Molinalogo

Molina Healthcare of Nebraska (Molina) is in alignment with Nebraska Medicaid’s Preferred Drug List (PDL). The list shows all the prescription and over-the-counter products members can get from a pharmacy. Some medications require prior authorization (PA) or have limitations on age, dosage and/or quantities. Molina complies with all of Nebraska Medicaid’s criteria found within the comprehensive PDL.

Nebraska Medicaid Preferred Drug List
Formulary Searchable Tool
Medical Preferred Drug List_January 2025

Molina’s decisions are based upon the information included with the PA request. Clinical notes are recommended.

  Pharmacy Prior Authorization Form

Pharmacy Policy Update Memos

 Q3 Pharmacy Policy Memo  

 Q4 Pharmacy Policy Memo

Nebraska Medicaid Clinical Criteria

  Growth Hormone (GH)
  Hepatitis C – Effective 01/01/2024
  Insulin-like Growth Factor (IFG) for Children

 

Molina Medicaid Clinical Criteria

  Abilify MyCite Kit (aripiprazole tablets with sensor) MNR

  Aldurazyme (laronidase) C28302-A1

  Alpha-1 Antitrypsin AAT Deficiency Enzyme C8797-A     

  Amondys 45 (casimersen) MNR 

  Amvuttra (vutrisiran) C24213-A
  Antimalarial Agents
  Atypical Antipsychotics

  Briumvi (ublituximab-xiiy)

  Cablivi (caplacizumab-yhdp) C19481-A
  Calcitonin Gene-Related Peptide (CGRP) Antagonist C15443-C
  Camzyos (mavacamten)
  Chemet (succimer)
  Crysvita (burosumab-twza) C14517-A
  Cuvposa (glycopyrrolate) oral solution
  Daraprim (pyrimethamine)
  Desmopressin Nasal and Oral (DDAVP)
  Diabetic Testing Supplies
  Duplication of Therapy/High Risk Combination
  Egrifta SV (tesamorelin) MNR
  Elaprase (idursulfase) C2720-A
  Empaveli (pegcetacoplan)
  Entyvio (vedolizumab) C6773-A
  Enzyme Replacement Therapy C9674-A
  Epidiolex (cannabidiol)
  Erythropoiesis-stimulating agents (ESAs) C15389-A
  Evenity (romosozumab-aqqg) C17324-A
  Evrysdi (risdiplam)
  Exondys 51 (eteplirsen) MNR C18464-A
  Fabrazyme (agalsidase beta) C4865-A
  Filspari (sparsentan)
  Filsuvez birch triterpenes gel C27686-A
  Firdapse (amifampridine)
  Furoscix (furosemide injection)
  Galafold (migalastat)
  Gattex (teduglutide [rDNA origin])
  Gender Dysphoria Hormone Therapy
  Givlaari (givosiran) C17924-A
  Hemostatic Agents
  High-Cost Outlier Targeted Drug Exception
  iDose TR travoprost intracameral implant C27707-A
  Igalmi (dexmedetomidine)
  Imcivree (setmelanotide) NC C22214-A
  Immunoglobulin (SCIg, IVIg) C21554-A
  Infliximab and Biosimilars C10421-A
  InPen (Insulin Smart Pen) NC C21865-A
  Insulin Patch NC C24238-A
  Iron Chelating Agents (Desferal, Exjade, Ferriprox, Jadenu)
  Iron Deficiency Anemia Agents C14569-A
  Isotretinoin
  Isturisa (osilodrostat)
  Kanuma (sebelipase alfa) C9974-A
  Keveyis (dichlorphenamide)
  Korlym (mifepristone)
  Korsuva (difelikefalin) C23743-A
  Kuvan (sapropterin dihydrochloride)
  Lemtrada (alemtuzumab) C6919-A
  Leqvio (inclisiran)
  Leuprolide long acting (Lupron Depot, Eligard, Lupron Depot Ped, Fensolvi, Camcevi)
  Lidocaine Patch
  Livtencity (maribavir)
  Lumizyme (alglucosidase alfa) C8716-A
  Lupkynis (voclosporin)
  Lyrica_Lyrica CR (pregabalin_pregabalin ER)

  Medical Necessity Review NE 599 CHIP C26331-A

  Medical Necessity NE Medicaid C25040-A

  Mepron (atovaquone)

  Mepsevii (vestronidase alfa-vjbk) C17942-A

  Myalept (metreleptin)

  Naglazyme galsulfase C28288-A

  Nasal Steroids
  NexoBrid (anacaulase-bcdb) C25200-A
  Nexviazyme (avalglucosidase alfa-ngpt) C21948-A
  Nitisinone (Orfadin, Nityr)
  Northera (droxidopa)
  Nplate (romiplostim) C6662-A
  Nuedexta (dextromethorphan/quinidine)
  Nulibry (fosdenopterin) C21306-A
  Nuplazid (pimavanserin)
  Ocrevus (ocrelizumab) C11250-A
  Octreotide
  Off-Label Use of Drugs and Biologic Agents
  Onpattro (patisiran)_Tegsedi (inotersen)
  Oxervate (cenegermin)
  Oxlumo (lumasiran) C21126-A
  Palynziq (pegvaliase-pqpz)
  Parsabiv (etelcalcetide) C17883-A
  Penicillamine (Depen, Cuprimine), Trientine (Cuvrior, Syprine)
  Prescription Compounded Product
  Prevymis (letermovir)
  Procysbi, Cystagon (cysteamine bitartrate) C6355-B
  Pulmozyme (dornase alfa)
  Prolia (denosumab) C8848-A
  Pyrukynd (mitapivat)
  Pulmonary Arterial Hypertension (PAH) C9837-A
  Qutenza (capsaicin) C2809-A
  Radicava (edaravone)
  Ravicti (glycerol phenylbutyrate)
  Recorlev (levoketoconazole)
  Regranex (becaplermin)
  Relizorb (immobilized lipase cartridge) MNR C17943-A
  Relyvrio (sodium phenylbutyrate/taurursodiol)
  Revcovi (elapegademase) C16329-A

  Rezdiffra (resmetirom) C28242-A

  Riluzole (Rilutek/Tiglutik/Exservan)
  Ryplazim (human plasminogen) C22238-A
  Santyl (collagenase)
  Savella (milnacipran)
  Sensipar (cinacalcet)
  Signifor (pasireotide diaspartate) C15367-A
  Serotonin - Norepinephrine Reuptake Inhibitors (SNRI)
  Sexual Dysfunction Criteria NC
  Seysara (sarecycline)
  Sodium Oxybate (Lumryz, Xyrem, Xywav)
  Soliris (eculizumab), Ultomiris (ravulizumab) C4867-A
  Spevigo (spesolimab-sbzo) C24676-A
  Standard Oncology Criteria
  Strensiq (asfotase alfa)
  Synarel (nafarelin acetate, nasal solution)
  Testosterone
  Thiola (tiopronin)
  Tysabri (natalizumab) C10276-A
  Tolvaptan
  Tzield (teplizumab-mzwv) C24729-A
  Uplizna (inebilizumab-cdon) C20171-A
  Valcyte (valganciclovir)
  Vibrant (transient device for constipation) NC
  Vijoice (alpelisib)
  Viltepso (viltolarsen) MNR C20406-A
  Vimizim (elosulfase alfa) C7068-A
  Voxzogo (vosoritide)

  Voydeya (danicopan) C28251-A

  Vyondys 53 (golodirsen) MNR C18466-A

  Vyvgart (efgartigimod) C23127-A

  Vyndaqel (tafamidis meglumine), Vyndamax (tafamidis)
  Xenpozyme (olipudase alfa-rpcp) C24670-A
  Xermelo (telotristat ethyl)

  Xolremdi (mavorixafor) 

  Zemplar (paricalcitol)
  Zokinvy (lonafarnib)
  Zoladex (goserelin acetate) C8757-A
  Ztalmy (ganaxolone)

 

Plan restrictions for certain Formulary drugs may require that other drugs be tried first . Nebraska Medicaid’s Preferred Drug List (PDL) designates which drugs require step therapy.  Drug samples from Providers or manufacturers are not considered as meeting step therapy requirements or as justification for exception requests. 

Claims Limitations Document

MAC Pricing (Maximum Allowable Cost)
CVS Nebraska Implementation Guide
Nebraska Pharmacy Part D Copay Faxblast

Prescription Drug Monitoring Program (PDMP) Training Videos
Prescription Drug Monitoring Program (PDMP) Registration FAQ

For a list of recalled drugs please refer to the FDA Drug Recalls page.