MO HealthNet Preferred Drug List Effective November 1, 2018 All Therapeutic Classes The MO HealthNet Preferred Drug List is not all inclusive nor does it guarantee coverage, but represents a summary of prescription coverage. For full criteria details see https://dss.mo.gov/mhd/cs/pharmacy/pages/clinedit.htm Page 1 of 24 PDL CLASS Preferred Drugs Non-Preferred Drugs Review Date ANTI-INFECTIVES: Antifungals for Onychomycosis Griseofulvin Susp Terbinafine Tabs Griseofulvin Caps/Tabs Griseofulvin Ultramicrosize Tabs Gris-PEG® Itraconazole Caps/Soln Onmel® Sporanox® Caps/Soln March/April ANTI-INFECTIVES: Antifungals for Thrush Clotrimazole Troche Fluconazole Tabs/Susp Nystatin Tabs/Susp Diflucan® Tabs/Susp Nystatin Pwd Oravig® Buccal March/April ANTI-INFECTIVES: Fluoroquinolones, Oral Ciprofloxacin Tabs Levofloxacin Tabs Avelox® Baxdela™ Cipro® Susp Cipro® Tabs/Susp Cipro® XR Ciprofloxacin ER Ciprofloxacin Susp Levaquin® Levofloxacin Soln Moxifloxacin Ofloxacin June/July ANTI-INFECTIVES: GI Antibiotics Metronidazole Tabs Neomycin Vancomycin Caps Dificid® Tabs Firvanq™ Flagyl® Caps/Tabs Metronidazole Caps Paramomycin Tindamax® Tinidazole Vancocin® Xifaxan® June/July ANTI-INFECTIVES: Hepatitis C Agents, Oral Direct Acting Antivirals Epclusa® Mavyret™ Vosevi® (Retreatment Only) Zepatier™ Daklinza™ Harvoni® Sovaldi® Technivie® Viekira Pak® Viekira XR™ June/July Preferred status based on duration of treatment and clinical condition. For full criteria see: https://dss.mo.gov/mhd/cs/pharmacy/pages/clinedit.htm ANTI-INFECTIVES: Inhaled Antibiotics Bethkis® Kitabis® Pak TOBI Podhaler™ Cayston® TOBI® Tobramycin Inhaled Tobramycin Pak March/April ANTI-INFECTIVES: Antivirals, General Acyclovir Caps/Tabs Acyclovir Susp Valacyclovir Famciclovir Valtrex® Zovirax® Caps/Tabs Zovirax® Susp March/April
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MO HealthNet Preferred Drug List Effective November 1, 2018
All Therapeutic Classes
The MO HealthNet Preferred Drug List is not all inclusive nor does it guarantee coverage, but represents a summary of prescription coverage. For full criteria details see https://dss.mo.gov/mhd/cs/pharmacy/pages/clinedit.htm
Page 1 of 24
PDL CLASS Preferred Drugs Non-Preferred Drugs Review
MO HealthNet Preferred Drug List Effective November 1, 2018
All Therapeutic Classes
The MO HealthNet Preferred Drug List is not all inclusive nor does it guarantee coverage, but represents a summary of prescription coverage. For full criteria details see https://dss.mo.gov/mhd/cs/pharmacy/pages/clinedit.htm
Page 2 of 24
PDL CLASS Preferred Drugs Non-Preferred Drugs Review
Date
ANTI-INFECTIVES: Vaginal Antibiotics
Cleocin® Vaginal Ovules Clindesse®
Nuvessa™ Vaginal Gel
Cleocin® Vaginal Crm Clindamycin Vaginal Crm MetroGel Vaginal® Gel
Metronidazole Vaginal Gel Vandazole® Vaginal Gel
June/July
ANTI-INFECTIVES: Cephalosporins, 1st
Generation
Cefadroxil Caps Cephalexin Caps/Susp
Cefadroxil Tabs/Susp Cephalexin Tabs
Keflex®
June/July ANTI-INFECTIVES:
Cephalosporins, 2nd Generation
Cefprozil Tabs/Susp Cefuroxime Tabs
Cefaclor Caps/Susp Cefaclor ER Tabs
Ceftin® Ceftin® Susp
ANTI-INFECTIVES: Cephalosporins, 3rd
Generation
Cefdinir Caps/Susp Suprax® Caps
Suprax® Chew Tabs
Cefixime Susp Cefpodoxime Tabs/Susp
Suprax® Tabs/Susp June/July
ANTI-INFECTIVES: Macrolides
Azithromycin Clarithromycin
E.E.S. 400® Erythromycin Base DR Caps
Clarithromycin ER E-Mycin ERYC®
Ery-Tab® Erythrocin® Stearate
Erythromycin Base Tabs PCE®
Zithromax®
June/July
ANTI-INFECTIVES: Penicillins
Amoxicillin Caps/Susp/Tabs Amoxicillin Chew Tabs
Ampicillin Caps Amox/Clavulanate
Susp/Tabs Amox/Clavulanate XR Bicillin® C-R Injection Penicillin V Susp/Tabs
Amox/Clavulanate Chew Tabs Amox/Clavulanate XR
Ampicillin Susp Augmentin XR™
Augmentin® 125 Susp Dicloxacillin
June/July
ANTI-INFECTIVES: Tetracyclines
Doxycycline Hyclate Caps Doxycycline Hyclate Tabs
Minocycline Caps Vibramycin® Susp
Acticlate® Adoxa®
Coremino® Demeclocycline
Doryx MPC® Doryx®
Doxycycline Hyclate DR Doxycycline Mono Caps/Tabs
Doxycycline Mono IR-DR Doxycycline Mono Susp
Minocin® Minocycline ER
Minocycline Tabs Morgidox® Kits
Okebo™ Oracea®
June/July
MO HealthNet Preferred Drug List Effective November 1, 2018
All Therapeutic Classes
The MO HealthNet Preferred Drug List is not all inclusive nor does it guarantee coverage, but represents a summary of prescription coverage. For full criteria details see https://dss.mo.gov/mhd/cs/pharmacy/pages/clinedit.htm
Page 3 of 24
PDL CLASS Preferred Drugs Non-Preferred Drugs Review
MO HealthNet Preferred Drug List Effective November 1, 2018
All Therapeutic Classes
The MO HealthNet Preferred Drug List is not all inclusive nor does it guarantee coverage, but represents a summary of prescription coverage. For full criteria details see https://dss.mo.gov/mhd/cs/pharmacy/pages/clinedit.htm
Page 4 of 24
PDL CLASS Preferred Drugs Non-Preferred Drugs Review
MO HealthNet Preferred Drug List Effective November 1, 2018
All Therapeutic Classes
The MO HealthNet Preferred Drug List is not all inclusive nor does it guarantee coverage, but represents a summary of prescription coverage. For full criteria details see https://dss.mo.gov/mhd/cs/pharmacy/pages/clinedit.htm
Page 5 of 24
PDL CLASS Preferred Drugs Non-Preferred Drugs Review
Date Pindolol
Propranolol LA/ER Soln Sorine®
Sotylize® Tenormin®
Timolol Maleate Toprol XL®
CARDIOVASCULAR: Beta-Blocker/
Diuretic Combination Agents
Atenolol/Chlorthalidone Bisoprolol/HCTZ
Metoprolol/HCTZ Propranolol/HCTZ
Corzide® Dutoprol™
Lopressor HCT® Metoprolol ER/ HCTZ
Nadolol/ Bendroflume-thiazide Tenoretic®
Ziac®
Sept/Oct
CARDIOVASCULAR: Calcium Channel
Blockers, Dihydropyridines
Amlodipine Felodipine ER Nifedipine ER Nifedipine IR
Adalat CC® Afeditad CR®
Isradipine Nicardipine HCl
Nimodipine Nisoldipine
Norvasc® Nymalize®
Procardia XL® Procardia®
Sular®
Sept/Oct
CARDIOVASCULAR: Calcium Channel Blockers, Non-
Dihydropyridines
Diltiazem ER Caps Diltiazem HCl Diltiazem XR
Verapamil HCl Verapamil ER Caps/Tabs
Calan SR® Cardizem CD® Cardizem LA® Cardizem SR®
Cartia XT® Dilacor XR®
Dilt CD® Diltia XT®
Diltiazem LA Matzim LA® Taztia XT®
Tiazac® Verapamil 360mg Caps
Verapamil ER PM Verapamil PM
Sept/Oct
CARDIOVASCULAR: Direct Renin Inhibitors &
Combination Agents
Tekturna® Tekturna HCT®
Sept/Oct
MO HealthNet Preferred Drug List Effective November 1, 2018
All Therapeutic Classes
The MO HealthNet Preferred Drug List is not all inclusive nor does it guarantee coverage, but represents a summary of prescription coverage. For full criteria details see https://dss.mo.gov/mhd/cs/pharmacy/pages/clinedit.htm
Page 6 of 24
PDL CLASS Preferred Drugs Non-Preferred Drugs Review
MO HealthNet Preferred Drug List Effective November 1, 2018
All Therapeutic Classes
The MO HealthNet Preferred Drug List is not all inclusive nor does it guarantee coverage, but represents a summary of prescription coverage. For full criteria details see https://dss.mo.gov/mhd/cs/pharmacy/pages/clinedit.htm
Page 7 of 24
PDL CLASS Preferred Drugs Non-Preferred Drugs Review
Date
CENTRAL NERVOUS SYSTEM: Agents for
Alzheimers, Cholinesterase
Inhibitors
Donepezil ODT Donepezil 5, 10mg
Exelon® Patch Memantine Tabs
Aricept® Donepezil 23mg
Galantamine Galantamine ER
Memantine Dose Pack Memantine ER
Memantine Soln
Namenda XR® Namenda® Tabs/Soln
Namzaric® Razadyne ER®
Razadyne® Tabs Rivastigmine Caps/Patch
Dec/Jan
CENTRAL NERVOUS SYSTEM: Anti-
Parkinsonism Agents, Non-Ergot Dopamine
Agonists
Pramipexole Ropinirole
Mirapex ER® Mirapex® Neupro®
Pramipexole ER
Requip XL® Requip®
Ropinirole ER
Dec/Jan
CENTRAL NERVOUS SYSTEM: Anti-
Parkinsonism Agents, Monoamine Oxidase
B Inhibitors
Azilect® Rasagiline Selegiline
Xadago® Zelapar® ODT
Dec/Jan
CENTRAL NERVOUS SYSTEM: Analgesics,
Cox-II Inhibitor Agents
Celecoxib Celebrex®
Dec/Jan
CENTRAL NERVOUS SYSTEM: Analgesics,
NSAIDS
Diclofenac Sodium Diclofenac ER
Diclofenac 1% Topical Soln Flector® Patch
Ibuprofen Chew Tabs OTC Ibuprofen OTC/Rx
Ibuprofen Susp/Drops OTC Ketorolac
Meloxicam Tabs Naproxen
Naproxen Sodium OTC
Arthrotec® Cambia®
Diclofenac Potassium Diclofenac Sodium Gel Diclofenac/Misoprostol
Diflunisal Duexis® Etodolac
Etodolac ER Fenoprofen Flurbiprofen
Indocin® Indocin® Supp Indomethacin
Indomethacin ER Ketoprofen
Ketoprofen ER Meclofenamate Mefenamic Acid
Dec/Jan
MO HealthNet Preferred Drug List Effective November 1, 2018
All Therapeutic Classes
The MO HealthNet Preferred Drug List is not all inclusive nor does it guarantee coverage, but represents a summary of prescription coverage. For full criteria details see https://dss.mo.gov/mhd/cs/pharmacy/pages/clinedit.htm
Page 8 of 24
PDL CLASS Preferred Drugs Non-Preferred Drugs Review
Date Meloxicam Susp
Mobic® Nabumetone
Nalfon® Naprelan®
Naproxen CR Naproxen Sodium Rx
Oxaprozin Pennsaid® Pump
Piroxicam Sprix®
Sulindac Tivorbex™
Tolmetin Sodium Vimovo®
Vivlodex™ Voltaren Gel®
Zipsor® Zorvolex™
CENTRAL NERVOUS SYSTEM: Analgesics, Opioids, Long Acting
Narcotics
Butrans® Embeda®
Fentanyl Patch (12, 25, 50, 75, 100mcg)
Hysingla® ER Morphine Sulfate ER Tabs
OxyContin®
Arymo® ER Belbuca® Film
Buprenorphine Patch Duragesic®
Exalgo® Fentanyl Patch 37.5, 62.5,
87.5mcg Hydromorphone ER
Kadian®
Morphabond™ ER Morphine ER Caps (gen Kadian)
MS Contin® Oxycodone ER
Oxymorphone ER Xtampza ER™ Zohydro® ER
Dec/Jan
CENTRAL NERVOUS SYSTEM: Analgesics, Opiate Dependence
Agents
Naltrexone Tabs Suboxone® Film
Vivitrol®
Bunavail® Buprenex®
Buprenorphine SL Tabs Buprenorphine/Naloxone SL
Film Buprenorphine/Naloxone SL
Tabs
Sublocade™ Zubsolv®
Dec/Jan
CENTRAL NERVOUS SYSTEM: Analgesics, Opiate Emergency
Reversal Agents
Narcan® Nasal Spray Naltrexone Syringe/Vial
Dec/Jan
MO HealthNet Preferred Drug List Effective November 1, 2018
All Therapeutic Classes
The MO HealthNet Preferred Drug List is not all inclusive nor does it guarantee coverage, but represents a summary of prescription coverage. For full criteria details see https://dss.mo.gov/mhd/cs/pharmacy/pages/clinedit.htm
Page 9 of 24
PDL CLASS Preferred Drugs Non-Preferred Drugs Review
Date
CENTRAL NERVOUS SYSTEM: Analgesics,
Tramadol Like Agents
Tramadol Tramadol ER Tabs (gen
Ultram® ER) Tramadol/APAP
ConZip® Nucynta®
Nucynta® ER Tramadol ER Caps/Tabs (gen
Ryzolt®) Ultracet® Ultram®
Dec/Jan
CENTRAL NERVOUS SYSTEM: Analgesics, Fibromyalgia Agents
MO HealthNet Preferred Drug List Effective November 1, 2018
All Therapeutic Classes
The MO HealthNet Preferred Drug List is not all inclusive nor does it guarantee coverage, but represents a summary of prescription coverage. For full criteria details see https://dss.mo.gov/mhd/cs/pharmacy/pages/clinedit.htm
Page 10 of 24
PDL CLASS Preferred Drugs Non-Preferred Drugs Review
Cyclobenzaprine Methocarbamol Orphenadrine ER Tizanidine Tabs
Amrix® Carisoprodol
Carisoprodol/ASA Dantrium® Dantrolene
Fexmid® Lorzone®
Metaxalone Robaxin® Skelaxin®
Soma® Tizanidine Caps
Zanaflex®
Dec/Jan
MO HealthNet Preferred Drug List Effective November 1, 2018
All Therapeutic Classes
The MO HealthNet Preferred Drug List is not all inclusive nor does it guarantee coverage, but represents a summary of prescription coverage. For full criteria details see https://dss.mo.gov/mhd/cs/pharmacy/pages/clinedit.htm
Page 11 of 24
PDL CLASS Preferred Drugs Non-Preferred Drugs Review
MO HealthNet Preferred Drug List Effective November 1, 2018
All Therapeutic Classes
The MO HealthNet Preferred Drug List is not all inclusive nor does it guarantee coverage, but represents a summary of prescription coverage. For full criteria details see https://dss.mo.gov/mhd/cs/pharmacy/pages/clinedit.htm
Page 12 of 24
PDL CLASS Preferred Drugs Non-Preferred Drugs Review
Date Fungoid® Kit OTC
Jublia® Kerydin™
Ketodan Foam Kit Lamisil Ultra® OTC
Lamisil® Gel/Spray OTC Loprox®
Crm/Gel/Kit/Susp/Shampoo Lotrimin® AF Crm OTC
Lotrisone® Crm Luliconazole 1% Crm
Luzu® Crm Mentax®
Miconazole Nitrate OTC Miconazole Oint/Spray OTC
Naftifine Crm Naftin® Crm/Gel
Nizoral® AD Shampoo Nizoral® Shampoo
Nystatin-TAC Crm/Oint Oxiconazole Crm Oxistat® Crm/Lot Pediaderm™ AF
MO HealthNet Preferred Drug List Effective November 1, 2018
All Therapeutic Classes
The MO HealthNet Preferred Drug List is not all inclusive nor does it guarantee coverage, but represents a summary of prescription coverage. For full criteria details see https://dss.mo.gov/mhd/cs/pharmacy/pages/clinedit.htm
Page 13 of 24
PDL CLASS Preferred Drugs Non-Preferred Drugs Review
Date
DERMATOLOGIC AGENTS: Topical Corticosteroids
Alclometasone Dip Crm/Oint
Betamethasone Dip Crm/Lot
Betamethasone Val Crm/Lot/Oint
Beta-Val Crm/Lot Clobetasol Emollient
Clobetasol Prop Crm/Gel/Oint/Soln
Fluticasone Prop Crm/Oint Hydrocortisone Rx
Crm/Oint/Lot Hydrocortisone OTC
Crm/Oint Mometasone Fur
Crm/Oint/Soln Triamcinolone Crm/Oint/Lot
Amcinonide Crm Apexicon E®
Betamet Dip Prop Gly Crm/Lot/Oint
Betamethasone Dip Gel/Oint Betamethasone Val Foam
Capex® Shampoo Clobetasol Emollient
Clobetasol Prop Foam/Spray Clobex® Lot/Shampoo
Clobex® Spray Clocortolone Crm
Cloderm® Cordran® Oint/Tape
Cutivate® Lot DermacinRx® Silapak Derma-Smoothe FS®
Hydrocortisone Val Crm/Oint Hydrocortisone/Urea Hydrocortosone/Aloe
Impoyz Kenalog® Aerosol Locoid Lipocream®
Luxiq® Micort-HC®
Nolix™ Olux-E® Pandel®
Pediaderm™ HC/TA Prednicarbate Crm/Oint
March/April
MO HealthNet Preferred Drug List Effective November 1, 2018
All Therapeutic Classes
The MO HealthNet Preferred Drug List is not all inclusive nor does it guarantee coverage, but represents a summary of prescription coverage. For full criteria details see https://dss.mo.gov/mhd/cs/pharmacy/pages/clinedit.htm
Page 14 of 24
PDL CLASS Preferred Drugs Non-Preferred Drugs Review
ENDOCRINE AND METABOLIC AGENTS: Topical Androgenic
Agents
Androderm®Gel Patch Androgel® Pump
Androgel® Pack Axiron®
Fortesta® Testim®
Testosterone (gen Androgel® Pump)
Testosterone (gen Androgel®)
Testosterone Gel (gen Fortesta®)
Testosterone Gel Pump (gen Axiron®)
March/April
MO HealthNet Preferred Drug List Effective November 1, 2018
All Therapeutic Classes
The MO HealthNet Preferred Drug List is not all inclusive nor does it guarantee coverage, but represents a summary of prescription coverage. For full criteria details see https://dss.mo.gov/mhd/cs/pharmacy/pages/clinedit.htm
Page 15 of 24
PDL CLASS Preferred Drugs Non-Preferred Drugs Review
Date Testosterone Transderm (gen
Testim®) Vogelxo® Gel/Pump/Packet
ENDOCRINE AND METABOLIC AGENTS: Antihyperglycemic,
Amylin-Analogs
Symlin® Symlin Pen®
June/July
ENDOCRINE AND METABOLIC AGENTS: Antihyperglycemic,
GLP-1 Receptor Agonist
Bydureon® Byetta® Victoza®
Adlyxin™ Bydureon® Bcise™ Auto Injector
Ozempic®
Trulicity® June/July
ENDOCRINE AND METABOLIC AGENTS: Antihyperglycemic, Alpha Glucosidase
Inhibitor
Acarbose Glyset®
Miglitol® Precose®
June/July
ENDOCRINE AND METABOLIC AGENTS: Antihyperglycemic,
Meglitinide
Nateglinide Repaglinide
Prandin® Starlix®
June/July
ENDOCRINE AND METABOLIC AGENTS: Antihyperglycemic,
Biguanide & Combination Agents
Glipizide/Metformin Glyburide/Metformin
Metformin HCl Metformin ER (gen
Glucophage XR)
Fortamet ER® Glucophage XR®
Glucophage® Glumetza ER®
Metformin ER (gen Fortamet OSM)
Metformin ER (gen Glumetza MOD)
Metformin Soln (gen Riomet®)
Repaglinide/Metformin Riomet®
June/July
ENDOCRINE AND METABOLIC AGENTS: Antihyperglycemic, DPP-IV (Dipeptidyl
Peptidase-4) Inhibitors &
Combination Agents
Glyxambi® Januvia®
Janumet® Janumet XR® Jentadueto®
Kombiglyze XR® Onglyza®
Tradjenta®
Alogliptin Alogliptin/Metformin
Alogliptin/Pioglitazone Jentadueto XR®
Kazano® Nesina™
Oseni
Qtern® Steglujan™
June/July
ENDOCRINE AND METABOLIC AGENTS: Antihyperglycemic, SGLT2-Inhibitors &
Combination Agents
Farxiga™ Invokana® Jardiance® Synjardy®
Synjardy XR®
Invokamet XR® Invokamet®
Segluromet™ Steglatro™
XigDuo XR®
June/July
MO HealthNet Preferred Drug List Effective November 1, 2018
All Therapeutic Classes
The MO HealthNet Preferred Drug List is not all inclusive nor does it guarantee coverage, but represents a summary of prescription coverage. For full criteria details see https://dss.mo.gov/mhd/cs/pharmacy/pages/clinedit.htm
Page 16 of 24
PDL CLASS Preferred Drugs Non-Preferred Drugs Review
Date
ENDOCRINE AND METABOLIC AGENTS: Antihyperglycemic, Thiazolidinediones
MO HealthNet Preferred Drug List Effective November 1, 2018
All Therapeutic Classes
The MO HealthNet Preferred Drug List is not all inclusive nor does it guarantee coverage, but represents a summary of prescription coverage. For full criteria details see https://dss.mo.gov/mhd/cs/pharmacy/pages/clinedit.htm
Page 17 of 24
PDL CLASS Preferred Drugs Non-Preferred Drugs Review
Date
ENDOCRINE AND METABOLIC AGENTS: Antihyperglycemic, Oral Sulfonylurea,
2nd Generation
Glimepiride Glipizide
Glipizide ER Glyburide
Glyburide Micronized
Amaryl® Glucotrol XL®
Glucotrol® Glynase® PresTab®
June/July
ENDOCRINE AND METABOLIC AGENTS:
Insulins
Humulin® N Vials Humulin® R Vials
Humulin® R 500 u/ml Pen/Vial
Novolin® N Vials Novolin® R Vials
Humulin® N Pen Humulin® R Pen
ReliOn N ReliOn R June/July
ENDOCRINE AND METABOLIC AGENTS: Insulins, Long-Acting
ENDOCRINE AND METABOLIC AGENTS: Insulins, Rapid-Acting
Humalog® Cartridge/Vial Novolog®
Cartridge/Pen/Vial
Afrezza® Cartridge Apidra® Solostar® Pen
Apidra® Vial Humalog 200 u/ml KwikPen®
Humalog KwikPen®
June/July
ENDOCRINE AND METABOLIC AGENTS: Antihyperglycemic, Insulin, Long Acting
Analog & GLP-1 Agonist
Soliqua® Xultophy®
June/July
ENDOCRINE AND METABOLIC AGENTS: Antihyperurecemic
Agents
Allopurinol Mitigare®
Probenecid Probenecid/Colchicine
Colchicine Caps/Tabs Colcrys® Duzallo® Uloric®
Zurampic® Zyloprim®
June/July
MO HealthNet Preferred Drug List Effective November 1, 2018
All Therapeutic Classes
The MO HealthNet Preferred Drug List is not all inclusive nor does it guarantee coverage, but represents a summary of prescription coverage. For full criteria details see https://dss.mo.gov/mhd/cs/pharmacy/pages/clinedit.htm
Page 18 of 24
PDL CLASS Preferred Drugs Non-Preferred Drugs Review
MO HealthNet Preferred Drug List Effective November 1, 2018
All Therapeutic Classes
The MO HealthNet Preferred Drug List is not all inclusive nor does it guarantee coverage, but represents a summary of prescription coverage. For full criteria details see https://dss.mo.gov/mhd/cs/pharmacy/pages/clinedit.htm
Page 19 of 24
PDL CLASS Preferred Drugs Non-Preferred Drugs Review
Date Prevacid® DR OTC Prevacid® Solutab
Prevacid® Susp Prilosec® Rx
Protonix® Rabeprazole Sodium
Zegerid® & OTC
GASTROINTESTINAL: Ulcerative Colitis
Agents, Oral
Balasalazide Delzicol® Lialda®
Sulfasalazine DR & IR
Apriso® Asacol HD®
Azulfidine EN® Azulfidine®
Budesonide (gen Uceris) Colazal®
Dipentum® Mesalamine (gen Asacol HD®)
Mesalamine (gen Lialda®) Pentasa® Uceris®
March/April
GASTROINTESTINAL: Ulcerative Colitis
Agents, Rectal
Canasa® Rect Supp Rowasa® Enema/Kit
Mesalamine Enema/Kit sfRowasa® Enema
Uceris® Foam March/April
HEMATOLOGICAL AGENTS:
Erythropoiesis Stimulating Agents
(ESAs)
Aranesp® Epogen® Procrit®
Mircera® Retacrit®
June/July
IMMUNOLOGIC AGENTS: Systemic
Immunomodulators, Cryopyrin-Associated
Periodic Syndrome (CAPS) Agents
Ilaris® Arcalyst®
June/July
IMMUNOLOGIC AGENTS: Targeted
Immune Modulators (Biologics/DMARDS)
Arava® Enbrel® Humira®
Leflunomide Ridaura®
Cosentyx®
Actemra® Benlysta® Cimzia® Entyvio® Ilumya™
Inflectra™ Kevzara® Kineret®
Oluminant® Orencia® & Clickjet®
Otezla® Remicade® Renflexis™
Siliq™ Simponi® & Aria®
June/July
MO HealthNet Preferred Drug List Effective November 1, 2018
All Therapeutic Classes
The MO HealthNet Preferred Drug List is not all inclusive nor does it guarantee coverage, but represents a summary of prescription coverage. For full criteria details see https://dss.mo.gov/mhd/cs/pharmacy/pages/clinedit.htm
Page 20 of 24
PDL CLASS Preferred Drugs Non-Preferred Drugs Review
MO HealthNet Preferred Drug List Effective November 1, 2018
All Therapeutic Classes
The MO HealthNet Preferred Drug List is not all inclusive nor does it guarantee coverage, but represents a summary of prescription coverage. For full criteria details see https://dss.mo.gov/mhd/cs/pharmacy/pages/clinedit.htm
Page 21 of 24
PDL CLASS Preferred Drugs Non-Preferred Drugs Review
MO HealthNet Preferred Drug List Effective November 1, 2018
All Therapeutic Classes
The MO HealthNet Preferred Drug List is not all inclusive nor does it guarantee coverage, but represents a summary of prescription coverage. For full criteria details see https://dss.mo.gov/mhd/cs/pharmacy/pages/clinedit.htm
Page 22 of 24
PDL CLASS Preferred Drugs Non-Preferred Drugs Review
MO HealthNet Preferred Drug List Effective November 1, 2018
All Therapeutic Classes
The MO HealthNet Preferred Drug List is not all inclusive nor does it guarantee coverage, but represents a summary of prescription coverage. For full criteria details see https://dss.mo.gov/mhd/cs/pharmacy/pages/clinedit.htm
Page 23 of 24
PDL CLASS Preferred Drugs Non-Preferred Drugs Review
Date
RESPIRATORY: Intranasal
Antihistamine
Azelastine Nasal
Astepro® Olopatadine Patanase®
March/April
RESPIRATORY: Intranasal Steroids
Fluticasone Nasacort® OTC
Beconase AQ® Budesonide Nasal
Dymista® Flonase Rx/OTC
Flonase® Sensimist™ Flunisolide
Fluticasone OTC Mometasone Furoate
Nasonex® Rx Omnaris®
Qnasl® Rhinocort Allergy OTC
Rhinocort AQ Sinuva™
Ticanase™ Triamcinolone Nasal
Triamcinolone Nasal OTC Xhance™ Zetonna®
March/April
RESPIRATORY: Leukotriene Receptor
Modifiers
Montelukast Tabs/Chew Montelukast Gran Pack
Accolate® Singulair® Gran Pak
Singulair® Tabs/Chew Zafirkulast
Zileuton ER Zyflo CR®
Zyflo®
March/April
RESPIRATORY: PAH-PPH Agents,
Prostacyclins, IV/SQ
Epoprostenol Flolan® Remodulin®
Veletri® Sept/Oct
RESPIRATORY: PAH-PPH Agents,
Prostacyclins, Inhaled
Ventavis® Tyvaso®
Sept/Oct
RESPIRATORY: PAH-PPH Agents,
Prostacyclins, Oral
Orenitram® ER Uptravi® Sept/Oct
RESPIRATORY: PAH-PPH Agents, ETRA
Letairis® Tracleer®
Opsumit® Sept/Oct
RESPIRATORY: PAH-PPH Agents, PDE5-I &
SGCS
Sildenafil Tabs Adcirca® Adempas®
Revatio® Tab/Inj
Sildenafil Inj Tadalafil
Sept/Oct
RESPIRATORY: Antihistamines, 2nd
Cetirizine OTC Tabs Cetirizine Rx Soln
Allegra® Allegra® ODT March/April
MO HealthNet Preferred Drug List Effective November 1, 2018
All Therapeutic Classes
The MO HealthNet Preferred Drug List is not all inclusive nor does it guarantee coverage, but represents a summary of prescription coverage. For full criteria details see https://dss.mo.gov/mhd/cs/pharmacy/pages/clinedit.htm
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PDL CLASS Preferred Drugs Non-Preferred Drugs Review