PROVIDER: PLEASE READ

1 Minnesota Fee-for-Service and Managed Care Medicaid Uniform Preferred Drug List effective: January 1, 2022. PROVIDER: PLEASE READ. Uniform preferred drug list (PDL) and preferred drug list changes Managed Care Organizations (MCOs) that offer drug benefits to Minnesota Health Care Programs (MHCP). members must use the Minnesota Department of Human Services' (DHS) Uniform PDL beginning July 1, 2019. The Uniform PDL will ensure a more consistent drug benefit for all members and minimize disruptions if a member's health plan changes. The Uniform PDL was reviewed and recommended by the Drug Formulary Committee and includes many commonly used medications. Members enrolled with an MCO will have access to all of the preferred drugs on the PDL, as well as the other drugs on their plan's List of Covered Drugs (formulary).

2 This change does not apply to members with dual Medicare and Medicaid coverage. See the Minnesota Uniform Preferred Drug List in the following section. DHS has created a Frequently Asked Questions for Providers Regarding the Uniform Preferred Drug List (PDF) guide to assist you in understanding your role in helping members remain on a nonpreferred drug or transition to a preferred drug on or after July 1, 2019. If a member is currently using a nonpreferred drug, you must do one of the following before July 1, 2019: Request a one-time continuation of therapy override if the member meets the Continuation of Therapy prior authorization criteria (PDF) for coverage of the nonpreferred drug for 90 days. Make your request to DHS if the member has fee-for-service coverage or to the MCO responsible for the member's coverage.

3 Request prior authorization for the Nonpreferred Drug (PDF) from DHS, if the member has fee-for-service coverage, or to the MCO responsible for the member's coverage. You may request the prior authorization (PA) before July 1, 2019, or during the 90-day continuation of therapy period. If a member currently has an approved PA for a nonpreferred drug, DHS or the member's MCO will honor the approved PA until the PA expires. After the PA expires, you must request a new PA to continue coverage or transition the member to a preferred drug. If you have additional questions, PLEASE contact: MHCP Provider Resource Center (for members in fee-for-service Medicaid) at 800-366-5411 or 651-431- 2700. MCO responsible for the member's coverage (for members in Managed Care Medicaid or MinnesotaCare).

4 See the table below. MCO Plan Pharmacy Contact Number(s). Blue Plus Prime Therapeutics 844-765-5940. HealthPartners 952-883-5813. 800-492-7259. Hennepin Health Navitus 612-596-1036. 800-647-0550. Itasca Medical Care Caremark 800-345-5413. MCO Plan Pharmacy Contact Number(s). Medica CVS Health 800-364-6331. Primewest Heatlth MedImpact 800-788-2949. South Country Health Alliance PerformRX 866-935-8874. UCare Express Scripts, Inc. (ESI) 877-558-7523 (physician authorizations). 800-595-7140 (Fairview Specialty specialty medications). ACNE AGENTS, TOPICAL section updated 10-1-2021. Preferred Nonpreferred BENZOYL PEROXIDE 10% WASH OTC (TOPICAL) ACANYA W/PUMP (TOPICAL). BENZOYL PEROXIDE 3% CLEANSER OTC (TOPICAL) ADAPALENE / BENZOYL PEROXIDE (EPIDUO) (TOPICAL).

5 BENZOYL PEROXIDE 5% WASH OTC (TOPICAL) ADAPALENE CREAM (TOPICAL). BENZOYL PEROXIDE 6% CLEANSER OTC (TOPICAL) ADAPALENE GEL (TOPICAL). BENZOYL PEROXIDE 9% CLEANSER OTC (TOPICAL) ADAPALENE GEL PUMP (TOPICAL). BENZOYL PEROXIDE GEL (TOPICAL) ADAPALENE SOLUTION (TOPICAL). BENZOYL PEROXIDE LOTION OTC (TOPICAL) AKLIEF (TOPICAL). CLINDAMYCIN / BENZOYL PEROXIDE (ACANYA) W/PUMP ATRALIN (TOPICAL). (AG) (TOPICAL) AVITA CREAM (TOPICAL). CLINDAMYCIN / BENZOYL PEROXIDE (BENZACLIN) AVITA GEL (TOPICAL). (TOPICAL) BENZACLIN (TOPICAL). CLINDAMYCIN / BENZOYL PEROXIDE (DUAC) (TOPICAL) BENZACLIN W/PUMP (TOPICAL). CLINDAMYCIN PHOSPHATE GEL (TOPICAL) BENZOYL PEROXIDE CLEANSER OTC (TOPICAL). CLINDAMYCIN PHOSPHATE LOTION (TOPICAL) BENZOYL PEROXIDE FOAM OTC (TOPICAL).

6 CLINDAMYCIN PHOSPHATE MED. SWAB (TOPICAL) BENZOYL PEROXIDE TOWELETTE OTC (TOPICAL). CLINDAMYCIN PHOSPHATE SOLUTION (TOPICAL) BP 10-1 (TOPICAL). DIFFERIN CREAM (TOPICAL) CLEOCIN T GEL (TOPICAL). DIFFERIN GEL PUMP (TOPICAL) CLEOCIN LOTION (TOPICAL). DIFFERIN LOTION (TOPICAL) CLINDACIN PAC KIT. ERYTHROMYCIN GEL (TOPICAL) CLINDAGEL (TOPICAL). ERYTHROMYCIN MED. SWAB (TOPICAL) CLINDAMYCIN / BENZOYL PEROXIDE (BENZACLIN). ERYTHROMYCIN SOLUTION (TOPICAL) W/PUMP (TOPICAL). ERYTHROMYCIN-BENZOYL PEROXIDE (TOPICAL) CLINDAMYCIN / TRETINOIN (TOPICAL). RETIN-A CREAM (TOPICAL) CLINDAMYCIN PHOSPHATE FOAM (TOPICAL). RETIN-A GEL (TOPICAL) DAPSONE GEL. SULFACETAMIDE/SULFUR CLEANSER (TOPICAL DIFFERIN GEL (TOPICAL). SULFACETAMIDE SODIUM/SULFUR (TOPICAL) EPIDUO FORTE GEL W/PUMP (TOPICAL).)

7 SULFACETAMIDE SUSPENSION (TOPICAL) FABIOR (TOPICAL). TAZORAC CREAM (TOPICAL) NEUAC (TOPICAL). TAZORAC GEL (TOPICAL) NEUAC KIT (TOPICAL). ONEXTON GEL (TOPICAL). ONEXTON W/PUMP (TOPICAL). RETIN-A MICRO , (TOPICAL). RETIN-A MICRO , PUMP (TOPICAL). RETIN-A MICRO PUMP (TOPICAL). RETIN-A MICRO PUMP (TOPICAL). TAZAROTENE CREAM (TOPICAL). TRETINOIN CREAM (TOPICAL). TRETINOIN GEL (AVITA, RETIN-A) (TOPICAL). TRETINOIN GEL (ATRALIN) (TOPICAL). TRETINOIN MICROSPHERES GEL , (TOPICAL). TRETINOIN MICROSPHERES GEL , PUMP. (TOPICAL). ZIANA (TOPICAL). ALZHEIMER'S AGENTS section updated 3-28-2019. Preferred Nonpreferred DONEPEZIL ODT (ORAL) ARICEPT (ORAL). DONEPEZIL TABLET (ORAL) ARICEPT 23 MG (ORAL). Preferred Nonpreferred MEMANTINE TABLET (ORAL) ARICEPT ODT (ORAL).

8 DONEPEZIL 23 MG (ORAL). EXELON (TRANSDERM.). EXELON CAPSULES (ORAL). GALANTAMINE ER (ORAL). GALANTAMINE SOLUTION (ORAL). GALANTAMINE TABLET (ORAL). MEMANTINE ER (ORAL). MEMANTINE SOLUTION (ORAL). NAMENDA TABLET (ORAL). NAMENDA TABLET DOSE PACK (ORAL). NAMENDA XR (ORAL). NAMZARIC (ORAL). NAMZARIC DOSE PACK (ORAL). RAZADYNE ER (ORAL). RAZADYNE TABLET (ORAL). RIVASTIGMINE (AG) (TRANSDERM.). RIVASTIGMINE (TRANSDERM.). RIVASTIGMINE CAPSULES (ORAL). ANALGESICS, NARCOTICS LONG section updated 10-1-2021. Preferred Nonpreferred BELBUCA (BUCCAL) ARYMO ER (ORAL). MORPHINE ER TABLET (ORAL) BUPRENORPHINE (TRANSDERM). FENTANYL (25, 50 MCG) TRANSDERM DURAGESIC MATRIX (TRANSDERM.). EMBEDA (ORAL). EXALGO (ORAL). FENTANYL (12, , , MG, 75, 100 MCG).

9 (TRANSDERM). HYDROCODONE ER (HYSINGLA ER) (ORAL). HYDROCODONE ER (ZOHYDRO ER) (ORAL). HYDROMORPHONE ER (ORAL). HYSINGLA ER (ORAL). KADIAN (ORAL). METHADONE CONC (ORAL). METHADONE SOLUTION (ORAL). METHADONE TABLET (ORAL). MORPHABOND ER (ORAL). MORPHINE ER CAPSULE (AVINZA) (ORAL). MORPHINE ER CAPSULE (KADIAN) (ORAL). MS CONTIN (ORAL). NUCYNTA ER (ORAL). OPANA ER (ORAL). OXYCONTIN (ORAL). OXYCODONE ER (ORAL). OXYMORPHONE ER (ORAL). XTAMPZA ER (ORAL). ZOHYDRO ER (ORAL). ANDROGENIC AGENTS section updated 10-1-2021. Preferred Nonpreferred ANDRODERM (TRANSDERM) AXIRON (TRANSDERM). ANDROGEL GEL PACKET (TRANSDERM.) FORTESTA (TRANSDERM). ANDROGEL GEL PUMP (TRANSDERM) NATESTO (NASAL). STRIANT (BUCCAL). TESTIM (TRANSDERM.). TESTOSTERONE GEL (FORTESTA) (TRANSDERM).

10 TESTOSTERONE GEL (TESTIM) (TRANSDERM). TESTOSTERONE GEL (VOGELXO) (TRANSDERM). TESTOSTERONE GEL PACKET (ANDROGEL) (TRANSDERM). TESTOSTERONE GEL PUMP (ANDROGEL) (TRANSDERM). TESTOSTERONE GEL PUMP (AXIRON) (TRANSDERM). VOGELXO GEL (TRANSDERM). VOGELXO GEL PACKET (TRANSDERM). VOGELXO GEL PUMP (TRANSDERM). ANGIOTENSIN MODULATOR COMBINATIONS section updated 10-1-2021. Preferred Nonpreferred AMLODIPINE / BENAZEPRIL (ORAL) AMLODIPINE / OLMESARTAN (ORAL). AMLODIPINE / VALSARTAN (ORAL) AMLODIPINE / OLMESARTAN / HCTZ (ORAL). AMLODIPINE / VALSARTAN / HCTZ (ORAL) AZOR (ORAL). BYVALSON (ORAL). EXFORGE (ORAL). EXFORGE HCT (ORAL)LOTREL (ORAL). LOTREL (ORAL). TARKA (ORAL). TELMISARTAN / AMLODIPINE (ORAL). TRANDOLAPRIL/VERAPAMIL (ORAL).