HHSC Preferred Drug List (PDL) Recommendations January 2018 Drug Utilization Review Board Meeting

Transcription

1 ACNE AGENTS, ORAL ABSORICA (ORAL) NPD NPD For this, the Board believed that the drug being recommended as preferred meets the fiscal requirements of the state and are the most safe and efficacious. ISOTRETINOIN (ORAL) PDL PDL ACNE AGENTS, TOPICAL ACANYA W/PUMP (TOPICAL) NPD NPD For this therapeutic drug class, the Board ACNE CLEARING SYSTEM OTC (TOPICAL) NPD NPD believed that all of the drugs being ACNEFREE SEVERE KIT OTC (TOPICAL) NPD NPD recommended as preferred demonstrated ACZONE GEL (TOPICAL) NPD NPD the greatest safety, efficacy, and value and ACZONE GEL W/PUMP (TOPICAL) NPD NPD provided clinicians with the greatest number ADAPALENE / BENZOYL PEROXIDE (EPIDUO) (TOPICAL) NPD NPD of first line options to use before requiring ADAPALENE CREAM (TOPICAL) NPD NPD Prior Authorization. ADAPALENE GEL (AG) (TOPICAL) NPD NPD ADAPALENE GEL (TOPICAL) NPD NPD ADAPALENE GEL PUMP (AG) (TOPICAL) NPD NPD ADAPALENE GEL PUMP (TOPICAL) NPD NPD ATRALIN (TOPICAL) NPD NPD AVAR CLEANSER (TOPICAL) NPD NPD AVAR FOAM (TOPICAL) NPD NPD AVAR LS CLEANSER (TOPICAL) NPD NPD AVAR LS MEDICATED PAD (TOPICAL) NPD NPD AVAR MEDICATED PAD (TOPICAL) NPD NPD AVAR-E (TOPICAL) NPD NPD AVAR-E LS (TOPICAL) NPD NPD AVITA CREAM (TOPICAL) NPD NPD AVITA GEL (TOPICAL) NPD NPD AZELEX (TOPICAL) NPD NPD BENZACLIN (TOPICAL) NPD NPD BENZACLIN W/PUMP (TOPICAL) PDL NPD Financial BENZAMYCIN (TOPICAL) NPD NPD BENZEPRO CLEANSER (TOPICAL) NPD NPD BENZEPRO FOAM (TOPICAL) NPD NPD BENZEPRO TOWELETTE (TOPICAL) NPD NPD Page 1 of 17

2 BENZOYL PEROXIDE 10% CREAM OTC (TOPICAL) NPD NPD BENZOYL PEROXIDE 10% WASH OTC (TOPICAL) NPD PDL Clinical / Financial BENZOYL PEROXIDE 3% CLEANSER OTC (TOPICAL) NPD NPD BENZOYL PEROXIDE 5% WASH OTC (TOPICAL) NPD PDL Clinical / Financial BENZOYL PEROXIDE 6% CLEANSER OTC (TOPICAL) NPD NPD BENZOYL PEROXIDE 9% CLEANSER OTC (TOPICAL) NPD NPD BENZOYL PEROXIDE CLEANSER (TOPICAL) NPD NPD BENZOYL PEROXIDE FOAM (TOPICAL) NPD NPD BENZOYL PEROXIDE GEL (TOPICAL) NPD NPD BENZOYL PEROXIDE GEL OTC (TOPICAL) PDL PDL BENZOYL PEROXIDE KIT (TOPICAL) NPD NPD BENZOYL PEROXIDE LOTION OTC (TOPICAL) NPD NPD BENZOYL PEROXIDE TOWELETTE (TOPICAL) NPD NPD BP 10-1 (TOPICAL) NPD NPD CLEARASIL DAILY CLEAR WASH OTC (TOPICAL) NPD NPD CLEOCIN T GEL (TOPICAL) NPD NPD CLEOCIN T LOTION (TOPICAL) NPD NPD CLEOCIN T MED. SWAB (TOPICAL) NPD NPD CLINDACIN PAC KIT (TOPICAL) NPD NPD CLINDAGEL (TOPICAL) NPD NPD CLINDAMYCIN / BENZOYL PEROXIDE (BENZACLIN) (TOPICAL) NPD NPD CLINDAMYCIN / BENZOYL PEROXIDE (BENZACLIN) W/PUMP (T NPD NPD CLINDAMYCIN / BENZOYL PEROXIDE (DUAC) (TOPICAL) NPD NPD CLINDAMYCIN / TRETINOIN (TOPICAL) NPD NPD CLINDAMYCIN PHOSPHATE FOAM (TOPICAL) NPD NPD CLINDAMYCIN PHOSPHATE GEL (TOPICAL) PDL PDL CLINDAMYCIN PHOSPHATE LOTION (TOPICAL) PDL NPD Financial CLINDAMYCIN PHOSPHATE MED. SWAB (TOPICAL) PDL PDL CLINDAMYCIN PHOSPHATE SOLUTION (TOPICAL) PDL PDL DAPSONE GEL (AG) (TOPICAL) NPD NPD DAPSONE GEL (TOPICAL) NPD NPD DIFFERIN CREAM (TOPICAL) NPD NPD DIFFERIN GEL (TOPICAL) NPD NPD DIFFERIN GEL OTC (TOPICAL) NR NPD Financial DIFFERIN GEL PUMP (TOPICAL) NPD NPD Page 2 of 17

3 DIFFERIN LOTION (TOPICAL) NPD NPD DUAC (TOPICAL) NPD NPD EPIDUO (TOPICAL) NPD NPD EPIDUO FORTE GEL W/PUMP (TOPICAL) NPD NPD ERYTHROMYCIN GEL (AG) (TOPICAL) NPD NPD ERYTHROMYCIN GEL (TOPICAL) NPD NPD ERYTHROMYCIN MED. SWAB (TOPICAL) NPD NPD ERYTHROMYCIN SOLUTION (TOPICAL) PDL PDL ERYTHROMYCIN-BENZOYL PEROXIDE (TOPICAL) NPD NPD EVOCLIN (TOPICAL) NPD NPD FABIOR (TOPICAL) NPD NPD KLARON (TOPICAL) NPD NPD NEUAC KIT (TOPICAL) NPD NPD ONEXTON W/PUMP (TOPICAL) NPD NPD OVACE PLUS CLEANSER ER (TOPICAL) NPD NPD OVACE PLUS CREAM ER (TOPICAL) NPD NPD OVACE PLUS FOAM (TOPICAL) NPD NPD OVACE PLUS LOTION (TOPICAL) NPD NPD OVACE PLUS WASH (TOPICAL) NPD NPD OVACE WASH (TOPICAL) NPD NPD PANOXYL 10 OTC (TOPICAL) NPD NPD PANOXYL 3 CREAM OTC (TOPICAL) NPD NPD PANOXYL-4 ACNE CREAMY WASH OTC (TOPICAL) NPD NPD PERSA-GEL OTC (TOPICAL) NPD NPD PLEXION CLEANSER (TOPICAL) NPD NPD RETIN-A CREAM (TOPICAL) NPD NPD RETIN-A GEL (TOPICAL) NPD NPD RETIN-A MICRO 0.04%, 0.1% (TOPICAL) NPD NPD RETIN-A MICRO 0.04%, 0.1% PUMP (TOPICAL) NPD NPD RETIN-A MICRO 0.08% PUMP (TOPICAL) NPD NPD ROSULA CLEANSER (TOPICAL) NPD NPD SALICYLIC ACID WASH OTC (TOPICAL) NPD NPD SSS 10-5 FOAM (TOPICAL) NPD NPD SULFACETAMIDE / SULFUR / UREA CLEANSER (TOPICAL) NPD NPD SULFACETAMIDE / SULFUR CLEANSER (TOPICAL) NPD NPD Page 3 of 17

4 SULFACETAMIDE / SULFUR LOTION (TOPICAL) NPD NPD SULFACETAMIDE / SULFUR MED. PAD (TOPICAL) NPD NPD SULFACETAMIDE / SULFUR SUSPENSION (TOPICAL) NPD NPD SULFACETAMIDE CLEANSER (TOPICAL) NPD NPD SULFACETAMIDE SHAMPOO (TOPICAL) NPD NPD SULFACETAMIDE SODIUM CLEANSER ER (TOPICAL) NPD NPD SULFACETAMIDE SODIUM/SULFUR (TOPICAL) NPD NPD SULFACETAMIDE SODIUM/SULFUR CLEANSER (TOPICAL) NPD NPD SULFACETAMIDE SODIUM/SULFUR CREAM (TOPICAL) NPD NPD SULFACETAMIDE SODIUM/SULFUR LOTION (TOPICAL) NPD NPD SULFACETAMIDE SODIUM/SULFUR SUNSCREEN (TOPICAL) NPD NPD SULFACETAMIDE SUSPENSION (TOPICAL) NPD NPD SULFACETAMIDE/SULFUR/CLEANSER KIT (TOPICAL) NPD NPD SUMADAN WASH (TOPICAL) NPD NPD SUMADAN XLT (TOPICAL) NPD NPD SUMAXIN CP KIT (TOPICAL) NPD NPD TAZAROTENE CREAM (AG) (TOPICAL) NPD NPD TAZAROTENE CREAM (TOPICAL) NPD NPD TAZORAC CREAM (TOPICAL) NPD NPD TAZORAC GEL (TOPICAL) NPD NPD TRETINOIN CREAM (TOPICAL) PDL PDL TRETINOIN GEL (ATRALIN) (TOPICAL) NPD NPD TRETINOIN GEL (AVITA, RETIN-A) (TOPICAL) PDL PDL TRETINOIN MICROSPHERES GEL 0.04%, 0.1% (TOPICAL) NPD NPD TRETINOIN MICROSPHERES GEL 0.04%, 0.1% (AG) (TOPICAL) NPD NPD TRETINOIN MICROSPHERES GEL 0.04%, 0.1% PUMP (AG) (TOP NPD NPD TRETINOIN MICROSPHERES GEL 0.04%, 0.1% PUMP (TOPICAL) NPD NPD VELTIN (TOPICAL) NPD NPD ZIANA (TOPICAL) NPD NPD ANALGESICS, NARCOTICS LONG ARYMO ER (ORAL) NPD NPD X For this therapeutic drug class, the Board BELBUCA (BUCCAL) NPD NPD believed that all of the drugs being BUPRENORPHINE (AG) (TRANSDERM) NPD NPD recommended as preferred demonstrated BUTRANS (TRANSDERM) PDL PDL the greatest safety, efficacy, and value and CONZIP (ORAL) NPD NPD Page 4 of 17

5 provided clinicians with the greatest number of first line options to use before requiring Prior Authorization. DURAGESIC MATRIX (TRANSDERM.) NPD NPD EMBEDA (ORAL) PDL PDL X EXALGO (ORAL) NPD NPD FENTANYL (37.5, 62.5, 87.5 MG) (TRANSDERM) NPD NPD FENTANYL (TRANSDERM) PDL PDL HYDROMORPHONE ER (AG) (ORAL) NPD NPD HYDROMORPHONE ER (ORAL) NPD NPD HYSINGLA ER (ORAL) PDL NPD X Financial KADIAN (ORAL) NPD NPD METHADONE CONC (ORAL) NPD NPD METHADONE SOL TABLET (ORAL) NPD NPD METHADONE SOLUTION (ORAL) NPD NPD METHADONE TABLET (ORAL) NPD NPD MORPHABOND ER (ORAL) NPD NPD X MORPHINE ER CAPSULE (AVINZA) (ORAL) NPD NPD MORPHINE ER CAPSULE (KADIAN) (ORAL) NPD NPD MORPHINE ER TABLET (ORAL) PDL PDL MS CONTIN (ORAL) NPD NPD NUCYNTA ER (ORAL) NPD NPD OPANA ER (ORAL) NPD NPD OXYCODONE ER (AG) (ORAL) NPD NPD OXYCONTIN (ORAL) NPD NPD OXYMORPHONE ER (ORAL) NPD NPD TRAMADOL ER (CONZIP) (AG) (ORAL) NPD NPD TRAMADOL ER (RYZOLT) (ORAL) PDL NPD Financial TRAMADOL ER (ULTRAM ER) (ORAL) PDL PDL XTAMPZA ER (ORAL) NPD NPD ZOHYDRO ER (ORAL) NPD NPD ANALGESICS, NARCOTICS SHORT ABSTRAL (SUBLINGUAL) NPD NPD For this therapeutic drug class, the Board ACTIQ (BUCCAL) NPD NPD believed that all of the drugs being APAP / CODEINE ELIXIR (ORAL) PDL PDL recommended as preferred demonstrated APAP / CODEINE TABLET (ORAL) PDL PDL the greatest safety, efficacy, and value and BUTALBITAL / CAFFEINE / APAP W/CODEINE (ORAL) NPD NPD Page 5 of 17

6 provided clinicians with the greatest number of first line options to use before requiring Prior Authorization. BUTALBITAL COMPOUND W/CODEINE (ORAL) NPD NPD BUTORPHANOL TARTRATE (NASAL) NPD NPD CAPITAL W-CODEINE (ORAL) NPD NPD CARISOPRODOL COMPOUND-CODEINE (ORAL) NPD NPD CODEINE (ORAL) NPD NPD DIHYDROCODEINE / APAP / CAFFEINE (ORAL) NPD NPD DILAUDID LIQUID (ORAL) NPD NPD DILAUDID TABLETS (ORAL) NPD NPD FENTANYL (BUCCAL) NPD NPD FENTORA (BUCCAL) NPD NPD FIORICET / CODEINE (ORAL) NPD NPD FIORINAL / CODEINE (ORAL) NPD NPD HYDROCODONE / APAP SOLUTION (ORAL) PDL PDL HYDROCODONE / APAP TABLET (ORAL) PDL PDL HYDROCODONE / IBUPROFEN (ORAL) PDL PDL HYDROMORPHONE LIQUID (ORAL) NPD NPD HYDROMORPHONE SUPPOSITORIES (RECTAL) NPD NPD HYDROMORPHONE TABLET (ORAL) PDL PDL IBUDONE (ORAL) NPD NPD X LAZANDA (NASAL) NPD NPD LEVORPHANOL (ORAL) NPD NPD LORTAB (ORAL) NPD NPD MEPERIDINE SOLUTION (ORAL) NPD NPD MEPERIDINE TABLET (ORAL) NPD NPD MORPHINE CONC SOLUTION (ORAL) NPD NPD MORPHINE IR TABLET (ORAL) PDL PDL MORPHINE SOLUTION (ORAL) PDL PDL MORPHINE SUPPOSITORIES (RECTAL) NPD NPD NORCO (ORAL) NPD NPD NUCYNTA (ORAL) NPD NPD OPANA (ORAL) NPD NPD Page 6 of 17

7 OXAYDO (ORAL) NPD NPD OXYCODONE / APAP SOLUTION (ORAL) NPD NPD OXYCODONE / APAP TABLET (ORAL) PDL PDL OXYCODONE / ASA (ORAL) NPD NPD OXYCODONE / IBUPROFEN (ORAL) NPD NPD OXYCODONE CAPSULE (ORAL) NPD NPD OXYCODONE CONC (ORAL) NPD NPD OXYCODONE SOLUTION (ORAL) PDL PDL OXYCODONE SYRINGE (ORAL) NPD NPD OXYCODONE TABLET (ORAL) PDL PDL OXYMORPHONE (ORAL) NPD NPD PENTAZOCINE / NALOXONE (ORAL) NPD NPD PERCOCET (ORAL) NPD NPD PRIMLEV (ORAL) NPD NPD REPREXAIN (ORAL) NPD NPD ROXICODONE TABLET (ORAL) NPD NPD SUBSYS (SUBLINGUAL) NPD NPD TRAMADOL (ORAL) PDL PDL TRAMADOL / APAP (ORAL) PDL PDL TREZIX (ORAL) NPD NPD TYLENOL-CODEINE (ORAL) NPD NPD ULTRACET (ORAL) NPD NPD ULTRAM (ORAL) NPD NPD ZAMICET (ORAL) NPD NPD ANGIOTENSIN MODULATOR COMBINATIONS AMLODIPINE / BENAZEPRIL (ORAL) PDL PDL For this, the Board AMLODIPINE / OLMESARTAN (AG) (ORAL) NPD NPD believed that all of the drugs being AMLODIPINE / OLMESARTAN (ORAL) NPD NPD recommended as preferred meet the fiscal AMLODIPINE / OLMESARTAN / HCTZ (AG) (ORAL) NPD NPD requirements of the state and are the most AMLODIPINE / OLMESARTAN / HCTZ (ORAL) NPD NPD safe and efficacious. AMLODIPINE / VALSARTAN (AG) (ORAL) PDL PDL AMLODIPINE / VALSARTAN (ORAL) PDL PDL AMLODIPINE / VALSARTAN / HCTZ (AG) (ORAL) PDL NPD Financial AMLODIPINE / VALSARTAN / HCTZ (ORAL) PDL NPD Financial AZOR (ORAL) NPD NPD Page 7 of 17

8 BYVALSON (ORAL) NPD NPD EXFORGE (ORAL) NPD NPD X EXFORGE HCT (ORAL) NPD NPD X LOTREL (ORAL) NPD NPD PRESTALIA (ORAL) NPD NPD X TARKA (ORAL) PDL NPD Financial TELMISARTAN / AMLODIPINE (ORAL) NPD NPD TRANDOLAPRIL / VERAPAMIL (AG) (ORAL) NPD NPD TRANDOLAPRIL / VERAPAMIL (ORAL) NPD NPD TRIBENZOR (ORAL) NPD NPD TWYNSTA (ORAL) NPD NPD ANGIOTENSIN MODULATORS ACCUPRIL (ORAL) NPD NPD For this therapeutic drug class, the Board ALTACE (ORAL) NPD NPD believed that all of the drugs being ATACAND (ORAL) NPD NPD recommended as preferred demonstrated ATACAND HCT (ORAL) NPD NPD the greatest safety, efficacy, and value and AVALIDE (ORAL) NPD NPD provided clinicians with the greatest number AVAPRO (ORAL) NPD NPD of first line options to use before requiring BENAZEPRIL (ORAL) PDL PDL Prior Authorization. BENAZEPRIL HCTZ (ORAL) NPD NPD BENICAR (ORAL) NPD NPD BENICAR HCT (ORAL) NPD NPD CANDESARTAN (AG) (ORAL) NPD NPD CANDESARTAN (ORAL) NPD NPD CANDESARTAN HCTZ (ORAL) NPD NPD CAPTOPRIL (ORAL) PDL NPD Financial CAPTOPRIL HCTZ (ORAL) PDL NPD Financial COZAAR (ORAL) NPD NPD DIOVAN (ORAL) PDL PDL X DIOVAN HCT (ORAL) NPD NPD X EDARBI (ORAL) NPD NPD EDARBYCLOR (ORAL) NPD NPD ENALAPRIL (ORAL) PDL PDL ENALAPRIL HCTZ (ORAL) PDL PDL ENTRESTO (ORAL) PDL PDL X Page 8 of 17

9 EPANED POWDER (ORAL) NPD NPD EPROSARTAN (ORAL) NPD NPD FOSINOPRIL (ORAL) PDL PDL FOSINOPRIL HCTZ (ORAL) NPD NPD HYZAAR (ORAL) NPD NPD IRBESARTAN (ORAL) PDL PDL IRBESARTAN HCTZ (ORAL) PDL PDL LISINOPRIL (ORAL) PDL PDL LISINOPRIL HCTZ (ORAL) PDL PDL LOSARTAN (ORAL) PDL PDL LOSARTAN HCTZ (ORAL) PDL PDL MICARDIS (ORAL) NPD NPD MICARDIS HCT (ORAL) NPD NPD MOEXIPRIL (ORAL) NPD NPD MOEXIPRIL HCTZ (ORAL) NPD NPD OLMESARTAN (AG) (ORAL) NPD NPD OLMESARTAN (ORAL) NPD NPD OLMESARTAN HCTZ (AG) (ORAL) NPD NPD OLMESARTAN HCTZ (ORAL) NPD NPD PERINDOPRIL (ORAL) NPD NPD PRINIVIL (ORAL) NPD NPD QBRELIS SOLUTION (ORAL) NPD NPD QUINAPRIL (ORAL) PDL PDL QUINAPRIL HCTZ (ORAL) NPD NPD RAMIPRIL (ORAL) PDL PDL TEKTURNA (ORAL) NPD NPD TEKTURNA HCT (ORAL) NPD NPD TELMISARTAN (AG) (ORAL) NPD NPD TELMISARTAN (ORAL) NPD NPD TELMISARTAN HCTZ (AG) (ORAL) NPD NPD TELMISARTAN HCTZ (ORAL) NPD NPD TRANDOLAPRIL (ORAL) NPD NPD VALSARTAN (AG) (ORAL) NPD NPD VALSARTAN (ORAL) NPD NPD VALSARTAN HCTZ (ORAL) NPD NPD Page 9 of 17

10 VASOTEC (ORAL) NPD NPD ZESTORETIC (ORAL) NPD NPD ZESTRIL (ORAL) NPD NPD ANTIMIGRAINE AGENTS, OTHER CAFERGOT (ORAL) NPD NPD For this, the Board CAMBIA (ORAL) NPD NPD believed that none of the drugs meet the DIHYDROERGOTAMINE MESYLATE (INJECTION) NPD NPD fiscal requirements of the state and are the DIHYDROERGOTAMINE MESYLATE (NASAL) NPD NPD most safe and efficacious. ERGOMAR (SUBLINGUAL) NPD NPD ERGOTAMINE TARTRATE/CAFFEINE (ORAL) NPD NPD ISOMETHEPTENE/CAFFEINE/APAP (ORAL) NPD NPD ISOMETHEPTENE/DICHLORALPHENAZONE/APAP (ORAL) NPD NPD MIGERGOT (RECTAL) NPD NPD MIGRANAL (NASAL) NPD NPD ANTIMIGRAINE AGENTS, TRIPTANS ALMOTRIPTAN (AG) (ORAL) NPD NPD For this therapeutic drug class, the Board ALMOTRIPTAN (ORAL) NPD NPD believed that all of the drugs being AMERGE (ORAL) NPD NPD recommended as preferred demonstrated AXERT (ORAL) NPD NPD the greatest safety, efficacy, and value and ELETRIPTAN (AG) (ORAL) NPD NPD provided clinicians with the greatest number ELETRIPTAN (ORAL) NPD NPD of first line options to use before requiring FROVA (ORAL) NPD NPD Prior Authorization. FROVATRIPTAN (ORAL) NPD NPD IMITREX (NASAL) NPD NPD IMITREX (ORAL) NPD NPD IMITREX KIT (SUBCUTANE.) NPD NPD IMITREX VIAL (SUBCUTANE.) NPD NPD MAXALT MLT (ORAL) NPD NPD MAXALT TABLET (ORAL) NPD NPD MIGRANOW KIT (MISCELL) NPD NPD NARATRIPTAN (ORAL) NPD NPD ONZETRA XSAIL (NASAL) NPD NPD RELPAX (ORAL) PDL NPD X Financial RIZATRIPTAN ODT (ORAL) NPD PDL Financial RIZATRIPTAN TABLET (ORAL) NPD PDL Financial Page 10 of 17

11 SUMATRIPTAN (NASAL) PDL NPD Financial SUMATRIPTAN (ORAL) PDL PDL SUMATRIPTAN KIT (SUBCUTANE.) PDL PDL SUMATRIPTAN KIT (SUN) (SUBCUTANE.) NPD NPD SUMATRIPTAN VIAL (SUBCUTANE.) NPD NPD SUMAVEL DOSEPRO (SUBCUTANE.) NPD NPD TREXIMET (ORAL) NPD NPD ZEMBRACE SYMTOUCH (SUBCUTANE.) NPD NPD ZOLMITRIPTAN ODT (AG) (ORAL) NPD NPD ZOLMITRIPTAN ODT (ORAL) NPD NPD ZOLMITRIPTAN TABLET (AG) (ORAL) NPD NPD ZOLMITRIPTAN TABLET (ORAL) NPD NPD ZOMIG (NASAL) PDL PDL ZOMIG TABLET (ORAL) NPD NPD ZOMIG ZMT (ORAL) NPD NPD BLADDER RELAXANT PREPARATIONS DARIFENACIN ER (AG) (ORAL) NPD NPD For this, the Board DARIFENACIN ER (ORAL) NPD NPD believed that all of the drugs being DETROL (ORAL) NPD NPD recommended as preferred meet the fiscal DETROL LA (ORAL) NPD NPD requirements of the state and are the most DITROPAN XL (ORAL) NPD NPD safe and efficacious. ENABLEX (ORAL) NPD NPD FLAVOXATE (ORAL) NPD NPD GELNIQUE (TRANSDERM.) NPD NPD GELNIQUE GEL PUMP (TRANSDERMAL) NPD NPD MYRBETRIQ (ORAL) NPD NPD X OXYBUTYNIN ER (AG) (ORAL) NPD NPD OXYBUTYNIN ER (ORAL) NPD NPD OXYBUTYNIN SYRUP (ORAL) PDL PDL OXYBUTYNIN TABLET (ORAL) PDL PDL OXYTROL (TRANSDERM.) NPD NPD OXYTROL FOR WOMEN OTC (TRANSDERMAL) NPD NPD TOLTERODINE (ORAL) NPD NPD TOLTERODINE ER (AG) (ORAL) NPD NPD TOLTERODINE ER (ORAL) NPD NPD Page 11 of 17

12 TOVIAZ (ORAL) PDL PDL X TROSPIUM (ORAL) NPD NPD TROSPIUM ER (ORAL) NPD NPD VESICARE (ORAL) PDL PDL H. PYLORI TREATMENT LANSOPRAZOLE/AMOXICILLIN/CLARITHROMYCIN (AG) (ORAL) NPD NPD For this, the Board LANSOPRAZOLE/AMOXICILLIN/CLARITHROMYCIN (ORAL) NPD NPD believed that all of the drugs being OMECLAMOX-PAK (ORAL) NPD NPD recommended as preferred meet the fiscal PREVPAC (ORAL) NPD NPD requirements of the state and are the most PYLERA (ORAL) PDL PDL IMMUNOMODULATORS, ATOPIC DERMATITIS DUPIXENT (SUBCUTANE.) NPD PEND For this, the Board ELIDEL (TOPICAL) NPD PEND elected to postpone review until April in EUCRISA (TOPICAL) NPD PEND X order to gather more information. PROTOPIC (TOPICAL) NPD PEND TACROLIMUS (AG) (TOPICAL) NPD PEND TACROLIMUS (TOPICAL) NPD PEND INTRANASAL RHINITIS AGENTS ASTEPRO (NASAL) NPD NPD For this therapeutic drug class, the Board AZELASTINE (ASTELIN) (NASAL) NPD PDL Financial believed that all of the drugs being AZELASTINE (ASTEPRO) (AG) (NASAL) NPD NPD recommended as preferred demonstrated AZELASTINE (ASTEPRO) (NASAL) NPD NPD the greatest safety, efficacy, and value and BECONASE AQ (NASAL) NPD NPD provided clinicians with the greatest number BUDESONIDE (NASAL) NPD NPD of first line options to use before requiring BUDESONIDE OTC (NASAL) NPD NPD Prior Authorization. CLARISPRAY OTC (NASAL) NPD NPD DYMISTA (NASAL) NPD NPD FLONASE (FUROATE) OTC (NASAL) NR NPD Financial FLONASE (PROPIONATE) OTC (NASAL) NPD NPD FLUNISOLIDE (NASAL) NPD NPD FLUTICASONE (NASAL) PDL PDL FLUTICASONE OTC (NASAL) NPD NPD IPRATROPIUM (NASAL) NPD NPD MOMETASONE (AG) (NASAL) NPD NPD Page 12 of 17

13 MOMETASONE (NASAL) NPD NPD NASACORT OTC (NASAL) NPD NPD NASONEX (NASAL) NPD NPD OLOPATADINE (AG) (NASAL) NPD NPD OLOPATADINE (NASAL) NPD NPD OMNARIS (NASAL) NPD NPD PATANASE (NASAL) PDL NPD Financial QNASL 40 (NASAL) NPD NPD QNASL 80 (NASAL) NPD NPD RHINOCORT ALLERGY OTC (NASAL) NPD NPD TICANASE (NASAL) NPD NPD TRIAMCINOLONE OTC (NASAL) NPD NPD VERAMYST (NASAL) NPD NPD ZETONNA (NASAL) NPD NPD MOVEMENT DISORDERS AUSTEDO (ORAL) NA NPD Financial For this, the Board INGREZZA (ORAL) NA NPD Financial believed that all of the drugs being TETRABENAZINE (ORAL) NA NPD Financial recommended as preferred meet the fiscal requirements of the state and are the most safe and efficacious. XENAZINE (ORAL) NA PDL Financial NEUROPATHIC PAIN CAPSAICIN OTC (TOPICAL) PDL PDL For this, the Board CYMBALTA (ORAL) NPD NPD believed that all of the drugs being DERMACINRX PHN PAK (TOPICAL) NPD NPD recommended as preferred meet the fiscal DULOXETINE (CYMBALTA) (ORAL) PDL PDL requirements of the state and are the most DULOXETINE (IRENKA) (ORAL) NPD NPD safe and efficacious. GRALISE (ORAL) NPD NPD HORIZANT (ORAL) NPD NPD LIDOCAINE (AG) (TOPICAL) NPD NPD LIDOCAINE (TOPICAL) NPD NPD LIDODERM (TOPICAL) NPD NPD LYRICA CAPSULE (ORAL) PDL PDL X Page 13 of 17

14 LYRICA SOLUTION (ORAL) PDL NPD X Financial QUTENZA KIT (TOPICAL) NPD NPD SAVELLA (ORAL) NPD NPD SAVELLA DOSE PACK (ORAL) NPD NPD ZOSTRIX OTC (TOPICAL) NPD NPD OPHTHALMICS, ANTI- INFLAMMATORY/IMMUNOMODULATOR RESTASIS (OPHTHALMIC) PDL PDL X For this, the Board RESTASIS MULTIDOSE (OPHTHALMIC) PDL NPD X Financial believed that the drug being recommended as preferred meets the fiscal requirements of the state and are the most safe and efficacious. XIIDRA (OPHTHALMIC) NPD NPD X PHOSPHATE BINDERS AURYXIA (ORAL) NPD NPD For this, the Board CALCIUM ACETATE CAPSULE (ORAL) PDL PDL believed that all of the drugs being CALCIUM ACETATE TABLET (ORAL) PDL PDL recommended as preferred meet the fiscal CALCIUM ACETATE TABLET OTC (ORAL) NPD NPD requirements of the state and are the most CALPHRON OTC (ORAL) PDL PDL safe and efficacious. ELIPHOS (ORAL) NPD NPD FOSRENOL CHEWABLE TABLET (ORAL) NPD NPD X FOSRENOL POWDER PACK (ORAL) NPD NPD X LANTHANUM CARBONATE CHEWABLE TABLET (ORAL) NPD NPD MAGNEBIND 400 RX (ORAL) PDL PDL PHOSLYRA (ORAL) NPD NPD RENAGEL (ORAL) PDL PDL X RENVELA POWDER PACK (ORAL) NPD NPD RENVELA TABLET (ORAL) NPD NPD SEVELAMER CARBONATE POWDER PACK (ORAL) NPD NPD SEVELAMER CARBONATE TABLET (AG) (ORAL) NPD NPD SEVELAMER CARBONATE TABLET (ORAL) NPD NPD VELPHORO (ORAL) NPD NPD Page 14 of 17

15 PLATELET AGGREGATION INHIBITORS AGGRENOX (ORAL) PDL PDL For this, the Board ASPIRIN/DIPYRIDAMOLE (AG) (ORAL) NPD NPD believed that all of the drugs being ASPIRIN/DIPYRIDAMOLE (ORAL) NPD NPD recommended as preferred meet the fiscal BRILINTA (ORAL) PDL PDL X requirements of the state and are the most CLOPIDOGREL (ORAL) PDL PDL safe and efficacious. DIPYRIDAMOLE (ORAL) NPD NPD EFFIENT (ORAL) PDL NPD Financial PLAVIX (ORAL) NPD NPD PRASUGREL (AG) (ORAL) NPD PDL Financial PRASUGREL (ORAL) NPD PDL Financial TICLOPIDINE (ORAL) NPD NPD YOSPRALA (ORAL) NPD NPD ZONTIVITY (ORAL) NPD NPD PROGESTINS FOR CACHEXIA MEGACE ES (ORAL) NPD NPD For this, the Board MEGESTROL SUSPENSION (MEGACE ES) (ORAL) NPD NPD believed that all of the drugs being MEGESTROL SUSPENSION (MEGACE) (ORAL) PDL PDL recommended as preferred meet the fiscal requirements of the state and are the most safe and efficacious. MEGESTROL TABLETS (ORAL) PDL PDL PROTON PUMP INHIBITORS ACIPHEX SPRINKLE (ORAL) NPD NPD X For this therapeutic drug class, the Board ACIPHEX TABLETS (ORAL) NPD NPD believed that all of the drugs being DEXILANT (ORAL) NPD NPD recommended as preferred demonstrated ESOMEPRAZOLE CAPSULES (ORAL) NPD NPD the greatest safety, efficacy, and value and ESOMEPRAZOLE CAPSULES OTC (ORAL) NPD NPD provided clinicians with the greatest number ESOMEPRAZOLE STRONTIUM (ORAL) NPD NPD of first line options to use before requiring LANSOPRAZOLE CAPSULES (ORAL) NPD NPD Prior Authorization. LANSOPRAZOLE CAPSULES OTC (ORAL) NPD NPD NEXIUM (ORAL) PDL PDL NEXIUM OTC (ORAL) NPD NPD Page 15 of 17

16 NEXIUM SUSPENSION (ORAL) PDL PDL OMEPRAZOLE (ORAL) PDL PDL OMEPRAZOLE / SODIUM BICARBONATE (ORAL) NPD NPD OMEPRAZOLE / SODIUM BICARBONATE OTC (ORAL) NPD NPD OMEPRAZOLE MAGNESIUM OTC (ORAL) NPD NPD OMEPRAZOLE OTC (ORAL) NPD NPD PANTOPRAZOLE (ORAL) PDL PDL PREVACID CAPSULES (ORAL) NPD NPD PREVACID CAPSULES OTC (ORAL) NPD NPD PREVACID SOLUTAB (ORAL) NPD NPD PRILOSEC OTC (ORAL) NPD NPD PRILOSEC SUSPENSION (ORAL) NPD NPD PROTONIX (ORAL) NPD NPD PROTONIX SUSPENSION (ORAL) PDL PDL RABEPRAZOLE TABLETS (ORAL) NPD NPD ZEGERID (ORAL) NPD NPD SMOKING CESSATION BUPROPION SR (ORAL) PDL PDL For this, the Board CHANTIX (ORAL) PDL PDL X believed that all of the drugs being CHANTIX DOSE PACK (ORAL) PDL PDL X recommended as preferred meet the fiscal NICODERM CQ (TRANSDERMAL) NPD NPD requirements of the state and are the most NICORETTE GUM OTC (BUCCAL) PDL PDL safe and efficacious. NICORETTE LOZENGE OTC (BUCCAL) PDL PDL NICOTINE GUM OTC (BUCCAL) PDL PDL NICOTINE LOZENGE OTC (BUCCAL) NPD PDL Clinical NICOTINE PATCH OTC (TRANSDERMAL) PDL PDL NICOTROL (INHALATION) NPD NPD NICOTROL NS (NASAL) NPD NPD For these products, the Board believed that none met the clinical and fiscal requirements of the state. GI MOTILITY, CHRONIC SYMPROIC (ORAL) NR NPD X Financial GLUCOCORTICOIDS, INHALED ARMONAIR RESPICLICK (INHALATION) NR NPD Financial GLUCOCORTICOIDS, INHALED TRELEGY ELLIPTA (INHALATION) NR NPD X Financial GLUCOCORTICOIDS, ORAL ZODEX (ORAL) NR NPD Financial HAE TREATMENTS HAEGARDA (SUB-Q) NR NPD Financial Page 16 of 17

17 HYPOGLYCEMICS, INSULIN AND RELATED AGEFIASP FLEXTOUCH PEN (SUBCUTANE.) NR NPD Financial HYPOGLYCEMICS, INSULIN AND RELATED AGEFIASP VIAL (SUBCUTANE.) NR NPD Financial HYPOGLYCEMICS, INSULIN AND RELATED AGEHUMALOG JUNIOR KWIKPEN (SUBCUTANE.) NR NPD X Financial STIMULANTS AND RELATED AGENTS COTEMPLA XR ODT (ORAL) NR NPD X Financial Page 17 of 17