA FLEXTOUCH 100 U/ML PEN (SUBCUTANE.) TRESIBA FLEXTOUCH 200 U/ML PEN (SUBCUTANE.)

HYPOGLYCEMICS, SGLT2 section updated 7-11-2018 Preferred Nonpreferred FARXIGA (ORAL) INVOKANA (ORAL) JARDIANCE (ORAL)

INVOKAMET (ORAL) INVOKAMET XR (ORAL) SEGLUROMET (ORAL) STEGLATRO (ORAL) SYNJARDY (ORAL) SYNJARDY XR (ORAL) XIGDUO XR (ORAL)

HYPOGLYCEMICS, SULFONYLUREAS section updated 4-22-2019 Preferred Nonpreferred GLIMEPIRIDE (ORAL) GLIPIZIDE (ORAL) GLIPIZIDE ER (ORAL) GLYBURIDE (ORAL) GLYBURIDE MICRONIZED (ORAL)

AMARYL (ORAL) GLUCOTROL (ORAL) GLUCOTROL XL (ORAL) GLYNASE (ORAL)

HYPOGLYCEMICS, TZD section updated 4-22-2019 Preferred Nonpreferred PIOGLITAZONE (ORAL) ACTOPLUS MET XR (ORAL)

AVANDIA (ORAL) DUETACT (ORAL) PIOGLITAZONE/GLIMEPIRIDE (ORAL) PIOGLITAZONE/METFORMIN (ORAL)

IMMUNOMODULATORS, ATOPIC DERMATITIS section updated 4-22-2019 Preferred Nonpreferred ELIDEL (TOPICAL) PROTOPIC (TOPICAL)

DUPIXENT (SUBCUTANE.) EUCRISA (TOPICAL) PIMECROLIMUS (TOPICAL) TACROLIMUS (TOPICAL)

IMMUNOSUPPRESSIVES, ORAL section updated 10-1-2019 Preferred Nonpreferred AZATHIOPRINE (ORAL) CYCLOSPORINE CAPSULE (ORAL) CYCLOSPORINE SOFTGEL (ORAL) CYCLOSPORINE, MODIFIED CAPSULE (ORAL) CYCLOSPORINE, MODIFIED SOLUTION (ORAL) MYCOPHENOLATE MOFETIL CAPSULE (ORAL) MYCOPHENOLATE MOFETIL TABLET (ORAL) TACROLIMUS (ORAL)

ASTAGRAF XL (ORAL) AZASAN (ORAL) CELLCEPT CAPSULE (ORAL) CELLCEPT SUSPENSION (ORAL) CELLCEPT TABLET (ORAL) ENVARSUS XR (ORAL) IMURAN (ORAL) MYCOPHENOLATE MOFETIL SUSPENSION (ORAL) MYCOPHENOLIC ACID (ORAL) MYFORTIC (ORAL)

Preferred Nonpreferred NEORAL CAPSULE (ORAL) NEORAL SOLUTION (ORAL) PROGRAF (ORAL) PROGRAF GRANULES PACK (ORAL) RAPAMUNE SOLUTION (ORAL) RAPAMUNE TABLET (ORAL) SANDIMMUNE CAPSULE (ORAL) SANDIMMUNE SOLUTION (ORAL) SIROLIMUS (ORAL) ZORTRESS (ORAL)

INTRANASAL RHINITIS AGENTS section updated 4-22-2019 Preferred Nonpreferred AZELASTINE (ASTELIN) (NASAL) AZELASTINE (ASTEPRO) (NASAL) FLUTICASONE (NASAL) IPRATROPIUM (NASAL) MOMETASONE (NASAL)

ASTEPRO (NASAL) BECONASE AQ (NASAL) BUDESONIDE (NASAL) DYMISTA (NASAL) FLUNISOLIDE (NASAL) NASONEX (NASAL) OLOPATADINE (NASAL) OMNARIS (NASAL) PATANASE (NASAL) QNASL 40 (NASAL) QNASL 80 (NASAL) SINUVA (SINUS IMPLANT) TICANASE (NASAL) VERAMYST (NASAL) XHANCE (NASAL) ZETONNA (NASAL)

LEUKOTRIENE MODIFIERS section updated 3-28-2019 Preferred Nonpreferred MONTELUKAST CHEWABLE TABLET (ORAL) MONTELUKAST TABLET (ORAL) ZAFIRLUKAST (ORAL)

ACCOLATE (ORAL) MONTELUKAST GRANULES (ORAL) SINGULAIR CHEWABLE TABLET (ORAL) SINGULAIR GRANULES (ORAL) SINGULAIR TABLET (ORAL) ZILEUTON ER (ORAL) ZYFLO (ORAL) ZYFLO CR (ORAL)

LIPOTROPICS, OTHER section updated 10-1-2019 Preferred Nonpreferred CHOLESTYRAMINE/ASPARTAME (ORAL) CHOLESTYRAMINE/SUCROSE (ORAL) COLESTIPOL GRANULES (ORAL) COLESTIPOL TABLET (ORAL) EZETIMIBE (ORAL) FENOFIBRATE CAPSULE (LOFIBRA) (ORAL) FENOFIBRATE TABLET (LOFIBRA) (ORAL) FENOFIBRATE TABLET (TRICOR) (ORAL)

ANTARA (ORAL) COLESEVELAM (ORAL) COLESEVELAM POWDER PACK (ORAL) COLESTID GRANULES (ORAL) COLESTID TABLET (ORAL) FENOFIBRATE (ANTARA) (ORAL) FENOFIBRATE (FENOGLIDE) (ORAL) FENOFIBRATE (TRIGLIDE) (ORAL)

Preferred Nonpreferred GEMFIBROZIL (ORAL) NIASPAN (ORAL) NIACIN TABLET OTC (ORAL) NIACIN CAPSULE ER OTC (ORAL) NIACIN ER (ORAL) NIACIN TABLET ER OTC (ORAL)

FENOFIBRATE CAPSULE (LIPOFEN) (ORAL) FENOFIBRIC ACID (FIBRICOR) (ORAL) FENOFIBRIC ACID (TRILIPIX) (ORAL) FENOGLIDE (ORAL) FIBRICOR (ORAL) JUXTAPID (ORAL) LOPID LIPOFEN (ORAL) LOFIBRA TABLET (ORAL) LOVAZA (ORAL) NIACOR (ORAL) OMEGA-3 ACID ETHYL ESTERS (ORAL) PRALUENT PEN (SUBCUTANEOUS) QUESTRAN (ORAL) QUESTRAN LIGHT (ORAL) REPATHA PUSHTRONEX (SUBCUTANEOUS) REPATHA SURECLICK (SUBCUTANEOUS) REPATHA SYRINGE (SUBCUTANEOUS) TRICOR (ORAL) TRIGLIDE (ORAL) TRILIPIX (ORAL) VASCEPA (ORAL) WELCHOL POWDER PACK (ORAL) WELCHOL TABLET (ORAL) ZETIA (ORAL)

LIPOTROPICS, STATINS section updated 10-1-2019 Preferred Nonpreferred ATORVASTATIN (ORAL) LOVASTATIN (ORAL) PRAVASTATIN (ORAL) SIMVASTATIN (ORAL) ROSUVASTATIN (ORAL)

ALTOPREV (ORAL) AMLODIPINE-ATORVASTATIN (ORAL) CADUET (ORAL) CRESTOR (ORAL) EZALLOR SPRINKLE (ORAL) EZETIMIBE-SIMVASTATIN (ORAL) FLUVASTATIN (ORAL) FLUVASTATIN ER (ORAL) LESCOL XL (ORAL) LIPITOR (ORAL) LIVALO (ORAL) PRAVACHOL (ORAL) VYTORIN (ORAL) ZOCOR (ORAL) ZYPITAMAG (ORAL)

MACROLIDES/KETOLIDES section updated 10-1-2019 Preferred Nonpreferred AZITHROMYCIN PACKET (ORAL) AZITHROMYCIN SUSPENSION (ORAL) AZITHROMYCIN TABLET (ORAL) CLARITHROMYCIN TABLET (ORAL) E.E.S. 400 TABLET (ORAL)

CLARITHROMYCIN ER (ORAL) CLARITHROMYCIN SUSPENSION (ORAL) E.E.S. 200 SUSPENSION (ORAL) ERYPED 200 SUSPENSION (ORAL) ERYPED 400 SUSPENSION (ORAL)

Preferred Nonpreferred ERYTHROMYCIN BASE CAPSULE DR (ORAL)

ERY-TAB (ORAL) ERYTHROCIN (ORAL) ERYTHROMYCIN BASE TABLET (ORAL) ERYTHROMYCIN ETHYLSUCCINATE TABLET 400MG (ORAL) ERYTHROMYCIN ETHYLSUCCINATE SUSPENSION 200MG (ORAL) ERYTHROMYCIN ETHYLSUCCINATE SUSPENSION 400MG (ORAL) PCE (ORAL) ZITHROMAX PACKET (ORAL) ZITHROMAX SUSPENSION (ORAL) ZITHROMAX TABLET (ORAL) ZMAX (ORAL)

MULTIPLE SCLEROSIS AGENTS section updated 10-1-2019 Preferred Nonpreferred AUBAGIO (ORAL) AVONEX (INTRAMUSC.) AVONEX PEN (INTRAMUSC.) BETASERON KIT (SUBCUTANE.) BETASERON VIAL (SUBCUTANE.) COPAXONE 20 MG/ML (SUBCUTANE.) GILENYA (ORAL) REBIF (SUBCUTANE.) REBIF REBIDOSE PEN INJCTR (SUBCUTANE.)

AMPYRA (ORAL) COPAXONE 40 MG/ML (SUBCUTANE.) EXTAVIA KIT (SUBCUTANE.) EXTAVIA VIAL (SUBCUTANE.) GLATIRAMER 20 MG/ML (SUBCUTANE.) GLATIRAMER 40 MG/ML (SUBCUTANE.) GLATOPA 20 MG/ML (SUBCUTANE.) GLATOPA 40 MG/ML (SUBCUTANE.) MAVENCLAD (ORAL) MAYZENT (ORAL) PLEGRIDY (SUBCUTANE.) TECFIDERA (ORAL)

NEUROPATHIC PAIN section updated 1-1-2020 Preferred Nonpreferred DULOXETINE (CYMBALTA GEN.) (ORAL) GABAPENTIN CAPSULE (ORAL) GABAPENTIN SOLUTION (ORAL) GABAPENTIN TABLET (ORAL) PREGABALIN CAPSULE (ORAL) SAVELLA (ORAL) SAVELLA DOSE PACK (ORAL)

CYMBALTA (ORAL) GRALISE (ORAL) HORIZANT (ORAL) IRENKA (ORAL) LIDOCAINE (TOPICAL) LIDODERM (TOPICAL) LIDOPURE PATCH (TOPICAL) LYRICA CAPSULE (ORAL) LYRICA CR (ORAL) LYRICA SOLUTION (ORAL) NEURONTIN CAPSULE (ORAL) NEURONTIN SOLUTION (ORAL) NEURONTIN TABLET (ORAL) PREGABALIN SOLUTION (ORAL) QUTENZA KIT (TOPICAL)

NSAIDS section updated 4-22-2019 Preferred Nonpreferred CELECOXIB (ORAL) CELEBREX (ORAL)

Preferred Nonpreferred MELOXICAM TABLET (ORAL) NAPROXEN TABLET (ORAL) FLURIBIPROFEN (ORAL) INDOMETHACIN CAPSULE (ORAL) DICLOFENAC SOCIUM (ORAL) DICLOFENAC SR (ORAL) SULINDAC (ORAL) NAPROXEN EC (ORAL) NABUMETONE (ORAL) KETOPROFEN (ORAL) KETOROLAC (ORAL) NAPROXEN SODIUM (ORAL)

DICLOFENAC GEL DUEXIS (ORAL) FENOPROFEN (ORAL) FLECTOR (TOPICAL) MOBIC TABLET (ORAL) MEFENAMIC ACID (ORAL) OXAPROZIN (ORAL) VIMOVO (ORAL) ZIPSOR (ORAL) ZORVOLEX (ORAL)

OPHTHALMIC ANTIBIOTICS section updated 3-28-2019 Preferred Nonpreferred CIPROFLOXACIN SOLUTION (OPHTHALMIC) OFLOXACIN (OPHTHALMIC) VIGAMOX (OPHTHALMIC)

AZASITE (OPHTHALMIC) BESIVANCE (OPHTHALMIC) CILOXAN DROPS (OPHTHALMIC) CILOXAN OINTMENT (OPHTHALMIC) GATIFLOXACIN (OPHTHALMIC) LEVOFLOXACIN (OPHTHALMIC) MOXEZA (OPHTHALMIC) MOXIFLOXACIN (VIGAMOX) (OPHTHALMIC) OCUFLOX (OPHTHALMIC) ZYMAXID (OPHTHALMIC)

OPHTHALMICS FOR ALLERGIC CONJUNCTIVITIS section updated 3-28-2019 Preferred Nonpreferred CROMOLYN SODIUM (OPHTHALMIC) KETOTIFEN OTC (OPHTHALMIC) OLOPATADINE (PATANOL) (OPHTHALMIC) OLOPATADINE DROPS (PATADAY) (OPHTHALMIC) PAZEO (OPHTHALMIC)

ALOCRIL (OPHTHALMIC) ALOMIDE (OPHTHALMIC) ALREX (OPHTHALMIC) AZELASTINE (OPHTHALMIC) BEPREVE (OPHTHALMIC) ELESTAT (OPHTHALMIC) EMADINE (OPHTHALMIC) EPINASTINE (OPHTHALMIC) LASTACAFT (OPHTHALMIC) PATADAY (OPHTHALMIC) PATANOL (OPHTHALMIC) ZADITOR OTC (OPHTHALMIC)

OPHTHALMICS, ANTI-INFLAMMATORIES section updated 7-11-2018 Preferred Nonpreferred DICLOFENAC (OPHTHALMIC) KETOROLAC (OPHTHALMIC) KETOROLAC LS (OPHTHALMIC)

ACULAR (OPHTHALMIC) ACULAR LS (OPHTHALMIC) ACUVAIL (OPHTHALMIC) BROMFENAC (OPHTHALMIC) BROMSITE (OPHTHALMIC) FLURBIPROFEN (OPHTHALMIC) NEVANAC (OPHTHALMIC) OCUFEN (OPHTHALMIC)

Preferred Nonpreferred PROLENSA (OPHTHALMIC)

OPHTHALMICS, GLAUCOMA AGENTS section updated 10-1-2019 Preferred Nonpreferred ALPHAGAN P 0.1% (OPHTHALMIC) ALPHAGAN P 0.15% (OPHTHALMIC) BRIMONIDINE (OPHTHALMIC) COMBIGAN (OPHTHALMIC) DORZOLAMIDE (OPHTHALMIC) DORZOLAMIDE / TIMOLOL (OPHTHALMIC) LATANOPROST 2.5 ML (OPHTHALMIC) TIMOLOL (OPHTHALMIC) TRAVATAN Z 2.5 ML (OPHTHALMIC) TRAVATAN Z 5 ML (OPHTHALMIC)

APRACLONIDINE (OPHTHALMIC) AZOPT (OPHTHALMIC) BETAGAN (OPHTHALMIC) BETAXOLOL (OPHTHALMIC) BETOPTIC S (OPHTHALMIC) BIMATOPROST 2.5ML (OPHTHALMIC) BIMATOPROST 5ML (OPHTHALMIC) BIMATOPROST 7.5ML (OPHTHALMIC) BRIMONIDINE P 0.15% (OPHTHALMIC) CARTEOLOL (OPHTHALMIC) COSOPT (OPHTHALMIC) COSOPT PF (OPHTHALMIC) DORZOLAMIDE / TIMOLOL/PF DROPS (OPHTHALMIC) IOPIDINE (OPHTHALMIC) ISTALOL (OPHTHALMIC) LEVOBUNOLOL (OPHTHALMIC) LUMIGAN 2.5ML (OPHTHALMIC) LUMIGAN 5ML (OPHTHALMIC) LUMIGAN 7.5ML (OPHTHALMIC) RHOPRESSA (OPHTHALMIC) ROCKLATAN (OPHTHALMIC) SIMBRINZA (OPHTHALMIC) TIMOLOL (ISTALOL) (OPHTHALMIC) TIMOPTIC (OPHTHALMIC) TIMOPTIC OCUDOSE (OPHTHALMIC) TIMOPTIC-XE (OPHTHALMIC) TRAVOPROST 2.5 ML (OPHTHALMIC) TRAVOPROST 5 ML (OPHTHALMIC) TRUSOPT (OPHTHALMIC) VYZULTA (OPHTHALMIC) XALATAN 2.5 ML (OPHTHALMIC) ZIOPTAN (OPHTHALMIC)

OPIATE DEPENDENCE TREATMENTS section updated 3-28-2019 Preferred Nonpreferred NALOXONE SYRINGE (INJECTION) NALOXONE VIAL (INJECTION) NARCAN SPRAY (NASAL) SUBOXONE FILM (SUBLINGUAL) BUPRENORPHINE/NALOXONE TAB (SUBLINGUAL)

BUNAVAIL (BUCCAL) BUPRENORPHINE HCL (SUBLINGUAL) BUPRENORPHINE/NALOXONE FILM (SUBLINGUAL) PROBUPHINE (IMPLANT) SUBLOCADE (SUBCUTANEOUS) ZUBSOLV (SUBLINGUAL)

OTIC ANTIBIOTICS section updated 3-28-2019 Preferred Nonpreferred CIPRO HC (OTIC) CIPRODEX (OTIC) OFLOXACIN (OTIC)

CIPROFLOXACIN (OTIC) OTOVEL (OTIC) OTIPRIO (OTIC)

Preferred Nonpreferred NEOMYCIN/POLYMYXIN/HC SOLN/SUSP (OTIC)

PAH AGENTS, ORAL AND INHALED section updated 10-1-2019 Preferred Nonpreferred LETAIRIS (ORAL) SILDENAFIL (ORAL) TRACLEER TABLET (ORAL)

ADCIRCA (ORAL) ADEMPAS (ORAL) AMBRISENTAN (ORAL) BOSENTAN (ORAL) OPSUMIT (ORAL) ORENITRAM ER (ORAL) REVATIO SUSPENSION (ORAL) REVATIO TABLET (ORAL) TALADAFIL (ADCIRCA) (ORAL) TRACLEER SUSPENSION (ORAL) TYVASO (INHALATION) UPTRAVI (ORAL) UPTRAVI TABLET DOSE PACK (ORAL) VENTAVIS (INHALATION)

PANCREATIC ENZYMES section updated 7-11-2018 Preferred Nonpreferred CREON (ORAL) ZENPEP (ORAL)

PANCREAZE (ORAL) PERTZYE (ORAL) ULTRESA (ORAL) VIOKACE (ORAL)

PHOSPHATE BINDERS section updated 3-28-2019 Preferred Nonpreferred CALCIUM ACETATE CAPSULE (ORAL) CALCIUM ACETATE TABLET (ORAL) PHOSLYRA (ORAL) RENAGEL (ORAL)

AURYXIA (ORAL) FOSRENOL CHEWABLE TABLET (ORAL) FOSRENOL POWDER PACK (ORAL) LANTHANUM CARBONATE CHEWABLE TABLET (ORAL) PHOSLO (ORAL) RENVELA POWDER PACK (ORAL) RENVELA TABLET (ORAL) SEVELAMER CARBONATE POWDER PACK (ORAL) SEVELAMER CARBONATE TABLET (ORAL) SEVELAMER HCL TABLET (ORAL) VELPHORO (ORAL)

PLATELET AGGREGATION INHIBITORS section updated 7-11-2018 Preferred Nonpreferred AGGRENOX (ORAL) CLOPIDOGREL (ORAL) DIPYRIDAMOLE (ORAL)

ASPIRIN/DIPYRIDAMOLE (ORAL) BRILINTA (ORAL) DURLAZA (ORAL) EFFIENT (ORAL) PERSANTINE (ORAL) PLAVIX (ORAL) PRASUGREL (ORAL) YOSPRALA (ORAL)

Preferred Nonpreferred ZONTIVITY (ORAL)

PROGESTINS FOR CACHEXIA section updated 3-28-2019 Preferred Nonpreferred MEGESTROL SUSPENSION (MEGACE) (ORAL) MEGESTROL TABLETS (ORAL)

MEGACE (ORAL) MEGACE ES (ORAL) MEGESTROL SUSPENSION (MEGACE ES) (ORAL)

PROTON PUMP INHIBITORS section updated 7-11-2018 Preferred Nonpreferred NEXIUM SUSPENSION (ORAL) OMEPRAZOLE (ORAL) PANTOPRAZOLE (ORAL) * Prilosec OTC, Prevacid OTC, Zegerid (omeprazole sodium

bicarb) excluded from coverage

ACIPHEX SPRINKLE (ORAL) ACIPHEX TABLETS (ORAL) DEXILANT (ORAL) ESOMEPRAZOLE CAPSULES (ORAL) ESOMEPRAZOLE STRONTIUM (ORAL) LANSOPRAZOLE CAPSULES (ORAL) LANSOPRAZOLE SOLUTAB (ORAL) NEXIUM (ORAL) OMEPRAZOLE / SODIUM BICARBONATE (ORAL) PREVACID CAPSULES (ORAL) PREVACID SOLUTAB (ORAL) PRILOSEC SUSPENSION (ORAL) PROTONIX (ORAL) PROTONIX SUSPENSION (ORAL) RABEPRAZOLE TABLETS (ORAL)

SEDATIVE HYPNOTICS section updated 1-1-2020 Preferred Nonpreferred ESZOPICLONE (ORAL) ROZEREM (ORAL) ZALEPLON (ORAL) ZOLPIDEM (ORAL)

AMBIEN (ORAL) AMBIEN CR (ORAL) BELSOMRA (ORAL) EDLUAR (SUBLINGUAL) HETLIOZ (ORAL) INTERMEZZO (SUBLINGUAL) LUNESTA (ORAL) RAMELTEON (ORAL) SONATA (ORAL) ZOLPIDEM (SUBLINGUAL) ZOLPIDEM ER (ORAL) ZOLPIMIST (ORAL)

SMOKING CESSATION section updated 3-28-2019 Preferred Nonpreferred BUPROPION SR (ORAL) CHANTIX (ORAL) CHANTIX DOSE PACK (ORAL) NICOTINE GUM OTC (BUCCAL) NICOTINE LOZENGE OTC (BUCCAL) NICOTINE PATCH OTC (TRANSDERMAL)

NICODERM CQ (TRANSDERMAL) NICOTROL (INHALATION) NICOTROL NS (NASAL) NICORETTE GUM OTC (BUCCAL) NICORETTE LOZENGE OTC (BUCCAL) ZYBAN (ORAL)

STIMULANTS AND RELATED AGENTS section updated 1-15-2020 Preferred Nonpreferred AMPHETAMINE SALT COMBO (ORAL) AMPHETAMINE SALT COMBO ER (ORAL) ATOMOXETINE (ORAL) DEXMETHYLPHENIDATE (ORAL) DEXTROAMPHETAMINE CAPSULE ER (ORAL) DEXTROAMPHETAMINE TABLET (ORAL) FOCALIN XR (ORAL) GUANFACINE ER (ORAL) METHYLIN CHEWABLE TABLETS (ORAL) METHYLPHENIDATE (ORAL) METHYLPHENIDATE CD (ORAL) METHYLPHENIDATE CHEWABLE TABLETS (ORAL) METHYLPHENIDATE ER (CONCERTA) (ORAL) METHYLPHENIDATE ER (METADATE ER) (ORAL) METHYLPHENIDATE ER 72 MG TABLETS (ORAL) RITALIN LA (ORAL) VYVANSE CAPSULE (ORAL) Fee-for-Service Medicaid requires a diagnosis code be transmitted with stimulants pharmacy claim.

ADDERALL XR (ORAL) ADZENYS ER SUSPENSION (ORAL) ADZENYS XR-ODT (ORAL) AMPHETAMINE SULFATE (ORAL) APTENSIO XR (ORAL) ) ARMODAFINIL (ORAL) CONCERTA (ORAL) COTEMPLA XR ODT (ORAL) DAYTRANA (TRANSDERMAL) DEXEDRINE SPANSULE (ORAL) DEXEDRINE TABLET (ORAL) DEXMETHYLPHENIDATE XR (ORAL) DEXTROAMPHETAMINE SOLUTION (ORAL) DYANAVEL XR (ORAL) EVEKEO (ORAL) FOCALIN (ORAL) INTUNIV (ORAL) METHYLIN SOLUTION (ORAL) METHYLPHENIDATE ER (RITALIN LA) (ORAL) METHYLPHENIDATE SOLUTION (ORAL) MYDAYIS ER (ORAL) PROCENTRA (ORAL) QUILLICHEW ER (ORAL) QUILLIVANT XR (ORAL) RITALIN (ORAL) STRATTERA (ORAL) VYVANSE CHEWABLE TABLET (ORAL) ZENZEDI (ORAL)

ULCERATIVE COLITIS AGENTS section updated 10-1-2019 Preferred Nonpreferred BALSALAZIDE (ORAL) CANASA (RECTAL) DELZICOL (ORAL) MESALAMINE (RECTAL) MESALAMINE KIT (RECTAL) PENTASA (ORAL) SULFASALAZINE (ORAL) SULFASALAZINE DR (ORAL)

APRISO (ORAL) ASACOL HD (ORAL) AZULFIDINE TABLET (ORAL) AZULFIDINE TABLET DR (ORAL) BUDESONIDE DR (ORAL) COLAZAL (ORAL) DIPENTUM (ORAL) GIAZO (ORAL) LIALDA (ORAL) MESALAMINE (ASACOL HD) (ORAL) MESALAMINE (CANASA) (RECTAL) MESALAMINE (DELZICOL) (ORAL) MESALAMINE (LIALDA) (ORAL) ROWASA (RECTAL) SFROWASA (RECTAL) UCERIS (ORAL) UCERIS (RECTAL)