Prescription Drug Program

Apple Health Medicaid: Fee-for-Service Preferred Drug List

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

Effective for dates of service on and after January 1, 2018, the Health Care Authority will make the following changes:

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

Drug classes that are subject to the Therapeutic Interchange Program (TIP), are noted in the drug class information. For more information on TIP, see Theraputic Interchange Program in the Prescription Drug Program Medicaid Billing Guide.

Drug Class Drug Name Change ACE Inhibitors Univasc Removed, no longer manufactured Galantamine Removed, no longer manufactured Alzheimer’s Drugs Aricept ODT Removed, no longer manufactured Exelon solution Removed, no longer manufactured Adrenaclick Non-Preferred, PA required

Anaphylaxis Agents: Adrenalin Non-Preferred, PA required Epinephrine, Self Epinephrine Non-Preferred, PA required Injectable (new drug class) Epinephrine (Mylan only) Preferred Epipen 2-Pak/ JR 2-Pak Non-Preferred, PA required

(Rev. 12/28/2017)(Eff. 1/1/2018) – 1 – Apple Health Medicaid PDL

Prescription Drug Program

Renamed drug class “Anticoagulants: Anticoagulants Entire class Factor XA and Thrombin Inhibitors.” Anticoagulants: Factor XA and Xarelto/ Starter Pack Preferred Thrombin Inhibitors Antidiabetics: Humulin N/ Kwikpen Preferred Insulin, Intermediate-Acting Novolin N/ Relion Non-Preferred (new drug class) Antidiabetics: Levemir/ Flextouch Preferred Insulin, Long-Acting Humalog Mix/ Kwikpen 50/50, Antidiabetics: 75/25, 70/30 Preferred Insulin, Pre-Mixed Novolog Mix/ Flexpen 70/30 (new drug class) Preferred

Novolin/ Relion 70/30 Non-Preferred

Apidra/ Solostar Non-Preferred Antidiabetics: Fiasp/ Flextouch Non-Preferred Insulin, Rapid- Acting Humalog/ Junior Kwikpen/ (new drug class) Kwikpen Preferred

Novolog/ Flexpen/ Penfill Preferred Humulin R/ U-500 (concentrated)/ U-500 Kwikpen Preferred Antidiabetics: Insulin, Short- Afrezza Non-Preferred Acting Novolin R/ Relion (new drug class) Non-Preferred

Relion R Non-Preferred

Antiemetics Akynzeo Removed, no longer manufactured

Client must have tried and failed, or is intolerant to, two preferred products before receiving a nonpreferred Antiemetics Entire class product for the same indication.

(Rev. 12/28/2017)(Eff. 1/1/2018) – 2 – Apple Health Medicaid PDL

Prescription Drug Program

Separated drug class into three classes “Antiemetics:5-HT3 Receptor Antiemetics Antagonists”, “Antiemetics: Other” Entire class and “Antiemetics: Substance P/Neurokinin 1 (NK1) Receptor Antagonists”

Antiemetics: Other (new drug class) Diclegis Preferred, PA required

Aprepitant Preferred Antiemetics: Substance Cinvanti Non-Preferred P/Neurokinin 1 (NK1) Receptor Emend/ Tripack Non-Preferred Antagonists Varubi Non-Preferred Single source brand products and Antivirals: HIV Entire class generics preferred. Exception: Juluca (new drug class) is Non-Preferred, PA required Atrovent HFA Preferred

Asthma and COPD Combivent Respimat Preferred Agents: Anticholinergics (new drug class) Cromolyn Sodium Preferred

Ipratropium Bromide Preferred Ipratropium Bromide/Albuterol Preferred Sulfate

Asthma or COPD – Long-Acting Beta- Agonist – Long Acting Muscarinic Agent Combinations Combined the two classes and (LABA – LAMA) renamed “Asthma and COPD Agents: Entire class Anti-Inflamatory & Muscarinic And Agents”

Asthma or COPD – Long-Acting Muscarinic Agents (LAMA) (Rev. 12/28/2017)(Eff. 1/1/2018) – 3 – Apple Health Medicaid PDL

Prescription Drug Program

Asthma and COPD Agents: Anti- Spiriva Respimat Non-Preferred Inflamatory & Muscarinic Agents Albuterol tab/ ER/syrup Preferred Asthma and COPD Agents: Beta Metaproterenol Non-Preferred Agonist, Oral Terbutaline Non-Preferred (new drug class) Vospire ER Non-Preferred Asthma or COPD – Long Acting Beta Foradil Aerolizer Removed, no longer manufactured Agonists (LABA)

Asthma or COPD – Renamed drug class “Asthma and Long Acting Beta Entire class COPD Agents: Beta Agonist, Long Agonists (LABA) Acting”

Asthma – Quick Relief Accuneb Removed, no longer manufactured

Asthma – Quick Renamed drug class “Asthma and Relief Entire class COPD Agents: Beta Agonist, Short Acting” Asthma and COPD Agents: Beta Proventil HFA Preferred Agonist, Short Acting Renamed drug class “Asthma and Asthma -- Inhaled Entire class COPD Agents: Inhaled Corticosteroid Corticosteroids”

Asthma and COPD Agents: Inhaled Qvar Non-Preferred Corticosteroids

Asthma or COPD - - Inhaled Renamed drug class “Asthma and Corticosteroids – Entire class COPD Agents: Inhaled Corticosteroid Long-Acting Beta- Combinations” Agonist Combinations

(Rev. 12/28/2017)(Eff. 1/1/2018) – 4 – Apple Health Medicaid PDL

Prescription Drug Program

Dulera Preferred Asthma and COPD Agents: Inhaled Fluticasone-Salmeterol Preferred Corticosteroid Symbicort Preferred Combinations Trelegy Added as Non-Preferred

Cinqair Non-Preferred, PA required Asthma and COPD Agents: Monoclonal Fasenra Non-Preferred, PA required Antibodies (new drug class) Nucala Non-Preferred, PA required

Xolair Non-Preferred, PA required Asthma or COPD -- PD4I Renamed drug class “Asthma and Phosphodiesterase – Entire class COPD Agents: Phosphodiesterase 4 4 Inhibitors Inhibitors”

Asthma and COPD Agents: Phosphodiesterase 4 Daliresp Non-Preferred, PA required Inhibitors

Aptensio XR Preferred Metadate CD Removed, no longer manufactured Attention Deficit/ Hyperactivity Quillichew ER Preferred Disorder Quillivant XR Preferred Ritalin SR Removed, no longer manufactured Levatol Removed, no longer manufactured Sectral Removed, no longer manufactured Beta Blockers Trandate Removed, no longer manufactured Zebeta Removed, no longer manufactured

Cytokine and CAM Arcalyst Added as Non-Preferred Antagonists Enbrel Mini Added as Non-Preferred (Rev. 12/28/2017)(Eff. 1/1/2018) – 5 – Apple Health Medicaid PDL

Prescription Drug Program

Diabetes Drugs – Renamed drug class “Antidiabetics: Entire class Amylin Agonist Amylin Agonist” Diabetes Drugs – DPP-4 Inhibitors Juvisync Added as Non-Preferred

Diabetes Drugs – Renamed drug class “Antidiabetics: Entire class DPP-4 Inhibitors DPP-4 Inhibitors”

Diabetes Drugs - Renamed drug class “Antidiabetics: Entire class GLP-1 Agonists GLP-1 Agonists”

Diabetes Drugs – Renamed drug class “Antidiabetics: Long-Acting Entire class Insulins, Long-Acting” Insulins

Diabetes Drugs -- Qtern Added as Non-Preferred SGLT-2 Inhibitors

Diabetes Drugs -- Renamed drug class “Antidiabetics: Entire class SGLT-2 Inhibitors SGLT-2 Inhibitors”

Diabetes Drugs – DiaBeta Removed, no longer manufactured Sulfonylureas

Diabetes Drugs – Renamed drug class “Antidiabetics: Sulfonylureas Entire class Sulfonylureas”

Diabetes Drugs – Renamed drug class “Antidiabetics: Thiazolidinediones Entire class Thiazolidinediones (TZDs)” (TZDs) Creon Preferred Pancreaze Non-Preferred Digestive Enzymes: Pancreatic Enzymes Pertzye Non-Preferred (new class) Viokase Non-Preferred Zenpep Preferred

(Rev. 12/28/2017)(Eff. 1/1/2018) – 6 – Apple Health Medicaid PDL

Prescription Drug Program

Direct-Acting Harvoni Non-Preferred Antiviral Agents for Hepatitis C Sovaldi Non-Preferred Genotropin/ Miniquick Preferred, PA required Norditropin/ Flexpro Preferred, PA required Humatrope/ Combo Pack Non-Preferred, PA required

Endocrine and Nutropin AQ Nusprin/ Pen Non-Preferred, PA required Metabolic Agents: Omnitrope Non-Preferred, PA required Growth Hormone Saizen/ Click.Easy/ (new drug class) Non-Preferred, PA required Reconstitution Kit Serostim Non-Preferred, PA required Zomacton Non-Preferred, PA required Zorbtive Non-Preferred, PA required

Estrogens Ortho Est Removed, no longer manufactured Histamine-2 Receptor Antagonist Axid Removed, no longer manufactured (H2RA) Insomnia Silenor Added as Non-Preferred, PA required

Multiple Sclerosis Renamed drug class “Multiple Drugs Entire class Sclerosis Agents”

Glatiramer Non-Preferred Glatopa Non-Preferred Mitoxantrone Removed from drug class Multiple Sclerosis Agents Ocrevus EA required

Rebif/ Titration Pack Preferred Rebif Rebidose/ Titration Pack Preferred Tysabri Removed PA requirement Nasacort AQ Removed, no longer manufactured Nasal Corticosteroids Veramyst Removed, no longer manufactured

(Rev. 12/28/2017)(Eff. 1/1/2018) – 7 – Apple Health Medicaid PDL

Prescription Drug Program

Cataflam Removed, no longer manufactured Nonsteroidal Anti- inflammatory Drugs Disalcid Removed, no longer manufactured (NSAID) Including Cyclo-oxygenase - 2 (Cox-II) Inhibitors Voltaren XR Removed, no longer manufactured

Overactive Bladder/Urinary Sanctura/ XR Removed, no longer manufactured Incontinence Brintellix Removed, no longer manufactured Second Generation Luvox CR Removed, no longer manufactured Antidepressants Wellbutrin Removed, no longer manufactured Bupropion (smoking deterrent) Preferred, EA required

Smoking Cessation Chantix Preferred, EA required (new drug class) Nicotrol Inhaler/ NS Non-Preferred, EA required Zyban Non-Preferred, EA required Naloxone Preferred Substance Use Disorder: Opioid Naltrexone Preferred Antagonists Narcan Preferred (new drug class) Vivitrol Preferred

Substance Use Bunvail Non-Preferred, PA required Disorder: Opioid Buprenorphine Non-Preferred, PA required Partial Antagonists (new drug class) Buprenorphine/ Naloxone Preferred

Probuphine Non-Preferred, PA required Substance Use Disorder: Opioid Suboxone Preferred Partial Antagonists Sublocade Non-Preferred, PA required (new drug class) Zubsolv Non-Preferred, PA required

Targeted Immune Renamed drug class “Cytokine and Entire class Modulators CAM Antagonists”

(Rev. 12/28/2017)(Eff. 1/1/2018) – 8 – Apple Health Medicaid PDL

Prescription Drug Program

Alsuma Removed, no longer manufactured Triptans Zecuity Removed, no longer manufactured

What is the preferred drug list?

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

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

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

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

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

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

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

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

(Rev. 12/28/2017)(Eff. 1/1/2018) – 9 – Apple Health Medicaid PDL

Prescription Drug Program

 Prescription claims submitted to the agency for non-preferred drugs that are subject to the Therapeutic Interchange Program (TIP) are reimbursed without authorization requirements when written by an endorsing practitioner who has indicated “DAW” on the prescription unless the drug requires restrictions for safety. See WAC 182-530-4150.

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

Drug Class Preferred Drugs Nonpreferred Drugs

ACE Inhibitors Generic: Generic: benazepril fosinopril Subject to captopril moexipril Therapeutic enalapril perindopril erbumine Interchange Program lisinopril quinapril (TIP). ramipril trandolapril

Client must have Brand: Brand: tried and failed, or is Accupril (quinapril) intolerant to, at least Aceon (perindopril) one preferred Altace (ramipril) products before Epaned (enalapril)** receiving a Lotensin (benazepril) nonpreferred product Mavik (trandolapril) for the same Qbrelis (lisinopril)** indication. Prinivil (lisinopril) Vasotec (enalapril) Zestril (lisinopril)

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

(Rev. 12/28/2017)(Eff. 1/1/2018) – 10 – Apple Health Medicaid PDL

Prescription Drug Program

Drug Class Preferred Drugs Nonpreferred Drugs

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

**Not subject to DAW-1 override. Anaphylaxis Generic: Generic: Agents: epinephrine (Mylan) epinephrine* Epinephrine, Self Injectable Brand: Brand: Adrenaclick (epinephrine)* Adrenalin (epinephrine)* Epipen 2-Pak (epinephrine)* Epipen-Jr 2-Pak (epinephrine)*

*PA required

Anticoagulants: Generic: Generic: Factor XA and Thrombin Inhibitors Brand: Brand: Eliquis (apixaban) Bevyxxa (betrixaban) Pradaxa (dabigatran) Savaysa (edoxaban tosylate) Xarelto (rivaroxaban) Xarelto Starter Pack (rivaroxaban)

(Rev. 12/28/2017)(Eff. 1/1/2018) – 11 – Apple Health Medicaid PDL

Prescription Drug Program

Drug Class Preferred Drugs Nonpreferred Drugs

Antidiabetics: Generic: Generic: Amylin Agonist Brand: Brand: SymlinPen (pramlintide acetate)* Client must try all preferred drugs with the same route of administration before a nonpreferred drug will be authorized unless contraindicated or not clinically appropriate. *EA required Antidiabetics: DPP- Generic: Generic: 4 Inhibitors alogliptin benzoate alogliptin-metformin Brand: Subject to alogliptin-pioglitazone Janumet (sitagliptin-metformin Therapeutic HCl) Interchange Program Brand: Janumet XR (sitagliptin-metformin (TIP). Jentadueto (linagliptin-metformin HCl SR) HCl) Januvia (sitagliptin) Client must try all Tradjenta (linagliptin) Jentadueto XR (linagliptin- preferred drugs with metformin HCl SR) the same route of Juvisync (sitagliptin- administration before simvastatin)** a nonpreferred drug Kazano (alogliptin-metformin will be authorized HCl) unless Kombiglyze XR (saxagliptin- contraindicated or not metformin HCl SR) clinically appropriate. Nesina (alogliptin benzoate) Onglyza (saxagliptin) Oseni (alogliptin-pioglitazone)

**Not subject to DAW-1 override.

(Rev. 12/28/2017)(Eff. 1/1/2018) – 12 – Apple Health Medicaid PDL

Prescription Drug Program

Drug Class Preferred Drugs Nonpreferred Drugs

Antidiabetics: GLP- Generic: Generic: 1 Agonists

Subject to Therapeutic Brand: Brand: Interchange Program Byetta (exenatide) Adlyxin (lixisenatide)** (TIP). Bydureon (exenatide) Soliqua (insulin glargine – Client must try all lixisenatide)** preferred drugs with Tanzeum (albiglutide) the same route of Trulicity (dulaglutide) administration before Victoza (liraglutide injection) a nonpreferred drug Xultophy (insulin degludec- will be authorized liraglutide)** unless contraindicated or not **Not subject to TIP or DAW-1 clinically appropriate. override Antidiabetics: Generic: Generic: Insulin, Intermediate-Acting Brand: Brand: Humulin N/ Kwikpen (insulin NPH) Novolin N/ Relion (insulin NPH)

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

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

(Rev. 12/28/2017)(Eff. 1/1/2018) – 13 – Apple Health Medicaid PDL

Prescription Drug Program

Drug Class Preferred Drugs Nonpreferred Drugs

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

Antidiabetics: Generic: Generic: Insulin, Short- Acting Brand: Brand: Humulin R/ U-500 (concentrated)/ U- Afrezza (insulin regular human) 500 Kwikpen (insulin regular Novolin R/ Relion (insulin regular human) human) Relion R (insulin regular human) Antidiabetics: Generic: Generic: SGLT-2 Inhibitors Brand: Brand: Subject to Farxiga (dapaglifozin propanediol) Glyxambi (empagliflozin- Therapeutic Invokamet (canaglifozin – metformin linagliptin) Interchange Program HCl) Invokamet XR (canaglifozin – (TIP). Invokana (canagliflozin) metformin HCl SR) Xigduo XR (dapaglifozin-metformin Jardiance (empagliflozin) Client must try all HCl SR) Qtern (dapagliflozin-saxagliptin) preferred drugs with Synjardy (empagliflozin-metformin the same route of hcl) administration before Synjardy XR (empagliflozin- a nonpreferred drug metformin hcl SR)** will be authorized unless **Not subject to TIP or DAW-1 contraindicated or not override clinically appropriate.

(Rev. 12/28/2017)(Eff. 1/1/2018) – 14 – Apple Health Medicaid PDL

Prescription Drug Program

Drug Class Preferred Drugs Nonpreferred Drugs

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

(Rev. 12/28/2017)(Eff. 1/1/2018) – 15 – Apple Health Medicaid PDL

Prescription Drug Program

Drug Class Preferred Drugs Nonpreferred Drugs

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

+EA required for age 18 and older +EA required for age 18 and older **Not subject to TIP or DAW-1 override. Antiemetics: Other Generic: Generic:

Subject to Brand: Brand: Therapeutic Diclegis (doxylamine-pyridoxine)* Interchange Program (TIP). *EA Required

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

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

(Rev. 12/28/2017)(Eff. 1/1/2018) – 16 – Apple Health Medicaid PDL

Prescription Drug Program

Drug Class Preferred Drugs Nonpreferred Drugs

Antiplatelets Generic: Generic: clopidogrel aspirin-dipyridamole ER Client must have prasugrel tried and failed, or is Brand: intolerant to, all Brand: preferred products Aggrenox (aspirin-dipyridamole before receiving a ER) nonpreferred product Brilinta (ticagrelor) for the same Effient (prasugrel HCl) indication. Plavix (clopidogrel bisulfate) Zontivity (vorapaxar sulfate)

Antivirals: HIV Generic: Generic: abacavir abacavir/lamivudine/zidovudine Brand: abacavir/lamivudine Combivir didanosine (lamivudine/zidovudine)* fosamprenavir Epivir (lamivudine)* lamivudine Epzicom (abacavir/lamivudine)* lamivudine/zidovudine Juluca (dolutegravir-rilpivirine)* lopinavir/ritonavir solution Kaletra sol (lopinavir/ritonavir)* nevirapine/ ER Lexiva tab (fosamprenavir)* stavudine Retrovir (zidovudine)* zidovudine/ syrup Trizivir (abacavir/lamivudine/zidovudine)* Brand: Videx EC (didanosine)* Aptivus (tipranavir) Viramune tab/ XR (nevirapine)* Atripla (efavirenz/emtricitab/tenofov) Zerit (stavudine)* Complera Ziagen (abacavir)* (emtricitab/rilpivirine/tenofov) Crixivan (indinavir) Descovy (emtricitabine/ tenofovir/ alafenamide) Edurant (rilpivirine) Emtriva (emtricitabine) Evotaz (atazanavir/cobicistat) Fuzeon (enfuvirtide) Genvoya (elvitegrav/cobic/emtricitab/tenofov) Intelence (etravirine)

*PA Required

(Rev. 12/28/2017)(Eff. 1/1/2018) – 17 – Apple Health Medicaid PDL

Prescription Drug Program

Drug Class Preferred Drugs Nonpreferred Drugs

Antivirals: HIV (continued) Brand: Invirase (saquinavir) Isentress/ HD (raltegravir) Kaletra tab (lopinavir/ritonavir) Lexiva susp (fosamprenavir) Norvir (ritonavir) Odefsey (emtricitab/rilpivirine/tenofov) Prezcobix (darunavir/cobicistat) Prezista (darunavir) Rescriptor (delavirdine) Retrovir IV (zidovudine) Reyataz (atazanavir) Selzentry/ sol (maraviroc) Stribild (elvitegrav/cobic/emtricitab/tenofov) Sustiva (efavirenz) Tivicay (dolutegravir) Triumeq (abacavir/dolutegravir/lamivudine) Truvada (emtricitab/tenofov) Tybost (cobicistat) Videx pediatric sol (didanosine) Viracept (nelfinavir) Viramune susp (nevirapine) Viread (tenofovir disoproxil)

(Rev. 12/28/2017)(Eff. 1/1/2018) – 18 – Apple Health Medicaid PDL

Prescription Drug Program

Drug Class Preferred Drugs Nonpreferred Drugs

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

Client must try all preferred drugs with the same indication before a nonpreferred drug will be authorized unless contraindicated or not clinically appropriate. Asthma and COPD Generic: Generic: Agents: cromolyn sodium Anticholinergics ipratropium bromide ipratropium bromide/albuterol sulfate Brand:

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

(Rev. 12/28/2017)(Eff. 1/1/2018) – 19 – Apple Health Medicaid PDL

Prescription Drug Program

Drug Class Preferred Drugs Nonpreferred Drugs

Asthma and COPD Generic: Generic: Agents: Anti- Inflamatory & Brand: Brand: Muscarinic Agents Spiriva Handihaler (tiotropium Anoro Ellipta (umeclidnium- bromide)* vilanterol)* Stiolto (tiotropium bromide- Bevespi Aerosphere Subject to olodaterol)* (glycopyrrolate-formoterol Therapeutic fumarate)*** Interchange Program Incruse Ellipta (umeclidinium (TIP). bromide)*

Seebri Neohaler

(glycopyrronium)*

Spiriva Respimat (tiotropium

bromide) *EA required Tudorza Pressair (aclidinium)* Utibron Neohaler (indacaterol- glycopyrrolate)*

*EA required ***Not subject to TIP or DAW-1 and EA required Asthma and COPD Generic: Generic: Agents: Beta Agonist, Long Brand: Brand: Acting Serevent Diskus (salmeterol)* Brovana (arformoterol)* Perforomist (formoterol Subject to fumarate)* Therapeutic Arcapta Neohaler (indacaterol)* Interchange Program Striverdi (olodaterol)* (TIP). *EA required *EA required Asthma and COPD Generic: Generic: Agents: Beta albuterol tab/ ER/syrup metaproterenol Agonist, Oral terbutaline Brand: Brand: Vospire ER (albuterol)

(Rev. 12/28/2017)(Eff. 1/1/2018) – 20 – Apple Health Medicaid PDL

Prescription Drug Program

Drug Class Preferred Drugs Nonpreferred Drugs

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

Asthma and COPD Generic: Generic: Agents: Inhaled budesonide Corticosteroids Brand: Brand: Aerospan (flunisolide HFA) Subject to Flovent HFA/Diskus (fluticasone Alvesco (ciclesonide HFA) Therapeutic propionate HFA/DPI) Armonair RespiClick Interchange Program (fluticasone)* (TIP). Arnuity Ellipta (fluticasone furoate) Asmanex 14 (mometasone furoate) Asmanex HFA (mometasone furoate) Asmanex Twisthaler (mometasone furoate DPI) Pulmicort Flexhaler (budesonide DPI) Pulmicort Respules (budesonide inhalation suspension) Qvar/ Redihaler (beclomethasone dipropionate MDI)

*PA required

(Rev. 12/28/2017)(Eff. 1/1/2018) – 21 – Apple Health Medicaid PDL

Prescription Drug Program

Drug Class Preferred Drugs Nonpreferred Drugs

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

Trelegy (fluticasone- *EA required umeclidinium-vilanterol)***

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

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

*PA Required Asthma and COPD Agents: Phosphodiesterase 4 Generic: Inhibitors Generic: Brand: Subject to Brand: Daliresp (roflumilast)* Therapeutic

Interchange Program *PA required (TIP).

(Rev. 12/28/2017)(Eff. 1/1/2018) – 22 – Apple Health Medicaid PDL

Prescription Drug Program

Drug Class Preferred Drugs Nonpreferred Drugs

Attention Deficit/ Generic: Generic: Hyperactivity amphetamine salt combo dextroamphetamine solution Disorder amphetamine salt combo XR methylphenidate chewable atomoxetine HCl EA is required for clonidine /ER Brand: stimulants prescribed dextroamphetamine Adderall (amphetamine salt for ADD/ADHD dextroamphetamine SA combo) diagnosis for adults. dexmethylphenidate Adderall XR (amphetamine salt dexmethylphenidate XR combo) Client must have guanfacine /ER Adzenys XR (amphetamine)** tried and failed, or is methylphenidate Concerta (methylphenidate HCl) intolerant to, all methylphenidate CD/ER/LA Cotempla (methylphenidate preferred products methylphenidate solution extended release)* before receiving a Daytrana (methylphenidate HCl) nonpreferred product Brand: transdermal patch for the same Aptensio XR (methylphenidate) Dexedrine (dextroamphetamine) indication. Quillichew ER (methylphenidate Dyanavel XR (amphetamine)** HCl) Evekeo (amphetamine)** Quillivant XR (methylphenidate HCl) Focalin (dexmethylphenidate) Strattera (atomoxetine HCl) Focalin XR (dexmethylphenidate) Vyvanse (lisdexamfetamine Intuniv (guanfacine) dimesylate) Kapvay (clonidine) Methylin (methylphenidate HCl) chewable/solution Mydayis (amphetamine- dextroamphetamine)* ProCentra (dextroamphetamine)** Ritalin (methylphenidate HCl) Ritalin LA (methylphenidate HCl)

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

(Rev. 12/28/2017)(Eff. 1/1/2018) – 23 – Apple Health Medicaid PDL

Prescription Drug Program

Drug Class Preferred Drugs Nonpreferred Drugs

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

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

(Rev. 12/28/2017)(Eff. 1/1/2018) – 24 – Apple Health Medicaid PDL

Prescription Drug Program

Drug Class Preferred Drugs Nonpreferred Drugs

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

**Not subject to DAW-1 override Digestive Enzymes: Generic: Generic: Pancreatic Enzymes Brand: Brand: Creon (lip-prot-amyl) Pancreaze (lip-prot-amyl) Zenpep (lip-prot-amyl) Pertzye (lip-prot-amyl) Viokase (lip-prot-amyl)

(Rev. 12/28/2017)(Eff. 1/1/2018) – 25 – Apple Health Medicaid PDL

Prescription Drug Program

Drug Class Preferred Drugs Nonpreferred Drugs

Direct-Acting Generic: Generic: Antiviral Agents for Hepatitis C Brand: Brand: Epclusa (sofosbuvir-velpatasvir)* Daklinza (daclatasvir)* Client must have Mavyret (glecaprevir-pibrentasvir)* Harvoni (ledipasvir-sofosbuvir)* tried and failed, or is Vosevi (sofosbuvir-velpatasvir- Olysio (simeprevir)* intolerant to, one voxilaprevir)* Sovaldi (sofosbuvir)* Technivie (ombitasvir- preferred drug within paritaprevir-ritonavir)* the drug class unless Viekira Pak (paritaprevir- contraindicated, not ritonavir-ombitasvir-dasabuvir)* clinically appropriate, Viekira XR (paritaprevir- or only one drug is ritonavir-ombitasvir-dasabuvir)** preferred. Zepatier (elbasvir-grazoprevir)**

*PA Required *PA Required **Not subject to TIP or DAW-1 override and PA required Endocrine and Generic: Generic: Metabolic Agents: Growth Hormone Brand: Brand: Genotropin/ Miniquick (somatropin)* Humatrope/ Combo Pack Norditropin/ Flexpro (somatropin)* (somatropin)* Nutropin AQ Nusprin/ Pen (somatropin)* Omnitrope (somatropin)* Saizen/ Click.Easy (somatropin)* Saizen Reconstitution Kit (somatropin)* Serostim (somatropin)* Zomacton (somatropin)* Zorbtive (somatropin)* *PA Required *PA Required

(Rev. 12/28/2017)(Eff. 1/1/2018) – 26 – Apple Health Medicaid PDL

Prescription Drug Program

Drug Class Preferred Drugs Nonpreferred Drugs

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

Generic Vaginal: Generic Vaginal:

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

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

(Rev. 12/28/2017)(Eff. 1/1/2018) – 27 – Apple Health Medicaid PDL

Prescription Drug Program

Drug Class Preferred Drugs Nonpreferred Drugs

Estrogen-Progestin Generic: Generic Oral: Combinations estradiol-norethindrone norethindrone acetate -ethinyl Brand Oral: Oral products subject estradiol Activella (estradiol- to Therapeutic norethindrone) Interchange Program Brand: Angeliq (estradiol-drospirenone) (TIP). Femhrt Low Dose (ethinyl estradiol-norethindrone) Transdermal products Prefest (estradiol-norgestimate) are not subject to Premphase (conjugated equine TIP. estrogens-medroxyprogesterone) Prempro (conjugated equine Client must have estrogens-medroxyprogesterone) tried and failed, or is intolerant to, all Generic Transdermal: preferred products before receiving a Brand Transdermal: nonpreferred product Climara Pro (estradiol- according to the levonorgestrel) formulation Combipatch (estradiol- prescribed for the norethindrone) same indication. Histamine-2 Generic: Generic: Receptor Antagonist ranitidine cimetidine (H2RA) famotidine Brand: nizatidine

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

(Rev. 12/28/2017)(Eff. 1/1/2018) – 28 – Apple Health Medicaid PDL

Prescription Drug Program

Drug Class Preferred Drugs Nonpreferred Drugs

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

Generic: Generic:

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

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

(Rev. 12/28/2017)(Eff. 1/1/2018) – 29 – Apple Health Medicaid PDL

Prescription Drug Program

Drug Class Preferred Drugs Nonpreferred Drugs

Long-Acting Generic: Generic: Opioids fentanyl transdermal levorphanol hydromorphone ER methadone* morphine sulfate /CR/SA/SR methadose* Must try and fail at morphine sulfate ER capsules/tablets oxymorphone HCL ER least two preferred oxycodone ER products before Brand: receiving a Brand: Arymo ER (morphine sulfate nonpreferred product ER)** Belbuca (buprenorphine)** Butrans (buprenorphine) transdermal Dolophine (methadone)* Duragesic (fentanyl) transdermal Embeda (morphine-naltrexone) Exalgo (hydromorphone HCl) Hysingla ER (hydrocodone bitartrate) Kadian (morphine sulfate SR) Methadone HCl Intensol (methadone)* MS Contin (morphine sulfate SA) Nucynta ER (tapentadol HCl) Opana ER (oxymorphone HCl) OxyContin (oxycodone ER) Xtampza ER (oxycodone ER)** Zohydro ER (hydrocodone bitartrate)

*PA Required **Not subject to DAW-1 override

(Rev. 12/28/2017)(Eff. 1/1/2018) – 30 – Apple Health Medicaid PDL

Prescription Drug Program

Drug Class Preferred Drugs Nonpreferred Drugs

Macrolides Generic: Generic: azithromycin Client must have packet/suspension/tablet Brand: tried and failed, or is clarithromycin tablet/suspension Biaxin (clarithromycin) intolerant to, one clarithromycin SR tablet tablet/suspension preferred drug within erythromycin base tablet Biaxin XL (clarithromycin) the drug class unless erythromycin EC capsule/tablet EES 400 (erythromycin contraindicated, not erythromycin ethylsuccinate ethylsuccinate) tablet clinically appropriate tablet/suspension PCE (erythromycin base) erythromycin stearate tablet Zithromax (azithromycin) powder erythromycin tablet packet/suspension/tablet Zmax (azithromycin SR) Brand: EES (erythromycin ethylsuccinate) granules Eryped 200 (erythromycin ethylsuccinate) Eryped 400 (erythromycin ethylsuccinate) Ery-Tab (erythromycin base EC) Erythrocin Stearate (erythromycin stearate) Multiple Sclerosis Generic: Generic: Agents glatiramer Brand: Avonex/ Pen (interferon ß 1a) Brand: Betaseron (interferon ß 1b) Aubagio (teriflunomide) Copaxone (glatiramer acetate) Extavia (interferon ß 1b) Gilenya (fingolimod) Glatopa (glatiramer) Rebif/ Titration Pack (interferon ß Lemtrada (alemtuzumab) 1a) Ocrevus (ocrelizumab)* Rebif Rebidose/ Titration Pack Plegridy/ Pen/ Starter Pak (interferon ß 1a) (peginterferon ß 1a) Tecfidera/ Starter Pack (dimethyl Tysabri (natalizumab) fumarate) Zinbryta (daclizumab)

*EA required

(Rev. 12/28/2017)(Eff. 1/1/2018) – 31 – Apple Health Medicaid PDL

Prescription Drug Program

Drug Class Preferred Drugs Nonpreferred Drugs

Nasal Generic: Generic: Corticosteroids budesonide OTC budesonide RX fluticasone propionate OTC/RX flunisolide RX Subject to triamcinolone acetonide OTC mometasone furoate Therapeutic triamcinolone acetonide RX Interchange Program Brand: (TIP). Brand: Beconase AQ (beclomethasone Client must have dipropionate) tried and failed, or is Flonase (fluticasone propionate) intolerant to, all Nasacort Allergy 24HR preferred products (triamcinolone acetonide) before receiving a Nasonex (mometasone furoate) nonpreferred product Omnaris (ciclesonide) for the same QNasl (beclomethasone indication. dipropionate)** Rhinocort Aqua (budesonide) Zetonna (ciclesonide)**

**Not subject to TIP or DAW-1 Newer Generic: Generic: Antihistamines cetirizine syrup /tablet azelastine nasal spray loratadine OTC cetirizine chewable cetirizine chewable – children’s Client must have Brand: desloratadine tried and failed, or is fexofenadine intolerant to, one levocetirizine dihydrochloride preferred drug within olopatadine the drug class unless contraindicated, not Brand: clinically appropriate Allegra (fexofenadine) Astepro (azelastine HCl nasal Subject to spray) Therapeutic Clarinex (desloratadine) Interchange Program Claritin (loratadine) (TIP). Patanase (olopatadine nasal spray) Xyzal (levocetirizine) Zyrtec (cetirizine)

(Rev. 12/28/2017)(Eff. 1/1/2018) – 32 – Apple Health Medicaid PDL

Prescription Drug Program

Drug Class Preferred Drugs Nonpreferred Drugs

Nonsteroidal Anti- Generic: Generic: inflammatory Drugs diclofenac potassium celecoxib** (NSAID) Including diclofenac sodium /SR/ER/EC diclofenac sodium topical gel* Cyclo-oxygenase - 2 diflunisal diclofenac sodium topical (Cox-II) Inhibitors etodolac /ER solution** fenoprofen meclofenamate sodium flurbiprofen Subject to ibuprofen Brand: Therapeutic indomethacin/SR Anaprox DS (naproxen Interchange Program ketoprofen /SR sodium) (TIP). ketorolac Cambia (diclofenac potassium) mefenamic acid solution Client must try all meloxicam Celebrex (celecoxib)** preferred drugs nabumetone Daypro (oxaprozin) before a nonpreferred naproxen /EC Feldene (piroxicam) drug will be naproxen sodium /ER/SA Flector (diclofenac epolamine)* authorized unless oxaprozin Indocin (indomethacin) contraindicated or not piroxicam Mediproxen (naproxen sodium) clinically appropriate. salsalate Mobic (meloxicam) sulindac Nalfon (fenoprofen) tolmetin Naprelan (naproxen sodium ER) Naprosyn /EC/DS (naproxen) Brand: Pennsaid (diclofenac sodium) sol* Ponstel (mefenamic acid) Rexaphenac (diclofenac sodium)* Solaraze (diclofenac sodium) gel* Tivorbex (indomethacin)*** Vivlodex (meloxicam)*** Voltaren (diclofenac sodium)* Zipsor (diclofenac potassium) Zorvolex (diclofenac)**

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

(Rev. 12/28/2017)(Eff. 1/1/2018) – 33 – Apple Health Medicaid PDL

Prescription Drug Program

Drug Class Preferred Drugs Nonpreferred Drugs

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

PCSK-9 Inhibitors Brand: Brand: Subject to Praluent (alirocumab)* Repatha (evolocumab)* Therapeutic Repatha Pushtronex (evolocumab)* Interchange Program Repatha Sureclick (evolocumab)* (TIP).

*PA required *PA required

(Rev. 12/28/2017)(Eff. 1/1/2018) – 34 – Apple Health Medicaid PDL

Prescription Drug Program

Drug Class Preferred Drugs Nonpreferred Drugs

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

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

(Rev. 12/28/2017)(Eff. 1/1/2018) – 35 – Apple Health Medicaid PDL

Prescription Drug Program

Drug Class Preferred Drugs Nonpreferred Drugs

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

*EA required **Not subject to DAW-1 override. ***Not subject to DAW-1 *EA required override, and PA required. **Not subject to DAW-1 override. ***Not subject to DAW-1 override, and PA required. (Rev. 12/28/2017)(Eff. 1/1/2018) – 36 – Apple Health Medicaid PDL

Prescription Drug Program

Drug Class Preferred Drugs Nonpreferred Drugs

Second Generation Generic: Generic: Antipsychotics aripiprazole clozapine tablet / ODT Brand: olanzapine/ODT/injection Abilify (aripiprazole) tablet Client must have paliperidone ER Clozaril (clozapine) tablet tried and failed, or is quetiapine / ER Fazaclo (clozapine) disintegrating intolerant to, 3 risperidone tablet/ODT/solution tablet preferred products ziprasidone capsules Geodon (ziprasidone HCl) capsule one of which must be Invega (paliperidone) tablet a generic, before Brand: Nuplazid (pimavanserin receiving a Abilify Maintena (aripiprazole) tartrate)*** nonpreferred product Aristada (aripiprazole lauroxil) Risperdal (risperidone) tablet/M- for the same Fanapt (iloperidone) tablet tab/solution indication. Fanapt Titration Pack (iloperidone) Seroquel / XR (quetiapine) Geodon (ziprasidone mesylate) IM Versacloz (clozapine)** injection Zyprexa (olanzapine) IM injection Invega Sustenna (paliperidone) IM Zyprexa (olanzapine) tablet injection Zyprexa Zydis (olanzapine) tablet Invega Trinza (paliperidone) Latuda (lurasidone HCL) Rexulti (brexpiprazole) Risperdal Consta (risperidone) injection **Not subject to TIP or DAW-1 Saphris (asenapine) sublingual tablet override. Vraylar (cariprazine HCl) ***Not subject to TIP or DAW-1 Zyprexa Relprevv (olanzapine override and PA required. pamoate) injection

(Rev. 12/28/2017)(Eff. 1/1/2018) – 37 – Apple Health Medicaid PDL

Prescription Drug Program

Drug Class Preferred Drugs Nonpreferred Drugs

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

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

*EA required *EA required

(Rev. 12/28/2017)(Eff. 1/1/2018) – 38 – Apple Health Medicaid PDL

Prescription Drug Program

Drug Class Preferred Drugs Nonpreferred Drugs

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

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

Brand: Narcan (naloxone) Vivitrol (naltrexone)

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

*PA Required (Rev. 12/28/2017)(Eff. 1/1/2018) – 39 – Apple Health Medicaid PDL

Prescription Drug Program

Drug Class Preferred Drugs Nonpreferred Drugs

Triptans Generic: Generic: rizatriptan benzoate almotriptan maleate Client must have sumatriptan tablets frovatriptan tried and failed, or is sumatriptan injection naratriptan HCl intolerant to, one sumatriptan nasal spray zolmitriptan preferred drug within the drug class unless Brand: Brand: contraindicated, not Amerge (naratriptan) clinically appropriate. Axert (almotriptan) Frova (frovatriptan) Imitrex tablets (sumatriptan) Imitrex injection (sumatriptan) Imitrex nasal spray (sumatriptan) Maxalt /MLT (rizatriptan) Onzetra Xsail (sumatriptan)** Relpax (eletriptan) Sumavel DosePro (sumatriptan) Zembrace Symtouch (sumatriptan succinate)** Zomig /ZMT (zolmitriptan)

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

(Rev. 12/28/2017)(Eff. 1/1/2018) – 40 – Apple Health Medicaid PDL