System Class Preferred Effective: January 1, 2017 Table 121‐0030‐1 Oregon Fee‐for‐Service Enforceable Physical Health Preferred Drug List Anaphylaxis Rescue Allergy/Cold EPINEPHRINE AUTO INJCT EPINEPHRINE (EPIPEN 2‐PAK ™) AUTO INJCT EPINEPHRINE (EPIPEN JR 2‐PAK ™) AUTO INJCT Antihistamines, Second Generation Allergy/Cold CETIRIZINE HCL SOLUTION *** CETIRIZINE HCL TABLET LORATADINE SOLUTION *** LORATADINE TAB RAPDIS *** LORATADINE TABLET Cough and Cold Allergy/Cold GUAIFENESIN ‡ GRAN PACK GUAIFENESIN ‡ LIQUID GUAIFENESIN ‡ SYRUP GUAIFENESIN ‡ TAB ER 12H GUAIFENESIN ‡ TABLET GUAIFENESIN ‡ TABLET ER GUAIFENESIN/CODEINE PHOSPHATE * LIQUID GUAIFENESIN/CODEINE PHOSPHATE * SYRUP GUAIFENESIN/CODEINE PHOSPHATE * TABLET GUAIFENESIN/DEXTROMETHORPHAN ‡ CAPSULE GUAIFENESIN/DEXTROMETHORPHAN ‡ DROPS GUAIFENESIN/DEXTROMETHORPHAN ‡ ELIXIR GUAIFENESIN/DEXTROMETHORPHAN ‡ GRAN PACK GUAIFENESIN/DEXTROMETHORPHAN ‡ LIQUID GUAIFENESIN/DEXTROMETHORPHAN ‡ LIQUID PKT GUAIFENESIN/DEXTROMETHORPHAN ‡ SYRUP GUAIFENESIN/DEXTROMETHORPHAN ‡ TAB ER 12H GUAIFENESIN/DEXTROMETHORPHAN ‡ TABLET GUAIFENESIN/DEXTROMETHORPHAN ‡ TBMP 12HR PSEUDOEPHEDRINE HCL ‡ CAPSULE PSEUDOEPHEDRINE HCL ‡ TABLET Nasal Allergy Inhalers Allergy/Cold FLUTICASONE PROPIONATE * SPRAY SUSP Analgesics, Topical Analgesics CAPSAICIN CREAM (G) Gout Analgesics ALLOPURINOL TABLET PROBENECID/COLCHICINE TABLET Muscle Relaxants, Oral Analgesics BACLOFEN TABLET CYCLOBENZAPRINE HCL TABLET *** TIZANIDINE HCL TABLET 1 Updated: December 27, 2016 * Drug coverage subject to meeting clinical prior authorization criteria ** Drug coverage subject to quantity limits *** Certain strengths may require Prior Authorization ‡ Age restricƟons apply
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System Class Preferred
Effective: January 1, 2017Table 121‐0030‐1 Oregon Fee‐for‐Service Enforceable Physical Health Preferred Drug List
Anaphylaxis RescueAllergy/Cold EPINEPHRINE AUTO INJCTEPINEPHRINE (EPIPEN 2‐PAK ™) AUTO INJCTEPINEPHRINE (EPIPEN JR 2‐PAK ™) AUTO INJCT
* Drug coverage subject to meeting clinical prior authorization criteria** Drug coverage subject to quantity limits*** Certain strengths may require Prior Authorization‡ Age restric ons apply
System Class Preferred
Effective: January 1, 2017Table 121‐0030‐1 Oregon Fee‐for‐Service Enforceable Physical Health Preferred Drug List
* Drug coverage subject to meeting clinical prior authorization criteria** Drug coverage subject to quantity limits*** Certain strengths may require Prior Authorization‡ Age restric ons apply
System Class Preferred
Effective: January 1, 2017Table 121‐0030‐1 Oregon Fee‐for‐Service Enforceable Physical Health Preferred Drug List
* Drug coverage subject to meeting clinical prior authorization criteria** Drug coverage subject to quantity limits*** Certain strengths may require Prior Authorization‡ Age restric ons apply
System Class Preferred
Effective: January 1, 2017Table 121‐0030‐1 Oregon Fee‐for‐Service Enforceable Physical Health Preferred Drug List
* Drug coverage subject to meeting clinical prior authorization criteria** Drug coverage subject to quantity limits*** Certain strengths may require Prior Authorization‡ Age restric ons apply
System Class Preferred
Effective: January 1, 2017Table 121‐0030‐1 Oregon Fee‐for‐Service Enforceable Physical Health Preferred Drug List
* Drug coverage subject to meeting clinical prior authorization criteria** Drug coverage subject to quantity limits*** Certain strengths may require Prior Authorization‡ Age restric ons apply
System Class Preferred
Effective: January 1, 2017Table 121‐0030‐1 Oregon Fee‐for‐Service Enforceable Physical Health Preferred Drug List
* Drug coverage subject to meeting clinical prior authorization criteria** Drug coverage subject to quantity limits*** Certain strengths may require Prior Authorization‡ Age restric ons apply
System Class Preferred
Effective: January 1, 2017Table 121‐0030‐1 Oregon Fee‐for‐Service Enforceable Physical Health Preferred Drug List
Calcium Channel Blockers ‐ Dihydropyridine, Oral
Cardiovascular AMLODIPINE BESYLATE TABLETNICARDIPINE HCL CAPSULENIFEDIPINE TAB ER 24NIFEDIPINE TABLET ER
Cardiovascular DILTIAZEM HCL CAP ER 12HDILTIAZEM HCL CAP ER 24HDILTIAZEM HCL CAP ER DEGDILTIAZEM HCL CAPSULE ERDILTIAZEM HCL TABLETVERAPAMIL HCL CAP24H PELVERAPAMIL HCL TABLETVERAPAMIL HCL TABLET ER
Combination Antihypertensives
Cardiovascular AMLODIPINE BES/OLMESARTAN MED TABLETBENAZEPRIL/HYDROCHLOROTHIAZIDE TABLETENALAPRIL/HYDROCHLOROTHIAZIDE TABLETLISINOPRIL/HYDROCHLOROTHIAZIDE TABLETLOSARTAN/HYDROCHLOROTHIAZIDE TABLETMETOPROLOL SUCCINATE/HCTZ TAB ER 24HOLMESARTAN/AMLODIPIN/HCTHIAZID TABLETOLMESARTAN/HYDROCHLOROTHIAZIDE TABLETTELMISARTAN/HYDROCHLOROTHIAZID TABLET
* Drug coverage subject to meeting clinical prior authorization criteria** Drug coverage subject to quantity limits*** Certain strengths may require Prior Authorization‡ Age restric ons apply
System Class Preferred
Effective: January 1, 2017Table 121‐0030‐1 Oregon Fee‐for‐Service Enforceable Physical Health Preferred Drug List
* Drug coverage subject to meeting clinical prior authorization criteria** Drug coverage subject to quantity limits*** Certain strengths may require Prior Authorization‡ Age restric ons apply
System Class Preferred
Effective: January 1, 2017Table 121‐0030‐1 Oregon Fee‐for‐Service Enforceable Physical Health Preferred Drug List
* Drug coverage subject to meeting clinical prior authorization criteria** Drug coverage subject to quantity limits*** Certain strengths may require Prior Authorization‡ Age restric ons apply
System Class Preferred
Effective: January 1, 2017Table 121‐0030‐1 Oregon Fee‐for‐Service Enforceable Physical Health Preferred Drug List
Gastrointestinal OMEPRAZOLE ** CAPSULE DRPANTOPRAZOLE SODIUM ** TABLET DR
10 Updated: December 27, 2016
* Drug coverage subject to meeting clinical prior authorization criteria** Drug coverage subject to quantity limits*** Certain strengths may require Prior Authorization‡ Age restric ons apply
System Class Preferred
Effective: January 1, 2017Table 121‐0030‐1 Oregon Fee‐for‐Service Enforceable Physical Health Preferred Drug List
Inflammatory Bowel DiseaseGastrointestinal BALSALAZIDE DISODIUM CAPSULEBUDESONIDE CAPDR ‐ ERMESALAMINE SUPP.RECTMESALAMINE (APRISO ™) CAP ER 24HMESALAMINE (LIALDA ™) TABLET DROLSALAZINE SODIUM CAPSULESULFASALAZINE TABLETSULFASALAZINE TABLET DR
11 Updated: December 27, 2016
* Drug coverage subject to meeting clinical prior authorization criteria** Drug coverage subject to quantity limits*** Certain strengths may require Prior Authorization‡ Age restric ons apply
System Class Preferred
Effective: January 1, 2017Table 121‐0030‐1 Oregon Fee‐for‐Service Enforceable Physical Health Preferred Drug List
Pancreatic EnzymesGastrointestinal LIPASE/PROTEASE/AMYLASE (CREON ™) CAPSULE DR
12 Updated: December 27, 2016
* Drug coverage subject to meeting clinical prior authorization criteria** Drug coverage subject to quantity limits*** Certain strengths may require Prior Authorization‡ Age restric ons apply
System Class Preferred
Effective: January 1, 2017Table 121‐0030‐1 Oregon Fee‐for‐Service Enforceable Physical Health Preferred Drug List
Benign Prostate Hypertrophy Drugs
Genito‐Urinary DOXAZOSIN MESYLATE TABLETFINASTERIDE TABLETTAMSULOSIN HCL CAP ER 24HTERAZOSIN HCL CAPSULE
ImmunoglobulinsImmunological GAMUNEX‐C ™ ‐ BRAND ONLY VIAL ***
13 Updated: December 27, 2016
* Drug coverage subject to meeting clinical prior authorization criteria** Drug coverage subject to quantity limits*** Certain strengths may require Prior Authorization‡ Age restric ons apply
System Class Preferred
Effective: January 1, 2017Table 121‐0030‐1 Oregon Fee‐for‐Service Enforceable Physical Health Preferred Drug List
* Drug coverage subject to meeting clinical prior authorization criteria** Drug coverage subject to quantity limits*** Certain strengths may require Prior Authorization‡ Age restric ons apply
System Class Preferred
Effective: January 1, 2017Table 121‐0030‐1 Oregon Fee‐for‐Service Enforceable Physical Health Preferred Drug List
* Drug coverage subject to meeting clinical prior authorization criteria** Drug coverage subject to quantity limits*** Certain strengths may require Prior Authorization‡ Age restric ons apply
System Class Preferred
Effective: January 1, 2017Table 121‐0030‐1 Oregon Fee‐for‐Service Enforceable Physical Health Preferred Drug List
Iron Replacement, OralNutritional FERROUS GLUCONATE TABLET ***FERROUS SULFATE ELIXIR ***FERROUS SULFATE LIQUIDFERROUS SULFATE TABLETFERROUS SULFATE TABLET DRFERROUS SULFATE TABLET ER ***IRON FUM, PS/FA/VIT C/L. CASEI POWD PACK
Multivitamins, OralNutritional BETA‐CAROTENE(A)‐VITS C,E/MINS * TABLETFOLIC ACID/VIT BCOMP,C * TABLETMULTIVIT,TX IRON,OTHER MINS * TABLETMULTIVITAMIN * TABLETMULTIVITAMIN WITH MINERALS/LUT * TABLETMULTIVITAMIN,THERAPEUTIC * TABLETMULTIVITAMIN/IRON/FOLIC ACID * TABLETMULTIVIT‐MIN/FA/LYCOPEN/LUTEIN * TABLETMV. MIN CMB#51/FA/VIT K1/UBI * TAB CHEWVITAMIN B COMPLEX * CAPSULE
Potassium and K‐Phos, OralNutritional NA PHOS,M‐B/K PHOS,MONOB TABLETPHOSPHORUS #1 TABLETPOT CHLORIDE/CAL PHOS/MAG TABLETPOTASSIUM TABLETPOTASSIUM BICARBONATE/CIT AC TABLET EFF ***POTASSIUM CHLORIDE TAB ER PRTPOTASSIUM CHLORIDE TABLET ERPOTASSIUM PHOSPHATE,MONOBASIC TABLET SOL
16 Updated: December 27, 2016
* Drug coverage subject to meeting clinical prior authorization criteria** Drug coverage subject to quantity limits*** Certain strengths may require Prior Authorization‡ Age restric ons apply
System Class Preferred
Effective: January 1, 2017Table 121‐0030‐1 Oregon Fee‐for‐Service Enforceable Physical Health Preferred Drug List
* Drug coverage subject to meeting clinical prior authorization criteria** Drug coverage subject to quantity limits*** Certain strengths may require Prior Authorization‡ Age restric ons apply
System Class Preferred
Effective: January 1, 2017Table 121‐0030‐1 Oregon Fee‐for‐Service Enforceable Physical Health Preferred Drug List
Prenatal VitaminsNutritional PRENAT VIT COMB.10/IRON/FA/DHA COMBO. PKGPRENATAL #103/IRON FUMARATE/FA TABLETPRENATAL #57/IRON/FA/DSS/DHA CAPSULEPRENATAL #79/IRON ASP GLY/FA#1 TABLETPRENATAL NO.13/IRON PS/FA CB#1 TAB CHEWPRENATAL NO.52/IRON/FA/DHA CAPSULEPRENATAL NO.75/IRON/FOLATE #1 TABLETPRENATAL NO.77/IRON ASP GLY/FA TABLETPRENATAL VIT #68/IRON/FA#6/DHA CAPSULEPRENATAL VIT #69/IRON/FA#6/DHA CAPSULEPRENATAL VIT #76/IRON,CARB/FA TABLETPRENATAL VIT 15/IRON CB/FA/DSS TABLETPRENATAL VIT 16/IRON CB/FA/DSS TABLETPRENATAL VIT COMB.10/IRON/FA TABLETPRENATAL VIT NO.112/FOLIC ACID TAB CHEWPRENATAL VIT NO.114/FA/GINGER TABLETPRENATAL VIT NO.127/IRON/FA TABLETPRENATAL VIT NO.73/IRON/FA TABLETPRENATAL VIT NO.87/IRON/FA/DHA CAPSULEPRENATAL VIT#4/IRON FUM,PS/FA CAPSULEPRENATAL VIT#65/IRON FUM,PS/FA CAPSULEPRENATAL VIT#84/IRON/FA#1/DHA CAPSULEPRENATAL VIT#85/IRON/FA#1/DHA CAPSULEPRENATAL VIT#86/IRON BISGLY/FA TABLETPRENATAL VIT27,CALCIUM/IRON/FA TABLETPRENATAL VIT37/IRON/FOLIC ACID TAB CHEWPRENATAL VITS #33/IRON/FA/DHA COMBO. PKGPRENATAL VITS#4/IRON FUM/FA CAPSULEPRENATAL#90/IRON FUM,PS/FA/DHA CAPSULEPRENATAL56/IRON/FOLIC ACID/DHA CAPSULEPV W‐O CAL/IRON PS CPLX/FA TAB CHEW
* Drug coverage subject to meeting clinical prior authorization criteria** Drug coverage subject to quantity limits*** Certain strengths may require Prior Authorization‡ Age restric ons apply
System Class Preferred
Effective: January 1, 2017Table 121‐0030‐1 Oregon Fee‐for‐Service Enforceable Physical Health Preferred Drug List
Antibiotic‐Steroids, Ophthalmic
Ophthalmics GENTAMICIN/PREDNISOL AC DROPS SUSPGENTAMICIN/PREDNISOL AC OINT. (G)NEO/POLYMYX B SULF/DEXAMETH DROPS SUSPNEO/POLYMYX B SULF/DEXAMETH OINT. (G)SULFACETM NA/PREDNISOL AC DROPS SUSPSULFACETM NA/PREDNISOL AC OINT. (G)TOBRAMYCIN/DEXAMETHASONE DROPS SUSPTOBRAMYCIN/DEXAMETHASONE OINT. (G)
* Drug coverage subject to meeting clinical prior authorization criteria** Drug coverage subject to quantity limits*** Certain strengths may require Prior Authorization‡ Age restric ons apply
System Class Preferred
Effective: January 1, 2017Table 121‐0030‐1 Oregon Fee‐for‐Service Enforceable Physical Health Preferred Drug List
* Drug coverage subject to meeting clinical prior authorization criteria** Drug coverage subject to quantity limits*** Certain strengths may require Prior Authorization‡ Age restric ons apply
System Class Preferred
Effective: January 1, 2017Table 121‐0030‐1 Oregon Fee‐for‐Service Enforceable Physical Health Preferred Drug List
Pulmonary Arterial Hypertension Oral and Inhaled Drugs
* Drug coverage subject to meeting clinical prior authorization criteria** Drug coverage subject to quantity limits*** Certain strengths may require Prior Authorization‡ Age restric ons apply
System Class Preferred
Effective: January 1, 2017Table 121‐0030‐1 Oregon Fee‐for‐Service Voluntary Mental Health Preferred Drug List
* Drug coverage subject to meeting clinical prior authorization criteria** Drug coverage subject to quantity limits*** Certain strengths may require Prior Authorization‡ Age restric ons apply
System Class Preferred
Effective: January 1, 2017Table 121‐0030‐1 Oregon Fee‐for‐Service Voluntary Mental Health Preferred Drug List
* Drug coverage subject to meeting clinical prior authorization criteria** Drug coverage subject to quantity limits*** Certain strengths may require Prior Authorization‡ Age restric ons apply