Preferred Drug List Updates Effective: Jan. 1, 2016
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1 Molina Healthcare regularly reviews and updates the Preferred Drug List (PDL). Items may be added, removed or changed. Below is the list of updates made to the PDL this quarter. Some items require a prior authorization (PA). View the PA List to see which drugs require PA. For a complete list of benefits, visit the Molina Healthcare website at under the Rx Info tab or call Provider Services at (855) Humalog Kwikpen Insulin Lispro Solution for injection 200unit/mL to PDL with PA required; Cresemba Isavuconazonium Capsule 186mg to PDL with PA required; Natesto Testosterone Nasal Gel 5.5mg to PDL with PA required; Toujeo Solostar Insulin Glargine Solution for injection 300units/mL to PDL with PA required; Afrezza Inhaled insulin Powder for inhalation Xigduo XR Dapaglifozin; Metformin Tablet 4unit; 4unit-8unit; 8unit-12unit 5-500mg; mg; mg; mg Glyxambi Empagliflozin; Linagliptin Tablet 10-5mg; 25-5mg Flonase Allergy Relief (OTC) Fluticasone Nasal Spray 50mcg Proair Respiclick Albuterol Powder for inhalation 90mcg Stiolto Respimat Tiotropium; Olodaterol Solution for inhalation 2.5mcg/2.5mcg Cholbam Cholic acid Capsule 50mg; 250mg Glatopa Glatiramer Solution for Injection 20mg to PDL with PA required; to PDL with PA required; to PDL with PA required; to PDL with PA required; to PDL with PA required; to PDL with PA required; to PDL with PA required; to PDL with PA required; Copaxone Glatiramer Solution for injection 20mg Removed Removed from PDL Colchicine s Colchicine Capsules 0.6mg Savaysa Edoxaban Tablet 15mg; 30mg; 60mg Obizur Antihemophilic factor Injection 500unit vial Kerydin Tavaborole Topical Solution 5% to PDL with PA required; to PDL with PA required; to PDL with SP requirement to PDL with PA required; MHO OH1215
2 Se-Natal PRENATAL MUL CAP plus DHA Capsule to PDL PRENATAL MV MIS plus DHA Capsule to PDL PRENATAL DHA CAP Capsule to PDL s and Minerals Tablet Se-Natal 19; Se- Natal 90; Se-Natal ONE to PDL Levemir Flextouch Insulin Detemir Solution for injection 100units/mL to PDL Epiduo Adapalene; Benzoyl Peroxide Lansoprazole Omeprazole Flurazepam Topical gel Oral powder for compounding kit Oral powder for compounding kit Capsule 0.1%-2.5%; 0.3%- 2.5% 0.27g; 0.45g; 0.9g 0.18g; 0.3g; 0.6g 15mg; 30mg to PDL with PA required; to PDL for children 7 and under to PDL for children 7 and under Quantity limited to 15 s in 25 days All Proton Pump Inhibitors Triazolam Tablet 0.125mg; 0.25mg Quantity limited to 10 tablets in 25 days Zaleplon Capsule 5mg; 10mg Quantity limited to 30 s in 25 days Zolpidem Tablet 5mg; 10mg Quantity limited to 30 tablets in 25 days Pyridoxine tablet 25mg to PDL Omeprazole, Lansoprazole, Pantoprazole, Nexium OTC, Prilosec OTC Capsule/tablet Colestipol Packets 5gram to PDL B-COMPLEX W/ C & FOLIC ACID CAP Capsule to PDL Removed quantity limit restricting PPI use to 6 months or less Zarxio Filgrastim Solution for injection 300mcg/0.5ml; 480mcg/0.8ml Belsomra Suvorexant Tablet 5mg; 10mg; 15mg; 20mg Oralair Mixed grass pollens allergen extract Sublingual tablet 300IR Natpara Parathyroid hormone Powder for injection 25mcg; 50mcg; 75mcg; 100mcg
3 Onexton clindamycin Topical gel % Spiriva Respimat Tiotropium Respiratory spray solution 1.25mcg; 2.5mcg Kitabis Pak Tobramycin Solution for inhalation 300mg/5mL Ibrance Palbociclib Capsule 75mg; 100mg; 125mg Lenvima Lenvatinib Capsule 10mg; 14mg; 20mg; 24mg Lynparza Olaparib Capsule 50mg Kuvan Sapropterin Tablet; powder for oral solution 100mg tablet; 100mg powder; 500mg powder Sotylize sotalol Oral solution 5mg/mL Corlanor Ivabradine Tablet 5mg; 7.5mg Incruse Ellipta Umeclidinium Powder for inhalation 62.5mcg Arnuity Ellipta Fluticasone Powder for inhalation 100mcg; 200mcg Kalydeco Ivacaftor Tablet; granules 150mg tablet; 50mg granules; 75mg granules Esbriet Pirfenidone Capsule 267mg Ofev Nintedanib Capsule 100mg; 150mg Gavilyte H and bisacodyl PEG plus bisacodyl Powder for oral solution and tablet 3350 electrolytes + 5mg tablet Akynzeo Netupitant; palonosetron Capsule 300mg/0.5mg Movantik Naloxegol Tablet 12.5mg; 25mg Nuvessa Metronidazole Vaginal gel 1.30% Irenka Duloxetine Delayed-release 40mg Evekeo Amphetamine Tablet 5mg; 10mg Aptensio XR Methylphenidate ER 10mg; 15mg; 20mg; 30mg; 40mg; 50mg; 60mg
4 Namzaric ER Donepezil; memantine 10mg-14mg; 10mg-28mg Plegridy Peginterferon beta-1a Solution for injection 63mcg/0.5mL; 125mcg/0.5mL Vanatol liquid Butalbital/ acetaminophen/caffeine Oral solution 50mg/325mg/40mg per 15 mls Ionsys Fentanyl Transdermal patch 40mcg Hysingla Hydrocodone bitartrate extended-release tablet 20mg; 30mg; 40mg; 60mg; 80mg; 100mg; 120mg Embeda Morphine; Naltrexone 20mg-0.8mg; 30mg-1.2mg; 50mg-2mg; 60mg- 2.4mg; 80mg- 3.2mg; 100mg- 4mg Rytary ER Carbidopa; Levodopa extended-release 23.75mg-95mg; 36.25mg-145mg; 48.75mg-195mg; 61.25mg-245mg Poly-vi-flor Multivitamin tablets Tablets Escavite liquid Enbrace Multivitamin with iron and fluoride s with Minerals and Liquid drops 0.25mg Capsule Thrivite 19 Multivitamin with Tablet Tristart DHA Capsule Prenate Essential with Minerals and Capsule
5 Focalgin 90 DHA Tablet Prenate Mini with Minerals and Capsule Prefera-OB Plus DHA Provida DHA with Minerals Capsule/tablet Capsule Granix syringe Tbo-filgrastim Prefilled syringe for injection 300mcg/0.5ml; 480mcg/0.8ml Feriva FA Feriva 21-7 Multivitamin with Minerals and Multivitamin with Minerals and Capsule Tablet Pazeo Olopatadine Ophthalmic solution 0.70% Uceris Budesonide Rectal foam 2mg Rosula Wash Sulfacetamine; Sulfur Topical wash % Avar Foam Sulfacetamine; Sulfur Topical foam 9.5-5%; 10-2% Ciclopirox 8% kit Nail laquer 8% Removed Removed from PA List Trianex Oint Triamcinolone Topical ointment 0.05% Epiduo Forte Adapalene; Benzoyl peroxide Topical gel pump % Zecuity Patch Sumatriptan Transdermal patch 6.5mg/4hr Cosentyx Secukinumab Jadenu Deferasirox Tablet Prefilled pen for injection 150mg/mL 90mg; 180mg; 360mg
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