February 2018 Preferred Drug List and PA Criteria

Medicaid Pharmacy Prior Authorization & Preferred Drug List

About • People enrolled in either traditional Medicaid (fee-for- Contents

service) or Medicaid managed care adhere to the same About ...... 1 formulary, and some drugs on the formulary may Formulary ...... 1 require prior authorization, either non-preferred, clinical, or both. Pharmacy prior authorization services Preferred Drug List ...... 2 needed by people enrolled in Medicaid managed care Clinical Prior Authorization ...... 3 are administered by the person’s managed care PDL Prior Authorization ...... 3 organization (MCO), while traditional Medicaid prior Obtaining PDL/Clinical Prior Authorization ...... 4 authorizations are administered by the Texas Prior Medicaid Managed Care ...... 4 Authorization Call Center. Traditional Medicaid ...... 4 Formulary Texas Medicaid Drug Utilization Review Board . 5 Education ...... 5 • The Medicaid formulary includes legend and over-the- counter drugs. In addition certain supplies and select Updates ...... 5 vitamin and mineral products are also available as a pharmacy benefit. Some drugs are subject to one or both types of prior authorization, clinical and non-preferred. • The Formulary Search identifies the list of covered Medicaid and CHIP drugs and whether a drug requires a PDL and/or a clinical prior authorization. o txvendordrug.com/formulary/formulary-search.

Rev. 02/2018 pol-mpapdl TxVendorDrug.com PAGE 1 OF 5

Medicaid Pharmacy Prior Authorization & Preferred Drug List

Preferred Drug List • The preferred drug list (PDL) is arranged by drug therapeutic class and contains a subset of many, but not all, drugs that are on the Medicaid formulary. Most drugs are identified as preferred or non- preferred. Drugs listed on the PDL as preferred or not listed at all are available to individuals without prior authorization unless there is a clinical prior authorization associated with that drug. (CHIP drugs are not subject to PDL requirements.) o txvendordrug.com/formulary/prior-authorization/preferred-drugs • The PDL PA Criteria Guide explains the criteria used to evaluate PA requests o paxpress.txpa.hidinc.com/pdl_crit_guide.pdf • Drugs that require clinical prior authorization are hyperlinked within the PDL, as shown in the example PDL entry below. Links will take the user to the specific clinical prior authorization document with a narrative that explains the purpose and requirements.

PDL THERAPEUTIC CLASS NAME Preferred Agents Non-Preferred Agents PA Criteria bacitracin ointment bacitracin packet • Treatment failure with preferred drugs within any subclass BACTROBAN (mupirocin) cream BACTROBAN (mupirocin) • Contraindication to preferred drugs ointment • Allergic reaction to preferred drugs • Clinical Prior Authorization applies

Rev. 02/2018 pol-mpapdl TxVendorDrug.com PAGE 2 OF 5

Medicaid Pharmacy Prior Authorization & Preferred Drug List

Clinical Prior Authorization • Clinical prior authorizations may apply to any individual drug or an entire drug class on the formulary, including some preferred and non-preferred drugs. There are certain clinical PAs that all MCOs are required to perform. Usage of all other clinical PAs will vary between MCOs at the discretion of each MCO. • All are approved by the Texas Medicaid Drug Utilization Board. • For Medicaid managed care: o txvendordrug.com/formulary/prior-authorization/mco-clinical-pa • Traditional Medicaid: o txvendordrug.com/formulary/prior-authorization/ffs-clinical-pa • The Clinical Prior Authorization Assistance Chart identifies which clinical PAs are utilized by each MCO: o txvendordrug.com/sites/txvendordrug/files/docs/prior-authorization/cpa-assistance-chart.pdf PDL Prior Authorization • Drugs identified as non-preferred on the PDL require a PDL prior authorization. The PDL PA Criteria Guide explains the criteria used to evaluate the PDL PA requests.

Rev. 02/2018 pol-mpapdl TxVendorDrug.com PAGE 3 OF 5

Medicaid Pharmacy Prior Authorization & Preferred Drug List Obtaining PDL/Clinical Prior Authorization As a prescribing provider you can help your Medicaid-eligible individuals receive medications quickly and conveniently with a few simple steps. Prescribing providers or their representatives should contact one of the following authorization authorities: Medicaid Managed Care • Pharmacy prior authorization call centers vary by MCO. The Prescriber Assistance Chart identifies each MCO and its prior authorization and member call center phone numbers. o txvendordrug.com/sites/txvendordrug/files/docs/managed-care/prescriber-assistance- chart.pdf Traditional Medicaid • The Texas PA Call Center accepts PA requests by phone at 1-877-PA-TEXAS (1-877-728-3927) or

online. Please note online submission is only available for PDL PA requests. o Texas Prior Authorization Call Center: txvendordrug.com/about/contact-us/prior-authorization o Account Registration Instructions: paxpress.txpa.hidinc.com/Account_Reg_Instructions.pdf o Provider Quick Reference: paxpress.txpa.hidinc.com/Provider_Quick_Ref_Guide.pdf • Xenical and Enzyme Replacement Therapy products require prior authorization but are reviewed internally by HHS staff. • Download forms from txvendordrug.com/formulary/prior-authorization/medicaid-ffs-forms

Rev. 02/2018 pol-mpapdl TxVendorDrug.com PAGE 4 OF 5

Medicaid Pharmacy Prior Authorization & Preferred Drug List Texas Medicaid Drug Utilization Review Board • The board makes recommendations for the PDL and clinical prior authorizations four times a year. • Close to 75 therapeutic classes are reviewed each year with approximately one-quarter of the classes reviewed at each meeting: o Decisions made at January and April meetings are included on the July release of the PDL. o Decisions made at July and October meetings are included on the January release of the PDL. Education • The pharmacy continuing education training module includes requirements related to pharmacy enrollment, using the online formulary and PDL, and obtaining prior authorization: o txhealthsteps.com/cms/?q=catalog/course/2388 • Prescriber’s Guide to Texas Medicaid Outpatient Pharmacy Prior Authorization quick course: o casestudies.txhealthsteps.com/stepsQuickCourses/prescribers/index.html Updates • Both the formulary and PDL are available for mobile devices through the free Epocrates drug information system: o txvendordrug.com/formulary/epocrates • Texas Medicaid Email Notification Service o txvendordrug.com/about/news/notices

For questions or comments about the PDL please email [email protected].

Rev. 02/2018 pol-mpapdl TxVendorDrug.com PAGE 5 OF 5

HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective February 1, 2018

PREFERRED DRUG LIST PUBLICATION LOG The PDL is published biannually (January, July). Recent changes to the PDL status are highlighted to reflect July 2017 PDL decisions: February 1, 2018: Published

ACNE AGENTS, ORAL Preferred Agents Non-Preferred Agents PA Criteria

AMNESTEEM (isotretinoin) ABSORICA (isotretinoin) ■ Treatment failure with CLARAVIS (isotretinoin) preferred drugs within any MYORISAN (isotretinoin) subclass ZENATANE (isotretinoin) ■ Contraindication to preferred drugs

■ Allergic reaction to preferred drugs

ACNE AGENTS, TOPICAL Preferred Agents Non-Preferred Agents PA Criteria Antibiotics clindamycin gel CLEOCIN-T (clindamycin) ■ Treatment failure with clindamycin lotion clindamycin foam preferred drugs within any clindamycin medicated swab erythromycin gel subclass clindamycin solution erythromycin medicated swab ■ Contraindication to preferred drugs erythromycin solution ■ Allergic reaction to preferred drugs

Search the Medicaid Formulary https://www.txvendordrug.com/formulary/formulary-search Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. Publication date: February 1, 2018

Page 1 of 69 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective February 1, 2018

ACNE AGENTS, TOPICAL Preferred Agents Non-Preferred Agents PA Criteria Benzoyl Peroxide benzoyl peroxide gel (Rx) benzoyl peroxide cleanser ■ Treatment failure with benzoyl peroxide cream preferred drugs within any benzoyl peroxide foam subclass benzoyl peroxide gel ■ Contraindication to preferred drugs benzoyl peroxide kit ■ Allergic reaction to benzoyl peroxide lotion preferred drugs benzoyl peroxide towelette benzoyl peroxide wash Retinoids tretinoin (Avita, Retin-A) adapalene ■ Treatment failure with ATRALIN (tretinoin) preferred drugs within any AVITA (tretinoin) subclass DIFFERIN (adapalene) ■ Contraindication to preferred drugs FABIOR (tazarotene) ■ Allergic reaction to RETIN-A (tretinoin) preferred drugs RETIN-A MICRO (tretinoin) TAZORAC (tazarotene) tretinoin gel (Atralin) tretinoin microspheres Combination and Other Agents

BENZACLIN (benzoyl peroxide/clindamycin) gel pump ACZONE 7.5% (dapsone) erythromycin/benzoyl peroxide ■ Treatment failure with AZELEX (azelaic acid) sulfacetamide preferred drugs within any BENZACLIN GEL (benzoyl sulfacetamide sodium subclass peroxide/clindamycin) sulfacetamide sodium/sulfur ■ Contraindication to preferred drugs clindamycin/benzoyl peroxide sulfacetamide/sulfur ■ Allergic reaction to DUAC (benzoyl peroxide/clindamycin) sulfacetamide/sulfur/urea preferred drugs EPIDUO (benzoyl VELTIN (clindamycin/tretinoin) peroxide/adapalene) ZIANA (clindamycin/tretinoin) EPIDUO FORTE (benzoyl peroxide/adapalene)

Page 2 of 69 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective February 1, 2018

ALZHEIMER’S AGENTS Preferred Agents Non-Preferred Agents PA Criteria Cholinesterase Inhibitors donepezil 5, 10 mg tablet ARICEPT (donepezil) ■ Treatment failure with donepezil ODT donepezil 23 mg tablet preferred drugs within any rivastigmine transdermal EXELON (rivastigmine) transdermal subclass galantamine ■ Contraindication to preferred drugs galantamine ER ■ Allergic reaction to RAZADYNE (galantamine) tablet preferred drugs rivastigmine capsules NMDA Receptor Antagonist memantine tablets memantine tablet dose pack ■ Treatment failure with NAMENDA (memantine) solution NAMENDA (memantine) tablets preferred drugs within any NAMENDA XR (memantine) subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs Cholinesterase Inhibitor/NMDA Receptor Antagonist Combinations NAMZARIC (donepezil/memantine)

Page 3 of 69 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective February 1, 2018

ANALGESICS, NARCOTIC – LONG ACTING Preferred Agents Non-Preferred Agents PA Criteria

BUTRANS (buprenorphine) ARYMO ER (morphine) NUCYNTA ER (tapentadol) ■ Treatment failure with EMBEDA (morphine/naloxone) BELBUCA (buprenorphine) OPANA ER (oxymorphone) preferred drugs within any fentanyl patch (12.5, 25, 50, 100 mcg) CONZIP (tramadol) oxycodone ER subclass ■ Contraindication to HYSINGLA ER (hydrocodone) DURAGESIC (fentanyl)  Opiate overutilization edit preferred drugs  Opiate overutilization edit EXALGO (hydromorphone)  OxyContin edit ■ Allergic reaction to fentanyl patch (37.5, 62.5, 87.5  Hydrocodone combination edit OXYCONTIN (oxycodone) preferred drugs morphine ER (generic MS Contin) mcg)  Opiate overutilization edit ■ Methadone will be tramadol ER (generic Ryzolt, Ultram ER) hydromorphone ER  OxyContin edit authorized for patients less KADIAN (morphine) oxymorphone ER than 24 months of age. methadone tramadol ER (generic Conzip) ■ Clinical Prior Authorization  Opiate overutilization edit XTAMPZA ER (oxycodone) Applies  Opiate/Benzo/Muscle  Opiate overutilization edit Relaxant Combo Edit  OxyContin edit morphine ER (generic Avinza,  Opiate/Benzo/Muscle Kadian) Relaxant Combo Edit MS CONTIN (morphine) ZOHYDRO ER (hydrocodone)

Page 4 of 69 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective February 1, 2018

ANALGESICS, NARCOTIC – SHORT ACTING (NON-PARENTERAL) Preferred Agents Non-Preferred Agents PA Criteria

APAP/codeine butalbital/ASA/caffeine/codeine morphine suppositories ■ Treatment failure with hydrocodone/APAP butalbital/APAP/caffeine/codeine NORCO (hydrocodone/APAP) preferred drugs within any hydrocodone/ibuprofen butorphanol NUCYNTA (tapentadol) subclass hydromorphone tablet CAPITAL W/CODEINE (APAP/codeine) OPANA (oxymorphone) ■ Contraindication to preferred drugs morphine tablets carisoprodol/aspirin/codeine oxycodone/ASA ■ Allergic reaction to morphine solution codeine oxycodone/ibuprofen preferred drugs oxycodone solution dihydrocodeine/ASA/caffeine oxycodone capsule ■ Clinical Prior Authorization oxycodone tablet DILAUDID (hydromorphone) oxycodone concentrated solution Applies oxycodone/APAP fentanyl buccal oxymorphone tramadol FENTORA (fentanyl) pentazocine/naloxone tramadol/APAP FIORICET W/CODEINE (butalbital/ PERCOCET (oxycodone/APAP) APAP/caffeine/codeine) REPREXAIN (hydrocodone/ibuprofen) FIORINAL W/CODEINE ROXICODONE (oxycodone) (butalbital/ASA/caffeine/codeine) TYLENOL-CODEINE (codeine/APAP) hydromorphone liquid ULTRACET (tramadol/APAP) hydromorphone suppositories ULTRAM (tramadol) IBUDONE (hydrocodone/ibuprofen) XARTEMIS XR (oxycodone/APAP) levorphanol XODOL (hydrodone/APAP) LORTAB (hydrocodone/APAP)  Opiate overutilization edit meperidine  Hydrocodone combination morphine concentrated solution edit

ANDROGENIC AGENTS, TOPICAL Preferred Agents Non-Preferred Agents PA Criteria

ANDROGEL (testosterone) ANDRODERM (testosterone) ■ Treatment failure with AXIRON (testosterone) preferred drugs within any FORTESTA (testosterone) subclass NATESTO (testosterone) ■ Contraindication to preferred drugs TESTIM (testosterone) ■ Allergic reaction to testosterone gel preferred drugs VOGELXO (testosterone)

Page 5 of 69 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective February 1, 2018

ANGIOTENSIN MODULATORS Preferred Agents Non-Preferred Agents PA Criteria Ace Inhibitors benazepril ACCUPRIL (quinapril) QBRELIS (lisinopril) solution ■ Treatment failure with captopril ALTACE (ramipril) trandolapril preferred drugs within any enalapril EPANED (enalapril) VASOTEC (enalapril) subclass fosinopril LOTENSIN (benazepril) ■ Contraindication to preferred drugs lisinopril MAVIK (trandolapril) ■ Allergic reaction to quinapril moexepril preferred drugs ramipril perindopril ■ Epaned will be authorized PRINIVIL (lisinopril) for patients six years of age and under ACE Inhibitor/Diuretic Combinations captopril/HCTZ ACCURETIC (quinapril/HCTZ) ■ Treatment failure with enalapril/HCTZ benazepril/HCTZ preferred drugs within any lisinopril/HCTZ fosinopril/HCTZ subclass moexipril/HCTZ ■ Contraindication to preferred drugs quinapril/HCTZ ■ Allergic reaction to ZESTORETIC (lisinopril/HCTZ) preferred drugs

Page 6 of 69 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective February 1, 2018

ANGIOTENSIN MODULATORS Preferred Agents Non-Preferred Agents PA Criteria Angiotensin II Receptor Blockers (ARBs)

DIOVAN (valsartan) ATACAND (candesartan) EDARBI (azilsartan) ■ Treatment failure with  Duplicate Therapy Edit  Duplicate Therapy Edit eprosartan preferred drugs within any subclass  Dose Optimization Edit  Dose Optimization Edit MICARDIS (telmisartan) ■ Contraindication to irbesartan AVAPRO (irbesartan)  Duplicate Therapy Edit preferred drugs  Duplicate Therapy Edit  Duplicate Therapy Edit  Dose Optimization Edit ■ Allergic reaction to  Dose Optimization Edit  Dose Optimization Edit telmisartan preferred drugs losartan BENICAR (olmesartan)  Duplicate Therapy Edit  Duplicate Therapy Edit Candesartan  Dose Optimization Edit  Dose Optimization Edit  Duplicate Therapy Edit valsartan  Dose Optimization Edit  Duplicate Therapy Edit COZAAR (losartan)  Dose Optimization Edit  Duplicate Therapy Edit  Dose Optimization Edit ARB/Diuretic Combinations irbesartan/HCTZ ATACAND-HCT (candesartan/HCTZ) MICARDIS-HCT (telmisartan/HCTZ) ■ Treatment failure with losartan/HCTZ AVALIDE (irbesartan/HCTZ) telmisartan /HCTZ preferred drugs within any  Duplicate Therapy Edit BENICAR-HCT (olmesartan/HCTZ) valsartan/HCTZ subclass ■ Contraindication to  Dose Optimization Edit candesartan/HCTZ preferred drugs DIOVAN-HCT (valsartan/HCTZ) ■ Allergic reaction to EDARBYCLOR preferred drugs (azilsartan/chlorthalidone) HYZAAR (losartan/HCTZ)  Duplicate Therapy Edit  Dose Optimization Edit

Page 7 of 69 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective February 1, 2018

ANGIOTENSIN MODULATORS Preferred Agents Non-Preferred Agents PA Criteria Direct Renin Inhibitors

TEKTURNA (aliskerin) ■ Treatment failure with preferred drugs within any subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs ■ Clinical Prior Authorization Applies Direct Renin Inhibitor/Diuretic Combinations

TEKTURNA HCT (aliskerin/HCTZ) ■ Treatment failure with preferred drugs within any subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs ■ Clinical Prior Authorization Applies ARB/Neprilysin Inhibitor Combinations

ENTRESTO (valsartan/sacubitril) ■ Treatment failure with preferred drugs within any subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs

Page 8 of 69 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective February 1, 2018

ANGIOTENSIN MODULATOR COMBINATIONS Preferred Agents Non-Preferred Agents PA Criteria benazepril /amlodipine AZOR (olmesartan/amlodipine) ■ Treatment failure with TARKA (trandolapril/verapamil) BYVALSON (valsartan/nebivolol) preferred drugs within any valsartan/amlodipine EXFORGE (valsartan/amlodipine) subclass valsartan/amlodipine/HCTZ EXFORGE HCT (valsartan/amlodipine/HCTZ) ■ Contraindication to preferred drugs LOTREL (benazepril/amlodipine) ■ Allergic reaction to PRESTALIA (perindopril/amlodipine) preferred drugs telmisartan/amlodipine ■ Clinical Prior Authorization trandolapril/verapamil Applies TRIBENZOR (olmesartan/amlodipine/HCTZ) TWYNSTA (telmisartan/amlodipine)

ANTI-ALLERGENS, ORAL Preferred Agents Non-Preferred Agents PA Criteria

None GRASTEK (Timothy grass pollen allergen extract) ■ Treatment failure with ORALAIR (Sweet Vernal, Orchard, Perennial Rye, Timothy, & Kentucky Blue preferred drugs within any Grass mixed pollens allergen extract) subclass RAGWITEK (short ragweed pollen allergen extract) ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs ■ Clinical Prior Authorization Applies

Page 9 of 69 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective February 1, 2018

ANTIBIOTICS, GASTROINTESTINAL Preferred Agents Non-Preferred Agents PA Criteria metronidazole tablet ALINIA (nitazoxanide) ■ Treatment failure with tinidazole DIFICID (fidaxomicin) preferred drugs within any vancomycin FLAGYL (metronidazole) subclass FLAGYL ER (metronidazole) ■ Contraindication to preferred drugs metronidazole capsule ■ Allergic reaction to neomycin preferred drugs paromomycin ■ Clinical Prior Authorization TINDAMAX (tinidazole) Applies VANCOCIN (vancomycin) XIFAXAN (rifaximin)

ANTIBIOTICS, INHALED Preferred Agents Non-Preferred Agents PA Criteria

BETHKIS (tobramycin) TOBI (tobramycin) solution ■ Treatment failure with CAYSTON (aztreonam) tobramycin solution preferred drugs within any subclass KITABIS PAK (tobramycin) TOBI PODHALER (tobramycin) ■ Contraindication to preferred drugs

■ Allergic reaction to preferred drugs

ANTIBIOTICS, TOPICAL Preferred Agents Non-Preferred Agents PA Criteria bacitracin ointment bacitracin packet ■ Treatment failure with BACTROBAN (mupirocin) cream bacitracin/polymyxin preferred drugs within any gentamicin BACTROBAN (mupirocin) ointment subclass mupirocin ointment CENTANY (mupirocin) ■ Contraindication to preferred drugs triple antibiotic ointment mupirocin cream ■ Allergic reaction to neomycin/polymyxin/pramoxine preferred drugs ■ Clinical Prior Authorization Applies

Page 10 of 69 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective February 1, 2018

ANTIBIOTICS, VAGINAL Preferred Agents Non-Preferred Agents PA Criteria

CLEOCIN (clindamycin) ovules CLEOCIN (clindamycin) cream ■ Treatment failure with Clindamycin METROGEL-VAGINAL (metronidazole) preferred drugs within any metronidazole NUVESSA (metronidazole) subclass VANDAZOLE (metronidazole) ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs

ANTICOAGULANTS Preferred Agents Non-Preferred Agents PA Criteria

ELIQUIS (apixaban) ARIXTRA (fondaparinux) ■ Treatment failure with enoxaparin COUMADIN (warfarin) preferred drugs within any FRAGMIN (dalteparin) syringe fondaparinux subclass PRADAXA (dabigatran) FRAGMIN (dalteparin) vial ■ Contraindication to preferred drugs warfarin LOVENOX (enoxaparin) ■ Allergic reaction to XARELTO (rivaroxaban) SAVAYSA (edoxaban) preferred drugs

ANTIDEPRESSANTS, OTHER Preferred Agents Non-Preferred Agents PA Criteria bupropion APLENZIN (bupropion) PRISTIQ (desvenlafaxine) ■ Treatment failure with bupropion SR desvenlafaxine ER REMERON (mirtazapine) preferred drugs within any bupropion XL EFFEXOR XR (venlafaxine) tranylcypromine subclass MARPLAN (isocarboxazid) EMSAM (selegiline) TRINTELLIX (vortioxetine) ■ Contraindication to preferred drugs mirtazapine FETZIMA (levomilnacipran) venlafaxine IR ■ Allergic reaction to phenelzine FORFIVO XL (bupropion) venlafaxine ER tablets preferred drugs trazodone KHEDEZLA (desvenlafaxine) VIIBRYD (vilazodone) venlafaxine ER capsules NARDIL (phenelzine) WELLBUTRIN (bupropion) Nefazodone WELLBUTRIN SR (bupropion) PARNATE (tranylcypromine) WELLBUTRIN XL (bupropion)

Page 11 of 69 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective February 1, 2018

ANTIDEPRESSANTS, SSRIS Preferred Agents Non-Preferred Agents PA Criteria citalopram BRISDELLE (paroxetine) paroxetine CR ■ Treatment failure with escitalopram tablets CELEXA (citalopram) PAXIL (paroxetine) preferred drugs within any fluoxetine IR escitalopram solution PAXIL CR (paroxetine) subclass fluvoxamine fluoxetine capsule DR PEXEVA (paroxetine) ■ Contraindication to preferred drugs paroxetine fluvoxamine ER PROZAC (fluoxetine) ■ Allergic reaction to sertraline LEXAPRO (escitalopram) ZOLOFT (sertraline) preferred drugs

ANTIDEPRESSANTS, TRICYCLIC Preferred Agents Non-Preferred Agents PA Criteria amitriptyline amoxapine TOFRANIL (imipramine) ■ Treatment failure with doxepin ANAFRANIL (clomipramine) preferred drugs within any imipramine clomipramine subclass maprotiline desipramine ■ Contraindication to preferred drugs nortriptyline capsule imipramine pamoate ■ Allergic reaction to NORPRAMIN (desipramine) preferred drugs nortriptyline solution PAMELOR (nortriptyline) protriptyline SURMONTIL (trimipramine)

Page 12 of 69 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective February 1, 2018

ANTIEMETIC-ANTIVERTIGO AGENTS (EXCLUDES INJECTABLES) Preferred Agents Non-Preferred Agents PA Criteria Anticholinergics, Antihistamines, Dopamine Antagonists

DICLEGIS (doxylamine/pyridoxine) COMPRO (prochlorperazine) ■ Treatment failure with dimenhydrinate metoclopramide ODT preferred drugs within any meclizine METOZOLV ODT (metoclopramide) subclass metoclopramide solution, tablets prochlorperazine (rectal) ■ Contraindication to preferred drugs phosphoric acid/dextrose/fructose promethazine suppositories ■ Allergic reaction to prochlorperazine (oral) REGLAN (metoclopramide) preferred drugs promethazine syrup, tablets TRANSDERM-SCOP (scopolamine) ■ Clinical Prior Authorization trimethobenzamide Applies Cannabinoids dronabinol MARINOL (dronabinol) ■ Treatment failure with preferred drugs within any subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs 5-HT3 Receptor Antagonists ondansetron ANZEMET (dolasetron) ■ Treatment failure with granisetron preferred drugs within any SANCUSO (granisetron) subclass SUSTOL (granisetron) ■ Contraindication to preferred drugs ZOFRAN (ondansetron) ■ Allergic reaction to

preferred drugs ■ Ondansetron solution will be authorized for patients six years of age and under ■ Clinical Prior Authorization Applies

Page 13 of 69 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective February 1, 2018

ANTIEMETIC-ANTIVERTIGO AGENTS (EXCLUDES INJECTABLES) Preferred Agents Non-Preferred Agents PA Criteria Substance P Antagonists & Combinations

AKYNZEO (netupitant/palonosetron) ■ Treatment failure with EMEND (aprepitant) preferred drugs within any subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs ■ Clinical Prior Authorization Applies

ANTIFUNGALS, ORAL Preferred Agents Non-Preferred Agents PA Criteria clotrimazole CRESEMBA (isavuconazonium LAMISIL (terbinafine) ■ Treatment failure with fluconazole sulfate) NOXAFIL (posaconazole) preferred drugs within any griseofulvin suspension DIFLUCAN (fluconazole) nystatin powder subclass ketoconazole flucytosine ORAVIG (miconazole) ■ Contraindication to preferred drugs nystatin GRIS-PEG (griseofulvin) SPORANOX (itraconazole) ■ Allergic reaction to terbinafine griseofulvin tablets VFEND (voriconazole) preferred drugs itraconazole voriconazole

Page 14 of 69 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective February 1, 2018

ANTIFUNGALS, TOPICAL Preferred Agents Non-Preferred Agents PA Criteria Antifungals clotrimazole BENSAL HP (benzoic acid/salicylic LAMISIL (terbinafine) ■ Treatment failure with ketoconazole cream, shampoo acid) LOPROX (ciclopirox) preferred drugs within any miconazole cream, powder ciclopirox MENTAX (butenafine) subclass nystatin CNL 8 (ciclopirox) miconazole ointment, spray ■ Contraindication to preferred drugs terbinafine DERMACINRX THERAZOLE PAK naftifine ■ Allergic reaction to tolnaftate cream, powder (betamethasone/clotrimazole/zinc NAFTIN (naftifine) oxide) preferred drugs oxiconazole Econazole OXISTAT (oxiconazole) ERTACZO (sertaconazole) tolnaftate aerosolized powder, EXTINA (ketoconazole) solution, spray FUNGOID (miconazole) VUSION (miconazole/ JUBLIA (efinaconazole) zinc/petrolatum) KERYDIN (tavaborole) XOLEGEL (ketoconazole) ketoconazole foam Antifungal/Steroid Combinations clotrimazole/betamethasone cream clotrimazole/betamethasone lotion ■ Treatment failure with LOTRISONE (clotrimazole/betamethasone) preferred drugs within any nystatin/triamcinolone subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs

Page 15 of 69 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective February 1, 2018

ANTIHISTAMINES, MINIMALLY SEDATING Preferred Agents Non-Preferred Agents PA Criteria Antihistamines cetirizine solution, tablets cetirizine capsule, chewable, 5mg/5mL solution ■ Treatment failure after no loratadine ODT, solution, tablets CLARINEX (desloratadine) less than a 30-day trial of desloratadine preferred drugs fexofenadine ■ Contraindication to preferred drugs levocetirizine ■ Allergic reaction to XYZAL (levocetirizine) preferred drugs ZYRTEC ODT (cetirizine) Antihistamine/Decongestant Combinations loratadine/pseudoephedrine cetirizine/pseudoephedrine ■ Treatment failure after no fexofenadine/pseudoephedrine less than a 30-day trial of SEMPREX-D (acrivastine/pseudoephedrine) preferred drugs ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs

ANTIHYPERTENSIVES, SYMPATHOLYTICS Preferred Agents Non-Preferred Agents PA Criteria

CATAPRES-TTS (clonidine) CATAPRES (clonidine) ■ Treatment failure with clonidine IR tablets clonidine transdermal preferred drugs within any guanfacine IR CLORPRES (clonidine / chlorthalidone) subclass methyldopa methyldopa / HCTZ ■ Contraindication to preferred drugs methyldopate ■ Allergic reaction to reserpine preferred drugs

Page 16 of 69 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective February 1, 2018

ANTIHYPERURICEMICS Preferred Agents Non-Preferred Agents PA Criteria allopurinol colchicine ■ Treatment failure with probenecid COLCRYS (colchicine) preferred drugs within any probenecid/colchicine ULORIC (febuxostat) subclass ZURAMPIC (lesinurad) ■ Contraindication to preferred drugs ZYLOPRIM (allopurinol) ■ Allergic reaction to

preferred drugs

ANTIMIGRAINE AGENTS Preferred Agents Non-Preferred Agents PA Criteria Triptans

RELPAX (eletriptan) almotriptan naratriptan ■ Treatment failure with sumatriptan injection kit AMERGE (naratriptan) ONZETRA XSAIL (sumatriptan) preferred drugs within any sumatriptan nasal AXERT (almotriptan) rizatriptan subclass sumatriptan tablets FROVA (frovatriptan) sumatriptan vial ■ Contraindication to preferred drugs ZOMIG (zolmitriptan) nasal IMITREX (sumatriptan) injection kit SUMAVEL DOSEPRO (sumatriptan) ■ Allergic reaction to IMITREX (sumatriptan) nasal TREXIMET (sumatriptan/naproxen) preferred drugs IMITREX (sumatriptan) tablets ZECUITY (sumatriptan) IMITREX (sumatriptan) vial ZEMBRACE SYMTOUCH (sumatriptan) MAXALT (rizatriptan) zolmitriptan tablets ZOMIG (zolmitriptan) tablets Non-Triptans CAMBIA (diclofenac) ■ Treatment failure with D.H.E. 45 (dihydroergotamine) preferred drugs within any dihydroergotamine mesylate subclass MIGRANAL (dihydroergotamine mesylate) ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs

Page 17 of 69 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective February 1, 2018

ANTIPARASITICS, TOPICAL Preferred Agents Non-Preferred Agents PA Criteria

NATROBA (spinosad) EURAX (crotamiton) ■ Treatment failure with permethrin lindane preferred drugs within any SKLICE (ivermectin) malathion subclass OVIDE (malathion) ■ Contraindication to preferred drugs piperonyl butoxide/pyrethrins ■ Allergic reaction to spinosad preferred drugs

ANTIPARKINSON’S AGENTS (ORAL/TRANSDERMAL) Preferred Agents Non-Preferred Agents PA Criteria Anticholinergics benztropine ■ Treatment failure with trihexyphenidyl preferred drugs within any subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs COMT Inhibitors

COMTAN (entacapone) ■ Treatment failure with entacapone preferred drugs within any TASMAR (tolcapone) subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs

Page 18 of 69 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective February 1, 2018

ANTIPARKINSON’S AGENTS (ORAL/TRANSDERMAL) Preferred Agents Non-Preferred Agents PA Criteria Dopamine Agonists bromocriptine MIRAPEX (pramipexole) ■ Treatment failure with pramipexole MIRAPEX ER (pramipexole) preferred drugs within any ropinirole NEUPRO transdermal (rotigotine) subclass pramipexole ER ■ Contraindication to preferred drugs REQUIP (ropinirole) ■ Allergic reaction to REQUIP XL (ropinirole) preferred drugs ropinirole ER MAO-B Inhibitors

AZILECT (rasagiline) ■ Treatment failure with selegiline preferred drugs within any ZELAPAR (selegiline) subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs Others amantadine carbidopa ■ Treatment failure with carbidopa/levodopa tablets carbidopa/levodopa ODT preferred drugs within any carbidopa/levodopa ER DUOPA (carbidopa/levodopa) subclass carbidopa/levodopa/entacapone LODOSYN (carbidopa) ■ Contraindication to preferred drugs RYTARY (carbidopa/levodopa) ■ Allergic reaction to SINEMET (carbidopa/levodopa) preferred drugs STALEVO (levodopa/carbidopa/entacapone)

Page 19 of 69 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective February 1, 2018

ANTIPSYCHOTICS Preferred Agents Non-Preferred Agents PA Criteria Antipsychotics

ABILIFY (aripiprazole) tablets perphenazine aripiprazole RISPERDAL (risperidone) ■ Treatment failure with  Antipsychotic Edit quetiapine IR  Antipsychotic Edit risperidone ODT preferred drugs within any subclass  Dose Optimization Edit risperidone tablets, solution  Dose Optimization Edit  Antipsychotic Edit ■ Contraindication to chlorpromazine  Antipsychotic Edit clozapine ODT  Dose Optimization Edit preferred drugs clozapine  Dose Optimization Edit CLOZARIL (clozapine) SEROQUEL (quetiapine) ■ Allergic reaction to FANAPT (iloperidone) SAPHRIS (asenapine) FAZACLO (clozapine) SEROQUEL XR (quetiapine) preferred drugs fluphenazine thioridazine GEODON (ziprasidone) VRAYLAR (cariprazine) ■ Clinical Prior Authorization haloperidol thiothixene INVEGA (paliperidone) ZYPREXA (olanzapine) Applies LATUDA (lurasidone) trifluoperazine loxapine  Antipsychotic Edit olanzapine VERSACLOZ (clozapine) molindone  Dose Optimization Edit  Antipsychotic Edit ziprasidone ORAP (pimozide) ZYPREXA ZYDIS (olanzapine)  Dose Optimization Edit paliperidone  Antipsychotic Edit olanzapine ODT pimozide  Dose Optimization Edit  Antipsychotic Edit REXULTI (brexpiprazole)  Dose Optimization Edit Antipsychotic/SSRI Combinations amitriptyline/perphenazine olanzapine/fluoxetine ■ Treatment failure with SYMBYAX (olanzapine/fluoxetine) preferred drugs within any subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs ■ Clinical Prior Authorization Applies

Page 20 of 69 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective February 1, 2018

ANTIPSYCHOTICS Preferred Agents Non-Preferred Agents PA Criteria Long-Acting Injectables

ABILIFY MAINTENA (aripiprazole) ZYPREXA RELPREVV (olanzapine) ■ Treatment failure with ARISTADA (aripiprazole) preferred drugs within any INVEGA SUSTENNA (paliperidone) subclass INVEGA TRINZA (paliperidone) ■ Contraindication to preferred drugs RISPERDAL CONSTA (risperidone) ■ Allergic reaction to preferred drugs ■ Clinical Prior Authorization Applies

ANTIVIRALS (ORAL/NASAL) Preferred Agents Non-Preferred Agents PA Criteria Antiherpetic acyclovir FAMVIR (famciclovir) ■ Treatment failure with famciclovir VALTREX (valacyclovir) preferred drugs within any valacyclovir ZOVIRAX (acyclovir) subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs Anti-influenza

RELENZA (zanamivir) ■ Treatment failure with rimantadine preferred drugs within any TAMIFLU (oseltamivir) subclass ■ Contraindication to preferred drugs

■ Allergic reaction to

preferred drugs

Page 21 of 69 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective February 1, 2018

ANTIVIRALS (ORAL/NASAL) Preferred Agents Non-Preferred Agents PA Criteria Anti-CMV

VALCYTE (valganciclovir) tablets VALCYTE (valganciclovir) solution ■ Treatment failure with valganciclovir tablets preferred drugs within any subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs

ANTIVIRALS, TOPICAL Preferred Agents Non-Preferred Agents PA Criteria acyclovir ointment XERESE (acyclovir/hydrocortisone) ■ Treatment failure with DENAVIR (penciclovir) ZOVIRAX (acyclovir) preferred drugs within any subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs

Page 22 of 69 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective February 1, 2018

ANXIOLYTICS Preferred Agents Non-Preferred Agents PA Criteria alprazolam tablet diazepam solution alprazolam ER TRANXENE T-TAB (clorazepate) ■ Treatment failure with  Anxiolytics and  Anxiolytics and alprazolam intensol  Anxiolytics and preferred drugs within any Sedative/Hypnotics Edit Sedative/Hypnotics Edit alprazolam ODT Sedative/Hypnotics Edit subclass  Opiate/Benzo/Muscle  Opiate/Benzo/Muscle ATIVAN (lorazepam) tablet  Opiate/Benzo/Muscle ■ Contraindication to preferred drugs Relaxant Combo Edit Relaxant Combo Edit diazepam intensol Relaxant Combo Edit ■ Allergic reaction to buspirone diazepam tablet meprobamate VALIUM (diazepam) tablet preferred drugs chlordiazepoxide  Anxiolytics and  Anxiolytics and XANAX XR (alprazolam)  Anxiolytics and Sedative/Hypnotics Edit Sedative/Hypnotics Edit  Anxiolytics and Sedative/Hypnotics Edit  Opiate/Benzo/Muscle  Opiate/Benzo/Muscle Sedative/Hypnotics Edit  Opiate/Benzo/Muscle Relaxant Combo Edit Relaxant Combo Edit  Opiate/Benzo/Muscle Relaxant Combo Edit lorazepam intensol oxazepam Relaxant Combo Edit clorazepate lorazepam tablet  Anxiolytics and XANAX (alprazolam) tablet  Anxiolytics and  Anxiolytics and Sedative/Hypnotics Edit  Anxiolytics and Sedative/Hypnotics Edit Sedative/Hypnotics Edit  Opiate/Benzo/Muscle Sedative/Hypnotics Edit  Opiate/Benzo/Muscle  Opiate/Benzo/Muscle Relaxant Combo Edit  Opiate/Benzo/Muscle Relaxant Combo Edit Relaxant Combo Edit Relaxant Combo Edit

BETA BLOCKERS (ORAL) Preferred Agents Non-Preferred Agents PA Criteria Beta Blockers acebutolol betaxolol propranolol ER ■ Treatment failure with atenolol BYSTOLIC (nebivolol) SECTRAL (acebutolol) preferred drugs within any bisoprolol CORGARD (nadolol) SOTYLIZE (sotalol) subclass metoprolol IR HEMANGEOL (propranolol) TENORMIN (atenolol) ■ Contraindication to preferred drugs metoprolol XL INDERAL LA (propranolol) timolol ■ Allergic reaction to propranolol IR INNOPRAN XL (propranolol) TOPROL XL (metoprolol succinate) preferred drugs sotalol nadolol ZEBETA (bisoprolol) pindolol

Page 23 of 69 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective February 1, 2018

BETA BLOCKERS (ORAL) Preferred Agents Non-Preferred Agents PA Criteria Beta Blocker Combinations atenolol/chlorthalidone CORZIDE (nadolol/bendroflumethiazide) ■ Treatment failure with bisoprolol/HCTZ DUTOPROL (metoprolol succinate ER/HCTZ) preferred drugs within any metoprolol/HCTZ subclass nadolol/bendroflumethiazide ■ Contraindication to preferred drugs propranolol/HCTZ ■ Allergic reaction to TENORETIC (atenolol/HCTZ) preferred drugs ZIAC (bisoprolol/HCTZ) Beta- and Alpha-Blockers carvedilol COREG (carvedilol) ■ Treatment failure with labetalol COREG CR (carvedilol) preferred drugs within any subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs

BILE SALTS Preferred Agents Non-Preferred Agents PA Criteria ursodiol ACTIGALL (ursodiol) ■ Treatment failure with CHENODAL (chenodiol) preferred drug CHOLBAM (cholic acid) ■ Contraindication to OCALIVA (obeticholic acid) preferred drug URSO (ursodiol) ■ Allergic reaction to preferred drug URSO FORTE (urosodiol)

Page 24 of 69 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective February 1, 2018

BLADDER RELAXANT PREPARATIONS Preferred Agents Non-Preferred Agents PA Criteria oxybutynin IR DETROL (tolterodine) oxybutynin ER ■ Treatment failure with TOVIAZ (fesoterodine) DETROL LA (tolterodine) OXYTROL (oxybutynin) preferred drugs within any VESICARE (solifenacin) DITROPAN XL (oxybutynin) tolterodine subclass ENABLEX (darifenacin) tolterodine ER ■ Contraindication to preferred drugs flavoxate trospium ■ Allergic reaction to GELNIQUE (oxybutynin) trospium ER preferred drugs MYRBETRIQ (mirabegron)

BONE RESORPTION SUPPRESSION AND RELATED AGENTS Preferred Agents Non-Preferred Agents PA Criteria Bisphosphonates alendronate tablets ACTONEL (risedronate) FOSAMAX (alendronate) ■ Treatment failure with alendronate solution FOSAMAX PLUS D preferred drugs within any ATELVIA (risedronate) (alendronate/vitamin D) subclass BINOSTO (alendronate) ibandronate ■ Contraindication to preferred drugs BONIVA (ibandronate) risedronate ■ Allergic reaction to etidronate preferred drugs Other Bone Resorption Suppression and Related Agents

FORTICAL (calcitonin) calcitonin nasal ■ Treatment failure with EVISTA (raloxifene) preferred drugs within any FORTEO (teriparatide) subclass MIACALCIN (calcitonin) ■ Contraindication to preferred drugs raloxifene ■ Allergic reaction to

preferred drugs

Page 25 of 69 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective February 1, 2018

BPH AGENTS Preferred Agents Non-Preferred Agents PA Criteria Alpha Blockers alfuzosin CARDURA (doxazosin) ■ Treatment failure with doxazosin FLOMAX (tamsulosin) preferred drugs within any tamsulosin RAPAFLO (silodosin) subclass terazosin UROXATRAL (alfuzosin) ■ Contraindication to preferred drugs

■ Allergic reaction to preferred drugs 5-Alpha-Reductase (5AR) Inhibitors finasteride AVODART (dutasteride) ■ Treatment failure with PROSCAR (finasteride) preferred drugs within any subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs Alpha Blocker/5AR Inhibitor Combinations

dutasteride/tamsulosin ■ Treatment failure with preferred drugs within any subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs

Page 26 of 69 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective February 1, 2018

BRONCHODILATORS, BETA AGONIST Preferred Agents Non-Preferred Agents PA Criteria Inhalers, Short-Acting

PROAIR HFA (albuterol) PROAIR RESPICLICK (albuterol) ■ Treatment failure with PROVENTIL HFA (albuterol) VENTOLIN HFA (albuterol) preferred drugs within any XOPENEX HFA (levalbuterol) subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs ■ History of intolerable side effects to preferred drugs Inhalers, Long-Acting

ARCAPTA (indacaterol) ■ Treatment failure with SEREVENT (salmeterol) preferred drugs within any STRIVERDI RESPIMAT (olodaterol) subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs ■ History of intolerable side effects to preferred drugs Inhalation Solution albuterol BROVANA (arformoterol) ■ Treatment failure with levalbuterol preferred drugs within any PERFOROMIST (formoterol) subclass XOPENEX (levalbuterol) ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs ■ History of intolerable side effects to preferred drugs

Page 27 of 69 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective February 1, 2018

BRONCHODILATORS, BETA AGONIST Preferred Agents Non-Preferred Agents PA Criteria Oral albuterol syrup albuterol tablet ■ Treatment failure with albuterol ER preferred drugs within any metaproterenol subclass terbutaline ■ Contraindication to preferred drugs

■ Allergic reaction to preferred drugs ■ History of intolerable side effects to preferred drugs

CALCIUM CHANNEL BLOCKERS (ORAL) Preferred Agents Non-Preferred Agents PA Criteria Short-Acting diltiazem isradipine ■ Treatment failure with verapamil nicardipine preferred drugs within any nifedipine subclass nimodipine ■ Contraindication to preferred drugs NYMALIZE (nimodipine) ■ Allergic reaction to PROCARDIA (nifedipine) preferred drugs Long-Acting amlodipine ADALAT CC (nifedipine) SULAR (nisoldipine) ■ Treatment failure with diltiazem ER CALAN SR (verapamil)  Duplicate Therapy Edit preferred drugs within any subclass felodipine ER CARDIZEM CD (diltiazem)  Dose Optimization Edit ■ Contraindication to nifedipine ER CARDIZEM LA (diltiazem) TIAZAC (diltiazem) preferred drugs verapamil ER capsules, tablets diltiazem LA verapamil 360 mg capsules ■ Allergic reaction to MATZIM LA (diltiazem) verapamil ER PM preferred drugs nisoldipine VERELAN (verapamil) NORVASC (amlodipine) VERELAN PM (verapamil) PROCARDIA XL (nifedipine)

Page 28 of 69 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective February 1, 2018

CEPHALOSPORINS AND RELATED ANTIBIOTICS (ORAL) Preferred Agents Non-Preferred Agents PA Criteria Beta Lactam/Beta-Lactamase Inhibitor Combinations amoxicillin/clavulanate tablets, XR tablets, suspension amoxicillin/clavulanate chewable ■ Treatment failure with AUGMENTIN suspension (amoxicillin/clavulanate) preferred drugs within any AUGMENTIN XR (amoxicillin/clavulanate) subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs Cephalosporins – First Generation cefadroxil capsules, suspension cefadroxil tablets ■ Treatment failure with cephalexin capsules, suspension cephalexin tablets preferred drugs within any KEFLEX (cephalexin) subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs Cephalosporins – Second Generation cefprozil suspension cefaclor ER ■ Treatment failure with cefuroxime tablets cefaclor IR capsules, suspension preferred drugs within any cefprozil tablets subclass CEFTIN (cefuroxime) ■ Contraindication to preferred drugs

■ Allergic reaction to preferred drugs Cephalosporins – Third Generation cefdinir CEDAX (ceftibuten) ■ Treatment failure with cefixime preferred drugs within any cefpodoxime subclass ceftibuten ■ Contraindication to preferred drugs SUPRAX (cefixime) ■ Allergic reaction to preferred drugs

Page 29 of 69 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective February 1, 2018

COLONY STIMULATING FACTORS Preferred Agents Non-Preferred Agents PA Criteria

GRANIX (tbo-filgrastim) LEUKINE (sargramostim) ■ Treatment failure with NEULASTA (pegfilgrastim) NEUPOGEN (filgrastim) syringe preferred drugs within any NEUPOGEN (filgrastim) vial ZARXIO (filgrastim-sndz) subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs

COPD AGENTS Preferred Agents Non-Preferred Agents PA Criteria Anticholinergics

ATROVENT HFA (ipratropium) INCRUSE ELLIPTA (umeclidinium) ■ Treatment failure with ipratropium inhalation solution SPIRIVA RESPIMAT (tiotropium) preferred drugs within any SEEBRI NEOHALER (glycopyrrolate) TUDORZA (aclidinium) subclass SPIRIVA HANDIHALER (tiotropium) ■ Contraindication to preferred drugs

■ Allergic reaction to preferred drugs Anticholinergic-Beta Agonist Combinations albuterol/ipratropium ANORO ELLIPITA (umeclidinium/vilanterol) ■ Treatment failure with COMBIVENT RESPIMAT (albuterol/ipratropium) preferred drugs within any STIOLTO RESPIMAT (tiotropium/olodaterol) subclass UTIBRON NEOHALER (glycopyrrolate/indacaterol) ■ Contraindication to preferred drugs

■ Allergic reaction to preferred drugs

Page 30 of 69 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective February 1, 2018

COPD AGENTS Preferred Agents Non-Preferred Agents PA Criteria Phosphodiesterase Inhibitors

DALIRESP (roflumilast) ■ Treatment failure with preferred drugs within any subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs

COUGH AND COLD AGENTS See Separate Preferred Cough and Cold Agent Listing. Cough & cold PA criteria

CYTOKINE AND CAM ANTAGONISTS Preferred Agents Non-Preferred Agents PA Criteria

COSENTYX (secukinumab) ACTEMRA (tocilizumab) OTEZLA (apremilast) ■ Treatment failure with ENBREL (etanercept) CIMZIA (certolizumab) SIMPONI (golimumab) preferred drugs within any HUMIRA (adalimumab) ILARIS (canakinumab) STELARA (ustekinumab) subclass KINERET (anakinra) XELJANZ (tofacitinib) ■ Contraindication to preferred drugs ORENCIA (abatacept) ■ Allergic reaction to preferred drugs

EPINEPHRINE, SELF-INJECTED Preferred Agents Non-Preferred Agents epinephrine (ADRENACKLICK) epinephrine (EPIPEN) ■ Treatment failure with EPIPEN preferred products EPIPEN JR ■ Contraindication to preferred products ■ Allergic reaction to preferred products

Page 31 of 69 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective February 1, 2018

ERYTHROPOIESIS STIMULATING PROTEINS Preferred Agents Non-Preferred Agents PA Criteria

EPOGEN (RhUEPO) ARANESP (darbepoetin) ■ Treatment failure with PROCRIT (RhUEPO) preferred drugs within any subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs ■ Clinical Prior Authorization Applies

FLUOROQUINOLONES, ORAL Preferred Agents Non-Preferred Agents PA Criteria

CIPRO (ciprofloxacin) suspension AVELOX (moxifloxacin) ■ Treatment failure with ciprofloxacin IR CIPRO (ciprofloxacin) tablets preferred drugs within any levofloxacin tablets ciprofloxacin ER subclass ciprofloxacin suspension ■ Contraindication to preferred drugs LEVAQUIN (levofloxacin) ■ Allergic reaction to levofloxacin solution preferred drugs moxifloxacin ofloxacin

Page 32 of 69 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective February 1, 2018

GI MOTILITY, CHRONIC Preferred Agents Non-Preferred Agents PA Criteria

None alosetron ■ Treatment failure with AMITIZA (lubiprostone) preferred drugs within any LINZESS (linaclotide) subclass (including OTC products) LOTRONEX (alosetron) ■ Contraindication to MOVANTIK (naloxegol) preferred drugs RELISTOR (methylnaltrexone) injection ■ Allergic reaction to RELISTOR (methylnaltrexone) oral preferred drugs VIBERZI (eluxadoline) ■ Clinical Prior Authorization Applies

GLUCOCORTICOIDS, INHALED Preferred Agents Non-Preferred Agents PA Criteria Glucocorticoids

ASMANEX (mometasone) AEROSPAN (flunisolide) ■ Treatment failure with FLOVENT (fluticasone) ALVESCO (ciclesonide) preferred drugs within any QVAR (beclomethasone) ARNUITY ELLIPTA (fluticasone) subclass budesonide respules ■ Contraindication to preferred drugs PULMICORT 0.25, 0.5 MG RESPULES (budesonide) (See comment under PA criteria) ■ Allergic reaction to preferred drugs PULMICORT 1 MG RESPULES (budesonide) ■ Pulmicort respules 0.25, 0.5 PULMICORT FLEXHALER (budesonide) mg will be authorized for patients under four years of age

Page 33 of 69 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective February 1, 2018

GLUCOCORTICOIDS, INHALED Preferred Agents Non-Preferred Agents PA Criteria Glucocorticoid/Bronchodilator Combinations

ADVAIR (fluticasone/salmeterol) AIRDUO RESPICLICK ■ Treatment failure with DULERA (mometasone/formoterol) (fluticasone/salmeterol) preferred drugs within any SYMBICORT (budesonide/formoterol) BREO ELLIPTA (fluticasone/vilanterol) subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs

GLUCOCORTICOIDS, ORAL Preferred Agents Non-Preferred Agents PA Criteria budesonide EC CORTEF (hydrocortisone) MILLIPRED (prednisolone) ■ Treatment failure with dexamethasone elixir, solution, tablets CORTISONE (hydrocortisone) PEDIAPRED (prednisone) preferred drugs within any hydrocortisone dexamethasone intensol prednisolone sodium phosphate ODT subclass methylprednisolone tablet dose pack DEXPAK (dexamethasone) prednisone intensol ■ Contraindication to preferred drugs prednisolone sodium phosphate solution EMFLAZA (deflazacort) prednisone tablet dose pack ■ Allergic reaction to prednisolone ENTOCORT EC (budesonide) RAYOS (prednisone) preferred drugs prednisone solution, tablets MEDROL (methylprednisolone) VERIPRED 20 (prednisolone) methylprednisolone tablets

GROWTH HORMONE Preferred Agents Non-Preferred Agents PA Criteria

GENOTROPIN HUMATROPE ■ Treatment failure with NORDITROPIN NUTROPIN AQ preferred drugs within any OMNITROPE subclass SAIZEN ■ Contraindication to preferred drugs SEROSTIM ■ Allergic reaction to ZORBTIVE preferred drugs ■ Clinical Prior Authorization Applies

Page 34 of 69 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective February 1, 2018

H. PYLORI TREATMENT Preferred Agents Non-Preferred Agents PA Criteria

PYLERA (bismuth subcitrate/metronidazole/tetracycline) lansoprazole/amoxicillin/clarithromycin ■ Treatment failure with PREVPAC (lansoprazole/amoxicillin/clarithromycin) preferred drugs within any subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs

HEPATITIS C AGENTS Preferred Agents Non-Preferred Agents PA Criteria Pegylated Interferons

PEG-INTRON (pegylated IFN alfa-2b) PEGASYS (pegylated IFN alfa-2a) ■ Treatment failure with preferred drugs within any subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs Polymerase/Protease Inhibitors

EPCLUSA (sofosbuvir/velpatasvir) – GENOTYPE 2 & 3 ONLY DAKLINZA (daclatasvir) ■ Treatment failure with TECHNIVIE (ombitasvir/paritaprevir/ritonavir) HARVONI (sofosbuvir/ledipasvir) preferred drugs within any VIEKIRA PAK (dasabuvir/ombitasvir/paritaprevir/ritonavir) OLYSIO (simeprevir) subclass VIEKIRA XR (dasabuvir/ombitasvir/paritaprevir/ritonavir) SOVALDI (sofosbuvir) ■ Contraindication to preferred drugs ZEPATIER (elbasvir/grazoprevir) ■ Allergic reaction to preferred drugs ■ Clinical Prior Authorization Applies

Page 35 of 69 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective February 1, 2018

HEPATITIS C AGENTS Preferred Agents Non-Preferred Agents PA Criteria Ribavirin ribavirin capsule REBETOL solution ■ Treatment failure with ribavirin tablet RIBASPHERE 400, 600 mg preferred drugs within any ribavirin dose pack subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs

HEREDITARY ANGIOEDEMA (HAE) TREATMENTS Preferred Agents Non-Preferred Agents PA Criteria

BERINERT (C1 esterase inhibitor) RUCONEST (C1 esterase inhibitor) ■ Treatment failure with CINRYZE (C1 esterase inhibitor) preferred drugs within any FIRAZYR (icatibant) subclass KALBITOR (ecallantide) ■ Contraindication to preferred drugs

■ Allergic reaction to preferred drugs

Page 36 of 69 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective February 1, 2018

HYPOGLYCEMICS, INCRETIN MIMETICS/ENHANCERS Preferred Agents Non-Preferred Agents PA Criteria Amylin Analogs SYMLIN (pramlintide) Patient must meet all of the following criteria: ■ Diagnosis of diabetes mellitus ■ Age >18 years ■ HbA1C in past 6 months ■ No history of gastroparesis, neurologic manifestations of diabetes or recent treatment of hypoglycemia ■ Clinical Prior Authorization Applies Incretin Enhancers

JENTADUETO (linagliptin/metformin) alogliptin ■ Treatment failure with KOMBIGLYZE XR (saxagliptin/metformin) alogilptin/metformin preferred drugs within any ONGLYZA (saxagliptin) alogliptin/pioglitazone subclass TRADJENTA (linagliptin) JANUMET (sitagliptin/metformin) ■ Contraindication to preferred drugs JANUMET XR (sitagliptin/metformin) ■ Allergic reaction to JANUVIA (sitagliptin) preferred drugs JENTADUETO XR (linagliptin/metformin) ■ Clinical Prior Authorization KAZANO (alogliptin /metformin ) Applies NESINA (alogliptin) OSENI (alogliptin / glimepiride)

Page 37 of 69 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective February 1, 2018

HYPOGLYCEMICS, INCRETIN MIMETICS/ENHANCERS Preferred Agents Non-Preferred Agents PA Criteria Incretin Mimetics

BYDUREON (exenatide ER) vials ADLYXIN (lixisenatide) ■ Treatment failure with BYETTA (exenatide) BYDUREON (exenatide ER) pens preferred drugs within any VICTOZA (liraglutide) TANZEUM (albiglutide) subclass TRULICITY (dulaglutide) ■ Contraindication to preferred drugs

■ Allergic reaction to preferred drugs ■ Clinical Prior Authorization Applies Incretin Enhancers/SGLT2 Inhibitor Combinations GLYXAMBI (empagliflozin/linagliptin) ■ Treatment failure with preferred drugs within any subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs ■ Clinical Prior Authorization Applies Incretin Mimetic/Insulin Combinations SOLIQUA (lixisenatide/insulin glargine) ■ Treatment failure with XULTOPHY (liraglutide/insulin degludec) preferred drugs within any subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs ■ Clinical Prior Authorization Applies

Page 38 of 69 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective February 1, 2018

HYPOGLYCEMICS, INSULIN Preferred Agents Non-Preferred Agents PA Criteria

HUMALOG (insulin lispro) vials AFREZZA (insulin) NOVOLIN (insulin) ■ Treatment failure with HUMALOG MIX (insulin lispro/lispro protamine) vials APIDRA (insulin glulisine) NOVOLIN 70/30 (insulin) preferred drugs within any HUMULIN (insulin) vials BASAGLAR (insulin glargine) TOUJEO (insulin glargine) subclass HUMULIN 500 UNITS/ML (insulin) vial HUMALOG (insulin lispro) pens TRESIBA (insulin degludec) ■ Contraindication to preferred drugs HUMULIN 70/30 (insulin) vials HUMALOG MIX (insulin lispro/lispro

LANTUS (insulin glargine) protamine) pens LEVEMIR (insulin detemir) HUMULIN (insulin) pens NOVOLOG (insulin aspart) HUMULIN 500 UNITS/ML (insulin) NOVOLOG MIX (insulin aspart/aspart protamine) pen HUMULIN 70/30 (insulin) pens

HYPOGLYCEMICS, MEGLITINIDES Preferred Agents Non-Preferred Agents PA Criteria nateglinide PRANDIMET (repaglinide/metformin) ■ Separate prescriptions for repaglinide PRANDIN (repaglinide) the individual components repaglinide/metformin should be used instead of the combination drug. STARLIX (nateglinide)

HYPOGLYCEMICS, METFORMIN Preferred Agents Non-Preferred Agents PA Criteria glyburide/metformin FORTAMET (metformin ER) ■ Separate prescriptions for metformin glipizide/metformin the individual components metformin ER (GLUCOPHAGE XR) GLUCOPHAGE (metformin) should be used instead of the combination drug. GLUCOPHAGE XR (metformin ER) GLUMETZA (metformin ER) metformin ER (FORTAMET) metformin ER (GLUMETZA) RIOMET (metformin)

Page 39 of 69 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective February 1, 2018

HYPOGLYCEMICS, SGLT2 Preferred Agents Non-Preferred Agents PA Criteria

FARXIGA (dapagliflozin) INVOKANA (canaglifozin) ■ Treatment failure with JARDIANCE (empagliflozin) preferred drugs within any subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs SGLT2 Combinations

SYNJARDY (empagliflozin/metformin) INVOKAMET (canagliflozin/metformin) ■ Treatment failure with INVOKAMET XR (canagliflozin/metformin) preferred drugs within any SYNJARDY XR (empagliflozin/metformin) subclass XIGDUO XR (dapagliflozin/metformin) ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs

HYPOGLYCEMICS, TZD Preferred Agents Non-Preferred Agents PA Criteria Thiazolinediones

Pioglitazone ACTOS (pioglitazone) ■ Treatment failure with AVANDIA (rosiglitazone) preferred drugs within any subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs ■ Clinical Prior Authorization Applies

Page 40 of 69 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective February 1, 2018

HYPOGLYCEMICS, TZD Preferred Agents Non-Preferred Agents PA Criteria TZD Combinations

ACTOPLUS MET (pioglitazone/metformin) ■ Separate prescriptions for ACTOPLUS MET XR (pioglitazone/metformin) the individual components pioglitazone/metformin should be used instead of the combination drug. pioglitazone/glimepiride

IMMUNE GLOBULINS Preferred Agents Non-Preferred Agents PA Criteria

CYTOGAM (CMV immune globulin) BIVIGAM (immune globulin) ■ Treatment failure with GAMMAGARD (immune globulin) CARIMUNE NF (immune globulin) preferred drugs within any GAMUNEX-C (immune globulin) CUVITRU (immune globulin) subclass HIZENTRA (immune globulin) FLEBOGAMMA DIF (immune globulin) ■ Contraindication to preferred drugs GAMMAKED (immune globulin) ■ Allergic reaction to HYQVIA (immune globulin) preferred drugs OCTAGAM (immune globulin) PRIVIGEN (immune globulin)

IMMUNOMODULATORS, ATOPIC DERMATITIS Preferred Agents Non-Preferred Agents PA Criteria

None DUPIXENT (dupilumab) ■ Prior authorization is ELIDEL (pimecrolimus) required for all products in EUCRISAhy (crisaborole) this class PROTOPIC (tacrolimus) ■ Clinical Prior Authorization Applies tacrolimus

Page 41 of 69 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective February 1, 2018

IMMUNOSUPPRESSIVES, ORAL Preferred Agents Non-Preferred Agents PA Criteria azathioprine ASTAGRAF XL (tacrolimus) PROGRAF (tacrolimus) ■ Treatment failure with cyclosporine, modified AZASAN (azathioprine) RAPAMUNE (sirolimus) tablets preferred drugs within any mycophenolate mofetil capsules, tablets CELLCEPT (mycophenolate mofetil) SANDIMMUNE (cyclosporine) subclass NEORAL (cyclosporine, modified) capsules cyclosporine ZORTRESS (everolimus) ■ Contraindication to preferred drugs RAPAMUNE (sirolimus) solution ENVARSUS XR (tacrolimus) ■ Allergic reaction to sirolimus tablets IMURAN (azathioprine) preferred drugs tacrolimus mycophenolate mofetil suspension mycophenolic acid MYFORTIC (mycophenolic acid) NEORAL (cyclosporine, modified) solution

INTRANASAL RHINITIS AGENTS Preferred Agents Non-Preferred Agents PA Criteria Glucocorticoids fluticasone BECONASE AQ (beclomethasone) triamcinolone ■ Treatment failure with budesonide VERAMYST (fluticasone furoate) preferred drugs within any CLARISPRAY OTC (fluticasone) ZETONNA (ciclesonide) subclass flunisolide ■ Contraindication to preferred drugs NASONEX (mometasone) ■ Allergic reaction to OMNARIS (ciclesonide) preferred drugs QNASL (beclomethasone dipropionate) Others

PATANASE (olopatadine) ASTEPRO (azelastine) ■ Treatment failure with ATROVENT (ipratropium) nasal spray preferred drugs within any azelastine subclass ipratropium nasal spray ■ Contraindication to preferred drugs olopatadine ■ Allergic reaction to preferred drugs

Page 42 of 69 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective February 1, 2018

INTRANASAL RHINITIS AGENTS Preferred Agents Non-Preferred Agents PA Criteria Combinations

DYMISTA (azelastine/fluticasone) ■ Treatment failure with preferred drugs within any subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs

IRON, ORAL See Separate Listing Of Preferred Oral Iron Drugs.

LEUKOTRIENE MODIFIERS Preferred Agents Non-Preferred Agents PA Criteria montelukast chewable tablets, tablets ACCOLATE (zafirlukast) ■ Treatment failure with montelukast granules preferred drugs within any SINGULAIR (montelukast) subclass zafirlukast ■ Contraindication to preferred drugs ZYFLO (zileuton) ■ Allergic reaction to ZYFLO CR (zileuton) preferred drugs ■ Clinical Prior Authorization Applies

Page 43 of 69 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective February 1, 2018

LINCOSAMIDES/OXAZOLIDINONES/STREPTOGRAMINS Preferred Agents Non-Preferred Agents PA Criteria clindamycin capsules CLEOCIN (clindamycin) ■ Treatment failure with clindamycin solution clindamycin injection preferred drugs within any linezolid suspension LINCOCIN (lincomycin) subclass linezolid tablets SIVEXTRO (tedizolid) ■ Contraindication to preferred drugs ZYVOX (linezolid) suspension ■ Allergic reaction to ZYVOX (linezolid) tablets preferred drugs

LIPOTROPICS, OTHER Preferred Agents Non-Preferred Agents PA Criteria Bile Acid Sequestrants cholestyramine COLESTID (colestipol) ■ Treatment failure with colestipol tablets colestipol granules preferred drugs within any QUESTRAN (cholestyramine) subclass QUESTRAN LIGHT (cholestyramine) ■ Contraindication to preferred drugs WELCHOL (colesevalam) ■ Allergic reaction to preferred drugs Cholesterol Absorption Inhibitors

ZETIA (ezetimibe) ■ Treatment failure with preferred drugs within any subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs

Page 44 of 69 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective February 1, 2018

LIPOTROPICS, OTHER Preferred Agents Non-Preferred Agents PA Criteria Fibric Acid Derivatives fenofibrate (generic Lipofen, Tricor) fenofibrate (generic Antara, Lofibra) TRICOR (fenofibrate) ■ Treatment failure with gemfibrozil fenofibric acid (generic Fibricor, TRIGLIDE (fenofibrate) preferred drugs within any Trilipix) TRILIPIX (fenofibric acid) subclass FENOGLIDE (fenofibrate) ■ Contraindication to LIPOFEN (fenofibrate) preferred drugs LOPID (gemfibrozil) ■ Allergic reaction to preferred drugs Homozygous Familial Hypercholesterolemia Treatments

JUXTAPID (lomitapide) ■ Treatment failure with KYNAMRO (mipomersen) preferred drugs within any subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs Niacin niacin OTC niacin ER ■ Treatment failure with NIACOR (niacin) NIASPAN (niacin) preferred drugs within any SLO-NIACIN OTC (niacin) subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs

Page 45 of 69 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective February 1, 2018

LIPOTROPICS, OTHER Preferred Agents Non-Preferred Agents PA Criteria Omega-3 Fatty Acids

LOVAZA (omega-3 fatty acids) ■ Treatment failure with omega-3 fatty acids preferred drugs within any VASCEPA (icosapent ethyl) subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs ■ Clinical Prior Authorization Applies PCSK9 Inhibitors

PRALUENT (alirocumab) ■ Trial and failure of REPATHA (evolocumab) atorvastatin, rosuvastatin, and ezetimibe.

LIPOTROPICS, STATINS Preferred Agents Non-Preferred Agents PA Criteria Statins

Atorvastatin ALTOPREV (lovastatin) LESCOL (fluvastatin) ■ Treatment failure with at  Duplicate Therapy Edit  Duplicate Therapy Edit LESCOL XL (fluvastatin) least two preferred drugs accounting for no less than  Dose Optimization Edit  Dose Optimization Edit LIPITOR (atorvastatin) 120 days of therapy  Duplicate Therapy Edit lovastatin CRESTOR (rosuvastatin) combined    Dose Optimization Edit Duplicate Therapy Edit Duplicate Therapy Edit ■ Contraindication to  Dose Optimization Edit  Dose Optimization Edit LIVALO (pitavastatin) preferred drugs pravastatin fluvastatin PRAVACHOL (pravastatin) ■ Allergic reaction to  Duplicate Therapy Edit  Duplicate Therapy Edit  Duplicate Therapy Edit preferred drugs  Dose Optimization Edit  Dose Optimization Edit  Dose Optimization Edit Simvastatin fluvastatin ER ZOCOR (simvastatin)  Duplicate Therapy Edit  Duplicate Therapy Edit  Duplicate Therapy Edit  Dose Optimization Edit  Dose Optimization Edit  Dose Optimization Edit

Page 46 of 69 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective February 1, 2018

LIPOTROPICS, STATINS Preferred Agents Non-Preferred Agents PA Criteria Statin Combinations

ADVICOR (lovastatin/niacin) ■ Treatment failure with at atorvastatin/amlodipine least two preferred drugs CADUET (atorvastatin/amlodipine) accounting for no less than 120 days of therapy VYTORIN (simvastatin/ezetimibe) combined ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs

MACROLIDES/KETOLIDES (ORAL) Preferred Agents Non-Preferred Agents PA Criteria Ketolides

KETEK (telithromycin) ■ Treatment failure with preferred drugs within any subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs Macrolides azithromycin BIAXIN (clarithromycin) ■ Treatment failure with clarithromycin suspension clarithromycin tablets preferred drugs within any ERY-TAB (erythromycin) clarithromycin ER subclass erythromycin base E.E.S. (erythromycin) ■ Contraindication to preferred drugs PCE (erythromycin) ERYPED (erythromycin) ■ Allergic reaction to ERYTHROCIN (erythromycin) preferred drugs KETEK (telithromycin) Z-MAX (azithromycin) ZITHROMAX (azithromycin)

Page 47 of 69 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective February 1, 2018

NEUROPATHIC PAIN Preferred Agents Non-Preferred Agents PA Criteria Oral Agents duloxetine (Cymbalta) CYMBALTA (duloxetine) ■ Treatment failure with gabapentin duloxetine (Irenka) preferred drugs within any LYRICA (pregabalin) GRALISE (gabapentin) subclass HORIZANT (gabapentin enacarbil ER) ■ Contraindication to preferred drugs SAVELLA (milnacipran) ■ Allergic reaction to preferred drugs Topical Agents

DERMACINRX PHN PAK (lidocaine ■ Treatment failure with patch, DermacinRX Moisturizing preferred drugs within any Complex Cream) subclass lidocaine patch ■ Contraindication to LIDODERM (lidocaine) preferred drugs ■ Allergic reaction to preferred drugs

Page 48 of 69 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective February 1, 2018

NSAIDS Preferred Agents Non-Preferred Agents PA Criteria Nonspecific ibuprofen ADVIL (ibuprofen) meclofenamate ■ Treatment failure with INDOCIN (indomethacin) ALEVE (naproxen) mefenamic acid preferred drugs within any indomethacin capsules ANAPROX (naproxen) nabumetone subclass ketorolac CHILDREN’S MOTRIN (ibuprofen) NALFON (fenoprofen) ■ Contraindication to preferred drugs  Ketorolac Edit DAYPRO (oxaprozin) NAPROSYN (naproxen) ■ Allergic reaction to diclofenac naproxen CR  Duplicate Therapy Edit preferred drugs naproxen tablets diclofenac SR naproxen EC naproxen sodium OTC diflunisal naproxen suspension etodolac naproxen sodium (Rx) etodolac SR oxaprozin FELDENE (piroxicam) piroxicam fenoprofen PONSTEL (meclofenamate) flurbiprofen SPRIX (ketorolac) INDOCIN (indomethacin) capsules, sulindac suspension tolmetin indomethacin ER capsules VOLTAREN (diclofenac) ketoprofen ZORVOLEX (diclofenac) ketoprofen ER NSAID/GI Protectant Combinations

ARTHROTEC (diclofenac/misoprostol) ■ Treatment failure with diclofenac/misoprostol preferred drugs within any DUEXIS (ibuprofen/famotidine) subclass VIMOVO (naproxen/ esomeprazole) ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs

Page 49 of 69 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective February 1, 2018

NSAIDS Preferred Agents Non-Preferred Agents PA Criteria COX-II Selective meloxicam tablets CELEBREX (celecoxib) MOBIC (meloxicam) ■ Treatment failure with  Duplicate Therapy Edit  Duplicate Therapy Edit  Duplicate Therapy Edit preferred drugs within any subclass  Dose Optimization Edit  COX-2 Inhibitors Edit  Dose Optimization Edit ■ Contraindication to  COX-2 Inhibitors Edit celecoxib  COX-2 Inhibitors Edit preferred drugs  Duplicate Therapy Edit ■ Allergic reaction to  COX-2 Inhibitors Edit preferred drugs meloxicam suspension ■ Clinical Prior Authorization  Duplicate Therapy Edit Applies  COX-2 Inhibitors Edit Topical NSAIDs

diclofenac ■ Treatment failure with FLECTOR (diclofenac) preferred drugs within any INDOCIN (indomethacin) suppositories subclass PAIN RELIEF COLLECTION KIT (oral naproxen, capsaicin/ menthol/ methyl ■ Contraindication to salicylate gel) preferred drugs PENNSAID (diclofenac) ■ Allergic reaction to preferred drugs VOLTAREN (diclofenac) XRYLIX KIT (diclofenac)

Page 50 of 69 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective February 1, 2018

OPHTHALMICS, ANTIBIOTIC – STEROID COMBINATIONS Preferred Agents Non-Preferred Agents PA Criteria

BLEPHAMIDE (sulfacetamide/prednisolone) BLEPHAMIDE S.O.P. (sulfacetamide/prednisolone) ■ Treatment failure with neomycin/polymyxin/dexamethasone MAXITROL (neomycin/polymyxin/ dexamethasone) preferred drugs within any sulfacetamide/prednisolone neomycin/bacitracin/polymyxin/hydrocortisone subclass TOBRADEX (tobramycin/dexamethasone) ointment neomycin/polymyxin/hydrocortisone ■ Contraindication to preferred drugs PRED-G (gentamicin/prednisolone) ■ Allergic reaction to TOBRADEX (tobramycin/dexamethasone) suspension preferred drugs TOBRADEX ST (tobramycin/dexamethasone) tobramycin/dexamethasone ZYLET (tobramycin/loteprednol)

OPHTHALMIC ANTIBIOTICS Preferred Agents Non-Preferred Agents PA Criteria Aminoglycosides gentamicin TOBREX (tobramycin) solution ■ Treatment failure with tobramycin preferred drugs within any TOBREX (tobramycin) ointment subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs Quinolones ciprofloxacin BESIVANCE (besifloxacin) ■ Treatment failure with MOXEZA (moxifloxacin) CILOXAN (ciprofloxacin) preferred drugs within any VIGAMOX (moxifloxacin) gatifloxacin subclass levofloxacin ■ Contraindication to preferred drugs OCUFLOX (ofloxacin) ■ Allergic reaction to ofloxacin preferred drugs

Page 51 of 69 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective February 1, 2018

OPHTHALMIC ANTIBIOTICS Preferred Agents Non-Preferred Agents PA Criteria Macrolides erythromycin AZASITE (azithromycin) ■ Treatment failure with ILOTYCIN (erythromycin) preferred drugs within any subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs Other bacitracin/polymyxin bacitracin ■ Treatment failure with polymyxin/trimethoprim BLEPH-10 (sulfacetamide) preferred drugs within any NATACYN (natamycin) subclass neomycin/bacitracin/polymyxin ■ Contraindication to preferred drugs neomycin/polymyxin/gramicidin ■ Allergic reaction to POLYTRIM (polymyxin/trimethoprim) preferred drugs sulfacetamide ointment, solution

OPHTHALMICS FOR ALLERGIC CONJUNCTIVITIS Preferred Agents Non-Preferred Agents PA Criteria cromolyn ALOCRIL (nedocromil) epinastine ■ Treatment failure with PAZEO (olopatadine) ALOMIDE (lodoxamide) ketotifen preferred drugs within any ALREX (loteprednol) LASTACAFT (alcaftadine) subclass azelastine olopatadine ■ Contraindication to preferred drugs BEPREVE (bepotastine) PATADAY (olopatadine) ■ Allergic reaction to ELESTAT (epinastine PATANOL (olopatadine) preferred drugs EMADINE (emedastine))

Page 52 of 69 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective February 1, 2018

OPHTHALMICS, ANTI-INFLAMMATORIES Preferred Agents Non-Preferred Agents PA Criteria NSAIDS diclofenac ACULAR (ketorolac) ■ Treatment failure with flurbiprofen ACULAR LS (ketorolac) preferred drugs within any ketorolac ACUVAIL (ketorolac) subclass NEVANAC (nepafenac) bromfenac ■ Contraindication to preferred drugs BROMSITE (bromfenac) ■ Allergic reaction to ILEVRO (nepafenac) preferred drugs ketorolac LS Steroids

DUREZOL (difluprednate) dexamethasone MAXIDEX (dexamethasone) ■ Treatment failure with LOTEMAX (loteprednol) suspension FLAREX (fluorometholone) OMNIPRED (prednisolone) preferred drugs within any prednisolone acetate fluorometholone PRED FORTE (prednisolone) subclass FML (fluorometholone) PRED MILD (prednisolone) ■ Contraindication to preferred drugs FML FORTE (fluorometholone) prednisolone sodium phosphate ■ Allergic reaction to FML S.O.P. (fluorometholone) VEXOL (rimexolone) preferred drugs LOTEMAX (loteprednol) gel, ointment

OPHTHALMICS, ANTI-INFLAMMATORY IMMUNOMODULATORS Preferred Agents Non-Preferred Agents PA Criteria

RESTASIS (cyclosporin) XIIDRA (lifitegrast) ■ Treatment failure with preferred drugs within any subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs

Page 53 of 69 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective February 1, 2018

OPHTHALMICS, GLAUCOMA AGENTS Preferred Agents Non-Preferred Agents PA Criteria Sympathomimetics brimonidine ALPHAGAN P (brimonidine) ■ Treatment failure with pilocarpine apraclonidine preferred drugs within any brimonidine P subclass IOPIDINE (apraclonidine) ■ Contraindication to preferred drugs

■ Allergic reaction to

preferred drugs Beta Blockers carteolol BETAGAN (levobunolol) ■ Treatment failure with levobunolol betaxolol preferred drugs within any timolol BETOPTIC S (betaxolol) subclass ISTALOL (timolol) ■ Contraindication to preferred drugs TIMOPTIC (timolol) ■ Allergic reaction to TIMOPTIC XE (timolol) preferred drugs Carbonic Anhydrase Inhibitors

AZOPT (brinzolamide) TRUSOPT (dorzolamide) ■ Treatment failure with dorzolamide preferred drugs within any subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs Prostaglandin Analogs latanoprost bimatoprost ■ Treatment failure with TRAVATAN-Z (travoprost) LUMIGAN (bimatoprost) preferred drugs within any travoprost subclass XALATAN (latanoprost) ■ Contraindication to preferred drugs ZIOPTAN (tafluprost) ■ Allergic reaction to

preferred drugs

Page 54 of 69 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective February 1, 2018

OPHTHALMICS, GLAUCOMA AGENTS Preferred Agents Non-Preferred Agents PA Criteria Combination Agents

COMBIGAN (brimonidine/timolol) COSOPT (dorzolamide/timolol) ■ Treatment failure with dorzolamide/timolol COSOPT PF (dorzolamide/timolol) preferred drugs within any SIMBRINZA (brinzolamide/brimonidine) subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs Miscellaneous

phospholine iodide ■ Treatment failure with preferred drugs within any subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs

OPIATE DEPENDENCE TREATMENTS Preferred Agents Non-Preferred Agents PA Criteria

BUNAVAIL (buprenorphine/naloxone) buprenorphine/naloxone ■ Treatment failure with  Opiate/Benzo/Muscle Relaxant Combo Edit EVZIO (naloxone) preferred drugs within any subclass  Buprenorphine Edit VIVITROL (naltrexone) ■ Contraindication to buprenorphine ZUBSOLV (buprenorphine/naloxone) preferred drugs naloxone syringe  Opiate/Benzo/Muscle Relaxant Combo Edit ■ Allergic reaction to naloxone vial  Buprenorphine Edit preferred drugs naltrexone ■ Clinical Prior Authorization NARCAN (naloxone) nasal Applies SUBOXONE (buprenorphine/naloxone) film

Page 55 of 69 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective February 1, 2018

OTIC ANTIBIOTICS Preferred Agents Non-Preferred Agents PA Criteria

CIPRODEX (ciprofloxacin/dexamethasone) CIPRO HC (ciprofloxacin/hydrocortisone) ■ Treatment failure with ciprofloxacin COLY-MYCIN S (colistin/neomycin/hydrocortisone) preferred drugs within any neomycin/polymyxin/hydrocortisone CORTISPORIN-TC (colistin/neomycin/hydrocortisone) subclass ofloxacin ■ Contraindication to preferred drugs OTOVEL (ciprofloxacin/fluocinolone) ■ Allergic reaction to preferred drugs

OTIC ANTI-INFECTIVES/ANESTHETICS Preferred Agents Non-Preferred Agents PA Criteria acetic acid acetic acid/hydrocortisone ■ Treatment failure with acetic acid/aluminum preferred drugs within any subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs

PAH AGENTS (ORAL, INHALATION) Preferred Agents Non-Preferred Agents PA Criteria

ADCIRCA (tadalafil) ADEMPAS (riociguat) ■ Treatment failure with LETAIRIS (ambrisentan) OPSUMIT (macitentan) preferred drugs within any sildenafil (generic Revatio) ORENITRAM ER (treprostinil) subclass TRACLEER (bosentan) REVATIO (sildenafil) ■ Contraindication to preferred drugs TYVASO Inhalation (treprostinil) ■ Allergic reaction to UPTRAVI (selexipag) preferred drugs VENTAVIS Inhalation (iloprost) ■ Clinical Prior Authorization Applies

Page 56 of 69 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective February 1, 2018

PANCREATIC ENZYMES Preferred Agents Non-Preferred Agents PA Criteria

CREON (pancrelipase) PANCREAZE (pancrelipase) ■ Treatment failure with ZENPEP (pancrelipase) PERTZYE (pancrelipase) preferred drugs within any VIOKACE (pancrelipase) subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs

PENICILLINS Preferred Agents Non-Preferred Agents PA Criteria amoxicillin amoxicillin ER ■ Treatment failure with ampicillin preferred drugs within any dicloxacillin subclass penicillin VK ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs

Page 57 of 69 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective February 1, 2018

PHOSPHATE BINDERS Preferred Agents Non-Preferred Agents PA Criteria calcium acetate AURYXIA (ferric citrate) Allergic reaction to preferred drug OR MAGNEBIND 400 RX (calcium carbonate, folic acid, magnesium carbonate) ELIPHOS (calcium acetate) treatment failure with preferred drug; RENAGEL (sevelamer HCl) FOSRENOL (lanthanum) AND diagnosis of ESRD and hyperphosphatemia despite dietary PHOSLYRA (calcium acetate) phosphorous restrictions AND at least RENVELA (sevelamer carbonate) one of the following: VELPHORO (sucroferric oxyhydroxide) ■ hypercalcemia (corrected serum calcium >10.2 mg/dL) ■ plasma PTH levels <150 pg/mL on two consecutive measurements ■ dialysis patients with severe vascular and/or soft tissue calcifications Clinical Prior Authorization Applies

PLATELET AGGREGATION INHIBITORS Preferred Agents Non-Preferred Agents PA Criteria

AGGRENOX (dipyridamole/aspirin) dipyridamole ■ Treatment failure with BRILINTA (ticagrelor) PERSANTINE (dipyridamole) preferred drug clopidogrel PLAVIX (clopidogrel) ■ Contraindication to EFFIENT (prasugrel) Ticlopidine preferred drug ZONTIVITY (vorapaxar) ■ Allergic reaction to preferred drug

PRENATAL VITAMINS See Separate Preferred Prenatal Vitamin Listing. PA Criteria: ■ Prenatal vitamins are covered only for females less than 50 years of age.

Page 58 of 69 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective February 1, 2018

PROGESTATIONAL AGENTS Preferred Agents Non-Preferred Agents PA Criteria

MAKENA (hydroxyprogesterone) ■ Clinical Prior Authorization Applies

PROGESTINS FOR CACHEXIA Preferred Agents Non-Preferred Agents PA Criteria megestrol MEGACE (megestrol) ■ Treatment failure with MEGACE ES (megestrol) preferred drug ■ Contraindication to preferred drug ■ Allergic reaction to preferred drug

PROTON PUMP INHIBITORS (ORAL) Preferred Agents Non-Preferred Agents PA Criteria

NEXIUM (esomeprazole) ACIPHEX (rabeprazole) rabeprazole ■ Treatment failure after no omeprazole Rx DEXILANT (dexlansoprazole) ZEGERID (omeprazole/sodium less than a 30 day trial of pantoprazole  Duplicate Therapy Edit bicarbonate) each preferred drug ■ Contraindication to PROTONIX (pantoprazole) suspension  Dose Optimization Edit preferred drugs esomeprazole ■ Allergic reaction to lansoprazole preferred drugs NEXIUM OTC (esomeprazole) ■ Prevacid Solutabs will be omeprazole OTC approved for children 10 omeprazole/sodium bicarbonate years of age and under PREVACID (lansoprazole) PROTONIX tablets (pantoprazole)

Page 59 of 69 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective February 1, 2018

SEDATIVE HYPNOTICS Preferred Agents Non-Preferred Agents PA Criteria Benzodiazepines flurazepam estazolam ■ Treatment failure with temazepam 15, 30 mg  Anxiolytics and preferred drugs within any triazolam Sedative/Hypnotics Edit subclass  Opiate/Benzo/Muscle ■ Contraindication to Relaxant Combo Edit preferred drugs RESTORIL (temazepam) ■ Allergic reaction to preferred drugs temazepam 7.5, 22.5 mg ■ Clinical Prior Authorization Applies Others zolpidem AMBIEN (zolpidem) LUNESTA (eszopiclone) ■ Treatment failure with AMBIEN CR (zolpidem) ROZEREM (ramelteon) preferred drugs within any BELSOMRA (suvorexant) SILENOR (doxepin) subclass EDLUAR (zolpidem) SONATA (zaleplon) ■ Contraindication to preferred drugs eszopiclone zaleplon ■ Allergic reaction to HETLIOZ (tasimelteon) zolpidem ER preferred drugs INTERMEZZO (zolpidem) ■ Clinical Prior Authorization Applies

Page 60 of 69 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective February 1, 2018

SKELETAL MUSCLE RELAXANTS Preferred Agents Non-Preferred Agents PA Criteria baclofen AMRIX (cyclobenzaprine ER) LORZONE (chlorzoxazone) ■ Treatment failure with carisoprodol (except 250 mg)  Opiate/Benzo/Muscle metaxolone preferred drugs within any chlorzoxazone Relaxant Combo Edit orphenadrine subclass cyclobenzaprine  Cyclobenzaprine Edit ROBAXIN (methocarbamol) ■ Contraindication to preferred drugs  Opiate/Benzo/Muscle carisoprodol 250 mg SKELAXIN (metaxolone) ■ Allergic reaction to Relaxant Combo Edit carisoprodol compound SOMA (carisoprodol) preferred drugs  Cyclobenzaprine Edit DANTRIUM (dantrolene) tizanidine capsules ■ Clinical Prior Authorization methocarbamol dantrolene ZANAFLEX (tizanidine) Applies tizanidine tablets FEXMID (cyclobenzaprine)  Opiate/Benzo/Muscle Relaxant Combo Edit  Cyclobenzaprine Edit

SMOKING CESSATION Preferred Agents Non-Preferred Agents PA Criteria bupropion SR NICODERM CQ (nicotine) ■ Treatment failure with CHANTIX (varenicline) nicotine lozenge preferred drugs within any NICORETTE (nicotine) gum NICOTROL (nicotine) subclass NICORETTE (nicotine) lozenge NICOTROL NS (nicotine) ■ Contraindication to preferred drugs nicotine gum ZYBAN (bupropion) ■ Allergic reaction to nicotine patch preferred drugs

Page 61 of 69 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective February 1, 2018

STEROIDS, TOPICAL Preferred Agents Non-Preferred Agents PA Criteria Low Potency fluocinolone oil alclometasone MICORT-HC (hydrocortisone) ■ Treatment failure with hydrocortisone cream, gel, lotion (OTC), ointment DERMA-SMOOTHE/FS (fluocinolone) PEDIADERM HC (hydrocortisone) preferred drugs within any hydrocortisone/aloe cream DESONATE (desonide) PEDIADERM TA (triamcinolone) subclass desonide TEXACORT (hydrocortisone) solution ■ Contraindication to preferred drugs hydrocortisone/mineral oil ointment ■ Allergic reaction to hydrocortisone lotion (Rx) preferred drugs Medium Potency fluticasone propionate cream, ointment beclomethasone valerate foam fluticasone propionate lotion ■ Treatment failure with mometasone cream, ointment, solution clocortolone cream hydrocortisone butyrate preferred drugs within any CLODERM (clocortolone) hydrocortisone valerate subclass CORDRAN (flurandrenolide) LUXIQ (betamethasone) ■ Contraindication to preferred drugs CUTIVATE (fluticasone) PANDEL (hydrocortisone probutate) ■ Allergic reaction to ELOCON (mometasone) prednicarbate preferred drugs fluocinolone acetonide SYNALAR (fluocinolone) flurandrenolide High Potency betamethasone dipropionate lotion amcinonide fluocinonide ■ Treatment failure with betamethasone dipropionate/propylene glycol cream betamethasone dipropionate cream, HALOG (halcinonide) preferred drugs within any betamethasone valerate cream gel, ointment KENALOG aerosol (triamcinolone) subclass triamcinolone acetonide cream, ointment betamethasone dipropionate/ SERNIVO (betamethasone ■ Contraindication to propylene glycol lotion, ointment dipropionate) preferred drugs betamethasone valerate lotion, TOPICORT (desoximetasone) ■ Allergic reaction to preferred drugs ointment triamcinolone acetonide aerosol, desoximetasone lotion diflorasone triamcinolone/dimethicone ELLZIA PAK (triamcinolone acetonide TRIANEX (triamcinolone) ointment/dimethicone) VANOS (fluocinonide) DIPROLENE (betamethasone dipropionate)

Page 62 of 69 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective February 1, 2018

STEROIDS, TOPICAL Preferred Agents Non-Preferred Agents PA Criteria Very High Potency clobetasol emollient APEXICON E (diflorasone) TEMOVATE (clobetasol) ■ Treatment failure with clobetasol propionate cream, gel, solution clobetasol lotion, shampoo preferred drugs within any halobetasol clobetasol propionate foam, subclass ointment, spray ■ Contraindication to CLOBEX (clobetasol) preferred drugs CLODAN (clobetasol) ■ Allergic reaction to preferred drugs OLUX, OLUX-E (clobetasol)

STIMULANTS AND RELATED AGENTS Preferred Agents Non-Preferred Agents PA Criteria Stimulants

ADDERALL XR (amphetamine salt combination) ADZENYS XR ODT (amphetamine) methylphenidate chewable tablets ■ Treatment failure with APTENSIO XR (methylphenidate) amphetamine salt combination ER methylphenidate ER preferred drugs within any amphetamine salt combination IR CONCERTA (methylphenidate)  Dose Optimization Edit subclass ■ Contraindication to DAYTRANA (methylphenidate) DESOXYN (methamphetamine)  ADD_ADHD Edit preferred drugs dexmethylphenidate IR DEXEDRINE (dextroamphetamine) methylphenidate solution ■ Allergic reaction to dextroamphetamine IR dexmethylphenidate ER modafinil preferred drugs DYANAVEL XR (amphetamine) dextroamphetamine ER NUVIGIL (armodafinil) ■ Methylin solution will not FOCALIN XR (dexmethylphenidate) dextroamphetamine solution PROCENTRA (dextroamphetamine) require previous use of a METHYLIN (methylphenidate) chewable tablets EVEKEO (amphetamine) PROVIGIL (modafinil) preferred drug for patients METHYLIN (methylphenidate) solution FOCALIN (dexmethylphenidate) QUILLICHEW ER (methylphenidate) under six years of age methylphenidate IR METADATE CD (methylphenidate) RITALIN (methylphenidate) ■ Clinical Prior Authorization methylphenidate ER (authorized generic Concerta) methamphetamine RITALIN LA (methylphenidate ER) Applies QUILLIVANT XR (methylphenidate) methylphenidate CD ZENZEDI (dextroamphetamine) VYVANSE (lisdexamfetamine) VYVANSE (lisdexamfetamine) chewable tablets

Page 63 of 69 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective February 1, 2018

STIMULANTS AND RELATED AGENTS Preferred Agents Non-Preferred Agents PA Criteria Non-Stimulants guanfacine ER clonidine ER ■ Treatment failure with STRATTERA (atomoxetine) INTUNIV (guanfacine ER) preferred drugs within any subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs ■ Clinical Prior Authorization Applies

TETRACYCLINES Preferred Agents Non-Preferred Agents PA Criteria doxycycline monohydrate 50, 100 mg capsules demeclocycline minocycline tablets ■ Treatment failure with minocycline capsules doxycycline hyclate IR minocycline ER preferred drugs within any VIBRAMYCIN (doxycycline) suspension doxycycline hyclate DR ORACEA (doxycycline) subclass doxycycline monohydrate 40, 75, 150 SOLODYN (minocycline) ■ Contraindication to preferred drugs mg capsules tetracycline ■ Allergic reaction to doxycycline monohydrate suspension, VIBRAMYCIN (doxycycline) capsule, preferred drugs tablets syrup

Page 64 of 69 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective February 1, 2018

ULCERATIVE COLITIS Preferred Agents Non-Preferred Agents PA Criteria Oral

DELZICOL (mesalamine) APRISO (mesalamine) ■ Treatment failure with LIALDA (mesalamine) ASACOL HD (mesalamine) preferred drugs within any sulfasalazine AZULFIDINE (sulfasalazine) subclass of same route sulfasalazine DR balsalazide ■ Contraindication to preferred drugs of same COLAZAL (balsalazide) route DIPENTUM (olsalazine) ■ Allergic reaction to GIAZO (balsalazide) preferred drugs of same PENTASA (mesalamine) route UCERIS (budesonide) Rectal

CANASA (mesalamine) mesalamine ■ Treatment failure with SFROWASA (mesalamine) preferred drugs within any UCERIS (budesonide) subclass of same route ■ Contraindication to preferred drugs of same route ■ Allergic reaction to preferred drugs of same route

UREA CYCLE DISORDERS Preferred Agents Non-Preferred Agents PA Criteria

BUPHENYL (sodium phenylbutyrate) RAVICTI (glycerol phenylbutyrate) ■ Treatment failure with CARBAGLU (carglumic acid) sodium phenylbutyrate powder preferred drugs within any subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs

Page 65 of 69 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective February 1, 2018

PDL Review and Implementation Schedule 2018 Date of Most Recent PDL Date of Next PDL Change 2019 Review Review CLASS Change (Tentative) (Tentative) JAN ACNE AGENTS, ORAL 7/1/2017 7/1/2018 JAN JAN ACNE AGENTS, TOPICAL 7/1/2017 7/1/2018 JAN JAN ANALGESICS, NARCOTICS LONG 7/1/2017 7/1/2018 JAN JAN ANALGESICS, NARCOTICS SHORT 7/1/2017 7/1/2018 JAN JAN ANGIOTENSIN MODULATOR COMBINATIONS 7/1/2017 7/1/2018 JAN JAN ANGIOTENSIN MODULATORS 7/1/2017 7/1/2018 JAN JAN ANTIMIGRAINE AGENTS, OTHER 7/1/2017 7/1/2018 JAN JAN ANTIMIGRAINE AGENTS, TRIPTANS 7/1/2017 7/1/2018 JAN JAN BLADDER RELAXANT PREPARATIONS 7/1/2017 7/1/2018 JAN JAN H. PYLORI TREATMENT 7/1/2017 7/1/2018 JAN JAN IMMUNOMODULATORS, ATOPIC DERMATITIS 7/1/2017 7/1/2018 JAN JAN INTRANASAL RHINITIS AGENTS 7/1/2017 7/1/2018 JAN JAN MOVEMENT DISORDERS N/A 7/1/2018 JAN JAN NEUROPATHIC PAIN 7/1/2017 7/1/2018 JAN JAN OPHTHALMIC ANTI-INFLAMMATORY/IMMUNOMODULATORS 7/1/2017 7/1/2018 JAN JAN PHOSPHATE BINDERS 7/1/2017 7/1/2018 JAN JAN PLATELET AGGREGATION INHIBITORS 7/1/2017 7/1/2018 JAN JAN PROGESTINS FOR CACHEXIA 7/1/2017 7/1/2018 JAN JAN PROTON PUMP INHIBITORS 7/1/2017 7/1/2018 JAN JAN SMOKING CESSATION 7/1/2017 7/1/2018 JAN APR ANTI-ALLERGENS, ORAL 7/1/2017 7/1/2018 APR APR ANTIBIOTICS, INHALED 7/1/2017 7/1/2018 APR APR ANTICOAGULANTS 7/1/2017 7/1/2018 APR APR ANTIDEPRESSANTS, OTHER 7/1/2017 7/1/2018 APR APR ANTIDEPRESSANTS, SSRIs 7/1/2017 7/1/2018 APR

Page 66 of 69 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective February 1, 2018

2018 Date of Most Recent PDL Date of Next PDL Change 2019 Review Review CLASS Change (Tentative) (Tentative) APR ANTIDEPRESSANTS, TRICYCLIC 7/1/2017 7/1/2018 APR APR ANTIHYPERURICEMICS 7/1/2017 7/1/2018 APR APR ANTIPARKINSONS AGENTS 7/1/2017 7/1/2018 APR APR ANXIOLYTICS 7/1/2017 7/1/2018 APR APR BETA-BLOCKERS 7/1/2017 7/1/2018 APR APR BILE SALTS 7/1/2017 7/1/2018 APR APR BPH TREATMENTS 7/1/2017 7/1/2018 APR APR BRONCHODILATORS, BETA AGONIST 7/1/2017 7/1/2018 APR APR COPD AGENTS 7/1/2017 7/1/2018 APR APR COUGH AND COLD 7/1/2017 7/1/2018 APR APR ERYTHROPOIESIS STIMULATING PROTEINS 7/1/2017 7/1/2018 APR APR GLUCOCORTICOIDS, INHALED 7/1/2017 7/1/2018 APR APR HAE TREATMENTS 7/1/2017 7/1/2018 APR APR HYPOGLYCEMICS, SLGT2 2/1/2018 7/1/2018 APR APR IMMUNE GLOBULINS, IV 7/1/2017 7/1/2018 APR APR LINCOSAMIDES/OXAZOLIDINONES/STREPTOGRAMINS 7/1/2017 7/1/2018 APR APR LIPOTROPICS, OTHER 7/1/2017 7/1/2018 APR APR LIPOTROPICS, STATINS 7/1/2017 7/1/2018 APR APR PAH AGENTS, ORAL AND INHALED 7/1/2017 7/1/2018 APR APR PANCREATIC ENZYMES 7/1/2017 7/1/2018 APR APR SEDATIVE HYPNOTICS 7/1/2017 7/1/2018 APR APR UREA CYCLE DISORDER, ORAL 7/1/2017 7/1/2018 APR JUL ALZHEIMERS AGENTS 2/1/2018 1/1/2019 JUL JUL ANTIHISTAMINES, MINIMALLY SEDATING 2/1/2018 1/1/2019 JUL JUL ANTIHYPERTENSIVES, SYMPATHOLYTIC 2/1/2018 1/1/2019 JUL JUL ANTIVIRALS, ORAL 2/1/2018 1/1/2019 JUL JUL CALCIUM CHANNEL BLOCKERS 2/1/2018 1/1/2019 JUL JUL CEPHALOSPORINS AND RELATED ANTIBIOTICS 2/1/2018 1/1/2019 JUL

Page 67 of 69 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective February 1, 2018

2018 Date of Most Recent PDL Date of Next PDL Change 2019 Review Review CLASS Change (Tentative) (Tentative) JUL FLUOROQUINOLONES, ORAL 2/1/2018 1/1/2019 JUL JUL GLUCOCORTICOIDS, ORAL 2/1/2018 1/1/2019 JUL JUL IMMUNOSUPPRESSIVES, ORAL 2/1/2018 1/1/2019 JUL JUL IRON, ORAL 2/1/2018 1/1/2019 JUL JUL LEUKOTRIENE MODIFIERS 2/1/2018 1/1/2019 JUL JUL NSAIDS 2/1/2018 1/1/2019 JUL JUL OPHTHALMIC ANTIBIOTICS 2/1/2018 1/1/2019 JUL JUL OPHTHALMIC ANTIBIOTIC-STEROID COMBINATIONS 2/1/2018 1/1/2019 JUL JUL OPHTHALMICS FOR ALLERGIC CONJUNCTIVITIS 2/1/2018 1/1/2019 JUL JUL OPHTHALMICS, ANTI-INFLAMMATORY 2/1/2018 1/1/2019 JUL JUL OPHTHALMICS, GLAUCOMA AGENTS 2/1/2018 1/1/2019 JUL JUL OTIC ANTIBIOTICS 2/1/2018 1/1/2019 JUL JUL OTIC ANTI-INFECTIVES & ANESTHETICS 2/1/2018 1/1/2019 JUL JUL PRENATAL VITAMINS 2/1/2018 1/1/2019 JUL JUL SKELETAL MUSCLE RELAXANTS 2/1/2018 1/1/2019 JUL JUL STEROIDS, TOPICAL 2/1/2018 1/1/2019 JUL JUL ULCERATIVE COLITIS 2/1/2018 1/1/2019 JUL OCT ANDROGENIC AGENTS 1/1/2017 N/A OCT OCT ANTIBIOTICS, GI 1/1/2017 N/A OCT OCT ANTIBIOTICS, TOPICAL 1/1/2017 N/A OCT OCT ANTIBIOTICS, VAGINAL 1/1/2017 N/A OCT OCT ANTIEMETICS/ANTIVERTIGO AGENTS 1/1/2017 N/A OCT OCT ANTIFUNGALS, ORAL 1/1/2017 N/A OCT OCT ANTIFUNGALS, TOPICAL 1/1/2017 N/A OCT OCT ANTIHISTAMINES, FIRST GENERATION N/A N/A OCT OCT ANTIPARASITICS, TOPICAL 1/1/2017 N/A OCT OCT ANTIPSYCHOTICS 1/1/2017 N/A OCT OCT ANTIVIRALS, TOPICAL 1/1/2017 N/A OCT

Page 68 of 69 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective February 1, 2018

2018 Date of Most Recent PDL Date of Next PDL Change 2019 Review Review CLASS Change (Tentative) (Tentative) OCT BONE RESORPTION SUPPRESSION AND RELATED 1/1/2017 N/A OCT OCT COLONY STIMULATING FACTORS 1/1/2017 N/A OCT OCT CYTOKINE AND CAM ANTAGONISTS 1/1/2017 N/A OCT OCT EPINEPHRINE, SELF-INJECTED 1/1/2017 N/A OCT OCT GI MOTILITY, CHRONIC 1/1/2017 N/A OCT OCT GROWTH HORMONE 1/1/2017 N/A OCT OCT HEPATITIS C AGENTS 7/1/2017 N/A OCT OCT HYPOGLYCEMICS, INCRETIN MIMETICS/ENHANCERS 1/1/2017 N/A OCT OCT HYPOGLYCEMICS, INSULIN AND RELATED 1/1/2017 N/A OCT OCT HYPOGLYCEMICS, MEGLITINIDES 1/1/2017 N/A OCT OCT HYPOGLYCEMICS, METFORMIN 1/1/2017 N/A OCT OCT HYPOGLYCEMICS, TZD 1/1/2017 N/A OCT OCT MACROLIDES-KETOLIDES 1/1/2017 N/A OCT OCT OPIATE DEPENDENCE TREATMENTS 1/1/2017 N/A OCT OCT PEDIATRIC VITAMIN PREPARATIONS N/A N/A OCT OCT PENICILLINS 1/1/2017 N/A OCT OCT STIMULANTS AND RELATED AGENTS 7/1/2017 N/A OCT OCT TETRACYCLINES 1/1/2017 N/A OCT

Page 69 of 69 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PDL and PA CRITERIA

Cough and Cold (Oral only) Preferred Agents Non‐Preferred Agents PA CRITERIA Agent Ingredients Agent Ingredients ALA‐HIST PE DEXBROMPHENIRAMIN/PHENYLEPHRIN ALA‐HIST IR DEXBROMPHENIRAMINE MALEATE All products restricted to APRODINE TRIPROLIDINE/PSEUDOEPHEDRINE CHILD DELSYM COUGH+COLD DIPHENHYDRA/PHENYLEPH/ACETAMIN patients aged 2 years and above CHEST CONGESTION RELIEF GUAIFENESIN DALLERGY CHLORPHENIRAMINE/PHENYLEPHRINE CHILD MUCINEX CHEST CONGESTION GUAIFENESIN ED A‐HIST PSE TRIPROLIDINE/PSEUDOEPHEDRINE CHILDREN'S MUCINEX GUAIFENESIN/PHENYLEPHRINE HCL MUCINEX FAST‐MAX NITE COLD‐FLU DIPHENHYDRA/PHENYLEPH/ACETAMIN CHILDREN'S MUCINEX DIPHENHYDRA/PHENYLEPH/ACETAMIN MUCINEX SINUS‐MAX DAY‐NIGHT DIPHENHYD/PE/ACETAMINOPHEN/GG COUGH SYRUP GUAIFENESIN RESPAIRE‐30 GUAIFENESIN/PSEUDOEPHEDRNE HCL Cough and Cold Products subject to PA DALLERGY DEXBROMPHENIRAMIN/PHENYLEPHRIN BROTAPP BROMPHENIRAMIN/PSEUDOEPHEDRINE DECONEX IR GUAIFENESIN/PHENYLEPHRINE HCL CHEST CONGESTION RELIEF PE GUAIFENESIN/PHENYLEPHRINE HCL DELSYM COUGH‐COLD NIGHTTIME DIPHENHYDRA/PHENYLEPH/ACETAMIN LORTUSS LQ DOXYLAMINE/PSEUDOEPHEDRINE HCL DIMAPHEN BROMPHENIRAMINE/PHENYLEPHRINE MAPAP SINUS PHENYLEPHRINE HCL/ACETAMINOPHN ED A‐HIST CHLORPHENIRAMINE/PHENYLEPHRINE MAXIPHEN GUAIFENESIN/PHENYLEPHRINE HCL ED BRON GP GUAIFENESIN/PHENYLEPHRINE HCL MUCUS RELIEF SINUS GUAIFENESIN/PHENYLEPHRINE HCL ED CHLORPED D CHLORPHENIRAMINE/PHENYLEPHRINE PAIN RELIEF SINUS PE PHENYLEPHRINE HCL/ACETAMINOPHN GUAIFENESIN GUAIFENESIN PHENYLEPHRINE‐PYRILAMINE PHENYLEPHRINE/PYRILAMINE GUAIFENESIN ER GUAIFENESIN PROMETHAZINE VC PHENYLEPHRINE HCL/PROMETH HCL GUAIFENESIN‐PSEUDOEPHEDRINE ER GUAIFENESIN/PSEUDOEPHEDRNE HCL RESCON DEXCHLORPHENIRAMIN/PSEUDOEPHED HISTEX‐PE PHENYLEPHRINE HCL/TRIPROLIDINE RESCON‐GG GUAIFENESIN/PHENYLEPHRINE HCL IOPHEN NR GUAIFENESIN RU‐HIST D BROMPHENIRAMINE/PHENYLEPHRINE LODRANE D BROMPHENIRAMIN/PSEUDOEPHEDRINE STAHIST AD CHLORCYCLIZINE/PSEUDOEPHEDRINE LOHIST‐D CHLORPHENIRAMINE/PSEUDOEPHED MUCINEX GUAIFENESIN MUCINEX D GUAIFENESIN/PSEUDOEPHEDRNE HCL MUCINEX FAST‐MAX COLD‐SINUS GUAIFEN/PHENYLEPH/ACETAMINOPHN MUCUS RELIEF GUAIFENESIN NASAL SPRAY OXYMETAZOLINE HCL NASOPEN PE THONZYLAMINE/PHENYLEPHRINE NOHIST‐LQ CHLORPHENIRAMINE/PHENYLEPHRINE ORGAN‐I NR GUAIFENESIN POLY HIST FORTE DOXYLAMINE/PHENYLEPHRINE HCL POLY‐VENT IR GUAIFENESIN/PSEUDOEPHEDRNE HCL Q‐TUSSIN GUAIFENESIN ROBAFEN GUAIFENESIN RYMED DEXCHLORPHENIRAM/PHENYLEPHRINE RYNEX PE BROMPHENIRAMINE/PHENYLEPHRINE RYNEX PSE BROMPHENIRAMIN/PSEUDOEPHEDRINE SILTUSSIN SA GUAIFENESIN SUDOGEST SINUS & ALLERGY CHLORPHENIRAMINE/PSEUDOEPHED TUSSIN GUAIFENESIN

Cough and Cold (Nasal Only) Preferred Agents Non‐Preferred Agents Agent Ingredients Agent Ingredients MUCINEX SINUS‐MAX GUAIFEN/PHENYLEPH/ACETAMINOPHN NOSE DROPS PHENYLEPHRINE HCL NASAL DECONGESTANT OXYMETAZOLINE HCL

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

Cough and Cold (Non‐Narcotic) Preferred Agents Non‐Preferred Agents PA CRITERIA Agent Ingredients Agent Ingredients ALA‐HIST DM BROMPHENIRAM/PHENYLEPHRINE/DM BROMFED DM BROMPHENIRAMINE/PSEUDOEPHED/DM All products restricted to ALAHIST DM D‐METHORPHAN/PE/DEXBROMPHENIR MUCINEX FAST‐MAX DAY‐NITE CONG DIPHENHYDRAM/PE/DM/ACETAMIN/GG patients aged 2 years and above AP‐HIST DM BROMPHENIRAM/PHENYLEPHRINE/DM VANATAB AC PYRILAMINE/CHLOPHEDIANOL BENZONATATE BENZONATATE VANATAB DM GUAIFEN/DEXTROMETHORPHAN/PE BROMPHENIRAMINE‐PSEUDOEPHED‐DM BROMPHENIRAMINE/PSEUDOEPHED/DM ALL‐NITE COLD‐FLU RELIEF DM/ACETAMINOPHEN/DOXYLAMINE BROTAPP DM BROMPHENIRAMINE/PSEUDOEPHED/DM ALLFEN DM GUAIFENESIN/DEXTROMETHORPHAN CHILD DELSYM COUGH+CHEST DM GUAIFENESIN/DEXTROMETHORPHAN CHILDREN'S COLD & COUGH DM BROMPHENIRAM/PHENYLEPHRINE/DM Cough and Cold Products subject to PA CHILD MUCINEX M‐S COLD DAY‐NTE DIPHENHYDRAM/PE/DM/ACETAMIN/GG DAY TIME COLD‐FLU RELIEF D‐METHORPHAN/PE/ACETAMINOPHEN CHILDREN'S DELSYM COUGH DEXTROMETHORPHAN POLISTIREX DIMAPHEN DM BROMPHENIRAM/PHENYLEPHRINE/DM CHILDREN'S MUCINEX PHENYLEPHRINE/DM/ACETAMINOP/GG ENDACOF‐DM BROMPHENIRAM/PHENYLEPHRINE/DM CHILDREN'S MUCINEX GUAIFEN/DEXTROMETHORPHAN/PE GUAIFENESIN‐DM ER GUAIFENESIN/DEXTROMETHORPHAN CHILDREN'S MUCINEX GUAIFENESIN/DEXTROMETHORPHAN MAPAP COLD FORMULA D‐METHORPHAN/PE/ACETAMINOPHEN CHLO TUSS DEXBROMPHEN/PSEUDOEPH/CHLOPHED MAXIPHEN DM GUAIFEN/DEXTROMETHORPHAN/PE COUGH DM ER DEXTROMETHORPHAN POLISTIREX MUCINEX FAST‐MAX DAY‐NITE COLD DIPHENHYDRAM/PE/DM/ACETAMIN/GG DECONEX DMX GUAIFEN/DEXTROMETHORPHAN/PE MUCINEX FAST‐MAX SEVERE COLD PHENYLEPHRINE/DM/ACETAMINOP/GG DELSYM DEXTROMETHORPHAN POLISTIREX NIGHT TIME COLD‐FLU RELIEF DM/ACETAMINOPHEN/DOXYLAMINE DELSYM COUGH‐COLD PHENYLEPHRINE/DM/ACETAMINOP/GG NINJACOF PYRILAMINE/CHLOPHEDIANOL DELSYM COUGH+CHEST CONGEST DM GUAIFENESIN/DEXTROMETHORPHAN NINJACOF‐A PYRILAM/CHLOPHED/ACETAMINOPHEN DEXTROMETHORPHAN POLISTIREX DEXTROMETHORPHAN POLISTIREX ROBAFEN CF GUAIFEN/DEXTROMETHORPHAN/PE ED A‐HIST DM CHLORPHENIRAMINE/PHENYLEPH/DM ROBAFEN COUGH DEXTROMETHORPHAN HBR ED‐A‐HIST DM CHLORPHENIRAMINE/PHENYLEPH/DM VANACOF‐8 PYRILAMINE/CHLOPHEDIANOL EXTRA ACTION COUGH GUAIFENESIN/DEXTROMETHORPHAN HISTEX‐DM TRIPROLIDINE/PHENYLEPHRINE/DM IOPHEN DM‐NR GUAIFENESIN/DEXTROMETHORPHAN KIDKARE CHLORPHENIRAMIN/PSEUDOEPHED/DM LOHIST‐DM BROMPHENIRAM/PHENYLEPHRINE/DM LORTUSS DM DOXYLAMINE/PSEUDOEPHEDRINE/DM M‐END DMX DEXBROMPHEN/PSEUDOEPHEDRINE/DM M‐HIST DM BROMPHENIRAM/PHENYLEPHRINE/DM MUCINEX COLD‐FLU‐SORE THROAT PHENYLEPHRINE/DM/ACETAMINOP/GG MUCINEX COUGH GUAIFENESIN/DEXTROMETHORPHAN MUCINEX DM GUAIFENESIN/DEXTROMETHORPHAN MUCINEX FAST‐MAX COLD‐FLU‐THRT PHENYLEPHRINE/DM/ACETAMINOP/GG MUCINEX FAST‐MAX CONGEST‐COUGH GUAIFEN/DEXTROMETHORPHAN/PE MUCINEX FAST‐MAX DM MAX GUAIFENESIN/DEXTROMETHORPHAN MUCINEX FAST‐MAX SEVERE COLD PHENYLEPHRINE/DM/ACETAMINOP/GG NOHIST‐DM CHLORPHENIRAMINE/PHENYLEPH/DM PEDIATRIC COUGH‐COLD CHLORPHENIRAMIN/PSEUDOEPHED/DM POLY‐HIST DM THONZYLAMINE/PHENYLEPHRINE/DM POLY‐HIST PD THONZYLAMINE/CHLOPHEDIANOL POLY‐VENT DM GUAIFENESIN/DM/PSEUDOEPHEDRINE PROMETHAZINE‐DM PROMETHAZINE/DEXTROMETHORPHAN Q‐TUSSIN DM GUAIFENESIN/DEXTROMETHORPHAN RESCON‐DM CHLORPHENIRAMIN/PSEUDOEPHED/DM ROBAFEN DM COUGH GUAIFENESIN/DEXTROMETHORPHAN ROBAFEN DM COUGH‐CHEST CONGEST GUAIFENESIN/DEXTROMETHORPHAN ROBAFEN‐DM GUAIFENESIN/DEXTROMETHORPHAN RYNEX DM BROMPHENIRAM/PHENYLEPHRINE/DM SILTUSSIN DM GUAIFENESIN/DEXTROMETHORPHAN SILTUSSIN DM DAS COUGH FORMULA GUAIFENESIN/DEXTROMETHORPHAN TUSSIN DM GUAIFENESIN/DEXTROMETHORPHAN VANACOF DEXCHLORPHENIR/PSE/CHLOPHEDIAN VANACOF DM GUAIFEN/DEXTROMETHORPHAN/PE

Cough and Cold (Narcotic) Preferred Agents Non‐Preferred Agents PA CRITERIA Agent Ingredients Agent Ingredients CHERATUSSIN AC CODEINE PHOSPHATE/GUAIFENESIN CHERATUSSIN DAC PSEUDOEPHED/CODEINE/GUAIFEN All products restricted to patients aged 2 years and above CODEINE‐GUAIFENESIN CODEINE PHOSPHATE/GUAIFENESIN FLOWTUSS GUAIFENESIN/HYDROCODONE GUAIFENESIN AC CODEINE PHOSPHATE/GUAIFENESIN HYCOFENIX HYDROCODONE/PSEUDOEPHED/GUAIF GUAIFENESIN‐CODEINE CODEINE PHOSPHATE/GUAIFENESIN HYDROCOD‐CPM‐PSEUDOEPHEDRINE HYDROCODONE/CPM/PSEUDOEPHED IOPHEN‐C NR CODEINE PHOSPHATE/GUAIFENESIN HYDROCODONE‐CHLORPHENIRAMNE ER HYDROCODONE/CHLORPHEN P‐STIREX PROMETHAZINE‐CODEINE PROMETHAZINE HCL/CODEINE HYDROCODONE‐HOMATROPINE MBR HYDROCODONE BIT/HOMATROP ME‐BR VIRTUSSIN AC CODEINE PHOSPHATE/GUAIFENESIN HYDROMET HYDROCODONE BIT/HOMATROP ME‐BR Cough and Cold Products subject to PA LORTUSS EX PSEUDOEPHED/CODEINE/GUAIFEN NINJACOF‐XG CODEINE PHOSPHATE/GUAIFENESIN PHENYLHISTINE DH PSEUDOEPHED/COD/CHLORPHENIR PROMETHAZINE VC‐CODEINE PROMETHAZINE/PHENYLEPH/CODEINE PROMETHAZINE‐PHENYLEPH‐CODEINE PROMETHAZINE/PHENYLEPH/CODEINE REZIRA PSEUDOEPHED/HYDROCODONE TUSSIONEX HYDROCODONE/CHLORPHEN P‐STIREX VIRTUSSIN DAC PSEUDOEPHED/CODEINE/GUAIFEN ZUTRIPRO HYDROCODONE/CPM/PSEUDOEPHED

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

Prenatal Vitamins Preferred Agents Non‐Preferred Agents Agent Ingredients Agent Ingredients CITRANATAL 90 DHA PNV72/IRON,GLUC/FOLIC/DSS/DHA CITRANATAL B‐CALM PRENATAL 48/IRON/FOLIC ACID/B6 CITRANATAL ASSURE PNV73/IRON,GLUC/FOLIC/DSS/DHA OB COMPLETE PRENATAL NO.123/IRON/FOLIC AC CITRANATAL HARMONY PNV59/IRON,CARB,FUM/FA/DSS/DHA OB COMPLETE PETITE PRENATAL56/IRON/FOLIC ACID/DHA PROVIDA OB PRENATAL VIT 65/IRON FUM,PS/FA PRENATE AM PRENATAL VIT114/FOLATE6/GINGER SELECT‐OB + DHA PRENATAL VIT 33/IRON/FOLIC/DHA PRENATE CHEWABLE PRENATAL VIT NO.112/FOLATE NO6 TRICARE PRENATAL VIT103/IRON FUM/FOLIC PRENATE DHA PRENATAL 78/IRON/FOLATE 1/DHA TRINATAL RX 1 PRENATAL VIT27,CALCIUM/IRON/FA PRENATE ELITE PRENATAL 114/IRON A‐G/FOLATE 1 VITAFOL NANO PRENATAL NO.75/IRON/FOLATE NO1 PRENATE ENHANCE PRENATAL VIT68/IRON/FA NO6/DHA VITAFOL ULTRA PNV 67/IRON PS/FOLATE NO.1/DHA PRENATE ESSENTIAL PRENATAL VIT 84/IRON/FA 1/DHA VITAFOL‐OB+DHA PRENATAL VIT 10/IRON/FOLIC/DHA PRENATE MINI PRENATAL VIT 87/IRON/FOLIC/DHA VITAFOL‐ONE PRENATAL 26/IRON PS/FOLIC/DHA PRENATE PIXIE PRENATAL VIT 85/IRON/FA 1/DHA VOL‐PLUS PRENATAL VIT,CAL 74/IRON/FOLIC PRENATE RESTORE PRENATAL VIT69/IRON/FOLATE6/DH PRENATE STAR PRENATAL NO.77/IRON ASP GLY/FA SELECT‐OB PRENATAL VITS/IRON/FOLIC ACID ACTIVE OB PNV NO.66/IRON,CARB/FOLIC/DHA COMPLETE NATAL DHA PRENATAL 2/IRON/FOLIC ACID/OM3 COMPLETENATE PRENATAL VIT 14/IRON FUM/FOLIC CONCEPT DHA PNV 16/IRON FUM,PS/FOLIC/OM‐3 CONCEPT OB PNV 15/IRON FUM,PS/FOLIC ACID DOTHELLE DHA PNV 16/IRON FUM,PS/FOLIC/OM‐3 ELITE‐OB PRENATAL NO.123/IRON/FOLIC AC EXTRA‐VIRT PLUS DHA PRENATAL 57/IRON/FOLIC/DSS/DHA FOCALGIN 90 DHA PNV72/IRON,GLUC/FOLIC/DSS/DHA FOCALGIN CA PNV73/IRON,GLUC/FOLIC/DSS/DHA FOLIVANE‐OB PNV 15/IRON FUM,PS/FOLIC ACID NESTABS PRENATAL VIT86/IRON/FOLIC ACID NESTABS ABC PRENATAL 86/IRON/FOLIC/DHA/EPA NESTABS DHA PRENATAL 87/IRON BIS/FOLIC/DHA NEXA PLUS PNV53/IRON FUM/FA/DOCUSATE/DHA OB COMPLETE GOLD PNV NO.106/IRON/FOLATE NO6/DHA OB COMPLETE ONE PNV 85/IRON/FOLIC/DHA/FISH OIL OB COMPLETE PREMIER PNV83/IRON,CARB,ASP/FOLIC ACID PR NATAL 400 PRENATAL 53/IRON/FOLIC AC/OMG3 PR NATAL 400 EC PNV19/IRON BG,S.P/FOLIC AC/OM3 PR NATAL 430 EC PRENATAL VIT 55/IRON/FOLIC/OM3 PREFERA‐OB ONE PNV 19/IRON PS,HEME/FOLIC/DHA PROVIDA DHA PRENAT90/IRON FUM,PS/FOLIC/DHA RELNATE DHA PNV 11/IRON FUM/FOLIC ACID/OM3 RULAVITE DHA PRENATAL 47/IRON/FOLATE 1/DHA SE‐NATAL 19 PNV119/IRON FUM/FOLIC/DOCUSATE SE‐NATAL 19 PNV NO.118/IRON FUMARATE/FA TARON‐C DHA PNV 16/IRON FUM,PS/FOLIC/OM‐3 THRIVITE 19 PNV119/IRON FUM/FOLIC/DOCUSATE THRIVITE RX PRENATAL VIT,CALC76/IRON/FOLIC TRICARE PRENATAL DHA ONE PNV20/IRON/FOLIC/DOCUSATE/OM3S TRINATAL GT PRENATAL VITS16/IRON/FOLIC/DSS TRISTART DHA PRENATAL 93/IRON/FOLATE 9/DHA TRIVEEN‐DUO DHA PRENATAL 53/IRON/FOLIC AC/OMG3 ULTIMATECARE ONE PNV,CALCIUM37/IRON/FOLIC/OMEG3 VIRT‐SELECT PNV 80/IRON FUM/FOLIC/DSS/DHA VITAFOL‐OB PRENATAL VIT 10/IRON FUM/FOLIC VOL‐NATE PRENATAL VIT,CAL 73/IRON/FOLIC VOL‐TAB RX PRENATAL VIT,CALC76/IRON/FOLIC VP‐CH‐PNV PRENATAL 34/IRON/FOLIC/DSS/DHA VP‐GGR‐B6 PNV/FOLIC AC/B6/CALCIUM/GINGER VP‐HEME OB PNV 21/IRON PS,HEME PPEP/FOLIC VP‐HEME ONE PNV 19/IRON PS,HEME/FOLIC/DHA VP‐PNV‐DHA PRENATAL NO.52/IRON/FA/DHA ZATEAN‐CH PNV 69/IRON/FOLIC/DOCUSATE/DHA ZATEAN‐PN DHA PRENATAL 47/IRON/FOLATE 1/DHA ZATEAN‐PN PLUS PRENATAL 68/IRON/FOLIC NO1/DHA

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

Iron Oral Agents Preferred Agents Non‐Preferred Agents Agent Ingredients Agent Ingredients CENTRATEX IRON FUM/FOLIC ACID/MV,MIN 15 ACTIVE FE IRON,CARBONYL/FOLIC ACID/MV‐MN FERATE FERROUS GLUCONATE FERIVA FA IRON/FOLAT6/C/B12/BIOT/COP/DSS FERGON FERROUS GLUCONATE FERIVA FA IRON/FOLAT1/C/B12/BIOT/DOCUSAT FERRALET 90 IRON CARB,GL/FA/B12/C/DOCUSATE FERRAPLUS 90 IRON/FOLIC ACID/B12/C/DOCUSATE HEMOCYTE PLUS IRON FUM/FOLIC ACID/MV,MIN 15 FOCALGIN DSS IRON CARB,GL/FA/B12/C/DOCUSATE HEMOCYTE‐F FERROUS FUMARATE/FOLIC ACID FUSION PLUS IRON,FM,PS/FOLIC/B,C18/L.CASEI INTEGRA IRON FUM,PS CMP/VIT C/NIACIN POLY‐IRON 150 FORTE IRON PS COMPLEX/B12/FOLIC ACID INTEGRA F IRON FUM,PS/FOLIC ACID/VITC/B3 TARON FORTE IRON BG,PS/VITC/B12/FA/CALCIUM INTEGRA PLUS IRON FUM,PS/FOLIC/BCOMP,C NO.9 IROSPAN IRON BG,PS/FOLIC/B,C NO.12/SUC NEPHRON FA IRON FUM/DOCUSAT/FOLIC/BCOMP,C SE‐TAN PLUS IRON FM,PS NO.1/FOLIC/MV NO.18 TANDEM DUAL ACTION FERROUS FUMARATE/IRON PS CPLX TANDEM PLUS IRON FM,PS NO.1/FOLIC/MV NO.18