1. No category

1
NEBRASKA MEDICAID PREFERRED DRUG LIST
As of 01/08/2015 (See Legend below Table)
Note: Only drugs that are part of the listed therapeutic categories are affected by the PREFERRED DRUG LIST.
For the most current version, check the Pharmacy Magellan Medicaid Administration, Inc. website at
https://nebraska.fhsc.com.
Additions and changes since the previous version are listed in italics.
Please note that some sections may continue onto the following page.
THERAPEUTIC
DRUG CLASS
ACNE AGENTS, TOPICAL
(Implementation 07/17/2014)
PREFERRED
DRUGS
AZELEX (azelaic acid)
BENZACLIN W/PUMP (clindamycin/benzoyl
peroxide)
benzoyl peroxide generic OTC
benzoyl peroxide generic Rx
clindamycin phosphate SOLUTION
DIFFERIN LOTION, CREAM (adapalene)
DUAC (clindamycin/benzoyl peroxide)
erythromycin GEL, SOLUTION
tretinoin CREAM
NON-PREFERRED
DRUGS
ACANYA
(clindamycin and benzoyl peroxide)
ACZONE (dapsone)
adapalene gel, cream (generic Differin)
AKNE-MYCIN (erythromycin)
ATRALIN (tretinoin)
AVITA (tretinoin)
BENZACLIN GEL (clindamycin/
benzoyl peroxide)
benzoyl peroxide foam (generic for
Benzefoam)
benzoyl peroxide gel Rx
CLINDAGEL (clindamycin)
clindamycin GEL, LOTION, FOAM
clindamycin/benzoyl peroxide (generic for
Benzaclin)
DIFFERIN GEL
EPIDUO (adapalene/benzoyl peroxide)
erythromycin-benzoyl peroxide (generic for
Benzamycin and Duac)
EVOCLIN (clindamycin)
FABIOR (tazarotene foam)
INOVA (benzoyl peroxide)
KLARON (sulfacetamide)
NEUAC (clindamycin/benzoyl peroxide)NR
RETIN-A GEL, CREAM
RETIN-A MICRO (tretinoin microspheres)
sulfacetamide
sulfacetamide/sulfur
SUMADAN (sulfacetamide/sulfur)
TAZORAC (tazarotene)
tretinoin GEL
tretinoin microspheres
(generic for Retin-A Micro)
VELTIN (clindamycin and tretinoin)
ZIANA (clindamycin and tretinoin)
BRAND PRODUCTS IN UPPER CASE generic names in lower case. If only the generic name is listed as preferred, then the BRAND name of that product is nonpreferred; unless the brand name product is ALSO listed as preferred.
*Indicates that a clinical prior authorization is required despite the medication’s status as preferred or non-preferred.
QL indicates quantity limits.
NR indicates product was not reviewed. New Drug criteria will apply.
THERAPEUTIC
DRUG CLASS
ALZHEIMER’S DRUGS
(Implementation 12/04/2014)
ANALGESICS, OPIATE
LONG-ACTING
(Implementation 07/17/2014)
ANALGESICS, OPIATE
SHORT-ACTING
(Implementation 07/17/2014)
2
PREFERRED
NON-PREFERRED
DRUGS
DRUGS
CHOLINESTERASE INHIBITORS
donepezil 23 (generic for Aricept 23)
donepezil (generic for Aricept)
galantamine (generic for Razadyne)
donepezil ODT (generic for Aricept ODT)
galantamine ER (generic for Razadyne
EXELON Transdermal (rivastigmine)
ER)
rivastigmine (generic for Exelon)
NMDA RECEPTOR ANTAGONIST
NAMENDA (memantine)
NAMENDA XR (memantine ER)
fentanyl patches
BUTRANS (buprenorphine, transdermal)*
KADIAN (morphine ER capsule)
CONZIP (tramadol extended release)*
methadone
DURAGESIC MATRIX (fentanyl)
morphine ER tablet (generic for MS Contin,
hydromorphone ER (generic for Exalgo)*
Oramorph SR)
morphine ER capsule (generic for Avinza)
OXYCONTIN (oxycodone ER)
morphine ER capsule (generic for Kadian)
NUCYNTA ER (tapentadol)*
oxycodone ER (generic for re-formulated
Oxycontin)
oxymorphone ER (generic for OPANA ER)
tramadol extended release* (generic for
ULTRAM ER)
ZOHYDRO ER (hydrocodone bitartrate
ER)
ORAL
codeine ORAL SOLUTION
acetaminophen/codeine
codeine ORAL
dihydrocodeine/aspirin/caffeine
hydrocodone/APAP
(generic for Synalgos DC)
hydrocodone/ibuprofen
ENDODAN (oxycodone/aspirin)
hydromorphone TABLETS
HYCET (hydrocodone/acetaminophen)
morphine ORAL
hydromorphone ORAL LIQUID,
SUPPOSITORIES (generic for
oxycodone TABLET
Dilaudid)
oxycodone/APAP
IBUDONE (hydrocodone/ibuprofen)
ROXICET SOLUTION
levorphanol
(oxycodone/acetaminophen)
tramadol
meperidine (generic for Demerol)
morphine SUPPOSITORIES
NUCYNTA (tapentadol)*
OXECTA (oxycodone)
oxycodone CAPSULE
oxycodone/aspirin
oxycodone/ibuprofen (generic for Combunox)
oxymorphone (generic for Opana)
pentazocine/APAP
pentazocine/naloxone
PRIMLEV (oxycodone/acetaminophen)
BRAND PRODUCTS IN UPPER CASE generic names in lower case. If only the generic name is listed as preferred, then the BRAND name of that product is nonpreferred; unless the brand name product is ALSO listed as preferred.
*Indicates that a clinical prior authorization is required despite the medication’s status as preferred or non-preferred.
QL indicates quantity limits.
NR indicates product was not reviewed. New Drug criteria will apply.
THERAPEUTIC
DRUG CLASS
ANDROGENIC DRUGS
(Topical)
(Implementation 07/17/2014)
ANGIOTENSIN MODULATORS
(Implementation 07/17/2014)
PREFERRED
DRUGS
3
NON-PREFERRED
DRUGS
ROXICODONE TABLET (oxycodone)
tramadol/APAP –generic for Ultracet
(note: separate ingredients preferred)
VICOPROFEN (hydrocodone/ibuprofen)
XARTEMIS XR NR
(oxycodone/acetaminophen)
XODOL (hydrocodone/acetaminophen)
ZAMICET (hydrocodone/acetaminophen
solution)
NASAL
butorphanol nasal spray
BUCCAL/TRANSMUCOSAL
ABSTRAL (fentanyl transmucosal)*
fentanyl transmucosal* (generic for Actiq)
FENTORA (fentanyl)*
SUBSYS (fentanyl spray)*
ANDROGEL (testosterone)
ANDRODERM (testosterone)
TESTIM (testosterone)
AXIRON (testosterone)
FORTESTA (testosterone)
testosterone (generic for Fortesta)
testosterone (generics for Testim and
Vogelxo)
VOGELXO (testosterone)
ACE INHIBITORS
benazepril (generic for Lotensin)
EPANED (enalapril) oral solution
captopril (generic for Capoten)
moexepril (generic for Univasc)
enalapril (generic for Vasotec)
perindopril (generic for Aceon)
fosinopril (generic for Monopril)
trandolapril (generic for Mavik)
lisinopril (generic for Prinivil/Zestril)
quinapril (generic for Accupril)
ramipril (generic for Altace)
ACE INHIBITOR/DIURETIC COMBINATIONS
benazepril/HCTZ (generic for Lotensin HCT)
fosinopril/HCTZ (generic for Monopril
HCT)
captopril/HCTZ (generic for Capozide)
moexepril/HCTZ (generic for Uniretic)
enalapril/HCTZ (generic for Vaseretic)
quinapril/HCTZ (generic for Accuretic)
lisinopril/HCTZ (generic Prinzide/Zestoretic)
BRAND PRODUCTS IN UPPER CASE generic names in lower case. If only the generic name is listed as preferred, then the BRAND name of that product is nonpreferred; unless the brand name product is ALSO listed as preferred.
*Indicates that a clinical prior authorization is required despite the medication’s status as preferred or non-preferred.
QL indicates quantity limits.
NR indicates product was not reviewed. New Drug criteria will apply.
THERAPEUTIC
DRUG CLASS
Individual prescriptions for the
components of these products should be
used for patients requiring these drug
combinations.
ANTIBIOTICS,
GASTROINTESTINAL
(Implementation 07/17/2014)
Note: Although azithromycin,
ciprofloxacin, and
trimethoprim/sulfamethoxazole are not
included in this review, they are available
without prior authorization.
4
PREFERRED
NON-PREFERRED
DRUGS
DRUGS
ANGIOTENSIN RECEPTOR BLOCKERS
DIOVAN (valsartan)
BENICAR (olmesartan)
irbesartan (generic for Avapro)
candesartan (generic for Atacand)
losartan (generic for Cozaar)
EDARBI (azilsartan medoxomil)
EDARBYCLOR (azilsartan/chlorthalidone)
eprosartan (generic for Teveten)
telmisartan (generic for Micardis)
valsartan (generic for Diovan)
ANGIOTENSIN RECEPTOR BLOCKER/DIURETIC COMBINATIONS
DIOVAN-HCT (valsartan/HCTZ)
BENICAR-HCT (olmesartan/HCTZ)
irbesartan/HCTZ (generic for Avalide)
candesartan/HCTZ (generic for AtacandHCT)
losartan/HCTZ (generic for Hyzaar)
telmisartan/HCTZ (generic for
Micardis-HCT)
TEVETEN-HCT (eprosartan/HCTZ)
valsartan-HCTZ (generic for Diovan-HCT)
ANGIOTENSIN MODULATOR /
CALCIUM CHANNEL BLOCKER COMBINATIONS
benazepril/amlodipine (generic for Lotrel)
AMTURNIDE (aliskiren/amlodipine/HCTZ)
TARKA (trandolapril/verapamil)
AZOR (olmesartan/amlodipine)
EXFORGE (valsartan/amlodipine)
TEKAMLO (aliskiren/amlodipine)
telmisartan/amlodipine (generic for
Twynsta)
TRIBENZOR
(amlodipine/olmesartan/HCTZ)
valsartan/amlodipine (generic for Exforge)
valsartan/amlodipine/HCTZ (generic for
Exforge HCT)
DIRECT RENIN INHIBITORS
TEKTURNA (aliskiren)
DIRECT RENIN INHIBITOR COMBINATIONS
AMTURNIDE (aliskiren/amlodipine/HCTZ)
TEKAMLO (aliskiren/amlodipine)
TEKTURNA/HCT (aliskiren/HCTZ)
metronidazole TABLETS
ALINIA (nitazoxanide)
neomycin
DIFICID (fidaxomicin)
FLAGYL ER (metronidazole)
vancomycin compounded oral solution
metronidazole CAPSULES
tinidazole (generic for Tindamax)
vancomycin capsules (generic for
Vancocin)
XIFAXAN (rifaximin)
BRAND PRODUCTS IN UPPER CASE generic names in lower case. If only the generic name is listed as preferred, then the BRAND name of that product is nonpreferred; unless the brand name product is ALSO listed as preferred.
*Indicates that a clinical prior authorization is required despite the medication’s status as preferred or non-preferred.
QL indicates quantity limits.
NR indicates product was not reviewed. New Drug criteria will apply.
5
THERAPEUTIC
DRUG CLASS
ANTIBIOTICS, INHALED
(Implementation 07/17/2014)
ANTIBIOTICS, TOPICAL
(Implementation 07/17/2014)
ANTIBIOTICS, VAGINAL
(Implementation 07/17/2014)
ANTICOAGULANTS
(Implementation 07/17/2014)
ANTIEMETICS /ANTIVERTIGO
AGENTS
(Implementation 07/17/2014)
PREFERRED
DRUGS
BETHKIS (tobramycin)
TOBI (tobramycin)
TOBI-PODHALER (tobramycin)*
bacitracin ointment
bacitracin/polymyxin (generic for Polysporin)
mupirocin OINTMENT (generic for
Bactroban)
neomycin/polymyxin/bacitracin (generic for
Neosporin, Triple AB)
CLEOCIN OVULES (clindamycin, vaginal
suppositories)
clindamycin (vaginal) (generic for Cleocin)
METROGEL (metronidazole, vaginal)
NON-PREFERRED
DRUGS
CAYSTON (aztreonam lysine)QL, *
tobramycin (generic for TOBI)
ELIQUIS (apixaban)
enoxaparin (generic for Lovenox)
FRAGMIN (dalteparin)
PRADAXA (dabigatran)
warfarin (generic for Coumadin)
XARELTO (rivaroxaban)
fondaparinux (generic for Arixtra)
LOVENOX (enoxaparin)
XARELTO STARTER PACK (rivaroxaban)
ALTABAX (retapamulin)
CENTANY (mupirocin ointment)
gentamicin OINTMENT, CREAM
mupirocin CREAM (generic for Bactroban)
CLINDESSE (clindamycin, vaginal)
metronidazole (vaginal)
VANDAZOLE (metronidazole, vaginal)
CANNABINOIDS
CESAMET (nabilone)
dronabinol (generic for Marinol)
5HT3 RECEPTOR BLOCKERS
ondansetron (generic for Zofran)
ANZEMET (dolasetron)
ondansetron ODT (generic for Zofran)
granisetron (generic for Kytril)
SANCUSO (granisetron)
ZUPLENZ (ondansetron)
NK-1 RECEPTOR ANTAGONIST
AKYNZEO (netupitant/palonosetron)NR
EMEND (aprepitant)QL, *
TRADITIONAL ANTIEMETICS
DICLEGIS (doxylamine/pyridoxine)**
COMPRO (prochlorperazine rectal)
**females only
METOZOLV ODT (metoclopramide)
dimenhydrinate (generic for Dramamine)
prochlorperazine rectal (generic for
Compazine)
hydroxyzine (generic for Vistaril)
promethazine suppositories 50mg
meclizine (generic for Antivert)
trimethobenzamide oral (generic for Tigan)
metoclopramide (generic for Reglan)
Marinol (dronabinol)
phosphoric acid/dextrose/fructose solution
(generic for Emetrol)
prochlorperazine oral (generic for
Compazine)
promethazine oral (generic for Phenergan)
promethazine suppositories 12.5mg, 25mg
TRANSDERM-SCOP (scopolamine)
BRAND PRODUCTS IN UPPER CASE generic names in lower case. If only the generic name is listed as preferred, then the BRAND name of that product is nonpreferred; unless the brand name product is ALSO listed as preferred.
*Indicates that a clinical prior authorization is required despite the medication’s status as preferred or non-preferred.
QL indicates quantity limits.
NR indicates product was not reviewed. New Drug criteria will apply.
THERAPEUTIC
DRUG CLASS
ANTIFUNGALS, ORAL
(Implementation 07/17/2014)
ANTIFUNGALS, TOPICAL
(Implementation 07/17/2014)
6
NON-PREFERRED
DRUGS
flucytosine (generic for Ancobon)*
GRIFULVIN V (griseofulvin)
griseofulvin tablets
griseofulvin ultramicrosize
itraconazole (generic for Sporanox)
ketoconazole (generic for Nizoral)
LAMISIL GRANULES (terbinafine)
NOXAFIL (posaconazole)*
NOXAFIL DR (posaconazole DR)*
nystatin POWDER for reconstitution
ONMEL (itraconazole)
ORAVIG (miconazole buccal)
SPORANOX (itraconazole)*
voriconazole (generic for VFEND)*
ANTIFUNGAL
ALEVAZOL (clotrimazole)NR
clotrimazole (generic for Lotrimin) RX, OTC
econazole (generic for Spectazole)
BENSAL HP (salicylic acid)
ketoconazole cream (generic for Nizoral)
ciclopirox cream/gel/suspension (generic
for Ciclodan, Loprox)
ketoconazole shampoo (generic for Nizoral)
ciclopirox
nail lacquer (solution) (generic
LAMISIL AT CREAM (terbinafine) OTC
for
Penlac)
LAMISIL AT GEL (terbinafine) OTC
ciclopirox shampoo (generic for Loprox)
LAMISIL SPRAY OTC (terbinafine)
DESENEX AERO POWDER OTC
miconazole OTC CREAM, SPRAY,
(miconazole)
POWDER
ERTACZO (sertaconazole)
NUZOLE (miconazole)
EXELDERM (sulconazole)
nystatin
EXTINA (ketoconazole)
selenium sulfide 2.5%
FUNGOID OTC
terbinafine OTC (generic for Lamisil AT)
NR
TINACTIN AERO POWDER (tolnaftate) OTC JUBLIA (efinaconazole)
ketoconazole FOAM (generic for Ketodan)
TINACTIN CREAM (tolnaftate) OTC
LOTRIMIN AF CREAM OTC
tolnaftate OTC (generic for Tinactin)
(clotrimazole)
LUZU (luliconazole)
MENTAX (butenafine)
miconazole OTC OINTMENT
NAFTIN (naftifine)
OXISTAT (oxiconazole)
selenium sulfide 2.25%
VUSION (miconazole/ zinc oxide)
ANTIFUNGAL/STEROID COMBINATIONS
clotrimazole/betamethasone CREAM
clotrimazole/betamethasone LOTION
(generic for Lotrisone)
(generic for Lotrisone)
nystatin/triamcinolone (gen. for Mycolog)
PREFERRED
DRUGS
clotrimazole (mucous membrane, troche)
fluconazole (generic for Diflucan)
griseofulvin suspension
GRIS-PEG (griseofulvin)
nystatin TABLET, SUSPENSION
terbinafine (generic for Lamisil)
BRAND PRODUCTS IN UPPER CASE generic names in lower case. If only the generic name is listed as preferred, then the BRAND name of that product is nonpreferred; unless the brand name product is ALSO listed as preferred.
*Indicates that a clinical prior authorization is required despite the medication’s status as preferred or non-preferred.
QL indicates quantity limits.
NR indicates product was not reviewed. New Drug criteria will apply.
THERAPEUTIC
DRUG CLASS
ANTIHISTAMINES, MINIMALLY
SEDATING
(Implementation 01/08/2015)
PREFERRED
DRUGS
cetirizine (generic for Zyrtec)
(swallow tablets and solution)
loratadine (generic for Claritin)
(swallow tablets and solution)
ANTIHYPERTENSIVES,
SYMPATHOLYTICS
(Implementation 01/08/2015)
CATAPRES-TTS (clonidine transdermal)
clonidine ORAL (generic for Catapres)
guanfacine (generic for Tenex)
methyldopa
allopurinol (generic for Zyloprim)
probenecid
probenecid/colchicine (generic for ColProbenecid)
ANTIHYPERURICEMICS
(Implementation 01/08/2015)
ANTIMIGRAINE DRUGSQL,
TRIPTANS
Note: There are Quantity Limits for entire
class.
7
NON-PREFERRED
DRUGS
cetirizine chewable (generic for Zyrtec)
desloratadine (generic for Clarinex)
desloratadine ODT (generic for Clarinex
Reditabs)
fexofenadine (generic for Allegra)
levocetirizine (generic for Xyzal)
loratadine dispersible (generic for Claritin
Reditabs)
clonidine transdermal
CLORPRES (chlorthalidone/clonidine)
methyldopa/hydrochlorothiazide
reserpine
COLCRYS (colchicine)*
ULORIC (febuxostat)*
ORAL
AXERT (almotriptan)
FROVA (frovatriptan)
IMITREX oral (sumatriptan)
naratriptan (generic for Amerge)
rizatriptan (generic for Maxalt/Maxalt MLT)
TREXIMET (sumatriptan/naproxen)
zolmitriptan (generic for Zomig/
Zomig ZMT)
RELPAX (eletriptan)
sumatriptan generic oral
(Implementation 07/17/2014)
NASAL
IMITREX (sumatriptan)
sumatriptan generic nasal
ZOMIG (zolmitriptan)
INJECTABLE
IMITREX (sumatriptan) PEN, CARTRIDGE
sumatriptan generic VIAL
ANTIPARASITICS, TOPICAL
(Implementation 07/17/2014)
permethrin 1% OTC (generic for Nix)
permethrin 5% RX (generic for Elimite)
pyrethrin/piperonyl butoxide
(generic for RID, A-200)
ALSUMA (sumatriptan)
IMITREX (sumatriptan) VIAL
sumatriptan SYRINGE, KIT
SUMAVEL DOSEPRO (sumatriptan)
EURAX (crotamiton) CREAM
EURAX (crotamiton) LOTION
lindane
malathion (generic for Ovide)
SKLICE (ivermectin)
spinosad (generic for Natroba)
ULESFIA (benzyl alcohol)
BRAND PRODUCTS IN UPPER CASE generic names in lower case. If only the generic name is listed as preferred, then the BRAND name of that product is nonpreferred; unless the brand name product is ALSO listed as preferred.
*Indicates that a clinical prior authorization is required despite the medication’s status as preferred or non-preferred.
QL indicates quantity limits.
NR indicates product was not reviewed. New Drug criteria will apply.
8
THERAPEUTIC
DRUG CLASS
ANTIPARKINSON’S
DRUGS(Oral)
(Implementation 01/08/2015)
PREFERRED
DRUGS
NON-PREFERRED
DRUGS
ANTICHOLINERGICS
benztropine (generic for Cogentin)
trihexyphenidyl (generic for Artane)
COMT INHIBITORS
entacapone (generic for Comtan)
TASMAR (tolcapone)
DOPAMINE AGONISTS
bromocriptine (generic for Parlodel)
MIRAPEX ER (pramipexole)*
pramipexole (generic for Mirapex)
NEUPRO (rotigotine)*
ropinirole (generic for Requip)
ropinirole extended release (generic for
REQUIP XL)*
MAO-B INHIBITORS
selegiline tablets (generic for Eldepryl)
AZILECT (rasagiline)
selegiline capsules (gen. for Eldepryl)
ZELAPAR (selegiline)
ANTIPSORIATICS, ORAL
(Implementation 01/08/2015)
ANTIPSORIATICS, TOPICAL
(Implementation 01/08/2015)
ANTIVIRALS, ORAL
(Implementation 07/17/2014)
OTHER ANTIPARKINSON’S DRUGS
carbidopa/levodopa (generic for Sinemet)
carbidopa/levodopa ODT (generic for
carbidopa/levodopa ER
Parcopa)
(generic for Sinemet CR)
levodopa/carbidopa/entacapone (generic
for Stalevo)
STALEVO (levodopa/carbidopa/entacapone)
acitretin (generic for Soriatane)
SORIATANE (acitretin)
methoxsalen (generic for Oxsoralen-Ultra)
OXSORALEN-ULTRA (methoxsalen)
8-MOP (methoxsalen)
calcipotriene CREAM
calcipotriene OINTMENT
calcipotriene solution
calcitriol (generic for Vectical)
calcipotriene/betamethasone
(generic for Taclonex ointment)
CALCITRENE (calcipotriene
ointment)
DOVONEX CREAM (calcipotriene)
SORILUX (calcipotriene foam)
TACLONEX SCALP (calcipotriene/
betamethasone)
ANTI-HERPETIC DRUGS
acyclovir (generic for Zovirax)
famciclovir (generic for Famvir)
valacyclovir (generic for Valtrex)
SITAVIG (acyclovir buccal) NR
ANTI-INFLUENZA DRUGS
amantadine CAPSULE, SYRUP
amantadine TABLET
(generic for Symmetrel)
RELENZA (zanamivir) inhalationQL
rimantadine (generic for Flumadine)
TAMIFLU (oseltamivir) QL
BRAND PRODUCTS IN UPPER CASE generic names in lower case. If only the generic name is listed as preferred, then the BRAND name of that product is nonpreferred; unless the brand name product is ALSO listed as preferred.
*Indicates that a clinical prior authorization is required despite the medication’s status as preferred or non-preferred.
QL indicates quantity limits.
NR indicates product was not reviewed. New Drug criteria will apply.
9
THERAPEUTIC
DRUG CLASS
ANTIVIRALS, TOPICAL
(Implementation 07/17/2014)
ANXIOLYTICS
(Implementation 01/08/2015)
BENIGN PROSTATIC
HYPERPLASIA (BPH)
TREATMENTS
(Implementation 07/17/2014)
BETA BLOCKERS (Oral)
(Implementation 07/17/2014)
PREFERRED
DRUGS
NON-PREFERRED
DRUGS
acyclovir OINTMENT (generic for
Zovirax)
DENAVIR (penciclovir)
XERESE (acyclovir/hydrocortisone)
ZOVIRAX Cream (acyclovir)
alprazolam ER (generic for
Xanax XR)
alprazolam ODT
alprazolam INTENSOL
diazepam INTENSOL
meprobamate
oxazepam
alprazolam tablet (generic for Xanax)
buspirone
chlordiazepoxide
clorazepate (generic forTranxene-T)
diazepam solution
diazepam tablet
lorazepam INTENSOL
lorazepam tablet (generic for Ativan)
ALPHA BLOCKERS
alfuzosin (generic for Uroxatral)
CARDURA XL (doxazosin)
doxazosin (generic for Cardura)
JALYN (dutasteride/tamsulosin)
RAPAFLO (silodosin)
tamsulosin (generic for Flomax)
UROXATRAL (alfuzosin)
terazosin (generic for Hytrin)
5-ALPHA-REDUCTASE (5AR) INHIBITORS
finasteride (generic for Proscar)
AVODART (dutasteride)
JALYN (dutasteride/tamsulosin)
BETA BLOCKERS
acebutolol (generic for Sectral)
betaxolol (generic for Kerlone)
atenolol (generic for Tenormin)
BYSTOLIC (nebivolol)
atenolol/chlorthalidone(generic for Tenoretic)
DUTOPROL
bisoprolol (generic for Zebeta)
(metoprolol XR and HCTZ)
bisoprolol/HCTZ (generic for Ziac)
HEMANGEOL (propranolol) oral solutionNR
metoprolol (generic for Lopressor)
INNOPRAN XL (propranolol)
metoprolol XL (generic for Toprol XL)
LEVATOL (penbutolol)
propranolol (generic for Inderal)
metoprolol/HCTZ (generic for
propranolol extended release (Inderal LA)
Lopressor HCT)
TOPROL XL (metoprolol)
nadolol (generic for Corgard)
nadolol/bendroflumethiazide
(generic for Corzide)
pindolol (generic for Viskin)
propranolol/hydrochlorothiazide
(generic for Inderide)
timolol (generic for Blocadren)
BETA- AND ALPHA- BLOCKERS
carvedilol (generic for Coreg)
COREG CR (carvedilol)
labetalol (generic for Trandate)
ANTIARRHYTHMIC
sotalol (generic for Betapace)
BRAND PRODUCTS IN UPPER CASE generic names in lower case. If only the generic name is listed as preferred, then the BRAND name of that product is nonpreferred; unless the brand name product is ALSO listed as preferred.
*Indicates that a clinical prior authorization is required despite the medication’s status as preferred or non-preferred.
QL indicates quantity limits.
NR indicates product was not reviewed. New Drug criteria will apply.
THERAPEUTIC
DRUG CLASS
BILE SALTS
(Implementation 01/08/2015)
BLADDER RELAXANT
PREPARATIONS
(Implementation 07/17/2014)
BONE RESORPTION
SUPPRESSION AND RELATED
DRUGS
(Implementation 07/17/2014)
BRONCHODILATORS,
BETA AGONIST
(Implementation 01/08/2015)
10
NON-PREFERRED
DRUGS
CHENODAL (chenodiol)
ursodiol capsule 300mg (generic for
Actigall)
ENABLEX (darifenacin)
GELNIQUE (oxybutynin)
MYRBETRIQ (mirabegron)
OXYTROL (oxybutynin)
tolterodine (generic for Detrol)
tolterodine ER (generic for Detrol LA)
trospium (generic for Sanctura)
trospium ER (generic for Sanctura XR)
BISPHOSPHONATES
alendronate (generic for Fosamax)
ACTONEL (risedronate)
(daily and weekly formulations)
ATELVIA DR (risedronate)
BINOSTO (alendronate effervescent)
etidronate disodium (generic for Didronel)
FOSAMAX Oral Solution
(alendronate)
FOSAMAX PLUS D
ibandronate (generic for Boniva)
risedronate (generic for Actonel)
OTHER BONE RESORPTION SUPPRESSION AND RELATED DRUGS
EVISTA (raloxifene)
calcitonin-salmon nasal
FORTICAL (calcitonin) nasal
FORTEO (teriparatide) subcutaneousQL
MIACALCIN (calcitonin) nasal
raloxifene (generic for Evista)
INHALERS-Short Acting
PROVENTIL HFA (albuterol)
PROAIR HFA (albuterol)
VENTOLIN HFA (albuterol)
XOPENEX HFA (levalbuterol)
INHALERS – Long Acting
FORADIL (formoterol)
ARCAPTA NEOHALER (indacaterol)
STRIVERDI RESPIMAT (olodaterol)
SEREVENT (salmeterol)
INHALATION SOLUTION
albuterol (2.5mg/3ml premix or 2.5mg/0.5ml)
albuterol low dose (0.63mg/3ml &
1.25mg/3ml)
albuterol/ipratropium(generic for Duoneb)
BROVANA (arformoterol)
levalbuterol (generic for Xopenex)
PERFOROMIST (formoterol)
ORAL
albuterol syrup
albuterol tablets
albuterol ER (generic for Vospire ER)
metaproterenol (formerly generic for
terbutaline (generic for Brethine)
Alupent)
PREFERRED
DRUGS
ursodiol 250mg tablet (generic for URSO)
ursodiol 500mg tablet (generic for URSO
FORTE)
oxybutynin IR (generic for Ditropan)
oxybutynin ER (generic for Ditropan XL)
TOVIAZ (fesoterodine ER)
VESICARE (solifenacin)
BRAND PRODUCTS IN UPPER CASE generic names in lower case. If only the generic name is listed as preferred, then the BRAND name of that product is nonpreferred; unless the brand name product is ALSO listed as preferred.
*Indicates that a clinical prior authorization is required despite the medication’s status as preferred or non-preferred.
QL indicates quantity limits.
NR indicates product was not reviewed. New Drug criteria will apply.
11
THERAPEUTIC
DRUG CLASS
CALCIUM CHANNEL
BLOCKERS (Oral)
(Implementation 07/17/2014)
CEPHALOSPORINS (Oral) and
RELATED ANTIBIOTICS
(Implementation 07/17/2014)
PREFERRED
DRUGS
NON-PREFERRED
DRUGS
SHORT-ACTING
Dihydropyridines
nifedipine (generic for Procardia)
isradipine (generic for Dynacirc)
nicardipine (generic for Cardene)
nimodipine (generic for Nimotop)
NYMALIZE (nimodipine solution)
Non-dihydropyridine
diltiazem (generic for Cardizem)
verapamil (generic for Calan, Isoptin)
LONG-ACTING
Dihydropyridines
amlodipine (generic for Norvasc)
CARDENE SR (nicardipine)
nifedipine ER (generic for Procardia XL,
felodipine ER (generic for Plendil)
Adalat CC)
nisoldipine (generic for Sular)
Non-dihydropyridines
diltiazem ER (generic for Cardizem CD)
CALAN SR (verapamil)
verapamil ER TABLET
diltiazem LA (generic for Cardizem LA)
verapamil ER PM (generic for Verelan PM)
MATZIM LA (diltiazem)
TIAZAC (diltiazem)
verapamil ER CAPSULE
verapamil 360mg capsule
BETA LACTAM/BETA-LACTAMASE INHIBITOR COMBINATIONS
amoxicillin/clavulanate TABLETS, CHEW
amoxicillin/clavulanate XR
TABLETS, SUSPENSION
(generic for Augmentin XR)
AUGMENTIN 125MG/5ML SUSPENSION
AUGMENTIN 250MG/5ML SUSPENSION
AUGMENTIN (amoxicillin/clavulanate)
CEPHALOSPORINS – First Generation
cefadroxil (oral) CAPSULE, SUSPENSION
cefadroxil (oral) TABLET
(generic for Duricef)
(generic for Duricef)
cephalexin CAPSULE, SUSPENSION
cephalexin TABLET
(generic for Keflex)
CEPHALOSPORINS – Second Generation
cefprozil (oral) (generic for Cefzil)
cefaclor (oral) (generic for Ceclor)
cefuroxime (oral tablet) (generic for Ceftin)
CEFTIN (cefuroxime) tablets, suspension
CEPHALOSPORINS – Third Generation
cefdinir (oral) (generic for Omnicef)
CEDAX (ceftibuten)
SUPRAX SUSPENSION, CAPSULE
cefpodoxime (oral) (generic for Vantin)
(cefixime)
SUPRAX CHEWABLE TABLET, TABLET
(cefixime)
BRAND PRODUCTS IN UPPER CASE generic names in lower case. If only the generic name is listed as preferred, then the BRAND name of that product is nonpreferred; unless the brand name product is ALSO listed as preferred.
*Indicates that a clinical prior authorization is required despite the medication’s status as preferred or non-preferred.
QL indicates quantity limits.
NR indicates product was not reviewed. New Drug criteria will apply.
12
THERAPEUTIC
DRUG CLASS
CHRONIC OBSTRUCTIVE
PULMONARY DISEASE (COPD)
AGENTS
(Implementation 01/08/2015)
COLONY STIMULATING
FACTORS
(Implementation 07/17/2014)
PREFERRED
DRUGS
NON-PREFERRED
DRUGS
INHALERS
ATROVENT HFA (ipratropium)
ANORO ELLIPTA (umeclidinium/
COMBIVENT RESPIMAT (albuterol/
vilanterol)
SPIRIVA RESPIMAT (tiotropium)NR
ipratropium)
SPIRIVA (tiotropium)
TUDORZA PRESSAIR (aclidinium br)
INHALATION SOLUTION
albuterol/ipratropium (generic for Duoneb)
ipratropium solution (generic for Atrovent)
ORAL AGENT
DALIRESP (roflumilast)*
XANTHINES (not reviewed by the PDL process but are covered without prior authorization)
theophylline
NEUPOGEN (filgrastim) VIAL*
NEUPOGEN (filgrastim) DISP SYR
(Entire class requires prior authorization
when administered outside physician
office or hospital)
CYTOKINE & CAM
ANTAGONISTS
(Implementation 01/08/2015)
(Note: only self-administered, out-patient
ENBREL (etanercept)
HUMIRA (adalimumab)
medications included in this review)
EPINEPHRINE, SELFINJECTED
(Implementation 01/08/2015)
EPIPEN
EPIPEN JR.
ERYTHROPOIESIS
STIMULATING PROTEINS
(Implementation 07/17/2014)
EPOGEN (rHuEPO)*
PROCRIT (rHuEPO)*
ACTEMRA subcutaneous (tocilizumab)
CIMZIA (certolizumab pegol)
KINERET (anakinra)
ORENCIA (abatacept) Subcutaneous
OTEZLA (apremilast oral)
SIMPONI (golimumab)
XELJANZ (tofacitinib oral)
AUVI-Q
epinephrine (generic for Adrenaclick)
ADRENACLICK
(Entire class requires prior authorization
when administered outside physician
office or hospital)
FLUOROQUINOLONES, ORAL
(Implementation 07/17/2014)
ciprofloxacin (generic for Cipro)
levofloxacin TABLETS (generic for Levaquin)
ciprofloxacin ER
ciprofloxacin suspension (generic for Cipro
Suspension)
levofloxacin oral solution
moxifloxacin (generic for Avelox)
NOROXIN (norfloxacin)
ofloxacin
BRAND PRODUCTS IN UPPER CASE generic names in lower case. If only the generic name is listed as preferred, then the BRAND name of that product is nonpreferred; unless the brand name product is ALSO listed as preferred.
*Indicates that a clinical prior authorization is required despite the medication’s status as preferred or non-preferred.
QL indicates quantity limits.
NR indicates product was not reviewed. New Drug criteria will apply.
13
THERAPEUTIC
DRUG CLASS
GLUCOCORTICOIDS, INHALED
(Implementation 01/08/2015)
GROWTH HORMONE
(Implementation 07/17/2014)
Entire class requires prior authorization
based on clinical criteria:
https://nebraska.fhsc.com/Downl
oads/NEfaxform_GH-201311.pdf
H.PYLORI TREATMENTS
(Implementation 07/17/2014)
HEPATITIS C TREATMENTS
(Implementation 07/17/2014)
Entire class requires prior authorization
based on clinical criteria:
https://nebraska.fhsc.com/Downl
oads/NEfaxform_HepatitisC201409.pdf
HISTAMINE II RECEPTOR
BLOCKERS
(Implementation 01/08/2015)
PREFERRED
DRUGS
NON-PREFERRED
DRUGS
GLUCOCORTICOIDS
ASMANEX (mometasone)
ALVESCO (ciclesonide)
AEROSPAN (flunisolide)
FLOVENT DISKUS (fluticasone)
FLOVENT HFA (fluticasone)
PULMICORT FLEXHALER (budesonide)
QVAR (beclomethasone)
GLUCOCORTICOID/BRONCHODILATOR COMBINATIONS
ADVAIR HFA
ADVAIR DISKUS (fluticasone/salmeterol)
BREO ELLIPTA (fluticasone/vilanterol)
DULERA (mometasone/formoterol)
SYMBICORT (budesonide/ formoterol)
INHALATION SOLUTION
budesonide respules (generic for
Pulmicort)
PULMICORT RESPULES (budesonide)
NORDITROPIN (somatropin)
GENOTROPIN (somatropin)
NUTROPIN (somatropin)
HUMATROPE (somatropin)
NUTROPIN AQ (somatropin)
OMNITROPE (somatropin)
SAIZEN (somatropin)
SEROSTIM (somatropin)
TEV-TROPIN (somatropin)
ZORBTIVE (somatropin)
OMECLAMOX-PAK (omeprazole,
PYLERA (bismuth, metronidazole,
clarithromycin, amoxicillin)
tetracycline)
lansoprazole/amoxicillin/clarithromycin
PREVPAC (lansoprazole, amoxicillin,
(generic for Prevpac)
clarithromycin)
INTERFERON
PEGASYS
INFERGEN (interferon alfacon-1)
(pegylated interferon alfa-2a)*
PEG-INTRON
(pegylated interferon alfa-2b)*
NUCLEOTIDE ANALOG POLYMERASE INHIBITOR
HARVONI (sofosbuvir/ledipasvir)NR
SOVALDI (sofosbuvir)*
PROTEASE INHIBITOR
INCIVEK (telaprevir)*
OLYSIO (simeprevir)*
VICTRELIS (boceprevir)*
RIBAVIRIN
ribavirin 200mg tablets/capsules
REBETOL SOLUTION (ribavirin)
famotidine tablet (generic for Pepcid)
cimetidine solution
ranitidine TABLET (generic for Zantac)
cimetidine tablet (generic for Tagamet)
ranitidine syrup
famotidine SUSPENSION
nizatidine (generic for Axid)
ranitidine CAPSULE
BRAND PRODUCTS IN UPPER CASE generic names in lower case. If only the generic name is listed as preferred, then the BRAND name of that product is nonpreferred; unless the brand name product is ALSO listed as preferred.
*Indicates that a clinical prior authorization is required despite the medication’s status as preferred or non-preferred.
QL indicates quantity limits.
NR indicates product was not reviewed. New Drug criteria will apply.
14
THERAPEUTIC
DRUG CLASS
HYPOGLYCEMICS,
ALPHA-GLUCOSIDASE
INHIBITORS
(Implementation 07/17/2014)
PREFERRED
DRUGS
acarbose (generic for Precose)
Glyset (miglitol)
HYPOGLYCEMICS, INCRETIN MIMETICS/ENHANCERS
(Implementation 07/17/2014)
Glucagon-Like Peptide-1
BYDUREON (exenatide ER) subcutaneous**
Receptor Agonist
BYETTA (exenatide) subcutaneous**
(GLP-1 RA)
** Requires metformin trial and diagnosis of
https://nebraska.fhsc.com/Downl
diabetes.
oads/NEfaxform_GLP-1_RA201406.pdf
Amylin Analog
https://nebraska.fhsc.com/Downl
oads/NEfaxform_Amylin201403.pdf
Dipeptidyl peptidase-4 (DPP-4)
JANUMET (sitagliptin/metformin)QL
Inhibitor
JANUMET XR(sitagliptin/metformin)QL
JANUVIA (sitagliptin)QL
JENTADUETO (linagliptin/metformin)QL
TRADJENTA (linagliptin)QL
HYPOGLYCEMICS, INSULIN
AND RELATED DRUGS
(Implementation 07/17/2014)
HUMALOG (insulin lispro)
HUMALOG MIX
(insulin lispro/lispro protamine)
HUMULIN (insulin)
LANTUS (insulin glargine)
LEVEMIR (insulin detemir)
HYPOGLYCEMICS,
MEGLITINIDES
(Implementation 07/17/2014)
NON-PREFERRED
DRUGS
BYDUREON PEN (exenatide ER)
subcutaneous**
TANZEUM (albiglutide)NR
TRULICITY (dulaglutide)NR
VICTOZA (liraglutide) subcutaneous**
SYMLIN (pramlintide) subcutaneous*
KAZANO (alogliptin/metformin)QL
KOMBIGLYZE XR
(saxagliptin/metformin)QL
NESINA (alogliptin)QL
ONGLYZA (saxagliptin)QL
OSENI (alogliptin/pioglitazone)QL
APIDRA (insulin glulisine)
NOVOLIN (insulin)
NOVOLOG (insulin aspart)
NOVOLOG MIX
(insulin aspart/aspart protamine)
Insulin pens /cartridges*
nateglinide (generic for Starlix)
PRANDIMET (repaglinide/metformin)
repaglinide (generic for Prandin)
metformin ER (generic for Fortamet)
GLUMETZA (metformin extended
release)
RIOMET (metformin oral solution)
HYPOGLYCEMICS,
METFORMINS
(Implementation 07/17/2014)
glipizide/metformin
glyburide/metformin (generic for
Glucovance)
metformin (generic for Glucophage)
metformin ER (generic for Glucophage XR)
HYPOGLYCEMICS, SGLT2
(Implementation 07/17/2014)
FARXIGA (dapagliflozin)*
INVOKAMET (canagliflozin/metformin)NR
INVOKANA (canagliflozin)*
JARDIANCE (empagliflozin)NR
XIGDUO XR (dapagliflozin/metformin)NR
THIAZOLIDINEDIONES (TZDs)
pioglitazone (generic for Actos)
AVANDIA (rosiglitazone)
HYPOGLYCEMICS, TZDs
(Implementation 07/17/2014)
BRAND PRODUCTS IN UPPER CASE generic names in lower case. If only the generic name is listed as preferred, then the BRAND name of that product is nonpreferred; unless the brand name product is ALSO listed as preferred.
*Indicates that a clinical prior authorization is required despite the medication’s status as preferred or non-preferred.
QL indicates quantity limits.
NR indicates product was not reviewed. New Drug criteria will apply.
15
THERAPEUTIC
DRUG CLASS
PREFERRED
DRUGS
NON-PREFERRED
DRUGS
TZD COMBINATIONS
ACTOPLUS MET XR
(pioglitazone/metformin)
AVANDAMET (rosiglitazone/metformin)
AVANDARYL (rosiglitazone/glipizide)
pioglitazone/glimepiride (generic for
Duetact)
pioglitazone/metformin (generic for
Actoplus Met)
Hypoglycemics: Additional Classes
The following hypoglycemic classes and the drugs noted are not reviewed by the PDL process but are covered without prior authorization.
HYPOGLYCEMICS,
SULFONYLUREAS
IMMUNOMODULATORS,
ATOPIC DERMATITIS
(Implementation 01/08/2015)
IMMUNOMODULATORS,
TOPICAL
(Implementation 01/08/2015)
INTRANASAL RHINITIS DRUGS
(Implementation 01/08/2015)
IRRITABLE BOWEL
SYNDROME
(Implementation 07/17/2014)
chlorpropamide
glimepiride (generic for Amaryl)
glipizide (generic for Glucotrol)
glipizide ER (generic for Glucotrol XL)
glyburide/micronized (generic for Diabeta,
Glynase)
tolazamide
tolbutamide
ELIDEL (pimecrolimus)
ALDARA (imiquimod)
PROTOPIC (tacrolimus)*
imiquimod (generic for Aldara)
ZYCLARA (imiquimod)
ANTICHOLINERGICS
ipratropium (generic for Atrovent)
ANTIHISTAMINES
ASTEPRO (azelastine)
azelastine (generic for Astelin)
PATANASE (olopatadine)
azelastine (generic for Astepro)
DYMISTA (azelastine/fluticasone)
olopatadine (generic for Patanase)
CORTICOSTEROIDS
fluticasone (generic for Flonase)
BECONASE AQ (beclomethasone)
NASONEX (mometasone)
budesonide (generic for Rhinocort Aqua)
flunisolide (generic for Nasalide)
OMNARIS (ciclesonide)
QNASL (beclomethasone)
triamcinolone (generic for Nasacort AQ)
VERAMYST (fluticasone)
ZETONNA (ciclesonide)
AMITIZA (lubiprostone)
LOTRONEX (alosetron)
LINZESS (linaclotide)
BRAND PRODUCTS IN UPPER CASE generic names in lower case. If only the generic name is listed as preferred, then the BRAND name of that product is nonpreferred; unless the brand name product is ALSO listed as preferred.
*Indicates that a clinical prior authorization is required despite the medication’s status as preferred or non-preferred.
QL indicates quantity limits.
NR indicates product was not reviewed. New Drug criteria will apply.
16
THERAPEUTIC
DRUG CLASS
LEUKOTRIENE MODIFIERS
(Implementation 01/08/2015)
LIPOTROPICS, OTHER
(non-statins)
(Implementation 07/17/2014)
Note: Several other forms of
OTC niacin and fish oil are also
covered under Medicaid with a
prescription without prior
authorization.
PREFERRED
DRUGS
ACCOLATE (zafirlukast)
montelukast tablets (generic for Singulair)
(chewable and swallow tablets)
NON-PREFERRED
DRUGS
montelukast GRANULES (generic for
Singulair Granules)
zafirlukast (generic for Accolate)
ZYFLO (zileuton)
ZYFLO CR (zileuton)
BILE ACID SEQUESTRANTS
colestipol (generic for Colestid)
cholestyramine (generic for Questran)
GRANULES
colestipol (generic for Colestid) TABLETS
QUESTRAN LIGHT (cholestyramine)
WELCHOL (colesevalam)
TREATMENT OF HOMOZYGOUS FAMILIAL HYPERCHOLESTEROLEMIA
JUXTAPID (lomitapide)*
KYNAMRO (mipomersen)*
FIBRIC ACID DERIVATIVES
fenofibrate (generic for Tricor)
fenofibrate (generic for Antara)
fenofibric acid (generic for Trilipix)
fenofibrate (generic for Lofibra)
gemfibrozil (generic for Lopid)
fenofibric acid (generic for Fibricor)
LIPOFEN (fenofibrate)
LOFIBRA (fenofibrate)
TRICOR (fenofibrate)
TRIGLIDE (fenofibrate)
TRILIPIX (fenofibric acid)
NIACIN
NIACOR (niacin IR)
ADVICOR (lovastatin/niacin ER)
NIASPAN (niacin ER)
niacin ER (generic for Niaspan)
OMEGA-3 FATTY ACIDS
omega-3 fatty acids (generic for Lovaza) If
triglycerides ≥ 500. (verified by faxed copy of lab
report)
LIPOTROPICS, STATINS
(Implementation 07/17/2014)
VASCEPA (icosapent)
CHOLESTEROL ABSORPTION INHIBITORS
ZETIA (ezetimibe)
STATINS
atorvastatin (generic for Lipitor)
ALTOPREV (lovastatin)
CRESTOR (rosuvastatin)*
fluvastatin (generic for Lescol)
lovastatin (generic for Mevacor)
LESCOL / XL (fluvastatin)
pravastatin (generic for Pravachol)
LIVALO (pitavastatin)
simvastatin (generic for Zocor)
BRAND PRODUCTS IN UPPER CASE generic names in lower case. If only the generic name is listed as preferred, then the BRAND name of that product is nonpreferred; unless the brand name product is ALSO listed as preferred.
*Indicates that a clinical prior authorization is required despite the medication’s status as preferred or non-preferred.
QL indicates quantity limits.
NR indicates product was not reviewed. New Drug criteria will apply.
17
THERAPEUTIC
DRUG CLASS
MACROLIDES AND
KETOLIDES (Oral)
(Implementation 07/17/2014)
MULTIPLE SCLEROSIS DRUGS
(Implementation 07/17/2014)
NSAID
(Implementation 01/08/2015)
https://nebraska.fhsc.com/Downl
oads/NEfaxform_CoxII201311.pdf
PREFERRED
DRUGS
NON-PREFERRED
DRUGS
STATIN COMBINATIONS
ADVICOR (lovastatin/niacin ER)
atorvastatin/ amlodipine
(generic for CADUET)
LIPTRUZET (ezetimibe/atorvastatin)
SIMCOR (simvastatin/niacin ER)
VYTORIN (simvastatin/ezetimibe)
KETOLIDES
KETEK (telithromycin)
MACROLIDES
azithromycin (generic for Zithromax)
ERYTHROCIN
EES 400 TABLET
clarithromycin ER (generic for Biaxin XL)
erythromycin base TABLET
clarithromycin IR (generic for Biaxin)
erythromycin base CAPSULE DR
clarithromycin suspension
ERYTAB
ZMAX (azithromycin ER)
EES 200 SUSPENSION
ZITHROMAX (azithromycin)
ERYPED 200 SUSPENSION
ERYPED 400 SUSPENSION
PCE (erythromycin)
AUBAGIO (teriflunomide)
AMPYRA (dalfampridine)
AVONEX (interferon beta-1a)
BETASERON (interferon beta-1b)
COPAXONE 20mg Syringe Kit (glatiramer)
COPAXONE 40mg Syringe (glatiramer)
EXTAVIA (interferon beta-1b)
GILENYA (fingolimod)
PLEGRIDY (peginterferon beta-1a)NR
REBIF (interferon beta-1a)
TECFIDERA (dimethyl fumarate)
COX-I SELECTIVE
diclofenac potassium (generic for Cataflam)
diclofenac SR (generic for Voltaren-XR)
diclofenac sodium (generic for Voltaren)
diflunisal (generic for Dolobid)
etodolac (generic for Lodine)
flurbiprofen (generic for Ansaid)
ibuprofen OTC, Rx (generic for Advil, Motrin)
etodolac SR
indomethacin capsules (generic for Indocin)
fenoprofen (generic for Nalfon)
indomethacin ER (generic for Indocin)
ketoprofen (generic for Orudis)
INDOCIN RECTAL
ketorolac (generic for Toradol)
INDOCIN SUSPENSION
meclofenamate (generic for Meclomen)
ketoprofen ER
meloxicam tablet (generic for Mobic)
mefenamic acid (generic for Ponstel)
nabumetone (generic for Relafen)
BRAND PRODUCTS IN UPPER CASE generic names in lower case. If only the generic name is listed as preferred, then the BRAND name of that product is nonpreferred; unless the brand name product is ALSO listed as preferred.
*Indicates that a clinical prior authorization is required despite the medication’s status as preferred or non-preferred.
QL indicates quantity limits.
NR indicates product was not reviewed. New Drug criteria will apply.
THERAPEUTIC
DRUG CLASS
NSAID (topical)
(Implementation 01/08/2015)
PREFERRED
DRUGS
naproxen Rx, OTC (generic for Naprosyn)
naproxen suspension (Naprosyn)
sulindac (generic for Clinoril)
18
NON-PREFERRED
DRUGS
meloxicam suspension (generic Mobic)
naproxen enteric coated
oxaprozin (generic for Daypro)
piroxicam (generic for Feldene)
tolmetin (generic for Tolectin)
ALL BRAND NAME NSAIDs ARE NONPREFERRED including:
CAMBIA (diclofenac oral solution)
DUEXIS (ibuprofen/famotidine)
SPRIX (ketorolac)
VIMOVO (naprosyn/esomeprazole)
ZIPSOR (diclofenac)
ZORVOLEX (diclofenac)
NSAID/GI PROTECTANT COMBINATIONS
diclofenac/misoprostol (generic for
Arthrotec)
COX-II SELECTIVE
CELEBREX (celecoxib)
diclofenac (generic for Pennsaid Solution)
FLECTOR PATCH (diclofenac)
PENNSAID PUMP (diclofenac)NR
VOLTAREN GEL (diclofenac)
Note: other oral oncology agents not listed here may also be available. See https://nebraska.fhsc.com/default.asp
for coverage information and prior authorization status for products not listed below.
ONCOLOGY AGENTS, ORAL,
BREAST CANCER
(Implementation 01/08/2015)
AROMATASE INHIBITORS
anastrozole (generic for Arimidex)
exemestane (generic for Aromasin)
letrozole (generic for Femara)
ANTIESTROGEN
tamoxifen
FARESTON (toremifene)
Note: other oral oncology agents not listed here may also be available. See https://nebraska.fhsc.com/default.asp
for coverage information and prior authorization status for products not listed below.
ONCOLOGY AGENTS, ORAL
(Implementation 01/08/2015)
Anti-Androgens
bicalutamide (generic for Casodex)
FLUTAMIDE
XTANDI (enzalutamide)
ZYTIGA (abiraterone)
NILANDRON (nilutamide)
BRAND PRODUCTS IN UPPER CASE generic names in lower case. If only the generic name is listed as preferred, then the BRAND name of that product is nonpreferred; unless the brand name product is ALSO listed as preferred.
*Indicates that a clinical prior authorization is required despite the medication’s status as preferred or non-preferred.
QL indicates quantity limits.
NR indicates product was not reviewed. New Drug criteria will apply.
19
THERAPEUTIC
DRUG CLASS
PREFERRED
DRUGS
NON-PREFERRED
DRUGS
Kinase Inhibitors
AFINITOR (everolimus)
BOSULIF (bosutinib)
CAPRELSA (vandetanib)
COMETRIQ (cabozantinib)
GILOTRIF (afatinib)
GLEEVEC (imatinib)
ICLUSIG (ponatinib)
IMBRUVICA (irutinib)
INLYTA (axitinib)
JAKAFI (ruxolitinib)
MEKINIST (trametinib)
NEXAVAR (sorafenib)
SPRYCEL (dasatinib)
STIVARGA (regorafenib)
SUTENT (sunitinib)
TAFINLAR (dabrafenib)
TARCEVA (erlotinib)
TASIGNA (nilotinib)
TYKERB (lapatinib)
VOTRIENT (pazopanib)
XALKORI (crizotinib)
ZELBORAF (vemurafenib)
ZYDELIG (idelalisib)
ZYKADIA (ceritinib)
ALKERAN (melphalan)
ERIVEDGE (vismodegib)
hydroxyurea (generic for Hydrea)
mercaptopurine
TEMODAR (temozolomide)
XELODA (capecitabine)
ZOLINZA (vorinostat)
OPHTHALMICS, ANTIBIOTICS
(Implementation 01/08/2015)
AFINITOR DISPERZ*
Others
capecitabine (generic for Xeloda)
temozolomide (generic for Temodar)*
PURIXAN (mercaptopurine oral
suspension)
FLUOROQUINOLONES
ciprofloxacin solution (generic for Ciloxan)
BESIVANCE (besifloxacin)
MOXEZA (moxifloxacin)
CILOXAN (ciprofloxacin)
ofloxacin (generic for Ocuflox)
gatifloxacin 0.5% (generic for Zymaxid)
VIGAMOX (moxifloxacin)
levofloxacin generic
MACROLIDES
erythromycin
AZASITE (azithromycin)
AMINOGLYCOSIDES
gentamicin drops and ointment
GARAMYCIN (gentamicin)
tobramycin (generic for Tobrex drops)
TOBREX ointment (tobramycin)
BRAND PRODUCTS IN UPPER CASE generic names in lower case. If only the generic name is listed as preferred, then the BRAND name of that product is nonpreferred; unless the brand name product is ALSO listed as preferred.
*Indicates that a clinical prior authorization is required despite the medication’s status as preferred or non-preferred.
QL indicates quantity limits.
NR indicates product was not reviewed. New Drug criteria will apply.
THERAPEUTIC
DRUG CLASS
OPHTHALMIC ANTIBIOTICSTEROID COMBINATIONS
(Implementation 01/08/2015)
OPHTHALMICS FOR
ALLERGIC CONJUNCTIVITIS
(Implementation 01/08/2015)
OPHTHALMICS,
ANTI-INFLAMMATORIES
(Implementation 01/08/2015)
20
PREFERRED
NON-PREFERRED
DRUGS
DRUGS
OTHER OPHTHALMIC ANTIBIOTICS
polymyxin B/trimethoprim (gen for Polytrim)
bacitracin
bacitracin/polymyxin B (generic
Polysporin)
NATACYN (natamycin)*
neomycin/bacitracin/polymyxin B ointment
neomycin/polymyxin B/gramicidin
sulfacetamide drops (generic for Bleph10)
sulfacetamide ointment
BLEPHAMIDE (prednisolone and
neomyxin/polymyxin/HC
sulfacetamide)
neomycin/bacitracin/poly/HC
BLEPHAMIDE S.O.P.
tobramycin/dexamethasone suspension
neomycin/polymyxin/dexamethasone
(generic for Tobradex)
(generic for Maxitrol)
TOBRADEX S.T. (tobramycin and
dexamethasone)
PRED-G DROPS SUSP (prednisolone and
gentamicin)
ZYLET (loteprednol, tobramycin)
PRED-G OINT (prednisolone and gentamicin)
sulfacetamide/prednisolone
TOBRADEX OINTMENT
(tobramycin and dexamethasone)
TOBRADEX SUSPENSION
(tobramycin and dexamethasone)
ALREX (loteprednol 0.2%)
ALOCRIL (nedocromil)
cromolyn (generic for Opticrom)
ALOMIDE (lodoxamide)
ketotifen OTC (generic for Zaditor)
azelastine (generic for Optivar)
PATADAY (olopatadine 0.2%)
BEPREVE (bepotastine besilate)
EMADINE (emedastine)
epinastine (generic for Elestat)
LASTACAFT (alcaftadine)
PATANOL (olopatadine 0.1%)
CORTICOSTEROIDS
dexamethasone (generic for Maxidex)
DUREZOL (difluprednate)
FLAREX (fluorometholone)
fluorometholone 0.1% (generic for FML)
FML FORTE (fluorometholone 0.25%)
FML S.O.P. (fluorometholone 0.1%
ointment)
LOTEMAX drops (loteprednol 0.5%)
MAXIDEX (dexamethasone)
PRED MILD (prednisolone)
FML (fluorometholone 0.1% drops)
LOTEMAX OINTMENT, GEL (loteprednol)
prednisolone acetate 1% (gen. for
Omnipred, Pred Forte)
prednisolone sodium phosphate 1%
VEXOL (rimexolone)
BRAND PRODUCTS IN UPPER CASE generic names in lower case. If only the generic name is listed as preferred, then the BRAND name of that product is nonpreferred; unless the brand name product is ALSO listed as preferred.
*Indicates that a clinical prior authorization is required despite the medication’s status as preferred or non-preferred.
QL indicates quantity limits.
NR indicates product was not reviewed. New Drug criteria will apply.
21
THERAPEUTIC
DRUG CLASS
OPHTHALMICS, GLAUCOMA
DRUG
(Implementation 01/08/2015)
PREFERRED
DRUGS
NON-PREFERRED
DRUGS
NSAID
diclofenac (generic for Voltaren)
ACUVAIL (ketorolac 0.45%)
flurbiprofen (generic for Ocufen)
bromfenac 0.09% (generic for Bromday)
ILEVRO (nepafenac 0.3%)
ketorolac LS 0.4% (generic for Acular LS)
ketorolac 0.5% (generic for Acular)
NEVANAC (nepafenac)
PROLENSA (bromfenac 0.07%)
MIOTICS
PHOSPHOLINE IODIDE (echothiophate
pilocarpine
iodide)NR
PILOPINE HS
SYMPATHOMIMETICS
Alphagan P (brimonidine 0.15%)
Alphagan P (brimonidine 0.1%)
brimonidine 0.2% (generic for Alphagan)
apraclonidine (generic for Iopidine)
brimonidine P 0.15% (gen for Alphagan P)
BETA BLOCKERS
BETOPTIC S (betaxolol)
betaxolol (generic for Betoptic)
carteolol (generic for Ocupress)
TIMOPTIC OCUDOSE
ISTALOL (timolol)
TIMOPTIC XE (timolol gel forming
solution)
levobunolol (generic for Betagan)
metipranolol (generic for Optipranolol)
timolol (generic for Timoptic)
CARBONIC ANHYDRASE INHIBITORS
AZOPT (brinzolamide)
TRUSOPT (dorzolamide)
dorzolamide (generic for Trusopt)
OTIC ANTIBIOTICS
(Implementation 01/08/2015)
PROSTAGLANDIN ANALOGS
latanoprost (generic for Xalatan)
LUMIGAN (bimatoprost)
TRAVATAN Z (travoprost)
RESCULA (unoprostone isopropyl)
travoprost (generic for Travatan)
XALATAN (latanoprost)
ZIOPTAN (tafluprost)
COMBINATION DRUGS
dorzolamide/timolol (generic for Cosopt)
COMBIGAN (brimonidine/timolol)
SIMBRINZA (brinzolamide/brimonidine)
COSOPT (dorzolamide/timolol)
CIPRODEX (ciprofloxacin/dexamethasone)
CIPRO HC (ciprofloxacin/hydrocortisone)
neomycin/polymyxin/hydrocortisone
COLY-MYCIN S
(generic for Cortisporin)
(neomycin/hydrocortisone/colistin)
ofloxacin (generic for Floxin)
CORTISPORIN-TC
(neomycin/hydrocortisone/colistin)
BRAND PRODUCTS IN UPPER CASE generic names in lower case. If only the generic name is listed as preferred, then the BRAND name of that product is nonpreferred; unless the brand name product is ALSO listed as preferred.
*Indicates that a clinical prior authorization is required despite the medication’s status as preferred or non-preferred.
QL indicates quantity limits.
NR indicates product was not reviewed. New Drug criteria will apply.
THERAPEUTIC
DRUG CLASS
OTIC ANTI INFECTIVES &
ANESTHETICS
(Implementation 01/08/2015)
PANCREATIC ENZYMES
(Implementation 07/17/2014)
PHOSPHATE BINDERS
(Implementation 07/17/2014)
PLATELET AGGREGATION
INHIBITORS
(Implementation 07/17/2014)
PULMONARY ARTERIAL
HYPERTENSION AGENTS
(Oral and inhaled)
(Implementation 07/17/2014)
PROTON PUMP INHIBITORS
(ORAL)
(Implementation 07/17/2014)
SEDATIVE HYPNOTICS
(Implementation 01/08/2015)
22
NON-PREFERRED
DRUGS
acetic acid/aluminum
(generic for Otic Domeboro)
acetic acid/hydrocortisone
(generic for Vosol HC)
CREON
PANCREAZE (pancrelipase)
PANCRELIPASETM (pancrelipase)
PERTZYE (pancrelipase)
ZENPEP (pancrelipase)
ULTRESA (pancrelipase)
VIOKACE (pancrelipase)
calcium acetate TABLET
calcium acetate CAPSULE
CALPHRON OTC (calcium acetate)
FOSRENOL (lanthanum)
ELIPHOS (calcium acetate)
PHOSLO (calcium acetate)
PHOSLYRA (calcium acetate)
RENVELA (sevelamer carbonate)
RENAGEL (sevelamer HCl)
VELPHORO (sucroferric oxyhydroxide)
AGGRENOX (dipyridamole/aspirin)
BRILINTA (ticagrelor)*
aspirin
EFFIENT (prasugrel)*
clopidogrel (generic for Plavix)
ticlopidine (generic for Ticlid)
dipyridamole (generic for Persantine)
ZONTIVITY (vorapaxar)NR
LETAIRIS (ambrisentan)
ADCIRCA (tadalafil) (for PAH only)*
sildenafil (generic for Revatio) (for PAH only*) ADEMPAS (riociguat)
TRACLEER (bosentan)
OPSUMIT (macitentan)
TYVASO INHALATION (treprostinil)
ORENITRAM ER (treprostinil)NR
VENTAVIS INHALATION (iloprost)
REVATIO SUSPENSION (for PAH only*)
omeprazole (generic for Prilosec) RX only
DEXILANT (dexlansoprazole)
pantoprazole (generic for Protonix)
esomeprazole strontium
lansoprazole (generic for Prevacid)
NEXIUM (esomeprazole)
NEXIUM SUSPENSION (esomeprazole)
omeprazole/sodium bicarbonate
(generic for Zegerid RX)
PREVACID Rx, SOLU-TAB (lansoprazole)
PRILOSEC (omeprazole)
rabeprazole (generic for Aciphex)
BENZODIAZEPINES
estazolam (generic for ProSom)
flurazepam (generic for Dalmane)
temazepam 15mg, 30mg
temazepam 7.5mg, 22.5mg
(generic for Restoril)
triazolam (generic for Halcion)
PREFERRED
DRUGS
acetic acid (generic for Vosol)
antipyrine/benzocaine
(generic similar to Auralgan)
BRAND PRODUCTS IN UPPER CASE generic names in lower case. If only the generic name is listed as preferred, then the BRAND name of that product is nonpreferred; unless the brand name product is ALSO listed as preferred.
*Indicates that a clinical prior authorization is required despite the medication’s status as preferred or non-preferred.
QL indicates quantity limits.
NR indicates product was not reviewed. New Drug criteria will apply.
23
THERAPEUTIC
DRUG CLASS
SKELETAL MUSCLE
RELAXANTS
(Implementation 07/17/2014)
STEROIDS TOPICAL
(Implementation 01/08/2015)
PREFERRED
DRUGS
NON-PREFERRED
DRUGS
OTHERS
zaleplon (generic for Sonata)
EDLUAR (zolpidem sublingual)
zolpidem (generic for Ambien)
eszopiclone (generic for Lunesta)
HETLIOZ (tasimelteon)*
INTERMEZZO (zolpidem)
ROZEREM (ramelteon)
SILENOR (doxepin)
zolpidem ER (generic for Ambien CR)
ZOLPIMIST(zolpidem oral spray)
baclofen (generic for Lioresal)
AMRIX (cyclobenzaprine)*
chlorzoxazone (generic for Parafon)
carisoprodol (generic for Soma)
cyclobenzaprine (generic for Flexeril)
carisoprodol compound
methocarbamol (generic for Robaxin)
dantrolene (generic for Dantrium)
tizanidine TABLETS (generic for Zanaflex)
LORZONE (chlorzoxazone)*
metaxalone (generic for Skelaxin)
orphenadrine (generic for Norflex)
orphenadrine compound
PARAFON FORTE (chlorzoxazone)
SOMA (carisoprodol)*
tizanidine CAPSULES
ZANAFLEX (tizanidine)
(brand name tablets and capsules)
LOW POTENCY
hydrocortisone cream , ointment
alclometasone dipropionate (generic for
Aclovate)
(generic for Cortaid)
CAPEX Shampoo (fluocinolone)
hydrocortisone OTC lotion
DESONATE (desonide gel)
hydrocortisone/aloe ointment, cream
desonide lotion (generic for
Desowen)
desonide cream, ointment
(generic for former products
Desowen, Tridesilon)
fluocinolone 0.01% OIL ( generic for
DERMA-SMOOTHE-FS)
hydrocortisone Rx lotion
hydrocortisone/aloe gel
hydrocortisone/urea
TEXACORT (hydrocortisone)
VERDESO (desonide)
BRAND PRODUCTS IN UPPER CASE generic names in lower case. If only the generic name is listed as preferred, then the BRAND name of that product is nonpreferred; unless the brand name product is ALSO listed as preferred.
*Indicates that a clinical prior authorization is required despite the medication’s status as preferred or non-preferred.
QL indicates quantity limits.
NR indicates product was not reviewed. New Drug criteria will apply.
24
THERAPEUTIC
DRUG CLASS
PREFERRED
DRUGS
NON-PREFERRED
DRUGS
MEDIUM POTENCY
betamethasone valerate (generic
fluticasone propionate cream/ointment
for Luxiq)
(generic for Cutivate)
clocortolone (generic for CLODERM)
mometasone furoate cream, solution,
CORDRAN TAPE (flurandrenolide)
ointment (generic for Elocon)
fluocinolone acetonide (generic for
Synalar)
fluticasone propionate lotion (generic for
Cutivate)
hydrocortisone butyrate (generic for
Locoid)
hydrocortisone butyrate/emoll (generic for
Locoid Lipocream)
hydrocortisone valerate (generic for
Westcort)
MOMEXIN (mometasone)
PANDEL (hydrocortisone probutate 0.1%)
prednicarbate (generic for Dermatop)
HIGH POTENCY
amcinonide cream, ointment, lotion
betamethasone valerate
(generic for Beta-Val)
betamethasone dipropionate
fluocinonide cream, ointment, gel
(generic for Diprolene)
betamethasone dipro/prop gly
fluocinonide emollient
(augmented)
triamcinolone acetonide ointment, cream
desoximetasone (generic for Topicort)
(generic for Kenalog)
diflorasone diacetate
fluocinonide SOLUTION
HALOG (halcinonide)
KENALOG AEROSOL (triamcinolone)
triamcinolone lotion
TRIANEX Ointment (triamcinolone)
VANOS (fluocinonide)
VERY HIGH POTENCY
clobetasol emollient (generic for Temovate-E) APEXICON-E (diflorasone)
clobetasol shampoo, lotion
clobetasol propionate (generic for Temovate)
halobetasol propionate (generic for Ultravate) clobetasol propionate FOAM
CLOBEX (clobetasol)
OLUX-E (clobetasol)
OLUX/OLUX-E CP (clobetasol)
BRAND PRODUCTS IN UPPER CASE generic names in lower case. If only the generic name is listed as preferred, then the BRAND name of that product is nonpreferred; unless the brand name product is ALSO listed as preferred.
*Indicates that a clinical prior authorization is required despite the medication’s status as preferred or non-preferred.
QL indicates quantity limits.
NR indicates product was not reviewed. New Drug criteria will apply.
25
THERAPEUTIC
DRUG CLASS
STIMULANTS AND RELATED
ADHD DRUGS
(Implementation 01/08/2015)
Note: Patients on nonpreferred stimulants prior to
the PDL are eligible for “grandfathering.”
QL= quantity limits may apply to
this class.
PREFERRED
DRUGS
NON-PREFERRED
DRUGS
CNS STIMULANTS
Amphetamine type
ADDERALL XR (amphetamine salt combo)
amphetamine salt combination ER
amphetamine salt combination IR
(generic for Adderall XR)
dextroamphetamine (generic for
Dexedrine)
VYVANSE (lisdexamfetamine)
dextroamphetamine solution (generic for
Procentra)
dextroamphetamine ER (generic for
Dexedrine ER)
methamphetamine (generic for
Desoxyn)
ZENZEDI (dextroamphetamine)
Methylphenidate type
FOCALIN (dexmethylphenidate)
dexmethylphenidate (generic for Focalin)
FOCALIN XR (dexmethylphenidate)
dexmethylphenidate XR (generic for
------------------------------------------------------------Focalin XR)
METHYLIN CHEWABLE (methylphenidate)
--------------------------------------------------------methylphenidate (generic for Ritalin)
methylphenidate solution
------------------------------------------------------------- METHYLIN SOLUTION (methylphenidate)
RITALIN (methylphenidate)
methylphenidate ER 10mg, 20mg
(generic for Ritalin-SR, Metadate ER)
-------------------------------------------------------------------------------------------------------------------- DAYTRANA (methylphenidate patch)
QUILLIVANT XR (methylphenidate
methylphenidate 30/70 (generic for
suspension)
Metadate CD)
methylphenidate 50/50 (generic for
RITALIN LA)
methylphenidate ER
(generic for Ritalin-SR)
--------------------------------------------------------CONCERTA (methylphenidate ER
18mg, 27mg, 36mg, 54mg)
methylphenidate ER 18mg, 27mg,
36mg, 54mg (generic Concerta)
MISCELLANEOUS
Note: generic guanfacine and clonidine
INTUNIV (guanfacine extended release)*
are available without prior authorization.
clonidine ER (generic for Kapvay)*
STRATTERA (atomoxetine)
ANALEPTICS
modafanil (generic for Provigil)*
NUVIGIL (armodafinil)*
BRAND PRODUCTS IN UPPER CASE generic names in lower case. If only the generic name is listed as preferred, then the BRAND name of that product is nonpreferred; unless the brand name product is ALSO listed as preferred.
*Indicates that a clinical prior authorization is required despite the medication’s status as preferred or non-preferred.
QL indicates quantity limits.
NR indicates product was not reviewed. New Drug criteria will apply.
26
THERAPEUTIC
DRUG CLASS
TETRACYCLINES
(Implementation 07/17/2014)
ULCERATIVE COLITIS
(Implementation 07/17/2014)
PREFERRED
DRUGS
NON-PREFERRED
DRUGS
doxycycline hyclate IR (generic for
Vibramycin)
doxycycline monohydrate 50MG, 100MG
capsules
minocycline HCl capsules
(generic for Minocin, Dynacin)
tetracycline HCl (generic for Sumycin)
demeclocycline*
DORYX (doxycycline pelletized)
doxycycline hyclate DR
(generic for Vibratabs)
doxycycline monohydrate TABLET,
SUSPENSION, 75MG and 150MG
CAPSULES
(Monodox, Adoxa)
doxycycline monohydrate (generic for
Oracea)
minocycline HCl tablets
(generic for Dynacin, Murac)
minocycline HCl extended release
(generic for Solodyn)
ORACEA (doxycycline monohydrate)
SOLODYN (minocycline HCl)
VIBRAMYCIN SUSPENSION (doxycycline)
ORAL
ASACOL HD 800mg (mesalamine)
APRISO (mesalamine)
ASACOL (mesalamine) 400MG
DELZICOL DR (mesalamine)
balsalazide (generic for Colazal)
DIPENTUM (olsalazine)
sulfasalazine / DR (generic for Azulfidine)
GIAZO (balsalazide)
LIALDA (mesalamine)
PENTASA (mesalamine)
UCERIS ORAL (budesonide)NR
UCERIS RECTAL FOAM (budesonide)NR
RECTAL
CANASA (mesalamine)
mesalamine
SFROWASA (mesalamine)
BRAND PRODUCTS IN UPPER CASE generic names in lower case. If only the generic name is listed as preferred, then the BRAND name of that product is nonpreferred; unless the brand name product is ALSO listed as preferred.
*Indicates that a clinical prior authorization is required despite the medication’s status as preferred or non-preferred.
QL indicates quantity limits.
NR indicates product was not reviewed. New Drug criteria will apply.