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 solution^NR
	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)
	nilotinib^NR
	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)
ORAL^DUR+
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 AGENTS^DUR+
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	ticagrelor^NR
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)