MISSISSIPPI DIVISION OF MEDICAID PREFERRED DRUG LIST Effective January 1, 2011
BODY SYSTEM THERAPEUTIC CLASS PREFERRED AGENTS NON-PREFERRED AGENTS NOTES ANALGESICS ANALGESICS, DURAGESIC (fentanyl) AVINZA (morphine) NARCOTIC-LONG-ACTING fentanyl patches EMBEDA (morphine/naltrexone) KADIAN (morphine) EXALGO (hydromorphone) methadone OPANA ER (oxymorphone) morphine ER oxycodone ER OXYCONTIN (oxycodone) RYZOLT (tramadol) ULTRAM ER (tramadol) ANALGESICS, NARCOTIC- acetaminophen/codeine butalbital/APAP/caffeine/codeine SHORT-ACTING aspirin/codeine butalbital/ASA/caffeine/codeine codeine DARVON-N (propoxyphene) dihydrocodeine/ APAP/caffeine DILAUDID liquid (hydromorphone) hydrocodone/APAP fentanyl hydrocodone/ibuprofen FENTORA (fentanyl) hydromorphone levorphanol IBUDONE (hydrocodone/ibuprofen) NUCYNTA (tapentadol) meperidine ONSOLIS (fentanyl) morphine OPANA (oxymorphone) oxycodone pentazocine/naloxone oxycodone/APAP propoxyphene oxycodone/aspirin propoxyphene/APAP oxycodone/ibuprofen REPREXAIN pentazocine/APAP (hydrocodone/ibuprofen) tramadol RYBIX (tramadol) tramadol/APAP VIMOVO (naproxen/esomeprazole) ZAMICET (hydrocodone/APAP)
ANALGESICS/ANESTHETICS, FLECTOR (diclofenac epolamine) PENNSAID Solution TOPICAL LIDODERM (lidocaine) (diclofenac sodium ) VOLTAREN Gel (diclofenac sodium)
ANTIHYPERURICEMICS allopurinol ULORIC (febuxostat)
colchicine
COLCRYS (colchicine)
probenecid
probenecid/colchicine
ORAL ANTIMIGRAINE AGENTS, TRIPTANS RELPAX (eletriptan) AMERGE (naratriptan) NR sumatriptan ALSUMA (sumatriptan) Unless otherwise stated, the listing of a particular brand or generic name includes all dosage forms of that drug. NR indicates a new drug that has not yet been reviewed by the 1 P&T Committee. See separate Antihistamine/Decongestant Product and Active Ingredient Cross-Reference List for complete list of product names and active ingredients. MISSISSIPPI DIVISION OF MEDICAID PREFERRED DRUG LIST Effective January 1, 2011 BODY SYSTEM THERAPEUTIC CLASS PREFERRED AGENTS NON-PREFERRED AGENTS NOTES TREXIMET (sumatriptan/naproxen) AXERT (almotriptan) ANALGESICS CAMBIA (diclofenac potassium) (continued) ANTIMIGRAINE AGENTS, FROVA (frovatriptan) TRIPTANS IMITREX (sumatriptan) (CONTINUED) MAXALT (rizatriptan) naratriptan ZOMIG (zolmitriptan)
NASAL
sumatriptan IMITREX (sumatriptan)
ZOMIG (zolmitriptan)
INJECTABLE
sumatriptan IMITREX (sumatriptan) FIBROMYALGIA AGENTS LYRICA (pregabalin) CYMBALTA (duloxetine) Cymbalta will be SAVELLA (milnacipran) approved for patients with diabetic neuropathy
NSAIDS NONSELECTIVE
diclofenac meclofenamate
etodolac mefenamic acid
fenoprofen nabumetone
flurbiprofen tolmetin
ibuprofen ZIPSOR (diclofenac)
indomethacin VIMOVO (naproxen/esomeprazole)
ketoprofen
ketorolac
naproxen
oxaprozin
piroxicam
sulindac
NSAID/GI PROTECTANT COMBINATIONS
ARTHROTEC
(diclofenac/misoprostol)
COX-II SELECTIVE
meloxicam CELEBREX (celecoxib)
Unless otherwise stated, the listing of a particular brand or generic name includes all dosage forms of that drug. NR indicates a new drug that has not yet been reviewed by the 2 P&T Committee. See separate Antihistamine/Decongestant Product and Active Ingredient Cross-Reference List for complete list of product names and active ingredients. MISSISSIPPI DIVISION OF MEDICAID PREFERRED DRUG LIST Effective January 1, 2011 BODY SYSTEM THERAPEUTIC CLASS PREFERRED AGENTS NON-PREFERRED AGENTS NOTES
ANALGESICS SKELETAL MUSCLE baclofen AMRIX (cyclobenzaprine ER) (continued) RELAXANTS chlorzoxazone carisoprodol cyclobenzaprine carisoprodol compound dantrolene FEXMID (cyclobenzaprine) methocarbamol orphenadrine tizanidine orphenadrine compound SKELAXIN (metaxolone) SOMA (carisoprodol) ZANAFLEX (tizanidine) CARDIOVASCULAR ANGIOTENSIN MODULATORS ACE INHIBITORS benazepril ACEON (perindopril) captopril moexepril enalapril perindopril fosinopril lisinopril quinapril ramipril trandolapril
ACE INHIBITOR/DIURETIC COMBINATIONS
benazepril/HCTZ moexepril/HCTZ
captopril/HCTZ
enalapril/HCTZ
fosinopril/HCTZ
lisinopril/HCTZ
quinapril/HCTZ
ANGIOTENSIN RECEPTOR BLOCKERS AVAPRO (irbesartan) ATACAND (candesartan) BENICAR (olmesartan) TEVETEN (eprosartan ) COZAAR (losartan) DIOVAN (valsartan) MICARDIS (telmisartan) losartan
Unless otherwise stated, the listing of a particular brand or generic name includes all dosage forms of that drug. NR indicates a new drug that has not yet been reviewed by the 3 P&T Committee. See separate Antihistamine/Decongestant Product and Active Ingredient Cross-Reference List for complete list of product names and active ingredients. MISSISSIPPI DIVISION OF MEDICAID PREFERRED DRUG LIST Effective January 1, 2011 BODY SYSTEM THERAPEUTIC CLASS PREFERRED AGENTS NON-PREFERRED AGENTS NOTES
ANGIOTENSIN MODULATORS (CONTINUED) CARDIOVASCULAR ANGIOTENSIN RECEPTOR BLOCKER/DIURETIC COMBINATIONS (CONTINUED) AVALIDE (irbesartan/HCTZ) ATACAND-HCT (candesartan/HCTZ)
BENICAR-HCT (olmesartan/HCTZ) TEVETEN-HCT (eprosartan/HCTZ)
DIOVAN-HCT (valsartan/HCTZ)
HYZAAR (losartan/HCTZ)
MICARDIS-HCT (telmisartan/HCTZ)
DIRECT RENIN INHIBITOR
TEKTURNA (aliskerin) DIRECT RENIN INHIBITOR COMBINATIONS TEKTURNA-HCT (aliskerin/HCTZ) TEKAMLO (aliskiren/amlodipine) NR VALTURNA (aliskerin/valsartan)
ANGIOTENSIN MODULATOR/ ACE INHIBITOR/CCB COMBINATIONS CCB COMBINATIONS benazepril/amlodipine LOTREL TARKA (trandolapril/verapamil) ANGIOTENSIN RECEPTOR BLOCKER/CCB COMBINATIONS AZOR (olmesartan/amlodipine) TWYNSTA (telmisartan/amlodipine) EXFORGE (valsartan/amlodipine) EXFORGE HCT (valsartan/amlodipine/HCTZ) TRIBENZOR (olmesartan/amlodipine/HCTZ) ANTICOAGULANTS ARIXTRA (fondaparinux) INNOHEP (tinzaparin) COUMADIN (warfarin) enoxaparin NR FRAGMIN (dalteparin) PRADAXA (dabigatran) NR LOVENOX (enoxaparin) warfarin
Unless otherwise stated, the listing of a particular brand or generic name includes all dosage forms of that drug. NR indicates a new drug that has not yet been reviewed by the 4 P&T Committee. See separate Antihistamine/Decongestant Product and Active Ingredient Cross-Reference List for complete list of product names and active ingredients. MISSISSIPPI DIVISION OF MEDICAID PREFERRED DRUG LIST Effective January 1, 2011 BODY SYSTEM THERAPEUTIC CLASS PREFERRED AGENTS NON-PREFERRED AGENTS NOTES
BETA-BLOCKERS BETA BLOCKERS CARDIOVASCULAR acebutolol betaxolol (CONTINUED) atenolol INNOPRAN XL (propranolol)
bisoprolol LEVATOL (penbutolol)
BYSTOLIC (nebivolol) sotalol
metoprolol
metopolol XL
nadolol
pindolol
propranolol
timolol
BETA- AND ALPHA- BLOCKERS
carvedilol COREG CR (carvedilol) labetalol BETA BLOCKER / DIURETIC COMBINATIONS atenolol/chlorthalidone bisoprolol/HCTZ metoprolol/HCTZ nadolol/bendroflumethiazide propranolol/HCTZ timolol/HCTZ
CALCIUM CHANNEL SHORT-ACTING BLOCKERS diltiazem isradipine nicardipine nifedipine verapamil LONG-ACTING amlodipine CARDENE SR (nicardipine) COVERA-HS (verapamil) CARDIZEM LA (diltiazem) diltiazem ER SULAR (nisoldipine) DYNACIRC CR (isradipine) nisoldipine felodipine ER verapamil ER PM nifedipine ER verapamil ER LIPOTROPICS, OTHER BILE ACID SEQUESTRANTS
(NON-STATINS) cholestyramine WELCHOL (colesevalam)
Unless otherwise stated, the listing of a particular brand or generic name includes all dosage forms of that drug. NR indicates a new drug that has not yet been reviewed by the 5 P&T Committee. See separate Antihistamine/Decongestant Product and Active Ingredient Cross-Reference List for complete list of product names and active ingredients. MISSISSIPPI DIVISION OF MEDICAID PREFERRED DRUG LIST Effective January 1, 2011 BODY SYSTEM THERAPEUTIC CLASS PREFERRED AGENTS NON-PREFERRED AGENTS NOTES colestipol CARDIOVASCULAR CHOLESTEROL ABSORPTION INHIBITORS (CONTINUED) LIPOTROPICS, OTHER ZETIA (ezetimibe) (CONTINUED) FIBRIC ACID DERIVATIVES fenofibrate ANTARA (fenofibrate) gemfibrozil FENOGLIDE (fenofibrate) TRICOR (fenofibrate) FIBRICOR (fenofibric acid) TRILIPIX (fenofibric acid) LIPOFEN (fenofibrate) TRIGLIDE (fenofibrate) NIACIN NIACOR (niacin) NIASPAN (niacin) OMEGA-3 FATTY ACIDS LOVAZA (omega-3 fatty acids) LIPOTROPICS, STATINS STATINS LESCOL (fluvastatin) ALTOPREV (lovastatin) LESCOL XL (fluvastatin) CRESTOR (rosuvastatin) LIPITOR (atorvastatin) LIVALO (pitavastatin) lovastatin pravastatin simvastatin STATIN COMBINATIONS CADUET (atorvastatin/amlodipine) ADVICOR (lovastatin/niacin) VYTORIN (simvastatin/ezetimibe) SIMCOR (simvastatin/niacin) PLATELET AGGREGATION AGGRENOX (dipyridamole/aspirin) EFFIENT (prasugrel) INHIBITORS dipyridamole ticlopidine PLAVIX (clopidogrel) PULMONARY ARTERIAL LETAIRIS (ambrisentan) ADCIRCA (tadalafil) HYPERTENSION AGENTS REVATIO (sildenafil) TYVASO (treprostinil) TRACLEER (bosentan) VENTAVIS (iloprost) CNS ALZHEIMER’S AGENTS CHOLINESTERASE INHIBITORS ARICEPT (donepezil) COGNEX (tacrine) ARICEPT ODT (donepezil) galantamine EXELON (rivastigmine) galantamine ER rivastigmine
Unless otherwise stated, the listing of a particular brand or generic name includes all dosage forms of that drug. NR indicates a new drug that has not yet been reviewed by the 6 P&T Committee. See separate Antihistamine/Decongestant Product and Active Ingredient Cross-Reference List for complete list of product names and active ingredients. MISSISSIPPI DIVISION OF MEDICAID PREFERRED DRUG LIST Effective January 1, 2011 BODY SYSTEM THERAPEUTIC CLASS PREFERRED AGENTS NON-PREFERRED AGENTS NOTES
CNS ALZHEIMER’S AGENTS NMDA RECEPTOR ANTAGONIST (CONTINUED) (continued) NAMENDA (memantine)
ANTICONVULSANTS HYDANTOINS
DILANTIN (phenytoin) PEGANONE (ethotoin)
PHENYTEK (phenytoin)
phenytoin
SUCCINIMIDES
ethosuximide CELONTIN (methsuximide)
ADJUVANTS
carbamazepine BANZEL (rufinamide)
CARBATROL (carbamazepine) FELBATOL (felbamate)
DEPAKOTE ER (divalproex) KEPPRA XR (levetiracetam)
DEPAKOTE SPRINKLE (divalproex) SABRIL (vigabatrin)
divalproex STAVZOR (valproic acid)
divalproex ER TRILEPTAL Tablets (oxcarbazepine) EQUETRO (carbamazepine) VIMPAT (lacosamide) gabapentin GABITRIL (tiagabine) LAMICTAL ODT (lamotrigine) LAMICTAL XR (lamotrigine) lamotrigine levetiracetam oxcarbazepine TEGRETOL XR (carbamazepine) topiramate TRILEPTAL Suspension (oxcarbazepine) valproic acid zonisamide
Unless otherwise stated, the listing of a particular brand or generic name includes all dosage forms of that drug. NR indicates a new drug that has not yet been reviewed by the 7 P&T Committee. See separate Antihistamine/Decongestant Product and Active Ingredient Cross-Reference List for complete list of product names and active ingredients. MISSISSIPPI DIVISION OF MEDICAID PREFERRED DRUG LIST Effective January 1, 2011 BODY SYSTEM THERAPEUTIC CLASS PREFERRED AGENTS NON-PREFERRED AGENTS NOTES
CNS ANTIDEPRESSANTS, OTHERS bupropion APLENZIN (buproprion HBr) (CONTINUED) bupropion XL bupropion SR mirtazapine EFFEXOR XR (venlafaxine) nefazodone EMSAM (selegiline transdermal) PRISTIQ (desvenlafaxine) MARPLAN (isocarboxazid) trazodone NARDIL (phenelzine) WELBUTRIN XL (bupropion HCl) tranylcypromine venlafaxine venlafaxine ER venlafaxine XR WELLBUTRIN SR
ANTIDEPRESSANTS, SSRIs citalopram LEXAPRO (escitalopram) Lexapro will be
fluoxetine paroxetine CR approved for adolescents age fluvoxamine PEXEVA (paroxetine) 12 to 17 years old. LUVOX CR (fluvoxamine) PROZAC WEEKLY (fluoxetine)
paroxetine IR
sertraline
ANTIPARKINSON’S AGENTS ANTICHOLINERGICS
benztropine
trihexyphenidyl
COMT INHIBITORS
COMTAN (entacapone)
TASMAR (tolcapone)
DOPAMINE AGONISTS
ropinirole MIRAPEX (pramipexole)
MIRAPEX ER (pramipexole)
NEUPRO (rotigotine)
REQUIP XL (ropinirole) MAO-B INHIBITORS selegiline AZILECT (rasagiline) ZELAPAR (selegiline) OTHERS
levodopa/carbidopa
STALEVO (levodopa/carbidopa/entacapone)
bromocriptine
Unless otherwise stated, the listing of a particular brand or generic name includes all dosage forms of that drug. NR indicates a new drug that has not yet been reviewed by the 8 P&T Committee. See separate Antihistamine/Decongestant Product and Active Ingredient Cross-Reference List for complete list of product names and active ingredients. MISSISSIPPI DIVISION OF MEDICAID PREFERRED DRUG LIST Effective January 1, 2011 BODY SYSTEM THERAPEUTIC CLASS PREFERRED AGENTS NON-PREFERRED AGENTS NOTES
CNS ANTIPSYCHOTICS ORAL (CONTINUED) ABILIFY (aripiprazole) FAZACLO (clozapine)
amitriptyline/perphenazine INVEGA (paliperidone)
chlorpromazine SYMBYAX (olanzapine/fluoxetine) clozapine ZYPREXA (olanzapine) FANAPT (iloperidone) fluphenazine GEODON (ziprasidone) haloperidol MOBAN (molindone) perphenazine risperidone SAPHRIS (asenapine)re(quetiapine) SEROQUEL XR (quetiapine) thioridazine thiothixene trifluoperazine INJECTABLE, ATYPICALS ABILIFY (aripiprazole) GEODON (ziprasidone) INVEGA SUSTENNA (paliperidone palmitate) RISPERDAL CONSTA (risperidone) ZYPREXA (olanzapine) ZYPREXA RELPREVV (olanzapine) MULTIPLE SCLEROSIS AGENTS AVONEX (interferon beta-1a) AMPYRA (dalfampridine) NR BETASERON (interferon beta-1b) EXTAVIA (interferon beta-1b) COPAXONE (glatiramer) GILENYA (fingolimod) NR REBIF (interferon beta-1a)
Unless otherwise stated, the listing of a particular brand or generic name includes all dosage forms of that drug. NR indicates a new drug that has not yet been reviewed by the 9 P&T Committee. See separate Antihistamine/Decongestant Product and Active Ingredient Cross-Reference List for complete list of product names and active ingredients. MISSISSIPPI DIVISION OF MEDICAID PREFERRED DRUG LIST Effective January 1, 2011 BODY SYSTEM THERAPEUTIC CLASS PREFERRED AGENTS NON-PREFERRED AGENTS NOTES
SEDATIVE HYPNOTICS BENZODIAZEPINES Single source benzodiazepines estazolam temazepam (7.5mg and 22.5mg) and barbiturates
flurazepam are NOT covered; temazepam (15mg and 30mg) PAs will not be triazolam issued for these drugs. Sedative/Hypnotics OTHERS are limited to 31 LUNESTA (eszopiclone) AMBIEN CR (zolpidem) cumulative units of
zaleplon EDLUAR (zolpidem) all/any strengths per month. Any zolpidem ROZEREM (ramelteon) quantity required SILENOR (doxepin) NR above these limits requires a PA.
STIMULANTS AND RELATED STIMULANTS - SHORT ACTING Prior authorization AGENTS required for amphetamine salt combination DESOXYN (methamphetamine) patients >21 yrs of dexmethylphenidate IR methamphetamine age. dextroamphetamine IR PROCENTRA (dextroamphetamine) FOCALIN (dexmethylphenidate) METHYLIN chewable tablets (methylphenidate) METHYLIN solution (methylphenidate)
methylphenidate IR
STIMULANTS - LONG ACTING ADDERALL XR (amphetamine salt combination) amphetamine salt combination ER CONCERTA (methylphenidate) dextroamphetamine ER DAYTRANA (methylphenidate) NUVIGIL (armodafinil) FOCALIN XR (dexmethylphenidate) PROVIGIL (modafinil) METADATE CD (methylphenidate) RITALIN LA (methylphenidate) methylphenidate ER VYVANSE (lisdexamfetamine) NON-STIMULANTS INTUNIV (guanfacine ER) STRATTERA (atomoxetine)
Unless otherwise stated, the listing of a particular brand or generic name includes all dosage forms of that drug. NR indicates a new drug that has not yet been reviewed by the 10 P&T Committee. See separate Antihistamine/Decongestant Product and Active Ingredient Cross-Reference List for complete list of product names and active ingredients. MISSISSIPPI DIVISION OF MEDICAID PREFERRED DRUG LIST Effective January 1, 2011 BODY SYSTEM THERAPEUTIC CLASS PREFERRED AGENTS NON-PREFERRED AGENTS NOTES
DERMATOLOGICAL ACNE AGENTS, TOPICAL ANTIBIOTICS Acne agents will be authorized only clindamycin AKNE-MYCIN (erythromycin) for patients less
erythromycin CLINDAGEL (clindamycin) than 21 years of CLINDAREACH (clindamycin) age. EVOCLIN (clindamycin) sulfacetamide
RETINOIDS
RETIN-A MICRO (tretinoin) ATRALIN (tretinoin)
DIFFERIN (adapalene)
EPIDUO
(adapalene/benzoyl peroxide)
TAZORAC (tazarotene)
TRETIN-X (tretinoin) NR
tretinoin
OTHERS
AZELEX (azelaic acid) ACANYA BENZACLIN (benzoyl peroxide/clindamycin) (benzoyl peroxide/clindamycin) benzoyl peroxide ACZONE (dapsone) CLINAC BPO (benzoyl peroxide) BENZEFOAM (benzoyl peroxide) INOVA (benzoyl peroxide) benzoyl peroxide/clindamycin NUOX (benzoyl peroxide/sulfur) CLARIFOAM EF (sodium sulfacetamide/sulfur) PANOXYL (benzoyl peroxide) DUAC (benzoyl peroxide/clindamycin) sodium sulfacetamide/sulfur erythromycin/benzoyl peroxide ZACLIR (benzoyl peroxide) ROSULA (sulfacetamide and sulfur)
SE BPO (benzoyl peroxide)
sodium sulfacetamide/sulfur/meratan
VELTIN (clindamycin/tretinoin) NR
ZIANA (clindaymcyin/tretinoin)
Unless otherwise stated, the listing of a particular brand or generic name includes all dosage forms of that drug. NR indicates a new drug that has not yet been reviewed by the 11 P&T Committee. See separate Antihistamine/Decongestant Product and Active Ingredient Cross-Reference List for complete list of product names and active ingredients. MISSISSIPPI DIVISION OF MEDICAID PREFERRED DRUG LIST Effective January 1, 2011 BODY SYSTEM THERAPEUTIC CLASS PREFERRED AGENTS NON-PREFERRED AGENTS NOTES DERMATOLOGICAL (CONTINUED)
ANTIFUNGALS, TOPICAL ANTIFUNGALS ciclopirox cream/gel/suspension BENSAL HP ciclopirox shampoo (benzoic acid/salicylic acid) clotrimazole CNL 8 (ciclopirox) econazole ERTACZO (sertaconazole) ketoconazole cream EXTINA (ketoconazole) NR ketoconazole shampoo KETOCON PLUS (ketoconazole) miconazole OTC LOPROX (ciclopirox) NAFTIN (naftifine) MENTAX (butenafine) nystatin OXISTAT (oxiconazole) NR terbinafine OTC PEDIADERM AF (nystatin) tolnaftate OTC VUSION (miconazole/petrolatum/ zinc oxide)
XOLEGEL (ketoconazole) ANTIFUNGAL/STEROID COMBINATIONS clotrimazole/betamethasone nystatin/triamcinolone
ANTIPARASITICS, TOPICAL EURAX (crotamiton) lindane
malathionpermethrin OVIDE (malathion)
ULESFIA (benzyl alcohol)
ATOPIC DERMATITIS ELIDEL (pimecrolimus)
PROTOPIC (tacrolimus)
STEROIDS, TOPICAL LOW POTENCY CAPEX (fluocinolone) alclometasone desonide DERMA-SMOOTHE-FS (fluocinolone) hydrocortisone DESONATE (desonide) DESONIL PLUS (desonide) NR DESOWEN (desonide) Unless otherwise stated, the listing of a particular brand or generic name includes all dosage forms of that drug. NR indicates a new drug that has not yet been reviewed by the 12 P&T Committee. See separate Antihistamine/Decongestant Product and Active Ingredient Cross-Reference List for complete list of product names and active ingredients. MISSISSIPPI DIVISION OF MEDICAID PREFERRED DRUG LIST Effective January 1, 2011 BODY SYSTEM THERAPEUTIC CLASS PREFERRED AGENTS NON-PREFERRED AGENTS NOTES PEDIACARE HC (hydrocortisone) PEDIADERM (hydrocortisone) NR SCALACORT DK (hydrocortisone) VERDESO (desonide) MEDIUM POTENCY
fluocinolone CLODERM (clocortolone)
hydrocortisone CORDRAN (flurandrenolide)
LUXIQ (betamethasone) CUTIVATE (fluticasone)
mometasone fluticasone
prednicarbate MOMEXIN (mometasone) STEROIDS, TOPICAL PANDEL (hydrocortisone probuate) LOCOID (hydrocortisone butyrate) (CONTINUED) HIGH POTENCY
amcinonide desoximetasone betamethasone diflorasone betamethasone dipropionate HALOG ( halcinonide) CAPEX (fluocinolone) KENALOG (triamcinolone) fluocinolone PEDIADERM TA (triamcinolone) NR fluocinonide VANOS (fluocinonide) triamcinolone halcinonide VERY HIGH POTENCY
clobetasol CLOBEX (clobetasol)
halobetasol HALONATE
(halobetasol/ammonium lactate) HALAC (halobetasol/ammoium lac) NR OLUX-E (clobetasol) OLUX-OLUX-E (clobetasol) ULTRAVATE (halobetasol) ENDOCRINE ANDROGENIC AGENTS ANDRODERM (testosterone patch) TESTIM (testosterone gel) ANDROGEL (testosterone gel)
BONE RESORPTION BISPHOSPHONATES SUPPRESSION AND RELATED ACTONEL (risedronate) BONIVA (ibandronate) AGENTS ACTONEL WITH CALCIUM (risedronate/calcium) PROLIA (denosumab)
alendronate
FOSAMAX PLUS D (alendronate/vitamin D)
OTHERS Unless otherwise stated, the listing of a particular brand or generic name includes all dosage forms of that drug. NR indicates a new drug that has not yet been reviewed by the 13 P&T Committee. See separate Antihistamine/Decongestant Product and Active Ingredient Cross-Reference List for complete list of product names and active ingredients. MISSISSIPPI DIVISION OF MEDICAID PREFERRED DRUG LIST Effective January 1, 2011 BODY SYSTEM THERAPEUTIC CLASS PREFERRED AGENTS NON-PREFERRED AGENTS NOTES FORTICAL (calcitonin) DIDRONEL (etidronate) MIACALCIN (calcitonin) EVISTA (raloxifene) calcitonin salmon FORTEO (teriparatide)
GROWTH HORMONE NUTROPIN (somatropin) GENOTROPIN (somatropin) Prior authorization NUTROPIN AQ (somatropin) HUMATROPE (somatropin) required for patients >18 yrs of NORDITROPIN (somatropin) age. OMNITROPE (somatropin) SAIZEN (somatropin) GROWTH HORMONE SEROSTIM (somatropin) (CONTINUED) TEV-TROPIN (somatropin) ENDOCRINE ZORBTIVE (somatropin) (CONTINUED) HYPOGLYCEMICS, INCRETIN BYETTA (exenatide) SYMLIN (pramlintide)
MIMETICS/ ENHANCERS JANUMET (sitagliptin/metformin) VICTOZA (liraglutide)
JANUVIA (sitagliptin)
ONGLYZA (saxagliptin)
HYPOGLYCEMICS, INSULIN LANTUS (insulin glargine) APIDRA (insulin glulisine) AND RELATED AGENTS LEVEMIR (insulin detemir) HUMALOG (insulin lispro) (INCLUDES VIALS AND PENS) NOVOLIN (insulin) HUMALOG MIX NOVOLOG (insulin aspart) (insulin lispro/lispro protamine) NOVOLOG MIX (insulin aspart/aspart protamine) HUMULIN (insulin) HYPOGLYCEMICS, PRANDIN (repaglinide) PRANDIMET (repaglinide/metformin) MEGLITINIDES STARLIX (nateglinide) HYPOGLYCEMICS, TZDS THIAZOLINEDIONES ACTOS (pioglitazone) AVANDIA (rosiglitazone)
TZD COMBINATIONS ACTOPLUS MET (pioglitazone/metformin) AVANDAMET DUETACT (pioglitazone/glimepiride) (rosiglitazone/metformin) AVANDARYL (rosiglitazone/glipizide) GASTROINTESTINAL ANTIEMETICS CANNABINOIDS CESAMET (nabilone) dronabinol
5HT3 RECEPTOR BLOCKERS All injectable 5HT3 receptor blockers ondansetron ANZEMET (dolasetron) closed to point of ondansetron solution granisetron sale. ondansetron ODT Ondansetron ODT SANCUSO (granisetron) Unless otherwise stated, the listing of a particular brand or generic name includes all dosage forms of that drug. NR indicates a new drug that has not yet been reviewed by the 14 P&T Committee. See separate Antihistamine/Decongestant Product and Active Ingredient Cross-Reference List for complete list of product names and active ingredients. MISSISSIPPI DIVISION OF MEDICAID PREFERRED DRUG LIST Effective January 1, 2011 BODY SYSTEM THERAPEUTIC CLASS PREFERRED AGENTS NON-PREFERRED AGENTS NOTES ZUPLENZ FILM (ondansetron) 4mg tablets are covered without a PA for ages 1-11.
NMDA RECEPTOR ANTAGONIST EMEND (aprepitant) BILE SALTS ACTIGALL (ursodiol) CHENODAL (chenodiol) URSO (ursodiol) URSO FORTE (ursodiol) ursodiol
H. PYLORI AGENTS HELIDAC (bismuth subsalicylate, metronidazole, PYLERA tetracycline) (bismuth subcitrate potassium, PREVPAC (lansoprazole, amoxicillin, clarithromycin) metronidazole, tetracycline) GASTROINTESTINAL PANCREATIC ENZYMES CREON (pancreatin) PANCRECARB MS (pancrelipase) (CONTINUED) pancrelipase PANCREAZE (pancrelipase)
VIOKASE (pancrelipase) PANCREASE MT (pancrelipase)
ZENPEP (pancrelipase) ULTRASE (pancrelipase)
PROTON PUMP INHIBITORS DEXILANT formerly KAPIDEX (dexlansoprazole) ACIPHEX (rabeprazole) omeprazole RX lansoprazole RX PREVACID SOLU-TAB (lansoprazole) NEXIUM (esomeprazole)
omeprazole sodium bicarbonate pantoprazole PREVACID Rx (lansoprazole) PRILOSEC RX (omeprazole) ZEGERID RX (omeprazole sodium bicarbonate) ULCERATIVE COLITIS AGENTS ORAL APRISO (mesalamine) LIALDA (mesalamine) ASACOL (mesalamine) ASACOL HD (mesalamine) balsalazide
DIPENTUM (olsalazine) PENTASA (mesalamine) sulfasalazine RECTAL CANASA (mesalamine) SFROWASA (mesalamine) mesalamine
Unless otherwise stated, the listing of a particular brand or generic name includes all dosage forms of that drug. NR indicates a new drug that has not yet been reviewed by the 15 P&T Committee. See separate Antihistamine/Decongestant Product and Active Ingredient Cross-Reference List for complete list of product names and active ingredients. MISSISSIPPI DIVISION OF MEDICAID PREFERRED DRUG LIST Effective January 1, 2011 BODY SYSTEM THERAPEUTIC CLASS PREFERRED AGENTS NON-PREFERRED AGENTS NOTES IMMUNOLOGIC CYTOKINE AND CAM ENBREL (etanercept) AMEVIVE (alefacept) Amevive, Orencia, AGENTS ANTAGONISTS HUMIRA (adalimumab) CIMZIA (certolizumab) Remicade and Stelara are for KINERET (anakinra) ORENCIA (abatacept) administration in
REMICADE (infliximab) hospital or clinic SIMPONI (golimumab) setting. PA will not STELARA (ustekinumab) NR be issued at Point of Sale without justification.
IMMNOSUPPRESSIVE, ORAL AZASAN (azathioprine)
azathioprine IMMUNOLOGIC CELLCEPT (mycophenolate) AGENTS cyclosporine (CONTINUED) cyclosporine modifed
GENGRAF (cyclosporine) Mycophenolate mofetil MYFORTIC (mycophenolic acid) NEORAL (cyclosporine) PROGRAF (tacrolimus) RAPAMUNE (sirolimus) SANDIMMUNE (cyclosporine) tacrolimus ZORTRESS (everolimus) INFECTIOUS ANTIBIOTICS, GI ALINIA (nitazoxanide) FLAGYL ER (metronidazole) DISEASE metronidazole tinadazole neomycin VANCOCIN (vancomycin) TINDAMAX (tinadazole) XIFAXAN (rifaximin)
ANTIBIOTICS, VAGINAL CLEOCIN OVULES (clindamcyin) CLINDESSE (clindamycin)
clindamycin METROGEL (metronidazole)
metronidazole
VANDAZOLE (metronidazole)
ANTIFUNGALS, ORAL clotrimazole ANCOBON (flucytosine)
fluconazole itraconazole
Unless otherwise stated, the listing of a particular brand or generic name includes all dosage forms of that drug. NR indicates a new drug that has not yet been reviewed by the 16 P&T Committee. See separate Antihistamine/Decongestant Product and Active Ingredient Cross-Reference List for complete list of product names and active ingredients. MISSISSIPPI DIVISION OF MEDICAID PREFERRED DRUG LIST Effective January 1, 2011 BODY SYSTEM THERAPEUTIC CLASS PREFERRED AGENTS NON-PREFERRED AGENTS NOTES GRIFULVIN V (griseofulvin) LAMISIL (terbinafine) GRIS-PEG (griseofulvin) NOXAFIL (posaconazole) ketoconazole ORAVIG (miconazole) nystatin TERBINEX Kit terbinafine (terbinafine/ciclopirox) VFEND (voriconazole) ANTIVIRALS, ORAL – acyclovir famciclovir ANTIHERPETIC AGENTS valacyclovir VALTREX (valacyclovir)
CEPHALOSPORINS AND BETA LACTAM/BETA-LACTAMASE INHIBITOR COMBINATIONS RELATED ANTIBIOTICS amoxicillin/clavulanate
AUGMENTIN 125 and 250 (amoxicillin/clavulanate) Suspension INFECTIOUS AUGMENTIN 250 mg (amoxicillin/ clavulanate) DISEASE Chewable Tablets (CONTINUED) AUGMENTIN XR (amoxicillin/clavulanate)
CEPHALOSPORINS – First Generation
cefadroxil cephalexin
CEPHALOSPORINS – Second Generation
cefaclor cefprozil cefuroxime CEPHALOSPORINS – Third Generation cefdinir suspension (for patients <18 yr only) CEDAX (ceftibuten) SUPRAX (cefixime) cefdinir capsules cefpodoxime SPECTRACEF (cefditoren)
FLUOROQUINOLONES, ORAL AVELOX (moxifloxacin) ciprofloxacin ER
ciprofloxacin tablets CIPRO (ciprofloxacin)
FACTIVE (gemifloxacin)
LEVAQUIN (levofloxacin)
NOROXIN (norfloxacin)
ofloxacin
PROQUIN XR (ciprofloxacin)
HEPATITIS C TREATMENTS PEGASYS (peginterferon alfa-2a) INFERGEN (interferon alfacon-1) Peg-Intron will be approved for PEG-INTRON (peginterferon alfa-2b) patients with Unless otherwise stated, the listing of a particular brand or generic name includes all dosage forms of that drug. NR indicates a new drug that has not yet been reviewed by the 17 P&T Committee. See separate Antihistamine/Decongestant Product and Active Ingredient Cross-Reference List for complete list of product names and active ingredients. MISSISSIPPI DIVISION OF MEDICAID PREFERRED DRUG LIST Effective January 1, 2011 BODY SYSTEM THERAPEUTIC CLASS PREFERRED AGENTS NON-PREFERRED AGENTS NOTES history of treatment failure and/or <18 yr of age
MACROLIDES/ KETOLIDES KETOLIDES KETEK (telithromycin) MACROLIDES
azithromycin clarithromycin ER
clarithromycin IR ZMAX (azithromycin)
erythromycin INFECTIOUS DISEASE TETRACYCLINES doxycycline ADOXA CK (doxycycline) (CONTINUED) minocycline IR ADOXA TT (doxycycline) tetracycline demeclocycline minocycline ER NUTRIDOX (doxycycline) ORACEA (doxycycline) SOLODYN (minocycline) NEPHROLOGIC ERYTHROPOIESIS ARANESP (darbepoetin) EPOGEN (rHuEPO) AGENTS STIMULATING PROTEINS PROCRIT (rHuEPO)
PHOSPHATE BINDERS ELIPHOS (calcium acetate) FOSRENOL (lanthanum)
PHOSLO (calcium acetate)
calcium acetate
RENAGEL (sevelamer HCl) RENVELA (sevelamer carbonate) NUTRITIONALS CALORIC AGENTS BOOST (includes all boost) COMPLEAT BRIGHT BEGINNINGS EO28 SPLAST CARNATION INSTANT BREAKFAST FIBERSOURCE DUOCAL ISOSOURCE ENSURE JEVITY JUVEN KINDERCAL GLUCERNA PEPTAMEN NUTREN (includes all nutren) PROMOTE OSMOLITE SIMPLE THICK PEDIASURE TOLEREX POLYCOSE VITAL PROMOD VIVONEX RESOURCE SCANDISHAKE TWOCAL HN
Unless otherwise stated, the listing of a particular brand or generic name includes all dosage forms of that drug. NR indicates a new drug that has not yet been reviewed by the 18 P&T Committee. See separate Antihistamine/Decongestant Product and Active Ingredient Cross-Reference List for complete list of product names and active ingredients. MISSISSIPPI DIVISION OF MEDICAID PREFERRED DRUG LIST Effective January 1, 2011 BODY SYSTEM THERAPEUTIC CLASS PREFERRED AGENTS NON-PREFERRED AGENTS NOTES
OPHTHALMICS OPHTHALMIC AZASITE (azithromycin) BESIVANCE (besifloxacin) ANTIBIOTICS bacitracin CILOXAN (ciprofloxacin) bacitracin/polymyxin ciprofloxacin erythromycin NATACYN (natamycin) gentamicin ofloxacin IQUIX (levofloxacin) QUIXIN (levofloxacin) polymyxin/trimethoprim ZYMAR (gatifloxacin) sulfacetamide ZYMAXID (gatifloxacin) tobramycin TOBREX (tobramycin) Ointment triple antibiotic VIGAMOX (moxifloxacin) OPHTHALMIC ANTIBIOTIC neomycin/bacitracin/polymycin/hc STEROID COMBINATIONS neomycin//polymycin/dexamethasone neomycin/polymycin/hc POLY-PRED (prednisolone/neomycin/polymyxin) PRED-G (gentamicin/prednisolone) sulfactamide/prednisolone TOBRADEX OINTMENT (tobramycin/dexamethasone) tobramycin/dexamethasone ZYLET (loteprednol/tobramycin)
OPHTHALMIC dexamethasone ACULAR LS (ketorolac)
ANTIINFLAMMATORIES diclofenac ACULAR PF (ketorolac)
FLAREX (fluorometholone) BROMDAY (brimfenac) NR
flurbiprofen DUREZOL (difluprednate)
FML FORTE (fluorometholone) PRED MILD (prednisolone)
FML SOP (fluorometholone) XIBROM (bromfenac)
ketotifen
LOTEMAX (loteprednol)
Unless otherwise stated, the listing of a particular brand or generic name includes all dosage forms of that drug. NR indicates a new drug that has not yet been reviewed by the 19 P&T Committee. See separate Antihistamine/Decongestant Product and Active Ingredient Cross-Reference List for complete list of product names and active ingredients. MISSISSIPPI DIVISION OF MEDICAID PREFERRED DRUG LIST Effective January 1, 2011 BODY SYSTEM THERAPEUTIC CLASS PREFERRED AGENTS NON-PREFERRED AGENTS NOTES MAXIDEX (dexamethasone) NEVANAC (nepafenac) OPHTHALMIC VEXOL (rimexolone) ANTIINFLAMMATORIES (CONTINUED)
OPHTHALMICS (continued) OPHTHALMICS FOR ALLERGIC ALREX (loteprednol) ACULAR (ketorolac) CONJUNCTIVITIS cromolyn ACUVAIL (ketorolac) ELESTAT (epinastine) ALAMAST (pemirolast) EMADINE (emedastine) ALOCRIL (nedocromil) ketotifen ALOMIDE (lodoxamide) OPTIVAR (azelastine) azelastine PATADAY (olopatadine) BEPREVE (bepotastine) PATANOL (olopatadine) OPHTHALMICS, GLAUCOMA AZOPT (brinzolamide) ALPHAGAN P (brimonidine) AGENTS betaxolol BETOPTIC S (betaxolol) BETIMOL (timolol) LUMIGAN (bimatoprost) brimonidine carteolol COMBIGAN (brimonidine/timolol) COSOPT (dorzolamide/timolol) dipivefrin dorzolamide dorzolamide/timolol ISTALOL (timolol) levobunolol metipranolol pilocarpine timolol TRAVATAN/TRAVATAN Z (travoprost) TRUSOPT (dorzolamide) XALATAN (latanoprost) OTICS OTIC ANTIBIOTICS CETRAXAL (ciprofloxacin) CIPRO HC CIPRODEX (ciprofloxacin/dexamethasone) (ciprofloxacin/hydrocortisone) COLY-MYCIN S (colistin/neomycin/ hydrocortisone) ofloxacin
Unless otherwise stated, the listing of a particular brand or generic name includes all dosage forms of that drug. NR indicates a new drug that has not yet been reviewed by the 20 P&T Committee. See separate Antihistamine/Decongestant Product and Active Ingredient Cross-Reference List for complete list of product names and active ingredients. MISSISSIPPI DIVISION OF MEDICAID PREFERRED DRUG LIST Effective January 1, 2011 BODY SYSTEM THERAPEUTIC CLASS PREFERRED AGENTS NON-PREFERRED AGENTS NOTES CORTISPORIN-TC (colistin/neomycin/ hydrocortisone) neomycin/polymyxin/hydrocortisone
RESPIRATORY ANTIHISTAMINES-FIRST brompheniramine ALDEX AN (doxylamine) GENERATION brompheniramine/diphenhydramine CONEX (brompheniramine) carbinoxamine DIPHENMAX (diphenhydramine) chlorpheniramine J-TAN (brompheniramine) clemastine J-TAN PD (brompheniramine) cyproheptadine dexchlorpheniramine diphenhydramine doxylamine MYCI CHLOR-TAN (chlorpheniramine) triprolidine VAZOL (brompheniramine) ANTIHISTAMINES-FIRST ALAHIST LQ (phenylephrine/diphenhydramine) ACCUHIST (pseudoephedrine/ GENERATION/ chlorpheniramine) DALLERGY drops (phenylephrine/chlorpheniramine) DECONGESTANT phenylephrine/brompheniramine ALLERDUR (pseudoephedrine/ COMBINATIONS dexchlorpheniramine) phenylephrine/chlorpheniramine ALERSULE (phenylephrine/ phenylephrine/diphenhydramine chlorpheniramine) phenylephrine/phenyltoloxamine/chlorpheniramine ALLERTAN(phenylephrine/pyrilamine/ phenylephrine/promethazine chlorpheniramine)
phenylephrine/pyrilamine ALLERX (phenylephrine/
phenylephrine/pyrilamine/chlorpheniramine chlorpheniramine)
POLY TAN D BROMFED (pseudoephedrine/ (pseudoephedrine/pyrilamine/brompheniramine) brompheniramine) pseudoephedrine/brompheniramine BROMFED-PD (pseudoephedrine/ pseudoephedrine/chlorpheniramine brompheniramine) pseudoephedrine/dexchlorpheniramine DALLERGY-JR pseudoephedrine/triprolidine (phenylephrine/chlorpheniramine) DECONSAL CT (phenylephrine/pyrilamine)
DISOPHROL (pseudoephedrine/ dexbrompheniramine)
DURATUSS DA (pseudoephedrine/ chlorpheniramine) Unless otherwise stated, the listing of a particular brand or generic name includes all dosage forms of that drug. NR indicates a new drug that has not yet been reviewed by the 21 P&T Committee. See separate Antihistamine/Decongestant Product and Active Ingredient Cross-Reference List for complete list of product names and active ingredients. MISSISSIPPI DIVISION OF MEDICAID PREFERRED DRUG LIST Effective January 1, 2011 BODY SYSTEM THERAPEUTIC CLASS PREFERRED AGENTS NON-PREFERRED AGENTS NOTES HISTEX (pseudoephedrine/ chlorpheniramine) HISTEX SR (pseudoephedrine/ brompheniramine)
J-TAN D (pseudoephedrine/
brompheniramine)
J-TAN D PD (pseudoephedrine/ brompheniramine)
RESPIRATORY ANTIHISTAMINES-FIRST MYCI CHLORPED D (CONTINUED) GENERATION/ (phenylephrine/chlorpheniramine) DECONGESTANT NY-TANNIC COMBINATIONS (phenylephrine/chlorpheniramine) (CONTINUED) PEDIATAN D (phenylephrine/chlorpheniramine) PHENA-PLUS (phenylephrine/ pyrilamine/chlorpheniramine)
PHENA-S (phenylephrine/pyrilamine/ chlorpheniramine) PHENA-S 12 (phenylephrine/ pyrilamine/chlorpheniramine) POLY HIST FORTE (phenylephrine/ pyrilamine/chlorpheniramine) POLY HIST PD (phenylephrine/ pyrilamine/chlorpheniramine) RESCON-JR (phenylephrine/chlorpheniramine)
RYNA 12 S
(phenylephrine/pyrilamine)
RYNA-12 (phenylephrine/pyrilamine)
RYNATAN (phenylephrine/chlorpheniramine) RYNATAN PEDIATRIC (phenylephrine/chlorpheniramine) SERADEX-LA (phenylephrine/brompheniramine) SUDAL 12 (pseudoephedrine/ chlorpheniramine)
TIBAMINE LA (pseudoephedrine/
chlorpheniramine)
TUSSANIL (phenylephrine/chlorpheniramine) VAZOBID (phenylephrine/brompheniramine) Unless otherwise stated, the listing of a particular brand or generic name includes all dosage forms of that drug. NR indicates a new drug that has not yet been reviewed by the 22 P&T Committee. See separate Antihistamine/Decongestant Product and Active Ingredient Cross-Reference List for complete list of product names and active ingredients. MISSISSIPPI DIVISION OF MEDICAID PREFERRED DRUG LIST Effective January 1, 2011 BODY SYSTEM THERAPEUTIC CLASS PREFERRED AGENTS NON-PREFERRED AGENTS NOTES VAZOTAB (phenylephrine/brompheniramine) VIRAVAN-P (pseudoephedrine/pyrilamine)
ANTIHISTAMINES-FIRST brompheniramine/pseudoephedrine ALLERX 10 (pseudoephedrine/ GENERATION/DECONGESTANT/ chlorpheniramine/phenylephrine/methscopolamine methscopolamine/ ANTICHOLINERGIC chlorpheniramine/phenylephrine) DALLERGY COMBINATIONS (chlorpheniramine/ phenylephrine/methscopolamine) ALLERX 30 (pseudoephedrine/ methscopolamine/ phenylephrine/chlorpheniramine/belladonna alkaloids RESPIRATORY chlorpheniramine/phenylephrine) ANTIHISTAMINES-FIRST phenylephrine/dexchlorpheniramine/methscopolamine (CONTINUED) ALLERX PE (phenylephrine/ GENERATION/DECONGESTANT/ pseudoephedrine/chlorpheniramine/methscopolamine chlorpheniramine/ ANTICHOLINERGIC pseudoephedrine/dexchlorpheniramine/methscopolamine methscopolamine) COMBINATIONS pseudoephedrine/methscopolamine/chlorpheniramine/ DALLERGY PE (chlorpheniramine/ (CONTINUED) phenylephrine phenylephrine/methscopolamine)
DALLERGY (pseudoephedrine/
chlorpheniramine/ methscopolamine) DURAHIST (pseudoephedrine/ chlorpheniramine/ methscopolamine) DURAHIST D (pseudoephedrine/ dexchlorpheniramine/
methscopolamine)
DURAHIST PE (phenylephrine/ chlorpheniramine/ methscopolamine) DURATAN PE (phenylephrine/ chlorpheniramine/ methscopalamine) EXTENDRYL chew tab (phenylephrine/ chlorpheniramine/ methcopolamine) EXTENDRYL JR (phenylephrine/ chlorpheniramine/ methscopolamine) EXTENDRYL SR (phenylephrine/ chlorpheniramine/ methscopolamine) EXTENDRYL syrup (phenylephrine/ dexchlorpheniramine/ methscopolamine) RESCON (pseudoephedrine/ chlorpheniramine) Unless otherwise stated, the listing of a particular brand or generic name includes all dosage forms of that drug. NR indicates a new drug that has not yet been reviewed by the 23 P&T Committee. See separate Antihistamine/Decongestant Product and Active Ingredient Cross-Reference List for complete list of product names and active ingredients. MISSISSIPPI DIVISION OF MEDICAID PREFERRED DRUG LIST Effective January 1, 2011 BODY SYSTEM THERAPEUTIC CLASS PREFERRED AGENTS NON-PREFERRED AGENTS NOTES TIME-HIST QD (pseudoephedrine/ chlorpheniramine/ methscopolamine)
VISRX (pseudoephedrine/
chlorpheniramine/ RESPIRATORY methscopolamine) (CONTINUED) ANTIHISTAMINES-MINIMALLY cetirizine CLARINEX (desloratadine) *Xyzal will be
SEDATING loratadine fexofenadine approved for patients failing XYZAL (levocetirizine)* therapy with cetirizine, loratadine or fexofenadine.
ANTIHISTAMINES- cetirizine/pseudoephedrine CLARINEX-D (desloratadine/
MINIMALLY SEDATING/ loratadine/pseudoephedrine pseudoephedrine)
DECONGESTANT SEMPREX-D (acrivastine/pseudoephedrine) fexofenadine/pseudoephedrine COMBINATIONS
DECONGESTANT/ pseudoephedrine/methscopolamine ALLERX-D (pseudoephedrine/ ANTICHOLINERGIC methscopolamine) COMBINATIONS EXTENDRYL PEM (phenylephrine/ methscopolamine) EXTENDRYL PSE (pseudoephedrine/ methscopolamine)
BRONCHODILATORS, ANTICHOLINERGICS ANTICHOLINERGIC ATROVENT HFA (ipratropium) ipratropium SPIRIVA (tiotropium) ANTICHOLINERGIC-BETA AGONIST COMBINATIONS COMBIVENT (albuterol/ipratropium) albuterol/ipratropium
BRONCHODILATORS, BETA INHALERS, SHORT-ACTING AGONIST VENTOLIN HFA (albuterol) MAXAIR (pirbuterol)
PROAIR HFA (albuterol)
PROVENTIL HFA (albuterol)
XOPENEX HFA (levalbuterol)
INHALERS, LONG ACTING
FORADIL (formoterol) SEREVENT (salmeterol) INHALATION SOLUTION
albuterol BROVANA (arformoterol)
Unless otherwise stated, the listing of a particular brand or generic name includes all dosage forms of that drug. NR indicates a new drug that has not yet been reviewed by the 24 P&T Committee. See separate Antihistamine/Decongestant Product and Active Ingredient Cross-Reference List for complete list of product names and active ingredients. MISSISSIPPI DIVISION OF MEDICAID PREFERRED DRUG LIST Effective January 1, 2011 BODY SYSTEM THERAPEUTIC CLASS PREFERRED AGENTS NON-PREFERRED AGENTS NOTES metaproterenol PERFOROMIST (formoterol) XOPENEX (levalbuterol)
RESPIRATORY (CONTINUED) BRONCHODILATORS, BETA AGONIST ORAL (CONTINUED) albuterol
metaproterenol terbutaline GLUCOCORTICOIDS, INHALED GLUCOCORTICOIDS AEROBID (flunisolide) ALVESCO (ciclosinide) AEROBID-M (flunisolide) ASMANEX (mometasone) Budesonide DULERA (mometasone/formoterol) FLOVENT Diskus (fluticasone) FLOVENT HFA (fluticasone) PULMICORT (budesonide) Respules PULMICORT (budesonide) Flexhaler QVAR (beclomethasone) GLUCOCORTICOID/BRONCHODILATOR COMBINATIONS ADVAIR Diskus (fluticasone/salmeterol) Duleda (mometasone/formoterol) ADVAIR HFA (fluticasone/salmeterol) SYMBICORT (budesonide/formoterol) INTRANASAL RHINITIS AGENTS ANTICHOLINERGICS ipratropium
ANTIHISTAMINES
ASTEPRO (azelastine) ASTELIN (azelastine)
PATANASE (olaptadine)
azelastine CORTICOSTEROIDS flunisolide BECONASE AQ (beclomethasone) NASAREL (flunisolide) FLONASE (fluticasone) NASONEX (mometasone) fluticasone VERAMYST (fluticasone) NASACORT AQ (triamcinolone) OMNARIS (ciclesonide)
Unless otherwise stated, the listing of a particular brand or generic name includes all dosage forms of that drug. NR indicates a new drug that has not yet been reviewed by the 25 P&T Committee. See separate Antihistamine/Decongestant Product and Active Ingredient Cross-Reference List for complete list of product names and active ingredients. MISSISSIPPI DIVISION OF MEDICAID PREFERRED DRUG LIST Effective January 1, 2011 BODY SYSTEM THERAPEUTIC CLASS PREFERRED AGENTS NON-PREFERRED AGENTS NOTES RHINOCORT AQUA (budesonide) LEUKOTRIENE MODIFIERS ACCOLATE (zafirlukast) ZYFLO CR (zafirlukast) SINGULAIR (montelukast)
UROLOGICAL BLADDER RELAXANT DETROL LA (tolterodine) DETROL (tolterodine) PREPARATIONS ENABLEX (darifenacin) oxybutynin ER GELNIQUE (oxybutynin) OXYTROL (oxybutynin) oxybutynin IR SANCTURA XR (trospium) TOVIAZ (fesoterodine fumurate) SANCTURA (trospium) VESICARE (solifenacin) BPH AGENTS ALPHA BLOCKERS doxazosin CARDURA XL (doxazosin) FLOMAX RAPAFLO (silodosin) JALYN (dutasteride/tamsulosin) tamsulosin terazosin UROXATRAL (alfuzosin) 5-ALPHA-REDUCTASE (5AR) INHIBITORS AVODART (dutasteride) finasteride
Unless otherwise stated, the listing of a particular brand or generic name includes all dosage forms of that drug. NR indicates a new drug that has not yet been reviewed by the 26 P&T Committee. See separate Antihistamine/Decongestant Product and Active Ingredient Cross-Reference List for complete list of product names and active ingredients.