Molinalogo

• Drug Formulary

  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
  Medical Preferred Drug List_July 2025
  Pharmacy Specialty Drug List
  Medical Preferred Drug List_January 2026
  Memo_PDL Changes_January 2026
  Medical PDL Update - July 2026

   

  Clinical Guidelines

  Buprenorphine: Practical Clinical Guidance for Prescribers
  

• Clinical Criteria

  Provider Memos: Clinical Pharmacy Policy Updates
  

   Q3 2024 Clinical Pharmacy Policy Updates  

   Q4 2024 Clinical Pharmacy Policy Updates

   Q1 2025 Clinical Pharmacy Policy Updates
   Q2 2025 Clinical Pharmacy Policy Updates
   Q2 2025 Clinical Pharmacy Policy Updates Additional
   Q3 2025 Clinical Pharmacy Policy Updates

   Q4 2025 Clinical Pharmacy Policy Updates
  

   Q1 2026 Clinical Pharmacy Policy Updates

   Q2 2026 Clinical Pharmacy Policy Updates
   Q2 2026 Clinical Pharmacy Policy Updates Additional 

    Q3 2026 Clinical Pharmacy Policy Updates 

Nebraska Medicaid Clinical Criteria

•   Bylvay odevixibat C22109_A
    Growth Hormone (GH)
    Hepatitis C – Effective 01/01/2024
    Insulin-like Growth Factor (IFG) for Children
  

    Livmarli maralixibat C22224_A
   

  Molina Medicaid Clinical Criteria

    Abilify MyCite Kit (aripiprazole tablets with sensor) MNR
  

    Acthar Gel (repository corticotropin injection) C8373-A

    Adakveo (crizanlizumab-tmca) C17920-A          

    Aldurazyme (laronidase) C28302-A
  

    Alpha-1 Antitrypsin AAT Deficiency Enzyme C8797-A     

    Amondys 45 (casimersen) MNR 

    Amvuttra (vutrisiran) C24213-A
  

    Anti-Infectives C30376-A

    Antimalarial Agents
    Antipsychotics
  

    Aphexda Motixafortide C2717171-A
  
    Benlysta (belimumab) C2722-A 

    Botulinum Toxin C8755-A 
    Brineura (cerliponase alfa) C11526-A

    Briumvi (ublituximab-xiiy)
  
    Calcitonin Gene-Related Peptide (CGRP) Antagonist C15443-C

    Camzyos (mavacamten)
    Chemet (succimer) 
  

    Cosela (trilaciclib) C21205-A

    Crysvita (burosumab-twza) C14517-A
  

    Cuvposa (glycopyrrolate) oral solution
  
    Dalvance (dalbavancin) C9351-A

   

    Daraprim (pyrimethamine)
    Daybue (trofinetide) C25469-A
    Dextenza (dexamethasone intracanalicular insert) C24242-A
    Dexycu (dexamethasone intraocular suspension) C16320-A
    Diabetic Testing Supplies
    Disposable Insulin Delivery Device C17724-A
    Duplication of Therapy/High Risk Combination C15341-A 
    Durysta (bimatoprost implant) C19830-A
    Duvyzat (givinostat) C28336-A
  
    Egrifta SV (tesamorelin) MNR
    Elaprase (idursulfase) C2720-A
  

   

    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 
    Eylea (aflibercept) and Biosimilars C5674-A
  
    Fabrazyme (agalsidase beta) C4865-A
    Filspari (sparsentan)
    Firdapse (amifampridine)
  
    Galafold (migalastat)
    Gamifant (emapalumab-lzsg) C15970-A
    Gattex (teduglutide [rDNA origin])
  

   

    Gazyva obinutuzumab C30345-A
    Gender Dysphoria Hormone Therapy
    Givlaari (givosiran) C17924-A
  
    Hemostatic Agents
  

   

    High-Cost Outlier Targeted Drug Exception C17973-A
  
    Imaavy (nipocalimab-aahu) C29627-A
    Imcivree (setmelanotide) NC C22214-A
    Immunoglobulin (SCIg, IVIg) C21554-A
    Infliximab and Biosimilars C10421-A
    InPen (insulin smart pen) C29696-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)
    Krystexxa (pegloticase) C2729-A
    Kuvan (sapropterin dihydrochloride)
  
    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
  

    Mozobil (plerixafor) C9017-A
    Naglazyme galsulfase C28288-A
  
    Nasal Steroids

    Nexviazyme (avalglucosidase alfa-ngpt) C21948-A
    Niktimvo (axatilimab-csfr) C29396-A
    Nitisinone (Orfadin, Nityr)
    Northera (droxidopa)
    Nplate (romiplostim) C6662-A
    Nuedexta (dextromethorphan/quinidine)
    Nulibry (fosdenopterin) C21306-A 
    Nulojix (belatacept) C9968-A
    Nuplazid (pimavanserin)
  
    Ocrevus (ocrelizumab) C11250-A
    Octreotide C8839-A
    Off-Label Use of Drugs and Biologic Agents C4141-A
    Onpattro (patisiran) Tegsedi (inotersen) C17894-A
    Oxervate (cenegermin) C16015-A
    Oxlumo (lumasiran) C21126-A 
    Ozurdex (dexamethasone intravitreal implant) C9975-A
  
    Palynziq (pegvaliase-pqpz)
    Parsabiv (etelcalcetide) C17883-A
    Physician Administered Drugs C11251-A
    PiaSky (crovalimab)
    Prescription Compounded Product C20382-A
    Prevymis (letermovir)
    Procysbi, Cystagon (cysteamine bitartrate) C6355-B
    Pulmozyme (dornase alfa) C9796-A
    Prolia (denosumab) C8848-A
    Pulmonary Arterial Hypertension (PAH) C9837-A
  
    Qutenza (capsaicin) C2809-A
  
    Ranibizumab and Biosimilars (Lucentis, Byooviz, Cimerli) C10417-A

   

    Ravicti (glycerol phenylbutyrate)
  

   

   

    Recorlev (levoketoconazole)
  

   

  Revcovi (elapegademase) C16329-A
  

    Rezdiffra (resmetirom) C28242-A
  

   

    Rituxan (rituximab) and Biosimilars C10423-A
    Ryplazim (human plasminogen) C22238-A
  
    Santyl (collagenase) 
    Saphnelo (anifrolumab-fnia) C21970-A
    Savella (milnacipran)
    Sensipar (cinacalcet)
    Sephience (sepiapterin) C29883-A
    Signifor (pasireotide diaspartate) C15367-A
    Serotonin - Norepinephrine Reuptake Inhibitors (SNRI)
    Sexual Dysfunction Criteria NC
    Seysara (sarecycline)
    Skyclarys (omaveloxolone) C25422-A
    Sodium Oxybate (Lumryz, Xyrem, Xywav)
    Soliris (eculizumab), Ultomiris (ravulizumab) C4867-A
    Spevigo (spesolimab-sbzo) C24676-A 
  

    Spravato (esketamine) C16762-A

    Standard Oncology Criteria
    Strensiq (asfotase alfa) 
  

    Sublocade (buprenorphine extended-release inj.) C15161-A
    Supprelin LA (histrelin acetate) Implant C20611-A
  

    Susvimo (ranibizumab) Intravitreal Implant C24231-A
  
    Tepezza (teprotumumab-trbw) C18462-A
    Testosterone
    Therapeutic Radiopharmaceuticals
    Thiola (tiopronin)
    Triptodur (triptorelin pamoate) C14649-A
    Tysabri (natalizumab) C10276-A
    Tolvaptan
  
    Vabysmo (faricimab-svoa) C22795-A
    Valcyte (valganciclovir) 
  

   

    Vibativ (telavancin) C14575-A

    Vibrant (transient device for constipation) NC
    Vijoice (alpelisib) C23736-A
    Vimizim (elosulfase alfa) C7068-A
    Voxzogo (vosoritide)
  

    Voydeya (danicopan) C28251-A

    Vyondys 53 (golodirsen) MNR C18466-A

   

    Vyndaqel (tafamidis meglumine), Vyndamax (tafamidis)
  
    Xenpozyme (olipudase alfa-rpcp) C24670-A
    Xiaflex (collagenase clostridium histolyticum) C24319-A
  

    Xipere (triamcinolone acetonide ocular inj) C22222-A

    Xolremdi (mavorixafor) 

    Xgeva (denosumab) C8849-A
  
    Zilretta (triamcinolone acetonide ER injection) C16855-A

    Zokinvy (lonafarnib)
    Zoladex (goserelin acetate) C8757-A
  

   

   

• Step Therapy

  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

• Pharmacy Billing

  MAC Pricing (Maximum Allowable Cost)
  CVS Nebraska Implementation Guide
  Memo_Independent Pharmacy Reimbursement Change_January 2026

   

  Paper Claims:
  For claims older than 30 days, pharmacies may submit paper claims by using a universal claim form.
  Forms can be obtained at this link: NCPDP- Universal Claim Forms

   

   

  Paper Claim Submission Address:
  CVS Caremark
  PO Box 52136
  Phoenix, AZ 85072-2136

   

• Prescription Drug Monitoring Program (PDMP)

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

• Drug Recalls

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