dms preferred drug list recommendations · mhd pdl recommendations 03.19.2020 1 preferred drug list...
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Preferred Drug List Recommendations
For the next phase of the PDL implementation, MHD will recommend the following to the Drug Prior Authorization Committee for review and approval at the upcoming meeting. The PA Committee will convene December 17, 2020, at 10:00 a.m. This list is subject to finalization by the Division. Companies wishing to discuss opportunities for supplemental rebates should contact Conduent State HealthCare, LLC at (804) 965-8117. All clinical information for consideration should be forwarded to Joshua Moore ([email protected]) or call (573) 751-6961. If a public presentation is desired contact Carmen Burton at: [email protected]
Alzheimer’s Agents, Cholinesterase Inhibitors Preferred Agents Non-Preferred Agents Donepezil ODT Aricept®
Donepezil 5, 10mg Tabs Donepezil 23mg Tabs Exelon® Patch Galantamine Soln/Tabs Memantine Tabs Galantamine ER
Memantine Soln Memantine ER Namenda®
Namenda XR®
Namzaric®
Razadyne®
Razadyne® ER Rivastigmine
Antiandrogenic Agents Preferred Agents Non-Preferred Agents Abiraterone Erleada™
Xtandi® Nubeqa®
Zytiga® 500mg Yonsa®
Zytiga® 250mg
Anticonvulsants, Dravet Syndrome – NEW Preferred Agents Non-Preferred Agents Epidiolex® Diacomit®
Fintepla®
Antiemetics, 5-HT3 and NK1 Injectable Agents Preferred Agents Non-Preferred Agents Fosaprepitant Akynzeo® Vial Ondansetron Amp/Syringe/Vial Aloxi®
Palonosetron Vial Cinvanti®
Emend® Vial Granisetron Vial Palonosetron Syringe Sustol®
Varubi® Vial Zofran® Vial
MHD PDL Recommendations 12.17.2020 1
Antiemetics, 5-HT3, NK1 and Other Select Non-Injectable Agents Preferred Agents Non-Preferred Agents Aprepitant Akynzeo® Caps Metoclopramide Soln/Tabs Anzemet®
Ondansetron ODT/Soln/Tabs Bonjesta®
Diclegis®
Doxylamine/Pyridoxine Emend® Caps/Pwd Packet Granisetron Tabs Metoclopramide ODT Reglan®
Sancuso®
Varubi® Tabs Zofran® ODT/Soln/Tabs Zuplenz®
Antiemetics, THC Derivatives Preferred Agents Non-Preferred Agents Dronabinol Cesamet®
Marinol®
Anti-Migraine, Alternative Oral Agents Preferred Agents Non-Preferred Agents Nurtec™ ODT Reyvow™
Ubrelvy™
Anti-Migraine, Serotonin (5-HT1) Receptor Agonists Preferred Agents Non-Preferred Agents Rizatriptan Almotriptan Sumatriptan Amerge®
Eletriptan Frova®
Frovatriptan Imitrex®
Maxalt®
Maxalt-MLT®
Naratriptan Onzetra® Xsail®
Relpax®
Sumatriptan/Naproxen Tosymra™
Treximet®
Zembrace™ Symtouch™
Zolmitriptan Zomig® Nasal Spray/Tabs Zomig-ZMT®
MHD PDL Recommendations 12.17.2020 2
Anti-Parkinsonism, Non-Ergot Dopamine Agents Preferred Agents Non-Preferred Agents Amantadine Apokyn®
Pramipexole Gocovri™
Ropinirole Kynmobi™
Mirapex®
Mirapex ER®
Neupro®
Osmolex™
Pramipexole ER Requip®
Requip XL®
Ropinirole ER
Anti-Parkinsonism, MAO-B Inhibitor Agents Preferred Agents Non-Preferred Agents Selegiline Azilect®
Rasagiline Xadago®
Zelapar®
Antipsychotics, Atypical Depot (Reference List) Reference Products Non-Reference Products Abilify Maintena™ Risperdal Consta®
Aristada® Zyprexa® Relprevv™
Aristada Initio®
Invega Sustenna®
Invega Trinza®
Perseris™
Antipsychotics, Atypical Oral & Transdermal (Reference List) Reference Products Non-Reference Products Aripiprazole Soln/Tabs Abilify®
Clozapine Tabs Abilify Mycite®
Fanapt® Aripiprazole ODT Latuda® Caplyta™
Olanzapine Clozapine ODT Olanzapine/Fluoxetine Clozaril®
Quetiapine Fazaclo®
Quetiapine ER Geodon®
Rexulti™ Invega®
Risperidone Nuplazid®
Saphris® Paliperidone ER Vraylar® Risperdal®
Ziprasidone Secuado®
Seroquel®
Seroquel XR®
Symbyax®
Versacloz®
Zyprexa®
Zyprexa® Zydis®
MHD PDL Recommendations 12.17.2020 3
Antiretrovirals, Treatment Agents (Reference List) Reference Products Non-Reference Products Abacavir Abacavir/Lamivudine/Zidovudine Abacavir/Lamivudine Aptivus®
Atazanavir Biktarvy®
Atripla® Combivir®
Cimduo™ Crixivan®
Complera® Descovy®
Delstrigo™ Didanosine Dovato® Efavirenz/Emtricitabine/Tenofovir Disoproxil
Fumarate Edurant® Efavirenz/Lamivudine/Tenofovir Disoproxil Efavirenz Emtricitabine/Tenofovir Disoproxil Fumarate Emtricitabine Emtriva®
Evotaz™ Epivir®
Isentress® Epzicom®
Isentress® HD Fosamprenavir Lamivudine Fuzeon®
Lamivudine/Zidovudine Genvoya®
Norvir® Intelence®
Pifeltro™ Invirase®
Prezcobix® Juluca Prezista® Kaletra®
Symfi™ Lexiva®
Symfi Lo™ Lopinavir/Ritonavir Symtuza™ Nevirapine Tenofovir Odefsey®
Tivicay® Rescriptor®
Triumeq® Retrovir®
Trogarzo™ Reyataz®
Truvada® Ritonavir Tybost® Rukobia Viread® Pwd Selzentry®
Stavudine Stribild®
Sustiva®
Temixys™
Trizivir®
Videx®
Viracept®
Viramune®
Viread® Tabs Zerit®
Ziagen®
Zidovudine
Calcitonin Gene-Related Peptide (CGRP) Receptors Preferred Agents Non-Preferred Agents Ajovy® Aimovig®
Emgality® 120mg/mL Emgality® 100mg/mL Vyepti™
MHD PDL Recommendations 12.17.2020 4
Cyclin-Dependent Kinase (CDK) 4/6 Inhibitors – NEW Preferred Agents Non-Preferred Agents Kisqali® Ibrance®
Kisqali® Femara® Co-Pack Verzenio™
Fibromyalgia Agents Preferred Agents Non-Preferred Agents Duloxetine 20, 30, 60mg Cymbalta®
Pregabalin Caps Drizalma Sprinkle™
Duloxetine 40mg Lyrica®
Pregabalin Soln Savella®
Glucagon Agents Preferred Agents Non-Preferred Agents Baqsimi™ Glucagon Kit (Fresenius Kabi) GlucaGen Hypokit® Gvoke™
Glucagon Kit (Eli Lilly)
Hereditary Angioedema (HAE) Treatment Agents Preferred Agents Non-Preferred Agents Berinert® Cinryze®
Haegarda® Firazyr®
Icatibant Kalbitor®
Takhzyro™ Ruconest®
IBS Agents, Anti-Diarrheal Preferred Agents Non-Preferred Agents
Alosetron Lotronex®
Viberzi®
IBS-C/CIC Agents Preferred Agents Non-Preferred Agents Amitiza® Motegrity™
Linzess® Trulance®
Zelnorm™
Neuropathic Pain Agents Preferred Agents Non-Preferred Agents Gabapentin Caps/Tabs Gabapentin Soln Lidocaine 5% Patch Gralise®
Horizant®
Lidoderm®
Neurontin®
Qutenza®
Ztlido™
MHD PDL Recommendations 12.17.2020 5
NSAIDS Preferred Agents Non-Preferred Agents Celecoxib Arthrotec®
Diclofenac 1% Gel OTC Cambia®
Diclofenac Sodium DR/EC Tabs Celebrex®
Ibuprofen Daypro®
Ketorolac Inj/Tabs Diclofenac 1% Gel Rx Meloxicam Diclofenac 1.3% Patch (gen Flector®) Naproxen OTC Diclofenac 1.5% Topical Soln Naproxen Tabs Rx (gen Naprosyn®) Diclofenac Caps (gen Zorvolex®)
Diclofenac Potassium Diclofenac Sodium ER (gen Voltaren® XR) Diclofenac/Misoprostol Diflunisal Duexis®
Etodolac Etodolac ER Feldene®
Fenoprofen Flector® Patch Flurbiprofen Indocin®
Indomethacin Indomethacin ER Ketoprofen Ketoprofen ER Ketorolac Nasal Spray Licart™
Meclofenamate Mefenamic acid Mobic®
Nabumetone Nalfon®
Naprelan®
Naprosyn®
Naproxen CR (gen Naprelan®) Naproxen DS (gen Anaprox® DS) Naproxen EC (gen Naprosyn® EC) Naproxen Sodium (gen Anaprox®) Naproxen Susp Naproxen/Esomeprazole Oxaprozin Pennsaid®
Piroxicam Qmiiz™ ODT Relafen™ DS Sprix®
Sulindac Tivorbex®
Tolmetin Vimovo®
Vivlodex®
Voltaren®
MHD PDL Recommendations 12.17.2020 6
Zipsor®
Zorvolex®
Opiate Dependence Agents Preferred Agents Non-Preferred Agents Buprenorphine SL Tabs Bunavail®
Buprenorphine/Naloxone SL Tabs Buprenorphine/Naloxone SL Film Naltrexone Tabs Probuphine®
Sublocade™ Zubsolv®
Suboxone® Film Vivitrol®
Opiate Emergency Reversal Agents Preferred Agents Non-Preferred Agents Naloxone Narcan®
Opioid Induced Constipation Agents Preferred Agents Non-Preferred Agents Movantik® Relistor®
Symproic®
Opioids, Long-Acting Preferred Agents Non-Preferred Agents Butrans® Arymo® ER Fentanyl Patch 12, 25, 50, 75, 100 mcg/hr Belbuca®
Morphine Sulfate ER Tabs (gen MS Contin®) Buprenorphine Patch Duragesic®
Fentanyl Patch 37.5, 62.5, 87.5 mcg/hr Hydrocodone ER (gen Zohdyro® ER) Hydromorphone ER Hysingla™ ER Kadian®
Morphine ER Caps (gen Avinza®) Morphine ER Caps (gen Kadian®) MS Contin®
Oxycodone ER Oxycontin®
Oxymorphone ER Xtampza® ER Zohydro® ER
Sedative Hypnotics Preferred Agents Non-Preferred Agents Doxepin 10, 25, 50, 75, 100, 150 mg Caps Ambien®
Eszopiclone Ambien CR®
Temazepam 15, 30mg Belsomra®
Zaleplon Dayvigo®
Zolpidem Tabs Doxepin 3, 6 mg Tabs Edluar®
Estazolam
MHD PDL Recommendations 12.17.2020 7
Flurazepam Halcion®
Hetlioz®
Intermezzo®
Lunesta®
Midazolam Syrup Ramelteon Restoril™
Rozerem®
Silenor®
Temazepam 7.5, 22.5mg Triazolam Zolpidem ER Zolpidem SL
Skeletal Muscle Relaxants Preferred Agents Non-Preferred Agents Baclofen Amrix®
Chlorzoxazone 250, 500mg Carisoprodol Cyclobenzaprine Tabs (gen Flexeril®) Carisoprodol/ASA Dantrolene Carisoprodol/ASA/Codeine Methocarbamol Chlorzoxazone 375, 750mg Orphenadrine ER Cyclobenzaprine 7.5 mg Tabs (gen Fexmid®) Tizanidine Tabs Cyclobenzaprine ER
Dantrium®
Fexmid®
Lorzone®
Metaxalone Norgesic Forte Orphenadrine/ASA/Caffeine Orphengesic Forte Robaxin®
Skelaxin®
Soma®
Tizanidine Caps Zanaflex®
Somatostatic Agents – NEW Preferred Agents Non-Preferred Agents Octreotide Bynfezia Pen™
Sandostatin® LAR Depot Mycapssa®
Sandostatin®
Somatuline® Depot
Tramadol Like Agents Preferred Agents Non-Preferred Agents Tramadol 50 mg (gen Ultram®) ConZip®
Tramadol ER Tabs (gen Ultram® ER) Nucynta®
Tramadol/APAP Nucynta® ER Tramadol 100 mg Tramadol ER Caps (gen ConZip®)
MHD PDL Recommendations 12.17.2020 8
Tramadol ER Tabs (gen Ryzolt™) Ultracet®
Ultram®
Vesicular Monoamine Transporter 2 (VMAT2) Inhibitors – NEW Preferred Agents Non-Preferred Agents Austedo® Ingrezza®
Tetrabenazine Xenazine®
MHD PDL Recommendations 12.17.2020 9