System
Class
Preferred
Effective: January 1, 2023
Table 121-0030-1 Oregon Fee-for-Service Enforceable Physical Health Preferred Drug List
Anaphylaxis Rescue
Allergy/Cold
epinephrine
AUTO INJCT
Antihistamines, Second
Generation
Allergy/Cold
cetirizine HCl
SOLUTION ***
cetirizine HCl
TABLET
loratadine
SOLUTION
loratadine
TAB RAPDIS ***
loratadine
TABLET
Cough and Cold
Allergy/Cold
codeine phosphate/guaifenesin *
LIQUID
codeine phosphate/guaifenesin *
SYRUP
codeine phosphate/guaifenesin *
TABLET
guaifenesin ‡
GRAN PACK
guaifenesin ‡
LIQUID
guaifenesin ‡
SYRUP
guaifenesin ‡
TAB ER 12H
guaifenesin ‡
TABLET
guaifenesin ‡
TABLET ER
guaifenesin/dextromethorphan ‡
CAPSULE
guaifenesin/dextromethorphan ‡
DROPS
guaifenesin/dextromethorphan ‡
ELIXIR
guaifenesin/dextromethorphan ‡
GRAN PACK
guaifenesin/dextromethorphan ‡
LIQUID
guaifenesin/dextromethorphan ‡
LIQUID PKT
guaifenesin/dextromethorphan ‡
SYRUP
guaifenesin/dextromethorphan ‡
TAB ER 12H
guaifenesin/dextromethorphan ‡
TABLET
pseudoephedrine HCl ‡
CAPSULE
pseudoephedrine HCl ‡
TABLET
Hereditary Angioedema
Allergy/Cold
C1 esterase inhibitor *
KIT
C1 esterase inhibitor *
VIAL
Nasal Allergy Inhalers
Allergy/Cold
fluticasone propionate ‡
SPRAY SUSP
CGRP Inhibitors
Analgesics
erenumab-aooe (AIMOVIG AUTOINJECTOR ™) *
AUTO INJCT
fremanezumab-vfrm (AJOVY AUTOINJECTOR ™) *
AUTO INJCT
fremanezumab-vfrm (AJOVY SYRINGE ™) *
SYRINGE
Gout
Analgesics
allopurinol
TABLET
colchicine **
TABLET
probenecid/colchicine
TABLET
Muscle Relaxants, Oral
Analgesics
baclofen
TABLET
cyclobenzaprine HCl
TABLET ***
methocarbamol
TABLET
tizanidine HCl
TABLET
1
Updated: December 20, 2022
* Drug coverage subject to meeting clinical prior authorization criteria
** Drug coverage subject to quantity limits
*** Certain strengths may require Prior Authorization
‡ Age restrictions apply
Note: New drugs in classes already evaluated for the PDL shall be
non-preferred until the new drug has been reviewed by the P&T
(see OAR 410-121-0030).
System
Class
Preferred
Effective: January 1, 2023
Table 121-0030-1 Oregon Fee-for-Service Enforceable Physical Health Preferred Drug List
Non-Steroidal Anti-
Inflammatory Drugs
Analgesics
celecoxib
CAPSULE
diclofenac potassium
TABLET ***
diclofenac sodium
TABLET DR
etodolac
TABLET
ibuprofen
CAPSULE
ibuprofen
DROPS SUSP
ibuprofen
ORAL SUSP
ibuprofen
TAB CHEW
ibuprofen
TABLET
indomethacin
CAPSULE
ketoprofen
CAPSULE
meloxicam
TABLET
nabumetone
TABLET
naproxen
TABLET
naproxen
TABLET DR
naproxen sodium
TABLET
oxaprozin
TABLET
salsalate
TABLET
sulindac
TABLET
Opioids, Long-Acting
Analgesics
fentanyl *
PATCH TD72
morphine sulfate *
TABLET ER
Opioids, Short-Acting
Analgesics
acetaminophen with codeine *
ELIXIR
acetaminophen with codeine *
SOLUTION
acetaminophen with codeine *
TABLET
butorphanol tartrate **
SPRAY
codeine sulfate *
TABLET
hydrocodone/acetaminophen **
SOLUTION
hydrocodone/acetaminophen **
TABLET
hydromorphone HCl **
SUPP.RECT
hydromorphone HCl **
TABLET
morphine sulfate **
SOLUTION
morphine sulfate **
SUPP.RECT
morphine sulfate **
TABLET
opium/belladonna alkaloids **
SUPP.RECT
oxycodone HCl **
SOLUTION
oxycodone HCl **
TABLET
oxycodone HCl/acetaminophen **
CAPSULE
oxycodone HCl/acetaminophen **
TABLET
tramadol HCl **
TABLET
Pain Medications, Topical
Analgesics
capsaicin
CREAM (G)
diclofenac sodium
GEL (GRAM) ***
lidocaine HCl
CREAM (G) ***
lidocaine HCl
JEL/PF APP
lidocaine HCl
SOLUTION
lidocaine/prilocaine
CREAM (G)
2
Updated: December 20, 2022
* Drug coverage subject to meeting clinical prior authorization criteria
** Drug coverage subject to quantity limits
*** Certain strengths may require Prior Authorization
‡ Age restrictions apply
Note: New drugs in classes already evaluated for the PDL shall be
non-preferred until the new drug has been reviewed by the P&T
(see OAR 410-121-0030).
System
Class
Preferred
Effective: January 1, 2023
Table 121-0030-1 Oregon Fee-for-Service Enforceable Physical Health Preferred Drug List
Serotonin Agonists, Nasal
Analgesics
sumatriptan **
SPRAY
zolmitriptan **
SPRAY
Serotonin Agonists, Oral
Analgesics
naratriptan HCl **
TABLET
sumatriptan succinate **
TABLET
zolmitriptan **
TAB RAPDIS
zolmitriptan **
TABLET
Serotonin Agonists,
Subcutaneous
Analgesics
sumatriptan succinate **
CARTRIDGE
sumatriptan succinate **
PEN INJCTR
sumatriptan succinate **
VIAL
Amoxicillin and Clavulanate,
Oral
Antibiotics
amoxicillin/potassium clav
SUSP RECON
amoxicillin/potassium clav
TAB CHEW
amoxicillin/potassium clav
TABLET
Antibiotics, Vaginal
Antibiotics
clindamycin phosphate
CREAM/APPL
clindamycin phosphate
SUPP.VAG
metronidazole
GEL W/APPL
Cephalosporins (1st Gen), Oral
Antibiotics
cephalexin
CAPSULE ***
cephalexin
SUSP RECON
Cephalosporins (2nd Gen),
Oral
Antibiotics
cefprozil
SUSP RECON
cefprozil
TABLET
cefuroxime axetil
TABLET
Cephalosporins (3rd Gen),
Oral
Antibiotics
cefdinir
CAPSULE
cefdinir
SUSP RECON
Clostridium Difficile Drugs
Antibiotics
metronidazole
CAPSULE
metronidazole
TABLET
vancomycin HCl
CAPSULE
vancomycin HCl
VIAL
Fluoroquinolones, Oral
Antibiotics
ciprofloxacin
SUS MC REC
ciprofloxacin HCl
TABLET
levofloxacin
SOLUTION
levofloxacin
TABLET
moxifloxacin HCl
TABLET
Macrolides, Oral
Antibiotics
azithromycin
SUSP RECON
azithromycin
TABLET
clarithromycin
TABLET
Oxazolidinones, Oral
Antibiotics
linezolid
SUSP RECON
linezolid
TABLET
3
Updated: December 20, 2022
* Drug coverage subject to meeting clinical prior authorization criteria
** Drug coverage subject to quantity limits
*** Certain strengths may require Prior Authorization
‡ Age restrictions apply
Note: New drugs in classes already evaluated for the PDL shall be
non-preferred until the new drug has been reviewed by the P&T
(see OAR 410-121-0030).
System
Class
Preferred
Effective: January 1, 2023
Table 121-0030-1 Oregon Fee-for-Service Enforceable Physical Health Preferred Drug List
Tetracyclines, Oral
Antibiotics
doxycycline hyclate **
CAPSULE
doxycycline hyclate **
TABLET
doxycycline monohydrate **
CAPSULE
doxycycline monohydrate **
SUSP RECON
tetracycline HCl **
CAPSULE
Antifungals, Oral
Antifungal
clotrimazole
TROCHE
fluconazole
SUSP RECON
fluconazole
TABLET
nystatin
ORAL SUSP
nystatin
TABLET
Hepatitis B
Antivirals
lamivudine *
SOLUTION
lamivudine *
TABLET
tenofovir disoproxil fumarate *
TABLET
Hepatitis C, Direct-Acting
Antivirals
Antivirals
glecaprevir/pibrentasvir (MAVYRET ™) **
TABLET
sofosbuvir/velpatasvir (SOFOSBUVIR-VELPATASVIR ™) **
TABLET
Hepatitis C, Other Agents
Antivirals
peginterferon alfa-2a *
SYRINGE
peginterferon alfa-2a *
VIAL
ribavirin *
CAPSULE
ribavirin *
TABLET
Herpes Simplex
Antivirals
acyclovir
CAPSULE
acyclovir
ORAL SUSP
acyclovir
TABLET
valacyclovir HCl
TABLET
4
Updated: December 20, 2022
* Drug coverage subject to meeting clinical prior authorization criteria
** Drug coverage subject to quantity limits
*** Certain strengths may require Prior Authorization
‡ Age restrictions apply
Note: New drugs in classes already evaluated for the PDL shall be
non-preferred until the new drug has been reviewed by the P&T
(see OAR 410-121-0030).
System
Class
Preferred
Effective: January 1, 2023
Table 121-0030-1 Oregon Fee-for-Service Enforceable Physical Health Preferred Drug List
HIV
Antivirals
abacavir sulfate
SOLUTION
abacavir sulfate
TABLET
abacavir sulfate/lamivudine
TABLET
abacavir/dolutegravir/lamivudi
TAB SUSP
abacavir/dolutegravir/lamivudi (TRIUMEQ ™)
TABLET
abacavir/lamivudine/zidovudine
TABLET
atazanavir sulfate
CAPSULE
atazanavir sulfate
POWD PACK
atazanavir sulfate/cobicistat (EVOTAZ ™)
TABLET
bictegrav/emtricit/tenofov ala (BIKTARVY ™)
TABLET
cabotegravir
SUSER VIAL
cabotegravir (APRETUDE ™)
SUSER VIAL
cabotegravir sodium
TABLET
cabotegravir/rilpivirine (CABENUVA ™)
SUSER VIAL
cobicistat
TABLET
darunavir ethanolate
ORAL SUSP
darunavir ethanolate
TABLET
darunavir/cob/emtri/tenof alaf (SYMTUZA ™)
TABLET
darunavir/cobicistat (PREZCOBIX ™)
TABLET
dolutegravir sodium
TAB SUSP
dolutegravir sodium
TABLET
dolutegravir sodium/lamivudine (DOVATO ™)
TABLET
dolutegravir/rilpivirine (JULUCA ™)
TABLET
doravirine (PIFELTRO ™)
TABLET
doravirine/lamivu/tenofov diso (DELSTRIGO ™)
TABLET
efavirenz
CAPSULE
efavirenz
TABLET
efavirenz/emtricit/tenofovr df
TABLET
efavirenz/lamivu/tenofov disop
TABLET
efavirenz/lamivu/tenofov disop (SYMFI ™)
TABLET
efavirenz/lamivu/tenofov disop (SYMFI LO ™)
TABLET
elviteg/cob/emtri/tenof alafen (GENVOYA ™)
TABLET
elviteg/cob/emtri/tenofo disop
TABLET
emtricita/rilpivirine/tenof DF
TABLET
emtricitab/rilpiviri/tenof ala (ODEFSEY ™)
TABLET
emtricitabine
CAPSULE
emtricitabine
SOLUTION
emtricitabine/tenofov alafenam (DESCOVY ™)
TABLET
emtricitabine/tenofovir (TDF)
TABLET
enfuvirtide
VIAL
etravirine
TABLET
fosamprenavir calcium
ORAL SUSP
fosamprenavir calcium
TABLET
ibalizumab-uiyk
VIAL
lamivudine
SOLUTION
lamivudine
TABLET
lamivudine/tenofovir disop fum
TABLET
lamivudine/tenofovir disop fum (CIMDUO ™)
TABLET
lamivudine/zidovudine
TABLET
lopinavir/ritonavir
SOLUTION
5
Updated: December 20, 2022
* Drug coverage subject to meeting clinical prior authorization criteria
** Drug coverage subject to quantity limits
*** Certain strengths may require Prior Authorization
‡ Age restrictions apply
Note: New drugs in classes already evaluated for the PDL shall be
non-preferred until the new drug has been reviewed by the P&T
(see OAR 410-121-0030).
System
Class
Preferred
Effective: January 1, 2023
Table 121-0030-1 Oregon Fee-for-Service Enforceable Physical Health Preferred Drug List
HIV
Antivirals
lopinavir/ritonavir
TABLET
maraviroc
SOLUTION
maraviroc
TABLET
nevirapine
ORAL SUSP
nevirapine
TAB ER 24H
nevirapine
TABLET
raltegravir potassium
POWD PACK
raltegravir potassium
TAB CHEW
raltegravir potassium
TABLET
rilpivirine
SUSER VIAL
rilpivirine HCl
TABLET
ritonavir
SOLUTION
ritonavir
TABLET
ritonavir (NORVIR ™)
POWD PACK
ritonavir (NORVIR ™)
TABLET
tipranavir
CAPSULE
zidovudine
CAPSULE
zidovudine
SYRUP
zidovudine
TABLET
zidovudine
VIAL
Influenza
Antivirals
oseltamivir phosphate **
CAPSULE
oseltamivir phosphate **
SUSP RECON
Antianginals
Cardiovascular
isosorbide dinitrate
TABLET
isosorbide mononitrate
TABLET
nitroglycerin
PATCH TD24
nitroglycerin
TAB SUBL
Anticoagulants, Oral and SQ
Cardiovascular
apixaban (ELIQUIS ™)
TAB DS PK
apixaban (ELIQUIS ™)
TABLET
dabigatran etexilate mesylate
CAPSULE
edoxaban tosylate
TABLET
enoxaparin sodium
SYRINGE
enoxaparin sodium
VIAL
rivaroxaban (XARELTO ™)
TAB DS PK
rivaroxaban (XARELTO ™)
TABLET
warfarin sodium
TABLET
Beta-Blockers, Oral
Cardiovascular
acebutolol HCl
CAPSULE
atenolol
TABLET
carvedilol
TABLET
labetalol HCl
TABLET
metoprolol succinate
TAB ER 24H
metoprolol tartrate
TABLET
nadolol
TABLET
propranolol HCl
CAP SA 24H
propranolol HCl
SOLUTION
propranolol HCl
TABLET
6
Updated: December 20, 2022
* Drug coverage subject to meeting clinical prior authorization criteria
** Drug coverage subject to quantity limits
*** Certain strengths may require Prior Authorization
‡ Age restrictions apply
Note: New drugs in classes already evaluated for the PDL shall be
non-preferred until the new drug has been reviewed by the P&T
(see OAR 410-121-0030).
System
Class
Preferred
Effective: January 1, 2023
Table 121-0030-1 Oregon Fee-for-Service Enforceable Physical Health Preferred Drug List
Calcium Channel Blockers -
Dihydropyridine, Oral
Cardiovascular
amlodipine besylate
TABLET
nicardipine HCl
CAPSULE
nifedipine
TAB ER 24
nifedipine
TABLET ER
Calcium Channel Blockers -
Non-Dihydropyridine, Oral
Cardiovascular
diltiazem HCl
CAP ER 12H
diltiazem HCl
CAP ER 24H
diltiazem HCl
CAP ER DEG
diltiazem HCl
CAP SA 24H
diltiazem HCl
TABLET
verapamil HCl
CAP24H PEL
verapamil HCl
TABLET
verapamil HCl
TABLET ER
Combination
Antihypertensives
Cardiovascular
amlodipine bes/olmesartan med
TABLET
benazepril/hydrochlorothiazide
TABLET
enalapril/hydrochlorothiazide
TABLET
lisinopril/hydrochlorothiazide
TABLET
losartan/hydrochlorothiazide
TABLET
olmesartan/amlodipin/hcthiazid
TABLET
olmesartan/hydrochlorothiazide
TABLET
telmisartan/hydrochlorothiazid
TABLET
Diuretics, Oral
Cardiovascular
amiloride HCl
TABLET
amiloride/hydrochlorothiazide
TABLET
bumetanide
TABLET
chlorthalidone
TABLET
furosemide
SOLUTION ***
furosemide
TABLET
hydrochlorothiazide
CAPSULE
hydrochlorothiazide
SOLUTION
hydrochlorothiazide
TABLET
indapamide
TABLET
spironolact/hydrochlorothiazid
TABLET
spironolactone
TABLET
torsemide
TABLET
triamterene
CAPSULE
triamterene/hydrochlorothiazid
CAPSULE
triamterene/hydrochlorothiazid
TABLET
7
Updated: December 20, 2022
* Drug coverage subject to meeting clinical prior authorization criteria
** Drug coverage subject to quantity limits
*** Certain strengths may require Prior Authorization
‡ Age restrictions apply
Note: New drugs in classes already evaluated for the PDL shall be
non-preferred until the new drug has been reviewed by the P&T
(see OAR 410-121-0030).
System
Class
Preferred
Effective: January 1, 2023
Table 121-0030-1 Oregon Fee-for-Service Enforceable Physical Health Preferred Drug List
Inhibitors of the Renin-
Angiotensin-Aldosterone
System (RAAS)
Cardiovascular
benazepril HCl
TABLET
candesartan cilexetil
TABLET
enalapril maleate
TABLET
fosinopril sodium
TABLET
irbesartan
TABLET
lisinopril
TABLET
losartan potassium
TABLET
olmesartan medoxomil
TABLET
quinapril HCl
TABLET
ramipril
CAPSULE
telmisartan
TABLET
valsartan
TABLET
Other Dyslipidemia Drugs
Cardiovascular
cholestyramine (with sugar)
POWD PACK
cholestyramine (with sugar)
POWDER
cholestyramine/aspartame
POWD PACK
cholestyramine/aspartame
POWDER
evolocumab (REPATHA PUSHTRONEX ™) *
WEAR INJCT
evolocumab (REPATHA SURECLICK ™) *
PEN INJCTR
evolocumab (REPATHA SYRINGE ™) *
SYRINGE
ezetimibe
TABLET
fenofibrate
TABLET ***
fenofibrate nanocrystallized
TABLET
fenofibrate,micronized
CAPSULE
fenofibric acid (choline)
CAPSULE DR
omega-3 acid ethyl esters *
CAPSULE
Platelet Inhibitors
Cardiovascular
aspirin
TAB CHEW
aspirin
TABLET
aspirin
TABLET DR
aspirin/dipyridamole
CPMP 12HR
cilostazol
TABLET
clopidogrel bisulfate
TABLET
dipyridamole
TABLET
prasugrel HCl
TABLET
Statins & Combos
Cardiovascular
atorvastatin calcium
TABLET
lovastatin
TABLET
pravastatin sodium
TABLET
rosuvastatin calcium
TABLET
simvastatin
TABLET
8
Updated: December 20, 2022
* Drug coverage subject to meeting clinical prior authorization criteria
** Drug coverage subject to quantity limits
*** Certain strengths may require Prior Authorization
‡ Age restrictions apply
Note: New drugs in classes already evaluated for the PDL shall be
non-preferred until the new drug has been reviewed by the P&T
(see OAR 410-121-0030).
System
Class
Preferred
Effective: January 1, 2023
Table 121-0030-1 Oregon Fee-for-Service Enforceable Physical Health Preferred Drug List
Acne
Dermatologicals
adapalene *
CREAM (G)
adapalene *
GEL (GRAM)
adapalene *
GEL W/PUMP
adapalene *
LOTION
adapalene/benzoyl peroxide *
GEL W/PUMP
azelaic acid *
GEL (GRAM)
benzoyl peroxide *
CLEANSER
benzoyl peroxide *
FOAM
benzoyl peroxide *
GEL (GRAM)
benzoyl peroxide *
LOTION
clindamycin phos/benzoyl perox *
GEL (GRAM)
clindamycin phos/benzoyl perox *
GEL W/PUMP
clindamycin phosphate *
FOAM
clindamycin phosphate *
GEL (GRAM)
clindamycin phosphate *
LOTION
clindamycin phosphate *
MED. SWAB
clindamycin phosphate *
SOLUTION
clindamycin/tretinoin *
GEL (GRAM)
dapsone *
GEL (GRAM)
erythromycin base in ethanol *
GEL (GRAM)
erythromycin base in ethanol *
MED. SWAB
erythromycin base in ethanol *
SOLUTION
erythromycin/benzoyl peroxide *
GEL (GRAM)
isotretinoin *
CAPSULE
sulfacetamide sodium *
SUSPENSION
tretinoin *
CREAM (G)
tretinoin *
GEL (GRAM)
tretinoin microspheres *
GEL (GRAM)
tretinoin microspheres *
GEL W/PUMP
Antibiotics, Topical
Dermatologicals
bacitracin
OINT. (G) ***
bacitracin zinc
OINT. (G)
bacitracin zinc/polymyxin B
OINT. (G)
bacitracin/polymyxin B sulfate
OINT. (G)
gentamicin sulfate
CREAM (G)
mupirocin
OINT. (G)
neomycin/bacitracin/polymyxinB
OINT. (G)
Antifungals, Topical
Dermatologicals
miconazole nitrate
CREAM (G)
nystatin
CREAM (G)
nystatin
OINT. (G)
9
Updated: December 20, 2022
* Drug coverage subject to meeting clinical prior authorization criteria
** Drug coverage subject to quantity limits
*** Certain strengths may require Prior Authorization
‡ Age restrictions apply
Note: New drugs in classes already evaluated for the PDL shall be
non-preferred until the new drug has been reviewed by the P&T
(see OAR 410-121-0030).
System
Class
Preferred
Effective: January 1, 2023
Table 121-0030-1 Oregon Fee-for-Service Enforceable Physical Health Preferred Drug List
Antiparasitics, Topical
Dermatologicals
permethrin
COMBO. PKG
permethrin
CREAM (G)
permethrin
LIQUID
piperonyl but/pyrethins/permet
KIT
piperonyl butoxide/pyrethrins
GEL (GRAM)
piperonyl butoxide/pyrethrins
KIT
piperonyl butoxide/pyrethrins
LIQUID
piperonyl butoxide/pyrethrins
SHAMPOO
Steroids, Topical
Dermatologicals
alclometasone dipropionate
CREAM (G)
alclometasone dipropionate
OINT. (G)
betamethasone dipropionate
CREAM (G)
betamethasone dipropionate
LOTION
betamethasone dipropionate
OINT. (G)
betamethasone valerate
CREAM (G)
betamethasone valerate
OINT. (G)
betamethasone/propylene glyc
CREAM (G)
clobetasol propionate
CREAM (G)
clobetasol propionate
OINT. (G)
clobetasol propionate
SOLUTION
desonide
CREAM (G)
desonide
OINT. (G)
desoximetasone
CREAM (G)
fluocinolone acetonide
CREAM (G)
fluocinolone acetonide
SOLUTION
fluocinonide
CREAM (G)
fluocinonide
SOLUTION
fluocinonide/emollient base
CREAM (G)
hydrocortisone
CREAM (G)
hydrocortisone
OINT. (G)
hydrocortisone acetate
CREAM (G)
hydrocortisone butyrate
SOLUTION
triamcinolone acetonide
CREAM (G)
triamcinolone acetonide
OINT. (G)
Topical Products for
Inflammatory Skin Diseases
Dermatologicals
calcipotriene
CREAM (G)
calcipotriene
SOLUTION
calcipotriene/betamethasone
OINT. (G)
pimecrolimus
CREAM (G)
tacrolimus
OINT. (G)
tazarotene
CREAM (G)
Androgens, Topical &
Parenteral
Endocrine
testosterone *
GEL (GRAM)
testosterone *
GEL MD PMP
testosterone *
GEL PACKET
testosterone cypionate *
VIAL
testosterone enanthate *
VIAL
10
Updated: December 20, 2022
* Drug coverage subject to meeting clinical prior authorization criteria
** Drug coverage subject to quantity limits
*** Certain strengths may require Prior Authorization
‡ Age restrictions apply
Note: New drugs in classes already evaluated for the PDL shall be
non-preferred until the new drug has been reviewed by the P&T
(see OAR 410-121-0030).
System
Class
Preferred
Effective: January 1, 2023
Table 121-0030-1 Oregon Fee-for-Service Enforceable Physical Health Preferred Drug List
Bone Metabolism Drugs
Endocrine
alendronate sodium
TABLET
ibandronate sodium
TABLET
risedronate sodium
TABLET
Diabetes, DPP-4 Inhibitors
Endocrine
saxagliptin HCl *
TABLET
sitagliptin phos/metformin HCl *
TABLET
sitagliptin phosphate *
TABLET
Diabetes, GLP-1 Receptor
Agonists
Endocrine
dulaglutide (TRULICITY ™) *
PEN INJCTR
exenatide *
PEN INJCTR
liraglutide *
PEN INJCTR
Diabetes, Glucagon
Endocrine
glucagon
VIAL
glucagon (BAQSIMI ™)
SPRAY
Diabetes, Insulins
Endocrine
HUMALOG ™ - BRAND ONLY
VIAL
HUMALOG KWIKPEN U-100 ™ - BRAND ONLY
INSULN PEN
HUMALOG TEMPO PEN U-100 ™ - BRAND ONLY
INSULN PEN
insulin aspart
CARTRIDGE
insulin aspart
INSULN PEN
insulin aspart
VIAL
insulin aspart prot/insuln asp *
INSULN PEN
insulin aspart prot/insuln asp *
VIAL
insulin detemir
INSULN PEN
insulin detemir
VIAL
insulin glulisine
INSULN PEN
insulin glulisine
VIAL
insulin lispro
CARTRIDGE
insulin lispro
INS PEN HF
insulin lispro
INSULN PEN
INSULIN LISPRO KWIKPEN U-100 ™ - BRAND ONLY
INSULN PEN
insulin lispro protamin/lispro
INSULN PEN
insulin lispro protamin/lispro
VIAL
insulin NPH hum/reg insulin hm *
INSULN PEN
insulin NPH hum/reg insulin hm *
VIAL
insulin NPH human isophane
VIAL
insulin regular, human
INSULN PEN
insulin regular, human
VIAL
insulin zinc human recombinant
VIAL
LANTUS ™ - BRAND ONLY *
VIAL
LANTUS SOLOSTAR ™ - BRAND ONLY *
INSULN PEN
Diabetes, Miscellaneous
Antidiabetic Agents
Endocrine
metformin HCl
TAB ER 24H
metformin HCl
TABLET
Diabetes, SGLT-2 Inhibitors
Endocrine
canagliflozin *
TABLET
dapagliflozin propanediol *
TABLET
empagliflozin *
TABLET
11
Updated: December 20, 2022
* Drug coverage subject to meeting clinical prior authorization criteria
** Drug coverage subject to quantity limits
*** Certain strengths may require Prior Authorization
‡ Age restrictions apply
Note: New drugs in classes already evaluated for the PDL shall be
non-preferred until the new drug has been reviewed by the P&T
(see OAR 410-121-0030).
System
Class
Preferred
Effective: January 1, 2023
Table 121-0030-1 Oregon Fee-for-Service Enforceable Physical Health Preferred Drug List
Diabetes, Sulfonylureas
Endocrine
glimepiride
TABLET
glipizide
TABLET
glyburide
TABLET
Diabetes, Thiazolidinediones
Endocrine
pioglitazone HCl
TABLET
Estrogen Replacement, Oral
Endocrine
drospirenone/estradiol ‡
TABLET
estradiol ‡
TABLET
estrogen,con/m-progest acet ‡
TABLET
estrogens, conjugated ‡
TABLET
estrogens,conj.,synthetic A ‡
TABLET
estropipate ‡
TABLET
Estrogen Replacement,
Topical
Endocrine
estradiol ‡
GEL MD PMP
estradiol ‡
PATCH TDSW
estradiol ‡
PATCH TDWK
Estrogen Replacement,
Vaginal
Endocrine
estradiol ‡
CREAM/APPL
estradiol ‡
TABLET
estradiol ‡
VAG RING
estradiol acetate ‡
VAG RING
estrogens, conjugated ‡
CREAM/APPL
Glucocorticoids, Oral
Endocrine
cortisone acetate
TABLET
dexamethasone
DROPS
dexamethasone
ELIXIR
dexamethasone
SOLUTION
dexamethasone
TAB DS PK
dexamethasone
TABLET
hydrocortisone
TABLET
methylprednisolone
TAB DS PK
methylprednisolone
TABLET
prednisolone
SOLUTION
prednisone
ORAL CONC
prednisone
SOLUTION
prednisone
TAB DS PK
prednisone
TABLET
prednisone
TABLET DR
Growth Hormones
Endocrine
somatropin (GENOTROPIN ™) *
CARTRIDGE
somatropin (GENOTROPIN ™) *
SYRINGE
somatropin (NORDITROPIN FLEXPRO ™) *
PEN INJCTR
Progestational Agents
Endocrine
hydroxyprogesterone caproat/PF (MAKENA ™) *
AUTO INJCT
medroxyprogesterone acetate
TABLET
norethindrone acetate
TABLET
progesterone, micronized
CAPSULE
Thyroid Hormone, Oral
Endocrine
levothyroxine sodium
TABLET
12
Updated: December 20, 2022
* Drug coverage subject to meeting clinical prior authorization criteria
** Drug coverage subject to quantity limits
*** Certain strengths may require Prior Authorization
‡ Age restrictions apply
Note: New drugs in classes already evaluated for the PDL shall be
non-preferred until the new drug has been reviewed by the P&T
(see OAR 410-121-0030).
System
Class
Preferred
Effective: January 1, 2023
Table 121-0030-1 Oregon Fee-for-Service Enforceable Physical Health Preferred Drug List
Vitamin D Analogs
Endocrine
calcitriol
AMPUL
calcitriol
CAPSULE
calcitriol
SOLUTION
Antacid, H. Pylori
Gastrointestinal
bismuth/metronid/tetracycline
CAPSULE
lansoprazole/amoxiciln/clarith
COMBO. PKG
Antacid, H2 Antagonists
Gastrointestinal
famotidine
TABLET
famotidine/Ca carb/mag hydrox
TAB CHEW
nizatidine
SOLUTION
ranitidine HCl
SYRUP
ranitidine HCl
TABLET
Antacid, Proton Pump
Inhibitors
Gastrointestinal
dexlansoprazole **
CAP DR BP
lansoprazole **
CAPSULE DR
omeprazole **
CAPSULE DR
pantoprazole sodium **
TABLET DR
rabeprazole sodium **
TABLET DR
Antidiarrheals
Gastrointestinal
loperamide HCl
CAPSULE
loperamide HCl
LIQUID
loperamide HCl
TABLET
Antiemetics, Conventional
Gastrointestinal
metoclopramide HCl
ORAL CONC
metoclopramide HCl
SOLUTION
metoclopramide HCl
TABLET
phosphorated carbo(dext-fruct)
SOLUTION
prochlorperazine
SUPP.RECT
prochlorperazine edisylate
SYRUP
prochlorperazine maleate
TABLET
promethazine HCl
SUPP.RECT
promethazine HCl
SYRUP
promethazine HCl
TABLET
Antiemetics, Newer
Gastrointestinal
ondansetron
TAB RAPDIS
ondansetron HCl
SOLUTION
ondansetron HCl
TABLET
Bile Therapy
Gastrointestinal
ursodiol
CAPSULE ***
ursodiol
TABLET
Hyoscyamine
Gastrointestinal
hyoscyamine sulfate
ELIXIR
hyoscyamine sulfate
TAB RAPDIS
13
Updated: December 20, 2022
* Drug coverage subject to meeting clinical prior authorization criteria
** Drug coverage subject to quantity limits
*** Certain strengths may require Prior Authorization
‡ Age restrictions apply
Note: New drugs in classes already evaluated for the PDL shall be
non-preferred until the new drug has been reviewed by the P&T
(see OAR 410-121-0030).
System
Class
Preferred
Effective: January 1, 2023
Table 121-0030-1 Oregon Fee-for-Service Enforceable Physical Health Preferred Drug List
Inflammatory Bowel Disease
Gastrointestinal
balsalazide disodium
CAPSULE
budesonide
CAPDR - ER
mesalamine
CAP ER 24H
mesalamine
SUPP.RECT
mesalamine
TABLET DR ***
olsalazine sodium
CAPSULE
sulfasalazine
TABLET
sulfasalazine
TABLET DR
14
Updated: December 20, 2022
* Drug coverage subject to meeting clinical prior authorization criteria
** Drug coverage subject to quantity limits
*** Certain strengths may require Prior Authorization
‡ Age restrictions apply
Note: New drugs in classes already evaluated for the PDL shall be
non-preferred until the new drug has been reviewed by the P&T
(see OAR 410-121-0030).
System
Class
Preferred
Effective: January 1, 2023
Table 121-0030-1 Oregon Fee-for-Service Enforceable Physical Health Preferred Drug List
Laxatives, Chronic
Constipation
Gastrointestinal
bisacodyl
TABLET
bisacodyl
TABLET DR
calcium polycarbophil
TABLET
cellulose
POWDER
docusate calcium
CAPSULE
docusate sodium
CAPSULE
docusate sodium
LIQUID
docusate sodium
SYRUP
docusate sodium
TABLET
fructooligosaccharides/polydex
LIQUID
glycerin/maltodextrin
LIQUID
guar gum
PACKET
guar gum
POWDER
inulin
TAB CHEW
lactulose
SOLUTION
magnesium citrate
SOLUTION
magnesium hydroxide
ORAL SUSP
magnesium hydroxide
TAB CHEW
methylcellulose
TABLET
methylcellulose (with sugar)
POWDER ***
polyethylene glycol 3350
POWDER
psyllium husk
CAPSULE ***
psyllium husk
POWDER
psyllium husk (with dextrose)
POWDER
psyllium husk (with sugar)
POWDER
psyllium husk/aspartame
POWD PACK
psyllium husk/aspartame
POWDER
psyllium seed
POWDER
psyllium seed (with dextrose)
PACKET
psyllium seed (with dextrose)
POWDER
psyllium seed (with sugar)
POWDER
psyllium seed/aspartame
POWDER
psyllium seed/sod bicarb
PACKET
psyllium/sucr/sacchar/dextrose
POWD PACK
senna leaf extract
SYRUP
senna/psyllium seed
GRANULES
sennosides
CAPSULE
sennosides
SYRUP
sennosides
TAB CHEW
sennosides
TABLET
sennosides/docusate sodium
TABLET
soluble corn fiber
POWDER
wheat dextrin
POWD PACK ***
wheat dextrin
POWDER
Pancreatic Enzymes
Gastrointestinal
lipase/protease/amylase (CREON ™)
CAPSULE DR
lipase/protease/amylase (ZENPEP ™)
CAPSULE DR
15
Updated: December 20, 2022
* Drug coverage subject to meeting clinical prior authorization criteria
** Drug coverage subject to quantity limits
*** Certain strengths may require Prior Authorization
‡ Age restrictions apply
Note: New drugs in classes already evaluated for the PDL shall be
non-preferred until the new drug has been reviewed by the P&T
(see OAR 410-121-0030).
System
Class
Preferred
Effective: January 1, 2023
Table 121-0030-1 Oregon Fee-for-Service Enforceable Physical Health Preferred Drug List
Benign Prostate Hypertrophy
Drugs
Genito-Urinary
doxazosin mesylate
TABLET
finasteride
TABLET
tamsulosin HCl
CAPSULE
terazosin HCl
CAPSULE
Overactive Bladder Drugs
Genito-Urinary
fesoterodine fumarate
TAB ER 24H
oxybutynin
PATCH TDSW
oxybutynin chloride
SYRUP
oxybutynin chloride
TAB ER 24
oxybutynin chloride
TABLET
solifenacin succinate
TABLET
Colony Stimulating Factors
Hematology-Oncology
filgrastim (NEUPOGEN ™)
SYRINGE
filgrastim (NEUPOGEN ™)
VIAL
pegfilgrastim-apgf
SYRINGE
sargramostim
VIAL
Erythropoetic Stimulating
Agents
Hematology-Oncology
darbepoetin alfa in polysorbat (ARANESP ™) *
SYRINGE
darbepoetin alfa in polysorbat (ARANESP ™) *
VIAL
Iron Chelators
Hematology-Oncology
deferoxamine mesylate
VIAL
Sickle Cell Disease
Hematology-Oncology
hydroxyurea
CAPSULE
Thrombocytopenia Drugs
Hematology-Oncology
eltrombopag olamine
POWD PACK
eltrombopag olamine
TABLET
romiplostim
VIAL
Biologics for Rare Conditions
Immunological
inebilizumab-cdon *
VIAL
ravulizumab-cwvz *
VIAL
satralizumab-mwge *
SYRINGE
Immunoglobulins
Immunological
GAMUNEX-C ™ - BRAND ONLY
VIAL
16
Updated: December 20, 2022
* Drug coverage subject to meeting clinical prior authorization criteria
** Drug coverage subject to quantity limits
*** Certain strengths may require Prior Authorization
‡ Age restrictions apply
Note: New drugs in classes already evaluated for the PDL shall be
non-preferred until the new drug has been reviewed by the P&T
(see OAR 410-121-0030).
System
Class
Preferred
Effective: January 1, 2023
Table 121-0030-1 Oregon Fee-for-Service Enforceable Physical Health Preferred Drug List
Immunosuppressants
Immunological
azathioprine
TABLET
cyclosporine
CAPSULE
cyclosporine
SOLUTION
cyclosporine, modified
CAPSULE
cyclosporine, modified
SOLUTION
everolimus
TABLET
mycophenolate mofetil
CAPSULE
mycophenolate mofetil
SUSP RECON
mycophenolate mofetil
TABLET
mycophenolate sodium
TABLET DR
sirolimus
SOLUTION
sirolimus
TABLET
tacrolimus
CAP ER 24H
tacrolimus
CAPSULE
tacrolimus
GRAN PACK
tacrolimus
TAB ER 24H
Targeted Immune Modulators
Immunological
adalimumab (HUMIRA ™) *
SYRINGEKIT
adalimumab (HUMIRA PEN ™) *
PEN IJ KIT
adalimumab (HUMIRA PEN CROHN'S-UC-HS ™) *
PEN IJ KIT
adalimumab (HUMIRA PEN PSOR-UVEITS-ADOL HS ™) *
PEN IJ KIT
adalimumab (HUMIRA(CF) ™) *
SYRINGEKIT
adalimumab (HUMIRA(CF) PEDIATRIC CROHN'S ™) *
SYRINGEKIT
adalimumab (HUMIRA(CF) PEN ™) *
PEN IJ KIT
adalimumab (HUMIRA(CF) PEN CROHN'S-UC-HS ™) *
PEN IJ KIT
adalimumab (HUMIRA(CF) PEN PEDIATRIC UC ™) *
PEN IJ KIT
adalimumab (HUMIRA(CF) PEN PSOR-UV-ADOL HS ™) *
PEN IJ KIT
etanercept (ENBREL ™) *
SYRINGE
etanercept (ENBREL ™) *
VIAL
etanercept (ENBREL MINI ™) *
CARTRIDGE
etanercept (ENBREL SURECLICK ™) *
PEN INJCTR
secukinumab (COSENTYX (2 SYRINGES) ™) *
SYRINGE
secukinumab (COSENTYX PEN ™) *
PEN INJCTR
secukinumab (COSENTYX PEN (2 PENS) ™) *
PEN INJCTR
secukinumab (COSENTYX SYRINGE ™) *
SYRINGE
Lysosomal Storage Disorders
Metabolic Disorders
taliglucerase alfa *
VIAL
17
Updated: December 20, 2022
* Drug coverage subject to meeting clinical prior authorization criteria
** Drug coverage subject to quantity limits
*** Certain strengths may require Prior Authorization
‡ Age restrictions apply
Note: New drugs in classes already evaluated for the PDL shall be
non-preferred until the new drug has been reviewed by the P&T
(see OAR 410-121-0030).
System
Class
Preferred
Effective: January 1, 2023
Table 121-0030-1 Oregon Fee-for-Service Enforceable Physical Health Preferred Drug List
Alzheimer's Disease Drugs
Neurology
donepezil HCl
TAB RAPDIS
donepezil HCl
TABLET
galantamine HBr
CAP24H PEL
galantamine HBr
TABLET
memantine HCl
CAP SPR 24
memantine HCl
SOLUTION
memantine HCl
TAB DS PK
memantine HCl
TABLET
memantine HCl/donepezil HCl
CAP SPR 24
memantine HCl/donepezil HCl
CAP24 DSPK
rivastigmine
PATCH TD24
rivastigmine tartrate
CAPSULE
Antiepileptics, Outpatient
Neurology
carbamazepine
ORAL SUSP
carbamazepine
TAB CHEW
carbamazepine
TAB ER 12H
carbamazepine
TABLET
diazepam
KIT
diazepam (VALTOCO ™)
SPRAY
ethosuximide
CAPSULE
ethosuximide
SOLUTION
gabapentin
CAPSULE
gabapentin
TABLET
lacosamide
TABLET
levetiracetam
SOLUTION
levetiracetam
TABLET
methsuximide
CAPSULE
midazolam (NAYZILAM ™)
SPRAY
oxcarbazepine
ORAL SUSP
oxcarbazepine
TABLET
phenobarbital
ELIXIR ***
phenobarbital
TABLET
phenytoin
ORAL SUSP
phenytoin
TAB CHEW
phenytoin sodium extended
CAPSULE
primidone
TABLET
rufinamide
TABLET
tiagabine HCl
TABLET
topiramate
TABLET
zonisamide
CAPSULE
18
Updated: December 20, 2022
* Drug coverage subject to meeting clinical prior authorization criteria
** Drug coverage subject to quantity limits
*** Certain strengths may require Prior Authorization
‡ Age restrictions apply
Note: New drugs in classes already evaluated for the PDL shall be
non-preferred until the new drug has been reviewed by the P&T
(see OAR 410-121-0030).
System
Class
Preferred
Effective: January 1, 2023
Table 121-0030-1 Oregon Fee-for-Service Enforceable Physical Health Preferred Drug List
Multiple Sclerosis
Neurology
COPAXONE ™ - BRAND ONLY
SYRINGE ***
interferon beta-1a
PEN IJ KIT
interferon beta-1a
SYRINGE
interferon beta-1a
SYRINGEKIT
interferon beta-1a/albumin
PEN INJCTR
interferon beta-1a/albumin
SYRINGE
interferon beta-1b
KIT
peginterferon beta-1a (PLEGRIDY ™) *
SYRINGE
peginterferon beta-1a (PLEGRIDY PEN ™) *
PEN INJCTR
Parkinson's Disease Drugs,
Oral & Topical
Neurology
amantadine HCl
CAPSULE
amantadine HCl
TABLET
benztropine mesylate
TABLET
carbidopa/levodopa
TABLET
carbidopa/levodopa
TABLET ER
carbidopa/levodopa/entacapone
TABLET
entacapone
TABLET
pramipexole di-HCl
TABLET
selegiline HCl
CAPSULE
trihexyphenidyl HCl
SOLUTION
trihexyphenidyl HCl
TABLET
Potassium Channel Blockers
Neurology
amifampridine *
TABLET
Spinal Muscular Atrophy
Neurology
onasemnogene abeparvovec-xioi (ZOLGENSMA ™) *
KIT
B-vitamins, Oral
Nutritional
cyanocobalamin (vitamin B-12)
TABLET ***
pyridoxine HCl (vitamin B6)
TABLET
thiamine HCl
TABLET ***
thiamine mononitrate (vit B1)
TABLET
Calcium/Vit D Replacement,
Oral
Nutritional
calcium carbonate
ORAL SUSP
calcium carbonate
TABLET
calcium carbonate/vitamin D3
TAB CHEW
calcium carbonate/vitamin D3
TABLET ***
cholecalciferol (vitamin D3)
CAPSULE ***
cholecalciferol (vitamin D3)
DROPS ***
cholecalciferol (vitamin D3)
TABLET ***
ergocalciferol (vitamin D2)
CAPSULE ***
Iron Replacement, Oral
Nutritional
ferrous gluconate
TABLET ***
ferrous sulfate
LIQUID
ferrous sulfate
TABLET
ferrous sulfate
TABLET DR
ferrous sulfate
TABLET ER ***
Magnesium Replacement,
Oral
Nutritional
magnesium
TABLET
magnesium oxide/vit B6
TABLET
19
Updated: December 20, 2022
* Drug coverage subject to meeting clinical prior authorization criteria
** Drug coverage subject to quantity limits
*** Certain strengths may require Prior Authorization
‡ Age restrictions apply
Note: New drugs in classes already evaluated for the PDL shall be
non-preferred until the new drug has been reviewed by the P&T
(see OAR 410-121-0030).
System
Class
Preferred
Effective: January 1, 2023
Table 121-0030-1 Oregon Fee-for-Service Enforceable Physical Health Preferred Drug List
Multivitamins, Oral
Nutritional
beta-carotene(A)-vits C,E/mins *
TABLET
folic acid/vit B complex and C *
TABLET
multivit 38/folate no.6/ginger *
TABLET
multivit 47/iron/folate 1/dha *
CAPSULE
multivit no.40/iron/folat1/dha *
CAPSULE
multivit no.42/iron/folate/dha *
CAPSULE
multivit no.48/iron fum/FA/dha *
CAPSULE
multivit with minerals/lutein *
TABLET
multivit37/iron/Lmfolate/algal *
CAPSULE
multivit41/iron/folate8/ps-dha *
CAP IR DR
multivitamin *
TABLET
multivitamin no.36/folate no.6 *
TAB CHEW
multivitamin,therapeutic *
TABLET
multivitamin/iron/folic acid *
TABLET
multivit-min/FA/lycopen/lutein *
TABLET
multivit-min69/iron/folic acid *
TABLET
mv-min 51/folic acid/vit K/ubi *
TAB CHEW
mv-mins 71/iron/folic no.1/dha *
CAPSULE
mvn no.53/iron/folic/dss/dha *
CAPSULE
mvn-min 74/iron fum/iron/FA *
CAPSULE
mvn-min75/iron/iron ps/om3/dha *
CAPSULE
vitamin B complex *
CAPSULE
Potassium and K-Phos, Oral
Nutritional
potassium
TABLET
potassium bicarbonate/cit ac
TABLET EFF ***
potassium chloride
TAB ER PRT
potassium chloride
TABLET ER
potassium phosphate,monobasic
TABLET SOL
sod phos di, mono/K phos mono
TABLET
sod phos,m-b/K phos,monob
TABLET
sodium,potassium phosphates
POWD PACK
20
Updated: December 20, 2022
* Drug coverage subject to meeting clinical prior authorization criteria
** Drug coverage subject to quantity limits
*** Certain strengths may require Prior Authorization
‡ Age restrictions apply
Note: New drugs in classes already evaluated for the PDL shall be
non-preferred until the new drug has been reviewed by the P&T
(see OAR 410-121-0030).
System
Class
Preferred
Effective: January 1, 2023
Table 121-0030-1 Oregon Fee-for-Service Enforceable Physical Health Preferred Drug List
Prenatal Vitamins
Nutritional
PNV 11/iron fum/folic acid/om3
CAPSULE
PNV 119/iron fum/folic acid
TABLET
PNV 30/iron carb,ag/folic/om3
CAPSULE
PNV 66/iron/folic/docusate/dha
CAPSULE
PNV 67/iron ps/folate no.1/dha
CAPSULE
PNV 69/iron/folic/docusate/dha
CAPSULE
PNV 76/iron,gluc/folic/dss/dha
COMBO. PKG
PNV 80/iron fum/folic/dss/dha
CAPSULE
PNV 85/iron/folic/dha/fish oil
CAPSULE
PNV cmb 52/iron/FA/omega-3/dha
COMBO. PKG
PNV no.118/iron fumarate/FA
TAB CHEW
PNV w-CA8/iron/FA/Lmefolate Ca
TABLET
PNV,Ca42/iron/FA/Lmefolate/dha
CAPSULE
PNV,calcium 72/iron/folic acid
TABLET
PNV/iron fum,b-g/folic acid
TABLET
PNV/iron ps cplx/folic acid
TABLET
PNV59/iron,carb,fum/FA/dss/dha
CAPSULE
PNV72/iron,gluc/folic/dss/dha
COMBO. PKG
PNV73/iron,gluc/folic/dss/dha
COMBO. PKG
PNV83/iron,carb,asp/folic acid
TABLET
prenatal 114/iron a-g/folate 1
TABLET
prenatal 118/iron/folate 6/dha
CAPSULE
prenatal 26/iron ps/folic/dha
CAPSULE
prenatal 59/iron/folic/dss/dha
CAPSULE
prenatal 78/iron/folate 1/dha
CAPSULE
prenatal 87/iron bis/folic/dha
COMBO. PKG
prenatal no.52/iron/FA/dha
CAPSULE
prenatal no.75/iron/folate no1
TABLET
prenatal no.77/iron asp gly/FA
TABLET
prenatal no13/iron ps/folate 1
TAB CHEW
prenatal vit 10/iron fum/folic
TABLET
prenatal vit 10/iron/folic/dha
COMBO. PKG
prenatal vit 14/iron fum/folic
TAB CHEW
prenatal vit 33/iron/folic/dha
COMBO. PKG
prenatal vit 85/iron/FA 1/dha
CAPSULE
prenatal vit 87/iron/folic/dha
CAPSULE
prenatal vit,calc76/iron/folic
TABLET
prenatal vit,calc78/iron/folic
TABLET
prenatal vit/iron carb&sulf/FA
TABLET
prenatal vit/iron fum/folic ac
TABLET
prenatal vit103/iron fum/folic
TABLET
prenatal vit128/iron/folic acd
TAB CHEW
prenatal vit136/iron/folic acd
TABLET
prenatal vit27,calcium/iron/FA
TABLET
prenatal vit68/iron/FA no6/dha
CAPSULE
prenatal vit69/iron/folate6/dh
CAPSULE
prenatal vit86/iron/folic acid
TABLET
prenatal,calc.40/iron/folate 1
TABLET
prenatal56/iron/folic acid/dha
CAPSULE
Pv w-o Vit A/iron/docus/FA/Zn
CAP SEQ
21
Updated: December 20, 2022
* Drug coverage subject to meeting clinical prior authorization criteria
** Drug coverage subject to quantity limits
*** Certain strengths may require Prior Authorization
‡ Age restrictions apply
Note: New drugs in classes already evaluated for the PDL shall be
non-preferred until the new drug has been reviewed by the P&T
(see OAR 410-121-0030).
System
Class
Preferred
Effective: January 1, 2023
Table 121-0030-1 Oregon Fee-for-Service Enforceable Physical Health Preferred Drug List
Prenatal Vitamins
Nutritional
Antibiotics, Ophthalmic
Ophthalmics
bacitracin/polymyxin B sulfate
OINT. (G)
ciprofloxacin HCl
DROPS
ciprofloxacin HCl
OINT. (G)
erythromycin base
OINT. (G)
gentamicin sulfate
DROPS
gentamicin sulfate
OINT. (G)
moxifloxacin HCl
DROPS
natamycin
DROPS SUSP
neomycin/polymyxn B/gramicidin
DROPS
ofloxacin
DROPS
polymyxin B sulf/trimethoprim
DROPS
sulfacetamide sodium
DROPS
tobramycin
DROPS
tobramycin
OINT. (G)
Antibiotic-Steroids,
Ophthalmic
Ophthalmics
gentamicin sulf/prednisolone
OINT. (G)
neomycin/polymyxin B/dexametha
DROPS SUSP
neomycin/polymyxin B/dexametha
OINT. (G)
sulfacetamide/prednisolone
OINT. (G)
tobramycin/dexamethasone
DROPS SUSP
tobramycin/dexamethasone
OINT. (G)
Anti-Inflammatory Drugs,
Ophthalmic
Ophthalmics
dexamethasone
DROPS SUSP
dexamethasone sodium phosphate
DROPS
diclofenac sodium
DROPS ***
fluorometholone
DROPS SUSP
fluorometholone
OINT. (G)
flurbiprofen sodium
DROPS
ketorolac tromethamine
DROPS
loteprednol etabonate
DROPS SUSP
prednisolone acetate
DROPS SUSP
Glaucoma Drugs
Ophthalmics
betaxolol HCl
DROPS
brimonidine tartrate
DROPS ***
brinzolamide
DROPS SUSP
carteolol HCl
DROPS
dorzolamide HCl/timolol maleat
DROPS
dorzolamide/timolol/PF
DROPERETTE
latanoprost
DROPS
latanoprost
DRPS EMULS
pilocarpine HCl
DROPS
timolol maleate
DROPS
travoprost
DROPS
Vascular Endothelial Growth
Factors
Ophthalmics
bevacizumab
VIAL
22
Updated: December 20, 2022
* Drug coverage subject to meeting clinical prior authorization criteria
** Drug coverage subject to quantity limits
*** Certain strengths may require Prior Authorization
‡ Age restrictions apply
Note: New drugs in classes already evaluated for the PDL shall be
non-preferred until the new drug has been reviewed by the P&T
(see OAR 410-121-0030).
System
Class
Preferred
Effective: January 1, 2023
Table 121-0030-1 Oregon Fee-for-Service Enforceable Physical Health Preferred Drug List
Otic Antibiotics
Otics
neomyc/colist/hydrocort/thonzn
DROPS SUSP
neomycin/polymyxin B/hydrocort
DROPS SUSP ***
ofloxacin
DROPS
ADHD Drugs
Psychiatric
CONCERTA ™ - BRAND ONLY ** ‡
TAB ER 24
dexmethylphenidate HCl ** ‡
CPBP 50-50
dexmethylphenidate HCl ** ‡
TABLET
dextroamphetamine/amphetamine ** ‡
CAP ER 24H
dextroamphetamine/amphetamine ** ‡
TABLET
lisdexamfetamine dimesylate ** ‡
CAPSULE
lisdexamfetamine dimesylate ** ‡
TAB CHEW
methylphenidate ** ‡
PATCH TD24
METHYLPHENIDATE ER ™ - BRAND ONLY ** ‡
TAB ER 24
methylphenidate HCl ** ‡
CPBP 30-70
methylphenidate HCl ** ‡
TABLET
Benzodiazepines
Psychiatric
clonazepam **
TABLET
Opioid Reversal Agents
Psychiatric
naloxone HCl
AMPUL
naloxone HCl
SPRAY
naloxone HCl
SYRINGE
naloxone HCl
VIAL
Sedatives
Psychiatric
melatonin *
TABLET
zolpidem tartrate *
TABLET
Substance Use Disorders,
Opioid & Alcohol
Psychiatric
acamprosate calcium
TABLET DR
buprenorphine (SUBLOCADE ™)
SOLER SYR
buprenorphine HCl/naloxone HCl (ZUBSOLV ™) **
TAB SUBL
buprenorphine HCl/naloxone HCl **
FILM
buprenorphine HCl/naloxone HCl **
TAB SUBL
naltrexone HCl
TABLET
naltrexone microspheres (VIVITROL ™)
SUS ER REC
Tobacco Smoking Cessation
Psychiatric
bupropion HCl
TAB ER 12H
nicotine
PATCH DYSQ
nicotine
PATCH TD24
nicotine polacrilex
GUM
nicotine polacrilex
LOZENGE
nicotine polacrilex
LOZNG MINI
varenicline tartrate ‡
TAB DS PK
varenicline tartrate ‡
TABLET
Anticholinergics, Inhaled
Pulmonary
ipratropium bromide
HFA AER AD
ipratropium bromide
SOLUTION
ipratropium/albuterol sulfate
AMPUL-NEB
tiotropium bromide
CAP W/DEV
tiotropium bromide
MIST INHAL
umeclidinium bromide
BLST W/DEV
23
Updated: December 20, 2022
* Drug coverage subject to meeting clinical prior authorization criteria
** Drug coverage subject to quantity limits
*** Certain strengths may require Prior Authorization
‡ Age restrictions apply
Note: New drugs in classes already evaluated for the PDL shall be
non-preferred until the new drug has been reviewed by the P&T
(see OAR 410-121-0030).
System
Class
Preferred
Effective: January 1, 2023
Table 121-0030-1 Oregon Fee-for-Service Enforceable Physical Health Preferred Drug List
Beta-Agonists, Inhaled Long
Acting
Pulmonary
salmeterol xinafoate
BLST W/DEV
Beta-Agonists, Inhaled Short-
Acting
Pulmonary
albuterol sulfate
HFA AER AD
albuterol sulfate
SOLUTION
albuterol sulfate
VIAL-NEB
Corticosteroids, Inhaled
Pulmonary
budesonide
AER POW BA
fluticasone propionate
AER W/ADAP
fluticasone propionate
BLST W/DEV
mometasone furoate
AER POW BA
Corticosteroids/LABA
Combination, Inhaled
Pulmonary
budesonide/formoterol fumarate
HFA AER AD
fluticasone propion/salmeterol
AER POW BA
fluticasone propion/salmeterol
BLST W/DEV
fluticasone propion/salmeterol
HFA AER AD
mometasone/formoterol
HFA AER AD
Cystic Fibrosis
Pulmonary
dornase alfa
SOLUTION
sodium chloride for inhalation
VIAL-NEB
tobramycin in 0.225% sod chlor
AMPUL-NEB
LAMA/LABA Combination,
Inhalers
Pulmonary
tiotropium Br/olodaterol HCl (STIOLTO RESPIMAT ™) *
MIST INHAL
umeclidinium brm/vilanterol tr *
BLST W/DEV
Miscellaneous Pulmonary
Agents
Pulmonary
montelukast sodium
TAB CHEW
montelukast sodium
TABLET
Pulmonary Arterial
Hypertension Oral and
Inhaled Drugs
Pulmonary
bosentan
TABLET
sildenafil citrate
TABLET ***
Pulmonary Arterial
Hypertension Parenteral
Pulmonary
epoprostenol sodium (glycine)
VIAL
Phosphate Binders
Renal
calcium acetate
CAPSULE
calcium acetate
TABLET ***
sevelamer carbonate
TABLET
sevelamer HCl
TABLET
24
Updated: December 20, 2022
* Drug coverage subject to meeting clinical prior authorization criteria
** Drug coverage subject to quantity limits
*** Certain strengths may require Prior Authorization
‡ Age restrictions apply
Note: New drugs in classes already evaluated for the PDL shall be
non-preferred until the new drug has been reviewed by the P&T
(see OAR 410-121-0030).
System
Class
Preferred
Effective: January 1, 2023
Table 121-0030-1 Oregon Fee-for-Service Voluntary Mental Health Preferred Drug List
Antiepileptics, Outpatient
Neurology
divalproex sodium
CAP DR SPR
divalproex sodium
TAB ER 24H
divalproex sodium
TABLET DR
lamotrigine
TABLET
valproic acid
CAPSULE
valproic acid (as sodium salt)
SOLUTION
Other Stimulants
Neurology
armodafinil *
TABLET
modafinil *
TABLET
ADHD Drugs
Psychiatric
atomoxetine HCl ** ‡
CAPSULE
viloxazine HCl (QELBREE ™) ** ‡
CAP ER 24H
Antidepressants
Psychiatric
amitriptyline HCl ‡
TABLET
bupropion HCl
TAB ER 24H
bupropion HCl
TAB SR 12H
bupropion HCl
TABLET
citalopram hydrobromide
SOLUTION
citalopram hydrobromide
TABLET
desipramine HCl ‡
TABLET
desvenlafaxine succinate
TAB ER 24H
doxepin HCl ‡
CAPSULE
doxepin HCl ‡
ORAL CONC
duloxetine HCl
CAPSULE DR
escitalopram oxalate
TABLET
fluoxetine HCl
CAPSULE
fluoxetine HCl
SOLUTION
fluoxetine HCl
TABLET
fluvoxamine maleate
TABLET
imipramine HCl ‡
TABLET
mirtazapine
TAB RAPDIS
mirtazapine
TABLET
nortriptyline HCl ‡
CAPSULE
nortriptyline HCl ‡
SOLUTION
paroxetine HCl
TABLET
protriptyline HCl ‡
TABLET
sertraline HCl
ORAL CONC
sertraline HCl
TABLET
trimipramine maleate ‡
CAPSULE
venlafaxine HCl
CAP ER 24H
venlafaxine HCl
TABLET
25
Updated: December 20, 2022
* Drug coverage subject to meeting clinical prior authorization criteria
** Drug coverage subject to quantity limits
*** Certain strengths may require Prior Authorization
‡ Age restrictions apply
Note: New drugs in classes already evaluated for the PDL shall be
non-preferred until the new drug has been reviewed by the P&T
(see OAR 410-121-0030).
System
Class
Preferred
Effective: January 1, 2023
Table 121-0030-1 Oregon Fee-for-Service Voluntary Mental Health Preferred Drug List
Antipsychotics, 1st Gen
Psychiatric
chlorpromazine HCl ‡
ORAL CONC
fluphenazine HCl ‡
ELIXIR
fluphenazine HCl ‡
ORAL CONC
fluphenazine HCl ‡
TABLET
haloperidol ‡
TABLET
haloperidol lactate ‡
ORAL CONC
loxapine succinate ‡
CAPSULE
perphenazine ‡
TABLET
thioridazine HCl ‡
ORAL CONC
thioridazine HCl ‡
TABLET
thiothixene ‡
CAPSULE
thiothixene HCl ‡
ORAL CONC
trifluoperazine HCl ‡
TABLET
Antipsychotics, 2nd Gen
Psychiatric
aripiprazole ‡
TABLET
asenapine maleate ‡
TAB SUBL
cariprazine HCl (VRAYLAR ™) ‡
CAP DS PK
cariprazine HCl (VRAYLAR ™) ‡
CAPSULE
clozapine ‡
TABLET
lurasidone HCl (LATUDA ™) ‡
TABLET
olanzapine ‡
TABLET
quetiapine fumarate ** ‡
TABLET
risperidone ‡
SOLUTION
risperidone ‡
TABLET
ziprasidone HCl ‡
CAPSULE
Antipsychotics, Parenteral
Psychiatric
aripiprazole (ABILIFY MAINTENA ™)
SUSER SYR
aripiprazole (ABILIFY MAINTENA ™)
SUSER VIAL
aripiprazole lauroxil (ARISTADA ™)
SUSER SYR
aripiprazole lauroxil,submicr. (ARISTADA INITIO ™)
SUSER SYR
chlorpromazine HCl
AMPUL
fluphenazine decanoate
VIAL
fluphenazine HCl
VIAL
haloperidol decanoate
AMPUL
haloperidol decanoate
VIAL
haloperidol lactate
SYRINGE
haloperidol lactate
VIAL
paliperidone palmitate (INVEGA HAFYERA ™)
SYRINGE
paliperidone palmitate (INVEGA SUSTENNA ™)
SYRINGE
paliperidone palmitate (INVEGA TRINZA ™)
SYRINGE
risperidone (PERSERIS ™)
SUSER SYR
risperidone microspheres **
VIAL
26
Updated: December 20, 2022
* Drug coverage subject to meeting clinical prior authorization criteria
** Drug coverage subject to quantity limits
*** Certain strengths may require Prior Authorization
‡ Age restrictions apply
Note: New drugs in classes already evaluated for the PDL shall be
non-preferred until the new drug has been reviewed by the P&T
(see OAR 410-121-0030).
