Unified Preferred Drug List

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 1

Ohio

Medicaid

Pharmacy Benefit Management Program

Unified Preferred Drug

List

Medicaid Fee-for-Service

and Managed Care

Plans

Effective January 1,

2024

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 2

Helpful Links

Prior Authorization (PA)

Prior Authorization (PA) Information |

pharmacy.medicaid.ohio.gov

• General Prior Authorization Requirements

• PA and Step Therapy Frequently Asked Questions

(FAQ)

Drug Coverage

Drug Coverage Information | pharmacy.medicaid.ohio.gov

• Drug Lookup Tool

• UPDL Criteria

• Quantity Limits

• Preferred Diabetic Supply List

General Information

- The Statewide UPDL is not an all-inclusive list of drugs covered by Ohio Department of Medicaid.

- Medications that are new to market will be non-preferred, PA required until reviewed by the Ohio

Department of Medicaid Pharmacy and Therapeutics (P&T) Committee.

- The document is listed in sections defined by therapeutic class. Drugs are listed by generic name if a generic is

available unless the brand name of the drug is preferred. In most cases, when a generic for a brand-name

drug is available, the generic drug will be preferred, and the brand name will be non‐preferred. Some drugs

may also require a specific manufacturer or the brand to be dispensed.

- Ohio Department of Medicaid will only cover drugs that are part of the Medicaid Drug Rebate Program, with

limited exceptions. This document may not reflect the most current rebate status of a drug (i.e., a drug may

be listed on the document but is non-rebateable and therefore non-payable).

- Some therapeutic categories are grandfathered. These categories will be denoted with an “*” next to their

title on the table on contents and their place within the criteria document.

- Some therapeutic categories may have quantity limits on specific drugs detailed in the criteria document,

however this is not an all-inclusive list. For a list of the quantity limits on specific drugs, please reference the

Quantity Limit Document found here: Quantity Limits Document | pharmacy.medicaid.ohio.gov

Terminology/Abbreviations:

AR (Age Restriction) – An edit allowing claims for members within a defined age range to be covered without PA

BvG (Brand Preferred Over the Generic) – The brand name drug is preferred over the generic equivalent

PA (Clinical Prior Authorization) – A prior authorization (PA) is required before the drug will be covered

QL (Quantity Limit) – A limit on the quantity that will be covered within a given time frame

ST (Step Therapy) – Drug requires a trial with one or more preferred drugs before being covered

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 3

New UPDL Criteria Format

- Beginning January 2023 and with a few minor exceptions, all therapeutic categories have the same standardized

outline format. The design of this new format is intended to have a cumulative approach bottom-to-top.

Example Category

LENGTH OF AUTHORIZATIONS: X days or Initial: X days; Subsequent: X days (if different)

GRANDFATHERING*:

Patients who have a claim for a non-preferred drug in the previous 120 days will be automatically approved to continue

the drug. Patients who have taken the drug previously, but do not have claims history (e.g. new to Medicaid), will need

to submit a prior authorization in order to continue coverage.

ALL AUTHORIZATIONS: Must be

prescribed in accordance with FDA approved labeling

CLINICAL PA CRITERIA (if applicable):

“DRUG” CRITERIA (if applicable):

STEP THERAPY CRITERIA:

•

Must have had an inadequate clinical response of at least X days with at least X preferred drugs

NON-PREFERRED CRITERIA:

• Must provide documentation of medical necessity beyond convenience for why the patient cannot be changed

to a preferred drug (i.e., allergies, drug-drug interactions, contraindications, or intolerances) OR

o For any nonsolid oral dosage formulation: must provide documentation of medical necessity for why

patient cannot be changed to a solid oral dosage formulation

•

Must have had an inadequate clinical response of at least X days with X preferred drugs

o For non-preferred extended-release formulations: must provide documentation of an inadequate clinical

response

with its immediate release formulation (if available)

o For non-preferred brand names that have preferred generics: must provide documentation of an

inadequate clinical response or allergy to two or more generic labelers (if available)

ADDITIONAL “DRUG” CRITERIA (if applicable):

ADDITIONAL INFORMATION (if applicable):

SUBSEQUENT AUTHORIZATION CRITERIA:

• Must provide documentation of patient’s response to treatment from baseline and/or attestation of clinical

stabilization

QL – Drug: X doses per X days

AR – a PA is required for patients X years and older OR younger than X years

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 4

Interpretation of New UPDL Criteria Format

- Beginning January 2023 and with a few minor exceptions, all therapeutic categories have the same standardized outline

format. The design of this new format is intended to have a cumulative approach bottom-to-top. The following

scenarios will aid in illustrating this point:

Scenario 1: Clinical PA drug

- All Authorizations

- Clinical PA Criteria

Scenario 2: Clinical PA drug with drug-specific criteria

- All Authorizations

- Drug-Specific Criteria

Scenario 3: Step-Therapy drug

- All Authorizations

- Clinical PA Criteria (if applicable)

- Step Therapy Criteria

Scenario 4: Non-Preferred drug

- All Authorizations

- Clinical PA Criteria (if applicable)

- Step Therapy Criteria (if applicable)

- Non-Preferred Criteria

Scenario 5: Non-Preferred drug with drug-specific criteria

- All Authorizations

- Clinical PA Criteria (if applicable)

- Step Therapy Criteria (if applicable)

- Non-Preferred Criteria

- Additional Drug-Specific Criteria

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 5

Table of Contents

Example Category ......................................................................................................................... 3

Analgesic Agents: Gout ......................................................................................................................... 8

Analgesic Agents: NSAIDS ...................................................................................................................... 8

Analgesic Agents: Opioids ..................................................................................................................... 8

Blood Formation, Coagulation, and Thrombosis Agents: Colony Stimulating Factors ............................... 9

Blood Formation, Coagulation, and Thrombosis Agents: Hematopoietic Agents ...................................... 9

Blood Formation, Coagulation, and Thrombosis Agents: Hemophilia Factor* .......................................... 9

Blood Formation, Coagulation, and Thrombosis Agents: Heparin-Related Preparations ........................ 10

Blood Formation, Coagulation, and Thrombosis Agents: Oral Anticoagulants........................................ 10

Blood Formation, Coagulation, and Thrombosis Agents: Oral Antiplatelet ............................................ 10

Cardiovascular Agents: Antiarrhythmics .............................................................................................. 12

Cardiovascular Agents: Lipotropics ...................................................................................................... 12

Cardiovascular Agents: Pulmonary Arterial Hypertension* ................................................................... 13

Central Nervous System (CNS) Agents: Alzheimer’s Agents* ................................................................. 13

Central Nervous System (CNS) Agents: Anti-Migraine Agents, Cluster Headache ................................... 14

Central Nervous System (CNS) Agents: Anti-Migraine Agents, Prophylaxis ............................................ 14

Central Nervous System (CNS) Agents: Anticonvulsants*...................................................................... 14

Central Nervous System (CNS) Agents: Anticonvulsants Rescue ............................................................ 14

Central Nervous System (CNS) Agents: Antidepressants* ..................................................................... 15

Central Nervous System (CNS) Agents: Attention Deficit Hyperactivity Disorder Agents ........................ 15

Central Nervous System (CNS) Agents: Fibromyalgia Agents ................................................................. 16

Central Nervous System (CNS) Agents: Medication Assisted Treatment of Opioid Addiction.................. 17

Central Nervous System (CNS) Agents: Movement Disorders ................................................................ 17

Central Nervous System (CNS) Agents: Multiple Sclerosis* ................................................................... 17

Central Nervous System (CNS) Agents: Narcolepsy ............................................................................... 17

Central Nervous System (CNS) Agents: Neuropathic Pain ..................................................................... 17

Central Nervous System (CNS) Agents: Parkinson's Agents ................................................................... 18

Central Nervous System (CNS) Agents: Restless Legs Syndrome ............................................................ 18

Central Nervous System (CNS) Agents: Sedative-Hypnotics, Non-Barbiturate ........................................ 18

Central Nervous System (CNS) Agents: Skeletal Muscle Relaxants, Non-Benzodiazepine ....................... 19

Central Nervous System (CNS) Agents: Smoking Deterrents ................................................................. 19

Dermatologic Agents: Oral Acne Products ............................................................................................ 19

Dermatologic Agents: Topical Acne Products ....................................................................................... 19

Endocrine Agents: Androgens .............................................................................................................. 20

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 6

Endocrine Agents: Diabetes – Hypoglycemia Treatments ..................................................................... 20

Endocrine Agents: Diabetes – Insulin ................................................................................................... 20

Endocrine Agents: Diabetes – Non-Insulin ............................................................................................ 21

Endocrine Agents: Endometriosis ........................................................................................................ 21

Endocrine Agents: Estrogenic Agents ................................................................................................... 22

Endocrine Agents: Osteoporosis – Bone Ossification Enhancers ............................................................ 22

Endocrine Agents: Progestin Agents .................................................................................................... 23

Endocrine Agents: Uterine Fibroids ...................................................................................................... 23

Gastrointestinal Agents: Anti-Emetics .................................................................................................. 23

Gastrointestinal Agents: Crohn’s Disease ............................................................................................. 23

Gastrointestinal Agents: Hepatic Encephalopathy ................................................................................ 24

Gastrointestinal Agents: Irritable Bowel Syndrome (IBS) with Diarrhea ................................................ 24

Gastrointestinal Agents: Pancreatic Enzymes ....................................................................................... 24

Gastrointestinal Agents: Proton Pump Inhibitors ................................................................................. 24

Gastrointestinal Agents: Ulcerative Colitis ........................................................................................... 24

Gastrointestinal Agents: Unspecified GI ............................................................................................... 25

Genitourinary Agents: Benign Prostatic Hyperplasia............................................................................. 25

Genitourinary Agents: Electrolyte Depleter Agents .............................................................................. 25

Genitourinary Agents: Urinary Antispasmodics .................................................................................... 25

Immunomodulator Agents: Systemic Inflammatory Disease ................................................................. 26

Infectious Disease Agents: Antibiotics – Cephalosporins ....................................................................... 26

Infectious Disease Agents: Antibiotics – Inhaled ................................................................................... 27

Infectious Disease Agents: Antibiotics – Macrolides ............................................................................. 27

Infectious Disease Agents: Antibiotics – Quinolones ............................................................................. 27

Infectious Disease Agents: Antibiotics – Tetracyclines .......................................................................... 27

Infectious Disease Agents: Antifungals................................................................................................. 27

Infectious Disease Agents: Antivirals – Hepatitis C Agents .................................................................... 27

Infectious Disease Agents: Antivirals – Herpes ..................................................................................... 28

Infectious Disease Agents: Antivirals – HIV* ......................................................................................... 28

Ophthalmic Agents: Antibiotic and Antibiotic-Steroid Combination Drops and Ointments .................... 29

Ophthalmic Agents: Antihistamines & Mast Cell Stabilizers .................................................................. 29

Ophthalmic Agents: Glaucoma Agents ................................................................................................. 30

Ophthalmic Agents: NSAIDs ................................................................................................................ 30

Ophthalmic Agents: Ophthalmic Steroids ............................................................................................. 30

Otic Agents: Antibacterial and Antibacterial/Steroid Combinations ...................................................... 31

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 7

Respiratory Agents: Antihistamines – Second Generation .................................................................... 31

Respiratory Agents: Epinephrine Auto-Injectors ................................................................................... 31

Respiratory Agents: Hereditary Angioedema ....................................................................................... 31

Respiratory Agents: Inhaled Agents ..................................................................................................... 31

Respiratory Agents: Leukotriene Receptor Modifiers & Inhibitors ........................................................ 32

Respiratory Agents: Monoclonal Antibodies-Anti-IL/Anti-IgE ................................................................ 32

Respiratory Agents: Nasal Preparations ............................................................................................... 32

Respiratory Agents: Other Agents ........................................................................................................ 33

Topical Agents: Antifungals ................................................................................................................. 33

Topical Agents: Antiparasitics .............................................................................................................. 33

Topical Agents: Corticosteroids ........................................................................................................... 33

Topical Agents: Immunomodulators .................................................................................................... 34

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 8

Analgesic Agents: Gout

PREFERRED

NON-PREFERRED

Allopurinol 100, 300mg

Allopurinol 200mg

Colchicine Tab

PA QL

Febuxostat

Colcrys Tab

PA QL

Gloperba Susp

Probenecid

Mitigare

BvG

Probenecid/Colchicine

Link to Criteria: Analgesic Agents: Gout

Analgesic Agents: NSAIDS

PREFERRED

NON-PREFERRED

Celecoxib

Diclofenac/Misoprostol

Diclofenac Sodium IR, DR, ER, Gel 1%

Diclofenac Gel 3%, Patch 1.3%, Soln 1.5%, 2%

Etodolac

Diclofenac Potassium

Fenoprofen 600mg

Diclotrex

Flurbiprofen

Elyxyb

Ibuprofen

Fenoprofen 400mg

Indocin

Ibuprofen/Famotidine

Indomethacin

Ketorolac Tromethamine Nasal Spray

Ketoprofen ER

Ketoprofen

Ketorolac

Licart Patch

Meclofenamate

Meloxicam Cap

Mefenamic Acid

Naproxen CR, DR, ER, EC

Meloxicam Tab

Naproxen/Esomeprazole

Nabumetone

Pennsaid

BvG

Naproxen IR

Qmiiz ODT

Naproxen Susp

Relafen DS

Oxaprozin

Zorvolex

Piroxicam

Sulindac

Link to Criteria: Analgesic Agents: NSAIDS

Analgesic Agents: Opioids

PREFERRED

NON-PREFERRED

Acetaminophen/Codeine

Acetaminophen/Caffeine/Dihydrocodeine

Butalbital/Acetaminophen/Caffeine/Codeine

Belbuca

Butalbital/Aspirin/Caffeine/Codeine

Benzhydrocodone/Acetaminophen

Butorphanol

Buprenorphine TD Patch Weekly

Butrans

BvG PA QL

Codeine

Butalbital/Acetaminophen/Caffeine/Codeine

50/300/40/30mg

Hydrocodone/Acetaminophen

Dsuvia

Hydromorphone IR

Fentanyl

Morphine IR Tab, Sol

Hydrocodone Bitartrate ER 12HR Cap

Morphine ER Tab

PA QL

Hydrocodone Bitartrate ER 24HR Tab

Nucynta IR

Nucynta ER

PA QL

Hydrocodone/Acetaminophen 5-300, 7.5-300, 10-

300mg

Oxycodone Cap, Sol, Tab

Hydrocodone/Ibuprofen

Oxycodone/Acetaminophen

Hydromorphone ER

Tramadol

Levorphanol

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 9

Analgesic Agents: Opioids

PREFERRED

NON-PREFERRED

Tramadol/Acetaminophen

Meperidine

Methadone

Morphine ER 24HR Cap

Oxycodone ER

Oxycodone/Ibuprofen

Oxymorphone IR, ER

Link to Criteria: Analgesic Agents: Opioids

Blood Formation, Coagulation, and Thrombosis Agents: Colony Stimulating Factors

PREFERRED

NON-PREFERRED

Neupogen

Fulphila

Nivestym

Fylnetra

Nyvepria

Granix

Ziextenzo

Leukine

Neulasta

Releuko

Rolvedon

Stimufend

Udenyca

Zarxio

Link to Criteria: Blood Formation, Coagulation, and Thrombosis Agents: Colony Stimulating Factors

Blood Formation, Coagulation, and Thrombosis Agents: Hematopoietic Agents

PREFERRED

NON-PREFERRED

Epogen

Aranesp

Mircera

Procrit

Retacrit

Link to Criteria: Blood Agents: Blood Formation, Coagulation, And Thrombosis Agents: Hematopoietic Agents

Blood Formation, Coagulation, and Thrombosis Agents: Hemophilia Factor*

PREFERRED

NON-PREFERRED

Advate

Altuviiio

Adynovate

Jivi

Afstyla

Nuwiq

Alphanate

Obizur

Alphanine SD

Rebinyn

Alprolix

Sevenfact

Benefix

Vonvendi

Corifact

Eloctate

Esperoct

Feiba

Hemlibra

Hemofil M

Humate-P

Idelvion

Ixinity

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 10

Blood Formation, Coagulation, and Thrombosis Agents: Hemophilia Factor*

PREFERRED

NON-PREFERRED

Koate

Kogenate FS

Kovaltry

Mononine

Novoeight

Novoseven RT

Profilnine

Recombinate

Rixubis

Wilate

Xyntha

Link to Criteria: Blood Formation, Coagulation, and Thrombosis Agents: Hemophilia Factors

Blood Formation, Coagulation, and Thrombosis Agents: Heparin-Related Preparations

PREFERRED

NON-PREFERRED

Enoxaparin

Fondaparinux

Fragmin

Link to Criteria: Blood Formation, Coagulation, and Thrombosis Agents: Heparin-Related Preparations

Blood Formation, Coagulation, and Thrombosis Agents: Oral Anticoagulants

PREFERRED

NON-PREFERRED

Eliquis

Dabigatran Cap

Pradaxa Cap

BvG

Pellet Pak

Savaysa

Warfarin

Xarelto Susp

Tab

Link to Criteria: Blood Formation, Coagulation, and Thrombosis Agents: Oral Anticoagulants

Blood Formation, Coagulation, and Thrombosis Agents: Oral Antiplatelet

PREFERRED

NON-PREFERRED

Aspirin

Yosprala

Aspirin/Dipyridamole ER

Zontivity

Brilinta

Clopidogrel

Prasugrel

Link to Criteria: Blood Formation, Coagulation, and Thrombosis Agents: Oral Antiplatelet

Cardiovascular Agents: Angina, Hypertension and Heart Failure

PREFERRED

NON-PREFERRED

Acebutolol

Aliskiren

Amlodipine

Aspruzyo Sprinkle

Amlodipine/Benazepril

Camzyos

Amlodipine/Olmesartan

Candesartan

Amlodipine/Valsartan

Candesartan/HCTZ

Amlodipine/Valsartan/HCTZ

Carospir

Atenolol

Carvedilol ER

Atenolol/Chlorthalidone

Clonidine ER (generic of Nexiclon XR)

Benazepril

Corlanor

Benazepril/HCTZ

Diltiazem 24HR ER Tabs

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 11

Cardiovascular Agents: Angina, Hypertension and Heart Failure

PREFERRED

NON-PREFERRED

Betaxolol

Edarbi

Bisoprolol

Edarbyclor

Bisoprolol/HCTZ

Hydralazine/HCTZ

Bystolic

BvG

Innopran XL

Captopril

Inpefa

Captopril/HCTZ

Isradipine

Cartia XT

Kapspargo

Carvedilol

Katerzia

Clonidine IR, Patch

Kerendia

Diltiazem

Levamlodipine

Diltiazem 12HR ER Cap

Nebivolol

Diltiazem 24HR ER Cap

Nimodipine

Doxazosin

Nisoldipine

Dutoprol

Norliqva

Enalapril Tab

Nymalize

Enalapril/HCTZ

Qbrelis

Enalapril Sol

Sotylize

Entresto

Tekturna/HCTZ

Eplerenone

Telmisartan

Felodipine ER

Telmisartan/HCTZ

Fosinopril

Verapamil 200, 300mg ER 24HR

Fosinopril/HCTZ

Verquvo

Guanfacine

Hemangeol

Hydralazine

Irbesartan

Irbesartan/HCTZ

Labetalol

Lisinopril

Lisinopril/HCTZ

Losartan

Losartan/HCTZ

Methyldopa

Methyldopa/HCTZ

Metoprolol Succinate

Metoprolol Tartrate

Metoprolol/HCTZ

Minoxidil

Moexipril

Nadolol

Nadolol/Bendroflumethiazide

Nicardipine

Nifedipine

Olmesartan

Olmesartan/Amlodipine/HCTZ

Olmesartan/HCTZ

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 12

Cardiovascular Agents: Angina, Hypertension and Heart Failure

PREFERRED

NON-PREFERRED

Propranolol

Propranolol/HCTZ

Quinapril

Quinapril/HCTZ

Ramipril

Ranolazine

Sotalol

Spironolactone

Spironolactone/HCTZ

Telmisartan/Amlodipine

Terazosin

Timolol

Trandolapril

Trandolapril/Verapamil

Valsartan

Valsartan/HCTZ

Verapamil IR, SR

Link to Criteria: Cardiovascular Agents: Angina, Hypertension & Heart Failure

Cardiovascular Agents: Antiarrhythmics

PREFERRED

NON-PREFERRED

Amiodarone 200mg

Amiodarone 100, 400mg

Disopyramide

Multaq

Dofetilide

Flecainide

Mexiletine

Norpace CR

Propafenone IR, ER

Quinidine IR, ER

Link to Criteria: Cardiovascular Agents: Antiarrhythmics

Cardiovascular Agents: Lipotropics

PREFERRED

NON-PREFERRED

Atorvastatin

Altoprev

Cholestyramine Regular, Light

Amlodipine/Atorvastatin

Colestipol Tab

Atorvaliq

Ezetimibe

Colesevelam

Fenofibrate 48, 145mg Tab

Colestipol Granules

Gemfibrozil

Ezallor

Lovastatin

Ezetimibe/Simvastatin

Niacin IR, ER OTC

Fenofibrate Cap

Omega-3-Acid Ethyl Esters

Fenofibrate 40, 54, 120, 160mg Tab

Praluent

Fenofibric Acid

Pravastatin

Fluvastatin

Prevalite

Juxtapid

Repatha

Livalo

Rosuvastatin

Nexletol

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 13

Cardiovascular Agents: Lipotropics

PREFERRED

NON-PREFERRED

Simvastatin

Nexlizet

Niacin ER Tab

Vascepa

BvG

Zypitamag

Link to Criteria: Cardiovascular Agents: Lipotropics

Cardiovascular Agents: Pulmonary Arterial Hypertension*

PREFERRED

NON-PREFERRED

Ambrisentan

Adempas

Sildenafil

Bosentan

Sildenafil Susp

AR PA

Epoprostenol

Tadalafil

Liqrev

Tadliq

AR PA

Opsumit

Tracleer Tab

BvG PA

Orenitram

Tracleer Susp

Treprostinil

Tyvaso

Uptravi

Ventavis

Link to Criteria: Cardiovascular Agents: Pulmonary Arterial Hypertension

Central Nervous System (CNS) Agents: Alzheimer’s Agents*

PREFERRED

NON-PREFERRED

Donepezil 5, 10mg, ODT, Tab

AR QL

Adlarity

Donepezil ODT

AR QL

Donepezil 23mg Tab

AR QL

Galantamine IR Tab, ER Cap

AR QL

Galantamine Sol

AR QL

Memantine Tab

Memantine ER, Sol

Rivastigmine Cap

AR QL

Namzaric

Rivastigmine Patch

Link to Criteria: Central Nervous System (CNS) Agents: Alzheimer’s Agents

Central Nervous System (CNS) Agents: Anti-Migraine Agents, Acute

PREFERRED

NON-PREFERRED

Imitrex Nasal Spray

BvG QL

Almotriptan

Naratriptan

Dihydroergotamine

Nurtec ODT

QL ST

Eletriptan

Rizatriptan

Ergomar

Sumatriptan Inj, Tab

Frovatriptan

Tosymra

BvG QL

Migergot

Onzetra Xsail

Reyvow

Sumatriptan/Naproxen

Sumatriptan Nasal Spray

Trudhesa

Ubrelvy

Zavzpret

Zolmitriptan

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 14

Link to Criteria: Central Nervous System (CNS) Agents: Anti-Migraine Agents, Acute

Central Nervous System (CNS) Agents: Anti-Migraine Agents, Cluster Headache

PREFERRED

NON-PREFERRED

Verapamil

Emgality

Link to Criteria: Central Nervous System (CNS) Agents: Anti-Migraine Agents, Cluster Headache

Central Nervous System (CNS) Agents: Anti-Migraine Agents, Prophylaxis

PREFERRED

NON-PREFERRED

Aimovig

Emgality

Ajovy

QL ST

Nurtec ODT

Cardiovascular Agents: Beta-Blockers

Qulipta

CNS Agents: Anticonvulsants

CNS Agents: Serotonin-Norepinephrine Reuptake Inhibitors

CNS Agents: Tricyclic Antidepressants

Link to Criteria: Central Nervous System (CNS) Agents: Anti-Migraine Agents, Prophylaxis

Link to Criteria: Central Nervous System (CNS) Agents: Anticonvulsants

Central Nervous System (CNS) Agents: Anticonvulsants Rescue

PREFERRED

NON-PREFERRED

Diastat

Diazepam Gel

Central Nervous System (CNS) Agents: Anticonvulsants*

PREFERRED

NON-PREFERRED

Banzel Tab

BvG

Aptiom

Briviact

Carbamazepine

Celontin

BvG

Clobazam

Clonazepam ODT

Clonazepam

Elepsia XR

Diacomit

PA QL

Felbamate

Divalproex IR, ER

Fintepla

Epidiolex

ST QL

Lamotrigine ER

Eprontia

Levetiracetam ER Tab

Ethosuximide

Oxcarbazepine Susp

Fycompa

Oxtellar XR

Gabapentin

Peganone

Lacosamide

Qudexy XR

BvG

Lamotrigine IR, ODT

Rufinamide Tab, Soln

Levetiracetam IR Tab, Sol

Spritam

Oxcarbazepine Tab

Sympazan

Phenobarbital

Tiagabine

Phenytoin

Topiramate Sprinkle Cap

Pregabalin

Trokendi XR

BvG

Primidone

Vigabatrin

Topiramate

Vigabatrin Powder

Trileptal Susp

BvG

Xcopri

Valproic Acid

Zonisade Susp

Zonisamide Cap

Ztalmy

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 15

Central Nervous System (CNS) Agents: Anticonvulsants Rescue

PREFERRED

NON-PREFERRED

Nayzilam

Valtoco

Link to Criteria: Central Nervous System (CNS) Agents: Anticonvulsants Rescue

Central Nervous System (CNS) Agents: Antidepressants*

PREFERRED

NON-PREFERRED

Bupropion

Aplenzin

Bupropion SR (generic of Wellbutrin SR)

Auvelity

Bupropion XL (generic of Wellbutrin XL)

Brisdelle

Citalopram Tab, Soln

Bupropion XL (generic of Forfivo XL)

Duloxetine 20, 30, 60mg

Citalopram Cap

Escitalopram

Clomipramine

Fluoxetine 10, 20, 40mg

Desvenlafaxine

Fluoxetine Sol

Drizalma Sprinkle

Fluvoxamine

Duloxetine 40mg

Mirtazapine

Emsam

Nefazodone

Fetzima

Paroxetine IR Tab, Sol

Fluoxetine 60mg, DR

Sertraline Tab

Fluvoxamine ER

Tranylcypromine

Marplan

Trazodone 50, 100, 150mg

Paroxetine Cap, ER Tab

Venlafaxine IR Tab, ER Cap

Pexeva

Phenelzine

Sertraline Cap

Trazodone 300mg

Trintellix

Venlafaxine ER Tab

Viibryd

BvG

Link to Criteria: Central Nervous System (CNS) Agents: Antidepressants

Central Nervous System (CNS) Agents: Attention Deficit Hyperactivity Disorder Agents

PREFERRED

NON-PREFERRED

Amphetamine/Dextroamphetamine IR, ER

Adhansia XR

Atomoxetine Cap

AR QL

Adzenys ER, XR ODT

Clonidine ER

Amphetamine Tab

Concerta

AR QL

Azstarys

Dexmethylphenidate Tab

AR QL

Cotempla XR ODT

Dexmethylphenidate ER (generic of Focalin XR)

AR QL

Daytrana

AR BvG

Dextroamphetamine IR Tab, ER Cap

AR QL

Evekeo ODT

Dextroamphetamine Sol

Jornay PM

Dyanavel XR

Methamphetamine

Guanfacine ER

Methylphenidate Chewable Tab

Methylphenidate ER Cap

AR QL

(generic of Metadate CD,

Ritalin LA)

Methylphenidate ER

AR QL

(generic of Aptensio XR, Relexxii)

Mydayis

Methylphenidate ER Tab

AR QL

(generic of Concerta,

Methylin ER, Ritalin SR)

Vyvanse Chewable Tab

Xelstrym

Zenzedi

AR QL

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 16

Central Nervous System (CNS) Agents: Attention Deficit Hyperactivity Disorder Agents

PREFERRED

NON-PREFERRED

Methylphenidate Sol

AR QL

Methylphenidate Tab

AR QL

Procentra

Qelbree

Quillichew ER

Quillivant XR

Ritalin LA

AR QL

Vyvanse Cap

Link to Criteria: Central Nervous System (CNS) Agents: Attention Deficit Hyperactivity Disorder Agents

Central Nervous System (CNS) Agents: Atypical Antipsychotics*

PREFERRED

NON-PREFERRED

Abilify Maintena

Abilify Asimtufii

Aripiprazole

Abilify Mycite

Aristada

Aripiprazole Sol

Aristada Initio

Asenapine

Clozapine

Caplyta

Fanapt

Clozapine ODT Rapdis

Geodon

Fluoxetine/Olanzapine

Invega Hafyera ER

Lybalvi

Invega Sustenna

Nuplazid

Invega Trinza

Olanzapine ODT

Lurasidone

Rexulti

Olanzapine

Secuado

Paliperidone Tab

Uzedy

Perseris

Versacloz

Quetiapine IR, ER

Vraylar

Risperdal Consta

Zyprexa Relprevv

Risperidone

Saphris

BvG ST

Vraylar

Ziprasidone

Link to Criteria: Central Nervous System (CNS) Agents: Atypical Antipsychotics

Central Nervous System (CNS) Agents: Fibromyalgia Agents

PREFERRED

NON-PREFERRED

Pregabalin

Savella

Link to Criteria: Central Nervous System (CNS) Agents: Fibromyalgia Agents

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 17

Central Nervous System (CNS) Agents: Medication Assisted Treatment of Opioid Addiction

PREFERRED

NON-PREFERRED

Buprenorphine/Naloxone

Buprenorphine

Clonidine

Lucemyra

Sublocade

Suboxone

Vivitrol

Zubsolv

Link to Criteria: Central Nervous System (CNS) Agents: Medication Assisted Treatment of Opioid Addiction

Central Nervous System (CNS) Agents: Movement Disorders

PREFERRED

NON-PREFERRED

Austedo

PA ST

Ingrezza

Tetrabenazine

Link to Criteria: Central Nervous System (CNS) Agents: Movement Disorders

Central Nervous System (CNS) Agents: Multiple Sclerosis*

PREFERRED

NON-PREFERRED

Aubagio

BvG

Bafiertam

Avonex

Extavia

Betaseron

Glatiramer

Copaxone

BvG

Glatopa

Dalfampridine

Kesimpta

Dimethyl Fumarate

Mavenclad

Fingolimod

Mayzent

Gilenya

Plegridy

Kesimpta

Ponvory

Rebif

Tascenso ODT

Teriflunomide

Vumerity

Zeposia

Link to Criteria: Central Nervous System (CNS) Agents: Multiple Sclerosis

Central Nervous System (CNS) Agents: Narcolepsy

PREFERRED

NON-PREFERRED

Amphetamine/Dextroamphetamine IR/ER

Sunosi

Armodafinil

Wakix

Dextroamphetamine ER

Xyrem

BvG

Methylphenidate ER

Xywav

Methylphenidate Tab

Modafinil

Link to Criteria: Central Nervous System (CNS) Agents: Narcolepsy

Central Nervous System (CNS) Agents: Neuropathic Pain

PREFERRED

NON-PREFERRED

Amitriptyline

Gralise

Carbamazepine

Horizant

Desipramine

Pregabalin ER

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 18

Central Nervous System (CNS) Agents: Neuropathic Pain

PREFERRED

NON-PREFERRED

Doxepin 10, 25, 50, 75, 100, 150mg

Ztlido

Doxepin Sol

Duloxetine

Gabapentin

Imipramine

Lidocaine Patch

Nortriptyline

Oxcarbazepine

Pregabalin

Ztlido

Link to Criteria: Central Nervous System (CNS) Agents: Neuropathic Pain

Central Nervous System (CNS) Agents: Parkinson's Agents

PREFERRED

NON-PREFERRED

Amantadine

Apokyn

Carbidopa

Carbidopa/Levodopa Dispersible Tab

Carbidopa/Levodopa

Carbidopa/Levodopa/Entacapone

Entacapone

Gocovri

Pramipexole

Inbrija

Ropinirole

Kynmobi

Selegiline

Neupro

Nourianz

Ongentys

Osmolex ER

Pramipexole ER

Rasagiline

Ropinirole ER

Rytary

Tolcapone

Xadago

Zelapar

Link to Criteria: Central Nervous System (CNS) Agents: Parkinson's Agents

Central Nervous System (CNS) Agents: Restless Legs Syndrome

PREFERRED

NON-PREFERRED

Pramipexole

Horizant

Ropinirole

Neupro

Link to Criteria: Central Nervous System (CNS) Agents: Restless Legs Syndrome

Central Nervous System (CNS) Agents: Sedative-Hypnotics, Non-Barbiturate

PREFERRED

NON-PREFERRED

Estazolam

Belsomra

Temazepam 15, 30mg

Dayvigo

Zaleplon

Doxepin 3, 6mg

Zolpidem

Eszopiclone

Intermezzo

Quviviq

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 19

Central Nervous System (CNS) Agents: Sedative-Hypnotics, Non-Barbiturate

PREFERRED

NON-PREFERRED

Ramelteon

Temazepam 7.5, 22mg

Zolpidem ER, SL

Link to Criteria: Central Nervous System (CNS) Agents: Sedative-Hypnotics, Non-Barbiturate

Central Nervous System (CNS) Agents: Skeletal Muscle Relaxants, Non-Benzodiazepine

PREFERRED

NON-PREFERRED

Baclofen Tab

Baclofen Solution

Chlorzoxazone 250, 500mg

Carisoprodol

Cyclobenzaprine 5, 10mg

Chlorzoxazone 375, 750mg

Dantrolene

Cyclobenzaprine 7.5mg

Methocarbamol

Cyclobenzaprine ER

Tizanidine Tab

Fleqsuvy

BvG

Lyvispah

Metaxalone

Orphenadrine

Tizanidine Cap

Link to Criteria: Central Nervous System (CNS) Agents: Skeletal Muscle Relaxants, Non-Benzodiazepine

Central Nervous System (CNS) Agents: Smoking Deterrents

PREFERRED

NON-PREFERRED

Bupropion

Chantix

Nicotine

Varenicline

Link to Criteria: Central Nervous System (CNS) Agents: Smoking Deterrents

Dermatologic Agents: Oral Acne Products

PREFERRED

NON-PREFERRED

Accutane

Absorica

Amnesteem

Absorica LD

Claravis

Isotretinoin

Myorisan

Zenatane

Link to Criteria: Dermatologic Agents: Oral Acne Products

Dermatologic Agents: Topical Acne Products

PREFERRED

NON-PREFERRED

Adapalene Gel 0.1%

Adapalene Cream, Sol 0.1%

Benzoyl Peroxide

Adapalene Gel 0.3%

Clindamycin Gel, Lot, Sol

Adapalene/Benzoyl Peroxide

Clindamycin/Benzoyl Peroxide

Aklief

Erythromycin

Altreno

Erythromycin/Benzoyl Peroxide

Amzeeq

Neuac

Arazlo

Sodium Sulfacetamide

Azelaic Acid Gel

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 20

Dermatologic Agents: Topical Acne Products

PREFERRED

NON-PREFERRED

Sodium Sulfacetamide/Sulfur Cream

Benzoyl Peroxide Foam

Sodium Sulfacetamide/Sulfur Wash Susp

Clindacin Kit

Tretinoin

Clindamycin Foam, Swabs

Clindamycin/Tretinoin

Dapsone Gel

Epsolay

Finacea Foam

Onexton Gel

Ovace Plus

Plixda

Sodium Sulfacetamide/Sulfur Gel

Sodium Sulfacetamide Pads

Tazarotene Cream, Foam, Gel 0.1%

Twyneo

Winlevi

Link to Criteria: Dermatologic Agents: Topical Acne Products

Endocrine Agents: Androgens

PREFERRED

NON-PREFERRED

Androderm

AR PA

Jatenzo

Testosterone Gel 1%

AR PA

Methyltestosterone

Testosterone Gel 1% Pump

AR PA

Natesto

Testopel

Testosterone Cypionate

Testosterone Gel 1.62%, 2%

Testosterone Sol 30mg/ACT

Tlando

Xyosted

Link to Criteria: Endocrine Agents: Androgens

Endocrine Agents: Diabetes – Hypoglycemia Treatments

PREFERRED

NON-PREFERRED

Baqsimi

Glucagon Emerg Kit [Labeler 00548 & 63323]

Glucagen Hypokit

Glucagon Emerg Kit [Labeler 00002]

Gvoke

Zegalogue

Link to Criteria: Endocrine Agents: Diabetes – Hypoglycemia Treatments

Endocrine Agents: Diabetes – Insulin

PREFERRED

NON-PREFERRED

Apidra

Admelog

Humalog 50-50

Afrezza

Humalog 75-25

Basaglar

Humalog U-100 Kwikpen, Vial

Fiasp

Humulin 70-30

Humalog U-100 Tempo Pen

Humulin R U-500

Humalog U-200

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 21

Endocrine Agents: Diabetes – Insulin

PREFERRED

NON-PREFERRED

Insulin Aspart

Humulin N U-100

Insulin Aspart Protamine/Insulin Aspart

Humulin R U-100

Insulin Lispro

Lyumjev

Lantus

BvG QL

Novolin 70-30

Levemir

Novolin N U-100

Novolog 70-30

Novolin R U-100

Novolog U-100

Rezvoglar

Toujeo

Semglee

BvG

Tresiba

BvG ST

Link to Criteria: Endocrine Agents: Diabetes – Insulin

Endocrine Agents: Diabetes – Non-Insulin

PREFERRED

NON-PREFERRED

Acarbose

Adlyxin

Actoplus Met XR

Alogliptin

Byetta

Alogliptin/Metformin

Alogliptin/Pioglitazone

Farxiga

Bydureon Bcise

Glimepiride

Glimepiride/Pioglitazone

Glipizide

Glucophage

Glipizide/Metformin

Glyxambi

Glyburide

Invokamet XR

Glyburide/Metformin

Jentadueto XR

Invokamet

Kombiglyze XR

BvG

Invokana

Metformin ER

(Generic of Fortamet, Glumetza)

Janumet

Metformin Sol

Janumet XR

Mounjaro

Januvia

Onglyza

BvG

Jardiance

Ozempic

Jentadueto

Qtern

Metformin IR, ER

(Generic of Glucophage XR)

Rybelsus

Miglitol

Segluromet

Nateglinide

Soliqua

Pioglitazone

Steglatro

Pioglitazone/Metformin

Steglujan

Repaglinide

Symlinpen

Repaglinide/Metformin

Synjardy XR

Synjardy

Trijardy XR

Tradjenta

Xigduo XR

Trulicity

Xultophy

Victoza

Xigduo XR

Link to Criteria: Endocrine Agents: Diabetes – Non-Insulin

Endocrine Agents: Endometriosis

PREFERRED

NON-PREFERRED

Danazol

Synarel

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 22

Endocrine Agents: Endometriosis

PREFERRED

NON-PREFERRED

Depo-Subq Provera 104

Lupaneta Pack

Lupron Depot

3.75, 11.25mg

Myfembree

QL ST

Orilissa

Zoladex

Link to Criteria: Endocrine Agents: Endometriosis

Endocrine Agents: Estrogenic Agents

PREFERRED

NON-PREFERRED

Climara Pro

Angeliq

Combipatch

Climara

Dotti

Divigel

BvG

Estradiol Cream, Tab

Duavee

Estradiol Patch

Elestrin

BvG

Estring

Estradiol 10mcg Vag Tab

Ethinyl Estradiol/Norethindrone Acetate

Estradiol/Norethindrone Acetate

Lyllana

Estrogel

BvG

Menest

Evamist

Premarin

Femring

Premphase

Menostar

Prempro

Minivelle

Prefest

Vivelle-Dot

Link to Criteria: Endocrine Agents: Estrogenic Agents

Endocrine Agents: Growth Hormone

PREFERRED

NON-PREFERRED

Genotropin

Humatrope

Norditropin

Nutropin

Zomacton

Omnitrope

Saizen

Serostim

Skytrofa

Sogroya

Zomacton

Link to Criteria: Endocrine Agents: Growth Hormone

Endocrine Agents: Osteoporosis – Bone Ossification Enhancers

PREFERRED

NON-PREFERRED

Alendronate Tab

Alendronate Susp

Calcitonin-Salmon

Fosamax Plus D

Forteo

PA QL

Risedronate

Hydroxyprogesterone Caproate

Tymlos

Ibandronate

Link to Criteria: Endocrine Agents: Osteoporosis – Bone Ossification Enhancers

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 23

Endocrine Agents: Progestin Agents

PREFERRED

NON-PREFERRED

Makena

Medroxyprogesterone Acetate Tab

Megestrol

Norethindrone Acetate

Progesterone

Progesterone In Oil

Link to Criteria: Endocrine Agents: Progestin Agents

Endocrine Agents: Uterine Fibroids

PREFERRED

NON-PREFERRED

Lupron Depot

3.75, 11.25mg

Myfembree

PA QL

Oriahnn

PA QL

Link to Criteria: Endocrine Agents: Uterine Fibroids

Gastrointestinal Agents: Anti-Emetics

PREFERRED

NON-PREFERRED

Aprepitant 40, 125mg

Aprepitant 80 mg

Diclegis

BvG

Aprepitant TriPac

Dimenhydrinate

Bonjesta

Diphenhydramine

Doxylamine/Pyridoxine

Emend 125mg Susp

Metoclopramide ODT

Emend 80mg

BvG

Sancuso

Emend TriPac

BvG

Zuplenz

Meclizine

Metoclopramide

Ondansetron

Phosphorated Carbohydrate

Prochlorperazine

Promethazine

Scopolamine

Trimethobenzamide

Link to Criteria: Gastrointestinal Agents: Anti-Emetics

Gastrointestinal Agents: Bowel Preparations

PREFERRED

NON-PREFERRED

Clenpiq

Moviprep

Gavilyte-C

PEG3350-SOD SUL-NACL-KCL-ASB-C 7.5-2.691G

Gavilyte-G

Plenvu

Golytely

SOD SULF-POTASS SULF-MAG SULF Soln

PEG-3350 and Electrolytes 236-22.7G, 420G

Suflave

Suprep

BvG

Sutab

Link to Criteria: Gastrointestinal Agents: Bowel Preparations

Gastrointestinal Agents: Crohn’s Disease

PREFERRED

NON-PREFERRED

Azathioprine

Ortikos ER

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 24

Gastrointestinal Agents: Crohn’s Disease

PREFERRED

NON-PREFERRED

Budesonide ER Cap

Mercaptopurine

Methotrexate

Sulfasalazine

Link to Criteria: Gastrointestinal Agents: Crohn’s Disease

Gastrointestinal Agents: Hepatic Encephalopathy

PREFERRED

NON-PREFERRED

Lactulose

Xifaxan

Link to Criteria: Gastrointestinal Agents: Hepatic Encephalopathy

Gastrointestinal Agents: Irritable Bowel Syndrome (IBS) with Diarrhea

PREFERRED

NON-PREFERRED

Diphenoxylate/Atropine

Alosetron

Loperamide

Viberzi

Xifaxan

Link to Criteria: Gastrointestinal Agents: Irritable Bowel Syndrome (IBS) with Diarrhea

Gastrointestinal Agents: Pancreatic Enzymes

PREFERRED

NON-PREFERRED

Creon

Pancreaze

Zenpep

Pertzye

Viokace

Link to Criteria: Gastrointestinal Agents: Pancreatic Enzymes

Gastrointestinal Agents: Proton Pump Inhibitors

PREFERRED

NON-PREFERRED

Lansoprazole Cap

Aciphex

Nexium Granules

BvG

Dexilant

BvG

Omeprazole Cap

Esomeprazole

Pantoprazole Tab

Esomeprazole Granules

Protonix Pak

AR BvG

Konvomep

Lansoprazole ODT

Omeprazole Tab

Omeprazole/Sodium Bicarbonate

Pantoprazole Packet

Prilosec Susp

Rabeprazole

Link to Criteria: Gastrointestinal Agents: Proton Pump Inhibitors

Gastrointestinal Agents: Ulcerative Colitis

PREFERRED

NON-PREFERRED

Balsalazide Disodium

Dipentum

Budesonide ER Tab

Mesalamine DR Tab 800mg

Mesalamine DR Cap, Tab 1.2gm

Mesalamine Supp

Mesalamine Enema

Uceris Foam

BvG QL

Mesalamine ER Cap 0.375mg

Zeposia

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 25

Gastrointestinal Agents: Ulcerative Colitis

PREFERRED

NON-PREFERRED

Pentasa

BvG

Sulfasalazine

Link to Criteria: Gastrointestinal Agents: Ulcerative Colitis

Gastrointestinal Agents: Unspecified GI

PREFERRED

NON-PREFERRED

Amitiza

Aemcolo

Bisacodyl

Gattex

Casanthranol/Docusate Sodium

Ibsrela

Dicyclomine

Linzess 72mcg

Diphenoxylate/Atropine

Motegrity

Lactulose

Mytesi

Linzess

145, 290mcg

Relistor

Loperamide

Symproic

Lubiprostone

Zorbtive

Movantik

Polyethylene Glycol

Psyllium Fiber

Senna

Trulance

Xifaxan

Link to Criteria: Gastrointestinal Agents: Unspecified GI

Genitourinary Agents: Benign Prostatic Hyperplasia

PREFERRED

NON-PREFERRED

Alfuzosin

Cardura XL

Doxazosin

Dutasteride/Tamsulosin

Dutasteride

Entadfi

Finasteride

Silodosin

Prazosin

Tadalafil

2.5, 5mg

Tamsulosin

Terazosin

Link to Criteria: Genitourinary Agents: Benign Prostatic Hyperplasia

Genitourinary Agents: Electrolyte Depleter Agents

PREFERRED

NON-PREFERRED

Calcium Acetate, Carbonate

Auryxia

Phoslyra

Lanthanum Carbonate

Sevelamer

Velphoro

Link to Criteria: Genitourinary Agents: Electrolyte Depleter Agents

Genitourinary Agents: Urinary Antispasmodics

PREFERRED

NON-PREFERRED

Gelnique

Darifenacin

Myrbetriq Tab

Fesoterodine

Oxybutynin

Gemtesa

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 26

Genitourinary Agents: Urinary Antispasmodics

PREFERRED

NON-PREFERRED

Oxytrol

Myrbetriq Granules

Solifenacin

Tolterodine

Toviaz

BvG

Trospium

Vesicare LS

Link to Criteria: Genitourinary Agents: Urinary Antispasmodics

Immunomodulator Agents: Systemic Inflammatory Disease

PREFERRED

NON-PREFERRED

Adbry

Actemra

Dupixent

Adalimumab-adaz (Generic of Hyrimoz)

Enbrel

Adalimumab-fkjp (Generic of Hulio)

Humira

Amjevita

Kineret

Cibinqo

Otezla

Cimzia

Taltz

PA ST

Cosentyx

Xeljanz IR

Cyltezo

Hadlima

Idacio

Ilumya

Kevzara

Litfulo

Olumiant

Orencia

Rinvoq

Siliq

Simponi

Skyrizi

Sotyktu

Stelara

Tremfya

Xeljanz Sol, XR

Yuflyma

Yusimry

Link to Criteria: Immunomodulator Agents for Systemic Inflammatory Disease

Infectious Disease Agents: Antibiotics – Cephalosporins

PREFERRED

NON-PREFERRED

Cefaclor IR, ER

Cefixime Cap

Cefaclor Susp

Cefixime Susp

Cefadroxil

Cefpodoxime

Cefdinir

Cephalexin 750mg

Cefprozil

Suprax Chewable Tab

Cefprozil Susp

Cefuroxime

Cephalexin 250, 500mg

Link to Criteria: Infectious Disease Agents: Antibiotics – Cephalosporins

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 27

Infectious Disease Agents: Antibiotics – Inhaled

PREFERRED

NON-PREFERRED

Tobramycin

PA QL

Arikayce

Bethkis

Cayston

Kitabis Pak

Tobi Podhaler

Link to Criteria: Infectious Disease Agents: Antibiotics – Inhaled

Infectious Disease Agents: Antibiotics – Macrolides

PREFERRED

NON-PREFERRED

Azithromycin

Eryped

Clarithromycin

Erythrocin Stearate

Erythromycin

Link to Criteria: Infectious Disease Agents: Antibiotics – Macrolides

Infectious Disease Agents: Antibiotics – Quinolones

PREFERRED

NON-PREFERRED

Ciprofloxacin

Baxdela

Ciprofloxacin Susp

Ciprofloxacin ER

Levofloxacin

Moxifloxacin

Ofloxacin

Link to Criteria: Infectious Disease Agents: Antibiotics – Quinolones

Infectious Disease Agents: Antibiotics – Tetracyclines

PREFERRED

NON-PREFERRED

Doxycycline 50, 100mg

Demeclocycline

Doxycycline Syr

Doxycycline 20, 40, 75, 150mg

Minocycline Cap

Doxycycline DR

Tetracycline

Minocycline IR, ER Tab

Vibramycin Susp

Nuzyra

Link to Criteria: Infectious Disease Agents: Antibiotics – Tetracyclines

Infectious Disease Agents: Antifungals

PREFERRED

NON-PREFERRED

Fluconazole

Brexafemme

Flucytosine

Cresemba

Griseofulvin

Itraconazole

Ketoconazole

Noxafil Susp

Terbinafine

Oravig

Posaconazole

Tolsura

Vivjoa

Voriconazole

Link to Criteria: Infectious Disease Agents: Antifungals

Infectious Disease Agents: Antivirals – Hepatitis C Agents

PREFERRED

NON-PREFERRED

Mavyret

Harvoni

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 28

Infectious Disease Agents: Antivirals – Hepatitis C Agents

PREFERRED

NON-PREFERRED

Pegasys

Ledipasvir/Sofosbuvir

Ribavirin

Sovaldi

Sofosbuvir/Velpatasvir

Vosevi

Zepatier

Link to Criteria: Infectious Disease Agents: Antivirals – Hepatitis C Agents

Infectious Disease Agents: Antivirals – Herpes

PREFERRED

NON-PREFERRED

Acyclovir

Famciclovir

Valacyclovir

Sitavig

Link to Criteria: Infectious Disease Agents: Antivirals – Herpes

Infectious Disease Agents: Antivirals – HIV*

PREFERRED

NON-PREFERRED

Abacavir Sulfate

Abacavir Susp

Abacavir/Lamivudine

Abacavir/Lamivudine/Zidovudine

Apretude

Aptivus

Atazanavir Sulfate

Cimduo

Biktarvy

Darunavir

Cimduo

Didanosine

Complera

Edurant

Delstrigo

Efavirenz/Lamivudine/Tenofovir Disoproxil Fumarate

Descovy

Emtricitabine

Dovato

Fosamprenavir

Efavirenz

Fuzeon

Efavirenz/Emtricitabine/Tenofovir

Intelence

BvG

Emtricitabine/Tenofovir Disoproxil Fumarate

Lamivudine Tab

Emtriva

BvG

Lamivudine Sol

Evotaz

Lamivudine/Zidovudine

Genvoya

Nevirapine IR, ER Tab

Isentress

Nevirapine Sol

Isentress Chew Tab

Norvir Powder, Sol

Juluca

Selzentry

BvG

Lopinavir/Ritonavir

Stavudine

Odefsey

Stribild

Pifeltro

Symfi

BvG

Prezcobix

Symfi Lo

BvG

Prezista

BvG

Tybost

Ritonavir Tab

Viracept

Rukobia ER

Symfi

BvG

Symfi Lo

BvG

Symtuza

Temixys

Tenofovir Disoproxil Fumarate 300mg

Tivicay

Tivicay PD

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 29

Infectious Disease Agents: Antivirals – HIV*

PREFERRED

NON-PREFERRED

Triumeq

Triumeq PD

Viread Tab, Powder

Zidovudine

Link to Criteria: Infectious Disease Agents: Antivirals – HIV

Ophthalmic Agents: Antibiotic and Antibiotic-Steroid Combination Drops and Ointments

PREFERRED

NON-PREFERRED

Bacitracin-Polymyxin

Azasite

Ciloxan

Bacitracin

Ciprofloxacin

Besivance

Erythromycin

Blephamide

Gentamicin

Gatifloxacin

Moxifloxacin

Levofloxacin

Neomycin/Polymyxin/Bacitracin

Moxifloxacin (Generic of Moxeza)

Neomycin/Polymyxin/Bacitracin/Hydrocortisone

Neomycin/Polymyxin/Hydrocortisone

Neomycin/Polymyxin/Dexamethasone

Pred-G

Neomycin/Polymyxin/Gramicidin

Sulfacetamide Sodium Ophth Oint 10%

Ofloxacin

Tobradex ST

BvG

Polymyxin/Trimethoprim

Zylet

Sulfacetamide Sodium Ophth Sol 10%

Sulfacetamide/Prednisolone

Tobramycin

Tobramycin/Dexamethasone 0.3/0.1%

Link to Criteria: Ophthalmic Agents: Antibiotic and Antibiotic-Steroid Combination Drops and Ointments

Ophthalmic Agents: Antihistamines & Mast Cell Stabilizers

PREFERRED

NON-PREFERRED

Azelastine

Alocril

Bepreve

BvG

Alomide

Cromolyn

Epinastine

Ketotifen

Zerviate

Olopatadine

Link to Criteria: Ophthalmic Agents: Antihistamines & Mast Cell Stabilizers

Ophthalmic Agents: Dry Eye Treatments

PREFERRED

NON-PREFERRED

Restasis Trays

BvG ST

Cequa

Xiidra

Eysuvis

Miebo

Restasis Multi-Dose

Tyrvaya

Xiidra

Link to Criteria: Ophthalmic Agents: Dry Eye Treatments

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 30

Ophthalmic Agents: Glaucoma Agents

PREFERRED

NON-PREFERRED

Alphagan P 0.1%

Apraclonidine

Alphagan P 0.15%

BvG

Betoptic S

Azopt

BvG ST

Bimatoprost

Betaxolol

Brimonidine 0.15%

Brimonidine 0.2%

Brinzolamide

Carteolol

Iopidine

Combigan

BvG ST

Istalol

Dorzolamide

Lumigan

Dorzolamide/Timolol

Timolol Maleate Droperette

Latanoprost

Travoprost

Levobunolol

Vyzulta

Metipranolol

Xelpros

Rhopressa

Zioptan

BvG

Rocklatan

Simbrinza

Timolol 0.5% Gel, Soln

Travatan Z

BvG ST

Link to Criteria: Ophthalmic Agents: Glaucoma Agents

Ophthalmic Agents: NSAIDs

PREFERRED

NON-PREFERRED

Diclofenac

Acuvail

Flurbiprofen

Bromfenac

Ketorolac

Bromsite

Ilevro

Nevanac

Prolensa

Link to Criteria: Ophthalmic Agents: NSAIDs

Ophthalmic Agents: Ophthalmic Steroids

PREFERRED

NON-PREFERRED

Alrex

BvG

Inveltys

Dexamethasone Sodium Phosphate

Lotemax SM

Difluprednate

Loteprednol

Durezol

Flarex

Fluorometholone

Fml Forte

Fml S.O.P.

Lotemax

BvG

Maxidex

Pred Forte

Pred Mild

Prednisolone Acetate

Prednisolone Sodium Phosphate

Link to Criteria: Ophthalmic Agents: Ophthalmic Steroids

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 31

Otic Agents: Antibacterial and Antibacterial/Steroid Combinations

PREFERRED

NON-PREFERRED

Cipro HC

Ciprofloxacin

Ciprodex

BvG

Ciprofloxacin/Dexamethasone

Cortisporin-TC

Ciprofloxacin/Fluocinolone

Neomycin/Polymyxin B/Hydrocortisone

Ofloxacin

Link to Criteria: Otic Agents: Antibacterial and Antibacterial/Steroid Combinations

Respiratory Agents: Antihistamines – Second Generation

PREFERRED

NON-PREFERRED

Cetirizine Syr, Tab

Cetirizine Chewable

Cetirizine/Pseudoephedrine

Clarinex-D

Loratadine Rapid Dissolve

Desloratadine

Loratadine Syr, Tab

Fexofenadine

Loratadine/Pseudoephedrine

Levocetirizine

Link to Criteria: Respiratory Agents: Antihistamines – Second Generation

Respiratory Agents: Cystic Fibrosis

PREFERRED

NON-PREFERRED

Kalydeco

PA QL

Bronchitol

Orkambi

PA QL

Symdeko

PA QL

Trikafta Pak

, Tab

Link to Criteria: Respiratory Agents: Cystic Fibrosis

Respiratory Agents: Epinephrine Auto-Injectors

PREFERRED

NON-PREFERRED

Epinephrine (labeler 49502)

Epipen

Symjepi

Epipen JR

Link to Criteria: Respiratory Agents: Epinephrine Auto-Injectors

Respiratory Agents: Hereditary Angioedema

PREFERRED

NON-PREFERRED

Haegarda

Berinert

Ruconest

Cinryze

Takhzyro

Icatibant Acetate

Kalbitor

Link to Criteria: Respiratory Agents: Hereditary Angioedema

Respiratory Agents: Inhaled Agents

PREFERRED

NON-PREFERRED

Advair Diskus

BvG

Aerospan HFA

Advair HFA

BvG

Airduo Digihaler, Respiclick

Albuterol HFA

Alvesco

Albuterol Nebulizer Sol 0.021% (0.63mg/3mL),

0.042% (1.25mg/3mL)

Arformoterol Nebulizer Sol

Armonair Digihaler, Respiclick

Albuterol Nebulizer Sol 0.083% (2.5mg/3mL), 0.5%

(5mg/mL) Conc

Arnuity Ellipta

Asmanex HFA

Albuterol Nebulizer Sol 0.083% (2.5mg/3mL), 0.5%

Bevespi Aerosphere

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 32

Respiratory Agents: Inhaled Agents

PREFERRED

NON-PREFERRED

Anoro Ellipta

Breo Ellipta

BvG

Asmanex Twisthaler

Breztri Aerosphere

Atrovent HFA

Budesonide/Formoterol

Budesonide Nebulizer Sol

AR QL

Duaklir Pressair

Combivent Respimat

Fluticasone/Salmeterol

Cromolyn Neb Sol

Formoterol Fumarate Nebulizer Sol

Dulera

Levalbuterol Nebulizer Sol

Flovent

BvG QL

Lonhala Magnair

Incruse Ellipta

Proair Digihaler, Respiclick

Ipratropium

Qvar

Ipratropium/Albuterol Nebulizer Sol

Tiotropium Inhaled Caps

Proair HFA

Trelegy Ellipta

Proventil HFA

Tudorza

Pulmicort Flexhaler

Wixela Inhub

Serevent Diskus

Xopenex HFA

Spiriva

BvG QL

Yupelri

Stiolto

Striverdi Respimat

Symbicort

BvG QL

Ventolin HFA

Link to Criteria: Respiratory Agents: Inhaled Agents

Respiratory Agents: Leukotriene Receptor Modifiers & Inhibitors

PREFERRED

NON-PREFERRED

Montelukast

Zileuton

Zafirlukast

Zyflo

Link to Criteria: Respiratory Agents: Leukotriene Receptor Modifiers & Inhibitors

Respiratory Agents: Monoclonal Antibodies-Anti-IL/Anti-IgE

PREFERRED

NON-PREFERRED

Dupixent

Nucala

Fasenra

Tezspire

Xolair

Link to Criteria: Respiratory Agents: Monoclonal Antibodies-Anti-IL/Anti-IgE

Respiratory Agents: Nasal Preparations

PREFERRED

NON-PREFERRED

Azelastine

Azelastine/Fluticasone Spray

Flunisolide

Beconase AQ

Fluticasone (Generic of Flonase)

Budesonide

Ipratropium

Mometasone

Olopatadine

Omnaris

Qnasl

Ryaltris

Xhance

Zetonna

Link to Criteria: Respiratory Agents: Nasal Preparations

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 33

Respiratory Agents: Other Agents

PREFERRED

NON-PREFERRED

Roflumilast

Link to Criteria: Respiratory Agents: Other Agents

Topical Agents: Antifungals

PREFERRED

NON-PREFERRED

Alevazol

Butenafine

Ciclopirox

Ciclopirox Kit

Clotrimazole

Ertaczo

Clotrimazole/Betamethasone

Jublia

Econazole

Ketoconazole Foam

Ketoconazole

Luliconazole

Miconazole

Miconazole/Zinc Oxide/White Petrolatum Oint

Nystatin

Naftifine

Nystatin/Triamcinolone

Oxiconazole

Terbinafine

Tavaborole

Tolnaftate

Link to Criteria: Topical Agents: Antifungals

Topical Agents: Antiparasitics

PREFERRED

NON-PREFERRED

Natroba

BvG

Eurax

Permethrin

Ivermectin Lot

Piperonyl Butoxide/Pyrethrins

Malathion

Vanalice

Spinosad

Link to Criteria: Topical Agents: Antiparasitics

Topical Agents: Corticosteroids

PREFERRED

NON-PREFERRED

Amcinonide

Alclometasone

Betamethasone Dip/Calcipotriene Oint

Apexicon E

Betamethasone Valerate

Betamethasone Dipropionate

Clobetasol Propionate

Betamethasone Dipropionate/Calcipotriene Susp

Derma-Smoothe/FS

BvG

Betamethasone Valerate Aerosol Foam

Desonide Cream, Oint

Bryhali

Diflorasone Diacetate

Clocortolone Pivalate

Fluocinolone Acetonide 0.01% Cream, Sol, 0.05%

Cordran Tape

Flurandrenolide

Desonate Gel

Fluticasone Propionate Cream, Oint

Desonide Lotion

Hydrocortisone

Desoximetasone

Mometasone Furoate

Fluocinolone Acetonide 0.01% Oil

Prednicarbate

Fluocinolone Acetonide 0.025%, 0.1%

Triamcinolone Cream, Lotion, Oint

Fluticasone Propionate Lotion

Halcinonide Cream

Halobetasol Propionate

Halog

Hydrocortisone Butyrate, Valerate

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 34

Topical Agents: Corticosteroids

PREFERRED

NON-PREFERRED

Impeklo

Pandel

Triamcinolone Spray

Link to Criteria: Topical Agents: Corticosteroids

Topical Agents: Immunomodulators

PREFERRD

NON-PREFERRED

Elidel

AR BvG ST

Eucrisa

Tacrolimus

AR ST

Hyftor

Opzelura

Pimecrolimus

Vtama

Zoryve

Link to Criteria: Topical Agents: Immunomodulators

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 35

Ohio

Medicaid

Pharmacy Benefit Management Program

Unified Preferred Drug

List

Medicaid Fee-for-Service

and Managed Care

Plans

Effective January 1, 2024

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 36

Helpful Links

Prior Authorization (PA)

Prior Authorization (PA) Information | pharmacy.medicaid.ohio.gov

• General Prior Authorization Requirements

• PA and Step Therapy Frequently Asked Questions

(FAQ)

Unified Preferred Drug List (UPDL)

Ohio Unified Preferred Drug List | pharmacy.medicaid.ohio.gov

• Unified Preferred Drug List (UPDL)

Terminology/Abbreviations:

AR (Age Restriction) – An edit allowing claims for members within a defined age range to be covered without PA

BvG (Brand Preferred Over the Generic) – The brand name drug is preferred over the generic equivalent

PA (Clinical Prior Authorization) – A prior authorization (PA) is required before the drug will be covered

QL (Quantity Limit) – A limit on the quantity that will be covered within a given time frame

General Information

- The Statewide UPDL is not an all-inclusive list of drugs covered by Ohio Department of Medicaid.

- Medications that are new to market will be non-preferred, PA required until reviewed by the Ohio Department of

Medicaid Pharmacy and Therapeutics (P&T) Committee.

- The document is listed in sections defined by therapeutic class. Drugs are listed by generic name if a generic is

available unless the brand name of the drug is preferred. In most cases, when a generic for a brand-name drug is

available, the generic drug will be preferred, and the brand name will be non‐preferred. Some drugs may also require

a specific manufacturer or the brand to be dispensed.

- Ohio Department of Medicaid will only cover drugs that are part of the Medicaid Drug Rebate Program, with limited

exceptions. This document may not reflect the most current rebate status of a drug (i.e., a drug may be listed on the

document but is non-rebateable and therefore non-payable).

- Some therapeutic categories are grandfathered. These categories will be denoted with an “*” next to their title on the

table on contents and their place within the criteria document.

- Some therapeutic categories may have quantity limits on specific drugs detailed in the criteria document, however

this is not an all-inclusive list. For a list of the quantity limits on specific drugs, please reference the Quantity Limit

Document found here: Quantity Limits Document | pharmacy.medicaid.ohio.gov

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 37

ST (Step Therapy) – Drug requires a trial with one or more preferred drugs before being covered

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 38

New UPDL Criteria Format

- With a few minor exceptions, all therapeutic categories have the same standardized outline format. The design of this

new format is intended to have a cumulative approach bottom-to-top.

Example Category

LENGTH OF AUTHORIZATIONS: X days or Initial: X days; Subsequent: X days (if different)

GRANDFATHERING*:

Patients who have a claim for a non-preferred drug in the previous 120 days will be automatically approved to continue the

drug. Patients who have taken the drug previously, but do not have claims history (e.g. new to Medicaid), will need to submit

a prior authorization in order to continue coverage.

ALL AUTHORIZATIONS: Must be

prescribed in accordance with FDA approved labeling

CLINICAL PA CRITERIA (if applicable):

“DRUG” CRITERIA (if applicable):

STEP THERAPY CRITERIA:

•

Must have had an inadequate clinical response of at least X days with at least X preferred drugs

NON-PREFERRED CRITERIA:

• Must provide documentation of medical necessity beyond convenience for why the patient cannot be changed to a

preferred drug (i.e., allergies, drug-drug interactions, contraindications, or intolerances) OR

o For any nonsolid oral dosage formulation: must provide documentation of medical necessity for why patient

cannot be changed to a solid oral dosage formulation

•

Must have had an inadequate clinical response of at least X days with X preferred drugs

o For non-preferred extended-release formulations: must provide documentation of an inadequate clinical

response

with its immediate release formulation (if available)

o For non-preferred brand names that have preferred generics: must provide documentation of an inadequate

clinical response or allergy to two or more generic labelers (if available)

ADDITIONAL “DRUG” CRITERIA (if applicable):

ADDITIONAL INFORMATION (if applicable):

SUBSEQUENT AUTHORIZATION CRITERIA:

• Must provide documentation of patient’s response to treatment from baseline and/or attestation of clinical

stabilization

QL – Drug: X doses per X days

AR – a PA is required for patients X years and older OR younger than X years

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 39

Interpretation of New UPDL Criteria Format

- Beginning January 2023 and with a few minor exceptions, all therapeutic categories have the same standardized outline

format. The design of this new format is intended to have a cumulative approach bottom-to-top. The following

scenarios will aid in illustrating this point:

Scenario 1: Clinical PA drug

- All Authorizations

- Clinical PA Criteria

Scenario 2: Clinical PA drug with drug-specific criteria

- All Authorizations

- Drug-Specific Criteria

Scenario 3: Step-Therapy drug

- All Authorizations

- Clinical PA Criteria (if applicable)

- Step Therapy Criteria

Scenario 4: Non-Preferred drug

- All Authorizations

- Clinical PA Criteria (if applicable)

- Step Therapy Criteria (if applicable)

- Non-Preferred Criteria

Scenario 5: Non-Preferred drug with drug-specific criteria

- All Authorizations

- Clinical PA Criteria (if applicable)

- Step Therapy Criteria (if applicable)

- Non-Preferred Criteria

- Additional Drug-Specific Criteria

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 40

Table of Contents

Example Category ....................................................................................................................... 38

Analgesic Agents: Gout ............................................................................................................... 43

Analgesic Agents: NSAIDs ........................................................................................................... 44

Analgesic Agents: Opioids ........................................................................................................... 45

Blood Formation, Coagulation, and Thrombosis Agents: Colony Stimulating Factors .................... 48

Blood Formation, Coagulation, and Thrombosis Agents: Hematopoietic Agents ........................... 49

Blood Formation, Coagulation, and Thrombosis Agents: Hemophilia Factors* .............................. 50

Blood Formation, Coagulation, and Thrombosis Agents: Heparin-Related Preparations ................ 51

Blood Formation, Coagulation, and Thrombosis Agents:

al Anticoagulants ............................... 52

Blood Formation, Coagulation, and Thrombosis Agents:

al Antiplatelet .................................... 53

Cardiovascular Agents: Angina, Hypertension & Heart Failure ...................................................... 54

Cardiovascular Agents: Antiarrhythmics ..................................................................................... 56

Cardiovascular Agents: Lipotropics ............................................................................................. 57

Cardiovascular Agents: Pulmonary Arterial Hypertension* .......................................................... 59

Central Nervous System (CNS) Agents: Alzheimer’s Agents* ....................................................... 60

Central Nervous System (CNS) Agents: Anti-Migraine Agents, Acute ........................................... 61

Central Nervous System (CNS) Agents: Anti-Migraine Agents, Cluster Headache .......................... 61

Central Nervous System (CNS) Agents: Anti-Migraine Agents, Prophylaxis ................................... 62

Central Nervous System (CNS) Agents: Anticonvulsants* ............................................................ 64

Central Nervous System (CNS) Agents: Anticonvulsants Rescue .................................................. 66

Central Nervous System (CNS) Agents: Antidepressants*............................................................ 67

Central Nervous System (CNS) Agents: Attention Defic

Hyperactivity Disorder Age

nts

............... 69

Central Nervous System (CNS) Agents: Antipsychotics* .............................................................. 70

Central Nervous System (CNS) Agents: Fibromyalgia Agents ....................................................... 72

Central Nervous System (CNS) Agents: Medication

Assisted

Treatment of Opioid

Addiction

........ 73

Central Nervous System (CNS) Agents: Movement Disorders ....................................................... 75

Central Nervous System (CNS) Agents: Multiple Sclerosis*.......................................................... 76

Central Nervous System (CNS) Agents: Narcolepsy ..................................................................... 77

Central Nervous System (CNS) Agents: Neuropathic Pain ............................................................ 78

Central Nervous System (CNS) Agents: Parkinson's Agents .......................................................... 79

Central Nervous System (CNS) Agents: Restless

egs

Synd

rome ................................................... 80

Central Nervous System (CNS) Agents: Sedative-Hypnotics, Non-Barbiturate ............................... 81

Central Nervous System (CNS) Agents: Skeletal

Mus

cle Relaxants,

Non

Ben

odia

zep

ine

.............. 82

Central Nervous System (CNS) Agents: Smoking Deterrents ........................................................ 83

Dermatologic Agents: Oral Acne Products .................................................................................. 84

Dermatologic Agents: Topical Acne Products ............................................................................... 85

Endocrine Agents: Androgens ..................................................................................................... 86

Endocrine Agents: Diabetes – Hypoglycemia Treatments ............................................................ 87

Endocrine Agents: Diabetes – Insulin ......................................................................................... 88

Endocrine Agents: Diabetes –

Non

Insulin

.................................................................................. 89

Endocrine Agents: Endometriosis ................................................................................................ 91

Endocrine Agents: Estrogenic

gen

......................................................................................... 92

Endocrine Agents: Growth Hormone .......................................................................................... 93

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 41

Endocrine Agents: Osteoporosis – Bone

Ossi

fic

ation

Enh

ancers .................................................. 95

Endocrine Agents: Progestin Agents ........................................................................................... 96

Endocrine Agents: Uterine Fibroids ............................................................................................ 97

Gastrointestinal Agents: Anti-Emetics ........................................................................................ 98

Gastrointestinal Agents: Bowel Preparations............................................................................... 99

Gastrointestinal Agents: Crohn’s Disease ................................................................................. 100

Gastrointestinal Agents: Hepatic Encephalopathy .................................................................... 101

Gastrointestinal Agents: Irritable Bowel Syndrome (IBS) with Diarrhea ..................................... 102

Gastrointestinal Agents: Pancreatic Enzymes ........................................................................... 103

Gastrointestinal Agents: Proton Pump

Inhibitors

...................................................................... 104

Gastrointestinal Agents: Ulcerative Colitis ................................................................................ 105

Gastrointestinal Agents: Unspecified GI ................................................................................... 106

Genitourinary Agents: Benign Prostatic Hyperplasia ................................................................. 107

Genitourinary Agents: Electrolyte Depleter Agents ................................................................... 108

Genitourinary Agents: Urinary Antispasmodics ........................................................................ 109

Immunomodulator Agents: Systemic Inflammatory Disease....................................................... 110

Infectious Disease Agents: Antibiotics – Cephalosporins ........................................................... 112

Infectious Disease Agents: Antibiotics – Inhaled ........................................................................ 113

Infectious Disease Agents: Antibiotics – Macrolides .................................................................. 114

Infectious Disease Agents: Antibiotics – Quinolones ................................................................. 115

Infectious Disease Agents: Antibiotics – Tetracyclines ................................................................ 116

Infectious Disease Agents: Antifungals ..................................................................................... 117

Infectious Disease Agents: Antivirals – Hepatitis C Agents ......................................................... 118

Infectious Disease Agents: Antivirals – Herpes .......................................................................... 119

Infectious Disease Agents: Antivirals – HIV* ............................................................................. 120

Ophthalmic Agents: Antibiotic and

Antibiotic

roid

Combination Drops and

Ointm

nts

......... 121

Ophthalmic Agents: Antihistamines & Mast Cell Stabilizers ....................................................... 122

Ophthalmic Agents: Dry Eye Treatments .................................................................................. 123

Ophthalmic Agents: Glaucoma Age

nts

..................................................................................... 124

Ophthalmic Agents: NSAIDs ..................................................................................................... 125

Ophthalmic Agents: Ophthalmic Steroids ................................................................................. 126

Otic Agents: Antibacterial and

Antibact

rial/Steroid Combinations

........................................... 127

Respiratory Agents: Antihistamines – Second Generation ......................................................... 128

Respiratory Agents: Cystic Fibrosis ............................................................................................ 129

Respiratory Agents: Epinephrine Auto-Injectors ........................................................................ 130

Respiratory Agents: Hereditary Angioedema ............................................................................. 131

Respiratory Agents: Inhaled Agents .......................................................................................... 132

Respiratory Agents: Leukotriene Receptor Modifiers & Inhibitors .............................................. 133

Respiratory Agents: Monoclonal Antibodies-Anti-IL/Anti-IgE ..................................................... 134

Respiratory Agents: Nasal Preparations .................................................................................... 135

Respiratory Agents: Other Agents ............................................................................................ 136

Topical Agents: Antifungals ..................................................................................................... 137

Topical Agents: Antiparasitics .................................................................................................. 138

Topical Agents: Corticosteroids ................................................................................................ 139

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 42

Topical Agents: Immunomodulators ........................................................................................ 140

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 43

Analgesic Agents: Gout

LENGTH OF AUTHORIZATIONS: 365 days except 180 days for Familial Mediterranean Fever

ALL AUTHORIZATIONS: Must be

prescribed in accordance with FDA approved labeling

CLINICAL PA CRITERIA:

• Must have had an inadequate clinical response with an NSAID and oral corticosteroid within

the last 30 days for acute gout diagnosis OR

• Must have had an inadequate clinical response of at least 30 days with the maximally

tolerated xanthine oxidase inhibitor dose for chronic gout diagnosis

NON-PREFERRED CRITERIA:

• Must provide documentation of medical necessity beyond convenience for why the patient

cannot be changed to a preferred drug (i.e., allergies, drug-drug interactions,

contraindications, or intolerances) OR

o For any nonsolid oral dosage formulation: must provide documentation of medical

necessity for why patient cannot be changed to a solid oral dosage formulation

•

Must have had an inadequate clinical response of at least 30 days with at least one preferred

drug

o For non-preferred extended-release formulations: must provide documentation of an

inadequate clinical response

with its immediate release formulation (if available)

o For non-preferred brand names that have preferred generics: must provide

documentation of an inadequate clinical response or allergy to two or more generic

labelers (if available)

ADDITIONAL COLCHICINE CAPSULE (MITIGARE) CRITERIA:

• Must have had an inadequate clinical response of 30 days with colchicine tablets

ADDITIONAL COLCHICINE SOLUTION (GLOPERBA) CRITERIA:

• Must be unable to swallow tablets or capsules for authorization of colchicine solution

SUBSEQUENT AUTHORIZATION CRITERIA:

• Must provide documentation of patient’s clinical response to treatment and ongoing safety

monitoring

QL – All colchicine products: 6 doses per claim for acute gout; 2 doses per day for 30 days for chronic

gout; 4 doses per day per 30 days for Familial Mediterranean Fever

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 44

Analgesic Agents: NSAIDs

LENGTH OF AUTHORIZATIONS: Dependent upon the table below

Authorization Length

H. Pylori Treatment

30 days

Transdermal/Topical

90 days

All Other Treatments

365 days

ALL AUTHORIZATIONS: Must be

prescribed in accordance with FDA approved labeling

NON-PREFERRED CRITERIA:

• Must provide documentation of medical necessity beyond convenience for why the patient

cannot be changed to a preferred drug (i.e., allergies, drug-drug interactions,

contraindications, or intolerances) OR

o For any nonsolid oral dosage formulation: must provide documentation of medical

necessity for why patient cannot be changed to a solid oral dosage formulation

•

Must have had an inadequate clinical response of at least 30 days with at least two preferred

drugs

o For non-preferred extended-release formulations: must provide documentation of an

inadequate clinical response

with its immediate release formulation (if available)

o For non-preferred brand names that have preferred generics: must provide

documentation of an inadequate clinical response or allergy to two or more generic

labelers (if available)

SUBSEQUENT AUTHORIZATION CRITERIA:

• Must provide documentation of patient’s clinical response to treatment and ongoing safety

monitoring

AR – Naproxen Suspension: a PA is required for patients 12 years old and older

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 45

Analgesic Agents: Opioids

**Ohio law requires prescribers to request and review an OARRS report before initially prescribing or personally

furnishing any controlled substance, such as an opioid analgesic or a benzodiazepine, and gabapentin**

LENGTH OF AUTHORIZATIONS: For the course of therapy, up to 180 days. Initial short-acting and

long-acting requests may only be authorized for up to 90 days

ALL AUTHORIZATIONS: Must be

prescribed in accordance with FDA approved labeling

BUPRENORPHINE TOPICAL (BUTRANS) CRITERIA:

•

For doses greater than 5 mcg/hour must provide documentation of an

inadequate clinical response

with at least one opioid formulation taken for at

least 60 of the last 90 days

MORPHINE SULFATE ER (KADIAN, MS CONTIN) & TAPENTADOL ER (NUCYNTA) CRITERIA:

•

Unless receiving for cancer pain, palliative care, or end-of-life/hospice care,

must provide documentation of an inadequate clinical response with at least

one opioid formulation taken for at least 60 of the last 90 days

•

Must also meet

LONG-ACTING OPIOID CRITERIA

NON-PREFERRED CRITERIA:

•

Must provide documentation of medical necessity beyond convenience for why the

patient cannot be changed to a preferred drug (i.e., allergies, drug-drug interactions,

contraindications, or intolerances) OR

For any nonsolid oral dosage formulation: must provide documentation of

medical necessity for why patient cannot be changed to a solid oral dosage

formulation

•

Must have had

an inadequate clinical response of at least 7 days of at least two unrelated

preferred drugs of the same duration of action (SHORT-ACTING or LONG-ACTING)

For non-preferred brand names that have preferred generics: must provide

documentation of an inadequate clinical response or allergy to two or more

generic labelers (if available)

•

Must also meet applicable SHORT-ACTING or LONG-ACTING OPIOID CRITERIA

ADDITIONAL SHORT-ACTING OPIOIDS CRITERIA:

•

The system defines an “initial request” as having no opioid claims in the previous 90 days

•

Initial short-acting requests can be authorized up to 90 days

Length of authorization is dependent on indication, previous patient utilization, and

requested length of therapy (could be more restrictive)

To exceed acute opioid limits, documentation of the following must be provided:

▪ Diagnosis code which must be for somatic type pain

▪ Prescriber attestation that the benefits and risks of opioid therapy have been

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 46

discussed with patient

Exemptions to the additional criteria:

▪ Patients receiving short-acting opioids for active cancer treatment, palliative

care, and end-of-life/hospice care, sickle cell, severe burn, traumatic

crushing of tissue, amputation, major orthopedic surgery

▪ Prescriber attestation that patient is opioid tolerant (i.e., new to Medicaid or

was on higher dose in hospital)

•

Subsequent short-acting requests can be authorized up to 180 days

Documentation of the following must be provided:

▪ Current treatment plan

▪ Demonstrated adherence to treatment plan through progress notes,

including pain and function scores, random urine screenings results

reviewed, concerns addressed, and no serious adverse outcomes observed

•

Dose escalation requests can be authorized up to 180 days

Documentation of the following must be provided:

▪ Prescriber attestation that dose escalation is likely to result in improved

function or pain control

▪ Requests for a cumulative daily dose > 80 MED must be prescribed by or in

consultation with a pain specialist, specialist in the area of the body

affected by pain, or anesthesiologist

Patients with initial prescriptions for opioid therapy, defined as no rx claims for opioids in the last 90

days, will be limited to 30 MED per

day and a maximum of 7 days per prescription. Prior

authorization will be required to exceed these limits.

ADDITIONAL LONG-ACTING OPIOIDS CRITERIA:

•

The system defines an “initial long-acting request” as having no opioid claims in the previous

90 days

•

Initial long-acting requests can be authorized up to 90 days

Documentation of the following must be provided:

▪ Request is a daily dose equivalent of ≤ 80 MED

▪ Inadequate clinical response to both non-opioid pharmacologic and non-

pharmacologic treatments

▪ Current use of opioids for ≥ 60 of the last 90 days

▪

Treatment plan including risk assessment, substance abuse history,

concurrent therapies, and requirements for random urine screenings

(baseline urine drug tests must be submitted)

▪ Pain and function scores at each visit

▪ Opioid contract required to be in place and submitted with PA form

Exemptions to the additional criteria:

▪ Patients receiving long-acting opioids for cancer pain, palliative care, or end-of-

life/hospice care

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 47

•

Subsequent long-acting requests can be authorized up to 180 days

Documentation of the following must be provided:

▪ Current treatment plan

▪ Demonstrated adherence to treatment plan through progress notes,

including pain and function scores, random urine screenings results

reviewed, concerns addressed, and no serious adverse outcomes observed

•

Dose escalation requests can be authorized up to 180 days

Documentation of the following must be provided:

▪ Prescriber attestation that dose escalation is likely to result in improved

function or pain control

▪ Requests for a cumulative daily dose > 80 MED must be prescribed by or in

consultation with a pain specialist, specialist in the area of the body

affected by pain, or anesthesiologist

ADDITIONAL TRANSMUCOSAL FENTANYL CRITERIA:

• Must be prescribed by an oncologist, pain specialist, or hospice/palliative prescriber

• Must be concurrently taking a long-acting opioid at a therapeutic dose of any of the

following for at least 7 days without adequate pain relief:

≥ 60 mg oral morphine/day

≥ 8 mg oral hydromorphone/day

≥ 25 mcg/hr transdermal fentanyl

≥ 25 mg oral oxymorphone/day

≥ 30 mg oral oxycodone/day

Equianalgesic dose of another opioid

BUPRENORPHINE BUCCAL FILM (BELBUCA) CRITERIA:

• Must meet ADDITIONAL LONG-ACTING OPIOID Criteria

QL – Transmucosal Fentanyl: 4 doses per day

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 48

Blood Formation, Coagulation, and Thrombosis Agents: Colony

Stimulating Factors

LENGTH OF AUTHORIZATIONS: Dependent upon diagnosis below

Diagnosis

Authorization Length

Acute Myeloid Leukemia (AML)

14 days or duration of

chemotherapy regimen

Malignancy at risk for febrile neutropenia or undergoing

myeloablative chemotherapy prior to allogeneic or autologous

bone marrow transplantation

14 days or duration of

chemotherapy regimen

Myeloid Engraftment for bone marrow transplant (BMT)

30 days

Severe, chronic neutropenia with absolute neutrophil count

(ANC) of less than 500/mm

and have symptoms associated

with neutropenia (e.g., fever, infections, oropharyngeal ulcers).

30 days

Hematopoietic radiation injury syndrome

30 days

ALL AUTHORIZATIONS: Must be

prescribed in accordance with FDA approved labeling

CLINICAL PA CRITERIA:

• Must provide documentation of diagnosis, patient’s weight, and duration of treatment

NON-PREFERRED CRITERIA:

• Must provide documentation of medical necessity beyond convenience for why the patient

cannot be changed to a preferred drug (i.e., allergies, drug-drug interactions,

contraindications, or intolerances) OR

o For any nonsolid oral dosage formulation: must provide documentation of medical

necessity for why patient cannot be changed to a solid oral dosage formulation

•

Must have had an inadequate clinical response of at least

14 days with

at least

one preferred

drug

o For non-preferred extended-release formulations: must provide documentation of an

inadequate clinical response

with its immediate release formulation (if available)

o For non-preferred brand names that have preferred generics: must provide

documentation of an inadequate clinical response or allergy to two or more generic

labelers (if available)

SUBSEQUENT AUTHORIZATION CRITERIA:

• Must provide documentation of patient’s clinical response to treatment and ongoing safety

monitoring

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 49

Blood Formation, Coagulation, and Thrombosis Agents:

Hematopoietic Agents

LENGTH OF AUTHORIZATIONS: Dependent upon diagnosis below

Authorization of epoetin alfa or darbepoetin:

Diagnosis

Hemoglobin

Level

Authorization Length

Anemia due to chronic renal failure, patient on dialysis

≤11

365 days

Anemia due to chronic renal failure, patient not on dialysis

≤10

365 days

Chemotherapy-induced anemia

≤10

90 days

Anemia in myelodysplastic syndrome

≤11

180 days

Authorization of epoetin alfa ONLY:

Diagnosis

Hemoglobin

Level

Authorization

Length

Autologous blood donation, patient will require blood

transfusions

>10 to ≤13

30 days

Anemia of prematurity, age ≤6 months

N/A

42 days

Anemia associated with chronic inflammatory disorders

(e.g., rheumatoid arthritis)

≤

180 days

Anemia associated with ribavirin combination therapy in

hepatitis C-infected patient

≤11

180 days

Anemia in zidovudine-treated HIV-infected patients

≤11

180 days

ALL AUTHORIZATIONS: Must be

prescribed in accordance with FDA approved labeling

NON-PREFERRED CRITERIA:

• Must provide documentation of medical necessity beyond convenience for why the patient

cannot be changed to a preferred drug (i.e., allergies, drug-drug interactions,

contraindications, or intolerances) OR

o For any nonsolid oral dosage formulation: must provide documentation of medical

necessity for why patient cannot be changed to a solid oral dosage formulation

•

Must have had an inadequate clinical response of at least

14 days with

at least

one preferred

drug

o For non-preferred extended-release formulations: must provide documentation of an

inadequate clinical response

with its immediate release formulation (if available)

o For non-preferred brand names that have preferred generics: must provide

documentation of an inadequate clinical response or allergy to two or more generic

labelers (if available)

SUBSEQUENT AUTHORIZATION CRITERIA:

• Must provide documentation of patient’s clinical response to treatment and ongoing safety

monitoring

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 50

Blood Formation, Coagulation, and Thrombosis Agents: Hemophilia

Factors*

LENGTH OF AUTHORIZATIONS: 365 Days

GRANDFATHERING*:

Patients who have a claim for a non-preferred drug in the previous 120 days will be automatically

authorized to continue the drug. Patients who have taken the drug previously, but do not have claims

history (e.g., new to Medicaid), will need to submit a prior authorization in order to continue

coverage.

ALL AUTHORIZATIONS: Must be

prescribed in accordance with FDA approved labeling

CLINICAL PA CRITERIA:

• Must provide documentation of patient’s body weight

NON-PREFERRED CRITERIA:

• Must provide documentation of medical necessity beyond convenience for why the patient

cannot be changed to a preferred drug (i.e., allergies, drug-drug interactions,

contraindications, or intolerances) OR

o For any nonsolid oral dosage formulation: must provide documentation of medical

necessity for why patient cannot be changed to a solid oral dosage formulation

•

Must have had an inadequate clinical response of at least

14 days with

at least

one preferred

drug

o For non-preferred extended-release formulations: must provide documentation of an

inadequate clinical response

with its immediate release formulation (if available)

o For non-preferred brand names that have preferred generics: must provide

documentation of an inadequate clinical response or allergy to two or more generic

labelers (if available)

ADDITIONAL EXTENDED HALF-LIFE FACTOR CRITERIA

• Must provide attestation that the patient is not a suitable candidate for treatment with a

shorter-acting half-life drug

SUBSEQUENT AUTHORIZATION CRITERIA:

• Must provide documentation of patient’s clinical response to treatment and ongoing safety

monitoring

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 51

Blood Formation, Coagulation, and Thrombosis Agents: Heparin-

Related Preparations

LENGTH OF AUTHORIZATIONS: Dependent upon criteria below

ALL AUTHORIZATIONS: Must be

prescribed in accordance with FDA approved labeling

NON-PREFERRED CRITERIA:b

• Must provide documentation of medical necessity beyond convenience for why the patient

cannot be changed to a preferred drug (i.e., allergies, drug-drug interactions,

contraindications, or intolerances) OR

o For any nonsolid oral dosage formulation: must provide documentation of medical

necessity for why patient cannot be changed to a solid oral dosage formulation

•

Must have had an inadequate clinical response of at least

14 days with

at least

one preferred

drug

o For non-preferred extended-release formulations: must provide documentation of an

inadequate clinical response

with its immediate release formulation (if available)

o For non-preferred brand names that have preferred generics: must provide

documentation of an inadequate clinical response or allergy to two or more generic

labelers (if available)

ADDITIONAL INFORMATION:

• For most indications: Guidelines from the American College of Chest Physicians limit duration

of therapy in the outpatient setting for most indications to less than 35 days and patients

should be transitioned to oral anticoagulant as soon as possible

• For requests over 35 days and/or the patient cannot be transitioned to an oral anticoagulant,

prescriber must submit additional documentation for reasoning:

o For patients with cancer – authorized up to 180 days

o For pregnant women – authorized up to 280 days

o For patients unable to take an oral anticoagulant – authorized up to 180 days

SUBSEQUENT AUTHORIZATION CRITERIA:

• Must provide documentation of patient’s clinical response to treatment and ongoing safety

monitoring

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 52

Blood Formation, Coagulation, and Thrombosis Agents:

Anticoagulants

LENGTH OF AUTHORIZATION: 365 days

ALL AUTHORIZATIONS: Must be

prescribed in accordance with FDA approved labeling

NON-PREFERRED CRITERIA:

• Must provide documentation of medical necessity beyond convenience for why the patient

cannot be changed to a preferred drug (i.e., allergies, drug-drug interactions,

contraindications, or intolerances) OR

o For any nonsolid oral dosage formulation: must provide documentation of medical

necessity for why patient cannot be changed to a solid oral dosage formulation

•

Must have had an inadequate clinical response of at least

14 days with

at least

two preferred

drugs

o For non-preferred extended-release formulations: must provide documentation of an

inadequate clinical response

with its immediate release formulation (if available)

o For non-preferred brand names that have preferred generics: must provide

documentation of an inadequate clinical response or allergy to two or more generic

labelers (if available)

SUBSEQUENT AUTHORIZATION CRITERIA:

• Must provide documentation of patient’s clinical response to treatment and ongoing safety

monitoring

AR – All drugs: a PA is required for patients older than 12 years old

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 53

Blood Formation, Coagulation, and Thrombosis Agents:

Antiplatelet

LENGTH OF AUTHORIZATION: 365 days

ALL AUTHORIZATIONS: Must be

prescribed in accordance with FDA approved labeling

NON-PREFERRED CRITERIA:

• Must provide documentation of medical necessity beyond convenience for why the patient

cannot be changed to a preferred drug (i.e., allergies, drug-drug interactions,

contraindications, or intolerances) OR

o For any nonsolid oral dosage formulation: must provide documentation of medical

necessity for why patient cannot be changed to a solid oral dosage formulation

•

Must have had an inadequate clinical response of at least

14 days with

at least

two preferred

drugs

o For non-preferred extended-release formulations: must provide documentation of an

inadequate clinical response

with its immediate release formulation (if available)

o For non-preferred brand names that have preferred generics: must provide

documentation of an inadequate clinical response or allergy to two or more generic

labelers (if available)

SUBSEQUENT AUTHORIZATION CRITERIA:

• Must provide documentation of patient’s clinical response to treatment and ongoing safety

monitoring

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 54

Cardiovascular Agents: Angina, Hypertension & Heart Failure

LENGTH OF AUTHORIZATIONS: 365 days except nimodipine: 21 days

ALL AUTHORIZATIONS: Must be

prescribed in accordance with FDA approved labeling

PROPRANOLOL ORAL SOLUTION (HEMANGEOL) CRITERIA:

• Must provide documentation of the patient’s weight

SACUBITRIL/VALSARTAN (ENTRESTO) CRITERIA:

• Must provide documentation of chronic heart failure classified as either NYHA Class II-IV or

ACC/AHA Stage B-D

NON-PREFERRED CRITERIA:

• Must provide documentation of medical necessity beyond convenience for why the patient

cannot be changed to a preferred drug (i.e., allergies, drug-drug interactions,

contraindications, or intolerances) OR

o For any nonsolid oral dosage formulation: must provide documentation of medical

necessity for why patient cannot be changed to a solid oral dosage formulation

•

Must have had an inadequate clinical response of at least 30 days of at least two preferred

drugs within the same class, if indicated for diagnosis

o For non-preferred extended-release formulations: must provide documentation of

inadequate clinical response with its immediate release formulation (if available)

o For non-preferred brand names that have preferred generics: must provide

documentation of

an inadequate clinical response

or allergy to two or more generic

labelers (if available)

ADDITIONAL FINERENONE (KERENDIA) CRITERIA:

• Must be on a maximally tolerated dose of an angiotensin-converting enzyme inhibitor or

angiotensin receptor blocker

• Must provide documentation of an inadequate clinical response to a SGLT2 Inhibitor OR

provide documentation of medical necessity beyond convenience for why the patient cannot

try a SGLT2 inhibitor (i.e., chronic kidney disease diagnosis)

ADDITIONAL MAVACAMTEN (CAMZYOS) CRITERIA:

• Must be prescribed by or in consultation with a cardiologist

• Must provide documentation of NYHA Class II-III symptoms and left ventricular ejection

fraction ≥55%

ADDITIONAL SOTAGLIFLOZIN (INPEFA) CRITERIA:

• Must provide documentation of an inadequate clinical response to at least two SGLT2

Inhibitors

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 55

ADDITIONAL VERICIGUAT (VERQUVO) CRITERIA:

• Must provide documentation of ejection fraction

• Must have been hospitalized for the treatment of heart failure in the previous 180 days or

needs treatment with an outpatient intravenous diuretic in the previous 90 days

• Must be treated with an agent from ALL the following unless contraindicated:

o Angiotensin-converting enzyme inhibitor, angiotensin II receptor blocker, OR an

angiotensin receptor neprilysin inhibitor

o Beta-blocker

o Aldosterone antagonist and/or SGLT2 inhibitor as appropriate for renal function

SUBSEQUENT AUTHORIZATION CRITERIA:

• Must provide documentation of patient’s clinical response to treatment and ongoing safety

monitoring

AR – Sotylize Solution: a PA is required for patients 6 years and older

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 56

Cardiovascular Agents: Antiarrhythmics

LENGTH OF AUTHORIZATIONS: 365 Days

ALL AUTHORIZATIONS: Must be

prescribed in accordance with FDA approved labeling

NON-PREFERRED CRITERIA:

• Must provide documentation of medical necessity beyond convenience for why the patient

cannot be changed to a preferred drug (i.e., allergies, drug-drug interactions,

contraindications, or intolerances) OR

o For any nonsolid oral dosage formulation: must provide documentation of medical

necessity for why patient cannot be changed to a solid oral dosage formulation

•

Must have had an inadequate clinical response of at least 30 days with at least one preferred

drug

o For non-preferred extended-release formulations: must provide documentation of

inadequate clinical response with its immediate release formulation (if available)

o For non-preferred brand names that have preferred generics: must provide

documentation of

an inadequate clinical response

or allergy to two or more generic

labelers (if available)

SUBSEQUENT AUTHORIZATION CRITERIA:

• Must provide documentation of patient’s clinical response to treatment and ongoing safety

monitoring

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 57

Cardiovascular Agents: Lipotropics

LENGTH OF AUTHORIZATIONS: See below

Juxtapid (Initial)

180 days

Vascepa, Lovaza, ACL inhibitors (Initial)

84 days

All others (Initial and Subsequent)

365 days

ALL AUTHORIZATIONS: Must be

prescribed in accordance with FDA approved labeling

CLINICAL PA CRITERIA:

• Must provide documentation of baseline labs AND have documented adherence to 90 days of

prescribed lipid lowering medications

• Must have had an inadequate clinical response of at least 90 days AND unable to reach goal

LDL-C (see below) despite treatment with maximally tolerated dose of high-potency statin

and ezetimibe (or a clinical reason that these drugs cannot be utilized)

NON-PREFERRED CRITERIA:

• Must provide documentation of medical necessity beyond convenience for why the patient

cannot be changed to a preferred drug (i.e., allergies, drug-drug interactions,

contraindications, or intolerances) OR

o For any nonsolid oral dosage formulation: must provide documentation of medical

necessity for why patient cannot be changed to a solid oral dosage formulation

•

Must have had an inadequate clinical response of at least 30 days (or 90 days for fibrates)

with at least one preferred drug in the same drug class

o For non-preferred extended-release formulations: must provide documentation of

inadequate clinical response with its immediate release formulation (if available)

o For non-preferred brand names that have preferred generics: must provide

documentation of

an inadequate clinical response

or allergy to two or more generic

labelers (if available)

ADDITIONAL LOVASTATIN ER (ALTOPREV), PITAVASTATIN (LIVALO), FLUVASTATIN (LESCOL)

CRITERIA

•

Must have had an inadequate clinical response of at least 30 days with two preferred drugs

in the same drug class

ADDITIONAL COLESEVELAM (WELCHOL) CRITERIA:

• Must provide documentation of a Type 2 Diabetes diagnosis

ADDITIONAL ICOSAPENT ETHYL (VASCEPA) CRITERIA:

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 58

• Must provide documentation of baseline labs indicating triglyceride levels ≥500mg/dL after

an inadequate clinical response to fibrates, niacin, and diet/exercise

• Must provide documentation of discontinuation of drugs known to increase triglyceride

levels (i.e., beta blockers, thiazides, and estrogens), if clinically appropriate

ADDITIONAL LOMITAPIDE (JUXTAPID) & ATP CITRATE LYASE (ACL) INHIBITOR CRITERIA:

• Must provide documentation of baseline labs AND have documented adherence to 90 days of

prescribed lipid lowering medications

• Must have had

inadequate clinical response of

at least 90 days AND unable to reach goal LDL-

C with high-potency statin, ezetimibe and PCSK9 inhibitor (or a clinical reason that these

drugs cannot be utilized)

ADDITIONAL INFORMATION:

• High potency statins: atorvastatin (Lipitor) 40-80mg & rosuvastatin (Crestor) 20-40mg

• LDL goals for Familial Hypercholesterolemia (includes Heterozygous & Homozygous FH): LDL ≤

100mg/dL for adults or LDL ≤ 110mg/dL for those < 18 years of age

• LDL goals for Clinical Atherosclerotic Cardiovascular Disease (ASCVD): LDL ≤ 70mg/dL

SUBSEQUENT AUTHORIZATION CRITERIA:

• Must provide documentation of patient’s clinical response to treatment and ongoing safety

monitoring

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 59

Cardiovascular Agents: Pulmonary Arterial Hypertension*

LENGTH OF AUTHORIZATIONS: 365 Days

GRANDFATHERING*:

Patients who have a claim for a non-preferred drug in the previous 120 days will be automatically

approved to continue the drug. Patients who have taken the drug previously, but do not have claims

history (e.g., new to Medicaid), will need to submit a prior authorization in order to continue

coverage.

ALL AUTHORIZATIONS: Must be

prescribed in accordance with FDA approved labeling

CLINICAL PA CRITERIA:

• Must provide documentation of NYHA Functional Class for Pulmonary Hypertension and

symptoms experienced by patient

NON-PREFERRED CRITERIA:

• Must provide documentation of medical necessity beyond convenience for why the patient

cannot be changed to a preferred drug (i.e., allergies, drug-drug interactions,

contraindications, or intolerances) OR

o For any nonsolid oral dosage formulation: must provide documentation of medical

necessity for why patient cannot be changed to a solid oral dosage formulation

•

Must have had an inadequate clinical response of at least 30 days with at least two preferred

drugs, one of which must be a phosphodiesterase-5 inhibitor

o For non-preferred extended-release formulations: must provide documentation of

inadequate clinical response with its immediate release formulation (if available)

o For non-preferred brand names that have preferred generics: must provide

documentation of

an inadequate clinical response

or allergy to two or more generic

labelers (if available)

ADDITIONAL INFORMATION:

• Patients who have class III or IV symptoms defined by the NYHA Functional Class for

Pulmonary Hypertension may be authorized for inhalation or intravenous agents

SUBSEQUENT AUTHORIZATION CRITERIA:

• Must provide documentation of patient’s clinical response to treatment and ongoing safety

monitoring

AR - Sildenafil Susp: a PA is required for patients 18 years and older

AR - Tadliq: a PA is required for patients younger than 18 years

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 60

Central Nervous System (CNS) Agents: Alzheimer’s Agents*

LENGTH OF AUTHORIZATIONS: 365 Days

GRANDFATHERING*:

Patients who have a claim for a non-preferred drug in the previous 120 days will be automatically

approved to continue the drug. Patients who have taken the drug previously, but do not have claims

history (e.g., new to Medicaid), will need to submit a prior authorization in order to continue

coverage.

ALL AUTHORIZATIONS: Must be

prescribed in accordance with FDA approved labeling

NON-PREFERRED CRITERIA:

• Must provide documentation of medical necessity beyond convenience for why the patient

cannot be changed to a preferred drug (i.e., allergies, drug-drug interactions,

contraindications, or intolerances) OR

o For any nonsolid oral dosage formulation: must provide documentation of medical

necessity for why patient cannot be changed to a solid oral dosage formulation

•

Must have had an inadequate clinical response of at least 30 days with at least two preferred

drugs

o For non-preferred extended-release formulations: must provide documentation of

inadequate clinical response with its immediate release formulation (if available)

o For non-preferred brand names that have preferred generics: must provide

documentation of

an inadequate clinical response

or allergy to two or more generic

labelers (if available)

SUBSEQUENT AUTHORIZATION CRITERIA:

• Must provide documentation of patient’s clinical response to treatment and ongoing safety

monitoring

AR – All drugs: a PA is required for patients younger than 40 years

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 61

Central Nervous System (CNS) Agents: Anti-Migraine Agents, Acute

LENGTH OF AUTHORIZATIONS: 180 Days

ALL AUTHORIZATIONS: Must be

prescribed in accordance with FDA approved labeling

STEP THERAPY CRITERIA:

•

Must have had an inadequate clinical response of at least 14 days with at least two preferred

drugs

NON-PREFERRED CRITERIA:

• Must provide documentation of medical necessity beyond convenience for why the patient

cannot be changed to a preferred drug (i.e., allergies, drug-drug interactions,

contraindications, or intolerances) OR

o For any nonsolid oral dosage formulation: must provide documentation of medical

necessity for why patient cannot be changed to a solid oral dosage formulation

•

Must have had an inadequate clinical response of at least 14 days with at least two preferred

drugs

o For non-preferred extended-release formulations: must provide documentation of

inadequate clinical response with its immediate release formulation (if available)

o For non-preferred brand names that have preferred generics: must provide

documentation of

an inadequate clinical response

or allergy to two or more generic

labelers (if available)

ADDITIONAL UBROGEPANT (UBRELVY) CRITERIA

• Must have had

an inadequate clinical response of at least 14 days with at least one preferred

oral CGRP antagonist

SUBSEQUENT AUTHORIZATION CRITERIA:

• Must provide documentation of patient’s clinical response to treatment and ongoing safety

monitoring

QL - Nurtec ODT: 8 doses per 30 days for acute treatment

Central Nervous System (CNS) Agents: Anti-Migraine Agents,

Cluster Headache

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 62

LENGTH OF AUTHORIZATIONS: 180 days

ALL AUTHORIZATIONS: Must be

prescribed in accordance with FDA approved labeling

NON-PREFERRED CRITERIA:

• Must provide documentation of medical necessity beyond convenience for why the patient

cannot be changed to a preferred drug (i.e., allergies, drug-drug interactions,

contraindications, or intolerances) OR

o For any nonsolid oral dosage formulation: must provide documentation of medical

necessity for why patient cannot be changed to a solid oral dosage formulation

•

Must have had an inadequate clinical response of at least 60 days to at least one preferred

drug

o For non-preferred extended-release formulations: must provide documentation of

inadequate clinical response with its immediate release formulation (if available)

o For non-preferred brand names that have preferred generics: must provide

documentation of

an inadequate clinical response

or allergy to two or more generic

labelers (if available)

ADDITIONAL INFORMATION:

•

An inadequate clinical response to verapamil is defined as a titration to at least 480mg daily

SUBSEQUENT AUTHORIZATION CRITERIA:

• Must provide documentation of patient’s clinical response to treatment and ongoing safety

monitoring

QL – Emgality: 3 doses per 30 days

Central Nervous System (CNS) Agents: Anti-Migraine Agents,

Prophylaxis

LENGTH OF AUTHORIZATIONS: Initial: 180 days; Subsequent: 365 days

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 63

ALL AUTHORIZATIONS: Must be

prescribed in accordance with FDA approved labeling

STEP THERAPY CRITERIA:

•

Must have had an inadequate clinical response of at least 30 days with at least three

preferred controller migraine drugs

•

Must include

objective documentation of severity, frequency, type of migraine, and number

of headache days per month (preferably a headache diary)

ERENUMAB (AIMOVIG) CRITERIA:

• Must have had an inadequate clinical response of at least 60 days with the 70mg dose to

request a dose increase

FREMANEZUMAB (AJOVY) CRITERIA:

• Must have demonstrated efficacy for at least 90 days before quarterly administration will be

authorized

NON-PREFERRED CRITERIA:

• Must provide documentation of medical necessity beyond convenience for why the patient

cannot be changed to a preferred drug (i.e., allergies, drug-drug interactions,

contraindications, or intolerances) OR

o For any nonsolid oral dosage formulation: must provide documentation of medical

necessity for why patient cannot be changed to a solid oral dosage formulation

•

Must have had an inadequate clinical response of at least 30 days with at least three

preferred controller migraine drugs

AND one step therapy drug

o For non-preferred extended-release formulations: must provide documentation of

inadequate clinical response with its immediate release formulation (if available)

o For non-preferred brand names that have preferred generics: must provide

documentation of

an inadequate clinical response

or allergy to two or more generic

labelers (if available)

ADDITIONAL INFORMATION:

• Controller migraine drug classes include beta-blockers, anticonvulsants, tricyclic

antidepressants, or serotonin-norepinephrine reuptake inhibitors

SUBSEQUENT AUTHORIZATION CRITERIA:

• Must provide documentation of patient’s clinical response to treatment (preferably a

headache diary or other objective documentation of severity, frequency, and number of

headache days per month).

QL – Nurtec ODT: 18 doses per 30 days for prophylactic treatment

QL – Aimovig, Ajovy: 1 dose per 30 days

QL – Emgality: 2 doses per 30 days (for initial loading dose only), then 1 dose per 30 days thereafter

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 64

Central Nervous System (CNS) Agents: Anticonvulsants*

LENGTH OF AUTHORIZATIONS: 365 days except Epidiolex and Diacomit – Initial: 180 days

GRANDFATHERING* (except Diacomit):

Patients who have a claim for a non-preferred drug in the previous 120 days will be automatically

approved to continue the drug. Patients who have taken the drug previously, but do not have claims

history (e.g., new to Medicaid), will need to submit a prior authorization in order to continue

coverage.

ALL AUTHORIZATIONS: Must be

prescribed in accordance with FDA approved labeling

STEP THERAPY CRITERIA:

•

Must have had an inadequate clinical response of at least 30 days with at least one preferred

drug

CANNABIDIOL (EPIDIOLEX) CRITERIA

• Must have had an inadequate clinical response of at least 30 days with any two of the

following anticonvulsants: clobazam, levetiracetam, valproic acid, lamotrigine, topiramate,

rufinamide, or felbamate within the past 365 days (members who meet this criteria will not

require a PA)

STIRIPENTOL (DIACOMIT) CRITERIA

• Must be prescribed by or in consultation with a neurologist

• Must be concomitantly taking clobazam (Onfi)

• Must provide documentation of addressed comorbidities and baseline hematologic testing

(CBC)

o Patients with phenylketonuria (PKU) must provide evidence of total daily amount of

phenylalanine

o Prescribers must include management plans for patients with neutrophil counts <1,500

cells/mm

or platelet count <150,000/µL

• Must provide documentation of patient’s weight

o Maximum daily dose does not exceed: 50 mg/kg/day or 3,000mg/day

• Must provide baseline average number of seizure days per month (measured monthly or

quarterly)

NON-PREFERRED CRITERIA:

• Must provide documentation of medical necessity beyond convenience for why the patient

cannot be changed to a preferred drug (i.e., allergies, drug-drug interactions,

contraindications, or intolerances) OR

o For any nonsolid oral dosage formulation: must provide documentation of medical

necessity for why patient cannot be changed to a solid oral dosage formulation

•

Must have had an inadequate clinical response of at least 30 days with at least two preferred

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 65

drugs

o For non-preferred extended-release formulations: must provide documentation of

inadequate clinical response with its immediate release formulation (if available)

o For non-preferred brand names that have preferred generics: must provide

documentation of

an inadequate clinical response

or allergy to two or more generic

labelers (if available)

• Prescriptions submitted from a prescriber who is credentialed as a neurology specialty with

Ohio Medicaid AND for drugs that are used only for seizures,

there must have been an

inadequate clinical response of at least 30 days

with one preferred drug. This provision

applies only to the standard tablet/capsule dosage form.

SUBSEQUENT AUTHORIZATION CRITERIA:

• Must provide documentation of patient’s clinical response to treatment and ongoing safety

monitoring (i.e., documented reduction in average number of seizure days per month

[measured monthly or quarterly])

AR – Vigabatrin Powder: a PA is required for patients 3 years and older

AR – Eprontia Solution: a PA is required for patients 12 years and older

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 66

Central Nervous System (CNS) Agents: Anticonvulsants Rescue

LENGTH OF AUTHORIZATIONS: 365 Days

ALL AUTHORIZATIONS: Must be

prescribed in accordance with FDA approved labeling

NON-PREFERRED CRITERIA:

• Must provide documentation of medical necessity beyond convenience for why the patient

cannot be changed to a preferred drug (i.e., allergies, drug-drug interactions,

contraindications, or intolerances) OR

o For any nonsolid oral dosage formulation: must provide documentation of medical

necessity for why patient cannot be changed to a solid oral dosage formulation

•

Must have had an inadequate clinical response with at least one preferred drug

o For non-preferred extended-release formulations: must provide documentation of

inadequate clinical response with its immediate release formulation (if available)

o For non-preferred brand names that have preferred generics: must provide

documentation of

an inadequate clinical response

or allergy to two or more generic

labelers (if available)

SUBSEQUENT AUTHORIZATION CRITERIA:

• Must provide documentation of patient’s clinical response to treatment and ongoing safety

monitoring

AR – Valtoco: a PA is required for patients younger than 6 years old

AR – Nayzilam: a PA is required for patients younger than 12 years old

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 67

Central Nervous System (CNS) Agents: Antidepressants*

LENGTH OF AUTHORIZATIONS: 365 Days

GRANDFATHERING*:

Patients who have a claim for a non-preferred drug in the previous 120 days will be automatically

approved to continue the drug. Patients who have taken the drug previously, but do not have claims

history (e.g., new to Medicaid), will need to submit a prior authorization in order to continue

coverage.

PSYCHIATRIST EXEMPTION:

Prescribers (as identified below) are exempt from prior authorization of any non-preferred

antidepressant, or step therapy of any preferred drug, in the standard tablet/capsule dosage forms.

Other dosage forms may still require prior authorization. The exemption will be processed by the

claims system when the pharmacy has submitted the prescriber on the claim using the individual

national provider identifier (NPI) for the prescriber.

Prescribers are defined as:

Physicians with a specialty in psychiatry, nurse practitioners certified in psychiatric mental health, or

clinical nurse specialists certified in psychiatric mental health, who are credentialed with the Ohio

Department of Medicaid.

ALL AUTHORIZATIONS: Must be

prescribed in accordance with FDA approved labeling

NON-PREFERRED CRITERIA:

• Must provide documentation of medical necessity beyond convenience for why the patient

cannot be changed to a preferred drug (i.e., allergies, drug-drug interactions,

contraindications, or intolerances) OR

o For any nonsolid oral dosage formulation: must provide documentation of medical

necessity for why patient cannot be changed to a solid oral dosage formulation

•

Must have had an inadequate clinical response of at least 30 days with at least two preferred

drugs

o For non-preferred extended-release formulations: must provide documentation of

inadequate clinical response with its immediate release formulation (if available)

o For non-preferred brand names that have preferred generics: must provide

documentation of

an inadequate clinical response

or allergy to two or more generic

labelers (if available)

ADDITIONAL DEXTROMETHORPHAN/BUPROPION (AUVELITY) CRITERIA

• Must have an inadequate clinical response of at least 30 days with ALL of the following:

o ONE dopamine/norepinephrine reuptake inhibitor (DNRI)

o ONE selective norepinephrine reuptake inhibitor (SNRI)

o TWO selective serotonin reuptake inhibitors (SSRIs) (ONE of which must be either

vilazodone (Viibryd) OR vortioxetine (Trintellix))

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 68

SUBSEQUENT AUTHORIZATION CRITERIA:

• Must provide documentation of patient’s clinical response to treatment and ongoing safety

monitoring

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 69

Central Nervous System (CNS) Agents: Attention Defic

Hyperactivity Disorder Age

nts

LENGTH OF AUTHORIZATIONS: 365 days

ALL AUTHORIZATIONS: Must be

prescribed in accordance with FDA approved labeling

STEP THERAPY CRITERIA:

•

Must have had an inadequate clinical response of at least 30 days with atomoxetine OR at

least two preferred stimulants ADHD agents.

NON-PREFERRED CRITERIA:

• Must provide documentation of medical necessity beyond convenience for why the patient

cannot be changed to a preferred drug (i.e., allergies, drug-drug interactions,

contraindications, or intolerances) OR

o For any nonsolid oral dosage formulation: must provide documentation of medical

necessity for why patient cannot be changed to a solid oral dosage formulation

•

Must have had an inadequate clinical response of at least 30 days with at least three

preferred drugs

o For non-preferred extended-release formulations: must provide documentation of

inadequate clinical response with its immediate release formulation (if available)

o For non-preferred brand names that have preferred generics: must provide

documentation of

an inadequate clinical response

or allergy to two or more generic

labelers (if available)

ADDITIONAL INFORMATION

• Requests for non-preferred immediate-release formulations must have all required trials with

preferred immediate-release drugs, and requests for non-preferred extended-release

formulations must have all required trials with preferred extended-release drugs

• For patients established on drugs that change from preferred to non-preferred on January 1,

a prior authorization is NOT required until after June 30

of that year.

SUBSEQUENT AUTHORIZATION CRITERIA:

• Must provide documentation of patient’s clinical response to treatment and ongoing safety

monitoring

AR – Adderall, Dexedrine, & Zenzedi IR: a PA is required for patients younger than 3 years

AR – Adderall XR, Atomoxetine, Cotempla XR-ODT, Daytrana, Dexedrine ER, Dexmethylphenidate,

Methylphenidate IR & ER, & Xelstrym: a PA is required for patients younger than 6 years

AR – Dextroamphetamine Solution & Dyanavel XR: a PA is required for patients 12 years and older

AR – Methylphenidate solution/suspension: a PA is required for patients younger than 6 years and 12 years

and older

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 70

Central Nervous System (CNS) Agents: Antipsychotics*

LENGTH OF AUTHORIZATIONS: 365 Days

GRANDFATHERING*:

Patients who have a claim for a non-preferred drug in the previous 120 days will be automatically

approved to continue the drug. Patients who have taken the drug previously, but do not have claims

history (e.g., new to Medicaid), will need to submit a prior authorization in order to continue

coverage.

PSYCHIATRIST EXEMPTION:

Prescribers (as identified below) are exempt from prior authorization of any non-preferred second-

generation antipsychotic, or step therapy of any preferred drug, in the standard tablet/capsule and long-

acting injectable dosage forms. Other dosage forms may still require prior authorization. The exemption

will be processed by the claims system when the pharmacy has submitted the prescriber on the claim

using the individual national provider identifier (NPI) for the prescriber.

Prescribers are defined as:

Physicians with a specialty in psychiatry, nurse practitioners certified in psychiatric mental health, or

clinical nurse specialists certified in psychiatric mental health, who are credentialed with the Ohio

Department of Medicaid.

ALL AUTHORIZATIONS: Must be

prescribed in accordance with FDA approved labeling

PALIPERIDONE PALMITATE (INVEGA HAFYERA) CRITERIA:

• Must have had 4 months of treatment with Invega Sustenna or 3 months with Invega Trinza

STEP THERAPY CRITERIA:

•

Must have had an inadequate clinical response of at least 30 days with at least one preferred

drug

NON-PREFERRED CRITERIA:

• Must provide documentation of medical necessity beyond convenience for why the patient

cannot be changed to a preferred drug (i.e., allergies, drug-drug interactions,

contraindications, or intolerances) OR

o For any nonsolid oral dosage formulation: must provide documentation of medical

necessity for why patient cannot be changed to a solid oral dosage formulation

•

Must have had an inadequate clinical response of at least 30 days with at least two preferred

drugs

o For non-preferred extended-release formulations: must provide documentation of

inadequate clinical response with its immediate release formulation (if available)

o For non-preferred brand names that have preferred generics: must provide

documentation of

an inadequate clinical response

or allergy to two or more generic

labelers (if available)

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 71

ADDITIONAL ARIPIPRAZOLE (ABILIFY MYCITE) CRITERIA:

• Must be prescribed by or in consultation with a psychiatrist following an aripiprazole serum

blood level draw indicating need for further investigation of adherence

ADDITIONAL OLANZAPINE/SAMIDORPHAN (LYBALVI) CRITERIA:

• Must provide documentation that patient is not using opioids or undergoing acute opioid

withdrawal

ADDITIONAL PIMAVANSERIN (NUPLAZID) CRITERIA:

• For Parkinson-related Hallucinations & Delusions ALL of the following must be met:

o Psychotic symptoms are severe and frequent enough to warrant treatment with an

antipsychotic AND are not related to dementia or delirium

o The patient’s other Parkinson’s Disease drugs have been reduced or adjusted and

psychotic symptoms persist OR patient is unable to tolerate adjustment of these other

drugs

o Must have been inadequate clinical response or contraindication to at least 30 days of

either quetiapine or clozapine

• An exemption to the criteria will be authorized for prescribers with a neurology specialty to a

patient with a history of the related condition

ADDITIONAL FLUOXETINE/OLANZAPINE (SYMBYAX) CRITERIA

• Must provide documentation for patient’s inability to use the individual drugs

ADDITIONAL INFORMATION

• Long-acting injectable antipsychotics may be billed by the pharmacy if they are not dispensed

directly to the patient. If not administered by the pharmacist, the drug must be released only

to the administering provider or administering provider’s staff, following all regulations for a

Prescription Pick-Up Station as described by the Ohio Board of Pharmacy

SUBSEQUENT AUTHORIZATION CRITERIA:

• Must provide documentation of patient’s clinical response to treatment and ongoing safety

monitoring

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 72

Central Nervous System (CNS) Agents: Fibromyalgia Agents

LENGTH OF AUTHORIZATIONS: 365 Days

ALL AUTHORIZATIONS: Must be

prescribed in accordance with FDA approved labeling

NON-PREFERRED CRITERIA:

• Must provide documentation of medical necessity beyond convenience for why the patient

cannot be changed to a preferred drug (i.e., allergies, drug-drug interactions,

contraindications, or intolerances) OR

o For any nonsolid oral dosage formulation: must provide documentation of medical

necessity for why patient cannot be changed to a solid oral dosage formulation

•

Must have had an inadequate clinical response of at least 14 days with at least two preferred

drugs in different classes (see Additional Information section below)

o For non-preferred extended-release formulations: must provide documentation of

inadequate clinical response with its immediate release formulation (if available)

o For non-preferred brand names that have preferred generics: must provide

documentation of

an inadequate clinical response

or allergy to two or more generic

labelers (if available)

ADDITIONAL INFORMATION

• Drugs and drug classes include gabapentin, pregabalin, short- and/or long-acting opioids,

skeletal muscle relaxants, SNRIs, SSRIs, trazodone, and tricyclic antidepressants

• The P&T Committee does not recommend the use of opioids for treatment of fibromyalgia

SUBSEQUENT AUTHORIZATION CRITERIA:

• Must provide documentation of patient’s clinical response to treatment and ongoing safety

monitoring

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 73

Central Nervous System (CNS) Agents: Medication

Assisted

Treatment of Opioid

Addiction

LENGTH OF AUTHORIZATIONS: 180 days except 14 days for Lucemyra

ALL AUTHORIZATIONS: Must be

prescribed in accordance with FDA approved labeling

NON-PREFERRED CRITERIA:

• Must provide documentation of medical necessity beyond convenience for why the patient

cannot be changed to a preferred drug (i.e., allergies, drug-drug interactions,

contraindications, or intolerances) OR

o For any nonsolid oral dosage formulation: must provide documentation of medical

necessity for why patient cannot be changed to a solid oral dosage formulation

•

Must have had an inadequate clinical response of at least 30 days with at least two preferred

drugs

o For non-preferred extended-release formulations: must provide documentation of

inadequate clinical response with its immediate release formulation (if available)

o For non-preferred brand names that have preferred generics: must provide

documentation of

an inadequate clinical response

or allergy to two or more generic

labelers (if available)

ADDITIONAL LOFEXIDINE (LUCEMYRA) CRITERIA

• May be authorized if ALL of the following criteria are met:

o Must provide medical justification supporting why an opioid taper (such as with

buprenorphine or methadone) cannot be used

o Must have had an inadequate clinical response or contraindication to clonidine

• Must provide documentation that the drug was initiated in an inpatient setting to be exempt

from the above criteria

BUPRENORPHINE SAFETY EDITS AND DRUG UTILIZATION REVIEW CRITERIA:

• Prescribing for buprenorphine products must follow the requirements of Ohio Administrative

Code rule 4731-33-03 Office based treatment for opioid addiction.

• In favor of eliminating prior authorization for all forms of oral short acting buprenorphine-

containing products, ODM and the Managed Care Plans will implement safety edits and a

retrospective drug utilization review process for all brand and generic forms of oral short acting

buprenorphine-containing products. Safety edits are in place for dosages over 24mg of

buprenorphine equivalents/day.

• Buprenorphine sublingual tablets (generic Subutex) will be restricted to pregnancy,

breastfeeding, or contraindication to preferred products

• Buprenorphine injection (Sublocade) dosing schedule will be limited to 300mg/30 days

ADDITIONAL INFORMATION

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 74

•

Vivitrol and Sublocade may be billed by the pharmacy if it is not dispensed directly to the

patient. If not administered by the

pharmacist, the drug must be released only to the

administering provider or administering provider's staff, following all regulations for a

Prescription Pick-Up Station as described by the Ohio Board of Pharmacy.

SUBSEQUENT AUTHORIZATION CRITERIA:

• Must provide documentation of patient’s clinical response to treatment and ongoing safety

monitoring

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 75

Central Nervous System (CNS) Agents: Movement Disorders

LENGTH OF AUTHORIZATIONS: 365 Days

ALL AUTHORIZATIONS: Must be

prescribed in accordance with FDA approved labeling

CLINICAL PA CRITERIA:

• Must be prescribed by or in consultation with a neurologist or psychiatrist

STEP THERAPY CRITERIA:

• Must have an inadequate clinical response of at least 90 days to a maximally tolerated dose

of tetrabenazine for Huntington’s Disease only

NON-PREFERRED CRITERIA:

• Must provide documentation of medical necessity beyond convenience for why the patient

cannot be changed to a preferred drug (i.e., allergies, drug-drug interactions,

contraindications, or intolerances) OR

o For any nonsolid oral dosage formulation: must provide documentation of medical

necessity for why patient cannot be changed to a solid oral dosage formulation

•

Must have had an inadequate clinical response of at least 30 days with at least two preferred

drugs

o For non-preferred extended-release formulations: must provide documentation of

inadequate clinical response with its immediate release formulation (if available)

o For non-preferred brand names that have preferred generics: must provide

documentation of

an inadequate clinical response

or allergy to two or more generic

labelers (if available)

SUBSEQUENT AUTHORIZATION CRITERIA:

• Must provide documentation of patient’s clinical response to treatment and ongoing safety

monitoring

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 76

Central Nervous System (CNS) Agents: Multiple Sclerosis*

LENGTH OF AUTHORIZATIONS: 365 Days

GRANDFATHERING*:

Patients who have a claim for a non-preferred drug in the previous 120 days will be automatically

approved to continue the drug. Patients who have taken the drug previously, but do not have claims

history (e.g., new to Medicaid), will need to submit a prior authorization in order to continue

coverage.

ALL AUTHORIZATIONS: Must be

prescribed in accordance with FDA approved labeling

NON-PREFERRED CRITERIA:

• Must provide documentation of medical necessity beyond convenience for why the patient

cannot be changed to a preferred drug (i.e., allergies, drug-drug interactions,

contraindications, or intolerances) OR

o For any nonsolid oral dosage formulation: must provide documentation of medical

necessity for why patient cannot be changed to a solid oral dosage formulation

•

Must have had an inadequate clinical response of at least 30 days with at least one preferred

drug

o For non-preferred extended-release formulations: must provide documentation of

inadequate clinical response with its immediate release formulation (if available)

o For non-preferred brand names that have preferred generics: must provide

documentation of

an inadequate clinical response

or allergy to two or more generic

labelers (if available)

ADDITIONAL SIPONIMOD (MAYZENT) CRITERIA:

• Must provide documentation of genotype, liver function tests (LFTS) complete blood count

(CBC), ophthalmic examination, varicella zoster virus antibodies, and electrocardiogram (ECG)

SUBSEQUENT AUTHORIZATION CRITERIA:

• Must provide documentation of patient’s clinical response to treatment and ongoing safety

monitoring

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 77

Central Nervous System (CNS) Agents: Narcolepsy

LENGTH OF AUTHORIZATIONS: 365 days

ALL AUTHORIZATIONS: Must be

prescribed in accordance with FDA approved labeling

NON-PREFERRED CRITERIA:

• Must provide documentation of medical necessity beyond convenience for why the patient

cannot be changed to a preferred drug (i.e., allergies, drug-drug interactions,

contraindications, or intolerances) OR

o For any nonsolid oral dosage formulation: must provide documentation of medical

necessity for why patient cannot be changed to a solid oral dosage formulation

• Must have had an inadequate clinical response of at least 30 days with at least two preferred

drugs - either (1) at least 30 days of modafinil or armodafinil; or (2) at least 7 days of a

preferred methylphenidate or amphetamine drug

o For non-preferred extended-release formulations: must provide documentation of

inadequate clinical response with its immediate release formulation (if available)

o For non-preferred brand names that have preferred generics: must provide

documentation of

an inadequate clinical response

or allergy to two or more generic

labelers (if available)

ADDITIONAL OXYBATE SALTS (XYWAV) CRITERIA:

• Must have documented adherence to sodium restricted diet

SUBSEQUENT AUTHORIZATION CRITERIA:

• Must provide documentation of patient’s clinical response to treatment and ongoing safety

monitoring

AR – Adderall IR: a PA is required for patients younger than 3 years

AR – Adderall XR, Dexedrine ER: a PA is required for patients younger than 6 years

AR – Methylphenidate: a PA is required for patients younger than 6 years

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 78

Central Nervous System (CNS) Agents: Neuropathic Pain

LENGTH OF AUTHORIZATIONS: 365 Days

ALL AUTHORIZATIONS: Must be

prescribed in accordance with FDA approved labeling

STEP THERAPY CRITERIA:

• Must have had an inadequate clinical response of at least 30 days with generic Lidocaine

patch

NON-PREFERRED CRITERIA:

• Must provide documentation of medical necessity beyond convenience for why the patient

cannot be changed to a preferred drug (i.e., allergies, drug-drug interactions,

contraindications, or intolerances) OR

o For any nonsolid oral dosage formulation: must provide documentation of medical

necessity for why patient cannot be changed to a solid oral dosage formulation

•

Must have had an inadequate clinical response of at least 30 days with at least two preferred

drugs in different drug classes

o For non-preferred extended-release formulations: must provide documentation of

inadequate clinical response with its immediate release formulation (if available)

o For non-preferred brand names that have preferred generics: must provide

documentation of

an inadequate clinical response

or allergy to two or more generic

labelers (if available)

SUBSEQUENT AUTHORIZATION CRITERIA:

• Must provide documentation of patient’s clinical response to treatment and ongoing safety

monitoring

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 79

Central Nervous System (CNS) Agents: Parkinson's Agents

LENGTH OF AUTHORIZATIONS: 365 Days

ALL AUTHORIZATIONS: Must be

prescribed in accordance with FDA approved labeling

NON-PREFERRED CRITERIA:

• Must provide documentation of medical necessity beyond convenience for why the patient

cannot be changed to a preferred drug (i.e., allergies, drug-drug interactions,

contraindications, or intolerances) OR

o For any nonsolid oral dosage formulation: must provide documentation of medical

necessity for why patient cannot be changed to a solid oral dosage formulation

•

Must have had an inadequate clinical response of at least 30 days with at least one preferred

drug

o For non-preferred extended-release formulations: must provide documentation of

inadequate clinical response with its immediate release formulation (if available)

o For non-preferred brand names that have preferred generics: must provide

documentation of

an inadequate clinical response

or allergy to two or more generic

labelers (if available)

ADDITIONAL APOMORPHINE (APOKIN/KYNMOBI), LEVODOPA INHALATION (INBRIJA), &

ISTRADEFYLLINE (NOURIANZ) CRITERIA:

• Must have had inadequate clinical response to at least 30 days with one other drug for the

treatment of “off episodes” (dopamine agonist, COMT inhibitor, or MAO-B inhibitor)

SUBSEQUENT AUTHORIZATION CRITERIA:

• Must provide documentation of patient’s clinical response to treatment and ongoing safety

monitoring

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 80

Central Nervous System (CNS) Agents: Restless

egs

Synd

rome

LENGTH OF AUTHORIZATIONS: 365 Days

ALL AUTHORIZATIONS: Must be

prescribed in accordance with FDA approved labeling

NON-PREFERRED CRITERIA:

• Must provide documentation of medical necessity beyond convenience for why the patient

cannot be changed to a preferred drug (i.e., allergies, drug-drug interactions,

contraindications, or intolerances) OR

o For any nonsolid oral dosage formulation: must provide documentation of medical

necessity for why patient cannot be changed to a solid oral dosage formulation

•

Must have had an inadequate clinical response of at least 30 days with at least one preferred

drug

o For non-preferred extended-release formulations: must provide documentation of

inadequate clinical response with its immediate release formulation (if available)

o For non-preferred brand names that have preferred generics: must provide

documentation of

an inadequate clinical response

or allergy to two or more generic

labelers (if available)

SUBSEQUENT AUTHORIZATION CRITERIA:

• Must provide documentation of patient’s clinical response to treatment and ongoing safety

monitoring

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 81

Central Nervous System (CNS) Agents: Sedative-Hypnotics, Non-

Barbiturate

LENGTH OF AUTHORIZATIONS: 180 Days

ALL AUTHORIZATIONS: Must be

prescribed in accordance with FDA approved labeling

NON-PREFERRED CRITERIA:

• Must provide documentation of medical necessity beyond convenience for why the patient

cannot be changed to a preferred drug (i.e., allergies, drug-drug interactions,

contraindications, or intolerances) OR

o For any nonsolid oral dosage formulation: must provide documentation of medical

necessity for why patient cannot be changed to a solid oral dosage formulation

•

Must have had an inadequate clinical response of at least 10 days with at least two preferred

drugs

o For non-preferred extended-release formulations: must provide documentation of

inadequate clinical response with its immediate release formulation (if available)

o For non-preferred brand names that have preferred generics: must provide

documentation of

an inadequate clinical response

or allergy to two or more generic

labelers (if available)

ADDITIONAL INFORMATION

• Non-controlled medications may be authorized if the prescriber indicates the patient has a

history of addiction

•

The P&T Committee does not recommend the use of flurazepam (Dalmane) or triazolam

(Halcion)

SUBSEQUENT AUTHORIZATION CRITERIA:

• Must provide documentation of patient’s clinical response to treatment and ongoing safety

monitoring

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 82

Central Nervous System (CNS) Agents: Skeletal

Mus

cle Relaxants,

Non

Ben

odia

zep

ine

LENGTH OF AUTHORIZATIONS: 365 Days

ALL AUTHORIZATIONS: Must be

prescribed in accordance with FDA approved labeling

NON-PREFERRED CRITERIA:

• Must provide documentation of medical necessity beyond convenience for why the patient

cannot be changed to a preferred drug (i.e., allergies, drug-drug interactions, contraindications,

or intolerances) OR

o For any nonsolid oral dosage formulation: must provide documentation of medical

necessity for why patient cannot be changed to a solid oral dosage formulation

•

Must have had an inadequate clinical response of at least 30 days with at least one preferred

drug

o For non-preferred extended-release formulations: must provide documentation of an

inadequate clinical response

with its immediate release formulation (if available)

o For non-preferred brand names that have preferred generics, requests must provide

documentation of an inadequate clinical response or allergy to two or more generic

labelers (if available)

ADDITIONAL BACLOFEN SOLUTION CRITERIA:

• Must provide documentation of trial with baclofen tablets or justification why a non-solid oral

dosage form is indicated

ADDITIONAL CARISOPRODOL (SOMA) CRITERIA:

• Must provide medical justification that no other muscle relaxant or agent to treat

fibromyalgia, or any musculoskeletal condition would serve the clinical needs of the

patient

SUBSEQUENT AUTHORIZATION CRITERIA:

• Must provide documentation of patient’s clinical response to treatment and ongoing safety

monitoring

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 83

Central Nervous System (CNS) Agents: Smoking Deterrents

All products are covered without a PA

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 84

Dermatologic Agents: Oral Acne Products

LENGTH OF AUTHORIZATIONS: 150 days

ALL AUTHORIZATIONS: Must be

prescribed in accordance with FDA approved labeling

CLINICAL PA CRITERIA:

• Must have had an inadequate clinical response of at least 90 days with at least one preferred

topical AND one preferred oral antibiotic for acne

• Must be absent of oral tretinoin in the past 56 days

• Patient must be Prescriber attests that patient is registered and meets all of the requirements

of the iPLEDGE program

NON-PREFERRED CRITERIA:

• Must provide documentation of medical necessity beyond convenience for why the patient

cannot be changed to a preferred drug (i.e., allergies, drug-drug interactions,

contraindications, or intolerances) OR

o For any nonsolid oral dosage formulation: must provide documentation of medical

necessity for why patient cannot be changed to a solid oral dosage formulation

•

Must have had an inadequate clinical response of at least 90 days with at least two preferred

drugs

o For non-preferred extended-release formulations: must provide documentation of

inadequate clinical response with its immediate release formulation (if available)

o For non-preferred brand names that have preferred generics: must provide

documentation of

an inadequate clinical response

or allergy to two or more generic

labelers (if available)

ADDITIONAL INFORMATION

• Authorization length will be for no more than 150 days at a time then must take 56 days off

SUBSEQUENT AUTHORIZATION CRITERIA:

• Must provide documentation of patient’s clinical response to treatment and ongoing safety

monitoring

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 85

Dermatologic Agents: Topical Acne Products

LENGTH OF AUTHORIZATIONS: 365 Days

ALL AUTHORIZATIONS: Must be

prescribed in accordance with FDA approved labeling

NON-PREFERRED CRITERIA:

• Must provide documentation of medical necessity beyond convenience for why the patient

cannot be changed to a preferred drug (i.e., allergies, drug-drug interactions,

contraindications, or intolerances) OR

o For any nonsolid oral dosage formulation: must provide documentation of medical

necessity for why patient cannot be changed to a solid oral dosage formulation

•

Must have had an inadequate clinical response of at least 30 days or (90 days for retinoids) of

at least three preferred drugs

o For non-preferred extended-release formulations: must provide documentation of

inadequate clinical response with its immediate release formulation (if available)

o For non-preferred brand names that have preferred generics: must provide

documentation of

an inadequate clinical response

or allergy to two or more generic

labelers (if available)

ADDITIONAL TRETINOIN/BENZOYL PEROXIDE (TWYNEO) CRITERIA

• Must provide documentation for patient’s inability to use the individual drugs

ADDITIONAL INFORMATION

• All retinoids - May be authorized with a diagnosis of skin cancer

• Tazarotene (Tazorac) - May be authorized with a diagnosis of psoriasis

SUBSEQUENT AUTHORIZATION CRITERIA:

• Must provide documentation of patient’s clinical response to treatment and ongoing safety

monitoring

AR - All topical retinoids: a PA is required for patients 24 years and older

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 86

Endocrine Agents: Androgens

LENGTH OF AUTHORIZATIONS: 365 Days

ALL AUTHORIZATIONS: Must be

prescribed in accordance with FDA approved labeling

CLINICAL PA CRITERIA:

• Must provide documentation of lab work to support the need for testosterone

supplementation

NON-PREFERRED CRITERIA:

• Must provide documentation of medical necessity beyond convenience for why the patient

cannot be changed to a preferred drug (i.e., allergies, drug-drug interactions,

contraindications, or intolerances) OR

o For any nonsolid oral dosage formulation: must provide documentation of medical

necessity for why patient cannot be changed to a solid oral dosage formulation

•

Must have had an inadequate clinical response of at least 90 days with ALL preferred drugs

o For non-preferred extended-release formulations: must provide documentation of

inadequate clinical response with its immediate release formulation (if available)

o For non-preferred brand names that have preferred generics: must provide

documentation of

an inadequate clinical response

or allergy to two or more generic

labelers (if available)

SUBSEQUENT AUTHORIZATION CRITERIA:

• Must provide documentation of patient’s clinical response to treatment and ongoing safety

monitoring (i.e., testosterone and hematocrit)

AR: All drugs: a PA is required for patients younger than 18 years

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 87

Endocrine Agents: Diabetes – Hypoglycemia Treatments

LENGTH OF AUTHORIZATIONS: 365 Days

ALL AUTHORIZATIONS: Must be

prescribed in accordance with FDA approved labeling

NON-PREFERRED CRITERIA:

• Must provide documentation of medical necessity beyond convenience for why the patient

cannot be changed to a preferred drug (i.e., allergies, drug-drug interactions,

contraindications, or intolerances) OR

o For any nonsolid oral dosage formulation: must provide documentation of medical

necessity for why patient cannot be changed to a solid oral dosage formulation

•

Must have had an inadequate clinical response of at least two one preferred drugs OR the

inability of the member and/or caregiver to administer a preferred glucagon product in a

timely fashion

o For non-preferred extended-release formulations: must provide documentation of

inadequate clinical response with its immediate release formulation (if available)

o For non-preferred brand names that have preferred generics: must provide

documentation of

an inadequate clinical response

or allergy to two or more generic

labelers (if available)

SUBSEQUENT AUTHORIZATION CRITERIA:

• Must provide documentation of patient’s clinical response to treatment and ongoing safety

monitoring

QL – All glucagon products: 2 doses per 34 days

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 88

Endocrine Agents: Diabetes – Insulin

LENGTH OF AUTHORIZATIONS: 365 Days

ALL AUTHORIZATIONS: Must be

prescribed in accordance with FDA approved labeling

STEP THERAPY CRITERIA:

•

Must have had an inadequate clinical response of at least 120 days with at least one

preferred drug

having a similar duration of action

NON-PREFERRED CRITERIA:

• Must provide documentation of medical necessity beyond convenience for why the patient

cannot be changed to a preferred drug (i.e., allergies, drug-drug interactions,

contraindications, or intolerances) OR

o For any nonsolid oral dosage formulation: must provide documentation of medical

necessity for why patient cannot be changed to a solid oral dosage formulation

•

Must have had an inadequate clinical response of at least 120 days with at least two

preferred drugs

having a similar duration of action

o For non-preferred extended-release formulations: must provide documentation of an

inadequate clinical response with its immediate release formulation (if available)

o For non-preferred brand names that have preferred generics: must provide

documentation of an

inadequate clinical response

or allergy to two or more generic

labelers (if available)

ADDITIONAL TEMPO PEN CRITERIA

• Must have had an inadequate clinical response or documentation of medical necessity

beyond convenience for why the patient cannot use the corresponding FlexPens or Kwikpens

ADDITIONAL INHALED INSULIN (AFREZZA) CRITERIA:

• Must provide documentation of spirometry testing prior to initiation with a predicted FEV1

≥70% - Will not be authorized for patients with asthma or COPD

• Must provide documentation of being nicotine-free for at least 180 days

ADDITIONAL INFORMATION

• An

inadequate clinical response

is defined as the inability to reach A1C goal after at least 120

days of current regimen with documented adherence and appropriate dose escalation.

•

Requests may be authorized for patients with a condition that is difficult to

control (i.e., prone

to ketoacidosis, hypoglycemia)

SUBSEQUENT AUTHORIZATION CRITERIA:

• Must provide documentation of patient’s clinical response to treatment and ongoing safety

monitoring

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 89

Endocrine Agents: Diabetes –

Non

Insulin

LENGTH OF AUTHORIZATIONS: 365 Days

ALL AUTHORIZATIONS: Must be

prescribed in accordance with FDA approved labeling

NON-PREFERRED CRITERIA:

• Must provide documentation of medical necessity beyond convenience for why the patient

cannot be changed to a preferred drug (i.e., allergies, drug-drug interactions,

contraindications, or intolerances) OR

o For any nonsolid oral dosage formulation: must provide documentation of medical

necessity for why patient cannot be changed to a solid oral dosage formulation

•

Must have had an inadequate clinical response of at least 120 days with at least three

preferred drugs

o For non-preferred extended-release formulations: must provide documentation of

inadequate clinical response with its immediate release formulation (if available)

o For non-preferred brand names that have preferred generics: must provide

documentation of

an inadequate clinical response

or allergy to two or more generic

labelers (if available)

ADDITIONAL ORAL AND INJECTABLE COMBINATION DRUGS CRITERIA

•

Must have had a trial of at least 120 days with

the individual drugs OR must provide

documentation of medical necessity beyond convenience for patient’s inability to use the

individual drugs

ADDITIONAL INFORMATION

•

An inadequate clinical response is dened as the inability to reach A1c goal aer at least 120

days of current regimen, with use of mulple drugs concomitantly per ADA guidelines,

documented adherence, and appropriate dose escalaon (must achieve maximum

recommended dose or document that maximum recommended dose is not tolerated or is

clinically inappropriate).

Must document A1c goal per ADA guidelines and baseline A1c.

•

Requests may be authorized for patients with a condition that is difficult to

control (i.e., prone

to ketoacidosis, hypoglycemia)

• For non-preferred drugs that have preferred drugs in the same drug class: must provide

documentation that there was at least one inadequate clinical response with a drug in same

drug class

SUBSEQUENT AUTHORIZATION CRITERIA:

•

Must provide documentaon of paent’s clinical response to treatment and ongoing safety

monitoring

Must document A1c goal per ADA guidelines and A1c trends including current value

(within last 6 months).

•

Must meet all inial clinical criteria for subsequent authorizaons.

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 90

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 91

Endocrine Agents: Endometriosis

LENGTH OF AUTHORIZATIONS: 365 Days

ALL AUTHORIZATIONS: Must be

prescribed in accordance with FDA approved labeling

STEP THERAPY CRITERIA:

•

Must have had an inadequate clinical response of at least 84 days with at least one preferred

NSAID and one preferred oral contraceptive

NON-PREFERRED CRITERIA:

• Must provide documentation of medical necessity beyond convenience for why the patient

cannot be changed to a preferred drug (i.e., allergies, drug-drug interactions,

contraindications, or intolerances) OR

o For any nonsolid oral dosage formulation: must provide documentation of medical

necessity for why patient cannot be changed to a solid oral dosage formulation

•

Must have had an inadequate clinical response of at least 84 days with at least one preferred

NSAID, one preferred oral contraceptive, AND one preferred step-therapy drug

o For non-preferred extended-release formulations: must provide documentation of

inadequate clinical response with its immediate release formulation (if available)

o For non-preferred brand names that have preferred generics: must provide

documentation of

an inadequate clinical response

or allergy to two or more generic

labelers (if available)

SUBSEQUENT AUTHORIZATION CRITERIA:

• Must provide documentation of patient’s clinical response to treatment and ongoing safety

monitoring

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 92

Endocrine Agents: Estrogenic

gen

LENGTH OF AUTHORIZATIONS: 365 Days

ALL AUTHORIZATIONS: Must be

prescribed in accordance with FDA approved labeling

NON-PREFERRED CRITERIA:

• Must provide documentation of medical necessity beyond convenience for why the patient

cannot be changed to a preferred drug (i.e., allergies, drug-drug interactions,

contraindications, or intolerances) OR

o For any nonsolid oral dosage formulation: must provide documentation of medical

necessity for why patient cannot be changed to a solid oral dosage formulation

•

Must have had an inadequate clinical response of at least 30 days with at least two preferred

drugs

o For non-preferred extended-release formulations: must provide documentation of

inadequate clinical response with its immediate release formulation (if available)

o For non-preferred brand names that have preferred generics: must provide

documentation of

an inadequate clinical response

or allergy to two or more generic

labelers (if available)

ADDITIONAL INFORMATION:

• Requests for non-preferred drugs must have

an inadequate clinical response

with preferred

drugs with the same delivery method

SUBSEQUENT AUTHORIZATION CRITERIA:

• Must provide documentation of patient’s clinical response to treatment and ongoing safety

monitoring

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 93

Endocrine Agents: Growth Hormone

LENGTH OF AUTHORIZATIONS: Initial: 180 days; Subsequent: 365 days

ALL AUTHORIZATIONS: Must be

prescribed in accordance with FDA approved labeling

CLINICAL PA CRITERIA:

Pediatric Approvals (under 18 years of age):

• Must be treated and followed by a pediatric endocrinologist, nephrologist, clinical

geneticist, endocrinologist, or gastroenterologist (or as appropriate for diagnosis)

• Must provide documentation to justify criteria being met, including height, weight, bone

age (children), date and results of most current x-ray, stimulus test results, IGF-1 levels,

and a growth chart (children)

• Must not being used in combination with another somatropin agent

Adult Approvals (18 years of age or older):

• Must be treated and following by an endocrinologist

• Must provide documentation of growth hormone deficiency by means of a negative response

to an appropriate stimulation test (clonidine test is not acceptable for adults)

• Must provide documentation of baseline evaluation of the following clinical indicators: (1)

insulin-like growth factor (IGF-1); (2) fasting lipid profile; (3) BUN; (4) fasting glucose; (5)

electrolytic levels; (6) evaluation of any new osteoarthritis and joint pain; (7) bone density test

• Must have had other hormonal deficiencies addressed with adequate replacement therapy

NON-PREFERRED CRITERIA:

• Must provide documentation of medical necessity beyond convenience for why the patient

cannot be changed to a preferred drug (i.e., allergies, drug-drug interactions,

contraindications, or intolerances) OR

o For any nonsolid oral dosage formulation: must provide documentation of medical

necessity for why patient cannot be changed to a solid oral dosage formulation

•

Must have had an inadequate clinical response of at least 90 days with at least one preferred

drug

o For non-preferred extended-release formulations: must provide documentation of an

inadequate clinical response

with its immediate release formulation (if available)

o For non-preferred brand names that have preferred generics: must provide

documentation of an inadequate clinical response or allergy to two or more generic

labelers (if available)

SUBSEQUENT AUTHORIZATION CRITERIA:

• Must provide documentation of patient’s clinical response to treatment and ongoing safety

monitoring (i.e., height, weight gain, improved body composition)

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 94

For adults:

must provide documentation by endocrinologist that discontinuing agent would

have a detrimental effect on body composition or other metabolic parameters

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 95

Endocrine Agents: Osteoporosis – Bone

Ossi

fic

ation

Enh

ancers

LENGTH OF AUTHORIZATIONS: 365 Days

ALL AUTHORIZATIONS: Must be

prescribed in accordance with FDA approved labeling

TERIPARATIDE (FORTEO™) CRITERIA:

• Must have had an inadequate clinical response of at least 365 days with one bisphosphonate

• A total lifetime duration of therapy of 730 days will be authorized between any parathyroid

analog

NON-PREFERRED CRITERIA:

• Must provide documentation of medical necessity beyond convenience for why the patient

cannot be changed to a preferred drug (i.e., allergies, drug-drug interactions,

contraindications, or intolerances) OR

o For any nonsolid oral dosage formulation: must provide documentation of medical

necessity for why patient cannot be changed to a solid oral dosage formulation

•

Must have had an inadequate clinical response of at least 365 days with at least one

preferred drug within the same class

o For non-preferred extended-release formulations: must provide documentation of an

inadequate clinical response

with its immediate release formulation (if available)

o For non-preferred brand names that have preferred generics: must provide

documentation of an inadequate clinical response or allergy to two or more generic

labelers (if available)

DDIT

NAL ABAL

OPAR

YMLOS™) CRIT

ERIA

• Must have had an inadequate clinical response of at least 365 days with one bisphosphonate

• A total lifetime duration of therapy of 730 days will be authorized between any parathyroid

analog

ADDITIONAL INFORMATION

• Patients should only be on ONE of the therapeutic classes (bisphosphonates, calcitonin-

salmon)

SUBSEQUENT AUTHORIZATION CRITERIA:

• Must provide documentation of patient’s clinical response to treatment and ongoing safety

monitoring

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 96

Endocrine Agents: Progestin Agents

All products are covered without a PA

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 97

Endocrine Agents: Uterine Fibroids

LENGTH OF AUTHORIZATIONS: Up to 180 Days

ALL AUTHORIZATIONS: Must be

prescribed in accordance with FDA approved labeling

CLINICAL PA CRITERIA:

• Must have had an inadequate

clinical response of at least 90 days with at least one preferred

oral contraceptive

NON-PREFERRED CRITERIA:

• Must provide documentation of medical necessity beyond convenience for why the patient

cannot be changed to a preferred drug (i.e., allergies, drug-drug interactions,

contraindications, or intolerances) OR

o For any nonsolid oral dosage formulation: must provide documentation of medical

necessity for why patient cannot be changed to a solid oral dosage formulation

•

Must have had an inadequate clinical response of at least 90 days with at least one preferred

drug

o For non-preferred extended-release formulations: must provide documentation of an

inadequate clinical response

with its immediate release formulation (if available)

o For non-preferred brand names that have preferred generics: must provide

documentation of an inadequate clinical response or allergy to two or more generic

labelers (if available)

ADDITIONAL INFORMATION:

• A total lifetime duration of therapy of 730 days between Oriahnn and Myfembree or 180 days

for Lupron Depot will be authorized

SUBSEQUENT AUTHORIZATION CRITERIA:

• Must provide documentation of patient’s clinical response to treatment and ongoing safety

monitoring

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 98

Gastrointestinal Agents: Anti-Emetics

LENGTH OF AUTHORIZATIONS: 365 Days

ALL AUTHORIZATIONS: Must be

prescribed in accordance with FDA approved labeling

NON-PREFERRED CRITERIA:

• Must provide documentation of medical necessity beyond convenience for why the patient

cannot be changed to a preferred drug (i.e., allergies, drug-drug interactions,

contraindications, or intolerances) OR

o For any nonsolid oral dosage formulation: must provide documentation of medical

necessity for why patient cannot be changed to a solid oral dosage formulation

•

Must have had an inadequate clinical response of at least 7 3 days with at least one preferred

drug

o For non-preferred extended-release formulations: must provide documentation of an

inadequate clinical response

with its immediate release formulation (if available)

o For non-preferred brand names that have preferred generics: must provide

documentation of an inadequate clinical response or allergy to two or more generic

labelers (if available)

SUBSEQUENT AUTHORIZATION CRITERIA:

• Must provide documentation of patient’s clinical response to treatment and ongoing safety

monitoring

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 99

Gastrointestinal Agents: Bowel Preparations

LENGTH OF AUTHORIZATIONS: 365 Days

ALL AUTHORIZATIONS: Must be

prescribed in accordance with FDA approved labeling

NON-PREFERRED CRITERIA:

• Must provide documentation of medical necessity beyond convenience for why the patient

cannot be changed to a preferred drug (i.e., allergies, drug-drug interactions,

contraindications, or intolerances) OR

o For any solid oral dosage formulation: must provide documentation of medical necessity

for why patient cannot be changed to a non-solid oral dosage formulation

•

Must have had an inadequate clinical response with at least one preferred drug

o For non-preferred brand names that have preferred generics: must provide

documentation of

an inadequate clinical response

or allergy to two or more generic

labelers (if available)

SUBSEQUENT AUTHORIZATION CRITERIA:

• Must provide documentation of patient’s clinical response to treatment and ongoing safety

monitoring

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 100

Gastrointestinal Agents: Crohn’s Disease

LENGTH OF AUTHORIZATIONS: 365 Days; Ortikos ER – based on indication

ALL AUTHORIZATIONS: Must be

prescribed in accordance with FDA approved labeling

NON-PREFERRED CRITERIA:

• Must provide documentation of medical necessity beyond convenience for why the patient

cannot be changed to a preferred drug (i.e., allergies, drug-drug interactions,

contraindications, or intolerances) OR

o For any nonsolid oral dosage formulation: must provide documentation of medical

necessity for why patient cannot be changed to a solid oral dosage formulation

•

Must have had an inadequate clinical response of at least 30 days with at least two preferred

drugs

o For non-preferred extended-release formulations: must provide documentation of an

inadequate clinical response

with its immediate release formulation (if available)

o For non-preferred brand names that have preferred generics: must provide

documentation of an inadequate clinical response or allergy to two or more generic

labelers (if available)

SUBSEQUENT AUTHORIZATION CRITERIA:

• Must provide documentation of patient’s clinical response to treatment and ongoing safety

monitoring

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 101

Gastrointestinal Agents: Hepatic Encephalopathy

LENGTH OF AUTHORIZATIONS: 365 Days

ALL AUTHORIZATIONS: Must be

prescribed in accordance with FDA approved labeling

STEP THERAPY CRITERIA:

•

Must have had an inadequate clinical response of at least 14 days with at least one preferred

drug

RIFAXAMIN (XIFAXAN) CRITERIA:

• Must have had an inadequate clinical response of at least 14 days to lactulose to be

authorized for monotherapy or add on therapy

NON-PREFERRED CRITERIA:

• Must provide documentation of medical necessity beyond convenience for why the patient

cannot be changed to a preferred drug (i.e., allergies, drug-drug interactions,

contraindications, or intolerances) OR

o For any nonsolid oral dosage formulation: must provide documentation of medical

necessity for why patient cannot be changed to a solid oral dosage formulation

•

Must have had an inadequate clinical response of at least 14 days with at least two preferred

drugs

o For non-preferred extended-release formulations: must provide documentation of an

inadequate clinical response

with its immediate release formulation (if available)

o For non-preferred brand names that have preferred generics: must provide

documentation of an inadequate clinical response or allergy to two or more generic

labelers (if available)

SUBSEQUENT AUTHORIZATION CRITERIA:

• Must provide documentation of patient’s clinical response to treatment and ongoing safety

monitoring

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 102

Gastrointestinal Agents: Irritable Bowel Syndrome (IBS) with

Diarrhea

LENGTH OF AUTHORIZATIONS: 365 Days

ALL AUTHORIZATIONS: Must be

prescribed in accordance with FDA approved labeling

STEP THERAPY CRITERIA:

•

Must have had an inadequate clinical response of at least 30 days with at least one preferred

drug

NON-PREFERRED CRITERIA:

• Must provide documentation of medical necessity beyond convenience for why the patient

cannot be changed to a preferred drug (i.e., allergies, drug-drug interactions,

contraindications, or intolerances) OR

o For any nonsolid oral dosage formulation: must provide documentation of medical

necessity for why patient cannot be changed to a solid oral dosage formulation

•

Must have had an inadequate clinical response of at least 30 days with at least two preferred

drugs

o For non-preferred extended-release formulations: must provide documentation of an

inadequate clinical response

with its immediate release formulation (if available)

o For non-preferred brand names that have preferred generics: must provide

documentation of an inadequate clinical response or allergy to two or more generic

labelers (if available)

SUBSEQUENT AUTHORIZATION CRITERIA:

• Must provide documentation of patient’s clinical response to treatment and ongoing safety

monitoring

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 103

Gastrointestinal Agents: Pancreatic Enzymes

LENGTH OF AUTHORIZATIONS: 365 Days

ALL AUTHORIZATIONS: Must be

prescribed in accordance with FDA approved labeling

NON-PREFERRED CRITERIA:

• Must provide documentation of medical necessity beyond convenience for why the patient

cannot be changed to a preferred drug (i.e., allergies, drug-drug interactions,

contraindications, or intolerances) OR

o For any nonsolid oral dosage formulation: must provide documentation of medical

necessity for why patient cannot be changed to a solid oral dosage formulation

•

Must have had an inadequate clinical response of at least 14 days with at least one preferred

drug

o For non-preferred extended-release formulations: must provide documentation of an

inadequate clinical response

with its immediate release formulation (if available)

o For non-preferred brand names that have preferred generics: must provide

documentation of an inadequate clinical response or allergy to two or more generic

labelers (if available)

SUBSEQUENT AUTHORIZATION CRITERIA:

• Must provide documentation of patient’s clinical response to treatment and ongoing safety

monitoring

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 104

Gastrointestinal Agents: Proton Pump

Inhibitors

LENGTH OF AUTHORIZATIONS: 180 days, except as listed under additional criteria

ALL AUTHORIZATIONS: Must be

prescribed in accordance with FDA approved labeling

NON-PREFERRED CRITERIA:

• Must provide documentation of medical necessity beyond convenience for why the patient

cannot be changed to a preferred drug (i.e., allergies, drug-drug interactions,

contraindications, or intolerances) OR

o For any nonsolid oral dosage formulation: must provide documentation of medical

necessity for why patient cannot be changed to a solid oral dosage formulation

•

Must have had an inadequate clinical response of at least 30 days with at least two preferred

drugs

o For non-preferred extended-release formulations: must provide documentation of an

inadequate clinical response

with its immediate release formulation (if available)

o For non-preferred brand names that have preferred generics: must provide

documentation of an inadequate clinical response or allergy to two or more generic

labelers (if available)

ADDITIONAL CRITERIA FOR PPI DOSES GREATER THAN ONCE DAILY

• For H. Pylori diagnosis: Must provide documentation of diagnosis

o Authorization length: 30 days

• For any of the following diagnoses: carcinoma of GI tract, COPD, Crest Syndrome, dyspepsia,

esophageal varices, gastritis, gastroparesis, scleroderma, symptomatic uncomplicated Barret’s

Esophagus, systemic mastocytosis, or Zollinger Ellison Syndrome: Must provide

documentation of diagnosis AND must have failed once-daily dosing of the requested drug

o Authorization length: 365 days

ADDITIONAL INFORMATION

•

Request may be authorized If the drug was initiated in the hospital for the treatment of a

condition such as a GI bleed or the presence of a gastrostomy and/or jejunostomy

(G, GJ, J-

tube)

SUBSEQUENT AUTHORIZATION CRITERIA:

• Must provide documentation of patient’s clinical response to treatment and ongoing safety

monitoring

AR - Protonix Pak/Pantoprazole Packet: a PA is required for patients 6 years and older

AR – Omeprazole & Pantoprazole Tab/Cap/ODT: a PA is required for patient 21 years and older

requesting more than once daily dosing

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 105

Gastrointestinal Agents: Ulcerative Colitis

LENGTH OF AUTHORIZATIONS: 365 Days; except Uceris foam – based on indication

ALL AUTHORIZATIONS: Must be

prescribed in accordance with FDA approved labeling

NON-PREFERRED CRITERIA:

• Must provide documentation of medical necessity beyond convenience for why the patient

cannot be changed to a preferred drug (i.e., allergies, drug-drug interactions,

contraindications, or intolerances) OR

o For any nonsolid oral dosage formulation: must provide documentation of medical

necessity for why patient cannot be changed to a solid oral dosage formulation

•

Must have had an inadequate clinical response of at least 30 days with at least two preferred

drugs

o For non-preferred extended-release formulations: must provide documentation of an

inadequate clinical response

with its immediate release formulation (if available)

o For non-preferred brand names that have preferred generics: must provide

documentation of an inadequate clinical response or allergy to two or more generic

labelers (if available)

SUBSEQUENT AUTHORIZATION CRITERIA:

• Must provide documentation of patient’s clinical response to treatment and ongoing safety

monitoring

QL – Budesonide ER 9mg tablets: 56 tablets per 90 days

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 106

Gastrointestinal Agents: Unspecified GI

LENGTH OF AUTHORIZATIONS: 365 days except 3 days for Aemcolo

ALL AUTHORIZATIONS: Must be

prescribed in accordance with FDA approved labeling

STEP THERAPY CRITERIA:

•

Must have had an inadequate clinical response to at least 14 days with at least two preferred

drugs

NON-PREFERRED CRITERIA:

• Must provide documentation of medical necessity beyond convenience for why the patient

cannot be changed to a preferred drug (i.e., allergies, drug-drug interactions,

contraindications, or intolerances) OR

o For any nonsolid oral dosage formulation: must provide documentation of medical

necessity for why patient cannot be changed to a solid oral dosage formulation

•

Must have had an inadequate clinical response of at least 14 days with at least three

preferred drugs, if indicated for diagnosis

o For non-preferred extended-release formulations: must provide documentation of an

inadequate clinical response

with its immediate release formulation (if available)

o For non-preferred brand names that have preferred generics: must provide

documentation of an inadequate clinical response or allergy to two or more generic

labelers (if available)

ADDITIONAL METHYLNALTREXONE (RELISTOR) AND NALDEMEDINE (SYMPROIC) CRITERIA:

• Must have a history of chronic pain requiring continuous opioid therapy for ≥84 days

ADDITIONAL RIFAMYCIN DELAYED-RELEASE (AEMCOLO) CRITERIA:

• Must have the inability to take, or failure of ALL of the following: azithromycin,

ciprofloxacin, levofloxacin, ofloxacin, or rifaximin

ADDITIONAL SOMATROPIN INJECTION (ZORBTIVE) AND TEDLOGLUTIDE (GATTEX) CRITERIA:

• Must have evidence of specialized parenteral nutritional support

• Must have documentation of appropriate lab assessment (bilirubin, alkaline phosphatase,

lipase, and amylase) at least 180 days prior to initiation

SUBSEQUENT AUTHORIZATION CRITERIA:

• Must provide documentation of patient’s clinical response to treatment and ongoing safety

monitoring (i.e., decreased frequency of specialized nutrition support or improvement in

symptoms)

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 107

Genitourinary Agents: Benign Prostatic Hyperplasia

LENGTH OF AUTHORIZATIONS: 365 Days

ALL AUTHORIZATIONS: Must be

prescribed in accordance with FDA approved labeling

TADALAFIL (CIALIS) CRITERIA:

• Must have had

an inadequate clinical response of

at least 30 days with at least one alpha-1

adrenergic blocker. and If prostate volume of > 30cc on imaging, a prostate specific antigen

(PSA) > 1.5ng/dL, or palpable prostate enlargement on digital rectal exam (DRE), then a trial of

at least 90 days of finasteride is required.”

NON-PREFERRED CRITERIA:

• Must provide documentation of medical necessity beyond convenience for why the patient

cannot be changed to a preferred drug (i.e., allergies, drug-drug interactions,

contraindications, or intolerances) OR

o For any nonsolid oral dosage formulation: must provide documentation of medical

necessity for why patient cannot be changed to a solid oral dosage formulation

•

Must have had an inadequate clinical response of at least 30 days with at least two preferred

drugs

o For non-preferred extended-release formulations: must provide documentation of an

inadequate clinical response

with its immediate release formulation (if available)

o For non-preferred brand names that have preferred generics: must provide

documentation of an inadequate clinical response or allergy to two or more generic

labelers (if available)

ADDITIONAL DUTASTERIDE/TAMSULOSIN (JALYN) & FINASTERIDE/TADALAFIL (ENTADFI) CRITERIA

• Must provide documentation for patient’s inability to use the individual drugs

SUBSEQUENT AUTHORIZATION CRITERIA:

• Must provide documentation of patient’s clinical response to treatment and ongoing safety

monitoring

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 108

Genitourinary Agents: Electrolyte Depleter Agents

LENGTH OF AUTHORIZATIONS: 365 Days

ALL AUTHORIZATIONS: Must be

prescribed in accordance with FDA approved labeling

NON-PREFERRED CRITERIA:

• Must provide documentation of medical necessity beyond convenience for why the patient

cannot be changed to a preferred drug (i.e., allergies, drug-drug interactions,

contraindications, or intolerances) OR

o For any nonsolid oral dosage formulation: must provide documentation of medical

necessity for why patient cannot be changed to a solid oral dosage formulation

•

Must have had an inadequate clinical response of at least 7 days with at least two preferred

drugs

o For non-preferred extended-release formulations: must provide documentation of an

inadequate clinical response

with its immediate release formulation (if available)

o For non-preferred brand names that have preferred generics: must provide

documentation of an inadequate clinical response or allergy to two or more generic

labelers (if available)

SUBSEQUENT AUTHORIZATION CRITERIA:

• Must provide documentation of patient’s clinical response to treatment and ongoing safety

monitoring

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 109

Genitourinary Agents: Urinary Antispasmodics

LENGTH OF AUTHORIZATIONS: 365 Days

ALL AUTHORIZATIONS: Must be

prescribed in accordance with FDA approved labeling

NON-PREFERRED CRITERIA:

• Must provide documentation of medical necessity beyond convenience for why the patient

cannot be changed to a preferred drug (i.e., allergies, drug-drug interactions,

contraindications, or intolerances) OR

o For any nonsolid oral dosage formulation: must provide documentation of medical

necessity for why patient cannot be changed to a solid oral dosage formulation

•

Must have had an inadequate clinical response of at least 30 days with at least two preferred

drugs with different active ingredients

o For non-preferred extended-release formulations: must provide documentation of an

inadequate clinical response

with its immediate release formulation (if available)

o For non-preferred brand names that have preferred generics: must provide

documentation of an inadequate clinical response or allergy to two or more generic

labelers (if available)

SUBSEQUENT AUTHORIZATION CRITERIA:

• Must provide documentation of patient’s clinical response to treatment and ongoing safety

monitoring

AR – Vesicare LS: a PA is required for patients younger than 2 years old AND 5 years and older

AR – Myrbetriq Granules: a PA is required for patients younger than 3 years old AND 5 years and older

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 110

Immunomodulator Agents: Systemic Inflammatory Disease

LENGTH OF AUTHORIZATIONS: Initial: 90 days; Subsequent: 365 days

ALL AUTHORIZATIONS:

• Must be

prescribed in accordance with FDA approved labeling

• First line treatment can vary based upon the severity of disease for certain diagnoses.

Documentation of the patient’s disease state and the criteria used to classify the severity is

required.

CLINICAL PA CRITERIA:

• Must have been an inadequate clinical response of at least 90 days with

at least

two

applicable first-line drugs indicated for diagnosis – provide documentation of the trialed

drugs, dosages, dates, and durations

• Authorization of dosing regimens (loading/maintenance) will be based upon diagnosis.

Document the requested loading and maintenance dosing on PA form, if applicable

• Must not have a current, active infection

• Must provide evidence of negative TB test prior to initiation of biologic therapy, if required by

labeling

STEP THERAPY CRITERIA:

•

Must had had an inadequate clinical response of at least 90 days with at least one preferred

TNF inhibitor indicated for diagnosis

NON-PREFERRED CRITERIA:

• Must provide documentation of medical necessity beyond convenience for why the patient

cannot be changed to a preferred drug (i.e., allergies, drug-drug interactions,

contraindications, or intolerances) OR

o For any nonsolid oral dosage formulation: must provide documentation of medical

necessity for why patient cannot be changed to a solid oral dosage formulation

•

Must have had an inadequate clinical response of at least 90 days with at least two preferred

drugs, if indicated for diagnosis

o For non-preferred extended-release formulations: must provide documentation of an

inadequate clinical response

with its immediate release formulation (if available)

o For non-preferred brand names that have preferred generics: must provide

documentation of an inadequate clinical response or allergy to two or more generic

labelers (if available)

ADDITIONAL ALOPECIA AREATA CRITERIA:

• Must be prescribed by or in consultation with a specialist (i.e., dermatologist,

rheumatologist)

• Must provide documentation of an inadequate clinical response of at least 90 days with a

topical steroid

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 111

ADDITIONAL ATOPIC DERMATITIS CRITERIA:

• Must have at least 10% body surface area (BSA) involvement with

two of the following:

topical corticosteroids or topical calcineurin inhibitors [e.g., Elidel] unless atopic dermatitis is

severe and involves >

25% BSA

ADDITIONAL CROHN’S DISEASE CRITERIA:

• Must provide documentation of Crohn's Disease Activity Index (CDAI) score of 220 or

higher to be considered moderate to severe disease

ADDITIONAL HIDRADENTIS SUPPURATIVA CRITERIA:

• Must provide documentation of Hurley Stage III to be classified as severe disease

ADDITIONAL PLAQUE PSORIASIS CRITERIA:

• For patients currently receiving phototherapy, initial authorization for preferred drugs

requires an inadequate clinical response to at least 90 days of phototherapy

• To classify as severe disease patient must present at least two of the following: Psoriasis

Area and Severity Index (PASI) score ≥ 11, BSA ≥ 10%, and Static Physician's Global

Assessment (sPGA) ≥ 3

ADDITIONAL ULCERATIVE COLITIS CRITERIA:

• If an inadequate clinical response after 90 days with one TNF inhibitor, further TNF inhibitors

will not be authorized

SUBSEQUENT AUTHORIZATION CRITERIA:

• Must provide documentation of patient’s clinical response to treatment and ongoing safety

monitoring

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 112

Infectious Disease Agents: Antibiotics – Cephalosporins

LENGTH OF AUTHORIZATIONS: Based on indication

ALL AUTHORIZATIONS: Must be

prescribed in accordance with FDA approved labeling

NON-PREFERRED CRITERIA:

• Must provide documentation of medical necessity beyond convenience for why the patient

cannot be changed to a preferred drug (i.e., allergies, drug-drug interactions,

contraindications, or intolerances) OR

o For any nonsolid oral dosage formulation: must provide documentation of medical

necessity for why patient cannot be changed to a solid oral dosage formulation

•

Must have had an inadequate clinical response of at least 3 days with at least one preferred

antibiotic

o For non-preferred extended-release formulations: must provide documentation of an

inadequate clinical response

with its immediate release formulation (if available)

o For non-preferred brand names that have preferred generics: must provide

documentation of an inadequate clinical response or allergy to two or more generic

labelers (if available)

ADDITIONAL INFORMATION

• Requests may be authorized if:

o The infection is caused by an organism resistant to ALL preferred

antibiotics

(must

provide diagnosis and any culture/sensitivity results)

o The patient is completing a course of therapy that was started in the hospital or other

similar location or was started before Medicaid eligibility, only the remaining course will

be authorized

SUBSEQUENT AUTHORIZATION CRITERIA:

• Must provide documentation of patient’s clinical response to treatment, ongoing safety

monitoring, AND medical necessity for continued use

AR - Cefaclor Suspension: a PA is required for patients 12 years and older

AR - Cefixime Suspension: a PA is required for patients 12 years and older

AR - Cefprozil Suspension: a PA is required for patients 12 years and older

AR - Suprax Chewable Tablet: a PA is required for patients 12 years and older

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 113

Infectious Disease Agents: Antibiotics – Inhaled

LENGTH OF AUTHORIZATIONS: Initial: 180 days; Subsequent: 365 days

ALL REQUESTS: Must be

prescribed in accordance with FDA approved labeling

CLINICAL PA CRITERIA:

• Must provide documentation of cultures demonstrating drug is prescribed in alignment with

approved indication

NON-PREFERRED CRITERIA:

• Must provide documentation of medical necessity beyond convenience for why the patient

cannot be changed to a preferred drug (i.e., allergies, drug-drug interactions,

contraindications, or intolerances) OR

o For any nonsolid oral dosage formulation: must provide documentation of medical

necessity for why patient cannot be changed to a solid oral dosage formulation

•

Must have had an inadequate clinical response of at least 28 days with at least one preferred

drug

o For non-preferred extended-release formulations: must provide documentation of an

inadequate clinical response

with its immediate release formulation (if available)

o For non-preferred brand names that have preferred generics: must provide

documentation of an inadequate clinical response or allergy to two or more generic

labelers (if available)

SUBSEQUENT AUTHORIZATION CRITERIA:

• Must provide documentation of patient’s clinical response to treatment and ongoing safety

monitoring (i.e., culture conversion, symptom improvement)

QL – Tobramycin drugs: 56 doses in 56 days

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 114

Infectious Disease Agents: Antibiotics – Macrolides

LENGTH OF AUTHORIZATIONS: Based on indication

ALL AUTHORIZATIONS: Must be

prescribed in accordance with FDA approved labeling

NON-PREFERRED CRITERIA:

• Must provide documentation of medical necessity beyond convenience for why the patient

cannot be changed to a preferred drug (i.e., allergies, drug-drug interactions,

contraindications, or intolerances) OR

o For any nonsolid oral dosage formulation: must provide documentation of medical

necessity for why patient cannot be changed to a solid oral dosage formulation

•

Must have had an inadequate clinical response of at least 3 days with at least one preferred

drug

o For non-preferred extended-release formulations: must provide documentation of an

inadequate clinical response

with its immediate release formulation (if available)

o For non-preferred brand names that have preferred generics: must provide

documentation of an inadequate clinical response or allergy to two or more generic

labelers (if available)

ADDITIONAL INFORMATION

• Requests may be authorized if:

o The infection is caused by an organism resistant to ALL preferred

antibiotics

(must

provide diagnosis and any culture/sensitivity results)

o The patient is completing a course of therapy that was started in the hospital or other

similar location or was started before Medicaid eligibility, only the remaining course will

be authorized

SUBSEQUENT AUTHORIZATION CRITERIA:

• Must provide documentation of patient’s clinical response to treatment, ongoing safety

monitoring, AND medical necessity for continued use

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 115

Infectious Disease Agents: Antibiotics – Quinolones

LENGTH OF AUTHORIZATIONS: Based on indication

ALL AUTHORIZATIONS: Must be

prescribed in accordance with FDA approved labeling

NON-PREFERRED CRITERIA:

• Must provide documentation of medical necessity beyond convenience for why the patient

cannot be changed to a preferred drug (i.e., allergies, drug-drug interactions,

contraindications, or intolerances) OR

o For any nonsolid oral dosage formulation: must provide documentation of medical

necessity for why patient cannot be changed to a solid oral dosage formulation

•

Must have had an inadequate clinical response of at least 3 days with at least one preferred

drug

o For non-preferred extended-release formulations: must provide documentation of an

inadequate clinical response

with its immediate release formulation (if available)

o For non-preferred brand names that have preferred generics: must provide

documentation of an inadequate clinical response or allergy to two or more generic

labelers (if available)

ADDITIONAL INFORMATION

• Requests may be authorized if:

o The infection is caused by an organism resistant to ALL preferred

antibiotics

(must

provide diagnosis and any culture/sensitivity results)

o The patient is completing a course of therapy that was started in the hospital or other

similar location or was started before Medicaid eligibility, only the remaining course will

be authorized

SUBSEQUENT AUTHORIZATION CRITERIA:

• Must provide documentation of patient’s clinical response to treatment, ongoing safety

monitoring, AND medical necessity for continued use

AR - Ciprofloxacin Suspension: a PA is required for patients 12 years and older

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 116

Infectious Disease Agents: Antibiotics – Tetracyclines

LENGTH OF AUTHORIZATIONS: Based on indication for acute infections or 365 days for acne

ALL REQUESTS: Must be

prescribed in accordance with FDA approved labeling

NON-PREFERRED CRITERIA:

• Must provide documentation of medical necessity beyond convenience for why the patient

cannot be changed to a preferred drug (i.e., allergies, drug-drug interactions,

contraindications, or intolerances) OR

o For any nonsolid oral dosage formulation: must provide documentation of medical

necessity for why patient cannot be changed to a solid oral dosage formulation

•

Must have had an inadequate clinical response of at least 3 days with at least one preferred

drug for acute infections OR at least 90 days with at least one preferred oral drug for acne

o For non-preferred extended-release formulations: must provide documentation of an

inadequate clinical response

with its immediate release formulation (if available)

o For non-preferred brand names that have preferred generics: must provide

documentation of an inadequate clinical response or allergy to two or more generic

labelers (if available)

ADDITIONAL INFORMATION

• Requests may be authorized if:

o The infection is caused by an organism resistant to ALL preferred

antibiotics

(must

provide diagnosis and any culture/sensitivity results)

o The patient is completing a course of therapy that was started in the hospital or other

similar location or was started before Medicaid eligibility, only the remaining course will

be authorized

SUBSEQUENT AUTHORIZATION CRITERIA:

• Must provide documentation of patient’s clinical response to treatment, ongoing safety

monitoring, AND medical necessity for continued use

AR – Vibramycin Suspension: a PA is required for patients 12 years and older

AR – Doxycycline Syrup: a PA is required for patients 12 years and older

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 117

Infectious Disease Agents: Antifungals

LENGTH OF AUTHORIZATIONS: Based on indication

ALL AUTHORIZATIONS: Must be

prescribed in accordance with FDA approved labeling

NON-PREFERRED CRITERIA:

• Must provide documentation of medical necessity beyond convenience for why the patient

cannot be changed to a preferred drug (i.e., allergies, drug-drug interactions,

contraindications, or intolerances) OR

o For any nonsolid oral dosage formulation: must provide documentation of medical

necessity for why patient cannot be changed to a solid oral dosage formulation

•

Must have had an inadequate clinical response of at least 7 days with at least one two

preferred drugs, if indicated for the diagnosis

o For non-preferred extended-release formulations: must provide documentation of an

inadequate clinical response

with its immediate release formulation (if available)

o For non-preferred brand names that have preferred generics: must provide

documentation of an inadequate clinical response or allergy to two or more generic

labelers (if available)

ADDITIONAL OTESECONAZOLE (VIVJOA) CRITERIA:

• Must provide documentation of at least three symptomatic episodes of vulvovaginal candidiasis

in the past 12 months

• Must provide documentation of non-reproductive potential (i.e., post-menopausal)

• Must have had an inadequate clinical response of at least 180 day maintenance course with

oral fluconazole shown by documentation of more than one breakthrough infection

ADDITIONAL INFORMATION:

• Requests may be authorized if:

o The infection is caused by an organism resistant to ALL preferred

antifungals

(must

provide diagnosis and any culture/sensitivity results)

o The patient is completing a course of therapy that was started in the hospital or other

similar location or was started before Medicaid eligibility, only the remaining course will

be authorized

SUBSEQUENT AUTHORIZATION CRITERIA:

• Must provide documentation of patient’s clinical response to treatment, ongoing safety

monitoring, AND medical necessity for continued use

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 118

Infectious Disease Agents: Antivirals – Hepatitis C Agents

LENGTH OF AUTHORIZATIONS: Dependent upon authorized course

ALL REQUESTS: Must be

prescribed in accordance with FDA approved labeling

CLINICAL PA CRITERIA:

• Only regimens recommended by the American Association for the Study of Liver Diseases

(AASLD) will be authorized

• Please see the Hepatitis C Direct Acting Antiviral Prior Authorization Form for criteria

NON-PREFERRED CRITERIA:

• Must provide documentation of medical necessity beyond convenience for why the patient

cannot be changed to a preferred drug (i.e., allergies, drug-drug interactions,

contraindications, or intolerances) OR

o For any nonsolid oral dosage formulation: must provide documentation of medical

necessity for why patient cannot be changed to a solid oral dosage formulation

•

Must have had an inadequate clinical response defined as not achieving SVR with guideline-

recommended preferred drugs

o For non-preferred extended-release formulations: must provide documentation of an

inadequate clinical response

with its immediate release formulation (if available)

o For non-preferred brand names that have preferred generics: must provide

documentation of an inadequate clinical response or allergy to two or more generic

labelers (if available)

ADDITIONAL INFORMATION:

• Requests for patients established on current therapy with prior payer (i.e., Commercial,

Fee-for-Service, Managed Care Plan, etc) will be authorized with documentation

• Requests for regimens including pegylated Interferons must include close monitoring

with periodic clinical and laboratory evaluations

• Requests for regimens including ribavirins must include documentation of at least two

reliable forms of contraception being used during therapy

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 119

Infectious Disease Agents: Antivirals – Herpes

LENGTH OF AUTHORIZATIONS: For the duration of the prescription (up to 180 days)

ALL AUTHORIZATIONS: Must be

prescribed in accordance with FDA approved labeling

NON-PREFERRED CRITERIA:

• Must provide documentation of medical necessity beyond convenience for why the patient

cannot be changed to a preferred drug (i.e., allergies, drug-drug interactions,

contraindications, or intolerances) OR

o For any nonsolid oral dosage formulation: must provide documentation of medical

necessity for why patient cannot be changed to a solid oral dosage formulation

•

Must have had an inadequate clinical response of at least 3 days with at least one preferred

drug

o For non-preferred extended-release formulations: must provide documentation of an

inadequate clinical response

with its immediate release formulation (if available)

o For non-preferred brand names that have preferred generics: must provide

documentation of an inadequate clinical response or allergy to two or more generic

labelers (if available)

SUBSEQUENT AUTHORIZATION CRITERIA:

• Must provide documentation of patient’s clinical response to treatment and ongoing safety

monitoring

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 120

Infectious Disease Agents: Antivirals – HIV*

LENGTH OF AUTHORIZATIONS: 365 Days

GRANDFATHERING*:

Patients who have a claim for a non-preferred drug in the previous 120 days will be automatically

approved to continue the drug. Patients who have taken the drug previously, but do not have claims

history (e.g., new to Medicaid), will need to submit a prior authorization in order to continue

coverage.

ALL AUTHORIZATIONS: Must be

prescribed in accordance with FDA approved labeling

ABACAVIR/DOLUTEGRAVIR/LAMIVUDINE (TRIUMEQ PD) CRITERIA:

• Must provide documentation of patient’s weight (only authorized for those 10 – 25 kg)

NON-PREFERRED CRITERIA:

• Must provide documentation of medical necessity beyond convenience for why the patient

cannot be changed to a preferred drug (i.e., allergies, drug-drug interactions,

contraindications, or intolerances) OR

o For any nonsolid oral dosage formulation: must provide documentation of medical

necessity for why patient cannot be changed to a solid oral dosage formulation

•

Must have had an inadequate clinical response of at least 30 days with at least one preferred

drug.

If applicable, the request must address the inability to use the individual components.

o For non-preferred extended-release formulations: must provide documentation of an

inadequate clinical response

with its immediate release formulation (if available)

o For non-preferred brand names that have preferred generics: must provide

documentation of an inadequate clinical response or allergy to two or more generic

labelers (if available)

SUBSEQUENT AUTHORIZATION CRITERIA:

• Must provide documentation of patient’s clinical response to treatment and ongoing safety

monitoring

AR – Isentress chewable tablet: a PA is required for patients 12 years and older

AR – Lamivudine solution: a PA is required for patients 3 years and older

AR – Nevirapine solution: a PA is required for patients 3 years and older

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 121

Ophthalmic Agents: Antibiotic and

Antibiotic

roid

Combination

Drops and

Ointm

nts

LENGTH OF AUTHORIZATIONS: 30 days

ALL AUTHORIZATIONS: Must be

prescribed in accordance with FDA approved labeling

NON-PREFERRED CRITERIA:

• Must provide documentation of medical necessity beyond convenience for why the patient

cannot be changed to a preferred drug (i.e., allergies, drug-drug interactions,

contraindications, or intolerances) OR

o For any nonsolid oral dosage formulation: must provide documentation of medical

necessity for why patient cannot be changed to a solid oral dosage formulation

•

Must have had an inadequate clinical response of at least 3 days with at least two preferred

drugs

o For non-preferred extended-release formulations: must provide documentation of an

inadequate clinical response

with its immediate release formulation (if available)

o For non-preferred brand names that have preferred generics: must provide

documentation of an inadequate clinical response or allergy to two or more generic

labelers (if available)

ADDITIONAL INFORMATION

• Requests may be authorized if:

o The infection is caused by an organism resistant to ALL preferred

antibiotics

(must

provide diagnosis and any culture/sensitivity results)

o The patient is completing a course of therapy that was started in the hospital or other

similar location or was started before Medicaid eligibility, only the remaining course will

be authorized

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 122

Ophthalmic Agents: Antihistamines & Mast Cell Stabilizers

LENGTH OF AUTHORIZATIONS: 365 Days

ALL AUTHORIZATIONS: Must be

prescribed in accordance with FDA approved labeling

NON-PREFERRED CRITERIA:

• Must provide documentation of medical necessity beyond convenience for why the patient

cannot be changed to a preferred drug (i.e., allergies, drug-drug interactions,

contraindications, or intolerances) OR

o For any nonsolid oral dosage formulation: must provide documentation of medical

necessity for why patient cannot be changed to a solid oral dosage formulation

•

Must have had an inadequate clinical response of at least 14 days with at least two preferred

drugs

o For non-preferred extended-release formulations: must provide documentation of an

inadequate clinical response

with its immediate release formulation (if available)

o For non-preferred brand names that have preferred generics: must provide

documentation of an inadequate clinical response or allergy to two or more generic

labelers (if available)

SUBSEQUENT AUTHORIZATION CRITERIA:

• Must provide documentation of patient’s clinical response to treatment and ongoing safety

monitoring

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 123

Ophthalmic Agents: Dry Eye Treatments

LENGTH OF AUTHORIZATIONS: 14 Days for Eysuvis; 365 Days for all other drugs

ALL AUTHORIZATIONS: Must be

prescribed in accordance with FDA approved labeling

STEP THERAPY CRITERIA:

•

Must have had an inadequate clinical response of at least 14 days with one artificial tear or

OTC dry eye drop in the previous 120 days

NON-PREFERRED CRITERIA:

• Must provide documentation of medical necessity beyond convenience for why the patient

cannot be changed to a preferred drug (i.e., allergies, drug-drug interactions,

contraindications, or intolerances) OR

o For any nonsolid oral dosage formulation: must provide documentation of medical

necessity for why patient cannot be changed to a solid oral dosage formulation

•

Must have had an inadequate clinical response of at least 14 days with at least one preferred

drug

o For non-preferred extended-release formulations: must provide documentation of an

inadequate clinical response

with its immediate release formulation (if available)

o For non-preferred brand names that have preferred generics: must provide

documentation of an inadequate clinical response or allergy to two or more generic

labelers (if available)

SUBSEQUENT AUTHORIZATION CRITERIA:

• Must provide documentation of patient’s clinical response to treatment and ongoing safety

monitoring

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 124

Ophthalmic Agents: Glaucoma Age

nts

LENGTH OF AUTHORIZATIONS: 365 Days

ALL AUTHORIZATIONS: Must be

prescribed in accordance with FDA approved labeling

STEP THERAPY CRITERIA:

•

Must have had an inadequate clinical response of at least 30 days with at least one preferred

drug in the same class, if available

NON-PREFERRED CRITERIA:

• Must provide documentation of medical necessity beyond convenience for why the patient

cannot be changed to a preferred drug (i.e., allergies, drug-drug interactions,

contraindications, or intolerances) OR

o For any nonsolid oral dosage formulation: must provide documentation of medical

necessity for why patient cannot be changed to a solid oral dosage formulation

•

Must have had an inadequate clinical response of at least 30 days with at least two preferred

drugs in the same class, if available

o For non-preferred extended-release formulations: must provide documentation of an

inadequate clinical response

with its immediate release formulation (if available)

o For non-preferred brand names that have preferred generics: must provide

documentation of an inadequate clinical response or allergy to two or more generic

labelers (if available)

SUBSEQUENT AUTHORIZATION CRITERIA:

• Must provide documentation of patient’s clinical response to treatment and ongoing safety

monitoring

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 125

Ophthalmic Agents: NSAIDs

LENGTH OF AUTHORIZATIONS: 30 days

ALL AUTHORIZATIONS: Must be

prescribed in accordance with FDA approved labeling

NON-PREFERRED CRITERIA:

• Must provide documentation of medical necessity beyond convenience for why the patient

cannot be changed to a preferred drug (i.e., allergies, drug-drug interactions,

contraindications, or intolerances) OR

o For any nonsolid oral dosage formulation: must provide documentation of medical

necessity for why patient cannot be changed to a solid oral dosage formulation

•

Must have had an inadequate clinical response of at least 3 days with at least one preferred

drug

o For non-preferred extended-release formulations: must provide documentation of an

inadequate clinical response

with its immediate release formulation (if available)

o For non-preferred brand names that have preferred generics: must provide

documentation of an inadequate clinical response or allergy to two or more generic

labelers (if available)

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 126

Ophthalmic Agents: Ophthalmic Steroids

LENGTH OF AUTHORIZATIONS: 30 days

ALL AUTHORIZATIONS: Must be

prescribed in accordance with FDA approved labeling

NON-PREFERRED CRITERIA:

• Must provide documentation of medical necessity beyond convenience for why the patient

cannot be changed to a preferred drug (i.e., allergies, drug-drug interactions,

contraindications, or intolerances) OR

o For any nonsolid oral dosage formulation: must provide documentation of medical

necessity for why patient cannot be changed to a solid oral dosage formulation

•

Must have had an inadequate clinical response of at least 14 days with at least two preferred

drugs

o For non-preferred extended-release formulations: must provide documentation of an

inadequate clinical response

with its immediate release formulation (if available)

o For non-preferred brand names that have preferred generics: must provide

documentation of an inadequate clinical response or allergy to two or more generic

labelers (if available)

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 127

Otic Agents: Antibacterial and

Antibact

rial/Steroid Combinations

LENGTH OF AUTHORIZATIONS: 30 days

ALL AUTHORIZATIONS: Must be

prescribed in accordance with FDA approved labeling

NON-PREFERRED CRITERIA:

• Must provide documentation of medical necessity beyond convenience for why the patient

cannot be changed to a preferred drug (i.e., allergies, drug-drug interactions,

contraindications, or intolerances) OR

o For any nonsolid oral dosage formulation: must provide documentation of medical

necessity for why patient cannot be changed to a solid oral dosage formulation

•

Must have had an inadequate clinical response of at least

7 days with

at least

one preferred

drug

o For non-preferred extended-release formulations: must provide documentation of an

inadequate clinical response

with its immediate release formulation (if available)

o For non-preferred brand names that have preferred generics: must provide

documentation of an inadequate clinical response or allergy to two or more generic

labelers (if available)

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 128

Respiratory Agents: Antihistamines – Second Generation

LENGTH OF AUTHORIZATIONS: 365 Days

ALL AUTHORIZATIONS: Must be

prescribed in accordance with FDA approved labeling

NON-PREFERRED CRITERIA:

• Must provide documentation of medical necessity beyond convenience for why the patient

cannot be changed to a preferred drug (i.e., allergies, drug-drug interactions,

contraindications, or intolerances) OR

o For any nonsolid oral dosage formulation: must provide documentation of medical

necessity for why patient cannot be changed to a solid oral dosage formulation

•

Must have had an inadequate clinical response of at least 30 days with at least two different

preferred drugs

o For non-preferred extended-release formulations: must provide documentation of an

inadequate clinical response

with its immediate release formulation (if available)

o For non-preferred brand names that have preferred generics: must provide

documentation of an inadequate clinical response or allergy to two or more generic

labelers (if available)

SUBSEQUENT AUTHORIZATION CRITERIA:

• Must provide documentation of patient’s clinical response to treatment and ongoing safety

monitoring

AR – Cetirizine Chewables: a PA is required for patients 6 years and older

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 129

Respiratory Agents: Cystic Fibrosis

LENGTH OF AUTHORIZATIONS: Initial: 90 days; Subsequent: 365 days

ALL AUTHORIZATIONS: Must be

prescribed in accordance with FDA approved labeling

CLINICAL PA CRITERIA:

• Must be prescribed by or in consultation with a pulmonologist or infectious disease specialist

• Must provide documentation of the genetic mutation

NON-PREFERRED CRITERIA:

• Must provide documentation of medical necessity beyond convenience for why the patient

cannot be changed to a preferred drug (i.e., allergies, drug-drug interactions,

contraindications, or intolerances) OR

o For any nonsolid oral dosage formulation: must provide documentation of medical

necessity for why patient cannot be changed to a solid oral dosage formulation

•

Must have had an inadequate clinical response of at least 30 days with at least one preferred

drug

o For non-preferred extended-release formulations: must provide documentation of an

inadequate clinical response

with its immediate release formulation (if available)

o For non-preferred brand names that have preferred generics: must provide

documentation of an inadequate clinical response or allergy to two or more generic

labelers (if available)

ADDITIONAL BRONCHITOL CRITERIA:

• Must be used as an add-on maintenance therapy

• Must provide documentation of a completed Bronchitol Tolerance Test

SUBSEQUENT AUTHORIZATION CRITERIA:

• Must provide documentation of patient’s clinical response to treatment (adherence to

treatment demonstrated by claims history AND one or more of the following: FEV1, weight

gain, sweat chloride, pulmonary exacerbations, etc.) and ongoing safety monitoring

AR – Trikafta Pak: a PA is required for patients 6 years and older

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 130

Respiratory Agents: Epinephrine Auto-Injectors

LENGTH OF AUTHORIZATIONS: 365 Days

ALL AUTHORIZATIONS: Must be

prescribed in accordance with FDA approved labeling

NON-PREFERRED CRITERIA:

• Must provide documentation of medical necessity beyond convenience for why the patient

cannot be changed to a preferred drug (i.e., allergies, drug-drug interactions,

contraindications, or intolerances) OR

o For any nonsolid oral dosage formulation: must provide documentation of medical

necessity for why patient cannot be changed to a solid oral dosage formulation

•

Must have had an inadequate clinical response to at least one preferred drug

o For non-preferred extended-release formulations: must provide documentation of an

inadequate clinical response

with its immediate release formulation (if available)

o For non-preferred brand names that have preferred generics: must provide

documentation of an inadequate clinical response or allergy to two or more generic

labelers (if available)

SUBSEQUENT AUTHORIZATION CRITERIA:

• Must provide documentation of patient’s clinical response to treatment and ongoing safety

monitoring

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 131

Respiratory Agents: Hereditary Angioedema

LENGTH OF AUTHORIZATIONS: Initial: 90 days; Subsequent: 180 Days

ALL AUTHORIZATIONS: Must be

prescribed in accordance with FDA approved labeling

CLINICAL PA CRITERIA:

• Must provide documentation of diagnosis (i.e., C1-INH deficiency or dysfunction (Type I or II

HAE)) and whether the drug will be used for prophylaxis or treatment

• Must provide documentation of at-home administration

NON-PREFERRED CRITERIA:

• Must provide documentation of medical necessity beyond convenience for why the patient

cannot be changed to a preferred drug (i.e., allergies, drug-drug interactions,

contraindications, or intolerances) OR

o For any nonsolid oral dosage formulation: must provide documentation of medical

necessity for why patient cannot be changed to a solid oral dosage formulation

•

Must have had an inadequate clinical response of at least 60 days with at least one preferred

drug

o For non-preferred extended-release formulations: must provide documentation of an

inadequate clinical response

with its immediate release formulation (if available)

o For non-preferred brand names that have preferred generics: must provide

documentation of an inadequate clinical response or allergy to two or more generic

labelers (if available)

SUBSEQUENT AUTHORIZATION CRITERIA:

• Must provide documentation of patient’s clinical response to treatment and ongoing safety

monitoring

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 132

Respiratory Agents: Inhaled Agents

LENGTH OF AUTHORIZATIONS: 365 Days

ALL AUTHORIZATIONS: Must be

prescribed in accordance with FDA approved labeling

NON-PREFERRED CRITERIA:

• Must provide documentation of medical necessity beyond convenience for why the patient

cannot be changed to a preferred drug (i.e., allergies, drug-drug interactions,

contraindications, or intolerances) OR

o For any nonsolid oral dosage formulation: must provide documentation of medical

necessity for why patient cannot be changed to a solid oral dosage formulation

•

Must have had an inadequate clinical response of at least 14 days with at least two preferred

drugs

within the same class and duration of action

o For non-preferred extended-release formulations: must provide documentation of an

inadequate clinical response

with its immediate release formulation (if available)

o For non-preferred brand names that have preferred generics: must provide

documentation of an inadequate clinical response or allergy to two or more generic

labelers (if available)

ADDITIONAL STEROID-CONTAINING INHALER CRITERIA

• May be authorized if documentation of one of the following is provided:

o Patient is 12 years or younger OR is disabled and is unable to use a preferred inhaler

o Patient has been non-compliant on a preferred inhaler due to taste, dry mouth, or

infection

o Patient is clinically unstable, as defined by current guidelines in terms of oral steroid

use or patient’s current symptomatology

SUBSEQUENT AUTHORIZATION CRITERIA:

• Must provide documentation of patient’s clinical response to treatment and ongoing safety

monitoring

AR - Albuterol Nebulizer Solution 0.021% (0.63mg/3mL), 0.042% (1.25mg/3mL): a PA is required for

patients 13 years and older

AR - Budesonide Nebulizer Solution: a PA is required for patients 7 years and older

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 133

Respiratory Agents: Leukotriene Receptor Modifiers & Inhibitors

LENGTH OF AUTHORIZATIONS: 365 Days

ALL AUTHORIZATIONS: Must be

prescribed in accordance with FDA approved labeling

STEP THERAPY CRITERIA:

•

Must have had an inadequate clinical response of at least 90 days with at least one preferred

drug

NON-PREFERRED CRITERIA:

• Must provide documentation of medical necessity beyond convenience for why the patient

cannot be changed to a preferred drug (i.e., allergies, drug-drug interactions,

contraindications, or intolerances) OR

o For any nonsolid oral dosage formulation: must provide documentation of medical

necessity for why patient cannot be changed to a solid oral dosage formulation

•

Must have had an inadequate clinical response of at least 90 days with at least two preferred

drugs

o For non-preferred extended-release formulations: must provide documentation of an

inadequate clinical response

with its immediate release formulation (if available)

o For non-preferred brand names that have preferred generics: must provide

documentation of an inadequate clinical response or allergy to two or more generic

labelers (if available)

SUBSEQUENT AUTHORIZATION CRITERIA:

• Must provide documentation of patient’s clinical response to treatment and ongoing safety

monitoring

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 134

Respiratory Agents: Monoclonal Antibodies-Anti-IL/Anti-IgE

LENGTH OF AUTHORIZATIONS: Initial: 180 days; Subsequent: 365 days

ALL AUTHORIZATIONS: Must be

prescribed in accordance with FDA approved labeling

CLINICAL PA CRITERIA:

• Must be prescribed by or in consultation with an applicable specialist (i.e., allergist/

immunologist, pulmonologist, or otolaryngologist)

• For Asthma – Must have had uncontrolled asthma symptoms and/or exacerbations despite at

least 30 days with:

o Medium dose preferred ICS/LABA inhaler for 6 years and older OR medium dose

preferred ICS/LABA inhaler with tiotropium or high dose ICS/LABA inhaler if 12 years

and older

• For Chronic Rhinosinusitis with Nasal Polyposis – Must have had an inadequate clinical

response of at least 30 days to

at least

one oral corticosteroid AND one nasal corticosteroid

spray

• For Chronic Urticaria – Must have had an inadequate clinical response to at least 14 days

with

at least

two different antihistamines

NON-PREFERRED CRITERIA:

• Must provide documentation of medical necessity beyond convenience for why the patient

cannot be changed to a preferred drug (i.e., allergies, drug-drug interactions, contraindications,

or intolerances) OR

o For any nonsolid oral dosage formulation: must provide documentation of medical

necessity for why patient cannot be changed to a solid oral dosage formulation

• Must have had an inadequate clinical response of at least 90 days with

at least

one preferred

drug

o For non-preferred extended-release formulations: must provide documentation of an

inadequate clinical response

with its immediate release formulation (if available)

o For non-preferred brand names that have preferred generics, requests must provide

documentation of an inadequate clinical response or allergy to two or more generic

labelers (if available)

SUBSEQUENT AUTHORIZATION CRITERIA:

• Must provide documentation of patient’s clinical response to treatment and ongoing safety

monitoring (i.e., PFT improvement, reduced affected BSA)

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 135

Respiratory Agents: Nasal Preparations

LENGTH OF AUTHORIZATIONS: 365 days

ALL AUTHORIZATIONS: Must be

prescribed in accordance with FDA approved labeling

NON-PREFERRED CRITERIA:

• Must provide documentation of medical necessity beyond convenience for why the patient

cannot be changed to a preferred drug (i.e., allergies, drug-drug interactions,

contraindications, or intolerances) OR

o For any nonsolid oral dosage formulation: must provide documentation of medical

necessity for why patient cannot be changed to a solid oral dosage formulation

•

Must have had an inadequate clinical response of at least 30 days with at least two preferred

drugs in the same class, if available

o For non-preferred extended-release formulations: must provide documentation of an

inadequate clinical response

with its immediate release formulation (if available)

o For non-preferred brand names that have preferred generics: must provide

documentation of an inadequate clinical response or allergy to two or more generic

labelers (if available)

SUBSEQUENT AUTHORIZATION CRITERIA:

• Must provide documentation of patient’s clinical response to treatment and ongoing safety

monitoring

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 136

Respiratory Agents: Other Agents

LENGTH OF AUTHORIZATIONS: Initial: 90 days; Subsequent: 180 days

ALL AUTHORIZATIONS: Must be

prescribed in accordance with FDA approved labeling

NON-PREFERRED CRITERIA:

• Must provide documentation of medical necessity beyond convenience for why the patient

cannot be changed to a preferred drug (i.e., allergies, drug-drug interactions,

contraindications, or intolerances) OR

o For any nonsolid oral dosage formulation: must provide documentation of medical

necessity for why patient cannot be changed to a solid oral dosage formulation

•

Must have had an inadequate clinical response of at least 90 days with at least one preferred

long

-acting beta agonist AND

one preferred

long-acting muscarinic antagonist-containing

inhalers

o For non-preferred extended-release formulations: must provide documentation of an

inadequate clinical response

with its immediate release formulation (if available)

o For non-preferred brand names that have preferred generics: must provide

documentation of an inadequate clinical response or allergy to two or more generic

labelers (if available)

ADDITIONAL ROFLUMILAST (DALIRESP) CRITERIA:

• Must be used in addition to a long-acting beta agonist AND a long-acting muscarinic

antagonist-containing inhalers

SUBSEQUENT AUTHORIZATION CRITERIA:

• Must provide documentation of patient’s clinical response to treatment, adherence to

maintenance inhaler per pharmacy claims, and ongoing safety monitoring

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 137

Topical Agents: Antifungals

LENGTH OF AUTHORIZATIONS: Up to 180 days for all agents except 365 days for Jublia

ALL AUTHORIZATIONS: Must be

prescribed in accordance with FDA approved labeling

NON-PREFERRED CRITERIA:

• Must provide documentation of medical necessity beyond convenience for why the patient

cannot be changed to a preferred drug (i.e., allergies, drug-drug interactions,

contraindications, or intolerances) OR

o For any nonsolid oral dosage formulation: must provide documentation of medical

necessity for why patient cannot be changed to a solid oral dosage formulation

•

Must have had an inadequate clinical response of at least 14 days with at least two preferred

drugs, if indicated for diagnosis

o For non-preferred extended-release formulations: must provide documentation of an

inadequate clinical response

with its immediate release formulation (if available)

o For non-preferred brand names that have preferred generics: must provide

documentation of an inadequate clinical response or allergy to two or more generic

labelers (if available)

ADDITIONAL EFINACONAZOLE (JUBLIA) CRITERIA:

•

Must have had an inadequate clinical response of at least 365 days with at least one preferred

topical drug AND at least 84 days with at least one preferred oral drug indicated for diagnosis

ADDITIONAL INFORMATION

• Requests may be authorized if:

o The infection is caused by an organism resistant to preferred

antibiotics

drugs (note

diagnosis and any culture/sensitivity results)

SUBSEQUENT AUTHORIZATION CRITERIA:

• Must provide documentation of patient’s clinical response to treatment and ongoing safety

monitoring

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 138

Topical Agents: Antiparasitics

LENGTH OF AUTHORIZATIONS: 14 Days

ALL AUTHORIZATIONS: Must be

prescribed in accordance with FDA approved labeling

NON-PREFERRED CRITERIA:

• Must provide documentation of medical necessity beyond convenience for why the patient

cannot be changed to a preferred drug (i.e., allergies, drug-drug interactions,

contraindications, or intolerances) OR

o For any nonsolid oral dosage formulation: must provide documentation of medical

necessity for why patient cannot be changed to a solid oral dosage formulation

•

Must have had an inadequate clinical response of at least 14 days with at least one preferred

drug

o For non-preferred extended-release formulations: must provide documentation of an

inadequate clinical response

with its immediate release formulation (if available)

o For non-preferred brand names that have preferred generics: must provide

documentation of an inadequate clinical response or allergy to two or more generic

labelers (if available)

SUBSEQUENT AUTHORIZATION CRITERIA:

• Must provide documentation of patient’s clinical response to treatment and ongoing safety

monitoring

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 139

Topical Agents: Corticosteroids

LENGTH OF AUTHORIZATIONS: 365 days for low/med potency; 90 days for high/very high potency

ALL AUTHORIZATIONS: Must be

prescribed in accordance with FDA approved labeling

NON-PREFERRED CRITERIA:

• Must provide documentation of medical necessity beyond convenience for why the patient

cannot be changed to a preferred drug (i.e., allergies, drug-drug interactions,

contraindications, or intolerances) OR

o For any nonsolid oral dosage formulation: must provide documentation of medical

necessity for why patient cannot be changed to a solid oral dosage formulation

•

Must have had an inadequate clinical response of at least 14 days with at least two preferred

drugs

o For non-preferred extended-release formulations: must provide documentation of an

inadequate clinical response

with its immediate release formulation (if available)

o For non-preferred brand names that have preferred generics: must provide

documentation of an inadequate clinical response or allergy to two or more generic

labelers (if available)

SUBSEQUENT AUTHORIZATION CRITERIA:

• Must provide documentation of patient’s clinical response to treatment and ongoing safety

monitoring

AR = Age Restriction

QL = Quantity Limit

ST = Step Therapy Required

PA = Clinical Prior Authorization Required

BvG = Brand Preferred Over Generic

Ohio Medicaid Unified PDL effective January 1, 2024 140

Topical Agents: Immunomodulators

LENGTH OF AUTHORIZATIONS: 365 Days

ALL AUTHORIZATIONS: Must be

prescribed in accordance with FDA approved labeling

STEP THERAPY CRITERIA:

•

Must have had an inadequate clinical response of at least 30 days with at least two topical

corticosteroids

NON-PREFERRED CRITERIA:

• Must provide documentation of medical necessity beyond convenience for why the patient

cannot be changed to a preferred drug (i.e., allergies, drug-drug interactions,

contraindications, or intolerances) OR

o For any nonsolid oral dosage formulation: must provide documentation of medical

necessity for why patient cannot be changed to a solid oral dosage formulation

•

Must have had an inadequate clinical response of at least 30 days with at least one preferred

drug

o For non-preferred extended-release formulations: must provide documentation of an

inadequate clinical response

with its immediate release formulation (if available)

o For non-preferred brand names that have preferred generics: must provide

documentation of an inadequate clinical response or allergy to two or more generic

labelers (if available)

SUBSEQUENT AUTHORIZATION CRITERIA:

• Must provide documentation of patient’s clinical response to treatment and ongoing safety

monitoring

AR - pimecrolimus and tacrolimus: a PA is required for patients younger than 2 years old