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

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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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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

Coverage may change 7/2020

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