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Preferred Drug List

 

 


MISSISSIPPI DIVISION OF
MEDICAID

UNIVERSAL PREFERRED DRUG
LIST

 

EFFECTIVE
7/01/2025

VERSION
2025_7

Updated
7/30/2025

 

 

General Preferred Drug List Information

 

·      
Gainwell
Technologies DUR+ process is a proprietary electronic prior authorization
system used for Medicaid pharmacy claims.

 

·      
Drug coverage subject to the rules
and regulations set forth in Sec. 1927 of Social Security Act. This is not an all-inclusive list of
available covered drugs and includes only managed categories. Unless
otherwise stated, the listing of a particular brand or generic name includes
all dosage forms of that drug. NR indicates a new drug that has not yet been
reviewed by the P&T Committee.

 

·      
PREFERRED BRANDS will not count toward the two-brand monthly Rx Limit.

 

·      
Drugs highlighted in yellow denote change in PDL status.

 

·      
To search the PDL, press CTRL + F.

 

 

 

 

Medication
Coverage Status Search Tool – Pharmacy Drug Coverage Inquiry

 

ACNE AGENTS

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

ANTI-INFECTIVES

Maximum Age
Limit

·  21
years: all acne agents except isotretinoin products

 

Topical
Clindamycin 1% lotion

·  21
years and older AND

·  Documented diagnosis of hidradenitis suppurativa

 

Note:

Isotretinoin products
available for all ages

Clindamycin 1% lotion only
available for ages 21 years and older with approvable diagnosis

Preferred clindamycin 1%
lotion for ages < 21 years does not require PA

 

 

 

clindamycin gel (generic CLEOCIN-T)

azelaic acid

clindamycin lotion, medicated swab, solution

CLEOCIN T
(clindamycin)

 

CLINDACIN
(clindamycin)

 

CLINDAGEL
(clindamycin)

 

clindamycin foam

 

clindamycin gel
(generic CLINDAGEL)

 

dapsone

 

ERY (erythromycin)

 

ERYGEL (erythromycin)

 

erythromycin

 

EVOCLIN (clindamycin)

 

KLARON (sulfacetamide)

 

MORGIDOX
(doxycycline)

 

sulfacetamide sodium
suspension

 

WINLEVI
(clascoterone) cream

ISOTRETINOIN PRODUCTS

AMNESTEEM (isotretinoin)

ABSORBICA
(isotretinoin)

CLARAVIS (isotretinoin)

isotretinoin

ZENATANE (isotretinoin)

 

KERATOLYTICS (BENZOYL
PEROXIDES)

ACNE MEDICATION (benzoyl peroxide)

BPO towelette (benzoyl peroxide)

benzoyl peroxide

 

LINTERA (benzoyl peroxide)

 

RETINOIDS

adapalene
gel, gel with pump

adapalene cream

RETIN-A (tretinoin)

AKLIEF (trifarotene)

tretinoin cream

ALTRENO (tretinoin)

 

ARAZLO (tazarotene)

 

ATRALIN (tretinoin)

 

DIFFERIN (adapalene)

 

FABIOR (tazarotene)

 

RETIN-A MICRO
(tretinoin)

 

RETIN-A MICRO PUMP
(tretinoin)

 

tretinoin gel

 

tretinoin microsphere

OTHERS/COMBINATION PRODUCTS

adapalene/benzoyl
peroxide gel

ACANYA (benzoyl
peroxide/clindamycin) gel

clindamycin/benzoyl
peroxide 1%-5% gel w/pump

CABTREO (clindamycin/adapalene/benzoyl
peroxide) gel

sodium sulfacetamide
w/sulfur 8%-4%, 9%-4.25%, 10-5% suspension

CLEANSING WASH
(sulfacetamide sodium/sulfur/urea) cleanser

 

clindamycin
phosphate/benzoyl peroxide 1.2%-2.5% gel

 

clindamycin
phosphate/tretinoin 1.2%-0.025% gel

 

clindamycin/benzoyl
peroxide 1%-5% gel

 

clindamycin/benzoyl
peroxide 1.2%-3.75% gel w/pump (generic ONEXTON)

 

EPIDUO FORTE
(adapalene/benzoyl peroxide) gel

 

erythromycin/benzoyl
peroxide gel

 

NEUAC (benzoyl
peroxide/clindamycin) cream, gel

 

ONEXTON (benzoyl
peroxide/clindamycin) gel

 

sodium sulfacetamide
w/sulfur 8%-4% cleanser

 

sodium sulfacetamide
w/sulfur 10%-2% cream

 

sodium sulfacetamide
w/sulfur 10%-5% cream, lotion

 

SSS (sodium
sulfacetamide/sulfur)10-5 cream, foam

 

TWYNEO (benzoyl
peroxide/tretinoin) cream

 

ZIANA
(clindamycin/tretinoin) gel

 

ZMA CLEAR (sodium sulfacetamide/sulfur)
suspension

ALPHA-1 PROTEINASE INHIBITORS

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

ARALAST NP

 

 

GLASSIA

 

PROLASTIN C

 

ZEMAIRA

 

ALZHEIMER’S AGENTS DUR+

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

CHOLINESTERASE INHIBITORS

Preferred Criteria

·  Documented approvable diagnosis

 

Non-Preferred Criteria

·  Documented approvable diagnosis AND

 

·  Have tried 2
different preferred agents in the past 6 months

 

NAMZARIC

·  Requires
clinical review

 

ZUNVEYL

·  Requires clinical
review

donepezil 5 mg, 10 mg
ODT, tablets

ADLARITY (donepezil)

galantamine

ARICEPT (donepezil)

galantamine ER

donepezil 23 mg
tablet

rivastigmine

EXELON (rivastigmine)

 

Zunveyl
(benzgalantamine gluconate)NR

NMDA RECEPTOR ANTAGONISTS

memantine

memantine ER

 

NAMENDA (memantine)

 

NAMENDA XR (memantine
ER)

COMBINATION AGENTS

 

NAMZARIC
(memantine/donepezil)

 

memantine/donepezil
ER

ANALGESICS, OPIOID-SHORT
ACTING DUR+

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

acetaminophen/caffeine/dihydrocodeine

ACTIQ (fentanyl)

MS DOM Opioid Initiative Criteria
details found here

·  Morphine Equivalent Daily Dose

·  Concomitant use of Opioids and Benzodiazepines

 

Minimum Age Limit

·  18 years:
codeine-containing products and tramadol-containing products

 

Quantity Limit (per 31 rolling days)

·      
62 tablets: butalbital/codeine combinations,
codeine combinations, dihydrocodeine combinations, fentanyl, hydrocodone,
hydromorphone, levorphanol, meperidine, morphine, oxycodone, oxymorphone,
pentazocine, tapentadol, tramadol

·      
186 tablets:
butalbital/acetaminophen, butalbital/aspirin

·      
5 mL: butorphanol nasal

·      
180 mL: oxycodone liquid

·      
280 mL: QDOLO

 

Non-Preferred Criteria

·        
Have tried 2 different preferred agents in the
past 6 months

 

MS DOM Opioid Initiative Criteria
details found here

·  Morphine Equivalent Daily Dose

·  Concomitant use of Opioids and Benzodiazepines

 

Minimum Age Limit

·  18 years:
BUTRANS and tramadol-containing products

 

 

acetaminophen/codeine

aspirin/butalbital/caffeine/codeine

codeine

butalbital/acetaminophen/caffeine/codeine

ENDOCET
(oxycodone/acetaminophen)

butorphanol

hydrocodone/acetaminophen

DILAUDID
(hydromorphone)

hydromorphone

fentanyl citrate

morphine sulfate

FENTORA (fentanyl)

oxycodone

FIORICET W/CODEINE
(butalbital/acetaminophen/codeine)

oxycodone/acetaminophen
(325 mg acetaminophen formulations)

hydrocodone/ibuprofen

tramadol 50 mg tablet

meperidine

tramadol/acetaminophen

NALOCET (oxycodone/acetaminophen)

 

levorphanol

 

oxymorphone

 

pentazocine/naloxone

 

PERCOCET
(oxycodone/acetaminophen)

 

PROLATE
(oxycodone/acetaminophen)

 

ROXICODONE
(oxycodone)

 

ROXYBOND (oxycodone)

 

SEGLENTIS (tramadol/celecoxib)

 

tramadol 25 mg, 75
mg, 100 mg tablet

 

tramadol solution

ANALGESICS, OPIOID-LONG ACTING DUR+

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

BUTRANS
(buprenorphine)

BELBUCA
(buprenorphine)

Quantity Limit (per 31 rolling days)

·  31 tablets: AVINZA, hydromorphone ER, HYSINGLA ER,
tramadol ER

·  62 tablets: methadone, morphine ER, OXYCONTIN,
oxymorphone ER, ZOHYDRO ER

·  62 films:
BELBUCA

·  10 patches: fentanyl

·  4 patches: BUTRANS

 

Non-Preferred Criteria

· 
Have tried 2 preferred agents in the past 6
months

 

fentanyl patch

buprenorphine patch

morphine sulfate ER
tablet

CONZIP (tramadol)

 

hydrocodone
bitartrate ER

 

hydromorphone ER

 

HYSINGLA ER
(hydrocodone)

 

methadone

 

methadone intensol

 

METHADOSE (methadone)

 

morphine sulfate ER
capsule

 

MS CONTIN (morphine)

 

oxycodone ER

 

OXYCONTIN (oxycodone)

 

oxymorphone ER

 

tramadol ER

ANALGESICS/ANESTHETICS (TOPICAL)

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

diclofenac 1%, 3% gel

DERMACINRX LIDOCAN
(lidocaine)

Quantity Limit (per
31 days)

·  1 bottle (112 mL): diclofenac 2% solution pump

·  1 bottle (150 mL): diclofenac 1.5% solution

 

 

Non-Preferred
Criteria

·  Have tried 2 preferred
agents in the past 6 months

 

Lidocaine
5% Patch

· 
Documented diagnosis of Herpetic Neuralgia OR

· 
Documented diagnosis of Diabetic Neuropathy

 

ZTLIDO

·  Documented diagnosis of postherpetic neuralgia OR

· 
History of 3 claims with preferred lidocaine 5%
patch in the past 6 months

 

 

 

 

lidocaine 4% cream,
patch, solution

DERMACINRX LIDOGEL
(lidocaine)

lidocaine 5% cream,
ointment, patch

DERMACINRX LIDOREX
(lidocaine)

lidocaine 40 mg/mL
solution

diclofenac epolamine

lidocaine/prilocaine
cream

diclofenac sodium 2%
solution pump

TRIDACAINE
(lidocaine) patch

DICLOGEN
(diclofenac/menthol/camphor) kit

TRIDACAINE XL
(lidocaine) patch

DOLOGESIC PAIN RELIEF
(lidocaine)

ULTRA LIDO
(lidocaine) cream, gel

LIDAFLEX (lidocaine)

 

lidocaine 3% cream

 

lidocaine 4% kit,
liquid

 

lidocaine/hydrocortisone

 

lidocaine/prilocaine
kit

 

LIDOCAN II, III, IV,
V (lidocaine)

 

LIDOCORT
(lidocaine/hydrocortisone)

 

LIDODERM (lidocaine)

 

LIDOTRAL (lidocaine)

 

LIXOFEN (diclofenac)

 

PENNSAID (diclofenac)

 

PLIAGLIS
(lidocaine/tetracaine)

 

TRIDACAINE II, III
(lidocaine) patch

 

ZTLIDO (lidocaine)

ANDROGENIC AGENTS DUR+

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

testosterone

ANDROGEL
(testosterone)

All
Agents

·  Limited to male
gender

 

Non-Preferred Criteria

· 
Have tried 2 different preferred agents in the
past 6 months

 

TLANDO

·  Requires clinical
review

 

JATENZO (testosterone
undecanoate)

 

NATESTO
(testosterone)

 

TESTIM (testosterone)

 

TLANDO (testosterone
undecanoate)

 

VOGELXO
(testosterone)

 

UNDECATREX
(testosterone undecanoate)

ANGIOTENSIN
MODULATORS DUR+

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

ANGIOTENSIN CONVERTING ENZYME (ACE) INHIBITORS

EPANED

·  Automatic approval
issued for 0-6 years of age

 

ENTRESTO

· 
Age ≥1 year and documented diagnosis
of Heart Failure with Systemic Ventricular Systolic Dysfunction

OR

· 
Age ≥ 18 years and documented
diagnosis of Heart Failure

 

Non-Preferred Criteria

·  ACEIs:

o Have tried 2
different preferred single entity agents in the past 6 months OR

o 90 days of therapy
with the requested agent in the past 105 days

· 
ACEI/CCB Combinations:

o Have tried 2
different preferred ACEI/CCB agents in the past 6 months OR

o 90 days of therapy
with the requested agent in the past 105 days

· 
ACEI/Diuretic Combinations:

o Have tried 2
different preferred ACEI/Diuretic agents in the past 6 months OR

o 90 days of therapy
with the requested agent in the past 105 days

· 
ARBs:

o Have tried 2
different preferred single entity agents in the past 6 months OR

o 90 days of therapy
with the requested agent in the past 105 days

· 
ARB/CCB and ARB/CCB/Diuretic Combinations:

o Have tried 1
preferred ARB/CCB agent in the past 6 months OR

o 90 days of therapy
with the requested agent in the past 105 days

· 
ARB/Diuretic Combinations:

o Have tried 2 different
preferred ARB/Diuretic agents in the past 6 months OR

o 90 days of therapy
with the requested agent in the past 105 days

· 
Direct Renin Inhibitors:

o Documented diagnosis
of Hypertension AND

o Have tried 2
different preferred ACEI or ARB single-entity agents in the past 6 months OR

o 90 days of therapy
with the requested agent in the past 105 days

· 
Direct Renin Inhibitor Combinations:

o Documented diagnosis
of Hypertension AND

o Have tried 2
different preferred ACEI or ARB diuretic agents in the past 6 months OR

o 90 days of therapy with the requested
agent in the past 105 days

o Have tried 2
different preferred ACEI/Diuretic agents in the past 6 months OR

o 90 days of therapy
with the requested agent in the past 105 days

 

benazepril

ACCUPRIL (quinapril)

captopril

ALTACE (ramipril)

enalapril

EPANED (enalapril)

fosinopril

LOTENSIN (benazepril)

lisinopril

moexipril

quinapril

perindopril

ramipril

QBRELIS (lisinopril)

trandolapril

VASOTEC (enalapril)

 

ZESTRIL (lisinopril)

ACE INHIBITOR (ACEI) COMBINATIONS

benazepril/amlodipine

ACCURETIC
(quinapril/hydrochlorothiazide)

benazepril/hydrochlorothiazide

LOTENSIN HCT
(benazepril/hydrochlorothiazide)

captopril/hydrochlorothiazide

LOTREL
(benazepril/amlodipine)

enalapril/hydrochlorothiazide

VASERETIC
(enalapril/hydrochlorothiazide)

fosinopril/hydrochlorothiazide

ZESTORETIC
(lisinopril/hydrochlorothiazide)

lisinopril/hydrochlorothiazide

 

quinapril/hydrochlorothiazide

 

trandolapril/verapamil
ER

 

ANGIOTENSIN
II RECEPTOR BLOCKERS (ARBs)

irbesartan

ATACAND (candesartan)

losartan

AVAPRO (irbesartan)

olmesartan

BENICAR (olmesartan)

telmisartan

candesartan

valsartan tablet

COZAAR (losartan)

 

EDARBI (azilsartan)

 

eprosartan

 

MICARDIS
(telmisartan)

 

valsartan solution

ARB
COMBINATIONS

ENTRESTO (valsartan/sacubitril) tablet DUR+

ATACAND HCT (candesartan/hydrochlorothiazide)

irbesartan/hydrochlorothiazide

AVALIDE (irbesartan/hydrochlorothiazide)

losartan/hydrochlorothiazide

AZOR (olmesartan/hydrochlorothiazide)

olmesartan/amlodipine

BENICAR HCT (olmesartan/hydrochlorothiazide)

olmesartan/hydrochlorothiazide

candesartan/hydrochlorothiazide

telmisartan/hydrochlorothiazide

DIOVAN-HCT (valsartan/hydrochlorothiazide)

valsartan/amlodipine

EDARBYCLOR (azilsartan/chlorthalidone)

valsartan/amlodipine/hydrochlorothiazide

ENTRESTO (valsartan/sacubitril) sprinkle
capsule

valsartan/hydrochlorothiazide

EXFORGE (valsartan/amlodipine)

 

EXFORGE HCT (valsartan/amlodipine/hydrochlorothiazide)

 

olmesartan/amlodipine/hydrochlorothiazide

 

telmisartan/amlodipine

 

TRIBENZOR
(olmesartan/amlodipine/hydrochlorothiazide)

 

valsartan/sacubitril

DIRECT RENIN INHIBITORS

 

aliskiren

 

TEKTURNA (aliskiren)

DIRECT RENIN INHIBITOR
COMBINATIONS

 

TEKTURNA HCT
(aliskiren/hydrochlorothiazide)

ANTIBIOTICS
(GI) & RELATED AGENTS

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

metronidazole tablet

AEMCOLO (rifamycin)

 

neomycin

DIFICID (fidaxomicin)

tinidazole

FIRVANQ (vancomycin)

vancomycin oral
solution

FLAGYL
(metronidazole)

 

LIKMEZ
(metronidazole)

 

metronidazole
125 mg tablet, 375 mg capsule

 

nitazoxanide

 

paromomycin

 

REBYOTA (fecal
microbiota, live-jslm)

 

VANCOCIN (vancomycin)

 

vancomycin capsule

 

VOWST (fecal microbio
spore, live-brpk)

 

XIFAXAN (rifaximin)

ANTIBIOTICS
(MISCELLANEOUS)

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

LINCOSAMIDE ANTIBIOTICS

Quantity Limit

·  6 tablets/month: SIVEXTRO

 

SIVEXTRO MANUAL PA

 

ZYVOX MANUAL PA

clindamycin

CLEOCIN (clindamycin)

 

CELOCIN PEDIATRIC
(clindamycin)

MACROLIDES

azithromycin

ERYPED (erythromycin
ethylsuccinate) suspension

clarithromycin

ERYTHROCIN
(erythromycin stearate)

clarithromycin ER

ZITHROMAX (azithromycin)

E.E.S (erythromycin
ethylsuccinate) suspension

 

ERY-TAB
(erythromycin)

 

erythromycin

 

erythromycin
ethylsuccinate

 

NITROFURANTOIN DERIVATIVES

nitrofurantoin
capsule

FURADANTIN (nitrofurantoin)
suspension

nitrofurantoin
monohydrate macrocrystals

MACROBID
(nitrofurantoin monohydrate macrocrystals)

 

nitrofurantoin
suspension

OXAZOLIDINONES

 

linezolid

 

SIVEXTRO (tedizolid)

 

ZYVOX (linezolid)

ANTIBIOTICS (TOPICAL)

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

bacitracin OTC

CENTANY (mupirocin)

 

bacitracin/polymyxin OTC

CENTANY AT
(mupirocin)

gentamicin sulfate

mupirocin cream

mupirocin ointment

XEPI (ozenoxacin)

neomycin/bacitracin/polymyxin
OTC

 

ANTIBIOTICS (VAGINAL)

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

CLEOCIN (clindamycin)

clindamycin phosphate

 

NUVESSA
(metronidazole)

CLINDESSE
(clindamycin)

 

SOLOSEC (secnidazole)

 

XACIATO (clindamycin)

ANTICOAGULANTS

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

LOW MOLECULAR WEIGHT
HEPARIN (LMWH)

Non-Preferred Criteria

·  LMWH:

o Have tried 1 preferred
agent in the past 6 months OR

o 90 days of therapy
with the requested agent in the past 105 days

 

·  Oral:

o Have tried 2
different preferred oral agents in the past 6 months OR

o 90 days of therapy with
the requested agent in the past 105 days

enoxaparin

ARIXTRA
(fondaparinux)

 

fondaparinux

 

FRAGMIN (dalteparin)

 

LOVENOX (enoxaparin)

ORAL

ELIQUIS (apixaban)

dabigatran

JANTOVEN (warfarin)

PRADAXA (dabigatran)
pellet pack

PRADAXA (dabigatran)
capsule

SAVAYSA (edoxaban)

warfarin

rivaroxaban

XARELTO (rivaroxaban)

 

ANTICONVULSANTS
DUR+

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

ADJUVANTS

Minimum Age Limit

· 
6 months: DIACOMIT

· 
1 year: BANZEL, EPIDIOLEX

· 
2 years: ONFI, SYMPAZAN

· 
2 years: VALTOCO

· 
12 years: NAYZILAM

 

Maximum Age Limit

· 
2 years: VIGAFYDE

 

Quantity Limit (per 31 days)

· 
2 twin packs: DIASTAT

· 
2 packages: NAYZILAM

· 
5 devices: VALTOCO

 

Non-Preferred Criteria

· 
Have tried 2 different preferred agents in the
past 6 months OR

· 
Documented diagnosis of Seizure AND

·  90 days of therapy
with the requested agent in the past 105 days

 

Banzel, Onfi, and Sympazan

· 
Documented diagnosis of Lennox-Gastaut Syndrome
and have tried 1 preferred agent for Lennox-Gastaut Syndrome in the
past 6 months

OR

· 
Documented diagnosis of Seizure and 90
days of therapy with the requested agent in the past 105 days

 

DIACOMIT

· 
Documented diagnosis of Dravet Syndrome AND

· 
1 claim for clobazam in the past 30 days

 

EPIDIOLEX

· 
Documented diagnosis of Dravet Syndrome,
Lennox-Gastaut Syndrome, or Seizures associated with Tuberous Sclerosis Complex OR

· 
1 claim for EPIDIOLEX in the past 30
days

 

FINTEPLA

· 
Requires clinical review

 

SABRIL Powder for Oral
Solution

· 
Documented diagnosis of Infantile Spasms OR

· 
Have tried 2 different preferred agents in the
past 6 months OR

· 
Documented diagnosis of Seizure AND

·  90 days of therapy
with the requested agent in the past 105 days

 

TOPIRAMATE ER

· 
Documented diagnosis of Seizure AND

·  90 days of therapy
with the requested agent in the past 105 days OR

· 
30 days of therapy with topiramate IR in the
past 6 months

 

VIGAFYDE

· 
Age ≤ 2 years AND

· 
Documented diagnosis of infantile spasms

 

XCOPRI

· 
Age ≥ 18 years

 

 

carbamazepine

APTIOM
(eslicarbazepine acetate)

carbamazepine ER
12-hour capsule

BANZEL (rufinamide)

DEPAKOTE ER
(divalproex)

BRIVIACT
(brivaracetam)

DEPAKOTE SPRINKLE
(divalproex)

carbamazepine ER
12-hour tablet

divalproex

CARBATROL
(carbamazepine)

divalproex ER

DEPAKOTE (divalproex)

divalproex sprinkle

DIACOMIT
(stiripentol)

EPIDIOLEX
(cannabidiol)

ELEPSIA XR
(levetiracetam)

lacosamide

EPRONTIA (topiramate)

lamotrigine

EQUETRO
(carbamazepine)

lamotrigine blue,
green, orange dose pack

Eslicarbazepine

levetiracetam

felbamate

levetiracetam ER

FELBATOL (felbamate)

oxcarbazepine tablet

FINTEPLA (fenfluramine)

tiagabine

FYCOMPA (perampanel)

topiramate

KEPPRA
(levetiracetam)

topiramate
sprinkle 15, 25 mg (generic Topamax)

KEPPRA XR
(levetiracetam)

TRILEPTAL
(oxcarbazepine) suspension

LAMICTAL
(lamotrigine)

valproic acid

LAMICTAL XR
(lamotrigine)

zonisamide

lamotrigine ER

 

lamotrigine ODT

 

lamotrigine ODT blue,
green, orange dose pack

 

MOTPOLY XR
(lacosamide)

 

oxcarbazepine
suspension

 

oxcarbazepine
ER

 

OXTELLAR XR
(oxcarbazepine)

 

QUDEXY XR
(topiramate)

 

ROWEEPRA
(levetiracetam)

 

rufinamide

 

SABRIL (vigabatrin)

 

SPRITAM
(levetiracetam)

 

SUBVENITE
(lamotrigine)

 

SUBVENITE
(lamotrigine) blue, green, orange dose pack

 

TEGRETOL
(carbamazepine)

 

TEGRETOL
XR (carbamazepine)

 

TOPAMAX
TABLET (topiramate)

 

TOPAMAX
SPRINKLE (topiramate)

 

topiramate
ER capsule (generic Trokendi XR)

 

topiramate
ER sprinkle capsule (generic Qudexy XR)

 

topiramate
sprinkle 50 mg

 

TRILEPTAL
(oxcarbazepine) tablet

 

TROKENDI
XR (topiramate)

 

vigabatrin

 

VIGADRONE
(vigabatrin)

 

VIGAFYDE
(vigabatrin)

 

VIGPODER
(vigabatrin)

 

VIMPAT
(lacosamide)

 

XCOPRI
(cenobamate)

 

ZONISADE
(zonisamide) suspension

 

ZTALMY
(ganaxolone)

HYDANTOINS

DILANTIN (phenytoin)

 

DILANTIN-125
(phenytoin)

 

PHENYTEK (phenytoin)

 

phenytoin

 

phenytoin ER

 

SELECTED BENZODIAZEPINES

clobazam

DIASTAT (diazepam)
rectal gel

diazepam rectal gel

LIBERVANT (diazepam)

NAYZILAM (midazolam)

ONFI (clobazam)

VALTOCO (diazepam)

SYMPAZAN (clobazam)

SUCCINIMIDES

ethosuximide

CELONTIN
(methsuximide)

 

methsuximide

 

ZARONTIN
(ethosuximide)

ANTIDEPRESSANTS,
OTHER DUR+

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

bupropion

APLENZIN (bupropion)

Minimum
Age Limit

·  18 years: all agents

 

Non-Preferred Criteria

· 
Have tried 2 different preferred agents in the past 6 months OR

· 
Have tried 1 preferred agent and 1 SSRI in the past 6 months OR

· 
90 days of therapy with the requested agent in
the past 105 days

 

AUVELITY and RALDESY

·   Requires clinical
review  

DRIZALMA Sprinkles 

·    Automatic approval
issued with a diagnosis of Generalized Anxiety Disorder for 7-11 years of age

DULOXETINE 

·  
Automatic approval
issued with a diagnosis of Generalized Anxiety Disorder for 7-17 years of age 

 

ZURZUVAE
MANUAL PA 

· 
90 days of therapy with the requested agent in
the past 105 days

 

 

bupropion SR

AUVELITY
(bupropion/dextromethorphan)

bupropion XL

desvenlafaxine ER

mirtazapine

DESYREL (trazodone)

trazodone

DRIZALMA SPRINKLE (duloxetine DR)

TRINTELLIX
(vortioxetine)

EFFEXOR XR
(venlafaxine)

venlafaxine

EMSAM (selegiline)

venlafaxine ER
capsule

FETZIMA
(levomilnacipran)

vilazodone

FORFIVO XL
(bupropion)

 

MARPLAN
(isocarboxazid)

 

NARDIL (phenelzine)

 

nefazodone

 

phenelzine

 

PRISTIQ
(desvenlafaxine)

 

REMERON (mirtazapine)

 

tranylcypromine

 

Trazodone solutionNR

 

venlafaxine ER tablet

 

VIIBRYD (vilazodone)

 

WELLBUTRIN SR
(bupropion)

 

WELLBUTRIN XL
(bupropion)

 

ZURZUVAE (zuranolone)

ANTIDEPRESSANTS, SSRIs DUR+

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

citalopram solution,
tablet

CELEXA (citalopram)

Minimum Age Limit

· 
6 years: ZOLOFT

· 
7 years: LEXAPRO, PROZAC

· 
8 years: fluvoxamine

· 
18 years: CELEXA, LUVOX CR, PAXIL, PROZAC 90 mg

 

Maximum Age Limit

·  60 years CELEXA

 

Non-Preferred Criteria

·  Have tried 2 different
preferred agents in the past 6 months OR

·  90 days of therapy with the
requested agent in the past 105 days

 

escitalopram

citalopram capsule

fluoxetine capsule

fluoxetine solution,
tablet

fluvoxamine

fluoxetine DR capsule

paroxetine tablet

fluvoxamine ER
capsule

paroxetine CR

LEXAPRO
(escitalopram)

paroxetine ER

paroxetine suspension,
capsule

sertraline tablet,
solution

PAXIL (paroxetine)

 

PAXIL CR (paroxetine)

 

PROZAC (fluoxetine)

 

sertraline capsule

 

ZOLOFT (sertraline)

ANTIEMETICS DUR+

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

5HT3 RECEPTOR BLOCKERS

Quantity Limit (per 31 days)

· 
6 tablets: AKYNZEO

· 
100 mL: ZOFRAN solution

 

Non-Preferred Agents

·  Have tried 1
preferred agent in the past 6 months

 

AKYNZEO MANUAL PA

 

Note: Injectables in this class are closed to
point of sale. PA required if not administered in clinic/hospital.

ondansetron solution,
tablet

ANZIMET (dolasetron)

ondansetron ODT 4 mg,
8 mg

granisetron

 

ondansetron ODT 16 mg
tablet

 

SANCUSO (granisetron)

ANTIEMETIC COMBINATIONS

DICLEGIS
(doxylamine/pyridoxine)

AKYNZEO
(netupitant/palonosetron)

 

BONJESTA
(doxylamine/pyridoxine)

 

doxylamine/pyridoxine

CANNABINOIDS

 

dronabinol

 

MARINOL (dronabinol)

NMDA RECEPTOR ANTAGONISTS

aprepitant

EMEND (aprepitant)

ANTIFUNGALS
(ORAL) DUR+

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

clotrimazole

ANCOBON (flucytosine)

Griseofulvin suspension

· 
Automatic approval issued for 0-11 years of age

 

Griseofulvin
tablets

· 
Automatic approval issued for 12-17 years of
age

 

Minimum Age Limit

·  18 years: CRESEMBA

 

Non-Preferred Criteria

· 
Have tried 2 different preferred agents in the
past 6 months

 

HIV
Opportunistic Infection

· 
Non-Preferred agent indicated for treatment (^)
AND

· 
Documented diagnosis of HIV

 

CRESEMBA MANUAL PA

 

SPORANOX

· 
Requires clinical review

 

fluconazole

BREXAFEMME
(ibrexafungerp)

nystatin

CRESEMBA (isavuconazonium
sulfate)

terbinafine

DIFLUCAN
(fluconazole)

 

flucytosine

 

griseofulvin

 

griseofulvin
ultramicrosize

 

itraconazole

 

ketoconazole

 

NOXAFIL
(posaconazole)

 

ORAVIG (miconazole)

 

Posaconazole

 

SPORANOX (itraconazole)

 

TOLSURA
(itraconazole)

 

VFEND (voriconazole)

 

VIVJOA
(oteseconazole)

 

voriconazole

ANTIFUNGALS
(TOPICAL) DUR+

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

ANTIFUNGALS

Non-Preferred
Criteria

·  Have tried 2
different preferred agents in the past 6 months

 

MICOTRIN
AC, MYCOZYL, and clotrimazole 30 mL solution

·  Require clinical
review

 

 

ciclopirox cream,
gel, solution, suspension

BENSAL HP (salicylic
acid)

clotrimazole cream,
solution Rx & OTC

CILODAN (ciclopirox)

econazole

ciclopirox shampoo

ketoconazole cream,
shampoo

clotrimazole solution
(NDC 50228-0502-61)

LUZU (luliconazole)

ERTACZO
(sertaconazole)

miconazole cream,
powder, solution OTC

EXTINA (ketoconazole)

miconazole/zinc
oxide/petrolatum ointment

JUBLIA
(efinaconazole)

nystatin cream,
ointment, powder

ketoconazole foam

terbinafine OTC

KETODAN
(ketoconazole)

tolnaftate cream,
solution OTC

LOPROX (ciclopirox)

 

luliconazole

 

MICOTRIN AC
(clotrimazole)

 

MYCOZYL AC
(clotrimazole)

 

MYCOZYL AP
(miconazole)

 

naftifine

 

NAFTIN (naftifine)

 

oxiconazole

 

OXISTAT (oxiconazole)

 

tavaborole

 

VOTRIZA-AL
(clotrimazole)

 

VUSION
(miconazole/zinc oxide/petrolatum)

ANTIFUNGAL/STEROID
COMBINATIONS

clotrimazole/betamethasone
cream

clotrimazole/betamethasone
lotion

nystatin/triamcinolone

 

ANTIFUNGALS (VAGINAL)

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

clotrimazole cream OTC

3-DAY VAGINAL CREAM
(clotrimazole)

 

clotrimazole-3 cream

GYNAZOLE 1
(butoconazole)

miconazole kit
OTC

terconazole
suppository

terconazole cream

 

ANTIHISTAMINES, MINIMALLY
SEDATING AND COMBINATIONS DUR+

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

MINIMALLY SEDATING
ANTIHISTAMINES

Non-Preferred Criteria

·  Documented diagnosis
of Allergy or Urticaria AND

·  Have tried 2
different preferred agents in the past 12 months

cetirizine capsule,
solution, tablet OTC

cetirizine chewable
tablet OTC

loratadine chewable
tablet, ODT, solution, tablet OTC

CLARINEX
(desloratadine)

 

desloratadine

 

levocetirizine

MINIMALLY SEDATING
ANTIHISTAMINE/DECONGESTANT COMBINATIONS

cetirizine/pseudoephedrine

CLARINEX-D 12 HOUR
(desloratadine/pseudoephedrine)

loratadine/pseudoephedrine

fexofenadine/pseudoephedrine

ANTIMIGRAINE
AGENTS, ACUTE TREATMENT

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

CGRP ORAL AND NASAL

Minimum Age Limit

· 
6 years: MAXALT

· 
12 years: almotriptan, sumatriptan/naproxen, ZOMIG
nasal spray

·  18 years: FROVA, IMITREX, naratripin,
NURTEC ODT, RELPAX, REYVOW, SYMBRAVO, TOSYMRA, UBRELVY, ZEMBRACE, ZOMIG
tablets

 

Quantity Limit (per 31 days)

·  ORAL

o  
4 tablets: REYVOW 50 mg

o  
6 tablets: almotriptan,
RELPAX, ZOMIG

o  
8 tablets: NURTEC ODT, REYVOW
100 mg

o  
9 tablets: naratriptan, FROVA,
IMITREX, sumatriptan/naproxen, SYMBRAVO

o  
12 tablets: MAXALT

o  
16 tablets: UBRELVY

·  NASAL

o  
1 box: all agents

 

CUMULATIVE Quantity Limit (per 31 days)

·  INJECTABLES

o  
4 injections: all agents

 

Non-Preferred Criteria

· 
ORAL

o  
Have tried 2 preferred oral agents in the past
90 days

·  NASAL

o  
Have tried 2 preferred oral agents in the past
90 days AND

o  
Have tried a preferred nasal agent in the past
90 days

 

Almotriptan and
sumatriptan/naproxen

· 
Automatic approval for 12-17 years of age

 

NURTEC ODT and UBRELVY MANUAL PA

· 
Documented diagnosis of Migraine AND

· 
Have tried 2 different triptans in the past 6
months AND

· 
No concurrent therapy with another CGRP agent
or strong CYP3A4 inhibitor

 

REYVOW

· 
Documented diagnosis of Migraine AND

· 
Have tried 2 different triptans in the past 90
days AND

· 
Have tried preferred NURTEC ODT in the past 90
days

 

SYMBRAVO

·  Requires clinical
review

 

ZAVZPRET MANUAL PA

· 
Documented diagnosis of Migraine AND

· 
Have tried 2 different triptans in the past 6
months AND

· 
Have tried both NURTEC ODT and UBRELVY in the
past 6 months AND

· 
No concurrent therapy with another CGRP AGENT

 

NURTEC ODT
(rimegepant)

ZAVZPRET (zavegepant)

UBRELVY (ubrogepant)

 

INJECTABLES

sumatriptan

IMITREX (sumatriptan)

 

ZEMBRACE SYMTOUCH
(sumatriptan)

NASAL

sumatriptan

IMITREX (sumatriptan)

 

TOSYMRA (sumatriptan)

 

zolmitriptan

 

ZOMIG (zolmitriptan)

TRIPTANS AND RELATED AGENTS
(ORAL) DUR+

naratriptan

almotriptan

rizatriptan

eletriptan

sumatriptan

FROVA (frovatriptan)

zolmitriptan

frovatriptan

zolmitriptan ODT

IMITREX (sumatriptan)

 

MAXALT (rizatriptan)

 

MAXALT MLT
(rizatriptan)

 

RELPAX (eletriptan)

 

REYVOW (lasmiditan)

 

sumatriptan/naproxen

 

ZOMIG (zolmitriptan)

ANTIMIGRAINE
AGENTS, PROPHYLAXIS

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

INJECTABLES

Preferred Injectables

· 
History of 3 claims with the requested agent in
the past 105 days OR

· 
New starts require clinical review

 

Non-preferred Injectables

·  Require clinical
review

 

AIMOVIG, AJOVY, and EMGALITY MANUAL PA

 

VYEPTI MANUAL PA

 

AIMOVIG Autoinjector
(erenumab-aooe) DUR+

EMGALITY Syringe
(galcanezumab-gnlm) 300 mg/mL

AJOVY Autoinjector
(fremanezumab-vfrm) DUR+

VYEPTI
(eptinezumab-jjmr)

AJOVY Syringe
(fremanezumab-vfrm) DUR+

 

EMGALITY Pen
(galcanezumab-gnlm) DUR+

 

EMGALITY Syringe (galcanezumab-gnlm) 120 mg/mL DUR+

 

ORAL

 

QULIPTA (atogepant)

 

NURTEC ODT
(rimegepant)

*ANTINEOPLASTICS
SELECTED SYSTEMIC ENZYME INHIBITORS

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

BOSULIF (bosutinib)
tablet

AFINITOR (everolimus)

FARYDAK MANUAL PA

 

IBRANCE

· 
Documented diagnosis of WD-DDLS for
retroperitoneal sarcoma OR

· 
All other indications require clinical review

 

LENVIMA

Documented diagnosis of thyroid cancer,
hepatocellular carcinoma, or renal cell carcinoma AND

· 
History of 1 claim for everolimus in the past
30 days AND

· 
History of 1 anti-angiogenic agent in the past
2 years OR

· 
All other indications require clinical review

 

LYNPARZA Tablets

·  Documented diagnosis of ovarian cancer,
fallopian tube or peritoneal cancer AND

·  History of platinum-based chemotherapy in the
past 2 years OR

All other indications require
clinical review MANUAL PA

 

 

 

 

 

 

 

CAPRESLA (vandetanib)

AFINITOR DISPERZ
(everolimus)

COMETRIQ
(cabozantinib)

AKEEGA (niraparib/abiraterone)

COTELLIC
(cobimetinib)

ALECENSA (alectinib)

everolimus

ALUNBRIG (brigatinib)

GILOTRIF (afatinib)

AUGTYRO
(repotrectinib)

ICLUSIG (ponatinib)

AYVAKIT (avapritinib)

imatinib

BALVERSA
(erdafitinib)

IMBRUVICA (ibrutinib)

BOSULIF (bosutinib)
capsule

INLYTA (axitinib)

BRAFTOVI
(encorafenib)

IRESSA (gefitinib)

BRUKINSA
(zanubrutinib)

JAKAFI (ruxolitinib)

CABOMETYX
(cabozantinib)

MEKINIST (trametinib)

CALQUENCE
(acalabrutinib)

NEXAVAR (sorafenib)

COPIKTRA (duvelisib)

ROZLYTREK
(entrectinib)

DANZITEN (nilotinib)

SPRYCEL (dasatinib)

dasatinib

STIVARGA
(regorafenib)

DATROWAY (datopotomab
deruxtecan-dlnk)NR

SUTENT (sunitinib)

DAURISMO (glasdegib)

TAFINLAR (dabrafenib)

ERIVEDGE (vismodegib)

TARCEVA (erlotinib)

ERLEADA (apalutamide)

TASIGNA (nilotinib)

erlotinib

TURALIO
(pexidartinib)

FOTIVDA (tivozanib)

TYKERB (lapatinib)

FRUZAQIA
(fruquintinib)

VOTRIENT (pazopanib)

GAVRETO (pralsetinib)

XALKORI (crizotinib)

gefitinib

XTANDI (enzalutamide)

GLEEVEC (imatinib)

ZELBORAF
(vemurafenib)

IBRANCE (palbociclib)

ZYDELIG (idelalisib)

IDHIFA (enasidenib)

ZYKADIA (ceritinib)

IMKELDI (imatinib)

 

INQOVI
(decitabine/cedazuridine)

 

INREBIC (fedratinib)

 

ITOVEBI (inavolisib)

 

IWILFIN
(eflornithine)

 

JAYPIRCA
(pirtobrutinib)

 

KISQALI (ribociclib)

 

KISQALI-FEMARA CO-PACK
(ribociclib/letrozole)

 

KOSELUGO
(selumetinib/vitamin E)

 

KRAZATI (adagrasib)

 

lapatinib

 

LAZCLUZE (lazertinib)

 

LENVIMA (lenvatinib)

 

LOBRENA (lorlatinib)

 

LUMAKRAS (sotorasib)

 

LYNPARZA (olaparib)

 

LYTGOBI (futibatinib)

 

MEKTOVI (binimetinib)

 

NERLYNX (neratinib)

 

NUBEQA (darolutamide)

 

nilotinibNR

 

ODOMZO (sonidegib)

 

OGSIVEO
(nirogacestat)

 

OJEMDA (tovorafenib)

 

OJJAARA (momelotinib)

 

ONUREG (azacitidine)

 

ORGOVYX (relugolix)

 

pazopanib

 

PEMAZYRE
(pemigatinib)

 

PIQRAY (alpelisib)

 

QINLOCK (ripretinib)

 

RETEVMO
(selpercatinib)

 

REVUFORJ (revumenib)

 

REZLIDHIA
(olutasidenib)

 

RUBRACA (rucaparib)

 

RYDAPT (midostaurin)

 

SCEMBLIX (asciminib)

 

sorafenib

 

sunitinib

 

TABRECTA (capmatinib)

 

TAGRISSO
(osimertinib)

 

TALZENNA
(talazoparib)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TAZVERIK
(tazemetostat)

 

TECENTRIQ HYBREZA
(atezolizumab/hyaluronidase-tqjs)

 

TEPMETKO (tepotinib)

 

TIBSOVO (ivosidenib)

 

TORPENZ (everolimus)

 

TRUQAP (capivasertib)

 

TUKYSA (tucatinib)

 

VANFLYTA
(quizartinib)

 

VERZENIO
(abemaciclib)

 

VITRAKVI (larotrectinib)

 

VIZIMPRO
(dacomitinib)

 

VONJO (pacritinib)

 

VORANIGO
(vorasidenib)

 

WELIREG (belzutifan)

 

XOSPATA
(gilteritinib)

 

XPOVIO (selinexor)

 

ZEJULA (niraparib)

ANTIOBESITY SELECT AGENTS

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

SAXENDA (liraglutide)

orlistat

All agents MANUAL PA required

 

WEGOVY (semaglutide)

XENICAL (orlistat)

ANTIPARASITICS
(TOPICAL) DUR+

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

PEDICULICIDES

Minimum Age Limit

·  2 months: permethrin 1%
(OTC), permethrin 5%

·  6 months: NATROBA, SKLICE

·  2 years: piperonyl/pyrethrins
(OTC)

·  4 years: NATROBA

·  6 years: OVIDE

·  18 years: EURAX

 

Non-Preferred Criteria

·  Pediculicides

o   Have tried 2
preferred topical lice agents in the past 90 days

·  Scabicides

·  Have tried permethrin 5% in the past
90 days

 

NATROBA (spinosad)

lindane

permethrin 1% cream OTC

malathion

VANALICE (piperonyl
butoxide/pyrethrins)

OVIDE (malathion)

 

SKLICE (ivermectin)

 

spinosad

SCABICIDES

ivermectin

CROTAN (crotamiton)

permethrin 5% cream

ELIMITE (permethrin)

 

EURAX (crotamiton)

 

STROMECTOL
(ivermectin)

ANTIPARKINSON’S
AGENTS (INJECTABLE)

PREFERRED
AGENTS

NON-PREFERRED
AGENTS

PA
CRITERIA

 

VYALEV
(foscarbidopa/foslevodopa)

VYALEV

·  
Requires clinical review

ANTIPARKINSON’S
AGENTS (ORAL) DUR+

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

ANTICHOLINERGICS

Non-Preferred Criteria

· 
Documented diagnosis of Parkinson’s disease AND

· 
Have tried 2 different preferred agents in the
past 6 months OR

· 
90 days of therapy with a selegiline agent in
the past 105 days

 

GOCOVRI

· 
Documented diagnosis of Parkinson’s disease AND

· 
30 days of therapy with amantadine IR in the
past 105 days AND

· 
30 days of therapy with a carbidopa/levodopa
combination agent in the past 45 days

 

LODOSYN and INBRIJA

· 
Documented diagnosis of Parkinson’s disease AND

· 
30 days of therapy with a carbidopa/levodopa
combination agent in the past 45 days

 

NOURIANZ

· 
Documented diagnosis of Parkinson’s Disease AND

· 
Have tried 1 preferred carbidopa/levodopa
combination agent in the past 30 days AND

· 
30 days of therapy with a preferred adjunctive
therapy in the past 45 days

 

XADAGO

· 
Documented diagnosis of Parkinso’ s Disease AND

· 
History of 30 days of therapy with a
carbidopa/levodopa combination agent in the past 45 days AND

· 
History of 30 days of therapy with a selegiline
agent the in past 45 days

 

benztropine

 

trihexyphenidyl

 

COMT INHIBITORS

entacapone

OGENTYS (opicapone)

 

TASMAR (tocapone)

 

tolcapone

DOPAMINE AGONISTS

pramipexole

NEUPRO (rotigotine)

ropinirole

pramipexole ER

 

ropinirole ER

MAO-B
INHIBITORS

selegiline

AZILECT (rasagiline)

 

rasagiline

 

XADAGO (safinamide)

 

ZELAPAR (selegiline)

OTHERS

amantadine

carbidopa/levodopa
ODT

bromocriptine

carbidopa/levodopa/entacapone

carbidopa

CREXONT
(carbidopa/levodopa)

carbidopa/levodopa
tablet

DHIVY (carbidopa/levodopa)

carbidopa/levodopa ER

DUOPA
(carbidopa/levodopa)

 

GOCOVRI (amantadine)

 

INBRIJA (levodopa)

 

LODOSYN (carbidopa)

 

NOURIANZ
(istradefylline)

 

OSMOLEX ER
(amantadine)

 

RYTARY
(carbidopa/levodopa)

 

SINEMET (carbidopa/levodopa)

 

STALEVO
(carbidopa/levodopa/entacapone)

ANTIPSORIATICS (TOPICAL)

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

calcipotriene cream

calcipotriene foam,
ointment, solution

 

ENSTILAR (calcipotriene/betamethasone)

calcipotriene/betamethasone

TACLONEX
(calcipotriene/betamethasone)

calcitriol ointment

 

DUOBRII
(halobetasol/tazarotene)

 

SORILUX
(calcipotriene)

 

tazarotene

 

VECTICAL (calcitriol)

 

VTAMA (tapinarof)

 

ZORYVE (roflumilast)

ANTIPSYCHOTICS
DUR+

PREFERRED AGENTS

NON-PREFERRED
AGENTS

PA
CRITERIA

INJECTABLE, ATYPICALS DUR+

Concurrent Therapy Limit for Age < 18 years

·  90 days with ≥ 2 agents in the last 120 days
will require a MANUAL PA

 

Minimum Age Limit

·  3 years: HALDOL

·  5 years: RISPERDAL, thioridazine

·  6 years: ABILIFY, trifluoperazine

·  10 years: LATUDA, SAPHRIS, SEROQUEL, SYMBYAX

·  12 years: INVEGA, molindone, perphenazine, pimozide,
thiothixene

·  13 years: REXULTI, ZYPREXA

·  18 years: ABILIFY MYCITE, CAPLYTA, CLOZARIL, COBENFY,
FANAPT, fluphenazine, GEODON, loxapine, LYBALVI, NUPLAZID,
perphenazine/amitriptyline, SECUADO, VRAYLAR, and all injectable agents

 

Quantity Limit

·  3 syringes/year: ARISTADA INITIO

 

Non-Preferred Criteria Atypical Agents

·  Have tried 2
preferred agents in the past 12 months OR

·  30 days of therapy
with the requested agent in the past 180 days

 

ARISTADO INTIO, ARISTADO ER, INVEGA
SUSTENNA, INVEGA TRINZA, PERSERID AND ZYPREXA RELPREEV

·  Documented diagnosis
of schizophrenia or schizoaffective disorder

 

ABILIFY MAINTENA, ABILIFY
ASIMTUFII, or RISPERDAL CONSTA

·  Documented diagnosis
of schizophrenia, schizoaffective disorder or bipolar disorder

 

INVEGA HAFYERA

·  Documented diagnosis
of schizophrenia or schizoaffective disorder AND

·  4 claims for INVEGA
SUSTENNA in the past year OR

·  1 claim for INVEGA
TRINZA in the past year OR

·  1 claim for INVEGA
HAFYERA in the past year

 

ERZOFRI, OPIPZA and risperidone ER

·  Require clinical review

 

NUPLAZID

·  Documented diagnosis of Parkinson s
Disease

 

VRAYLAR

·  Documented diagnosis
of schizophrenia, schizoaffective disorder, bipolar disorder OR

·  Documented diagnosis
major depressive disorder AND

o          30
days of therapy with an antidepressant in the past 45 days OR

o          1
claim for a 90-day supply of an antidepressant in the past 105 days

 

ABILIFY ASIMTUFII
(aripiprazole)

ERZOFRI
(paliperidone palmitate)     

ABILIFY MAINTENA
(aripiprazole)

GEODON (ziprasidone)

ARISTADA, ARISTADA INITIO
(aripiprazole lauroxil)

olanzapine

INVEGA HAFYERA
(paliperidone)

risperidone ER

INVEGA SUSTENNA
(paliperidone palmitate)

RYKINDO (risperidone)

INVEGA TRINZA
(paliperidone)

ziprasidone

PERSERIS
(risperidone)

ZYPREXA (olanzapine)

RISPERIDAL CONSTA
(risperidone)

ZYPREXA RELPREVV
(olanzapine)

UZEDY (risperidone)

 

ORALDUR+

aripiprazole tablet

ABILIFY
(aripiprazole)

asenapine

ABILIFY MYCITE
(aripiprazole)

clozapine tablet

ADASUVE (loxapine)

fluphenazine

aripiprazole ODT,
solution

haloperidol

CAPLYTA
(lumateperone)

haloperidol lactate

chlorpromazine

olanzapine

clozapine ODT

perphenazine

CLOZARIL (clozapine)

perphenazine/amitriptyline

COBENFY
(xanomeline/trospium)

quetiapine

FANAPT (iloperidone)

quetiapine ER

GEODON (ziprasidone)

risperidone

IGALMI
(dexmedetomidine)

thioridazine

INVEGA (paliperidone)

trifluoperazine

LATUDA (lurasidone)

VRAYLAR (cariprazine)

lurasidone

ziprasidone

LYBALVI (olanzapine/samidorphan)

 

NUPLAZID (pimavanserin)

 

olanzapine/fluoxetine

 

OPIPZA (aripiprazole)

 

paliperidone ER

 

REXULTI (brexpiprazole)

 

RISPERDAL (risperidone)

 

SAPHRIS (asenapine)

 

SEROQUEL (quetiapine)

 

SEROQUEL XR (quetiapine ER)

 

SYMBYAX (olanzapine/fluoxetine)

 

VERSACLOZ (clozapine)

 

ZYPREXA, ZYPREXA ZYDIS (olanzapine)

TRANSDERMAL, ATYPICALS

 

SECUADO (asenapine)

 

 

ANTIRETROVIRALS
DUR+

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

CAPSID INHIBITORS

Non-Preferred Criteria

· 
1 claim with the requested agent in the past
105 days

 

STRIBILD MANUAL PA

 

SUNLENCA

·  Requires clinical
review

 

TROGARZO

·  Requires clinical
review

 

TYBOST
MANUAL PA

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SUNLENCA
(lenacapavir)

CD4 DIRECTED ATTACHMENT
INHIBITORS

 

RUKOBIA (fostemsavir)

CD4 DIRECTED HIV-1
INHIBITORS

 

TROGARZO
(ibalizumab-uiyk)

COMBINATION PRODUCTS NRTIs

abacavir/lamivudine

COMBIVIR
(lamivudine/zidovudine)

CABENUVA
(cabotegravir/rilpivirine)

EPZICOM
(abacavir/lamivudine)

DOVATO
(dolutegravir/lamivudine)

 

lamivudine/zidovudine

 

COMBINATION PRODUCTS
NUCLEOSIDE AND NUCLEOTIDE ANALOG RTIs

DESCOVY
(emtricitabine/tenofovir alafenamide)

TRUVADA
(emtricitabine/tenofovir)

emtricitabine/tenofovir

 

COMBINATION PRODUCTS NUCLEOSIDE
AND NUCLEOTIDE ANALOG AND NON-NUCLEOSIDE RTIs

DELSTRIGO
(doravirine/lamiviudine/tenofovir)

ATRIPLA
(efavirenz/emtricitabine/tenofovir)

efavirenz/emtricitabine/tenofovir

CIMDUO
(lamivudine/tenofovir)

ODEFSEY (emtricitabine/rilpivirine/tenofovir)

COMPLERA
(emtricitabine/rilpivirine/tenofovir)

COMBINATION PRODUCTS
PROTEASE INHIBITORS

lopinavir/ritonavir

KALETRA
(lopinavir/ritonavir)

ENTRY INHIBITORS CCR5
CO-RECEPTOR ANTAGONISTS

 

maraviroc

 

SELZENTRY (maraviroc)

ENTRY INHIBITORS FUSION
INHIBITORS

 

FUZEON (enfuvirtide)

INTEGRASE STRAND TRANSFER
INHIBITORS

APRETUDE
(cabotegravir)

cabotegravir ER

ISENTRESS
(raltegravir)

ISENTRESS HD
(raltegravir)

TIVICAY, TIVICAY PD
(dolutegravir)

VOCABRIA
(cabotegravir)

NON-NUCLEOSIDE REVERSE
TRANSCRIPTASE INHIBTORS (NNRTI)

EDURANT (rilpivirine)

etravirine

efavirenz

INTELENCE
(etravirine)

 

nevirapine,
nevirapine ER

 

PIFELTRO (doravirine)

NUCLEOSIDE REVERSE
TRANSCRIPTASE INHIBTORS (NRTI)

abacavir

didanosine

EMTRIVA
(emtricitabine)

emtricitabine

lamivudine

EPIVIR (lamivudine)

ZIAGEN (abacavir)

RETROVIR (zidovudine)

zidovudine

stavudine

 

VIREAD (tenofovir
disoproxil fumarate)

PHARMACOENHANCER CYTOCHROME
P450 INHIBITORS

 

TYBOST (cobicistat)

PROTEASE INHIBITORS
(NON-PEPTIDIC)

PREZISTA (darunavir)

APTIVUS (tipranavir)

 

darunavir

 

PREZCOBIX
(darunavir/cobicistat)

PROTEASE INHIBITORS
(PEPTIDIC)

atazanavir

fosamprenavir

EVOTAZ
(atazanavir/cobicistat)

LEXIVA
(fosamprenavir)

ritonavir

NORIVIR (ritonavir)

 

REYATAZ (atazanavir)

 

VIRACEPT (nelfinavir)

SINGLE PRODUCT REGIMENS

BIKTARVY
(bictegravir/emtricitabine/tenofovir)

efavirenz/lamivudine/tenofovir

GENVOYA (elvitegravir/cobicistat/emtricitabine/
tenofovir alafenamide)

JULUCA
(dolutegravir/rilpivirine)

SYMFI
(efavirenz/lamivudine/tenofovir)

rilpivirine ER

SYMFI LO
(efavirenz/lamivudine/tenofovir)

STRIBILD (elvitegravir/cobicistat/emtricitabine/tenofovir
disoproxil fumarate)

TRIUMEQ
(abacavir/dolutegravir/lamivudine)

SYMTUZA
(darunavir/cobicistat/emtricitabine/tenofovir alafenamide)

TRIUMEQ PD (abacavir/dolutegravir/lamivudine)

 

ANTIVIRALS,
ORAL

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

ANTI-CYTOMEGALOVIRUS AGENTS

 

PREVYMIS

·  Requires clinical
review

 

Valganciclovir solution

· 
Automatic approval issued for 0-12 years of age

 

valganciclovir tablet

LIVTENCITY
(maribavir)

 

PREVYMIS (letermovir)

 

VALCYTE
(valganciclovir)

 

valganciclovir
solution

ANTI-HERPETIC AGENTS

acyclovir

SITAVIG (acyclovir)

famciclovir

VALTREX
(valacyclovir)

valacyclovir

 

ANTI-INFLUENZA AGENTS

oseltamivir

FLUMADINE
(rimantadine)

 

RAPIVAB (peramivir)

 

RELENZA (zanamivir)

 

rimantadine

 

TAMIFLU (oseltamivir)

 

XOFLUZA (baloxavir)

ANTIVIRALS, TOPICAL

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

ZOVIRAX (acyclovir)
cream

acyclovir

 

 

DENAVIR (penciclovir)

 

penciclovir

 

XERESE
(acyclovir/hydrocortisone)

 

ZOVIRAX (acyclovir)
ointment

AROMATASE INHIBITORS

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

anastrozole

ARIMIDEX
(anastrazole)

 

exemestane

AROMASIN (exemestane)

letrozole

FEMARA (letrozole)

ATOPIC
DERMATITIS

PREFERRED
AGENTS

NON-PREFERRED
AGENTS

PA CRITERIA

ADBRY (tralokinumab-ldrm)

CIBINQO (abrocitinib)

Minimum Age Limit

·  3 months: EUCRISA

·  2 years: ELIDEL, tacrolimus 0.03%

·  12 years: OPZELURA

·  16 years: tacrolimus 0.1%

ADBRY Autoinjector (tralokinumab-ldrm)

EBGLYSS Pen (lebrikizumab-lbkz)

DUPIXENT (dupilumab) DUR+

NEMLUVIO (nemolizumab-ilto)

ELIDEL (pimecrolimus)

OPZELURA
(ruxolitinib)

EUCRISA (crisaborole) DUR+

ZORYVE
(roflumilast) 0.15% cream

pimecrolimus

 

tacrolimus

 

ADBRY MANUAL PA

 

CIBINQO

·  Requires clinical
review

 

DUPIXENT

· 
1 claim with DUPIXENT in the past 60 days OR

· 
New starts require clinical review (see manual
PA links below)

o   Asthma MANUAL PA

o  Atopic Dermatitis MANUAL PA

o  Bullous Pemphigoid MANUAL PA

o  COPD MANUAL PA

o   Eosinophilic Esophagitis MANUAL PA

o   Nasal Polyposis MANUAL PA

o  Prurigo Nodularis MANUAL PA

 

EBGLYSS

·  Requires clinical
review

 

EUCRISA

·  30 days of therapy
with a calcineurin inhibitor or topical steroid in the past 6 months

 

OPZELURA

· 
30 days of therapy with ELIDEL, EUCRISA or
tacrolimus in the past 6 months

BETA
BLOCKERS, ANTIANGINALS & SINUS NODE AGENTS DUR+

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

ANTIANGINALS

ASPRUZYO SPRINKLE

·  Requires clinical
review

 

Ranolazine ER

· 
Documented diagnosis of angina AND

· 
1 claim for a calcium channel blocker,
beta-blocker, nitrate, or combination agent in the past 30 days OR 90
days of therapy with the requested agent in the past 105 days

 

Non-Preferred Criteria

· 
Have tried 2 different preferred agents in the
past 6 months OR

· 
90 days of therapy with the requested agent in
the past 105 days

 

COREG CR

· 
Documented diagnosis of hypertension AND

· 
Have tried generic carvedilol AND 1
preferred agent in the past 6 months OR

·  90 days of therapy with the requested agent
in the past 105 days

 

CORLANOR MANUAL PA

 

HEMANGEOL

·  Documented diagnosis
of infantile hemangioma

 

 

 

ASPRUZYO SPRINKLE
(ranolazine)

 

ranolazine ER

BETA- AND ALPHA-BLOCKERS

carvedilol

carvedilol ER

labetalol

COREG (carvedilol)

 

COREG CR (carvedilol)

BETA-BLOCKER/DIURETIC
COMBINATIONS

atenolol/chlorthalidone

TENORETIC
(atenolol/chlorthalidone)

bisoprolol/hydrochlorothiazide

ZIAC
(bisoprolol/hydrochlorothiazide)

metoprolol/hydrochlorothiazide

 

propranolol/hydrochlorothiazide

 

BETA-BLOCKERS

acebutolol

BETAPACE (sotalol)

atenolol

BETAPACE AF (sotalol)

bisoprolol

betaxolol

HEMANGEOL
(propranolol)

BYSTOLIC (nebivolol)

metoprolol succinate

INDERAL LA
(propranolol)

metoprolol tartrate

INDERAL XL
(propranolol)

nadolol

INNOPRAN XL
(propranolol)

nebivolol

KAPSPARGO SPRINKLE
(metoprolol succinate)

pindolol

LOPRESSOR (metoprolol
tartrate)

propranolol

SOTYLIZE (sotalol)

propranolol ER

TENORMIN (atenolol)

SORINE (sotalol)

TOPROL XL (metoprolol
succinate)

sotalol

 

sotalol AF

 

timolol

 

SINUS NODE AGENTS

 

CORLANOR (ivabradine)

 

ivabradine

BILE
SALTS

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

ursodiol

BYLVAY (odevixibat)

 

 

CHENODAL (chenodiol)

 

IQIRVO (elafibranor)

 

LIVDELZI (seladelpar)

 

LIVMARLI (maralixibat)

 

OCALIVA (obeticholic
acid)

 

RELTONE (ursodiol)

 

URSO FORTE (ursodiol)

BLADDER RELAXANT
PREPARATIONS DUR+

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

MYRBETRIQ
(mirabegron)

darifenacin ER

Non-Preferred Criteria

·  Have tried 2
different preferred agents in the past 6 months

oxybutynin

DETROL (tolterodine)

oxybutynin ER

DETROL LA
(tolterodine)

solifenacin

fesoterodine

 

GEMTESA (vibegron)

 

mirabegron ER

 

tolterodine

 

tolterodine ER

 

TOVIAZ (fesoterodine)

 

trospium

 

trospium ER

 

VESICARE
(solifenacin)

 

VESICARE LS
(solifenacin)

BONE
RESORPTION SUPPRESSION AND RELATED AGENTS DUR+

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

BISPHOSPHONATES

Non-Preferred Criteria

· 
Documented diagnosis of osteoporosis or
osteopenia AND

· 
Have tried 2 different preferred agents in the
past 6 months

 

 

 

 

 

 

 

 

 

 

 

alendronate tablet

ACTONEL (risedronate)

ibandronate tablet

alendronate solution

risedronate

ATELVIA (risedronate)

 

BINOSTO (alendronate)

 

FOSAMAX (alendronate)

 

FOSAMAX PLUS D
(alendronate/vitamin D3)

 

ibandronate
syringe/vial

 

risedronate DR

OTHERS

FORTEO (teriparatide)

calcitonin salmon

raloxifene

EVENITY
(romosozumab-aqqg)

 

EVISTA (raloxifene)

 

JUBBONTI
(denosumab-bbdz)NR

 

MIACALCIN (calcitonin
salmon)

 

OSENVELT
(denosumab-bmwo)NR

 

PROLIA (denosumab)

 

teriparatide

 

STOBOCLO
(denoxumab-bmwo)NR

 

TYMLOS
(abaloparatide)

 

WYOST
(denosumab-bbdz)NR

 

XGEVA (denosumab)

BPH AGENTS DUR+

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

5-ALPHA-REDUCTASE
INHIBITORS

CARDURA, FLOMAX, PROSCAR, terazosin, or UROXATRAL Female

·  Documented
State-accepted diagnosis

 

Non-Preferred Criteria Male

· 
Have tried 2 different preferred agents in the
past 6 months OR

· 
90 days of therapy with the requested agent in
the past 105 days

 

ENTADFI

·  Requires clinical
review

dutasteride

AVODART (dutasteride)

finasteride

ENTADFI
(finasteride/tadalafil)

 

PROSCAR (finasteride)

ALPHA BLOCKERS

alfuzosin ER

CARDURA (doxazosin)

doxazosin

CARDURA XL
(doxazosin)

tamsulosin

dutasteride/tamsulosin

terazosin

FLOMAX (tamsulosin)

 

RAPAFLO (silodosin)

 

silodosin

PHOSPHODIESTERASE TYPE 5
(PDE5) INHIBITORS

 

CIALIS (tadalafil)

 

tadalafil

BRONCHODILATORS & COPD
AGENTS

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

ANTICHOLINERGIC-BETA
AGONIST COMBINATIONS

Minimum Age Limit

· 
6 years: SPIRIVA RESPIMAT

 

SPIRIVA
RESPIMAT

· 
Automatic approval issued for diagnosis of
asthma for ≥ 6 years of age

 

BREZTRI
AEROSPHERE

· 
3 claims with BREZTRI AEROSPHERE in the past
105 days OR

· 
New starts require clinical review

 

Non-Preferred Criteria

· 
1 claim for a preferred agent in the past 6
months OR

· 
3 claims with the requested agent in the past
105 days

 

Minimum Age Limit

· 
4 years: SEREVENT, XOPENEX HFA

·  6 years: XOPENEX Solution

·  18 years: BROVANA,
PERFOROMIST, STRIVERDI RESPIMAT

 

Quantity Limit (per 31 days)

·  10.7 units BREZTRI AEROSPHERE

 

XOPENEX HFA and Solution

· 
1 claim for a preferred albuterol (inhaler or
vials) in the past 30 days

 

ANORO ELLIPTA
(umeclidinium/vilanterol)

BEVESPI AEROSPHERE
(glycopyrrolate/formoterol)

COMBIVENT RESPIMAT
(ipratropium/albuterol)

DUAKLIR PRESSAIR
(aclidinium/formoterol)

ipratropium/albuterol

 

STIOLTO RESPIMAT
(tiotropium/olodaterol)

 

ANTICHOLINERGIC-BETA
AGONIST-GLUCOCORTICOIDS COMBINATIONS

 

BREZTRI AEROSPHERE
(budesonide/glycopyrrolate/formoterol) DUR+

 

TRELEGY ELLIPTA
(fluticasone/umeclidinium/vilanterol)

ANTICHOLINERGICS AND COPD
AGENTS

ATROVENT HFA
(ipratropium)

DALIRESP
(roflumilast)

INCRUSE ELLIPTA
(umeclidinium)

OHTUVAYRE
(ensifentrine)

ipratropium

roflumilast

SPIRIVA HANDIHALER
(tiotropium)

SPIRIVA RESPIMAT
(tiotropium) DUR+

 

tiotropium

 

TUDORZA PRESSAIR
(aclidinium)

 

YUPERI (revefenacin)

INHALATION SOLUTION DUR+

albuterol

arformoterol

 

BROVANA
(arformoterol)

 

formoterol,
formoterol fumarate

 

levalbuterol

 

PERFOROMIST
(formoterol)

INHALERS, LONG ACTING DUR+

SEREVENT DISKUS
(salmeterol)

 

STRIVERDI RESPIMAT
(olodaterol)

 

INHALERS, SHORT ACTING

albuterol HFA

levalbuterol HFA

VENTOLIN HFA
(albuterol)

PROAIR DIGIHALER
(albuterol)

 

XOPENEX HFA
(levalbuterol)

ORAL

albuterol IR

albuterol ER

terbutaline

 

CALCIUM
CHANNEL BLOCKERS DUR+

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

LONG-ACTING

Quantity
Limit (per 21 days)

·  252 capsules: nimodipine

· 
2520 mL: nimodipine

 

Non-Preferred
Criteria Long Acting

· 
Have tried 2 different preferred Long Acting
CCB agents in the past 6 months OR

· 
90 days of therapy with the requested agent in
the past 105 days

 

Non-Preferred
Criteria Short Acting

· 
Have tried 2 different preferred Short Acting CCB agents in the past
6 months OR

· 
90 days of therapy with the requested agent in
the past 105 days

 

Nimodipine

· 
Documented diagnosis of subarachnoid hemorrhage
in the past 45 days AND

·  Duration of therapy
limited to 21 days

 

amlodipine

CARDIZEM CD
(diltiazem)

CARTIA XT (diltiazem)

CARDIZEM LA
(diltiazem)

diltiazem ER 24 HR

diltiazem ER 12 HR

diltiazem CD 24 HR

diltiazem LA 24 HR

diltiazem XR 24 HR

KATERZIA (amlodipine)

DILT-XR 24 HR
(diltiazem)

levamlodipine

felodipine

MATZIM LA (diltiazem)

nifedipine ER

nisoldipine

TAZTIA XT (diltiazem)

NORVASC (amlodipine)

verapamil ER

PROCARDIA XL
(nifedipine)

verapamil SR

SULAR (nisoldipine)

 

TIADYLT ER
(diltiazem)

 

TIAZAC (diltiazem)

 

verapamil PM

 

VERELAN PM
(verapamil)

SHORT-ACTING

diltiazem

CARDIZEM (diltiazem)

nicardipine

isradipine

nifedipine

nimodipine
capsule and solution

verapamil

NORLIQVA (amlodipine)

 

NYMALIZE (nimodipine)

CALORIC AGENTS

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

BOOST

All
non-preferred caloric/nutritional agents (which are all other products except
those specifically listed as preferred) require a manual prior authorization.

Non-Preferred Agents MANUAL PA

 

 

 

 

 

 

 

 

 

 

BREAKFAST ESSENTIALS

BRIGHT BEGINNINGS

DUOCAL

ENSURE

NUTREN

OSMOLITE

PEDIASURE

PROMOD

RESOURCE

TWOCAL HN

CEPHALOSPORINS AND RELATED
ANTIBIOTICS (ORAL)

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

BETA LACTAM/BETA-LACTAMASE
INHIBITOR COMBINATIONS

Non-Preferred Criteria All Cephalosporin
Generations

·  Have tried 2
different preferred agents in the past 6 months

 

Maximum Age Limit

·  18 years: cefdinir suspension

 

 

 

 

 

 

 

 

 

 

amoxicillin/clavulanate

amoxicillin/clavulanate
ER

 

AUGMENTIN
(amoxicillin/clavulanate)

CEPHALOSPORINS FIRST
GENERATION

cefadroxil

cephalexin tablet

cephalexin capsule,
suspension

 

CEPHALOSPORINS SECOND
GENERATION

cefaclor capsule

cefaclor ER

cefprozil

cefaclor suspension

cefuroxime

 

CEPHALOSPORINS THIRD
GENERATION

cefdinir

cefixime suspension

cefixime capsule

SUPRAX (cefixime)

cefpodoxime

 

COLONY
STIMULATING FACTORS

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

FULPHILA
(pegfilgrastim-jmdb)

FYLNETRA
(pegfilgrastim-pbbk)

 

NEUPOGEN (filgrastim)

GRANIX
(tbo-filgrastim)

 

LEUKINE
(sargramostim)

 

NEULASTA, NEULASTA
ONPRO (pegfilgrastim)

 

NIVESTYM (filgrastim-aafi)

 

NYVEPRIA
(pegfilgrastim-apgf)

 

RELEUKO
(filgrastim-ayow)

 

RYZNEUTA
(efbemalenograstim alfa-vuxw)NR

 

ROLVEDON
(eflapegrastim-xnst)

 

STIMUFEND
(pegfilgrastim-fpgk)

 

UDENYCA, UDENYCA ONBODY
(pegfilgrastim-cbqv)

 

ZARXIO
(filgrastim-sndz)

 

ZIEXTENZO
(pegfilgrastim-bmez)

CYSTIC FIBROSIS AGENTS DUR+

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

PULMOZYME (dornase
alfa)

ALYFTREK (vanzacaftor/tezacaftor/deutivacaftor)

Minimum Age Limit

· 
1 month: KALYDECO granules

·  3 months: PULMOZYME

· 
1 year: ORKAMBI

·  2 years: COLY-MYCIN M,
TRIKAFTA granules

·  6 years: ALYFTREK, BETHKIS, KALYDECO
tablet, KITABIS, SYMDEKO, TOBI, TOBI PODHALER, TRIKAFTA tablet

· 
7 years: CAYSTON

· 
18 years: BRONCHITOL

 

Maximum Age Limit

· 
2 years: ORKAMBI 75-94 mg granules

· 
5 years: KALYDECO, ORKAMBI
100-125 mg granules, ORKAMBI 200-125 mg granules, TRIKAFTA granules

· 
11 years: TRIKAFTA 50-25-37.5 mg tablets

 

Preferred Agents

· 
Documented diagnosis of Cystic Fibrosis OR

· 
Require clinical review

 

ALYFTREK MANUAL PA

 

KALYDECO MANUAL PA

 

ORKAMBI MANUAL PA

 

SYMDEKO MANUAL PA

 

TOBI PODHALER Require clinical
review

 

TRIKAFTA MANUAL PA

 

tobramycin (generic
TOBI)

BETHKIS (tobramycin)

 

BRONCHITOL (mannitol)

 

CAYSTON (aztreonam)

 

colistimethate

 

COLY-MYCIN M
(colistin)

 

KALYDECO (ivacaftor)

 

KITABIS (tobramycin)

 

ORKAMBI
(lumacaftor/ivacaftor)

 

SYMDEKO
(tezacaftor/ivacaftor)

 

TOBI (tobramycin)

 

TOBI PODHALER
(tobramycin)

 

tobramycin (generic
BETHKIS & KITABIS)

 

TRIKAFTA
(elexacaftor/tezacaftor/ivacaftor)

CYTOKINE
& CAM ANTAGONISTS DUR+

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

ACTEMRA (tocilizumab)
syringe, vial

ABRILADA
(adalimumab-afzb)

Preferred Agents Criteria details found here

 

Non-Preferred Agents

·  Require clinical review

 

IV Administered Agents

·  Require clinical review

 

                                                                         

 

 

AVSOLA
(infliximab-axxq)

ACTEMRA ACTPEN
(tocilizumab)

ENBREL (etanercept)

adalimumab-aaty

HUMIRA (adalimumab)

adalimumab-adaz

KINERET (anakinra)

adalimumab-adbm

methotrexate

adalimumab-fkjp

OLUMIANT
(baricitinib)

adalimumab-ryvk

ORENCIA CLICKJECT
(abatacept)

AMJEVITA
(adalimumab-atto)

ORENCIA VIAL
(abatacept)

ARCALYST (rilonacept)

OTEZLA (apremilast)

BIMZELX
(bimekizumab-bkzx)

RINVOQ (upadacitinib)

CIMZIA (certolizumab)

RINVOQ LQ
(upadacitinib)

COSENTYX
(secukinumab)

SIMPONI (golimumab)

CYLTEZO
(adalimumab-adbm)

TALTZ (ixekizumab)

ENTYVIO (vedolizumab)

TYENNE Syringe, Vial
(tocilizumab-aazg)

HADLIMA
(adalimumab-bwwd)

XELJANZ (tofacitinib)
tablet

HULIO
(adalimumab-fkjp)

 

HYRIMOZ
(adalimumab-adaz)

 

IDACIO (adalimumab-aacf)

 

ILARIS (canakinumab)

 

ILUMYA
(tildrakizumab-asmn)

 

INFLECTRA
(infliximab-dyyb)

 

infliximab

 

JYLAMVO
(methotrexate)

 

KEVZARA (sarilumab)

 

LITFULO
(ritlecitinib)

 

OMVOH
(mirikizumab-mrkz)

 

ORENCIA SYRINGE
(abatacept)

 

OTREXUP
(methotrexate)

 

OTULFI (ustekinumab-aauz)

 

PYZCHIVA (ustekinumab-ttwe)

 

RASUVO (methotrexate)

 

REMICADE (infliximab)

 

RENFLEXIS
(infliximab-abda)

 

SILIQ (brodalumab)

 

SIMLANDI
(adalimumab-ryvk)

 

SIMPONI ARIA
(golimumab)

 

SKYRIZI
(risankizumab-rzaa)

 

SOTYKTU
(deucravacitinib)

 

SPEVIGO
(spesolimab-sbzo)

 

STELARA (ustekinumab)

 

TOFIDENCE
(tocilizumab-bavi)

 

TREMFYA
(guselkumab)

 

TREXALL
(methotrexate)

 

TYENNE Autoinjector
(tocilizumab-aazg)

 

XATMEP (methotrexate)

 

XELJANZ (tofacitinib)
solution

 

XELJANZ XR
(tofacitinib)

 

YESINTEK (ustekinumab-kfce)

 

YUFLYMA
(adalimumab-aaty)

 

YUSIMRY
(adalimumab-aqvh)

 

ZYMFENTRA
(infliximab-dyyb)

ERYTHROPOIESIS STIMULATING
PROTEINS DUR+

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

EPOGEN (epoetin alfa)

ARANESP (darbepoetin
alfa)

Non-Preferred
Criteria

· Documented diagnosis
of cancer or chronic renal failure OR

· 
Antineoplastic therapy in the past 6 months AND

· 
Have tried a preferred RETACRIT or EPOGEN in
the past 6 months OR

· 
1 claim for the requested agent in the past 105
days

JESDUVROQ

· Requires clinical review

 

MIRCERA

·  Documented diagnosis of
chronic renal failure in the past 2 years

MIRCERA (methoxy
polyethylene glycol-epoetin-beta)

JESDUVROQ
(daprodustat)

RETACRIT (epoetin
alfa-epbx)

PROCRIT (epoetin
alfa)

 

VAFSEO (vadadustat)

FACTOR DEFICIENCY PRODUCTS DUR+

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

FACTOR VIII

HEMLIBRA

· 
3 claims with HEMLIBRA in the past 105 days OR

· 
New starts require clinical review MANUAL PA

 

 

 

 

 

 

 

 

 

 

 

ADVATE

ADYNOVATE

AFSTYLA

ELOCTATE

ALPHANATE

ESPEROCT

ALTUVIIIO

JIVI

FEIBA

KCENTRA

HEMOFIL M

OBIZUR

HUMATE-P

VONVENDI

KOATE

 

KOGENATE FS

 

KOVALTRY

 

NOVOEIGHT

 

NUWIQ

 

RECOMBINATE

 

WILATE

 

XYNTHA, XYNTHA
SOLOFUSE

 

FACTOR IX

ALPHANINE SD

BEQVEZ

ALPROLIX

REBINYN

BENEFIX

 

IDELVION

 

IXINITY

 

PROFILNINE

 

RIXUBIS

 

OTHER HEMOPHILIA PRODUCTS

COAGADEX (factor X)

ALHEMO (concizumab-mtci)

FIBRYGA (fibrinogen)

CORIFACT (factor XIII)

HEMLIBRA
(emicizumab-kxwh) DUR+

HYMPAVZI
(marstacimab-hncq)

RIASTAP (fibrinogen)

NOVOSEVEN RT (factor
VII)

 

SEVENFACT (factor
VII)

 

TRETTEN (factor XIII)

FIBROMYALGIA/NEUROPATHIC
PAIN AGENTS

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

duloxetine (generic
CYMBALTA)

CYMBALTA (duloxetine)

 

 

 

 

 

 

gabapentin

DIRZALMA SPRINKLE
(duloxetine)

pregabalin

duloxetine 40 mg DR
capsules (generic IRENKA)

SAVELLA (milnacipran)

gabapentin ER

 

GABARONE (gabapentin)

 

GRALISE (gabapentin)

 

HORIZANT (gabapentin
enacarbil)

 

LYRICA, LYRICA CR (pregabalin)

 

NEURONTIN
(gabapentin)

 

pregabalin ER

FLUOROQUINOLONES DUR+

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

ciprofloxacin tablet

BAXDELA
(delafloxacin)

Non-Preferred Criteria

· 
1 claim for a preferred agent in the past 30
days

 

CIPRO Suspension for Age
< 12 Years

·  Documented diagnosis of
Cystic Fibrosis or Anthrax infection or exposure OR

·  Documented diagnosis or
Pneumonic plague or tularemia AND

· 
History of doxycycline in the past 3 months OR

· 
7 days of therapy with a preferred agent from 2
of the classes below in the past 3 months:

oPenicillin, 2nd or 3rd generation cephalosporin
or macrolide

                            

LEVAQUIN Suspension for Age
< 12 Years

·  Documented diagnosis of Anthrax infection or exposure OR

·  History of 7 days of therapy with a preferred from 2 of the following
classes in the past 3 months

o   
Penicillin, 2nd or 3rd
generation cephalosporins, or macrolide AND

·  History of ciprofloxacin suspension in the past 3 months

 

levofloxacin tablet

CIPRO (ciprofloxacin)

 

ciprofloxacin
suspension

 

levofloxacin solution

 

moxifloxacin

 

ofloxacin

GAUCHER’S DISEASE

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

ELELYSO
(taliglucerase alfa)

CERDELGA (eliglustat)

 

 

 

 

ZAVESCA (miglustat)

CEREZYME
(imiglucerase)

 

miglustat

 

VPRIV (velaglucerase
alfa)

 

YARGESA (miglustat)

GENITAL WARTS & ACTINIC
KERATOSIS AGENTS

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

CONDYLOX (podofilox)

CARAC (fluorouracil)

Minimum Age Limit

·  12 years: ALDARA, ZYCLARA

· 
18 years: CONDYLOX, PICATO, VEREGEN

fluorouracil

EFUDEX (fluorouracil)

imiquimod

VEREGEN
(sinecatechins)

podofilox

ZYCLARA (imiquimod)

GI
ULCER THERAPIES

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

H2 RECEPTOR ANTAGONISTS

Prilosec 2.5 mg suspension

· 
Automatic approval issued for 0-2 years of age

 

Prilosec 10 mg suspension

·  Requires clinical review

 

 

 

 

 

 

 

 

 

famotidine

cimetidine

 

nizatidine

 

PEPCID (famotidine)

OTHERS

CARAFATE (sucralfate)
suspension

CARAFATE (sucralfate)
tablet

misoprostol

CYTOTEC (misoprostol)

sucralfate

DARTISLA
(glycopyrrolate)

 

VOQUEZNA (vonoprazan)

PROTON PUMP INHIBITORS

esomeprazole capsule

DEXILANT (dexlansoprazole)

NEXIUM (esomeprazole)
packet

dexlansoprazole

omeprazole

esomeprazole packet

pantoprazole

KONVOMEP
(omeprazole/sodium bicarbonate)

 

lansoprazole Rx

 

NEXIUM (esomeprazole)
capsule

 

omeprazole/sodium bicarbonate

 

PREVACID
(lansoprazole)

 

PRILOSEC (omeprazole)
packet

 

PROTONIX
(pantoprazole)

 

rabeprazole

 

ZEGERID
(omeprazole/sodium bicarbonate)

GLUCOCORTICOIDS
(INHALED)

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

GLUCOCORTICOIDS

Non-Preferred Criteria

· 
Glucocorticoids

o 2 preferred
single-entity agents in the past 6 months OR

o90 days of therapy
with the requested agent in the past 105 days

·  Glucocorticoid/Bronchodilator
Combinations

o 2 preferred
combination agents in the past 6 months OR

o 90 days of therapy
with the requested agent in the past 105 days

· 
Note:

o Institutional-sized
products are non-preferred

 

AIRDUO DIGIHALER

· 
Requires clinical review

 

ARMONAIR DIGIHALER

· 
Requires clinical review

 

PROAIR DIGIHALER Require clinical
review

 

Minimum Age Limit

·  18 years: AIRSUPRA

 

Quantity Limit (per 31 days)

· 
2 inhalers: AIRSUPRA — MANUAL PA

 

ASMANEX (mometasone)

ALVESCO (ciclesonide)

budesonide 0.25 mg
and 0.5 mg

ARMONAIR DIGIHALER
(fluticasone)

fluticasone diskus

ARNUITY ELLIPTA
(fluticasone)

fluticasone HFA

ASMANEX HFA
(mometasone)

PULMICORT FLEXHALER
(budesonide)

budesonide 1 mg

QVAR REDIHALER
(beclomethasone)

FLOVENT HFA
(fluticasone)

 

FLOVENT DISKUS
(fluticasone)

 

PULMICORT
(budesonide) nebulizer solution

GLUCOCORTICOID/BRONCHODILATOR
COMBINATIONS

ADVAIR DISKUS
(fluticasone/salmeterol)

AIRDUO DIGIHALER
(fluticasone/salmeterol)

ADVAIR HFA (fluticasone/salmeterol)

AIRSUPRA
(albuterol/budesonide)

DULERA
(mometasone/formoterol)

BREO ELLIPTA
(fluticasone/vilanterol)

fluticasone/salmeterol
diskus

BREYNA
(budesonide/formoterol)

fluticasone/salmeterol
HFA

budesonide/formoterol

SYMBICORT
(budesonide/formoterol)

fluticasone/vilanterol

 

WIXELA INHUB
(fluticasone/salmeterol)

GROWTH HORMONES DUR+

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

GENOTROPIN
(somatropin)

HUMATROPE (somatropin)

All Agents

·  Age ≥ 18 years

oDocumented diagnosis
of craniopharyngioma, panhypopituitarism, Prader-Willi Syndrome, Turner
Syndrome or an approvable adult diagnosis OR

o Documented procedure
of cranial irradiation

 

·  Age < 18 years

o Documented diagnosis
of idiopathic short stature AND

o Documented approvable
pediatric diagnosis OR

o Documented approvable
pediatric diagnosis

 

Minimum Age Limit

·  3 years: NGENLA

 

Maximum Age Limit

·  18 years: NGENLA and SKYTROFA

 

Non-Preferred Criteria

· 
Documented approvable diagnosis for age as
above AND

· 
Have tried 1 preferred agent in the past 6
months OR

· 
84 days of therapy with the requested agent in
the past 105 days

 

SKYTROFA

· 
< 18 years AND

· 
No history of diagnosis of Prader-Willi
Syndrome AND

· 
28 days of therapy with a preferred
short-acting growth hormone in the past 105 days

NORDITROPIN FLEXPRO
(somatropin)

NGENLA
(somatrogon-ghla)

SKYTROFA
(lonapegsomatropin-tcgd)

OMNITROPE
(somatropin)

 

SEROSTIM (somatropin)

 

SOGROYA
(somapacitan-beco)

 

VOXZOGO (vosoritide)

 

ZOMACTON (somatropin)

H. PYLORI COMBINATION
TREATMENTS

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

PYLERA (bismuth subcitrate
potassium/metronidazole/ tetracycline)

bismuth subcitrate
potassium/metronidazole/tetracycline

Quantity
Limit

·  1 treatment
course/year: all agents

lansoprazole/amoxicillin/clarithromycin

OMECLAMOX
(omeprazole/clarithromycin/amoxicillin)

TALICIA
(omeprazole/amoxicillin/rifabutin)

 

VOQUEZNA DUAL PAK
(vonoprazan/amoxicillin)

 

VOQUEZNA TRIPLE PAK
(vonoprazan/amoxicillin/clarithromycin)

HEPATITIS
B TREATMENTS

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

entecavir

adefovir dipivoxil

 

lamivudine HBV

BARACLUDE (entecavir)

tenofovir disoproxil
fumarate

VEMLIDY (tenofovir
alafenamide)

 

VIREAD (tenofovir
disoproxil fumarate)

HEPATITIS C TREATMENTS

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

MAVYRET
(glecaprevir/pibrentasvir) ∞

EPCLUSA
(sofosbuvir/velpatasvir) ∞

∞ EPCLUSA, HARVONI,
MAVYRET, SOVALDI, VOSEVI, ZEPATIER

· 
Require MANUAL PA

 

Note:

·  EPCLUSA, HARVONI, MAVYRET and SOVALDI have FDA-approved pediatric
indications

 

PEGASYS
(peginterferon alfa-2a)

HARVONI
(ledipasvir/sofosbuvir) ∞

ribavirin tablet

ledipasvir/sofosbuvir
∞

sofosbuvir/velpatasvir

ribavirin capsule

 

SOVALDI (sofosbuvir) ∞

 

VIEKIRA PAK
(ombitasvir/paritaprevir/ritonavir)

 

VOSEVI
(sofosbuvir/velpatasvir/voxilaprevir) ∞

 

ZEPATIER
(elbasvir/grazoprevir) ∞

HEREDITARY ANGIOEDEMA
TREATMENTS

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

BERINERT (C1 esterase
inhibitor)

CINRYZE (C1 esterase
inhibitor)

 

icatibant

FIRAZYR (icatibant)

 

KALBITOR
(ecallantide)

 

ORLADEYO
(berotralstat)

 

RUCONEST (C1 esterase
inhibitor)

 

SAJAZIR (icatibant)

 

TAKHZYRO
(lanadelumab-flyo)

HYPERURICEMIA
& GOUT DUR+

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

allopurinol

ALOPRIM (allopurinol)

Non-Preferred
Criteria

·  Have tried 2
different preferred agents in the past 6 months

colchicine tablet

colchicine capsule

probenecid

COLCRYS (colchicine)

probenecid/colchicine

febuxostat

 

GLOPERBA (colchicine)

 

MITIGARE (colchicine)

 

ULORIC (febuxostat)

 

ZYLOPRIM
(allopurinol)

HYPOGLYCEMIA TREATMENT

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

BAQSIMI (glucagon)

GVOKE (glucagon) Step
Edit

Minimum
Age Limit

·  1 year: BAQSIMI

·  2 years: GVOKE

·  6 years: ZEGALOGUE

 

Quantity
Limit (per 31 days)

·  2 packs (or kits): BAQSIMI, glucagon,
GVOKE, ZEGALOGUE

 

Non-Preferred
Criteria GVOKE

·  1 claim with preferred BAQSIMI or ZEGALOGUE in the past 30 days

GLUCAGEN (glucagon)

 

glucagon emergency
kit

 

glucagon vial

 

ZEGALOGUE (dasiglucagon)

 

HYPOGLYCEMICS, BIGUANIDES

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

metformin

BRYNOVIN solution
(sitagliptin)

Non-Preferred Criteria

· 
Have tried 2 different preferred DPP4 agents in
the past 6 months OR

· 
90 days of therapy with the requested agent in
the past 105 days

Note:

Concomitant use of a GLP-1 agent and a DPP-4
agent requires clinical review

 

Minimum Age Limit

· 
18 years: BRYNOVIN solution

 

 

metformin ER (generic
GLUCOPHAGE XR)

GLUMETZA (metformin)

JANUMET
(sitagliptin/metformin)

metformin ER (generic
FORTAMET)

JANUMET XR
(sitagliptin/metformin)

metformin ER (generic
GLUMETZA)

JANUVIA (sitagliptin)

metformin solution

JENTADUETO
(linagliptin/metformin)

RIOMET (metformin)

TRADJENTA
(linagliptin)

alogliptin

 

alogliptin/metformin

 

JENTADUETO XR (linagliptin/metformin)

 

KAZANO (alogliptin/metformin)

 

KOMBIGLYZE XR (saxagliptin/metformin)

 

NESINA (alogliptin)

 

ONGLYZA (saxagliptin)

 

OSENI (alogliptin/pioglitazone)

 

saxagliptin

 

saxagliptin/metformin ER

 

sitagliptin

 

sitagliptin/metformin

 

ZITUVIMET (sitagliptin/metformin)

 

ZITUVIMET XR
(sitagliptin/metformin)

 

ZITUVIO (sitagliptin)

HYPOGLYCEMICS,
INCRETIN MIMETICS/ENHANCERS DUR+

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

BYETTA (exenatide)

BYDUREON (exenatide)

Minimum Age Limit

· 
10 years: BYDUREON BCISE, TRULICITY, VICTOZA

· 
18 years: BYETTA, BMOUNJARO, OZEMPIC, RYBELSUS

 

Preferred Criteria

·       
Documented diagnosis of Type 2 Diabetes AND

·       
No history of SAXENDA or WEGOVY in the past 30
days

OR

·       
No documented diagnosis for Type 2 Diabetes AND

·       
84 days of therapy with the requested agent in
the past 105 days

 

Non-Preferred Criteria

·       
Documented diagnosis of Type 2 Diabetes AND

·       
No history of SAXENDA or WEGOVY in the past 30
days AND

·       
84 days of therapy with TRULICITY in the past 6
months AND

·       
84 days of therapy with either preferred BYETTA
or VICTOZA in the past 6 months

OR

·       
Documented diagnosis of Type 2 Diabetes AND

·       
84 days of therapy with the request agent in
the past 105 days

Note:

· 
Concomitant use of a GLP-1 agonist and a DPP-4
agent requires clinical review.

· 
Please see the PDL category Anti-obesity Select
Agents for a list of covered agents.

 

RYBELSUS 1.5 mg
and 3 mg

Require clinical review

 

TRULICITY
(dulaglutide)

exenatide

VICTOZA (liraglutide)

liraglutide

 

MOUNJARO
(tirzepatide)

 

OZEMPIC (semaglutide)

 

RYBELSUS
(semaglutide)

 

SOLIQUA (insulin
glargine/lixisenatide)

 

SYMLINPEN (pramlintide)

 

XULTOPHY (insulin
degludec/liraglutide)

HYPOGLYCEMICS, INSULINS
& RELATED AGENTS DUR+

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

HUMALOG MIX 75/25 vial
(insulin lispro/lispro protamine)

ADMELOG (insulin
lispro)

Non-Preferred Criteria

· 
Documented diagnosis of Diabetes Mellitus AND

· 
Have tried 1 preferred agent in the past 6
months OR

· 
1 claim with the requested agent in the past
105 days

 

Quantity
Limit

·  Insulin quantity limits can be found here

 

Note:

·  Insulin pen formulations are not covered for Long Term Care (LTC)
beneficiaries.

 

 

HUMULIN 70/30 vial
(insulin NPH/regular)

AFREZZA (insulin
regular)

HUMULIN N (insulin
NPH)

APIDRA (insulin
glulisine)

HUMULIN R (insulin
regular)

BASAGLAR (insulin
glargine)

HUMULIN R U-500
(insulin regular)

FIASP (insulin
aspart/niacinamide)

insulin aspart

HUMALOG; HUMALOG
JUNIOR, KWIKPEN, TEMPO PEN (insulin lispro)

insulin aspart
protamine mix 70/30 vial

insulin lispro

HUMALOG MIX KWIKPEN
50/50, 75/25 (insulin lispro/lispro protamine)

insulin lispro
protamine mix 75/25 vial

HUMULIN 70/30 KWIKPEN
(insulin N/regular)

LANTUS (insulin
glargine)

HUMULIN N KWIKPEN
(insulin N)

TOUJEO (insulin
glargine)

insulin degludec

TOUJEO MAX (insulin
glargine)

insulin glargine

 

insulin glargine-yfgn

 

LEVEMIR (insulin
detemir)

 

LYUMJEV (insulin
lispro-aabc)

 

NOVOLIN 70/30
(insulin NPH/regular)

 

NOVOLIN N (insulin
NPH)

 

NOVOLIN R (insulin
regular)

 

NOVOLOG (insulin
aspart)

 

NOVOLOG MIX 70/30
(insulin aspart protamine/aspart)

 

REZVOGLAR (insulin
glargine-aglr)

 

SEMGLEE (insulin
glargine-yfgn)

 

TRESIBA (insulin
degludec)

HYPOGLYCEMICS, MEGLITINIDES
DUR+

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

nateglinide

 

 

 

repaglinide

 

HYPOGLYCEMICS, SODIUM
GLUCOSE COTRANSPORTER-2 (SGLT-2) INHIBITORS DUR+

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

SGLT-2 INHIBITORS

Non-Preferred Criteria

· 
Have tried 2 different preferred SGLT-2
inhibitors in the past 6 months OR

· 
90 days of therapy with the requested agent in
the past 105 days

 

 

 

 

 

 

 

FARXIGA
(dapagliflozin)

dapagliflozin

JARDIANCE
(empagliflozin)

INPEFA
(sotagliflozin)

 

INVOKANA
(canagliflozin)

 

STEGLATRO
(ertugliflozin)

SGLT-2 INHIBITOR
COMBINATIONS

GLYXAMBI
(empagliflozin/linagliptin)

dapagliflozin/metformin
ER

SYNJARDY (empagliflozin/metformin)

INVOKAMET
(canagliflozin/metformin)

SYNJARDY XR
(empagliflozin/metformin)

INVOKAMET XR
(canagliflozin/metformin)

TRIJARDY XR
(empagliflozin/linagliptin/metformin)

QTERN
(dapagliflozin/saxagliptin)

 

SEGLUROMET
(ertugliflozin/metformin)

 

STEGLUJAN
(ertugliflozin/sitagliptin)

 

XIGDUO XR
(dapagliflozin/metformin)

HYPOGLYCEMICS,
THIAZOLIDINEDIONES (TZDs) and TZD Combinations

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

pioglitazone

ACTOPLUS MET
(pioglitazone/metformin)

 

pioglitazone/metformin

ACTOS (pioglitazone)

pioglitazone/glimepiride

DUETACT
(pioglitazone/glimepiride)

IDIOPATHIC PULMONARY
FIBROSIS DUR+

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

OFEV (nintedanib)

ESBRIET (pirfenidone)

All Agents

·   Documented
diagnosis of Idiopathic Pulmonary Fibrosis

 

OFEV

·   Documented diagnosis
of Idiopathic Pulmonary Fibrosis OR

·  
90
days of therapy with Ofev in the past 105 days

 

ESBRIET or
pirfenidone

·   Requires clinical
review

 

pirfenidone

IMMUNE
GLOBULINS

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

BIVIGAM

ALYGLO

 

 

 

 

 

 

 

 

 

 

 

FLEBOGAMMA

ASCENIV

GAMASTAN

CABLIVI

GAMMAGARD

CUTAQUIG

GAMMAGARD S-D

CUVITRU

GAMUNEX-C

GAMMAKED

HIZENTRA

GAMMAPLEX

HYQVIA

OCTAGAM

PANZYGA

 

PRIVIGEN

 

XEMBIFY

 

IMMUNOLOGIC THERAPIES FOR
ASTHMA

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

DUPIXENT (dupilumab) DUR+

CINQAIR (reslizumab)

CINQAIR

· 
Requires clinical review

See below for additional PA Criteria/DUR+ Rules

FASENRA
(benralizumab)

NUCALA (mepolizumab)

XOLAIR (omalizumab)

TEZSPIRE
(tezepelumab-ekko)

DUPIXENT

· 
1 claim with DUPIXENT in the past 60 days OR

· 
New starts require clinical review (see manual
PA links below)

o   Asthma MANUAL PA

o  Atopic Dermatitis MANUAL PA

o  COPD MANUAL PA

o   Eosinophilic Esophagitis MANUAL PA

o   Nasal Polyposis MANUAL PA

o   Prurigo Nodularis MANUAL PA

 

FASENRA

·  Requires clinical
review MANUAL PA

 

NUCALA

· 
Requires clinical review

 

TEZSPIRE

· 
Requires clinical review

 

XOLAIR

· 
1 claim with XOLAIR in the past 45 days OR

· 
New starts require clinical review MANUAL
PA

IMMUNOSUPPRESSIVE AGENTS, ORAL

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

AZASAN (azathioprine)

ASTAGRAF XL
(tacrolimus)

Minimum Age Limit

· 
13 years: RAPAMUNE

·  18 years: ZORTRESS

 

Maximum Age Limit

· 
12 years: PROGRAF Granules

 

 

 

 

 

azathioprine

ENVARSUS XR
(tacrolimus)

CELLCEPT
(mycophenolate)

MYFORTIC
(mycophenolate)

cyclosporine

PROGRAF (tacrolimus)

everolimus

REZUROCK
(belumosudil)

mycophenolate

ZORTRESS (everolimus)

mycophenolic acid

 

NEORAL (cyclosporine)

 

RAPAMUNE (sirolimus)

 

SANDIMMUNE
(cyclosporine)

 

sirolimus

 

tacrolimus

 

 

Preferred Criteria

·  AZASAN

o Documented diagnosis
of kidney transplant, RA, or a State-accepted diagnosis

·  CELLCEPT

o Documented diagnosis
of heart, kidney, or liver transplant or a State-accepted diagnosis

·  GENGRAF, NEORAL,
SANDIMMUNE

o Documented diagnosis
of heart transplant, kidney transplant, liver transplant, psoriasis, RA, or a
State-accepted diagnosis

·  Everolimus

o Documented diagnosis
of kidney or liver transplant

·  RAPAMUNE

o Documented diagnosis
of kidney transplant

·  Tacrolimus

o Documented diagnosis
of heart, kidney, liver, or lung transplant or a State-accepted diagnosis

 

Non-Preferred Criteria

·  MYHIBBIN Suspension

o Documented diagnosis
of heart, kidney, or liver transplant or a State-accepted diagnosis AND

o 30 days of therapy
with mycophenolate suspension in the past 105 days OR

o 90 days of therapy
with MYHIBBIN Suspension in the past 105 days

·  ASTAGRAF XR or
ENVARSUS XR

oDocumented diagnosis
of heart, kidney, liver, or lung transplant or a State-accepted diagnosis AND

o 30 days of therapy
with tacrolimus IR in the past 105 days OR

o 90 days of therapy
with the requested agent in the past 105 days

·  PROGRAF Granules

oAge ≤ 11 years AND

oDocumented diagnosis
of heart, kidney, liver, or lung transplant or a State-accepted diagnosis

·  MYFORTIC

o Documented diagnosis
of kidney transplant or psoriasis

·  ZORTRESS

oDocumented diagnosis
of kidney or liver transplant

 

INTRANASAL
RHINITIS AGENTS

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

ANTICHOLINERGICS

Non-Preferred
Criteria Corticosteroids

· 
Documented diagnosis of allergic rhinitis AND

·  Have tried 1
different preferred agent in the past 6 months

 

 

ipratropium

 

ANTIHISTAMINE/CORTICOSTEROID
COMBINATIONS

 

azelastine/fluticasone

 

DYMISTA
(azelastine/fluticasone)

 

RYALTRIS
(olopatadine/mometasone)

ANTIHISTAMINES

azelastine

olopatadine

 

PATANASE
(olopatadine)

CORTICOSTEROIDS

fluticasone

BECONASE AQ
(beclomethasone)

 

flunisolide

 

mometasone

 

NASONEX (mometasone)

 

OMNARIS (ciclesonide)

 

QNASL
(beclomethasone)

 

XHANCE (fluticasone)

 

ZETONNA (ciclesonide)

IRON CHELATING AGENTS

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

deferasirox (all
manufacturers except those listed as non-preferred)

deferasirox
(manufacturers starting with 45963, 62332)

JADENU MANUAL PA

 

 

deferiprone 1,000 mg
tablet

deferiprone 500 mg
tablet

EXJADE (deferasirox)

FERRIPROX
(deferiprone)

JADENU, JADENU
SPRINKLE (deferasirox)

IRRITABLE BOWEL SYNDROME/SHORT
BOWEL SYNDROME AGENTS/SELECTED AGENTS DUR+

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

IRRITABLE BOWEL SYNDROME
CONSTIPATION DUR+

Minimum Age Limit

·  1 year: GATTEX

·  6 years: LINZESS 72 mcg

·  18 years: AMITIZA, IBSRELA,
LINZESS 145 mcg & 290 mcg, MOTEGRITY, MOVANTIK, MYTESI, RELISTOR,
SYMPROIC, TRULANCE, VIBERZI

 

Gender Limit

·  Female AMITIZA 8 mcg

 

 

 

LINZESS (linaclotide)

AMITIZA
(lubiprostone)

lubiprostone

IBSRELA (tenapanor)

TRULANCE
(plecanatide)

MOTEGRITY
(prucalopride)

 

MOVANTIK (naloxegol)

 

prucalopride

 

RELISTOR
(methylnaltrexone)

 

SYMPROIC
(naldemedine)

IRRITABLE BOWEL SYNDROME
DIARRHEA

dicyclomine

alosetron

ED-SPAZ (hyoscyamine)

LOTRONEX (alosetron) DUR+

hyoscyamine,
hyoscyamine ER

VIBERZI (eluxadoline)
DUR+

HYOSYNE (hyoscyamine)

 

LEVSIN, LEVSIN-SL
(hyoscyamine)

 

NULEV (hyoscyamine)

 

OSCIMIN, OSCIMIN SL
(hyoscyamine)

 

SHORT BOWEL SYNDROME AND
SELECTED GI AGENTS DUR+

 

GATTEX (teduglutide)

 

MYTESI (crofelemer)

IRRITABLE BOWEL SYNDROME CONSTIPATION DUR+

Chronic Idiopathic
Constipation (CIC): Amitiza 24 mcg, LINZESS 72 mcg, LINZESS 145
mcg, MOTEGRITY, TRULANCE

·  Preferred CIC Agents

o Documented diagnosis of
CIC in the past year AND

o No history of GI or bowel
obstruction

·  LINZESS 72 mcg

o Age 6-17 years AND

o Documented diagnosis of
CIC or pediatric functional constipation in the past year AND

o No history of GI or bowel
obstruction

·  Non-Preferred CIC Agents

o Documented diagnosis of
CIC AND

o No history of GI or bowel
obstruction AND

o Have tried 2 preferred CIC
agents in the past 6 months OR

o 1 claim with the requested
agent in the past 105 days

 

Irritable Bowel Syndrome
Constipation Dominant (IBS-C): AMITIZA 8 mcg, IBSRELA, LINZESS 290 mcg,
TRULANCE

·  Preferred IBS-C Agents

o Documented diagnosis of
IBS-C in the past year AND

o No history of GI or bowel
obstruction

·  Non-Preferred IBS-C Agents

o Documented diagnosis of
IBS-C in the past year AND

o No history of GI or bowel
obstruction AND

o Have tried 2 preferred
IBS-C agents in the past 6 months OR

o 1 claim with the requested
agent in the past 105 days

 

Opioid Induced
Constipation (OIC): AMITIZA 24 mcg, MOVANTIK, RELISTOR, SYMPROIC

·  Preferred OIC Agents

o Documented diagnosis of
OIC and chronic pain in the past year AND

o No history of GI or bowel
obstruction AND

o 1 claim for an opioid in
the past 30 days

·  Non-Preferred OIC Agents

o All preferred criteria met
AND

o Have tried 1 preferred OIC
agents in the past 6 months OR

o 1 claim with the requested
agent in the past 105 days

 

 

·  Relistor Injection

o Above OIC criteria OR

o Documented diagnosis of
OIC and active cancer in the past year AND

o No history of GI or bowel
obstruction AND

o 1 claim for an opioid in
the past 30 days

 

IRRITABLE BOWEL SYNDROME DIARRHEA

·  VIBERZI [New starts require
clinical review]

Documented diagnosis of
IBS D in the past year and 1 claim for Viberzi in the past 105 days

o  

· 
LOTRONEX

o 1 claim for LOTRONEX in
the past 105 days OR

o New starts require
clinical review MANUAL PA

· 
XIFAXAN (see Antibiotics, GI)

 

SHORT BOWEL SYNDROME AND SELECTED GI AGENTS DUR+

HIV/AIDS
Non-infectious Diarrhea

·  MYTESI

o Documented diagnosis
of HIV/AIDS and non-infectious diarrhea in the past year AND

o 1 claim for an antiretroviral
in the past 30 days

Short Bowel Syndrome
(SBS)

·  GATTEX

o 1 claim for GATTEX in
the past 105 days OR

o New starts require
clinical review

 

 

 

LEUKOTRIENE MODIFIERS DUR+

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

montelukast

ACCOLATE
(zafirlukast)

Minimum Age Limit

·  12 years: ZYFLO & ZYFLO
CR

 

Non-Preferred Criteria

· 
Have tried 2 different preferred agents in the
past 6 months

zafirlukast

SINGULAIR
(montelukast)

 

zileuton

 

ZYFLO (zileuton)

LIPOTROPICS,
OTHER (NON-STATINS)

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

ACL INHIBITORS AND
COMBINATIONS

Non-Preferred Criteria Fibric Acid
Derivatives

o Have tried 2 different
preferred Fibric Acid Derivative agents in the past 6 months

 

JUXTAPID MANUAL PA

 

KYNAMRO

· 
Requires clinical review

 

LEQVIO

· 
Requires clinical review

 

NEXLETOL and NEXLIZET

· 
Require clinical review

 

PRALUENT MANUAL PA

 

REPATHA MANUAL PA

 

WELCHOL

· 
Documented diagnosis of Type 2 Diabetes AND

· 
30 days of therapy with an antidiabetic agent
in the past 6 months OR

90 days of therapy with WELCHOL in the past 105 days

 

 

NEXLETOL (bempedoic
acid)

 

NEXLIZET (bempedoic
acid/ezetimibe)

ANGIOPOIETIN-LIKE 3
INHIBITORS

 

EVKEEZA
(evinacumab-dgnb)

BILE ACID SEQUESTRANTS

cholestyramine

colesevelam

cholestyramine light

COLESTID (colestipol)

colestipol tablet

colestipol packet

 

PREVALITE
(cholestyramine)

 

QUESTRAN
(cholestyramine)

 

QUESTRAN LIGHT
(cholestyramine)

 

WELCHOL (colesevelam)

CHOLESTEROL ABSORPTION
INHIBITORS

ezetimibe

ZETIA (ezetimibe)

FIBRIC ACID DERIVATIVES

fenofibrate

fenofibric acid

gemfibrozil

FENOGLIDE
(fenofibrate)

 

FIBRICOR (fenofibric
acid)

 

LIPOFEN (fenofibrate)

 

LOPID (gemfibrozil)

 

TRICOR (fenofibrate)

 

TRILIPIX (fenofibric
acid)

MTP INHIBITOR

 

JUXTAPID (lomitapide)

NIACIN

niacin ER

 

OMEGA-3 FATTY ACIDS

omega-3 acid ethyl
esters

icosapent ethyl

 

LOVAZA (omega-3 acid
ethyl esters)

PCSK-9
INHIBITORS

REPATHA (evolocumab)

LEQVIO (inclisiran)

 

PRALUENT (alirocumab)

LIPOTROPICS, STATINS DUR+

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

STATINS

Minimum Age Limit

·  10 years: ATORVALIQ
Suspension

 

Non-Preferred Criteria

· 
Have tried 2 different preferred statin or
statin combination agents in the past 6 months OR

·  90 days of therapy
with the requested agent in the past 105 days

 

Simvastatin

Daily doses ≥
80 mg require clinical review

atorvastatin

ALTOPREV (lovastatin)

lovastatin

ATORVALIQ
(atorvastatin)

pravastatin

CRESTOR
(rosuvastatin)

rosuvastatin

EZALLOR SPRINKLE
(rosuvastatin)

simvastatin

FLOLIPID
(simvastatin)

 

fluvastatin

 

fluvastatin ER

 

LESCOL XL
(fluvastatin)

 

LIPITOR
(atorvastatin)

 

LIVALO (pitavastatin)

 

pitavastatin

 

ZOCOR (simvastatin)

 

ZYPITAMAG
(pitavastatin)

STATIN
COMBINATIONS

ezetimibe/simvastatin

amlodipine/atorvastatin

 

CADUET
(amlodipine/atorvastatin)

 

VYTORIN
(ezetimibe/simvastatin)

MISCELLANEOUS
BRAND/GENERIC

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

ALLERGEN
EXTRACT IMMUNOTHERAPY

CUMULATIVE quantity limit (per 31 days)

·  31 tablets: alprazolam ER

 

Quantity Limit (per 31 days)

·  2 kits: epinephrine

 

EVRYSDI MANUAL PA

 

 

GRASTEK

 

ORALAIR

 

RAGWITEK

EPINEPHRINE

epinephrine (Mylan)

AUVI-Q (epinephrine)

 

epinephrine (all
other manufacturers)

 

EPIPEN (epinephrine)

                          

EPIPEN JR
(epinephrine)

 

NEFFY (epinephrine)

MISCELLANEOUS

alprazolam

alprazolam ER

hydroxyzine HCL

CAMZYOS (mavacamten)

hydroxyzine pamoate

CRENESSITY (crinecerfont)

megestrol

EVRYSDI (risdiplam)

REVLIMID
(lenalidomide)

KORLYM (mifepristone)

 

lenalidomide

 

TRYNGOLZA (olezarsen)

 

VERQUVO (vericiguat)

 

VISTARIL (hydroxyzine
pamoate)

 

XANAX, XANAX XR
(alprazolam)

SUBLINGUAL
NITROGLYCERIN

 

nitroglycerin

 

NITROLINGUAL
(nitroglycerin)

 

NITROSTAT
(nitroglycerin)

 

MOVEMENT DISORDER AGENTS DUR+

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

AUSTEDO
(deutetrabenazine)

INGREZZA INITIATION
PACK (valbenazine)

AUSTEDO and AUSTEDO XR

·  Documented diagnosis
of Huntington’s chorea OR

· 
Documented diagnosis of tardive dyskinesia AND

· 
90 days of therapy with either agent in the
past 105 days OR

· 
New starts require clinical review MANUAL PA

 

 

INGREZZA

·  Documented diagnosis
of Huntington’s chorea OR

· 
Documented diagnosis of tardive dyskinesia AND

· 
90 days of therapy with this agent in the past
105 days OR

· 
New starts require clinical review MANUAL PA

AUSTEDO XR
(deutetrabenazine)

XENAZINE
(tetrabenazine)

INGREZZA
(valbenazine)

 

INGREZZA SPRINKLE (valbenazine)

 

tetrabenazine

 

MULTIPLE
SCLEROSIS AGENTS DUR+

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

BETASERON (interferon
beta-1b)

AMPYRA
(dalfampridine)

Preferred
Agents

·  Documented diagnosis of
multiple sclerosis

 

Non-Preferred Criteria

· 
Documented diagnosis of multiple sclerosis AND

· 
Have tried 2 different preferred agents in the
past 6 months OR

· 
3 claims with the requested agent in the last
105 days

 

KESIMPTA, PONVORY, TASCENSO
ODT, and ZEPOSIA

· 
Require clinical review

 

MAVENCLAD MANUAL PA

 

MAYZENT MANUAL PA

 

OCREVUS and OCREVUS ZUNOVO MANUAL PA

COPAXONE (glatiramer)
20 mg

AUBAGIO
(teriflunomide)

dalfampridine ER

AVONEX (interferon
beta-1a)

dimethyl fumarate

BAFIERTAM (monomethyl
fumarate)

fingolimod

BRIUMVI
(ublituximab-xiiy)

REBIF (interferon
beta-1b)

COPAXONE (glatiramer)
40 mg

REBIF REBIDOSE
(interferon beta-1b)

GILENYA (fingolimod)

teriflunomide

glatiramer

TYSABRI (natalizumab)

GLATOPA (glatiramer)

 

KESIMPTA PEN
(ofatumumab)

 

MAVENCLAD
(cladribine)

 

MAYZENT (siponimod)

 

OCREVUS (ocrelizumab)

 

OCREVUS
ZUNOVO (ocrelizumab/hyaluronidase-ocsq)

 

PLEGRIDY (peginterferon
beta-1a)

 

PONVORY (ponesimod)

 

TASCENSO ODT
(fingolimod)

 

TECFIDERA (dimethyl
fumarate)

 

VUMERITY (diroximel
fumarate)

 

ZEPOSIA (ozanimod)

MUSCULAR
DYSTROPHY AGENTS

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

EMFLAZA (deflazacort)

AGAMREE (vamorolone)

AGAMREE MANUAL PA

 

ELEVIDYS MANUAL PA

 

EMFLAZA MANUAL PA

 

EXONDYS MANUAL PA

 

VILTEPSO MANUAL PA

 

VYONDYS MANUAL PA

 

 

AMONDYS-45
(casimersen)

 

deflazacort

 

DUVYZAT
(givinostat)

 

ELEVIDYS
(delandistrogene moxeparvovec-rokl)

 

EXONDYS-51
(eteplirsen)

 

VILTEPSO
(viltolarsen)

 

VYONDYS-53
(golodirsen)

NSAIDS

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

COX
II SELECTIVE

Quantity Limit (per 31 days)

·  20 tablets: ketorolac tablets

 

ELYXYB

·  Requires clinical
review

 

Non-Preferred
Criteria COX II Selective

· 
No history of a contraindicated GI disorder or coagulation disorder AND

·  Documented diagnosis of
Osteoarthritis, Rheumatoid Arthritis, Familial Adenomatous Polyposis, or
Ankylosing Spondylitis AND

·  Have tried 1 preferred
COX-II selective agent OR

·  90 days of therapy with
the requested agent in the past 105 days

 

Non-Preferred Criteria Non-Selective &
Combinations

·  No history of a
contraindicated GI disorder or coagulation disorder AND

·  Have tried 2 different preferred non-selective
agents in the past 6 months

 

meloxicam

CELEBREX (celecoxib)

 

celecoxib

 

ELYXYB (celecoxib)

NON-SELECTIVE

diclofenac sodium

DAYPRO (oxaprozin)

diclofenac sodium ER

diclofenac potassium

EC-naproxen DR 500 mg
tablet

DOLOBID
(diflunisal)

etodolac tablet

etodolac capsule,
etodolac ER

flurbiprofen

FELDENE (piroxicam)

ibuprofen

fenoprofen

indomethacin capsule

indomethacin ER,
indomethacin suppository

ketoprofen

ketoprofen

ketorolac

kiprofen

nabumetone

LOFENA (diclofenac
potassium)

naproxen 250 mg, 500
mg

meclofenamate

piroxicam

mefenamic acid

sulindac

NALFON (fenoprofen)

 

NAPRELAN (naproxen)

 

NAPROSYN 375 mg
(naproxen)

 

naproxen 375 mg,
naproxen CR 375 mg, naproxen ER 500 mg

 

oxaprozin

 

RELAFEN DS
(nabumetone)

 

TOLECTIN 600 mg
(tolmetin)

 

tolmetin

NSAID/GI
PROTECTANT COMBINATIONS

 

ARTHROTEC 50 mg, 75
mg (diclofenac/misoprostol)

 

diclofenac/misoprostol

 

ibuprofen/famotidine

 

naproxen/esomeprazole

 

VIMOVO
(naproxen/esomeprazole)

OPHTHALMIC AGENTS

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

ANTIBIOTICS

Minimum Age Limit

·  16 years: RESTASIS

·  17 years: XIIDRA

· 
18 years: CEQUA, MIEBO, TRYPTYR, VEVYE

 

Quantity Limit (per 31 days)

·  2 mL: VEVYE

·  3 mL: MIEBO

·  5.5 mL: RESTASIS Multidose

· 
60 units: CEQUA, RESTASIS
Droperette, TRYPTYR, XIIDRA

 

Non-Preferred Criteria

·  Anti-Inflammatory Agents

o Have tried 2 different preferred
agents in the past 6 months

 

·  Dry Eye Agents

o History of 1 claim for
both RESTASIS Droperette and XIIDRA in the past 6 months

 

EYSUVIS

·  Require clinical
review

 

MIEBO

·  Requires clinical
review

 

RESTASIS Multidose

·  Require clinical
review

 

TRYPTYR

·  Requires clinical
review

 

TYRVAYA

·  Requires clinical
review

 

VEVYE

·  Requires clinical
review

 

bacitracin/polymyxin

AZASITE
(azithromycin)

ciprofloxacin

bacitracin

erythromycin

BESIVANCE
(besifloxacin)

gentamicin

CILOXAN
(ciprofloxacin)

moxifloxacin

gatifloxacin

ofloxacin

NATACYN (natamycin0

polymyxin
B/trimethoprim

neomycin/bacitracin/polymyxin

tobramycin

OCUFLOX (ofloxacin)

 

sulfacetamide

 

TOBREX (tobramycin)

 

VIGAMOX
(moxifloxacin)

ANTIBIOTIC-STEROID
COMBINATIONS

BLEPHAMIDE S.O.P.
(sulfacetamide/prednisolone)

MAXITROL
(neomycin/polymyxin/dexamethasone)

neomycin/bacitracin/polymyxin/hydrocortisone

neomycin/polymyxin/gramicidin

neomycin/polymyxin/dexamethasone

TOBRADEX ST (tobramycin/dexamethasone)

PRED-G
(gentamicin/prednisolone)

 

sulfacetamide/prednisolone

 

TOBRADEX
(tobramycin/dexamethasone)

 

tobramycin/dexamethasone

 

ZYLET
(tobramycin/loteprednol)

 

ANTI-INFLAMMATORY
AGENTSDUR+

dexamethasone

ACULAR, ACULAR LS
(ketorolac)

diclofenac sodium

ACUVAIL (ketorolac)

difluprednate

bromfenac

FLAREX
(fluorometholone)

BROMSITE (bromfenac)

fluorometholone

DUREZOL
(difluprednate)

flurbiprofen

FML (fluorometholone)

FML FORTE
(fluorometholone)

ILEVRO (nepafenac)

ketorolac

INVELTYS
(loteprednol)

MAXIDEX
(dexamethasone)

LOTEMAX, LOTEMAX SM
(loteprednol)

PRED MILD
(prednisolone)

loteprednol

prednisolone acetate

NEVANAC (nepafenac)

prednisolone sodium
phosphate

PRED FORTE
(prednisolone)

 

PROLENSA (bromfenac)

DRY
EYE AGENTS

RESTASIS Droperette
(cyclosporine)

CEQUA (cyclosporine)

XIIDRA (lifitegrast)

cyclosporine

 

EYSUVIS (loteprednol)

 

MIEBO
(perfluorohexyloactane)

 

RESTASIS Multidose
(cyclosporine)

 

TYRVAYA (varenicline)

 

VEVYE (cyclosporine)

OPHTHALMIC, GLAUCOMA AGENTS

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

BETA
BLOCKERS

Minimum Age Limit

· 
18 years: IYUZEH

 

Non-Preferred Criteria

· 
Have tried 2 different preferred agents in the
past 6 months OR

·  90 days of therapy
with the requested agent in the past 105 days

 

 

 

 

 

 

 

 

 

 

BETIMOL (timolol)

betaxolol

carteolol

BETOPTIC S
(betaxolol)

ISTALOL (timolol)

timolol droperette,
daily drop, gel

levobunolol

TIMOPTIC; TIMOPTIC
OCUDOSE, XE (timolol)

timolol drops 0.25%,
0.5%

 

CARBONIC
ANHYDRASE INHIBITORS

dorzolamide

AZOPT (brinzolamide)

 

brinzolamide

COMBINATION
AGENTS

COMBIGAN
(brimonidine/timolol)

brimonidine/timolol

dorzolamide/timolol

COSOPT
(dorzolamide/timolol)

SIMBRINZA
(brinzolamide/brimonidine)

dorzolamide/timolol
PF

PARASYMPATHOMIMETICS

pilocarpine

PHOSPHOLINE IODIDE
(echothiophate iodide)

PROSTAGLANDIN
ANALOGS

latanoprost

bimatoprost

 

IYUZEH (latanoprost)

 

LUMIGAN (bimatoprost)

 

tafluprost

 

TRAVATAN Z
(travoprost)

 

travoprost

 

VYZULTA (latanoprostene
bunod)

 

XALATAN (latanoprost)

 

XELPROS (latanoprost)

 

ZIOPTAN (tafluprost)

RHO
KINASE INHIBITORS/COMBINATIONS

RHOPRESSA
(netarsudil)

 

ROCKLATAN
(netarsudil/latanoprost)

 

SYMPATHOMIMETICS

ALPHAGAN P (brimonidine)

brimonidine 0.1%,
0.15%

brimonidine 0.2%

 

OPHTHALMICS FOR ALLERGIC
CONJUNCTIVITIS

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

ALREX (loteprednol)

ALOCRIL (nedocromil)

Non-Preferred
Criteria

· 
Have tried 2 different preferred agents in the
past 6 months

 

VERKAZIA

·  Requires clinical
review

azelastine

ALOMIDE (lodoxamide)

cromolyn

bepotastine

ketotifen OTC

BEPREVE (bepotastine)

olopatadine

epinastine

ZADITOR (ketotifen)

LASTACAFT
(alcaftadine)

 

VERKAZIA
(cyclosporine)

 

ZERVIATE (cetirizine)

OPIATE
DEPENDENCE TREATMENTS

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

DEPENDENCE

Buprenorphine/naloxone
provider summary found here

 

 

SUBLOCADE MANUAL PA

 

VIVITROL MANUAL PA

buprenorphine/naloxone
SL tablet DUR+

BRIXADI
(buprenorphine)

naltrexone

buprenorphine
DUR+

SUBOXONE
(buprenorphine/naloxone) DUR+

buprenorphine/naloxone
film DUR+

 

lofexidine

 

LUCEMYRA (lofexidine)

 

SUBLOCADE
(buprenorphine)

 

VIVITROL (naltrexone)

 

ZUBSOLV
(buprenorphine/naloxone)

TREATMENT

KLOXXADO (naloxone)

LIFEMS NALOXONE
(naloxone convenience kit)

naloxone

 

NARCAN (naloxone)

 

OPVEE (nalmefene)

 

REXTOVY (naloxone)

 

ZIMHI (naloxone)

 

OTIC ANTIBIOTICS

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

CIPRO HC
(ciprofloxacin/hydrocortisone)

ciprofloxacin

Maximum Age Limit

· 
9 years: CIPRO HC

 

Ciprofloxacin/Dexamethasone
Suspension Criteria

· 
Age ≥ 6 months AND

· 
Experiencing otorrhea secondary to recent,
post-tympanostomy tube placement AND

· 
Continued otorrhea after 10 days of otic
treatment with ciprofloxacin ophthalmic solution and dexamethasone
ophthalmic suspension

CORTISPORIN-TC
(neomycin/colistin/hydrocortisone)

ciprofloxacin/fluocinolone

fluocinolone

ciprofloxacin/dexamethasone

neomycin/polymyxin/hydrocortisone

DERMOTIC
(fluocinolone)

 

FLAC OTIC OIL
(fluocinolone)

 

hydrocortisone/acetic
acid

 

OTOVEL
(ciprofloxacin/fluocinolone)

PANCREATIC ENZYMES

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

CREON
(lipase/protease/amylase)

PERTZYE
(lipase/protease/amylase)

Non-Preferred Criteria

· 
Have tried 2 different preferred agents in the
past 6 months

ZENPEP
(lipase/protease/amylase)

VIOKACE
(lipase/protease/amylase)

PARATHYROID
AGENTS

PREFERRED
AGENTS

NON-PREFERRED
AGENTS

PA
CRITERIA

calcitriol

doxercalciferol

 

cinacalcet

RAYALDEE (calcifediol)

ergocalciferol

ROCALTROL (calcitriol)

paricalcitol

SENSIPAR (cinacalcet)

ZEMPLAR (paricalcitol)

YORVIPATH
(palopegteriparatide)

PHOSPHATE BINDERS

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

calcium acetate

AURYXIA (ferric
citrate)

 

CALPHRON (calcium
acetate)

FOSRENOL (lanthanum)

sevelamer carbonate
tablet

lanthanum

 

MAGNEBIND (calcium
carbonate/magnesium)

 

RENVELA (sevelamer)

 

sevelamer carbonate
packet, sevelamer HCl

 

VELPHORO (sucroferric
oxyhydroxide)

 

XPHOZAH (tenapanor)

PLATELET AGGREGATION
INHIBITORS

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

aspirin/dipyridamole

EFFIENT (prasugrel)

Non-Preferred Criteria

· 
Documented diagnosis AND

· 
Have tried 2 different preferred agents in the
past 6 months OR

·  90 days of therapy
with the requested agent in the past 105 days

 

ZONTIVITY MANUAL PA

BRILINTA (ticagrelor)

PLAVIX (clopidogrel)

cilostazol

ticagrelorNR

clopidogrel

 

dipyridamole

 

pentoxifylline

 

prasugrel

 

PLATELET STIMULATING AGENTS

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

NPLATE (romiplostim)

ALVAIZ (eltrombopag)

 

PROMACTA
(eltrombopag) tablet

DOPTELET
(avatrombopag)

 

MULPLETA
(lusutrombopag)

 

PROMACTA
(eltrombopag) packet

 

TAVALISSE
(fostamatinib)

POTASSIUM REMOVING AGENTS

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

LOKELMA (sodium
zirconium cyclosilicate)

KIONEX (sodium
polystyrene sulfonate)

 

SPS (sodium
polystyrene sulfonate) suspension

sodium polystyrene
sulfonate

 

SPS (sodium
polystyrene sulfonate) enema

 

VELTASSA (patiromer
calcium sorbitex)

PRENATAL VITAMINS

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

CLASSIC PRENATAL

All prenatal vitamins are non-preferred except
for those specifically indicated as preferred.

 

 

 

 

 

 

List of Preferred NDC’s for Prenatal Vitamins can be found here

COMPLETE NATAL DHA

COMPLETENATE

M-NATAL PLUS

NIVA-PLUS

PRENATAL PLUS
VITAMIN-MINERAL

PNV 72, 95, 124, and
137 / IRON / FOLIC ACID

SE-NATAL-19

STUART ONE

THRIVITE RX

TRICARE

TRINATAL RX 1

WESNATAL DHA COMPLETE

WESTAB PLUS

PSEUDOBULBAR AFFECT AGENTS

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

 

NUEDEXTA
(dextromethorphan/quinidine)

Non-Preferred Criteria

· 
Documented diagnosis of pseudobulbar affect
disorder OR

·  90 days of therapy
with NUEDEXTA in the past 105 days

PULMONARY
ANTIHYPERTENSIVE AGENTS

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

ACTIVIN
SIGNALING INHIBITORS

Minimum Age Limit

· 
18 years: ADEMPAS, OPSYNVI, TADLIQ

 

Maximum Age Limit

· 
12 years: REVATIO suspension 

 

Preferred Criteria

· 
PAH Agents

o Documented diagnosis
of pulmonary hypertension

 

· 
Sildenafil tablets

o ≤ 1 year of age
and documented diagnosis of pulmonary hypertension, patent ductus
arteriosus, or persistent fetal circulation OR

o ≥ 1 year of age
and documented diagnosis of pulmonary hypertension OR

o 90 days of therapy
with the requested agent in the past 105 days

 

· 
Sildenafil suspension

· 
< 12
years of age AND

· 
Documented
diagnosis of pulmonary hypertension, patent ductus arteriosus, or persistent
fetal circulation, or a history of a heart transplant OR

· 
90
days stable therapy with sildenafil suspension in the past 105 days

 

Non-Preferred Criteria

· 
Documented diagnosis of pulmonary hypertension AND

· 
Have tried 1 preferred PAH agent in the past 6
months OR

· 
90 days of therapy with the requested agent in
the past 105 days

 

OPSUMIT, OPSYNVI, ORENITRAM ER, TYVASO, and VENTAVIS

· 
Require clinical review

 

 

 

WINREVAIR
(sotatercept-csrk)

COMBINATION
AGENTS

 

OPSYNVI
(macitentan/tadalafil)

ENDOTHELIN
RECEPTOR ANTAGONISTS

ambrisentan

OPSUMIT (macitentan)

bosentan

TRACLEER (bosentan)

LETAIRIS
(ambrisentan)

TRYVIO (aprocitentan)

PDE5
INHIBITORS

sildenafil (generic
REVATIO) tablet, suspension

ADCIRCA (tadalafil)

tadalafil

ALYQ (tadalafil)

 

REVATIO (sildenafil)

 

TADLIQ (tadalafil)

PROSTACYCLINS

 

ORENITRAM ER
(treprostinil)

 

ORENITRAM TITRATION
PAK (treprostinil)

 

TYVASO (treprostinil)

 

VENTAVIS (iloprost)

SELECTIVE
PROSTACYCLINE RECEPTOR AGONISTS

 

UPTRAVI (selexipag)

SOLUABLE
GUANYLATE CYCLASE STIMULATORS

 

ADEMPAS (riociguat)

ADEMPAS

· 
Documented diagnosis of persistent/recurrent
chronic thromboembolic pulmonary hypertension (WHO Group 4) or pulmonary
arterial hypertension (WHO Group 1) AND

· 
Have tried 1 preferred PAH agent in the past 6
months OR

· 
90 days of therapy with ADEMPAS in the past 105
days

 

 

TADLIQ

· 
Documented diagnosis of pulmonary hypertension AND

· 
Have tried preferred sildenafil suspension in
the past 6 months OR

· 
90 days of therapy with TADLIQ in the past 105
days

 

UPTRAVI

· 
Documented diagnosis of pulmonary hypertension AND

· 
Have tried 1 preferred endothelin receptor
antagonist in the past 6 months AND

· 
Have tried 1 preferred PDE5 inhibitor in the
past 6 months OR

· 
90 days of therapy with UPTRAVI in the past 105
days

 

ROSACEA
TREATMENTS

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

metronidazole

AVAR (sulfacetamide
sodium/sulfur)

Note:

· 
Topical Sulfonamides used for Rosacea will
require a manual PA for age > 21 years.

·  Other labeled
indications are limited to < 21 years.

 

AVAR LS
(sulfacetamide sodium/sulfur)

 

AVAR-E (sulfacetamide
sodium/sulfur)

 

BP 10-1
(sulfacetamide sodium/sulfur)

 

brimonidine

 

EPSOLAY (benzoyl
peroxide)

 

FINACEA (azelaic
acid)

 

METROCREAM
(metronidazole)

 

METROGEL
(metronidazole)

 

MIRVASO (brimonidine)

 

NORITATE
(metronidazole)

 

OVACE (sulfacetamide
sodium)

 

OVACE PLUS
(sulfacetamide sodium)

 

RHOFADE
(oxymetazoline)

 

ROSADAN (metronidazole)

 

ROSULA (sulfacetamide
sodium/sulfur)

 

sodium sulfacetamide

 

 

sodium
sulfacetamide/sulfur

 

SOOLANTRA
(ivermectin)

 

SUMADAN
(sulfacetamide sodium/sulfur)

 

SUMADAN XLT (sulfacetamide
sodium/sulfur/avob

 

SUMAXIN
(sulfacetamide sodium/sulfur)

 

SUMAXIN CP
(sulfacetamide sodium/sulfur)

 

SUMAXIN TS
(sulfacetamide sodium/sulfur)

SEDATIVE HYPNOTIC AGENTS

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

BENZODIAZEPINES
DUR+

MS DOM Opioid Initiative Criteria
details found here

·  Concomitant use of Opioids and Benzodiazepines

 

Maximum Age Limit

·  64 years: zolpidem 7.5 mg, 10
mg, and 12.5 mg

 

Gender and Dose Limit

·  Female: AMBIEN 5 mg, AMBIEN
CR 6.25 mg, INTERMEZZO 1.75 mg

·  Male: all strengths of
zolpidem

 

Non-Preferred Criteria

· 
Have tried 2 different preferred agents in the
past 6 months

 

HETLIOZ
capsules

·  Age 18
years or older AND

·  Documented
diagnosis of circadian rhythm sleep disorder

OR

·  Age 16
years and older AND

·  Documented
diagnosis of Smith-Magenis syndrome

 

HETLIOZ liquid

· 
Age 3-15 years AND

· 
Documented diagnosis of Smith-Magenis syndrome

 

Note:

·  Single-source benzodiazepines and barbiturates are
NOT covered.

o PA s will NOT be
issued for these drugs.

 

See below for additional PA
Criteria/DUR+ Rules

estazolam

flurazepam

temazepam 15 mg, 30
mg capsule

HALCION (triazolam)

 

quazepam

 

RESTORIL (temazepam)

 

temazepam 7.5 mg,
22.5 mg capsule

 

triazolam

OTHERS
DUR+

eszopiclone

AMBIEN (zolpidem)

ramelteon

AMBIEN CR (zolpidem)

zaleplon

BELSOMRA (suvorexant)

zolpidem tablet

DAYVIGO (lemborexant)

 

doxepin

 

EDULAR (zolpidem)

 

HETLIOZ LQ
(tasimelteon)

 

LUNESTA (eszopiclone)

 

QUVIVIQ
(daridorexant)

 

ROZEREM (ramelteon)

 

tasimelteon

 

zolpidem capsule

 

zolpidem sublingual
tablet

 

zolpidem ER

CUMULATIVE Quantity Limit Benzodiazepines

·   31 units/31 days: Quantity limit per rolling days for all strengths. DUR+ will allow an early refill override
for one dose or therapy change per year.

 

CUMULATIVE Quantity Limit Triazolam

·  
10 units/31 days: Quantity limit per rolling days for all strengths.

·   60 units/365 days: Quantity limit per rolling days for all strengths.

 

CUMULATIVE Quantity Limit Non-Benzodiazepines

·  
31 units/31 days: Quantity limit per rolling days for all strengths. DUR+ will allow an early refill override
for one dose or therapy change per year.

 

CUMULATIVE Quantity Limit HETLIOZ LQ

·  
1 bottle (48 mL or 158 mL): Quantity limit per rolling days for all strengths. DUR+ will allow an early refill override
for one dose or therapy change per year.

 

CUMULATIVE Quantity Limit ZOLPIMIST

·  
1 canister/31 days: male; Quantity limit per rolling days for all strengths. DUR+ will allow an early refill override
for one dose or therapy change per year.

·   1 canister/62 days: female; Quantity limit per rolling days for all strengths. DUR+ will allow an early refill override
for one dose or therapy change per year.

 

SELECT CONTRACEPTIVE PRODUCTS

PREFERRED
AGENTS

NON-PREFERRED
AGENTS

PA
CRITERIA

INJECTABLE CONTRACEPTIVES

Non-Preferred Criteria

·  1 claim with the requested
agent in the past 105 days

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

medroxyprogesterone

DEPO-PROVERA (medroxyprogesterone)

INTRAVAGINAL CONTRACEPTIVES

ANNOVERA (segesterone/ethinyl estradiol)

PHEXXI (lactic acid/citric acid/potassium
bitartrate)

ENILLORING (etonogestrel/ethinyl estradiol)

 

NUVARING (etonogestrel/ethinyl estradiol)

 

ORAL CONTRACEPTIVES DUR+

All oral contraceptives
are preferred except for those specifically indicated as non-preferred.

AMETHIA (levonorgestrel/ethinyl estradiol)

AMETHYST (levonorgestrel/ethinyl estradiol)

BALCOLTRA (levonorgestrel/ethinyl estradiol)

BEYAZ (drospirenone/ethinyl
estradiol/levomefolate)

CAMRESE (levonorgestrel/ethinyl estradiol)

CAMRESE LO (levonorgestrel/ethinyl estradiol)

JOLESSA (levonorgestrel/ethinyl estradiol)

LO LOESTRIN FE (norethindrone/ethinyl
estradiol/iron)

LOESTRIN (norethindrone/ethinyl estradiol)

LOESTRIN FE (norethindrone/ethinyl
estradiol/iron)

MINZOYA (levonorgestrel/ethinyl estradiol/iron)

NATAZIA (estradiol valerate/dienogest)

NEXTSTELLIS (drospirenone/estetrol)

OCELLA (ethinyl estradiol/drospirenone)

SAFYRAL (drospirenone/ethinyl
estradiol/levomefolate)

SIMPESSE (levonorgestrel/ethinyl estradiol)

TAYTULLA (norethindrone/ethinyl estradiol/iron)

TYDEMY (drospirenone/ethinyl
estradiol/levomefolate)

YASMIN (ethinyl estradiol/drospirenone)

YAZ (ethinyl estradiol/drospirenone)

TRANSDERMAL
CONTRACEPTIVES

XULANE
(norelgestromin/ethinyl estradiol)

norelgestromin/ethinyl
estradiol

 

TWIRLA
(levonorgestrel/ethinyl estradiol)

 

ZAFEMY (norelgestromin/ethinyl
estradiol)

SICKLE CELL AGENTS

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

DROXIA (hydroxyurea)

ADAKVEO
(crizanlizumab-tmca)

ENDARI MANUAL PA

hydroxyurea

CASGEVY
(exagamglogene autotemcel)

 

ENDARI (glutamine)

 

HYDREA (hydroxyurea)

 

l-glutamine

 

LYFGENIA (lovotibeglogene
autotemcel)

 

SIKLOS (hydroxyurea)

SKELETAL MUSCLE RELAXANTS DUR+

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

baclofen 5 mg, 10 mg,
20 mg tablet

AMRIX
(cyclobenzaprine)

Quantity Limit

·  84 tablets/180 days: carisoprodol

 

Non-Preferred Criteria

· 
Documented diagnosis of an approvable
indication AND

· 
Have tried 2 different preferred agents in the
past 6 months

 

Baclofen granules, solution,
and suspension

· 
Require clinical review.

 

Carisoprodol

· 
Documented diagnosis of acute musculoskeletal
condition AND

· 
No history with meprobamate in the past 105
days AND

·  History of 1 claim
for cyclobenzaprine in the past 21 days

 

Carisoprodol with codeine

· 
Requires clinical review.

 

 

Metaxalone 640 mg and TANLOR

· 
Requires clinical review

 

chlorzoxazone

baclofen 15 mg tablet

cyclobenzaprine 5 mg,
10 mg tablet

baclofen suspension

methocarbamol

carisoprodol

tizanidine tablet

carisoprodol/aspirin

 

cyclobenzaprine 7.5
mg tablet

 

cyclobenzaprine ER

 

DANTRIUM (dantrolene)

 

dantrolene

 

FEXMID
(cyclobenzaprine)

 

FLEQSUVY (baclofen)

 

LORZONE
(chlorzoxazone)

 

LYVISPAH (baclofen)

 

metaxalone

 

NORGESIC
(orphenadrine/aspirin/caffeine)

 

NORGESIC FORTE
(orphenadrine/aspirin/caffeine)

 

orphenadrine

 

orphenadrine/aspirin/caffeine

 

ORPHENGESIC FORTE (orphenadrine/aspirin/caffeine)

 

SOMA (carisoprodol)

 

TANLOR
(methocarbamol)

 

tizanidine capsule

 

ZANAFLEX (tizanidine)

SMOKING
DETERRENTS

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

NICOTINE
TYPE

Minimum Age Limit

·  18 years: CHANTIX

 

Quantity Limit

·  336 tablets/year: CHANTIX 0.5 mg tabs,
1 mg tabs, and continuing pack

· 
2 treatment
courses/year: CHANTIX Starter Pack

nicotine gum OTC

NICOTROL INHALER
CARTRIDGE

nicotine lozenge OTC

NICOTROL NASAL SPRAY

nicotine patch OTC

 

NON-NICOTINE
TYPE

bupropion SR

 

CHANTIX (varenicline)

 

varenicline

 

STEROIDS
(TOPICAL)

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

LOW
POTENCY

Non-Preferred Criteria

·  Low Potency

o Have tried 2
different preferred low potency agents in the past 6 months

·  Medium Potency

o Have tried 2 different
preferred medium potency agents in the past 6 months

·  High Potency

o Have tried 2
different preferred high potency agents in the past 6 months

·  Very High Potency

o Have tried 2 different
preferred very high potency agents in the past 6 months

 

Clobetasol 0.025%

·  Requires clinical
review.

 

 

alclometasone

fluocinolone

DERMA-SMOOTHE-FS
(fluocinolone)

hydrocortisone lotion

desonide

HYDROXYM
(hydrocortisone)

hydrocortisone cream,
ointment, solution

PROCTOCORT
(hydrocortisone)

MEDIUM
POTENCY

fluticasone

BESER (fluticasone)

mometasone

CAPEX (fluocinolone)

PANDEL
(hydrocortisone probutate)

clocortolone

prednicarbate cream

CLODERM (clocortolone)

 

flurandrenolide

 

fluticasone lotion

 

LOCOID
(hydrocortisone butyrate)

 

prednicarbate
ointment

 

SYNALAR
(fluocinolone)

HIGH
POTENCY

betamethasone
dipropionate cream, lotion

amcinonide

betamethasone dipropionate
augmented

betamethasone
dipropionate ointment

betamethasone
valerate

desoximetasone

fluocinolone

diflorasone

fluocinonide

Halcinonide

fluocinonide-E

HALOG (halcinonide)

triamcinolone cream,
ointment, lotion

KENALOG (triamcinolone)

 

TOPICORT
(desoximetasone)

 

triamcinolone spray

 

VANOS (fluocinonide)

VERY
HIGH POTENCY

clobetasol cream,
foam, gel, ointment, shampoo, solution

APEXICON E
(diflorasone)

clobetasol-E

BRYHALI (halobetasol)

halobetasol

clobetasol emulsion

 

clobetasol 0.025%
cream

 

CLOBEX (clobetasol)

 

CLODAN (clobetasol)

 

DIPROLENE
(betamethasone)

 

halobetasol

 

IMPEKLO (clobetasol)

 

IMPOYZ (clobetasol)
0.025% cream

 

 

LEXETTE (halobetasol)

 

 

OLUX (clobetasol)

 

TEMOVATE (clobetasol)

 

TOVET (clobetasol)

 

ULTRAVATE
(halobetasol)

STIMULANTS
AND RELATED AGENTS DUR+

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

SHORT-ACTING

Minimum Age Limit

· 
3 years: ADDERALL, EVEKEO, PROCENTRA, ZENZEDI

·  6 years: ADDERALL XR,
ADHANSIA XR, ADZENYS ER SUSPENSION, ADZENYS XR ODT, APTENSIO XR, atomoxetine,
AZSTARYS, clonidine ER, CONCERTA ER, COTEMPLA XR ODT, DAYTRANA, DESOXYN,
DEXEDRINE, DYANAVEL XR, EVEKEO ODT, FOCALIN, FOCALIN XR, JORNAY PM, METADATE
CD, METHYLIN, ONYDA XR, QELBREE, QUILLICHEW, QUILLIVANT XR, RELEXXII ER,
RITALIN LA, VYVANSE, XELSTRYM

·  7 years: XYREM

·  13 years: MYDAYIS

·  16 years: modafinil

· 
18 years: armodafinil, SUNOSI, WAKIX

 

Maximum Age Limit

·  18 years: clonidine ER,
COTEMPLA XR ODT, DAYTRANA, EVEKEO ODT, guanfacine ER

 

Quantity Limit Stimulants
(per 31 days)

· 
31 tablets: ADDERALL XR,
ADHANSIA XR, ADZENYS XR ODT, APTENSIO XR, AZSTARYS, CONCERTA ER 18, 27, &
54 mg, COTEMPLA XR-ODT 8.6 mg, DAYTRANA, DEXEDRINE Spansule, DYANAVEL XR
Tablet, FOCALIN XR, JORNAY PM, METADATE CD, METHYLIN ER, MYDAYIS 37.5 mg
& 50 mg, QUILLICHEW, RELEXXII ER, RITALIN LA & SR, VYVANSE, XELSTRYM

· 
62 tablets: ADDERALL, CONCERTA
ER 36 mg, COTEMPLA XR-ODT 17.3 & 25.9 mg, DESOXYN, EVEKEO, FOCALIN,
METHYLIN, RITALIN, ZENZEDI

·  248 mL: DYANAVEL XR
Suspension

·  310 mL: METHYLIN, PROCENTRA

·  372 mL: QUILLIVANT XR

 

Quantity Limit Narcolepsy
(per 31 days)

· 
31 tablets: armodafinil 150,
200 & 250 mg, modafinil 200 mg, SUNOSI

· 
46.5 tablets: modafinil 100 mg

· 
62 tablets: armodafinil 50 mg, WAKIX

 

Quantity Limit Non-Stimulants (per 31 days)

·  31 tablets: atomoxetine,
guanfacine ER, QELBREE 100 mg

·  62 tablets: QELBREE 150 mg and
200 mg

·  124 tablets: clonidine ER

·  1 bottle (30 mL or 60
mL): ONYDA XR Suspension

 

dexmethylphenidate

ADDERALL
(dextroamphetamine/amphetamine)

dextroamphetamine

amphetamine

dextroamphetamine/amphetamine

EVEKEO (amphetamine)

Methylphenidate
tablet

dextroamphetamine
solution

PROCENTRA
(dextroamphetamine)

EVEKEO ODT
(amphetamine)

FOCALIN
(dexmethylphenidate)

 

methamphetamine

 

METHYLN
(methylphenidate)

 

Methylphenidate
chewable tablet

 

RITALIN
(methylphenidate)

 

ZENZEDI (dextroamphetamine)

LONG-ACTING

ADDERALL XR
(dextroamphetamine/amphetamine)

ADZENYS XR ODT
(amphetamine)

CONCERTA
(methylphenidate)

APTENSIO XR
(methylphenidate)

dexmethylphenidate ER

AZSTARYS (serdexmethylphenidate/dexmethylphenidate)

dextroamphetamine ER

COTEMPLA XR ODT
(methylphenidate)

dextroamphetamine/amphetamine
ER (generic ADDERALL XR)

DAYTRANA
(methylphenidate)

DYANAVEL XR
(amphetamine) suspension

DEXEDRINE (dextroamphetamine)

lisdexamfetamine

dextroamphetamine/amphetamine
ER (generic MYDAYIS ER)

methylphenidate CD

DYANAVEL XR
(amphetamine) tablets

methylphenidate ER
tablet

FOCALIN XR
(dexmethylphenidate)

methylphenidate LA

JORNAY PM (methylphenidate)

QUILLICHEW ER
(methylphenidate)

methylphenidate patch

QUILLIVANT XR
(methylphenidate)

methylphenidate ER
capsule

VYVANSE
(lisdexamfetamine) capsules

MYDAYIS
(dextroamphetamine/amphetamine)

 

RELEXXII (methylphenidate)

 

RITALIN LA
(methylphenidate)

 

VYVANSE
(lisdexamfetamine) chewable tablets

 

XELSTRYM
(dextroamphetamine)

NARCOLEPSY

armodafinil

NUVIGIL (armodafinil)

modafinil

PROVIGIL (modafinil)

SUNOSI (solriamfetol)

sodium oxybate

XYREM (sodium
oxybate)

WAKIX (pitolisant)

 

XYWAV
(calcium/magnesium/potassium/sodium oxybate)

NON-STIMULANTS

atomoxetine

INTUNIV (guanfacine)

clonidine ER (generic
Kapvay only)

ONYDA
XR (clonidine)

guanfacine ER

STRATTERA
(atomoxetine)

QELBREE (viloxazine)

 

Non-Preferred Short Acting
Criteria

ADD/ADHD

· 
Documented diagnosis of ADD/ADHD AND

· 
Have tried 2 different preferred Short Acting agents
in the past 6 months OR

· 
1 claim for a 30-day supply with the requested
agent in the past 105 days

 

Narcolepsy: ADDERALL,
EVEKEO, METHYLIN, PROCENTRA, RITALIN, ZENZEDI

· 
Documented diagnosis of narcolepsy AND

· 
30 days of therapy with preferred modafinil or
armodafinil in the past 6 months AND

· 
1 preferred agent indicated for narcolepsy in
the past 6 months OR

· 
Have tried 1 claim for a 30-day supply with the
requested agent in the past 105 days

Non-Preferred Long Acting
Criteria

ADD/ADHD

· 
Documented diagnosis of ADD/ADHD AND

· 
Have tried 2 different preferred Long-Acting
agents in the past 6 months OR

·  1 claim for a 30-day
supply with the requested agent in the past 105 days

 

Narcolepsy: ADDERALL XR,
APTENSIO XR, CONCERTA ER, DEXEDRINE, METADATE CD, METHYLIN ER, MYDAYIS,
NUVIGIL, PROVIGIL, QUILLICHEW, QUILLIVANT XR, RITALIN LA

· 
Documented diagnosis of narcolepsy AND

· 
30 days of therapy with preferred modafinil or
armodafinil in the past 6 months AND

· 
1 different preferred agent indicated for
narcolepsy in the past 6 months OR

· 
1 claim for a 30-day supply with the requested
agent in the past 105 days

Armodafinil

· 
Documented diagnosis of narcolepsy, obstructive
sleep apnea, shift work sleep disorder, or bipolar depression

 

Atomoxetine

·  Age ≥ 21 years AND

· 
Documented diagnosis of ADD/ADHD

 

Clonidine ER

·  Documented diagnosis
of ADD/ADHD

 

Guanfacine ER

·  Documented diagnosis
of ADD/ADHD

 

JORNAY PM

· 
Diagnosis of ADD/ADHD AND

·  History of 84 days of
therapy (each) with 2 different preferred LA methylphenidate products in the
past 12 months AND

·  History of 84 days of
therapy with 1 preferred non-methylphenidate LA stimulant in the past 12
months OR

· 
History of 84 days of therapy with JORNAY PM in
the past 105 days

 

Modafinil

· 
Documented diagnosis of narcolepsy, obstructive
sleep apnea, shift work sleep disorder, depression, sleep deprivation or
Steinert Myotonic Dystrophy Syndrome

 

ONYDA XR

· 
Requires clinical review

 

 

 

 

QELBREE

· 
Documented diagnosis of ADD/ADHD AND

· 
30 days of therapy with a preferred ADHD agent
in the past 105 days OR

· 
30 days of therapy with QELBREE in the past 105
days

 

SUNOSI

· 
Documented diagnosis of narcolepsy or
obstructive sleep apnea AND

· 
30 days of therapy with preferred modafinil or
armodafinil in the past 6 months

 

VYVANSE

· 
Documented diagnosis of binge eating disorder
or ADD/ADHD

· 
90 days of
therapy with Vyvanse in the past 90 days

 

VYVANSE chewable

·  Requires clinical
review

 

WAKIX

· 
Requires clinical review

 

XYREM

· Diagnosis of
narcolepsy or excessive daytime sleepiness OR

·  30 days of therapy
with this agent in the past 105 days

 

XYWAV

· 
Requires clinical review

 

 

TETRACYCLINES DUR+

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

doxycycline hyclate

demeclocycline

Non-Preferred Agents

· 
Have tried 2 different preferred agents in the
past 6 months

 

Demeclocycline

·  Documented diagnosis
of Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH) will
allow for automatic approval

 

ORACEA

·  Requires clinical
review

doxycycline
monohydrate capsule

DORYX (doxycycline
hyclate)

minocycline capsule

DORYX MPC
(doxycycline hyclate)

tetracycline capsule

doxycycline hyclate
DR

 

doxycycline IR/DR

 

doxycycline
monohydrate suspension, tablet

 

LYMEPAK (doxycycline
hyclate)

 

MINOCIN (minocycline)

 

minocycline tablet

 

minocycline ER

 

MINOLIRA ER
(minocycline)

 

MORGIDOX (doxycycline
hyclate)

 

NUZYRA (omadacycline)

 

ORACEA (doxycycline
monohydrate)

 

SOLODYN (minocycline)

 

tetracycline tablet

ULCERATIVE COLITIS & CROHN’S
AGENTS DUR+ *See Cytokine & CAM Antagonists Class for
Additional Agents*

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

ORAL

Non-Preferred Criteria

· 
Documented diagnosis of Ulcerative Colitis AND

· 
Have tried 2 different preferred agents in the
past 6 months OR

· 
90 days of therapy with the requested agent in
the past 105 days

 

VELSIPITY

· 
Requires clinical review

APRISO (mesalamine)

AZULFIDINE
(sulfasalazine)

balsalazide

COLAZAL (balsalazide)

budesonide

DELZICOL (mesalamine)

PENTASA (mesalamine)

DIPENTUM (olsalazine)

sulfasalazine

LIALDA (mesalamine)

sulfasalazine DR

mesalamine

UCERIS (budesonide)

mesalamine DR,
mesalamine ER

 

VELSIPITY (etrasimod)

RECTAL

mesalamine
suppository

budesonide

 

CANASA (mesalamine)

 

mesalamine enema

 

ROWASA (mesalamine)

 

SFROWASA (mesalamine)

 

UCERIS (budesonide)

UREA CYCLE DISORDER AGENTS

PREFERRED AGENTS

NON-PREFERRED AGENTS

PA CRITERIA

CARBAGLU (carglumic
acid)

BUPHENYL (sodium
phenylbutyrate)

 

 

carglumic
acid

 

OLPRUVA (sodium
phenylbutyrate)

 

PHEBURANE (sodium
phenylbutyrate)

 

RAVICTI (glycerol
phenylbutyrate)