January 2021 Preferred Drug List and PA Criteria

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

PREFERRED DRUG LIST PUBLICATION LOG The PDL is published biannually (January, July). Recent changes to the PDL status are highlighted: January 28, 2021: Published March 5, 2021: Antiemetic-Antivertigo Agents: Removed PA Criteria “Ondansetron solution will be authorized for patients six years of age and under” March 5, 2021: Antihistamines, First Generation class: Replaced PEDIACLEAR (triprolidine) with PEDIACLEAR PD DROPS OTC (triprolidine) and PEDIACLEAR-8 LIQUID OTC (pryrilamine maleate). PEDIACLEAR ALLERGY DROPS OTC (triprolidine) and PEDIACLEAR COUGH OTC (diphenhydramine HCL) listed as non-preferred. March 5, 2021: Hypoglycemics, Incretin Mimetics/Enhancers: Trijardy XR (empagliflozin/linagliptin/metformin) moved from “Incretins” subclass to “Incretin Enhancers/SGLT2 Inhibitor Combinations” subclass March 5, 2021: Lipotropics, Other: Removed PA criteria “Trial and failure of atorvastatin, rosuvastatin, and ezetimibe” March 5, 2021: Phosphate Binders: Formatting correction of the PA criteria “Dialysis patients with severe vascular and/or soft tissue calcifications” March 5, 2021: Clinical PA link additions or corrections: Diacomit, Epidiolex, antiemetic-antivertigo agents, Colcrys, Gocovri, Osmolex, Forteo, Glatiramer, Lyrica, Zelboraf, Makena

ACNE AGENTS, ORAL Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria AMNESTEEM (isotretinoin) ABSORICA (isotretinoin) ■ Treatment failure with CLARAVIS (isotretinoin) ABSORICA LD (isotretinoin) preferred drugs within isotretinoin any subclass MYORISAN (isotretinoin) ■ Contraindication to preferred drugs ZENATANE (isotretinoin) ■ Allergic reaction to preferred drugs ■ Treatment of stage-four advanced, metastatic cancer and associated conditions

To verify formulary coverage for any drugs listed on PDL, Search the Medicaid Formulary: txvendordrug.com/formulary/formulary-search Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. Publication date: January 28, 2021

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

ACNE AGENTS, TOPICAL Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria Antibiotics

clindamycin gel (Clindagel) CLEOCIN-T (clindamycin) ■ Treatment failure with clindamycin pledgets clindamycin foam preferred drugs within clindamycin solution clindamycin lotion any subclass erythromycin gel, solution erythromycin medicated swab ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs ■ Treatment of stage-four advanced, metastatic cancer and associated conditions

The following Clinical Prior Authorization applies to all drugs in the class: ■ Topical Acne Agents

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

ACNE AGENTS, TOPICAL continued Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria Benzoyl Peroxide

benzoyl peroxide gel (Rx) BENZEFOAM FOAM OTC (topical) ■ Treatment failure with benzoyl peroxide wash benzoyl peroxide cleanser preferred drugs within benzoyl peroxide cream any subclass benzoyl peroxide foam ■ Contraindication to preferred drugs benzoyl peroxide gel ■ Allergic reaction to preferred benzoyl peroxide kit drugs benzoyl peroxide lotion ■ Treatment of stage-four benzoyl peroxide towelette advanced, metastatic cancer and associated conditions

The following Clinical Prior Authorization applies to all drugs in the class: ■ Topical Acne Agents

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

ACNE AGENTS, TOPICAL continued Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria Retinoids

tretinoin cream (Avita, Retin-A) AKLIEF (trifarotene) ■ Treatment failure with tretinoin gel adapalene preferred drugs within ALTRENO (tretinoin) any subclass ATRALIN (tretinoin) ■ Contraindication to preferred drugs AVITA (tretinoin) ■ Allergic reaction to preferred DIFFERIN (adapalene) drugs FABIOR (tazarotene) ■ Treatment of stage-four tazarotene advanced, metastatic cancer TAZORAC (tazarotene) and associated conditions tretinoin gel (Atralin) tretinoin microspheres The following Clinical Prior Authorization applies to all drugs in the class: ■ Topical Retinoids

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

ACNE AGENTS, TOPICAL continued Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria Combination and Other Agents benzoyl peroxide/clindamycin (Duac) ACZONE 7.5% (dapsone) erythromycin/benzoyl peroxide ■ Treatment failure with AZELEX (azelaic acid) sulfacetamide preferred drugs within BENZACLIN GEL (benzoyl sulfacetamide sodium any subclass peroxide/clindamycin) sulfacetamide sodium/sulfur ■ Contraindication to preferred drugs benzoyl peroxide (Epiduo) sulfacetamide/sulfur ■ Allergic reaction to preferred clindamycin/benzoyl peroxide sulfacetamide/sulfur/urea drugs clindamycin/tretinoin ZIANA (clindamycin/tretinoin) ■ Treatment of stage-four dapsone advanced, metastatic cancer DUAC (benzoyl and associated conditions peroxide/clindamycin) EPIDUO (benzoyl The following Clinical Prior peroxide/adapalene) Authorization applies to all drugs in EPIDUO FORTE (benzoyl the class: peroxide/adapalene) ■ Retinoids ■ Topical Acne Agents

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

ALZHEIMER’S AGENTS Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria Cholinesterase Inhibitors ■ Treatment failure with preferred drugs within donepezil 5, 10 mg tablet* ARICEPT (donepezil)* any subclass donepezil 23 mg tablet* donepezil ODT* ■ Contraindication to EXELON (rivastigmine) transdermal galantamine* preferred drugs galantamine ER ■ Allergic reaction to RAZADYNE (galantamine) tablet* preferred drugs RAZADYNE ER (galantamine ER) ■ Treatment of stage-four rivastigmine capsules advanced, metastatic cancer rivastigmine transdermal and associated conditions ■ For drugs in a therapeutic class or subclass with no preferred option, the provider must obtain a PDL prior authorization

NMDA Receptor Antagonist Dose Optimization applies to memantine tablets memantine solution some strengths where a “*” is memantine tablet dose pack noted NAMENDA (memantine) tablets NAMENDA XR (memantine)

Cholinesterase Inhibitor/NMDA Receptor Antagonist Combinations NAMZARIC (donepezil/memantine)

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

ANALGESICS, NARCOTIC – LONG ACTING Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria BUTRANS (buprenorphine) BELBUCA (buprenorphine) MS CONTIN (morphine) ■ Treatment failure with EMBEDA (morphine/naloxone) buprenorphine patch NUCYNTA ER (tapentadol) preferred drugs within fentanyl patch (12.5, 25, 50, 75, 100 mcg) DURAGESIC (fentanyl) OPANA ER (oxymorphone) any subclass morphine ER (generic MS Contin) EXALGO (hydromorphone) oxycodone ER ■ Contraindication to preferred drugs tramadol ER (Ultram ER) fentanyl patch (37.5, 62.5, 87.5 OXYCONTIN (oxycodone) ■ Allergic reaction to XTAMPZA ER (oxycodone) mcg) oxymorphone ER preferred drugs hydromorphone ER tramadol ER (generic Conzip, Ryzolt) ■ Treatment of stage-four HYSINGLA ER (hydrocodone) advanced, metastatic cancer KADIAN (morphine) and associated conditions methadone ■ Methadone oral solution MORPHABOND ER (morphine) will be authorized for morphine ER (generic Avinza, patients less than 24 months of age. Kadian)

The following Clinical Prior Authorization applies to all drugs in the class: ■ Morphine Milligram Equivalent ■ Opiate Overutilization ■ Opiate/Benzodiazepine/Mus cle Relaxant

A drug specific prior authorization applies to drugs with a hyperlink

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

ANALGESICS, NARCOTIC – SHORT ACTING (NON-PARENTERAL) Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria APAP/codeine ACTIQ (fentanyl) NALOCET (oxycodone/APAP) ■ Treatment failure with hydrocodone/APAP APADAZ (benzhydrocodone/APAP) NORCO (hydrocodone/APAP) preferred drugs within hydrocodone/ibuprofen butalbital/ASA/caffeine/codeine NUCYNTA (tapentadol) any subclass hydromorphone tablet butalbital/APAP/caffeine/codeine OPANA (oxymorphone) ■ Contraindication to preferred drugs morphine tablets butorphanol oxycodone/ASA ■ Allergic reaction to morphine solution carisoprodol/aspirin/codeine oxycodone/ibuprofen preferred drugs oxycodone solution codeine oxycodone capsule ■ Treatment of stage-four oxycodone tablet dihydrocodeine/ASA/caffeine oxycodone concentratedsolution advanced, metastatic cancer oxycodone/APAP DILAUDID (hydromorphone) oxymorphone and associated conditions tramadol fentanyl buccal pentazocine/naloxone tramadol/APAP FENTORA (fentanyl) PERCOCET (oxycodone/APAP) The following Clinical Prior FIORINAL W/CODEINE ROXICODONE (oxycodone) Authorization applies to all drugs (butalbital/ASA/caffeine/codeine) SUBSYS (fentanyl) in the class: hydromorphone liquid TYLENOL-CODEINE (codeine/APAP) ■ Morphine Milligram Equivalent hydromorphone suppositories ULTRACET (tramadol/APAP) ■ Opiate Overutilization IBUDONE (hydrocodone/ibuprofen) ULTRAM (tramadol) LAZANDA (fentanyl) ■ Opiate/Benzodiazepine/Mus cle Relaxant levorphanol meperidine A drug specific prior morphine concentrated solution authorization applies to drugs with a hyperlink

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

ANDROGENIC AGENTS, TOPICAL Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria ANDROGEL (testosterone) pump ANDRODERM (testosterone) ■ Treatment failure with ANDROGEL (testosterone) packet preferred drugs within FORTESTA (testosterone) any subclass TESTIM (testosterone) ■ Contraindication to preferred drugs testosterone gel ■ Allergic reaction to VOGELXO (testosterone) preferred drugs ■ Treatment of stage-four advanced, metastatic cancer and associated conditions

The following Clinical Prior Authorization applies to all drugs in the class: ■ Androgenic Agents

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

ANGIOTENSIN MODULATORS Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria Ace Inhibitors

benazepril ACCUPRIL (quinapril) QBRELIS (lisinopril) solution ■ Treatment failure with enalapril ALTACE (ramipril)* trandolapril* preferred drugs within fosinopril* captopril VASOTEC (enalapril) any subclass lisinopril EPANED (enalapril) ■ Contraindication to preferred drugs quinapril moexepril ■ Allergic reaction to ramipril* perindopril* preferred drugs PRINIVIL (lisinopril) ■ Treatment of stage-four advanced, metastatic cancer and associated conditions ■ Epaned will be authorized for patients six years of age and under

Dose Optimization applies to some strengths where a “*” is noted

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

ANGIOTENSIN MODULATORS continued Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria

ACE Inhibitor/Diuretic Combinations

enalapril/HCTZ ACCURETIC ■ Treatment failure with preferred lisinopril/HCTZ (quinapril/HCTZ) drugs within any subclass benazepril/HCTZ ■ Contraindication to captopril/HCTZ preferred drugs fosinopril/HCTZ ■ Allergic reaction to preferred drugs moexipril/HCTZ ■ Treatment of stage-four advanced, quinapril/HCTZ metastatic cancer and associated VASERETIC conditions (enalapril/HCTZ) ZESTORETIC The following Clinical Prior (lisinopril/HCTZ) Authorization applies to all drugs in the class: ■ Duplicate Therapy

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

ANGIOTENSIN MODULATORS continued Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria Angiotensin II Receptor Blockers (ARBs)

DIOVAN (valsartan)* ATACAND (candesartan)* EDARBI (azilsartan) ■ Treatment failure with irbesartan* AVAPRO (irbesartan)* eprosartan preferred drugs within losartan* BENICAR (olmesartan)* MICARDIS (telmisartan)* any subclass candesartan* olmesartan* ■ Contraindication to preferred drugs COZAAR (losartan)* telmisartan* ■ Allergic reaction to valsartan* preferred drugs ■ Treatment of stage-four advanced, metastatic cancer and associated conditions

The following Clinical Prior Authorization applies to all drugs in the class: ■ Duplicate Therapy

Dose Optimization applies to some strengths where a “*” is noted

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

ANGIOTENSIN MODULATORS continued Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria ARB/Diuretic Combinations ■ Treatment failure with preferred drugs within irbesartan/HCTZ ATACAND-HCT (candesartan/HCTZ) MICARDIS-HCT (telmisartan/HCTZ) any subclass losartan/HCTZ* AVALIDE (irbesartan/HCTZ) olmesartan/HCTZ ■ Contraindication to BENICAR-HCT (olmesartan/HCTZ) telmisartan /HCTZ preferred drugs candesartan/HCTZ valsartan/HCTZ ■ Allergic reaction to DIOVAN-HCT (valsartan/HCTZ) preferred drugs EDARBYCLOR ■ Treatment of stage-four (azilsartan/chlorthalidone) advanced, metastatic cancer HYZAAR (losartan/HCTZ)* and associated conditions ■ For drugs in a therapeutic class or subclass with no preferred option, the provider must obtain a PDL prior authorization

The following Clinical Prior Authorization applies to all drugs in the class: ■ Duplicate Therapy

Dose Optimization applies to Direct Renin Inhibitors some strengths where a “*” is TEKTURNA (aliskerin) noted

A drug specific prior Direct Renin Inhibitor/Diuretic Combinations authorization applies to drugs with a hyperlink

TEKTURNA HCT (aliskerin/HCTZ)

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

ANGIOTENSIN MODULATORS continued Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria ARB/Neprilysin Inhibitor Combinations

ENTRESTO (valsartan/sacubitril) ■ Treatment failure with preferred drugs within any subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs ■ Treatment of stage-four advanced, metastatic cancer and associated conditions

The following Clinical Prior Authorization applies to all drugs in the class: ■ Duplicate Therapy

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

ANGIOTENSIN MODULATOR COMBINATIONS Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria benazepril /amlodipine AZOR (olmesartan/amlodipine) ■ Treatment failure with valsartan/amlodipine BYVALSON (valsartan/nebivolol) preferred drugs within EXFORGE (valsartan/amlodipine) any subclass LOTREL (benazepril/amlodipine) ■ Contraindication to preferred drugs olmesartan/amlodipine ■ Allergic reaction to olmesartan/amlodipine/HCTZ preferred drugs telmisartan/amlodipine ■ Treatment of stage-four trandolapril/verapamil advanced, metastatic cancer valsartan/amlodipine/HCTZ and associated conditions

A drug specific prior authorization applies to drugs with a hyperlink

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

ANTI-ALLERGENS, ORAL Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria ORALAIR (Sweet Vernal, Orchard, Perennial Rye, Timothy, & Kentucky Blue ■ Treatment failure with Grass mixed pollens allergen extract) preferred drugs within PALFORZIA MAINTENANCE SACHET (peanut allergen powder) any subclass PALFORZIA TITRATION CAPSULE (peanut allergen powder) ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs ■ Treatment of stage-four advanced, metastatic cancer and associated conditions ■ For drugs in a therapeutic class or subclass with no preferred option, the provider must obtain a PDL prior authorization

A drug specific prior authorization applies to drugs with a hyperlink

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

ANTIBIOTICS, GASTROINTESTINAL Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria FIRVANQ(vancomycin) DIFICID (fidaxomicin) ■ Treatment failure with metronidazole tablet FLAGYL (metronidazole) preferred drugs within neomycin metronidazole capsule any subclass tinidazole paromomycin ■ Contraindication to TINDAMAX (tinidazole) preferred drugs VANCOCIN (vancomycin) ■ Allergic reaction to preferred drugs vancomycin ■ Treatment of stage-four XIFAXAN (rifaximin) advanced, metastatic cancer and associated conditions

A drug specific prior authorization applies to drugs with a hyperlink

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

ANTIBIOTICS, INHALED Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria ARIKAYCE (amikacin) TOBI (tobramycin) solution ■ Treatment failure with BETHKIS (tobramycin) tobramycin solution preferred drugs within CAYSTON (aztreonam) any subclass KITABIS PAK (tobramycin) ■ Contraindication to preferred drugs TOBI PODHALER (tobramycin) ■ Allergic reaction to preferred drugs ■ Treatment of stage-four advanced, metastatic cancer and associated conditions

The following Clinical Prior Authorization applies to all drugs in the class: ■ Antibiotics, Inhaled

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

ANTIBIOTICS, TOPICAL Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria bacitracin ointment CENTANY (mupirocin) ■ Treatment failure with mupirocin ointment gentamicin preferred drugs within triple antibiotic ointment mupirocin cream any subclass neomycin/polymyxin/pramoxine mupirocin ointment syringe ■ Contraindication to XEPI (ozenoxacin) preferred drugs ■ Allergic reaction to preferred drugs ■ Treatment of stage-four advanced, metastatic cancer and associated conditions

ANTIBIOTICS, VAGINAL Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria CLEOCIN (clindamycin) ovules CLEOCIN (clindamycin) cream ■ Treatment failure with CLINDESSE (clindamycin) clindamycin preferred drugs within NUVESSA (metronidazole) metronidazole any subclass SOLOSEC (secnidazole) ■ Contraindication to preferred drugs VANDAZOLE (metronidazole) ■ Allergic reaction to preferred drugs ■ Treatment of stage-four advanced, metastatic cancer and associated conditions

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

ANTICOAGULANTS Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria ELIQUIS (apixaban) ARIXTRA (fondaparinux) ■ Treatment failure with enoxaparin BEVYXXA (betrixaban) preferred drugs within FRAGMIN (dalteparin) syringe COUMADIN (warfarin) any subclass PRADAXA (dabigatran) fondaparinux ■ Contraindication to preferred drugs warfarin FRAGMIN (dalteparin) vial ■ Allergic reaction to XARELTO (rivaroxaban) LOVENOX (enoxaparin) preferred drugs SAVAYSA (edoxaban) ■ Treatment of stage-four advanced, metastatic cancer and associated conditions

The following Clinical Prior Authorization applies to all drugs in the class: ■ Duplicate Therapy

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

ANTICONVULSANTS Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria APTIOM (eslicarbazine) ■ All of the agents in the BANZEL (rufinamide) Anticonvulsants class are BRIVIACT (brivaracetam) preferred carbamazepine carbamazepine ER, XR A drug specific prior CARBATROL (carbamazepine) authorization applies to drugs CELONTIN (methsuximide) with a hyperlink clobazam clonazepam DEPAKOTE (divalproex sodium) DEPAKOTE ER (divalproex sodium) DIACOMIT (stiripentol) DIASTAT (diazepam) DIASTAT ACUDIAL (diazepam) diazepam DILANTIN (phenytoin) DILANTIN INFATAB (phenytoin) divalproex divalproex ER EPIDIOLEX (cannabidiol) EQUETRO (carbamazepine) ethosuximide felbamate FELBATOL (felbamate) FINTEPLA (fenfluramine) FYCOMPA (perampanel) GABITRIL (tiagabine) KEPPRA (levetiracetam) KEPPRA XR (levetiracetam) KLONOPIN (clonazepam) LAMICTAL (lamotrigine) tablet, ODT LAMICTAL XR (lamotrigine) lamotrigine tablet, ODT levetiracetam levetiracetam XR To verify formulary coverage for any drugs listed on PDL, Search the Medicaid Formulary: txvendordrug.com/formulary/formulary-search Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. Publication date: January 28, 2021

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

ANTICONVULSANTS continued Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria MYSOLINE (primidone) ■ All of the agents in the NAYZILAM (midazolam) Anticonvulsants class are ONFI (clobazam) preferred oxcarbazepine OXTELLAR XR (oxcarbazepine) PEGANONE (ethotoin) phenobarbital PHENYTEK (phenytoin) phenytoin primidone QUDEXY XR (topiramate) SABRIL (vigabatrin) SPRITAM (levetiracetam) SYMPAZAN (clobazam) TEGRETOL (carbamazepine) TEGRETOL XR (carbamazepine) tiagabine TOPAMAX (topiramate) topiramate topiramate ER TRILEPTAL (oxcarbazepine) TROKENDI XR (topiramate) valproic acid VALTOCO (diazepam) zonisamide vigabatran VIMPAT (lacosamide) XCOPRI (cenobamate) ZARONTIN (ethosuximide)

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

ANTIDEPRESSANTS, OTHER Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria bupropion APLENZIN (bupropion) PRISTIQ (desvenlafaxine) ■ Treatment failure with bupropion SR desvenlafaxine ER REMERON (mirtazapine)* preferred drugs within any subclass bupropion XL* EFFEXOR XR (venlafaxine)* tranylcypromine ■ Contraindication to mirtazapine* EMSAM (selegiline) TRINTELLIX (vortioxetine) preferred drugs phenelzine FETZIMA (levomilnacipran) venlafaxine ER tablets* ■ Allergic reaction to trazodone VIIBRYD (vilazodone) FORFIVO XL (bupropion) preferred drugs venlafaxine ER capsules* WELLBUTRIN SR (bupropion) KHEDEZLA (desvenlafaxine) ■ Treatment of stage-four venlafaxine IR MARPLAN (isocarboxazid) WELLBUTRIN XL (bupropion)* advanced, metastatic cancer NARDIL (phenelzine) and associated conditions nefazodone Dose Optimization applies to some strengths where a “*” is noted

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

ANTIDEPRESSANTS, SSRIS Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria citalopram* BRISDELLE (paroxetine) paroxetine CR* ■ Treatment failure with escitalopram tablets* CELEXA (citalopram)* PAXIL (paroxetine)* preferred drugs within fluoxetine IR escitalopram solution PAXIL CR (paroxetine)* any subclass fluvoxamine fluoxetine capsule DR PROZAC (fluoxetine) ■ Contraindication to preferred drugs paroxetine* fluoxetine 60mg tablets ZOLOFT (sertraline)* ■ Allergic reaction to sertraline* fluvoxamine ER preferred drugs LEXAPRO (escitalopram)* ■ Treatment of stage-four advanced, metastatic cancer and associated conditions

Dose Optimization applies to some strengths where a “*” is noted

ANTIDEPRESSANTS, TRICYCLIC Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria amitriptyline amoxapine SURMONTIL (trimipramine) ■ Treatment failure with doxepin ANAFRANIL (clomipramine) TOFRANIL (imipramine) preferred drugs within imipramine clomipramine trimipramine any subclass nortriptyline capsule desipramine ■ Contraindication to preferred drugs imipramine pamoate ■ Allergic reaction to maprotiline preferred drugs nortriptyline solution ■ Treatment of stage-four PAMELOR (nortriptyline) advanced, metastatic cancer protriptyline and associated conditions

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

ANTIEMETIC-ANTIVERTIGO AGENTS (EXCLUDES INJECTABLES) Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria Anticholinergics, Antihistamines, Dopamine Antagonists ■ Treatment failure with preferred drugs within dimenhydrinate BONJESTA (doxylamine/pyridoxine) any subclass meclizine COMPRO (prochlorperazine) ■ Contraindication to metoclopramide solution, tablets DICLEGIS (doxylamine/pyridoxine) preferred drugs phosphoric acid/dextrose/fructose doxylamine/pyridoxine ■ Allergic reaction to prochlorperazine tablets metoclopramide ODT preferred drugs promethazine syrup, tablets prochlorperazine suppositories ■ Treatment of stage-four promethazine suppositories advanced, metastatic cancer REGLAN (metoclopramide) and associated conditions scopolamine patches ■ For drugs in a therapeutic class or subclass with no TRANSDERM-SCOP (scopolamine) preferred option, the trimethobenzamide provider must obtain a PDL prior authorization

Cannabinoids The following Clinical Prior Authorization applies to all drugs dronabinol in the class: MARINOL (dronabinol) ■ Antiemetic-Antivertigo Agents

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

ANTIEMETIC-ANTIVERTIGO AGENTS (EXCLUDES INJECTABLES) continued Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria 5-HT3 Receptor Antagonists ■ Treatment failure with preferred drugs within ondansetron ANZEMET (dolasetron) any subclass granisetron ■ Contraindication to SANCUSO (granisetron) preferred drugs ZOFRAN (ondansetron) ■ Allergic reaction to ZUPLENZ (ondansetron) preferred drugs ■ Treatment of stage-four advanced, metastatic cancer and associated conditions ■ For drugs in a therapeutic class or subclass with no preferred option, the provider must obtain a PDL prior authorization

A drug specific prior authorization applies to drugs with a hyperlink

Substance P Antagonists & Combinations The following Clinical Prior aprepitant Authorization applies to all drugs AKYNZEO (netupitant/palonosetron) in the class: EMEND (aprepitant) ■ Antiemetic

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

ANTIFUNGALS, ORAL Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria clotrimazole ANCOBON (flucytosine) NOXAFIL (posaconazole) ■ Treatment failure with fluconazole CRESEMBA (isavuconazonium nystatin powder preferred drugs within griseofulvin suspension sulfate) ORAVIG (miconazole) any subclass ketoconazole DIFLUCAN (fluconazole) posaconazole ■ Contraindication to preferred drugs nystatin flucytosine SPORANOX (itraconazole) ■ Allergic reaction to terbinafine griseofulvin tablets TOLSURA (itraconazole) preferred drugs itraconazole VFEND (voriconazole) ■ Treatment of voriconazole stage-four advanced, metastatic cancer and associated conditions

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

ANTIFUNGALS, TOPICAL Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria Antifungals ■ Treatment failure with preferred drugs within BENSAL HP (benzoic acid/salicylic LOPROX (ciclopirox) clotrimazole any subclass acid) MENTAX (butenafine) ketoconazole shampoo ■ Contraindication to miconazole cream, powder ciclopirox miconazole ointment, spray preferred drugs nystatin clotrimazole solution RX naftifine ■ Allergic reaction to terbinafine DERMACINRX THERAZOLE PAK oxiconazole preferred drugs tolnaftate cream, powder (betamethasone/clotrimazole/zinc OXISTAT (oxiconazole) ■ Treatment of stage-four oxide) VUSION (miconazole/ advanced, metastatic cancer econazole zinc/petrolatum) and associated conditions EXTINA (ketoconazole) FUNGOID (miconazole) JUBLIA (efinaconazole) KERYDIN (tavaborole) ketoconazole cream, foam Antifungal/Steroid Combinations clotrimazole/betamethasone cream clotrimazole/betamethasone lotion LOTRISONE (clotrimazole/betamethasone) nystatin/triamcinolone

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

ANTIHISTAMINES, FIRST GENERATION

Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria Antihistamines

carbinoxamine liquid carbinoxamine tablets RYCLORA (dexchlorpheniramine) ■ Treatment failure after no clemastine tablet OTC chlorpheniramine ER tablets RYVENT (carbinoxamine) less than a 30-day trial of preferred drugs clorpheniramine IR tablets clemastine tablets THERAFLU NIGHTIME ■ Contraindication to diphenhydramine elixir (diphenhydramine) cyproheptadine syrup, tablet preferred drugs ED CHLORPRED (chlorpheniramine/ triprolidine diphenhydramine capsules, liquid, tablet ■ Allergic reaction to phenylephrine) VANACLEAR (triprolidine) PD DROPS HISTEX (triprolidine) liquid, PD DROPS preferred drugs KARBINAL ER (carbinoxamine) VANAHIST (triprolidine) PD DROPS Hydroxyzine ■ Treatment of stage-four suspension VANAMINE (diphenhydramine) PD PEDIACLEAR PD DROPS OTC (triprolidine) advanced, metastatic cancer DROPS M-HIST (triprolidine) PD DROPS and associated conditions PEDIACLEAR-8 LIQUID OTC (pryrilamine VISTARIL (hydroxyzine) maleate) MICLARA LQ OTC (triprolidine) PEDIACLEAR ALLERGY DROPS OTC The following Clinical Prior (triprolidine) Authorization applies to all drugs PEDIACLEAR COUGH OTC in the class: (diphenhydramine HCL) ■ Duplicate Therapy

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

ANTIHISTAMINES, MINIMALLY SEDATING Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria Antihistamines

cetirizine solution, tablets* cetirizine chewable ■ Treatment failure after no loratadine solution, tablets CLARINEX (desloratadine) less than a 30-day trial of desloratadine preferred drugs fexofenadine ■ Contraindication to preferred drugs levocetirizine ■ Allergic reaction to loratadine ODT preferred drugs ■ Treatment of stage-four advanced, metastatic cancer and associated conditions

The following Clinical Prior Authorization applies to all drugs in the class: ■ Duplicate Therapy

Dose Optimization applies to some strengths where a “*” is noted

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

ANTIHISTAMINES, MINIMALLY SEDATING continued Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria Antihistamine/Decongestant Combinations

cetirizine/pseudoephedrine ■ Treatment failure after no loratadine/pseudoephedrine less than a 30-day trial of SEMPREX-D (acrivastine/pseudoephedrine) preferred drugs ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs ■ Treatment of stage-four advanced, metastatic cancer and associated conditions ■ For drugs in a therapeutic class or subclass with no preferred option, the provider must obtain a PDL prior authorization

The following Clinical Prior Authorization applies to all drugs in the class: ■ Duplicate Therapy

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

ANTIHYPERTENSIVES, SYMPATHOLYTICS Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria CATAPRES-TTS (clonidine) CATAPRES (clonidine) ■ Treatment failure with clonidine IR tablets clonidine transdermal preferred drugs within guanfacine IR methyldopa / HCTZ any subclass methyldopa ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs ■ Treatment of stage-four advanced, metastatic cancer and associated conditions

A drug specific prior authorization applies to drugs with a hyperlink

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

ANTIHYPERURICEMICS Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria allopurinol colchicine ■ Treatment failure with probenecid COLCRYS (colchicine) preferred drugs within probenecid/colchicine GLOPERBA (colchicine) any subclass ULORIC (febuxostat) ■ Contraindication to preferred drugs ZYLOPRIM (allopurinol) ■ Allergic reaction to preferred drugs ■ Treatment of stage-four advanced, metastatic cancer and associated conditions

A drug specific prior authorization applies to drugs with a hyperlink

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

ANTIMIGRAINE AGENTS Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria Triptans

rizatriptan almotriptan ONZETRA XSAIL (sumatriptan) ■ Treatment failure with sumatriptan injection kit AMERGE (naratriptan) RELPAX (eletriptan) preferred drugs within any subclass sumatriptan syringe eletriptan sumatriptan injection kit (SUN ■ Contraindication to sumatriptan tablets FROVA (frovatriptan) Pharma Global) preferred drugs sumatriptan vial frovatriptan sumatriptan nasal ■ Allergic reaction to ZOMIG (zolmitriptan) nasal IMITREX (sumatriptan) injection kit sumatriptan/naproxen preferred drugs IMITREX (sumatriptan) nasal SUMAVEL DOSEPRO (sumatriptan) ■ Treatment of stage-four IMITREX (sumatriptan) tablets TOSYMRA (sumatriptan) advanced, metastatic cancer IMITREX (sumatriptan) vial TREXIMET (sumatriptan/naproxen) and associated conditions MAXALT (rizatriptan) ZEMBRACE SYMTOUCH (sumatriptan) naratriptan zolmitriptan tablets A drug specific prior authorization applies to drugs ZOMIG (zolmitriptan) tablets with a hyperlink

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

ANTIMIGRAINE AGENTS continued Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria Non-Triptans

AIMOVIG (erenumab) AJOVY (fremanezumab-vfrm) ■ Treatment failure with EMGALITY (galcanezumab-gnlm) CAMBIA (diclofenac) preferred drugs within UBRELVY (ubrogepant) D.H.E. 45 (dihydroergotamine) any subclass dihydroergotamine mesylate ■ Contraindication to EMGALITY 100 mg (cluster headache) (galcanezumab-gnlm) preferred drugs MIGRANAL (dihydroergotamine mesylate) ■ Allergic reaction to NURTEC ODT (rimegepant) preferred drugs REYVOW (lasmiditan) ■ Treatment of stage-four advanced, metastatic cancer and associated conditions

A drug specific prior authorization applies to drugs with a hyperlink

ANTIPARASITICS, TOPICAL Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria NATROBA (spinosad) CROTAN (crotamiton) ■ Treatment failure with permethrin EURAX (crotamiton) preferred drugs within VANALICE GEL OTC (piperonyl butoxide/pyrethrum) lindane any subclass malathion ■ Contraindication to preferred drugs OVIDE (malathion) ■ Allergic reaction to SKLICE (ivermectin) preferred drugs

■ Treatment of stage-four advanced, metastatic cancer and associated conditions To verify formulary coverage for any drugs listed on PDL, Search the Medicaid Formulary: txvendordrug.com/formulary/formulary-search Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. Publication date: January 28, 2021

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

ANTIPARKINSON’S AGENTS (ORAL/TRANSDERMAL) Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria Anticholinergics ■ Treatment failure with preferred drugs within

benztropine any subclass trihexyphenidyl ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs ■ Treatment of stage-four advanced, metastatic cancer and associated conditions ■ For drugs in a therapeutic class or subclass with no COMT Inhibitors preferred option, the provider must obtain a PDL

COMTAN (entacapone) prior authorization entacapone TASMAR (tolcapone)

tolcapone

Dopamine Agonists pramipexole bromocriptine ropinirole MIRAPEX (pramipexole) MIRAPEX ER (pramipexole) NEUPRO transdermal (rotigotine) pramipexole ER REQUIP (ropinirole) REQUIP XL (ropinirole) ropinirole ER

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

ANTIPARKINSON’S AGENTS (ORAL/TRANSDERMAL) continued Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria MAO-B Inhibitors ■ Treatment failure with preferred drugs within

AZILECT (rasagiline) any subclass rasagiline ■ Contraindication to selegiline preferred drugs XADAGO (safinamide) ■ Allergic reaction to ZELAPAR (selegiline) preferred drugs ■ Treatment of stage-four Others advanced, metastatic cancer amantadine carbidopa and associated conditions carbidopa/levodopa tablets carbidopa/levodopa ODT ■ For drugs in a therapeutic carbidopa/levodopa ER DUOPA (carbidopa/levodopa) class or subclass with no carbidopa/levodopa/entacapone GOCOVRI (amantadine) preferred option, the INBRIJA (levodopa) provider must obtain a PDL prior authorization LODOSYN (carbidopa)

NOURIANZ (istradefylline) A drug specific prior OSMOLEX ER (amantadine) authorization applies to drugs RYTARY (carbidopa/levodopa) with a hyperlink SINEMET (carbidopa/levodopa) SINEMET CR (carbidopa/levodopa) STALEVO (levodopa/carbidopa/entacapone)

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

ANTIPSYCHOTICS Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria Antipsychotics

aripiprazole tablets* perphenazine ABILIFY (aripiprazole) tablets* pimozide ■ Treatment failure with chlorpromazine quetiapine IR ABILIFY MYCITE (aripiprazole) quetiapine ER preferred drugs within any subclass clozapine risperidone tablets*, solution aripiprazole ODT, solution REXULTI (brexpiprazole) ■ Contraindication to thioridazine clozapine ODT RISPERDAL (risperidone)* fluphenazine preferred drugs thiothixene CAPLYTA (lumateperone) risperidone ODT* haloperidol ■ Allergic reaction to trifluoperazine CLOZARIL (clozapine) SAPHRIS (asenapine) preferred drugs haloperidol decanoate ziprasidone FANAPT (iloperidone) SECUADO (asenapine) ■ Treatment of stage-four LATUDA (lurasidone) FAZACLO (clozapine) SEROQUEL (quetiapine) advanced, metastatic cancer olanzapine* fluphenazine decanoate SEROQUEL XR (quetiapine) and associated conditions olanzapine ODT* GEODON (ziprasidone) capsule, IM VERSACLOZ (clozapine) HALDOL (haloperidol) decanoate VRAYLAR (cariprazine) The following Clinical Prior haloperidol lactate injection ZYPREXA (olanzapine)* Authorization applies to all drugs in the class: INVEGA (paliperidone) ZYPREXA ZYDIS (olanzapine)* ■ Antipsychotics loxapine NUPLAZID (pimavanserin) A drug specific prior olanzapine IM authorization applies to drugs ORAP (pimozide) with a hyperlink paliperidone Dose Optimization applies to some strengths where a “*” is noted

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

ANTIPSYCHOTICS Continued Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria Antipsychotic/SSRI Combinations

amitriptyline/perphenazine olanzapine/fluoxetine ■ Treatment failure with SYMBYAX (olanzapine/fluoxetine) preferred drugs within any subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs ■ Treatment of stage-four advanced, metastatic cancer and associated conditions

The following Clinical Prior Authorization applies to all drugs in the class: ■ Antipsychotics

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

ANTIPSYCHOTICS Continued Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria Long-Acting Injectables

ABILIFY MAINTENA (aripiprazole) PERSERIS (risperidone) ■ Treatment failure with ARISTADA (aripiprazole) ZYPREXA RELPREVV (olanzapine) preferred drugs within ARISTADA INITIO (aripiprazole) any subclass INVEGA SUSTENNA (paliperidone) ■ Contraindication to preferred drugs INVEGA TRINZA (paliperidone) ■ Allergic reaction to RISPERDAL CONSTA (risperidone) preferred drugs ■ Treatment of stage-four advanced, metastatic cancer and associated conditions

The following Clinical Prior Authorization applies to all drugs in the class: ■ Antipsychotics

A drug specific prior authorization applies to drugs with a hyperlink

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

ANTIVIRALS (ORAL/NASAL) Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria Antiherpetic ■ Treatment failure with preferred drugs within acyclovir VALTREX (valacyclovir) any subclass famciclovir ZOVIRAX (acyclovir) ■ Contraindication to valacyclovir preferred drugs ■ Allergic reaction to preferred drugs Anti-influenza ■ Treatment of stage-four oseltamivir rimantadine advanced, metastatic cancer and associated conditions RELENZA (zanamivir) TAMIFLU (oseltamivir) XOFLUZA (baloxavir)

Anti-CMV VALCYTE (valganciclovir) tablets, solution valganciclovir tablets, solution

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

ANTIVIRALS, TOPICAL Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria acyclovir ointment XERESE (acyclovir/hydrocortisone) ■ Treatment failure with DENAVIR (penciclovir) ZOVIRAX (acyclovir) preferred drugs within any subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs ■ Treatment of stage-four advanced, metastatic cancer and associated conditions

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

ANXIOLYTICS Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria alprazolam tablet diazepam solution alprazolam ER TRANXENE T-TAB (clorazepate) ■ Treatment failure with buspirone diazepam tablet alprazolam intensol XANAX XR (alprazolam) preferred drugs within chlordiazepoxide lorazepam intensol alprazolam ODT XANAX (alprazolam) tablet any subclass clorazepate lorazepam tablet diazepam intensol ■ Contraindication to preferred drugs meprobamate ■ Allergic reaction to oxazepam preferred drugs ■ Treatment of stage-four advanced, metastatic cancer and associated conditions

The following Clinical Prior Authorization applies to all drugs in the class: ■ Anxiolytics ■ Opiate/Benzodiazepine/Mus cle Relaxant

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

BETA BLOCKERS (ORAL) Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria Beta Blockers ■ Treatment failure with preferred drugs within acebutolol betaxolol propranolol ER any subclass atenolol BYSTOLIC (nebivolol) SOTYLIZE (sotalol) ■ Contraindication to bisoprolol INDERAL LA (propranolol) TENORMIN (atenolol) preferred drugs HEMANGEOL (propranolol) INNOPRAN XL (propranolol) timolol ■ Allergic reaction to metoprolol IR KAPSPARGO (metoprolol succinate) TOPROL XL (metoprolol succinate) preferred drugs metoprolol XL nadolol ■ Treatment of stage-four advanced, metastatic cancer propranolol IR pindolol and associated conditions sotalol

A drug specific prior Beta Blocker Combinations authorization applies to drugs with a hyperlink atenolol/chlorthalidone CORZIDE (nadolol/bendroflumethiazide) bisoprolol/HCTZ DUTOPROL (metoprolol succinate ER/HCTZ) metoprolol/HCTZ nadolol/bendroflumethiazide propranolol/HCTZ TENORETIC (atenolol/HCTZ) ZIAC (bisoprolol/HCTZ)

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

BETA BLOCKERS (ORAL) continued Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria Beta- and Alpha-Blockers

carvedilol carvedilol ER* ■ Treatment failure with labetalol COREG (carvedilol) preferred drugs within COREG CR (carvedilol)* any subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs ■ Treatment of stage-four advanced, metastatic cancer and associated conditions

Dose Optimization applies to some strengths where a “*” is noted

BILE SALTS Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria ursodiol tablet ACTIGALL (ursodiol) ■ Treatment failure with CHENODAL (chenodiol) preferred drug CHOLBAM (cholic acid) ■ Contraindication to OCALIVA (obeticholic acid) preferred drug URSO (ursodiol) ■ Allergic reaction to preferred drugs URSO FORTE (urosodiol) ■ Treatment of stage-four ursodiol capsule advanced, metastatic cancer and associated conditions

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

BLADDER RELAXANT PREPARATIONS Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria oxybutynin IR darifenacin OXYTROL (oxybutynin) ■ Treatment failure with oxybutynin ER* DETROL (tolterodine) tolterodine preferred drugs within any subclass TOVIAZ (fesoterodine) DETROL LA (tolterodine)* tolterodine ER* ■ Contraindication to VESICARE (solifenacin)* DITROPAN XL (oxybutynin)* trospium preferred drugs ENABLEX (darifenacin) trospium ER ■ Allergic reaction to flavoxate preferred drugs GELNIQUE (oxybutynin) ■ Treatment of stage-four MYRBETRIQ (mirabegron) advanced, metastatic cancer and associated conditions

Dose Optimization applies to some strengths where a “*” is noted

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

BONE RESORPTION SUPPRESSION AND RELATED AGENTS Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria Bisphosphonates ■ Treatment failure with preferred drugs within alendronate tablets ACTONEL (risedronate) any subclass alendronate solution ■ Contraindication to ATELVIA (risedronate) preferred drugs BINOSTO (alendronate) ■ Allergic reaction to preferred drugs BONIVA (ibandronate) etidronate ■ Treatment of stage-four EVENITY (romosozumab-aqqg) advanced, metastatic cancer FOSAMAX (alendronate) and associated conditions ■ For drugs in a therapeutic FOSAMAX PLUS D (alendronate/vitamin D) class or subclass with no ibandronate risedronate preferred option, the provider must obtain a PDL Other Bone Resorption Suppression and Related Agents prior authorization calcitonin nasal EVISTA (raloxifene) A drug specific prior FORTEO (teriparatide) authorization applies to drugs raloxifene with a hyperlink teriparatide TYMLOS (abaloparatide)

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

BPH AGENTS Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria Alpha Blockers ■ Treatment failure with preferred drugs within alfuzosin CARDURA (doxazosin)* any subclass doxazosin* FLOMAX (tamsulosin)* ■ Contraindication to tamsulosin RAPAFLO (silodosin) preferred drugs terazosin* ■ Allergic reaction to preferred drugs ■ Treatment of stage-four 5-Alpha-Reductase (5AR) Inhibitors advanced, metastatic cancer finasteride AVODART (dutasteride) and associated conditions dutasteride ■ For drugs in a therapeutic class or subclass with no PROSCAR (finasteride) preferred option, the Alpha Blocker/5AR Inhibitor Combinations provider must obtain a PDL prior authorization dutasteride/tamsulosin JALYN (dutasteride/tamsulosin) Dose Optimization applies to some strengths where a “*” is noted Phosphodiesterase 5 Inhibitors tadalafil

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

BRONCHODILATORS, BETA AGONIST Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria Inhalers, Short-Acting ■ Treatment failure with preferred drugs within PROAIR HFA (albuterol) levalbuterol any subclass PROVENTIL HFA (albuterol) PROAIR DIGIHALER (albuterol) ■ Contraindication to PROAIR RESPICLICK (albuterol) preferred drugs VENTOLIN HFA (albuterol) ■ Allergic reaction to XOPENEX HFA (levalbuterol) preferred drugs ■ Treatment of stage-four advanced, metastatic cancer and associated conditions ■ For drugs in a therapeutic class or subclass with no preferred option, the provider must obtain a PDL prior authorization

The following Clinical Prior Authorization applies to all drugs in the class: Inhalers, Long-Acting ■ Duplicate Therapy ARCAPTA (indacaterol) SEREVENT (salmeterol) STRIVERDI RESPIMAT (olodaterol)

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

BRONCHODILATORS, BETA AGONIST continued Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria Inhalation Solution ■ Treatment failure with preferred drugs within albuterol BROVANA (arformoterol) any subclass levalbuterol ■ Contraindication to PERFOROMIST (formoterol) preferred drugs XOPENEX (levalbuterol) ■ Allergic reaction to preferred drugs ■ Treatment of stage-four advanced, metastatic cancer and associated conditions

The following Clinical Prior Authorization applies to all drugs in the class: ■ Duplicate Therapy

Oral albuterol syrup albuterol tablet albuterol ER metaproterenol terbutaline

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

CALCIUM CHANNEL BLOCKERS (ORAL) Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria Short-Acting

diltiazem CALAN (verapamil) ■ Treatment failure with verapamil CARDIZEM (diltiazem) preferred drugs within Isradipine any subclass nicardipine ■ Contraindication to preferred drugs nifedipine ■ Allergic reaction to nimodipine preferred drugs NYMALIZE (nimodipine) ■ Treatment of stage-four PROCARDIA (nifedipine) advanced, metastatic cancer and associated conditions Long-Acting Dose Optimization applies to some amlodipine* ADALAT CC (nifedipine)* PROCARDIA XL (nifedipine)* strengths where a “*” is noted CARTIA XT (diltiazem) CALAN SR (verapamil) TIAZAC (diltiazem) diltiazem ER CARDIZEM CD (diltiazem) verapamil 360 mg capsules CARDIZEM LA (diltiazem) verapamil ER PM* felodipine ER diltiazem LA VERELAN (verapamil) nifedipine ER* KATERZIA (amlodipine) VERELAN PM (verapamil) TAZTIA XT (diltiazem) MATZIM LA (diltiazem) verapamil ER capsules, tablets* nisoldipine* NORVASC (amlodipine)*

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

CEPHALOSPORINS AND RELATED ANTIBIOTICS (ORAL) Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria Beta Lactam/Beta-Lactamase Inhibitor Combinations ■ Treatment failure with preferred drugs within amoxicillin/clavulanate tablets, suspension amoxicillin/clavulanate chewable, XR tablets any subclass AUGMENTIN suspension (amoxicillin/clavulanate) ■ Contraindication to AUGMENTIN XR (amoxicillin/clavulanate) preferred drugs ■ Allergic reaction to preferred drugs ■ Treatment of stage-four advanced, metastatic cancer and associated conditions

Cephalosporins – First Generation

cefadroxil capsules, suspension cefadroxil tablets cephalexin tablets cephalexin capsules, suspension

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

CEPHALOSPORINS AND RELATED ANTIBIOTICS (ORAL) continued Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria Cephalosporins – Second Generation ■ Treatment failure with preferred drugs within cefprozil suspension cefaclor ER any subclass cefprozil tablets cefaclor IR capsules, suspension ■ Contraindication to cefuroxime tablets preferred drugs ■ Allergic reaction to preferred drugs ■ Treatment of stage-four advanced, metastatic cancer and associated conditions

Cephalosporins – Third Generation

cefdinir cefixime cefpodoxime ceftibuten SUPRAX (cefixime)

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

COLONY STIMULATING FACTORS Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria NEUPOGEN (filgrastim) vial, syringe FULPHILA (pegfilgrastim - jmdb) ■ Treatment failure with UDENYCA (pegfilgrastim-cbqv) GRANIX (tbo-filgrastim) preferred drugs within LEUKINE (sargramostim) any subclass NEULASTA (pegfilgrastim) ■ Contraindication to NIVESTYM (filgrastim-aafi) preferred drugs ZARXIO (filgrastim-sndz) ■ Allergic reaction to preferred drugs ZIEXTENZO SYRINGE (pegfilgrastim-bmez) ■ Treatment of stage-four advanced, metastatic cancer and associated conditions

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

COPD AGENTS Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria Anticholinergics ■ Treatment failure with preferred drugs within ATROVENT HFA (ipratropium) INCRUSE ELLIPTA (umeclidinium) any subclass ipratropium inhalation solution LONHALA MAGNAIR (glycopyrrolate) ■ Contraindication to SPIRIVA HANDIHALER (tiotropium) SEEBRI NEOHALER (glycopyrrolate) preferred drugs SPIRIVA RESPIMAT (tiotropium) ■ Allergic reaction to TUDORZA (aclidinium) preferred drugs ■ Treatment of stage-four advanced, metastatic cancer and associated conditions ■ For drugs in a therapeutic class or subclass with no Anticholinergic-Beta Agonist Combinations preferred option, the provider must obtain a PDL albuterol/ipratropium ANORO ELLIPITA (umeclidinium/vilanterol) prior authorization BEVESPI AEROSPHERE (glycopyrrolate/formoterol) DUAKLIR PRESSAIR (aclidinium/formoterol) COMBIVENT RESPIMAT (albuterol/ipratropium) UTIBRON NEOHALER (glycopyrrolate/indacaterol) The following Clinical Prior STIOLTO RESPIMAT (tiotropium/olodaterol) YUPELRI (revefenacin) Authorization applies to all drugs in the class: ■ Duplicate Therapy Phosphodiesterase Inhibitors DALIRESP (roflumilast)

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

COUGH AND COLD AGENTS

See Separate Preferred Cough and Cold Agent Listing. ■ Treatment failure with preferred drugs within any subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs ■ Treatment of stage-four advanced, metastatic cancer and associated conditions

The following Clinical Prior Authorization applies to all drugs in the class: ■ Cough & cold PA criteria

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

CYTOKINE AND CAM ANTAGONISTS Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria ENBREL (etanercept) ACTEMRA (tocilizumab) RINVOQ ER (upadacitinib) ■ Treatment failure with HUMIRA (adalimumab) CIMZIA (certolizumab) SILIQ (brodalumab) preferred drugs within OTEZLA (apremilast) COSENTYX (secukinumab) SIMPONI (golimumab) any subclass ILARIS (canakinumab) SKYRIZI (risankizumab-rzaa) ■ Contraindication to preferred drugs ILUMYA (tildrakizumab-asmn) STELARA (ustekinumab) ■ Allergic reaction to KEVZARA (sarilumab) TALTZ (ixekizumab) preferred drugs KINERET (anakinra) TREMFYA (guselkumab) ■ Treatment of stage-four OLUMIANT (baricitinib) XELJANZ (tofacitinib) advanced, metastatic cancer ORENCIA (abatacept) XELJANZ XR (tofacitinib) and associated conditions

The following Clinical Prior Authorization applies to all drugs in the class: ■ Cytokine and CAM Antagonists

EPINEPHRINE, SELF-INJECTED Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria epinephrine (Mylan authorized epinephrine (generic ADRENACLICK) ■ Treatment failure with generic EPIPEN and EPIPEN JR) epinephrine (generic EPIPEN and preferred products EPIPEN JR) ■ Contraindication to EPIPEN (epinephrine) preferred products EPIPEN JR (epinephrine) ■ Allergic reaction to SYMJEPI (epinephrine) preferred products ■ Treatment of stage-four advanced, metastatic cancer and associated conditions

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

ERYTHROPOIESIS STIMULATING PROTEINS Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria ARANESP (darbepoetin) MIRCERA (PEG-EPO) ■ Treatment failure with EPOGEN (RhUEPO) PROCRIT (RhUEPO) preferred drugs within RETACRIT (RhUEPO) any subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs ■ Treatment of stage-four advanced, metastatic cancer and associated conditions

The following Clinical Prior Authorization applies to all drugs in the class: ■ Erythropoiesis-Stimulating Agents

FLUOROQUINOLONES, ORAL Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria ciprofloxacin IR AVELOX (moxifloxacin) ■ Treatment failure with ciprofloxacin suspension BAXDELA (delafloxacin) preferred drugs within levofloxacin tablets CIPRO (ciprofloxacin) tablets any subclass CIPRO (ciprofloxacin) suspension ■ Contraindication to preferred drugs ciprofloxacin ER ■ Allergic reaction to LEVAQUIN (levofloxacin) preferred drugs levofloxacin solution ■ Treatment of stage-four moxifloxacin advanced, metastatic cancer ofloxacin and associated conditions

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

GI MOTILITY, CHRONIC Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria AMITIZA (lubiprostone) alosetron ■ Treatment failure with LINZESS (linaclotide) LOTRONEX (alosetron) preferred drugs within MOVANTIK (naloxegol) MOTEGRITY (prucalopride) any subclass (including OTC products) RELISTOR (methylnaltrexone) injection ■ Contraindication to RELISTOR (methylnaltrexone) oral preferred drugs SYMPROIC (naldemedine) ■ Allergic reaction to TRULANCE (plecanatide) preferred drugs VIBERZI (eluxadoline) ■ Treatment of stage-four advanced, metastatic cancer and associated conditions

The following Clinical Prior Authorization applies to all drugs in the class: ■ GI Motility

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

GLUCAGON AGENTS Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria BAQSIMI (glucagon) glucagon emergency kit (Fresenius) ■ Treatment failure with preferred drugs within any glucagon injection GVOKE (glucagon) subclass glucagon emergency kit (Lilly) ■ Contraindication to PROGLYCEM (diazoxide) preferred drugs ■ Allergic reaction to preferred drugs ■ Treatment of stage-four advanced, metastatic cancer and associated conditions

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

GLUCOCORTICOIDS, INHALED Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria Glucocorticoids

ASMANEX (mometasone) ALVESCO (ciclesonide) ■ Treatment failure with FLOVENT HFA (fluticasone) ARMONAIR RESPICLICK (fluticasone) preferred drugs within PULMICORT 0.25, 0.5 MG RESPULES (budesonide) ARNUITY ELLIPTA (fluticasone) any subclass PULMICORT 1 MG RESPULES (budesonide) ASMANEX HFA (mometasone) ■ Contraindication to preferred drugs budesonide respules ■ Allergic reaction to FLOVENT DISKUS (fluticasone) preferred drugs PULMICORT FLEXHALER (budesonide) ■ Treatment of stage-four QVAR (beclomethasone) advanced, metastatic cancer and associated conditions

The following Clinical Prior Authorization applies to all drugs in the class: ■ Duplicate Therapy

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

GLUCOCORTICOIDS, INHALED continued Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria Glucocorticoid/Bronchodilator Combinations ADVAIR (fluticasone/salmeterol) BREO ELLIPTA (fluticasone/vilanterol) ■ Treatment failure with DULERA (mometasone/formoterol) fluticasone/salmeterol (Air Duo) preferred drugs within SYMBICORT (budesonide/formoterol) TRELEGY ELLIPTA any subclass (fluticasone/umeclidinium/vilanterol) ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs ■ Treatment of stage-four advanced, metastatic cancer and associated conditions

The following Clinical Prior Authorization applies to all drugs in the class: ■ Duplicate Therapy

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

GLUCOCORTICOIDS, ORAL Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria budesonide EC CORTEF (hydrocortisone) prednisolone sodium phosphate ODT, ■ Treatment failure with dexamethasone elixir, solution, tablets dexamethasone intensol solution preferred drugs within hydrocortisone DEXPAK (dexamethasone) prednisone intensol any subclass methylprednisolone tablet dose pack DXEVO (dexamethasone) prednisone tablet dose pack ■ Contraindication to preferred drugs prednisolone sodium phosphate EMFLAZA (deflazacort) TAPERDEX (dexamethasone) ■ Allergic reaction to prednisolone ENTOCORT EC (budesonide) preferred drugs prednisone solution, tablets MEDROL (methylprednisolone) ■ Treatment of stage-four methylprednisolone tablets advanced, metastatic cancer MILLIPRED (prednisolone) and associated conditions

The following Clinical Prior Authorization applies to all drugs in the class: ■ Duplicate Therapy

A drug specific prior authorization applies to drugs with a hyperlink

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

GROWTH HORMONE Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria GENOTROPIN HUMATROPE ■ Treatment failure with NORDITROPIN NUTROPIN AQ preferred drugs within OMNITROPE any subclass SAIZEN ■ Contraindication to preferred drugs SEROSTIM ■ Allergic reaction to ZORBTIVE preferred drugs ■ Treatment of stage-four advanced, metastatic cancer and associated conditions

The following Clinical Prior Authorization applies to all drugs in the class: ■ Growth Hormone

H. PYLORI TREATMENT Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria PYLERA (bismuth subcitrate/metronidazole/tetracycline) lansoprazole/amoxicillin/clarithromycin ■ Treatment failure with OMECLAMOX PAK (omeprazole/amoxicillin/clarithromycin) preferred drugs within any subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs ■ Treatment of stage-four advanced, metastatic cancer and associated conditions

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

HEMOPHILIA TREATMENT Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria Factor VIII ■ All of the agents in the Hemophilia Treatment class ADVATE KOATE DVI are preferred ADYNOVATE KOGENATE FS AFSTYLA KOVALTRY ELOCTATE NOVOEIGHT ESPEROCT NUWIQ HEMOFIL M OBIZUR HUMATE P RECOMBINATE JIVI XYNTHA

Factor IX ALPHANINE SD RIXUBIS ALPROLIX BENEFIX IDELVION IXINITY MONONINE PROFILNINE REBINYN Other ALPHANATE (von Willebrand factor/Factor VIII) COAGADEX (Factor X) CORIFACT (Factor XIII) FEIBA NF (activated prothrombin complex) HEMLIBRA (emicizumab-kxwh) NOVOSEVEN RT (Factor VIIa) TRETTEN (Factor XIII) VOVENDI (von Willebrand factor) WILATE (von Willebrand factor/Factor VIII) To verify formulary coverage for any drugs listed on PDL, Search the Medicaid Formulary: txvendordrug.com/formulary/formulary-search Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. Publication date: January 28, 2021

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

HEPATITIS C AGENTS Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria Pegylated Interferons ■ Treatment failure with preferred drugs within

PEGASYS (pegylated IFN alfa-2a) any subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs ■ Treatment of stage-four advanced, metastatic cancer and associated conditions ■ For drugs in a therapeutic class or subclass with no Polymerase/Protease Inhibitors preferred option, the EPCLUSA (sofosbuvir/velpatasvir) DAKLINZA (daclatasvir) provider must obtain a PDL prior authorization MAVYRET (glecaprevir/pibrentasvir) HARVONI (ledipasvir/sofosbuvir) tablets, pellet pack

VOSEVI (sofosbuvir, velpatasvir, voxilaprevir) ledipasvir/sofosbuvir The following Clinical Prior sofosbuvir/velpatasvir Authorization applies to all drugs SOVALDI (sofosbuvir) tablets, pellet pack in the class: TECHNIVIE (ombitasvir/paritaprevir/ritonavir) ■ Manual Prior Authorization VIEKIRA PAK (dasabuvir/ombitasvir/paritaprevir/ritonavir) VIEKIRA XR (dasabuvir/ombitasvir/paritaprevir/ritonavir) ZEPATIER (elbasvir/grazoprevir)

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

HEPATITIS C AGENTS continued Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria Ribavirin

ribavirin capsule REBETOL solution ■ Treatment failure with ribavirin tablet RIBASPHERE 400, 600 mg preferred drugs within ribavirin dose pack any subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs ■ Treatment of stage-four advanced, metastatic cancer and associated conditions

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

HEREDITARY ANGIOEDEMA (HAE) TREATMENTS Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria BERINERT (C1 esterase inhibitor) RUCONEST (C1 esterase inhibitor) ■ Treatment failure with CINRYZE (C1 esterase inhibitor) TAKHZYRO (lanadelumab-flyo) preferred drugs within FIRAZYR (icatibant) any subclass HAEGARDA (C1 esterase inhibitor) ■ Contraindication to preferred drugs KALBITOR (ecallantide) ■ Allergic reaction to preferred drugs ■ Treatment of stage-four advanced, metastatic cancer and associated conditions

The following Clinical Prior Authorization applies to all drugs in the class: ■ Hereditary Angioedema

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

HIV/AIDS Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria Antiretroviral Single Agent Products ■ All of the agents in the HIV/AIDS class are abacavir REYATAZ (atazanavir) preferred APTIVUS (tipranavir) ritonavir atazanavir RUKOBIA (fostemsavir) CRIXIVAN (indinavir) SELZENTRY (maraviroc) didanosine stavudine EDURANT (rilpivirine) SUSTIVA (efavirenz) efavirenz tenofovir disoproxil fumarate EMTRIVA (emtricitabine) TIVICAY (dolutegravir) EPIVIR (lamivudine) TROGARZO (ibalizumab-uiyk) fosamprenavir TYBOST (cobicistat) FUZEON (enfuvirtide) VIDEX (didanosine) INTELENCE (etravirine) VIRACEPT (nelfinavir) INVIRASE (saquinavir) VIRAMUNE (nevirapine) ISENTRESS (raltegravir) VIRAMUNE XR (nevirapine) lamivudine VIREAD (tenofovir disoproxil LEXIVA (fosamprenavir) fumurate) Nevirapine ZIAGEN (abacavir) NORVIR (ritonavir) zidovudine PIFELTRO (doravirine) PREZCOBIX (darunavir/cobicistat) PREZISTA (darunavir) RETROVIR (zidovudine)

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

HIV/AIDS continued Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria Antiretroviral Combinations ■ All of the agents in the HIV/AIDS class are preferred abacavir/lamivudine GENVOYA (elvitegravir/cobicistat/ abacavir/lamivudine/zidovudine emtricitabine/tenofovir ATRIPLA alafenamide) (efavirenz/emtricitabine/tenofovir) JULUCA (dolutegravir/rilpivirine) BIKTARVY KALETRA (lopinavir/ritonavir) (bictegravir/emtricitabine/tenofovir) lamivudine/zidovudine CIMDUO (lamivudine/tenofovir DF) lopinavir/ritonavir COMBIVIR (lamivudine/zidovudine) ODEFSEY (emtricitabine/rilpivirine/ COMPLERA tenofovir alafenamide) (emtricitabine/rilpivirine/tenfovir STRIBILD (elvitegravir/cobicistat/ DF) emtricitabine/tenofovir DF) DELSTRIGO (doravirine/lamivudine/ SYMFI (efavirenz/lamivudine/ tenofovir DF) tenofovir DF) DESCOVY (emtricitabine/tenofovir SYMFI LO (efavirenz/lamivudine/ alafenamide) tenofovir DF) DOVATO (dolutegravir/lamivudine) SYMTUZA (darunavir/cobicistat/ EPZICOM (abacavir/lamivudine) emtricitabine/tenofovir DF) EVOTAZ (atazanavir/cobicistat) TEMIXYS (lamivudine/tenofovir DF) TRIUMEQ (abacavir/dolutegravir/ lamivudine) TRIZIVIR (abacavir/lamivudine/ zidovudine) TRUVADA (emtricitabine/ tenofovir DF)

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

HYPOGLYCEMICS, INCRETIN MIMETICS/ENHANCERS Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria Amylin Analogs

SYMLIN (pramlintide) ■ Treatment failure with preferred drugs within any subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs ■ Treatment of stage-four advanced, metastatic cancer and associated conditions

A drug specific prior authorization applies to drugs with a hyperlink

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

HYPOGLYCEMICS, INCRETIN MIMETICS/ENHANCERS continued Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria Incretin Enhancers

JANUVIA (sitagliptin) alogliptin ■ Treatment failure with JENTADUETO (linagliptin/metformin) alogilptin/metformin preferred drugs within KOMBIGLYZE XR (saxagliptin/metformin) alogliptin/pioglitazone any subclass ONGLYZA (saxagliptin) JANUMET (sitagliptin/metformin) ■ Contraindication to preferred drugs TRADJENTA (linagliptin) JANUMET XR (sitagliptin/metformin) ■ Allergic reaction to JENTADUETO XR (linagliptin/metformin) preferred drugs KAZANO (alogliptin /metformin) ■ Treatment of stage-four NESINA (alogliptin) advanced, metastatic cancer OSENI (alogliptin /pioglitazone) and associated conditions

The following Clinical Prior Authorization applies to all drugs in the class: ■ DPP4 Inhibitor

A drug specific prior authorization applies to drugs with a hyperlink

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

HYPOGLYCEMICS, INCRETIN MIMETICS/ENHANCERS continued Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria Incretin Mimetics

BYDUREON (exenatide ER) pens, vials ADLYXIN (lixisenatide) ■ Treatment failure with BYETTA (exenatide) BYDUREON BCISE (exenatide ER) preferred drugs within VICTOZA (liraglutide) OZEMPIC (semaglutide) any subclass RYBELSUS (semaglutide) ■ Contraindication to TRULICITY (dulaglutide) preferred drugs ■ Allergic reaction to preferred drugs ■ Treatment of stage-four advanced, metastatic cancer and associated conditions

The following Clinical Prior Authorization applies to all drugs in the class: ■ GLP-1 Receptor Antagonists

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

HYPOGLYCEMICS, INCRETIN MIMETICS/ENHANCERS continued Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria Incretin Enhancers/SGLT2 Inhibitor Combinations ■ Treatment failure with preferred drugs within GLYXAMBI (empagliflozin/linagliptin) QTERN (dapagliflozin/saxagliptin) any subclass STEGLUJAN (ertugliflozin/sitagliptin) ■ Contraindication to TRIJARDY XR (empagliflozin/linagliptin/metformin) preferred drugs

■ Allergic reaction to Incretin Mimetic/Insulin Combinations preferred drugs ■ Treatment of stage-four SOLIQUA (lixisenatide/insulin glargine) advanced, metastatic cancer XULTOPHY (liraglutide/insulin degludec) and associated conditions The following Clinical Prior Authorization applies to all drugs in the class: ■ DPP4 Inhibitor

The following Clinical Prior Authorization applies to all drugs in the class: ■ GLP-1 Receptor Antagonists

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

HYPOGLYCEMICS, INSULIN Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria HUMALOG (insulin lispro) pens, vials ADMELOG (insulin lispro) AFREZZA (insulin) ■ Treatment failure with HUMALOG JUNIOR KWIKPEN (insulin lispro) APIDRA (insulin glulisine) preferred drugs within HUMALOG MIX (insulin lispro/lispro protamine) pens, vials BASAGLAR (insulin glargine) FIASP (insulin any subclass HUMULIN N (insulin) vials aspart) HUMALOG 200 UNITS/ML ■ Contraindication to HUMULIN R (insulin) vials HUMULIN N (insulin) pen preferred drugs ■ Allergic reaction to HUMULIN R 500 UNITS/ML (insulin) pens, vials insulin lispro preferred drugs HUMULIN R 70/30 (insulin) pens, vials LYUMJEV (insulin lispro) ■ Treatment of stage-four LANTUS (insulin glargine) NOVOLIN (insulin) pens advanced, metastatic cancer LEVEMIR (insulin detemir) NOVOLIN 70/30 (insulin) TOUJEO (insulin and associated conditions NOVOLIN (insulin) vials glargine) TRESIBA (insulin degludec) NOVOLOG (insulin aspart) NOVOLOG MIX (insulin aspart/aspart protamine)

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

HYPOGLYCEMICS, MEGLITINIDES Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria nateglinide repaglinide/metformin ■ Treatment failure with repaglinide STARLIX (nateglinide) preferred drugs within any subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs ■ Treatment of stage-four advanced, metastatic cancer and associated conditions

The following Clinical Prior Authorization applies to all drugs in the class: ■ Duplicate Therapy

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

HYPOGLYCEMICS, METFORMIN Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria glyburide/metformin FORTAMET (metformin ER) ■ Treatment failure with metformin glipizide/metformin preferred drugs within metformin ER (GLUCOPHAGE XR) GLUCOPHAGE (metformin) any subclass GLUCOPHAGE XR (metformin ER) ■ Contraindication to preferred drugs GLUMETZA (metformin ER) ■ Allergic reaction to metformin ER (FORTAMET) preferred drugs metformin ER (GLUMETZA) ■ Treatment of stage-four RIOMET (metformin) advanced, metastatic cancer RIOMET ER (metformin) and associated conditions

HYPOGLYCEMICS, SGLT2 Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria FARXIGA (dapagliflozin) STEGLATRO (ertugliflozin) ■ Treatment failure with INVOKANA (canaglifozin) preferred drugs within JARDIANCE (empagliflozin) any subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs ■ Treatment of stage-four advanced, metastatic cancer and associated conditions

The following Clinical Prior Authorization applies to all drugs in the class: ■ SGLT2 Inhibitor

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

HYPOGLYCEMICS, SGLT2 continued Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria SGLT2 Combinations

SYNJARDY (empagliflozin/metformin) INVOKAMET (canagliflozin/metformin) ■ Treatment failure with XIGDUO XR (dapagliflozin/metformin) INVOKAMET XR (canagliflozin/metformin) preferred drugs within any subclass SEGLUROMET (ertugliflozin/metformin) ■ Contraindication to SYNJARDY XR (empagliflozin/metformin) preferred drugs ■ Allergic reaction to preferred drugs ■ Treatment of stage-four advanced, metastatic cancer and associated conditions

The following Clinical Prior Authorization applies to all drugs in the class: ■ SGLT2 Combinations

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

HYPOGLYCEMICS, TZD Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria Thiazolidinediones

pioglitazone AVANDIA (rosiglitazone) ■ Treatment failure with preferred drugs within any subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs ■ Treatment of stage-four advanced, metastatic cancer and associated conditions

The following Clinical Prior Authorization applies to all drugs in the class: ■ Thiazolidinediones

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

HYPOGLYCEMICS, TZD continued Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria TZD Combinations ACTOPLUS MET XR (pioglitazone/metformin) ■ Separate prescriptions for DUETACT (pioglitazone/glimepiride) the individual components pioglitazone/metformin should be used instead of the combination drug. pioglitazone/glimepiride ■ Treatment of stage-four advanced, metastatic cancer and associated conditions ■ Treatment failure with preferred drugs within any subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs ■ For drugs in a therapeutic class and/or subclass with no preferred option, the provider must obtain a PDL prior authorization

The following Clinical Prior Authorization applies to all drugs in the class: ■ Thiazolidinediones

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

IMMUNE GLOBULINS Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria CYTOGAM (CMV immune globulin) ASCENIV (immune globulin) PRIVIGEN (immune globulin) ■ Treatment failure with GAMMAGARD (immune globulin) BIVIGAM (immune globulin) XEMBIFY (immune globulin) preferred drugs within GAMMAKED (immune globulin) CARIMUNE NF (immune globulin) any subclass GAMUNEX-C (immune globulin) CUTAQUIG (immune globulin) ■ Contraindication to preferred drugs HIZENTRA (immune globulin) vial CUVITRU (immune globulin) ■ Allergic reaction to FLEBOGAMMA DIF (immune globulin) preferred drugs HYQVIA (immune globulin) ■ Treatment of stage-four HIZENTRA (immune globulin) syringe advanced, metastatic cancer OCTAGAM (immune globulin) and associated conditions PANZYGA (immune globulin)

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

IMMUNOMODULATORS, ASTHMA Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria FASENRA PEN (benralizumab) NUCALA (mepolizumab) ■ Treatment failure with preferred drugs within any subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs ■ Treatment of stage-four advanced, metastatic cancer and associated conditions ■ The PA criteria above apply to Dupixent for Asthma The following Clinical Prior Authorization applies to all drugs in the class: Immunomodulators, Asthma

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

IMMUNOMODULATORS, ATOPIC DERMATITIS Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria EUCRISA (crisaborole) DUPIXENT (dupilumab) ■ Treatment failure with ELIDEL (pimecrolimus) preferred drugs within tacrolimus any subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs ■ Treatment of stage-four advanced, metastatic cancer and associated conditions ■ Dupixent, in this therapeutic PDL class, is for Atopic Dermatitis indication. The clinical prior authorization linked here includes the product’s other indications.

A drug specific prior authorization applies to drugs with a hyperlink

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

IMMUNOSUPPRESSIVES, ORAL Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria azathioprine ASTAGRAF XL (tacrolimus) PROGRAF (tacrolimus) ■ Treatment failure with cyclosporine, modified CELLCEPT (mycophenolate mofetil) RAPAMUNE (sirolimus) tablets preferred drugs within mycophenolate mofetil capsules, tablets cyclosporine SANDIMMUNE (cyclosporine) any subclass NEORAL (cyclosporine, modified) capsules ENVARSUS XR (tacrolimus) sirolimus solution ■ Contraindication to preferred drugs RAPAMUNE (sirolimus) solution mycophenolate mofetil suspension ZORTRESS (everolimus) ■ Allergic reaction to sirolimus tablets mycophenolic acid preferred drugs tacrolimus MYFORTIC (mycophenolic acid) ■ Treatment of stage-four NEORAL (cyclosporine, modified) advanced, metastatic cancer solution and associated conditions

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

INTRANASAL RHINITIS AGENTS Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria Glucocorticoids ■ Treatment failure with preferred drugs within BECONASE AQ (beclomethasone) fluticasone any subclass budesonide ■ Contraindication to fluticasone OTC preferred drugs flunisolide ■ Allergic reaction to mometasone preferred drugs NASONEX (mometasone) ■ Treatment of stage-four OMNARIS (ciclesonide) advanced, metastatic cancer QNASL (beclomethasone dipropionate) and associated conditions triamcinolone ■ The PA criteria above XHANCE (fluticasone) apply to Dupixent for Chronic Rhinosinusitis ■ For drugs in a therapeutic class or subclass with no Others preferred option, the provider must obtain a PDL azelastine (generic ASTELIN) ASTEPRO (azelastine) prior authorization azelastine (generic ASTEPRO)

ipratropium nasal spray olopatadine PATANASE (olopatadine)

Combinations DYMISTA (azelastine/fluticasone)

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

IRON, ORAL

See Separate Listing of Preferred Oral Iron Drugs. ■ Treatment failure with preferred drugs within any subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs ■ Treatment of stage-four advanced, metastatic cancer and associated conditions

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

LEUKOTRIENE MODIFIERS Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria montelukast chewable tablets, tablets montelukast granules ■ Treatment failure with SINGULAIR (montelukast) preferred drugs within zafirlukast any subclass zileuton ■ Contraindication to preferred drugs ZYFLO CR (zileuton) ■ Allergic reaction to preferred drugs ■ Treatment of stage-four advanced, metastatic cancer and associated conditions

The following Clinical Prior Authorization applies to all drugs in the class: ■ Leukotriene Modifiers

LINCOSAMIDES/OXAZOLIDINONES/STREPTOGRAMINS Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria clindamycin capsules CLEOCIN (clindamycin) ■ 14-day treatment trial with clindamycin solution LINCOCIN (lincomycin) a preferred drug within the linezolid SIVEXTRO (tedizolid) past 180 days ZYVOX (linezolid) ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs ■ Treatment of stage-four advanced, metastatic cancer and associated conditions

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

LIPOTROPICS, OTHER Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria Adenosine Triphosphate-Citrate Lyase Inhibitor ■ Treatment failure with preferred drugs within NEXLETOL (bempedoic acid) any subclass NEXLIZET (bempedoic acid/ezetimibe) ■ Contraindication to preferred drugs Bile Acid Sequestrants ■ Allergic reaction to preferred drugs cholestyramine colesevalam ■ Treatment of stage-four colestipol tablets COLESTID (colestipol) advanced, metastatic cancer colestipol granules and associated conditions QUESTRAN (cholestyramine) ■ For drugs in a therapeutic QUESTRAN LIGHT (cholestyramine) class or subclass with no WELCHOL (colesevalam) preferred option, the provider must obtain a PDL prior authorization Cholesterol Absorption Inhibitors

ZETIA (ezetimibe) ezetimibe

Fibric Acid Derivatives fenofibrate (generic Lofibra, Tricor) fenofibrate (generic Antara, TRICOR (fenofibrate) gemfibrozil Fenoglide, Lipofen) TRIGLIDE (fenofibrate) fenofibric acid (generic Fibricor, TRILIPIX (fenofibric acid) Trilipix) FENOGLIDE (fenofibrate) LIPOFEN (fenofibrate) LOPID (gemfibrozil)

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

LIPOTROPICS, OTHER continued Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria Homozygous Familial Hypercholesterolemia Treatments ■ Treatment failure with preferred drugs within

JUXTAPID (lomitapide) any subclass KYNAMRO (mipomersen) ■ Contraindication to Niacin preferred drugs ■ Allergic reaction to niacin OTC niacin ER preferred drugs NIASPAN (niacin) ■ Treatment of stage-four advanced, metastatic cancer and associated conditions ■ For drugs in a therapeutic class or subclass with no preferred option, the provider must obtain a PDL prior authorization

A drug specific prior authorization applies to drugs with a hyperlink

Omega-3 Fatty Acids LOVAZA (omega-3 fatty acids) omega-3 fatty acids VASCEPA (icosapent ethyl)

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

LIPOTROPICS, OTHER continued Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria PCSK9 Inhibitors

PRALUENT (alirocumab) ■ Trial of atorvastatin, REPATHA (evolocumab) rosuvastatin, and ezetimibe ■ Concurrent therapy of atorvastatin or rosuvastatin ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs ■ Treatment of stage-four advanced, metastatic cancer and associated conditions ■ For drugs in a therapeutic class or subclass with no preferred option, the provider must obtain a PDL prior authorization

Clinical prior authorizations applies to all PCSK9 inhibitors: ■ PCSK9 Inhibitors

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

LIPOTROPICS, STATINS Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria Statins ■ Treatment failure with at least two preferred drugs atorvastatin* CRESTOR (rosuvastatin)* LIVALO (pitavastatin) accounting for no less than lovastatin* EZALLOR SPRINKLE (rosuvastatin) PRAVACHOL (pravastatin)* 120 days of therapy pravastatin* fluvastatin* ZOCOR (simvastatin)* combined rosuvastatin* fluvastatin ER ZYPITAMAG (pitavastatin) ■ Contraindication to simvastatin* LESCOL XL (fluvastatin) preferred drugs LIPITOR (atorvastatin)* ■ Allergic reaction to preferred drugs ■ Treatment of stage-four advanced, metastatic cancer and associated conditions ■ For drugs in a therapeutic class or subclass with no preferred option, the provider must obtain a PDL prior authorization

The following Clinical Prior Authorization applies to all drugs in the class: ■ Duplicate Therapy

Statin Combinations Dose Optimization applies to some strengths where a “*” is atorvastatin/amlodipine noted CADUET (atorvastatin/amlodipine) simvastatin/ezetimibe VYTORIN (simvastatin/ezetimibe)

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

MACROLIDES (ORAL) Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria azithromycin clarithromycin suspension erythromycin base filmtab ■ A 7-day treatment trial clarithromycin tablets clarithromycin ER erythromycin ethylsuccinate with at least one ERYPED (erythromycin) E.E.S. (erythromycin) suspension preferred agent in the last 180 days (Exception may erythromycin base ERY-TAB (erythromycin) ZITHROMAX (azithromycin) apply when a preferred ERYTHROCIN (erythromycin) drug requires less than a 7-day treatment trial) ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs ■ Treatment of stage-four advanced, metastatic cancer and associated conditions ■ For clients with diagnosis of Gastroparesis, Cerebral Palsy Gastroparesis, and GERD associated with Gastrostomy complications, a 90-day PA duration will be approved

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

MOVEMENT DISORDERS Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria AUSTEDO (deutetrabenazine) tetrabenazine ■ Treatment failure with INGREZZA (valbenazine) XENAZINE (tetrabenazine) preferred drugs within any subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs ■ Treatment of stage-four advanced, metastatic cancer and associated conditions

The following Clinical Prior Authorization applies to all drugs in the class: ■ VMAT2 Inhibitors

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

MULTIPLE SCLEROSIS AGENTS Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria AMPYRA (dalfampridine) ■ All of the agents in the AUBAGIO (teriflunomide) Multiple Sclerosis class are AVONEX (interferon beta-1a) preferred BAFIERTAM (monomethyl fumarate) BETASERON (interferon beta-1b) A drug specific prior COPAXONE (glatiramer) authorization applies to drugs with a hyperlink dalfampridine dimethyl fumarate EXTAVIA (interferon beta-1b) GILENYA (fingolimod) glatiramer KESIMPTA (ofatumumab) MAVENCLAD (cladribine) MAYZENT (siponimod) PLEGRIDY (peginterferon beta-1a) REBIF (interferon beta-1a) TECFIDERA (dimethyl fumarate) TYSABRI (natalizumab) VUMERITY (diroximel fumarate) ZEPOSIA (ozanimod)

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

NEUROPATHIC PAIN Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria Oral Agents ■ Treatment failure with preferred drugs within CYMBALTA (duloxetine) duloxetine (Cymbalta) any subclass RIZALMA SPRINKLE (duloxetine) gabapentin ■ Contraindication to pregabalin capsule duloxetine (Irenka) preferred drugs GABACAINE KIT ■ Allergic reaction to (gabapentin/lidocaine) preferred drugs GRALISE (gabapentin) ■ Treatment of stage-four HORIZANT (gabapentin enacarbil ER) advanced, metastatic cancer LYRICA (pregabalin) and associated conditions LYRICA CR (pregabalin) SAVELLA (milnacipran) A drug specific prior authorization applies to drugs with a hyperlink

Topical Agents capsaicin OTC lidocaine patch LIDODERM (lidocaine) LIDOPURE (lidocaine) ZILACAINEPATCH (lidocaine) ZTLIDO (lidocaine)

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

NSAIDS Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria Nonspecific

diclofenac potassium ADVIL (ibuprofen) ketorolac ■ Treatment failure with ibuprofen ALEVE (naproxen) meclofenamate preferred drugs within any subclass indomethacin capsules ANAPROX(naproxen) mefenamic acid ■ Contraindication to naproxen EC CHILDREN’S MOTRIN (ibuprofen) nabumetone preferred drugs naproxen sodium OTC DAYPRO (oxaprozin) NALFON (fenoprofen) ■ Allergic reaction to naproxen tablets NAPROSYN (naproxen) diclofenac sodium preferred drugs naproxen CR diclofenac SR ■ Treatment of stage-four diflunisal naproxen sodium (Rx) advanced, metastatic cancer etodolac naproxen suspension and associated conditions etodolac SR oxaprozin The following Clinical Prior FELDENE (piroxicam) piroxicam Authorization applies RELAFEN DS (nabumetone) to all drugs fenoprofen in the class: flurbiprofen sulindac ■ Duplicate Therapy INDOCIN (indomethacin) capsules, tolmetin suspension ZORVOLEX (diclofenac) A drug specific prior indomethacin ER capsules authorization applies to drugs ketoprofen with a hyperlink ketoprofen ER

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

NSAIDS continued Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria NSAID/GI Protectant Combinations

ARTHROTEC (diclofenac/misoprostol) ■ Treatment failure with diclofenac/misoprostol preferred drugs within DUEXIS (ibuprofen/famotidine) any subclass VIMOVO (naproxen/ esomeprazole) ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs ■ Treatment of stage-four advanced, metastatic cancer and associated conditions ■ For drugs in a therapeutic class or subclass with no preferred option, the provider must obtain a PDL prior authorization

The following Clinical Prior Authorization applies to all drugs in the class: ■ Duplicate Therapy

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

NSAIDS continued Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria COX-II Selective

meloxicam tablets* CELEBREX (celecoxib) ■ Treatment failure with celecoxib preferred drugs within MOBIC (meloxicam)* any subclass QMIIZ ODT (meloxicam) ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs ■ Treatment of stage-four advanced, metastatic cancer and associated conditions

The following Clinical Prior Authorization applies to all drugs in the class: ■ Duplicate Therapy ■ Cox II Inhibitors

Dose Optimization applies to some strengths where a “*” is noted

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

NSAIDS continued Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria Topical NSAIDs

diclofenac gel 1% FLECTOR (diclofenac) ■ Treatment failure with VOLTAREN gel (diclofenac) INDOCIN (indomethacin) suppositories preferred drugs within PENNSAID (diclofenac) any subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs ■ Treatment of stage-four advanced, metastatic cancer and associated conditions

The following Clinical Prior Authorization applies to all drugs in the class: ■ Duplicate Therapy

A drug specific prior authorization applies to drugs with a hyperlink

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

ONCOLOGY, ORAL - BREAST Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria anastrozole All of the agents in the ARIMIDEX (anastrozole) Oncology, Oral - Breast class are preferred AROMASIN (exemestane) capecitabine cyclophosphamide exemestane FARESTON (toremifene) FEMARA (letrozole) IBRANCE (palbociclib) KISQALI (ribociclib) KISQALI/FEMARA KIT (ribociclib/letrozole) letrozole NERLYNX (neratinib) PIQRAY (alpelisib) SOLTAMOX (tamoxifen) TALZENNA (talazoparib) tamoxifen toremifene TUKYSA (tucatinib) TYKERB (lapatinib) VERZENIO (abemaciclib) XELODA (capecitabine)

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021 u

ONCOLOGY, ORAL - HEMATOLOGIC Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria ALKERAN (melphalan) mercaptopurine All of the agents in the BOSULIF (bosutinib) MYLERAN (busulfan) Oncology, Oral - Hematologic class are preferred BRUKINSA (zanubrutinib) NINLARO (ixazomib) CALQUENCE (acalabrutinib) POMALYST (pomalidomide) COPIKTRA (duvelisib) PURIXAN (mercaptopurine) DAURISMO (glasdegib) REVLIMID (lenalidomide) FARYDAK (panobinostat) RYDAPT (midostaurin) GLEEVEC (imatinib) SPRYCEL (dasatinib) ICLUSIG (ponatinib) TABLOID (thioguanine) IDHIFA (enasidenib) TASIGNA (nilotinib) imatinib THALOMID (thalidomide) IMBRUVICA (ibrutinib) TIBSOVO (ivosidenib) INQOVI (decitabine/cedazuridine) tretinoin INREBIC (fedratinib) VENCLEXTA (venetoclax) JAKAFI (ruxolitinib) XOSPATA (gilteritinib) LEUKERAN (chlorambucil) XPOVIO (selinexor) MATULANE (procarbazine) ZOLINZA (vorinostat) melphalan ZYDELIG (idelalisib)

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

ONCOLOGY, ORAL - LUNG Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria ALECENSA (alectinib) All of the agents in the ALUNBRIG (brigatinib) Oncology, Oral - Lung class are preferred erlotinib GILOTRIF (afatinib) HYCAMTIN (topotecan) IRESSA (gefitinib) LORBRENA (lorlatinib) RETEVMO (selpercatinib) ROZLYTREK (entrectinib) TABRECTA (capmatinib) TAGRISSO (osimertinib) TARCEVA (erlotinib) VIZIMPRO (dacomitinib) XALKORI (crizotinib) ZYKADIA (ceritinib)

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

ONCOLOGY, ORAL - OTHER Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria AYVAKIT (avapritinib) All of the agents in the BALVERSA (erdafitinib) Oncology, Oral - Other class are preferred CAPRELSA (vandetanib) COMETRIQ (cabozantinib) KOSELUGO (selumetinib) LONSURF (trifluridine/tipiracil) LYNPARZA (olaparib) PEMAZYRE (pemigatinib) QINLOCK (ripretinib) RUBRACA (rucaparib) STIVARGA (regorafenib) TAZVERIK (tazemetostat) TEMODAR (temozolomide) temozolomide TURALIO (pexidartinib) VITRAKVI (larotrectinib) ZEJULA (niraparib)

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

ONCOLOGY, ORAL - PROSTATE Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria abiraterone All of the agents in the bicalutamide Oncology, Oral - Prostate class are preferred EMCYT (estramustine) ERLEADA (apalutamide) flutamide nilutamide NUBEQA (darolutamide) XTANDI (enzalutamide) YONSA (abiraterone) ZYTIGA (abiraterone)

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

ONCOLOGY, ORAL – RENAL CELL Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria AFINITOR (everolimus) All of the agents in the CABOMETYX (cabozantinib) Oncology, Oral – Renal Cell class are preferred everolimus INLYTA (axitinib) NAXAVAR (sorafenib) SUTENT (sunitinib) VOTRIENT (pazopanib)

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

ONCOLOGY, ORAL – SKIN Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria BRAFTOVI (encorafenib) All of the agents in the COTELLIC (cobimetinib) Oncology, Oral – Skin class are preferred ERIVEDGE (vismodegib)

MEKINIST (trametinib) A drug specific prior MEKTOVI (binimetinib) authorization applies to drugs ODOMZO (sonidegib) with a hyperlink TAFINLAR (dabrafenib) ZELBORAF (vemurafenib)

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

OPHTHALMICS, ANTIBIOTIC – STEROID COMBINATIONS Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria BLEPHAMIDE (sulfacetamide/prednisolone) BLEPHAMIDE S.O.P. (sulfacetamide/prednisolone) ■ Treatment failure with neomycin/polymyxin/dexamethasone MAXITROL (neomycin/polymyxin/ dexamethasone) preferred drugs within sulfacetamide/prednisolone neomycin/bacitracin/polymyxin/hydrocortisone any subclass TOBRADEX (tobramycin/dexamethasone) ointment neomycin/polymyxin/hydrocortisone ■ Contraindication to preferred drugs PRED-G (gentamicin/prednisolone) ■ Allergic reaction to TOBRADEX (tobramycin/dexamethasone) suspension preferred drugs TOBRADEX ST (tobramycin/dexamethasone) ■ Treatment of stage-four tobramycin/dexamethasone advanced, metastatic cancer ZYLET (tobramycin/loteprednol) and associated conditions

OPHTHALMIC ANTIBIOTICS Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria Aminoglycosides

GENTAK (gentamicin) TOBREX (tobramycin) solution ■ Treatment failure with gentamicin preferred drugs within tobramycin any subclass TOBREX (tobramycin) ointment ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs ■ Treatment of stage-four advanced, metastatic cancer and associated conditions

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OPHTHALMIC ANTIBIOTICS continued Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria Quinolones ■ Treatment failure with preferred drugs within ciprofloxacin BESIVANCE (besifloxacin) any subclass ofloxacin CILOXAN (ciprofloxacin) ■ Contraindication to preferred drugs gatifloxacin ■ Allergic reaction to levofloxacin preferred drugs MOXEZA (moxifloxacin) ■ Treatment of stage-four moxifloxacin advanced, metastatic cancer OCUFLOX (ofloxacin) and associated conditions VIGAMOX (moxifloxacin)

Macrolides

erythromycin AZASITE (azithromycin)

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021 OPHTHALMIC ANTIBIOTICS continued Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria Other

bacitracin/polymyxin bacitracin ■ Treatment failure with polymyxin/trimethoprim BLEPH-10 (sulfacetamide) preferred drugs within NATACYN (natamycin) any subclass neomycin/bacitracin/polymyxin ■ Contraindication to preferred drugs neomycin/polymyxin/gramicidin ■ Allergic reaction to POLYTRIM (polymyxin/trimethoprim) preferred drugs sulfacetamide ointment, solution ■ Treatment of stage-four advanced, metastatic cancer and associated conditions

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

OPHTHALMICS FOR ALLERGIC CONJUNCTIVITIS Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria cromolyn ALOCRIL (nedocromil) ketotifen ■ Treatment failure with PAZEO (olopatadine) ALOMIDE (lodoxamide) LASTACAFT (alcaftadine) preferred drugs within ALREX (loteprednol) olopatadine any subclass azelastine PATADAY (olopatadine) ■ Contraindication to preferred drugs BEPREVE (bepotastine) PATADAY OTC (olopatadine) ■ Allergic reaction to ELESTAT (epinastine) PATANOL (olopatadine) preferred drugs EMADINE (emedastine) ZERVIATE (cetirizine) ■ Treatment of stage-four epinastine advanced, metastatic cancer and associated conditions

OPHTHALMICS, ANTI-INFLAMMATORIES Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria NSAIDS

diclofenac ACULAR (ketorolac) ■ Treatment failure with ketorolac ACULAR LS (ketorolac) preferred drugs within ACUVAIL (ketorolac) any subclass bromfenac ■ Contraindication to preferred drugs flurbiprofen ■ Allergic reaction to ILEVRO (nepafenac) preferred drugs ketorolac LS ■ Treatment of stage-four NEVANAC (nepafenac) advanced, metastatic cancer and associated conditions

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OPHTHALMICS, ANTI-INFLAMMATORIES continued Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria Steroids

DUREZOL (difluprednate) dexamethasone MAXIDEX (dexamethasone) ■ Treatment failure with LOTEMAX (loteprednol) ointment FLAREX (fluorometholone) OMNIPRED (prednisolone) preferred drugs within any subclass prednisolone acetate fluorometholone PRED FORTE (prednisolone) ■ Contraindication to FML (fluorometholone) PRED MILD (prednisolone) preferred drugs FML FORTE (fluorometholone) prednisolone sodium phosphate ■ Allergic reaction to ML S.O.P. (fluorometholone) preferred drugs ■ Treatment of stage-four INVELTYS (loteprednol) advanced, metastatic cancer LOTEMAX (loteprednol) gel, suspension and associated conditions loteprednol

OPHTHALMICS, ANTI-INFLAMMATORY IMMUNOMODULATORS Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria RESTASIS (cyclosporine) RESTASIS MULTIDOSE (cyclosporine) ■ Treatment failure with CEQUA (cyclosporine) preferred drugs within XIIDRA (lifitegrast) any subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs ■ Treatment of stage-four advanced, metastatic cancer and associated conditions

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

OPHTHALMICS, GLAUCOMA AGENTS Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria Sympathomimetics ■ Treatment failure with preferred drugs within brimonidine ALPHAGAN P (brimonidine) any subclass pilocarpine apraclonidine ■ Contraindication to brimonidine P preferred drugs IOPIDINE (apraclonidine) ■ Allergic reaction to preferred drugs ■ Treatment of stage-four advanced, metastatic cancer and associated conditions

Beta Blockers carteolol betaxolol levobunolol BETOPTIC S (betaxolol) timolol ISTALOL (timolol) timolol (Istalol) TIMOPTIC (timolol) TIMOPTIC XE (timolol)

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

OPHTHALMICS, GLAUCOMA AGENTS continued Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria

Carbonic Anhydrase Inhibitors

AZOPT (brinzolamide) TRUSOPT (dorzolamide) ■ Treatment failure with dorzolamide preferred drugs within any subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs ■ Treatment of stage-four advanced, metastatic cancer and associated conditions

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

OPHTHALMICS, GLAUCOMA AGENTS continued Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria Rho Kinase Inhibitor ■ Treatment failure with RHOPRESSA (netarsudil) preferred drugs within any subclass ROCKLATAN (netarsudil/latanoprost) ■ Contraindication to Prostaglandin Analogs preferred drugs latanoprost bimatoprost ■ Allergic reaction to preferred drugs TRAVATAN-Z (travoprost) LUMIGAN (bimatoprost) ■ Treatment of stage-four VYZULTA (latanoprostene bunod) advanced, metastatic cancer XALATAN (latanoprost) and associated conditions XELPROS (latanoprost) ■ For drugs in a therapeutic ZIOPTAN (tafluprost) class or subclass with no preferred option, the provider must obtain a PDL prior authorization

Combination Agents COMBIGAN (brimonidine/timolol) COSOPT (dorzolamide/timolol) dorzolamide/timolol COSOPT PF (dorzolamide/timolol) SIMBRINZA (brinzolamide/brimonidine) dorzolamide/timolol

Miscellaneous phospholine iodide

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021 OPIATE DEPENDENCE TREATMENTS Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria BUNAVAIL (buprenorphine/naloxone)* ■ Treatment failure with buprenorphine* preferred drugs within buprenorphine/naloxone* any subclass LUCEMYRA (lofexidine) ■ Contraindication to preferred drugs naloxone syringe, vial ■ Allergic reaction to naltrexone preferred drugs NARCAN (naloxone) nasal ■ Treatment of stage-four SUBOXONE (buprenorphine/naloxone) film* advanced, metastatic cancer VIVITROL (naltrexone) and associated conditions ZUBSOLV (buprenorphine/naloxone)* The following Clinical Prior Authorization applies to drugs with an “*” in the class: ■ Duplicate Therapy ■ Opiate/Benzodiazepine/Mus cle Relaxant

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021 OTIC ANTIBIOTICS Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria CIPRODEX (ciprofloxacin/dexamethasone) CIPRO HC (ciprofloxacin/hydrocortisone) ■ Treatment failure with neomycin/polymyxin/hydrocortisone COLY-MYCIN S (colistin/neomycin/hydrocortisone) preferred drugs within ofloxacin ciprofloxacin any subclass OTOVEL (ciprofloxacin/fluocinolone) ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs ■ Treatment of stage-four advanced, metastatic cancer and associated conditions OTIC ANTI-INFECTIVES/ANESTHETICS Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria acetic acid acetic acid/hydrocortisone ■ Treatment failure with PINNACAINE (benzocaine) preferred drugs within any subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs ■ Treatment of stage-four advanced, metastatic cancer and associated conditions

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021 PAH AGENTS (ORAL, INHALATION) Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria ADCIRCA (tadalafil) ADEMPAS (riociguat) ■ Treatment failure with ambrisentan LETAIRIS (ambrisentan) preferred drugs within REVATIO (sildenafil) suspension OPSUMIT (macitentan) any subclass sildenafil tablet (generic Revatio) ORENITRAM ER (treprostinil) ■ Contraindication to preferred drugs TRACLEER (bosentan) tablet REVATIO (sildenafil) ■ Allergic reaction sildenafil suspension (generic to preferred drugs Revatio) ■ Treatment of stage-four tadalafil (generic Adcirca) advanced, metastatic cancer TRACLEER (bosentan) suspension and associated conditions TYVASO Inhalation (treprostinil) UPTRAVI (selexipag) A drug specific prior VENTAVIS Inhalation (iloprost) authorization applies to drugs with a hyperlink

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

PANCREATIC ENZYMES Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria CREON (pancrelipase) PANCREAZE (pancrelipase) ■ Treatment failure with ZENPEP (pancrelipase) PERTZYE (pancrelipase) preferred drugs within VIOKACE (pancrelipase) any subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs ■ Treatment of stage-four advanced, metastatic cancer and associated conditions

PEDIATRIC VITAMIN PREPARATIONS See Separate Listing Of Preferred Pediatric Vitamin Preparations. ■ Treatment failure with preferred drugs within any subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs ■ Treatment of stage-four advanced, metastatic cancer and associated conditions

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

PENICILLINS Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria amoxicillin ■ Treatment failure with ampicillin preferred drugs within dicloxacillin any subclass penicillin VK ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs ■ Treatment of stage-four advanced, metastatic cancer and associated conditions

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

PHOSPHATE BINDERS Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria calcium acetate AURYXIA (ferric citrate) ■ Treatment failure with RENAGEL (sevelamer HCl) ELIPHOS (calcium acetate) preferred drug FOSRENOL (lanthanum) ■ Allergic reaction to lanthanum preferred drugs PHOSLYRA (calcium acetate) ■ Treatment of stage-four advanced, metastatic cancer RENVELA (sevelamer carbonate) and associated conditions sevelamer ■ Diagnosis of ESRD, VELPHORO (sucroferric oxyhydroxide) hyperphosphatemia AND at least one of the following:  Hypercalcemia (corrected serum calcium >10.2 mg/dL)  Plasma PTH levels <150 pg/mL on two consecutive measurements  Dialysis patients with severe vascular and/or soft tissue calcifications

A drug specific prior authorization applies to drugs with a hyperlink

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

PLATELET AGGREGATION INHIBITORS Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria AGGRENOX (dipyridamole/aspirin) dipyridamole ■ Treatment failure BRILINTA (ticagrelor) dipyridamole/aspirin with preferred drug clopidogrel EFFIENT (prasugrel) ■ Contraindication to prasugrel PLAVIX (clopidogrel) preferred drug ZONTIVITY (vorapaxar) ■ Allergic reaction to preferred drug ■ Treatment of stage-four advanced, metastatic cancer and associated conditions

A drug specific prior authorization applies to drugs with a hyperlink

PRENATAL VITAMINS See Separate Preferred Prenatal Vitamin Listing. ■ Treatment failure with preferred drugs within any subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs ■ Treatment of stage-four advanced, metastatic cancer and associated conditions ■ Prenatal vitamins are covered only for females less than 50 years of age.

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

PROGESTATIONAL AGENTS Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria MAKENA AUTO INJECTOR hydroxyprogesterone ■ Treatment failure (hydroxyprogesterone) with preferred drug MAKENA (hydroxyprogesterone) ■ Contraindication to preferred drug ■ Allergic reaction to preferred drug ■ Treatment of stage-four advanced, metastatic cancer and associated conditions

A drug specific clinical prior authorization applies to drugs with a hyperlink

PROGESTINS FOR CACHEXIA Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria megestrol suspension, tablets megestrol ES suspension (generic ■ Treatment failure with Megace ES) preferred drug ■ Contraindication to preferred drug ■ Allergic reaction to preferred drug ■ Treatment of stage-four advanced, metastatic cancer and associated conditions

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

PROTON PUMP INHIBITORS (ORAL) Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria omeprazole Rx* ACIPHEX (rabeprazole) rabeprazole ■ Treatment failure after no pantoprazole* DEXILANT (dexlansoprazole) ZEGERID (omeprazole/sodium less than a 30-day trial of NEXIUM suspension (esomeprazole) esomeprazole* bicarbonate) each preferred drug PROTONIX (pantoprazole) suspension lansoprazole* ■ Contraindication to preferred drugs NEXIUM capsules (esomeprazole)* ■ Allergic reaction NEXIUM OTC (esomeprazole)* to preferred drugs omeprazole OTC* ■ Treatment of stage-four omeprazole/sodium bicarbonate advanced, metastatic cancer PREVACID (lansoprazole)* and associated conditions PROTONIX tablets (pantoprazole)* ■ Prevacid Solutabs will be approved for children 10 years of age and under

The following Clinical Prior Authorization applies to all drugs in the class: ■ Proton Pump Inhibitor

Dose Optimization applies to some strengths where a “*” is noted

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

ROSACEA AGENTS, TOPICAL Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria metronidazole cream, gel azelaic acid ■ Treatment failure after no FINACEA (azelaic acid) less than a 30-day trial of ivermectin every preferred drug METROCREAM (metronidazole) ■ Contraindication to METROGEL (metronidazole) preferred drugs metronidazole lotion ■ Allergic reaction to preferred drugs MIRVASO (brimonidine) ■ Treatment of stage-four NORITATE (metronidazole) advanced, metastatic cancer RHOFADE (oxymetazoline) and associated conditions ROSADAN KIT (metronidazole) SOOLANTRA (ivermectin) The following Clinical Prior Authorization applies to all drugs in the class: ■ Rosacea Agents, Topical

Dose Optimization applies to some strengths where a “*” is noted

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

SEDATIVE HYPNOTICS Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria Benzodiazepines

flurazepam DAYVIGO (lemborexant) ■ Treatment failure with temazepam 15, 30 mg Estazolam preferred drugs within triazolam RESTORIL (temazepam) any subclass temazepam 7.5, 22.5 mg ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs ■ Treatment of stage-four advanced, metastatic cancer and associated conditions

The following Clinical Prior Authorization applies to all drugs in the class: ■ Anxiolytics and Sedatives/Hypnotics ■ Opiate/Benzodiazepine/Mus cle Relaxant

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

SEDATIVE HYPNOTICS continued Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria Others

eszopiclone AMBIEN (zolpidem) LUNESTA (eszopiclone) ■ Treatment failure with zaleplon AMBIEN CR (zolpidem) ROZEREM (ramelteon) preferred drugs within zolpidem BELSOMRA (suvorexant) SILENOR (doxepin) any subclass EDLUAR (zolpidem) SONATA (zaleplon) ■ Contraindication to preferred drugs HETLIOZ (tasimelteon) zolpidem ER ■ Allergic reaction to INTERMEZZO (zolpidem) preferred drugs ■ Treatment of stage-four advanced, metastatic cancer and associated conditions

A drug specific prior authorization applies to drugs with a hyperlink

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

SICKLE CELL ANEMIA TREATMENTS Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria DROXIA (hydroxyurea) ENDARI (glutamine) ■ Treatment failure with hydroxyurea OXBRYTA (voxelotor)* preferred drugs within any subclass SIKLOS (hydroxyurea) ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs ■ Treatment of stage-four advanced, metastatic cancer and associated conditions

The following Clinical Prior Authorization applies to drugs with an “*” in the class: ■ Sickle Cell Anemia Treatments

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

SKELETAL MUSCLE RELAXANTS Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria baclofen AMRIX (cyclobenzaprine ER)* LORZONE (chlorzoxazone)* ■ Treatment failure with carisoprodol (except 250 mg)* carisoprodol 250 mg* metaxolone* preferred drugs within cyclobenzaprine* carisoprodol compound NORGESIC FORTE any subclass methocarbamol* chlorzoxazone* (orphenadrine/aspririn/caffeine) ■ Contraindication to preferred drugs tizanidine tablets DANTRIUM (dantrolene) orphenadrine* ■ Allergic reaction to dantrolene ROBAXIN (methocarbamol)* preferred drugs FEXMID (carisoprodol)* SKELAXIN (metaxolone)* ■ Treatment of stage-four SOMA (carisoprodol)* advanced, metastatic cancer tizanidine capsules and associated conditions ZANAFLEX (tizanidine) The following Clinical Prior Authorization applies to drugs with an “*” in the class: ■ Opiate/Benzodiazepine/Mus cle Relaxant

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

SMOKING CESSATION Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria bupropion SR NICODERM CQ (nicotine) ■ Treatment failure with CHANTIX (varenicline) NICORETTE (nicotine) gum preferred drugs within nicotine gum NICORETTE (nicotine) lozenge any subclass nicotine lozenge NICOTROL (nicotine) ■ Contraindication to preferred drugs nicotine patch NICOTROL NS (nicotine) ■ Allergic reaction to ZYBAN (bupropion) preferred drugs ■ Treatment of stage-four advanced, metastatic cancer and associated conditions

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

STEROIDS, TOPICAL Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria Low Potency ■ Treatment failure with preferred drugs within DERMA-SMOOTHE/FS (fluocinolone) alclometasone MICORT-HC (hydrocortisone) any subclass hydrocortisone cream, ointment DESONATE (desonide) TEXACORT (hydrocortisone) solution ■ Contraindication to hydrocortisone/aloe cream desonide preferred drugs PROCTOSOL-HC (hydrocortisone) fluocinolone oil ■ Allergic reaction to hydrocortisone lotion (Rx) preferred drugs ■ Treatment of stage-four advanced, metastatic cancer and associated conditions

Medium Potency

fluticasone propionate cream, ointment beclomethasone valerate foam fluticasone propionate lotion mometasone cream, ointment, solution BESER KIT (fluticasone) hydrocortisone butyrate clocortolone cream hydrocortisone valerate CLODERM (clocortolone) LUXIQ (betamethasone) CORDRAN (flurandrenolide) PANDEL (hydrocortisone probutate) CUTIVATE (fluticasone) prednicarbate ELOCON (mometasone) fluocinolone acetonide flurandrenolide

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

STEROIDS, TOPICAL continued Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria High Potency ■ Treatment failure with preferred drugs within betamethasone dipropionate lotion Amcinonide fluocinonide any subclass betamethasone dipropionate/propylene glycol cream betamethasone dipropionate cream, HALOG (halcinonide) ■ Contraindication to betamethasone valerate cream, ointment gel, ointment KENALOG aerosol (triamcinolone) preferred drugs triamcinolone acetonide cream, lotion, ointment betamethasone dipropionate/ SERNIVO (betamethasone ■ Allergic reaction to propylene glycol lotion, ointment dipropionate) preferred drugs betamethasone valerate lotion, TOPICORT (desoximetasone) ■ Treatment of stage-four desoximetasone triamcinolone acetonide aerosol, advanced, metastatic cancer and associated conditions diflorasone TRIANEX (triamcinolone) DIPROLENE (betamethasone VANOS (fluocinonide) dipropionate)

Very High Potency

clobetasol emollient APEXICON E (diflorasone) TEMOVATE (clobetasol) clobetasol propionate cream, gel, ointment, solution BRYHALI (halobetasol propionate) ULTRAVATE (halobetasol propionate) halobetasol cream, ointment clobetasol lotion, shampoo ULTRAVATE X PAC (halobetasol/lactic clobetasol propionate foam, spray acid) CLOBEX (clobetasol) halobetasol foam LEXETTE (halobetasol propionate) OLUX (clobetasol)

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

STIMULANTS AND RELATED AGENTS Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria Stimulants

amphetamine salt combination IR ADDERALL XR (amphetamine salt JORNAY PM (methylphenidate ER)* ■ Treatment failure with amphetamine salt combination ER* combination)* methamphetamine preferred drugs within APTENSIO XR (methylphenidate) ADHANSIA XR (methylphenidate) methylphenidate CD* any subclass DAYTRANA (methylphenidate)* ADZENYS XR ODT (amphetamine) methylphenidate chewable tablets ■ Contraindication to preferred drugs dexmethylphenidate IR ADZENYS ER (amphetamine) methylphenidate ER* ■ Allergic reaction to dexmethylphenidate ER* suspension methylphenidate solution preferred drugs dextroamphetamine IR amphetamine salt combination ER* modafinil amphetamine sulfate ■ Treatment of stage-four DYANAVEL XR (amphetamine) MYDAYIS (amphetamine salt advanced, metastatic cancer armodafinil METHYLIN (methylphenidate) solution combination ER) and associated conditions methylphenidate IR CONCERTA (methylphenidate)* NUVIGIL (armodafinil) COTEMPLA XR ODT methylphenidate ER (authorized generic Concerta)* PROCENTRA (dextroamphetamine) A drug specific prior (methylphenidate) QUILLICHEW ER (methylphenidate) PROVIGIL (modafinil) authorization applies to drugs DESOXYN (methamphetamine) QUILLIVANT XR (methylphenidate) RITALIN (methylphenidate) with a hyperlink DEXEDRINE (dextroamphetamine) VYVANSE (lisdexamfetamine) RITALIN LA (methylphenidate ER)* dextroamphetamine ER VYVANSE (lisdexamfetamine) chewable tablets SUNOSI (solriamfetol) Dose Optimization applies to dextroamphetamine solution ZENZEDI (dextroamphetamine) some strengths where a “*” is EVEKEO (amphetamine) noted FOCALIN (dexmethylphenidate) FOCALIN XR (dexmethylphenidate)*

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

STIMULANTS AND RELATED AGENTS continued Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria Non-Stimulants

atomoxetine clonidine ER ■ Treatment failure with guanfacine ER INTUNIV (guanfacine ER) preferred drugs within STRATTERA (atomoxetine) any subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs ■ Treatment of stage-four advanced, metastatic cancer and associated conditions

The following Clinical Prior Authorization applies to all drugs in the class: ■ ADHD Agents

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

TETRACYCLINES Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria doxycycline hyclate capsule demeclocycline MINOLIRA ER (minocycline) ■ Treatment failure with doxycycline monohydrate 50, 100 mg capsules doxycycline hyclate IR NUZYRA tablet (omadacycline) preferred drugs within any subclass minocycline capsules doxycycline hyclate DR ORACEA (doxycycline) ■ Contraindication to VIBRAMYCIN (doxycycline) suspension doxycycline monohydrate 40, 75, 150 SOLODYN (minocycline) preferred drugs mg capsules tetracycline ■ Allergic reaction to doxycycline monohydrate suspension, VIBRAMYCIN (doxycycline) capsule, preferred drugs tablets syrup minocycline tablets ■ Treatment of stage-four advanced, metastatic cancer minocycline ER and associated conditions

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

THROMBOPOIESIS STIMULATING PROTEINS Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria NPLATE (romiplostim) DOPTELET (avatrombopag) ■ Treatment failure with PROMACTA (eltrombopag) MULPLETA (lusutrombopag) preferred drugs within TAVALISSE (fostamatinib) any subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs ■ Treatment of stage-four advanced, metastatic cancer and associated conditions Rectal

mesalamine CANASA (mesalamine) ■ Treatment failure with UCERIS (budesonide) preferred drugs ■ Contraindication to preferred drugs of same route ■ Allergic reaction to preferred drugs of same route ■ Treatment of stage-four advanced, metastatic cancer and associated conditions

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

ULCERATIVE COLITIS Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria Oral

DELZICOL (mesalamine) APRISO (mesalamine) DIPENTUM (olsalazine) ■ Treatment failure with LIALDA (mesalamine) ASACOL HD (mesalamine) GIAZO (balsalazide) preferred drugs sulfasalazine AZULFIDINE (sulfasalazine) mesalamine ■ Contraindication to sulfasalazine DR balsalazide PENTASA (mesalamine) preferred drugs of same route budesonide DR UCERIS (budesonide) ■ Allergic reaction to COLAZAL (balsalazide) preferred drugs of same route ■ Treatment of stage-four advanced, metastatic cancer and associated conditions

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 28, 2021

UREA CYCLE DISORDERS Preferred Agents Non-Preferred Agents PA Criteria Client must meet at least one of the listed PA criteria BUPHENYL (sodium phenylbutyrate) RAVICTI (glycerol phenylbutyrate) ■ Treatment failure with CARBAGLU (carglumic acid) sodium phenylbutyrate powder preferred drugs within any subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs ■ Treatment of stage-four advanced, metastatic cancer and associated conditions

The following Clinical Prior Authorization applies to all drugs in the class: ■ Urea Cycle Disorders

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PDL and PA CRITERIA

For all classes listed below the standard PA criteria apply: ■ Treatment failure with preferred drugs within any subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs ■ Treatment of stage-four advanced, metastatic cancer and associated conditions

COUGH AND COLD ORAL Preferred Agents Non-Preferred Agents Agent Ingredients Agent Ingredients ALA-HIST IR TABLET OTC (ORAL) dexbrompheniramine maleate DEXBROMPHENIRAMINE/PHENYLEPHRINE OTC (ORAL) dexbrompheniramin/phenylephrin ALA-HIST PE TABLET OTC (ORAL) dexbrompheniramin/phenylephrin DIPHENHYDRAMINE/PHENYLEPHRINE/APAP POWDER PACK OTC (ORAL) diphenhyd/phenyleph/acetaminop CHILDREN'S MUCINEX LIQUID OTC (C) (ORAL) diphenhyd/phenyleph/acetaminop DOXYLAMINE/PHENYLEPHRINE OTC (ORAL) doxylamine/phenylephrine HCl DECONEX IR TABLET OTC (ORAL) guaifenesin/phenylephrine HCl ED A-HIST LIQUID OTC (ORAL) chlorpheniramine/phenylephrine ED A-HIST TABLET OTC (ORAL) chlorpheniramine/phenylephrine GUAIFENESIN/PHENYLEPHRINE TABLET OTC (ORAL) guaifenesin/phenylephrine HCl ED BRON GP LIQUID OTC (ORAL) guaifenesin/phenylephrine HCl GUAIFENESIN/PHENYLEPHRINE TABLET OTC (ORAL) guaifenesin/pseudoephedrne HCl GUAIFENESIN 200 MG TABLET OTC (ORAL) guaifenesin GUAIFENESIN/PHENYLEPHRINE/APAP TABLET OTC (ORAL) guaifen/phenyleph/acetaminophn GUAIFENESIN 400 MG TABLET OTC (ORAL) guaifenesin GUAIFENESIN/PSEUDOEPHEDRNE TABLET OTC (ORAL) guaifenesin/pseudoephedrne HCl GUAIFENESIN LIQUID OTC (ORAL) guaifenesin LOHIST-D LIQUID OTC (ORAL) chlorpheniramine/pseudoephed GUAIFENESIN TABLET ER OTC (ORAL) guaifenesin LORTUSS LQ LIQUID OTC (ORAL) doxylamine/pseudoephedrine HCl GUAIFENESIN/PSE TABLET ER OTC (ORAL) guaifenesin/pseudoephedrne HCl MUCINEX FAST-MAX NITE COLD-FLU LIQUID OTC (ORAL) diphenhyd/phenyleph/acetaminop HISTEX-PE LIQUID OTC (ORAL) phenylephrine HCl/triprolidine PHENYLEPHRINE/APAP TABLET OTC (ORAL) phenylephrine HCl/acetaminophn MUCINEX D TABLET ER 12H OTC (ORAL) guaifenesin/pseudoephedrne HCl PHENYLEPHRINE/APAP/CHLORPHENIRAMINE TABLET OTC (ORAL) phenylephrine/acetaminophn/cpm MUCINEX ER TABLET OTC (ORAL) guaifenesin PHENYLEPHRINE/BROMPHENIRAMINE TABLET OTC (ORAL) brompheniramine/phenylephrine MUCINEX FAST-MAX COLD-SINUS TABLET OTC (ORAL) guaifen/phenyleph/acetaminophn POLY-VENT IR TABLET OTC (ORAL) guaifenesin/pseudoephedrne HCl MUCINEX GRAN PACK OTC (ORAL) guaifenesin RESCON TABLET OTC (ORAL) dexchlorpheniramin/pseudoephed MUCUS-CHEST CONGESTION LIQUID OTC (ORAL) guaifenesin RESCON-GG LIQUID OTC (ORAL) guaifenesin/phenylephrine HCl NASOPEN PE LIQUID OTC (ORAL) thonzylamine/phenylephrine RYMED TABLET OTC (ORAL) dexchlorpheniram/phenylephrine NOHIST-LQ LIQUID OTC (ORAL) chlorpheniramine/phenylephrine STAHIST AD TABLET OTC (ORAL) chlorcyclizine/pseudoephedrine POLY HIST FORTE TABLET OTC (ORAL) doxylamine/phenylephrine HCl PSE/CHLORPHENIRAMINE TABLET OTC (ORAL) chlorpheniramine/pseudoephed PSE/TRIPROLIDINE TABLET OTC (ORAL) triprolidine/pseudoephedrine RYNEX PE SOLUTION OTC (ORAL) brompheniramine/phenylephrine RYNEX PSE LIQUID OTC (ORAL) brompheniramin/pseudoephedrine

COUGH AND COLD NASAL Preferred Agents Non-Preferred Agents Agent Ingredients Agent Ingredients OXYMETAZOLINE 12 HR NASAL SPRAY OTC (NASAL) oxymetazoline HCl

COUGH AND COLD, NARCOTIC Preferred Agents Non-Preferred Agents Agent Ingredients Agent Ingredients GUAIFENESIN/CODEINE LIQUID OTC (ORAL) codeine phosphate/guaifenesin GUAIFENESIN/PSE/CODEINE SYRUP OTC (ORAL) pseudoephed/codeine/guaifen PROMETHAZINE/CODEINE SYRUP (ORAL) promethazine HCl/codeine HYDROCODONE/CHLORPHENIRAMINE SUSPENSION ER 12H (ORAL) hydrocodone/chlorphen p-stirex HYDROCODONE/HOMATROPINE SYRUP (ORAL) hydrocodone bit/homatrop me-br HYDROCODONE/HOMATROPINE TABLET (ORAL) hydrocodone bit/homatrop me-br NINJACOF-XG LIQUID OTC (ORAL) codeine phosphate/guaifenesin

COUGH AND COLD, NON-NARCOTIC Preferred Agents Non-Preferred Agents Agent Ingredients Agent Ingredients ALA-HIST DM LIQUID OTC (ORAL) d-methorphan/pe/dexbromphenir CHILDREN'S DAYCLEAR ALLERGY CHEWABLE OTC (ORAL) pyrilamine/chlophedianol ALAHIST CF TABLET OTC (ORAL) d-methorphan/pe/dexbromphenir CHLO TUSS LIQUID OTC (ORAL) dexbromphen/pseudoeph/chlophed BENZONATATE CAPSULE (ORAL) benzonatate DM/APAP/DOXYLAMINE CAPSULE OTC (ORAL) DM/acetaminophen/doxylamine BROM-PSE-DM SYRUP (ORAL) brompheniramine/pseudoephed/DM DM/APAP/DOXYLAMINE LIQUID OTC (ORAL) DM/acetaminophen/doxylamine BROMPHENIRAMINE/PHENYLEPHRINE/DM SOLUTION OTC (ORAL) brompheniram/phenylephrine/DM DM/CHLORPHENIRAMINE TABLET OTC (ORAL) chlorpheniramine/dextromethorp BROTAPP DM ELIXIR OTC (ORAL) brompheniramine/pseudoephed/DM DM/PHENYLEPHRINE/APAP CAPSULE OTC (ORAL) d-methorphan/PE/acetaminophen CHILD MUCINEX M-S COLD DAY-NTE LIQUID SEQUELES OTC (ORAL) diphenhydram/PE/DM/acetamin/GG DM/PHENYLEPHRINE/APAP LIQUID OTC (ORAL) d-methorphan/PE/acetaminophen CHILDREN'S MUCINEX LIQUID OTC (NN) (ORAL) guaifen/dextromethorphan/PE DM/PHENYLEPHRINE/APAP POWDER PACK OTC (ORAL) d-methorphan/PE/acetaminophen CHILDREN'S MUCINEX LIQUID OTC (NN) (ORAL) phenylephrine/DM/acetaminop/GG DM/PHENYLEPHRINE/APAP TABLET OTC (ORAL) d-methorphan/PE/acetaminophen DECONEX DMX TABLET OTC (ORAL) guaifen/dextromethorphan/PE DM/PHENYLEPHRINE/APAP/DOXYLAMINE LIQUID OTC (ORAL) DM/PE/acetaminophen/doxylamine DELSYM SUSPENSION ER 12H OTC (ORAL) dextromethorphan polistirex DURAFLU TABLET OTC (ORAL) pseudoeph/DM/guaifen/acetamin DEXTROMETHORPHAN CAPSULE OTC (ORAL) dextromethorphan HBr ED A-HIST DM TABLET OTC (ORAL) chlorpheniramine/phenyleph/DM DEXTROMETHORPHAN SUSPENSION ER 12H OTC (ORAL) dextromethorphan polistirex GUAIFENESIN/DM TABLET OTC (ORAL) guaifenesin/dextromethorphan DM/PSE/CHLORPHENIRAMINE LIQUID OTC (ORAL) chlorpheniramin/pseudoephed/DM M-END DMX LIQUID OTC (ORAL) dexbromphen/pseudoephedrine/DM ED-A-HIST DM LIQUID OTC (ORAL) chlorpheniramine/phenyleph/DM MUCINEX FAST-MAX DAY-NITE COLD LIQUID SEQ OTC (ORAL) diphenhydram/PE/DM/acetamin/GG GUAIFEN/DEXTROMETHORPHAN/PE OTC (ORAL) guaifen/dextromethorphan/PE MUCINEX FAST-MAX DAY-NITE CONG TABLET OTC (ORAL) diphenhydram/PE/DM/acetamin/GG GUAIFENESIN/DM LIQUID OTC (ORAL) guaifenesin/dextromethorphan MUCINEX FAST-MAX SEVERE COLD LIQUID OTC (ORAL) phenylephrine/DM/acetaminop/GG GUAIFENESIN/DM TABLET ER 12H OTC (ORAL) guaifenesin/dextromethorphan MUCUS DM MAX TABLET ER 12H OTC (ORAL) guaifenesin/dextromethorphan GUAIFENESIN/DM/PHENYLEPHRINE LIQUID OTC (ORAL) guaifen/dextromethorphan/PE NINJACOF LIQUID OTC (ORAL) pyrilamine/chlophedianol GUAIFENESIN/DM/PHENYLEPHRINE SYRUP OTC (ORAL) guaifen/dextromethorphan/PE PHENYLEPHRINE/DM/APAP/GUAIFENESIN CAPLET OTC (ORAL) phenylephrine/DM/acetaminop/GG HISTEX-DM SYRUP OTC (ORAL) triprolidine/phenylephrine/DM POLY-HIST PD DROPS OTC (ORAL) thonzylamine/chlophedianol LOHIST-DM LIQUID OTC (ORAL) brompheniram/phenylephrine/DM POLYTUSSIN DM OTC (ORAL) dexchlorphen/phenylephrine/DM MUCINEX COLD-FLU & SORE THROAT LIQUID OTC (ORAL) phenylephrine/DM/acetaminop/GG RESCON-DM LIQUID OTC (ORAL) chlorpheniramin/pseudoephed/DM MUCINEX COUGH GRAN PACK OTC (ORAL) guaifenesin/dextromethorphan VANACOF DMX LIQUID OTC (ORAL) guaifen/dextromethorphan/PE MUCINEX DM TABLET ER 12H OTC (ORAL) guaifenesin/dextromethorphan MUCINEX FAST-MAX CONGEST-COUGH TABLET OTC (ORAL) guaifen/dextromethorphan/PE MUCINEX FAST-MAX DM MAX LIQUID OTC (ORAL) guaifenesin/dextromethorphan NOHIST-DM LIQUID OTC (ORAL) chlorpheniramine/phenyleph/DM POLY-HIST DM LIQUID OTC (ORAL) thonzylamine/phenylephrine/DM POLY-VENT DM TABLET OTC (ORAL) guaifenesin/DM/pseudoephedrine PROMETHAZINE/DM SYRUP (ORAL) promethazine/dextromethorphan RYNEX DM SOLUTION OTC (ORAL) brompheniram/phenylephrine/DM VANACOF DM LIQUID OTC (ORAL) guaifen/dextromethorphan/PE VANACOF LIQUID OTC (ORAL) dexchlorphenir/pse/chlophedian VANATAB DM TABLET OTC (ORAL) guaifen/dextromethorphan/PE

1 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PDL and PA CRITERIA

IRON, ORAL Preferred Agents Non-Preferred Agents Agent Ingredients Agent Ingredients FERROUS FUMARATE TABLET OTC (ORAL) ferrous fumarate CITRANATAL BLOOM (ORAL) iron carb,gl/FA/B12/C/docusate FERROUS FUMARATE/FA/MULTIVITAMIN & MINERALS CAPSULE (ORAL) iron fum/folic acid/mv,min 15 CORVITE 150 TABLET (ORAL) iron,carb/folate6/mv,min no.41 FERROUS FUMARATE/IRON POLYSACCHARIDES/FA/MULTIVITAMIN CAPSULE (ORAL) iron fm,ps no.1/folic/mv no.18 CORVITE FE TABLET (ORAL) iron/folate no.6/mv,mins no.40 FERROUS GLUCONATE TABLET OTC (ORAL) ferrous gluconate FEOSOL TABLET OTC (ORAL) iron polysacch/iron heme polyp FERROUS SULFATE DROPS OTC (ORAL) ferrous sulfate FER-IN-SOL DROPS OTC (ORAL) ferrous sulfate FERROUS SULFATE SOLUTION OTC (ORAL) ferrous sulfate FERGON TABLET OTC (ORAL) ferrous gluconate FERROUS SULFATE TABLET ER OTC (ORAL) ferrous sulfate FERIVA 21-7 (ORAL) iron/C/folate/B12/zinc/succin FERROUS SULFATE TABLET OTC (ORAL) ferrous sulfate FERIVA FA CAPSULE (ORAL) iron/C/folate/B12/biot/cupric FERROUS SULFATE, DRIED TABLET ER OTC (ORAL) ferrous sulfate, dried FERRIMIN 150 TABLET OTC (ORAL) ferrous fumarate HEMOCYTE PLUS CAPSULE (ORAL) iron fum/folic acid/mv,min 15 FERROUS SULFATE/ASCORBIC ACID/FA TABLET ER OTC (ORAL) ferrous sulfate/vit C/folic ac HEMOCYTE-F TABLET (ORAL) ferrous fumarate/folic acid FUSION PLUS CAPSULE (ORAL) iron,fm,ps/folic/B,C18/L.casei INTEGRA F CAPSULE (ORAL) iron fum,ps/folic acid/vitC/B3 HEMOCYTE TABLET OTC (ORAL) ferrous fumarate INTEGRA PLUS CAPSULE (ORAL) iron fum,ps/folic/Bcomp,C no.9 IROSPAN TABLET (ORAL) iron bg,ps/folic/B,C no.12/suc IRON CARBONYL/ASCORBIC ACID TABLET OTC (ORAL) iron,carbonyl/ascorbic acid NEPHRON FA TABLET (ORAL) vit B comp C no.24/iron/folic IRON POLYSACCHARIDES CAPSULE OTC (ORAL) iron polysaccharide complex TARON FORTE CAPSULE (ORAL) iron bg,ps/vitC/B12/FA/calcium IRON POLYSACCHARIDES/B12/FA CAPSULE (ORAL) iron ps complex/B12/folic acid TANDEM PLUS CAPSULE (ORAL) iron fm,ps no.1/folic/mv no.18

PEDIATRIC VITAMIN PREPARATIONS Preferred Agents Non-Preferred Agents Agent Ingredients Agent Ingredients MULTIVITAMINS WITH FLUORIDE DROPS (ORAL) pedi multivit no.2 w-fluoride FLORIVA CHEW (ORAL) pedi multivit no.85/fluoride MULTIVITS WITH IRON & FLUORIDE DROPS (ORAL) pedi multivit 45/fluoride/iron FLORIVA PLUS DROPS OTC (ORAL) pedi multivit no.161/fluoride PEDI MVI NO.16 WITH FLUORIDE TAB CHEW (ORAL) pedi multivit no.16 w-fluoride FLUORIDE/VITAMINS A,C,AND D DROPS (ORAL) ped mvit A,C,D3 no.21/fluoride POLY-VI-FLOR CHEW (ORAL) pedi multivit no.33/fluoride POLY-VI-FLOR DROPS (ORAL) pedi multivit no.37 w-fluoride POLY-VI-FLOR WITH IRON CHEW (ORAL) pedi multivit 33/fluoride/iron POLY-VI-FLOR WITH IRON DROPS (ORAL) pedi multivit 37/fluoride/iron QUFLORA (ORAL) pedi multivit 84 with fluoride QUFLORA (ORAL) pedi multivit no.63 w-fluoride QUFLORA (ORAL) pedi multivit no.83 w-fluoride QUFLORA FE (ORAL) ped multivit 142/iron/fluoride QUFLORA FE (ORAL) ped multivit 151/iron/fluoride QUFLORA OTC (ORAL) pedi multivit no.157/fluoride TRI-VI-FLORO DROPS (ORAL) ped mvit A,C,D3 no.38/fluoride TRI-VITAMIN WITH FLUORIDE (ORAL) ped mvit A,C,D3 no.21/fluoride

PRENATAL VITAMINS Preferred Agents Non-Preferred Agents Agent Ingredients Agent Ingredients CITRANATAL 90 DHA (ORAL) PNV72/iron,gluc/folic/dss/dha CITRANATAL DHA (ORAL) PNV 76/iron,gluc/folic/dss/dha CITRANATAL ASSURE (ORAL) PNV73/iron,gluc/folic/dss/dha COMPLETENATE CHEW TABLET (ORAL) prenatal vit 14/iron fum/folic CITRANATAL B-CALM (ORAL) prenatal 48/iron/folic acid/B6 CONCEPT DHA (ORAL) mvn-min75/iron/iron ps/om3/dha CITRANATAL HARMONY (ORAL) PNV59/iron,carb,fum/FA/dss/dha CONCEPT OB (ORAL) mvn-min 74/iron fum/iron/FA CITRANATAL RX (ORAL) prenatal81/iron/folic/docusate FE C/FA (ORAL) multivit-min69/iron/folic acid PNV2/IRON B-G SUC-P/FA/OMEGA-3 (ORAL) PNV cmb 52/iron/FA/omega-3/dha NESTABS (ORAL) prenatal vit86/iron/folic acid PROVIDA OB (ORAL) prenatal vit 65/iron fum,ps/FA NESTABS DHA (ORAL) prenatal 87/iron bis/folic/dha SELECT-OB + DHA (ORAL) prenatal vit 33/iron/folic/dha OB COMPLETE ONE (ORAL) PNV 85/iron/folic/dha/fish oil TRICARE (ORAL) prenatal vit103/iron fum/folic OB COMPLETE PETITE (ORAL) prenatal56/iron/folic acid/dha TRINATAL RX 1 (ORAL) prenatal vit27,calcium/iron/FA OB COMPLETE PREMIER (ORAL) PNV83/iron,carb,asp/folic acid VITAFOL NANO (ORAL) prenatal no.75/iron/folate no1 OB COMPLETE TABLET (ORAL) multivit-min69/iron/folic acid VITAFOL ULTRA (ORAL) PNV 67/iron ps/folate no.1/dha PNV COMBO#47/IRON/FA #1/DHA (ORAL) multivit 47/iron/folate 1/dha VITAFOL-OB (ORAL) prenatal vit 10/iron fum/folic PNV NO.118/IRON FUMARATE/FA CHEW TABLET (ORAL) PNV no.118/iron fumarate/FA VITAFOL-OB+DHA (ORAL) prenatal vit 10/iron/folic/dha PNV NO.15/IRON FUM & PS CMP/FA (ORAL) mvn-min 74/iron fum/iron/FA VITAFOL-ONE (ORAL) prenatal 26/iron ps/folic/dha PNV W-CA NO.40/IRON FUM/FA CMB NO.1 (ORAL) prenatal,calc.40/iron/folate 1 PNV WITH CA NO.68/IRON/FA NO.1/DHA (ORAL) mv-mins 71/iron/folic no.1/dha PNV#16/IRON FUM & PS/FA/OM-3 (ORAL) mvn-min75/iron/iron ps/om3/dha PRENATAL VIT #76/IRON,CARB/FA (ORAL) prenatal vit,calc76/iron/folic PRENATE AM (ORAL) multivit 38/folate no.6/ginger PRENATE CHEWABLE TABLET (ORAL) multivitamin no.36/folate no.6 PRENATE DHA (ORAL) prenatal 78/iron/folate 1/dha PRENATE ELITE (ORAL) prenatal 114/iron a-g/folate 1 PRENATE ENHANCE (ORAL) prenatal vit68/iron/FA no6/dha PRENATE ESSENTIAL (ORAL) multivit no.40/iron/folat1/dha PRENATE MINI (ORAL) prenatal vit 87/iron/folic/dha PRENATE PIXIE (ORAL) prenatal vit 85/iron/FA 1/dha PRENATE RESTORE (ORAL) prenatal vit69/iron/folate6/dh PRENATE STAR (ORAL) prenatal no.77/iron asp gly/FA SELECT-OB TAB CHEW (ORAL) prenatal vit128/iron/folic acd TRISTART DHA (ORAL) prenatal 93/iron/folate 9/dha VITAFOL TAB CHEW (ORAL) PNV 112/iron/folic/om3/dha/epa VP-PNV-DHA (ORAL) prenatal no.52/iron/FA/dha