August 2021 Molina Healthcare of Michigan Preferred Drug List (Formulary) •• 1 Non-Discrimination Notification ill~!?r~~~ Molina Healthcare of Michigan Your Extended FamilJI Medicaid Molina Healthcare of Michigan (Molina) complies with all Federal civil rights laws that relate to healthcare services. Molina offers healthcare services to all members without regard to race, color, national origin, age, disability, or sex. Molina does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Thi s includes gender identity, pregnancy and sex stereotyping. To help you talk with us, Molina provides services free of cha rge: • Aids and services to people with disabilities o Skilled sign language interpreters o Written material in other formats (large print, audio, accessible electronic formats, Braille) • Language services to people who speak another la nguage or have limited English skills o Skilled interpreters o Written material translated in your language o Material that is simply written in plain language If you need these services, contact Molina Member Services at (888) 898-7969. Hearing Impaired: Ml Relay (800) 649-3777 or 711. If you think that Molina failed to provide these services or treated you differently based on your race, color, national origin, age, disability, or sex, you can file a complaint. You can file a complaint in person, by mail, fax, or email. If you need help writing your complaint, we w ill help you. Ca ll our Civil Ri ght s Coordinator at (866) 606-3889, or TTY, 711. Mail your complaint to: Civil Rights Coordinator 200 Oceangate Long Beach, CA 90802 You can also email your complaint to [email protected]. Or, fax your complaint to (248) 925-1765. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights. Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. You can mail it to: U.S. Department of Hea lth and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 You can also send it to a website through the Office for Civi l Rights Complaint Portal, ava ilable at https ://ocrporta l. hhs.gov/ocr /portal/lobby. jsf. If you need help, call 1-800-368-1019; TTY 800-537-7697. M olina Healthcare Notice 1557 - M l M edicaid Updated 10.14.16 •• 1 Non-Discrimination Tag Line- Section 1557 i))Mflr~~~ Molina Healthcare of Michigan, Inc. Your Extended F~ Medicaid English ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-888-898- 7969 (TTY: 711). Spanish ATENCION: si habla espaiiol, tiene a su disposici6n servicios gratuitos de asistencia lingiiistica. Llame al 1-888-898-7969 (TTY: 711). Arabic f-2Y. J..,.,:il .u~l, ~ _)lfo :i..,;y.lll o.lc-W\ wl...~ l)~ ,Wll _foj\ ~ ~ 1:i,1 ::U._,,.J... .(711 :/4IJ ~I <....:ii.A f-2..;) 1-888-898-7969 Chinese 5±~ : :ittl*fif~ffl~R g:ix , tioJ ~~-311~~13~J:tJJ§a~ 0 §~ i~~ 1-888-898-7969 ( TTY : 711 ) 0 Syriac «~ '9~:-. '9~_? ,,<;;;a&\r< ~ '9~~~ ~ '9~~ ,~ :«;m9, ~ -4- '9'\C -~~ ~ r<X:.\.~:-. 1-888-898-7969 (TTY: 711) Vietnamese CHU Y: NSu b~n n6i TiSng Vi~t, c6 cac djch vv h6 trq ng6n ngfr miSn phi danh cho b~n. Gqi s6 1-888-898-7969 (TTY: 711). Albanian KUJDES: Nese flitni shqip, per ju ka ne dispozicion sherbime te asistences gjuhesore, pa pagese. Telefononi ne 1-888-898-7969 (TTY: 711). Korean 4~: e1;:;o,~ Af~ofAI~ ~~. ~o, ::i::1~ A-HJI A ~ ~fi~ 01~of~ 4 'x.!.;;:;;uo . 1- 888-898-7969 (TTY: 711) ~o~ ~~Jo~ 4~Al2. Bengali "f5$1" ~: ~ ~~ <TT~"TT, <!>"'<IT ~ ~, ~ M:"-mIB ~ ~ ~ t~ ~I C~ ~ 1-888-898-7969 (TTY: 711) I Polish UWAGA: Jezeli m6wisz po polsku, mozesz skorzystac z bezplatnej pomocy j.;zykowej. Zadzwon pod numer 1-888-898-7969 (TTY: 711 ). German ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfugung. Rufnummer: 1-888-898-7969 (TTY: 711). Italian ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare ii numero 1-888-898-7969 (TTY: 711). Japanese 3.1~:f;:i:Ji : E3:.$:~B~~li~.no@~~, 1ftt;j!,j.O) ~ ~B~fi~ ~f!Jffl L'f=f::lt*-t o 1-888-898-7969 (TTY: 711) *--c', i61lr~lil:."'C~i.IM!-(t::~L'o Russian BHHMAHHE: EcJIH Bbl roBopHTe Ha pyccKoM ~3b!Ke, TO BaM ;:iocryrrnu 6ecrmaTHhre ycJiyrH rrepeBo;:ia. 3BOHHTe 1-888-898-7969 (TeJieraiirr: 711 ). Serbo­ OBAVJESTENJE: Ako govorite srpsko-hrvatski, usluge jezicke pomoci dostupne su vam Croatian besplatno. Nazovite 1-888-898-7969 (TTY- Telefon za osobe sa ostecenim govorom iii sluhom: 711). Tagalog P AUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-888-898-7969 (TTY: 711 ). MHMI - 1557 tag lines_v4 Created 10/14/16, rev 12/14/16 Table of Contents INTRODUCTION ........................................................................................12 PREFACE ..............................................................................................12 PHARMACY AND THERAPEUTICS (P&T) COMMITTEE ...............................................12 DRUG LIST PRODUCT DESCRIPTIONS ................................................................13 GENERIC SUBSTITUTION ..............................................................................13 PLAN DESIGN ..........................................................................................13 CATEGORIES OF CONSIDERATION ...................................................................13 PRIOR AUTHORIZATION REQUEST PROCEDURE ....................................................13 PRIOR AUTHORIZATION HELPFUL HINTS ............................................................14 LEGEND ................................................................................................14 .........................................................................................................14 REQUESTING FORMULARY CHANGES ...............................................................14 .........................................................................................................14 STATE OF MICHIGAN, MEDICAID CARVE-OUT .......................................................14 NON-COVERED MEDICATIONS ........................................................................18 URGENT AND AFTER-HOURS MEDICATION POLICY .................................................18 NOTICE .................................................................................................18 ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS - DRUGS TO TREAT NERVOUS SYSTEM DISORDERS .........................................19 ANALEPTICS .....................................................................................19 ALLERGENIC EXTRACTS/BIOLOGICALS MISC - DRUGS FOR ALLERGIES .........................................................................................................19 ALLERGENIC EXTRACTS .....................................................................19 ALTERNATIVE MEDICINES - COMPLEMENTARY AND ALTERNATIVE MEDICINES .......................................................................................19 ALTERNATIVE MEDICINE - M'S ............................................................19 AMINOGLYCOSIDES - DRUGS TO TREAT INFECTIONS .......................19 AMINOGLYCOSIDES - DRUGS TO TREAT INFECTIONS ............................19 ANALGESICS - ANTI-INFLAMMATORY - DRUGS TO TREAT PAIN AND INFLAMMATION CONDITIONS ...........................................................20 ANTI-TNF-ALPHA - MONOCLONAL ANTIBODIES .....................................20 ANTIRHEUMATIC - ENZYME INHIBITORS ..............................................20 INTERLEUKIN-6 RECEPTOR INHIBITORS ..............................................20 NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS) ......................20 PHOSPHODIESTERASE 4 (PDE4) INHIBITORS .......................................23 PYRIMIDINE SYNTHESIS INHIBITORS ..................................................23 SELECTIVE COSTIMULATION MODULATORS ..........................................24 SOLUBLE TUMOR NECROSIS FACTOR RECEPTOR AGENTS .......................24 ANALGESICS - NONNARCOTIC ...........................................................24 ANALGESIC COMBINATIONS ...............................................................24 ANALGESICS OTHER ..........................................................................24 SALICYLATES ...................................................................................24 ANALGESICS - OPIOID - DRUGS TO TREAT PAIN ...............................25 OPIOID AGONISTS ............................................................................25 OPIOID COMBINATIONS ....................................................................30 OPIOID PARTIAL AGONISTS ...............................................................32 1 ANDROGENS-ANABOLIC - DRUGS TO REGULATE MALE HORMONES ...32 ANDROGENS ....................................................................................32 ANORECTAL AND RELATED PRODUCTS ..............................................33 RECTAL STEROIDS ............................................................................33 ANTACIDS - DRUGS FOR ULCERS AND STOMACH ACID ......................33 ANTACID COMBINATIONS ..................................................................33 ANTACIDS - ALUMINUM SALTS ...........................................................34 ANTACIDS - BICARBONATE ................................................................34