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System Class Preferred Effective: January 1, 2017 Table 121‐0030‐1 Oregon Fee‐for‐Service Enforceable Physical Health Preferred Drug List Anaphylaxis Rescue Allergy/Cold EPINEPHRINE AUTO INJCT EPINEPHRINE (EPIPEN 2‐PAK ™) AUTO INJCT EPINEPHRINE (EPIPEN JR 2‐PAK ™) AUTO INJCT Antihistamines, Second Generation Allergy/Cold CETIRIZINE HCL SOLUTION *** CETIRIZINE HCL TABLET LORATADINE SOLUTION *** LORATADINE TAB RAPDIS *** LORATADINE TABLET Cough and Cold Allergy/Cold GUAIFENESIN ‡ GRAN PACK GUAIFENESIN ‡ LIQUID GUAIFENESIN ‡ SYRUP GUAIFENESIN ‡ TAB ER 12H GUAIFENESIN ‡ TABLET GUAIFENESIN ‡ TABLET ER GUAIFENESIN/CODEINE PHOSPHATE * LIQUID GUAIFENESIN/CODEINE PHOSPHATE * SYRUP GUAIFENESIN/CODEINE PHOSPHATE * TABLET GUAIFENESIN/DEXTROMETHORPHAN ‡ CAPSULE GUAIFENESIN/DEXTROMETHORPHAN ‡ DROPS GUAIFENESIN/DEXTROMETHORPHAN ‡ ELIXIR GUAIFENESIN/DEXTROMETHORPHAN ‡ GRAN PACK GUAIFENESIN/DEXTROMETHORPHAN ‡ LIQUID GUAIFENESIN/DEXTROMETHORPHAN ‡ LIQUID PKT GUAIFENESIN/DEXTROMETHORPHAN ‡ SYRUP GUAIFENESIN/DEXTROMETHORPHAN ‡ TAB ER 12H GUAIFENESIN/DEXTROMETHORPHAN ‡ TABLET GUAIFENESIN/DEXTROMETHORPHAN ‡ TBMP 12HR PSEUDOEPHEDRINE HCL ‡ CAPSULE PSEUDOEPHEDRINE HCL ‡ TABLET Nasal Allergy Inhalers Allergy/Cold FLUTICASONE PROPIONATE * SPRAY SUSP Analgesics, Topical Analgesics CAPSAICIN CREAM (G) Gout Analgesics ALLOPURINOL TABLET PROBENECID/COLCHICINE TABLET Muscle Relaxants, Oral Analgesics BACLOFEN TABLET CYCLOBENZAPRINE HCL TABLET *** TIZANIDINE HCL TABLET 1 Updated: December 27, 2016 * Drug coverage subject to meeting clinical prior authorization criteria ** Drug coverage subject to quantity limits *** Certain strengths may require Prior Authorization ‡ Age restricƟons apply

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Page 1: Oregon Medicaid Preferred Drug List - January 1, 2017 Medicaid Preferred Drug...Table 121‐0030‐1 Oregon Fee‐for‐Service Enforceable Physical Health Preferred Drug List Allergy

System Class Preferred

Effective: January 1, 2017Table 121‐0030‐1 Oregon Fee‐for‐Service Enforceable Physical Health Preferred Drug List

Anaphylaxis RescueAllergy/Cold EPINEPHRINE AUTO INJCTEPINEPHRINE (EPIPEN 2‐PAK ™) AUTO INJCTEPINEPHRINE (EPIPEN JR 2‐PAK ™) AUTO INJCT

Antihistamines, Second Generation

Allergy/Cold CETIRIZINE HCL SOLUTION ***CETIRIZINE HCL TABLETLORATADINE SOLUTION ***LORATADINE TAB RAPDIS ***LORATADINE TABLET

Cough and ColdAllergy/Cold GUAIFENESIN ‡ GRAN PACKGUAIFENESIN ‡ LIQUIDGUAIFENESIN ‡ SYRUPGUAIFENESIN ‡ TAB ER 12HGUAIFENESIN ‡ TABLETGUAIFENESIN ‡ TABLET ERGUAIFENESIN/CODEINE PHOSPHATE * LIQUIDGUAIFENESIN/CODEINE PHOSPHATE * SYRUPGUAIFENESIN/CODEINE PHOSPHATE * TABLETGUAIFENESIN/DEXTROMETHORPHAN ‡ CAPSULEGUAIFENESIN/DEXTROMETHORPHAN ‡ DROPSGUAIFENESIN/DEXTROMETHORPHAN ‡ ELIXIRGUAIFENESIN/DEXTROMETHORPHAN ‡ GRAN PACKGUAIFENESIN/DEXTROMETHORPHAN ‡ LIQUIDGUAIFENESIN/DEXTROMETHORPHAN ‡ LIQUID PKTGUAIFENESIN/DEXTROMETHORPHAN ‡ SYRUPGUAIFENESIN/DEXTROMETHORPHAN ‡ TAB ER 12HGUAIFENESIN/DEXTROMETHORPHAN ‡ TABLETGUAIFENESIN/DEXTROMETHORPHAN ‡ TBMP 12HRPSEUDOEPHEDRINE HCL ‡ CAPSULEPSEUDOEPHEDRINE HCL ‡ TABLET

Nasal Allergy InhalersAllergy/Cold FLUTICASONE PROPIONATE * SPRAY SUSP

Analgesics, TopicalAnalgesics CAPSAICIN CREAM (G)

GoutAnalgesics ALLOPURINOL TABLETPROBENECID/COLCHICINE TABLET

Muscle Relaxants, OralAnalgesics BACLOFEN TABLETCYCLOBENZAPRINE HCL TABLET ***TIZANIDINE HCL TABLET

1 Updated: December 27, 2016

* Drug coverage subject to meeting clinical prior authorization criteria** Drug coverage subject to quantity limits*** Certain strengths may require Prior Authorization‡ Age restric ons apply

Page 2: Oregon Medicaid Preferred Drug List - January 1, 2017 Medicaid Preferred Drug...Table 121‐0030‐1 Oregon Fee‐for‐Service Enforceable Physical Health Preferred Drug List Allergy

System Class Preferred

Effective: January 1, 2017Table 121‐0030‐1 Oregon Fee‐for‐Service Enforceable Physical Health Preferred Drug List

Non‐Steroidal Anti‐Inflammatory Drugs

Analgesics DICLOFENAC POTASSIUM TABLETDICLOFENAC SODIUM TABLET DRETODOLAC TABLETFLURBIPROFEN TABLETIBUPROFEN CAPSULEIBUPROFEN DROPS SUSPIBUPROFEN ORAL SUSPIBUPROFEN TAB CHEWIBUPROFEN TABLETINDOMETHACIN CAPSULEKETOPROFEN CAPSULEKETOROLAC TROMETHAMINE ** TABLETMELOXICAM TABLETNABUMETONE TABLETNAPROXEN TABLETNAPROXEN TABLET DRNAPROXEN SODIUM TABLETOXAPROZIN TABLETSULINDAC TABLET

Opioids, Long‐ActingAnalgesics FENTANYL ** PATCH TD72MORPHINE SULFATE ** TABLET ER

Opioids, Short‐ActingAnalgesics ACETAMINOPHEN WITH CODEINE * ORAL SUSPACETAMINOPHEN WITH CODEINE * SOLUTIONACETAMINOPHEN WITH CODEINE * TABLETBUTORPHANOL TARTRATE ** SPRAYCODEINE SULFATE * TABLETHYDROCODONE/ACETAMINOPHEN ** SOLUTIONHYDROCODONE/ACETAMINOPHEN ** TABLETHYDROMORPHONE HCL ** SUPP.RECTHYDROMORPHONE HCL ** TABLETMORPHINE SULFATE ** SOLUTIONMORPHINE SULFATE ** SUPP.RECTMORPHINE SULFATE ** TABLETOPIUM/BELLADONNA ALKALOIDS ** SUPP.RECTOXYCODONE HCL ** SOLUTIONOXYCODONE HCL ** TABLETOXYCODONE HCL/ACETAMINOPHEN ** TABLETTRAMADOL HCL ** TABLET

Triptans, NasalAnalgesics SUMATRIPTAN ** SPRAY

Triptans, OralAnalgesics NARATRIPTAN HCL ** TABLETSUMATRIPTAN SUCCINATE ** TABLET

Triptans, SubcutaneousAnalgesics SUMATRIPTAN SUCCINATE ** CARTRIDGESUMATRIPTAN SUCCINATE ** PEN INJCTRSUMATRIPTAN SUCCINATE ** VIAL

2 Updated: December 27, 2016

* Drug coverage subject to meeting clinical prior authorization criteria** Drug coverage subject to quantity limits*** Certain strengths may require Prior Authorization‡ Age restric ons apply

Page 3: Oregon Medicaid Preferred Drug List - January 1, 2017 Medicaid Preferred Drug...Table 121‐0030‐1 Oregon Fee‐for‐Service Enforceable Physical Health Preferred Drug List Allergy

System Class Preferred

Effective: January 1, 2017Table 121‐0030‐1 Oregon Fee‐for‐Service Enforceable Physical Health Preferred Drug List

Amoxicillin and Clavulanate, Oral

Antibiotics AMOXICILLIN/POTASSIUM CLAV SUSP RECONAMOXICILLIN/POTASSIUM CLAV TAB CHEWAMOXICILLIN/POTASSIUM CLAV TABLET

Cephalosporins (1st Gen), OralAntibiotics CEPHALEXIN CAPSULE ***CEPHALEXIN SUSP RECON

Cephalosporins (2nd Gen), Oral

Antibiotics CEFPROZIL SUSP RECONCEFPROZIL TABLETCEFUROXIME AXETIL SUSP RECONCEFUROXIME AXETIL TABLET

Cephalosporins (3rd Gen), OralAntibiotics CEFDINIR CAPSULECEFDINIR SUSP RECON

Clostridium Difficile AntibioticsAntibiotics METRONIDAZOLE CAPSULEMETRONIDAZOLE TABLETMETRONIDAZOLE TABLET ERVANCOMYCIN HCL CAPSULEVANCOMYCIN HCL VIAL

Fluroquinolones, OralAntibiotics CIPROFLOXACIN SUS MC RECCIPROFLOXACIN HCL TABLETLEVOFLOXACIN SOLUTIONLEVOFLOXACIN TABLET

Macrolides, OralAntibiotics AZITHROMYCIN SUSP RECONAZITHROMYCIN TABLETCLARITHROMYCIN TABLET

Oxazolidinones, OralAntibiotics LINEZOLID SUSP RECONLINEZOLID TABLET

Tetracyclines, OralAntibiotics DOXYCYCLINE HYCLATE CAPSULEDOXYCYCLINE HYCLATE TABLETDOXYCYCLINE MONOHYDRATE CAPSULE ***DOXYCYCLINE MONOHYDRATE SUSP RECONTETRACYCLINE HCL CAPSULE

Antifungals, OralAntifungal CLOTRIMAZOLE TROCHEFLUCONAZOLE SUSP RECONFLUCONAZOLE TABLETNYSTATIN ORAL SUSPNYSTATIN TABLET

Hepatitis BAntivirals LAMIVUDINE * SOLUTIONLAMIVUDINE * TABLETTENOFOVIR DISOPROXIL FUMARATE * TABLET

3 Updated: December 27, 2016

* Drug coverage subject to meeting clinical prior authorization criteria** Drug coverage subject to quantity limits*** Certain strengths may require Prior Authorization‡ Age restric ons apply

Page 4: Oregon Medicaid Preferred Drug List - January 1, 2017 Medicaid Preferred Drug...Table 121‐0030‐1 Oregon Fee‐for‐Service Enforceable Physical Health Preferred Drug List Allergy

System Class Preferred

Effective: January 1, 2017Table 121‐0030‐1 Oregon Fee‐for‐Service Enforceable Physical Health Preferred Drug List

Hepatitis C, Direct‐Acting Antivirals

Antivirals DACLATASVIR DIHYDROCHLORIDE * TABLETELBASVIR/GRAZOPREVIR (ZEPATIER ™) * TABLETLEDIPASVIR/SOFOSBUVIR (HARVONI ™) * TABLETSOFOSBUVIR * TABLETSOFOSBUVIR/VELPATASVIR (EPCLUSA ™) * TABLET

Hepatitis C, Other AgentsAntivirals PEGINTERFERON ALFA‐2A * PEN INJCTRPEGINTERFERON ALFA‐2A * SYRINGEPEGINTERFERON ALFA‐2A * VIALPEGINTERFERON ALFA‐2B * KITPEGINTERFERON ALFA‐2B * PEN IJ KITRIBAVIRIN * CAPSULERIBAVIRIN * TABLET

Herpes SimplexAntivirals ACYCLOVIR CAPSULEACYCLOVIR ORAL SUSPACYCLOVIR TABLET

4 Updated: December 27, 2016

* Drug coverage subject to meeting clinical prior authorization criteria** Drug coverage subject to quantity limits*** Certain strengths may require Prior Authorization‡ Age restric ons apply

Page 5: Oregon Medicaid Preferred Drug List - January 1, 2017 Medicaid Preferred Drug...Table 121‐0030‐1 Oregon Fee‐for‐Service Enforceable Physical Health Preferred Drug List Allergy

System Class Preferred

Effective: January 1, 2017Table 121‐0030‐1 Oregon Fee‐for‐Service Enforceable Physical Health Preferred Drug List

HIVAntivirals ABACAVIR SULFATE SOLUTIONABACAVIR SULFATE TABLETABACAVIR SULFATE/LAMIVUDINE TABLETABACAVIR/DOLUTEGRAVIR/LAMIVUDI TABLETABACAVIR/LAMIVUDINE/ZIDOVUDINE TABLETATAZANAVIR SULFATE CAPSULEATAZANAVIR SULFATE POWD PACKATAZANAVIR SULFATE/COBICISTAT (EVOTAZ ™) TABLETCOBICISTAT TABLETDARUNAVIR ETHANOLATE ORAL SUSPDARUNAVIR ETHANOLATE TABLETDARUNAVIR/COBICISTAT TABLETDELAVIRDINE MESYLATE TAB DISPERDELAVIRDINE MESYLATE TABLETDIDANOSINE CAPSULE DRDIDANOSINE SOLN RECONDOLUTEGRAVIR SODIUM TABLETEFAVIRENZ CAPSULEEFAVIRENZ TABLETEFAVIRENZ/EMTRICITAB/TENOFOVIR TABLETELVITEG/COBI/EMTRIC/TENOFO ALA (GENVOYA ™) TABLETELVITEG/COBI/EMTRIC/TENOFO DIS TABLETELVITEGRAVIR TABLETEMTRICITA/RILPIVIRINE/TENOF DF TABLETEMTRICITAB/RILPIVIRI/TENOF ALA TABLETEMTRICITABINE CAPSULEEMTRICITABINE SOLUTIONEMTRICITABINE/TENOFOV ALAFENAM (DESCOVY ™) TABLETEMTRICITABINE/TENOFOVIR (TDF) TABLETENFUVIRTIDE VIALETRAVIRINE TABLETFOSAMPRENAVIR CALCIUM ORAL SUSPFOSAMPRENAVIR CALCIUM TABLETINDINAVIR SULFATE CAPSULELAMIVUDINE SOLUTIONLAMIVUDINE TABLETLAMIVUDINE/ZIDOVUDINE TABLETLOPINAVIR/RITONAVIR SOLUTIONLOPINAVIR/RITONAVIR TABLETMARAVIROC TABLETNELFINAVIR MESYLATE TABLETNEVIRAPINE ORAL SUSPNEVIRAPINE TAB ER 24HNEVIRAPINE TABLETRALTEGRAVIR POTASSIUM POWD PACKRALTEGRAVIR POTASSIUM TAB CHEWRALTEGRAVIR POTASSIUM TABLETRILPIVIRINE HCL TABLETRITONAVIR CAPSULERITONAVIR SOLUTION

5 Updated: December 27, 2016

* Drug coverage subject to meeting clinical prior authorization criteria** Drug coverage subject to quantity limits*** Certain strengths may require Prior Authorization‡ Age restric ons apply

Page 6: Oregon Medicaid Preferred Drug List - January 1, 2017 Medicaid Preferred Drug...Table 121‐0030‐1 Oregon Fee‐for‐Service Enforceable Physical Health Preferred Drug List Allergy

System Class Preferred

Effective: January 1, 2017Table 121‐0030‐1 Oregon Fee‐for‐Service Enforceable Physical Health Preferred Drug List

HIVAntivirals RITONAVIR (NORVIR ™) TABLETSAQUINAVIR MESYLATE CAPSULESAQUINAVIR MESYLATE TABLETSTAVUDINE CAPSULESTAVUDINE SOLN RECONTIPRANAVIR CAPSULETIPRANAVIR/VITAMIN E TPGS SOLUTIONZIDOVUDINE CAPSULEZIDOVUDINE SYRUPZIDOVUDINE TABLETZIDOVUDINE VIAL

InfluenzaAntivirals OSELTAMIVIR PHOSPHATE * CAPSULEOSELTAMIVIR PHOSPHATE * SUSP RECON

ACEIs, ARBs and DRIsCardiovascular BENAZEPRIL HCL TABLETENALAPRIL MALEATE TABLETLISINOPRIL TABLETLOSARTAN POTASSIUM TABLETOLMESARTAN MEDOXOMIL TABLETRAMIPRIL CAPSULETELMISARTAN TABLET

AntianginalsCardiovascular ISOSORBIDE DINITRATE CAPSULE ERISOSORBIDE DINITRATE TABLETISOSORBIDE MONONITRATE TABLETNITROGLYCERIN CAPSULE ERNITROGLYCERIN PATCH TD24NITROGLYCERIN TAB SUBL

Anticoagulants, Oral and SQCardiovascular APIXABAN (ELIQUIS ™) TABLETDABIGATRAN ETEXILATE MESYLATE (PRADAXA ™) CAPSULEDALTEPARIN SODIUM,PORCINE SYRINGEEDOXABAN TOSYLATE (SAVAYSA ™) TABLETENOXAPARIN SODIUM SYRINGEENOXAPARIN SODIUM VIALRIVAROXABAN (XARELTO ™) TAB DS PKRIVAROXABAN (XARELTO ™) TABLETWARFARIN SODIUM TABLET

Beta‐Blockers, OralCardiovascular ACEBUTOLOL HCL CAPSULEATENOLOL TABLETCARVEDILOL TABLETLABETALOL HCL TABLETMETOPROLOL SUCCINATE TAB ER 24HMETOPROLOL TARTRATE TABLETPROPRANOLOL HCL TABLET

6 Updated: December 27, 2016

* Drug coverage subject to meeting clinical prior authorization criteria** Drug coverage subject to quantity limits*** Certain strengths may require Prior Authorization‡ Age restric ons apply

Page 7: Oregon Medicaid Preferred Drug List - January 1, 2017 Medicaid Preferred Drug...Table 121‐0030‐1 Oregon Fee‐for‐Service Enforceable Physical Health Preferred Drug List Allergy

System Class Preferred

Effective: January 1, 2017Table 121‐0030‐1 Oregon Fee‐for‐Service Enforceable Physical Health Preferred Drug List

Calcium Channel Blockers ‐ Dihydropyridine, Oral

Cardiovascular AMLODIPINE BESYLATE TABLETNICARDIPINE HCL CAPSULENIFEDIPINE TAB ER 24NIFEDIPINE TABLET ER

Calcium Channel Blockers ‐ Non‐Dihydropyridine, Oral

Cardiovascular DILTIAZEM HCL CAP ER 12HDILTIAZEM HCL CAP ER 24HDILTIAZEM HCL CAP ER DEGDILTIAZEM HCL CAPSULE ERDILTIAZEM HCL TABLETVERAPAMIL HCL CAP24H PELVERAPAMIL HCL TABLETVERAPAMIL HCL TABLET ER

Combination Antihypertensives

Cardiovascular AMLODIPINE BES/OLMESARTAN MED TABLETBENAZEPRIL/HYDROCHLOROTHIAZIDE TABLETENALAPRIL/HYDROCHLOROTHIAZIDE TABLETLISINOPRIL/HYDROCHLOROTHIAZIDE TABLETLOSARTAN/HYDROCHLOROTHIAZIDE TABLETMETOPROLOL SUCCINATE/HCTZ TAB ER 24HOLMESARTAN/AMLODIPIN/HCTHIAZID TABLETOLMESARTAN/HYDROCHLOROTHIAZIDE TABLETTELMISARTAN/HYDROCHLOROTHIAZID TABLET

Diuretics, OralCardiovascular AMILORIDE HCL TABLETAMILORIDE/HYDROCHLOROTHIAZIDE TABLETBUMETANIDE TABLETFUROSEMIDE SOLUTION ***FUROSEMIDE TABLETHYDROCHLOROTHIAZIDE CAPSULEHYDROCHLOROTHIAZIDE TABLETINDAPAMIDE TABLETSPIRONOLACT/HYDROCHLOROTHIAZID TABLETSPIRONOLACTONE TABLETTORSEMIDE TABLETTRIAMTERENE CAPSULETRIAMTERENE/HYDROCHLOROTHIAZID CAPSULE

Other Dyslipidemia DrugsCardiovascular CHOLESTYRAMINE (WITH SUGAR) POWD PACKCHOLESTYRAMINE (WITH SUGAR) POWDERCHOLESTYRAMINE/ASPARTAME POWD PACKCHOLESTYRAMINE/ASPARTAME POWDERFENOFIBRATE TABLET ***GEMFIBROZIL TABLET

7 Updated: December 27, 2016

* Drug coverage subject to meeting clinical prior authorization criteria** Drug coverage subject to quantity limits*** Certain strengths may require Prior Authorization‡ Age restric ons apply

Page 8: Oregon Medicaid Preferred Drug List - January 1, 2017 Medicaid Preferred Drug...Table 121‐0030‐1 Oregon Fee‐for‐Service Enforceable Physical Health Preferred Drug List Allergy

System Class Preferred

Effective: January 1, 2017Table 121‐0030‐1 Oregon Fee‐for‐Service Enforceable Physical Health Preferred Drug List

Platelet InhibitorsCardiovascular ASPIRIN TAB CHEWASPIRIN TABLETASPIRIN TABLET DRASPIRIN/DIPYRIDAMOLE CPMP 12HRCILOSTAZOL TABLETCLOPIDOGREL BISULFATE TABLETDIPYRIDAMOLE TABLET

Statins & Combos (High Potency)

Cardiovascular ATORVASTATIN CALCIUM TABLETSIMVASTATIN TABLET

Statins & Combos (Low‐Medium Potency)

Cardiovascular LOVASTATIN TABLETPRAVASTATIN SODIUM TABLET

Antibiotics, TopicalDermatologicals BACITRACIN OINT. (G) ***BACITRACIN ZINC OINT. (G)BACITRACIN ZINC/POLYMYX B SULF OINT. (G)BACITRACIN/POLYMYXIN B SULFATE OINT. (G)GENTAMICIN SULFATE CREAM (G)MUPIROCIN OINT. (G)NEOMYCIN SU/BACITRAC ZN/POLY OINT. (G)

Antifungals, TopicalDermatologicals MICONAZOLE NITRATE CREAM (G)NYSTATIN CREAM (G)NYSTATIN OINT. (G)

Antiparasitics, TopicalDermatologicals PERMETHRIN COMBO. PKGPERMETHRIN CREAM (G)PERMETHRIN LIQUIDPIP BUTOX/PYRETHRINS/PERMETH KITPIPERONYL BUTOXIDE/PYRETHRINS GEL (GRAM)PIPERONYL BUTOXIDE/PYRETHRINS KITPIPERONYL BUTOXIDE/PYRETHRINS LIQUIDPIPERONYL BUTOXIDE/PYRETHRINS SHAMPOO

Antipsoriatics, TopicalDermatologicals CALCIPOTRIENE * CREAM (G)CALCIPOTRIENE * SOLUTIONCALCIPOTRIENE/BETAMETHASONE * OINT. (G)TAZAROTENE * CREAM (G)TAZAROTENE * GEL (GRAM)

8 Updated: December 27, 2016

* Drug coverage subject to meeting clinical prior authorization criteria** Drug coverage subject to quantity limits*** Certain strengths may require Prior Authorization‡ Age restric ons apply

Page 9: Oregon Medicaid Preferred Drug List - January 1, 2017 Medicaid Preferred Drug...Table 121‐0030‐1 Oregon Fee‐for‐Service Enforceable Physical Health Preferred Drug List Allergy

System Class Preferred

Effective: January 1, 2017Table 121‐0030‐1 Oregon Fee‐for‐Service Enforceable Physical Health Preferred Drug List

Steroids, TopicalDermatologicals ALCLOMETASONE DIPROPIONATE CREAM (G)ALCLOMETASONE DIPROPIONATE OINT. (G)BETAMETHASONE DIPROPIONATE CREAM (G)BETAMETHASONE DIPROPIONATE LOTIONBETAMETHASONE DIPROPIONATE OINT. (G)BETAMETHASONE VALERATE CREAM (G)BETAMETHASONE VALERATE OINT. (G)CLOBETASOL PROPIONATE CREAM (G)CLOBETASOL PROPIONATE OINT. (G)DESONIDE CREAM (G)DESONIDE OINT. (G)FLUOCINOLONE ACETONIDE CREAM (G)FLUOCINOLONE ACETONIDE SOLUTIONFLUOCINONIDE CREAM (G)FLUOCINONIDE SOLUTIONFLUOCINONIDE/EMOLLIENT BASE CREAM (G)HYDROCORTISONE CREAM (G) ***HYDROCORTISONE OINT. (G)HYDROCORTISONE ACETATE CREAM (G)HYDROCORTISONE BUTYRATE SOLUTIONTRIAMCINOLONE ACETONIDE CREAM (G)TRIAMCINOLONE ACETONIDE OINT. (G)

Androgens, Topical & Parenteral

Endocrine TESTOSTERONE ‡ GEL (GRAM)TESTOSTERONE ‡ GEL MD PMPTESTOSTERONE ‡ GEL PACKETTESTOSTERONE CYPIONATE ‡ VIALTESTOSTERONE ENANTHATE ‡ VIAL

Bone Metabolism DrugsEndocrine ALENDRONATE SODIUM TABLETIBANDRONATE SODIUM TABLETRISEDRONATE SODIUM TABLET

Diabetes, DPP‐4 InhibitorsEndocrine SITAGLIPTIN PHOS/METFORMIN HCL (JANUMET ™) * TABLETSITAGLIPTIN PHOSPHATE (JANUVIA ™) * TABLET

Diabetes, GLP‐1 Receptor Agonists

Endocrine EXENATIDE * PEN INJCTR

9 Updated: December 27, 2016

* Drug coverage subject to meeting clinical prior authorization criteria** Drug coverage subject to quantity limits*** Certain strengths may require Prior Authorization‡ Age restric ons apply

Page 10: Oregon Medicaid Preferred Drug List - January 1, 2017 Medicaid Preferred Drug...Table 121‐0030‐1 Oregon Fee‐for‐Service Enforceable Physical Health Preferred Drug List Allergy

System Class Preferred

Effective: January 1, 2017Table 121‐0030‐1 Oregon Fee‐for‐Service Enforceable Physical Health Preferred Drug List

Diabetes, InsulinsEndocrine INSULIN ASPART VIALINSULIN ASPART * CARTRIDGEINSULIN ASPART * INSULN PENINSULIN ASPART PROT/INSULN ASP VIALINSULIN ASPART PROT/INSULN ASP * INSULN PENINSULIN DETEMIR * INSULN PENINSULIN GLARGINE,HUM.REC.ANLOG VIALINSULIN GLARGINE,HUM.REC.ANLOG * INSULN PENINSULIN LISPRO VIALINSULIN LISPRO PROTAMIN/LISPRO VIALINSULIN NPH HUM/REG INSULIN HM VIALINSULIN NPH HUM/REG INSULIN HM * INSULN PENINSULIN NPH HUMAN ISOPHANE VIALINSULIN REGULAR, HUMAN VIALINSULIN ZINC HUMAN RECOMBINANT VIAL

Diabetes, Miscellaneous Antidiabetic Agents

Endocrine METFORMIN HCL TAB ER 24HMETFORMIN HCL TABLET

Diabetes, SulfonylureasEndocrine GLIMEPIRIDE TABLETGLIPIZIDE TABLETGLYBURIDE TABLET

Diabetes, ThiazolidinedionesEndocrine PIOGLITAZONE HCL TABLET

Estrogen Replacement, OralEndocrine ESTRADIOL ‡ TABLETESTROPIPATE ‡ TABLET

Estrogen Replacement, TopicalEndocrine ESTRADIOL ‡ PATCH TDSWESTRADIOL ‡ PATCH TDWK

Estrogen Replacement, VaginalEndocrine ESTRADIOL TABLETESTROGENS, CONJUGATED CREAM/APPL

Growth HormonesEndocrine SOMATROPIN * CARTRIDGESOMATROPIN * PEN INJCTRSOMATROPIN * SYRINGE

Progestational AgentsEndocrine HYDROXYPROGESTERONE CAPROATE (MAKENA ™) * VIAL

Antacid, H2 AntagonistsGastrointestinal FAMOTIDINE TABLET ***RANITIDINE HCL SYRUPRANITIDINE HCL TABLET ***

Antacid, Proton Pump Inhibitors

Gastrointestinal OMEPRAZOLE ** CAPSULE DRPANTOPRAZOLE SODIUM ** TABLET DR

10 Updated: December 27, 2016

* Drug coverage subject to meeting clinical prior authorization criteria** Drug coverage subject to quantity limits*** Certain strengths may require Prior Authorization‡ Age restric ons apply

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Effective: January 1, 2017Table 121‐0030‐1 Oregon Fee‐for‐Service Enforceable Physical Health Preferred Drug List

Antiemetics, NewerGastrointestinal ONDANSETRON ** TAB RAPDISONDANSETRON HCL ** SOLUTIONONDANSETRON HCL ** TABLET

Inflammatory Bowel DiseaseGastrointestinal BALSALAZIDE DISODIUM CAPSULEBUDESONIDE CAPDR ‐ ERMESALAMINE SUPP.RECTMESALAMINE (APRISO ™) CAP ER 24HMESALAMINE (LIALDA ™) TABLET DROLSALAZINE SODIUM CAPSULESULFASALAZINE TABLETSULFASALAZINE TABLET DR

11 Updated: December 27, 2016

* Drug coverage subject to meeting clinical prior authorization criteria** Drug coverage subject to quantity limits*** Certain strengths may require Prior Authorization‡ Age restric ons apply

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Effective: January 1, 2017Table 121‐0030‐1 Oregon Fee‐for‐Service Enforceable Physical Health Preferred Drug List

Laxatives, Chronic Constipation

Gastrointestinal BISACODYL TABLETBISACODYL TABLET DRCALCIUM POLYCARBOPHIL TABLETCELLULOSE POWDERDOCUSATE CALCIUM CAPSULEDOCUSATE SODIUM CAPSULEDOCUSATE SODIUM LIQUIDDOCUSATE SODIUM SYRUPDOCUSATE SODIUM TABLETFOS/MALTODEXTRIN LIQUIDFRUCTOOLIGOSACCHARIDES/POLYDEX LIQUIDFRUCTOOLIGOSACCHARIDES/POLYDEX LIQUID PKTGLYCERIN/MALTODEXTRIN LIQUIDGUAR GUM PACKETGUAR GUM POWDERINULIN TAB CHEWLACTULOSE SOLUTIONMAGNESIUM CITRATE SOLUTIONMAGNESIUM HYDROXIDE ORAL SUSPMAGNESIUM HYDROXIDE TAB CHEWMETHYLCELLULOSE TABLETMETHYLCELLULOSE (WITH SUGAR) POWDER ***POLYETHYLENE GLYCOL 3350 POWDERPSYLLIUM HUSK CAPSULEPSYLLIUM HUSK POWDERPSYLLIUM HUSK (WITH DEXTROSE) POWDERPSYLLIUM HUSK (WITH SUGAR) POWDERPSYLLIUM HUSK/ASPARTAME POWD PACKPSYLLIUM HUSK/ASPARTAME POWDERPSYLLIUM HUSK/CALCIUM CARB CAPSULEPSYLLIUM SEED POWDERPSYLLIUM SEED (WITH DEXTROSE) PACKETPSYLLIUM SEED (WITH DEXTROSE) POWDERPSYLLIUM SEED (WITH SUGAR) POWDERPSYLLIUM SEED (WITH SUGAR) WAFERPSYLLIUM SEED/ASPARTAME POWDERPSYLLIUM SEED/SOD BICARB PACKETSENNA LEAF TEA (GRAM)SENNA LEAF EXTRACT SYRUPSENNOSIDES SYRUPSENNOSIDES TAB CHEWSENNOSIDES TABLETSENNOSIDES/DOCUSATE SODIUM TABLETSENNOSIDES/PSYLLIUM HUSK CAPSULESOLUBLE CORN FIBER POWDERWHEAT DEXTRIN POWD PACK ***WHEAT DEXTRIN POWDER

Pancreatic EnzymesGastrointestinal LIPASE/PROTEASE/AMYLASE (CREON ™) CAPSULE DR

12 Updated: December 27, 2016

* Drug coverage subject to meeting clinical prior authorization criteria** Drug coverage subject to quantity limits*** Certain strengths may require Prior Authorization‡ Age restric ons apply

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Effective: January 1, 2017Table 121‐0030‐1 Oregon Fee‐for‐Service Enforceable Physical Health Preferred Drug List

Benign Prostate Hypertrophy Drugs

Genito‐Urinary DOXAZOSIN MESYLATE TABLETFINASTERIDE TABLETTAMSULOSIN HCL CAP ER 24HTERAZOSIN HCL CAPSULE

Overactive Bladder DrugsGenito‐Urinary FESOTERODINE FUMARATE TAB ER 24HHYOSCYAMINE SULFATE ELIXIRHYOSCYAMINE SULFATE TAB RAPDISOXYBUTYNIN PATCH TDSWOXYBUTYNIN CHLORIDE SYRUPOXYBUTYNIN CHLORIDE TAB ER 24OXYBUTYNIN CHLORIDE TABLET

Colony Stimulating FactorsHematology‐Oncology FILGRASTIM SYRINGEFILGRASTIM VIALFILGRASTIM‐SNDZ SYRINGEPEGFILGRASTIM SYR W/ INJPEGFILGRASTIM SYRINGESARGRAMOSTIM VIALTBO‐FILGRASTIM (GRANIX ™) SYRINGE

Erythropoetic Stimulating Agents

Hematology‐Oncology DARBEPOETIN ALFA IN POLYSORBAT (ARANESP ™) * SYRINGEDARBEPOETIN ALFA IN POLYSORBAT (ARANESP ™) * VIALPROCRIT ™ ‐ BRAND ONLY * VIAL

Iron ChelatorsHematology‐Oncology DEFEROXAMINE MESYLATE VIAL

Biologics for Autoimmune Conditions

Immunological ADALIMUMAB (HUMIRA ™) * SYRINGEKITADALIMUMAB (HUMIRA PEDIATRIC CROHN'S ™) * SYRINGEKITADALIMUMAB (HUMIRA PEN ™) * PEN IJ KITADALIMUMAB (HUMIRA PEN CROHN‐UC‐HS STARTER ™) * PEN IJ KITADALIMUMAB (HUMIRA PEN PSORIASIS‐UVEITIS ™) * PEN IJ KITETANERCEPT (ENBREL ™) * PEN INJCTRETANERCEPT (ENBREL ™) * SYRINGEETANERCEPT (ENBREL ™) * VIAL

ImmunoglobulinsImmunological GAMUNEX‐C ™ ‐ BRAND ONLY VIAL ***

13 Updated: December 27, 2016

* Drug coverage subject to meeting clinical prior authorization criteria** Drug coverage subject to quantity limits*** Certain strengths may require Prior Authorization‡ Age restric ons apply

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Effective: January 1, 2017Table 121‐0030‐1 Oregon Fee‐for‐Service Enforceable Physical Health Preferred Drug List

ImmunosuppressantsImmunological AZATHIOPRINE TABLETCYCLOSPORINE CAPSULECYCLOSPORINE SOLUTIONCYCLOSPORINE, MODIFIED CAPSULECYCLOSPORINE, MODIFIED SOLUTIONEVEROLIMUS TABLETMYCOPHENOLATE MOFETIL CAPSULEMYCOPHENOLATE MOFETIL SUSP RECONMYCOPHENOLATE MOFETIL TABLETMYCOPHENOLATE SODIUM TABLET DRSIROLIMUS SOLUTIONSIROLIMUS TABLETTACROLIMUS CAPSULE

Alzheimer's Disease DrugsNeurology DONEPEZIL HCL TABLET ***GALANTAMINE HBR CAP24H PELGALANTAMINE HBR TABLETMEMANTINE HCL SOLUTIONMEMANTINE HCL TAB DS PKMEMANTINE HCL TABLETRIVASTIGMINE PATCH TD24

Antiepileptics (oral & rectal)Neurology CARBAMAZEPINE ORAL SUSPCARBAMAZEPINE TAB CHEWCARBAMAZEPINE TAB ER 12HCARBAMAZEPINE TABLETDIASTAT ™ ‐ BRAND ONLY KITDIASTAT ACUDIAL ™ ‐ BRAND ONLY KITETHOSUXIMIDE CAPSULEETHOSUXIMIDE SOLUTIONETHOTOIN TABLETGABAPENTIN CAPSULELACOSAMIDE (VIMPAT ™) TABLETLEVETIRACETAM SOLUTIONLEVETIRACETAM TABLETMETHSUXIMIDE CAPSULEOXCARBAZEPINE ORAL SUSPOXCARBAZEPINE TABLETPHENOBARBITAL ELIXIRPHENOBARBITAL TABLETPHENYTOIN ORAL SUSPPHENYTOIN TAB CHEWPHENYTOIN SODIUM EXTENDED CAPSULEPRIMIDONE TABLETRUFINAMIDE TABLETTIAGABINE HCL TABLETTOPIRAMATE TABLETZONISAMIDE CAPSULE

14 Updated: December 27, 2016

* Drug coverage subject to meeting clinical prior authorization criteria** Drug coverage subject to quantity limits*** Certain strengths may require Prior Authorization‡ Age restric ons apply

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Effective: January 1, 2017Table 121‐0030‐1 Oregon Fee‐for‐Service Enforceable Physical Health Preferred Drug List

Multiple SclerosisNeurology GLATIRAMER ACETATE SYRINGE ***INTERFERON BETA‐1A PEN IJ KITINTERFERON BETA‐1A SYRINGEINTERFERON BETA‐1A SYRINGEKITINTERFERON BETA‐1A/ALBUMIN KITINTERFERON BETA‐1A/ALBUMIN PEN INJCTRINTERFERON BETA‐1A/ALBUMIN SYRINGEINTERFERON BETA‐1B KIT

Parkinson's Disease Drugs, Oral & Topical

Neurology BENZTROPINE MESYLATE TABLETCARBIDOPA/LEVODOPA TABLETCARBIDOPA/LEVODOPA TABLET ERCARBIDOPA/LEVODOPA/ENTACAPONE TABLETENTACAPONE TABLETPRAMIPEXOLE DI‐HCL TABLETSELEGILINE HCL CAPSULETRIHEXYPHENIDYL HCL ELIXIRTRIHEXYPHENIDYL HCL TABLET

B‐vitamins, OralNutritional CYANOCOBALAMIN (VITAMIN B‐12) DROPS ***CYANOCOBALAMIN (VITAMIN B‐12) LOZENGECYANOCOBALAMIN (VITAMIN B‐12) TAB IR ERCYANOCOBALAMIN (VITAMIN B‐12) TAB RAPDIS ***CYANOCOBALAMIN (VITAMIN B‐12) TAB SUBL ***CYANOCOBALAMIN (VITAMIN B‐12) TABLET ***LEVOMEFOLATE/ALGAL OIL CAPSULEPYRIDOXINE HCL TABLETTHIAMINE HCL TABLET ***THIAMINE MONONITRATE TABLET

Calcium/Vit D Replacement, Oral

Nutritional CALCIUM CARBONATE CAPSULECALCIUM CARBONATE ORAL SUSPCALCIUM CARBONATE TAB CHEWCALCIUM CARBONATE TABLETCALCIUM CARBONATE/VITAMIN D3 CAPSULE ***CALCIUM CARBONATE/VITAMIN D3 LIQUIDCALCIUM CARBONATE/VITAMIN D3 TAB CHEWCALCIUM CARBONATE/VITAMIN D3 TABLET ***CALCIUM CITRATE TABLET ***CHOLECALCIFEROL (VITAMIN D3) CAPSULE ***CHOLECALCIFEROL (VITAMIN D3) SPRAY SUSPCHOLECALCIFEROL (VITAMIN D3) TABLET ***ERGOCALCIFEROL (VITAMIN D2) CAPSULEERGOCALCIFEROL (VITAMIN D2) TABLET

15 Updated: December 27, 2016

* Drug coverage subject to meeting clinical prior authorization criteria** Drug coverage subject to quantity limits*** Certain strengths may require Prior Authorization‡ Age restric ons apply

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Iron Replacement, OralNutritional FERROUS GLUCONATE TABLET ***FERROUS SULFATE ELIXIR ***FERROUS SULFATE LIQUIDFERROUS SULFATE TABLETFERROUS SULFATE TABLET DRFERROUS SULFATE TABLET ER ***IRON FUM, PS/FA/VIT C/L. CASEI POWD PACK

Magnesium Replacement, OralNutritional MAGNESIUM TABLETMAGNESIUM AMINO ACID CHELATE TABLETMAGNESIUM CARBONATE LIQUIDMAGNESIUM CITRATE TABLETMAGNESIUM GLUCONATE TABLETMAGNESIUM OXIDE CAPSULEMAGNESIUM OXIDE/MAGNESIUM TABLETMAGNESIUM OXIDE/PYRIDOXINE HCL TABLET

Multivitamins, OralNutritional BETA‐CAROTENE(A)‐VITS C,E/MINS * TABLETFOLIC ACID/VIT BCOMP,C * TABLETMULTIVIT,TX IRON,OTHER MINS * TABLETMULTIVITAMIN * TABLETMULTIVITAMIN WITH MINERALS/LUT * TABLETMULTIVITAMIN,THERAPEUTIC * TABLETMULTIVITAMIN/IRON/FOLIC ACID * TABLETMULTIVIT‐MIN/FA/LYCOPEN/LUTEIN * TABLETMV. MIN CMB#51/FA/VIT K1/UBI * TAB CHEWVITAMIN B COMPLEX * CAPSULE

Potassium and K‐Phos, OralNutritional NA PHOS,M‐B/K PHOS,MONOB TABLETPHOSPHORUS #1 TABLETPOT CHLORIDE/CAL PHOS/MAG TABLETPOTASSIUM TABLETPOTASSIUM BICARBONATE/CIT AC TABLET EFF ***POTASSIUM CHLORIDE TAB ER PRTPOTASSIUM CHLORIDE TABLET ERPOTASSIUM PHOSPHATE,MONOBASIC TABLET SOL

16 Updated: December 27, 2016

* Drug coverage subject to meeting clinical prior authorization criteria** Drug coverage subject to quantity limits*** Certain strengths may require Prior Authorization‡ Age restric ons apply

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Prenatal VitaminsNutritional IRON,CARBONYL/FA/MULTIVIT‐MIN TABLETPNV #14/FERROUS FUM/FOLIC ACID TAB CHEWPNV #15/IRON FUM,PS/FOLIC ACID CAPSULEPNV #78/IRON ASP GLY/FA#1/DHA CAPSULEPNV #8/IRON PS CMP,ASPG/FA/DHA COMBO. PKGPNV #86/IRON POLY/FA/DHA/EPA COMBO. PKGPNV #87/IRON BISGLY/FA/DHA COMBO. PKGPNV 11‐IRON FUM‐FOLIC ACID‐OM3 CAPSULEPNV 16/IRON FUM,PS/FOLIC/OM‐3 CAPSULEPNV 18/FE,CARB/FA/DSS/UBI/DHA TABLETPNV 19/IRON PS,HEME/FOLIC/DHA CAPSULEPNV 21/IRON PS,HEME PPEP/FOLIC TABLETPNV 22/IRON,GLUC/FOLIC/DSS/DHA COMBO. PKGPNV 30/IRON CARB,AG/FOLIC/OM3 CAPSULEPNV 76/IRON,GLUC/FOLIC/DSS/DHA COMBO. PKGPNV 85/IRON/FOLIC/DHA/FISH OIL CAPSULEPNV COMBO#47/IRON/FA #1/DHA CAPSULEPNV NO.118/IRON FUMARATE/FA TAB CHEWPNV NO.66/IRON,CARBONYL/FA/DHA CAPSULEPNV NO.81/IRON,GLUC/FOLIC/DSS TABLETPNV W‐CA #40/IRON FUM/FA CMB#1 TABLETPNV WITH CA #68/IRON/FA#1/DHA CAPSULEPNV WITH CA NO.65/IRON POLY/FA CAPSULEPNV WITH CA#74/IRON/FOLIC ACID TABLETPNV WITH CA,NO.70/IRON/FA/DHA CAPSULEPNV WITH CA,NO.72/IRON/FA TABLETPNV#20/IRON/FA/DS/FISH/DHA/EPA CAPSULEPNV#26/IRON POLY/FA/DHA CAPSULEPNV#67/IRON PS/FA CMB#1/DHA CAPSULEPNV,CALC 35/IRON/FOLIC/DSS/OM3 CAPSULEPNV,CALCIUM37/IRON/FOLIC/OMEG3 CAPSULEPNV/FOLIC AC/B6/CALCIUM/GINGER TABLETPNV113/FE/L‐MEF/OM3/DHA/EPA/FS CMB TABAMPPNV115/IRON FUMARATE/FA/DSS TABLETPNV123/IRON CAR/FA/OM3/DHA/EPA CAPSULEPNV19/IRON BD HC,S‐P/FOLIC/OM3 CMBPKGDRCPPNV2/IRON B‐G SUC‐P/FA/OMEGA‐3 COMBO. PKGPNV34/IRON,CARBONYL/FA/DSS/DHA CAPSULEPNV39/IRON FUMARATE/FA/DSS/DHA CAPSULEPNV53/IRON B‐G HCL‐P/FA/OMEGA3 COMBO. PKGPNV53/IRON FUM/FA/DOCUSATE/DHA CAPSULEPNV55/IRON BG HC,SUCC‐P/FA/OM3 CMBPKGDRCPPNV59/IRON,CARB,FUM/FA/DSS/DHA CAPSULEPNV66/IRON FUMARATE/FA/DSS/DHA CAPSULEPNV69/IRON,CARBONYL/FA/DSS/DHA CAPSULEPNV72/IRON,GLUC/FOLIC/DSS/DHA COMBO. PKGPNV73/IRON,GLUC/FOLIC/DSS/DHA COMBO. PKGPNV80/IRON FUMARATE/FA/DSS/DHA CAPSULEPNV81/IRON EDTA,PS/FOLIC/OMEG3 CMBPKGDRCPPNV83/IRON,CARB/IRON ASP GL/FA TABLET

17 Updated: December 27, 2016

* Drug coverage subject to meeting clinical prior authorization criteria** Drug coverage subject to quantity limits*** Certain strengths may require Prior Authorization‡ Age restric ons apply

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Effective: January 1, 2017Table 121‐0030‐1 Oregon Fee‐for‐Service Enforceable Physical Health Preferred Drug List

Prenatal VitaminsNutritional PRENAT VIT COMB.10/IRON/FA/DHA COMBO. PKGPRENATAL #103/IRON FUMARATE/FA TABLETPRENATAL #57/IRON/FA/DSS/DHA CAPSULEPRENATAL #79/IRON ASP GLY/FA#1 TABLETPRENATAL NO.13/IRON PS/FA CB#1 TAB CHEWPRENATAL NO.52/IRON/FA/DHA CAPSULEPRENATAL NO.75/IRON/FOLATE #1 TABLETPRENATAL NO.77/IRON ASP GLY/FA TABLETPRENATAL VIT #68/IRON/FA#6/DHA CAPSULEPRENATAL VIT #69/IRON/FA#6/DHA CAPSULEPRENATAL VIT #76/IRON,CARB/FA TABLETPRENATAL VIT 15/IRON CB/FA/DSS TABLETPRENATAL VIT 16/IRON CB/FA/DSS TABLETPRENATAL VIT COMB.10/IRON/FA TABLETPRENATAL VIT NO.112/FOLIC ACID TAB CHEWPRENATAL VIT NO.114/FA/GINGER TABLETPRENATAL VIT NO.127/IRON/FA TABLETPRENATAL VIT NO.73/IRON/FA TABLETPRENATAL VIT NO.87/IRON/FA/DHA CAPSULEPRENATAL VIT#4/IRON FUM,PS/FA CAPSULEPRENATAL VIT#65/IRON FUM,PS/FA CAPSULEPRENATAL VIT#84/IRON/FA#1/DHA CAPSULEPRENATAL VIT#85/IRON/FA#1/DHA CAPSULEPRENATAL VIT#86/IRON BISGLY/FA TABLETPRENATAL VIT27,CALCIUM/IRON/FA TABLETPRENATAL VIT37/IRON/FOLIC ACID TAB CHEWPRENATAL VITS #33/IRON/FA/DHA COMBO. PKGPRENATAL VITS#4/IRON FUM/FA CAPSULEPRENATAL#90/IRON FUM,PS/FA/DHA CAPSULEPRENATAL56/IRON/FOLIC ACID/DHA CAPSULEPV W‐O CAL/IRON PS CPLX/FA TAB CHEW

Antibiotics, OphthalmicOphthalmics BACITRACIN/POLYMYXIN B SULFATE OINT. (G)CIPROFLOXACIN HCL DROPSCIPROFLOXACIN HCL OINT. (G)ERYTHROMYCIN BASE OINT. (G)GENTAMICIN SULFATE DROPSGENTAMICIN SULFATE OINT. (G) ***MOXIFLOXACIN HCL DROPSNATAMYCIN DROPS SUSPNEOMYCIN/POLYMYXN B/GRAMICIDIN DROPSOFLOXACIN DROPSPOLYMYXIN B SULF/TRIMETHOPRIM DROPSSULFACETAMIDE SODIUM DROPSTOBRAMYCIN DROPSTOBRAMYCIN OINT. (G)

18 Updated: December 27, 2016

* Drug coverage subject to meeting clinical prior authorization criteria** Drug coverage subject to quantity limits*** Certain strengths may require Prior Authorization‡ Age restric ons apply

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Effective: January 1, 2017Table 121‐0030‐1 Oregon Fee‐for‐Service Enforceable Physical Health Preferred Drug List

Antibiotic‐Steroids, Ophthalmic

Ophthalmics GENTAMICIN/PREDNISOL AC DROPS SUSPGENTAMICIN/PREDNISOL AC OINT. (G)NEO/POLYMYX B SULF/DEXAMETH DROPS SUSPNEO/POLYMYX B SULF/DEXAMETH OINT. (G)SULFACETM NA/PREDNISOL AC DROPS SUSPSULFACETM NA/PREDNISOL AC OINT. (G)TOBRAMYCIN/DEXAMETHASONE DROPS SUSPTOBRAMYCIN/DEXAMETHASONE OINT. (G)

Anti‐Inflammatory Drugs, Ophthalmic

Ophthalmics DEXAMETHASONE DROPS SUSPDEXAMETHASONE SOD PHOSPHATE DROPSDICLOFENAC SODIUM DROPS ***FLUOROMETHOLONE DROPS SUSPFLUOROMETHOLONE OINT. (G)FLURBIPROFEN SODIUM DROPSKETOROLAC TROMETHAMINE DROPSLOTEPREDNOL ETABONATE DROPS SUSPPREDNISOLONE ACETATE DROPS SUSP

Glaucoma DrugsOphthalmics BETAXOLOL HCL DROPSBRIMONIDINE TARTRATE DROPS ***BRINZOLAMIDE DROPS SUSPCARTEOLOL HCL DROPSDORZOLAMIDE HCL/TIMOLOL MALEAT DROPSDORZOLAMIDE/TIMOLOL/PF DROPERETTELATANOPROST DROPSPILOCARPINE HCL DROPSTIMOLOL MALEATE DROPSTRAVOPROST DROPS

Vascular Endothelial Growth Factors

Ophthalmics BEVACIZUMAB VIAL

Otic AntibioticsOtics NEOMYCIN SU/COLIST/HC/THONZON DROPS SUSPNEOMYCIN/POLYMYXIN B SULF/HC DROPS SUSP ***OFLOXACIN DROPS

ADHD DrugsPsychiatric DEXMETHYLPHENIDATE HCL CPBP 50‐50DEXMETHYLPHENIDATE HCL (FOCALIN XR ™) CPBP 50‐50DEXTROAMPHETAMINE/AMPHETAMINE TABLETFOCALIN ™ ‐ BRAND ONLY TABLETLISDEXAMFETAMINE DIMESYLATE (VYVANSE ™) CAPSULEMETADATE CD ™ ‐ BRAND ONLY CPBP 30‐70METHYLPHENIDATE PATCH TD24METHYLPHENIDATE HCL TABLET

BenzodiazepinesPsychiatric CLONAZEPAM ** TABLET

19 Updated: December 27, 2016

* Drug coverage subject to meeting clinical prior authorization criteria** Drug coverage subject to quantity limits*** Certain strengths may require Prior Authorization‡ Age restric ons apply

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Effective: January 1, 2017Table 121‐0030‐1 Oregon Fee‐for‐Service Enforceable Physical Health Preferred Drug List

Opioid Reversal AgentsPsychiatric NALOXONE HCL SPRAYNALOXONE HCL SYRINGENALOXONE HCL VIAL

SedativesPsychiatric ZOLPIDEM TARTRATE ** TABLET

Substance Use Disorders, Opioid & Alcohol

Psychiatric ACAMPROSATE CALCIUM TABLET DRBUPRENORPHINE HCL/NALOXONE HCL (SUBOXONE ™) * FILMBUPRENORPHINE HCL/NALOXONE HCL * TAB SUBLNALTREXONE HCL TABLET

Tobacco Smoking CessationPsychiatric BUPROPION HCL TABLET ERNICOTINE * CARTRIDGENICOTINE * SPRAYNICOTINE ** PATCH DYSQNICOTINE ** PATCH TD24NICOTINE POLACRILEX ** GUMNICOTINE POLACRILEX ** LOZENGEVARENICLINE TARTRATE (CHANTIX ™) ** TAB DS PKVARENICLINE TARTRATE (CHANTIX ™) ** TABLET

Anticholinergics, InhaledPulmonary IPRATROPIUM BROMIDE HFA AER ADIPRATROPIUM BROMIDE SOLUTIONIPRATROPIUM/ALBUTEROL SULFATE AMPUL‐NEBTIOTROPIUM BROMIDE (SPIRIVA ™) CAP W/DEV

Beta‐Agonists, Inhaled Long Acting

Pulmonary FORMOTEROL FUMARATE CAP W/DEVSALMETEROL XINAFOATE BLST W/DEV

Beta‐Agonists, Inhaled Short‐Acting

Pulmonary ALBUTEROL SULFATE HFA AER ADALBUTEROL SULFATE SOLUTIONALBUTEROL SULFATE VIAL‐NEB

Corticosteroids, InhaledPulmonary BECLOMETHASONE DIPROPIONATE AER W/ADAPBUDESONIDE AER POW BAFLUTICASONE PROPIONATE AER W/ADAPFLUTICASONE PROPIONATE BLST W/DEV

Corticosteroids/LABA Combination, Inhaled

Pulmonary BUDESONIDE/FORMOTEROL FUMARATE HFA AER ADFLUTICASONE/SALMETEROL BLST W/DEVFLUTICASONE/SALMETEROL HFA AER AD

Cystic FibrosisPulmonary DORNASE ALFA ** SOLUTIONSODIUM CHLORIDE FOR INHALATION VIAL‐NEBTOBRAMYCIN/NEBULIZER (KITABIS PAK ™) ** AMPUL‐NEB

Miscellaneous Pulmonary Agents

Pulmonary MONTELUKAST SODIUM TAB CHEWMONTELUKAST SODIUM TABLET

20 Updated: December 27, 2016

* Drug coverage subject to meeting clinical prior authorization criteria** Drug coverage subject to quantity limits*** Certain strengths may require Prior Authorization‡ Age restric ons apply

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System Class Preferred

Effective: January 1, 2017Table 121‐0030‐1 Oregon Fee‐for‐Service Enforceable Physical Health Preferred Drug List

Pulmonary Arterial Hypertension Oral and Inhaled Drugs

Pulmonary BOSENTAN TABLETSILDENAFIL CITRATE TABLET

Pulmonary Arterial Hypertension Parenteral Drugs

Pulmonary EPOPROSTENOL SODIUM (GLYCINE) VIAL

Phosphate BindersRenal CALCIUM ACETATE CAPSULECALCIUM ACETATE TABLET ***SEVELAMER HCL * TABLET

21 Updated: December 27, 2016

* Drug coverage subject to meeting clinical prior authorization criteria** Drug coverage subject to quantity limits*** Certain strengths may require Prior Authorization‡ Age restric ons apply

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System Class Preferred

Effective: January 1, 2017Table 121‐0030‐1 Oregon Fee‐for‐Service Voluntary Mental Health Preferred Drug List

Antiepileptics (oral & rectal)Neurology DIVALPROEX SODIUM CAP SPRINKDIVALPROEX SODIUM TAB ER 24HDIVALPROEX SODIUM TABLET DRLAMOTRIGINE TABLETVALPROIC ACID CAPSULEVALPROIC ACID (AS SODIUM SALT) SOLUTION

ADHD DrugsPsychiatric ATOMOXETINE HCL CAPSULE

AntidepressantsPsychiatric AMITRIPTYLINE HCL TABLETANAFRANIL ™ ‐ BRAND ONLY CAPSULEBUPROPION HCL TABLETBUPROPION HCL TABLET ERCITALOPRAM HYDROBROMIDE ‡ SOLUTIONCITALOPRAM HYDROBROMIDE ‡ TABLETDESIPRAMINE HCL TABLETDOXEPIN HCL CAPSULEDOXEPIN HCL ORAL CONCESCITALOPRAM OXALATE ‡ TABLETFLUOXETINE HCL ‡ CAPSULEFLUOXETINE HCL ‡ SOLUTIONFLUOXETINE HCL ‡ TABLETFLUVOXAMINE MALEATE ‡ TABLETIMIPRAMINE HCL TABLETMAPROTILINE HCL TABLETMIRTAZAPINE TAB RAPDISMIRTAZAPINE TABLETNORTRIPTYLINE HCL CAPSULENORTRIPTYLINE HCL SOLUTIONPAROXETINE HCL ‡ TABLETPROTRIPTYLINE HCL TABLETSERTRALINE HCL ‡ ORAL CONCSERTRALINE HCL ‡ TABLETTRIMIPRAMINE MALEATE CAPSULEVENLAFAXINE HCL CAP ER 24HVENLAFAXINE HCL TABLET

Antipsychotics, 1st GenPsychiatric FLUPHENAZINE HCL ELIXIRFLUPHENAZINE HCL ORAL CONCFLUPHENAZINE HCL TABLETHALOPERIDOL TABLETHALOPERIDOL LACTATE ORAL CONCLOXAPINE SUCCINATE CAPSULEPERPHENAZINE TABLETTHIORIDAZINE HCL TABLETTHIOTHIXENE CAPSULETRIFLUOPERAZINE HCL TABLET

22 Updated: December 27, 2016

* Drug coverage subject to meeting clinical prior authorization criteria** Drug coverage subject to quantity limits*** Certain strengths may require Prior Authorization‡ Age restric ons apply

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System Class Preferred

Effective: January 1, 2017Table 121‐0030‐1 Oregon Fee‐for‐Service Voluntary Mental Health Preferred Drug List

Antipsychotics, 2nd GenPsychiatric ASENAPINE MALEATE (SAPHRIS ™) TAB SUBLCLOZAPINE TABLETLURASIDONE HCL (LATUDA ™) TABLETOLANZAPINE TABLETQUETIAPINE FUMARATE ** TABLETRISPERIDONE SOLUTIONRISPERIDONE TABLET

Antipsychotics, ParenteralPsychiatric ARIPIPRAZOLE (ABILIFY MAINTENA ™) SUSER SYRARIPIPRAZOLE (ABILIFY MAINTENA ™) SUSER VIALARIPIPRAZOLE LAUROXIL (ARISTADA ™) SUSER SYRCHLORPROMAZINE HCL AMPULFLUPHENAZINE DECANOATE VIALFLUPHENAZINE HCL VIALHALOPERIDOL DECANOATE AMPULHALOPERIDOL DECANOATE VIALHALOPERIDOL LACTATE AMPULHALOPERIDOL LACTATE VIALRISPERIDONE MICROSPHERES ** SYRINGE

23 Updated: December 27, 2016

* Drug coverage subject to meeting clinical prior authorization criteria** Drug coverage subject to quantity limits*** Certain strengths may require Prior Authorization‡ Age restric ons apply


ALASKA MEDICAID PREFERRED DRUG LIST THERAPEUTIC CLASS LISTING

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Louisiana Medicaid Preferred Drug List (PDL)/Non-Preferred ...ldh.la.gov/assets/HealthyLa/Pharmacy/PDL.pdf · LA Medicaid Preferred Drug List (PDL)/Non-Preferred Drug List (NPDL)

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Maryland Medicaid Preferred Drug List - Provider · PDF fileMaryland Medicaid Preferred Drug List PDL Effective July 1, 2016 Note: For most multi-source products, the generic product(s)

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“Auto PA” = System automated criteria looks for specific ... · Florida Medicaid Preferred Drug List (updated 05-14-2019) The Florida Medicaid Preferred Drug List (PDL) is subject