MO HealthNet Preferred Drug List Effective November 1 ...MO HealthNet Preferred Drug List Effective November 1, 2018 All Therapeutic Classes The MO HealthNet Preferred Drug List is

MO HealthNet Preferred Drug List Effective November 1, 2018

All Therapeutic Classes

The MO HealthNet Preferred Drug List is not all inclusive nor does it guarantee coverage, but represents a summary of prescription coverage. For full criteria details see https://dss.mo.gov/mhd/cs/pharmacy/pages/clinedit.htm

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PDL CLASS Preferred Drugs Non-Preferred Drugs Review

Date

ANTI-INFECTIVES: Antifungals for Onychomycosis

Griseofulvin Susp Terbinafine Tabs

Griseofulvin Caps/Tabs Griseofulvin Ultramicrosize Tabs

Gris-PEG® Itraconazole Caps/Soln

Onmel® Sporanox® Caps/Soln

March/April

ANTI-INFECTIVES: Antifungals for

Thrush

Clotrimazole Troche Fluconazole Tabs/Susp

Nystatin Tabs/Susp

Diflucan® Tabs/Susp Nystatin Pwd

Oravig® Buccal March/April

ANTI-INFECTIVES: Fluoroquinolones,

Oral

Ciprofloxacin Tabs Levofloxacin Tabs

Avelox® Baxdela™

Cipro® Susp

Cipro® Tabs/Susp Cipro® XR

Ciprofloxacin ER Ciprofloxacin Susp

Levaquin® Levofloxacin Soln

Moxifloxacin Ofloxacin

June/July

ANTI-INFECTIVES: GI Antibiotics

Metronidazole Tabs Neomycin

Vancomycin Caps

Dificid® Tabs Firvanq™

Flagyl® Caps/Tabs Metronidazole Caps

Paramomycin

Tindamax® Tinidazole Vancocin® Xifaxan®

June/July

ANTI-INFECTIVES: Hepatitis C Agents, Oral Direct Acting

Antivirals

Epclusa® Mavyret™

Vosevi® (Retreatment Only) Zepatier™

Daklinza™ Harvoni® Sovaldi®

Technivie®

Viekira Pak® Viekira XR™

June/July

Preferred status based on duration of treatment and clinical condition. For full criteria see: https://dss.mo.gov/mhd/cs/pharmacy/pages/clinedit.htm

ANTI-INFECTIVES: Inhaled Antibiotics

Bethkis® Kitabis® Pak

TOBI Podhaler™

Cayston® TOBI®

Tobramycin Inhaled

Tobramycin Pak

March/April

ANTI-INFECTIVES: Antivirals, General

Acyclovir Caps/Tabs Acyclovir Susp

Valacyclovir

Famciclovir Valtrex®

Zovirax® Caps/Tabs Zovirax® Susp

March/April

https://dss.mo.gov/mhd/cs/pharmacy/pages/clinedit.htm




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Date

ANTI-INFECTIVES: Vaginal Antibiotics

Cleocin® Vaginal Ovules Clindesse®

Nuvessa™ Vaginal Gel

Cleocin® Vaginal Crm Clindamycin Vaginal Crm MetroGel Vaginal® Gel

Metronidazole Vaginal Gel Vandazole® Vaginal Gel

June/July

ANTI-INFECTIVES: Cephalosporins, 1st

Generation

Cefadroxil Caps Cephalexin Caps/Susp

Cefadroxil Tabs/Susp Cephalexin Tabs

Keflex®

June/July ANTI-INFECTIVES:

Cephalosporins, 2nd Generation

Cefprozil Tabs/Susp Cefuroxime Tabs

Cefaclor Caps/Susp Cefaclor ER Tabs

Ceftin® Ceftin® Susp

ANTI-INFECTIVES: Cephalosporins, 3rd

Generation

Cefdinir Caps/Susp Suprax® Caps

Suprax® Chew Tabs

Cefixime Susp Cefpodoxime Tabs/Susp

Suprax® Tabs/Susp June/July

ANTI-INFECTIVES: Macrolides

Azithromycin Clarithromycin

E.E.S. 400® Erythromycin Base DR Caps

Clarithromycin ER E-Mycin ERYC®

Ery-Tab® Erythrocin® Stearate

Erythromycin Base Tabs PCE®

Zithromax®

June/July

ANTI-INFECTIVES: Penicillins

Amoxicillin Caps/Susp/Tabs Amoxicillin Chew Tabs

Ampicillin Caps Amox/Clavulanate

Susp/Tabs Amox/Clavulanate XR Bicillin® C-R Injection Penicillin V Susp/Tabs

Amox/Clavulanate Chew Tabs Amox/Clavulanate XR

Ampicillin Susp Augmentin XR™

Augmentin® 125 Susp Dicloxacillin

June/July

ANTI-INFECTIVES: Tetracyclines

Doxycycline Hyclate Caps Doxycycline Hyclate Tabs

Minocycline Caps Vibramycin® Susp

Acticlate® Adoxa®

Coremino® Demeclocycline

Doryx MPC® Doryx®

Doxycycline Hyclate DR Doxycycline Mono Caps/Tabs

Doxycycline Mono IR-DR Doxycycline Mono Susp

Minocin® Minocycline ER

Minocycline Tabs Morgidox® Kits

Okebo™ Oracea®

June/July




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Date Solodyn®

Targadox™ Tetracycline

Vibramycin® Caps Vibramycin® Syrup

Ximino™

CARDIOVASCULAR: Angiotensin

Converting Enzyme Inhibitors (ACEIs)

Benazepril Enalapril

Fosinopril Lisinopril Quinapril Ramipril

Accupril® Altace®

Captopril Epaned®

Fosinopril Lotensin®

Moexipril HCl Perindopril

Prinivil® Qbrelis® Quinapril

Trandolapril Vasotec® Zestril®

Sept/Oct

CARDIOVASCULAR: ACE

Inhibitors/Diuretic Combination Agents

Benazepril/HCTZ Enalapril/HCTZ Lisinopril/HCTZ

Accuretic® Captopril/HCTZ Fosinopril/HCTZ Moexipril/HCTZ Quinapril/HCTZ

Quinaretic® Vaseretic® Zestoretic®

Sept/Oct

CARDIOVASCULAR: ACE

Inhibitors/Calcium Channel Blocker

Combination Agents

Amlodipine/Benazepril Tarka®

Lotrel® Prestalia®

Trandolapril/Verapamil Sept/Oct

CARDIOVASCULAR: Angiotensin Receptor

Blockers (ARBs)

Irbesartan Losartan

Micardis® Valsartan

Atacand® Avapro® Benicar®

Candesartan Cozaar® Diovan® Edarbi®

Eprosartan Olmesartan Telmisartan

Sept/Oct


Receptor/Calcium Channel Blocker

Combination Agents

Valsartan/Amlodipine Azor® Exforge®

Olmesartan/Amlodipine

Telmisartan/Amlodipine Twynsta®

Sept/Oct




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Date


Receptor/Calcium Channel Blocker/

Thiazide Combination Agents

Exforge® HCT Olmesartan/Amlodipine/HCTZ

Tribenzor® Valsartan/Amlodipine/HCTZ Sept/Oct

CARDIOVASCULAR: Angiotensin Receptor

Blocker/Diuretic Combination Agents

Irbesartan/HCTZ Losartan HCTZ Micardis HCT

Valsartan HCTZ

Atacand HCT® Avalide®

Benicar HCT® Candesartan HCTZ

Diovan HCT®

Edarbyclor® Hyzaar®

Olmesartan HCTZ Telmisartan/HCTZ

Sept/Oct

CARDIOVASCULAR: Anticoagulants, Oral

Eliquis® Pradaxa® Savaysa® Warfarin Xarelto®

Coumadin®

Sept/Oct

CARDIOVASCULAR: Anticoagulants,

Injectables

Fragmin® Lovenox®

Arixtra® Enoxaprin

Fondaparinux Sept/Oct

CARDIOVASCULAR: Antiplatelets

Aggrenox® Brilinta®

Clopidogrel Dipyridamole

Aspirin/Dipyridamole Cilostazol Effient® Plavix®

Prasugrel Ticlodipine Yosprala™ Zontivity®

Sept/Oct

CARDIOVASCULAR: Beta-Blockers

Acebutolol Atenolol

Bisoprolol Carvedilol

Labetalol HCl Metoprolol Succinate Metoprolol Tartrate

Propranolol HCl Sotalol

Betapace AF® Betapace®

Betaxolol HCl Bystolic®

Coreg CR® Coreg®

Corgard® Hemangeol® Soln

Inderal LA® Inderal XL®

Inderal® InnoPran XL®

Kapspargo® Sprinkle Caps Levatol®

Lopressor Nadolol

Sept/Oct




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Date Pindolol

Propranolol LA/ER Soln Sorine®

Sotylize® Tenormin®

Timolol Maleate Toprol XL®

CARDIOVASCULAR: Beta-Blocker/

Diuretic Combination Agents

Atenolol/Chlorthalidone Bisoprolol/HCTZ

Metoprolol/HCTZ Propranolol/HCTZ

Corzide® Dutoprol™

Lopressor HCT® Metoprolol ER/ HCTZ

Nadolol/ Bendroflume-thiazide Tenoretic®

Ziac®

Sept/Oct

CARDIOVASCULAR: Calcium Channel

Blockers, Dihydropyridines

Amlodipine Felodipine ER Nifedipine ER Nifedipine IR

Adalat CC® Afeditad CR®

Isradipine Nicardipine HCl

Nimodipine Nisoldipine

Norvasc® Nymalize®

Procardia XL® Procardia®

Sular®

Sept/Oct

CARDIOVASCULAR: Calcium Channel Blockers, Non-

Dihydropyridines

Diltiazem ER Caps Diltiazem HCl Diltiazem XR

Verapamil HCl Verapamil ER Caps/Tabs

Calan SR® Cardizem CD® Cardizem LA® Cardizem SR®

Cartia XT® Dilacor XR®

Dilt CD® Diltia XT®

Diltiazem LA Matzim LA® Taztia XT®

Tiazac® Verapamil 360mg Caps

Verapamil ER PM Verapamil PM

Sept/Oct

CARDIOVASCULAR: Direct Renin Inhibitors &

Combination Agents

Tekturna® Tekturna HCT®

Sept/Oct




Page 6 of 24


Date

CARDIOVASCULAR: Lipotropics,

Homozygous Familial Hypercholesterol-

emia Agents

Juxtapid®

Sept/Oct

CARDIOVASCULAR: Lipotropics, Niacin

Derivatives

Niacor Niacin ER

Niaspan®

Sept/Oct

CARDIOVASCULAR: Lipotropics, Statins

(HMG-CoA Reductase Inhibitors) &

Combination Agents

Atorvastatin Lovastatin Pravastatin

Rosuvastatin Simvastatin

Altoprev® Amlodipine/Atorvastatin

Caduet® Crestor®

Ezetimibe Ezetimibe/Simvastatin

Fluvastatin Fluvastatin ER

Lescol XL® Lipitor® Livalo®

Pravachol® Vytorin®

Zetia® Zocor®

Zypitamag ™

Sept/Oct

CARDIOVASCULAR: Sympatholytic Agents

Catapres-TTS Patch® Clonidine

Guanfacine Methyldopa

Reserpine

Catapres® Tabs Clonidine Transdermal

Lucemyra™ Methyldopa/HCTZ

Sept/Oct

CARDIOVASCULAR: Lipotropics,

Triglyceride Lowering Agents

Gemfibrozil Fenofibrate (gen Lofibra®) 54, 67 , 134, 160, 200mg Fenofibrate (gen Tricor®)

48, 145mg Fenofibric Acid (gen Trilipix®) 45, 135mg

Fenofibrate (gen Antara®) Fenofibrate (gen Fenoglide®)

Fenofibrate (gen Lipofen®) Fenofibric (gen Fibricor®)

Fenoglide® Fibricor® Lipofen® Lofibra®

Lopid® Lovaza®

Omega-3 Acid Ethyl Esters Tricor®

Triglide® Trilipix®

Vascepa®

Sept/Oct




Page 7 of 24


Date

CENTRAL NERVOUS SYSTEM: Agents for

Alzheimers, Cholinesterase

Inhibitors

Donepezil ODT Donepezil 5, 10mg

Exelon® Patch Memantine Tabs

Aricept® Donepezil 23mg

Galantamine Galantamine ER

Memantine Dose Pack Memantine ER

Memantine Soln

Namenda XR® Namenda® Tabs/Soln

Namzaric® Razadyne ER®

Razadyne® Tabs Rivastigmine Caps/Patch

Dec/Jan

CENTRAL NERVOUS SYSTEM: Anti-

Parkinsonism Agents, Non-Ergot Dopamine

Agonists

Pramipexole Ropinirole

Mirapex ER® Mirapex® Neupro®

Pramipexole ER

Requip XL® Requip®

Ropinirole ER

Dec/Jan


Parkinsonism Agents, Monoamine Oxidase

B Inhibitors

Azilect® Rasagiline Selegiline

Xadago® Zelapar® ODT

Dec/Jan

CENTRAL NERVOUS SYSTEM: Analgesics,

Cox-II Inhibitor Agents

Celecoxib Celebrex®

Dec/Jan


NSAIDS

Diclofenac Sodium Diclofenac ER

Diclofenac 1% Topical Soln Flector® Patch

Ibuprofen Chew Tabs OTC Ibuprofen OTC/Rx

Ibuprofen Susp/Drops OTC Ketorolac

Meloxicam Tabs Naproxen

Naproxen Sodium OTC

Arthrotec® Cambia®

Diclofenac Potassium Diclofenac Sodium Gel Diclofenac/Misoprostol

Diflunisal Duexis® Etodolac

Etodolac ER Fenoprofen Flurbiprofen

Indocin® Indocin® Supp Indomethacin

Indomethacin ER Ketoprofen

Ketoprofen ER Meclofenamate Mefenamic Acid

Dec/Jan




Page 8 of 24


Date Meloxicam Susp

Mobic® Nabumetone

Nalfon® Naprelan®

Naproxen CR Naproxen Sodium Rx

Oxaprozin Pennsaid® Pump

Piroxicam Sprix®

Sulindac Tivorbex™

Tolmetin Sodium Vimovo®

Vivlodex™ Voltaren Gel®

Zipsor® Zorvolex™

CENTRAL NERVOUS SYSTEM: Analgesics, Opioids, Long Acting

Narcotics

Butrans® Embeda®

Fentanyl Patch (12, 25, 50, 75, 100mcg)

Hysingla® ER Morphine Sulfate ER Tabs

OxyContin®

Arymo® ER Belbuca® Film

Buprenorphine Patch Duragesic®

Exalgo® Fentanyl Patch 37.5, 62.5,

87.5mcg Hydromorphone ER

Kadian®

Morphabond™ ER Morphine ER Caps (gen Kadian)

MS Contin® Oxycodone ER

Oxymorphone ER Xtampza ER™ Zohydro® ER

Dec/Jan

CENTRAL NERVOUS SYSTEM: Analgesics, Opiate Dependence

Agents

Naltrexone Tabs Suboxone® Film

Vivitrol®

Bunavail® Buprenex®

Buprenorphine SL Tabs Buprenorphine/Naloxone SL

Film Buprenorphine/Naloxone SL

Tabs

Sublocade™ Zubsolv®

Dec/Jan

CENTRAL NERVOUS SYSTEM: Analgesics, Opiate Emergency

Reversal Agents

Narcan® Nasal Spray Naltrexone Syringe/Vial

Dec/Jan




Page 9 of 24


Date


Tramadol Like Agents

Tramadol Tramadol ER Tabs (gen

Ultram® ER) Tramadol/APAP

ConZip® Nucynta®

Nucynta® ER Tramadol ER Caps/Tabs (gen

Ryzolt®) Ultracet® Ultram®

Dec/Jan

CENTRAL NERVOUS SYSTEM: Analgesics, Fibromyalgia Agents

Duloxetine Lyrica® Caps

Cymbalta® Duloxetine 40mg

Lyrica® CR Lyrica® Soln

Savella®

Dec/Jan


Neuropathic Pain Agents

Gabapentin Tabs/Caps Lidocaine 5% Patch

Gabapentin Soln Gralise®

Horizant® Lidoderm® Neurontin® Qutenza®

Dec/Jan

CENTRAL NERVOUS SYSTEM:

Antipsychotics, Depot Formulations

Abilify Maintena™ Aristada®

Aristada Initio™ Invega Sustenna®

Invega Trinza® Perseris™

Risperdal Consta® Zyprexa® Relprevv™

Dec/Jan

CENTRAL NERVOUS SYSTEM: Multiple Sclerosis Agents

Aubagio®** Avonex® Dose Pack

Betaseron® Copaxone® 20mg Syringe

Gilenya®** Rebif ®

Rebif® Rebidose®

Copaxone® 40mg Syringe Extavia®

Glatiramer 20mg/ml Glatiramer 40mg/ml Glatopa™ 20mg/ml Glatopa™ 40mg/ml

Lemtrada® Vial Ocrevus™

Plegridy® Tecfidera® Tysabri®

June/July

**Pending trial of one injectable agent

CENTRAL NERVOUS SYSTEM: Sedative

Hypnotics, Benzodiazepines

Temazepam 15, 30mg Estazolam Flurazepam

Halcion® Restoril™

Temazepam 7.5, 22.5mg Triazolam

Dec/Jan

CENTRAL NERVOUS SYSTEM: Sedative Hypnotics, Non-

Eszopiclone Zaleplon

Zolpidem Tabs

Ambien CR® Ambien®

Belsomra® Edluar®

Dec/Jan




Page 10 of 24


Date

Benzodiazepines Intermezzo® Silenor®

Zolpidem ER Zolpidem SL Zolpimist™ Lunesta®

CENTRAL NERVOUS SYSTEM: Sedative

Hypnotics, Non-

Benzodiazepines, Melatonin Receptor

Agonists

Hetlioz® Rozerem®

Dec/Jan


Migraine, Serotonin (5-HT1) Receptor

Agonists

Relpax® Rizatriptan ODT/Tabs

Sumatriptan Car/Kit/Syringe/Vial

Sumatriptan Nasal Spray Sumatriptan Tabs

Almotriptan Amerge® Eletriptan

Frova® Frovatriptan

Imitrex® Car/Kit/Syringe/Vial Imitrex® Nasal Spray/Tabs

Maxalt® Maxalt-MLT® Naratriptan

Onzetra® Xsail® Sumatriptan/Naproxen

Sumavail® DosePro® Treximet®

Zembrace™ Symtouch™ Zolmitriptan ODT/Tabs

Zomig® Nasal Spray/Tabs Zomig-ZMT®

Dec/Jan

CENTRAL NERVOUS SYSTEM: Skeletal Muscle Relaxants

Baclofen Chlorzoxazone

Cyclobenzaprine Methocarbamol Orphenadrine ER Tizanidine Tabs

Amrix® Carisoprodol

Carisoprodol/ASA Dantrium® Dantrolene

Fexmid® Lorzone®

Metaxalone Robaxin® Skelaxin®

Soma® Tizanidine Caps

Zanaflex®

Dec/Jan




Page 11 of 24


Date

DERMATOLOGIC AGENTS: Topical

Agents for Psoriasis

Calcipotriene Soln Dovonex® Crm

Vectical®

Calcipotriene Crm/Oint Calcipotriene/Betamethasone

Calcitriene® Calcitriol Oint

Dovonex® Enstilar®

Sorilux® Foam Taclonex® Oint

Taclonex® Scalp®

March/April


Agents for Actinic Keratosis

Fluorouracil 5% Crm (gen Efudex®)

Fluorouracil Soln Imiquimod (gen Aldara®)

Aldara® Carac®

Diclofenac 3% Gel Efudex® Crm

Fluorouracil 0.5% Crm (gen Carac®)

Imiquimod 3.75% (gen Zyclara Pump) Picato®

Solaryze 3% Tolak™

Zyclara®

March/April


Antibiotic/Benzoyl Peroxide

BenzaClin w/Pump® Clindamycin/Benzoyl Peroxide (gen Duac)

Erythromycin/Benzoyl Peroxide (gen Benzamycin)

Acanya Gel® BenzaClin®

Clindamycin/Benzoyl Peroxide (gen Acanya Gel® Pump)

Clindamycin/Benzoyl Peroxide

(gen BenzaClin)

Duac® Neuac Gel®

Onexton Gel®

March/April

DERMATOLOGIC AGENTS: Topical Anti-

Fungals

Butenafine 1% Crm OTC Ciclopirox Crm/Soln

Clotrimazole Crm/Soln OTC Clotrimazole Crm

Clotrimazole/ Betamethasone Crm

Ketoconazole Crm/Shampoo

Lamisil AT® Crm OTC Lotrimin® AF Crm OTC

Miconazole Crm/Pwd OTC Nystatin Crm/Oint/Pwd

Terbinafine Crm OTC Tolnaftate Crm/Soln OTC

Alevazol® OTC Azolen™ Tincture OTC

Bensal HP® CicloDan® & Kit Ciclopirox 8% Kit

Ciclopirox Solution Ciclopirox Gel/Shampoo/Kit

Clotrimazole Soln Rx Clotrimazole/Betamethasone

Lot CNL8™ Nail Kit

Dermacin Rx Therazole® pak Desenex® Pwd OTC

Econazole Cream/Foam Ecoza™ Foam

Ertaczo® Excelderm® Crm/Soln

Extina® Fungi-Nail® OTC

March/April




Page 12 of 24


Date Fungoid® Kit OTC

Jublia® Kerydin™

Ketodan Foam Kit Lamisil Ultra® OTC

Lamisil® Gel/Spray OTC Loprox®

Crm/Gel/Kit/Susp/Shampoo Lotrimin® AF Crm OTC

Lotrisone® Crm Luliconazole 1% Crm

Luzu® Crm Mentax®

Miconazole Nitrate OTC Miconazole Oint/Spray OTC

Naftifine Crm Naftin® Crm/Gel

Nizoral® AD Shampoo Nizoral® Shampoo

Nystatin-TAC Crm/Oint Oxiconazole Crm Oxistat® Crm/Lot Pediaderm™ AF

PediPak® Pediprox-4 Nail Kit

Penlac® Sponix® OTC

Tinactin® Crm/Pwd/Spray OTC Tolnaftate Pwd/Spray OTC

Vusion® Xolegel®

DERMATOLOGIC AGENTS: Topical Antiparasitics,

Treatment of Lice & Scabies

Natroba™ Permethrin OTC/Rx Crm

Sklice®

Crotan™ 10% Lot Elimite™ Crm

Eurax® Lindane

Malathion Lot

Nix® Complete Kit Ovide®

Spinosad Ulesfia®

March/April


Antivirals

Abreva® OTC Zovirax® Crm

Acyclovir Oint Denavir® Xerese®

Zovirax® Oint

March/April




Page 13 of 24


Date

DERMATOLOGIC AGENTS: Topical Corticosteroids

Alclometasone Dip Crm/Oint

Betamethasone Dip Crm/Lot

Betamethasone Val Crm/Lot/Oint

Beta-Val Crm/Lot Clobetasol Emollient

Clobetasol Prop Crm/Gel/Oint/Soln

Fluticasone Prop Crm/Oint Hydrocortisone Rx

Crm/Oint/Lot Hydrocortisone OTC

Crm/Oint Mometasone Fur

Crm/Oint/Soln Triamcinolone Crm/Oint/Lot

Amcinonide Crm Apexicon E®

Betamet Dip Prop Gly Crm/Lot/Oint

Betamethasone Dip Gel/Oint Betamethasone Val Foam

Capex® Shampoo Clobetasol Emollient

Clobetasol Prop Foam/Spray Clobex® Lot/Shampoo

Clobex® Spray Clocortolone Crm

Cloderm® Cordran® Oint/Tape

Cutivate® Lot DermacinRx® Silapak Derma-Smoothe FS®

Dermatop® Crm/Oint Desonate® Gel

Desonide Crm/Oint/Lot Desonil Plus

Desowen® Crm/Oint/Lot Desoximetasone 0.25% Spray

Desoximetasone Crm/Gel/Oint Diflorasone Discet Crm/Oint

Diprolene® Lot Ellzia® Pak

Elocon® Crm/Oint/Soln Fluocinolone Crm/Oint/Soln

Fluocinonide Crm/Gel/Oint/Soln Fluocinonide Emollient

Flurandrenolide Crm/Oint/Lot Halobetasol Prop Crm/Oint

Hydrocortisone Buty Crm/Emol/Oint/Soln/Lot

Hydrocortisone Min Oil/Petrolat Oint

Hydrocortisone Val Crm/Oint Hydrocortisone/Urea Hydrocortosone/Aloe

Impoyz Kenalog® Aerosol Locoid Lipocream®

Luxiq® Micort-HC®

Nolix™ Olux-E® Pandel®

Pediaderm™ HC/TA Prednicarbate Crm/Oint

March/April




Page 14 of 24


Date Psorcon®

Sernivo™ Spray Silazone-II™

Synalar® Crm/Oint Topicort® Crm/Oint/Spray Triamcinolone Acetonide

Aerosol Triamcinolone Acetonide/

Dimeth Trianex® Oint

Tridesilon® Ultravate® Lot

Ultravate® Pac Crm/Oint Ultravate® Pac X Crm/Oint

Vanos® Verdeso®

DERMATOLOGIC AGENTS: Atopic

Dermatitis

Elidel® Eucrisa™

Dupixent®

Protopic® Tacrolimus

March/April

DERMATOLOGIC AGENTS: Topical Retinoid Agents

Differin® Crm/Lot Differin® Gel/Pump Retin-A® Crm/Gel

Tazorac® Gel

Adapalene 0.1% Crm/Gel/Lot/Soln

Adapalene/Benzoyl Peroxide Atralin® Avita®

Clindamycin/Tretinoin Differin® Gel OTC

Epiduo® Epiduo® Forte

Fabior®

Plixda™ Retin-A® Micro® Gel/Pump

Tazorac® Crm Tazarotene Crm

Tretinoin Crm/Gel Tretinoin Micro Gel

Tretin-X Veltin® Ziana®

March/April

ENDOCRINE AND METABOLIC AGENTS: Topical Androgenic

Agents

Androderm®Gel Patch Androgel® Pump

Androgel® Pack Axiron®

Fortesta® Testim®

Testosterone (gen Androgel® Pump)

Testosterone (gen Androgel®)

Testosterone Gel (gen Fortesta®)

Testosterone Gel Pump (gen Axiron®)

March/April




Page 15 of 24


Date Testosterone Transderm (gen

Testim®) Vogelxo® Gel/Pump/Packet

ENDOCRINE AND METABOLIC AGENTS: Antihyperglycemic,

Amylin-Analogs

Symlin® Symlin Pen®

June/July


GLP-1 Receptor Agonist

Bydureon® Byetta® Victoza®

Adlyxin™ Bydureon® Bcise™ Auto Injector

Ozempic®

Trulicity® June/July

ENDOCRINE AND METABOLIC AGENTS: Antihyperglycemic, Alpha Glucosidase

Inhibitor

Acarbose Glyset®

Miglitol® Precose®

June/July


Meglitinide

Nateglinide Repaglinide

Prandin® Starlix®

June/July


Biguanide & Combination Agents

Glipizide/Metformin Glyburide/Metformin

Metformin HCl Metformin ER (gen

Glucophage XR)

Fortamet ER® Glucophage XR®

Glucophage® Glumetza ER®

Metformin ER (gen Fortamet OSM)

Metformin ER (gen Glumetza MOD)

Metformin Soln (gen Riomet®)

Repaglinide/Metformin Riomet®

June/July

ENDOCRINE AND METABOLIC AGENTS: Antihyperglycemic, DPP-IV (Dipeptidyl

Peptidase-4) Inhibitors &

Combination Agents

Glyxambi® Januvia®

Janumet® Janumet XR® Jentadueto®

Kombiglyze XR® Onglyza®

Tradjenta®

Alogliptin Alogliptin/Metformin

Alogliptin/Pioglitazone Jentadueto XR®

Kazano® Nesina™

Oseni

Qtern® Steglujan™

June/July

ENDOCRINE AND METABOLIC AGENTS: Antihyperglycemic, SGLT2-Inhibitors &

Combination Agents

Farxiga™ Invokana® Jardiance® Synjardy®

Synjardy XR®

Invokamet XR® Invokamet®

Segluromet™ Steglatro™

XigDuo XR®

June/July




Page 16 of 24


Date

ENDOCRINE AND METABOLIC AGENTS: Antihyperglycemic, Thiazolidinediones

(TZDs) & Combination Agents

Pioglitazone Actos® ActosplusMet XR®

ActosplusMet® Avandia®

Duetact® Pioglitazone/Glimepiride Pioglitazone/Metformin

June/July

ENDOCRINE AND METABOLIC AGENTS:

Agents for Bone Ossification,

Bisphosphonates

Alendronate Tabs Ibandronate Tabs

Actonel® Tabs Alendronate Soln

Atelvia® Binosto®

Boniva® Tabs Didronel® Etidronate

Fosamax Plus D® Fosamax®

Risedronate

June/July


Agents for Bone Ossification,

Calcitonin Agents

Calcitonin-Salmon Nasal Miacalcin®

June/July


Agents for Bone Ossification, Human

Parathyroid Hormone,

Recombinant & Analogs, RANKL

Inhibitor

Forteo® Natpara® Parsabiv™

Prolia® Tymlos™

June/July


Agents for Bone Ossification, SERMS

Evista® Raloxifene

June/July


Growth Hormones and Growth Factors

Egrifta® Genotropin®

Increlex® Norditropin®

Nutropin AQ® & Nuspin®

Humatrope® Omnitrope®

Saizen® Serostim®

Tev-Tropin®

Zomacton® Zorbtive®

June/July




Page 17 of 24


Date

ENDOCRINE AND METABOLIC AGENTS: Antihyperglycemic, Oral Sulfonylurea,

2nd Generation

Glimepiride Glipizide

Glipizide ER Glyburide

Glyburide Micronized

Amaryl® Glucotrol XL®

Glucotrol® Glynase® PresTab®

June/July


Insulins

Humulin® N Vials Humulin® R Vials

Humulin® R 500 u/ml Pen/Vial

Novolin® N Vials Novolin® R Vials

Humulin® N Pen Humulin® R Pen

ReliOn N ReliOn R June/July

ENDOCRINE AND METABOLIC AGENTS: Insulins, Long-Acting

Lantus® Vial Lantus® Solostar® Pen

Levemir® Vial Levemir® FlexTouch® Pen

Basaglar® KwikPen Toujeo® Solostar® Pen Tresiba® Flextouch Pen June/July


Insulins, Mix

Humalog® Mix 75/25 Pen/Vial

Humalog® Mix 50/50 Pen/Vial

Humulin® 70/30 Vial Novolog® Mix 70/30

Pen/Vial

Humulin® 70/30 Pen Novolin® 70/30 Vial

ReliOn 70/30

June/July

ENDOCRINE AND METABOLIC AGENTS: Insulins, Rapid-Acting

Humalog® Cartridge/Vial Novolog®

Cartridge/Pen/Vial

Afrezza® Cartridge Apidra® Solostar® Pen

Apidra® Vial Humalog 200 u/ml KwikPen®

Humalog KwikPen®

June/July

ENDOCRINE AND METABOLIC AGENTS: Antihyperglycemic, Insulin, Long Acting

Analog & GLP-1 Agonist

Soliqua® Xultophy®

June/July

ENDOCRINE AND METABOLIC AGENTS: Antihyperurecemic

Agents

Allopurinol Mitigare®

Probenecid Probenecid/Colchicine

Colchicine Caps/Tabs Colcrys® Duzallo® Uloric®

Zurampic® Zyloprim®

June/July




Page 18 of 24


Date

GASTROINTESTINAL: Antiemetics, 5-HT3

Agents & Other

Diclegis® Ondansetron

Ondansetron ODT

Aloxi® Akynzeo® Anzemet® Aprepitant Bonjesta ® Cesamet® Emend®

Emend® Pack/Pwd Packet Metoclopramide

Metoclopramide ODT Palonosetron (IV)

Sancuso® Varubi® Zofran®

Zuplenz®

Dec/Jan

GASTROINTESTINAL: Bile Salt Agents

Ursodiol Tabs Actigall® Chenodal® Cholbam® Ocaliva®

Urso Forte® Urso®

Ursodiol Caps

June/July

GASTROINTESTINAL: IBS-C/CIC Agents

Amitiza® Linzess®

Trulance® Dec/Jan

GASTROINTESTINAL: Agents for Opioid

Induced Constipation, Opioid Antagonists

Movantik® Relistor Tab/Inj Symproic®

Dec/Jan

GASTROINTESTINAL: IBS Agents, Anti-

Diarrheal

Alosetron Lotronex®

Viberzi® Dec/Jan

GASTROINTESTINAL: Pancreatic Enzymes

Creon® Pancrelipase

Zenpep®

Pancreaze® Pertzye® Viokace®

March/April

GASTROINTESTINAL: Proton Pump

Inhibitors

Esomeprazole Rx Caps Lansoprazole Rx Caps

Nexium® Rx Susp Omeprazole Rx Pantoprazole Prilosec OTC

Protonix Susp

Aciphex® Aciphex® Sprinkle

Dexilant™ DR Esomeprazole Magnesium

Esomeprazole OTC Esomeprazole Strontium Lansoprazole ODT/Soln

Lansoprazole OTC Nexium® OTC/Rx Caps

Omeprazole Magnesium OTC Omeprazole OTC

Omeprazole/Bicarb Rx Prevacid®

Sept/Oct




Page 19 of 24


Date Prevacid® DR OTC Prevacid® Solutab

Prevacid® Susp Prilosec® Rx

Protonix® Rabeprazole Sodium

Zegerid® & OTC

GASTROINTESTINAL: Ulcerative Colitis

Agents, Oral

Balasalazide Delzicol® Lialda®

Sulfasalazine DR & IR

Apriso® Asacol HD®

Azulfidine EN® Azulfidine®

Budesonide (gen Uceris) Colazal®

Dipentum® Mesalamine (gen Asacol HD®)

Mesalamine (gen Lialda®) Pentasa® Uceris®

March/April

GASTROINTESTINAL: Ulcerative Colitis

Agents, Rectal

Canasa® Rect Supp Rowasa® Enema/Kit

Mesalamine Enema/Kit sfRowasa® Enema

Uceris® Foam March/April

HEMATOLOGICAL AGENTS:

Erythropoiesis Stimulating Agents

(ESAs)

Aranesp® Epogen® Procrit®

Mircera® Retacrit®

June/July

IMMUNOLOGIC AGENTS: Systemic

Immunomodulators, Cryopyrin-Associated

Periodic Syndrome (CAPS) Agents

Ilaris® Arcalyst®

June/July

IMMUNOLOGIC AGENTS: Targeted

Immune Modulators (Biologics/DMARDS)

Arava® Enbrel® Humira®

Leflunomide Ridaura®

Cosentyx®

Actemra® Benlysta® Cimzia® Entyvio® Ilumya™

Inflectra™ Kevzara® Kineret®

Oluminant® Orencia® & Clickjet®

Otezla® Remicade® Renflexis™

Siliq™ Simponi® & Aria®

June/July




Page 20 of 24


Date Stelara® Taltz®

Tremfya™ Xeljanz®

Xeljanz® XR

OPHTHALMIC: Antihistamines

Alaway® OTC Ketotifen OTC

Olopatadine (gen Patanol®) Pazeo®

Zaditor® OTC

Azelastine 0.05% Bepreve® Elestat®

Emadine® Epinastine Lastacaft®

Olopatadine (gen Pataday®) Optivar® Pataday® Patanol®

March/April

OPHTHALMIC: Mast Cell Stabilizers

Cromolyn Sodium Ophthalmic

Alocril® Alomide® March/April

OPHTHALMIC: NSAIDS

Diclofenac Flurbiprofen Sodium

Ilevro® Ketorolac Ophth 0.4%, 0.5%

Acular LS® Acular® Acuvail®

Bromfenac

Bromsite™ Nevanac® Prolensa®

March/April

OPHTHALMIC: "Soft" Corticosteroids

Durezol®

Alrex® Lotemax® Drops/Gel/Oint March/April

OPHTHALMIC: Glaucoma,

Prostaglandin Agonists

Latanoprost Travatan-Z®

Bimatoprost Lumigan® Travaprost Vyzulta™ Xalatan® Zioptan®

March/April

OPHTHALMIC: Glaucoma, Rho Kinase (ROCK

Inhibitors)

Rhopressa®

March/April

OPHTHALMIC: Glaucoma, Alpha 2

Receptor Agonist/Carbonic

Anhydrase Inhibitor (CAI)

Simbrinza®

March/April

OPHTHALMIC: Antibiotics,

Fluoroquinolones

Ciprofloxacin HCl Drops Moxeza®

Ofloxacin Drops Vigamox®

Besivance® Ciloxan® Drops/Oint

Gatifloxacin 0.5% Levofloxacin 0.5%

Moxifloxacin (gen Vigamox®)

March/April




Page 21 of 24


Date Ocuflox® Drops

Zymaxid®

OTIC PREPARATIONS: Fluoroquinolone &

Combination Agents

CiproDex® Cipro HC® Ciprofloxacin Otic Ofloxacin Otic 3%

Otovel™

March/April

RENAL and GENITOURINARY:

BPH Inhibitors

Alfuzosin Doxazosin

Dutasteride Finasteride 5mg

Tamsulosin Terazosin

Avodart® Cardura®

Cardura® XL Cialis®

Dutasteride/Tamsulosin Flomax®

Jayln® Proscar® Rapaflo® Tadalafil

Uroxatral®

June/July


Electrolyte Depleters, Phosphate Lowering

Agents

Calcium Acetate Caps Eliphos® Renagel®

Renvela® Tabs

Auryxia™ Calcium Acetate Tabs OTC/Rx

Calphron® Fosrenol® Tabs/Pwd

Lanthanum Carbonate Phoslyra®

Renvela® Pwd Pack Sevelamer Carbonate Tabs

Sevelamer Pwd Pack Velphoro®

June/July


Urinary Tract Antispasmodics

Enablex® Oxybutynin

Oxybutynin ER Toviaz®

Vesicare®

Darifenacin ER Detrol/Detrol LA®

Ditropan XL® Flavoxate Gelnique®

Myrbetriq® Oxytrol® for Women

Oxytrol® OTC/Rx

Tolterodine Tolterodine ER

Trospium/Trospium ER Urispas®

Urogesic Blue™

June/July

RESPIRATORY: Anticholinergics, Long

Acting

Spiriva HandiHaler® Seebri Neohaler®

Incruse Ellipta® Lonhala™ Magnair™

Spiriva Respimat® Tudorza Pressair®

March/April




Page 22 of 24


Date

RESPIRATORY: Anticholinergics, Short Acting, &

Combination Agents

Atrovent HFA® Combivent Respimat®

Ipratropium Soln Ipratropium-Albuterol

March/April

RESPIRATORY: Anticholinergics,

LABA Combination Agents

Bevespi Aerosphere™ Stiolto Respimat® Utibron Neohaler®

Anoro Ellipta®

March/April

RESPIRATORY: Anticholinergics,

LABA/ICS Combination Agents

Trelegy Ellipta®

March/April

RESPIRATORY: PDE4 Inhibitor for COPD,

Oral

Daliresp®

March/April

RESPIRATORY: Beta-Adrenergic Agents,

Long Acting

Serevent® Arcapta® Neohaler® Brovana®

Perforomist® Striverdi® Respimat®

March/April

RESPIRATORY: Beta Adrenergic Agonists,

Short-Acting, Nebulized

Albuterol Sulfate Levalbuterol Xopenex®

March/April

RESPIRATORY: Beta-Adrenergic Agents,

Short Acting

ProAir HFA® Proventil HFA®

Levalbuterol HFA ProAir Respiclick®

Ventolin HFA® Xopenex HFA®

March/April

RESPIRATORY: Self Injectable

Epinephrines

Epinephrine Inj (gen EpiPen®)

Epinephrine Inj (gen EpiPen Jr.®)

EpiPen Jr.® EpiPen®

March/April

RESPIRATORY: Inhaled

Corticosteroids (ICS)

Asmanex® Twisthaler Flovent HFA®

Pulmicort® Respules

Aerospan® HFA Alvesco®

Armonair™ Respiclick® Arnuity Ellipta® Asmanex® HFA

Budesonide Respules Flovent Diskus®

Pulmicort® Flexhaler Q-VAR®

Q-VAR® Redihaler™

March/April

RESPIRATORY: Inhaled

Corticosteroid, Long Acting Beta Agonist

(ICS-LABA)

Advair Diskus® Dulera®

Symbicort®

Advair HFA® AirDuo™ Respiclick®

Breo Ellipta™

Fluticasone/Salmeterol March/April




Page 23 of 24


Date

RESPIRATORY: Intranasal

Antihistamine

Azelastine Nasal

Astepro® Olopatadine Patanase®

March/April

RESPIRATORY: Intranasal Steroids

Fluticasone Nasacort® OTC

Beconase AQ® Budesonide Nasal

Dymista® Flonase Rx/OTC

Flonase® Sensimist™ Flunisolide

Fluticasone OTC Mometasone Furoate

Nasonex® Rx Omnaris®

Qnasl® Rhinocort Allergy OTC

Rhinocort AQ Sinuva™

Ticanase™ Triamcinolone Nasal

Triamcinolone Nasal OTC Xhance™ Zetonna®

March/April

RESPIRATORY: Leukotriene Receptor

Modifiers

Montelukast Tabs/Chew Montelukast Gran Pack

Accolate® Singulair® Gran Pak

Singulair® Tabs/Chew Zafirkulast

Zileuton ER Zyflo CR®

Zyflo®

March/April

RESPIRATORY: PAH-PPH Agents,

Prostacyclins, IV/SQ

Epoprostenol Flolan® Remodulin®

Veletri® Sept/Oct


Prostacyclins, Inhaled

Ventavis® Tyvaso®

Sept/Oct


Prostacyclins, Oral

Orenitram® ER Uptravi® Sept/Oct

RESPIRATORY: PAH-PPH Agents, ETRA

Letairis® Tracleer®

Opsumit® Sept/Oct

RESPIRATORY: PAH-PPH Agents, PDE5-I &

SGCS

Sildenafil Tabs Adcirca® Adempas®

Revatio® Tab/Inj

Sildenafil Inj Tadalafil

Sept/Oct

RESPIRATORY: Antihistamines, 2nd

Cetirizine OTC Tabs Cetirizine Rx Soln

Allegra® Allegra® ODT March/April




Page 24 of 24


Date

Generation Levocetirizine Rx Tabs Loratadine OTC Tabs/Soln

Loradatine Tabs RapDis OTC

Allegra® ODT OTC Allegra® OTC

Cetirizine OTC Caps/Chew Tabs Cetirizine OTC Soln

Clarinex® Clarinex® Syrup

Clarinex® Tabs RapDis Claritin® Rx

Claritin® Syrup Rx Claritin® Tabs RapDis Rx

Desloratadine Fexofenadine

Fexofendaine OTC Levocetirizine Soln Rx

Levocetirizine Tabs OTC Loratadine OTC Caps

Loratadine OTC Chew Tabs Xyzal® OTC

Xyzal® Rx Zyrtec®

Zyrtec® OTC Zyrtec® Syrup

RESPIRATORY: Antihistamines, 2nd

Generation, & Decongestant

Combination Agents

Cetirizine-D OTC Loratadine-D OTC

Alavert-D Allegra-D® Rx/OTC

Clarinex-D®

Claritin-D® Rx Fexofenadine-PSE

Semprex-D® Zyrtec-D®

March/April

MISC: Methotrexate Products

Methotrexate PF Vials Methotrexate Tabs Methotrexate Vials

Otrexup™ Auto-Injector Rasuvo® Auto-Injector

Trexall® Tabs

Xatmep™ Soln

June/July

Documents

MO HealthNet Preferred Drug List Effective November 1 ...MO HealthNet Preferred Drug List Effective November 1, 2018 All Therapeutic Classes The MO HealthNet Preferred Drug List is