MICHIGAN DRUG ASSISTANCE PROGRAM 1 Last Updated: 7/1/15 All Previous Versions Obsolete

HIV / AIDS Related Treatments HIV Treatment and Prevention Website: http://www.aidsinfo.nih.gov/ Antiretrovirals

Nucleoside/Nucleotide Reverse Non-Nucleoside Reverse CCR-5 Inhibitor Selzentry () - MIDAP will no longer utilize the previous form of medical Transcriptase Inhibitors Transcriptase Inhibitors necessity for authorizing tropism assay coverage (ZIAGEN) (RESCRIPTOR) Process for obtaining tropism assay: Abacavir/ (EPZICOM) (SUSTIVA) - Any MIDAP patient that requires a tropism test Abacavir/lamivudine/ (VIRAMUNE, VIRAMUNE XR) * will need to complete the ViiV Healthcare Tropsim (TRIZIVIR) (INTELENCE) Access Program certificate form. These may be obtained by your local ViiV representative. (VIDEX EC*, VIDEX (EDURANT) - Please note that the Trofile assay requires the HIV- soln) Protease Inhibitors & Combinations 1 RNA PCR to be >1000 copies/mL. (EMTRIVA) (REYATAZ) - The Trofile DNA assay should only be used when Emtricitabine/Tenefovir (TRUVADA) (PREZISTA) the HIV-1 RNA PCR is less than the lower limit of Lamivudine (EPIVIR)* (LEXIVA) detection (ie. undetectable). Lamivudine/zidovudine Process for obtaining Selzentry (maraviroc) (CRIXIVAN) (COMBIVIR)* coverage: / (KALETRA) (ZERIT)* - MIDAP will approve the use of Selzentry for (VIRACEPT)* Tenofovir (VIREAD) members who have tropism results of R5 virus Ritonavir (NORVIR) ONLY. Dual / mixed virus will not be approved. Zidovudine (RETROVIR)* (INVIRASE) - To obtain coverage of this drug, please fax the lab HIV Inhibitor (APTIVUS) result to the MIDAP Office at 1-517-335-7723 (ISENTRESS) Darunavir/ (PREZCOBIX) - Please allow 2 days for processing. (TIVICAY) Atazanavir/Cobicistat (EVOTAZ)

Fusion Inhibitors NNRTI/NRTI Combination (FUZEON) Efavirenz/emtricitabine/tenofovir (ATRIPLA) /Cobicistat/Emtricitabine/ Pharmacokinetic Enhancers Emtricitabine/rilpivirine/tenofovir (COMPLERA) Tenofovir (STRIBILD) Cobicistat (TYBOST) Abacavir/dolutegravir/lamivudine (TRIUMEQ) Opportunistic Infections PCP infections Toxoplasmosis Fungal infections Co-trimoxazole, TMP/SMX Co-trimoxazole, TMP/SMX Amphotericin B* (BACTRIM/SEPTRA SS, DS)* (BACTRIM/SEPTRA SS, DS)* Clotrimazole (MYCELEX)* Dapsone Dapsone Ketoconazole (NIZORAL)* (excluding shampoo) Pentamidine (PENTAM)* Pyrimethamine (DARAPRIM) Terbinafine (LAMISIL)* Atovaquone (MEPRON) PA Leucovorin* Fluconazole (DIFLUCAN)* Primaquine* Azithromycin (ZITHROMAX)* Voriconazole (VFEND)* Trimethoprim* Clindamycin (CLEOCIN)* Itraconazole (SPORANOX)* Clindamycin (CLEOCIN)* Leucovorin* Nystatin* Mycobacterial infections Sulfadiazine Others Azithromycin (ZITHROMAX)* Atovaquone (MEPRON) PA Hepatitis B Vaccine Clarithromycin (BIAXIN)* Herpes infections Hepatitis A Vaccine Ethambutol (MYAMBUTOL)* Acyclovir (ZOVIRAX)* ST1 Pneumococcal Vaccine Rifabutin (MYCOBUTIN) Famciclovir (FAMVIR)* ST2 Influenza Vaccine Ciprofloxacin (CIPRO)* Valacyclovir (VALTREX)* ST2 Ribavirin (REBETOL, RIBASPHERE, Levofloxicin (LEVAQUIN)* CMV infections COPEGUS)* Cryptosporidiosis Cidofovir (VISTIDE) Interferon alfa-2b (INTRON-A) Paromomycin* * Peginterferon alfa-2a (PEGASYS) Atovaquone (MEPRON) PA Ganciclovir* Peginterferon alfa-2b (PEG-INTRON KIT) Azithromycin (ZITHROMAX)* Valganciclovir (VALCYTE)*

1) BRAND NAMEs indicated by CAPITAL, generic names indicated by lower case, * indicates the generic equivalent is available. 2) MANDATORY GENERIC PROGRAM - MIDAP excludes coverage of brand-name drugs with FDA approved generic equivalents. 3) PA = Prior Authorization required. 4) QL= Quantity Limit. 5) Step Therapy: ST1 = the prerequisite drug for ST2 drug(s) in same category; ST2 drugs require a trial of ST1 drug in same category.

MICHIGAN DRUG ASSISTANCE PROGRAM 2 Last Updated: 7/1/15 All Previous Versions Obsolete Analgesics Antiretroviral Agents and Boosters Cidofovir (VISTIDE) Nonsteroidal Anti-inflammatory Agents Abacavir (ZIAGEN) Famciclovir (FAMVIR)* ST2 Celecoxib (CELEBREX) Abacavir/dolutegravir/lamivudine Foscarnet * Diclofenac (VOLTAREN)* (TRIUMEQ) Ganciclovir * Abacavir/lamivudine (EPZICOM) Oseltamivir (TAMIFLU) Diclofenac/misoprostol (ARTHROTEC) Abacavir/lamivudine/zidovudine Ribavirin (REBETOL, RIBASPHERE, Nabumetone* (TRIZIVIR) COPEGUS)* Ibuprofen 800mg (MOTRIN 800mg)* Atazanavir (REYATAZ) Rimantadine (FLUMADINE)*

Atazanavir/Cobicistat (EVOTAZ) Valacyclovir (VALTREX)* ST2 Opiate Agonists Cobicistat (TYBOST) Valganciclovir (VALCYTE) acetaminophen /caffeine/butabital Darunavir (PREZISTA) Zanamivir (RELENZA) (FIORICET)* Darunavir/Cobicistat (PREZCOBIX acetaminophen/caffeine/butabital/codeine Delavirdine (RESCRIPTOR) Cephalosporins (FIORICET/CODEINE)* Cephalexin (KEFLEX)* Asa/caffeine/butabital (FIORINAL)* Didanosine (VIDEX EC*, VIDEX soln) Dolutegravir (TIVICAY) Asa/caffeine/butabital/codeine Efavirenz (SUSTIVA) Quinolones (FIORINAL/CODEINE)* Ciprofloxacin (CIPRO)* Efavirenz /emtricitabine/tenofovir Codeine* Levofloxicin (LEVAQUIN)* (ATRIPLA) Codeine/Acetaminophen (TYLENOL #3, Elvitegravir/Cobicistat/Emtricitabine/ Ofloxacin * #4)* Tenofovir (STRIBILD) Fentanyl (DURAGESIC)* PA Emtricitabine (EMTRIVA) Macrolides Hydrocodone/Acetaminophen (VICODIN, Emtricitabine/tenofovir (TRUVADA) Azithromycin (ZITHROMAX)* VICODIN ES, LORTAB)* Emtricitabine/rilpivirine/tenofovir Clarithromycin (BIAXIN*, BIAXIN XL) Hydromorphone (DILAUDID)* (COMPLERA) Erythromycin* Meperidine (DEMEROL)* Enfuvirtide (FUZEON) Penicillins Methadone* Etravirine (INTELENCE) Amoxicillin (TRIMOX, AMOXIL)* Morphine (ROXANOL, MS-CONTIN)* Fosamprenavir (LEXIVA) Amoxicllin/clavulanic acid Morphine (ORAMORPH SR) Indinavir (CRIXIVAN) (AUGMENTIN*, AUGMENTIN ES- Oxycodone (OXY-IR)* Lamivudine (EPIVIR)* 600, AUGMENTIN XR) Oxycodone/Acetaminophen (PERCOCET)* Lamivudine/zidovudine (COMBIVIR)* Penicillin* Tramadol (ULTRAM)* Maraviroc (SELZENTRY) Penicillin inj (BICILLIN LA)

Tramadol/Acetaminophen (ULTRACET)* Nelfinavir (VIRACEPT) Tetracyclines Oxycodone (OXYCONTIN) PA Nevirapine (VIRAMUNE)* Doxycycline* Raltegravir (ISENTRESS) Rilpiviring (EDURANT) Anti-Infectives Vaginal Antimicrobials Ritonavir (NORVIR) Antifungal Antibiotics Metronidazole (METROGEL)* vag Amphotericin B (AMPHOCIN)* Saquinavir ( INVIRASE) Stavudine (ZERIT)* Ophthalmic Antimicrobials Clotrimazole (MYCELEX)* Ciprofloxacin (CILOXAN)* Tenofovir (VIREAD)* Fluconazole (DIFLUCAN)* Erythromycin* Tipranavir (APTIVUS) Itraconazole (SPORANOX)* Ofloxacin (OCUFLOX)* Zidovudine (RETROVIR)* Ketoconazole (NIZORAL)*(excluding Otic Antimicrobials Antituberculosis Agents shampoo) Ciprofloxacin/dexamethasone Ethambutol (MYAMBUTOL)* Terbinafine (LAMISIL)* (CIPRODEX) Isoniazid* Voriconazole (VFEND)* Ciprofloxacin/hc (CIPRO HC) Pyridoxine* (adjunct to Isoniazid only) Pyrazinamide* Antiprotozoals, Miscellaneous Topical Antimicrobials Atovaquone (MEPRON) PA Rifabutin (MYCOBUTIN)* Rifampin (RIFADIN)* Acyclovir (ZOVIRAX) Paromomycin * Clindamycin (CLEOCIN-T)* Pentamidine (PENTAM)* Other Antivirals Clotrimazole/betamethasone Acyclovir (ZOVIRAX)* ST1 (LOTRISONE)* Entecavir (BARACLUDE) Erythromycin* 1) BRAND NAMEs indicated by CAPITAL, generic names indicated by lower case, * indicates the generic equivalent is available. 2) MANDATORY GENERIC PROGRAM - MIDAP excludes coverage of brand-name drugs with FDA approved generic equivalents. 3) PA = Prior Authorization required. 4) QL= Quantity Limit. 5) Step Therapy: ST1 = the prerequisite drug for ST2 drug(s) in same category; ST2 drugs require a trial of ST1 drug in same category.

MICHIGAN DRUG ASSISTANCE PROGRAM 3 Last Updated: 7/1/15 All Previous Versions Obsolete Metronidazole (METROCREAM*, Diltiazem (CARDIZEM, TAZTIA XT) * Antipsychotics METROGEL) Felodipine (PLENDIL) * Haloperidol ( oral)* Nystatin* Nifedipine XL, ER (PROCARDIA, Chlorpromazine (oral)* Silvadene (SSD)* ADALAT) * Olanzapine (ZYPREXA)* Terbinafine (LAMISIL AT)* Verapamil (COVERA HS) Risperidone (RISPERDAL) Verapamil (VERELAN, ISOPTIN SR, Quetiapine (SEROQUEL) # Other Antimicrobials CALAN, CALAN SR)* # low doses only covered for tapering, Co-trimoxazole, TMP/SMX (BACTRIM not for use as a sedative/hypnotic / SEPTRA SS, DS)* Central Agonists Clindamycin (CLEOCIN)* Clonidine (CATAPRES)* Anxiolytics, Sedatives and Hypnotics Dapsone Minoxidil* Buspirone (BUSPAR)* Metronidazole (FLAGYL)* Zolpidem (AMBIEN*, AMBIEN CR) Lipid Lowering Agents Primaquine Pyrimethamine (DARAPRIM) Atorvastatin (LIPITOR)* Benzodiazepines Sulfadiazine Cholestyramine (QUESTRAN)* Alprazolam (XANAX)* Trimethoprim* Fenofibrate* (LOFIBRA) Clonazepam (KLONOPIN)*

Gemfibrozil (LOPID)* Diazepam (VALIUM)* Interferons Niacin (NIASPAN) Lorazepam (ATIVAN)* Interferon alfa-2b (INTRON-A) Pravastatin (PRAVACHOL)* Temazepam (RESTORIL)* Peginterferon alfa-2a (PEGASYS)

Peginterferon alfa-2b (PEG-INTRON Nitrates and Nitrites Selective Serotonin Agonists KIT ) Nitroglycerin sublingual tab, spray, cap* Sumatriptan (IMITREX)*

Skeletal Muscle Relaxants Cardiovasculars Diuretics Baclofen* Furosemide (LASIX)* Angiotensin II Receptor Antagonists Cyclobenzaprine (FLEXERIL)* Hydrochlorothiazide * Losartan (COZAAR)* ST1 Tizanidine (ZANAFLEX)* Losartan/hctz (HYZAAR)* ST1 Hctz/triamterene (DYAZIDE, Smoking Cessation Valsartan (DIOVAN) ST2 MAXZIDE) * Bupropion (ZYBAN) Valsartan/hctz Nicotine patch ( NICODERM CQ)* (DIOVAN HCT) ST2 CNS Nicotine lozenge Anticonvulsants Nicotine nasal spray (NICOTROL NS) Angiotensin-Converting Enzyme Divalproex sodium (DEPAKOTE, Nicotine inhaler (NICOTROL INH) Inhibitors DEPAKOTE ER)* Nicotine gum (NICORETTE)* Benazepril (LOTENSIN)* Gabapentin (NEURONTIN)* Varenicline (CHANTIX) Enalapril (VASOTEC)* Levetiracetam (KEPPRA)* Substance Abuse Agents Enalapril/hctz (VASERETIC)* Phenytoin (DILANTIN)* Acamprosate (CAMPRAL) Lisinopril (PRINIVIL, ZESTRIL)* Topiramate (TOPAMAX)* Buprenorphine (SUBUTEX)* Lisinopril/hctz (PRINZIDE, Buprenorphine/naloxone (SUBOXONE) ZESTORETIC)* Antidepressants Naloxone injectable / Carpuject Syringe Quinapril (ACCUPRIL)* Amitriptyline ST1* Endocrine Ramipril (ALTACE)* Bupropion ST1 (WELLBUTRIN SR* Antidiabetic: Combinations WELLBUTRIN XL) Glyburide/metformin (GLUCOVANCE)* Beta-Adrenergic Blocking Agents Citalopram ST1 (CELEXA)* Rosiglitazone/ Atenolol (TENORMIN)* Doxepin ST1* metformin (AVANDAMET) PA Atenolol/chlorthalidone (TENORETIC)* Escitalopram (LEXAPRO)* Antidiabetic: Bigunanides Timolol* Fluoxetine ST1 (PROZAC)* Metoprolol (LOPRESSOR*, TOPROL Metformin (GLUCOPHAGE Mirtazapine ST1 (REMERON)* XL) GLUCOPHAGE XL)* Propranolol (INDERAL LA)* Paroxetine ST1 (PAXIL*, PAXIL CR) Sertraline ST1 (ZOLOFT)* Antidiabetic: Sulfonylureas Calcium-Channel Blocking Agents Venlafaxine (EFFEXOR)* Glipizide (GLUCOTROL, XL) * Glyburide (DIABETA,) * Amlodipine (NORVASC)* Venlafaxine (EFFEXOR XR) ST2

1) BRAND NAMEs indicated by CAPITAL, generic names indicated by lower case, * indicates the generic equivalent is available. 2) MANDATORY GENERIC PROGRAM - MIDAP excludes coverage of brand-name drugs with FDA approved generic equivalents. 3) PA = Prior Authorization required. 4) QL= Quantity Limit. 5) Step Therapy: ST1 = the prerequisite drug for ST2 drug(s) in same category; ST2 drugs require a trial of ST1 drug in same category.

MICHIGAN DRUG ASSISTANCE PROGRAM 4 Last Updated: 7/1/15 All Previous Versions Obsolete Antidiabetic: Thiazolidinediones ULTRASE, PANGESTYME, Pioglitazone (ACTOS) PA VIOKASE) Inhaled Corticosteroids Rosiglitazone (AVANDIA) PA Beclomethasone (QVAR)

Proton-Pump Inhibitors Flunisolide (AEROSPAN) Amoxicillin/clarithromycin/lansoprazole Antidiabetic: Insulins (PREVPAC) Leukotrene Modifier NOVOLOG (all formulations) Lansoprazole (PREVACID OTC) Montelukast (SINGULAIR)* NOVOLIN (all formulations) Omeprazole (PRILOSEC, PRILOSEC Nasal Corticosteroids NOVOLOG MIX FLEXPEN OTC)* Beclomethasone (BECONASE AQ) LANTUS, LANTUS SOLOSTAR HUMULIN (all formulations) Histamine H2-Antagonists Urologicals HUMALOG (all formulations) Famotidine (PEPCID)* Oxybutynin (DITROPAN, HUMALOG MIX Nizatidine (AXID)* DITROPAN XL)* Ranitidine (ZANTAC)* Tamsulosin (FLOMAX)* Bone Metabolism Terazosin* Alendronate (FOSAMAX)* Anticholinergics/Motility Dicyclomine (BENTYL)* Topical Agents Estrogen and Estrogen Modifier Metoclopramide (REGLAN)* Topical Anti-inflammatory Agents Conjugated estrogens tablet, vaginal Desonide (DESOWEN)* cream (PREMARIN) Miscellaneous GI Hydrocortisone 2.5% cream* Lactulose* Triamcinolone cream, oint, lot* Thyroid Agents Megestrol (MEGACE) Levothyroxine (LEVOXYL, Mesalamine, 5-ASA (ROWASA*, Miscellaneous Dermatological Agent SYNTHROID) * ASACOL) Imiquimod (ALDARA)* Podofilox (CONDYLOX)* Androgens Blood Modifiers, Ophthalmic Agents Oxandrolone (OXANDRIN)* Nutritionals, Electrolytes Timolol (TIMOPTIC, Testostosterone injection(DEPO- Anticoagulants/Antiplatelets TIMOPTIC -XE)* TESTOSTERONE, DELATESTRYL) Cilostazol (PLETAL)* Testostosterone topical Clopidogrel (PLAVIX)* Other (ANDRODERM,ANDROGEL, Warfarin (COUMADIN)* Vaccines TESTIM) Hepatitis B Vaccine Hematopoietic Agents Hepatitis A Vaccine Corticosteroids Epoetin alfa (EPOGEN, PROCRIT) PA Pneumococcal Vaccine Prednisone* Filgrastim, G-CSF (NEUPOGEN) PA Influenza / H1N1 Vaccine

Gastrointestinal Potassium replacement Other Aldesleukin (PROLEUKIN) * Antiemetics Potassium chloride* Epinephrine (EPIPEN) Dronabinol (MARINOL)*QL: max 20mg/day Respiratory Hydroxyurea (HYDREA)* Prochlorperazine (COMPAZINE)* Antihistamines Leucovorin* Promethazine (PHENERGAN)* Cetirizine (ZYRTEC) OTC only Hydroxyurea ( DROXIA)* Trimethobenzamide (TIGAN)* Cetirizine/p-ephedrine (ZYRTEC-D) OTC only Dental Products and Diabetes Supplies Antidiarrheal Agents Diphenhydramine (BENADRYL)* PREVIDENT-5000 Diphenoxylate/atropine ( LOMOTIL)* Loratadine ( CLARITIN) OTC only Insulin syringe Loperamide (IMODIUM A-D)* Lancets Opium tincture Bronchodilators TruTrack Blood Glucose Monitor Albuterol (PROVENTIL HFA)* TruTrack Teststrip Digestants Ipratropium (ATROVENT)* Pancrelipase (LIPRAM-UL20, INDEX 1) BRAND NAMEs indicated by CAPITAL, generic names indicated by lower case, * indicates the generic equivalent is available. 2) MANDATORY GENERIC PROGRAM - MIDAP excludes coverage of brand-name drugs with FDA approved generic equivalents. 3) PA = Prior Authorization required. 4) QL= Quantity Limit. 5) Step Therapy: ST1 = the prerequisite drug for ST2 drug(s) in same category; ST2 drugs require a trial of ST1 drug in same category.

MICHIGAN DRUG ASSISTANCE PROGRAM 5 Last Updated: 7/1/15 All Previous Versions Obsolete BACTRIM DS, 1,3 COMPAZINE, 4 A BACTRIM SS, 1,3 COMPLERA, 1,2 CONDYLOX, 4 Abacavir, 1, 2 Conjugated estrogens tablet, vaginal cream, 4 Abacavir/dolutegravir/lamivudine 1,2 COPEGUS, 1, 2 Abacavir/lamivudine, 1, 2 BARACLUDE 2 Co-trimoxazole, 1, 3 Abacavir/lamivudine/zidovudine, 1, 2 Beclomethasone, 4 Acamprosate, 3 BECLOVENT, 4 ACCUPRIL, 3 BECONASE AQ, 4 COUMADIN, 4 Acetaminophen, 2 Benazepril, 3 COVERA-HS, 3 Acrivastine/pseudophedrine, 4 BENTYL, 4 COZAAR, 3 ACTOS, 3 BIAXIN, 1, 2 Acyclovir, 1, 2 BIAXIN XL, 2 CRIXIVAN, 1, 2 ADALAT, 3 BICILLIN LA, 2 Cyclobenzaprine, 3 AEROSPAN, 4 Buprenorphine, 3 CYTOVENE, 1, 2 Albuterol, 4 Buprenorphine/naloxone, 3 Bupropion, 3 ALDARA, 4 D Aldesleukin, 4 BUSPAR, 3 Alendronate, 4 Dapsone, 1, 3 Alprazolam, 3 C DARAPRIM, 1, 3 ALTACE, 3 DARVOCET-N, 2 AMBIEN, 3 CAMPRAL, 3 DARVON, 2 AMBIEN CR, 3 CARDIZEM, 3 Darunavir, 1, 2 Amitriptyline, 3 Carpuject, 3 Darunavir/Cobicistat, 1,2 Amlodipine, 3 CATAPRESS, 3 DELATESTRYL, 4 Amoxicillin, 2, 4 CELEBREX, 2 Delavirdine, 1, 2 Amoxicillin/clarithromycin/lansoprazole, 4 Celecoxib, 2 DEMEROL, 2 Amoxicllin/clavulanic acid, 2 CELEXA, 3 DEPAKOTE, 3 AMOXIL, 2 Cephalexin, 2 DEPAKOTE ER, 3 AMPHOCIN, 1, 2 Cetirizine, 4 DEPO-TESTOSTERONE, 4 Amphotericin B, 1, 2 Cetirizine/pseudoephedrine, 4 Desonide, 4 ANDRODERM, 4 CHANTIX, 3 DESOWEN, 4 ANDROGEL, 4 Chlorpromazine, 3 DIABETA, 3 ANDROXY, 4 Cholestyramine, 3 Diazepam, 3 Acetaminophen /caffeine/butabital, 2 Cidofovir, 2 Diclofenac, 2 Acetaminophen /caffeine/butabital/codeine, 2 Cilostazol, 4 Diclofenac/misoprostol, 2 APTIVUS, 1, 2 CILOXAN, 2 Dicyclomine, 4 ARTHROTEC, 2 CIPRO, 1, 2 Didanosine, 1, 2 Asa/caffeine/butabital, 2 CIPRO HC, 2 DIFLUCAN, 1, 2 Asa/caffeine/butabital/codeine, 2 CIPRODEX, 2 DILANTIN, 3 Asa/codeine, 2 Ciprofloxacin, 1, 2 DILAUDID, 2 ASACOL, 4 Ciprofloxacin/dexamethasone, 2 Diltiazem, 3 Atazanavir, 1, 2 Ciprofloxacin/hc, 2 DIOVAN, 3 Atazanavir/Cobicistat, 1,2 Citalopram, 3 DIOVAN HCT, 3 Atenolol, 3 Clarithromycin, 1, 2 Diphenhydramine, 4 Atenolol/chlorthalidone, 3 CLARITIN, 4 Diphenoxylate/atropine, 4 ATIVAN, 3 CLARITIN-D, 4 DITROPAN, 4 Atorvastatin, 3 CLEOCIN, 1, 3 DITROPAN XL, 4 Atovaquone, 1, 2 CLEOCIN-T, 2 divalproex sodium, 3 ATROVENT, 4 Clindamycin, 1, 2, 3 Dolutegravir, 1,2 ATRIPLA, 1, 2 Clonazepam, 3 Doxepin, 3 AUGMENTIN, 2 Clonidine, 3 Doxycycline, 2 AVANDAMET, 3 Clopidogrel, 4 Dronabinol, 4 AVANDIA, 3 Clotrimazole, 1, 2 DROXIA, 4 AXID, 4 Clotrimazole/betamethasone, 2 DURAGESIC, 2 Azithromycin, 1, 2 Cobicistat 1,2 DYAZIDE, 3 Cobicistat/atazanavir,1,2 B Cobicistat/darunavir, 1,2 E Codeine, 2 Baclofen, 3 Codeine/Acetaminophen , 2 Edurant, 1,2 COMBIVIR, 1, 2 Efavirenz, 1, 2 1) BRAND NAMEs indicated by CAPITAL, generic names indicated by lower case, * indicates the generic equivalent is available. 2) MANDATORY GENERIC PROGRAM - MIDAP excludes coverage of brand-name drugs with FDA approved generic equivalents. 3) PA = Prior Authorization required. 4) QL= Quantity Limit. 5) Step Therapy: ST1 = the prerequisite drug for ST2 drug(s) in same category; ST2 drugs require a trial of ST1 drug in same category.

MICHIGAN DRUG ASSISTANCE PROGRAM 6 Last Updated: 7/1/15 All Previous Versions Obsolete EFFEXOR, 3 GLUCOPHAGE, 3 Lamivudine/zidovudine, 1, 2 EFFEXOR XR, 3 GLUCOPHAGE XL, 3 Lancets, 4 ELAVIL, 3 GLUCOTROL, 3 Lansoprazole OTC, 4 Elvitegravir/Cobicistat/Emtricitabine/ GLUCOTROL, XL, 3 LANTUS, 4 Tenofovir , 1,2 GLUCOVANCE, 3 LANTUS SOLOSTAR, 4 Emtricitabine, 1, 2 Glyburide, 3 Leucovorin, 1, 4 Emtricitabine/tenofovir, 1, 2 Glyburide/metformin, 3 LEVAQUIN, 1, 2 Emtricitabine/rilpivirine/tenofovir, 1,2 Levetiracetam, 3 EMTRIVA, 1, 2 H Levofloxicin, 1, 2 Enalapril, 3 Levothyroxine, 4 LEVOXYL, 4 Enalapril/hctz, 3 HALDOL, 3 LEXAPRO, 3 Enfuvirtide, 1, 2 Haloperidol, 3 LEXIVA, 1, 2 Entecavir 2 Hctz/triamterene, 3 LIORESAL, 3 Epinephrine, 4 Hepatitis A Vaccine, 1, 4 LIPITOR, 3 EPIPEN, 4 Hepatitis B Vaccine, 1, 4 LIPRAM-UL20, 4 EPIVIR, 1, 2 HUMALOG, 4 Lisinopril, 3 Epoetin alfa, 4 HUMATIN, 1, 2 Lisinopril/hctz, 3 EPOGEN, 4 HUMULIN, 4 LOFIBRA, 3 EPZICOM, 1, 2 HYDREA, 4 LOMOTIL, 4 Erythromycin, 2 Hydrochlorothiazide, 3 LONITEN, 3 Escitalopram, 3 Hydrocodone/Acetaminophen , 2 LONOX, 4 Ethambutol, 1, 2 Hydrocortisone 2.5% cream, 4 Loperamide, 4 EVOTAZ, 1,2 Hydromorphone, 2 Hydroxyurea, 4 LOPID, 3 HYTRIN, 4 Lopinavir/ritonavir, 1, 2 F HYZAAR, 3 LOPRESSOR, 3 Loratadine, 4 Famciclovir, 1, 2 Loratadine/pseudoephedrine, 4 Famotidine, 4 I Lorazepam, 3 FAMVIR, 1, 2 LORTAB, 2 Ibuprofen, 2 Felodipine, 3 Losartan, 3 Fenofibrate, 3 ISENTRESS 1,2 Losartan/hctz, 3 Fentanyl, 2 Imiquimod, 4 LOTENSIN, 3 Filgrastim, 4 IMITREX, 3 LOTRISONE, 2 FIORICET, 2 IMODIUM, 4 FIORICET/CODEINE, 2 INDERAL, 3 FIORINAL, 2 INDERAL LA, 3 M FIORINAL/CODEINE, 2 Indinavir, 1, 2 Maraviroc 1,2 FLAGYL, 3 Influenza Vaccine, 1, 4 MARINOL, 4 FLEXERIL, 3 Insulin glargine, 4 MAXZIDE, 3 FLOMAX, 4 Insulin syringe, 4 MEGACE, 4 FLOXIN, 2 Interferon alfa-2b, 1, 3 Megestrol, 4 Fluconazole, 1, 2 INTRON-A, 1, 3 Meperidine, 2 FLUMADINE, 2 INVIRASE, 1, 2 MEPRON, 1, 2 Flunisolide, 4 Ipratropium, 4 Mesalamine, 4 Fluoxetine, 3 Isoniazid, 2 Metformin, 3 Itraconazole, 1, 2 Folinic acid, 1, 4 Methadone, 2 Fomivirsen, 1, 2 Methyltestosterone, 4 FOSAMAX, 4 K Metoclopramide, 4 Fosamprenavir, 1, 2 Metoprolol, 3 Foscarnet, 1, 2 KALETRA, 1, 2 METROCREAM, 2 FOSCARVIR, 1, 2 KEFLEX, 2 METROGEL, 2 Furosemide, 3 KEPPRA, 3 Metronidazole, 2, 3 FUZEON, 1, 2 Ketoconazole, 1, 2 MICRONASE, 3 KLONOPIN, 3 Minoxidil, 3 G Mirtazapine, 3 L Montelukast, 4 G-CSF, 4 Morphine, 2 Gabapentin, 3 Lactulose, 4 MOTRIN, 2 Ganciclovir, 1, 2 LAMISIL, 1, 2 MS-CONTIN, 2 Gemfibrozil, 3 LAMISIL AT, 2 MYAMBUTOL, 1, 2 Glipizide, 3 Lamivudine, 1, 2 1) BRAND NAMEs indicated by CAPITAL, generic names indicated by lower case, * indicates the generic equivalent is available. 2) MANDATORY GENERIC PROGRAM - MIDAP excludes coverage of brand-name drugs with FDA approved generic equivalents. 3) PA = Prior Authorization required. 4) QL= Quantity Limit. 5) Step Therapy: ST1 = the prerequisite drug for ST2 drug(s) in same category; ST2 drugs require a trial of ST1 drug in same category.

MICHIGAN DRUG ASSISTANCE PROGRAM 7 Last Updated: 7/1/15 All Previous Versions Obsolete MYCELEX, 1, 2 PEG-INTRON KIT, 1, 3 RESTORIL, 3 MYCOBUTIN, 1, 2 Penicillin, 2 RETROVIR, 1, 2 PENTAM, 1, 2 REYATAZ, 1, 2 Pentamidine, 1, 2 RIBASPHERE, 1, 2 N PEN-VK, 2 Ribavirin, 1, 2 Nabumetone, 2 PEPCID, 4 Rifabutin, 1, 2 Naloxone, 3 PERCOCET, 2 Rifampin, 2 Nelfinavir, 1, 2 PHENERGAN, 4 RIFADIN, 2 NEUPOGEN, 4 Phenytoin, 3 Rilpivirine 1,2 NEURONTIN, 3 Pioglitazone, 3 Rimantadine, 2 Nevirapine, 1, 2 PLAVIX, 4 RISPERDAL, 3 Niacin, 3 PLENDIL, 3 Risperidone, 3 NIASPAN, 3 PLETAL, 4 Ritonavir, 1, 2 NICODERM, 3 Pneumococcal Vaccine, 1, 4 Rosiglitazone, 3 NICORETTE, 3 podofilox, 4 Rosiglitazone/metformin, 3 Nicotine gum, 3 Potassium chloride, 4 ROWASA, 4 Nicotine lozenge, 3 PRAVACHOL, 3 ROXANOL, 2 Nicotine nasal spray, 3 Pravastatin, 3 Prednisone, 4 Nicotine patch, 3 S NICOTROL, 3 PREMARIN, 4 NICOTROL INH, 3 PREZCOBIX, 1,2 Saquinavir, 1, 2 NICOTROL NS, 3 PREVACID OTC, 4 SELZENTRY 1,2 Nifedipine ER, 3 PREVIDENT, 4 SEMPREX-D, 4 Nifedipine XL, 3 PREVPAC, 4 SEPTRA DS, 1,3 Nitroglycerin sublingual tab, spray, cap, 3 PREZISTA, 1, 2 SEPTRA SS, 1,3 Nizatidine, 4 PRILOSEC, 4 SEROQUEL, 3 NIZORAL, 1, 2 Primaquine, 1, 3 Sertraline, 3 NORVASC, 3 PRINIVIL, 3 Silvadene, 3 NORVIR, 1, 2 PRINZIDE, 3 SINGULAIR, 4 NOVOLIN, 3 PROCARDIA, 3 Sodium fluoride, 4 NOVOLIN 70/30, 4 Prochlorperazine, 4 SPORANOX, 1, 2 NOVOLOG, 3 PROCRIT, 4 SSD, 2 NOVOLOG MIX FLEXPEN, 4 PROLEUKIN, 4 Stavudine, 1, 2 Nystatin, 1, 2 Promethazine, 4 STRIBILD 1,2 Propoxyphene, 2 SUBOXONE, 3 Propoxyphene/Acetaminophen , 2 SUBUTEX, 3 O Propranolol, 3 Sulfadiazine, 1, 3 PROVENTIL, 4 OCUFLOX, 2 SUSTIVA, 1, 2 PROZAC, 3 Ofloxacin, 2 SYNTHROID, 4 Pyrimethamine, 1, 3 Olanzapine, 3 Omeprazole, 4 Pyrazinamide, 2 Opium tincture, 4 pyridoxine, 2 T ORAMORPH SR, 2 Tamsulosin, 4 Oxybutynin, 4 TAZTIA XT, 3 Oxycodone, 2 Q Temazepam, 3 Oxycodone/Acetaminophen , 2 Tenofovir, 1, 2 OXYCONTIN, 2 QUESTRAN, 3 TENORETIC, 3 OXY-IR, 2 Quetiapine, 3 TENORMIN, 3 Quinapril, 3 Terazosin, 4 P QVAR, 4 Terbinafine, 1, 3 Testostosterone injection, 4 PANCREASE, 4 R Testostosterone oral, 4 Pancrelipase, 4 Testostosterone topical, 4 PANGESTYME, 4 Raltegravir 1, 2 TESTRED, 4 Paromomycin, 1, 2 Ramipril, 3 Teststrip, 4 Paroxetine, 3 Ranitidine, 4 THORAZINE, 3 PAXIL, 3 REBETOL, 1, 2 TIGAN, 4 PAXIL CR, 3 REGLAN, 4 Timolol, 3, 4 PEGASYS, 1, 3 RELAFEN, 2 TIMOPTIC XE, 4 Peginterferon alfa-2a, 1, 3 REMERON, 3 Tipranavir, 1, 2 Peginterferon alfa-2b, 1, 3 RESCRIPTOR, 1, 2 Tivicay, 1,2 1) BRAND NAMEs indicated by CAPITAL, generic names indicated by lower case, * indicates the generic equivalent is available. 2) MANDATORY GENERIC PROGRAM - MIDAP excludes coverage of brand-name drugs with FDA approved generic equivalents. 3) PA = Prior Authorization required. 4) QL= Quantity Limit. 5) Step Therapy: ST1 = the prerequisite drug for ST2 drug(s) in same category; ST2 drugs require a trial of ST1 drug in same category.

MICHIGAN DRUG ASSISTANCE PROGRAM 8 Last Updated: 7/1/15 All Previous Versions Obsolete Tizanidine, 3 VALIUM, 3 WELLBUTRIN SR, 3 TMP/SMZ ,1,3 Valsartan, 3 WELLBUTRIN XL, 3 TOPROL XL, 3 Valsartan/hctz, 3 Tramadol, 2 VALTREX, 1, 2 X Tramadol/Acetaminophen , 2 Varenicline, 3 Triamcinolone cream, oint, lot, 4 VASORETIC, 3 XANAX, 3 TRICOR, 3 VASOTEC, 3 TRIUMEQ 1,2 Venlafaxine, 3 Trimethobenzamide, 4 Verapamil, 3 Z Trimethoprim, 1, 3 VERELAN, 3 ZANAFLEX, 3 TRIMOX, 2 VFEND, 1, 2 ZANTAC, 4 TRIZIVIR, 1, 2 VICODIN, 2 ZERIT, 1, 2 TRUVADA, 1, 2 VICODIN ES, 2 ZESTORETIC, 3 TYBOST 1,2 VIDEX, 1, 2 ZESTRIL, 3 TYLENOL #3, 2 VIDEX EC, 1, 2 ZIAGEN, 1, 2 TYLENOL #4, 2 VIOKASE, 4 Zidovudine, 1, 2 VIRACEPT, 1, 2 ZITHROMAX, 1, 2 U VIRAMUNE, 1, 2 ZOLOFT, 3 VIRAMUNE XR, 1,2 Zolpidem, 3 ULTRACET, 2 VIREAD, 1, 2 ZOVIRAX, 1, 2 ULTRAM, 2 VISTIDE, 1, 2 ZYBAN, 3 ULTRASE, 4 VITRAVENE, 1, 2 ZYPREXA, 3 VOLTAREN, 2 ZYRTEC, 4 V Voriconazole, 1, 2 ZYRTEC-D, 4

Valacyclovir, 1, 2 W 5-ASA, 4 VALCYTE, 1, 2 Valganciclovir, 1, 2 Warfarin, 4

1) BRAND NAMEs indicated by CAPITAL, generic names indicated by lower case, * indicates the generic equivalent is available. 2) MANDATORY GENERIC PROGRAM - MIDAP excludes coverage of brand-name drugs with FDA approved generic equivalents. 3) PA = Prior Authorization required. 4) QL= Quantity Limit. 5) Step Therapy: ST1 = the prerequisite drug for ST2 drug(s) in same category; ST2 drugs require a trial of ST1 drug in same category.