Transcription
Michigan Preferred Drug List (PDL)/Single PDLEffective 07/01/2022Preferred Agents do not require prior authorization, except as noted in the chart at the bottom of the pageANALGESICSDrug ClassPreferred AgentsNarcotics – Long Actingmorphine sulfate ER tabletstramadol ER tabletsNarcotics – Short and Intermediate taminophenhydromorphone oral tablets2morphine sulfate tablets, solution2morphine sulfate suppoxycodone tabs (5mg,10mg,15mg)2oxycodone oral solution2oxycodone /acetaminophen1 Prior Authorization Not Required for Beneficiaries Under the Age of 12.2 Quantity limits apply – Refer to document l/medicaid/mi/doc/en-us/MIRx quantity limits.pdf3 Prior Authorization Required if Beneficiary is Over the Age of 654 PA required if a benzodiazepine is found in beneficiary drug history5 Providers should consult yearly CDC guidelines for Influenza6 Prior Authorization Required for Beneficiaries Under 15 years of age7 Prior Authorization Required for Beneficiaries Under 18 years of age8 Components of product must be in drug history9 Electronic Step edit:2 or more NSAIDs on MPPL in historyNon-Preferred AgentsBelbuca 2buprenorphine films 2Conzip ER Diskets Embeda 2hydrocodone ER (generic Hysingla )hydromorphone ER Hysingla ER Kadian methadonemorphine sulfate ER caps (generic Avinza )morphine sulfate ER caps (generic Kadian )MS Contin Nucynta ER Oramorph SR Oxycontin 2oxycodone ER2oxymorphone ERtramadol ER capsulesUltram ER Xtampza ER 2Zohydro ER Actiq 2Apadaz benzhydrocodone/acetaminophenbutorphanol2codeine / acetaminophen/caffeine /butalbitalcodeine / aspirin /caffeine /butalbitalDemerol tablets, solution 2Dilaudid all forms2fentanyl citrate buccal210 Prior Authorization Required for Beneficiaries Under Age of 1211 Prior Authorization Required for Beneficiaries over 5 years of age12 Prior Authorization Required for Beneficiaries over 14 years of age13 Prior Authorization Required if Beneficiary is Over the Age of 7514 Prior Authorization Required for Beneficiaries Under 2 years of age15 Prior Authorization Required for Beneficiaries Under 16 years of ageAPAP Acetaminophen ASA AspirinCR, ER, SR, XL, XR, SA, LA Extended Release, HCT Hydrochlorothiazide Clinical PA required; refer to MI Clinical and PDL PA Criteria and PDL Criteria at https://michigan.magellanrx.com/providerVersion 07012022v1Page 1 of 39
Michigan Preferred Drug List (PDL)/Single PDLEffective 07/01/2022Preferred Agents do not require prior authorization, except as noted in the chart at the bottom of the pageANALGESICSDrug ClassPreferred Agentstramadoltramadol/acetaminophenNarcotics – TransdermalButrans 2fentanyl patches (generic only) 2Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)diclofenacdiclofenac topical gel 1%diclofenac topical solution 1.5%ibuprofenindomethacin1 Prior Authorization Not Required for Beneficiaries Under the Age of 12.2 Quantity limits apply – Refer to document l/medicaid/mi/doc/en-us/MIRx quantity limits.pdf3 Prior Authorization Required if Beneficiary is Over the Age of 654 PA required if a benzodiazepine is found in beneficiary drug history5 Providers should consult yearly CDC guidelines for Influenza6 Prior Authorization Required for Beneficiaries Under 15 years of age7 Prior Authorization Required for Beneficiaries Under 18 years of age8 Components of product must be in drug history9 Electronic Step edit:2 or more NSAIDs on MPPL in historyNon-Preferred AgentsFentora 2Fioricet w/ Codeine Fiorinal w/ Codeine hydrocodone/ ibuprofenhydromorphone suppositorylevorphanolLorcet , Lorcet HD , Lorcet Plus Lortab meperidine tablets, solution2Norco Nucynta Oxaydo oxycodone/aspirinoxycodone caps 2oxycodone tabs (20mg, 30mg)2oxycodone oral conc soln2oxycodone oral oxonePercocet Roxicodone 2Rybix ODT Stadol , Stadol NS 2Talwin , Talwin NX tramadol oral solution (generic for Qdolo )Tylox Ultram / Ultracet buprenorphine patches2Duragesic 2fentanyl patches 37.5mg, 62.5mg and 87.5mg onlyArthrotec Daypro diclofenac ERdiclofenac epolamine 1.3% patchdiclofenac-misoprostol10 Prior Authorization Required for Beneficiaries Under Age of 1211 Prior Authorization Required for Beneficiaries over 5 years of age12 Prior Authorization Required for Beneficiaries over 14 years of age13 Prior Authorization Required if Beneficiary is Over the Age of 7514 Prior Authorization Required for Beneficiaries Under 2 years of age15 Prior Authorization Required for Beneficiaries Under 16 years of ageAPAP Acetaminophen ASA AspirinCR, ER, SR, XL, XR, SA, LA Extended Release, HCT Hydrochlorothiazide Clinical PA required; refer to MI Clinical and PDL PA Criteria and PDL Criteria at https://michigan.magellanrx.com/providerVersion 07012022v1Page 2 of 39
Michigan Preferred Drug List (PDL)/Single PDLEffective 07/01/2022Preferred Agents do not require prior authorization, except as noted in the chart at the bottom of the pageANALGESICSDrug ClassPreferred Agentsketoprofen immediate releaseketorolacmeloxicamnabumetonenaproxen OTCnaproxen (generic for Naprosyn )sulindac1 Prior Authorization Not Required for Beneficiaries Under the Age of 12.2 Quantity limits apply – Refer to document l/medicaid/mi/doc/en-us/MIRx quantity limits.pdf3 Prior Authorization Required if Beneficiary is Over the Age of 654 PA required if a benzodiazepine is found in beneficiary drug history5 Providers should consult yearly CDC guidelines for Influenza6 Prior Authorization Required for Beneficiaries Under 15 years of age7 Prior Authorization Required for Beneficiaries Under 18 years of age8 Components of product must be in drug history9 Electronic Step edit:2 or more NSAIDs on MPPL in historyNon-Preferred Agentsdiclofenac potassiumdiflunisalDuexis EC-Naprosyn EC-naproxenetodolac / etodolac ERFeldene fenoprofenFlector Patch 2flurbiprofenIndocin oral suspension1indomethacin ext releaseketoprofen ext releaseLicart 2Lofena meclofenamate sodiummefenamic acidMobic Motrin Nalfon Naprelan CR naproxen (generic for Anaprox)naproxen delayed releasenaproxen/esomeprazole (generic for Vimovo)naproxen suspensionoxaprozinPennsaid piroxicamRelafen DS Sprix tolmetin sodiumVimovo Vivlodex Voltaren gelZipsor Zorvolex 10 Prior Authorization Required for Beneficiaries Under Age of 1211 Prior Authorization Required for Beneficiaries over 5 years of age12 Prior Authorization Required for Beneficiaries over 14 years of age13 Prior Authorization Required if Beneficiary is Over the Age of 7514 Prior Authorization Required for Beneficiaries Under 2 years of age15 Prior Authorization Required for Beneficiaries Under 16 years of ageAPAP Acetaminophen ASA AspirinCR, ER, SR, XL, XR, SA, LA Extended Release, HCT Hydrochlorothiazide Clinical PA required; refer to MI Clinical and PDL PA Criteria and PDL Criteria at https://michigan.magellanrx.com/providerVersion 07012022v1Page 3 of 39
Michigan Preferred Drug List (PDL)/Single PDLEffective 07/01/2022Preferred Agents do not require prior authorization, except as noted in the chart at the bottom of the pageANALGESICSDrug ClassPreferred AgentsNon-Preferred AgentsNon-Steroidal Anti-Inflammatory –Cox II InhibitorsOpioid Use Disorder Treatmentscelecoxib 2,9Celebrex 2, 9buprenorphine SL tabs2buprenorphine/naloxone SL tabs2naltrexone tabletsSublocade SC injectionSuboxone SL films2Vivitrol IM injectionZubsolv SL tabs 2buprenorphine/naloxone SL film (generic Suboxone films)2Opioid Withdrawal Symptom Managementclonidine tabsguanfacine/guanfacine ERLucemyra 1 Prior Authorization Not Required for Beneficiaries Under the Age of 12.2 Quantity limits apply – Refer to document l/medicaid/mi/doc/en-us/MIRx quantity limits.pdf3 Prior Authorization Required if Beneficiary is Over the Age of 654 PA required if a benzodiazepine is found in beneficiary drug history5 Providers should consult yearly CDC guidelines for Influenza6 Prior Authorization Required for Beneficiaries Under 15 years of age7 Prior Authorization Required for Beneficiaries Under 18 years of age8 Components of product must be in drug history9 Electronic Step edit:2 or more NSAIDs on MPPL in history10 Prior Authorization Required for Beneficiaries Under Age of 1211 Prior Authorization Required for Beneficiaries over 5 years of age12 Prior Authorization Required for Beneficiaries over 14 years of age13 Prior Authorization Required if Beneficiary is Over the Age of 7514 Prior Authorization Required for Beneficiaries Under 2 years of age15 Prior Authorization Required for Beneficiaries Under 16 years of ageAPAP Acetaminophen ASA AspirinCR, ER, SR, XL, XR, SA, LA Extended Release, HCT Hydrochlorothiazide Clinical PA required; refer to MI Clinical and PDL PA Criteria and PDL Criteria at https://michigan.magellanrx.com/providerVersion 07012022v1Page 4 of 39
Michigan Preferred Drug List (PDL)/Single PDLEffective 07/01/2022Preferred Agents do not require prior authorization, except as noted in the chart at the bottom of the pageANTIBIOTICS / ANTI-INFECTIVESDrug ClassAntibiotics – InhaledAntifungals – OralAntifungals – TopicalPreferred AgentsBethkis Cayston Kitabis Tobi-Podhaler clotrimazole trochesfluconazole2griseofulvin oral suspensionketoconazole tabletsnystatin oral susp, tabletsterbinafine2tobramycin solution (inhalation)TOBI inhalationciclopirox cream (generic for Loprox, Ciclodan)ciclopirox 8% solution (generic for Ciclodan)clotrimazole OTC cream, solutionclotrimazole Rx creamclotrimazole/betamethasone creamketoconazolemiconazole nitrate nystatinnystatin/triamcinolone cream, ointmenttolnaftate cream, powder1 Prior Authorization Not Required for Beneficiaries Under the Age of 12.2 Quantity limits apply – Refer to document l/medicaid/mi/doc/en-us/MIRx quantity limits.pdf3 Prior Authorization Required if Beneficiary is Over the Age of 654 PA required if a benzodiazepine is found in beneficiary drug history5 Providers should consult yearly CDC guidelines for Influenza6 Prior Authorization Required for Beneficiaries Under 15 years of age7 Prior Authorization Required for Beneficiaries Under 18 years of age8 Components of product must be in drug history9 Electronic Step edit:2 or more NSAIDs on MPPL in historyNon-Preferred AgentsBrexafemme2 Cresemba Diflucan 2flucytosinegriseofulvin tabletsgriseofulvin microsize tabletsgriseofulvin ultramicrosizeitraconazole2 Noxafil , Noxafil DR Oravig posaconazoleSporanox 2 Tolsura Vfend voriconazole butenafineCiclodan ciclopirox shampoociclopirox suspension (generic for Loprox )clotrimazole / betamethasone lotionclotrimazole Rx solutioneconazole nitrateErtaczo Exelderm Extina Fungoid-D Jublia Kerydin ketoconazole foamKetodan Loprox 10 Prior Authorization Required for Beneficiaries Under Age of 1211 Prior Authorization Required for Beneficiaries over 5 years of age12 Prior Authorization Required for Beneficiaries over 14 years of age13 Prior Authorization Required if Beneficiary is Over the Age of 7514 Prior Authorization Required for Beneficiaries Under 2 years of age15 Prior Authorization Required for Beneficiaries Under 16 years of ageAPAP Acetaminophen ASA AspirinCR, ER, SR, XL, XR, SA, LA Extended Release, HCT Hydrochlorothiazide Clinical PA required; refer to MI Clinical and PDL PA Criteria and PDL Criteria at https://michigan.magellanrx.com/providerVersion 07012022v1Page 5 of 39
Michigan Preferred Drug List (PDL)/Single PDLEffective 07/01/2022Preferred Agents do not require prior authorization, except as noted in the chart at the bottom of the pageANTIBIOTICS / ANTI-INFECTIVESDrug ClassAntivirals – HerpesAntivirals – Influenza5Antivirals – TopicalCephalosporins - 1st GenerationPreferred Agentsacyclovir tablets, capsules, za 2rimantadineTamiflu 2Xofluza acyclovir ointmentDenavir Zovirax creamcefadroxil capsules2cefadroxil suspensioncephalexinNon-Preferred AgentsLotrimin AF luliconazoleLuzu Mentax miconazole/zinc oxide/petrolatumNaftin naftifineoxiconazoleOxistat tavaboroleVusion Sitavig Valtrex Zovirax Flumadine acyclovir creamXerese Zovirax ointmentcefadroxil tablets2Keflex Cephalosporins - 2nd Generationcefuroxime2cefprozil tablets2cefprozil suspensioncefaclor2cefaclor ER2Cephalosporins - 3rd Generationcefdinir capsules, suspension2cefixime capsulesSuprax capsulescefixime suspensioncefpodoxime tablets2cefpodoxime suspensionSuprax chew tabs, suspension1 Prior Authorization Not Required for Beneficiaries Under the Age of 12.2 Quantity limits apply – Refer to document l/medicaid/mi/doc/en-us/MIRx quantity limits.pdf3 Prior Authorization Required if Beneficiary is Over the Age of 654 PA required if a benzodiazepine is found in beneficiary drug history5 Providers should consult yearly CDC guidelines for Influenza6 Prior Authorization Required for Beneficiaries Under 15 years of age7 Prior Authorization Required for Beneficiaries Under 18 years of age8 Components of product must be in drug history9 Electronic Step edit:2 or more NSAIDs on MPPL in history10 Prior Authorization Required for Beneficiaries Under Age of 1211 Prior Authorization Required for Beneficiaries over 5 years of age12 Prior Authorization Required for Beneficiaries over 14 years of age13 Prior Authorization Required if Beneficiary is Over the Age of 7514 Prior Authorization Required for Beneficiaries Under 2 years of age15 Prior Authorization Required for Beneficiaries Under 16 years of ageAPAP Acetaminophen ASA AspirinCR, ER, SR, XL, XR, SA, LA Extended Release, HCT Hydrochlorothiazide Clinical PA required; refer to MI Clinical and PDL PA Criteria and PDL Criteria at https://michigan.magellanrx.com/providerVersion 07012022v1Page 6 of 39
Michigan Preferred Drug List (PDL)/Single PDLEffective 07/01/2022Preferred Agents do not require prior authorization, except as noted in the chart at the bottom of the pageANTIBIOTICS / ANTI-INFECTIVESDrug ClassPreferred AgentsHepatitis CPegasys 2Hepatitis C – Direct-Acting AntiviralsMavyret Macrolidesazithromycin2clarithromycin2erythromycin ethylsuccinate tabletserythromycin ethylsuccinate 200mg suspErythrocin Oxazolidinoneslinezolid tablets2QuinolonesCipro suspensionciprofloxacin suspension, tablets2levofloxacin2Non-Preferred Agentsribavirin dose packPeg-Intron ribavirin1 Prior Authorization Not Required for Beneficiaries Under the Age of 12.2 Quantity limits apply – Refer to document l/medicaid/mi/doc/en-us/MIRx quantity limits.pdf3 Prior Authorization Required if Beneficiary is Over the Age of 654 PA required if a benzodiazepine is found in beneficiary drug history5 Providers should consult yearly CDC guidelines for Influenza6 Prior Authorization Required for Beneficiaries Under 15 years of age7 Prior Authorization Required for Beneficiaries Under 18 years of age8 Components of product must be in drug history9 Electronic Step edit:2 or more NSAIDs on MPPL in historyEpclusa Harvoni ledipasvir/sofosbuvir (generic for Harvoni)sofosbuvir/velpatasvir (generic for Epclusa)Sovaldi Viekira Pak Vosevi Zepatier clarithromycin ERE.E.S. tablets and 400mg suspensionE.E.S. 200mg suspensionEryPed Ery-Tab erythromycin baseerythromycin ethylsuccinate 400mg suspensionZithromax tablets2, suspensionlinezolid suspensionSivextro 2 Zyvox 2Baxdela Cipro tablets2moxifloxacin2ofloxacin10 Prior Authorization Required for Beneficiaries Under Age of 1211 Prior Authorization Required for Beneficiaries over 5 years of age12 Prior Authorization Required for Beneficiaries over 14 years of age13 Prior Authorization Required if Beneficiary is Over the Age of 7514 Prior Authorization Required for Beneficiaries Under 2 years of age15 Prior Authorization Required for Beneficiaries Under 16 years of ageAPAP Acetaminophen ASA AspirinCR, ER, SR, XL, XR, SA, LA Extended Release, HCT Hydrochlorothiazide Clinical PA required; refer to MI Clinical and PDL PA Criteria and PDL Criteria at https://michigan.magellanrx.com/providerVersion 07012022v1Page 7 of 39
Michigan Preferred Drug List (PDL)/Single PDLEffective 07/01/2022Preferred Agents do not require prior authorization, except as noted in the chart at the bottom of the pageANTIBIOTICS / ANTI-INFECTIVESDrug ClassPreferred AgentsNon-Preferred AgentsOphthalmic Fluoroquinolonesciprofloxacinmoxifloxacin (generic for Vigamox )ofloxacinBesivance Ciloxan gatifloxacinlevofloxacinMoxeza moxifloxacin (generic for Moxeza )Ocuflox Vigamox Zymaxid Ophthalmic MacrolidesOtic Quinoloneserythromycin ointmentCiprodex ofloxacin oticAzasite ciprofloxacin oticciprofloxacin/dexamethasone (generic for Ciprodex )ciprofloxacin/fluocinolone (generic for Otovel )Cipro HC Otovel Topical Antibioticsmupirocin ointmentGastrointestinal AntibioticsFirvanq metronidazole tabletsneomycin tabletstinidazole tabletsvancomycin capsulesCentany mupirocin creamXepi 2Aemcolo 2 Dificid Flagyl capsulesmetronidazole capsulesnitazoxanide tabletsVancocin vancomycin solutionXifaxan 200mg2,10 Xifaxan 550mg7 Vaginal AntibioticsCleocin Ovulesclindamycin (generic for Cleocin) 2% creammetronidazole (generic for Metro-Gel and Vandazole) gelNuvessa 1.3% gelCleocin 2% creamClindesse 2% creamMetro-Gel 0.75% gelVandazole (0.75% gel)1 Prior Authorization Not Required for Beneficiaries Under the Age of 12.2 Quantity limits apply – Refer to document l/medicaid/mi/doc/en-us/MIRx quantity limits.pdf3 Prior Authorization Required if Beneficiary is Over the Age of 654 PA required if a benzodiazepine is found in beneficiary drug history5 Providers should consult yearly CDC guidelines for Influenza6 Prior Authorization Required for Beneficiaries Under 15 years of age7 Prior Authorization Required for Beneficiaries Under 18 years of age8 Components of product must be in drug history9 Electronic Step edit:2 or more NSAIDs on MPPL in history10 Prior Authorization Required for Beneficiaries Under Age of 1211 Prior Authorization Required for Beneficiaries over 5 years of age12 Prior Authorization Required for Beneficiaries over 14 years of age13 Prior Authorization Required if Beneficiary is Over the Age of 7514 Prior Authorization Required for Beneficiaries Under 2 years of age15 Prior Authorization Required for Beneficiaries Under 16 years of ageAPAP Acetaminophen ASA AspirinCR, ER, SR, XL, XR, SA, LA Extended Release, HCT Hydrochlorothiazide Clinical PA required; refer to MI Clinical and PDL PA Criteria and PDL Criteria at https://michigan.magellanrx.com/providerVersion 07012022v1Page 8 of 39
Michigan Preferred Drug List (PDL)/Single PDLEffective 07/01/2022Preferred Agents do not require prior authorization, except as noted in the chart at the bottom of the pageASTHMA / COPDDPI dry powder inhaler; MDI metered dose inhaler; ISI inhalation spray inhalerDrug ClassAnticholinergic Agents - Short ActingAnticholinergic Agents - Long ActingPreferred AgentsAtrovent HFA 2 (MDI)ipratropium nebulizer solutionIncruse Ellipta (DPI)Spiriva 2 (DPI)Spiriva Respimat 2 (ISI)Non-Preferred AgentsLonhala Magnair nebulizer solutionSeebri Neohaler (DPI)Tudorza Pressair (DPI)Yupelri nebulizer solutionBeta Adrenergic and Anticholinergic CombinationsAnoro Ellipta (DPI)Bevespi Aerosphere (MDI)Combivent RESPIMAT (ISI)ipratropium/albuterol nebulizer solutionStiolto Respimat (ISI)Duaklir Pressair (DPI)Utibron Neohaler (DPI)Beta Adrenergic/ Anticholinergic/ CorticosteroidCombinationsTrelegy Ellipta (DPI)Breztri Aerosphere (MDI)Beta Adrenergics – Short Actingalbuterol sulfate nebulizer solutionProAir HFA 2 (MDI)Ventolin HFA 2 (MDI)albuterol HFA2 (MDI)levalbuterol HFA2 (MDI)levalbuterol nebulizer solutionProAir Digihaler (DPI)ProAir Respiclick 2 (DPI)Proventil HFA 2 (MDI)Xopenex HFA 2 (MDI)Xopenex nebulizer solution1 Prior Authorization Not Required for Beneficiaries Under the Age of 12.2 Quantity limits apply – Refer to document l/medicaid/mi/doc/en-us/MIRx quantity limits.pdf3 Prior Authorization Required if Beneficiary is Over the Age of 654 PA required if a benzodiazepine is found in beneficiary drug history5 Providers should consult yearly CDC guidelines for Influenza6 Prior Authorization Required for Beneficiaries Under 15 years of age7 Prior Authorization Required for Beneficiaries Under 18 years of age8 Components of product must be in drug history9 Electronic Step edit:2 or more NSAIDs on MPPL in history10 Prior Authorization Required for Beneficiaries Under Age of 1211 Prior Authorization Required for Beneficiaries over 5 years of age12 Prior Authorization Required for Beneficiaries over 14 years of age13 Prior Authorization Required if Beneficiary is Over the Age of 7514 Prior Authorization Required for Beneficiaries Under 2 years of age15 Prior Authorization Required for Beneficiaries Under 16 years of ageAPAP Acetaminophen ASA AspirinCR, ER, SR, XL, XR, SA, LA Extended Release, HCT Hydrochlorothiazide Clinical PA required; refer to MI Clinical and PDL PA Criteria and PDL Criteria at https://michigan.magellanrx.com/providerVersion 07012022v1Page 9 of 39
Michigan Preferred Drug List (PDL)/Single PDLEffective 07/01/2022Preferred Agents do not require prior authorization, except as noted in the chart at the bottom of the pageASTHMA / COPDDPI dry powder inhaler; MDI metered dose inhaler; ISI inhalation spray inhalerDrug ClassPreferred AgentsNon-Preferred AgentsBeta Adrenergics – Long ActingSerevent 2 (DPI)Arcapta Neohaler (DPI)arformoterol nebulizer solution formoterol nebulizer solution Brovana nebulizer solution Perforomist nebulizer solution Striverdi Respimat (ISI) Beta Adrenergic and Corticosteroid InhalerCombinationsAdvair Diskus 2 (DPI)Advair HFA 2 (MDI)Dulera 2 (MDI)Symbicort 2 (MDI)AirDuo Digihaler 2 (DPI)AirDuo Respiclick 2 (DPI)Breo Ellipta 2 (DPI)budesonide/formoterol2 (generic for Symbicort)fluticasone/salmeterol2 (generic for Advair Diskus)fluticasone/salmeterol2 (generic for AirDuo)Wixela 2 (DPI) (fluticasone/salmeterol)Daliresp Asmanex Twisthaler 110 mcg (DPI)1,2Asmanex Twisthaler 220 mcg (DPI)2budesonide 0.25, 0.5mg, 1mg nebulizer solutionFlovent HFA 2 (MDI)Alvesco (MDI) ArmonAir Digihaler (DPI)Arnuity Ellipta (DPI)Asmanex HFA 2 (DPI)Flovent Diskus (DPI)Pulmicort Flexihaler 2 (DPI)Pulmicort 0.25mg, 0.5mg, 1mg RespulesQVAR Redihaler (MDI)Phospodiesterase-4 (PDE-4) InhibitorsInhaled Glucocorticoids1 Prior Authorization Not Required for Beneficiaries Under the Age of 12.2 Quantity limits apply – Refer to document l/medicaid/mi/doc/en-us/MIRx quantity limits.pdf3 Prior Authorization Required if Beneficiary is Over the Age of 654 PA required if a benzodiazepine is found in beneficiary drug history5 Providers should consult yearly CDC guidelines for Influenza6 Prior Authorization Required for Beneficiaries Under 15 years of age7 Prior Authorization Required for Beneficiaries Under 18 years of age8 Components of product must be in drug history9 Electronic Step edit:2 or more NSAIDs on MPPL in history10 Prior Authorization Required for Beneficiaries Under Age of 1211 Prior Authorization Required for Beneficiaries over 5 years of age12 Prior Authorization Required for Beneficiaries over 14 years of age13 Prior Authorization Required if Beneficiary is Over the Age of 7514 Prior Authorization Required for Beneficiaries Under 2 years of age15 Prior Authorization Required for Beneficiaries Under 16 years of ageAPAP Acetaminophen ASA AspirinCR, ER, SR, XL, XR, SA, LA Extended Release, HCT Hydrochlorothiazide Clinical PA required; refer to MI Clinical and PDL PA Criteria and PDL Criteria at https://michigan.magellanrx.com/providerVersion 07012022v1Page 10 of 39
Michigan Preferred Drug List (PDL)/Single PDLEffective 07/01/2022Preferred Agents do not require prior authorization, except as noted in the chart at the bottom of the pageALLERGYDrug ClassPreferred AgentsNon-Preferred AgentsAntihistamines – 2nd Generationcetirizine tabscetirizine 1mg/ml solutionlevocetirizine tabletsloratadine / loratadine ODTcetirizine chewable tabs, soft gelscetirizine 5mg/5ml solution (cups)Clarinex desloratadinefexofenadine tabletslevocetirizine solutionLeukotriene Inhibitorsmontelukast tablets, 4mg chew tabs11, 5mg chew tabs12Accolate montelukast granulesSingulair tablets, 4mg chew tabs11, 5mg chew tabs12Singulair granules11Zyflo zafirlukastZileuton ER Nasal AnticholinergicsNasal Antihistaminesipratropium nasalazelastine (generic for Astepro and Astelin)Nasal Corticosteroidsfluticasone (Rx)1 Prior Authorization Not Required for Beneficiaries Under the Age of 12.2 Quantity limits apply – Refer to document l/medicaid/mi/doc/en-us/MIRx quantity limits.pdf3 Prior Authorization Required if Beneficiary is Over the Age of 654 PA required if a benzodiazepine is found in beneficiary drug history5 Providers should consult yearly CDC guidelines for Influenza6 Prior Authorization Required for Beneficiaries Under 15 years of age7 Prior Authorization Required for Beneficiaries Under 18 years of age8 Components of product must be in drug history9 Electronic Step edit:2 or more NSAIDs on MPPL in historyazelastine/fluticasoneDymista olopatadinePatanase Nasal Beconase AQ budesonideflunisolidefluticasone (OTC)mometasoneNasonex Omnaris Qnasl triamcinoloneXhance Zetonna 10 Prior Authorization Required for Beneficiaries Under Age of 1211 Prior Authorization Required for Beneficiaries over 5 years of age12 Prior Authorization Required for Beneficiaries over 14 years of age13 Prior Authorization Required if Beneficiary is Over the Age of 7514 Prior Authorization Required for Beneficiaries Under 2 years of age15 Prior Authorization Required for Beneficiaries Under 16 years of ageAPAP Acetaminophen ASA AspirinCR, ER, SR, XL, XR, SA, LA Extended Release, HCT Hydrochlorothiazide Clinical PA required; refer to MI Clinical and PDL PA Criteria and PDL Criteria at https://michigan.magellanrx.com/providerVersion 07012022v1Page 11 of 39
Michigan Preferred Drug List (PDL)/Single PDLEffective 07/01/2022Preferred Agents do not require prior authorization, except as noted in the chart at the bottom of the pageCARDIAC MEDICATIONSDrug ClassPreferred AgentsNon-Preferred AgentsACE Inhibitorsbenazepril/ benazepril HCTenalapril/ enalapril HCTlisinopril/ lisinopril HCTAccupril Accuretic Altace captopril/ captopril HCTEpaned fosinopril/ fosinopril HCTLotensin / Lotensin HCT moexipril / moexipril HCTperindoprilPrinivil Qbrelis quinapril / quinapril HCTramipriltrandolaprilVasotec / Vaseretic Zestril / Zestoretic Alpha Adrenergic AgentsCatapres TTS 2clonidineguanfacinemethyldopaclonidine transdermal 2methyldopa / HCTZAntihypertensive Combinations: ACEI-CCBamlodipine / benazeprilLotrel Prestalia Tarka trandolapril / verapamilAntihypertensive Combinations: zor Exforge / Exforge HCT telmisartan/amlodipineTribenzor 1 Prior Authorization Not Required for Beneficiaries Under the Age of 12.2 Quantity limits apply – Refer to document l/medicaid/mi/doc/en-us/MIRx quantity limits.pdf3 Prior Authorization Required if Beneficiary is Over the Age of 654 PA required if a benzodiazepine is found in beneficiary drug history5 Providers should consult yearly CDC guidelines for Influenza6 Prior Authorization Required for Beneficiaries Under 15 years of age7 Prior Authorization Required for Beneficiaries Under 18 years of age8 Components of product must be in drug history9 Electronic Step edit:2 or more NSAIDs on MPPL in history10 Prior Authorization Required for Beneficiaries Under Age of 1211 Prior Authorization Required for Beneficiaries over 5 years of age12 Prior Authorization Required for Beneficiaries over 14 years of age13 Prior Authorization Required if Beneficiary is Over the Age of 7514 Prior Authorization Required for Beneficiaries Under 2 years of age15 Prior Authorization Required for Beneficiaries Under 16 years of ageAPAP Acetaminophen ASA AspirinCR, ER, SR, XL, XR, SA, LA Extended Release, HCT Hydrochlorothiazide Clinical PA required; refer to MI Clinical and PDL PA Criteria and PDL Criteria at https://michigan.magellanrx.com/providerVersion 07012022v1Page 12 of 39
Michigan Preferred Drug List (PDL)/Single PDLEffective 07/01/2022Preferred Agents do not require prior authorization, except as noted in the chart at the bottom of the pageCARDIAC MEDICATIONSDrug ClassPreferred AgentsAngiotensin Receptor Antagonistslosartan/ losartan HCTolmesartan/ olmesartan HCTvalsartan/ valsartan HCTAngiotensin II-Receptor Neprilysin Inhibitors(ARNIs)Entresto 2Direct Renin Inhibitors Beta Blockersatenololatenolol / chlorthalidonebisoprolol fumarate HCTBystolic carvedilollabetalolmetoprolol / metoprolol XLmetoprolol succinatemetoprolol tartratepropranolol / propranolol LASorine sotalol / sotalol AF1 Prior Authorization Not Required for Beneficiaries Under the Age of 12.2 Quantity limits apply – Refer to document l/medicaid/mi/doc/en-us/MIRx quantity limits.pdf3 Prior Authorization Required if Beneficiary is Over the Age of 654 PA required if a benzodiazepine is found in beneficiary drug history5 Providers should consult yearly CDC guidelines for Influenza6 Prior Authorization Required for Beneficiaries Under 15 years of age7 Prior Authorization Required for Beneficiaries Under 18 years of age8 Components of product must be in drug history9 Electronic Step edit:2 or mor
6 Prior Authorization Required for Beneficiaries Under 15 years of age 7 Prior Authorization Required for Beneficiaries Under 18 years of age 8 Components of product must be in drug history 9 Electronic Step edit:2 or more NSAIDs on MPPL in history 10 Prior Authorization Required for Beneficiaries Under Age of 12
