Preferred Drug List Effective Date: 7/1/2021

Office of Pharmacy Services Medicaid Pharmacy Program Preferred Drug List Effective Date: 7/1/2021

Only drugs that are part of the listed therapeutic categories are affected by the Medicaid Preferred Drug List (PDL). Therapeutic categories not listed here are not part of the PDL and will continue to be covered as they always have for Maryland Medicaid participants. Note: Brand names listed in parentheses are only listed as a reference. For most multi-source products, the generic products are usually preferred and the branded innovator product is non- preferred. If a generic product is non-preferred, the corresponding brand product is also non-preferred except where specifically noted as “(generic only)”. PDL products that are new to market require prior authorization until they are reviewed.

ANALGESICS Drug Class Preferred Requires Prior Authorization Analgesics, Narcotics (Long fentanyl patches (All strengths except buprenorphine patch (Butrans)ql Acting) 37.5mcg, 62.5mcg, 87.5mcg)cc,ql fentanyl 37.5mcg, 62.5mcg, 87.5mcg morphine sulfate SR (MS Contin)ql patchescc,ql Xtampza ER hydrocodone ER (Hysingla ER, Zohydro ER)cc,ql hydromorphone ER (Exalgo)ql methadone (Dolophine)ql morphine sulfate ER (Avinza)ql morphine sulfate ER (Kadian)ql oxycodone ER (Oxycontin)ql oxymorphone ER (Opana ER)ql tramadol ER (Conzip, Ryzolt, Ultram ER)ql Belbucaql Morphabond ER Nucynta ERql

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ANALGESICS Drug Class Preferred Requires Prior Authorization Analgesics, Narcotics acetaminophen/codeine (Tylenol w/ benzhydrocodone/acetaminophen (Short Acting) codeine)ql (Apadaz) butalbital/acetaminophen/codeine/caffeineql butalbital/aspirin/codeine/caffeineql codeine tablets butorphanol nasal spray hydrocodone/acetaminophen tablets (Lorcet, carisoprodol/codeine/aspirin Norco, Vicodin)ql dihydrocodeine/acetaminophen/caffeine hydromorphone tablets (Dilaudid) fentanyl buccal (Actiq)cc,ql morphine sulfate tablets, solution hydrocodone/acetaminophen solution oxycodone capsules, tablets, solution (Lortab)ql oxycodone/acetaminophen (Percocet)ql hydrocodone/ibuprofen (Vicoprofen) tramadol 50mg (Ultram)ql hydromorphone solution, suppositories tramadol/acetaminophen (Ultracet)ql levorphanol meperidine (Demerol) morphine suppositories oxycodone syringe oxycodone/acetaminophen (Prolate)ql oxycodone concentrated solution oxycodone/aspirin (Percodan) oxymorphone (Opana) pentazocine/naloxone (Talwin NX) tramadol 100mg (Ultram)ql Abstralcc,ql Fentoracc,ql Nucynta Oxaydo

Anti-Migraine Agents, Ajovy (Step Therapy)cc,ql Aimovig (Step Therapy)cc,ql Other Emgality 120mg/mL (Step Therapy)cc,ql Emgality 100mg/mL (Step Therapy)cc,ql *Appears in 2 places within Nurtec ODTcc,ql PDL document. Reyvowcc,ql Ubrelvycc,ql Vyepticc,ql

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ANALGESICS Drug Class Preferred Requires Prior Authorization Anti-Migraine Agents, rizatriptan, rizatriptan ODT (Maxalt, Maxalt almotriptan (Axert)ql Triptans MLT)ql eletriptan (Relpax)ql sumatriptan nasal, syringe, tablets, vial frovatriptan (Frova)ql (Imitrex)ql naratriptan (Amerge)ql sumatriptan kit (Imitrex)ql sumatriptan/naproxen (Treximet)ql zolmitriptan, zolmitriptan ODT (Zomig, Zomig ZMT)ql Onzetra Xsail Tosymra Zembrace Symtouch Zomig nasalql Neuropathic Pain capsaicin OTC duloxetine 40mg (Irenka)ql duloxetine (Cymbalta)cc,ql gabapentin solution (Neurontin) gabapentin capsules, tablets (Neurontin) pregabalin XR (Lyrica CR) lidocaine patch (Lidoderm)ql pregabalin solution pregabalin capsulesql Drizalma Sprinklecc Gralise Horizant Qutenza Kit Savella ZTlido

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ANALGESICS Drug Class Preferred Requires Prior Authorization Nonsteroidal Anti- diclofenac (Cataflam) celecoxib (Celebrex) cc,ql Inflammatories (NSAIDS) diclofenac gel (Voltaren Gel) diclofenac epolamine patch (Flector) ibuprofen Rx, OTC (Motrin) diclofenac potassium (Zipsor) indomethacin (Indocin) diclofenac topical solution (Pennsaid) meloxicam tablets (Mobic) diclofenac/capsicum oleoresin kit nabumetone (Relafen) diclofenac/misoprostol (Arthrotec) naproxen Rx, OTC (Aleve, Naprosyn) diclofenac SR (Voltaren XL) sulindac (Clinoril) diflunisal (Dolobid) etodolac, etodolac XL (Lodine, Lodine XL) fenoprofen flurbiprofen (Ansaid) ibuprofen chewable tabs OTC indomethacin ER (Indocin SR) ketoprofen, ketoprofen ER (Orudis, Oruvail) ketorolac (Toradol) ketorolac nasal spray (Sprix) meclofenamate (Meclomen) mefenamic acid (Ponstel) meloxicam (Vivlodex) meloxicam suspension naproxen/esomeprazole (Vimovo) naproxen EC naproxen sodium RX naproxen CR, Suspension oxaprozin (Daypro) piroxicam (Feldene) tolmetin, tolmetin DS (Tolectin, Tolectin DS) Duexis Ibupak Kit Indocin suppositories, suspension Licart Patchcc,ql Pennsaid Pump Qmiiz ODTcc,ql Relafen DS Tivorbex Venngel One Kit Zorvolex

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ANALGESICS Drug Class Preferred Requires Prior Authorization Opioid Use Disorder buprenorphine (Subutex)cc,ql buprenorphine/naloxone film (Suboxone) Treatments naloxone (Narcan) (generic only)ql naltrexone (Revia)cc buprenorphine/naloxone tablets Bunavailql (Suboxone)ql Narcan nasal spray Lucemyraql Sublocadecc,ql Suboxone film (Brand only)ql Vivitrolcc Zubsolvql Skeletal Muscle Relaxants baclofen (Lioresal) carisoprodol (Soma) chlorzoxazone (Parafon) carisoprodol compound (Soma Compound) cyclobenzaprine (Flexeril)ql cyclobenzaprine ER (Amrix)ql methocarbamol (Robaxin) dantrolene (Dantrium) orphenadrine ER (Norflex) metaxalone (Skelaxin) tizanidine tablets (Zanaflex) tizanidine capsules (Zanaflex) Lorzone Norgesic Forte

ANTI-INFECTIVES Drug Class Preferred Requires Prior Authorization Antibiotics, GI metronidazole tablets (Flagyl) metronidazole capsules (Flagyl capsules) neomycin nitazoxanide tablets (Alinia) tinidazole (Tindamax) paromomycin vancomycin capsules (Vancocin) vancomycin solution Firvanq Dificidcc,ql Solosec Xifaxancc,ql Antibiotics, Inhaled Bethkis (Brand only)cc,ql tobramycin inhalation solution (Tobi)cc,ql Kitabis Pak (Brand only)cc ql tobramycin pak (Kitabis) (generic only)cc,ql Tobi Podhaler cc,ql tobramycin solution (Bethkis) (generic only)cc,ql Arikaycecc,ql Caystoncc,ql Antibiotics, Topical bacitracin OTC mupirocin cream (Bactroban Cream) gentamicin Centany mupirocin ointment (Bactroban Ointment) neomycin/polymyxin/pramoxine OTC triple antibiotic OTC

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ANTI-INFECTIVES Drug Class Preferred Requires Prior Authorization Antibiotics, Vaginal clindamycin (Cleocin) Vandazole metronidazole vaginal (Metrogel) Cleocin ovules Clindesse Nuvessa Antifungals, Oral clotrimazole troches (Mycelex) flucytosine (Ancobon) fluconazole (Diflucan) griseofulvin tablets (Gris Peg, GriFulvin V) griseofulvin suspension (GriFulvin V) itraconazole (Sporanox) ketoconazole (Nizoral) posaconazole (Noxafil) nystatin suspension, tablets voriconazole (Vfend) terbinafine (Lamisil) Cresemba Oravig Tolsura Antifungals, Topical clotrimazole cream Rx, OTC ciclopirox (Loprox, Loprox Kit, Loprox clotrimazole solution OTC Shampoo, Penlac) clotrimazole/betamethasone cream clotrimazole solution Rx (Lotrisone) clotrimazole/betamethasone lotion ketoconazole cream, shampoo (Nizoral) (Lotrisone) miconazole cream OTC econazole (Spectazole) nystatin ketoconazole foam (Ketodan) nystatin/triamcinolone (Mycolog) luliconazole (Luzu)cc,ql terbinafine OTC miconazole ointment, powder, spray OTC tolnaftate OTC miconazole nitrate/zinc oxide/petrolatum (Vusion) naftifine (Naftin) oxiconazole cream (Oxistat) Alevazol OTC Bensal HP Desenex spray powder Ertaczo Exelderm Fungoid OTC Jublia Kerydin Lamisil OTC Lotrimin AF, Ultra OTC Mentax Oxistat lotion Trilociclo Kit

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ANTI-INFECTIVES Drug Class Preferred Requires Prior Authorization Antiparasitics, Topical permethrin Rx, OTC (Elimite, Acticin) ivermectin (Sklice)cc,ql piperonyl/pyrethrins OTC lindane shampoocc malathion (Ovide)cc,ql spinosad (Natroba)cc,ql Eurax Antivirals, Oral acyclovir (Zovirax) famciclovir (Famvir) oseltamivir (Tamiflu)ql rimantadine (Flumadine) valacyclovir (Valtrex) Relenza Sitavig Xofluza Antivirals, Topical acyclovir cream (Zovirax) acyclovir ointment (Zovirax ointment) docosanol 10% cream (Abreva OTC) Denavir Xerese Cephalosporins and amoxicillin/clavulanate tablets, suspension amoxicillin/clavulanate chewable tablets Related Antibiotics (Augmentin, Augmentin ES) (Augmentin) cefaclor capsules (Ceclor) amoxicillin/clavulanate ER (Augmentin XR) cefadroxil capsules (Duricef) cefaclor suspension, ER tablets (Ceclor, cefdinir (Omnicef) Ceclor CD) cefprozil (Cefzil) cefadroxil suspension, tablets (Duricef) cefuroxime tablets (Ceftin) cefixime capsules, suspension (Suprax) cephalexin capsules, suspension (Keflex) cefpodoxime (Vantin) cephalexin tablets (Keflex) Augmentin 125 suspension Suprax chewable Fluoroquinolones, Oral ciprofloxacin tablets (Cipro) ciprofloxacin suspension (Cipro) levofloxacin tablets (Levaquin) levofloxacin solution (Levaquin) moxifloxacin (Avelox) ofloxacin (Floxin) Baxdela Hepatitis B Agents entecavir (Baraclude) adefovir dipivoxil (Hepsera) lamivudine HBV tablets Baraclude solution Epivir HBV solution Vemlidy

Hepatitis C Agents ribavirin (Copegus, Rebetol) ledipasvir/sofosbuvir (Harvoni)cc sofosbuvir/velpatasvir (Epclusa)cc Harvoni Pellet Packcc Mavyretcc Sovaldicc Pegasys Sovaldi Pellet Packcc PegIntron Viekira Pakcc Vosevicc Zepatiercc

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ANTI-INFECTIVES Drug Class Preferred Requires Prior Authorization Macrolides/Ketolides azithromycin (Zithromax) clarithromycin suspension (Biaxin) clarithromycin tablets (Biaxin) clarithromycin ER (Biaxin XL) erythromycin base capsule DR erythromycin base tablet erythromycin ethyl succinate oral erythromycin ethylsuccinate tablet (EES 400) suspension (EryPed, E.E.S) Erythrocin Ery-Tab Tetracyclines doxycycline hyclate (Vibramycin) demeclocycline (Declomycin) doxycycline monohydrate 50mg, 100mg doxycycline hyclate DR (Doryx) capsules (Monodox) doxycycline monohydrate capsules 75mg, doxycycline monohydrate tablets 150mg minocycline capsules (Minocin) doxycycline monohydrate suspension tetracycline (Sumycin) (Vibramycin) minocycline tablets minocycline ER (Solodyn, Ximino) Doryx MPC Morgidox Kit Nuzyra Vibramycin syrup

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BLOOD MODIFIERS Drug Class Preferred Requires Prior Authorization Antihyperuricemics allopurinol (Zyloprim) colchicine capsules (Mitigare)ql probenecid colchicine tablets (Colcrys)ql probenecid/colchicine febuxostat (Uloric) Gloperba Colony Stimulating Factors Granix vial Fulphila Neupogen Granix syringe Leukine Neulasta Nivestym Nyvepria Udenycacc,ql Zarxio Ziextenzo Erythropoiesis Stimulating Aranesp Epogen Proteins Retacrit Mircera Procrit Reblozyl Phosphate Binders calcium acetate (PhosLo) lanthanum carbonate (Fosrenol) sevelamer carbonate (Renvela) sevelamer carbonate powder pack Calphron OTC (Renvela) sevelamer HCl (Renagel) Auryxia Fosrenol powder pack Magnebind 400Rx Phoslyra Velphoro

CARDIOVASCULAR Drug Class Preferred Requires Prior Authorization Angiotensin Modulator amlodipine/benazepril (Lotrel) amlodipine/olmesartan/HCTZ (Tribenzor) Combinations amlodipine/olmesartan (Azor) amlodipine/telmisartan (Twynsta) amlodipine/valsartan (Exforge) trandolapril/verapamil (Tarka) amlodipine/valsartan/HCTZ (Exforge HCT)

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CARDIOVASCULAR Drug Class Preferred Requires Prior Authorization Angiotensin Modulators benazepril, benazepril/HCTZ (Lotensin, aliskiren (Tekturna) Lotensin HCT) candesartan, candesartan/HCTZ (Atacand, enalapril, enalapril/HCTZ (Vasotec, Atacand HCT) Vaseretic) captopril, captopril/HCTZ (Capozide) irbesartan, irbesartan/HCTZ (Avapro, eprosartan (Teveten) Avalide) fosinopril, fosinopril/HCTZ (Monopril, lisinopril, lisinopril/HCTZ (Prinivil, Zestril, Monopril HCT) Prinzide, Zestoretic) moexipril (Univasc) losartan, losartan/HCTZ (Cozaar, Hyzaar) perindopril (Aceon) olmesartan, olmesartan/HCTZ (Benicar, telmisartan, telmisartan/HCTZ (Micardis, Benicar HCT) Micardis HCT) quinapril, quinapril/HCTZ (Accupril, trandolapril (Mavik) Accuretic) Edarbi, Edarbyclor ramipril (Altace) Epaned solution valsartan, valsartan/HCTZ (Diovan, Qbrelis Diovan HCT) Tekturna HCT Entrestocc,ql Anticoagulants enoxaparin (Lovenox)ql fondaparinux (Arixtra)ql warfarin (Coumadin) Eliquis Dose Pack Eliquis tablets Fragminql Pradaxaql Savaysa Xarelto Dose Pack Xarelto 2.5mg tabletscc,ql Xarelto tablets (except 2.5mg)

Antihypertensives, clonidine patch (Catapres TTS)ql methyldopa/HCTZ (Aldoril) Sympatholytics clonidine tablet (Catapres) guanfacine (Tenex) methyldopa (Aldomet)

Beta Blockers atenolol, atenolol/chlorthalidone acebutolol (Sectral) (Tenormin, Tenoretic) betaxolol (Kerlone) bisoprolol (Zebeta) carvedilol ER (Coreg CR) bisoprolol/HCTZ (Ziac) metoprolol/HCTZ (Lopressor HCT) carvedilol (Coreg) nadolol/bendroflumethiazide (Corzide) labetalol (Normodyne, Trandate) pindolol (Visken) metoprolol succinate XL (Toprol XL) propranolol/HCTZ (Inderide) metoprolol tartrate (Lopressor) timolol (Blocadren) nadolol (Corgard) Bystolic propranolol (Inderal) Hemangeol propranolol LA (Inderal LA) Kapspargo sotalol, sotalol AF (Betapace, Betapace AF) Sotylize

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CARDIOVASCULAR Drug Class Preferred Requires Prior Authorization Calcium Channel Blockers amlodipine (Norvasc) diltiazem ER tablets (Cardizem LA) diltiazem (Cardizem) felodipine (Plendil) diltiazem ER capsules (Cardizem CD, Tiazac) isradipine (Dynacirc) nifedipine ER (Adalat CC, Procardia XL) nicardipine (Cardene) verapamil (Calan) nifedipine (Adalat, Procardia) verapamil ER tablets (Calan SR) nimodipine (Nimotop) nisoldipine (Sular) verapamil ER capsules (Verelan, Verelan PM) Katerzia Nymalize, Nymalize syringe Lipotropics, Other cholestyramine (Questran) colesevelam (Welchol) colestipol tablet (Colestid) colestipol granules (Colestid) ezetimibe (Zetia) fenofibrate (Antara, Fenoglide, Lipofen, fenofibrate nanocrystals (Tricor) Lofibra, Triglide) gemfibrozil (Lopid) fenofibric acid (Fibricor, Trilipix) niacin ER (Niaspan) Evkeezacc omega-3 ethyl esters (Lovaza) Juxtapidcc Nexletolcc,ql Nexlizetcc,ql Praluentcc,ql Repathacc,ql Vascepa Lipotropics, Statins atorvastatin (Lipitor) amlodipine/atorvastatin (Caduet) lovastatin (Mevacor) ezetimibe/simvastatin (Vytorin) pravastatin (Pravachol) fluvastatin, fluvastatin ER (Lescol, Lescol XL) rosuvastatin (Crestor) Altoprev simvastatin (Zocor) Ezallor Sprinkle Livalo Zypitamag Platelet Aggregation clopidogrel (Plavix)ql aspirin/dipyridamole (Aggrenox)ql Inhibitors dipyridamole (Persantine)ql Zontivity prasugrel (Effient)ql Brilintaql

CARDIOVASCULAR Drug Class Preferred Requires Prior Authorization PAH Agents, Oral and ambrisentan (Letairis) sildenafil suspension (Revatio)cc,ql Inhaled bosentan tablets (Tracleer) Adempas sildenafil tablets (Revatio)cc,ql Opsumitcc,ql tadalafil (Adcirca)cc,ql Orenitram ERcc,ql Tracleer tablets for suspension Tyvasocc Uptravicc,ql Ventavis

CENTRAL NERVOUS SYSTEM THE MENTAL HEALTH FORMULARY CAN BE FOUND AT THE LINK HERE Drug Class Preferred Requires Prior Authorization Anticonvulsants carbamazepine (Tegretol) carbamazepine ER (Carbatrol) (generic clobazam tablets (Onfi) ql only) clonazepam (Klonopin) carbamazepine suspension (Tegretol) diazepam rectal (Diastat, Diastat Acudial) (generic only) divalproex, divalproex ER (Depakote, carbamazepine XR (Tegretol XR) Depakote ER) clobazam suspension (Onfi)cc,ql lamotrigine (Lamictal) clonazepam ODT (Klonopin ODT) levetiracetam tablets, solution (Keppra) divalproex sprinkles (Depakote sprinkles) oxcarbazepine tablets (Trileptal) (generic only) phenobarbital ethosuximide (Zarontin) phenytoin, phenytoin ER (Dilantin, Dilantin felbamate (Felbatol) Infatabs, Phenytek) lamotrigine dose pack primidone (Mysoline) lamotrigine XR (Lamictal XR) topiramate (Topamax) lamotrigine ODT (Lamictal ODT) topiramate sprinkles (Topamax Sprinkles) levetiracetam ER (Keppra XR) valproic acid (Depakene) oxcarbazepine suspension (generic only) zonisamide (Zonegran) tiagabine (Gabitril) (generic only) Carbatrol (Brand only) topiramate ER (Qudexy XR)cc,ql Depakote Sprinkle (Brand only) rufinamide tablets (Banzel)cc,ql Gabitril (Brand only) Aptiomcc, Tegretol suspension (Brand only) Banzel suspension (Brand only) cc,ql Trileptal suspension (Brand only) Briviact Valtoco Celontin Vimpatql Diacomit capsules, powder pack Epidiolexcc,ql Equetro Finteplacc Fycompacc Lamictal XR dose pack Nayzilam Oxtellar XR Peganone Sabril powder pack, tablets (Brand only) Spritam Sympazancc ql Trokendi XR Xcopri

CENTRAL NERVOUS SYSTEM THE MENTAL HEALTH FORMULARY CAN BE FOUND AT THE LINK HERE Drug Class Preferred Requires Prior Authorization Antidepressants, Other bupropion, bupropion SR, bupropion XL bupropion XL (Forfivo XL) (Wellbutrin, Wellbutrin SR, Wellbutrin XL) desvenlafaxine ER (Pristiq) mirtazapine, mirtazapine ODT (Remeron, desvenlafaxine fumarate ER Remeron ODT) nefazodone (Serzone) trazodone (Desyrel) phenelzine (Nardil) venlafaxine (Effexor) tranylcypromine (Parnate) venlafaxine ER capsules (Effexor XR) venlafaxine ER tablets Aplenzin Emsam Fetzima Marplan Spravatocc,ql Trintellix Viibryd Zulressocc,ql Antidepressants, citalopram tablets, solution (Celexa)ql escitalopram solution (Lexapro) Selective Serotonin escitalopram tablets (Lexapro) fluoxetine capsules 60mg Reuptake Inhibitors fluoxetine capsules, solution (all strengths fluoxetine tablets (Sarafem) (SSRIs) except 60mg) (Prozac) fluoxetine weekly (Prozac weekly) fluvoxamine (Luvox) fluvoxamine ER (Luvox CR) paroxetine (Paxil) paroxetine CR (Paxil CR) sertraline tablets, concentrated solution paroxetine 7.5mg capsules (Brisdelle)cc,ql (Zoloft) Paxil suspension Pexeva

Anti-Migraine Agents, Ajovy (Step Therapy)cc,ql Aimovig (Step Therapy)cc,ql Other Emgality 120mg/mL (Step Therapy)cc,ql Emgality 100mg/mL (Step Therapy)cc,ql *Excluded from the Mental Nurtec ODTcc,ql Health Formulary. Reyvowcc,ql Ubrelvycc,ql Vyepticc,ql

CENTRAL NERVOUS SYSTEM THE MENTAL HEALTH FORMULARY CAN BE FOUND AT THE LINK HERE Drug Class Preferred Requires Prior Authorization Antipsychotics 1st Tier asenapine (Saphris)cc,ql Antipsychotic Review aripiprazole (Abilify)ql clozapine ODT (Fazaclo)cc ql cc Programs aripiprazole ODT(Abilify Discmelt) molindone chlorpromazine (Thorazine) olanzapine/fluoxetine (Symbyax)cc,ql clozapine (Clozaril) paliperidone (Invega)cc,ql fluphenazine (Prolixin) Abilify MyCitecc fluphenazine decanoate inj (Prolixin Inj.)ql Adasuvecc haloperidol (Haldol) Caplytacc haloperidol decanoate inj (Haldol IM)ql Fanaptcc,ql loxapine capsules (Loxitane) Nuplazidcc,ql olanzapine IM (Zyprexa IM)ql Perseriscc,ql olanzapine ODT (Zyprexa Zydis)ql Rexulticc,ql olanzapine tablets (Zyprexa)ql Secuadocc perphenazine (Trilafon) Versaclozcc perphenazine/amitriptyline (Triavil) Zyprexa Relprevvcc,ql pimozide (Orap) quetiapine (Seroquel)ql quetiapine ER (Seroquel XR)ql risperidone, risperidone ODT (Risperdal)ql thioridazine (Mellaril) thiothixene (Navane) trifluoperazine (Stelazine) ziprasidone (Geodon)ql ziprasidone IM (Geodon IM) Abilify Maintenaql Aristadaql Aristada Initioql Invega Sustennaql Invega Trinzacc,ql Risperdal Constaql 2nd Tier Latudacc,ql Vraylarcc,ql

CENTRAL NERVOUS SYSTEM THE MENTAL HEALTH FORMULARY CAN BE FOUND AT THE LINK HERE Drug Class Preferred Requires Prior Authorization Sedative Hypnotics eszopiclone (Lunesta)(Step Therapy)cc,ql doxepin (Silenor) flurazepam (Dalmane)ql estazolam (ProSom)ql temazepam 15mg, 30mg (Restoril)ql ramelteon (Rozerem) ql triazolam (Halcion)ql temazepam 7.5mg, 22.5mgql zaleplon (Sonata)ql zolpidem SL (Intermezzo)ql zolpidem (Ambien)ql zolpidem ER (Ambien CR) Belsomracc,ql Dayvigocc,ql Edluarql Hetliozcc,ql Hetlioz LQcc Stimulants and Related 1st Tier amphetamine ER suspension (Adzenys ER) Agents amphetamine salt combo (Adderall) amphetamine salt combo ER (Adderall XR) clonidine ER tablets (Kapvay)cc,ql (generic only) dexmethylphenidate tablets (Focalin) amphetamine sulfate (Evekeo) dextroamphetamine capsules (Dexedrine ER) armodafinil (Nuvigil)cc,ql dextroamphetamine tablets dexmethylphenidate XR (Focalin XR) guanfacine ER (Intuniv)cc,ql (generic only) methylphenidate CD capsules (Metadate CD) dextroamphetamine solution (Procentra) methylphenidate ER capsules (Ritalin LA) methamphetamine (Desoxyn) methylphenidate ER tablets (Ritalin SR) methylphenidate chewable (Methylin methylphenidate oral solution (Methylin) chewable) methylphenidate tablets (Ritalin) methylphenidate CR tablets (All strengths modafinil (Provigil)cc,ql except 72mg) (Concerta) (generic only) Adderall XR (Brand only) methylphenidate CR tablets 72mg Concerta (Brand only) methylphenidate ER capsules (Aptensio XR) Daytrana Adhansia XR cc Focalin XR (Brand only) Adzenys XR ODT Vyvanse Cotempla XR ODT Vyvanse chewable tabletscc Dyanavel XR 2nd Tier Evekeo ODT atomoxetine (Strattera)cc Jornay PM Mydayis ER Quillichew ER Quillivant XR Sunosicc,ql Wakixcc,ql Zenzedi

ENDOCRINE Drug Class Preferred Requires Prior Authorization Androgenic Agents testosterone gel pump (Androgel) testosterone gel packet (Androgel) Androdermcc,ql testosterone gel (Testim) testosterone gel (Vogelxo) testosterone gel pump (Axiron) testosterone gel pump (Fortesta) Bone Resorption alendronate tablets (Fosamax)ql alendronate solution (Fosamax Solution)ql Suppression and Related calcitonin salmon nasal (Miacalcin)ql ibandronate (Boniva)ql Agents raloxifene (Evista)ql risedronate (Actonel, Atelvia)ql teriparatidecc,ql Binostoql Evenity Forteocc,ql Fosamax Plus Dql Proliacc,ql Teriparatidecc,ql Tymloscc,ql Growth Hormone Genotropincc Humatropecc Norditropincc Omnitropecc Nutropin AQcc Saizencc Serostimcc Zomactoncc Zorbtivecc Hypoglycemics, Incretin Bydureon alogliptin (Nesina) Mimetics and Enhancers Byetta alogliptin/metformin (Kazano) Glyxambicc,ql alogliptin/pioglitazone (Oseni) Janumet, Janumet XR Adlyxin Januvia Bydureon BCise Jentadueto Jentadueto XR Onglyza Kombiglyze XR Symlin Ozempic Tradjenta Qterncc,ql Trulicity Rybelsus Victozaql Soliqua Steglujancc,ql Trijardy XRcc,ql Xultophy

ENDOCRINE Drug Class Preferred Requires Prior Authorization Hypoglycemics, Insulins insulin aspart (Novolog) (Brand and generic) Admelog insulin aspart mix 70/30 (Novolog 70/30 Afrezza Mix) (Brand and generic) Apidra insulin lispro pen, vial (Humalog pen, vial) Basaglar (Brand and generic) Fiasp insulin lispro Junior Kwikpen (Humalog Humalog 200 unit/mL pen Junior Kwikpen) (Brand and generic) Lyumjev insulin lispro mix 75/25 pen (Humalog Mix Novolin pen, vial 75/25 pen) (Brand and generic) Novolin 70/30 Humalog cartridge Semglee Humalog Mix 50/50 pen, vial Toujeo SoloStar, Toujeo Max Solostar Humalog Mix 75/25 vial Tresiba Humulin pen, vial Humulin 70/30 pen, vial Humulin 500 pen, vial Lantus Levemir

Hypoglycemics, nateglinide (Starlix) repaglinide/metformin (Prandimet) Meglitinides repaglinide (Prandin) Hypoglycemics, glipizide/metformin (Metaglip) metformin ER (Fortamet)cc,ql Metformins glyburide/metformin (Glucovance) metformin ER (Glumetza)cc,ql metformin (Glucophage) metformin solution (Riomet) metformin ER (Glucophage XR) Riomet ER suspension Hypoglycemics, SGLT2 Farxiga (Step Therapy)cc,ql Invokamet (Step Therapy)cc,ql Inhibitors Invokana (Step Therapy)cc,ql Invokamet XR (Step Therapy)cc,ql Jardiance (Step Therapy)cc,ql Segluromet (Step Therapy)cc,ql Steglatro (Step Therapy)cc,ql Synjardy (Step Therapy)cc,ql Synjardy XR (Step Therapy)cc,ql Xigduo XR (Step Therapy)cc,ql Hypoglycemics, TZDs pioglitazone (Actos) pioglitazone/glimepiride (Duetact) pioglitazone/metformin (ActoPlusMet) Avandia

GASTROINTESTINAL Drug Class Preferred Requires Prior Authorization Antiemetic/Antivertigo dimenhydrinate OTC aprepitant capsules, tripack (Emend)ql Agents meclizine Rx, OTC (Bonine, Antivert) dimenhydrinate Rx metoclopramide solution, tablets, vial doxylamine/pyridoxine (Diclegis) cc,ql (Reglan) dronabinol (Marinol)cc,ql ondansetron ODT, solution, tablets, vial fosaprepitant dimeglumine IV (Emend) (Zofran)ql granisetron (Kytril)ql prochlorperazine tablets (Compazine) metoclopramide ODT (Metozolv ODT) promethazine injectable, solution, tablets metoclopramide syringe (Reglan) (Phenergan) ondansetron syringe (Zofran) promethazine suppositories (except 50mg) palonosetron (Aloxi) scopolamine patches (TransDerm Scop) prochlorperazine injectable, suppositories (Compro) promethazine 50mg suppositories trimethobenzamide (Tigan) Akynzeo capsulescc Akynzeo IVcc Bonjesta Cinvanti Emend powder packetsql Sancusoql Sustol Varubi Zuplenz Bile Salts ursodiol capsules (Actigall) Chenodal ursodiol tablets (URSO, URSO Forte) Cholbam Ocaliva GI Motility, Chronic lubiprostone (Amitiza)cc,ql alosetron (Lotronex) Linzesscc,ql Motegritycc,ql Movantikcc,ql Relistorcc,ql Symproiccc,ql Trulancecc,ql Viberzicc,ql Pancreatic Enzymes Creonql Pancreazeql Zenpepql Pertzyeql Viokaceql

GASTROINTESTINAL Drug Class Preferred Requires Prior Authorization Proton Pump Inhibitors esomeprazole packet for suspension esomeprazole magnesium (Nexium) (Nexium) esomeprazole OTC lansoprazole capsules (Prevacid) lansoprazole OTC omeprazole capsules (Prilosec) lansoprazole ODT (generic only) pantoprazole capsules, suspension omeprazole OTC (Protonix) omeprazole/sodium bicarb (Zegerid) Prevacid Solutab (Brand only) rabeprazole (Aciphex) Aciphex Sprinkles Dexilant Prilosec suspension Ulcerative Colitis Agents balsalazide (Colazal) budesonide ER (Uceris) mesalamine enema (sfRowasa) mesalamine (Lialda) sulfasalazine, sulfasalazine DR (Azulfidine, mesalamine ER (Apriso) Azulfidine DR) mesalamine DR (Delzicol) Pentasa mesalamine HD (Asacol HD) mesalamine rectal kit (Rowasa) mesalamine rectal (Canasa) Dipentum Uceris Rectal

IMMUNOLOGICS Drug Class Preferred Requires Prior Authorization Cytokine and CAM Enbrel Actemracc Antagonists Humira Arcalystcc Otezla (Step Therapy)cc,ql Avsolacc Cimziacc Cosentyxcc Enspryngcc Entyviocc Ilariscc Ilumyacc Inflectracc Kevzaracc Kineretcc Olumiantcc Orenciacc,ql Remicadecc Renflexiscc Rinvoq ERcc Siliqcc Simponicc Skyrizicc Stelaracc,ql Taltzcc,ql Tremfyacc Upliznacc Xeljanz (tablet, solution), Xeljanz XRcc,ql Immunosuppressives, Oral azathioprine (Imuran) cyclosporine capsules (Sandimmune) cyclosporine modified capsules, solution cyclosporine modified Softgel (Gengraf) (Neoral) everolimus (Zortress) mycophenolic acid (Myfortic) mycophenolate mofetil suspension (generic mycophenolate mofetil capsules, tablets only) (Cellcept) Astagraf XL sirolimus (Rapamune) Envarsus XR tacrolimus (Prograf) Prograf Granules Pack Cellcept suspension (Brand only) Sandimmune solution

NEUROLOGICS Drug Class Preferred Requires Prior Authorization Alzheimer’s Agents donepezil, donepezil ODT (all strengths donepezil 23mg (Aricept) except 23mg) (Aricept, Aricept ODT) galantamine, galantamine ER (Razadyne, memantine tablets (Namenda) Razadyne ER) rivastigmine capsules, patches (Exelon)ql memantine dose pack memantine solution memantine ER (Namenda XR) Namzaric, Namzaric dose pack Antiparkinson’s Agents amantadine (Symmetrel) bromocriptine (Parlodel) benztropine (Cogentin) carbidopa (Lodosyn) carbidopa/levodopa IR (Sinemet) carbidopa/levodopa ODT (Parcopa) carbidopa/levodopa ER (Sinemet CR) entacapone (Comtan) carbidopa/levodopa/entacapone (Stalevo) pramipexole ER (Mirapex ER) pramipexole (Mirapex) rasagiline (Azilect) ropinirole (Requip) ropinirole ER (Requip XL) selegiline (Eldepryl) tolcapone (Tasmar) trihexyphenidyl (Artane) Apokyn Duopa Gocovri Inbrija Kynmobi Neupro Nourianz Ongentys Osmolex ER Rytary Xadago Zelapar

NEUROLOGICS Drug Class Preferred Requires Prior Authorization Multiple Sclerosis Agents Avonex dalfampridine ER (Ampyra) cc,ql Betaseron kit dimethyl fumarate DR (Tecfidera) cc,ql Copaxone 20mg (Brand only) glatiramer acetate 20mg (Glatopa) (generic only) glatiramer acetate 40mg (Copaxone) Aubagiocc,ql Bafiertamcc,ql Extavia kitcc,ql Gilenyacc,ql Kesimptacc Lemtradacc,ql Mavencladcc,ql Mayzentcc Ocrevuscc,ql Plegridy, Plegridy IM cc,ql Rebif Tysabricc,ql Vumeritycc,ql Zeposiacc,ql

OPHTHALMICS Drug Class Preferred Requires Prior Authorization Ophthalmics, Allergic cromolyn (Crolom) azelastine (Optivar) Conjunctivitis ketotifen OTC (Zaditor OTC) epinastine (Elestat) Alrex olopatadine (Pataday, Patanol) Pazeo Alocril Alomide Bepreve Lastacaft Pataday OTC Zerviate

OPHTHALMICS Drug Class Preferred Requires Prior Authorization Ophthalmics, Antibiotics bacitracin/polymyxin B ointment bacitracin ciprofloxacin solution (Ciloxan) gatifloxacin (Zymaxid) erythromycin gentamicin ointment gentamicin (Garamycin) levofloxacin (Quixin) moxifloxacin (Vigamox) moxifloxacin (Moxeza) neomycin/bacitracin/polymyxin ointment neomycin/polymyxin/gramicidin ofloxacin (Ocuflox) (Neosporin) polymyxin/trimethoprim (Polytrim) sulfacetamide ointment sulfacetamide solution (Bleph-10) AzaSite tobramycin (Tobrex Drops) Besivance Ciloxan ointment Natacyn Tobrex ointment Ophthalmics, neomycin/polymyxin/dexamethasone neomycin/bacitracin/polymyxin/ Antibiotic/Steroid (Maxitrol) hydrocortisone Combinations sulfacetamide/prednisolone neomycin/polymyxin/hydrocortisone tobramycin/dexamethasone drops Blephamide, Blephamide S.O.P. (Tobradex) Pred-G Tobradex ointment Tobradex ST Zylet Ophthalmics, Glaucoma brimonidine (Alphagan P) apraclonidine (Iopidine) Agents carteolol (Ocupress) betaxolol dorzolamide (Trusopt) bimatoprost 0.03% (Lumigan) dorzolamide/timolol (Cosopt) brinzolamide (Azopt) latanoprost (Xalatan) timolol (Istalol) levobunolol (Betagan) Betoptic S pilocarpine (Pilocar) Cosopt PF timolol (Timoptic, Timoptic XE) Lumigan 0.01% travoprost (Travatan Z) Phospholine Iodide Combigan Simbrinza Rhopressa Timoptic Ocudose Rocklatan Vyzulta Xelpros Zioptan

OPHTHALMICS Drug Class Preferred Requires Prior Authorization Ophthalmics, Anti- diclofenac (Voltaren) bromfenac (Xibrom) Inflammatories fluorometholone (FML) dexamethasone (Decadron) ketorolac (Acular) flurbiprofen (Ocufen) prednisolone acetate (Pred Forte) ketorolac LS (Acular LS) Durezol loteprednol (Lotemax drops, Lotemax gel) Ilevro prednisolone sodium Pred Mild Acuvail Bromsite Dextenza Dexycu Eysuvis Flarex FML Forte FML SOP Iluvien Inveltys Lotemax ointment Maxidex Nevanac Ozurdex Prolensa Retisert Triesence Yutiq Ophthalmics, Restasis multidose Cequa Anti-Inflammatory/ Restasis single-use Immunomodulator Xiidra

OTIC Drug Class Preferred Requires Prior Authorization Otic Antibiotics ciprofloxacin/dexamethasone (Ciprodex) ciprofloxacin neomycin/polymyxin/HC (Cortisporin) Cipro HC ofloxacin (Floxin Otic) Cortisporin TC Otiprio Otovel

RESPIRATORY Drug Class Preferred Requires Prior Authorization Antihistamines, Minimally cetirizine, cetirizine D tablets, solution, Rx, cetirizine capsules, chewable, 5mg/5mL Sedating OTC (Zyrtec, Zyrtec D) solution OTC fexofenadine tablets, OTC (Allegra OTC) desloratadine, desloratadine ODT (Clarinex, levocetirizine tablets (Xyzal) Clarinex RDT) loratadine, loratadine D, loratadine ODT; fexofenadine ODT OTC Rx, OTC (Claritin, Claritin D) fexofenadine D OTC (Allegra D) levocetirizine solution (Xyzal) loratadine capsule OTC

Clarinex D Quzyttir

Bronchodilators, Beta albuterol neb 0.083%, 5mg/ml albuterol tablets Agonists albuterol neb 0.63mg/3ml, 1.25mg/3ml albuterol ER (Vospire ER) (AccuNeb) albuterol HFA (ProAir HFA) (generic only ql albuterol syrup (Proventil, Ventolin) albuterol HFA (Proventil, Ventolin HFA)ql ProAir HFA (Brand only)ql levalbuterol neb (Xopenex) Serevent levalbuterol HFA (Xopenex HFA)ql metaproterenol (Alupent) terbutaline (Brethine) Arcapta Neohaler Brovana Perforomist ProAir Digihaler ProAir Respiclickql Striverdi Respimat

RESPIRATORY Drug Class Preferred Requires Prior Authorization COPD Agents ipratropium neb (Atrovent) Bevespi Aerosphere ipratropium/albuterol neb (DuoNeb) Daliresp Anoro Ellipta Duaklir Pressair Atrovent HFA Incruse Ellipta Combivent Respimatql Lonhala Magnair Spiriva Handihaler Seebri Neohaler Stiolto Respimat Spiriva Respimat Tudorza Pressair Utibron Neohaler Yupelri

RESPIRATORY Drug Class Preferred Requires Prior Authorization Glucocorticoids, Inhaled budesonide/formoterol (Symbicort) budesonide inhalation suspension 1mg budesonide inhalation suspension 0.25mg, (generic only) 0.5mg (Pulmicort Respules) fluticasone/salmeterol (Advair Diskus) Advair HFA fluticasone/salmeterol (AirDuo Respiclick) Asmanex AirDuo Digihaler Dulera Alvesco Flovent HFA Arnuity Ellipta Pulmicort Respules 1mg (Brand only) Asmanex HFA Breo Ellipta Breztri Aerosphere Flovent Diskus Pulmicort Flexhalerql QVAR Redihaler Trelegy Ellipta Intranasal Rhinitis Agents azelastine nasal (Astelin) azelastine nasal (Astepro) fluticasone nasal (Flonase) azelastine/fluticasone nasal (Dymista) ipratropium (Atrovent Nasal) budesonide nasal (Rhinocort Allergy OTC) flunisolide (Nasarel, Nasalide) fluticasone (Ticanase) mometasone nasal (Nasonex) olopatadine (Patanase) triamcinolone OTC (Nasacort OTC) Beconase AQ Flonase OTC Omnaris Qnasl Xhance Zetonna Leukotriene Modifiers montelukast chewables, tablets (Singulair) montelukast granules (Singulair Granules) zafirlukast (Accolate) zileuton CR (Zyflo CR) Zyflo Epinephrine, Self-Injected epinephrine 0.15mg (EpiPen Jr.)ql epinephrine 0.15mg (Adrenaclick)ql epinephrine 0.3mg (EpiPen)ql epinephrine 0.3mg (Adrenaclick)ql Symjepi

TOPICAL DERMATOLOGICS Drug Class Preferred Requires Prior Authorization Acne Agents, Topical benzoyl peroxide OTC (except 9% cleanser) adapalene cream, gel (Differin)cc clindamycin (all forms except the foam and adapalene/benzoyl peroxide (Epiduo) lotion) benzoyl peroxide 9% cleanser OTC clindamycin/benzoyl peroxide (Duac) bp-10-1 tretinoin (Avita, Retin-A)cc clindamycin foam, lotion Differin lotioncc clindamycin/benzoyl peroxide (Acanya, Benzaclin) clindamycin/tretinoin (Ziana) dapsone (Aczone) erythromycin gel, pledgets erythromycin/benzoyl peroxide (Benzamycin) sulfacetamide sulfacetamide/sulfur sulfacetamide/sulfur/urea tazarotene cream, foam (Tazorac, Fabior)cc tretinoin micro (Retin-A Micro)cc AcneFree Clearing System Aklief Altreno Amzeeq Arazlo Avar Clindacin Differin Gel OTC Epiduo Forte Gel w/Pump Neuac Onexton Ovace Retin-A Micro 0.06%, 0.08%cc Sumaxin CP Kit Tazorac gelcc Immunomodulators, pimecrolimus (Elidel) Dupixentcc Atopic Dermatitis tacrolimus (Protopic) Eucrisa

UROLOGIC Drug Class Preferred Requires Prior Authorization BPH Treatments alfuzosin (Uroxatral) dutasteride/tamsulosin (Jalyn) doxazosin (Cardura) silodosin (Rapaflo) dutasteride (Avodart) Cardura XL finasteride (Proscar) tamsulosin (Flomax) terazosin (Hytrin) Bladder Relaxant oxybutynin, oxybutynin ER (Ditropan, darifenacin ER (Enablex) Preparations Ditropan XL) flavoxate solifenacin (Vesicare) tolterodine, tolterodine ER (Detrol, Detrol Toviaz LA) trospium, trospium ER (Sanctura, Sanctura XR) Gelnique Myrbetriq Oxytrol Vesicare LS