Molina Healthcare of Michigan Preferred Drug List (Formulary) (10/01/2019) 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 ...................................................................................................................................................................................................5 STATE OF MICHIGAN, MEDICAID CARVE-OUT ......................................................................................................................................................................................6 STATE OF MICHIGAN, MEDICAID CARVE-OUT LIST .............................................................................................................................................................................6 NON-COVERED MEDICATIONS ................................................................................................................................................................................................................8 NOTICE ........................................................................................................................................................................................................................................................8 FORMULARY UPDATES ............................................................................................................................................................................................................................9 ANALGESICS ............................................................................................................................................................................................................................................10 NSAIDs ............................................................................................................................................................................................................................................10 NSAIDs, TOPICAL ...........................................................................................................................................................................................................................10 COX-2 INHIBITORS.........................................................................................................................................................................................................................10 GOUT ...............................................................................................................................................................................................................................................10 OPIOID ANALGESICS ....................................................................................................................................................................................................................10 NON-OPIOID ANALGESICS ...........................................................................................................................................................................................................11 VISCOSUPPLEMENTS ...................................................................................................................................................................................................................11 ANTI-INFECTIVES .....................................................................................................................................................................................................................................11 ANTIBACTERIALS...........................................................................................................................................................................................................................11 ANTIFUNGALS ................................................................................................................................................................................................................................12 ANTIMALARIALS .............................................................................................................................................................................................................................13 ANTIRETROVIRAL AGENTS ..........................................................................................................................................................................................................13 ANTITUBERCULAR AGENTS .........................................................................................................................................................................................................13 ANTIVIRALS ....................................................................................................................................................................................................................................13 MISCELLANEOUS...........................................................................................................................................................................................................................13 ANTINEOPLASTIC AGENTS ....................................................................................................................................................................................................................14 ALKYLATING AGENTS ...................................................................................................................................................................................................................14 ANTIMETABOLITES ........................................................................................................................................................................................................................14 CYTOPROTECTIVE AGENTS ........................................................................................................................................................................................................14 HORMONAL ANTINEOPLASTIC AGENTS ....................................................................................................................................................................................14 IMMUNOMODULATORS .................................................................................................................................................................................................................15 KINASE INHIBITORS ......................................................................................................................................................................................................................15 TOPOISOMERASE INHIBITORS ....................................................................................................................................................................................................15 MISCELLANEOUS...........................................................................................................................................................................................................................15 CARDIOVASCULAR..................................................................................................................................................................................................................................15