unified preferred drug list for ohio...
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UNIFIED PREFERRED DRUG LIST FOR OHIO MEDICAID UPDL coverage for Ohio Medicaid Managed Care Plans and Traditional Fee-for-Service is provided for commonly prescribed drug classes by pediatric primary care providers. This information is intended for use by providers to select cost-effective medications for their patients and includes medications covered on the UPDL. It is not a substitute for individual patient factors and clinical judgment. If there is a discrepancy between Medicaid’s published UPDL and this document, use the published UPDL as final guide; Medicaid and the MCPs reserve the right to make changes that may not be reflected here. For evidence-based prescribing guidelines, please visit www.partnersforkids.org/resources > Prescribing Resources. Average cost per script is based on generic drug when available using an average length of therapy. Prices are for reference and actual cost may vary based on drug strength, quantity and other factors. Bolded medications are generically available. = Covered PA = Prior authorization NC = Not covered Follow the links below to access the complete formularies for Ohio Medicaid Plans:
Ohio Medicaid UPDL Buckeye CareSource Molina Paramount UHC Community Look-up Tool* Look-up Tool* Look-up Tool*
*If there is a discrepancy between UPDL and Look-up Tool, use UPDL as final guide
TABLE OF CONTENTS Topic Page Acne
2 - 3
Allergy • Allergic Anaphylactic Reaction • Allergic Conjunctivitis • Allergic Rhinitis
4 4 5
Asthma • Inhaled Corticosteroids (ICS) • Long Acting Beta Agonist & ICS Combos; Short Acting Beta Agonists
6 7
Behavioral Health • Anxiety Disorders & Depression • Attention Deficit Hyperactivity Disorder (ADHD)
8
9 - 10
Atopic Dermatitis 11 – 12
Diabetes
13 - 15
Gastroesophageal Reflux
16
Head Lice
17
Oral Antibiotics
18 – 20
Otic Antibiotics
20
Antifungals
21 – 22
UNIFIED PREFERRED DRUG LIST FOR OHIO MEDICAID UPDL coverage for Ohio Medicaid Managed Care Plans and Traditional Fee-for-Service is provided for commonly prescribed drug classes by pediatric primary care providers. This information is intended for use by providers to select cost-effective medications for their patients and includes medications covered on the UPDL. It is not a substitute for individual patient factors and clinical judgment. If there is a discrepancy between Medicaid’s published UPDL and this document, use the published UPDL as final guide; Medicaid and the MCPs reserve the right to make changes that may not be reflected here. For evidence-based prescribing guidelines, please visit www.partnersforkids.org/resources > Prescribing Resources. Average cost per script is based on generic drug when available using an average length of therapy. Prices are for reference and actual cost may vary based on drug strength, quantity and other factors. Bolded medications are generically available. = Covered PA = Prior authorization NC = Not covered
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Last updated 5/2020 by PFK Pharmacy
Coverage may change 7/2020
Acne treatment options continued on next page.
Generic Drug Name (Brand) Strength
Average Cost Per
Script
Uni
fied
PDL
2.5%, 5%, 10% Gel $21
5%, 10% Liquid $24
1% Gel, 1% Lotion $95
1% Solution $35
2% Gel $225
2% Solution $50
0.1% Cream, 0.1% Lotion (Rx) $294
brand only
0.3% Gel $297
brand only
0.1% Gel (OTC) 15g $8 PA
Tretinoin (Retin-A®)
0.025%, 0.05%, 0.1% Cream;
0.01%, 0.025% Gel $304
Adapalene (Differin®)
ACNETopical Anti-bacterials
Benzoyl Peroxide (BPO®)
Clindamycin Phosphate (Cleocin-T®)
Erythromycin
Topical Retinoids
UNIFIED PREFERRED DRUG LIST FOR OHIO MEDICAID UPDL coverage for Ohio Medicaid Managed Care Plans and Traditional Fee-for-Service is provided for commonly prescribed drug classes by pediatric primary care providers. This information is intended for use by providers to select cost-effective medications for their patients and includes medications covered on the UPDL. It is not a substitute for individual patient factors and clinical judgment. If there is a discrepancy between Medicaid’s published UPDL and this document, use the published UPDL as final guide; Medicaid and the MCPs reserve the right to make changes that may not be reflected here. For evidence-based prescribing guidelines, please visit www.partnersforkids.org/resources > Prescribing Resources. Average cost per script is based on generic drug when available using an average length of therapy. Prices are for reference and actual cost may vary based on drug strength, quantity and other factors. Bolded medications are generically available. = Covered PA = Prior authorization NC = Not covered
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Last updated 5/2020 by PFK Pharmacy
Coverage may change 7/2020
Generic Drug Name (Brand) Strength
Average Cost Per
Script
Uni
fied
PDL
Benzoyl Peroxide/ Erythromycin (Benzamycin®)
5-3% Gel $398
1-5% Gel (Benzaclin®) $286
1.2-5% Gel (Duac®) $423
Doxycycline monohydrate 50 mg, 100 mg (capsule preferred) $44
Minocycline 50 mg, 75 mg, 100 mg (capsule preferred) $51
Isotretinoin (Claravis®, Myorisan®, Zenatane®)
10 mg, 20 mg, 30 mg, 40 mg $540 PA
ACNE (CONTINUED)Topical Combinations
Clindamycin/ Benzoyl Peroxide
Oral Antibiotics
Oral Retinoids
UNIFIED PREFERRED DRUG LIST FOR OHIO MEDICAID UPDL coverage for Ohio Medicaid Managed Care Plans and Traditional Fee-for-Service is provided for commonly prescribed drug classes by pediatric primary care providers. This information is intended for use by providers to select cost-effective medications for their patients and includes medications covered on the UPDL. It is not a substitute for individual patient factors and clinical judgment. If there is a discrepancy between Medicaid’s published UPDL and this document, use the published UPDL as final guide; Medicaid and the MCPs reserve the right to make changes that may not be reflected here. For evidence-based prescribing guidelines, please visit www.partnersforkids.org/resources > Prescribing Resources. Average cost per script is based on generic drug when available using an average length of therapy. Prices are for reference and actual cost may vary based on drug strength, quantity and other factors. Bolded medications are generically available. = Covered PA = Prior authorization NC = Not covered
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Last updated 5/2020 by PFK Pharmacy
Coverage may change 7/2020
Allergy treatment options continued on next page.
Generic Drug Name (Brand) Strength
Average Cost Per
Script
Uni
fied
PDL
Auvi-Q® 0.3mg/0.3mL, 0.15mg/0.15mL $2,940 NC
EpiPen® 0.3mg/0.3mL, 0.15mg/0.15mL PA
EpiPen Jr.® 0.15mg/0.3mL PA
Epinephrine Auto-injector (Mylan brand generic)
0.3mg/0.3mL, 0.15mg/0.3mL $247
Symjepi™ 0.3mg/0.3mL, 0.15mg/0.3mL $312
Azelastine 0.05% $57
Cromolyn 4% $37
Ketotifen (Alaway®, Zatidor®)
0.025% $9
$365
ALLERGIC CONJUNCTIVITISOphthalmic Antihistamines
ALLERGIC ANAPHYLACTIC REACTIONEpinephrine Auto-injector
UNIFIED PREFERRED DRUG LIST FOR OHIO MEDICAID UPDL coverage for Ohio Medicaid Managed Care Plans and Traditional Fee-for-Service is provided for commonly prescribed drug classes by pediatric primary care providers. This information is intended for use by providers to select cost-effective medications for their patients and includes medications covered on the UPDL. It is not a substitute for individual patient factors and clinical judgment. If there is a discrepancy between Medicaid’s published UPDL and this document, use the published UPDL as final guide; Medicaid and the MCPs reserve the right to make changes that may not be reflected here. For evidence-based prescribing guidelines, please visit www.partnersforkids.org/resources > Prescribing Resources. Average cost per script is based on generic drug when available using an average length of therapy. Prices are for reference and actual cost may vary based on drug strength, quantity and other factors. Bolded medications are generically available. = Covered PA = Prior authorization NC = Not covered
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Last updated 5/2020 by PFK Pharmacy
Coverage may change 7/2020
Generic Drug Name (Brand) Strength
Average Cost Per
Script
Uni
fied
PDL
5 mg, 10 mg $21
1 mg/mL $45 ≤6 yo
5 mg, 10 mg Chew $100 ≤6 yo
60 mg, 180 mg $48 PA30 mg/5 mL $27 PA
10 mg $15
1 mg/mL $21
5 mg Orally-disintegrating $28
Azelastine 0.15%, 0.1% $40
Budesonide (Rhinocort® Allergy)
32 mcg/act $27 PA
Flunisolide 25 mcg/act $72
Fluticasone (Flonase®)
50 mcg/act $21
Triamcinolone (Nasacort®)
55 mcg/act $17 NC
Cetirizine (Zyrtec®)
Nasal Steroids
ALLERGIC RHINITISOral Antihistamines
Fexofenadine (Allegra®)
Loratadine (Claritin®)
Nasal Antihistamines
UNIFIED PREFERRED DRUG LIST FOR OHIO MEDICAID UPDL coverage for Ohio Medicaid Managed Care Plans and Traditional Fee-for-Service is provided for commonly prescribed drug classes by pediatric primary care providers. This information is intended for use by providers to select cost-effective medications for their patients and includes medications covered on the UPDL. It is not a substitute for individual patient factors and clinical judgment. If there is a discrepancy between Medicaid’s published UPDL and this document, use the published UPDL as final guide; Medicaid and the MCPs reserve the right to make changes that may not be reflected here. For evidence-based prescribing guidelines, please visit www.partnersforkids.org/resources > Prescribing Resources. Average cost per script is based on generic drug when available using an average length of therapy. Prices are for reference and actual cost may vary based on drug strength, quantity and other factors. Bolded medications are generically available. = Covered PA = Prior authorization NC = Not covered
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Last updated 5/2020 by PFK Pharmacy
Coverage may change 7/2020
Asthma treatment options continued on next page.
Generic Drug Name (Brand) Strength
Average Cost Per
Script
Uni
fied
PDL
Beclomethasone (Qvar® RediHaler™)
40 mcg, 80 mcg DPI $252 PA
Budesonide (Pulmicort Flexhaler®)
90 mcg, 180 mcg DPI $248
Budesonide (Pulmicort® Respules®)
0.25 mg/2 mL, 0.5 mg/2mL $207
< 6 yo
Fluticasone furoate (Arnuity™ Ellipta®)
100 mcg, 200 mcg DPI $232 PA
Fluticasone propionate (Flovent® Diskus®)
50 mcg, 100 mcg, 250 mcg DPI $289
Fluticasone propionate (Flovent® HFA)
44 mcg/act, 110 mcg/act, 220 mcg/act $312
Mometasone furoate (Asmanex® HFA)
100 mcg/act, 200 mcg/act $250 PA
Mometasone furoate (Asmanex® Twisthaler®)
110 mcg, 220 mcg DPI $270
ASTHMAInhaled Corticosteroids
UNIFIED PREFERRED DRUG LIST FOR OHIO MEDICAID UPDL coverage for Ohio Medicaid Managed Care Plans and Traditional Fee-for-Service is provided for commonly prescribed drug classes by pediatric primary care providers. This information is intended for use by providers to select cost-effective medications for their patients and includes medications covered on the UPDL. It is not a substitute for individual patient factors and clinical judgment. If there is a discrepancy between Medicaid’s published UPDL and this document, use the published UPDL as final guide; Medicaid and the MCPs reserve the right to make changes that may not be reflected here. For evidence-based prescribing guidelines, please visit www.partnersforkids.org/resources > Prescribing Resources. Average cost per script is based on generic drug when available using an average length of therapy. Prices are for reference and actual cost may vary based on drug strength, quantity and other factors. Bolded medications are generically available. = Covered PA = Prior authorization NC = Not covered
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Last updated 5/2020 by PFK Pharmacy
Coverage may change 7/2020
Generic Drug Name (Brand) Strength
Average Cost Per
Script
Uni
fied
PDL
Formoterol/Budesonide (Symbicort® HFA)
Brand Preferred
80-4.5 mcg/act, 160-4.5 mcg/act $320
Formoterol/Mometasone (Dulera® HFA)
100-5 mcg/act, 200-5 mcg/act $374
Salmeterol/Fluticasone (Advair® Diskus)
(Prasco brand generic)
100-50 mcg, 250-50 mcg, 500-50 mcg DPI $119
Salmeterol/Fluticasone (Wixela™ Inhub™)
100-50 mcg, 250-50 mcg, 500-50
mcg DPI$448 PA
Salmeterol/Fluticasone (Advair® HFA)
45-21 mcg/act, 115-21 mcg/act, 230-21 mcg/act
$382 PA
Salmeterol/Fluticasone (AirDuo® RespiClick®)
55-14 mcg, 113-14 mcg, 232-14 mcg $384 PA
Albuterol Solution 2.5 mg/3 mL $47
Albuterol (Albuterol Sulfate HFA
Preferred) 90 mcg/act $60
Montelukast (Singulair®)
4 mg (Oral packet), 4 mg, 5 mg (Chewable),
10 mg (Tablet)$22
Beta-2 Adrenergic Agonists
Leukotriene Receptor Antagonists
ASTHMA (CONTINUED)Inhaled Beta-2 Adrenergic Agonist/Corticosteroid
UNIFIED PREFERRED DRUG LIST FOR OHIO MEDICAID UPDL coverage for Ohio Medicaid Managed Care Plans and Traditional Fee-for-Service is provided for commonly prescribed drug classes by pediatric primary care providers. This information is intended for use by providers to select cost-effective medications for their patients and includes medications covered on the UPDL. It is not a substitute for individual patient factors and clinical judgment. If there is a discrepancy between Medicaid’s published UPDL and this document, use the published UPDL as final guide; Medicaid and the MCPs reserve the right to make changes that may not be reflected here. For evidence-based prescribing guidelines, please visit www.partnersforkids.org/resources > Prescribing Resources. Average cost per script is based on generic drug when available using an average length of therapy. Prices are for reference and actual cost may vary based on drug strength, quantity and other factors. Bolded medications are generically available. = Covered PA = Prior authorization NC = Not covered
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Last updated 5/2020 by PFK Pharmacy
Coverage may change 7/2020
UNIFIED PREFERRED DRUG LIST FOR OHIO MEDICAID UPDL coverage for Ohio Medicaid Managed Care Plans and Traditional Fee-for-Service is provided for commonly prescribed drug classes by pediatric primary care providers. This information is intended for use by providers to select cost-effective medications for their patients and includes medications covered on the UPDL. It is not a substitute for individual patient factors and clinical judgment. If there is a discrepancy between Medicaid’s published UPDL and this document, use the published UPDL as final guide; Medicaid and the MCPs reserve the right to make changes that may not be reflected here. For evidence-based prescribing guidelines, please visit www.partnersforkids.org/resources > Prescribing Resources. Average cost per script is based on generic drug when available using an average length of therapy. Prices are for reference and actual cost may vary based on drug strength, quantity and other factors. Bolded medications are generically available. = Covered PA = Prior authorization NC = Not covered
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Last updated 5/2020 by PFK Pharmacy
Coverage may change 7/2020
ADHD treatment options continued on next page.
UNIFIED PREFERRED DRUG LIST FOR OHIO MEDICAID UPDL coverage for Ohio Medicaid Managed Care Plans and Traditional Fee-for-Service is provided for commonly prescribed drug classes by pediatric primary care providers. This information is intended for use by providers to select cost-effective medications for their patients and includes medications covered on the UPDL. It is not a substitute for individual patient factors and clinical judgment. If there is a discrepancy between Medicaid’s published UPDL and this document, use the published UPDL as final guide; Medicaid and the MCPs reserve the right to make changes that may not be reflected here. For evidence-based prescribing guidelines, please visit www.partnersforkids.org/resources > Prescribing Resources. Average cost per script is based on generic drug when available using an average length of therapy. Prices are for reference and actual cost may vary based on drug strength, quantity and other factors. Bolded medications are generically available. = Covered PA = Prior authorization NC = Not covered
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Last updated 5/2020 by PFK Pharmacy
Coverage may change 7/2020
UNIFIED PREFERRED DRUG LIST FOR OHIO MEDICAID UPDL coverage for Ohio Medicaid Managed Care Plans and Traditional Fee-for-Service is provided for commonly prescribed drug classes by pediatric primary care providers. This information is intended for use by providers to select cost-effective medications for their patients and includes medications covered on the UPDL. It is not a substitute for individual patient factors and clinical judgment. If there is a discrepancy between Medicaid’s published UPDL and this document, use the published UPDL as final guide; Medicaid and the MCPs reserve the right to make changes that may not be reflected here. For evidence-based prescribing guidelines, please visit www.partnersforkids.org/resources > Prescribing Resources. Average cost per script is based on generic drug when available using an average length of therapy. Prices are for reference and actual cost may vary based on drug strength, quantity and other factors. Bolded medications are generically available. = Covered PA = Prior authorization NC = Not covered
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Last updated 5/2020 by PFK Pharmacy
Coverage may change 7/2020
Atopic Dermatitis treatment options continued on next page.
Generic Drug Name (Brand) Strength
Average Cost Per
Script
Uni
fied
PDL
Hydrocortisone External0.5, 1, 2.5%
Cream/Ointment; 1%, 2.5% Lotion
$16
Alclometasone diprionate (Aclovate®) 0.05% Cream, Ointment $67 PA
Betamethasone valerate (Beta Val®) 0.1% Lotion $72
Desonide (Desowen®) 0.05% Cream, Lotion $150
Cream
Fluocinolone acetonide (Derma-Smoothe/FS®)
0.01% Oil, Solution, Cream $78
Triamcinolone acetonide (Kenalog®) 0.025% Cream, Lotion $28
Class 7 Topical Corticosteroids-Least Potent
Class 6 Topical Corticosteroids-Low Potency
Classes 1-3 topical corticosteroids are not listed since most patients are treated with classes 4-7 topical corticosteroids. 45g and 60g package size used for pricing.
ATOPIC DERMATITIS
UNIFIED PREFERRED DRUG LIST FOR OHIO MEDICAID UPDL coverage for Ohio Medicaid Managed Care Plans and Traditional Fee-for-Service is provided for commonly prescribed drug classes by pediatric primary care providers. This information is intended for use by providers to select cost-effective medications for their patients and includes medications covered on the UPDL. It is not a substitute for individual patient factors and clinical judgment. If there is a discrepancy between Medicaid’s published UPDL and this document, use the published UPDL as final guide; Medicaid and the MCPs reserve the right to make changes that may not be reflected here. For evidence-based prescribing guidelines, please visit www.partnersforkids.org/resources > Prescribing Resources. Average cost per script is based on generic drug when available using an average length of therapy. Prices are for reference and actual cost may vary based on drug strength, quantity and other factors. Bolded medications are generically available. = Covered PA = Prior authorization NC = Not covered
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Last updated 5/2020 by PFK Pharmacy
Coverage may change 7/2020
Generic Drug Name (Brand) Strength
Average Cost Per
Script
Uni
fied
PDL
Betamethasone valerate (Beta Val®) 0.1% Cream $40
Desonide (Desowen®) 0.05% Ointment $93
Fluticasone propionate (Cutivate®) 0.05% Cream, Lotion $68
Cream
Hydrocortisone valerate (Westcort®) 0.2% Cream $181 PA
Hydrocortisone butyrate (Locoid®)
0.1% Ointment, Cream, Lotion $90 PA
Triamcinolone acetonide (Kenalog®)
0.025% Ointment, 0.1% Lotion $23
Fluocinolone acetonide (Synalar®) 0.025% Ointment $135 PA
Hydrocortisone valerate (Westcort®) 0.2% Ointment $200 PA
Mometasone furoate (Elocon®) 0.1% Cream, Lotion $81
Triamcinolone acetonide (Kenalog®) 0.1% Cream, Ointment $10
Classes 1-3 topical corticosteroids are not listed since most patients are treated with classes 4-7 topical corticosteroids. 45g and 60g package size used for pricing.
ATOPIC DERMATITIS (CONTINUED)Class 5 Topical Corticosteroids-Lower Mid
Class 4 Topical Corticosteroids Medium Potency
UNIFIED PREFERRED DRUG LIST FOR OHIO MEDICAID UPDL coverage for Ohio Medicaid Managed Care Plans and Traditional Fee-for-Service is provided for commonly prescribed drug classes by pediatric primary care providers. This information is intended for use by providers to select cost-effective medications for their patients and includes medications covered on the UPDL. It is not a substitute for individual patient factors and clinical judgment. If there is a discrepancy between Medicaid’s published UPDL and this document, use the published UPDL as final guide; Medicaid and the MCPs reserve the right to make changes that may not be reflected here. For evidence-based prescribing guidelines, please visit www.partnersforkids.org/resources > Prescribing Resources. Average cost per script is based on generic drug when available using an average length of therapy. Prices are for reference and actual cost may vary based on drug strength, quantity and other factors. Bolded medications are generically available. = Covered PA = Prior authorization NC = Not covered
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Last updated 5/2020 by PFK Pharmacy
Coverage may change 7/2020
Diabetes treatment options continued on next page.
Generic Drug Name (Brand) Strength
Average Cost Per
Script
Uni
fied
PDL
Insulin degludec (Tresiba®)
100, 200 units/mL Flextouch pen
(3mL/pen)$915 PA
100 units/mL vial $370
100 units/mL Flextouch pen (3mL/pen) $555
Insulin glargine (Basaglar®)
100 units/mL Kwikpen (3mL/pen) $392 PA
100 units/mL vial $340
100 units/ml Solostar pen (3mL/pen) $510
Insulin glargine (Lantus®)
DIABETESLong Acting Insulin
Insulin detemir (Levemir®)
UNIFIED PREFERRED DRUG LIST FOR OHIO MEDICAID UPDL coverage for Ohio Medicaid Managed Care Plans and Traditional Fee-for-Service is provided for commonly prescribed drug classes by pediatric primary care providers. This information is intended for use by providers to select cost-effective medications for their patients and includes medications covered on the UPDL. It is not a substitute for individual patient factors and clinical judgment. If there is a discrepancy between Medicaid’s published UPDL and this document, use the published UPDL as final guide; Medicaid and the MCPs reserve the right to make changes that may not be reflected here. For evidence-based prescribing guidelines, please visit www.partnersforkids.org/resources > Prescribing Resources. Average cost per script is based on generic drug when available using an average length of therapy. Prices are for reference and actual cost may vary based on drug strength, quantity and other factors. Bolded medications are generically available. = Covered PA = Prior authorization NC = Not covered
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Last updated 5/2020 by PFK Pharmacy
Coverage may change 7/2020
Diabetes treatment options continued on next page.
Generic Drug Name (Brand) Strength
Average Cost Per
Script
Unifi
ed P
DL
100 units/mL vial $178 PA
100 units/mL KwikPen (3mL/pen) $566 PA
Insulin NPH (Novolin® N) 100 units/mL vial $165 PA
100 units/mL vial $360
100 units/mL Flexpen (3mL/pen) $671
100 units/mL vial $342
100 units/mL KwikPen (3mL/pen) $636
100 units/mL vial $178
100 units/mL KwikPen (3mL/pen) $566
Insulin NPH/insulin regular (Novolin 70/30®) 100 units/mL vial $165
Insulin aspart protamine/insulin aspart
(Novolog 70-30®)
Insulin lispro protamine/ insulin lispro
(Humalog 50/50® and Humalog 75/25®)
Insulin NPH/insulin regular (Humulin 70/30®)
DIABETES (CONTINUED)Intermediate Acting Insulin
Insulin NPH (Humulin® N)
Mixed Insulin
UNIFIED PREFERRED DRUG LIST FOR OHIO MEDICAID UPDL coverage for Ohio Medicaid Managed Care Plans and Traditional Fee-for-Service is provided for commonly prescribed drug classes by pediatric primary care providers. This information is intended for use by providers to select cost-effective medications for their patients and includes medications covered on the UPDL. It is not a substitute for individual patient factors and clinical judgment. If there is a discrepancy between Medicaid’s published UPDL and this document, use the published UPDL as final guide; Medicaid and the MCPs reserve the right to make changes that may not be reflected here. For evidence-based prescribing guidelines, please visit www.partnersforkids.org/resources > Prescribing Resources. Average cost per script is based on generic drug when available using an average length of therapy. Prices are for reference and actual cost may vary based on drug strength, quantity and other factors. Bolded medications are generically available. = Covered PA = Prior authorization NC = Not covered
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Last updated 5/2020 by PFK Pharmacy
Coverage may change 7/2020
Generic Drug Name (Brand) Strength
Average Cost Per
Script
Uni
fied
PDL
100 units/mL vial $348
100 units/mL FlexTouch (3mL/pen) $645
100 units/mL vial $348 PA
100 units/ml FlexTouch pen (3mL/pen) $671 PA
100 units/mL vial $341 PA
100 units/ml SoloStar pen (3mL/pen) $658 PA
100 units/mL vial $165
100 units/mL KwikPen (3mL/pen) $318
100 units/mL vial $280 PA
100 units/mL SoloStar (3mL/pen) $541 PA
Insulin regular (Humulin R®) 100 units/mL vial $178
Insulin regular (Novolin R®) 100 units/mL vial $165
Insulin aspart (Fiasp®)
Insulin glulisine (Apidra®)
Insulin lispro (Humalog®)
Generic Preferred
Insulin lispro (Admelog®)
DIABETES (CONTINUED)Short Acting Insulin
Insulin aspart (Novolog®)
UNIFIED PREFERRED DRUG LIST FOR OHIO MEDICAID UPDL coverage for Ohio Medicaid Managed Care Plans and Traditional Fee-for-Service is provided for commonly prescribed drug classes by pediatric primary care providers. This information is intended for use by providers to select cost-effective medications for their patients and includes medications covered on the UPDL. It is not a substitute for individual patient factors and clinical judgment. If there is a discrepancy between Medicaid’s published UPDL and this document, use the published UPDL as final guide; Medicaid and the MCPs reserve the right to make changes that may not be reflected here. For evidence-based prescribing guidelines, please visit www.partnersforkids.org/resources > Prescribing Resources. Average cost per script is based on generic drug when available using an average length of therapy. Prices are for reference and actual cost may vary based on drug strength, quantity and other factors. Bolded medications are generically available. = Covered PA = Prior authorization NC = Not covered
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Last updated 5/2020 by PFK Pharmacy
Coverage may change 7/2020
Generic Drug Name (Brand) Strength
Average Cost Per
Script
Uni
fied
PDL
10, 20, 40 mg $15
40 mg/5mL $114
20 mg, 40 mg Capsules $33 PA
20 mg OTC Nexium® 24HR
$20 PA
15 mg, 30 mg capsules $11
15 mg, 30 mg Solutabs $498 PA
3 mg/mL Compounded suspension
$75
3 mg/mL First® Lansoprazole
$83 NC
10, 20, 40 mg capsules $19
2 mg/mL Compounded suspension
$75
2 mg/mL First® Omeprazole
$72 NC
20 mg, 40 mg tablets $13
40 mg packet $570
Protonix® suspension $540 < 6 yo
H2 AntihistaminesFamotidine(Pepcid®)
Proton Pump Inhibitors
GASTROESOPHAGEAL REFLUX
Esomeprazole (Nexium®)
Lansoprazole (Prevacid®)
Omeprazole (Prilosec®)
Pantoprazole (Protonix®)
UNIFIED PREFERRED DRUG LIST FOR OHIO MEDICAID UPDL coverage for Ohio Medicaid Managed Care Plans and Traditional Fee-for-Service is provided for commonly prescribed drug classes by pediatric primary care providers. This information is intended for use by providers to select cost-effective medications for their patients and includes medications covered on the UPDL. It is not a substitute for individual patient factors and clinical judgment. If there is a discrepancy between Medicaid’s published UPDL and this document, use the published UPDL as final guide; Medicaid and the MCPs reserve the right to make changes that may not be reflected here. For evidence-based prescribing guidelines, please visit www.partnersforkids.org/resources > Prescribing Resources. Average cost per script is based on generic drug when available using an average length of therapy. Prices are for reference and actual cost may vary based on drug strength, quantity and other factors. Bolded medications are generically available. = Covered PA = Prior authorization NC = Not covered
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Last updated 5/2020 by PFK Pharmacy
Coverage may change 7/2020
Generic Drug Name (Brand) Strength
Average Cost Per
Script
Uni
fied
PDL
Benzyl alcohol (Ulesfia®)
5% $284 NC
Ivermectin lotion (Sklice®)
0.5% $412 PA
Malathion lotion (Ovide®)
0.5% $266 PA
Permethrin (Nix®)
1% $15
Pyrethrins/piperonyl butoxide (LiceMD®/RID®) 0.33%-4% $10
Spinosad (Natroba®)
0.9% $294 PA
HEAD LICETopical Pediculocides
UNIFIED PREFERRED DRUG LIST FOR OHIO MEDICAID UPDL coverage for Ohio Medicaid Managed Care Plans and Traditional Fee-for-Service is provided for commonly prescribed drug classes by pediatric primary care providers. This information is intended for use by providers to select cost-effective medications for their patients and includes medications covered on the UPDL. It is not a substitute for individual patient factors and clinical judgment. If there is a discrepancy between Medicaid’s published UPDL and this document, use the published UPDL as final guide; Medicaid and the MCPs reserve the right to make changes that may not be reflected here. For evidence-based prescribing guidelines, please visit www.partnersforkids.org/resources > Prescribing Resources. Average cost per script is based on generic drug when available using an average length of therapy. Prices are for reference and actual cost may vary based on drug strength, quantity and other factors. Bolded medications are generically available. = Covered PA = Prior authorization NC = Not covered
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Last updated 5/2020 by PFK Pharmacy
Coverage may change 7/2020
Oral antibiotics continued on next page.
Generic Drug Name (Brand) Strength
Average Cost Per
Script
Uni
fied
PDL
125, 250 mg chew $10
250, 500 mg capsule $6
125 mg/5mL, 250 mg/5 mL, 400 mg/5 mL $14
250 mg-62.5 mg/5mL, 400 mg-57 mg/5 mL $69
875 mg-125 mg $54
Augmentin™ ES (Not interchangeable w ith other
suspensions; Target clavulanic acid dose is 6.4mg/kg/day)
600 mg-42.9 mg/5mL (high dose amoxicillin only)
$81
Amoxicillin/ Clavulanate (Augmentin XR™)
(Use for patients > 40 kg)
1,000 mg-62.5 mg $70
125mg/5mL, 250 mg/5 mL $14
250 mg, 500 mg $14
250 mg, 500 mg (capsule preferred)
$8
250 mg/5 mL $38
300 mg $51
250 mg/5 mL $83
CephalosporinsCephalexin
(Keflex®)
Cefdinir (Omnicef®)
ORAL ANTIBIOTICSPenicillins
Amoxicillin
Amoxicillin/ Clavulanate (Augmentin™)
Penicillin V Potassium (Pen VK®)
UNIFIED PREFERRED DRUG LIST FOR OHIO MEDICAID UPDL coverage for Ohio Medicaid Managed Care Plans and Traditional Fee-for-Service is provided for commonly prescribed drug classes by pediatric primary care providers. This information is intended for use by providers to select cost-effective medications for their patients and includes medications covered on the UPDL. It is not a substitute for individual patient factors and clinical judgment. If there is a discrepancy between Medicaid’s published UPDL and this document, use the published UPDL as final guide; Medicaid and the MCPs reserve the right to make changes that may not be reflected here. For evidence-based prescribing guidelines, please visit www.partnersforkids.org/resources > Prescribing Resources. Average cost per script is based on generic drug when available using an average length of therapy. Prices are for reference and actual cost may vary based on drug strength, quantity and other factors. Bolded medications are generically available. = Covered PA = Prior authorization NC = Not covered
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Last updated 5/2020 by PFK Pharmacy
Coverage may change 7/2020
Oral antibiotics continued on next page.
Generic Drug Name (Brand) Strength
Average Cost Per
Script
Uni
fied
PDL
250 mg, 500 mg $5
250 mg/5 mL, 500 mg/5mL $156
< 12 yo
250 mg, 500 mg $2
25mg/mL $70
250 mg, 500 mg $28
100 mg/5mL, 200 mg/5 ml $35
125 mg/5 mL, 250 mg/5mL $134
250 mg, 500 mg $51
Erythromycin (E.E.S.®, Ery-Tab®)
250 mg, 333 mg, 400 mg, 500 mg $265
Erythromycin Ethylsuccinate (EryPed®)
400 mg/5 mL $794 PA
400 mg-80 mg, 800 mg-160 mg $7
200 mg-40 mg/5 mL $25
Levofloxacin (Levaquin®)
Macrolides
Azithromycin (Zithromax®)
Clarithromycin (Biaxin®)
SulfonamidesSulfamethoxazole/
Trimethoprim (Bactrim®)
ORAL ANTIBIOTICS (CONTINUED)Fluoroquinolones
Ciprofloxacin (Cipro®)
UNIFIED PREFERRED DRUG LIST FOR OHIO MEDICAID UPDL coverage for Ohio Medicaid Managed Care Plans and Traditional Fee-for-Service is provided for commonly prescribed drug classes by pediatric primary care providers. This information is intended for use by providers to select cost-effective medications for their patients and includes medications covered on the UPDL. It is not a substitute for individual patient factors and clinical judgment. If there is a discrepancy between Medicaid’s published UPDL and this document, use the published UPDL as final guide; Medicaid and the MCPs reserve the right to make changes that may not be reflected here. For evidence-based prescribing guidelines, please visit www.partnersforkids.org/resources > Prescribing Resources. Average cost per script is based on generic drug when available using an average length of therapy. Prices are for reference and actual cost may vary based on drug strength, quantity and other factors. Bolded medications are generically available. = Covered PA = Prior authorization NC = Not covered
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Last updated 5/2020 by PFK Pharmacy
Coverage may change 7/2020
Generic Drug Name (Brand) Strength
Average Cost Per
Script
Uni
fied
PDL
75 mg, 150 mg $21
75 mg/5 mL $124
Metronidazole (Flagyl®)
250, 500 mg $5
Nitrofurantoin monohydrate macrocrystal (MacroBid®)
100 mg $37
Nitrofurantoin (Furadantin®)
25 mg/5 mL $636
0.3% Floxin® Otic $308
0.3% Ocuflox® Opthl. $135
Ciprofloxacin/dexamethasone (Ciprodex®)
0.3/0.1% suspension $227
Ciprofloxacin (Cetraxal®)
0.2% solution $102 PA
Otic Anti-infectives
Ofloxacin
ORAL ANTIBIOTICS (CONTINUED)Miscellaneous
Clindamycin (Cleocin®)
OTIC ANTIBIOTICS
UNIFIED PREFERRED DRUG LIST FOR OHIO MEDICAID UPDL coverage for Ohio Medicaid Managed Care Plans and Traditional Fee-for-Service is provided for commonly prescribed drug classes by pediatric primary care providers. This information is intended for use by providers to select cost-effective medications for their patients and includes medications covered on the UPDL. It is not a substitute for individual patient factors and clinical judgment. If there is a discrepancy between Medicaid’s published UPDL and this document, use the published UPDL as final guide; Medicaid and the MCPs reserve the right to make changes that may not be reflected here. For evidence-based prescribing guidelines, please visit www.partnersforkids.org/resources > Prescribing Resources. Average cost per script is based on generic drug when available using an average length of therapy. Prices are for reference and actual cost may vary based on drug strength, quantity and other factors. Bolded medications are generically available. = Covered PA = Prior authorization NC = Not covered
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Last updated 5/2020 by PFK Pharmacy
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Antifungal treatment options continued on next page
Generic Drug Name (Brand) Strength
Average Cost Per
Script
Unifi
ed P
DL
Ketoconazole 200 mg $95
50 mg, 100 mg, 150 mg, 200 mg $12
40mg/mL suspension $180
100 mg $156 PA
10 mg/mL solution $693 PA
Terbinafine (Lamisil®)
250 mg $10
125 mg, 250 mg Ultramicrosize $164
500 mg Microsize $255
125/5 mg/mL Microsize Suspension $98
500,000 units $39
100,000 units/mL $29
Griseofulvin (Grifluvin V®)
Nystatin
ANTIFUNGALSOral Antifungals
Fluconazole (Diflucan®)
Itraconazole (Sporanox®)
UNIFIED PREFERRED DRUG LIST FOR OHIO MEDICAID UPDL coverage for Ohio Medicaid Managed Care Plans and Traditional Fee-for-Service is provided for commonly prescribed drug classes by pediatric primary care providers. This information is intended for use by providers to select cost-effective medications for their patients and includes medications covered on the UPDL. It is not a substitute for individual patient factors and clinical judgment. If there is a discrepancy between Medicaid’s published UPDL and this document, use the published UPDL as final guide; Medicaid and the MCPs reserve the right to make changes that may not be reflected here. For evidence-based prescribing guidelines, please visit www.partnersforkids.org/resources > Prescribing Resources. Average cost per script is based on generic drug when available using an average length of therapy. Prices are for reference and actual cost may vary based on drug strength, quantity and other factors. Bolded medications are generically available. = Covered PA = Prior authorization NC = Not covered
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Last updated 5/2020 by PFK Pharmacy
Coverage may change 7/2020
Generic Drug Name (Brand) Strength
Average Cost Per
Script
Uni
fied
PDL
100,000 units/g Cream $35
100,000 units/g Ointment $34
100,000 units/g Powder $23
1% Cream $6
1% Vaginal Cream (RX, OTC) $8
2% Vaginal Cream (OTC) $10
1% Solution $101
2% Cream $40
2% Shampoo $24
2% Foam $708 PA
2% Cream $6
2% Vaginal Cream $11
2% Powder $6
Terbinafine (Lamisil®)
1% Cream $12
Clotrimazole
Ketoconazole (Extina®, Nizoral®)
Miconazole (Lotrimin®)
ANTIFUNGALS (CONTINUED)Topical Antifungals
Nystatin
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