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Preferred Drug ListPrescribers may request an override for non-preferred drugs by calling the Magellan Medicaid Administration (MMA) Help Desk at: Toll Free 1800-424-7895 and choose the PDL option. This Preferred Drug List is subject to change without notice. New products in a reviewed drug classare considered NON-PREFERRED until the committee has reevaluated the evidence for the drug class. The effective implementation date statedfor each drug class is the date claims will be edited at point-of-sale.7/1/2021For the most up-to-date Preferred Drug List visit ALLERGY-ASTHMAOPIATE DEPENDENCEANTIHYPERLIPIDEMICSANTIHISTAMINES -- NON-SEDATING-ORALOPIATE DEPENDENCE TREATMENTSHMG-CoA REDUCTASE INHIBITORSORIGINAL POSTED PREFERRED STATUS: 1/25/2005ORIGINAL POSTED PREFERRED STATUS: 2/3/2017ORIGINAL POSTED PREFERRED STATUS: 3/30/2005ORIGINAL EDIT EFFECTIVE DATE: 3/25/2005ORIGINAL EDIT EFFECTIVE DATE: 4/1/2017ORIGINAL EDIT EFFECTIVE DATE: 6/8/2005RE-REVIEW POSTED PREFERRED STATUS: 11/2007RE-REVIEW: 8/10/18REVISED EDIT EFFECTIVE DATE: 6/10/2008RE-REVIEW POSTED PREFERRED STATUS: 10/26/2010RE-REVIEW POSTED PREFERRED STATUS: 5/27/2014REVISED EDIT EFFECTIVE DATE 12/28/2010PREFERREDREVISED EDIT EFFECTIVE DATE: 5/30/2014RE-REVIEW POSTED PREFERRED STATUS: 2/14/18SUBOXONE FILM (BRAND)UPDATED 7/1/2021REVISED EDIT EFFECTIVE DATE: 4/1/2018BUPRENORPHINE SUBLINGUAL TABLETSVIVITROL*PREFERREDNON-PREFERRED –INCLUDE BUT NOT LIMITED TOATORVASTATIN (generic for LIPITOR)PREFERREDBUNAVAIL*PRAVASTATIN (generic for PRAVACHOL)CETIRIZINE 1MG/ML SOL, 10MG SWALLOW TAB (ZYRTEC)BUPRENORPHINE/NALOXONE SUBLINGUAL TAB *ROSUVASTATIN (generic for CRESTOR)LORATADINE (CLARITIN)BUPRENORPHINE/NALOXONE SUBLINGUAL FILM (GENERIC)*SIMVASTATIN (generic for ZOCOR)LOVASTATINZUBSOLV *NON-PREFERRED –INCLUDE BUT NOT LIMITED TONON-PREFERRED –INCLUDE BUT NOT LIMITED TOMEDICAL BILLING ONLYALTOPREVPROBUPHINEATORVASTATIN/AMLODIPINE (generic for CADUET)ACRIVASTINE/PSEUDOEPHEDRINE (SEMPREX-D)SUBLOCADECADUETCETIRIZINE 5MG, 10MG CHEWABLE TAB (ZYRTEC)*CRESTORCETIRIZINE/PSEUDOEPHEDRINE (ZYRTEC-D)*FLUVASTATIN (generic for LESCOL)DESLORATADINE (CLARINEX)LESCOL XLDESLORATADINE/PSEUDOEPHEDRINE (CLARINEX-D)*LIVALO (PITAVASTATIN)FEXOFENADINE (ALLEGRA)*SIMVASTATIN/EZETIMIBE (generic for VYTORIN)FEXOFENADINE/PSEUDOEPHEDRINE (ALLEGRA-D)*VYTORINLEVOCETIRIZINE (XYZAL)*ZOCORLORATADINE/PSEUDOEPHEDRINE (CLARITIN-D)**Please refer to the PDL Criteria Overview for more detailGENERIC (SAMPLE BRAND) LISTED FOR REFERENCE ONLY
Preferred Drug ListPrescribers may request an override for non-preferred drugs by calling the Magellan Medicaid Administration (MMA) Help Desk at: Toll Free 1800-424-7895 and choose the PDL option. This Preferred Drug List is subject to change without notice. New products in a reviewed drug classare considered NON-PREFERRED until the committee has reevaluated the evidence for the drug class. The effective implementation date statedfor each drug class is the date claims will be edited at point-of-sale.7/1/2021For the most up-to-date Preferred Drug List visit ANTIHYPERTENSIVE AGENTSANTIHYPERTENSIVE AGENTSANTIHYPERTENSIVE AGENTSANGIOTENSIN-CONVERTING ENZYME INHIBITORSANGIOTENSIN-CONVERTING ENZYME INHIBITORSANGIOTENSIN II RECEPTOR ANTAGONISTSORIGINAL POSTED PREFERRED STATUS: 11/16/2005ORIGINAL POSTED PREFERRED STATUS: 11/16/2005ORIGINAL POSTED PREFERRED STATUS: 12/20/2005ORIGINAL EDIT EFFECTIVE DATE: 11/16/2005ORIGINAL EDIT EFFECTIVE DATE: 11/16/2005ORIGINAL EDIT EFFECTIVE DATE: 2/21/2006REVISED POSTED PREFERRED STATUS: 11/21/2007REVISED POSTED PREFERRED STATUS: 11/21/2007REVISED POSTED PREFERRED STATUS: 8/12/2011REVISED EDIT EFFECTIVE DATE: 1/23/2008REVISED EDIT EFFECTIVE DATE: 1/23/2008REVISED EDIT EFFECTIVE DATE: 10/12/2011RE-REVIEW POSTED PREFERRED STATUS: 6/17/2010RE-REVIEW POSTED PREFERRED STATUS: 6/17/2010RE-REVIEW POSTED PREFERRED STATUS: 3/6/2013REVISED EDIT EFFECTIVE DATE: 8/17/2010REVISED EDIT EFFECTIVE DATE: 8/17/2010REVISED EDIT EFFECTIVE DATE: 5/7/2013RE-REVIEW POSTED PREFERRED STATUS: 11/10/17RE-REVIEW POSTED PREFERRED STATUS: 11/10/17REVISED EDIT EFFECTIVE DATE: 02/15/2016REVISED EDIT EFFECTIVE DATE: 1/1/18REVISED EDIT EFFECTIVE DATE: 1/1/18RE-REVIEW POSTED PREFERRED STATUS: 11/10/17UPDATED: 01/01/2021UPDATED: 01/01/2021REVISED EDIT EFFECTIVE DATE: 1/1/18UPDATED: 01/01/2021PREFERREDBENAZEPRIL (LOTENSIN)NON-PREFERRED –INCLUDE BUT NOT LIMITED TOBENAZEPRIL/AMLODIPINE (LOTREL)PREFERREDIRBESARTAN (AVAPRO)IRBESARTAN/HCTZ (AVALIDE)BENAZEPRIL/HCTZ (LOTENSIN HCT)CAPTOPRIL* (CAPOTEN)LOSARTAN (COZAAR)ENALAPRIL (VASOTEC)CAPTOPRIL/HCTZ (CAPOZIDE))LOSARTAN/HCTZ (HYZAAR)ENALAPRIL/HCTZ (VASERETIC)ENALAPRIL SOLUTION (EPANED)FOSINOPRIL (MONOPRIL)LISINOPRIL SOLUTION (QBRELIS)OLMESARTAN (BENICAR)OLMESARTAN/AMLODIPINE (AZOR)FOSINOPRIL/HCTZ (MONOPRIL HCT)MOEXIPRIL (UNIVASC)VALSARTAN (DIOVAN)LISINOPRIL (PRINIVIL, ZESTRIL)MOEXIPRIL/HCTZ (UNIRETIC)VALSARTAN/HCTZ (DIOVAN HCT)LISINOPRIL/HCTZ (PRINZIDE, ZESTORETIC)PERINDOPRIL (ACEON)VALSARTAN/AMLODIPINE (EXFORGE)QUINAPRIL (ACCUPRIL)TRANDOLAPRIL (MAVIK)VALSARTAN/AMLODIPINE/HCTZ (EXFORGE HCT)QUINAPRIL/HCTZ (ACCURETIC)TRANDOLAPRIL/VERAPAMIL (TARKA)VALSARTAN/SACUBITRIL (ENTRESTO)*RAMIPRIL CAPSULES (ALTACE CAPSULES)NON-PREFERRED –NON-PREFERRED AGENTS LISTED IN NEXT COLUMN*Please refer to the PDL Criteria Overview for more detailGENERIC (SAMPLE BRAND) LISTED FOR REFERENCE ONLY
Preferred Drug ListPrescribers may request an override for non-preferred drugs by calling the Magellan Medicaid Administration (MMA) Help Desk at: Toll Free 1800-424-7895 and choose the PDL option. This Preferred Drug List is subject to change without notice. New products in a reviewed drug classare considered NON-PREFERRED until the committee has reevaluated the evidence for the drug class. The effective implementation date statedfor each drug class is the date claims will be edited at point-of-sale.7/1/2021For the most up-to-date Preferred Drug List visit ANTIHYPERTENSIVE AGENTSANTIHYPERTENSIVE AGENTSANTIHYPERTENSIVE AGENTSANGIOTENSIN II RECEPTOR ANTAGONISTSBETA ADRENERGIC BLOCKERSCALCIUM CHANNEL BLOCKERSORIGINAL POSTED PREFERRED STATUS: 7/18/2005ORIGINAL POSTED PREFERRED STATUS: 5/12/2005ORIGINAL POSTED PREFERRED STATUS: 12/20/2005ORIGINAL EDIT EFFECTIVE DATE: 10/5/2005ORIGINAL EDIT EFFECTIVE DATE: 7/12/2005ORIGINAL EDIT EFFECTIVE DATE: 2/21/2006RE-REVIEW POSTED PREFERRED STATUS: 10/17/2007RE-REVIEW POSTED PREFERRED STATUS: 6/17/2010REVISED POSTED PREFERRED STATUS: 8/12/2011RE-REVIEW POSTED PREFERRED STATUS: 11/15/2018REVISED EDIT EFFECTIVE DATE: 8/17/2010REVISED EDIT EFFECTIVE DATE: 10/12/2011UPDATED 01/01/2021RE-REVIEW POSTED PREFERRED STATUS: 3/6/2013PREFERREDPREFERREDREVISED EDIT EFFECTIVE DATE: 5/7/2013ATENOLOLAMLODIPINE (NORVASC)REVISED EDIT EFFECTIVE DATE: 02/15/2016METOPROLOL TARTRATEAMLODIPINE/VALSARTAN (EXFORGE)RE-REVIEW POSTED PREFERRED STATUS: 11/10/17REVISED EDIT EFFECTIVE DATE: 1/1/18UPDATED: 01/01/2021PROPRANOLOL IMMEDIATE RELEASEBISOPROLOLAMLODIPINE./BENAZEPRIL (LOTREL)CARVEDILOLAMLODIPINE/OLEMSARTAN (AZOR)AMLODIPINE/VALSARTAN/HCT (EXFORGE HCT)METOPROLOL SUCCINATEDILTIAZEM ER CAPSULE (DILACOR XR, TIAZAC)TIMOLOLDILTIAZEM TABLETNON-PREFERRED –INCLUDE BUT NOT LIMITED TOACEBUTOLOLNIFEDIPINE IR (PROCARDIA)PINDOLOLNIFEDIPINE CC, ER (ADALAT CC, PROCARDIA XL)AZILSARTAN (EDARBI)SOTALOLVALSARTAN/AMLODIPINE (EXFORGE)AZILSARTAN/CHLORTHALIDONE (EDARBYCLOR)BETAXOLOLVERAPAMIL TABLETCANDESARTAN (ATACAND)LABETALOLVERAPAMIL ER TABLETS (CALAN SR)CANDESARTAN/HCTZ (ATANCAND HCT)PROPRANOLOL SOLUTIONEPROSARTAN (TEVETEN)PROPRANOLOL/HCTZOLMESARTAN/HCTZ (BENICAR HCT)BISOPROLOL/HCTZNON-PREFERRED –INCLUDE BUT NOT LIMITED TOOLMESARTAN/AMLODIPINE/HCTZ ASTATIN (CADUET)TELMISARTAN (MICARDIS)AMLODIPINE/OLMESARTAN/HCTZ (TRIBENZOR)TELMISARTAN/AMLODIPINE (TWYNSTA)NON-PREFERRED –INCLUDE BUT NOT LIMITED TOTELMISARTAN/HCTZ (MICARDIS HCT)CARVEDILOL ERFELODIPINE ER (PLENDIL)NADOLOLISRADIPINE (DYNACIRC)NEBIVOLOL (BYSTOLIC)ISRADIPINE CR (DYNACIRC CR)PENBUTOLOLNICARDIPINE (CARDENE)PROPRANOLOL ER (INDERAL LA, INNOPRAN XL)NICARDIPINE ER (CARDENE SR)PROPRANOLOL SOLUTION (HEMANGEOL)NIMOPDIPINESOTALOL (SOTYLIZE)NISOLDIPINE ER (SULAR ER)NADOLOL/BENDROFLUMETHAZIDEVERAPAMIL ER CAPSULES (VERELAN)METOPROLOL/HCTZVERAPAMIL ER PM CAPSULES (VERELAN PM)*Please refer to the PDL Criteria Overview for more detailGENERIC (SAMPLE BRAND) LISTED FOR REFERENCE ONLYDILTIAZEM CD, ER, LA, XR, OR XT (CARDIZEM)
Preferred Drug ListPrescribers may request an override for non-preferred drugs by calling the Magellan Medicaid Administration (MMA) Help Desk at: Toll Free 1800-424-7895 and choose the PDL option. This Preferred Drug List is subject to change without notice. New products in a reviewed drug classare considered NON-PREFERRED until the committee has reevaluated the evidence for the drug class. The effective implementation date statedfor each drug class is the date claims will be edited at point-of-sale.7/1/2021For the most up-to-date Preferred Drug List visit ANTIHYPERTENSIVE AGENTSANTI-INFECTIVESANTI-INFECTIVESDIRECT RENIN INHIBITORSANTI-INFECTIVE & OTIC ANTIBIOTIC/CORTICOSTEROID COMBINATIONSHEPATITIS C AGENTSORIGINAL POSTED PREFERRED STATUS: 6/17/2010ORIGINAL EDIT EFFECTIVE DATE: 8/17/2010UPDATED: 01/01/2021ORIGINAL POSTED PREFERRED STATUS: 8/10/2016ORIGINAL POSTED PREFERRED STATUS: 8/10/2016ORIGINAL EDIT EFFECTIVE DATE: 10/1/2016ORIGINAL EDIT EFFECTIVE DATE: 10/1/2016RE-REVIEW POSTED PREFERRED STATUS: 10/1/2019RE-REVIEW POSTED PREFERRED STATUS: 2/14/18PREFERREDNONEREVISED EDIT EFFECTIVE DATE: 4/1/2018PREFERREDUPDATED 4/1/2021ACETIC ACID 2% OTIC (ACETASOL)NON-PREFERRED –INCLUDE BUT NOT LIMITED TOACETIC ACID/HC OTIC DROPS (ACETASOL HC)PREFERREDCIPROFLOXACIN 0.3%/DEXAMETHASONE 0.1% (CIPRODEX)MAVYRET* (GLECAPREVIR/PIBRENTASVIR )NEOMYCIN/POLYMIXIN/HC SOLN/SUSP (CORTISPORIN)RIBAVIRIN TABLETS OR CAPSULES 200MG*OFLOXACIN 0.3% SOLUTION (FLOXIN OTIC)SOFOSBUVIR/VELPATASVIR (GENERIC FOR EPCLUSA)*ELBASVIR/GRAZOPREVIR (ZEPATIER)*ALISKIREN (TEKTURNA)NON-PREFERRED –INCLUDE BUT NOT LIMITED TOALISKIREN/HCTZ (TEKTURNA HCT)CIPROFLOXACIN OTIC 0.2%NON-PREFERRED –INCLUDE BUT NOT LIMITED TOCIPROFLOXACIN 0.2%/HC 1% (CIPRO HC OTIC)EPCLUSA ONIUM (COLY-MYCIN S)HARVONI* (LEDIPASVIR/ SOFOSBUVIR)HC/NEOMYCIN/COLISTIN/THONZONIUM (CORTISPORIN TC)LEDIPASVIR/ SOFOSBUVIR (GENERIC FOR HARVONI)SOVALDI* (SOFOSBUVIR )VIEKIRA PAK* (OMBITASVIR/ PARITAPREVIR/ RITONAVIR/ DASABUVIR )VOSEVI* (SOFOSBUVIR/VELPATASVIR/VOXILAPREVIR)*Please refer to the PDL Criteria Overview for more detailGENERIC (SAMPLE BRAND) LISTED FOR REFERENCE ONLY
Preferred Drug ListPrescribers may request an override for non-preferred drugs by calling the Magellan Medicaid Administration (MMA) Help Desk at: Toll Free 1800-424-7895 and choose the PDL option. This Preferred Drug List is subject to change without notice. New products in a reviewed drug classare considered NON-PREFERRED until the committee has reevaluated the evidence for the drug class. The effective implementation date statedfor each drug class is the date claims will be edited at point-of-sale.7/1/2021For the most up-to-date Preferred Drug List visit BIOLOGIC AND IMMUNOLOGIC AGENTSBIOLOGIC AND IMMUNOLOGIC AGENTSCARDIOVASCULAR AGENTSIMMUNOLOGIC AGENTSIMMUNOLOGIC AGENTSPULMONARY HYPERTENSION TREATMENTSTargeted Immune ModulatorsORAL INHALED INJECTEDORIGINAL POSTED PREFERRED STATUS: 4/14/2006ORIGINAL POSTED PREFERRED STATUS: 2/3/2017ORIGINAL POSTED PREFERRED STATUS: 7/28/2011ORIGINAL EDIT EFFECTIVE DATE: 6/13/2006ORIGINAL EDIT EFFECTIVE DATE: 4/1/2017ORIGINAL EDIT EFFECTIVE DATE: 9/27/2011RE-REVIEW POSTED PREFERRED STATUS: 5/31/2012RE-REVIEW POSTED PREFERRED STATUS: 10/1/2019ORIGINAL POSTED PREFERRED STATUS: 5/6/2014REVISED EDIT EFFECTIVE DATE: 7/1/2012ORIGINAL EDIT EFFECTIVE DATE: 7/8/2014RE-REVIEW POSTED PREFERRED STATUS: 11/10/17PREFERREDRE-REVIEW: 11/09/2016REVISED EDIT EFFECTIVE DATE: 1/1/18AMBRISENTAN TABLETS (LETAIRIS)* BRAND ONLYRE-REVIEW: 1/1/2020UPDATED 01/01/2021BOSENTAN TABLETS (TRACLEER)* BRAND ONLYPREFERREDPREFERREDEPOPROSTENOLVIALS* -GENERIC ONLYAVONEX (INTERFERON BETA - 1A )ENBREL* (ETANERCEPT )SILDENAFIL TABLETS (REVATIO)*TECFIDERA (DIMETHYL FUMARATE )- BRAND ONLYHUMIRA *(ADALIMUMAB )SILDENAFIL VIAL*TECFIDERA STARTER PAK (DIMETHYL FUMARATE)- BRAND ONLYOTEZLA* (APREMILAST)TADALAFIL TABLETS (ADCIRCA)*Disease-modifying Drugs for Multiple SclerosisCOPAXONE (GLATIRAMER 20MG )-BRAND ONLYTREPROSTINIL VIAL* - GENERIC ONLYNON-PREFERRED – INCLUDE BUT NOT LIMITED TONON-PREFERRED –INCLUDE BUT NOT LIMITED TOACTEMRA (TOCILIZUMAB)AUBAGIO (TERIFLUNOMIDE )CIMZIA (CERTOLIZUMAB)BAFIERTAM (MONOMETHYL FUMARATE )COSENTYX (SECUKINUMAB)AMBRISENTAN TABLETS* -GENERIC ONLYBETASERON (INTERFERON BETA - 1B )ILARIS (CANAKINUMAB)BOSENTAN TABLETS* - GENERIC ONLYCOPAXONE (GLATIRAMER 40MG )BRAND AND GENERICILUMYA (TIDRAKIZUMAB -ASMM )EPOPROSTENOL VIALS* (FLOLAN) - BRAND ONLYDIMETHYL FUMARATE (GENERIC FOR TECFIDERA)KEVZARA (SARILUMAB)EPOPROSTENOL VIALS* (VELETRI) -BRAND AND GENERICEXTAVIA (INTERFERON BETA - 1B KIT)KINERET (ANAKINRA)ILOPROST INHALATION (VENTAVIS)*GILENYA (FINGOLIMOD)OLUMIANT (BARICITINIB)MACITENTAN (OPSUMIT)*GLATIRAMER 20MG -GENERIC ONLYORENCIA (ABATACEPT)RIOCIGUAT(ADEMPAS)*GLATOPA (GLATIRAMER 20MG)RINVOQ (UPADACITINIB)SELEXIPAG(UPTRAVI)*KESIMPTA (OFATUMUMAB )SILIQ (BRODALUMAB )SILDENAFIL SUSPENSION (REVATIO)*MAVENCLAD (CLADRIBINE)SIMPONI (GOLIMUMAB)TREPROSTINIL TABLETS (ORENITRAM ER)*MAYZENT (SIPONIMOD)STELARA (USTEKINUMAB)TREPROSTINIL INHALATION (TYVASO)*REBIF (INTERFERON BETA - 1A/ALBUMIN)SKYRIZI (RISANKIZUMAB-RZAA)TREPROSTINIL VIAL (REMODULIN) * BRAND ONLYVUMERITY (DIROXIMEL FUMARATE)TALTZ (IXEKIZUMAB)ZEPOSIA (OZANIMOD)TREMFYA (GUSELKUMAB)ARCALYST (RILONACEPT)XELJANZ (TOFACITINIB)*Please refer to the PDL Criteria Overview for more detailGENERIC (SAMPLE BRAND) LISTED FOR REFERENCE ONLYNON-PREFERRED –INCLUDE BUT NOT LIMITED TO
Preferred Drug ListPrescribers may request an override for non-preferred drugs by calling the Magellan Medicaid Administration (MMA) Help Desk at: Toll Free 1800-424-7895 and choose the PDL option. This Preferred Drug List is subject to change without notice. New products in a reviewed drug classare considered NON-PREFERRED until the committee has reevaluated the evidence for the drug class. The effective implementation date statedfor each drug class is the date claims will be edited at point-of-sale.7/1/2021For the most up-to-date Preferred Drug List visit CENTRAL NERVOUS SYSTEM AGENTSCENTRAL NERVOUS SYSTEM AGENTSANTIDEPRESSANTSANTIDEPRESSANTSCENTRAL NERVOUS SYSTEM AGENTSADHDSSRIs, SSNRIs, SNRIsSSRIs, SSNRIs, SNRIsAmphetamine Salts, Amphetamine-Like Drugs,Norepinephrine Reuptake Inhibitors, Alpha-2 AgonistORIGINAL POSTED PREFERRED STATUS: 2/7/2007ORIGINAL POSTED PREFERRED STATUS: 2/7/2007ORIGINAL EDIT EFFECTIVE DATE: 4/10/2007ORIGINAL EDIT EFFECTIVE DATE: 4/10/2007ORIGINAL POSTED PREFERRED STATUS: 5/7/2007RE-REVIEW POSTED PREFERRED STATUS: 10/8/2009RE-REVIEW POSTED PREFERRED STATUS: 10/8/2009ORIGINAL EDIT EFFECTIVE DATE: 7/10/2007REVISED EDIT EFFECTIVE DATE: 1/1/2010REVISED EDIT EFFECTIVE DATE: 1/1/2010REVISED POSTED PREFERRED STATUS: 5/11/2009RE-REVIEW POSTED PREFERRED STATUS: 5/2/2011RE-REVIEW POSTED PREFERRED STATUS: 5/2/2011REVISED EDIT EFFECTIVE DATE: 7/21/2009REVISED EDIT EFFECTIVE DATE: 7/1/2011REVISED EDIT EFFECTIVE DATE: 7/1/2011RE-REVIEW POSTED PREFERRED STATUS: 2/16/2012RE-REVIEW POSTED PREFERRED STATUS: 5/6/2014RE-REVIEW POSTED PREFERRED STATUS: 5/6/2014REVISED EDIT EFFECTIVE DATE: 4/17/2012REVISED EDIT EFFECTIVE DATE: 6/5/2014REVISED EDIT EFFECTIVE DATE: 6/5/2014RE-REVIEW POSTED PREFERRED STATUS: 11/10/17RE-REVIEW POSTED PREFERRED STATUS: 11/15/18REVISED EDIT EFFECTIVE DATE: 1/1/18UPDATED 01/01/2021PREFERREDBUPROPION EXTENDED RELEASE (WELLBUTRIN XL)*NON-PREFERRED -INCLUDE BUT NOT LIMITED TOPREFERREDBUPROPION REGULAR RELEASE (WELLBUTRIN)*BUPROPION HBR ER TABLET (APLENZIN)*ADDERALL XR* (BRAND ONLY)BUPROPION SUSTAINED RELEASE (WELLBUTRIN SR)*BUPROPION HCL ER TABLET (FORFIVO XL)*AMPHETAMINE SALTS TABLET* (generic for ADDERALL)CITALOPRAM (CELEXA)*DESVENLAFAXINE ER (KHEDEZLA ER, PRISTIQ ER)*ATOMOXETINE (generic for STRATTERA)*DULOXETINE (CYMBALTA)FLUOXETINE 10MG, 15MG, 20MG TABLET, 40MG CAPSULE,ESCITALOPRAM 5MG TABLET, 5MG/5ML SOL'N (LEXAPRO)*AND 90MG DELAYED RELEASE (PROZAC)*CLONIDINE IR (generic for CATAPRES)*CONCERTA *(BRAND ONLY)ESCITALOPRAM 10MG, 20MG TABLET (LEXAPRO)*FLUVOXAMINE EXTENDED RELEASE (LUVOX CR)DEXTROAMPHETAMINE 5MG, 10MG TABLET* (generic for Zenzedi)FLUOXETINE 10MG, 20MG CAPSULE, AND 20MG/5MLLEVOMILNACIPRAN (FETZIMA ER)*FOCALIN* (BRAND ONLY)MILNACIPRAN (SAVELLA)*FOCALIN XR* (BRAND ONLY)FLUVOXAMINE (LUVOX)*MIRTAZAPINE ODT TABLET (REMERON SOLTAB)*GUANFACINE IR TABLET* (generic for TENEX)MIRTAZAPINE 7.5MG (REMERON)* Effective 6/5/2014NEFAZODONE (SERZONE)*GUANFACINE ER TABLET* (generic for INTUNIV)MIRTAZAPINE 15MG, 30MG, 45MG TABLET (REMERON)*PAROXETINE CR TABLET; SUSPENSION (PAXIL)*METHYLPHENIDATE TABLET *(generic for RITALIN)PAROXETINE HCL TABLET (PAXIL)*PAROXETINE MESYLATE (BRISDELLE)VYVANSE CAPSULES *SERTRALINE (ZOLOFT)*PAROXETINE MESYLATE (PEXEVA)*VYVANSE CHEW TABLETS *VENLAFAXINE ER CAPSULES (EFFEXOR XR)* Effective 6/5/14VENLAFAXINE ER TABLET (EFFEXOR XR)*VENLAFAXINE REGULAR RELEASE TABLET (EFFEXOR)*VILAZODONE (VIIBRYD)*SOLUTION (PROZAC)*VORTIOXETINE (BRINTELLIX)*NON-PREFERRED –INCLUDE BUT NOT LIMITED TOADHANSIA XRNON-PREFERRED –NON-PREFERRED AGENTS LISTED IN NEXT COLUMN*Please refer to the PDL Criteria Overview for more detailADZENYS ER SUSPENSION, ADZENYS XR ODTNON-PREFERRED AGENTS CONTINUED IN NEXT COLUMNGENERIC (SAMPLE BRAND) LISTED FOR REFERENCE ONLY
Preferred Drug ListPrescribers may request an override for non-preferred drugs by calling the Magellan Medicaid Administration (MMA) Help Desk at: Toll Free 1800-424-7895 and choose the PDL option. This Preferred Drug List is subject to change without notice. New products in a reviewed drug classare considered NON-PREFERRED until the committee has reevaluated the evidence for the drug class. The effective implementation date statedfor each drug class is the date claims will be edited at point-of-sale.7/1/2021For the most up-to-date Preferred Drug List visit CENTRAL NERVOUS SYSTEM AGENTSCENTRAL NERVOUS SYSTEM AGENTSATTENTION DEFICIT DISORDER/HYPERACTIVITY DISORDERFIBROMYALGIA AGENTSAmphetamine Salts, Amphetamine-Like Drugs,CENTRAL NERVOUS SYSTEM AGENTSFIBROMYALGIA AGENTSORIGINAL POSTED PREFERRED STATUS 7/20/2011ORIGINAL POSTED PREFERRED STATUS 7/20/2011ORIGINAL EDIT EFFECTIVE DATE: 9/20/2011ORIGINAL EDIT EFFECTIVE DATE: 9/20/2011ORIGINAL EDIT EFFECTIVE DATE: 7/10/2007PREFERREDREVISED POSTED PREFERRED STATUS: 5/11/2009AMITRIPTYLINE (ELAVIL)NON-PREFERRED – CONTINUED FROM PREVIOUS CLMINCLUDE BUT NOT LIMITED TOREVISED EDIT EFFECTIVE DATE: 7/21/2009CITALOPRAM (CELEXA)*ETHOTOIN TABLET (PEGANONE)*RE-REVIEW POSTED PREFERRED STATUS: 2/16/2012CYCLOBENAZAPRINE 10MG TABLET (FLEXERIL)FLUOXETINE 10MG, 15MG, 20MG TABLET, 40MG CAPSULE &REVISED EDIT EFFECTIVE DATE: 4/17/2012FLUOXETINE 10MG, 20MG CAPSULE, 20MG/5ML SOLUTIONNorepinephrine Reuptake Inhibitors, Alpha-2 AgonistORIGINAL POSTED PREFERRED STATUS: 5/7/2007UPDATED 01/01/2021(PROZAC)*90MG DELAYED RELEASE (PROZAC, SARAFEM)*FLUVOXAMINE EXTENDED RELEASE CAPSULE (LUVOX CR)*NON-PREFERRED –INCLUDE BUT NOT LIMITED TOGABAPENTIN CAPSULE (NEURONTIN)FLUVOXAMINE TABLET (LUVOX)*NORTRIPTYLINE (PAMELOR)GABAPENTIN 250MG/5ML SOLUTION (NEURONTIN)*AMPHETAMINE SALTS ER CAPSULE (ADDERALL XR - GENERIC ONLY)PAROXETINE HCL TABLET (PAXIL)*GABAPENTIN 600MG, 800MG TABLET (NEURONTIN)*CLONIDINE ER SUSPENSION (NEXICLON XR)DULOXETINE (CYMBALTA)* Effective 1/1/19I
updated: 01/01/2021 original posted preferred status: 8/10/2016 original posted preferred status: 8/10/2016 original edit effective date: 10/1/2016 original edit effective date: 10/1/2016 re-review posted preferred status: 10/1/2019 re-review posted preferred status: 2/14/18. preferred. r
