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
Page 1 of 24
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
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
Page 2 of 24
PDL CLASS Preferred Drugs Non-Preferred Drugs Review
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
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
Page 3 of 24
PDL CLASS Preferred Drugs Non-Preferred Drugs Review
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
CARDIOVASCULAR: Angiotensin
Receptor/Calcium Channel Blocker
Combination Agents
Valsartan/Amlodipine Azor® Exforge®
Olmesartan/Amlodipine
Telmisartan/Amlodipine Twynsta®
Sept/Oct
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
Page 4 of 24
PDL CLASS Preferred Drugs Non-Preferred Drugs Review
Date
CARDIOVASCULAR: Angiotensin
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
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
Page 5 of 24
PDL CLASS Preferred Drugs Non-Preferred Drugs Review
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
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
Page 6 of 24
PDL CLASS Preferred Drugs Non-Preferred Drugs Review
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
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
Page 7 of 24
PDL CLASS Preferred Drugs Non-Preferred Drugs Review
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
CENTRAL NERVOUS SYSTEM: Anti-
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
CENTRAL NERVOUS SYSTEM: Analgesics,
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
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
Page 8 of 24
PDL CLASS Preferred Drugs Non-Preferred Drugs Review
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
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
Page 9 of 24
PDL CLASS Preferred Drugs Non-Preferred Drugs Review
Date
CENTRAL NERVOUS SYSTEM: Analgesics,
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
CENTRAL NERVOUS SYSTEM: Analgesics,
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
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
Page 10 of 24
PDL CLASS Preferred Drugs Non-Preferred Drugs Review
Date
Benzodiazepines Intermezzo® Silenor®
Zolpidem ER Zolpidem SL Zolpimist™ Lunesta®
CENTRAL NERVOUS SYSTEM: Sedative
Hypnotics, Non-
Benzodiazepines, Melatonin Receptor
Agonists
Hetlioz® Rozerem®
Dec/Jan
CENTRAL NERVOUS SYSTEM: Anti-
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
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
Page 11 of 24
PDL CLASS Preferred Drugs Non-Preferred Drugs Review
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
DERMATOLOGIC AGENTS: Topical
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
DERMATOLOGIC AGENTS: Topical
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
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
Page 12 of 24
PDL CLASS Preferred Drugs Non-Preferred Drugs Review
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
DERMATOLOGIC AGENTS: Topical
Antivirals
Abreva® OTC Zovirax® Crm
Acyclovir Oint Denavir® Xerese®
Zovirax® Oint
March/April
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
Page 13 of 24
PDL CLASS Preferred Drugs Non-Preferred Drugs Review
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
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
Page 14 of 24
PDL CLASS Preferred Drugs Non-Preferred Drugs Review
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
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
Page 15 of 24
PDL CLASS Preferred Drugs Non-Preferred Drugs Review
Date Testosterone Transderm (gen
Testim®) Vogelxo® Gel/Pump/Packet
ENDOCRINE AND METABOLIC AGENTS: Antihyperglycemic,
Amylin-Analogs
Symlin® Symlin Pen®
June/July
ENDOCRINE AND METABOLIC AGENTS: Antihyperglycemic,
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
ENDOCRINE AND METABOLIC AGENTS: Antihyperglycemic,
Meglitinide
Nateglinide Repaglinide
Prandin® Starlix®
June/July
ENDOCRINE AND METABOLIC AGENTS: Antihyperglycemic,
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
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
Page 16 of 24
PDL CLASS Preferred Drugs Non-Preferred Drugs Review
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
ENDOCRINE AND METABOLIC AGENTS:
Agents for Bone Ossification,
Calcitonin Agents
Calcitonin-Salmon Nasal Miacalcin®
June/July
ENDOCRINE AND METABOLIC AGENTS:
Agents for Bone Ossification, Human
Parathyroid Hormone,
Recombinant & Analogs, RANKL
Inhibitor
Forteo® Natpara® Parsabiv™
Prolia® Tymlos™
June/July
ENDOCRINE AND METABOLIC AGENTS:
Agents for Bone Ossification, SERMS
Evista® Raloxifene
June/July
ENDOCRINE AND METABOLIC AGENTS:
Growth Hormones and Growth Factors
Egrifta® Genotropin®
Increlex® Norditropin®
Nutropin AQ® & Nuspin®
Humatrope® Omnitrope®
Saizen® Serostim®
Tev-Tropin®
Zomacton® Zorbtive®
June/July
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
Page 17 of 24
PDL CLASS Preferred Drugs Non-Preferred Drugs Review
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
ENDOCRINE AND METABOLIC AGENTS:
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
ENDOCRINE AND METABOLIC AGENTS:
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
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
Page 18 of 24
PDL CLASS Preferred Drugs Non-Preferred Drugs Review
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
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
Page 19 of 24
PDL CLASS Preferred Drugs Non-Preferred Drugs Review
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
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
Page 20 of 24
PDL CLASS Preferred Drugs Non-Preferred Drugs Review
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
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
Page 21 of 24
PDL CLASS Preferred Drugs Non-Preferred Drugs Review
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
RENAL and GENITOURINARY:
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
RENAL and GENITOURINARY:
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
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
Page 22 of 24
PDL CLASS Preferred Drugs Non-Preferred Drugs Review
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
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
Page 23 of 24
PDL CLASS Preferred Drugs Non-Preferred Drugs Review
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
RESPIRATORY: PAH-PPH Agents,
Prostacyclins, Inhaled
Ventavis® Tyvaso®
Sept/Oct
RESPIRATORY: PAH-PPH Agents,
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
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
Page 24 of 24
PDL CLASS Preferred Drugs Non-Preferred Drugs Review
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