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Program

Washington Preferred Drug List

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

Effective for dates of service on and after January 19, 2016, the Health Care Authority will make the following changes:

Drug Class Drug Name Preferred Status

Long-Acting Non-preferred, not subject to Seebri Neohaler® DAW-1 override/ TIP

Long-Acting Beta-Agonist Non-preferred, not subject to Utibron Neohaler® Combinations DAW-1 override/ TIP

Non-preferred, not subject to Long-Acting Opioids Belbuca® DAW-1 override

NSAIDS Vivlodex® Non-preferred

Drug Class Drug Name Change

NSAIDs All in drug class Removal of EA requirement

(Rev. 1/12/16)(Eff. 1/19/2016) - 1 - Washington PDL Prescription Drug Program

What is the Washington 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 (PDL). (WAC 182-530-4100)

What is the process to obtain drugs on the Washington 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 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 the Washington 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 the Washington 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.

(Rev. 1/12/16)(Eff. 1/19/2016) - 2 - Washington PDL Prescription Drug Program

HCA requires pharmacies to obtain authorization for non-preferred drugs when a therapeutic equivalent is on the Washington PDL. The following table shows the preferred and non-preferred drug in each therapeutic drug class on the Washington 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 hydrochlorothiazide, rather than benazepril AND the combination product.

(Rev. 1/12/16)(Eff. 1/19/2016) - 3 - Washington PDL Prescription Drug Program

Drug Class Preferred Drugs Non-preferred Drugs ACE Inhibitors Generic: Generic: benazepril fosinopril captopril moexipril enalapril perindopril erbumine lisinopril quinapril ramipril trandolapril

Brand: Brand: Accupril® (quinapril) Aceon® (perindopril) Altace® (ramipril) Epaned® (enalapril)** Lotensin® (benazepril) Mavik® (trandolapril) 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 memantine 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 Provider Namenda Titration Pak® Namzaric® Guide.) (memantine) (memantine/donepezil)** Razadyne® /ER (galantamine)

**Not subject to DAW-1 override.

(Rev. 1/12/16)(Eff. 1/19/2016) - 4 - Washington PDL Prescription Drug Program

Drug Class Preferred Drugs Non-preferred Drugs Antiemetics Generic: Generic: ondansetron / injection granisetron tablet/injection* ondansetron solution* ondansetron ODT tablet* Brand: Aloxi® (palonosetron) injection* Brand: Anzemet® (dolasetron) tablet/injection* Granisol® (granisetron) solution* Sancuso® (granisetron) transdermal patch** Zofran® (ondansetron) tablet /injection Zofran® (ondansetron) solution* Zofran® ODT® (ondansetron) tablet* Zuplenz® (ondansetron oral *EA required for age 18 and older soluble)**

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

(Rev. 1/12/16)(Eff. 1/19/2016) - 5 - Washington PDL Prescription Drug Program

Drug Class Preferred Drugs Non-preferred Drugs Attention Deficit/ Generic: Generic: Hyperactivity amphetamine salt combo ER Disorder amphetamine salt combo XR dextroamphetamine dexmethylphenidate dextroamphetamine SA Not subject to TIP. dexmethylphenidate XR For more information ER Brand: on TIP, see methylphenidate Adderall® (amphetamine salt Therapeutic methylphenidate CD/ER/LA/SR combo) Interchange Program Adderall XR® (amphetamine salt in the Prescription Brand: combo) Drug Program Focalin XR® Aptensio XR® (methylphenidate) Medicaid Provider (dexmethylphenidate) Concerta® (methylphenidate HCl) Guide. Intuniv™ (guanfacine) Daytrana™ (methylphenidate HCl) Strattera® ( HCl) transdermal patch EA is required for Vyvanse™ (lisdexamfetamine Dexedrine® (d-amphetamine) stimulants prescribed dimesylate) Evekeo® (amphetamine)** for ADD/ADHD Focalin® (dexmethylphenidate) diagnosis for adults) Kapvay® (clonidine) Metadate CD™ (methylphenidate HCl) Metadate ER™ (methylphenidate HCl) Methylin® (methylphenidate HCl) chewable/solution ProCentra® (d-amphetamine) sol Quillivant® XR (methylphenidate HCl) Ritalin® (methylphenidate HCl) Ritalin LA® (methylphenidate HCl) Ritalin SR® (methylphenidate HCl)

**Not subject to DAW-1 override.

(Rev. 1/12/16)(Eff. 1/19/2016) - 6 - Washington PDL Prescription Drug Program

Drug Class Preferred Drugs Non-preferred Drugs Atypical Generic: Generic: Antipsychotic Drugs tablet / ODT Brand: Not subject to TIP. /ODT/injection Aristada® (aripiprazole For more information ER lauroxil)** on TIP, see Clozaril® (clozapine) tablet Therapeutic tablet/ODT/solution Fazaclo® (clozapine) Interchange Program capsules disintegrating tablet in the Prescription Geodon® (ziprasidone HCl) Drug Program Brand: capsule Medicaid Provider Abilify® (aripiprazole) Invega Trinza® (paliperidone)** Guide. tablet/solution/Discmelt® Rexulti® ()** Abilify® (aripiprazole) IM Risperdal® (risperidone) tablet/M- injection tab®/solution Abilify Maintena® (aripiprazole) Seroquel® (quetiapine) tablet Fanapt® () tablet Versacloz® (clozapine)** Fanapt Titration Pack® Zyprexa® (olanzapine) tablet (iloperidone) Zyprexa Zydis® (olanzapine) Geodon® (ziprasidone mesylate) tablet IM injection Invega™ (paliperidone) tablet Invega Sustenna® (paliperidone) IM injection Latuda® ( HCL) **Not subject to TIP or DAW-1 Risperdal Consta® (risperidone) override. injection Saphris® () sublingual tablet Seroquel® XR (quetiapine) Zyprexa® (olanzapine) IM injection Zyprexa Relprevv® (olanzapine pamoate) injection

(Rev. 1/12/16)(Eff. 1/19/2016) - 7 - Washington PDL Prescription Drug Program

Drug Class Preferred Drugs Non-preferred Drugs Beta Blockers Generic: Generic: Brand: Bystolic® () Coreg® /CR® () carvedilol Corgard® () Inderal® LA () succinate ER InnoPran XL® (propranolol) metoprolol tartrate Kerlone® (betaxolol) nadolol Levatol® () Lopressor® (metoprolol tartrate) propranolol/ER Sectral® (acebutolol) Tenormin® (atenolol) Toprol XL (metoprolol succinate) Brand: Trandate® (labetalol) Zebeta® (bisoprolol) Calcium Channel Generic: Generic: Blockers /CD/ER/XR ER Brand: nifedipine ER Adalat® /CC (nifedipine) /ER Calan® /SR () verapamil /XR Cardizem® /CD/LA (diltiazem) Cartia XT® (diltiazem) Brand: Isoptin® SR (verapamil) Norvasc® (amlodipine) Procardia® /XL (nifedipine) Sular® (nisoldipine) Taztia XT® (diltiazem) Tiazac® (diltiazem) Verelan® /PM (verapamil)

(Rev. 1/12/16)(Eff. 1/19/2016) - 8 - Washington PDL Prescription Drug Program

Drug Class Preferred Drugs Non-preferred Drugs Direct-Acting Generic: Generic: Antiviral Agents for Hepatitis C Brand: Brand: Harvoni® (ledipasvir/sofosbuvir)* Daklinza® (daclatasvir)* Not subject to TIP. Sovaldi® (sofosbuvir)* Olysio® (simeprevir)* For more information Technivie® (ombitasvir/ on TIP, see paritaprevir/ritonavir)* Therapeutic Victrelis® (boceprevir)*** Interchange Program Viekira Pak™ in the Prescription (paritaprevir/ritonavir/ Drug Program ombitasvir/dasabuvir)* Medicaid Provider Guide. *PA Required **Not subject to TIP or DAW-1 *PA Required override and PA required

(Rev. 1/12/16)(Eff. 1/19/2016) - 9 - Washington PDL Prescription Drug Program

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. Cenestin® (synthetic conjugated For more information Brand Oral: estrogens) on TIP, see Duavee® (conjugated estrogens- Therapeutic bazedoxifene)** Interchange Program Enjuvia® (synthetic conjugated in the Prescription estrogens) Drug Program Estrace® (estradiol) tablet Medicaid Provider Femtrace® (estradiol) Guide. Menest® (esterified estrogens) Ortho-Est® (estropipate) Premarin® (conjugated equine estrogens) tablet

Generic Transdermal: estradiol transdermal patch (weekly)

Brand Transdermal: Alora® (estradiol) patch (biweekly) Climara® (estradiol) patch (weekly) Divigel® (estradiol) gel Elestrin™ (estradiol) gel Estrasorb® (estradiol) emulsion 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.

(Rev. 1/12/16)(Eff. 1/19/2016) - 10 - Washington PDL Prescription Drug Program

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

Generic Transdermal:

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

(Rev. 1/12/16)(Eff. 1/19/2016) - 11 - Washington PDL Prescription Drug Program

Drug Class Preferred Drugs Non-preferred Drugs Histamine-2 Generic: Generic: Receptor Antagonist ranitidine cimetidine (H2RA) famotidine Brand: nizatidine Not subject to TIP. For more information Brand: on TIP, see Axid® (nizatidine) Therapeutic Pepcid® (famotidine) Interchange Program Tagamet HB® (cimetidine) in the Prescription Zantac® (ranitidine) Drug Program Medicaid Provider Guide. Inhaled Beta- Generic short-acting nebulized: Generic short-acting nebulized: Agonists albuterol inhalation solution levalbuterol

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

Brand short-acting inhaled: Brand short-acting inhaled: ProAir™ HFA (albuterol) inhaler Maxair Autohaler™ () inhaler ProAir™ Respiclick (albuterol) inhaler** Proventil® HFA (albuterol) inhaler Ventolin® HFA (albuterol) inhaler Xopenex® HFA (levalbuterol) inhaler Brand long-acting inhaled: Serevent® Diskus® () Brand long-acting nebulized: Arcapta™ () Brovana™ () Perforomist™ ()

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

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

(Rev. 1/12/16)(Eff. 1/19/2016) - 12 - Washington PDL Prescription Drug Program

Drug Class Preferred Drugs Non-preferred Drugs Inhaled Generic: Generic: Corticosteroids budesonide Brand: Brand: Aerospan® (flunisolide HFA) Flovent® HFA/Diskus® Alvesco® (ciclesonide HFA) (fluticasone propionate HFA/DPI) Arnuity Ellipta® (fluticasone Qvar® (beclomethasone furoate)** dipropionate MDI) Asmanex HFA® (mometasone Pulmicort Respules® 1mg/2ml furoate) (budesonide inhalation Asmanex Twisthaler® suspension) (mometasone furoate DPI) Pulmicort Flexhaler® (budesonide DPI) Pulmicort Respules® (budesonide inhalation suspension)

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

(Rev. 1/12/16)(Eff. 1/19/2016) - 13 - Washington PDL Prescription Drug Program

Drug Class Preferred Drugs Non-preferred Drugs Long-Acting Generic: Generic: Anticholinergics Brand: Brand: Spiriva Handihaler® (tiotropium Incruse Ellipta® ()* bromide)** Spiriva Respimat® (tiotropium Seebri Neohaler® bromide)* (glycopyrronium)** Tudorza Pressair® (aclidinium)* *EA required *EA required **Not subject to TIP or DAW-1 Long-Acting Beta- Generic: Generic: Agonist Combinations Brand: Brand: Advair Diskus® Dulera® (mometasone furoate- /HFA®(fluticasone/salmeterol)* formoterol fumarate) * Anoro Ellipta® Stioloto® (- (umeclidnium/) + olodaterol)** Breo Ellipta® (fluticasone furoate- Symbicort® vilanterol)* (budesonide/formoterol)* Utibron Neohaler® +EA required (indacaterol/glycopyrrolate)** *PA Required

*PA Required **Not subject to TIP or DAW-1

(Rev. 1/12/16)(Eff. 1/19/2016) - 14 - Washington PDL Prescription Drug Program

Drug Class Preferred Drugs Non-preferred Drugs Long-Acting Opioids Generic: Generic: methadone* fentanyl transdermal Not subject to TIP. methadose* hydromorphone For more information morphine sulfate /CR/SA/SR levorphanol on TIP, see morphine sulfate ER oxycodone ER Therapeutic capsules/tablets Interchange Program oxymorphone HCL ER Brand: in the Prescription Avinza® (morphine sulfate ER) Drug Program Brand: Belbuca® ()** Medicaid Provider Methadone HCl Intensol® Butrans ® (buprenorphine) Guide. (methadone)* transdermal Dolophine® (methadone) * Duragesic® (fentanyl) transdermal Exalgo ® (hydromorphone HCl) Hysingla ER® (hydrocodone bitartrate)** Kadian® (morphine sulfate SR) MS Contin® (morphine sulfate SA) Nucynta ER® (tapentadol HCl)** Opana ER® (oxymorphone HCl) OxyContin® (oxycodone ER) Zohydro ER® (hydrocodone bitartrate)** *PA Required *PA Required **Not subject to DAW-1 override

(Rev. 1/12/16)(Eff. 1/19/2016) - 15 - Washington PDL Prescription Drug Program

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 Therapeutic erythromycin 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 Provider 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 mitoxantrone 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) Therapeutic Copaxone® (glatiramer acetate) Lemtrada® (alemtuzumab)** Interchange Program Gilenya® (fingolimod) Plegridy® (interferon ß 1a) in the Prescription Glatopa® (glatiramer acetate) Plegridy Pen® (interferon ß 1a) Drug Program Tecfidera® (dimethyl fumarate) Plegridy Starter Pak® (interferon Medicaid Provider Tecfidera Starter Pack® (dimethyl ß 1a) Guide. fumarate) Rebif® (interferon ß 1a) Rebif Titration Pack® (interferon ß 1a) Rebif Rebidose® (interferon ß 1a) Rebif Rebidose Titration Pack® (interferon ß 1a) Tysabri® (natalizumab)*

*PA required *PA required **Not subject to TIP or DAW-1

(Rev. 1/12/16)(Eff. 1/19/2016) - 16 - Washington PDL Prescription Drug Program

Drug Class Preferred Drugs Non-preferred Drugs Nasal Generic: Generic: Corticosteroids fluticasone propionate budesonide triamcinolone acetonide flunisolide

Brand: Brand: Beconase AQ ® (beclomethasone dipropionate) Flonase® (fluticasone propionate) 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

Brand: Brand: Eliquis® (apixaban)** Savaysa® (edoxaban tosylate)*** Pradaxa® (dabigatran)** Xarelto® (rivaroxaban)** Xarelto Starter Pack® (rivaroxaban)** **Not subject to TIP and PA required **Not subject to TIP and PA required ***Not subject to TIP or DAW-1 override and PA required

(Rev. 1/12/16)(Eff. 1/19/2016) - 17 - Washington PDL Prescription Drug Program

Drug Class Preferred Drugs Non-preferred Drugs Newer Generic: Generic: Antihistamines cetirizine syrup /tablet azelastine nasal spray (formerly Non- loratadine OTC cetirizine chewable sedating cetirizine chewable – children’s Antihistamines) Brand: desloratadine fexofenadine levocetirizine 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:

Brand: Brand: Byetta® (exenatide)* Bydureon® (exenatide)* Farxiga® (dapaglifozin Invokana® (canagliflozin)* propanediol)* Januvia® (sitagliptin)* Tradjenta® (linagliptin)* 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

(Rev. 1/12/16)(Eff. 1/19/2016) - 18 - Washington PDL Prescription Drug Program

Drug Class Preferred Drugs Non-preferred Drugs Newer Sedative/ Generic: Generic: Hypnotics zaleplon* eszopiclone zolpidem* zolpidem ER

Brand: Brand: Rozerem® (ramelteon) Ambien /CR® (zolpidem tartrate)* Belsomra® (suvorexant)** Edluar ® (zolpidem tartrate) sublingual Lunesta® (eszopiclone)* Sonata® (zaleplon)* Zolpimist (zolpidem tartrate) *EA required *EA required **Not subject to TIP or DAW-1

(Rev. 1/12/16)(Eff. 1/19/2016) - 19 - Washington PDL Prescription Drug Program

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 Cyclo-oxygenase - 2 diflunisal solution* (Cox-II) Inhibitors etodolac /ER meclofenamate sodium fenoprofen flurbiprofen Brand: ibuprofen Anaprox® /DS (naproxen indomethacin/SR sodium) ketoprofen /SR Cambia™ (diclofenac potassium) ketorolac solution*** Cataflam® (diclofenac potassium) meloxicam Celebrex® (celecoxib)** nabumetone Daypro® (oxaprozin) naproxen /EC Disalcid® (salsalate) naproxen sodium /ER/SA Feldene® (piroxicam) oxaprozin Flector® (diclofenac piroxicam epolamine)*** salsalate Indocin® (indomethacin) sulindac Mediproxen® (naproxen sodium) tolmetin Mobic® (meloxicam) Nalfon® (fenoprofen) Brand: 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) gel*** 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 chloride tablets/syrup HCl Incontinence tartrate Brand short acting: Brand short acting: Detrol® (tolterodine tartrate) Sanctura® (trospium chloride)

Generic long acting: Generic long acting: oxybutynin ER tolterodine tartrate ER Brand long acting: trospium chloride ER Detrol LA® (tolterodine tartrate) Ditropan XL® (oxybutynin Brand long acting: chloride) Enablex® ( hydrobromide) Gelnique® (oxybutynin chloride) topical gel Myrbetriq® () Oxytrol® (oxybutynin chloride) Sanctura XR® (trospium chloride) Toviaz® ( fumarate) Vesicare® ( succinate) PD4I Generic: Generic: Phosphodiesterase – 4 Inhibitors Brand: Brand: Daliresp® (roflumilast)*

*EA required

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Drug Class Preferred Drugs Non-preferred Drugs Proton Pump Generic: Generic: Inhibitors omeprazole OTC/RX esomprazole magnesium (Limited to 90 days pantoprazole sodium esomeprazole strontium** duration) lansoprazole Brand: omeprazole/sodium bicarbonate Nexium® granules rabeprazole sodium (esomeprazole)+ Protonix Pack® (pantoprazole)* Brand: Aciphex® (rabeprazole) Dexilant® (dexlansoprazole) Nexium® (esomeprazole) Prevacid® (lansoprazole) capsules Prevacid® SoluTab™ (lansoprazole)* Prilosec OTC® (omeprazole magnesium) tablets Prilosec® Rx (omeprazole) Protonix® (pantoprazole) Zegerid® (omeprazole sodium bicarbonate) *EA required + Preferred only for children ages *EA required 17 and younger **Not subject to TIP or DAW-1 override.

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Drug Class Preferred Drugs Non-preferred Drugs Second Generation Generic: Generic: budeprion SR* duloxetine bupropion HCl duloxetine EC** Not subject to TIP. bupropion SR* fluvoxamine ER For more information bupropion XL* on TIP, see citalopram Therapeutic escitalopram Brand: Interchange Program fluoxetine HCl Aplenzin® (bupropion in the Prescription fluvoxamine hydrobromide ER) Drug Program /ODT/soltab Brintellix® (vortioxetine)** Medicaid Provider HCl / ER Brisdelle® (paroxetine Guide. sertraline mesylate)** venlafaxine ER capsules/tablets Celexa® (citalopram) venlafaxine HCl Cymbalta® (duloxetine HCl) Desvenlafaxine ER® (desvenlafaxine) Brand: Effexor® XR (venlafaxine HCl) Fetzima® (levomilnacipran HCl)** Fetzima® Titration Pack (levomilnacipran HCl)** Forfivo® XL (bupropion SR)** Irenka® (duloxetine EC)** 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)** Viibryd® (vilazodone) Wellbutrin® (bupropion HCl) Wellbutrin® /SR/XL (bupropion HCl /SR/XL)* Zoloft® (sertraline) *EA required

*EA required **Not subject to DAW-1 override.

(Rev. 1/12/16)(Eff. 1/19/2016) - 23 - Washington PDL Prescription Drug Program

Drug Class Preferred Drugs Non-preferred Drugs Skeletal Muscle Generic: Generic: Relaxants carisoprodol* methocarbamol dantrolene metaxalone citrate ER Brand: Brand: Amrix® (cyclobenzaprine) Dantrium® (dantrolene) Fexmid® (cyclobenzaprine) Lorzone® (chlorzoxazone) Norflex® (orphenadrine) Parafon Forte® (chlorzoxazone) Robaxin® (methocarbamol) Skelaxin® (metaxalone) Soma® (carisoprodol)* Zanaflex® (tizanidine)

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

(Rev. 1/12/16)(Eff. 1/19/2016) - 24 - Washington 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)** Therapeutic Humira Pen® (adalimumab)* Entyvio® (vedolizumab)** Interchange Program Ilaris® (canakinumab)** in the Prescription Kineret® (anakinra)* Drug Program Orencia® (abatacept)* Medicaid Provider Otezla® (apremilast)** Guide. Remicade® (infliximab)* Rituxan® (rituximab)* Simponi® (golimumab)* Stelara® (ustekinumab)* Xeljanz® (tofacitinib citrate)*

*EA required *EA required **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. 1/12/16)(Eff. 1/19/2016) - 25 - Washington PDL Prescription Drug Program

Drug Class Preferred Drugs Non-preferred Drugs Triptans Generic: Generic: rizatriptan benzoate almotriptan maleate sumatriptan tablets naratriptan HCl sumatriptan injection zolmitriptan 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) Relpax® (eletriptan) Sumavel™ DosePro™ (sumatriptan) Zecuity® (sumatriptan succinate) Zomig® /ZMT (zolmitriptan)

(Rev. 1/12/16)(Eff. 1/19/2016) - 26 - Washington PDL