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Totalcare Medicaid 2017 Q2 GB Preferred Drug List Molina Healthcare of New York, Inc. 2017 *Molina mandates the use of generic drugs, if available. Brand names listed are for reference only. THIS LIST IS SUBJECT TO CHANGE. You can get more information and updates to this document on our website at www.molinahealthcare.com MCD_CO_ESIPREFDRUGQ3_0817_08/27/2017 6025633NY0417 Table of Contents Anti - Infectives....................................................................................................................................................3 Antineoplastic / Immunosuppressant Drugs ......................................................................................................12 Autonomic / Cns Drugs, Neurology / Psych ......................................................................................................17 Cardiovascular, Hypertension / Lipids...............................................................................................................34 Dermatologicals/Topical Therapy......................................................................................................................41 Diagnostics / Miscellaneous Agents ..................................................................................................................56 Ear, Nose / Throat Medications..........................................................................................................................64 Endocrine/Diabetes ............................................................................................................................................66 Gastroenterology ..............................................................................................................................................107 Immunology, Vaccines / Biotechnology..........................................................................................................118 Musculoskeletal / Rheumatology .....................................................................................................................121 Obstetrics / Gynecology...................................................................................................................................122 Ophthalmology.................................................................................................................................................127 Respiratory And Allergy ..................................................................................................................................131 Urologicals .......................................................................................................................................................146 Vitamins, Hematinics / Electrolytes.................................................................................................................148 Index.................................................................................................................................................................176 1 List of Abbreviations Brand: Brand Generic: Generic NC: NC NF: NF OTC: Over the Counter. An OTC drug is a non-prescription drug. PA: Prior Authorization. The Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescriptions. If you don’t get approval, we may not cover the drug. QL: Quantity Limit. For certain drugs, the Plan limits the amount of the drug that we will cover. ST: Step Therapy. In some cases, the Plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B. 2 Drug Name Tier PA/Step/QLL Drug Name Tier PA/Step/QLL s/OTC s/OTC Anti - Infectives LAMISIL ORAL Brand GRANULES IN Antifungal Agents PACKET amphotericin b Generic MICONAZOLE Brand AMPHOTERICIN B Brand MYCAMINE Brand (BULK) NOXAFIL ORAL Brand CANCIDAS Brand NYSTATIN Brand clotrimazole mucous Generic (BULK) POWDER membrane 1 BILLION UNIT, CRESEMBA Brand 10 BILLION UNIT, 15 BILLION UNIT, FLUCONAZOLE Brand 150 MILLION (BULK) UNIT, 2 BILLION fluconazole in Generic UNIT, 5 BILLION dextrose(iso-o) UNIT, 50 MILLION UNIT, 500 fluconazole in nacl Generic MILLION UNIT (iso-osm) nystatin oral Generic fluconazole oral Generic suspension for SODIUM Brand reconstitution CAPRYLATE fluconazole oral Generic SPORANOX ORAL Brand tablet 100 mg, 200 SOLUTION mg, 50 mg TERBINAFINE Brand fluconazole oral Generic QL (BULK) tablet 150 mg terbinafine hcl oral Generic flucytosine Generic voriconazole Generic FLUCYTOSINE Brand VORICONAZOLE Brand (BULK) (BULK) griseofulvin Generic Antivirals microsize abacavir Generic griseofulvin Generic ultramicrosize abacavir-lamivudine Generic itraconazole Generic QL abacavir- Generic lamivudine- ITRACONAZOLE Brand zidovudine (BULK) ACYCLOVIR Brand KETOCONAZOLE Brand (BULK) (BULK) POWDER ketoconazole oral Generic You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 3 Drug Name Tier PA/Step/QLL Drug Name Tier PA/Step/QLL s/OTC s/OTC acyclovir oral Generic EVOTAZ Brand capsule famciclovir Generic QL acyclovir oral Generic foscarnet Generic suspension 200 mg/5 ml FUZEON Brand SUBCUTANEOUS acyclovir oral tablet Generic RECON SOLN acyclovir sodium Generic ganciclovir sodium Generic intravenous recon soln GENVOYA Brand ACYCLOVIR, Brand IDOXURIDINE Brand MICRONIZED INTELENCE Brand (BULK) INVIRASE Brand adefovir Generic ISENTRESS Brand amantadine hcl Generic KALETRA Brand AMANTADINE Brand HCL (BULK) lamivudine Generic APTIVUS Brand lamivudine- Generic zidovudine ATRIPLA Brand LEXIVA Brand BARACLUDE Brand ORAL SOLUTION lopinavir-ritonavir Generic cidofovir Generic moderiba Generic PA COMPLERA Brand moderiba dose pack Generic PA CRIXIVAN ORAL Brand nevirapine Generic CAPSULE 200 MG, NORVIR Brand 400 MG ODEFSEY Brand DESCOVY Brand oseltamivir Generic QL didanosine Generic PREZCOBIX Brand EDURANT Brand PREZISTA Brand EMTRIVA Brand RAPIVAB Brand entecavir Generic RELENZA Brand QL EPIVIR HBV Brand DISKHALER ORAL SOLUTION RESCRIPTOR Brand EPIVIR ORAL Brand SOLUTION RETROVIR Brand INTRAVENOUS EPZICOM Brand You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 4 Drug Name Tier PA/Step/QLL Drug Name Tier PA/Step/QLL s/OTC s/OTC REYATAZ ORAL Brand VIDEX 2 GRAM Brand CAPSULE 150 MG, PEDIATRIC 200 MG, 300 MG VIRACEPT ORAL Brand REYATAZ ORAL Brand TABLET POWDER IN VIREAD Brand PACKET ZEPATIER Brand PA; QL ribasphere Generic PA ZIAGEN ORAL Brand ribasphere ribapak Generic PA SOLUTION ribavirin inhalation Generic zidovudine Generic ribavirin oral Generic PA capsule Cephalosporins ribavirin oral tablet Generic PA AVYCAZ Brand 200 mg cefaclor oral capsule Generic rimantadine Generic cefaclor oral Generic SELZENTRY Brand PA suspension for reconstitution 125 stavudine Generic mg/5 ml, 250 mg/5 STRIBILD Brand ml, 375 mg/5 ml SUSTIVA Brand cefaclor oral tablet Generic extended release 12 SYNAGIS Brand PA hr TAMIFLU ORAL Brand QL cefadroxil oral Generic SUSPENSION FOR capsule RECONSTITUTIO N cefadroxil oral Generic suspension for TECHNIVIE Brand PA; QL reconstitution 250 TIVICAY Brand mg/5 ml, 500 mg/5 ml TRIUMEQ Brand cefadroxil oral tablet Generic TRIZIVIR Brand cefazolin Generic TRUVADA Brand cefazolin in dextrose Generic TYZEKA Brand (iso-os) intravenous valacyclovir Generic QL piggyback 1 gram/50 ml, 2 gram/50 ml VALACYCLOVIR Brand (BULK) cefdinir Generic valganciclovir Generic cefditoren pivoxil Generic VEMLIDY Brand cefepime Generic You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 5 Drug Name Tier PA/Step/QLL Drug Name Tier PA/Step/QLL s/OTC s/OTC cefepime in Generic AZITHROMYCIN Brand dextrose,iso-osm (BULK) cefixime Generic clarithromycin Generic cefotaxime Generic CLARITHROMYCI Brand N (BULK) cefotetan Generic e.e.s. 400 oral tablet Generic cefoxitin Generic E.E.S. GRANULES Brand cefoxitin in dextrose, Generic iso-osm ERYPED 200 Brand cefpodoxime Generic ERYPED 400 Brand cefprozil Generic ery-tab oral Generic tablet,delayed ceftazidime Generic release (dr/ec) 250 CEFTAZIDIME Brand mg, 333 mg (BULK) ERY-TAB ORAL Brand ceftibuten Generic TABLET,DELAYE ceftriaxone in Generic D RELEASE dextrose,iso-os (DR/EC) 500 MG ceftriaxone injection Generic erythrocin (as Generic recon soln 1 gram, stearate) oral tablet 10 gram, 2 gram, 250 mg 250 mg, 500 mg ERYTHROMYCIN Brand ceftriaxone Generic (BULK) intravenous ERYTHROMYCIN Brand cefuroxime axetil Generic ESTOLATE oral tablet (BULK) cefuroxime sodium Generic ERYTHROMYCIN Brand injection recon soln ETHYLSUCCINAT 750 mg E cefuroxime sodium Generic erythromycin Generic intravenous ethylsuccinate oral suspension for cefuroxime-dextrose Generic reconstitution (iso-osm) erythromycin Generic cephalexin Generic ethylsuccinate oral ZERBAXA Brand tablet Erythromycins / Other Macrolides erythromycin oral Generic capsule,delayed azithromycin Generic release(dr/ec) You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 6 Drug Name Tier PA/Step/QLL Drug Name Tier PA/Step/QLL s/OTC s/OTC erythromycin oral Generic CHLORAMPHENI Brand tablet COL (BULK) erythromycin- Generic CHLORAMPHENI Brand sulfisoxazole COL PALMITATE Miscellaneous Antiinfectives chloramphenicol
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