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Molina Healthcare of Washington Medicaid Preferred Drug ...

January 2018 Molina Healthcare of Washington Medicaid Preferred Drug List ( formulary ) Molina Healthcare of Washington Medicaid Preferred Drug List ( formulary ) (01/01/ 2018 ) INTRODUCTION .. 4 PREFACE .. 4 PHARMACY AND THERAPEUTICS (P&T) COMMITTEE .. 4 DRUG LIST PRODUCT DESCRIPTIONS .. 4 PRESCRIPTION QUANTITIES .. 4 GENERIC SUBSTITUTION .. 4 PLAN DESIGN .. 5 PRIOR AUTHORIZATION REQUEST PROCEDURE .. 5 PRIOR AUTHORIZATION HELPFUL HINTS .. 5 NON-COVERED MEDICATIONS .. 5 CARVED-OUT MEDICATIONS (MEDICATIONS COVERED UNDER THE APPLE HEALTH FEE-FOR-SERVICE PROGRAM).

5 INTRODUCTION We are pleased to provide the 2018 Molina Healthcare of Washington Medicaid Preferred Drug List (Formulary) as a useful reference and informational tool. This document can assist medical providers in selecting clinically-appropriate and cost-effective

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Transcription of Molina Healthcare of Washington Medicaid Preferred Drug ...

1 January 2018 Molina Healthcare of Washington Medicaid Preferred Drug List ( formulary ) Molina Healthcare of Washington Medicaid Preferred Drug List ( formulary ) (01/01/ 2018 ) INTRODUCTION .. 4 PREFACE .. 4 PHARMACY AND THERAPEUTICS (P&T) COMMITTEE .. 4 DRUG LIST PRODUCT DESCRIPTIONS .. 4 PRESCRIPTION QUANTITIES .. 4 GENERIC SUBSTITUTION .. 4 PLAN DESIGN .. 5 PRIOR AUTHORIZATION REQUEST PROCEDURE .. 5 PRIOR AUTHORIZATION HELPFUL HINTS .. 5 NON-COVERED MEDICATIONS .. 5 CARVED-OUT MEDICATIONS (MEDICATIONS COVERED UNDER THE APPLE HEALTH FEE-FOR-SERVICE PROGRAM).

2 5 LEGEND .. 6 REQUESTING formulary CHANGES .. 6 NOTICE .. 6 ANALGESICS .. 7 ANALGESICS, 7 NSAIDs .. 7 NSAIDs, TOPICAL .. 7 COX-2 7 GOUT .. 7 OPIOID ANALGESICS .. 7 NON-OPIOID ANALGESICS .. 8 VISCOSUPPLEMENTS .. 8 ANTI-INFECTIVES .. 8 8 ANTIFUNGALS .. 9 ANTIMALARIALS .. 10 ANTIRETROVIRAL AGENTS .. 10 ANTITUBERCULAR AGENTS .. 11 ANTIVIRALS .. 11 12 ANTINEOPLASTIC AGENTS .. 12 ALKYLATING AGENTS .. 12 ANTIMETABOLITES .. 13 CYTOPROTECTIVE AGENTS .. 13 HORMONAL ANTINEOPLASTIC AGENTS .. 13 IMMUNOMODULATORS .. 13 KINASE INHIBITORS .. 13 14 14 ACE INHIBITORS.

3 14 ACE INHIBITOR/DIURETIC 14 ADRENOLYTICS, CENTRAL .. 14 ALDOSTERONE RECEPTOR ANTAGONISTS .. 14 ALPHA BLOCKERS .. 14 ANGIOTENSIN II RECEPTOR ANTAGONISTS/DIURETIC COMBINATIONS .. 14 15 ANTILIPEMICS .. 15 BETA-BLOCKERS .. 16 BETA-BLOCKER/DIURETIC COMBINATIONS .. 16 CALCIUM CHANNEL BLOCKERS .. 16 DIGITALIS GLYCOSIDES .. 16 DIURETICS .. 16 NITRATES .. 17 PULMONARY ARTERIAL HYPERTENSION .. 17 1 17 CENTRAL NERVOUS SYSTEM .. 18 ANTIANXIETY .. 18 ANTICONVULSANTS .. 18 ANTIDEMENTIA .. 19 ANTIDEPRESSANTS .. 19 ANTIPARKINSONIAN AGENTS .. 19 20 ATTENTION DEFICIT HYPERACTIVITY DISORDER.

4 22 FIBROMYALGIA .. 23 HUNTINGTON'S DISEASE 23 HYPNOTICS .. 23 MIGRAINE .. 23 MOOD STABILIZERS .. 23 MULTIPLE SCLEROSIS AGENTS .. 23 MUSCULOSKELETAL THERAPY AGENTS .. 24 MYASTHENIA GRAVIS .. 24 NARCOLEPSY/CATAPLEXY .. 24 24 24 ENDOCRINE AND METABOLIC .. 24 ANDROGENS .. 24 ANTIDIABETICS .. 25 CALCIUM RECEPTOR ANTAGONISTS .. 26 CALCIUM REGULATORS .. 26 CARNITINE DEFICIENCY AGENTS .. 27 CONTRACEPTIVES .. 27 ENDOMETRIOSIS .. 29 ESTROGENS .. 29 ESTROGEN/PROGESTINS .. 29 ESTROGEN/SELECTIVE ESTROGEN RECEPTOR MODULATOR COMBINATIONS .. 29 GLUCOCORTICOIDS.

5 29 GLUCOSE ELEVATING AGENTS .. 29 HUMAN GROWTH HORMONES .. 29 HYPERPARATHYROID TREATMENT, VITAMIN D ANALOGS .. 29 INSULIN-LIKE GROWTH FACTORS .. 29 PHOSPHATE BINDER AGENTS .. 29 POTASSIUM-REMOVING AGENTS .. 30 PROGESTINS .. 30 SELECTIVE ESTROGEN RECEPTOR MODULATORS .. 30 THYROID AGENTS .. 30 VASOPRESSINS .. 30 30 GASTROINTESTINAL .. 31 ANTACIDS .. 31 ANTIDIARRHEALS .. 31 ANTIEMETICS .. 31 ANTISPASMODICS .. 31 31 H2 RECEPTOR ANTAGONISTS .. 31 INFLAMMATORY BOWEL DISEASE .. 32 IRRITABLE BOWEL SYNDROME .. 32 LAXATIVES/STOOL SOFTENERS .. 32 PANCREATIC ENZYMES.

6 32 PROSTAGLANDINS .. 33 PROTON PUMP INHIBITORS .. 33 SALIVA STIMULANTS .. 33 33 33 BENIGN PROSTATIC HYPERPLASIA .. 33 URINARY ANTISPASMODICS .. 33 VAGINAL ANTI-INFECTIVES .. 33 34 2 HEMATOLOGIC .. 34 ANTICOAGULANTS .. 34 ANTIHEMOPHILIC AGENTS .. 34 HEMATOPOIETIC GROWTH FACTORS .. 34 HEREDITARY ANGIOEDEMA 34 PLATELET AGGREGATION 35 PLATELET SYNTHESIS INHIBITORS .. 35 35 IMMUNOLOGIC AGENTS .. 35 AUTOIMMUNE AGENTS .. 35 DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs) .. 35 IMMUNE GLOBULINS .. 35 IMMUNOMODULATORS .. 35 IMMUNOSUPPRESSANTS.

7 35 VACCINES .. 36 NUTRITIONAL/SUPPLEMENTS .. 36 ELECTROLYTES .. 36 VITAMINS AND MINERALS .. 36 RESPIRATORY .. 37 ANAPHYLAXIS TREATMENT AGENTS .. 37 37 ANTICHOLINERGIC/BETA AGONIST COMBINATIONS .. 37 ANTIHISTAMINES .. 37 BETA AGONISTS .. 38 COUGH AND COLD .. 38 CYSTIC FIBROSIS .. 38 LEUKOTRIENE MODIFIERS .. 39 MAST CELL STABILIZERS .. 39 MEDICAL 39 NASAL ANTIHISTAMINES .. 39 NASAL DECONGESTANTS .. 39 NASAL STEROIDS .. 39 PHOSPHODIESTERASE-4 INHIBITORS .. 39 RESPIRATORY SYNCYTIAL VIRUS .. 39 STEROID/BETA AGONIST 39 STEROID INHALANTS .. 39 XANTHINES.

8 39 39 TOPICAL .. 40 DERMATOLOGY .. 40 MOUTH/THROAT/DENTAL AGENTS .. 43 OPHTHALMIC .. 43 OTIC .. 45 46 IRRIGATION SOLUTIONS .. 46 MEDICAL 46 INDEX .. 47 3 INTRODUCTION We are pleased to provide the 2018 Molina Healthcare of Washington Medicaid Preferred Drug List ( formulary ) as a useful reference and informational tool. This document can assist medical providers in selecting clinically-appropriate and cost-effective products for their patients. The drugs represented have been reviewed by a Pharmacy and Therapeutics (P&T) Committee and are approved for inclusion.

9 The document is reflective of current medical practice as of the date of review. The information contained in this document and its appendices is provided solely for the convenience of medical providers. We do not warrant or assure accuracy of such information nor is it intended to be comprehensive in nature. All the information in the document is provided as a reference for drug therapy selection. The document is subject to state-specific regulations and rules, including, but not limited to, those regarding generic substitution, controlled substance schedules, preference for brands and mandatory generics whenever applicable.

10 We assume no responsibility for the actions or omissions of any medical provider based upon reliance, in whole or in part, on the information contained herein. The medical provider should consult the drug manufacturer's product literature or standard references for more detailed information. PREFACE The document is organized by sections. Each section is divided by therapeutic drug class primarily defined by mechanism of action. Products are listed by generic name with brand name for reference only. Unless the cited drug is available as an injectable or an exception is specifically noted, generally, all applicable dosage forms and strengths of the drug cited are included in the document.


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