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Mississippi Division of Medicaid Preferred Drug List

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Mississippi Division of Medicaid Preferred Drug List MISSISSIPPI DIVISION OF MEDICAID PREFERRED DRUG LIST Effective July 1, 2010 BODY SYSTEM THERAPEUTIC CLASS PREFERRED AGENTS NON-PREFERRED AGENTS NOTES ANALGESICS ANALGESICS, DURAGESIC (fentanyl) AVINZA (morphine) NARCOTIC-LONG-ACTING fentanyl patches EMBEDA (morphine/naltrexone) KADIAN (morphine) OPANA ER (oxymorphone) methadone oxycodone ER morphine ER OXYCONTIN (oxycodone) RYZOLT (tramadol) ULTRAM ER (tramadol) ANALGESICS, NARCOTIC- acetaminophen/codeine butalbital/APAP/caffeine/codeine SHORT-ACTING aspirin/codeine butalbital/ASA/caffeine/codeine codeine DARVON-N (propoxyphene) dihydrocodeine/ APAP/caffeine DILAUDID liquid (hydromorphone) hydrocodone/APAP fentanyl hydrocodone/ibuprofen FENTORA (fentanyl) hydromorphone levorphanol IBUDONE (hydrocodone/ibuprofen) NUCYNTA (tapentadol) meperidine ONSOLIS (fentanyl) morphine OPANA (oxymorphone) oxycodone pentazocine/naloxone oxycodone/APAP propoxyphene oxycodone/aspirin REPREXAIN oxycodone/ibuprofen (hydrocodone/ibuprofen) pentazocine/APAP RYBIX (tramadol) propoxyphene/APAP ZAMICET (hydrocodone/APAP) tramadol tramadol/APAP ANALGESICS/ANESTHETICS, FLECTOR (diclofenac epolamine) TOPICAL LIDODERM (lidocaine) VOLTAREN Gel (diclofenac sodium) ANTIHYPERURICEMICS allopurinol COLCRYS (colchicine) colchicine ULORIC (febuxostat) probenecid probenecid/colchicine ANTIMIGRAINE AGENTS, 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. NR indicates a new drug that has not yet been reviewed by the 1 P&T Committee. 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, 2010 BODY SYSTEM THERAPEUTIC CLASS PREFERRED AGENTS NON-PREFERRED AGENTS NOTES ANALGESICS ANTIMIGRAINE AGENTS, NASAL TRIPTANS (continued) IMITREX (sumatriptan) ZOMIG (zolmitriptan) (CONTINUED) sumatriptan INJECTABLE IMITREX (sumatriptan) sumatriptan FIBROMYALGIA AGENTS LYRICA (pregabalin) CYMBALTA (duloxetine) Cymbalta will be SAVELLA (milnacipran) approved for patients with diabetic neuropathy NSAIDS NONSELECTIVE diclofenac meclofenamate etodolac mefenamic acid fenoprofen nabumetone flurbiprofen tolmetin ibuprofen ZIPSOR (diclofenac) indomethacin ketoprofen ketorolac naproxen oxaprozin piroxicam sulindac NSAID/GI PROTECTANT COMBINATIONS ARTHROTEC (diclofenac/misoprostol) PREVACID NAPRAPAC (naproxen/lansoprazole) COX-II SELECTIVE meloxicam CELEBREX (celecoxib) 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 2 P&T Committee. 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, 2010 BODY SYSTEM THERAPEUTIC CLASS PREFERRED AGENTS NON-PREFERRED AGENTS NOTES ANALGESICS SKELETAL MUSCLE baclofen AMRIX (cyclobenzaprine ER) (continued) RELAXANTS chlorzoxazone carisoprodol cyclobenzaprine carisoprodol compound dantrolene FEXMID (cyclobenzaprine) methocarbamol orphenadrine tizanidine orphenadrine compound SKELAXIN (metaxolone) SOMA (carisoprodol) ZANAFLEX (tizanidine) CARDIOVASCULAR ANGIOTENSIN MODULATORS ACE INHIBITORS benazepril ACEON (perindopril) captopril moexepril enalapril perindopril fosinopril lisinopril quinapril ramipril trandolapril ACE INHIBITOR/DIURETIC COMBINATIONS benazepril/HCTZ captopril/HCTZ enalapril/HCTZ fosinopril/HCTZ lisinopril/HCTZ moexepril/HCTZ quinapril/HCTZ ANGIOTENSIN RECEPTOR BLOCKERS AVAPRO (irbesartan) ATACAND (candesartan) BENICAR (olmesartan) TEVETEN (eprosartan) COZAAR (losartan) DIOVAN (valsartan) MICARDIS (telmisartan) 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 3 P&T Committee. 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, 2010 BODY SYSTEM THERAPEUTIC CLASS PREFERRED AGENTS NON-PREFERRED AGENTS NOTES CARDIOVASCULAR ANGIOTENSIN MODULATORS (CONTINUED) (CONTINUED) ANGIOTENSIN RECEPTOR BLOCKER/DIURETIC COMBINATIONS AVALIDE (irbesartan/HCTZ) ATACAND-HCT (candesartan/HCTZ) BENICAR-HCT (olmesartan/HCTZ) TEVETEN-HCT (eprosartan/HCTZ) DIOVAN-HCT (valsartan/HCTZ) HYZAAR (losartan/HCTZ) MICARDIS-HCT (telmisartan/HCTZ) DIRECT RENIN INHIBITOR TEKTURNA (aliskerin) DIRECT RENIN INHIBITOR COMBINATIONS TEKTURNA-HCT (aliskerin/HCTZ) VALTURNA (Aliskerin/valsartan) ANGIOTENSIN MODULATOR/ ACE INHIBITOR/CCB COMBINATIONS CCB COMBINATIONS benazepril/amlodipine LOTREL TARKA (trandolapril/verapamil) ANGIOTENSIN RECEPTOR BLOCKER/CCB COMBINATIONS AZOR (olmesartan/amlodipine) TWYNSTA (telmisartan/amlodipine) EXFORGE (valsartan/amlodipine) EXFORGE HCT (valsartan/amlodipine/HCTZ) ANTICOAGULANTS, ARIXTRA (fondaparinux) INNOHEP (tinzaparin) INJECTABLE FRAGMIN (dalteparin) LOVENOX (enoxaparin) BETA-BLOCKERS BETA BLOCKERS acebutolol betaxolol atenolol BYSTOLIC (nebivolol) bisoprolol INNOPRAN XL (propranolol) metoprolol LEVATOL (penbutolol) metopolol XL sotalol nadolol pindolol propranolol timolol 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. NR indicates a new drug that has not yet been reviewed by the 4 P&T Committee. 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, 2010 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 felodipine ER verapamil ER PM nifedipine ER verapamil 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) FIBRICOR (fenofibric acid) TRILIPIX (fenofibric acid) LIPOFEN (fenofibrate) TRIGLIDE (fenofibrate) NIACIN NIACOR (niacin) NIASPAN (niacin) OMEGA-3 FATTY ACIDS LOVAZA (omega-3 fatty acids) 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 5 P&T Committee. 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, 2010 BODY SYSTEM THERAPEUTIC CLASS PREFERRED AGENTS NON-PREFERRED AGENTS NOTES CARDIOVASCULAR LIPOTROPICS, STATINS STATINS (CONTINUED) LESCOL (fluvastatin) ALTOPREV (lovastatin) LESCOL XL (fluvastatin) CRESTOR (rosuvastatin) LIPITOR (atorvastatin) lovastatin pravastatin simvastatin STATIN COMBINATIONS CADUET (atorvastatin/amlodipine) ADVICOR (lovastatin/niacin) VYTORIN (simvastatin/ezetimibe) SIMCOR (simvastatin/niacin) PLATELET AGGREGATION AGGRENOX (dipyridamole/aspirin) EFFIENT (prasugrel) INHIBITORS dipyridamole ticlopidine PLAVIX (clopidogrel) PULMONARY ARTERIAL LETAIRIS (ambrisentan) ADCIRCA (tadalafil) HYPERTENSION AGENTS REVATIO (sildenafil) TYVASO (treprostinil) TRACLEER (bosentan) VENTAVIS (iloprost) CNS ALZHEIMER’S AGENTS CHOLINESTERASE INHIBITORS ARICEPT (donepezil) COGNEX (tacrine) ARICEPT ODT (donepezil) galantamine EXELON (rivastigmine) galantamine ER NMDA RECEPTOR ANTAGONIST NAMENDA (memantine) ANTICONVULSANTS HYDANTOINS DILANTIN (phenytoin) PEGANONE (ethotoin) PHENYTEK (phenytoin) phenytoin SUCCINIMIDES ethosuximide CELONTIN (methsuximide) ADJUVANTS carbamazepine BANZEL (rufinamide) CARBATROL (carbamazepine) FELBATOL (felbamate) DEPAKOTE ER (divalproex) KEPPRA XR (levetiracetam) DEPAKOTE SPRINKLE (divalproex) SABRIL (vigabatrin) divalproex STAVZOR (valproic acid) divalproex ER TRILEPTAL Tablets (oxcarbazepine) EQUETRO (carbamazepine) VIMPAT (lacosamide) 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 6 P&T Committee. 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, 2010 BODY SYSTEM THERAPEUTIC CLASS PREFERRED AGENTS NON-PREFERRED AGENTS NOTES CNS ANTICONVULSANTS gabapentin (CONTINUED) (CONTINUED) GABITRIL (tiagabine) LAMICTAL ODT (lamotrigine) LAMICTAL XR (lamotrigine) lamotrigine levetiracetam
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