Medicaid Drug Formulary - McLaren Health Plan

Medicaid Drug Formulary Oct. 2021

Key

*

Generic Available

AG

Age Limits

F

Females Only

M

Males Only

OTC

Over the Counter

P

Preventive

PA

Prior Authorization

QL

Quantity Limit

SP

Specialty Pharmacy

ST

Step Therapy

MHP20190104

G-3245 Beecher Road ? Flint, Michigan ? 48532 tel 888-327-0671 ? fax 833-540-8648

Rev. 10/2021

Table of Contents

Allergy .......................................................................................................................................................................................3 Antiemesis/Antivertigo.............................................................................................................................................................. 7 Asthma And Copd.................................................................................................................................................................... 8 Autonomic Nervous System Disorders...................................................................................................................................17 Behavioral Health - Antidepressants...................................................................................................................................... 18 Behavioral Health - Other....................................................................................................................................................... 25 Cardiovascular Disease - Arrhythmia..................................................................................................................................... 47 Cardiovascular Disease - Cardiac Stimulant.......................................................................................................................... 48 Cardiovascular Disease - Hypertension................................................................................................................................. 48 Cardiovascular Disease - Lipid Irregularity.............................................................................................................................58 Cardiovascular Disease - Miscellaneous Agents................................................................................................................... 62 Cardiovascular Disease - Vasodilation...................................................................................................................................62 Contraception/Oxytocics .........................................................................................................................................................63 Dermatology - Acne................................................................................................................................................................71 Dermatology - Antiinfective.....................................................................................................................................................72 Dermatology - Antiinflammatory............................................................................................................................................. 76 Dermatology - Miscellaneous................................................................................................................................................. 81 Dermatology - Psoriasis/Eczema........................................................................................................................................... 83 Diabetes................................................................................................................................................................................. 84 Ear - General Disorders..........................................................................................................................................................93 Electrolyte Regulation.............................................................................................................................................................94 Endocrine Disorder - Fertility.................................................................................................................................................. 95 Endocrine Disorder - Other.....................................................................................................................................................95 Endocrine Disorder - Thyroid..................................................................................................................................................98 Eye - General Disorders......................................................................................................................................................... 99 Eye - Glaucoma....................................................................................................................................................................103 Eye - Miscellaneous............................................................................................................................................................. 105 Gout And Related Diseases................................................................................................................................................. 106 Hematological Disorders...................................................................................................................................................... 106 Hormonal Deficiency............................................................................................................................................................ 116 Immunization........................................................................................................................................................................ 118 Immunosuppression/Modulation ...........................................................................................................................................120 Infectious Disease - Bacterial............................................................................................................................................... 120 Infectious Disease - Fungal.................................................................................................................................................. 124 Infectious Disease - Miscellaneous...................................................................................................................................... 125 Infectious Disease - Parasitic............................................................................................................................................... 127 Infectious Disease - Viral......................................................................................................................................................127 Inflammatory Disease...........................................................................................................................................................138 Local Anesthesia.................................................................................................................................................................. 145 Lower Gastrointestinal Disorders - Bowel Inflammat............................................................................................................146 Lower Gastrointestinal Disorders - Other............................................................................................................................. 147 Medical Supplies.................................................................................................................................................................. 152 Miscellaneous Agents...........................................................................................................................................................166

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Neoplastic Disease...............................................................................................................................................................168 Neurological Disease - Miscellaneous..................................................................................................................................178 Oral/Pharyngeal Disorders................................................................................................................................................... 180 Other Drugs.......................................................................................................................................................................... 181 Other Respiratory Disorders.................................................................................................................................................189 Pain Management - Analgesics............................................................................................................................................190 Parkinsons Disease..............................................................................................................................................................200 Seizure Disorder...................................................................................................................................................................202 Skeletal Muscle Disorder......................................................................................................................................................214 Smoking Cessation...............................................................................................................................................................215 Upper Gastrointestinal Disorders - Digestive....................................................................................................................... 216 Upper Gastrointestinal Disorders - Spastic Disease............................................................................................................ 219 Upper Gastrointestinal Disorders - Ulcer Disease................................................................................................................219 Urinary Tract - Functional Disorders.....................................................................................................................................223 Vaginal Disorders................................................................................................................................................................. 225 Vitamin And/Or Mineral Deficiency.......................................................................................................................................226

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Drug

Allergy Allergenic Extracts, Therapeutics PALFORZIA (LEVEL 1) ORAL CAPSULE, SPRINKLE 3 MG (1 MG X 3) PALFORZIA (LEVEL 2) ORAL CAPSULE, SPRINKLE 6 MG (1 MG X 6) PALFORZIA (LEVEL 3) ORAL CAPSULE, SPRINKLE 12 MG (1 MG X 2, 10 MG X 1) PALFORZIA (LEVEL 4) ORAL CAPSULE, SPRINKLE 20 MG PALFORZIA (LEVEL 5) ORAL CAPSULE, SPRINKLE 40 MG (20 MG X 2) PALFORZIA (LEVEL 6) ORAL CAPSULE, SPRINKLE 80 MG (20 MG X 4) PALFORZIA (LEVEL 7) ORAL CAPSULE, SPRINKLE 120 MG (20 MG X 1, 100 MG X 1) PALFORZIA (LEVEL 8) ORAL CAPSULE, SPRINKLE 160 MG (20 MG X 3, 100 MG X1) PALFORZIA (LEVEL 9) ORAL CAPSULE, SPRINKLE 200 MG (100 MG X 2) PALFORZIA (LEVEL 10) ORAL CAPSULE, SPRINKLE 240 MG (20 MG X 2, 100 MG X 2) PALFORZIA (LEVEL 11 UP-DOSE) ORAL POWDER IN PACKET 300 MG PALFORZIA INITIAL DOSE ORAL CAPSULE, SPRINKLE 0.5/1/1.5/3/6 MG PALFORZIA LEVEL 11 MAINTENANCE ORAL POWDER IN PACKET 300 MG Antihistamines - 1St Generation ALLER-CHLOR ORAL TABLET 4 MG

ALLER-G-TIME ORAL TABLET 25 MG

ALLERGY (CHLORPHENIRAMINE) ORAL TABLET 4 MG ALLERGY (DIPHENHYDRAMINE) ORAL CAPSULE 25 MG ALLERGY (DIPHENHYDRAMINE) ORAL TABLET 25 MG ALLERGY ORAL LIQUID 12.5 MG/5 ML

ALLERGY RELIEF(CHLORPHENIRAMN) ORAL TABLET 4 MG

Status

Notes

Common Formulary Common Formulary Common Formulary

Common Formulary Common Formulary

Common Formulary

Common Formulary

Common Formulary

Common Formulary

Common Formulary

Common Formulary Common Formulary Common Formulary

Common Formulary Common Formulary Common Formulary Common Formulary Common Formulary Common Formulary Common Formulary

PA; SP PA; SP PA; SP PA; SP PA; SP PA; SP PA; SP PA; SP PA; SP PA; SP PA; SP PA; SP PA; SP

Age (Max 64 Years)

Age (Max 64 Years) Age (Max 64 Years)

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Drug

ALLERGY RELIEF(DIPHENHYDRAMIN) ORAL CAPSULE 25 MG ALLERGY RELIEF(DIPHENHYDRAMIN) ORAL LIQUID 12.5 MG/5 ML ALLERGY RELIEF(DIPHENHYDRAMIN) ORAL TABLET 25 MG ALLERGY-TIME ORAL TABLET 4 MG

BANOPHEN ORAL CAPSULE 25 MG, 50 MG BANOPHEN ORAL TABLET 25 MG

carbinoxamine maleate oral liquid 4 mg/5 ml carbinoxamine maleate oral tablet 4 mg

CHILDREN'S ALLERGY (DIPHENHYD) ORAL LIQUID 12.5 MG/5 ML CHILDREN'S DIPHENHYDRAMINE ORAL LIQUID 12.5 MG/5 ML chlorpheniramine maleate oral tablet 4 mg chlorpheniramine maleate oral tablet extended release 12 mg clemastine oral tablet 2.68 mg

(Aller-Chlor)

COMPLETE ALLERGY MEDICINE ORAL CAPSULE 25 MG COMPLETE ALLERGY MEDICINE ORAL TABLET 25 MG COMPLETE ALLERGY ORAL CAPSULE 25 MG COMPLETE ALLERGY ORAL TABLET 25 MG cyproheptadine oral syrup 2 mg/5 ml

cyproheptadine oral tablet 4 mg

DAYHIST ALLERGY ORAL TABLET 1.34 MG DIPHEDRYL ORAL LIQUID 12.5 MG/5 ML DIPHENHIST ORAL CAPSULE 25 MG

diphenhydramine hcl injection solution 50 mg/ml diphenhydramine hcl injection syringe 50 mg/ml diphenhydramine hcl oral capsule 25 mg (Allergy

(diphenhydramine))

4

Status

Common Formulary Common Formulary Common Formulary Common Formulary Common Formulary Common Formulary Common Formulary Common Formulary Common Formulary Common Formulary Common Formulary Common Formulary Common Formulary Common Formulary Common Formulary Common Formulary Common Formulary Common Formulary Common Formulary Common Formulary Common Formulary Common Formulary Common Formulary Common Formulary Common Formulary

Notes Age (Max 64 Years) Age (Max 64 Years) Age (Max 64 Years) Age (Max 64 Years)

Age (Max 64 Years) Age (Max 64 Years) Age (Max 64 Years) Age (Max 64 Years) Age (Max 64 Years) Age (Max 64 Years)

Age (Max 64 Years) Age (Max 64 Years) Age (Max 64 Years) Age (Max 64 Years)

Drug

Status

Notes

diphenhydramine hcl oral capsule 50 mg

diphenhydramine hcl oral liquid 12.5 mg/5 ml diphenhydramine hcl oral tablet 25 mg

hydroxyzine hcl oral solution 10 mg/5 ml hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg hydroxyzine pamoate oral capsule 100 mg hydroxyzine pamoate oral capsule 25 mg, 50 mg promethazine oral syrup 6.25 mg/5 ml

promethazine oral tablet 12.5 mg, 25 mg, 50 mg SILADRYL SA ORAL LIQUID 12.5 MG/5 ML VALU-DRYL ALLERGY ORAL CAPSULE 25 MG VISTARIL ORAL CAPSULE 25 MG, 50 MG Antihistamines - 2Nd Generation 24HR ALLERGY RELIEF ORAL TABLET 5 MG ALL DAY ALLERGY (CETIRIZINE) ORAL CAPSULE 10 MG ALL DAY ALLERGY (CETIRIZINE) ORAL SOLUTION 1 MG/ML ALL DAY ALLERGY (CETIRIZINE) ORAL TABLET 10 MG ALLER-EASE ORAL TABLET 180 MG, 60 MG ALLERGY RELIEF (CETIRIZINE) ORAL CAPSULE 10 MG ALLERGY RELIEF (CETIRIZINE) ORAL TABLET 10 MG ALLERGY RELIEF (FEXOFENADINE) ORAL TABLET 180 MG ALLERGY RELIEF (LEVOCETIRIZIN) ORAL TABLET 5 MG ALLERGY RELIEF (LORATADINE) ORAL SOLUTION 5 MG/5 ML ALLERGY RELIEF (LORATADINE) ORAL TABLET 10 MG ALLERGY RELIEF (LORATADINE) ORAL TABLET,DISINTEGRATING 10 MG cetirizine oral solution 1 mg/ml

(Banophen) (Allergy) (Aller-G-Time) (Vistaril)

(All Day Allergy (cetirizine))

Common Formulary Common Formulary Common Formulary PDL Preferred PDL Preferred

PDL Preferred

PDL Preferred

Common Formulary Common Formulary Common Formulary Common Formulary PDL Non-Preferred

PDL Preferred

PDL Non-Preferred

PDL Preferred

PDL Preferred

PDL Non-Preferred

PDL Non-Preferred

PDL Preferred

PDL Non-Preferred

PDL Preferred

PDL Preferred

PDL Preferred

PDL Preferred

PDL Preferred

Age (Max 64 Years) Age (Max 64 Years)

Age (Min 2 Years and Max 64 Years) Age (Min 2 Years and Max 64 Years) Age (Max 64 Years) PA

PA

PA PA PA

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Drug

Status

Notes

cetirizine oral solution 5 mg/5 ml cetirizine oral tablet 10 mg cetirizine oral tablet 5 mg cetirizine oral tablet,chewable 10 mg, 5 mg CHILD ALLERGY RELF(CETIRIZINE) ORAL SOLUTION 1 MG/ML CHILDREN'S ALLERGY RELIEF(LOR) ORAL SOLUTION 5 MG/5 ML CHILDREN'S ALLERGY RELIEF(LOR) ORAL TABLET,CHEWABLE 5 MG CHILDREN'S ALLERGY(CETIRIZINE) ORAL SOLUTION 1 MG/ML CHILDREN'S CETIRIZINE ORAL SOLUTION 1 MG/ML CHILDREN'S CETIRIZINE ORAL TABLET,CHEWABLE 10 MG, 5 MG CHILDREN'S LORATADINE ORAL TABLET,CHEWABLE 5 MG CHILD'S ALL DAY ALLERGY(CETIR) ORAL SOLUTION 1 MG/ML CLARINEX ORAL TABLET 5 MG desloratadine oral tablet 5 mg desloratadine oral tablet,disintegrating 2.5 mg desloratadine oral tablet,disintegrating 5 mg fexofenadine oral tablet 180 mg, 60 mg levocetirizine oral solution 2.5 mg/5 ml levocetirizine oral tablet 5 mg loratadine oral solution 5 mg/5 ml loratadine oral tablet 10 mg loratadine oral tablet,disintegrating 10 mg Nasal Antihistamine azelastine nasal aerosol,spray 137 mcg (0.1 %) azelastine nasal spray,non-aerosol 205.5 mcg (0.15 %) olopatadine nasal spray,non-aerosol 0.6 % PATANASE NASAL SPRAY,NONAEROSOL 0.6 % Nasal Antihistamine & Anti-Inflam. Steroid Comb. azelastine-fluticasone nasal spray,nonaerosol 137-50 mcg/spray DYMISTA NASAL SPRAY,NONAEROSOL 137-50 MCG/SPRAY

PDL Non-Preferred PA

(All Day Allergy (cetirizine)) PDL Preferred

PDL Preferred

(Children's Cetirizine)

PDL Non-Preferred PA

PDL Preferred

PDL Preferred

PDL Preferred

PDL Preferred

PDL Preferred

PDL Non-Preferred PA

PDL Preferred

PDL Preferred

(Clarinex)

PDL Non-Preferred PA PDL Non-Preferred PA PDL Non-Preferred PA; Age (Max 11 Years)

PDL Non-Preferred PA

(Aller-ease)

PDL Non-Preferred PA

(Xyzal)

PDL Non-Preferred PA

(24HR Allergy Relief)

PDL Preferred

(Allergy Relief (loratadine)) PDL Preferred

(Allergy Relief (loratadine)) PDL Preferred

(Allergy Relief (loratadine)) PDL Preferred

(Patanase)

PDL Preferred PDL Preferred PDL Non-Preferred PA PDL Non-Preferred PA

(Dymista)

PDL Non-Preferred PA PDL Non-Preferred PA

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Drug

Nasal Anti-Inflammatory Steroids

24 HOUR NASAL ALLERGY NASAL

AEROSOL,SPRAY 55 MCG

ALLERGY RELIEF (FLUTICASONE)

NASAL SPRAY,SUSPENSION 50

MCG/ACTUATION

BECONASE AQ NASAL SPRAY,NON-

AEROSOL 42 MCG (0.042 %)

budesonide nasal spray,non-aerosol 32 (Rhinocort Allergy)

mcg/actuation

flunisolide nasal spray,non-aerosol 25

mcg (0.025 %)

fluticasone propionate nasal

(Allergy Relief

spray,suspension 50 mcg/actuation

(fluticasone))

mometasone nasal spray,non-aerosol 50 (Nasonex)

mcg/actuation

NASAL ALLERGY NASAL

AEROSOL,SPRAY 55 MCG

NASONEX NASAL SPRAY,NON-

AEROSOL 50 MCG/ACTUATION

OMNARIS NASAL SPRAY,NON-

AEROSOL 50 MCG

QNASL NASAL HFA AEROSOL

INHALER 40 MCG/ACTUATION, 80

MCG/ACTUATION

triamcinolone acetonide nasal

(24 Hour Nasal Allergy)

aerosol,spray 55 mcg

XHANCE NASAL AEROSOL BREATH

ACTIVATED 93 MCG/ACTUATION

ZETONNA NASAL HFA AEROSOL

INHALER 37 MCG/ACTUATION

Nasal Mast Cell Stabilizers Agents

cromolyn nasal spray,non-aerosol 5.2 (Nasal Allergy Symptom

mg/spray (4 %)

Control)

NASAL ALLERGY SYMPTOM

CONTROL NASAL SPRAY,NON-

AEROSOL 5.2 MG/SPRAY (4 %)

Antiemesis/Antivertigo

Antiemetic, Cannibinoid-Type

dronabinol oral capsule 10 mg

(Marinol)

dronabinol oral capsule 2.5 mg, 5 mg (Marinol)

Antiemetic/Antivertigo Agents AKYNZEO (NETUPITANT) ORAL CAPSULE 300-0.5 MG aprepitant oral capsule 125 mg, 40 mg

aprepitant oral capsule 80 mg

(Emend)

Status

PDL Non-Preferred PA PDL Non-Preferred PA

PDL Non-Preferred PA PDL Non-Preferred PA PDL Non-Preferred PA

PDL Preferred PDL Non-Preferred PA PDL Non-Preferred PA PDL Non-Preferred PA PDL Non-Preferred PA PDL Non-Preferred PA

PDL Non-Preferred PA PDL Non-Preferred PA PDL Non-Preferred PA

Common Formulary Common Formulary

Notes

Common

Formulary

Common

PA

Formulary

PDL Non-Preferred PA; QL (1 EA per 1 FILL)

PDL Non-Preferred PDL Non-Preferred

PA; QL (1 EA per 1 FILL); Age (Min 12 Years) PA; QL (2 EA per 1 FILL); Age (Min 12 Years)

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