Mississippi Division of Medicaid Universal Preferred Drug List

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MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

Conduent’s SmartPA Pharmacy Application (SmartPA) is a proprietary electronic prior authorization system used for Medicaid fee for service claims. MSCAN plans may/may not -have electronic PA functionality. However, they must adhere to Medicaid’s PA criteria. THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS ACNE AGENTS ANTI-INFECTIVE clindamycin gel (generic Cleocin-T) ACZONE (dapsone) Maximum Age Limit clindamycin lotion AKNE-MYCIN (erythromycin) • 21 years – all agents except clindamycin solution azelaic acid isotretinoins AMZEEQ FOAM (minocycline) AZELEX (azelaic acid) CLEOCIN-T (clindamycin) CLINDAMYCIN PAC (clindamycin) CLINDAGEL (clindamycin)

clindamycin foam

clindamycin gel daily (generic Clindagel) dapsone ERY (erythromycin) ERYGEL (erythromycin) erythromycin gel, swabs, solution EVOCLIN (clindamycin) KLARON (sulfacetamide) sulfacetamide RETINOIDS RETIN-A (tretinoin) adapalene tretinoin cream AKLIEF (trifarotene) ALTRENO (tretinoin) ARAZLO (tazarotene) ATRALIN (tretinoin) AVITA (tretinoin) DIFFERIN (adapalene) FABIOR (tazarotene) PLIXDA (adapalene) 1 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

Conduent’s SmartPA Pharmacy Application (SmartPA) is a proprietary electronic prior authorization system used for Medicaid fee for service claims. MSCAN plans may/may not -have electronic PA functionality. However, they must adhere to Medicaid’s PA criteria. RETIN-A MICRO (tretinoin) tazarotene TAZORAC (tazarotene) tretinoin gel tretinoin micro COMBINATION DRUGS/OTHERS adapalene/benzoyl peroxide ACANYA (benzoyl peroxide/clindamycin) benzoyl peroxide/clindamycin (generic DUAC) AKTIPAK ( erythromycin/benzoyl peroxide) sodium sulfacetamide/sulfur foam/gel/suspension BENZACLIN GEL (benzoyl peroxide/clindamycin) SSS 10/5 Cream (sodium sulfacetamide/sulfur) BENZACLIN KIT (benzoyl peroxide/ clindamycin) BENZAMYCIN PAK (benzoyl peroxide/ erythromycin) DUAC (benzoyl peroxide/clindamycin) EPIDUO (adapalene/benzoyl peroxide) EPIDUO FORTE (adapalene/benzoyl peroxide) erythromycin/benzoyl peroxide INOVA 4/1 (benzoyl peroxide/salicylic acid) INOVA 8/2 (benzoyl peroxide/salicylic acid) NEUAC (benzoyl peroxide/clindamycin) ONEXTON (benzoyl peroxide/clindamycin) PRASCION (sulfacetamide sodium/sulfur) ROSANIL (sulfacetamide sodium/sulfur) SE BPO (benzoyl peroxide) sodium sulfacetamide/sulfur cleanser/cream/lotion/pads sodium sulfacetamide/sulfur/meratan SSS 10/5 Foam (sodium sulfacetamide/sulfur) sulfacetamide sodium/sulfur/urea VELTIN (clindamycin/tretinoin) ZENCIA WASH (sulfacetamide sodium/sulfur) ZIANA (clindamycin/tretinoin) KERATOLYTICS (BENZOYL PEROXIDES) 2 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

ISOTRETINOIN ACCUTANE (istotretinoin) ABSORICA (isotretinoin) Available for all ages AMNESTEEM (isotretinoin) ABSORICA LD (isotretinoin) CLARAVIS (isotretinoin) isotretinoin MYORISAN(isotretinoin) ZENATANE (isotretinoin)

ALPHA-1 PROTEINASE INHIBITORS ARALAST (alpha-1 proteinase inhibitor) GLASSIA (alpha-1 proteinase inhibitor) PROLASTIN C (alpha-1 proteinase inhibitor) ZEMAIRA (alpha-1 proteinase inhibitor)

ALZHEIMER’S AGENTS SmartPA CHOLINESTERASE INHIBITORS donepezil (tablets and ODT) 5mg, 10mg ARICEPT (donepezil) All Agents galantamine ARICEPT 23 MG (donepezil) • Documented diagnosis for both galantamine ER ARICEPT ODT (donepezil) preferred and non-preferred rivastigmine capsules donepezil 23mg Non-Preferred Criteria 3 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

oxycodone/ibuprofen FIORINAL W/ CODEINE days. (butalbital/ASA/caffeine/codeine) 4 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

Conduent’s SmartPA Pharmacy Application (SmartPA) is a proprietary electronic prior authorization system used for Medicaid fee for service claims. MSCAN plans may/may not -have electronic PA functionality. However, they must adhere to Medicaid’s PA criteria. pentazocine/APAP hydrocodone/ibuprofen • 62 tablets – bultalbital/codeine tramadol IBUDONE (hydrocodone/ibuprofen) combinations, codeine, tramadol/APAP LAZANDA NASAL SPRAY (fentanyl) dihydrocodeine combinations, levorphanol fentanyl, hydromorphone, levorphanol, meperidine, morphine, LORCET (hydrocodone/APAP) oxycodone, oxycodone/ibuprofen, LORTAB (hydrocodone/APAP) oxymorphone, pentazocine, MAGNACET (oxycodone/APAP) tapentadol, tramadol meperidine solution meperidine tablet • 62 tablets CUMULATIVE – NALOCET (oxycodone/APAP) hydrocodone combinations, NORCO (hydrocodone/APAP) oxycodone combinations NUCYNTA (tapentadol) • 124 tablets – butalbital/APAP 750 ONSOLIS (fentanyl) • 145 tablets – butalbital/APAP 650 OPANA (oxymorphone) • 186 tablets – butalbital/APAP 325, OXAYDO (oxycodone) butalbital/ASA 325 oxymorphone • 5mL (2 x 2.5 bottles) – pentazocine/naloxone butorphanol nasal PERCOCET (oxycodone/APAP) • 180 mL CUMULATIVE – PERCODAN (oxycodone/ASA) oxycodone liquids PRIMLEV (oxycodone/APAP) • 280 mL CUMULATIVE – Qdolo PROLATE (oxycodone/APAP) QDOLO (tramadol)NR REPREXAINE (hydrocodone/ibuprofen) ROXICET (oxycodone/acetaminophen) ROXICODONE (oxycodone) ROXYBOND (oxycodone) SUBSYS (fentanyl) SYNALGOS-DC (dihydrocodeine/ aspirin/caffeine) TYLENOL W/CODEINE (APAP/codeine) TYLOX (oxycodone/APAP) ULTRACET (tramadol/APAP) ULTRAM (tramadol) VICODIN (hydrocodone/APAP) 5 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

ANALGESICS, OPIOID - LONG ACTING SmartPA BUTRANS (buprenorphine) ARYMO ER (morphine) MS DOM Opioid Initiative fentanyl patches BELBUCA (buprenorphine) • Short-Acting Opioids morphine ER tablets buprenorphine patch • Long-Acting Opioids CONZIP ER (tramadol) • Morphine Equivalent Daily Dose DOLOPHINE (methadone) • Concomitant use of Opioids and DURAGESIC (fentanyl) Benzodiazepines EMBEDA (morphine/naltrexone) Criteria details found here EXALGO (hydromorphone) hydromorphone ER HYSINGLA ER (hydrocodone) Minimum Age Limit KADIAN (morphine) • 18 years – Xartemis XR, Zohydro ER, tramadol products methadone

MORPHABOND (morphine) Quantity Limit morphine ER capsules Applicable quantity limit per rolling MS CONTIN (morphine) days NUCYNTA ER (tapentadol) • 31 tablets/31 days - Conzip ER, OPANA ER (oxymorphone) Exalgo ER, Hysingla ER, Ryzolt, oxycodone ER Ultram ER OXYCONTIN (oxycodone) • 62 tablets/31 days – Arymo ER, oxymorphone ER Belbuca, Embeda, Kadian, methadone, Morphabond, morphine RYZOLT (tramadol) ER, Nucynta ER, Opana ER, tramadol ER 6 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

Non-Preferred Criteria • Have tried 2 different preferred agents in the past 6 months OR • Documented diagnosis of cancer OR Antineoplastic therapy AND • 90 consecutive days on the requested agent in the past 105 days

ANALGESICS/ANESTHETICS (Topical) diclofenac sodium 1% gel capsaicin Non-Preferred Criteria diclofenac sodium 1.5% solution diclofenac epolamine patch SmartPA • Have tried 1 preferred agent in the VOLTAREN Gel (diclofenac sodium) SmartPA diclofenan sodium 3% gel past 6 months

FLECTOR Patch(diclofenac epolamine) SmartPA Lidoderm FROTEK (ketoprofen) • Documented diagnosis of Herpetic NR LICART (diclofenac epolamine) Neuralgia OR LIDAMANTLE HC (lidocaine/hydrocortisone) • Documented diagnosis of Diabetic LIDO TRANS PAK (lidocaine) Neuropathy lidocaine lidocaine 5% patch ZTlido lidocaine/prilocaine • Documented diagnosis of Herpetic LIDODERM (lidocaine) SmartPA Neuralgia LIDTOPIC MAX (lidocaine) PENNSAID 2% Solution (diclofenac sodium) SmartPA

7 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

Conduent’s SmartPA Pharmacy Application (SmartPA) is a proprietary electronic prior authorization system used for Medicaid fee for service claims. MSCAN plans may/may not -have electronic PA functionality. However, they must adhere to Medicaid’s PA criteria. SYNERA (lidocaine/tetracaine) TRANZAREL (lidocaine) VENNGEL ONE 1% kit (diclofenac sodium) XRYLIDERM (lidocaine) xylocaine ZOSTRIX (capsaicin) ZTlido (lidocaine) ANDROGENIC AGENTS SmartPA ANDRODERM (testosterone patch) ANDROGEL (testosterone gel) All Agents testosterone gel packets ANDROXY (fluoxymesterone) • Limited to male gender AXIRON (testosterone gel) FORTESTSA (testosterone gel) Non-Preferred Criteria • Have tried 2 different preferred JATENZO (testosterone undecanoate) agents in the past 6 months NATESTO (testosterone) STRIANT (testosterone) TESTIM (testosterone gel) testosterone pump VOGELXO (testosterone) XYOSTED (testosterone enanthate) ANGIOTENSIN MODULATORS SmartPA ACE INHIBITORS benazepril ACCUPRIL (quinapril) Minimum Age Limit captopril ACEON (perindopril) • ≤ 6 years – Epaned Smart PA will enalapril ALTACE (ramipril) automatically be issued for this age EPANED (enalapril) fosinopril LOTENSIN (benazepril) Non-Preferred Criteria lisinopril MAVIK (trandolapril) • Have tried 2 different preferred quinapril moexipril single entity agents in the past 6 ramipril perindopril months OR trandolapril PRINIVIL (lisinopril) QBRELIS (lisinopril) 8 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

ACE INHIBITOR COMBINATIONS benazepril/amlodipine ACCURETIC (quinapril/HCTZ) Non-Preferred Criteria benazepril/HCTZ CAPOZIDE (captopril/HCTZ) ACE Inhibitor/CCB captopril/HCTZ LOTENSIN HCT (benazepril/HCTZ) • Have tried 2 different preferred enalapril/HCTZ LOTREL(benazepril/amlodipine) ACEI/CCB agents in the past 6 months OR fosinopril/HCTZ moexipril/HCTZ • 90 consecutive days on the lisinopril/HCTZ PRESTALIA (perindopril/amlodipine) PRINZIDE (lisinopril/HCTZ) requested agent in the past 105 quinapril/HCTZ days TARKA (trandolapril/verapamil) trandolapril/verapamil UNIRETIC (moexipril/HCTZ) ACE Inhibitor/Diuretic VASERETIC (enalapril/HCTZ) • Have tried 2 different preferred ZESTORETIC (lisinopril/HCTZ) ACEI/Diuretic agents in the past 6 months OR • 90 consecutive days on the requested agent in the past 105 days

ANGIOTENSIN II RECEPTOR BLOCKERS (ARBs) irbesartan ATACAND (candesartan) Non-Preferred Criteria losartan AVAPRO (irbesartan) • Have tried 2 different preferred olmesartan BENICAR (olmesartan) single entity agents in the past 6 telmisartan candesartan months OR • 90 consecutive days on the valsartan COZAAR (losartan) requested agent in the past 105

DIOVAN (valsartan) days EDARBI (azilsartan) eprosartan MICARDIS (telmisartan) TEVETEN (eprosartan) 9 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

ARB/Diuretic • Have tried 2 different preferred ARB/Diuretic products in the past 6 months OR • 90 consecutive days on the requested agent in the past 105 days

DIRECT RENIN INHIBITORS TEKTURNA (aliskiren) Non-Preferred Criteria

10 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

past 6 months OR • 90 consecutive days on the requested agent in the past 105 days ANTIBIOTICS (GI) FIRVANQ (vancomycin) DIFICID (fidaxomicin) metronidazole FLAGYL (metronidazole) neomycin FLAGYL ER (metronidazole) tinidazole paromomycin TINDAMAX (tinidazole) VANCOCIN (vancomycin) vancomycin XIFAXAN (rifaximin)

ANTIBIOTICS (MISCELLANEOUS)

11 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

MACROLIDES azithromycin BIAXIN (clarithromycin) clarithromycin ER BIAXIN SUSPENSION (clarithromycin) clarithromycin IR BIAXIN XL (clarithromycin) E.E.S.FILM TAB (erythromycin ethylsuccinate) clarithromycin suspension E-MYCIN (erythromycin) E.E.S. Suspension (erythromycin ethylsuccinate) ERYC (erythromycin) ERY-TAB (erythromycin) ERYPED Suspension (erythromycin

erythromycin ethylsuccinate) ERYTHROCIN (erythromycin stearate) erythromycin estolate erythromycin ethylsuccinate PCE (erythromycin) ZITHROMAX (azithromycin) ZMAX (azithromycin) NITROFURAN DERIVATIVES nitrofurantoin FURADANTIN (nitrofurantoin) nitrofurantoin monohydrate macrocyrstals MACROBID (nitrofurantoin monohydrate macrocyrstals) MACRODANTIN (nitrofurantoin)

OXAZOLIDINONES SIVEXTRO (tedizolid) Sivextro – MANUAL PA ZYVOX (linezolid) Zyvox - MANUAL PA

12 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

Conduent’s SmartPA Pharmacy Application (SmartPA) is a proprietary electronic prior authorization system used for Medicaid fee for service claims. MSCAN plans may/may not -have electronic PA functionality. However, they must adhere to Medicaid’s PA criteria. Quantity Limit • 6 tablets/month – Sivextro PLEUROMUTLINS XENLETA (lefamulin ANTIBIOTICS (Topical) bacitracinOTC ALTABAX (retapamulin) bacitracin/polymixinOTC CORTISPORIN (bacitracin/neomycin/ gentamicin sulfate polymyxin/HC) mupirocin ointment mupirocin cream neomycin/bacitracin/polymyxinOTC NEOSPORIN (neomycin/bacitracin/polymyxin)OTC XEPI (ozenoxacin) ANTIBIOTICS (VAGINAL) CLEOCIN OVULES (clindamycin) AVC (sulfanilamide) CLINDESSE (clindamycin) CLEOCIN CREAM (clindamycin) metronidazole vaginal clindamycin cream METROGEL (metronidazole) NUVESSA (metronidazole) SOLOSEC (secnidazole) VANDAZOLE (metronidazole) ANTICOAGULANTS SmartPA ORAL COUMADIN (warfarin) BEVYXXA (betrixaban) DVT Prophylaxis - following hip ELIQUIS (apixaban) SAVAYSA (edoxaban tosylate) replacement PRADAXA (dabigatran) XARELTO 10MG, ELIQUIS, PRADAXA 110MG warfarin • 70 total days of therapy per XARELTO (rivaroxaban) calendar year • Documented diagnosis of hip replacement AND • Duration of therapy limited to 35 days 13 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

DVT Prophylaxis - following knee replacement XARELTO 10MG & ELIQUIS • 70 total days of therapy per calendar year • Documented diagnosis of knee replacement AND • Duration of therapy limited to 12 days

Eliquis 5mg Starter Pack - ONLY approved for treatment of DVT/PE

XARELTO 2.5MG • Documented diagnosis of coronary artery disease OR • Documented diagnosis of peripheral artery disease AND • History of therapy with aspirin in the past 30 days AND • History of 90 days therapy with anti- platelet agent in the past year OR • History of 30 days therapy with warfarin in the past year

Non-Preferred Criteria • Have tried 2 different preferred agents in the past 6 months OR • 1 claim with the requested agent in the past 90 days

LOW MOLECULAR WEIGHT HEPARIN (LMWH) 14 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

LMWH Non-Preferred Criteria • Have tried 1 different preferred agent in the past 6 months OR • 90 consecutive days on the requested agent in the past 105 days ANTICONVULSANTS SmartPA ADJUVANTS carbamazepine APTIOM (eslicarbazepine) Minimum Age Limit carbamazepine suspension BANZEL (rufinamide) • 1 year – Banzel, Epidiolex carbamazepine ER BRIVIACT (brivaracetam) • 2 years – Diacomit, Onfi, DEPAKOTE ER (divalproex) carbamazepine XR Sympazan

DEPAKOTE SPRINKLE (divalproex) CARBATROL (carbamazepine) Non-Preferred Criteria divalproex DEPAKENE (valproic acid) 15 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

EPITOL (carbamazepine) EPIDIOLEX (cannabidiol) • 90 consecutive days on the NR gabapentin ELEPSIA XR (levetiracetam) requested agent in the past 105

GABITRIL (tiagabine) EQUETRO (carbamazepine) days days AND lamotrigine felbamate • Documented diagnosis of seizure

levetiracetam FELBATOL (felbamate) Banzel,Onfi,Sympazan levetiracetam ER FINTEPLA (fenfluramine) FYCOMPA (perampanel) • Documented diagnosis of Lennox- oxcarbazepine Gastaut AND KEPPRA (levetiracetam) oxcarbazepine suspension • Have tried 1 different preferred KEPPRA XR (levetiracetam) topiramate tablet agent for Lennox-Gastaut in the topiramate sprinkle capsule LAMICTAL (lamotrigine) past 6 months OR LAMICTAL CHEWABLE (lamotrigine) valproic acid • 90 consecutive days on the LAMICTAL ODT (lamotrigine) VIMPAT (lacosamide) requested agent in the past 105 LAMICTAL XR (lamotrigine) zonisamide days days AND lamotrigine ER/XR • Documented diagnosis of seizure lamotrigine ODT NEURONTIN (gabapentin) Diacomit OXTELLAR XR (oxcarbazepine) • Documented diagnosis of Dravet QUDEXY XR (topiramate) syndrome AND ROWEEPRA (levetiracetam) • Active claim for clobazam SABRIL (vigabatrin) SPRITAM (levetiracetam) Epidiolex STAVZOR (valproic acid) • Documented diagnosis of Dravet TEGRETOL (carbamazepine) syndrome or seizures associated with tuberous sclerosis complex OR TEGRETOL SUSPENSION (carbamazepine) • Documented diagnosis of Lennox- TEGRETOL XR (carbamazepine) Gastaut AND tiagabine • Have tried 1 different preferred TOPAMAX TABLET (topiramate) agent for Lennox-Gastaut in the TOPAMAX Sprinkle (topiramate) past 6 months OR topiramate ER (generic Qudexy XR) Step Edit • 1 claim for the requested agent in TRILEPTAL Tablets (oxcarbazepine) the past 30 days 16 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

Sabril Powder for Oral Solution • Documented diagnosis of infantile spasms OR • Have tried 2 different preferred agents in the past 6 months OR • 90 consecutive days on the requested agent in the past 105 days days AND • Documented diagnosis of seizure

Topiramate ER – Step Edit • 90 consecutive days on the requested agent in the past 105 days AND • Documented diagnosis of seizure OR • 30 day trial with topiramate IR in the past 6 months

SELECTED BENZODIAZEPINES clobazam DIASTAT (diazepam rectal) Minimum Age Limit diazepam rectal gel DIASTAT ACCUDIAL (diazepam rectal) • 12 years – Nayzilam NAYZILAM (midazolam) ONFI (clobazam) • 6 years – Valtoco VALTOCO (diazepam) ONFI SUSPENSION (clobazam) SYMPAZAN (clobazam) Quantity Limit • 2 Twin Packs/31 days – Diastat • 2 Packages /31 days – Nayzilam • 2 Cartons/31 days - Valtoco 17 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

HYDANTOINS DILANTIN (phenytoin) PEGANONE (ethotoin) PHENYTEK (phenytoin) phenytoin

SUCCINIMIDES ethosuximide CELONTIN (methsuximide) ZARONTIN (ethosuximide)

ANTIDEPRESSANTS, OTHER SmartPA bupropion APLENZIN (bupropion HBr) Minimum Age Limit bupropion SR desvenlafaxine ER • 18 years - all drugs bupropion XL desvenlafaxine fumarate ER • 7-17 years – duloxetine (except TRINTELLIX (vortioxetine) DESYREL (trazodone) Drizalma Sprinkle) Smart PA will automatically be mirtazapine DRIZALMA SPRINKLE (duloxetine) issued for this age range with a trazodone EFFEXOR (venlafaxine) diagnosis of GAD (generalized venlafaxine EFFEXOR XR (venlafaxine) anxiety disorder) venlafaxine ER capsules EMSAM (selegiline transdermal) • 7-11 years – Drizalma Sprinkle VIIBRYD (vilazodone) FETZIMA ER (levomilnacipran) Smart PA will automatically be FORFIVO XL (bupropion) issued for this age range with a KHEDEZLA ER (desvenlafaxine) diagnosis of GAD (generalized MARPLAN (isocarboxazid) anxiety disorder) NARDIL (phenelzine)

nefazodone Non-Preferred Criteria OLEPTRO ER (trazodone) • Have tried 2 different preferred PARNATE (tranylcypromine) ‘Antidepressants, Other’ Class in phenelzine the past 6 months OR PRISTIQ (desvenlafaxine) • Have tried BOTH a preferred REMERON (mirtazapine) ‘Antidepressant, SSRI’ and 18 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

WELLBUTRIN XL (bupropion HCl) Cymbalta and Irenka (see Fibromyalgia Agents)

ANTIDEPRESSANTS, SSRIs SmartPA citalopram CELEXA (citalopram) Minimum Age Limit escitalopram fluoxetine DR • 6 years - Zoloft fluoxetine capsules fluvoxamine ER • 7 years – Prozac fluvoxamine LEXAPRO (escitalopram) • 8 years - Luvox paroxetine CR LUVOX (fluvoxamine) • 12 years - Lexapro paroxetine IR LUVOX CR (fluvoxamine) • 18 years – Celexa, Luvox CR, sertraline paroxetine suspension Paxil, Pexeva, Prozac 90 mg PAXIL CR (paroxetine) PAXIL SUPENSION (paroxetine) Citalopram Criteria PAXIL Tablets (paroxetine) • <18 years and 90 consecutive days PEXEVA (paroxetine) on citalopram in the past 105 days PROZAC (fluoxetine) OR SARAFEM (fluoxetine) • < 60 years AND max daily dose < ZOLOFT (sertraline) 40 mg/day OR • > 60 years AND max daily dose < 20 mg/day

Non-Preferred Criteria • Have tried 2 different preferred agents in the past 6 months OR • 90 consecutive days on the requested agent in the past 105 days 19 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

Non-Preferred Agents • Have tried 1 preferred agent in the past 6 months

Injectables in this class closed to point of sale. PA required if not administered in clinic/hospital ANTIEMETIC COMBINATIONS AKYNZEO (netupitant/palonosetron) Akynzeo - MANUAL PA BONJESTA (doxylamine/pyridoxine) DICLEGIS (doxylamine/pyridoxine) doxylamine/pyridoxine CANNABINOIDS CESAMET (nabilone) MARINOL (dronabinol) dronabinol SYNDROS (dronabinol) NMDA RECEPTOR ANTAGONIST EMEND (aprepitant) aprepitant Varubi - MANUAL PA VARUBI (rolapitant) ANTIFUNGALS (Oral) SmartPA

20 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

TOLSURA (itraconazole) Cresemba - MANUAL PA VFEND (voriconazole) ^ • Minimum age limit > 18 years AND voriconazole ^ • Documented diagnosis of invasive aspergillosis OR invasive mucormycosis AND • Prescriber is an oncologist/hematologist or infectious disease specialist

Sporanox • HIV opportunistic infection criteria OR • Documented diagnosis of a transplant OR • History of an immunosuppressant in the past 6 months OR

21 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

22 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

ANTIHISTAMINES, MINIMALLY SEDATING AND COMBINATIONS SmartPA MINIMALLY SEDATING ANTIHISTAMINES cetirizine tabletsOTC cetirizine chewableOTC Non-Preferred Criteria cetirizine syrupRx & OTC CLARINEX (desloratadine) • Documented diagnosis of allergy or loratadine odt OTC desloratadine ODT urticaria AND loratadine syrupOTC desloratadine tablet • Have tried 2 different preferred agents in the past 12 months loratadine tabletOTC fexofenadine syru fexofenadine table levocetirizine syrup levocetirizine tablet XYZAL Solution (levocetirizine) XYZAL Tablets (levocetirizine)

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)

23 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

ANTIMIGRAINE AGENTS, CALCITONIN GENE RELATED PEPTIDE INHIBITOR ORAL NURTEC ODT (rimegepant) UBRELVY (ubrogepant) Minimum Age Limit • 18 years – Nurtec ODT, Ubrelvy

Quantity Limit • 8 tablets/31 day – Nurtec ODT • 16 tablets/31 day – Ubrelvy

Nurtec ODT • Documented diagnosis of migraine AND • Have tried 2 different triptans in the past 6 months AND • No concurrent therapy with another CGRP agent

Ubrelvy • Documented diagnosis of migraine AND • Have tried 2 different triptans in the past 6 months AND • Have tried preferred Nurtec ODT in the past 6 months AND • No concurrent therapy with another CGRP agent AND • No concurrent therapy with a strong CYP3A4 inhibitor

24 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

ANTIMIGRAINE AGENTS, TRIPTANS & RELATED AGENTSSmartPA ORAL naratriptan almotriptan Minimum Age Limit – ALL rizatriptan AMERGE (naratriptan) FORMULATIONS rizatriptan ODT AXERT (almotriptan) • 6 years – Maxalt sumatriptan tablets eletriptan • 12-17 years – Axert, Treximet, Zomig nasal spray Smart PA will zolmitriptan FROVA (frovatriptan) automatically be issued for this age zolmitriptan ODT frovatriptan range IMITREX (sumatriptan) • 18 years – Amerge, Frova, Imitrex, MAXALT (rizatriptan) Onzetra Xsail, Relpax, Reyvow, MAXALT MLT(rizatriptan) Tosymra, Zembrace Symtouch, RELPAX (eletriptan) Zomig tablets REYVOW (lasmiditan) TREXIMET (sumatriptan/naproxen) Quantity Limit - ORAL ZOMIG (zolmitriptan) • 4 tablets/31 days – Reyvow 50 mg • 6 tablets/31 days - Axert, Relpax

Zomig

• 8 tablets/31 days – Reyvow 100 mg • 9 tablets/31 days - Amerge, Frova, Imitrex, Treximet • 12 tablets/31 days – Maxalt

Non-Preferred Criteria - ORAL • Have tried 2 preferred preferred oral agents in the past 90 days 25 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

Reyvow • Documented diagnosis of migraine AND • Have tried 2 different triptans in the past 90 days AND • Have tried preferred Nurtec ODT in the past 90 days AND

NASAL sumatriptan IMITREX (sumatriptan) Quantity Limit - NASAL ONZETRA Xsail (sumatriptan) • 1 box/31 days TOSYMRA (sumatriptan) ZOMIG (zolmitriptan) Non-Preferred Criteria - NASAL • Have tried 2 preferred oral agents

in the past 90 days AND • Have tried either a preferred nasal sumatriptan or injectable sumatriptan in the past 90 days INJECTABLES sumatriptan IMITREX (sumatriptan) CUMULATIVE Quantity Limit - ZEMBRACE (sumatriptan) INJECTION 4 injections/31 days

*ANTINEOPLASTICS – SELECTED SYSTEMIC ENZYME INHIBITORS AFINITOR (everolimus) ALECENSA (alectinib) Farydak - MANUAL PA BOSULIF (bosutinib) ALUNBRIG (brigatnib) • Documented diagnosis of multiple

CAPRELSA (vandetanib) AYVAKIT (avapritinib) myeloma AND COMETRIQ (cabozantinib) BALVERSA (erdafitinib) COTELLIC (cobimetinib) BRAFTOVI (encorafenib) • Used in combination with GILOTRIF (afatanib) BRUKINSA (zanubrutinib) bortezomib and dexamethasone ICLUSIG (ponatinib) CABOMETYX (cabozantinib s-malate) per PI AND imatinib mesylate CALQUENCE (acalabrutinib) IMBRUVICA (ibrutnib) COPIKTRA (duvelisib) 26 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

JAKAFI (ruxolitinib) ERLEADA (apalutamide) immunomodulatory agent MEKINIST (trametinib dimethyl sulfoxide) erlotinib

NEXAVAR (sorafenib) everolimus Ibrance ROZLYTREK (entrectinib) FARYDAK (panobinostat) SPRYCEL (dasatinib) FOTIVDA (tivozanib)NR • Documented diagnosis of WD- STIVARGA (regorafenib) GAVRETO (pralsetinib)NR DDLS for retroperitoneal sarcoma SUTENT (sunitinib) GLEEVEC (imatinib mesylate) OR TAFINLAR (dabrafenib) GLEOSTINE (lomustine) • All other indications evaluated through clinical review TARCEVA (erlotinib) IBRANCE (palbociclib) SmartPA

TASIGNA (nilotinib) IDHIFA (enasidenib) Lenvima TURALIO (pexidartinib) INQOVI (cedazuridine/decitabine)NR TYKERB (lapatinib ditosylate) INREBIC (fedratinib) • Documented diagnosis of thyroid vandetanib KISQALI (ribociclib) cancer OR VOTRIENT (pazopanib) KOSELUGO (selumetinib) • Documented diagnosis of XALKORI (crizotinib) lapatinib ditosylate hepatocellular carcinoma OR XTANDI (enzalutamide) LENVIMA (lenvatinib) SmartPA • Documented diagnosis of renal cell ZELBORAF (vemurafenib) LORBRENA (lorlatinib) carcinoma AND • History of 1 claim for everolimus in ZYDELIG (idelalisib) LYNPARZA (olaparib) SmartPA the past 30 days AND ZYKADIA (ceritnib) MEKTOVI (binimetnib) NERLYNX (neratinib maleate) • History of 1 anti-angiogenic agent NUBEQA (darolutamide) in the past 2 years OR ODOMZO (sonidegib) • All other indications evaluated ONUREG (azacitidine)NR through clinical review ORGOVYX (relugolix)NR Lynparza Capsules - MANUAL PA PEMAZYRE (pemigatinib) PIQRAY (alpelisib) Lynparza Tablets QINLOCK (ripretinib) • Documented diagnosis of ovarian RETEVMO (selpercatinib) cancer, fallopian tube or peritoneal RUBRACA (rucaparib) cancer AND RYDAPT (midostaurin) • History of platinum-based TABRECTA (capmatinib) chemotherapy in the past 2 years TAGRISSO (osimertinib) OR TALZENNA (talazoparib) 27 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

ANTIPARASITICS (Topical) SmartPA PEDICULICIDES permethrin 1%OTC lindane Minimum Age/Weight Limit for NATROBA (spinosad) malathion Pediculicides OVIDE (malathion) • 50 kg - lindane shampoo SKLICE (ivermectin) • 2 months – permethrin 1%(OTC) spinosad • 6 months – Natroba, Sklice • 2 years – piperonyl/pyrethrins VANALICE (piperonyl butoxide/pyrethrins (OTC)

• 6 years – Ovide

Non-Preferred Criteria • Have tried 2 preferred topical lice agents in the past 90 days

SCABICIDES permethrin 5% ELIMITE (permethrin) Minimum Age/Weight Limit for STROMECTOL Tablet (ivermectin) EURAX CREAM (crotamiton) Topical Scabicides EURAX LOTION (crotamiton) • 50 kg - lindane lotion • 2 months – permethrin 5% 28 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

Non-Preferred Criteria • History of permethrin 5% in the past 90 days

ANTIPARKINSON’S AGENTS (Oral) SmartPA ANTICHOLINERGICS benztropine COGENTIN (benztropine) Non-Preferred Criteria trihexyphenidyl • Documented diagnosis of Parkinson’s disease AND • Have tried 2 different preferred agents in the past 6 months OR • 90 consecutive days on the requested agent in the past 105 days COMT INHIBITORS entacapone COMTAN (entacapone) ONGENTYS (opicapone)NR TASMAR (tolcapone) tolcapone DOPAMINE AGONISTS ropinirole KYNMOBI FILM (apomorphine) MIRAPEX (pramipexole) MIRAPEX ER (pramipexole) NEUPRO (rotigotine) pramipexole pramipexole ER REQUIP (ropinirole) REQUIP XL (ropinirole) ropinirole ER

29 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

MAO-B INHIBITORS selegiline AZILECT (rasagiline) Xadago ELDEPRYL (selegiline) • Documented diagnosis of rasagiline Parkinson’s disease AND XADAGO (safinamide) • History of a preferred carbidopa/levodopa combination ZELAPAR (selegiline) product in the past 30 days AND

• History of selegiline product in the past 45 days

OTHERS amantadine DUOPA (levodopa/carbidopa) Lodosyn and Inbrija bromocriptine GOCOVRI (amantadine) • Documented diagnosis of

carbidopa INBRIJA (levodopa) Parkinson’s disease AND levodopa/carbidopa ODT levodopa/carbidopa • History of a carbidopa/levodopa levodopa/carbidopa/entacapone combination product in the past 45

LODOSYN (carbidopa) days NOURIANZ (istradefylline) OSMOLEX ER (amantadine) Nourianz PARCOPA (levodopa/carbidopa) • Documented diagnosis of PARLODEL (bromocriptine) Parkinson’s Disease AND RYTARY ER (levodopa/carbidopa) • History of a preferred SINEMET (levodopa/carbidopa) carbidopa/levodopa combination SINEMET CR (levodopa/carbidopa) product in the past 30 days AND STALEVO (levodopa/carbidopa/entacapone) • History of 30 days therapy with a preferred adjunctive therapy in the past 45 days ANTIPSYCHOTICS SmartPA

30 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

SAPHRIS (asenapine) GEODON (ziprasidone) Caplyta, Clozaril, Fanapt,

thioridazine HALDOL (haloperidol) fluphenazine, Geodon, loxapine, thiothixene INVEGA ER(paliperidone) Nuplazid, Rexulti, Secuado, trifluoperazine LATUDA (lurasidone) Vraylar, ziprasidone NUPLAZID (pimavanserin) olanzapine/fluoxetine Concurrent Therapy Limit – Ages 0-17 years paliperidone ER • 90 days with >2 antipsychotics in REXULTI (brexpiprazole) the last 120 days will require a RISPERDAL (risperidone) Manual PA SEROQUEL (quetiapine)

SEROQUEL XR (quetiapine) Non-Preferred Criteria – Atypical SYMBYAX (olanzapine/fluoxetine) Agents VERSACLOZ (clonazpine) • Have tried 2 preferred atypical VRAYLAR (cariprazine) antipsychotic agents in the past 12 ZYPREXA (olanzapine) months OR • 30 consecutive days on the requested atypical agent in the past 180 days

31 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

INJECTABLE, ATYPICALS SmartPA ARISTADA ER (aripiprazole lauroxil) ABILIFY (aripiprazole) ARISTADA INITIO (aripiprazole lauroxil) GEODON (ziprasidone) Minimum Age Limit ABILIFY MAINTENA (aripirazole) olanzapine • 18 years – all injectable agents INVEGA SUSTENNA (paliperidone palmitate) ZYPREXA (olanzapine) INVEGA TRINZA (paliperidone) ZYPREXA RELPREVV (olanzapine) Quantity Limit PERSERIS (risperidone) • 3 syringes/year – Aristada Initio RISPERDAL CONSTA (risperidone) Long Acting Injectable Agents All Agents • Documented diagnosis of schizophrenia or schizoaffective disorder

Abilify Maintena or Risperdal Consta • Documented diagnosis of schizophrenia or schizoaffective disorder OR • Documented diagnosis of bipolar disorder

TRANSDERMAL, ATYPICALS SECUADO (asenapine)

32 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

GENVOYA DOVATO (dolutegravir/lamivudine) • Intolerance or contraindication to (elvitegravir/cobicistat/emtricitabine/tenofovir) efavirenz/lamivudine/tenofovir preferred combination of drugs ODEFSEY (emtricitabine/rilpivirine/tenofovir AF) efavirenz/lamivudine/tenofovir lo AND JULUCA (dolutegravir/rilpivirine) SYMFI (efavirenz/lamivudine/tenofovir) • Medical reasoning beyond STRIBILD SYMFI-LO (efavirenz/lamivudine/tenofovir) convenience or enhanced (elvitegravir/cobicistat/emtricitabine/tenofovir) compliance over preferred agents SYMTUZA (darunavir/cobicistat/ AND

emtricitabine/tenofovir) • CrCl > 70mL/min to initiate therapy

TRIUMEQ (abacavir/lamivudine/ dolutegravir) OR CrCl >50mL/min to continue therapy

INTEGRASE STRAND TRANSFER INHIBITORS ISENTRESS (raltegravir potassium) ISENTRESS HD (raltegravir potassium) Non-Preferred Criteria TIVICAY (dolutegravir sodium) VITEKTA (elvitegravir) • 1 claim with the requested agent in TIVICAY PD (dolutegravir sodium) the past 105 days

NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NRTI) abacavir sulfate didanosine DR capsule EMTRIVA (emtricitabine) emtricitabine EMTRIVA SOLUTION (emtricitabine) EPIVIR (lamivudine) lamivudine RETROVIR (zidovudine) tenofovir disoproxil fumarate stavudine ZIAGEN Solution (abacavir sulfate) VIDEX EC (didanosine) zidovudine VIDEX SOLUTION (didanosine)

VIREAD (tenofovir disoproxil fumarate) ZIAGEN Tablet (abacavir sulfate)

33 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

PHARMACOENHANCER – CYTOCHROME P450 INHIBITOR TYBOST (cobicistat) Tybost - MANUAL PA

PROTEASE INHIBITORS (PEPTIDIC) atazanavir CRIXIVAN (indinavir) EVOTAZ (atazanavir/cobicistat) fosamprenavir NORVIR SOLUTION (ritonavir) INVIRASE (saquinavir mesylate) ritonavir LEXIVA (fosamprenavir) NORVIR POWDER(ritonavir) NORVIR TABLET (ritonavir) REYATAZ (atazanavir) VIRACEPT (nelfinavir mesylate)

PROTEASE INHIBITORS (NON-PEPTIDIC) PREZISTA (darunavir ethanolate) APTIVUS (tipranavir) PREZCOBIX (darunavir/cobicistat)

ENTRY INHIBITORS – CCR5 CO-RECEPTOR ANTAGONISTS SELZENTRY (maraviroc)

ENTRY INHIBITORS – FUSION INHIBITORS FUZEON (enfuvirtide)

34 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

COMBINATION PRODUCTS - NRTIs abacavir/lamivudine abacavir/lamivudine/zidovudine lamivudine/zidovudine CABENUVA (cabotegravir/rilpivirine)NR COMBIVIR (lamivudine/zidovudine) DOVATO (dolutegravir/lamivudine) EPZICOM (abacavir/lamivudine) JULUCA (dolutegravir/rilpivirine) TRIZIVIR (abacavir/lamivudine/zidovudine)

COMBINATION PRODUCTS – NUCLEOSIDE & NUCLEOTIDE ANALOG RTIs DESCOVY (emtricitabine/tenofovir alafenam) TRUVADA (emtricitabine/tenofovir) emtricitabine/tenofovir

COMBINATION PRODUCTS – NUCLEOSIDE & NUCLEOTIDE ANALOGS & NON-NUCLEOSIDE RTIs CIMDUO (lamivudine/tenofovir) ATRIPLA (efavirenz/emtricitabine/tenofovir) DELSTRIGO (doravirine/lamivudine/tenofovir) efavirenz/emtricitabine/tenofovir all other labelers efavirenz/emtricitabine/tenofovir labeler 00093 COMPLERA (emtricitabine/rilpivirine/tenofovir) ODEFSEY (emtricitabine/rilpivirine/tenofovir AF) TEMIXYS (lamivudine/tenofovir)

COMBINATION PRODUCTS – PROTEASE INHIBITORS KALETRA (lopinavir/ritonavir) lopinavir/ritonavir

CD4 DIRECTED ATTACHMENT INHIBITOR RUKOBIA (fostemsavir tromethamine ER)

35 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

Prevymis Prevention (prophylaxis) of cytomegalovirus (CMV) infection and disease • 18 years or older AND • Post hematopoietic stem cell transplant (HSCT) within the past 28 days AND • CMV sero-positive recipient [R+] AND • NO severe (Child-Pugh Class C) hepatic impairment

ANTI-HERPETIC AGENTS acyclovir famciclovir valacyclovir FAMVIR (famciclovir) SITAVIG (acyclovir) VALTREX (valacyclovir) ZOVIRAX (acyclovir)

ANTI-INFLUENZA AGENTS

36 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

AROMATASE INHIBITORS anastrozole ARIMIDEX (anastrozole) exemestane AROMASIN (exemestane) letrozole FEMARA (letrozole)

ATOPIC DERMATITIS SmartPA pimecrolimus labeler 68682 DUPIXENT (dupilumab) Minimum Age Limit tacrolimus ELIDEL (pimecrolimus) • 2 years – Elidel, Protopic 0.03% EUCRISA (crisaborole) • 6 years – Protopic 0.1% pimecrolimus

PROTOPIC (tacrolimus) Eucrisa

• History of 28 days of therapy with a calcineurin inhibitor AND • History of 28 days of therapy with a topical steroid in the past year OR • MANUAL PA

37 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

BETA BLOCKERS, ANTIANGINALS & SINUS NODE AGENTSSmartPA acebutolol BETAPACE (sotalol) Bystolic atenolol betaxolol • 90 consecutive days on the bisoprolol CORGARD (nadolol) requested agent in the past 105 days OR BYSTOLIC (nebivolol) Step Edit HEMANGEOL (propranolol) INDERAL LA (propranolol) • Have tried 1 preferred agent in the metoprolol INDERAL XL (propranolol) past 6 months metoprolol ER INNOPRAN XL (propranolol) nadolol KAPSPARGO SPRINKLES (metoprolol) Non-Preferred Criteria pindolol KERLONE (bextaxolol) • Have tried 2 different preferred propranolol LEVATOL (penbutolol) agents in the past 6 months OR propranolol ER LOPRESSOR (metoprolol) • 90 consecutive days on the sotalol SECTRAL (acebutolol) requested agent in the past 105 SOTYLIZE (sotalol) days TENORMIN (atenolol) TOPROL XL (metoprolol) ZEBETA (bisoprolol) BETA- AND ALPHA-BLOCKERS 38 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

ANTIANGINALS RANEXA (ranolazine) Ranexa ranolazine • Documented diagnosis of angina AND • 1 claim for a calcium channel blocker, beta-blocker, nitrate, or combination agent in the past 30 days OR • 90 consecutive days on the requested agent in the past 105 days SINUS NODE AGENTS 39 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

BONE RESORPTION SUPPRESSION AND RELATED AGENTS SmartPA BISPHOSPHONATES alendronate ACTONEL (risedronate) Non-Preferred Criteria ibandronate ACTONEL WITH CALCIUM (risedronate/calcium) • Documented diagnosis for osteoporosis or osteopenia AND 40 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

OTHERS calcitonin salmon EVENITY (romosozumab-aqqg) EVISTA (raloxifene) FORTEO (teriparatide) MIACALCIN (calcitonin) PROLIA (denosumab) raloxifene TYMLOS (abaloparatide) XGEVA (denosumab) BPH AGENTS SmartPA ALPHA BLOCKERS alfuzosin CARDURA (doxazosin) Female doxazosin CARDURA XL (doxazosin) • Cardura, Flomax, Proscar, tamsulosin dutasteride/tamsulosin terazosin, or Uroxatral AND terazosin FLOMAX (tamsulosin) • Documented diagnosis based on a State accepted diagnosis HYTRIN (terazosin)

JALYN (dutasteride/tamsulosin) Non-Preferred Criteria - MALE RAPAFLO (silodosin) • Have tried 2 different preferred silodosin agents in the past 6 months OR UROXATRAL (alfuzosin)

41 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

5-ALPHA-REDUCTASE (5AR) INHIBITORS finasteride AVODART (dutasteride) dutasteride PROSCAR (finasteride) PDE5 INHIBITORS CIALIS (tadalafil)

BRONCHODILATORS & COPD AGENTS ANTICHOLINERGICS & COPD AGENTS ATROVENT HFA (ipratropium) DALIRESP (roflumilast) Minimum Age Limit ipratropium INCRUSE ELLIPTA (umeclidinium) 6 years – Spiriva Respimat SPIRIVA HANDIHALER (tiotropium) LONHALA MAGNAIR (glycopyrrolate) SEEBRI (glycopyrrolate) Spiriva Respimat SPIRIVA RESPIMAT (tiotropium) SmartPA • Automatic approval for > 6 years with a diagnosis of asthma TUDORZA PRESSAIR (aclidinium)

YUPELRI (revefenacin)

ANTICHOLINERGIC-BETA AGONIST COMBINATIONS albuterol/ipratropium DUAKLIR PRESSAIR (aclidinium/formoterol) ANORO ELLIPTA (umeclidinium/vilanterol) STIOLTO RESPIMAT (tiotropium/olodaterol) BEVESPI (glycopyrrolate/formoterol)

COMBIVENT RESPIMAT (albuterol/ipratropium) SmartPA UTIBRON (indacaterol/glycopyrrolate)

ANTICHOLINERGIC-BETA AGONIST-GLUCOCORTICOIDS COMBINATIONS

42 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

BRONCHODILATORS, BETA AGONIST INHALERS, SHORT-ACTING PROAIR HFA (albuterol) albuterol HFA Minimum Age Limit PROAIR RESPICLICK (albuterol) levalbuterol HFA • 4 years - Xopenex HFA VENTOLIN HFA (albuterol) PROAIR DIGIHALER (albuterol) PROVENTIL HFA (albuterol) Xopenex HFA XOPENEX HFA (levalbuterol) SmartPA • 1 claim for a preferred albuterol inhaler in the past 30 days

ProAir Digihaler • Requires clinical review

INHALERS, LONG ACTING SmartPA SEREVENT (salmeterol) ARCAPTA (indacaterol) Minimum Age Limit STRIVERDI RESPIMAT (olodaterol) • 4 years – Serevent • 18 years – Arcapta, Striverdi Respimat

Arcapta & Striverdi Respimat • Documented diagnosis of COPD AND • Have tried 1 preferred agent in the past 6 months OR • 90 consecutive days on the requested agent in the past 105 days

43 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

INHALATION SOLUTION SmartPA albuterol BROVANA (arformoterol) Minimum Age Limit formoterol • 6 years – Xopenex levalbuterol • 18 years – Brovana, Perforomist metaproterenol PERFOROMIST (formoterol) Non-Preferred Criteria XOPENEX (levalbuterol) • 1 claim for a different preferred agent in the past 6 months OR • 3 claims with the requested agent in the past 105 days

Xopenex • 1 claim for a preferred albuterol in the past 30 days

ORAL albuterol ER VOSPIRE ER (albuterol) albuterol IR metaproterenol terbutaline

CALCIUM CHANNEL BLOCKERS SmartPA SHORT-ACTING diltiazem CALAN (verapamil) Quantity Limit - nimodipine nicardipine CARDIZEM (diltiazem) • 252 tablets/ 21 days nifedipine isradipine • 2520 mL/21 days verapamil nimodipine NYMALIZE SOLUTION (nimodipine) Non-Preferred Criteria PROCARDIA (nifedipine)

44 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

nimodipine • Documented diagnosis of subarachnoid hemorrhage in the past 45 days AND • Duration of therapy limited to 21 days LONG-ACTING amlodipine ADALAT CC (nifedipine) Non-Preferred Criteria DILT XR 24 HR Caps (diltiazem) CALAN SR (verapamil) • Have tried 2 different preferred diltiazem ER Cap 24 HR (generic Cardizem CD) CARDENE SR (nicardipine) Long Acting CCB agents in the past diltiazem ER Cap 24 HR CARDIZEM CD (diltiazem) 6 months OR • 90 consecutive days on the felodipine ER CARDIZEM LA (diltiazem) DILACOR XR (diltiazem) requested agent in the past 105 nifedipine ER days verapamil ER diltiazem ER Cap 12 HR diltiazem ER Tab 24 HR KATERZIA (amlodipine) nisoldipine NORVASC (amlodipine) PROCARDIA XL (nifedipine) SULAR (nisoldipine) TIAZAC (diltiazem) verapamil ER PM VERELAN/VERELAN PM (verapamil)

CALORIC AGENTS

45 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

CEPHALOSPORINS AND RELATED ANTIBIOTICS (Oral) BETA LACTAM/BETA-LACTAMASE INHIBITOR COMBINATIONS amoxicillin/clavulanate AUGMENTIN 125 and 250 Suspension amoxicillin/clavulanate XR (amoxicillin/clavulanate) AUGMENTIN (amoxicillin/clavulanate) Tablets AUGMENTIN XR (amoxicillin/clavulanate) MOXATAG (amoxicillin)

CEPHALOSPORINS – First Generation SmartPA cefadroxil cephalexin tablets Non-Preferred Criteria – all

cephalexin capsules DAXBIA (cephalexin) generations cephalexin suspension KEFLEX (cephalexin) • Have tried 2 different preferred

agents in the past 6 months

CEPHALOSPORINS – Second Generation SmartPA

46 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

CYSTIC FIBROSIS AGENTS SmartPA BETHKIS (tobramycin) BRONCHITOL (mannitol)NR Minimum Age Limit KITABIS (tobramycin) CAYSTON (aztreonam) • 3 months – Pulmozyme

tobramycin(generic TOBI) colistmethate • 4 months – Kalydeco Granules COLY-MYCIN M (colistimethate sodium) • 2 years – Coly-Mycin M, Orkambi KALYDECO (ivacaftor) Granules ORKAMBI (lumacaftor/ivacaftor) • 6 years – Bethkis, Kalydeco tablet, PULMOZYME (dornase alfa) Kitabis, Orkambi 100/125mg tablet, SYMDEKO (tezacaftor/ivacaftor) Symdeko, TOBI, TOBI Podhaler, TOBI (tobramycin) Trikafta

TOBI PODHALER (tobramycin) • 7 years – Cayston 47 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

Maximum Age Limit • 5 years – Kalydeco and Orkambi Granules

All Agents • Documented diagnosis Cystic Fibrosis

Colistimethate • Documented diagnosis of Cystic Fibrosis OR • Requires clinical review

Kalydeco – MANUAL PA Orkambi – MANUAL PA Symdeko – MANUAL PA Trikafta – MANUAL PA

TOBI Podhaler • Requires clinical review

CYTOKINE & CAM ANTAGONISTS ENBREL (etanercept) ACTEMRA (tocilizumab) HUMIRA (adalimumab) ARCALYST (rilonacept) Enbrel methotrexate AVSOLA (infliximab)NR • Age > 2 years AND TALTZ (ixekizumab) CIMZIA (certolizumab) • Documented diagnosis of juvenile idiopathic arthritis OR XELJANZ IR (tofacitinib) COSENTYX (secukinumab • Age limit > 4 years AND 48 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

ORENCIA (abatacept) Humira OTEZLA (apremilast) • Age > 2 years AND OTREXUP (methotrexate) • Documented diagnosis of juvenile RASUVO (methotrexate) idiopathic arthritis OR REMICADE (infliximab) • Age > 5 years AND RENFLEXIS (infliximab-abda) • Documented diagnosis of ulcerative RHEUMATREX (methotrexate) colitis OR RINVOQ (upadacitinib) • Age > 6 years AND SILIQ (brodalumab) • Documented diagnosis of Crohn’s SIMPONI (golimumab) disease OR SKYRIZI (risankizumab) • Age > 12 years AND • Documented diagnosis of STELARA (ustekinumab) hidradenitis suppurativa OR TREMFYA (guselkumab) • Age > 18 years AND TREXALL (methotrexate) • Documented diagnosis of

XELJANZ Oral Solution (tofacitinib) ankylosing spondylitis, Crohn’s XELJANZ XR (tofacitinib) disease, hidradenitis suppurativa, plaque psoriasis, psoriatic arthritis, rheumatoid arthritis, ulcerative colitis, or uveitis

Taltz • Age > 6 years AND • Documented diagnosis of plaque psoriasis OR • Age > 18 years AND 49 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

Xeljanz • Age > 18 years AND • Documented diagnosis of rheumatoid arthritis or ulcerative colitis OR • Trial and failure of two preferred agents for a documented diagnosis of psoriatic arthritis

Cosentyx • Age > 6 years AND • Documented diagnosis of plaque psoriasis AND • Have tried 90 days therapy with both Enbrel and Taltz OR • Age > 18 years AND • Documented diagnosis of ankylosing spondylitis, plaque psoriasis, or psoriatic arthritis AND • Have tried 90 days therapy with both Humira and Taltz OR • All other indications evaluated through clinical review

All other Non-Preferred Agents • Require clinical review

IV Administered Agents

50 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

ERYTHROPOIESIS STIMULATING PROTEINS SmartPA EPOGEN (rHuEPO) ARANESP (darbepoetin) Mircera MIRCERA (methoxy polyethylene glycol-epoetin- PROCRIT (rHuEPO) • Documented diagnosis chronic beta) renal failure in the past 2 years RETACRIT (rHuEPO) Non-Preferred Criteria • Documented diagnosis of cancer or chronic renal failure OR Antineoplastic therapy in the past 6 months AND • Trial of a preferred Retacrit or Epogen in the past 6 months OR • 1 claim for the requested agent in the past 105 days

FACTOR DEFICIENCY PRODUCTS FACTOR VIII ADVATE ADYNOVATE AFSTYLA ELOCTATE ALPHANATE ESPEROCT FEIBA NF HEXILATE FS HEMOFIL M JIVI HUMATE-P KCENTRA KOATE KOVALTRY KOGENATE FS OBIZUR NOVOEIGHT VONVENDI NUWIQ

51 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

OTHER FACTOR PRODUCTS COAGADEX CORIFACT FIBRYGA HEMLIBRA SmartPA RIASTAP NOVOSEVEN RT SEVENFACTNR TRETTEN FIBROMYALGIA/NEUROPATHIC PAIN AGENTS duloxetine CYMBALTA (duloxetine) SmartPA Cymbalta and Irenka (see gabapentin duloxetine DR Antidepressant, Other)

pregabalin GRALISE (gabapentin) Minimum Age Limit – automatic SAVELLA (milnacipran) HORIZANT (gabapentin) approval for ages 7-17 with a SmartPA IRENKA (duloxetine) diagnosis of GAD (Generalized LYRICA (pregabalin) Anxiety Disorder) for preferred LYRICA CR (pregabalin) duloxetine

52 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

FLUOROQUINOLONES (Oral) SmartPA ciprofloxacin tablets AVELOX (moxifloxacin) Non-Preferred Criteria levofloxacin tablets BAXDELA (delaflozacin) • 1 claim for a preferred agent in past CIPRO (ciprofloxacin) 30 days CIPRO SUSPENSION (ciprofloxacin) Cipro Suspension for age < 12 CIPRO XR (ciprofloxacin) years ciprofloxacin ER • Anthrax infection or exposure OR ciprofloxacin suspension • Cystic Fibrosis OR FACTIVE (gemifloxacin) • Pneumonic plague OR tularemia LEVAQUIN (levofloxacin) AND history of doxycycline in the levofloxacin solution past 3 months OR moxifloxacin • 7 days of therapy with a preferred NOROXIN (norfloxacin) agent from 2 of the classes below ofloxacin in the past 3 months o Penicillin, 2nd or 3rd generation cephalosporin, or macrolide

Levaquin solution for age < 12 years • Anthrax infection or exposure OR • 7 days of therapy with a preferred agent from 2 of the classes below in the past 3 months o Penicillin, 2nd or 3rd generation cephalosporin, or macrolide AND • Cipro suspension in the past 3 months

53 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

NOTE: Institutional sized products are Non-Preferred 54 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

GLUCOCORTICOID/BRONCHODILATOR COMBINATIONS ADVAIR DISKUS (fluticasone/salmeterol) AIRDUO Digihaler (fluticasone/salmeterol) Non-Preferred Criteria

ADVAIR HFA (fluticasone/salmeterol) AIRDUO Respiclick (fluticasone/salmeterol) • 90 consecutive days on the DULERA (mometasone/formoterol) BREO ELLIPTA (fluticasone/vilanterol) requested agent in the past 105 budesonide/formoterol fluticasone/salmeterol (generic AIRDUO) days OR fluticasone/salmeterol (generic ADVAIR) SYMBICORT (budesonide/formoterol) Have tried 2 different preferred WIXELA INHUB (fluticasone/salmeterol) agents in the past 6 months

AirDuo Digihaler • Requires clinical review

GI ULCER THERAPIES H2 RECEPTOR ANTAGONISTS cimetidine solution AXID (nizatidine) famotidine solution cimetidine tablets famotidine tablets nizatidine tablets nizatidine solution PEPCID (famotidine)

PROTON PUMP INHIBITORS esomeprazole magnesium DR Capsule ACIPHEX SPRINKLE (rabeprazole) Prilosec suspension NEXIUM PACKET (esomeprazole) ACIPHEX Tablet (rabeprazole) • Automatic approval for 0 - 2 years omeprazole Rx DEXILANT (dexlansoprazole) pantoprazole esomeprazole strontium DR Capsule lansoprazole Rx NEXIUM Rx DR Capsule (esomeprazole) omeprazole sod. bicarb. PREVACID Rx (lansoprazole)

55 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

GROWTH HORMONE SmartPA NORDITROPIN (somatropin) GENOTROPIN (somatropin) All Agents for Age > 18 years NUTROPIN AQ (somatropin) HUMATROPE (somatropin) • Documented diagnosis of OMNITROPE (somatropin) craniopharyngioma, SAIZEN (somatropin) panhypopituitarism, Prader-Willi Syndrome, Turner Syndrome or an SEROSTIM (somatropin) approvable indication OR ZOMACTON (somatropin) • Documented procedure of cranial ZORBTIVE (somatropin) irradiation

Non-Preferred Criteria • Have tried 1 preferred agent in the past 6 months OR • 84 consecutive days on the requested agent in the past 105 days H. PYLORI COMBINATION TREATMENTS PYLERA (bismuth subcitrate potassium, lansoprazole, amoxicillin, clarithromycin Quantity Limit metronidazole, tetracycline) OMECLAMOX (omeprazole, clarithromycin, • 1 treatment course/year amoxicillin)

56 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

HEPATITIS C TREATMENTS MAVYRET (glecaprevir/pibrentasvir)∞ COPEGUS (ribavirin) PEGASYS (peginterferon alfa-2a) DAKLINZA (daclatasvir) ∞ Daklinza, Epclusa, Harvoni, PEG-INTRON (peginterferon alfa-2b) EPCLUSA (sofosbuvir/velpatasvir) ∞ Mavyret, Sovaldi, Vosevi, Zepatier ribavirin tablets HARVONI (ledipasvir/sofosbuvir)∞ • Require clinical review

sofosbuvir/velpatasvir∞ ledipasvir/sofosbuvir∞ Note: Harvoni and Sovaldi have FDA

MODERIBA (ribavirin) pediatric indications OLYSIO (simeprevir) REBETOL (ribavirin) RIBASPHERE (ribavirin) RIBASPHERE RIBAPAK DOSEPACK (ribavirin) ribavirin capsules SOVALDI (sofosbuvir)∞ TECHNIVIE (ombitasvir/paritaprevir/ritonavir) VIEKIRA (ombitasvir/paritaprevir/ritonavir) VIEKIRA XR (ombitasvir/paritaprevir/ritonavir) VOSEVI (sofosbuvir/velpatasvir/voxilaprevir)∞ ZEPATIER (elbasvir/grazoprevir)∞ HEREDITARY ANGIOEDEMA

57 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

HYPERURICEMIA & GOUT SmartPA allopurinol colchicine tablet Non-Preferred Criteria colchicine capsule COLCRYS (colchicine) • Have tried 2 different preferred probenecid febuxostat agents in the past 6 months probenecid/colchicine LOPERBA (colchicine)

MITIGARE (colchicine)

ULORIC (febuxostat) ZYLOPRIM (allopurinol)

HYPOGLYCEMIA TREATMENT, GLUCAGON BAQSIMI (glucagon)Step Edit GVOKE (glucagon) Minimum Age Limit glucagen vial ZEGALOGUE (dasiglucagon)NR • 2 years – Gvoke glucagon kit • 4 years – Baqsimi • 6 years – Zegalogue

Quantity Limit • 2 packs/31 days – Baqsimi • 2 syringes/31 days – Gvoke, Zegalogue 58 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

Non-Preferred Criteria • Have tried 1 different preferred glucagon in the past 30 days

Baqsimi • Have tried 1 different preferred glucagon in the past 365 days OR • 1 claim with Baqsimi in the past 365 days

Gvoke • 1 claim with Baqsimi in the past 30 days

Zegalogue • 1 claim with Baqsimi in the past 30 days

HYPOGLYCEMICS, BIGUANIDES SmartPA metformin HCL tablet FORTAMET ER metformin HCL ER 24HR tablet (generic GLUCOPHAGE (metformin) • Clinical review required for GlucophageXR) GLUCOPHAGE XR (metformin ER) addition of a fourth concurrent GLUMETZA (metformin ER) oral agent in a different drug metformin 24HR (generic Fortamet) class metformin 24HR (generic Glumetza) o Concurrent therapy with the RIOMET SOLUTION* (metformin) incoming claim is defined as 20 or more days’ supply of the drug in the past 30 days o 2-drug combination agents count as 2 classes and 3-

59 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

HYPOGLYCEMICS, DPP4s and COMBINATON SmartPA JANUMET (sitagliptin/metformin) alogliptin JANUMET XR (sitagliptin/metformin) alogliptin/metformin • Clinical review required with JANUVIA (sitagliptin) alogliptin/pioglitazone concomitant use of GLP-1 JENTADUETO (linagliptin/metformin) JENTADUETO XR (linagliptin/metformin) product in the past 30 days OR TRADJENTA (linagliptin) KAZANO (alogliptin/metformin) • Addition of a fourth concurrent oral agent in a different drug KOMBIGLYZE XR (saxagliptin/metformin)* class NESINA (alogliptin) o Concurrent therapy with the * ONGLYZA (saxagliptin) incoming claim is defined as OSENI (alogliptin/pioglitazone) 20 or more days’ supply of the drug in the past 30 days o 2-drug combination agents count as 2 classes and 3- drug combination agents count as 3 classes

Kombiglyze XR and Onglyza • 90 consecutive days on the requested agent in the past 105 days

HYPOGLYCEMICS, INCRETIN MIMETICS/ENHANCERS SmartPA BYETTA (exenatide) ADLYXIN (lixisenatide) VICTOZA (liraglutide) BYDUREON (exenatide) • Clinical review required with BYDUREON BCISE (exenatide) concomitant use of DPP-4 product in the past 30 days OR 60 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

Symlin is excluded from all criteria

HYPOGLYCEMICS, INSULINS AND RELATED AGENTS SmartPA HUMULIN N, R, 70/30 VIALOTC (insulin) AFREZZA (insulin) Insulin pen formulations are not HUMULIN R U500 VIAL (insulin) ADMELOG (insulin lispro) covered for Long Term Care (LTC) insulin aspart APIDRA (insulin glulisine) beneficiaries.

insulin aspart flexpen APIDRA SOLOSTAR (insulin glulisine) Non-Preferred Criteria insulin aspart mix BASAGLAR (insulin glargine) • Documented diagnosis of Diabetes insulin aspart mix flexpen FIASP (insulin aspart) Mellitus AND Insulin lispro HUMALOG JR (insulin lispro) • Have tried 1 preferred product in insulin lispro kwikpen HUMALOG KWIKPEN U100 (insulin lispro) the past 6 months OR LANTUS SOLOSTAR & VIAL (insulin glargine) HUMALOG KWIKPEN U200 (insulin lispro) • 1 claim with the requested agent in LEVEMIR FLEXPEN & VIAL (insulin detemir) HUMALOG MIX KWIKPEN (insulin lispro/ lispro the past 105 days protamine) HUMALOG MIX VIAL (insulin lispro/ lispro protamine) HUMALOG VIAL (insulin lispro) HUMULIN N, 70/30 KWIKPEN (insulin) OTC HUMULIN R U500 KWIKPEN* 61 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

HYPOGLYCEMICS, MEGLITINIDES SmartPA nateglinide PRANDIMET (repaglinide/metformin) repaglinide PRANDIN (repaglinide) • Clinical review required with repaglinide/metformin addition of a fourth concurrent STARLIX (nateglinide) oral agent in a different drug class

o Concurrent therapy with the incoming claim is defined as 20 or more days’ supply of the drug in the past 30 days o 2-drug combination agents count as 2 classes and 3- drug combination agents count as 3 classes

HYPOGLYCEMICS, SODIUM GLUCOSE COTRANSPORTER-2 INHIBITORS SmartPA HYPOGLYCEMICS, SODIUM GLUCOSE COTRANSPORTER-2 INHIBITORS 62 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

HYPOGLYCEMICS, SODIUM GLUCOSE COTRANSPORTER-2 INHIBITOR COMBINATIONS INVOKAMET (canaglifozin/metformin) GLYXAMBI (empagliflozin/linagliptin) SYNJARDY (empagliflozin/metformin) INVOKAMET XR (canaglifozin/metformin) QTERN (dapaglifozin/saxagliptin) SEGLUROMET (ertugliflozin/metformin) STEGLUJAN (ertugliflozin/sitagliptin) SYNJARDY XR (empagliflozin/metformin) TRIJARDY XR (empagliflozin/linagliptin/metformin) XIGDUO XR (dapaglifozin/metformin)

HYPOGLYCEMICS, TZDS THIAZOLIDINEDIONES pioglitazone ACTOS (pioglitazone) AVANDIA (rosiglitazone) • Clinical review required for addition of a fourth concurrent oral agent in a different drug class o Concurrent therapy with the incoming claim is defined as

63 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

TZD COMBINATIONS pioglitazone/metformin ACTOPLUS MET (pioglitazone/metformin) ACTOPLUSMET XR (pioglitazone/metformin) AVANDAMET (rosiglitazone/metformin) AVANDARYL (rosiglitazone/glipizide) DUETACT (pioglitazone/glimepiride) pioglitazone/glimepiride IDIOPATHIC PULMONARY FIBROSIS SmartPA ESBRIET (pirfenidone) All Agents OFEV (nintedanib) • Documented diagnosis Idiopathic Pulmonary Fibrosis Esbriet & OFEV • No concurrent therapy with either agent IMMUNOSUPPRESSIVE (ORAL) SmartPA AZASAN (azathioprine) ASTAGRAF XL (tacrolimus) Minimum Age Limit azathioprine ENVARSUS XR (tacrolimus) • 13 years - Rapamune CELLCEPT (mycophenolate) HECORIA (tacrolimus) • 18 years - Zortress cyclosporine MYFORTIC (mycophenolic acid) Astagraf, Cellcept, Envarsus XR, cyclosporine modified PROGRAF (tacrolimus) Hecoria, Prograf GENGRAF (cyclosporine) • Documented diagnosis for heart IMURAN (azathioprine) transplant, kidney transplant, liver mycophenolic acid transplant, or a State accepted mycophenolate mofetil diagnosis

64 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

ZORTRESS (everolimus) Gengraf, Neoral, Sandimmune • Documented diagnosis of heart transplant, kidney transplant, liver transplant, psoriasis, RA, or a State accepted diagnosis OR • Clinical review required for a diagnosis of Kimura’s disease or multifocal motor neuropathy

Myfortic • Documented diagnosis of kidney transplant or psoriasis

Rapamune • Documented diagnosis of kidney transplant

Zortress • Documented diagnosis of kidney transplant or liver transplant IMMUNE GLOBULINS CARIMUNE NF ASCENIV FLEBOGAMMA DIF BIVIGAM GAMASTAN SD CABLIVI GAMMAGARD CUTAQUIG GAMMAKED CUVITRU GAMUNEX-C GAMMAGARD SD

65 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

Fasenra pen, Nucala autoinjector, Nucala syringe • Documented diagnosis of severe persistent asthma AND • 90 days therapy with an ICS/LABA combination product in the past 120 days OR • 90 days therapy with both an ICS and a LABA or a leukotriene modifier in the past 120 days AND • 2 claims for at least 3 days each with an oral corticosteroid in the past 365 days AND • 1 claim with an ICS/LABA combination product in the past 30 days OR • 1 claim with both an ICS and a LABA or a leukotriene modifier in the past 30 days AND • No concurrent therapy with a different asthma immunologic therapy

66 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

Dupixent – MANUAL PA

• INTRANASAL RHINITIS AGENTS ANTICHOLINERGICS ipratropium ATROVENT (ipratropium) ANTIHISTAMINES azelastine ASTEPRO (azelastine) olopatadine PATANASE (olopatadine)

ANTIHISTAMINE/CORTICOSTEROID COMBINATION SmartPA DYMISTA (azelastine/fluticasone) TICALAST (azelastine/fluticasone)

CORTICOSTEROIDS SmartPA fluticasone Rx Only BECONASE AQ (beclomethasone) Non-Preferred Criteria budesonide • Documented diagnosis for allergic flunisolide rhinitis AND mometasone • Have tried 1 different preferred agent in the past 6 months NASONEX (mometasone)

OMNARIS (ciclesonide) QNASL (beclomethasone) TICANASE KIT (flonase kit) triamcinolone VERAMYST (fluticasone) XHANCE (fluticasone) ZETONNA (ciclesonide) 67 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

IRON CHELATING AGENTS deferasirox all strengths EXJADE (deferasirox) Jadenu – MANUAL PA FERRIPROX (deferiprone) JADENU (deferasirox) JADENU SPRINKLES (deferasirox)

IRRITABLE BOWEL SYNDROME/SHORT BOWEL SYNDROME AGENTS/SELECTED GI AGENTS SmartPA IRRITABLE BOWEL SYNDROME CONSTIPATION AMITIZA (lubiprostone) LINZESS 72mcg (linaclotide) Minimum Age Limit All Subclasses LINZESS 145mcg, 290mcg (linaclotide) lubiprostone • 18 years – except Bentyl, Gattex, MOVANTIK (naloxegol) MOTEGRITY (prucalopride) Levsin RELISTOR (methylnaltrexone) SYMPROIC (naldemedine) Gender Limit TRULANCE (plecanatide) • Female – Amitiza 8mcg ZELNORM (tegaserod) Chronic Idiopathic Constipation (CIC) AMITIZA 24MCG, LINZESS 72MCG, LINZESS 145 MCG, MOTEGRITY, TRULANCE

All CIC Agents • Documented diagnosis of CIC in the past year AND • No history of GI or bowel obstruction

Non-Preferred CIC Agents • Above CIC criteria AND • 30 days of therapy with 2 preferred agents in the past 6 months OR

68 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

Irritable Bowel Syndrome – Constipation Dominant (IBS-C) AMITIZA 8MCG, LINZESS 290 MCG, TRULANCE

All IBS-C Agents • Documented diagnosis of IBS-C in the past year AND • No history of GI or bowel obstruction

Non-Preferred IBS-C Agents • Above IBS-C criteria AND • 30 days of therapy with 2 preferred agents in the past 6 months OR • 1 claim with the requested agent in the past 105 days

Opioid Induced Constipation (OIC) AMITIZA 24MCG, MOVANTIK, RELISTOR, SYMPROIC

All OIC Agents • Documented diagnosis of OIC in the past year AND • 1 claim for an opioid in the past 30 days AND • No history of GI or bowel obstruction AND • Documented diagnosis of chronic pain in the past year

69 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

Non- Preferred OIC Agents • Above OIC criteria AND • 30 days of therapy with 2 preferred agents in the past 6 months OR • 1 claim with the requested agent in the past 105 days

Relistor Injection • Above OIC criteria AND • Documented diagnosis of active cancer in the past year AND • Documented diagnosis of palliative care in the past 6 months

IRRITABLE BOWEL SYNDROME DIARRHEA dicyclomine alosetron Viberzi hyoscyamine BENTYL (dicyclomine) • Documented diagnosis of Irritable LEVSIN (hyoscyamine) Bowel Syndrome – Diarrhea LEVSIN-SL (hyoscyamine) Dominant (IBS-D) in the past year LOTRONEX (alosetron) AND VIBERZI (eluxadoline)* • 30 days of therapy with 2 preferred agents in the past 6 months OR • 1 claim with the requested agent in the past 105 days

Lotronex • 1 claim for the requested agent in the past 105 days OR • MANUAL PA - All new patients require manual review. 70 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

Xifaxan - (see Antibiotics, GI)

SHORT BOWEL SYNDROME AND SELECTED GI AGENTS FULYZAQ (crofelemer) GATTEX (teduglutide) MYTESI (crofelemer) Carcinoid Syndrome Agent NUTRESTORE POWDER PACK (glutamine) XERMELO XERMELO (telotristat ethyl) • Documented diagnosis of carcinoid ZORBTIVE (somatropin) syndrome in the past year AND • 1 claim for a somatostatin analog in the past 30 days

HIV/AIDS Non-infectious Diarrhea FULYZAQ, MYTESI • Documented diagnosis of HIV/AIDS in the past year AND • Documented diagnosis of non- infectious diarrhea in the past year AND • 1 claim for an antiretroviral in the past 30 days

Short Bowel Syndrome (SBS) GATTEX, NUTRESTORE, ZORBTIVE

Gattex or Zorbtive • 1 claim for the requested agent in the past 105 days OR • All new patients require clinical review

Nutrestore 71 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

LEUKOTRIENE MODIFIERS SmartPA montelukast granules ACCOLATE (zafirlukast) Minimum Age Limit montelukast tablets SINGULAIR Tablets (montelukast) • 12 years – Zyflo & Zyflo CR zafirlukast SINGULAR GRANULES (montelukast granules) zileuton Non-Preferred Criteria • Have tried 2 different preferred ZYFLO CR (zileuton) agents in the past 6 months

LIPOTROPICS, OTHER (NON-STATINS) SmartPA ACL INHIBITORS AND COMBINATIONS NEXLETOL(bempedoic acid) Nexletol and Nexlizet NEXLIZET (bempedoic acid/ezetimibe) • Requires clinical review

BILE ACID SEQUESTRANTS cholestyramine colesevelam All Agents, All Sub-Classes both colestipol COLESTID (colestipol) Preferred (exception is Zetia) and QUESTRAN (cholestyramine) Non-Preferred WELCHOL (colesevelam) • 90 consecutive days on the requested agent in the past 105 days OR • Have tried 1 statin or statin combination agent in the past year OR • One of the following exceptions o Welchol AND Type 2 diabetes AND 1 preferred oral antidiabetic agent in the past 180 days OR o Pregnant female OR

72 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

Non-Preferred Criteria • Have tried 2 different preferred Non-statin Lipotropic agents in the past 6 months OMEGA-3 FATTY ACIDS omega 3 acid ethyl esters LOVAZA (omega-3-acid ethyl esters) Non-Preferred Criteria VASCEPA (icosapent ethyl) • Have tried 2 different preferred Non-statin Lipotropic agents in the past 6 months

CHOLESTEROL ABSORPTION INHIBITORS ezetimibe ZETIA (ezetimibe) Zetia does not have to meet the trial of 1 statin or statin combination agent in the past year FIBRIC ACID DERIVATIVES fenofibrate nanocrystallized ANTARA (fenofibrate, micronized) Fibric Acid Derivative Non- gemfibrozil fenofibrate 40mg tablet Preferred Criteria fenofibrate, micronized • Have tried 2 different fibric acid fenofibric acid derivatives in the past 6 months FENOGLIDE (fenofibrate) FIBRICOR (fenofibric acid) LIPOFEN (fenofibrate) LOFIBRA (fenofibrate) LOPID (gemfibrozil) TRICOR (fenofibrate nanocrystallized) 73 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

NIACIN niacin ER NIASPAN (niacin) Non-Preferred Criteria NIACOR (niacin) • Have tried 2 different preferred Non-statin Lipotropic agents in the past 6 months PCSK-9 INHIBITOR PRALUENT (alirocumab) Praluent - MANUAL PA REPATHA (evolocumab) Repatha - MANUAL PA

LIPOTROPICS, STATINS SmartPA STATINS atorvastatin ALTOPREV (lovastatin) Simvastatin 80mg lovastatin CRESTOR (rosuvastatin) • 12 months of therapy with pravastatin EZALLOR SPRINKLE (rosuvastatin) simvastatin 80mg AND rosuvastatin FLOLIPID (simvastatin) • NO myopathy contraindication

simvastatin fluvastatin ER Non-Preferred Criteria fluvastatin LESCOL (fluvastatin) 74 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

MISCELLANEOUS BRAND/GENERIC CLONIDINE clonidine patches CATAPRES (clonidine) clonidine tablets CATAPRES-TTS (clonidine)

EPINEPHRINE epinephrine autoinject pens (labeler 49502) ADRENACLICK (epinephrine) Quantity Limit SYMJEPI (epinephrine) AUVI-Q (epinephrine) • 2 kits/31 days EPINEPHRINE SNAP EMS KIT (epinephrine) EPIPEN (epinephrine) EPIPEN JR (epinephrine)

MISCELLANEOUS alprazolam alprazolam ER Alprazolam ER CUMULATIVE hydroxyzine hcl syrup EVRYSDI (risdiplam) quantity limit hydroxyzine pamoate hydroxyprogesterone caproate • 31 tablets/31 days

75 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

ALLERGEN EXTRACT IMMUNOTHERAPY Evrysdi- MANUAL PA GRASTEK ORALAIR PALFORZIA RAGWITEK

SUBLINGUAL NITROGLYCERIN nitroglycerin lingual 12gm nitroglycerin lingual 4.9gm nitroglycerin sublingual NITROLINGUAL (nitroglycerin) 4.9gm NITROLINGUAL PUMPSPRAY (nitroglycerin) NITROMIST (nitroglycerin) 12gm NITROSTAT SUBLINGUAL (nitroglycerin) MOVEMENT DISORDER AGENTS SmartPA AUSTEDO (deutetrabenazine) XENAZINE (tetrabenazine) Austedo INGREZZA (valbenazine) • Documented diagnosis of tetrabenazine Huntington’s chorea OR • Documented diagnosis of tardive dyskinesia AND • 90 days therapy with Austedo in the past 105 days OR • MANUAL PA

Ingrezza • Documented diagnosis of tardive dyskinesia AND • 90 days therapy with Ingrezza in the past 105 days OR 76 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

MULTIPLE SCLEROSIS AGENTS SmartPA AUBAGIO (teriflunomide) AMPYRA (dalfampridine) All Agents AVONEX (interferon beta-1a) BAFIERTAM (monomethyl fumarate) • Documented diagnosis of multiple AVONEX PEN (interferon beta-1a) COPAXONE 40mg (glatiramer) sclerosis BETASERON (interferon beta-1b) dimethyl fumarate Non-Preferred Criteria COPAXONE 20mg (glatiramer) EXTAVIA (interferon beta-1b) • Have tried 2 different preferred dalfampridine glatiramer agents in the past 6 months OR GILENYA (fingolimod) GLATOPA (glatiramer) • 3 claims with the requested agent NR REBIF (interferon beta-1a) KESIMPTA (ofatumumab) in the last 105 days REBIF REBIDOSE (interferon beta-1a) MAVENCLAD (cladribine) MAYZENT (siponimod) Kesimpta, Ponvory and Zeposia OCREVUS (ocrelizumab) • Requires clinical review PLEGRIDY (interferon beta-1a) PONVORY (ponesimod)NR Mavenclad – MANUAL PA TECFIDERA (dimethyl fumarate) Mayzent – MANUAL PA VUMERITY (diroximel fumarate)

ZEPOSIA (ozanimod) Ocrevus – MANUAL PA

MUSCULAR DYSTROPHY AGENTS AMONDYS 45 (casimersen)NR Emflaza – MANUAL PA EMFLAZA (deflazacort) Exondys – MANUAL PA EXONDYS 51 (eteplirsen) Viltepso –MANUAL PA VILTEPSO (viltolarsen) Vyondys – MANUAL PA VYONDYS 53 (golodirsen)

77 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

Conduent’s SmartPA Pharmacy Application (SmartPA) is a proprietary electronic prior authorization system used for Medicaid fee for service claims. MSCAN plans may/may not -have electronic PA functionality. However, they must adhere to Medicaid’s PA criteria. NSAIDS SmartPA NON-SELECTIVE diclofenac EC ADVIL (ibuprofen) Non-Preferred Criteria diclofenac IR ANAPROX (naproxen) • Have tried 2 different preferred non- diclofenac SR CAMBIA (diclofenac) selective or NSAID/GI protectant CATAFLAM (diclofenac) etodolac IR tab combination agents in the past 6 DAYPRO (oxaprozin) months flurbiprofen etodolac cap ibuprofen etodolac tab SR ibuprofen suspensionOTC FELDENE (piroxicam) indomethacin FENORTHO (fenoprofen) ketoprofen fenoprofen ketorolac INDOCIN capsules, suspension & suppositories nabumetone (indomethacin) naproxen 250mg and 500mg indomethacin cap ER naproxen suspension ketoprofen ER piroxicam meclofenamate sulindac mefenamic acid NALFON (fenoprofen) NAPRELAN (naproxen) NAPROSYN (naproxen) naproxen 275mg and 550mg NUPRIN (ibuprofen) oxaprozin PONSTEL (mefenamic acid) PROFENO (fenoprofen) RELAFEN DS (nabumetone) SPRIX NASAL SPRAY (ketorolac) TIVORBEX (indomethacin) tolmetin VOLTAREN XR (diclofenac) ZIPSOR (diclofenac) 78 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

NSAID/GI PROTECTANT COMBINATIONS ARTHROTEC (diclofenac/misoprostol) Non-Preferred Criteria diclofenac/misoprostol • Have tried 2 different preferred non- DUEXIS (ibuprofen/famotidine) selective or NSAID/GI protectant VIMOVO (naproxen/esomeprazole) combination agents in the past 6 months COX II SELECTIVE meloxicam CELEBREX (celecoxib) Non-Preferred Criteria – COX II celecoxib • Documented diagnosis of MOBIC (meloxicam) Osteoarthritis, Rheumatoid Arthritis, NULOX (meloxicam) Familial Adenomatous Polyposis, or Ankylosing Spondylitis AND QMIIZ ODT (meloxicam) • 90 consecutive days on the VIVLODEX (meloxicam) requested agent in the past 105 days OR • Have tried 1 preferred COX-II Selective and 1 preferred Non- Selective Agent OR • Have tried 1 preferred COX-II Selective agent and a documented diagnosis of GI Bleed, GERD, PUD, GI Perforation, or Coagulation Disorder

OPHTHALMIC ANTIBIOTICS bacitracin/neomycin/gramicidin AZASITE (azithromycin) bacitracin/polymyxin bacitracin ciprofloxacin BESIVANCE (besifloxacin)

79 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

80 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

OPHTHALMIC ANTI-INFLAMMATORIES SmartPA dexamethasone ACULAR (ketorolac) Non-Preferred Criteria diclofenac ACULAR LS (ketorolac) • Have tried 2 different preferred DUREZOL (difluprednate) ACUVAIL (ketorolac) agents in the past 6 months FLAREX (fluorometholone) BROMDAY (bromfenac)

fluorometholone bromfenac flurbiprofen BROMSITE (bromfenac) FML FORTE (fluorometholone) FML (fluorometholone) FML SOP (fluorometholone) ILEVRO (nepafenac) ketorolac INVELTYS (loteprednol etabonate) loteprednol etabonate LOTEMAX (loteprednol) MAXIDEX (dexamethasone) LOTEMAX SM (loteprednol) prednisolone acetate OCUFEN (flurbiprofen) prednisolone NA phosphate OMNIPRED (prednisolone) PRED MILD (prednisolone) NEVANAC (nepafenac) VEXOL (rimexolone) PRED FORTE (prednisolone) PROLENSA (bromfenac) VOLTAREN (diclofenac) OPHTHALMICS FOR ALLERGIC CONJUNCTIVITIS SmartPA ALREX (loteprednol) ALOCRIL (nedocromil) Non-Preferred Criteria azelastine ALOMIDE (lodoxamide) • Have tried 2 different preferred cromolyn BEPREVE (bepotastine) agents in the past 6 months olopatadine 0.1% epinastine olopatadine 0.2% LASTACAFT (alcaftadine) PATADAY (olopatadine) PATANOL (olopatadine) PAZEO (olopatadine) ZERVIATE (cetirizine) 81 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

Quantity Limit • 5.5 mL/31 days – Restasis Multidose • 60 units/31 days – Cequa, Restasis droperette, Xiidra

Non-Preferred Criteria • History of 4 claims for Restasis in the past 6 months

OPHTHALMIC, GLAUCOMA AGENTS SmartPA BETA BLOCKERS BETIMOL (timolol) BETAGAN (levobunolol) Non-Preferred Criteria carteolol betaxolol • Have tried 2 different preferred ISTALOL (timolol) BETOPTIC S (betaxolol) agents in the past 6 months OR levobunolol OPTIPRANOLOL (metipranolol) • 90 consecutive days on the requested agent in the past 105 metipranolol timolol gel days timolol drops 0.25%, 0.5% timolol daily drop 0.5% (generic Istalol) TIMOPTIC (timolol) TIMOPTIC XE (timolol) CARBONIC ANHYDRASE INHIBITORS

82 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

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

PARASYMPATHOMIMETICS pilocarpine CARBOPTIC (carbachol) ISOPTO CARBACHOL (carbachol) ISOPTO CARPINE (pilocarpine) PHOSPHOLINE IODIDE (echothiophate iodide) PILOPINE HS (pilocarpine)

PROSTAGLANDIN ANALOGS latanoprost bimatoprost LUMIGAN (bimatoprost) TRAVATAN Z (travoprost) travoprost XALATAN (latanoprost) XELPROS (lantanoprost) VYZULTA (latananoprostene bunod) ZIOPTAN (tafluprost)

RHO KINASE INHIBITORS/COMBINATIONS RHOPRESSA (netarsudil) ROCKLATAN (netarsudil/latanoprost) SYMPATHOMIMETICS

83 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

Probuphine – MANUAL PA Sublocade – MANUAL PA Vivitrol - MANUAL PA

TREATMENT naloxone injection EVZIO (naloxone)

NARCAN NASAL SPRAY (naloxone) 84 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

OTIC ANTIBIOTICS CIPRODEX (ciprofloxacin/dexamethasone) ciprofloxacin Maximum Age Limit CIPRO HC (ciprofloxacin/hydrocortisone) Age Edit ciprofloxacin/dexamethasone • 9 years - Cipro HC ofloxacin ciprofloxacin/fluocinolone CORTISPORIN-TC (colistin/neomycin/ hydrocortisone) DERMOTIC (fluocinolone) FLAC OIL DROP (fluocinolone oil) hydrocortisone/acetic acid drop fluocinolone oil neomycin/polymyxin/hydrocortisone OTIPRIO (ciprofloxacin) OTOVEL (ciprofloxacin/fluocinolone) PANCREATIC ENZYMES SmartPA CREON (pancreatin) PANCREAZE (pancrelipase) Non-Preferred Criteria ZENPEP (pancrelipase) PERTZYE (pancrelipase) • Have tried 2 different preferred VIOKACE (pancrelipase) agents in the past 6 months

PARATHYROID AGENTS calcitriol cinacalcet ergocalciferol doxercalciferol paricalcitol DRISDOL (ergocalciferol) ROCALTROL (calcitriol) HECTOROL (doxercalciferol) ZEMPLAR (paricalcitol) NATPARA (parathyroid hormone) RAYALDEE (calcifediol) SENSIPAR (cinacalcet)

PHOSPHATE BINDERS calcium acetate AURYXIA (ferric citrate)

85 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

PLATELET AGGREGATION INHIBITORS SmartPA BRILINTA (ticagrelor) DURLAZA ER (aspirin) Zontivity – MANUAL PA cilostazol EFFIENT (prasugrel) clopidogrel omeprazole/asprin Non-Preferred Criteria dipyridamole PERSANTINE (dipyridamole) • Documented diagnosis AND • Have tried 2 different preferred dipyridamole/aspirin PLAVIX (clopidogrel) agents in the past 6 months OR pentoxifylline PLETAL (cilostazol) • 90 consecutive days on the ticlopidine prasugrel requested agent in the past 105 YOSPRALA (aspirin/omeprazole) days

ZONTIVITY (vorapaxar)

PLATELET STIMULATING AGENTS PROMACTA (eltrombopag olamine) DOPTELET (avatrombopag maleate) MULPLETA (lusutrombopag) NPLATE (romiplostim) TAVALISSE (fostamatinib disodium)

PRENATAL VITAMINS COMPLETE NATAL DHA Products not listed here are assumed to be Non- CONCEPT DHA Capsule Preferred.

86 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

PSEUDOBULBAR AFFECT AGENTS NUEDEXTA (dextromethorphan/quinidine) Non-Preferred Criteria • 90 consecutive days on the requested agent in the past 105 days OR • Documented diagnosis of Pseudobulbar Affect PULMONARY ANTIHYPERTENSIVESSmartPA ENDOTHELIN RECEPTOR ANTAGONIST ambrisentan LETAIRIS (ambrisentan)* All PAH Agents bosentan tablets OPSUMIT (macitentan) • Documented diagnosis of TRACLEER (bosentan) pulmonary hypertension

Non-Preferred Criteria • Have tried 1 preferred PAH agent in the past 6 months OR • 90 consecutive days on the requested agent in the past 105 days

PDE5’s sildenafil (generic Revatio) tablet ADCIRCA (tadalafil) Non-Preferred Criteria tadalafil REVATIO (sildenafil) tablet • Have tried 1 preferred PAH agent in REVATIO (sildenafil) suspension the past 6 months OR

87 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

Revatio suspension • < 12 years of age AND • Documented diagnosis of Pulmonary Hypertension, Patent Ductus Arteriosus, or Persistent Fetal Circulation or history of heart transplant OR • 90 consecutive days on the requested agent in the past 105 days

Revatio tablets • < 1 year of age AND • Documented diagnosis of Pulmonary Hypertension, Patent Ductus Arteriosus, or Persistent Fetal Circulation OR • 90 consecutive days on the requested agent in the past 105 days OR • > 1 years of age AND • Have tried 1 preferred PAH agent in the past 6 months OR • 90 consecutive days on the requested agent in the past 105 days

PROSTACYCLINS ORENITRAM ER (treprostinil) Non-Preferred Criteria

88 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

SELECTIVE PROSTACYCLIN RECEPTOR AGONISTS UPTRAVI (selexipag) Non-Preferred Criteria • Have tried 1 preferred PAH agent in the past 6 months OR 90 consecutive days on the requested agent in the past 105 days

SOLUABLE GUANYLATE CYCLASE STIMULATORS ADEMPAS (riociguat) Adempas • Have tried 1 preferred PAH agent in the past 6 months OR • 90 consecutive days on the requested agent in the past 105 days OR • Clinical review required for PAH WHO Group 4

ROSACEA TREATMENTS metronidazole (cream, gel, lotion) AVAR (sulfacetamide sodium/sulfur) FINACEA (azelaic acid) Topical Sulfonamides used for METROCREAM (metronidazole cream) Rosacea will require a manual PA for METROGEL (metronidazole gel) >21 years. Other labeled indications METROLOTION (metronidazole lotion) are limited to <21 years. MIRVASO (brimonidine) 89 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

SEDATIVE HYPNOTICS BENZODIAZEPINES SmartPA estazolam DALMANE (flurazepam) Single source benzodiazepines and

flurazepam DAYVIGO (lemborexant) barbiturates are NOT covered – NO temazepam (15mg and 30mg) DORAL (quazepam) PA’s will be issued for these drugs. HALCION (triazolam)

quazepam MS DOM Opioid Initiative RESTORIL (temazepam) • Concomitant use of Opioids and temazepam (7.5mg and 22.5mg) Benzodiazepines triazolam Criteria details found here

Quantity Limit – CUMULATIVE Quantity limit per rolling days for all strengths. SmartPA will allow an early refill override for one dose or therapy change per year. • 31 units/31 days - all strengths

Triazolam – CUMULATIVE

90 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

Non-Preferred Criteria • Have tried 2 different preferred agents in the past 6 months

Hetlioz capsules • Documented diagnosis of circadian rhythm sleep disorder AND

91 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

Hetlioz liquid • Documented diagnosis of Smith- Magenis syndrome AND • 3 - 15 years of age

SELECT CONTRACEPTIVE PRODUCTS INJECTABLE CONTRACEPTIVES medroxyprogesterone acetate IM DEPO-PROVERA IM (medroxyprogesterone acetate) DEPO-SUBQ PROVERA 104 (medroxyprogesterone acetate)

INTRAVAGINAL CONTRACEPTIVES ANNOVERA (segesterone/ethinyl estradiol) etonogestrel/ethinyl estradiol NUVARING (etonogestrel/ethinyl estradiol) ORAL CONTRACEPTIVES SmartPA ALL CONTRACEPTIVES ARE PREFERRED AMETHIA (levonorgestrel/ethinyl estradiol) Non-Preferred Criteria EXCEPT FOR THOSE SPECIFICALLY AMETHYST (levonorgestrel/ethinyl estradiol) • 1 claim with the requested agent in INDICATED AS NON-PREFERRED AUROVELA 24FE (norethindrone/ethinyl the past 105 days estradiol/iron) BEYAZ (ethinyl estradiol / drospirenone/levomefolate) BLISOVI 24FE (norethindrone/ethinyl estradiol/iron) BRIELLYN (norethindrone/ethinyl estradiol) CAMRESE (levonorgestrel/ethinyl estradiol) 92 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

93 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

SKELETAL MUSCLE RELAXANTS SmartPA baclofen AMRIX (cyclobenzaprine ER) Non-Preferred Agents chlorzoxazone carisoprodol • Documented diagnosis for an cyclobenzaprine 5mg, 10mg carisoprodol compound approvable indication AND methocarbamol cyclobenzaprine 7.5mg, 15mg • Have tried 2 different preferred agents in the past 6 months tizanidine tablets cyclobenzaprine ER

DANTRIUM (dantrolene) Carisoprodol dantrolene • Documented diagnosis of acute FEXMID (cyclobenzaprine) musculoskeletal condition AND FLEXERIL (cyclobenzaprine) • NO history with meprobamate in LORZONE (chlorzoxazone) the past 90 days AND metaxalone • 1 claim for cyclobenzaprine in the NORGESIC FORTE (orphenedrine) past 21 days OR a documented orphenadrine intolerance to cyclobenzaprine orphenadrine compound AND orphenadrine ER • Quantity Limit PARAFON FORTE DSC (chlorzoxazone) o 18 tablets - to allow tapering ROBAXIN (methocarbamol) off SKELAXIN (metaxalone) o 84 tablets/6 months

SOMA (carisoprodol) Carisoprodol with codeine tizanidine capsules • Requires clinical review ZANAFLEX (tizanidine)

SMOKING DETERRENT NICOTINE TYPE

94 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

Quantity Limit • Chantix 0.5 mg, 1mg tablets and continuing pack – 336 tablets/year • Chantix Starter – 2 treatment courses/year STEROIDS (Topical) SmartPA LOW POTENCY CAPEX (fluocinolone) alclometasone Non-Preferred Criteria desonide DERMA-SMOOTHE-FS (fluocinolone) • Have tried 2 different preferred low hydrocortisone cr, oint, soln. DESONATE (desonide) potency agents in the past 6 DESOWEN (desonide) months fluocinolone oil hydrocortisone lotion PEDIACARE HC (hydrocortisone) PEDIADERM (hydrocortisone) VERDESO (desonide) MEDIUM POTENCY fluocinolone betamethasone valerate foam Non-Preferred Criteria hydrocortisone CLODERM (clocortolone) • Have tried 2 different preferred mometasone cr, oint. CUTIVATE (fluticasone) medium potency agents in the past 6 months 95 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

VERY HIGH POTENCY clobetasol lotion BRYHALI (halobetasol) Non-Preferred Criteria clobetasol shampoo, spray clobetasol emollient • Have tried 2 different preferred clobetasol propionate cream clobetasol propionate foam, ge very high potency agents in the clobetasol propionate ointment CLOBEX (clobetasol) past 6 months 96 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

STIMULANTS AND RELATED AGENTS SmartPA SHORT-ACTING amphetamine salt combination ADDERALL (amphetamine salt combination) Minimum Age Limit dexmethylphenidate IR Amphetamine sulfate (generic EVEKO) • 3 years - Adderall, Evekeo, dextroamphetamine IR DESOXYN (methamphetamine) Procentra, Zenzedi methylphenidate IR dextroamphetamine solution • 6 years – Desoxyn, Evekeo ODT, Focalin, Methylin methylphenidate solution EVEKEO (amphetamine)

EVEKEO ODT(amphetamine) PROCENTRA (dextroamphetamine) Maximum Age Limit FOCALIN (dexmethylphenidate) • 18 years – Evekeo ODT methamphetamine METHYLIN solution (methylphenidate) Quantity Limit methylphenidate chewable Applicable quantity limit per rolling RITALIN (methylphenidate) days ZENZEDI (dextroamphetamine) • 62 tablets/31 days – Adderall, Desoxyn, Evekeo, Focalin, Methylin, Zenzedi • 310 mL/31 days – Methylin solution, Procentra

97 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

Documented diagnosis of ADHD – ALL Short Acting AGENTS

Non-Preferred Criteria ADD/ADHD • Documented diagnosis of ADD/ADHD AND • Have tried 2 different preferred Short Acting agents in the past 6 months OR • 1 claim for a 30 day supply with the requested agent in the past 105 days

Documented diagnosis of narcolepsy – ADDERALL, EVEKEO, METHYLIN, PROCENTRA, RITALIN, ZENZEDI

LONG-ACTING amphetamine salt combination ER ADDERALL XR (amphetamine salt combination) Minimum Age Limit dexmethylphenidate ER ADHANSIA XR (methylphenidate) • 6 years – Adderall XR, Adhansia DYANAVEL XR (amphetamine) ADZENYS XR ODT (amphetamine) XR, Adzenys ER Suspension, methylphenidate CD (generic Metadate CD) ADZENYS ER SUSPENSION (amphetamine) Adzenys XR ODT, Aptensio XR, Azstarys,Concerta, Cotempla XR methylphenidate ER (generic Concerta) amphetamine susp 24 hr (generic ADZENYS ER) ODT, Daytrana, Dexedrine, methylphenidate ER Tabs (generic Ritalin SR) APTENSIO XR (methylphenidate) Dynavel XR Focalin XR, Jornay methylphenidate ER/LA Caps (generic Ritalin LA) CONCERTA (methylphenidate) PM, Metadate, CD, QUILLICHEW (methylphenidate) COTEMPLA XR-ODT (methylphenidate) methylphenidate ER 72mg, VYVANSE (lisdexamfetamine) DAYTRANA (methylphenidate) Quillichew, Quillivant XR, Ritalin VYVANSE CHEWABLE (lisdexamfetamine) DEXEDRINE (dextroamphetamine) LA, Vyvanse dextroamphetamine ER • 13 years – Mydayis

98 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

RELEXXI (methylphenidate) Quantity Limit RITALIN LA (methylphenidate) Applicable quantity limit per rolling RITALIN SR (methylphenidate) days • 31 tablets/31 days – Adderall XR, Adhansia XR, Adzenys XR ODT, Aptensio XR, Concerta 18, 27, & 54 mg, Cotempla XR-ODT 8.6 mg , Daytrana, Dexedrine Spansule, Focalin XR, Jornay PM, Metadate CD, Methylin ER, methylphenidate ER 72mg, Nuvigil 150, 200 & 250 mg, Provigil 200mg, Quillichew, Ritalin LA & SR, Vyvanse, Sunosi • 46.5 tablets/31 days – Provigil 100 mg • 62 tablets/31 days – Concerta 36mg, Cotempla XR-ODT 17.3 & 25.9 mg, Nuvigil 50mg • 248 mL/31 days – Dynavel XR • 372 mL/31 days – Quillivant XR

Documented diagnosis of ADHD – ALL Long Acting AGENTS

Documented diagnosis of binge eating disorder – VYVANSE

99 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

NARCOLEPSY armodafinil NUVIGIL (armodafinil) Documented diagnosis of modafinil PROVIGIL (modafinil) narcolepsy – ADDERALL XR, SUNOSI (solriamfetol) WAKIX (pitolisant) APTENSIO XR, CONCERTA ER, DEXEDRINE, METADATE CD, XYREM (sodium oxybate) XYWAV (calcium, magnesium, potassium and METHYLIN ER, MYDAYIS, NUVIGIL, sodium oxyblates)NR PROVIGIL,QUILLICHEW, QUILLIVANT XR, RITALIN LA, SUNOSI

Non-Preferred Criteria narcolepsy • Documented diagnosis of narcolepsy AND • 30 days of therapy with preferred modafinil or armodafinil in the past 6 months AND • 1 different preferred Long Acting agent indicated for narcolepsy in the past 6 months OR • 1 claim for a 30 day supply with the requested agent in the past 105 days

100 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

Provigil • Documented diagnosis of narcolepsy, obstructive sleep apnea, shift work sleep disorder, depression, sleep deprivation or Steinert Myotonic Dystrophy Syndrome

Sunosi • Documented diagnosis of narcolepsy or obstructive sleep apnea AND • 30 days of therapy with preferred modafinil or armodafinil in the past 6 months

Wakix • Documented diagnosis of narcolepsy with or without cataplexy AND • 30 days of therapy with preferred modafinil or armodafinil in the past 6 months OR • Documented diagnosis of narcolepsy without cataplexy or substance abuse disorder

Xyrem and Xywav

101 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

NON-STIMULANTS atomoxetine clonidine ER Minimum Age Limit guanfacine ER Step Edit INTUNIV (guanfacine ER) 6 years – Intuniv, Kapvay, Qelbree, NR Strattera QELBREE (viloxazine) 18 years – Wakix STRATTERA (atomoxetine) Maximum Age Limit

• 18 years – Intuniv, Kapvay, Qelbree • 21 years – diagnosis of ADD/ADHD is required for Strattera

Quantity Limit Applicable quantity limit per rolling days • 31 tablets/31 days – Intuniv, Qelbree 100 mg, Strattera • 62 tablets/31days – Qelbree 150 mg and 200 mg, Wakix • 124 tablets/31 days – Kapvay

Intuniv • Have tried the short acting guanfacine in the past 6 months OR • 1 claim for a 30 day supply with guanfacine ER in the past 105 days

Kapvay • Documented diagnosis of ADD or ADHD AND 102 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

Qelbree • Documented diagnosis of ADD or ADHD AND • 1 claim for a 30 day supply with atomoxetine in the past 105 days

TETRACYCLINES SmartPA doxycycline hyclate caps/tabs ACTICLATE (doxycyline) Non-Preferred Agents doxycycline monohydrate caps (50mg & 100mg) ADOXA (doxycycline monohydrate) • Have tried 2 different preferred minocycline caps IR demeclocycline agents in the past 6 months tetracycline doxycycline hyclate (generic Doryx) Demeclocycline doxycycline monohydrate caps (75mg & 150mg) • Documented diagnosis of Diabetes doxycycline monohydrate tabs Insipidus or SIADH will allow DORYX (doxycycline hyclate) automatic approval. DYNACIN (minocycline) MINOCIN (minocycline) MINOLIRA (minocycline) minocycline ER minocycline tabs MONODOX (doxycycline monohydrate) NUZYRA (omadacycline tosylate) OKEBO (doxycycline) ORACEA (doxycycline) SEYSARA (sarecycline) SOLODYN (minocycline) 103 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2021 UNIVERSAL PREFERRED DRUG LIST Version 2021.13a Updated: 8-30-2021 (For All Medicaid, MSCAN and CHIP Beneficiaries)

RECTAL mesalamine suppository CANASA (mesalamine) ROWASA (mesalamine) SF-ROWASA (mesalamine) UCERIS Foam (budesonide)

104 Drug coverage subject to the rules and regulations set forth in Sec. 1927 of Social Security Act.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. Drugs highlighted in yellow denote a change in PDL status. An * denotes existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. A # denotes existing users will NOT be grandfathered. To search the PDL, press CTRL + F