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Department of Human Services Approved PDL for IOWA Medicaid Program ALPHA DRUG LIST Trusted, Reliable, Innovative

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Department of Human Services Approved PDL for IOWA Medicaid Program ALPHA DRUG LIST Trusted, Reliable, Innovative Department of Human Services Approved PDL for IOWA Medicaid Program ALPHA DRUG LIST trusted, reliable, innovative Highlighted drugs denote new changes to the Effective Date 01/01/2019 PDL since previous update Column Header Explanations: P, N, R or NR: B, G or O: P = Preferred B = Brand N = Non-Preferred G = Generic R = Recommended O = OTC NR = Non-Recommended B Drug Name Drug Category P, N, Comment or R or G NR A G Abacavir Sulfate Antiretrovirals - Rti - Nucleoside/Nucleotide Analogues P G Abacavir Sulfate-Lamivudine-Zidovudine Antiretrovirals - Combinations NR G Abacavir-lamivudine Antiretrovirals - Combinations P B ABILIFY Antipsychotics - Atypicals N PA Required B ABILIFY DISCMELT Antipsychotics - Atypicals NP PA Required B ABILIFY MAINTENA Antipsychotics - Atypicals P B ABSORICA Acne Products: Isotretinoin N PA Required B ABSTRAL Narcotics - Misc. NP PA Required G Acamprosate Calcium Alcohol Deterrents P B ACANYA Topical - Acne Preparations P PA Required G Acarbose Diabetic - Alphaglucosidase P B ACCOLATE Antiasthmatic - Leukotriene Receptor Antagonists NP B ACCUPRIL ACE Inhibitors NP B ACCURETIC ACE and Thiazide Combo's NP G Acebutolol HCl Beta Blockers - Cardio Selective P O Acetaminophen Analgesics - Misc. P G Acetaminophen w/ Codeine Narcotics - Misc. P PA Required < 18 years of age G Acetazolamide Diuretics P G Acetic Acid Urological - Misc. P G Acetic Acid (Otic) Ear P G Acetic Acid-Aluminum Acetate Ear NP G Acetylcysteine Antiasthmatic - Mucolytics P 12/17/2018 9:18:23 AM Page 1 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR A B ACIPHEX Gi - Proton Pump Inhibitor NP PA Required G Acitretin Anti-Psoriatics - Non-Biologicals NP B ACTEMRA Anti-Inflammatories, Non-Nsaid NP PA Required B ACTIGALL Gi - Misc. NP B ACTIMMUNE Interferon Gamma NP B ACTIQ Narcotics - Misc. NP PA Required B ACTIVASE Tissue Plasminogen Activator P B ACTIVELLA Estrogen Combos NP B ACTONEL Osteoporosis NP B ACTOPLUS MET Diabetic - Thiazol / Biguanide Combo NP B ACTOPLUS MET XR Diabetic - Thiazol / Biguanide Combo NP B ACTOS Diabetic - Thiazol NP B ACULAR Op. Nsaid'S NP B ACUVAIL Op. Nsaid'S NP G Acyclovir Herpes Agents P G Acyclovir Sodium Herpes Agents P G Acyclovir SUSP Herpes Agents P G Acyclovir Topical Topical - Antivirals NP B Aczone Topical - Acne Preparations N PA Required B ADALAT CC Calcium Channel Blockers--Nifedipines NP G Adapalene cream Topical - Acne Preparations NP PA Required G Adapalene gel 0.1% Topical - Acne Preparations P PA Required G Adapalene gel 0.3% Topical - Acne Preparations P PA Required G Adapalene lotion Topical - Acne Preparations NP PA Required G adapalene solution Topical - Acne Preparations N PA Required G Adapalene/benzoyl peroxide Topical - Acne Preparations N PA Required B ADCIRCA Pulmonary Anti-Hypertensives NP Grandfather Existing Users B ADDERALL Stimulants - Amphetamines - Short Acting NP PA Required B ADDERALL XR Stimulants - Amphetamines - Long Acting NP PA Required G Adefovir Dipivoxil Hepatitis B Only NP B ADEMPAS Pulmonary Anti-Hypertensives NP PA Required B Adlyxin Diabetic - Non-Insulin Injectables N PA Required B Admelog Diabetic - Insulin N B Admelog Solostar Diabetic - Insulin Penfills N PA Required 12/17/2018 9:18:23 AM Page 2 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR A B ADOXA Tetracyclines NP PA Required B ADRENACLICK Anaphylaxis Therapy NP B ADRENALIN Anaphylaxis Therapy NP B ADVAIR Antiasthmatic - Adrenergic Combos P B ADVAIR HFA Antiasthmatic - Adrenergic Combos P B ADVATE Antihemophilia Factor VIII Agents P B ADVICOR Cholesterol - Hmg COA + Absorb Inhibitors: Low Potency Drugs/Combinations NP B Adynovate Antihemophilia Factor VIII Agents N B Adzenys er oral suspension Stimulants N PA Required B Adzenys XR ODT STIMULANTS NP PA Required B AEROSPAN Antiasthmatic - Steroid Inhalants N B AFINITOR Antineoplastics - Protein-Tyrosine Kinase Inhibitors R PA Required B Afluria 2018-19 Influenza Agents P Those 0-18 should be referred to the Vaccines for Children Program. B Afluria PF 2018-19 Influenza Agents P Those 0-18 should be referred to the Vaccines for Children Program. B Afluria Quad 2018-19 Influenza Agents P Those 0-18 should be referred to the Vaccines for Children Program. B AFREZZA Diabetic - Insulin NP B Afstyla Antihemophilia Factor VIII Agents N B AGGRENOX Platelet Aggr. Inhibitors / Combo's - Misc. P B AGRYLIN Platelet Aggr. Inhibitors / Combo's - Misc. NP B A-HYDROCORT Glucocorticoids - Mineralocorticoids P B Aimovig CGRP Inhibitors N PA Required B Airduo respiclick Antiasthmatic - Adrenergic Combos N B Ajovy CGRP Inhibitors N PA Required B AKNE-MYCIN Topical - Acne Preparations NP PA Required B AKYNZEO Antiemetic - 5-HT3 Receptor Antagonists/ Substance P Neurokinin NP PA Required B ALBENZA Anthelmintics P G Albumin, Human Electrolytes/ Nutritionals NP G Albuterol Sulfate NEBU 0.63MG/3 Antiasthmatic - Beta - Adrenergics P Preferred < 2 years of age G Albuterol Sulfate Soln Nebu 0.083% (2.5 MG/3ML) Antiasthmatic - Beta - Adrenergics P G Albuterol Sulfate Soln Nebu 0.5% (5 MG/ML) Antiasthmatic - Beta - Adrenergics P G Albuterol Sulfate Soln Nebu 1.25 MG/3ML (Base Equiv) Antiasthmatic - Beta - Adrenergics NP G Albuterol Sulfate Syrup 2 MG/5ML Antiasthmatic - Beta - Adrenergics P 12/17/2018 9:18:23 AM Page 3 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR A G Albuterol Sulfate Tab 2 MG Antiasthmatic - Beta - Adrenergics NP G Albuterol Sulfate Tab 4 MG Antiasthmatic - Beta - Adrenergics NP G Albuterol Sulfate Tab SR 12HR 4 MG Antiasthmatic - Beta - Adrenergics P G Albuterol Sulfate Tab SR 12HR 8 MG Antiasthmatic - Beta - Adrenergics P B ALCAINE Op. Misc NP G Alclometasone Dipropionate Topical - Corticosteroids - Low Potency N PA Required B ALDACTAZIDE TAB 25/25 Diuretics NP B ALDACTAZIDE TABS 50/50 Diuretics P B ALDACTONE Diuretics NP B ALDARA Topical - Genital Warts NP Payable for members who are 12 years of age and older. Quantity limitations of 12 packets/4 weeks (28 days) or a total of 48 packets/16 weeks (112 days). B ALDURAZYME Mucopolysaccharidosis P B Alecensa Antineoplastics - Protein-Tyrosine Kinase Inhibitors NR PA Required G Alendronate Sodium Osteoporosis P G Alendronate Sodium SOLN Osteoporosis NP G Alfuzosin HCl BPH P B ALINIA Antiprotozoal Agents P B ALKERAN Antineoplastics - Nitrogen Mustards R G Allopurinol Gout P G Almotriptan Migraine - Selective Serotonin Agonists (5HT)--Tabs NP PA Required B ALOCRIL Op. Antiallergics - Mast Cell Stabilizers NP G Alogliptin Diabetic - Other N PA Required G Alogliptin-metformin Diabetic - Other N PA Required G Alogliptin-pioglitazone Diabetic - Other N PA Required B ALOMIDE Op. Antiallergics - Mast Cell Stabilizers NP B ALORA Estrogens - Patches P G Alosetron Gi - Irritable Bowel Syndrome Agents NP B ALOXI Antiemetic - 5-HT3 Receptor Antagonists/ Substance P Neurokinin NP PA Required B ALPHAGAN P SOL 0.1% Op. Selective Alpha Adrenergic Agonists P B ALPHAGAN P SOLN 0.15% Op. Selective Alpha Adrenergic Agonists P B ALPHANATE Antihemophilia Factor von Willebrand Factor Agents P B ALPHANINE SD Antihemophilia Factor IX Agents P G Alprazolam Anxiolytics - Benzodiazepines P 12/17/2018 9:18:23 AM Page 4 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR A B ALPRAZOLAM INTENSOL Anxiolytics - Benzodiazepines P G Alprazolam Tab SR 24HR 0.5 MG Anxiolytics - Long Acting NP PA Required G Alprazolam Tab SR 24HR 1 MG Anxiolytics - Long Acting NP PA Required G Alprazolam Tab SR 24HR 2 MG Anxiolytics - Long Acting NP PA Required G Alprazolam Tab SR 24HR 3 MG Anxiolytics - Long Acting NP PA Required G Alprazolam Tablet Disperse Anxiolytics - Benzodiazepines NP PA Required B ALPROLIX Antihemophilia Factor IX Agents P B ALREX Op. Antiinflammatory / Steroids Ophth. P B ALTABAX Topical - Antibiotic NP B ALTACE ACE Inhibitors NP B ALTOPREV Cholesterol - Hmg COA + Absorb Inhibitors: Low Potency Drugs/Combinations NP B Alunbrig Antineoplastics - Protein-Tyrosine Kinase Inhibitors NR PA Required B ALVESCO Antiasthmatic - Steroid Inhalants NP G Amantadine HCl Cap 100 MG Anti-Parkinsonian Drugs P G Amantadine HCl Syrup 50 MG/5ML Anti-Parkinsonian Drugs P G Amantadine HCl Tab 100 MG Anti-Parkinsonian Drugs NP B AMARYL Diabetic - Oral Sulfonylureas NP B AMBIEN Sedative/Hypnotics - Non-Benzodiazepines NP PA Required B AMBIEN CR Sedative/Hypnotics - Non-Benzodiazepines NP PA Required B AMBISOME Antifungals - Assorted P PA Required > 90 days G Amcinonide Cream 0.1% Topical - Corticosteroids - High Potency N PA Required G Amcinonide LOTN Topical - Corticosteroids - High Potency N PA Required G Amcinonide OINT Topical - Corticosteroids - High Potency N PA Required B AMERGE Migraine - Selective Serotonin Agonists (5HT)--Tabs NP PA Required B Amicar Hemostatic P G Amikacin Sulfate Amino Glycosides P G Amiloride & Hydrochlorothiazide Diuretics P G Amiloride HCl Diuretics P G Amino Acid Electrolyte Infusion Electrolytes/ Nutritionals P G Amino Acid Infusion Electrolytes/ Nutritionals NP G Amino Acid Infusion SOLN 6% Electrolytes/ Nutritionals P G Aminocaproic Acid Hemostatic P G Aminophylline Antiasthmatic - Xanthines P B AMINOSYN Electrolytes/ Nutritionals P 12/17/2018 9:18:23 AM Page 5 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR A B AMINOSYN II Electrolytes/ Nutritionals P B AMINOSYN-HBC Electrolytes/ Nutritionals NP B AMINOSYN-PF Electrolytes/ Nutritionals NP G Amiodarone HCl Tab 200 MG Antiarrhythmics P G Amiodarone HCl TABS 400MG Antiarrhythmics NP B AMITIZA GI, Constipation - IBS-OIC P PA Required G Amitriptyline HCl Antidepressants - Tri-Cyclics P G Amlodipine Besylate Calcium Channel Blockers--Amlodipines
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