AIDS Related Treatments

MICHIGAN DRUG ASSISTANCE PROGRAM 1 Last Updated: 8/26/19 All Previous Versions Obsolete

HIV / AIDS Related Treatments HIV Treatment and Prevention Website: http://www.aidsinfo.nih.gov/ Antiretrovirals Nucleoside/Nucleotide Non-Nucleoside Reverse Transcriptase CCR-5 Inhibitor Reverse Transcriptase Inhibitors Maraviroc (SELZENTRY) Inhibitors Fusion Inhibitors Abacavir (ZIAGEN) Delavirdine (RESCRIPTOR) Enfuvirtide (FUZEON) Abacavir/lamivudine (EPZICOM) Efavirenz (SUSTIVA) Abacavir/lamivudine/zidovudine Nevirapine (VIRAMUNE, VIRAMUNE XR) Post-attachment Inhibitors (TRIZIVIR) * Ibalizumab (TROGARZO) PA Didanosine (VIDEX EC)* Etravirine (INTELENCE) Pharmacokinetic Enhancers Doravirine (PIFELTRO) Rilpivirine (EDURANT) Cobicistat (TYBOST) Emtricitabine (EMTRIVA) Protease Inhibitors & Combinations NNRTI/NRTI, INSTI/NRTI, INSTI/NNRTI Emtricitabine/Tenofovir Atazanavir (REYATAZ) Combinations (TRUVADA, DESCOVY) Darunavir (PREZISTA) Abacavir/dolutegravir/lamivudine (TRIUMEQ) Lamivudine (EPIVIR)* Fosamprenavir (LEXIVA) Bictegravir/emtricitabine/tenofovir (BIKTARVY) Lamivudine/zidovudine Indinavir (CRIXIVAN) Dolutegravir/rilpivirine (JULUCA) (COMBIVIR)* Lopinavir/ritonavir (KALETRA) Darunavir/cobicistat/tenofovir/emtricitabine Stavudine (ZERIT)* Nelfinavir (VIRACEPT)* (SYMTUZA) Tenofovir (VIREAD, VEMLIDY) Ritonavir (NORVIR) Doravirine/lamivudine/tenofovir DF (DELSTRIGO) Zidovudine (RETROVIR)* Saquinavir (INVIRASE) Efavirenz/emtricitabine/tenofovir (ATRIPLA) HIV Integrase Inhibitor Tipranavir (APTIVUS) Efavirenz/lamivudine/tenofovir (SYMFI, SIMFI LO) Raltegravir(ISENTRESS, HD) Darunavir/Cobicistat (PREZCOBIX) Elvitegravir/Cobicistat/Emtricitabine/ Tenofovir Dolutegravir (TIVICAY) Atazanavir/Cobicistat (EVOTAZ) (STRIBILD, GENVOYA) Emtricitabine/rilpivirine/tenofovir (COMPLERA) Lamivudine/tenofovir (CIMDUO) Rilpivirine, emtricitabine, tenofovir (ODEFSEY) Hepatitis C Direct Acting Antivirals Elbasvir/grazoprevir (ZEPATIER) PA Ledipasvir/sofosbuvir (HARVONI) PA Glecaprevir/pibrentasvir (MAVYRET) PA Sofosbuvir (EPCLUSA) PA Opportunistic Infections PCP infections Toxoplasmosis Fungal infections Co-trimoxazole, TMP/SMX Co-trimoxazole, TMP/SMX Amphotericin B* (BACTRIM/SEPTRA SS, DS)* (BACTRIM/SEPTRA SS, DS)* Clotrimazole (MYCELEX)* Dapsone Dapsone Ketoconazole (NIZORAL)* (not shampoo) Pentamidine (PENTAM)* Pyrimethamine (DARAPRIM) Terbinafine (LAMISIL)* Atovaquone (MEPRON) PA Leucovorin* Fluconazole (DIFLUCAN)* Primaquine* Azithromycin (ZITHROMAX)* Voriconazole (VFEND)* Trimethoprim* Clindamycin (CLEOCIN)* Itraconazole (SPORANOX)* Clindamycin (CLEOCIN)* Leucovorin* Nystatin* Mycobacterial infections Sulfadiazine Others Azithromycin (ZITHROMAX)* Atovaquone (MEPRON) PA Hepatitis B Vaccine Clarithromycin (BIAXIN)* Herpes infections Hepatitis A Vaccine Ethambutol (MYAMBUTOL)* Acyclovir (ZOVIRAX)* ST1 Pneumococcal Vaccine Rifabutin (MYCOBUTIN) Famciclovir (FAMVIR)* ST2 Influenza Vaccine Ciprofloxacin (CIPRO)* Valacyclovir (VALTREX)* ST2 Ribavirin (REBETOL, RIBASPHERE, Levofloxicin (LEVAQUIN)* CMV infections COPEGUS)* Cryptosporidiosis Cidofovir (VISTIDE) Interferon alfa-2b (INTRON-A) Paromomycin* Foscarnet* Peginterferon alfa-2a (PEGASYS) Atovaquone (MEPRON) PA Valganciclovir (VALCYTE)* Peginterferon alfa-2b (PEG-INTRON KIT) Azithromycin (ZITHROMAX)*

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

MICHIGAN DRUG ASSISTANCE PROGRAM 2 Last Updated: 8/26/19 All Previous Versions Obsolete Analgesics Delavirdine (RESCRIPTOR) Rimantadine (FLUMADINE)* Nonsteroidal Anti-inflammatory Agents Didanosine (VIDEX EC*, VIDEX soln) Valacyclovir (VALTREX)* ST2 Celecoxib (CELEBREX) Efavirenz (SUSTIVA) Valganciclovir (VALCYTE) Zanamivir (RELENZA) Diclofenac (VOLTAREN)* Efavirenz /emtricitabine/tenofovir (ATRIPLA) Diclofenac/misoprostol (ARTHROTEC) Efavirenz/lamivudine/tenofovir (SYMFI, Cephalosporins Nabumetone* SIMFI LO) Cephalexin (KEFLEX)* Ibuprofen 800mg (MOTRIN 800mg)* Elvitegravir/Cobicistat/Emtricitabine/ Ceftriaxone INJ (ROCEPHIN)* Tenofovir (STRIBILD, GENVOYA) Opiate Agonists Emtricitabine (EMTRIVA) Quinolones Codeine* Emtricitabine/tenofovir (TRUVADA, Ciprofloxacin (CIPRO)* Codeine/Acetaminophen (TYLENOL #3, DESCOVY) Levofloxicin (LEVAQUIN)* #4)* Emtricitabine/rilpivirine/tenofovir Fentanyl (DURAGESIC)* PA (COMPLERA) Macrolides Hydrocodone/Acetaminophen (VICODIN, Enfuvirtide (FUZEON) Azithromycin (ZITHROMAX)* VICODIN ES, LORTAB)* Etravirine (INTELENCE) Clarithromycin (BIAXIN*, BIAXIN XL Methadone* PA Fosamprenavir (LEXIVA) Erythromycin*

Morphine (ROXANOL, MS-CONTIN)* Ibalizumab(TROGARZO) Penicillins Morphine (ORAMORPH SR) Indinavir (CRIXIVAN) Amoxicillin (TRIMOX, AMOXIL)* Oxycodone (OXY-IR)* Lamivudine (EPIVIR)* Amoxicllin/clavulanic acid Oxycodone/Acetaminophen (PERCOCET)* Lamivudine/tenofovir (CIMDUO) Lamivudine/zidovudine (COMBIVIR)* (AUGMENTIN*, AUGMENTIN ES- Tramadol (ULTRAM)* 600, AUGMENTIN XR) Maraviroc (SELZENTRY) Tramadol/Acetaminophen (ULTRACET)* Penicillin* Oxycodone (OXYCONTIN) PA Nelfinavir (VIRACEPT) Penicillin inj (BICILLIN LA) Nevirapine (VIRAMUNE)* Anti-Infectives Raltegravir (ISENTRESS) Tetracyclines Antifungal Antibiotics Rilpiviring (EDURANT) Doxycycline* Amphotericin B (AMPHOCIN)* Rilpivirine, emtricitabine, tenofovir Clotrimazole (MYCELEX)* (ODEFSEY) Vaginal Antimicrobials Fluconazole (DIFLUCAN)* Ritonavir (NORVIR) Metronidazole (METROGEL)* vag Itraconazole (SPORANOX)* Saquinavir ( INVIRASE) Ketoconazole (NIZORAL)*(excluding Stavudine (ZERIT)* Ophthalmic Antimicrobials shampoo) Tenofovir (VIREAD, VEMLIDY)* Ciprofloxacin (CILOXAN)* Terbinafine (LAMISIL)* Tipranavir (APTIVUS) Erythromycin* Voriconazole (VFEND)* Zidovudine (RETROVIR)* Ofloxacin (OCUFLOX)*

Antiprotozoals, Miscellaneous Antituberculosis Agents Otic Antimicrobials Atovaquone (MEPRON) PA Ethambutol (MYAMBUTOL)* Ciprofloxacin/dexamethasone Paromomycin * Isoniazid* (CIPRODEX) Pentamidine (PENTAM)* Pyridoxine* (adjunct to Isoniazid only) Ciprofloxacin/hc (CIPRO HC) Pyrazinamide* Antiretroviral Agents and Boosters Rifabutin (MYCOBUTIN)* Topical Antimicrobials Abacavir (ZIAGEN) Rifampin (RIFADIN)* Acyclovir (ZOVIRAX) Abacavir/dolutegravir/lamivudine Clindamycin (CLEOCIN-T)* (TRIUMEQ) Other Antivirals Clotrimazole/betamethasone Abacavir/lamivudine (EPZICOM) Acyclovir (ZOVIRAX)* ST1 (LOTRISONE)* Abacavir/lamivudine/zidovudine Entecavir (BARACLUDE) Erythromycin* (TRIZIVIR) Cidofovir (VISTIDE) Metronidazole (METROCREAM*, Cobicistat (TYBOST) Famciclovir (FAMVIR)* ST2 METROGEL) Darunavir (PREZISTA) Foscarnet * Nystatin* Darunavir/Cobicistat (PREZCOBIX Oseltamivir (TAMIFLU) Darunavir/cobicistat/tenofovir/ Ribavirin (REBETROL, RIBASPHERE, emtricitabine (SYMTUZA) COPEGUS)

MICHIGAN DRUG ASSISTANCE PROGRAM 3 Last Updated: 8/26/19 All Previous Versions Obsolete Other Antimicrobials Central Agonists Olanzapine (ZYPREXA)* Co-trimoxazole, TMP/SMX Clonidine (CATAPRES)* Risperidone (RISPERDAL) (BACTRIM / SEPTRA SS, DS)* Minoxidil* Quetiapine (SEROQUEL) # * Clindamycin (CLEOCIN)* # low doses only covered for tapering Dapsone Lipid Lowering Agents Quetiapine XR (SEROQUEL XR)* Metronidazole (FLAGYL)* Atorvastatin (LIPITOR)* Primaquine Cholestyramine (QUESTRAN)* Benzodiazepines Pyrimethamine (DARAPRIM) Fenofibrate* (LOFIBRA) Alprazolam (XANAX)* Sulfadiazine Niacin (NIASPAN) Trimethoprim* Clonazepam (KLONOPIN)* Pravastatin (PRAVACHOL)* Diazepam (VALIUM)* Interferons Rosuvastatin (CRESTOR) Lorazepam (ATIVAN)* Ezetimibe (ZETIA) PA Interferon alfa-2b (INTRON-A) Temazepam (RESTORIL)*

Peginterferon alfa-2a (PEGASYS) Nitrates and Nitrites Mood Stabilizers Peginterferon alfa-2b (PEG-INTRON Nitroglycerin sublingual tab, spray, cap* Lithium carbonate KIT) Lithium carbonate ER

Diuretics Cardiovasculars Furosemide (LASIX)* Selective Serotonin Agonists Angiotensin II Receptor Antagonists Hydrochlorothiazide * Sumatriptan (IMITREX)* Losartan (COZAAR)* ST1 Hctz/triamterene (DYAZIDE, Losartan/hctz (HYZAAR)* ST1 MAXZIDE) * Skeletal Muscle Relaxants Valsartan/hctz (DIOVAN HCT) Baclofen* ST2 Cyclobenzaprine (FLEXERIL)* CNS Tizanidine (ZANAFLEX)* Anticonvulsants

Angiotensin-Converting Enzyme Divalproex sodium (DEPAKOTE, Inhibitors DEPAKOTE ER)* Smoking Cessation Bupropion (ZYBAN) Benazepril (LOTENSIN)* Gabapentin (NEURONTIN)* Nicotine patch ( NICODERM CQ)* Enalapril (VASOTEC)* Levetiracetam (KEPPRA)* Enalapril/hctz (VASERETIC)* Nicotine lozenge Phenytoin (DILANTIN)* Nicotine nasal spray (NICOTROL NS) Lisinopril (PRINIVIL, ZESTRIL)* Nicotine inhaler (NICOTROL INH) Lisinopril/hctz (PRINZIDE, Antidepressants Nicotine gum (NICORETTE)* ZESTORETIC)* Amitriptyline ST1* Varenicline (CHANTIX) Quinapril (ACCUPRIL)* Bupropion ST1 (WELLBUTRIN SR)* Ramipril (ALTACE)* Citalopram ST1 (CELEXA)* Substance Abuse Agents Doxepin ST1* Acamprosate (CAMPRAL) Beta-Adrenergic Blocking Agents Duloxetine (CYMBALTA)* Buprenorphine (SUBUTEX)* Atenolol (TENORMIN)* Escitalopram (LEXAPRO)* Buprenorphine/naloxone (SUBOXONE) Naloxone injectable / Carpuject Syringe Atenolol/chlorthalidone (TENORETIC)* Fluoxetine ST1 (PROZAC)* Timolol* Naloxone nasal spray (NARCAN) Mirtazapine ST1 (REMERON)* Metoprolol (LOPRESSOR*, TOPROL XL) Paroxetine ST1 (PAXIL) * Endocrine Sertraline ST1 (ZOLOFT)* Propranolol (INDERAL LA)* Antidiabetic: Combinations Trazodone Glyburide/metformin (GLUCOVANCE)* Venlafaxine (EFFEXOR)* Calcium-Channel Blocking Agents Amlodipine (NORVASC)* Anxiolytics, Sedatives and Hypnotics Antidiabetic: Bigunanides Diltiazem (CARDIZEM, TAZTIA XT) * Metformin (GLUCOPHAGE, Buspirone (BUSPAR)* Felodipine (PLENDIL) * GLUCOPHAGE XL)* Zolpidem (AMBIEN*, AMBIEN CR) Nifedipine XL, ER (PROCARDIA,

ADALAT) * Antidiabetic: Sulfonylureas Verapamil (COVERA HS) Antipsychotics Glipizide (GLUCOTROL, XL) * Verapamil (VERELAN, ISOPTIN SR, Aripiprazole (ABILIFY)* Glyburide (DIABETA,) * CALAN, CALAN SR)* Haloperidol (oral)*

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

MICHIGAN DRUG ASSISTANCE PROGRAM 4 Last Updated: 8/26/19 All Previous Versions Obsolete Antidiabetic: Thiazolidinediones Digestants Inhaled Corticosteroids Pioglitazone (ACTOS) PA Pancrelipase (LIPRAM-UL20, Beclomethasone (QVAR RediHaler) ULTRASE, PANGESTYME, Flunisolide (AEROSPAN) Antidiabetic: DPP-4 Inhibitors VIOKASE) Sitagliptin (JANUVIA) PA Combination Inhalers Proton-Pump Inhibitors Fluticasone/salmeterol (AIRDUO)* Antidiabetic: GLP-1 Lansoprazole (PREVACID OTC) Liraglutide (VICTOZA) PA Omeprazole (PRILOSEC, PRILOSEC Leukotrene Modifier OTC)* Montelukast (SINGULAIR)* Antidiabetic: Insulins BASAGLAR Histamine H2-Antagonists Nasal Corticosteroids NOVOLOG (all formulations) Famotidine (PEPCID)* Beclomethasone (BECONASE AQ)

NOVOLIN (all formulations) Ranitidine (ZANTAC)* NOVOLOG MIX FLEXPEN Urologicals LANTUS, LANTUS SOLOSTAR Anticholinergics/Motility Oxybutynin (DITROPAN, DITROPAN XL)* HUMULIN (all formulations) Dicyclomine (BENTYL)* Tamsulosin (FLOMAX)* HUMALOG (all formulations) Metoclopramide (REGLAN)* Terazosin* HUMALOG MIX Miscellaneous GI Lactulose* Topical Agents Bone Metabolism Megestrol (MEGACE) Topical Anti-inflammatory Agents Alendronate (FOSAMAX)* Desonide (DESOWEN)* Mesalamine, 5-ASA (ROWASA*, Hydrocortisone 2.5% cream* Estrogen and Estrogen Modifier ASACOL) Conjugated estrogens tablet, vaginal Triamcinolone cream, oint, lot* cream (PREMARIN) Blood Modifiers, Miscellaneous Dermatological Agent Imiquimod (ALDARA)* Nutritionals, Electrolytes Thyroid Agents Podofilox (CONDYLOX)* Anticoagulants/Antiplatelets Levothyroxine (LEVOXYL, Cilostazol (PLETAL)* SYNTHROID) * Ophthalmic Agents Clopidogrel (PLAVIX)* Timolol (TIMOPTIC, TIMOPTIC - Androgens Warfarin (COUMADIN)* XE)* Oxandrolone (OXANDRIN)* Testostosterone injection(DEPO- Hematopoietic Agents Other TESTOSTERONE, DELATESTRYL) Epoetin alfa (EPOGEN, PROCRIT) PA Vaccines Testostosterone topical Filgrastim, G-CSF (NEUPOGEN) PA Hepatitis B Vaccine (ANDRODERM,ANDROGEL, Hepatitis A Vaccine TESTIM) PA Phosphate Binders Pneumococcal Vaccine Sevelamer (RENVELA) Influenza / H1N1 Vaccine Corticosteroids Potassium replacement Gardasil 9 Prednisone* Potassium chloride* Other

Respiratory Aldesleukin (PROLEUKIN) * Gastrointestinal Antihistamines Epinephrine (EPIPEN) Antiemetics Cetirizine (ZYRTEC) OTC only Hydroxyurea (HYDREA)* Dronabinol (MARINOL)*QL: max 20mg/day Cetirizine/p-ephedrine (ZYRTEC-D) OTC Leucovorin* Prochlorperazine (COMPAZINE)* Diphenhydramine (BENADRYL)* Hydroxyurea ( DROXIA)* Promethazine (PHENERGAN)* Fexofenadine (ALLEGRA)* Trimethobenzamide (TIGAN)* Loratadine ( CLARITIN) OTC only Dental Products and Diabetes Supplies PREVIDENT-5000

Insulin syringe Antidiarrheal Agents Short Acting Bronchodilators Albuterol (PROVENTIL HFA)* Lancets Diphenoxylate/atropine ( LOMOTIL)* Inhaled Anticholinergics TruTrack Blood Glucose Monitor Loperamide (IMODIUM A-D)* Ipratropium (ATROVENT)* TruTrack Teststrip Opium tincture Tiotropium (SPIRIVA) 1) BRAND NAMEs indicated by CAPITAL, generic names indicated by lower case, * indicates the generic equivalent is available. 2) MANDATORY GENERIC PROGRAM - MIDAP excludes coverage of brand-name drugs with FDA approved generic equivalents. 3) PA = Prior Authorization required. 4) QL= Quantity Limit. 5) Step Therapy: ST1 = the prerequisite drug for ST2 drug(s) in same category; ST2 drugs require a trial of ST1 drug in same category.

MICHIGAN DRUG ASSISTANCE PROGRAM 5 Last Updated: 8/26/19 All Previous Versions Obsolete

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

MICHIGAN DRUG ASSISTANCE PROGRAM 6 Last Updated: 8/26/19 All Previous Versions Obsolete Dronabinol, 4 Foscarnet, 1, 2 Itraconazole, 1, 2 Duloxetine, 3 FOSCARVIR, 1, 2 DROXIA, 4 Furosemide, 3 DURAGESIC, 2 FUZEON, 1, 2 DYAZIDE, 3 J G JANUVIA, 4 E JULUCA, 1,2 G-CSF, 4 Edurant, 1,2 Gabapentin, 3 Efavirenz, 1, 2 Gardasil 9, 4 Efavirenz/emtricitabine/tenofovir, 1,2 Gemfibrozil, 3 K Efavirenz/lamivudine/tenofovir, 1,2 GENVOYA 1,2 KALETRA, 1, 2 EFFEXOR, 3 Glecaprevir/pibrentasvir, 1 KEFLEX, 2 EFFEXOR XR, 3 Glipizide, 3 KEPPRA, 3 ELAVIL, 3 GLUCOPHAGE, 3 Ketoconazole, 1, 2 Elbasvir/grazoprevir, 1 GLUCOPHAGE XL, 3 KLONOPIN, 3 Elvitegravir/Cobicistat/Emtricitabine/ GLUCOTROL, 3 Tenofovir, 1,2 GLUCOTROL, XL, 3 Emtricitabine, 1, 2 GLUCOVANCE, 3 L Emtricitabine/tenofovir, 1, 2 Glyburide, 3 Glyburide/metformin, 3 Lactulose, 4 Emtricitabine/rilpivirine/tenofovir, 1,2 LAMISIL, 1, 2 EMTRIVA, 1, 2 LAMISIL AT, 2 Enalapril, 3 H Lamivudine, 1, 2 Enalapril/hctz, 3 Lamivudine/tenofovir, 1,2 Enfuvirtide, 1, 2 HALDOL, 3 Lamivudine/zidovudine, 1, 2 Entecavir 2 Haloperidol, 3 Lancets, 4 EPCLUSA, 1 HARVONI, 1 Lansoprazole OTC, 4 Epinephrine, 4 Hctz/triamterene, 3 LANTUS, 4 EPIPEN, 4 Hepatitis A Vaccine, 1, 4 LANTUS SOLOSTAR, 4 EPIVIR, 1, 2 Hepatitis B Vaccine, 1, 4 Ledipasvir/sofosbuvir, 1 Epoetin alfa, 4 HUMALOG, 4 Leucovorin, 1, 4 EPOGEN, 4 HUMATIN, 1, 2 LEVAQUIN, 1, 2 EPZICOM, 1, 2 HUMULIN, 4 Levetiracetam, 3 Erythromycin, 2 HYDREA, 4 Levofloxicin, 1, 2 Escitalopram, 3 Hydrochlorothiazide, 3 Levothyroxine, 4 Ethambutol, 1, 2 Hydrocodone/Acetaminophen , 2 LEVOXYL, 4 EVOTAZ, 1,2 Hydrocortisone 2.5% cream, 4 LEXAPRO, 3 Ezetimibe, 3 Hydromorphone, 2 LEXIVA, 1, 2 Hydroxyurea, 4 LIORESAL, 3 F HYTRIN, 4 Liraglutide, 4 HYZAAR, 3 LIPITOR, 3 Famciclovir, 1, 2 LIPRAM-UL20, 4 Famotidine, 4 I Lisinopril, 3 FAMVIR, 1, 2 Lisinopril/hctz, 3 Felodipine, 3 Ibalizumab, 1,2 Lithium carbonate, 3 Fenofibrate, 3 Ibuprofen, 2 Lithium carbonate ER, 3 Fentanyl, 2 ISENTRESS 1,2 LOFIBRA, 3 Fexofenadine, 4 Imiquimod, 4 LOMOTIL, 4 Filgrastim, 4 IMITREX, 3 LONITEN, 3 FLAGYL, 3 IMODIUM, 4 LONOX, 4 FLEXERIL, 3 INDERAL, 3 Loperamide, 4 FLOMAX, 4 INDERAL LA, 3 Lopinavir/ritonavir, 1, 2 Fluconazole, 1, 2 Indinavir, 1, 2 LOPRESSOR, 3 FLUMADINE, 2 Influenza Vaccine, 1, 4 Loratadine, 4 Flunisolide, 4 Insulin glargine, 4 Loratadine/pseudoephedrine, 4 Fluoxetine, 3 Insulin syringe, 4 Lorazepam, 3 Fluticasone / Salmeterol, 4 Interferon alfa-2b, 1, 3 LORTAB, 2 Folinic acid, 1, 4 INTRON-A, 1, 3 Losartan, 3 Fomivirsen, 1, 2 INVIRASE, 1, 2 Losartan/hctz, 3 FOSAMAX, 4 Ipratropium, 4 LOTENSIN, 3 Fosamprenavir, 1, 2 Isoniazid, 2 LOTRISONE, 2 1) BRAND NAMEs indicated by CAPITAL, generic names indicated by lower case, * indicates the generic equivalent is available. 2) MANDATORY GENERIC PROGRAM - MIDAP excludes coverage of brand-name drugs with FDA approved generic equivalents. 3) PA = Prior Authorization required. 4) QL= Quantity Limit. 5) Step Therapy: ST1 = the prerequisite drug for ST2 drug(s) in same category; ST2 drugs require a trial of ST1 drug in same category.

MICHIGAN DRUG ASSISTANCE PROGRAM 7 Last Updated: 8/26/19 All Previous Versions Obsolete M O Propoxyphene/Acetaminophen , 2 Propranolol, 3 Maraviroc 1,2 OCUFLOX, 2 PROVENTIL, 4 MARINOL, 4 ODEFSEY, 1,2 PROZAC, 3 MAVYRET, 1 Ofloxacin OPTH, 2 Pyrimethamine, 1, 3 MAXZIDE, 3 Olanzapine, 3 Pyrazinamide, 2 MEGACE, 4 Omeprazole, 4 Pyridoxine, 2 Megestrol, 4 Opium tincture, 4 MEPRON, 1, 2 ORAMORPH SR, 2 Mesalamine, 4 Oxybutynin, 4 Metformin, 3 Oxycodone, 2 Q Methadone, 2 Oxycodone/Acetaminophen , 2 QUESTRAN, 3 Methyltestosterone, 4 OXYCONTIN, 2 Quetiapine, 3 Metoclopramide, 4 OXY-IR, 2 Quetiapine XR, 3 Metoprolol, 3 Quinapril, 3 METROCREAM, 2 QVAR RediHaler, 4 METROGEL, 2 P Metronidazole, 2, 3 PANCREASE, 4 MICRONASE, 3 Pancrelipase, 4 R Minoxidil, 3 PANGESTYME, 4 Raltegravir 1, 2 Mirtazapine, 3 Paromomycin, 1, 2 Ramipril, 3 Montelukast, 4 Paroxetine, 3 Ranitidine, 4 Morphine, 2 PAXIL, 3 REBETOL, 1, 2 MOTRIN, 2 PEGASYS, 1, 3 REGLAN, 4 MS-CONTIN, 2 Peginterferon alfa-2a, 1, 3 RELAFEN, 2 MYAMBUTOL, 1, 2 Peginterferon alfa-2b, 1, 3 REMERON, 3 MYCELEX, 1, 2 PEG-INTRON KIT, 1, 3 RENVELA, 4 MYCOBUTIN, 1, 2 Penicillin, 2 RESCRIPTOR, 1, 2 PENTAM, 1, 2 RESTORIL, 3 N Pentamidine, 1, 2 RETROVIR, 1, 2 PEN-VK, 2 REYATAZ, 1, 2 Nabumetone, 2 PEPCID, 4 RIBASPHERE, 1, 2 Naloxone, 3 PERCOCET, 2 Ribavirin, 1, 2 NARCAN, 3 PHENERGAN, 4 Rifabutin, 1, 2 Nelfinavir, 1, 2 Phenytoin, 3 Rifampin, 2 NEUPOGEN, 4 PIFELTRO 1,2 RIFADIN, 2 NEURONTIN, 3 Pioglitazone, 3 Rilpivirine 1,2 Nevirapine, 1, 2 PLAVIX, 4 Rilpivirine, emtricitabine, tenofovir, 1,2 Niacin, 3 PLENDIL, 3 Rimantadine, 2 NIASPAN, 3 PLETAL, 4 RISPERDAL, 3 NICODERM, 3 Pneumococcal Vaccine, 1, 4 Risperidone, 3 NICORETTE, 3 Podofilox, 4 Ritonavir, 1, 2 Nicotine gum, 3 Potassium chloride, 4 ROCEPHIN INJ, 2 Nicotine lozenge, 3 PRAVACHOL, 3 Rosuvastatin, 3 Nicotine nasal spray, 3 Pravastatin, 3 ROWASA, 4 Nicotine patch, 3 Prednisone, 4 ROXANOL, 2 NICOTROL, 3 PREMARIN, 4 NICOTROL INH, 3 PREZCOBIX, 1,2 NICOTROL NS, 3 PREVACID OTC, 4 S Nifedipine ER, 3 PREVIDENT, 4 Saquinavir, 1, 2 Nifedipine XL, 3 PREZISTA, 1, 2 SELZENTRY 1,2 Nitroglycerin sublingual tab, spray, cap, 3 PRILOSEC, 4 SEMPREX-D, 4 NIZORAL, 1, 2 Primaquine, 1, 3 SEPTRA DS, 1,3 NORVASC, 3 PRINIVIL, 3 SEPTRA SS, 1,3 NORVIR, 1, 2 PRINZIDE, 3 SEROQUEL, 3 NOVOLIN, 3 PROCARDIA, 3 SEROQUEL XR, 3 NOVOLIN 70/30, 4 Prochlorperazine, 4 Sertraline, 3 NOVOLOG, 3 PROCRIT, 4 Sevelarmer, 4 NOVOLOG MIX FLEXPEN, 4 PROLEUKIN, 4 Silvadene, 3 Nystatin, 1, 2 Promethazine, 4 SYMFI, 1,2 Propoxyphene, 2 SIMFI LO, 1,2 1) BRAND NAMEs indicated by CAPITAL, generic names indicated by lower case, * indicates the generic equivalent is available. 2) MANDATORY GENERIC PROGRAM - MIDAP excludes coverage of brand-name drugs with FDA approved generic equivalents. 3) PA = Prior Authorization required. 4) QL= Quantity Limit. 5) Step Therapy: ST1 = the prerequisite drug for ST2 drug(s) in same category; ST2 drugs require a trial of ST1 drug in same category.

MICHIGAN DRUG ASSISTANCE PROGRAM 8 Last Updated: 8/26/19 All Previous Versions Obsolete SINGULAIR, 4 Trazodone, 3 VIRACEPT, 1, 2 Sitagliptin, 4 Triamcinolone cream, oint, lot, 4 VIRAMUNE, 1, 2 Sodium fluoride, 4 TRICOR, 3 VIRAMUNE XR, 1,2 Sofosbuvir, 1 TRIUMEQ 1,2 VIREAD, 1, 2 SPIRIVA, 4 Trimethobenzamide, 4 VISTIDE, 1, 2 SPORANOX, 1, 2 Trimethoprim, 1, 3 VITRAVENE, 1, 2 SSD, 2 TRIMOX, 2 VOLTAREN, 2 Stavudine, 1, 2 TRIZIVIR, 1, 2 Voriconazole, 1, 2 STRIBILD 1,2 TROGARZO, 1,2 SUBOXONE, 3 TRUVADA, 1, 2 SUBUTEX, 3 TYBOST 1,2 W Sulfadiazine, 1, 3 TYLENOL #3, 2 Warfarin, 4 SUSTIVA, 1, 2 TYLENOL #4, 2 WELLBUTRIN SR, 3 SYMTUZA, 1,2 SYNTHROID, 4 U X T ULTRACET, 2 ULTRAM, 2 XANAX, 3 Tamsulosin, 4 ULTRASE, 4 TAZTIA XT, 3 Z Temazepam, 3 V Tenofovir, 1, 2 ZANAFLEX, 3 TENORETIC, 3 Valacyclovir, 1, 2 ZANTAC, 4 TENORMIN, 3 VALCYTE, 1, 2 ZEPATIER, 1 Terazosin, 4 Valganciclovir, 1, 2 ZERIT, 1, 2 Terbinafine, 1, 2 VALIUM, 3 ZESTORETIC, 3 Testostosterone injection, 4 Valsartan/hctz, 3 ZESTRIL, 3 Testostosterone oral, 4 VALTREX, 1, 2 ZETIA, 3 Testostosterone topical, 4 Varenicline, 3 ZIAGEN, 1, 2 TESTRED, 4 VASORETIC, 3 Zidovudine, 1, 2 Teststrip, 4 VASOTEC, 3 ZITHROMAX, 1, 2 THORAZINE, 3 VEMLIDY, 1,2 ZOLOFT, 3 TIGAN, 4 Venlafaxine, 3 Zolpidem, 3 Timolol, 3, 4 Verapamil, 3 ZOVIRAX, 1, 2 TIMOPTIC XE, 4 VERELAN, 3 ZYBAN, 3 Tiotropium, 4 VFEND, 1, 2 ZYPREXA, 3 Tipranavir, 1, 2 VICODIN, 2 ZYRTEC, 4 Tivicay, 1,2 VICODIN ES, 2 ZYRTEC-D, 4 Tizanidine, 3 VICTOZA, 4 TMP/SMZ ,1,3 VIDEX, 1, 2 5-ASA, 4 TOPROL XL, 3 VIDEX EC, 1, 2 Tramadol, 2 VIOKASE, 4 Tramadol/Acetaminophen , 2