Louisiana Medicaid Preferred Drug List (PDL)/Non-Preferred Drug List (NPDL)
• The PDL applies to all individuals enrolled in Louisiana Medicaid, including those covered by one of the managed care organizations (MCOs)
and those in the Fee-for-Service (FFS) program.
• The PDL is a list of over 100 therapeutic classes reviewed by the Pharmaceutical & Therapeutics (P&T) committee. With the exception of
excluded drug classes listed in the provider manual, medications that are not included in this PDL are almost always covered without the
requirement of prior authorization. Examples: digoxin, hydrochlorothiazide, amoxicillin suspension
• To locate any medication on this list when searching electronically, you may use the keyboard shortcut CTRL + F to search.
• There is a mandatory generic substitution unless the brand is preferred, or when both the brand and generic are preferred.
• When the brand is non-preferred and the prescriber has determined it to be medically necessary, “Brand medically necessary” or “Brand necessary”
must be written on the prescription in the prescriber’s handwriting or noted via an electronic prescription and the pharmacist enters “1” in the DAW
field 408-D8. For more information, please refer to the Provider Manual.
• Medications listed as non-preferred are available through the prior authorization (PA) process. See chart below for PA contact information. All
MCOs and FFS use the same PA Request Form.
• Some medications require a diagnosis code at the pharmacy to indicate the condition treated or to override a limit, such as quantity, patient age,
or duration limit. These medications are found on the Diagnosis Code List.
• New medications in classes reviewed by P&T will be added as non-preferred and require prior authorization until the next P&T committee
meeting. Please refer to the following criteria: New Drugs Introduced into the Market / Non-Preferred
• This PDL/NPDL applies only to medications dispensed in the outpatient retail pharmacy setting.
• Requests for overrides to use a medication outside of established limits, such as diagnosis or quantity limits, can be made according to the:
Medically Necessary Policy
• Any statement highlighted and underlined in blue is a hyperlink to more information.
DIABETIC SUPPLY LIST
Effective 10/28/2023
Pharmacy Prior Authorization Information Phone Numbers for MCOs and FFS
Click this Link for
Diabetic Supplies
Preferred Drug List
MCOs: Aetna Better Health of Louisiana, AmeriHealth Caritas Louisiana, Healthy Blue, Humana, LA
Healthcare Connections, United Healthcare: contact
Magellan Medicaid Administration 1-800-424-1664
Fee-for-Service (FFS) Louisiana Legacy Medicaid 1-866-730-4357
LA Medicaid Preferred Drug List (PDL)/Non-Preferred Drug List (NPDL) Effective Date: July 1, 2024
Additional Point-of-Sale (POS) Edits May Apply Drugs highlighted in yellow indicate a new addition or a change in status Page | 1
Descriptive Therapeutic Class
Drugs on PDL
Drugs on NPDL which Require Prior Authorization (PA)
ACNE AGENTS, TOPICAL (1)
Clindamycin/Benzoyl Peroxide Gel (Generic for Benzaclin®)
Adapalene Cream (Generic for Differin®)
*Request Form
Clindamycin/Benzoyl Peroxide Gel (Generic for Duac®)
Adapalene Gel (AG; Generic)
*Criteria
Clindamycin Phosphate Gel (Generic)
Adapalene Gel Pump (Generic for Differin®)
*POS Edits
Clindamycin Phosphate Lotion (Generic)
Adapalene/Benzoyl Peroxide (Generic for Epiduo®)
Clindamycin Phosphate Medicated Swab (Generic)
Adapalene/Benzoyl Peroxide Gel with Pump (AG; Generic for Epiduo Forte®)
Clindamycin Phosphate Solution (Generic)
Adapalene/Benzoyl Peroxide/Clindamycin Gel (Cabtreo™)
Erythromycin Gel (AG; Generic)
Azelaic Acid (Azelex®)
Erythromycin Solution (Generic)
Clascoterone Cream (Winlevi®)
Tretinoin Cream (Generic; Retin-A®)
Clindamycin/Benzoyl Peroxide Gel with Pump (Generic; Acanya®)
Clindamycin/Benzoyl Peroxide Gel with Pump (Generic for Benzaclin®)
Clindamycin/Benzoyl Peroxide Gel with Pump (AG; Generic; Onexton®)
Clindamycin/Benzoyl Peroxide Gel, Gel/Emollient Combo 94 (Neuac®; Neuac® Kit)
Clindamycin Phosphate Foam (Generic)
Clindamycin Phosphate Gel (AG; Generic; Clindagel®)
Clindamycin Phosphate Lotion (Cleocin-T®)
Clindamycin Phosphate/Skin Cleanser 19 (Clindacin® Pac Kit)
Clindamycin/Tretinoin Gel (AG; Generic; Ziana®)
Dapsone Gel, Gel with Pump (AG; Generic; Aczone®)
Erythromycin Medicated Swab (Generic)
Erythromycin/Benzoyl Peroxide Gel (Generic; Benzamycin®)
Minocycline Topical Foam (Amzeeq™)
Sulfacetamide Sodium Cleanser ER (Ovace® Plus)
Sulfacetamide Sodium Cleanser, Cleanser ER (Generic)
Sulfacetamide Sodium Cream ER (Ovace® Plus)
Sulfacetamide Sodium Lotion (Ovace Plus®)
Sulfacetamide Sodium Shampoo (Generic; Ovace® Plus)
Sulfacetamide Sodium Suspension (Generic)
LA Medicaid Preferred Drug List (PDL)/Non-Preferred Drug List (NPDL) Effective Date: July 1, 2024
Additional Point-of-Sale (POS) Edits May Apply Drugs highlighted in yellow indicate a new addition or a change in status Page | 2
Descriptive Therapeutic Class
Drugs on PDL
Drugs on NPDL which Require Prior Authorization (PA)
ACNE AGENTS, TOPICAL (1) Continued
(Preferred agents listed on page 1)
Sulfacetamide Sodium Wash (Ovace® Plus)
Sulfacetamide Sodium/Sulfur Cream (Avar-e®; Avar-e Green®; Avar-e LS®)
Sulfacetamide Sodium/Sulfur (Generic)
Sulfacetamide Sodium/Sulfur Cleanser (Avar® LS)
Sulfacetamide Sodium/Sulfur Cleanser (Avar®, ZMA Clear®)
Sulfacetamide Sodium/Sulfur Cleanser (Generic)
Sulfacetamide Sodium/Sulfur Cream (Generic)
Sulfacetamide Sodium/Sulfur Foam (SSS 10-5®)
Sulfacetamide Sodium/Sulfur Lotion (Generic)
Sulfacetamide Sodium/Sulfur Medicated Pads (Generic)
Sulfacetamide Sodium/Sulfur Suspension (Generic)
Sulfacetamide Sodium/Sulfur Wash (BP 10-1®)
Sulfacetamide Sodium/Sulfur/Cleanser 23 Kit (Sumaxin® CP Kit)
Sulfacetamide Sodium/Sulfur/Urea Cleanser (Generic)
Tazarotene Cream (AG; Generic for Tazorac®)
Tazarotene Foam (AG; Fabior®)
Tazarotene Gel (Generic for Tazorac®)
Tazarotene Lotion (Arazlo™)
Tretinoin 0.04% & 0.1% Gel (AG; Retin-A® Micro)
Tretinoin 0.04% & 0.1% Gel with Pump (AG; Generic; Retin-A® Micro)
Tretinoin 0.06% Pump (Retin-A® Micro)
Tretinoin 0.08% Pump (Generic; Retin-A® Micro)
Tretinoin Gel (AG; Generic; Retin-A®)
Tretinoin Gel (Generic; Atralin®)
Tretinoin Lotion (Altreno®)
LA Medicaid Preferred Drug List (PDL)/Non-Preferred Drug List (NPDL) Effective Date: July 1, 2024
Additional Point-of-Sale (POS) Edits May Apply Drugs highlighted in yellow indicate a new addition or a change in status Page | 3
Descriptive Therapeutic Class
Drugs on PDL
Drugs on NPDL which Require Prior Authorization (PA)
ADD/ADHD (2)
Amphetamine Salt Combo ER Capsule (AG; Generic; Adderall XR®)
Amphetamine ODT (Adzenys XR ODT®)
Stimulants and Related Agents
Amphetamine Salt Combo Tablet (Generic; Adderall®)
Amphetamine Sulfate ODT (Evekeo® ODT)
*Request Form
Atomoxetine Capsule (Generic)
Amphetamine Sulfate Tablet (Generic; Evekeo®)
*Criteria
Dexmethylphenidate ER Capsule (AG; Generic)
Amphetamine Suspension, Tablet (Dyanavel XR®)
*POS Edits
Dexmethylphenidate Tablet (Generic)
Amphetamine/Dextroamphetamine XR Capsule (Mydayis®)
Dextroamphetamine Tablet (Generic)
Armodafinil Tablet (AG; Generic; Nuvigil®)
Guanfacine ER Tablet (Generic)
Atomoxetine Capsule (Strattera®)
Lisdexamfetamine Capsule (Generic; Vyvanse®)
Clonidine ER Tablet (Generic)
Lisdexamfetamine Chewable Tablet (Generic; Vyvanse®)
Dexmethylphenidate ER Capsule (Focalin XR®)
Methylphenidate CD Capsule (AG; Generic for Metadate CD®)
Dexmethylphenidate Tablet (Focalin®)
Methylphenidate ER Capsule (Generic for Ritalin LA®)
Dextroamphetamine IR Tablet (Zenzedi®)
Methylphenidate ER Chewable (QuilliChew ER®)
Dextroamphetamine Solution (Generic; ProCentra®)
Methylphenidate ER Suspension (Quillivant XR®)
Dextroamphetamine Sulfate ER Capsule (Generic; Dexedrine® Spansule®)
Methylphenidate ER Tablet (AG; Generic for Concerta®)
Dextroamphetamine Transdermal (Xelstrym®)
Methylphenidate IR Tablet (Generic)
Guanfacine ER Tablet (Intuniv®)
Methylphenidate Solution (Generic)
Methamphetamine Tablet (Generic; Desoxyn®)
Modafinil Tablet (Generic)
Methylphenidate ER Capsule (AG; Generic; Aptensio XR®)
Methylphenidate ER Capsule (Jornay PM®, Ritalin LA®)
Methylphenidate ER Tablet (Concerta®)
Methylphenidate ER Tablet (Generic for Metadate ER)
Methylphenidate ER Tablet 72 mg (AG; Generic; Relexxii™)
Methylphenidate IR Chewable Tablet (Generic)
Methylphenidate IR Tablet (Ritalin®)
Methylphenidate Solution (Methylin®)
Methylphenidate Transdermal Patch (AG; Generic; Daytrana®)
Methylphenidate XR ODT (Cotempla XR ODT®)
Modafinil Tablet (Provigil®)
Pitolisant HCl Tablet (Wakix®)
Serdexmethylphenidate/Dexmethylphenidate Capsule (Azstarys™)
Solriamfetol HCl Tablet (Sunosi™)
Viloxazine ER Capsule (Qelbree™)
LA Medicaid Preferred Drug List (PDL)/Non-Preferred Drug List (NPDL) Effective Date: July 1, 2024
Additional Point-of-Sale (POS) Edits May Apply Drugs highlighted in yellow indicate a new addition or a change in status Page | 4
Descriptive Therapeutic Class
Drugs on PDL
Drugs on NPDL which Require Prior Authorization (PA)
ALLERGY (3)
Cetirizine 1 mg/mL Solution OTC, Tablet OTC (Generic)
Cetirizine Capsule OTC, Chewable Tablet OTC, 5 mg/5mL Solution OTC (Generic)
Antihistamines – Minimally Sedating
Cetirizine Solution RX (1 mg/mL) (Generic)
Desloratadine ODT (Generic)
*Request Form
Cetirizine-D Tablet OTC (Generic)
Desloratadine Tablet (Generic; Clarinex®)
*Criteria
Levocetirizine Tablet (Generic)
Desloratadine/Pseudoephedrine ER Tablet (Clarinex-D 12-Hour®)
*POS Edits
Levocetirizine Tablet OTC (Generic)
Fexofenadine 60 mg Tablet OTC, 180 mg Tablet OTC, Suspension OTC (Generic)
Loratadine ODT OTC, Solution OTC, Tablet OTC (Generic)
Fexofenadine-D 12-hour Tablet OTC, 24-hour Tablet OTC (Generic)
Loratadine-D Tablet OTC (Generic)
Levocetirizine Solution (Generic)
Loratadine Chewable Tablet OTC (Generic)
ALLERGY (3)
Azelastine Nasal Spray (AG; Generic for Astepro®)
Azelastine/Fluticasone Nasal Spray (AG; Generic; Dymista®)
Rhinitis Agents, Nasal
Azelastine Nasal Spray (Generic for Astelin®)
Beclomethasone Nasal Spray (Beconase AQ®; Qnasl 40®; Qnasl 80®)
*Request Form
Fluticasone Propionate Nasal Spray (Generic)
Ciclesonide Nasal Spray (Omnaris®; Zetonna®)
*Criteria
Ipratropium Bromide Nasal Spray (Generic)
Flunisolide Nasal Spray (Generic)
*POS Edits
Fluticasone Propionate Nasal Spray (Xhance®)
Mometasone Furoate Implant (Sinuva™)
Mometasone Nasal Spray (Generic)
Olopatadine Nasal Spray (AG; Generic; Patanase®)
Olopatadine/Mometasone Nasal Spray (Ryaltris®)
ALZHEIMER’S AGENTS (4)
Donepezil ODT, Tablet (Generic)
Aducanumab-avwa IV Solution (Aduhelm™)
Cholinesterase Inhibitors
Memantine Tablet (AG; Generic)
Donepezil 23 mg Tablet (Generic)
*Request Form
Rivastigmine Transdermal Patch (AG; Generic)
Donepezil Tablet (Aricept®)
*Criteria
Donepezil Transdermal Patch (Adlarity®)
*POS Edits
Galantamine ER Capsule, Solution, Tablet (Generic)
Lecanemab-irmb (Leqembi™)
*Aduhelm™ REQUEST FORM
Memantine ER Capsule (AG; Generic; Namenda XR®)
* Leqembi™ REQUEST FORM
Memantine ER Capsule Dose Pack (Namenda XR® Titration Pack)
Memantine Solution (Generic)
Memantine Tablet (Namenda®)
Memantine Tablet Dose Pack (AG; Namenda® Titration Pack)
Memantine/Donepezil ER Capsule (Namzaric®, Namzaric® Titration Pack)
Rivastigmine Capsule (Generic)
Rivastigmine Transdermal Patch (Exelon®)
LA Medicaid Preferred Drug List (PDL)/Non-Preferred Drug List (NPDL) Effective Date: July 1, 2024
Additional Point-of-Sale (POS) Edits May Apply Drugs highlighted in yellow indicate a new addition or a change in status Page | 5
Descriptive Therapeutic Class
Drugs on PDL
Drugs on NPDL which Require Prior Authorization (PA)
ANDROGENIC AGENTS (5)
Testosterone Gel (AG; Generic for Vogelxo®)
Testosterone Gel (Testim®)
*Request Form
Testosterone Gel Packet (AG for Vogelxo®)
Testosterone Gel Packet (Generic for Androgel®)
*Criteria
Testosterone Gel Pump (AG; Generic for Vogelxo®)
Testosterone Gel Pump (AG; Generic; Fortesta®)
*POS Edits
Testosterone Gel Pump (Generic for Androgel®)
Testosterone Gel Pump (Androgel®)
Testosterone Transdermal System (Androderm®)
Testosterone Gel Pump (Generic Axiron®)
Testosterone Gel Pump (Vogelxo®)
Testosterone Nasal (Natesto®)
ANTHELMINTICS (6)
Albendazole Tablet (Generic)
Ivermectin Tablet (Stromectol®)
*Request Form
Ivermectin Tablet (Generic)
Praziquantel Tablet (Biltricide®)
*Criteria
Mebendazole Chewable Tablet (Emverm®)
*POS Edits
Praziquantel Tablet (Generic)
ANTI-ALLERGENS, ORAL (7)
NONE
Grass Pollen Allergen Extract [Timothy Grass] Sublingual Tablet (Grastek®)
*Request Form
House Dust Mite Allergen Extract Sublingual Tablet (Odactra®)
*Criteria
Mixed Grass Allergen Extracts Sublingual Tablet (Oralair®)
*POS Edits
Peanut Allergen Maintenance Sachet (Palforzia®)
Peanut Allergen Titration Capsule (Palforzia®)
Ragweed Pollen Allergen Extract Sublingual Tablet (Ragwitek®)
ANTICONVULSANTS (8)
Brivaracetam Solution, Tablet (Briviact®)
Carbamazepine ER Capsule (Equetro®)
*Request Form
Cannabidiol Solution (Epidiolex®)
Carbamazepine Suspension (Generic; Tegretol®)
*Criteria
Carbamazepine Chewable Tablet (Generic)
Carbamazepine Tablet (Tegretol®)
*POS Edits
Carbamazepine ER Capsule (Generic; Carbatrol®)
Clobazam Film (Sympazan®)
Carbamazepine ER Tablet (AG; Generic; Tegretol® XR)
Clobazam Suspension, Tablet (Onfi®)
Carbamazepine Tablet (Generic)
Clonazepam Tablet (Klonopin®)
Cenobamate Daily Dose Pack, Tablet, Titration Pack (Xcopri®)
Divalproex Sodium DR Tablet, ER Tablet (Depakote®; Depakote® ER)
Clobazam Suspension, Tablet (Generic)
Ethosuximide Capsule, Syrup (Zarontin®)
Clonazepam ODT, Tablet (Generic)
Felbamate Suspension (Felbatol®)
Diazepam Nasal Spray (Valtoco®)
Fenfluramine Solution (Fintepla®)
Diazepam Rectal (AG; Diastat®)
Lacosamide ER Capsule (Motpoly XR™)
LA Medicaid Preferred Drug List (PDL)/Non-Preferred Drug List (NPDL) Effective Date: July 1, 2024
Additional Point-of-Sale (POS) Edits May Apply Drugs highlighted in yellow indicate a new addition or a change in status Page | 6
Descriptive Therapeutic Class
Drugs on PDL
Drugs on NPDL which Require Prior Authorization (PA)
ANTICONVULSANTS (8) Continued
Diazepam Rectal Device (AG; Diastat® AcuDial™)
Lacosamide Solution, Tablet (Vimpat®)
Divalproex DR Tablet (Generic)
Lamotrigine Dispersible Tablet, ODT, Tablet (Lamictal®)
Divalproex ER Tablet (Generic)
Lamotrigine ODT Titration Kit, Tablet Starter Kit (Generic; Lamictal®)
Divalproex Sodium DR Sprinkle (Generic; Depakote® Sprinkles)
Lamotrigine ER Tablet, Titration Kit (Lamictal® XR)
Eslicarbazepine Acetate Tablet (Aptiom®)
Levetiracetam ER Tablet (Keppra XR®)
Ethosuximide Capsule (AG; Generic)
Levetiracetam Tablet for Oral Suspension (Spritam®)
Ethosuximide Syrup (Generic)
Levetiracetam Solution, Tablet (Keppra®)
Felbamate Suspension (Generic)
Levetiracetam ER Tablet (Elepsia™ XR)
Felbamate Tablet (Generic; Felbatol®)
Oxcarbazepine Tablet (Trileptal®)
Lacosamide Solution, Tablet (Generic)
Phenytoin 100mg Capsule (Dilantin®)
Lamotrigine Dispersible Tablet, ER Tablet, ODT, Tablet (Generic)
Phenytoin Chewable Tablet (Dilantin® Infatabs®)
Levetiracetam ER Tablet, Solution, Tablet (Generic)
Phenytoin Sodium Capsule (Phenytek®)
Methsuximide Capsule (Celontin®)
Phenytoin Suspension (Dilantin®)
Midazolam Nasal Spray (Nayzilam®)
Primidone Tablet (Mysoline®)
Oxcarbazepine Suspension (Generic; Trileptal®)
Tiagabine Tablet (Generic; Gabitril®)
Oxcarbazepine Tablet (Generic)
Topiramate ER Capsule (Generic; Qudexy® XR)
Oxcarbazepine XR Tablet (Oxtellar XR®)
Topiramate Solution (Eprontia™)
Perampanel Suspension, Tablet (Fycompa®)
Topiramate Sprinkle, Tablet (Topamax®)
Phenobarbital Elixir, Tablet (Generic)
Zonisamide Suspension (Zonisade™)
Phenytoin 100mg Capsule (Generic)
Phenytoin 30 mg Capsule (Dilantin®)
Phenytoin Chewable Tablet (Generic)
Phenytoin Sodium Capsule (Generic for Phenytek®)
Phenytoin Suspension (AG; Generic)
Primidone Tablet (Generic)
Rufinamide Suspension, Tablet (Generic; Banzel®)
Stiripentol Capsule, Powder Pack (Diacomit®)
Topiramate ER Capsule (AG for Qudexy® XR)
Topiramate ER Capsule (Generic; Trokendi XR®)
Topiramate Sprinkle, Tablet (Generic)
Valproic Acid Capsule, Solution (Generic)
Vigabatrin Powder Pack, Tablet (Generic; Sabril®; Vigadrone®)
Zonisamide Capsule (Generic)
LA Medicaid Preferred Drug List (PDL)/Non-Preferred Drug List (NPDL) Effective Date: July 1, 2024
Additional Point-of-Sale (POS) Edits May Apply Drugs highlighted in yellow indicate a new addition or a change in status Page | 7
Descriptive Therapeutic Class
Drugs on PDL
Drugs on NPDL which Require Prior Authorization (PA)
ANTIPSYCHOTIC AGENTS (9)
ORAL AGENTS
ORAL AGENTS
Antipsychotic Oral/Transdermal Agents
Aripiprazole Tablet (Generic)
Aripiprazole ODT, Solution (Generic)
*Request Form
Cariprazine Capsule, Therapy Pack (Vraylar®)
Aripiprazole Tablet, Tablet with Sensor (Abilify®; Abilify® Mycite®)
*Criteria
Chlorpromazine Oral Concentrate, Tablet (Generic)
Asenapine Sublingual Tablet (AG; Generic; Saphris®)
*POS Edits
Clozapine Tablet (Generic)
Asenapine Transdermal Patch (Secuado®)
Fluphenazine Tablet (Generic)
Brexpiprazole Tablet (Rexulti®)
Haloperidol Lactate Oral Concentrate (Generic)
Clozapine ODT (Generic)
Haloperidol Tablet (Generic)
Clozapine Suspension (Versacloz®)
Loxapine Capsule (Generic)
Clozapine Tablet (Clozaril®)
Lurasidone Tablet (Generic)
Fluphenazine Elixir/Solution (Generic)
Olanzapine ODT, Tablet (Generic)
Iloperidone Tablet, Titration Pack (Fanapt®)
Perphenazine Tablet (Generic)
Loxapine Inhalation (Adasuve®)
Perphenazine/Amitriptyline Tablet (Generic)
Lumateperone Capsule (Caplyta™)
Pimozide Tablet (Generic)
Lurasidone Tablet (Latuda®)
Quetiapine ER Tablet (Generic)
Molindone Tablet (Generic)
Quetiapine Tablet (Generic)
Olanzapine Tablet, ODT (Zyprexa®; Zyprexa Zydis®)
Risperidone Solution, Tablet (Generic)
Olanzapine/Fluoxetine Capsule (Generic; Symbyax®)
Thioridazine Tablet (Generic)
Olanzapine/Samidorphan Tablet (Lybalvi™)
Thiothixene Capsule (Generic)
Paliperidone ER Tablet (AG; Generic; Invega®)
Trifluoperazine Tablet (Generic)
Pimavanserin Capsule, Tablet (Nuplazid®)
Ziprasidone Capsule (AG; Generic)
Quetiapine ER Tablet, Tablet (Seroquel XR®; Seroquel®)
Risperidone ODT (Generic)
Risperidone Solution, Tablet (Risperdal®)
Ziprasidone Capsule (Geodon®)
LA Medicaid Preferred Drug List (PDL)/Non-Preferred Drug List (NPDL) Effective Date: July 1, 2024
Additional Point-of-Sale (POS) Edits May Apply Drugs highlighted in yellow indicate a new addition or a change in status Page | 8
Descriptive Therapeutic Class
Drugs on PDL
Drugs on NPDL which Require Prior Authorization (PA)
ANTIPSYCHOTIC AGENTS (9)
INJECTABLE AGENTS
INJECTABLE AGENTS
Antipsychotic Injectable Agents
Aripiprazole Lauroxil (Aristada®; Aristada® Initio®)
Chlorpromazine Ampule (Generic)
*Request Form
Aripiprazole Suspension ER (Abilify Asimtufii®/Maintena®)
Fluphenazine Vial (Generic)
*Criteria
Fluphenazine Decanoate (Generic)
Haloperidol Decanoate Ampule (Haldol®)
*POS Edits
Haloperidol Decanoate, Lactate (Generic)
Olanzapine Solution (Generic; Zyprexa®)
Paliperidone (Invega® Hafyera™/Sustenna®/Trinza®)
Olanzapine Suspension (Zyprexa® Relprevv®)
Risperidone ER Suspension (Intramuscular) (Risperdal® Consta®)
Risperidone ER Suspension (Intramuscular) (Rykindo®)
Risperidone ER Suspension (Subcutaneous) (Perseris®; Uzedy)
Ziprasidone Vial (Generic; Geodon®)
ANTIVIRALS, ORAL (10)
Acyclovir Capsule, Suspension, Tablet (Generic)
Acyclovir Buccal Tablet (Sitavig®)
*Request Form
Famciclovir Tablet (Generic)
Baloxavir Marboxil Tablet (Xofluza®)
*Criteria
Oseltamivir Capsule, Suspension (Generic)
Oseltamivir Capsule, Suspension (Tamiflu®)
*POS Edits
Valacyclovir Tablet (Generic)
Rimantadine Tablet (Generic)
Valacyclovir Caplet (Valtrex®)
Zanamivir Inhalation Powder (Relenza® Diskhaler®)
ANXIOLYTICS (11)
Alprazolam Tablet (Generic)
Alprazolam ER Tablet (Generic; Xanax XR®)
*Request Form
Buspirone Tablet (Generic)
Alprazolam Intensol Concentrate, ODT (Generic)
*Criteria
Lorazepam Tablet (Generic)
Alprazolam Tablet (Xanax®)
*POS Edits
Chlordiazepoxide Capsule (Generic)
Clorazepate Dipotassium Tablet (Generic)
Diazepam Intensol Concentrate, Solution, Syringe, Tablet, Vial (Generic)
Lorazepam ER Capsule (Loreev XR™)
Lorazepam Intensol Concentrate (Generic)
Lorazepam Tablet (Ativan®)
Meprobamate Tablet (Generic)
Oxazepam Capsule (Generic)
LA Medicaid Preferred Drug List (PDL)/Non-Preferred Drug List (NPDL) Effective Date: July 1, 2024
Additional Point-of-Sale (POS) Edits May Apply Drugs highlighted in yellow indicate a new addition or a change in status Page | 9
Descriptive Therapeutic Class
Drugs on PDL
Drugs on NPDL which Require Prior Authorization (PA)
ASTHMA/COPD (12)
INHALATION
INHALATION
Bronchodilator, Anticholinergics (COPD)
Inhalation
Ipratropium Inhalation Aerosol MDI (Atrovent HFA®)
Aclidinium Bromide/Formoterol Fumarate (Duaklir® Pressair®)
Ipratropium Nebulizer Solution (Generic)
Aclidinium Bromide Inhalation Powder (Tudorza® Pressair®)
*Request Form
Ipratropium/Albuterol Sulfate (Combivent® Respimat®)
Glycopyrrolate/Formoterol Fumarate (Bevespi Aerosphere®)
*Criteria
Ipratropium/Albuterol Sulfate Nebulizer Solution (Generic)
Revefenacin Inhalation Solution (Yupelri®)
*POS Edits
Tiotropium Inhalation Powder (Generic; Spiriva® HandiHaler®)
Tiotropium Bromide Inhalation Spray (Spiriva® Respimat®)
Tiotropium/Olodaterol (Stiolto® Respimat®)
Umeclidinium Inhalation Powder (Incruse® Ellipta®)
Umeclidinium/Vilanterol Inhalation Powder (Anoro® Ellipta®)
ASTHMA/COPD (12)
ORAL
ORAL
Bronchodilator, Anticholinergics (COPD)
Oral
Roflumilast Tablet (Generic)
Roflumilast Tablet (Daliresp®)
*Request Form
*Criteria
*POS Edits
ASTHMA/COPD (12)
INHALATION
INHALATION
Bronchodilator, Beta-Adrenergic
Inhalation/Oral Agents
Albuterol Sulfate Nebulizer Solution 0.63 mg/3 mL (AG; Generic)
Albuterol Sulfate ER Tablet, Syrup, Tablet (Generic)
Albuterol Sulfate Nebulizer Solution 1.25 mg/3 mL (AG; Generic)
Albuterol Sulfate Inhalation Powder (ProAir® Digihaler™)
*Request Form
Albuterol Sulfate Nebulizer Solution 2.5 mg/3 mL (Generic)
Albuterol Sulfate Inhalation Powder (ProAir® RespiClick®)
*Criteria
Albuterol Sulfate Nebulizer Solution 100 mg/20 mL (Generic)
Arformoterol Inhalation Solution (AG; Generic; Brovana®)
*POS Edits
Albuterol Sulfate Nebulizer Solution 2.5 mg/0.5 mL (Generic)
Formoterol Inhalation Solution (AG; Generic; Perforomist®)
Albuterol Sulfate MDI (AG; Generic; ProAir HFA®)
Levalbuterol Nebulizer Solution (Generic)
Albuterol Sulfate MDI (AG; Generic; Proventil HFA®)
Levalbuterol Nebulizer Solution Concentrate (Generic)
Albuterol Sulfate MDI (AG; Ventolin HFA®)
Levalbuterol MDI (AG; Xopenex HFA®)
Salmeterol Xinafoate (Serevent® Diskus®)
Olodaterol (Striverdi® Respimat®)
Terbutaline Sulfate Tablet (AG; Generic)
LA Medicaid Preferred Drug List (PDL)/Non-Preferred Drug List (NPDL) Effective Date: July 1, 2024
Additional Point-of-Sale (POS) Edits May Apply Drugs highlighted in yellow indicate a new addition or a change in status Page | 10
Descriptive Therapeutic Class
Drugs on PDL
Drugs on NPDL which Require Prior Authorization (PA)
ASTHMA/COPD (12)
Budesonide Respules 0.25 mg, 0.5 mg, 1 mg (Generic)
Albuterol/Budesonide (AirSupra HFA®)
Glucocorticoids, Inhalation
Budesonide/Formoterol MDI (AG; Generic; Symbicort®)
Beclomethasone Breath-Actuated HFA (QVAR® RediHaler®)
*Request Form
Fluticasone Furoate Inhalation Powder (Arnuity Ellipta®)
Budesonide DPI (Pulmicort® Flexhaler®)
*Criteria
Fluticasone MDI (AG; Flovent® HFA)
Budesonide Respules 0.25 mg, 0.5 mg, 1 mg (Pulmicort® Respules®)
*POS Edits
Fluticasone/Salmeterol DPI (AG; Generic; Advair® Diskus®)
Budesonide/Glycopyrrolate/Formoterol Inhalation (Breztri Aerosphere™)
Fluticasone/Salmeterol DPI (Wixela Inhub®)
Ciclesonide MDI (Alvesco®)
Fluticasone/Salmeterol MDI (AG; Advair HFA®)
Fluticasone Propionate Inhalation Powder (Armonair® Digihaler™)
Fluticasone/Umeclidinium/Vilanterol Inh Powder (Trelegy Ellipta®)
Fluticasone Propionate Inhalation Powder (Flovent® Diskus®)
Mometasone Inhalation Powder (Asmanex® Twisthaler®)
Fluticasone/Salmeterol Inhalation Powder (AG; AirDuo® RespiClick®)
Mometasone/Formoterol MDI (Dulera®)
Fluticasone/Salmeterol Inhalation Powder (AirDuo® Digihaler™)
Fluticasone/Vilanterol Inhalation Powder (AG; Breo Ellipta®)
Mometasone Furoate MDI (Asmanex HFA®)
ASTHMA/COPD (12)
Benralizumab Pen (Fasenra®)
Mepolizumab Auto-Injector (Nucala®)
Immunomodulators
Benralizumab Syringe (Fasenra®)
Mepolizumab Syringe (Nucala®)
*Request Form
Omalizumab Syringe (Xolair®)
Mepolizumab Vial (Nucala®)
*Criteria
Omalizumab Vial (Xolair®)
Reslizumab Vial (Cinqair®)
*POS Edits
Tezepelumab-ekko Syringe, Pen (Tezspire™)
ASTHMA/COPD (12)
Montelukast Chewable Tablet (Generic)
Montelukast Chewable Tablet, Tablet (Singulair®)
Leukotriene Modifiers
Montelukast Tablet (Generic)
Montelukast Granules (Generic; Singulair®)
*Request Form
Zafirlukast Tablet (AG; Generic; Accolate®)
*Criteria
Zileuton ER Tablet (Generic)
*POS Edits
Zileuton Tablet (Zyflo®)
LA Medicaid Preferred Drug List (PDL)/Non-Preferred Drug List (NPDL) Effective Date: July 1, 2024
Additional Point-of-Sale (POS) Edits May Apply Drugs highlighted in yellow indicate a new addition or a change in status Page | 11
Descriptive Therapeutic Class
Drugs on PDL
Drugs on NPDL which Require Prior Authorization (PA)
BOTULINUM TOXINS (13)
AbobotulinumtoxinA (Dysport®)
IncobotulinumtoxinA (Xeomin®)
*Request Form
OnabotulinumtoxinA (Botox®)
RimabotulinumtoxinB (Myobloc®)
*Criteria
*POS Edits
COLONY STIMULATING
FACTORS (14)
Filgrastim Syringe, Vial (Neupogen®)
Eflapegrastim-xnst Syringe (Rolvedon™)
Pegfilgrastim-pbbk Syringe (Fylnetra®)
Filgrastim-aafi Syringe, Vial (Nivestym®)
*Request Form
Filgrastim-ayow Syringe, Vial (Releuko®)
*Criteria
Filgrastim-sndz Syringe (Zarxio®)
*POS Edits
Pegfilgrastim Kit, Syringe (Neulasta®)
Pegfilgrastim-apgf Syringe (Nyvepria®)
Pegfilgrastim-bmez Syringe (Ziextenzo®)
Pegfilgrastim-cbqv Autoinjector; Syringe (Udenyca®)
Pegfilgrastim-fpgk Syringe (Stimufend®)
Pegfilgrastim-jmdb Syringe (Fulphila®)
Sargramostim Vial (Leukine®)
Tbo-Filgrastim Injection Syringe, Vial (Granix®)
CYSTIC FIBROSIS, ORAL (15)
NONE
Elexacaftor/Tezacaftor/Ivacaftor Packet, Tablet (Trikafta®)
*Request Form
Ivacaftor Packet, Tablet (Kalydeco®)
*Criteria
Lumacaftor/Ivacaftor Packet, Tablet (Orkambi®)
*POS Edits
Mannitol Inhalation Capsule (Bronchitol®)
Tezacaftor/Ivacaftor Tablet (Symdeko®)
LA Medicaid Preferred Drug List (PDL)/Non-Preferred Drug List (NPDL) Effective Date: July 1, 2024
Additional Point-of-Sale (POS) Edits May Apply Drugs highlighted in yellow indicate a new addition or a change in status Page | 12
Descriptive Therapeutic Class
Drugs on PDL
Drugs on NPDL which Require Prior Authorization (PA)
DEPRESSION (16)
Bupropion HCl IR Tablet (Generic)
Brexanolone IV Solution (Zulresso™)
Antidepressants, Other
Bupropion HCl SR 12-Hour Tablet (Generic)
Bupropion HBr ER 24-Hour Tablet (Aplenzin®)
*Request Form
Bupropion HCl XL 24-Hour Tablet (Generic)
Bupropion HCl SR 12-Hour (Wellbutrin SR®)
*Criteria
Mirtazapine ODT (Generic)
Bupropion HCl XL (AG; Forfivo XL®)
*POS Edits
Mirtazapine Tablet (Generic)
Bupropion HCl XL 24-Hour (Wellbutrin XL®)
Trazodone Tablet (Generic)
Desvenlafaxine ER (No Brand)
Venlafaxine ER Capsule (Generic)
Desvenlafaxine Succinate ER Tablet (AG; Generic; Pristiq®)
Venlafaxine IR Tablet (Generic)
Dextromethorphan/Bupropion Tablet (Auvelity™)
Esketamine Nasal Spray (Spravato®)
Isocarboxazid Tablet (Marplan®)
Levomilnacipran ER Capsule, Titration Pack (Fetzima®)
Mirtazapine ODT, Tablet (Remeron® ODT; Remeron®)
Nefazodone Tablet (Generic)
Phenelzine Tablet (Generic, Nardil®)
Selegiline Transdermal Patch (Emsam®)
Tranylcypromine Sulfate Tablet (Generic)
Venlafaxine Besylate ER Tablet (Generic)
Venlafaxine ER Capsule (Effexor XR®)
Venlafaxine ER Tablet (AG; Generic)
Vilazodone Dose Pack (Viibryd® Starter Pack)
Vilazodone Tablet (AG; Generic; Viibryd®)
Vortioxetine Tablet (Trintellix®)
Zuranolone Capsule (Zurzuvae™)
LA Medicaid Preferred Drug List (PDL)/Non-Preferred Drug List (NPDL) Effective Date: July 1, 2024
Additional Point-of-Sale (POS) Edits May Apply Drugs highlighted in yellow indicate a new addition or a change in status Page | 13
Descriptive Therapeutic Class
Drugs on PDL
Drugs on NPDL which Require Prior Authorization (PA)
DEPRESSION (16)
Citalopram Solution, Tablet (Generic)
Citalopram Capsule (Generic)
Selective Serotonin Reuptake Inhibitors
(SSRIs)
Escitalopram Tablet (Generic)
Citalopram Tablet (Celexa®)
Fluoxetine Capsule, Solution (Generic)
Escitalopram Solution (Generic)
*Request Form
Fluvoxamine Maleate Tablet (Generic)
Escitalopram Tablet (Lexapro®)
*Criteria
Paroxetine Tablet (Generic)
Fluoxetine Capsule (Prozac®)
*POS Edits
Sertraline Concentrate, Tablet (Generic)
Fluoxetine Delayed Release Capsule, Tablet, 60mg Tablet (Generic)
Fluvoxamine Maleate ER Capsule (Generic)
Paroxetine Suspension (Generic; Paxil®)
Paroxetine Tablet (Paxil®)
Paroxetine CR Tablet (AG; Generic; Paxil CR®)
Paroxetine Mesylate Capsule (AG; Generic for Brisdelle®)
Paroxetine Mesylate Tablet (Pexeva®)
Sertraline Capsule (Generic)
Sertraline Concentrate, Tablet (Zoloft®)
DERMATOLOGY (17)
Mupirocin Ointment (Generic)
Gentamicin Sulfate Cream, Ointment (Generic)
Antibiotics, Topical
Mupirocin Cream (Generic)
*Request Form
Mupirocin Ointment (Centany® Kit)
*Criteria
Ozenoxacin Cream (Xepi®)
*POS Edits
DERMATOLOGY (17)
Clotrimazole Rx Cream (Generic)
Ciclopirox Cream, Gel, 8% Solution (Generic)
Antifungals, Topical
Clotrimazole Rx Solution (Generic)
Ciclopirox 0.77% Suspension (AG; Generic)
*Request Form
Clotrimazole/Betamethasone Cream (Generic)
Ciclopirox Shampoo (Generic for Loprox®)
*Criteria
Ketoconazole Cream (Generic)
Ciclopirox 8% Solution Treatment Kit (Generic)
*POS Edits
Ketoconazole Shampoo Rx (Generic)
Ciclopirox/Skin Cleanser No. 40 (Loprox® Kit)
Nystatin Cream, Ointment, Topical Powder (Generic)
Clotrimazole/Betamethasone Lotion (Generic)
Nystatin/Triamcinolone Cream (Generic)
Econazole Nitrate Cream (Generic)
Nystatin/Triamcinolone Ointment (Generic)
Efinaconazole Solution (Jublia®)
Ketoconazole Foam (AG; Generic for Extina®)
LA Medicaid Preferred Drug List (PDL)/Non-Preferred Drug List (NPDL) Effective Date: July 1, 2024
Additional Point-of-Sale (POS) Edits May Apply Drugs highlighted in yellow indicate a new addition or a change in status Page | 14
Descriptive Therapeutic Class
Drugs on PDL
Drugs on NPDL which Require Prior Authorization (PA)
DERMATOLOGY (17)
(Preferred agents listed on page 13)
Ketoconazole Foam; Foam Kit (Ketodan®)
Antifungals, Topical Continued
Luliconazole Cream (AG; Luzu®)
Miconazole/Zinc Oxide/White Petrolatum (AG; Vusion®)
Naftifine Cream (Generic)
Naftifine Gel (Generic; Naftin®)
Oxiconazole Lotion (Oxistat®)
Oxiconazole Cream (Generic for Oxistat®)
Salicylic Acid Ointment (Generic; Bensal HP®)
Sertaconazole Cream (Ertaczo®)
Sulconazole Cream, Solution (AG; Exelderm®)
Tavaborole Solution (Generic for Kerydin®)
DERMATOLOGY (17)
Permethrin Cream (Generic)
Crotamiton Cream, Lotion (Eurax®)
Antiparasitic Agents, Topical
Spinosad Suspension (Generic; Natroba®)
Crotamiton Lotion (Crotan®)
*Request Form
Lindane Shampoo (Generic)
*Criteria
Malathion Lotion (Generic; Ovide®)
*POS Edits
DERMATOLOGY (17)
Acitretin Capsule (AG; Generic)
Methoxsalen Rapid Softgel (Generic)
Antipsoriatics, Oral
*Request Form
*Criteria
*POS Edits
LA Medicaid Preferred Drug List (PDL)/Non-Preferred Drug List (NPDL) Effective Date: July 1, 2024
Additional Point-of-Sale (POS) Edits May Apply Drugs highlighted in yellow indicate a new addition or a change in status Page | 15
Descriptive Therapeutic Class
Drugs on PDL
Drugs on NPDL which Require Prior Authorization (PA)
DERMATOLOGY (17)
Calcipotriene Cream (Generic)
Calcipotriene Ointment (Generic)
Antipsoriatics, Topical
Calcipotriene Solution (Generic)
Calcipotriene Foam (AG; Generic; Sorilux®)
*Request Form
Calcipotriene/Betamethasone Dipropionate Foam (Enstilar®)
*Criteria
Calcipotriene/Betamethasone Dipropionate Ointment (AG; Generic; Taclonex®)
*POS Edits
Calcipotriene/Betamethasone Dipropionate Susp (AG; Generic; Taclonex Scalp®)
Calcitriol Ointment (AG; Generic; Vectical®)
Halobetasol/Tazarotene Lotion (Duobrii®)
Roflumilast Cream (Zoryve™)
Tapinarof Cream (Vtama®)
DERMATOLOGY (17)
Acyclovir Ointment (Generic)
Acyclovir Cream (AG; Generic; Zovirax®)
Antiviral Agents, Topical
Acyclovir Ointment (Zovirax®)
*Request Form
Acyclovir/Hydrocortisone Cream (Xerese®)
*Criteria
Penciclovir Cream (AG; Generic; Denavir®)
*POS Edits
DERMATOLOGY (17)
Crisaborole Ointment (Eucrisa®)
Roflumilast Foam (Zoryve®)
Atopic Dermatitis Immunomodulators
Dupilumab Pen (Dupixent®)
Ruxolitinib Cream (Opzelura™)
*Request Form
Dupilumab Syringe (Dupixent®)
Tacrolimus Ointment (AG; Generic; Protopic®)
*Criteria
Pimecrolimus Cream (AG; Generic; Elidel®)
*POS Edits
Tralokinumab-ldrm Syringe (Adbry™)
DERMATOLOGY (17)
Ammonium Lactate Cream, Lotion (Generic)
Emollient Combination No. 10 (Biafine®)
Emollients
Emollient Combination No. 10 (Luxamend®)
*Request Form
Emollient Combination No. 43 (Promiseb®)
*Criteria
Emollient Combination No. 103 (Ceracade®)
*POS Edits
Hyaluronic Acid/Grape Seed Extract/Vitamin C & E (Atopiclair®)
LA Medicaid Preferred Drug List (PDL)/Non-Preferred Drug List (NPDL) Effective Date: July 1, 2024
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Descriptive Therapeutic Class
Drugs on PDL
Drugs on NPDL which Require Prior Authorization (PA)
DERMATOLOGY (17)
Imiquimod 5% Cream Packet (Generic for Aldara®)
Imiquimod (Generic; Zyclara®)
Immunomodulators, Topical
Podofilox Gel (Condylox®)
Podofilox Solution (Generic)
*Request Form
Sinecatechins (Veregen®)
*Criteria
Sirolimus (Hyftor™)
*POS Edits
DERMATOLOGY (17)
Hydrocortisone Rectal Cream, Topical Cream (Generic)
Alclometasone Dipropionate Cream, Ointment (Generic)
Steroids, Topical
Hydrocortisone Lotion (Generic)
Desonide Cream, Lotion, Ointment (Generic)
Low Potency
Hydrocortisone Ointment (Generic)
Fluocinolone Acetonide Body Oil, Scalp Oil (Generic; Derma-Smoothe/FS®)
*Request Form
Fluocinolone Acetonide Shampoo (Capex®)
*Criteria
Hydrocortisone Gel (Hydroxym®)
*POS Edits
Hydrocortisone Solution (Texacort®)
DERMATOLOGY (17)
Fluticasone Propionate Cream (Generic)
Betamethasone Valerate Foam (Generic; Luxiq®)
Steroids, Topical
Fluticasone Propionate Ointment (Generic)
Clocortolone Pivalate Cream (AG; Generic; Cloderm®)
Medium Potency
Mometasone Furoate Cream (Generic)
Fluocinolone Acetonide Cream (Generic)
*Request Form
Mometasone Furoate Ointment (Generic)
Fluocinolone Acetonide Ointment, Solution (Generic; Synalar®)
*Criteria
Mometasone Furoate Solution (Generic)
Fluocinolone Acetonide/Emollient No. 65 Cream Kit, Ointment Kit (Synalar®)
*POS Edits
Fluocinolone Acetonide/Skin Cleanser No.28 Kit (Synalar® TS)
Flurandrenolide Cream, Ointment (Generic)
Flurandrenolide Lotion (AG; Generic)
Fluticasone Propionate Lotion (Generic; Beser™)
Fluticasone Propionate Lotion Kit (Beser™)
Hydrocortisone Butyrate Lotion (AG; Generic; Locoid®)
Hydrocortisone Butyrate Cream, Ointment, Solution (Generic)
Hydrocortisone Butyrate/Emollient (AG; Generic)
Hydrocortisone Probutate Cream (Pandel®)
Hydrocortisone Valerate Cream, Ointment (Generic)
Prednicarbate Cream; Ointment (Generic)
Triamcinolone Acetonide Dental Paste (Generic; Oralone®)
LA Medicaid Preferred Drug List (PDL)/Non-Preferred Drug List (NPDL) Effective Date: July 1, 2024
Additional Point-of-Sale (POS) Edits May Apply Drugs highlighted in yellow indicate a new addition or a change in status Page | 17
Descriptive Therapeutic Class
Drugs on PDL
Drugs on NPDL which Require Prior Authorization (PA)
DERMATOLOGY (17)
Betamethasone Dipropionate/Propylene Glycol Cream (Generic)
Amcinonide Cream (Generic)
Steroids, Topical
Betamethasone Valerate Cream (Generic)
Betamethasone Dipropionate Cream, Gel, Lotion, Ointment (Generic)
High Potency
Betamethasone Valerate Lotion (Generic)
Betamethasone Dipropionate/Propylene Glycol Lotion (Generic)
*Request Form
Betamethasone Valerate Ointment (Generic)
Betamethasone Dipropionate/Propylene Glycol Ointment (Generic; Diprolene®)
*Criteria
Triamcinolone Acetonide Cream (Generic)
Desoximetasone Cream, Gel, Ointment (Generic)
*POS Edits
Triamcinolone Acetonide Lotion (Generic)
Desoximetasone Spray (Generic; Topicort®)
Triamcinolone Acetonide Ointment (Generic)
Diflorasone Diacetate Cream (Generic for Psorcon®)
Diflorasone Diacetate Ointment (Generic)
Fluocinonide Cream 0.05% (Generic)
Fluocinonide Cream 0.1% (Generic; Vanos®)
Fluocinonide Emollient, Gel, Ointment, Solution (Generic)
Halcinonide Cream (AG; Generic; Halog®)
Halcinonide Ointment, Solution (Halog®)
Triamcinolone Acetonide Aerosol (Generic; Kenalog Aerosol®)
DERMATOLOGY (17)
Clobetasol Propionate Cream (Generic)
Clobetasol Propionate Foam (Generic for Olux®)
Steroids, Topical
Clobetasol Propionate Emollient (Generic)
Clobetasol Propionate Emollient Foam (Generic; Tovet®)
Very High Potency
Clobetasol Propionate Gel (Generic)
Clobetasol Propionate Emulsion Foam (AG; Generic; Olux-E®)
*Request Form
Clobetasol Propionate Ointment (Generic)
Clobetasol Propionate Kit (Tovet™ Kit)
*Criteria
Clobetasol Propionate Solution (Generic)
Clobetasol Propionate Lotion (Generic)
*POS Edits
Halobetasol Propionate Cream (Generic)
Clobetasol Propionate Shampoo (Generic; Clobex®; Clodan®)
Halobetasol Propionate Ointment (Generic)
Clobetasol Propionate Spray (AG; Generic; Clobex®)
Clobetasol/Skin Cleanser No. 28 (Clodan® Kit)
Clobetasol Propionate Lotion (Impeklo®)
Diflorasone Diacetate Cream (Apexicon E®)
Halobetasol Propionate Foam (AG; Lexette™)
Halobetasol Propionate Lotion (Bryhali®)
Halobetasol Propionate Lotion (Ultravate®)
LA Medicaid Preferred Drug List (PDL)/Non-Preferred Drug List (NPDL) Effective Date: July 1, 2024
Additional Point-of-Sale (POS) Edits May Apply Drugs highlighted in yellow indicate a new addition or a change in status Page | 18
Descriptive Therapeutic Class
Drugs on PDL
Drugs on NPDL which Require Prior Authorization (PA)
DIABETES (18)
Acarbose (Generic)
Miglitol (Generic)
Alpha-Glucosidase Inhibitors
*Request Form
*Criteria
*POS Edits
DIABETES (18)
Dasiglucagon Auto-Injector (Zegalogue™)
Dasiglucagon Syringe (Zegalogue™)
Glucagon Agents
Glucagon Nasal (Baqsimi®)
Diazoxide Oral Suspension (Generic; Proglycem®)
*Request Form
Glucagon, Human Recombinant Inj. (Generic)
Glucacon Subcutaneous Pen, Syringe, Vial (Gvoke®)
*Criteria
Glucagon, Human Recombinant Inj. Emergency Kit (Amphastar)
Glucagon Injection Emergency Kit (Fresenius Kabi)
*POS Edits
DIABETES (18)
Dulaglutide Pen (Trulicity®)
Alogliptin Tablet (AG; Nesina®)
Hypoglycemics
Exenatide Solution Pens (Byetta®)
Alogliptin/Metformin Tablet (AG; Kazano®)
Incretin Mimetics/Enhancers
Linagliptin Tablet (Tradjenta®)
Alogliptin/Pioglitazone Tablet (AG; Oseni®)
*Request Form
Linagliptin/Metformin Tablet (Jentadueto®)
Empagliflozin/Linagliptin/Metformin Tablet (Trijardy™ XR)
*Criteria
Liraglutide Pen (Victoza®)
Exenatide Microspheres ER Auto-Injector (Bydureon BCise
®
)
*POS Edits
Semaglutide Pen (Ozempic®)
Linagliptin/Empagliflozin (Glyxambi®) (See SGLT2 Criteria)
Semaglutide Tablet (Rybelsus®)
Linagliptin/Metformin Tablet ER (Jentadueto XR®)
Sitagliptin Tablet (Januvia®)
Liraglutide/Insulin Degludec (Xultophy®) (See Insulins & Related Agents Criteria)
Sitagliptin/Metformin Tablet (Janumet®)
Lixisenatide/ Insulin Glargine (Soliqua®) (See Insulins & Related Agents Criteria)
Sitagliptin/Metformin Tablet ER (Janumet XR®)
Pramlintide Pen (SymlinPen®)
Saxagliptin Tablet (Generic; Onglyza®)
Saxagliptin/Dapagliflozin Tablet (Qtern®) (See SGLT2 Criteria)
Saxagliptin/Metformin ER Tablet (Generic; Kombiglyze XR®)
Sitagliptin Tablet (Zituvio™)
Sitagliptin/Ertugliflozin Tablet (Steglujan®) (See SGLT2 Criteria)
Tirzepatide Pen (Mounjaro®)
LA Medicaid Preferred Drug List (PDL)/Non-Preferred Drug List (NPDL) Effective Date: July 1, 2024
Additional Point-of-Sale (POS) Edits May Apply Drugs highlighted in yellow indicate a new addition or a change in status Page | 19
Descriptive Therapeutic Class
Drugs on PDL
Drugs on NPDL which Require Prior Authorization (PA)
DIABETES (18)
Insulin Aspart Cartridge, Pen, Vial (AG; Novolog®)
Insulin Aspart Cartridge, Pen, Vial (Fiasp® Penfill®/PumpCart®/FlexTouch®; Fiasp®)
Hypoglycemics
Insulin Aspart Protamine/Aspart Pen (AG; Novolog Mix 70/30®)
Insulin Degludec Pen, Vial (Generic; Tresiba® FlexTouch®; Tresiba®)
Insulins & Related Agents
Insulin Aspart Protamine/Aspart Vial (AG; Novolog Mix 70/30®)
Insulin Detemir Pen, Vial (Levemir®)
*Request Form
Insulin Glargine Pen, Vial (Generic; Lantus® SoloStar®; Lantus®)
Insulin Glargine U-100 (Basaglar® KwikPen®; Basaglar® Tempo Pen™)
*Criteria
Insulin Glulisine Pen, Vial (Apidra® SoloStar®; Apidra®)
Insulin Glargine-aglr (Rezvoglar® KwikPen®)
*POS Edits
Insulin Vial OTC (Humulin® N; Humulin® R)
Insulin Glargine-yfgn Pen, Vial (Generic; Semglee®)
Insulin Regular 500 units/mL Pen, Vial (Humulin® R U-500)
Insulin Glargine Pen (Generic; Toujeo® Solostar®, Toujeo® Max Solostar®)
Insulin Isophane (NPH)/Insulin Regular Pen OTC (Humulin® 70/30)
Insulin Lispro Pen, Vial (Admelog® SoloStar®; Admelog®)
Insulin Isophane (NPH)/Insulin Regular Vial OTC (Humulin® 70/30)
Insulin Lispro Pen (Humalog® KwikPen®; Humalog® Tempo Pen™)
Insulin Lispro (AG; Humalog® Junior KwikPen®)
Insulin Lispro-aabc Pen (Lyumjev® KwikPen®; Lyumjev® Tempo Pen™)
Insulin Lispro Cartridge (Humalog®)
Insulin Lispro-aabc Vial (Lyumjev®)
Insulin Lispro Pen, Vial (AG; Humalog®)
Insulin Isophane (NPH)/Insulin Regular Pen OTC, Vial OTC (Novolin® 70/30)
Insulin Lispro Protamine/Insulin Lispro KwikPen (AG)
Insulin Human Pen OTC, Vial OTC (Novolin® N; Novolin® R)
Insulin Lispro Protamine/Insulin Lispro Pen, Vial (Humalog® Mix)
Insulin Human in 0.9% Sodium Chloride Piggyback IV (Myxredlin®)
Insulin Human Inhalation Powder Cartridge (Afrezza®)
Insulin Human Pen OTC (Humulin® N Kwikpen®)
DIABETES (18)
Nateglinide (Generic)
NONE
Hypoglycemics
Repaglinide (Generic)
Meglitinides
*Request Form
*Criteria
*POS Edits
DIABETES (18)
Canagliflozin Tablet (Invokana®)
Canagliflozin/Metformin ER Tablet (Invokamet® XR)
Hypoglycemics
Canagliflozin/Metformin Tablet (Invokamet®)
Empagliflozin/Metformin ER Tablet (Synjardy® XR)
Sodium-Glucose Co-Transporter 2
(SGLT2) Inhibitors
Dapagliflozin Tablet (AG; Farxiga®)
Ertugliflozin Tablet (Steglatro®)
Dapagliflozin/Metformin ER Tablet (AG; Xigduo® XR)
Ertugliflozin/Metformin Tablet (Segluromet®)
*Request Form
Empagliflozin Tablet (Jardiance®)
Sotagliflozin Tablet (Inpefa®)
*Criteria
Empagliflozin/Metformin Tablet (Synjardy®)
*POS Edits
LA Medicaid Preferred Drug List (PDL)/Non-Preferred Drug List (NPDL) Effective Date: July 1, 2024
Additional Point-of-Sale (POS) Edits May Apply Drugs highlighted in yellow indicate a new addition or a change in status Page | 20
Descriptive Therapeutic Class
Drugs on PDL
Drugs on NPDL which Require Prior Authorization (PA)
DIABETES (18)
Glimepiride (Generic)
Glipizide ER (Glucotrol® XL)
Hypoglycemics
Glipizide (Generic)
Sulfonylureas
Glipizide ER (Generic)
*Request Form
Glyburide (Generic)
*Criteria
Glyburide Micronized (Generic)
*POS Edits
DIABETES (18)
Pioglitazone (Generic)
Pioglitazone (Actos®)
Hypoglycemics
Pioglitazone/Glimepiride (AG)
Thiazolidinediones (TZDs)
Pioglitazone/Metformin (Generic; Actoplus Met®)
*Request Form
*Criteria
*POS Edits
DIABETES (18)
Glipizide-Metformin (Generic)
Metformin ER (Generic for Fortamet™)
Metformins
Glyburide-Metformin (Generic)
Metformin ER (Generic; Glumetza™)
*Request Form
Metformin (Generic)
Metformin Solution (Generic; Riomet™)
*Criteria
Metformin ER (Generic for Glucophage® XR)
Metformin Suspension (Riomet ER™)
*POS Edits
Metformin Tablet 625mg (Generic)
LA Medicaid Preferred Drug List (PDL)/Non-Preferred Drug List (NPDL) Effective Date: July 1, 2024
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Descriptive Therapeutic Class
Drugs on PDL
Drugs on NPDL which Require Prior Authorization (PA)
DIGESTIVE DISORDERS (19)
Meclizine Tablet (AG; Generic)
Amisulpride Vial (Barhemsys®)
Antiemetic/Antivertigo Agents
Metoclopramide Solution (Generic)
Aprepitant Capsule, Pack (Generic; Emend®; Emend TriPack®)
*Request Form
Metoclopramide Tablet (Generic)
Aprepitant Powder for Oral Suspension Packet (Emend®)
*Criteria
Metoclopramide Vial (Generic)
Aprepitant Vial (Aponvie®, Cinvanti®)
*POS Edits
Ondansetron ODT (Generic)
Dimenhydrinate Vial (Generic)
Ondansetron Solution (Generic)
Dolasetron Mesylate (Anzemet®)
Ondansetron Tablet (Generic)
Doxylamine/Pyridoxine Tablet (AG; Generic; Diclegis®)
Ondansetron Vial (Generic)
Doxylamine/Pyridoxine Tablet (Bonjesta®)
Prochlorperazine Tablet (Generic)
Dronabinol Oral (AG; Generic; Marinol®)
Promethazine Ampule (Generic)
Fosaprepitant Dimeglumine Vial (AG; Generic; Emend®)
Promethazine Rectal 12.5 mg (Generic)
Fosnetupitant/Palonosetron Vial (Akynzeo®)
Promethazine Rectal 25 mg (Generic)
Granisetron Tablet, Vial (Generic)
Promethazine Syrup (Generic)
Granisetron ER Syringe (Sustol®)
Promethazine Tablet (Generic)
Granisetron Transdermal Patch (Sancuso®)
Promethazine Vial (Generic)
Meclizine Tablet (Antivert®)
Scopolamine Transdermal (Generic)
Metoclopramide Tablet (Reglan®)
Metoclopramide Nasal (Gimoti®)
Netupitant/Palonosetron HCl Capsule (Akynzeo®)
Ondansetron Syringe (Generic)
Palonosetron Vial (AG; Generic for Aloxi®)
Prochlorperazine Rectal (Generic; Compro®)
Prochlorperazine Vial (Generic)
Promethazine Ampule, Vial (Phenergan®)
Promethazine Suppository 50mg (Generic)
Rolapitant Tablet (Varubi®)
Scopolamine Transdermal (Transderm-Scop®)
Trimethobenzamide Vial (Tigan®)
Trimethobenzamide Capsule (Generic)
LA Medicaid Preferred Drug List (PDL)/Non-Preferred Drug List (NPDL) Effective Date: July 1, 2024
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Descriptive Therapeutic Class
Drugs on PDL
Drugs on NPDL which Require Prior Authorization (PA)
DIGESTIVE DISORDERS (19)
Ursodiol 300 mg Capsule (Generic)
Chenodiol Tablet (Chenodal®)
Bile Acid Salts
Ursodiol Tablet (Generic)
Cholic Acid Capsule (Cholbam®)
*Request Form
Maralixibat Solution (Livmarli™)
*Criteria
Obeticholic Acid Tablet (Ocaliva®)
*POS Edits
Odevixibat Capsule, Pellet (Bylvay®)
Ursodiol Capsule (Reltone®)
Ursodiol Tablet (URSO 250®/URSO Forte®)
DIGESTIVE DISORDERS (19)
Famotidine Suspension (Generic)
Cimetidine Tablet (Generic)
Histamine II Receptor Blockers
Famotidine Tablet (Generic)
Famotidine Piggyback (Generic)
*Request Form
Famotidine Tablet (Pepcid®)
*Criteria
Famotidine Vial (Generic)
*POS Edits
Nizatidine Capsule (Generic)
DIGESTIVE DISORDERS (19)
Pancrelipase (Creon®)
Pancrelipase (Pertzye®)
Pancreatic Enzymes
Pancrelipase (Zenpep®)
Pancrelipase (Viokace®)
*Request Form
*Criteria
*POS Edits
DIGESTIVE DISORDERS (19)
Esomeprazole Suspension (Generic; Nexium®)
Dexlansoprazole Capsule (AG; Generic; Dexilant®)
Proton Pump Inhibitors
Lansoprazole Capsule (Generic)
Esomeprazole Capsule (Generic; Nexium®)
*Request Form
Omeprazole Capsule Rx (Generic)
Lansoprazole Capsule (Prevacid®)
*Criteria
Pantoprazole Suspension (Generic; Protonix®)
Lansoprazole ODT (Generic; Prevacid® SoluTab®)
*POS Edits
Pantoprazole Tablet (Generic)
Omeprazole Granules for Suspension (Prilosec®)
Omeprazole/Sodium Bicarbonate for Oral Suspension (Konvomep®)
Omeprazole/Sodium Bicarbonate Rx Capsule, Packet (Generic; Zegerid®)
Pantoprazole Tablet (Protonix®)
Rabeprazole Tablet (Generic; AcipHex®)
LA Medicaid Preferred Drug List (PDL)/Non-Preferred Drug List (NPDL) Effective Date: July 1, 2024
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Descriptive Therapeutic Class
Drugs on PDL
Drugs on NPDL which Require Prior Authorization (PA)
DIGESTIVE DISORDERS (19)
Balsalazide Capsule (Generic)
Balsalazide Capsule (Colazal®)
Ulcerative Colitis Agents
Mesalamine ER Capsule (AG; Generic; Apriso®)
Budesonide Rectal Foam (Generic; Uceris®)
*Request Form
Mesalamine Suppositories (AG; Generic for Canasa®)
Budesonide DR Tablet (AG; Generic; Uceris®)
*Criteria
Sulfasalazine Tablet (AG; Generic)
Mesalamine DR Tablet (Generic for Asacol HD®)
*POS Edits
Sulfasalazine DR Tablet (AG)
Mesalamine DR Capsule (AG; Generic; Delzicol®)
Mesalamine Enema (Rowasa®; sfRowasa®; Generic for sfRowasa®)
Mesalamine Kit (Generic; Rowasa®)
Mesalamine DR Tablet MMX® (AG; Generic; Lialda®)
Mesalamine ER Capsule (Generic; Pentasa®)
Mesalamine Suppositories (Canasa®)
Olsalazine Capsule (Dipentum®)
Sulfasalazine DR Tablet, Tablet (Azulfidine EN-Tabs®; Azulfidine®)
ENZYME REPLACEMENTS (20)
NONE
Eliglustat Capsule (Cerdelga®)
*Request Form
Imiglucerase 400-unit Vial (Cerezyme®)
*Criteria
Miglustat Capsule (AG; Generic; Zavesca®)
*POS Edits
Taliglucerase alfa Vial (Elelyso®)
Velaglucerase alfa 400-unit Vial (Vpriv®)
EPINEPHRINE, SELF-INJECTED (21)
Epinephrine 0.1 mg Auto-Injector (Auvi-Q®)
Epinephrine 0.15 mg, 0.3 mg Auto-Injector (Auvi-Q®)
*Request Form
Epinephrine 0.15 mg Auto-Injector (AG; Generic; EpiPen Jr®)
Epinephrine 0.15 mg, 0.3 mg Auto-Injector (AG for Adrenaclick®)
*Criteria
Epinephrine 0.3 mg Auto-Injector (AG; Generic; EpiPen®)
Epinephrine Syringe (Symjepi®)
*POS Edits
LA Medicaid Preferred Drug List (PDL)/Non-Preferred Drug List (NPDL) Effective Date: July 1, 2024
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Descriptive Therapeutic Class
Drugs on PDL
Drugs on NPDL which Require Prior Authorization (PA)
GI MOTILITY, CHRONIC (22)
Linaclotide Capsule (Linzess®)
Alosetron Tablet (AG; Generic; Lotronex®)
*Request Form
Lubiprostone Capsule (AG; Generic; Amitiza®)
Eluxadoline Tablet (Viberzi®)
*Criteria
Methylnaltrexone Syringe, Vial (Relistor®)
Methylnaltrexone Tablet (Relistor®)
*POS Edits
Naloxegol Tablet (Movantik®)
Naldemedine Tablet (Symproic®)
Plecanatide Tablet (Trulance®)
Prucalopride Tablet (Motegrity®)
Tenapanor Tablet (Ibsrela®)
GLUCOCORTICOIDS, ORAL (23)
Budesonide EC Capsules (Generic)
Budesonide DR Capsule (Tarpeyo™)
*Request Form
Dexamethasone Tablet (Generic)
Budesonide ER Capsule (Ortikos™)
*Criteria
Hydrocortisone Tablet (Generic)
Cortisone Acetate (Generic)
*POS Edits
Methylprednisolone Tablet Dose Pack (Generic)
Deflazacort Suspension, Tablet (Emflaza®)
Prednisolone Sodium Phosphate Solution (Generic)
Dexamethasone Tablet (Hemady®)
Prednisolone Solution (Generic)
Dexamethasone Tablet Therapy Pack (Taperdex®)
Prednisone Tablet (Generic)
Dexamethasone Elixir, Intensol Concentrate, Solution, Tablet Dose Pack (Generic)
Hydrocortisone Tablet (Cortef®)
Hydrocortisone Capsule (Alkindi® Sprinkle)
Methylprednisolone Tablet, Dose Pack (Medrol®)
Methylprednisolone Tablet 4 mg, 8 mg, 16 mg, 32 mg (Generic)
Prednisolone Tablet, Tablet Dose Pack (Millipred®)
Prednisolone Sodium Phosphate 10 mg/5 mL (Generic Millipred®)
Prednisolone Sodium Phosphate 20 mg/5 mL (Generic Veripred®)
Prednisolone Sodium Phosphate ODT (AG; Generic)
Prednisone Delayed Release Tablet (Rayos®)
Prednisone Intensol Concentrate, Solution, Tablet Dose Pack (Generic)
LA Medicaid Preferred Drug List (PDL)/Non-Preferred Drug List (NPDL) Effective Date: July 1, 2024
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Descriptive Therapeutic Class
Drugs on PDL
Drugs on NPDL which Require Prior Authorization (PA)
GOUT AGENTS (24)
Allopurinol Tablet 100mg, 300mg (Generic)
Allopurinol Tablet 200mg (AG)
Antihyperuricemics
Colchicine Tablet (AG; Generic)
Colchicine Capsule (AG; Mitigare®)
*Request Form
Febuxostat Tablet (Generic)
Colchicine Solution (Gloperba®)
*Criteria
Probenecid Tablet (Generic)
Colchicine Tablet (Colcrys®)
*POS Edits
Probenecid/Colchicine Tablet (Generic)
Febuxostat Tablet (Uloric®)
Pegloticase Intravenous (Krystexxa®)
GROWTH DEFICIENCY (25)
Somatropin Cartridge, Syringe (Genotropin®)
Lonapegsomatropin-tcgd Cartridge (Skytrofa®)
Growth Hormones
Somatropin Pen (Norditropin® FlexPro®)
Somapacitan-beco Pen (Sogroya®)
*Request Form
Somatrogon-ghla Pen (Ngenla®)
*Criteria
Somatropin Cartridge (Humatrope®)
*POS Edits
Somatropin Pen (Nutropin AQ® NuSpin®)
Somatropin Cartridge, Vial (Omnitrope®)
Somatropin Vial (Saizen®)
Somatropin Vial (Serostim®)
Somatropin Vial (Zomacton®)
GROWTH FACTORS (26)
NONE
Mecasermin Subcutaneous (Increlex®)
*Request Form
Tesamorelin Acetate Subcutaneous (Egrifta SV®)
*Criteria
Vosoritide Vial (Voxzogo™)
*POS Edits
LA Medicaid Preferred Drug List (PDL)/Non-Preferred Drug List (NPDL) Effective Date: July 1, 2024
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Descriptive Therapeutic Class
Drugs on PDL
Drugs on NPDL which Require Prior Authorization (PA)
H. PYLORI TREATMENT (27)
Bismuth Subcitrate /Metronidazole/Tetracycline (Generic; Pylera®)
Bismuth Subsalicylate/Metronidazole/Tetracycline (Helidac®)
*Request Form
Lansoprazole/Amoxicillin/Clarithromycin (Generic Prevpac®)
*Criteria
Omeprazole/Amoxicillin/Rifabutin (Talicia®)
*POS Edits
Omeprazole/Clarithromycin/Amoxicillin (Omeclamox-Pak®)
Vonoprazan Tablet (Voquezna®)
Vonoprazan/Amoxicillin (Voquezna DualPak®)
Vonoprazan/Amoxicillin/Clarithromycin (Voquezna TriplePak®)
HEART DISEASE, HYPERLIPIDEMIA (28)
Apixaban Dose Pack, Tablet (Eliquis®)
Dabigatran Pellet Pack (Pradaxa®)
Anticoagulants
Dabigatran Capsule (Generic; Pradaxa®)
Dalteparin Syringe, Vial (Fragmin®)
*Request Form
Enoxaparin Syringe, Vial (AG; Generic)
Edoxaban Tablet (Savaysa®)
*Criteria
Rivaroxaban Tablet (Xarelto®; Xarelto® Starter Pack)
Enoxaparin Syringe, Vial (Lovenox®)
*POS Edits
Warfarin Tablet (Generic)
Fondaparinux Syringe (Generic; Arixtra®)
Rivaroxaban Suspension (Xarelto®)
HEART DISEASE, HYPERLIPIDEMIA (28)
Aspirin/Dipyridamole ER Capsule (Generic)
Clopidogrel Tablet (Plavix®)
Anticoagulants
Clopidogrel Tablet (Generic)
Prasugrel Tablet (Effient®)
Platelet Aggregation Inhibitors
Dipyridamole Tablet (Generic)
*Request Form
Prasugrel Tablet (Generic)
*Criteria
Ticagrelor Tablet (Brilinta®)
*POS Edits
LA Medicaid Preferred Drug List (PDL)/Non-Preferred Drug List (NPDL) Effective Date: July 1, 2024
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Descriptive Therapeutic Class
Drugs on PDL
Drugs on NPDL which Require Prior Authorization (PA)
HEART DISEASE, HYPERLIPIDEMIA (28)
Benazepril (Generic)
Aliskiren (AG; Generic; Tekturna®)
Hypertension
Benazepril/HCTZ (Generic)
Aliskiren/HCTZ (Tekturna HCT®)
ACE Inhibitors & Direct Renin Inhibitors
Enalapril Solution (AG; Generic)
Azilsartan Medoxomil (Edarbi®)
*Request Form
Enalapril Tablet (Generic)
Azilsartan/Chlorthalidone (Edarbyclor®)
*Criteria
Enalapril/HCTZ (Generic)
Candesartan (AG; Generic; Atacand®)
*POS Edits
Fosinopril (Generic)
Candesartan/HCTZ (AG; Generic; Atacand HCT®)
Fosinopril/HCTZ (Generic)
Captopril (Generic)
Irbesartan (Generic)
Captopril/HCTZ (Generic)
Irbesartan/HCTZ (Generic)
Enalapril Solution (Epaned®)
Lisinopril (Generic)
Enalapril Tablet (Vasotec®)
Lisinopril/HCTZ (Generic)
Enalapril/HCTZ (Vaseretic®)
Losartan (Generic)
Eprosartan (Generic)
Losartan/HCTZ (Generic)
Irbesartan (Avapro®)
Olmesartan (AG; Generic)
Irbesartan/HCTZ (Avalide®)
Olmesartan/HCTZ (AG; Generic)
Lisinopril Solution (Qbrelis®)
Quinapril (Generic)
Lisinopril (Zestril®)
Quinapril/HCTZ (AG; Generic)
Lisinopril/HCTZ (Zestoretic®)
Ramipril (Generic)
Losartan (Cozaar®)
Sacubitril/Valsartan (Entresto®)
Losartan/HCTZ (Hyzaar®)
Valsartan (Generic)
Moexipril (Generic)
Valsartan/HCTZ (Generic)
Olmesartan (Benicar®)
Olmesartan/HCTZ (Benicar HCT®)
Perindopril (Generic)
Quinapril (Accupril®)
Ramipril (Altace®)
Telmisartan (Generic; Micardis®)
Telmisartan/HCTZ (Generic; Micardis HCT®)
Trandolapril (Generic)
Valsartan (Diovan®)
Valsartan Solution (Generic)
Valsartan/HCTZ (Diovan HCT®)
LA Medicaid Preferred Drug List (PDL)/Non-Preferred Drug List (NPDL) Effective Date: July 1, 2024
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Descriptive Therapeutic Class
Drugs on PDL
Drugs on NPDL which Require Prior Authorization (PA)
HEART DISEASE, HYPERLIPIDEMIA (28)
Amlodipine/Benazepril (Generic)
Amlodipine/Benazepril (Lotrel®)
Hypertension
Amlodipine/Olmesartan (AG; Generic)
Amlodipine/Olmesartan (Azor®)
Angiotensin Modulators/Calcium Channel
Blockers Combinations
Amlodipine/Valsartan (Generic)
Amlodipine/Olmesartan/HCTZ (AG; Generic; Tribenzor®)
Amlodipine/Valsartan (Exforge®)
*Request Form
Amlodipine/Valsartan/HCTZ (Generic; Exforge HCT®)
*Criteria
Telmisartan/Amlodipine (Generic)
*POS Edits
Trandolapril/Verapamil (Generic)
HEART DISEASE, HYPERLIPIDEMIA (28)
Acebutolol Capsule (Generic)
Atenolol Tablet (Tenormin®)
Hypertension
Atenolol Tablet (Generic)
Betaxolol Tablet (Generic)
Beta Blocker Agents
Atenolol/Chlorthalidone Tablet (Generic)
Bisoprolol/HCTZ Tablet (Ziac®)
*Request Form
Bisoprolol Tablet (Generic)
Carvedilol (Coreg®)
*Criteria
Bisoprolol/HCTZ Tablet (Generic)
Carvedilol ER Capsule (AG; Generic; Coreg CR®)
*POS Edits
Carvedilol Tablet (Generic)
Metoprolol/HCTZ Tablet (Generic)
Labetalol Tablet (Generic)
Metoprolol Succinate Capsule (Kapspargo Sprinkle®)
Metoprolol Succinate ER Tablet (AG; Generic)
Metoprolol Succinate ER Tablet (Toprol XL®)
Metoprolol Tartrate Tablet (Generic)
Metoprolol Tartrate Tablet (Lopressor®)
Nadolol Tablet (Generic)
Nadolol Tablet (Corgard®)
Nebivolol Tablet (Generic; Bystolic®)
Pindolol Tablet (Generic)
Propranolol Oral Solution (Hemangeol®)
Propranolol ER Capsule (Inderal XL®)
Propranolol ER Capsule (AG; Generic)
Propranolol ER Capsule (Innopran XL®)
Propranolol Solution (Generic)
Propranolol LA Capsule (Inderal LA®)
Propranolol Tablet (Generic)
Propranolol/HCTZ Tablet (Generic)
Sotalol Tablet (Generic)
Sotalol Solution (Sotylize®)
Timolol Maleate Tablet (Generic)
LA Medicaid Preferred Drug List (PDL)/Non-Preferred Drug List (NPDL) Effective Date: July 1, 2024
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Descriptive Therapeutic Class
Drugs on PDL
Drugs on NPDL which Require Prior Authorization (PA)
HEART DISEASE, HYPERLIPIDEMIA (28)
Amlodipine Tablet (Generic)
Amlodipine Solution (Norliqva®)
Hypertension
Diltiazem ER Capsule (Generic)
Amlodipine Suspension (Katerzia™)
Calcium Channel Blockers
Diltiazem IR Tablet (Generic)
Amlodipine Tablet (Norvasc®)
*Request Form
Felodipine ER Tablet (Generic)
Diltiazem CD (Cardizem CD®; Cardizem CD® 360 mg; Tiazac®)
*Criteria
Nifedipine ER Tablet (Generic)
Diltiazem LA Tablet (AG; Generic; Cardizem LA®; Matzim LA®)
*POS Edits
Nifedipine IR Capsule (Generic)
Isradipine Capsule (Generic)
Verapamil ER Tablet (Generic)
Levamlodipine Tablet (AG)
Verapamil IR Tablet (Generic)
Nicardipine Capsule (Generic)
Nifedipine ER Tablet (Procardia XL®)
Nimodipine Capsule (Generic)
Nimodipine Oral Syringe, Solution (Nymalize®)
Nisoldipine Tablet (Generic)
Verapamil 360 mg Capsule (Generic)
Verapamil ER PM Capsule (AG; Generic; Verelan PM®)
Verapamil ER Capsule (Generic for Verelan®)
HEART DISEASE, HYPERLIPIDEMIA (28)
Alirocumab Subcutaneous Pen (Praluent®)
Bempedoic Acid Tablet (Nexletol™)
Lipotropics, Other
Cholestyramine/Sucrose Powder (Generic Questran®)
Bempedoic Acid and Ezetimibe Tablet (Nexlizet™)
*Request Form
Colestipol Granules (Generic)
Cholestyramine/Aspartame Powder (Generic)
*Criteria
Colestipol Tablet (Generic)
Cholestyramine/Sucrose Packet, Powder (Questran®)
*POS Edits
Evolocumab Auto-Injector (Repatha® SureClick®)
Colesevelam Powder Pack, Tablet (AG; Generic; Welchol®)
Evolocumab Cartridge (Repatha® Pushtronex®)
Colestipol Granules, Tablet (Colestid®)
Evolocumab Prefilled Syringe (Repatha®)
Evinacumab-dgnb Vial (Evkeeza®)
Ezetimibe (Generic)
Ezetimibe (Zetia®)
LA Medicaid Preferred Drug List (PDL)/Non-Preferred Drug List (NPDL) Effective Date: July 1, 2024
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Descriptive Therapeutic Class
Drugs on PDL
Drugs on NPDL which Require Prior Authorization (PA)
HEART DISEASE, HYPERLIPIDEMIA (28)
Fenofibrate Nanocrystallized Tablet (Generic Tricor® 48 mg)
Fenofibrate Capsule Micronized (AG; Generic for Antara®)
Lipotropics, Other Continued
Fenofibrate Nanocrystallized Tablet (Generic Tricor® 145 mg)
Fenofibrate Capsule (Generic; Lipofen®)
Fenofibrate Capsule, Tablet (Generic for Lofibra®)
Fenofibrate Tablet (AG; Generic; Fenoglide®)
Gemfibrozil Tablet (Generic)
Fenofibrate Tablet Nanocrystallized Tablet (Tricor®)
Icosapent Ethyl Capsule (Generic; Vascepa®)
Fenofibric Acid Tablet (Generic for Fibricor®)
Niacin ER Tablet (Generic)
Fenofibric Acid Choline Capsule (AG; Generic; Trilipix®)
Omega-3-acid Ethyl Esters Capsule (Generic®)
Gemfibrozil Tablet (Lopid®)
Inclisiran Syringe (Leqvio®)
Lomitapide Capsule (Juxtapid®)
Omega-3-acid Ethyl Esters Capsule (Lovaza®)
HEART DISEASE, HYPERLIPIDEMIA (28)
Ambrisentan Tablet (Generic)
Ambrisentan Tablet (Letairis®)
Pulmonary Arterial Hypertension (PAH)
Bosentan Tablet (Generic; Tracleer®)
Bosentan Suspension (Tracleer®)
*Request Form
Sildenafil Tablet (Generic for Revatio®)
Iloprost Inhalation Solution (Ventavis®)
*Criteria
Sildenafil Oral Suspension (AG; Generic for Revatio®)
Macitentan Tablet (Opsumit®)
*POS Edits
Tadalafil Tablet (Generic for Adcirca®)
Riociguat Tablet (Adempas®)
Selexipag Tablet, Dose Pack (Uptravi®)
Sildenafil Suspension (Liqrev®)
Sildenafil Suspension, Tablet (Revatio®)
Tadalafil Suspension (Tadliq®)
Tadalafil Tablet (Adcirca®)
Treprostinil ER Tablet, Titration Kit (Orenitram ER®; Orenitram® Month 1/2/3)
Treprostinil Inhalation Powder, Inhalation Solution (Tyvaso DPI™; Tyvaso®)
LA Medicaid Preferred Drug List (PDL)/Non-Preferred Drug List (NPDL) Effective Date: July 1, 2024
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Descriptive Therapeutic Class
Drugs on PDL
Drugs on NPDL which Require Prior Authorization (PA)
HEART DISEASE, HYPERLIPIDEMIA (28)
Atorvastatin Tablet (Generic)
Amlodipine/Atorvastatin Tablet (AG; Generic; Caduet®)
Statins & Statin Combination Agents
Lovastatin Tablet (Generic)
Atorvastatin Calcium (Atorvaliq®)
*Request Form
Pravastatin Tablet (Generic)
Atorvastatin Tablet (Lipitor®)
*Criteria
Rosuvastatin Tablet (Generic)
Ezetimibe/Simvastatin Tablet (Generic; Vytorin®)
*POS Edits
Simvastatin Tablet (Generic)
Fluvastatin Capsule (Generic)
Fluvastatin ER Tablet (AG; Generic; Lescol XL®)
Lovastatin ER Tablet (Altoprev®)
Pitavastatin Tablet (Livalo®)
Pitavastatin Tablet (Generic; Zypitamag®)
Rosuvastatin Tablet (Crestor®)
Rosuvastatin Capsule (Ezallor™ Sprinkle)
Simvastatin Tablet (Zocor®)
HEART DISEASE, HYPERLIPIDEMIA (28)
Clonidine Patch (Generic; Catapres-TTS®)
Clonidine ER Suspension (AG for Nexiclon®)
Sympatholytics
Clonidine Tablet (Generic)
Methyldopate HCl (Intravenous)
*Request Form
Guanfacine Tablet (Generic)
Methyldopa/HCTZ Tablet (Generic)
*Criteria
Methyldopa Tablet (AG; Generic)
*POS Edits
HEART DISEASE, HYPERLIPIDEMIA (28)
Isosorbide Dinitrate Tablet (Generic)
Isosorbide Dinitrate Tablet (AG; Isordil®)
Vasodilators, Coronary
Isosorbide Dinitrate/Hydralazine Tablet (AG; Generic; BiDil®)
Nitroglycerin Translingual Spray (AG; Generic; Nitrolingual®)
*Request Form
Isosorbide Mononitrate Tablet (Generic)
Nitroglycerin Transdermal Patch (Nitro-Dur®)
*Criteria
Isosorbide Mononitrate SR Tablet (Generic)
Nitroglycerin Sublingual Tablet (Nitrostat®)
*POS Edits
Nitroglycerin Sublingual Tablet (AG; Generic)
Vericiguat (Verquvo®)
Nitroglycerin Transdermal Ointment (Nitro-Bid®)
Nitroglycerin Transdermal Patch (AG; Generic)
LA Medicaid Preferred Drug List (PDL)/Non-Preferred Drug List (NPDL) Effective Date: July 1, 2024
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Descriptive Therapeutic Class
Drugs on PDL
Drugs on NPDL which Require Prior Authorization (PA)
HEMATOLOGIC AGENTS,
HEMATOPOIETIC AGENTS (29)
Darbepoetin Syringe (Aranesp®)
Epoetin alfa-epbx Vial (Retacrit®) [by Vifor]
Darbepoetin Vial (Aranesp®)
Epoetin alfa Vial (Procrit®)
Erythropoietins
Epoetin alfa-epbx Vial (Retacrit®) [by Pfizer]
Luspatercept-aamt Vial (Reblozyl®)
*Request Form
Epoetin alfa Vial (Epogen®)
Methoxy Polyethylene Glycol-Epoetin Beta Syringe (Mircera®)
*Criteria
*POS Edits
HEMODIALYSIS (30)
Calcium Acetate Capsule (Generic)
Calcium Acetate Solution (Phoslyra®)
Phosphate Binders
Sevelamer Carbonate Tablet (AG; Generic; Renvela®)
Calcium Acetate Tablet (Generic)
*Request Form
Calcium Carbonate/Magnesium Carbonate/FA (MagneBind 400 Rx®)
*Criteria
Ferric Citrate Tablet (Auryxia®)
*POS Edits
Lanthanum Carbonate Chewable Tablet (Generic; Fosrenol®)
Lanthanum Carbonate Powder Pack (Fosrenol®)
Sevelamer Carbonate Powder Pack (Generic; Renvela®)
Sevelamer HCl Tablet (AG; Generic for RenaGel®)
Sucroferric Oxyhydroxide Chewable Tablet (Velphoro®)
Tenapanor Tablet (Xphozah™)
LA Medicaid Preferred Drug List (PDL)/Non-Preferred Drug List (NPDL) Effective Date: July 1, 2024
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Descriptive Therapeutic Class
Drugs on PDL
Drugs on NPDL which Require Prior Authorization (PA)
HEMOPHILIA TREATMENT (31)
Emicizumab-kxwh (Hemlibra®)
Anti-Inhibitor Coagulant Complex (Feiba NF®)
*Request Form
Factor IX Human Recombinant, GlycoPEGylated (Rebinyn®)
Etranacogene Dezaparvovec-drlb (Hemgenix®)
*Criteria
Factor IX Human Recombinant (BeneFIX® Kit)
Factor IX Complex (PCC) 3-Factor (Profilnine® SD)
*POS Edits
Factor VIIa, Recombinant (NovoSeven® RT)
Factor IX Human (AlphaNine SD®)
Factor VIII (Kovaltry®)
Factor IX Human Recombinant (Ixinity®)
Factor VIII, B-Domain-Deleted (Xyntha® Kit)
Factor IX Recombinant (Rixubis®)
Factor VIII, B-Domain-Deleted (Xyntha® Solofuse® Syringe Kit)
Factor IX Recombinant, Albumin Fusion (Idelvion®)
Factor VIII, B-Domain-Truncated (Novoeight®)
Factor IX Recombinant, Fc Fusion Protein (Alprolix®)
Factor VIII, HEK B-Domain-Deleted (Nuwiq®)
Factor VIIa, (Recombinant)-jncw (Sevenfact®)
Factor VIII, Recombinant, PEGylated-aucl (Jivi®)
Factor VIII, Full-Length (Advate®)
Factor VIII/VWF (Alphanate®)
Factor VIII (Kogenate FS®)
Factor VIII/VWF (Humate-P® Kit)
Factor VIII, Full-Length PEGylated (Adynovate®)
Factor VIII/VWF (Wilate®)
Factor VIII, Human (Hemofil-M®)
Factor X (Coagadex®)
Factor VIII, Human Kit (Koate DVI®)
Factor XIII Concentrate, Human (Corifact® Kit)
Factor VIII, Human Vial (Koate DVI®)
Factor VIII, Recombinant Fc-VWF-XTEN Fusion Protein-ehtl (Altuviiio™)
Factor VIII, Recombinant Glycopegylated-exei (Esperoct®)
Factor VIII, Recombinant Porcine (Obizur®)
Factor VIII, Recombinant (Recombinate®)
Factor VIII, Recombinant, Fc Fusion (Eloctate®)
Factor VIII, Single-Chain, B-Domain Truncated (Afstyla®)
Factor XIII A-Subunit, Recombinant (Tretten®)
Prothrombin Complex Concentrate Human-lans (Balfaxar®)
Valoctocogene Roxaparvovec-rvox (Roctavian™)
Von Willebrand Factor, Recombinant (Vonvendi®)
LA Medicaid Preferred Drug List (PDL)/Non-Preferred Drug List (NPDL) Effective Date: July 1, 2024
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Descriptive Therapeutic Class
Drugs on PDL
Drugs on NPDL which Require Prior Authorization (PA)
HEREDITARY ANGIOEDEMA (32)
C1 Esterase Inhibitor Subcutaneous Vial (Haegarda®)
Berotralstat Hydrochloride Capsule (Orladeyo®)
*Request Form
Icatibant Acetate Subcutaneous Syringe (Generic)
C1 Esterase Inhibitor Intravenous Kit, Vial (Berinert®)
*Criteria
C1 Esterase Inhibitor Intravenous (Cinryze®)
*POS Edits
C1 Esterase Inhibitor, Recombinant Intravenous Vial (Ruconest®)
Ecallantide Subcutaneous Vial (Kalbitor®)
Icatibant Acetate Subcutaneous Syringe (Firazyr®)
Lanadelumab-flyo Subcutaneous Syringe, Vial (Takhzyro®)
HIV-AIDS (33)
Abacavir Solution, Tablet (Generic; Ziagen®)
NONE
*Request Form
Abacavir/Dolutegravir/Lamivudine Tablet (Triumeq®)
*Criteria
Abacavir/Dolutegravir/Lamivudine Soluble Tablet (Triumeq PD®)
*POS Edits
Abacavir/Lamivudine Tablet (Generic; Epzicom®)
Abacavir/Lamivudine/Zidovudine Tablet (Trizivir®)
Atazanavir Capsule (Generic)
Atazanavir Capsule, Powder Pack (Reyataz®)
Atazanavir Sulfate/Cobicistat Tablet (Evotaz®)
Bictegravir/Emtricitabine/Tenofovir AF Tablet (Biktarvy®)
Cabotegravir (Apretude™)
Cabotegravir/Rilpivirine IM (Cabenuva®)
Cobicistat Tablet (Tybost®)
Darunavir Ethanolate Tablet (Generic; Prezista®)
Darunavir Ethanolate Suspension (Prezista®)
Darunavir/Cobicistat/Emtricitabine/Tenofovir AF (Symtuza®)
Darunavir/Cobicistat Tablet (Prezcobix®)
Didanosine Capsule DR (Generic)
Dolutegravir Sodium Suspension, Tablet (Tivicay PD®; Tivicay®)
Dolutegravir Sodium/Lamivudine Tablet (Dovato®)
Dolutegravir/Rilpivirine Tablet (Juluca®)
Doravirine Tablet (Pifeltro®)
Doravirine/Lamivudine/Tenofovir DF Tablet (Delstrigo®)
Efavirenz Capsule (Generic for Sustiva®)
LA Medicaid Preferred Drug List (PDL)/Non-Preferred Drug List (NPDL) Effective Date: July 1, 2024
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Descriptive Therapeutic Class
Drugs on PDL
Drugs on NPDL which Require Prior Authorization (PA)
HIV-AIDS (33) Continued
Efavirenz Tablet (Generic)
NONE
Efavirenz/Emtricitabine/Tenofovir DF Tablet (Generic; Atripla®)
Efavirenz/Lamivudine/Tenofovir DF Tablet (Generic; Symfi Lo®)
Efavirenz/Lamivudine/Tenofovir DF Tablet (Generic; Symfi®)
Elvitegravir/Cobicistat/Emtricitabine/Tenofovir AF (Genvoya®)
Elvitegravir/Cobicistat/Emtricitabine/Tenofovir DF (Stribild®)
Emtricitabine/Rilpivirine/Tenofovir DF Tablet (Complera®)
Emtricitabine/Rilpivirine/Tenofovir AF Tablet (Odefsey®)
Emtricitabine Capsule (Generic; Emtriva®)
Emtricitabine Solution (Emtriva®)
Emtricitabine/Tenofovir AF Tablet (Descovy®)
Emtricitabine/Tenofovir DF Tablet (Generic; Truvada®)
Enfuvirtide Vial (Fuzeon®)
Etravirine Tablet (Generic; Intelence®)
Fosamprenavir Tablet (Generic; Lexiva®)
Fosamprenavir Suspension (Lexiva®)
Fostemsavir Tromethamine Tablet (Rukobia®)
Ibalizumab-uiyk Vial (Trogarzo®)
Lamivudine Solution, Tablet (Generic; Epivir®)
Lamivudine/Tenofovir DF Tablet (Cimduo®)
Lamivudine/Zidovudine Tablet (Generic; Combivir®)
Lenacapavir Subcutaneous, Tablet (Sunlenca®)
Lopinavir/Ritonavir Solution (Generic; Kaletra®)
Lopinavir/Ritonavir Tablet (Generic; Kaletra®)
Maraviroc Solution (Selzentry®)
Maraviroc Tablet (Generic; Selzentry®)
Nelfinavir Mesylate Tablet (Viracept®)
Nevirapine ER Tablet (Generic for Viramune XR®)
Nevirapine Suspension (Generic for Viramune®)
Nevirapine Tablet (Generic)
Raltegravir Potassium Chewable, Powder Pack, Tablet (Isentress®)
LA Medicaid Preferred Drug List (PDL)/Non-Preferred Drug List (NPDL) Effective Date: July 1, 2024
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Descriptive Therapeutic Class
Drugs on PDL
Drugs on NPDL which Require Prior Authorization (PA)
HIV-AIDS (33) Continued
Raltegravir Potassium Tablet (Isentress HD®)
NONE
Rilpivirine HCl Tablet (Edurant®)
Ritonavir Powder Pack (Norvir®)
Ritonavir Tablet (Generic; Norvir®)
Stavudine Capsule (Generic)
Tenofovir Disoproxil Fumarate Tablet (Generic)
Tenofovir Disoproxil Fumarate Powder, Tablet (Viread®)
Tipranavir Capsule (Aptivus®)
Zidovudine Syrup (Generic; Retrovir®)
Zidovudine Capsule, Tablet (Generic)
IDIOPATHIC PULMONARY FIBROSIS (34)
Nintedanib Capsule (Ofev®)
Pirfenidone Capsule, Tablet (Esbriet®)
*Request Form
Pirfenidone Capsule (Generic)
*Criteria
Pirfenidone Tablet (Generic)
*POS Edits
IMMUNE GLOBULINS (IG) (35)
IG Injection [(Human) Gamunex®-C]
Cytomegalovirus IG IV [(Human) Cytogam®]
*Request Form
IG Intravenous [(Human) Gammagard Liquid]
Hepatitis B IG Intravenous [(Human) HepaGam B®]
*Criteria
IG Intravenous [(Human) Privigen®]
Hepatitis B IG Syringe [(Human) HyperHEP B® S/D]
*POS Edits
IG Subcutaneous Syringe [(Human) Hizentra®]
Hepatitis B IG Vial [(Human) HyperHEP B® S/D]
IG Subcutaneous Vial [(Human) Hizentra®]
IG Infusion [(Human) Hyqvia®]
IG Injection [(Human) Gammaked™]
IG Intravenous [(Human) Flebogamma® DIF]
IG Intravenous [(Human) Gammagard S/D]
IG Intravenous [(Human) Gammaplex®]
IG Intravenous [(Human) Octagam®]
IG Intravenous [(Human-ifas) Panzyga®]
LA Medicaid Preferred Drug List (PDL)/Non-Preferred Drug List (NPDL) Effective Date: July 1, 2024
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Descriptive Therapeutic Class
Drugs on PDL
Drugs on NPDL which Require Prior Authorization (PA)
IMMUNE GLOBULINS (IG) Cont. (35)
(Preferred agents listed on page 36)
IG Intravenous [(Human-slra) Asceniv™]
IG Intravenous [(Human) Bivigam®]
IG Subcutaneous [(Human) Cuvitru®]
IG Subcutaneous [(Human-hipp) Cutaquig®]
IG Subcutaneous [(Human-klhw) Xembify®]
IG Vial [(Human) GamaSTAN®]
IG Vial [(Human) GamaSTAN® S/D]
Rabies IG [(Human) Kedrab™]
Rabies IG Vial [(Human) HyperRAB®]
Varicella Zoster IG [(Human) Varizig®]
IMMUNOSUPPRESSIVES, ORAL (36)
Azathioprine Tablet (Generic)
Avacopan Capsule (Tavneos™)
*Request Form
Cyclosporine Capsule – MODIFIED 25 mg, 100 mg
Azathioprine (Azasan®; Imuran®)
*Criteria
Cyclosporine Softgel – MODIFIED 50 mg (Generic)
Belumosudil Tablet (Rezurock™)
*POS Edits
Mycophenolate Mofetil Capsule (Generic)
Cyclosporine Capsule 25 mg, 100 mg (Generic; Sandimmune®)
Mycophenolate Mofetil Tablet (Generic)
Cyclosporine Capsule – MODIFIED (Neoral®)
Mycophenolic Acid as Mycophenolate Sodium (Generic)
Cyclosporine Solution – MODIFIED (Generic; Neoral®)
Sirolimus Solution (Generic; Rapamune®)
Cyclosporine Solution (Sandimmune®)
Sirolimus Tablet (AG; Generic; Rapamune®)
Everolimus Tablet (Generic; Zortress®)
Tacrolimus Capsule (Generic)
Mycophenolate Mofetil Capsule (CellCept®)
Mycophenolate Mofetil Suspension (CellCept®)
Mycophenolate Mofetil Tablet (CellCept®)
Mycophenolate Mofetil Suspension (Generic)
Mycophenolic Acid as Mycophenolate Sodium (Myfortic®)
Tacrolimus Capsule (Prograf®)
Tacrolimus Granule Packet (Prograf®)
Tacrolimus ER Capsule (Astagraf® XL)
Tacrolimus ER Tablet (Envarsus® XR)
LA Medicaid Preferred Drug List (PDL)/Non-Preferred Drug List (NPDL) Effective Date: July 1, 2024
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Descriptive Therapeutic Class
Drugs on PDL
Drugs on NPDL which Require Prior Authorization (PA)
INFECTIOUS DISORDERS (37)
Amoxicillin/Clavulanate Suspension (AG; Generic)
Amoxicillin/Clavulanate ER Tablet, Chewable Tablet (Generic)
Antibiotics
Amoxicillin/Clavulanate Tablet (AG; Generic)
Amoxicillin/Clavulanate Suspension (Augmentin® 125mg/5ml)
Cephalosporin and Related Antibiotics
Cefadroxil Capsule (Generic)
Cefaclor Capsule, ER Tablet, Suspension (Generic)
*Request Form
Cefdinir Capsule, Suspension (Generic)
Cefadroxil Suspension, Tablet (Generic)
*Criteria
Cefprozil Suspension, Tablet (Generic)
Cefixime Capsule (AG; Generic for Suprax®)
*POS Edits
Cefuroxime Tablet (Generic)
Cefixime Suspension (Generic for Suprax®)
Cephalexin Capsule, Suspension (Generic)
Cefpodoxime Proxetil Suspension, Tablet (Generic)
Cephalexin Tablet (Generic)
INFECTIOUS DISORDERS (37)
Ciprofloxacin Tablet (Generic)
Ciprofloxacin Suspension (Generic; Cipro®)
Antibiotics
Levofloxacin Tablet (Generic)
Ciprofloxacin Tablet (Cipro®)
Fluoroquinolones
Delafloxacin Tablet (Baxdela®)
*Request Form
Levofloxacin Solution (Generic)
*Criteria
Moxifloxacin Tablet (Generic)
*POS Edits
Ofloxacin Tablet (Generic)
INFECTIOUS DISORDERS (37)
Metronidazole Tablet (Generic)
Fecal Microbiota Spores, Live-brpk (Vowst™)
Antibiotics
Neomycin Tablet (Generic)
Fidaxomicin Suspension, Tablet (Dificid®)
Gastrointestinal Antibiotics
Tinidazole Tablet (Generic)
Metronidazole Capsule (Generic; Flagyl®)
*Request Form
Vancomycin HCl Capsule (AG; Generic)
Metronidazole Suspension (Likmez™)
*Criteria
Nitazoxanide Tablet (AG; Generic)
*POS Edits
Paromomycin Capsule (Generic)
Rifamycin Tablet (Aemcolo®)
Rifaximin Tablet (Xifaxan®)
Secnidazole Oral Granules (Solosec
TM
)
Vancomycin HCl Capsule (Vancocin®)
Vancomycin Solution (AG; Generic; Firvanq®)
Vancomycin Solution 250mg/5ml (Generic)
LA Medicaid Preferred Drug List (PDL)/Non-Preferred Drug List (NPDL) Effective Date: July 1, 2024
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Descriptive Therapeutic Class
Drugs on PDL
Drugs on NPDL which Require Prior Authorization (PA)
INFECTIOUS DISORDERS (37)
Tobramycin Solution (AG; Generic; Bethkis®)
Amikacin Inhalation Suspension (Arikayce®)
Antibiotics
Tobramycin Solution (Generic for Tobi®)
Aztreonam Solution (Cayston®)
Inhaled Antibiotics
Tobramycin Solution (Tobi®)
*Request Form
Tobramycin Capsule (Tobi Podhaler®)
*Criteria
Tobramycin Inhalation Solution Pak (AG; Kitabis Pak®)
*POS Edits
INFECTIOUS DISORDERS (37)
Clindamycin Capsule (Generic)
Clindamycin Capsule (Cleocin®)
Antibiotics
Clindamycin Palmitate Solution (Generic)
Clindamycin Palmitate Solution (Cleocin®)
Lincosamides
Clindamycin Phosphate in D5W Piggyback Injection (Generic)
*Request Form
Clindamycin Phosphate Injection Vial (Generic; Cleocin®)
*Criteria
Clindamycin in 0.9% Sodium Chloride Piggyback Intravenous (Generic)
*POS Edits
Lincomycin HCl Vial (Generic; Lincocin®)
INFECTIOUS DISORDERS (37)
Azithromycin Packet (AG)
Azithromycin Packet, Suspension, Tablet (Zithromax®)
Antibiotics
Azithromycin Suspension, Tablet (Generic)
Clarithromycin ER Tablet, Suspension (Generic)
Macrolides - Ketolides
Clarithromycin Tablet (Generic)
Erythromycin Base DR Capsule, Tablet (Generic)
*Request Form
Erythromycin Base DR Tablet (Generic)
Erythromycin Base DR Tablet (Ery-Tab®)
*Criteria
Erythromycin Ethyl Succinate Suspension (AG; Generic; E.E.S.® 200; EryPed® 200)
*POS Edits
Erythromycin Ethyl Succinate Suspension (AG; Generic; EryPed® 400)
Erythromycin Ethyl Succinate Tablet (E.E.S. ® 400)
Erythromycin Stearate Filmtab (Erythrocin®)
LA Medicaid Preferred Drug List (PDL)/Non-Preferred Drug List (NPDL) Effective Date: July 1, 2024
Additional Point-of-Sale (POS) Edits May Apply Drugs highlighted in yellow indicate a new addition or a change in status Page | 40
Descriptive Therapeutic Class
Drugs on PDL
Drugs on NPDL which Require Prior Authorization (PA)
INFECTIOUS DISORDERS (37)
Nitrofurantoin Macrocrystals Capsule (Generic)
Nitrofurantoin Macrocrystals Capsule 25 mg, 50 mg, 100 mg (Macrodantin®)
Antibiotics
Nitrofurantoin Monohydrate Macrocrystals Capsule (AG; Generic)
Nitrofurantoin Monohydrate Macrocrystals Capsule 100 mg (Macrobid®)
Nitrofuran Derivatives
Nitrofurantoin Suspension (AG; Generic; Furadantin®)
*Request Form
*Criteria
*POS Edits
INFECTIOUS DISORDERS (37)
Linezolid Tablet (AG; Generic)
Linezolid in 0.9% Sodium Chloride IV (AG)
Antibiotics
Linezolid in Dextrose 5% IV (Generic; Zyvox®)
Oxazolidinones
Linezolid Suspension (AG; Generic; Zyvox®)
*Request Form
Linezolid Tablet (Zyvox®)
*Criteria
Tedizolid IV (Sivextro®)
*POS Edits
Tedizolid Tablet (Sivextro®)
INFECTIOUS DISORDERS (37)
NONE
Lefamulin Acetate Tablet, Vial (Xenleta®)
Antibiotics
Pleuromutilins
*Request Form
*Criteria
*POS Edits
LA Medicaid Preferred Drug List (PDL)/Non-Preferred Drug List (NPDL) Effective Date: July 1, 2024
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Descriptive Therapeutic Class
Drugs on PDL
Drugs on NPDL which Require Prior Authorization (PA)
INFECTIOUS DISORDERS (37)
Doxycycline Hyclate Capsule (Generic)
Demeclocycline Tablet (Generic)
Antibiotics
Doxycycline Hyclate Tablet (Generic)
Doxycycline Calcium Syrup (Vibramycin®)
Tetracyclines
Doxycycline Monohydrate 50 mg Capsule (AG; Generic)
Doxycycline Hyclate DR Tablet (Doryx® MPC)
*Request Form
Doxycycline Monohydrate 100 mg Capsule (AG; Generic)
Doxycycline Hyclate DR Tablet (AG; Generic; Doryx®)
*Criteria
Doxycycline Monohydrate Tablet (Generic)
Doxycycline Hyclate Capsule/Skin Cleanser (Morgidox® Kit)
*POS Edits
Minocycline Capsule (Generic)
Doxycycline Monohydrate 40 mg DR Capsule (AG)
Doxycycline Monohydrate Capsule 75 mg (AG; Generic)
Doxycycline Monohydrate Capsule 150 mg (AG; Generic)
Doxycycline Monohydrate Suspension (Generic)
Minocycline ER Tablet (Generic; MinoLira ER®; Solodyn®)
Minocycline Tablet (Generic)
Omadacycline Tosylate Tablet (Nuzyra®)
Tetracycline Capsule (Generic)
INFECTIOUS DISORDERS (37)
Clindamycin Vaginal Cream (Generic for Cleocin®)
Clindamycin Vaginal Cream (Cleocin®)
Antibiotics
Metronidazole Vaginal Gel (Nuvessa®)
Clindamycin Vaginal Cream (Clindesse®)
Vaginal
Metronidazole Vaginal Gel (Generic for MetroGel-Vaginal®)
Clindamycin Vaginal Gel (Xaciato™)
*Request Form
Clindamycin Vaginal Ovules (Cleocin®)
*Criteria
Metronidazole Vaginal Gel (Vandazole®)
*POS Edits
LA Medicaid Preferred Drug List (PDL)/Non-Preferred Drug List (NPDL) Effective Date: July 1, 2024
Additional Point-of-Sale (POS) Edits May Apply Drugs highlighted in yellow indicate a new addition or a change in status Page | 42
Descriptive Therapeutic Class
Drugs on PDL
Drugs on NPDL which Require Prior Authorization (PA)
INFECTIOUS DISORDERS (37)
Clotrimazole Troche (Generic)
Fluconazole Suspension, Tablet (Diflucan®)
Antifungals
Fluconazole Suspension (Generic)
Flucytosine Capsule (AG; Generic)
Antifungals, Oral
Fluconazole Tablet (Generic)
Griseofulvin Tablet, Ultramicrosize Tablet (Generic)
*Request Form
Griseofulvin Suspension (Generic)
Ibrexafungerp Citrate Tablet (Brexafemme™)
*Criteria
Nystatin Suspension (Generic)
Isavuconazonium Capsule (Cresemba®)
*POS Edits
Nystatin Tablet (Generic)
Itraconazole Capsule, Solution (Generic; Sporanox®)
Terbinafine Tablet (Generic)
Itraconazole Capsule (Tolsura®)
Ketoconazole Tablet (Generic)
Miconazole Buccal Tablet (Oravig®)
Oteseconazole Capsule (Vivjoa™)
Posaconazole Suspension Packet (Noxafil®)
Posaconazole Suspension, Tablet (AG; Generic; Noxafil®)
Voriconazole Suspension, Tablet (Generic; Vfend®)
INFECTIOUS DISORDERS (37)
Sofosbuvir/Velpatasvir (AG for Epclusa®)
Elbasvir/Grazoprevir (Zepatier®)
Hepatitis C Agents
Sofosbuvir/Velpatasvir/Voxilaprevir Tablet (Vosevi®)
Glecaprevir/Pibrentasvir Pellet Pack, Tablet (Mavyret®)
Direct Acting Antiviral Agents
Ledipasvir/Sofosbuvir Tablet (AG; Harvoni®)
*Request Form
Ledipasvir/Sofosbuvir Pellet Pack (Harvoni®)
*Hepatitis C DAA Criteria
Sofosbuvir Pellet Pack, Tablet (Sovaldi®)
*Hepatitis C DAA Worksheet
Sofosbuvir/Velpatasvir Tablet, Pellet Pack (Epclusa®)
*Patient Treatment Agreement
*POS Edits
INFECTIOUS DISORDERS (37)
Peginterferon alfa 2a Syringe (Pegasys®)
Ribavirin Capsule (Generic)
Hepatitis C Agents
Peginterferon alfa 2a Vial (Pegasys®)
Not Direct Acting Antiviral Agents
Ribavirin Tablet (Generic)
*Request Form
*Criteria
*POS Edits
LA Medicaid Preferred Drug List (PDL)/Non-Preferred Drug List (NPDL) Effective Date: July 1, 2024
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Descriptive Therapeutic Class
Drugs on PDL
Drugs on NPDL which Require Prior Authorization (PA)
LUPUS IMMUNOMODULATORS (38)
NONE
Anifrolumab-fnia Vial (Saphnelo®)
*Request Form
Belimumab Auto-Injector, IV, Syringe, Vial (Benlysta®)
*Criteria
Voclosporin Capsule (Lupkynis®)
*POS Edits
METHOTREXATE (39)
Methotrexate PF Vial (AG; Generic)
Methotrexate Auto-Injector (Otrexup®)
*Request Form
Methotrexate Tablet
Methotrexate Auto-Injector (Rasuvo®)
*Criteria
Methotrexate Vial
Methotrexate PF Syringe (RediTrex®)
*POS Edits
Methotrexate Solution (Xatmep®)
Methotrexate Tablet (Trexall™)
MOVEMENT DISORDERS (40)
Deutetrabenazine Tablet (Austedo®; Austedo XR®)
Tetrabenazine Tablet (Xenazine®)
*Request Form
Tetrabenazine Tablet (Generic)
*Criteria
Valbenazine Capsule (Ingrezza®)
*POS Edits
Valbenazine Capsule Initiation Pack (Ingrezza®)
LA Medicaid Preferred Drug List (PDL)/Non-Preferred Drug List (NPDL) Effective Date: July 1, 2024
Additional Point-of-Sale (POS) Edits May Apply Drugs highlighted in yellow indicate a new addition or a change in status Page | 44
Descriptive Therapeutic Class
Drugs on PDL
Drugs on NPDL which Require Prior Authorization (PA)
MULTIPLE SCLEROSIS (41)
Dalfampridine ER Tablet (Generic)
Alemtuzumab Vial (Lemtrada®)
Multiple Sclerosis Agents
Dimethyl Fumarate DR Capsule (Generic)
Cladribine Tablet (Mavenclad®)
Immunomodulatory Agents
Dimethyl Fumarate DR Starter Pack (Generic)
Dalfampridine ER Tablet (Ampyra®)
*Request Form
Fingolimod Capsule (Generic for Gilenya®)
Dimethyl Fumarate Capsule, Starter Pack (Tecfidera®)
*Criteria
Glatiramer Acetate Syringe 20mg, 40mg (Generic; Copaxone®)
Diroximel Fumarate Capsule (Vumerity®)
*POS Edits
Interferon β-1a Pen Kit (Avonex® Pen)
Fingolimod Capsule (Gilenya®)
Interferon β-1b Kit (Betaseron®)
Fingolimod Lauryl Sulfate Orally Disintegrating Tablet (Tascenso ODT™)
Interferon β-1a Syringe, Syringe Kit (Avonex®)
Interferon β-1a Auto-Injector, Titration Pack (Rebif® Rebidose®)
Interferon β-1a Vial Kit (Avonex®)
Interferon β-1a Syringe, Titration Pack (Rebif®)
Ofatumumab Pen (Kesimpta®)
Interferon β-1b Kit, Vial (Extavia®)
Teriflunomide Tablet (Generic)
Monomethyl Fumarate Capsule DR (Bafiertam®)
Natalizumab Vial (Tysabri®)
Ocrelizumab Vial (Ocrevus®)
Ozanimod Capsule, Starter Kit, Starter Pack (Zeposia®)
Peginterferon β -1a IM, Subcutaneous (Plegridy®)
Ponesimod Starter Pack, Tablet (Ponvory®)
Siponimod Dose Pack, Tablet (Mayzent®)
Teriflunomide Tablet (Aubagio®)
Ublituximab-xiiy Vial (Briumvi®)
LA Medicaid Preferred Drug List (PDL)/Non-Preferred Drug List (NPDL) Effective Date: July 1, 2024
Additional Point-of-Sale (POS) Edits May Apply Drugs highlighted in yellow indicate a new addition or a change in status Page | 45
Descriptive Therapeutic Class
Drugs on PDL
Drugs on NPDL which Require Prior Authorization (PA)
ONCOLOGY (42)
Anastrozole Tablet (Generic)
Abemaciclib Tablet (Verzenio®)
Oral – Breast
Capecitabine Tablet (Generic)
Alpelisib Tablet (Piqray®)
*Request Form
Cyclophosphamide Capsule, Tablet (Generic)
Anastrozole Tablet (Arimidex®)
*Criteria
Exemestane Tablet (Generic)
Capecitabine Tablet (Xeloda®)
*POS Edits
Fulvestrant Syringe (AG; Generic)
Capivasertib Tablet (Truqap™)
Letrozole Tablet (Generic)
Elacestrant Tablet (Orserdu®)
Palbociclib Capsule (Ibrance®)
Exemestane Tablet (Aromasin®)
Palbociclib Tablet (Ibrance®)
Fulvestrant Syringe (Faslodex®)
Tamoxifen Citrate Tablet (Generic)
Lapatinib Ditosylate Tablet (Generic; Tykerb®)
Letrozole Tablet (Femara®)
Neratinib Maleate Tablet (Nerlynx®)
Ribociclib Succinate Tablet (Kisqali®)
Ribociclib Succinate/Letrozole Tablet (Kisqali/Femara Kit®)
Talazoparib Capsule (Talzenna®)
Tamoxifen Citrate Solution (Soltamox®)
Toremifene Citrate Tablet (Generic; Fareston®)
Tucatinib Tablet (Tukysa™)
ONCOLOGY (42)
Busulfan Tablet (Myleran®)
Acalabrutinib Capsule, Tablet (Calquence®)
Oral – Hematologic
Chlorambucil Tablet (Leukeran®)
Asciminib Tablet (Scemblix®)
*Request Form
Dasatinib Tablet (Sprycel®)
Azacitidine Tablet (Onureg™)
*Criteria
Hydroxyurea Capsule (Generic)
Bosutinib Tablet (Bosulif®)
*POS Edits
Ibrutinib Capsule (Imbruvica®)
Decitabine/Cedazuridine Tablet (Inqovi®)
Ibrutinib Tablet (Imbruvica®)
Duvelisib Capsule (Copiktra®)
Imatinib Mesylate Tablet (Generic)
Enasidenib Mesylate Tablet (Idhifa®)
Lenalidomide Capsule (Generic; Revlimid®)
Fedratinib Capsule (Inrebic®)
Melphalan Tablet (Generic)
Gilterinib Tablet (Xospata®)
Mercaptopurine Tablet (Generic)
Glasdegib Tablet (Daurismo®)
Procarbazine HCl Capsule (Matulane®)
Hydroxyurea Capsule (Hydrea®)
Ruxolitinib Phosphate Tablet (Jakafi®)
Ibrutinib Suspension (Imbruvica®)
LA Medicaid Preferred Drug List (PDL)/Non-Preferred Drug List (NPDL) Effective Date: July 1, 2024
Additional Point-of-Sale (POS) Edits May Apply Drugs highlighted in yellow indicate a new addition or a change in status Page | 46
Descriptive Therapeutic Class
Drugs on PDL
Drugs on NPDL which Require Prior Authorization (PA)
ONCOLOGY (42)
Tretinoin Capsule (Generic)
Idelalisib Tablet (Zydelig®)
Oral – Hematologic Continued
Venetoclax Tablet (Venclexta®)
Imatinib Mesylate Tablet (Gleevec®)
Venetoclax Starting Pack Tablet (Venclexta®)
Ivosidenib Tablet (Tibsovo®)
Ixazomib Citrate Capsule (Ninlaro®)
Mercaptopurine Suspension (Purixan®)
Midostaurin Capsule (Rydapt®)
Momelotinib Tablet (Ojjaara™)
Nilotinib HCl Capsule (Tasigna®)
Olutasidenib Capsule (Rezlidhia®)
Pacritinib Capsule (Vonjo®)
Pomalidomide Capsule (Pomalyst®)
Ponatinib HCl Tablet (Iclusig®)
Quizartinib Dihydrochloride (Vanflyta®)
Selinexor Tablet (Xpovio®)
Thalidomide Capsule (Thalomid®)
Vorinostat Capsule (Zolinza®)
Zanubrutinib Capsule (Brukinsa™)
ONCOLOGY (42)
Afatinib Dimaleate Tablet (Gilotrif®)
Adagrasib Tablet (Krazati®)
Oral – Lung
Alectinib HCl Capsule (Alecensa®)
Brigatinib Tablet (Alunbrig®)
*Request Form
Crizotinib Capsule (Xalkori®)
Capmatinib Tablet (Tabrecta™)
*Criteria
Osimertinib Mesylate Tablet (Tagrisso®)
Ceritinib Tablet (Zykadia®)
*POS Edits
Topotecan HCl Capsule (Hycamtin®)
Crizotinib Pellet (Xalkori®)
Dacomitinib Tablet (Vizimpro®)
Entrectinib Capsule, Pellet Pack (Rozlytrek®)
Erlotinib HCl Tablet (Generic; Tarceva®)
Gefitinib Tablet (Generic; Iressa®)
Lorlatinib Tablet (Lorbrena®)
Mobocertinib Capsule (Exkivity®)
LA Medicaid Preferred Drug List (PDL)/Non-Preferred Drug List (NPDL) Effective Date: July 1, 2024
Additional Point-of-Sale (POS) Edits May Apply Drugs highlighted in yellow indicate a new addition or a change in status Page | 47
Descriptive Therapeutic Class
Drugs on PDL
Drugs on NPDL which Require Prior Authorization (PA)
ONCOLOGY (42)
(Preferred agents listed on page 46)
Pralsetinib Capsule (Gavreto™)
Oral – Lung Continued
Repotrectinib Capsule (Augtyro™)
Selpercatinib Capsule (Retevmo™)
Sotorasib Tablet (Lumakras™)
Tepotinib HCl Tablet (Tepmetko®)
ONCOLOGY (42)
Niraparib Tosylate Capsule (Zejula®)
Avapritinib Tablet (Ayvakit™)
Oral – Other
Selumetinib Capsule (Koselugo™)
Cabozantinib S-Malate Capsule (Cometriq®)
*Request Form
Temozolomide Capsule (Generic)
Erdafitinib Tablet (Balversa™)
*Criteria
Eflornithine Tablet (Iwilfin™)
*POS Edits
Futibatinib Tablet Therapy Pack (Lytgobi®)
Fruquintinib Capsule (Fruzaqla®)
Infagratinib Phosphate Capsule (Truseltiq™)
Larotrectinib Capsule (Vitrakvi®)
Larotrectinib Solution (Vitrakvi®)
Niraparib Tosylate Tablet (Zejula®)
Nirogacestat Tablet (Ogsiveo™)
Olaparib Capsule, Tablet (Lynparza®)
Pemigatinib Tablet (Pemazyre®)
Pexidartinib Capsule (Turalio®)
Pirtobrutinib Tablet (Jaypirca®)
Regorafenib Tablet (Stivarga®)
Ripretinib Tablet (Qinlock™)
Rucaparib Camsylate Tablet (Rubraca®)
Tazemetostat Tablet (Tazverik™)
Trifluridine/Tipiracil HCl Tablet (Lonsurf®)
Vandetanib Tablet (Caprelsa®)
LA Medicaid Preferred Drug List (PDL)/Non-Preferred Drug List (NPDL) Effective Date: July 1, 2024
Additional Point-of-Sale (POS) Edits May Apply Drugs highlighted in yellow indicate a new addition or a change in status Page | 48
Descriptive Therapeutic Class
Drugs on PDL
Drugs on NPDL which Require Prior Authorization (PA)
ONCOLOGY (42)
Abiraterone Acetate Tablet (Generic for Zytiga®)
Abiraterone Acetate Tablet (Zytiga®)
Oral – Prostate
Bicalutamide Tablet (Generic)
Abiraterone Acetate Submicronized Tablet (Yonsa®)
*Request Form
Enzalutamide Capsule, Tablet (Xtandi®)
Apalutamide Tablet (Erleada®)
*Criteria
Flutamide Capsule (Generic)
Bicalutamide Tablet (Casodex®)
*POS Edits
Darolutamide Tablet (Nubeqa®)
Estramustine Phosphate Sodium Capsule (Emcyt®)
Nilutamide Tablet (AG; Generic)
Niraparib/Abiraterone Tablet (Akeega®)
Relugolix Tablet (Orgovyx®)
ONCOLOGY (42)
Axitinib Tablet (Inlyta®)
Belzutifan Tablet (Welireg ™)
Oral - Renal Cell
Everolimus Tablet (Generic)
Cabozantinib S-Malate Tablet (Cabometyx®)
*Request Form
Lenvatinib Mesylate Capsule (Lenvima®)
Everolimus Tablet (Afinitor®)
*Criteria
Pazopanib HCl Tablet (Votrient®)
Everolimus Tablet for Oral Suspension (Generic; Afinitor Disperz®)
*POS Edits
Sorafenib Tosylate Tablet (Generic; Nexavar®)
Tivozanib HCl Capsule (Fotivda™)
Sunitinib Malate Capsule (Generic; Sutent®)
ONCOLOGY (42)
Cobimetinib Fumarate Tablet (Cotellic®)
Binimetinib Tablet (Mektovi®)
Oral - Skin
Dabrafenib Mesylate Capsule (Tafinlar®)
Dabrafenib Mesylate Tablet for Oral Suspension (Tafinlar®)
*Request Form
Sonidegib Phosphate Capsule (Odomzo®)
Encorafenib Capsule (Braftovi®)
*Criteria
Trametinib Dimethyl Sulfoxide Tablet (Mekinist®)
Trametinib Dimethyl Sulfoxide for Oral Solution (Mekinist®)
*POS Edits
Vemurafenib Tablet (Zelboraf®)
Vismodegib Capsule (Erivedge®)
OPHTHALMIC DISORDERS (43)
Azelastine HCl Solution (Generic)
Bepotastine Solution (AG; Generic; Bepreve®)
Allergic Conjunctivitis
Cromolyn Sodium Solution (Generic)
Cetirizine Solution (Zerviate™)
*Request Form
Loteprednol Suspension (Alrex®)
Epinastine Solution (Generic)
*Criteria
Olopatadine HCl 0.1% Solution (Generic for Patanol®)
Lodoxamide Tromethamine Solution (Alomide®)
*POS Edits
Nedocromil Sodium Solution (Alocril®)
Olopatadine HCl 0.2% Solution Rx (Generic for Pataday®)
LA Medicaid Preferred Drug List (PDL)/Non-Preferred Drug List (NPDL) Effective Date: July 1, 2024
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Descriptive Therapeutic Class
Drugs on PDL
Drugs on NPDL which Require Prior Authorization (PA)
OPHTHALMIC DISORDERS (43)
Bacitracin/Polymyxin B Sulfate Ointment (Generic)
Azithromycin Solution (AzaSite®)
Antibiotics
Ciprofloxacin Ophthalmic Solution (Generic)
Bacitracin Ointment (Generic)
*Request Form
Erythromycin Base Ointment (Generic)
Besifloxacin Suspension (Besivance®)
*Criteria
Gentamicin Sulfate Solution (Generic)
Ciprofloxacin Ointment (Ciloxan®)
*POS Edits
Moxifloxacin Solution (AG; Generic for Vigamox®)
Gatifloxacin Solution (Generic; Zymaxid®)
Neomycin/Polymyxin B/Gramicidin Solution (Generic)
Moxifloxacin Solution (Generic for Moxeza®)
Ofloxacin Ophthalmic Solution (Generic)
Moxifloxacin Solution (Vigamox®)
Polymyxin B Sulfate/Trimethoprim Solution (Generic)
Natamycin Suspension (Natacyn®)
Sulfacetamide Sodium Solution (Generic)
Neomycin/Bacitracin/Polymyxin B Ointment (AG; Generic)
Tobramycin Solution (Generic)
Ofloxacin Solution (Ocuflox®)
Sulfacetamide Sodium Ointment (Generic)
Tobramycin Ointment (Tobrex®)
OPHTHALMIC DISORDERS (43)
Neomycin/Polymyxin B/Dexamethasone Ointment (Generic)
Neomycin/Bacitracin/Polymyxin B/Hydrocortisone Ointment (Generic)
Antibiotic-Steroid Combinations
Neomycin/Polymyxin B/Dexamethasone Suspension (Generic)
Neomycin/Polymyxin B/Dexamethasone Ointment, Suspension (Maxitrol®)
*Request Form
Sulfacetamide/Prednisolone Solution (Generic)
Neomycin/Polymyxin B/Hydrocortisone Suspension (Generic)
*Criteria
Tobramycin/Dexamethasone Ointment (TobraDex®)
Tobramycin/Dexamethasone ST (TobraDex ST®)
*POS Edits
Tobramycin/Dexamethasone Drops (AG; Generic; TobraDex®)
Tobramycin/Loteprednol Suspension (Zylet®)
LA Medicaid Preferred Drug List (PDL)/Non-Preferred Drug List (NPDL) Effective Date: July 1, 2024
Additional Point-of-Sale (POS) Edits May Apply Drugs highlighted in yellow indicate a new addition or a change in status Page | 50
Descriptive Therapeutic Class
Drugs on PDL
Drugs on NPDL which Require Prior Authorization (PA)
OPHTHALMIC DISORDERS (43)
Dexamethasone Sodium Phosphate Solution (Generic)
Bromfenac Sodium 0.07% Solution (Prolensa®)
Anti-Inflammatories
Diclofenac Sodium Solution (Generic)
Bromfenac Sodium 0.075% Solution (BromSite®)
*Request Form
Difluprednate Emulsion (AG; Generic; Durezol®)
Bromfenac Sodium 0.09% Solution (Generic)
*Criteria
Fluorometholone 0.1% Suspension (Generic)
Dexamethasone Insert (Dextenza®)
*POS Edits
Flurbiprofen Sodium Solution (Generic)
Dexamethasone/PF Suspension (Dexycu™)
Ketorolac Tromethamine LS Solution 0.4% (Generic)
Dexamethasone Suspension (Maxidex®)
Ketorolac Tromethamine Solution 0.5% (Generic)
Dexamethasone Intravitreal Implant (Ozurdex®)
Prednisolone Acetate 1% Suspension (Generic)
Fluocinolone Acetonide Intravitreal Implant (Iluvien®; Retisert®)
Fluocinolone Acetonide Intravitreal Implant (Yutiq®)
Fluorometholone 0.1% Suspension (FML®)
Fluorometholone 0.25% Suspension (FML Forte®)
Fluorometholone Acetate 0.1% Suspension (Flarex®)
Ketorolac Tromethamine 0.4% 0.5% Solution (Acular LS; Acular®)
Ketorolac Tromethamine PF Solution 0.45% (Acuvail®)
Loteprednol Etabonate 1% Ophthalmic Suspension (Inveltys®)
Loteprednol Gel (AG; Generic; Lotemax®)
Loteprednol Ointment (Lotemax®)
Loteprednol Suspension (AG; Generic; Lotemax®)
Nepafenac 0.1% Suspension (Nevanac®)
Nepafenac 0.3% Suspension (Ilevro®)
Prednisolone Acetate 0.12% Solution (Pred Mild®)
Prednisolone Acetate 1% Suspension (Pred Forte®)
Prednisolone Sodium Phosphate Solution (Generic)
Triamcinolone Acetonide Suspension (Triesence®)
Triamcinolone Acetonide/PF (Xipere®)
LA Medicaid Preferred Drug List (PDL)/Non-Preferred Drug List (NPDL) Effective Date: July 1, 2024
Additional Point-of-Sale (POS) Edits May Apply Drugs highlighted in yellow indicate a new addition or a change in status Page | 51
Descriptive Therapeutic Class
Drugs on PDL
Drugs on NPDL which Require Prior Authorization (PA)
OPHTHALMIC DISORDERS (43)
Cyclosporine 0.05% Emulsion (AG; Generic; Restasis®)
Cyclosporine 0.09% Solution (Cequa®)
Anti-Inflammatory/Immunomodulators
Cyclosporine 0.05% Emulsion (Restasis® Multidose™)
Cyclosporine 0.1% Emulsion (Verkazia®)
*Request Form
Lifitegrast Solution (Xiidra®)
Cyclosporine 0.1% Solution (Vevye™)
*Criteria
Loteprednol Etabonate Suspension (Eysuvis®)
*POS Edits
Perfluorohexyloctane/PF (Miebo®)
Varenicline Nasal Spray (Tyrvaya®)
OPHTHALMIC DISORDERS (43)
NONE
Cysteamine HCl Solution (Cystadrops®)
Cystinosis
Cysteamine HCl Solution (Cystaran®)
*Request Form
*Criteria
*POS Edits
OPHTHALMIC DISORDERS (43)
Brimonidine 0.15% Solution (Generic; Alphagan P® 0.15%)
Apraclonidine Solution 0.5% (Generic; Iopidine®)
Glaucoma Agents
Brimonidine 0.2% Solution (Generic)
Apraclonidine Solution 1% (Iopidine®)
Intraocular Pressure (IOP) Reducers
Brimonidine/Brinzolamide Suspension (Simbrinza®)
Betaxolol 0.25% Suspension (Betoptic S®)
*Request Form
Brimonidine/Timolol Solution (AG; Generic; Combigan®)
Betaxolol 0.5% Solution (Generic)
*Criteria
Carteolol Solution (Generic)
Bimatoprost 0.01% Solution 2.5 mL, 5mL, 7.5mL (Lumigan®)
*POS Edits
Dorzolamide Solution (Generic)
Bimatoprost 0.03% Solution 2.5 mL, 5mL, 7.5mL (Generic)
Dorzolamide/Timolol Solution (Generic)
Bimatoprost Implant (Durysta®)
Latanoprost 2.5mL Solution (Generic)
Brimonidine 0.1% Solution (Generic; Alphagan P®)
Levobunolol Solution (Generic)
Brinzolamide Suspension (AG; Generic; Azopt®)
Netarsudil Mesylate Solution (Rhopressa®)
Dorzolamide Solution (Trusopt®)
Netarsudil Mesylate/Latanoprost Solution (Rocklatan®)
Dorzolamide/Timolol Solution (Cosopt®)
Timolol Maleate Solution (Generic)
Dorzolamide/Timolol/PF Solution (Generic; Cosopt PF®)
Timolol Maleate Gel-Forming Solution (Generic Timoptic-XE®)
Echothiophate Iodide Solution (Phospholine Iodide®)
Travoprost Solution 2.5 mL, 5 mL (AG; Generic; Travatan Z®)
Latanoprost Emulsion (Xelpros®)
Latanoprost Solution 2.5 mL (Xalatan®)
Latanoprost/PF Solution (Iyuzeh®)
Latanoprostene Bunod Solution (Vyzulta®)
LA Medicaid Preferred Drug List (PDL)/Non-Preferred Drug List (NPDL) Effective Date: July 1, 2024
Additional Point-of-Sale (POS) Edits May Apply Drugs highlighted in yellow indicate a new addition or a change in status Page | 52
Descriptive Therapeutic Class
Drugs on PDL
Drugs on NPDL which Require Prior Authorization (PA)
OPHTHALMIC DISORDERS (43)
(Preferred agents listed on page 51)
Pilocarpine HCl Solution (Generic for Isopto Carpine®)
Glaucoma Agents
Pilocarpine HCl Solution (Vuity™)
Intraocular Pressure (IOP) Reducers Cont
Tafluprost Solution (AG; Generic; Zioptan®)
Timolol Solution (Betimol®)
Timolol Maleate LA Solution (AG; Generic; Istalol®)
Timolol Maleate 0.25% Solution (Generic; Timoptic® Ocudose®)
Timolol Maleate 0.5% Solution (AG; Generic; Timoptic® Ocudose®)
OPIATE DEPENDENCE AGENTS (44)
Buprenorphine Sublingual Tablet (Generic)
Lofexidine Tablet (Lucemyra®)
*Request Form
Buprenorphine Syringe (Sublocade®; Brixadi®)
Naloxone Injection (Zimhi™)
*Criteria
Buprenorphine/Naloxone Sublingual Film (Generic; Suboxone®)
Naloxone Spray (Kloxxado®)
*POS Edits
Buprenorphine/Naloxone Sublingual Tablet (Generic)
Buprenorphine/Naloxone Sublingual Tablet (Zubsolv®)
Nalmefene Nasal Spray (Opvee®)
Naloxone Nasal Spray (AG; Generic; Narcan®)
Naloxone Syringe, Vial (Generic)
Naltrexone Extended-Release Suspension Vial (Vivitrol®)
Naltrexone Tablet (Generic)
OSTEOPOROSIS (45)
Alendronate Tablet (Generic)
Abaloparatide Pen (Tymlos®)
Bone Resorption Suppression Agents
Calcitonin-Salmon Nasal (Generic)
Alendronate Effervescent Tablet, Tablet (Binosto®; Fosamax®)
*Request Form
Ibandronate Tablet (Generic)
Alendronate Solution (Generic)
*Criteria
Raloxifene Tablet (Generic)
Alendronate/Vitamin D Tablet (Fosamax Plus D®)
*POS Edits
Denosumab Syringe (Prolia®)
Raloxifene Tablet (Evista®)
Risedronate Tablet (AG; Generic; Actonel®)
Risedronate DR Tablet (AG; Generic; Atelvia®)
Romosozumab-aqqg Syringe (Evenity®)
Teriparatide Pen (Brand)
Teriparatide Pen (Generic; Forteo®)
LA Medicaid Preferred Drug List (PDL)/Non-Preferred Drug List (NPDL) Effective Date: July 1, 2024
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Descriptive Therapeutic Class
Drugs on PDL
Drugs on NPDL which Require Prior Authorization (PA)
OTIC AGENTS (46)
Ciprofloxacin/Dexamethasone Susp (AG; Generic; Ciprodex®)
Ciprofloxacin Solution (Generic)
Antibiotics
Neomycin/Polymyxin B/Hydrocortisone Solution (AG; Generic)
Ciprofloxacin/Fluocinolone Acetonide Solution (AG; Otovel®)
*Request Form
Neomycin/Polymyxin B/Hydrocortisone Suspension (AG; Generic)
Ciprofloxacin/Hydrocortisone Suspension (Cipro HC Otic®)
*Criteria
Ofloxacin Solution (Generic)
Colistin/Neomycin/Thonzonium/HC Suspension (Cortisporin® TC)
*POS Edits
OTIC AGENTS (46)
Acetic Acid Solution (Generic)
NONE
Anti-Infectives and Anesthetics
Acetic Acid/Hydrocortisone Solution (Generic)
*Request Form
*Criteria
*POS Edits
PAIN MANAGEMENT (47)
Atogepant Tablet (Qulipta™)
Eptinezumab-jjmr Vial (Vyepti™)
Antimigraine Agents
Erenumab-aooe Autoinjector (Aimovig®)
Galcanezumab-gnlm 100 mg Syringe (Emgality®)
CGRP Antagonists
Fremanezumab-vfrm Autoinjector, 3-Pack, Syringe (Ajovy®)
Zavegepant Nasal (Zavzpret®)
*Request Form
Galcanezumab-gnlm Pen, 120 mg Syringe (Emgality®)
*Criteria
Rimegepant Disintegrating Tablet (Nurtec™ ODT)
*POS Edits
Ubrogepant Tablet (Ubrelvy™)
PAIN MANAGEMENT (47)
NONE
Celecoxib Oral Solution (Elyxyb™)
Antimigraine Agents
Diclofenac Potassium Oral Powder Packet (AG; Generic for Cambia®)
Ergotamines
Dihydroergotamine Mesylate Injection (Generic)
*Request Form
Dihydroergotamine Mesylate Nasal (AG; Generic; Migranal®)
*Criteria
Dihydroergotamine Mesylate Nasal (Trudhesa™)
*POS Edits
Ergotamine Tartrate Sublingual (Ergomar®)
Ergotamine Tartrate/Caffeine Rectal (Migergot®)
LA Medicaid Preferred Drug List (PDL)/Non-Preferred Drug List (NPDL) Effective Date: July 1, 2024
Additional Point-of-Sale (POS) Edits May Apply Drugs highlighted in yellow indicate a new addition or a change in status Page | 54
Descriptive Therapeutic Class
Drugs on PDL
Drugs on NPDL which Require Prior Authorization (PA)
PAIN MANAGEMENT (47)
Rizatriptan ODT (Generic)
Almotriptan Tablet (Generic)
Antimigraine Agents
Rizatriptan Tablet (Generic)
Eletriptan Tablet (AG; Generic; Relpax®)
Triptans
Sumatriptan Nasal (AG; Generic; Imitrex®)
Frovatriptan Tablet (Generic; Frova®)
*Request Form
Sumatriptan Tablet (Generic)
Lasmiditan Tablet (Reyvow®)
*Criteria
Sumatriptan Vial (Generic)
Naratriptan (Generic for Amerge®)
*POS Edits
Rizatriptan Tablet (Maxalt®)
Rizatriptan Tablet (Maxalt MLT®)
Sumatriptan Auto-Injector (Zembrace® SymTouch®)
Sumatriptan Kit (AG; Generic; Imitrex®)
Sumatriptan Kit (SUN)
Sumatriptan Nasal (Onzetra® Xsail®)
Sumatriptan Nasal (Tosymra™)
Sumatriptan Tablet (Imitrex®)
Sumatriptan/Naproxen (Generic; Treximet®)
Zolmitriptan Tablet (Generic; Zomig®)
Zolmitriptan ODT (Generic for Zomig ZMT®)
Zolmitriptan Nasal (AG; Generic; Zomig®)
LA Medicaid Preferred Drug List (PDL)/Non-Preferred Drug List (NPDL) Effective Date: July 1, 2024
Additional Point-of-Sale (POS) Edits May Apply Drugs highlighted in yellow indicate a new addition or a change in status Page | 55
Descriptive Therapeutic Class
Drugs on PDL
Drugs on NPDL which Require Prior Authorization (PA)
PAIN MANAGEMENT (47)
Adalimumab Pen Kit (Humira®)
Abatacept Injection Clickject, Syringe, Vial (Orencia®)
Cytokine and CAM Antagonists
Adalimumab Syringe Kit (Humira®)
Abrocitinib Tablet (Cibinqo™)
*Request Form
Apremilast Tablet (Otezla®)
Adalimumab-atto Kit, Pen Kit (Amjevita®)
*Criteria
Etanercept Cartridge (Enbrel Mini®)
Adalimumab-aacf Autoinjector Kit, Pen Kit (Idacio®)
*POS Edits
Etanercept Pen (Enbrel SureClick®)
Adalimumab-aaty Kit, Pen Kit (Yuflyma®)
Etanercept Syringe (Enbrel®)
Adalimumab-adaz Kit, Pen Kit (Generic; Hyrimoz®)
Etanercept Vial (Enbrel®)
Adalimumab-adbm Kit, Pen Kit (Generic; Cyltezo®)
Infliximab Vial (Generic for Remicade®)
Adalimumab-afzb Kit, Pen Kit (Abrilada™)
Tofacitinib Citrate Tablet (Xeljanz®)
Adalimumab-aqvh Pen Kit (Yusimry®)
Adalimumab-bwwd Kit, Pen Kit (Hadlima®)
Adalimumab-fkjp Kit, Pen Kit (Generic; Hulio®)
Anakinra Syringe (Kineret®)
Baricitinib Tablet (Olumiant®)
Bimekizumab-bkzx Pen, Syringe (Bimzelx®)
Brodalumab Syringe (Siliq®)
Canakinumab/PF Vial (Ilaris®)
Certolizumab Pegol Kit, Syringe Kit (Cimzia®)
Deucravacitinib Tablet (Sotyktu®)
Etrasimod Tablet (Velsipity™)
Golimumab Pen, Syringe (Simponi®)
Golimumab Vial (Simponi Aria®)
Guselkumab Autoinjector, Syringe (Tremfya®)
Inebilizumab-cdon Vial (Uplizna™)
Infliximab Vial (Remicade®)
Infliximab-abda Vial (Renflexis®)
Infliximab-axxq Vial (Avsola™)
Infliximab-dyyb Vial (Inflectra®)
Ixekizumab Autoinjector, Syringe (Taltz®)
LA Medicaid Preferred Drug List (PDL)/Non-Preferred Drug List (NPDL) Effective Date: July 1, 2024
Additional Point-of-Sale (POS) Edits May Apply Drugs highlighted in yellow indicate a new addition or a change in status Page | 56
Descriptive Therapeutic Class
Drugs on PDL
Drugs on NPDL which Require Prior Authorization (PA)
PAIN MANAGEMENT (47)
(Preferred agents listed on page 55)
Mirkizumab-mrkz Pen, Vial (Omvoh™)
Cytokine and CAM Antagonists
Rilonacept Vial (Arcalyst®)
Risankizumab-rzaa On-Body Cartridge, Pen, Syringe, Vial (Skyrizi®)
Sarilumab Pen, Syringe (Kevzara®)
Satralizumab-mwge Syringe (Enspryng™)
Secukinumab Pen, Syringe, Vial (Cosentyx®)
Spesolimab-sbzo Vial (Spevigo®)
Tildrakizumab-asmn Syringe (Ilumya®)
Tocilizumab Pen, Syringe, Vial (Actemra®)
Tofacitinib Citrate ER Tablet (Xeljanz® XR)
Tofacitinib Citrate Solution (Xeljanz®)
Upadacitinib ER Tablet (Rinvoq™)
Ustekinumab Syringe, Vial (Stelara®)
Vedolizumab Pen, Vial (Entyvio®)
LA Medicaid Preferred Drug List (PDL)/Non-Preferred Drug List (NPDL) Effective Date: July 1, 2024
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Descriptive Therapeutic Class
Drugs on PDL
Drugs on NPDL which Require Prior Authorization (PA)
PAIN MANAGEMENT (47)
Acetaminophen with Codeine Elixir (Generic)
Benzhydrocodone/Acetaminophen (AG; Apadaz®)
Narcotic Analgesics - Short-Acting
Acetaminophen with Codeine Tablet (Generic)
Butalbital/Caffeine/APAP/Codeine Capsule (Generic; Fioricet® with Codeine)
*Request Form
Hydrocodone/Acetaminophen Solution (Generic)
Butalbital Compound with Codeine Capsule (Generic)
*Criteria
Hydrocodone/Acetaminophen Tablet (Generic)
Butorphanol Tartrate Nasal (Generic)
*POS Edits
Hydromorphone Tablet (Generic)
Carisoprodol Compound with Codeine Tablet (Generic)
Morphine Sulfate IR Tablet (Generic)
Codeine Tablet (Generic)
Morphine Sulfate Oral Syringe (Generic)
Dihydrocodeine Bitartrate/Acetaminophen/Caffeine Capsule, Tablet (Generic)
Oxycodone HCl Tablet (Generic)
Fentanyl Buccal Lozenge (Generic for Actiq®)
Oxycodone/Acetaminophen Tablet (Generic)
Fentanyl Buccal Tablet (Generic; Fentora®)
Tramadol 50 mg Tablet (Generic)
Hydrocodone/Ibuprofen Tablet (Generic)
Tramadol/Acetaminophen Tablet (Generic)
Hydromorphone Tablet (Dilaudid®)
Hydromorphone Liquid, Suppository (Generic)
Levorphanol Tablet (Generic)
Meperidine Solution, Tablet (Generic)
Morphine Oral Concentrate, Suppository (Generic)
Morphine Solution (AG, Generic)
Oxycodone HCl Tablet (Roxicodone®, Roxybond®)
Oxycodone Capsule, Oral Concentrate, Solution (Generic)
Oxycodone/Acetaminophen Tablet (Nalocet®, Percocet®)
Oxycodone/Acetaminophen Solution, Tablet (Generic for Prolate®)
Oxycodone/Acetaminophen Solution (Generic)
Oxymorphone IR Tablet (Generic)
Pentazocine/Naloxone Tablet (Generic)
Sufentanil Sublingual Tablet (Dsuvia®)
Tapentadol Tablet (Nucynta®)
Tramadol 25mg, 100 mg Tablet (Generic)
Tramadol Solution (AG)
Tramadol/Celecoxib Tablet (Seglentis®)
LA Medicaid Preferred Drug List (PDL)/Non-Preferred Drug List (NPDL) Effective Date: July 1, 2024
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Descriptive Therapeutic Class
Drugs on PDL
Drugs on NPDL which Require Prior Authorization (PA)
PAIN MANAGEMENT (47)
Buprenorphine Transdermal (AG; Generic; Butrans®)
Buprenorphine Buccal Film (Belbuca®)
Narcotic Analgesics - Long-Acting
Fentanyl Transdermal 12 mcg (Generic)
Fentanyl Transdermal 37.5 mcg, 62.5mcg, 87.5mcg (Generic)
*Request Form
Fentanyl Transdermal 25 mcg (Generic)
Hydrocodone Bitartrate ER Capsule (Generic for Zohydro ER®)
*Criteria
Fentanyl Transdermal 50 mcg (Generic)
Hydrocodone Bitartrate ER Tablet (Generic; Hysingla ER®)
*POS Edits
Fentanyl Transdermal 75 mcg (Generic)
Hydromorphone ER Tablet (Generic)
Fentanyl Transdermal 100 mcg (Generic)
Morphine Sulfate ER Capsule (Generic for Avinza®)
Morphine Sulfate ER Tablet (Generic)
Morphine Sulfate ER Capsule (Generic for Kadian®)
Oxycodone Myristate Capsule (Xtampza® ER)
Morphine Sulfate ER Tablet (MS Contin®)
Oxycodone ER Tablet (AG; OxyContin®)
Oxymorphone ER Tablet (Generic)
Tapentadol ER Tablet (Nucynta ER®)
Tramadol ER Capsule (AG; Conzip®)
Tramadol ER Tablet (Generic Ryzolt®)
Tramadol ER Tablet (Generic Ultram ER®)
PAIN MANAGEMENT (47)
Duloxetine Capsule (Generic for Cymbalta®)
Capsaicin/Skin Cleanser (Qutenza Kit®)
Neuropathic Pain
Gabapentin Capsule (Generic)
Duloxetine Capsule (Cymbalta®)
*Request Form
Gabapentin Solution (AG; Generic)
Duloxetine Capsule (Generic for Irenka®)
*Criteria
Gabapentin Tablet (Generic)
Duloxetine DR Capsule (Drizalma Sprinkle™)
*POS Edits
Lidocaine Patch (AG; Generic; Lidoderm®)
Gabapentin Capsule, Solution, Tablet (Neurontin®)
Lidocaine Topical System (Ztlido®)
Gabapentin Enacarbil Tablet (Horizant®)
Milnacipran Tablet (Savella®)
Gabapentin ER Tablet (Gralise®)
Milnacipran Tablet (Savella Dose Pak®)
Lidocaine Topical Patch (DermacinRx Lidocan™)
Pregabalin Capsule (AG; Generic)
Pregabalin Capsule (Lyrica®)
Pregabalin Solution (AG; Generic)
Pregabalin Solution (Lyrica®)
Pregabalin ER Tablet (Generic; Lyrica CR®)
LA Medicaid Preferred Drug List (PDL)/Non-Preferred Drug List (NPDL) Effective Date: July 1, 2024
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Descriptive Therapeutic Class
Drugs on PDL
Drugs on NPDL which Require Prior Authorization (PA)
PAIN MANAGEMENT (47)
Celecoxib (AG; Generic)
Celecoxib (Celebrex®)
Non-Steroidal Anti-Inflammatory Drugs
(NSAIDS)
Diclofenac Sodium Tablet (Generic)
Diclofenac Epolamine Patch (AG; Flector®)
Diclofenac Sodium Transdermal Gel (Generic)
Diclofenac Epolamine Patch (Licart™)
*Request Form
Ibuprofen Suspension Rx (Generic)
Diclofenac Potassium Capsule (AG; Generic; Zipsor®)
*Criteria
Ibuprofen Tablet Rx (Generic)
Diclofenac Potassium Tablet (Generic; Lofena®)
*POS Edits
Indomethacin Capsule (Generic)
Diclofenac Sodium 1.5% Topical Solution (Generic)
Ketorolac Tablet (Generic)
Diclofenac Sodium 2% Topical Solution (AG; Generic; Pennsaid® Pump)
Meloxicam Tablet (Generic)
Diclofenac SR Tablet (Generic)
Nabumetone Tablet (Generic)
Diclofenac/Misoprostol Tablet (Generic; Arthrotec®)
Naproxen Suspension (AG; Generic)
Diflunisal Tablet (Generic)
Naproxen Tablet (Generic)
Etodolac Capsule, SR Tablet, Tablet (Generic)
Sulindac Tablet (Generic)
Fenoprofen Capsule (AG; Nalfon®)
Fenoprofen Tablet (Generic; Nalfon®)
Flurbiprofen Tablet (Generic)
Ibuprofen/Famotidine Tablet (AG; Generic; Duexis®)
Indomethacin ER Capsule (Generic)
Ketoprofen Capsule, ER Capsule (Generic)
Ketorolac Nasal Spray (AG)
Meclofenamate Sodium Capsule (Generic)
Mefenamic Acid Capsule (Generic)
Meloxicam, Submicronized Capsule (Generic)
Nabumetone Tablet (Relafen DS™)
Naproxen EC Tablet (AG; Generic)
Naproxen Sodium CR Tablet (AG; Generic; Naprelan®)
Naproxen Sodium Tablet (Generic)
Naproxen/Esomeprazole Tablet (AG; Generic; Vimovo®)
Oxaprozin Tablet (Generic)
Piroxicam Capsule (Generic)
Tolmetin Sodium Capsule, Tablet (Generic)
LA Medicaid Preferred Drug List (PDL)/Non-Preferred Drug List (NPDL) Effective Date: July 1, 2024
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Descriptive Therapeutic Class
Drugs on PDL
Drugs on NPDL which Require Prior Authorization (PA)
PAIN MANAGEMENT (47)
Baclofen Tablet (Generic)
Baclofen Granule Pack (Lyvispah™)
Skeletal Muscle Relaxant
Cyclobenzaprine Tablet (Generic)
Baclofen Solution (AG 5mg/5ml; Generic for Ozobax DS® 10mg/5ml)
*Request Form
Methocarbamol Tablet (Generic)
Baclofen Suspension (AG; Generic; Fleqsuvy®)
*Criteria
Tizanidine Tablet (Generic)
Carisoprodol Compound Tablet (Generic)
*POS Edits
Carisoprodol Tablet 250 mg, 350 mg (Generic; Soma®)
Chlorzoxazone Tablet (Generic; Lorzone®)
Cyclobenzaprine ER Capsule (AG; Generic; Amrix®)
Cyclobenzaprine Tablet (Fexmid®)
Dantrolene Sodium (AG; Generic; Dantrium®)
Metaxalone Tablet (Generic)
Orphenadrine ER Tablet (Generic)
Orphenadrine/Aspirin/Caffeine (Generic for Norgesic®)
Orphenadrine/Aspirin/Caffeine (Generic; Norgesic Forte®)
Tizanidine Capsule (Generic; Zanaflex®)
Tizanidine Tablet (Zanaflex®)
PARKINSON'S (48)
Amantadine Capsule (Generic)
Amantadine Hydrochloride ER Capsule (Gocovri®)
Antiparkinson Agents
Amantadine Syrup (Generic)
Amantadine Hydrochloride ER Tablet (Osmolex ER®)
Anticholinergic and Other
Benztropine Tablet (Generic)
Amantadine Tablet (Generic)
*Request Form
Carbidopa/Levodopa ER Tablet (Generic)
Apomorphine Cartridge (Generic; Apokyn®)
*Criteria
Carbidopa/Levodopa Tablet (Generic)
Bromocriptine Capsule, Tablet (Generic)
*POS Edits
Carbidopa/Levodopa/Entacapone Tablet (Generic)
Carbidopa Tablet (Generic; Lodosyn®)
Pramipexole Tablet (Generic)
Carbidopa/Levodopa Enteral Suspension (Duopa®)
Ropinirole Tablet (Generic)
Carbidopa/Levodopa ER Capsule (Rytary®)
Selegiline Tablet (Generic)
Carbidopa/Levodopa ODT (Generic)
Trihexyphenidyl Elixir (Generic)
Carbidopa/Levodopa Tablet (Dhivy®, Sinemet®)
Trihexyphenidyl Tablet (Generic)
Carbidopa/Levodopa/Entacapone Tablet (Stalevo®)
Entacapone Tablet (Generic)
Istradefylline Tablet (Nourianz™)
Levodopa Capsule for Inhalation (Inbrija®)
Opicapone Capsule (Ongentys®)
LA Medicaid Preferred Drug List (PDL)/Non-Preferred Drug List (NPDL) Effective Date: July 1, 2024
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Descriptive Therapeutic Class
Drugs on PDL
Drugs on NPDL which Require Prior Authorization (PA)
PARKINSON'S (48)
(Preferred agents listed on page 60)
Pramipexole ER Tablet (Generic; Mirapex ER®)
Antiparkinson Agents
Rasagiline Tablet (Generic; Azilect®)
Anticholinergic and Other - Continued
Ropinirole ER Tablet (Generic)
Rotigotine Patch (Neupro®)
Safinamide Tablet (Xadago®)
Selegiline Disintegrating Tablet (Zelapar®)
Selegiline Capsule (Generic)
Tolcapone Tablet (Generic)
PEDIATRIC MULTIVITAMINS (49)
Pediatric MVI A, C, D3 No. 21 / FL Drop (Generic)
Pediatric MVI A, C, D3 No. 21 / FL Drop (Tri-Vitamin with FL)
*Request Form
Pediatric MVI No. 2 / FL Drop (Generic)
Pediatric MVI No. 63 / FL Chewable (Quflora™)
*Criteria
Pediatric MVI No. 17 / FL Chewable (Generic)
Pediatric MVI No. 83 / FL 0.25 mg/ml Drop (Quflora™)
*POS Edits
Pediatric MVI No. 45 / FL & Fe Drop (Generic)
Pediatric MVI No. 84 / FL 0.5 mg/ml Drop (Quflora™)
Pediatric MVI No. 85 / FL Chewable (Floriva™)
Pediatric MVI No. 142 / FL & Fe Chewable (Quflora™ FE)
Pediatric MVI No. 151 / FL & Fe Drop (Quflora™ FE)
Pediatric MVI No. 175 / FL Chewable (Poly-Vi-Flor®)
Pediatric MVI No. 175 / FL & Fe Chewable (Poly-Vi-Flor® Fe)
Pediatric MVI No. 220 / FL 0.25mg Drop (Poly-Vi-Flor®)
Pediatric MVI No. 220 / FL & Fe Drop (Poly-Vi-Flor® Fe)
PITUITARY SUPPRESSIVE AGENTS (50)
Leuprolide Acetate Syringe Kit (Fensolvi®)
Histrelin Implant Kit (Supprelin LA®)
*Request Form
Leuprolide Acetate Subcutaneous Kit, Subcutaneous Vial (Generic)
Leuprolide Acetate Depot (AG)
*Criteria
Leuprolide Acetate (Lupron Depot®)
Leuprolide Acetate Subcutaneous (Eligard®)
*POS Edits
Leuprolide Acetate (Lupron Depot Kit®)
Leuprolide Mesylate Syringe (Camcevi™)
Nafarelin Acetate Nasal Solution (Synarel®)
Leuprolide Acetate (Lupron Depot-Ped Kit®)
Leuprolide Acetate (Lupron Depot-Ped®)
Triptorelin Pamoate Vial (Trelstar®)
Triptorelin Pamoate Kit (Triptodur®)
LA Medicaid Preferred Drug List (PDL)/Non-Preferred Drug List (NPDL) Effective Date: July 1, 2024
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Descriptive Therapeutic Class
Drugs on PDL
Drugs on NPDL which Require Prior Authorization (PA)
POTASSIUM BINDERS (51)
Sodium Polystyrene Sulfonate Powder (Generic)
Patiromer Sorbitex Calcium Powder Packet (Veltassa®)
*Request Form
Sodium Zirconium Cyclosilicate (Lokelma®)
*Criteria
*POS Edits
PROGESTATIONAL AGENTS (52)
Medroxyprogesterone Acetate Tablet (AG; Generic)
Medroxyprogesterone Acetate Tablet (Provera®)
*Request Form
Norethindrone Acetate Tablet (Generic)
Norethindrone Acetate Tablet (Aygestin®)
*Criteria
Progesterone Capsule (Generic)
Progesterone Vial (Generic)
*POS Edits
Progesterone, Micronized, Capsule (Prometrium®)
Progesterone, Micronized, Vaginal Gel (Crinone®)
PROSTATE (53)
Alfuzosin ER Tablet (Generic)
Doxazosin ER Tablet, Tablet (Cardura XL®; Cardura®)
Benign Prostatic Hyperplasia (BPH)
Doxazosin Tablet (AG; Generic)
Dutasteride Capsule (Avodart®)
*Request Form
Dutasteride Capsule (Generic)
Dutasteride/Tamsulosin Capsule (Generic; Jalyn®)
*Criteria
Finasteride Tablet (Generic)
Finasteride Tablet (Proscar®)
*POS Edits
Tamsulosin Capsule (Generic)
Finasteride/Tadalafil (Entadfi®)
Terazosin Capsule (Generic)
Silodosin Capsule (Generic; Rapaflo®)
Tadalafil 2.5mg Tablet (Generic for Cialis®)
Tadalafil 5mg Tablet (AG; Generic; Cialis®)
Tamsulosin Capsule (Flomax®)
LA Medicaid Preferred Drug List (PDL)/Non-Preferred Drug List (NPDL) Effective Date: July 1, 2024
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Descriptive Therapeutic Class
Drugs on PDL
Drugs on NPDL which Require Prior Authorization (PA)
SEDATIVE/HYPNOTICS (54)
Temazepam Capsule 15 mg, 30 mg (AG; Generic)
Daridorexant Tablet (Quviviq™)
*Request Form
Triazolam Tablet (Generic)
Dexmeditomidine Film (Igalmi™)
*Criteria
Zolpidem Tablet (Generic)
Doxepin Tablet (AG; Generic; Silenor®)
*POS Edits
Zolpidem Tartrate ER Tablet (Generic)
Estazolam Tablet (Generic)
Eszopiclone Tablet (Generic; Lunesta®)
Flurazepam Capsule (Generic)
Lemborexant Tablet (Dayvigo®)
Quazepam Tablet (AG)
Ramelteon Tablet (Generic; Rozerem®)
Suvorexant Tablet (Belsomra®)
Tasimelteon Capsule (Generic; Hetlioz®)
Tasimelteon /Suspension (Hetlioz LQ™)
Temazepam Capsule 7.5mg, 15mg, 30mg (Restoril®)
Temazepam 7.5 mg, 22.5 mg (Generic)
Triazolam Tablet (Halcion®)
Zaleplon Capsule (Generic)
Zolpidem Tartrate ER Tablet (Ambien CR®)
Zolpidem Tartrate Sublingual (Edluar®)
Zolpidem Tartrate Sublingual (Generic for Intermezzo®)
Zolpidem Tartrate Capsule (Generic)
Zolpidem Tartrate Tablet (Ambien®)
SICKLE CELL ANEMIA (55)
Hydroxyurea Capsule (Droxia®)
Crizanlizumab-tmca Infusion (Adakveo®)
*Request Form
Exagamglogene autotemcel (Casgevy™)
*Criteria
Hydroxyurea Tablet (Siklos®)
*POS Edits
L-glutamine Powder Pack (Endari™)
Lovtibeglogene autotemcel (Lyfgenia®)
Voxelotor Tablet (Oxbryta®)
LA Medicaid Preferred Drug List (PDL)/Non-Preferred Drug List (NPDL) Effective Date: July 1, 2024
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Descriptive Therapeutic Class
Drugs on PDL
Drugs on NPDL which Require Prior Authorization (PA)
SINUS NODE INHIBITORS (56)
NONE
Ivabradine Solution (Corlanor®)
*Request Form
Ivabradine Tablet (Corlanor®)
*Criteria
*POS Edits
SMOKING CESSATION PRODUCTS (57)
Bupropion SR Tablet (Generic)
Nicotine Inhaler (Nicotrol Inhaler®)
*Request Form
Nicotine Buccal Gum OTC, Buccal Lozenge OTC (Generic)
Nicotine Nasal Spray (Nicotrol Nasal Spray®)
*Criteria
Nicotine Patch OTC (Generic)
*POS Edits
Varenicline Tablet (Generic; Chantix®; Chantix Dose Pack®)
SPINAL MUSCULAR ATROPHY (58)
NONE
Nusinersen (Spinraza®)
*Request Form
Onasemnogene Abeparvovec-xioi (Zolgensma®)
*Criteria
Risdiplam (Evrysdi™)
*POS Edits
*SPINRAZA REQUEST FORM
THROMBOPOIESIS STIMULATING
PROTEINS (59)
Eltrombopag Tablet (Promacta®)
Avatrombopag Tablet (Doptelet®)
Eltrombopag Suspension Packet (Promacta®)
*Request Form
Fostamatinib Disodium Hexahydrate Tablet (Tavalisse®)
*Criteria
Lusutrombopag Tablet (Mulpleta®)
*POS Edits
Romiplostim Vial (Nplate®)
LA Medicaid Preferred Drug List (PDL)/Non-Preferred Drug List (NPDL) Effective Date: July 1, 2024
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Descriptive Therapeutic Class
Drugs on PDL
Drugs on NPDL which Require Prior Authorization (PA)
UREA CYCLE DISORDERS (60)
Sodium Phenylbutyrate Pellet (Pheburane®)
Carglumic Acid (Generic; Carbaglu®)
*Request Form
Glycerol Phenylbutyrate (Ravicti®)
*Criteria
Sodium Phenylbutyrate Powder, Tablet (Generic; Buphenyl®)
*POS Edits
Sodium Phenylbutyrate Pellet for Oral Suspension (Olpruva®)
UROLOGY INCONTINENCE (61)
Fesoterodine Fumarate ER Tablet (Generic)
Darifenacin ER Tablet (Generic)
Bladder Relaxant Preparations
Mirabegron ER Tablet (Myrbetriq®)
Fesoterodine Fumarate ER Tablet (Toviaz®)
*Request Form
Oxybutynin Syrup (Generic)
Flavoxate Tablet (Generic)
*Criteria
Oxybutynin 5mg Tablet (Generic)
Mirabegron ER Granules for Oral Suspension (Myrbetriq®)
*POS Edits
Oxybutynin ER Tablet (Generic)
Oxybutynin 2.5mg Tablet (Generic)
Solifenacin Tablet (Generic)
Oxybutynin Transdermal Gel (Gelnique®)
Oxybutynin Transdermal Patch Rx (Oxytrol®)
Solifenacin Tablet, Suspension (VESIcare®; VESIcare® LS)
Tolterodine Tablet (Generic; Detrol®)
Tolterodine ER Capsule (AG; Generic; Detrol LA®)
Trospium ER Capsule, Tablet (Generic)
Vibegron Tablet (Gemtesa®)
UTERINE DISORDER TREATMENTS (62)
Elagolix Tablet (Orilissa®)
NONE
*Request Form
Elagolix/Estradiol/Norethindrone Capsule (Oriahnn®)
*Criteria
Relugolix/Estradiol/Norethindrone Acetate (Myfembree™)
*POS Edits
LA Medicaid Preferred Drug List (PDL)/Non-Preferred Drug List (NPDL) Effective Date: July 1, 2024
Additional Point-of-Sale (POS) Edits May Apply Drugs highlighted in yellow indicate a new addition or a change in status Page | 66
ADDITIONAL AGENTS THAT HAVE POINT-OF-SALE (POS) REQUIREMENT(S)
AL – Age Limit
DS – Maximum Days’ Supply Allowed
PA – Prior Authorization
BH – Behavioral Health Clinical Authorization for Children
Younger than 7 Years of Age
DT – Duration of Therapy Limit
PU – Prior Use of other Medication is Required
BY – Diagnosis Codes Bypass Some Requirements
DX – Diagnosis Code Requirement
QL – Quantity Limit
CL – Additional Clinical Information is Required
ER – Early Refill
RX – Specific Prescription Requirement
CU – Concurrent Use with Other Medications is Restricted
MD – Maximum Dose Limit
TD – Therapeutic Duplication
DD – Drug-Drug Interaction
MME – Maximum Morphine Milligram Equivalent
YQ – Yearly Quantity Limit
Acetaminophen
MD
Givlaari® (Givosiran)
CL
Radicava®, Radicava ORS® (Edaravone)
DX
Acthar® (Corticotropin)
CL
HyperTET SD (Tetanus IG)
CL
Ranexa® (Ranolazine)
CL
Actimmune® (Interferon Gamma-1b)
DX
Imipramine
BH, TD
Reclast® (Zoledronic acid)
CL, QL
Adzynma (ADAMTS13, recombinant-krhn)
DX
Intron-A® (Interferon Alfa-2B Recombinant)
DX
Relyvrio™ (Sodium Phenylbutyrate/Taurursodiol)
DX
Agamree® (Vamorolone)
CL
Jadenu® (Deferasirox)
DX
Remodulin® (Treprostinil Sodium) Injection
DX
Aldurazyme™ (Laronidase)
CL
Javygtor™ (Sapropterin)
CL
Rilutek® (Riluzole)
DX
Amitriptyline
BH, TD
Joenja® (Leniolisib Phosphate)
DX
Rivfloza™ (Nedosiran)
CL
Amitriptyline/Chlordiazepoxide
BH
Jynarque® (Tolvaptan)
CL
Rystiggo® (Rozanolixizumab-noli)
DX
Amondys 45® (Casimersen)
CL
Kerendia® (Finerenone)
CL
Samsca® (Tolvaptan)
CL, QL
Amoxapine
BH, TD
Keveyis® (Dichlorphenamide)
CL, QL
Skyclarys™ (Omaveloxolone)
CL, QL
Amvuttra™ (Vutrisiran)
DX
Kuvan® (Sapropterin Dihydrochloride)
CL
Skysona® (Elivaldogene Autotemcel)
CL
Aspirin
MD
Lamzede® (Velmanase alfa-tycv)
DX
Sohonos™ (Palovarotene)
DX
Aspruzyo Sprinkle™ (Ranolazine)
CL
Lidocaine Patch Kit (Brand Example-Prilo Patch II®)
CL
Soliris® (Eculizumab)
DX
Besremi® (Ropeginterferon alfa-2b-njft)
DX
Litfulo™ (Ritlecitinib)
CL
Spironolactone
DX
Beyaz® (Drospirenone/Ethinyl Estradiol/ Levomefolate Calcium)
DX
Lithium
BH
Strensiq® (Asfotase alfa)
DX
Brineura™ (Cerliponase alfa)
DX
Lorazepam Injectable
BH, BY, CU,
TD
Sylatron® (Peginterferon alfa-2b)
DX
Cablivi® (Caplacizumab-yhdp)
CL
Lumizyme® (Alglucosidase alfa)
DX
Synagis® (Palivizumab) REQUEST FORM
AL, ER, CL
Camzyos™ (Mavacamten)
CL, QL
Maprotiline
BH
Tegsedi™ (Inotersen)
DX
Chlordiazepoxide/Clidinium
BH
Mepsevii™ (Vestronidase alfa-vjbk)
CL
Testosterone (Oral, Injectable)
DX
Chlorpromazine Injectable
BH
Methadone
CL, BY, CU,
DX, MME, PU,
QL, TD
Tiglutik™ (Riluzole)
DX
LA Medicaid Preferred Drug List (PDL)/Non-Preferred Drug List (NPDL) Effective Date: July 1, 2024
Additional Point-of-Sale (POS) Edits May Apply Drugs highlighted in yellow indicate a new addition or a change in status Page | 67
Clomipramine
BH, TD
Mosquito Repellant to Decrease Zika Virus
Exposure Risk FFS Notice MCO Notice
AL, DX, QL
Tikosyn® (Dofetilide)
CL
Cortrophin™ (Repository corticotropin)
CL
Mytesi® (Crofelemer)
CL
Trimipramine
BH, TD
Cuprimine® (Penicillamine)
CL, QL
Nabi-HB (Hepatitis B IG)
CL
Twyneo® (Tretinoin/Benzoyl Peroxide)
CL, AL, QL
Cuvrior™ (Trientine Tetrahydrochloride)
CL, QL
Naglazyme™ (Galsulfase)
CL
Tzield® (Teplizumab-mzwv)
CL
Daraprim® (Pyrimethamine)
CL
Nexplanon® (Etonogestrel)
QL
Ultomiris® (Ravulizumab-cwvz)
DX
Daybue® (Trofinetide)
DX
Nexviazyme® (Avalglucosidase-alfa)
DX
Veletri® (Epoprostenol)
DX
Depen® (Penicillamine)
CL, QL
Nityr® (Nitisinone)
CL
Vijoice® (Alpelisib)
CL
Desipramine
BH, TD
Nocdurna® (Desmopressin)
QL
Viltepso® (Viltolarsen)
CL
Doxepin (10 mg-150 mg)
BH, TD
Nortriptyline
BH, TD
Vimizim™ (Elosulfase alfa)
CL
Elaprase™ (Idursulfase)
CL
Novarel® (Human Chorionic Gonadotropin)
DX
Vyjuvek™ (Beremagene Geperpavec-svdt)
CL
Elevidys™ (Delandistrogene Moxeparvovec-rokl)
CL
Nuedexta® (Dextromethorphan/Quinidine)
CL, QL
Vyndamax™, Vyndaqel® (Tafamidis)
CL, QL
Elfabrio® (Pegunigalsidase alfa-iwxj)
DX
Nulibry™ (Fosdenopterin)
CL
Vyondys 53® (Golodirsen)
CL
Empaveli® (Pegcetacoplan)
DX
Onpattro® (Patisiran)
DX
Vyvgart® (Efgartigimod alfa-fcab), Vyvgart®
Hytrulo (Efgartigimod alfa and Hyaluronidase-qvfc)
DX
Eohilia™ (Budesonide)
AL, DT, DX
Orfadin® (Nitisinone)
CL
Wainua™ (Eplontersen)
DX
Estrogenic Agents & Combos
DX
Oxlumo® (Lumasiran)
CL
Wegovy® (Semaglutide)
PATIENT TREATMENT AGREEMENT
CL
Exjade® (Deferasirox)
DX
Palynziq® (Pegvaliase-pqpz)
CL, PU
Xenical® (Orlistat)
AL, DS, DX,
RX, QL
Exondys 51® (Eteplirsen)
CL
Pamidronate Disodium
CL
Xenpozyme™ (Olipudase alfa-rpcp)
DX
Exservan™ (Riluzole)
DX
Pombility™ (Cipaglucosidase alfa-atga) +
Opfolda™ (Miglustat)
DX
Xyrem® (Sodium Oxybate)
CL, TD
Fabhalta® (Iptacopan)
DX
Pregnyl® (Human Chorionic Gonadotropin)
DX
Xywav™ (Oxybate Salts)
CL, TD
Fabrazyme® (Agalsidase beta)
DX, TD
Progestational Agents, Other
DX
Ycanth™ (Cantharidin)
AL, DX
Ferriprox® (Deferiprone)
DX
Proleukin® (Aldesleukin)
DX
Zilbrysq® (Zilucoplan)
DX
Fetroja® (Cefiderocol)
CL
Protriptyline
BH, TD
Zonalon® (Doxepin Topical)
AL, DX,
TD, QL
Filsuvez® (Birch triterpenes)
CL
Prudoxin® (Doxepin Topical)
AL, DX,
TD, QL
Ztalmy® (Ganaxolone)
DX, PU, PA
Firdapse® (Amifampridine)
DX, MD
Pulmozyme® (Dornase Alfa)
DX
Zymfentra™ (Infliximab)
CL
Flolan® (Epoprostenol Sodium)
DX
Pyrukynd® (Mitapivat)
DX
Zynteglo® (Betibeglogene Autotemcel)
CL
Galafold® (Migalastat)
DX, TD
Qalsody® (Tofersen)
DX
Gattex® (Teduglutide)
CL
Qualaquin® (Quinine) 324 mg
DS, DX,
QL
