April 2017 Molina Healthcare of Michigan Preferred Drug List (Formulary) Molina Healthcare of Michigan Preferred Drug List (Formulary) (04/01/2017) INTRODUCTION ..........................................................................................................................................................................................................................................4 PREFACE .....................................................................................................................................................................................................................................................4 PHARMACY AND THERAPEUTICS (P&T) COMMITTEE ..........................................................................................................................................................................4 DRUG LIST PRODUCT DESCRIPTIONS ...................................................................................................................................................................................................4 GENERIC SUBSTITUTION ..........................................................................................................................................................................................................................4 PLAN DESIGN .............................................................................................................................................................................................................................................5 PRIOR AUTHORIZATION REQUEST PROCEDURE .................................................................................................................................................................................5 PRIOR AUTHORIZATION HELPFUL HINTS ..............................................................................................................................................................................................5 LEGEND .......................................................................................................................................................................................................................................................5 REQUESTING FORMULARY CHANGES ...................................................................................................................................................................................................6 STATE OF MICHIGAN, MEDICAID CARVE-OUT ......................................................................................................................................................................................6 STATE OF MICHIGAN, MEDICAID CARVE-OUT LIST .............................................................................................................................................................................7 NON-COVERED MEDICATIONS ................................................................................................................................................................................................................8 NOTICE ........................................................................................................................................................................................................................................................8 ANALGESICS ..............................................................................................................................................................................................................................................9 NSAIDs ..............................................................................................................................................................................................................................................9 COX-2 INHIBITORS...........................................................................................................................................................................................................................9 GOUT .................................................................................................................................................................................................................................................9 OPIOID ANALGESICS ......................................................................................................................................................................................................................9 NON-OPIOID ANALGESICS ...........................................................................................................................................................................................................10 VISCOSUPPLEMENTS ...................................................................................................................................................................................................................10 ANTI-INFECTIVES .....................................................................................................................................................................................................................................10 ANTIBACTERIALS...........................................................................................................................................................................................................................10 ANTIFUNGALS ................................................................................................................................................................................................................................11 ANTIMALARIALS .............................................................................................................................................................................................................................12 ANTIRETROVIRAL AGENTS ..........................................................................................................................................................................................................12 ANTITUBERCULAR AGENTS .........................................................................................................................................................................................................12 ANTIVIRALS ....................................................................................................................................................................................................................................12 MISCELLANEOUS...........................................................................................................................................................................................................................12 ANTINEOPLASTIC AGENTS ....................................................................................................................................................................................................................13 ALKYLATING AGENTS ...................................................................................................................................................................................................................13 ANTIMETABOLITES ........................................................................................................................................................................................................................13 CYTOPROTECTIVE AGENTS ........................................................................................................................................................................................................13 HORMONAL ANTINEOPLASTIC AGENTS ....................................................................................................................................................................................13 IMMUNOMODULATORS .................................................................................................................................................................................................................14 KINASE INHIBITORS ......................................................................................................................................................................................................................14 TOPOISOMERASE INHIBITORS ....................................................................................................................................................................................................14 MISCELLANEOUS...........................................................................................................................................................................................................................14 CARDIOVASCULAR..................................................................................................................................................................................................................................14 ACE INHIBITORS ............................................................................................................................................................................................................................14 ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS