ANTI-ALLERGENS, ORAL GRASTEK (SUBLINGUAL) NPD NPD ORALAIR (SUBLINGUAL) NPD NPD For this, the Board believed that none of the drugs meet the fiscal requirements of the state RAGWITEK (SUBLINGUAL) NPD NPD ANTIBIOTICS, INHALED BETHKIS (INHALATION) PDL PDL X For this, the Board believed CAYSTON (INHALATION) PDL PDL that all of the drugs being recommended as KITABIS PAK (INHALATION) PDL PDL X preferred meet the fiscal requirements of the state TOBI (INHALATION) NPD NPD TOBI PODHALER (INHALATION) PDL PDL X TOBRAMYCIN PAK (AG) (INHALATION) NPD NPD TOBRAMYCIN SOLUTION (AG) (INHALATION) NPD NPD TOBRAMYCIN SOLUTION (INHALATION) NPD NPD ANTICOAGULANTS ARIXTRA (SUBCUTANE.) NPD NPD For this, the Board believed COUMADIN (ORAL) NPD NPD that all of the drugs being recommended as ELIQUIS (ORAL) PDL PDL X preferred meet the fiscal requirements of the state ENOXAPARIN SODIUM VIAL (AG) (SUBCUTANEOUS) PDL PDL ENOXAPARIN SODIUM VIAL (SUBCUTANEOUS) PDL PDL ENOXAPARIN SYRINGE (AG) (SUBCUTANE.) PDL PDL ENOXAPARIN SYRINGE (SUBCUTANE.) PDL PDL FONDAPARINUX (SUBCUTANE.) NPD NPD FRAGMIN DISP SYRIN (SUBCUTANE.) PDL PDL FRAGMIN VIAL (SUBCUTANE.) NPD NPD LOVENOX SYRINGE (SUBCUTANE.) NPD NPD X LOVENOX VIAL (SUBCUTANE.) NPD NPD X PRADAXA (ORAL) PDL PDL X SAVAYSA (ORAL) NPD NPD WARFARIN (ORAL) PDL PDL XARELTO (ORAL) PDL PDL X XARELTO DOSE PACK (ORAL) PDL PDL X 1 of 19
ANTIDEPRESSANTS, OTHER APLENZIN (ORAL) NPD NPD For this therapeutic drug class, the Board believed BUPROPION (ORAL) PDL PDL that all of the drugs being recommended as BUPROPION SR (ORAL) PDL PDL preferred demonstrated the greatest safety, BUPROPION XL (ORAL) PDL PDL efficacy, and value and provided clinicians with the DESVENLAFAXINE ER (KHEDEZLA) (AG) (ORAL) NPD NPD greatest number of first line options to use before DESVENLAFAXINE ER (NO BRAND) (ORAL) NPD NPD requiring Prior Authorization. DESVENLAFAXINE ER (PRISTIQ) (AG) (ORAL) NPD NPD DESVENLAFAXINE ER (PRISTIQ) (ORAL) NPD NPD DESVENLAFAXINE FUMARATE ER (ORAL) NPD NPD EFFEXOR XR (ORAL) NPD NPD EMSAM (TRANSDERMAL) NPD NPD FETZIMA (ORAL) NPD NPD FORFIVO XL (ORAL) NPD NPD KHEDEZLA (ORAL) NPD NPD MARPLAN (ORAL) PDL PDL MIRTAZAPINE ODT (ORAL) PDL PDL MIRTAZAPINE TABLET (ORAL) PDL PDL NARDIL (ORAL) NPD NPD NEFAZODONE (ORAL) NPD NPD PARNATE (ORAL) NPD NPD PHENELZINE (ORAL) PDL PDL PRISTIQ (ORAL) NPD NPD REMERON ODT (ORAL) NPD NPD REMERON TABLET (ORAL) NPD NPD TRANYLCYPROMINE SULFATE (ORAL) NPD NPD TRAZODONE (ORAL) PDL PDL TRINTELLIX (ORAL) NPD NPD VENLAFAXINE (ORAL) NPD NPD VENLAFAXINE ER CAPSULES (ORAL) PDL PDL VENLAFAXINE ER TABLETS (AG) (ORAL) NPD NPD VENLAFAXINE ER TABLETS (ORAL) NPD NPD VIIBRYD (ORAL) NPD NPD VIIBRYD DOSE PACK (ORAL) NPD NPD WELLBUTRIN SR (ORAL) NPD NPD WELLBUTRIN XL (ORAL) NPD NPD 2 of 19
ANTIDEPRESSANTS, SSRIs BRISDELLE (ORAL) NPD NPD For this therapeutic drug class, the Board believed CELEXA TABLET (ORAL) NPD NPD that all of the drugs being recommended as CITALOPRAM SOLUTION (ORAL) PDL PDL preferred demonstrated the greatest safety, CITALOPRAM TABLET (ORAL) PDL PDL efficacy, and value and provided clinicians with the ESCITALOPRAM SOLUTION (ORAL) NPD NPD greatest number of first line options to use before ESCITALOPRAM TABLET (ORAL) PDL PDL requiring Prior Authorization. FLUOXETINE 60 MG (ORAL) PDL PDL FLUOXETINE CAPSULE (ORAL) PDL PDL FLUOXETINE CAPSULE DR (ORAL) NPD NPD FLUOXETINE SOLUTION (ORAL) PDL PDL FLUOXETINE TABLET (ORAL) PDL PDL FLUVOXAMINE (ORAL) PDL PDL FLUVOXAMINE ER (ORAL) NPD NPD LEXAPRO SOLUTION (ORAL) NPD NPD LEXAPRO TABLET (ORAL) NPD NPD PAROXETINE (BRISDELLE) (AG) (ORAL) NPD NPD PAROXETINE (BRISDELLE) (ORAL) NPD NPD PAROXETINE CR (ORAL) NPD NPD PAROXETINE TABLET (ORAL) PDL PDL PAXIL (ORAL) NPD NPD PAXIL CR (ORAL) NPD NPD PAXIL SUSPENSION (ORAL) NPD NPD PEXEVA (ORAL) NPD NPD PROZAC CAPSULE (ORAL) NPD NPD SARAFEM (ORAL) NPD NPD SERTRALINE CONC (ORAL) PDL PDL SERTRALINE TABLET (ORAL) PDL PDL ZOLOFT CONC (ORAL) NPD NPD ZOLOFT TABLET (ORAL) NPD NPD ANTIDEPRESSANTS, TRICYCLIC AMITRIPTYLINE (ORAL) PDL PDL For this, the Board believed AMOXAPINE (ORAL) NPD NPD that all of the drugs being recommended as ANAFRANIL (ORAL) NPD NPD preferred meet the fiscal requirements of the state CLOMIPRAMINE (ORAL) NPD NPD DESIPRAMINE (ORAL) NPD NPD DOXEPIN CAPSULE (ORAL) PDL PDL DOXEPIN CONC (ORAL) PDL PDL IMIPRAMINE (ORAL) PDL PDL IMIPRAMINE PAMOATE (ORAL) NPD NPD MAPROTILINE (ORAL) PDL NPD Financial 3 of 19
ANTIDEPRESSANTS, TRICYCLIC CONTINUED NORPRAMIN (ORAL) NPD NPD NORTRIPTYLINE CAPSULE (ORAL) PDL PDL NORTRIPTYLINE SOLUTION (ORAL) NPD NPD PAMELOR CAPSULE (ORAL) NPD NPD PROTRIPTYLINE (ORAL) NPD NPD SURMONTIL (ORAL) NPD NPD TRIMIPRAMINE (ORAL) NPD NPD ANTIHYPERURICEMICS ALLOPURINOL (ORAL) PDL PDL For this, the Board believed COLCHICINE CAPSULE (AG) (ORAL) NPD NPD that all of the drugs being recommended as COLCHICINE TABLET (AG) (ORAL) NPD NPD preferred meet the fiscal requirements of the state COLCRYS (ORAL) NPD NPD DUZALLO (ORAL) NR NPD Financial MITIGARE (ORAL) NPD NPD X PROBENECID (ORAL) PDL PDL PROBENECID / COLCHICINE (ORAL) PDL PDL ULORIC (ORAL) NPD NPD ZURAMPIC (ORAL) NPD NPD ZYLOPRIM (ORAL) NPD NPD ANTIPARKINSON'S AGENTS AMANTADINE CAPSULE (ORAL) PDL PDL NPD/PDL/No Changes: For this therapeutic drug AMANTADINE SYRUP (ORAL) PDL PDL class, the Board believed that all of the drugs being AMANTADINE TABLET (ORAL) PDL PDL recommended as preferred demonstrated the AZILECT (ORAL) NPD NPD greatest safety, efficacy, and value and provided BENZTROPINE (ORAL) PDL PDL clinicians with the greatest number of first line BROMOCRIPTINE (ORAL) PDL PDL options to use before requiring Prior Authorization. CARBIDOPA (ORAL) NPD CARBIDOPA / LEVODOPA (ORAL) PDL PDL NPD CARBIDOPA / LEVODOPA ER (ORAL) PDL PDL CARBIDOPA / LEVODOPA ODT (ORAL) NPD NPD CARBIDOPA/LEVODOPA/ENTACAPONE (ORAL) PDL PDL DUOPA (MISCELL) NPD NPD ENTACAPONE (ORAL) NPD NPD GOCOVRI (ORAL) NR NPD Financial LODOSYN (ORAL) NPD NPD MIRAPEX (ORAL) NPD NPD MIRAPEX ER (ORAL) NPD NPD NEUPRO (TRANSDERM) NPD NPD PRAMIPEXOLE (ORAL) PDL PDL PRAMIPEXOLE ER (ORAL) NPD NPD 4 of 19
ANTIPARKINSON'S AGENTS CONTINUED RASAGILINE (ORAL) NPD NPD REQUIP (ORAL) NPD NPD REQUIP XL (ORAL) NPD NPD ROPINIROLE (ORAL) PDL PDL ROPINIROLE ER (ORAL) NPD NPD RYTARY (ORAL) NPD NPD SELEGILINE CAPSULE (ORAL) NPD NPD SELEGILINE TABLET (ORAL) NPD NPD SINEMET (ORAL) NPD NPD SINEMET CR (ORAL) NPD NPD STALEVO (ORAL) NPD NPD TASMAR (ORAL) NPD NPD TOLCAPONE (ORAL) NPD NPD TRIHEXYPHENIDYL ELIXIR (ORAL) PDL PDL TRIHEXYPHENIDYL TABLET (ORAL) PDL PDL XADAGO (ORAL) NPD NPD ZELAPAR (ORAL) NPD NPD ANXIOLYTICS ALPRAZOLAM ER (ORAL) NPD NPD For this, the Board believed ALPRAZOLAM INTENSOL (ORAL) NPD NPD that all of the drugs being recommended as ALPRAZOLAM ODT (ORAL) NPD NPD preferred meet the fiscal requirements of the state ALPRAZOLAM TABLET (ORAL) PDL PDL ATIVAN TABLET (ORAL) NPD NPD BUSPIRONE (ORAL) PDL PDL CHLORDIAZEPOXIDE (ORAL) PDL PDL CLORAZEPATE (ORAL) PDL PDL DIAZEPAM INTENSOL (ORAL) NPD NPD DIAZEPAM SOLUTION (ORAL) PDL PDL DIAZEPAM TABLET (ORAL) PDL PDL LORAZEPAM INTENSOL (ORAL) PDL PDL LORAZEPAM TABLET (ORAL) PDL PDL MEPROBAMATE (ORAL) NPD NPD OXAZEPAM (ORAL) NPD NPD TRANXENE T-TAB (ORAL) NPD NPD VALIUM TABLET (ORAL) NPD NPD XANAX TABLET (ORAL) NPD NPD XANAX XR (ORAL) NPD NPD 5 of 19
BETA-BLOCKERS ACEBUTOLOL (ORAL) PDL PDL For this therapeutic drug class, the Board believed ATENOLOL (ORAL) PDL PDL that all of the drugs being recommended as ATENOLOL / CHLORTHALIDONE (ORAL) PDL PDL preferred demonstrated the greatest safety, BETAPACE / AF (ORAL) NPD NPD efficacy, and value and provided clinicians with the BETAXOLOL (ORAL) NPD NPD greatest number of first line options to use before BISOPROLOL (ORAL) PDL PDL requiring Prior Authorization. BISOPROLOL HCTZ (ORAL) PDL PDL BYSTOLIC (ORAL) NPD NPD CARVEDILOL (ORAL) PDL PDL CARVEDILOL ER (ORAL) NPD NPD COREG (ORAL) NPD NPD COREG CR (ORAL) NPD NPD CORGARD (ORAL) NPD NPD DUTOPROL (ORAL) NPD NPD HEMANGEOL (ORAL) NPD NPD X INDERAL LA (ORAL) NPD NPD INDERAL XL (ORAL) NPD NPD INNOPRAN XL (ORAL) NPD NPD LABETALOL (ORAL) PDL PDL LEVATOL (ORAL) NPD NPD LOPRESSOR (ORAL) NPD NPD METOPROLOL (ORAL) PDL PDL METOPROLOL / HCTZ (ORAL) NPD NPD METOPROLOL XL (ORAL) PDL PDL NADOLOL (ORAL) NPD NPD NADOLOL / BENDROFLUMETHIAZIDE (ORAL) NPD NPD PINDOLOL (ORAL) NPD NPD PROPRANOLOL / HCTZ (ORAL) NPD NPD PROPRANOLOL ER (ORAL) NPD NPD PROPRANOLOL SOLUTION (ORAL) PDL PDL PROPRANOLOL TABLET (ORAL) PDL PDL SOTALOL (ORAL) PDL PDL SOTYLIZE (ORAL) NPD NPD TENORETIC (ORAL) NPD NPD TENORMIN (ORAL) NPD NPD TIMOLOL (ORAL) NPD NPD TOPROL XL (ORAL) NPD NPD ZIAC (ORAL) NPD NPD 6 of 19
BILE SALTS ACTIGALL (ORAL) NPD NPD CHENODAL (ORAL) NPD NPD CHOLBAM (ORAL) NPD NPD For this, the Board believed OCALIVA (ORAL) NPD NPD that all of the drugs being recommended as URSO/URSO FORTE TABLET (ORAL) NPD NPD preferred meet the fiscal requirements of the state URSODIOL 300 MG CAPSULE (ORAL) NPD NPD URSODIOL TABLET (ORAL) PDL PDL BPH TREATMENTS ALFUZOSIN (ORAL) PDL PDL For this, the Board believed AVODART (ORAL) NPD NPD that all of the drugs being recommended as CARDURA (ORAL) NPD NPD preferred meet the fiscal requirements of the state CARDURA XL (ORAL) NPD NPD DOXAZOSIN (ORAL) PDL PDL DUTASTERIDE (ORAL) NPD NPD DUTASTERIDE/TAMSULOSIN (ORAL) NPD NPD FINASTERIDE (ORAL) PDL PDL FLOMAX (ORAL) NPD NPD JALYN (ORAL) NPD NPD PROSCAR (ORAL) NPD NPD RAPAFLO (ORAL) NPD NPD TAMSULOSIN (ORAL) PDL PDL TERAZOSIN (ORAL) PDL PDL UROXATRAL (ORAL) NPD NPD BRONCHODILATORS, BETA AGONIST ALBUTEROL ER (ORAL) NPD NPD For this, the Board believed ALBUTEROL NEB SOLN 0.63, 1.25 MG (INHALATION) PDL PDL that all of the drugs being recommended as ALBUTEROL NEB SOLN 100 MG/20 ML (INHALATION) PDL PDL preferred meet the fiscal requirements of the state ALBUTEROL NEB SOLN 2.5 MG/0.5 ML (INHALATION) PDL PDL ALBUTEROL NEB SOLN 2.5 MG/3 ML (INHALATION) PDL PDL ALBUTEROL SYRUP (ORAL) PDL PDL ALBUTEROL TABLET (ORAL) NPD NPD ARCAPTA NEOHALER (INHALATION) NPD NPD X BROVANA (INHALATION) NPD NPD LEVALBUTEROL HFA (AG) (INHALATION) NPD NPD LEVALBUTEROL NEB SOLN (INHALATION) NPD NPD LEVALBUTEROL NEB SOLN CONC (INHALATION) NPD NPD METAPROTERENOL SYRUP (ORAL) NPD NPD METAPROTERENOL TABLET (ORAL) NPD NPD PERFOROMIST (INHALATION) NPD NPD PROAIR HFA (INHALATION) PDL PDL 7 of 19
BRONCHODILATORS, BETA AGONIST CONTINUED PROAIR RESPICLICK (INHALATION) NPD NPD PROVENTIL HFA (INHALATION) PDL NPD Safety SEREVENT (INHALATION) NPD NPD STRIVERDI RESPIMAT (INHALATION) NPD NPD X TERBUTALINE (ORAL) NPD NPD VENTOLIN HFA (INHALATION) NPD NPD XOPENEX HFA (INHALATION) NPD NPD XOPENEX NEB SOLN (INHALATION) NPD NPD COPD AGENTS ANORO ELLIPTA (INHALATION) NPD NPD X For this, the Board believed ATROVENT HFA (INHALATION) PDL PDL that all of the drugs being recommended as BEVESPI AEROSPHERE (INHALATION) NPD PDL X Clinical and financial preferred meet the fiscal requirements of the state COMBIVENT RESPIMAT (INHALATION) PDL PDL X DALIRESP (ORAL) NPD NPD INCRUSE ELLIPTA (INHALATION) NPD NPD X IPRATROPIUM / ALBUTEROL (INHALATION) PDL PDL IPRATROPIUM NEBULIZER (INHALATION) PDL PDL SEEBRI NEOHALER (INHALATION) PDL NPD X Financial SPIRIVA (INHALATION) PDL PDL SPIRIVA RESPIMAT (INHALATION) NPD NPD X STIOLTO RESPIMAT (INHALATION) PDL PDL X TUDORZA PRESSAIR (INHALATION) NPD NPD UTIBRON NEOHALER (INHALATION) PDL NPD X Financial COUGH AND COLD, COLD AFRIN SPRAY OTC (NASAL) NPD NPD For this therapeutic drug class, the Board believed ALA-HIST IR TABLET OTC (ORAL) NPD PDL X Financial that all of the drugs being recommended as ALA-HIST PE TABLET OTC (ORAL) PDL PDL X preferred demonstrated the greatest safety, BROTAPP LIQUID OTC (ORAL) NPD NPD efficacy, and value and provided clinicians with the CHILD DELSYM COUGH+COLD LIQUID OTC (ORAL) NPD NPD greatest number of first line options to use before CHILDREN'S MUCINEX LIQUID OTC (C) (ORAL) PDL PDL X requiring Prior Authorization. DALLERGY DROPS OTC (ORAL) NPD NPD DALLERGY LIQUID OTC (ORAL) NPD NPD DECONEX IR TABLET OTC (ORAL) PDL PDL X DELSYM COUGH & COLD LIQUID OTC (C) (ORAL) PDL PDL X DIMETAPP SOLUTION OTC (ORAL) NPD NPD DIPHENHYDRAMINE/PHENYLEPHRINE/APAP LIQUID OTC (ORAL) NPD NPD ED A-HIST LIQUID OTC (ORAL) PDL PDL ED A-HIST PSE TABLET OTC (ORAL) NPD NPD 8 of 19
COUGH AND COLD, COLD CONTINUED ED A-HIST TABLET OTC (ORAL) PDL PDL ED BRON GP LIQUID OTC (ORAL) PDL PDL ED CHLORPED D DROPS OTC (ORAL) PDL NPD Financial GUAIFENESIN 200 MG TABLET OTC (ORAL) PDL PDL GUAIFENESIN 400 MG TABLET OTC (ORAL) PDL PDL GUAIFENESIN LIQUID OTC (ORAL) PDL PDL GUAIFENESIN TABLET ER OTC (ORAL) PDL PDL GUAIFENESIN/PHENYLEPHRINE LIQUID OTC (ORAL) NPD NPD GUAIFENESIN/PHENYLEPHRINE TABLET OTC (ORAL) NPD NPD GUAIFENESIN/PHENYLEPHRINE/APAP TABLET OTC (ORAL) NPD NPD GUAIFENESIN/PSE TABLET ER OTC (ORAL) PDL PDL HISTEX-PE LIQUID OTC (ORAL) PDL PDL X IBUPROFEN/PSE TABLET OTC (ORAL) NPD NPD LODRANE D CAPSULE OTC (ORAL) PDL NPD Financial LOHIST-D LIQUID OTC (ORAL) PDL NPD Financial MUCINEX COLD & SINUS LIQUID OTC (ORAL) NPD NPD X MUCINEX D TABLET ER 12H OTC (ORAL) PDL PDL X MUCINEX ER TABLET OTC (ORAL) PDL PDL X MUCINEX FAST-MAX COLD-SINUS TABLET OTC (ORAL) PDL PDL MUCINEX FAST-MAX NITE COLD-FLU LIQUID OTC (ORAL) NPD NPD X MUCINEX GRAN PACK OTC (ORAL) PDL PDL X MUCINEX SINUS-MAX LIQUID OTC (ORAL) PDL PDL X MUCINEX SINUS-MAX TABLET OTC (ORAL) PDL PDL X NAPROXEN/PSE TABLET OTC (ORAL) NPD NPD NASOPEN PE LIQUID OTC (ORAL) PDL PDL X NEO-SYNEPHRINE SPRAY OTC (NASAL) NPD NPD NOHIST-LQ LIQUID OTC (ORAL) PDL PDL OXYMETAZOLINE 12 HR NASAL SPRAY OTC (NASAL) PDL PDL OXYMETAZOLINE MIST OTC (NASAL) NPD NPD PHENYLEPHRINE FOUR SPRAY OTC (NASAL) NPD NPD PHENYLEPHRINE NOSE DROPS OTC (NASAL) NPD NPD PHENYLEPHRINE/APAP TABLET OTC (ORAL) NPD NPD PHENYLEPHRINE/BROMPHENIRAMINE SOLUTION OTC (ORAL) PDL PDL PHENYLEPHRINE/BROMPHENIRAMINE TABLET OTC (ORAL) NPD NPD PHENYLEPHRINE/CHLORPHENIRAMINE TABLET OTC (ORAL) NPD NPD PHENYLEPHRINE/PROMETHAZINE SYRUP (ORAL) NPD NPD 9 of 19
COUGH AND COLD, COLD CONTINUED PHENYLEPHRINE/PYRILAMINE TABLET OTC (ORAL) NPD NPD POLY HIST FORTE TABLET OTC (ORAL) PDL PDL X POLY-VENT IR TABLET OTC (ORAL) PDL PDL X PROMETHAZINE VC SYRUP (QUALITEST) (ORAL) NPD NPD PSE/CHLORPHENIRAMINE TABLET OTC (ORAL) PDL PDL PSE/TRIPROLIDINE TABLET OTC (ORAL) PDL PDL RESCON-GG LIQUID OTC (ORAL) NPD NPD RESPAIRE-30 CAPSULE OTC (ORAL) NPD NPD RYMED TABLET OTC (ORAL) PDL NPD Financial RYNEX PE SOLUTION OTC (ORAL) PDL PDL RYNEX PSE LIQUID OTC (ORAL) PDL PDL STAHIST AD TABLET OTC (ORAL) NPD NPD VICKS VAPOINHALER OTC (NASAL) NPD NPD COUGH AND COLD, NARCOTIC FLOWTUSS SOLUTION (ORAL) NPD NPD For this, the Board believed GUAIFENESIN/CODEINE LIQUID OTC (ORAL) PDL PDL that all of the drugs being recommended as GUAIFENESIN/PSE/CODEINE SYRUP OTC (ORAL) NPD NPD preferred meet the fiscal requirements of the state HISTEX-AC SYRUP OTC (ORAL) NPD NPD X HYCOFENIX SOLUTION (ORAL) NPD NPD HYDROCODONE/CHLORPHENIRAMINE SUSPENSION ER 12H (ORAL) NPD NPD HYDROCODONE/HOMATROPINE SYRUP (ORAL) NPD NPD HYDROCODONE/HOMATROPINE TABLET (ORAL) NPD NPD M-CLEAR WC LIQUID (ORAL) NPD NPD X M-END PE LIQUID (ORAL) NPD NPD X NINJACOF-XG LIQUID OTC (ORAL) NPD NPD POLY-TUSSIN AC LIQUID OTC (ORAL) NPD NPD X PROMETHAZINE/CODEINE SYRUP (ORAL) PDL PDL PROMETHAZINE/PHENYLEPHRINE/CODEINE (QUALITEST) SYRUP (ORAL) NPD NPD PROMETHAZINE/PHENYLEPHRINE/CODEINE SYRUP (ORAL) NPD NPD PSE/HYDROCODONE/CHLORPHENIRAMINE SOLUTION (ORAL) NPD NPD ROBAFEN AC (ORAL) NPD NPD TUSSICAPS CAPSULE ER 12H (ORAL) NPD NPD TUSSIONEX SUSPENSION ER 12H (ORAL) NPD NPD TUZISTRA XR SUSPENSION (ORAL) NPD NPD 10 of 19
COUGH AND COLD, NON-NARCOTIC ALAHIST CF TABLET OTC (ORAL) NPD PDL X Financial For this therapeutic drug class, the Board believed ALA-HIST DM LIQUID OTC (ORAL) PDL PDL X that all of the drugs being recommended as ALKA-SELTZER PLUS DAY & NIGHT CAPSULE OTC (ORAL) NPD NPD preferred demonstrated the greatest safety, BENZONATATE CAPSULE (ORAL) PDL NPD Clinical efficacy, and value and provided clinicians with the BROMFED DM SYRUP (ORAL) NPD NPD greatest number of first line options to use before BROMPHENIRAMINE/PHENYLEPHRINE/DM LIQUID OTC requiring Prior Authorization. (ORAL) PDL PDL BROMPHENIRAMINE/PHENYLEPHRINE/DM SOLUTION OTC (ORAL) PDL PDL BROM-PSE-DM SYRUP (ORAL) PDL PDL BROTAPP DM ELIXIR OTC (ORAL) PDL PDL CHILD COLD-COUGH DAY-NIGHT SOLUTION SEQUELS OTC (ORAL) NPD NPD CHILD MUCINEX M-S COLD DAY-NTE LIQUID SEQUELES OTC (ORAL) PDL PDL X CHILDREN'S MUCINEX LIQUID OTC (NN) (ORAL) PDL PDL X CHLO HIST SOLUTION OTC (ORAL) PDL PDL X CHLO TUSS LIQUID OTC (ORAL) PDL PDL X CHLORASEPTIC TOTAL LOZENGE OTC (ORAL) NPD NPD CORICIDIN HBP SOFTGEL OTC (ORAL) NPD NPD DECONEX DMX TABLET OTC (ORAL) PDL PDL X DELSYM COUGH & COLD LIQUID OTC (NN) (ORAL) PDL PDL DELSYM SUSPENSION ER 12H OTC (ORAL) PDL PDL X DEXTROMETHORPHAN CAPSULE OTC (ORAL) NPD NPD DEXTROMETHORPHAN LIQUID OTC (ORAL) NPD NPD DEXTROMETHORPHAN SUSPENSION ER 12H OTC (ORAL) PDL PDL DEXTROMETHORPHAN SYRUP OTC (ORAL) NPD NPD DIMETAPP DM SOLUTION OTC (ORAL) NPD NPD DM/APAP/DOXYLAMINE CAPSULE OTC (ORAL) NPD NPD DM/APAP/DOXYLAMINE LIQUID OTC (ORAL) NPD NPD DM/CHLORPHENIRAMINE TABLET OTC (ORAL) NPD NPD DM/PHENYLEPHRINE/APAP CAPSULE OTC (ORAL) NPD NPD DM/PHENYLEPHRINE/APAP LIQUID OTC (ORAL) NPD NPD DM/PHENYLEPHRINE/APAP TABLET OTC (ORAL) NPD NPD DM/PHENYLEPHRINE/APAP/CHLORPHENIRAMINE TABLET OTC (ORAL) NPD NPD DM/PSE/CHLORPHENIRAMINE LIQUID OTC (ORAL) PDL PDL DURAFLU TABLET OTC (ORAL) PDL NPD X Financial ED A-HIST DM TABLET OTC (ORAL) PDL NPD Financial 11 of 19
COUGH AND COLD, NON-NARCOTIC CONTINUED ED-A-HIST DM LIQUID OTC (ORAL) PDL PDL GUAIFENESIN/DM CAPSULE OTC (ORAL) NPD NPD GUAIFENESIN/DM LIQUID OTC (ORAL) PDL PDL GUAIFENESIN/DM TABLET OTC (ORAL) NPD NPD GUAIFENESIN/DM/PHENYLEPHRINE LIQUID OTC (ORAL) NPD NPD GUAIFENESIN/DM/PHENYLEPHRINE SYRUP OTC (ORAL) NPD NPD HISTEX-DM SYRUP OTC (ORAL) PDL PDL X LOHIST-DM LIQUID (ORAL) PDL PDL LORTUSS DM LIQUID OTC (ORAL) PDL NPD Financial M-END DMX LIQUID OTC (ORAL) PDL PDL X MUCINEX COLD-FLU & SORE THROAT LIQUID OTC (ORAL) PDL PDL X MUCINEX COUGH GRAN PACK OTC (ORAL) PDL PDL X MUCINEX DM TABLET ER 12H OTC (ORAL) PDL PDL X MUCINEX DM TABLET ER 12H OTC (ORAL) PDL PDL X MUCINEX FAST-MAX COLD-FLU TABLET OTC (ORAL) PDL PDL MUCINEX FAST-MAX COLD-FLU-THROAT CAPSULE OTC (ORAL) NPD NPD X MUCINEX FAST-MAX COLD-SINUS CAPSULE OTC (ORAL) NPD NPD X MUCINEX FAST-MAX CONGEST-COLD TABLET OTC (ORAL) NPD NPD X MUCINEX FAST-MAX CONGEST-COUGH TABLET OTC (ORAL) PDL PDL X MUCINEX FAST-MAX DAY-NITE COLD LIQUID SEQ OTC (ORAL) NPD PDL X Financial MUCINEX FAST-MAX DAY-NITE COLD-FLU CAPSULE OTC (ORAL) PDL PDL X MUCINEX FAST-MAX DAY-NITE CONG LIQUID OTC (ORAL) PDL PDL X MUCINEX FAST-MAX DM MAX LIQUID OTC (ORAL) PDL PDL X MUCINEX FAST-MAX SEVERE COLD LIQUID OTC (ORAL) PDL PDL X MUCINEX SEVERE CONGEST-COUGH LIQUID OTC (ORAL) PDL NPD Financial NINJACOF LIQUID OTC (ORAL) NPD NPD NOHIST-DM LIQUID OTC (ORAL) PDL PDL PHENYLEPHRINE/DM LIQUID OTC (ORAL) NPD NPD PHENYLEPHRINE/DM/APAP/GUAIFENESIN CAPLET OTC (ORAL) NPD NPD PHENYLEPHRINE/DM/APAP/GUAIFENESIN LIQUID OTC (ORAL) NPD NPD 12 of 19
COUGH AND COLD, NON-NARCOTIC CONTINUED POLY-HIST DM LIQUID OTC (ORAL) PDL PDL X POLY-HIST PD DROPS OTC (ORAL) PDL NPD X Financial POLYTUSSIN DM OTC (ORAL) NPD NPD POLY-VENT DM TABLET OTC (ORAL) PDL PDL X PROMETHAZINE/DM SYRUP (ORAL) PDL PDL RESCON-DM LIQUID OTC (ORAL) PDL NPD Financial ROBITUSSIN CAPSULE OTC (ORAL) NPD NPD ROBITUSSIN COUGH & COLD CF LIQUID OTC (ORAL) NPD NPD ROBITUSSIN LONG-ACTING LIQUID OTC (ORAL) NPD NPD RYNEX DM SOLUTION OTC (ORAL) PDL PDL TESSALON PERLE CAPSULE (ORAL) NPD NPD VANACOF AC LIQUID OTC (ORAL) NPD NPD X VANACOF DM LIQUID OTC (ORAL) PDL PDL X VANACOF LIQUID OTC (ORAL) PDL PDL X VANATAB AC TABLET OTC (ORAL) NPD NPD X VANATAB DM TABLET OTC (ORAL) NPD NPD X ERYTHROPOIESIS STIMULATING PROTEINS ARANESP DISP SYRIN (INJECTION) NPD NPD ARANESP VIAL (INJECTION) NPD NPD EPOGEN (INJECTION) PDL PDL For this, the Board believed that all of the drugs being recommended as preferred meet the fiscal requirements of the state PROCRIT (INJECTION) PDL PDL GLUCOCORTICOIDS, INHALED ADVAIR DISKUS (INHALATION) PDL PDL For this, the Board believed ADVAIR HFA (INHALATION) PDL PDL that all of the drugs being recommended as AEROSPAN (INHALATION) NPD NPD preferred meet the fiscal requirements of the state AIRDUO RESPICLICK (INHALATION) NPD NPD ALVESCO (INHALATION) NPD NPD ARMONAIR RESPICLICK (INHALATION) NPD NPD ARNUITY ELLIPTA (INHALATION) NPD NPD X ASMANEX (INHALATION) PDL PDL ASMANEX HFA (INHALATION) NPD NPD BREO ELLIPTA (INHALATION) NPD NPD X BUDESONIDE 0.25, 0.5 MG RESPULES (INHALATION) NPD NPD BUDESONIDE 1 MG RESPULES (INHALATION) NPD NPD DULERA (INHALATION) PDL PDL FLOVENT DISKUS (INHALATION) PDL NPD Financial 13 of 19
GLUCOCORTICOIDS, INHALED CONTINUED FLOVENT HFA (INHALATION) PDL PDL FLUTICASONE/SALMETEROL (AIRDUO) (AG) (INHALATION) NPD NPD PULMICORT 0.25, 0.5 MG RESPULES (INHALATION) NPD PDL X Financial PULMICORT 1 MG RESPULES (INHALATION) NPD PDL X Financial PULMICORT FLEXHALER (INHALATION) NPD NPD QVAR (INHALATION) PDL NPD Financial QVAR REDIHALER (INHALATION) NR NPD X Financial SYMBICORT (INHALATION) PDL PDL TRELEGY ELLIPTA (INHALATION) NPD NPD HAE TREATMENTS BERINERT (INTRAVEN) PDL PDL For this, the Board believed that all of the drugs being recommended as preferred meet the fiscal requirements of the state CINRYZE (INTRAVEN) PDL PDL FIRAZYR (SUB-Q) PDL PDL HAEGARDA (SUB-Q) NPD NPD KALBITOR (SUB-Q) PDL PDL RUCONEST (INTRAVEN) NPD NPD X HYPOGLYCEMICS, SGLT2 FARXIGA (ORAL) PDL PEND X For this, the Board elected INVOKAMET (ORAL) NPD PEND X to postpone review until November in order to INVOKAMET XR (ORAL) NPD PEND X gather more information. INVOKANA (ORAL) NPD PEND X JARDIANCE (ORAL) PDL PEND X STEGLATRO (ORAL) NR PEND SYNJARDY (ORAL) PDL PEND X SYNJARDY XR (ORAL) NPD PEND X XIGDUO XR (ORAL) NPD PEND X IMMUNE GLOBULINS BIVIGAM (INTRAVEN) NPD NPD For this, the Board believed CARIMUNE NF NANOFILTERED (INTRAVEN) NPD NPD that all of the drugs being recommended as CUVITRU (SUBCUT.) NPD NPD preferred meet the fiscal requirements of the state CYTOGAM (INTRAVEN) PDL PDL FLEBOGAMMA DIF (INTRAVEN) NPD NPD GAMASTAN S-D VIAL (INTRAMUSC) PDL PDL GAMMAGARD LIQUID (INJECTION) PDL PDL GAMMAGARD S-D (INTRAVEN) PDL PDL GAMMAKED (INTRAVEN) NPD NPD GAMMAPLEX (INTRAVEN) NPD NPD GAMUNEX-C (INJECTION) PDL PDL HEPAGAM B (INTRAMUSC) PDL PDL 14 of 19
IMMUNE GLOBULINS CONTINUED HIZENTRA (SUBCUT.) PDL PDL HYQVIA (SUBCUT.) NPD NPD OCTAGAM (INTRAVEN) NPD NPD PRIVIGEN (INTRAVEN) NPD NPD IMMUNOMODULATORS, ATOPIC DERMATITIS DUPIXENT (SUBCUTANE.) NPD NPD For this, the Board believed that all of the drugs being recommended as preferred meet the fiscal requirements of the state ELIDEL (TOPICAL) NPD NPD EUCRISA (TOPICAL) NPD PDL X Clinical PROTOPIC (TOPICAL) NPD NPD TACROLIMUS (AG) (TOPICAL) NPD NPD TACROLIMUS (TOPICAL) NPD NPD LINCOSAMIDES/OXAZOLIDINONES/STREPTOGRAMI NS CLEOCIN CAPSULES (ORAL) NPD NPD For this, the Board believed CLEOCIN PALMITATE (ORAL) NPD NPD that all of the drugs being recommended as CLEOCIN PHOSPHATE PIGGYBACK (INJECTION) NPD NPD preferred meet the fiscal requirements of the state CLEOCIN PHOSPHATE VIAL (INJECTION) NPD NPD CLINDAMYCIN CAPSULES (ORAL) PDL PDL CLINDAMYCIN IN 0.9 % SODIUM CHLORIDE PIGGYBACK (INTRAVEN.) NPD NPD CLINDAMYCIN PALMITATE SOLUTION (ORAL) PDL PDL CLINDAMYCIN PHOSPHATE PIGGYBACK (INJECTION) NPD NPD CLINDAMYCIN PHOSPHATE VIAL (INJECTION) NPD NPD LINCOCIN (INJECTION) NPD NPD LINCOMYCIN (INJECTION) NPD NPD LINEZOLID (AG) (INTRAVEN) PDL PDL LINEZOLID (INTRAVEN) PDL PDL LINEZOLID SUSPENSION (AG) (ORAL) PDL PDL LINEZOLID SUSPENSION (ORAL) PDL PDL LINEZOLID TABLET (AG) (ORAL) PDL PDL LINEZOLID TABLET (ORAL) PDL PDL SIVEXTRO (INTRAVEN) NPD NPD SIVEXTRO (ORAL) NPD NPD SYNERCID (INJECTION) NPD NPD ZYVOX (INJECTION) NPD NPD ZYVOX SUSPENSION (ORAL) NPD NPD ZYVOX TABLET (ORAL) NPD NPD 15 of 19
LIPOTROPICS, OTHER ANTARA (ORAL) NPD NPD For this therapeutic drug class, the Board believed that all of the drugs being recommended as preferred demonstrated the greatest safety, efficacy, and value and provided clinicians with the greatest number of first line options to use before requiring Prior Authorization. CHOLESTYRAMINE/ASPARTAME (ORAL) PDL PDL CHOLESTYRAMINE/SUCROSE (ORAL) PDL PDL COLESTID GRANULES (ORAL) NPD NPD COLESTIPOL GRANULES (ORAL) NPD NPD COLESTIPOL TABLET (ORAL) PDL PDL EZETIMIBE (ORAL) NPD NPD FENOFIBRATE (ANTARA) (AG) (ORAL) NPD NPD FENOFIBRATE (ANTARA) (ORAL) NPD NPD FENOFIBRATE (FENOGLIDE) (AG) (ORAL) NPD NPD FENOFIBRATE (FENOGLIDE) (ORAL) NPD NPD FENOFIBRATE CAPSULE (LIPOFEN) (ORAL) PDL PDL FENOFIBRATE CAPSULE (LOFIBRA) (ORAL) NPD NPD FENOFIBRATE TABLET (AG) (TRICOR) (ORAL) PDL PDL FENOFIBRATE TABLET (LOFIBRA) (ORAL) NPD NPD FENOFIBRATE TABLET (TRICOR) (ORAL) PDL PDL FENOFIBRIC ACID (FIBRICOR) (ORAL) NPD NPD FENOFIBRIC ACID (TRILIPIX) (AG) (ORAL) NPD NPD FENOFIBRIC ACID (TRILIPIX) (ORAL) NPD NPD FENOGLIDE (ORAL) NPD NPD GEMFIBROZIL (ORAL) PDL PDL JUXTAPID (ORAL) PDL NPD Financial KYNAMRO (SUBCUTANE.) PDL NPD Financial LIPOFEN (ORAL) NPD NPD LOPID (ORAL) NPD NPD LOVAZA (ORAL) NPD NPD NIACIN CAPSULE ER OTC (ORAL) PDL PDL NIACIN ER (ORAL) NPD NPD NIACIN TABLET ER OTC (ORAL) PDL PDL NIACIN TABLET OTC (ORAL) PDL PDL NIACOR (ORAL) PDL PDL NIASPAN (ORAL) NPD NPD OMEGA-3 ACID ETHYL ESTERS (ORAL) NPD NPD OMEGA-3 OTC (ORAL) PDL PDL OMERA OTC (ORAL) NPD NPD PRALUENT PEN (SUBCUTANEOUS) NPD NPD REPATHA PUSHTRONEX (SUBCUTANEOUS) NPD NPD X REPATHA SURECLICK (SUBCUTANEOUS) NPD NPD X REPATHA SYRINGE (SUBCUTANEOUS) NPD NPD X RESTORA OTC (ORAL) NPD NPD 16 of 19
LIPOTROPICS, OTHER CONTINUED SLO-NIACIN OTC (ORAL) PDL PDL TRICOR (ORAL) NPD NPD TRIGLIDE (ORAL) NPD NPD TRILIPIX (ORAL) NPD NPD VASCEPA (ORAL) NPD NPD WELCHOL POWDER PACK (ORAL) NPD NPD WELCHOL TABLET (ORAL) NPD NPD ZETIA (ORAL) PDL PDL LIPOTROPICS, STATINS ALTOPREV (ORAL) NPD NPD For this, the Board believed AMLODIPINE-ATORVASTATIN (ORAL) NPD NPD that all of the drugs being recommended as ATORVASTATIN (ORAL) PDL PDL preferred meet the fiscal requirements of the state CADUET (ORAL) NPD NPD CRESTOR (ORAL) NPD NPD EZETIMIBE-SIMVASTATIN (ORAL) NPD NPD FLUVASTATIN (ORAL) NPD NPD FLUVASTATIN ER (AG) (ORAL) NPD NPD FLUVASTATIN ER (ORAL) NPD NPD LESCOL XL (ORAL) NPD NPD LIPITOR (ORAL) NPD NPD LIVALO (ORAL) NPD NPD LOVASTATIN (ORAL) PDL PDL PRAVACHOL (ORAL) NPD NPD PRAVASTATIN (ORAL) PDL PDL ROSUVASTATIN (ORAL) NPD NPD SIMVASTATIN (ORAL) PDL PDL VYTORIN (ORAL) NPD NPD ZOCOR (ORAL) NPD NPD PAH AGENTS, ORAL AND INHALED ADCIRCA (ORAL) PDL PDL For this, the Board believed ADEMPAS (ORAL) NPD NPD that all of the drugs being recommended as LETAIRIS (ORAL) PDL PDL X preferred meet the fiscal requirements of the state OPSUMIT (ORAL) NPD NPD X ORENITRAM ER (ORAL) NPD NPD REVATIO SUSPENSION (ORAL) NPD NPD REVATIO TABLET (ORAL) NPD NPD SILDENAFIL (ORAL) PDL PDL TRACLEER SUSPENSION (ORAL) NR NPD Financial TRACLEER TABLET (ORAL) PDL PDL X TYVASO (INHALATION) NPD NPD 17 of 19
PAH AGENTS, ORAL AND INHALED CONTINUED UPTRAVI (ORAL) NPD NPD UPTRAVI TABLET DOSE PACK (ORAL) NPD NPD VENTAVIS (INHALATION) NPD NPD PANCREATIC ENZYMES CREON (ORAL) PDL PDL X For this, the Board believed PANCREAZE (ORAL) NPD NPD that all of the drugs being recommended as PERTZYE (ORAL) NPD NPD X preferred meet the fiscal requirements of the state VIOKACE (ORAL) NPD NPD ZENPEP (ORAL) PDL PDL X SEDATIVE HYPNOTICS AMBIEN (ORAL) NPD NPD For this therapeutic drug class, the Board believed AMBIEN CR (ORAL) NPD NPD that all of the drugs being recommended as BELSOMRA (ORAL) NPD NPD preferred demonstrated the greatest safety, EDLUAR (SUBLINGUAL) NPD NPD efficacy, and value and provided clinicians with the ESTAZOLAM (ORAL) NPD NPD greatest number of first line options to use before ESZOPICLONE (ORAL) NPD NPD requiring Prior Authorization. FLURAZEPAM (ORAL) PDL PDL HALCION (ORAL) NPD NPD HETLIOZ (ORAL) NPD NPD INTERMEZZO (SUBLINGUAL) NPD NPD LUNESTA (ORAL) NPD NPD RESTORIL (ORAL) NPD NPD ROZEREM (ORAL) NPD NPD SILENOR (ORAL) NPD NPD TEMAZEPAM (ORAL) PDL PDL TEMAZEPAM 22.5 MG (ORAL) NPD NPD TEMAZEPAM 7.5 MG (ORAL) NPD NPD TRIAZOLAM (ORAL) PDL PDL ZALEPLON (ORAL) NPD NPD ZOLPIDEM (ORAL) PDL PDL ZOLPIDEM (SUBLINGUAL) NPD NPD ZOLPIDEM ER (ORAL) NPD NPD ZOLPIMIST (ORAL) NPD NPD 18 of 19
UREA CYCLE DISORDERS, ORAL BUPHENYL POWDER (ORAL) PDL PDL BUPHENYL TABLET (ORAL) PDL PDL For this, the Board believed CARBAGLU (ORAL) PDL PDL that all of the drugs being recommended as RAVICTI (ORAL) NPD NPD preferred meet the fiscal requirements of the state SODIUM PHENYLBUTYRATE POWDER (ORAL) NPD NPD SODIUM PHENYLBUTYRATE TABLET (ORAL) NPD NPD For these products, the Board believed that Enbrel met the clinical and fiscal requirements of the state. CYTOKINE AND CAM ANTAGONISTS ENBREL CARTRIDGE (SUBCUTANE.) NR PDL X Financial HYPOGLYCEMICS, INCRETIN MIMETICS/ENHANCERS BYDUREON BCISE (SUBCUTANE.) NR NPD X Financial HYPOGLYCEMICS, INCRETIN MIMETICS/ENHANCERS OZEMPIC (SUBCUTANE.) NR NPD Financial HYPOGLYCEMICS, INCRETIN MIMETICS/ENHANCERS QTERN (ORAL) NR NPD X Financial HYPOGLYCEMICS, INSULIN AND RELATED AGENTS ADMELOG SOLOSTAR PEN (SUBCUTANE.) NR NPD Financial HYPOGLYCEMICS, INSULIN AND RELATED AGENTS ADMELOG VIAL (SUBCUTANE.) NR NPD Financial NEUROPATHIC PAIN LYRICA CR (ORAL) NR NPD Financial OPHTHALMICS, GLAUCOMA AGENTS VYZULTA (OPHTHALMIC) NR NPD Financial STIMULANTS AND RELATED AGENTS ADZENYS ER SUSPENSION (ORAL) NR NPD Financial TETRACYCLINES XIMINO (ORAL) NR NPD Financial ACNE AGENTS, TOPICAL RETIN-A MICRO 0.06% PUMP (TOPICAL) NR NPD Financial ANTIBIOTICS, GI SOLOSEC (ORAL) NR NPD Financial 19 of 19