New Hampshire Department of Health and Human Services Fee-For-Service Medicaid Preferred Drug List (PDL) Effective Date: April 15, 2021

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New Hampshire Department of Health and Human Services Fee-for-Service Medicaid Preferred Drug List (PDL) Effective Date: April 15, 2021

TABLE OF CONTENTS

ANALGESICS – LONG ACTING OPIOIDS ...... 4 ANALGESICS – ANTI-INFLAMMATORY – NON-SELECTIVE NSAIDS ...... 4 ANALGESICS – TRAMADOL AND TRAMADOL-LIKE DERIVATIVES ...... 5 ANTIBIOTICS – SECOND GENERATION CEPHALOSPORINS ...... 5 ANTIBIOTICS – THIRD GENERATION CEPHALOSPORINS ...... 5 ANTIBIOTICS – MACROLIDES ...... 6 ANTIBIOTICS – SECOND GENERATION QUINOLONES ...... 6 ANTIBIOTICS – THIRD GENERATION QUINOLONES...... 6 ANTIBIOTICS – HERPETIC ANTIVIRALS ...... 7 ANTIBIOTICS – INHALED ...... 7 ANTIBIOTICS – VAGINAL ...... 7 ANTICONVULSANTS – CARBAMAZEPINE DERIVATIVES ...... 8 ANTICONVULSANTS – FIRST GENERATION ...... 8 ANTICONVULSANTS – OTHER ...... 9 ANTICONVULSANTS – SECOND GENERATION ...... 9 ANTIFUNGALS – ONYCHOMYCOSIS ...... 10 ANTIPARKINSON’S AGENTS – DOPAMINE RECEPTOR AGONISTS ...... 10 ANTIVIRALS – TREATMENT/PROPHYLAXIS OF INFLUENZA ...... 10 BEHAVIORAL HEALTH – ATYPICAL ANTIPSYCHOTICS AND COMBOS ...... 11 BEHAVIORAL HEALTH – ALZHEIMER’S AGENTS ...... 12 BEHAVIORAL HEALTH – NOVEL ANTIDEPRESSANTS ...... 12 BEHAVIORAL HEALTH – ANXIOLYTICS ...... 13 BEHAVIORAL HEALTH – SEROTONIN REUPTAKE INHIBITORS AND COMBOS ...... 13 BEHAVIORAL HEALTH – SEDATIVE HYPNOTICS ...... 14 BEHAVIORAL HEALTH – ANTIHYPERKINESIS ...... 15 CARDIOVASCULAR – ACE INHIBITORS AND COMBINATIONS ...... 16 CARDIOVASCULAR – ANGIOTENSIN II RECEPTOR BLOCKERS AND COMBINATIONS ...... 17 CARDIOVASCULAR – ANTIANGINAL AND ANTI-ISCHEMIC ...... 17

CARDIOVASCULAR – BETA-BLOCKERS AND COMBINATION ...... 18 CARDIOVASCULAR – CALCIUM CHANNEL BLOCKERS (DHP) ...... 19 CARDIOVASCULAR – CALCIUM CHANNEL BLOCKERS (NON-DHP) AND COMBINATIONS ...... 19 CARDIOVASCULAR – CHOLESTEROL ABSORPTION INHIBITORS AND COMBINATIONS ...... 19 CARDIOVASCULAR – STATINS AND COMBINATIONS ...... 20 CARDIOVASCULAR – HIGH POTENCY STATINS AND COMBINATIONS ...... 20 CARDIOVASCULAR – TRIGLYCERIDE LOWERING AGENTS ...... 20 CARDIOVASCULAR – PLATELET INHIBITORS ...... 21 CARDIOVASCULAR – NIACIN DERIVATIVES ...... 21 CARDIOVASCULAR – ORAL PULMONARY HYPERTENSION AGENTS ...... 22 CENTRAL NERVOUS SYSTEM – TRIPTANS ...... 22 CENTRAL NERVOUS SYSTEM – CALCITONIN GENE-RELATED PEPTIDE INHIBITORS – MIGRAINE AND CLUSTER HEADACHE PREVENTION ...... 22 CENTRAL NERVOUS SYSTEM – MULTIPLE SCLEROSIS ...... 23 CENTRAL NERVOUS SYSTEM – MOVEMENT DISORDERS ...... 23 ENDOCRINOLOGY – ALPHA-GLUCOSIDASE INHIBITORS ...... 24 ENDOCRINOLOGY – BIGUANIDES AND COMBOS ...... 24 ENDOCRINOLOGY – DIPEPTIDYL PEPTIDASE-4 (DPP4) INHIBITORS AND COMBINATIONS ...... 25 ENDOCRINOLOGY – GLUCAGON AGENTS ...... 25 ENDOCRINOLOGY – GLUCAGON-LIKE PEPTIDE-1 (GLP-1) AGONISTS AND COMBINATIONS ...... 26 ENDOCRINOLOGY – GROWTH HORMONE ...... 26 ENDOCRINOLOGY – INSULINS ...... 27 ENDOCRINOLOGY – INSULINS (CONTINUED) ...... 28 ENDOCRINOLOGY – MEGLITINIDES ...... 28 ENDOCRINOLOGY – POTASSIUM BINDERS ...... 28 ENDOCRINOLOGY – SODIUM GLUCOSE CO-TRANSPORTER 2 INHIBITOR AND COMBINATIONS ...... 29 ENDOCRINOLOGY – THIAZOLIDINEDIONES AND COMBINATIONS ...... 29 ENDOCRINOLOGY – 2ND GENERATION SULFONYLUREAS AND COMBINATIONS ...... 29 GASTROINTESTINAL – ANTIEMETICS*** ...... 30 GASTROINTESTINAL – BOWEL DISORDERS/GI MOTILITY, CHRONIC ...... 30 GASTROINTESTINAL – HEPATITIS C AGENTS ...... 31 GASTROINTESTINAL – PROTON PUMP INHIBITORS AND COMBINATIONS*** ...... 31 GASTROINTESTINAL – ULCERATIVE COLITIS ...... 32 GENITOURINARY/RENAL – ALPHA BLOCKERS FOR BENIGN PROSTATIC HYPERPLASIA ...... 33 GENITOURINARY/RENAL – ANDROGEN HORMONE INHIBITORS...... 33 GENITOURINARY/RENAL – ELECTROLYTE DEPLETERS ...... 33 GENITOURINARY/RENAL – URINARY ANTISPASMODICS ...... 34 HEMATOLOGIC – ANTICOAGULANTS ...... 34 HEMATOLOGIC – HEMATOPOIETIC AGENTS ...... 34 HIV/AIDS – ORAL PRODUCTS ...... 35 IMMUNOLOGIC – SYSTEMIC IMMUNOMODULATORS ...... 36

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MISCELLANEOUS – PANCREATIC ENZYMES ...... 37 MISCELLANEOUS – SKELETAL MUSCLE RELAXANTS ...... 37 MISCELLANEOUS – SMOKING CESSATION ...... 37 MISCELLANEOUS – TOPICAL ANDROGENIC AGENTS ...... 38 OPHTHALMIC/GLAUCOMA – ALPHA 2 ADRENERGIC AGENTS ...... 38 OPHTHALMIC/GLAUCOMA – BETA BLOCKER AGENTS ...... 38 OPHTHALMIC/GLAUCOMA – CARBONIC ANHYDRASE INHIBITORS ...... 39 OPHTHALMIC/GLAUCOMA – PROSTAGLANDIN AGONISTS ...... 39 OPHTHALMIC/GLAUCOMA – RHO KINASE INHIBITOR ...... 39 OPHTHALMIC/ANTIHISTAMINES – ANTIHISTAMINES ...... 39 OPHTHALMIC/ANTIBIOTIC – QUINOLONES ...... 40 OPHTHALMIC – NONSTEROIDAL ANTIINFLAMMATORY ...... 40 OPIATE DEPENDENCE TREATMENT**...... 40 OSTEOPOROSIS – BISPHOSPHONATES ...... 41 OSTEOPOROSIS – NASAL CALCITONINS ...... 41 OTIC/ANTIBIOTIC – QUINOLONES AND COMBINATIONS ...... 41 PROGESTATIONAL AGENTS TO PREVENT PRETERM BIRTH ...... 41 RESPIRATORY – CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) ...... 42 RESPIRATORY – LEUKOTRIENE MODIFIERS ...... 42 RESPIRATORY – SHORT ACTING BETA ADRENERGICS AND COMBINATIONS – INHALERS/NEBS ...... 43 RESPIRATORY – LONG ACTING BETA ADRENERGICS AND COMBINATIONS – INHALERS/NEBS ...... 43 RESPIRATORY – INHALED CORTICOSTEROIDS ...... 44 RESPIRATORY – INHALED CORTICOSTEROIDS ADRENERGIC AND COMBINATIONS ...... 44 RESPIRATORY – NASAL ANTIHISTAMINES ...... 44 RESPIRATORY – NASAL CORTICOSTEROIDS*** ...... 45 RESPIRATORY – LOW SEDATING ANTIHISTAMINES AND COMBINATIONS ...... 45 SELF INJECTION EPINEPHRINE*** ...... 45 TOPICAL – ANTIPARASITICS ...... 46 TOPICAL – STEROIDS ...... 46 TOPICAL – STEROIDS (CONTINUED) ...... 47 TOPICAL – TOPICAL AGENTS FOR PSORIASIS ...... 48 TOPICAL – TOPICAL COMBINATION BENZOYL PEROXIDE AND CLINDAMYCIN PRODUCTS ...... 48 TOPICAL – ATOPIC DERMATITIS ...... 48 TOPICAL – TOPICAL RETINOIDS ...... 49 TOPICAL – TOPICAL ANTIVIRALS ...... 49 TOPICAL – TOPICAL ANTIBIOTICS ...... 50 UTERINE DISORDER TREATMENTS ...... 50

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* Indicates a generic is available without PA. ** Indicates when additional Prior Approval is required for the therapeutic class, even when using a preferred product. *** Indicates when quantity limits apply. This list may not include all available formulations listed specifically by name.

ANALGESICS – LONG ACTING OPIOIDS

PREFERRED** NON-PREFERRED**  buprenorphine patch (generic for Butrans®)  Arymo ER®  fentanyl patch (generic for Duragesic®)  Belbuca®  hydrocodone bitartrate ER (generic for Zohydro ER®)  Butrans®  hydromorphone ER (generic for Exalgo®)  Duragesic®  morphine ER (generic for Avinza®, Kadian®)  Hysingla ER®  morphine sulfate SA (generic MS Contin®)  Kadian®  oramorph SA (generic for MS Contin®)  Morphabond ER™  oxycodone SA  MS Contin®  oxymorphone ER (generic for Opana ER®)  Oxycontin®***  Xtampza ER®  Zohydro ER® Trial and failure of 2 Preferred products required prior to Non-Preferred products.

ANALGESICS – ANTI-INFLAMMATORY – NON-SELECTIVE NSAIDS

PREFERRED** NON-PREFERRED**  celecoxib (generic for Celebrex®)  Celebrex®  meloxicam Tab (generic for Mobic®)  Mobic Tab  naproxen-esomeprazole Tab (generic for Vimovo®)  QMIIZ® ODT  Vimovo®  Vivlodex® Trial and failure of 2 Preferred products required prior to Non-Preferred products.

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ANALGESICS – TRAMADOL AND TRAMADOL-LIKE DERIVATIVES

PREFERRED NON-PREFERRED  tramadol (generic for Ultram®)  ConZip®  tramadol/acetaminophen (generic for Ultracet®)  Nucynta®  tramadol ER (generic for Ryzolt ER®, Ultram ER®)**  Nucynta ER®**  Ultracet®*  Ultram®* Trial and failure of 1 Preferred product required prior to Non-Preferred products.

ANTIBIOTICS – SECOND GENERATION CEPHALOSPORINS

PREFERRED NON-PREFERRED  cefaclor caps  cefaclor ER tabs  cefaclor Susp (generic for Ceclor®)  cefprozil susp/tabs (generic for Cefzil Susp/Tabs®)  cefuroxime (generic for Ceftin®) Trial and failure of 2 Preferred products required prior to Non-Preferred products.

ANTIBIOTICS – THIRD GENERATION CEPHALOSPORINS

PREFERRED NON-PREFERRED  cefdinir cap/susp (generic for Omnicef cap/susp®)  Suprax cap*/chew ®  cefixime cap/susp (generic for Suprax®)  Suprax susp®*  cefpodoxime (generic for Vantin®) Trial and failure of 2 Preferred products required prior to Non-Preferred products.

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ANTIBIOTICS – MACROLIDES

PREFERRED NON-PREFERRED  azithromycin (generic for Zithromax®)***  Eryped 400 susp®  clarithromycin/ER/susp (generic for Biaxin®/XL/susp)***  Ery-Tab®  E.E.S.®  Erythrocin®  Eryped 200 susp®  Zithromax®*  erythromycin base cap  erythromycin base tab (generic for E-Mycin®)  erythromycin ethylsuccinate (generic for E.E.S.®) Trial and failure of 2 Preferred products required prior to Non-Preferred products.

ANTIBIOTICS – SECOND GENERATION QUINOLONES

PREFERRED*** NON-PREFERRED***  ciprofloxacin (generic for Cipro®)  Cipro®*  Cipro susp®  ofloxacin (generic for Floxin®) Qty limits apply Trial and failure of 2 Preferred products required prior to Non-Preferred products.

ANTIBIOTICS – THIRD GENERATION QUINOLONES

PREFERRED*** NON-PREFERRED***  levofloxacin (generic for Levaquin®)  Baxdela®  moxifloxacin (generic for Avelox®)  ofloxacin (generic for Floxin®) Qty limits apply Trial and failure of 1 Preferred product required prior to Non-Preferred products.

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ANTIBIOTICS – HERPETIC ANTIVIRALS

PREFERRED NON-PREFERRED  acyclovir (generic for Zovirax®)  Sitavig®  famciclovir (generic for Famvir®)  Valtrex®*  valacyclovir (generic for Valtrex®)  Zovirax®susp* Trial and failure of 2 Preferred products required prior to Non-Preferred products.

ANTIBIOTICS – INHALED

PREFERRED NON-PREFERRED  Bethkis®  Arikayce®  Kitabis® Pak  Cayston®  tobramycin (generic for Bethkis®)  Tobi®/ podhaler  tobramycin pak/ solution Trial and failure of 2 Preferred products required prior to Non-Preferred products.

ANTIBIOTICS – VAGINAL

PREFERRED NON-PREFERRED  clindamycin  Cleocin® Cream*/Ovules  Clindesse®  Metrogel®*  metronidazole  Nuvessa™  Vandazole® Trial and failure of 2 Preferred products required prior to Non-Preferred products.

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ANTICONVULSANTS – CARBAMAZEPINE DERIVATIVES

PREFERRED NON-PREFERRED  carbamazepine chew/susp/tab/XR (generic for  Carbatrol®* Tegretol®/XR)  Equetro®  carbamazepine ER (generic for Carbatrol®)  Oxtellar XR®  Epitol®  Tegretol susp/tab/XR®*  oxcarbazepine susp (generic for Trileptal® Susp)  Trileptal® susp/tab*  oxcarbazepine tab (generic for Trileptal®) Trial and failure of 1 Preferred product required prior to Non-Preferred products

ANTICONVULSANTS – FIRST GENERATION

PREFERRED NON-PREFERRED  Celontin®  Depakote®*  Depakote Sprinkle®  Depakote ER®*  Dilantin Infatab/Chew tab®  Dilantin cap/susp®*  divalproex/ER/sprinkle (generic for  Felbatol®* Depakote®/ER/Sprinkle)  Mysoline®*  ethosuximide cap/syrup (generic for Zarontin®)  Peganone®  felbamate (generic for Felbatol®)  Phenytek®*  phenytoin cap/susp/chew (generic for  Zarontin cap/syrup®* Dilantin®/cap/susp/chew)  phenytoin (generic for Phenytek®)  primidone (generic for Mysoline®)  valproic acid cap/syrup (generic for Depakene®) Trial and failure of 2 Preferred products required prior to Non-Preferred products

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ANTICONVULSANTS – OTHER

NASAL

PREFERRED NON-PREFERRED  Valtoco®  Nayzilam® Trial and failure of 1 Preferred product required prior to Non-Preferred product

RECTAL

PREFERRED NON-PREFERRED  diazepam (generic for Diastat®)  Diastat®/Acudial™* Trial and failure of 1 Preferred product required prior to Non-Preferred product

ANTICONVULSANTS – SECOND GENERATION

PREFERRED NON-PREFERRED  clobazam (generic for Onfi®)  Aptiom®  gabapentin (generic for Neurontin®)  Banzel®*  Gabitril®  Briviact®  lamotrigine/ODT/XR (generic for Lamictal®/ODT/XR)  Diacomit®  levetiracetam/ER (generic for Keppra/XR®)  Epidiolex®  pregabalin (generic for Lyrica®) (requires additional  Fintepla® clinical PA)  Fycompa®  rufinamide susp (generic for Banzel®)  Keppra tab/sol®*  tiagabine (generic for Gabitril®)  Keppra XR®*  topiramate (generic for Topamax®)  Lamictal tab®*  topiramate ER (generic for Qudexy XR®)  Lamictal ODT®*  vigabatrin (generic for Sabril®)  Lamictal XR®*  zonisamide (generic for Zonegran®)  Lyrica® (requires additional clinical PA)/CR  Neurontin®*  Onfi®*  Qudexy XR®*  Sabril®*  Spritam®  Sympazan®  Topamax®*  Trokendi XR®  Vimpat®  Xcopri® Trial and failure of 2 Preferred products required prior to Non-Preferred products

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ANTIFUNGALS – ONYCHOMYCOSIS

PREFERRED** NON-PREFERRED**  ciclopirox (generic for Penlac®)  Jublia®  itraconazole  Kerydin® (tavaborole)  oxiconazole (generic for Oxistat®)  Lamisil®  tavaborole (generic for Kerydin®)  Luzu®  terbinafine (generic of Lamisil®)  Oxistat®  Penlac®  Sporanox® Trial and failure of 2 Preferred products required prior to Non-Preferred products.

ANTIPARKINSON’S AGENTS – DOPAMINE RECEPTOR AGONISTS

PREFERRED NON-PREFERRED  pramipexole/ER (generic for Mirapex®/ER)  Inbrija™  ropinirole/ER (generic for Requip®/XL)  Kynmobi™  Mirapex*ER®*  Neupro® Trial and failure of 1 or more Preferred products based on diagnosis required prior to Non-Preferred products

ANTIVIRALS – TREATMENT/PROPHYLAXIS OF INFLUENZA

PREFERRED NON-PREFERRED  amantadine (generic for Symmetrel®)  Flumadine tablet®*  oseltamivir (generic for Tamiflu®)  Relenza®***  rimantadine (generic for Flumadine®)  Xofluza™  Tamiflu®*** Trial and failure of 2 Preferred products required prior to Non-Preferred products.

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BEHAVIORAL HEALTH – ATYPICAL ANTIPSYCHOTICS AND COMBOS

PREFERRED NON-PREFERRED  Abilify Maintena®  Abilify®*  aripiprazole/ODT/solution (generic for  Abilify MyCite® Abilify®/DiscMelt/oral solution)  Adasuve®  Aristada®  Aristada Initio®  asenapine (generic for Saphris ®)  Caplyta®  clozapine (generic for Clozaril®)  Clozaril®*  clozapine ODT (generic for Fazaclo®)  Fanapt®  Invega Sustenna/Trinza®  Fazaclo®*  olanzapine/ODT (generic for Zyprexa®)  Geodon®/IM*  olanzapine/fluoxetine (generic for Symbyax®)  Invega®*  paliperidone (generic for Invega®)  Latuda®  quetiapine/ER (generic for Seroquel/XR®)  Nuplazid®  Risperdal Consta®***  Perseris®  risperidone/ODT (generic for Risperdal®/MT)  Rexulti®  ziprasidone (generic for Geodon®)  Risperdal®*  Saphris®*  Secuado® Transdermal System  Seroquel®/XR*  Symbyax®*  Versacloz®  Vraylar®  Zyprexa®*/IM/Relprevv/Zydis Trial and failure of 1 Preferred product required prior to Non-Preferred products

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BEHAVIORAL HEALTH – ALZHEIMER’S AGENTS

PREFERRED NON-PREFERRED  donepezil/ODT/23 mg (generic for Aricept®/ODT/23 mg)  Aricept®*  Exelon® patch  Aricept 23mg®*  galantamine/ER (generic for Razadyne®)  Namenda®/XR* (not a cholinesterase inhibitor)  memantine tab/dose pack/soln (generic for Namenda®  Namzaric® tab/dose pack/soln)  Razadyne®ER* (formerly Reminyl®)  memantine ER (generic for Namenda XR®)  rivastigmine capsule/patch (generic for Exelon® capsule/patch) Trial and failure of 2 Preferred products required prior to Non-Preferred products

BEHAVIORAL HEALTH – NOVEL ANTIDEPRESSANTS

PREFERRED NON-PREFERRED  bupropion (generic for Wellbutrin®)  Aplenzin®  bupropion SR (generic for Wellbutrin SR®)  Cymbalta®** (requires additional clinical PA)  bupropion XL (generic for Forfivo XL®)  Drizalma® Sprinkle** (requires additional clinical PA)  bupropion XL (generic for Wellbutrin XL®)  Effexor XR®*  desvenlafaxine ER (generic for Pristiq®)  Emsam®  duloxetine** (generic for Cymbalta®, Irenka™) (requires  Fetzima® additional clinical PA)  Forfivo XL®*  mirtazapine (generic for Remeron®)  Pristiq®*  mirtazapine RapDis (generic for Remeron Sol-Tabs®)  Remeron®*  nefazodone (generic for Serzone®)  Remeron Sol-Tabs®*  trazodone (generic for Desyrel®)  Spravato®  venlafaxine (generic for Effexor®)  Trintellix®  venlafaxine ER (generic for Effexor XR®/Venlafaxine XR®)  Viibryd®  Wellbutrin SR®*  Wellbutrin XL®* Trial and failure of 2 Preferred products required prior to Non-Preferred products

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BEHAVIORAL HEALTH – ANXIOLYTICS

PREFERRED NON-PREFERRED  alprazolam/XR (generic for Xanax®/XR)  Ativan®*  buspirone (generic for Buspar®)  Klonopin®*  chlordiazepoxide (generic for Librium®)  Tranxene®*  clonazepam (generic for Klonopin®)  Xanax®*  clorazepate (generic for Tranxene®)  Xanax XR®*  diazepam (generic for Valium®)  lorazepam (generic for Ativan®)  oxazepam (generic for Serax®) Trial and failure of 3 Preferred products required prior to Non-Preferred products

BEHAVIORAL HEALTH – SEROTONIN REUPTAKE INHIBITORS AND COMBOS

Note: Recipients < 12 years of age exempt from PDL in SSRI category.

PREFERRED NON-PREFERRED  citalopram (generic for Celexa®)  Brisdelle®*  escitalopram/soln (generic for Lexapro®)  Celexa®*  fluoxetine/Weekly (generic for  Lexapro tab®* Prozac®/Weekly/Sarafem®)  Paxil®/CR*  fluvoxamine/ER (generic for Luvox® CR)  Pexeva®  olanzapine/fluoxetine (generic for Symbyax®)  Prozac®*  paroxetine/ER (generic for Paxil®/Brisdelle®/CR)  Sarafem®*  sertraline (generic for Zoloft®)  Symbyax®*  Zoloft®* Trial and failure of 1 Preferred product required prior to Non-Preferred products

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BEHAVIORAL HEALTH – SEDATIVE HYPNOTICS

PREFERRED NON-PREFERRED  doxepin (generic for Silenor®)  Ambien®/CR*  estazolam (generic for Prosom®)  Belsomra®  eszopiclone (generic for Lunesta®)  Dayvigo®  flurazepam (generic for Dalmane®)  Edluar®  ramelteon (generic for Rozerem®)  Halcion®*  temazepam (generic for Restoril®)  Lunesta®*  triazolam (generic for Halcion®)  Restoril®*  zaleplon (generic for Sonata®)  Rozerem®  zolpidem/ER (generic for Ambien®/CR)  Silenor®*  zolpidem SL (generic for Intermezzo®) Trial and failure of 2 Preferred products required prior to Non-Preferred products

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BEHAVIORAL HEALTH – ANTIHYPERKINESIS

**Criteria for approval: < 21 years of age exempt from prior approval for preferred drugs.

PREFERRED** NON-PREFERRED**  Adderall® (generic)  Adhansia XR™  Adderall XR®  Adzenys XR-ODT®  amphetamine salt combo/XR (generic for Adderall®/XR)  Adzenys ® ER susp  amphetamine sulfate (generic for Evekeo®)  Cotempla XR-ODT®  Aptensio XR®  Daytrana®  atomoxetine (generic for Strattera®)  Desoxyn®  clonidine ER (generic for Kapvay®)  Dexedrine ER®  Concerta®  Dyanavel XR®  dexmethylphenidate/XR (generic for Focalin/XR®)  Evekeo®/ODT  dextroamphetamine /ER (generic for Dexedrine®/ER)  Intuniv®  dextroamphetamine soln (generic for ProCentra®)  Jornay PM®  Focalin/ XR®  Mydayis®  guanfacine ER (generic for Intuniv®)  ProCentra®  methamphetamine (generic for Desoxyn®)  Quillichew ER®  Methylin® soln  Quillivant XR®  methylphenidate CD (generic for Metadate CD®)  Ritalin®  methylphenidate chewable (generic for Methylin® chew)  Ritalin LA®  methylphenidate ER (generic for Aptensio XR®)  Strattera®  methylphenidate ER (generic for Concerta®/Ritalin LA®)  Zenzedi®  methylphenidate soln (generic for Methylin® soln)  methylphenidate/SR (generic for Ritalin/ SR®)  Relexxii®  Vyvanse® Trial and failure of 2 Preferred products required prior to Non-Preferred products

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CARDIOVASCULAR – ACE INHIBITORS AND COMBINATIONS

PREFERRED NON-PREFERRED  amlodipine/benazepril (generic for Lotrel®)  Accupril®*  benazepril (generic for Lotensin®)  Accuretic®*  benazepril/HCTZ (generic for Lotensin HCT®)  Altace®*  captopril (generic for Capoten®)  Epaned® (non-preferred for adults only)  captopril/HCTZ (generic for Capozide®)  Katerzia®  enalapril (generic for Vasotec®)  Lotensin®*/HCT  enalapril/HCTZ (generic for Vaseretic®)  Lotrel®*  fosinopril  Prestalia®  fosinopril/HCTZ  Prinivil®*  lisinopril (generic for Prinivil® and Zestril®)  Qbrelis®  lisinopril/HCTZ (generic for Prinzide® and Zestoretic®)  Tarka®*  moexipril  Vaseretic®*  perindopril (generic for Aceon®)  Vasotec®*  quinapril (generic for Accupril®)  Zestoretic®*  quinapril/HCTZ (generic for Accuretic®)  Zestril®*  ramipril (generic for Altace®)  trandolapril (generic for Mavik®)  trandolapril/verapamil (generic for Tarka®) Trial and failure of 3 Preferred products required prior to Non-Preferred products.

NH DHHS Fee-for-Service Medicaid PDL | Page 16

CARDIOVASCULAR – ANGIOTENSIN II RECEPTOR BLOCKERS AND COMBINATIONS

PREFERRED NON-PREFERRED  amlodipine/olmesartan (generic for Azor®)  Atacand®*/HCT  amlodipine/olmesartan/HCTZ (generic for Tribenzor®)  Avalide®*  amlodipine/valsartan (generic for Exforge®)  Avapro®*  amlodipine/valsartan/HCTZ  Azor®*  candesartan (generic for Atacand®)  Benicar®*/HCT*  candesartan/HCTZ (generic for Atacand HCT®)  Cozaar®*  Diovan®  Diovan HCT®*  Entresto®  Edarbi®  eprosartan (generic for Teveten®)  Edarbyclor®  irbesartan (generic for Avapro®)  Exforge®/HCT*  irbesartan/HCTZ (generic for Avalide®)  Hyzaar®*  losartan (generic for Cozaar®)  Micardis®/HCT*  losartan/HCTZ (generic for Hyzaar®)  Tribenzor®*  olmesartan (generic for Benicar®)  olmesartan/HCTZ (generic for Benicar HCT®)  telmisartan (generic for Micardis®)  telmisartan/amlodipine (generic for Twynsta)  telmisartan /HCTZ (generic for Micardis HCT®)  valsartan (generic for Diovan®)  valsartan/HCTZ (generic for Diovan HCT®) Trial and failure of 2 Preferred products required prior to Non-Preferred products.

CARDIOVASCULAR – ANTIANGINAL AND ANTI-ISCHEMIC

PREFERRED NON-PREFERRED  ranolazine ER  Ranexa®*  Trial and failure of 1 Preferred product required prior to Non-Preferred products.

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CARDIOVASCULAR – BETA-BLOCKERS AND COMBINATION

PREFERRED NON-PREFERRED  acebutolol (generic for Sectral®)  Betapace®*  atenolol (generic for Tenormin®)  Betapace AF®*  atenolol/chlorthalidone (generic for Tenoretic®)  Bystolic®  betaxolol (generic for Kerlone®)  Coreg®/CR*  bisoprolol (generic for Zebeta®)  Corgard®  bisoprolol /HCTZ (generic for Ziac®)  Hemangeol®  carvedilol/ER (generic for Coreg®/CR)  InderalLA®*  labetalol (generic for Normodyne® and Trandate®)  Inderal XL®  metoprolol (generic for Lopressor®)  Innopran XL®  metoprolol/HCTZ (generic for Lopressor HCT®)  Kapspargo Sprinkle®  metoprolol succinate (generic for Toprol XL®)  Lopressor®*  nadolol (generic for Corgard®)  Sotylize®  nadolol/bendroflumethiazide (generic for Corzide®)  Tenoretic®*  pindolol (generic for Visken®)  Tenormin®*  propanolol (generic for Inderal®)  Toprol XL®*  propralolol ER (generic for Inderal LA®)  Ziac®*  propranolol/HCTZ (generic for Inderide®)  sotalol (generic for Betapace®)  sotalol AF (generic for Betapace AF®)  Sorine®  timolol (generic for Blocadren®) Trial and failure of 3 Preferred products required prior to Non-Preferred products.

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CARDIOVASCULAR – CALCIUM CHANNEL BLOCKERS (DHP)

PREFERRED NON-PREFERRED  amlodipine (generic for Norvasc®)  Adalat CC®*  felodipine ER (generic for Plendil®)  Katerzia®  isradipine (generic for Dynacirc®)  Norvasc®*  nicardipine (generic for Cardene®)  Nymalize®  nifedipine IR (generic for Procardia®)  Prestalia®  nifedipine SA/ER/XL (generic for Procardia XL®)  Procardia®*/XL  nimodipine (generic for Nimotop®)  Sular®  nisoldipine Trial and failure of 3 Preferred products required prior to Non-Preferred products.

CARDIOVASCULAR – CALCIUM CHANNEL BLOCKERS (NON-DHP) AND COMBINATIONS

PREFERRED NON-PREFERRED  Cartia XT®  Calan SR®*  diltiazem ER (generic for Cardizem CD®)  Cardizem®*  diltiazem HCL (generic for Cardizem®)  Cardizem CD®*  diltiazem SR (generic for Cardizem SR®)  Cardizem LA®  diltiazem XR (generic for Dilacor XR®)  Tarka®  Taztia XT®  Tiazac®  verapamil (generic for Calan®, Isoptin® and Verelan®)  Verelan®/PM*  verapamil ER (generic for Calan SR® and Isoptin SR®)  verapamil ER PM (generic for Verelan PM®) Trial and failure of 2 Preferred products required prior to Non-Preferred products.

CARDIOVASCULAR – CHOLESTEROL ABSORPTION INHIBITORS AND COMBINATIONS

PREFERRED NON-PREFERRED  ezetimibe (generic for Zetia®)  Vytorin®*  ezetimibe/simvastatin (generic for Vytorin®)  Zetia®* Trial and failure of 2 high potency statins Preferred products required prior to Non-Preferred products.

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CARDIOVASCULAR – STATINS AND COMBINATIONS

PREFERRED NON-PREFERRED  fluvastatin/ER (generic for Lescol®/XL)  Altoprev® (formerly Altocor®)  lovastatin (generic for Mevacor®)  Lescol XL®*  pravastatin (generic for Pravachol®)  Pravachol®*  Zypitamag* Trial and failure of 2 Preferred products required prior to Non-Preferred products.

CARDIOVASCULAR – HIGH POTENCY STATINS AND COMBINATIONS

PREFERRED NON-PREFERRED  amlodipine/atorvastatin (generic for Caduet®)  Caduet®*  atorvastatin (generic for Lipitor®)  Crestor®*  ezetimibe/simvastatin (generic for Vytorin®)  Ezallor Sprinkle®  rosuvastatin (generic for Crestor®)  Lipitor®*  simvastatin (generic for Zocor®)  Livalo®  Vytorin®*  Zocor®* Trial and failure of 2 Preferred products required prior to Non-Preferred products.

CARDIOVASCULAR – TRIGLYCERIDE LOWERING AGENTS

PREFERRED NON-PREFERRED  fenofibrate (generic for Antara®, Fenoglide®, Lofibra®,  Antara®* Lipofen®, Tricor®, Triglide®)  Fenoglide®*  fenofibric acid (generic for Fibricor®, Trilipix®)  Lipofen®*  gemfibrozil (generic for Lopid®)  Lopid®*  icosapent ethyl (generic for Vascepa®)  Lovaza®*  omega-3 ethyl ester (generic for Lovaza®)  Tricor®*  Trilipix®*  Vascepa®* Trial and failure of 2 high potency statins required prior to Non-Preferred products.

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CARDIOVASCULAR – PLATELET INHIBITORS

PREFERRED NON-PREFERRED  Aggrenox®  Effient®*  aspirin/dipyridamole (generic for Aggrenox®)  Plavix®*  Brilinta®  Zontivity®  clopidogrel (generic for Plavix®)  dipyridamole (generic for Persantine®)  prasugrel (generic for Effient®) Trial and failure of 2 Preferred products required prior to Non-Preferred products.

CARDIOVASCULAR – NIACIN DERIVATIVES

PREFERRED NON-PREFERRED  niacin ER  Niaspan® Trial and failure of 1 Preferred product required prior to Non-Preferred products.

NH DHHS Fee-for-Service Medicaid PDL | Page 21

CARDIOVASCULAR – ORAL PULMONARY HYPERTENSION AGENTS

PREFERRED NON-PREFERRED  ambrisentan (generic for Letairis®)  Adcirca®**  bosentan (generic for Tracleer®)  Adempas®  Letairis®  Opsumit®  sildenafil (generic for Revatio®)**  Orenitram® ER  tadalafil (generic for Adcirca®)**  Revatio®**  Tracleer®*  Uptravi® Trial and failure of 1 Preferred product required prior to Non-Preferred products.

CENTRAL NERVOUS SYSTEM – TRIPTANS

PREFERRED*** NON-PREFERRED***  almotriptan (generic for Axert®)  Amerge®*  eletriptan (generic for Relpax®)  Frova®*  frovatriptan (generic for Frova®)  Imitrex®*  naratriptan (generic for Amerge®)  Maxalt tablet/MLT®*  rizatriptan/ODT (generic for Maxalt®/MLT)  ONZETRA® Xsail®  sumatriptan (generic for Imitrex®)  Relpax®*  sumatriptan/naproxen (generic for Treximet®)  Reyvow®  zolmitriptan (generic for Zomig®)  Tosymra®  Treximet®*  Zembrace SymTouch®  Zomig®* Qty limits apply Trial and failure of 2 Preferred products required prior to Non-Preferred products

CENTRAL NERVOUS SYSTEM – CALCITONIN GENE-RELATED PEPTIDE INHIBITORS – MIGRAINE AND CLUSTER HEADACHE PREVENTION

PREFERRED**/*** NON-PREFERRED**/***  Ajovy®  Aimovig®  Emgality™  Vyepti® Qty limits apply Trial and failure of 1 Preferred product required prior to Non-Preferred products

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CENTRAL NERVOUS SYSTEM – MULTIPLE SCLEROSIS

DISEASE MODIFYING THERAPY

PREFERRED NON-PREFERRED  Avonex®***  Aubagio®  Betaseron®***  Extavia®  Copaxone®***  Lemtrada®  dimethyl fumarate DR (generic for Tecfidera®)  Mavenclad®  Gilenya®  Mayzent®  Glatopa®***  Ocrevus®  glatiramer (generic for Copaxone®)***  Plegridy®  Tecfidera®  Rebif®***  Tysabri®  Vumerity®  Zeposia® Trial and failure of 3 Preferred products required prior to Non-Preferred products

OTHER

PREFERRED NON-PREFERRED  dalfampridine ER (generic for Ampyra®)  Ampyra®* Trial and failure of 1 Preferred product required prior to Non-Preferred products

CENTRAL NERVOUS SYSTEM – MOVEMENT DISORDERS

PREFERRED** NON-PREFERRED**  Austedo®  Ingrezza®  tetrabenazine (generic for Xenazine®)  Xenazine® Trial and failure of 1 Preferred product required prior to Non-Preferred products

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ENDOCRINOLOGY – ALPHA-GLUCOSIDASE INHIBITORS

PREFERRED NON-PREFERRED  acarbose (generic for Precose®)  Glyset®*  miglitol (generic for Glyset®)  Precose®* Trial and failure of 2 Preferred products required prior to Non-Preferred products.

ENDOCRINOLOGY – BIGUANIDES AND COMBOS

PREFERRED NON-PREFERRED  alogliptin/metformin (generic for Kazano®)  ACTOplusmet®*  Janumet®  Fortamet®*  Janumet XR®  Glumetza®*  Kazano®*  Invokamet®/XR  metformin (generic for Riomet®)  Riomet®*/ER Susp  metformin (generic for Glucophage®)  Segluromet®  metformin ER (generic for Glumetza®)  Synjardy®/XR  metformin ER (generic for Fortamet®)  Trijardy XR®  metformin/glipizide (generic for Metaglip®)  Xigduo XR®  metformin/glyburide (generic for Glucovance®)  metformin XL (generic for Glucophage XR®)  pioglitazone/metformin (generic for Actoplus Met®)  repaglinide/metformin (generic for PrandiMet®) Trial and failure of 1 Preferred product required prior to Non-Preferred products.

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ENDOCRINOLOGY – DIPEPTIDYL PEPTIDASE-4 (DPP4) INHIBITORS AND COMBINATIONS

PREFERRED NON-PREFERRED  alogliptin (generic for Nesina®)  Jentadueto XR®  alogliptin/pioglitazone (generic for Oseni®)  Nesina®*  alogliptin/metformin (generic for Kazano®)  Oseni®*  Glyxambi®  Qtern®  Janumet®  Steglujan®  Janumet XR®  Trijardy XR®  Januvia®  Jentadueto®  Kazano®*  Kombiglyze XR®  Onglyza®  Tradjenta® Trial and failure of 1 Preferred product required prior to Non-Preferred products.

ENDOCRINOLOGY – GLUCAGON AGENTS

PREFERRED NON-PREFERRED  Baqsimi® Nasal Powder  Glucagon Emergency Kit (Fresenius Kabi)  diazoxide suspension  Gvoke ® HypoPen, PFS  Glucagon emergency kit (human recombinant injection, Eli Lilly)  glucagon injection  Proglycem® suspension (oral) Trial and failure of 1 Preferred product required prior to Non-Preferred products

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ENDOCRINOLOGY – GLUCAGON-LIKE PEPTIDE-1 (GLP-1) AGONISTS AND COMBINATIONS

PREFERRED NON-PREFERRED  Bydureon®  Adlyxin®  Byetta®  Bydureon BCise®  Victoza®  Ozempic®  Rybelsus®  Soliqua®  Symlin® Pens**  Trulicity®  Xultophy® Trial and failure of 1 Preferred product required prior to Non-Preferred products.

ENDOCRINOLOGY – GROWTH HORMONE

PREFERRED** NON-PREFERRED**  Genotropin®  Humatrope®  Norditropin®  Nutropin AQ®  Omnitrope®  Saizen®  Serostim®  Zomacton®  Zorbtive® Trial and failure of 2 Preferred products required prior to Non-Preferred products.

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ENDOCRINOLOGY – INSULINS

RAPID ACTING

PREFERRED NON-PREFERRED  Humalog® vial  Admelog®  Humalog cartridge/pen®  Afrezza**  Humalog Junior Kwikpen®  Apidra vial/SoloSTAR®  insulin aspart vial/cartridge/pen (generic for Novolog®)  Fiasp® Flextouch/vial/Penfill  insulin lispro vial/kwikpen (generic for Humalog  Humalog Kwikpen® vial/cartridge/pen®)  Lyumjev™  Novolog vial/cartridge/FlexPen® Trial and failure of 1 Preferred product required prior to Non-Preferred products.

SHORT ACTING

PREFERRED NON-PREFERRED  Humulin R®  Novolin R®  Humulin R 500 Kwikpen®/pen/vial Trial and failure of 1 Preferred product required prior to Non-Preferred products.

INTERMEDIATE ACTING

PREFERRED NON-PREFERRED  Humulin N®  Humulin N Kwikpen®  Novolin N® Trial and failure of 1 Preferred product required prior to Non-Preferred products.

LONG ACTING

PREFERRED NON-PREFERRED  Lantus SoloSTAR®  Basaglar Kwikpen®  Lantus® vial  Toujeo Solostar/Max Solostar®  Levemir FlexTouch®  Tresiba Flextouch® pen  Levemir vial®  Tresiba vial® Trial and failure of 1 Preferred product required prior to Non-Preferred products.

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ENDOCRINOLOGY – INSULINS (CONTINUED)

PREMIXED COMBINATIONS

PREFERRED NON-PREFERRED  Humalog Mix 75/25 vial and Kwikpen®  Humulin 70/30 Kwikpen®  Humalog Mix 50/50 vial and Kwikpen®  Novolin 70/30®  Humulin 70/30 vial®  insulin aspart protamine vial/pen (generic for Novolog® Mix 70/30)  insulin lispro protamine vial/pen (generic for Humalog Mix® 75/25)  Novolog Mix 70/30®  Novolog Mix 70/30 FlexPen® Trial and failure of 1 Preferred product required prior to Non-Preferred products.

ENDOCRINOLOGY – MEGLITINIDES

PREFERRED NON-PREFERRED  nateglinide (generic for Starlix®)  Prandin®*  repaglinide (generic for Prandin®)  Starlix®*  repaglinide/metformin (generic for PrandiMet®) Trial and failure of 1 Preferred product required prior to Non-Preferred products.

ENDOCRINOLOGY – POTASSIUM BINDERS

PREFERRED NON-PREFERRED  Lokelma®  Veltassa®  sodium polystyrene sulfonate Trial and failure of 2 Preferred products required prior to Non-Preferred products.

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ENDOCRINOLOGY – SODIUM GLUCOSE CO-TRANSPORTER 2 INHIBITOR AND COMBINATIONS

PREFERRED NON-PREFERRED  Farxiga®  Invokamet®/XR  Glyxambi®  Qtern®  Invokana®  Segluromet®  Jardiance®  Steglatro®  Steglujan®  Synjardy®/XR  Trijardy XR®  Xigduo XR® Trial and failure of 1 Preferred product required prior to Non-Preferred products.

ENDOCRINOLOGY – THIAZOLIDINEDIONES AND COMBINATIONS

PREFERRED NON-PREFERRED  alogliptin/pioglitazone (generic for Oseni®)  Actos®*  pioglitazone (generic for Actos®)  Actoplus Met/XR®*  pioglitazone/glimepiride (generic for Duetact®)  Avandia®  pioglitazone/metformin (generic for Actoplus Met®)  Duetact®*  Oseni®* Trial and failure of 1 Preferred product required prior to Non-Preferred products.

ENDOCRINOLOGY – 2ND GENERATION SULFONYLUREAS AND COMBINATIONS

PREFERRED NON-PREFERRED  glimepiride (generic for Amaryl®)  Amaryl®*  glipizide/ metformin (generic for Metaglip®)  Duetact®*  glipizide (generic for Glucotrol®)  Glucotrol®/XL*  glipizide ER (generic for Glucotrol XL®)  Glynase®*  glyburide (generic for Micronase®, DiaBeta®)  glyburide/metformin (generic for Glucovance®)  glyburide micronized (generic for Glynase®)  pioglitazone/glimepiride (generic for Duetact®) Trial and failure of 2 Preferred products required prior to Non-Preferred products.

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GASTROINTESTINAL – ANTIEMETICS***

PREFERRED NON-PREFERRED  aprepitant/ pack (generic for Emend®/pack)  Akynzeo®  doxylamine succ/pyridoxine HCL (generic for Diclegis®)  Cinvanti®  granisetron tab (generic for Kytril®)  Diclegis®*  ondansetron (generic for Zofran®)  Emend®*/pack  Sancuso®  Sustol®  Varubi®  Zofran®*  Zuplenz® Qty limits apply Trial and failure of 2 Preferred products required prior to Non-Preferred products.

GASTROINTESTINAL – BOWEL DISORDERS/GI MOTILITY, CHRONIC

PREFERRED** NON-PREFERRED**  alosetron  Amitiza®  Linzess®  Motegrity®  Lotronex®  Relistor®  lubiprostone (generic for Amitiza®)  Symproic®  Movantik®  Trulance®  Viberzi®  Zelnorm™ Trial and failure of 2 Preferred products required prior to Non-Preferred products.

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GASTROINTESTINAL – HEPATITIS C AGENTS

PEGYLATED INTERFERON ALPHA PRODUCTS

PREFERRED** NON-PREFERRED**  Pegasys® syringe/vial  PEG-Intron®

Trial and failure of 1 Preferred product required prior to Non-Preferred products. RIBAVIRIN PRODUCTS

PREFERRED** NON-PREFERRED**  Ribavirin Trial and failure of 1 Preferred product required prior to Non-Preferred products. DIRECT ACTING ANTIVIRAL PRODUCTS

PREFERRED** NON-PREFERRED**  ledipasvir-sofosbuvir (generic for Harvoni®)  Epclusa®  Mavyret™  Harvoni®  sofosbuvir/velpatasvir (generic for Epclusa®)  Harvoni® Pellet Pack  Vosevi®  Sovaldi®  Sovaldi® Pellet Pack  Viekira Pak®  Zepatier® Trial and failure of 1 Preferred product required prior to Non-Preferred products.

GASTROINTESTINAL – PROTON PUMP INHIBITORS AND COMBINATIONS***

PREFERRED NON-PREFERRED  esomeprazole (generic for Nexium®) (RX)  AcipHex/sprinkles®  lansoprazole/ solutab (generic for Prevacid/ solutab) (RX)  Dexilant® (formerly known as Kapidex®)  Nexium suspension  Nexium® (RX)  omeprazole (generic for Prilosec®) (RX)  Prevacid® capsules (RX)/Solutab  omeprazole/sodium bicarbonate (generic for Zegerid®)  Prilosec® (RX)  pantoprazole tab/susp (generic for Protonix®)  Protonix®  Protonix® suspension  Zegerid®  rabeprazole (generic for AcipHex®) Trial and failure of 2 Preferred products required prior to Non-Preferred products.

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GASTROINTESTINAL – ULCERATIVE COLITIS

ORAL

PREFERRED NON-PREFERRED  Apriso®  Asacol HD®  balsalazide (generic for Colazol®)  Azulfidine®/ENTAB*  budesonide ER (generic for Uceris®)  Colazal®*  Lialda®  Delzicol®*  mesalamine (generic for Asacol HD®, Lialda®)  Dipentum®  mesalamine DR (generic for Delzicol®)  Uceris®*  mesalamine ER (generic for Apriso®)  Pentasa®  sulfasalazine (generic for Azulfidine®) Trial and failure of 2 Preferred products required prior to Non-Preferred products.

RECTAL

PREFERRED NON-PREFERRED  Canasa supp.®  Rowasa®*  mesalamine enema (generic for Rowasa®)  SFRowasa®  mesalamine kit (generic for Rowasa® kit)  Uceris® Rectal Foam  mesalamine supp. (generic for Canasa supp.®) Trial and failure of 2 Preferred products required prior to Non-Preferred products.

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GENITOURINARY/RENAL – ALPHA BLOCKERS FOR BENIGN PROSTATIC HYPERPLASIA

PREFERRED NON-PREFERRED  alfuzosin (generic for Uroxatral®)  Flomax®*  dutasteride/tamsulosin (generic for Jalyn®)  Jalyn®*  silodosin (generic for Rapaflo®)  Rapaflo®*  tamsulosin (generic for Flomax®) Trial and failure of 2 Preferred products required prior to Non-Preferred products

GENITOURINARY/RENAL – ANDROGEN HORMONE INHIBITORS

PREFERRED NON-PREFERRED  dutasteride (generic for Avodart®)  Avodart®*  finasteride (generic for Proscar®)  Proscar®* Trial and failure of 1 Preferred product required prior to Non-Preferred products

GENITOURINARY/RENAL – ELECTROLYTE DEPLETERS

PREFERRED NON-PREFERRED  calcium acetate (generic for PhosLo®)  Auryxia®  lanthanum (generic for Fosrenol®)  Fosrenol®*  sevelamer (generic for Renvela®)  Magnebind 400®  sevelamer HCL (generic for Renagel®)  Phoslyra®  Renagel®*  Renvela®*  Velphoro® Trial and failure of 1 Preferred product required prior to Non-Preferred products

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GENITOURINARY/RENAL – URINARY ANTISPASMODICS

PREFERRED NON-PREFERRED  darifenacin ER (generic for Enablex®)  Detrol/LA®*  flavoxate  Ditropan XL®*  oxybutynin /ER (generic for Ditropan®/XL)  Enablex®*  solifenacin succinate (generic for Vesicare®)  Gelnique®  tolterodine/ER (generic for Detrol®/LA)  Myrbetriq®  Toviaz®  Oxytrol®  trospium /ER (generic for Sanctura /XR®)  Vesicare®*

Trial and failure of 3 Preferred products required prior to Non-Preferred products

HEMATOLOGIC – ANTICOAGULANTS

PREFERRED NON-PREFERRED  Eliquis®  Arixtra®*  enoxaparin (generic for Lovenox®)  Bevyxxa®  fondaparinux (generic for Arixtra®)  Fragmin®  Pradaxa®  Lovenox®*  warfarin (generic for Coumadin®)  Savaysa®  Xarelto®  Xarelto dose pack® Trial and failure of 2 Preferred products required prior to Non-Preferred products

HEMATOLOGIC – HEMATOPOIETIC AGENTS

PREFERRED** NON-PREFERRED**  Epogen®***  Aranesp®***  Retacrit®***  Mircera®***  Procrit®***  Reblozyl® Qty limits apply Trial and failure of 1 Preferred product required prior to Non-Preferred products

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HIV/AIDS – ORAL PRODUCTS

PREFERRED NON-PREFERRED  abacavir  lopinavir/ritonavir  abacavir/lamivudine  nevirapine ER  abacavir/lamivudine/zidovudine  nevirapine  Aptivus®  Norvir®  atazanavir  Odefsey®  Atripla®  Pifeltro™  Biktarvy®  Prezcobix®  Cimduo®  Prezista®  Combivir®  Retrovir®  Complera®  Reyataz®  Crixivan®  ritonavir  Delstrigo™  Rukobia®  Descovy®  Selzentry®  didanosine  stavudine  Dovato®  Stribild®  Edurant®  Sustiva®  efavirenz  Symfi®  efavirenz-emtricitabine-tenofovir  Symfi lo® disoproxil fumarate (generic for Atripla®)  Symtuza®  efavirenz-lamivudine-tenofovir disoproxil  Temixys™ fumarate (generic for Symfi®)  tenofovir disoproxil fumarate  efavirenz-lamivudine-tenofovir disoproxil  Tivicay®/PD Susp fumarate (generic for Symfi® lo)  Triumeq®  emtricitabine (generic for Emtriva®)  Trizivir®  emtricitabine-tenofovir disoproxil  Truvada® fumarate (generic for Truvada®)  Tybost®  Emtriva®  Videx®  Epivir®  Viracept®  Epzicom®  Viramune®  Evotaz®  Viramune® XR  fosamprenavir  Viread®  Fuzeon®  Ziagen®  Genvoya®  zidovudine  Intelence®  Invirase®  Isentress®  Isentress® hd  Juluca®  Kaletra®  lamivudine  lamivudine-zidovudine  Lexiva®

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IMMUNOLOGIC – SYSTEMIC IMMUNOMODULATORS

PREFERRED** NON-PREFERRED**  Cosentyx®  Actemra®/Actpen  Enbrel®  Arcalyst®  Humira®  Avsola®  Cimzia®  Entyvio®  Ilaris®  Ilumya™  Inflectra®  Kevzara®  Kineret®  Olumiant®  Orencia®  Otezla®  Remicade®  Renflexis®  Rinvoq®  Siliq®  Simponi/Aria®  Skyrizi™  Stelara®  Taltz®  Tremfya®  Xeljanz®/XR Trial and failure of 1 or more Preferred products based on diagnosis required prior to Non-Preferred products

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MISCELLANEOUS – PANCREATIC ENZYMES

PREFERRED NON-PREFERRED  Creon®  Pancreaze®  Zenpep®  Pertzye®  Viokace® Trial and failure of 2 Preferred products required prior to Non-Preferred products

MISCELLANEOUS – SKELETAL MUSCLE RELAXANTS

PREFERRED NON-PREFERRED  baclofen  Amrix®*  carisoprodol/compound (generic for Soma®/  Dantrium®* compound)**  Fexmid®  chlorzoxazone (generic for Parafon Forte®)  Lorzone®  cyclobenzaprine (generic for Flexeril®)  Norgesic Forte®  cyclobenzaprine ER (generic for Amrix®)  Robaxin®*  dantrolene sodium (generic for Dantrium®)  Skelaxin®*  metaxalone (generic for Skelaxin®)  Soma®**  methocarbamol (generic for Robaxin®)  Zanaflex®*  orphenadrine citrate (generic for Norflex®)  tizanidine (generic for Zanaflex®)

Trial and failure of 3 Preferred products required prior to Non-Preferred products

MISCELLANEOUS – SMOKING CESSATION

PREFERRED NON-PREFERRED  bupropion SR (generic for Zyban®)  Nicotrol inhalation/NS®  Chantix®  nicotine gum/lozenges/patch Trial and failure of 1 Preferred product required prior to Non-Preferred products

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MISCELLANEOUS – TOPICAL ANDROGENIC AGENTS

PREFERRED NON-PREFERRED  testosterone (generic for AndroGel®, Fortesta® Testim®,  Androderm® Vogelxo®)  AndroGel®*  Fortesta®*  Testim®*  Vogelxo®* Trial and failure of 1 Preferred product required prior to Non-Preferred products

OPHTHALMIC/GLAUCOMA – ALPHA 2 ADRENERGIC AGENTS

PREFERRED NON-PREFERRED  Alphagan P®  Iopidine®*  apraclonidine (generic for Iopidine®)  brimonidine/P (generic for Alphagan®/P)  Simbrinza®

Trial and failure of all Preferred products required prior to Non-Preferred products

OPHTHALMIC/GLAUCOMA – BETA BLOCKER AGENTS

PREFERRED NON-PREFERRED  betaxolol (generic for Betoptic®)  Betoptic S®  carteolol (generic for Ocupress®)  Cosopt®*/PF®  Combigan®  Istalol®*  dorzolamide/timolol/PF (generic for Cosopt®*/PF®)  Timoptic®/XE*  levobunolol (generic for Betagan®)  Timoptic® Ocudose  timolol (generic for Timoptic®)  timolol XE (generic for Timoptic XE®)

Trial and failure of 5 Preferred products required prior to Non-Preferred products

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OPHTHALMIC/GLAUCOMA – CARBONIC ANHYDRASE INHIBITORS

PREFERRED NON-PREFERRED  brimonidine/dorzolamide/PF  Azopt®  dorzolamide/PF (generic for Trusopt®)  Cosopt®*/PF®  dorzolamide/timolol/PF (generic for Cosopt®*/PF®)  Trusopt®*  Simbrinza®

Trial and failure of 2 Preferred products required prior to Non-Preferred products

OPHTHALMIC/GLAUCOMA – PROSTAGLANDIN AGONISTS

PREFERRED NON-PREFERRED  bimatoprost (generic for Lumigan®)  Lumigan ®*  latanoprost/PF (generic for Xalatan®)  Vyzulta™  travoprost (generic for Travatan®)  Xalatan®*/***  Travatan Z®  Xelpros™  Zioptan® Trial and failure of 2 Preferred products required prior to Non-Preferred products

OPHTHALMIC/GLAUCOMA – RHO KINASE INHIBITOR

PREFERRED** NON-PREFERRED**  Rhopressa™  Rocklatan™

OPHTHALMIC/ANTIHISTAMINES – ANTIHISTAMINES

PREFERRED NON-PREFERRED  azelastine (generic for Optivar®)  Alocril®  cromolyn sodium  Alomide®  epinastine (generic for Elestat®)  Alrex®  olopatadine (generic for Patanol®/Pataday®)  Bepreve®  Pazeo®  Lastacaft®  Zerviate® Trial and failure of 2 Preferred products required prior to Non-Preferred products

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OPHTHALMIC/ANTIBIOTIC – QUINOLONES

PREFERRED NON-PREFERRED  ciprofloxacin (generic for Ciloxan®)  Besivance®  gatifloxacin (generic for Zymaxid®)  Ciloxan®*  levofloxacin (generic for Quixin®)  Moxeza®*  moxifloxacin (generic for Moxeza®)  Ocuflox®  moxifloxacin (generic for Vigamox®)  Zymaxid®*  ofloxacin  Vigamox® Trial and failure of 2 Preferred products required prior to Non-Preferred products

OPHTHALMIC – NONSTEROIDAL ANTIINFLAMMATORY

PREFERRED NON-PREFERRED  bromfenac (generic for Xibrom®)  Acular®*  diclofenac drops (generic for Voltaren opth drops®)  Acular LS®*  flurbiprofen (generic for Ocufen®)  Acuvail®  Ilevro®  BromSite®  ketorolac 0.5% (generic for Acular®)  Nevanac®  ketorolac 0.4% (generic for Acular LS®)  Prolensa® Trial and failure of 2 Preferred products required prior to Non-Preferred products

OPIATE DEPENDENCE TREATMENT**

PREFERRED NON-PREFERRED  buprenorphine (generic for Subutex®)**  Bunavail®  buprenorphine/naloxone (generic for Suboxone®)  Zubsolv®  Suboxone® Trial and failure of 2 Preferred products required prior to Non-Preferred products.

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OSTEOPOROSIS – BISPHOSPHONATES

PREFERRED NON-PREFERRED  alendronate (generic for Fosamax®)  Actonel®*  ibandronate (generic for Boniva®)  Atelvia®  risedronate (generic for Actonel®)  Binosto®  risedronate DR (generic for Atelvia®)  Boniva®*  Fosamax®*/D Trial and failure of 2 Preferred products required prior to Non-Preferred products.

OSTEOPOROSIS – NASAL CALCITONINS

PREFERRED NON-PREFERRED  calcitonin salmon (generic for Miacalcin®) Trial and failure of 1 Preferred product required prior to Non-Preferred products.

OTIC/ANTIBIOTIC – QUINOLONES AND COMBINATIONS

PREFERRED NON-PREFERRED  Ciprodex otic®  Cipro HC otic®  ciprofloxacin (generic for Cetraxal)  Otovel®*  ciprofloxacin/dexamethasone (generic for Ciprodex otic®)  ciprofloxacin/fluocinolone (generic for Otovel®)  ofloxacin otic (generic for Floxin otic®) Trial and failure of 2 Preferred products required prior to Non-Preferred products

PROGESTATIONAL AGENTS TO PREVENT PRETERM BIRTH

PREFERRED NON-PREFERRED  hydroxyprogesterone caproate (im/sdv)  Makena® auto injector (sq)  Makena® sdv (im)

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RESPIRATORY – CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)

PREFERRED NON-PREFERRED  Atrovent HFA®  Anoro Ellipta®  Bevespi Aerosphere®  Daliresp®  Combivent Respimat®  Duaklir® Pressair  ipratropium/albuterol (generic for DuoNeb®)  Incruse Ellipta®  ipratropium nebulizer  Lonhala Magnair®  Spiriva HandiHaler®***  Seebri Neohaler®  Stiolto Respimat®  Spiriva Respimat®  Tudorza Pressair®  Utibron Neohaler®  Yupelri™ Trial and failure of 2 Preferred products required prior to Non-Preferred products.

RESPIRATORY – LEUKOTRIENE MODIFIERS

Note: Recipients ≤ 10 years of age will be exempt from the PDL in the LTRA category.

PREFERRED NON-PREFERRED  montelukast (generic for Singulair®)  Accolate®*  zafirlukast (generic for Accolate®)  Singulair®*  zileuton ER (generic for Zyflo CR®)  Zyflo® Trial and failure of 2 Preferred products required prior to Non-Preferred products.

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RESPIRATORY – SHORT ACTING BETA ADRENERGICS AND COMBINATIONS – INHALERS/NEBS

PREFERRED NON-PREFERRED  albuterol sulfate HFA (generic for ProAir HFA®, Proventil  ProAir Digihaler® HFA®, Ventolin HFA®)  ProAir Respiclick®  albuterol neb (generic for Proventil®/Ventolin® neb)  Ventolin HFA®*  albuterol/ipratropium (generic for DuoNeb®)  Xopenex®  levalbuterol (generic for Xopenex®)  Xopenex HFA®*  ProAir HFA®  Proventil HFA® Trial and failure of 1 Preferred product required prior to Non-Preferred products.

RESPIRATORY – LONG ACTING BETA ADRENERGICS AND COMBINATIONS – INHALERS/NEBS

PREFERRED NON-PREFERRED  Bevespi Aerosphere®  Anoro Ellipta®  Dulera®  Arcapta®  Serevent Diskus®  Brovana®  Perforomist®  Striverdi Respimat®  Trelegy Ellipta® Trial and failure of 1 Preferred product required prior to Non-Preferred products.

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RESPIRATORY – INHALED CORTICOSTEROIDS

PREFERRED NON-PREFERRED  Asmanex®  Alvesco®  budesonide (generic for Pulmicort®)  Arnuity Ellipta®  Flovent Diskus®  Asmanex HFA®  Flovent HFA®  Pulmicort Flexhaler®  Pulmicort® respules  QVAR® Redihaler

Trial and failure of 3 Preferred products required prior to Non-Preferred products.

RESPIRATORY – INHALED CORTICOSTEROIDS ADRENERGIC AND COMBINATIONS

PREFERRED NON-PREFERRED  Advair Diskus®  AirDuo RespiClick®*  Advair HFA®  Breo Ellipta®  budesonide/formoterol fumarate (generic for  Trelegy Elllipta® Symbicort®)  Dulera®  fluticasone/salmeterol (generic for Advair Diskus®)  fluticasone/salmeterol (generic for AirDuo RespiClick®)  Symbicort®  Wixela Inhub (generic for Advair Diskus®) Trial and failure of 3 Preferred products required prior to Non-Preferred products.

RESPIRATORY – NASAL ANTIHISTAMINES

PREFERRED NON-PREFERRED  azelastine (generic for Astelin®/Astepro®)  Dymista®  azelastine/fluticasone (generic for Dymista®)  Patanase®*  olopatadine (generic for Patanase®)  Xhance™ Trial and failure of 2 Preferred products required prior to Non-Preferred products

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RESPIRATORY – NASAL CORTICOSTEROIDS***

PREFERRED NON-PREFERRED  azelastine/fluticasone (generic for Dymista®)  Beconase AQ®  budesonide (generic for Rhinocort Aqua®)  Dymista®  flunisolide (generic for Nasarel®)  Nasonex®*  fluticasone (generic for Flonase®)  Omnaris®  mometasone (generic for Nasonex®)

Qty limits apply Trial and failure of 2 Preferred products required prior to Non-Preferred products

RESPIRATORY – LOW SEDATING ANTIHISTAMINES AND COMBINATIONS

PREFERRED NON-PREFERRED  cetirizine tabs/syrup/chew (generic for Zyrtec®  Clarinex®* OTC/chew)  Clarinex-D®*  desloratadine/ODT (generic for Clarinex®)  fexofenadine (OTC/RX)  levocetirizine tab/solution (generic for Xyzal® OTC)  loratadine (OTC/RX) (generic for Claritin® OTC/RX)  loratadine syrup (OTC/RX) (generic for Claritin Syrup® OTC/RX)  loratadine Dis (OTC/RX) (generic for Claritin Dis® OTC/RX) Trial and failure of 3 Preferred products required prior to Non-Preferred products

SELF INJECTION EPINEPHRINE***

PREFERRED NON-PREFERRED  Epinephrine (generic for Adrenaclick®, EpiPen®, EpiPen  EpiPen® Jr.®)  EpiPen Jr.®  Symjepi™ Trial and failure of 1 Preferred product required prior to Non-Preferred products

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TOPICAL – ANTIPARASITICS

PREFERRED NON-PREFERRED  ivermectin (generic for Sklice®)  Crotan®  lindane  Eurax®  malathion  Ovide®  Natroba®  Sklice®*  permethrin (OTC/RX)  spinosad (generic for Natroba®) Trial and failure of 1 Preferred product required prior to Non-Preferred products

TOPICAL – STEROIDS

VERY HIGH POTENCY

PREFERRED NON-PREFERRED  clobetasol foam (generic for Olux-E® foam)  ApexiCon E®  clobetasol cream/soln/gel/oint (generic for Temovate®  Bryhali® cream/soln/gel/oint)  Clobex®*  clobetasol ltn./shamp./spr. (generic for Clobex®  Lexette® ltn./shamp./spr.)  Olux/E®*  halobetasol propionate (generic for Halac®, Ultravate®,  Temovate®* Halonate®)  Tovet Kit®  halobetasol propionate foam (generic for Lexette®)  Ultravate®* Trial and failure of 1 Preferred product required prior to Non-Preferred products

HIGH POTENCY

PREFERRED NON-PREFERRED  amcinonide  Diprolene®  betamethasone dipropionate (augmented generic for  Halog®* Diprolene AF)  Kenalog aerosol®  betamethasone valerate  Topicort®*  desoximetasone (generic for Topicort®)  Trianex®  diflorasone diacetate  Vanos®  fluocinonide/E  halcinonide (generic for Halog®)  triamcinolone Trial and failure of 2 Preferred products required prior to Non-Preferred products

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TOPICAL – STEROIDS (CONTINUED)

MEDIUM POTENCY

PREFERRED NON-PREFERRED  Beser™  Beser Kit™  betamethasone valerate foam (generic for Luziq®)  Cloderm®*  clocortolone (generic for Cloderm®)  Cordran tape®*  fluocinolone acetate (generic for Synalar®)  Cutivate® Cream/Lotion  flurandrenolide (generic for Cordran®)  Locoid®*  fluticasone propionate  Pandel®  hydrocortisone butyrate/valerate  Synalar®*  hydrocortisone butyrate lotion (generic for Locoid®)  mometasone  prednicarbate Trial and failure of 2 Preferred products required prior to Non-Preferred products

LOW POTENCY

PREFERRED NON-PREFERRED  alclometasone dipropionate  Aqua Glycolic HC®  desonide  Capex Shampoo®  fluocinolone (generic for Derma Smoothe®)  Derma-Smoothe FS®  hydrocortisone acetate (OTC/RX) cr/oint  Desonate®  Texacort® Trial and failure of 2 Preferred products required prior to Non-Preferred products

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TOPICAL – TOPICAL AGENTS FOR PSORIASIS

PREFERRED NON-PREFERRED  betamethasone/calcipotriene (generic for Taclonex®)  Dovonex®*  calcipotriene cream/ solution/oint. (generic for  Duobrii® Dovonex®)  Enstilar®  calcitriol (generic for Vectical®)  Sorilux®  Taclonex®*  Vectical®* Trial and failure of 2 Preferred products required prior to Non-Preferred products

TOPICAL – TOPICAL COMBINATION BENZOYL PEROXIDE AND CLINDAMYCIN PRODUCTS

PREFERRED NON-PREFERRED  BenzaClin®  Acanya®*  clindamycin/benzoyl peroxide (generic for BenzaClin®,  Onexton® Duac®, Acanya®) Trial and failure of 1 Preferred product required prior to Non-Preferred products

TOPICAL – ATOPIC DERMATITIS

PREFERRED** NON-PREFERRED**  pimecrolimus (generic for Elidel®)  Dupixent®  Protopic®  Elidel®  tacrolimus (generic for Protopic®)  Eucrisa® Trial and failure of 2 Preferred products required prior to Non-Preferred products

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TOPICAL – TOPICAL RETINOIDS

PREFERRED NON-PREFERRED  adapalene (generic for Differin®, Plixda®)  Aklief®  adapalene/benzoyl peroxide (generic for Epiduo®)  Altreno®  clindamycin/tretinoin (generic for Veltin®)  Arazlo®  Differin®  Atralin®*  Retin-A cream/gel®  Avita®*  tretinoin (generic for Atralin®, Avita®, Retin-A®/Micro)  Epiduo Forte®  tazarotene cream (generic for Tazorac®)  Fabior®  Plixda®*  Retin A Micro®*  Retin A Micro Pump®  Tazorac®  Tretin-X®/Combo Pack  Ziana® Trial and failure of 2 Preferred products required prior to Non-Preferred products

TOPICAL – TOPICAL ANTIVIRALS

PREFERRED NON-PREFERRED  acyclovir (generic for Zovirax oint/cream®)  Xerese®  Denavir®  Zovirax cream®  Zovirax oint® Trial and failure of 2 Preferred products required prior to Non-Preferred products

NH DHHS Fee-for-Service Medicaid PDL | Page 49

TOPICAL – TOPICAL ANTIBIOTICS

PREFERRED NON-PREFERRED  mupirocin oint/cream (generic for Bactroban®  Centany® oint/cream) Trial and failure of 1 Preferred product required prior to Non-Preferred products

UTERINE DISORDER TREATMENTS

PREFERRED NON-PREFERRED  Orilissa®

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