Skip to Main Content

Q3 2015 MHS Preferred Drug List (PDL) Provider Notice

Date: 12/30/15

Click here for a PDF version of this notice. 

The Managed Health Services (MHS) Pharmacy and Therapeutics (P&T) Committee approved the following medications for addition to the MHS PDLs for Healthy Indiana Plan 2.0 (HIP) and Hoosier Care Connect members. These additions are effective 12/1/2015.

Therapeutic Class



Acne Products

erythromycin 2% gel

MPL 1/ claim

Sulfacetamide sodium wash 

Antiadrenergic Agents – Centrally Acting


Beta Blockers

timolol maleate oral tab 
Coreg® CR (carvedilol)

MDD 1/day


ELLA (ulipristal 30mg tab)

QL 4/365 DAYS

Hormone Replacement Therapy


progesterone vaginal insert 
estradiol vaginal cream

QL 43/30 DAYS


progesterone vaginal suppositories 

Multiple Sclerosis Agents


Avonex (Interferon Beta-1a)

PA Required

Plegridy (Peginterferon beta-1a)

PA Required

Tecfidera (dimethy fumarate0

PA Required

Copaxone (Glatiramer 40mg Inj.)

PA Required



choline magnesium trisalicylate 
salsalate tab 
aspirin 81mg Tab 

Topical Corticosteroids


augmented betamethasone dipropionate 0.05% cream

MPL 1/ claim

betamethasone valerate 0.1% cream, lotion and ointment

MPL 1/ claim

clobetasol propionate emulsion 0.05% foam

MPL 1/ claim

Bile Acid Agent

Cholbam (cholic acid)

PA Required, QL = 5/day

Respiratory Agent (CF)

Orkambi (lumacaftor, ivacaftor)

PA Required

Atypical Antipsychotic


Rexulti (brexpiprazole)

MDD 1/day

Aristada (aripiprazole)

QL 1/28 days, Age 18 and  older


Qudexy XR (topiramate)

MDD 1/day


Vitamin B12 injection (cyanocobalamin) 

The following clinical edits were approved by the P&T Committee with an effective date of 2/1/2016. MHS will attempt to convert members to preferred alternatives or obtain the necessary authorization by working directly with the prescriber and only as approval is granted.




Celecoxib (Celebrex)

Prior Authorization

  • Age >65 years, OR
  • current use of corticosteroid, OR
  • current use of an anticoagulant (aspirin, warfarin, low molecular weight heparin, direct thrombin inhibitors, factor Xa inhibitors, and clopidogrel), OR
  • prior gastrointestinal bleed or active peptic ulcer disease (not GERD); OR
  • Failure of meloxicam and two other PDL generic NSAIDs at prescription strength, each for trial must be for ≥ 4 weeks OR;
  • contraindication to meloxicam and ALL other PDL NSAIDs

Ranexa (Ranolazine)

Prior Authorization

A. Diagnosis of chronic anginaB. Age ≥18 years;


C. Failure of concurrent use of a beta- blocker and long-acting nitrate OR failure of concurrent use of a calcium channel blocker and long-acting nitrate, unless contraindicated;

Hemangeol (propranolol HCL Soulution)

Prior Authorization

A. Patient with documented diagnosis of proliferating infantile hemangioma.B. For infants younger than 2 months of age, the patient must be hospitalized for monitoring during induction of treatment if patient has PHACE syndrome.


C. Patient must weigh less than 12.5 kg in weight.

Regranex (becaplermin)

Prior Authorization

A. Diagnosis of diabetes;B. Chronic lower extremity ulcer present ≥8 weeks;


C. Diagnosis of Stage III or IV lower extremity ulcer(s) as defined in the IAET guideline to chronic wound staging;

D. Age ≥16 years;

E. Failure of wound care, including initial sharp debridement, pressure relief, and infection control;

F. Documentation of proper and adequate wound care, wound devoid of infection.

Sodium Glucose Co Transporter-2 (SGLT-2)

Step Therapy

Initial Approval Criteria (must meet all):


  1. Age ≥18 years;
  2. Failure of adherent use of  metformin at ≥ 2000mg/day for  ≥ 3  months, unless contraindicated;
  3. Failure of adherent use of  a PDL DPP-IV inhibitor for  ≥ 3  months, unless contraindicated;
  4. Requested dose is within the FDA approved limit.


The P&T Committee has approved the following list of medications to be moved to non-preferred status on the HIP and Hoosier Care Connect PDLs. These medications will remain available through the prior authorization process. MHS will attempt to convert members to preferred alternatives by working directly with the prescriber and only as approval is granted. The effective date of these changes is 2/1/2016.

Therapeutic Class

Medication Moving

Preferred Alternative(s)

Acne and Rosacea Products

Azelex (azelaic acid)

clindamycin topical, erythromycin, metronidazole, sulfacetaminde sodium, benzyl peroxide, tretinoin (generics), nezoyl peroxide/clindamycin

Noritate (metronidazole)
Sulfacetamide sodium 10%
benzoyl peroxide Foam (BenzEFoam)
Zaclir (benzoyl peroxide)
Avar LS, Avar E- LS (sulfacetamide/sulfur cleanser)
Sumaxin, Sumaxin TS(sulfacetamide/sulfur)
Epiduo (benzoyl peroxide, adapalene)
Panretin (alitretinoin)
Avita, Atralin (tretinoin)
Acanya (benzoyl peroxide/clindamycin)
benzoyl peroxid/erythromycin
Ziana (Clindamycycin/tretinoin)
Benziq LS, Benziq, Benziq Wash (benzoyl peroxide/ aloe vera)

Antimalarial Preparations

Quinine sulfate (Qualaquin)

chloroquine, hydroxychloroquine, primaquine, Coartem, Malarone, mefloquine

Daraprim (pyrimethamine)

Antituberculosis Agents

Paser (aminosalicylic acid)

ethambutol, Trecator (ethionamide), isoniazid, pyrazinamide, rifampin

Cycloserine (Seromycine)
Rifabutin (Mycobutin)
Priftin (rifapentine)
Rifater (rifampin,isoniazid,pyrazinamide)
Rifamate (rifampin, isoniazid)

Beta Blockers

Bystolic (nebivolol)

acebutolol, atenolol, bisoprolol, levatol (penbutolol), nadolol, metoprolol (IR/ER), pindolol, propranolol (IR/ER), sotalol, carvedilol, labetalol

Calcium Channel Blockers

Cardene SR (nicardipine)

amlodipine, diltiazem, felodipine, nicardipine, nifedipine (IR/ER), verapamil (IR/ER)

Nimodipine (Nimotop)
Nisoldipine (Sular)
Verelan PM (verapamil ER)


Therapeutic Class

Medication Moving

Preferred Alternative(s)


Falessa Kit (Ethinyl estradiol, levonorgestrel, folic acid, levomefolate)

Multiple products

Hormone Replacement Therapy

Cenestin, Enjuvia(conjugated estrogens, synthetic)

estradiol tabs, estropipate, Premarin, Estratest, Femhrt, Prempro, Premphase, Provera, Aygestin, Prometrium, Combipatch, Climara

Menest(esterified estrogens)
Angeliq(estradiol/ drospirenone)
Duavee(conjugated estrogen/bazedoxifene)
Activella(estradiol/ norethindrone)
Jinteli(ethinyl estradiol/ norethindrone)
Prefest(estradiol/ norgestimate)
Climara Pro(estradiol/ levonorgestrel)
Divigel, Elestrin(estradiol gel)
Estrasorb(estradiol Emulsion)
Evamist(estradiol Spray)
Vagifem(estradiol vaginal tablets)
Premarin Injection(conjugated estrogens)
Overactive Bladder AgentsEnablex (darifenacin)

tolterodine (IR/ER), oxybutynin (IR/ER tabs), Sanctura (trospium), flavoxate

Gelnique (oxybutynin topical Gel)
Oxytrol (oxybutynin Patch)
Sanctura XR (trospium ER)
Toviaz (fesoterodine)
Vesicare (solifenacin)

Muscle Relaxants

Dantrolene (Dantrium)

baclofen, chlorzoxazone, cyclobenzaprine (5mg,10mg tab), methocarbamol, orphenadrine

Fexmid, Amrix (Cyclobenzaprine)
Metaxalone (Skelaxin)
Tizanidine (Zanaflex)


Therapeutic Class

Medication Moving

Preferred Alternative(s)


diclofenac Na(Pennsaid transdermal soln.)

diclofenac sodium, diclofenac potassium, etodoloac, flurbiprofen, ibuprofen, indomethacin, ketoprofen, ketorolac, nabumetone, naproxen (IR/EC), oxaprozin, piroxicam, sulindac, aspirin, diflunisal, salsalate

Zipsor(diclofenac potassium liquid cap)
Flector (diclofenac patch)
Indocin (indomethacin suppository, Suspension)
Ponstel (mefanamic acid)
Mobic Suspension(meloxicam suspension)
Naprelan (naproxen ER tabs)
Sprix (ketorolac nasal spray)
Tolmetin (Tolectin)
Voltaren gel (diclofenac gel)
Zorvolex (diclofenac tabs)
Diclofenac sodium/ misoprostol (Arthrotec)

Topical Corticosteroids

alclometasone dipropionate 0.05% cream, ointment (Aclovate)

Very High Potency:

aug. betamethasone 0.05% oint, lotion

clobetasol 0.05% oint, soln, cream ,gel, foam

High Potency:

aug. betamethasone 0.05% cream

diflorasone 0.05% cream

fluocinonide 0.05% emulisified cream, gel

betamethasone 0.05% oint

triamcinolone 0.5% oint

Medium Potency:

triamcinolone 0.025%, 0.1%, 0.5% ointment, cream, 0.025%,0.1% lotion

betamethasone 0.05% cream, lotion

fluocinolone 0.025% cream, 0.025% oint

Low Potency:

fluocinolone 0.01% cream, soln

hydrocortisone 0.5%, 1%, 2.5% cream, ointment, lotion


betamethasone/clotrimazole cr, lot

triamcinolone/nystatin cream, ointment


hydrocortisone rectal cream 1%, 2.5%, suppository 25mg

hydrocortisone/pramoxine cream, lotion, ointment

Last Updated: 04/15/2020