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Program

Apple Health Medicaid: Fee-for-Service Preferred Drug List

What is new in this version of the preferred drug list?

Effective for dates of service on and after March 1, 2017, the Health Care Authority will make the following changes:

Drug Class Drug Name Change Client must have tried and failed, or is intolerant to, all preferred products before Alzheimer’s Entire class receiving a non-preferred product for the same indication. Client must have tried and failed, or is intolerant to, all preferred products before Antiemetics Entire class receiving a non-preferred product for the same indication. Client must have tried and failed, or is intolerant to, all preferred products before Antiplatelets Entire class receiving a non-preferred product for the same indication. Client must have tried and failed, or is Attention Deficit/ intolerant to, all preferred products before Hyperactivity Entire class receiving a non-preferred product for the Disorder same indication. Atypical Changed title of drug class to “Second Entire class Antipsychotics Generation Antipsychotics” Atypical Client must have tried and failed, or is Antipsychotics intolerant to, 3 preferred products for the Entire class (Second Generation same indication before receiving a non- Antipsychotics) preferred product. Atypical Antipsychotics (Second Generation Abilify® IM Removed, no longer manufactured Antipsychotics) injection

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Atypical Antipsychotics (Second Generation Abilify® Removed, no longer manufactured Antipsychotics) solution

Atypical Antipsychotics Abilify® tablets Non-Preferred (Second Generation Antipsychotics) Atypical Antipsychotics Abilify® (Second Generation Removed, no longer manufactured Discmelt Antipsychotics)

Atypical Antipsychotics (Second Generation Aristada® Preferred Antipsychotics)

Atypical Antipsychotics (Second Generation Invega Trinza® Preferred Antipsychotics)

Atypical Antipsychotics (Second Generation Rexulti® Preferred Antipsychotics)

Atypical Antipsychotics Seroquel®/ (Second Generation Non-Preferred XR® Antipsychotics)

Atypical Antipsychotics (Second Generation Vraylar® Preferred Antipsychotics)

Atypical Antipsychotics Zyprexa® IM (Second Generation Non-Preferred injection Antipsychotics)

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Client must have tried and failed, or is intolerant to, all preferred products before Long-Acting Insulins Entire class receiving a non-preferred product for the same indication. Client must have tried and failed, or is Nasal intolerant to, all preferred products before Entire class Corticosteroids receiving a non-preferred product for the same indication. Changed title of drug class to “Insomnia”. Added subclasses. Removed all EA and PA requirements, only PDL rules apply. Newer Sedative/ Entire class Client must have tried and failed, or is Hypnotics intolerant to, all preferred products before receiving a non-preferred product for the same indication. Added to class as non-preferred, Targeted Immune unstudied, not subject to TIP/DAW. Inflectra® Modulators

Removed all EA and PA requirements, only PDL rules apply. Client must have Targeted Immune Entire class tried and failed, or is intolerant to, all Modulators preferred products before receiving a non- preferred product for the same indication.

What is the preferred drug list?

The Health Care Authority (agency) and Labor & Industries (L & I) have developed a list of preferred drugs within a chosen therapeutic class that are selected based on clinical evidence of safety, efficacy, and effectiveness. The drugs within a chosen therapeutic class are studied by an evidence-based practice center (EPC). A written report on the comparative safety, efficacy, and effectiveness from the EPC is evaluated by the Washington State Pharmacy and Therapeutic Committee which makes recommendations to the state agencies regarding the selection of the preferred drugs on the Washington Preferred Drug List (WPDL). (WAC 182-530-4100)

What is the process to obtain drugs on the preferred drug list?

1. Preferred Drugs - Prescription claims for preferred drugs submitted to the agency are reimbursed without authorization requirements unless the drug requires authorization for:

a. Safety criteria; b. Special subpopulation criteria; or

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c. Limits based on age, gender, dose, or quantity.

2. Non-preferred Drugs - Prescription claims for non-preferred drugs submitted to the agency are reimbursed without authorization requirements when written by an Endorsing Practitioner who has indicated “DAW” on the prescription unless the drug requires restrictions for safety. See WAC 182-530-4150.

3. Prescription claims for non-preferred drugs submitted to the agency are reimbursed only after authorizing criteria are met if written by a non-endorsing practitioner.

4. Pharmacies must call the agency for authorization when required. Call 800-848-2842 (Option 1) or fax to 866-668-1214.

What are the authorization criteria that must be met to obtain a nonpreferred drug?

• For most drug classes on this PDL, the authorization criteria is that the client must have tried and failed, or is intolerant to, at least one preferred drug. Drugs may have criteria that go beyond these basic criteria for the reasons stated in #1 on the previous page.

• Drugs that are in drug classes on this PDL that have not been studied by the evidence- based practice center(s) and have not been reviewed by the P&T committee will be treated as non-preferred drugs and will require authorization.

HCA requires pharmacies to obtain authorization for non-preferred drugs when a therapeutic equivalent is on this PDL. The following table shows the preferred and non-preferred drug in each therapeutic drug class on the Apple Health Medicaid Fee-For-Service PDL.

Note: The agency changed the format for multiple drug listings. A slash ( / ) is used to denote multiple forms of a drug. For example: “Cardizem® /CD/LA/SR” represents immediate release Cardizem, as well as the CD, LA, and SR forms. A hyphen ( - ) is used to indicate combination products. For example: “benazepril- HCTZ” represents the combination product of benazepril and , rather than benazepril AND the combination product.

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Drug Class Preferred Drugs Non-preferred Drugs

ACE Inhibitors Generic: Generic: benazepril moexipril enalapril perindopril erbumine lisinopril quinapril ramipril trandolapril

Brand: Brand: Accupril® (quinapril) Aceon® (perindopril) Altace® (ramipril) Epaned® (enalapril)** Lotensin® (benazepril) Mavik® (trandolapril) Qbrelis® (lisinopril)** Prinivil® (lisinopril) Univasc® (moexipril) Vasotec® (enalapril) Zestril® (lisinopril)

**Not subject to TIP or DAW-1 override. Alzheimer's Drugs Generic: Generic: donepezil /ODT rivastigmine tartrate patch Not subject to galantamine therapeutic galantamine HBR Brand: interchange program Aricept® /ODT (donepezil) (TIP). For more memantine titration pak Exelon® (rivastigmine) patch information on TIP, rivastigmine tartrate capsules Exelon® (rivastigmine) see Theraputic capsule/solution Interchange Program Namenda® XR (memantine)** in the Prescription Brand: Namenda XR Titration Pak® Drug Program Namenda® (memantine) (memantine)** Medicaid Billing Namenda Titration Pak® Namzaric® (memantine- Guide. (memantine) donepezil)** Razadyne® /ER (galantamine) Client must have tried and failed, or is **Not subject to DAW-1 override. intolerant to, all preferred products before receiving a non-preferred product for the same indication.

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Drug Class Preferred Drugs Non-preferred Drugs

Antiemetics Generic: Generic: tablet/injection Client must have tried tablet/ injection Brand: and failed, or is ondansetron solution+ Aloxi® () injection intolerant to, all ondansetron ODT tablet Anzemet® () preferred products tablet/injection before receiving a Brand: Sancuso® (granisetron) non-preferred product transdermal patch** for the same Varubi® (rolapitant)** indication. Zofran® (ondansetron) tablet /injection Zofran® (ondansetron) solution+ Zofran® ODT® (ondansetron) tablet Zuplenz® (ondansetron oral soluble)**

+EA required for age 18 and older +EA required for age 18 and older **Not subject to TIP or DAW-1 override. Antiplatelets Generic: Generic: clopidogrel aspirin-dipyridamole ER Not subject to TIP. For more information Brand: Brand: on TIP, see Aggrenox® (aspirin-dipyridamole Theraputic ER) Interchange Program Brilinta® (ticagrelor) in the Prescription Effient® (prasugrel HCl) Drug Program Plavix ® (clopidogrel bisulfate) Medicaid Billing Zontivity® (vorapaxar sulfate) Guide.

Client must have tried and failed, or is intolerant to, all preferred products before receiving a non-preferred product for the same indication.

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Drug Class Preferred Drugs Non-preferred Drugs

Attention Deficit/ Generic: Generic: Hyperactivity salt combo ER Disorder amphetamine salt combo XR dextroamphetamine solution dextroamphetamine methylphenidate chewable Not subject to TIP. dextroamphetamine SA For more information dexmethylphenidate Brand: on TIP, see dexmethylphenidate XR Adderall® (amphetamine salt Theraputic ER combo) Interchange Program methylphenidate Adderall XR® (amphetamine salt in the Prescription methylphenidate CD/ER/LA/SR combo) Drug Program Adzenys XR® (amphetamine)** Medicaid Billing Brand: Aptensio XR® Guide. Strattera® (atomoxetine HCl) (methylphenidate)** Vyvanse™ (lisdexamfetamine Concerta® (methylphenidate HCl) EA is required for dimesylate) Daytrana™ (methylphenidate stimulants prescribed HCl) transdermal patch for ADD/ADHD Dexedrine® (dextroamphetamine) diagnosis for adults. Dyanavel XR® (amphetamine)** Evekeo® (amphetamine)** Client must have tried Focalin® (dexmethylphenidate) and failed, or is Focalin XR® intolerant to, all (dexmethylphenidate) preferred products Intuniv™ (guanfacine) before receiving a Kapvay® (clonidine) non-preferred product Metadate CD™ (methylphenidate for the same HCl) indication. Methylin® (methylphenidate HCl) chewable/solution ProCentra® (dextroamphetamine) Quillichew ER® (methylphenidate HCl)** Quillivant® XR (methylphenidate HCl) Ritalin® (methylphenidate HCl) Ritalin LA® (methylphenidate HCl) Ritalin SR® (methylphenidate HCl)

**Not subject to DAW-1 override.

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Drug Class Preferred Drugs Non-preferred Drugs

Beta Blockers Generic: Generic: Brand: Bystolic® () Coreg® /CR® () carvedilol Corgard® () Inderal® LA () succinate ER Inderal® XL (propranolol)** metoprolol tartrate InnoPran XL® (propranolol) nadolol Kerlone® (betaxolol) Levatol® () propranolol/ER Lopressor® (metoprolol tartrate) Sectral® (acebutolol) Tenormin® (atenolol) Brand: Toprol XL (metoprolol succinate) Trandate® (labetalol) Zebeta® (bisoprolol)

**Not subject to TIP or DAW-1 override Calcium Channel Generic: Generic: Blockers amlodipine isradipine /CD/ER/XR nifedipine felodipine ER nicardipine Brand: nifedipine ER Adalat® CC (nifedipine) nisoldipine /ER Calan® /SR () verapamil /XR Cardizem® /CD/LA (diltiazem) Isoptin® SR (verapamil) Brand: Norvasc® (amlodipine) Procardia® /XL (nifedipine) Sular® (nisoldipine) Tiazac® (diltiazem) Verelan® /PM (verapamil)

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Drug Class Preferred Drugs Non-preferred Drugs

Direct-Acting Generic: Generic: Antiviral Agents for Hepatitis C Brand: Brand: Epclusa® (sofosbuvir- Daklinza® (daclatasvir)* Not subject to TIP. velpatasvir)* Olysio® (simeprevir)* For more information Harvoni® (ledipasvir-sofosbuvir)* Technivie® (ombitasvir- on TIP, see Sovaldi® (sofosbuvir)* paritaprevir-ritonavir)* Theraputic Victrelis® (boceprevir)*** Interchange Program Viekira Pak™ (paritaprevir- in the Prescription ritonavir-ombitasvir-dasabuvir)* Drug Program Viekira XR™ (paritaprevir- Medicaid Billing ritonavir-ombitasvir-dasabuvir)** Guide. Zepatier® (elbasvir- grazoprevir)***

*PA Required *PA Required **Not subject to TIP or DAW-1 override and PA required

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Drug Class Preferred Drugs Non-preferred Drugs

Estrogens Generic Oral: Generic Oral: estradiol tablets Transdermal products estropipate tablets Brand Oral: are not subject to TIP. Duavee® (conjugated estrogens- For more information Brand Oral: bazedoxifene)** on TIP, see Enjuvia® (synthetic conjugated Therapeutic estrogens) Interchange Program Estrace® (estradiol) tablet in the Prescription Menest® (esterified estrogens) Drug Program Ortho-Est® (estropipate) Medicaid Billing Premarin® (conjugated equine Guide estrogens) tablet

Generic Transdermal: estradiol transdermal patch (weekly)

Brand Transdermal: Alora® (estradiol) patch (biweekly) Climara® (estradiol) patch (weekly) Divigel® (estradiol) gel Elestrin™ (estradiol) gel Estrogel® (estradiol) gel Evamist® (estradiol) spray** Menostar® (estradiol) patch (weekly) Minivelle® (estradiol) patch (biweekly) Vivelle® DOT (estradiol) patch (biweekly)

**Not subject to TIP or DAW-1 override.

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Drug Class Preferred Drugs Non-preferred Drugs

Estrogens (cont.) Generic Vaginal: Generic Vaginal:

Transdermal products Brand Vaginal: Brand Vaginal: are not subject to TIP. Estring® (estradiol) vaginal ring Estrace® (estradiol) vaginal For more information cream on TIP, see Femring® (estradiol) vaginal ring Therapeutic Premarin® (conjugated equine Interchange Program estrogen) vaginal cream in the Prescription Vagifem® (estradiol) vaginal Drug Program tablets Medicaid Billing Guide Estrogen-Progestin Generic: Generic Oral: Combinations estradiol-norethindrone norethindrone acetate -ethinyl Brand Oral: Transdermal products estradiol Activella® (estradiol- are not subject to TIP. norethindrone) For more information Brand: Angeliq® (estradiol- on TIP, see drospirenone) Therapeutic Femhrt Low Dose® (ethinyl Interchange Program estradiol-norethindrone) in the Prescription Prefest® (estradiol-norgestimate) Drug Program Premphase® (conjugated equine Medicaid Billing estrogens-medroxyprogesterone) Guide Prempro® (conjugated equine estrogens-medroxyprogesterone)

Generic Transdermal:

Brand Transdermal: Climara Pro® (estradiol- levonorgestrel) Combipatch® (estradiol- norethindrone)

**Not subject to TIP or DAW-1 override.

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Drug Class Preferred Drugs Non-preferred Drugs

Histamine-2 Generic: Generic: (H2RA) Brand: Not subject to TIP. For more information Brand: on TIP, see Axid® (nizatidine) Theraputic Pepcid® (famotidine) Interchange Program Pepcid Complete® (famotidine – in the Prescription calcium carbonate – magnesium Drug Program hydroxide) Medicaid Billing Tagamet HB® (cimetidine) Guide. Zantac® (ranitidine) Inhaled Beta- Generic nebulized: Generic nebulized: albuterol inhalation solution levalbuterol

Brand nebulized: Accuneb® (albuterol) inhalation solution Xopenex® (levalbuterol) inhalation solution

Brand inhaled: Brand inhaled: ProAir™ HFA (albuterol) ProAir™ Respiclick (albuterol) Proventil® HFA (albuterol) Ventolin® HFA (albuterol) Xopenex® HFA (levalbuterol)

Brand long-acting inhaled: Brand long-acting nebulized: Serevent® Diskus® ()* Brovana® ()* Perforomist® ( fumarate)*

Brand long-acting inhaled: Arcapta™ Neohaler™ ()* Foradil® Aerolizer® (formoterol)* Striverdi® (olodaterol)**

*EA required *EA required **Not subject to TIP or DAW-1 override and EA Required.

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Drug Class Preferred Drugs Non-preferred Drugs

Inhaled Generic: Generic: Corticosteroids Brand: Brand: Aerospan® ( HFA) Flovent® HFA/Diskus® Alvesco® ( HFA) ( propionate HFA/DPI) Arnuity Ellipta® (fluticasone Qvar® (beclomethasone furoate)** dipropionate MDI) Asmanex 14® ( Pulmicort Respules® 1mg/2ml furoate) (budesonide inhalation Asmanex HFA® (mometasone suspension) furoate) Asmanex Twisthaler® (mometasone furoate DPI) Pulmicort Flexhaler® (budesonide DPI) Pulmicort Respules® (budesonide inhalation suspension)

**Not subject to TIP or DAW-1 override. Inhaled Generic: Generic: Corticosteroids – Long-Acting Beta- Brand: Brand: Advair Diskus® /HFA® Dulera® (mometasone furoate- Combinations (fluticasone-salmeterol) formoterol fumarate)* Breo Ellipta® (- Symbicort® (budesonide- ) formoterol)

*EA required

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Drug Class Preferred Drugs Non-preferred Drugs

Insomnia Benzodiazepine receptor Benzodiazepine receptor agonists: agonists: Client must have tried Generic: Generic: and failed, or is zaleplon eszopiclone intolerant to, all zolpidem zolpidem ER preferred products before receiving a Brand: Brand: non-preferred product Ambien /CR® (zolpidem tartrate) for the same Edluar® (zolpidem tartrate) indication. sublingual Intermezzo® (zolpidem tartrate) sublingual Lunesta® (eszopiclone) Sonata® (zaleplon) Zolpimist (zolpidem tartrate)

Non-benzodiazepine receptor Non-benzodiazepine receptor agonists: agonists: Generic: Generic:

Brand: Brand: Rozerem® (ramelteon) Belsomra® (suvorexant)**

**Not subject to TIP or DAW-1 Insulin-Release Generic immediate release: Generic: Stimulant Type Oral glimepiride chlorpropamide Hypoglycemics glipizide /ER/XL repaglinide glyburide tolazamide glyburide micronized tolbutamide nateglinide Brand: Brand: Amaryl® (glimepiride) DiaBeta® (glyburide) Glucotrol® /XL (glipizide) Glynase® (glyburide micronized) Prandin® (repaglinide) Starlix® (nateglinide) Generic: Generic: Modifiers sodium Brand: Accolate® (zafirlukast) Brand: Singulair® (montelukast) Zyflo /CR® ()

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Drug Class Preferred Drugs Non-preferred Drugs

Long-Acting Beta- Generic: Generic: Agonist – Long Acting Muscarinic Brand: Brand: Agent Combinations Anoro Ellipta® (umeclidnium- Bevespi Aerosphere® (LABA – LAMA) vilanterol)* (glycopyrrolate-formoterol fumarate)*** *EA required Stiolto® (tiotropium bromide- olodaterol)*** Utibron Neohaler® (indacaterol- glycopyrrolate)***

***Not subject to TIP or DAW-1 and EA required Long-Acting Insulins Generic: Generic:

Client must have tried Brand: Brand: and failed, or is Lantus® (insulin glargine)* Levemir® (insulin detemir)* intolerant to, all Lantus Solostar® (insulin Levemir Flextouch® (insulin preferred products glargine)* detemir)* before receiving a Toujeo Solostar® (insulin non-preferred product glargine)* for the same Tresiba® Flextouch® (insulin indication. degludec)**

*EA required *EA required **Not subject to TIP or DAW-1 and EA required Long-Acting Generic: Generic: Muscarinic Agents (LAMA) Brand: Brand: Spiriva Handihaler® (tiotropium Incruse Ellipta® (umeclidinium bromide)* bromide)*** Spiriva Respimat® (tiotropium Seebri Neohaler® bromide) (glycopyrronium)*** Tudorza Pressair® (aclidinium)*

*EA required *EA required **Not subject to TIP or DAW-1 ***Not subject to TIP or DAW-1 and EA required

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Drug Class Preferred Drugs Non-preferred Drugs

Long-Acting Opioids Generic: Generic: fentanyl transdermal levorphanol Not subject to TIP. hydromorphone methadone* For more information morphine sulfate /CR/SA/SR methadose* on TIP, see morphine sulfate ER oxymorphone HCL ER Theraputic capsules/tablets Interchange Program oxycodone ER Brand: in the Prescription Avinza® (morphine sulfate ER) Drug Program Brand: Belbuca® (buprenorphine)** Medicaid Billing Butrans ® (buprenorphine) Guide. transdermal Dolophine® (methadone)* Duragesic® (fentanyl) transdermal Exalgo ® (hydromorphone HCl) Hysingla ER® (hydrocodone bitartrate) Kadian® (morphine sulfate SR) Methadone HCl Intensol® (methadone)* MS Contin® (morphine sulfate SA) Nucynta ER® (tapentadol HCl) Opana ER® (oxymorphone HCl) OxyContin® (oxycodone ER) Xtampza® (oxycodone ER)** Zohydro ER® (hydrocodone bitartrate)

*PA Required **Not subject to DAW-1 override

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Drug Class Preferred Drugs Non-preferred Drugs

Macrolides Generic: Generic: azithromycin Not subject to TIP. packet/suspension/tablet Brand: For more information clarithromycin tablet/suspension Biaxin® (clarithromycin) on TIP, see clarithromycin SR tablet tablet/suspension Theraputic base tablet Biaxin XL® (clarithromycin) Interchange Program erythromycin EC capsule/tablet EES 400 ® (erythromycin in the Prescription erythromycin ethylsuccinate ethylsuccinate) tablet Drug Program tablet/suspension PCE® (erythromycin base) Medicaid Billing erythromycin stearate tablet Zithromax® (azithromycin) Guide. erythromycin tablet powder packet/suspension/tablet Zmax® (azithromycin SR) Brand: EES® (erythromycin ethylsuccinate) granules Eryped 200® (erythromycin ethylsuccinate) Eryped 400® (erythromycin ethylsuccinate) Ery-Tab® (erythromycin base EC) Erythrocin Stearate® (erythromycin stearate) Multiple Sclerosis Generic: Generic: Drugs Brand: Not subject to TIP. Avonex® (interferon ß 1a) Brand: For more information Avonex Pen® (interferon ß 1a) Aubagio® (teriflunomide) on TIP, see Betaseron® (interferon ß 1b) Extavia® (interferon ß 1b) Theraputic Copaxone® (glatiramer acetate) Lemtrada® (alemtuzumab) Interchange Program Gilenya® (fingolimod) Plegridy® (peginterferon ß 1a) in the Prescription Glatopa® (glatiramer acetate) Plegridy Pen® (peginterferon ß Drug Program Tecfidera® (dimethyl fumarate) 1a) Medicaid Billing Tecfidera Starter Pack® (dimethyl Plegridy Starter Pak® Guide. fumarate) (peginterferon ß 1a) Rebif® (interferon ß 1a) Rebif Titration Pack® (interferon Client must have tried ß 1a) and failed, or is Rebif Rebidose® (interferon ß 1a) intolerant to, all Rebif Rebidose Titration Pack® preferred products (interferon ß 1a) before receiving a Tysabri® (natalizumab)* non-preferred product Zinbryta™ (daclizumab) for the same indication. *PA required

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Drug Class Preferred Drugs Non-preferred Drugs

Nasal Generic: Generic: Corticosteroids budesonide OTC budesonide RX OTC flunisolide RX Client must have tried acetonide OTC mometasone furoate and failed, or is triamcinolone acetonide RX intolerant to, all Brand: preferred products Brand: before receiving a Beconase AQ ® (beclomethasone non-preferred product dipropionate) for the same Flonase® (fluticasone propionate) indication. Nasacort® Allergy 24HR (triamcinolone acetonide) Nasacort AQ® (triamcinolone acetonide) Nasonex® (mometasone furoate) Omnaris® (ciclesonide) QNasl® (beclomethasone dipropionate)** Rhinocort Aqua® (budesonide) Veramyst™ (fluticasone furoate) Zetonna® (ciclesonide)**

**Not subject to TIP or DAW-1 Newer Generic: Generic: Anticoagulants

Not subject to TIP. Brand: Brand: For more information Eliquis® (apixaban) Savaysa® (edoxaban tosylate) on TIP, see Pradaxa® (dabigatran) Xarelto® (rivaroxaban) Theraputic Xarelto Starter Pack® Interchange Program (rivaroxaban) in the Prescription Drug Program Medicaid Billing Guide.

Client must have tried and failed, or is intolerant to, all preferred products before receiving a non-preferred product for the same indication.

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Drug Class Preferred Drugs Non-preferred Drugs

Newer Generic: Generic: syrup /tablet OTC cetirizine chewable cetirizine chewable – children’s Brand: dihydrochloride

Brand: Allegra® (fexofenadine) Astelin® (azelastine HCl nasal spray) Astepro® (azelastine HCl nasal spray) Clarinex® (desloratadine) Claritin® (loratadine) Patanase® (olopatadine nasal spray) Xyzal® (levocetirizine) Zyrtec® (cetirizine) Newer Diabetic Generic: Generic: alogliptin benzoate* Brand: Byetta® (exenatide)* Brand: Farxiga® (dapaglifozin Bydureon® (exenatide)* propanediol)* Invokana® (canagliflozin)* Tradjenta® (linagliptin)* Januvia® (sitagliptin)* Jardiance® (empagliflozin)*** Nesina® (alogliptin benzoate)* Onglyza® (saxagliptin)* SymlinPen®(pramlintide acetate)** Tanzeum® (albiglutide)*** Trulicity® (dulaglutide)*** Victoza® (liraglutide injection)*

*PA Required *PA Required. **Not subject to TIP ***Not subject to TIP or DAW-1 override and PA required

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Drug Class Preferred Drugs Non-preferred Drugs

Nonsteroidal Anti- Generic: Generic: inflammatory Drugs diclofenac potassium celecoxib** (NSAID) Including diclofenac sodium /SR/ER/EC diclofenac sodium topical gel*** Cyclo-oxygenase - 2 diflunisal diclofenac sodium topical (Cox-II) Inhibitors etodolac /ER solution*** fenoprofen meclofenamate sodium flurbiprofen ibuprofen Brand: indomethacin/SR Anaprox® /DS (naproxen ketoprofen /SR sodium) ketorolac Cambia™ (diclofenac potassium) mefenamic acid solution*** meloxicam Cataflam® (diclofenac potassium) nabumetone Celebrex® (celecoxib)** naproxen /EC Daypro® (oxaprozin) naproxen sodium /ER/SA Disalcid® (salsalate) oxaprozin Feldene® (piroxicam) piroxicam Flector® (diclofenac salsalate epolamine)*** sulindac Indocin® (indomethacin) tolmetin Mediproxen® (naproxen sodium) Mobic® (meloxicam) Brand: Nalfon® (fenoprofen) Naprelan® (naproxen sodium ER) Naprosyn® /EC/DS (naproxen) Pennsaid® (diclofenac sodium) sol*** Ponstel® (mefenamic acid) Rexaphenac® (diclofenac sodium)*** Solaraze® (diclofenac sodium) gel*** Tivorbex® (indomethacin)** Vivlodex® (meloxicam) Voltaren® (diclofenac sodium)*** Voltaren XR® (diclofenac sodium) Zipsor® (diclofenac potassium) Zorvolex® (diclofenac)**

* PA required ** Not subject to TIP *** Not subject to TIP or DAW-1 override and PA required.

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Drug Class Preferred Drugs Non-preferred Drugs

Overactive Generic short acting: Generic short acting: Bladder/Urinary oxybutynin chloride tablets/syrup flavoxate HCl Incontinence tolterodine tartrate trospium chloride

Brand short acting: Brand short acting: Detrol® (tolterodine tartrate) Sanctura® (trospium chloride)

Generic long acting: Generic long acting: oxybutynin ER darifenacin hydrobromide ER tolterodine tartrate ER trospium chloride ER

Brand long acting: Brand long acting: Detrol LA® (tolterodine tartrate) Ditropan XL® (oxybutynin chloride) Enablex® (darifenacin hydrobromide) Gelnique® (oxybutynin chloride) topical gel Myrbetriq® () Oxytrol® (oxybutynin chloride) Sanctura XR® (trospium chloride) Toviaz® (fesoterodine fumarate) Vesicare® (solifenacin succinate) PCSK-9 Inhibitors Generic: Generic:

(Proprotein Brand: Brand: Convertase Repatha® (evolocumab)* Praluent® (alirocumab)* Subtilisin Kexin Repatha Sureclick® Type 9) (evolocumab)* Repatha Pushtronex®

(evolocumab)*

*PA required *PA required PD4I Generic: Generic: Phosphodiesterase – 4 Inhibitors Brand: Brand: Daliresp® (roflumilast)*

*EA required

(Rev. 2/13/2017)(Eff. 3/01/2017) - 21 - Apple Health Medicaid PDL Prescription Drug Program

Drug Class Preferred Drugs Non-preferred Drugs

Proton Pump Generic: Generic: Inhibitors OTC/RX magnesium (Limited to 90 days sodium esomeprazole strontium** duration) omeprazole- sodium

Brand: Brand: Nexium® granules Aciphex® (rabeprazole) (esomeprazole)+ Dexilant® () Protonix Pack® (pantoprazole)* Nexium® (esomeprazole) Prevacid® (lansoprazole) capsules Prevacid® SoluTab™ (lansoprazole)* Prilosec OTC® (omeprazole magnesium) tablets Prilosec® Rx (omeprazole) Protonix® (pantoprazole) Zegerid® (omeprazole-sodium bicarbonate)

*EA required *EA required + Preferred only for children ages **Not subject to TIP or DAW-1 17 and younger override.

(Rev. 2/13/2017)(Eff. 3/01/2017) - 22 - Apple Health Medicaid PDL Prescription Drug Program

Drug Class Preferred Drugs Non-preferred Drugs

Second Generation Generic: Generic: HCl citalopram HBR solution bupropion SR* desvenlafaxine ER Not subject to TIP. bupropion XL* duloxetine For more information citalopram tablet duloxetine EC** on TIP, see escitalopram tablet escitalopram solution Theraputic HCl capsule/solution fluoxetine HCl tablet Interchange Program tablet fluvoxamine ER in the Prescription /ODT/soltab Drug Program paroxetine HCl paroxetine ER Medicaid Billing sertraline tablet sertraline HCl solution Guide. venlafaxine ER capsules venlafaxine ER tablets venlafaxine HCl Brand: Aplenzin® (bupropion Brand: hydrobromide ER) Brintellix® ()** Brisdelle® (paroxetine mesylate)** Celexa® (citalopram) Cymbalta® (duloxetine HCl) Effexor® XR (venlafaxine HCl) Fetzima® / Titration Pack (levomilnacipran HCl)** Forfivo® XL (bupropion SR)** Irenka® (duloxetine HCl) Khedezla® (desvenlafaxine fumarate)** Lexapro® (escitalopram) Luvox CR® (fluvoxamine) Paxil® /CR (paroxetine HCl) Pexeva® (paroxetine mesylate) Pristiq® (desvenlafaxine succinate) Prozac® /Prozac Weekly® (fluoxetine HCl) Remeron® /SolTab (mirtazapine) Sarafem® (fluoxetine)** Trintellix® (vortioxetine)** Viibryd® () Wellbutrin® (bupropion HCl) Wellbutrin® SR/XL (bupropion *EA required HCl /SR/XL)* **Not subject to DAW-1 override. Zoloft® (sertraline)

(Rev. 2/13/2017)(Eff. 3/01/2017) - 23 - Apple Health Medicaid PDL Prescription Drug Program

Drug Class Preferred Drugs Non-preferred Drugs

Second Generation Generic: Generic: Antipsychotics tablet / ODT Brand: Not subject to TIP. /ODT/injection Abilify® (aripiprazole) tablet For more information ER Clozaril® (clozapine) tablet on TIP, see Fazaclo® (clozapine) Theraputic tablet/ODT/solution disintegrating tablet Interchange Program capsules Geodon® (ziprasidone HCl) in the Prescription capsule Drug Program Brand: Invega™ (paliperidone) tablet Medicaid Billing Abilify Maintena® (aripiprazole) Nuplazid® ( Guide. Aristada® () tartrate)*** Fanapt® () tablet Risperdal® (risperidone) Client must have tried Fanapt Titration Pack® tablet/M-tab®/solution and failed, or is (iloperidone) Seroquel® / XR® (quetiapine) intolerant to, 3 Geodon® (ziprasidone mesylate) Versacloz® (clozapine)** preferred products IM injection Zyprexa® (olanzapine) IM before receiving a Invega Sustenna® (paliperidone) injection non-preferred product IM injection Zyprexa® (olanzapine) tablet for the same Invega Trinza® (paliperidone) Zyprexa Zydis® (olanzapine) indication. Latuda® ( HCL) tablet Rexulti® () Risperdal Consta® (risperidone) injection Saphris® () sublingual tablet **Not subject to TIP or DAW-1 Vraylar® ( HCl) override. Zyprexa Relprevv® (olanzapine ***Not subject to TIP or DAW-1 pamoate) injection override and PA required.

(Rev. 2/13/2017)(Eff. 3/01/2017) - 24 - Apple Health Medicaid PDL Prescription Drug Program

Drug Class Preferred Drugs Non-preferred Drugs

Skeletal Muscle Generic: Generic: Relaxants baclofen carisoprodol* chlorzoxazone methocarbamol dantrolene metaxalone citrate ER Brand: Brand: Amrix® (cyclobenzaprine) Dantrium® (dantrolene) Fexmid® (cyclobenzaprine) Lorzone® (chlorzoxazone) Metaxall® (metaxalone) Norflex® (orphenadrine) Parafon Forte® (chlorzoxazone) Robaxin® (methocarbamol) Skelaxin® (metaxalone) Soma® (carisoprodol)* Zanaflex® (tizanidine)

*PA required Statin-type Generic: Generic: Cholesterol fluvastatin fluvastatin ER Lowering Agents lovastatin pravastatin Brand: simvastatin Altoprev® (lovastatin SR) Lescol® /XL (fluvastatin) Brand: Livalo® (pitavastatin calcium) Mevacor® (lovastatin) Pravachol® (pravastatin) Zocor® (simvastatin)

High Potency Generic: High Potency Generic: atorvastatin rosuvastatin*

High Potency Brand: High Potency Brand: Crestor® (rosuvastatin)* Lipitor® (atorvastatin)

*Not subject to DAW-1 override

(Rev. 2/13/2017)(Eff. 3/01/2017) - 25 - Apple Health Medicaid PDL Prescription Drug Program

Drug Class Preferred Drugs Non-preferred Drugs

Targeted Immune Generic: Generic: Modulators Brand: Brand: Not subject to TIP. Enbrel® (etanercept) Actemra® (tocilizumab) For more information Enbrel Sureclick® (etanercept) Cimzia® (certolizumab pegol) on TIP, see Humira® (adalimumab) Cosentyx® (secukinumab)** Theraputic Humira Pen® (adalimumab) Entyvio® (vedolizumab)** Interchange Program Ilaris® (canakinumab)** in the Prescription Inflectra® (infliximab-dyyb)** Drug Program Kineret® (anakinra) Medicaid Billing Orencia® (abatacept) Guide. Orencia Clickject® (abatacept) Otezla® (apremilast)** Client must have tried Remicade® (infliximab) and failed, or is Rituxan® (rituximab) intolerant to, all Simponi® (golimumab) preferred products Stelara® (ustekinumab) before receiving a Stelara® IV solution non-preferred product (ustekinumab)** for the same Taltz® (ixekizumab)** indication. Xeljanz® (tofacitinib citrate) Xeljanz XR® (tofacitinib citrate)**

**Not subject to DAW-1 override Thiazolidinediones Generic: Generic: (TZDs) pioglitazone HCl Brand: Brand: Actos® tablet (pioglitazone HCl) Avandia® tablet (rosiglitazone maleate)*

*PA required

(Rev. 2/13/2017)(Eff. 3/01/2017) - 26 - Apple Health Medicaid PDL Prescription Drug Program

Drug Class Preferred Drugs Non-preferred Drugs

Triptans Generic: Generic: benzoate maleate tablets sumatriptan injection HCl sumatriptan nasal spray

Brand: Brand: Alsuma® (sumatriptan succinate) Amerge® (naratriptan) Axert® (almotriptan) Frova® (frovatriptan) Imitrex® tablets (sumatriptan) Imitrex® injection (sumatriptan) Imitrex® nasal spray (sumatriptan) Maxalt® /MLT (rizatriptan) Onzetra Xsail® (sumatriptan)** Relpax® () Sumavel™ DosePro™ (sumatriptan) Zembrace Symtouch® (sumatriptan succinate)** Zomig® /ZMT (zolmitriptan)

**Not subject to TIP or DAW-1 override.

(Rev. 2/13/2017)(Eff. 3/01/2017) - 27 - Apple Health Medicaid PDL