Kentucky Medicaid Pharmacy Program Single Preferred Drug List (PDL) Effective: September 2, 2021
GENERAL DEFINITION OF TERMS
Clinical Criteria (CC) – Due to the nature of some medications, prior authorization (PA) is required for the medication to be covered. Medications with this indicator may require prior use of a different medication or drug product, a qualifying diagnosis to be reported and/or appropriate clinical criteria to be satisfied before prior authorization is approved. Prescriptions exceeding plan limitations such as a Quantity Limit (QL), Maximum Duration (MD), or Age Edit (AE), in addition to those subject to Clinical Criteria (CC), will require additional approval. All non-preferred agents require prior authorization. Quantity Limits (QL) – Quantity limits have been placed on medications to be consistent with the maximum dosage that the Food and Drug Administration (FDA) has approved to be both safe and effective. Medications where the quantity exceeds the FDA’s maximum daily dose will require PA. Prescriptions exceeding plan limitations will require PA. Medication with Maximum Duration (MD) – Medications indicated will be available for a defined period (e.g., 60 days) per rolling year (365 days) before requiring a new or additional PA. Age Edit (AE) – Medications indicated are available for members above or below a given age without PA. Maintenance Drugs – Maintenance drugs are medications that generally require regular, long-term use and are prescribed for the treatment of a chronic medical condition. The following classes are examples of common maintenance drugs. Maintenance drugs, as determined by First Databank (FDB) or Medi-Span, can be processed for up to a 92 days’ supply for KY Medicaid recipients.
• ACE Inhibitors • Beta Blockers • COPD Agents • Diabetes Drugs • Lipotropics • Antidepressants • Antipsychotics • Anticonvulsants
To view the most current PA criteria, please go to https://kyportal.magellanmedicaid.com/provider/public/home.xhtml.
To request a PA, please submit the Kentucky Medicaid Pharmacy Prior Authorization Form to the member’s plan.
© 2021 Magellan Health, Inc. All rights reserved. Magellan Medicaid Administration, part of the Magellan Rx Management division of Magellan Health, Inc. Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/ Magellan Medicaid Administration Clinical Support Center: Phone 800-477-3071; Fax 800-365-8835
I. CARDIOVASCULAR
Drug Class Preferred Agents Non-Preferred Agents ACE Inhibitors benazepril Accupril® enalapril Altace® lisinopril captopril quinapril enalapril solution ramipril Epaned™ CC fosinopril Lotensin® moexipril perindopril Prinivil® Qbrelis™ CC, QL trandolapril Vasotec® Zestril® ACEI + Diuretic benazepril/HCTZ Accuretic® Combinations lisinopril/HCTZ captopril/HCTZ enalapril/HCTZ fosinopril/HCTZ Lotensin HCT® quinapril/HCTZ Vaseretic® Zestoretic® Angiotensin Receptor Entresto™ Atacand® Blockers irbesartan Avapro® losartan Benicar® olmesartan candesartan valsartan Cozaar® Diovan® Edarbi™ eprosartan Micardis® telmisartan ARB + Diuretic irbesartan/HCTZ Atacand HCT® Combinations losartan/HCTZ Avalide® olmesartan/HCTZ Benicar HCT® valsartan/HCTZ candesartan/HCTZ Diovan HCT® Edarbyclor™ Hyzaar® Micardis HCT® telmisartan/HCTZ
AE = Age Edits CC = Clinical Criteria MD = Medications with QL = Quantity Limits Maximum Duration
Page 2 | Kentucky Medicaid Single Preferred Drug List Effective September 2, 2021
Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/ Magellan Medicaid Administration Clinical Support Center: Phone 800-477-3071; Fax 800-365-8835
I. CARDIOVASCULAR
Drug Class Preferred Agents Non-Preferred Agents Angiotensin Modulator + amlodipine/benazepril Azor™ CCB Combinations valsartan/amlodipine Exforge® valsartan/amlodipine/HCTZ Exforge HCT® Lotrel® olmesartan/amlodipine olmesartan/amlodipine/HCTZ Tarka® Tribenzor® telmisartan/amlodipine verapamil/trandolapril Anti-Anginal & Anti- ranolazine ER Corlanor® CC Ischemic Agent Ranexa® Oral Anti-Arrhythmics amiodarone 100, 200 mg amiodarone 400 mg disopyramide Betapace® dofetilide Betapace AF® flecainide Multaq® mexiletine Norpace® propafenone Norpace® CR quinidine sulfate Pacerone® Sorine® propafenone SR/ER sotalol quinidine gluconate ER sotalol AF Rythmol SR® Sotylize® CC Tikosyn® Direct Renin Inhibitors N/A aliskiren Tekturna® Tekturna HCT® Beta Blockers atenolol acebutolol bisoprolol betaxolol metoprolol tartrate Bystolic™ metoprolol succinate ER Corgard® nadolol Hemangeol™ propranolol Inderal® LA propranolol ER Inderal® XL InnoPran XL® Kapspargo™ Lopressor® pindolol Tenormin® timolol Toprol XL® Beta Blockers + Diuretic atenolol/chlorthalidone Lopressor® HCT Combinations bisoprolol/HCTZ metoprolol tartrate/HCTZ nadolol/bendroflumethiazide propranolol/HCTZ Tenoretic® Ziac®
AE = Age Edits CC = Clinical Criteria MD = Medications with QL = Quantity Limits Maximum Duration
Page 3 | Kentucky Medicaid Single Preferred Drug List Effective September 2, 2021
Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/ Magellan Medicaid Administration Clinical Support Center: Phone 800-477-3071; Fax 800-365-8835
I. CARDIOVASCULAR
Drug Class Preferred Agents Non-Preferred Agents Alpha/Beta Blockers carvedilol carvedilol ER labetalol Coreg® Coreg CR® Calcium Channel Blockers amlodipine Adalat CC® (DHP) nifedipine ER/SA/SR felodipine ER isradipine Katerzia™ nicardipine nifedipine IR CC nimodipine CC nisoldipine ER Norvasc® Nymalize® CC Procardia® Procardia XL® Sular® ER Calcium Channel Blockers Cartia XT Calan® SR (Non-DHP) diltiazem Cardizem® diltiazem ER/CD Cardizem CD® Dilt-XR Cardizem LA® Taztia XT® diltiazem ER (generic Cardizem LA®) Tiadylt ER® Matzim LA™ verapamil Tiazac ER® verapamil ER (except 360 mg capsules) verapamil ER 360 mg capsules verapamil ER PM Verelan® Verelan PM® Pulmonary Arterial Alyq® CC, QL Adcirca™ QL Hypertension (PAH) ambrisentan CC Adempas® Agents sildenafil CC bosentan tablets tadalafil CC, QL Letairis™ Tracleer® tablets CC Opsumit® Ventavis® CC Orenitram ER™ Revatio™ Tracleer® 32 mg tablets for suspension CC Tyvaso™ Uptravi® QL Lipotropics: Bile Acid cholestyramine colesevelam Sequestrants cholestyramine light Colestid® colestipol tablets colestipol granules/packets Prevalite® Questran® Questran Light® Welchol®
AE = Age Edits CC = Clinical Criteria MD = Medications with QL = Quantity Limits Maximum Duration
Page 4 | Kentucky Medicaid Single Preferred Drug List Effective September 2, 2021
Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/ Magellan Medicaid Administration Clinical Support Center: Phone 800-477-3071; Fax 800-365-8835
I. CARDIOVASCULAR
Drug Class Preferred Agents Non-Preferred Agents Lipotropics: Fibric Acid fenofibrate nanocrystallized (generic Tricor®) Antara® Derivatives fenofibric acid (generic Trilipix® DR) fenofibrate (generic Lipofen®, Fenoglide®) gemfibrozil fenofibric acid (generic Fibricor®) Fenoglide® Fibricor® Lipofen® Lopid® TriCor® Trilipix® DR Lipotropics: Other ezetimibe icosapent ethyl niacin ER Juxtapid® CC omega-3 acid ethyl esters Lovaza® Nexletol™ CC, AE, QL Nexlizet™ CC, AE, QL Niaspan® ER Praluent® CC Repatha™ CC Vascepa® Zetia® Lipotropics: Statins atorvastatin QL Altoprev® QL lovastatin QL amlodipine/atorvastatin CC, QL pravastatin QL Caduet® QL rosuvastatin QL Crestor® QL simvastatin QL Ezallor™ Sprinkle QL ezetimibe/simvastatin QL fluvastatin QL fluvastatin ER QL Lescol® QL Lescol XL® QL Lipitor® QL Livalo® QL Pravachol® QL Vytorin™ QL Zocor® QL Zypitamag QL Platelet Aggregation Brilinta™ aspirin/dipyridamole Inhibitors cilostazol Effient™ clopidogrel Plavix® dipyridamole Zontivity™ prasugrel Anticoagulants Eliquis® Arixtra™ enoxaparin fondaparinux Jantoven® Fragmin® Pradaxa® Lovenox® warfarin Savaysa™ Xarelto®
AE = Age Edits CC = Clinical Criteria MD = Medications with QL = Quantity Limits Maximum Duration
Page 5 | Kentucky Medicaid Single Preferred Drug List Effective September 2, 2021
Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/ Magellan Medicaid Administration Clinical Support Center: Phone 800-477-3071; Fax 800-365-8835
II. GASTROINTESTINAL
Drug Class Preferred Agents Non-Preferred Agents Anti-Emetics: Other meclizine Compazine® metoclopramide oral solution, tablets Compro® prochlorperazine tablets Bonjesta® CC promethazine syrup, tablets Diclegis™ CC, QL promethazine 12.5, 25 mg suppositories doxylamine/pyridoxine CC, QL scopolamine patches Gimoti™ CC, QL metoclopramide ODT Phenadoz® Phenergan® prochlorperazine suppositories promethazine 50 mg suppositories Reglan® Tigan® Transderm-Scop® Trimethobenzamide Antivert® Oral Anti-Emetics: 5-HT3 ondansetron Aloxi® QL Antagonists Anzemet® granisetron Sancuso® CC, QL Zofran® Zuplenz® Oral Anti-Emetics: NK-1 Emend® capsules QL Akynzeo® QL Antagonists aprepitant QL Emend® powder packet QL Varubi® CC, QL Oral Anti-Emetics: Δ-9- dronabinol CC, QL Cesamet® CC, QL THC Derivatives Marinol® CC, QL H2 Receptor Antagonists famotidine cimetidine nizatidine Pepcid® Proton Pump Inhibitors esomeprazole magnesium capsules QL Aciphex® QL lansoprazole capsules QL Dexilant™ QL Nexium® suspension QL esomeprazole suspension QL omeprazole capsules QL esomeprazole strontium QL pantoprazole tablets QL lansoprazole ODT QL Nexium® capsules QL omeprazole suspension QL omeprazole/sodium bicarbonate QL pantoprazole suspension QL Prevacid® QL Prilosec® QL Protonix® QL rabeprazole QL Zegerid® QL
AE = Age Edits CC = Clinical Criteria MD = Medications with QL = Quantity Limits Maximum Duration
Page 6 | Kentucky Medicaid Single Preferred Drug List Effective September 2, 2021
Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/ Magellan Medicaid Administration Clinical Support Center: Phone 800-477-3071; Fax 800-365-8835
II. GASTROINTESTINAL
Drug Class Preferred Agents Non-Preferred Agents Anti-Ulcer Protectants Carafate® suspension Carafate® tablets misoprostol Cytotec® sucralfate tablets sucralfate suspension H. pylori Treatment Pylera® QL Helidac® QL lansoprazole/amoxicillin/clarithromycin QL Omeclamox-Pak™ QL Prevpac® QL Talicia® Antispasmodics/ dicyclomine Anaspaz® Anticholinergics glycopyrrolate Bentyl® hyoscyamine chlordiazepoxide/clidinium methscopolamine Cuvposa® Hyosyne® Levbid® Levsin® Librax® Oscimin® Phenohytro® phenobarbital/hyoscyamine/atropine/scopolamine propantheline Robinul® Robinul Forte® Symax® Bile Salts ursodiol capsules, tablets Actigall® Chenodal® Cholbam® Ocaliva® CC, QL Urso®, Urso Forte® Antidiarrheals diphenoxylate with atropine tablets diphenoxylate with atropine liquid loperamide Lomotil® Motofen® Mytesi™ CC, QL opium paregoric Restora® Ulcerative Colitis Agents Apriso™ Asacol® HD balsalazide Azulfidine® Lialda™ Azulfidine EN-tabs® mesalamine enema (generic Rowasa®) budesonide ER (generic Uceris®) mesalamine suppository (generic Canasa®) Canasa® Pentasa® Colazal® sulfasalazine Delzicol® sulfasalazine EC Dipentum® Giazo® mesalamine oral formulations (generics of Apriso™, Delzicol®, and Lialda™) Rowasa®, sfRowasa® Uceris®
AE = Age Edits CC = Clinical Criteria MD = Medications with QL = Quantity Limits Maximum Duration
Page 7 | Kentucky Medicaid Single Preferred Drug List Effective September 2, 2021
Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/ Magellan Medicaid Administration Clinical Support Center: Phone 800-477-3071; Fax 800-365-8835
II. GASTROINTESTINAL
Drug Class Preferred Agents Non-Preferred Agents Laxatives and Cathartics lactulose solution (including Constulose®, Enulose®, Generlac) alvimopan MoviPrep® Clenpiq™ polyethylene glycol (PEG) 3350 bottle CoLyte® PEG 3350/electrolyte solution for reconstitution (including Entereg® GaviLyte-C®, GaviLyte-G®) GaviLyte-N® PEG 3350/electrolyte solution with flavor packs GoLYTELY® Kristalose® NuLYTELY® OsmoPrep® Tablets PEG 3350 powder packets PEG-3350, sodium sulfate, sodium chloride, potassium chloride, sodium ascorbate and ascorbic acid for oral solution Prepopik™ Suprep® Sutab® TriLyte® GI Motility Agents Amitiza® CC, QL alosetron CC, QL Linzess® CC, QL Lotronex® CC, QL Movantik® CC, QL lubiprostone QL Motegrity™ CC, QL Relistor® CC, QL Symproic® CC, QL Trulance™ CC, QL Viberzi® CC,QL
III. RESPIRATORY
Drug Class Preferred Agents Non-Preferred Agents Antibiotics, Inhaled Bethkis® QL Arikayce® CC, QL Kitabis™ Pak QL Cayston® QL TOBI® QL TOBI Podhaler® QL tobramycin inhalation solution QL Minimally Sedating cetirizine oral solution/syrup Clarinex® Antihistamines levocetirizine tablets Clarinex-D® 12 Hr desloratadine levocetirizine solution Semprex D® Intranasal Antihistamines azelastine 0.1%, 0.15% olopatadine and Anticholinergics ipratropium nasal spray Patanase™
AE = Age Edits CC = Clinical Criteria MD = Medications with QL = Quantity Limits Maximum Duration
Page 8 | Kentucky Medicaid Single Preferred Drug List Effective September 2, 2021
Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/ Magellan Medicaid Administration Clinical Support Center: Phone 800-477-3071; Fax 800-365-8835
III. RESPIRATORY
Drug Class Preferred Agents Non-Preferred Agents QL QL Short-Acting Beta2 albuterol inhalation solution albuterol HFA Adrenergic Agonists albuterol low-dose inhalation solution QL albuterol oral syrup, tablets QL ProAir® HFA QL albuterol ER tablets QL terbutaline tablets QL levalbuterol HFA QL levalbuterol inhalation solution QL metaproterenol oral syrup QL ProAir® Digihaler™ QL ProAir RespiClick® QL Proventil® HFA QL Ventolin HFA® QL Xopenex® QL Xopenex HFA® QL QL QL Long-Acting Beta2 Serevent® Diskus Arcapta™ Neohaler™ Adrenergic Agonists arformoterol CC, QL Brovana® CC, QL formoterol CC, QL Perforomist™ CC, QL Striverdi® Respimat® QL Beta Agonists: Advair® Diskus QL AirDuo™ Digihaler™ CC, QL Combination Products Advair® HFA QL AirDuo™ RespiClick® CC, Q, AE Dulera® QL Breo® Ellipta® QL Symbicort® QL budesonide/formoterol QL fluticasone/salmeterol Wixela™ Inhub™ QL COPD Agents albuterol-ipratropium inhalation solution QL Breztri Aerosphere™ QL Anoro® Ellipta® QL Daliresp™ CC, QL Atrovent® HFA QL Duaklir® Pressair® Bevespi Aerosphere™ QL Incruse® Ellipta® QL Combivent® Respimat® QL Lonhala™ Magnair™ CC, QL ipratropium inhalation solution QL Seebri Neohaler® CC, QL Spiriva HandiHaler® QL Spiriva® Respimat® QL Stiolto™ Respimat® QL Trelegy Ellipta CC, QL Tudorza® Pressair™ QL Utibron Neohaler™ CC, QL Yupelri® CC, QL Inhaled Corticosteroids Asmanex® Twisthaler QL Alvesco® QL budesonide inhalation suspension AE, QL ArmonAir™ Digihaler™ QL Flovent HFA® QL ArmonAir™ RespiClick® Arnuity® Ellipta® QL Asmanex® HFA QL Flovent Diskus® QL Pulmicort Flexhaler® QL Pulmicort Respules® QL QVAR® RediHaler™
AE = Age Edits CC = Clinical Criteria MD = Medications with QL = Quantity Limits Maximum Duration
Page 9 | Kentucky Medicaid Single Preferred Drug List Effective September 2, 2021
Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/ Magellan Medicaid Administration Clinical Support Center: Phone 800-477-3071; Fax 800-365-8835
III. RESPIRATORY
Drug Class Preferred Agents Non-Preferred Agents Intranasal Corticosteroids fluticasone propionate QL azelastine/fluticasone QL Beconase AQ® QL budesonide Children’s Qnasl™ QL Dymista® QL flunisolide QL mometasone QL Nasonex® QL Omnaris™ QL Qnasl™ QL Veramyst® QL Xhance™ CC Zetonna™ QL Leukotriene Modifiers montelukast chewables, tablets QL Accolate® QL montelukast granules AE, QL Singulair® QL zileuton ER QL zafirlukast QL Zyflo® QL Zyflo CR® QL Self-Injectable epinephrine 0.3 mg (generic EpiPen®) QL epinephrine 0.3 mg (generic Adrenaclick®) QL Epinephrine epinephrine 0.15 mg (generic EpiPen Jr.®) QL epinephrine 0.15 mg (generic Adrenaclick®) QL EpiPen® QL EpiPen Jr.® QL Symjepi™ QL
IV. CENTRAL NERVOUS SYSTEM
Drug Class Preferred Agents Non-Preferred Agents Alzheimer’s Agents donepezil 5 and 10 mg tablets, ODT Aricept® Exelon® Patch donepezil 23 mg tablets CC memantine tablets galantamine rivastigmine capsules galantamine ER memantine ER memantine solution Namzaric® Namenda® tablets Namenda XR® Razadyne® rivastigmine patch
AE = Age Edits CC = Clinical Criteria MD = Medications with QL = Quantity Limits Maximum Duration
Page 10 | Kentucky Medicaid Single Preferred Drug List Effective September 2, 2021
Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/ Magellan Medicaid Administration Clinical Support Center: Phone 800-477-3071; Fax 800-365-8835
IV. CENTRAL NERVOUS SYSTEM
Drug Class Preferred Agents Non-Preferred Agents Antianxiety Agents alprazolam IR tablets MD alprazolam ER/XR MD buspirone alprazolam ODT MD chlordiazepoxide MD alprazolam intensol MD diazepam oral solution, tablets MD Ativan® MD lorazepam MD clorazepate MD diazepam Intensol MD doxepin QL (generic Silenor®) lorazepam intensol/oral concentrate MD meprobamate oxazepam MD Silenor® QL Tranxene-T® MD Xanax® MD Xanax XRMD Antidepressants: MAOIs N/A Emsam® Marplan® Nardil® phenelzine tranylcypromine Antidepressants: Other bupropion Aplenzin™ bupropion XL 150, 300 mg tablets bupropion XL 450 mg tablets bupropion SR Forfivo XL™ trazodone nefazodone Spravato™ CC, QL Viibryd™ Trintellix™ Wellbutrin®/Wellbutrin® SR/Wellbutrin® XL Antidepressants: SNRIs desvenlafaxine succinate ER (generic Pristiq®) desvenlafaxine ER base venlafaxine desvenlafaxine fumarate ER venlafaxine ER capsules Effexor XR® Fetzima® Khedezla™ Pristiq® venlafaxine ER tablets
AE = Age Edits CC = Clinical Criteria MD = Medications with QL = Quantity Limits Maximum Duration
Page 11 | Kentucky Medicaid Single Preferred Drug List Effective September 2, 2021
Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/ Magellan Medicaid Administration Clinical Support Center: Phone 800-477-3071; Fax 800-365-8835
IV. CENTRAL NERVOUS SYSTEM
Drug Class Preferred Agents Non-Preferred Agents Antidepressants: SSRIs citalopram Brisdelle™ CC escitalopram tablets Celexa® fluoxetine capsules, solution escitalopram solution fluoxetine ER fluoxetine 90 mg DR, tablets QL paroxetine fluvoxamine sertraline fluvoxamine ER Lexapro™ paroxetine controlled release Paxil® Paxil® CR Pexeva® Prozac® Sarafem® Zoloft® Antidepressants: Tricyclics amitriptyline amoxapine clomipramine Anafranil® doxepin concentrate desipramine imipramine hydrochloride doxepin capsules, tablets mirtazapine imipramine pamoate nortriptyline capsule maprotiline Norpramin® nortriptyline solution Pamelor® protriptyline Remeron® Surmontil® Tofranil® trimipramine Anticonvulsants: First Celontin® clonazepam ODT Generation clobazam QL Depakene® clonazepam tablets QL Depakote® diazepam rectal gel QL Depakote ER® divalproex delayed-release Depakote® Sprinkle divalproex sodium ER Diastat® QL divalproex sprinkle Dilantin® ethosuximide Felbatol® felbamate Klonopin® QL Peganone® Mysoline® phenobarbital CC Nayzilam® CC, QL phenytoin IR/ER Onfi™ QL primidone CC Phenytek® valproate Sympazan™ CC, QL valproic acid Zarontin® Valtoco® QL
AE = Age Edits CC = Clinical Criteria MD = Medications with QL = Quantity Limits Maximum Duration
Page 12 | Kentucky Medicaid Single Preferred Drug List Effective September 2, 2021
Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/ Magellan Medicaid Administration Clinical Support Center: Phone 800-477-3071; Fax 800-365-8835
IV. CENTRAL NERVOUS SYSTEM
Drug Class Preferred Agents Non-Preferred Agents Anticonvulsants: Second Banzel® CC, QL Briviact® QL Generation Gabitril® QL Diacomit™ CC, QL lamotrigine chewable tablets, tablets (except dose packs) Elepsia® XR QL levetiracetam ER QL Epidiolex™ CC levetiracetam solution, tablets QL Fintepla® CC, QL Sabril® CC Fycompa™ QL topiramate QL Keppra® solution, tablets QL zonisamide QL Keppra XR® QL Lamictal® Lamictal ODT® Lamictal® XR™ QL lamotrigine dose packs lamotrigine ER QL lamotrigine ODT Qudexy® XR QL rufinamide QL Spritam QL tiagabine QL Topamax® QL topiramate ER QL Trokendi XR™ QL vigabatrin Vimpat® QL Xcopri® CC, QL Anticonvulsants: carbamazepine tablets Aptiom® QL Carbamazepine carbamazepine ER capsules (generic Carbatrol®) carbamazepine suspension Derivatives carbamazepine ER tablets Carbatrol® Equetro™ Epitol® oxcarbazepine QL Oxtellar™ XR QL Tegretol® suspension Tegretol® tablets Tegretol® XR Trileptal® QL First-Generation amitriptyline/perphenazine Adasuve® Antipsychotics chlorpromazine molindone fluphenazine pimozide haloperidol loxapine perphenazine thioridazine thiothixene trifluoperazine
AE = Age Edits CC = Clinical Criteria MD = Medications with QL = Quantity Limits Maximum Duration
Page 13 | Kentucky Medicaid Single Preferred Drug List Effective September 2, 2021
Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/ Magellan Medicaid Administration Clinical Support Center: Phone 800-477-3071; Fax 800-365-8835
IV. CENTRAL NERVOUS SYSTEM
Drug Class Preferred Agents Non-Preferred Agents Second-Generation aripiprazole tablets CC, QL Abilify® oral formulations QL Antipsychotics asenapine CC, QL aripiprazole ODT, oral solution clozapine tablets CC, QL Caplyta® CC, QL Latuda® CC, QL clozapine ODT QL olanzapine CC, QL Clozaril® QL quetiapine CC, QL Fanapt™ QL quetiapine ER CC, QL FazaClo® QL risperidone CC, QL Geodon® capsules QL Vraylar™ CC, QL Invega® QL ziprasidone capsules CC, QL olanzapine/fluoxetine CC, QL Nuplazid™ CC, QL paliperidone QL Rexulti® QL Risperdal® QL Saphris® CC, QL Secuado® QL Seroquel® QL Seroquel® XR QL Symbyax® CC, QL Versacloz® QL Zyprexa® QL Antipsychotics: Injectable Abilify Maintena™ CC, QL Haldol® Decanoate QL Aristada ER™ CC, QL Haldol® Lactate QL Aristada Initio™ CC, QL Perseris™ fluphenazine decanoate CC, QL ziprasidone injection QL Geodon® injection CC, QL Zyprexa® QL haloperidol decanoate CC, QL Zyprexa® Relprevv QL haloperidol lactate CC, QL Invega® Sustenna® CC, QL Invega Trinza™ CC, QL olanzapine CC, QL Risperdal® Consta® CC, QL
AE = Age Edits CC = Clinical Criteria MD = Medications with QL = Quantity Limits Maximum Duration
Page 14 | Kentucky Medicaid Single Preferred Drug List Effective September 2, 2021
Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/ Magellan Medicaid Administration Clinical Support Center: Phone 800-477-3071; Fax 800-365-8835
IV. CENTRAL NERVOUS SYSTEM
Drug Class Preferred Agents Non-Preferred Agents Stimulants and Related Adderall XR® CC, QL Adderall® QL Agents Concerta® CC, QL Adhansia XR™ QL atomoxetine CC, QL Adzenys ER™ dexmethylphenidate CC, QL Adzenys XR-ODT™ QL dextroamphetamine CC, QL amphetamine ER suspension QL Focalin XR® CC, QL amphetamine sulfate QL guanfacine ER CC, QL Aptensio XR® QL Methylin® solution QL clonidine ER QL methylphenidate solution, tablets CC, QL Cotempla XR-ODT™ QL mixed amphetamine salts tablets CC, QL Daytrana® QL Vyvanse® capsules, chewable tablets CC, QL Desoxyn® QL Dexedrine® QL dexmethylphenidate ER QL dextroamphetamine ER QL dextroamphetamine solution QL dextroamphetamine sulfate tablets (generic for Zenzedi®) QL Dyanavel® XR QL Evekeo® QL Evekeo® ODT QL Focalin® QL Intuniv® QL Jornay PM™ QL Metadate® ER QL methamphetamine QL methylphenidate CD (generic Metadate CD®) QL methylphenidate chewable tablets QL methylphenidate ER tablets QL methylphenidate ER OROS (generic Concerta®) QL methylphenidate LA (generic Ritalin LA®) QL mixed amphetamine salts ER capsules QL Mydayis™ QL ProCentra® QL QuilliChew ER™ QL Quillivant XR® QL Relexxii QL Ritalin® QL Ritalin LA® QL Strattera® QL Zenzedi® QL
AE = Age Edits CC = Clinical Criteria MD = Medications with QL = Quantity Limits Maximum Duration
Page 15 | Kentucky Medicaid Single Preferred Drug List Effective September 2, 2021
Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/ Magellan Medicaid Administration Clinical Support Center: Phone 800-477-3071; Fax 800-365-8835
IV. CENTRAL NERVOUS SYSTEM
Drug Class Preferred Agents Non-Preferred Agents Anti-Migraine: 5-HT1 Imitrex® nasal QL almotriptan QL Receptor Agonists rizatriptan QL Amerge® QL rizatriptan ODT QL Cambia™ sumatriptan syringe, tablet, vial QL eletriptan QL Frova™ QL frovatriptan QL Imitrex® kit, vial, tablet QL Maxalt® QL Maxalt-MLT® QL naratriptan QL Onzetra™ Xsail™ CC, AE, QL Relpax™ QL sumatriptan kit QL sumatriptan nasal spray QL sumatriptan/naproxen QL Treximet™ QL Tosymra ™ Zembrace™ SymTouch™, CC, QL zolmitriptan tablet, nasal spray QL zolmitriptan ODT QL Zomig® QL Zomig-ZMT® QL Anti-Migraine: CGRP Ajovy™ CC, AE,QL Aimovig™ CC, AE, QL Inhibitors Emgality™ 120 mg/mL CC, AE, QL Emgality™ 100 mg/mL CC, AE, QL Ubrelvy™ CC, AE, QL Nurtec™ ODT CC, AE, QL Reyvow™ CC, AE, QL Dopamine Receptor bromocriptine Mirapex® ER Agonists pramipexole Neupro® ropinirole Parlodel® pramipexole ER ropinirole ER Movement Disorders tetrabenazine Austedo® CC, QL Ingrezza® CC, QL Xenazine® Narcolepsy Agents modafinil CC, QL armodafinil QL Nuvigil® QL Provigil® QL Sunosi™ CC, QL Wakix® CC, QL Xyrem® CC, QL Xywav™ CC, QL
AE = Age Edits CC = Clinical Criteria MD = Medications with QL = Quantity Limits Maximum Duration
Page 16 | Kentucky Medicaid Single Preferred Drug List Effective September 2, 2021
Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/ Magellan Medicaid Administration Clinical Support Center: Phone 800-477-3071; Fax 800-365-8835
IV. CENTRAL NERVOUS SYSTEM
Drug Class Preferred Agents Non-Preferred Agents Neuropathic Pain duloxetine DR (generic Cymbalta®) Cymbalta® gabapentin QL duloxetine (generic Irenka™) Lidoderm® QL Drizalma Sprinkle™ pregabalin CC, QL Gralise™ Horizant® lidocaine 5% patch QL Lyrica® QL Lyrica® CR QL Neurontin® QL pregabalin ER QL Savella® ZTlido™ CC Parkinson’s Disease amantadine Azilect® benztropine carbidopa entacapone Comtan® levodopa/carbidopa Duopa™ levodopa/carbidopa CR Gocovri™ levodopa/carbidopa ODT Inbrija™ levodopa/carbidopa/entacapone Kynmobi™ CC, QL selegiline Lodosyn® trihexyphenidyl Nourianz™ CC QL Ongentys® CC, QL Osmolex™ ER rasagiline Rytary™ Sinemet® Sinemet® CR Stalevo® Tasmar® tolcapone Xadago® CC, QL Zelapar™
AE = Age Edits CC = Clinical Criteria MD = Medications with QL = Quantity Limits Maximum Duration
Page 17 | Kentucky Medicaid Single Preferred Drug List Effective September 2, 2021
Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/ Magellan Medicaid Administration Clinical Support Center: Phone 800-477-3071; Fax 800-365-8835
IV. CENTRAL NERVOUS SYSTEM
Drug Class Preferred Agents Non-Preferred Agents Sedative Hypnotic Agents temazepam 15 mg, 30 mg MD, QL Ambien® MD, QL zolpidem MD, QL Ambien CR® MD, QL Belsomra® MD, QL Dayvigo™ MD, QL Doral® MD, QL Edluar® CC, MD, QL estazolam MD, QL eszopiclone MD, QL flurazepam MD, QL Halcion® MD, QL Hetlioz® CC, QL Hetlioz LQ® CC, QL Intermezzo® MD, QL Lunesta™ MD, QL ramelteon CC, MD, QL Restoril® MD, QL Rozerem® CC, MD, QL Sonata® MD, QL temazepam 7.5 mg, 22.5 mg MD, QL triazolam MD, QL zaleplon MD, QL zolpidem ER MD, QL zolpidem SL MD, QL Zolpimist™ MD, QL Skeletal Muscle Relaxants baclofen QL Amrix® QL, MD chlorzoxazone QL carisoprodol QL, MD cyclobenzaprine QL carisoprodol compound QL, MD methocarbamol QL cyclobenzaprine ER QL, MD orphenadrine QL Dantrium® QL tizanidine tablets QL dantrolene QL, CC Fexmid® QL, MD Lorzone® QL metaxalone QL Norgesic Forte Robaxin® QL Skelaxin® QL Soma® QL, MD tizanidine capsules QL Zanaflex® QL Spinal Muscular Atrophy N/A Evrysdi™ CC Zolgensma® CC Tobacco Cessation bupropion SR QL Commit® QL Chantix® AE, QL NicoDerm® QL nicotine buccal/gum/lozenge QL NicoDerm CQ® QL nicotine transdermal system QL Nicorelief® QL Nicotrol® Inhaler QL Nicorette® QL Nicotrol® NS QL Nicotrol® Patch QL
AE = Age Edits CC = Clinical Criteria MD = Medications with QL = Quantity Limits Maximum Duration
Page 18 | Kentucky Medicaid Single Preferred Drug List Effective September 2, 2021
Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/ Magellan Medicaid Administration Clinical Support Center: Phone 800-477-3071; Fax 800-365-8835
V. ANALGESICS
Drug Class Preferred Agents Non-Preferred Agents Narcotic Agonist/ N/A butorphanol NS Antagonists pentazocine/naloxone QL Narcotics: Short-Acting codeine/APAP CC, AE, MD, QL Apadaz™ MD, QL hydrocodone/APAP CC, MD, QL Ascomp® with codeine CC, AE, QL hydrocodone/ibuprofen CC, MD, QL benzhydrocodone/APAP MD, QL hydromorphone tablets CC, MD, QL butalbital/APAP/caffeine/codeine CC, AE, QL morphine concentrate, solution, tablets CC, MD, QL butalbital compound/codeine CC, AE, QL oxycodone solution, tablets CC, MD, QL carisoprodol/ASA/codeine MD, AE, QL oxycodone/APAP CC, MD, QL codeine MD, AE, QL tramadol 50 mg CC, MD, AE, QL Demerol™ MD, QL tramadol/APAP MD, AE, QL dihydrocodeine bitartrate/APAP/caffeine MD, QL Dilaudid® MD, QL hydromorphone liquid, suppositories MD, QL levorphanol MD, QL Lorcet® MD, QL Lorcet® HD MD, QL Lortab® MD, QL meperidine solution, tablets MD, QL morphine suppository MD, QL Nalocet MD, QL Norco® MD, QL Nucynta™ MD, QL Oxaydo® MD, QL oxycodone capsules, concentrate MD, QL oxycodone/ASA MD, QL oxymorphone MD, QL Percocet® MD, QL Roxicodone® MD, QL tramadol 100 mg MD, AE, QL Ultracet® MD, AE, QL Ultram® MD, AE, QL
AE = Age Edits CC = Clinical Criteria MD = Medications with QL = Quantity Limits Maximum Duration
Page 19 | Kentucky Medicaid Single Preferred Drug List Effective September 2, 2021
Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/ Magellan Medicaid Administration Clinical Support Center: Phone 800-477-3071; Fax 800-365-8835
V. ANALGESICS
Drug Class Preferred Agents Non-Preferred Agents Narcotics: Long-Acting Butrans™ CC, QL Belbuca™ AE, QL fentanyl transdermal 12, 25, 50, 75, 100 mcg CC, QL buprenorphine film AE, QL morphine sulfate ER (generic MS Contin®) CC, QL buprenorphine patch QL tramadol ER (generic Ryzolt®, Ultram® ER) CC, AE, QL ConZip™ AE, QL Duragesic® QL fentanyl transdermal 37.5, 62.5, 87.5 mcg , QL hydrocodone ER QL hydromorphone ER QL Hysingla™ ER QL Kadian® QL methadone CC, QL morphine sulfate SA (generic Kadian®, Avinza™) QL MS Contin® QL Nucynta® ER CC,QL oxycodone ER QL OxyContin® QL oxymorphone ER QL tramadol ER (generic ConZip™) AE, QL Xtampza™ ER AE, QL Zohydro ER™ QL Narcotics: Fentanyl Buccal N/A Actiq® CC, QL Products fentanyl citrate lollipop CC, QL Fentora® CC, QL Subsys® CC Opiate Dependence Bunavail® AE, QL N/A Treatments buprenorphine AE, QL buprenorphine/naloxone SL films AE, QL buprenorphine/naloxone SL tablets AE, QL Lucemyra™ AE, QL naltrexone AE Probuphine® AE Sublocade™ AE, QL Suboxone® films AE, QL Vivitrol® AE Zubsolv® AE, QL
AE = Age Edits CC = Clinical Criteria MD = Medications with QL = Quantity Limits Maximum Duration
Page 20 | Kentucky Medicaid Single Preferred Drug List Effective September 2, 2021
Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/ Magellan Medicaid Administration Clinical Support Center: Phone 800-477-3071; Fax 800-365-8835
Non-Steroidal Anti- celecoxib QL Arthrotec® Inflammatory Drugs diclofenac sodium DR/EC tablets Celebrex® QL (NSAIDs) diclofenac sodium topical gel (1%) Daypro® ibuprofen diclofenac epolamine patches CC indomethacin diclofenac sodium/misoprostol ketorolac tablets QL diclofenac potassium meloxicam tablets diclofenac sodium SR/ER naproxen sodium tablets diclofenac 1.5% topical solution CC naproxen tablets diflunisal sulindac Diclofex DC Dicloheal-60 Kit Duexis® CC EC-Naprosyn® etodolac etodolac ER Feldene® fenoprofen Flector® CC flurbiprofen ibuprofen/famotidine Indocin® indomethacin ER ketoprofen ketoprofen ER ketorolac nasal spray CC Licart™ CC meclofenamate mefenamic acid meloxicam capsules CC Mobic® nabumetone Nalfon® Naprelan® CR Naprosyn® naproxen CR/ER/DR naproxen suspension naproxen/esomeprazole CC, QL oxaprozin Pennsaid® CC piroxicam Relafen™, Relafen™ DS Sprix™ CC tolmetin Vimovo™ CC, QL Vivlodex™ CC, QL Voltaren® topical gel Ziclopro Kit™ Zipsor™ Zorvolex® CC
AE = Age Edits CC = Clinical Criteria MD = Medications with QL = Quantity Limits Maximum Duration
Page 21 | Kentucky Medicaid Single Preferred Drug List Effective September 2, 2021
Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/ Magellan Medicaid Administration Clinical Support Center: Phone 800-477-3071; Fax 800-365-8835
VI. ANTI-INFECTIVES
Drug Class Preferred Agents Non-Preferred Agents Antibiotics: cefadroxil capsules cefadroxil tablets, suspension Cephalosporins 1st cephalexin Keflex® Generation Antibiotics: cefaclor capsule cefaclor ER Cephalosporins 2nd cefprozil Ceftin® Generation cefuroxime axetil Antibiotics: cefdinir cefixime Cephalosporins 3rd cefpodoxime Generation Suprax® Antibiotics: Firvanq™ CC Dificid® QL Gastrointestinal (GI) metronidazole tablets Flagyl® neomycin Humatin® tinidazole metronidazole capsules vancomycin capsules CC nitazoxanide Xifaxan® CC, QL paromomycin Solosec™ CC, QL Vancocin® vancomycin solution Antibiotics: azithromycin clarithromycin ER Macrolides/Ketolides clarithromycin E.E.S 400® tablets erythromycin base capsules DR E.E.S.® granules for suspension erythromycin ethylsuccinate 200mg suspension EryPed® Ketek® Ery-Tab® Erythrocin® erythromycin base tablets erythromycin ethylsuccinate 400mg suspension Zithromax® Antibiotics: linezolid tablets CC, QL, MD linezolid suspension QL, MD Oxazolidinones Sivextro™ QL Zyvox® QL, MD Antibiotics: Penicillins amoxicillin amoxicillin/clavulanate chewable tablets amoxicillin/clavulanate tablets, suspension amoxicillin/clavulanate ER ampicillin Augmentin XR® dicloxacillin penicillin V Antibiotics: Pleuromutilins N/A Xenleta™ CC, QL Antibiotics: Quinolones ciprofloxacin tablets Baxdela™ AE, QL levofloxacin tablets ciprofloxacin ER ciprofloxacin suspension Cipro® Cipro XR® Levaquin® levofloxacin solution moxifloxacin ofloxacin
AE = Age Edits CC = Clinical Criteria MD = Medications with QL = Quantity Limits Maximum Duration
Page 22 | Kentucky Medicaid Single Preferred Drug List Effective September 2, 2021
Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/ Magellan Medicaid Administration Clinical Support Center: Phone 800-477-3071; Fax 800-365-8835
VI. ANTI-INFECTIVES
Drug Class Preferred Agents Non-Preferred Agents Antibiotics: Sulfonamides, trimethoprim Bactrim® Folate Antagonist trimethoprim/sulfamethoxazole Bactrim DS® sulfadiazine Sulfatrim® suspension Antibiotics: Tetracyclines demeclocycline Doryx® and Doryx® MPC doxycycline hyclate doxycycline hyclate DR capsules, tablets doxycycline monohydrate 50 mg, 100 mg capsules doxycycline IR-DR doxycycline monohydrate suspension, tablets doxycycline monohydrate 40, 75, 150 mg capsules minocycline capsules doxycycline “kits” or “packs” minocycline tablets minocycline ER Morgidox® Nuzyra™ CC, QL Oracea™ Solodyn® tetracycline Vibramycin® Ximino™ Antibiotics: Vaginal Cleocin® Ovules Cleocin® cream Clindesse® clindamycin vaginal 2% cream Nuvessa® MetroGel Vaginal® Vandazole® metronidazole vaginal 0.75% gel Antifungals: Oral clotrimazole Ancobon® fluconazole Cresemba® griseofulvin suspension Diflucan® itraconazole capsules CC flucytosine nystatin suspension, tablets griseofulvin microsize tablets terbinafine griseofulvin ultramicrosize Gris-PEG® itraconazole solution ketoconazole Lamisil® Noxafil® nystatin powder Onmel™ Oravig™ posaconazole Sporanox® Tolsura Vfend® voriconazole Antivirals: Herpes acyclovir Sitavig® famciclovir Valtrex® valacyclovir
AE = Age Edits CC = Clinical Criteria MD = Medications with QL = Quantity Limits Maximum Duration
Page 23 | Kentucky Medicaid Single Preferred Drug List Effective September 2, 2021
Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/ Magellan Medicaid Administration Clinical Support Center: Phone 800-477-3071; Fax 800-365-8835
VI. ANTI-INFECTIVES
Drug Class Preferred Agents Non-Preferred Agents Antivirals: Influenza oseltamivir QL Flumadine® Relenza® rimantadine Tamiflu® QL Xofluza™ CC, QL Anti-Infectives: entecavir adefovir Hepatitis B Epivir-HBV® solution Baraclude™ lamivudine HBV Epivir-HBV® tablet Hepsera® Vemlidy® CC, QL Hepatitis C: Direct-Acting Mavyret™ CC, AE, QL Epclusa® CC, AE, QL Antiviral Agents sofosbuvir/velpatasvir CC, AE, QL Harvoni® CC, AE, QL Vosevi™ CC, AE, QL ledipasvir/sofosbuvir CC, AE, QL Sovaldi™ CC, AE, QL Viekira Pak® CC, AE, QL Zepatier™ CC,AE, QL Hepatitis C: Interferons PEGASYS® ProClick CC, QL PEGASYS® vial CC, QL PEGASYS® syringe CC, QL PEGIntron™ CC, QL Hepatitis C: Ribavirins ribavirin CC Moderiba™ CC ribavirin dose pack CC
AE = Age Edits CC = Clinical Criteria MD = Medications with QL = Quantity Limits Maximum Duration
Page 24 | Kentucky Medicaid Single Preferred Drug List Effective September 2, 2021
Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/ Magellan Medicaid Administration Clinical Support Center: Phone 800-477-3071; Fax 800-365-8835
VI. ANTI-INFECTIVES
Drug Class Preferred Agents Non-Preferred Agents Antiretrovirals: abacavir QL abacavir-lamivudine-zidovudine HIV/AIDS abacavir-lamivudine Aptivus® atazanavir QL Combivir® Atripla® QL Crixivan® Biktarvy® QL didanosine DR QL Cimduo™ QL Dovato QL Complera® QL efavirenz/emtricitabine/tenofovir disoproxil Delstrigo™ QL fumarate QL Descovy® CC, QL efavirenz/lamivudine/tenofovir disoproxil Edurant® fumarate QL efavirenz emtricitabine QL Emtriva® QL emtricitabine/tenofovir disoproxil fumarate QL Evotaz™ QL Epivir® QL Genvoya® QL Epzicom® Intelence® etravirine Isentress® fosamprenavir Fuzeon® lamivudine QL Invirase® lamivudine-zidovudine Juluca QL lopinavir-ritonavir tablets, solution Kaletra® tablets, solution Odefsey® QL Lexiva® Pifeltro™ QL nevirapine QL Prezista® nevirapine ER QL ritonavir tablets Norvir® tablets, solution QL, powder packets Selzentry® Prezcobix® QL stavudine capsules QL ritonavir solution stavudine solution Reyataz® QL Stribild® QL Rukobia® CC, QL Symfi™ QL Sustiva® Symfi Lo™ QL Symtuza™ QL tenofovir disoproxil fumarate tablets QL Temixys™ QL Tivicay® tablets QL Tivicay® suspension Triumeq® QL Videx® solution Trizivir® Viracept® Truvada® CC, QL Viramune® QL Tybost® Viramune XR® QL Videx® EC QL Viread® powder packets zidovudine syrup, tablets Viread® tablets QL Vocabria™ CC, AE, QL Zerit® capsules QL Ziagen® QL zidovudine capsules
AE = Age Edits CC = Clinical Criteria MD = Medications with QL = Quantity Limits Maximum Duration
Page 25 | Kentucky Medicaid Single Preferred Drug List Effective September 2, 2021
Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/ Magellan Medicaid Administration Clinical Support Center: Phone 800-477-3071; Fax 800-365-8835
VII. ENDOCRINE AND METABOLIC AGENTS
Drug Class Preferred Agents Non-Preferred Agents Diabetes: Insulins and Humalog® cartridge, vial and KwikPen® Admelog® and Admelog Solostar® CC Related Agents Humalog® Junior (Jr) KwikPen® Afrezza® Humalog® Mix vial and KwikPen® Apidra™ vial and Solostar® Humulin® R vial Basaglar® KwikPen® CC Humulin® R U-500 vial and KwikPen® Fiasp® vial, pen and FlexTouch® CC Humulin® 70/30 vial and KwikPen® Humalog® 200 unit/mL KwikPen® insulin aspart cartridge vial and pen Humulin® N and Humulin® N KwikPen® insulin aspart/insulin aspart protamine pen and vial Lyumjev™ pen and vial CC insulin lispro pen, vial and Jr, KwikPen® Novolin® R, N vial, pen insulin lispro/insulin lispro protamine KwikPen® Novolin® 70/30 vial, pen Lantus® and Lantus® Solostar Semglee™ pen and vial CC Levemir® and Levemir® FlexTouch® Symlin® CC, AE Novolog® vial, cartridge, and FlexTouch® Toujeo® Solostar® and Max Solostar® Novolog® Mix vial and FlexPen® Tresiba® vial and FlexTouch® Diabetes: DPP-4 Inhibitors Glyxambi® CC, QL alogliptin QL Janumet™ CC, QL alogliptin/metformin QL Janumet XR™ CC, QL alogliptin/pioglitazone QL Januvia™ CC, QL Jentadueto® XR QL Jentadueto™ CC, QL Kazano® QL Tradjenta™ CC, QL Kombiglyze™ XR QL Nesina® QL Onglyza™ QL Oseni® QL Qtern® QL Steglujan™ QL Trijardy® XR QL Diabetes: GLP-1 Receptor Byetta™ CC, QL Adlyxin™ QL Agonists Trulicity™ CC, QL Bydureon® BCise™ Victoza® CC, QL Ozempic® QL Rybelsus® QL Soliqua™ CC, QL Xultophy® CC, QL Diabetes: Alpha- acarbose QL Glyset® QL Glucosidase Inhibitors miglitol QL Precose® QL Diabetes: Metformins glyburide/metformin Fortamet™ metformin tablets glipizide/metformin metformin ER tablets (generic Glucophage XR®) Glucovance® Glumetza™ metformin ER (generic Fortamet™, Glumetza®) Riomet™ Riomet ER™ Diabetes: Meglitinides nateglinide QL Prandin® QL repaglinide QL repaglinide/metformin QL Starlix® QL
AE = Age Edits CC = Clinical Criteria MD = Medications with QL = Quantity Limits Maximum Duration
Page 26 | Kentucky Medicaid Single Preferred Drug List Effective September 2, 2021
Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/ Magellan Medicaid Administration Clinical Support Center: Phone 800-477-3071; Fax 800-365-8835
VII. ENDOCRINE AND METABOLIC AGENTS
Drug Class Preferred Agents Non-Preferred Agents Diabetes: Sulfonylureas glimepiride Amaryl® glipizide chlorpropamide glipizide extended-release Glucotrol® glyburide Glucotrol XL® glyburide micronized Glynase PresTab® tolazamide tolbutamide Diabetes: pioglitazone QL Actos® QL Thiazolidinediones ActoPlus Met® QL ActoPlus Met® XR QL Avandia® QL Duetact™ QL pioglitazone/glimepiride QL pioglitazone/metformin QL Diabetes: SGLT2 Inhibitors Farxiga™ CC, QL Invokamet® XR QL Invokana® CC, QL Segluromet™ QL Invokamet™ CC, QL Steglatro™ AE, QL Jardiance® CC, QL Synjardy® XR QL Synjardy® CC, QL Xigduo™ XR CC, QL Glucagon Agents Baqsimi™ CC diazoxide glucagon, recombinant glucagon HCl Proglycem® Gvoke™ Growth Hormones Genotropin® CC Humatrope® CC Norditropin® CC Nutropin AQ NuSpin® CC Norditropin FlexPro® CC Omnitrope® CC Saizen® CC Serostim® CC Zomacton® CC Zorbtive® CC Bone Resorption alendronate tablets QL Actonel® QL Suppression and Related ibandronate tablets QL alendronate solution QL Agents raloxifene Atelvia™ QL teriparatide CC, QL Boniva® QL calcitonin-salmon Evenity™ CC, AE, QL Evista® Forteo™, QL Fosamax® QL Fosamax Plus D™ QL Miacalcin® Prolia™ Reclast® risedronate QL Tymlos™ CC, AE, QL zoledronic acid
AE = Age Edits CC = Clinical Criteria MD = Medications with QL = Quantity Limits Maximum Duration
Page 27 | Kentucky Medicaid Single Preferred Drug List Effective September 2, 2021
Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/ Magellan Medicaid Administration Clinical Support Center: Phone 800-477-3071; Fax 800-365-8835
VII. ENDOCRINE AND METABOLIC AGENTS
Drug Class Preferred Agents Non-Preferred Agents Progestins for Cachexia megestrol acetate 40 mg/mL QL, tablets Megace ES® megestrol acetate 625 mg/5 mL Pancreatic Enzymes Creon® Pancreaze™ Zenpep® Pertzye™ Viokace™ Androgenic Agents Androderm® Androgel® Gel Packet Androgel® Gel Pump Fortesta® Natesto™ Testim® testosterone gel pump, packet (generic Androgel®) testosterone gel (generic Axiron®, Fortesta®, Testim®, Vogelxo®) Vogelxo® Oral Steroids budesonide EC Alkindi® Sprinkle dexamethasone solution, tablets Celestone® hydrocortisone Cortef® methylprednisolone dose pack, tablets cortisone prednisolone solution Decadron® prednisolone sodium phosphate dexamethasone elixir prednisone dose pack, tablets, solution dexamethasone intensol DexPak® Dxevo Emflaza® CC, QL Entocort EC® Hemady® Medrol® methylprednisolone 8 mg, 16 mg tablets Millipred® Ortikos™ prednisone intensol prednisolone sodium phosphate ODT Rayos® TaperDex™ Veripred 20® ZoDex™
AE = Age Edits CC = Clinical Criteria MD = Medications with QL = Quantity Limits Maximum Duration
Page 28 | Kentucky Medicaid Single Preferred Drug List Effective September 2, 2021
Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/ Magellan Medicaid Administration Clinical Support Center: Phone 800-477-3071; Fax 800-365-8835
VIII. IMMUNOLOGIC AGENTS
Drug Class Preferred Agents Non-Preferred Agents Immunomodulators Cosentyx® CC, QL Actemra® CC, QL Enbrel® CC QL Cimzia® CC, QL Humira® CC, QL Enspryng™ CC, QL Ilumya™ CC Kevzara® CC, QL Kineret® CC, QL Olumiant® CC, QL Orencia® CC, QL Otezla® CC, QL Rinvoq™ CC, QL Siliq™ CC, QL Simponi™ CC, QL Skyrizi™ CC, QL Stelara™ CC, QL Taltz® CC, QL Tremfya™ CC, QL Xeljanz® CC, QL Xeljanz® XR CC, QL Immunomodulators, Elidel® Dupixent® CC, QL Atopic Dermatitis Eucrisa® CC, QL pimecrolimus Protopic® tacrolimus Multiple Sclerosis Agents Avonex® CC, QL Ampyra™ QL Betaseron® CC, QL Aubagio® QL Copaxone® 20 mg CC, QL Bafiertam™ QL Gilenya™ CC, QL Copaxone® 40 mg QL Rebif® CC, QL dalfampridine ER QL Tecfidera™ CC, QL dimethyl fumarate QL Extavia® QL glatiramer acetate QL Glatopa™ QL Kesimpta® CC, QL Mavenclad® CC, QL Mayzent® CC, QL Plegridy® Vumerity™ QL Zeposia® CC, QL
AE = Age Edits CC = Clinical Criteria MD = Medications with QL = Quantity Limits Maximum Duration
Page 29 | Kentucky Medicaid Single Preferred Drug List Effective September 2, 2021
Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/ Magellan Medicaid Administration Clinical Support Center: Phone 800-477-3071; Fax 800-365-8835
VIII. IMMUNOLOGIC AGENTS
Drug Class Preferred Agents Non-Preferred Agents Immunosuppressants azathioprine Astagraf XL™ CellCept® suspension Azasan® cyclosporine CellCept® capsules, tablets cyclosporine modified Envarsus® XR Gengraf® everolimus mycophenolate mofetil capsules, tablets Imuran® mycophenolic acid mycophenolate mofetil suspension sirolimus Myfortic® tacrolimus Neoral® Prograf® Rapamune® Sandimmune® Zortress®
IX. BLOOD MODIFIERS
Drug Class Preferred Agents Non-Preferred Agents Erythropoiesis Stimulating Aranesp® CC Epogen® Proteins Retacrit™ CC Mircera® Procrit® Reblozyl® CC, AE Thrombopoiesis Promacta® tablets CC Doptelet® CC, QL Stimulating Agents Mulpleta® CC, QL Nplate™ CC Promacta® suspension packets CC Tavalisse™ CC, QL Antihyperuricemics allopurinol colchicine capsules CC colchicine tablets CC Colcrys® CC probenecid febuxostat QL probenecid/colchicine Gloperba® CC Mitigare® CC Uloric® CC, QL Zyloprim® Colony Stimulating Factors Neupogen® CC, QL Granix® QL Fulphila™ QL Leukine® QL Neulasta® QL Nivestym™ QL Nyvepria™ QL Udenyca™ QL Zarxio® QL Ziextenzo® QL
AE = Age Edits CC = Clinical Criteria MD = Medications with QL = Quantity Limits Maximum Duration
Page 30 | Kentucky Medicaid Single Preferred Drug List Effective September 2, 2021
Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/ Magellan Medicaid Administration Clinical Support Center: Phone 800-477-3071; Fax 800-365-8835
IX. BLOOD MODIFIERS
Drug Class Preferred Agents Non-Preferred Agents Phosphate Binders calcium acetate Auryxia™ MagneBind® 400 RX Fosrenol® Phoslyra™ lanthanum carbonate Renvela™ tablets Renagel® Renvela™ powder packets sevelamer carbonate powder packets sevelamer carbonate tablets sevelamer hydrochloride Velphoro®
X. OPHTHALMICS
Drug Class Preferred Agents Non-Preferred Agents Ophthalmic Antivirals trifluridine Viroptic® Vitrasert® intraocular implant Zirgan® Ophthalmic Quinolones ciprofloxacin Besivance™ ofloxacin Ciloxan® moxifloxacin (generic Vigamox™) gatifloxacin levofloxacin Moxeza™ moxifloxacin (generic Moxeza™) Ocuflox® Quixin® Vigamox™ Zymaxid™ Ophthalmic Antibiotics, bacitracin AzaSite™ Non-Quinolones bacitracin/polymyxin B Bleph®-10 erythromycin 0.5% ointment Garamycin® gentamicin solution/ointment Ilotycin® polymyxin B/trimethoprim Natacyn® sulfacetamide solution Neocidin® tobramycin solution neomycin/polymyxin B/bacitracin neomycin/polymyxin B/gramicidin Neosporin® Polytrim® sulfacetamide ointment Tobrex®
AE = Age Edits CC = Clinical Criteria MD = Medications with QL = Quantity Limits Maximum Duration
Page 31 | Kentucky Medicaid Single Preferred Drug List Effective September 2, 2021
Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/ Magellan Medicaid Administration Clinical Support Center: Phone 800-477-3071; Fax 800-365-8835
X. OPHTHALMICS
Drug Class Preferred Agents Non-Preferred Agents Ophthalmic Antibiotic- Blephamide® Blephamide® S.O.P. Steroid Combinations dexamethasone/neomycin sulfate/polymyxin B dexamethasone/tobramycin hydrocortisone/bacitracin zinc/neomycin sulfate/polymyxin B hydrocortisone/neomycin sulfate/polymyxin B TobraDex® Maxitrol® Pred-G® Pred-G® S.O.P. prednisolone sodium phosphate/sulfacetamide sodium TobraDex® ST Zylet™ Ophthalmic olopatadine 0.1% (generic Patanol®) azelastine Antihistamines olopatadine 0.2% (generic Pataday™) bepotastine Bepreve™ Elestat™ epinastine Lastacaft™ Optivar® Pataday™ Patanol® Pazeo™ Zerviate™ Ophthalmic Beta Blockers levobunolol betaxolol timolol maleate (except preservative-free) Betoptic S® carteolol Istalol® metipranolol timolol maleate once daily (generic Istalol®) timolol PF (preservative-free) Timoptic® Timoptic XE® Ophthalmic Carbonic dorzolamide Azopt® Anhydrase Inhibitors Trusopt® Ophthalmic Combinations Combigan™ Cosopt® for Glaucoma dorzolamide/timolol (except preservative-free) Cosopt PF® Simbrinza™ dorzolamide/timolol PF (preservative-free) Ophthalmic naphazoline Altafrin® Vasoconstrictors phenylephrine Mydfrin® Neofrin® Ophthalmic Mast Cell cromolyn sodium Alocril® Stabilizers Alomide®
AE = Age Edits CC = Clinical Criteria MD = Medications with QL = Quantity Limits Maximum Duration
Page 32 | Kentucky Medicaid Single Preferred Drug List Effective September 2, 2021
Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/ Magellan Medicaid Administration Clinical Support Center: Phone 800-477-3071; Fax 800-365-8835
X. OPHTHALMICS
Drug Class Preferred Agents Non-Preferred Agents Ophthalmic Mydriatics & atropine sulfate Cyclogyl® Mydriatic Combinations cyclopentolate Cyclomydril® tropicamide Homatropaire® homatropine Isopto Atropine® Isopto Homatropine® Isopto Hyoscine® Mydriacyl® Paremyd® Ophthalmic NSAIDs diclofenac Acular® flurbiprofen Acular LS® ketorolac Acuvail® bromfenac BromSite™ Ilevro™ Nevanac™ Ocufen® Prolensa™ Voltaren® Ophthalmic Prostaglandin latanoprost QL bimatoprost QL Agonists Lumigan® QL Travatan Z® travoprost Vyzulta™ AE, QL Xalatan® QL Xelpros™ Zioptan® QL Ophthalmic Anti- dexamethasone sodium phosphate Alrex® Inflammatory Steroids Durezol™ Flarex® fluorometholone FML® prednisolone acetate FML Forte® prednisolone sodium phosphate FML S.O.P.® Inveltys™ Lotemax™ loteprednol Maxidex® Omnipred™ Ozurdex™ Pred Forte® Pred Mild® Retisert™ Triesence® Vexol® Ophthalmic Alphagan P® 0.15% Alphagan P® 0.1% Sympathomimetics brimonidine 0.2% apraclonidine brimonidine 0.15%
AE = Age Edits CC = Clinical Criteria MD = Medications with QL = Quantity Limits Maximum Duration
Page 33 | Kentucky Medicaid Single Preferred Drug List Effective September 2, 2021
Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/ Magellan Medicaid Administration Clinical Support Center: Phone 800-477-3071; Fax 800-365-8835
X. OPHTHALMICS
Drug Class Preferred Agents Non-Preferred Agents Ophthalmic Restasis® CC Cequa™ Immunomodulators Xiidra™ CC, QL Eysuvis™ Ophthalmics, Glaucoma Rhopressa® CC, AE, QL Isopto Carpine® Agents (Other) Rocklatan™ CC, AE, QL pilocarpine
XI. OTICS
Drug Class Preferred Agents Non-Preferred Agents Otic Antibiotics Ciprodex® Otic ciprofloxacin 0.2% hydrocortisone/neomycin/polymyxin B Cipro HC® Otic ofloxacin 0.3% solution ciprofloxacin/dexamethasone ciprofloxacin/fluocinolone Otovel™ Otic Anesthetics and Anti- acetic acid acetic acid/hydrocortisone Inflammatories DermOtic® fluocinolone acetonide 0.01% oil
XII. RENAL AND GENITOURINARY
Drug Class Preferred Agents Non-Preferred Agents Alpha Blockers for BPH alfuzosin ER Cardura® doxazosin Cardura XL® tamsulosin Flomax® terazosin Rapaflo™ silodosin dutasteride/tamsulosin 5-Alpha Reductase (5AR) finasteride CC Avodart® Inhibitors dutasteride Jalyn® Proscar® Bladder Relaxants oxybutynin QL darifenacin ER QL oxybutynin ER QL Detrol® QL solifenacin QL Detrol® LA QL Toviaz™ QL Ditropan® XL QL Enablex® QL flavoxate QL Gelnique™ CC, QL Myrbetriq™ tablets, suspension QL Oxytrol® QL tolterodine QL tolterodine ER QL trospium QL trospium ER QL Vesicare® QL Vesicare LS®
AE = Age Edits CC = Clinical Criteria MD = Medications with QL = Quantity Limits Maximum Duration
Page 34 | Kentucky Medicaid Single Preferred Drug List Effective September 2, 2021
Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/ Magellan Medicaid Administration Clinical Support Center: Phone 800-477-3071; Fax 800-365-8835
XIII. DERMATOLOGICS
Drug Class Preferred Agents Non-Preferred Agents Topical Antiviral Agents acyclovir ointment acyclovir cream Zovirax® cream Denavir® Xerese™ Zovirax® ointment Topical Antibiotic Agents gentamicin Centany® mupirocin ointment mupirocin cream Xepi™ CC, QL Topical Antiparasitic Natroba® Crotan™ Agents permethrin 5% cream Elimite™ Eurax® ivermectin lotion lindane malathion Ovide® Sklice® spinosad Ulesfia®
AE = Age Edits CC = Clinical Criteria MD = Medications with QL = Quantity Limits Maximum Duration
Page 35 | Kentucky Medicaid Single Preferred Drug List Effective September 2, 2021
Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/ Magellan Medicaid Administration Clinical Support Center: Phone 800-477-3071; Fax 800-365-8835
XIII. DERMATOLOGICS
Drug Class Preferred Agents Non-Preferred Agents Topical Acne Agents adapalene gel (except pump) Acanya™ clindamycin gel, medicated swab (pledget), solution Aczone™ clindamycin/benzoyl peroxide (generic BenzaClin® or Duac®; adapalene cream, gel pump, solution, swab excluding pumps) adapalene/benzoyl peroxide erythromycin solution Aklief® erythromycin/benzoyl peroxide Altreno™ Retin-A® cream, gel Amzeeq™ selenium sulfide Arazlo™ Atralin™
Avar™, Avar E™, Avar E LS™, Avar LS™ Avita® BenzaClin® Benzamycin® BenzePrO™ benzoyl peroxide cleanser, kit, microspheres, gel, foam, medicated pad, towelette BP 10-1® BPO®, BPO-5®, BPO-10® BP Wash™ Brevoxyl® Cleocin-T® Clenia™ Plus Clindacin PAC™ Clindacin® ETZ Clindagel® clindamycin foam, lotion clindamycin/benzoyl peroxide gel pump clindamycin/tretinoin Clindavix Kit® dapsone gel Dermapak Plus Kit Differin® Duac® Effaclar Duo® Epiduo™, Epiduo Forte™ Erygel® erythromycin gel, medicated swab Fabior® Inova™, Inova™ 4-1, Inova™ 8-2 Klaron® Neuac® Pacnex® PanOxyl® Persa-Gel® Plixda™ PR benzoyl peroxide OC8®
AE = Age Edits CC = Clinical Criteria MD = Medications with QL = Quantity Limits Maximum Duration
Page 36 | Kentucky Medicaid Single Preferred Drug List Effective September 2, 2021
Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/ Magellan Medicaid Administration Clinical Support Center: Phone 800-477-3071; Fax 800-365-8835
XIII. DERMATOLOGICS
Drug Class Preferred Agents Non-Preferred Agents Topical Acne Agents (see previous page) Onexton™ (continued) Ovace® Ovace Plus® Retin-A Micro® Rosula® sodium sulfacetamide sodium sulfacetamide/sulfur sodium sulfacetamide/sulfur/urea SSS 10-5® sulfacetamide cleanser sulfacetamide/urea Sumadan™, Sumadan™ XLT Sumaxin® Tazorac® tazarotene Tretin-X™ tretinoin tretinoin microsphere Vanoxide-HC® Ziana™ Oral Acne Agents Amnesteem® Absorica™ isotretinoin Absorica LD™ Topical Rosacea Agents MetroCream® azelaic acid MetroGel® Azelex® Finacea® ivermectin 1% cream metronidazole cream, gel, lotion Mirvaso® Noritate® Rhofade® CC, QL Rosadan® Kit Soolantra® Zilxi™
AE = Age Edits CC = Clinical Criteria MD = Medications with QL = Quantity Limits Maximum Duration
Page 37 | Kentucky Medicaid Single Preferred Drug List Effective September 2, 2021
Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/ Magellan Medicaid Administration Clinical Support Center: Phone 800-477-3071; Fax 800-365-8835
XIII. DERMATOLOGICS
Drug Class Preferred Agents Non-Preferred Agents Topical Antifungal Agents clotrimazole cream, solution Ciclodan® cream, kit, solution clotrimazole/betamethasone cream ciclopirox ketoconazole cream, shampoo clotrimazole/betamethasone lotion nystatin cream, ointment, powder econazole nystatin/triamcinolone cream, ointment Ertaczo® Exelderm® Extina® Jublia® CC Kerydin™ CC ketoconazole foam Ketodan™ Loprox® Lotrimin® Lotrisone® luliconazole Luzu® Mentax® miconazole/zinc oxide/petrolatum naftifine Naftin® Nyamyc® Nystop® Oxistat® oxiconazole Penlac® tavaborole Vusion® CC Topical Steroids alclometasone dipropionate amcinonide betamethasone dipropionate cream, lotion ApexiCon®/ApexiCon E® betamethasone dipropionate (augmented) cream Aqua Glycolic®/Aqua Glycolic HC® betamethasone valerate cream, ointment Balneol® clobetasol propionate cream, gel, ointment, shampoo, solution Beser™ Derma-Smoothe/FS® betamethasone dipropionate ointment desonide cream, ointment betamethasone dipropionate augmented ointment fluocinonide solution betamethasone valerate foam, lotion fluticasone propionate cream, ointment Bryhali™ halobetasol propionate cream, ointment Capex® Shampoo hydrocortisone cream, gel, lotion, ointment clobetasol emollient hydrocortisone valerate cream clobetasol propionate foam, lotion, spray mometasone furoate cream, ointment, solution Clobetex® Kit triamcinolone acetonide cream, lotion, ointment Clobex® clocortolone Clodan® Cloderm® Cordran® Tape Cutivate® Dermatop® Desonate® AE = Age Edits CC = Clinical Criteria MD = Medications with QL = Quantity Limits Maximum Duration
Page 38 | Kentucky Medicaid Single Preferred Drug List Effective September 2, 2021
Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/ Magellan Medicaid Administration Clinical Support Center: Phone 800-477-3071; Fax 800-365-8835
XIII. DERMATOLOGICS
Drug Class Preferred Agents Non-Preferred Agents desonide gel, lotion desoximetasone DesRx™ diflorasone diacetate Diprolene® Diprolene AF® fluocinolone acetonide oil fluocinolone acetonide fluocinonide emollient fluocinonide cream, gel, ointment flurandrenolide fluticasone propionate lotion halcinonide cream halobetasol propionate foam Halog® hydrocortisone-aloe hydrocortisone butyrate hydrocortisone butyrate/emollient hydrocortisone valerate hydrocortisone-urea Impeklo™ Kenalog® Lexette Locoid® Locoid Lipocream® Luxiq® MiCort-HC® Olux®/Olux-E® Pandel® prednicarbate Psorcon® Sernivo™ Silazone-II™ Synalar®, Synalar® TS Temovate® Texacort® Topicort® Tovet™ triamcinolone acetonide spray Trianex® Tritocin™ Ultravate, Ultravate® X Vanos™
AE = Age Edits CC = Clinical Criteria MD = Medications with QL = Quantity Limits Maximum Duration
Page 39 | Kentucky Medicaid Single Preferred Drug List Effective September 2, 2021
Magellan Medicaid Administration/Kentucky Website: https://kentucky.magellanmedicaid.com/ Magellan Medicaid Administration Clinical Support Center: Phone 800-477-3071; Fax 800-365-8835
XIII. DERMATOLOGICS
Drug Class Preferred Agents Non-Preferred Agents Topical Psoriasis Agents calcipotriene cream, ointment, solution calcipotriene foam calcipotriene/betamethasone Calcitrene™ calcitriol ointment Dovonex® Duobrii™ Enstilar® MD Sorilux™ Taclonex® ointment, suspension Taclonex® Scalp Vectical™ Oral Psoriasis Agents acitretin methoxsalen Oxsoralen-Ultra® Soriatane®
AE = Age Edits CC = Clinical Criteria MD = Medications with QL = Quantity Limits Maximum Duration
Page 40 | Kentucky Medicaid Single Preferred Drug List Effective September 2, 2021