# Ohio Department of Medicaid
## 30 Day Change Notice
### Effective Date: July 1, 2025

| THERAPEUTIC CLASS | NO PA REQUIRED PREFERRED |
| --- | --- |
| Cardiovascular Agents: Angina, Hypertension and Heart Failure | bisoprolol 5, 10mg<br>labetalol 100, 200, 300mg<br>spironolactone tab |
| Cardiovascular Agents: Antiarrhythmics | MULTAQ |
| Central Nervous System (CNS) Agents: Fibromyalgia Agents | SAVELLA |
| Central Nervous System (CNS) Agents: Neuropathic Pain | GRALISE<br>HORIZANT |
| Central Nervous System (CNS) Agents: Skeletal Muscle Relaxants, Non-Benzodiazepine | methocarbamol 500, 750mg |
| Central Nervous System (CNS) Agents: Restless Legs Syndrome | HORIZANT |
| Endocrine Agents: Diabetes – Non-Insulin | glimepiride 1, 2, 4mg |
| Gastrointestinal Agents: Bowel Preparations | MOVIPREP |
| Gastrointestinal Agents: Crohn’s Disease | mercaptopurine tab |
| Gastrointestinal Agents: Ulcerative Colitis | mesalamine ER cap 500mg<br>PENTASA 250mg |
| Gastrointestinal Agents: Unspecified GI | polyethylene glycol oral powder bottle |
| Infectious Disease Agents: Antivirals – HIV*<br>LEGACY CATEGORY | RUKOBIA<br>VIREAD 150, 200mg |
| Respiratory Agents: Inhaled Agents | arformoterol neb |
| Topical Agents: Antifungals | tolnaftate cream, powder |
| Topical Agents: Immunomodulators | pimecrolimus [labeler 68682] |

| THERAPEUTIC CLASS | CLINICAL CRITERIA REQUIRED PREFERRED |
| --- | --- |
| Respiratory Agents: Cystic Fibrosis | ALYFTREK |

| THERAPEUTIC CLASS | PA REQUIRED NON-PREFERRED |
| --- | --- |



# Ohio Department of Medicaid
## 30 Day Change Notice
### Effective Date: July 1, 2025

| Analgesic Agents: Opioids | tramadol IR 75mg |
| --- | --- |
| Blood Formation, Coagulation, and Thrombosis Agents: Hemophilia A, von Willebrand Disease, and Factor XIII Deficiency*<br>LEGACY CATEGORY | HYMPAVZI |
| Blood Formation, Coagulation, and Thrombosis Agents: Hemophilia B*<br>LEGACY CATEGORY | HYMPAVZI |
| Blood Formation, Coagulation, and Thrombosis Agents: Oral Anticoagulants | rivaroxaban tab |
| Blood Formation, Coagulation, and Thrombosis Agents: Oral Antiplatelet | ticagrelor |
| Cardiovascular Agents: Angina, Hypertension and Heart Failure | bisoprolol 2.5mg<br>CORLANOR SOLN<br>ivabradine tab<br>labetalol 400mg<br>quinidine IR, ER |
| Cardiovascular Agents: Antiarrhythmics | memantine/donepezil cap 14-10, 21-10, 28-10mg |
| Central Nervous System (CNS) Agents: Alzheimer’s Agents*<br>LEGACY CATEGORY | VIGAFYDE |
| Central Nervous System (CNS) Agents: Anticonvulsants*<br>LEGACY CATEGORY | EQUETRO<br>ERZOFRI<br>OPIPZA |
| Central Nervous System (CNS) Agents: Atypical Antipsychotics*<br>LEGACY CATEGORY | gabapentin ER |
| Central Nervous System (CNS) Agents: Neuropathic Pain | VYALEV |
| Central Nervous System (CNS) Agents: Parkinson’s Agents | methocarbamol 1000mg |
| Central Nervous System (CNS) Agents: Skeletal Muscle Relaxants, Non-Benzodiazepine | methocarbamol 1000mg |
| Endocrine Agents: Androgens | AZMIRO |
| Endocrine Agents: Diabetes – Hypoglycemia Treatments | glucagon emerg kit labeler 00378 |
| Endocrine Agents: Diabetes – Non-Insulin | glimepiride 3mg<br>metformin IR 750mg<br>ZITUVIMET XR |
| Gastrointestinal Agents: Ulcerative Colitis | PENTASA 500mg |
| Gastrointestinal Agents: Unspecified GI | polyethylene glycol oral powder packet<br>prucalopride |
| Genitourinary Agents: Electrolyte Depleter Agents | ferric citrate tab |
| Immunomodulator Agents: Systemic Inflammatory Disease | NEMLUVIO |
| Infectious Disease Agents: Antibiotics – Cephalosporins | cefaclor ER |
| Infectious Disease Agents: Antivirals – HIV*<br>LEGACY CATEGORY | EMTRIVA SOLN<br>VIREAD 250, 300mg TAB |

Date of Notice: 6/1/2025

# Ohio Department of Medicaid
## 30 Day Change Notice
### Effective Date: July 1, 2025

| Ophthalmic Agents: Glaucoma Agents | BETIMOL 0.25%<br>timolol hemihydrate soln 0.5% |
| --- | --- |
| Respiratory Agents: Epinephrine | epinephrine (labeler 00093, 00115)<br>NEFFY |
| Respiratory Agents: Inhaled Agents | BROVANA<br>umeclidinium/vilanterol |
| Topical Agents: Antifungals | tolnaftate soln |
| Topical Agents: Immunomodulators | pimecrolimus [labeler 00591, 68462] |

## THERAPEUTIC CATEGORIES WITH CHANGES IN CRITERIA
- Analgesic Agents: Gout
- Analgesic Agents: NSAIDs
- Analgesic Agents: Opioids
- Blood Formation, Coagulation, and Thrombosis Agents: Colony Stimulating Factors
- Blood Formation, Coagulation, and Thrombosis Agents: Hematopoietic Agents
- Blood Formation, Coagulation, and Thrombosis Agents: Hemophilia A, von Willebrand Disease, and Factor XIII Deficiency* LEGACY CATEGORY
- Blood Formation, Coagulation, and Thrombosis Agents: Hemophilia B* LEGACY CATEGORY
- Blood Formation, Coagulation, and Thrombosis Agents: Heparin-Related Preparations
- Blood Formation, Coagulation, and Thrombosis Agents: Oral Anticoagulants
- Blood Formation, Coagulation, and Thrombosis Agents: Oral Antiplatelet
- Cardiovascular Agents: Angina, Hypertension and Heart Failure
- Cardiovascular Agents: Antiarrhythmics
- Cardiovascular Agents: Lipotropics
- Cardiovascular Agents: Pulmonary Arterial Hypertension* LEGACY CATEGORY
- Central Nervous System (CNS) Agents: Alzheimer’s Agents* LEGACY CATEGORY
- Central Nervous System (CNS) Agents: Anticonvulsants* LEGACY CATEGORY
- Central Nervous System (CNS) Agents: Anticonvulsants Rescue
- Central Nervous System (CNS) Agents: Antidepressants* LEGACY CATEGORY
- Central Nervous System (CNS) Agents: Attention Deficit Hyperactivity Disorder Agents
- Central Nervous System (CNS) Agents: Atypical Antipsychotics* LEGACY CATEGORY
- Central Nervous System (CNS) Agents: Fibromyalgia Agents
- Central Nervous System (CNS) Agents: Medication Assisted Treatment of Opioid Addiction
- Central Nervous System (CNS) Agents: Multiple Sclerosis* LEGACY CATEGORY
- Central Nervous System (CNS) Agents: Narcolepsy
- Central Nervous System (CNS) Agents: Neuropathic Pain
- Central Nervous System (CNS) Agents: Parkinson’s Agents
- Central Nervous System (CNS) Agents: Restless Legs Syndrome
- Central Nervous System (CNS) Agents: Sedative-Hypnotics, Non-Barbiturate
- Central Nervous System (CNS) Agents: Skeletal Muscle Relaxants, Non-Benzodiazepine
- Dermatologic Agents: Oral Acne Products
- Dermatologic Agents: Topical Acne Products
- Endocrine Agents: Androgens
- Endocrine Agents: Diabetes – Hypoglycemia Treatments
- Endocrine Agents: Diabetes – Insulin

Date of Notice: 6/1/2025

# Ohio Department of Medicaid
## 30 Day Change Notice
### Effective Date: July 1, 2025

- Endocrine Agents: Diabetes – Non-Insulin
- Endocrine Agents: Endometriosis
- Endocrine Agents: Estrogenic Agents
- Endocrine Agents: Growth Hormone
- Endocrine Agents: Osteoporosis – Bone Ossification Enhancers
- Gastrointestinal Agents: Anti-Emetics
- Gastrointestinal Agents: Bowel Preparations
- Gastrointestinal Agents: Crohn’s Disease
- Gastrointestinal Agents: Irritable Bowel Syndrome (IBS) with Diarrhea
- Gastrointestinal Agents: Pancreatic Enzymes
- Gastrointestinal Agents: Proton Pump Inhibitors
- Gastrointestinal Agents: Ulcerative Colitis
- Gastrointestinal Agents: Unspecified GI
- Genitourinary Agents: Benign Prostatic Hyperplasia
- Genitourinary Agents: Electrolyte Depleter Agents
- Genitourinary Agents: Urinary Antispasmodics
- Hyperkalemia Agents: Potassium Binders
- Immunomodulator Agents: Systemic Inflammatory Disease
- Infectious Disease Agents: Antibiotics – Cephalosporins
- Infectious Disease Agents: Antibiotics – Inhaled
- Infectious Disease Agents: Antibiotics – Macrolides
- Infectious Disease Agents: Antibiotics – Quinolones
- Infectious Disease Agents: Antibiotics – Tetracyclines
- Infectious Disease Agents: Antifungals
- Infectious Disease Agents: Antivirals – Hepatitis C Agents
- Infectious Disease Agents: Antivirals – Herpes
- Infectious Disease Agents: Antivirals – HIV* LEGACY CATEGORY
- Ophthalmic Agents: Antibiotic and Antibiotic-Steroid Combination Drops and Ointments
- Ophthalmic Agents: Antihistamines & Mast Cell Stabilizers
- Ophthalmic Agents: Dry Eye Treatments
- Ophthalmic Agents: Glaucoma Agents
- Ophthalmic Agents: NSAIDs
- Ophthalmic Agents: Ophthalmic Steroids
- Otic Agents: Antibacterial and Antibacterial/Steroid Combinations
- Respiratory Agents: Antihistamines – Second Generation
- Respiratory Agents: Cystic Fibrosis
- Respiratory Agents: Epinephrine
- Respiratory Agents: Hereditary Angioedema
- Respiratory Agents: Inhaled Agents
- Respiratory Agents: Leukotriene Receptor Modifiers & Inhibitors
- Respiratory Agents: Monoclonal Antibodies-Anti-IL/Anti-IgE
- Respiratory Agents: Nasal Preparations
- Respiratory Agents: Pulmonary Fibrosis
- Topical Agents: Antifungals
- Topical Agents: Antiparasitics
- Topical Agents: Corticosteroids
- Topical Agents: Immunomodulators

Date of Notice: 6/1/2025

# Ohio Department of Medicaid
## 30 Day Change Notice
### Effective Date: July 1, 2025

| THERAPEUTIC CLASS | SUMMARY OF CHANGE |
| --- | --- |
| Analgesic Agents: Gout | **NON-PREFERRED CRITERIA:**<br>• Must have had an inadequate clinical response of at least 30 days with at least one preferred drug in this UPDL category and indicated for diagnosis |
| Analgesic Agents: NSAIDs | **NON-PREFERRED CRITERIA:**<br>• Must have had an inadequate clinical response of at least 30 days with at least two preferred drugs in this UPDL category and indicated for diagnosis |
| Analgesic Agents: Opioids | **NON-PREFERRED CRITERIA:**<br>• Must have had an inadequate clinical response of at least 7 days of at least two unrelated preferred drugs with different active ingredients of the same duration of action (SHORT-ACTING or LONG-ACTING)<br>**AR – All codeine and tramadol containing products:** a PA is required for patients younger than 12 years old |
| Blood Formation, Coagulation, and Thrombosis Agents: Colony Stimulating Factors | **NON-PREFERRED CRITERIA:**<br>• Must have had an inadequate clinical response of at least 14 days with at least one preferred drug in this UPDL category and indicated for diagnosis |
| Blood Formation, Coagulation, and Thrombosis Agents: Hematopoietic Agents | **NON-PREFERRED CRITERIA:**<br>• Must have had an inadequate clinical response of at least 14 days with at least one preferred drug in this UPDL category and indicated for diagnosis |
| Blood Formation, Coagulation, and Thrombosis Agents: Hemophilia A, von Willebrand Disease, and Factor XIII Deficiency*<br>LEGACY CATEGORY | **NON-PREFERRED CRITERIA:**<br>• Must have had an inadequate clinical response of at least 14 days with at least one preferred drug in this UPDL category and indicated for diagnosis<br>**ADDITIONAL HYMPAVZI (MARSTACIMAB-HNCQ) CRITERIA**<br>• Must have had an inadequate clinical response of at least 30 days with HEMLIBRA |
| Blood Formation, Coagulation, and Thrombosis Agents: Hemophilia B*<br>LEGACY CATEGORY | **NON-PREFERRED CRITERIA:**<br>• Must have had an inadequate clinical response of at least 14 days with at least one preferred drug in this UPDL category and indicated for diagnosis |
| Blood Formation, Coagulation, and Thrombosis Agents: Heparin-Related Preparations | **NON-PREFERRED CRITERIA:**<br>• Must have had an inadequate clinical response of at least 14 days with at least one preferred drug in this UPDL category and indicated for diagnosis |

Date of Notice: 6/1/2025

# Ohio Department of Medicaid
## 30 Day Change Notice
### Effective Date: July 1, 2025

| THERAPEUTIC CLASS | SUMMARY OF CHANGE |
| --- | --- |
| Blood Formation, Coagulation, and Thrombosis Agents: Oral Anticoagulants | **NON-PREFERRED CRITERIA:**<br>• Must have had an inadequate clinical response of at least 14 days with at least two preferred drugs in this UPDL category and indicated for diagnosis<br>**All products are covered without a PA**<br>**LENGTH OF AUTHORIZATION:** 365 days |
| Blood Formation, Coagulation, and Thrombosis Agents: Oral Antiplatelet | **NON-PREFERRED CRITERIA:**<br>• Must have had an inadequate clinical response of at least 30 days with at least one preferred drug in this UPDL category and indicated for diagnosis |
| Cardiovascular Agents: Angina, Hypertension and Heart Failure | **NON-PREFERRED CRITERIA:**<br>• Must have had an inadequate clinical response of at least 30 days with at least two preferred drugs within the same sub-section classification in this UPDL category and indicated for diagnosis with the same mechanism of action, if available and indicated for the same diagnosis in this UPDL category |
| Cardiovascular Agents: Antiarrhythmics | **NON-PREFERRED CRITERIA:**<br>• Must have had an inadequate clinical response of at least 30 days with at least one preferred drug in this UPDL category and indicated for diagnosis |
| Cardiovascular Agents: Lipotropics | **NON-PREFERRED CRITERIA:**<br>• Must have had an inadequate clinical response of at least 30 days (or 90 days for fibrates) with at least one preferred drug within the same sub-section classification in this UPDL category and indicated for diagnosis in the same drug class |
| Cardiovascular Agents: Pulmonary Arterial Hypertension*<br>LEGACY CATEGORY | **NON-PREFERRED CRITERIA:**<br>• Must have had an inadequate clinical response of at least 30 days with at least two preferred drugs in this UPDL category and indicated for diagnosis, if available, one of which must be a phosphodiesterase-5 inhibitor |
| Central Nervous System (CNS) Agents: Alzheimer’s Agents*<br>LEGACY CATEGORY | **NON-PREFERRED CRITERIA:**<br>• Must have had an inadequate clinical response of at least 30 days with at least two preferred drugs in this UPDL category and indicated for diagnosis |
| Central Nervous System (CNS) Agents: Anti-Migraine Agents, Acute | **NON-PREFERRED CRITERIA:**<br>• Must have had an inadequate clinical response of at least 14 days with at least one preferred drug and one step therapy drug in this UPDL category and indicated for diagnosis, if available one of which has the same mechanism of action if available |
| Central Nervous System (CNS) Agents: Anti-Migraine Agents, Cluster Headache | **NON-PREFERRED CRITERIA:**<br>• Must have had an inadequate clinical response of at least 60 days to at least one preferred drug in this UPDL category and indicated for diagnosis |

Date of Notice: 6/1/2025

# Ohio Department of Medicaid
## 30 Day Change Notice
### Effective Date: July 1, 2025

| THERAPEUTIC CLASS | SUMMARY OF CHANGE |
| --- | --- |
| Agents: Anticonvulsants*<br>LEGACY CATEGORY | • Must have had an inadequate clinical response of at least 30 days with at least two preferred drugs in this UPDL category and indicated for diagnosis<br>• For prescribers who are credentialed as a neurology specialty with Ohio Medicaid, there must have been an inadequate clinical response of at least 30 days with one preferred anticonvulsant drug in the standard tablet/capsule dosage form.<br>• Prescriptions submitted from a prescriber who is credentialed as a neurology specialty with Ohio Medicaid AND for drugs that are used only for seizures, there must have been an inadequate clinical response of at least 30 days with one preferred drug. This provision applies only to the standard tablet/capsule dosage form. |
| Central Nervous System (CNS) Agents: Anticonvulsants Rescue | **AR – VALTOCO:** a PA is required for patients younger than 6 2 years old |
| Central Nervous System (CNS) Agents: Antidepressants*<br>LEGACY CATEGORY | **NON-PREFERRED CRITERIA:**<br>• Must have had an inadequate clinical response of at least 30 days with at least two preferred drugs in this UPDL category and indicated for diagnosis |
| Central Nervous System (CNS) Agents: Attention Deficit Hyperactivity Disorder Agents | **NON-PREFERRED CRITERIA:**<br>• Must have had an inadequate clinical response of at least 30 days with at least two preferred drugs in this UPDL category and indicated for diagnosis, if available |
| Central Nervous System (CNS) Agents: Atypical Antipsychotics*<br>LEGACY CATEGORY | **NON-PREFERRED CRITERIA:**<br>• Must have had an inadequate clinical response of at least 30 days with at least two preferred drugs in this UPDL category and indicated for diagnosis |
| Central Nervous System (CNS) Agents: Fibromyalgia Agents | **All products are covered without a PA**<br>**LENGTH OF AUTHORIZATIONS:** 365 Days<br>**NON-PREFERRED CRITERIA:**<br>• Must have had an inadequate clinical response of at least 14 days with at least two preferred drugs in different classes (see Additional Information section below)<br>**ADDITIONAL INFORMATION:**<br>• Drugs and drug classes include gabapentin, pregabalin, short- and/or long-acting opioids, skeletal muscle relaxants, SNRIs, SSRIs, trazodone, and tricyclic antidepressants |
| Central Nervous System (CNS) Agents: Medication Assisted Treatment of Opioid Addiction | **BUPRENORPHINE SAFETY EDITS AND DRUG UTILIZATION REVIEW CRITERIA:** |

Date of Notice: 6/1/2025

# Ohio Department of Medicaid
## 30 Day Change Notice
### Effective Date: July 1, 2025

## Agents: Medication Assisted Treatment of Opioid Addiction
- buprenorphine injection (SUBLOCADE) dosing schedule will be limited to 300mg/30 days

#
| Date:  |
| Is the individual receiving opioids, benzodiazepines, sedative hypnotics, carisoprodol or tramadol? If answering “No” to the previous question, skip this question if answering “No” to the previous question. | Yes ☐ No ☐ |
| Has the prescriber coordinated care with the prescriber(s) of the above listed substances and evaluated the risks and benefits of the combined use of these medications? | Yes ☐ No ☐ |
| Lab testing requirements: met at least twice per quarter for first year of treatment, once per quarter thereafter? | Yes ☐ No ☐ |

Date of Notice: 6/1/2025

# Ohio Department of Medicaid
## 30 Day Change Notice
### Effective Date: July 1, 2025





Lucemyra length of authorization is 14 days

### SIGNATURE AND DATE
☐ I attest that I am a member of the prescriber’s staff in accordance with Ohio Administrative Code rule 5160-9-03, as applicable. Only the prescribing provider or a member of the prescribing provider’s staff may request prior authorization.

Prescriber’s Signature (or staff of prescriber) ________________________ Date: ____________

If a staff member is attesting, please print your name: ________________________

## THERAPEUTIC CATEGORIES WITH CHANGES IN CRITERIA
- Central Nervous System (CNS) Agents: Multiple Sclerosis*<br>LEGACY CATEGORY | **NON-PREFERRED CRITERIA:**<br>• Must have had an inadequate clinical response of at least 30 days with at least one preferred drug in this UPDL category and indicated for diagnosis |
| --- | --- |
| Central Nervous System (CNS) Agents: Narcolepsy | **NON-PREFERRED CRITERIA:**<br>• Must have had an inadequate clinical response with at least two preferred drugs - either at least 30 days of armodafinil or modafinil; OR at least 7 days of a preferred amphetamine or methylphenidate drug in this UPDL category and indicated for diagnosis |
| Central Nervous System (CNS) Agents: Neuropathic Pain | **NON-PREFERRED CRITERIA:**<br>• Must have had an inadequate clinical response of at least 30 days with at least two preferred drugs within the same sub-section classification in different drug classes in this UPDL category and indicated for diagnosis |
| **ADDITIONAL GABAPENTIN (GRALISE) AND GABAPENTIN ENCARBIL (HORIZANT) CRITERIA:** | • Must have had an inadequate clinical response to a preferred gabapentin product |

Date of Notice: 6/1/2025

Ohio Department of Medicaid

30 Day Change Notice

Effective Date: July 1, 2025

Date of Notice: 6/1/2025

Ohio Department of Medicaid

30 Day Change Notice

Effective Date: July 1, 2025

| Gastrointestinal Agents: Anti-Emetics | • Must have had an inadequate clinical response of at least 3 days with at least one preferred drug in this UPDL category within the same mechanism of action, if sub-section classification and indicated for diagnosis, if available. |

| Gastrointestinal Agents: Bowel Preparations | • Must have had an inadequate clinical response with at least one preferred drug in this UPDL category and indicated for diagnosis |

| Gastrointestinal Agents: Crohn's Disease | • Must have had an inadequate clinical response of at least 30 days with at least two preferred drugs in this UPDL category and indicated for diagnosis |

| Gastrointestinal Agents: Irritable Bowel Syndrome (IBS) with Diarrhea | • Must have had an inadequate clinical response of at least 14 days with at least one preferred drug and one step therapy drug in this UPDL category and indicated for diagnosis |

| Gastrointestinal Agents: Pancreatic Enzymes | • Must have had an inadequate clinical response of at least 14 days with at least two preferred drugs in this UPDL category and indicated for diagnosis |

| Gastrointestinal Agents: Proton Pump Inhibitors | • Must have had an inadequate clinical response of at least 30 days with at least two preferred drugs in this UPDL category and indicated for diagnosis |

| Gastrointestinal Agents: Ulcerative Colitis | • Must have had an inadequate clinical response of at least 30 days with at least two preferred drugs in this UPDL category within the same route of administration, if sub-section classification and indicated for diagnosis, if available |

Date of Notice: 6/1/2025

Ohio Department of Medicaid

30 Day Change Notice

Effective Date: July 1, 2025

Date of Notice: 6/1/2025

Ohio Department of Medicaid

30 Day Change Notice

Effective Date: July 1, 2025

Date of Notice: 6/1/2025

Ohio Department of Medicaid

30 Day Change Notice

Effective Date: July 1, 2025

| | • Must have had an inadequate clinical response of at least 14 days with at least one preferred prophylaxis drug in this UPDL category and indicated for diagnosis to request a non-preferred prophylaxis drug. |

Date of Notice: 6/1/2025

Ohio Department of Medicaid

30 Day Change Notice

Effective Date: July 1, 2025

| Respiratory Agents: Monoclonal Antibodies-Anti-IL/Anti-IgE | CLINICAL PA CRITERIA: |

| | • For Chronic Obstructive Pulmonary Disease (COPD): |

| | ○ The patient must have an eosinophilic count of greater than or equal to 300 cells per mcL within 12 months prior to initiation of therapy AND |

| | ○ The patient has a history of uncontrolled disease, as indicated by greater than or equal to 2 COPD exacerbations or greater than or equal to 1 COPD exacerbation resulting in a hospitalization despite being on standard of care, defined as triple therapy (LAMA+LABA+ICS) for at least 3 months prior to request, and at a stable dose for at least 1 month prior. |

| Respiratory Agents: Monoclonal Antibodies-Anti-IL/Anti-IgE | NON-PREFERRED CRITERIA: |

| | • Must have had an inadequate clinical response of at least 90 days with at least one preferred drug in this UPDL category and indicated for diagnosis |

| Respiratory Agents: Nasal Preparations | • Must have had an inadequate clinical response of at least 14 days with at least two preferred drugs in this UPDL category within the same mechanism of action, if sub-section classification and indicated for diagnosis, if available |

| Respiratory Agents: Pulmonary Fibrosis | • Must have had an inadequate clinical response of at least 30 days with at least one preferred drug in this UPDL category and indicated for diagnosis |

| Topical Agents: Antifungals | • Must have had an inadequate clinical response of at least 14 days with at least two preferred drugs in this UPDL category and indicated for diagnosis if indicated for diagnosis |

| Topical Agents: Antiparasitics | • Must have had an inadequate clinical response of at least 14 days with at least one preferred drug in this UPDL category and indicated for diagnosis |

Date of Notice: 6/1/2025

Ohio Department of Medicaid

30 Day Change Notice

Effective Date: July 1, 2025

Date of Notice: 6/1/2025