Oregon Medicaid Preferred Drug List - January 1, 2017 Medicaid Preferred Drug...Table 121‐0030‐1...
Transcript of Oregon Medicaid Preferred Drug List - January 1, 2017 Medicaid Preferred Drug...Table 121‐0030‐1...
System Class Preferred
Effective: January 1, 2017Table 121‐0030‐1 Oregon Fee‐for‐Service Enforceable Physical Health Preferred Drug List
Anaphylaxis RescueAllergy/Cold EPINEPHRINE AUTO INJCTEPINEPHRINE (EPIPEN 2‐PAK ™) AUTO INJCTEPINEPHRINE (EPIPEN JR 2‐PAK ™) AUTO INJCT
Antihistamines, Second Generation
Allergy/Cold CETIRIZINE HCL SOLUTION ***CETIRIZINE HCL TABLETLORATADINE SOLUTION ***LORATADINE TAB RAPDIS ***LORATADINE TABLET
Cough and ColdAllergy/Cold GUAIFENESIN ‡ GRAN PACKGUAIFENESIN ‡ LIQUIDGUAIFENESIN ‡ SYRUPGUAIFENESIN ‡ TAB ER 12HGUAIFENESIN ‡ TABLETGUAIFENESIN ‡ TABLET ERGUAIFENESIN/CODEINE PHOSPHATE * LIQUIDGUAIFENESIN/CODEINE PHOSPHATE * SYRUPGUAIFENESIN/CODEINE PHOSPHATE * TABLETGUAIFENESIN/DEXTROMETHORPHAN ‡ CAPSULEGUAIFENESIN/DEXTROMETHORPHAN ‡ DROPSGUAIFENESIN/DEXTROMETHORPHAN ‡ ELIXIRGUAIFENESIN/DEXTROMETHORPHAN ‡ GRAN PACKGUAIFENESIN/DEXTROMETHORPHAN ‡ LIQUIDGUAIFENESIN/DEXTROMETHORPHAN ‡ LIQUID PKTGUAIFENESIN/DEXTROMETHORPHAN ‡ SYRUPGUAIFENESIN/DEXTROMETHORPHAN ‡ TAB ER 12HGUAIFENESIN/DEXTROMETHORPHAN ‡ TABLETGUAIFENESIN/DEXTROMETHORPHAN ‡ TBMP 12HRPSEUDOEPHEDRINE HCL ‡ CAPSULEPSEUDOEPHEDRINE HCL ‡ TABLET
Nasal Allergy InhalersAllergy/Cold FLUTICASONE PROPIONATE * SPRAY SUSP
Analgesics, TopicalAnalgesics CAPSAICIN CREAM (G)
GoutAnalgesics ALLOPURINOL TABLETPROBENECID/COLCHICINE TABLET
Muscle Relaxants, OralAnalgesics BACLOFEN TABLETCYCLOBENZAPRINE HCL TABLET ***TIZANIDINE HCL TABLET
1 Updated: December 27, 2016
* Drug coverage subject to meeting clinical prior authorization criteria** Drug coverage subject to quantity limits*** Certain strengths may require Prior Authorization‡ Age restric ons apply
System Class Preferred
Effective: January 1, 2017Table 121‐0030‐1 Oregon Fee‐for‐Service Enforceable Physical Health Preferred Drug List
Non‐Steroidal Anti‐Inflammatory Drugs
Analgesics DICLOFENAC POTASSIUM TABLETDICLOFENAC SODIUM TABLET DRETODOLAC TABLETFLURBIPROFEN TABLETIBUPROFEN CAPSULEIBUPROFEN DROPS SUSPIBUPROFEN ORAL SUSPIBUPROFEN TAB CHEWIBUPROFEN TABLETINDOMETHACIN CAPSULEKETOPROFEN CAPSULEKETOROLAC TROMETHAMINE ** TABLETMELOXICAM TABLETNABUMETONE TABLETNAPROXEN TABLETNAPROXEN TABLET DRNAPROXEN SODIUM TABLETOXAPROZIN TABLETSULINDAC TABLET
Opioids, Long‐ActingAnalgesics FENTANYL ** PATCH TD72MORPHINE SULFATE ** TABLET ER
Opioids, Short‐ActingAnalgesics ACETAMINOPHEN WITH CODEINE * ORAL SUSPACETAMINOPHEN WITH CODEINE * SOLUTIONACETAMINOPHEN WITH CODEINE * TABLETBUTORPHANOL TARTRATE ** SPRAYCODEINE SULFATE * TABLETHYDROCODONE/ACETAMINOPHEN ** SOLUTIONHYDROCODONE/ACETAMINOPHEN ** TABLETHYDROMORPHONE HCL ** SUPP.RECTHYDROMORPHONE HCL ** TABLETMORPHINE SULFATE ** SOLUTIONMORPHINE SULFATE ** SUPP.RECTMORPHINE SULFATE ** TABLETOPIUM/BELLADONNA ALKALOIDS ** SUPP.RECTOXYCODONE HCL ** SOLUTIONOXYCODONE HCL ** TABLETOXYCODONE HCL/ACETAMINOPHEN ** TABLETTRAMADOL HCL ** TABLET
Triptans, NasalAnalgesics SUMATRIPTAN ** SPRAY
Triptans, OralAnalgesics NARATRIPTAN HCL ** TABLETSUMATRIPTAN SUCCINATE ** TABLET
Triptans, SubcutaneousAnalgesics SUMATRIPTAN SUCCINATE ** CARTRIDGESUMATRIPTAN SUCCINATE ** PEN INJCTRSUMATRIPTAN SUCCINATE ** VIAL
2 Updated: December 27, 2016
* Drug coverage subject to meeting clinical prior authorization criteria** Drug coverage subject to quantity limits*** Certain strengths may require Prior Authorization‡ Age restric ons apply
System Class Preferred
Effective: January 1, 2017Table 121‐0030‐1 Oregon Fee‐for‐Service Enforceable Physical Health Preferred Drug List
Amoxicillin and Clavulanate, Oral
Antibiotics AMOXICILLIN/POTASSIUM CLAV SUSP RECONAMOXICILLIN/POTASSIUM CLAV TAB CHEWAMOXICILLIN/POTASSIUM CLAV TABLET
Cephalosporins (1st Gen), OralAntibiotics CEPHALEXIN CAPSULE ***CEPHALEXIN SUSP RECON
Cephalosporins (2nd Gen), Oral
Antibiotics CEFPROZIL SUSP RECONCEFPROZIL TABLETCEFUROXIME AXETIL SUSP RECONCEFUROXIME AXETIL TABLET
Cephalosporins (3rd Gen), OralAntibiotics CEFDINIR CAPSULECEFDINIR SUSP RECON
Clostridium Difficile AntibioticsAntibiotics METRONIDAZOLE CAPSULEMETRONIDAZOLE TABLETMETRONIDAZOLE TABLET ERVANCOMYCIN HCL CAPSULEVANCOMYCIN HCL VIAL
Fluroquinolones, OralAntibiotics CIPROFLOXACIN SUS MC RECCIPROFLOXACIN HCL TABLETLEVOFLOXACIN SOLUTIONLEVOFLOXACIN TABLET
Macrolides, OralAntibiotics AZITHROMYCIN SUSP RECONAZITHROMYCIN TABLETCLARITHROMYCIN TABLET
Oxazolidinones, OralAntibiotics LINEZOLID SUSP RECONLINEZOLID TABLET
Tetracyclines, OralAntibiotics DOXYCYCLINE HYCLATE CAPSULEDOXYCYCLINE HYCLATE TABLETDOXYCYCLINE MONOHYDRATE CAPSULE ***DOXYCYCLINE MONOHYDRATE SUSP RECONTETRACYCLINE HCL CAPSULE
Antifungals, OralAntifungal CLOTRIMAZOLE TROCHEFLUCONAZOLE SUSP RECONFLUCONAZOLE TABLETNYSTATIN ORAL SUSPNYSTATIN TABLET
Hepatitis BAntivirals LAMIVUDINE * SOLUTIONLAMIVUDINE * TABLETTENOFOVIR DISOPROXIL FUMARATE * TABLET
3 Updated: December 27, 2016
* Drug coverage subject to meeting clinical prior authorization criteria** Drug coverage subject to quantity limits*** Certain strengths may require Prior Authorization‡ Age restric ons apply
System Class Preferred
Effective: January 1, 2017Table 121‐0030‐1 Oregon Fee‐for‐Service Enforceable Physical Health Preferred Drug List
Hepatitis C, Direct‐Acting Antivirals
Antivirals DACLATASVIR DIHYDROCHLORIDE * TABLETELBASVIR/GRAZOPREVIR (ZEPATIER ™) * TABLETLEDIPASVIR/SOFOSBUVIR (HARVONI ™) * TABLETSOFOSBUVIR * TABLETSOFOSBUVIR/VELPATASVIR (EPCLUSA ™) * TABLET
Hepatitis C, Other AgentsAntivirals PEGINTERFERON ALFA‐2A * PEN INJCTRPEGINTERFERON ALFA‐2A * SYRINGEPEGINTERFERON ALFA‐2A * VIALPEGINTERFERON ALFA‐2B * KITPEGINTERFERON ALFA‐2B * PEN IJ KITRIBAVIRIN * CAPSULERIBAVIRIN * TABLET
Herpes SimplexAntivirals ACYCLOVIR CAPSULEACYCLOVIR ORAL SUSPACYCLOVIR TABLET
4 Updated: December 27, 2016
* Drug coverage subject to meeting clinical prior authorization criteria** Drug coverage subject to quantity limits*** Certain strengths may require Prior Authorization‡ Age restric ons apply
System Class Preferred
Effective: January 1, 2017Table 121‐0030‐1 Oregon Fee‐for‐Service Enforceable Physical Health Preferred Drug List
HIVAntivirals ABACAVIR SULFATE SOLUTIONABACAVIR SULFATE TABLETABACAVIR SULFATE/LAMIVUDINE TABLETABACAVIR/DOLUTEGRAVIR/LAMIVUDI TABLETABACAVIR/LAMIVUDINE/ZIDOVUDINE TABLETATAZANAVIR SULFATE CAPSULEATAZANAVIR SULFATE POWD PACKATAZANAVIR SULFATE/COBICISTAT (EVOTAZ ™) TABLETCOBICISTAT TABLETDARUNAVIR ETHANOLATE ORAL SUSPDARUNAVIR ETHANOLATE TABLETDARUNAVIR/COBICISTAT TABLETDELAVIRDINE MESYLATE TAB DISPERDELAVIRDINE MESYLATE TABLETDIDANOSINE CAPSULE DRDIDANOSINE SOLN RECONDOLUTEGRAVIR SODIUM TABLETEFAVIRENZ CAPSULEEFAVIRENZ TABLETEFAVIRENZ/EMTRICITAB/TENOFOVIR TABLETELVITEG/COBI/EMTRIC/TENOFO ALA (GENVOYA ™) TABLETELVITEG/COBI/EMTRIC/TENOFO DIS TABLETELVITEGRAVIR TABLETEMTRICITA/RILPIVIRINE/TENOF DF TABLETEMTRICITAB/RILPIVIRI/TENOF ALA TABLETEMTRICITABINE CAPSULEEMTRICITABINE SOLUTIONEMTRICITABINE/TENOFOV ALAFENAM (DESCOVY ™) TABLETEMTRICITABINE/TENOFOVIR (TDF) TABLETENFUVIRTIDE VIALETRAVIRINE TABLETFOSAMPRENAVIR CALCIUM ORAL SUSPFOSAMPRENAVIR CALCIUM TABLETINDINAVIR SULFATE CAPSULELAMIVUDINE SOLUTIONLAMIVUDINE TABLETLAMIVUDINE/ZIDOVUDINE TABLETLOPINAVIR/RITONAVIR SOLUTIONLOPINAVIR/RITONAVIR TABLETMARAVIROC TABLETNELFINAVIR MESYLATE TABLETNEVIRAPINE ORAL SUSPNEVIRAPINE TAB ER 24HNEVIRAPINE TABLETRALTEGRAVIR POTASSIUM POWD PACKRALTEGRAVIR POTASSIUM TAB CHEWRALTEGRAVIR POTASSIUM TABLETRILPIVIRINE HCL TABLETRITONAVIR CAPSULERITONAVIR SOLUTION
5 Updated: December 27, 2016
* Drug coverage subject to meeting clinical prior authorization criteria** Drug coverage subject to quantity limits*** Certain strengths may require Prior Authorization‡ Age restric ons apply
System Class Preferred
Effective: January 1, 2017Table 121‐0030‐1 Oregon Fee‐for‐Service Enforceable Physical Health Preferred Drug List
HIVAntivirals RITONAVIR (NORVIR ™) TABLETSAQUINAVIR MESYLATE CAPSULESAQUINAVIR MESYLATE TABLETSTAVUDINE CAPSULESTAVUDINE SOLN RECONTIPRANAVIR CAPSULETIPRANAVIR/VITAMIN E TPGS SOLUTIONZIDOVUDINE CAPSULEZIDOVUDINE SYRUPZIDOVUDINE TABLETZIDOVUDINE VIAL
InfluenzaAntivirals OSELTAMIVIR PHOSPHATE * CAPSULEOSELTAMIVIR PHOSPHATE * SUSP RECON
ACEIs, ARBs and DRIsCardiovascular BENAZEPRIL HCL TABLETENALAPRIL MALEATE TABLETLISINOPRIL TABLETLOSARTAN POTASSIUM TABLETOLMESARTAN MEDOXOMIL TABLETRAMIPRIL CAPSULETELMISARTAN TABLET
AntianginalsCardiovascular ISOSORBIDE DINITRATE CAPSULE ERISOSORBIDE DINITRATE TABLETISOSORBIDE MONONITRATE TABLETNITROGLYCERIN CAPSULE ERNITROGLYCERIN PATCH TD24NITROGLYCERIN TAB SUBL
Anticoagulants, Oral and SQCardiovascular APIXABAN (ELIQUIS ™) TABLETDABIGATRAN ETEXILATE MESYLATE (PRADAXA ™) CAPSULEDALTEPARIN SODIUM,PORCINE SYRINGEEDOXABAN TOSYLATE (SAVAYSA ™) TABLETENOXAPARIN SODIUM SYRINGEENOXAPARIN SODIUM VIALRIVAROXABAN (XARELTO ™) TAB DS PKRIVAROXABAN (XARELTO ™) TABLETWARFARIN SODIUM TABLET
Beta‐Blockers, OralCardiovascular ACEBUTOLOL HCL CAPSULEATENOLOL TABLETCARVEDILOL TABLETLABETALOL HCL TABLETMETOPROLOL SUCCINATE TAB ER 24HMETOPROLOL TARTRATE TABLETPROPRANOLOL HCL TABLET
6 Updated: December 27, 2016
* Drug coverage subject to meeting clinical prior authorization criteria** Drug coverage subject to quantity limits*** Certain strengths may require Prior Authorization‡ Age restric ons apply
System Class Preferred
Effective: January 1, 2017Table 121‐0030‐1 Oregon Fee‐for‐Service Enforceable Physical Health Preferred Drug List
Calcium Channel Blockers ‐ Dihydropyridine, Oral
Cardiovascular AMLODIPINE BESYLATE TABLETNICARDIPINE HCL CAPSULENIFEDIPINE TAB ER 24NIFEDIPINE TABLET ER
Calcium Channel Blockers ‐ Non‐Dihydropyridine, Oral
Cardiovascular DILTIAZEM HCL CAP ER 12HDILTIAZEM HCL CAP ER 24HDILTIAZEM HCL CAP ER DEGDILTIAZEM HCL CAPSULE ERDILTIAZEM HCL TABLETVERAPAMIL HCL CAP24H PELVERAPAMIL HCL TABLETVERAPAMIL HCL TABLET ER
Combination Antihypertensives
Cardiovascular AMLODIPINE BES/OLMESARTAN MED TABLETBENAZEPRIL/HYDROCHLOROTHIAZIDE TABLETENALAPRIL/HYDROCHLOROTHIAZIDE TABLETLISINOPRIL/HYDROCHLOROTHIAZIDE TABLETLOSARTAN/HYDROCHLOROTHIAZIDE TABLETMETOPROLOL SUCCINATE/HCTZ TAB ER 24HOLMESARTAN/AMLODIPIN/HCTHIAZID TABLETOLMESARTAN/HYDROCHLOROTHIAZIDE TABLETTELMISARTAN/HYDROCHLOROTHIAZID TABLET
Diuretics, OralCardiovascular AMILORIDE HCL TABLETAMILORIDE/HYDROCHLOROTHIAZIDE TABLETBUMETANIDE TABLETFUROSEMIDE SOLUTION ***FUROSEMIDE TABLETHYDROCHLOROTHIAZIDE CAPSULEHYDROCHLOROTHIAZIDE TABLETINDAPAMIDE TABLETSPIRONOLACT/HYDROCHLOROTHIAZID TABLETSPIRONOLACTONE TABLETTORSEMIDE TABLETTRIAMTERENE CAPSULETRIAMTERENE/HYDROCHLOROTHIAZID CAPSULE
Other Dyslipidemia DrugsCardiovascular CHOLESTYRAMINE (WITH SUGAR) POWD PACKCHOLESTYRAMINE (WITH SUGAR) POWDERCHOLESTYRAMINE/ASPARTAME POWD PACKCHOLESTYRAMINE/ASPARTAME POWDERFENOFIBRATE TABLET ***GEMFIBROZIL TABLET
7 Updated: December 27, 2016
* Drug coverage subject to meeting clinical prior authorization criteria** Drug coverage subject to quantity limits*** Certain strengths may require Prior Authorization‡ Age restric ons apply
System Class Preferred
Effective: January 1, 2017Table 121‐0030‐1 Oregon Fee‐for‐Service Enforceable Physical Health Preferred Drug List
Platelet InhibitorsCardiovascular ASPIRIN TAB CHEWASPIRIN TABLETASPIRIN TABLET DRASPIRIN/DIPYRIDAMOLE CPMP 12HRCILOSTAZOL TABLETCLOPIDOGREL BISULFATE TABLETDIPYRIDAMOLE TABLET
Statins & Combos (High Potency)
Cardiovascular ATORVASTATIN CALCIUM TABLETSIMVASTATIN TABLET
Statins & Combos (Low‐Medium Potency)
Cardiovascular LOVASTATIN TABLETPRAVASTATIN SODIUM TABLET
Antibiotics, TopicalDermatologicals BACITRACIN OINT. (G) ***BACITRACIN ZINC OINT. (G)BACITRACIN ZINC/POLYMYX B SULF OINT. (G)BACITRACIN/POLYMYXIN B SULFATE OINT. (G)GENTAMICIN SULFATE CREAM (G)MUPIROCIN OINT. (G)NEOMYCIN SU/BACITRAC ZN/POLY OINT. (G)
Antifungals, TopicalDermatologicals MICONAZOLE NITRATE CREAM (G)NYSTATIN CREAM (G)NYSTATIN OINT. (G)
Antiparasitics, TopicalDermatologicals PERMETHRIN COMBO. PKGPERMETHRIN CREAM (G)PERMETHRIN LIQUIDPIP BUTOX/PYRETHRINS/PERMETH KITPIPERONYL BUTOXIDE/PYRETHRINS GEL (GRAM)PIPERONYL BUTOXIDE/PYRETHRINS KITPIPERONYL BUTOXIDE/PYRETHRINS LIQUIDPIPERONYL BUTOXIDE/PYRETHRINS SHAMPOO
Antipsoriatics, TopicalDermatologicals CALCIPOTRIENE * CREAM (G)CALCIPOTRIENE * SOLUTIONCALCIPOTRIENE/BETAMETHASONE * OINT. (G)TAZAROTENE * CREAM (G)TAZAROTENE * GEL (GRAM)
8 Updated: December 27, 2016
* Drug coverage subject to meeting clinical prior authorization criteria** Drug coverage subject to quantity limits*** Certain strengths may require Prior Authorization‡ Age restric ons apply
System Class Preferred
Effective: January 1, 2017Table 121‐0030‐1 Oregon Fee‐for‐Service Enforceable Physical Health Preferred Drug List
Steroids, TopicalDermatologicals ALCLOMETASONE DIPROPIONATE CREAM (G)ALCLOMETASONE DIPROPIONATE OINT. (G)BETAMETHASONE DIPROPIONATE CREAM (G)BETAMETHASONE DIPROPIONATE LOTIONBETAMETHASONE DIPROPIONATE OINT. (G)BETAMETHASONE VALERATE CREAM (G)BETAMETHASONE VALERATE OINT. (G)CLOBETASOL PROPIONATE CREAM (G)CLOBETASOL PROPIONATE OINT. (G)DESONIDE CREAM (G)DESONIDE OINT. (G)FLUOCINOLONE ACETONIDE CREAM (G)FLUOCINOLONE ACETONIDE SOLUTIONFLUOCINONIDE CREAM (G)FLUOCINONIDE SOLUTIONFLUOCINONIDE/EMOLLIENT BASE CREAM (G)HYDROCORTISONE CREAM (G) ***HYDROCORTISONE OINT. (G)HYDROCORTISONE ACETATE CREAM (G)HYDROCORTISONE BUTYRATE SOLUTIONTRIAMCINOLONE ACETONIDE CREAM (G)TRIAMCINOLONE ACETONIDE OINT. (G)
Androgens, Topical & Parenteral
Endocrine TESTOSTERONE ‡ GEL (GRAM)TESTOSTERONE ‡ GEL MD PMPTESTOSTERONE ‡ GEL PACKETTESTOSTERONE CYPIONATE ‡ VIALTESTOSTERONE ENANTHATE ‡ VIAL
Bone Metabolism DrugsEndocrine ALENDRONATE SODIUM TABLETIBANDRONATE SODIUM TABLETRISEDRONATE SODIUM TABLET
Diabetes, DPP‐4 InhibitorsEndocrine SITAGLIPTIN PHOS/METFORMIN HCL (JANUMET ™) * TABLETSITAGLIPTIN PHOSPHATE (JANUVIA ™) * TABLET
Diabetes, GLP‐1 Receptor Agonists
Endocrine EXENATIDE * PEN INJCTR
9 Updated: December 27, 2016
* Drug coverage subject to meeting clinical prior authorization criteria** Drug coverage subject to quantity limits*** Certain strengths may require Prior Authorization‡ Age restric ons apply
System Class Preferred
Effective: January 1, 2017Table 121‐0030‐1 Oregon Fee‐for‐Service Enforceable Physical Health Preferred Drug List
Diabetes, InsulinsEndocrine INSULIN ASPART VIALINSULIN ASPART * CARTRIDGEINSULIN ASPART * INSULN PENINSULIN ASPART PROT/INSULN ASP VIALINSULIN ASPART PROT/INSULN ASP * INSULN PENINSULIN DETEMIR * INSULN PENINSULIN GLARGINE,HUM.REC.ANLOG VIALINSULIN GLARGINE,HUM.REC.ANLOG * INSULN PENINSULIN LISPRO VIALINSULIN LISPRO PROTAMIN/LISPRO VIALINSULIN NPH HUM/REG INSULIN HM VIALINSULIN NPH HUM/REG INSULIN HM * INSULN PENINSULIN NPH HUMAN ISOPHANE VIALINSULIN REGULAR, HUMAN VIALINSULIN ZINC HUMAN RECOMBINANT VIAL
Diabetes, Miscellaneous Antidiabetic Agents
Endocrine METFORMIN HCL TAB ER 24HMETFORMIN HCL TABLET
Diabetes, SulfonylureasEndocrine GLIMEPIRIDE TABLETGLIPIZIDE TABLETGLYBURIDE TABLET
Diabetes, ThiazolidinedionesEndocrine PIOGLITAZONE HCL TABLET
Estrogen Replacement, OralEndocrine ESTRADIOL ‡ TABLETESTROPIPATE ‡ TABLET
Estrogen Replacement, TopicalEndocrine ESTRADIOL ‡ PATCH TDSWESTRADIOL ‡ PATCH TDWK
Estrogen Replacement, VaginalEndocrine ESTRADIOL TABLETESTROGENS, CONJUGATED CREAM/APPL
Growth HormonesEndocrine SOMATROPIN * CARTRIDGESOMATROPIN * PEN INJCTRSOMATROPIN * SYRINGE
Progestational AgentsEndocrine HYDROXYPROGESTERONE CAPROATE (MAKENA ™) * VIAL
Antacid, H2 AntagonistsGastrointestinal FAMOTIDINE TABLET ***RANITIDINE HCL SYRUPRANITIDINE HCL TABLET ***
Antacid, Proton Pump Inhibitors
Gastrointestinal OMEPRAZOLE ** CAPSULE DRPANTOPRAZOLE SODIUM ** TABLET DR
10 Updated: December 27, 2016
* Drug coverage subject to meeting clinical prior authorization criteria** Drug coverage subject to quantity limits*** Certain strengths may require Prior Authorization‡ Age restric ons apply
System Class Preferred
Effective: January 1, 2017Table 121‐0030‐1 Oregon Fee‐for‐Service Enforceable Physical Health Preferred Drug List
Antiemetics, NewerGastrointestinal ONDANSETRON ** TAB RAPDISONDANSETRON HCL ** SOLUTIONONDANSETRON HCL ** TABLET
Inflammatory Bowel DiseaseGastrointestinal BALSALAZIDE DISODIUM CAPSULEBUDESONIDE CAPDR ‐ ERMESALAMINE SUPP.RECTMESALAMINE (APRISO ™) CAP ER 24HMESALAMINE (LIALDA ™) TABLET DROLSALAZINE SODIUM CAPSULESULFASALAZINE TABLETSULFASALAZINE TABLET DR
11 Updated: December 27, 2016
* Drug coverage subject to meeting clinical prior authorization criteria** Drug coverage subject to quantity limits*** Certain strengths may require Prior Authorization‡ Age restric ons apply
System Class Preferred
Effective: January 1, 2017Table 121‐0030‐1 Oregon Fee‐for‐Service Enforceable Physical Health Preferred Drug List
Laxatives, Chronic Constipation
Gastrointestinal BISACODYL TABLETBISACODYL TABLET DRCALCIUM POLYCARBOPHIL TABLETCELLULOSE POWDERDOCUSATE CALCIUM CAPSULEDOCUSATE SODIUM CAPSULEDOCUSATE SODIUM LIQUIDDOCUSATE SODIUM SYRUPDOCUSATE SODIUM TABLETFOS/MALTODEXTRIN LIQUIDFRUCTOOLIGOSACCHARIDES/POLYDEX LIQUIDFRUCTOOLIGOSACCHARIDES/POLYDEX LIQUID PKTGLYCERIN/MALTODEXTRIN LIQUIDGUAR GUM PACKETGUAR GUM POWDERINULIN TAB CHEWLACTULOSE SOLUTIONMAGNESIUM CITRATE SOLUTIONMAGNESIUM HYDROXIDE ORAL SUSPMAGNESIUM HYDROXIDE TAB CHEWMETHYLCELLULOSE TABLETMETHYLCELLULOSE (WITH SUGAR) POWDER ***POLYETHYLENE GLYCOL 3350 POWDERPSYLLIUM HUSK CAPSULEPSYLLIUM HUSK POWDERPSYLLIUM HUSK (WITH DEXTROSE) POWDERPSYLLIUM HUSK (WITH SUGAR) POWDERPSYLLIUM HUSK/ASPARTAME POWD PACKPSYLLIUM HUSK/ASPARTAME POWDERPSYLLIUM HUSK/CALCIUM CARB CAPSULEPSYLLIUM SEED POWDERPSYLLIUM SEED (WITH DEXTROSE) PACKETPSYLLIUM SEED (WITH DEXTROSE) POWDERPSYLLIUM SEED (WITH SUGAR) POWDERPSYLLIUM SEED (WITH SUGAR) WAFERPSYLLIUM SEED/ASPARTAME POWDERPSYLLIUM SEED/SOD BICARB PACKETSENNA LEAF TEA (GRAM)SENNA LEAF EXTRACT SYRUPSENNOSIDES SYRUPSENNOSIDES TAB CHEWSENNOSIDES TABLETSENNOSIDES/DOCUSATE SODIUM TABLETSENNOSIDES/PSYLLIUM HUSK CAPSULESOLUBLE CORN FIBER POWDERWHEAT DEXTRIN POWD PACK ***WHEAT DEXTRIN POWDER
Pancreatic EnzymesGastrointestinal LIPASE/PROTEASE/AMYLASE (CREON ™) CAPSULE DR
12 Updated: December 27, 2016
* Drug coverage subject to meeting clinical prior authorization criteria** Drug coverage subject to quantity limits*** Certain strengths may require Prior Authorization‡ Age restric ons apply
System Class Preferred
Effective: January 1, 2017Table 121‐0030‐1 Oregon Fee‐for‐Service Enforceable Physical Health Preferred Drug List
Benign Prostate Hypertrophy Drugs
Genito‐Urinary DOXAZOSIN MESYLATE TABLETFINASTERIDE TABLETTAMSULOSIN HCL CAP ER 24HTERAZOSIN HCL CAPSULE
Overactive Bladder DrugsGenito‐Urinary FESOTERODINE FUMARATE TAB ER 24HHYOSCYAMINE SULFATE ELIXIRHYOSCYAMINE SULFATE TAB RAPDISOXYBUTYNIN PATCH TDSWOXYBUTYNIN CHLORIDE SYRUPOXYBUTYNIN CHLORIDE TAB ER 24OXYBUTYNIN CHLORIDE TABLET
Colony Stimulating FactorsHematology‐Oncology FILGRASTIM SYRINGEFILGRASTIM VIALFILGRASTIM‐SNDZ SYRINGEPEGFILGRASTIM SYR W/ INJPEGFILGRASTIM SYRINGESARGRAMOSTIM VIALTBO‐FILGRASTIM (GRANIX ™) SYRINGE
Erythropoetic Stimulating Agents
Hematology‐Oncology DARBEPOETIN ALFA IN POLYSORBAT (ARANESP ™) * SYRINGEDARBEPOETIN ALFA IN POLYSORBAT (ARANESP ™) * VIALPROCRIT ™ ‐ BRAND ONLY * VIAL
Iron ChelatorsHematology‐Oncology DEFEROXAMINE MESYLATE VIAL
Biologics for Autoimmune Conditions
Immunological ADALIMUMAB (HUMIRA ™) * SYRINGEKITADALIMUMAB (HUMIRA PEDIATRIC CROHN'S ™) * SYRINGEKITADALIMUMAB (HUMIRA PEN ™) * PEN IJ KITADALIMUMAB (HUMIRA PEN CROHN‐UC‐HS STARTER ™) * PEN IJ KITADALIMUMAB (HUMIRA PEN PSORIASIS‐UVEITIS ™) * PEN IJ KITETANERCEPT (ENBREL ™) * PEN INJCTRETANERCEPT (ENBREL ™) * SYRINGEETANERCEPT (ENBREL ™) * VIAL
ImmunoglobulinsImmunological GAMUNEX‐C ™ ‐ BRAND ONLY VIAL ***
13 Updated: December 27, 2016
* Drug coverage subject to meeting clinical prior authorization criteria** Drug coverage subject to quantity limits*** Certain strengths may require Prior Authorization‡ Age restric ons apply
System Class Preferred
Effective: January 1, 2017Table 121‐0030‐1 Oregon Fee‐for‐Service Enforceable Physical Health Preferred Drug List
ImmunosuppressantsImmunological AZATHIOPRINE TABLETCYCLOSPORINE CAPSULECYCLOSPORINE SOLUTIONCYCLOSPORINE, MODIFIED CAPSULECYCLOSPORINE, MODIFIED SOLUTIONEVEROLIMUS TABLETMYCOPHENOLATE MOFETIL CAPSULEMYCOPHENOLATE MOFETIL SUSP RECONMYCOPHENOLATE MOFETIL TABLETMYCOPHENOLATE SODIUM TABLET DRSIROLIMUS SOLUTIONSIROLIMUS TABLETTACROLIMUS CAPSULE
Alzheimer's Disease DrugsNeurology DONEPEZIL HCL TABLET ***GALANTAMINE HBR CAP24H PELGALANTAMINE HBR TABLETMEMANTINE HCL SOLUTIONMEMANTINE HCL TAB DS PKMEMANTINE HCL TABLETRIVASTIGMINE PATCH TD24
Antiepileptics (oral & rectal)Neurology CARBAMAZEPINE ORAL SUSPCARBAMAZEPINE TAB CHEWCARBAMAZEPINE TAB ER 12HCARBAMAZEPINE TABLETDIASTAT ™ ‐ BRAND ONLY KITDIASTAT ACUDIAL ™ ‐ BRAND ONLY KITETHOSUXIMIDE CAPSULEETHOSUXIMIDE SOLUTIONETHOTOIN TABLETGABAPENTIN CAPSULELACOSAMIDE (VIMPAT ™) TABLETLEVETIRACETAM SOLUTIONLEVETIRACETAM TABLETMETHSUXIMIDE CAPSULEOXCARBAZEPINE ORAL SUSPOXCARBAZEPINE TABLETPHENOBARBITAL ELIXIRPHENOBARBITAL TABLETPHENYTOIN ORAL SUSPPHENYTOIN TAB CHEWPHENYTOIN SODIUM EXTENDED CAPSULEPRIMIDONE TABLETRUFINAMIDE TABLETTIAGABINE HCL TABLETTOPIRAMATE TABLETZONISAMIDE CAPSULE
14 Updated: December 27, 2016
* Drug coverage subject to meeting clinical prior authorization criteria** Drug coverage subject to quantity limits*** Certain strengths may require Prior Authorization‡ Age restric ons apply
System Class Preferred
Effective: January 1, 2017Table 121‐0030‐1 Oregon Fee‐for‐Service Enforceable Physical Health Preferred Drug List
Multiple SclerosisNeurology GLATIRAMER ACETATE SYRINGE ***INTERFERON BETA‐1A PEN IJ KITINTERFERON BETA‐1A SYRINGEINTERFERON BETA‐1A SYRINGEKITINTERFERON BETA‐1A/ALBUMIN KITINTERFERON BETA‐1A/ALBUMIN PEN INJCTRINTERFERON BETA‐1A/ALBUMIN SYRINGEINTERFERON BETA‐1B KIT
Parkinson's Disease Drugs, Oral & Topical
Neurology BENZTROPINE MESYLATE TABLETCARBIDOPA/LEVODOPA TABLETCARBIDOPA/LEVODOPA TABLET ERCARBIDOPA/LEVODOPA/ENTACAPONE TABLETENTACAPONE TABLETPRAMIPEXOLE DI‐HCL TABLETSELEGILINE HCL CAPSULETRIHEXYPHENIDYL HCL ELIXIRTRIHEXYPHENIDYL HCL TABLET
B‐vitamins, OralNutritional CYANOCOBALAMIN (VITAMIN B‐12) DROPS ***CYANOCOBALAMIN (VITAMIN B‐12) LOZENGECYANOCOBALAMIN (VITAMIN B‐12) TAB IR ERCYANOCOBALAMIN (VITAMIN B‐12) TAB RAPDIS ***CYANOCOBALAMIN (VITAMIN B‐12) TAB SUBL ***CYANOCOBALAMIN (VITAMIN B‐12) TABLET ***LEVOMEFOLATE/ALGAL OIL CAPSULEPYRIDOXINE HCL TABLETTHIAMINE HCL TABLET ***THIAMINE MONONITRATE TABLET
Calcium/Vit D Replacement, Oral
Nutritional CALCIUM CARBONATE CAPSULECALCIUM CARBONATE ORAL SUSPCALCIUM CARBONATE TAB CHEWCALCIUM CARBONATE TABLETCALCIUM CARBONATE/VITAMIN D3 CAPSULE ***CALCIUM CARBONATE/VITAMIN D3 LIQUIDCALCIUM CARBONATE/VITAMIN D3 TAB CHEWCALCIUM CARBONATE/VITAMIN D3 TABLET ***CALCIUM CITRATE TABLET ***CHOLECALCIFEROL (VITAMIN D3) CAPSULE ***CHOLECALCIFEROL (VITAMIN D3) SPRAY SUSPCHOLECALCIFEROL (VITAMIN D3) TABLET ***ERGOCALCIFEROL (VITAMIN D2) CAPSULEERGOCALCIFEROL (VITAMIN D2) TABLET
15 Updated: December 27, 2016
* Drug coverage subject to meeting clinical prior authorization criteria** Drug coverage subject to quantity limits*** Certain strengths may require Prior Authorization‡ Age restric ons apply
System Class Preferred
Effective: January 1, 2017Table 121‐0030‐1 Oregon Fee‐for‐Service Enforceable Physical Health Preferred Drug List
Iron Replacement, OralNutritional FERROUS GLUCONATE TABLET ***FERROUS SULFATE ELIXIR ***FERROUS SULFATE LIQUIDFERROUS SULFATE TABLETFERROUS SULFATE TABLET DRFERROUS SULFATE TABLET ER ***IRON FUM, PS/FA/VIT C/L. CASEI POWD PACK
Magnesium Replacement, OralNutritional MAGNESIUM TABLETMAGNESIUM AMINO ACID CHELATE TABLETMAGNESIUM CARBONATE LIQUIDMAGNESIUM CITRATE TABLETMAGNESIUM GLUCONATE TABLETMAGNESIUM OXIDE CAPSULEMAGNESIUM OXIDE/MAGNESIUM TABLETMAGNESIUM OXIDE/PYRIDOXINE HCL TABLET
Multivitamins, OralNutritional BETA‐CAROTENE(A)‐VITS C,E/MINS * TABLETFOLIC ACID/VIT BCOMP,C * TABLETMULTIVIT,TX IRON,OTHER MINS * TABLETMULTIVITAMIN * TABLETMULTIVITAMIN WITH MINERALS/LUT * TABLETMULTIVITAMIN,THERAPEUTIC * TABLETMULTIVITAMIN/IRON/FOLIC ACID * TABLETMULTIVIT‐MIN/FA/LYCOPEN/LUTEIN * TABLETMV. MIN CMB#51/FA/VIT K1/UBI * TAB CHEWVITAMIN B COMPLEX * CAPSULE
Potassium and K‐Phos, OralNutritional NA PHOS,M‐B/K PHOS,MONOB TABLETPHOSPHORUS #1 TABLETPOT CHLORIDE/CAL PHOS/MAG TABLETPOTASSIUM TABLETPOTASSIUM BICARBONATE/CIT AC TABLET EFF ***POTASSIUM CHLORIDE TAB ER PRTPOTASSIUM CHLORIDE TABLET ERPOTASSIUM PHOSPHATE,MONOBASIC TABLET SOL
16 Updated: December 27, 2016
* Drug coverage subject to meeting clinical prior authorization criteria** Drug coverage subject to quantity limits*** Certain strengths may require Prior Authorization‡ Age restric ons apply
System Class Preferred
Effective: January 1, 2017Table 121‐0030‐1 Oregon Fee‐for‐Service Enforceable Physical Health Preferred Drug List
Prenatal VitaminsNutritional IRON,CARBONYL/FA/MULTIVIT‐MIN TABLETPNV #14/FERROUS FUM/FOLIC ACID TAB CHEWPNV #15/IRON FUM,PS/FOLIC ACID CAPSULEPNV #78/IRON ASP GLY/FA#1/DHA CAPSULEPNV #8/IRON PS CMP,ASPG/FA/DHA COMBO. PKGPNV #86/IRON POLY/FA/DHA/EPA COMBO. PKGPNV #87/IRON BISGLY/FA/DHA COMBO. PKGPNV 11‐IRON FUM‐FOLIC ACID‐OM3 CAPSULEPNV 16/IRON FUM,PS/FOLIC/OM‐3 CAPSULEPNV 18/FE,CARB/FA/DSS/UBI/DHA TABLETPNV 19/IRON PS,HEME/FOLIC/DHA CAPSULEPNV 21/IRON PS,HEME PPEP/FOLIC TABLETPNV 22/IRON,GLUC/FOLIC/DSS/DHA COMBO. PKGPNV 30/IRON CARB,AG/FOLIC/OM3 CAPSULEPNV 76/IRON,GLUC/FOLIC/DSS/DHA COMBO. PKGPNV 85/IRON/FOLIC/DHA/FISH OIL CAPSULEPNV COMBO#47/IRON/FA #1/DHA CAPSULEPNV NO.118/IRON FUMARATE/FA TAB CHEWPNV NO.66/IRON,CARBONYL/FA/DHA CAPSULEPNV NO.81/IRON,GLUC/FOLIC/DSS TABLETPNV W‐CA #40/IRON FUM/FA CMB#1 TABLETPNV WITH CA #68/IRON/FA#1/DHA CAPSULEPNV WITH CA NO.65/IRON POLY/FA CAPSULEPNV WITH CA#74/IRON/FOLIC ACID TABLETPNV WITH CA,NO.70/IRON/FA/DHA CAPSULEPNV WITH CA,NO.72/IRON/FA TABLETPNV#20/IRON/FA/DS/FISH/DHA/EPA CAPSULEPNV#26/IRON POLY/FA/DHA CAPSULEPNV#67/IRON PS/FA CMB#1/DHA CAPSULEPNV,CALC 35/IRON/FOLIC/DSS/OM3 CAPSULEPNV,CALCIUM37/IRON/FOLIC/OMEG3 CAPSULEPNV/FOLIC AC/B6/CALCIUM/GINGER TABLETPNV113/FE/L‐MEF/OM3/DHA/EPA/FS CMB TABAMPPNV115/IRON FUMARATE/FA/DSS TABLETPNV123/IRON CAR/FA/OM3/DHA/EPA CAPSULEPNV19/IRON BD HC,S‐P/FOLIC/OM3 CMBPKGDRCPPNV2/IRON B‐G SUC‐P/FA/OMEGA‐3 COMBO. PKGPNV34/IRON,CARBONYL/FA/DSS/DHA CAPSULEPNV39/IRON FUMARATE/FA/DSS/DHA CAPSULEPNV53/IRON B‐G HCL‐P/FA/OMEGA3 COMBO. PKGPNV53/IRON FUM/FA/DOCUSATE/DHA CAPSULEPNV55/IRON BG HC,SUCC‐P/FA/OM3 CMBPKGDRCPPNV59/IRON,CARB,FUM/FA/DSS/DHA CAPSULEPNV66/IRON FUMARATE/FA/DSS/DHA CAPSULEPNV69/IRON,CARBONYL/FA/DSS/DHA CAPSULEPNV72/IRON,GLUC/FOLIC/DSS/DHA COMBO. PKGPNV73/IRON,GLUC/FOLIC/DSS/DHA COMBO. PKGPNV80/IRON FUMARATE/FA/DSS/DHA CAPSULEPNV81/IRON EDTA,PS/FOLIC/OMEG3 CMBPKGDRCPPNV83/IRON,CARB/IRON ASP GL/FA TABLET
17 Updated: December 27, 2016
* Drug coverage subject to meeting clinical prior authorization criteria** Drug coverage subject to quantity limits*** Certain strengths may require Prior Authorization‡ Age restric ons apply
System Class Preferred
Effective: January 1, 2017Table 121‐0030‐1 Oregon Fee‐for‐Service Enforceable Physical Health Preferred Drug List
Prenatal VitaminsNutritional PRENAT VIT COMB.10/IRON/FA/DHA COMBO. PKGPRENATAL #103/IRON FUMARATE/FA TABLETPRENATAL #57/IRON/FA/DSS/DHA CAPSULEPRENATAL #79/IRON ASP GLY/FA#1 TABLETPRENATAL NO.13/IRON PS/FA CB#1 TAB CHEWPRENATAL NO.52/IRON/FA/DHA CAPSULEPRENATAL NO.75/IRON/FOLATE #1 TABLETPRENATAL NO.77/IRON ASP GLY/FA TABLETPRENATAL VIT #68/IRON/FA#6/DHA CAPSULEPRENATAL VIT #69/IRON/FA#6/DHA CAPSULEPRENATAL VIT #76/IRON,CARB/FA TABLETPRENATAL VIT 15/IRON CB/FA/DSS TABLETPRENATAL VIT 16/IRON CB/FA/DSS TABLETPRENATAL VIT COMB.10/IRON/FA TABLETPRENATAL VIT NO.112/FOLIC ACID TAB CHEWPRENATAL VIT NO.114/FA/GINGER TABLETPRENATAL VIT NO.127/IRON/FA TABLETPRENATAL VIT NO.73/IRON/FA TABLETPRENATAL VIT NO.87/IRON/FA/DHA CAPSULEPRENATAL VIT#4/IRON FUM,PS/FA CAPSULEPRENATAL VIT#65/IRON FUM,PS/FA CAPSULEPRENATAL VIT#84/IRON/FA#1/DHA CAPSULEPRENATAL VIT#85/IRON/FA#1/DHA CAPSULEPRENATAL VIT#86/IRON BISGLY/FA TABLETPRENATAL VIT27,CALCIUM/IRON/FA TABLETPRENATAL VIT37/IRON/FOLIC ACID TAB CHEWPRENATAL VITS #33/IRON/FA/DHA COMBO. PKGPRENATAL VITS#4/IRON FUM/FA CAPSULEPRENATAL#90/IRON FUM,PS/FA/DHA CAPSULEPRENATAL56/IRON/FOLIC ACID/DHA CAPSULEPV W‐O CAL/IRON PS CPLX/FA TAB CHEW
Antibiotics, OphthalmicOphthalmics BACITRACIN/POLYMYXIN B SULFATE OINT. (G)CIPROFLOXACIN HCL DROPSCIPROFLOXACIN HCL OINT. (G)ERYTHROMYCIN BASE OINT. (G)GENTAMICIN SULFATE DROPSGENTAMICIN SULFATE OINT. (G) ***MOXIFLOXACIN HCL DROPSNATAMYCIN DROPS SUSPNEOMYCIN/POLYMYXN B/GRAMICIDIN DROPSOFLOXACIN DROPSPOLYMYXIN B SULF/TRIMETHOPRIM DROPSSULFACETAMIDE SODIUM DROPSTOBRAMYCIN DROPSTOBRAMYCIN OINT. (G)
18 Updated: December 27, 2016
* Drug coverage subject to meeting clinical prior authorization criteria** Drug coverage subject to quantity limits*** Certain strengths may require Prior Authorization‡ Age restric ons apply
System Class Preferred
Effective: January 1, 2017Table 121‐0030‐1 Oregon Fee‐for‐Service Enforceable Physical Health Preferred Drug List
Antibiotic‐Steroids, Ophthalmic
Ophthalmics GENTAMICIN/PREDNISOL AC DROPS SUSPGENTAMICIN/PREDNISOL AC OINT. (G)NEO/POLYMYX B SULF/DEXAMETH DROPS SUSPNEO/POLYMYX B SULF/DEXAMETH OINT. (G)SULFACETM NA/PREDNISOL AC DROPS SUSPSULFACETM NA/PREDNISOL AC OINT. (G)TOBRAMYCIN/DEXAMETHASONE DROPS SUSPTOBRAMYCIN/DEXAMETHASONE OINT. (G)
Anti‐Inflammatory Drugs, Ophthalmic
Ophthalmics DEXAMETHASONE DROPS SUSPDEXAMETHASONE SOD PHOSPHATE DROPSDICLOFENAC SODIUM DROPS ***FLUOROMETHOLONE DROPS SUSPFLUOROMETHOLONE OINT. (G)FLURBIPROFEN SODIUM DROPSKETOROLAC TROMETHAMINE DROPSLOTEPREDNOL ETABONATE DROPS SUSPPREDNISOLONE ACETATE DROPS SUSP
Glaucoma DrugsOphthalmics BETAXOLOL HCL DROPSBRIMONIDINE TARTRATE DROPS ***BRINZOLAMIDE DROPS SUSPCARTEOLOL HCL DROPSDORZOLAMIDE HCL/TIMOLOL MALEAT DROPSDORZOLAMIDE/TIMOLOL/PF DROPERETTELATANOPROST DROPSPILOCARPINE HCL DROPSTIMOLOL MALEATE DROPSTRAVOPROST DROPS
Vascular Endothelial Growth Factors
Ophthalmics BEVACIZUMAB VIAL
Otic AntibioticsOtics NEOMYCIN SU/COLIST/HC/THONZON DROPS SUSPNEOMYCIN/POLYMYXIN B SULF/HC DROPS SUSP ***OFLOXACIN DROPS
ADHD DrugsPsychiatric DEXMETHYLPHENIDATE HCL CPBP 50‐50DEXMETHYLPHENIDATE HCL (FOCALIN XR ™) CPBP 50‐50DEXTROAMPHETAMINE/AMPHETAMINE TABLETFOCALIN ™ ‐ BRAND ONLY TABLETLISDEXAMFETAMINE DIMESYLATE (VYVANSE ™) CAPSULEMETADATE CD ™ ‐ BRAND ONLY CPBP 30‐70METHYLPHENIDATE PATCH TD24METHYLPHENIDATE HCL TABLET
BenzodiazepinesPsychiatric CLONAZEPAM ** TABLET
19 Updated: December 27, 2016
* Drug coverage subject to meeting clinical prior authorization criteria** Drug coverage subject to quantity limits*** Certain strengths may require Prior Authorization‡ Age restric ons apply
System Class Preferred
Effective: January 1, 2017Table 121‐0030‐1 Oregon Fee‐for‐Service Enforceable Physical Health Preferred Drug List
Opioid Reversal AgentsPsychiatric NALOXONE HCL SPRAYNALOXONE HCL SYRINGENALOXONE HCL VIAL
SedativesPsychiatric ZOLPIDEM TARTRATE ** TABLET
Substance Use Disorders, Opioid & Alcohol
Psychiatric ACAMPROSATE CALCIUM TABLET DRBUPRENORPHINE HCL/NALOXONE HCL (SUBOXONE ™) * FILMBUPRENORPHINE HCL/NALOXONE HCL * TAB SUBLNALTREXONE HCL TABLET
Tobacco Smoking CessationPsychiatric BUPROPION HCL TABLET ERNICOTINE * CARTRIDGENICOTINE * SPRAYNICOTINE ** PATCH DYSQNICOTINE ** PATCH TD24NICOTINE POLACRILEX ** GUMNICOTINE POLACRILEX ** LOZENGEVARENICLINE TARTRATE (CHANTIX ™) ** TAB DS PKVARENICLINE TARTRATE (CHANTIX ™) ** TABLET
Anticholinergics, InhaledPulmonary IPRATROPIUM BROMIDE HFA AER ADIPRATROPIUM BROMIDE SOLUTIONIPRATROPIUM/ALBUTEROL SULFATE AMPUL‐NEBTIOTROPIUM BROMIDE (SPIRIVA ™) CAP W/DEV
Beta‐Agonists, Inhaled Long Acting
Pulmonary FORMOTEROL FUMARATE CAP W/DEVSALMETEROL XINAFOATE BLST W/DEV
Beta‐Agonists, Inhaled Short‐Acting
Pulmonary ALBUTEROL SULFATE HFA AER ADALBUTEROL SULFATE SOLUTIONALBUTEROL SULFATE VIAL‐NEB
Corticosteroids, InhaledPulmonary BECLOMETHASONE DIPROPIONATE AER W/ADAPBUDESONIDE AER POW BAFLUTICASONE PROPIONATE AER W/ADAPFLUTICASONE PROPIONATE BLST W/DEV
Corticosteroids/LABA Combination, Inhaled
Pulmonary BUDESONIDE/FORMOTEROL FUMARATE HFA AER ADFLUTICASONE/SALMETEROL BLST W/DEVFLUTICASONE/SALMETEROL HFA AER AD
Cystic FibrosisPulmonary DORNASE ALFA ** SOLUTIONSODIUM CHLORIDE FOR INHALATION VIAL‐NEBTOBRAMYCIN/NEBULIZER (KITABIS PAK ™) ** AMPUL‐NEB
Miscellaneous Pulmonary Agents
Pulmonary MONTELUKAST SODIUM TAB CHEWMONTELUKAST SODIUM TABLET
20 Updated: December 27, 2016
* Drug coverage subject to meeting clinical prior authorization criteria** Drug coverage subject to quantity limits*** Certain strengths may require Prior Authorization‡ Age restric ons apply
System Class Preferred
Effective: January 1, 2017Table 121‐0030‐1 Oregon Fee‐for‐Service Enforceable Physical Health Preferred Drug List
Pulmonary Arterial Hypertension Oral and Inhaled Drugs
Pulmonary BOSENTAN TABLETSILDENAFIL CITRATE TABLET
Pulmonary Arterial Hypertension Parenteral Drugs
Pulmonary EPOPROSTENOL SODIUM (GLYCINE) VIAL
Phosphate BindersRenal CALCIUM ACETATE CAPSULECALCIUM ACETATE TABLET ***SEVELAMER HCL * TABLET
21 Updated: December 27, 2016
* Drug coverage subject to meeting clinical prior authorization criteria** Drug coverage subject to quantity limits*** Certain strengths may require Prior Authorization‡ Age restric ons apply
System Class Preferred
Effective: January 1, 2017Table 121‐0030‐1 Oregon Fee‐for‐Service Voluntary Mental Health Preferred Drug List
Antiepileptics (oral & rectal)Neurology DIVALPROEX SODIUM CAP SPRINKDIVALPROEX SODIUM TAB ER 24HDIVALPROEX SODIUM TABLET DRLAMOTRIGINE TABLETVALPROIC ACID CAPSULEVALPROIC ACID (AS SODIUM SALT) SOLUTION
ADHD DrugsPsychiatric ATOMOXETINE HCL CAPSULE
AntidepressantsPsychiatric AMITRIPTYLINE HCL TABLETANAFRANIL ™ ‐ BRAND ONLY CAPSULEBUPROPION HCL TABLETBUPROPION HCL TABLET ERCITALOPRAM HYDROBROMIDE ‡ SOLUTIONCITALOPRAM HYDROBROMIDE ‡ TABLETDESIPRAMINE HCL TABLETDOXEPIN HCL CAPSULEDOXEPIN HCL ORAL CONCESCITALOPRAM OXALATE ‡ TABLETFLUOXETINE HCL ‡ CAPSULEFLUOXETINE HCL ‡ SOLUTIONFLUOXETINE HCL ‡ TABLETFLUVOXAMINE MALEATE ‡ TABLETIMIPRAMINE HCL TABLETMAPROTILINE HCL TABLETMIRTAZAPINE TAB RAPDISMIRTAZAPINE TABLETNORTRIPTYLINE HCL CAPSULENORTRIPTYLINE HCL SOLUTIONPAROXETINE HCL ‡ TABLETPROTRIPTYLINE HCL TABLETSERTRALINE HCL ‡ ORAL CONCSERTRALINE HCL ‡ TABLETTRIMIPRAMINE MALEATE CAPSULEVENLAFAXINE HCL CAP ER 24HVENLAFAXINE HCL TABLET
Antipsychotics, 1st GenPsychiatric FLUPHENAZINE HCL ELIXIRFLUPHENAZINE HCL ORAL CONCFLUPHENAZINE HCL TABLETHALOPERIDOL TABLETHALOPERIDOL LACTATE ORAL CONCLOXAPINE SUCCINATE CAPSULEPERPHENAZINE TABLETTHIORIDAZINE HCL TABLETTHIOTHIXENE CAPSULETRIFLUOPERAZINE HCL TABLET
22 Updated: December 27, 2016
* Drug coverage subject to meeting clinical prior authorization criteria** Drug coverage subject to quantity limits*** Certain strengths may require Prior Authorization‡ Age restric ons apply
System Class Preferred
Effective: January 1, 2017Table 121‐0030‐1 Oregon Fee‐for‐Service Voluntary Mental Health Preferred Drug List
Antipsychotics, 2nd GenPsychiatric ASENAPINE MALEATE (SAPHRIS ™) TAB SUBLCLOZAPINE TABLETLURASIDONE HCL (LATUDA ™) TABLETOLANZAPINE TABLETQUETIAPINE FUMARATE ** TABLETRISPERIDONE SOLUTIONRISPERIDONE TABLET
Antipsychotics, ParenteralPsychiatric ARIPIPRAZOLE (ABILIFY MAINTENA ™) SUSER SYRARIPIPRAZOLE (ABILIFY MAINTENA ™) SUSER VIALARIPIPRAZOLE LAUROXIL (ARISTADA ™) SUSER SYRCHLORPROMAZINE HCL AMPULFLUPHENAZINE DECANOATE VIALFLUPHENAZINE HCL VIALHALOPERIDOL DECANOATE AMPULHALOPERIDOL DECANOATE VIALHALOPERIDOL LACTATE AMPULHALOPERIDOL LACTATE VIALRISPERIDONE MICROSPHERES ** SYRINGE
23 Updated: December 27, 2016
* Drug coverage subject to meeting clinical prior authorization criteria** Drug coverage subject to quantity limits*** Certain strengths may require Prior Authorization‡ Age restric ons apply