Jan. 2019 Preferred Drug List and PA Criteria

Transcript

1 Medicaid Pharmacy Prior Authorization & Preferred Drug List About Contents People • Medicaid or Medicaid enrolled in either traditional managed care adhere to the same formulary . Some 1 About ... drugs on the formulary may require prior authorization, 1 ... Formulary . , or clinical , non-preferred either both 2 ... Preferred Drug List people Pharmacy prior authorization services for o Clinical P rior Authorization ... 3 enrolled in Medicaid managed care are ... 3 PDL Prior Authorization administered by th managed care e person’s organization 4 Obtaining PDL/Clinical Prior Authorization ... o Traditional Medicaid prior authorizations are Medicaid Managed Care ... 4 administered by the Texas Prior Authorization Call . 4 Traditional Medicaid ... Center. Texas Medicaid Drug Utilization Review Board . 5 Formulary ... Education 5 5 Updates ... Medicaid formulary The - -the • includes legend and over counter drugs. In addition certain supplies and select vitamin and mineral products are also available as a pharmacy benefit. Some drugs are subject to one or both types of prior authorization, clinical and preferred. non- The Formulary Search identifies the list of covered Medicaid and CHIP drugs and whether a drug • requires a . and/or a clinical prior authorization preferred o txvendordrug.com/formulary/formulary -search . 5 pol -mpapdl TxVendorDrug.com PAGE 1 OF

2 Medicaid Pharmacy Prior Authorization & Preferred Drug List Preferred Drug List is arranged by drug therapeutic class and contains a subset of many, but • The preferred drug list ” or “non- “preferred not all, drugs that are on the Medicaid formulary. Most drugs are identified as “preferred as list ”. Drugs listed on the preferred ” or not listed at all are available to all people without prior authorization unless there is a clinical prior authorization associated with that drug. (CHIP drugs are not subject to PDL requirements.) -drugs txvendordrug.com/formulary/prior- authorization/preferred o • The PDL Prior Authorization Criteria Guide explains t he criteria used to evaluate prior requests authorization o paxpress.txpa.hidinc.com/pdl_crit_guide.pdf list gs that require clinical prior authorization are hyperlinked within the Dru • , as shown in the . Links will take the user to the specific clinical prior authorization document example entry below the with a narrative that explains purpose and requirements. LASS HERAPEUTIC T C AME N Preferred Agents Non -Preferred Agents Prior Authorization Criteria Treatment failure with preferred drugs within any subclass • bacitracin packet bacitracin ointment • Contraindication to preferred drugs BACTROBAN (mupirocin) cream BACTROBAN (mupirocin) Allergic reaction to preferred drugs • ointment • Clinical Prior Authorization applies pol 5 -mpapdl TxVendorDrug.com PAGE 2 OF

3 Medicaid Pharmacy Prior Authorization & Preferred Drug List Clinical Prior Authorization Clinical prior authorizations • may apply to any individual drug or an entire drug class on the formulary, There are certain clinical prior preferred drugs. including some preferred and non- are required to perform. Usage of all other clinical s that all managed care health plans authorization health plan health plans at the s will vary between prior authorization . n of each discretio • All are approved by the Texas Medicaid Drug Utilization Board. For Medicaid managed care: • -c linical- o authorization/mco txvendordrug.com/formulary/prior- pa Traditional Medicaid : • -pa o txvendordrug.com/formulary/prior- authorization/ffs -c linical The Clinical Prior Authorization Assistance Chart identifies which • s are prior authorization clinical utilized by each : health plan -authorization/cpa o -chart.pdf -assistance txvendordrug.com/sites/txvendordrug/files/docs/prior PDL Prior Authorization PDL Prior Authorization Drugs identified as “non- preferred ” require a PDL prior authorization. The • Criteria Guide explains the criteria used to evaluate the prior authorization preferred drug list requests. OF pol -mpapdl TxVendorDrug.com PAGE 3 5

4 Medicaid Pharmacy Prior Authorization & Preferred Drug List Obtaining Prior Authorization medications quickly and receive As a prescribing provider you can help people enrolled in Medicaid sentatives should contact one of Prescribing providers or their repre conveniently with a few simple steps. the following authorization authorities: Medicaid Managed Care rescriber Assistance Chart • P health plan. The Pharmacy prior authorization call centers vary by health plan and its prior authorization and identifies each member call center phone numbers. -assistance care/prescriber txvendordrug.com/sites/txvendordrug/files/docs/managed- o - chart.pdf Traditional Medicaid requests by phone at The Texas Prior Authorization Call Center accepts prior authorization • -3927) or online. Please note online submission is only available for 728 -877- PA-TEXAS (1 1- 877- requests. PDL prior authorization Texas Prior Authorization Call Center : txvendordrug.com/about/contact -authorization -us/prior o : paxpress.txpa.hidinc.com/Account_Reg_Instructions.pdf Account Registration Instructions o o Provider Quick Reference : paxpress.txpa.hidinc.com/Provider_Quick_Ref_Guide.pdf require prior authorization but are reviewed therapy products replacement enzyme and Xenical • internally by HHS staff. -authorization/medicaid -ffs -forms • Download forms from txvendordrug.com/formulary/prior OF pol -mpapdl TxVendorDrug.com PAGE 4 5

5 & Medicaid Pharmacy Prior Authorization Preferred Drug List Drug Utilization Review Board Texas Medicaid and clinical prior authorizations four The board makes recommendations for the preferred drug list • times a year . -quarter of the classes Close to 75 therapeutic classes are reviewed each year with approximately one • : reviewed at each meeting preferred at January and April meetings are included on the July release of the Decisions made o drug list . o Decisions made at July and October meetings are included on the January release of the preferred drug lis . Education • The pharmacy continuing education training module includes requirements related to pharmacy , and enrollment, using the online formulary and preferred drug list obtaining prior authorization: txhealthsteps.com/cms/?q=catalog/course/2388 o course quick Prescriber’s Guide to Texas Medicaid Outpatient Pharmacy Prior Authorization • : o epsQuickCourses/prescribers/index.html casestudies.txhealthsteps.com/st Updates • the Epocrates using mobile devices Both the formulary and preferred drug list are available for free on drug information system: o txvendordrug.com/formulary/epocrates • Texas Medicaid Email Notification Service txvendordrug.com/about/news/notices o For questions or comments about the Medicaid formulary or preferred drug list please email [email protected] . OF pol -mpapdl TxVendorDrug.com PAGE 5 5

6 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 31, 2019 IST L P OG L UBLICATION P REFERRED D RUG The PDL is published biannually (January, July). Recent changes to the PDL status are highlighted : January 31, 2019 : Published , A CNE A GENTS RAL O PA Criteria -Preferred Agents Preferred Agents Non AMNESTEEM (isotretinoin) ABSORICA (isotretinoin) ■ Treatment failure with preferred drugs within any CLARAVIS (isotretinoin) subclass MYORISAN (isotretinoin) Contraindication to ■ ZENATANE (isotretinoin) preferred drugs ■ Allergic reaction to preferred drugs T , GENTS A CNE A OPICAL -Preferred Agents Non PA Criteria Preferred Agents Antibiotics gel clindamycin -T (clindamycin) CLEOCIN Treatment failure with ■ preferred drugs within any clindamycin foam clindamycin medicated swab subclass erythromycin gel clindamycin solution ■ Contraindication to clindamycin lotion erythromycin solution preferred drugs erythromycin medicated swab ■ Allergic reaction to preferred drugs Benzoyl Peroxide benzoyl peroxide gel (Rx) benzoyl peroxide cleans er ■ Treatment failure with preferred drugs within any benzoyl peroxide cream benzoyl peroxide wash subclass benzoyl peroxide foam Contraindication to ■ benzoyl peroxide gel preferred drugs benzoyl peroxide kit Allergic reaction to ■ benzoyl peroxide lotion preferred drugs benzoyl peroxide towelette https://www.txvendordrug.com/formulary/formulary -search Search the Medicaid Formulary Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. Publication date: January 31, 2019 “PDL PA Criteria ” in the third column is not relevant but providers must obtain PDL prior authorization. the For drugs in therapeutic classes and/or subclasses that do not have a preferred drug option, 68 Page 1 of

7 HEALTH AND HUMAN SERVICES COMMISSION AUTHORIZATION (PA) CRITERIA TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR Effective January 31, 2019 T , GENTS A CNE A OPICAL PA Criteria -Preferred Agents Non Preferred Agents Retinoids adapalene -A) Retin tretinoin (Avita, ■ Treatment failure with preferred drugs within any ATRALIN (tretinoin) subclass AVITA (tretinoin) ■ Contraindication to DIFFERIN (adapalene) preferred drugs (tazarotene) FABIOR Allergic reaction to ■ RETIN -A (tretinoin) rugs preferred d RETIN -A MICRO (tretinoin) TAZORAC (tazarotene) tretinoin gel (Atralin) tretinoin microspheres Combination and Other Agents ACZONE (dapsone) 7.5% erythromycin/benzoyl peroxide AZELEX (azelaic acid) sulfacetamide GEL BENZACLIN (benzoyl sulfacetamide sodium peroxide/clindamycin) sulfacetamide sodium/sulfur clindamycin/benzoyl peroxide sulfacetamide/sulfur DUAC (benzoyl peroxide/clindamycin) sulfacetamide/sulfur/urea EPIDUO (benzoyl VELTIN (clindamycin/tretinoin) peroxide/adapalene) ZIANA (clindamycin/tretinoin) EPIDUO FORTE (benzoyl peroxide/adapalene) https://www.txvendordrug.com/formulary/formulary -search Search the Medicaid Formulary Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. Publication date: January 31, 2019 “PDL PA Criteria ” in the third column is not relevant but providers must obtain PDL prior authorization. the For drugs in therapeutic classes and/or subclasses that do not have a preferred drug option, 68 Page 2 of

8 HEALTH AND HUMAN SERVICES COMMISSION AUTHORIZATION (PA) CRITERIA TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR Effective January 31, 2019 GENTS A S ’ LZHEIMER A PA Criteria -Preferred Agents Non Preferred Agents Cholinesterase Inhibitors (donepezil) ARICEPT donepezil 5, 10 mg tablet ■ Treatment failure with preferred drugs within any donepezil ODT donepezil 23 mg tablet subclass transdermal (rivastigmine) rivastigmine transdermal EXELON Contraindication to ■ galantamine preferred drugs galantamine ER ■ Allergic reaction to RAZADYNE tablet (galantamine) preferred drugs rivastigmine capsules Clinical Prior Authorization ■ Applies NMDA Receptor Antagonist memantine tablets memantine tablet dose pack ■ Treatment failure with preferred drugs within any NAMENDA (memantine) tablets subclass NAMENDA XR (memantine) ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs Cholinesterase Inhibitor/NMDA Receptor Antagonist Combinations NAMZARIC (donepezil/memantine) ■ Clinical Prior Authorization Applies https://www.txvendordrug.com/formulary/formulary -search Search the Medicaid Formulary Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. Publication date: January 31, 2019 “PDL PA Criteria ” in the third column is not relevant but providers must obtain PDL prior authorization. the For drugs in therapeutic classes and/or subclasses that do not have a preferred drug option, 68 Page 3 of

9 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 31, 2019 CTING A A L – ARCOTIC N , NALGESICS ONG Non Preferred Agents PA Criteria -Preferred Agents (buprenorphine) ) ARYMO ER (morphine MS CONTIN (morphine) BUTRANS Treatment failure with ■ preferred drugs within any BELBUCA (buprenorphine NUCYNTA ER (tapentadol) ) EMBEDA (morphine/naloxone) subclass fentanyl patch (12.5, 25, 50, 100 mcg) (oxymorphone) OPANA ER CONZIP (tramadol) Contraindication to ■ DURAGESIC (fentanyl) oxycodone ER morphine ER (generic MS Contin) preferred drugs EXALGO (hydromorphone) tramadol ER (Ultram ER) Opiate overutilization edit • Allergic reaction to ■ fentanyl patch (37.5, 62.5, 87.5 OxyContin edit • preferred drugs mcg) OXYCONTIN (oxycodone) Methadone oral solution ■ hydromorphone ER • Opiate overutilization edit will be authorized for HYSINGLA ER (hydrocodone) patients less than 24 OxyContin edit • months of age. • Opiate overutilization edit oxymorphone ER Authorization ■ Clinical Prior • Hydrocodone combination tramadol ER (generic Conzip, ) Ryzolt Applies edit XTAMPZA ER (oxycodone) (morphine) KADIAN • Opiate overutilization edit methadone • OxyContin edit Opiate overutilization edit • • Opiate/Benzo/Muscle • Opiate/Benzo/Muscle Relaxant Combo Edit Relaxant Combo Edit ZOHYDRO ER (hydrocodone) MORPHABOND ER (morphine) morphine ER , (generic Avinza Kadian) Search the Medicaid Formulary https://www.txvendordrug.com/formulary/formulary -search Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. Publication date: January 31, 2019 the “PDL PA Criteria ” in the third column is not relevant but providers must obtain PDL prior authorization. For drugs in therapeutic classes and/or subclasses that do not have a preferred drug option, 4 of Page 68

10 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 31, 2019 ) ARENTERAL -P ON (N N A HORT S – ARCOTIC A NALGESICS , CTING Preferred Agents PA Criteria -Preferred Agents Non morphine suppositories butalbital/ASA/caffeine/codeine APAP/codeine Treatment failure with ■ preferred drugs within any (hydrocodone/APAP) NORCO butalbital/APAP/caffeine/codeine hydrocodone/APAP subclass butorphanol (tapentadol) NUCYNTA hydrocodone/ibuprofen ■ Contraindication to OPANA (oxymorphone) CAPITAL W/CODEINE hydromorphone tablet (APAP/codeine) preferred drugs tablets morphine oxycodone/ASA carisoprodol/aspirin/codeine ■ Allergic reaction to solution /ibuprofen codeine oxycodone morphine preferred drugs dihydrocodeine/ASA/caffeine oxycodone oxycodone capsule solution Clinical Prior Authorization ■ oxycodone (hydromorphone) concentrated solution oxycodone tablet DILAUDID Applies fentanyl buccal oxycodone/APAP oxymorphone pentazocine/naloxone (fentanyl) tramadol FENTORA FIORICET W/CODEINE (butalbital tramadol/APA / (oxycodone/APAP) P PERCOCET APAP/caffeine/ codeine) REPREXAIN (hydrocodone/ibuprofen) FIORINAL W/CODEINE (oxycodone) ROXICODONE (butalbital/ASA/caffeine/codeine) ROXYBOND (oxycodone) hydromorphone liquid • Opiate overutilization edit suppositories hydromorphone drocodone combination Hy • (hydrocodone/ibuprofen) IBUDONE edit levor phanol • Mo rphine Milligram LORTAB (hydrocodone/APAP) t Equivalent Edi meperidine TYLENOL -CODEINE (codeine/APAP) concentrat ed morphine solution ULTRACET (tramadol/APAP) ) ULTRAM (tramadol XARTEMIS XR (oxycodone/APAP) XODOL (hydrodone/APAP) • Opiate overutilization edit Hydrocodone combination • edit Search the Medicaid Formulary https://www.txvendordrug.com/formulary/formulary -search Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. Publication date: January 31, 2019 the “PDL PA Criteria ” in the third column is not relevant but providers must obtain PDL prior authorization. For drugs in therapeutic classes and/or subclasses that do not have a preferred drug option, Page 68 5 of

11 HEALTH AND HUMAN SERVICES COMMISSION AUTHORIZATION (PA) CRITERIA TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR Effective January 31, 2019 OPICAL T , GENTS A NDROGENIC A Preferred Agents Non -Preferred Agents PA Criteria ANDROGEL (testosterone) ANDRODERM (testosterone) pump Treatment failure with ■ preferred drugs within any ANDROGEL (testosterone) packet subclass AXIRON (testosterone) ■ Contraindication to FORTESTA (testosterone) preferred drugs NATESTO (testosterone) ■ Allergic reaction to TESTIM (testosterone) preferred drugs testosterone gel VOGELXO (testosterone) ODULATORS M NGIOTENSIN A -Preferred Agents Non PA Criteria Preferred Agents Ace Inhibitors (lisinopril) QBRELIS solution benazepril ACCUPRIL (quinapril) ■ Treatment failure with preferred drugs within any trandolapril ALTACE (ramipril) enalapril subclass fosinopril captopril VASOTEC (enalapril) Contraindication to ■ EPANED (enalapril) lisinopril preferred drugs LOTENSIN quinapril (benazepril) Allergic reaction to ■ MAVIK (trandolapril) ramipril preferred drugs moexepril ■ Epaned will be authorized perindopril for patients six years of age PRINIVIL (lisinopril) and under ■ Clinical Prior Authorization Applies https://www.txvendordrug.com/formulary/formulary -search Search the Medicaid Formulary Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. Publication date: January 31, 2019 “PDL PA Criteria ” in the third column is not relevant but providers must obtain PDL prior authorization. the For drugs in therapeutic classes and/or subclasses that do not have a preferred drug option, 68 Page 6 of

12 HEALTH AND HUMAN SERVICES COMMISSION AUTHORIZATION (PA) CRITERIA TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR January 31, 2019 Effective ODULATORS M NGIOTENSIN A Preferred Agents Non -Preferred Agents PA Criteria ACE Inhibitor/Diuretic Combinations ACCURETIC (quinapril/HCTZ) enalapril/HCTZ ■ Treatment failure with preferred drugs within any lisinopril/HCTZ benazepril/HCTZ subclass captopril/HCTZ Contraindication to ■ fosinopril/HCTZ preferred drugs moexipril /HCTZ ■ Allergic reaction to quinapril/HCTZ preferred drugs (lisinopril/HCTZ) ZESTORETIC Clinical Prior Authorization ■ Applies II Receptor Blockers (ARBs) Angiotensin DIOVAN (valsartan) ATACAND (candesartan) EDARBI (azilsartan) Treatment failure with ■ preferred drugs within any eprosartan • Duplicate Therapy Edit Duplicate Therapy Edit • subclass MICARDIS (telmisartan) • Dose Optimization Edit • Optimization Edit Dose ■ Contraindication to • Duplicate Therapy Edit irbesartan AVAPRO (irbesartan) preferred drugs • Dose Optimization Edit Duplicate Therapy Edit • Duplicate Therapy Edit • Allergic reaction to ■ telmisartan • Dose Optimization Edit • Dose Optimization Edit preferred drugs • Duplicate Therapy Edit BENICAR (olmesartan) losartan ■ Clinical Prior Authorization Candesartan Dose Optimization Edit • • Duplicate Therapy Edit Applies valsartan • Duplicate Therapy Edit Dose Optimization Edit • • Edit Duplicate Therapy • Edit Dose Optimization COZAAR (losartan) • Dose Optimization Edit Duplicate Therapy Edit • Dose Optimization Edit • -search https://www.txvendordrug.com/formulary/formulary Search the Medicaid Formulary Publication date: January 31, 2019 Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. ” in the third column is not relevant but providers must obtain PDL prior authorization. Criteria the For drugs in therapeutic classes and/or subclasses that do not have a preferred drug option, “PDL PA Page 68 7 of

13 HEALTH AND HUMAN SERVICES COMMISSION AUTHORIZATION (PA) CRITERIA TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR January 31, 2019 Effective ODULATORS M NGIOTENSIN A -Preferred Agents Non Preferred Agents PA Criteria ARB/Diuretic Combinations CTZ) ATACAND -HCT (candesartan/H irbesartan/HCTZ MICARDIS -HCT (telmisartan/H CTZ) Treatment failure with ■ preferred drugs within any AVALIDE (irbesartan/HCTZ) /HCTZ losartan/HCTZ telmisartan subclass valsartan/HCTZ (olmesartan/HCTZ) -HCT BENICAR Duplicate Therapy Edit • Contraindication to ■ candesartan/HCTZ Dose Optimization Edit • preferred drugs (valsartan/HCTZ) DIOVAN- HCT ■ Allergic reaction to EDARBYCLOR preferred drugs (azilsartan/chlorthalidone) ■ Clinical Prior Authorization HYZAAR (losartan/HCTZ) Applies • Duplicate Therapy Edit • Dose Optimization Edit Direct Renin Inhibitors TEKTURNA (aliskerin) Clinical Prior Authorization ■ Applies Direct Renin Inhibitor/Diuretic Combinations (aliskerin/HCTZ) TEKTURNA HCT Clinical Prior Authorization ■ Applies ARB/Neprilysin Inhibitor Combinations ENTRESTO (valsartan/sacubitril) ■ Treatment failure with preferred drugs within any subclass ■ Contraindication to preferred drugs Allergic reaction to ■ preferred drugs https://www.txvendordrug.com/formulary/formulary -search Search the Medicaid Formulary Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. Publication date: January 31, 2019 “PDL PA Criteria ” in the third column is not relevant but providers must obtain PDL prior authorization. the For drugs in therapeutic classes and/or subclasses that do not have a preferred drug option, 68 Page 8 of

14 HEALTH AND HUMAN SERVICES COMMISSION AUTHORIZATION (PA) CRITERIA TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR Effective January 31, 2019 OMBINATIONS C ODULATOR M NGIOTENSIN A PA Criteria Non -Preferred Agents Preferred Agents benazepril /amlodipine AZOR (olmesartan/amlodipine) ■ Treatment failure with preferred drugs within any valsartan/amlodipine BYVALSON (valsartan/nebivolol) subclass (valsartan/amlodipine) EXFORGE Contraindication to ■ EXFORGE HCT (valsartan/amlodipine/HCTZ) preferred drugs LOTREL (benazepril/amlodipine) Allergic reaction to ■ PRESTALIA (perindopril/amlodipine) preferred drugs TARKA (trandolapril/verapamil) Clinical Prior Authorization ■ telmisartan/amlodipine Applies trandolapril/verapamil (olmesartan/amlodipine/HCTZ) TRIBENZOR TWYNSTA (telmisartan/amlodipine) valsartan/amlodipine/HCTZ RAL O , LLERGENS -A NTI A Non Preferred Agents -Preferred Agents PA Criteria GRASTEK (Timothy grass pollen allergen extract) Clinical Prior Authorization ■ Applies ORALAIR (Sweet Vernal, Orchard, Perennial Rye, Timothy, & Kentucky B lue Grass mixed pollens allergen extract) (short ragweed pollen allergen extract) RAGWITEK -search Search the Medicaid Formulary https://www.txvendordrug.com/formulary/formulary Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. Publication date: January 31, 2019 the ” in the third column is not relevant but providers must obtain PDL prior authorization. Criteria “PDL PA For drugs in therapeutic classes and/or subclasses that do not have a preferred drug option, 68 Page 9 of

15 HEALTH AND HUMAN SERVICES COMMISSION AUTHORIZATION (PA) CRITERIA TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR January 31, 2019 Effective ASTROINTESTINAL G , NTIBIOTICS A Preferred Agents PA Criteria Non -Preferred Agents (nitazoxanide) ALINIA FIRVANQ (vancomycin) Treatment failure with ■ preferred drugs within any DIFICID (fidaxomicin) metronidazole tablet subclass FLAGYL (metronidazole) neomycin Contraindication to ■ metronidazole capsule tinidazole preferred drugs paromomycin Allergic reaction to ■ SOLOSEC (secnidazole) preferred drugs TINDAMAX (tinidazole) Clinical Prior Authorization ■ VANCOCIN (vancomycin) Applies vancomycin XIFAXAN (rifaximin) , BIOTICS NTI A NHALED I PA Criteria -Preferred Agents Non Preferred Agents BETHKIS (tobramycin) TOBI (tobramycin) solution ■ Treatment failure with preferred drugs within any tobramycin solution CAYSTON (aztreonam) subclass KITABIS PAK (tobramycin) Contraindication to ■ TOBI PODHALER (tobramycin) preferred drugs ■ Allergic reaction to preferred drugs A OPICAL T , NTIBIOTICS PA Criteria -Preferred Agents Non Preferred Agents bacitracin packet bacitracin ointment ■ Treatment failure with preferred drugs within any bacitracin/polymyxin gentamicin subclass CENTANY (mupirocin) ointment mupirocin ■ Contraindication to mupirocin cream triple antibiotic ointment preferred drugs mupirocin ointment syringe Allergic reaction to ■ neomycin/polymyxin/pramoxine preferred drugs ■ Clinical Prior Authorization Applies https://www.txvendordrug.com/formulary/formulary -search Search the Medicaid Formulary Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. Publication date: January 31, 2019 “PDL PA Criteria ” in the third column is not relevant but providers must obtain PDL prior authorization. the For drugs in therapeutic classes and/or subclasses that do not have a preferred drug option, 68 Page 10 of

16 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 31, 2019 , NTIBIOTICS A V AGINAL Preferred Agents -Preferred Agents PA Criteria Non cream CLEOCIN (clindamycin) (clindamycin) ovules CLEOCIN ■ Treatment failure with preferred drugs within any METROGEL -VAGINAL (metronidazole) clindamycin subclass VANDAZOLE (metronidazole) CLINDESSE (clindamycin) ■ Contraindication to metronidazole preferred drugs NUVESSA (metronidazole) Allergic reaction to ■ preferred drugs NTICOAGULANTS A Preferred Agents Non -Preferred Agents PA Criteria ARIXTRA (fondaparinux) ELIQUIS (apixaban) ■ Treatment failure with preferred drugs within any COUMADIN (warfarin) enoxaparin subclass fondaparinux FRAGMIN (dalteparin) syringe ■ Contraindication to PRADAXA (dabigatran) (dalteparin) vial FRAGMIN preferred drugs (enox warf aparin) arin LOVENOX ■ Allergic reaction to SAVAYSA (edoxaban) XARELTO (rivaroxaban) preferred drugs Clinical Prior Auth ■ orization Applies https://www.txvendordrug.com/formulary/formulary -search Search the Medicaid Formulary Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. Publication date: January 31, 2019 ” in the third column is not relevant but providers must obtain PDL prior authorization. Criteria For drugs in therapeutic classes and/or subclasses that do not have a preferred drug option, “PDL PA the Page 11 of 68

17 HEALTH AND HUMAN SERVICES COMMISSION AUTHORIZATION (PA) CRITERIA TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR Effective January 31, 2019 NTIDEPRESSANTS A O THER , -Preferred Agents Non Preferred Agents PA Criteria PRISTIQ (desvenlafaxine) APLENZIN (bupropion) bupropion Treatment failure with ■ preferred drugs within any REMERON desvenlafaxine ER bupropion SR (mirtazapine) subclass EFFEXOR XR (venlafaxine) tranylcypromine bupropion XL ■ Contraindication to TRINTELLIX (vortioxetine) EMSAM (selegiline) MARPLAN (isocarboxazid) preferred drugs venlafaxine IR FETZIMA (levomilnacipran) mirtazapine Allergic reaction to ■ venlafaxine ER tablets (bupropion) FORFIVO XL phenelzine preferred drugs KHEDEZLA (desvenlafaxine) VIIBRYD (vilazodone) trazodone ■ zation Clinical Prior Authori NARDIL (phenelzine) WELLBUTRIN SR venlafaxine ER capsules (bupropion) Applies nefazodone (bupropion) WELLBUTRIN XL ) PARNATE ( tranylcypromine , NTIDEPRESSANTS A SSRI S -Preferred Agents Preferred Agents PA Criteria Non citalopram BRISDELLE (paroxetine) paro xetine CR Treatment failure with ■ preferred drugs within any CELEXA (paroxetine) PAXIL (citalopram) escitalopram tablets subclass (paroxetine) fluoxetine IR escitalopram PAXIL CR solution Contraindication to ■ (paroxetine) PEXEVA fluvoxamine fluoxetine capsule DR preferred drugs fluvoxamine ER paroxetine (fluoxetine) PROZAC Allergic reaction to ■ (sertraline) LEXAPRO ZOLOFT (escitalopram) sertraline preferred drugs ■ Clinical Prior Authorization Applies https://www.txvendordrug.com/formulary/formulary -search Search the Medicaid Formulary Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. Publication date: January 31, 2019 “PDL PA Criteria ” in the third column is not relevant but providers must obtain PDL prior authorization. the For drugs in therapeutic classes and/or subclasses that do not have a preferred drug option, 68 Page 12 of

18 HEALTH AND HUMAN SERVICES COMMISSION AUTHORIZATION (PA) CRITERIA TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR Effective January 31, 2019 RICYCLIC T , NTIDEPRESSANTS A -Preferred Agents Preferred Agents Non PA Criteria SURMONTIL (trimipramine) amitriptyline amoxapine Treatment failure with ■ preferred drugs wi thin any trimipramine ANAFRANIL (clomipramine) doxepin subclass clomipramine imipramine Contraindication to ■ desipramine nortriptyline capsule preferred drugs imipramine pamoate ■ Allergic reaction to NORPRAMIN (desipramine) preferred drugs nortriptyline solution maprotiline PAMELOR (nortriptyline) protriptyline NTIVERTIGO -A GENTS A A NTIEMETIC (E XCLUDES NJECTABLES ) I PA Criteria -Preferred Agents Non Preferred Agents Anticholinergics, Antihistamines, Dopamine Antagonists BONJESTA (doxylamine/pyridoxine) dimenhydrinate Treatment failure with ■ preferred drugs within any COMPRO (prochlorperazine) meclizine subclass metoclopramide solution, tablets DICLEGIS (doxylamine/pyridoxine) Contraindication to ■ metoclopramide ODT phosphoric acid/dextrose/fructose preferred drugs prochlorperazine (rectal) prochlorperazine (oral) ■ Allergic reaction to promethazine promethazine suppositories syrup, tablets preferred drugs oclopramide) REGLAN (met ■ Clinical Prior Authorization -SCOP (scopolamine) TRANSDERM Applies trimethobenzamide Cannabinoids dronabinol -search https://www.txvendordrug.com/formulary/formulary Search the Medicaid Formulary Publication date: January 31, 2019 Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. ” in the third column is not relevant but providers must obtain PDL prior authorization. “PDL PA For drugs in therapeutic classes and/or subclasses that do not have a preferred drug option, Criteria the Page 13 68 of

19 HEALTH AND HUMAN SERVICES COMMISSION AUTHORIZATION (PA) CRITERIA TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR January 31, 2019 Effective A A NTIVERTIGO -A NTIEMETIC GENTS I XCLUDES (E ) NJECTABLES PA Criteria -Preferred Agents Non Preferred Agents 5-HT3 Receptor Antagonists ondansetron ANZEMET (dolasetron) ■ Treatment failure with preferred drugs within any granisetron subclass (granisetron) SANCUSO Contraindication to ■ SUSTOL (granisetron) preferred drugs ZOFRAN (ondansetron) ■ Allergic reaction to preferred drugs Ondansetron s olution will ■ be authorized for patients six years of age and under Clinical Prior Authorization ■ Applies & Combinations Substance P Antagonists (netupitant/palonosetron) AKYNZEO ■ Clinical Prior Authorization Applies EMEND (aprepitant) NTIFUNGALS , O A RAL -Preferred Agents Non Preferred Agents PA Criteria LAMISIL (terbinafine) clotrimazole Treatment failure with CRESEMBA (isavuconazonium ■ sulfate) preferred drugs within any NOXAFIL (posaconazole) fluconazole subclass DIFLUCAN (fluconazole) nystatin powder griseofulvin suspension Contraindication to ■ cytosine flu ORAVIG (miconazole) ketoconazole preferred drugs GRIS -PEG (griseofulvin) SPORANOX (itraconazole) nystatin ■ Allergic reaction to griseofulvin tablets (voriconazole) VFEND terbinafine preferred drugs itraconazole voriconazole https://www.txvendordrug.com/formulary/formulary -search Search the Medicaid Formulary Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. Publication date: January 31, 2019 “PDL PA Criteria ” in the third column is not relevant but providers must obtain PDL prior authorization. the For drugs in therapeutic classes and/or subclasses that do not have a preferred drug option, 68 Page 14 of

20 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 31, 2019 A NTIFUNGALS T , OPICAL PA Criteria -Preferred Agents Preferred Agents Non Antifungals LAMISIL (terbinafine) clotrimazole Treatment failure with ■ BENSAL HP (benzoic acid/salicylic preferred drugs within any acid) (ciclopirox) LOPROX ketoconazole shampoo subclass ciclopirox MENTAX (butenafine) miconazole cream, powder Contraindication to ■ DERMACINRX THERAZOLE PAK miconazole ointment, spray nystatin preferred drugs (betamethasone/clotrimazole/zinc naftifine terbinafine oxide) Allergic reaction to ■ NAFTIN (naftifine) tolnaftate cream, powder preferred drugs econazole oxiconazole ERTACZO (sertaconazole) OXISTAT (oxiconazole) EXTINA (ketoconazole) tolnaftate aerosolized powder, FUNGOID (miconazole) solution, spray JUBLIA (efinaconazole) VUSION (miconazole/ KERYDIN (tavaborole) zinc/petrolatum) ketoconazole cream, foam XOLEGEL (ketoconazole) Antifungal/Steroid Combinations clotrimazole/betamethasone lotion clotrimazole/betamethasone cream ■ Treatment failure with preferred drugs within any LOTRISONE (clotrimazole/betamethasone) subclass nystatin/triamcinolone ■ Contraindication to drugs preferred ■ Allergic reaction to preferred drugs -search https://www.txvendordrug.com/formulary/formulary Search the Medicaid Formulary Publication date: January 31, 2019 Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. the For drugs in therapeutic classes and/or subclasses that do not have a preferred drug option, “PDL PA Criteria ” in the third column is not relevant but providers must obtain PDL prior authorization. of 15 68 Page

21 HEALTH AND HUMAN SERVICES COMMISSION AUTHORIZATION (PA) CRITERIA TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR Effective January 31, 2019 NTIHISTAMINES A F , IRST G ENERATION Preferred Agents Non -Preferred Agents PA Criteria Antihistamines AHIST (chlorpheniramine) liquid carbinoxamine ■ Treatment failure after no KARBINAL ER (carbinoxamine) -day trial of less than a 30 suspension BENADRYL (diphenhydramine) clorpheniramine IR tablets preferre d drugs M-HIST (triprolidine) PD DROPS carbinoxamine tablets syrup cyproheptadine Contraindication to ■ PEDIAVENT (dexbrompheniramine) chlorpheniramine ER tablets diphenhydramine capsule, elixer, preferred drugs RYVENT (carbinoxamine) liquid, tablet tablets clemastine Allergic reaction to ■ triprolidine HISTEX (triprolidine) liquid, PD cyproheptadine tablet preferred drugs DROPS VANACLEAR (triprolidine) PD DROPS diphenhydramine chew, elixer, Clinical Prior Authorization ■ hydroxyzine VANAHIST (triprolidine) PD DROPS RAPDIS, syrup Applies VANAMINE (diphenhydramine) PD ED CHLORPRED (chlorpheniramine/ DROPS phenylephrine) (hydroxyzine) VISTARIL HISTEX (triprolidine) CHEW, PDX DROPS https://www.txvendordrug.com/formulary/formulary -search Search the Medicaid Formulary Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. Publication date: January 31, 2019 “PDL PA Criteria ” in the third column is not relevant but providers must obtain PDL prior authorization. the For drugs in therapeutic classes and/or subclasses that do not have a preferred drug option, 68 Page 16 of

22 HEALTH AND HUMAN SERVICES COMMISSION AUTHORIZATION (PA) CRITERIA TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR Effective January 31, 2019 EDATING S INIMALLY M , NTIHISTAMINES A Preferred Agents Non -Preferred Agents PA Criteri a Antihistamines cetirizine solution, tablets cetirizine capsule, chewable , 5mg/5mL solution Treatment failure after no ■ less than a 30 -day trial of CLARINEX (desloratadine) loratadine solution, tablets preferred drugs desloratadine ■ Contraindication to fexofenadine preferred drugs levocetirizine Allergic reaction to ■ loratadine ODT preferred drugs XYZAL (levocetirizine) ■ Clinical Prior Authorization ZYRTEC ODT (cetirizine) Applies Antihistamine/Decongestant Combinations cetirizine/pseudoephedrine ■ Treatment failure after no -day trial of than a 30 less fexofenadine/pseudoephedrine preferred drugs loratadine/pseudoephedrine ■ Contraindication to -D SEMPREX (acrivastine/pseudoephedrine) preferred drugs ■ Allergic reaction to preferred drugs ■ Clinical Prior Authorization Applies S , NTIHYPERTENSIVES A YMPATHOLYTICS PA Criteria -Preferred Agents Non Preferred Agents CATAPRES (clonidine) -TTS (clonidine) CATAPRES Treatment failure with ■ preferred drugs within any clonidine transdermal IR tablets clonidine subclass methyldopa / HCTZ guanfacine IR ■ Contraindication to methyldopate methyldopa preferred drugs Allergic reaction to ■ preferred drugs https://www.txvendordrug.com/formulary/formulary -search Search the Medicaid Formulary Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. Publication date: January 31, 2019 “PDL PA Criteria ” in the third column is not relevant but providers must obtain PDL prior authorization. the For drugs in therapeutic classes and/or subclasses that do not have a preferred drug option, 68 Page 17 of

23 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 31, 2019 ■ Clinical Prior Authorizati on Applies A NTIHYPERURICEMICS -Preferred Agents Non Preferred Agents PA Criteria allopurinol colchicine ■ Treatment failure with preferred drugs within any COLCRYS (colchicine) probenecid subclass DUZALLO (allopurinol/lesinurad) probenecid/colchicine ■ Contraindication to ULORIC (febuxostat) preferred drugs ZURAMPIC (lesinurad) ■ Allergic reaction to ZYLOPRIM (allopurinol) preferred drugs GENTS A NTIMIGRAINE A Preferred Agents -Preferred Agents PA Criteria Non Triptans ONZETRA XSAIL (sumatriptan) rizatriptan almotriptan Treatment failure with ■ preferred drugs within any RELPAX (eletriptan) AMERGE (naratriptan) sumatriptan injection kit subclass sumatriptan vial AXERT (almotriptan) sumatriptan tablets Contraindication to ■ sumatriptan nasal FROVA (frovatriptan) nasal ZOMIG (zolmitriptan) preferred drugs SUMAVEL DOSEPRO (sumatriptan) IMITREX (sumatriptan) injection kit ■ Allergic reaction to TREXIMET IMITREX (sumatriptan) nasal (sumatriptan/naproxen) preferred drugs tablets IMITREX (sumatriptan) ZEMBRACE SYMTOUCH (sumatriptan) Clinical Prior Authorization ■ IMITREX (sumatriptan) vial zolmitriptan tablets Applies MAXALT (rizatriptan) zolmitriptan ) tablets ZOMIG ( naratriptan Non -Triptans AIMOVIG (erenumab) ical Prior Authorization Clin ■ Applies (diclofenac) CAMBIA D.H.E. 45 (dihydroergotamine) dihydroergotamine mesylate MIGRANAL (dihydroergotamine mesylate) https://www.txvendordrug.com/formulary/formulary -search Search the Medicaid Formulary Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. Publication date: January 31, 2019 “PDL PA Criteria ” in the third column is not relevant but providers must obtain PDL prior authorization. the For drugs in therapeutic classes and/or subclasses that do not have a preferred drug option, 68 Page 18 of

24 HEALTH AND HUMAN SERVICES COMMISSION AUTHORIZATION (PA) CRITERIA TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR January 31, 2019 Effective T A NTIPARASITICS , OPICAL PA Criteria -Preferred Agents Non Preferred Agents NATROBA (spinosad) EURAX (crotamiton) ■ Treatment failure with preferred drugs within any lindane permethrin subclass malathion SKLICE (ivermectin) Contraindication to ■ OVIDE ( malathion) preferred drugs piperonyl butoxide/pyrethrins ■ Allergic reaction to spinosad preferred drugs NTIPARKINSON A ) RANSDERMAL /T RAL (O GENTS A S ’ PA Criteria -Preferred Agents Preferred Agents Non Anticholinergics benztropine ■ Treatment failure with preferred drugs within any trihexyphenidyl subclass ■ Contraindication to preferred drugs Allergic reaction to ■ preferred drugs COMT Inhibitors COMTAN (entacapone) entacapone TASMAR (tolcapone) Dopamine Agonists bromocriptine MIRAPEX (pramipexole) Treatment failure with ■ preferred drugs within any MIRAPEX ER (pramipexole) pramipexole subclass NEUPRO t ransdermal (rotigotine) ropinirole ■ Contraindication to pramipexole ER preferred drugs REQUIP (ropinirole) ■ Allergic reaction to REQUIP XL (ropinirole) preferred drugs ropinirole ER https://www.txvendordrug.com/formulary/formulary -search Search the Medicaid Formulary Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. Publication date: January 31, 2019 “PDL PA Criteria ” in the third column is not relevant but providers must obtain PDL prior authorization. the For drugs in therapeutic classes and/or subclasses that do not have a preferred drug option, 68 Page 19 of

25 HEALTH AND HUMAN SERVICES COMMISSION AUTHORIZATION (PA) CRITERIA TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR Effective January 31, 2019 S GENTS ’ NTIPARKINSON A (O RAL A /T RANSDERMAL ) Preferred Agents Non -Preferred Agents PA Criteria -B Inhibitors MAO AZILECT (rasagiline) selegiline XADAGO (safinamide) ZELAPAR (selegiline) Others amantadine carbidopa ■ Treatment failure with preferred drugs within any carbidopa/levodopa ODT carbidopa/levodopa tablets subclass DUOPA (carbidopa/levodopa) carbidopa/levodopa ER Contraindication to ■ GOCOVRI (amantadine) carbidopa/levodopa/entacapone preferred drugs LODOSYN (carbidopa) ■ Allergic reaction to OSMOLEX ER (amantadine) preferred drugs RYTARY (carbidopa/levodopa) SINEMET (carbidopa/levodopa) STALEVO (levodopa/carbidopa/entacapone) https://www.txvendordrug.com/formulary/formulary -search Search the Medicaid Formulary Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. Publication date: January 31, 2019 “PDL PA Criteria ” in the third column is not relevant but providers must obtain PDL prior authorization. the For drugs in therapeutic classes and/or subclasses that do not have a preferred drug option, 68 Page 20 of

26 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 31, 2019 NTIPSYCHOTICS A -Preferred Agents Non Preferred Agents PA Criteria Antipsychotics ABILIFY (aripiprazole) tablets tablets pimozide perphenazine aripiprazole Treatment failure with ■ preferred drugs within any REXULTI (brexpiprazole) IR quetiapine Antipsychotic Edit • Antipsychotic Edit • subclass , solution risperidone tablets RISPERDAL (risperidone) Dose Optimization Edit • • Dose Optimization Edit Contraindication to ■ risper idone ODT Antipsychotic Edit • chlorpromazine aripiprazole ODT, solution preferred drugs Antipsychotic Edit • clozapine ODT • Dose Optimization Edit clozapine Allergic reaction to ■ SAPHRIS Dose Optimization Edit • fluphenazine (asenapine) CLOZARIL (clozapine) preferred drugs (quetiapine) haloperidol thioridazine FANAPT SEROQUEL (iloperidone) Clinical Prior Authorization ■ FAZACLO LATUDA (quetiapine) thiothixene (lurasidone) (clozapine) SEROQUEL XR Applies trifluoperazine VERSACLOZ (clozapine) (ziprasidone) olanzapine GEODON INVEGA (paliperidone) (cariprazine) VRAYLAR ziprasidone Antipsychotic Edit • (olanzapine) loxapine ZYPREXA • Dose Optimization Edit mavanserin) (pi NUPLAZID • ic Edit Antipsychot olanzapine ODT (pimozide) ORAP Dose Optimization Edit • Antipsychotic Edit • paliperidone ZYPREXA ZYDIS (olanzapine) • Dose Optimization Edit • Antipsychotic Edit • Dose Optimization Edit Antipsychotic/SSRI Combinations amitriptyline/perphenazine olanzapine/fluoxetine Treatment failure with ■ preferred drugs within any SYMBYAX (olanzapine/fluoxetine) subclass ■ Contraindication to preferred drugs Allergic reaction to ■ preferred drugs ■ Clinical Prior Authorization Applies https://www.txvendordrug.com/formulary/formulary Search the Medicaid Formulary -search Publication date: January 31, 2019 Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. ” in the third column is not relevant but providers must obtain PDL prior authorization. Criteria For drugs in therapeutic classes and/or subclasses that do not have a preferred drug option, the “PDL PA 21 68 of Page

27 HEALTH AND HUMAN SERVICES COMMISSION AUTHORIZATION (PA) CRITERIA TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR Effective January 31, 2019 NTIPSYCHOTICS A -Preferred Agents Non Preferred Agents PA Criteria Long -Acting Injectables ABILIFY MAINTENA (aripiprazole) (risperidone) PERSERIS Treatment failure with ■ preferred drugs within any (olanzapine) ZYPREXA RELPREVV (aripiprazole) ARISTADA subclass ARISTADA INITIO (aripiprazole) ■ Contraindication to (paliperidone) INVEGA SUSTENNA preferred drugs INVEGA TRINZA (paliperidone) ■ Allergic reaction to RISPERDAL CONSTA (risperidone) preferred drugs Clinical Prior Authorization ■ Applies / RA (O ) NASAL NTIVIRALS A L Preferred Agents Non -Preferred Agents PA Criteria Antiherpetic acyclovir VALTREX (valacyclovir) ■ Treatment failure with preferred drugs within any ZOVIRAX (acyclovir) famciclovir subclass valacyclovir ■ Contraindication to preferred drugs Allergic reaction to ■ preferred drugs Anti -influenza RELENZA (zanamivir) ■ Treatment failure with preferred drugs within any rimantadine subclass TAMIFLU (oseltamivir) ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs https://www.txvendordrug.com/formulary/formulary -search Search the Medicaid Formulary Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. Publication date: January 31, 2019 “PDL PA Criteria ” in the third column is not relevant but providers must obtain PDL prior authorization. the For drugs in therapeutic classes and/or subclasses that do not have a preferred drug option, 68 Page 22 of

28 HEALTH AND HUMAN SERVICES COMMISSION AUTHORIZATION (PA) CRITERIA TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR Effective January 31, 2019 L RA (O NTIVIRALS A NASAL ) / PA Criteria -Preferred Agents Non Preferred Agents Anti -CMV VALCYTE (valganciclovir) tablets VALCYTE (valganciclovir) solution Treatment failure with ■ preferred drugs within any valganciclovir tablets subclass Contraindication to ■ preferred drugs ■ Allergic reaction to preferred drugs OPICAL T NTIVIRALS A , Preferred Agents Non -Preferred Agents PA Criteria XERESE (acyclovir/hydrocortisone) acyclovir ointment Treatment failure with ■ preferred drugs within any ZOVIRAX (acyclovir) DENAVIR (penciclovir) subclass ■ Contraindication to preferred drugs Allergic reaction to ■ preferred drugs https://www.txvendordrug.com/formulary/formulary -search Search the Medicaid Formulary Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. Publication date: January 31, 2019 “PDL PA Criteria ” in the third column is not relevant but providers must obtain PDL prior authorization. the For drugs in therapeutic classes and/or subclasses that do not have a preferred drug option, 68 Page 23 of

29 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 31, 2019 A NXIOLYTICS -Preferred Agents Non Preferred Agents PA Criteria TRANXENE T -TAB (clorazepate) alprazolam ER alprazolam tablet diazepam solution ■ Treatment failure with preferred drugs within any alprazolam intensol • • Anxiolytics and Anxiolytics and Anxiolytics and • subclass Sedative/Hypnotics Edit Sedative/Hypnotics Edit Sedative/Hypnotics Edit alprazolam ODT ■ Contraindication to • • Opiate/Benzo/Muscle Opiate/Benzo/Muscle Opiate/Benzo/Muscle • (lorazepam) tablet ATIVAN preferred drugs Relaxant Combo Edit Relaxant Combo Edit Relaxant Combo Edit diazepam intensol Allergic re action to ■ buspirone VALIUM (diazepam) tablet diazepam tablet meprobamate preferred drugs XANAX XR (alprazolam) chlordiazepoxide • Anxiolytics and • Anxiolytics and ■ Clinical Prior Authorization Sedative/Hypnotics Edit • • Anxiolytics and Anxiolytics and Sedative/Hypnotics Edit Applies Sedative/Hypnotics Edit Sedative/Hypnotics Edit Opiate/Benzo/Muscle • Opiate/Benzo/Muscle • Relaxant Combo Edit Opiate/Benzo/Muscle Opiate/Benzo/Muscle • • Relaxant Combo Edit Relaxant Combo Edit lorazepam intensol Relaxant Combo Edit oxazepam lorazepam tablet clorazepate XANAX (alprazolam) tablet Anxiolytics and • Anxiolytics • • Anxiolytics and and • Anxiolytics and Sedative/Hypnotics Edit Sedative/Hypnotics Edit Sedative/Hypnotics Edit Sedative/Hypnotics Edit Opiate/Benzo/Muscle • Opiate/Benzo/Muscle • Opiate/Benzo/Muscle • Opiate/Benzo/Muscle • Relaxant Combo Edit Relaxant Combo Edit Relaxant Combo Edit Relaxant Combo Edit ) (O LOCKERS B ETA B RAL PA Criteria -Preferred Agents Non Preferred Agents Beta Blockers propranolol ER acebutolol betaxolol Treatment failure with ■ preferred drugs within any SOTYLIZE (sotalol) BYSTOLIC ( nebivolol) atenolol subclass CORGARD (nadolol) TENORMIN (atenolol) bisoprolol Contraindication to ■ timolol HEMANGEOL (propranolol) metoprolol IR preferred drugs INDERAL LA TOPROL XL (metoprolol succinate) metoprolol XL (propranolol) ■ Allergic reaction to INNOPRAN XL (propranolol) propranolol IR preferred drugs nadolol sotalol Clinical Prior Authorization ■ pindolol Applies Search the Medicaid Formulary https://www.txvendordrug.com/formulary/formulary -search Publication date: January 31, 2019 Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. For drugs in therapeutic classes and/or subclasses that do not have a preferred drug option, ” in the third column is not relevant but providers must obtain PDL prior authorization. the “PDL PA Criteria 68 of Page 24

30 HEALTH AND HUMAN SERVICES COMMISSION AUTHORIZATION (PA) CRITERIA TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR Effective January 31, 2019 ) RAL (O LOCKERS B ETA B PA Criteria -Preferred Agents Non Preferred Agents Blocker Combinations Beta (metoprolol succinate ER/HCTZ) DUTOPROL atenolol/chlorthalidone Treatment failure with ■ preferred drugs within any bisoprolol/HCTZ metoprolol/HCTZ subclass nadolol/bendroflumethiazide ■ Contraindication to propranolol/HCTZ preferred drugs TENORETIC (atenolol/HCTZ) ■ reaction to Allergic ZIAC (bisoprolol/HCTZ) preferred drugs Clinical Prior Authorization ■ Applies -Blockers Beta - and Alpha carvedilol) COREG ( carvedilol ■ Treatment failure with preferred drugs within any COREG CR ( carvedilol) labetalol subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs Clinical Prior Authorization ■ Applies S ILE B ALTS Preferred Agents PA Criteria -Preferred Agents Non ACTIGALL (ursodiol) ursodiol tablet Treatment failure with ■ preferred drug CHENODAL (chenodiol) ■ Contraindication to CHOLBAM (cholic acid) preferred drug obeticholic acid) OCALIVA ( Allergic reaction to ■ URSO (ursodiol) preferred drug URSO FORTE (urosodiol) ursodiol capsule https://www.txvendordrug.com/formulary/formulary -search Search the Medicaid Formulary Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. Publication date: January 31, 2019 “PDL PA Criteria ” in the third column is not relevant but providers must obtain PDL prior authorization. the For drugs in therapeutic classes and/or subclasses that do not have a preferred drug option, 68 Page 25 of

31 HEALTH AND HUMAN SERVICES COMMISSION AUTHORIZATION (PA) CRITERIA TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR Effective January 31, 2019 REPARATIONS P ELAXANT R LADDER B PA Criteria -Preferred Agents Non Preferred Agents oxybutynin ER DETROL (tolterodine) oxybutynin IR Treatment failure with ■ preferred drugs within any DETROL LA TOVIAZ (fesoterodine) (tolterodine) OXYTROL (oxybutynin) subclass tolterodine VESICARE (solifenacin) (oxybutynin) DITROPAN XL Contraindication to ■ tolterodine ER ENABLEX (darifenacin) preferred drugs trospium flavoxate ■ Allergic reaction to GELNIQ trospium ER UE (oxybutynin) preferred drugs MYRBETRIQ (mirabegron) Clinical Prior Authorization ■ Applies S A UPPRESSION ESORPTION R A ELATED R ONE B ND GENTS Preferred Agents Non -Preferred Agents PA Criteria Bisphosphonates FOSAMAX (alendronate) ACTONEL (risedronate) alendronate tablets ■ Treatment failure with preferred drugs within any FOSAMAX PLUS D alendronate solution subclass (alendronate/vitamin D) ATELVIA (risedronate) ■ Contraindication to ibandronate BINOSTO (alendronate) preferred drugs risedronate BONIVA (ibandronate) ■ Allergic reaction to etidronate preferred drugs Related Agents Other Bone Resorption Suppression and calcitonin nasal ■ Clinical Prior Authorization Applies EVISTA (raloxifene) FORTEO (teriparatide) Raloxifene TYMLOS (abaloparatide) Search the Medicaid Formulary https://www.txvendordrug.com/formulary/formulary -search Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. Publication date: January 31, 2019 For drugs in therapeutic classes and/or subclasses that do not have a preferred drug option, “PDL PA the ” in the third column is not relevant but providers must obtain PDL prior authorization. Criteria 26 of 68 Page

32 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 31, 2019 A BPH GENTS Preferred Agents Non PA Criteria -Preferred Agents Alpha Blockers alfuzosin CARDURA (doxazosin) ■ Treatment failure with preferred drugs within any FLOMAX (tamsulosin) doxazosin subclass RAPAFLO (silodosin) tamsulosin Contraindication to ■ UROXATRAL (alfuzosin) terazosin preferred drugs ■ Allergic reaction to preferred drugs ■ Clinical Prior Authorization Applies 5-Alpha -Reductase (5AR) Inhibitors AVODART (dutasteride) finasteride ■ Treatment failure with preferred drugs within any PROSCAR (finasteride) subclass Contraindication to ■ preferred drugs ■ Allergic reaction to preferred drugs Alpha Blocker/5AR Inhibitor Combinations dutasteride/tamsulosin https://www.txvendordrug.com/formulary/formulary -search Search the Medicaid Formulary Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. Publication date: January 31, 2019 “PDL PA Criteria ” in the third column is not relevant but providers must obtain PDL prior authorization. the For drugs in therapeutic classes and/or subclasses that do not have a preferred drug option, 68 Page 27 of

33 HEALTH AND HUMAN SERVICES COMMISSION AUTHORIZATION (PA) CRITERIA TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR Effective January 31, 2019 GONIST A ETA B , RONCHODILATORS B Non Preferred Agents -Preferred Agents PA Criteria -Acting Inhalers, Short (albuterol) PROAIR HFA PROAIR RESPICLICK (albuterol) ■ Treatment failure with preferred drugs within any PROVENTIL HFA (albuterol) subclass (albuterol) VENTOLIN HFA Contraindication to ■ XOPENEX HFA (levalbuterol) preferred drugs ■ Allergic reaction to preferred drugs ■ Clinical Prior Authorization Applies -Acting Inhalers, Long (indacaterol) ARCAPTA ■ Clinical Prior Authorization Applies SEREVENT (salmeterol) (olodaterol) STRIVERDI RESPIMAT Inhalation Solution albuterol BROVANA (arformoterol) ■ Treatment failure with ugs within any preferred dr levalbuterol subclass PERFOROMIST (formoterol) Contraindication to ■ XOPENEX (levalbuterol) preferred drugs ■ Allergic reaction to preferred drugs ■ Clinical Prior Authorization Applies Oral albuterol syrup albuterol tablet Treatment failure with ■ preferred drugs within any albuterol ER subclass metaproterenol ■ Contraindication to terbutaline preferred drugs Allergic reaction to ■ preferred drugs https://www.txvendordrug.com/formulary/formulary -search Search the Medicaid Formulary Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. Publication date: January 31, 2019 “PDL PA Criteria ” in the third column is not relevant but providers must obtain PDL prior authorization. the For drugs in therapeutic classes and/or subclasses that do not have a preferred drug option, 68 Page 28 of

34 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 31, 2019 RAL (O LOCKERS B C ALCIUM C HANNEL ) PA -Preferred Agents Non Preferred Agents Criteria -Acting Short diltiazem isradipine Treatment failure with ■ preferred drugs within any nicardipine verapamil subclass nifedipine ■ Contraindication to nimodipine preferred drugs NYMALIZE (nimodipine) Allergic reaction to ■ PROCARDIA (nifedipine) preferred drugs Clinical Prior Authorization ■ Applies -Acting Long (nifedipine) PROCARDIA XL (nifedipine) ADALAT CC amlodipine Treatment failure with ■ preferred drugs within any (diltiazem) TIAZAC ER (verapamil) CALAN SR diltiazem subclass 60 mg capsules verapamil 3 (diltiazem) CARDIZEM CD felodipine ER Contraindication to ■ verapamil ER PM nifedipine ER (diltiazem) CARDIZEM LA preferred drugs (verapamil) diltiazem LA VERELAN capsules, tablets verapamil ER Allergic reaction to ■ VERELAN PM MATZIM LA (diltiazem) (verapamil) preferred drugs nisoldipine ■ Clinical Prior Authorization NORVASC ( amlodipine) Applies C (O ELATED R NTIBIOTICS A EPHALOSPORINS AND ) RAL Preferred Agents Non PA Criteria -Preferred Agents Beta Lactam/Beta -Lactamase Inhibitor Combinations tablets, amoxicillin/clavulanate amoxicillin/clavulanate chewable XR tablets, suspension ■ Treatment failure with preferred drugs within any AUGMENTIN suspension (amoxicillin/clavulanate) subclass AUGMENTIN XR (amoxicillin/clavulanate) Contraindication to ■ preferred drugs ■ Allergic reaction to preferred drugs https://www.txvendordrug.com/formulary/formulary -search Search the Medicaid Formulary Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. Publication date: January 31, 2019 “PDL PA Criteria ” in the third column is not relevant but providers must obtain PDL prior authorization. the For drugs in therapeutic classes and/or subclasses that do not have a preferred drug option, 68 Page 29 of

35 HEALTH AND HUMAN SERVICES COMMISSION AUTHORIZATION (PA) CRITERIA TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR Effective January 31, 2019 A ELATED R EPHALOSPORINS AND C (O RAL NTIBIOTICS ) PA Criteria Preferred Agents Non -Preferred Agents Cephalosporins – First Generation cefadroxil cefadroxil tablets capsules, suspension Treatment failure with ■ preferred drugs within any cephalexin tablets cephalexin capsules, suspension subclass KEFLEX (cephalexin) ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs – Second Generation Cephalosporins cefprozil suspension cefaclor ER Treatment failure with ■ preferred drugs within any IR capsules, suspension cefaclor cefuroxime tablets subclass cefprozil tablets Contraindication to ■ CEFTIN (cefuroxime) preferred drugs ■ Allergic reaction to preferred drugs – Third Generation Cephalosporins cefdinir CEDAX (ceftibuten) ■ Treatment failure with preferred drugs within any cefixime subclass cefpodoxime ■ Contraindication to ceftibuten preferred drugs SUPRAX (cefixime) ■ Allergic reaction to preferred drugs https://www.txvendordrug.com/formulary/formulary -search Search the Medicaid Formulary Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. Publication date: January 31, 2019 “PDL PA Criteria ” in the third column is not relevant but providers must obtain PDL prior authorization. the For drugs in therapeutic classes and/or subclasses that do not have a preferred drug option, 68 Page 30 of

36 HEALTH AND HUMAN SERVICES COMMISSION AUTHORIZATION (PA) CRITERIA TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR Effective January 31, 2019 ACTORS F TIMULATING S OLONY C PA Criteria -Preferred Agents Non Preferred Agents LEUKINE (sargramostim) FULPHILA (pegfilgrastim - jmdb) Treatment failure with ■ preferred drugs within any NEULASTA (pegfilgrastim) GRANIX (tbo -filgrastim) subclass NEUPOGEN (filgrastim) vial, syringe -sndz) ZARXIO (filgrastim Contraindication to ■ preferred drugs ■ Allergic reaction to preferred drugs A COPD GENTS Preferred Agents Non -Preferred Agents PA Criteria Anticholinergics INCRUSE ELLIPTA (umeclidinium) ATROVENT HFA (ipratropium) ■ Treatment failure with preferred drugs within any ipratropium inhalation solution LONHALA MAGNAIR (glycopyrrolate) subclass SEEBRI NEOHALER (glycopyrrolate) SPIRIVA HANDIHALER (tiotropium) ■ Contraindication to SPIRIVA RESPIMAT (tiotropium) preferred drugs (aclidinium) TUDORZA Allergic reaction to ■ preferred drugs Anticholinergic -Beta Agonist Combinations (umeclidinium/vilanterol) albuterol/ipratropium ANORO ELLIPITA ■ Treatment failure with preferred drugs w ithin any UTIBRON NEOHALER (glycopyrrolate/indacaterol) BEVESPI AEROSPHERE (glycopyrrolate/formoterol) subclass COMBIVENT RESPIMAT (albuterol/ipratropium) ■ Contraindication to STIOLTO RESPIMAT (tiotropium/olodaterol) preferred drugs ■ Allergic reaction to preferred drugs Clinical Prior Authorization ■ Applies Phosphodiesterase Inhibitors (roflumilast) DALIRESP https://www.txvendordrug.com/formulary/formulary -search Search the Medicaid Formulary Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. Publication date: January 31, 2019 “PDL PA Criteria ” in the third column is not relevant but providers must obtain PDL prior authorization. the For drugs in therapeutic classes and/or subclasses that do not have a preferred drug option, 68 Page 31 of

37 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 31, 2019 C OUGH AND C GENTS A OLD See Separate Preferred Cough and Cold Agent Listing. Cough & cold PA criteria C YTOKINE AND CAM A NTAGONISTS Preferred Agents -Preferred Agents PA Criteria Non (apremilast) OTEZLA (etanercept) ACTEMRA (tocilizumab) ENBREL Treatment failure with ■ preferred drugs within any SILIQ (brodalumab) CIMZIA (certolizumab) HUMIRA (adalimumab) subclass SIMPONI (golimumab) COSENTYX (secukinumab) Contraindication to ■ STELARA (ustekinumab) ILARIS (canakinumab) preferred drugs TALTZ (ixekizumab) KEVZARA (sarilumab) Allergic reaction to ■ TREMFYA (guselkumab) KINERET (anakinra) preferred drugs XELJANZ (tofacitinib) ORENCIA (abatacept) , PINEPHRINE S ELF -I E NJECTED Non -Preferred Agents Preferred Agents epinephrine (generic ADRENACLICK) epinephrine (generic EPIPEN and ■ Treatment failure with preferred products EPIPEN JR) EPIPEN ■ Contraindication to EPIPEN JR products preferred ■ Allergic reaction to preferred products E ROTEINS P TIMULATING S RYTHROPOIESIS Non Preferred Agents -Preferred Agents PA Criteri a (RhUEPO) ARANESP (darbepoetin) EPOGEN Treatment failure with ■ preferred drugs within any -EPO) MIRCERA (PEG (RhUEPO) PROCRIT subclass (RhUEPO) RETACRIT ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs ■ Clinical Prior Authorization Applies Search the Medicaid Formulary https://www.txvendordrug.com/formulary/formulary -search Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. Publication date: January 31, 2019 For drugs in therapeutic classes and/or subclasses that do not have a preferred drug option, “PDL PA the ” in the third column is not relevant but providers must obtain PDL prior authorization. Criteria 32 of 68 Page

38 HEALTH AND HUMAN SERVICES COMMISSION AUTHORIZATION (PA) CRITERIA TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR Effective January 31, 2019 O , F LUOROQUINOLONES RAL Preferred Agents -Preferred Agents Non Criteria PA AVELOX (moxifloxacin) ciprofloxacin IR ■ Treatment failure with preferred drugs within any BAXDELA (delafloxacin) ciprofloxacin suspension subclass levofloxacin tablets CIPRO (ciprofloxacin) tablets ■ Contraindication to CIPRO (ciprofloxacin) suspension preferred drugs ciprofloxacin ER ■ Allergic reaction to LEVAQUIN (levofloxacin) preferred drugs levofloxacin solution moxifloxacin ofloxacin HRONIC GI C , OTILITY M Preferred Agents Non -Preferred Agents PA Criteria alosetron LINZESS (linaclotide) ■ Treatment failure with preferred drugs within any MOVANTIK AMITIZA (naloxegol) (lubiprostone) (including OTC subclass LOTRONEX (alosetron) products ) RELISTOR (methylnaltre xone) injection ■ Contraindication to RELISTOR (methylnaltrexone) oral preferred drugs SYMPROIC (naldemedine) ■ Allergic reaction to TRULANCE (plecanatide) preferred drugs VIBERZI (eluxadoline) ■ Clinical Prior Authorization Applies https://www.txvendordrug.com/formulary/formulary -search Search the Medicaid Formulary Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. Publication date: January 31, 2019 “PDL PA Criteria ” in the third column is not relevant but providers must obtain PDL prior authorization. the For drugs in therapeutic classes and/or subclasses that do not have a preferred drug option, 68 Page 33 of

39 HEALTH AND HUMAN SERVICES COMMISSION AUTHORIZATION (PA) CRITERIA TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR Effective January 31, 2019 , G LUCOCORTICOIDS NHALED I PA Criteria Preferred Agents Non -Preferred Agents Glucocorticoids ASMANEX AEROSPAN (flunisolide) (mometasone) Treatment failure with ■ preferred drugs within any ALVESCO HFA FLOVENT (ciclesonide) (fluticasone) subclass PULMICORT 0.25, 0.5 MG RESPULES (fluticasone) ARNUITY ELLIPTA (budesonide) ■ Contraindication to ARMONAIR RESPICLICK (fluticasone) PULMICORT 1 MG RESPULES (budesonide) preferred drugs respules budesonide Allergic reaction to ■ FLOVENT (fluticasone) DISKUS preferred drugs PULMICORT (budesonide) FLEXHALER ■ Clinical Prior Authorization QVAR (beclomethasone) Applies Glucocorticoid/Bronchodilator Combinations (fluticasone/salmeterol) ADVAIR Treatment failure with ■ AIRDUO RESPICLICK (fluticasone/salmeterol) preferred drugs within any (mometasone/formoterol) DULERA subclass BREO ELLIPTA (fluticasone/vilanterol) SYMBICORT (budesonide/formoterol) ■ Contraindication to TRELEGY ELLIPTA preferred drugs (fluticasone/umeclidinium/vilanterol) Al lergic reaction to ■ preferred drugs Clinical Prior Authorization ■ Applies LUCOCORTICOIDS , O RAL G Preferred Agents PA Criteria -Preferred Agents Non (hydrocortisone) CORTEF budesonide EC PEDIAPRED (prednisone) ■ Treatment failure with preferred drugs within any prednisolone sodium phosphate ODT, CORTISONE (hydrocortisone) dexamethasone elixir , solution, tablets subclass solution dexamethasone intensol hydrocortisone ■ Contraindication to prednisone intensol DEXPAK methylprednisolone tablet dose pack (dexamethasone) preferred drugs prednisone tablet dose pack EMFLAZA prednisolone sodium phosphate (deflazacort) reaction to Allergic ■ RAYOS (prednisone) ENTOCORT EC (budesonide) prednisolone preferred drugs TAPERDEX (dexamethasone) prednisone solution, tablets (methylprednisolone) MEDROL ■ Clinical Prior Authorization 20 (prednisolone) VERIPRED tablets methylprednisolone Applies (dexamethasone) ZODEX MILLIPRED (prednisolone) Search the Medicaid Formulary https://www.txvendordrug.com/formulary/formulary -search Publication date: January 31, 2019 Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. For drugs in therapeutic classes and/or subclasses that do not have a preferred drug option, the Criteria ” in the third column is not relevant but providers must obtain PDL prior authorization. “PDL PA 68 Page 34 of

40 HEALTH AND HUMAN SERVICES COMMISSION AUTHORIZATION (PA) CRITERIA TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR Effective January 31, 2019 ORMONE H ROWTH G Preferred Agents PA Criteria -Preferred Agents Non HUMATROPE GENOTROPIN ■ Treatment failure with preferred drugs within any NUTROPIN AQ NORDITROPIN subclass OMNITROPE ■ Contraindication to SAIZEN preferred drugs SE ROSTIM Allergic reaction to ■ ZORBTIVE preferred drugs ■ Clinical Prior Authorization Applies REATMENT T PYLORI H. Preferred Agents -Preferred Agents Non PA Criteria lansoprazole/amoxicillin/clarithromycin PYLERA (bismuth subcitrate/metronidazole/tetracycline) Treatment failure with ■ preferred drugs within any PREVPAC (lansoprazole/amoxicillin/clarithromycin) subclass Contraindication to ■ preferred drugs Allergic reaction to ■ preferred drugs C EPATITIS H A GENTS -Preferred Agents Agents Non Preferred PA Criteria Pegylated Interferons -2b) -INTRON (pegylated IFN alfa PEG 2a) PEGASYS (pegylated IFN alfa- ■ Treatment failure with preferred drugs within any subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs https://www.txvendordrug.com/formulary/formulary -search Search the Medicaid Formulary Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. Publication date: January 31, 2019 “PDL PA Criteria ” in the third column is not relevant but providers must obtain PDL prior authorization. the For drugs in therapeutic classes and/or subclasses that do not have a preferred drug option, 68 Page 35 of

41 HEALTH AND HUMAN SERVICES COMMISSION AUTHORIZATION (PA) CRITERIA TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR Effective January 31, 2019 GENTS A C EPATITIS H -Preferred Agents Agents Preferred Non PA Criteria Polymerase/Protease Inhibitors (sofosbuvir/velpatasvir ) daclatasvir) EPCLUSA DAKLINZA ( Treatment failure with ■ preferred drugs within any MAVYRET (glecaprevir/pibrentasvir) HARVONI (sofosbuvir/ledipasvir) subclass (sofosbuvir) SOVALDI VOSEVI (sofosbuvir, velpatasvir, voxilaprevir) Contraindication to ■ (ombitasvir/paritaprevir/ritonavir) TECHNIVIE preferred drugs VIEKIRA PAK (dasabuvir/ombitasvir/paritaprevir/ritonavir) Allergic reaction to ■ VIEKIRA XR (dasabuvir/ombitasvir/paritaprevir/ritonavir) preferred drugs (elbasvir/grazoprevir) ZEPATIER Clinical Prior Authorization ■ Applies Ribavirin REBETOL solution ribavirin capsule Treatment failure with ■ preferred drugs within any RIBASPHERE 400, 600 mg ribavirin tablet subclass ribavirin dose pack ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs (HAE) H EREDITARY A NGIOEDEMA T REATMENTS Preferred Agents Non -Preferred Agents PA Criteria HAEGARDA (C1 esterase inhibitor) - ) C1 esterase inhibitor BERINERT ( ■ Treatment failure with RUCONEST ( C1 esterase inhibitor ) preferred drugs within any C1 esterase inhibitor ) CINRYZE ( subclass ) FIRAZYR (icatibant ■ Contraindication to ecallantide ) KALBITOR ( preferred drugs Allergic reaction to ■ preferred drugs https://www.txvendordrug.com/formulary/formulary -search Search the Medicaid Formulary Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. Publication date: January 31, 2019 “PDL PA Criteria ” in the third column is not relevant but providers must obtain PDL prior authorization. the For drugs in therapeutic classes and/or subclasses that do not have a preferred drug option, 68 Page 36 of

42 HEALTH AND HUMAN SERVICES COMMISSION AUTHORIZATION (PA) CRITERIA TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR Effective January 31, 2019 NCRETIN I , YPOGLYCEMICS IMETICS H M NHANCERS /E Preferred Agents -Preferred Agents PA Criteria Non Amylin Analogs (pramlintide) SYMLIN Patient must meet all of the following criteria: Diagnosis of diabetes ■ mellitus ■ Age >18 years ■ HbA1C in past 6 months ■ No history of gastroparesis, neurologic manifestations of diabetes or recent treatment of hypoglycemia ■ Clinical Prior Authorization Applies Incretin Enhancers JENTADUETO (linagliptin/metformin) alogliptin Treatment failure with ■ preferred drugs within any alogilptin/metformin KOMBIGLYZE XR (saxagliptin/metformin) subclass alogliptin/pioglitazone ONGLYZA (saxagliptin) ■ Contraindication to JANUMET (sitagliptin/metformin) TRADJENTA (linagliptin) preferred drugs JANUMET XR (sitagliptin/metformin) ■ Allergic reaction to JANUVIA (sitagliptin) preferred drugs JENTADUETO XR (linagliptin/metformin) Clinical Prior Authorization ■ KAZANO (alog liptin /metformin ) Applies NESINA (alogliptin) OSENI (alogliptin / glimepiride) Search the Medicaid Formulary https://www.txvendordrug.com/formulary/formulary -search Publication date: January 31, 2019 Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. For drugs in therapeutic classes and/or subclasses that do not have a preferred drug option, the Criteria ” in the third column is not relevant but providers must obtain PDL prior authorization. “PDL PA 68 Page 37 of

43 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 31, 2019 H /E IMETICS M NCRETIN I , YPOGLYCEMICS NHANCERS Non Preferred Agents PA Criteria -Preferred Agents Incretin Mimetics (lixisenatide) ADLYXIN BYDUREON (exenatide ER) pens, ■ Treatment failure with preferred drugs within any vials BYDUREON BCISE (exenatide ER) subclass BYETTA (exenatide) OZEMPIC (semaglutide) Contraindication to ■ VICTOZA (liraglutide) TRULICITY (dulaglutide) preferred drugs Allergic reaction to ■ preferred drugs ■ Clinical Prior Authorization Applies Incretin Enhancers/SGLT2 Inhibitor Combinations QTERN (dapagliflozin/saxagliptin) GLYXAMBI (empagliflozin/linagliptin) Clinical Prior Authorization ■ STEGLUJAN (ertugliflozin/sitagliptin) Applies Incretin Mimetic/Insulin Combinations SOLIQUA insulin glargine) (lixisenatide/ ■ Clinical Prior Authorization Applies nsulin (liraglutide/i ) XULTOPHY degludec NSULIN I , YPOGLYCEMICS H -Preferred Agents PA Criteria Non Preferred Agents ADMELOG (insulin lispro) HUMULIN (insulin) pens HUMALOG (insulin lispro) vials Treatment failure with ■ AFREZZA (insulin) preferred drugs within any HUMULIN 500 UNITS/ML (insulin) HUMALOG MIX (insulin lispro/lispro protamine) vials subclass pen APIDRA (insulin glulisine) HUMULIN (insulin) vials Contraindication to ■ HUMULIN 70/30 (insulin) pens BASAGLAR (insulin glargine) HUMULIN 500 UNITS/ML (insulin) vial preferred drugs NOVOLIN (insulin) FIASP (insulin aspart) HUMULIN 70/30 (insulin) vials HUMALOG (insulin lispro) pens NOVOLIN 70/30 (insulin) LANTUS (insulin glargine) TOUJEO (insulin glargine) HUMALOG JUNIOR KWIKPEN (insulin LEVEMIR (insulin detemir) lispro) TRESIBA (insulin degludec) NOVOLOG (insulin aspart) HUMALOG MIX (insulin lispro/lispro NOVOLOG MIX (insulin aspart/aspart protamine) protamine) pens https://www.txvendordrug.com/formulary/formulary -search Search the Medicaid Formulary Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. Publication date: January 31, 2019 “PDL PA Criteria ” in the third column is not relevant but providers must obtain PDL prior authorization. the For drugs in therapeutic classes and/or subclasses that do not have a preferred drug option, 68 Page 38 of

44 HEALTH AND HUMAN SERVICES COMMISSION AUTHORIZATION (PA) CRITERIA TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR Effective January 31, 2019 EGLITINIDES M , YPOGLYCEMICS H Non PA Criteria -Preferred Agents Preferred Agents (repaglinide) PRANDIN nateglinide ■ Separate prescriptions for the individual components repaglinide repaglinide/metformin should be used instead of (nateglinide) STARLIX the combination drug. Clinical Prior Authorization ■ Applies H , M ETFORMIN YPOGLYCEMICS PA Criteria -Preferred Agents Non Preferred Agents FORTAMET (metformin ER) glyburide/metformin Separate prescriptions for ■ the individual components glipizide/metformin metformin should be used instead of GLUCOPHAGE (metformin) metformin ER (GLUCOPHAGE XR) the combination drug. XR (metformin ER) GLUCOPHAGE GLUMETZA (metformin ER) metformin ER (FORTAMET) metformin ER (GLUMETZA) RIOMET (metformin) SGLT2 , YPOGLYCEMICS H PA Criteria -Preferred Agents Preferred Agents Non INVOKANA (canaglifozin) FARXIGA (dapagliflozin) ■ Treatment failure with preferred drugs within any STEGLATRO (ertugliflozin) JARDIANCE (empagliflozin) subclass Contraindication to ■ preferred drugs Allergic reaction to ■ preferred drugs https://www.txvendordrug.com/formulary/formulary -search Search the Medicaid Formulary Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. Publication date: January 31, 2019 “PDL PA Criteria ” in the third column is not relevant but providers must obtain PDL prior authorization. the For drugs in therapeutic classes and/or subclasses that do not have a preferred drug option, 68 Page 39 of

45 HEALTH AND HUMAN SERVICES COMMISSION AUTHORIZATION (PA) CRITERIA TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR Effective January 31, 2019 SGLT2 , YPOGLYCEMICS H Preferred Agents Non -Preferred Agents PA Criteria SGLT2 Combinations SYNJARDY (empagliflozin/metformin) INVOKAMET (canagliflozin/metformin) Treatment failure with ■ preferred drugs within any INVOKAMET XR (canagliflozin/metformin) XIGDUO XR (dapagliflozin/metformin) subclass (ertugliflozin/metformin) SEGLUROMET Contraindication to ■ SYNJARDY XR (empagliflozin/metformin) preferred drugs Allergic reaction to ■ preferred drugs YPOGLYCEMICS H TZD , Preferred Agents PA Criteria -Preferred Agents Non Thiazolinediones pioglitazone (pioglitazone) ACTOS Treatment failure with ■ preferred drugs within any (rosiglitazone) AVANDIA subclass Contraindication to ■ preferred drugs ■ Allergic reaction to preferred drugs ■ Clinical Prior Authorization Applies TZD Combinations ACTOPLUS MET (pioglitazone/metformin) ■ Separate prescriptions for the individual components pioglitazone/metformin) ACTOPLUS MET XR ( should be used instead of pioglitazone/metformin . the combination drug pioglitazone/glimepiride ■ Clinical Prior Authorization Applies https://www.txvendordrug.com/formulary/formulary -search Search the Medicaid Formulary Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. Publication date: January 31, 2019 “PDL PA Criteria ” in the third column is not relevant but providers must obtain PDL prior authorization. the For drugs in therapeutic classes and/or subclasses that do not have a preferred drug option, 68 Page 40 of

46 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 31, 2019 G I MMUNE LOBULINS Preferred Agents Non PA Criteria -Preferred Agents CYTOGAM (CMV immune globulin) BIVIGAM (immune globulin) Treatment failure with ■ preferred drugs within any CARIMUNE NF (immune globulin) GAMMAGARD (immune globulin) subclass CUVITRU (immune globulin) -C (immune globulin) GAMUNEX ■ Contraindication to FLEBOGAMMA DIF (immune globulin) HIZENTRA (immune globulin) preferred drugs GAMMAKED (immune globulin) Allergic reaction to ■ HYQVIA (immune globulin) preferred drugs OCTAGAM (immune globulin) globulin) PRIVIGEN (immune MMUNOMODULATORS I A TOPIC D ERMATITIS , Preferred Agents -Preferred Agents PA Criteria Non DUPIXENT (dupilumab) EUCRISA (crisaborole) ■ Treatment failure with preferred drugs within any ecrolimus) (pim ELIDEL subclass (tacrolimus) PROTOPIC this therapeutic ■ Dupixent, in tacrolimus PDL class, is for Atopic The Dermatitis indication. clinical prior authorization linked here includes indications for both atopic dermatitis and eosinophilic asthma. ■ Contraindication to preferred drugs ■ Allergic reaction to preferred dru gs Clinical Prior Authorization ■ Applies https://www.txvendordrug.com/formulary/formulary -search Search the Medicaid Formulary Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. Publication date: January 31, 2019 “PDL PA Criteria ” in the third column is not relevant but providers must obtain PDL prior authorization. the For drugs in therapeutic classes and/or subclasses that do not have a preferred drug option, 68 Page 41 of

47 HEALTH AND HUMAN SERVICES COMMISSION AUTHORIZATION (PA) CRITERIA TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR Effective January 31, 2019 MMUNO SUPPRESSIVES , I O RAL Preferred Agents Non PA Criteria -Preferred Agents PROGRAF (tacrolimus) ASTAGRAF XL (tacrolimus) azathioprine Treatment failure with ■ preferred drugs within any RAPAMUNE (sirolimus) tablets AZASAN (azathioprine) cyclosporine, modified subclass SANDIMMUNE (cyclosporine) CELLCEPT (mycophenolate mofetil) mycophenolate mofetil capsules, tablets ■ Contraindication to ZORTRESS (everolimus) cyclosporine NEORAL (cyclosporine, modified) capsules preferred drugs ENVARSUS XR (tacrolimus) RAPAMUNE (sirolimus) solution ■ Allergic reaction to IMURAN (azathioprine ) sirolimus tablets preferred drugs mycophenolate mofetil suspension tacrolimus mycophenolic acid MYFORTIC (mycophenolic acid) NEORAL (cyclosporine, modified) solution R NTRANASAL I GENTS A HINITIS Preferred Agents Non -Preferred Agents PA Criteria Glucocorticoids fluticasone BECONASE AQ (beclomethasone) triamcinolone Treatment failure with ■ preferred drugs within any budesonide VERAMYST (fluticasone furoate) subclass CLARISPRAY (fluticasone) OTC ZETONNA (ciclesonide) ■ Contraindication to flunisolide preferred drugs NASONEX (mometasone) ■ Allergic reaction to OMNARIS (ciclesonide) preferred drugs QNASL (beclomethasone dipropionate) Search the Medicaid Formulary https://www.txvendordrug.com/formulary/formulary -search Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. Publication date: January 31, 2019 the “PDL PA Criteria ” in the third column is not relevant but providers must obtain PDL prior authorization. For drugs in therapeutic classes and/or subclasses that do not have a preferred drug option, of Page 68 42

48 HEALTH AND HUMAN SERVICES COMMISSION AUTHORIZATION (PA) CRITERIA TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR Effective January 31, 2019 GENTS A HINITIS R NTRANASAL I PA Criteria -Preferred Agents Non Preferred Agents Others (generic ASTELIN) (azelastine) azelastine ASTEPRO ■ Treatment failure with preferred drugs within any ATROVENT (ipratropium) nasal spray subclass azelastine (generic ASTEPRO) ■ Contraindication to ipratropium nasal spray preferred drugs olopatadine Allergic reaction to ■ (olopatadine) PATANASE preferred drugs Clinical Prior Authorization ■ Applies Combinations DYMISTA (azelastine/fluticasone) I , RON RAL O See Separate Listing Of Preferred Oral Iron Drugs. L EUKOTRIENE M ODIFIERS Preferred Agents PA Criteria -Preferred Agents Non chewable tablets, tablets (zafirlukast) ACCOLATE montelukast Treatment failure with ■ preferred drugs within any montelukast granules subclass SINGULAIR ( montelukast) Contraindication to ■ zafirlukast preferred drugs (zileuton) ZYFLO ■ Allergic reaction to ZYFLO CR (zileuton) preferred drugs ■ Clinical Prior Authorization Applies https://www.txvendordrug.com/formulary/formulary -search Search the Medicaid Formulary Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. Publication date: January 31, 2019 “PDL PA Criteria ” in the third column is not relevant but providers must obtain PDL prior authorization. the For drugs in therapeutic classes and/or subclasses that do not have a preferred drug option, 68 Page 43 of

49 HEALTH AND HUMAN SERVICES COMMISSION AUTHORIZATION (PA) CRITERIA TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR Effective January 31, 2019 TREPTOGRAMINS /S XAZOLIDINONES /O INCOSAMIDES L Non -Preferred Agents PA Criteria Preferred Agents clindamycin capsules CLEOCIN (clindamycin) ■ Treatment failure with preferred drugs within any clindamycin injection clindamycin solution subclass LINCOCIN (lincomycin) linezolid suspension ■ Contraindication to SIVEXTRO (tedizolid) linezolid tablets preferred drugs ZYVOX (linezolid) ■ tion to Allergic reac preferred drugs , O IPOTROPICS L THER PA Criteria -Preferred Agents Non Preferred Agents Bile Acid Sequestrants cholestyramine COLESTID (colestipol) ■ Treatment failure with preferred drugs within any colestipol granules colestipol tablet s subclass QUESTRAN (cholestyramine) ■ Contraindication to QUESTRAN LIGHT (cholestyramine) preferred drugs WELCHOL (colesevalam) Allergic reaction to ■ preferred drugs Cholesterol Absorption Inhibitors ZETIA (ezetimibe) Treatment failure with ■ preferred drugs within any subclass ■ Contraindication to preferred drugs Allergic reaction to ■ preferred drugs https://www.txvendordrug.com/formulary/formulary -search Search the Medicaid Formulary Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. Publication date: January 31, 2019 “PDL PA Criteria ” in the third column is not relevant but providers must obtain PDL prior authorization. the For drugs in therapeutic classes and/or subclasses that do not have a preferred drug option, 68 Page 44 of

50 HEALTH AND HUMAN SERVICES COMMISSION AUTHORIZATION (PA) CRITERIA TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR January 31, 2019 Effective L O , IPOTROPICS THER PA Criteria -Preferred Agents Non Preferred Agents Fibric Acid Derivatives TRICOR (fenofibrate) (generic Antara, Lofibra ) fenofibrate (generic Lipofen, Tricor) fenofibrate ■ Treatment failure with preferred drugs within any TRIGLIDE (fenofibrate) fenofibric acid (generic Fibricor , gemfibrozil subclass ) Trilipix TRILIPIX (fenofibric acid) Contraindication to ■ FENOGLIDE (fenofibrate) preferred drugs LIPOFEN (fenofibrate) ■ Allergic reaction to LOPID (gemfibrozil) preferred drugs Homozygous Familial Hypercholesterolemia Treatments JUXTAPID (lomitapide) KYNAMRO (mipomersen) Niacin OTC niacin niacin ER ■ Treatment failure with preferred drugs within any (niacin) NIACOR (niacin) NIASPAN subclass SLO -NIACIN OTC (niacin) ■ Contraindication to preferred d rugs Allergic reaction to ■ preferred drugs Clinical Prior Authorization ■ Applies -3 Fatty Acids Omega LOVAZA -3 fatty acids) (omega ■ Clinical Prior Authorization Applies -3 fatty acids omega VASCEPA (icosapent ethyl) PCSK9 Inhibitors (alirocumab) PRALUENT ■ Trial and failure of (evolocumab) REPATHA atorvastatin, rosuvastatin, and ezetimibe. Clinical Prior Authorization ■ Applies https://www.txvendordrug.com/formulary/formulary -search Search the Medicaid Formulary Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. Publication date: January 31, 2019 “PDL PA Criteria ” in the third column is not relevant but providers must obtain PDL prior authorization. the For drugs in therapeutic classes and/or subclasses that do not have a preferred drug option, 68 Page 45 of

51 HEALTH AND HUMAN SERVICES COMMISSION AUTHORIZATION (PA) CRITERIA TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR Effective January 31, 2019 L , IPOTROPICS S TATINS Preferred Agents Non -Preferred Agents PA Criteria Statins (fluvastatin) LESCOL XL ALTOPREV (lovastatin) atorvastatin ■ Treatment failure with at least two preferred drugs LIPITOR (atorvastatin) Duplicate Therapy Edit • • Duplicate Therapy Edit accounting for no less than • Duplicate Therapy Edit Dose Optimization Edit • • Dose Optimization Edit 120 days of therapy CRESTOR (rosuvastatin) lovastatin • Dose Optimization Edit combined LIVALO (pitavastatin) • Duplicate Therapy Edit py Edit • Duplicate Thera Contraindication to ■ PRAVACHOL (pravastatin) Dose Optimization Edit • Dose Optimization Edit • preferred drugs • Duplicate Therapy Edit pravastatin fluvastatin ■ Allergic reaction to preferred drugs Dose Optimization Edit • • Duplicate Therapy Edit • Duplicate Therapy Edit Clinical Prior Authorization ■ ZOCOR (simvastatin) • • Optimization Edit Dose Optimization Edit Dose Applies • Duplicate Therapy Edit simvastatin fluvastatin ER • Dose Optimization Edit • Duplicate Therapy Edit • Duplicate Therapy Edit (pitavastatin) ZYPITAMAG Dose Optimization Edit • Dose Optimization Edit • Statin Combinations atorvastatin/amlodipine Clinical Prior Authorization ■ Applies CADUET ( atorvastatin/amlodipine) VYTORIN ( simvastatin/ezetimibe) ACROLIDES ) M (O RAL Preferred Agents PA Criteria -Preferred Agents Non ZITHROMAX (azithromycin) azithromycin clarithromycin suspension, tablets ■ Treatment failure with preferred drugs within any clarithromycin ER erythromycin base subclass E.E.S. (erythromycin) Contraindication to ■ ERYPED (erythromycin) preferred drugs -TAB (erythromycin) ERY Allergic reaction to ■ ERYTHROCIN (erythromycin) preferred drugs https://www.txvendordrug.com/formulary/formulary -search Search the Medicaid Formulary Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. Publication date: January 31, 2019 “PDL PA Criteria ” in the third column is not relevant but providers must obtain PDL prior authorization. the For drugs in therapeutic classes and/or subclasses that do not have a preferred drug option, 68 Page 46 of

52 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA January 31, 2019 Effective MOVEMENT DISORDERS Preferred Agents -Preferred Agents Non PA Criteria AUSTEDO (deutetrabenazine) XENAZINE (tetrabenazine) Treatment failure with ■ INGREZZA (valbenazine) preferred drugs within any tetrabenazine subclass ■ Contraindication to preferred drugs Allergic reaction to ■ preferred drugs ■ Clinical Prior Authorization Applies AIN P EUROPATHIC N Preferred Agents PA Criteria -Preferred Agents Non Oral Agents (duloxetine) CYMBALTA (Cymbalta) duloxetine Treatment failure with ■ preferred drugs within any gabapentin duloxetine (Irenka) subclass GRALISE (gabapentin) LYRICA (pregabalin) capsule Contraindication to ■ HORIZANT (gabapentin enacar bil ER) preferred drugs LYRICA (pregabalin) solution Allergic reaction to ■ LYRICA CR (pregabalin) preferred drugs SAVELLA (milnacipran) ■ Clinical Prior Authorization Applies Topical Agents capsaicin OTC (lidocaine DERMACINRX PHN PAK patch, DermacinRX Moisturizing Complex Cream) lidocaine patch LIDODERM (lidocaine) https://www.txvendordrug.com/formulary/formulary -search Search the Medicaid Formulary Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. Publication date: January 31, 2019 “PDL PA Criteria ” in the third column is not relevant but providers must obtain PDL prior authorization. the For drugs in therapeutic classes and/or subclasses that do not have a preferred drug option, 68 Page 47 of

53 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 31, 2019 NSAIDS -Preferred Agents Non Preferred Agents PA Criteria Nonspecific ibuprofen ketorolac ADVIL (ibuprofen) ■ Treatment failure with preferred drugs within any in domethacin capsules ALEVE (naproxen) Ketorolac Edit • subclass ANAPROX OTC naproxen sodium (naproxen) • Duplicate Therapy Edit Contraindication to ■ CHILDREN’S MOTRIN (ibuprofen) naproxen tablets meclofenamate preferred drugs (diclofenac) (oxaprozin DAYPRO VOLTAREN ) mefenamic acid Allergic reaction to ■ diclofenac nabumetone preferred drugs diclofenac SR fenoprofen) NALFON ( Clinical Prior Authorization ■ diflunisal (naproxen) NAPROSYN Applies etodolac CR naproxen etodolac SR naproxen EC (piroxicam) FELDENE naproxen sodium (Rx) fenoprofen naproxen suspension flurbiprofen oxaprozin (indomethacin) capsules , INDOCIN piroxicam suspension SPRIX (ketorolac) indomethacin ER capsules sulindac ketoprofen tolmetin ketoprofen ER (diclofenac) ZORVOLEX NSAID/GI Protectant Combinations ARTHROTEC (diclofenac/misoprostol) ■ Treatment failure with preferred drugs within any diclofenac/misoprostol subclass XIS (ibuprofen/famotidine) DUE Contraindication to ■ VIMOVO (naproxen/ esomeprazole) preferred drugs ■ Allergic reaction to preferred drugs ■ Clinical Prior Authorization Applies Search the Medicaid Formulary https://www.txvendordrug.com/formulary/formulary -search Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. Publication date: January 31, 2019 the “PDL PA Criteria ” in the third column is not relevant but providers must obtain PDL prior authorization. For drugs in therapeutic classes and/or subclasses that do not have a preferred drug option, 68 Page 48 of

54 HEALTH AND HUMAN SERVICES COMMISSION AUTHORIZATION (PA) CRITERIA TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR Effective January 31, 2019 NSAIDS Non -Preferred Agents Preferred Agents PA Criteria -II Selective COX CELEBREX tablets meloxicam (celecoxib) MOBIC (meloxicam) ■ Treatment failure with preferred drugs within any • Duplicate Therapy Edit • Duplicate Therapy Edit • Duplicate Therapy Edit subclass • -2 Inhibitors Edit COX • Dose Optimization Edit • Dose Optimization Edit ■ Contraindication to celecoxib COX • • COX -2 Inhibitors Edit -2 Inhibitors Edit preferred drugs Edit Duplicate Therapy • Allergic reaction to ■ COX -2 Inhibitors Edit • preferred drugs meloxicam suspension ■ Clinical Prior Authorization • Duplicate Therapy Edit Applies • -2 Inhibitors Edit COX Topical NSAIDs diclofenac ■ Clinical Prior Authorization Applies FLECTOR (diclofenac) INDOCIN (indomethacin) suppositories PENNSAID (diclofenac) VOLTAREN (diclofenac) XRYLIX KIT (diclofenac) S NTIBIOTIC A , PHTHALMICS O – OMBINATIONS C TEROID PA Criteria Preferred Agents Non -Preferred Agents BLEPHAMIDE S.O.P. (sulfacetamide/prednisolone) BLEPHAMIDE (sulfacetamide/prednisolone) ■ Treatment failure with preferred drugs within a ny MAXITROL (neomycin/polymyxin/ dexamethasone) neomycin/polymyxin/dexamethasone subclass neomycin/bacitracin/polymyxin/hydrocortisone sulfacetamide/prednisolone ■ Contraindication to neomycin/polymyxin/ hydrocortisone TOBRADEX (tobramycin/dexamethasone) ointment preferred drugs -G (gentamicin/prednisolone) PRED ■ Allergic reaction to TOBRADEX (tobramycin/dexamethasone) suspension preferred drugs TOBRADEX ST (tobramycin/dexamethasone) tobramycin/dexamethasone ZYLET (tobramycin/loteprednol) https://www.txvendordrug.com/formulary/formulary -search Search the Medicaid Formulary Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. Publication date: January 31, 2019 “PDL PA Criteria ” in the third column is not relevant but providers must obtain PDL prior authorization. the For drugs in therapeutic classes and/or subclasses that do not have a preferred drug option, 68 Page 49 of

55 HEALTH AND HUMAN SERVICES COMMISSION AUTHORIZATION (PA) CRITERIA TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR Effective January 31, 2019 O NTIBIOTICS A PHTHALMIC Non Preferred Agents -Preferred Agents PA Criteria Aminoglycosides TOBREX (tobramycin) gentamicin solution ■ Treatment failure with preferred drugs within any tobramycin subclass ointment TOBREX (tobramycin) Contraindication to ■ preferred drugs ■ Allergic reaction to preferred drugs Quinolones BESIVANCE (besifloxacin) ciprofloxacin ■ Treatment failure with preferred drugs within any CILOXAN (ciprofloxacin) MOXEZA (moxifloxacin) subclass gatifloxacin Contraindication to ■ levofloxacin preferred drugs moxifloxacin Allergic reaction to ■ OCUFLOX (ofloxacin) preferred drugs ofloxacin VIGAMOX (moxifloxacin) Macrolides AZASITE (azithromycin) erythromycin Treatment failure with ■ preferred drugs within any subclass Contraindication to ■ preferred drugs ■ Allergic reaction to preferred drugs https://www.txvendordrug.com/formulary/formulary -search Search the Medicaid Formulary Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. Publication date: January 31, 2019 “PDL PA Criteria ” in the third column is not relevant but providers must obtain PDL prior authorization. the For drugs in therapeutic classes and/or subclasses that do not have a preferred drug option, 68 Page 50 of

56 HEALTH AND HUMAN SERVICES COMMISSION AUTHORIZATION (PA) CRITERIA TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR January 31, 2019 Effective NTIBIOTICS A PHTHALMIC O Non PA Criteria -Preferred Agents Preferred Agents Other bacitracin bacitracin/polymyxin Treatment failure with ■ preferred drugs within any BLEPH -10 (sulfacetamide) polymyxin/trimethoprim subclass NATACYN (natamycin) ■ Contraindication to neomycin/bacitracin/polymyxin preferred drugs neomycin/polymyxin/gramicidin ■ reaction to Allergic POLYTRIM (polymyxin/trimethoprim) preferred drugs , solution sulfacetamide ointment ONJUNCTIVITIS C A PHTHALMICS FOR O LLERGIC PA Criteria -Preferred Agents Non Preferred Agents epinastine cromolyn ALOCRIL (nedocromil) Treatment failure with ■ preferred drugs within any ketotifen ALOMIDE (lodoxamide) PAZEO (olopatadine) subclass LASTACAFT (alcaftadine) ALREX (loteprednol) Contraindication to ■ olopatadine azelastine preferred drugs PATADAY (olopatadine) BEPREVE (bepotastine) ■ Allergic reaction to PATANOL (olopatadine) (epi nastine ) ELESTAT preferred drugs EMADINE (emedastine) https://www.txvendordrug.com/formulary/formulary -search Search the Medicaid Formulary Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. Publication date: January 31, 2019 “PDL PA Criteria ” in the third column is not relevant but providers must obtain PDL prior authorization. the For drugs in therapeutic classes and/or subclasses that do not have a preferred drug option, 68 Page 51 of

57 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 31, 2019 O NFLAMMATORIES -I NTI A , PHTHALMICS -Preferred Agents Non Preferred Agents PA Criteria NSAIDS diclofenac ACULAR (ketorolac) Treatment failure with ■ preferred drugs within any ACULAR LS (ketorolac) flurbiprofen subclass ketorolac ACUVAIL (ketorolac) Contraindication to ■ bromfenac NEVANAC (nepafenac) preferred drugs BROMSITE (bromfenac) ■ Allergic reaction to ILEVRO (nepafenac) preferred drugs ketorolac LS ■ Clinical Prior Authorization Applies Steroids MAXIDEX (dexamethasone) dexamethasone DUREZOL (difluprednate) Treatment failure with ■ preferred drugs within any OMNIPRED (prednisolone) FLAREX (fluorometholone) suspension LOTEMAX (loteprednol) subclass PRED FORTE (prednisolone) fluorometholone prednisolone acetate Contraindication to ■ PRED MILD (prednisolone) FML (fluorometholone) preferred drugs prednisolone sodium phosphate FML FORTE (fluorometholone) Allergic reaction to ■ FML S.O.P. (fluorometholone) preferred drugs LOTEMAX (loteprednol) gel, ointment -I , PHTHALMICS O NTI A MMUNOMODULATORS I NFLAMMATORY Preferred Agents Non -Preferred Agents PA Criteria (cyclosporin) RESTASIS MULTIDOSE (cyclosporin) RESTASIS Treatment failure with ■ preferred drugs within any (lifitegrast) XIIDRA subclass Contraindication to ■ preferred drugs ■ Allergic reaction to preferred drugs https://www.txvendordrug.com/formulary/formulary -search Search the Medicaid Formulary Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. Publication date: January 31, 2019 “PDL PA Criteria ” in the third column is not relevant but providers must obtain PDL prior authorization. the For drugs in therapeutic classes and/or subclasses that do not have a preferred drug option, 68 Page 52 of

58 HEALTH AND HUMAN SERVICES COMMISSION AUTHORIZATION (PA) CRITERIA TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR Effective January 31, 2019 GENTS A LAUCOMA G , PHTHALMICS O Preferred Agents -Preferred Agents Non PA Criteria Sympathomimetics ALPHAGAN P (brimonidine) brimonidine Treatment failure with ■ preferred drugs within any apraclonidine pilocarpine subclass brimonidine P ■ Contraindication to IOPIDINE (apraclonidine) preferred drugs ■ Allergic reaction to preferred drugs Beta Blockers carteolol BETAGAN (levobunolol) ■ Treatment failure with preferred drugs within any betaxolol levobunolol subclass BETOPTIC S (betaxolol) timolol ■ Contraindication to ISTALOL (timolol) preferred drugs TIMOPTIC (timolol) ■ Allergic reaction to (timolol) TIMOPTIC XE preferred drugs Clinical Prior Authorization ■ Applies Carbonic Anhydrase Inhibitors AZOPT (brinzolamide) TRUSOPT (dorzolamide) Treatment failure with ■ preferred drugs within any dorzolamide subclass ■ Contraindication to preferred drugs Allergic reaction to ■ preferred drugs Rho Kinase Inhibitor RHOPRESSA (netarsudil) https://www.txvendordrug.com/formulary/formulary -search Search the Medicaid Formulary Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. Publication date: January 31, 2019 “PDL PA Criteria ” in the third column is not relevant but providers must obtain PDL prior authorization. the For drugs in therapeutic classes and/or subclasses that do not have a preferred drug option, 68 Page 53 of

59 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 31, 2019 PHTHALMICS O LAUCOMA A G , GENTS Preferred Agents Non -Preferred Agents PA Criteria Prostaglandin Analogs latanoprost bimatoprost Treatment failure with ■ preferred drugs within any LUMIGAN (bimatoprost) -Z (travoprost) TRAVATAN subclass VYZULTA (latanoprostene bunod) ■ Contraindication to XALATAN (latanoprost) preferred drugs ZIOPTAN (tafluprost) Allergic reaction to ■ preferred drugs Combination Agents COMBIGAN (brimonidine/timolol) COSOPT (dorzolamide/timolol) ■ Treatment failure with preferred drugs within any dorzolamide/timolol COSOPT PF (dorzolamide/timolol) subclass SIMBRINZA (brinzolamide/brimonidine) ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs Miscellaneous phospholine iodide https://www.txvendordrug.com/formulary/formulary -search Search the Medicaid Formulary Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. Publication date: January 31, 2019 “PDL PA Criteria ” in the third column is not relevant but providers must obtain PDL prior authorization. the For drugs in therapeutic classes and/or subclasses that do not have a preferred drug option, 68 Page 54 of

60 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 31, 2019 EPENDENCE D PIATE O T REATMENTS Preferred Agents -Preferred Agents PA Criteria Non buprenorphine/naloxone BUNAVAIL (buprenorphine/naloxone) ■ Treatment failure with preferred drugs within any EVZIO (naloxone) Opiate/Benzo/Muscle Relaxant Combo Edit • subclass LUCEMYRA (lofexidine) • Buprenorphine Edit ■ Contraindication to buprenorphine preferred drugs naloxone syringe, vial Allergic reaction to ■ naltrexone preferred drugs NARCAN (naloxone) nasal ■ Clinical Prior Authorization film (buprenorphine/naloxone) SUBOXONE Applies VIVITROL (naltrexone) ZUBSOLV (buprenorphine/naloxone) • Opiate/Benzo/Muscle Relaxant Combo Edit • Buprenorphine Edit O TIC A NTIBIOTICS Preferred Agents PA Criteria -Preferred Agents Non CIPRODEX (ciprofloxacin/dexamethasone) CIPRO HC (ciprofloxacin/hydrocortisone) ■ Treatment failure with preferred drugs within any hydrocortisone) COLY -MYCIN S (colistin/neomycin/ ciprofloxacin subclass ofloxacin neomycin/polymyxin/hydrocortisone ■ Contraindication to OTOVEL (ciprofloxacin/fluocinolone) preferred drugs Allergic reaction to ■ preferred drugs A TIC NESTHETICS /A NFECTIVES O -I NTI PA Criteria -Preferred Agents Preferred Agents Non acetic acid/hydrocortisone acetic acid ■ Treatment failure with preferred drugs within any subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs https://www.txvendordrug.com/formulary/formulary -search Search the Medicaid Formulary Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. Publication date: January 31, 2019 “PDL PA Criteria ” in the third column is not relevant but providers must obtain PDL prior authorization. the For drugs in therapeutic classes and/or subclasses that do not have a preferred drug option, 68 Page 55 of

61 HEALTH AND HUMAN SERVICES COMMISSION AUTHORIZATION (PA) CRITERIA TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR Effective January 31, 2019 NHALATION I , RAL (O GENTS A PAH ) Preferred Agents Non -Preferred Agents PA Criteria ADEMPAS (riociguat) ADCIRCA (tadalafil) ■ Treatment failure with preferred drugs within any OPSUMIT (macitentan) LETAIRIS (ambrisentan) subclass ORENITRAM ER (treprostinil) (generic Revatio) sildenafil ■ Contraindication to REVATIO (sildenafil) TRACLEER (bosentan) tablet preferred drugs TRACLEER (bosentan) suspension Allergic reaction to ■ TYVASO Inhalation (treprostinil) preferred drugs UPTRAVI (selexipag) ■ Clinical Prior Authorization VENTAVIS Inhalation (iloprost) Applies NZYMES E P ANCREATIC Preferred Agents PA Criteria -Preferred Agents Non CREON (pancrelipase) PANCREAZE (pancrelipase) ■ Treatment failure with preferred drugs within any PERTZYE (pancrelipase) ZENPEP (pancrelipase) subclass VIOKACE (pancrelipase) Contraindication to ■ preferred drugs Allergic reaction to ■ preferred drugs EDIATRIC VITAMIN PRE P PARATIONS See Separate Listing Of Preferred Pediatric Vitamin Preparations. P ENICILLINS Preferred Agents Non PA Criteria -Preferred Agents amoxicillin Treatment failure with ■ preferred drugs within any ampicillin subclass dicloxacillin Contraindication to ■ penicillin VK preferred drugs ■ Allergic reaction to preferred drugs https://www.txvendordrug.com/formulary/formulary -search Search the Medicaid Formulary Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. Publication date: January 31, 2019 “PDL PA Criteria ” in the third column is not relevant but providers must obtain PDL prior authorization. the For drugs in therapeutic classes and/or subclasses that do not have a preferred drug option, 68 Page 56 of

62 HEALTH AND HUMAN SERVICES COMMISSION AUTHORIZATION (PA) CRITERIA TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR Effective January 31, 2019 INDERS B HOSPHATE P PA Criteria -Preferred Agents Non Preferred Agents AURYXIA (ferric citrate) acetate calcium Allergic reaction to preferred drug OR treatment failure with preferred drug; ELIPHOS (calcium acetate) MAGNEBIND 400 RX (calcium carbonate , folic acid, magnesium carbonate) iagnosis of ESRD and AND d FOSRENOL (lanthanum) RENAGEL (sevelamer HCl) hyperphosphatemia despite dietary PHOSLYRA (calcium acetate) at least phosphorous restrictions AND RENVELA (sevelamer carbonate) of the following: one ) sucroferric oxyhydroxide VELPHORO ( hypercalcemia (corrected ■ serum calcium >10.2 mg/dL) plasma PTH levels <150 ■ pg/mL on two consecutive measurements dialysis patients with severe ■ vascular and/or soft tissue calcifications Clinical Prior Authorization Applies P A GGREGATION I NHIBITORS LATELET PA Criteria -Preferred Agents Non Preferred Agents AGGRENOX dipyridamole (dipyridamole/aspirin) Treatment failure with ■ preferred drug EFFIENT (prasugrel) BRILINTA (ticagrelor) Contraindication to ■ (dipyridamole) PERSANTINE clopidogrel preferred drug prasugrel PLAVIX (clopidogrel) ■ Allergic reaction to Ticlopidine preferred drug ZONTIVITY (vorapaxar) ■ Clinical Prior Authorization Applies V ITAMINS RENATAL P See Separate Preferred Prenatal Vitamin Listing. PA Criteria: ■ Prenatal vitamins are covered only for females less than 50 years of age. https://www.txvendordrug.com/formulary/formulary -search Search the Medicaid Formulary Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. Publication date: January 31, 2019 “PDL PA Criteria ” in the third column is not relevant but providers must obtain PDL prior authorization. the For drugs in therapeutic classes and/or subclasses that do not have a preferred drug option, 68 Page 57 of

63 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 31, 2019 GENTS A ROGESTATIONAL P -Preferred Agents Non Preferred Agents PA Criteria Clinical Prior Authorization ■ MAKENA AUTO INJECTOR Applies (hydroxyprogesterone) (hydroxyprogesterone) MAKENA C ACHEXIA P ROGESTINS FOR Preferred Agents Non -Preferred Agents PA Criteria megestrol MEGACE (megestrol) ■ Treatment failure with preferred drug MEGACE ES (megestrol) ■ Contraindication to preferred drug ■ Allergic reaction to preferred drug RAL (O ROTON P P ) I UMP NHIBITORS Preferred Agents Non -Preferred Agents PA Criteria rabeprazole NEXIUM ( ACIPHEX (rabeprazole) esomeprazole) Treatment failure after no ■ n a 30 day trial of less tha DEXILANT (dexlansoprazole) ZEGERID (omeprazole/sodium Rx omeprazole each preferred drug bicarbonate) pantoprazole Duplicate Therapy Edit • ■ Contraindication to PROTONIX (pantoprazole) suspension • Dose Optimization Edit preferred drugs esomeprazole ■ Allergic reaction to lansoprazole preferred drugs NEXIUM OTC (esomeprazole) Prevacid Solutabs will be ■ omeprazole OTC approved for children 10 years of age and under omeprazole/sodium bicarbonate (lansoprazole) PREVACID Clinical Prior Authorization ■ Applies tablets (pantoprazole) PROTONIX https://www.txvendordrug.com/formulary/formulary -search Search the Medicaid Formulary Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. Publication date: January 31, 2019 “PDL PA Criteria ” in the third column is not relevant but providers must obtain PDL prior authorization. the For drugs in therapeutic classes and/or subclasses that do not have a preferred drug option, 68 Page 58 of

64 HEALTH AND HUMAN SERVICES COMMISSION AUTHORIZATION (PA) CRITERIA TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR Effective January 31, 2019 YPNOTICS EDATIVE H S Preferred Agents -Preferred Agents PA Criteria Non Benzodiazepines flurazepam estazolam ■ Treatment failure with preferred drugs within any 15, 30 mg temazepam • Anxiolytics and subclass Sedative/Hypnotics Edit triazolam ■ Contraindication to Opiate/Benzo/Muscle • preferred drugs Relaxant Combo Edit Allergic reaction to ■ (temazepam) RESTORIL preferred drugs tema zepam 7.5, 22.5 mg ■ Clinical Prior Authorization Applies Others (zolpidem) AMBIEN LUNESTA (eszopiclone) zolpidem Treatment failure with ■ ugs within any preferred dr (zolpidem) AMBIEN CR (ramelteon) ROZEREM subclass SILENOR (doxepin) BELSOMRA (suvorexant) ■ Contraindication to (zaleplon) EDLUAR (zolpidem) SONATA preferred drugs eszopiclone zaleplon ■ Allergic reaction to HETLIOZ (tasimelteon) zolpidem ER preferred drugs INTERMEZZO (zolpidem) ■ Clinical Prior Authorization Applies M KELETAL S ELAXANTS R USCLE Preferred Agents Non PA Criteria -Preferred Agents AMRIX (cyclobenzaprine ER) baclofen (chlorzoxazone) LORZONE Treatment failure with ■ preferred drugs within any (except 250 mg) carisoprodol metaxolone Opiate/Benzo/Muscle • subclass Relaxant Combo Edit cyclobenzaprine orphenadrine Contraindication to ■ Cyclobenzaprine Edit • (methocarbamol) ROBAXIN • Opiate/Benzo/Muscle preferred drugs Combo Edit Relaxant 250 mg carisoprodol SKELAXIN (metaxolone) Allergic reaction to ■ Cyclobenzaprine Edit carisoprodol compound • (carisoprodol) SOMA preferred drugs chlorzoxazone methocarbamol tizanidine capsules ■ Clinical Prior Authorizati on tizanidine DANTRIUM (dantrolene) tablet s ZANAFLEX (tizanidine) Applies dantrolene -search https://www.txvendordrug.com/formulary/formulary Search the Medicaid Formulary Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. Publication date: January 31, 2019 ” in the third column is not relevant but providers must obtain PDL prior authorization. Criteria “PDL PA the For drugs in therapeutic classes and/or subclasses that do not have a preferred drug option, 59 of 68 Page

65 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 31, 2019 C ESSATION MOKING S -Preferred Agents Non Preferred Agents PA Criteria bupropion SR NICODERM CQ (nicotine) ■ Treatment failure with preferred drugs within any NICOTROL (nicotine) CHANTIX (varenicline) subclass NICOTROL NS (nicotine) NICORETTE (nicotine) gum Contraindication to ■ (bupropion) ZYBAN NICORETTE (nicotine) lozenge preferred drugs nicotine gum Allergic reaction to ■ lozenge nicotine preferred drugs nicotine patch Clinical Prior Authorization ■ Applies TEROIDS S , OPICAL T Preferred Agents PA Criteria -Preferred Agents Non Low Potency MICORT -HC (hydrocortisone) -SMOOTHE/FS (fluocinolone) DERMA alclometasone ■ Treatment failure with preferred drugs within any TEXACORT (hydrocortisone ) solution DESONATE (desonide) (OTC) , ointment hydrocortisone cream, lotion subclass desonide hydrocortisone/aloe cream Contraindication to ■ fluocinolone oil preferred drugs hydrocortisone/mineral oil ointment ■ Allergic reaction to hydrocortisone lotion (Rx) preferred drugs Medium Potency fluticasone propionate lotion fluticasone propionate cream, ointment beclomethasone valerate foam Treatment failure with ■ preferred drugs within any hydrocortisone butyrate , solution clocortolone cream mometasone cream, ointment subclass hydrocortisone valerate CLODERM (clocortolone) Contraindication to ■ LUXIQ (betamethasone) CORDRAN (flurandrenolide) preferred drugs PANDEL (hydrocortisone probutate) CUTIVATE (fluticasone) ■ Allergic reaction to prednicarbate OCON (mometasone) EL preferred drugs SYNALAR (fluocinolone ) ocinolone acetonide flu flurandrenolide -search Search the Medicaid Formulary https://www.txvendordrug.com/formulary/formulary Publication date: January 31, 2019 Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. For drugs in therapeutic classes and/or subclasses that do not have a preferred drug option, the Criteria ” in the third column is not relevant but providers must obtain PDL prior authorization. “PDL PA 68 Page 60 of

66 HEALTH AND HUMAN SERVICES COMMISSION AUTHORIZATION (PA) CRITERIA TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR Effective January 31, 2019 , TEROIDS OPICAL S T Preferred Agents PA Criteria Non -Preferred Agents High Potency fluocinonide amcinonide betamethasone dipropionate lotion ■ Treatment failure with preferred drugs within any HALOG (halcinonide) betamethasone dipropionate cream, dipropionate/propylene glycol cream betamethasone subclass gel, ointment KENALOG aerosol (triamcinolone) betamethasone valerate cream ■ Contraindication to betamethasone dipropionate/ SERNIVO (betamethasone acetonide cream, ointment triamcinolone preferred drugs propylene glycol lotion, ointment dipropionate) Allergic reaction to ■ betamethasone valerate lotion, (desoximetasone) TOPICORT preferred d rugs ointment triamcinolone acetonide aerosol, desoximetasone lotion diflorasone triamcinolone/dimethicone DIPROLENE (betamethasone TRIANEX (triamcinolone) dipropionate) VANOS (fluocinonide) ELLZIA PAK (triamcinolone acetonide ointment/dimethicone) Very High Potency TEMOVATE (clobetasol) clobetasol emollient APEXICON E (diflorasone) Treatment failure with ■ preferred drugs within any lotion , shampoo clobetasol clobetasol propionate cream, gel, solution subclass foam, clobetasol propionate halobetasol Contraindication to ■ ointment, spray preferred drugs CLOBEX (clobetasol) ■ Allergic reaction to CLODAN (clobetasol) preferred drugs (clobetasol) OLUX Search the Medicaid Formulary -search https://www.txvendordrug.com/formulary/formulary Publication date: January 31, 2019 Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. ” in the third column is not relevant but providers must obtain PDL prior authorization. Criteria For drugs in therapeutic classes and/or subclasses that do not have a preferred drug option, the “PDL PA 68 Page 61 of

67 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA January 31, 2019 Effective TIMULANTS AND S GENTS A ELATED R Preferred Agents -Preferred Agents PA Criteria Non Stimulants (amphetamine) ADZENYS XR ODT methylphenidate chewable tablets ADDERALL XR (amphetamine salt combination) Treatment failure with ■ preferred drugs within any ADZENYS ER (amphetamine) methylphenidate ER APTENSIO XR (methylphenidate) subclass suspension amphetamine salt combination IR • Dose Optimization Edit n to Contraindicatio ■ amphetamine salt combination ER DAYTRANA (methylphenidate) • ADD_ADHD Edit preferred drugs CONCERTA (methylphenidate) dexmethylphenidate IR methylphenidate solution ■ Allergic reaction to COTEMPLA XR ODT IR dextroamphetamine modafinil preferred drugs ) (methylphenidate (amphetamine) DYANAVEL XR MYDAYIS (amphetamine salt ■ Methylin solution will not (methamphetamine) DESOXYN combination ER) FOCALIN XR methylphenidate) (dex require previous use of a DEXEDRINE (dextroamphetamine) NUVIGIL (armodafinil) (methylphenidate) METHYLIN solution preferred drug for patients ER dexmethylphenidate under six years of age PROCENTRA (dextroamphetamine) methylphenidate IR dextroamphetamine ER (modafinil) PROVIGIL ■ Clinical Prior Authorization generic Concerta) methylphenidate ER ( authorized dextroamphetamine solution Applies RITALIN (methylphenidate) (methylphenidate) QUILLICHEW ER (amphetamine) EVEKEO RITALIN LA (methylphenidate ER) QUILLIVANT XR (methylphenidate) (dexmethylphenidate) FOCALIN (dextroamphetamine) ZENZEDI (lisdexamfetamine) VYVANSE METADATE CD (methylphenidate) chewable tablets (lisdexamfetamine) VYVANSE methamphetamine methylphenidate CD -Stimulants Non clonidine ER atomoxetine Treatment failure with ■ preferred drugs within any guanfacine ER INTUNIV (guanfacine ER) subclass STRATTERA (atomoxetine) ■ Contraindication to preferred drugs Allergic reaction to ■ preferred drugs Clinical Prior Authorization ■ Applies Search the Medicaid Formulary https://www.txvendordrug.com/formulary/formulary -search Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. Publication date: January 31, 2019 “PDL PA Criteria the For drugs in therapeutic classes and/or subclasses that do not have a preferred drug option, ” in the third column is not relevant but providers must obtain PDL prior authorization. 62 of 68 Page

68 HEALTH AND HUMAN SERVICES COMMISSION AUTHORIZATION (PA) CRITERIA TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR January 31, 2019 Effective T ETRACYCLINES PA Criteria -Preferred Agents Non Preferred Agents ORACEA (doxycycline) doxycycline monohydrate 50, 100 mg capsules demeclocycline ■ Treatment failure with preferred drugs within any SOLODYN (minocycline) doxycycline hyclate IR minocycline capsules subclass tetracycline doxycycline hyclate DR suspension VIBRAMYCIN (doxycycline) ■ Contraindication to e, capsul VIBRAMYCIN (doxycycline) doxycycline monohydrate 40, 75, 150 preferred drugs syrup mg capsules ■ Allergic reaction to XIMINO (minocycline) doxycycline monohydrate suspension, preferred drugs tablets minocycline tablets minocycline ER C LCERATIVE U OLITIS PA Criteria -Preferred Agents Non Preferred Agents Oral DELZICOL (mesalamine) APRISO (mesalamine) ■ Treatment failure with preferred drugs within any ASACOL HD (mesalamine) LIALDA (mesalamine) of same route subclass AZULFIDINE (sulfasalazine) sulfasalazine Contraindication to ■ balsalazide sulfasalazine DR preferred drugs of same COLAZAL (balsalazide) route DIPENTUM (olsalazine) ■ Allergic reaction to GIAZO (balsalazide) preferred drugs of same PENTASA (mesalamine) route UCERIS (budesonide) Rectal mesalamine CANASA (mesalamine) Treatment failure with ■ preferred drugs within any SFROWASA (mesalamine) of same route subclass UCERIS (budesonide) Contraindication to ■ same preferred drugs of route Allergic reaction to ■ preferred drugs of same route https://www.txvendordrug.com/formulary/formulary -search Search the Medicaid Formulary Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. Publication date: January 31, 2019 “PDL PA Criteria ” in the third column is not relevant but providers must obtain PDL prior authorization. the For drugs in therapeutic classes and/or subclasses that do not have a preferred drug option, 68 Page 63 of

69 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 31, 2019 ISORDERS D YCLE C REA U Non PA Criteria -Preferred Agents Preferred Agents BUPHENYL (sodium phenylbutyrate) RAVICTI (glycerol phenylbutyrate) Treatment failure with ■ preferred drugs within any sodium phenylbutyrate powder CARBAGLU (carglumic acid) subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs https://www.txvendordrug.com/formulary/formulary -search Search the Medicaid Formulary Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. Publication date: January 31, 2019 the Criteria ” in the third column is not relevant but providers must obtain PDL prior authorization. “PDL PA For drugs in therapeutic classes and/or subclasses that do not have a preferred drug option, Page 64 of 68

70 HEALTH AND HUMAN SERVICES COMMISSION AUTHORIZATION (PA) CRITERIA TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR Effective January 31, 2019 PDL Review and Implementation Schedule Change Review 2019 Date of Most Recent PDL 2020 Date of Next PDL (Tentative) Review CLASS Change (Tentative) JAN 7/1/2019 JAN ACNE AGENTS, ORAL 7/1/2018 JAN 7/1/2019 7/1/2018 JAN ACNE AGENTS, TOPICAL JAN 7/1/2019 ANALGESICS, NARCOTICS LONG JAN 7/1/2018 7/1/2019 JAN JAN ANALGESICS, NARCOTICS SHORT 7/1/2018 JAN 7/1/2019 7/1/2018 ANGIOTENSIN MODULATOR COMBINATIONS JAN 7/1/2019 JAN 7/1/2018 ANGIOTENSIN MODULATORS JAN JAN 7/1/2019 JAN ANTIMIGRAINE AGENTS, OTHER 7/1/2018 7/1/2019 JAN JAN ANTIMIGRAINE AGENTS, TRIPTANS 7/1/2018 7/1/2019 JAN JAN BLADDER RELAXANT PREPARATIONS 7/1/2018 JAN 7/1/2019 7/1/2018 H. PYLORI TREATMENT JAN JAN 7/1/2019 JAN /2019 1 1/ IMMUNOMODULATORS, ATOPIC DERMATITIS 7/1/2019 JAN INTRANASAL RHINITIS AGENTS 7/1/2018 JAN JAN 7/1/2019 7/1/2018 MOVEMENT DISORDERS JAN 7/1/2019 JAN NEUROPATHIC PAIN 7/1/2018 JAN 7/1/2019 JAN JAN PHOSPHATE BINDERS 7/1/2018 JAN 7/1/2019 JAN PLATELET AGGREGATION INHIBITORS 7/1/2018 JAN 7/1/2019 JAN PROGESTINS FOR CACHEXIA 7/1/2018 7/1/2019 JAN JAN 7/1/2018 PROTON PUMP INHIBITORS 7/1/2019 JAN 7/1/2018 JAN SMOKING CESSATION JAN 3/9/2018 JAN STIMULANTS AND RELATED AGENTS 7/1/2019 7/1/2019 APR APR ANTI ALLERGENS, ORAL 7/1/2018 - 7/1/2019 APR ANTIBIOTICS, INHALED 7/1/2018 APR 7/1/2019 APR 7/1/2018 ANTICOAGULANTS APR 7/1/2019 APR APR 7/1/2018 ANTIDEPRESSANTS, OTHER 7/1/2019 7/1/2018 ANTIDEPRESSANTS, SSRIs APR APR https://www.txvendordrug.com/formulary/formulary -search Search the Medicaid Formulary Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. Publication date: January 31, 2019 “PDL PA Criteria ” in the third column is not relevant but providers must obtain PDL prior authorization. the For drugs in therapeutic classes and/or subclasses that do not have a preferred drug option, 68 Page 65 of

71 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 31, 2019 2019 Date of Most Recent PDL Date of Next PDL Change 2020 Review Change (Tentative) CLASS Review (Tentative) 7/1/2019 APR APR ANTIDEPRESSANTS, TRICYCLIC 7/1/2018 7/1/2019 7/1/2018 ANTIHYPERURICEMICS APR APR 7/1/2019 APR ANTIPARKINSONS AGENTS 7/1/2018 APR 7/1/2019 APR APR ANTIVIRALS, ORAL /2019 1 1/ 7/1/2019 7/1/2018 ANXIOLYTICS APR APR 7/1/2019 APR BETA - BLOCKERS 7/1/2018 APR 7/1/2019 APR BILE SALTS APR 7/1/2018 7/1/2019 APR APR BPH TREATMENTS 7/1/2018 7/1/2019 APR APR BRONCHODILATORS, BETA AGONIST 7/1/2018 7/1/2019 7/1/2018 COPD AGENTS APR APR 7/1/2019 APR 7/1/2018 COUGH AND COLD APR 7/1/2019 7/1/2018 ERYTHROPOIESIS STIMULATING PROTEINS APR APR 7/1/2019 APR 7/1/2018 APR GLUCOCORTICOIDS, INHALED 7/1/2019 7/1/2018 APR APR HAE TREATMENTS 7/1/2019 IMMUNE GLOBULINS, IV 7/1/2018 APR APR 7/1/2019 LINCOSAMIDES/OXAZOLIDINONES/STREPTOGRAMINS 7/1/2018 APR APR 7/1/2019 LIPOTROPICS, OTHER 7/1/2018 APR APR 7/1/2019 LIPOTROPICS, STATINS 7/1/2018 APR APR 7/1/2019 APR PAH AGENTS, ORAL AND INHALED 7/1/2018 APR 7/1/2019 PANCREATIC ENZYMES APR APR 7/1/2018 7/1/2019 /2019 PEDIATRIC VITAMIN PREPARATIONS 1/ 1 APR APR 7/1/2019 APR APR PRENATAL VITAMINS 1/ 1 /2019 7/1/2019 APR APR SEDATIVE HYPNOTICS 7/1/2018 7/1/2019 APR APR UREA CYCLE DISORDER, ORAL 7/1/2018 ALZHEIMERS AGENTS JUL JUL 1/1/2019 1/1/20 20 1/1/2020 1/1/2019 JUL ANTIHISTAMINES, MINIMALLY SEDATING JUL 1/1/2020 1/1/2019 JUL JUL ANTIHYPERTENSIVES, SYMPATHOLYTIC 1/1/2020 1 1/ ANTIPSYCHOTICS JUL JUL /2019 https://www.txvendordrug.com/formulary/formulary -search Search the Medicaid Formulary Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. Publication date: January 31, 2019 “PDL PA Criteria ” in the third column is not relevant but providers must obtain PDL prior authorization. the For drugs in therapeutic classes and/or subclasses that do not have a preferred drug option, 68 Page 66 of

72 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 31, 2019 Review 2020 Date of Next PDL Change Date of Most Recent PDL 2019 Change (Tentative) Review CLASS (Tentative) 1/1/2019 1/1/2020 CALCIUM CHANNEL BLOCKERS JUL JUL 1/1/2020 1/1/2019 JUL CEPHALOSPORINS AND RELATED ANTIBIOTICS JUL 1/1/2020 1/1/2019 JUL FLUOROQUINOLONES, ORAL JUL 1/1/2019 1/1/2020 JUL GLUCOCORTICOIDS, ORAL JUL 1/1/2019 1/1/2020 JUL IMMUNOSUPPRESSIVES, ORAL JUL 1/1/2019 1/1/2020 IRON, ORAL JUL JUL 1/1/2020 1/1/2019 JUL LEUKOTRIENE MODIFIERS JUL 1/1/2020 1/1/2019 NSAIDS JUL JUL 1/1/2020 1/1/2019 OPHTHALMIC ANTIBIOTICS JUL JUL 1/1/2019 1/1/2020 - OPHTHALMIC ANTIBIOTIC JUL JUL STEROID COMBINATIONS 1/1/2019 1/1/2020 JUL OPHTHALMICS FOR ALLERGIC CONJUNCTIVITIS JUL 1/1/2020 1/1/2019 OPHTHALMICS, ANTI - INFLAMMATORY JUL JUL 1/1/2020 1/1/2019 JUL OPHTHALMIC ANTI - INFLAMMATORY/IMMUNOMODULATORS JUL 1/1/2019 1/1/2020 JUL JUL OPHTHALMICS, GLAUCOMA AGENTS 1/1/2020 1/1/2019 JUL OTIC ANTIBIOTICS JUL 1/1/2019 1/1/2020 OTIC ANTI - INFECTIVES & ANESTHETICS JUL JUL 1/1/2020 JUL N/A JUL PROGESTATIONAL AGENTS 1/1/2020 1/1/2019 JUL JUL SKELETAL MUSCLE RELAXANTS 1/1/2019 1/1/2020 JUL JUL STEROIDS, TOPICAL 1/1/2019 1/1/2020 ULCERATIVE COLITIS JUL JUL 1/1/2020 1/1/2019 OCT ANDROGENIC AGENTS OCT 1/1/2020 1/1/2019 OCT ANTIBIOTICS, GI OCT 1/1/2020 1/1/2019 OCT OCT ANTIBIOTICS, TOPICAL 1/1/2019 1/1/2020 OCT OCT ANTIBIOTICS, VAGINAL 1/1/2020 1/1/2019 OCT OCT ANTIEMETICS/ANTIVERTIGO AGENTS 1/1/2019 1/1/2020 OCT OCT ANTIFUNGALS, ORAL 1/1/2020 1/1/2019 OCT OCT ANTIFUNGALS, TOPICAL 1/1/2020 1/1/2019 OCT OCT ANTIHISTAMINES, FIRST GENERATION https://www.txvendordrug.com/formulary/formulary -search Search the Medicaid Formulary Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. Publication date: January 31, 2019 “PDL PA Criteria ” in the third column is not relevant but providers must obtain PDL prior authorization. the For drugs in therapeutic classes and/or subclasses that do not have a preferred drug option, 68 Page 67 of

73 HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 31, 2019 Date of Most Recent PDL 2020 Date of Next PDL Change 2019 Review (Tentative) (Tentative) Review CLASS Change 1/1/2020 1/1/2019 OCT ANTIPARASITICS, TOPICAL OCT 1/1/2019 1/1/2020 OCT OCT TOPICAL ANTIVIRALS, 1/1/2020 1/1/2019 BONE RESORPTION SUPPRESSION AND RELATED OCT OCT 1/1/2019 1/1/2020 OCT COLONY STIMULATING FACTORS OCT 1/1/2020 3/9/2018 OCT OCT CYTOKINE AND CAM ANTAGONISTS 1/1/2019 1/1/2020 INJECTED - EPINEPHRINE, SELF OCT OCT 1/1/2019 1/1/2020 OCT GI MOTILITY, CHRONIC OCT 1/1/2019 1/1/2020 OCT OCT GROWTH HORMONE 1/1/2019 1/1/2020 HEPATITIS C AGENTS OCT OCT 1/1/2020 1/1/2019 OCT HYPOGLYCEMICS, INCRETIN MIMETICS/ENHANCERS OCT 1/1/2020 1/1/2019 HYPOGLYCEMICS, INSULIN AND RELATED OCT OCT 1/1/2019 1/1/2020 OCT HYPOGLYCEMICS, MEGLITINIDES OCT 1/1/2019 1/1/2020 OCT HYPOGLYCEMICS, METFORMIN OCT 1/1/2020 OCT OCT 1/1/2019 HYPOGLYCEMICS, SLGT2 1/1/2020 1/1/2019 OCT OCT HYPOGLYCEMICS, TZD 1/1/2019 1/1/2020 KETOLIDES OCT OCT MACROLIDES - 1/1/2019 1/1/2020 OCT OPIATE DEPENDENCE TREATMENTS OCT 1/1/2019 1/1/2020 PENICILLINS OCT OCT 1/1/2019 1/1/2020 OCT OCT TETRACYCLINES https://www.txvendordrug.com/formulary/formulary -search Search the Medicaid Formulary Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. Publication date: January 31, 2019 “PDL PA Criteria ” in the third column is not relevant but providers must obtain PDL prior authorization. the For drugs in therapeutic classes and/or subclasses that do not have a preferred drug option, 68 Page 68 of

74 Iron Oral Agents - Preferred Agents Agent Ingredients IRON FUM/FOLIC ACID/MV,MIN 15 CENTRATEX FERROUS SULFATE CHILDREN'S FERROUS SULFATE FERROUS SULFATE CHILDREN'S IRON FERROUS SULFATE FEOSOL FERATE FERROUS GLUCONATE FEROSUL FERROUS SULFATE FERRALET 90 IRON CARB,GL/FA/B12/C/DOCUSATE FERROUS SULFATE FERRO-TIME FERROUS FUMARATE FERROUS FUMARATE FERROUS SULFATE FERROUS SULFATE FERROUSUL FERROUS SULFATE IRON FUM/FOLIC ACID/MV,MIN 15 HEMOCYTE PLUS HEMOCYTE-F FERROUS FUMARATE/FOLIC ACID IFEREX 150 IRON POLYSACCHARIDE COMPLEX IFEREX 150 FORTE IRON PS COMPLEX/B12/FOLIC ACID IRON FUM,PS/FOLIC ACID/VITC/B3 INTEGRA F INTEGRA PLUS IRON FUM,PS/FOLIC/BCOMP,C NO.9 IRON FERROUS SULFATE FERROUS SULFATE, DRIED IRON IRON,CARBONYL/ASCORBIC ACID IRON 100-VITAMIN C IRON FUM/DOCUSAT/FOLIC/BCOMP,C NEPHRON FA SE-TAN PLUS IRON FM,PS NO.1/FOLIC/MV NO.18 FERROUS SULFATE SLOW RELEASE IRON TANDEM PLUS IRON FM,PS NO.1/FOLIC/MV NO.18 Iron Oral Agents - Non-Preferred Agents Ingredients Agent CITRANATAL BLOOM IRON CARB,GL/FA/B12/C/DOCUSATE CORVITE 150 IRON,CARB/FOLATE6/MV,MIN NO.41 CORVITE FE IRON/FOLATE NO.6/MV,MINS NO.40

75 FEOSOL IRON POLYSACCH/IRON HEME POLYP FERGON FERROUS GLUCONATE FER-IN-SOL FERROUS SULFATE FERIVA 21-7 IRON/FOLATE NO1/C/B12/ZINC/DSS FERIVA FA IRON/FOLAT1/C/B12/BIOT/DOCUSAT FERRAPLUS 90 IRON/FOLIC ACID/B12/C/DOCUSATE FERRIMIN 150 FERROUS FUMARATE FOLITAB 500 FERROUS SULFATE/VIT C/FOLIC AC FUSION PLUS IRON,FM,PS/FOLIC/B,C18/L.CASEI HEMOCYTE FERROUS FUMARATE IROSPAN IRON BG,PS/FOLIC/B,C NO.12/SUC TARON FORTE IRON BG,PS/VITC/B12/FA/CALCIUM WEE CARE IRON,CARBONYL

76 Pediatric Vitamin Preparations - Preferred Agents Agent Ingredients PEDI MULTIVIT NO.2 W-FLUORIDE MULTIVITAMIN WITH FLUORIDE PEDI MULTIVIT NO.16 W-FLUORIDE MULTIVITAMIN WITH FLUORIDE PEDI MULTIVIT 45/FLUORIDE/IRON MULTI-VITAMIN W-FLUORIDE-IRON PEDI MULTIVIT 45/FLUORIDE/IRON MULTIVITAMIN-IRON-FLUORIDE Non-Preferred Agents Pediatric Vitamin Preparations - Ingredients Agent PEDI MULTIVIT 47/IRON/FLUORIDE ESCAVITE PEDI MULTIVIT 78/IRON/FLUORIDE ESCAVITE D PEDI MULTIVIT 86/IRON/FLUORIDE ESCAVITE LQ FLORIVA PEDI MULTIVIT NO.85/FLUORIDE PEDI MULTIVIT NO.130/FLUORIDE FLORIVA PLUS PEDI MULTIVIT NO.33/FLUORIDE POLY-VI-FLOR POLY-VI-FLOR PEDI MULTIVIT NO.37 W-FLUORIDE POLY-VI-FLOR WITH IRON PEDI MULTIVIT 33/FLUORIDE/IRON POLY-VI-FLOR WITH IRON PEDI MULTIVIT 37/FLUORIDE/IRON PEDI MULTIVIT 84 WITH FLUORIDE QUFLORA PEDI MULTIVIT NO.157/FLUORIDE QUFLORA QUFLORA PEDI MULTIVIT NO.63 W-FLUORIDE QUFLORA PEDI MULTIVIT NO.83 W-FLUORIDE PED MULTIVIT 142/IRON/FLUORIDE QUFLORA FE PED MULTIVIT 151/IRON/FLUORIDE QUFLORA FE TRI-VI-FLOR PED MVIT A,C,D3 NO.38/FLUORIDE TRI-VITAMIN WITH FLUORIDE PED MVIT A,C,D3 NO.21/FLUORIDE TRI-VITE WITH FLUORIDE PED MVIT A,C,D3 NO.21/FLUORIDE PED MVIT A,C,D3 NO.21/FLUORIDE VITAMINS A,C,D AND FLUORIDE Prenatal Vitamins - Preferred Agents Ingredients Agent

77 CITRANATAL 90 DHA PNV72/IRON,GLUC/FOLIC/DSS/DHA CITRANATAL ASSURE PNV73/IRON,GLUC/FOLIC/DSS/DHA PRENATAL 48/IRON/FOLIC ACID/B6 CITRANATAL B-CALM CITRANATAL DHA PNV 76/IRON,GLUC/FOLIC/DSS/DHA CITRANATAL HARMONY PNV59/IRON,CARB,FUM/FA/DSS/DHA CITRANATAL RX PRENATAL81/IRON/FOLIC/DOCUSATE PROVIDA OB PRENATAL VIT 65/IRON FUM,PS/FA SELECT-OB + DHA PRENATAL VIT 33/IRON/FOLIC/DHA TRICARE PRENATAL VIT103/IRON FUM/FOLIC TRINATAL RX 1 PRENATAL VIT27,CALCIUM/IRON/FA VITAFOL NANO PRENATAL NO.75/IRON/FOLATE NO1 VITAFOL ULTRA PNV 67/IRON PS/FOLATE NO.1/DHA VITAFOL-OB+DHA PRENATAL VIT 10/IRON/FOLIC/DHA VITAFOL-ONE PRENATAL 26/IRON PS/FOLIC/DHA VOL-PLUS MULTIVIT-MINS60/IRON FUM/FOLIC

78 Preferred Agents Non- Prenatal Vitamins - Agent Ingredients PRENATAL 2/IRON/FOLIC ACID/OM3 COMPLETE NATAL DHA PRENATAL VIT 14/IRON FUM/FOLIC COMPLETENATE CONCEPT DHA PNV 16/IRON FUM,PS/FOLIC/OM-3 PNV 15/IRON FUM,PS/FOLIC ACID CONCEPT OB ELITE-OB PRENATAL NO.123/IRON/FOLIC AC EXTRA-VIRT PLUS DHA PRENATAL 57/IRON/FOLIC/DSS/DHA FOLIVANE-OB PNV 15/IRON FUM,PS/FOLIC ACID PRENATAL VIT86/IRON/FOLIC ACID NESTABS NESTABS ABC PRENATAL 86/IRON/FOLIC/DHA/EPA NESTABS DHA PRENATAL 87/IRON BIS/FOLIC/DHA OB COMPLETE PRENATAL NO.123/IRON/FOLIC AC PNV 85/IRON/FOLIC/DHA/FISH OIL OB COMPLETE ONE OB COMPLETE PETITE PRENATAL56/IRON/FOLIC ACID/DHA OB COMPLETE PREMIER PNV83/IRON,CARB,ASP/FOLIC ACID PRENATAL VIT114/FOLATE6/GINGER PRENATE AM PRENATE CHEWABLE PRENATAL VIT NO.112/FOLATE NO6 PRENATAL 78/IRON/FOLATE 1/DHA PRENATE DHA PRENATAL 114/IRON A-G/FOLATE 1 PRENATE ELITE PRENATAL VIT68/IRON/FA NO6/DHA PRENATE ENHANCE PRENATAL VIT 84/IRON/FA 1/DHA PRENATE ESSENTIAL PRENATAL VIT 87/IRON/FOLIC/DHA PRENATE MINI PRENATE PIXIE PRENATAL VIT 85/IRON/FA 1/DHA PRENATAL VIT69/IRON/FOLATE6/DH PRENATE RESTORE PRENATAL NO.77/IRON ASP GLY/FA PRENATE STAR PROVIDA DHA PRENAT90/IRON FUM,PS/FOLIC/DHA PRENATAL VIT128/IRON/FOLIC ACD SELECT-OB SE-NATAL 19 PNV NO.118/IRON FUMARATE/FA SE-NATAL 19 PNV119/IRON FUM/FOLIC/DOCUSATE TARON-C DHA PNV 16/IRON FUM,PS/FOLIC/OM-3

79 THRIVITE 19 MV, MIN 59/IRON/FOLIC/DOCUSATE THRIVITE RX PRENATAL VIT,CALC76/IRON/FOLIC PRENATAL 93/IRON/FOLATE 9/DHA TRISTART DHA TRIVEEN-DUO DHA PRENATAL 53/IRON/FOLIC AC/OMG3 VIRT-SELECT PNV 80/IRON FUM/FOLIC/DSS/DHA VITAFOL-OB PRENATAL VIT 10/IRON FUM/FOLIC VOL-NATE MULTIVIT-MINS NO.64/IRON/FOLIC VOL-TAB RX MV-MINS NO.50/IRON,CARB/FOLIC VP-CH-PNV PRENATAL 34/IRON/FOLIC/DSS/DHA VP-GGR-B6 PNV/FOLIC AC/B6/CALCIUM/GINGER VP-HEME OB PNV 21/IRON PS,HEME PPEP/FOLIC VP-HEME ONE PNV 19/IRON PS,HEME/FOLIC/DHA VP-PNV-DHA PRENATAL NO.52/IRON/FA/DHA ZATEAN-PN DHA PRENATAL 47/IRON/FOLATE 1/DHA ZATEAN-PN PLUS PRENATAL 68/IRON/FOLIC NO1/DHA

80 Cough & Cold (Oral Only) - Preferred Agents All products restricted to patients aged 2 years and above. Cough and Cold Products subject to PA Agent Ingredients ALA-HIST IR TABLET OTC (ORAL) DEXBROMPHENIRAMINE MALEATE DEXBROMPHENIRAMIN/PHENYLEPHRIN ALA-HIST PE TABLET OTC (ORAL) DIPHENHYDRA/PHENYLEPH/ACETAMIN CHILDREN'S MUCINEX LIQUID OTC (C) (ORAL) GUAIFENESIN CHILDREN'S MUCINEX LIQUID OTC (C) (ORAL) GUAIFENESIN/PHENYLEPHRINE HCL CHILDREN'S MUCINEX LIQUID OTC (C) (ORAL) GUAIFENESIN/PHENYLEPHRINE HCL DECONEX IR TABLET OTC (ORAL) ED A-HIST LIQUID OTC (ORAL) CHLORPHENIRAMINE/PHENYLEPHRINE CHLORPHENIRAMINE/PHENYLEPHRINE ED A-HIST TABLET OTC (ORAL) GUAIFENESIN/PHENYLEPHRINE HCL ED BRON GP LIQUID OTC (ORAL) GUAIFENESIN 400 MG TABLET OTC (ORAL) GUAIFENESIN GUAIFENESIN GUAIFENESIN LIQUID OTC (ORAL) GUAIFENESIN TABLET ER OTC (ORAL) GUAIFENESIN GUAIFENESIN/PSE TABLET ER OTC (ORAL) GUAIFENESIN/PSEUDOEPHEDRNE HCL HISTEX-PE LIQUID OTC (ORAL) PHENYLEPHRINE HCL/TRIPROLIDINE MUCINEX D TABLET ER 12H OTC (ORAL) GUAIFENESIN/PSEUDOEPHEDRNE HCL MUCINEX ER TABLET OTC (ORAL) GUAIFENESIN MUCINEX FAST-MAX COLD-SINUS TABLET OTC (ORAL) GUAIFEN/PHENYLEPH/ACETAMINOPHN GUAIFENESIN MUCINEX GRAN PACK OTC (ORAL) MUCINEX SINUS-MAX TABLET OTC (ORAL) GUAIFEN/PHENYLEPH/ACETAMINOPHN NASOPEN PE LIQUID OTC (ORAL) THONZYLAMINE/PHENYLEPHRINE NOHIST-LQ LIQUID OTC (ORAL) CHLORPHENIRAMINE/PHENYLEPHRINE PHENYLEPHRINE/BROMPHENIRAMINE SOLUTION OTC (ORAL) BROMPHENIRAMINE/PHENYLEPHRINE POLY HIST FORTE TABLET OTC (ORAL) DOXYLAMINE/PHENYLEPHRINE HCL POLY-VENT IR TABLET OTC (ORAL) GUAIFENESIN/PSEUDOEPHEDRNE HCL PSE/CHLORPHENIRAMINE TABLET OTC (ORAL) CHLORPHENIRAMINE/PSEUDOEPHED PSE/TRIPROLIDINE TABLET OTC (ORAL) TRIPROLIDINE/PSEUDOEPHEDRINE RYNEX PE SOLUTION OTC (ORAL) BROMPHENIRAMINE/PHENYLEPHRINE RYNEX PSE LIQUID OTC (ORAL) BROMPHENIRAMIN/PSEUDOEPHEDRINE

81 Cough & Cold (Oral Only) - Non-Preferred Agents All products restricted to patients aged 2 years and above. Cough and Cold Products subject to PA Agent Ingredients BROTAPP LIQUID OTC (ORAL) BROMPHENIRAMIN/PSEUDOEPHEDRINE DALLERGY DROPS OTC (ORAL) CHLORPHENIRAMINE/PHENYLEPHRINE ED A-HIST PSE TABLET OTC (ORAL) TRIPROLIDINE/PSEUDOEPHEDRINE CHLORPHENIRAMINE/PHENYLEPHRINE ED CHLORPED D DROPS OTC (ORAL) GUAIFENESIN/PHENYLEPHRINE HCL GUAIFENESIN/PHENYLEPHRINE TABLET OTC (ORAL) BROMPHENIRAMIN/PSEUDOEPHEDRINE LODRANE D CAPSULE OTC (ORAL) LOHIST-D LIQUID OTC (ORAL) CHLORPHENIRAMINE/PSEUDOEPHED DIPHENHYDRA/PHENYLEPH/ACETAMIN MUCINEX FAST-MAX NITE COLD-FLU LIQUID OTC (ORAL) PHENYLEPHRINE/APAP TABLET OTC (ORAL) PHENYLEPHRINE HCL/ACETAMINOPHN BROMPHENIRAMINE/PHENYLEPHRINE PHENYLEPHRINE/BROMPHENIRAMINE TABLET OTC (ORAL) PHENYLEPHRINE/PYRILAMINE TABLET OTC (ORAL) PHENYLEPHRINE/PYRILAMINE PHENYLEPHRINE HCL/PROMETH HCL PROMETHAZINE VC SYRUP (QUALITEST) (ORAL) RESCON TABLET OTC (ORAL) DEXCHLORPHENIRAMIN/PSEUDOEPHED RESCON-GG LIQUID OTC (ORAL) GUAIFENESIN/PHENYLEPHRINE HCL RESPAIRE-30 CAPSULE OTC (ORAL) GUAIFENESIN/PSEUDOEPHEDRNE HCL DEXCHLORPHENIRAM/PHENYLEPHRINE RYMED TABLET OTC (ORAL) STAHIST AD TABLET OTC (ORAL) CHLORCYCLIZINE/PSEUDOEPHEDRINE

82 Cough & Cold (Nasal Only) - Preferred Agents All products restricted to patients aged 2 years and above. Cough and Cold Products subject to PA Agent Ingredients OXYMETAZOLINE HCL OXYMETAZOLINE 12 HR NASAL SPRAY OTC (NASAL) Cough & Cold Narcotic - Preferred Agents All products restricted to patients aged 2 years and above. Cough and Cold Products subject to PA Ingredients Agent CODEINE PHOSPHATE/GUAIFENESIN GUAIFENESIN/CODEINE LIQUID OTC (ORAL) PROMETHAZINE HCL/CODEINE PROMETHAZINE/CODEINE SYRUP (ORAL) Cough & Cold Narcotic - Non-Preferred Agents All products restricted to patients aged 2 years and above. Cough and Cold Products subject to PA Agent Ingredients GUAIFENESIN/HYDROCODONE FLOWTUSS SOLUTION (ORAL) GUAIFENESIN/PSE/CODEINE SYRUP OTC (ORAL) PSEUDOEPHED/CODEINE/GUAIFEN HYDROCODONE/CHLORPHEN P-STIREX HYDROCODONE/CHLORPHENIRAMINE SUSPENSION ER 12H (ORAL) HYDROCODONE BIT/HOMATROP ME-BR HYDROCODONE/HOMATROPINE SYRUP (ORAL) HYDROCODONE BIT/HOMATROP ME-BR HYDROCODONE/HOMATROPINE TABLET (ORAL) CODEINE PHOSPHATE/GUAIFENESIN NINJACOF-XG LIQUID OTC (ORAL) PROMETHAZINE/PHENYLEPHRINE/CODEINE (QUALITEST) SYRUP (ORAL) PROMETHAZINE/PHENYLEPH/CODEINE PSE/HYDROCODONE/CHLORPHENIRAMINE SOLUTION (ORAL) HYDROCODONE/CPM/PSEUDOEPHED TUSSIONEX SUSPENSION ER 12H (ORAL) HYDROCODONE/CHLORPHEN P-STIREX HYDROCODONE/CPM/PSEUDOEPHED ZUTRIPRO SOLUTION (ORAL) Cough & Cold Non-Narcotic - Preferred Agents All products restricted to patients aged 2 years and above. Cough and Cold Products subject to PA Ingredients Agent D-METHORPHAN/PE/DEXBROMPHENIR ALAHIST CF TABLET OTC (ORAL) D-METHORPHAN/PE/DEXBROMPHENIR ALA-HIST DM LIQUID OTC (ORAL) BROMPHENIRAM/PHENYLEPHRINE/DM BROMPHENIRAMINE/PHENYLEPHRINE/DM SOLUTION OTC (ORAL)

83 BROM-PSE-DM SYRUP (ORAL) BROMPHENIRAMINE/PSEUDOEPHED/DM BROTAPP DM ELIXIR OTC (ORAL) BROMPHENIRAMINE/PSEUDOEPHED/DM CHILD MUCINEX M-S COLD DAY-NTE LIQUID SEQUELES OTC (ORAL) DIPHENHYDRAM/PE/DM/ACETAMIN/GG GUAIFEN/DEXTROMETHORPHAN/PE CHILDREN'S MUCINEX LIQUID OTC (NN) (ORAL) CHILDREN'S MUCINEX LIQUID OTC (NN) (ORAL) GUAIFENESIN/DEXTROMETHORPHAN CHILDREN'S MUCINEX LIQUID OTC (NN) (ORAL) PHENYLEPHRINE/DM/ACETAMINOP/GG CHLO TUSS LIQUID OTC (ORAL) DEXBROMPHEN/PSEUDOEPH/CHLOPHED DECONEX DMX TABLET OTC (ORAL) GUAIFEN/DEXTROMETHORPHAN/PE DELSYM SUSPENSION ER 12H OTC (ORAL) DEXTROMETHORPHAN POLISTIREX DEXTROMETHORPHAN SUSPENSION ER 12H OTC (ORAL) DEXTROMETHORPHAN POLISTIREX CHLORPHENIRAMIN/PSEUDOEPHED/DM DM/PSE/CHLORPHENIRAMINE LIQUID OTC (ORAL) ED-A-HIST DM LIQUID OTC (ORAL) CHLORPHENIRAMINE/PHENYLEPH/DM GUAIFENESIN/DEXTROMETHORPHAN GUAIFENESIN/DM LIQUID OTC (ORAL) HISTEX-DM SYRUP OTC (ORAL) TRIPROLIDINE/PHENYLEPHRINE/DM LOHIST-DM LIQUID (ORAL) BROMPHENIRAM/PHENYLEPHRINE/DM M-END DMX LIQUID OTC (ORAL) DEXBROMPHEN/PSEUDOEPHEDRINE/DM MUCINEX COLD-FLU & SORE THROAT LIQUID OTC (ORAL) PHENYLEPHRINE/DM/ACETAMINOP/GG GUAIFENESIN/DEXTROMETHORPHAN MUCINEX COUGH GRAN PACK OTC (ORAL) GUAIFENESIN/DEXTROMETHORPHAN MUCINEX DM TABLET ER 12H OTC (ORAL) MUCINEX DM TABLET ER 12H OTC (ORAL) GUAIFENESIN/DEXTROMETHORPHAN MUCINEX FAST-MAX CONGEST-COUGH TABLET OTC (ORAL) GUAIFEN/DEXTROMETHORPHAN/PE MUCINEX FAST-MAX DAY-NITE COLD LIQUID SEQ OTC (ORAL) DIPHENHYDRAM/PE/DM/ACETAMIN/GG MUCINEX FAST-MAX DM MAX LIQUID OTC (ORAL) GUAIFENESIN/DEXTROMETHORPHAN MUCINEX FAST-MAX SEVERE COLD LIQUID OTC (ORAL) PHENYLEPHRINE/DM/ACETAMINOP/GG NOHIST-DM LIQUID OTC (ORAL) CHLORPHENIRAMINE/PHENYLEPH/DM POLY-HIST DM LIQUID OTC (ORAL) THONZYLAMINE/PHENYLEPHRINE/DM POLY-VENT DM TABLET OTC (ORAL) GUAIFENESIN/DM/PSEUDOEPHEDRINE PROMETHAZINE/DM SYRUP (ORAL) PROMETHAZINE/DEXTROMETHORPHAN RYNEX DM SOLUTION OTC (ORAL) BROMPHENIRAM/PHENYLEPHRINE/DM VANACOF DM LIQUID OTC (ORAL) GUAIFEN/DEXTROMETHORPHAN/PE VANACOF LIQUID OTC (ORAL) DEXCHLORPHENIR/PSE/CHLOPHEDIAN

84 Cough & Cold Non-Narcotic - Non-Preferred Agents All products restricted to patients aged 2 years and above. Cough and Cold Products subject to PA Agent Ingredients BENZONATATE CAPSULE (ORAL) BENZONATATE BROMPHENIRAMINE/PSEUDOEPHED/DM BROMFED DM SYRUP (ORAL) DEXTROMETHORPHAN CAPSULE OTC (ORAL) DEXTROMETHORPHAN HBR DM/ACETAMINOPHEN/DOXYLAMINE DM/APAP/DOXYLAMINE CAPSULE OTC (ORAL) DM/ACETAMINOPHEN/DOXYLAMINE DM/APAP/DOXYLAMINE LIQUID OTC (ORAL) DM/PHENYLEPHRINE/APAP TABLET OTC (ORAL) D-METHORPHAN/PE/ACETAMINOPHEN PSEUDOEPH/DM/GUAIFEN/ACETAMIN DURAFLU TABLET OTC (ORAL) ED A-HIST DM TABLET OTC (ORAL) CHLORPHENIRAMINE/PHENYLEPH/DM GUAIFEN/DEXTROMETHORPHAN/PE GUAIFENESIN/DM/PHENYLEPHRINE LIQUID OTC (ORAL) GUAIFENESIN/DM/PHENYLEPHRINE SYRUP OTC (ORAL) GUAIFEN/DEXTROMETHORPHAN/PE MUCINEX FAST-MAX CONGEST-COLD TABLET OTC (ORAL) PHENYLEPHRINE/DM/ACETAMINOP/GG MUCINEX FAST-MAX DAY-NITE CONG TABLET OTC (ORAL) DIPHENHYDRAM/PE/DM/ACETAMIN/GG NINJACOF LIQUID OTC (ORAL) PYRILAMINE/CHLOPHEDIANOL PYRILAM/CHLOPHED/ACETAMINOPHEN NINJACOF-A LIQUID OTC (ORAL) POLY-HIST PD DROPS OTC (ORAL) THONZYLAMINE/CHLOPHEDIANOL POLYTUSSIN DM OTC (ORAL) DEXCHLORPHEN/PHENYLEPHRINE/DM RESCON-DM LIQUID OTC (ORAL) CHLORPHENIRAMIN/PSEUDOEPHED/DM RONDEC-D (ORAL) PSEUDOEPHEDRINE/CHLOPHEDIANOL VANATAB AC TABLET OTC (ORAL) PYRILAMINE/CHLOPHEDIANOL VANATAB DM TABLET OTC (ORAL) GUAIFEN/DEXTROMETHORPHAN/PE

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