MISSISSIPPI DIVISION OF MEDICAID PREFERRED DRUG LIST Effective July 1, 2009 (Changes to previous PDL highlighted) BODY SYSTEM THERAPEUTIC CLASS PREFERRED AGENTS NON-PREFERRED AGENTS NOTES ANALGESICS ANALGESICS, DURAGESIC (fentanyl) AVINZA (morphine) Avinza will be NARCOTIC-LONG- fentanyl patches oxycodone ER authorized for ACTING patients on stable KADIAN (morphine) OPANA ER (oxymorphone) treatment. methadone OXYCONTIN (oxycodone) NR morphine ER RYZOLT (tramadol) ULTRAM ER (tramadol) ANALGESICS, acetaminophen/codeine DARVON-N (propoxyphene) All products
NARCOTIC- aspirin/codeine DILAUDID liquid (hydromorphone) containing SHORT-ACTING oxycodone short- butalbital/APAP/caffeine/codeine fentanyl transmucosal acting oral butalbital/ASA/caffeine/codeine FENTORA (fentanyl) tablets/capsules codeine levorphanol are limited to 62
dihydrocodeine/ APAP/caffeine MAGNACET (oxycodone/APAP) total cumulative NR hydrocodone/APAP NUCYNTA (tapentadol) units of all/any strengths per hydrocodone/ibuprofen OPANA (oxymorphone) month. Oxycodone hydromorphone REPREXAIN oral liquid is meperidine (hydrocodone/ibuprofen) limited to 180 total
morphine SYNALGOS-DC cumulative
oxycodone (dihydrocodeine/APAP/caffeine) milliliters of all/any strengths per oxycodone/APAP VOPAC (codeine/APAP) month. Any oxycodone/aspirin XODOL (hydrocodone/APAP) quantity required oxycodone/ibuprofen ZYDONE (hydrocodone/APAP) above these limits dihydrocodeine/APAP/caffeine needs a PA.
pentazocine/APAP pentazocine/naloxone propoxyphene propoxyphene/APAP tramadol tramadol/APAP
ANTIMIGRAINE, ORAL TRIPTANS IMITREX (sumatriptan) AMERGE (naratriptan)
RELPAX (eletriptan) AXERT (almotriptan) sumatriptan FROVA (frovatriptan)
TREXIMET (sumatriptan/naproxen) MAXALT (rizatriptan) ZOMIG (zolmitriptan)
Unless otherwise stated, the listing of a particular brand or generic name includes all dosage forms of that drug. Note that the highlighted non-preferred brand name drugs with NR 1 superscript following the name indicates a new brand name drug that has not been reviewed. See separate Antihistamine/Decongestant Product and Active Ingredient Cross- Reference List for complete list of product names and active ingredients.
MISSISSIPPI DIVISION OF MEDICAID PREFERRED DRUG LIST Effective July 1, 2009 (Changes to previous PDL highlighted) BODY SYSTEM THERAPEUTIC CLASS PREFERRED AGENTS NON-PREFERRED AGENTS NOTES ANALGESICS ANTIMIGRAINE, NAS AL (CONTINUED) TRIPTANS IMITREX (sumatriptan) ZOMIG (zolmitriptan) (CONTINUED) sumatriptan INJECTABLE IMITREX (sumatriptan) sumatriptan NSAIDS NONSELECTIVE Ibuprofen RX is diclofenac meclofenamate covered; only ibuprofen etodolac mefenamic acid ZIPSOR (diclofenac)NR suspension OTC fenoprofen is covered. flurbiprofen ibuprofen indomethacin ketoprofen ketorolac nabumetone naproxen RX oxaprozin piroxicam sulindac tolmetin NSAID/GI PROTECTANT COMBINATIONS ARTHROTEC (diclofenac/misoprostol) PREVACID NAPRAPAC (naproxen/lansoprazole) COX-II SELECTIVE meloxicam CELEBREX (celecoxib) SKELETAL MUSCLE baclofen AMRIX (cyclobenzaprine ER) RELAXANTS cyclobenzaprine carisoprodol dantrolene carisoprodol compound tizanidine FEXMID (cyclobenzaprine) SKELAXIN (metaxolone) SOMA (carisoprodol) ZANAFLEX (tizanidine)
Unless otherwise stated, the listing of a particular brand or generic name includes all dosage forms of that drug. Note that the highlighted non-preferred brand name drugs with NR 2 superscript following the name indicates a new brand name drug that has not been reviewed. See separate Antihistamine/Decongestant Product and Active Ingredient Cross- Reference List for complete list of product names and active ingredients.
MISSISSIPPI DIVISION OF MEDICAID PREFERRED DRUG LIST Effective July 1, 2009 (Changes to previous PDL highlighted) BODY SYSTEM THERAPEUTIC CLASS PREFERRED AGENTS NON-PREFERRED AGENTS NOTES CARDIOVASCULAR ANGIOTENSIN ACE INHIBITORS MODULATORS ACEON (perindopril)
benazepril
captopril
enalapril fosinopril lisinopril
moexepril
quinapril
ramipril trandolapril
ACE INHIBITOR/DIURETIC COMBINATIONS benazepril/HCTZ captopril/HCTZ enalapril/HCTZ
fosinopril/HCTZ
lisinopril/HCTZ moexepril/HCTZ quinapril/HCTZ ANGIOTENSIN II RECEPTOR BLOCKERS
AVAPRO (irbesartan) ATACAND (candesartan) BENICAR (olmesartan) TEVETEN (eprosartan) COZAAR (losartan) DIOVAN (valsartan) MICARDIS (telmisartan) ARB/DIURETIC COMBINATIONS
AVALIDE (irbesartan/HCTZ) ATACAND-HCT BENICAR-HCT (olmesartan/HCTZ) (candesartan/HCTZ) DIOVAN-HCT (valsartan/HCTZ) TEVETEN-HCT (eprosartan/HCTZ) HYZAAR (losartan/HCTZ)
MICARDIS-HCT (telmisartan/HCTZ)
DIRECT RENIN INHIBITOR TEKTURNA (aliskerin) DIRECT RENIN INHIBITOR/DIURETIC COMBINATIONS
TEKTURNA-HCT
(aliskerin/HCTZ)
Unless otherwise stated, the listing of a particular brand or generic name includes all dosage forms of that drug. Note that the highlighted non-preferred brand name drugs with NR 3 superscript following the name indicates a new brand name drug that has not been reviewed. See separate Antihistamine/Decongestant Product and Active Ingredient Cross- Reference List for complete list of product names and active ingredients.
MISSISSIPPI DIVISION OF MEDICAID PREFERRED DRUG LIST Effective July 1, 2009 (Changes to previous PDL highlighted) BODY SYSTEM THERAPEUTIC CLASS PREFERRED AGENTS NON-PREFERRED AGENTS NOTES CARDIOVASCULAR ANGIOTENSIN ACE INHIBITOR/CCB COMBINATIONS (CONTINUED) MODULATORS/CCB benazepril/amlodipine COMBINATIONS TARKA (trandolapril/verapamil)
ARB/CCB COMBINATIONS AZOR (olmesartan/amlodipine) EXFORGE (valsartan/amlodipine)
ANTICOAGULANTS, ARIXTRA (fondaparinux) INNOHEP (tinzaparin) INJECTABLE FRAGMIN (dalteparin) LOVENOX (enoxaparin)
BETA-BLOCKERS BETA BLOCKERS acebutolol LEVATOL (penbutolol)
bisoprolol BYSTOLIC (nebivolol) INNOPRAN XL (propranolol)
metoprolol metopolol XL
BETA- AND ALPHA- BLOCKERS
carvedilol COREG CR (carvedilol) labetalol
Unless otherwise stated, the listing of a particular brand or generic name includes all dosage forms of that drug. Note that the highlighted non-preferred brand name drugs with NR 4 superscript following the name indicates a new brand name drug that has not been reviewed. See separate Antihistamine/Decongestant Product and Active Ingredient Cross- Reference List for complete list of product names and active ingredients.
MISSISSIPPI DIVISION OF MEDICAID PREFERRED DRUG LIST Effective July 1, 2009 (Changes to previous PDL highlighted) BODY SYSTEM THERAPEUTIC CLASS PREFERRED AGENTS NON-PREFERRED AGENTS NOTES CARDIOVASCULAR BETA-BLOCKERS BETA BLOCKER / DIURETIC COMBINATIONS (CONTINUED) (CONTINUED) atenolol/chlorthalidone
bisoprolol/HCTZ metoprolol/HCTZ nadolol/bendroflumethiazide propranolol/HCTZ timolol/HCTZ
CALCIUM CHANNEL SHORT-ACTING
BLOCKERS diltiazem isradipine
nicardipine nifedipine verapamil LONG-ACTING
amlodipine CARDENE SR (nicardipine) COVERA-HS (verapamil) CARDIZEM LA (diltiazem) diltiazem ER SULAR (nisoldipine) DYNACIRC CR (isradipine) Nisoldipine verapamil ER PM felodipine ER nifedipine ER
LIPOTROPICS, OTHER BILE ACID SEQUESTRANTS
(NON-STATINS) cholestyramine WELCHOL (colesevalam)
colestipol
CHOLESTEROL ABSORPTION INHIBITORS ZETIA (ezetimibe) FIBRIC ACID DERIVATIVES
fenofibrate ANTARA (fenofibrate) gemfibrozil FENOGLIDE (fenofibrate) TRICOR (fenofibrate) LIPOFEN (fenofibrate) TRILIPIX (fenofibric acid) TRIGLIDE (fenofibrate)
NIACIN NIACOR (niacin) NIASPAN (niacin)
Unless otherwise stated, the listing of a particular brand or generic name includes all dosage forms of that drug. Note that the highlighted non-preferred brand name drugs with NR 5 superscript following the name indicates a new brand name drug that has not been reviewed. See separate Antihistamine/Decongestant Product and Active Ingredient Cross- Reference List for complete list of product names and active ingredients.
MISSISSIPPI DIVISION OF MEDICAID PREFERRED DRUG LIST Effective July 1, 2009 (Changes to previous PDL highlighted) BODY SYSTEM THERAPEUTIC CLASS PREFERRED AGENTS NON-PREFERRED AGENTS NOTES CARDIOVASCULAR LIPOTROPICS, OTHER OMEGA-3 FATTY ACIDS (CONTINUED) (NON-STATINS) LOVAZA (omega-3 fatty acids) (CONTINUED) LIPOTROPICS, STATINS STATINS LESCOL (fluvastatin) ALTOPREV (lovastatin) LESCOL XL (fluvastatin) CRESTOR (rosuvastatin) LIPITOR (atorvastatin) lovastatin pravastatin simvastatin STATIN COMBINATIONS CADUET (atorvastatin/amlodipine) ADVICOR (lovastatin/niacin) SIMCOR (simvastatin/niacin) VYTORIN (simvastatin/ezetimibe)
PLATELET AGGRENOX (dipyridamole/aspirin) ticlopidine NR AGGREGATION dipyridamole EFFIENT (prasugrel) INHIBITORS PLAVIX (clopidogrel) NR PULMONARY LETAIRIS (ambrisentan) ADCIRCA (tadalafil) ARTERIAL REVATIO (sildenafil) HYPERTENSION TRACLEER (bosentan) CNS ALZHEIMER’S CHOLINESTERASE INHIBITORS AGENTS ARICEPT (donepezil) COGNEX (tacrine)
ARICEPT ODT (donepezil) galantamine EXELON Oral (rivastigmine) galantamine ER EXELON Patches (rivastigmine) NMDA RECEPTOR ANTAGONIST NAMENDA (memantine)
ANTICONVULSANTS HYDANTOINS DILANTIN (phenytoin) PEGANONE (ethotoin)
PHENYTEK (phenytoin) phenytoin
SUCCINIMIDES
Ethosuximide CELONTIN (methsuximide)
Unless otherwise stated, the listing of a particular brand or generic name includes all dosage forms of that drug. Note that the highlighted non-preferred brand name drugs with NR 6 superscript following the name indicates a new brand name drug that has not been reviewed. See separate Antihistamine/Decongestant Product and Active Ingredient Cross- Reference List for complete list of product names and active ingredients.
MISSISSIPPI DIVISION OF MEDICAID PREFERRED DRUG LIST Effective July 1, 2009 (Changes to previous PDL highlighted) BODY SYSTEM THERAPEUTIC CLASS PREFERRED AGENTS NON-PREFERRED AGENTS NOTES CNS ANTICONVULSANTS ADJUVANTS
(CONTINUED) (CONTINUED) carbamazepine BANZEL (rufinamide)
CARBATROL (carbamazepine) FELBATOL (felbamate) DEPAKOTE ER (divalproex) DEPAKOTE (divalproex) DEPAKOTE SPRINKLE (divalproex) KEPPRA solution (levetiracetam) divalproex KEPPRA tablets (levetiracetam) divalproex ER KEPPRA XR (levetiracetam)
EQUETRO (carbamazepine) LAMICTAL (lamotrigine) NR gabapentin LAMICTAL ODT (lamotrigine) NR GABITRIL (tiagabine) LAMICTAL XR (lamotrigine) lamotrigine TOPAMAX (topiramate) levetiracetam STAVZOR (valproic acid) VIMPAT (lacosamide) levetiracetam solution LYRICA (pregabilin) oxcarbazepine TEGRETOL XR (carbamazepine) topiramate
TRILEPTAL Suspension (oxcarbazepine)
valproic acid zonisamide NR ANTIDEPRESSANTS, bupropion IR APLENZIN (buproprion HBr) Cymbalta will be OTHERS bupropion SR CYMBALTA (duloxetine) approved for patients with EFFEXOR XR (venlafaxine) EMSAM (selegiline transdermal) fibromyalgia or mirtazapine NARDIL (phenelzine) diabetic PRISTIQ (desvenlafaxine succinate) PARNATE (tranylcypromine) neuropathy trazodone venlafaxine WELLBUTRIN XL (bupropion HCl) VENLAFAXINE ER (venlafaxine)
ANTIDEPRESSANTS, citalopram LEXAPRO (escitalopram) SSRIs fluoxetine LUVOX CR (fluvoxamine)
fluvoxamine paroxetine CR paroxetine PAXIL CR (paroxetine) sertraline PEXEVA (paroxetine) PROZAC WEEKLY (fluoxetine) SARAFEM (fluoxetine)
Unless otherwise stated, the listing of a particular brand or generic name includes all dosage forms of that drug. Note that the highlighted non-preferred brand name drugs with NR 7 superscript following the name indicates a new brand name drug that has not been reviewed. See separate Antihistamine/Decongestant Product and Active Ingredient Cross- Reference List for complete list of product names and active ingredients.
MISSISSIPPI DIVISION OF MEDICAID PREFERRED DRUG LIST Effective July 1, 2009 (Changes to previous PDL highlighted) BODY SYSTEM THERAPEUTIC CLASS PREFERRED AGENTS NON-PREFERRED AGENTS NOTES CNS ANTIPARKINSON’S ANTICHOLINERGICS (CONTINUED) AGENTS benztropine trihexyphenidyl
COMT INHIBITORS COMTAN (entacapone) TASMAR (tolcapone)
DOPAMINE AGONISTS ropinirole MIRAPEX (pramipexole) NEUPRO (rotigotine) REQUIP XL (ropinirole) MAO-B INHIBITORS
selegiline AZILECT (rasagiline) ZELAPAR (selegiline) OTHERS
levodopa/carbidopa STALEVO (levodopa/carbidopa/entacapone) ANTIPSYCHOTICS, ABILIFY (aripiprazole) INVEGA (paliperidone) ATYPICAL NR GEODON (ziprasidone) INVEGA SUSTENNA (paliperidone)
risperidone RISPERDAL (risperidone) SEROQUEL (quetiapine) RISPERDAL M (risperidone) SEROQUEL XR (quetiapine) SYMBYAX (olanzapine/fluoxetine) ZYPREXA (olanzapine)
MULTIPLE SCLEROSIS AVONEX (interferon beta-1a) AGENTS BETASERON (interferon beta-1b) COPAXONE (glatiramer) REBIF (interferon beta-1a)
Unless otherwise stated, the listing of a particular brand or generic name includes all dosage forms of that drug. Note that the highlighted non-preferred brand name drugs with NR 8 superscript following the name indicates a new brand name drug that has not been reviewed. See separate Antihistamine/Decongestant Product and Active Ingredient Cross- Reference List for complete list of product names and active ingredients.
MISSISSIPPI DIVISION OF MEDICAID PREFERRED DRUG LIST Effective July 1, 2009 (Changes to previous PDL highlighted) BODY SYSTEM THERAPEUTIC CLASS PREFERRED AGENTS NON-PREFERRED AGENTS NOTES CNS SEDATIVE, BENZODIAZEPINES Single source (CONTINUED) HYPNOTICS estazolam brand benzodiazepines flurazepam and barbiturates temazepam are NOT covered. triazolam No PAs will be OTHERS issued. Quantity LUNESTA (eszopiclone) AMBIEN CR (zolpidem) limit of up to 31 EDLUAR (zolpidem)NR cumulative units of ROZEREM (ramelteon) all/any strengths zaleplon per month. Any zolpidem quantity required above these limits needs a PA. STIMULANTS AND STIMULANTS - SHORT ACTING RELATED AGENTS amphetamine salt combination DESOXYN (methamphetamine) dextroamphetamine/amphetamine ER PROCENTRA solution dexmethylphenidate IR (dextroamphetamine) dextroamphetamine IR FOCALIN (dexmethylphenidate) METHYLIN chewable tablets (methylphenidate) METHYLIN solution (methylphenidate) methylphenidate STIMULANTS - LONG ACTING ADDERALL XR PROVIGIL (modafinil) NR (amphetamine salt combination) NUVIGIL (armodafinil) CONCERTA (methylphenidate) RITALIN LA (methylphenidate) DAYTRANA (methylphenidate) dextroamphetamine ER FOCALIN XR (dexmethylphenidate) METADATE CD (methylphenidate) methylphenidate ER VYVANSE (lisdexamfetamine) NON-STIMULANTS STRATTERA (atomoxetine)
Unless otherwise stated, the listing of a particular brand or generic name includes all dosage forms of that drug. Note that the highlighted non-preferred brand name drugs with NR 9 superscript following the name indicates a new brand name drug that has not been reviewed. See separate Antihistamine/Decongestant Product and Active Ingredient Cross- Reference List for complete list of product names and active ingredients.
MISSISSIPPI DIVISION OF MEDICAID PREFERRED DRUG LIST Effective July 1, 2009 (Changes to previous PDL highlighted) BODY SYSTEM THERAPEUTIC CLASS PREFERRED AGENTS NON-PREFERRED AGENTS NOTES DERMATOLOGICAL ACNE AGENTS, ANTIBIOTICS Acne agents will TOPICAL clindamycin AKNE-MYCIN (erythromycin) be authorized only erythromycin for patients less CLINDAGEL (clindamycin) than 21 years of CLINDAREACH (clindamycin) age. EVOCLIN (clindamycin)
RETINOIDS
RETIN-A MICRO (tretinoin) ATRALIN (tretinoin)
DIFFERIN (adapalene) EPIDUO
(adapalene/benzoyl peroxide) TAZORAC (tazarotene) tretinoin
OTHERS AZELEX (azelaic acid) ACZONE (dapsone) BENZACLIN BENZAMYCIN PAK (benzoyl peroxide/clindamycin) (benzoyl peroxide/erythromycin)
benzoyl peroxide BREVOXYL (benzoyl peroxide) CLINAC BPO (benzoyl peroxide) BREZE (benzoyl peroxide) erythromycin/benzoyl peroxide DUAC (benzoyl peroxide/clindamycin) NUOX (benzoyl peroxide/sulfur) INOVA (benzoyl peroxide) sodium sulfacetamide LAVOCLEN (benzoyl peroxide)
sodium sulfacetamide/sulfur NEOBENZ MICRO (benzoyl peroxide)
ZACLIR (benzoyl peroxide) TRIAZ (benzoyl peroxide) ZACARE (benzoyl peroxide) ZIANA (clindaymcyin/tretinoin) ANALGESICS, FLECTOR (diclofenac epolamine)
TOPICAL LIDODERM Patch (lidocaine)
VOLTAREN Gel (diclofenac sodium)
Unless otherwise stated, the listing of a particular brand or generic name includes all dosage forms of that drug. Note that the highlighted non-preferred brand name drugs with NR10 superscript following the name indicates a new brand name drug that has not been reviewed. See separate Antihistamine/Decongestant Product and Active Ingredient Cross- Reference List for complete list of product names and active ingredients.
MISSISSIPPI DIVISION OF MEDICAID PREFERRED DRUG LIST Effective July 1, 2009 (Changes to previous PDL highlighted) BODY SYSTEM THERAPEUTIC CLASS PREFERRED AGENTS NON-PREFERRED AGENTS NOTES DERMATOLOGICAL ANTIFUNGALS, ANTIFUNGALS (CONTINUED) TOPICAL clotrimazole ciclopirox
econazole CNL 8 (ciclopirox) ketoconazole ERTACZO (sertaconazole) miconazole OTC EXELDERM (sulconazole) NAFTIN (naftifine) EXTINA (ketoconazole) nystatin LOPROX (ciclopirox)
terbinafine OTC MENTAX (butenafine)
tolnaftate OTC OXISTAT (oxiconazole) VUSION (miconazole/petrolatum/zinc oxide) XOLEGEL (ketoconazole) ANTIFUNGAL/STEROID COMBINATIONS
clotrimazole/betamethasone nystatin/triamcinolone
ANTIPARASITICS, EURAX (crotamiton) lindane NR TOPICAL ULESFIA (benzyl alcohol) malathion OVIDE (malathion) permethrin ATOPIC DERMATITIS ELIDEL (pimecrolimus) PROTOPIC (tacrolimus)
STEROIDS, TOPICAL LOW POTENCY
alclometasone DESOWEN (desonide)
DESONATE (desonide) VERDESO (desonide) desonide
hydrocortisone
Unless otherwise stated, the listing of a particular brand or generic name includes all dosage forms of that drug. Note that the highlighted non-preferred brand name drugs with NR11 superscript following the name indicates a new brand name drug that has not been reviewed. See separate Antihistamine/Decongestant Product and Active Ingredient Cross- Reference List for complete list of product names and active ingredients.
MISSISSIPPI DIVISION OF MEDICAID PREFERRED DRUG LIST Effective July 1, 2009 (Changes to previous PDL highlighted) BODY SYSTEM THERAPEUTIC CLASS PREFERRED AGENTS NON-PREFERRED AGENTS NOTES DERMATOLOGICAL STEROIDS, TOPICAL MEDIUM POTENCY (CONTINUED) (CONTINUED) CORDRAN (flurandrenolide) CLODERM (clocortolone)
fluticasone CORDRAN TAPE (flurandrenolide) hydrocortisone butyrate LOCOID (hydrocortisone butyrate) NR hydrocortisone valerate MOMEXIN (mometasone) LUXIQ (betamethasone) mometasone prednicarbate HIGH POTENCY betamethasone amcinonide CAPEX (fluocinolone) DERMA-SMOOTHE/FS(fluocinolone) fluocinolone desoximetasone fluocinonide diflorasone triamcinolone HALOG (halcinonide) NR KENALOG aerosol (triamcinolone) VANOS (fluocinonide) VERY HIGH POTENCY clobetasol halobetasol ULTRAVATE (halobetasol) ENDOCRINE ANDROGENIC ANDRODERM TESTIM (testosterone gel) AGENTS (testosterone transdermal) ANDROGEL (testosterone gel)
BONE RESORPTION BISPHOSPHONATES
SUPPRESSION AND ACTONEL (risedronate) BONIVA (ibandronate) REL ATED AGENTS (ORAL) ACTONEL WITH CALCIUM FOSAMAX (alendronate) (risedronate/calcium) alendronate FOSAMAX PLUS D (alendronate/vitamin D)
Unless otherwise stated, the listing of a particular brand or generic name includes all dosage forms of that drug. Note that the highlighted non-preferred brand name drugs with NR12 superscript following the name indicates a new brand name drug that has not been reviewed. See separate Antihistamine/Decongestant Product and Active Ingredient Cross- Reference List for complete list of product names and active ingredients.
MISSISSIPPI DIVISION OF MEDICAID PREFERRED DRUG LIST Effective July 1, 2009 (Changes to previous PDL highlighted) BODY SYSTEM THERAPEUTIC CLASS PREFERRED AGENTS NON-PREFERRED AGENTS NOTES ENDOCRINE BONE RESORPTION OTHER BONE RESORPTION (CONTINUED) SUPPRESSION AND SUPPRESSION AND RELATED AGENTS RELATED AGENTS EVISTA (raloxifene) FORTEO (teriparatide) (ORAL) (CONTINUED)
FORTICAL (calcitonin) MIACALCIN (calcitonin) calcitonin salmon (nasal) GROWTH HORMONES GENOTROPIN (somatropin) HUMATROPE (somatropin) NUTROPIN (somatropin) NORDITROPIN (somatropin)
NUTROPIN AQ (somatropin) OMNITROPE (somatropin) SAIZEN (somatropin) SEROSTIM (somatropin) TEV-TROPIN (somatropin) ZORBTIVE (somatropin) NR HYPOGLYCEMICS, BYETTA (exenatide) ONGLYZA (saxagliptin)
INCRETIN JANUMET (sitagliptin/metformin) SYMLIN (pramlintide) MIMETIC/ENHANCERS JANUVIA (sitagliptin) (INCLUDES VIALS AND PENS)
HYPOGLYCEMICS, LANTUS (insulin glargine) APIDRA (insulin glulisine) INSULIN AND LEVEMIR (insulin detemir) HUMALOG (insulin lispro) RELATED AGENTS NOVOLIN (insulin) HUMALOG MIX (INCLUDES VIALS AND NOVOLOG (insulin aspart) (insulin lispro/lispro protamine) PENS) NOVOLOG MIX HUMULIN (insulin) (insulin aspart/aspart protamine)
HYPOGLYCEMICS, PRANDIN (repaglinide) PRANDIMET (repaglinide/metformin) MEGLITINIDES STARLIX (nateglinide) HYPOGLYCEMICS, THIAZOLINEDIONES TZDS ACTOS (pioglitazone)
AVANDIA (rosiglitazone)
TZD COMBINATIONS ACTOPLUS MET (pioglitazone/metformin)
AVANDAMET (rosiglitazone/metformin)
AVANDARYL (rosiglitazone/glipizide) DUETACT (pioglitazone/glimepiride)
Unless otherwise stated, the listing of a particular brand or generic name includes all dosage forms of that drug. Note that the highlighted non-preferred brand name drugs with NR13 superscript following the name indicates a new brand name drug that has not been reviewed. See separate Antihistamine/Decongestant Product and Active Ingredient Cross- Reference List for complete list of product names and active ingredients.
MISSISSIPPI DIVISION OF MEDICAID PREFERRED DRUG LIST Effective July 1, 2009 (Changes to previous PDL highlighted) BODY SYSTEM THERAPEUTIC CLASS PREFERRED AGENTS NON-PREFERRED AGENTS NOTES GASTROINTESTINAL ANTIEMETICS CANNABINOIDS All injectable 5HT3 CESAMET (nabilone) receptor blockers dronabinol closed to point of sale. 5HT3 RECEPTOR BLOCKERS ondansetron ANZEMET (dolasetron) granisetron SANCUSO Transdermal (granisetron)
NMDA RECEPTOR ANTAGO NIST EMEND (aprepitant) H. PYLORI HELIDAC (bismuth subsalicylate, PYLERA (bismuth subcitrate, potassium, metronidazole, tetracycline) metronidazole, tetracycline)
PREVPAC (lansoprazole, amoxicillin,
clarithromycin)
PANCREATIC CREON (pancreatin) PANCRECARB MS (pancrelipase) Pancrecarb MS is ENZYMES DYGASE (pancreatin) approved if currently on stable LAPASE (pancreatin) treatment with this LIPRAM (pancrelipase) drug. PANCREASE MT (pancrelipase) pancrelipase ULTRASE (pancrelipase) VIOKASE (pancrelipase)
PROTON PUMP KAPIDEX (dexlansoprazole) ACIPHEX (rabeprazole)
INHIBITORS omeprazole NEXIUM (esomeprazole) PREVACID (lansoprazole) pantoprazole PRILOSEC suspension (omeprazole) ZEGERID (omeprazole/sodium bicarbonate) ULCERATIVE COLITIS ORAL
AGENTS ASACOL / ASACOL HD (mesalamine) APRISO (mesalamine)
balsalazide DIPENTUM (olsalazine) LIALDA (mesalamine) PENTASA (mesalamine) sulfasalazine
RECTAL CANASA (mesalamine) SFROWASA (mesalamine) mesalamine Unless otherwise stated, the listing of a particular brand or generic name includes all dosage forms of that drug. Note that the highlighted non-preferred brand name drugs with NR14 superscript following the name indicates a new brand name drug that has not been reviewed. See separate Antihistamine/Decongestant Product and Active Ingredient Cross- Reference List for complete list of product names and active ingredients.
MISSISSIPPI DIVISION OF MEDICAID PREFERRED DRUG LIST Effective July 1, 2009 (Changes to previous PDL highlighted) BODY SYSTEM THERAPEUTIC CLASS PREFERRED AGENTS NON-PREFERRED AGENTS NOTES IMMUNOLOGIC CYTOKINE AND CAM CIMZIA (certolizumab) AMEVIVE (alefacept) Amevive, Orencia AGENTS ANTAGONISTS ENBREL (etanercept) ORENCIA (abatacept) and Remicade are for administration HUMIRA (adalimumab) REMICADE (infliximab) NR in hospital or clinic KINERET (anakinra) SIMPONI (golimumab) setting. PA will not be issued at Point of Sale without justification. INFECTIOUS ANTIBIOTICS, GI ALINIA (nitazoxanide) FLAGYL ER (metronidazole) DISEASE metronidazole VANCOCIN (vancomycin) XIFAXAN (rifaximin) neomycin TINDAMAX (tinadazole) ANTIBIOTICS, CLEOCIN OVULES (clindamcyin) CLINDESSE (clindamycin) VAGINAL clindamycin metronidazole
ANTIFUNGALS, ORAL clotrimazole ANCOBON (flucytosine) fluconazole GRIFULVIN V (griseofulvin) GRIS-PEG (griseofulvin) itraconazole ketoconazole LAMISIL GRANULES (terbinafine) nystatin NOXAFIL (posaconazole) terbinafine VFEND (voriconazole)
ANTIVIRALS, ORAL – acyclovir FAMVIR (famciclovir) ANTIHERPETIC VALTREX (valacyclovir) AGENTS CEPHALOSPORINS BET A LACTAM/BETA-LACTAMASE INHIBITOR COMBINATIONS AND RELATED amoxicillin/clavulanate ANTIBIOTICS AUGMENTIN XR
(amoxicillin/clavulanate) CEPHALOSPORINS – First Generation cefadroxil cephalexin CEPHALOSPORINS – Second Generation
cefaclor RANICLOR (cefaclor) cefprozil cefuroxime
Unless otherwise stated, the listing of a particular brand or generic name includes all dosage forms of that drug. Note that the highlighted non-preferred brand name drugs with NR15 superscript following the name indicates a new brand name drug that has not been reviewed. See separate Antihistamine/Decongestant Product and Active Ingredient Cross- Reference List for complete list of product names and active ingredients.
MISSISSIPPI DIVISION OF MEDICAID PREFERRED DRUG LIST Effective July 1, 2009 (Changes to previous PDL highlighted) BODY SYSTEM THERAPEUTIC CLASS PREFERRED AGENTS NON-PREFERRED AGENTS NOTES INFECTIOUS CEPHALOSPORINS CEPHALOSPORINS – Third Generation DISEASE AND RELATED cefdinir CEDAX (ceftibuten) (CONTINUED) ANTIBIOTICS SUPRAX (cefixime) (CONTINUED) cefpodoxime SPECTRACEF (cefditoren) FLUOROQUINOLONES, AVELOX (moxifloxacin) ciprofloxacin ER ORAL ciprofloxacin CIPRO suspension (ciprofloxacin) PROQUIN XR (ciprofloxacin) FACTIVE (gemifloxacin) LEVAQUIN (levofloxacin) NOROXIN (norfloxacin) ofloxacin HEPATITIS C PEGASYS (peginterferon alfa-2a) INFERGEN (interferon alfacon-1) Peg-Intron TREATMENTS PEG-INTRON (peginterferon alfa-2b) approved for patients currently PEG-INTRON REDIPEN on stable (peginterferon alfa-2b) treatment. MACROLIDES/ KETOLIDES KETOLIDES KETEK (telithromycin) MACROLIDES azithromycin clarithromycin ER clarithromycin IR ZMAX (azithromycin) erythromycin NEPHROLOGIC ERYTHROPOIESIS ARANESP (darbepoetin) EPOGEN (rHuEPO) AGENTS STIMULATING PROCRIT (rHuEPO) PROTEINS
PHOSPHATE ELIPHOS (calcium acetate) RENVELA (sevelamer carbonate) BINDERS FOSRENOL (lanthanum) PHOSLO (calcium acetate) calcium acetate RENAGEL (sevelamer HCl) NR OPHTHALMICS OPHTHALMIC AZASITE (azithromycin) BESIVANCE (besifloxacin) QUINOLONES/ erythromycin CILOXAN (ciprofloxacin) MACROLIDES IQUIX (levofloxacin) ciprofloxacin VIGAMOX (moxifloxacin) ofloxacin QUIXIN (levofloxacin) ZYMAR (gatifloxacin)
Unless otherwise stated, the listing of a particular brand or generic name includes all dosage forms of that drug. Note that the highlighted non-preferred brand name drugs with NR16 superscript following the name indicates a new brand name drug that has not been reviewed. See separate Antihistamine/Decongestant Product and Active Ingredient Cross- Reference List for complete list of product names and active ingredients.
MISSISSIPPI DIVISION OF MEDICAID PREFERRED DRUG LIST Effective July 1, 2009 (Changes to previous PDL highlighted) BODY SYSTEM THERAPEUTIC CLASS PREFERRED AGENTS NON-PREFERRED AGENTS NOTES OPHTHALMICS OPHTHALMICS, ACULAR LS (ketorolac) ACUVAIL (ketorolac) NR (CONTINUED) NSAIDS ACULAR PF (ketorolac) diclofenac XIBROM (bromfenac) flurbiprofen NEVANAC (nepafenac) OPHTHALMICS FOR ALREX (loteprednol) ACULAR (ketorolac) ALLERGIC cromolyn ALAMAST (pemirolast) CONJUNCTIVITIS ELESTAT (epinastine) ALOCRIL (nedocromil)
OPTIVAR (azelastine) ALOMIDE (lodoxamide) PATADAY (olopatadine) EMADINE (emedastine) PATANOL (olopatadine) ketotifen OPHTHALMICS, AZOPT (brinzolamide) ALPHAGAN P (brimonidine) GLAUCOMA AGENTS betaxolol BETOPTIC S (betaxolol)
BETIMOL (timolol) LUMIGAN 5 ML/ 7.5 ML (bimatoprost) brimonidine carteolol COMBIGAN (brimonidine/timolol) COSOPT (dorzolamide/timolol)
dipivefrin ISTALOL (timolol LA) levobunolol LUMIGAN 2.5 ML (bimatoprost) metipranolol
pilocarpine
timolol TRAVATAN/TRAVATAN Z (travoprost) TRUSOPT (dorzolamide) XALATAN (latanoprost) NR OTICS OTIC CIPRODEX CETRAXAL (ciprofloxacin) FLUOROQUINOLONES (ciprofloxacin/dexamethasone) CIPRO HC (ciprofloxacin/hydrocortisone) FLOXIN (ofloxacin) ofloxacin
Unless otherwise stated, the listing of a particular brand or generic name includes all dosage forms of that drug. Note that the highlighted non-preferred brand name drugs with NR17 superscript following the name indicates a new brand name drug that has not been reviewed. See separate Antihistamine/Decongestant Product and Active Ingredient Cross- Reference List for complete list of product names and active ingredients.
MISSISSIPPI DIVISION OF MEDICAID PREFERRED DRUG LIST Effective July 1, 2009 (Changes to previous PDL highlighted) BODY SYSTEM THERAPEUTIC CLASS PREFERRED AGENTS NON-PREFERRED AGENTS NOTES RESPIRATORY ANTIHISTAMINE/ ANTIHISTAMINES-FIRST GENERATION DECONGESTANTS brompheniramine maleate ALA-HIST brompheniramine tannate (brompheniramine/diphenhydramine) brompheniramine/diphenhydramine Aldex AN carbinoxamine maleate CONEX (brompheniramine) chlorpheniramine maleate Diphenmax chlorpheniramine tannate J-tan clemastine fumarate J-tan PD cyproheptadine hcl dexchlorpheniramine maleate diphenhydramine hcl diphenhydramine tannate doxylamine succinate MYCI CHLORPED (chlorpheniramine) MYCI CHLOR-TAN (chlorpheniramine) PEDIATAN (chlorpheniramine) POLY TAN (pyrilamine/ dexbrompheniramine) P-TEX (brompheniramine) triprolidine hcl VAZOL (brompheniramine)
ANTIHISTAMINES-FIRST GENERATION/DECONGESTANT COMBINATIONS
ALA-HIST D ACCUHIST (PSE/chlorpheniramine) (brompheniramine/diphenhydramine/ ALLERDUR (PSE/dexchlorpheniramine) phenylephrine) ALERSULE ALAHIST LQ (phenylephrine/chlorpheniramine) (phenylephrine/diphenhydrmine) ALLERTAN (phenylephrine/pyrilamine/ DALLERGY drops chlorpheniramine) (phenylephrine/chlorpheniramine) ALLERX (phenylephrine/chlorpheniramine) NALDEX BROMFED (PSE/brompheniramine) (phenylephrine/dexchlorpheniramine) BROMFED-PD (PSE/brompheniramine) phenylephrine/brompheniramine DALLERGY-JR suspension phenylephrine/chlorpheniramine maleate (phenylephrine/chlorpheniramine) phenylephrine/chlorpheniramine tannate DECONSAL CT (phenylephrine/pyrilamine) phenylephrine/diphenhydramine DISOPHROL (PSE/dexbrompheniraminel) phenylephrine/phenyltoloxamine/ DURATUSS DA (PSE/chlorpheniramine) chlorpheniramine HISTEX (PSE/chlorpheniramine) phenylephrine/promethazine hcl HISTEX SR (PSE/brompheniramine) phenylephrine/pyrilamine maleate J-tan D phenylephrine/pyrilamine tannate J-tan D PD phenylephrine/pyrilamine/ MYCI CHLORPED D (phenylephrine/ chlorpheniramine chlorpheniramine) POLY TAN D NY-TANNIC (PSE/pyrilamine/brompheniramine) (phenylephrine/chlorpheniramine) Unless otherwise stated, the listing of a particular brand or generic name includes all dosage forms of that drug. Note that the highlighted non-preferred brand name drugs with NR18 superscript following the name indicates a new brand name drug that has not been reviewed. See separate Antihistamine/Decongestant Product and Active Ingredient Cross- Reference List for complete list of product names and active ingredients.
MISSISSIPPI DIVISION OF MEDICAID PREFERRED DRUG LIST Effective July 1, 2009 (Changes to previous PDL highlighted) BODY SYSTEM THERAPEUTIC CLASS PREFERRED AGENTS NON-PREFERRED AGENTS NOTES RESPIRATORY ANTIHISTAMINE/ PSE/brompheniramine PEDIATAN D (CONTINUED) DECONGESTANTS PSE/chlorpheniramine (phenylephrine/chlorpheniramine) (CONTINUED) PSE/chlorpheniramine tannate PHENA-PLUS (phenylephrine/pyrilamine/ PSE/dexchlorpheniramine tannate chlorpheniramine) PSE/triprolidine PHENA-S (phenylephrine/pyrilamine/ RYNESA 12S (phenylephrine/pyrilamine) chlorpheniramine) PHENA-S 12 (phenylephrine/ pyrilamine/chlorpheniramine) POLY HIST FORTE (phenylephrine/pyrilamine/ chlorpheniramine) POLY HIST PD (phenylephrine/pyrilamine/ chlorpheniramine) Rescon-JR RYNA 12 S (phenylephrine/pyrilamine) RYNA-12 (phenylephrine/pyrilamine) RYNATAN (phenylephrine/chlorpheniramine) RYNATAN PEDIATRIC (phenylephrine/chlorpheniramine) SERADEX-LA (phenylephrine/brompheniramine) SUDAL 12 (PSE/chlorpheniramine) TIBAMINE LA (PSE/chlorpheniramine) TUSSANIL (phenylephrine/chlorpheniramine) VAZOBID (phenylephrine/brompheniramine) VAZOTAB (phenylephrine/brompheniramine) VIRAVAN-P (PSE/pyrilamine) ANTIHISTAMINES-FIRST GENERATION/DECONGESTANT/ANTICHOLINERGIC COMBINATIONS
brompheniramine/PSE; chlorpheniramine/ ALLERX 10 (PSE/methscopolamine/
phenylephrine/methscopolamine chlorpheniramine/phenylephrine)
chlorpheniramine/phenylephrine/ ALLERX 30 (PSE/methscopolamine/
methscopolamine chlorpheniramine/phenylephrine)
DALLERGY cap, syrup, tab ALLERX PE
(chlorpheniramine/phenylephrine/ (phenylephrine/chlorpheniramine/
methscopolamine) methcopolamine)
phenylephrine/chlorpheniramine/belladonna DALLERGY PE
alkaloids (chlorpheniramine/phenylephrine/
phenylephrine/dexchlorpheniramine/ methscopolamine) methscopolamine DALLERGY PSE (PSE/chlorpheniramine/
Unless otherwise stated, the listing of a particular brand or generic name includes all dosage forms of that drug. Note that the highlighted non-preferred brand name drugs with NR19 superscript following the name indicates a new brand name drug that has not been reviewed. See separate Antihistamine/Decongestant Product and Active Ingredient Cross- Reference List for complete list of product names and active ingredients.
MISSISSIPPI DIVISION OF MEDICAID PREFERRED DRUG LIST Effective July 1, 2009 (Changes to previous PDL highlighted) BODY SYSTEM THERAPEUTIC CLASS PREFERRED AGENTS NON-PREFERRED AGENTS NOTES RESPIRATORY ANTIHISTAMINE/ PSE/chlorpheniramine/methscopolamine methscopolamine) (CONTINUED) DECONGESTANTS PSE/dexchlorpheniramine/methscopolamine DURAHIST (PSE/ (CONTINUED) PSE/methscopolamine/chlorpheniramine/ chlorpheniramine/methscopolamine) phenylephrine DURAHIST D (PSE/dexchlorpheniramine/ methscopolamine) DURAHIST PE (phenylephrine/ chlorpheniramine/methscopolamine) DURATAN PE (phenylephrine/ chlorpheniramine/methscopalamine) EXTENDRYL chew tab (phenylephrine/ chlorpheniramine/methcopolamine) EXTENDRYL JR (phenylephrine/ chlorpheniramine/m ethscopolamine) EXTENDRYL SR (phenylephrine/ chlorpheniramine/methscopolamine) EXTENDRYL syrup (phenylephrine/ dexchlorpheniramine/methscopolamine) Rescon TIME-HIST QD (PSE/ chlorpheniramine/ methscopolamine) Visrx
ANTIHISTAMINES-MINIMALLY SEDATING
cetirizine ALLEGRA (fexofenadine) *Xyzal will be approved for loratadine CLARINEX (desloratadine) patients failing fexofenadine XYZAL (levocetirizine)* therapy with OTC
cetirizine,
loratadine, or fexofenadine.
ANTIHISTAMINES-MINIMALLY SEDATING/DECONGESTANT COMBINATIONS cetirizine/PSE CLARINEX-D (desloratadine/PSE) loratadine/PSE ALLEGRA-D (fexofenadine/PSE)
SEMPREX-D (acrivastine/PSE)
Unless otherwise stated, the listing of a particular brand or generic name includes all dosage forms of that drug. Note that the highlighted non-preferred brand name drugs with NR20 superscript following the name indicates a new brand name drug that has not been reviewed. See separate Antihistamine/Decongestant Product and Active Ingredient Cross- Reference List for complete list of product names and active ingredients.
MISSISSIPPI DIVISION OF MEDICAID PREFERRED DRUG LIST Effective July 1, 2009 (Changes to previous PDL highlighted) BODY SYSTEM THERAPEUTIC CLASS PREFERRED AGENTS NON-PREFERRED AGENTS NOTES RESPIRATORY ANTIHISTAMINE/ DECONGESTANT/ANTICHOLINERGIC COMBINATIONS (CONTINUED) DECONGESTANTS PSE/methscopolam ine ALLERX-D (PSE/methscopolamine) (CONTINUED) EXTENDRYL PSE (PSE/methscopolamine) EXTENDRYL PEM (phenylephrine/methscopolamine)
BRONCHODILATORS, ANTICHOLINERGICS
ANTICHOLINERGIC ATROVENT HFA (ipratropium) ipratropium SPIRIVA (tiotropium) ANTICHOLINERGIC-BETA AGONIST COMBINATIONS
COMBIVENT (albuterol/ipratropium) albuterol/ipratropium
BRONCHODILATORS, INHALERS, SHORT-ACTING
BETA AGONIST albuterol MAXAIR (pirbuterol)
PROAIR HFA (albuterol) XOPENEX HFA (levalbuterol)
PROVENTIL HFA (albuterol) VENTOLIN HFA (albuterol) INHALERS, LONG ACTING FORADIL (formoterol) SEREVENT (salmeterol)
INHALATION SOLUTION albuterol BROVANA (arformoterol) metaproterenol
PERFOROMIST (formoterol)
XOPENEX (levalbuterol)
ORAL albuterol metaproterenol terbutaline
Unless otherwise stated, the listing of a particular brand or generic name includes all dosage forms of that drug. Note that the highlighted non-preferred brand name drugs with NR21 superscript following the name indicates a new brand name drug that has not been reviewed. See separate Antihistamine/Decongestant Product and Active Ingredient Cross- Reference List for complete list of product names and active ingredients.
MISSISSIPPI DIVISION OF MEDICAID PREFERRED DRUG LIST Effective July 1, 2009 (Changes to previous PDL highlighted) BODY SYSTEM THERAPEUTIC CLASS PREFERRED AGENTS NON-PREFERRED AGENTS NOTES RESPIRATORY GLUCOCORTICOIDS, GLUCOCORTICOIDS (CONTINUED) INHALED AEROBID (flunisolide) ALVESCO (ciclosinide)
AEROBID-M (flunisolide) PULMICORT
ASMANEX (mometasone) (budesonide) Flexhaler AZMACORT (triamcinolone) FLOVENT Diskus (fluticasone) FLOVENT HFA (fluticasone)
PULMICORT (budesonide) Respules QVAR (beclomethasone) GLUCOCORTICOID/BRONCHODILATOR COMBINATIONS ADVAIR Diskus (fluticasone/salmeterol)
ADVAIR HFA (fluticasone/salmeterol)
SYMBICORT (budesonide/formoterol)
INTRANASAL RHINITIS ANTICHOLINERGICS AGENTS ipratropium ANTIHISTAMINES ASTELIN (azelastine) ASTEPRO (azelastine) PATANASE (olaptadine) CORTICOSTEROIDS FLONASE (fluticasone) BECONASE AQ (beclomethasone) flunisolide NASACORT AQ (triamcinolone) fluticasone OMNARIS (ciclesonide) NASAREL (flunisolide) RHINOCORT AQUA (budesonide) NASONEX (mometasone) VERAMYST (fluticasone) LEUKOTRIENE ACCOLATE (zafirlukast) ZYFLO CR (zafirlukast) MODIFIERS SINGULAIR (montelukast) UROLOGICAL BLADDER RELAXANT DETROL LA (tolterodine) DETROL (tolterodine) NR PREPARATIONS ENABLEX (darifenacin) GELNIQUE (oxybutynin)
oxybutynin oxybutynin ER OXYTROL Transdermal (oxybutynin) TOVIAZ (fesoterodine fumurate) SANCTURA (trospium) VESICARE (solifenacin) SANCTURA XR (trospium)
Unless otherwise stated, the listing of a particular brand or generic name includes all dosage forms of that drug. Note that the highlighted non-preferred brand name drugs with NR22 superscript following the name indicates a new brand name drug that has not been reviewed. See separate Antihistamine/Decongestant Product and Active Ingredient Cross- Reference List for complete list of product names and active ingredients.
MISSISSIPPI DIVISION OF MEDICAID PREFERRED DRUG LIST Effective July 1, 2009 (Changes to previous PDL highlighted) BODY SYSTEM THERAPEUTIC CLASS PREFERRED AGENTS NON-PREFERRED AGENTS NOTES UROLOGICAL BPH AGENTS ALPHA BLOCKERS (CONTINUED) doxazosin CARDURA XL (doxazosin) FLOMAX (tamsulosin) RAPAFLO (silodosin) terazosin UROXATRAL (alfuzosin) 5-ALPHA-REDUCTASE (5AR) INHIBITORS AVODART (dutasteride) finasteride
Unless otherwise stated, the listing of a particular brand or generic name includes all dosage forms of that drug. Note that the highlighted non-preferred brand name drugs with NR23 superscript following the name indicates a new brand name drug that has not been reviewed. See separate Antihistamine/Decongestant Product and Active Ingredient Cross- Reference List for complete list of product names and active ingredients.