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Wisconsin Medicaid, BadgerCare Plus Standard, and SeniorCare Preferred Drug List – Quick Reference(Effective 01/01/2021)KEY:All lowercase letters generic productLeading capital letter brand name productP Preferred productNP Non-preferred product (requires PA)Uses PA/PDLExemption Form available via STAT-PAor Paper PA processUses PA/DGAForm/Sec. VIPaper PA process onlyRefer to topic #15937DR Diagnosis RestrictionDAPO Prior Authorization processed through DrugAuthorization and Policy Override centerBrand BeforeGeneric DrugRefer to topic #20077Uses specific Drug PAForm - available viaSTAT-PA orPaper PA processUses specific Drug PAForm - available viaPaper PA process onlyUses PA/DGAForm/Sec. VIIPaper PA process onlyRefer to topic #15937Monthly Changesto the PDL SCN Wisconsin SeniorCare does not cover over-the-counter drugs. For Levels 2b and 3, SeniorCare does not cover drugs that do not have a signed SeniorCare Rebate Agreementbetween the manufacturer and the Department of Health Services. Providers may refer to the Numeric Listing of Manufacturers That Have Signed Rebate Agreements data table onthe Pharmacy page of the Providers area of the Portal. Providers may refer to the data tables on the Pharmacy page of the Providers area of the Portal for more tm.spage Prior Authorization forms are available ?panel Forms

Wisconsin Medicaid, BadgerCare Plus Standard, and SeniorCare Preferred Drug List – Quick Reference(Effective 01/01/2021)Acne Agents, Topicalbenzoyl peroxide OTC 2.5%,SCN5%, 10%clindamycin/benzoyl peroxide(Gen-Duac)clindamycin gel (Gen-Cleocin T)clindamycin solutionerythromycin solutionsodium sulfacetamide-sulfurcleanser, wash, suspensionDifferin 0.1% cream, lotionSCNDifferin 0.3% gel pumpSCNEpiduoSCNRetin-A (not micro)NOTE: Topical federal legend acne drugsnot listed are either non-preferred ornoncovered.Alzheimer’s Agentsdonepezil 5mg,10mgdonepezil ODT 5mg,10mgmemantine solution,tablet, titration pack*rivastigmine capsExelon patchdonepezil 23mggalantamine tabletsgalantamine ER capsgalantamine solutionmemantine ER capsDR(Gen-Namenda XR)*rivastigmine patchNamzaric capsuleNamzaric dose pack*memantine products are not covered formembers 17 years of age or youngerAnalgesics/Anesthetics, Topicalcapsaicin OTCSCNdiclofenac 1% gel(Gen-Voltaren RX)diclofenac sodium 1% gel OTC(Gen-Voltaren OTC)lidocaine 5% ointmentlidocaine 5% trans patchUses PA/PDLExemption Form available via STAT-PAor Paper PA esics/Anesthetics, Topical (cont)diclofenac 1.3% patch(Gen-Flector)diclofenac 1.5% solution(Gen-Pennsaid)FlectorLicart patchSCNPennsaidSCNZtlidoSCNAnalgesics, MiscellaneousacetaminophenSCNaspirinSCNibuprofen OTC chewable,SCNsuspension, tabletsnaproxen EsgicAnalgesics, Opioids Long-Actingfentanyl transdermal 12mcg,25mcg, 50mcg, 75mcg, 100mcgmorphine ER tabletstramadol ER tab(Gen-Ultram ER)Butrans transdermalEmbeda ERHysingla ERbuprenorphine transdermalfentanyl transdermal 37.5mcg,62.5mcg, 87.5mcghydrocodone ER(Gen-Zohydro ER)hydromorphone ERmethadone tablet, solutionmorphine ER capsulesoxycodone ERoxymorphone ERtramadol ER cap (Gen-Conzip)SCNtramadol ER tab (Gen-Ryzolt)Uses PA/DGAForm/Sec. VIPaper PA process onlyRefer to topic #15937Brand BeforeGeneric DrugRefer to topic NPNPNPNPNPNPNPAnalgesics, Opioids Long-Acting (cont)Arymo ERSCNBelbuca FilmConzipSCNExalgo ERKadianMorphabond ERNucynta EROxycontinXartemis XRXtampza ERSCNZohydro ERSCNAnalgesics, Opioids drocodone/apap 325mghydrocodone/ibuprofenmorphineoxycodone solution, tabletsoxycodone/apap 325mgtramadol 50mg tabtramadol/apap 325mgbenzhydrocodone/apap tabbutorphanol morphone liquid, xycodone capsules, ne/naloxonetramadol 100mg tabCapital w-codeineDilaudid LiquidIbudoneNalocetSCNNucyntaUses specific Drug PAForm - available viaSTAT-PA orPaper PA processUses specific Drug PAForm - availablevia Paper PAprocess NPNPNPNPNPNPNPNPNPNPNPNPNPNPAnalgesics, Opioids Short-Acting Synalgos-DCNPVicodin 5/300NPVicodin 7.5/300NPVicodin 10/300NPXodolNPZamicetNP*Combination products containing any otherstrength of apap besides 325 mg.Analgesics, Opioids Short-Acting – FentanylMucosal Agentsfentanyl citrate oral SCNNPSubsysSCNNPAndrogenic Agentstestosterone gel, pumpP(Gen-Vogelxo)Androgel gel, pumpPtestosterone gel, pumpNP(Gen-Androgel)testosterone gel (Gen-Testim)SCNNPtestosterone pumpNP(Gen-Axiron and Fortesta)AndrodermNPAxironNPFortestaNPNatesto nasal spraySCNNPTestimSCNNPVogelxoNPAndrogenic Agents, Injectabletestosterone cypionate*Ptestosterone enanthate*PDepo-testosterone*PXyostedNP* Policy for obtaining provider-administered drugsapplies. Refer to topic #5697.Uses PA/DGAForm/Sec. VIIPaper PA process onlyRefer to topic #15937Page 2 of 13Monthly Changesto the PDL

Wisconsin Medicaid, BadgerCare Plus Standard, and SeniorCare Preferred Drug List – Quick Reference(Effective 01/01/2021)Angiotensin Modulators, ACE ilPbenazepril/HCTZNPcaptopril/HCTZSCN Epaned *SCN NPQbrelis solutionSCN NPPrestaliaSCN NP*Prior Authorization is not required for members12 years of age and younger.Angiotensin Modulators, ARBs and /HCTZPEntrestoPaliskiren tabs (Gen-Tekturna)SCNNPcandesartan tabletsNPcandesartan/HCTZNPeprosartan rNPBenicar/HCTZNPEdarbiNPEdarbyclorNPAngiotensin Modulators, ARBs and TZAngiotensin Modulators, nstaAntibiotics, Beta-Lactamamoxicillinamoxicillin clavulanateamoxicillin clavulanate 250mgsuspensionampicillincefaclor capscefadroxil caps, suspcefdinircefprozilSCNcefuroximecephalexin caps, suspcephalexin 750mgSCNdicloxacillinpenicillinAugmentin 125mg suspCeftin 125mg, 250mg suspSCNSuprax caps, chew tab, tabs,SCNsuspamoxicillin clavulanate XRcefaclor suspSCNcefaclor tab ERcefadroxil tabletcefixime capsuleSCNcefixime PPPNPNPNPNPNPNPAntibiotics, Beta-Lactam (cont)cefpodoximecephalexin tabsDaxbiaSpectracefAntibiotics, GImetronidazole tabletsneomycintinidazolevancomycin capsuleFirvanq 50mg/mlXifaxanmetronidazole capsuleDificid tablet, suspensionFlagyl ERSolosecvancomycin 50mg/ml(Gen-Firvanq)Antibiotics, InhaledBethkisKitabis Paktobramycin (Gen-Tobi)tobramycin (Gen-Bethkis)CaystonTobiTobi PodhalerAntibiotics, Macrolides/Ketolidesazithromycinclarithromycin susp, tableterythromycin capsule, tablet,granule, suspensionE.E.S. filmtab, granulesErypedEry-Tab DRErythrocinPCEclarithromycin ER taberythromycin filmtabAntibiotics, Tetracyclinesdoxycycline hyclate capsuledoxycycline hyclate 20mg tabsdoxycycline monohydrate50mg, 100mg capsulesdoxycycline monohydrate PNPNPSCNPPPPPPPPNPNPPPPPAntibiotics, Tetracyclines (cont)minocycline capsdemeclocyclinedoxycycline hyclate DRdoxycycline hyclate tabsdoxycycline monohydrate suspdoxycycline monohydrate 75mg,150mg capsulesminocycline tabsminocycline ER (Gen-Solodyn)tetracyclineDoryx DRMinolira ERMorgidox capsNuzyraOraceaSolodyn ER 55mg, 65mg, 80mg,105mg, 115mgVibramycin syrup, suspensionXimino ERAntibiotics, Topicalbacitracin ointment OTCbacitracin/polymyxin B oint.OTCmupirocin ointmentneomycin/bacitracin zinc/polymyxin B oint OTCneomycin/bacitracin zinc/polymyxin B/pramoxine oint.OTCgentamicin cream, ointmentmupirocin creamBactroban nasalCentanyXepi 1% creamAntibiotics, VaginalclindamycinCleocin NPPPPPNPPPage 3 of 13Uses PA/PDLExemption Form available via STAT-PAor Paper PA processUses PA/DGAForm/Sec. VIPaper PA process onlyRefer to topic #15937Brand BeforeGeneric DrugRefer to topic #20077Uses specific Drug PAForm - available viaSTAT-PA orPaper PA processUses specific Drug PAForm - availablevia Paper PAprocess onlyUses PA/DGAForm/Sec. VIIPaper PA process onlyRefer to topic #15937Monthly Changesto the PDL

Wisconsin Medicaid, BadgerCare Plus Standard, and SeniorCare Preferred Drug List – Quick Reference(Effective 01/01/2021)Anticoagulants (cont)warfarinEliquisEliquis Dose PackPradaxaXareltoXarelto Dose tscarbamazepine chew tabsclobazam susp, tabsclonazepam tabletsdiazepam rectaldivalproex tabletsdivalproex ER tabletsethosuximidegabapentin caps, tabslamotrigine tabletslamotrigine dispertabslamotrigine Dose Pklamotrigine ER tabletslevetiracetam solution, tabslevetiracetam ER tabsoxcarbazepineoxcarbazepine suspensionphenobarbitalphenytoinpregabalin (Gen-Lyrica)primidonetopiramatetopiramate sprinklevalproic acidzonisamideCarbatrol ERCelontinDepakote sprinkleDilantin 30mg capDilantin InfatabEpidiolexDRFelbatol suspension, tabletGabitrilUses PA/PDLExemption Form available via STAT-PAor Paper PA PPPPPPPPPPPPAnticonvulsants (cont)Lamictal Starter KitsPeganoneRoweepraSabrilTegretol tabTegretol suspensionTegretol XRcarbamazepine suspension,tabletscarbamazepine ER caps, tabsclonazepam ODTdivalproex sprinklefelbamate suspension, tabletlamotrigine ODTrufinamide suspension(Gen-Banzel)tiagabinetopiramate oFinteplaDRFycompaLamictal ODTLamictal ODT Starter KitLamictal XRLamictal XR Starter KitNayzilam nasal sprayOxtellar XRPhenytekQudexySpritamSympazanDRTrileptal suspensionTrokendi XRValtoco nasal sprayVigadroneVimpatVimpat solutionXcopriUses PA/DGAForm/Sec. VIPaper PA process onlyRefer to topic PNPNPNPNPNPNPNPNPNPNPNPNPNPNPAntidepressants, Otherbupropionbupropion SRbupropion XL (Gen-Wellbutrin)desvenlafaxine ER (Gen-Pristiq)duloxetine DR 20mg, 30mg,60mg capsmirtazapinephenelzinetranylcypromine sulfatetrazodonevenlafaxinevenlafaxine ER capsulesMarplanNardilbupropion XL (Gen-Forfivo XL)desvenlafaxine ER (No Brand)duloxetine 40mg DR capsnefazodonevenlafaxine ER tabletsAplenzin ERDrizalma sprinkle DREmsamFetzimaForfivo XLTrintellixViibrydAntidepressants, SSRIcitalopramescitalopramfluoxetine 10mg, 20mg, 40mgcapsfluoxetine solutionfluvoxamineparoxetinesertralinePaxil suspensionfluoxetine 90mg capsfluoxetine 10mg, 20mg, 60mgtabletsfluvoxamine ERparoxetine 7.5mg cap(Gen-Brisdelle)paroxetine CR (Gen-Paxil PPPPNPNPNPNPSCNNPAntidepressants, SSRI metoclopramideondansetron tablet, ODT, sol.prochlorperazine tablet,suppositorytrimethobenzamide capsEmend capsulesaprepitant capsulesmetoclopramide ODTAkynzeoAnzemetEmend Powder imenhydrinate OTCmeclizinemeclizine OTCpromethazine tablet,suppository, syrupDiclegisTransderm-Scopdoxylamine succinate /pyridoxine (Gen-Diclegis)scopolamine patchBonjestaAntiemetics, CannabinoidsdronabinolCesametAntifungals, Oralclotrimazole trochefluconazolegriseofulvin suspensiongriseofulvin ultra-micro tabsitraconazoleketoconazole PPPPPPPPPage 4 of 13Brand BeforeGeneric DrugRefer to topic #20077Uses specific Drug PAForm - available viaSTAT-PA orPaper PA processUses specific Drug PAForm - availablevia Paper PAprocess onlyUses PA/DGAForm/Sec. VIIPaper PA process onlyRefer to topic #15937Monthly Changesto the PDL

Wisconsin Medicaid, BadgerCare Plus Standard, and SeniorCare Preferred Drug List – Quick Reference(Effective 01/01/2021)Antifungals, Oral (cont)NoxafilSporanox (liquid)flucytosinegriseofulvin micro tabletsitraconazole solutionposaconazole (Gen-Noxafil)voriconazole suspension, tabAncobonCresembaGrifulvin V TabletsOravigTolsuraVfendAntifungals, Topicalciclopirox solutionclotrimazole OTCclotrimazole Rxclotrimazole/betamethasonecreamketoconazole cream, shampoomiconazole OTCnystatintolnaftate OTCAlevazolciclopirox cream, gel, shampoo,suspensionclotrimazole/betamethasone lotioneconazole nitrateketoconazole foamluliconazole creammiconazole/zinc/pet ointmentnaftifine cream, gelnystatin/triamcinoloneoxiconazole creamBensal HPErtaczoExeldermExtinaJubliaKerydinLuzu NPNPNPNPNPNPNPNPNPNPNPAntifungals, Topical (cont)OxistatSCNVusionSCNNOTE: Sprays and Kits are not covered.Antihistamines, Minimally Sedatingcetirizine syrup, tabletsSCNcetirizine DSCNlevocetirizine tabletsloratadine syrup, tabletsSCNloratadine DSCNdesloratadinedesloratadine ODTfexofenadine OTCSCNlevocetirizine solutionClarinexClarinex DSemprex-DSCNAntihypertensives, Sympatholyticsclonidine (oral)guanfacinemethyldopaCatapres-TTSclonidine trans patchmethyldopa/HCTZSCNAntiparasitics, Topicalpermethrin OTCSCNpermethrin RxEurax CreamNatrobaivermectin lotion (Gen-Sklice)malathionspinosadCrotan LotionSCNEurax LotionSCNLindaneSkliceAntiparkinson's levodopacarbidopa/levodopa ERcarbidopa/levodopa NPPPPPPPAntiparkinson’s Agents (cont)carbidopa/levodopa/entacaponecarbidopa 25mg ntacaponepramipexole ERrasagilineropinirole ERtolcaponeAzilectComtanGocovri ERInbrijaKynmobi filmNeupro patchesNourianz tabletsOngentysOsmolex ERRytary ERStalevoTasmarXadagoZelaparAntipsoriatics, OralacitretinmethoxsalenAntipsoriatics, Topicalcalcipotriene cream, ointment,solutionTaclonex e ointcalcipotriene/betamethasonedipropionate suspension(Gen-Taclonex)calcitriol ointtazarotene creamDuobrii NNPNPNPNPAntipsoriatics, Topical ole*Paripiprazole pine*Polanzapine*Polanzapine e fumarate ziprasidone capsules*PLatuda*SCNPVraylar*SCNPclozapine ODT*NPmolindone tablets*NPolanzapine/fluoxetine*NPpaliperidone ER tablets*NPthioridazine*NPAbilify o*SCNNPNuplazid*SCNNPRexulti*NPSaphris*NPSecuado patch*SCNNPSymbyax*NPVersacloz*SCNNP*PA required for children 8 years of age andyounger. Use PA Drug Attachment forAntipsychotic Drugs for Children 8 Years of Ageand Younger.Page 5 of 13Uses PA/PDLExemption Form available via STAT-PAor Paper PA processUses PA/DGAForm/Sec. VIPaper PA process onlyRefer to topic #15937Brand BeforeGeneric DrugRefer to topic #20077Uses specific Drug PAForm - available viaSTAT-PA orPaper PA processUses specific Drug PAForm - availablevia Paper PAprocess onlyUses PA/DGAForm/Sec. VIIPaper PA process onlyRefer to topic #15937Monthly Changesto the PDL

Wisconsin Medicaid, BadgerCare Plus Standard, and SeniorCare Preferred Drug List – Quick Reference(Effective 01/01/2021)Antipsychotics, Injectablefluphenazine decanoate *haloperidol decanoate*Abilify Maintena*Aristada*Aristada Initio ER*Haldol Decanoate*Invega Sustenna*Invega Trinza*Perseris ER*Risperdal Consta*Zyprexa Relprevv*ziprasidone vial*SCNSCNSCNPPPPPPPPPPPNP*Policy for obtaining provider-administered drugsapplies. Refer to topic #5697.Antivirals, NXofluzaAntivirals, OtheracyclovirvalacyclovirfamciclovirAntivirals, TopicalZovirax cream, ointmentacyclovir cream, ointmentDenavirSCNXereseAnxiolyticsalprazolam ERalprazolam intensol, tabletbuspironechlordiazepoxidediazepam solution, tabletlorazepam intensol, tabletalprazolam ODTclorazepatediazepam intensolmeprobamateoxazepamBPH Agents, Alpha Reductase InhibitorsdutasterideUses PA/PDLExemption Form available via STAT-PAor Paper PA processPPNPNPNPPPNPPNPNPNPPPPPPPNPNPNPNPNPPBPH Agents, Alpha Reductase Inhibitors (cont)finasteridePdutasteride/tamsulosinSCNNPBPH Agents, nNPsilodosin capsuleNPCardura XLNPRapafloNPBeta metoprolol ERPpropranololPpropranolol ERPsotalolPacebutololNPbetaxololNPcarvedilol ERNPmetoprolol/HCTZNPnadololNPnadolol bendroflumethiazide olicSCNNPCoreg CRSCNNPHemangeolSCNNPInderal XLNPInnopran XLNPKapspargo sprinklesNPLevatolNPLopressor HCTNPSotylizeNPBile SaltsursodiolPChenodalSCNNPUses PA/DGAForm/Sec. VIPaper PA process onlyRefer to topic #15937Brand BeforeGeneric DrugRefer to topic #20077Bile Salts (cont)CholbamOcalivaBladder Relaxant Preparationsdarifenacin ERoxybutynin tablet, ER tablet,syrupsolifenacin tabsToviaztolterodinetolterodine ERtrospiumtrospium ERDetrolDetrol LAGelniqueMyrbetriq EROxytrolBone Resorption Suppressionalendronatecalcitonin-salmon nasalibandronateForteoalendronate sodium eActonelAtelviaBinostoBonivaFosamax Plus DTymlosBronchodilators, Beta Agonistsalbuterolalbuterol ERalbuterol HFA*albuterol neb (2.5mg/0.5ml)albuterol neb (2.5mg/3ml)albuterol neb (100mg/20ml)albuterol neb low-dose(0.63mg/3ml)Uses specific Drug PAForm - available viaSTAT-PA orPaper PA dilators, Beta Agonists (cont)albuterol neb low-doseP(1.25mg/3ml)terbutaline tabletsPProair HFAPSereventSCNPVentolin HFASCNPlevalbuterol nebulizerNPlevalbuterol istSCNNPProAir DigihalerNPProAir RespiclickNPProventil HFANPStriverdi RespimatNPXopenex HFASCNNP* NOTE: Product added temporarily during thepublic health COVID-19 emergencyCalcium Channel Blocking AgentsamlodipinePdiltiazemPdiltiazem ER capsulesSCNPnifedipine ERPnifedipine IRPnimodipinePverapamil tabletsPverapamil ER tabletPverapamil SR tabletPdiltiazem ER tabletsSCNNPfelodipine amil ER capsuleSCNNPverapamil SR capsuleNPverapamil ER PMSCNNPverapamil 360mg capsuleNPCardizem LANPKaterzia suspensionSCNNPMatzim LANPNymalizeNPPage 6 of 13Uses specific Drug PAForm - availablevia Paper PAprocess onlyUses PA/DGAForm/Sec. VIIPaper PA process onlyRefer to topic #15937Monthly Changesto the PDL

Wisconsin Medicaid, BadgerCare Plus Standard, and SeniorCare Preferred Drug List – Quick Reference(Effective 01/01/2021)COPD Agentsipratropium nebulizerPipratropium/albuterol nebulizerPAnoro ElliptaSCNPAtrovent HFAPCombivent RespimatPSpirivaPStiolto RespimatPBevespi AerosphereNPBreztri Aerosphere HFANPDalirespNPDuaklir PressairSCNNPIncruse ElliptaSCNNPLonhala Ma