January 2020 Molina Healthcare of Michigan Preferred Drug List (Formulary) 1 Molina Healthcare of Michigan Preferred Drug List (Formulary) (01/01/2020) INTRODUCTION ..........................................................................................................................................................................................................................................5 PREFACE .....................................................................................................................................................................................................................................................5 PHARMACY AND THERAPEUTICS (P&T) COMMITTEE ..........................................................................................................................................................................5 DRUG LIST PRODUCT DESCRIPTIONS ...................................................................................................................................................................................................5 GENERIC SUBSTITUTION ..........................................................................................................................................................................................................................5 PLAN DESIGN .............................................................................................................................................................................................................................................6 PRIOR AUTHORIZATION REQUEST PROCEDURE .................................................................................................................................................................................6 PRIOR AUTHORIZATION HELPFUL HINTS ..............................................................................................................................................................................................6 LEGEND .......................................................................................................................................................................................................................................................6 REQUESTING FORMULARY CHANGES ...................................................................................................................................................................................................6 STATE OF MICHIGAN, MEDICAID CARVE-OUT ......................................................................................................................................................................................7 STATE OF MICHIGAN, MEDICAID CARVE-OUT LIST .............................................................................................................................................................................7 NON-COVERED MEDICATIONS ................................................................................................................................................................................................................9 NOTICE ........................................................................................................................................................................................................................................................9 FORMULARY UPDATES ..........................................................................................................................................................................................................................10 ANALGESICS ............................................................................................................................................................................................................................................11 NSAIDs ............................................................................................................................................................................................................................................11 NSAIDs, TOPICAL ...........................................................................................................................................................................................................................11 COX-2 INHIBITORS.........................................................................................................................................................................................................................11 GOUT ...............................................................................................................................................................................................................................................11 OPIOID ANALGESICS ....................................................................................................................................................................................................................11 NON-OPIOID ANALGESICS ...........................................................................................................................................................................................................12 VISCOSUPPLEMENTS ...................................................................................................................................................................................................................12 ANTI-INFECTIVES .....................................................................................................................................................................................................................................12 ANTIBACTERIALS...........................................................................................................................................................................................................................12 ANTIFUNGALS ................................................................................................................................................................................................................................13 ANTIMALARIALS .............................................................................................................................................................................................................................14 ANTIRETROVIRAL AGENTS ..........................................................................................................................................................................................................14 ANTITUBERCULAR AGENTS .........................................................................................................................................................................................................14 ANTIVIRALS ....................................................................................................................................................................................................................................14 MISCELLANEOUS...........................................................................................................................................................................................................................14 ANTINEOPLASTIC AGENTS ....................................................................................................................................................................................................................15 ALKYLATING AGENTS ...................................................................................................................................................................................................................15 ANTIMETABOLITES ........................................................................................................................................................................................................................15 CYTOPROTECTIVE AGENTS ........................................................................................................................................................................................................15 HORMONAL ANTINEOPLASTIC AGENTS ....................................................................................................................................................................................15 IMMUNOMODULATORS .................................................................................................................................................................................................................16 KINASE INHIBITORS ......................................................................................................................................................................................................................16 TOPOISOMERASE INHIBITORS ....................................................................................................................................................................................................16 MISCELLANEOUS...........................................................................................................................................................................................................................16 CARDIOVASCULAR..................................................................................................................................................................................................................................16