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Therapeutic Drug Class

Therapeutic Drug Class

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 10/01/2013 PREFERRED DRUG LIST Version 2013.26 Updated: 9-27-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS AGENTS (Topical) ANTI-INFECTIVE AZELEX () ACZONE () Acne agents will be authorized only for AKNE-MYCIN () patients less than 21 years of age. erythromycin CLEOCIN-T (clindamycin) CLINDAGEL (clindamycin) ERY (erythromycin) EVOCLIN (clindamycin) FINACEA (azelaic acid) KLARON (sulfacetamide) sulfacetamide

RETINOIDS TAZORAC () AVITA (tretinoin) ATRALIN (tretinoin) DIFFERIN (adapalene) RETIN-A (tretinoin) RETIN-A MICRO (tretinoin) tretinoin micro

COMBINATION DRUGS/OTHERS DUAC (/clindamycin) ACANYA (benzoyl peroxide/clindamycin) EPIDUO (adapalene/benzoyl peroxide) BENZACLIN GEL (benzoyl peroxide/clindamycin) sodium sulfacetamide/ BENZACLIN KIT (benzoyl peroxide/ clindamycin) cream/cleanser/foam/gel/lotion/suspension BENZAMYCIN PAK (benzoyl peroxide/ erythromycin) benzoyl peroxide/clindamycin CLENIA (sulfacetamide sodium/sulfur) erythromycin/benzoyl peroxide INOVA 4/1 (benzoyl peroxide/) INOVA 8/2 (benzoyl peroxide/salicylic acid) PRASCION (sulfacetamide sodium/sulfur) 1 This is not an all-inclusive list of available covered drugs and includes only managed categories. 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 P&T Committee. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 4-1-2014. **Users of these products as of 9-30-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 10/01/2013 PREFERRED DRUG LIST Version 2013.26 Updated: 9-27-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS ROSANIL (sulfacetamide sodium/sulfur) SE BPO (benzoyl peroxide) sodium sulfacetamide/sulfur pads sodium sulfacetamide/sulfur/meratan sulfacetamide sodium/sulfur/urea VELTIN (clindamycin/tretinoin) ZENCIA WASH (sulfacetamide sodium/sulfur) ZIANA (clindamycin/tretinoin) (BENZOYL PEROXIDES) benzoyl peroxide BENZEFOAM ULTRA (benzoyl peroxide) BP10 (benzoyl peroxide) BPO (benzoyl peroxide) INOVA (benzoyl peroxide) LAVOCLEN (benzoyl peroxide)

ALZHEIMER’S AGENTS SmartPA INHIBITORS ARICEPT () donepezil SmartPA Criteria: ARICEPT 23 MG (donepezil) • Documented diagnosis (based on ARICEPT ODT (donepezil) galantamine ER labeled indication) found in the past 2 EXELON () RAZADYNE (galantamine) years medical claims – ALL DRUGS AND EXELON Solution (rivastigmine) RAZADYNE ER (galantamine)

rivastigmine Non-Preferred Criteria • 30 days of therapy with 2 different preferred agents in the past 6 months OR • 90 days completed therapy with the same agent in the past 105 days NMDA RECEPTOR ANTAGONIST NAMENDA TABS (memantine) NAMENDA SOLUTION(memantine) NAMENDA XR (memantine)NR

2 This is not an all-inclusive list of available covered drugs and includes only managed categories. 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 P&T Committee. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 4-1-2014. **Users of these products as of 9-30-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 10/01/2013 PREFERRED DRUG LIST Version 2013.26 Updated: 9-27-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS ANALGESICS, NARCOTIC - SHORT ACTING SmartPA acetaminophen/codeine ABSTRAL (fentanyl) SmartPA Criteria: codeine ACTIQ (fentanyl) • Suboxone/ Subutex concurrent therapy dihydrocodeine/ APAP/ butalbital/APAP/caffeine/codeine o Opioids are limited to a 5 day supply hydrocodone/APAP butalbital/ASA/caffeine/codeine while on Suboxone or Subutex therapy with a maximum cumulative hydrocodone/ butorphanol tartrate (nasal) total of 10 days. hydromorphone DEMEROL (meperidine) meperidine DILAUDID (hydromorphone) Other Criteria at the Point of Sale: morphine fentanyl Applicable quantity limit in 31 rolling oxycodone FENTORA (fentanyl) days. oxycodone/APAP FIORICET W/ CODEINE • 62 tablets in 31 days – oxycodone/ (butalbital/APAP/caffeine/codeine) codeine, oxycodone/ibuprofen,

oxycodone/ibuprofen FIORINAL W/ CODEINE meperidine, hydromorphone, pentazocine/APAP (butalbital/ASA/caffeine/codeine) fentanyl, bultalbital/codeine IBUDONE (hydrocodone/ibuprofen) combinations, morphine, tramadol levorphanol tapentadol, dihydrocodeine tramadol/APAP LORCET (hydrocodone/APAP) combinations, tramadol, LORTAB (hydrocodone/APAP) pentazocine, MAGNACET (oxycodone/APAP) • 124 tablets in 31 days – NORCO (hydrocodone/APAP) butalbital/APAP 750 NUCYNTA (tapentadol) • 145 tablets in 31 days – ONSOLIS (fentanyl) butalbital/APAP 650 • in 31 days – OPANA (oxymorphone) 186 tablets butalbital/APAP 325, OXECTA (oxycodone) butalbital/ASA 325 pentazocine/naloxone • 5mL (2 x 2.5 bottles) in 31 PERCOCET (oxycodone/APAP) days – butorphanol nasal PERCODAN (oxycodone/ASA) REPREXAINE (hydrocodone/ibuprofen) Applicable CUMULATIVE quantity limit ROXICET (oxycodone/acetaminophen) in 31 rolling days RYBIX (tramadol) • 62 tablets in 31 days – SUBSYS (fentanyl) hydrocodone combinations, SYNALGOS-DC (dihydrocodeine/ aspirin/caffeine) oxycodone combinations TYLENOL W/CODEINE (APAP/codeine) • 180 ml – hydrocodone liquids, TYLOX (oxycodone/APAP) oxycodone liquids 3 This is not an all-inclusive list of available covered drugs and includes only managed categories. 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 P&T Committee. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 4-1-2014. **Users of these products as of 9-30-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 10/01/2013 PREFERRED DRUG LIST Version 2013.26 Updated: 9-27-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS ULTRACET (tramadol/APAP) • 480 mL – hydrocodone liquids ULTRAM (tramadol) VICODIN (hydrocodone/APAP) VICOPROFEN (hydrocodone/ibuprofen) XODOL (hydrocodone/acetaminophen) ZAMICET (hydrocodone/APAP) ZOLVIT (hydrocodone/APAP) ZYDONE (hydrocodone/acetaminophen)

ANALGESICS, NARCOTIC - LONG ACTING SmartPA DURAGESIC (fentanyl) AVINZA (morphine) SmartPA Criteria: methadone BUTRANS (buprenorphine) • Suboxone/ Subutex concurrent therapy morphine ER CONZIP ER (tramadol)NR o Opioids are limited to a 5 day supply OPANA ER (oxymorphone) DOLOPHINE (methadone) while on Suboxone or Subutex therapy with a maximum cumulative EMBEDA (morphine/naltrexone) total of 10 days. EXALGO (hydromorphone) • Avinza fentanyl patches o 30 days of therapy with Opana ER KADIAN (morphine) or morphine ER in the past 6 months MS CONTIN (morphine) OR NUCYNTA ER (tapentadol) o 90 days completed therapy with the oxycodone ER same agent in the past 105 days OXYCONTIN (oxycodone) AND oxymorphone ER o Quantity limit of 31 tablets in 31 days RYZOLT (tramadol) • OxyContin Documented diagnosis of cancer tramadol ER o found in the past 2 years medical ULTRAM ER (tramadol) claims OR

o Antineoplastic therapy in the past 6 months AND o 30 days of therapy with Kadian, Opana ER, morphine ER , Avinza or Duragesic patch in the past 6 months AND o Quantity limit of 62 tablets in 31 days. 4 This is not an all-inclusive list of available covered drugs and includes only managed categories. 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 P&T Committee. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 4-1-2014. **Users of these products as of 9-30-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 10/01/2013 PREFERRED DRUG LIST Version 2013.26 Updated: 9-27-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS • Non-Preferred Criteria o 30 days of therapy with 2 different preferred agents in the past 6 months OR o 90 days completed therapy with the same agent in the past 105 days AND o Applicable quantity limit in 31 rolling days. • 31 tablets in 31 days – Exalgo ER, Ultram ER, Ryzolt, Conzip ER, • 62 tablets in 31 days – Methadone, Kadian, Morphine ER, Embeda, oxycodone ER, Opana ER, • 10 patches in 31 days – Duragesic • 4 patches in 31 days - Butrans ANALGESICS/ANAESTHETICS (Topical) SmartPA SmartPA VOLTAREN Gel (diclofenac sodium) capsaicin SmartPA Criteria: SmartPA FLECTOR (diclofenac epolamine) Non-Preferred Criteria LIDAMANTLE HC (lidocaine/hydrocortisone) • One claim for 1 preferred agent in the lidocaine past 6 months OR lidocaine/prilocaine • 90 days completed therapy with the SmartPA LIDODERM (lidocaine) same agent in the past 105 days SmartPA PENNSAID Solution (diclofenac sodium ) • Lidoderm xylocaine o Documented diagnosis found in the SYNERA (lidocaine/tetracaine) past years medical claims for ZOSTRIX (capsaicin) Herpetic Neuralgia OR o Documented diagnosis found in the past years medical claims for Diabetic Neuropathy

5 This is not an all-inclusive list of available covered drugs and includes only managed categories. 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 P&T Committee. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 4-1-2014. **Users of these products as of 9-30-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 10/01/2013 PREFERRED DRUG LIST Version 2013.26 Updated: 9-27-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS ANDROGENIC AGENTS SmartPA TESTIM (testosterone gel) ANDRODERM (testosterone patch) SmartPA Criteria: ANDROGEL (testosterone gel) • Limited to male patients AND AXIRON (testosterone gel) • 30 days of therapy with 1 different FORTESTSA (testosterone gel) preferred agent in the past 6 months OR

• 90 days completed therapy with the same agent in the past 105 days ANGIOTENSIN MODULATORS SmartPA ACE INHIBITORS benazepril ACCUPRIL (quinapril) SmartPA Criteria: captopril ALTACE (ramipril) • ACE Inhibitor enalapril LOTENSIN (benazepril) o 30 days of therapy with 2 different MAVIK (trandolapril) fosinopril preferred single entity agents in the moexipril past 6 months OR lisinopril perindopril 90 days completed therapy with the quinapril o PRINIVIL (lisinopril) same agent in the past 105 days ramipril UNIVASC (moexipril) trandolapril VASOTEC (enalapril) ZESTRIL (lisinopril) ACE INHIBITOR COMBINATIONS benazepril/HCTZ ACCURETIC (quinapril/HCTZ) • ACE Inhibitor/CCB captopril/HCTZ benazepril/amlodipine o 30 days of therapy with 2 different enalapril/HCTZ LOTENSIN HCT (benazepril/HCTZ) preferred ACEI/CCB agents in the fosinopril/HCTZ moexipril/HCTZ past 6 months OR 90 days completed therapy with the lisinopril/HCTZ trandolapril/verapamil o same agent in the past 105 days LOTREL(benazepril/amlodipine) UNIRETIC (moexipril/HCTZ) VASERETIC (enalapril/HCTZ) quinapril/HCTZ • ZESTORETIC (lisinopril/HCTZ) ACE Inhibitor/Diuretic TARKA (trandolapril/verapamil) 30 days of therapy with 2 different o preferred ACEI/Diuretic agents in the past 6 months OR o 90 days of completed therapy with the same agent in the past 105 days. 6 This is not an all-inclusive list of available covered drugs and includes only managed categories. 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 P&T Committee. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 4-1-2014. **Users of these products as of 9-30-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 10/01/2013 PREFERRED DRUG LIST Version 2013.26 Updated: 9-27-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS ANGIOTENSIN II RECEPTOR BLOCKERS (ARBs) AVAPRO (irbesartan) ATACAND (candesartan) • ARB BENICAR (olmesartan) candesartan o 30 days of therapy with 2 different DIOVAN (valsartan) COZAAR (losartan) preferred single entity agents in the losartan EDARBI (azilsartan) past 6 months OR • 90 days completed therapy with the MICARDIS (telmisartan) eprosartan same agent in the past 105 days irbesartan TEVETEN (eprosartan) ARB COMBINATIONS AVALIDE (irbesartan/HCTZ) ATACAND-HCT (candesartan/HCTZ) • ARB/CCB (includes ARB/CCB/Diuretic) BENICAR-HCT (olmesartan/HCTZ) AZOR (olmesartan/amlodipine) o 30 days of therapy with 1 different DIOVAN-HCT (valsartan/HCTZ) candesartan/HCTZ preferred ARB/CCB agent in the EXFORGE (valsartan/amlodipine) EDARBYCLOR (azilsartan/chlorthalidone) past 6 months OR 90 days completed therapy with the EXFORGE HCT (valsartan/amlodipine/HCTZ) irbesartan/HCTZ o same agent in the past 105 days HYZAAR (losartan/HCTZ) losartan/HCTZ MICARDIS-HCT (telmisartan/HCTZ) TEVETEN-HCT (eprosartan/HCTZ) • ARB/Diuretic TRIBENZOR (olmesartan/amlodipine/HCTZ) o 30 days of therapy with 2 different TWYNSTA (telmisartan/amlodipine) preferred ARB/Diuretic products in the past 6 months OR o 90 days of completed therapy with the same agent in the past 105 days DIRECT RENIN INHIBITORS TEKTURNA (aliskiren) • Direct Renin Inhibitor o Documented diagnosis found in the past 2 years medical claims for hypertension AND o 30 days of therapy with 2 different preferred ACEI or ARB single-entity products in the past 6 months OR o 90 days completed therapy with the same agent in the past 105 days

7 This is not an all-inclusive list of available covered drugs and includes only managed categories. 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 P&T Committee. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 4-1-2014. **Users of these products as of 9-30-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 10/01/2013 PREFERRED DRUG LIST Version 2013.26 Updated: 9-27-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS DIRECT RENIN INHIBITOR COMBINATIONS AMTURNIDE (aliskiren/amlodipine/hctz) • Direct Renin Inhibitor Combinations

TEKAMLO (aliskiren/amlodipine) o Documented diagnosis found in the TEKTURNA-HCT (aliskiren/hctz) past 2 years medical claims for VALTURNA (aliskiren/valsartan) hypertension AND 30 days of therapy with 2 different o preferred ACEI or ARB diuretic agents in the past 6 months OR o 90 days completed therapy with the same agent in the past 105 days

ANTIBIOTICS (Topical) bacitracin ALTABAX (retapamulin) bacitracin/polymixin BACTROBAN OINTMENT (mupirocin) BACTROBAN cream (mupirocin) CORTISPORIN (bacitracin/neomycin/ gentamicin polymyxin/HC) mupirocin ointment mupirocin cream (GI) ALINIA (nitazoxanide) DIFICID () *Xifaxan –requires a manual PA FLAGYL ER (metronidazole) • Documented diagnosis of Hepatic neomycin VANCOCIN (vancomycin) Encephalopathy on manual PA request TINDAMAX () vancomycin AND tinidazole XIFAXAN () o One trial of Lactulose OR o Documented treatment failure or intolerance to lactulose OR o Hospital discharge on Xifaxan OR o One claim for Xifaxan in the past 365 days

ANTIBIOTICS (VAGINAL) CLEOCIN OVULES (clindamycin) AVC () clindamycin CLEOCIN CREAM (clindamycin) METROGEL (metronidazole) CLINDESSE (clindamycin) VANDAZOLE (metronidazole) metronidazole vaginal 8 This is not an all-inclusive list of available covered drugs and includes only managed categories. 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 P&T Committee. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 4-1-2014. **Users of these products as of 9-30-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 10/01/2013 PREFERRED DRUG LIST Version 2013.26 Updated: 9-27-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS ANTICOAGULANTS SmartPA SmartPA LMWH COUMADIN (warfarin) ARIXTRA (fondaparinux) Pradaxa:

FRAGMIN (dalteparin) SmartPA LMWH ELIQUIS (apixaban) • Minimum Age requirements – 18 years SmartPA LMWH LOVENOX (enoxaparin) SmartPA LMWH enoxaparin AND SmartPA SmartPA LMWH PRADAXA (dabigatran) fondaparinux • Documented diagnosis of atrial SmartPA fibrillation found in the past 2 years XARELTO 10mg (rivaroxaban) XARELTO 15 & 20mg (rivaroxaban) warfarin medical claims AND • NO documented diagnosis of cardiac valve disease found in the past 2 years medical claims AND • Documented diagnosis of 1 of the following in the past 2 years medical claims (Stroke, TIA, Systemic embolism, Diabetes Mellitus, Left Ventricular Dysfunction, Heart Failure) o OR Age >75 (EXCEPTION) does not have to meet the diagnosis criteria above o OR Age 65-75 (EXCEPTION) – documented diagnosis of hypertension found in the past 2 years medical claims AND • NO documented diagnosis of pathologic bleeding found in the past 6 months medical claims AND • NO documented diagnosis of rheumatic heart disease or severe renal impairment found in the past 2 years medical claims AND • NO documented diagnosis of mechanical valve prosthesis and dialysis found in the past years medical claims AND • NO active rifampin claims AND • Applicable quantity limit - 60 tablets 9 This is not an all-inclusive list of available covered drugs and includes only managed categories. 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 P&T Committee. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 4-1-2014. **Users of these products as of 9-30-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 10/01/2013 PREFERRED DRUG LIST Version 2013.26 Updated: 9-27-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS

Xarelto 10mg : • Diagnosis of Atrial Fibrillation will require a Manual PA

SmartPA Criteria • Limited to 70 days of therapy per calendar year • Documented diagnosis of knee replacement in past 30 days of medical claims or submitted on pharmacy claim o AND therapy limits of < 12 days • OR documented diagnosis of hip replacement in past 30 days of medical claims or submitted on pharmacy claim o AND therapy limits of < 35 days

LMWH: • 30 days of therapy with 2 different preferred agents in the past 6 months OR • 90 days completed therapy with the same agent in the past 105 days

• LMWH therapy is found in prescription history in the past 3months o AND documented diagnosis of cancer in the past 2 years medical claims o OR Female with a documented diagnosis of pregnancy found in the past 280 days medical claims OR • NO LMWH therapy is found in prescription history in the past 3months o AND duration of therapy is < 17 10 This is not an all-inclusive list of available covered drugs and includes only managed categories. 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 P&T Committee. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 4-1-2014. **Users of these products as of 9-30-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 10/01/2013 PREFERRED DRUG LIST Version 2013.26 Updated: 9-27-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS days o OR documented diagnosis of cancer in the past 2 years medical claims o OR Female with a documented diagnosis of pregnancy found in the past 280 days medical claims o OR documented diagnosis of total hip/knee replacement or hip fracture surgery in the past 6 months medical claims • AND duration of therapy < 35 days

Coumadin: • Non-Preferred Criteria o 90 days completed therapy with the same agent in the past 105 days ANTICONVULSANTS SmartPA ADJUVANTS carbamazepine BANZEL (rufinamide) SmartPA Criteria: CARBATROL (carbamazepine) carbamazepine XR DEPAKOTE ER (divalproex) DEPAKENE (valproic acid) Lamictal XR/carbamazepine ER/XR: • DEPAKOTE SPRINKLE (divalproex) DEPAKOTE (divalproex) Documented diagnosis of seizures found in the past 2 years medical divalproex EQUETRO (carbamazepine) NR claims AND FANATREX SUSPENSION (gabapentin) divalproex ER • 90 days completed therapy with the felbamate EPITOL (carbamazepine) same agent in the past 105 days gabapentin FELBATOL (felbamate) GRALISE (gabapentin) GABITRIL (tiagabine) Banzel/Onfi: lamotrigine HORIZANT (gabapentin) • 90 days completed therapy with the KEPPRA (levetiracetam) levetiracetam same agent in the past 105 days KEPPRA XR (levetiracetam) oxcarbazepine OR LAMICTAL (lamotrigine) TEGRETOL XR (carbamazepine) • Minimum Age Requirements – LAMICTAL CHEWABLE (lamotrigine) TOPAMAX Sprinkle (topiramate) o Rufinamide – 4 years LAMICTAL ODT (lamotrigine) Clobazam – 2 years topiramate o LAMICTAL XR (lamotrigine) AND 11 This is not an all-inclusive list of available covered drugs and includes only managed categories. 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 P&T Committee. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 4-1-2014. **Users of these products as of 9-30-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 10/01/2013 PREFERRED DRUG LIST Version 2013.26 Updated: 9-27-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS TRILEPTAL Suspension (oxcarbazepine) levetiracetam ER • Documented diagnosis of Lennox- valproic acid NEURONTIN (gabapentin) Gastaut found in the past 2 years VIMPAT (lacosamide) oxcarbazepine suspension medical claims zonisamide OXTELLAR XR (oxcarbazepine) AND POTIGA (ezogabine) • 30 days of therapy with 1 different SABRIL (vigabatrin) preferred agents for Lennox-Gastaut in STAVZOR (valproic acid) the past 6 months TEGRETOL (carbamazepine) Non-Preferred Agents tiagabine • 30 days of therapy with 2 different topiramate capsule preferred agents in the past 6 months OR TRILEPTAL Tablets (oxcarbazepine) NR • 90 days completed therapy with the TROKENDI XR (topiramate) same agent in the past 105 days ZONEGRAN (zonisamide) SELECTED BENZODIAZEPINES DIASTAT (diazepam rectal) diazepam rectal gel Onfi: ONFI (clobazam) • 90 days completed therapy with the same agent in the past 105 days OR • Documented diagnosis of Lennox- Gastaut found in the past 2 years medical claims AND • 30 days of therapy with 1 different preferred agents for Lennox-Gastaut in the past 6 months

Diastat • Quantity limits of 3 Twin Packs/31 days HYDANTOINS DILANTIN (phenytoin) PEGANONE (ethotoin) PHENYTEK (phenytoin) phenytoin SUCCINIMIDES ethosuximide CELONTIN (methsuximide)

12 This is not an all-inclusive list of available covered drugs and includes only managed categories. 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 P&T Committee. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 4-1-2014. **Users of these products as of 9-30-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 10/01/2013 PREFERRED DRUG LIST Version 2013.26 Updated: 9-27-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS ZARONTIN (ethosuximide) ANTIDEPRESSANTS, OTHER SmartPA bupropion APLENZIN (bupropion HBr) SmartPA Criteria: bupropion SR bupropion XL • Minimum age requirement – 18 years EFFEXOR XR (venlafaxine) desvenlafaxine (all drugs) mirtazapine DESYREL (trazodone) • 30 days of therapy with 2 different PRISTIQ (desvenlafaxine) EFFEXOR (venlafaxine) preferred antidepressants, others class trazodone EMSAM (selegiline transdermal) in the past 6 months OR WELLBUTRIN XL (bupropion HCl) FORFIVO XL (bupropion) • 30 days of therapy with BOTH preferred MARPLAN (isocarboxazid) SSRI and antidepressants, others class NARDIL (phenelzine) in the past 6 months OR nefazodone • 90 days completed therapy with the OLEPTRO ER (trazodone) same agent in the past 105 days REMERON (mirtazapine) tranylcypromine Cymbalta (see Fibromyalgia Agents) venlafaxine venlafaxine ER venlafaxine XR VIIBRYD (vilazodone) WELLBUTRIN (bupropion) WELLBUTRIN SR ANTIDEPRESSANTS, SSRIs SmartPA citalopram CELEXA (citalopram) SmartPA Criteria: fluoxetine escitalopram • Minimum age requirements apply to all fluvoxamine LUVOX (fluvoxamine) drugs LUVOX CR (fluvoxamine) LEXAPRO (escitalopram) o Citalopram – 9 years paroxetine IR paroxetine CR o Escitalopram – 12 years PAXIL CR (paroxetine) paroxetine suspension o Fluoxetine – 7 years Fluoxetine 90 mg – 18 years PAXIL SUPENSION PAXIL Tablets (paroxetine) o Fluvoxamine – 8 years sertraline PEXEVA (paroxetine) o PROZAC (fluoxetine) o Fluvoxamine SR – 18 years Paroxetine – 18 years SARAFEM (fluoxetine) o o Sertraline – 6 years 13 This is not an all-inclusive list of available covered drugs and includes only managed categories. 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 P&T Committee. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 4-1-2014. **Users of these products as of 9-30-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 10/01/2013 PREFERRED DRUG LIST Version 2013.26 Updated: 9-27-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS ZOLOFT (sertraline) • 30 days of therapy with 2 different preferred SSRI’s in the past 6 months OR • 90 days of completed therapy with the same agent in the past 105 days

Lexapro • Age requirement 12 – 17 years OR • Documented diagnosis of depression found in past 2 years medical claims AND o 30 days of therapy with 2 different preferred SSRI antidepressants in the past 6 months OR o 90 days completed therapy with the same agent in the past 105 days • Documented diagnosis of anxiety disorder in the past 2 years AND o 30 days of therapy with BOTH sertraline and paroxetine IR in the past 6 months OR o 90 days completed therapy with the same agent the past 105 days ANTIEMETICS SmartPA 5HT3 RECEPTOR BLOCKERS ondansetron ANZEMET (dolasetron) All injectable 5HT3 receptor blockers ondansetron solution granisetron closed to point of sale. GRANISOL (granisetron) ondansetron ODT SmartPA Criteria: SANCUSO (granisetron) • Age requirements – ondansetron ODT ZOFRAN (ondansetron) and Zuplenz 4mg strengths only ZOFRAN ODT (ondansetron) o 4-11 years ZUPLENZ (ondansetron) o One claim with a preferred antiemetic in the past 6 months 14 This is not an all-inclusive list of available covered drugs and includes only managed categories. 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 P&T Committee. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 4-1-2014. **Users of these products as of 9-30-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 10/01/2013 PREFERRED DRUG LIST Version 2013.26 Updated: 9-27-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS ANTIEMETIC COMBINATIONS DICLEGIS (doxylamine/pyridoxine) CANNABINOIDS CESAMET (nabilone) MARINOL (dronabinol) dronabinol NMDA RECEPTOR ANTAGONIST EMEND (aprepitant) Emend • Documented diagnosis of cancer found in past 2 years medical claims OR • Antineoplastic history in the past 6 months AND o One claim with a preferred antiemetic in the past 6 months ANTIFUNGALS (Oral) SmartPA clotrimazole ANCOBON (flucytosine) SmartPA Criteria: fluconazole DIFLUCAN (fluconazole) • Documented diagnosis of HIV found in GRIFULVIN V (griseofulvin, microsize) griseofulvin ultramicrosize tablet the past 2 years medical claims AND griseofulvin microsize tablets/capsules/susp itraconazole oral antifungal with a labeled indication for HIV opportunistic infection OR GRIS-PEG (griseofulvin) ketoconazole • One claim for 2 different preferred nystatin LAMISIL (terbinafine) agents in the past 6 months OR terbinafine MYCOSTATIN Tablets (nystatin) • Itraconazole NIZORAL (ketoconazole) o Documented diagnosis of transplant NOXAFIL (posaconazole) found in the past 2 years of medical ONMEL (itraconazole) claims OR SPORANOX (itraconazole) o History of an immunosuppressant in TERBINEX Kit (terbinafine/ciclopirox) the past 6 months OR VFEND (voriconazole) o One claim for 2 different preferred voriconazole agents in the past 6 months

15 This is not an all-inclusive list of available covered drugs and includes only managed categories. 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 P&T Committee. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 4-1-2014. **Users of these products as of 9-30-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 10/01/2013 PREFERRED DRUG LIST Version 2013.26 Updated: 9-27-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS ANTIFUNGALS (Topical) SmartPA ANTIFUNGALS ciclopirox cream/gel/suspension BENSAL HP (benzoic acid/salicylic acid) SmartPA Criteria: clotrimazole CICLODAN KIT • One claim for 2 preferred agents in the econazole ciclopirox kit//solution past 6 months ketoconazole cream CNL 8 (ciclopirox) ketoconazole shampoo ERTACZO (sertaconazole) miconazole OTC EXELDERM (sulconazole) nystatin EXTINA (ketoconazole) terbinafine OTC cream,gel,spray ketoconazole foam tolnaftate OTC LAMISIL (terbinafine) solution LOPROX (ciclopirox) MENTAX (butenafine) NAFTIN (naftifine) NIZORAL (ketoconazole) OXISTAT (oxiconazole) PEDIADERM AF (nystatin) PENLAC (ciclopirox) VUSION (miconazole/petrolatum/zinc oxide) XOLEGEL (ketoconazole)

ANTIFUNGAL/STEROID COMBINATIONS clotrimazole/betamethasone cream clotrimazole/betamethasone lotion nystatin/triamcinolone LOTRISONE (clotrimazole/betamethasone)

ANTIHISTAMINES, MINIMALLY SEDATING AND COMBINATIONS SmartPA MINIMALLY SEDATING ANTIHISTAMINES cetirizine ALLEGRA (fexofenadine) SmartPA Criteria: loratadine CLARINEX (desloratadine) • Documented diagnosis of allergy or fexofenadine RX urticaria in the past 2 years medical levocetirizine claims AND • XYZAL Solution (levocetirizine) 30 days of therapy with 2 different preferred agents in the past 12 months 16 This is not an all-inclusive list of available covered drugs and includes only managed categories. 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 P&T Committee. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 4-1-2014. **Users of these products as of 9-30-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 10/01/2013 PREFERRED DRUG LIST Version 2013.26 Updated: 9-27-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS XYZAL Tablets (levocetirizine) OR • 90 days completed therapy with the same agent in the past 105 days MINIMALLY SEDATING ANTIHISTAMINE/DECONGESTANT COMBINATIONS cetirizine/pseudoephedrine ALLEGRA-D (fexofenadine/ pseudoephedrine) loratadine/pseudoephedrine CLARITIN-D (loratadine/pseudoephedrine) CLARINEX-D (desloratadine/ pseudoephedrine) fexofenadine/pseudoephedrine ZYRTEC-D (cetirizine/pseudoephedrine)

ANTIMIGRAINE AGENTS, TRIPTANS SmartPA ORAL MAXALT (rizatriptan) AMERGE (naratriptan) SmartPA Criteria: MAXALT MLT(rizatriptan) AXERT (almotriptan) • Minimum age requirements apply to all RELPAX (eletriptan) FROVA (frovatriptan) drug formulations below TREXIMET (sumatriptan/naproxen) IMITREX (sumatriptan) o Almotriptan – 12 years Eletriptan – 18 years ZOMIG (zolmitriptan) naratriptan o Frovatriptan – 18 years rizatriptan o o Naratriptan – 18 years sumatriptan o Rizatriptan – 6 years zolmitriptan o Sumatriptan – 18 years o Sumatriptan/Naproxen – 18 years o Zolmitriptan – 18 years

Oral products • One claim for a preferred oral agent in the past year

Other Criteria at the Point of Sale: Applicable quantity limit in 31 rolling days. • 12 tablets in 31 days - rizatriptan • 9 tablets in 31 days – naratriptan, frovatriptan,

17 This is not an all-inclusive list of available covered drugs and includes only managed categories. 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 P&T Committee. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 4-1-2014. **Users of these products as of 9-30-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 10/01/2013 PREFERRED DRUG LIST Version 2013.26 Updated: 9-27-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS sumatriptan, sumatriptan/naproxen • 6 tablets in 31 days – almotriptan, zolmitriptan, eletriptan NASAL IMITREX (sumatriptan) sumatriptan Nasal Products ZOMIG (zolmitriptan) • One claim for a preferred nasal agent in the past year

Applicable quantity limit in 31 rolling days. • 1 box in 31 days INJECTABLE sumatriptan IMITREX (sumatriptan) Injectable Products • One claim for a preferred injectable agent in the past year

Applicable CUMULATIVE quantity limit in 31 rolling days • 4 injections in 31 days

ANTINEOPLASTICS – SELECTED SYSTEMIC ENZYME INHIBITORS AFINITOR (everolimus) BOSULIF (bosutinib) CAPRELSA (vandetanib) COMETRIQ (cabozantinib) GLEEVEC (imatinib mesylate) ICLUSIG (ponatinib) INLYTA (axitinib) IRESSA (gefitinib) JAKAFI (ruxolitinib) NEXAVAR (sorafenib) SPRYCEL (dasatinib) STIVARGA (regorafenib) SUTENT (sunitinib) 18 This is not an all-inclusive list of available covered drugs and includes only managed categories. 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 P&T Committee. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 4-1-2014. **Users of these products as of 9-30-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 10/01/2013 PREFERRED DRUG LIST Version 2013.26 Updated: 9-27-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS TARCEVA (erlotinib) TASIGNA (nilotinib) TYKERB (lapatinib ditosylate) vandetanib VOTRIENT (pazopanib) XALKORI (crizotinib) ZELBORAF (vemurafenib)

ANTIPARASITICS (Topical) SmartPA EURAX (crotamiton) lindane SmartPA Criteria: NATROBA (spinosad) • Minimum age/weight requirements permethrin OVIDE (malathion) apply to all drug formulations for the SKLICE (ivermectin) treatment of head lice: Benzyl Alcohol Solution – 6 months ULESFIA (benzyl alcohol) o Ivermectin – 6 months o o Lindane Shampoo – 50 kg o Malathion – 6 years o Permethrin 1% – 2 months o Piperonyl/Pyrethrins – 2 years o Spinosad – 4 years

• Natroba o History of permethrin 1% topical OR piperonyl/pyrethrin in the past 90 days

• Non Preferred Agents o History of permethrin 1% topical OR piperonyl/pyrethrin in the past 90 days AND o History of Natroba in the past 90 days

19 This is not an all-inclusive list of available covered drugs and includes only managed categories. 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 P&T Committee. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 4-1-2014. **Users of these products as of 9-30-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 10/01/2013 PREFERRED DRUG LIST Version 2013.26 Updated: 9-27-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS ANTIPARKINSON’S AGENTS (Oral) SmartPA benztropine COGENTIN (benztropine) SmartPA Criteria: trihexyphenidyl • Documented diagnosis of Parkinson’s disease in the past 2 years medical claims AND • 30 days of therapy with 2 different preferred agents in the past 6 months OR • 90 days completed therapy with the same agent in the past 105 days COMT INHIBITORS COMTAN (entacapone) TASMAR (tolcapone) DOPAMINE AGONISTS ropinirole MIRAPEX (pramipexole) MIRAPEX ER (pramipexole) NEUPRO (rotigotine) pramipexole REQUIP (ropinirole) REQUIP XL (ropinirole) ropinerole ER MAO-B INHIBITORS selegiline AZILECT (rasagiline) ELDEPRYL (selegiline) ZELAPAR (selegiline) OTHERS amantadine levodopa/carbidopa ODT Lodosyn bromocriptine LODOSYN (carbidopa) • Approved for augmentation of levodopa/carbidopa PARCOPA (levodopa/carbidopa) carbidopa/levodopa only. PARLODEL (bromocriptine) • Pharmacy claims history of a SINEMET (levodopa/carbidopa) combination carbidopa/levodopa SINEMET CR (levodopa/carbidopa) product in the past 45 days must be STALEVO (levodopa/carbidopa/entacapone) present. 20 This is not an all-inclusive list of available covered drugs and includes only managed categories. 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 P&T Committee. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 4-1-2014. **Users of these products as of 9-30-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 10/01/2013 PREFERRED DRUG LIST Version 2013.26 Updated: 9-27-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS ANTIPSYCHOTICS SmartPA ORAL SmartPA SmartPA ABILIFY (aripiprazole) CLOZARIL (clozapine) SmartPA Criteria: SmartPA Atypical Antipsychotics amitriptyline/perphenazine FAZACLO (clozapine) • chlorpromazine SmartPA Minimum age requirements apply to all SmartPA HALDOL (haloperidol) oral drug formulations below clozapine SmartPA INVEGA (paliperidone) o Aripiprazole – 6 years SmartPA Asenapine – 18 years FANAPT (iloperidone) NAVANE (thiothixene) o fluphenazine SmartPA o Clozapine – 18 years SmartPA olanzapine o Haloperidol – 3 years GEODON (ziprasidone) SmartPA Iloperidone – 18 years SmartPA olanzapine/fluoxetine o haloperidol SmartPA o Lurasidone – 18 years SmartPA quetiapine Olanzapine – 13 years LATUDA (lurasidone) SmartPA o RISPERDAL (risperidone) o Olanzapine/Fluoxetine – 10 years perphenazine SmartPA Paliperidone – 18 years SmartPA SYMBYAX (olanzapine/fluoxetine) o risperidone Quetiapine IR – 10 years SmartPA o SmartPA ziprasidone Quetiapine SR – 10 years SAPHRIS (asenapine) o SmartPA Risperidone – 5 years SmartPA ZYPREXA (olanzapine) o SEROQUEL (quetiapine) o Ziprasidone – 18 years SmartPA SEROQUEL XR (quetiapine) Abilify Tablets (all strengths, ODT thioridazine formulation excluded) thiothixene New Starts: trifluoperazine • 2.5mg, 5mg, 7.5mg, 10mg, and 15 mg dosages will require tablet splitting. Use ½ tablet of the higher strength. • 1 tablet splitter per year • Detailed Abilify Tablet Splitting; click here

Invega Tablets • 30 days of therapy with risperidone in the past 12 months OR • 30 days of therapy with the same agent in the past 105 days

21 This is not an all-inclusive list of available covered drugs and includes only managed categories. 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 P&T Committee. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 4-1-2014. **Users of these products as of 9-30-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 10/01/2013 PREFERRED DRUG LIST Version 2013.26 Updated: 9-27-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS Non Preferred Criteria • 30 days of therapy with 1 preferred atypical antipsychotic agent in the past 12 months OR • 30 days of therapy with the same agent in the past 105 days SmartPA INJECTABLE, ATYPICALS ABILIFY (aripiprazole) Effective 11-1-2012, injectable GEODON (ziprasidone) antipsychotics are closed to POS INVEGA SUSTENNA (paliperidone palmitate) except for Long Term Care beneficiaries. RISPERDAL CONSTA (risperidone)

ZYPREXA (olanzapine) SmartPA Criteria for Long Term Care ZYPREXA RELPREVV (olanzapine) Long Acting Injectable Agents: • Minimum Age requirement AND • Documented diagnosis (based on labeled indications) found in the past 2 years medical claims AND • Non-Compliant with the oral form of the injection OR • History of claims for the same injectable agent in the past 90 days. o History defined as: o 3 claims - Abilify Maintena, Invega Sustenna, Zyprexa Relprevv 6 claims - Risperdal Consta ANTIVIRALS (Oral) – ANTIHERPETIC AGENTS acyclovir famciclovir valacyclovir FAMVIR (famciclovir) VALTREX (valacyclovir) ZOVIRAX (acyclovir)

22 This is not an all-inclusive list of available covered drugs and includes only managed categories. 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 P&T Committee. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 4-1-2014. **Users of these products as of 9-30-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 10/01/2013 PREFERRED DRUG LIST Version 2013.26 Updated: 9-27-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS ANTIVIRALS (Topical) DENAVIR (penciclovir) XERESE (acyclovir/hydrocortisone) ZOVIRAX Ointment (acyclovir) ZOVIRAX Cream (acyclovir) ATOPIC DERMATITIS SmartPA ELIDEL (pimecrolimus) PROTOPIC (tacrolimus) SmartPA Criteria: • Minimum age requirements o Elidel – 2 years o Protopic 0.03% - 2 years o Protopic 0.1% - 6 years

Non Preferred Criteria • One claim for a different preferred agent in the past 6 months OR • 90 days of completed therapy with the same agent in the past 105 days

BETA BLOCKERS SmartPA acebutolol BETAPACE (sotalol) SmartPA Criteria: atenolol Bystolic bisoprolol CORGARD (nadolol) • 90 days completed therapy with the BYSTOLIC (nebivolol)* INDERAL LA (propranolol) same agent in the past 105 days OR • 30 days of therapy with 1 different metoprolol INNOPRAN XL (propranolol) LEVATOL (penbutolol) preferred agent in the past 6 months metoprolol XL LOPRESSOR (metoprolol) nadolol SECTRAL (acebutolol) Sotalol pindolol sotalol • Documented diagnosis found in the propranolol TENORMIN (atenolol) past 2 years medical claims for atrial ZEBETA (bisoprolol) fibrillation OR • TOPROL XL (metoprolol) 30 days of therapy with 2 different preferred , Beta and Alpha Blocker or Beta Blocker Combo agents in the past 6 months OR • 90 days completed therapy with the same agent in the past 105 days

23 This is not an all-inclusive list of available covered drugs and includes only managed categories. 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 P&T Committee. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 4-1-2014. **Users of these products as of 9-30-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 10/01/2013 PREFERRED DRUG LIST Version 2013.26 Updated: 9-27-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS

Non Preferred Agents • 30 days of therapy with 2 different preferred Beta Blocker, Beta and Alpha Blocker or Beta Blocker Combo agents in the past 6 months OR • 90 days completed therapy with the same agent in the past 105 days

BETA- AND ALPHA-BLOCKERS carvedilol COREG (carvedilol) Coreg CR labetalol COREG CR (carvedilol) • Documented diagnosis found in the TRANDATE (labetalol) past 2 years medical claims for hypertension AND • 30 days of therapy with carvedilol AND a different preferred Beta Blocker, Beta and Alpha Blocker or Beta Blocker Combo agent in the past 6 months OR 90 days completed therapy with the same agent in the past 105 days BETA BLOCKER/DIURETIC COMBINATIONS atenolol/chlorthalidone CORZIDE (nadolol/bendroflumethiazide) Non Preferred Agents bisoprolol/HCTZ DUTOPROL (metoprolol/HCTZ) • 30 days of therapy with 2 different metoprolol/HCTZ LOPRESSOR HCT (metoprolol/HCTZ) preferred Beta Blocker, Beta and Alpha TENORETIC (atenolol/chlorthalidone) nadolol/bendroflumethiazide Blocker or Beta Blocker Combo agents ZIAC (bisoprolol/HCTZ) in the past 6 months OR propranolol/HCTZ 90 days completed therapy with the timolol/HCTZ same agent in the past 105 days

BILE SALTS ursodiol ACTIGALL (ursodiol) CHENODAL (chenodiol) URSO (ursodiol) URSO FORTE (ursodiol)

24 This is not an all-inclusive list of available covered drugs and includes only managed categories. 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 P&T Committee. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 4-1-2014. **Users of these products as of 9-30-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 10/01/2013 PREFERRED DRUG LIST Version 2013.26 Updated: 9-27-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS BLADDER RELAXANT PREPARATIONS SmartPA oxybutynin IR DETROL (tolterodine) Smart PA Criteria: TOVIAZ (fesoterodine fumarate) DETROL LA (tolterodine) • 30 days of therapy with 2 different DITROPAN XL (oxybutynin) preferred agents in the past 6 months ENABLEX (darifenacin) OR • 90 days completed therapy with the GELNIQUE (oxybutynin) same agent in the past 105 days MYRBETRIQ (mirabegron) oxybutynin ER OXYTROL (oxybutynin) SANCTURA (trospium) SANCTURA XR (trospium) tolterodine trospium VESICARE (solifenacin)

BONE RESORPTION SUPPRESSION AND RELATED AGENTS SmartPA BISPHOSPHONATES ACTONEL (risedronate) alendronate solution SmartPA Criteria: alendronate ATELVIA (risedronate) • Documented diagnosis found in the BINOSTO (alendronate) BONIVA (ibandronate) past 2 years medical claims for FOSAMAX PLUS D (alendronate/vitamin D) DIDRONEL (etidronate) osteoporosis or osteopenia AND • One claim for 2 different preferred FOSAMAX (alendronate) ibandronate agents in the past 6 months OR • PROLIA (denosumab) 90 days completed therapy with the same agent in the past 105 days

OTHERS FORTICAL (calcitonin) calcitonin salmon MIACALCIN (calcitonin) EVISTA (raloxifene) FORTEO (teriparatide)

25 This is not an all-inclusive list of available covered drugs and includes only managed categories. 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 P&T Committee. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 4-1-2014. **Users of these products as of 9-30-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 10/01/2013 PREFERRED DRUG LIST Version 2013.26 Updated: 9-27-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS BPH AGENTS SmartPA ALPHA BLOCKERS doxazosin alfuzosin SmartPA Criteria: FLOMAX (tamsulosin) CARDURA (doxazosin) • Male patient AND terazosin CARDURA XL (doxazosin) • 30 days of therapy with 2 different UROXATRAL (alfuzosin) JALYN (dutasteride/tamsulosin) preferred agent in the past 6 months OR RAPAFLO (silodosin) • 90 days completed therapy with the tamsulosin same agent in the past 105 days

• Female Patient AND o Alfuzosin, doxazosin IR, finasteride, tamsulosin, and terazosin AND . Documented diagnosis found in the past 2 years medical claims based on a state accepted diagnosis 5-ALPHA-REDUCTASE (5AR) INHIBITORS AVODART (dutasteride) PROSCAR (finasteride) finasteride

PDE5 INHIBITORS

CIALIS (tadalafil) Cialis: (Requires a Manual PA) • Limited to Male Patients AND • Documented diagnosis found in the past 2 years medical claims for Benign Prostatic Hypertrophy AND • NO documented diagnosis of Erectile Dysfunction found in the past 2 years medical claims AND • Prescriber signed waiver stating treatment is NOT for Erectile Dysfunction AND • 30 days therapy with 2 different preferred agents in the past 6 months

26 This is not an all-inclusive list of available covered drugs and includes only managed categories. 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 P&T Committee. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 4-1-2014. **Users of these products as of 9-30-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 10/01/2013 PREFERRED DRUG LIST Version 2013.26 Updated: 9-27-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS BRONCHODILATORS & COPD AGENTS ANTICHOLINERGICS & COPD AGENTS ATROVENT HFA (ipratropium) DALIRESP (roflumilast) ipratropium TUDORZA PRESSAIR (aclidinium) SPIRIVA (tiotropium)

ANTICHOLINERGIC-BETA AGONIST COMBINATIONS albuterol/ipratropium COMBIVENT RESPIMAT (albuterol/ipratropium)

BRONCHODILATORS, BETA AGONIST INHALERS, SHORT-ACTING PROVENTIL HFA (albuterol) MAXAIR (pirbuterol) SmartPA SmartPA Criteria: PROAIR HFA (albuterol) Xopenex HFA VENTOLIN HFA (albuterol) • Age requirements – 4 years AND XOPENEX HFA (levalbuterol) SmartPA • One claim for a short acting albuterol inhaler in the past 30 days

Non Preferred Criteria o One claim for a short acting albuterol inhaler in the past 6 months SmartPA INHALERS, LONG ACTING FORADIL (formoterol) ARCAPTA (indacaterol) SmartPA Criteria: SEREVENT (salmeterol) Foradil • Age requirements – 5 years

Serevent • Age requirements – 4 years AND • 30 days of therapy with a preferred long acting agent in the past 6 months OR • 90 days completed therapy with the same agent in the past 105 days

27 This is not an all-inclusive list of available covered drugs and includes only managed categories. 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 P&T Committee. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 4-1-2014. **Users of these products as of 9-30-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 10/01/2013 PREFERRED DRUG LIST Version 2013.26 Updated: 9-27-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS Arcapta • Documented diagnosis found in the past 2 years medical claims for COPD AND • Age requirements – 18 years AND • 30 days of therapy with a preferred long acting agent in the past 6 months OR • 90 days completed therapy with the same agent in the past 105 days SmartPA INHALATION SOLUTION albuterol ACCUNEB (albuterol) SmartPA Criteria: BROVANA (arformoterol) Xopenex Inhalation Solution levalbuterol • Age requirements – 6 years AND metaproterenol • One claim for an albuterol solution in PERFOROMIST (formoterol) the past 30 days XOPENEX (levalbuterol) Brovana or Perforomist • Age requirements – 18 years AND • One claim for 1 different preferred Inhalation Solution in the past 6 months OR • 3 claims for the same agent in the past 105 days

Non Preferred Agents • One claim for 1 different preferred Inhalation Solution in the past 6 months OR • 3 claims for the same agent in the past 105 days ORAL albuterol VOSPIRE ER (albuterol) metaproterenol terbutaline

28 This is not an all-inclusive list of available covered drugs and includes only managed categories. 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 P&T Committee. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 4-1-2014. **Users of these products as of 9-30-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 10/01/2013 PREFERRED DRUG LIST Version 2013.26 Updated: 9-27-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS CALCIUM CHANNEL BLOCKERS SmartPA SHORT-ACTING diltiazem CALAN (verapamil) SmartPA Criteria: nicardipine CARDIZEM (diltiazem) • nimodipine nifedipine isradipine o documented diagnosis found in the verapamil nimodipine past 45 days for subarachnoid PROCARDIA (nifedipine) hemorrhage AND o quantity < to 21 days maximum therapy (252 capsules/2520mL) • Short Acting CCB o 30 days of therapy with 2 different preferred Short Acting CCB agents in the past 6 months OR o 90 days completed therapy with the same agent in the past 105 days

LONG-ACTING amlodipine ADALAT CC (nifedipine) • Long Acting CCB diltiazem ER CALAN SR (verapamil) o 30 days of therapy with 2 different DYNACIRC CR (isradipine) CARDENE SR (nicardipine) preferred Long Acting CCB agents felodipine ER CARDIZEM CD (diltiazem) in the past 6 months OR 90 days completed therapy with the nifedipine ER CARDIZEM LA (diltiazem) o DILACOR XR (diltiazem) same agent in the past 105 days verapamil ER nisoldipine NORVASC (amlodipine) PROCARDIA XL (nifedipine) SULAR (nisoldipine) TIAZAC (diltiazem) verapamil ER PM VERELAN/VERELAN PM (verapamil)

CALORIC AGENTS BOOST (includes all Boost) COMPLEAT BRIGHT BEGINNINGS EO28 SPLASH CARNATION INSTANT BREAKFAST FIBERSOURCE 29 This is not an all-inclusive list of available covered drugs and includes only managed categories. 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 P&T Committee. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 4-1-2014. **Users of these products as of 9-30-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 10/01/2013 PREFERRED DRUG LIST Version 2013.26 Updated: 9-27-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS DUOCAL ISOSOURCE ENSURE JEVITY JUVEN KINDERCAL GLUCERNA PEPTAMEN NUTREN (includes all Nutren) PROMOTE OSMOLITE SIMPLY THICK PEDIASURE TOLEREX POLYCOSE VITAL PROMOD VIVONEX RESOURCE SCANDISHAKE TWOCAL HN

CEPHALOSPORINS AND RELATED ANTIBIOTICS (Oral) BETA LACTAM/BETA-LACTAMASE INHIBITOR COMBINATIONS amoxicillin/clavulanate amoxicillin/clavulanate XR AUGMENTIN 125 and 250 (amoxicillin/clavulanate) AUGMINTIN (amoxicillin/clavulanate) Tablets Suspension MOXATAG (amoxicillin) AUGMENTIN XR (amoxicillin/clavulanate) SmartPA CEPHALOSPORINS – First Generation cefadroxil KEFLEX (cephalexin) SmartPA Criteria: cephalexin Cephalosporins (all generations) • One claim for 2 different preferred agents in the past 6 months SmartPA CEPHALOSPORINS – Second Generation cefaclor cefuroxime suspension cefprozil CEFTIN (cefuroxime) cefuroxime tablets SmartPA CEPHALOSPORINS – Third Generation cefdinir suspension (for patients <18 yr only) CEDAX (ceftibuten) Cefdinir suspension cefdinir capsules cefditoren • Maximum age requirement – 18 years cefpodoxime OR o One claim for 2 different preferred 30 This is not an all-inclusive list of available covered drugs and includes only managed categories. 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 P&T Committee. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 4-1-2014. **Users of these products as of 9-30-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 10/01/2013 PREFERRED DRUG LIST Version 2013.26 Updated: 9-27-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS SPECTRACEF (cefditoren) agents in the past 6 months SUPRAX (cefixime)

CYSTIC FIBROSIS AGENTS CAYSTON (aztreonam)** SmartPA Criteria COLY-MYCIN M (colistimethate sodium)** • Documented diagnosis found in the KALYDECO (ivacaftor) past 2 years medical claims Cystic PULMOZYME (dornase alfa)** Fibrosis TOBI (tobramycin)** TOBI PODHALER (tobramycin) Kalydeco: • Documented diagnosis found in the past 2 years medical claims Cystic Fibrosis AND • One claim for Kalydeco in the past 105 days

Manual PA: • Kalydeco – new starts after 7.1.2013 • TOBI Podhaler

CYTOKINE & CAM ANTAGONISTS ENBREL (etanercept) AMEVIVE (alefacept) Amevive, Orencia, Remicade and HUMIRA (adalimumab) CIMZIA (certolizumab) Stelara are for administration in hospital KINERET (anakinra) or clinic setting. PA will not be issued at Point of Sale without justification. ORENCIA (abatacept) REMICADE (infliximab) SIMPONI (golimumab) STELARA (ustekinumab) XELJANZ (tofacitinib) ERYTHROPOIESIS STIMULATING PROTEINS SmartPA ARANESP (darbepoetin) EPOGEN (rHuEPO) SmartPA Criteria: PROCRIT (rHuEPO) OMONTYS (peginesatide) Omontys

31 This is not an all-inclusive list of available covered drugs and includes only managed categories. 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 P&T Committee. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 4-1-2014. **Users of these products as of 9-30-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 10/01/2013 PREFERRED DRUG LIST Version 2013.26 Updated: 9-27-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS • Minimum age requirement – 18 years AND • Documented diagnosis found in the past 2 years medical claims for chronic renal failure AND • Documented procedure code found in the past 180 days medical claims for dialysis

Non Preferred Agents • Documented diagnosis found in the past 2 years medical claims for cancer or chronic renal failure OR Antineoplastic therapy in the past 6 months AND Procrit history in the past 6 months claims

FIBROMYALGIA AGENTS SmartPA LYRICA (pregabalin) CYMBALTA (duloxetine) SmartPA Criteria SAVELLA (milnacipran) Cymbalta • Documented diagnosis of fibromyalgia found in past 2 years medical claims AND o 30 days of therapy with BOTH Lyrica and Savella in the past 6 months OR o 90 days completed therapy with the same agent in the past 105 days

• Documented diagnosis of depression found in past 2 years medical claims AND o 30 days of therapy with 2 different preferred antidepressants, other products in the past 6 months OR 32 This is not an all-inclusive list of available covered drugs and includes only managed categories. 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 P&T Committee. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 4-1-2014. **Users of these products as of 9-30-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 10/01/2013 PREFERRED DRUG LIST Version 2013.26 Updated: 9-27-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS o 30 days of therapy with BOTH preferred SSRI and antidepressant other in the past 6 months OR o 90 days completed therapy with the same agent in the past 105 days

• Documented diagnosis of anxiety found in past 2 years medical claims AND o 30 days of therapy with 2 of the following: sertraline , paroxetine IR, or Effexor XR in the past 6 months OR o 90 days completed therapy with the same agent in the past 105 days

• Documented diagnosis of Diabetic Peripheral Neuropathy found in past 2 years medical claims AND o 30 days of therapy with Lyrica in the past 6 months OR o 90 days completed therapy with the same agent in the past 105 days

FLUOROQUINOLONES (Oral) SmartPA AVELOX () ER SmartPA Criteria: ciprofloxacin tablets CIPRO (ciprofloxacin) Non Preferred Oral Tablets CIPRO XR (ciprofloxacin) • One claim for 1 preferred agent in the FACTIVE () past 30 days

LEVAQUIN () Levaquin Tablets levofloxacin • One claim for ciprofloxacin, NOROXIN () moxifloxacin, or SMX/TMP in the past 14 days OR • One claim for 1 preferred agent in the past 30 days 33 This is not an all-inclusive list of available covered drugs and includes only managed categories. 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 P&T Committee. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 4-1-2014. **Users of these products as of 9-30-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 10/01/2013 PREFERRED DRUG LIST Version 2013.26 Updated: 9-27-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS

• Levofloxacin solution o Age < 12 years AND . Documented diagnosis found in the past 3 months medical claims for anthrax infection or exposure OR . 7 days of therapy with a preferred agent from 2 of the preferred classes below in the past 3 months • Penicillin, 2nd or 3rd generation cephalosporin, or macrolide AND • Ciprofloxacin suspension in the past 3 months claims OR o Age >12 years AND o One claim for ciprofloxacin, moxifloxacin, or SMX/TMP in the past 14 days OR o One claim for 1 preferred agent in the past 30 days

• Ciprofloxacin suspension o Age < 12 years AND . Documented diagnosis found in the past 3 months medical claims for anthrax infection or exposure OR . Documented diagnosis found in the past 2 years for cystic fibrosis OR . Documented diagnosis found in the past 3 months claims for pneumonic plague or tularemia AND history of found 34 This is not an all-inclusive list of available covered drugs and includes only managed categories. 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 P&T Committee. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 4-1-2014. **Users of these products as of 9-30-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 10/01/2013 PREFERRED DRUG LIST Version 2013.26 Updated: 9-27-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS in claims in the past 3 months OR . 7 days of therapy with a preferred agent from 2 of the preferred classes below in the past 3 months • Penicillin, 2nd or 3rd generation cephalosporin, or macrolide OR o Age >12 years AND o One claim for 1 preferred agent in the past 30 days GENITAL WARTS & RELATED AGENTS ALDARA (imiquimod)* imiquimod *Aldara Age Edit: Payable for members CONDYLOX (podofilox) PICATO (ingenol) who are 12 years of age and older. podofilox VEREGEN (sinecatechins) ZYCLARA (imiquimod) GLUCOCORTICOIDS (Inhaled) SmartPA SmartPA GLUCOCORTICOIDS ASMANEX (mometasone) ALVESCO (ciclesonide) SmartPA Criteria: FLOVENT Diskus (fluticasone) budesonide • Pulmicort Flexhaler FLOVENT HFA (fluticasone) o Minimum age requirement - 6 years QVAR (beclomethasone) Non Preferred Agents PULMICORT (budesonide) Flexhaler • 30 days of therapy with 2 different PULMICORT (budesonide) Respules preferred agents in the past 6 months OR 90 days completed therapy with the same agent in the past 105 days GLUCOCORTICOID/BRONCHODILATOR COMBINATIONS NR ADVAIR Diskus (fluticasone/salmeterol) BREO ELLIPTA (fluticasone/vilanterol) ADVAIR HFA (fluticasone/salmeterol) DULERA (mometasone/formoterol) SYMBICORT (budesonide/formoterol) 35 This is not an all-inclusive list of available covered drugs and includes only managed categories. 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 P&T Committee. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 4-1-2014. **Users of these products as of 9-30-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 10/01/2013 PREFERRED DRUG LIST Version 2013.26 Updated: 9-27-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS GROWTH HORMONE SmartPA GENOTROPIN (somatropin) HUMATROPE (somatropin) SmartPA Criteria: NORDITROPIN (somatropin) OMNITROPE (somatropin) Age >18 NUTROPIN AQ (somatropin) SAIZEN (somatropin) • Documented diagnosis found in the SEROSTIM (somatropin) past 2 years medical claims for craniopharyngioma, Prader-Willi TEV-TROPIN (somatropin) Syndrome, or Turner Syndrome OR • Documented procedure found in the past 2 years medical claims for cranial irradiation

Non Preferred Agents • 28 days of therapy with 1 preferred agent in the past 6 months OR • 84 days of completed therapy with the same agent in the past 105 days

H. PYLORI COMBINATION TREATMENTS HELIDAC (bismuth subsalicylate, metronidazole, PYLERA (bismuth subcitrate potassium, Limited to 1 treatment course per year ) metronidazole, tetracycline) PREVPAC (lansoprazole, amoxicillin, OMECLAMOX (omeprazole, clarithromycin, clarithromycin) amoxicillin) HEPATITIS C TREATMENTS SmartPA INCIVEK (telaprevir)* INFERGEN (interferon alfacon-1) *Incivek & Victrelis require manual PA PEGASYS (peginterferon alfa-2a) ribavirin PEG-INTRON (peginterferon alfa-2b) REBETOL (ribavirin) SmartPA Criteria: Non Preferred Interferon Agents RIBAPAK DOSEPACK (ribavirin) RIBASPHERE (ribavirin) • One claim for a preferred peginterferon VICTRELIS (boceprevir)* agent in the past 6 months OR • One claim with the same agent in the past 12 months

36 This is not an all-inclusive list of available covered drugs and includes only managed categories. 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 P&T Committee. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 4-1-2014. **Users of these products as of 9-30-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 10/01/2013 PREFERRED DRUG LIST Version 2013.26 Updated: 9-27-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS HYPERURICEMIA & GOUT SmartPA allopurinol ULORIC (febuxostat) SmartPA Criteria: COLCRYS (colchicine) ZYLOPRIM (allopurinol) • 30 days of therapy with 2 different probenecid preferred agents in the past 6 months probenecid/colchicine OR 90 days completed therapy with the o same agent in the past 105 days HYPOGLYCEMICS, INCRETIN MIMETICS/ENHANCERS BYETTA (exenatide) BYDUREON (exenatide) JANUMET (sitagliptin/metformin) JANUMET XR (sitagliptin/metformin) JANUVIA (sitagliptin) JENTADUETO (linagliptin/metformin) KOMBIGLYZE XR (saxagliptin/metformin) JUVISYNC (sitagliptin/simvastatin) KAZANO (alogliptin/metformin) ONGLYZA (saxagliptin) TRADJENTA (linagliptin) NESINA (alogliptin) OSENI (alogliptin/pioglitazone)

SYMLIN (pramlintide) VICTOZA (liraglutide)

HYPOGLYCEMICS, INSULINS AND RELATED AGENTS SmartPA HUMALOG VIAL (insulin lispro) APIDRA (insulin glulisine) SmartPA Criteria: HUMALOG MIX VIAL (insulin lispro/ lispro HUMALOG KWIKPEN (insulin lispro) • Documented diagnosis found in the protamine) HUMALOG MIX KWIKPEN (insulin lispro/ lispro past 2 years medical claims for HUMULIN VIAL (insulin) protamine) Diabetes Mellitus AND • LANTUS SOLOSTAR & VIAL (insulin glargine) HUMULIN KWIKPEN (insulin) 30 days of therapy with 1 preferred * product in the past 6 months OR LEVEMIR FLEXPEN & VIAL (insulin detemir) NOVOLIN FLEXPEN (insulin) 90 days completed therapy with the NOVOLIN VIAL (insulin) same agent in the past 105 days NOVOLOG FLEXPEN & VIAL (insulin aspart) NOVOLOG MIX FLEXPEN & VIAL (insulin aspart/ aspart protamine) HYPOGLYCEMICS, MEGLITINIDES PRANDIN (repaglinide) nateglinide PRANDIMET (repaglinide/metformin) repaglinide 37 This is not an all-inclusive list of available covered drugs and includes only managed categories. 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 P&T Committee. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 4-1-2014. **Users of these products as of 9-30-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 10/01/2013 PREFERRED DRUG LIST Version 2013.26 Updated: 9-27-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS STARLIX (nateglinide)

HYPOGLYCEMICS, SODIUM GLUCOSE COTRANSPORTER-2 INHIBITORS INVOKANA (canagliflozin)

HYPOGLYCEMICS, TZDS THIAZOLIDINEDIONES pioglitazone ACTOS (pioglitazone) AVANDIA (rosiglitazone)

TZD COMBINATIONS ACTOPLUS MET (pioglitazone/metformin) ACTOPLUSMET XR (pioglitazone/metformin) DUETACT (pioglitazone/glimepiride) AVANDARYL (rosiglitazone/glipizide) AVANDAMET (rosiglitazone/metformin) pioglitazone/metformin

IMMNOSUPPRESSIVE (ORAL) SmartPA AZASAN (azathioprine) HECORIA (tacrolimus)NR SmartPA Criteria: azathioprine • Cyclosporine & Cyclosporine, modified CELLCEPT (mycophenolate) o Documented diagnosis found in the cyclosporine past 2 years medical claims for heart transplant, kidney transplant, liver cyclosporine modified transplant, psoriasis, RA or a state GENGRAF (cyclosporine) accepted diagnosis OR mycophenolate mofetil o A manual PA review for a diagnosis of MYFORTIC (mycophenolic acid) Kimura’s disease or multifocal motor NEORAL (cyclosporine) neuropathy PROGRAF (tacrolimus) RAPAMUNE (sirolimus) • Tacrolimus & CellCept SANDIMMUNE (cyclosporine) o Documented diagnosis found in the tacrolimus past 2 years medical claims for heart transplant, kidney transplant, liver 38 This is not an all-inclusive list of available covered drugs and includes only managed categories. 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 P&T Committee. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 4-1-2014. **Users of these products as of 9-30-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 10/01/2013 PREFERRED DRUG LIST Version 2013.26 Updated: 9-27-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS ZORTRESS (everolimus) transplant or a state accepted diagnosis

• Myfortic (mycophenolate sodium) o Documented diagnosis found in the past 2 years medical claims for kidney transplant or psoriasis

• Sirolimus o Minimum age requirement – 13 years AND o Documented diagnosis found in the past 2 years medical claims for kidney transplant

• Everolimus o Minimum age requirement – 18 years AND o Documented diagnosis found in the past 2 years medical claims for kidney transplant

INTRANASAL RHINITIS AGENTS ANTICHOLINERGICS ipratropium ATROVENT (ipratropium)

ANTIHISTAMINES ASTELIN (azelastine) ASTEPRO (azelastine) PATANASE (olopatadine) azelastine

SmartPA ANTIHISTAMINE/CORTICOSTEROID COMBINATION DYMISTA (azelastine/fluticasone)

39 This is not an all-inclusive list of available covered drugs and includes only managed categories. 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 P&T Committee. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 4-1-2014. **Users of these products as of 9-30-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 10/01/2013 PREFERRED DRUG LIST Version 2013.26 Updated: 9-27-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS SmartPA CORTICOSTEROIDS BECONASE AQ (beclomethasone) flunisolide SmartPA Criteria: FLONASE (fluticasone) fluticasone • Documented diagnosis found in the NASAREL (flunisolide) NASACORT AQ (triamcinolone) past 2 years medical claims for allergic NASONEX (mometasone) OMNARIS (ciclesonide) rhinitis AND • One claim for 2 different preferred ZETONNA (ciclesonide) QNASL (beclomethasone) agents in the past 6 months OR RHINOCORT AQUA (budesonide) • 90 days completed therapy with the triamcinolone same agent in the past 105 days VERAMYST (fluticasone)

IRRITABLE BOWEL SYNDROME/SHORT BOWEL SYNDROME AGENTS dicyclomine AMITIZA (lubiprostone) SmartPA Criteria: hyoscyamine BENTYL (dicyclomine) • Amitiza, Linzess, Lotronex, or Zorbtive FULYZAQ (crofelemer) users will be grandfathered GATTEX (teduglutide) o 1 claim with the same agent in the LEVSIN (hyoscyamine) past 105 days LEVSIN-SL (hyoscyamine) Other Non Preferred Agents – require LINZESS (linaclotide) Manual PA LOTRONEX (alosetron) NUTRESTORE POWDER PACK (glutamine) ZORBTIVE (somatropin)

LEUKOTRIENE MODIFIERS SmartPA ACCOLATE (zafirlukast) montelukast SmartPA Criteria: SINGULAIR (montelukast) ZYFLO CR (zileuton) • Zyflo or Zyflo CR zafirlukast o Minimum age requirement - 12 years

Non Preferred Agents • 30 days of therapy with 2 different preferred agents in the past 6 months OR • 90 days completed therapy with the same agent in the past 105 days

40 This is not an all-inclusive list of available covered drugs and includes only managed categories. 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 P&T Committee. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 4-1-2014. **Users of these products as of 9-30-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 10/01/2013 PREFERRED DRUG LIST Version 2013.26 Updated: 9-27-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS LIPOTROPICS, OTHER (Non-statins) SmartPA BILE ACID SEQUESTRANTS cholestyramine COLESTID (colestipol) SmartPA Criteria colestipol QUESTRAN (cholestyramine) Criteria for all drugs: WELCHOL (colesevelam) • 90 days completed therapy with the same agent in the past 105 days OR • 30 days completed therapy with a statin or statin combination agent in the past 1 year OR • One of the following exceptions: o A female patient with a documented diagnosis of pregnancy found in medical claims in the past 280 days OR o Documented diagnosis found in the past 2 years medical claims for liver disease OR o Documented diagnosis found in the past 2 years medical claims for hypertriglyceridemia OR o Clinical justification provided for the reason the patient is unable to take a statin or statin combination product

AND

Welchol • Documented diagnosis found in the past 2 years medical claims for diabetes AND • 30 days of therapy with a preferred oral antidiabetic agent in the past 180 days

OR • 30 days therapy with 2 different preferred bile acid sequestrants OR 41 This is not an all-inclusive list of available covered drugs and includes only managed categories. 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 P&T Committee. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 4-1-2014. **Users of these products as of 9-30-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 10/01/2013 PREFERRED DRUG LIST Version 2013.26 Updated: 9-27-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS • A female patient with a documented diagnosis of pregnancy in the past 280 days

OMEGA-3 FATTY ACIDS LOVAZA (omega-3-acid ethyl esters) VASCEPA (icosapent ethyl) Non Preferred Agents 30 days of therapy with 2 different preferred non-statin lipotropics in the past 6 months CHOLESTEROL ABSORPTION INHIBITORS ZETIA (ezetimibe)

FIBRIC ACID DERIVATIVES ANTARA (fenofibrate, micronized) fenofibrate, micronized Fibric Acid Derivative gemfibrozil fenofibrate nanocrystallized 145mg 30 days of therapy with 2 different fibric TRICOR (fenofibrate nanocrystallized) fenofibric acid acid derivatives in the past 6 months TRILIPIX (fenofibric acid) FIBRICOR (fenofibric acid) LIPOFEN (fenofibrate) LOFIBRA (fenofibrate) LOPID (gemfibrozil) TRIGLIDE (fenofibrate) MTP INHIBITOR JUXTAPID (lomitapide) APOLIPOPROTEIN B-100 SYNTHESIS INHIBITOR KYNAMRO (mipomersen)

NIACIN NIACOR (niacin) NIASPAN (niacin)

42 This is not an all-inclusive list of available covered drugs and includes only managed categories. 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 P&T Committee. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 4-1-2014. **Users of these products as of 9-30-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 10/01/2013 PREFERRED DRUG LIST Version 2013.26 Updated: 9-27-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS LIPOTROPICS, STATINS SmartPA STATINS atorvastatin ALTOPREV (lovastatin) SmartPA Criteria: CRESTOR (rosuvastatin) LIVALO (pitavastatin) • 30 days of therapy with 2 different LESCOL (fluvastatin) MEVACOR (lovastatin) preferred agents in the past 6 months LESCOL XL (fluvastatin) PRAVACHOL (pravastatin) OR • 90 days completed therapy with the LIPITOR (atorvastatin) ZOCOR (simvastatin) same agent in the past 105 days lovastatin pravastatin Simvastatin 80mg: simvastatin • 12 months of therapy with simvastatin 80mg in the past 18 months AND • NO documented myopathies found in medical claims in the past 12 months

STATIN COMBINATIONS atorvastatin/amlodipine ADVICOR (lovastatin/niacin) Prior to consideration of a non- CADUET (atorvastatin/amlodipine) preferred statin combination, the SIMCOR (simvastatin/niacin) patient must first have an VYTORIN (simvastatin/ezetimibe) unsuccessful trial with the preferred statin combination plus an unsuccessful trial with a preferred statin and calcium channel blocker (single agents) used together. MACROLIDES/KETOLIDES (Oral) KETOLIDES KETEK (telithromycin)

MACROLIDES

Azithromycin BIAXIN (clarithromycin) clarithromycin ER BIAXIN XL (clarithromycin) E.E.S. (erythromycin ethylsuccinate) clarithromycin IR E-MYCIN (erythromycin) E.E.S. Suspension (erythromycin ethylsuccinate) ERYC (erythromycin) ERYPED Suspension (erythromycin ERY-TAB (erythromycin) 43 This is not an all-inclusive list of available covered drugs and includes only managed categories. 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 P&T Committee. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 4-1-2014. **Users of these products as of 9-30-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 10/01/2013 PREFERRED DRUG LIST Version 2013.26 Updated: 9-27-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS ethylsuccinate) ERYTHROCIN (erythromycin stearate) erythromycin erythromycin estolate

PCE (erythromycin) ZITHROMAX (azithromycin) ZMAX (azithromycin) MISCELLANEOUS BRAND/GENERIC CATAPRES-TTS (clonidine) clonidine patches clonidine tablets CATAPRES (clonidine)

MISCELLANEOUS alprazolam alprazolam ER Suboxone References can be found at: CARAFATE SUSPENSION (sucralfate) KORLYM (mifepristone) http://www.medicaid.ms.gov/Document MEGACE ES (megestrol) megestrol suspension 625mg/5mL s/Pharmacy/Suboxone%20Resources.p sucralfate suspension df. SUBOXONE (buprenorphine/naloxone) NR ZUBSOLV (buprenorphine/naloxone) SmartPA Criteria • Alprazolam ER: Applicable CUMULATIVE quantity limit in 31 rolling days . 31 tablets . Exception: previous beneficiaries with a paid claim for 2 tablets per day in the past 90 days are allowed to remain on cumulative of 62 tablets.

SUBLINGUAL NITROGLYCERIN nitroglycerin lingual 12gm nitroglycerin lingual 4.9gm nitroglycerin sublingual NITROLINGUAL (nitroglycerin) 4.9gm NITROLINGUAL PUMPSPRAY (nitroglycerin) NITROMIST (nitroglycerin) 12gm NITROSTAT SUBLINGUAL (nitroglycerin)

44 This is not an all-inclusive list of available covered drugs and includes only managed categories. 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 P&T Committee. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 4-1-2014. **Users of these products as of 9-30-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 10/01/2013 PREFERRED DRUG LIST Version 2013.26 Updated: 9-27-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS MULTIPLE SCLEROSIS AGENTS SmartPA AVONEX (interferon beta-1a) AMPYRA (dalfampridine) SmartPA Criteria: COPAXONE (glatiramer) AUBAGIO (teriflunomide) • Documented diagnosis found in the REBIF (interferon beta-1a) BETASERON (interferon beta-1b) past 2 years medical claims for multiple EXTAVIA (interferon beta-1b) sclerosis AND • One claim for 2 different preferred GILENYA (fingolimod) agents in the past 6 months OR TECFIDERA (dimethyl fumarate) • 3 claims with the same agent in the past 105 days

*Ampyra – Requires Manual PA: 1. For patients that have a gait disorder associated with MS; and 2. Initial authorizations will be approved for 12 weeks with a baseline Timed 25- foot Walk (T25FW) assessment; and 3. Additional prior authorizations will be considered at 6 month intervals after assessing the benefit to the patient as measured by a 20% improvement in the T25FW from baseline. Renewal will not be approved if the 20% improvement is not maintained; and 4. Prior authorizations will not be considered for patients with a seizure diagnosis or in patients will moderate to severe renal impairment. 5. Max dose of 20 mg daily; and #60 units in 30 days; approved for ages 18 and above

NSAIDS NON-SELECTIVE diclofenac EC ADVIL (ibuprofen) SmartPA Criteria: etodolac tab ANAPROX (naproxen) • Non-Selective agents: CAMBIA (diclofenac) 30 days therapy with 2 different 45 This is not an all-inclusive list of available covered drugs and includes only managed categories. 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 P&T Committee. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 4-1-2014. **Users of these products as of 9-30-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 10/01/2013 PREFERRED DRUG LIST Version 2013.26 Updated: 9-27-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS flurbiprofen CATAFLAM (diclofenac) preferred agents in the past 6 months ibuprofen DAYPRO (oxaprozin) indomethacin diclofenac SR ketorolac etodolac cap naproxen etodolac tab SR sulindac FELDENE (piroxicam) fenoprofen INDOCIN (indomethacin) indomethacin cap ER ketoprofen ketoprofen ER meclofenamate mefenamic acid nabumetone NALFON (fenoprofen) NAPRELAN (naproxen) NAPROSYN (naproxen) NUPRIN (ibuprofen) oxaprozin piroxicam PONSTEL (mefenamic acid) SPRIX NASAL SPRAY (ketorolac) tolmetin VOLTAREN XR (diclofenac) ZIPSOR (diclofenac) NSAID/GI PROTECTANT COMBINATIONS ARTHROTEC (diclofenac/misoprostol) diclofenac/misoprostol DUEXIS (ibuprofen/famotidine) VIMOVO (naproxen/esomeprazole)

SmartPA COX II SELECTIVE meloxicam CELEBREX (celecoxib) SmartPA Criteria • COX II Selective Agents: 46 This is not an all-inclusive list of available covered drugs and includes only managed categories. 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 P&T Committee. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 4-1-2014. **Users of these products as of 9-30-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 10/01/2013 PREFERRED DRUG LIST Version 2013.26 Updated: 9-27-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS MOBIC (meloxicam) o Documented diagnosis found in the past 2 years medical claims for Osteoarthritis, Rheumatoid Arthritis, Familial Adenomatous Polyposis, or Ankylosing Spondylitis AND . 30 days of therapy with 1 preferred COX-II Selective agent OR . 90 days completed therapy with the same agent in the past 105 days OR . 30 days of therapy with 1 preferred COX-II Selective agent AND . 30 days of therapy with 1 preferred Non-Selective Agent OR . 30 days of therapy with 1 preferred COX-II Selective agent AND . Documented diagnosis found in the past 2 years medical claims for GI Bleed, GERD, PUD, GI Perforation, or Coagulation Disorder

OPHTHALMIC ANTIBIOTICS bacitracin AZASITE (azithromycin) bacitracin/neomycin/gramicidin BESIVANCE () bacitracin/polymyxin BLEPH-10 (sulfacetamide) erythromycin CILOXAN (ciprofloxacin) gentamicin ciprofloxacin MOXEZA (moxifloxacin) GARAMYCIN (gentamicin) neomycin/bacitracin/polymyxin b levofloxacin

47 This is not an all-inclusive list of available covered drugs and includes only managed categories. 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 P&T Committee. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 4-1-2014. **Users of these products as of 9-30-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 10/01/2013 PREFERRED DRUG LIST Version 2013.26 Updated: 9-27-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS polymyxin/ NATACYN (natamycin) sulfacetamide NEO-POLYCIN (neomy/baci/polymyxin b) tobramycin NEOSPORIN (bacitracin/neomycin/gramicidin) VIGAMOX (moxifloxacin) (oxy-tcn/polymyx sul) TOBREX (tobramycin) oint OCUFLOX (ofloxacin) ofloxacin POLYTRIM (polymyxin/trimethoprim) ZYMAR () ZYMAXID (gatifloxacin) STEROID COMBINATIONS neomycin/bacitracin/polymyxin/hc BLEPHAMIDE (sulfacetamide/prednisolone) neomycin//polymyxin/dexamethasone MAXITROL(neomycin/polymyxin/dexamethasone) PRED-G (gentamicin/prednisolone) sulfacetamide/prednisolone TOBRADEX OINTMENT (tobramycin/dexamethasone) tobramycin/dexamethasone ZYLET (loteprednol/tobramycin) OPHTHALMIC ANTI-INFLAMMATORIES SmartPA dexamethasone ACULAR LS (ketorolac) SmartPA Criteria: diclofenac ACUVAIL (ketorolac) • One claim for 2 different preferred FLAREX (fluorometholone) BROMDAY (bromfenac) agents in the past 6 months flurbiprofen bromfenac FML FORTE (fluorometholone) DUREZOL (difluprednate) FML SOP (fluorometholone) OCUFEN (flurbiprofen) ILEVRO (nepafenac) PROLENSA (bromfenac) MAXIDEX (dexamethasone) PRED MILD (prednisolone) NEVANAC (nepafenac) PRED FORTE (prednisolone) prednisolone acetate VOLTAREN (diclofenac) prednisolone NA phosphate VEXOL (rimexolone)

48 This is not an all-inclusive list of available covered drugs and includes only managed categories. 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 P&T Committee. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 4-1-2014. **Users of these products as of 9-30-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 10/01/2013 PREFERRED DRUG LIST Version 2013.26 Updated: 9-27-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS OPHTHALMICS FOR ALLERGIC SmartPA cromolyn ALAMAST (pemirolast) SmartPA Criteria: ketotifen OTC ALOCRIL (nedocromil) • 30 days of therapy with 2 different LOTEMAX (loteprednol) ALOMIDE (lodoxamide) preferred agents in the past 6 months OPTIVAR (azelastine) ALREX (loteprednol) OR 90 days completed therapy with the PATADAY (olopatadine) azelastine same agent in the past 105 days PATANOL (olopatadine) BEPREVE (bepotastine) ELESTAT (epinastine) EMADINE (emedastine) epinastine LASTACAFT (alcaftadine)

OPHTHALMICS, AGENTS SmartPA BETA BLOCKERS betaxolol BETAGAN () SmartPA Criteria: BETIMOL (timolol) BETOPTIC S (betaxolol) • Documented diagnosis found in the OPTIPRANOLOL () past 2 years medical claims for ISTALOL (timolol) timolol gel glaucoma AND • 30 days of therapy with 2 different levobunolol TIMOPTIC (timolol) preferred agents in the past 6 months metipranolol OR timolol solution 90 days completed therapy with the same agent in the past 105 days CARBONIC ANHYDRASE INHIBITORS AZOPT () TRUSOPT (dorzolamide)

COMBINATION AGENTS COMBIGAN (/timolol) COSOPT PF(dorzolamide/timolol) COSOPT (dorzolamide/timolol) SIMBRINZA (brinzolamide/brimonidine) dorzolamide/timolol

49 This is not an all-inclusive list of available covered drugs and includes only managed categories. 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 P&T Committee. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 4-1-2014. **Users of these products as of 9-30-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 10/01/2013 PREFERRED DRUG LIST Version 2013.26 Updated: 9-27-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS PARASYMPATHOMIMETICS CARBOPTIC () ISOPTO CARBACHOL (carbachol) ISOPTO CARPINE (pilocarpine) PHOSPHOLINE IODIDE (echothiophate iodide) PILOPINE HS (pilocarpine)

PROSTAGLANDIN ANALOGS LUMIGAN () TRAVATAN Z () RESCULA ()NR travoprost XALATAN (latanoprost) ZIOPTAN ()

SYMPATHOMIMETICS ALPHAGAN P 0.15% (brimonidine) ALPHAGAN P 0.1% (brimonidine) brimonidine dipivefrin PROPINE (dipivefrin) OTIC ANTIBIOTICS CIPRO HC (ciprofloxacin/hydrocortisone) ciprofloxacin CIPRODEX (ciprofloxacin/dexamethasone) DERMOTIC (fluocinolone) COLY-MYCIN S (colistin/neomycin/ ofloxacin hydrocortisone) CORTISPORIN-TC (colistin/neomycin/ hydrocortisone) neomycin/polymyxin/hydrocortisone PANCREATIC ENZYMES SmartPA CREON (pancreatin) PANCRELIPASE SmartPA Criteria: PANCREAZE (pancrelipase) PERTZYE • 30 days of therapy with 2 different ZENPEP (pancrelipase) ULTRESA preferred agents in the past 6 months VIOKASE OR • 90 days completed therapy with the

same agent in the past 105 days 50 This is not an all-inclusive list of available covered drugs and includes only managed categories. 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 P&T Committee. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 4-1-2014. **Users of these products as of 9-30-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 10/01/2013 PREFERRED DRUG LIST Version 2013.26 Updated: 9-27-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS PARATHYROID AGENTS calcitriol DRISDOL (ergocalciferol) ergocalciferol HECTOROL (doxercalciferol) ZEMPLAR (paricalcitol) ROCALTROL (calcitriol) SENSIPAR (cinacalcet)

PHOSPHATE BINDERS ELIPHOS (calcium acetate) calcium acetate RENAGEL (sevelamer HCl) FOSRENOL (lanthanum) PHOSLYRA (calcium acetate) PHOSLO (calcium acetate) RENVELA (sevelamer carbonate)

PLATELET AGGREGATION INHIBITORS SmartPA AGGRENOX (dipyridamole/aspirin) BRILINTA (ticagrelor) SmartPA Criteria: dipyridamole cilostazol Brilinta PLAVIX (clopidogrel) clopidogrel • Documented diagnosis found in the EFFIENT (prasugrel) past 2 years medical claims for Acute Coronary Syndrome or Percutaneous PERSANTINE (dipyridamole) Coronary Intervention OR PLETAL (cilostazol) • 30 days of therapy with Brilinta in the ticlopidine past 60 days

Pletal • Documented diagnosis found in the past 2 years medical claims for an approvable indication OR • 90 days completed therapy with the same agent in the past 105 days

Effient • Documented diagnosis found in the past 2 years medical claims for Acute Coronary Syndrome or Percutaneous

51 This is not an all-inclusive list of available covered drugs and includes only managed categories. 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 P&T Committee. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 4-1-2014. **Users of these products as of 9-30-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 10/01/2013 PREFERRED DRUG LIST Version 2013.26 Updated: 9-27-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS Coronary Intervention

Non Preferred Agents • Documented diagnosis found in the past 2 years medical claims for an approvable indication AND • 30 days of therapy with 2 different preferred agents in the past 6 months OR • 90 days completed therapy with the same agent in the past 105 days

PRENATAL VITAMINS CONCEPT DHA Capsule B-NEXA Tablet Products not listed here are assumed to FE C PLUS Tablet CAVAN-EC SOD DHA VITAMINS be non-preferred. PAIRE OB PLUS DHA COMBO PACK CITRANATAL 90 DHA PACK PRENATAL PLUS Tablet CITRANATAL ASSURE COMBO PACK PREQUE 10 TABLET CITRANATAL B-CALM PACK SE-NATAL CHEWABLE Tablet CITRANATAL DHA PACK TARON-C DHA Capsule CITRANATAL HARMONY Capsule TRICARE PRENATAL Tablet CITRANATAL HARMONY Capsule VOL-PLUS Tablet CITRANATAL RX Tablet COMPLETE NATAL DHA COMPLETENATE Tablet CHEW CONCEPT OB Capsule CORENATE-DHA COMBO PACK DUET DHA BALANCED COMBO PACK DUET DHA BALANCED COMBO PACK ED CYTE F Tablet FOLCAL DHA Capsule FOLCAPS OMEGA-3 Capsule FOLIVANE-EC CALCIUM DHA COMBO FOLIVANE-OB Capsule FOLIVANE-PRX DHA NF Capsule GESTICARE DHA COMBO PACK ICAR-C PLUS SR Capsule 52 This is not an all-inclusive list of available covered drugs and includes only managed categories. 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 P&T Committee. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 4-1-2014. **Users of these products as of 9-30-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 10/01/2013 PREFERRED DRUG LIST Version 2013.26 Updated: 9-27-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS ICAR-C PLUS Tablet NATAFORT Tablet NATELLE ONE Capsule NESTABS DHA COMBO PACK NESTABS PRENATAL Tablet NEXA SELECT Capsule PNV-DHA SOFTGEL PNV-SELECT Tablet PR NATAL 400 COMBO PACK PR NATAL 430 COMBO PACK PR NATAL 430 EC COMBO PACK PREFERA OB Tablet PREFERA-OB ONE SOFTGEL PREFERA-OB PLUS DHA COMBO PACK PREFERA-OB PLUS DHA COMBO PACK PREFERA-OB Tablet PRENATABS FA Tablet PRENATAL 19 Tablet PRENATAL PLUS IRON Tablet PRENATAL VITAMINS Tablet PRENATE DHA SOFTGEL PRENATE ELITE Tablet PRENATE ESSENTIAL SOFTGEL PRENATE PLUS Tablet PRENAVITE Tablet PRENEXA Capsule PREQUE 10 Tablet PREQUE 10 Tablet RELNATE DHA PRENATAL SOFTGEL ROVIN-NV DHA Capsule ROVIN-NV Tablet SE-CARE CHEWABLE Tablet SELECT-OB + DHA PACK SELECT-OB CAPLET SE-NATAL 19 CHEWABLE Tablet SE-NATAL 19 Tablet SE-TAN DHA Capsule 53 This is not an all-inclusive list of available covered drugs and includes only managed categories. 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 P&T Committee. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 4-1-2014. **Users of these products as of 9-30-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 10/01/2013 PREFERRED DRUG LIST Version 2013.26 Updated: 9-27-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS TARON-BC Tablet TARON-PREX PRENATAL DHA CAP PROTON PUMP INHIBITORS SmartPA ACIPHEX (rabeprazole) DEXILANT (dexlansoprazole) SmartPA Criteria: NEXIUM (esomeprazole) lansoprazole RX • Documented diagnosis found in the PROTONIX PACKET (pantoprazole) omeprazole RX past 2 years medical claims AND • omeprazole sod. bicarb. 30 days of therapy with 2 different preferred agents in the past 6 months pantoprazole OR PREVACID Rx (lansoprazole) 90 days completed therapy with the PREVACID SOLU-TAB (lansoprazole) same agent in the past 105 days PRILOSEC RX (omeprazole) PROTONIX (pantoprazole) PULMONARY ANTIHYPERTENSIVES – ENDOTHELIN RECEPTOR ANTAGONISTS LETAIRIS (ambrisentan) SmartPA Criteria: TRACLEER (bosentan) • Documented diagnosis found in the past 2 years medical claims for pulmonary hypertension PULMONARY ANTIHYPERTENSIVES – PDE5s SmartPA ADCIRCA (tadalafil) REVATIO (sildenafil) SmartPA Criteria: sildenafil • Documented diagnosis found in the past 2 years medical claims for pulmonary hypertension

Revatio • Age <1 year AND o Documented diagnosis found in the past 1 year medical claims for Pulmonary Hypertension, Patent Ductus Arteriosus, or Persistent Fetal Circulation OR • Age > 18 years AND o 30 days of therapy with 1 preferred 54 This is not an all-inclusive list of available covered drugs and includes only managed categories. 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 P&T Committee. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 4-1-2014. **Users of these products as of 9-30-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 10/01/2013 PREFERRED DRUG LIST Version 2013.26 Updated: 9-27-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS PAH agent in the past 6 months OR o 90 days completed therapy with the same agent in the past 105 days

Sildenafil • Minimum age requirement of 12 years AND • Documented diagnosis found in the past 2 years medical claims for Pulmonary Hypertension, Patent Ductus Arteriosus, or Persistent Fetal Circulation OR • Documented diagnosis found in the past 2 years medical claims for Heart Transplant PULMONARY ANTIHYPERTENSIVES – PROSTACYCLINS TYVASO (treprostinil) SmartPA Criteria: VENTAVIS (iloprost) • Documented diagnosis found in the past 2 years medical claims for pulmonary hypertension

Non Preferred Agents • 30 days of therapy with 1 preferred PAH agent in the past 6 months OR • 90 days completed therapy with the same agent in the past 105 days

SEDATIVE HYPNOTICS BENZODIAZEPINES estazolam DALMANE (flurazepam) Single source benzodiazepines and flurazepam DORAL (quazepam) barbiturates are NOT covered; PAs will temazepam (15mg and 30mg) HALCION (triazolam) not be issued for these drugs. RESTORIL (temazepam) triazolam temazepam (7.5mg and 22.5mg) Sedative/Hypnotics are limited to 31 cumulative units of all/any strengths per 55 This is not an all-inclusive list of available covered drugs and includes only managed categories. 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 P&T Committee. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 4-1-2014. **Users of these products as of 9-30-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 10/01/2013 PREFERRED DRUG LIST Version 2013.26 Updated: 9-27-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS month. Any quantity required above these limits requires a PA. SmartPA OTHERS LUNESTA (eszopiclone) AMBIEN (zolpidem) SmartPA Criteria: zaleplon AMBIEN CR (zolpidem) Applicable CUMULATIVE quantity limit zolpidem EDLUAR (zolpidem) in 31 rolling days • INTERMEZZO (zolpidem) 31 tablets in 31 days • 1 Canister in 31 days – ROZEREM (ramelteon) Zolpimist SILENOR (doxepin) • 1 Canister (Zolpimist ) SONATA (zaleplon) Female - 62 days zolpidem ER Male – 31 days ZOLPIMIST (zolpidem) Applicable dosage and gender limitations for zolpidem products: • Female – zolpidem 5mg, 6.25mg, and 1.75 mg • Male – all zolpidem strengths

• One claim for 2 different preferred agents in the past 6 months

SELECT CONTRACEPTIVE PRODUCTS ALL CONTRACEPTIVES ARE PREFERRED AMETHIA (levonorgestrel/ethinyl ) ** SmartPA Criteria EXCEPT FOR THOSE SPECIFICALLY AMETHYST (levonorgestrel/ethinyl estradiol) ** Oral Contraceptive Products INDICATED AS NON-PREFERRED BEYAZ (ethinyl • One claim in the past 105 days estradiol//levomefolate) BRIELLYN (norethindrone/ethinyl estradiol) ** Depo Provera Injection CAMRESE (levonorgestrel/ethinyl estradiol) ** 90 days completed therapy with the CAMRESE LO (levonorgestrel/ethinyl estradiol) ** same agent in the past 105 days DEPO-PROVERA IM (medroxyprogesterone acetate)** DEPO-SUBQ PROVERA 104 (medroxyprogesterone acetate)** ethinyl estradiol/drospirenone**

56 This is not an all-inclusive list of available covered drugs and includes only managed categories. 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 P&T Committee. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 4-1-2014. **Users of these products as of 9-30-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 10/01/2013 PREFERRED DRUG LIST Version 2013.26 Updated: 9-27-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS GENERESS FE (norethindrone/ethinyl estradiol/fe) ** Gianvi (ethinyl estradiol/drospirenone) GILDAGIA (norethindrone/ethinyl estradiol) ** INTROVALE (levonorgestrel/ethinyl estradiol) ** JOLESSA (levonorgestrel/ethinyl estradiol) ** LOESTRIN 24 FE (norethindrone/ethinyl estradiol) ** LO LOESTRIN FE (norethindrone/ethinyl estradiol) ** LORYNA (ethinyl estradiol/drospirenone) ** NATAZIA (estradiol valerate/dienogest) ** norethindrone/ethinyl estradiol/fe chew tab OCELLA (ethinyl estradiol/drospirenone) OVCON-35 (norethindrone/ethinyl estradiol) ** PHILITH (norethindrone/ethinyl estradiol) ** QUASENSE (levonorgestrel/ethinyl estradiol) ** SAFYRAL (ethinyl estradiol/drospirenone/levomefolate) ** SYEDA (ethinyl estradiol/drospirenone) ** TILIA FE (norethindrone/ethinyl estradiol/fe) ** TRI-LEGEST FE (norethindrone/ethinyl estradiol/fe) ** VESTURA (ethinyl estradiol/drospirenone) ** WYMZYA FE (norethindrone/ethinyl estradiol/fe) ZARAH (ethinyl estradiol/drospirenone) ** ZENCHENT FE (norethindrone/ethinyl estradiol/fe) ZEOSA (norethindrone/ethinyl estradiol/fe)

SKELETAL MUSCLE RELAXANTS SmartPA baclofen AMRIX (cyclobenzaprine ER) SmartPA Criteria: chlorzoxazone carisoprodol Carisoprodol cyclobenzaprine carisoprodol compound • Documented diagnosis found in medical 57 This is not an all-inclusive list of available covered drugs and includes only managed categories. 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 P&T Committee. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 4-1-2014. **Users of these products as of 9-30-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 10/01/2013 PREFERRED DRUG LIST Version 2013.26 Updated: 9-27-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS methocarbamol cyclobenzaprine ER claims in the past 3 months for an acute tizanidine tablets dantrolene musculoskeletal condition AND FEXMID (cyclobenzaprine) • NO history of meprobamate therapy in LORZONE (chlorzoxazone) the past 90 days AND metaxalone • One claim for cyclobenzaprine in the orphenadrine past 21 days OR a documented intolerance to cyclobenzaprine AND orphenadrine compound • Quantity limits of 84 tablets total in the PARAFON FORTE DSC (chlorzoxazone) past 6 months OR ROBAXIN (methocarbamol) • One claim for 18 tablets of carisoprodol SKELAXIN (metaxalone) to taper off SOMA (carisoprodol) tizanidine capsules Non Preferred Agents ZANAFLEX (tizanidine) • Documented diagnosis found in the past 2 years medical claims for an approvable indication AND • One claim for 2 different preferred agents in the past 6 months OR • Documented diagnosis found in the past 2 years medical claims for a chronic musculoskeletal disorder AND • 90 days completed therapy with the same agent in the past 105 days STEROIDS (Topical) SmartPA LOW POTENCY CAPEX (fluocinolone) alclometasone SmartPA Criteria: DESOWEN (desonide) lotion DERMA-SMOOTHE-FS (fluocinolone) • Low Potency Agents desonide cr, oint. DESONATE (desonide) o One claim for 2 different preferred hydrocortisone cr, oint, soln. desonide lotion low potency agents in the past 6 months OR DESOWEN (desonide) o 90 days completed therapy with the fluocinolone oil same agent in the past 105 days hydrocortisone lotion PEDIACARE HC (hydrocortisone) PEDIADERM (hydrocortisone) VERDESO (desonide) 58 This is not an all-inclusive list of available covered drugs and includes only managed categories. 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 P&T Committee. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 4-1-2014. **Users of these products as of 9-30-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 10/01/2013 PREFERRED DRUG LIST Version 2013.26 Updated: 9-27-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS MEDIUM POTENCY fluocinolone CLODERM (clocortolone) SmartPA Criteria: hydrocortisone CUTIVATE (fluticasone) • Medium Potency Agents mometasone cr, oint. DERMATOP (prednicarbate) o One claim for 2 different preferred prednicarbate cr ELOCON (mometasone) medium potency agents in the past 6 months OR PANDEL (hydrocortisone probutate) fluticasone o 90 days completed therapy with the LUXIQ (betamethasone) same agent in the past 105 days mometasone solution MOMEXIN (mometasone) prednicarbate oint SYNALAR (fluocinolone)

HIGH POTENCY amcinonide cr, lot amcinonide oint SmartPA Criteria betamethasone dipropionate cr, gel, lotion betameth diprop/prop gly cr, lot, oint • High Potency Agents betamethasone valerate cr, lotion, oint. betamethasone dipropionate oint. o One claim for 2 different preferred CAPEX (fluocinolone) BETA-VAL (betamethasone valerate) high potency agents in the past 6 months OR fluocinolone desoximetasone o 90 days completed therapy with the fluocinonide diflorasone same agent in the past 105 days triamcinolone DIPROLENE AF (betamethasone diprop/prop gly) ELOCON (mometasone) HALOG (halcinonide) KENALOG (triamcinolone) PEDIADERM TA (triamcinolone) TOPICORT (desoximetasone) TRIANEX (triamcinolone) VANOS (fluocinonide) VERY HIGH POTENCY clobetasol emollient clobetasol propionate foam SmartPA Criteria clobetasol propionate cr, gel, oint, sol CLOBEX (clobetasol) • Very High Potency Agents halobetasol DIPROLENE (betamethasone diprop/prop gly) o One claim for 2 different preferred HALONATE very high potency agents in the past (halobetasol/ammonium lactate) 6 months OR 59 This is not an all-inclusive list of available covered drugs and includes only managed categories. 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 P&T Committee. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 4-1-2014. **Users of these products as of 9-30-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 10/01/2013 PREFERRED DRUG LIST Version 2013.26 Updated: 9-27-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS

HALAC (halobetasol/ammoium lac) o 90 days completed therapy with the TEMOVATE (clobetasol propionate) same agent in the past 105 days OLUX (clobetasol) OLUX-E (clobetasol) ULTRAVATE (halobetasol)

STIMULANTS AND RELATED AGENTS SmartPA SHORT-ACTING amphetamine salt combination ADDERALL (amphetamine salt combination) Applicable quantity limit in 31 rolling dexmethylphenidate IR DESOXYN (methamphetamine) days dextroamphetamine IR methamphetamine • 62 tablets in 31 days – FOCALIN (dexmethylphenidate) methylphenidate solution Adderall IR, Concerta 36mg, Desoxyn, dextroamphetamine METHYLIN chewable tablets (methylphenidate) IR, Focalin IR, Focalin XR 15 METHYLIN solution (methylphenidate) & 20mg, methylphenidate IR, methylphenidate IR Nuvigil 50mg, methylphenidate PROCENTRA (dextroamphetamine) IR • 31 tablets in 31 days – Adderall XR, Concerta 18, 27, & 54 mg, Daytrana, Dexedrine Spansule, Focalin XR 5 & 10mg, Intuniv ER, Metadate CD, Methylin ER, Nuvigil 150 & 200 mg, Provigil 200mg, Ritalin LA & SR, Strattera, and Vyvanse • 46.5 tablets in 31 days – Provigil 100 mg • 155 mL in 31 days – methylphenidate solution, dextroamphetamine solution • 124 tablets in 31 days – Kapvay 0.1mg • 372 mL in 31 days – methylphenidate ER solution 60 This is not an all-inclusive list of available covered drugs and includes only managed categories. 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 P&T Committee. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 4-1-2014. **Users of these products as of 9-30-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 10/01/2013 PREFERRED DRUG LIST Version 2013.26 Updated: 9-27-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS

SmartPA Criteria: Short Acting Agents • Minimum age requirements apply to all drug formulations below o Amphetamine salts – 3 years o Dexmethylphenidate IR – 6 years o Dextroamphetamine IR – 3 years o Methylphenidate – 6 years o Methamphetamine – 6 years

• 30 days therapy with 2 different preferred Short Acting agents OR • 1 claim for a 30 day supply in the past 180 days LONG-ACTING ADDERALL XR (amphetamine salt amphetamine salt combination ER Long Acting Agents combination)*(Requires trial of Vyvanse before CONCERTA (methylphenidate) • Minimum age requirements apply to all approval)* DEXEDRINE (dextroamphetamine) drug formulations below DAYTRANA (methylphenidate) dextroamphetamine ER o Armodafinil – 17 years Modafinil – 16 years FOCALIN XR (dexmethylphenidate) methylphenidate CD (generic Metadate CD) o METADATE CD (methylphenidate) o All other long acting agents – 6 NUVIGIL (armodafinil) years methylphenidate ER (generic Concerta) PROVIGIL (modafinil)

QUILLIVANT XR (methylphenidate) RITALIN LA (methylphenidate) Adderall XR: VYVANSE (lisdexamfetamine) • 1 claim for a 30 day supply in the past 180 days OR • 30 days of therapy with Vyvanse in the past 6 months

Non Preferred Agents • 30 days therapy with 2 different preferred Long Acting agents in the past 6 months OR • 1 claim for a 30 day supply in the past 180 days 61 This is not an all-inclusive list of available covered drugs and includes only managed categories. 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 P&T Committee. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 4-1-2014. **Users of these products as of 9-30-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 10/01/2013 PREFERRED DRUG LIST Version 2013.26 Updated: 9-27-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS

Nuvigil or Provigil • Documented diagnosis found in the past 2 years medical claims for Narcolepsy, Obstructive Sleep Apnea, or Shift Work Disorder AND • 30 days therapy with 2 different preferred Short Acting or Long Acting agents in the past 6 months OR • 1 claim for a 30 day supply with the same agent in the past 180 days

NON-STIMULANTS STRATTERA (atomoxetine) INTUNIV (guanfacine ER) Kapvay/Intuniv KAPVAY (clonidine extended-release) • 1 claim for a 30 day supply in the past 180 days OR • Age requirement – 6 to 17 years AND • Documented diagnosis found in the past 2 years medical claims for ADD or ADHD AND • 30 days of therapy with a Short Acting or Long Acting agent in the past 6 months OR • 30 days therapy with Strattera in the past 6 months OR • 30 days therapy with short acting product (Intuniv - guanfacine or Kapvay - clonidine)

TETRACYCLINES SmartPA doxycycline hyclate caps/tabs ADOXA (doxycycline monohydrate) SmartPA Criteria: doxycycline monohydrate caps (50mg & 100mg) demeclocycline • Demeclocycline - a documented caps IR doxycycline monohydrate caps (75mg & 150mg) diagnosis found in the past 2 years tetracycline doxycycline monohydrate tabs medical claims for Diabetes Insipidus or SIADH DYNACIN (minocycline)

62 This is not an all-inclusive list of available covered drugs and includes only managed categories. 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 P&T Committee. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 4-1-2014. **Users of these products as of 9-30-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 10/01/2013 PREFERRED DRUG LIST Version 2013.26 Updated: 9-27-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS minocycline ER Non Preferred Agents minocycline tabs One claims for 2 different preferred ORACEA (doxycycline) agents in the past 6 months SOLODYN (minocycline) VIBRAMYCIN cap/susp/syrup ULCERATIVE COLITIS AGENTS ORAL APRISO (mesalamine) ASACOL HD (mesalamine) SmartPA Criteria ASACOL (mesalamine) AZULFIDINE (sulfasalazine) Giazo balsalazide AZULFIDINE ER (sulfasalazine) • Limited to Male Patients AND • DELZICOL (mesalamine) COLAZAL (balsalazide) Non Preferred Criteria

DIPENTUM (olsalazine) GIAZO (balsalazide) • Documented diagnosis found in the PENTASA 250mg (mesalamine) LIALDA (mesalamine) past 2 years medical claims for sulfasalazine PENTASA 500mg (mesalamine) NR Ulcerative Colitis AND UCERIS (budesonide) • 30 days therapy with 2 different preferred agents in the past 6 months OR • 90 days completed therapy with the same agent in the past 105 days

RECTAL CANASA (mesalamine) SFROWASA (mesalamine) mesalamine

63 This is not an all-inclusive list of available covered drugs and includes only managed categories. 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 P&T Committee. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 4-1-2014. **Users of these products as of 9-30-13 will be grandfathered To search the PDL, press CTRL + F

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