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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 July 1, 2018, the Health Care Authority will make the following changes:

Change Due to the implementation of the Apple Health Preferred Drug List (PDL), a PDL that will be used by all managed care plans and the fee-for-service (FFS), the following changes have occurred:

• New drug classes have been added. This means drugs not previously on the PDL have been added with preferred and nonpreferred statuses. Some drugs also have additional prior authorization (PA) requirements.

• Many existing drug classes have a new name and may have been split into two or more drug classes.

• For existing drug classes, preferred statuses may have changed. Some drugs may have additional PA requirements that did not previously require PA.

What is the preferred drug list?

The Health Care Authority (the agency) has 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 evaluated by the Drug Use Review Board, which makes recommendations to the agency regarding the selection of the preferred drugs. The Apple Health (Medicaid) Fee-For-Service Preferred Drug List includes drug classes from the Washington Preferred Drug List (PDL) and the Apple Health Preferred Drug List, as well as additional classes and restrictions that pertain only to Fee-For-Service Medicaid clients. The Therapeutic Interchange Program (TIP) only applies to drug classes that are also included on the Washington Preferred Drug List (PDL).

(Rev. 06/27/2018) (Eff. 7/1/2018) – 1 – Apple Health Medicaid PDL

Prescription Drug Program

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

• Unless otherwise indicated, the authorization criteria is that the client must have tried and failed, or is intolerant to, at least two or more preferred drugs within the drug class unless contraindicated, not clinically appropriate, or only one drug is preferred. Drugs may have criteria that go beyond these basic criteria.

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

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

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

 Safety criteria;  Special subpopulation criteria; or  Limits based on age, gender, dose, or quantity.

• Nonpreferred Drugs - Prescription claims for nonpreferred drugs submitted to the agency are reimbursed only after authorizing criteria are met.

• Prescription claims submitted to the agency for non-preferred drugs that are subject to the Therapeutic Interchange Program (TIP) 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.

Pharmacies must contact the agency for authorization when required. To request authorization call 1-800-562-3022 or fax a Pharmacy Information Authorization form (13-835A) to 866-668- 1214.

(Rev. 06/27/2018) (Eff. 7/1/2018) – 2 – Apple Health Medicaid PDL

Prescription Drug Program

Drug Class Preferred Drugs Nonpreferred Drugs

Allergy : Generic: Generic: epinephrine (Mylan) epinephrine* Vasopressor Self- Injectables Brand: Brand: Adrenalin (epinephrine)* Adrenaclick (epinephrine)* Epipen 2-Pak (epinephrine)* Epipen-Jr 2-Pak (epinephrine)*

*PA required

Alzheimer's Drugs Generic: Generic: donepezil /ODT rivastigmine tartrate patch Client must have HBR tried and failed, or is memantine Brand: intolerant to, all memantine titration pak Aricept (donepezil) preferred products rivastigmine tartrate capsules Exelon (rivastigmine) patch before receiving a Exelon (rivastigmine) capsule nonpreferred product Namenda XR (memantine)** for the same Brand: Namenda XR Titration Pak indication. Namenda (memantine) (memantine)** Namenda Titration Pak (memantine) Namzaric (memantine- donepezil)** Razadyne /ER (galantamine)

**Not subject to DAW-1 override.

(Rev. 06/27/2018) (Eff. 7/1/2018) – 3 – Apple Health Medicaid PDL

Prescription Drug Program

Drug Class Preferred Drugs Nonpreferred Drugs

Analgesics - Opioid: Generic: Generic: Long Acting - transdermal* fentanyl 37.5mcg, 62.5mcg, Agonist morphine sulfate ER tablets* 87.5mcg* oxymorphone HCL ER* hydromorphone ER* tramadol ER tablets* levorphanol* methadone* Brand: methadose* morphine sulfate ER capsules* oxycodone ER* tramadol ER caps/ biphasic release*

Brand: Arymo ER (morphine sulfate ER)** Belbuca ()** Butrans (buprenorphine) * Conzip (tramadol ER)* Dolophine (methadone)* Duragesic (fentanyl)* Embeda (morphine-naltrexone)* Exalgo (hydromorphone HCl)* Hysingla ER (hydrocodone bitartrate)* Kadian (morphine sulfate SR)* Methadone HCl Intensol (methadone)* Morphabond ER (morphine sulfate SR)* MS Contin (morphine sulfate SA)* Nucynta ER (tapentadol HCl)* Opana ER (oxymorphone HCl)* OxyContin (oxycodone ER)* Xtampza ER (oxycodone ER)** Zohydro ER (hydrocodone bitartrate)* *PA Required *PA Required ** PA Required and not subject to DAW-1 override

(Rev. 06/27/2018) (Eff. 7/1/2018) – 4 – Apple Health Medicaid PDL

Prescription Drug Program

Drug Class Preferred Drugs Nonpreferred Drugs

Analgesics : Generic: Generic: Agents – naratriptan HCl almotriptan maleate 5-HT1 Agonists rizatriptan benzoate sumatriptan tablets frovatriptan sumatriptan injection zolmitriptan sumatriptan nasal spray Brand: Brand: Amerge (naratriptan)* Axert (almotriptan)* Frova (frovatriptan)* Imitrex tablets (sumatriptan)* Imitrex injection (sumatriptan)* Imitrex nasal spray (sumatriptan)* Maxalt /MLT (rizatriptan)* Onzetra Xsail (sumatriptan)** Relpax (eletriptan)* Sumavel DosePro (sumatriptan) Zembrace Symtouch (sumatriptan succinate)** Zomig /ZMT (zolmitriptan)*

*PA Required **Not subject to TIP or DAW-1 override. : Generic: Generic: Cephalosporins – 1st cefadroxil Generation cefazolin* Brand: cefazolin-dextrose* Daxbia (cephalexin) cephalexin Keflex (cephalexin)*

Brand: Cefadyl (cephapirin)*

*PA Required *PA Required

(Rev. 06/27/2018) (Eff. 7/1/2018) – 5 – Apple Health Medicaid PDL

Prescription Drug Program

Drug Class Preferred Drugs Nonpreferred Drugs

Antibiotics : Generic: Generic: Cephalosporins – cefaclor cefaclor ER 2nd Generation cefaclor susp* cefotetan* Brand: cefotetan-dextrose* Ceftin (cefuroxime) cefoxitin sodium* cefprozil cefuroxime tabs cefuroxime solution*

Brand: Cefotan (cefotetan)* Zinacef (cefuroxime)*

*PA Required *PA Required Antibiotics : Generic: Generic: Cephalosporins – cefdinir ceftibuten 3rd Generation cefixime cefotaxime solution* Brand: cefpodoxime Cedax ceftibuten ceftazidime* Fortaz (ceftazidime)* ceftazidime-dextrose* Suprax susp (cefixime)* ceftriaxone* ceftriaxone-dextrose*

Brand: Suprax (cefixime) Tazicef (ceftazidime)*

*PA Required *PA Required Antibiotics : Generic: Generic: Cephalosporins – 4th cefepime* Generation cefepime-dextrose* Brand: Maxipime inj (cefepime)* Brand: Maxipime IV (cefepime)*

*PA Required *PA Required

(Rev. 06/27/2018) (Eff. 7/1/2018) – 6 – Apple Health Medicaid PDL

Prescription Drug Program

Drug Class Preferred Drugs Nonpreferred Drugs

Antibiotics : Inhaled Generic: Generic: - nebu* Brand: Brand: Tobi (tobramycin)* Bethkis (tobramycin)* Kitabis pak (tobramycin)* Tobi podhaler (tobramycin)*

*PA Required *PA Required Antibiotics : Inhaled Generic: Generic: - Other Brand: Brand: Cayston (aztreonam)*

*PA Required Anticoagulants : Generic: Generic: Coumarin Anticoagulants Brand: Brand: Coumadin (warfarin)* Jantoven (warfarin) *PA Required Anticoagulants : Generic: Generic: Factor XA and Thrombin Brand: Brand: Inhibitors Eliquis/ Starter Pack (apixaban) Savaysa ( tosylate) Pradaxa (dabigatran) Xarelto (rivaroxaban) Xarelto Starter Pack (rivaroxaban)

Anticoagulants : Generic: Generic: Heparins and enoxaparin fondaparinux Heparinoid Agents heparin* heparin DCU* Brand: heparin lock flush* Arixtra (fondaparinux)* heparin-D5W* Fragmin (dalteparin) heparin-nalc* Lovenox (enoxaparin)* heparin-sodium chloride*

Brand:

*PA Required *PA Required

(Rev. 06/27/2018) (Eff. 7/1/2018) – 7 – Apple Health Medicaid PDL

Prescription Drug Program

Drug Class Preferred Drugs Nonpreferred Drugs

Anticonvulsants : Generic: Generic: AMPA Glutamate Receptor Antagonist Brand: Brand: Fycompa (perampanel)*

*PA Required Anticonvulsants : Generic: Generic: Benzodiazepines Clonazepam ODT gel* Brand: Brand: Klonipin (clonazepam)* Diastat Acudial/ Pediatric Onfi (clobazam)* (diazepam)*

*PA Required *PA Required Anticonvulsants : Generic: Generic: Carbamates felbamate* Brand: Brand: Felbatol (felbamate)*

Anticonvulsants : Generic: Generic: GABA Modulators tiagabine* vigabatrin* Brand: Gabatril (tiagabine)* Brand: Sabril Pack (vigabatrin)* Sabril tab (vigabatrin)*

*PA Required *PA Required Anticonvulsants : Generic: Generic: Hydantoins fosphenytoin* Brand: phenytoin solution* Dilantin/ Infatab/ 125 (phenytoin)* Peganone (ethotoin) Brand: Phenytek (phenytoin)* Cerebyx (fosphenytoin)*

*PA Required *PA Required

(Rev. 06/27/2018) (Eff. 7/1/2018) – 8 – Apple Health Medicaid PDL

Prescription Drug Program

Drug Class Preferred Drugs Nonpreferred Drugs

Anticonvulsants : Generic: Generic: MISC cabamazepine/ ER ODT/ starter and titration kit* lamotrigine ER* levetiracetam inj/ IV* levetiracetam tabs/ ER Brand: Aptiom (eslicarbazepine)* topiramate Banzel ()* Briviact tabs/ oral solution (brivaracetam)* Brand: Carbatrol (cabamazepine)* Briviact IV (brivaracetam)* Keppra/ XR (levetiracetam)* Epitol (cabamazepine) Lamictal (lamotrigine)* Roweepra/ XR (levetiracetam) Lyrica ()* Trokendi XR (topiramate) Mysoline (primidone)* Vimpat IV (lacosamide)* Neurontin (gabapentin)* Vimpat oral solution/ tabs Oxtellar XR (oxcarbazepine)* (lacosamide) Potiga (ezogabine)* Qudexy XR (topiramate)* Spirtam ((levetiracetam)* Tegretol/ XR (cabamazepine)* Topamax/ Sprinkle (topiramate)* Trileptal (oxcarbazepine)* Zonegran (zonisamide)*

*PA Required *PA Required Anticonvulsants : Generic: Generic: Succunimides Brand: ethosuximide*

Brand: Celontin (methsuximide)* Zarontin (ethosuximide)*

*PA Required Anticonvulsants : Generic: Generic: Valproic Acid divalproex/ DR/ ER Brand: valproic acid Depacon (valproate)* Depakene (valproate)* Brand: Depakote/ ER/ Sprinkles (divalproex)*

*PA Required (Rev. 06/27/2018) (Eff. 7/1/2018) – 9 – Apple Health Medicaid PDL

Prescription Drug Program

Drug Class Preferred Drugs Nonpreferred Drugs

Antidiabetics : Generic: Generic: Incretin Mimetics and Enhancers - Brand: Brand: Amylin Analogs SymlinPen (pramlintide acetate)*

*PA Required Antidiabetics : Generic: Generic: Incretin Mimetics and Enhancers - Brand: Brand: DPP-4 Inhibitors / Glyxambi (empagliflozin- SLGT2 Inhibitor linagliptin)* Combinations Qtern (dapagliflozin-saxagliptin)* Steglujan (empagliflozin- saxagliptin)*

*PA Required Antidiabetics : Generic: Generic: Incretin Mimetics alogliptin-pioglitazone* and Enhancers - Brand: DPP-4 Inhibitors / Brand: Oseni (alogliptin-pioglitazone)* TZD Combinations *PA Required *PA Required Antidiabetics : Generic: Generic: Incretin Mimetics alogliptin and Enhancers - Brand: alogliptin-metformin DPP-4 Inhibitors Janumet (sitagliptin-metformin HCl) Janumet XR (sitagliptin-metformin Brand: Subject to HCl SR) Jentadueto XR (linagliptin- Therapeutic Januvia (sitagliptin) metformin HCl SR) Interchange Program Jentadueto (linagliptin-metformin Kazano (alogliptin-metformin (TIP). HCl) HCl) Tradjenta (linagliptin) Kombiglyze XR (saxagliptin- metformin HCl SR) Nesina (alogliptin benzoate) Onglyza (saxagliptin)

(Rev. 06/27/2018) (Eff. 7/1/2018) – 10 – Apple Health Medicaid PDL

Prescription Drug Program

Drug Class Preferred Drugs Nonpreferred Drugs

Antidiabetics : Generic: Generic: Incretin Mimetics and Enhancers - Brand: Brand: GLP-1 Agonists / Soliqua (insulin glargine – Insulin lixisenatide)* Combinations Xultophy (insulin degludec- liraglutide)*

*PA Required

Antidiabetics : Generic: Generic: Incretin Mimetics and Enhancers - GLP-1 Agonists Brand: Brand: Subject to Bydureon/ BCISE/ Pen (exenatide) Adlyxin/ Starter Pack Therapeutic Byetta (exenatide) (lixisenatide)** Interchange Program Victoza (liraglutide injection) Bydureon (exenatide) (TIP). Ozempic (semaglutide)** Tanzeum (albiglutide) Trulicity (dulaglutide)

**Not subject to TIP or DAW-1 override Antidiabetics : Generic: Generic: Insulin - Intermediate-Acting Brand: Brand: Humulin N/ Kwikpen (insulin NPH) Novolin N/ Relion (insulin NPH)

Antidiabetics : Generic: Generic: Insulin - Long- Acting Brand: Brand: Lantus/ Solostar (insulin glargine) Basaglar Kwikpen (insulin Levemir/ Flextouch (insulin detemir) glargine)* Toujeo Solostar (insulin glargine) Tresiba Flextouch (insulin degludec)

*PA Required

(Rev. 06/27/2018) (Eff. 7/1/2018) – 11 – Apple Health Medicaid PDL

Prescription Drug Program

Drug Class Preferred Drugs Nonpreferred Drugs

Antidiabetics: Generic: Generic: Insulin - Pre-Mixed Brand: Brand: Humalog Mix/ Kwikpen (insulin Novolin/ Relion (insulin NPH lispro protamine & lispro) 50/50, isophane & regular human) 70/30 75/25, 70/30 Novolog Mix/ Flexpen (insulin aspart protamine & aspart) 70/30

Antidiabetics: Generic: Generic: Insulin – Rapid Acting Brand: Brand: Humalog/ Junior Kwikpen/ Kwikpen Admelog / Solostar (insulin lispro) (insulin lispro) Apidra/ Solostar (insulin glulisine) Novolog/ Flexpen/ Penfill (insulin Fiasp/ Flextouch (insulin aspart) aspart)

Antidiabetics: Generic: Generic: Insulin – Short Acting Brand: Brand: Humulin R/ U-500 (concentrated)/ U- Afrezza (insulin regular human)* 500 Kwikpen (insulin regular Novolin R/ Relion (insulin regular human) human) Relion R (insulin regular human)

*PA Required Antidiabetics: Generic: Generic: SGLT-2 Inhibitors Brand: Brand: Subject to Farxiga (dapaglifozin propanediol) Invokamet XR (canaglifozin – Therapeutic Invokamet (canaglifozin – metformin metformin HCl SR) Interchange Program HCl) Jardiance (empagliflozin) (TIP). Invokana (canagliflozin) Synjardy (empagliflozin-metformin Xigduo XR (dapaglifozin-metformin hcl) Client must try all HCl SR) Synjardy XR (empagliflozin- preferred drugs with metformin hcl SR)** the same route of administration before **Not subject to TIP or DAW-1 a nonpreferred drug override will be authorized unless contraindicated or not clinically appropriate. (Rev. 06/27/2018) (Eff. 7/1/2018) – 12 – Apple Health Medicaid PDL

Prescription Drug Program

Drug Class Preferred Drugs Nonpreferred Drugs

Antidiabetics: Generic immediate release: Generic: Sulfonylureas /ER/XL Subject to glyburide Therapeutic glyburide micronized Interchange Program (TIP). Brand: Brand: Amaryl (glimepiride) Client must try one Glucotrol /XL (glipizide) preferred drug with Glynase (glyburide micronized) the same route of Prandin (repaglinide) administration before Starlix (nateglinide) a nonpreferred drug will be authorized unless contraindicated or not clinically appropriate. Antidiabetics: Generic: Generic: Thiazolidinediones pioglitazone HCl (TZDs) Brand: Brand: Subject to Actos tablet (pioglitazone HCl) Therapeutic Avandia tablet (rosiglitazone Interchange Program maleate) (TIP).

Antiemetics / Generic: Generic: Antivertigo : 5-HT3 granisetron tablet/injection Receptor ondansetron tablet/ injection Brand: ondansetron solution Aloxi (palonosetron) injection Antagonists ondansetron ODT tablet Anzemet (dolasetron) Subject to tablet/injection Therapeutic Brand: Sancuso (granisetron) transdermal Interchange Program patch (TIP). Sustol (granisetron ER) Zofran (ondansetron) tablet /injection* Zofran (ondansetron) solution* Zofran ODT® (ondansetron)* Zuplenz (ondansetron oral soluble)

*PA Required

(Rev. 06/27/2018) (Eff. 7/1/2018) – 13 – Apple Health Medicaid PDL

Prescription Drug Program

Drug Class Preferred Drugs Nonpreferred Drugs

Antiemetics / Generic: Generic: Antivertigo : Other Brand: Brand: Subject to Diclegis (doxylamine-pyridoxine)* Therapeutic Interchange Program *EA Required (TIP).

Antiemetics / Generic: Generic: Antivertigo : aprepitant Substance Brand: Brand: Cinvanti (aprepitant)* P/Neurokinin 1 Emend/ Tripack (aprepitant)* (NK1) Receptor Varubi tablet (rolapitant) Antagonists Varubi emul (rolapitant)**

Subject to *PA Required Therapeutic **Not subject to TIP or DAW-1 Interchange Program override (TIP).

(Rev. 06/27/2018) (Eff. 7/1/2018) – 14 – Apple Health Medicaid PDL

Prescription Drug Program

Drug Class Preferred Drugs Nonpreferred Drugs

Antipsychotics / Generic: Generic: Antimanic Agents : aripiprazole clozapine ODT* Antipsychotics – 2nd clozapine tablet olanzapine-fluoxetine Generation olanzapine/ODT/injection paliperidone ER Brand: quetiapine / ER Abilify (aripiprazole) tablet* risperidone tablet/ODT/solution Clozaril (clozapine) tablet* ziprasidone capsules Fanapt Titration Pack (iloperidone) Brand: Fazaclo (clozapine) disintegrating Abilify Maintena (aripiprazole) tablet* Aristada (aripiprazole lauroxil) Geodon (ziprasidone HCl) Fanapt (iloperidone) tablet capsule* Geodon (ziprasidone mesylate) IM Invega (paliperidone) tablet* injection Risperdal (risperidone) tablet/M- Invega Sustenna (paliperidone) IM tab/solution* injection Seroquel / XR (quetiapine)* Invega Trinza (paliperidone) Symbyax (olanzapine-fluoxetine)* Latuda (lurasidone HCL) Zyprexa (olanzapine) IM Rexulti (brexpiprazole) injection/ tablet* Risperdal Consta (risperidone) Zyprexa Zydis (olanzapine) injection tablet* Saphris (asenapine) sublingual tablet Versacloz (clozapine) Zyprexa Relprevv (olanzapine pamoate) injection *PA Required

(Rev. 06/27/2018) (Eff. 7/1/2018) – 15 – Apple Health Medicaid PDL

Prescription Drug Program

Drug Class Preferred Drugs Nonpreferred Drugs

Antivirals: Generic: Generic: C Agents Brand: Brand: Epclusa (-velpatasvir)* Daklinza (daclatasvir)* Mavyret (glecaprevir-pibrentasvir)* Harvoni (ledipasvir-sofosbuvir)* Vosevi (sofosbuvir-velpatasvir- Olysio ()* voxilaprevir)* Sovaldi (sofosbuvir)* Technivie (ombitasvir- paritaprevir-)* Viekira Pak (paritaprevir- ritonavir-ombitasvir-dasabuvir)* Viekira XR (paritaprevir- ritonavir-ombitasvir-dasabuvir)** Zepatier (elbasvir-grazoprevir)**

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

(Rev. 06/27/2018) (Eff. 7/1/2018) – 16 – Apple Health Medicaid PDL

Prescription Drug Program

Drug Class Preferred Drugs Nonpreferred Drugs

Antivirals: HIV Generic: Generic: abacavir abacavir/lamivudine/zidovudine Brand: abacavir/lamivudine Biktarvy (bictegravir- atazanavir emtricitabine-tenofovir) didanosine Combivir (lamivudine/zidovudine)* fosamprenavir Epivir (lamivudine)* lamivudine Epzicom (abacavir/lamivudine)* lamivudine/zidovudine Juluca (dolutegravir-rilpivirine) lopinavir/ritonavir solution Kaletra sol (lopinavir/ritonavir)* / ER Lexiva tab (fosamprenavir)* stavudine Norvir (ritonavir)* tenofovir disoproxil Retrovir (zidovudine)* zidovudine/ syrup Sustiva (efavirenz)* Symfi Lo (efavirenz-lamivudine- Brand: tenofovir) Aptivus (tipranavir) Trizivir Atripla (efavirenz/emtricitab/tenofov) (abacavir/lamivudine/zidovudine)* Complera Trogarzo (ibalizumab-uiyk) (emtricitab/rilpivirine/tenofov) Videx EC (didanosine)* Crixivan () Viramune tab/ XR (nevirapine)* Descovy (emtricitabine/ tenofovir/ Viread 300 mg tab (tenofovir alafenamide) disoproxil)* Edurant (rilpivirine) Zerit (stavudine)* Emtriva (emtricitabine) Ziagen (abacavir)* Evotaz (atazanavir/cobicistat) Fuzeon (enfuvirtide) Genvoya (elvitegrav/cobic/emtricitab/tenofov) Intelence (etravirine) Invirase (saquinavir) Isentress/ HD (raltegravir) Kaletra tab (lopinavir/ritonavir) Lexiva susp (fosamprenavir) Odefsey (emtricitab/rilpivirine/tenofov)

*PA Required

(Rev. 06/27/2018) (Eff. 7/1/2018) – 17 – Apple Health Medicaid PDL

Prescription Drug Program

Drug Class Preferred Drugs Nonpreferred Drugs

Antivirals: HIV (continued) Brand: Prezcobix (darunavir/cobicistat) Prezista (darunavir) Rescriptor (delavirdine) Retrovir IV (zidovudine) Reyataz (atazanavir) Selzentry/ sol (maraviroc) Stribild (elvitegrav/cobic/emtricitab/tenofov) Tivicay (dolutegravir) Triumeq (abacavir/dolutegravir/lamivudine) Truvada (emtricitab/tenofov) Tybost (cobicistat) Videx pediatric sol (didanosine) Viracept (nelfinavir) Viramune susp (nevirapine) Viread 150mg, 200mg, 250mg tab (tenofovir disoproxil) Viread oral powder (tenofovir disoproxil)

Asthma -- Generic: Generic: Leukotriene montelukast sodium Modifiers Brand: Accolate (zafirlukast) Subject to Brand: Singulair (montelukast) Therapeutic Zyflo /CR (zileuton) Interchange Program (TIP).

Client must try all preferred drugs with the same indication before a nonpreferred drug will be authorized unless contraindicated or not clinically appropriate.

(Rev. 06/27/2018) (Eff. 7/1/2018) – 18 – Apple Health Medicaid PDL

Prescription Drug Program

Drug Class Preferred Drugs Nonpreferred Drugs

Asthma and COPD Generic: Generic: Agents: cromolyn sodium Anticholinergics ipratropium bromide ipratropium bromide/albuterol sulfate Brand:

Brand: Atrovent HFA (ipratropium bromide) Combivent Respimat (ipratropium/albuterol)

Asthma and COPD Generic: Generic: Agents: Beta Agonist - Long Brand: Acting Serevent Diskus (salmeterol)* Brand: Brovana (arformoterol)* Subject to Perforomist (formoterol fumarate) Therapeutic Arcapta Neohaler (indacaterol)* Interchange Program Striverdi (olodaterol)* (TIP). *EA required *EA required Asthma and COPD Generic: Generic: Agents: Beta albuterol tab/ ER/syrup metaproterenol Agonist - Oral terbutaline Brand: Brand: Vospire ER (albuterol)*

*PA Required Asthma and COPD Generic: Generic: Agents: Beta albuterol inhalation solution levalbuterol/ HFA Agonist - Short Acting Brand: Brand: Proair Respiclick (albuterol) Subject to Proair HFA (albuterol) Ventolin HFA (albuterol) Therapeutic Proventil HFA (albuterol) Xopenex/ HFA/ Concentrate Interchange Program (levalbuterol) (TIP).

(Rev. 06/27/2018) (Eff. 7/1/2018) – 19 – Apple Health Medicaid PDL

Prescription Drug Program

Drug Class Preferred Drugs Nonpreferred Drugs

Asthma and COPD Generic: Generic: Agents: Inhaled fluticasone-salmeterol* Brand: Combinations Advair Diskus /HFA (fluticasone- Brand: salmeterol) AirDuo/ RespiClick (fluticasone- Subject to Dulera (mometasone furoate- salmeterol)** Therapeutic formoterol fumarate) Breo Ellipta (fluticasone furoate- Interchange Program Symbicort (budesonide-formoterol) vilanterol) (TIP). Trelegy Elipta (fluticasone-

umeclidinium-vilanterol)***

*PA Required ** Not subject to TIP or DAW-1 override and PA Required ***Not subject to TIP or DAW-1 override. Asthma and COPD Generic: Generic: Agents: Inhaled budesonide Brand: Brand: Aerospan (flunisolide HFA) Subject to Flovent HFA/Diskus (fluticasone Alvesco (ciclesonide HFA) Therapeutic propionate HFA/DPI) Anoro Ellipta (umeclidnium- Interchange Program Pulmicort Flexhaler vilanterol)* (TIP). (budesonide DPI) Armonair RespiClick (fluticasone)* Arnuity Ellipta (fluticasone furoate) Asmanex HFA (mometasone furoate) Asmanex Twisthaler (mometasone furoate DPI) Bevespi Aerosphere (glycopyrrolate-formoterol fumarate)*** Pulmicort Respules (budesonide inhalation suspension)*

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

(Rev. 06/27/2018) (Eff. 7/1/2018) – 20 – Apple Health Medicaid PDL

Prescription Drug Program

Drug Class Preferred Drugs Nonpreferred Drugs

Asthma and COPD Generic: Generic: Agents: Long Acting Muscarinic Brand: Brand: Agents / Long Stiolto (tiotropium bromide- Utibron Neohaler (indacaterol- Acting Beta Agonist olodaterol)* glycopyrrolate)* Combinations Qvar/ Redihaler (beclomethasone dipropionate MDI

*EA required *EA required Asthma and COPD Generic: Generic: Agents: Long Acting Muscarinic Brand: Brand: Agents Spiriva Handihaler (tiotropium Incruse Ellipta (umeclidinium bromide) bromide)* Seebri Neohaler Subject to (glycopyrronium)* Therapeutic Spiriva Respimat (tiotropium Interchange Program bromide) (TIP). Tudorza Pressair (aclidinium)*

*EA required

Asthma and COPD Generic: Generic: Agents: Monoclonal Brand: Brand: Cinqair ()* Fasenra (benralizumab)* Nucala ()* Xolair ()*

*PA Required Generic:

Asthma and COPD Generic: Brand: Agents: Daliresp (roflumilast)* Phosphodiesterase 4 Brand:

Inhibitors

*PA required

(Rev. 06/27/2018) (Eff. 7/1/2018) – 21 – Apple Health Medicaid PDL

Prescription Drug Program

Drug Class Preferred Drugs Nonpreferred Drugs

Beta Blockers Generic: Generic: acebutolol Subject to atenolol Brand: Therapeutic betaxolol Bystolic (nebivolol) Interchange Program bisoprolol Coreg /CR () (TIP). carvedilol Corgard (nadolol) labetalol Inderal LA () metoprolol succinate ER Inderal XL (propranolol)** metoprolol tartrate InnoPran XL (propranolol) nadolol Lopressor (metoprolol tartrate) pindolol Tenormin (atenolol) propranolol/ER Toprol XL (metoprolol succinate) timolol **Not subject to TIP or DAW-1 Brand: override

Calcium Channel Generic: Generic: Blockers /CD/ER Subject to ER Therapeutic Brand: Interchange Program nifedipine ER Adalat CC (nifedipine) (TIP). ER Calan /SR () verapamil /ER Cardizem /CD/LA (diltiazem) Isoptin SR (verapamil) Brand: Norvasc (amlodipine) Procardia /XL (nifedipine) Sular (nisoldipine) Tiazac (diltiazem) Verelan /PM (verapamil) Cardiovascular Generic: Generic: Agents–

Antihyperlipidemics Brand: Brand: PCSK-9 Inhibitors Praluent (alirocumab)* Repatha (evolocumab)*

Subject to Repatha Pushtronex (evolocumab)*

Therapeutic Repatha Sureclick (evolocumab)*

Interchange Program

(TIP).

*PA required *PA required

(Rev. 06/27/2018) (Eff. 7/1/2018) – 22 – Apple Health Medicaid PDL

Prescription Drug Program

Drug Class Preferred Drugs Nonpreferred Drugs

Generic: captopril-HCTZ Generic: Cardiovascular moexipril-HCTZ amlodipine-benazepril Agents – benazepril-HCTZ Antihypertensives : Brand: enalapril-HCTZ Angiotensin Accuretic (quinapril-HCTZ)* fosinopril-HCTZ Modulators - ACE Lotensin HCT (benazepril- quinapril-HCTZ Inhibitor HCTZ)*

Combinations Lotrel (amlodipine-benazepril)* Brand: Prestalia (perindopril-amlodipine)

*PA Required Cardiovascular Generic: Generic: Agents – benazepril moexipril Antihypertensives : captopril perindopril erbumine Angiotensin enalapril quinapril Modulators - ACE fosinopril trandolapril Inhibitors lisinopril ramipril Brand: Subject to Accupril (quinapril)* Therapeutic Brand: Aceon (perindopril)* Interchange Program Altace (ramipril)* (TIP). Epaned (enalapril)** Lotensin (benazepril)* Qbrelis (lisinopril)** Prinivil (lisinopril)* Vasotec (enalapril)* Zestril (lisinopril)*

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

(Rev. 06/27/2018) (Eff. 7/1/2018) – 23 – Apple Health Medicaid PDL

Prescription Drug Program

Drug Class Preferred Drugs Nonpreferred Drugs

Cardiovascular Generic: Generic: Agents – amlodipine-valsartan amlodipine-olmesartan Antihypertensives : irbesartan-HCTZ amlodipine-valsartan-HCTZ Angiotensin losartan-HCTZ candesartan-HCTZ Modulators – olmesartan-HCTZ olmesartan-amlodipine-HCTZ Angiotensin II valsartan-HCTZ -amlodipine Receptor Blocker telmisartan-HCTZ Combinations Brand: Brand: Atacand HCT (candesartan- HCTZ)* Avalide (irbesartan-HCTZ)* Azor (amlodipine-olmesartan)* Benicar HCT (olmesartan- HCTZ)* Byvalson (nebivolol-valsartan) Diovan HCT (valsartan-HCTZ)* Edarbyclor (azilsartan- chlorthalidone) Exforge (amlodipine-valsartan)* Exforge HCT (amlodipine- valsartan-HCTZ)* Hyzaar (losartan-HCTZ)* Micardis HCT (telmisartan- HCTZ)* Tribenzor (olmesartan-amlodipine- HCTZ)* Twynsta (telmisartan- amlodipine)*

*PA Required

(Rev. 06/27/2018) (Eff. 7/1/2018) – 24 – Apple Health Medicaid PDL

Prescription Drug Program

Drug Class Preferred Drugs Nonpreferred Drugs

Cardiovascular Generic: Generic: Agents – irbesartan candesartan Antihypertensives : losartan eprosartan Angiotensin olmesartan telmisartan Modulators – valsartan Angiotensin II Brand: Receptor Blockers Brand: Atacand (candesartan)* Avapro (irbesartan)* Benicar (olmesartan)* Cozaar (losartan)* Diovan (valsartan)* Edarbi (azilsartan) Micardis (telmisartan)*

*PA Required Cardiovascular Generic: Generic: Agents – Antihypertensives : Brand: Brand: Angiotensin Tekturna HCT (-HCTZ)* Modulators – Direct Renin Inhibitor Combinations *PA Required Cardiovascular Generic: Generic: Agents – Antihypertensives : Brand: Brand: Angiotensin Tekturna (aliskiren)* Modulators – Direct Renin Inhibitor *PA Required Cardiovascular Generic: Generic: Agents – Antihypertensives : Brand: Brand: Angiotensin Entresto (sacubitril-valsartan)* Modulators – Neprilysin Inhib (ARNI) - Angiotensin II Receptor Combinations *PA Required

(Rev. 06/27/2018) (Eff. 7/1/2018) – 25 – Apple Health Medicaid PDL

Prescription Drug Program

Drug Class Preferred Drugs Nonpreferred Drugs

Cardiovascular Generic: Generic: Agents – MISC: Pulmonary Brand: Brand: – Letaris ()* Opsumit (macitentan)* Endothelin Tracleer ()* Receptor Antagonist *PA Required *PA Required Cardiovascular Generic: Generic: Agents – MISC: * Pulmonary Brand: Hypertension – Brand: Revatio (sildenafil)* PDEI Adcirca (tadalafil)*

*PA Required *PA Required Cardiovascular Generic: Generic: Agents – MISC: Pulmonary Brand: Brand: Hypertension – Uptravi (selexipag)* Prostacyclin Receptor Agonists *PA Required Cardiovascular Generic: Generic: Agents – MISC: Pulmonary Brand: Brand: Hypertension – Tyvaso (treprostinil)* Orenitram (treprostinil)* Prostaglandin Ventavis (iloprost)* Vasodilators *PA Required *PA Required Cardiovascular Generic: Generic: Agents – MISC: Pulmonary Brand: Brand: Hypertension – Adempas (riociguat)* SGC Stimulator *PA Required

(Rev. 06/27/2018) (Eff. 7/1/2018) – 26 – Apple Health Medicaid PDL

Prescription Drug Program

Drug Class Preferred Drugs Nonpreferred Drugs

Cytokine and CAM Generic: Generic: Antagonists Brand: Brand: Enbrel/ Sureclick ()* Actemra ()* Humira/ Pen/ Pediatric Arcalyst ()* ()* Cimzia ()* Cosentyx ()* Enbrel Mini (etanercept)* Entyvio ()* Ilaris (canakinumab)* Inflectra (-dyyb)* Kevzara (sarilumab)* Kineret ()* Orencia ()* Orencia Clickject (abatacept)* Otezla ()* Remicade (infliximab)* Renflexis (infliximab-abda)* Siliq (brodalumab)** Simponi ()* Simponi Aria (golimumab)* Stelara ()* Stelara IV solution (ustekinumab)** Taltz (ixekizumab)** Tremfya (guselkumab) ** Xeljanz ( citrate)* Xeljanz XR (tofacitinib citrate)**

*PA Required **PA Required and not subject to DAW-1 override *PA Required Dermatologics : Generic: Generic: Immunosuppressive * Agents - Topical Brand: Elidel ()* Brand: Protopic (tacrolimus)*

*PA Required *PA Required

(Rev. 06/27/2018) (Eff. 7/1/2018) – 27 – Apple Health Medicaid PDL

Prescription Drug Program

Drug Class Preferred Drugs Nonpreferred Drugs

Digestive Enzymes: Generic: Generic: Pancreatic Enzymes Brand: Brand: Creon (lip-prot-amyl) Pancreaze (lip-prot-amyl) Zenpep (lip-prot-amyl) Pertzye (lip-prot-amyl) Viokase (lip-prot-amyl)

Endocrine and Generic: Generic: Metabolic Agents: testosterone cypionate methyltestosterone* - testosterone enanthate testosterone inj/ pump/ topical Testosterone testosterone gel* soln* testosterone pump (Activis)* Brand: Brand: Androgel/ Pump (testosterone)* Androderm (testosterone)* Android (methyltestosterone)* Aveed (testosterone)* Axiron (testosterone)* Depo-Testosterone (testosterone cypionate)* Fortesta (testosterone)* Methitest (methyltestosterone)* Natesto (testosterone)* Striant (testosterone)* Testim (testosterone)* Testopel (testosterone)* Testred (methyltestosterone)* *PA Required Vogelxo/ Pump (testosterone)*

*PA Required

(Rev. 06/27/2018) (Eff. 7/1/2018) – 28 – Apple Health Medicaid PDL

Prescription Drug Program

Drug Class Preferred Drugs Nonpreferred Drugs

Endocrine and Generic: Generic: Metabolic Agents: Growth Brand: Brand: Genotropin/ Miniquick (somatropin)* Humatrope/ Combo Pack Norditropin/ Flexpro (somatropin)* (somatropin)* Nutropin AQ Nusprin/ Pen (somatropin)* Omnitrope (somatropin)* Saizen/ Click.Easy (somatropin)* Saizen Reconstitution Kit (somatropin)* Serostim (somatropin)* Zomacton (somatropin)* Zorbtive (somatropin)*

*PA Required *PA Required Endocrine and Generic: Generic: Metabolic Agents: medroxyprogesterone megestrol Brand: norethindrone Aygestin (norethindrone)* Crinone (progesterone)* Intrarosa ()* Brand: Makena auto-injector Makena inj (hydroxyprogesterone)* (hydroxyprogesterone)* Megace ES (megestrol)* *PA Required Prometrium (progesterone)* Provera (medroxyprogesterone)*

*PA Required

(Rev. 06/27/2018) (Eff. 7/1/2018) – 29 – Apple Health Medicaid PDL

Prescription Drug Program

Drug Class Preferred Drugs Nonpreferred Drugs

Estrogens Generic Oral: Generic Oral: tablets Oral products subject estropipate tablets Brand Oral: to Therapeutic Duavee (conjugated - Interchange Program Brand Oral: bazedoxifene)** (TIP). Enjuvia (synthetic conjugated estrogens) Transdermal products Estrace (estradiol) tablet are not subject to Menest (esterified estrogens) TIP. Premarin (conjugated equine estrogens) tablet Client must have tried and failed, or is Generic Transdermal: intolerant to, all estradiol transdermal patch preferred products (weekly) before receiving a nonpreferred product Brand Transdermal: according to the Alora (estradiol) patch (biweekly) formulation Climara (estradiol) patch (weekly) prescribed for the Divigel (estradiol) gel same indication. Elestrin (estradiol) gel Estrogel (estradiol) gel Evamist (estradiol) spray** Menostar (estradiol) patch (weekly) Minivelle (estradiol) patch (biweekly) Vivelle DOT (estradiol) patch (biweekly)

Generic Vaginal: Generic Vaginal:

Brand Vaginal: Brand Vaginal: Estring (estradiol) vaginal ring Estrace (estradiol) vaginal cream Femring (estradiol) vaginal ring Premarin (conjugated equine ) vaginal cream Vagifem (estradiol) vaginal tablets

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

(Rev. 06/27/2018) (Eff. 7/1/2018) – 30 – Apple Health Medicaid PDL

Prescription Drug Program

Drug Class Preferred Drugs Nonpreferred Drugs

Estrogen-Progestin Generic: Generic Oral: Combinations estradiol-norethindrone norethindrone acetate -ethinyl Brand Oral: Oral products subject estradiol Activella (estradiol- to Therapeutic norethindrone) Interchange Program Brand: Angeliq (estradiol-) (TIP). Femhrt Low Dose (ethinyl estradiol-norethindrone) Transdermal products Prefest (estradiol-norgestimate) are not subject to Premphase (conjugated equine TIP. estrogens-medroxyprogesterone) Prempro (conjugated equine Client must have estrogens-medroxyprogesterone) tried and failed, or is intolerant to, all Generic Transdermal: preferred products before receiving a Brand Transdermal: nonpreferred product Climara Pro (estradiol- according to the levonorgestrel) formulation Combipatch (estradiol- prescribed for the norethindrone) same indication. Gastrointestinal Generic: Generic: Agents – MISC : balsalazide mesalamine DR Inflammatory mesalamine Bowel Agents sulfasalazine Brand: Azulfidine/ En-tabs Brand: (sulfasalazine)* Apriso (mesalamine) Asacol HD (mesalamine) Canasa (mesalamine) Colazal (balsalazide)* Delzicol (mesalamine) Dipentum (olsalazine) Lialda (mesalamine) Giazo (balsalazide) Pentasa (mesalamine) Rowasa (mesalamine)* Sfrowasa (mesalamine)

*PA Required

(Rev. 06/27/2018) (Eff. 7/1/2018) – 31 – Apple Health Medicaid PDL

Prescription Drug Program

Drug Class Preferred Drugs Nonpreferred Drugs

Gastrointestinal Generic: Generic: Agents – MISC : dicyclomine alosetron* Irritable Bowel glycopyrrolate belladonna-opium Syndrome (IBS) hyoscyamine / ER/ ODT chlordiazepoxide-clidinium Agents / GI Motility Brand: Brand: Amitiza (lubiprostone)* Anaspaz (hyoscyamine) Ed-Spaz (hyoscyamine) Bentyl (dicyclomine)* Linzess (linaclotide)* Cuvposa (glycopyrrolate) Nulev (hyoscyamine) Entereg (alvimopan)* Oscimin/ SR (hyoscyamine) Levsin soln (hyoscyamine) Levsin tabs/ SL(hyoscyamine)* Librax (chlordiazepoxide- clidinium)* Lotronex (alosetron )* Movantik (naloxegol)* Relistor (methylnaltrexone)* Robinul/ forte (glycopyrrolate)* Symproic (naldemedine)* Trulance (plecanatide)* Viberzi (eluxadoline)*

*PA Required *PA Required Gastrointestinal Generic: Generic: Agents – MISC : calcium acetate lanthanum carbonate* Phosphate Binder sevelamer carbonate* Agents Brand: Calphron (calcium acetate) Brand: Phoslyra (calcium acetate) Auryxia (ferric citrate)* Renagel (sevelamer)* Eliphos (calcium acetate)* Renvela (sevelamer)* Fosrenol (lanthanum carbonate)* Velphoro (sucroferric)*

*PA Required *PA Required

(Rev. 06/27/2018) (Eff. 7/1/2018) – 32 – Apple Health Medicaid PDL

Prescription Drug Program

Drug Class Preferred Drugs Nonpreferred Drugs

Hematological Generic: Generic: Agents – MISC : anagrelide prasugrel Platelet Aggregation -dipyridamole Inhibitors Brand: clopidogrel Aggrenox (aspirin-dipyridamole dipyridamole ER)* Agrylin (anagrelide)* Brand: Durlaza (aspirin ER) Brilinta (ticagrelor) Effient (prasugrel HCl)* Kengreal (cangrelor tetrasodium) Plavix (clopidogrel bisulfate)* Yosprala (aspirin-) Zontivity (vorapaxar sulfate)

Histamine-2 Generic: Generic: Receptor Antagonist ranitidine (H2RA) famotidine Brand: nizatidine

Brand: Pepcid (famotidine) Pepcid Complete (famotidine – calcium carbonate – magnesium hydroxide) Tagamet HB (cimetidine) Zantac (ranitidine)

(Rev. 06/27/2018) (Eff. 7/1/2018) – 33 – Apple Health Medicaid PDL

Prescription Drug Program

Drug Class Preferred Drugs Nonpreferred Drugs

Insomnia Benzodiazepine receptor agonists: Benzodiazepine receptor agonists: Subject to Generic: Therapeutic zaleplon Generic: Interchange Program zolpidem eszopiclone (TIP). zolpidem ER Brand: Client must have Brand: tried and failed, or is Ambien /CR (zolpidem tartrate) intolerant to, all Edluar (zolpidem tartrate)** preferred products Intermezzo (zolpidem tartrate)** before receiving a Lunesta (eszopiclone) nonpreferred product Sonata (zaleplon) for the same Zolpimist (zolpidem tartrate)** indication. Non-benzodiazepine receptor Non-benzodiazepine receptor agonists: agonists:

Generic: Generic:

Brand: Brand: Rozerem (ramelteon)* Belsomra ()** Silenor ()***

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

(Rev. 06/27/2018) (Eff. 7/1/2018) – 34 – Apple Health Medicaid PDL

Prescription Drug Program

Drug Class Preferred Drugs Nonpreferred Drugs

Macrolides Generic: Generic: Client must have packet/suspension/tablet Brand: tried and failed, or is tablet/suspension Biaxin (clarithromycin) intolerant to, one clarithromycin SR tablet tablet/suspension preferred drug within base tablet Biaxin XL (clarithromycin) the drug class unless erythromycin EC capsule/tablet EES 400 (erythromycin contraindicated, not erythromycin ethylsuccinate ethylsuccinate) tablet clinically appropriate tablet/suspension PCE (erythromycin base) erythromycin stearate tablet Zithromax (azithromycin) powder erythromycin tablet 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) Nasal Generic: Generic: Corticosteroids budesonide OTC budesonide RX fluticasone propionate OTC/RX flunisolide RX Subject to triamcinolone acetonide OTC mometasone furoate Therapeutic triamcinolone acetonide RX Interchange Program Brand: (TIP). Brand: Beconase AQ (beclomethasone Client must have dipropionate) tried and failed, or is Flonase (fluticasone propionate) intolerant to, all Nasacort 24HR preferred products (triamcinolone acetonide) before receiving a Nasonex (mometasone furoate) nonpreferred product Omnaris (ciclesonide) for the same QNasl (beclomethasone indication. dipropionate)** Rhinocort Aqua (budesonide) Zetonna (ciclesonide)**

**Not subject to TIP or DAW-1

(Rev. 06/27/2018) (Eff. 7/1/2018) – 35 – Apple Health Medicaid PDL

Prescription Drug Program

Drug Class Preferred Drugs Nonpreferred Drugs

Newer Generic: Generic: syrup /tablet azelastine nasal spray OTC cetirizine chewable cetirizine chewable – children’s Client must have Brand: tried and failed, or is intolerant to, one levocetirizine dihydrochloride preferred drug within olopatadine the drug class unless contraindicated, not Brand: clinically appropriate Allegra (fexofenadine) Astepro (azelastine HCl nasal Subject to spray) Therapeutic Clarinex (desloratadine) Interchange Program Claritin (loratadine) (TIP). Patanase (olopatadine nasal spray) Xyzal (levocetirizine) Zyrtec (cetirizine)

(Rev. 06/27/2018) (Eff. 7/1/2018) – 36 – Apple Health Medicaid PDL

Prescription Drug Program

Drug Class Preferred Drugs Nonpreferred 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 Subject to Brand: Therapeutic indomethacin/SR Anaprox DS (naproxen Interchange Program ketoprofen /SR sodium) (TIP). ketorolac Cambia (diclofenac potassium) solution Client must try all meloxicam Celebrex (celecoxib)** preferred drugs nabumetone Daypro (oxaprozin) before a nonpreferred naproxen /EC Feldene (piroxicam) drug will be naproxen sodium /ER/SA Flector (diclofenac epolamine)* authorized unless oxaprozin Indocin (indomethacin) contraindicated or not piroxicam Mediproxen (naproxen sodium) clinically appropriate. salsalate Mobic (meloxicam) sulindac Nalfon (fenoprofen) tolmetin Naprelan (naproxen sodium ER) Naprosyn /EC/DS (naproxen) Brand: Pennsaid (diclofenac sodium) sol* Ponstel (mefenamic acid) Rexaphenac (diclofenac sodium)* Solaraze (diclofenac sodium) gel* Tivorbex (indomethacin)*** Vivlodex (meloxicam)*** Voltaren (diclofenac sodium)* Zipsor (diclofenac potassium) Zorvolex (diclofenac)**

*PA required & not subject to TIP ** Not subject to TIP *** Not subject to TIP or DAW-1 override

(Rev. 06/27/2018) (Eff. 7/1/2018) – 37 – Apple Health Medicaid PDL

Prescription Drug Program

Drug Class Preferred Drugs Nonpreferred Drugs

Opthalmic Agents : Generic: Generic: Glaucoma Agents apraclonidine brimonidine-timolol betaxolol dorzolamide brimatoprost dorzolamide-timolol cartelol latanoprost mitipranolol levobunolol pilocarpine timolol Brand: Brand: Betagan (levobunolol)* Alphagan P (brimonidine) Betopic-S (betaxolol) Azopt (brinzolamide) Cosopt (dorzolamide-timolol)* Combigan (brimonidine) Cosopt PF (dorzolamide-timolol) Simbrinza (brinzolamide- Iopidine (apraclonidine)* brimonidine) Isopto Carpine (pilocarpine)* Timoptic-XE (timolol) Istalol (timolol)* Travatan Z (travoprost) Lumigan (brimatoprost) Miochol-E (acetylcholine) Miostat (carbachol) Phospholine Iodide (echothiophate) Timoptic (timolol)* Timoptic Ocudose (timolol) Trusopt (dorzolamide)* Vyzulta (latanoprostene) Xalatan (latanoprost)* Zioptan (tafluprost)

*PA required Opthalmic Agents : Generic: Generic: Nonsteroidal Anti- diclofenac bromfenac inflammatory flurbiprofen Agents ketolorac Brand: Acular/ LS (ketolorac)* Brand: Acuvail (ketolorac) Ilevro (nepafenac) Bromsite (bromfenac) Nevanac (nepafenac) Prolensa (bromfenac)

*PA required

(Rev. 06/27/2018) (Eff. 7/1/2018) – 38 – Apple Health Medicaid PDL

Prescription Drug Program

Drug Class Preferred Drugs Nonpreferred Drugs

Opthalmic Agents : Generic: Generic: Opthalmic ciprofloxin bacitracin Antibiotics erythromyacin bacitracin-polymyxin gatifloxacin ofloxacin levofloxacin polymyxin B-trimethoprim moxifloxacin tobraycin -bacitracin-polymyxin neomycin-polymyxin-gramicidin Brand: Moxeza (moxifloxacin) Brand: Vigamox (moxifloxacin) Azasite (azithromyacin) Besivance (besifloxacin) Ciloxan ointment (ciprofloxin) Ciloxan solution (ciprofloxin)* Gentak (gentamicin) Neo-polycin (neomycin- bacitracin-polymyxin) Neosporin (neomycin-polymyxin- gramicidin)* Ocuflox (ofloxacin)* Polycin (polymyxin B- trimethoprim) Polytrim (polymyxin B- trimethoprim) Tobrex ointment (tobraycin) Tobrex solution (tobraycin)* Zymaxid (gatifloxacin)*

*PA required Opthalmic Agents : Generic: Generic: Opthalmic sodium Antibiotics - Brand: Sulfonamides Brand: Bleph-10 (sulfacetamide sodium)*

*PA required

(Rev. 06/27/2018) (Eff. 7/1/2018) – 39 – Apple Health Medicaid PDL

Prescription Drug Program

Drug Class Preferred Drugs Nonpreferred Drugs

Opthalmic Agents : Generic: Generic: Opthalmic Steriods sodium phosphate sodium phosphate - Topical prednisolone acetate Brand: Alrex (loteprednol) Brand: Flarex (fluorometholone) Durezol (difluprednate) FML/ Forte (fluorometholone) FML Liquifilm (fluorometholone)* Lotemax (loteprednol) Maxidex (dexamethasone) Omnipred (prednisolone)* Pred Forte (prednisolone)* Pred Mild (prednisolone)

*PA required Opthalmic Agents : Generic: Generic: Otic Anti-infectives neomycin-polymyxin- ciprofloxin ofloxacin Brand: Brand: Coly-Mycin S (neomyacin- Cipro HC (ciprofloxacin- colistin-HC-thonzonium) hydrocortisone) Floxin Otic (ofloxacin)* Ciprodex (ciprofloxacin- Otiprio (ciprofloxin) dexamethasone) Otovel (ciprofloxacin- fluocinolone)

*PA required Psychotherapeutic Generic: Generic: and Nuerological HCl Agents – MISC : clonidine /ER Brand: ADHD / Anti- guanfacine /ER Intuniv (guanfacine)* Narcolepsy – Non- Kapvay (clonidine)* Stimulants Brand: Strattera (atomoxetine HCl)*

*PA required

(Rev. 06/27/2018) (Eff. 7/1/2018) – 40 – Apple Health Medicaid PDL

Prescription Drug Program

Drug Class Preferred Drugs Nonpreferred Drugs

Psychotherapeutic Generic: Generic: and Neurological amphetamine-dextroamphetamine/ methamphetamine* Agents – MISC : XR ADHD / Anti- dextroamphetamine/ ER Brand: Narcolepsy – Adderall/ XR (amphetamine- Stimulants - Brand: dextroamphetamine)* Amphetamines Vyvanse (lisdexamfetamine Adzenys ER/ XR-ODT dimesylate) (amphetamine)** Desoxyn (methamphetamine)* Dexedrine tabs (dextroamphetamine) Dexedrine XR (dextroamphetamine)* Dyanavel XR (amphetamine) Evekeo (amphetamine) Mydayis (amphetamine- dextroamphetamine)** ProCentra (dextroamphetamine)*** Zenzedi (dexamphetamine)**

*PA required **Not subject to DAW-1 override ***Not subject to DAW-1 override and PA required

(Rev. 06/27/2018) (Eff. 7/1/2018) – 41 – Apple Health Medicaid PDL

Prescription Drug Program

Drug Class Preferred Drugs Nonpreferred Drugs

Psychotherapeutic Generic: Generic: and Neurological dexmethylphenidate methylphenidate ER 72 mg Agents – MISC : dexmethylphenidate XR ADHD / Anti- methylphenidate Brand: Narcolepsy – methylphenidate CD/ER/LA Concerta (methylphenidate HCl)* Stimulants - methylphenidate solution Cotempla XR-ODT Methylphenidates (methylphenidate extended Brand: release)*** Aptensio XR (methylphenidate) Daytrana (methylphenidate HCl)* Methylin (methylphenidate HCl) Focalin/ XR Metadate ER (methylphenidate HCl) (dexmethylphenidate)* Quillichew ER (methylphenidate Metadate CD (methylphenidate HCl) HCl)* Quillivant XR (methylphenidate HCl) Ritalin (methylphenidate HCl)* Ritalin LA (methylphenidate HCl)*

*PA required ***Not subject to DAW-1 override and PA required Psychotherapeutic Generic: Generic: and Neurological armodafinil* Agents – MISC : modafinil* Brand: ADHD / Anti- Nuvigil (armodafinil)* Narcolepsy – Brand: Provigil (modafinil)* Stimulants - MISC *PA required *PA required Psychotherapeutic Generic: Generic: and Neurological glatiramer Agents – MISC : Brand: Multiple Sclerosis Avonex/ Pen ( ß 1a) Brand: Agents Betaseron (interferon ß 1b) Ampyra (dalfampridine)* Copaxone (glatiramer acetate) Aubagio () Gilenya () Extavia (interferon ß 1b) Rebif/ Titration Pack (interferon ß Glatopa (glatiramer) 1a) Lemtrada () Rebif Rebidose/ Titration Pack Ocrevus ()** (interferon ß 1a) Plegridy/ Pen/ Starter Pak Tecfidera/ Starter Pack (dimethyl (peginterferon ß 1a) fumarate) Tysabri () Zinbryta ()

*PA required **EA required (Rev. 06/27/2018) (Eff. 7/1/2018) – 42 – Apple Health Medicaid PDL

Prescription Drug Program

Drug Class Preferred Drugs Nonpreferred Drugs

Psychotherapeutic Generic: Generic: and Neurological gum/ transdermal patch Agents – MISC : Brand: Smoking Brand: Nicotrol Inhaler/ NS (nicotine)* Deterrents- Nicotine Replacement Products *PA required

Overactive Generic short acting: Generic short acting: Bladder/Urinary oxybutynin chloride tablets/syrup flavoxate HCl Incontinence tolterodine tartrate trospium chloride Subject to Therapeutic Brand short acting: Brand short acting: Interchange Program Detrol (tolterodine tartrate) (TIP). Generic long acting: Client must try all Generic long acting: darifenacin hydrobromide ER preferred drugs with oxybutynin chloride ER the same route of tolterodine tartrate ER administration before trospium chloride ER a nonpreferred drug Brand long acting: will be authorized Brand long acting: Detrol LA (tolterodine tartrate) unless Ditropan XL (oxybutynin chloride) contraindicated or not Enablex (darifenacin clinically appropriate. hydrobromide) Gelnique (oxybutynin chloride) topical gel Myrbetriq (mirabegron) Oxytrol (oxybutynin chloride) Toviaz (fesoterodine fumarate) Vesicare (solifenacin succinate)

(Rev. 06/27/2018) (Eff. 7/1/2018) – 43 – Apple Health Medicaid PDL

Prescription Drug Program

Drug Class Preferred Drugs Nonpreferred Drugs

Proton Pump Generic: Generic: Inhibitors omeprazole OTC/RX magnesium (Limited to 60 days pantoprazole sodium esomeprazole strontium** duration) lansoprazole omeprazole-sodium bicarbonate Subject to rabeprazole sodium Therapeutic Interchange Program Brand: Brand: (TIP). Nexium granules (esomeprazole)+ Aciphex (rabeprazole) Protonix Pack (pantoprazole)* Dexilant (dexlansoprazole) Client must try all Nexium (esomeprazole) preferred drugs with Prevacid (lansoprazole) capsules the same route of Prevacid SoluTab (lansoprazole)* administration before Prilosec OTC (omeprazole a nonpreferred drug magnesium) tablets will be authorized Prilosec Rx (omeprazole) unless Protonix (pantoprazole) contraindicated or not Zegerid (omeprazole-sodium clinically appropriate. bicarbonate)

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

(Rev. 06/27/2018) (Eff. 7/1/2018) – 44 – Apple Health Medicaid PDL

Prescription Drug Program

Drug Class Preferred Drugs Nonpreferred Drugs

Second Generation Generic: Generic: Antidepressants bupropion HCl citalopram HBR solution bupropion SR* desvenlafaxine ER Client must have bupropion XL* duloxetine tried and failed, or is citalopram tablet escitalopram solution intolerant to, two escitalopram tablet fluoxetine HCl tablet preferred drugs fluoxetine HCl capsule/solution fluvoxamine ER within the drug class fluvoxamine tablet unless mirtazapine /ODT/soltab paroxetine ER contraindicated, not paroxetine HCl HCl solution clinically appropriate. sertraline tablet venlafaxine ER tablets venlafaxine ER capsules venlafaxine HCl Brand: Aplenzin (bupropion hydrobromide ER) Brand: Brisdelle (paroxetine mesylate)*** Celexa (citalopram) Cymbalta (duloxetine HCl) Effexor XR (venlafaxine HCl) Fetzima / Titration Pack (levomilnacipran HCl)** Forfivo XL (bupropion SR)** Khedezla (desvenlafaxine)** Lexapro (escitalopram) Paxil /CR (paroxetine HCl) Pexeva (paroxetine mesylate)** Pristiq (desvenlafaxine succinate) Prozac /Prozac Weekly (fluoxetine HCl) Remeron /SolTab (mirtazapine) Sarafem (fluoxetine)*** Trintellix (vortioxetine)** Viibryd (vilazodone) Wellbutrin SR/XL (bupropion HCl /SR/XL)* Zoloft® (sertraline)

*EA required **Not subject to DAW-1 override. ***Not subject to DAW-1 *EA required override, and PA required. **Not subject to DAW-1 override. ***Not subject to DAW-1 override, and PA required. (Rev. 06/27/2018) (Eff. 7/1/2018) – 45 – Apple Health Medicaid PDL

Prescription Drug Program

Drug Class Preferred Drugs Nonpreferred Drugs

Skeletal Muscle Generic: Generic: Relaxants carisoprodol* cyclobenzaprine + Subject to methocarbamol dantrolene Therapeutic tizanidine metaxalone Interchange Program citrate ER (TIP). Brand: Brand: Client must try all Amrix (cyclobenzaprine SR)** preferred drugs Dantrium (dantrolene) before a nonpreferred Fexmid (cyclobenzaprine) drug will be Lorzone (chlorzoxazone) authorized unless Metaxall (metaxalone) contraindicated or not Parafon Forte (chlorzoxazone) clinically appropriate. Robaxin (methocarbamol) Skelaxin (metaxalone) Soma (carisoprodol)* Zanaflex (tizanidine)

+PA required for cyclobenzaprine *PA required 7.5mg tablets **Not subject to TIP/DAW-1 override Smoking Cessation Generic: Generic: bupropion (smoking deterrent)* Brand: Brand: Zyban (bupropion smoking Chantix (varenicline)* deterrent)*

*EA required *EA required

(Rev. 06/27/2018) (Eff. 7/1/2018) – 46 – Apple Health Medicaid PDL

Prescription Drug Program

Drug Class Preferred Drugs Nonpreferred Drugs

Statin-type Generic: Generic: fluvastatin fluvastatin ER Lowering Agents pravastatin Brand: Subject to Altoprev (lovastatin SR) Therapeutic FloLipid (simvastatin) Interchange Program Brand: Lescol /XL (fluvastatin) (TIP). Livalo (pitavastatin calcium)** Mevacor (lovastatin) Client must have Pravachol (pravastatin) tried and failed, or is Zocor (simvastatin) intolerant to, one High Potency Generic: preferred drug within High Potency Generic: the drug class unless rosuvastatin* contraindicated, not High Potency Brand: clinically appropriate. High Potency Brand: Crestor (rosuvastatin)* Lipitor (atorvastatin)

*Not subject to DAW-1 override **Not subject to TIP/DAW-1 override Substance Use Generic: Generic: Disorder: Opioid naloxone Antagonists naltrexone Brand:

Brand: Narcan (naloxone) Vivitrol (naltrexone)

Substance Use Generic: Generic: Disorder: Opioid buprenorphine/naloxone buprenorphine* Partial Antagonists Brand: Brand: Suboxone (buprenorphine/naloxone) Bunavail (buprenorphine/naloxone)* Probuphine Implant Kit (buprenorphine)* Sublocade (buprenorphine)* Zubsolv (buprenorphine/naloxone)*

*PA Required

(Rev. 06/27/2018) (Eff. 7/1/2018) – 47 – Apple Health Medicaid PDL